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Maine Quality Counts
Chronic Disease Improvement Collaborative 2
Request for Application
Introduction
Thank you for your interest in the Chronic Disease Improvement Collaborative. Maine Quality Counts (QC), under a contract with the Maine Center for Disease Control and Prevention (Maine CDC), is conducting a collaborative to provide quality improvement support for primary care practices in Maine to improve population health outcomes for patients with hypertension (HTN) and diabetes mellitus (DM). QC will work with primary care practices, provider groups and health systems to improve care through the implementation of quality improvement (QI) processes and the use of Electronic Health Records and Health Information Technology at the provider and system level to ensure reliable systems of care.
Components of the Chronic Disease Improvement Collaborative 2
Maine Quality Counts will offer quality improvement support beginning in the summer of 2015, to include a minimum of 5 and maximum of 10 practices, over a 12 month period (June 2015 – June 2016), and running for 12 months.
The collaborative will provide practice level coaching that will support primary care practices in implementing best practices in chronic disease care and will result in improvements in
hypertension and diabetes outcomes among their patients.
The collaborative will support practices in identifying specific strategies to focus improvement work addressing at least one of the four key drivers to improve BOTH hypertension and diabetes:
(1) optimize registries;
(2) standardize care processes;
(3) incorporate planned care into every visit; and (4) support patient self-management.
Application Process
Interested practices are required to complete this online application in full by Friday, July 3, 2015 by 5PM. Please note that only online applications will be accepted. QC staff will contact interested practices to discuss the project. If selected, practices must complete and submit the Maine Quality
PDF VERSION for REFERENCE ONLY
Only online applications will be accepted
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Counts Chronic Disease Improvement Collaborative for Diabetes and Hypertension Initiative
Memorandum of Agreement (MOA) and Business Associate Agreement (BAA) by June 15, 2015. The MOA and BAA will be available at the Maine Quality Counts website:
www.mainequalitycounts.org/CDIC or you may access them here.
Practices will be selected and notified by: July 10, 2015
CDIC2 Recruitment Informational Webinar: June 25, 2015 (optional)
TeamSTEPPS in person all day training: July 30, 2015 (if not completed previously) CDIC2 Launch Webinar: September 17, 2015 (required)
Applicant Information for CDIC2 1. Contact Information
Practice Site Name Contact Person Email Address Telephone Number Fax Number Website Address Practice Mailing Address
o Street o City/Town o Zip/Postal Code Practice Physical Address
o Street o City/Town o Zip/Postal Code Clinical Provider Lead
o Clinical Provider Lead Telephone Number o Clinical Provider Lead Email Address Lead Administrator
o Lead Administrator Telephone Number o Lead Administrator Email Address
Lead Health Information Technology (HIT) Staff Person o Lead HIT Telephone Number
o Lead HIT Email Address Website
2. Practice Type (choose all that apply):
Single site primary care practice, privately owned
Multi-site primary care practice, privately owned (Please indicated practice group name below
Primary care practice, hospital owned
Residency practice (Please indicate, below, name of residency program Federally Qualified Health Center
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Rural Health Center Other
Please specify: ____________________________________________ 3. Primary care available at this practice (choose all that apply):
Family medicine Internal medicine Pediatrics
Other (please specify) _______________________________________________ 4. What is the estimated number of active primary care patients receiving medical care in your
practice site that are over age 18? Fewer than 1,000 1,001 – 5,000 5,001 – 10,000 10,001 – 20,000 20,001 – 50,000 Over 50,000
5. Practice or organizational leadership is interested in and committed to receiving quality improvement support to improve team-based chronic disease management efforts focused on diabetes and/or hypertension.
Yes
No
Unsure
6. Practice is not engaged in other large-scale improvement projects or does not have other demanding competing priorities.
Yes
No
Not sure
7. Practice or organization is willing and able to identify an “improvement” champion who will be the practice facilitator’s point person.
Yes
No
Unsure
8. Participants of CDIC2 will test a modified Breakthrough Series Collaborative using the Model for Improvement (modified from the IHI’s Collaborative Model for Achieving Breakthrough
Improvement), a structured approach that teams use to accelerate and guide improvement. (Please answer Yes/No to the following):
Organize a Lead Team at your practice (e.g., provider, clinical or admin. staff, etc.) Collect and submit monthly data and monthly Plan-Study-Do-Act Cycles
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Work with Quality Improvement coaches both virtually and onsite
Participate in TeamSTEPPS for Primary Care (if not completed previously) to include: a) 1-hour onboarding webinar on June 3, 2015
b) 3 online video modules with corresponding debrief worksheets c) One full day in-person training on July 30, 2015
Attend 3 Learning Sessions (Oct. 22, 2015; Mar. 17, 2016 & June 16, 2016) Attend 4 Webinars (Sept. 17, 2015; Dec. 17, 2015; Feb. 25, 2016 & Apr. 21, 2016) Complete 3 virtual (online) practice-based self-study learning opportunities Conduct a pre/post assessment
9. Does the practice currently have a Patient/Family Advisor or Advisory Council (or similar group) or other formal mechanism for regularly soliciting input from patients in the practice in its improvement efforts?
Yes
No
Not sure
10. Are you currently collecting and reviewing the following clinical performance measures as part of your quality assurance/quality improvement program? (check all that apply):
The percentage of patients 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year. (NQF 18)
Our practice site collects other clinical performance measures for hypertension
The percentage of members 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the
measurement year. (NQF 59)
Our practice site collects other clinical performance measures for diabetes Our practice site collects other clinical performance measures besides those for
hypertension and diabetes
Our practice site does not collect performance measures
11. Please briefly describe your practice/system’s strategies for improving processes to standardize care processes and team-based practice teams, to improve population health outcomes for patients with hypertension (HTN) and diabetes mellitus (DM).
______________________________________________________________________________ 12. Is your practice interested in obtaining Diabetes Self-Management (DSMT) accreditation? (The
purposed of CMS’ DSMT is to give beneficiaries the knowledge and skills needed to adopt diabetes self-care behaviors and to make lifestyle changes needed to improve health outcomes).
Yes
No
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Our practice is already certified or has a site in the local community to which we refer patients
13. Is your practice interested in becoming certified as a National Diabetes Prevention Program (NDPP) site? (The CDC-led NDPP is an evidence-based lifestyle change program that helps participants make achievable and realistic lifestyle changes to reduce their risk of type 2 diabetes).
Yes
No
Not sure
Our practice is already certified or has a site in the local community to which we refer patients
14. Does this practice site refer patients to other community services for training, technical assistance, and information relating to disease care management? Please mark which of the following you refer to:
Health Maine Partnership Area Agency on Aging
Community Action Partnership (CAP) Catholic Charities
Visiting Nurses Peer Support Groups
Health Clubs (YMCA/YWCA, Community Centers, Private clubs, etc.) Nutrition Counseling (Weight Watchers, Dieticians, etc.)
National Diabetes Prevention Program (NDPP)
Center for Medicare Diabetes Self-Management Training (DSMT)
Telephone help lines (Tobacco Cessation, interactive telephone-based programs, etc) Other (Please Specify) ________________________________________________ 15. Does your practice or center currently have an Electronic Health Record (EHR) system installed
and in use?
Yes
No
16. Please select your vendor from the list of certified systems below and indicate the version number or name. If “other”, please specify:
Allscripts Athena GE Centricity eClinicalWorks (eCW) e-MDs Epic Greenway CompuGroup (HealthPort) IMS
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Resource Patient Management System (RPMS) Vitera
Sevocity SuccessEHS
Other (please specify) ____________________________________________
17. Do you have access to Health Information Technology (HIT) staff who are able to support you and your practice with Electronic Health Record (EHR) needs and technical support to work on a data integration project with Maine CDC and HealthInfoNet?
Yes
No
Not sure
18. Is your practice’s EHR or Information Technology (IT) system currently sending data to HealthInfoNet (HIN) systems?
Yes
No
Not sure
19. Is your EHR system based on the international program standard known as “HL7” so it can support the transfer of clinical and administrative data between software applications?
Yes
No
Not sure
20. If your EHR is based on HL7 (version 2.5 or 2.7), can your EHR share Vital Signs? Yes
No
Not sure
N/A
You may elaborate on your answer below.
____________________________________________________________________ 21. Would you be willing to submit data in one of the following three ways?
Electronic Medical Record (Y/N) HealthInfoNet (Y/N)
Selected Chart Review (a subset of patients, approximately 20 Charts) (Y/N) Other (Please Specify): ___________________________________________
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22. When will your practice have an Electronic Health Record System? 3 months
6 months 1 year or more Not planned
23. Would you be willing to submit data in the following three ways? Electronic Medical Record
HealthInfoNet
Selected Chart Review (a subset of patients, approximately 20 charts)
24. Do you have access to Health Information Technology (HIT) staff who are able to support you and your practice with EHR needs and technical support to work on a data integration project with Maine CDC and HealthInfoNet (HIN)?
Yes
No
Not sure
25. Please indicate whether your practice site has implemented any of the following approaches to team-based care (check all that apply):
Practice uses a team-based approach to care delivery that includes expanded roles of non-physician providers (e.g. nurse practitioners, physician assistants, nurses, medical assistants) to improve clinical workflows
Practice uses planned visits for patients with chronic conditions
Practice has systems in place to delegate specific testing or exams (e.g., ordering of routine screening tests, diabetic foot exams) to non-physician staff through use of standing orders or other established protocols
Practice attended TeamSTEPPS in Primary Care training on March 5, 2015 Practice regularly uses huddles to plan care for scheduled visits
None
Other (Please Specify): _____________________________________________ 26. Please indicate whether your practice regularly uses any of the following reminder systems to
flag patients in need of services? (check all that apply): Disease registry that generates clinician reminders Disease registry that generates patient reminders Checklists/Flowcharts for chronic diseases Checklists/Flowcharts for preventive screening
Computer recall system (for patients needing services)
Telephone recall of patients needing services by nurse/office staff Periodic chart audit
None
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27. A disease registry allows practices to identify patients with one or more specific conditions, supporting the practice’s ability to track and manage care for those patients both individually and as a population. Does this practice site currently use a disease registry?
Yes
No
28. If yes, please indicate which registry is being used: Registry function is provided by our EMR Touch Every Life
MaineHealth Clinical Improvement Registry (CIR) ScoreHealth
Other (Please Specify): _________________________________________________ 29. Do you use your registry to track and manage patients over age 18 with diabetes and/or
hypertension?
Yes
No
30. Please indicate for which conditions it is routinely used at this practice site (check all that apply): Cardiovascular disease
Diabetes Obesity Hypertension Preventive Care
Other (Please specify): __________________________________________________ 31. Does this practice site have care managers who work directly with patients and providers in the
practice?
Yes
No
Not sure
32. Please indicate the patient populations primarily served by the care managers in your practice (check all that apply):
Patients with chronic illness who are failing to meet treatment goals
Patients with high levels of health care utilization (e.g. patients with frequent ED visits, hospitalizations, etc.)
Patients identified as having high health care costs
Other (Please Specify): _________________________________________________ 33. Does your practice site currently participate in any clinical quality public reporting program?
(check all that apply):
Maine Health Management Coalition Pathways to Excellence/Get Better Maine Program NCQA Diabetes
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Bridges to Excellence Diabetes Program Bridges to Excellence Cardiac Care Program
CMS Provider Quality Improvement System (PQRS) Program
No
Other (Please Specify): _________________________________________________ 34. Do any of your contacts with payers include a reward for achieving quality targets?
Yes
No
Not Sure
End of Survey Thank you!
