Transcript Peak Vista Union Pilot Study Final

A Pilot Study of a Care Coordination
Model in a Community Health Center
Peak Vista Community Health Centers
September 16, 2015
Public Health in the Rockies
Peak Vista Community Health Centers
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Federally Qualified Health Center
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History/Current
 43 Years In Colorado Springs
 82,000 patients
 700 staff
 26 locations
Patients
 Low income, underserved
 No patient denied care
 Substantial Medicaid population (68%)
 Medicare (10%)
 Uninsured (15%) Private Insurance (5%)
Current Challenges
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Payment Reform
Very little specific information (no clear
timeline/model) but it’s coming!
 Move from Fee for Service to Pay for Performance
 Team Based, Coordinated Care
 Better Outcomes
 Greater Patient Satisfaction
 Reduction of Cost of Care
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Current Challenges
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Paradigm Shift
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Public Health Aspects
 Population Health
 Research, Data Analysis (Epis)
 Identifying Risk Factors/Upstream
(Determinants)
 Prevention
 Improved Collaboration (Programs, Services)
 Especially with local Health Departments
Planning & Implementation
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Create a Pilot Program in One Clinical Setting
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Coordinated Care Teams
 Care Group approach to improving outcomes
 Less Reliance on Provider (Physician, Mid-Level)
 Larger role for Nurses
 Inclusion of Resource Navigator, Pharmacist
Less Emphasis on Encounter Rate, More on Outcomes
Population Health Focus
Population Health Study
 Ultimately will Inform Upstreaming Initiatives
Purpose/Goals
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Test the feasibility of care coordination in our clinics
Improve the health outcomes of our patients
Create effective collaboration among the care team
Increase efficiency in the clinic
Reduce the number of unnecessary appointments
Encourage patients to be actively engaged in their
healthcare
Improve the patient experience
Study Design
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Longitudinal
Observational
Combined retrospective/prospective
approach
Retrospective chart review
 Used previous 1-year period to define our study
population and establish baseline measures
 Follow group for 6 months to 1 year
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Setting
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Union clinic
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Location
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Providers
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Near downtown Colorado Springs
3 physicians/2 mid-levels
Patients
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Panel of 5106 patients
714 Diabetics
Sample Selection
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Inclusion/Exclusion criteria
Patients assigned to a Union provider
 Appointment within last year
 <80 years old
 Diabetic patients (ICD-9 code 250.0-250.93)
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Total patients in study- 5051
Total diabetics in study- 691
Program/Intervention
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Implementation of care coordination model
Pre-visit planning
 Communication/sharing knowledge
 Medication management
 Assessing patient needs and goals
 Monitoring and follow-up
 Helping with transitions of care
 Linking to community resources
 Population health management
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Data Collection
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Data collected from routine office visits
Entered into EHR system by care team
Baseline data
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Most recent clinical measures of patients seen
within 1 year prior to start of study
Follow-up data
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Collect data at 6 months, 1 year
Clinical Quality Measures
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Diabetics
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A1c
Weight/BMI
Adherence to medications (Statins, ACE Inhibitors, ARB)
Microalbumin
Fasting lipid profile/LDL
Foot exam/Eye exam
All patients
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Screenings (Mammogram, colonoscopy, pap smear)
Vaccinations (Flu, Pneumonia, Tetanus)
Smoking status/tobacco counseling
Number of office visits
Data Analysis
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Compare clinical measures from baseline
and end of study
 All
patients- preventive services
 Diabetics
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Compare patient outcomes among
diabetic risk groups
 Uncontrolled vs controlled
Anticipated Use of Study Results
Identify successes as well as opportunities
for improvement
 Streamline the care team daily workflow
 Evaluate population health management
capabilities
 Identify additional clinical measures of
interest
 Expand care coordination to other clinics
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Challenges
Identifying and Selecting Leadership
 Understanding of the Goal
 Trust
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 Of
Leadership
 In Each Other’s Abilities
Challenges
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Culture Change
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Provider/Team Training – Let it Go
Patient Centered
 Patient Needs
 Be where the patient is
 Motivational Interviewing
Everyone’s Opinion is Important
Top of License
Prevention vs. Current Condition (Upstream)
Understanding Population Health
Willingness to Try – Failure or Success Acceptable