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Transforming health care through focused learning
By Katie Murray / August 29, 2018 /   Loading Disqus...

At the Rhode Island Foundation’s annual meeting this year, we honored the Care Transformation Collaborative (CTC-RI) with our Community Leadership Award for their innovation, leadership, and impact in the health care realm. As the seventh post in my series on evaluation and learning, I want to highlight the strong work of CTC-RI through their in-depth learning practices and the data that help contribute to and document transformational change.

CTC-RI was co-convened in 2008 by the Office of the Health Insurance Commissioner and the Executive Office of Health and Human Services to promote care through the patient-center medical home (PCMH) model. PCMH practices employ a health care team, led by their doctors, to make sure that all of the pieces are in place to keep patients healthy. The PCMH goal is improved care, lowered costs, and better health outcomes for Rhode Islanders.

When CTC-RI first began there were just five pilot practices. Since then, CTC-RI has worked with 109 practices and more than 750 primary care providers who provide care to more than 650,000 Rhode Islanders. Before becoming full PCMH practices, each of the 81 offices participated in a rigorous, year-long learning experience in a cohort with other practices on their transformation journeys. CTC-RI recently convened a group of practices with activities focused on the need for behavioral health care in primary care practices and another that focused on issues related to maternal depression.

CTC-RI practices receive comprehensive, guided support including time with practice facilitators/coaches who spend time at the office with clinicians and staff and can tailor their support to the unique needs of the practice. Practice facilitators may make recommendations around daily routines and workflow, technology improvements, roles for new clinical staff such as nurse care managers and psychologists, as well as changes in the collection and use of data.

Participating practices also have shared learning opportunities through regular meetings. In June I attended one such meeting of approximately 40 clinical and support staff from 12 practices who are members of CTC’s Integrated Behavioral Health care for pediatrics. Funding for behavioral health services in primary care practices was supported by the Rhode Island Foundation’s Fund for a Healthy Rhode Island 2015 grant program. The practices participating in the June meeting also are members of CTC-RI’s PCMH-Kids program, which is creating patient-centered care in pediatric practices.

The meeting focused very specifically on identifying adolescents at risk for substance abuse. Clinicians from 11 practices reported on their activities in this area, which included a robust discussion of a particular screening tool for adolescent drug and alcohol use. Reporting from these practices was hardly routine or vague. All practitioners in the room were readily engaged in many critical topics related to the issue including patient candor, self-administered surveys versus in-person administration by staff, pros and cons of data tracking in hard copy versus an electronic medical record, confidentiality of the information, and follow-up care for at-risk patients. The session even included role-playing by practitioners with local actors who were recruited to represent skeptical adolescents. This group of practices convenes quarterly for similar practical discussions and will continue to do so for the full year of the learning collaborative.

The CTC-RI team also guides practices around precise measurement specifications that are required for reporting by the Office of the Health Insurance Commissioner. Measures include adult BMI assessment, screening for adult clinical depression and follow up planning, controlling high blood pressure, and comprehensive diabetes control. In monthly meetings and shared data review, practices explore definitions related to each of the measures. For example, practices need to know exactly which patients to include in their reporting by age and enrollment in the practice to determine the appropriate numerators and denominators.

Practices also need to use a uniform measurement timeframe. By definition some timeframes are 12 months and others are 24 months. Each measure also has cases when records may, and should, be excluded from calculations. The attention to these definitions is very important for accurate reporting, for determining year-over-year changes in critical clinical health outcomes, and for informing the incentive payments to practices. Alignment of incentive payments with achieving process measures (such as screening) and outcome measures (such as control) help to improve the quality of primary care, one of the Foundation’s Healthy Lives sector strategies.

While the CTC-RI staff need to explore the nitty-gritty details of the data, the organization also uses high-level data to monitor system-level changes that are occurring. Foremost among them is understanding the contribution of CTC-RI practices to reducing health care costs for Rhode Islanders. In a study conducted in 2017 using data from Rhode Island’s All Payer’s Claims Database, CTC-RI found that that total cost of care spending in 2016 for patients at CTC practices was $217 million less than spending at non-PCMH practices. Understanding the drivers and monitoring the trend of health care costs are important first steps towards controlling health care spending.

Patient centered and accessible primary care are important for improved health outcomes. The PCMH model promotes prevention and wellness, and offers greater access to the primary care team for coordinated treatment. The Rhode Island pediatric PCMH model (PCMH-Kids) was developed with grant support from the Rhode Island Foundation to the Executive Office of Health and Human Services in 2013. Now overseen by CTC-RI, pediatric practices are increasingly adopting the PCMH-Kids model with the goal of providing patient centered primary care which meets the unique needs of children and their families. Through the Foundation’s investments and the continued transformation of primary care, we hope to see progress towards the targets of 90% of adults having a routine annual checkup and 75% of children having a medical home by the year 2025.

The data and related evaluation and learning from initiatives led by organizations such as CTC-RI are critical to understanding the impact of their work. The PCMH model is demonstrating positive progress toward increased primary care access, utilization, and quality, all necessary if our health care system is going to continue the journey toward the Triple Aim goals of improved care, improved health, and lower costs. CTC-RI is a strong teacher as they lead the way. 

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