Clinical Performance
Clinical Performance
Mount Sinai PPS is actively working with partners to implement clinical initiatives to achieve key performance measures in our three clinical focus areas. These include: (1) Chronic Disease Management; (2) Access, Prevention, and Health promotion; and (3) Care Transitions, Coordination and Management.
MSPPS developed the following five clinical strategies to help guide these implementation activities.
- Identifying, monitoring, and managing patients with diabetes, hypertension, cardiovascular disease, schizophrenia, bi-polar disorder, or are using an antipsychotic;
- Conducting treatment and referral/follow-up for patients who screen positive for acute depression episodes;
- Managing medication for patients who require depression treatment;
- Improving adult access to care; and
- Improving tobacco cessation programs for patients/clients who smoke.
Some clinical strategies fit across multiple clinical focus areas. We are working closely with partners to develop performance dashboards to track progress on performance measures across the board.
Read below for how each clinical strategy fits into each of the three clinical focus areas. Click on the blue buttons to read about our partners' implementation efforts.
01
01 Chronic Disease Management
Chronic Disease Management
This clinical focus area aims to effectively improve and establish chronic disease management including depression, diabetes, cardiovascular disease, schizophrenia, and high blood pressure.
- Establish/improve processes for identification, monitoring, and management for patients with diabetes/cardiovascular disease, hypertension, diabetes/cardiovascular disease with schizophrenia
- Establish/improve the implementation of a treatment plan and referral/follow-up process for patients who screen positive for acute depression episodes
- Establish/improve the implementation of a medication management plan for patients who require ongoing depression treatment
Clinical Strategy #3: Medication management:
Gay Men’s Health Crisis (GMHC) updated its electronic medical record (EMR) to include a medication adherence percentage scale to quantify adherence for behavioral health medications. Providers have begun to use this tool and GMHC will use data generated by the tool to evaluate the efficacy of interventions.
Clinical Strategy #2: Depression Screening Management:
Callen-Lorde is implementing new methods within its organization to increase its depression screening rates. In order to achieve this goal, Callen-Lorde is actively performing chart reviews, developing a system to give feedback to nursing staff about their individual depression screening rates, and adding a checkbox to its clinic communication sheets specific to completion of the PHQ-2 screening tool. Callen-Lorde will continue to monitor these workflow updates and complete case reviews to evaluate screening rates and identify opportunities for improvement.
Clinical Strategy #1: Diabetes Management
Community Healthcare Network (CHN) has purchased hand held retinal cameras and contracted with an ophthalmology service to interpret the cameras’ images to ensure their diabetic patients are receiving annual screenings for retinopathy. By working closely with their Nurse Managers, CHN was able to overcome early challenges such as defining an effective workflow, acquiring the skill to capture good images, and using data to identify patients needing the screening. The cameras are now in use at six clinical sites, and have been instrumental in detecting retinopathy and other pathologies in its patients. Thirty-one percent of the patients who are successfully scanned were diagnosed with a retinal pathology, including retinopathy.
Clinical Strategy #1: Diabetes Management
Ryan Health implemented a multidisciplinary workgroup to improve the number of diabetic patients receiving a retinal screening. The group is made up of physicians, nurses, patient service representatives, and clinical operations staff. They work together to design appropriate screening workflows, review the screening rates on a weekly basis, and revise the way staff ask patients to obtain this screening. As a result, the West 97th Street site saw an increase in retinal screenings from 49% in September 2018 to 68% in November 2018.
Clinical Strategy #1: Chronic Disease Management
Alliance for Positive Change has implemented a Pre-Visit Planning (PVP) strategy to maximize the collaboration and communication between care coordinators and patients and engage patients in their health care decisions. Alliance launched a PVP tool through a MSPPS workgroup in which care coordinators and patients review questions about the patients’ health, medications, and next steps. The care coordinator shares the PVP tool with the patients’ health care provider to fill in any gaps of information. The care coordinator and the patient refer back to the tool for continuity.
Alliance for Positive Change recently presented at February's NYS Fourth Annual Statewide Learning Symposium. Please click here to view its poster presentation.
Clinical Strategy #2: Depression Screening Management:
Apicha Community Health Center (CHC) implemented a new depression screening workflow to improve the referral and follow-up process for patients who screen positive. Prior to its involvement with MSPPS, there was no systematic way of monitoring and tracking depression screenings in the organization. However, since January 2018, Apicha CHC has implemented a new population health management system, ICDP, across its organization to monitor and track these screenings along with analyzing any trends within this data. This tool also integrates seamlessly within Apicha CHC’s EHR. From January 1, 2018 to June 30, 2018, Apicha CHC administered the PHQ-2 exam to 402 patients and 284 of them screened positive. These patients then took the PHQ-9 exam which resulted in 99 patients screening positive. 41% of these patients received follow-up activity documents in their records which could include referral to a mental health service or a discussion with the provider on his/her behavioral/mental health. Apicha CHC’s goal is to increase the percentage of patients screened and documents to 60% by June 30, 2019.
Along with ICDP’s ability to track depression screenings, it also has the ability to send alerts to the care management team if a patient doesn’t attend his/her appointment. Upon receiving the alert, the care manager will follow-up with the patient either via phone call, text, or email to reschedule that patient’s visit. These new systematic improvements resulted in a steady decrease in the number of no-show¬ patients from 40% to 22%.
Clinical Strategy #2: Depression Screening Management:
In late 2017, Planned Parenthood of New York City (PPNYC) implemented a new workflow around depression screenings across its five sites within New York City. The organization targeted two cohorts: patients coming in for a well-visit, and patients who planned on becoming pregnant within the year across their five sites with the screening. During an appointment, a healthcare associate (HCA) will explain to patients the purpose of this screening and then verbally administer the PHQ-2 screening tool. If the patient replies with YES to any of the questions, a PHQ-9 is then administered shortly after. In order to maintain and protect the privacy and comfort of the patient, the HCA will provide the patient with the PHQ-9 tool and leave the room until the patient has completed the tool. Once the PHQ-9 is completed, the HCA updates the electronic health record with this information and a calculation is performed to help determine the patient’s next steps.
During that visit, a provider will then review the results with the patient. If a patient scores above a six on the PHQ-9 screening tool, the provider will encourage the patient to meet with a social worker on that same day to develop a safety plan. PPNYC is unique in the sense that it has social workers on-site at all five of its locations. Vice President of HealthCare Planning at PPNYC, Alice Berger, R.N., M.P.H., said of this, “Because we have social workers on all of our sites, it was an opportunity for us to put this warm-hand off plan in place for where we could refer patients, especially if they score in the moderate or severe bracket.”
To ensure consistency across the five sites, Planned Parenthood distributed emails to its staff on this new process and held in-person trainings to review this new workflow. Supervisors also reviewed this process with the HCAs to make these screenings more automatic during patient visits.
Results: To date 2,097 patients have been screened for depression using the PHQ-2screening tool. PPNYC has received positive feedback. The inclusion of depression screenings into its workflow not only aligns with Mount Sinai PPS’ behavioral health strategy, but also aligns in the direction in which healthcare is moving in general. In fact, PPNYC has found that there are a fair number of patients screened who are diagnosed with mild depression, which helps them bring forward inform new resources and strategies.
For more information on PPNYC, please click here.
02
02 Access, Prevention, Health Promotion
Access, Prevention, Health Promotion
This clinical focus area aims to increase access to preventive care and health promotion.
- Establish/improve a program that increases adult access to care
- Establish/improve tobacco cessation programs for patients/clients who smoke
Clinical Strategy #5: Tobacco Cessation Improvement
Community Healthcare Network (CHN) has begun sending informational emails to its staff providers to educate them on different tobacco cessation topics/techniques for their patients. The topics are designed to address questions that a knowledgeable primary care provider might ask such as, “How do I dose the nicotine patch?”, “Is Chantix contraindicated in people with depression?”, and “Are e-cigarettes better than combustion cigarettes?” CHN leveraged its partnership with New York City Treats Tobacco (NYCTT) in developing the content of the messages. Additionally, CHN dedicated its August 2018 behavioral health team meeting to educate the entire behavioral health team comprised of therapists and providers on the increased prevalence of cigarette smoking among patients with behavioral health issues and how to appropriately treat these issues.
Clinical Strategy #4: Access to Care:
Community Healthcare Network (CHN) is collaborating with CityMD to provide CHN’s primary care patients with efficient, coordinated referrals for urgent and off-hours care. CityMD patients will also have access to primary care providers at CHN. CHN and CityMD are working together to improve access for Medicaid members and reducing hospital ED usage for non-emergent care.
Clinical Strategy #4: Access to care:
Planned Parenthood of New York City (PPNYC) implemented a system called, the Online Appointment Scheduling System (DOCASAP software), which allows patients to schedule appointments online. Since its launch in November 2017, approximately 30% of sexual and reproductive health appointments have been booked online. The organization plans to expand its appointments to other service areas.
Clinical Strategy #4: Access to care:
Advantage Care Physicians created a new type of visit in its scheduling system: Nurse Visits. These visits are used to address some acute care conditions such as upper respiratory infections and for follow-up care with established patients, such as blood pressure checks, HbA1c tests, or a flu shots. The availability of these visits has increased access to care for patients, allowed physicians to focus on more complex cases, and increased autonomy for nurses.
Clinical Strategy #4: Access to care:
Callen-Lorde’s recently implemented FlexCare, an open access program that offers primary care patients the option to walk in for a visit without a scheduled appointment. The program aims to reduce no-show rates for scheduled appointments, minimize the number of patients utilizing urgent care facilities for non-urgent requests, and increase access to primary care. Two medical providers are available to see Callen-Lorde patients Monday to Friday from 12pm to 5pm.
As a part of the pilot, which started in September 2017, patients who missed at least six appointments in a six month period received an outreach letter and phone call with information about the program. Since the pilot, Callen-Lorde has seen a 20% increase in the number of patients who are using a FlexCare provider for their primary care. Approximately 15-20 patients utilize this service daily.
Clinical Strategy #5: Tobacco Cessation Improvement
The Institute for Family Health (IFH) implemented a workgroup for their tobacco initiative that originated from DY4PP2 Clinical Strategy 5 aimed at improving tobacco cessation programs for patients/clients who use tobacco. The workgroup is comprised of internal team members that meet weekly to further discuss how they can improve tobacco cessation efforts within the IFH practices. Team members include a Mental Health Clinician, Director of Population Performance, Director of Substance Use prevention, Family Doctor (with interest in smoking cessation), and the Director of Advanced Primary Care. This workgroup was formed in April 2018 and allows staff the ability to note tobacco users with comorbidities, strategize how to implement a harm reduction model, adjust workflows/policies/procedures, train staff and provide outreach to patients. Most recently, IFH updated its EMR system to help identify those clients that have a high cardiovascular risk which could be significantly reduced by tobacco cessation.
03
03 Care Transition, Coordination and Management
Care Transition, Coordination and Management
This clinical focus area aims to develop an integrated delivery system, develop transition services after hospitalization, and reduce hospital readmissions.
- Establish/improve the implementation of a treatment plan and referral/follow-up process for patients who screen positive for acute depression episodes
- Establish/improve the implementation of a medication management plan for patients who require ongoing depression treatment
Clinical Strategy #3: Medication management:
Gay Men’s Health Crisis (GMHC) updated its electronic medical record (EMR) to include a medication adherence percentage scale to quantify adherence for behavioral health medications. Providers have begun to use this tool and GMHC will use data generated by the tool to evaluate the efficacy of interventions.
Clinical Strategy #2: Depression Screening Management:
Callen-Lorde is implementing new methods within its organization to increase its depression screening rates. In order to achieve this goal, Callen-Lorde is actively performing chart reviews, developing a system to give feedback to nursing staff about their individual depression screening rates, and adding a checkbox to its clinic communication sheets specific to completion of the PHQ-2 screening tool. Callen-Lorde will continue to monitor these workflow updates and complete case reviews to evaluate screening rates and identify opportunities for improvement
Clinical Strategy #2: Depression Screening Management
Apicha Community Health Center (CHC) implemented a new depression screening workflow to improve the referral and follow-up process for patients who screen positive. Prior to its involvement with MSPPS, there was no systematic way of monitoring and tracking depression screenings in the organization. However, since January 2018, Apicha CHC has implemented a new population health management system, ICDP, across its organization to monitor and track these screenings along with analyzing any trends within this data. This tool also integrates seamlessly within Apicha CHC’s EHR. From January 1, 2018 to June 30, 2018, Apicha CHC administered the PHQ-2 exam to 402 patients and 284 of them screened positive. These patients then took the PHQ-9 exam which resulted in 99 patients screening positive. 41% of these patients received follow-up activity documents in their records which could include referral to a mental health service or a discussion with the provider on his/her behavioral/mental health. Apicha CHC’s goal is to increase the percentage of patients screened and documents to 60% by June 30, 2019.
Along with ICDP’s ability to track depression screenings, it also has the ability to send alerts to the care management team if a patient doesn’t attend his/her appointment. Upon receiving the alert, the care manager will follow-up with the patient either via phone call, text, or email to reschedule that patient’s visit. These new systematic improvements resulted in a steady decrease in the number of no-show¬ patients from 40% to 22%
Clinical Strategy #2: Depression Screening Management:
In late 2017, Planned Parenthood of New York City (PPNYC) implemented a new workflow around depression screenings across its five sites within New York City. The organization targeted two cohorts: patients coming in for a well-visit, and patients who planned on becoming pregnant within the year across their five sites with the screening. During an appointment, a healthcare associate (HCA) will explain to patients the purpose of this screening and then verbally administer the PHQ-2 screening tool. If the patient replies with YES to any of the questions, a PHQ-9 is then administered shortly after. In order to maintain and protect the privacy and comfort of the patient, the HCA will provide the patient with the PHQ-9 tool and leave the room until the patient has completed the tool. Once the PHQ-9 is completed, the HCA updates the electronic health record with this information and a calculation is performed to help determine the patient’s next steps.
During that visit, a provider will then review the results with the patient. If a patient scores above a six on the PHQ-9 screening tool, the provider will encourage the patient to meet with a social worker on that same day to develop a safety plan. PPNYC is unique in the sense that it has social workers on-site at all five of its locations. Vice President of HealthCare Planning at PPNYC, Alice Berger, R.N., M.P.H., said of this, “Because we have social workers on all of our sites, it was an opportunity for us to put this warm-hand off plan in place for where we could refer patients, especially if they score in the moderate or severe bracket.”
To ensure consistency across the five sites, Planned Parenthood distributed emails to its staff on this new process and held in-person trainings to review this new workflow. Supervisors also reviewed this process with the HCAs to make these screenings more automatic during patient visits.
Results: To date 2,097 patients have been screened for depression using the PHQ-2screening tool. PPNYC has received positive feedback. The inclusion of depression screenings into its workflow not only aligns with Mount Sinai PPS’ behavioral health strategy, but also aligns in the direction in which healthcare is moving in general. In fact, PPNYC has found that there are a fair number of patients screened who are diagnosed with mild depression, which helps them bring forward inform new resources and strategies.
For more information on PPNYC, please click here.
For a list of the corresponding DSRIP measures that fall under each clinical strategy, please click here to download the PDF overview.
