(El Paso) HCA DSRIP - Congestive Heart Failure Clinic ...



CONGESTIVE HEART FAILURE CLINIC

• Identifying Project and Provider Information: Category 2: Expand Chronic Care Management Models; Project Option 2.2.2: Apply evidence-based care management model to patients identified as having high-risk health care needs; 0941090802.2.2; HCA Las Palmas Del Sol (0941090802).

• Project Description: We propose to implement a Chronic Care Management Model relating to patients with Congestive Heart Failure (CHF). The Congestive Heart Failure Initiative will consist of a multi-disciplinary team of expert health professionals to deliver optimal patient care through the utilization of current evidence-based guidelines and the development and implementation of new initiatives to meet service delivery gaps. The multi-disciplinary care team will be composed of physicians, physician extenders, educators, behavioral health professionals, pharmacological advisors, dieticians, nursing staff, and health care navigators. This initiative will also enable the hospital to collaborate with community-based home-health agencies whereby the home-health agencies will provide timely feedback to help the prevention of unnecessary readmissions. The model will also include a Clinical Information System (registry) to structure, organize, and trend patient data for registries, performance measurements, and prevention services. This registry we are considering is called CDEMS and is used by community health centers, primary care practices, rural clinics, hospitals, and quality improvement projects across the United States and in Canada, India, Haiti, and South Africa. This program was developed and is shared by the Washington Diabetes Prevention and Control Program. Using a registry that is widely utilized will better allow our organization to report on patient populations with chronic health conditions. Applications of self-management principles through patient-centered interventions will include education resources, skill training, tele-scales, and psychosocial support. By applying self-management principles, the support will empower and prepare patients to manage their health and healthcare. Finally, this program will commit to the education and training of healthcare professionals to include physicians, nurses, ancillary staff, and community-based partners; such training will provide awareness of the resources available.

o Goals: Utilizing current evidence-based guidelines to create hospital wide standard protocols/pathways for the prevention, detection and management of heart failure will result in healthier patients, decreased readmissions and cost savings. Delivering optimal patient care in line with current evidence-based guidelines to decrease complications and meet delivery gaps related to CHF due to lack of collaborative management and lack of understanding, by the patient. Promoting self-awareness and self-management with the result of improved outcomes and increased continuity of care. Developing a centralized approach to CHF management based upon clinical practice guidelines, which will result in improved overall health for the hypertensive patient.

o Challenges: It will be difficult to notify the public of this available resource. ED discharge and wrap-up of outpatient visits will be the best patient-care opportunities to notify patients with Congestive Heart Failure of this outpatient resource designed specifically for their needs.

• Starting Point/Baseline: Las Palmas Del Sol is using protocols designed by the American Heart Association “Get With the Guidelines” program and CMS core measures that allows for in-house concurrent reviews by Quality management personnel. There is no centralized program that brings these protocols together.

• Rationale:

o The leading cause of death in the United States among all ethnicities is heart disease; it is also a common cause of illness and disability. The principal form of heart disease is coronary heart disease (CHD), also called ischemic heart disease. It is caused by buildup of cholesterol deposits in the coronary arteries that feed the heart. In the U.S. there are about 1.1 million persons who have a heart attack or myocardial infarction every year. According to the Texas Department of Health, in 1999 the death rate in El Paso County due to heart disease was 203.5 per 100,000 population per year, compared to a rate of 272.7 per 100,000 population per year for Texas as a whole. While Hispanics have a CHD death rate that is less than that of the U.S. population as a whole, it is still the number one cause of death among Hispanics. The rate for CHD for the U.S. population as a whole is 216 per 100,000 population per year compared to 151 per 100,000 population per year for Hispanics.

o There are many definitions of “chronic condition,” some more expansive than others. We characterize it as any condition that requires ongoing adjustments by the affected person and interactions with the health care system. The most recent data show that more than 145 million people, or almost half of all Americans, live with a chronic condition. That number is projected to increase by more than one percent per year by 2030, resulting in an estimated chronically ill population of 171 million. Almost half of all people with chronic illness have multiple conditions. As a result, many managed care and integrated delivery systems have taken a great interest in correcting the many deficiencies in current management of diseases such as diabetes, heart disease, depression, asthma and others. Those deficiencies include:

▪ Rushed practitioners not following established practice guidelines

▪ Lack of care coordination

▪ Lack of active follow‐up to ensure the best outcomes

▪ Patients inadequately trained to manage their illnesses

• Related Category 3 Outcome Measure(s): OD-3: Potentially Preventable Re-Admissions—30 day Readmission Rates; IT-3.2: Congestive Heart Failure 30 day readmission rate; (094109802.3.7).

• Relationship to Other Projects: This project is part of LPDS’s larger plans to expand and develop primary care and specialty care services, while improving access to care and containing the costs of care. Specifically, this project will complement LPDS’s Diabetes Management Registry project (094109802.1.3); both of these projects are targeted towards patient populations for whom delivery system reform could result in great improvements in the cost and quality of care, as well as improvements in overall patient population health.

• Relationship to Other Performing Providers’ Projects in the RHP: TBD

• Plan for Learning Collaborative: TBD

• Project Valuation: $7,663,758. The valuation of each LPDS project takes into account the transformational impact of the project, the population served by the project (both number of people and complexity of patient needs), the alignment of the project with community needs, and the magnitude of costs avoided or reduced by the project. In particular, this project has been valued based on the need for these services for this patient population (i.e., congestive heart failure patients), and the possibility of significant cost and quality improvement when the project is implemented.

|094109802.2.2 |2.2.2 |2.2.2.X |Congestive Heart Failure Clinic |

|HCA Las Palmas Del Sol |094109802 |

|Related Category 3 Outcome |094109802.3.7 |IT-3.2 |Congestive Heart Failure 30 day readmission rate |

|Measure(s): | | | |

|Year 2 |Year 3 |Year 4 |Year 5 |

|(10/1/2012 – 9/30/2013) |(10/1/2013 – 9/30/2014) |(10/1/2014 – 9/30/2015) |(10/1/2015 – 9/30/2016) |

|Milestone 1: Establish baseline for metrics P-2.1, |Milestone 2 [P-2]: Train staff in the Chronic |Milestone 6 [I-17]: Apply the Chronic Care Model |Milestone 7 [I-17]: Apply the Chronic Care Model to |

|P-3.1, P-4.1, P-9.1, and I-17.1. |Care Model, including the essential components |to targeted chronic diseases which are prevalent |targeted chronic diseases which are prevalent locally. |

| |of a delivery system that supports high-quality |locally. | |

|Metric 1: Establish baseline for future years. |clinical and chronic disease care. | |Metric 1 [I-17.1]: X additional patients receive care |

| | |Metric 1 [I-17.1]: X additional patients receive |under the Chronic Care Model for a chronic disease or for |

|Milestone 1 Estimated Incentive Payment: $1,874,284|Metric 1 [P-2.1]: Increase percent of staff |care under the Chronic Care Model for a chronic |MCC. |

| |trained. |disease or for MCC. |Baseline/Goal: 10% increase over DY 4. |

| |Baseline/Goal: 10% increase over DY 2 baseline. |Baseline/Goal: 10% increase over DY 2 baseline. |Data Source: Registry. |

| |Data Source: HR; training program materials. |Data Source: Registry. | |

| | | |Milestone 7 Estimated Incentive Payment: $1,694,064 |

| |Milestone 2 Estimated Incentive Payment: |Milestone 6 Estimated Incentive Payment: | |

| |$511,186 |$2,050,687 | |

| | | | |

| |Milestone 3 [P-3]: Develop a comprehensive care | | |

| |management program. | | |

| | | | |

| |Metric 1 [P-3.1]: Documentation of care | | |

| |management program. Best practices such as the | | |

| |Wagner Chronic Care Model and the Institute of | | |

| |Chronic Illness’s Care Assessment Model may be | | |

| |utilized in program development. | | |

| |Baseline/Goal: n/a | | |

| |Data Source: Program materials. | | |

| | | | |

| |Milestone 3 Estimated Incentive Payment: | | |

| |$511,186 | | |

| | | | |

| |Milestone 4 [P-4]: Formalize multi-disciplinary | | |

| |teams, pursuant to the chronic care model | | |

| |defined by the Wagner Chronic Care Model or | | |

| |similar. | | |

| | | | |

| |Metric 1 [P-4.1]: Increase the number of | | |

| |multi-disciplinary teams or number of clinic | | |

| |sites with formalized teams. | | |

| |Baseline/Goal: 1 additional site. | | |

| |Data Source: TBD by provider. | | |

| | | | |

| |Milestone 4 Estimated Incentive Payment: | | |

| |$511,186 | | |

| | | | |

| |Milestone 5 [P-9]: Develop program to identify | | |

| |and manage chronic care patients needing further| | |

| |clinical intervention. | | |

| | | | |

| |Metric 1 [P-9.1]: Increase the number of | | |

| |patients identified as needing screening test, | | |

| |preventative tests, or other clinical services. | | |

| |Baseline/Goal: 10% increase over DY 2 baseline. | | |

| |Data Source: EHR; patient registry. | | |

| | | | |

| |Milestone 5 Estimated Incentive Payment: | | |

| |$511,185 | | |

|Year 2 Estimated Milestone Bundle Amount: |Year 3 Estimated Milestone Bundle Amount: |Year 4 Estimated Milestone Bundle Amount: |Year 5 Estimated Milestone Bundle Amount: $1,694,064 |

|$1,874,284 |$2,044,743 |$2,050,687 | |

|TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD: $7,663,758 |

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