Experience & Learning Event September 18, 2014 April Reporting - - PowerPoint PPT Presentation

Biannual Regional Shared Experience & Learning Event

September 18, 2014

April Reporting

• DY3

– Approved: 237 of 402 milestones/metrics – Payment: $50.6 million (includes monitoring costs) – Remaining DY3: $240.8 million

• DY2 CF Approved

– Approved: 42 of 105 CF milestones/metrics – Payment: $24.2 million

• Total estimated payment: $74.8 million

Category 3 Outcome by OD

OD-1 39% OD-2 2% OD-3 8% OD-4 5% OD-5 0% OD-6 5% OD-7 2% OD-9 12% OD-10 4% OD-11 7% OD-12 12% OD-13 2% OD-14 2% OD-15 0%

Distribution of P4P and P4R Outcome Options

20 40 60 80 100

OD-15 Infectious Disease Management OD-14 Healthcare Workforce OD-13 Palliative Care OD-12 Primary Prevention OD-11 Behavioral Health/Substance Abuse Care OD-10 Quality of Life/Functional Status OD-9 Right Care, Right Setting OD-7 Oral Health OD-6 Patient Satistaction OD-5 Cost of Care OD-4 Potentially Preventable Complications,… OD-3 Potentiall Preventable Readmissions (PPRs) - 30… OD-2 Potentially Preventable Admissions OD-1 Primary Care and Chronic Disease Management

P4P P4R

Most Frequently Selected Cat 3 Outcomes

Outcome ID Outcome Title # of Projects # of Providers IT-1.10 IT-1.10 Diabetes care: HbA1c poor control (>9.0%) 14 11 IT-1.2 IT-1.2 Annual monitoring for patients on persistent medications - Angiotensin Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARBs) 13 4 IT-3.1 IT-3.1 Hospital-Wide All-Cause Unplanned Readmission Rate 12 2 IT-1.7 IT-1.7 Controlling high blood pressure 11 9 IT-1.12 IT-1.12 Diabetes care: Retinal eye exam 9 2 IT-9.2 IT-9.2 Reduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) per 100,000 8 8 IT-9.4.b IT-9.4.b Reduce Emergency Department visits for Diabetes 7 7 IT-6.2.a IT-6.2.a Client Satisfaction Questionnaire 8 (CSQ-8) 7 3 IT-1.22 IT-1.22 Asthma Percent of Opportunity Achieved 7 7 IT-1.8 IT-1.8 Depression management: Screening and Treatment Plan for Clinical Depression 6 3 Grand Total 94 56

83

Plan Modifications

Change Requests

200

Technical Corrections

16

Providers

Providers: HCA, THR Denton, Dallas County HHS, Baylor Scott & White, UTSW, Parkland, Metrocare, Methodist-Dallas, and CMC

Learning Collaborative

• Focus on sharing best practices, learning about

projects, & progress updates

• Process Improvement Cohort
• Cohorts transitioned to Improvement

Collaboratives

– Behavioral Health & ED/Readmissions – Measure the success of RHP 9 – Report monthly or as appropriate for measure

• Aim of Improvement Collaborative:

Reduce Readmissions

Behavioral Health Improvement Collaborative

• Integration of primary care &

behavioral health

• Intervention for targeted populations
• Enhance service availability to

appropriate levels

• Development of crisis stabilization

services

• Workforce enhancement

ED/Readmissions Improvement Collaborative

• Expanding primary & specialty

capacity

• Improving clinical assessment &

monitoring for chronic diseases

• Identification of patients at high risk

for readmissions

• Improving the patient experience

• Midpoint Assessment

– 81 of 131 projects selected

• October Reporting

– Biannual Report – Category 3 Baselines – QPI Reporting

• Learning Collaborative

– Speaker Series # 2: November 11, 2014 – Improvement Collaborative – Biannual Event: January 29, 2015 – PCMH Conference: Spring 2015

RHP 9 Video

Future of Healthcare: Transformation and the Affordable Care Act

Fred Cerise, MD, MPH CEO, Parkland Health & Hospital System

Future of Healthcare: Transformation and the Affordable Care Act

Fred Cerise, M.D., M.P.H. Parkland Health and Hospital System September 18, 2014

14

The Affordable Care Act

• Signed into law by President Obama in March 2010
• Expands insurance coverage through

– Policies that make it easier for individuals to purchase insurance – Subsidies for individuals to purchase insurance – Expansion of Medicaid – Requires individuals and certain employers to have/provide health insurance

• Delivery system reforms designed to

– Contain costs – Improve quality

15

International Comparison

• f Health Spending 1980–2008

16 1000 2000 3000 4000 5000 6000 7000 8000

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

United States Norway Switzerland Canada Netherlands Germany France Denmark Australia Sweden United Kingdom New Zealand

2 4 6 8 10 12 14 16

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

United States France Switzerland Germany Canada Netherlands New Zealand Denmark Sweden United Kingdom Norway Australia

Average spending on health per capita ($US PPP) Total expenditures on health as percent of GDP

Source: OECD Health Data 2010. June 2010.

U.S. Ranks Last of Eleven

17

Uninsured by State

2013-midyear 2014

18 Source: Gallup August 5, 2014

National Health Expenditure Projections: 2013-1023

• Affordable Care Act coverage expansions
• Faster economic growth
• Aging population
• Spending to increase 5.6% in 2014
• Spending increase 6% per year through 2023
• Health share of GDP to grow from 17.2  19.3%

Source: Health Affairs, October 2014. 19

Cumulative Increases in Health Premiums, Workers’ Contributions to Premiums and Workers’ Earnings, 1999-2013

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2013. Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1999-2013; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1999-2013 (April to April). 20

National Health Expenditures

Average Annual Growth

The combined effects of ACA coverage expansions, faster economic growth, and aging of the population will fuel health spending by 5.6% in 2014 and 6.0% per year for 2015–23 with a shift in the mix of payers

59 56 56 54 54 53 52 41 44 44 46 46 47 48 10 20 30 40 50 60 70 2008 2012 2013 2014 2015 2019 2023 Private Government

Source: Sisko, A; Keehan, S; Cuckler, G; Madison, A; Smith, S; Wolfe, C; Stone, D; Lizonitz, J; Poisal, A. “National Health Expenditure Projections, 2013–23:Faster Growth Expected With Expanded Coverage And Improving Economy.” Health Affairs. Oct 2014. 21

ACA: Predominant Reform

• Expand coverage

– Early indications are 5 – 10 million reduction in uninsured (2.5 – 5% reduction) – Higher cost sharing for many new to the market – Questionable impact on beneficiaries and providers

22

No Coverage for Some

In states that do no expand Medicaid under the ACA, there will be large gaps in coverage available for adults

Note: Applies to states that do not expand coverage. In most states not moving forward with the expansion, adults without children are ineligible for Medicaid. 23

Coverage Gap for Adults

24

Without Medicaid expansion, 4.8 million uninsured non-elderly adults below poverty may fall into the coverage gap

Notes: Excludes legal immigrants who have been in the country for five years or less and immigrants who are not lawfully present. The poverty level for a family of 3 in 2013 is $19,530. Source: Kaiser Family Foundation Analysis based on 2014 Medicaid eligibility levels and 2012-2013 Current Population Survey.

ACA Enrollment at Parkland

• 24,000 (16%) of patients eligible for Parkland’s

indigent care program are eligible for Marketplace subsidies

• 1,162 patients with ACA Marketplace plans seen at

Parkland between January 1, 2014 – July 15, 2014

• Open enrollment for 2015 coverage starts on

November 15, 2014 and runs through February 15, 2015

25

Coverage under the ACA

26

Source: Health Care Coverage under the Affordable Care Act – A Progress Report. David Blumenthal M.D., M.P.P. and Sara Collins, PhD. NEJM, July 17, 2014.

“…the sustainability of the coverage expansions will depend to a great extent on the ability to control the overall costs of care in the United States. Otherwise, premiums will become increasingly unaffordable for consumers, employers, and the federal government. Insurers who seek to control those costs through increasingly narrow provider networks across all U.S. insurance markets may ultimately leave Americans less satisfied with their health care. Developing and spreading innovative approaches to health care delivery that provide greater quality at lower cost is the next great challenge facing the nation.”

The Next Great Challenge

27

Institute of Medicine

July 24, 2013 To improve value, CMS should incentivize the clinical and financial integration of health care delivery systems, encouraging

– Coordination of care among providers – Real-time sharing of data to track service use and health

• utcomes

– Assumption of risk for managing the care continuum of their populations

28

ACA: Delivery System Reforms

• Health Homes
• Accountable Care Organizations
• Bundled Payments
• Reduce payments for readmissions and health care

acquired conditions

• Value-Based Purchasing

29

30

Center for Medicare & Medicaid Innovation

• Grant funds for projects provided for in ACA
• Approved projects must

– Lower cost – Improve quality

• Why this remains challenging for providers

31

Center for Medicare & Medicaid Innovation: Themes

• Doing less

– Better Back Care – SMARTCare

• Coordinating care/reducing visits

– e-Consults and e-Referrals

• Why should we expect the hospital to fix everything?

– Medical respite care for homeless

32

Patient-Centered Outcomes Research Institute

• Funds Clinical Effectiveness Research
• Findings may not be construed as mandates,

guidelines, or recommendations for payment, coverage, or used to deny coverage.

“Our projects will emphasize approaches that use electronic health records (EHRs) to identify those at high risk of poor outcomes and system-based

• utreach programs to deliver high-quality, patient-centered care to those

most in need.”

• - Dr. Ethan Halm

33

Comparative Effectiveness of FIT, Colonoscopy, and Usual Care Screening Strategies Aim: Optimize colon cancer screening through personalized regimens in an integrated safety- net clinical provider network serving a large and diverse population of under- and uninsured patients in Dallas “The best test is the test that gets done”

• CDC

34

Transforming Care at Parkland

• Customizing care to improve outcomes and efficiency
• Question the status quo

– Outpatient Antibiotic Treatment (Video) – Parkland Center for Clinical Innovation

• Readmission work

– Community Connections – Sharing savings with community partners

• Predicting sepsis among hospitalized /ED patients

35

OPAT: Data Analysis

2009 - 2013

OPAT: 987 patients Home Health: 264 patients Inpatient: 404 patients Primary diagnosis : no difference between all 3 groups with p=.728

36

Note: OPAT stands for Outpatient Parenteral Antimicrobial Therapy

OPAT: Clinical Outcomes

Outcome OPAT Home Health P-value 30 day all cause readmissions: 2011 17% 28% <.01 60 day all cause readmissions: 2012 24% 37% <.01 180 day all cause readmissions: 2013 37% 52% <.01 Deceased: Overall 4% 11% .002

37

OPAT: Summary

• Decreased length of stay (LOS)
• Reduces risk of hospital acquired infections with shortened

LOS and transition to home setting

• Safe and Effective
• Gives patients a choice
• Implications for other resource limited settings to think

‘outside the box’ of the hospital to deliver care and improve resource utilization

38

Transforming Care at Parkland

• Customizing care to improve outcomes and efficiency
• Question the status quo

– Outpatient Antibiotic Treatment OPAT Video – Parkland Center for Clinical Innovation

• Readmission work

– Community Connections – Sharing savings with community partners

• Predicting sepsis among hospitalized /ED patients

39

Summary

• Health care is expensive and unaffordable for the entire

U.S. population given current practices

• Pressure to provide ongoing access while reducing costs
• Systems must create scale and influence across the

continuum of care

• Systems must be able to measure results and report in

clear, simple terms

40

41

Questions?

Texas Healthcare Transformation and Quality Improvement Program Waiver

Lisa Kirsch Medicaid / CHIP Deputy Director for Healthcare Texas Health & Human Services Commission

Texas Healthcare Transformation and Quality Improvement Program Waiver

September 18, 2014 Lisa Kirsch, Chief Deputy Medicaid/CHIP Director

1115 Transformation Waiver Overview

• Five Year Waiver 2011 – 2016
• Managed care expansion
• Allows statewide Medicaid managed care services –

STAR, STAR+PLUS, and children’s dental managed care

• Supplemental financing component
• Preserves historic upper payment limit (UPL) hospital

funding under a new methodology

• Uncompensated Care (UC) Pool ($17.6 billion)
• Delivery System Reform Incentive Payment (DSRIP) Pool

($11.4 billion)

• Creates Regional Healthcare Partnerships (RHPs)

44

20 RHPs

45

Waiver Goals Advance the Triple Aim: 1) Better care for individuals (including access, quality and health outcomes) 2) Better health for populations 3) Reduced per person costs of providing care Texas DSRIP focuses on both the Medicaid and Low Income Uninsured populations

46

DSRIP Progress to Date

• Waiver approved - December 2011
• 20 Regional Healthcare Partnerships (RHPs)

established - May 2012

• Technical assistance summit - August 2012
• Key protocols approved - August/September 2012
• RHP Plans submitted to HHSC - December 31, 2012
• 20 RHP Plans with over 1300 Category 1 & 2

projects submitted to CMS Spring 2013

• Initial approval of most 4-year projects - May 2013

47

DSRIP Progress to Date

• DSRIP reporting opportunities - August and October 2013,

April 2014

• Over 220 3-year projects received initial CMS approval -

May 2014

• Revised Category 3 outcomes framework negotiated between

CMS and HHSC – February 2014

• Category 3 outcomes finalized for each Category 1 or 2

project – August 2014

• Regional learning collaborative events – 2013/2014
• Independent Assessor/Compliance Monitor contractor on

board - June 2014

• Midpoint assessment review started – August 2014

48

49

DSRIP Status

• There are 1,491 approved and active DSRIP

projects.

• 1,274 4-year projects
• 217 3-year projects
• Major project focuses:
• Over 25% - behavioral healthcare
• 20% - access to primary care
• 18% - chronic care management and helping patients

with complex needs navigate the healthcare system

• 9% - access to specialty care
• 8% - health promotion and disease prevention

50

DSRIP Status

• Through July 2014, DSRIP participants have

earned payments of about $2.58 billion all funds for submission of plans and metric achievement for demonstration years (DYs) 2 and 3.

• The next opportunity to report on DSRIP

achievement will be in October 2014 for payment in January 2015.

• HHSC will be scheduling webinars for early October

related to October reporting, including how to fill out the new Category 3 baseline template and updated Quantifiable Patient Impact (QPI) template

DSRIP Projects – Measuring Success

• Texas is one of the first states to do DSRIP
• Protocols allow providers to select metrics for each

project and what is measured varies across projects

• HHSC will be working with providers, stakeholders

and evaluator to identify best practices

• Along with the metrics reported, other data from

providers also will inform the success of projects

• The level of collaboration among healthcare

providers and other systems continues to evolve

51

DSRIP Projects – Measuring Success

• Learning collaboratives, including regional and statewide
• HHSC’s formal evaluation of the waiver
• An interim evaluation report is due to CMS in 2015
• DSRIP metrics reporting
• Quantifiable Patient Impact (QPI) metrics DY3-5
• Category 3 – improvement in outcome measures related to

each project in DY4-5

• Midpoint assessment beginning now to evaluate the

progress of the projects so far, and to determine if they require any modifications or technical assistance to be successful

52

DSRIP Projects – Measuring Success

Category 3 Outcomes

• It was a challenge to develop an appropriate menu and achievement

methodology given the variety of Texas DSRIP providers and Category 1 & 2 projects

• Over 300 approved measures
• Most measures have a measure steward (AHRQ, NCQA, CDC, NQF) and

are validated

• Some measures were created based on evidence-based guidelines and

practices

• In general, denominators will be on a population larger than the

population served by the Category 1 or 2 project

• The direct correlation between the outcome and Category 1 or 2

intervention will vary by project and size of denominator compared with number served by the project

53

Waiver Extension/Renewal

• The Texas Transformation Waiver is a 5-year Medicaid

demonstration waiver from 2011-2016.

• The Transformation Waiver includes Texas' largest Medicaid

managed care programs (STAR and STAR+PLUS, plus children’s dental managed care), the Uncompensated Care (UC) pool and the Delivery System Reform Incentive Payment (DSRIP) pool.

• To continue these programs and pools, Texas must request a

waiver renewal/extension.

54

Waiver Renewal

• The waiver expires on September 30, 2016.
• Per the Texas waiver terms:
• HHSC must submit a transition plan to the Centers for Medicare &

Medicaid Services (CMS) by March 31, 2015, based on the experience with the DSRIP pools, actual uncompensated care trends in the State, and investment in value based purchasing or

• ther reform options.
• HHSC must submit a renewal request to CMS no later than

September 30, 2015, to request to extend/renew the waiver.

• A waiver renewal request must:
• Meet public notice requirements.
• Include a demonstration summary, demonstration objectives, and

provide evidence of how objectives were met.

55

Pool Transition Plan Due March 2015

• For the March transition plan submission, HHSC plans to

convey the continued need for both UC and DSRIP funds in Texas.

• Texas’ UC burden has not decreased, and the existing funding

sources do not offset all UC costs for Medicaid and indigent patients.

• Regarding DSRIP, more time is needed to evaluate project
• utcomes and lessons learned.
• Texas’ almost 1500 projects received initial approval from mid-2013

through mid-2014.

• Outcomes baseline data will be reporting later this year to measure
• utcomes improvements in years 4 & 5 of the waiver.
• Early results indicate many promising projects, but more information is

needed to identify best practices and how to sustain and replicate them.

56

Timeline to Develop Renewal Request

• HHSC will work with Texas stakeholders to develop the waiver

renewal request.

• HHSC will use information from this summit, the Executive Waiver

Committee, and a forthcoming stakeholder survey to get input about the future of the DSRIP program.

• HHSC plans to begin to draft the renewal request this year prior to the

84th Legislative Session.

• Texas Legislative Session – January-May 2015
• HHSC will hold stakeholder meetings regarding the renewal request

around the state during summer 2015.

• Renewal request due to CMS September 30, 2015
• If Texas submits a 3-year renewal request with no changes to the waiver

terms and conditions, CMS has six months to approve or deny.

• If Texas requests a 5-year renewal, then both HHSC and CMS may request

changes to the current waiver terms and conditions.

57

DSRIP Considerations

DSRIP issues to consider for renewal

• A strength of Texas' DSRIP program is its regional approach to

delivery system reform, with different types of providers working together to improve care.

• HHSC plans to work to further align its quality strategy for Medicaid

managed care and DSRIP.

• How to build on the RHP structure to further strengthen and support

systems of care?

• Given the time it took to get the DSRIP program off the ground

and the deadline for submitting the renewal request, we need to work together to show how DSRIP is improving care for individuals, particularly for Medicaid and low-income uninsured patients, as well as population health.

• Project-level data, preliminary outcomes information, learning

collaboratives, midpoint assessment results, formal waiver evaluation

58

DSRIP Considerations

A possible scenario for the DSRIP renewal ask:

• Request to continue existing projects that are demonstrating

success (but did not get approved and underway until mid- DY2 through mid-DY3).

• Give these projects more time to demonstrate outcomes

improvement

• Allow time to identify best practices
• Develop a strategic plan to further align DSRIP initiatives

and Medicaid managed care.

• For DSRIP funds not allocated to projects as of DY5:
• Use for new, promising initiatives or to enhance successful

projects?

• Establish shared bonus pool for high-performing RHPs?

59

Themes to Consider Based on September Statewide Summit

• DSRIP is a substantial federal investment – Texas needs to

demonstrate the value of the investment

• Need to continue to move to strengthen healthcare systems

– a community of providers coordinating across the care continuum

• Outcomes measurement is important – consider some

funding for shared outcomes at the RHP and/or State level?

• Sustainability going forward – how to take what’s being

learned through DSRIP, sustain/replicate best practices, and embed these practices into everyday Medicaid business?

• Texas is at the forefront of DSRIP renewal (CA is a year

ahead of TX) – need to think what the next phase of DSRIP could look like to build on what we’ve learned so far

60

Next Steps

• Types of questions that will be included in the DSRIP

survey to be released soon:

• After this initial waiver term ends, would you support continuing the

projects that are active at that time to improve healthcare delivery in Texas?

• Would you recommend any structural or administrative changes to the

DSRIP program?

• Would you recommend any financing changes to the DSRIP program?
• Would you recommend any changes regarding how HHSC handles DSRIP

requirements for large/urban providers vs. small/rural providers?

• Would you support an incentive bonus pool for RHPs with particularly

strong achievement? If so, what measures would you recommend for demonstrating regional achievement?

• Do you have suggestions on how to further align DSRIP with Medicaid

managed care?

61

Waiver Communications

• Find updated materials and outreach details:
• http://www.hhsc.state.tx.us/1115-waiver.shtml
• Submit questions to:
• TXHealthcareTransformation@hhsc.state.tx.us

62

Break: 15 Minutes

Let's Work Together

Population Health through Regional Collaboration

Kristin Jenkins, JD President, Dallas-Fort Worth Hospital Council Foundation

Population Health Improvement through Regional Information Sharing and Collaboration RHP 9 Learning Collaborative September 18, 2014

www.dfwhcfoundation.org

Lessons in Collaboration

www.dfwhcfoundation.org

Mission

To serve as a catalyst for continual improvement in community health and healthcare delivery through education, research, communication, collaboration and coordination.

Vision

Act as a trusted community resource to expand knowledge and develop new insight for the continuous improvement of health and healthcare.

67

www.dfwhcfoundation.org

General Collaboration Information

Non-profit foundation affiliated with Dallas-Fort

Non-profit foundation affiliated with Dallas-Fort Worth Hospital Council Information & Quality Services Center in existence for 14 years Service contracts in place with Business Associate Agreements 80+ facilities participate Data submitted to the Texas Healthcare Information Collaborative Information used by all participants and shared with the community

www.dfwhcfoundation.org

Contributing Facilities and Patients

www.dfwhcfoundation.org

How much data is captured in the DFWHC Data Warehouse?

70

www.dfwhcfoundation.org

Information and Quality Services Collaborative Community Health Collaborative Research Collaborative Workforce Development Center Board of Trustees

North Texas Regional Extension Center Texas Quality Initiative

71

Foundation Structure

www.dfwhcfoundation.org

Foundation Committee Structure

DFWHC Foundation Board

• f Trustees

North Texas Health Information and Quality Collaborative Community Health Collaborative Workforce Advisory Committee Research Collaborative North Texas Regional Extension Center Advisory Board Texas Quality Initiative Advisory Board

www.dfwhcfoundation.org

Committee Sub-Structure for Data Management/Use

North Texas Information and Quality Services

Patient Safety and Quality Committee IS Technical Advisory Committee Product Development/Data Users Group Research Committee Nominating Committee

www.dfwhcfoundation.org

Page 74

www.dfwhcfoundation.org

General Description of Information Submitted

• Claims from all participating

hospitals

• “Blinding” of patient identifiers
• No blinding of any other data

elements

• All payers - including self-pay

patients

• All patient encounters except

– outpatient lab – hospital-based outpatient clinic

www.dfwhcfoundation.org

• North Texas Data from 2003 to Present
• Texas State Data 2004 to Present
• Case level detail
• Diagnosis codes 1-25
• Procedure codes 1-25
• All Charge Data

(Total Charge only in Texas State Data)

• Physician ID and Name

(Not included in Texas State Data)

Inpatient Claims Information

www.dfwhcfoundation.org

• North Texas Data from 2006 to Present

– 44 volunteer hospitals 2006 -2009 – All Facilities beginning Q4 2009

• Case level detail
• Diagnosis codes 1-25
• Procedure codes 1-25
• All Charge Data

Outpatient Claims Information

www.dfwhcfoundation.org

Physician ID and Name ER Encounters with NYU Algorithm Observation, GI and Cardiology Encounters Outpatient Claims Information Unique to DFWHC Foundation

www.dfwhcfoundation.org

Regional Enterprise Master Patient Index (REMPI)

• Probabilistic electronic tool that matches patient

encounters across hospitals and systems when applied to the Information and Quality Services Center Data Set

• Identification and analysis of patient activity

regardless of encounter location or payer

• Readmissions
• ER utilization
• Imaging utilization

www.dfwhcfoundation.org

• Regional STS Certified Clinical

Data Registry

• > 90% of North Texas CABG and

AVR Encounters

• REMPI Matching to Claims

Warehouse Information

Texas Quality Initiative

www.dfwhcfoundation.org

Lessons in Collaboration

www.dfwhcfoundation.org

Business Intelligence

 Quality Metrics – Hospital Engagement Network and AHRQ Measures  Improvement of Cardiovascular Services  Readmission Analyses  ER “Frequent Flyer” Reports  Market segment assessments – by service line, physician and geography  Community Health Needs Assessments and Regional Community Health Improvement Reporting  ACO Alignment Information  Regional Health Information Exchange Support  Grants/Research  Compliance and Duplicates

www.dfwhcfoundation.org

• Run on THCIC State Data

– About 1 year lag to most current quarter

• Run on DFWHC Region Wide data

– About 2.5 months lag to end of most current month

www.dfwhcfoundation.org

Using the Information -Community and Population Health Management

• Chronic Conditions
• Emergency Room Utilization
• Form 990 Analyses –

Community Benefit

• 1115 Waiver Metrics

www.dfwhcfoundation.org

Lessons in Collaboration

www.dfwhcfoundation.org

Emergency Room Use Examples

*Source: http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Feb2014/ib_2014feb_enrollment.pdf

• Emergency Room Visits increasing in North Texas at a rate higher than

population growth

• Population Increases in Tarrant and Dallas Counties from 2010 through

2012: 3.9% and 3.6%, respectively*

• Increase in ER visits in North Texas 2010 through 2012:

15.25% (see next slide)

• ER Use is an expensive proposition for the insured population and the tax

payer Upcoming Policy Considerations:

• 1. Impact of the ACA on Health and Cost
• 2. Local solutions for local health needs
• 3. Competitive market for economic growth – healthy

workforce and healthy community

www.dfwhcfoundation.org

Evaluation of High ER Use by Patients Using the REMPI….. And the volume of ER Visits made by those patients

www.dfwhcfoundation.org Statistics of ER cases, Diabetes prevalence and Payer information for high ER visit Zip codes in Dallas and Tarrant counties

Counties Dallas Tarrant High ER visits Zip codes 75216 75217 75243 76119 76112 Number of Patients 6954 7615 6423 5716 4711 ER cases 22500 23839 20688 19163 16622 %Diabetes Prevalence in ER visitors (number of cases with Diabetes) 15% (3027) 14.1% (2943) 8.2% (1591) 11% (2108) 10.2% (1706) Dialysis/end stage kidney complications 1.18% (266) 0.77%(184) 0.42%(87) 0.88%(169) 1.06% (117) Insured 2943 2959 2404 3014 2841 Medicaid 7590 8115 7981 7408 5829 Medicare 3143 2459 1691 1979 1903 Uninsured 8945 10049 8555 6605 5992

www.dfwhcfoundation.org Demographic Information of the Patients in high ER visit Zip codes in Dallas and Tarrant Counties

Counties Dallas Tarrant High ER visits Zip codes 75216 75217 75243 76119 76112

Number of Patients

6,954 7,615 6,423 5,716 4,711

ER cases

22,500 23,839 20,688 19,163 16,622

Adult vs. Pediatric Average Age

43 / 5 40 / 5 38 / 5 41 / 5 39 / 5

Cases

18,212 / 4,288 17,675 / 6,164 15,186 / 5,502 13,971 / 5,192 13,241 / 3,421

Race Black

13,914 7,716 11,860 10,597 9,440

Other

5,351 9,566 4,782 3,919 3,195

White

3,220 6,520 3,564 4,399 3,928

Asian or Pacific Islander

9 19 341 213 51

American Indian / Eskimo / Aleut

6 18 142 35 8

Ethnicity Hispanic or Latino

6,061 8,937 4,401 3,821 1,962

Not Hispanic or Latino

16,439 14,902 16,283 15,334 14,656

NYU Emergent

7,316 7,625 6,302 6,631 5,528

Indeterminate

5,391 5,960 5,140 4,394 3,644

Injury

2,734 2,986 2,673 2,614 2,432

Non-emergent

2,810 3,017 3,114 2,246 2,085

Other

4,248 4,252 3,459 3,277 2,933

Charges Total Charge

53,091,917 59,211,405 49,671,622 45,301,906 41,567,840

Average Charge

2,360 2,484 2,401 2,364 2,501

www.dfwhcfoundation.org ER Hot Blocks in zip code 75216

www.dfwhcfoundation.org Demographic information for the Hot Blocks in zip code 75216

Hot blocks Zip 75216 3500 Block E OVERTON RD 3000 Block E LEDBETTER DR 3300 Block SOUTHERN OAKS BLVD 2700 Block E LEDBETTER DR 2900 Block E KIEST BLVD

ER cases Patients

202 158 100 87 77

Cases

525 407 303 243 233

Adult vs. Pediatric Average Age

39 / 7 38 / 5 40 / 7 39 / 3 30 / 4

Cases

431 / 94 329 / 78 239 / 64 191 / 52 182 / 52

Race Black

332 283 199 147 157

Other

187 116 87 91 72

White

6 8 17 5 4

Ethnicity Not Hispanic

• r Latino

383 338 257 215 208

Hispanic or Latino

142 69 46 28 25

NYU Emergent

162 128 105 77 77

Indeterminate

111 117 59 66 71

Non-emergent

80 54 46 32 26

Injury

69 44 37 33 21

Other

103 64 56 35 38

Charges Total Charge

1,061,538 784,330 844,011 567,963 407,853

Avg Charge

2,022 1,927 2,786 2,337 1,750

www.dfwhcfoundation.org Clinical information of the Patients with high ER visits in zip code 75216

1 2 18 17 BMC University - 15 TH Dallas - 13 HCA Med City Dallas - 2 BMC University - 1 TH Dallas - 1 PHS Parkland - 1 Dal Reg Med Cen - 1 MHS Dallas MC - 1 Cervicalgia Acute bronchitis Abdominal pain, epigastric Bronchitis, not specified as acute or chronic Neck sprain and strain Diabetes mellitus without mention of complication, type II or unspec type Sprain and strain of unspecified site of shoulder and upper arm Periapical abscess without sinus Other acute postoperative pain Unspecified disorder of the teeth and supporting structures 85,624 21,917 4,757 1,289

Emergent

5 12

Indeterminate

3 3

Non-emergent

3 1

Injury

4

Other

3 1 Medicare Medicaid

NYU Payer information

Top Patient 75216 Review

ER cases Hospitals Visited Top 5 Primary Diagnosis codes Total Charge Average Charge

K

www.dfwhcfoundation.org Demographic information for the Hot Blocks in zip code 75217

Hot blocks Zip 75217 200 Block STONEPOR T DR 100 Block S MARDEAUX LN 300 Block N JIM MILLER RD 9700 Block BRUTON RD 200 Block S JIM MILLER RD

ER cases Patients

155 130 85 90 85

Cases

490 399 237 239 221

Adult vs. Pediatric Average Age

37 / 6 34 / 7 32 / 4 34 / 7 38 / 5

Cases

399 / 91 303 / 96 207 / 30 173 / 66 181 / 40

Race Black

316 243 111 142 136

Other

162 151 124 74 79

White

12 5 2 23 6

Ethnicity Not Hispanic

• r Latino

400 303 205 168 159

Hispanic or Latino

90 96 32 71 62

NYU Emergent

143 144 73 82 84

Indeterminate

118 90 48 71 42

Non-emergent

101 52 36 30 31

Injury

50 48 33 22 23

Other

78 65 47 34 41

Charges Total Charge

1,120,587 892,353 579,708 667,821 578,728

Avg Charge

2,287 2,236 2,446 2,794 2,619

www.dfwhcfoundation.org Clinical information of the Patients with high ER visits in zip code 75217

1 2 49 22 BMC University - 29 BMC University - 22 MHS Charlton MC - 16 Tenet Doctors Hosp - 2 Dal Reg Med Cen - 2 Headache Headache Migraine, unspecified without mention of intractable migraine without mention of status migrainosus Other acute pain Unspecified essential hypertension Acute pharyngitis Sprain and strain of unspecified site of back Abdominal pain, unspecified site Sprain and strain of unspecified site of hand Diabetes with unspecified complication, type I [juvenile type] 93,524 65,260 1,909 2,966

Emergent

2 6

Indeterminate

4 5

Non-emergent

40 2

Injury

2 5

Other

1 4 Medicare Medicaid

NYU Payer information

Top Patient 75217 Review

ER cases Hospitals Visited Top 5 Primary Diagnosis codes Total Charge Average Charge

www.dfwhcfoundation.org Demographic information for the Hot Blocks in zip code 75243

Hot blocks Zip 75243 9600 Block FOREST LN 9700 Block FOREST LN 9300 Block SKILLMAN ST 9900 Block ADLETA BLVD 11600 Block AUDELIA RD

ER cases Patients

484 349 284 292 228

Cases

1312 1088 762 743 659

Adult vs. Pediatric Average Age

34 / 4 34 / 4 32 / 4 33 / 5 35 / 4

Cases

834 / 478 798 / 290 545 / 217 615 / 128 493 / 166

Race Black

634 700 462 581 478

Other

382 230 184 123 91

White

255 155 116 39 87

Asian or Pacific Islander

25 3 2

Ethnicity Not Hispanic

• r Latino

947 898 586 621 535

Hispanic or Latino

365 190 176 122 124

NYU Emergent

390 399 252 215 191

Indeterminate

344 261 167 210 176

Non- emergent

193 170 126 114 97

Injury

169 119 77 65 103

Other

216 139 140 139 92

Charges Total Charge 2,938,617 2,744,064 1,668,263 1,677,357 1,545,803 Avg Charge

2,240 2,522 2,189 2,258 2,346

www.dfwhcfoundation.org Clinical information of the Patients with high ER visits in zip code 75243

1 2 62 53 TH Dallas - 22 BRMC Plano - 8 HCA Med City Dallas - 22 HCA MC Plano - 8 BMC Garland - 12 PHS Parkland - 7 PHS Parkland - 5 TH Plano - 7 UTSW St. Paul - 1 TH Allen - 5 Abdominal pain, unspecified site Urinary tract infection, site not specified Chest pain, other Headache Chest pain, unspecified Acute bronchitis Abdominal pain, other specified site Nausea with vomiting Painful respiration Thoracic sprain and strain 316,385 202,065 5,103 3,813

Emergent

41 14

Indeterminate

10 17

Non-emergent

3 8

Injury

4 10

Other

4 4 Medicaid Uninsured

NYU Payer information

Top Patient 75243 Review

ER cases Hospitals Visited Top 5 Primary Diagnosis codes Total Charge Average Charge

www.dfwhcfoundation.org

ER Dashboards - Quality Data

Following is a look at the top uninsured patients with a COPD diagnosis in the past year.

www.dfwhcfoundation.org

ER Patients in North Texas 2010 2011 2012 Number of Patients* 1,240,553 1,326,211 1,402,052 ER cases** 2,009,755 2,204,780 2,316,305 Diabetes Prevalence in ER visitors (number of cases with Diabetes and Percent Prevalence) 151,556 (8.19%) 173,867 (7.63%) 187,901(7.46%) Dialysis/end stage kidney complications 24,296 28,693 33,279 NYU Case Counts Emergent *** 630,759 680,392 724,861 Indeterminate 418,193 464,627 485,108 Injury 436,816 469,059 473,246 Non-emergent 213,742 241,231 258,625 Mental Health 42,266 47,366 54,309 Alcohol 10,374 11,577 12,264 Substance Abuse 3,984 4,972 5,819 Unclassified 253,621 285,556 302,073 Charges Total Charge 5,403,037,974 6,293,336,132 6,911,427,074

New York University Algorithm (NYU) case counts and Total Charges of ER cases in North Texas in 2010-2012

*number of out patient emergency room patients during 2010-2012 ** number of ER visits made by these unique patients during 2010-2012 *** preventable and non-preventable as well as primary care treatable emergent visits

www.dfwhcfoundation.org

NYU Algorithm– Non-Emergent Encounters

• Emergent/Primary Care Treatable - Based on information in the record, treatment was required within 12

hours, but care could have been provided effectively and safely in a primary care setting. The complaint did not require continuous observation, and no procedures were performed or resources used that are not available in a primary care setting (e.g., CAT scan or certain lab tests)

• Non-emergent - The patient's initial complaint, presenting symptoms, vital signs, medical history, and age

indicated that immediate medical care was not required within 12 hours

www.dfwhcfoundation.org

Single County OP ED Cases

www.dfwhcfoundation.org

56,624 63,915 72,392

10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 2010 2011 2012

Mental Health, Alcohol and Substance Abuse related ER cases in North Texas in 2010-2012

www.dfwhcfoundation.org

Single County OP ED Cases

www.dfwhcfoundation.org

Single County OP ED Cases – Classification Percentages: Visit Types

www.dfwhcfoundation.org

0% 10% 20% 30% 40% 50% 2010 2011 2012 Insured Uninsured Medicaid Medicare

Payer information of ER cases in North Texas in 2010-2012

www.dfwhcfoundation.org

ER Patients by Counties Dallas Tarrant Collin Denton Johnson Ellis All Others* Number of Patients** 544,187 386,786 123,737 101,207 45,560 32,547 168,028 ER cases*** 912,302 665,347 184,934 157,806 84,758 50,573 260,585 ER cases per 1000 patients 1670 1720 1491 1558 1860 1553 1552 %Diabetes Prevalence in ER visitors (number of cases with Diabetes) 9.1% (81,402) 8.1% (54,021) 6.0% (11,139) 6.2% (9,735) 7.9% (6,746) 8.3% (4,192) 7.9% (20,666) Dialysis/end stage kidney complications 2.1% (19,003) 1.2% (7,924) 0.8% (1,421) 0.7% (1,054) 0.8% (714) 1.1% (569) 1% (2,594) Adult vs Pediatric Average Age 42 / 6 43 / 7 44 / 7 43 / 7 45 / 7 45 / 7 46 / 7 Cases 653,891 / 258,411 483,635 / 181,712 127,351 / 57,583 110,992 / 46,814 60,440 / 24,318 35,444 / 15,129 199,477 / 61,158 NYU Emergent**** 282,107 210,784 56,079 49,401 26,250 16,004 84,135 Indeterminate 209,267 135,095 34,912 29,372 17,413 10,309 48,929 Injury 161,359 137,269 44,568 38,501 18,856 11,629 60,816 Non-emergent 107,392 73,269 19,542 16,682 10,180 5,186 26,478 Other 152,176 108,930 29,833 23,850 12,058 7,445 40,226 Charges Total Charge 2,487,677,034 1,920,854,981 697,030,380 591,201,929 235,147,078 136,061,779 843,453,893 Average Charge 2,727 2,887 3,769 3,746 2,774 2,690 3,237

*include any emergency room visit outside these 6 counties including counties outside the state of Texas. **number of out patient emergency room patients in 2012 *** number of ER visits made by these unique patients in 2012 **** preventable and non-preventable as well as primary care treatable emergent visits

Statistics, Diabetes and Kidney complications prevalence, NYU and Charges information for ER visits in North Texas Counties in 2012*

www.dfwhcfoundation.org

Readmission Quality Data

www.dfwhcfoundation.org

Readmission Quality Data

www.dfwhcfoundation.org

www.healthyntexas.org

www.dfwhcfoundation.org

Grants and Research – Partial List

• Cardiac Research- UTSW Heart Study
• VTE – Baylor and Sanofi Aventis
• Injury Prevention Center and Genesis – Domestic Abuse and Child

Endangerment

• Abdominal Aortic Aneurysms Registry – Baylor Research Institute
• Tarrant County United Way Aging Study
• EPA and ER Admission Study – Emory and Georgia Tech
• Readmission Studies (multiple with local partners)
• Trauma studies – Parkland/UTSW
• Cardiovascular Surgery Research (3 projects) – Baylor Research Institute
• Multiple submitted studies through UNTHSC –ER and Behavioral Health
• Hospital Engagement Network CMS Contractor
• Public Policy evaluations of Mental and Physical Health patients - Meadows

www.dfwhcfoundation.org

ACO Alignment Information

• Physician Patterns
• “Leakage” to non-ACO aligned providers
• Patient Analyses by geography, payer mix, migration,

readmission, ER visits and co-morbidities, APR-DRG risk categories

• Combined clinical and claims warehouses and

business intelligence across all providers within the continuum of care

• Privacy Issues**

www.dfwhcfoundation.org

Regional Health Information Exchange Support

Current

Use of the Regional Master Patient Index for matching in NTAHP HIE

Future HIE Analytics for Regional Exchange of

patient information Warehouse to include clinical and claims information

www.dfwhcfoundation.org

New partners – More insight

• Physician Claims

Warehouse

• LTAC Claims
• SNF MDS
• Home Health

Providers

www.dfwhcfoundation.org

Lessons in Collaboration

www.dfwhcfoundation.org

Questions? Contact

Kristin Jenkins kjenkins@dfwhcfoundation.org

• r 817-319-3587

Dallas-Fort Worth Hospital Council Education and Research Foundation Thank you!

Dan Corley, PhD Director of Authorization & Utilizations

RHP9 IMPROVEMENT

COGNITIVE ENHANCEMENT THERAPY

(CET)

PROVIDER IDENTIFICATION: 121988304.2.1

DAN CORLEY, PHD, LPC, NCC, CCMHC

DIRECTOR OF AUTHORIZATION AND UTILIZATIONS

1SKYLINE DRIVE | PO BOX 747 | TERRELL, TEXAS 75160 (972) 382-9600, EXT. 2101

• 14 Counties of North Texas
• 56 Facilities
• 425 Employees

LAKES IS SPLIT BETWEEN MH & MR

WITH SPECIALTY AND NEW SERVICES

Substance Use 1115 Waiver



John Delaney

Executive Director & 1115 Agency Leader for Waiver Projects



James W. Williams

Director of Behavioral Health & 1115 BH Leader for Waiver Projects

Executive Staff



Brenda Gonzales

Center Director



Heidi Ross

Lead Trainer (certified)



Laura Collins

Trainer (certified)



Venessia Rieper

Trainer 

Dan Corley

1115 Compliance Oversight



Debbie Goggans

Operational Manager

Waiver Staff CET Program Staff

PROJECT TEAM

CET IS AN ACTIVE TREATMENT THAT CHANGES PARTICIPANTS’ BRAINS:

• To have increased capacity to learn
• To remember what they learn
• To act in real time
• To improve their social cognition
• To act wisely in novel social and

vocational situations

• To have hope

COGNITIVE ENHANCEMENT THERAPY

The project is the therapeutic application for a neurodevelopment approach to recovery from schizophrenia and like conditions through activating frontal lobe executive function with:

• computerized challenges,
• social awareness training and
• social skills development.

The development occurs over the course of a year.

WHAT IS CET?

• CET

T aims s to remediate mediate the e brain in

• For

r st stable ble client ients s wh who have ve not t ful ully y re recove covered red but ut are at a plateau teau

• Combini

mbining ng sp speci ecialized lized compu mputer ter exercises ercises, , so social ial cogniti nition

• n group

ups s and indivi ividu dual al coachi ching ng

• Utilizes

izes a coaching ching method thodology

• logy
• 48

48 once ce-a-we week ek se sess ssions ions

CET FOCUSES ON NEGATIVE SYMPTOMS OF SCHIZOPHRENIA

• Flat or blunted emotion
• Lack of motivation or energy, often on Auto Pilot
• Limited or impoverished speech
• Lack of pleasure or interest in things

Cognitive difficulties are also usually present:

• Slow, effortful thinking process
• Concrete thinking
• Poor concentration and memory
• Difficultly understanding or expressing feelings
• Difficulty integrating thoughts, feelings and behaviors

COMPONENTS OF CET

1. Specialized computer exercises conducted in pairs in a group setting 2. Homework reporting in social cognition group, no one can hide 3. Weekly Psycho-ed talks 4. Cognitive Group Exercises done in pairs 5. Individual ‘coaching’ once a week

AIM OF PROJECT

CET is meant to enhance the mental capacities that underlay social awareness and appropriate interaction building the internal skills to be able to interact with the community with greater understanding and ease. Our goal is to:

• Improve access to Behavioral Health services (CN.5)
• Reduce ED use (CN.12)
• Provide specialized recovery services for Chronic Disease

conditions (CN.8)

TYPICAL CET DAY…

11:00 – 12:00 Computer Exercises 12:00 – 12:30 Break 12:30 – 2:00 Group Individual coaching sessions are held with each client during the week to work on homework questions.

COMPUTER WORK

• One hour a week
• Done in pairs
• Pairs support each other
• A chance for socialization
• Prepares participants for group
• Continues during the course of the group
• Progressively more challenging and more abstract

COGNITIVE ENHANCEMENT THERAPY Tuesday, January 16, 2007

Group #9 • Session 20

Welcome Back: Judy Selection of Chairperson: Review of Homework: a) Describe a recent situation in which you disagreed with another person b) Describe your perspective c) Describe their perspective Psycho-Educational Talk: Foresightfulness Speaker: Ray Exercise: Word Sort Coach: Judy Participants: Sam and Jo Feedback: Everyone Homework: a) Tell about a time when you could have been more foresightful. b) Tell how being foresightful would have made the situation different.

Next Group Meeting is Tuesday January 23, 2007

EFFECTS OF CET ON EMPLOYMENT OUTCOMES IN EARLY SCHIZOPHRENIA; EACK, ET AL

10 20 30 40 50 60 70 80

CET EFFECTS ON EARLY SCHIZOPHRENIA

(N = 58)

% Improvement

CET EST 1 Year 2 Years

Processing Speed Social Cognition Social Adjustment Neurocognition Symptoms Cognitive Style

Eack et al., 2009. Psychiatry Serv. 60:1468-1476.

"It's important for the field to recognize that while we've been waiting now for 30 years for a drug that will improve social outcomes, we've been ignoring the results of many studies showing that psychosocial treatment achieves psychosocial results. And that most of those results are in some ways more meaningful for patients and their families than just the absence of a relapse.” William McFarlane, MD

Director of the Center for Psychiatric Research Maine Medical Center Research Institute 9/10/10

Ken Costigan Project Manager, Operational Excellence

RHP 9 Shared Learning & Experience Event

134

Expand Chronic Care Management Models

• Parkland Health & Hospital System first opened its

doors in 1894

– 861 adult patient beds – 107 neonatal patient beds – 10,000 employees – Averages more than 1 million patient visits annually.

• Scope of Service

– Services include a Level I Trauma Center, – Second largest civilian burn center in the U.S. – Level III Neonatal Intensive Care Unit – 20 community-based clinics – 12 school-based clinics – Numerous outreach and education programs

• Parkland is the primary teaching hospital for the

University of Texas Southwestern Medical Center. 135

About Parkland

The Community’s Health System

Narrative Summary

• Based on evidence-based care models, a team of providers will

focus efforts on the implementation of a Chronic Care Model for management of diabetes, chronic kidney disease and congestive heart failure for Parkland’s patients.

• A Chronic Care Model developed by Edward H. Wagner has been

widely accepted for its success and is categorized into four elements:

1. Increased provider expertise and skill, 2. Educating and supporting patients 3. Making care delivery more team-based and planned 4. Making better use of registry-based information systems

136

Expand Chronic Care Management Models

• Total estimated Category 2 incentive of ~$31M
• Total estimated Category 3 incentive of ~$5.6M

137

Project At a Glance

Start

Mon 10/1/12

Finish

Fri 9/30/16

October 21 April 11 October 1 March 21 March 1 August 21 February 11 August 1 DY2

Mon 10/1/12 - Mon 9/30/13

DY3 Tue 10/1/13 - Tue 9/30/14 DY4 Wed 10/1/14 - Wed 9/30/15 DY5 Thu 10/1/15 - Fri 9/30/16 Develop a comprehensive care management program Expand the Chronic Care Model to primary care clinics Formalize multi‐disciplinary teams Review project data and respond to it every week with tests of new ideas, practices, tools, or solutions Develop program to identify and manage chronic care patients needing further clinical intervention Apply the Chronic Care Model to targeted chronic diseases, which are prevalent locally Apply the Chronic Care Model to targeted chronic diseases, which are prevalent locally

Expand Chronic Care Management Models

• IT-1.10 - Diabetes care: HbA1c poor control (>9.0%)
• IT-1.12 - Diabetes care: Retinal eye exam
• IT-1.2 - Annual monitoring for patients on persistent medications
• IT-3.1 - All Cause 30-day Readmission Rate

138

Category 3 Measures

Start

Mon 10/1/12

Finish

Fri 9/30/16

October 21 April 11 October 1 March 21 March 1 August 21 February 11 August 1 DY2

Mon 10/1/12 - Mon 9/30/13

DY3 Tue 10/1/13 - Tue 9/30/14 DY4 Wed 10/1/14 - Wed 9/30/15 DY5 Thu 10/1/15 - Fri 9/30/16 Develop a comprehensive care management program Expand the Chronic Care Model to primary care clinics Formalize multi‐disciplinary teams Review project data and respond to it every week with tests of new ideas, practices, tools, or solutions Develop program to identify and manage chronic care patients needing further clinical intervention Apply the Chronic Care Model to targeted chronic diseases, which are prevalent locally Apply the Chronic Care Model to targeted chronic diseases, which are prevalent locally

Expand Chronic Care Management Models

• Established chronic disease management elements (Wagner Model)

– Referral guidelines, patient self-management, patient severity stratification (PCCI), metric selection for population measurement (registry), support tools, provider-to-provider communication, care coordination (specialty selection)

139

DY2 Accomplishments

Start

Mon 10/1/12

Finish

Fri 9/30/16

October 21 April 11 October 1 March 21 March 1 August 21 February 11 August 1 DY2

Mon 10/1/12 - Mon 9/30/13

DY3 Tue 10/1/13 - Tue 9/30/14 DY4 Wed 10/1/14 - Wed 9/30/15 DY5 Thu 10/1/15 - Fri 9/30/16 Develop a comprehensive care management program Expand the Chronic Care Model to primary care clinics Formalize multi‐disciplinary teams Review project data and respond to it every week with tests of new ideas, practices, tools, or solutions Develop program to identify and manage chronic care patients needing further clinical intervention Apply the Chronic Care Model to targeted chronic diseases, which are prevalent locally Apply the Chronic Care Model to targeted chronic diseases, which are prevalent locally

• Expanded Chronic Care

Model to 12 Health Centers in the Dallas area (Parkland System)

140

Expand Chronic Care Management Models

DY2 Accomplishments

Expand Chronic Care Management Models

• Expansion of the multidisciplinary team

– Social work, clinical pharmacy, dieticians, NP/PA, nursing, physicians

141

DY3 Accomplishments

Start

Mon 10/1/12

Finish

Fri 9/30/16

October 21 April 11 October 1 March 21 March 1 August 21 February 11 August 1 DY2

Mon 10/1/12 - Mon 9/30/13

DY3 Tue 10/1/13 - Tue 9/30/14 DY4 Wed 10/1/14 - Wed 9/30/15 DY5 Thu 10/1/15 - Fri 9/30/16 Develop a comprehensive care management program Expand the Chronic Care Model to primary care clinics Formalize multi-disciplinar y teams Review project data and respond to it every week with tests of new ideas, practices, tools, or solutions Develop program to identify and manage chronic care patients needing further clinical intervention Apply the Chronic Care Model to targeted chronic diseases, which are prevalent locally Apply the Chronic Care Model to targeted chronic diseases, which are prevalent locally

Expand Chronic Care Management Models

142

DY3 Accomplishments

• Daily provider view for identifying high risk patients

Expand Chronic Care Management Models

143

DY3 Accomplishments

Successes

• Category 3 selection – why?
• Patient successes
• Focusing of CCM efforts
• Multi-disciplinary approach (team medicine)

144

Jamie Becker, PhD Clinical Psychologist

Pediatric to Adult Care Transition:

Building a Patient Transition Program Jamie A. Becker, PhD

Clinical Psychologist, Children’s Medical Center Assistant Professor, UT Southwestern

147  Privileged and Confidential

Overview

• Children’s Medical Center
• Pediatric to Adult Care Transition
• Office of Patient Transition
• Framework, Tools, and Resources
• Questions

148  Privileged and Confidential

Children’s Medical Center

• Private, not-for-profit health system with 550+ beds
• Primary to quaternary care for North Texas Region
• 3 campuses (Dallas, Plano, and Southlake)
• 16 MyChildren’s pediatric primary care practices
• 50+ specialty and subspecialty programs
• Solid organ and bone marrow transplantation
• Cancer, sickle cell, cystic fibrosis, and heart
• 7 disease-specific care certified programs
• Pediatric Level 1 Trauma Center
• Level 4 Neonatal Intensive Care Unit
• Primary pediatric teaching facility for the University of Texas Southwestern Medical Center
• 6,000 employees and 2,100+ medical and dental staff

149  Privileged and Confidential

Pediatric to Adult Care Transition

Background

• Position Paper on Transition (Society of Adolescent Medicine, 1993)
• Consensus Statement (American Academy of Pediatrics, 2002)
• Clinical Report (American Academy of Pediatrics, 2011)

Definition of Transition: “a multifaceted, active process that attends to the medical, psychosocial, and education/vocation needs of adolescents as they move from child to adult-centered care” that is “purposeful, planned, and timely” (Blum et al., 1993). Definition of children with special healthcare needs: “those who have or are at an increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that of required by children generally” (McPherson, et al.).

150  Privileged and Confidential

Pediatric to Adult Care Transition

Complex Chronic Life Long Chronic Episodic Chronic

High Complexity/ Low Volume with High Transition Needs Low Complexity/ High Volume with Low Transition Needs Episodic Chronic: conditions that are expected to last at least a year but not likely to last Life Long Chronic: conditions that are likely to be life long and are generally static or affecting one body system Complex Chronic: significant chronic conditions in two or more organ systems and/or conditions that have shortened life expectancies

*Pyramid is based upon Clinical Risk Group (CRG’s)

151  Privileged and Confidential

Office of Patient Transition

Facilitate effective transition of teenagers and young adults with chronic conditions and special healthcare needs to adult healthcare .

Mission Concurrently build and maintain the infrastructure and support for providers and medical care teams to adequately and effectively provide the skills, knowledge and tools required for adolescents and young adults with chronic health conditions to maximize the independent management of their healthcare needs and successfully transition their care into the adult system. Goals  Improve chronic disease management specifically related to the pediatric to adult healthcare transition experience  Continuity of care and care coordination for at-risk and complex chronic patient populations  Decrease hospital readmissions and costs  Improve access to healthcare and appropriate quality patient care Alignment with Triple Aim and RHP 9 Priorities Objectives  Develop a common framework to facilitate healthcare transition of adolescents and young adults with chronic health conditions to adult providers  Assist clinical programs in customization of the framework to develop transition processes that meet the unique needs

• f each clinics’ patient populations

 Focus on patients’ health management education and skill building to optimize health and independence in adulthood  Improve access and utilization of existing hospital, community, and health insurance resources and communication and coordination with adult providers

152  Privileged and Confidential

Office of Patient Transition

Transition Clinical Council

• Purpose: To serve as representatives for each

clinical program engaged in hospital-wide transition efforts coordinated by the Office of Patient Transition, through bidirectional information sharing and communication

• Objectives:
• Receive direction from the Office regarding

plans, policy, shared research, tools, improvements, and opportunities

• Provide feedback to the Office.
• Collaborate with the Office and other clinical

transition programs, helping to educate colleagues and implement transition programming. Transition Advisory Board

• Purpose: To provide

governance and oversight to transition efforts across Children’s.

• Objectives:
• Assist in the development
• f common transition

framework and components

• Provide ongoing guidance

in patient transition

• perations and

programmatic implementations

153  Privileged and Confidential

Framework

Based upon literature and the Center for Health Care Transition Improvement

(Maternal and Child Health Bureau and The National Center to Advance Adolescent Health)

• Incorporates Got Transition Program’s Six Core Elements
• Transition Policy
• Transition Tracking and Monitoring
• Transition Readiness
• Transition Planning/Integration into Adult Approach to Care
• Transfer to Adult Approach to Care
• Transfer Completion/Ongoing Care
• Policy and guidelines: addresses patient populations needing transition and

provides direction and best practices for transitioning teens and young adults

• Documentation in EMR outlines standard core components of transition and
• ffers common mechanism for planning and communication

154  Privileged and Confidential

EMR Documentation Project

Pediatric to Adult Care Transition Plan

Considerations:

• Create a standardized and comprehensive tool to aid in transition process (i.e.

provide transition framework)

• Design a tool that is easy to use, navigate, and access for all clinics
• Develop a tool to assist with coordination and communication of transition

planning (with incorporation into notes and medical summaries)

• Link the tool with other Epic modules (MyChart, Care Everywhere, etc)
• Build reports and registries for tracking and patient care

155  Privileged and Confidential

EMR Documentation Project

Pediatric to Adult Care Transition Plan

Six sections including a skills readiness assessment

• Providers and Specialties
• Healthcare Coverage
• Skills Checklist
• Medical Information Sharing, Privacy, Decision-making
• Concise Medical Summary
• Transfer Checklist

156  Privileged and Confidential

Tools and Resources for Program Development

• Internal website for staff and physicians
• Staff education and resources
• Patient education and tools (links for EMR documentation)
• Adult referral database
• Community resource database
• External website for patients and families
• Feedback, outcomes, data, and patient tracking

Questions?

Jamie Becker, PhD Jamie.Becker@childrens.com

Thank You!

Let's Work Together