Transcript Drilling Down the Data and Developing

Drilling Down the Data and
Developing Interventions
September 17, 2015; 3:00 am – 4:30 pm
Improving Care for
Most at Risk Patients
Nanette Brey Magnani, EdD, NQC Coach
Stephanie Hedgepeth, CQM MSDH
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Agencies Work Presented
• EPA RG
• Shannon McElroy, Program Director, Family First Health Center
• Rebecca Geiser, Program Manager, Pinnacle Health
• Chelsea Shepherd, NP, Katey Ruppert, QI Coordinator, St. Luke’s University Healthcare Network
• Greater Chicago QM Group – Access CHN, Christian CHC, CDPH-C Clinic, Howard Brown Health
Center
• Kelly Sellers, CQI Analyst, Howard Brown Health Center
• Cori Blum, Medical Director, CDPH Care Clinics
• Brandi Godbolt, Community & Speciatly Services Manager, Heartland Health Outreach
• MA Statewide QM Group
• Paul Cassidy, Program Director, Greater New Bedford CHC
• Adrianne Jiles, Data Manager, Holyoke HC
• Mississippi Statewide QM Group
• Kawanis Collins, Program Director, SW, Magnolia Medical Center
• Stephanie Hedgepeth, Clinical Quality Manager, MSDH
• NY Upstate LN, IVY Clinic, Arnot Ogden Medical Center, Ellmira, NY
• Anna Lechowska, QI/Data Manager
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Meeting Outcomes
• Understand why and how to drill down data
• Learn how grantees are using drilled down data to achieve
high rates
• Learn interactive exercises to use for training your staff.
• Consider processes for continuous QI and sustaining
drilled down process (if time)
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Agenda
3:00
3:10
3:25
4:05
4:15
4:20
4:30
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Welcome and Introductions
Why and How to Drill Down Data
Grantee Examples
Training exercises
CQI and Sustaining Drilled Down Process
Q&A
Evaluation
Adjourn! Thank you.
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Keep Our Eyes on the Goal!
The Hypothesis: Treatment IS Prevention
Comprehensive
Public Health
Approach
↑ Testing and
Treatment
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↓
Community
Viral Load
↓
HIV Incidence
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Can “Better Become Best?”
Results
What is Best? Is it 75% 85% 95%
100%
Process
What is the “Best” Continuous
Quality Improvement Process?
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Drilling Down Data
Why now?
• HRSA/HAB/NQC’s support and focus on quality management
for many years
• NHAS, Care Continuum, In+Care Campaign and RG/TA focus
on retention and VL suppression
• RW programs have improved and achieved relatively high rates
of retention and suppression
• RW programs now have the capacity to identify individual
patients not meeting their measures
• RW programs have multi disciplinary teams!
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The best care we know how
to give,
for every patient,
at every site,
every day.
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Quality Improvement
Designing a System for the Most at Risk
Fundamental Concept of Improvement:
“Every system is perfectly designed to achieve exactly the
results it achieves”
What system can be designed to achieve continuous
improvement for most at risk patients - the few?
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Principles of Improvement
Same Principles, applied to the few:
•Understand work in terms of processes and systems
•Develop solutions by teams of providers and patients
•Focus on patient needs – individual and subpopulation
•Test and measure effects of changes, trend data
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Model for Improvement (MFI)
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How to Drill Down Data
Who are the 20%? How To Find Out?
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What is Drilling Down the Data?
It is a process of analyzing your patient care data
in increasing detail to understand who is meeting
performance measures and who is not
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Why Drill Down the Data?
 Helps identify barriers to care
 Helps look beyond the numbers
 Helps identify areas for improvement
 Encourages involvement from all
clinic team members
 Helps to improve care in the clinic
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Prioritization Strategies
Viral Load
15
Barrier
# of Patients
Average VL
Transportation
10
290
Unstable Housing
4
1,580
Insurance
1
74
Disclosure Issues
13
5,439
Refuses Tx
1
30,982
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Prioritization Strategies
Key Populations
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Key Population
Barrier
# of Patients
Men Who Have Sex
with Men
Transportation
4
Unstable Housing
6
Insurance
1
Disclosure Issues
11
Refuses Treatment
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Four Steps to Drilling Down the Data
1. Develop a list of patients who do not meet the
defined criteria of your measure
2. Identify reasons each patient does not meet the
criteria
3. Tally the reasons
4. Develop targeted follow-up plans to address the
most common or relevant issues
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Step 1: Develop a List of Patients
Example: Patients not retained in care:
1. Compile a list of patients who have not been seen during
the time period used to define retention.
2. Remove those from the list who meet the exclusion
criteria
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1,008 
100
Total Pt Case
Load
Pts not RIC

16
Excluded

84
Remaining to drill down
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Step 2: Identify Reasons
1. Conduct an assessment of the factors causing an absence
from care
2. Use a multidisciplinary team to review all available
information from patient records to identify any barriers to
care
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Step 3: Tally the Reasons
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Barrier
# of Patients = 84
Transportation
14
Unstable Housing
16
Insurance
10
Disclosure Issues
15
Refuses Tx
3
Lack of Child Care
8
Active Substance Use
10
Clinic Hours
6
Language Barrier
2
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Step 4: Develop a Targeted Follow-Up Plan
1.
Using data from steps 2 and 3, identify that are most critical to patient
health and that affect most patients
2.
Develop a plan to address these issues
3.
Consider prioritizing your follow-up by examining the needs of key
populations or by
looking at the health indicators
such as average viral load
4.
Report out the progress/status of
patients at multidisciplinary team
meetings
5. Document.
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Benefits
1. Your clinic will be able to serve those most in need by
tailoring activities to best meet those needs
2. Your clinic will be more likely to achieve improvement
3. Your clinic can target resources more wisely
4. Foster ongoing relationships with patients by meeting their
needs
5. Improve overall engagement in care
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Questions on How To Drill Down Data
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Grantee Examples – Lightning Rounds!
• What did we learn?
• What tools and tips can
we share?
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Categories for Data Collection, Aggregating and
Reporting Data
• Greater Chicago QM Group – Kelly Sellers, Howard
Brown Health Center
•
•
•
•
•
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Process for determining categories
Example of spreadsheet
Examples of individual agency data
Aggregated data
Individualized intervention
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GCQM Group Categories with Sample Data
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Site 2: Chicago Department of Public Health
(n=41)
CDPH- Barriers to VL Suppression
0
2
4
6
Number of Patients
8
10
12
14
16
Other
20
44%
Mental health/ depression
34%
Lost to follow-up
29%
Prescribed, not taking meds
17%
Patient's choice- refuse medication, no prescription
12%
Newly on meds/ preparing to start (within 6 mos)
12%
Substance abuse
10%
Housing instability/ homelessness
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18
7%
Lapse in insurance/ benefits (ADAP, Medicaid, marketplace, etc.)
5%
Transferred
5%
Ineffective regimen (resistance, other)
2%
Co-morbidities (cancer, diabetes, high blood pressure)
2%
Newly enrolled*
0
Deceased
0
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Site 4: Howard Brown Health Center
(n=50)
HBHC- Barriers to VL Suppression
0
5
Number of Patients
10
15
20
Newly on meds/ preparing to start (within 6 mos)
40%
Mental health/ depression
40%
Other
38%
Lapse in insurance/ benefits (ADAP, Medicaid, marketplace, etc.)
34%
Newly enrolled*
26%
Prescribed, not taking meds
26%
Substance abuse
20%
Lost to follow-up
18%
Co-morbidities (cancer, diabetes, high blood pressure)
16%
Housing instability/ homelessness
16%
Transferred
16%
Patient's choice- refuse medication, no prescription
8%
Deceased
Ineffective regimen (resistance, other)
29
25
2%
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Aggregate Regional Data
(n=194)
Regional Data- Barriers to VL Suppression
Prescribed, not taking meds
31%
Mental health/ depression
28%
Lost to follow-up
26%
Other
26%
Lapse in insurance/ benefits (ADAP, Medicaid, marketplace, etc.)
23%
Newly enrolled*
19%
Newly on meds/ preparing to start (within 6 mos)
18%
Substance abuse
15%
Co-morbidities (cancer, diabetes, high blood pressure)
14%
Housing instability/ homelessness
11%
Patient's choice- refuse medication, no prescription
7%
Transferred
6%
Ineffective regimen (resistance, other)
2%
Deceased
1%
0
10
20
30
40
50
60
70
Number of Patients
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Regional Barriers & Demographics
Prescribed, Not Taking Meds by Race & Gender
2%
Black or African American Female
5%
3%
20%
Black or African American Male
Black or African American Transgender Female (M-F)
10%
Multiple Male
5%
Not Specified Male
2%
Other Male
3%
Unknown Male
3%
Unknown Transgender Female (M-F)
White Female
47%
White Male
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Regional Barriers & Demographics
Mental Health/Depression by Race
4% 2%
27%
Asian or Pacific Islander
Black or African American
Not Specified
Unknown
51%
White
Other
14%
2%
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Regional Barriers & Demographics
Lost to Follow-up by Race
6%
18%
Black or African American
Multiple
Other
4%
Unknown
4%
White
68%
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Heartland Health Outreach
Viral Load Suppression-Checklist Intervention
QI Project Results
•
Baseline 2012: 65% Suppression Rate
•
*Data was cleaned in 2013 which contributed to
increase from 65% to 75%.
•
Improvement Goal:
•
To increase the number of participants who with viral load
suppression (<200 copies/ml) to 85% by August 2014
•
Interventions: Targeted to specific needs of patients; listed
on checklist (Adherence Counseling, weekly pillboxes, and DOT
(Direct
Observation Therapy) were the
interventions most frequently used.
•
•
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Measures: QI Project - % of patients with targeted
intervention; % w decreasing VLs; % suppressed
Total Patients with
targeted intervention
20
1 died
19
5 did not return
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Received targeted
Interventions
14
% Decreasing VLs
100%
Patient Population Results – 78%
Documented on an Excel Spreadsheet
•
Plan:
Case Managers used the checklist with participants
that had VL <200 copies. One Case Manager used the checklist
•
with all of his patients. Clinic Medical Providers were
kept abreast of interventions during weekly multidisciplinary
meetings.
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Paper Checklist
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Tracking Interventions based on Checklist
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E PA QM Regional Group
• Family First Health Center- Shannon McElroy
• Pinnacle Health Services – Rebecca Geiser
• St. Luke’s Health Care Network - Katey Rupert
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Family First Health – Retention Project
2-Year Project
Measure

Initial
8/1/14
Goal
6/19/15
Medical Visit Frequency
64.5%
75%
75%
Viral Load Suppression
83.4%
85%
88%



Out of care list
decrease
50%

Drilled Down Categories

Race
Ethnicity
Age
Poverty
Provider
Risk
Gender
Location

Data Findings
•There were no significant disparities in any of
the data except for poverty level
•Approximately 75% of those clients who were
considered “out of care” were under 100% of
poverty
•This became the initial group of focus for ARTAS
implementation
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Policy, Process, Tool Changes
Refills – the committee decided on a limit of 5 months
of medication refills to entice clients to come in for their
6 month follow-up
Lab work – the committee decided that no refills
should be given if lab work was not completed
Pocket calendars for clients to write down their appts.
Over 50 calendars have been given and more ordered
for 2016-2017 (we are not tracking who they are given
to or when they are given)
Review “out of care” client list quarterly at provider
meetings and provide dual outreach (case manager
and Linkage to Care Coordinator) to clients out of care
Weekly huddles to discuss all clients who are
scheduled for a visit
Utilize DOH field staff as needed if a client cannot be
found
ARTAS:
•
ARTAS was implemented in December 2014 by
the Linkage to Care Coordinator
•
12 clients have been enrolled, and 11 clients
have completed the program by attending a
medical appointment
•
Of those 11 clients, 10 agreed to continue with
case management
•
We are currently in a recruitment phase for
ARTAS
Next Steps:
1. Project will continue through fy16
2. Then, sustained!
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Viral Load Suppression Rate
Patients not virally suppressed: 53 as of May 31, 2015
• Previous interventions: financial counseling, appointment monitoring, case management, social work
services
• GAP: No intervention for those lost to care and unreachable by phone or mail
• New interventions: ARTAS and clinic-based treatment adherence
Reason not
virally
suppressed
Number of
patients
Intervention
Lost to care
27
Outreach and
ARTAS
Retained,
prescribed
ART, but not
adherent
20
Clinic-based
treatment
adherence
New patients
6
Routine clinical
care
**14 new patients since February 2015
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In+Care: Medical Visit Frequency
Percentage (%)
Medical Visit Frequency
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
ARTAS
6-month no visit
review
Start of
Consistent
messaging
5-month no
visit review
4-month no
visit review
Month
Interventions Overview:
•Monthly case review
•
Patients without visit in 6 months
•
Added 4 (Dec ‘14) and 5 months (May ‘14) to monitor upcoming
patients
•Assign clinic and case management team members to contact patients to get
back into care
•ARTAS (evidence-based linkage & retention intervention; used primarily for
new patients)
•Consistent messaging
•
Expanded retention counseling to other team member
(Behavioral Health consultant, case management,
prevention staff (ARTAS))
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In+Care: Medical Visit Frequency
-
Implementing same retention
interventions tested in Bethlehem
-
Medical visit frequency measure not
populated yet (clinic opened 1 year,
measurement period of 2 years)
-
•
Monthly case review data shown below,
comparable to Bethlehem
Sustainability:
-
Maintaining interventions tested
-
Medical visit frequency measure
maintained at/around 90% since August
2014
-
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Easton site (new as of April 2014):
No visit in 6-month (chart below)
Low number of patients on
monthly case review each month
compared to beginning of
project; sustaining decrease for
approximately 1 year
No Visit in 6-months "FBI List"
# of patients
•
14
12
10
8
6
4
2
0
Start of
Project
Month
Bethlehem
Easton
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In+Care: Viral Load Suppression
Brief Review:
•
1. Form a QI team to specifically address VLS
•
2. Utilize CAREWare to identify non-suppressed patients
•
3. Team creates a Fishbone diagram, Driver diagram to
identify barriers to viral load suppression
•
4. Team categorizes patients by barriers to identify which
barriers impact VLS the most
•
5. Interventions tested with a PDSA for 5 of the largest
barriers to VLS
•
6. Consumers recruited and are actively involved with the
PDSA interventions (patient involvement via interviews
regarding perceived barriers to VLS)
VLS Rates During QI Project
End of
Project
95%
Percentage (%)
•
90%
85%
80%
75% Start of
70%
Cycle 2
Began
Project
Date
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In+Care: Viral Load Suppression
Viral Load Suppression Trend Data
Date
Cycle 1 Interventions:
Cycle 2 Interventions:
1.
1. Evaluating environmental
stressors
2. Follow up on patients new to
HAART
3. Mental Health Barrier
4. Health Literacy Assessment
5. Improved patient
communication
2.
3.
4.
5.
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Faster data entry into
CAREWare
Follow up on patients new to
HAART
Mental Health Barrier
Insurance Barrier
Improved communication
between patients and staff
Oct-15
Jun-15
Feb-15
Oct-14
Jun-14
Project
Easton
Jun-12
70%
Bethlehem
Oct-13
75% Start of
Cycle 2
Began
Feb-14
80%
Jun-13
85%
Feb-13
Percentage (%)
90%
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
Oct-12
End of
Projec
t
95%
Percentage (%)
VLS Rates During QI Project
Month
Data above highlights trend data from start of 2-year
project (Jun‘13-Apr‘15)
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MA Statewide QM Group
• Holyoke Health Center
• Adrianne Jiles
• Greater New Bedford CHC
• Paul Cassidy – Sustaining processes
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Holyoke HC - 2015 Average Viral Load
Jan 85%.....................................................................................Aug 89%
166/195
162/183
40,000
38,301
-2 pts
-2 pts
35,000
-2 pts
31,872
32,888
+2 pts
-2 pts
26,658
26,335
38,029
32,350
+2 pts
30,986
30,000
+3 pts
+6 pts
+3 pts
27,780
-3 pts
+2 pts
-3 pts
29,516
29,197
28,338
30,196
-4 pts
26,533
Average Viral Load (copies/mL)
25,000
20,000
15,000
10,000
5,000
0
Beginning
End
January
n=31
Beginning
End
February
n=29
Beginning
End
March
n= 30
Beginning
End
April
n= 29
Key:
"-" Patients
46 that had an undetectable viral load (<200 copies/mL) when labs were updated during the month
Month
"+" Patients that were new to the detectable viral load list for the month
Beginning
End
May
n= 31
Beginning
End
June
n= 30
Beginning
End
July
n= 27
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Targeted Individual Interventions
• Appointment reminder calls
• Reminder calls for updated labs
• Adherence counseling- Setting medication reminder alarms on
phone
• Appointments with ID Providers
• Testing Med Resistance
• Changing Medications
• Appointments with Medical Case Managers
• Visiting nurse
Hopeful Intervention
• Adherence Counselor Referral
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Mississippi Statewide
QM Group
Process and Interventions
*Pro. Coordinator-Print list of clients not suppressed
*NP and Pro. Coordinator- review list, compare to lab results,
start HART
*SW/Case Manager- reminder calls for apt, arrange
transportation to apt, pharmacy verification of pick up
*Data Clerk –Check data for errors (deceased, transferred, labs
incomplete, etc.)
*NP, RN Case Manager, SW Case Manager, Pro. Coordinator
provide ongoing adherence education , address barriers, etc.
(pamphlets, teach back tools, pill planners, transport to local
pharmacy, switch to mail order)
NEXT STEP
This project will be ongoing because of positive results. It will continue to be monitored and
individual interventions will be implemented as needed.
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Challenges
• Requires a higher degree of
commitment
• This is not “low hanging fruit”
work
• Need to mobilize clinic team
• Care structures differ
• Coordination of efforts
• Measurement of interventions
can be tricky
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Benefits
• Patient-centered
• Commitment of team; know
patients on list really well
• Provider interest especially with
VL suppression
• Effective use of Multi
Disciplinary Teams to reach most
at risk patients
• Reduced VL in the community
• Reduction of “burden” over time
• Can be sustained!
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Training Exercise
Picture this…
Your table represents a
multidisciplinary team reviewing a
list of clients who are not
suppressed. Each of you will provide
feedback for one client at a time to
identify their primary barrier to care,
adherence, and ultimately viral
suppression.
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Drilling Down Your Data
• We will pass around bags of Skittles.
• Take a small handful for your cup.
• Don’t eat them… yet!
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Your table represents a MULTIDISCIPLINARY TEAM, each of you representing
a different discipline. One person has to be the note taker as well.
As a team you will review a list of 30 clients and provide feedback as to
why each client is not virally suppressed.
You will take turns providing input, one client each, around and around the
table until all clients have an identified barrier. You will draw a skittle from your
cup and the color will determine the barrier.
After you have identified the barriers to suppression for all 30 clients, as a team you will
suggest interventions to try for each client. You may list more than one per client.
Lost to Care
>180 Days
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Prescribed,
but not
taking meds
Transportation
Newly
Diagnosed
Mental
Health/
Depression
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Time for Reflection
Debrief
• Report out thoughts on the exercise
• Share your experience of the process
•
•
•
•
Did this exercise help you better understand drilling down data?
What hit home?
What missed the mark?
How will you take what you learned back to your team?
• How could we improve this activity?
• Would this activity be useful in future training with your teams?
Consumer groups?
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Sustaining Drilled Down Process and
Improvement
• Develop a process diagram
• Track interventions and results
• Process or interim measures
• Outcome measures
• Agencies Process Diagrams
• Pinnacle Health
• Greater New Bedford CHC
• Arnot Ogden Medical Center – Ivy Clinic
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GNBCHC
Outcome Measures: Results
Performance Measures: Percentage of patients regardless of age with a
diagnosis of HIV/AIDS with a viral load <200 copies/ml at last viral load test
during the measurement year.
Interventions: Adherence Nurse – extend time for not suppressed patients;
outreach workers finding clients not suppressed, social workers; HIV physician
reviewing patient list for medications, resistance, and reinforcing importance of
adherence.
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73%
76%
80.5%
84%
85%
Baseline
2011
May 2012
3-month
follow up
6-month
follow up
18-month
follow up
Sustained
through
October
2014
Sustained
through
August
2015
Flowcharts
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Monthly MULTI DISCIPLINARY MTGS – Process to Manage Patients <200 VL
RE- START WEEKLY MTGS-3/MONTH
•REVIEW PATIENTS
•TAKE NOTES
•DEVELOP CARE PLAN TEMPLATE
•DEVELOP PATIENT SPECIFIC CARE PLANS
•TEAM MAKES RECOMMENDATIONS
•ASSIGNED STAFF PRESENT PLAN TO PATIENT
FOR PATIENT INPUT
•FOLLOW –UP ON RECCOMENDATIONS
•INTERVENTION IS INDIVIDUALIZED
Prepare
Reports
Identifying
Patients Not
Suppressed.
RN INTERVENTION
•DEVELOP AND IMPLEMENT
CARE PLAN
•FOLLOW -UP
***
BARRIERS TO VIRAL LOAD SUPRESSION
•SUBSTANCE ABUSE
•HOMELESSNESS
•NOT ATTENDING APPOINTMENTS
•MENTAL HEALTH ISSUES
•REFUSE MEDICATIONS
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DATA
ENTRY
SOCIAL WORK
INTERVENTION
•FOLLOW-UP ON PLAN
•Increase visit to 45 min
for VL>200
SCHEDULED TEAM MEETINGSREVIEW RESULTS OF
INTERVENTIONS
# OF PATIENTS WITH VL >200
REVIEWED
# WITH TARGETED CARE PLANS
PATIENT RESPONSE TO
INTERVENTION
3+ years – BEST QI Process!
PEER NAVIGATOR
INTERVENTION
•FOLLOW –UP ON PLAN
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IVY Clinic - Arnot Ogden Medical Center Results
VL Suppression and Undetectable
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Arnot Ogden Medical Center – IVY Clinic – 4.5 years – BEST QI Process!
Collection of Data by QI Coordinator
(based on Excell spreadsheets, eMD and AIRS reporting)
Meeting of the Team (second Friday of
the month), review of the data
Patients on HAART with HIV viral load
over 100
Patients not seen in 6 months
Review most recent clinic and adherence
data for the client
Identify individual retention problems
Contact the patient with lab results
(NP)
□ Schedule f/u bloodwork
□ Schedule visit with NP to discuss
the lab results
□ Schedule appointment with
Treatment Adherence Counselor
CM follows up with the patient
CM follows up with CBO
□ Schedule medical appointment with the provider
□ Schedule case management review with CM (if
needed, to follow up on patient’s issues)
□ Review outcome of interventions at the end of the month.
□ Update viroload information and follow up on scheduled appointments
□ Review client’s chart in eMD for possible coordination of care needs.
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De-Brief
• What ideas can you test out with your team?
• Do the ideas need adapting? If so, in what way?
• How might you involve consumers?
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SUMMARY
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contacts
To order brochures:
Pamela Harris, OMD, 212-417-4553
Email: [email protected]
To download a copy of the brochure: URL:
http://www.hivguidelines.org/quality-ofcare/quality-improvement- resources/drillingdown-data-to-understand-barriers-to-care/
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Contacts
Nanette Brey Magnani, NQC Coach
[email protected]
Stephanie Hedgepeth, Clinical Quality Manager, MSDH
[email protected]
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Agencies Work Presented - Contacts
• EPA RG - Family First Health Center, St. Luke’s Healthcare Network
• Shannon McElroy, [email protected]
• Chelsea Shepherd, NP, Katey Ruppert, QI Coordinator [email protected],
[email protected]
• Greater Chicago QM Group – Access CHN, Christian CHC, CDPH-C Clinic, Howard Brown;
Heartland Health Outreach
• Kelly Sellers, CQI Analyst, HBHC, [email protected]
• Brandi Godbolt, Supervisor, [email protected]
• MA Statewide QM Group – Greater New Bedford CHC, Holyoke HC
• Paul Cassidy, Program Director, [email protected]
• Adrianne Jiles, Data Manager [email protected]
• Mississippi Statewide QM Group – Magnolia MC, MSDH
• Kawanis Collins, Program Director, SW, [email protected]
• Stephanie Hedgepeth, Clinical Quality Manager, MSDH
• NY Upstate LN, IVY Clinic, Arnot Ogden Medical Center, Ellmira, NY
• Anna Lechowska, QI/Data Manager, [email protected]
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To receive a copy of this presentation along
with the recording, contact
[email protected]
The recording can be accessed through the
following link:
https://meetny.webex.com/meetny/lsr.php?RCID=6383d694851b4810a80f9
977164f537b
Thank you all for attending!
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