A Tale of Three Regions: Texas 1115 Waiver Journey Regional Healthcare Partnership 3 Shannon Evans, MBA, LSSGB Regional Healthcare Partnership 6

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1 A Tale of Three Regions: Texas 1115 Waiver Journey Regional Healthcare Partnership 3 Shannon Evans, MBA, LSSGB Regional Healthcare Partnership 6 Carol Huber, MBA Regional Healthcare Partnership 1 Daniel Deslatte, MPA

2 REGIONAL HEALTHCARE PARTNERSHIP 3 Shannon Evans, Manager, Health System Strategy Operations 2 #VITAL2016

3 1115 WAIVER BACKGROUND MEDICAID SUPPLEMENTAL PAYMENTS Direct reimbursement for services has been below provider costs for many years and continues to shrink To assist providers caring for a large percentage of Medicaid and/or uninsured patients, programs were created: Disproportionate Share for Hospitals (DSH) Upper Payment Limit (UPL)

4 UPL PROGRAM Payments not to exceed what Medicare would have paid for the same service States use IGTs to provide the state s contribution to these UPL payments

5 1115 WAIVER Waiver: A CMS approved waiver to the Social Security Act that currently funds Medicaid. Provides flexibility for Texas to expand risk-based managed care statewide and preserve UPL funding; redirects the supplemental payments that historically existed under the UPL program in order to improve care delivery systems and capacity, while emphasizing accountability and transparency, and requiring demonstrated improvements at the provider level for the receipt of funding. Uncompensated Care (UC) Pool: Funding available to RHP participants under the waiver to defray UC costs. This is a completely separate pool from DSRIP pool and funding established to help defray UC costs provided to Medicaid eligible or to individuals who have no source of third party coverage. Delivery System Reform Incentive Payments (DSRIP) Pool: Initiatives designed to provide incentive payments to hospitals and other providers for investments in delivery system reforms that increase access to health care, improve the quality of care, and enhance the health of patients and families they serve.

6 Regional Health Partnership 3 (RHP3) There are 26 providers with active DSRIP projects, including: Hospitals Academic Health Science Centers Local Public Health Departments Local Mental Health Authorities RHP3 Quick Facts: 9 counties 8,580 square miles 4.8 million residents 51% Anglo/31% Hispanic 16.8% live below poverty line 8% average unemployment 26% without health coverage $50,363 per capita income Providers selected project areas from a menu called the RHP Planning Protocol All proposed projects were reviewed and approved by HHSC and CMS. Incentives are paid for achieving approved milestones and metrics. 190 outcome measures were selected by RHP3 providers. Baselines were set in DY3. DY4 incentives will be paid for reporting and performance. DY5 incentives will be paid for performance only. Providers choose one re more community needs. RHP3 includes 25 community needs derived from over 40 community needs assessments throughout the Region Provider County Project Focus Outcome Measure Community Need 177 Projects worth approximately $2.2 billion in incentive payments

7 Local Mental Health Authorities (LMHAs) 7

8 KEY REGIONAL CHALLENGES Inadequate number of primary and specialty care providers High prevalence of chronic disease Diverse patient population, varying economic, educational and cultural backgrounds High number of Uninsured Patients High prevalence of behavioral health conditions and lack of an integrated care solutions Fragmentation of patient services throughout a large, uncoordinated health care system Limited access to public transportation and emergency services Aging population and increased need for high cost services Inadequate IT infrastructure for improved care coordination 8 #VITAL2016

9 Community Needs Inadequate access to primary care Inadequate access to specialty care Inadequate access to behavioral healthcare Inadequate access to dental care Inadequate access to care for veterans Inadequate access to care for those with special needs Inadequate access to care coordination High rates of inappropriate ER utilization High rates of preventable hospital readmissions High rates of preventable hospital admissions High rates of chronic disease & inadequate access to services High rates of tobacco use & excessive alcohol use High teen birth rates High rates of poor birth outcomes low birth-weight babies Insufficient access to services for pregnant low income women Shortage of primary and specialty care physicians High rate of sexually transmitted diseases Insufficient access to integrated care behavioral healthcare Lack of immunization compliance Lack of access to programs providing health promotion Inadequate transportation options Insufficient access to services designed to address disparities Lack of patient navigation Limited use of electronic health records Graduate medical education

10 REGION 3 DSRIP PROJECT FOCUS Chronic Care Behavioral Health Patient Navigation Healthcare Transformation Emergency Center Utilization Process Improvement / Patient Experience Primary / Specialty Care

11 REGION 3 QUANTIFIABLE PATIENT IMPACT Encounters DY 3-4 Actual: 926,421 DY 3-4 Target: 813,741 DY 3-4 Achievement: 114% Individuals DY 3-4 Actual: 715,109 DY 3-4 Target: 325,456 DY 3-4 Achievement: 220%

12 QUALITY OUTCOME DOMAINS Primary Care and Chronic Disease Management Potentially Preventable Admissions Potentially Preventable Readmissions Potentially Preventable Complications Cost of Care Patient Satisfaction Oral Health Perinatal Outcomes and Maternal & Child Health Right Care, Right Setting Quality of Life / Functional Status Behavioral Health / Substance Abuse Care Primary Prevention Palliative Care Healthcare Workforce Infectious Disease Management

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14 REGION 3 COHORTS ACCOMPLISHMENTS Patient Navigation EC Utilization Behavioral Health: Continuity of Care Integrated Care Readmission Start Date Collaboration Best Practices Goal / Charter Develop two comprehensive web based tools: Patient navigation Regional Continuing Education Tool for CHWs Outcomes Memorandum of Understanding with institutions to share data Development of Navigation website Decrease nonemergent EC visits Increase area clinics visits Evaluation of navigation models Meetings with ECs to: prevent inappropriate EC use and navigate patients to area clinics ID strategies to address all cause 30- day readmission rates Evaluate Primary Behavioral Health Care via the Organizational Assessment Toolkit (OATI) Analysis of regional hospital discharge data correlating patient characteristics with readmission OATI pilots Engage providers to collaboratively impact regional readmission rates Completed a survey to identify specific readmission focus areas ID common best practices and process improvement / implementation Shared document with community partners Discussing challenges to collaboration

15 REGION 3 SUCCESSES Collaboration & Shared Learning Community Engagement Additional Services/Programs Improved Patient Outcomes Improved Patient Access Cost Savings

16 REGION 3 NEXT STEPS/CHALLENGES Waiver Renewal Further Community Engagement Shift in Funding Weights Downstream Healthcare Impact Sustainability Alternative Payment Models

17 REGIONAL HEALTHCARE PARTNERSHIP 3 Keep Calm and DSRIP On! For additional RHP 3 updates and information please visit You can also contact the RHP3 Anchor team at setexasrhp@harrishealth.org #VITAL2016

18 Regional Healthcare Partnership 6 Carol Huber, RHP 6 Director 18 #VITAL2016

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21 RHP 6 Community Needs Addressed through DSRIP Projects and Collaboration CN 1 CN 2 CN 3 CN 4 CN 5 CN 6 Quality of care in Texas is below the national average High rates of chronic conditions require improved management and prevention Poor access to medical and dental care Lack of integrated behavioral health services Poor maternal and child health outcomes High rates of communicable and vaccinepreventable diseases projects projects projects projects projects projects 21

22 How does RHP 6 compare to the entire state? Variable Texas RHP 6 RHP 6 Range Percent Hispanic 38% 54% 17-94% Percent of residents ages % 62% 50-64% Percent of residents with less than high school education Percent of deaths due to cardiovascular disease and diabetes 20% 19% 9 42% 34% 34% 30-75% Percent of mothers under 18 years of age 4.9% 5.5% 3-33% Per capita personal income $38,609 $35,989 $18K 50K Unemployment rate 8.2% 7.4% 5-16% Percent living below poverty 16.5% 16.2% 9-35% Percent uninsured 26% 24% 19-37% 22 Source: RHP 6 Plan, submitted to HHSC December 2012

23 RHP 6 Projects 7% 5% 6% Behavioral Health (37) 30% Primary Care (23) 7% 11% Care Mgmt/Navigation (20) Specialty Care (13) Health Promotion (9) 16% 18% Process Improvement (9) Telemedicine (6) 23

24 RHP 6 Interactive Tool

25 Project Challenges and Lessons Learned Challenges Planning and coordination Provider /staff recruitment and retention Technology, equipment and space Data Policy, legal, or contract challenges Securing buy-in and communicating effectively Patient participation Lessons Learned Value of partnerships and communication Importance of planning Good use of technology and data systems Ability to adapt and use resources efficiently How to recruit providers

26 Transformation is Collaboration among providers and stakeholders Set common aim Cross-sector workgroups Performance Bonus Pool? Actionable project list Address project challenges Networking Opportunities Through their design and leadership, Regional Healthcare Partnerships drive collaboration and transformation.

27 Readmissions Learning Collaborative Based on the Institute for Healthcare Improvement Breakthrough Series Model Partners in learning with UTMB / RHP 2 and the Improvement Science Research Network Engagement from hospitals, community mental health centers, health plans, HASA, academic researchers, and community partners Shared Aim: Reduce readmissions by 5% 10 hospital teams signed up to participate 7 teams completed the entire process (attrition due to staffing resources and data issues) 27

28 DY 5 ACES Align * Collaborate * Evaluate * Sustain Align Document regional strategies/efforts for addressing community needs. Identify active participants and community stakeholders working on each area of need to better promote and facilitate collaboration among key entities. Collaborate - Organize and facilitate meetings targeting relevant and engaged providers and stakeholders to better understand and maximize opportunities for alignment. Evaluate Identify key indicators and assess how DSRIP is improving health and transforming care in RHP 6. Provide program evaluation technical assistance and peer review to DSRIP providers. Aggregate and communicate RHP 6 DSRIP outcomes. Sustain - Explore and promote strategies and opportunities for sustaining successful DSRIP projects beyond waiver funding.

29 Why focus on program evaluation and sustainability? 1 DY5 Stretch Activity 3 2 Continue project in Waiver 2.0? 3 Waiver 2.0 updates (QPI, MLIU, next logical step ) 4 DY6 milestones=$$ 5 Life after DSRIP And Contribute to the transformation body of knowledge And Provide best care and services for patients 29

30 What is required for sustainability? It takes more than just money. 30

31 What is REALLY required for sustainability? Org Capacity Env t Support Funding Stability Logic Model Data Plan Program Evaluation Sustainability Program Adapt n Strategic Planning Partnerships Communication

32 Ability to Impact 7 RHP 6 Sustainability Assessments: Domain Score vs Ability to Impact Partnerships Organizational Capacity Strategic Planning Program Evaluation Program Adaptability Communications Environmental Stability Funding Stability Domain Score 32 Completed assessments: 76 of 124 projects (61%) 18 of 24 providers (75%)

33 Sustainability Retreat Learning Collaborative May 2016

34 Are we there yet? 34

35 Cat 3 Outcomes so far! 4 Cat 3 Outcomes Reported October DY Fully Achieved Partially Achieved Not Achieved Outcomes Achieved Diabetes Care and Control Readmissions ED Throughput Quality (Falls, CAUTI, Stroke) Patient Satisfaction Low Birth Weight births Preventive Care QPI (October DY4 Reported) Projects Reporting DY4 Result DY4 Target Patients Served / Positively Impacted Patient Visits / Encounters , , , ,314 82% of projects have achieved their DY5 target

36 DSRIP Incentives Earned (DY 1-4) DSRIP Incentives (All Funds) $58,414,641 $227,089 $796,881,504 Earned Not Yet Earned Lost Provider Achievement of Allocated DSRIP Incentives % 50-59% 60-69% 70-79% 80-89% %

37 RHP 6 Logic Model (conceptual) Inputs Performing Providers Financial investments Staff Facilities HHSC/CMS Policy Activities Collaborative learning Process and Improvement milestones and other efforts, including: Enroll patients Conduct patient visits Develop & implement protocols Care transitions CHW encounters Short/Medium Term Outcomes Cat 3 outcomes Potentially Preventable Events (Cat 4) Patient satisfaction Reduce cost of care Increase provider capacity Improve performance on HEDIS and other quality measures Incidence/prevalence of infectious and chronic disease Recognize / Address / Impact social determinants Achieve collaborative cross-sector integrated system of care Long Term Outcomes Mortality Years of Potential Life Lost Health Equity

38 Contact Information Carol Huber Director, RHP6

39 Regional Healthcare Partnership 1 Daniel Deslatte, MPA Vice President UT Health Northeast

40 About the UT System Founded in 1883, now nine general academic institutions, and six health-related institutions: - 90,000+ employees - $15 billion annual operating budget - Currently adding two new health-related institutions As a health system, the University of Texas is the most significant provider of healthcare in Texas: - 2,000 inpatient beds owned or operated - 78,000 admissions for 1.45 million inpatient days annually million outpatient encounters last year 40 #VITAL2016

41 UT Health Northeast has three roles in the 1115 Waiver: Our Role - Anchor: Administrator for the Northeast Texas Regional Healthcare Partnership, roughly $1.2 billion partnership with three dozen providers, including hospitals, mental health authorities, and public health departments - Provider: Responsible for $160 million in DSRIP projects - IGT Entity: Provides the non-federal share of waiver payments based on Federal Medical Assistance Percentages (FMAP) 41 #VITAL2016

42 Start With Why 42 #VITAL2016

43 Northeast Texas Northeast Texas Texas Population 1.3 million 25.1 million Counties Rural Population 53.9% 17.5% Median Age Per Capita Income $19,386 $24,870 Bachelor s Degree 13.2% 25.8% Minority Population 24.8% 29.6% Hispanic Origin 13.1% 37.6% Northeast Texas is older, poorer, less well educated and at greater risk of early death than the state average. 43 #VITAL2016

44 Sample Projects Behavioral Health: Crisis stabilization centers, jail diversion projects, behavioral-physical health integration, technology infrastructure to better coordinate care Primary/Specialty Care: Creation of medical homes, expanded hour clinics, pediatric obesity interventions, emergency room diversion programs, pediatric asthma Other: Community health worker training, potentially preventable admissions/readmission reduction programs, cancer screening and early detection 44 #VITAL2016

45 Initial Outcomes At least 500,000 new encounters for patients in underserved rural communities. - At least 50,000 encounters in behavioral health - Primary care, care coordination, and medical home account for the largest amount of new encounters and individuals Quality indicators are trending upwards: - RHP 1 beats the Texas average on half of proposed bonus pool Medicaid quality indicators - Individual provider level quality metrics are encouraging 45 #VITAL2016

46 Pediatric Asthma Breath of Life Mobile Clinic partners with 36 school districts in 11 Northeast Texas counties to help keep kids out of the hospital and emergency room and in school and activities Serves 2,400 children 80% reduction in ED Use 90% reduction in hospitalization 46 #VITAL2016

47 Challenges for UC Providers Declining UC Caps: UC allocation drops from 88% of total funding 2011 to 50% in Shift from UPL Model to UC Model: UC funds are harder to access than historic UPL funding. Limited IGT Sources: IGT funds are finite, and there are competing demands, including DSH and DSRIP. Other Federal Funding Issues: Federal sequestration, rate cuts, audits, and recoupment is additional strain on health systems. 47 #VITAL2016

48 DSRIP Revenue Recognition Expense Revenue Recognition Payment FY 13 (DY 2) PM 1 PM 2 PM 3 PM 1 PM 3 FY 14 (DY 3) PM 2 PM 1 PM 3 FY 15 (DY 4) PM 2 48 #VITAL2016

49 Lessons Learned & Trends Increasing emphasis on collaboration among providers - Evolution from learning collaboratives (MA) to Regional Healthcare Partnerships (TX) to Performing Provider Systems (NY) - Locally designed with flexibility, but expectation of a rigorous process that includes entire communities Increasingly difficult expectations - TX: Risk based, pay for performance projects with a shift from process to outcomes measures - Increasing focus on population health and risk - Different perspectives on valuation 49 #VITAL2016

50 Lessons Learned & Trends DSRIP is about transformation of the entire healthcare system, including non-hospitals - CMS is very focused on what happens after DSRIP - Focus on community needs assessments that feed DSRIP project planning and involve non-hospital providers Trend towards data driven environment - How do you demonstrate value? - Difficult balance between rigorous analysis and ability to make course corrections 50 #VITAL2016

51 Contact Information Daniel Deslatte, MPA Vice President, Planning & Public Policy UT Health Northeast Direct: #VITAL2016

52 Discussion 52