Project Option: 1



Project Option: 1.9.1: A Proposal to Expand Neurology Care to a Multi-site, Geographically Distributed Ambulatory Neurology Network

RHP Performing Provider / TPI: TEXAS TECH HS CTR FAMILY MED /084597603

Unique Project Identifier: 84597603.1.3

Description:

Project Goal: The overall goal of this project is to address a critical lack of access to neurology providers in our region and to address the geographic distribution of these providers to further improve access.

We propose to accomplish this through three initiatives: 1) over DY2-5 we will recruit a significant cohort of physician and non-physician neurology providers, including general and specialty neurologist, to address the immediate access issues; 2) we will expand to a least one additional geographically distinct site better matching provider resources to patient locations, linking these sites and our primary care providers through an electronic referral system and enterprise EMR, and 3) we will establish a neurology residency program as a long term solution to significant provider shortages in the region.

Challenges: Providers within the Region, both private and public, have been aware of the crisis in neurology care for some time and efforts to address this critical provider shortage have been in place for several years. The Performing Provider has had two open neurology positions for two years and has been unsuccessful in recruiting to these positions. We are aware that the two largest private hospitals in the Region have likewise had active, yet unsuccessful, neurology searches ongoing for several years.

We believe there are multiple reasons for the failure of these searches. First, there is not a well defined, integrated vision for neurologic care neither within the community nor within the performing provider’s strategic plan to date. The recruitment of one or two providers in the face of such profound shortages raises questions of future call coverage support and opportunities for professional collaboration, and is very unappealing. The performing provider’s current clinical space is in basement space leased from the state psychiatric facility on our main campus in the Central region. This is exceptionally unattractive to providers as well as patients. We are aware of some resistance from patients to accessing care at this location because of its location within a psychiatric facility.

Finally, we believe the lack of a neurology residency program, and the inability to commit to establishing one, has made the idea of establishing an academic practice in El Paso very unappealing to applicants. We are at a stalemate: Neither the private nor academic settings have been able to address this critical need in our Region.

This project is a bold response to these challenges. We believe that by clearly articulating a programmatic vision that includes the recruitment of significant number of providers AND the establishment of a residency in neurology, we will be able to attract significant interest in these positions. The recruitment of these providers, in turn, begins to address the critical access issues faced by our Region’s low income patients. As we develop a provider infrastructure with some redundancy, we are able to provide services in geographically distinct areas of the Region. In addition, the establishment of the residency program will provide a potential source to train people and nurture them to stay in the area.

Included in the Appendix to this project are multiple letters of support from private and military neurologists in our region, confirming the critical need for these services in our region.

Relationship to Regional Goals: This project is responsive to several of our Regional goals; most clearly to increase the number of specialists and services offered in the community. Also important is ability this program will provide to address chronic diseases such as epilepsy, stroke, and dementia.

Expected 5 year outcome for providers and patients:

At the end of DY5, we anticipate having being able to provide a comprehensive, coordinated care to the spectrum of neurologic disease in the Region, integrating primary and specialty care. Indigent and Medicaid patients will experience significantly improved access to neurological services through the recruitment of a large number of providers and a strategy to provide care in geographically separate areas that mirror our population base, and we will have a fully accredited residency program in place.

Baseline: Neurology care in Region 15 is in a state of crisis. In 2010, the Paso del Norte Foundation sponsored a region wide planning symposium addressing and documenting health care needs in a broad area which includes Region 15 This survey documented that Region 15 is underserved in 18 of the 24 assessed specialties and neurology was identified as one of the top five greatest needs (1). Data from this survey indicated that the counties comprising Region 15 were underserved by 10 neurologists. These data represent a significant underestimate of our current needs. Since that estimate was obtained, two neurologists (both on the full time faculty of the Paul L. Foster School of Medicine) are no longer practicing in the area; and 3) One neurologist, included in the survey as full time, is actually in administrative medicine and his clinical practice is approximately 20%.

Apart from the acute care of patients with stroke, neurology is largely an outpatient practice; however the status of outpatient neurology is equally dismal or worse. Waiting time for a new patient appointment to see a provider in the community is believed to be in the range of 90 days. Paul L. Foster school of Medicine, which provides the bulk of neurologic care to indigent and Medicaid populations, has a single neurologist on the full time faculty. The current time to 3rd available new appointment for this provider is 179 days. There is no neurology residency program at the current time in this Region. We provide care in a single location in the Region, in central El Paso.

More compelling are the demographics of our existing neurology provider base: of the 10 neurologists in the city not associated with the Military or Veterans systems, 5 graduated medical school in 1975 or earlier suggesting that these providers are nearing the ends of their clinical career and will not likely be able to contribute to any increase in clinical availability. Apart from pediatric neurology and one neuro-interventionalist, the region has no neurologist with fellowship training in any of the subspecialty areas such as dementia, movement disorders, epilepsy or vascular neurology. Hospitals in our RHP are either relying on locums coverage or tele-neurology to meet their in-patient neurology needs.

Our project consists of three key components: 1) We propose to recruit a significant cohort of neurologists in both general neurology and subspecialties, and neurology physician extenders to the Region, 2) establish ambulatory neurology practices in at least one additional location to best match the geographic distribution of patients within our region as well as expand our current ambulatory capacity, and 3) we propose to establish a neurology residency program.

Our recruitment plan consists of recruiting a cohort of 9 FTE neurologists and 2 neurology physician extenders over a 4 year period. We will begin with a senior physician to service as a Chair and establish recruitment priorities. We anticipate recruiting both general neurologists, and specialists in areas such as stroke, neurocritical care, epilepsy, movement disorders, rehabilitation, and dementia. This strategy accomplishes two goals: it provides a continuum of care from primary care to neurologist to neurology subspecialist, and back to primary care, all linked by a common EMR, and it provides the necessary faculty resources to support a neurology residency program.

The existing provider population, including the Performing Provider, is heavily distributed in the central area of El Paso. Geographically, the population of our region is divided in three distinct areas, separated by the Franklin Mountains which split El Paso into the west, central and east areas, with the east representing the faster growth rate. This results in long distances and difficult access conditions, particularly for those who depend on public transportation.

As a solution to this challenge, we propose to establish ambulatory outpatient neurology services to at least one additional site within our Region over the 4 year demonstration project and evaluate the feasibility of a 3rd distinct site. The planning process will include a needs assessment, evaluation of current patient demographics, review of potential ambulatory sites and a feasibility study of including ancillary testing such as EMG and EEG in this site. Once the first site is established, we will begin an evaluation process for a 3rd geographically distinct site.

We intend to establish a neurology residency program. The need for additional residency slots is critical. Nationally in 2012, only 346 categorical neurology slots were offered. This actually represents a decline of 13% over 5 years in the number of slots offered. However fill rates for slots have averaged 95% over this same time period, so there is every reason to believe that opening additional residency positions will lead to an increase in neurologists (1). Since most West Texas medical residents stay within a 75 mile radius of their training site to set up practice (2), a neurology residency represents the single best way to address, in a sustainable manner, the provider base necessary to meet our region’s needs, and also addresses a core reason for the failure of multiple neurology searches to date in the Region by both academic and private providers.

The process of establishing a residency de novo is a 2.5 to 3 year process, and requires the expenditure of substantial resources in planning educational needs, establishing affiliations, recruitment of faculty, review and approval of the residency plan by national accrediting organizations PRIOR to the being able to recruit and accept trainees into the residency. As such, it is a logical and appropriate project for funding intended to transform the care delivery system.

The third goal of this project is to reduce the average time to third available new appointment to 60 days or less. Given the current wait time of 179 days, this represents a profound improvement. We are hopeful that the full funding and implementation of this DSRIP project will result in even shorter wait times, however given the current wait times and provider shortages, it is impossible to measure the unmet demand in our population.

In the face of a geographically distributed provider base, electronic means of communication are critical to achieving efficiencies in the referral process and return to the primary care provider. As part of the infrastructure development for this project, we will investigate, deploy and utilize an electronic referral system between primary care providers and neurology within the enterprise.

The Performing Provider is the single largest multi-specialty provider group in the Region, and the largest providers of primary and specialty care within the Region. Paul L. Foster School of Medicine, part of the Texas Tech Health Sciences Center, provides nearly 250,000 outpatient visits a year. Unfunded and low income patients rely heavily on our services. Thirty-seven percent of CDC's Behavioral Risk Factor Surveillance System respondents from El Paso, the predominant population center in our region, report no health insurance, compared to a nationwide rate of 15.1%. In the Performing Provider’s outpatient setting, approximately 35% of our patient visits have no third party funding and an additional 35% have Medicaid or Medicaid like coverage. Given the profound shortage of neurology providers in the region, it is highly unlikely that this vulnerable population will have access to these services apart from this project. The development of neurology services within the Performing Provider represents the best opportunity to integrate care management, primary care and necessary consultative services through a single provider referral network and EMR to meet well documented needs of our unfunded and Medicaid patient base.

In support of this, we will engage in a process of regular interaction and feedback across our enterprise and the RHP. In DY 1 and 2, our milestones reflect the recruitment of neurology providers and the planning for an electronic referral system. Consequently, we will engage clinical affairs, finance, providers, and information technology in this effort. Subsequent DY’s will engage the Office of Graduate Medical Education in support of establishing the residency program. We will participate in learning initiatives sponsored by the RHP in DY2-5.

Rationale:

Project Components: We chose project option 1.9.3 “Other” project option as the best fit for this project. Our strategy combines options 1.9.1 (a-c) and 1.9.2. (b,c,d):

a) Identify high impact/most impacted specialty services and gaps in care and coordination

b) Increase the number of residents/trainees choosing targeted shortage specialties

c) Design workforce enhancement initiatives to support access to specialty providers in underserved markets and areas (recruitment and retention)

d) Increase number of specialty clinic locations

e) Implement transparent, standardized referrals across the system

f) Conduct quality improvement for project

We have already identifies neurology as a representing a high impact provider shortage issue, proposed substantial recruitment of these specialists to the Region, and an increase in training of residents through the establishment of a training program. The project also contains substantial elements of 1.9.2 including an enhanced referral system and multiple clinic locations. We anticipate the quality improvement component will be accomplished in at least monthly meetings with providers, school leadership, EMR, IT and finance as this highly integrated project is rolled out.

The metrics we have chosen for our milestones reflect specific steps required to accomplish these ambitious goals; the most important of which is the recruitment of a large number of providers needed in the region as documented by the needs assessment. Additionally, the roll out of an electronic referral system requires tight integration between the providers, IT and EMR, and these metric reflect those steps.

Community Need: This project reflects CN.2: improving access to secondary and specialty care within the region.

How does this project reflect a new initiative or a significantly enhances an existing initiative. This is a new initiative for the performing provider. As noted above, a neurology residency, a large cohort of neurology providers, and the provision of care in geographically distinct areas have never been contemplated by the Performing Provider prior to this waiver opportunity.

Related Category 3 Outcomes

We propose the following Category 3 outcomes to support this project:

OD-11 Addressing Health Care Disparities in Minority Populations:

• IT-11.1 Improvement in Clinical Indicator in identified disparity group: We propose to utilize a metric which reflects a decrease in the rate of reoccurrence of seizures in a Hispanic population with epilepsy followed in our neurology program .

Relationship to Other Projects and Measures:

This project has potential relationships to two other projects proposed by the Performing Provider:

84597603.2.1 - The establishment of a Medical Home in the Department of Family Medicine ambulatory program. The linking of primary and specialty care, inherent in the design of a medical home, is essential to the appropriate, timely, and cost effective delivery of care. Since many of these patients are likely to have chronic illnesses, the establishment of a primary care team, linked by a common EMR, will optimize care.

84597603.1.2 - The Establishment of a Disease Management Registry. and The Disease Management Registry program proposes to focus initially on Diabetes which is disproportionally present in our population. Nonetheless, the infrastructure and capabilities being developed with the establishment of a Disease Management Registry are easily adaptable to chronic conditions commonly seen in a neurology practice such as stroke, Parkinson’s disease, epilepsy and dementia.

Relationship to Other Providers’ Projects in the RHP: A number of our Regional partners are creating discharge navigation programs. We anticipate interacting with these providers to facilitate the smooth transition of patients with neurological disease to the outpatient setting.

Plan for Learning Collaborative: We will participate in the Region’s learning collaborative.

Project Valuation: The Performing Provider considered a series of factors in establishing a valuation for each project. These included the amount of human resources required to meet the milestones of the project, through new hires as well as the assignment of existing support personnel such as Information Technology, EMR and administrative support. We considered what non personnel resources would be required, such as equipment specialized for a certain specialty, and what, if any, additional space would be required to house the initiative. We considered timing issues related to when we had to add resources compared to when a corresponding milestone could be achieved. We also considered the amounts of potential professional fee revenues the project may generate, and offset these against resource demands.

We made a risk assessment for each project, considering the complexity, the scope, the extent to which any single point failure in the milestones would jeopardize downstream success, the degree of inter-dependence on other projects within the waiver program as well as institutional initiatives outside the waiver, and the amount of time required to manage the project. We made an assessment of potential general community benefit.

Finally, we considered organizational priorities, and to what extent the Performing Provider was able to justify partial support of these efforts as meeting existing institutional requirements or objectives.

1. Paso del Norte Blue Ribbon Committee for a Strategic Health Framework. Phase One: Needs Assessment Report. March 24, 2011. On File.

2. National Resident Matching Program, Results and Data: 2012 Main Residency Match. National Resident Matching Program, Washington, DC. 2012.

3. Texas Tech University Health Sciences Center Factbook. Sixteenth ed December 2008.

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