NJII-Garden Practice Transformation Network · NJII-Garden Practice Transformation Network • $50M CMMI Grant • Transform 10,000 providers • Better care to 500,000 chronic patients

NJII-Garden Practice Transformation Network

• $50M CMMI Grant

• Transform 10,000 providers

• Better care to 500,000 chronic patients

(includes attention to the underserved)

• Oct 2015 thru Sept 2019 (Dovetails into MIPS Reporting for

2019)

• Goals

Get 75% of these providers enrolled in value based

Better care for patients, access, information…

Lower costs when coordinated

Prepare providers for MIPS and Alternative Payment

Models

NJII Garden Practice Transformation Network 2017

PRACTICE TRANSFORMATION

UNDERSTANDING VALUE BASED

HEALTHCARE DELIVERY

Thomas R. Ortiz, MD, FAAFP

NJ Innovations Institute

Garden Practice Transformation Network

Chief Medical and Information Officer

www.NJII/ptn.org

[email protected]


Forest Hill Family Health Associates, PA

35 year history of comprehensive family primary care

services in Newark, NJ

2001-Adapted EMR technology

2009-began the process of practice transformation

consistent with premise of ACA

2011-NCQA recognized Level 3 PCMH

2013-selected by CMS as a participant in CPCI, 2017 CPC+

Began participation in Physician owned IPA-Osler Health

Network-an advanced payment model

2016-had a banner year for Quality and RevenueNJII Garden Practice Transformation Network 2017

“I own my data that

demonstrates my value.”

“I therefore, control my future and sustain my practice.”

“I can take advantage of revenue incentives, set goals, take risks

and have joy in practice!”NJII Garden Practice Transformation Network 2017

“This Opportunity for Docs will reassert our

value and control over the health care

delivery system”

From Care Delivery methods to Practice Finance

Provide Patient Satisfaction and Clinical Quality Outcomes

Align Incentives across the Medical Neighborhood

Encourage Population Care through Risk Stratification and

Care Coordination

Create Shared Savings Bonus


Why Practice Transformation?

“A change in form from one to another, a metamorphosis, or

a paradigm shift”

Streamlines for efficiencies in practice

Improves Practice satisfaction

Improves patient experience and outcomes

Increases revenues, short and long term

Learn to collect, review and use clinical data

Prepare for value based payment system-MIPS/MACRA


Learning Objectives

What is the Definition of Value?

How Value is being Measured

How Quality and Cost Ratios Lead to Reform in Payment Models

How Value Leads to Practice Efficiencies and joy in Practice

What are the Benefits of Participation in GPTN


Definition of Value

Value = Quality Clinical Outcomes + Patient Satisfaction

The Cost to Provide it


5 Point Standardized Initial GPTN

Recommended Transformation Work Plan

#1- Develop an AIMS/mission statement that is consistent

with PTN AIMS/goals for practice transformation as a team.

*Broad aims and specific aims for following items


#2 Risk Stratification is Basis to Population

Care Management Pull these reports from your EMR patient files monthly:

All Diabetic patients with A1C >9%, in past 12 months

All Hypertensive patients with BP >140/90, in past 12 months

All Patients who admit to smoking, Smoking cessation report by CPT code

All Patients >50 years without Colorectal cancer screen-FOBT annually or Colonoscopy in 10 year intervals

All diabetic patients w/o Nephropathy screening, Microalbuminuria

Meaningful Use Report

CMS QRUR Report

Begin Risk Stratification and Empanelment Process:

Call patients identified in above process for appointments to begin coordinated care/ chronic disease management


#3 Team Based Care

Org board: Organizational chart

• Flow chart – practice personnel

• Chain of command communications

Jobs descriptions:

• Care Coordinator/Pop Care Manager

• HIT Super user

Duties and responsibilities

• Roles

• Scripts


#4 Begin Reducing Unnecessary Hospitalizations

and ER visits with Transition of Care

Management (TCM)

Requires Hospital outreach to ED docs, IT Dept. and hospitalists to enhance provider-to-provider electronic communication on ADTs

How does practice manage discharges workflows?

Direct messaging capabilities

Set up email communication or utilize fax

Workflow of patient outreach and TCM

Outreach to inpatient case managers

Access to care by phone/enhanced access


#5 Lab HL7 Bi-Directional Interface

Set up a EMR interface to “talk” to one or two

laboratory vendors for improved results timeline and to

avoid duplicate testing

Allows for discreet lab generated data to be

electronically entered into EMR program graphs, flow

charts and reports needed for quality tracking and

transmission

Eliminates paper


KPI Metrics for GPTN

Adult smoking rates- >18y/o decrease by 1%

A1C Control-% of pts.18-75w/ DM & A1C>9%

BP Control-% of pts. 18-75w HTN<140/90

Colorectal Ca Screen-% pts. >50 w/colon or FOBT

Microalbuminuria in Pts. w/ DM-% test done

Preventable ER visits- total # reduction in ER visit

Increase in transitional care management TCM- % of pts. receiving TCM services following D/C from a qualified facility

Advanced Care Planning- % of pts. >65yo who have received some ACP/POLST


The Business Proposition:

Return on Investment Calculator NJII/ptn.org

Practice ROI Calculator north jersey M/C rate x #of patients = added revenue

Code

Description

Average

Medicare

Fee for

North J.

# of

patients

Added

Revenue

G0402 Welcome to Medicare visit 172.33 50 8616.5

G0438 Annual wellness visit 157.26 150 23589

G0438 Subsequent annual wellness visit (every 365

days) 105.05 550 57777.5

99407 Smoking cessation 30.34 200 6068

99406 Smoking cessation 15.64 200 3128

96103 Depression screening 40.81 500 20405

99496 Transition in care 7 day 259.37 400 103748

99495 Transition in Care 14 day 184.37 300 55311

99490 Chronic Care Management 45.01 1200 54012

99497 POLST 30 min 93.61 100 9361

99498 POLST F/U 81 50 4050

Total 346066NJII Garden Practice Transformation Network 2017

The Business Proposition:

Advanced Payment Model (APM)

The Blended Rate Payment Concept

Up Front payment

for Care

Coordination

FFS Schedule or

capitation

Qualificatio

n by Metrics

by Plan

Cost savings

Gain Sharing

PMPM paid $ billed per visit by code Clinical-EMR Arranged by Contract 50/50

Based on risk

stratification capture data

Utilization-

Claims MLR /Total cost of care

$5-100 ROI Calculator

Patient

satisfaction

-Survey


Milestone

(P/S)

Change

Concept Ref

Milestone Description Intervention

P4/S4 1.1.3 Practice can demonstrate that it encourages patients and families to collaborate in

goal setting, decision making, and self-management.

1. Ottawa SDM Tool

2. Ask Me 3

P3/S3 None Practice has reduced unnecessary hospitalizations. 1. TCM (scores 2)

2. Document avoidance of 30-day

readmissions (score 3)

P6/S6 1.2.2 Practice sets clear expectations for each team member’s functions and responsibilities

to optimize efficiency, outcomes, and accountability.

1. Practices identifies what person(s) are

responsible for reviewing daily ADTs,

receiving CCDs, conducting interactive

contact, and linking patients to

community resources. (min. score 1)

P10 1.3.3 The practice provides care management for patients at highest risk of hospitalizations

and/or complications and has a standard approach to documentation.

1. TCM (min score 2)

P11/S8 1.4.4 Practice facilitates referrals to appropriate community resources, including community

organizations and agencies as well as direct care providers.

1. Using TCM, practice conducts non face-

to-face services linking patients to

community resources (min score 2)

P13 1.5.1 Practice follows up via phone, visit, or electronic means with patients within a

designated time interval (24 hours/ 48 hours/ 72 hours/ 7 days) after an emergency

room visit or hospital discharge.

1. Practice receives ADTs,

admission/discharge reports from

hospitals, or connected to HIE to track

(score 1)

2. As part of TCM, practice conducts

interactive contact within 2 days of

discharge (min. score 2)P16 1.6.4 Practice uses population reports or registries to identify care gaps and acts to reduce

them.

1. Practice receives ADTs,

admission/discharge reports from

hospitals, or connected to HIE to track

(score 2)

P19/S14 2.2.1 Practice uses an organized approach (e.g. use of PDSAs, Model for Improvement,

Lean, FMEA, Six Sigma) to identify and act on improvement opportunities.

1. Practice is piloting TCM using tests of

change to identify successes/barriers

prior to full implementation (min. score

2)

P23/S18 3.1.1 Practice uses sound business practices, including budget management and return on

investment calculations.

1. Practice makes use of ROI calculator (or

a similar tool) to determine potential

revenue, hiring opportunities, etc. for

TCM

Overall practice performance

KPIs

ER and IP Utilization

Patient Population Risk-Stratification

Clinical metric trends

Gaps in Care

PQRS The QRUR-Quality and Cost

PCP DASHBOARDS- The Metrics

PATIENT VISITS 2017 JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC TOTAL

# of Patients Seen 1161 940 1171 1172 1283 1317 1145 1366 9555

# of New Patients 37 26 53 67 55 50 48 65 401

# of F/U Visits 586 485 604 669 744 783 685 858 5414

# of Walk Ins 539 429 514 456 485 486 410 442 3761

No Show/Cancellation

# of No Show 203 139 197 174 211 277 194 249 1644

# of Reschedule 12 10 6 17 17 34 17 20 133

# of Cancelled 95 102 116 91 141 171 103 170 989

Scheduled Appointments

# of Appointments Made 1003 779 1015 1029 1180 1323 1119 1338 8786

# of Appointments Kept 624 512 658 712 799 778 705 952 5740

Appointment Statistics

% of Appointments Kept 62% 66% 65% 69% 68% 59% 63% 71% 65%

% of No Shows 20% 18% 19% 17% 18% 21% 17% 19% 19%

% of Walk Ins 46% 46% 44% 39% 38% 37% 36% 32% 40%

Daily Provider Stats

AN 262 264 285 250 254 233 150 293 1991

TH 422 398 321 377 337 392 381 308 2936

TO 122 84 119 128 66 93 68 97 777

RV 326 159 292 227 271 285 248 292 2100

NK 109 157 310 274 245 307 1402

PI 29 35 45 33 45 45 53 69 354

SD: Behavioral Health 35 26 36 36 32 32 30 33 260

CT: Home Visits 4 9 9 14 13 10 9 9 77

CDE: Diabetic Educators 7 1 2 2 5 4 5 12 38

2017 EMERGENCY ROOM UTILIZATION ANALYSIS: QUARTER 1 & 2

QTR 1 QTR 2

# Of ER Visits 238 166

# of Unique

Patients 215 150

Risk Stratification

LOW RISK 119 83

MOD RISK 82 58

HIGH RISK 24 13

NO RISK 13 12

# OF UNIQUE PATIENTS

Empanelled

Provider QTR 1 QTR 2

TO 11 17

AN 49 38

RV 51 26

TH 104 65

NK - 4

Total 215 150

# OF ER VISITS

QTR 1 QTR 2

12 19

57 42

58 30

111 71

- 4

238 166

Top Diagnoses QTR 1 QTR 2

ABDOMINAL ISSUES 29 7

LUNG ISSUES 27 11

VIRUS/COLD/FEVER 25 12

SKIN ISSUES 17 15

BACK PAIN 18 14

CHEST PAIN 15 NA

JAN FEB MAR APR MAY JUN

# OF ER VISITS 78 93 67 25 71 70

# OF F/U OFFICE VISITS 46 59 32 18 29 33

0

10

20

30

40

50

60

70

80

90

100

2017 ER VISITS PER MONTH VS FOLLOW UP OFFICE VISITS


# OF PATIENTS 10 10 3 2 6 4

0

2

4

6

8

10

12

2017 MONTHLY ER FREQUENT FLYERS

Patients who visited ER 3+

times during QTR 2

# of

admissions

PATIENT 1 3

2017 EMERGENCY ROOM UTILIZATION ANALYSIS FOR

MEDICARE PATIENTS: QUARTER 1 & 2

Medicare TCM Compliance QTR 1 QTR 2

# OF ER VISITS 24 13

F/U OFFICE VISIT WITHIN 7-

14 DAYS/TCM

OPPORTUNITIES

14 6

TCM CODE-99496 12 1

TCM CODE-99495 1 0

MODERATE COMPLEXITY: 1-14 DAYS

99495

HIGH COMPLEXITY: 1-7 DAYS 99496


# OF ER VISITS 7 10 7 3 6 4

# OF OFFICE VISITS 6 5 3 2 3 1

0

2

4

6

8

10

12

MONTHLY MEDICARE ER VISITS VS F/U OFFICE VISITS

2017 HOSPITAL ADMISSIONS ANALYSIS: QUARTER 1 & 2

QTR 1 QTR 2

# Of Admissions 64 71

# of Unique

Patients 56 59

Risk Stratification

LOW RISK 2 6

MOD RISK 28 24

HIGH RISK 31 37

NO RISK 3 4

# OF UNIQUE PATIENTS

Empanelled

Provider QTR 1 QTR 2

TO 11 15

AN 24 19

RV 9 7

TH 12 14

NK - 4

Total 56 59

# OF ADMISSIONS

QTR 1 QTR 2

13 17

29 24

9 8

13 16

- 6

0 6

Patients with 3+ admissions

during QTR 2

# of

admissions

PATIENT 1 3

PATIENT 2 3

Top Diagnoses QTR 1 QTR 2

LUNG DISORDERS 13 9

HEART CONDITIONS 9 10

KIDNEY DISORDERS 8 NA

ABD/DIGESTIVE/GI

ISSUES 6 7

SKIN ISSUES 5 9

STROKE NA 4

DIABETES NA 4


# OF ADMISSIONS 23 21 20 24 21 26

# OF F/U OFFICEVISITS

12 8 11 11 8 10

0

5

10

15

20

25

30

2017 HOSPITAL ADMISSIONS VS F/U OFFICE VISITS


# OF PATIENTS 4 3 1 2 0 2

0

1

2

3

4

5

2017 MONTHLY READMISSIONS

2017 Health Practice Management

2017 HOSPITAL ADMISSIONS ANALYSIS FOR MEDICARE PATIENTS: QUARTER 1 & 2

Medicare TCM Compliance QTR 1 QTR 2

# OF VISITS 29 22

F/U OFFICE VISIT WITHIN 7-

14 DAYS/TCM

OPPORTUNITIES12 10

TCM CODE-99496 9 8

TCM CODE-99495 1 1

MODERATE COMPLEXITY: 1-14 DAYS, 99495HIGH COMPLEXITY: 1-7 DAYS, 99496


# OF ADMISSIONS 13 11 5 7 5 10

# OF F/U OFFICE VISITS 6 3 3 3 2 5

0

2

4

6

8

10

12

14

MONTHLY MEDICARE ADMISSIONS VS F/U OFFICE VISITS

CONTINUITY OF CARE

Provider Name Total # of Pts Seen

# of Empaneled Pts

Seen by Assigned

Provider

% Continuity with

Empaneled Provider

AN 150 82 55%

TH 381 273 72%

TO 68 63 93%

RV 248 152 61%

NK 245 107 44%

0 #DIV/0!

TOTAL 1092 677 62%

May 57%

NOTE FROM HEALTH PRACTICE MANAGEMENT'S

HEALTH INFORMATICS DEPARTMENT:

Continuity of Care Has Increased

RISK STRATIFICATION# of Visit OpportunitIes to Risk Stratify 98

Missed Opportunities by Empanelled Clinician 27

% of Risk Stratification Compliance 72%

Provider Name

# of Empaneled Pts Seen by

Assigned Provider

Missed Opportunities by

Empanelled Clinician

AN 82 3

TH 273 3

TO 63 7

RV 152 4

NK 107 2

0

TOTAL 677 19



1. Clinicians: If your empanelled patient is not risk

stratified: It is your responsibility to provide risk

stratification. Please make sure this is documented in

patient record.

If you change a patient's risk stratification, please

send a note to Health Informatics (TR or JCC) to

ensure patient risk stratification is updated

appropriately in EMR so our data is as accurate as

possible.

FOREST HILL FAMILY HEALTH

ASSOCIATES

PATIENT RISK STRATIFICATION AND

CONTINUITY OF CARE

JULY 2017

RISK STRATIFICATION: JANUARY-JUNE 2017

# of Visit Opportunities to Risk Stratify 449

Missed Opportunities by Empanelled

Clinician104

% of Risk Stratification Compliance 77%

FHFHA 2017 Risk Stratification Data

97% of total active patients (1 year period: July 2016-June 2017)

have been risk-stratified

Low risk: 50%

Moderate Risk: 37%

High Risk: 10%



1. Clinicians: If your empanelled patient is not

risk stratified: It is your responsibility to provide

risk stratification. Please make sure this is

documented in patient record.

If you change a patient's risk stratification,

please send a note to Health Informatics (TR or

JCC) to ensure patient risk stratification is

updated appropriately in EMR so our data is as

accurate as possible.

QTR 1 COMPARISONS 2013 2014 2015 2016

2017 QTR 1

2017 QTR 2

Total Diabetic Pts 410 396 458 435 395 433

Controlled AIC <8 126 140 153 158 144 154

Percentage of

Controlled Diabetics 31% 35% 33% 36% 36% 36%

YEARLY COMPARISONS 2013 2014 2015 2016

Total Diabetic Pts 697 747 726 687

Controlled AIC <8 428 488 461 438

Percentage of Controlled

Diabetics 61% 65% 63% 64%

QTR 1 COMPARISONS 2013 2014 2015 2016

2017

QTR 1

2017

QTR 2

Total Hypertensive

Pts 536 576 692 700 753 841

Controlled BP 379 399 493 611 655 762

Percentage of

Controlled

Hypertensive 71% 69% 71% 87% 87% 90%

0

200

400

600

800

1000

2013 2014 2015 2016 2017QTR 1

2017QTR 2

COMPARISON OF CONTROLLED HYPERTENSIVE

PATIENTS

Total Hypertensive Pts Controlled BP

YEARLY COMPARISONS 2013 2014 2015 2016

Total Hypertensive Pts 986 1144 1235 1339

Controlled BP 832 930 1063 1269

Percentage of Controlled

Hypertensive 84% 81% 86% 95%

*Controlled BP: Systolic is 139 or lessand Diastolic is 89 or less

MONTHLY DATA

REPORTS(Documented in

Practice Partners and Recorded in)

Measure Numerator Denominator Quality Rate

Body Mass Index (BMI) Must be below 25 to close gap 126 1581 8.0%

Mammography (Breast Cancer Screening) age 50-74 217 407 53.3%

Cervical Cancer Screening (Pap) age 21-64 within 3 yrs 6 28 21.4%

Colonoscopy (Colorectal Cancer Screening) age 50-75 194 627 30.9%

Diabetes Care: A1C in last 12 months age 18-75 204 349 58.5%

Diabetes Care: Retinal Eye Exam (18-75) 3 58 5.2%

Diabetes Care: Nephropathy age 18-75 39 58 67.2%

Diabetes Care: A1C <8% 18-75 26 34 76.5%Adult Access to Preventable/Ambulatory Health Services ages 20-65 238 270 88.1%

*Screening for Clinical Depression 7 293 2.4%

GOAL: IF WE OUTREACH AT LISTED # PATIENTS

OUR POTENTIAL OUTCOME IS :Needed

Opp.# of Closed Gaps Denominator Target %

1376 1502 1581 95.0%

170 387 407 95.1%

21 27 28 96.4%

402 596 627 95.1%

128 332 349 95.1%

52 55 58 94.8%

16 55 58 94.8%

6 32 34 94.1%

19 257 270 95.2%

271 278 293 94.9%

Targeted Levels

95th Percentile

2017 PATIENT SATISFACTION SURVEY:

QUARTER 1 RESULTSQ1: Did your doctor give you an easy to understand

explanation about the next steps for any health

questions or concerns? YES

Q2: Did this doctor use pictures, drawings, or videos

to explain things to you? YES

Q3: At today's visit, did the clerks and receptionists

treat you with courtesy and respect? YES

Q4: Did anyone talk to you about specific things you

could do to prevent illness? ALWAYS

Q5: Did anyone ask you if there are things that make

it hard for you to take care of your health? ALWAYS

Q6: Did anyone talk to you about all the prescription

medicines you were taking? ALWAYS

Q7: In the last 12 months, when you phoned this

office to get an emergency appointment for care you

needed right away, how often did you get an

appointment as soon as you needed? ALWAYS

Q8: Did you get the information about what to do if

you needed care during the evenings, weekends, or

holidays? YES

Q9: In the last 12 months, when you phoned this

doctor's office during regular office hours, how often

did you get any answer to your medical questions that

same day or in a reasonable time? ALWAYS

Q10: When you talk about starting or stopping a

prescription medicine, did this doctor ask you what

you thought about what was best for you? ALWAYS

Q11: When you and this doctor talked about a

procedure (mammogram, colonoscopy, etc.) did this

doctor ask what you thought was best for you?

ALWAYS

Q12: In the last 3 months when this doctor ordered a

blood test, x ray, or other test for you, did someone

from this doctor's office follow up to give you those

results? ALWAYS

2016 QTR 1 RESULTS

(50 SURVEYS)

2016 QTR 2 RESULTS

(50 SURVEYS)

2016 QTR 3 RESULTS

(50 SURVEYS)

2016 QTR 4 RESULTS

(50 SURVEYS)

2017 QTR 1 RESULTS

(50 SURVEYS)

2017 QTR 2 RESULTS

(50 SURVEYS)

Q1 86% ( yes) 80% (yes) 85% (yes) 70%(yes) 84%(yes) 80% (yes)

Q2 64% (yes) 54% (yes) 26% (yes) 28% (yes) 27%(yes) 44% (yes)

Q3 96% (yes) 95% (yes)SAME 95%

(yes)SAME

95%(yes)73%(yes) 97% (yes)

Q4 27% (always) 36% (always) 40% (always) 39% (always) 47%(always) 41% (always)

Q5 20% (always) 61% (always) 30% (always) 33% (always) 38%(always)45% (always)



Q8 79% (yes) 61% (yes) 52% (yes) 58% (yes) 61%(yes) 55% (yes)



Q11 24% (always) 42% (always) 44% (always) 41% (always)SAME

41%(always)47% (always)


Patient Satisfaction Survey must obtain feedback from patients/families on their experiences with the practice and care related to:

* access* communication* care coordination* whole person care/self management support

TCPI Opioid Management Initiative

Sign the Pledge

Sign up for and demonstrate your utilization of the State

Controlled Drug Registry

Develop a policy and procedure on opiate prescription

management and document the use of a Chronic Pain

Management contract on the EHR for medically necessary

and continuous opiate and/or controlled drug dependent

patients


Participate in

Learning Collaborative Programming and all Data

Collection Efforts by GPTN

Participate in all CPC learning sessions in your region by official

TCPI, SANs and Teaching Faculty

Fully engage and cooperate by providing regular status

information as requested, for the purposes of monitoring

progress towards Milestones and KIPs and/or for the purposes of

providing support to meet the Milestones and KPI thresholds.

As a contractor for CMS, the faculty is bound by confidentiality

agreements


Use Health Information Technology

Attest that each provider within your practice is engaged

with, and working towards, attestation for Stage II of

Meaningful Use in the timelines set by the CMS Meaningful

Use program now incorporated into MIPS-QPP

Plug into your local HIE- CRISP


Transforming Clinical Practice Initiative (TCPI)Model

and Goals

This is where TCPI and the New Jersey Innovations Institute’s

Garden Practice Transformation Network (GPTN) comes in to

provide hands on support to you and your practice for

developing the skills and tools needed to improve care

delivery and make the transition from the current fee for

service system to a value based system, ultimately into an

alternative payment model.


Summary of Key Benefits of GPTN to Participating

Clinicians

Optimize healthcare outcomes and safety for your patients with assistance

from trained GPTN coaches providing evidence based quality improvement

and patient engagement resources that align with existing processes and

quality initiatives

Learn how to achieve and maintain benchmark status and thrive under

MACRA, MIPS-QPP, AAPM and APMs through GPTN and TCPI Learning

Activities

Get ahead of the 2019 mandated reimbursement curve and implement

patient-centered, quality focused strategies now.

Collaborate and lead with local, regional and national colleagues to

influence healthcare transformation


Q & A


Contact Info:Thomas R. Ortiz, MD, FAAFP

NJ Innovations InstituteGarden Practice Transformation Network

Chief Medical and Information Officer

www.NJII/ptn.org

[email protected]

201-463-2234

http://www.njii/ptn.org

mailto:[email protected]

Documents

NJII-Garden Practice Transformation Network · NJII-Garden Practice Transformation Network • $50M CMMI Grant • Transform 10,000 providers • Better care to 500,000 chronic patients