biannual regional shared experience & learning...

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

0 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

C:/Users/mroche/Desktop/THOT Master - Copy.mp4

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 of Health Spending 1980–2008

16

0

1000

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80

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81

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United StatesNorwaySwitzerlandCanadaNetherlandsGermanyFranceDenmarkAustraliaSwedenUnited KingdomNew Zealand

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1980

1981

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United StatesFranceSwitzerlandGermanyCanadaNetherlandsNew ZealandDenmarkSwedenUnited KingdomNorwayAustralia

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

0

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 outcomes

– 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

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 outreach 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

C:/Users/mroche/Desktop/OPAT patient video.mp4

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


24% 37% <.01


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

C:/Users/mroche/Desktop/OPAT patient video.mp4

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 other 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

outcomes 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

outcomes 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:

• [email protected]

62

http://www.hhsc.state.tx.us/1115-waiver.shtml



mailto:[email protected]

Break: 15 Minutes

Let's Work Together

C:/Users/mroche/Desktop/Let's Work Together.pptx

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

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=CXhrrhEfDGZ-rM&tbnid=SDkNBx5-ws2YjM:&ved=0CAUQjRw&url=http://zackwoo.com/gregtozian/?page_id=1595&ei=EW4IVLTTCsLX8AGn8IHABw&bvm=bv.74649129,d.b2U&psig=AFQjCNHrLW7waN8eKUOshVBd9bmrSbgXgA&ust=1409924941476459


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


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


Contributing Facilities and Patients


How much data is captured in the DFWHC Data

Warehouse?

70


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


Foundation Committee Structure

DFWHC Foundation Board of 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


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


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


• 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


• 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


Physician ID and Name

ER Encounters with NYU

Algorithm

Observation, GI and Cardiology

Encounters

Outpatient

Claims

Information

Unique to

DFWHC

Foundation

http://www.google.com/url?sa=i&rct=j&q=Unique&source=images&cd=&cad=rja&docid=zwjILIc6ywlKFM&tbnid=U9pfELgqbLXZVM:&ved=0CAUQjRw&url=http://saveourpostoffice.com/category/economics&ei=NAI-UeTtCKbQ2wW4pYG4Cg&bvm=bv.43287494,d.aWc&psig=AFQjCNGzx2p6bGPpOLpgUGLQvAj7mGtqZg&ust=1363104660695490


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


• Regional STS Certified Clinical Data Registry

• > 90% of North Texas CABG and AVR Encounters

• REMPI Matching to Claims Warehouse Information

Texas

Quality

Initiative

http://www.google.com/url?sa=i&rct=j&q=Heart&source=images&cd=&cad=rja&docid=GHwbRJY5upUulM&tbnid=6pTcGeXmVuKEiM:&ved=0CAUQjRw&url=http://360healthcare.com/category/articles/naturopathic-medicine-articles/&ei=DQo-UZXJC6LE2gW-_oDYBA&bvm=bv.43287494,d.aWc&psig=AFQjCNF93698bgEaI8WWxdD-CREWl56e-g&ust=1363106687718144


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

http://www.google.com/url?sa=i&rct=j&q=Business+Intelligence&source=images&cd=&cad=rja&docid=L_QwxdIzxCEIIM&tbnid=hFTU10Ae1sLHXM:&ved=0CAUQjRw&url=http://www.mosel.ro/main/Business_Intelligence&ei=HQQ-UYHKHrD22QXpnoCYCA&bvm=bv.43287494,d.aWc&psig=AFQjCNERk-UhXPH-KJeRMiavtueLbBu3gg&ust=1363105085465905


• 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

http://www.google.com/url?sa=i&rct=j&q=Timeliness&source=images&cd=&cad=rja&docid=TufN3G-wqR5ElM&tbnid=y1IansmkCLMR2M:&ved=0CAUQjRw&url=http://247transcription.ca/&ei=PgU-Uf2FF5LE2QWfsIGYDg&bvm=bv.43287494,d.aWc&psig=AFQjCNFb0tzvpvRNym7aRvz5kU_QGTPm-g&ust=1363105459075399


Using the Information -Community and Population Health Management

• Chronic Conditions

• Emergency Room Utilization

• Form 990 Analyses –

Community Benefit

• 1115 Waiver Metrics


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

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


Evaluation of High ER Use by Patients Using the REMPI…..

And the volume of ER Visits made by those patients


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


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


ER Hot Blocks in zip code 75216


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

or 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


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, epigastricBronchitis, 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 0

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



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


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

or 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



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

hypertensionAcute pharyngitis


unspecified site of back

Abdominal pain,

unspecified site


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


codes

Total Charge

Average Charge



Hot blocks

Zip 75243

9600 Block

FOREST

LN

9700 Block

FOREST

LN

9300 Block

SKILLMAN

ST

9900 Block

ADLETA

BLVD

11600

Block

AUDELIA

RD


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 0 0 2

Ethnicity

Not Hispanic

or 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



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 siteNausea 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


codes

Total Charge

Average Charge


ER Dashboards - Quality Data

Following is a look at the top uninsured patients with a COPD

diagnosis in the past year.


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


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


Single County OP ED Cases


56,624

63,915

72,392

0

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


Single County OP ED Cases


Single County OP ED Cases – Classification Percentages: Visit Types


0%

10%

20%

30%

40%

50%

2010 2011 2012

Insured

Uninsured

Medicaid

Medicare

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


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*


Readmission Quality Data


www.healthyntexas.org

http://www.healthyntexas.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


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**


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


New partners –

More insight

• Physician Claims Warehouse

• LTAC Claims

• SNF MDS

• Home Health Providers

http://www.google.com/url?sa=i&rct=j&q=launch&source=images&cd=&cad=rja&docid=tfaysn3-YX0axM&tbnid=Jvm0S1QcyoENLM:&ved=0CAUQjRw&url=http://stereo.gsfc.nasa.gov/launch.shtml&ei=ow8-UejyHeXo2AXqnIHQAw&bvm=bv.43287494,d.aWc&psig=AFQjCNFDzpq0e7TVjP_QIcIZFfWC6GwidA&ust=1363108066800248


Questions? Contact

Kristin Jenkins

[email protected]

or 817-319-3587

Dallas-Fort Worth Hospital Council

Education and Research Foundation

Thank you!

mailto:[email protected]

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 aims to remediate the brain

• For stable clients who have not fully recovered but

are at a plateau

• Combining specialized computer exercises, social

cognition groups and individual coaching

• Utilizes a coaching methodology

• 48 once-a-week sessions

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

0

10

20

30

40

50

60

70

80

CET EFFECTS ON EARLY SCHIZOPHRENIA (N = 58)

% Im

pro

vem

ent

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


• 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


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


care management

program




teams



tools, or solutions




intervention



locally




• 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


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


care management

program


Model to primary care

clinics


teams



tools, or solutions




intervention



locally



• Expanded Chronic Care

Model to 12 Health

Centers in the Dallas area

(Parkland System)

140


DY2 Accomplishments


• 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


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


care management

program



Formalize multi-disciplinar

y teams

Review project data and

respond to it every week with

tests of new ideas, practices,

tools, or solutions




intervention



locally




142

DY3 Accomplishments

• Daily provider view for identifying high risk patients


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


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


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.).


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)


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

of 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


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

of common transition

framework and

components

• Provide ongoing guidance

in patient transition

operations and

programmatic

implementations


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

offers common mechanism for planning and communication


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


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


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

[email protected]

Thank You!

Let's Work Together

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