Agenda: Friday April 6, 2018

Agenda: Friday April 6, 2018 Time & Meeting Room Session: Session Description: Speaker(s): Session Track: Friday, April 6 7:30AM 8:30AM Frio Concho Brazos Breakout Sessions III III.1) Project ECHO: Enhancing Community Medical Care with Video Enhanced Consultation and Monitoring III.2) PREVENT Disease NOW! III.3) A Financial Tool to Plan PCMH Support by Key Functions PCPs frequently refer patients for specialty consultation because they lack expertise in specific areas of practice. Project ECHO uses case-based learning to educate PCPs about complex medical conditions that can be safely and appropriately managed in the patient's medical home. Using hepatitis C as an example, this workshop will discuss our success in setting up a treatment network and will encourage audience participation in shaping future needs in primary care. Woven Health Clinic is turning the traditional health care model completely upside down by focusing the majority of its resources on disease prevention, as opposed to treatment. PREVENT Disease NOW! implements evidence-based medical best practices to reduce modifiable risk factors related to chronic disease. The program is a comprehensive approach to assessing lifestyle risks, giving immunizations, medications, cancer screenings and patient education for physical and mental health. Additionally, it employs nutrition therapy, CBT, behavior change, goal setting, exercise prescriptions and counseling sessions. This program addresses traditional disease prevention and management, but also focuses on weight management, customized healthy diet, physical activity, stress management, tobacco cessation and sleep hygiene. Woven Health's patients are all low income, uninsured, allowing the true costs of care to be captured and analyzed. Their patient-centered team-based approach is resulting in physically and mentally healthier patients at an efficient and affordable cost. Delivering patient-centered care requires some functions that are not traditionally included in most primary care practices. Understanding these functions and providing the right level of financial support is essential for delivering the type of team care that the PCMH demands. We describe a functional model that isolates 6 key functions: 1) welcome/front door, 2) clinical processes/refills/triage, 3) same day access support, 4) patient coaching/navigation/transitions of care, 5) Norman L. Sussman, MD, FAASLD, Baylor College of Medicine Lisa Rigby, EMBA, Woven Health Clinic; Poonam Misra, BSN, MS, FNP, Woven Health Clinic Carlos Jaen, MD, PhD, FAAFP, UT Health San Antonio: La- Keisha Harrell, MBA, UT Health San Antonio Physicians, Integrated care

Pecos Sabine III.3) (continued) III.4) How to Use a Chronic Disease Management Registry: Case Report From an Academic Internal Medicine Practice III.5) Integration of Behavioral Health Into Primary Care Settings, Lessons from the UT Southwestern Vital Sign6 Program outreach/population health, and 6) finance/administrative support. We show examples of how this model can identify necessary investment for each of the components for a network of 5 primary care clinics in San Antonio, TX. We demonstrate how expenses related to each of the functions can be compared using an expense per MD ratio. The tool may be used for calibrating investments in each function and to improve resource utilization across clinics in a network or to identify areas that need further resources. This case report will highlight a major population health initiative put forward at the Internal Medicine Clinic of the Texas Tech University Health Sciences Center (TTUHSC) of El Paso. We will also seek to make light of useful tips on how to use a chronic disease management registry. TTUHSC of El Paso is a large multispecialty practice and part of the largest medical school in the US-Mexico Border. As part of the DSRIP project the institution sought to implement a Chronic Disease Management Registry which was rolled out initially in the Internal Medicine (IM) clinics for both Faculty and Residents. Since its implementation, we have been able to implement workflow changes including the development of a more structured Pre-Visit planning process, limit the number of point-of-care alert burden for physicians, empower quality improvement across the organization and set the platform for powerful outreach capabilities. The U.S. Preventive Services Task Force recommends depression screening for the general adult population, with adequate systems in place to accurately diagnose, treat and provide follow-up. The VitalSign6 Program strives to enhance healthcare access and the standard of care for those affected by depression. Through the utilization of VS6, an innovative web-based application, community partners have access to validated depression screening, assessment tools, curbside consultation, teletherapy and clinical decision support as part of measurement-based care treatment for depression. VitalSign6 is dedicated to improving the quality of care for patients by: Improving access to mental health care and contributing to overall patient wellness through the implementation of universal screening and depression treatment Reducing stigma and empowering patients to discuss mental health by making depression screening part of routine care or the sixth vital sign Achieving full and sustained remission of depressive symptoms through the implementation of measurement-based care treatment Primary Care Center; Ramon Cancino, MD, MSc, UT Health San Antonio Diego De la Mora, MD, FACP, Paul L. Foster School of Medicine Robert Kinney, Ph.D., UT Southwestern Center for Depression Research and Clinical Care Integrated Care

10:00AM 11:00AM Frio Concho Brazos Pecos Breakout Sessions IV IV.1) Using Data Analytics to Improve Clinical Performance IV.2) Working Together to Improve Primary Care Oral Health Across Texas - a Multidisciplinary Evidence Based Approach IV.3) Strategies for Staying Independent in Primary Care Practice IV.4) Transitions of Care: Practice Management Strategies and Tools Knowledge is power. Data analytics allows physicians and providers to achieve improved quality and patient outcomes at lower costs using information to highlight areas of suboptimal performance. Medicare and private payers mandate reduction in quality variations and cost variations. Implementing data collection and robust analytics can be challenging as it requires technology, collection and analysis of data, process improvement, and evaluation in a continuous cycle. Lack of knowledge and economic incentive, along with personal preferences, concerns about malpractice risk, and inadequate decision-support tools, further complicates this endeavor. However, the improvement in clinical performance is well worth working through the challenges. Patient outcomes improve, and patients are healthier and happier. Physicians and providers are able to identify evidence-based interventions that positively affect the patient population. Data can help streamline workflow processes for greater efficiency at lower cost. Knowledge can empower and guide clinical decision-making that is effective and patient-centered. Since 2000, the national call to improve oral health care via partnerships across Family Medicine, Pediatrics, Nursing, Physician Assistants and the Dental communities has come from the U.S. Surgeon General's 2000 report, Oral Health in America, the CDC s 2010 Healthy People 2020 Goals and the Institute of Medicine (IOM) 2011 report, Advancing Oral Health in America and Improving Access to Oral Health Care for Vulnerable and Underserved Populations. Here in Texas, the Texas Health Institute (THI) and Texas Oral Health Coalition (TxOHC) have developed a collaborative initiative to unite provider groups and advance the oral health across the state. As part of the TxOHC s Advancing the Oral Health Movement in Texas (ATOHMIT) goal for Oral Health Integration into Primary Care, we have developed the Oral Health Tip Sheets for easy access to evidence based oral health information for all primary care providers and their patients. Many Primary Care Physicians know what the problems that cause independent physicians to decide to become employed or retire. Let's talk about the strategies that can keep physicians INDEPENDENT The presenters will discuss how they used QI tools and specific interventions to develop an effective transitions of care program. They will review QI tools like process mapping and fish bone) and describe interventions (e.g., tracking Yvonne Mounkhoune, RN, BSN, MA, PCMH CCE, Texas Medical Association Stephanie Rowan, RN, MSN, UT Health San Antonio, Dental School Luis Benavides, MD, Seventh Flag ACO; Greg Fuller, MD, Catalyst Health Chandana Tripathy, MD, UT Health San Antonio; Ruby Integrated Care Public Policy/Payment Transitions of Care

Sabine IV.4) (continued) IV.5) Community Collaboration to Implement Social Determinants of Health Screening in Patient Centered Medical Homes hospitalizations and discharges) that produced measurable outcomes like reduced readmissions by aggressively followingup on discharged patients. After describing two different practice management strategies for transitions of care (i.e., Case Manager Led Model and Nurse Practitioner Led Model), they will divide participants into small groups to outline the transitions of care processes in their practices. Participants will then describe how they will improve transitions of care in their practices. Presenters will provide a packet with online resources attendees can access to improve their transitions of care. This workshop highlights methods for implementing social determinants of health screening. The Centers for Children and Women are two NCQA level III patient centered medical homes in Houston who serve over 24,000 patients with Texas Children s Health Plan, a Medicaid and CHIP managed care organization. Both Centers offer obstetrics-gynecology, behavioral health and pediatric departments with a multitude of ancillary services. In accordance with recent recommendations from the American Academy of Pediatrics, our pediatric departments implemented food insecurity screenings. Recent data shows 26% of children in Southeast Texas live with food insecurity. The development of our screening tool occurred through collaboration with community and institutional partners. This input allowed us to overcome barriers to screening methods and ensure the clinics were capturing our food insecure patients and offering appropriate resources. This workshop will explore the collaboration, interventions and challenges of initiating social determinants of health screening to an underserved population. Mathew, ACNP, RN, MSN, UT Health San Antonio Sydnee Lucas, DNP, RN, APRN, FNP-BC, The Center for Children and Women; Stephanie Marton, MD, MPH, The Center for Children and Women- Greenspoint; Brittany Richardson, MD, The Center for Children and Women

11:15AM 12:15PM Frio Concho Brazos Breakout Sessions V V.1) Community Centered Health Homes: Operationalizing the Community Clinic s role in Advancing Health, Not Just Health Care V.2) From Patients to Policy: Improving Transition From Adolescent to Adult Medicine Through Interprofessional Collaboration V.3) Achieving Population Health Goals Using the Community Centered Health Homes (CCHH s) are clinics that take an active role in addressing the community conditions affecting health and health equity. EHF has funded 13 community based clinics to advance this work in Texas in Austin, Waco, Tyler, and the greater Houston area. This session will use a talk-show format with a panel of 3-4 CCHH practitioners in Texas to describe their accomplishments along with the benefits and challenges of becoming a CCHH. The session will also highlight opportunities for new clinics to come on board with EHF s next cohort of grant-funded CCHH s and how to prepare. Ample time will be given for the audience to ask the panel and presenter questions about the CCHH model, how it is related to value based care and population health, early signs of impact and changes in practice, and features of the current or next cohort of clinics supported by EHF. In an era of healthcare transformation, where practitioners seek tools to improve population health, our interprofessional approach provides a framework for health care teams to identify and address individual health harming non-clinical needs and effect change. This session will describe this patients-to-policy approach through the example of the transition from adolescent to adult medicine. We consider transition not only from an organizational perspective, but from the patient s lived experience. Through this view of transition as an opportunity to address medical needs and mitigate select root causes of poor health in adults, we created a universal screening tool and improved our ability to accurately document patients relevant statuses. Presenters will (1) share strategies for incorporating a community health perspective into CHC practice to support system change through holistic interventions, and (2) facilitate discussion of best practices and challenges in building cross-sector partnerships that bridge the various providers of care and support for vulnerable populations. Population health management strives to address individuals health needs at all points along the continuum of care, including the community setting, through participation, engagement and targeted interventions for a defined population. Population health is not static because a patient s risk, disease state or social situation can change at any time. Because the patient-centered medical home model leverages Kenneth D. Smith, PhD, University of Texas Medical Branch; Rhonda Mundhenk, JD, MPH, Lone Star Circle of Care; Valerie Smith, MD, FAAP, St Paul Children's Foundation; Jackson Griggs, MD, FAAFP, Heart of Texas Family Health Center; Robert Nnake, MBA, Memorial Hermann Celia Neavel MD, FSAHM, FAAFP, People s Community Clinic; Keegan Warren Clem, JD, LLM, People's Community Clinic; Sula Coria-Garza, People s Community Clinic; Araceli Ramos, People s Community Clinic Patricia Marine Barrett, MHSA, National Committee for Quality Assurance (NCQA) Transitions of Care

Pecos Sabine V.3) (continued) V.4) Supporting the Medical Home through Effective BH Integration in Primary Care Settings: An Overview of the Collaborative Care Model V.5) Implementation of the Medical Home Model for Children with Special Needs population health data for targeted treatment and clinical interventions, it is an ideal model to use as a building block for effective population health strategies. This session will identify concepts of population health management and how the patient-centered medical home model can be used to build a strong population health management program, as well as how PCMH can help you manage patients as they move through the continuum of care to ultimately deliver better health outcomes for the patients. The Medical Home model seeks to improve engagement and care for all patients. Effective strategies for engaging and serving those with behavioral health conditions are needed to attain successful outcomes and recoup treatment costs with this population. Access to mental healthcare is also of concern given the national psychiatric workforce shortage. Presenters will provide an overview of the Collaborative Care Model, an evidence-based approach to integrating primary and behavioral health care with proven positive impact on access to care, health outcomes, and return on investment. This presentation includes the evidence base for this team-based care model that promotes the medical home and standardized strategies and tools for overcoming challenges inherent in merging primary care and behavioral health to develop successful and effective collaboration. Implementation of the new CPT codes for collaborative care that enhance reimbursement for provision of coordinated, integrated care in a medical home model will also be discussed. This session will be highly interactive with audience participation expected. The session will open with a brief presentation of the Driscoll Health Plan (DHP) Health Home Model followed by a series of questions that have been prepared by the moderator that will help to bring greater clarity to how this model of health home functions in a two physician, suburban medical practice. The panel is composed of individuals very familiar with the conceptualization, development as well as implementation of the DHP Health Home Model. There will be ample time allotted allowing for a robust dialogue between the panel members and the audience. Bren Manaugh, LCSW- S, CPHQ, Health Management Associates, Lori Raney, MD, Health Management Associates Mary Dale Peterson, MD, MSHCA; Fred McCurdy, MD, PhD, MBA, FAAP, FACPE; Carmen Rocco, MD; Maria Mata, RN, Driscoll Health Plan Integrated Care CNE: A&M Rural and Community Health Institute (ARCHI) is an approved provider of continuing nursing education by the Texas Nurses Association Approver, an accredited approver with distinction by the American Nurses Credentialing Center s Commission on Accreditation. ARCHI is providing Continuing Nursing Education contact hours for this activity. This CNE activity is being jointly provided by A&M Rural and Community Health Institute (ARCHI) collaboratively with the Texas Medical Home Initiative and Texas Health Institute. CME: This live activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through a joint providership between the Texas Academy of Family Physicians and Texas Health Institute. TAFP is accredited by the ACCME to provide continuing medical education for physicians. TAFP designates this live activity for a maximum of 11.75 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.