TEXAS HEALTHCARE TRANSFORMATION & QUALITY IMPROVEMENT PROGRAM. Bluebonnet Trails Community Services

TEXAS HEALTHCARE TRANSFORMATION & QUALITY IMPROVEMENT PROGRAM Regional Healthcare Partnership Region 4 Bluebonnet Trails Community Services Delivery System Reform Incentive Payment (DSRIP) Projects

Category 1 DSRIP Projects: Infrastructure Development NONE SUBMITTED

Category 2 DSRIP Projects: Program Innovation & Redesign

Bluebonnet Trails Community Mental Health and Mental Retardation Center dba/bluebonnet Trails Community Services Establish/Expand a Patient Care Navigation Program; Patient Navigator for Persons with Chronic Illnesses Project Identifier: 126844305.2.1 Provider: Bluebonnet Trails Community Services (BTCS) is the state designated Local Mental Health Authority for Gonzales County in Region 4 as well as for seven other Counties in three other RHP s located east of and parallel to IH 35 extending north of Austin, Texas. We are responsible for an array of public services and for behavioral health planning and coordination throughout our local service area. We operate a clinic co-located with the local Federally Qualified Health Center (FQHC) and provide the only public behavioral health services in the County. Intervention(s): BTCS, in collaboration with Gonzales Memorial Hospital and the local FQHC will implement a patient navigation project for frequent users of the ED due to chronic health conditions including behavioral health disorders. 2 RN s will be located at the Hospital and provide assessment, triage, diversion and referral. Those without PCP s will be referred to establish ongoing care and a medical home. Need for the project: Leadership at the Hospital and the Mental Health Task Force for Gonzales County have identified a group of about 50 patients who are frequent users of the ED, defined as more than 5 visits a year. These patients account for a disproportionate cost to the Hospital and the ED. Navigation will reduce the cost and improve overall health and well-being for this group of patients. This project addresses all three of the needs in the RHP 4 Community Needs Assessment plan. It supports: CN.1 Improve access to care for primary care and specialty services; CN.2 Improve the provision and coordination of health care services for persons with chronic conditions; and CN.3 Expand access to behavioral health services. Target population: The target population is patients who have visited the Gonzales Memorial Hospital ED more than 5 times in a year. BTCS served 770 persons in Gonzales County in FY 2012; 565 persons with mental illnesses. An average of 43% of the adults and 76% of the children with mental illnesses were eligible for Medicaid or CHIP and approximately 25 % of non-medicaid adults were indigent. We expect about 75 % of the persons benefitting from these services to be Medicaid or CHIP eligible or uninsured. Category 1 or 2 expected patient benefits: The starting point/baseline for this service in DY 2 is 0 since no such service currently exists in this County. The project seeks to serve 30 people in DY 4 and 50 people in DY 5. Those served will be high utilizers of the ED with multiple visits per year. We plan to intervene at the point of the visit and to assist the individuals in connecting for ongoing care through a medical home, thereby reducing future ED utilization. Category 3 outcomes: IT-3.1 Our goal is to reduce all cause 30 day readmission rate for these high utilizers by a percentage TBD after baseline is established in DY 3. RHP Plan for Region 4 624

Category 2 DSRIP Project Narrative Template Category: Category 2 Innovation and Redesign Project Area and Option: Project Area 9 - Establish/Expand a Patient Care Navigation Program; Project Option 1 Provide navigation services to targeted patients who are at high risk of disconnect from institutional health care (for example, patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, recent immigrants, the uninsured, those with low health literacy, frequent visitors to the ED, and others.) Title of Project: Patient Navigator for Persons with Chronic Illnesses RHP Project Identification Number: 126844305.2.1 Performing Provider Name Bluebonnet Trails Community Mental Health and Mental Retardation Center dba/bluebonnet Trails Community Services Performing Provider TPI #: 126844305 Project Description: Bluebonnet Trails Community Services (BTCS) is the state designated Local Mental Health Authority (LMHA) for Gonzales County in Region 4 as well as for seven other Counties located east of and parallel to IH 35 extending north of Austin, Texas in Travis County. In that capacity we are responsible for an array of public services as well as for behavioral health planning and coordination throughout our local service area. We operate a clinic colocated with the local FQHC and provide behavioral health services in Gonzales County and we have responsibility to identify gaps in service or barriers to access for persons diagnosed with behavioral health disorders residing in the area. BTCS proposes to work in collaboration with the Gonzales Health Care System, and specifically with Gonzales Memorial Hospital and local Federally Qualified Health Center (FQHC), Community Health Centers of South Central Texas, within that System, to implement a patient navigation project for persons who are frequent users of the Emergency Department (ED) due to chronic health conditions including behavioral health disorders. We have a good relationship with the hospital, the FQHC and with other health care providers in Gonzales County. BTCS staff frequently assists the hospital with assessment, discharge and continuity of care issues for BTCS patients and therefore are familiar with key staff, facilities and resources. We held planning discussions with the leadership of Gonzales Memorial Hospital and are in agreement that we will locate the navigation program staff within the hospital itself. BTCS is in a long term partnership with the FQHC, Community Health Centers of South Central Texas, which will further enhance this project to ensure accessibility to a medical home. Plans for the project are to hire two RN s to deliver the navigation services. The RNs will provide patient education, assessment and guidance on follow up care and they will identify community resources and directly link and advocate for the patients. The goals will be for the patient navigators to provide enhanced social support and culturally competent care to this high risk population. They will help and support the patients as they seek access throughout the continuum of health care. In addition they will ensure timely, RHP Plan for Region 4 625

coordinated and site appropriate health care and if needed behavioral health care. The patient navigators will work closely with hospital and emergency department staff to divert non urgent patients to other more appropriate levels of care. This includes connecting patients to primary care providers who can offer a medical home where the patient can benefit from education and disease self-management opportunities. If needed, the navigators will connect patients to mental health and substance abuse services offered in the community. The challenges BTCS and patients face in this county are documented in the RHP 4 Community Needs Assessment. Also, BTCS has participated as a member of the Gonzales County Mental Health Task Force to identify behavioral health gaps and needs. Health disparity is often driven by income disparity. The data finds 19.8% of adults and 31.8% of children under 18 in Gonzales County below the poverty level. Additionally, 29.3 % of the adults in the County are without insurance or any third party coverage. The entire county has been designated a health care provider shortage area for behavioral health and for primary care according to US Department of HHS, HRSA. Additionally, the RHP 4 needs data shows there are no specialists other than one Ob/Gyn and an Occupational Medicine physician practicing in Gonzales County. An area of concern that the hospital leadership, task force members and BTCS have identified is the repeated ED visits by a group of patients some of whom are BTCS patients and some of whom are not. Anecdotal evidence indicates reasons for the multiple ED visits by this group of patients, ranges from chronic behavioral health issues, mental illnesses and substance use disorders to chronic physical health issues such as asthma, chronic pain, cardiopulmonary disease, etc., but frequently triggered by behavioral health conditions. A large number of visits to the EDs throughout the US are related to anxiety, symptoms of mental illness and/or substance abuse. Poverty and provider shortages coupled with cognitive deficits that are symptoms of mental illnesses, makes finding and accessing care difficult for many in Gonzales County. We believe a special intervention provided by people who are trained in behavioral health assessment and in chronic illness assessment and management is required. The target population is composed of patients identified as having multiple emergency department/hospitalizations over the last year. Most of the patients have chronic health problems often exacerbated by substance abuse and mental illness. They tend to have poor compliance with treatment recommendations, often lack a medical home and have few natural community supports such as friends and family. This project will address this problem by providing the opportunity for a person-centered intervention to connect the individuals to services at the point that they need them the most, i.e., at the point they are seeking emergency care. We expect to use community resources to fill unmet social needs such as housing, transportation, income, food and medication. For those who are in need of behavioral health services either as a short term stabilization strategy or for long-term, we will connect patients to BTCS or to primary care practitioners who can support behavioral health treatment. We plan to provide transportation to make access to healthcare as smooth as possible. This approach is aimed at resolving the multiple issues that lead to repeated visits to the ED. Our goal is to do all we can to ensure connection to aftercare and follow up rather than quick treatment and release from the ED with instructions for aftercare but no community support. RHP Plan for Region 4 626

This project advances the regional goal of integrating primary and behavioral health care. It also addresses the triple aim of CMS with respect to improved patient care including access and health outcomes. It also advances CMS aim of cost reduction by addressing ED use by these high utilizers. It addresses the Regional goal to improve access to comprehensive behavioral health services and access for all. Over the next five years we expect the outcomes of this project to be the continued development robust alternatives to ED care and improve the performing provider and the healthcare system in the region. We expect the patients who receive navigation services to reduce utilization of EDs and reduce preventable readmissions as a result. These outcomes are directly achievable due to the goals and interventions described above. Starting Point/Baseline: Since this program has not been established, we will use the remainder of DY 2 to identify the target population and establish the baseline. Our plan is that the baseline will be calculated on three months of emergency department admissions at Gonzales Memorial Hospital. We do not have current data to identify those from Gonzales County who are accessing ED services and at what frequency, but an important first step in this project will be to explore some other means of gathering and tracking that data. Since BTCS has not provided this service we expect to spend most of DY 2 in planning and gathering data. Rationale: In Category 2 Innovation and Redesign; we selected Project Area 9 Establish/Expand a Patient Care Navigation Program ; Project Option 1 Provide navigation services to targeted patients who are at high risk of disconnect from institutional health care(for example, patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, recent immigrants, the uninsured, those with low health literacy, frequent visitors to the ED, and others.) We selected this Project Area and Option because it describes the goal and intent of our project, which is to establish a patient navigation program for persons with multiple chronic conditions including cognitive impairments and who are frequent visitors to the ED. Since this is a wholly new program for Gonzales County we expect to follow and carry out each of the required core project components: a) Identify frequent ED users and use navigators as part of a preventable ED reduction program. Train health care navigators in cultural competency. b) Deploy innovative health care personnel, such as case managers/workers, community health workers and other types of health professionals as patient navigators. c) Connect patients to primary and preventive care. d) Increase access to care management and/or chronic care management, including education in chronic disease self-management. e) Conduct quality improvement for project using methods such as rapid cycle improvement. Activities may include, but are not limited to, identifying project impacts, identifying lessons learned, opportunities to scale all or part of the project to a broader patient population, and identifying key challenges associated with expansion of the project, including special considerations for safety-net populations. RHP Plan for Region 4 627

As described earlier we will spend most of DY 2 identifying frequent ED users. We plan to use RN s who can address the needs of this population. We are in partnership with the FQHC and co-locate behavioral health services with primary care services at a single site in Gonzales. Finally, our QM department is charged with responsibility for managing a rapid cycle improvement process for this project, similar to that we are using currently with other projects at BTCS. The Process Milestones we selected for DY2 and DY3 support these core components and are: P-1. Milestone: Conduct a needs assessment to identify the patient population(s) to be targeted with the Patient Navigator program; P-2. Milestone: Establish/expand a health care navigation program to provide support to patient populations who are most at risk of receiving disconnected and fragmented care including program to train the navigators, develop procedures and establish continuing navigator education; and P-3. Milestone: Provide care management/navigation services to targeted patients. The Metrics we are using include: development of program policies and procedures, hiring staff and medical record evidence that we are providing care to this population. We selected Implementation Milestones for DYs 4 and 5: The project seeks to serve 30 people in DY 4 and 50 people in DY 5. Those served will be high utilizers of the ED with multiple visits per year. We plan to intervene at the point of the visit and to assist the individuals in connecting for ongoing care through a medical home, thereby reducing future ED utilization. We selected Improvement Milestones Number of patient interventions and Metric, Number served in the target population in order to demonstrate quantifiable patient impact. The number of high utilizers served who receive navigation services will reduce potentially preventable readmissions and improve lives by linkage to primary care. This project addresses all three of the needs in the RHP 4 Community Needs Assessment plan. It supports: CN.1 Improve access of care for primary care and specialty services; CN.2 Improve the provision and coordination of health care services for persons with chronic conditions; and CN.3 Expand access to behavioral health services. BTCS has been engaged in planning for a number of years with the local FQHC, Community Health Centers of South Central Texas, to build and establish a clinic site that integrates behavioral health care and primary care in Gonzales County. This navigation project is enhanced by that delivery system reform. During 2012, BTCS and our partner FQHC planned for and were awarded a federal grant through the Health Resources and Services Administration (HRSA) Division of the US Department of HHS to develop a primary care/behavioral health care clinic site in a county adjacent to Gonzales County, in Seguin. These federal funds will not be used to support the patient navigation program in Gonzales County. The needed integration is already in place in Gonzales County where we do plan to provide options for care and a medical home. RHP Plan for Region 4 628

Related Category 3 Outcome Measure(s): The Category 3 Outcome Measure that we selected is OD-3 Potentially Preventable Re-Admissions- 30 day Readmission Rates (PPRs IT-3.1 All cause 30 day readmission rate- NQF 1789. This is a stand-alone measure. We selected this measure because the goal of this project is to help people who have multiple visits to EDs and we believe in many cases that have resulted in admission and readmission to hospital. We believe that measuring the reduction in re-hospitalization will be a good indicator of success for the program. Over the four yeas of the project we expect to dramatically reduce the number of ED visits for the target population and the associated inpatient admissions. These reductions will occur by improved chronic disease management, linkage to a primary care provider and medical home. The RN will be hired and trained to deliver culturally and linguistically appropriate services to the target population. Patients will be diverted from EDs/hospitals and linked with primary care providers who can offer a medical home. Navigators will also link patients to social support programs and behavioral health programs where a need is identified. It is expected that utilization of programs such as self-management support, patient education, improved patient provider communication and coordination with community resources will lead to increased patient engagement in maintaining their health. This outcome supports RHP 4 goals to improve health for low-income populations and link to a medical home. Relationship to other Projects: In RHP 4 BTCS has one project but also a complementary project in an adjacent county in RHP 6 to establish a new treatment site for outpatient substance abuse care. The navigation project will be able to refer to services offered through the substance abuse clinic and thereby initiate much needed treatment and reduce returns to the ED. This is project fills a gap in services that the patient navigators will need for referral and care. This projects focus on improving patient access to care, educating and assisting patients in the use of appropriate health care settings and will enhance the following regional projects: 1309585-05.1.1 Expand Primary care capacity using community health workers; and 138305109.2.1 Dual Diagnosis Crisis stabilization project. Related Category 4 measures include potentially preventable admissions measures in RD-1, and patient satisfaction in RD-4. Learning Collaboratives: 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 that we will collaborate with who have similar projects include Gonzales Health Care System and Gulf Bend Center. We believe it is important to improving and adjusting the care provided. Project Valuation: The project seeks to serve 30 people in DY 4 and 50 people in DY 5. Those served will be high utilizers of the ED with multiple visits per year. We plan to intervene at the point of the visit and to assist the individuals in connecting for ongoing care through a medical home, thereby reducing future ED utilization. The valuation calculated for this project used cost-utility analysis which measures program cost in dollars and the health consequences in utility-weighted units that were applied to the factors existing in this underserved area, including: limited access to primary care and to behavioral health care, poverty and the link between chronic health conditions and chronic behavioral health conditions. The valuation study was prepared by professors H. Shelton Brown, Ph.D. and A. Hasanat Alamgir, Ph.D. both RHP Plan for Region 4 629

of the UT Houston School of Public Health and Thomas Bohman, Ph.D. of the UT Austin Center for Social Work Research based on a model that included quality-adjusted life-years (QALYs) and an extensive literature of similar interventions and cost savings and health outcomes related to those interventions. The QALY index incorporates costs averted when known (e.g., emergency room visits that are avoided). A description of the method used, titled Valuing Transformation Projects, has been posted on the performing provider website which will be linked to www.bbtrrails.org under the Medicaid 1115 Transformation Waiver tab. Complete write-up of the project will be available at performing provider site. RHP Plan for Region 4 630

126844305.2.1 2.9.1 2.9.1 A)-E) PATIENT NAVIGATOR FOR PERSONS WITH CHRONIC ILLNESSES Bluebonnet Trails Community Mental Health and Mental Retardation Center dba/ Bluebonnet Trails Community Services Related Category 3 Outcome Measure(s): Year 2 (10/1/2012 9/30/2013) Milestone 1 P-1: Conduct a needs assessment to identify the patient population(s) to be targeted with the Patient Navigator program. Metric 1 P1.1: Provide report identifying the following: Patient characteristics; Service gaps; Triage and referral; Number of patients; Number of staff; Program location. Baseline/Goal: N/A/Produce a comprehensive report documenting all points above. Data Source: Program documentation, EHR, claims, needs assessment Survey Milestone 1 Estimated Incentive Payment (maximum amount): $272,935 126844305 IT 3.1 126844305.3.1 Potentially Preventable Re-Admissions -30 day Readmission Rates (PPRs) All cause 30 day readmission rate- NQF 1789 Year 3 (10/1/2013 9/30/2014) Milestone 2 P-2: Establish/expand a health care navigation program to provide support to patient populations who are most at risk of receiving disconnected and fragmented care including program to train the navigators, develop procedures and establish continuing navigator education. Metric 1 P2.1: Number of people trained as patient navigators, number of navigation procedures, or number of continuing education sessions for patient navigators. Baseline/Goal: At the beginning of DY 2 patient navigators did not exist therefore, baseline for all is 0. Goals: Develop the training program with procedures and continuing education. Deploy 2 navigators, RN s. Data Source: Workforce development plan for patient navigator recruitment, training and education Year 4 (10/1/2014 9/30/2015) Milestone 4 [I-X]: Number of patient interventions. Metric 1 [I-X.1]: Number of patient in target population served by this patient navigation service. Baseline/Goal: Baseline Baseline 0 for DY 2 since no such service currently exists in the RHP; Goal - Serve 30 people in DY4 who are high utilizers of ED services. Data Source: EHR and ED records Milestone 4 Estimated Incentive Payment: $320,627 Year 5 (10/1/2015 9/30/2016) Milestone 5 [I-X]: Number of patient interventions. Metric 1 [I-X.1]: Number of patient in target population served by this patient navigation service. Baseline/Goal: Baseline Baseline 0 for DY 2 since no such service currently exists in the RHP; Goal - Serve 50 people in DY5 who are high utilizers of ED services. Data Source: EHR and ED records Milestone 5 Estimated Incentive Payment: $309,785 Milestone 2 Estimated Incentive Payment: $149,859 Milestone 3 P-3: Provide navigation services to targeted patients. RHP Plan for Region 4 631

Category 3 DSRIP Projects: Quality Improvements

Category 3 DSRIP Project Narrative Template Outcome Domain: OD-3 Potentially Preventable Re-Admissions- 30 day Readmission Rates (PPRs) Title of Category 1 or 2 Project: Patient Navigator for Persons with Chronic Illnesses Title of Outcome Measure (Improvement Target): IT-3.1 All cause 30 day readmission rate- NQF 1789 Unique RHP Outcome Identification Number (e.g. [TPI].3.1): 126844305.3.1 Performing Provider Name: Bluebonnet Trails Community Mental Health and Mental Retardation Center dba/bluebonnet Trails Community Services Performing Provider TPI #: 126844305 Outcome Measure Description: Process Milestone for DY 2 P- 1 Project planning - engage stakeholders, identify current capacity and needed resources, determine timelines and document implementation plans. Process Milestones for DY 3 P- 2 Establish baseline rates P- 3 Develop and test data systems Improvement Target for DY 4 and 5 will be: IT-3.1 All cause 30 day readmission rate- NQF 1789 for patients 18 and older Improvement Milestone for DY 4. Reduce all cause 30 day readmission rate by 5% of baseline TBD in DY 3. Improvement Milestone for DY 5 Reduce all cause 30 day readmission rate by 10% of baseline TBD in DY 3. Rationale: DY 2: We must work with community providers and multiple health care systems to inventory capacity, determine when to initiate program, identify resource needs, complete agreements for data sharing and agreements for site utilization. DY 3: This population of high frequent visitors to ED is not identified or characterized. We must develop sources of information across multiple health care systems; identify the group and establish a baseline. The Improvement Target for DY 4 and 5, IT-3.1, is a stand-alone measure. We selected this measure because the goal of this project is to help people who have been frequent visitors to ED and even though a root cause might be the presence of behavioral health conditions, the admission cause will vary across a variety of physical and mental conditions. We believe that measuring the reduction in re-hospitalization will be a good indicator of success for the RHP Plan for Region 4 1020

program. Over the four years of the project we expect to dramatically reduce the number of ED visits for the target population and the associated inpatient admissions. These reductions will occur by improved chronic disease management, linkage to a primary care provider and medical home. Project Valuation: By targeting and serving 30 high utilizers of ED services in DY 4 and 50 in DY 5 we expect to improve lives and cost and effectiveness of the health care system. We are confident we will impact hospitalization use. The valuation calculated for this project used cost-utility analysis which measures program cost in dollars and the health consequences in utility-weighted units that were applied to the factors existing in this underserved area, including: limited access to primary care and to behavioral health care, poverty and the link between chronic health conditions and chronic behavioral health conditions. The valuation study was prepared by professors H. Shelton Brown, Ph.D. and A. Hasanat Alamgir, Ph.D. both of the UT Houston School of Public Health and Thomas Bohman, Ph.D. of the UT Austin Center for Social Work Research based on a model that included quality-adjusted life-years (QALYs) and an extensive literature of similar interventions and cost savings and health outcomes related to those interventions. The QALY index incorporates costs averted when known (e.g., emergency room visits that are avoided). A description of the method used, titled Valuing Transformation Projects, has been posted on the performing provider website which will be linked to www.bbtrrails.org under the Medicaid 1115 Transformation Waiver tab. Complete write-up of the project will be available at performing provider site. RHP Plan for Region 4 1021

126844305.3.1 IT-3.1 IT-3.1 All cause 30 day readmission rate- NQF 1789 Bluebonnet Trails Community Mental Health and Mental Retardation Center dba/bluebonnet Trails Community TPI: 126844305 Services Related Category 1 or 2 Projects:: 126844305.2.1 Starting Point/Baseline: No new outpatient substance abuse treatment site currently exists Year 2 (10/1/2012 9/30/2013) Process Milestone 1 P- 1 Project planning - engage stakeholders, identify current capacity and needed resources, determine timelines and document implementation plans. Baseline/Goal: N/A Data Source: Program Documents Process Milestone 1 Estimated Incentive Payment (maximum amount): $14,365 Year 2 Estimated Outcome Amount: (add incentive payments amounts from each milestone/outcome improvement target): $14,365 Year 3 (10/1/2013 9/30/2014) Process Milestone 2: P- 3 Develop and test data systems Baseline/Goal: N/A Data Source: EHR; Business Intelligence Process Milestone 2 Estimated Incentive Payment: $16,651 Process Milestone 3: P- 2 Establish baseline rates for all cause 30 day readmissions Baseline/Goal: N/A Data Source: EHR; Business Intelligence Process Milestone 2 Estimated Incentive Payment: $16,651 Year 3 Estimated Outcome Amount: $33,302 Year 4 (10/1/2014 9/30/2015) Outcome Improvement Target 1 : 3.1 All cause 30 day readmission rate- NQF 1789 for patients 18 and older Baseline: DY 3 all cause30-day readmissions Goal: 5% reduction in DY 3 all cause 30-day readmissions. Data Source: Hospital Records Outcome Improvement Target 1 Estimated Incentive Payment: $35,625 Year 4 Estimated Outcome Amount: $35,625 Year 5 (10/1/2015 9/30/2016) Outcome Improvement Target 2: 3.1 All cause 30 day readmission rate- NQF 1789 for patients 18 and older Baseline: DY 3 all cause 30-day readmissions Goal: 10% reduction in DY 3 all cause 30-day readmissions. Data Source: Hospital Records Outcome Improvement Target 2 Estimated Incentive Payment: $77,446 Year 5 Estimated Outcome Amount: $77,446 TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD (add outcome amounts over DYs 2-5): $160,738 RHP Plan for Region 4 1022

Category 4 DSRIP Projects: Population-Focused Improvements EXEMPT