PCMH Dashboard Purpose: to help participating primary care practices evaluate their effectiveness and support improvements in: Access Patient Experience Provider and Staff Job Satisfaction Patient Self-Health Management Diabetes Management Screenings Diabetes Management Testing Outcomes Health Plan Utilization Measures: -Emergency Department Visits -Hospitalizations -Re-Hospitalizations -Prescription Generic Use
Authors: Carol Deibel Kyrsten Chambers
Patient-Centered Primary Care Collaborative of Central Ohio Patient-Centered Medical Home (PCMH) Improvement Dashboard February 2012
Why is This Being Done? The Patient‐Centered Medical Home Improvement Dashboard was developed as “a good place to start’ measuring quality improvement over time in participating primary care practices. Note: This Dashboard version provides baseline data from 2010. Future Dashboards will include data from 2011 and are planned to be released in May and November of 2012.
How is it Put Together? The Dashboard was created by the Patient‐Centered Primary Care Collaborative of Central Ohio, comprised of primary care teams, health plans, employers, and other strategic partners, working to improve patient‐centered primary care in Central Ohio, starting with the Patient‐Centered Medical Home model. Collection processes for each measurement were developed to respect the patient‐provider relationship and the practices’ needs: Patient Experience and Patient Self‐Health Management Surveys were administered through two mailings, which included personalized cover letters from the practice to the patients Provider and Staff Job Satisfaction surveys were completed on the jobsite through an online survey instrument Diabetes Management Screenings and Testing Outcomes were collected by external nurse consultants and through electronic record data pulls Access Measures were compiled by practice administrators’ completion of Provider Continuity of Care and Same Day Appointment Worksheets Utilization Measures were sourced from the following 5 health plans participating in the collaborative: Aetna, Anthem Blue Cross and Blue Shield, Medigold, The Ohio State University Health Plan and UnitedHealthcare.
What is Included?
Included in the February 2012 Improvement Dashboard Update is de‐identi ied data from 5 primary care sites participating in the Patient‐Centered Primary Care Collaborative of Central Ohio: American Health Network‐Hilliard
Mount Carmel Medical Group‐Pickerington
Central Ohio Primary Care‐Central Ohio Medicine
Village Family Medicine
Lower Lights Christian Health Center The ive primary care practice site Dashboards can be found on the following pages (presented in random order).
Table of Contents February 2012
1-8 PCMH Improvement Dashboard‐Site A
9-16 PCMH Improvement Dashboard‐Site B 17-24 PCMH Improvement Dashboard‐Site C 25-32 PCMH Improvement Dashboard‐Site D 33-40 PCMH Improvement Dashboard‐Site E
PCMH Dashboard Purpose: to help participating primary care practices evaluate their effectiveness and support improvements in: Access Patient Experience
Patient-Centered Primary Care Collaborative of Central Ohio
Provider and Staff Job Satisfaction
Patient-Centered Medical Home (PCMH) Improvement Dashboard Site A February 2012
Patient Self-Health Management Diabetes Management Screenings Diabetes Management Testing Outcomes Health Plan Utilization Measures: -Emergency Department Visits -Hospitalizations -Re-Hospitalizations -Prescription Generic Use
1
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site A
PCMH A: Access Measures
The Access measures utilized for this collection reflect the patients' ability to schedule a same day appointment at their Primary Care practice site and to schedule appointments with their personal primary care provider. Same Day Appointments and Continuity of Care data was sourced from practice records collected March-July 2011. Continuity of Care % of Patients seen by Personal Primary Care Provider
Same Day Appointments % of Schedule made Available 100.0%
100.0%
90.0%
90.0%
80.0%
80.0%
70.0%
70.0%
60.0%
60.0%
50.0%
50.0%
39.4%
40.0%
84.8%
81.5%
40.0% 30.0%
23.3%
30.0% 20.0%
20.0%
10.0%
10.0% 0.0%
0.0%
PCMH A
PCMH A
Average: Other 4 PCMHs
PCMH A: Patient Experience
Average: Other 4 PCMHs
Patient experience measures were collected through a survey that assesses patients' experiences with their primary care provider and office staff. The survey instrument used was obtained from the Agency for Healthcare Research and Quality (AHRQ): Clinician & Group Consumer Assessment of Healthcare Providers and Systems (CG CAHPS). https://www.cahps.ahrq.gov/content/products/CG/PROD_CG_CG40Products.asp?p=1021&s=213 Adult Patient Experience How often you are satisfied with: Patient/Doctor Communication
100%
100%
90%
90%
80%
80%
70%
70%
% of Respondents
% of Respondents
Adult Patient Experience How often you are satisfied with: Access to Care
60% 50% 40% 30%
60% 50% 40% 30%
20%
20%
10%
10%
0% Never
Almost Never
Sometimes
Usually
Almost Always
0% Never
Always
Almost Never
Sometimes
Usually
Almost Always
Always 79%
Patient/Doctor Communication
Access to care PCMH A
8%
4%
7%
15%
22%
44%
PCMH A
1%
0%
1%
6%
12%
Average: Other 4 PCMHs
10%
4%
9%
15%
23%
39%
Average: Other 4 PCMHs
1%
1%
3%
7%
15%
58%
National 50th %tile
National 50th %tile
73% 78%
Coordinated By:
2
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site A
PCMH A: Patient Experience Continued
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Patient Experience Overall Rating of Personal Doctor
% of Respondents
% of Respondents
Patient Experience Courteous and Helpful Office Staff
Never
Almost Never
PCMH A
1%
1%
Average: Other 4 PCMHs
1%
2%
Sometimes
Usually
Courteous and helpful office staff 4% 6% 6%
13%
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Almost Always
Always
21%
67%
PCMH A
1%
5-6 7-8 Overall rating of personal doctor 1% 2% 19%
20%
60%
Average: Other 4 PCMHs
1%
2%
70%
National 50th %tile
National 50th %tile
0-2
77%
19%
74%
Patient Experience Health Literacy 100%
90%
90%
80%
80%
70%
70%
% of Respondents
100%
% of Respondents
5%
9-10
76%
Patient Experience Follow up of Test Results
60% 50% 40% 30% 20%
60% 50% 40% 30% 20%
10% 0%
Never
Almost Never
PCMH A
7%
3%
Average: Other 4 PCMHs
7%
3%
National 50th %tile
3-4
Sometimes
Usually
Follow-up of test results 5% 9% 5%
7%
10%
Almost Always
Always
11%
66%
13%
0%
Never
Almost Never
Sometimes
Usually
64%
PCMH A
1%
1%
Health literacy 2% 6%
68%
Average: Other 4 PCMHs
1%
1%
3%
9%
Almost Always
Always
15%
75%
16%
69%
Coordinated By:
3
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site A
PCMH A: Diabetes Management % Completed Screenings of Patients
Diabetes Management Screening and Testing Outcome measures are based on Hedis and NCQA Standards: http://www.ncqa.org/tabid/59/Default.aspx Diabetes Management Screenings and Testing Outcomes were collected by external nurse consultants and via electronic record data pulls March-June 2011. % of Diabetes Screenings Completed
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
Average: Other 4 PCMHs National Comparative
69.8%
93.1%
PCMH A
86.0%
77.9%
Average: Other 4 PCMHs
92.6%
89.7%
Foot Exam 51.2% 83.3%
Diabetes Management Screening and Testing Outcome measures are based on Hedis and NCQA Standards: http://www.ncqa.org/tabid/59/Default.aspx Outcomes National Comparative sourced from NCQA Diabetes Provider Recognition Program point Table 1: http://www.ncqa.org/tabid/1023/Default.aspx Diabetes Management Screenings and Testing Outcomes were collected by external nurse consultants and via electronic record data pulls March-June 2011. Blood Pressure Levels 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
A1c >9% 20.5%
A1c <8% 72.6%
A1c<7% 53.4%
12.4%
75.7%
51.3%
15.0%
41.2%
Eye Exam
Blood Sugar Levels
PCMH A
Smoking Cessation 93.0%
LDL-C
PCMH A: Diabetes Management % of Total Patients in Each Outcome Measure (for Patients receiving Screenings) 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
24.4%
Kidney Assessment 59.3%
A1c
60.0%
40.0%
Cholesterol Levels
BP â&#x2030;Ľ140/90mm Hg
BP <140/90mm Hg
BP <130/80mm Hg
PCMH A
37.2%
62.8%
47.7%
Average: Other 4 PCMHs
27.8%
72.2%
46.9%
National Comparative
35.0%
25.0%
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
LDL-C â&#x2030;Ľ130 mg/dl 23.9%
LDL-C <100mg/dl 46.3%
Average: Other 4 PCMHs
14.0%
62.8%
National Comparative
37.0%
36.0%
PCMH A
Coordinated By:
4
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site A
PCMH A: Patients Self-Health Management
The patients with Diabetes whose screening and test results were reviewed, also were asked to participate in a survey. The Patient Activation Measurement (PAM) survey asks questions regarding confidence to manage your own health. The PAM survey was obtained from Insignia Health: http://www.insigniahealth.com/solutions/patient-activation-measure. "US Adults with Diabetes " was obtained from the Center for Studying Health System Change 2007: http://www.hschange.com/CONTENT/1019/?words=engaged%20consumers. The PAM survey was collected May-July 2011.
Patients with Diabetes Self Health Management Assessment % in each stage 100% 90% 80%
33.2%
42.9%
37.9%
70% 60%
31.0%
50% 40%
35.3%
38.1%
30% 20% 10%
22.5% 18.9%
4.8% 14.3%
13.3%
PCMH A
Average: Other 4 PCMHs
US Adults with Diabetes
Stage 4: % of Patients that have adopted new actions and behaviors to maintain health
42.9%
33.2%
37.9%
Stage 3: % of Patients starting to build confidence and take action to maintain and improve health
38.1%
31.0%
35.3%
Stage 2: % of Patients that lack confidence or understanding of their health regimen as needed to take action
4.8%
22.5%
18.9%
Stage 1: % of Patients that do not feel confident enough to start to build a role in self-health management
14.3%
13.3%
7.9%
0%
7.9%
Coordinated By:
5
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site A
PCMH A: Staff Job Satisfaction
Primary Care practice sites' providers and office staff were asked to complete online surveys to measure job satisfaction. The survey instrument used was obtained from: Mind Garden, Inc. www.mindgarden.com, the Maslach Burnout Inventory survey: http://www.rci.rutgers.edu/~sjacksox/PDF/EvaluatingStress.pdf Surveys were collected March-June 2011.
Level of Optimism/Idealism % of Primary Care Practitioners and Staff with Each Level
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
% of Respondents
% of Respondents
Level of Job Energy % of Primary Care Providers and Staff with Each Level
54.5% 41.0%
36.8% 18.2%
27.3%
22.2%
Low
Moderate PCMH A
% of Respondents
45.5% 22.3%
22.0% 9.1%
Moderate PCMH A
High
Average: Other 4 PCMHs
Types of Job Satisfaction Survey Questions Asked:
Feelings of Workplace Success and Accomplishment % of Primary Care Practitioners and Staff with each level
Energy: Strain, burnout, exhaustion, etc.
90.9% 74.5%
80.0%
55.7% 45.5%
Low
High
Average: Other 4 PCMHs
100.0%
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
Optimism/Idealism: Interest, enthusiasm, cynicism, etc.
60.0%
Workplace Success and Accomplishment: Problem solving, accomplishments, confidence, etc.
40.0% 20.0% 0.0%
0.0%
8.3%
Low
9.1%
17.2%
Moderate PCMH A
High
Average: Other 4 PCMHs
Coordinated By:
6
Patient-Centered Primary Care Collaborative of Central Ohio Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site A
PCMH A: Utilization Measures
The Utilization measures in this collection may reflect a Primary Care Provider's impact on important health care services received outside of the practice site. Utilization Measures were sourced from some of the Health Plans participating in the Patient-Centered Primary Care Collaborative of Central Ohio, and for Site A reflect 1,946 attributed patients from 4 Health Plans. The dates of service were year: 2010.
Frequency of Hospitalizations per 1000 patients per year
Frequency of ED Visits per 1000 patients per year 500
200
400
150
269
300
215
122
100
200
62 50
100 0
0
PCMH A
Average: Other 4 PCMHs
PCMH A
Frequency of Re-hospitalizations (percent of original hospitalizations)
Average: Other 4 PCMHs
% of Prescriptions filled by Generic 100.0%
15.0% 80.0% 10.0%
8.2%
71.2%
72.7%
PCMH A
Average: Other 4 PCMHs
60.0%
8.7%
40.0% 5.0% 20.0% 0.0%
0.0%
PCMH A
Average: Other 4 PCMHs
Coordinated By:
Health Plan Data Included: Aetna, Anthem, The Ohio State University Health Plan and UnitedHealthcare 7
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site A
PCMH A: Utilization Measures
The Utilization measures in this collection may reflect a Primary Care Provider's impact on important health care services received outside of the practice site. Utilization Measures will be sourced from some of the Health Plans participating in the Patient-Centered Primary Care Collaborative of Central Ohio.
Draft of measures new for 2012
High Tech Imaging Visits **Display Only**
Ambulatory Care Sensitive Admissions **Display Only** 200.0 150.0 100.0 50.0 -
200.0
Data Will Be Available in November 2012 PCMH A
150.0 100.0 50.0 -
Average: Other 4 PCMHs
PCMH A
Admissions for Patients with Diabetes **Display Only** 200.0 150.0 100.0 50.0 -
Average: Other 4 PCMHs
Inpatient Length of Stay for Patients with Diabetes (each stay limited to a max of 15) **Display Only**
Data Will Be Available in November 2012 PCMH A
Data Will Be Available in November 2012
20.0 15.0 10.0 5.0 0.0
Average: Other 4 PCMHs
Data Will Be Available in November 2012 PCMH A
Average: Other 4 PCMHs
Coordinated By:
8
PCMH Dashboard Purpose: to help participating primary care practices evaluate their effectiveness and support improvements in: Access Patient Experience
Patient-Centered Primary Care Collaborative of Central Ohio
Provider and Staff Job Satisfaction
Patient-Centered Medical Home (PCMH) Improvement Dashboard Site B February 2012
Patient Self-Health Management Diabetes Management Screenings Diabetes Management Testing Outcomes Health Plan Utilization Measures: -Emergency Department Visits -Hospitalizations -Re-Hospitalizations -Prescription Generic Use
9
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site B
PCMH B: Access Measures
The Access measures utilized for this collection reflect the patients' ability to schedule a same day appointment at their Primary Care practice site and to schedule appointments with their personal primary care provider. Same Day Appointments and Continuity of Care data was sourced from practice records collected March-July 2011. Continuity of Care % of Patients seen by Personal Primary Care Provider
Same Day Appointments % of Schedule made Available 100.0%
100.0%
90.0%
90.0%
80.0%
80.0%
70.0%
70.0%
60.0%
60.0%
85.2%
80.1%
50.0%
50.0%
34.7%
40.0%
40.0%
24.5%
30.0%
30.0%
20.0%
20.0%
10.0%
10.0% 0.0%
0.0%
PCMH B
PCMH B
Average: Other 4 PCMHs
PCMH B: Patient Experience
Average: Other 4 PCMHs
Patient experience measures were collected through a survey that assesses patients' experiences with their primary care provider and office staff. The survey instrument used was obtained from the Agency for Healthcare Research and Quality (AHRQ): Clinician & Group Consumer Assessment of Healthcare Providers and Systems (CG CAHPS). https://www.cahps.ahrq.gov/content/products/CG/PROD_CG_CG40Products.asp?p=1021&s=213 Adult Patient Experience How often you are satisfied with: Patient/Doctor Communication
100%
100%
90%
90%
80%
80%
70%
70%
% of Respondents
% of Respondents
Adult Patient Experience How often you are satisfied with: Access to Care
60% 50% 40% 30%
60% 50% 40% 30%
20%
20%
10%
10%
0% Never
Almost Never
Sometimes
Usually
Almost Always
0% Never
Always
Almost Never
Sometimes
Usually
Almost Always
Always 70%
Patient/Doctor Communication
Access to care PCMH B
7%
4%
8%
13%
30%
38%
PCMH B
1%
1%
3%
7%
19%
Average: Other 4 PCMHs
10%
4%
9%
15%
21%
40%
Average: Other 4 PCMHs
1%
1%
3%
7%
14%
58%
National 50th %tile
National 50th %tile
75% 78%
Coordinated By:
10
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site B
PCMH B: Patient Experience Continued
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Patient Experience Overall Rating of Personal Doctor
% of Respondents
% of Respondents
Patient Experience Courteous and Helpful Office Staff
Never
Almost Never
PCMH B
1%
1%
Average: Other 4 PCMHs
1%
2%
Sometimes
Usually
Courteous and helpful office staff 7% 15% 5%
11%
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Almost Always
Always
26%
51%
PCMH B
1%
5-6 7-8 Overall rating of personal doctor 3% 4% 22%
18%
64%
Average: Other 4 PCMHs
1%
1%
70%
National 50th %tile
National 50th %tile
0-2
70%
18%
75%
Patient Experience Health Literacy 100%
90%
90%
80%
80%
70%
70%
% of Respondents
100%
% of Respondents
4%
9-10
76%
Patient Experience Follow up of Test Results
60% 50% 40% 30% 20%
60% 50% 40% 30% 20%
10% 0%
Never
Almost Never
PCMH B
3%
1%
Average: Other 4 PCMHs
8%
4%
National 50th %tile
3-4
Sometimes
Usually
Follow-up of test results 3% 5% 6%
8%
10%
Almost Always
Always
11%
76%
13%
0%
Never
Almost Never
Sometimes
Usually
62%
PCMH B
0%
1%
Health literacy 3% 7%
68%
Average: Other 4 PCMHs
2%
1%
3%
8%
Almost Always
Always
20%
70%
15%
71%
Coordinated By:
11
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site B
PCMH B: Diabetes Management % Completed Screenings of Patients
Diabetes Management Screening and Testing Outcome measures are based on Hedis and NCQA Standards: http://www.ncqa.org/tabid/59/Default.aspx Diabetes Management Screenings and Testing Outcomes were collected by external nurse consultants and via electronic record data pulls March-June 2011. % of Diabetes Screenings Completed
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
Average: Other 4 PCMHs National Comparative
62.9%
92.1%
PCMH B
97.0%
93.0%
Average: Other 4 PCMHs
89.9%
86.0%
Foot Exam 90.0% 73.6%
Diabetes Management Screening and Testing Outcome measures are based on Hedis and NCQA Standards: http://www.ncqa.org/tabid/59/Default.aspx Outcomes National Comparative sourced from NCQA Diabetes Provider Recognition Program point Table 1: http://www.ncqa.org/tabid/1023/Default.aspx Diabetes Management Screenings and Testing Outcomes were collected by external nurse consultants and via electronic record data pulls March-June 2011. Blood Pressure Control 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
A1c >9% 10.3%
A1c <8% 76.3%
A1c<7% 44.3%
14.9%
74.7%
53.6%
15.0%
29.3%
Eye Exam
Blood Sugar Control
PCMH B
Smoking Cessation 97.0%
LDL-C
PCMH B: Diabetes Management % of Total Patients in Each Outcome Measure (for Patients receiving Screenings) 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
72.0%
Kidney Assessment 87.0%
A1c
60.0%
40.0%
Cholesterol Control
BP â&#x2030;Ľ140/90mm Hg
BP <140/90mm Hg
BP <130/80mm Hg
PCMH B
28.0%
72.0%
31.0%
Average: Other 4 PCMHs
30.1%
69.9%
51.1%
National Comparative
35.0%
25.0%
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
LDL-C â&#x2030;Ľ130 mg/dl 16.1%
LDL-C <100mg/dl 63.4%
Average: Other 4 PCMHs
15.9%
58.5%
National Comparative
37.0%
36.0%
PCMH B
Coordinated By:
12
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site B
PCMH B: Patients Self-Health Management
The patients with Diabetes whose screening and test results were reviewed, also were asked to participate in a survey. The Patient Activation Measurement (PAM) survey asks questions regarding confidence to manage your own health. The PAM survey was obtained from Insignia Health: http://www.insigniahealth.com/solutions/patient-activation-measure. "US Adults with Diabetes " was obtained from the Center for Studying Health System Change 2007: http://www.hschange.com/CONTENT/1019/?words=engaged%20consumers. The PAM survey was collected May-July 2011.
Patients with Diabetes Self Health Management Assessment % in each stage 100% 90% 80% 70%
31.5% 50.0%
37.9%
60%
33.6%
50% 40%
35.3% 27.8%
30%
19.5%
20% 10% 0%
18.9%
16.7%
15.5%
5.6%
7.9%
PCMH B
Average: Other 4 PCMHs
US Adults with Diabetes
Stage 4: % of Patients that have adopted new actions and behaviors to maintain health
50.0%
31.5%
37.9%
Stage 3: % of Patients starting to build confidence and take action to maintain and improve health
27.8%
33.6%
35.3%
Stage 2: % of Patients that lack confidence or understanding of their health regimen as needed to take action
16.7%
19.5%
18.9%
Stage 1: % of Patients that do not feel confident enough to start to build a role in self-health management
5.6%
15.5%
7.9%
Coordinated By:
13
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site B
PCMH B: Staff Job Satisfaction
Primary Care practice sites' providers and office staff were asked to complete online surveys to measure job satisfaction. The survey instrument used was obtained from: Mind Garden, Inc. www.mindgarden.com, the Maslach Burnout Inventory survey: http://www.rci.rutgers.edu/~sjacksox/PDF/EvaluatingStress.pdf Surveys were collected March-June 2011.
Level of Optimism/Idealism % of Primary Care Practitioners and Staff with Each Level
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
50.0% 36.7% 22.2%
% of Respondents
% of Respondents
Level of Job Energy % of Primary Care Providers and Staff with Each Level
42.2%
27.8%
21.1%
Low
Moderate PCMH B
66.7% 50.4% 22.2%
21.5%
Moderate PCMH B
Average: Other 4 PCMHs
28.1%
11.1%
Low
High
High
Average: Other 4 PCMHs
Types of Job Satisfaction Survey Questions Asked:
Feelings of Workplace Success and Accomplishment % of Primary Care Practitioners and Staff with each level
Energy: Strain, burnout, exhaustion, etc.
100.0%
% of Respondents
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
77.8%
80.0%
77.8%
Optimism/Idealism: Interest, enthusiasm, cynicism, etc.
60.0%
Workplace Success and Accomplishment: Problem solving, accomplishments, confidence, etc.
40.0% 20.0%
5.6%
6.9%
16.7%
15.3%
0.0%
Low
Moderate PCMH B
High
Average: Other 4 PCMHs
Coordinated By:
14
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site B
PCMH B: Utilization Measures
The Utilization measures in this collection may reflect a Primary Care Provider's impact on important health care services received outside of the practice site. Utilization Measures were sourced from some of the Health Plans participating in the Patient-Centered Primary Care Collaborative of Central Ohio, and for Site B reflect 2,744 attributed patients from 4 Health Plans. The dates of service were year: 2010.
Frequency of Hospitalizations per 1000 patients per year
Frequency of ED Visits per 1000 patients per year 500
200
400
150
277
300 200
100
182
50
100 0
0
PCMH B
Average: Other 4 PCMHs
PCMH B
Frequency of Re-hospitalizations (percent of original hospitalizations)
% of Prescriptions filled by Generic (more is better) 80.0%
9.7%
Average: Other 4 PCMHs
100.0%
15.0%
10.0%
80 50
74.2%
72.0%
PCMH B
Average: Other 4 PCMHs
60.0%
8.4%
40.0% 5.0% 20.0% 0.0%
0.0%
PCMH B
Average: Other 4 PCMHs
Coordinated By:
Health Plan Data Included: Aetna, Anthem, Medigold and UnitedHealthcare 15
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site B
PCMH B: Utilization Measures
The Utilization measures in this collection may reflect a Primary Care Provider's impact on important health care services received outside of the practice site. Utilization Measures will be sourced from some of the Health Plans participating in the Patient-Centered Primary Care Collaborative of Central Ohio.
Draft of measures new for 2012
High Tech Imaging Visits **Display Only**
Ambulatory Care Sensitive Admissions **Display Only** 200.0 150.0 100.0 50.0 -
200.0
Data Will Be Available in November 2012 PCMH B
150.0 100.0 50.0 -
Average: Other 4 PCMHs
PCMH B
Admissions for Patients with Diabetes **Display Only** 200.0 150.0 100.0 50.0 -
Average: Other 4 PCMHs
Inpatient Length of Stay for Patients with Diabetes (each stay limited to a max of 15) **Display Only**
Data Will Be Available in November 2012 PCMH B
Data Will Be Available in November 2012
20.0 15.0 10.0 5.0 0.0
Average: Other 4 PCMHs
Data Will Be Available in November 2012 PCMH B
Average: Other 4 PCMHs
Coordinated By:
16
PCMH Dashboard Purpose: to help participating primary care practices evaluate their effectiveness and support improvements in: Access Patient Experience
Patient-Centered Primary Care Collaborative of Central Ohio
Provider and Staff Job Satisfaction
Patient-Centered Medical Home (PCMH) Improvement Dashboard Site C February 2012
Patient Self-Health Management Diabetes Management Screenings Diabetes Management Testing Outcomes Health Plan Utilization Measures: -Emergency Department Visits -Hospitalizations -Re-Hospitalizations -Prescription Generic Use
17
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site C
PCMH C: Access Measures
The Access measures utilized for this collection reflect the patients' ability to schedule a same day appointment at their Primary Care practice site and to schedule appointments with their personal primary care provider. Same Day Appointments and Continuity of Care data was sourced from practice records collected March-July 2011. Continuity of Care % of Patients seen by Personal Primary Care Provider 98.7%
Same Day Appointments % of Schedule made Available 100.0%
100.0%
90.0%
90.0%
80.0%
80.0%
70.0%
70.0%
60.0%
60.0%
50.0%
50.0%
40.0% 30.0%
40.0%
28.4%
19.1%
20.0%
80.5%
30.0% 20.0% 10.0%
10.0%
0.0%
0.0%
PCMH C
PCMH C
Average: Other 4 PCMHs
PCMH C: Patient Experience
Average: Other 4 PCMHs
Patient experience measures were collected through a survey that assesses patients' experiences with their primary care provider and office staff. The survey instrument used was obtained from the Agency for Healthcare Research and Quality (AHRQ): Clinician & Group Consumer Assessment of Healthcare Providers and Systems (CG CAHPS). https://www.cahps.ahrq.gov/content/products/CG/PROD_CG_CG40Products.asp?p=1021&s=213 Adult Patient Experience How often you are satisfied with: Patient/Doctor Communication
100%
100%
90%
90%
80%
80%
70%
70%
% of Respondents
% of Respondents
Adult Patient Experience How often you are satisfied with: Access to Care
60% 50% 40% 30%
60% 50% 40% 30%
20%
20%
10%
10%
0% Never
Almost Never
Sometimes
Usually
Almost Always
0% Never
Always
Almost Never
Sometimes
Usually
Almost Always
Always 72%
Patient/Doctor Communication
Access to care PCMH C
13%
5%
8%
15%
21%
38%
PCMH C
1%
1%
3%
7%
15%
Average: Other 4 PCMHs
9%
4%
9%
15%
24%
40%
Average: Other 4 PCMHs
1%
1%
2%
7%
14%
58%
National 50th %tile
National 50th %tile
74% 78%
Coordinated By:
18
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site C
PCMH C: Patient Experience Continued
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Patient Experience Overall Rating of Personal Doctor
% of Respondents
% of Respondents
Patient Experience Courteous and Helpful Office Staff
Never
Almost Never
PCMH C
1%
2%
Average: Other 4 PCMHs
1%
1%
Sometimes
Usually
Courteous and helpful office staff 4% 14% 6%
11%
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Almost Always
Always
18%
61%
PCMH C
7%
5-6 7-8 Overall rating of personal doctor 3% 4% 20%
20%
61%
Average: Other 4 PCMHs
1%
1%
70%
National 50th %tile
National 50th %tile
0-2
72%
19%
75%
Patient Experience Health Literacy 100%
90%
90%
80%
80%
70%
70%
% of Respondents
100%
% of Respondents
4%
9-10
76%
Patient Experience Follow up of Test Results
60% 50% 40% 30% 20%
60% 50% 40% 30% 20%
10% 0%
Never
Almost Never
PCMH C
16%
6%
Average: Other 4 PCMHs
5%
3%
National 50th %tile
3-4
Sometimes
Usually
Follow-up of test results 5% 8% 5%
7%
10%
Almost Always
Always
11%
54%
13%
0%
Never
Almost Never
Sometimes
Usually
67%
PCMH C
2%
1%
Health literacy 3% 9%
68%
Average: Other 4 PCMHs
1%
1%
3%
8%
Almost Always
Always
17%
68%
16%
71%
Coordinated By:
19
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site C
PCMH C: Diabetes Management % Completed Screenings of Patients
Diabetes Management Screening and Testing Outcome measures are based on Hedis and NCQA Standards: http://www.ncqa.org/tabid/59/Default.aspx Diabetes Management Screenings and Testing Outcomes were collected by external nurse consultants and via electronic record data pulls March-June 2011. % of Diabetes Screenings Completed
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
Average: Other 4 PCMHs National Comparative
66.3%
92.2%
PCMH C
91.9%
91.9%
Average: Other 4 PCMHs
91.1%
86.2%
Foot Exam 89.5% 73.7%
Diabetes Management Screening and Testing Outcome measures are based on Hedis and NCQA Standards: http://www.ncqa.org/tabid/59/Default.aspx Outcomes National Comparative sourced from NCQA Diabetes Provider Recognition Program point Table 1: http://www.ncqa.org/tabid/1023/Default.aspx Diabetes Management Screenings and Testing Outcomes were collected by external nurse consultants and via electronic record data pulls March-June 2011. Blood Pressure Control 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
A1c >9% 13.0%
A1c <8% 77.4%
A1c<7% 57.4%
14.3%
74.5%
50.3%
15.0%
34.8%
Eye Exam
Blood Sugar Control
PCMH C
Smoking Cessation 96.8%
LDL-C
PCMH C: Diabetes Management % of Total Patients in Each Outcome Measure (for Patients receiving Screenings) 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
50.0%
Kidney Assessment 73.4%
A1c
60.0%
40.0%
Cholesterol Control
BP â&#x2030;Ľ140/90mm Hg
BP <140/90mm Hg
BP <130/80mm Hg
PCMH C
23.8%
76.2%
59.8%
Average: Other 4 PCMHs
31.1%
68.9%
43.9%
National Comparative
35.0%
25.0%
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
LDL-C â&#x2030;Ľ130 mg/dl 7.0%
LDL-C <100mg/dl 72.8%
Average: Other 4 PCMHs
18.2%
56.1%
National Comparative
37.0%
36.0%
PCMH C
Coordinated By:
20
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site C
PCMH C: Patients Self-Health Management
The patients with Diabetes whose screening and test results were reviewed, also were asked to participate in a survey. The Patient Activation Measurement (PAM) survey asks questions regarding confidence to manage your own health. The PAM survey was obtained from Insignia Health: http://www.insigniahealth.com/solutions/patient-activation-measure. "US Adults with Diabetes " was obtained from the Center for Studying Health System Change 2007: http://www.hschange.com/CONTENT/1019/?words=engaged%20consumers. The PAM survey was collected May-July 2011.
Patients with Diabetes Self Health Management Assessment % in each stage 100% 90% 80%
33.0%
44.0%
37.9%
70% 60%
32.5%
50% 40%
32.0%
30% 20% 10% 0%
35.3%
19.7% 18.9%
16.0% 14.9%
8.0%
7.9%
PCMH C
Average: Other 4 PCMHs
US Adults with Diabetes
Stage 4: % of Patients that have adopted new actions and behaviors to maintain health
44.0%
33.0%
37.9%
Stage 3: % of Patients starting to build confidence and take action to maintain and improve health
32.0%
32.5%
35.3%
Stage 2: % of Patients that lack confidence or understanding of their health regimen as needed to take action
16.0%
19.7%
18.9%
Stage 1: % of Patients that do not feel confident enough to start to build a role in self-health management
8.0%
14.9%
7.9%
Coordinated By:
21
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site C
PCMH C: Staff Job Satisfaction
Primary Care practice sites' providers and office staff were asked to complete online surveys to measure job satisfaction. The survey instrument used was obtained from: Mind Garden, Inc. www.mindgarden.com, the Maslach Burnout Inventory survey: http://www.rci.rutgers.edu/~sjacksox/PDF/EvaluatingStress.pdf Surveys were collected March-June 2011.
Level of Optimism/Idealism % of Primary Care Practitioners and Staff with Each Level
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
38.5%
30.8%
% of Respondents
% of Respondents
Level of Job Energy % of Primary Care Providers and Staff with Each Level
47.0% 34.0%
30.8%
19.0%
Low
Moderate PCMH C
% of Respondents
51.6% 38.5%
33.7% 14.7% 0.0%
Moderate PCMH C
84.6%
High
Average: Other 4 PCMHs
Types of Job Satisfaction Survey Questions Asked:
Feelings of Workplace Success and Accomplishment % of Primary Care Practitioners and Staff with each level 80.0%
61.5%
Low
High
Average: Other 4 PCMHs
100.0%
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
Energy: Strain, burnout, exhaustion, etc. 76.1%
Optimism/Idealism: Interest, enthusiasm, cynicism, etc.
60.0%
Workplace Success and Accomplishment: Problem solving, accomplishments, confidence, etc.
40.0% 20.0%
7.7%
6.4%
7.7%
17.6%
0.0%
Low
Moderate PCMH C
High
Average: Other 4 PCMHs
Coordinated By:
22
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site C
PCMH C: Utilization Measures
The Utilization measures in this collection may reflect a Primary Care Provider's impact on important health care services received outside of the practice site. Utilization Measures were sourced from some of the Health Plans participating in the Patient-Centered Primary Care Collaborative of Central Ohio, and for Site C reflect 4,491 attributed patients from 4 Health Plans. The dates of service were year: 2010.
Frequency of Hospitalizations per 1000 patients per year
Frequency of ED Visits per 1000 patients per year 500
200
400 300
150
267
222
100
200
77
60 50
100 0
0
PCMH C
Average: Other 4 PCMHs
PCMH C
Frequency of Re-hospitalizations (percent of original hospitalizations)
Average: Other 4 PCMHs
% of Prescriptions filled by Generic 100.0%
15.0% 80.0%
9.2%
10.0%
69.6%
73.1%
PCMH C
Average: Other 4 PCMHs
60.0%
6.3%
40.0%
5.0% 20.0% 0.0%
0.0%
PCMH C
Average: Other 4 PCMHs
Coordinated By:
Health Plan Data Included: Aetna, Anthem, Medigold, and UnitedHealthcare 23
Patient-Centered Primary Care Collaborative of Central Ohio Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site C
PCMH C: Utilization Measures
The Utilization measures in this collection may reflect a Primary Care Provider's impact on important health care services received outside of the practice site. Utilization Measures will be sourced from some of the Health Plans participating in the Patient-Centered Primary Care Collaborative of Central Ohio.
Draft of measures new for 2012
High Tech Imaging Visits **Display Only**
Ambulatory Care Sensitive Admissions **Display Only** 200.0 150.0 100.0 50.0 -
200.0
Data Will Be Available in November 2012 PCMH C
150.0 100.0 50.0 -
Average: Other 4 PCMHs
PCMH C
Admissions for Patients with Diabetes **Display Only** 200.0 150.0 100.0 50.0 -
Average: Other 4 PCMHs
Inpatient Length of Stay for Patients with Diabetes (each stay limited to a max of 15) **Display Only**
Data Will Be Available in November 2012 PCMH C
Data Will Be Available in November 2012
20.0 15.0 10.0 5.0 0.0
Average: Other 4 PCMHs
Data Will Be Available in November 2012 PCMH C
Average: Other 4 PCMHs
Coordinated By:
24
PCMH Dashboard Purpose: to help participating primary care practices evaluate their effectiveness and support improvements in: Access Patient Experience
Patient-Centered Primary Care Collaborative of Central Ohio
Provider and Staff Job Satisfaction
Patient-Centered Medical Home (PCMH) Improvement Dashboard Site D February 2012
Patient Self-Health Management Diabetes Management Screenings Diabetes Management Testing Outcomes Health Plan Utilization Measures: -Emergency Department Visits -Hospitalizations -Re-Hospitalizations -Prescription Generic Use
25
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site D
PCMH D: Staff Job Satisfaction
Primary Care practice sites' providers and office staff were asked to complete online surveys to measure job satisfaction. The survey instrument used was obtained from: Mind Garden, Inc. www.mindgarden.com, the Maslach Burnout Inventory survey: http://www.rci.rutgers.edu/~sjacksox/PDF/EvaluatingStress.pdf Surveys were collected March-June 2011.
Level of Optimism/Idealism % of Primary Care Practitioners and Staff with Each Level
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
51.9%
14.8%
46.3% 30.7%
23.0%
Low
Moderate PCMH D
% of Respondents
% of Respondents
Level of Job Energy % of Primary Care Providers and Staff with Each Level
33.3%
% of Respondents
25.9%
29.6% 17.8%
81.5%
26.3%
Moderate PCMH D
High
Average: Other 4 PCMHs
Types of Job Satisfaction Survey Questions Asked:
Feelings of Workplace Success and Accomplishment % of Primary Care Practitioners and Staff with each level 80.0%
55.9% 44.4%
Low
High
Average: Other 4 PCMHs
100.0%
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
Energy: Strain, burnout, exhaustion, etc. 76.9%
Optimism/Idealism: Interest, enthusiasm, cynicism, etc.
60.0%
Workplace Success and Accomplishment: Problem solving, accomplishments, confidence, etc.
40.0% 20.0%
7.4%
6.4%
11.1%
16.7%
0.0%
Low
Moderate PCMH D
High
Average: Other 4 PCMHs
Coordinated By:
26
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site D
PCMH D: Access Measures
The Access measures utilized for this collection reflect the patients' ability to schedule a same day appointment at their Primary Care practice site and to schedule appointments with their personal primary care provider. Same Day Appointments and Continuity of Care data was sourced from practice records collected March-July 2011. Continuity of Care % of Patients seen by Personal Primary Care Provider
Same Day Appointments % of Schedule made Available 100.0%
100.0%
90.0%
90.0%
80.0%
80.0%
70.0%
70.0%
60.0%
60.0%
50.0%
50.0%
40.0%
83.8%
PCMH D
Average: Other 4 PCMHs
40.0%
29.3%
30.0%
85.5%
25.9%
30.0%
20.0%
20.0%
10.0%
10.0% 0.0%
0.0%
PCMH D
Average: Other 4 PCMHs
PCMH D: Patient Experience
Patient experience measures were collected through a survey that assesses patients' experiences with their primary care provider and office staff. The survey instrument used was obtained from the Agency for Healthcare Research and Quality (AHRQ): Clinician & Group Consumer Assessment of Healthcare Providers and Systems (CG CAHPS). https://www.cahps.ahrq.gov/content/products/CG/PROD_CG_CG40Products.asp?p=1021&s=213 Adult Patient Experience How often you are satisfied with: Patient/Doctor Communication
100%
100%
90%
90%
80%
80%
70%
70%
% of Respondents
% of Respondents
Adult Patient Experience How often you are satisfied with: Access to Care
60% 50% 40% 30%
60% 50% 40% 30%
20%
20%
10%
10%
0% Never
Almost Never
Sometimes
Usually
Almost Always
0% Never
Always
Almost Never
Sometimes
Usually
Almost Always
Always 82%
Patient/Doctor Communication
Access to care PCMH D
4%
3%
5%
13%
25%
50%
PCMH D
0%
0%
1%
4%
12%
Average: Other 4 PCMHs
11%
5%
9%
15%
23%
37%
Average: Other 4 PCMHs
1%
1%
3%
8%
15%
58%
National 50th %tile
National 50th %tile
72% 78%
Coordinated By:
27
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site D
PCMH D: Patient Experience Continued
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Patient Experience Overall Rating of Personal Doctor
% of Respondents
% of Respondents
Patient Experience Courteous and Helpful Office Staff
Never
Almost Never
PCMH D
0%
1%
Average: Other 4 PCMHs
1%
2%
Sometimes
Usually
Courteous and helpful office staff 1% 6% 6%
13%
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Almost Always
Always
19%
74%
PCMH D
0%
5-6 7-8 Overall rating of personal doctor 0% 1% 13%
20%
58%
Average: Other 4 PCMHs
1%
2%
70%
National 50th %tile
National 50th %tile
0-2
85%
20%
72%
Patient Experience Health Literacy 100%
90%
90%
80%
80%
70%
70%
% of Respondents
100%
% of Respondents
5%
9-10
76%
Patient Experience Follow up of Test Results
60% 50% 40% 30% 20%
60% 50% 40% 30% 20%
10% 0%
Never
Almost Never
PCMH D
1%
1%
Average: Other 4 PCMHs
9%
4%
National 50th %tile
3-4
Sometimes
Usually
Follow-up of test results 2% 5% 6%
8%
10%
Almost Always
Always
10%
82%
13%
0%
Never
Almost Never
Sometimes
Usually
60%
PCMH D
0%
0%
Health literacy 2% 5%
68%
Average: Other 4 PCMHs
2%
1%
4%
9%
Almost Always
Always
13%
79%
17%
68%
Coordinated By:
28
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site D
PCMH D: Diabetes Management % Completed Screenings of Patients
Diabetes Management Screening and Testing Outcome measures are based on Hedis and NCQA Standards: http://www.ncqa.org/tabid/59/Default.aspx Diabetes Management Screenings and Testing Outcomes were collected by external nurse consultants and via electronic record data pulls March-June 2011. % of Diabetes Screenings Completed
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
Average: Other 4 PCMHs National Comparative
69.9%
95.7%
PCMH D
85.5%
86.7%
Average: Other 4 PCMHs
92.7%
87.5%
Foot Exam 69.0% 78.8%
Diabetes Management Screening and Testing Outcome measures are based on Hedis and NCQA Standards: http://www.ncqa.org/tabid/59/Default.aspx Outcomes National Comparative sourced from NCQA Diabetes Provider Recognition Program point Table 1: http://www.ncqa.org/tabid/1023/Default.aspx Diabetes Management Screenings and Testing Outcomes were collected by external nurse consultants and via electronic record data pulls March-June 2011. Blood Pressure Control 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
A1c >9% 3.3%
A1c <8% 85.4%
A1c<7% 65.6%
16.7%
72.5%
48.3%
15.0%
39.9%
Eye Exam
Blood Sugar Control
PCMH D
Smoking Cessation 82.7%
LDL-C
PCMH D: Diabetes Management % of Total Patients in Each Outcome Measure (for Patients receiving Screenings) 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
29.4%
Kidney Assessment 58.9%
A1c
60.0%
40.0%
Cholesterol Control
BP â&#x2030;Ľ140/90mm Hg
BP <140/90mm Hg
BP <130/80mm Hg
PCMH D
25.9%
74.1%
51.4%
Average: Other 4 PCMHs
30.6%
69.4%
46.0%
National Comparative
35.0%
25.0%
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
LDL-C â&#x2030;Ľ130 mg/dl 12.1%
LDL-C <100mg/dl 63.7%
Average: Other 4 PCMHs
16.9%
58.4%
National Comparative
37.0%
36.0%
PCMH D
Coordinated By:
29
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site D
PCMH D: Patients Self-Health Management
The patients with Diabetes whose screening and test results were reviewed, also were asked to participate in a survey. The Patient Activation Measurement (PAM) survey asks questions regarding confidence to manage your own health. The PAM survey was obtained from Insignia Health: http://www.insigniahealth.com/solutions/patient-activation-measure. "US Adults with Diabetes " was obtained from the Center for Studying Health System Change 2007: http://www.hschange.com/CONTENT/1019/?words=engaged%20consumers. The PAM survey was collected May-July 2011.
Patients with Diabetes Self Health Management Assessment % in each stage 100% 90% 80%
34.2%
39.0%
37.9%
70% 60%
30.4%
50% 40%
40.7%
30% 20% 10%
35.3%
21.1% 18.9%
10.2% 10.2%
14.3%
PCMH D
Average: Other 4 PCMHs
US Adults with Diabetes
Stage 4: % of Patients that have adopted new actions and behaviors to maintain health
39.0%
34.2%
37.9%
Stage 3: % of Patients starting to build confidence and take action to maintain and improve health
40.7%
30.4%
35.3%
Stage 2: % of Patients that lack confidence or understanding of their health regimen as needed to take action
10.2%
21.1%
18.9%
Stage 1: % of Patients that do not feel confident enough to start to build a role in self-health management
10.2%
14.3%
7.9%
0%
7.9%
Coordinated By:
30
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site D
PCMH D: Utilization Measures
The Utilization measures in this collection may reflect a Primary Care Provider's impact on important health care services received outside of the practice site. Utilization Measures were sourced from some of the Health Plans participating in the Patient-Centered Primary Care Collaborative of Central Ohio, and for Site D reflect 4,710 attributed patients from 5 Health Plans. The dates of service were year: 2010.
Frequency of Hospitalizations per 1000 patients per year
Frequency of ED Visits per 1000 patients per year 500
200
400
150
277
300 200
100
182
79
72
PCMH D
Average: Other 4 PCMHs
50
100 0
0
PCMH D
Average: Other 4 PCMHs
Frequency of Re-hospitalizations (percent of original hospitalizations)
% of Prescriptions filled by Generic 100.0%
15.0% 80.0%
10.7% 10.0%
74.2%
65.3%
60.0%
8.1%
40.0% 5.0% 20.0% 0.0%
0.0%
PCMH D
Average: Other 4 PCMHs
PCMH D
Average: Other 4 PCMHs
Coordinated By:
Health Plan Data Included: Aetna, Anthem, Medigold, The Ohio State University Health Plan and UnitedHealthcare 31
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site D
PCMH D: Utilization Measures
The Utilization measures in this collection may reflect a Primary Care Provider's impact on important health care services received outside of the practice site. Utilization Measures will be sourced from some of the Health Plans participating in the Patient-Centered Primary Care Collaborative of Central Ohio.
Draft of measures new for 2012
High Tech Imaging Visits **Display Only**
Ambulatory Care Sensitive Admissions **Display Only** 200.0 150.0 100.0 50.0 -
200.0
Data Will Be Available in November 2012 PCMH D
150.0 100.0 50.0 -
Average: Other 4 PCMHs
PCMH D
Admissions for Patients with Diabetes **Display Only** 200.0 150.0 100.0 50.0 -
Average: Other 4 PCMHs
Inpatient Length of Stay for Patients with Diabetes (each stay limited to a max of 15) **Display Only**
Data Will Be Available in November 2012 PCMH D
Data Will Be Available in November 2012
20.0 15.0 10.0 5.0 0.0
Average: Other 4 PCMHs
Data Will Be Available in November 2012 PCMH D
Average: Other 4 PCMHs
Coordinated By:
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PCMH Dashboard Purpose: to help participating primary care practices evaluate their effectiveness and support improvements in: Access Patient Experience
Patient-Centered Primary Care Collaborative of Central Ohio
Provider and Staff Job Satisfaction
Patient-Centered Medical Home (PCMH) Improvement Dashboard Site E February 2012
Patient Self-Health Management Diabetes Management Screenings Diabetes Management Testing Outcomes Health Plan Utilization Measures: -Emergency Department Visits -Hospitalizations -Re-Hospitalizations -Prescription Generic Use
33
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site E
PCMH E: Access Measures
The Access measures utilized for this collection reflect the patients' ability to schedule a same day appointment at their Primary Care practice site and to schedule appointments with their personal primary care provider. Same Day Appointments and Continuity of Care data was sourced from practice records. Continuity of Care % of Patients seen by Personal Primary Care Provider
Same Day Appointments % of Schedule made Available 100.0%
100.0%
90.0%
90.0%
80.0%
80.0%
70.0%
70.0%
60.0%
60.0%
86.4% 75.0%
50.0%
50.0% 40.0%
40.0%
30.6%
30.0% 20.0%
30.0% 20.0%
10.2%
10.0%
10.0% 0.0%
0.0%
PCMH E
PCMH E
Average: Other 4 PCMHs
PCMH E: Patient Experience
Average: Other 4 PCMHs
Patient experience measures were collected through a survey that assesses patients' experiences with their primary care provider and office staff. The survey instrument used was obtained from the Agency for Healthcare Research and Quality (AHRQ): Clinician & Group Consumer Assessment of Healthcare Providers and Systems (CG CAHPS). https://www.cahps.ahrq.gov/content/products/CG/PROD_CG_CG40Products.asp?p=1021&s=213 Adult Patient Experience How often you are satisfied with: Patient/Doctor Communication
100%
100%
90%
90%
80%
80%
70%
70%
% of Respondents
% of Respondents
Adult Patient Experience How often you are satisfied with: Access to Care
60% 50% 40% 30%
60% 50% 40% 30%
20%
20%
10%
10%
0% Never
Almost Never
Sometimes
PCMH E
15%
6%
15%
Average: Other 4 PCMHs
8%
4%
7%
0% Never
Almost Never
PCMH E
3%
1%
5%
43%
Average: Other 4 PCMHs
1%
1%
2%
58%
National 50th %tile
Almost Always
Always
17%
18%
30%
14%
25%
Usually
Almost Always
Always
10%
15%
66%
6%
15%
76%
Usually
Patient/Doctor Communication
Access to care
National 50th %tile
Sometimes
78%
Coordinated By:
34
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site E
PCMH E: Patient Experience Continued
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Patient Experience Overall Rating of Personal Doctor
% of Respondents
% of Respondents
Patient Experience Courteous and Helpful Office Staff
Never
Almost Never
PCMH E
2%
3%
Average: Other 4 PCMHs
0%
1%
Sometimes
Usually
Courteous and helpful office staff 11% 15% 4%
10%
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Almost Always
Always
16%
53%
PCMH E
2%
5-6 7-8 Overall rating of personal doctor 2% 9% 20%
21%
63%
Average: Other 4 PCMHs
1%
2%
70%
National 50th %tile
National 50th %tile
0-2
67%
19%
76%
Patient Experience Health Literacy 100%
90%
90%
80%
80%
70%
70%
% of Respondents
100%
% of Respondents
3%
9-10
76%
Patient Experience Follow up of Test Results
60% 50% 40% 30% 20%
60% 50% 40% 30% 20%
10% 0%
Never
Almost Never
PCMH E
9%
6%
Average: Other 4 PCMHs
7%
2%
National 50th %tile
3-4
Sometimes
Usually
Follow-up of test results 11% 8% 4%
7%
10%
Almost Always
Always
21%
45%
11%
70% 68%
0%
Never
Almost Never
PCMH E
3%
1%
Average: Other 4 PCMHs
1%
1%
Almost Always
Always
Health literacy 6% 13%
14%
62%
3%
16%
73%
Sometimes
Usually
7%
Coordinated By:
35
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site E
PCMH E: Diabetes Management % Completed Screenings of Patients
Diabetes Management Screening and Testing Outcome measures are based on Hedis and NCQA Standards: http://www.ncqa.org/tabid/59/Default.aspx Diabetes Management Screenings and Testing Outcomes were collected by external nurse consultants and via electronic record data pulls March-June 2011. % of Diabetes Screenings Completed
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
Smoking Cessation 96.0%
44.0%
69.6%
92.4%
LDL-C
Eye Exam
PCMH E
96.0%
87.3%
Average:Other 4 PCMHs
90.1%
87.4%
PCMH E: Diabetes Management % of Total Patients in Each Outcome Measure (for Patients receiving Screenings)
84.7% 74.9%
Blood Pressure Control 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
Cholesterol Control
BP â&#x2030;Ľ140/90mm Hg
BP <140/90mm Hg
BP <130/80mm Hg
A1c >9% 22.9%
A1c <8% 63.6%
A1c<7% 37.9%
PCMH E
33.3%
66.7%
45.3%
Average:Other 4 PCMHs
11.8%
77.9%
55.2%
Average:Other 4 PCMHs
28.7%
71.3%
47.5%
National Comparative
15.0%
60.0%
40.0%
National Comparative
35.0%
25.0%
PCMH E
Foot Exam
Diabetes Management Screening and Testing Outcome measures are based on Hedis and NCQA Standards: http://www.ncqa.org/tabid/59/Default.aspx Outcomes National Comparative sourced from NCQA Diabetes Provider Recognition Program point Table 1: http://www.ncqa.org/tabid/1023/Default.aspx Diabetes Management Screenings and Testing Outcomes were collected by external nurse consultants and via electronic record data pulls March-June 2011.
Blood Sugar Control 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
13.3%
Kidney Assessment 60.0%
A1c
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
LDL-C â&#x2030;Ľ130 mg/dl 20.6%
LDL-C <100mg/dl 51.1%
Average:Other 4 PCMHs
14.8%
61.6%
National Comparative
37.0%
36.0%
PCMH E
Coordinated By:
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Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site E
PCMH E: Patients Self-Health Management
The patients with Diabetes whose screening and test results were reviewed, also were asked to participate in a survey. The Patient Activation Measurement (PAM) survey asks questions regarding confidence to manage your own health. The PAM survey was obtained from Insignia Health: http://www.insigniahealth.com/solutions/patient-activation-measure. "US Adults with Diabetes " was obtained from the Center for Studying Health System Change 2007: http://www.hschange.com/CONTENT/1019/?words=engaged%20consumers.
Patients with Diabetes Self Health Management Assessment % in each stage 100%
0.0%
90%
23.5%
80%
44.0%
37.9%
70% 60% 50%
47.1%
40%
34.6%
35.3%
30% 20%
18.9%
29.4%
11.9% 9.5%
7.9%
PCMH E
Average:Other 4 PCMHs
US Adults with Diabetes
Stage 4: % of Patients that have adopted new actions and behaviors to maintain health
0.0%
44.0%
37.9%
Stage 3: % of Patients starting to build confidence and take action to maintain and improve health
23.5%
34.6%
35.3%
Stage 2: % of Patients that lack confidence or understanding of their health regimen as needed to take action
47.1%
11.9%
18.9%
Stage 1: % of Patients that do not feel confident enough to start to build a role in self-health management
29.4%
9.5%
7.9%
10% 0%
Coordinated By:
37
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site E
PCMH E: Staff Job Satisfaction
Primary Care practice sites' providers and office staff were asked to complete online surveys to measure job satisfaction.
The survey instrument used was obtained from: Mind Garden, Inc. www.mindgarden.com, the Maslach Burnout Inventory survey: http://www.rci.rutgers.edu/~sjacksox/PDF/EvaluatingStress.pdf Surveys were collected March-June 2011.
Level of Optimism/Idealism % of Primary Care Practitioners and Staff with Each Level
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
50.0%
20.8%
29.2%
21.5%
Low
36.3%
Moderate PCMH E
% of Respondents
% of Respondents
Level of Job Energy % of Primary Care Providers and Staff with Each Level
42.2%
% of Respondents
100.0%
Moderate
High
Average: Other 4 PCMHs
Optimism/Idealism: Interest, enthusiasm, cynicism, etc.
54.2%
Workplace Success and Accomplishment: Problem solving, accomplishments, confidence, etc.
33.3% 5.2%
24.3%
21.1%
Energy: Strain, burnout, exhaustion, etc.
83.7%
12.5%
12.5%
Types of Job Satisfaction Survey Questions Asked:
80.0%
20.0%
54.5%
37.5%
PCMH E
Feelings of Workplace Success and Accomplishment % of Primary Care Practitioners and Staff with each level
40.0%
50.0%
Low
High
Average: Other 4 PCMHs
60.0%
100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
11.1%
0.0%
Low
Moderate PCMH E
High
Average: Other 4 PCMHs
Coordinated By:
38
Patient-Centered Primary Care Collaborative of Central Ohio
Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site E
PCMH E: Utilization Measures
500
489
The Utilization measures in this collection may reflect a Primary Care Provider's impact on important health care services received outside of the practice site. Utilization Measures were sourced from some of the Health Plans participating in the Patient-Centered Primary Care Collaborative of Central Ohio, and for Site E reflect 227 attributed patients from 4 Health Plans. The dates of service were year: 2010.
Frequency of Hospitalizations per 1000 patients per year
Frequency of ED Visits per 1000 patients per year 200
400
150
300 100
200
200
50
100 0
0
PCMH E
Average: Other 4 PCMHs
PCMH E
Frequency of Re-hospitalizations (percent of original hospitalizations)
% of Prescriptions filled by Generic 80.0%
8.3%
Average: Other 4 PCMHs
100.0%
15.0%
10.0%
78 57
81.7% 70.1%
60.0%
8.7%
40.0% 5.0% 20.0% 0.0%
0.0%
PCMH E
Average: Other 4 PCMHs
PCMH E
Average: Other 4 PCMHs
Coordinated By:
Health Plan Data Included: Aetna, Anthem, Medigold and UnitedHealthcare 39
Patient-Centered Primary Care Collaborative of Central Ohio Patient-Centered Medical Home (PCMH) Improvement Dashboard-Site E
PCMH E: Utilization Measures
The Utilization measures in this collection may reflect a Primary Care Provider's impact on important health care services received outside of the practice site. Utilization Measures will be sourced from some of the Health Plans participating in the Patient-Centered Primary Care Collaborative of Central Ohio.
Draft of measures new for 2012
High Tech Imaging Visits **Display Only**
Ambulatory Care Sensitive Admissions **Display Only** 200.0 150.0 100.0 50.0 -
200.0
Data Will Be Available in November 2012 PCMH E
150.0 100.0 50.0 -
Average: Other 4 PCMHs
PCMH E
Admissions for Patients with Diabetes **Display Only** 200.0 150.0 100.0 50.0 -
Average: Other 4 PCMHs
Inpatient Length of Stay for Patients with Diabetes (each stay limited to a max of 15) **Display Only**
Data Will Be Available in November 2012 PCMH E
Data Will Be Available in November 2012
20.0 15.0 10.0 5.0 0.0
Average: Other 4 PCMHs
Data Will Be Available in November 2012 PCMH E
Average: Other 4 PCMHs
Coordinated By:
40