1 Healthcare Effectiveness Data and Information Set (HEDIS) Measures for Chlamydia and Cervical Cancer Screening Meggan Leary, MN, RN, CNL RN- Risk & Quality Planned Parenthood of Wisconsin Disclosures: None

2 Planned Parenthood of WisconsinMission: To empower all individuals to manage their sexual and reproductive health through patient services, education and advocacy Largest reproductive health care provider in Wisconsin Serving more than 61,000 people annually Established in 1935 (over 80 years ago!)

3 PPWI: Health Centers Planned Parenthood of Wisconsin has 21 health centers throughout the state of Wisconsin. Eau Claire Whitehall Wisconsin Rapids Black River Falls Green Bay Appleton Manitowoc Sparta Oshkosh Legend Planned Parenthood Health Centers Delegate Agency Health Centers Options Essential Health Clinics La Crosse Sheboygan Viroqua Portage West Bend Operate 21 Health Centers throughout the State 19 Family Planning Centers 1 also provides Colposcopy Services (West Allis) 2 Abortion Centers (Madison & Milwaukee) 2 Delegate Agencies As the Title X grant recipient for WI, delegate agencies apply to us for Title X funds. We share our clinical protocols and provide training so that they can provide similar services in areas of the state where PPWI services are not easily accessible. Richland Center Madison (2) Waukesha Milwaukee (5) West Allis Racine Janesville Prairie du Chien Kenosha Beloit Delavan 3

4 PPWI: Health Services Preventative Health ExamsCancer Screening (Breast Exams, Pap Testing) Birth Control STI Testing & Treatment Pregnancy Testing & Options Counseling HPV Vaccine Midlife Services Abortion Care Colposcopy Education

5 Patient Visits By Type: October 2016- September 2016Agency/Statewide: 2015 Agency Annual Report ( ) NEO

6 PPWI: Education School-based & Community-based Education Programs for youth and adults Parent Workshops Peer Youth Health Educators Sex Ed Texting Program Promotores de Salud Professional Training for Organizations Annual Safe Healthy Strong Conference

7 HEDIS HEDIS stands for “Healthcare Effectiveness Data and Information Set” A tool used by >90% of America's health plans to measure performance on important dimensions of care and service 80+ specific measures developed by National Committee for Quality Assurance (NCQA) that are used to evaluate a broad range of health issues Persistence of Beta-Blocker Treatment After a Heart Attack Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults The National Committee for Quality Assurance is a private, non-profit dedicated to improving health care quality HEDIS make it possible to compare how health plans, physicians and health care organizations are meeting evidence-based care standards

8 HEDIS Measures at PPWI Chlamydia (CT) Screening in Women -Percentage of unduplicated female clients, age 16-24, who were identified as sexually active, who had at least one test for CT during the measurement year Cervical Cancer Screening -Percentage of unduplicated female clients, age 21-64, who were screened for cervical cancer using either of the following criteria: Women age 21–64 who had cervical cytology performed in the past 3 years Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed in the past 5 years Preventing Inappropriate Cervical Cancer Screening in Adolescent Females – Percentage of unduplicated female clients who were not screened for cervical cancer Obviously not all HEDIS measures apply to the care provided at PPWI. The following are the specific measures that we’re tracking and working to improve:

9 HEDIS Measures at PPWI Smoking Cessation Counseling - Percentage of clients who are current tobacco users with whom cessation methods or strategies were provided or discussed during the measurement year. BMI Measurement- Percentage of patients who had their body mass index (BMI) documented at an outpatient visit within the past year Some measures, such as measuring BMI, are automatically done by the EHR

10 PPFA Continuous Quality Improvement (CQI) GoalsPlanned Parenthood Federation of America (PPFA) developed a CQI workgroup in January 2013 Currently 30 out of 56 affiliates participate Trend and compare data on a quarterly basis Includes applicable HEDIS measures and metrics around contraceptive use Allows us to compare “apples to apples” with other Planned Parenthood affiliate doing the same work with a similar scope of practice

11 PPFA Continuous Quality Improvement (CQI) GoalsContraceptive measures developed by the U.S. Office of Population Affairs Contraception- Percentage of women at risk of an unintended pregnancy who report using a most or moderately effective form of contraception LARC Contraception- Percentage of women at risk for unintended pregnancy who report using an IUD or implant In addition to the HEDIS measures listed on the previous slides, we also track these metrics Office of Population Affairs is the office within the Department of Health and Human Services that administers the Title X program Endorsed by the National Quality Forum Most Effective Contraception = Sterilization (male or female) and Long-Acting Reversible Contraceptives (e.g. IUDs, Implants) Moderately Effective = oral (pill), patch, ring, diaphragm, cervical cap)

12 Chlamydia Screening Introduced HEDIS to staff in December 2015First training on CT screening initiative in February 2016 % = Baseline Measurement: 39% (2015) CDC Goal: 100% NCQA 50th Percentile Benchmark: 58% Sexually active, female clients, age 16-24, who had at least one test for CT during the measurement year All sexually active, female clients, age 16-24, seen at PPWI during the measurement year This is the first HEDIS measure that we took an active, agency-wide approach to improving PPWI performs combined CT/GC testing NCQA Benchmark: 50th Percentile for health plans that report their HEDIS data

13 Chlamydia Screening StrategiesConsistently use opt-out messaging “Would you like STI screening?” vs. “You are due for routine chlamydia and gonorrhea screening. We’ll do that as part of your visit today.” Utilize Health Center Champions Participate in monthly teleconferences to share best practices and help each other address problems Keep HEDIS momentum going in their health center Frame STI screening as part of routine care Preventative care posters in waiting rooms Opt-Out Messaging Although the metric only applies to females, we’re using opt-out messaging on all patients that are at risk Train staff to quickly identify different ways to see patient’s last screening date in EHR Some centers have front desk staff identifying patient’s due for screening and flagging charts For some, does not come naturally and requires practice Made scripts available A small amount of push-back related to patient autonomy Champions were usually unlicensed support staff Allows them to grow as a leader within their health center

14 Chlamydia Screening StrategiesPreventative care posters in waiting rooms Messaging to reduce stigma (we do this for all patients…we’re not judging your lifestyle or sexual history)

15 Chlamydia Screening StrategiesTarget different types of visits Offer CT/GC screening at all visit types Emergency Contraception and Pregnancy Test visits = recent unprotected sex Collect data and share with centers & staff Metrics posted in break rooms Weekly “shout outs” highlighting top performing health centers Incentives for clinics that meet their goals Quarterly financial incentive for staff when health center meets metric goals

16 Overcoming Common BarriersPatients Time May Not Believe They Are at Risk Asymptomatic Based on their sexual history Fear of Screening Process Discomfort Embarrassment Cost (self-pay patients) Fear of screening patients Some male patients think it required urethral swab We never turn patients away for inability to pay Free testing in April for GYT month

17 Overcoming Common BarriersStaff Adding more services to the visit with no additional time allotted And concern about it’s effect on customer service metrics, such as cycle time and patient satisfaction surveys Modifying workflows to accommodate specimen collection Prioritizing self-collected vaginal swabs for female patients Obtaining “buy in” and maintaining momentum RN on staff who works with clinics to improve efficiency Worked closely with staff to implement strategies for incorporating it into current workflows. Send quarterly positivity rates to show staff the percentage of STIs were identifying at each clinic Shows that their efforts are effective Sometimes surprising when the positivity rates are higher at smaller/ rural centers than in large urban areas

18 Results 2015 Q3 Baseline: 39% 2017 Q1 Average: 80%* NQF version pulls exclusively from claims-based codes. PPFA version pulls from claims-based codes and EHR fields

19 Cervical Cancer ScreeningInitial training on Pap screening initiative in September 2016 % = Baseline Measurement: 20% (Q2 of 2016) NCQA 50th Percentile Benchmark: 61% Female patients age who’ve had a Pap test in last 3 years OR a co-test in the past 5 years (depending on age) Unduplicated female patients age 21-64 Working to replicate the success we’ve had with CT screening NCQA Benchmark: 50th Percentile for health plans that report their HEDIS data

20 PPWI Current Screening GuidelinesRoutine screening in patients without known risk factors HEDIS measure focuses on routine screening. Patients with a history of abnormal Pap test(s) will likely have alternative recommendations Utilized similar strategies as Chlamydia screening Female Patients Routine Screening in Patients without Risk Factors < 21 years old No routine screening 21-29 years old Pap test every 3 years 30-64 years old Co-Test (Pap + HPV test) every 5 years > 65 years old Whether or not to discontinue screening depends on Pap history.

21 Cervical Cancer Screening Barriers for PatientsTime Financial Concerns (self-pay patients) Patients may not believe they are at risk Had HPV vaccine Based on their sexual history Patients uncomfortable with procedure / speculum Never had speculum placed before History of sexual assault or trauma Transgender patients

22 Cervical Cancer Screening Barriers for StaffUnlike CT screening, requires speculum exam with clinician Can’t always accommodate a Pap if the patient is not scheduled for an exam Some non-exam visits are seen via telemedicine Can be easily added to vaginal exam for most symptomatic patients & IUC insertions/removals Thinking about Pap tests only in the context of annual, preventative visit Pap is a lab test that can be added to any visit type Pap testing performed elsewhere Old habits die hard…need to re-train our brains We are able to collect information about a patient’s last pap, if was performed with another provider BUT our EHR doesn’t have a very clean way of using this data Staff may add this info but it is not currently required Staff do not get “credit” for these patients toward their incentive pay since we haven't found a good way to run it in a report

23 Avoiding Unnecessary ScreeningMyth: Female patients should start getting Pap tests as soon as they become sexually active The risks of performing Pap tests on patients <21 years old outweigh the benefits Myth: All females presenting should for an annual, preventative exam should get a Pap as a routine part of the visit A Pap should only be collected if the patient is due for screening. Either Routine, age-based screening recommendations OR Intervals recommended based on prior abnormal results Myth: Routine screening more often than every 3 years (or 5 years if co-testing for ages 30-64) will increase the chance that cervical cancer is detected early More frequent screening does NOT provide more protection Train staff that more testing isn’t necessarily better.

24 Results 2016 Q2 Baseline: 20% 2017 Q1 Average: 31% Work in progressSignificant increase in abnormal results and colposcopies Had to enlist an additional provider and additional follow-up staff to keep up Multiple cancers identified Greater amount of high-grade pap results requiring treatment I think we’ll see a significant increase once we figure out how to accurate collect data on patients who are up-to-date on cervical cancer screening but whose last test was performed outside of the affiliate

25 Lessons Learned Utilizing “champions” to support changes within the health centers Applying benchmarks to our data makes it more meaningful Staff take pride in providing quality care Evidence-based interventions help staff understand the “why” behind protocol and changes Want to see the results STI positivity rates, colposcopy data, etc. Recognition for staff that are performing well Acknowledgement Financial incentives Champions helped garner buy-in from staff and were able to enhance their skills

26 Questions