Medicaid 1115 Waiver Program

Medicaid 1115 Waiver Program

Catherine Gibson, Chief Waiver OfficerUniversity Medical Center of El PasoAnchor Hospital – Region 159/27/13

Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver

On December 11, 2011, CMS formally approved this program for Texas 5 year Waiver – 2011-2016

Purpose: To transform and improve healthcare to the Medicaid and Under-Funded Patients in Texas by:

Better access to health-care services Improving the quality of health-care and health systems Cost effectiveness of services and health systems Regional collaboration and coordination

Each Region forms a Regional Healthcare Partnership Plan (RHP) Project Categories include:

Infrastructure Development Program Innovation and Redesign Patient Outcomes Hospital Core Measure Reporting

Regional Healthcare Partnership (RHP) Regions

RHP Regions of Texas 20 Regions Developed in Texas We are Region 15 comprised of:

El Paso and Hudspeth Counties

Region 15 holds monthly Public Meetings On or around the last Wednesday of each month Location: El Paso First Health Plans Contact: Cathy Gibson, Chief Waiver Officer [email protected]

Region 15’s RHP plan is developed and located on the Region 15 RHP Website:www.umcelpaso.org

Region 15–RHP (link on webpage) Contains all information and documents from Region 15 Public

meetings to date.

Region 15 Community Needs Assessment

Regional Strategic Health Framework Needs Assessment Report Phase 1 – Needs Assessment Phase 2 – Priority Ranking

Region 15 formally adopted the Paso del Norte Regional Health Assessment

Top Priorities Diabetes / Obesity Behavioral Health Primary Care Secondary / Specialty Care Behavioral Health

Region 15 projects will center around these priority areas

Region 15 RHP Plan Approved by HHSC on 3/2/13

CMS is in the process of approving all RHP Plans for Texas

Texas Medicaid 1115 Waiver Program has 1300 Projects under review by CMS

Region 15 has 53 Projects UMC EHN El Paso Health Department El Paso Childrens Hospital Texas Tech HCA Tenet

Region 15 ProjectsDSRIP

UMC – 17 Projects

Adding Residents and Fellows to New and Existing Hospital Services Electronic Medical Record Programs UMC Neighborhood Health Clinics

Expanding clinic hours in 3 clinics to include evening and weekend Performance Enhancement Establishing Certified Medical Homes Chronic Care Models Coumadin Clinic

Inserting Medical Treatment in the Shelters Expanding Hospice Program Comprehensive Discharge Navigation Program Nurse Advise Call Lines and Surgery Guidebooks for Pre and Post

Surgeries Psychiatric Liaison Inpatient Services Emergency Department / Inpatient LEAN Efficiency Graduate Nursing Simulation Lab Primary and Specialty Care


Texas Tech – 9 Projects

Enterprise-wide Disease Management Registry

NCQA Designation as Medical Home

Addition of Child Psychiatry Fellowships

Expanding Neurology Care

Enhancing & Expanding Comprehensive Breast Care Services

Increasing Access to Surgical Services

Establishing a Minimally Invasive Surgery Fellowship Program

Increasing Access to Ocular Care

Expanding Pediatric Primary Care


Emergence – 5 Projects

Increase number of Psychiatrists and Licensed Behavioral Health Providers in El Paso

Develop an Extended Observation Unit (EOU)

Develop a Crisis Respite Unit

Crisis Continuum for Intellectual Developmental Disability (IDD)

Evidence-based Practices are Empirically Based Treatment Modalities that are Proven to Result in Positive Outcomes


Tenet (Providence and Sierra East) – 8 Projects

Discharge Planning Assessment and Intervention

Develop Program to Improve Cultural Competency of Staff

Establishing New Urgent Care Centers

Form 2 Specialty Clinics


Las Palmas Del Sol – 7 Projects

Establish Outpatient Women’s Centers

Establish a Diabetes Information system

Tele-Psychiatric Consultation in the Emergency Department

Clinical Information Registry for Heart Disease Patients

Develop Strategies for Recruiting and Retaining Primary Care Providers

Recruit 2 Specialists or Expand 2 Specialty Clinics

Implement Hospitalist Model


Health Department – 5 ProjectsEl Paso Childrens Hospital - 1 Project

Health Department

Establish a Community Health Atlas Establish Mobile Dental Clinics Automated Emergency Dispatch Regional Data Validation of HIE Disease Management Registry

EPCH

Pediatric Hospitalist Model

UMC Neighborhood Health ClinicsDSRIP Projects

Opening a new Primary Care Clinic at Crossroads and Mesa with expanded evening and weekend hours serving the Westside of the City of El Paso.

# Providers Hours/Days The placement of this new clinic will create between 10,000 and 20,000 visits by the end of the Waiver term

in 2016. The outcome improvement target is to improve patient satisfaction and also to adequately control patients on

blood pressure monitoring medication

Expansion of current services - This project will expand access to primary and urgent care in the RHP Region, and more specifically the East area of El Paso County by relocating and expanding the Montwood Clinic to a much larger site offering many additional services including additional primary care staff, evening and Saturday hours, Women’s Health Services including ultrasound, a regional laboratory and a pharmacy.

We expect to have approximately 50,000 visits which also include lab, pharmacy and ultrasound services by the end of the Waiver term in 2016.

The outcome improvement target is to improve patient satisfaction and also to adequately control patients on blood pressure monitoring medication

Expansion of current services- This project will expand access to primary and urgent care in the RHP Region, and more specifically El Paso County. UMC will expand primary and urgent care staffing, services and hours at two existing Neighborhood Health Centers at Ysleta and Fabens helping them to become minor hub sites which provide lab in addition to primary care.

There are currently no evening or weekend hours at either the Ysleta or Fabens Neighborhood Healthcare Centers. Many providers are extremely busy with third next available appointments out over a month.

The outcome improvement target is to improve patient satisfaction


Improve the quality of care given at the UMC neighborhood health centers (NHCs) by upgrading the EMR system to better document and track disease progressions and provide a scorecard to measure improvement.

electronically prescribe medications, meeting meaningful use standards, and tracking HEDIS measures UMC will add key staff to enhance and interpret reporting methodologies that enable quality improvement and rapid-

cycle change. By 2016, this quality of care initiative will impact 63,500 patients The outcome improvement target is decrease the hemoglobin A1c measurement to 8% or below for patients

discharged to the NHCs with diabetes within 1 year

Implement the Medical Home Model in the UMC neighborhood health centers, resulting in better coordination of care, greater access, and enhanced quality of patient care. Development of a patient registry including layered reporting of performance measures and decision support so that cost, access and quality are measurable and improvement can be demonstrated.

Currently care at NHC is reactive instead of proactive and planned. Multiple studies have shown that increased access to planned, proactive primary care and support staff and greater involvement of the patient in making their own health care decisions improve total health care costs.

By providing the right care at the right time and in the right setting, over time, patients may see their health improve, rely less on costly ED visits, incur fewer avoidable hospital stays, and report greater patient satisfaction.

NHC will obtain Medical Home Recognition 300 new patients assigned to medical home will be contacted for their first patient visit within 60-120 days.

We expect this project to improve the quality of care given by establishing a medical home for 31,775 patients by the end of the Waiver in 2016.

The outcome improvement target is to reduce the 30 readmission rates for these diabetic patients


Diabetes Chronic Care - This project will redesign the outpatient delivery system to coordinate care for patients with chronic diseases and improve patient outcomes, with a focus on diabetic patients.

We will coordinate an appointment for Diabetic patients within 4 days from discharge at UMC to UMC-NHC for patients without a PCP or NHC patients.

Utilizing the Chronic Care Model and a team approach including PCP, Pharmacist, Registered Dietitian, Social Worker and Exercise Physiologist we will create a comprehensive medical home for Diabetic patients, track their process in a registry system and help the patient increase their understanding of diabetes and establish their own self-management goals.

UMC-NHC are currently not utilizing the Chronic Care Model nor has a specialized diabetic program upon discharge from UMC despite having a large number of diabetic patients who would benefit from a more systematic approach to helping them manage their diabetes.

The outcome improvement target is to reduce 30 diabetes readmission rates

Establish a Coumadin Clinic – Basic Services to be provided include:

establishment of a medical home, patient assessment, monitoring of anticoagulation, dosage adjustment, medication education and management, patient education (including nutrition counseling and self-management), and follow-up care.

This clinic goes well beyond the traditional Coumadin Clinic to get to the root causes of what caused the patient to have the problems so severe that they were hospitalized and that then needed Coumadin as part of the medication plan. The clinic will treat the whole patient and work on helping the patient get under control the underlying conditions that caused their hospitalization.

The clinic uses a team approach including physician, NP, clinical pharmacist, nutritionist, social worker, physical therapist and exercise physiologist to health the patient regain their health. The clinic will increase patient well-being and satisfaction, and reduce the number of readmissions to treat stroke and coronary artery disease and related bleeding.

Currently there is no Coumadin Clinic in the El Paso area for uninsured/ Medicaid patients. UMC currently is discharging 6-10 patients every week in this category or patients who do not have an established Primary Care Provider. This is a very dangerous situation due to the complexity of the patient’s health status following discharge on this medication. Currently 80% of the patients being discharged from UMC are on Medicaid or are Uninsured with only 20% having Medicare or private insurance.

This population has had a high readmission rate due to lack of appropriate primary care. The outcome improvement target is to reduce the readmission rates for this patient population

Expand Resident and Fellowship Programs and Establish a Graduate Nurse Residency

Program

Additional Resident and Fellowship slots for Cardiology, Nephrology, Radiology, and GI will be provided by UMC to increase access to services at the hospital.

The outcome improvement target is to survey graduating residents and fellows and improve retention of these specialties in the El Paso area.

Development of a comprehensive graduate nursing program including a simulation lab and specialty care focused training

The outcome improvement target is to survey graduating nurses and improve retention of these specialties in the El Paso area.

Insert Medical Care and Wellness into the El Paso Shelters

This project will provide nursing care and an in-house wellness program to residents at the Salvation Army.

Diabetes treatment will be a large portion of care provided for this target population; however, the residents will receive any ongoing medical care they need via RN’s who are located in the Salvation Army.

This project will develop a program for clients to gain control of their healthcare through disease management, medication compliance, appropriate diet and nutrition, and lifestyle changes.

Under this project, UMC will contract with VNA to develop and implement an evidence-based nursing program in order to provide primary and preventive healthcare to residents of the Salvation Army shelter in El Paso.

Annually, this bilingual, culturally sensitive program will serve approximately 350 homeless families with children (over 1,000 unique individuals) by educating the population about preventative healthcare and wellness (including education on nutrition, fitness, counseling, and health management—including management of chronic diseases).

The wellness program will directly provide for a nutritionist, a chef, and kitchen equipment, supplemental nutritious foods including fresh produce, a wellness counselor, fitness resources, and prescription drug vouchers.

The outcome improvement target is to reduce hospital admission rates for this patient population

This project will provide nursing care to residents at the Rescue Mission.

Implement innovative evidence-based strategies to reduce, prevent and manage chronic diseases (including but not limited to diabetes, obesity, hepatitis C, cirrhosis / liver disorders, and hypertension), in children and adults.

Clients will receive nursing care in the shelter to better address ongoing maintenance of chronic conditions and to treat urgent conditions as they arise.

This project will develop innovative strategies to reduce, prevent and manage chronic diseases in children and adults. VNA nurses will provide preventive screening, monitoring, and non-emergent care, supported by three medical directors which will be critical for the needs of this population.

The outcome improvement target is to reduce hospital admission rates for this patient population

Emergency Department Throughput and Psychiatric Liaison Nursing on the Hospital

Units

ED Lean Project – To increase access to care and provide more timely and quality care to UMC patients, multiple teams and processes are being implemented to reduce the wait time for a patient to be seen in the ER, and the wait time to admit a patient waiting in the ED to a hospital bed. Improvement in our processes will also improve the discharge process for inpatients who are ready for discharge home.

The outcome improvement target is to prevent patients from leaving the emergency room without being seen by a doctor and the reduce the wait times for admission

Nurse Psychiatric Liaison – UMC is not a psychiatric institution, but treats a large number of patients in the EL Paso community for medical conditions (who may also have a secondary psychiatric diagnosis. Those patients will be identified and consulted for follow-up psychiatric care upon discharge from the hospital.

The outcome improvement target is to reduce readmission rates for this patient population

Discharge Navigators – This project will create a coordinated system of care upon discharge within the hospital to ensure the continuity of health care as patients transfer between different locations.

Patient care navigators / case management positions will discharge our Medicaid and Unfunded patients with chronic conditions to appropriate medical homes for follow-up healthcare treatment utilizing other UMC projects that will provide for clinic growth and expansion, as well as appropriate home health care services, and finally coordinating homeless and transient patients to our partner homeless residential facilities.

UMC expects that the effective targeting and navigation of high-risk and chronic care patients will greatly reduce or eliminate return emergency room visits while also reducing hospital inpatient days for this population. This project will also increase patient awareness of self-care best practices and increase support inside and outside of the hospital for discharged patients.

The outcome improvement target is to reduce the 30 day readmission rate for this patient population

Addressing Surgical Patients Needs and EMR Programs to Improve Patient Care

Surgery Guidebook and Nurse Advise Line

UMC will develop an educational guidebook for surgical patients, including resources for pre-surgery, intra-surgery, post-surgery, discharge, and follow-up. UMC will create a 24/7 nurse advice line for surgical patients to access with questions and concerns. We will tailor the nurse advice line to be able to give more detailed support regarding the same issues and questions addressed by the surgery guidebook.

Outcome improvement target is to reduce readmission rates for this patient population due to complications

EMR - UMC will participate in nationally validated, risk-adjusted, outcomes-based programs to measure and improve the quality of trauma and surgical care (TQIP and NSQIP).

UMC will implement robust electronic medical record (EMR) and data collection systems to provide the infrastructure for improving patient care and decreasing the incidence of Potentially Preventable Complications and Healthcare Acquired Conditions.

The target population is our surgical and trauma patients which are at a higher risk for contracting a complication. However, the implementation of a robust EMR along with participation in an outcomes-based program will benefit all of our patients.

Hire/train quality improvement staff in well-proven quality and efficiency improvement principles, tools, and processes to measure improvement and trends

Outcome improvement target is to reduce catheter associated urinary tract infection rates of hospital patients

Region 15 Learning CollaborativeDiabetes

Plan for Learning Collaborative for Diabetes in Region 15 will be submitted October, 2013 for the next 3 years

DSRIP projects and subcontracts addressing Diabetes: UMC

30 Day Readmission Rates for Diabetes Discharge Navigation Primary Medical Care in Salvation Army and Rescue Mission in

collaboration with VNA Nursing High intensity chronic care disease management –Tendercare

Home Health Care Neighborhood Health Clinics

Questions

Cathy Gibson, Chief Waiver Officer for UMC, Anchor Entity [email protected] 915-521-7523

Health & Medicine

Medicaid 1115 Waiver Program