Message from the Medical Director

Health Care Transformation Requires Innovation and Partnership

	Dan Elliott, M.D., MSCE, FACP

As you know, the world of health care is undergoing rapid transformation. Everyone is in agreement that we need to achieve the Triple Aim – better health, better health care and lower cost – but for some time, this has felt distant from day-to-day practice. Now changes in payment models, such as the introduction of Accountable Care Organizations, are dramatically changing the landscape, putting pressure on organizations and communities to rethink the way they provide and pay for care. CMS has indicated that the speed of change to value-based payment is only going to increase, and we need to be ready.

Christiana Care Quality Partners was designed to help our community of physicians optimize care and deliver the Triple Aim. In 2015, our first full year, we established the foundation and structure of a meaningful clinical network. To some, Quality Partners may appear to be “just another payor,” and one, no less, with a small patient volume, currently some 20,000 individuals. But many of you have begun to see the benefits of a strong physician network, uniting us to lead our community in delivering high quality, high value, collaborative care. Collectively, the 2,600 physician members are Quality Partners’ most important asset. The organization will succeed only if physicians in our community begin to see Quality Partners as an organization in which we can work together to engage in value-based payment.

In my few short months as medical director, I have watched our committee members grow increasingly comfortable engaging in concepts that are critical to our future success, such as changes in payment/reimbursement, defining quality, understanding the value of data and developing care coordination capabilities. Our community providers will need the expertise to address this essential work, and your participation and engagement as network physician partners will be crucial to our collective continued progress.

Now with one full year of network life under our belts, which has been focused on the basics of building a strong foundation, we must turn our attention in 2016 to assume responsibility for the cost and the quality of care we provide to our patients. As you and I know, this effort is so much more than hitting a quality metric, conceived from a sum total of measures that we can potentially deconstruct to reveal significant flaws. The task ahead will also require more than simply cutting costs, or commercially speaking, “decreasing our per-member per-month (PMPM) costs.” It will require us as physicians to rethink the way we deliver care as a community, and to identify the key supports that we need to develop across our community.

A key goal for 2016 will be to strengthen our network identity and further build a shared culture of high performance as an integrated network. This starts with the commitment of each individual provider to serve his or her patients with the most efficient and effective care delivery system possible and to actively communicate and collaborate with the other providers in the network to achieve this universal goal. It also requires identifying and taking meaningful steps toward developing a shared infrastructure to facilitate our work as a network. We are currently engaged in defining these critical next steps.

This newsletter is an important conduit for communication within and beyond our network. We intend to include updates from your colleagues who serve as committee chairs and Service Line representatives, review current network performance, identify key clinical areas to define our standards of care and keep you abreast of key administrative and clinical changes within the Quality Partners network. We hope you find this information helpful.

As we look back to 2015 as our “foundation” year, my intent is that one year from now we will look back at 2016 as the year we took dramatic steps toward developing a sustainable and innovative, high performance clinical network for our patients and our providers.

Your feedback is encouraged and appreciated.

Best regards,

Dan Elliott, M.D., MSCE, FACP

Medical Director, Christiana Care Quality Partners

On the line – news from our Quality Partner Service Line Leads

Strategy + Bench Strength = Success for the Acute Medicine Service Line

By John Powell, M.D., MHCDS, FACEP, medical director of the Christiana Hospital Emergency Department and Quality Partners Leader for the Acute Medicine Service Line.

Our health system’s transition to a new “service line” structure will improve our ability to provide optimum care and services to our community.

Our health system’s transition to a new “service line” structure will improve our ability to provide optimum care and services to our community.

We are strengthening the vitality of our organization while simultaneously improving the patient experience within it. When you think about it – the two are mutually dependent.

In this effort, the Acute Medicine Service Line (AMSL), a Medicine/Emergency Medicine collaborative, has what I would consider an ideal lineup. Our Leadership Team oversees strategic issues and is directed by Virginia Collier, M.D., MACP, service line leader, Charles Reese, IV, M.D., FACEP, service line associate leader, our operational and nursing leaders, IT liaison and Quality Partner leader (that is my role).

Our key assets and “bench strength” come from the members of the Operational Teams we have assembled. These are the A-listers selected from both Medicine and Emergency Medicine. The hands-on, day-to-day experience of this multi-specialty collective is essential to discern the doable, or “what is possible,” and to transform our strategic goals into practice.

With the new service line structure comes the mandate to standardize patient care in line with institutional goals and to decrease variation among providers both inside hospital walls as well as outside in our community.

One of the benefits of the service line structure is that it helps us to prioritize the work we must do and to direct our resources for optimum outcomes. There are many competing ideas for improvement worthy of attention. By setting our annual operating goals as guideposts, we can be an effective force for system wide changes that reflect our institutional priorities.

A main objective of both the AMSL Leadership and Operational teams is to develop pathways of care designed to improve not only quality and safety but also efficiency and cost-effectiveness. Our pathways will be patient-centric, multidisciplinary in scope, evidence-based and hardwired to lead us into practicing the best medicine for our patients.

We chose to target Chronic Obstructive Pulmonary Disease (COPD) for our initial pathway development, drawing on work already in progress in our Medicine units and Emergency Departments. We gathered nurses, unit-based leaders, hospitalists, pulmonary and critical care specialists, respiratory therapists, case managers and pharmacists to construct the best way to care for our COPD patients in ways that produce the greatest value.

At this juncture, I think it is important to discern the difference between a pathway and a guideline. A pathway may begin as a guideline, but is more intricate and prescribed in what it seeks to accomplish. A pathway should improve the quality of care a patient receives and includes prompts for recommended tests, interventions and imbedded metrics to measure results.

The COPD pathway, for example, might initially begin upon ED arrival with early intervention of standardized, best practices and specialty services that continue through discharge. The beauty of the pathway is that it will ultimately extend to care outside hospital walls. It will blend community resources, patient education on self-management and provider services in a fully integrated continuum of care designed to better manage the patient’s COPD, reduce ED revisits and lower the rate of 30-day hospital readmissions.

In addition to formalizing care pathways, the Acute Medicine Service Line continues to aim for high value scores on all the standard metrics and to standardize care among other disease processes such as sepsis, GI bleeding, pneumonia, syncope, diabetic ketoacidosis and cellulitis. Pathways may develop from these key initiatives in the future.

Right now we are starting with what we know on the inpatient side. The next major step is to address transitions of care to outpatient offices where patients will have the appropriate services wrapped around the care they received in the hospital. This approach will improve our organizational vitality and enhance patient experiences.

Acute Medicine Service Line Leadership Team
Service Line Leader: Virginia Collier, M.D., MACP
Associate Service Line Leader: Charlie Reese, IV, M.D., FACEP
Operational Leader: Kate Rudolph, M.S.
Nursing Leader: Linda Laskowski-Jones, MS, RN
Nursing Leader: Joanne McAuliffe, DNP, RN/MSN, OCN, NEA-BC
CCQP Leader: John Powell, M.D., MHCDS, FACEP
IT Liaison: Bid Schreppler

Acute Medicine Service Line Operational Team - Medicine
Physician Operational Leader: LeRoi Hicks, M.D., MPH
Associate Physician Operational Leader: Vinay Maheshwari, M.D.
Nurse Operational Leader: Suzanne Heath, MS, BSN, RN-BC
Nurse Operational Leader: Mike Knorr, BSN, RN, PCCN
Operational Leader: Kate Rudolph, M.S
Operational Leader: Fran Gott, III, MBA, RRT
Medical Group of Christiana Care: Roger Kerzner, M.D.
Patient Advisor: Christine Chastain-Warheit

Acute Medicine Service Line Operational Team - Emergency Medicine
Physician Operational Leader: Tom Sweeney, M.D., MMM
Associate Physician Operational Leader: Paul Sierzenski, M.D.
Nurse Operational Leader: Karen Toulson, MSN, MBA, RN, CEN, NE-BC
IT Liaison: Tim Shiuh

Clinical Vignettes - The first in our series on Type 2 Diabetes

A Pharmacologic approach to Patients with Type 2 Diabetes – the Prediabetes Stage

By M. James Lenhard, M.D., FACE, FACP, Section Chief, Endocrinology; Medical Director, Metabolic Health Services, and Medical Director, Weight Management Center

Prediabetes is not thought to be a true disease state, but rather a continuum on the spectrum between normal glucose tolerance and overt diabetes. Prediabetes includes impaired fasting glucose, (IFG), impaired glucose tolerance (IGT) and combined glucose intolerance (CGI). These are not clinical entities but rather risk factors for diabetes and cardiovascular disease.

Prediabetes is associated with:

• Physical inactivity
• Obesity (especially abdominal, or visceral)
• Dyslipidemia – High triglycerides and/or low HDL cholesterol
• Hypertension

• An A1C of 5.9-6.1 percent for considering pharmacologic therapy is a suggestion and not a threshold effect. Initiating therapy sooner or later than this is perfectly acceptable, as long as lifestyle modification is attempted first.
• Patients who revert from prediabetes to normal glucose tolerance are ~50 percent less likely to progress to diabetes, even if they again slide into the prediabetes range. A less aggressive approach is appropriate for these patients.
• Just as the A1C can episodically rise in diabetes patients, so can this occur in patients with prediabetes. If there is a small rise in the A1C in the setting of extenuating circumstances, it may not indicate true progression.
• An attempt should be made to distinguish prediabetes associated with the metabolic syndrome from prediabetes of aging.
• Prediabetes is abundantly common in older patients, increasing by ~10 percent per decade. Most of the studies have focused on prediabetes in younger individuals or women with a history of gestational diabetes. A slower rate of progression is often found in older patients, and a less aggressive approach seems appropriate, unless they are obese and have other metabolic disorders.

In Action – following the work of our Quality Partners Committees

Clinical Operations Committee Drives Innovation and Collaboration within the Quality Partner Care Network

By Nathan A. Merriman, M.D.

Quality Partner’s Clinical Operations Committee is tasked with defining and understanding network needs as they pertain to clinical operations and to assist service line leaders with clinical pathway analysis and implementation.

Committee membership is a diverse mix of both Christiana Care physicians and private-practice physicians in the community. Their terms of service extend from one to three years. “Our purpose is to drive the mission of the entire clinical network toward becoming more patient centric, provider sensitive and system aware,” explained Gastroenterologist Nathan Merriman, M.D., MSCE, Clinical Operations Committee chair. “As a committee, we can facilitate that model in a collaborative way with all providers in the network to improve the coordination of care for our patients.”

This multispecialty group meets monthly and members have seen their scope of work evolve dramatically. “Initially, we focused on managing the medical pharmaceuticals process and on developing a robust radiology authorization process that would facilitate physician to physician decision-making,” he explained. “Our mandate grew rapidly, however, into a more comprehensive approach to clinical pathway facilitation and driving collaborative care across the entire network.”

Currently, the committee is focused on the role of information technology in facilitating care coordination and on developing goals for care management. As the service lines develop and implement their respective clinical pathways, the committee will focus on monitoring and analyzing performance outcomes and on establishing a reporting /feedback mechanism for the benefit of all network providers.

Clinical Operations Committee Members
Beth Fisher Jones, D.O., Christiana Care Family Medicine at Middletown
Cynthia Heldt, M.D., The Medical Group of Christiana Care
William Egan, M.D., General Surgery
Steven Katz, M.D., Christiana Care Anesthesiology
Roger Kerzner, M.D., The Medical Group of Christiana Care
Jamil Khatri, M.D., Regional Hematology & Oncology
Nathan Merriman, M.D., MSCE, Gastroenterology Associates, PA, Committee Chairman
John Powell, M.D., FAAEM, Doctors for Emergency Services
Elizabeth Zadzielski, M.D., Christiana Care Obstetrics-Gynecology
Neil Hockstein, M.D., ENT & Allergy of Delaware

Christiana Care Launches Medicare Accountable Care Organization Shared Savings Program

Christiana Care Quality Partners officially launched its Accountable Care Organization Medicare Shared Savings Program on Jan. 1, 2016. The ACO includes 152 primary care physicians from across Delaware. We are particularly pleased that it represents a partnership with employed and private providers affiliated with Christiana Care Health System, Bayhealth Medical Center, Nanticoke Health Services and Westside Family Healthcare. This statewide partnership will allow us to develop a network that we expect will serve more than 25,000 Medicare beneficiaries in the state.

Alan Greenglass, president of Christiana Care Quality Partners and Christiana Care Quality Partners – ACO and senior vice president of Network Development, addresses providers at an ACO kick-off event.

The Quality Partners ACO provides physician members an ideal opportunity to join in transformational change to provide value-based care to patients in our community. Physician members will focus on achieving high clinical quality standards and may share in any savings generated through improvements in the care we provide and help build a collaborative and supportive infrastructure that will position all of us well for the future.

As participants in the ACO, members and their patients will benefit from Christiana Care’s Care Link, a robust information technology-enabled care coordination network that works directly with physicians to support their patients. Care Link harnesses an information technology platform that integrates available sources of a person’s health data – including admission and emergency department visit information, physician visits, lab results, radiologic reports, pharmaceutical use and claims data. This information is integrated into care coordination software that supports Care Link’s interdisciplinary team in providing care coordination services to providers and their patients.

Health Care Delivery Transformation

Six big trends to watch for in health care this year...

Administrative Updates

Year One Primary & Specialty Care Pay-for-Value Outcomes

The goal of Quality Partners is to work collaboratively with the physicians and other healthcare providers throughout our local community to find innovative ways to provide high-quality and cost effective healthcare that our neighbors value. Quality Partners is pleased to announce that based on the outstanding level of care provided during our first year, over $500,000 has been awarded in pay-for-value incentives across the specialties of primary care, hospitalist medicine, nephrology, and emergency medicine.

• - More than 5,000 preventive health interventions performed
• - Primary care physicians reached an 87% generic prescribing rate
• - Establishment of a palliative care program for Emergency Medicine staff
• - Reduction in 72 hour readmission and revisit rates for inpatients

Overview of Primary Care Outcomes

Submit Vaccine Records to the Delaware Vaccine Registry (DelVAX)

State law requires all providers to submit all vaccination records to the Delaware Vaccine Registry (DelVAX). If you have not already done so, you can sign in/up for the registry by clicking here.

Action Required: Register with Geisinger's New Clearinghouse

Please be advised that as of Jan. 1, 2016 Geisinger has transitioned its electronic payments to providers from Emdeon to InstaMed. If you are currently receiving electronic payments and remits from Gesinger, we strongly recommend you register with InstaMed. If you currently receive EFTs and/or electronic EOPs and have not registered with Instamed by Jan. 1, 2016 your practice will revert back to receiving all of this information via postal mail.

Register with Instamed. If you have questions about the registration process or other specifics, contact InstaMed directly at 866-945-7990 or via e-mail. If you have any concerns or issues with this process, contact your provider relations representative.

Care Management Update

Through our partnership with xG Health Solutions, Quality Partners provides Case & Condition Management for Christiana Care Health System employees and their families. Through the use of specially trained nurses, this service complements the physician’s plan of care by:

• Coordinating care and benefits
• Providing patient education
• Performing medicine reconciliation
• Closing care gaps

Resubmitting Denied Claims

When appealing a denied claim, it is critical that you resubmit the claim using Geisinger’s CRFF form along with your supporting documentation. Simply re-submitting the claim again will result in another denial. Click here for the CRFF form and contact your provider relations representative if you have additional questions.

Who to Call at Quality Partners

Click here for a list of numbers you can call based on your need. Do not hesitate to contact your Provider Relations Representative anytime you need assistance. Unsure who your dedicated representative is? Just give us a call at 302-623-7959 and we will put you in touch with the right person.

Provider Relations Representatives
Martin Weitzman 302-623-0363
Angela Williams 302-623-0357

The Quality Partners Team
Alan Greenglass, M.D., Chief Executive Officer
Doug Azar, Senior Vice President
Dan Elliott, M.D., Medical Director
Mike Cinkala, Director, Provider Relations
Amanda Klockars-McMullen, Ph.D., RN, CPHQ, Program Director, Quality & Performance Improvement
Melissa Maule, Administrative Assistant
Martin Weitzman, Provider Relations Representative
Angela Williams, Provider Relations Representative