TEXAS HEALTHCARE TRANSFORMATION & QUALITY IMPROVEMENT PROGRAM. CHRISTUS Spohn Hospital Corpus Christi

Transcription

1 TEXAS HEALTHCARE TRANSFORMATION & QUALITY IMPROVEMENT PROGRAM Regional Healthcare Partnership Region 4 CHRISTUS Spohn Hospital Corpus Christi Delivery System Reform Incentive Payment (DSRIP) Projects

2 Category 1 DSRIP Projects: Infrastructure Development

3 CHRISTUS Spohn Hospital Corpus Christi/ Project 1.1: Expand Primary Care Capacity Unique Identifier Provider: CHRISTUS Spohn Hospital Corpus Christi is a 730-bed hospital in Corpus Christi serving a 460 square mile area and a population of approximately 460,000. The Hospital is comprised of 3 facilities on 3 campuses. Intervention(s): This project will increase the space, hours, and staffing for Spohn Corpus Christi s primary care clinics in order to serve additional patients, improve timely access to care, and to increase patients use of primary and preventative care instead of inappropriate use of the Emergency Department. Need for the project: Currently, 4 of Spohn s clinics and the Hector P. Garcia clinic where Spohn residents provide care only operate Monday-Friday hours, and only one clinic has expanded hours in the evenings. Our data shows that 21% of Nueces County residents are completely uninsured, meaning that 73,000 residents in the County have no 3 rd party payer source and are therefore likely to require access to the clinics intended to provide primary care to patients without an ability to pay for services. Thus, Spohn needs to expand its primary care capacity to treat more patients, and provide hours accessible by working and school-age patients. Target population: The target population is Nueces County residents with no insurance who require primary care services. Spohn s Family Health Centers (FHCs) clinics and the neighboring Hector P. Garcia clinic (where Spohn physician-residents provide treatment) typically treat a total of 19,500 patients per year (approximately 83% of whom are Medicaideligible or uninsured, totaling 16,200 patients), providing an approximate 67,000 encounters annually (84% of which are Medicaid-eligible or uninsured, totaling 56,000 visits). With 73,000 uninsured residents alone in Nueces County who would be eligible to receive care at these clinics, there is ample need for expanded care, and the project will target providing existing patients with easier access to care and allowing for additional patients to access care. Category 1 or 2 expected patient benefits: The project seeks to increase the space available for treating patients in Spohn s Northside Family Health Center from 5,000 square feet to at least 8,000 square feet in DY3, to increase the availability of after-hours/weekend clinic visits by six hours by DY4, to add a total of 4 additional providers in the clinics by DY4, and to increase the volume of visits across the clinics by 15% over DY2 s numbers by DY5 (an expected 10,050 additional encounters for an estimated increased patient population of patients). Category 3 outcomes: IT Our goal is a 5% reduction in all (non-urgent/non-emergent) ED visits by the end of DY4, and a 10% reduction in all (non-urgent/non-emergent) ED visits by the end of DY5. RHP Plan for Region 4 179

4 Expand Primary Care Hours/Staffing Identifying Project and Provider Information: Project 1.1: Expand Primary Care Capacity Project Option 1.1.2: Expand Existing Primary Care Capacity CHRISTUS Spohn Hospital Corpus Christi/ Unique Identifier Project Description: CHRISTUS Spohn Hospital Corpus Christi (Spohn) intends to increase the space, hours, and staffing in five local primary care clinics in order to serve additional patients, improve timely access to care, and to increase patients use of primary and preventative care instead of inappropriate use of the Emergency Department. Project Goals/5 Year Expected Outcome: o Provide an additional 4 providers (total) in the local clinics o Increase clinic space in FHC from 5000 sq. ft. to at least 8000 sq. ft. o Increase hours at target locations by at least 2 hours (weekend or after-hours) per week o 15% increase in primary care visits over baseline established in DY2 of patient volume at Spohn s FHCs (estimated 10,500 additional visits by end of DY5) Project Challenges: o Recruiting and retaining additional staff (specifically Community Health Workers) o Provider cooperation in providing additional hours of availability to an increased patient population o Identifying strategies for increasing the available amount of space for treating patients in existing FHCs o Patient education about the increased availability of services Spohn will address challenges by taking a coordinated approach to making these imperative improvements to the primary care clinic hours, staffing, and space. This includes engaging in provider education, aggressive recruiting, creative strategizing, and reaching out to the community to assure that the increased capacity is followed by increased utilization of the FHC services. Relationship to Regional Goals: Region 4 intends to transform healthcare delivery to focus on patient outcomes and satisfaction by creating easier access to quality primary and preventative care. This project is 100% patient-focused, and will also improve the institutional cost of providing care throughout the Region by reducing the number of patients seeking primary care treatment in area Emergency Departments. Starting Point/Baseline: 4 of 5 clinics operate Monday-Friday hours; one clinic has expanded hours in the evenings. Spohn s four Family Health Clinics and Hector P. Garcia where Spohn residents provide care provided approximately 67,000 visits to approximately 19,500 patients in FY RHP Plan for Region 4 180

5 Rationale: Spohn chose this project because 20% of Nueces County residents, and 31% of Nueces County children, live in poverty and therefore traditionally suffer from limited access to primary care. Additionally, 21% of Nueces County residents are completely uninsured, meaning they have no source of 3 rd party payment to cover healthcare bills. Nueces County has a higher percentage of Preventable Hospital Admissions than the statewide average for the following conditions that can be managed through regular access to primary care providers: Asthma, COPD, CHF, bacterial pneumonia, and diabetes long-term complications. These statistics highlight the need for expanded primary care capacity in the existing clinics in Nueces County. The cost (financial and to patient quality of life) of preventable hospital admissions and misuse of the ED have a deep impact on the long-term health outcomes for patients, which Spohn seeks to improve through this project. Milestones and Metrics: Spohn chose its DY2, DY3, and DY4 milestones in an effort to create infrastructure for improving access to primary care at its clinics. Hiring additional providers, increasing space, and offered increased clinical hours are each core components of this project, but they are also imperative to affecting a meaningful impact for patients. Spohn chose its DY 5 milestone to give effect to the overarching goal of this project, which is to increase the volume of patients using Spohn s clinics to access primary and preventative care, which will improve patient outcomes and reduce the institutional cost of providing healthcare to the indigent community. Ties to Community Needs Assessment Unique IDs: CN.1, CN.3, CN.6, CN.7, CN.10, CN.12 Related Category 3 Outcome Measure(s): Right Care, Right Setting (3.9.2 ED Appropriate Utilization) Increasing available hours in the community FHCs will increase the number of available primary care appointments to indigent and uninsured patients in the community. Spohn expects this increase in capacity to result in a reduced misuse of the ED. A review of Spohn s ED admission data for FY12 revealed almost 44,000 ED visits were non-urgent/non-emergent visits that could be handled in the primary care setting. Of those, almost 70% were provided to Medicaid-eligible and uninsured patients (30,000 encounters). The day delay to follow-up appointments has been established as a major factor in PPR as patients are discharged with 5-7 days of prescriptions for new and refilled medications. Relationship to Other Performing Providers Projects in the RHP: Many of the projects in this region are related to expansion of care and improving access to care. This project s focus on expanding care will support and enhance these Category 1 and 2 projects in our RHP: , Introduce Expand or Enhance Telemedicine/Telehealth; Expand Primary Care Capacity; Primary Care Redesign; and , Expand Care Transitions program. Related Category 4 measures include potentially preventable admissions measures in RD-1 and Patient Satisfaction in RD-4.1 Relationship to Other Performing Providers Projects and Plan for Learning Collaborative: We plan to participate in a region-wide learning collaborative(s) as offered by the Anchor entity for Region 4, Nueces County Hospital District. Our participation in this collaborative with other Performing Providers within the region that have similar projects will facilitate sharing of challenges RHP Plan for Region 4 181

6 and testing of new ideas and solutions to promote continuous improvement in our Region s healthcare system. Other providers with similar projects with whom we will participate in the learning collaborative include Memorial Hospital, Jackson County Hospital District, Yoakum Community Hospital, Corpus Christi Medical Center, and Driscoll Children s hospital. Project Valuation: The Waiver provides the opportunity for CHRISTUS Spohn Corpus Christi ( Spohn ) to support and implement Delivery System Reform Incentive Payment ( DSRIP ) projects that will transform the delivery of healthcare in our region. Based on the final Program and Funding Mechanics Protocol and current guidance from the Texas Health and Human Services Commission, we understand that the RHP Plan must contain a narrative that describes the overall regional and individual project approach for valuing each project. Therefore, in order to implement an objective, reasonable, and equitable method for valuing DSRIP projects, Spohn prepared a valuation template to value each of its projects. The valuation template considers four criteria for each project: 1. Achieves Waiver Goals. Relative to Spohn s other proposed projects, to what extent does the project achieve the waiver goals of enhancing access, assuring quality of care, and improving the health of patients? Spohn considered how the project proposes to address the following: a. Improve the health care infrastructure to better serve the Medicaid and uninsured residents of Region 4. b. Further develop and maintain a coordinated care delivery system c. Improve outcomes while containing cost growth 2. Addresses Community Need(s). Relative to Spohn s other proposed projects, to what extent does the project address community needs? Spohn considered the following attributes when scoring projects on this domain: a. Will the project address one or more community needs identified: i. In the region s workgroup initiatives; and/or ii. In the region s community needs assessment? b. How significant is the expected impact? 3. Population Served. Spohn considered how many patients the project will impact, either in total volume of patients or the type of population the project will serve (for example, predominately Medicaid and uninsured). 4. Project Investment. Relative to the Spohn s other proposed projects, how large is the expected investment to successfully implement this project and achieve the milestones and metrics? 14 The scores across each of the criteria are then summed to produce a total score, called the Value Weight of Project. The valuation template then calculates initial project values for the projects based on Spohn s allocation of funding and each project s Value Weight, relative to the Value Weights of Spohn s other projects. After each project is valued, Spohn will ensure that each project comports with the final Program and Funding Mechanics Protocol, which (1) limits the amount allocated to any 14 For each proposed project, SPOHN scores the projects on a scale of 1-5 for each criteria, with a 1 having a minimal impact or investment and 5 having the largest impact or investment. RHP Plan for Region 4 182

7 category 1 or 2 project to 10% of Spohn s total Pass 1 allocation, and (2) proscribes the maximum funding distribution allocation to categories 1 and 2. This project is Spohn s highest in value because it serves the Triple Aims of the Waiver by focusing on patient satisfaction and health outcomes while also addressing systemic deficits in primary care and addressing the high cost of providing care. The project addresses community needs (as evidenced by the Community Needs Assessment) and serves the entire indigent population of Nueces County who are able to travel to one of Spohn s FHCs or the Hector P Garcia clinic (as all residents need primary care). This project will take significant investment in transformation, including adding hours, providers, and space, but will ultimately create great value for the Region. RHP Plan for Region 4 183

8 A B C Related Category 3 Outcome Measure(s): Year 2 (10/1/2012 9/30/2013) Milestone 1 [P-4]: Expand hours of one primary care clinic to include evening and weekend hours Metric 1 [P-4.1]: Increase number of hours at primary care clinic over baseline Baseline/Goal: Increase clinic hours in at least one FHC to include 2 additional hours per week after 5pm or during the weekend (improvement over baseline, as evidenced by DY1 clinic schedules) Data Source: Clinic schedules Milestone 1 Estimated Incentive Payment (maximum amount): $977, Milestone 2 [P-5]: Hire additional primary care providers and staff. Metric 1 [P-5.1]: Documentation of increased number of providers and staff Baseline/Goal: Hire/contract two (2 total) Community Health Workers to staff Spohn s primary care clinics. Data Source: Staffing schedules, HR documents EXPAND PRIMARY CARE CAPACITY CHRISTUS SPOHN HOSPITAL CORPUS CHRISTI IT-9.2 Right Care Right Setting ED appropriate utilization-all (non-urgent/nonemergent) ED visits Year 3 (10/1/2013 9/30/2014) Milestone 3 [P-4]: Expand hours of a primary care clinic to include evening and weekend hours Metric 1 [P-4.1]: Increase number of hours at primary care clinics over baseline Baseline/Goal: Increase clinic hours in at least one primary care clinic to include 2 additional hours per week after 5pm or during the weekend over DY2 hours of availability. Data Source: Clinic schedules Milestone 3 Estimated Incentive Payment (maximum amount): $999, Milestone 4 [P-1]: Expand existing primary care clinics. Metric 1 [P-1.1]: Expanded space Baseline/Goal: Increase available space for treating patients in Spohn s Northside FHC from 5000 square feet to at least 8000 square feet Data Source: Documentation of the additional space in the Northside primary care clinic (i.e. evidence of remodeling) Milestone 4 Estimated Incentive Year 4 (10/1/2014 9/30/2015) Milestone 5 [P-4]: Expand hours of a primary care clinic to include evening and weekend hours Metric 1 [P-4.1]: Increase number of hours at primary care clinic over baseline Baseline/Goal: Increase clinic hours in at least one primary care clinic to include 2 additional hours per week after 5pm or during the weekend over DY3 hours of availability. Data Source: Clinic schedules Milestone 5 Estimated Incentive Payment (maximum amount): $997, Milestone 6 [P-5]: Hire additional primary care providers and staff. Metric 1 [P-5.1]: Documentation of increased number of providers and staff Baseline/Goal: Hire/contract 2 additional providers to staff Spohn s primary care clinics. Data Source: Staffing schedules, HR documents Milestone 6 Estimated Incentive Payment (maximum amount): $ Milestone 1 Estimated Incentive Year 5 (10/1/2015 9/30/2016) Milestone 7 [I-12]: Increase Primary Care Clinic volume of visits and evidence of improved Metric 1 [I-12.1]: Documentation of increased number of visits. Demonstrate improvement over prior reporting period. Goal: 15% increase in primary care visits over DY2 numbers, as averaged across Spohn s four (4) primary care clinics and the Hector P. Garcia clinic (an estimated 10,050 additional Medicaid/self-pay encounters over DY2, for a total of 61,640 Medicaid-eligible/self-pay visits). Data Source: Clinic scheduler, clinic records Milestone 7 Estimated Incentive Payment (maximum amount): $1,611,290 RHP Plan for Region 4 184

9 A B C Related Category 3 Outcome Measure(s): Year 2 (10/1/2012 9/30/2013) Milestone 2 Estimated Incentive Payment (maximum amount): $977, EXPAND PRIMARY CARE CAPACITY CHRISTUS SPOHN HOSPITAL CORPUS CHRISTI IT-9.2 Right Care Right Setting ED appropriate utilization-all (non-urgent/nonemergent) ED visits Year 3 (10/1/2013 9/30/2014) Payment (maximum amount): $999, Year 4 (10/1/2014 9/30/2015) Payment (maximum amount): $997, Year 5 (10/1/2015 9/30/2016) Year 2 Estimated Milestone Bundle Amount: (add incentive payments amounts from each milestone): Year 3 Estimated Milestone Bundle Amount: $1,998,619 Year 4 Estimated Milestone Bundle Amount: $1,995,521 $1,954,139 TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD (add milestone bundle amounts over Years 2-5): $7,559,569 Year 5 Estimated Milestone Bundle Amount: $1,611,290 RHP Plan for Region 4 185

10 CHRISTUS Spohn Hospital Corpus Christi/ Implement a Chronic Disease Registry, Unique Identifier Provider: CHRISTUS Spohn Hospital Corpus Christi is a 730-bed hospital in Corpus Christi serving a 460 square mile area and a population of approximately 460,000. The Hospital is comprised of 3 facilities on 3 campuses. Intervention(s): Spohn will implement a Chronic Disease registry to assist Spohn in tracking and managing patients with conditions, which will initially focus on patients with CHF and diabetes. The chronic disease database/repository will be created for Spohn by heartbase to support and sustain management of patients in our Care Transitions/Care Partners program, which focuses on using RN Coaches to coordinate the care for chronically ill patients. Need for the project: Current documentation by the Care Transitions/Care Partners teams is handwritten paper format and Care Transitions nurses call the inpatient case managers (CM) daily to identify patients for potential discharge. The registry will allow streamlined documentation and increased efficiency for the Care Transitions and Care Partners teams that is untenable under the current documentation system. The registry and repository will link to the EMR and provide the ability to track, trend and alert both inpatient and outpatient care providers to multiple hospitalizations and ED visits regardless of facility or location within the Spohn hospital system. Automated acquisition, storage and access to this data will enhance identification of individual patient needs to analyze and report trends in resource utilization. Target population: The target population of this project includes charity, Medicaid and selfpay patients with CHF and/or diabetes who are not currently enrolled in our Care Transitions or Care Partners programs ( target population ). Patients are identified by case managers in the acute care setting and referrals submitted to the Community Outreach department for program enrollment. Currently, 237 patients covered through the County s indigent program are enrolled in Care Transitions for CHF/Diabetes. Each of those patients receives 5 encounters as part of the program, after which 80% of those patients are referred into the Care Partners program for 90 additional visits per patient over 18 months (for a total of 18,285 patient encounters). This project seeks to enroll the target population into these programs, which Spohn estimates will impact 1400 additional enrollees who will receive an total of approximately 110,000 encounters (based on current trends). Category 1 or 2 expected patient benefits: Spohn expects to have the registry implemented in at least 4 clinics with approximately 1400 enrollees by the end of DY4, which Spohn expects to result in at least 50% of targeted patients receiving educational, disease-appropriate information after visits with the Care Transition team by the end of DY5 (an estimated 700 enrollees). These interventions should improve patient self-management skills, short- and long-term health outcomes, and patient satisfaction with the healthcare delivery system. Category 3 outcomes: IT- 3.2: Our goal is for the use of the registry to result in an 8% reduction from DY2 s CHF patient all-cause 30-day readmission rates for Spohn s Corpus Christi campuses by the end of DY5. RHP Plan for Region 4 186

11 Implement Chronic Disease Registry Category 1: Infrastructure Development Identifying Project and Provider Information: Implement a Chronic Disease Registry, CHRISTUS Spohn Hospital Corpus Christi/ Unique Identifier Project Description: Spohn will implement a Chronic Disease registry to assist Spohn in tracking and managing patients conditions. The project will initially focus on CHF and diabetes. Spohn will enter patient data into the registry, and will then use the information contained in the registry to take a proactive approach to managing the conditions of patients with CHF and diabetes. This includes engaging these patients in education, community outreach, regular status checks with their primary care providers, maintaining an active support system, and engaging patients to exercise self-management of their conditions. Upon implementing the registry and using it proactively, Spohn will use the reports generated by the registry to develop and implement a plan for quality improvement in the medical care provided to patients with these chronic conditions. The implementation of this plan will likely include identifying best practices and training staff to expand their use of those practices, discovering why certain patients are frequent-flyers and taking steps to provide additional support to those patients, and to determine how many, if any, of the chronic conditions could be better managed with additional input or support from other providers within Spohn s network. More specifically, a chronic disease database/repository will be created for Spohn by heartbase to support and sustain management of patients in our Care Transitions/Care Partners program, which focuses on using RN Coaches to coordinate the care for chronically ill patients. heartbase is our current vendor for national registries cardiovascular benchmark reporting of AMI, CHF and Open Heart Surgery with expansion to stroke and core measure data to The Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS). heartbase is a certified vendor by TJC, CMS, American College of Cardiology (ACC) and Society of Thoracic Surgery (STS) with representation on international cardiovascular Health Information Exchange ( HIE ) teams. This database will combine registry and longitudinal tracking of patients with chronic disease by automating patient documentation currently used by the Care Transitions and Care Partners (CHW) programs. Initial focus will be patients with CHF and diabetes but capability will incorporate all chronic disease and potential co-existing behavioral health diagnoses. The database will utilize a combined set of elements. Data points will not be duplicated but rather shared if they are the same data point, like ICD9 (Future ICD-10) and patient name. The registry will interface with Meditech, our current inpatient EMR, and Athena, the future EMR for our Family Health Centers ( FHC ) and the current EMR at Hector P Garcia. Automation of the named documents and proposed interfaces will provide a provider and patient portal to a chronic disease repository that is used by all six Spohn facilities, related clinics and doctor offices. The database vision is one where the community stores all related chronic disease information on a server that is shared by hospital, clinics, physicians, and patients that participate in this program at CHRISTUS Spohn Health System. Access will be via a web-based front end with secured areas for both patients RHP Plan for Region 4 187

12 and staff and will also have the ability to interface with the developing health information network of South Texas, HINSTX. The proposed registry will also have the ability to interface and house future proposed telehealth/telemedicine devices used to remotely access and monitor patients in their homes by the Care Transition and Care Partners teams as well as regional primary care providers. Project Goals/5 Year Expected Outcome: o Registry implemented at four local clinics with 1400 enrollees by the end of DY 4 At least 50% of targeted patients receiving educational, disease-appropriate information after visits to the FHCs (approximately 700 patients) o Engage in quality improvement by collecting and disseminating best practices from each FHC Project Challenges: o Creating and implementing the actual registry (which will include provider training and assistance from third parties) o Collecting accurate and current data regarding the health status of FHC patients o Training providers to engage in effective outreach, support, and management for patients with these chronic diseases o Maintaining the registry consistently o Sharing information across FHCs in an organized and effective manner Spohn will address these challenges by taking deliberate steps towards implementing the registry in an organized and thoughtful manner. The registry will not useful if providers cannot use it properly or do not understand the value of increased patient outreach and education. Thus, creating the registry and training our providers are the most important steps in DYs 2-3. In DYs 4-5, the FHCs can begin taking steps to improve on current practices using the registry for guidance and to stay organized. The registry itself will allow the FHCs to share more information than they may currently be able to do on a day-to-day basis. Relationship to Regional Goals: Region 4 wants to transform care delivery from a disease-focused model of episodic care to a patient-centered, coordinated delivery model that improve patient satisfaction and outcomes while reducing the systemic costs of treating unmanaged chronic care conditions. This project addresses these goals head on. Starting Point/Baseline: Current documentation by the Care Transitions/Care Partners teams is handwritten paper format. Care Transitions nurses call the inpatient case managers (CM) daily to identify patients for potential discharge. They are often contacted by individual unit staff when patients not identified by CM receive discharge orders. Currently 237 patients covered through the County s indigent program are enrolled in Care Transitions for CHP/Diabetes. Each of those patients receives 5 encounters as part of the program, after which 80% of those patients are referred into the Care Partners program for 90 additional visits per patient over 18 months (for a total of 18,285 patient encounters). RHP Plan for Region 4 188

13 Rationale: On a macro level, Region 4 has a high incidence of chronic disease, as noted in the Region s Community Needs Assessment: Regional hospital admissions and related data indicate that there is a prevalence of chronic conditions that lead to preventable hospitalizations, and which require a coordinated care management team approach to maximize patient outcomes. RHP Plan, p. 29. Additionally, chronic diseases including CHF, COPD, Diabetes, and asthma are linked with Nueces County having a higher rate of Potentially Preventable Admissions than the statewide average. Avoidable hospitalization has a twofold negative impact on the delivery system: (1) patient health outcomes and satisfaction are reduced in the long- and short-term, and (2) the cost of delivering care is immediately and going forward more expensive when patients conditions deteriorate to an acute level. This project will provide a substantial infrastructure to identification, tracking and monitoring Medicaid/uninsured/Self-pay patients regardless of entry point into the CHRISTUS Spohn Health System. This capability will link patients throughout the region and provide a future avenue for global integration to external HIEs. In addition to access and exchange of information, the registry/repository will allow streamlined documentation and increased efficiency for the Care Transitions and Care Partners teams. This flow of communication does not currently exist. A frequently occurring example of the breakdown in the current system identified by the Care Transitions/Care Partners staff is patients missing their scheduled clinic appointments because they are inpatients at the hospital. Our planned registry will provide patient and hospital alerts to maximize the efficiency of communication and disease management. Milestones and Metrics: Spohn chose its DY 2-3 milestones in metrics in order to develop, test, and implement the registry, as well as train staff to populate it and use it successfully. Spohn chose its DY 4-5 milestones and metrics in order to effectuate improved care for patients with the targeted chronic conditions and to engage in quality improvement by the end of DY5. Community Needs Identification Number Addressed by this Project: CN.3, CN.7, CN.12 Related Category 3 Outcome Measure(s): OD 3: Potentially Preventable Readmissions; Improvement Target 3.2: CHF 30 Day Readmissions Automation and integration of Care Transitions and Care Partners programs with interfaces to hospital and clinic EMRs will streamline communication and provide longitudinal tracking and monitoring of chronically ill patients upon discharge from the inpatient setting. Spohn selected this outcome measure because one goal behind developing the registry is to longitudinally track patients with CHF and develop alerts for those who experience frequent readmissions, regardless of cause. This project is intended to help Spohn to identify those patients that are at risk for readmission to the hospital (often multiple times) upon discharge and intervene to prevent the causes of their readmission (including the inability to self-manage CHF in the outpatient setting). Relationship to other Projects: This automated infrastructure will finally provide a link between inpatient and outpatient care provided to individual patients in an efficient and streamlined manner to facilitate integrated care coordination in multiple settings. It is related to the following projects also proposed in this waiver plan: 189 RHP Plan for Region 4

14 PADnet telehealth/telemedicine This project also addresses streamlining care for chronic conditions and is a related cardiac condition Establish Medical Homes Part of the Medical Home model involves comprehensive management of patients conditions before they deteriorate, which is the specific purpose of the chronic disease registry Cost of Care Delivery Primary Care Redesign The hospitalist and resident teams assigned to patients will use the chronic disease registry to track their patients Diabetes Cellphone Application Diabetes is another chronic condition that will be tracked in the registry, and the information will be used for outreach under this program Expand Care Transitions program The chronic disease registry will assist the RN Coaches in managing chronically ill patients conditions. Related Category 4 measures included Potentially Preventable Admissions measures in RD-1, Potentially Preventable Complications in RD-3, and Patient Satisfaction in RD-4. This project provides integration of information with all 3 CHRISTUS Spohn Health System community facilities and CSHA. This is crucial to regional patient outcomes as patients transfer to Alice and Victoria from all remote areas of the RHP. This infrastructure and its ability to interface with future development of HINSTX will support the flow of communication beyond the CSHS boundaries and throughout the lifespan of the patients Relationship to Other Performing Providers Projects and Plan for Learning Collaborative: We plan to participate in a region-wide learning collaborative(s) as offered by the Anchor entity for Region 4, Nueces County Hospital District. Our participation in this collaborative with other Performing Providers within the region that have similar projects will facilitate sharing of challenges and testing of new ideas and solutions to promote continuous improvement in our Region s healthcare system. Other providers with similar projects with whom we will participate in the learning collaborative include Corpus Christi Medical Center and Driscoll Children s hospital. Project Valuation: The Waiver provides the opportunity for CHRISTUS Spohn Corpus Christi ( Spohn ) to support and implement Delivery System Reform Incentive Payment ( DSRIP ) projects that will transform the delivery of healthcare in our region. Based on the final Program and Funding Mechanics Protocol and current guidance from the Texas Health and Human Services Commission, we understand that the RHP Plan must contain a narrative that describes the overall regional and individual project approach for valuing each project. Therefore, in order to implement an objective, reasonable, and equitable method for valuing DSRIP projects, Spohn prepared a valuation template to value each of its projects. The valuation template considers four criteria for each project: 1. Achieves Waiver Goals. Relative to Spohn s other proposed projects, to what extent does the project achieve the waiver goals of enhancing access, assuring quality of care, and improving the health of patients? Spohn considered how the project proposes to address the following: RHP Plan for Region 4 190

15 a. Improve the health care infrastructure to better serve the Medicaid and uninsured residents of Region 4. b. Further develop and maintain a coordinated care delivery system c. Improve outcomes while containing cost growth 2. Addresses Community Need(s). Relative to Spohn s other proposed projects, to what extent does the project address community needs? Spohn considered the following attributes when scoring projects on this domain: a. Will the project address one or more community needs identified: i. In the region s workgroup initiatives; and/or ii. In the region s community needs assessment? b. How significant is the expected impact? 3. Population Served. Spohn considered how many patients the project will impact, either in total volume of patients or the type of population the project will serve (for example, predominately Medicaid and uninsured). 4. Project Investment. Relative to the Spohn s other proposed projects, how large is the expected investment to successfully implement this project and achieve the milestones and metrics? 15 The scores across each of the criteria are then summed to produce a total score, called the Value Weight of Project. The valuation template then calculates initial project values for the projects based on Spohn s allocation of funding and each project s Value Weight, relative to the Value Weights of Spohn s other projects. After each project is valued, Spohn will ensure that each project comports with the final Program and Funding Mechanics Protocol, which (1) limits the amount allocated to any category 1 or 2 project to 10% of Spohn s total Pass 1 allocation, and (2) proscribes the maximum funding distribution allocation to categories 1 and 2. Spohn valued this project based on its application to the goals of the Waiver, in that it focuses on improving patient outcomes while reducing the systemic cost of providing care. The registry will allow Spohn to make proactive choices to maintain the health status of chronically ill patients, which will benefit their quality of life and satisfaction with their health care greatly. The high incidence of chronic disease in Nueces County means that the registry addresses known community needs and will serve a broad population of the County s residents. Finally, creating, implementing, and proactively using the registry will require investment in technology, staff training, project planning, and community outreach. 15 For each proposed project, SPOHN scores the projects on a scale of 1-5 for each criteria, with a 1 having a minimal impact or investment and 5 having the largest impact or investment. RHP Plan for Region 4 191

16 A, B, C, D 1.3. IMPLEMENT A CHRONIC DISEASE REGISTRY CHRISTUS SPOHN HOSPITAL CORPUS CHRISTI Related Category IT 3.2 Congestive Heart Failure 30 day readmission rate Outcome Measure(s): Year 2 (10/1/2012 9/30/2013) Milestone 1 [P-1]: Identify 1 or more target patient populations diagnosed with selected diseases or multiple chronic conditions Metric 1 [P-1.1]: Documentation of patient population to be entered into the registry Baseline/Goal: Registry Development for 2 major chronic diseases/conditions; CHF and diabetes Data Source: Performing Provider documents Milestone 1 Estimated Incentive Payment (maximum amount): $804, Milestone 2 [P-2]: Review current registry capability and assess future needs. Metric 1 [P-2.1]: Documentation of review of current registry capability and assessment of future needs Baseline/Goal: Approval of comprehensive proposal to develop electronic infrastructure for longitudinal data registry Data Source: Registry Project Management Plan/Proposal Milestone 2 Estimated Incentive Year 3 (10/1/2013 9/30/2014) Milestone 3 [P-3]: Develop crossfunctional team to evaluate registry program Metric 1 [P-3.1]: Documentation of personnel assigned to registry evaluations Baseline/Goal: Spohn multidisciplinary team development of chronic disease registry Numerator: number of personnel assigned to enter the registry Denominator: total number of personnel Data Source: Registry Project Management Plan/Proposal Milestone 3 Estimated Incentive Payment (maximum amount): $822,961 Milestone 4 [P-4]: Implement/expand a functional disease management registry Metric 1 [P-4.1]: Registry functionality is available in X% of Performing Provider s sites and includes an expanded number of targeted diseases or clinical conditions. Baseline/goal: The registry measuring CHF and diabetes will be Year 4 (10/1/2014 9/30/2015) Milestone 5 [P-8]: Create/ disseminate protocols for registrydriven reminders and reports for clinicians and providers regarding key health indicator monitoring and management in patients with targeted diseases. Metric 1 [P-8.1]: Submitted protocols for the specified conditions and health indicators Baseline/Goal: Spohn will create protocols for using the information stored in the registry to address diabetes and CHF in each of its five FHCs. Data Source: Protocols Milestone 5 Estimated Incentive Payment (maximum amount): $821,685 Milestone 6 [I-15]: Increase the percentage of patients enrolled in the registry. Metric 1 [I-15.1]: Percentage of patients in the registry with targeted chronic conditions Baseline/Goal: Increase the percentage of the FHCs diabetic and CHF patients (across the board) entered into the registry by 10% over the percentage in the Year 5 (10/1/2015 9/30/2016) Milestone 7 [I-22]: Increase the percentage of patients with chronic disease entered into the registry who receive instructions appropriate for their chronic disease, such as: activity level, diet, medication management, etc. Metric 1 [I-22.1]: Percentage of patients with chronic disease who receive appropriate disease specific discharge instructions. Goal: 50% of patients with diabetes or CHF will receive disease appropriate instructions after appointments at each FHC on how to manage their condition day-today (for diabetics, specifically diet information and medication management; for CHF patients, specifically medication management and activity level) Spohn estimates this to constitute 700 patients Numerator: the number of patients with chronic disease who receive appropriate disease specific instructions Denominator: number of patients with targeted chronic disease entered into the registry Data Source: Disease registry or EHR RHP Plan for Region 4 192

17 A, B, C, D 1.3. IMPLEMENT A CHRONIC DISEASE REGISTRY CHRISTUS SPOHN HOSPITAL CORPUS CHRISTI Related Category IT 3.2 Congestive Heart Failure 30 day readmission rate Outcome Measure(s): Year 2 (10/1/2012 9/30/2013) Payment (maximum amount): $804, Year 3 (10/1/2013 9/30/2014) implemented and used for management and outreach in at least 80% of Spohn s FHC sites (4/5 clinics). Data source: documentation of installation and adoption of the registry Milestone 4 Estimated Incentive Payment (maximum amount): $822,961 Year 4 (10/1/2014 9/30/2015) registry in DY3 (if DY3 reflects 100% of these patients are in the registry, then the FHCs will maintain this percentage by adding all new patients with the targeted condition into the registry by the end of DY4 Spohn hopes to have 1400 enrollees in DY5) Numerator: number of CHF and diabetic patients in the registry Denominator: number of diabetic and CHF patients assigned to this clinic for routine care Data Source: Registry and/or EHR Milestone 6 Estimated Incentive Payment (maximum amount): $821,685 Year 5 (10/1/2015 9/30/2016) Milestone 7 Estimated Incentive Payment (maximum amount): $663,472 Milestone 8 [Additional Process Milestones in Planning Protocol Instructions] Redesign the processes in order to be more effective, incorporating learnings (Quality Improvement) Metric: documentation of redesign assessment and steps taken to make the process more effective Baseline/goal: Identify one best practice from any of the 5 FHCs regarding (1) diabetes management, and (2) CHF management, and implement the best practices at each FHC or expand upon the concept Data source: Documentation of assessment of best practices and steps taken to implement the best practices at each FHC Year 2 Estimated Milestone Bundle Amount:: $1,609,291 Year 3 Estimated Milestone Bundle Amount: $1,645,922 Year 4 Estimated Milestone Bundle Amount: $1,643,370 TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD (add milestone bundle amounts over Years 2-5): $6,225,528 Milestone 8 Estimated Incentive Payment: 663,472 Year 5 Estimated Milestone Bundle Amount: $1,326,945 RHP Plan for Region 4 193

18 CHRISTUS Spohn Hospital Corpus Christi Project 1.7: Introduce, Expand, or Enhance Telemedicine/Telehealth Unique project ID number: Provider: CHRISTUS Spohn Hospital Corpus Christi is a 730-bed hospital in Corpus Christi serving a 460 square mile area and a population of approximately 460,000. The Hospital is comprised of 3 facilities on 3 campuses. Intervention(s): Spohn plans to implement a system for early detection and ongoing treatment and management of peripheral arterial disease (PAD) in Region 4, using a new telemedicine disease management system that allows specialist input at primary care provider (PCP) offices for both diagnostics and treatment plans. The PADnet Disease Management System provides patients that present at PCP offices with access to specialists to address issues with PAD. Need for the project: As a screening tool, PADnet is recommended for early detection and intervention in people with symptoms or at risk for peripheral arterial disease (PAD).Currently, diagnostics are performed manually using a blood pressure cuff to calculate a ratio (ankle and brachial pressures) indicative of PAD. This current method provides only a numeric value reflective of the differences in the two pressures and does not produce graphic representation of flow. Patients are then sent to a cardiologist or cardiovascular (CV) surgeon for follow-up, diagnostics and treatment plan with or without requisite interventions. Current wait times for indigent patients in Nueces County to see a cardiologist ranges from days. PAD is very painful and as it progresses undetected or untreated it can result in skin ulcers, gangrene, and amputation. Target population: The target population of this project includes Nueces County residents at risk for PAD who seek treatment in Spohn s clinics and the Hector P Garcia clinic where Spohn physician-residents provide care, and require cardiovascular referrals. Spohn intends to screen its high risk clinic patients with diabetes who are not currently symptomatic for PAD. Spohn s FHCs and neighboring clinics treat approximately 19,500 patients per year, approximately 7800 (40%) of which are diabetic and many of whom are high risk because of their family history, ethnicity and/or age. Spohn will identify those patients based on diabetes, hypertension, and history of smoking, and screen them for PAD. Category 1 or 2 expected patient benefits: Through implementing the use of PADnet in local clinics, Spohn expects the benefits to patients to include 1000 PADnet screenings in DY3, 1750 PADnet screenings in DY4, and 2500 PADnet screenings in DY5, as well as a 5% reduction in the wait time experienced by indigent patients for a cardiology consult by the end of DY3, and a 5% increase in telemedicine cardiology consults for patients residing in geographically underserved areas served by Spohn s clinics from the first year of operation by the end of DY5. Category 3 outcomes: IT-1.11: Our goal is a 10% increase in the number of diabetic patients with controlled blood pressure, which should decrease those patients risk of developing PAD. RHP Plan for Region 4 194

19 Introduce PADnet for Peripheral Arterial Disease Screening and Treatment Category 1: Infrastructure Development Identifying Project and Provider Information: Project 1.7: Introduce, Expand, or Enhance Telemedicine/Telehealth Project Option 1.7.6: Implement an electronic consult processing system to increase efficiency of specialty referral process by enabling specialists to provide advice and guidance to primary care physicians that will address their questions without the need for face-to-face visits when medically appropriate. CHRISTUS Spohn Hospital Corpus Christi/ TPI Unique project ID number: Project Description: Spohn plans to implement a system for early detection and to mitigate the adverse effects of chronic disease rampant in Region 4, using a new telemedicine disease management system that allows specialist input at primary care provider (PCP) offices for both diagnostics and interventions. The PADnet Disease Management System provides patients who present at PCP offices with access to specialists to address issues with peripheral arterial disease (PAD). Spohn expects this to result in fewer unnecessary referrals to specialists for treatment the PCP is able to provide personally, earlier detection for patients who need immediate intervention, and greater care coordination between PCPs and cardiac specialists. No federal funds have been received or are being used for this project. Project Goals/5-Year Expected Outcome: The remote diagnostic devices can be located in PCP offices and will allow for increased communications through telemedicine with cardiologists or cardiovascular surgeons to interpret, diagnose and prescribe treatment or work in collaboration with the PCP to determine an appropriate follow-up/prevention plan when no interventions are needed. Finally, through quality improvement initiatives, the project will assess the project s impact, lessons learned and opportunities to scale the project to a broader population. Implementation of PADnet will help demonstrate the benefits of early detection and intervention for PAD, both for patient quality of life, satisfaction and long-term health outcomes and for the systemic cost of providing care to the chronically ill. Specific goals include: 5% increase in PADnet screenings in DY3, over baseline set in DY2; 10% increase over DY2 baseline in DY4; 15% increase over DY2 baseline in DY5 5% reduction in wait time to cardiovascular consult for PAD in DY3 (using records from DY2 to measure improvement) Implement the use of PADnet in at least 3 FHCs by the end of DY4 This project is related to Region 4 goals in that it seeks to prevent diabetes related complications by allowing rural and indigent patients to access real-time diagnostics and reads by a specialist. These complications are costly to Region 4 communities in that they increase the cost of delivering care (often because they lead to ED visits), reduce productivity in the work-force, and cause ripple-effects for affected families. Any and all providers in the Region can access this network through purchasing the diagnostic equipment, which is fairly low cost. RHP Plan for Region 4 195

20 Project Challenges: Identifying cardiac specialists willing to provide electronic consults for patients in Nueces County Implementing new technology in the FHCs Training providers in the FHCs to use the PADnet technology Educating patients about the benefits of using electronic consults Spohn will address these challenges by coordinating with stakeholders to identify appropriate partners for the project (i.e. specialists to provide the consults) and by using DY2 to train providers and create processes that are consistent across the FHCs. Finally, Spohn will train providers on how to present the PADnet telemedicine option to patients in a manner that alerts them to the benefits of using this technology. Starting Point/Baseline: Diagnostics are currently performed manually using a blood pressure cuff to calculate a ratio (ankle and brachial pressures) indicative of PAD. This current method provides only a numeric value reflective of the differences in the two pressures and does not produce graphic representation of flow. Patients are then sent to a cardiologist or cardiovascular (CV) surgeon for follow-up, diagnostics or planned interventions. Depending on the severity of the disease, peripheral artery angioplasty, stenting, surgical revascularization and amputation are all possible interventions. For less severe disease or those with high risk factors, minor disease can benefit from medical treatment. In the past year, 651 interventional or surgical treatments have been performed on patients for PAD at Spohn; of those, 20% were Medicaid-eligible or self-pay. Early detection and the option of peripheral interventions for symptomatic or at risk patients has shifted the ratio of amputations to interventions to 50:50 from previous ratios of 70:30 as recently as Rationale: Like many diagnostic modalities designed for early detection of potentially life altering diseases, PADnet provides a solution that decreases the cost and burden of diagnostic on the patient and healthcare system. For the Medicaid, charity and self-pay patients in RHP 4, patients suspected of having or at risk for PAD have historically been referred to a Cardiology/CV Surgeon for evaluation. PAD in its moderate to advanced stages is associated with high pain levels especially with weightbearing patients. Severe circulatory compromise results in swelling of the lower extremities and often open ulcers or wounds. Uninsured/underinsured patients often skip specialist appointments due to expense of the visit, time missed at work for a doctor visit or because they think they can tolerate it a little longer. They are often unaware that the PAD does not go away on its own but can be treated successfully if identified during the early stages. Another identified barrier in our region is the delay obtaining an appointment with these specialties. Current wait times for indigent patients to see a cardiologist ranges from days. One key to determine the precedence for screening in RHP 4 as well as other areas of the state is to analyze current statistics: Approximately 5 million Americans in the US are affected by PAD RHP Plan for Region 4 196