PROJECT ADVISORY COMMITTEE (PAC) - Suffolk Care pdf slides without... · 26-09-2017 · PROJECT ADVISORY COMMITTEE (PAC) Tuesday, September 26, 2017 9:00am-12:00pm Hyatt Regency

PROJECT ADVISORY COMMITTEE (PAC)

Tuesday, September 26, 2017

9:00am-12:00pm

Hyatt Regency Long Island

Hosted by the Office of Population Health at Stony Brook Medicine

WELCOME REMARKS

Presented by

Linda S. Efferen, MD, MBA

Interim Chief of Operations

VP, Medical Director

Suffolk Care Collaborative

MEETING AGENDA

9:00 am – 9:10 am Welcome Remarks


Interim Chief Operating Officer &

VP Medical Director,


9:10 am – 10:25 amThe "Spirit" of Motivational Interviewing: Best

Practices to Support Self-Management

Damara Gutnick, MD

Medical Director,

Montefiore Hudson Valley Collaborative

10:25 am – 10:35 am Break

10:35 am – 11:20 amThe NYS Smokers' Quitline: Motivating Tobacco

Users to Become and Stay Tobacco Free

Patricia Bax, RN, MS, TTS, CC

Marketing and Outreach Coordinator,

New York State Smokers' Quitline and Roswell Park

Cessation Services

11:20 am –11:40 amUsing Education to Empower Patients to Manage

Chronic Diseases

Jessica Schreck, RD, CDN

Family Health and Diabetes Educator,

Cornell Cooperative Extension

Leslie Vicale, MPH

Project Manager, Clinical Improvement Strategy, Suffolk Care

Collaborative

11:40 am – 11:55 amAligning Patient Engagement Interventions

And Performance Metrics

Kevin Bozza, MPA, FACHE, CPHQ, RHIT

Vice President, Population Health Management Services

11:55 am – 12:00 pmClosing Remarks

Question & Answers


Interim Chief Operating Officer &

VP Medical Director,


Source: NYC Health and Hospitals Corporation

DSRIP PPS PROGRESS UPDATE

MY2 STATEWIDE RESULTS

POTENTIALLY PREVENTABLE READMISSIONS

MY2 STATEWIDE RESULTS

POTENTIALLY PREVENTABLE EMERGENCY ROOM

VISITS

Suffolk Care Collaborative PAC Meeting

THE “SPIRIT” OF MOTIVATIONAL INTERVIEWING:

BEST PRACTICES TO SUPPORT SELF

MANAGEMENT Damara Gutnick, MD

Medical Director, Montefiore Hudson Valley Collaborative

September 26, 2017

THE NYS SMOKERS' QUITLINE:

MOTIVATING TOBACCO USERS

TO BECOME AND STAY

TOBACCO FREE

Patricia Bax, RN, MS, CC, TTS

September 26, 2017

Agenda

• Welcome

• Smoking Prevalence Data

• Roswell Park Cancer Institute and

Quitline Program Overview

• Historical View and Responding to Change

• Provider Referral Program

• Meet Annie

• Questions and Answers

• Conclusion

Think About a Time…

New York State Department of Health

Bureau of Tobacco Control

New York

Statewide Plan:

Vision: All New Yorkers living in a tobacco-free society.

Mission: To reduce disease, disability and death, and

alleviate the societal, health care system and economic

burdens tobacco use and secondhand smoke exposure

cause in New York State.

Historical View

That Was Then…• Quitline call volume heavily

driven by media

• Media tags promoted Quitline number

and FREE Nicotine Replacement Therapy

• Quitline provided choices of NRT

• Enhanced services for uninsured and Medicaid

tobacco users

• NYS funded 19 Cessation Centers to focus on

individual practice level provider training

That Was Then…Media

Primary Driving Forces

Affordable Care Act

Delivery System Reform Incentive

Payment (DSRIP) Program: reducing

avoidable hospital use 25% over 5 years

Performance Improvement Projects for

Medicaid Managed Care Plans

NYS DOH Bureau of Tobacco Control’s

emphasis on sustainability and health

systems change

Primary Driving Forces

Health Systems Transformation in New York State

Expansion of Medicaid Cessation Benefits

All 18 MMC plans cover all 7 FDA-approved meds for all

enrollees

2 meds can be prescribed at one time

(combination therapy)

Unlimited trials (formerly 2-90 day annual trial limits)

No pre-authorization (some co-pays remain)

Health Systems Change

CDC. Best Practices for Comprehensive Tobacco Control Programs — 2014. Atlanta, GA: US

Department of Health and Human Services, Centers for Disease Control and Prevention; 2014.

Institutionalizing tobacco cessation interventions

into routine clinical care in health care systems…

Goals are to ensure:

1. every patient is screened for tobacco use and

tobacco use status is documented

2. patients who use tobacco are advised to quit

and provided with options for evidence-based

treatments

Responding to a Changing

Environment: NYS DOH

This Is Now…

• Changes in national health care landscape

• NYS media messaging: “Talk to Your Provider”

• Promotion of Medicaid cessation benefits

• Transitioned from 19 Cessation Centers to 8 Health

Systems for a Tobacco-Free NY Contractors

• NYSSQL viewed as an ancillary health system

support: focus on health system changes

accordant with principles of

population-based policy interventions

Paradigm Shift in Messaging


Environment: NYSSQL

This Is Now…

• Moving away from relying on media for referrals

and call volume

• Supporting NYS media messaging:

“Talk to Your Provider” and “use your health

care plan benefits”

• Changing messaging and materials

• Increasing collaborations and partnerships to

create or enhance existing health systems

• Building sustainable policy-driven referral

systems


Environment: NYSSQL

This Is Now…

• Connecting participants to their health plan

cessation benefits

• Working directly with health plan staff to learn

more about access and benefits

• Serving as an adjunct to onsite cessation

interventions

• Emphasizing sustainability, evaluation and

quality improvement

Roswell Park Cancer Institute:

Tobacco Control Program

Over 60 years of local, state,

national and international work

Operates the Cancer Information

Services hotline, NYS AIDS Hotline,

and NYS Smokers’ Quitline

Contracted by Community Partners of WNY to

promote tobacco cessation among lower SES

populations and those with poor mental health

Skilled Team:

• Specially-trained Coaches

• Decades of experience

• Videographer

• Web and Digital Communications Specialist

• Data Management Specialists

Prior to the inception of RPCS, Roswell Park Cancer Institute

was the NYSSQL’s inaugural vendor in 1999.

In 2009, RPCS initiated vendor services for 2 health plans.

Presently, RPCS provides cessation services for 2 state

Quitlines, 5 health plans, and a multi-state large food market.

Roswell Park Cessation

Services

Quitline Services

• Cessation coaching

• Nicotine patches (phone and

online registration)

• Interactive and informational

website resources

• Text messaging services

• Social media

• Triage to known health plan

programs

• Provider patient referral services

• Best practice resources

• Liaison for NYS DOH BTC

Contractors

Referral Process

Opt-to-Quit™ Model

Adoption of a policy that

systematically identifies all

tobacco using patients.

As an adjunct to the Health

Site’s intervention, patients are

referred to the NYSSQL (unless

they opt out), then contacted

and offered NYSSQL services.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Characteristics of NYSSQL Callers in 2016

Education Insurance Income Mental Health

Reaching Disparate

Populations

Ready to Assist!

• Introductory conference calls

• Webinars

• Print and web information

• Consultation

• Collaboration

• Customized service

• Reports (access to NYSSQL Partner Site)

Meet Annie

Characteristics: 58 year old female

Smoked since she was 18,

usually 2-3 packs per day

Married with two children,

four grandchildren

Medicaid Managed Care Member

High school graduate

Recently diagnosed with COPD and advised by

her doctor to stop smoking

Prior quit attempts going cold turkey

Annie’s Provider Refers

Her to the Quitline!

Assessment

Motivation

Readiness to quit

Confidence level

Triggers

Quit Date: within 30 days

Quit Plan:

Stop-smoking medications

Coaching and support

Examples

“Tell me what you like about your smoking.”

“What makes you think it’s time for a change?”

“What happens when you use tobacco?”

“How were you able to be tobacco free for a

few months?”

“Tell me more about when this first began.”

“What was quitting like for you?”

“What’s different about quitting this time?”

Patients Not Ready To Make A Quit Attempt

Now: Enhancing Motivation to Quit

Patients not ready to make a quit attempt may

respond to a motivational intervention.

The clinician can motivate patients to consider a quit

attempt with the "5 R's": Relevance, Risks,

Rewards, Roadblocks,

and Repetition.

The "5 R's"

The "5 R's"

Relevance: Use facts to encourage

patient to indicate reasons quitting is

relevant (risk to my own health, risk

to my family and friend's health, etc.)

Risks: Ask patient to identify the

negative consequences of tobacco

use. Highlight most relevant: shortness

of breath, exacerbation of asthma,

harm to pregnancy, impotence, risk of

heart attack, cancer and stroke,

increased risk of health complications

for others.

The "5 R's"

Rewards: Ask tobacco user to identify potential benefits of quitting,

such as improves health, smell, taste, length of life, improves self

esteem, good example for kids, healthier babies, perform better

physically, reduced wrinkles, etc.

Roadblocks: Ask tobacco user to identify barriers or impediments

to quitting and note elements of treatment (problem solving,

pharmacotherapy) to address these barriers. Barriers might include

withdrawal symptoms, fear of failure, weight gain, lack of support,

depression, and enjoyment of tobacco.

Repeat: Repeat above motivational interventions as needed.

Internet Citation: Patients Not Ready To Make A Quit Attempt Now (The "5 R's"). Content last reviewed

December 2012. Agency for Healthcare Research and Quality, Rockville, MD.

http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/5rs.html

Keys to Success

Remember…

The Suffolk Care

Collaborative’s Learning Center

Together…

We Are Making a Difference!

Thank You!

Patricia Bax, RN, MS, CC, TTS

Marketing and Outreach Coordinator

NYS Smokers’ Quitline

Roswell Park Cessation Services

716-845-4365 [email protected]

mailto:[email protected]

USING EDUCATION TO EMPOWER PATIENTS TO MANAGE CHRONIC DISEASES

Presented by:


Family Health and Diabetes Educator,

Cornell Cooperative Extension

Leslie Vicale, MPH

Project Manager, Clinical Improvement Strategy,


Using Education to Empower Patients to Manage Chronic Disease


Cornell Cooperative Extension of Suffolk County

Challenges of Chronic DiseaseMillions of American struggle to live with and manage their health

• 80% of older adults live with one or more chronic disease

• Impacts quality of life

• NYS DOH: Suffolk County, 7.9% of population with diagnosed diabetes

Cost of Chronic Disease

• Greater than two-thirds of total healthcare costs

• In older adults 95% of costs are from chronic disease

• $245 billion in total costs of diagnosed diabetes in the United States in 2012

• ONLY 1% of healthcare dollars goes to prevention

What is Self- Management

• A tool for patients living with a chronic disease

• Caregivers

• Individual

• Group Classes

AADE Curriculums, Stanford CDSMP & DSMP, Outpatient Counseling (CDE/RD/RN)

Group vs. Individual

Classes

• Foster dialogues between participants

• Allow for more interactive activities

• Great for patient and caregivers/partners

• Creates support system

Counseling

• Allows for individual tailoring

• Good for learning disabled

• Can be done in house

• Encourages more personal disclosure

Goals• Monitoring

• Medication Compliance

• Stress Management

• Effective Communication

• Appropriate Exercise

• Meal planning/Nutrition

• Decision-Making

• Symptom Management

• Working with Healthcare Providers

Health Benefits

• Improved self-reported health

• Improved health status: fatigue, shortness of breath, depression, pain, stress, and sleep

• Improved health-related quality of life

• Improved communication with doctors, medication compliance, and health literacy

Cost Benefits- Stanford Study

As a translational research study by the National Study of CDSMP surveyed 1,170 community-dwelling CDSMP participants at baseline, 6 months, and 12 months from 22 organizations in 17 states.

• $714 per person savings in emergency room visits and hospital utilization

• $364 per person nets savings after accounting for program costs

• Potential savings of $6.6 billion by reaching 10% of Americans with one or more chronic disease

Better Choices, Better Health®

Self-Management Programs• Developed by Stanford University

• 2½ hours once a week for six weeks

• Community settings such as churches, community centers, libraries and hospitals

• Facilitated from a highly detailed manual by two trained leaders

• Classes are highly participative

• Mutual support and success build the participants’ confidence in their ability to manage their health and maintain active and fulfilling lives

Participant Letters

Questions ??

1 Centers for Disease Control and Prevention. Healthy Aging at a Glance 2011. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2011. 2 Lochner KA, Cox CS. Prevalence of Multiple Chronic Conditions Among Medicare Beneficiaries, United States, 2010. Prev Chronic Dis 2013. 3 Centers for Disease Control and Prevention. The State of Aging and Health in America 2013. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2013. 4 The State of Chronic Disease Prevention: Hearing Before the Committee on Health, Education, Labor, and Pensions. (6) 2011. 5 Ory, M. G., Ahn, S., Jiang L., Smith, M. L., Ritter, P., Whitelaw, N., & Lorig, K. (2013). Successes of a National Study of the Chronic Disease Self-Management Program: Meeting the Triple Aim of Health Care Reform. Medical Care, 51(11), 992-998.

Better Choices, Better Health® Workshop Series

• The focused population for the SCC DSRIP

programs are patients: o With a principle diagnosis of hypertension, hypercholesterolemia,

OR

o With a diabetes diagnosis, AND

o Insured by Medicaid, AND

o Age 18 and over

*Both workshop series are also open to non-Medicaid beneficiaries.

**CDSMP workshops are open to patients suffering from any chronic disease

HOW TO REFER A PATIENT

• Referrals can be made by providers, care managers, or by the patient

• Send a referral form to one of the partnered CBO’s

• Referral forms can be found on the SCC website: https://suffolkcare.org/forpartners/Self-Management-Education-Services/better-choices

• Call one of the partnered CBO’s

• Visit the workshop registration website: http://bit.ly/2xJTxi2

HOW TO REFER A PATIENT

https://suffolkcare.org/forpartners/Self-Management-Education-Services/better-choices

http://bit.ly/2xJTxi2

• Information about

patient workshop

completion will be

reported back to the

referring clinician.

Kansas Department of Health and Environment, Bureau of Health Promotion. (2016). Referral Toolkit: Tools for Better Health, Health Care Providers.

Topeka, KS.

REFERRAL FEEDBACK LOOP

ALIGNING PATIENT ENGAGEMENT INTERVENTIONS

AND PERFORMANCE METRICS

Kevin Bozza, MPA, FACHE, CPHQ, RHIT

Vice President, Population Health Management Services

• Highlight a subset of the DSRIP performance measures that may potentially be impacted through the patient engagement techniques and strategies described today

• As of Measurement Year 3 (MY3) all of these measures have flipped from Pay-for-Reporting (P4R) to Pay-for-Performance (P4P)

• Review current performance, opportunities for improvement and next steps

OVERVIEW

• Eight measures in the DSRIP program focus on

patients adhering to a medication regiment

• Measures are within the Chronic Disease and

Behavioral Health programs

MEDICATION ADHERENCE


ASTHMA

SCC ClinicalPrograms

Projects (# Measures)

Measures

Chronic Disease Asthma (3) • Asthma Medication Ratio (5-64 Years) – Ratio of controller medications to total asthma medications

• Medication Management (5-64 Years) – patients with persistent Asthma filled prescription for asthma controller during at least 50% of their treatment period; 75% of their treatment period


ASTHMA

Salient Data: MY3 Month 7 (February 1, 2016 – January 31, 2017)

As of January 31, 2017 (Month 7 of MY3), SCC is meeting the performance target for

2 of the 3 measures.


CARDIOVASCULAR DISEASE



Measures

Chronic Disease

Cardiovascular (2)

• Statin Therapy for patients with Cardiovascular Disease – Males age 21 to 75 or females age 40 to 75, who were dispensed at least one high or moderate intensity statin medication.

• Statin Therapy for Patients with Cardiovascular Disease – Males age 21 to 75 or females age 40 to 75, who achieved a proportion of days covered of 80% for the treatment period.


CARDIOVASCULAR DISEASE



1 of 2 measures.


BEHAVIORAL HEALTH



Measures

Behavioral Health 3ai (3) • Adherence to Antipsychotic Medications for People with Schizophrenia – People age 19 to 64 with schizophrenia dispensed at least 2 antipsychotic medications during the measurement year and remained on the antipsychotic medication for at least 80% of their treatment period.

• Antidepressant Medication Management -People 18 and older diagnosed with depression and treated with an antidepressant medication who remained on antidepressant medication during the entire 12-week acute treatment phase (Acute Phase); who remained on antidepressant medication for at least six months (Continuation Phase Treatment)


BEHAVIORAL HEALTH



1 of 3 measures.

• Two measures in the DSRIP program focus on

patients knowing their “numbers” to maintain

normal blood pressure and blood sugar levels

• Measures are within the Chronic Disease

Programs

• Both Measures are based on Medical Record

Abstraction

TEST RESULTS

TEST RESULTS

DIABETES/CARDIOVASCULAR DISEASE



Measures

Chronic Disease

Cardiovascular(1)

Diabetes (1)

• Controlling High Blood Pressure – The number of people, who have hypertension, and whose blood pressure was adequately controlled as follows: below 140/90 if age 18-59; below 140/90 if age 60 to 85 with diabetes diagnosis; or below 150/90 if age 60 to 85 without a diagnosis of diabetes.

• Comprehensive Diabetes Care – Hemoglobin HbA1c Poor control (>9.0%) – The number of people, 18 to 75, with diabetes whose most recent A1c indicated poor control, was missing or did not have a HbA1c.

TEST RESULTS

DIABETES/CARDIOVASCULAR DISEASE

MY2 established the baseline for the MY3 Performance target.

* Measurement Year 3 Medical Record Abstraction Process Is in Progress.

• Three measures in the DSRIP program focus on

smoking and tobacco use cessation

• Measures cross the Chronic Disease Programs

• All three measures are based on CG-CAHPS

survey responses

SMOKING AND TOBACCO USE CESSATION




Measures

Chronic Disease Cardiovascular/Diabetes (3)

• Medical Assistance with Smoking and Tobacco use Cessation o Advised to Quito Discussed Cessation Medicationo Discussed Cessation Strategies

In MY2, the SCC met the performance targets for 1 of the 3 measures.

* Measurement Year 3 CG-CAHPS surveys in progress.


• Measures cross the Chronic Disease Programs

• Both measures are based on CG-CAHPS

survey responses

ASPIRIN USE/FLU VACCINATIONS



Measures

Chronic Disease

Cardiovascular (1)

Cardiovascular/Diabetes (1)

• Aspirin Use – The number of respondents who are men, age 46 to 65, with at least one cardiovascular risk factor; men, age 66 to 79, regardless of risk factors; and women, age 56 to 79, with at least two cardiovascular risk factors who are currently taking aspirin daily or every other day.

• Flu Shots for Adults Age 18-64 – The number of respondents, age 18 to 64, who have had a flu shot.



In MY2, the SCC met the performance targets for 1 of the 2 measures.

* Measurement Year 3 CG-CAHPS surveys in progress.

• Deployed Corrective Action Planning Process Across the PPS o Distributed to Network HUBs August 11th for follow-up

o Focus on Gap-Closure Strategies via Managed Care Patient Portals and correcting patient panels

• Two Ambulatory PI Training Sessions ScheduledSeptember 12th and October 10th

• August Internal Program Management Meetings Focused on Performance Measures & Gap-Closure Strategieso Chronic Disease – Asthma Medication Ratio and potential coding

issues

o Behavioral Health Program – Medication adherence; performance improvement at the OASAS and PROS sites; Enhanced TOC Model

o Care Transitions Program – Discussing strategies to address PPRs/PPVs at our High Volume Hospitals

PLANS UNDERWAY

CLOSING REMARKS

80

Presented by


Interim Chief of Operations

VP, Medical Director


Documents

PROJECT ADVISORY COMMITTEE (PAC) - Suffolk Care pdf slides without... · 26-09-2017 · PROJECT ADVISORY COMMITTEE (PAC) Tuesday, September 26, 2017 9:00am-12:00pm Hyatt Regency