R EGIONAL M EETING Please sign in for this meeting so that meeting - - PowerPoint PPT Presentation

June 2, 2014

The Northeast Texas Regional Healthcare Partnership

REGIONAL MEETING

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Meeting Agenda

• Regional Update – Discuss the status of the regional

health plan and major updates from HHSC, CMS, and regional partners.

• Regional Sharing & Learning – Discuss lessons learned

from DSRIP projects around the region.

• Learning Collaborative – Behavioral Health Integration

THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT TYLER

Major Updates from CMS

• New Three-Year Projects Approved: RHP 1 added 8 new

projects to our regional health plan, including projects from a new provider – ACCESS MHMR.

• Revised Protocols Approved: New versions formalize

changes to Waiver operations.

• New Project Officer: New point of contact for the Texas

Waiver is Paul Boben, who has been working on financial aspects of the waiver for a couple of years.

THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT TYLER

April DY 3 Reporting Update

• Metric Reporting: Do not report a metric as “achieved”

unless it is fully achieved. HHSC made some manual adjustments but cannot do this in the future.

• NMI Requests: HHSC will be sending “NMI – Needs

More Information” requests to providers very soon. Please reply back as soon as possible to avoid delays in payments.

• DSRIP Monitoring Contract: Myers & Stauffer, LLC was

awarded the DSRIP Compliance Monitoring contract by

• HHSC. Mid-point assessment work will begin soon.

THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT TYLER

Waiver & Plan Evaluation

• The Standard Terms and Conditions and the Program

Funding and Mechanics Protocol requires HHSC to conduct an evaluation of certain elements of the waiver and regional health plans.

• These evaluation activities are matched at the

administrative cost rate (50/50) using IGT from providers in each region.

• HHSC has administrative rules pending that prescribe the

methods available to IGT providers to contribute IGT necessary to fund waiver evaluation.

THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT TYLER

Waiver & Plan Evaluation

• Proposed HHSC rules allow HHSC to either withhold or

receive excess IGT from providers in order to fund waiver evaluation. OPTION 1: WITHHOLDING

THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT TYLER

Project Valuation $1,000,000 IGT Required $413,100 HHSC Withholding (1%) $4,131 IGT Submitted for Project $408,969 Federal Match $581,031 Total to Provider (IGT + Federal) $990,000

Waiver & Plan Evaluation

• Proposed HHSC rules allow HHSC to either withhold or

receive excess IGT from providers in order to fund waiver evaluation. OPTION 2: EXCESS IGT PROVIDED

THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT TYLER

Project Valuation $1,000,000 IGT Required $413,100 IGT Entity Provides Extra 1% $4,131 Total IGT Submitted $417,231 Federal Match $586,900 Total to Provider (IGT + Federal) $1,000,000

July Plan Modifications

• Late July 2014: HHSC will send plan modification

requests to providers. This will be the last time for providers to initiate plan modifications.

• Early Achievement: If you are achieving QPI goals two

years early, HHSC recommends that you proactively increase future QPI targets via plan modification.

• Category 3 Changes: Likely will be handled separately

from plan modification process.

• Other: HHSC and/or compliance monitor could require

modifications after July 2014.

THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT TYLER

Looking Ahead for RHP 1

• September Regional Meeting: Focus on provider

projects, poster and presentation session with HHSC and local providers.

• Annual Report: Help us tell the region’s story by sharing

examples of successful projects and patient impact.

• Learning Collaborative: Focus on behavioral health

integration, but growing to two topics per year.

THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT TYLER

RHP HP 1 Regi giona

• nal

l Learning ning Col

• llaborative

laborative Ju June 2, 2014 14 Care re Tran ansitions, sitions, Telehea ehealth lth and nd ED Naviga vigation tion

• 1. Readmission scope and causes
• 2. Best practices and models to reduce

readmissions

• 3. Highlighting 2 DSRIP projects aimed

at reducing potentially preventable readmissions

• 4. Emergency Department over

utilization

• 5. ED Navigation project

HMHD Service Area Hunt County population 86,139

Hunt Memorial Hospital District

• Hunt Regional Medical Center

Greenville - 192 acute care beds

• Hunt Regional Community

Hospital – 25 critical access beds

• FY 2013 Inpatient admissions –

6,853

• FY 2013 ED visits – 47,799
• Operates County EMS service

 Nearly 20% of Medicare hospitalizations are followed by

readmission within 30 days (1 in 5).

 90% of readmissions within 30 days appear to be

unplanned, the result of clinical deterioration.

 MedPAC: 75% of readmissions preventable, adding $12

Billion/yr to Medicare spending.

 Only half of the patients readmissions within 30 days had

a physician visit before readmission.

 70% of readmissions have chronic conditions.

Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the medicare fee-for-service program. The New England Journal of Medicine, 360(14), 1418-1428. Available at: http://www.commonwealthfund.org/Publications/In-the-Literature/2009/Apr/Rehospitalizations- Among-Patients-in-the-Medicare-Fee-for-Service.aspx

Source: Thorpe, K et al., “Chronic Conditions Account for Rise in Medicare Spending from 1987 to 2006,” Health Affairs, April 2010; Health Care Advisory Board interviews and analysis.

Source: Thorpe K and Howard D, “The Rise in Spending Among Medicare Beneficiaries: The Role of Chronic Disease Prevalence and Changes in Treatment Intensity,” Health Affairs, 379, August 2006; Innovations Center Futures Database; Health Care Advisory Board interviews and analysis.

 Age greater than 80 years  Five or more comorbidities  Functional impairment  Past or current diagnosis of depression  Lack of documented education provided to

the patient and/or family upon discharge

 Alcohol abuse  Inadequate support system

 Residing in a low-income community  Complicated Healthcare Environment  Lack of continuity between care sites and

practitioner offices

 Lack of communication between

clinicians/practitioners

 Hospital /Office/Post Acute Care/Nursing

Facility/Assisted Living

Golden, A.G., Tewary, S., Dang, S., Roos, B.A., 2010. Care management’s challenges and opportunities to reduce the rapid rehospitalization of frail community-dwelling older adults. The Gerontologist. 2010; 50(4):451-458. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20185522

 Identify patient’s at high risk for readmission

• r failed care transition

 Stratify risks of readmission to target

interventions

 Interventions to improve each high risk area

“8 P’s”

 Improve outcomes and patient experience

Source: Society for Hospital Medicine http://www.hospitalmedicine.org

 Discharge education through Discharge

Advocates

 Implementing After Hospital Care Plan  Discharge follow-up

Source: Boston University https://www.bu.edu/fammed/projectred

 Medication management  Patient centered record for care

continuity

 Self-management and family care

giver tools

 Prompt follow-up with

primary/specialty care

Source: The Care Transitions Program, Eric Coleman, MD http://www.caretransitions.org

 Advanced Practice Nurse implements in-

hospital and home discharge planning

 In-hospital APRN visit- individualized DC

plan, education on care plan, coordination of home services, validation

• f learning

 Post DC- home visit at 48 hours and 7

days, weekly telephonic follow-up

Source: University of Pennsylvania, Mary Naylor, RN, PhD http://www.transitionalcare.info/index.html

 Social Work Coordinator to transition patient

from hospital to community

 Pre-discharge assess risks  Post- discharge patient follow-up at 2 days

and as needed

 Follow-up at 30 days

Source: Illinois Transitional Care Consortium http://www.transitionalcare.org/the-bridge-model

Hunt Regional Care Transitions program:

• Implemented Project RED with 2 Discharge Educators
• Developed readmission risk stratification and alert

system

• Good To Go and disease specific patient education
• Patients discharged with a primary/specialist

appointment

• Conduct post discharge telephonic follow-up
• Conduct a readmission root cause analysis on

readmitted patients

• Category 3 Outcome Measure: Reducing all cause 30-

day readmissions

 Educate the patient about his or her diagnosis  Make appointments for follow-up  Discuss any diagnostic tests completed in the

hospital and who will follow up on results

 Organize post-discharge services  Confirm the Medication Plan  Reconcile the discharge plan with national guidelines  Review what to do if a problem arises  Assess the patients degree of understanding using

the teach back method

 Give the patient a written discharge plan at the time

• f discharge

 Provide telephone follow-up 2-3 days after discharge

All inpatients are screened for readmission risk upon admission in the electronic medical record. Patients at a medium and high risk receive a Care Transitions consult. Risk factors:

Hunt Regional Telehealth Project:

 Remote patient monitoring of CHF patients  Intensive outpatient case management  Patient education focusing on self-

management

 Reconciling the treatment plan with the

American Heart Association Heart Failure guidelines

 Category 3 Outcome Measure: Reducing CHF

30-day readmissions

1.

Patient takes vital signs and answers daily health questions at home.

2.

Information is transmitted via land or cell line to Phillips data server and formatted into electronic medical record

3.

Information is reviewed by telehealth nurse via internet

4.

Telehealth nurse calls

• r makes home visit to

assist patient

Patients receive in home education on heart failure self-management techniques including:

 The heart failure disease process  Signs and symptoms of exacerbation and

corrective actions

 When and where to seek help  Lifestyle modifications including diet,

exercise and smoking cessation

 Diet and fluid restriction, weight monitoring  Heart failure medications- action, side

effects and adverse reactions

 Advance care planning

• Determine All Cause 30 day

readmission baseline rates

• Complete readmission root

cause analysis on readmitted failure patients

• Study root cause analysis and

aggregate causes

• Monitor All Cause 30

Day Readmission Rates

• Refine Care

Transitions interventions from Root Cause Analysis

• Implement Care Transitions

Project

• Implement Readmission Risk

Assessment in Meditech for all admissions

• Implement Project RED

components to patients at a high risk of readmission

• Provide patients with chronic

diseases disease specific education and self- management tools

• Arrange 1st follow-up PCP or

specialty care appointment and transportation prior to hospital discharge

• Ensure patient has the

resources to obtain medication

• r provide it prior to discharge
• Provide telephonic follow-up
• Reduce All Cause 30 day

Readmission Rates

• Review evidence based

best practices to reduce readmissions

• Develop Care Transitions

project incorporating evidence based interventions

• Engage Stakeholders

Plan Do Study Act

• Don’t reinvent the wheel, there are many

care transition models that provide a good starting framework.

• Network and build relationships with

healthcare providers outside of the hospital, they have tremendous resources to offer our patients.

• Ensure patients leave with an a follow-up

appointment prior to discharge.

• Follow-up phone calls are critical to ensure

patient needs are met.

• Give patients a hospital direct contact

person.

• In addition to medical components, social

support and resources are extremely important factors in readmissions.

Emergency Department’s have evolved into the safety net healthcare provider for the nations Medicaid, uninsured and people with limited access to healthcare providers. Over the previous decade:

 The US population grew by 12%  Hospital visits increased 13%  ED visits increased by 26%  425 ED’s closed  Hospitals had a net loss of 198,000 hospital

beds

Institute of Medicine, Hospital-Based Emergency Care: At the Breaking Point. Available at: http://www.nap.edu/catalog/11621.html

Medicaid beneficiaries access the ED more than any other payor group:

 Medicaid 81 visits/100 enrollees  Uninsured 40 visits/100 patients  Private insurance 20 visits/100 enrollees

Institute of Medicine, Hospital-Based Emergency Care: At the Breaking Point. Available at: http://www.nap.edu/catalog/11621.html

 EMTALA ~ ED’s can not restrict access based

• n inability to pay

 Decreasing numbers of primary care

providers accepting Medicaid

 Limited access to specialty care  Patient culture

 ED Navigation Project Objective: provide

navigation services to high risk/high need patients to support timely, coordinated care in the most appropriate setting.

 Related Category 3 outcome measure:

Reduce ED visits for ambulatory sensitive conditions.

 Model: based on the Institute for Healthcare

Improvement Care Coordination Model

Future ure State ate: The Objec jective Curren ent State ate: The Gap HRMC Actions: ns: The Bridge

Decreased d ED utiliza zati tion

• n for non-

emerge gent t care High volume of urgent and acute primary care provided in the ED  Implementation of the ED Navigation Program  Implementation of ED Medical Screening Prima mary care capacity ty for the uninsured d and Medic dicaid d popu pulati tion

• n

Lack of primary care capacity for the uninsured and Medicaid population  Implementation of Primary Care DSRIP project  Partnership with Greenville Community Health Service Agency to provide primary and urgent visits Public transpo porta tati tion

• n for health

thcare needs ds Limited public transportation  Agreement with The Connection to provide healthcare related transportation to ED Navigation patients Resources for under derserved d patients ts to receive post t discharge ge medic dicati tion

• ns

Patients unable to obtain post discharge medication  Medication Assistance Policy developed  Resources, funds to provide emergency post discharge medication for free to ED Navigation Patients  Procedure developed outlining ongoing medication assistance from Medicaid, Prescription Drug Assistance Programs, FISH Ministries, Prescription Drug program (grant) at Hunt Regional Home Care Discharge ge follow

• w-up

Limited follow-up after ED discharge  Implement ED Navigation Program which will provide telephonic follow-up to ED Navigation patients and home visits to the highest volume ED super-users Improv proved d health th liter teracy y and the patients ts under dersta tandin ding g their diagn gnos

• sis, aftercare and self-

manage gement t plan Poor Health Literacy  Patient disease self-management education incorporating the “teach-back” method  Patient education packets developed Hunt t County ty Commu munity y Resource Guide de that outlines available ble resou

• urces

Limited knowledge of Community Resources  Developed Community Resource Guide

 We must find methods to incentivize patients to

seek care from their PCP versus the ED to reduce ED utilization.

 It will take time and perseverance to change

patient behavior from seeking primary/urgent care in the ED to primary care.

 In addition to establishing care with a PCP, it is

equally important to address transportation, ability to obtain discharge medication, lifestyle modification and self-management strategies;

 Mental illness, depression and drug abuse are

significant factors in the ED super-user population.

Reducing Congestive Heart Failure Readmission by improving care transition process

127278302.2.17 –Apply systematic Approach to Improve Quality /Efficiency for CHF patients

QI Learning Collaborative – RHP1 Meeting June - 02, 2014

Adapted from Pittsburgh regional health Initiative and network for regional healthcare improvement

Traditional Model

Adapted from Pittsburgh regional health Initiative and network for regional healthcare improvement

Fix 1 : Improved Patient Education

Adapted from Pittsburgh regional health Initiative and network for regional healthcare improvement

Fix 2 : Improved Care in Hospital

Adapted from Pittsburgh regional health Initiative and network for regional healthcare improvement

Fix 3 : Adequate post discharge support

Adapted from Pittsburgh regional health Initiative and network for regional healthcare improvement

Fix 4 : Reduce ER Visits

Adapted from Pittsburgh regional health Initiative and network for regional healthcare improvement

Goal : Reducing Readmissions

PSC & CHW – Roles & Responsibilities

• 1. Patient Services Coordinator (PSC)
• Assesses barriers to patient’s access to care

– Including the need for CHW intervention

• 2. Community Health Worker (CHW)
• Health coach

– Reinforcement of provider/nursing education

• Peer-to-peer support
• Social support
• So much more…

Burgess, Grayson –PSC & CHW roles and responsibilities

PSC/CHW Referral Process

Staffing Plan of PSC & CHW’s with respect to reducing CHF readmissions

CHW & PSC Clinic integration benefits

• Better Care Coordination

– Med reconciliation, follow up appointments with PCP

• Patient Education

– Why/how to take medications, discharge education

• Better Self Management Support

– Coaching, financial and transportation assistance

• Proactive interventions

– Home visits, phone calls , continuous monitoring

Thank You

For More information on Patient Service coordinators and Community Health workers Contact Grayson Burgess grayson.burgess@uthct.edu 903-877-8960 Carlton Allen carlton.allen@uthct.edu 903-877-8939

Heart Failure Risk Stratification Scoring Tool

Adrian Nedelcut Good Shepherd Medical Center

GSMC CHF Readmission Team

MallikChowdary Yenigella

• Dr. Emmanuel Elueze

Adrian Nedelcut

• Dr. Hafiz Fakih
• Dr. Rumit Thakkar

Lydia Dejong Rhonda Tramel Marylu Kilpatrick Susan Cooper Brandon Amyx Missy McKee Marcia Oxsheer Joey Sutton

Problem Statement

Lack of a region-personalized risk stratification scoring tool that would accurately show the correlation between the patient's risk factors and their probability

• f readmission.

Readmission rates for GSMC CHF patients show an ascending trend from 18.65% in 2012 to 25.63% in

• 2013. Our CHF cases have been shown to constitute

approximately 50% of the total readmissions. The national average for CHF readmissions is 23%. CMS reimbursement linked to the Readmission Reduction program constitutes of 2% of all CMS payments for FY 2015.

Goal

The purpose of this study was to develop a convenient and inexpensive method for identifying an individual's risk for hospital readmission for CHF using the information derived exclusively from the data sources available at the time of patient arrival. The goal is reduce the current CHF readmission rate by half if these patients are monitored appropriately and are provided continuum-of-care solutions for their disease management.

Data Analysis

A total of 1024 admissions for CHF were recorded within the last 6 quarters which included 235

• readmissions. Of these 235 readmissions, 43

individual patients accounted for approximatively 50% of all CHF readmissions (N=110) which is approximatively 5% of the entire CHF patients population (N=955). Following the 80/20 rule we decided to focus on this subgroup and analyze the common factors that contributed to these patients' readmissions.

Process

• We did not have a risk stratification scoring tool

that would accurately show the correlation between the patient's risk factors and their probability of readmission.

• The tools present in literature did not provide a

reproducible model for our patient population.

• Multivariate analysis of subgroup of patients that

readmitted more than twice within 30 days post discharge.

Risk Stratification Tool

• ld score new score

Demographics

Lack of social/family support Has social/family support

• 14

Age > 70 0.5

• 14

Lack of financial support 0.5 9 Race w 11 Race b

• 10

Race a 18

Pathology

CHF 2 20 EF 0-15 50 EF 16-35 6 EF 35-50 15 EF 51+ 29 ELOS > 5 days 1

• 13

COPD/Pneumonia 2 24 AMI 1 15 High risk meds - Insulin, Warfarin 1 20 More than 10 meds 1

• 36
• ld score new score

Past medical history

Hx of Readmission 30days 1 45 HF,COPD, DM or CRF 2 Hx LOS > 7 days 1

Literacy and patient engagement

Literacy low 37 Literacy medium Literacy high Patient engagement low Patient engagement medium Patient engagement high

Results

CORRELATION 0.807419

Risk Stratification Tool

y = 0.0002x2 - 0.0287x + 2.8805 R² = 0.8814 1 2 3 4 5 6 7 8 9 10 50 100 150 200 250

Readmissions Score

Polynomial distribution

readmissions

• Poly. (readmissions)

Scoring

• 40-85 – 75% chance of readmitting twice
• 86-115 – 83% chance of readmitting three

times

• 115-150- 100% chance of readmitting four

times or more (over 150 points)

QUESTIONS…????

THANK YOU

To reduce readmission rates of Heart Failure patients by 40% by the end of 2014 by improving compliance with preventive measures.

Average HF Readmission Rates: October 2011 - September 2012 = 20.22% October 2012 – September 2013 = 14.80%

To achieve a HF Readmission Rate

• f 13.6% or less by the end of the

first quarter of 2014 and to maintain that reduction for all of the calendar year.

A comprehensive analysis of the baseline data for readmission causation revealed the most common factors to be:

• Non-Compliance to medication

therapy, weight monitoring, and diet

• Failure to follow up with physician

Implemented a Transitional Care Program to include: 1.) Case Management scheduling patient follow up visits with the physician 2.) Transitional Care Nurse visiting the patient at home 3, 10 and 20 days after discharge for compliance monitoring and reinforcement education.

Summary Data 46 HF patients discharged 1Qtr 2014 Of those, 27 qualified for referral to TCN 6 out of 27 refused services 10 of 27 were not referred 11 of 27 were seen by TCN.

Data Analysis

Compliance barriers identified immediately post-implementation, but improved with nursing education/scripting: January – 33% improved compliance February – 50% improved compliance March – 90% improved compliance

HF Readmission team now focusing on:

• Improving referral process
• Decreasing patient refusals
• Continued work to further improve

compliance as readmission rates are still above goal.

RHP 1 Regional Learning Collaborative

QI Initiative to Reduce CHF Readmissions

Current Condition

• Increased CHF readmission rate compared to

previous year.

• July 13 – November 13 had an average of 21%

readmission (all payors)

Counter Measures

• Reduce readmits with increased education

from Registered Dieticians prior to discharge

• Focus will be on diets and fluid restrictions

that will lead to better overall health

• utcomes

Plan

• Met with contracted dieticians to highlight

why this is a need for our facility and what

• ther efforts would lead to better outcomes
• Set to begin tracking RD education December

13

Early Results

Discharge education by RD’s on HF patients:

• Dec 13 – 41%
• Jan 14 – 55.6%
• Feb 14 – 78%
• Mar 14 – 78.3%

HF Readmission Rate

• Dec 13 – 10.6%
• Jan 14 – 13.8%
• Feb 14 – 12.2%
• Mar 14 – 13.9%

Questions

MEDICAID WAIVER PROJECTS IMPLEMENT/EXPAND CARE TRANSITIONS PROGRAM

June 2, 2014 Project 0941008002.2.3 Presenter: Mary Elizabeth Jackson

Trinity Mother Frances 474 bed acute care facility 350 physicians and mid-levels 39 specialties in 36 locations throughout east Texas Primary referral site – Largest number of patients seen in ER in Smith County Need Conducted a needs assessment and established ties with community-based organizations to create support for post-discharge

Overview

Project Goal

• Improve coordination of care from inpatient to outpatient,

post-acute and home care settings

• Prevent increased health care costs and hospital

readmissions

Regional Goals

• Support hospitals’ collaborative efforts to improve access
• Move toward triple aim
• Satisfaction - Improve patient experience of care
• Quality - Improving the health of populations
• Cost – Reduction of per capita costs of care

Goals

CHALLENGES:

• New concept, so there is little experience with care teams
• utside of the acute care setting
• Senior population often lacks support group in primary and

secondary area

• Inability to make immediate medical decision

Easy Access

• Hired a CHF Nurse Navigator, Susie Howell
• Timely, protocol driven scheduling of testing and procedures
• Timely diagnosis
• Multidisciplinary care team with standardized care

CARE TRANSITION

Care Transition Team

CEO MFH & LPOHH: John McGreevy Chief of Cardiology: Dr. Flagg Sanford Clinical Coordinator for Cardiology Observation Unit: David McCaskill, ANP

• Dept. of Emergency Medicine: Dr. Luis Haro

Administrative Director Patient Progression: Robyn Silber, RN Clinical Director of Care Management: Holly Morawski, RN Chief of Primary Care Services: Dr. Roger Fowler

Overview

• New project so there are no protocols
• Develop /establish evidence-based protocols using American

Heart Association 2009 guidelines for diagnosis & management for heart failure

• Implement standardized care transition policies and

procedures

• Conduct an assessment with community-based organizations

to create a support network for targeted patients post discharge

• High risk patients have a more stringent follow-up procedure

CARE TRANSITION PROJECT

Overview

• Hospitalization
• Contact patient and family and complete assessment
• Review discharge planning documents
• Determine need for home visit
• After Hospitalization
• Phone call or MyChart within 2 business days
• Verify transitional appointment has been made
• If visit is >14 days, call patient back to verify assessment
• Repeat calls every 7 – 14 days until endpoint

Guidelines for contact

Guidelines for Contact

• If Patient Readmitted
• Visit patient in hospital during business hours to

assess reason for readmit

• If unable to see patient, do phone interview after

discharge and restart entire protocol

• Discharge
• If patient has not been readmitted by 45 days post-

discharge then dismiss from service by phone call

Challenges and Lessons Learned

• Difficult to get timely outpatient appointment until new

clinic opened

• Developing multi-disciplinary teams is challenging
• Importance of communication
• Between providers and departments in caring for patients
• Budgets and staffing to cover additional volumes

Questions and Answers

Project Summation

MEDICAID WAIVER PROJECTS Expand Specialty Services

Pulmonology and Cardiology Pulmonary Lung Nodule Clinic Heart Valve Clinic June 2, 2014 Project 094108002.1.2 Presenter: Andrea Anderson

Trinity Mother Frances

• 474 bed acute care facility
• 350 physicians and mid-levels
• 39 specialties in 36 locations throughout east Texas
• Primary referral site

Need - Gap Analysis for Specialists

• Inpatient and outpatient care
• Willing to travel to regional clinics
• Focus on Pulmonary and Cardiology Clinics

Overview

Project Goal

• Increase the capacity for specialty services
• Adding providers to accommodate demand

Regional Goals

• Support hospitals’ collaborative efforts to improve

access

• Move toward triple aim
• Satisfaction - Improve patient experience of care
• Quality - Improving the health of populations
• Cost – Reduction of per capita costs of care

Goals

Outpatient Pulmonary Clinic opened March 2013 Goals of Lung Nodule Clinic

• Easy Access
• Clinical Coordinator to facilitate
• Timely, protocol driven scheduling of testing and procedures
• Timely diagnosis
• Multidisciplinary care team with standardized care

Team

• Pulmonologist(s)
• Cardiothoracic Surgeon
• Nurse Practitioner
• Nurse Navigator/Program Coordinator
• Clinical Support Staff

Pulmonary Lung Nodule Clinic

Overview

• Early identification of lung cancer
• Defined protocols to refer lung nodules above a certain size
• Distinct pathways for care based on nodule size
• Patients identified through imaging, CTs, and by PCPs in the

region educated by the Pulmonologist or Navigator

• High risk patients have a more stringent follow-up procedure
• Guidelines consider cancer’s high/low risk factors
• Multispecialty visits
• Testing ordered prior to visits based on protocols
• Prior review of each case determines need for surgical consult
• Case review by Navigator and physicians

Pulmonary Lung Nodule Clinic

Opened June 2013 Overview

• Echo alert protocols were developed for use by Imaging
• Patients having 1 of 3 criteria for potential heart valve problems, are

referred to the clinic

• Nurse Navigator
• Data mining for patients fitting criteria or risk factors
• Communication with Cardiologist, Cardiothoracic Surgeon & PCP
• Ensured appropriate diagnostic testing is completed
• Guides patient through the process
• Multidisciplinary care team with standardized care
• Tests are reviewed by physicians prior to visits
• Collaborative decision to treat medically or surgically
• If surgery is required, the patient is scheduled prior to leaving the

clinic

Heart Valve Clinic

Challenges and Lessons Learned

• Provider recruitment for inpatient, outpatient, travel
• The correct mix of providers on multi-disciplinary teams
• Importance of communication
• Between providers and departments in caring for patients
• Budgets and staffing to cover additional volumes

Questions and Answers

Project Summation

Tel eleN eNICU ICU

Our Journey

Comm mmun unity ity

Tyler, Texas has a population of 100,000 Trinity Mother Francis Hospital (TMF)delivers over 2,500 babies annually The TMF Level III NICU admits over 500 neonates annually

Par artner nersh ship ip

Program started in September 2013 Collaboration with Dallas Children’s Medical Center University of Texas Southwestern- Division of Neonatology https://www.youtube.com/watch?v=MzYmkhzwq LQ

Cur urrent ent Stat ate

Dozen’s of consultations via TeleNICU resulting in many infants remaining in Tyler, and several reverse transfers. In anticipation of approval of the Medicaid Waiver, we began an Out Patient Pediatric Cardiology Clinic with Dallas Children’s in November of 2011 with the goal of increasing our pediatric Echocardiograms and allow families to have follow care in their home facility, reducing the need to go to Dallas for this service. Echocardiograms increasing both in the NICU and our Pediatric Cardiac clinic.

Fu Futur ure e Stat ate

TeleGenitics Pediatric TelePsychiatry TeleFetal/TeleMFM TeleED TMF as a “hub” for smaller communities