Closing a significant care gap while achieving quality outcomes

According to the Centers for Disease Control and Prevention, diabetes is the leading cause of adult-onset blindness. With today's therapies, however, more than 95 percent of vision loss is preventable.

Despite these encouraging odds, many health systems continue to struggle with providing diabetic retinopathy exams (DREs) for their patients with diabetes, as well as patient compliance with the exam. Without DREs, these patients are at significantly greater risk for developing diabetic retinopathy.

Across the U.S., healthcare systems are evaluated on various levels of patient compliance. Those that don't meet specific metrics for DREs, for example, are identified as having a care gap, and CoxHealth was among them.

CoxHealth, the only locally-owned, not-for-profit health system in Springfield, Mo., operates five hospitals and more than 80 physician clinics. Through those avenues, the system administered care to roughly 24,000 patients with diabetes in early 2016, yet its compliance rate for DREs was just 32 percent – a care gap that proved both clinically and financially detrimental to the organization.

Clinically, patients had undiagnosed pathologies, which deterred interventional care. Financially, the system suffered from a failure to attain HEDIS (Healthcare Effectiveness Data and Information Set) quality scores. As a result, from a health plan perspective, CoxHealth Plans – an affiliate of CoxHealth and the only locally based health insurance company in the Ozarks – was only achieving a Star Rating of two rather than hitting the goal of four or five.

It was clear that something had to change.

Two years ago, when I assumed my role as the medical director for CoxHealth's Regional Services, one of my initial responsibilities was to close the care gap for diabetic eye exams. I must admit that I, along with my team, struggled to make an impact on this task. It was evident that we needed to strategically approach this issue in order to find success.

To close the gap, CoxHealth's needs were threefold:
• A solution that was user friendly
• A solution that would standardize workflows with minimal impact to providers
• A solution that is as automated

Based on these criteria, we concluded that a programmatic approach, supported by a bi-directional Cerner Electronic Health Record (EHR) interface, was the best way to drive the results we needed. Intelligent Retinal Imaging Systems (IRIS) was selected to help close our DRE care gap.

However, another essential component toward achieving our goal was to integrate the IRIS solution into our EHR. Without this integration, we would almost be defeating the purpose of the DRE in terms of making it easier to conduct, complete, and have a physician review and act on the results. Once CoxHealth's needs and direction were established, implementation began. A majority of our patients with diabetes are treated across 14 CoxHealth clinic locations, so that is where our efforts were targeted.
The entire implementation, from concept to delivery, took 10 weeks to complete – a very aggressive timeline for any project at CoxHealth – but it was important to place a sense of urgency on this project to ensure completion.

Additionally, the timing was necessary to meet major payer schedules and for increased Risk Adjustment Factor (RAF) scores. We needed to collect at least five or six months of data utilization to make an impact on RAF scores which, along with HEDIS measures, were probably two of our weakest areas.

In the first five months of the program, 2443 patients received a DRE. With this milestone, CoxHealth made significant inroads in several key areas:

• Closing care gaps: 400 patients (16.3 percent) were diagnosed with diabetic retinopathy who otherwise would have likely gone undiagnosed and untreated. Of these patients, 374 were diagnosed with non-proliferative (early stage) diabetic retinopathy, while 26 were given proliferative, vision-threatening diagnoses.

• Improving risk-based performance: 400 diagnoses of diabetic retinopathy will directly elevate HCC (Hierarchical Condition Categories) RAF scores in patients with risk-based payer contracts, and 132 diagnoses of Macular Edema will also help elevate HCC RAF scores in patients with diabetes.

• Enhancing outcomes: A total of 800 eye pathologies were identified, and these patients were referred to an ophthalmologist for treatment they otherwise probably would not have received.

• Automating results: Discrete data is now integrated directly back into the patients' charts, allowing primary care physicians to see end organ damage and create more aggressive care plans. Also, managing the disease in primary care minimizes or altogether avoids expensive therapies in most cases. The patient population is a key beneficiary of reduced cost-of-care.

• Meeting deadlines: As noted earlier, CoxHealth set and achieved its 10-week implementation and training goals with all its exam site targets. This will have a positive impact on our 2016 performance.

Another key result of the implementation is patient and provider satisfaction. For example, primary care physicians can now provide more comprehensive care to their patients with diabetes because they no longer need to spend time on low-value, inefficient tasks. They also have eliminated the need for multiple appointments and office visits.

The success of this implementation can be credited both to the buy-in of our internal leadership team and our collaborative partnership with IRIS. Our physicians realize that this is "best practice" and are assured their patients are receiving the right standard of care. It's also one less burden lifted off their already weighty workload.

Implementation of the IRIS DRE and its integration with the CoxHealth EHR is helping close CoxHealth's diabetic eye exam care gap and elevating HCC RAF scores in risk-based contracts. This means that Cox is receiving increased payments from its payers to care for at-risk members. It also increases revenue from quality incentives, which enables the organization to remain progressive in our mission to improve the health of the communities we serve through quality healthcare, education, and research.

Just five months post implementation, approximately 250 DREs are being performed each month. We are confident we can reach top level goals, having already seen STAR performance for one of our key payers at greater than 60 percent.

In addition to the results we have achieved to date and the visceral impact this program has made from both the patient and provider perspective, CoxHealth would like to emulate this type of implementation in other areas of the organization. We consider this to be a testament to the program's unparalleled success.

Dr. Mark Costley is the medical director for CoxHealth's Regional Services. CoxHealth is a five-hospital, 860 bed health system headquartered in Springfield, Missouri. It serves a 25 county region of Southwest Missouri and Northwest Arkansas.

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