Integrating Social Determinant of Health Data with Regional Quality Data Reporting
by Heidi Christman, Director of Communications, HCGC
Central Ohio providers continue to be open and transparent with one another about how they perform on specific quality measures with an eye on improving health and healthcare delivery across the region. HCGC is pleased to release our second regional quality report of 2019 with data on nine clinical quality measures from11 healthcare organizations representing over 140 primary care practice sites that are caring for more than 640,000 patients across Central Ohio. Our Quality Improvement Learning Group (QILG) hosts quarterly work sessions for practices and quality improvement system leaders to evaluate regional performance, set goals, and align improvement activities at a system and practice level.
Since 2014, the report has been released twice a year, providing benchmarking, trends and important insights to help as practices strive for continuous improvement. Over the years, HCGC has increased the number of practices from just over 80 reporting in 2014, to 159 in the report released earlier this year. The number of quality measures has also increased as a result of the collaborative work of the QILG.
For the first time, the most current report includes social determinant of health (SDOH) data. HCGC is excited to add this important data to our regional quality reporting, as we feel as though it will inform, expand and improve the clinical data we will continue to collect in conjunction with the traditional regional quality report. We have been able to add SDOH data because of our work with the Central Ohio Pathways HUB (the HUB.) Patient level data has been collected on both risks and outcomes that have addressed client needs in real time through the outstanding work of community health workers (CHWs) identifying, meeting with, and serving clients around central Ohio. The CHWs work at 10 care coordination agencies (CCAs), and are able to find, treat and measure client progress and SDOH data via the HUB’s information technology system. The current report focuses on HUB adult (18+ y/o males & 45+ y/o women) clients to align with the clinical data in the quality report. In this section of the report, we have highlighted hypertension data, again, as a way to align with the Controlling High Blood Pressure measure in the traditional quality report. The two sets of data are not exact comparisons in terms of reporting and collection. The HUB data is self-reported by clients, while the clinical quality transparency data is currently self-reported at the practice level. While we realize that this is just a start, and not yet actionable, we are hopeful that adding SDOH data will provide the building blocks to start gathering, analyzing and one day, acting upon this important information. In the future, we hope to add other SDOH measures that align with the clinical data, including depression/PHQ-9, breast health, pregnancy and infant mortality and diabetes/A1C.
The HUB continues to grow rapidly in terms of clients, services and agencies participating. This growth provides potential for the SDOH data to add further insight to the regional quality report as a whole regarding service delivery, trends, and gaps.
HCGC’s vision for continuing to add this data is to have a functioning integrated data system with multi-level reporting that can be contributed to and shared with providers and community partners to inform connections, performance and improvement work. It is our hope that integrating social and clinical data at a regional level will drive a cultural change in transparency and improvement, not just from a clinical and cost perspective, but also as a way to impact social and public health at a community level.
If you have questions, or would like to participate in our Quality Improvement Learning Group or the Central Ohio Pathways HUB, please contact David Brackett at firstname.lastname@example.org or Carrie Baker at email@example.com.
Emerging Opportunities to Provide Care Coordination through the Central Ohio Pathways HUB
by Heidi Christman, Director of Communications, HCGC
Since January of this year, HCGC has been managing the Central Ohio Pathways HUB, a care coordination program that links the most at-risk populations in our region to services that address their social, economic, and both mental and physical health needs. We have seen great success in connecting clients with several services including insurance enrollment; establishing a medical home with a primary care physician; access to mental health services; addiction and cessation services for drugs, alcohol and nicotine; prenatal and postnatal care for new mothers and their babies; stable, affordable housing; reliable, coordinated transportation; chronic disease management; and various education opportunities regarding a plethora of subject matter including safe sleep for babies and insurance renewal requirements. Through the supervision of ten Care Coordination Agencies (CCAs), our HUB Community Health Workers (CHWs) have enrolled 387 clients in the HUB, with 251 of those individuals being currently active in the system. Those 387 clients have accounted for over 2,800 Pathways, or connections to the aforementioned and other care and services.
At just nine months under HCGC management and just seven months of actively accepting clients, we have seen great opportunity in how we deliver these services to the community. HUBs around the country, and certainly in the state of Ohio have typically been focused on Infant Mortality and efforts to decrease racial disparities in that space. The Central Ohio Pathways HUB has certainly continued that tradition. Since March of this year, our HUB has twenty nine closed Pregnancy Pathways resulting in thirty live births (one set of twins), and twenty five of those births resulted in healthy birthweight babies, including the set of twins. Nineteen of these babies were born to black mothers, six to white mothers, and the remainder were born to mothers of various racial and ethnic backgrounds.
We are proud of this work and plan to expand and improve upon it, and we have also seen great opportunity to utilize all twenty Pathways in other sectors of the population at large. We have been thrilled to share the HUB model with our partners in the Columbus City Attorney’s Office. Since June, City Attorney Zach Klein and his team have put in place a theft diversion pilot program, which allows petty theft offenders to enter the HUB at their first court appearance. If they complete the six-month program by showing progress and a will to engage, the offense is removed from their record. There are currently HUB 26 clients enrolled in this program. City Attorney Klein and the Columbus City Council awarded Central Ohio Pathways HUB $25,000 to cover the care of clients who are not eligible for Medicaid coverage, or, as we call those instances in the HUB, in-kind clients.
Another exciting partnership that we have established just in time for Breast Cancer Awareness Month is with the Susan G. Komen of Columbus Foundation. Komen of Columbus has provided our HUB with a $15,000 grant to provide breast health education and referrals for screening and treatment to women and men who are being seen by a CHW. These grant dollars will also fund in-kind clients who are not covered by Medicaid Managed Care.
Fifty percent of breast cancer deaths in black women in Columbus are found in five zip codes. There are great racial disparities in access to quality breast health screening and referral, and Komen sees the HUB model as a great way to start to help narrow those gaps in access. CHWs in the HUB have access to unique populations, some of which are in those five area codes that are disproportionately affected by lack of access to breast health services. Through this work, CHWs will educate both women and men on self-breast health awareness, encourage clients to assess risk, identify clients at risk and link to available resources, continue addressing the other needs and social determinants of health of clients at risk, and provide feedback to Komen about barriers or issues in the system. CHWs will officially begin providing these services on October 1st, and HCGC looks forward to supporting this important work in our community.
For more information on the Central Ohio Pathways HUB, please visit our website, hcgc.org, or contact the HUB Executive Director, Jenelle Hoseus at firstname.lastname@example.org.
Columbus Medical Association Guest Blog:
Let’s “Move the Needle” on Flu Vaccination in Ohio
The Columbus Medical Association (CMA) is excited to announce that today is the launch of the “Move the Needle Challenge,” an innovative approach to increasing flu vaccinations across Ohio while providing an opportunity for physicians to receive their MOC Part IV quality improvement project credit.
CMA, in collaboration with the Healthcare Collaborative of Greater Columbus (HCGC), is a sponsor for MOC Part IV credit through the AMBS. Already, the CMA has an existing menu of approved Q/I projects and the ability to create new initiatives tailored to specific physicians. But what if all physicians in Central Ohio and beyond collectively participated on one project that would demonstrate the impact they can make in the community? Would it provide a sense of accomplishment for physicians and prove they can work together, outside of systems and specialties, for the greater good?
CMA hopes to answer these questions with the “Move the Needle Challenge.” This initiative is intended for practices, physicians, and patients to pass on to their colleagues or friends so they too can take the “challenge” and increase the number of those vaccinated for the flu this year.
The first organization to accept this challenge is Central Ohio Primary Care (COPC). “Our goal in this campaign is to increase vaccination by 20% between now and the end of the year; we challenge all clinicians in all practice settings across our community to join us," said Bill Wulf, MD, CEO Central Ohio Primary Care. "At Central Ohio Primary Care, we take flu vaccinations for ALL of our patients seriously and are so proud and excited to work with the Columbus Medical Association and our physician colleagues across the community to improve influenza vaccination rates.” said Wulf.
Each practice or participant will be able to set their own goals based on their own data and this is free for members of the CMA. "With CMA's Maintenance of Certification Part IV effort, physicians can receive needed quality improvement credits for their Medical Boards; and patients will be more protected during flu season - it's the right thing to do for our community," Wulf added. So, do what’s right for the community and take the challenge today.
Using Technology to Strengthen Information Sharing Between Clinical and Social Service Organizations in our Community
by Carrie Baker, President and CEO, Healthcare Collaborative of Greater Columbus
For the last several years, the Healthcare Collaborative of Greater Columbus (HCGC) has been working with community partners to work within what we call a "medical neighborhood" so we strengthen information sharing and relationships between clinical and social service organizations in our community.
Because of our partners’ strong commitment to this work we all, as individuals and as a community, have learned so much and embarked on improving quality, value and patient experience by collaborating in our community with the assistance of CliniSync's technology platform to exchange patient data.
We recognize that patient healthcare outcomes are dependent on so much more than what happens inside a primary care or hospital’s physical space. Environmental, social and behavioral factors deeply influence health and healthcare status and are often sighted as a reason many people can’t achieve optimal health, both in our region and across the state and country.
Addressing social determinants of health and promoting better connectivity and coordination among all providers – primary care, behavioral health, social services – and by utilizing state-of-the-art technology to assist in doing so is a hallmark of HCGC’s mission and the core of this work with our partners.
A well-coordinated patient experience requires a complete picture of a patient’s health information. This means that every patient’s healthcare provider has a single point of access for referrals and information sharing—from local healthcare providers, social service agencies, and other healthcare stakeholders.
We know that technology cannot replace strong provider relationships, but it can augment a difficult world where data --from screenings and assessments to making a referral and having access to the referral outcomes in real-time --can make a difference. We know that a single, HIPAA compliant portal where all those working with a patient can communicate, reduce duplication or even locate patients and their records is the right path to be taking. And we are grateful, thanks to all of our partners below, to report that in 2018, CliniSync referrals nearly doubled!
As HCGC embarks on more quality and cost data collection and reporting, on addressing social determinants of health through the Central Ohio Pathways HUB in our community. Together, we support specific pilots and projects in the region-addressing transportation needs: reducing senior malnutrition, engaging employers and patients in taking more of a leadership role in the quality of the healthcare they buy/receive.
In partnership with all of you, we believe 2019 will continue to see increases in collaboration via technology. Below is a list of Medical Neighborhood Partners, with more signing up each week. For additional information, please always feel free to contact email@example.com for more information.
Creating Optimism in Advanced Care Planning Conversations
By Jonathan Thorne, M.D., Internal Medicine
“Quality” and “value” metrics are becoming the vernacular for the American healthcare industry payment models, but do we, healthcare providers, offer our patients choices to achieve the highest “quality of life” and receive the best “economical value” during the final weeks or months before they die? The data reveals missed opportunities abound when it comes to discussing goals of care, Advanced Directives and their documentation.
Retrospectively, my medical school education and residency training zeroed in on identifying and treating every disease in the Kelley’s Textbook of Internal Medicine. As an outpatient PCP for 18 years, my focus was on making sure that I met national standard benchmarks of “quality” healthcare including hgbA1c for diabetics, BP for hypertensive patients, routine vaccines at annual physicals, etc. Of course during my early years in practice, when I was documenting on paper and had more time to spend with each patient, conversations about end of life goals were less taxing and less forced. Then, electronic health records arrived and my time was suddenly consumed with documentation, which is ubiquitous across all medical fields.
As I transitioned into a new role in the local emergency department evaluating my medical group’s patients to reduce ED overutilization and offer alternative treatment plans instead of hospitalizations, I realized that very few patients had Advanced Directives or code status in their records. Many patients have terminal illnesses, end-stage chronic diseases and are severely debilitated physically or mentally, but have not had significant meaningful conversations concerning their prognosis and eventual death with their health care team or families. Furthermore, unexpected situations similar to the unfortunate 1990 Terri Schiavo case occur every day resulting in the emotional division of family members, eventual death of an individual and ultimately the death of a family. Hopeless patient suffering and lack of knowledge about prognosis creates anxiety, worry and depression for everyone involved. Tentatively, I began to give patients and their caregivers the information that they really wanted to know despite being a new face to their health care team. Their appreciation was palpable.
The paucity of meaningful conversations and documentation in combination with the overwhelmingly positive patient and family feedback emboldened me to initiate a pilot program in my company in 2017. Starting with building our electronic health record documentation template into the social history, then having discussions with our nurse and social worker care coordinators who were eager to learn more and help educate patients about advanced directives. However, no one is more impactful with these end of life conversations than the physician providers on the health care team, from PCP’s to specialists, surgeons, gynecologists, etc.
Lastly, during a recent patient “group education” meeting, patients and their family members added that they have financial concerns about costly medical procedures, medications and hospitalizations. Most had experiences with loved ones who had died despite increasingly expensive interventions. If they had been informed of a poor prognosis based on measurable functional status tool, such as ECOG or Palliative Performance scales, then they believed that unnecessary suffering and medical expenses would have been avoided. When I noted statistics revealing healthcare costs are an increasing cause for claiming bankruptcy for Medicare patients and the average one night hospital stay in the lowest acuity bed was over $2000 (a critical care bed was over $10,000), they were less than enthused to be hospitalized if they have a poor long term prognosis. Every patient attending the meeting was interested in learning more about Palliative and Hospice care and the means to attain those services when appropriate.
We all owe our patients and their loved ones the peace of mind that accompanies informed decisions regarding advanced care planning and quality of life during their last months and days. If you were in their shoes, wouldn’t you desire the highest quality and value of care? Do you have your Advanced Directives in place and feel confident that your loved ones know what your desires are when you are incapacitated? I am optimistic that as a healthcare community, central Ohio providers will empower our patients and each other to have impactful conversations about what “quality” and “value” mean to each individual.
Quality Transparency and Improvement Across Central Ohio
by Krista Stock, HCGC VP of Quality and Transformation
Central Ohio providers continue to be open and transparent with one another about how they perform on specific quality measures with an eye on improving health and healthcare delivery across the region. HCGC is excited to share the latest regional quality report for nine quality measures based on 2018 data from 16 healthcare organizations representing 159 practice sites that are caring for over 820,000 patients across Central Ohio. The report also features the top performing practices for each measure. This quality transparency and improvement project continues to grow and evolve and we couldn’t be prouder of the collaborative spirit of all of these healthcare leaders who are voluntarily sharing their data and their quality improvement processes and outcomes with one another.
These partner organizations know that although their improvement activities are key to moving the needle on performance metrics, building a culture of improvement is equally important. Without the right culture, the improvement work could merely be an exercise in checking boxes. Earlier this month, project partners convened to share how they are building a culture of improvement within their organizations. Two physician leaders from two different organizations shared how they are engaging providers and care teams in improvement initiatives by being open and transparent with quality data. They are sharing quality performance scores via reports and dashboards across their organizations. Providers can see how one another perform on specific quality metrics, allowing them to benchmark themselves against one another and identify where improvement opportunities exist. Data is constantly updated so that care teams know how their efforts are impacting their patients. Care teams appreciate the transparency and engage in improvement efforts more readily because they can see the data and monitor changes in performance as they make improvements. Building feedback loops for providers and their care teams helps shape a continuous quality improvement culture. It takes time, but building the right culture is foundational to improving how we deliver care for all of our patients.
As we continue to monitor how we are performing as a region, we constantly remind ourselves that this can be a slow process. But getting as many providers and care teams working together as possible, we can start to make more impactful changes that will benefit all patients in the region. We continue to work with these providers to identify and support collaborative improvement opportunities and welcome other provider organizations who want to be part of this important work. For more information about participating in this project, please visit our website or contact HCGC’s Vice President of Quality and Transformation, Krista Stock at firstname.lastname@example.org.
A Collaborative Approach to Connecting New Mothers to Mental Health Services
By Stephanie Costa, M.D., Kingsdale Gynecologic Associates
Chair, Department of OB/GYN, Riverside Methodist Hospital
I have been a practicing physician in the Columbus area for over twenty years. During that time I have enjoyed cultivating a deep relationship with patients, and I especially enjoy the partnership that develops over the course of one or more pregnancies with my patients. Understandably, it saddens me to see vibrant and loving young women affected by depression or anxiety. Because of the many changes that happen in the body during pregnancy and the postpartum period, women are at risk for developing mood disorders during this otherwise exciting time. Couple that with social expectations to be strong, multitasking superwomen, and many of my patients start to struggle during their pregnancy. This can become increasingly problematic during the postpartum time when sleep deprivation and uncertainties about parenting, not to mention any pre-existing life circumstances or stressors, also come into play.
When I had identified depression or anxiety in my patients in the past, I found that attempts to connect patients to resources for counseling/therapy were less than ideal. It was very difficult and time consuming to try to find an affordable and accessible therapist for patients. When I learned about the planned work between the Healthcare Collaborative of Greater Columbus (HCGC) and Perinatal Outreach and Encouragement for Moms (POEM), I felt I needed to become involved in this effort to improve women’s access to quality mental health care.
The recent collaboration between HCGC, POEM, and community OB/GYN’s and Pediatricians has already been impactful. POEM has provided an easy, streamlined referral process that has markedly decreased the amount of time our office staff has spent making mental health referrals. Once our staff has made an online referral to POEM, our patients typically have a kind voice reaching out to them within 24 hours to arrange their mental health referral. This decreases stress on the patient, and gives them a source of hope that things will improve. Because of the communication back from POEM, I am better able to follow up on a treatment plan for patients. Another important benefit is the increased screening and awareness in our office. Instead of only screening at the postpartum visit, we are now screening at the initial OB visit, at the start of the third trimester, and again postpartum. Our pediatric partners are screening for depression and anxiety when new mothers are taking their baby in for newborn checkups. With the increased screening, patients are becoming aware of symptoms and realizing how common mood disorders are. Many women have not reached out for help previously. Now, I feel we are able to better identify mood disorders and refer before symptoms escalate.
By identifying depression or anxiety earlier, we are hoping to not only improve how women are feeling, but also to have an impact on the health of the infant. Studies have shown that infants born to mothers with anxiety or depression are at increased risk for growth restriction, difficult deliveries, feeding issues, bonding issues, and decreased mental development. Perhaps this work will ultimately reduce the rate of neonatal morbidity and mortality in our community in addition to improving the quality of life for mothers. I have noticed that once we have identified anxiety or
depression in a patient, then initiated treatment, women seem to enjoy their pregnancies more, and are better able to juggle the complexities of the postpartum period. Furthermore, when patients become pregnant again, they are recognizing symptoms and enlisting the help of available resources so they are better able to handle pregnancy and life stressors.
It has been rewarding and invigorating to join HCGC, POEM, and pediatric colleagues to make a meaningful impact on the health and well-being of women and infants in Central Ohio. It also makes me realize that if each one of us contributes in some small way, we can create a shift toward better health for our community.
Carrying Out HCGC’s Mission of Optimal Health for all People in Central Ohio through the
Central Ohio Pathways HUB
By Jenelle Hoseus, MBA, Executive Director, Central Ohio Pathways HUB
With its long-standing history of catalyzing collaboration, HCGC took on an exciting new program earlier this year. As of January 1, 2019, HCGC began management of the Central Ohio Community Pathways HUB.
Previously managed by the United Way of Central Ohio, the work was transferred to HCGC, and we have spent the last several months working through the details and creating processes to ensure the success of the program. Through an RFP process, six new Care Coordination Agencies (CCAs) were selected and the program went live on March 1st! We are so excited to have such an incredible group of local partners to facilitate the work of the HUB. The new CCAs are:
How the Model Works and Early Successes
The aforementioned CCAs all employ Community Health Workers (CHWs) who work in the local community to find at risk individuals and connect them to services to help them achieve better health outcomes and reduce health disparities.
The 19 CHWs and their 11 supervisors are putting in tireless effort and it’s already showing in the data. In the first twenty days of the program, CHWs have engaged 44 clients and identified 260 Pathways, or connections to care and services, to meet their needs. We are elated that the work has gotten off to such a resoundingly positive start.
Many may know the Pathways model in the infant mortality space – where studies have shown remarkable return on investment. Buckeye Health Plan’s study of the efforts in Northwest Ohio showed $2.36 ROI for every dollar spent on the program. We fully intend to use this program for the Infant Mortality Pathway in Central Ohio, but plan to also focus on the other 19 Pathways. Our aim is to utilize all 20 Pathways available through the HUB to ensure people across the region with varying health needs can benefit from the connections made through this model. To learn more about the HUB and the 20 Pathways, visit the Central Ohio Pathways HUB page of our website.
Sharing the work of the HUB with the Community
On March 19th the HUBs from around Ohio came together to host an Advocacy Day at the Capitol to engage and educate our legislators about the work we do. Representative Mark Romanchuk (R), Minority Leader Emilia Sykes (D), and Commission on Minority Health Director Angela Dawson came to support our efforts and helped the HUB representatives with targeting messaging for legislative visits. Having their support in our attempts at the Statehouse has been invaluable and appreciated.
On April 18th, HCGC will host a Regional Learning Session focused on Population Health, where we will be holding a specific discussion around our efforts with the HUB. All six CCAs have been invited to come speak about their mission and experiences to date with the model. For more information and to register for the session, please click here.
As we look forward, we are planning to truly make a difference for those most in need in Central Ohio. The work that the CHWs are doing will go on to impact hundreds, even thousands of lives. To be able to be a part of this necessary and impactful work is an honor for the entire HCGC team. If you are interested in learning more about the HUB, please contact me at email@example.com.
By Krista Stock, Vice President of Quality and Transformation, HCGC
Earlier this month, HCGC hosted a webinar focused on exploring price and quality transparency. Jeffrey Geppert of Battelle Memorial Institute and Dominic Lorusso and Lewis Baez of FAIR Health presented about how price and quality transparency have evolved and where there is opportunity for improvement. If you missed it, you can review slides and resources by clicking here.
HCGC continues to ask ourselves and the community, “does higher quality equate to lower costs in healthcare?” Related, we have been pondering questions like, “is there more we can be doing as a community with cost and quality transparency efforts?” And, “what data are most useful for consumers, employers, providers, enrollees, and others?” We believe these strategic questions will help guide HCGC improvement efforts in partnership with the community.
Since 2014, HCGC has been leading the quality transparency project with our provider partners to collect and share quality data for specific measures that they collaboratively identify as important for patient care. The performance data are shared among the project partners to help one another better understand how we perform as a region and to identify opportunities for improvement.
We initially learned from this project that the process of collecting the data is difficult. Information systems, such as electronic health records, were not primarily developed to support data collection of the clinical care processes. But, they continue to evolve and improve to help providers monitor gaps in care and ways to improve how care is delivered. Beyond the data collection, project partners learned that being transparent is a positive experience and allows all of us to gain new insights into how we can work together to make improvements within our organizations and across our community. Project organization partners, representing 140 primary care practice sites across Central Ohio, currently include:
Berger Health Partners
Central Ohio Primary Care
Heart of Ohio Health Center
Hilliard Family Medicine
Holzer Health System
Lower Lights Christian Community Health Center
Mount Carmel Medical Group
The Ohio State University Wexner Medical Center-Primary Care
We have new providers joining this project every year and look forward to broadening the impact this work has across the region. To learn more about who participates and the collaborative work these providers are doing in the community, please go to our website or contact me at firstname.lastname@example.org
During our webinar earlier this month, we heard that cost data are difficult to find. Recent price transparency efforts and mandates for hospitals to post their prices online are a good first step, but don’t necessarily provide a clear picture of what a patient might actually pay for a service. What can consumers do? One resource for getting cost estimates for specific healthcare services is FAIR Health. Beyond that, talking with their health plan, employer, and provider are good ways to start better understanding price and costs and to potentially avoid surprise medical bills. Recently, HCGC created a data subcommittee of our Board to look at issues of claims data, quality data, and engagement of community employers to see if there are ways we can all collaborate and translate various data sources into useable information for all of us.
We are excited to continue supporting transparency efforts in our community and we hope that others will join these efforts. If you are interested in learning more, please reach out and become involved.