Data and Measurement

Phase I: Implementing Foundations for Improvement

DOMAIN 4: USE DATA AND MEASUREMENT TO GUIDE PRACTICE CHANGE AND SYSTEM TRANSFORMATION

Use measurement and data to systematically address population health priorities for patient populations with complex needs including behavioral health, medical and social determinants

July – Oct 2016

  • Introduce the BHICCI suite of measures as a population and health management data framework for improving health outcomes for populations with complex needs
  • Develop and test workflows for obtaining first clinical metric (PHQ-9) and incorporating into routine clinical processes (such as PC and care management visits).
  • Introduce and test use of Systematic Caseload Reviews to identify areas for clinical improvement at a population or sub-population level
  • Offer training and technical assistance in use of a Population Heath tool (Excel Registry) for individual patient care and across Target Population
  • Provide support to sites that elect to develop registry functionality in EHRs
  • Begin collecting and entering client data into registry/EHRs
  • Initiate design for transition to web-based registry solution

Oct 2016 – Feb 2017

  • Using IEHP, BHICCI baseline evaluation data and health care organization data, identify and track population level outcomes of target populations in need of integrated complex care
  • Use risk modeling and other objective data to identify a second focus for measurement; propose and test use of a second tool (e.g. SUD tool).
  • Test and implement regular use of Systematic Caseload Reviews to identify areas for clinical improvement at a population or sub-population level
  • Provide technical assistance and training on web-based registry solution
  • Continue to support sites that use EHRs as registry

Feb – July 2017

  • Identify, design and test specific improvements in care for target patient populations with behavioral health and medical conditions as identified through SCR measures and other data
    • Test research and practice-based practices such as disease management, self-management support
  • Continue SCR for populations identified by condition, lack of improvement on measure

Jul 2017 – Feb 2018

  • Measure population level improvements in care for target patient populations based on IEHP, health care organization and eval­uation measures and data.
  • Propose care and wellness improvement BENCHMARKS for target population with reports broken down by organization, clinic, provider, and patient. Test using these reports to drive outcomes im­provement at all levels.
  • Implement care and wellness improvement strategies for target patient populations based on population level outcomes for BH/ medical conditions
Train teams to use data and measurement to guide clinical practice and organizational improvement

July – Oct 2016

  • Introduce team to use of client and system level measures for improvement
  • Develop workflows to use Registry/EHR tool for care management/care coordination

Oct 2016 – Feb 2017

  • Test the repeated use of measures over time to monitor and improve clients’ clinical outcomes
  • Systematic Caseload Reviews (SCR) identify areas for clinical improvement at a population or subpopulation level

Feb – July 2017

  • Continue to use clinical outcome data to guide patietn and popula­tion level improvement through SCR
  • Introduce and test use of measurement-based practice beyond the BHICCI TP within clinic and/or other sites.

Jul 2017 – Feb 2018

  • Implement measurement-based practice beyond the BHICCI TP within clinic
  • Organization spreads use of measure­ment-based practice.

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