Title: Using Quantitative Data to focus Medical Home Facilitation Interventions in the Massachusetts Patient Centered Medical Home Initiative (MA PCMHI)

1. Using Quantitative Data for Medical
Home Facilitation in the Massachusetts
Patient Centered Medical Home
Initiative (MA PCMHI)
Sai Cherala, M.D., M.P.H.
Joan Johnston, R.N., C.I.H., C.P.E.
Jaime Vallejos, M.D., M.P.H.
Judith Steinberg, M.D., M.P.H.
Christine Johnson, Ph.D.
Commonwealth Medicine
UMass Medical School

2. Presenter Disclosures
(1) The following personal financial relationships with
commercial interests relevant to this presentation
existed during the past 12 months:
Sai Cherala
“No relationships to disclose”

3. Introduction
 The Patient‐Centered Medical Home (PCMH) offers an
innovative model of care: comprehensive primary
care, quality improvement, care management, and
enhanced access in a patient centered environment
Objective:
 To evaluate how targeted practice facilitation has
improved clinical performance in a PCMH
demonstration

4. Background: Massachusetts Patient
Centered Medical Home Initiative
 Multi-payer, statewide initiative
 Sponsored by Massachusetts Health & Human Services;
legislatively mandated
 46 participating practices
 3-year demonstration: March, 2011 − March, 2014
 Includes payment reform and technical assistance

5. Technical Assistance: Massachusetts
Patient Centered Medical Home Initiative
 Three‐year Learning Collaborative
• Periodic Learning Sessions
• Monthly conference calls or webinars
• Online courses
• Monthly submission and review of practice‐level
performance data
• Support for obtaining NCQA PCMH recognition
 Practice Facilitation

6. Clinical Quality Measures
Adult Diabetes
 HbgA1c Control (<8%)
 HbgA1c Control (>9%)
 BP < 140/90 mmHg
 LDL Control < 100mg/dL
 Screened for Depression
 Self-Management Goal
Adult Prevention
 Adult Weight Screening and
Follow-up
 Tobacco Use Assessment
 Tobacco Cessation Intervention
Other Adult Target
 Blood Pressure Control
 Hypertension with Documented
Self-Management Goal
 Depression with Documented
PHQ-9 Score
 Depression with Documented Self-
Management Goal
Childhood Prevention
 Immunization Status Multiple
vaccines
 Weight Assessment and Counseling
for Children and Adolescents
Pediatric Asthma
 Use of Appropriate Medications for
Asthma
 Persistent Asthma Patients with
Action Plan
Other Pediatric Target
 Follow-up Care for Children
Prescribed ADHD Medication
 Management Plan for Children
Prescribed ADHD Medication
Care Coordination/ Care Management
 Follow-up after Hospital Discharge
 Highest Risk Patients with Care Plan
Operations
 Continuity of Care

7. Clinical Quality Measures that Showed Significant
Improvement in Change over Time
25.2 23.8
37.1
82.4
46.5
16.7 17.3
11.5
18.6
46.4
22.3
36.1
48.7
32.0
47.6
90.5
51.3
25.3
21.4
19.3
62.7 63.1
61.2
64.7
0
10
20
30
40
50
60
70
80
90
100
Screened for
Depression
Self-
Management
Goal
Adult Weight
Screening &
Follow-Up
Tobacco Use
Assessment
Tobacco
Cessation
Intervention
Hypertension
Self-
Management
Goal
Depression
PHQ-9 Score
Depression
Self-
Management
Goal
Patients With
Action Plan
Immunization
Status
Multiple
Vaccines 1
Immunization
Status
Multiple
Vaccines 2
Care Plans for
Highest Risk
Patients
Percent
Baseline Time 11
11 of 22 measures showed statistically significant improvement
Adult Diabetes Adult Prevention Other Adult Measures Pediatric
Asthma
Childhood
Prevention
Care
Management

8. Targeted Medical Home Facilitation:
Approach
 Underperforming practices were targeted for facilitation follow-
up
 Intervention focused on the performance on certain measures
and which also included the implementation of key
components of the PCMH
 Started in the year 3 of the intervention
 Customized interventions were developed and delivered by
three practice facilitators over a six-month period
 Following the targeted facilitation, practices were assessed for
the impact of the targeted facilitation on the performance of
measure

9. Targeted Medical Home Facilitation:
Focus
 On aggregate analysis, we identified five measures
with a trend toward improvement from baseline.
• Screening for depression for adults
• Tobacco cessation counseling for adults who have been
identified as smokers;
• Self-management goals for adult diabetics,
• Use of appropriate medications for pediatric patients with
persistent asthma; and
• Follow-up after hospital discharge.

10. Targeted Medical Home Facilitation:
Methods
 Analysis: Using ANOVA, we analyzed the individual practice
contribution to the aggregate for each of these measures.
 Interventions: Facilitators used a wide array of tools
including: practice-wide assessments, PCMH team based
care workflows, Lean trainings and online courses.
 Variables included: Change in clinical performance over
the demonstration
 Data sources: Clinical data submission, practice-wide
assessments, facilitators interviews

11. Targeted Medical Home Facilitation:
Results
For measures marked * Baseline is Time 6
23.8 25.7 26.0
29.4 31.1 32.0
46.5
41.2
47.7
44.5 44.1
46.8
49.9 48.9 49.7 50.1 51.3
17.3 16.7
19.7
22.7 22.8 21.4
0
10
20
30
40
50
60
Time 1 Time 2 Time 3 Time 4 Time 5 Time 6 Time 7 Time 8 Time 9 Time 10 Time 11
Rate
Self-Management Goal for Adult Diabetics*
Tobacco Cessation Counseling for Adult with History of Smoking
Screening for Depression for Adults*
Intervention Started
3 out of 5 measures of focus showed significant improvement

12. Targeted Medical Home Facilitation:
Results II

13. Targeted Medical Home Facilitation:
Lessons Learned
 Develop infrastructure and procedures that support effective
use of data monitoring through training, introduction of
dashboards, and other resources
Assessing the practice and providing regular performance feedback
and using this data to inform QI
 Building the internal capacity of a practice to engage in data-
driven change
Provide training to the practice staff and providers on QI methods
and strategies
 Adapting EMR functionality for QI
Provide technical assistance in specific areas, such as registry
development for implementing team-based care and other
foundational elements of PCMH

14.  Quality Improvement Study
 Multiple Interventions
 Length of time
Limitations

15.  At the close of the MA PCMHI initiative (3 years),
11 of 22 clinical measures showed statistically
significant improvement
 Measures that showed significant improvement:
 Process measures
 New or newly documented processes
 Targeted practice facilitation, informed by analysis
of practice level and aggregate clinical quality data,
may be effective in promoting achievement of
practice and initiative goals in PCMH
implementation
Summary

16. Conclusions
 Quality of care in the management of chronic
diseases, prevention and screening, and high risk care
management was significantly improved in this PCMH
demonstration
 Supporting practices in developing a QI infrastructure
and skillset is a foundational element of the building
of the medical home that facilitates overall change
 Practice transformation takes time

17. Acknowledgments
We would like to acknowledge the Massachusetts Executive Office of
Health and Human Services (EOHHS), the MA PCMHI Leadership and
Medical Home Facilitator Teams, as well as MA PCMHI participating
practices without whom this work would not be possible.
Contact Information:
Sai Cherala, M.D., M.P.H.
Assistant Professor
Senior Clinical Analyst
Commonwealth Medicine
UMass Medical School
Sai.Cherala@umassmed.edu