REGIONAL HEALTHCARE PARTNERSHIP

Texas Healthcare Transformation and Quality

Improvement Program

REGIONAL HEALTHCARE PARTNERSHIP (RHP) PLAN

Plan Modification Request - New 3-Year Projects

RHP #5/South Texas

RHP Lead Contact: Eddie Olivarez Chief Administrative Officer Hidalgo County Health & Human Services 1304 S. 25th Avenue Edinburg, TX 78542 956-383-8858 [email protected]

RHP Plan for [RHP 5/South Texas] 1

mailto:[email protected]

Table of Contents Instructions ............................................................................................................................................. 1

Section I. RHP Organization .............................................................................................................. 2

Section II. Stakeholder Engagement .............................................................................................. 5 A. RHP Participants Engagement ............................................................................................................ 5 B. Public Engagement ................................................................................................................................. 5

Section III. DSRIP Projects ................................................................................................................. 7 Category 1: Infrastructure Development and Category 2: Program Innovation and Redesign ............................................................................................................................................................... 7 C. Category 3: Quality Improvements ............................................................................................... 24 D. Category 4: Population-Focused Improvements Hospitals only ...................................... 283

Section IV. RHP Participation Certifications .......................................................................... 304


Instructions Supporting Documents: RHPs shall refer to Attachment I (RHP Planning Protocol, including updated Category 1 and 2 RHP Planning Protocol for 3-year projects), and Attachment J (RHP Program Funding and Mechanics Protocol), as guides to complete the sections that follow. This plan must comport with the two protocols and fulfill the requirements of the checklist. Timeline: HHSC Receipt Deadline What to submit How to submit 5:00 pm Central Time, December 20, 2013

New 3-year projects and workbooks Mail to address below

All submissions will be date and time stamped when received. It is the RHP’s responsibiility to appropriately mark and deliver the proposed new 3-year projects to HHSC by the specified date and time. Submission Requirements: New project narratives in Microsoft Word format, milestone and metric table (Excel file) for each project, new provider information in Microsoft Word format and certifications as a PDF file must be submitted to be considered for new 3-year projects. Providers shall submit individual files for each project to their Anchor to compile into one submission packet. You must adhere to the page limits specified in each section using a minimum 12 point font for narrative or the RHP Plan will be immediately returned. Mailed Submissions: All files should be submitted electronically on one CD or one USB drive along with one hard copy of each project (do not include hardbound copies of the workbook).

Please mail RHP Plan packets to:

Sandra Frazier, MC - H425 Texas Health and Human Services Commission Healthcare Transformation Waiver Operations

4900 N. Lamar Blvd.Austin, Texas 78751 Communication: HHSC will contact the RHP Lead Contact with any questions or concerns. IGT Entities and Performing Providers will also be contacted in reference to their specific Delivery System Reform Incentive Payment (DSRIP) projects.


Section I. RHP Organization This section to be filled out by new participating entities only (i.e. entities not already included in the table submitted with the original RHP Plan submission in December 2012). This may include entities that have joined the RHP since the December 2012 submission and now, such as a new Intergovernmental (IGT) Entity that agreed to fund a project in August 2013. Please list the participants in your RHP by type of participant: IGT Entity or Performing Provider including the name of the organization, lead representative, and the contact information for the lead representative (address, email, phone number). The lead representative is HHSC’s single point of contact regarding the entity’s participation in the plan. Please provide accurate information, particularly TPI, TIN, and ownership type, otherwise there may be delays in your payments. Add additional rows as needed.

RHP Participant Type

Texas Provider Identifier (TPI)

Texas Identification Number (TIN)

Ownership Type (state owned, non-state public, private)

Organization Name

Lead Representative

Lead Representative Contact Information (address, email, phone number)

IGT Entities (specify type of government entity, e.g. county, hospital district)

County 17460004207005 Public Cameron County via the Local Provider Participation Fund

Yvette Salinas, Health Administrator

Cameron County Department of Health and Human Services Administrative Office 1390 W. Expressway 83 San Benito, TX 78586 Phone (956) 247-3685

County 17460007170060 Non-state public

Hidalgo County

Eddie Olivarez 1304 South 25th Avenue Edinburg, Texas 78542 [email protected] 956-383-8858







Organization Name

Lead Representative


UT Health Science Center

111810101 760459500 State-owned UT Health Science Center- Houston

Joseph B McCormick, MD, MS

80 Fort Brown St Brownsville, TX 78520 [email protected] 956-882-5152

Performing Providers (specify type of provider, e.g. public or private hospital, children’s hospital, CMHC, that will receive DSRIP payments under the RHP plan, some of which may also receive UC)

Private Hospital 020947001 16216695722501 Private Valley Regional Medical Center

Susan Andrews / Marcia Patterson

100-A East Alton Gloor Blvd., Brownsville, TX 78526 [email protected] 956-350-7106

Private Hospital 112716902 16216560223003 Private Rio Grande Regional Hospital

Cris Rivera / Chuck Mallon

101 E. Ridge Rd., McAllen, TX 78503 [email protected] 956-632-6000









Organization Name

Lead Representative


Private Hospital 154504801 15621435187000 Private Harlingen Medical Center

Deborah Meeks, Chief Nursing Officer

5501 S. Expressway 77, Harlingen, Texas 78550 [email protected] 956-365-1013

UT Health Science Center

111810101 760459500 State-owned UT Health Science Center- Houston

Joseph B McCormick, MD, MS

80 Fort Brown St Brownsville, TX 78520 [email protected] 956-882-5152

Private Hospital 94113001 12330692604501 Private McAllen Hospitals LP dba South Texas Health Systems

Lorenzo Olivarez Jr.

1400 W. Trenton Edinburg, TX 78539 (956) 388-2126 [email protected]

Private Hospital 135035706 17413930607324 Private Knapp Medical Center

Dinah Gonzalez, Administrator and CFO

P O Box 1110 Weslaco, Texas 78596 [email protected] 956-969-5112





Section II. Stakeholder Engagement

A. RHP Participants Engagement Hidalgo County, RHP 5 Anchor, keeps communication with all DSRIP providers, UC providers, and stakeholders regularly by email, providing 1115 Waiver updates, upcoming deadlines, and communication from HHSC/CMS. Hidalgo County has provided the performing providers and hospitals all information HHSC has sent regarding the opportunity to propose 3-year projects to be added and included in the RHP plan. RHP 5 proposed a total of forty-six 3-year projects. The 3-year projects are proposed by nine providers, which include three returning providers and six new providers. There are a total of six hospitals, two physician practices affiliated with an Academic Health Science Center, and one mental health center. RHP 5 evaluated and prioritized the proposed 3-year projects based on regional needs. RHP 5 had a total of six evaluators who were responsible for evaluating and ranking the proposed 3-year projects based on regional/community needs. Since RHP 5 did not have a variety of IGT entities, RHP 5 ranked the projects based on the average final score and did not alternate projects by IGT entity.

B. Public Engagement RHP 5 utilized a similar evaluating template as RHP 1 & RHP 20 and a project narrative template as RHP 20. Region 5 Anchor requested that all providers proposing 3-year projects submit project narratives by October 11, 2013 to allow enough time for the evaluators (6 volunteers) to review all projects. Once all project narratives were submitted to the Anchor, the information along with the scoring template were emailed to the 6 evaluators for review. Once the review was finalized and submitted to the RHP Anchor by each evaluator, the Anchor took the average of each review (per project) to come up with the final score for each project. The proposed 3-year projects did not have a variety of IGT providers; therefore, the Anchor was unable to alternate projects by IGT entity. The Anchor prioritized the list in accordance with the Project Score, and with the available funding in RHP 5 all proposed projects would be able to be funded, pending HHSC/CMS project approval. RHP 5 Anchor keeps communication with all DSRIP providers, UC providers, and stakeholders regularly, providing 1115 Waiver updates, upcoming deadlines, and communication from HHSC/CMS. During one of our semi-annual meetings that took place on September 12, 2013 - RHP 5 Anchor reminded the providers/hospitals that the deadline to submit the proposed projects (prioritized list) was approaching. Once the Anchor created the project summary template and HHSC sent the prioritized list spreadsheet; the RHP Anchor sent out an email requesting that all providers submitting 3-year projects submit project information in both


templates for evaluation and review. Once the Anchor determined the deadline for project summary submission was on October 11, 2013; RHP 5 held two public hearings on October 22, 2013 in Hidalgo County Commissioners' Court and on October 24, 2013 in Cameron County Commissioners' Court for public comment on the proposed 3-year projects. The public hearing notice was sent out to the performing providers and hospitals by email and was available on the Hidalgo County website along with the proposed 3-year projects.


Section III. DSRIP Projects Category 1: Infrastructure Development and Category 2: Program Innovation and Redesign


THREE-YEAR DSRIP PROJECT SUMMARY RHP 05

Unique Project Identifier: 020947001.2.100 Provider Name/TPI: Columbia Valley Healthcare System, L.P. d/b/a Valley Regional Medical

Center / 020947001 Brief Project Description 2.12.2 – Implement Care Transitions Programs – Focused on Chronic Disease Management of Diabetes - Valley Regional Medical Center (Valley Regional) intends to implement a program to facilitate the transition of care for patients with diabetes, which will implement a discharge planning program and post-discharge support program. Establishing self-management and wellness programs for our targeted population will provide the best opportunity for positive results and ongoing outcomes. This project can focus on the development of pilot interventions to improve patient care using tactics such as:

• Discharge checklists • “Hand off” communication plans with receiving providers in the community • Wellness initiatives targeting high‐risk patients • Patient and family education initiatives including patient self‐management skills and

“teach‐back” • Post‐discharge medication planning

Description of Intervention Valley Regional will focus on preventing readmissions for diabetes patients. Under the program, a nurse practitioner and certified diabetes educator will facilitate an interdisciplinary collaboration to transition patients from hospital to home self-care. The nurse practitioner will facilitate the intervention from discharge through the month following discharge by identifying and meeting with the patient, and conducting a follow-up visit post-discharge. In addition, the nurse practitioner will conduct 3 follow-up calls. This project will be comprised of the following milestones:

• P‐3: Establish a process for hospital‐based case managers to follow up with identified patients hospitalized related to diabetes to provide standardized discharge instructions and patient education, which address activity, diet, medications, follow‐up care, weight, and worsening symptoms; and, where appropriate, additional patient education and/or coaching as identified during discharge;

• P-11: Review project data and respond to it every week with tests of new ideas, practices, tools, or solutions. This data should be collected with simple, interim measurement systems, and should be based on self-reported data and sampling that is sufficient for the purposes of improvement; and

• I‐11: Improve the percentage of diabetic patients receiving standardized care according to the approved clinical protocols and care transitions policies.

o Total patient impact: 12,000 patient encounters; Medicaid and Uninsured patient impact: 4,000 patient encounters.


Need for the project The RHP 5 plan notes diabetes and obesity as its first “key health challenge.” (RHP 5 Plan, Page 7). The plan cites diabetes and obesity as the third leading cause of mortality in this region behind heart disease and cancer, and an underlying component of over half of hospital admissions for heart attack, hypertension, sepsis and stroke. (RHP Plan, Page 29-30). Two community needs identified in the RHP 5 plan include the inadequate integration of care and the lack of patient-centered care. (CN3 and CN4). This project will attempt to target a more patient centered model and integrate care and address one of the biggest health challenges in the region. Target population Valley Regional expects to have a large impact on the Medicaid and uninsured population in the region. Currently, Valley Regional serves an overall patient population that is 47% Medicaid eligible or uninsured. Valley Regional expects this project’s impact to be at least 30% for the Medicaid and uninsured inpatient diabetic population at Valley Regional.

Category 1 or 2 expected patient benefits Valley Regional expects to implement a diabetes-targeted Care Transition program over the course of the Waiver in order to improve patient outcomes through a more comprehensive approach to diabetes care. Valley Regional expects this program to help facilitate a higher rate of controlled diabetes among community members with this chronic disease. Valley Regional intends to provide 3000 patient encounters in DY3, 4,000 patient encounters in DY4, and 5,000 patient encounters in DY5 for a total intervention of 12,000 patient encounters in DY3-DY5.

Category 3 outcomes expected patient benefits IT‐1.10 Diabetes care: HbA1c poor control (>9.0%) 233‐ NQF 0059 (Standalone measure) –helping patients control their blood sugar levels. Valley Regional aims to improve the percentage of patients in Cameron County with uncontrolled blood sugar levels by educating the diabetic community on diabetes medication and diet management tactics, leading to better control of diabetic conditions. Patient education, follow-up, and management will result in better overall health outcomes for the targeted population, including increased quality of life, reduced use of acute care, and slower progression of this chronic disease. Achieving this outcome will require Valley Regional to not only communicate with the target population, but to affect their lifestyle choices. Patients will need to reduce poor eating habits, increase physical activity, and manage their medications (when applicable), which Valley Regional cannot force patients to do on a regular basis. Valley Regional intends to reach out to the community through innovative methods (including social media, creating coalitions, and other methods of community outreach) to create support networks and community engagement in accomplishing this outcome, which is meant to benefit individuals at-risk and the community as a whole.


Project Narrative

• Identifying Project and Provider Information:

• Title of Project: Implement Care Transitions Programs – Focused on Chronic Disease Management of Diabetes

• Unique RHP project identification number: 020947001.2.100

• Performing Provider name/TPI: Columbia Valley Healthcare System, L.P. d/b/a Valley Regional Medical Center (Valley Regional) / 020947001

• Project Option: 2.12.2

• Project Description:

• Overview of Project: Valley Regional intends to implement a program to facilitate the transition of care for patients with diabetes, including implementing a discharge planning program and post-discharge support program. Establishing self-management and wellness programs for our targeted population will provide the best opportunity for positive results and ongoing outcomes. Valley Regional will focus on preventing readmissions for diabetes patients. Under the program, a nurse practitioner and certified diabetes educator will facilitate an interdisciplinary collaboration to transition patients from hospital to home self-care. The nurse practitioner will facilitate the intervention from discharge through the month following discharge by identifying and meeting with the patient, and conducting a follow-up visit post-discharge. In addition, the nurse practitioner will conduct 3 follow-up calls.

• Project Goals: This project will focus on the development of pilot interventions to improve patient care using tactics such as: Discharge checklists “Hand off” communication plans with receiving providers in the community Wellness initiatives targeting high-risk patients Patient and family education initiatives including patient self-management skills

and “teach-back” Post-discharge medication planning

This project aims to reach the vast majority of diabetics treated at Valley Regional. Specifically, Valley Regional aims to achieve 12,000 patient encounters over the three years of this project.

• Challenges or issues faced by the Performing Provider: Valley Regional has a high readmission rate for patients with diabetes because diabetic patients and families can


be resistant to dietary restrictions and exercise and sometimes have difficulty complying with consistent blood-sugar monitoring.

• How the project addresses those challenges: This project implements new interventions to transition care to diabetics treated at Valley Regional. Valley Regional will conduct direct patient follow-up to help patients avoid common causes of readmission such as inadequate medication management, diet, or other lifestyle concerns.

• 3-year expected outcome for Performing Provider and patients: Valley Regional expects to impact 12,000 patient encounters (30% of those Medicaid or uninsured) with this project.

• How the project is related to the regional goals: The RHP 5 plan notes diabetes and obesity as its first “key health challenge.” (RHP 5 Plan, Page 7). The RHP plan cites diabetes and obesity as the third leading cause of mortality in this region behind heart disease and cancer, and an underlying component of over half of hospital admissions for heart attack, hypertension, sepsis and stroke. (RHP Plan, Page 29-30). Two community needs identified in the RHP 5 plan include the inadequate integration of care and the lack of patient-centered care. (CN3 and CN4).

• Specialty care information (for projects from project option 1.9): Not Applicable

• Starting Point/Baseline: Valley Regional has not established a baseline because this is a new

initiative. We anticipate 3,000 patient encounters in the first year.

• Quantifiable Patient Impact: Valley Regional will measure the number of patient encounters of individuals receiving care according to the care transition guidelines / protocol. Valley Regional intends to provide 3000 patient encounters in DY3, 4,000 patient encounters in DY4, and 5,000 patient encounters in DY5 for a total intervention of 12,000 patient encounters in DY3-DY5. Of those encounters, Valley Regional expects 30% of the encounters to be with Medicaid and uninsured patients.

• Rationale: Valley Regional faces substantial challenges from patients who are not sufficiently able to manage diabetes-related complications to avoid readmission or other health complications. Without sufficient information and an understanding of their diagnoses, medication, and self-care needs, patients cannot fully participate in their care during and after hospital stays. Additionally, insufficient discharge processes create unnecessary stress for medical staff, reducing their effectiveness. A comprehensive and reliable discharge plan, along with post-discharge support, can reduce readmission rates, improve health outcomes, and ensure quality transitions. The RHP 5 plan notes diabetes and obesity as its first “key health challenge.” (RHP 5 Plan, Page 7). The plan cites diabetes and obesity as the third leading cause of mortality in this region behind heart disease and cancer, and an underlying component of over half of hospital


admissions for heart attack, hypertension, sepsis and stroke. (RHP Plan, Page 29-30). Two community needs identified in the RHP 5 plan include the inadequate integration of care and the lack of patient-centered care. (CN3 and CN4). This project will attempt to target a more patient centered model and integrate care and address one of the biggest health challenges in the region. This is a new project for Valley Regional. Valley Regional selected the following three milestones:

o P-3: Establish a process for hospital-based case managers to follow up with identified patients hospitalized related to diabetes to provide standardized discharge instructions and patient education, which address activity, diet, medications, follow-up care, weight, and worsening symptoms; and, where appropriate, additional patient education and/or coaching as identified during discharge;

o P-11. Milestone: Review project data and respond to it every week with tests of new ideas, practices, tools, or solutions. This data should be collected with simple, interim measurement systems, and should be based on self-reported data and sampling that is sufficient for the purposes of improvement; and

o I-11: Improve the percentage of diabetic patients receiving standardized care according to the approved clinical protocols and care transitions policies.

Valley Regional selected these milestones because they most closely align with the hospital’s potential to develop a meaningful intervention and demonstrate improvement through operationalizing that intervention.

• Project Core Components:

o Valley Regional will accomplish the CQI core components by reviewing project data and responding to it every week with tests of new ideas, practices, tools, or solutions, which will collect data with simple, interim measurement systems, and based on self-reported data and sampling that is sufficient for the purposes of improvement.

o Additionally, Valley Regional will internally evaluate the success or failure of each

project at each reporting opportunity to evaluate what improvements can make the project more effective.

• Customizable Process or Improvement Milestones: None

• Related Category 3 Outcome Measure(s): IT-1.10 Diabetes care: HbA1c poor control (>9.0%)

233- NQF 0059 (Standalone measure) –helping patients control their blood sugar levels. Since diabetes-related complications are a substantial issue for this region, this outcome matches the intent of the project and an important area where this region could show improvement. Valley Regional has not established a baseline for this measure yet, but 26% of Rio Grande Valley residents currently suffer from diabetes, indicating there is a substantial need for providers to


focus on these issues. By helping diabetics manage their own care when transitioning out of the hospital, Valley Regional expects to reduce the incidence of diabetes related complications related to poor blood glucose control. Valley Regional aims to improve the percentage of patients in Cameron County with uncontrolled blood sugar levels by educating the diabetic community on diabetes medication and diet management tactics, leading to better control of diabetic conditions. Patient education, follow-up, and management will result in better overall health outcomes for the targeted population, including increased quality of life, reduced use of acute care, and slower progression of this chronic disease. Achieving this outcome will require Valley Regional to not only communicate with the target population, but to affect their lifestyle choices. Patients will need to reduce poor eating habits, increase physical activity, and manage their medications (when applicable), which Valley Regional cannot force patients to do on a regular basis. Valley Regional intends to reach out to the community through innovative methods (including social media, creating coalitions, and other methods of community outreach) to create support networks and community engagement in accomplishing this outcome, which is meant to benefit individuals at-risk and the community as a whole.

• Relationship to other Projects (including Other Performing Providers’ Projects in the RHP):

Diabetes and diabetes related complications are one of the key health challenges in this region, leading some other providers to submit projects that touched on diabetes related issues. However, only two current projects in the region address diabetes issues: one project for a region-wide disease registry and one for gestational diabetes. Only one other proposed 3-year project addresses care transitions for diabetics, but it is focused on mental health services in Hidalgo County. This project is distinct and addresses a key health need in this part of the region and is the only similar project planned for Cameron County.

• Plan for Learning Collaborative: Valley Regional looks forward to participating in RHP 5’s learning collaborative once the Anchor develops specific plans for this region’s meetings. For this project, the reduction in diabetes-related complications should lead to substantial benefits across the region. This is one of the region’s highest health priorities and many providers are implementing projects aimed at reducing the number of patients with diabetes and reducing the complications of that disease. A regional learning collaborative should focus on determining the most effective means of implementing change with this region’s diabetic population.

• Project Valuation: Valley Regional valued this project at $4,000,000 over the 3 remaining years of the Waiver. This value is based on the substantial projected patient impact, particularly to the Medicaid and uninsured patients. This project expects to have 12,000 total patient encounters and 4,000 encounters with Medicaid and uninsured patients over the duration of the project. This project meets a key community need concerning diabetes-related illnesses. This is a large scale project that should reduce long-term costs by helping patients better adjust to their own management of their diabetes-related conditions and reduce some need for additional treatment.


Tropical Texas Behavioral Health (TTBH) Three Year Projects – Category 1: • Tropical Texas Behavioral Health • Enhance service availability of appropriate levels of behavioral health care • 138708601.1.100 Provider: A brief description of the provider, including the provider’s size and role as a provider in the region’s health care infrastructure.

Tropical Texas Behavioral Health (TTBH) is the Local Mental Health Authority (LMHA) serving Cameron, Hidalgo and Willacy counties in South Texas; a 3,100 square mile area with a population of approximately 1.2 million. In FY 2011, TTBH served more than 23,000 unduplicated individuals.

Intervention(s): Clearly state the intervention(s). This project will fund the acquisition and operation of two mobile clinics to provide access to comprehensive behavioral health care to families living in the many colonias and other outlying areas in Hidalgo, Cameron and Willacy counties. The project will enable more individuals to receive routine mental health services by bringing clinical staff to residents of remote areas, in person and via telemedicine, when traveling to our clinics is an extreme hardship.

Need for the project: A brief description of the need for the project including data as appropriate.

Some of the greatest needs in the Rio Grande Valley (RGV) for assistance with transportation to access basic services and necessities are in the colonias spread throughout Hidalgo, Cameron and Willacy Counties. In 2009, of the more than 2,294 colonias located primarily along the Texas border with Mexico and the 400,000 people living in them, 1,128 were located in the RGV, with a population of 207,198. The mobile clinics will address this need by delivering BH services to the elderly and impoverished residents of the colonias.

Target population: The number of people that will be served by the project and percent that are expected to be Medicaid/low-income uninsured individuals.

By Demonstration Year 5, the mobile BH clinics will serve at least 120 unique individuals and deliver at least 405 service encounters in these outlying areas. As the population that will benefit most from this intervention will largely be the residents of the colonias, we estimate only 25% of persons served will be Medicaid eligible and 70% or more will be very low-income uninsured.

Category 1 or 2 expected patient benefit and description of the Quantifiable Patient Impact (QPI) metric(s): Clearly state the expected benefit of the project to patients based on Category 1 or 2 milestones.

The project will deliver necessary routine behavioral health services to individuals with extreme difficulty accessing services prior to its implementation. At least 70 unique individuals will be served and 135 service encounters completed in DY 3; Ninety (90) individuals served and 270 encounters will be completed in DY 4; and at least 120 unique individuals will be served and 405 service encounters completed in DY 5.

Description of Category 3 measure(s): IT-11.27.d: Adult Needs and Strengths Assessment (ANSA)


The ANSA is an effective multi-purpose assessment tool that supports care planning and level of care decision-making for adults with behavioral health (mental health or substance use) challenges, facilitates quality improvement initiatives, and allows for the monitoring of service outcomes. Beginning in September 2013, the Texas Department of State Health Services (DSHS) replaced the Texas Recommended Assessment Guidelines (TRAG) with the ANSA as the instrument used to conduct uniform assessments of individuals seeking behavioral health care through the DSHS system.


Identifying Project and Provider Information: 1.12 Enhance Service Availability of Appropriate Levels of Behavioral Health Care Unique RHP Project identification number: 138708601.1.100 Performing Provider/TPI: Tropical Texas Behavioral Health/138708601 Project Option 1.12.3 Develop and staff a number of mobile clinics that can provide access to care in very remote, inaccessible, or impoverished areas of Texas. Project Description: This project will enhance the availability of appropriate levels of behavioral health care through the operation of two mobile behavioral health clinics to provide access to care in remote areas across the Rio Grande Valley (RGV). The delivery of comprehensive behavioral health services delivered by mobile clinic will be prioritized for individuals and families living in the numerous colonias and other outlying areas in Hidalgo, Willacy and Cameron Counties. This will increase the number of people in need who will be able to benefit from routine and preventive mental health care by bringing treatment teams to residents in remote areas of the RGV, for whom travelling to our clinics is a significant hardship. TTBH will purchase, equip and staff two customized recreational vehicles, one to serve Hidalgo County and the other Cameron and Willacy Counties, to deliver behavioral health services to our clients residing in colonias located throughout our service area. Each mobile unit will be staffed by a treatment team consisting of a Licensed Practitioner of the Healing Arts (LPHA) and a Qualified Mental Health Professional of Community Services (QMHP-CS) to deliver services including screening and intake assessments, case management, cognitive behavioral therapy, psychosocial rehabilitative and skills training services and medication training and support services. The mobile clinics will also be equipped with telemedicine technology to allow for the delivery of Physician services. Project goals:

• Put two fully staffed mobile behavioral health clinics into operation in the RGV by the end of DY 3.

• Increase the frequency of early screening for behavioral health risks among low income and uninsured populations.

• Improve access to behavioral health services for residents of the colonias, a historically marginalized and undertreated segment of the population.

• Increase the number of unique individuals receiving routine behavioral health services from our mobile clinics annually and to at least 120 by DY 5.

• Increase the number of behavioral health service encounters delivered from our mobile clinics annually and to at least 405 by DY 5.

• Increase the percentage of persons served by the mobile clinics who report satisfaction with improved access to care to at least 80% by DY 5.

The project meets the following regional goals:

• Increase access to behavioral health services by expanding mental health workforce capacity to help prevent admission/readmission to inpatient psychiatric care.

• Increase access to primary and specialty care services in the short-term, with a focus on individuals with chronic conditions, to ensure they have access to the most appropriate care for their condition, regardless of where they live or their ability to pay.


• Increase the capacity of safety net providers in the region to provide patient-centered care and care management, particularly for patients with chronic conditions, to improve health literacy, self-care management skills, and more effectively access or navigate the health care system appropriately.

Challenges:

• As this intervention will initiated using only two mobile units staffed by two clinical professionals, the primary challenge we face will be determining which areas to target for these services given the large number of colonias and their distribution across our 3,100 square mile catchment area.

• Recruitment and retention of the clinical professionals to staff the mobile clinics. Addressed by:

• We will develop a strategy for prioritizing the areas to be served and the schedule for deploying the mobile clinics. This will likely be based on an analysis of data that considers factors including proximity of the colonias to our clinics and to one another, population concentrations within the colonias and any correlations between geographic location and rates of no-shows or case closures for individuals who do not return for services.

• Staff recruitment and retention challenges will be addressed using existing strategies including: o Competitive hiring and salary structure based on years of experience o Structured career ladder advancement opportunities for each position o Productivity incentive opportunities o Tuition reimbursement opportunities o Re-location reimbursement o Opportunities for training and education to enhance staff competencies and promote

professional development. 3-Year Expected Outcome for Provider and Patients: Our mobile behavioral health clinic project will achieve the delivery of necessary routine behavioral health services to low-income persons in the colonias who, due to the effects of financial hardship and isolation, had more difficulty than most accessing services prior to its implementation. The clinics will allow us to increase outreach in these areas and improve our ability to identify persons in need of assessment for previously undiagnosed conditions. In doing so, we will be able to contact more people who may otherwise have delayed or foregone treatment due to real barriers to accessing care. Contacts by the staff of the mobile clinics are also likely to identify individuals in need of referral to TTBH for primary care services and will facilitate linkage to scheduled transportation services for low-income uninsured clients being implemented as part of our comprehensive expansion of behavioral health services already in process. We will increase the number of unique persons receiving behavioral health services through the mobile clinics from at least 70 in DY 3, to at least 90 in DY 4 and at least 120 by the end of DY 5. We will also increase the number of behavioral health service encounters delivered from the mobile clinics from 135 in DY 3, to 270 in DY 4 and 405 by the end of DY 5. The project will increase access to the right care at the right time in the right setting; increase utilization of routine behavioral health services; and decrease the need for costly and potentially repetitive emergency interventions. Using a validated


standardized outcome measure we expect to show that receipt of routine behavioral health care at clinically indicated frequencies will result in significant improvements in functioning, quality of life and the experience of care for those served by the mobile clinics. Starting Point/Baseline: The baseline for this service is zero. This will be a new addition to our service array and infrastructure. Quantifiable Patient Impact: Tropical Texas Behavioral Health (TTBH) will increase the number of unique persons receiving behavioral health services through the mobile clinics from at least 70 in DY 3, to at least 90 in DY 4 and at least 120 by the end of DY 5. We will increase the number of behavioral health service encounters delivered out of the mobile clinics from 135 in DY 3, to 270 in DY 4 and 405 by the end of DY 5. Rationale: As discussed in our regional plan, the municipalities of the Lower Rio Grande Valley are diverse, including urban and rural communities and numerous colonias. The Office of the Secretary of State defines colonias as residential areas within 50 miles of the Texas-Mexico border that frequently lack the most basic necessities: potable water and sewer systems, electricity, paved roads and safe and sanitary housing. According to the Texas Water Code, colonias generally qualify as economically distressed areas due to the lack of adequate drinking and waste water services and average household incomes that are below the average household income of the county in which they are located. These areas pose a potentially serious threat to the health and quality of life of the colonias residents and to the health of the public due to: the lack of infrastructure to safely manage wastewater and provide safe drinking water; crowded living conditions; and poor access to routine and preventive healthcare services. The office of the Texas Secretary of State reports that, “In addition to a shortage of primary care providers, colonia residents' difficulty in accessing health care is compounded by other factors, including having to travel long distances to health care facilities, fear of losing wages for time spent away from work, inconvenient health care facility hours, lack of awareness of available health care programs and no health insurance. As a result, many colonia residents' health care problems go unreported and untreated.” While colonias are found in Texas, New Mexico, Arizona and California, Texas has both the largest number of colonias and the largest colonia population. In 2009, there were more than 2,294 Texas colonias located primarily along the state's 1,248 mile border with Mexico, with approximately 400,000 Texans living in them. In 2010 the 3 counties in the TTBH catchment area were reported to have the following number of colonias and populations: County Number of colonias Population Hidalgo 934 156,527 Cameron 178 47,681 Willacy 16 3,460 Total 1,128 207,668 In 2011 the Lower Rio Grande Valley Development Council (LRGVDC) reported that “Some of the highest [transportation] needs continue to be in the colonias spread all over Hidalgo County, with many in Willacy and Cameron Counties as well.” “These areas need regularly scheduled service


throughout the day to meet a variety of needs including commuter, medical and shopping.” In FY 2011, TTBH served an average of 2,115 people from local colonias each month and a total of 25,405 persons (duplicated) for the year. As the population in many areas of the RGV grows at some of the highest rates in the state and the nation, the population living in colonias is also increasing, and with it the demand for behavioral health care. Any delay in the ability to access services or any break or disruption in services can result in functional loss, worsening of symptoms and in the worst case, behavioral health crises. Delays in accessing appropriate behavioral health care have been linked to disproportionately high rates of a range of negative and expensive outcomes for people with mental illness and society including disability, unemployment, homelessness, substance abuse, incarceration, emergency department usage, inpatient hospitalization, complications of co-morbid medical illness and suicide. Additionally, delays in accessing routine community-based mental health care often results in more expensive and frequently avoidable emergency interventions. Treatment compliance is also impacted by cultural beliefs about mental health services and the isolation of colonias and other remote communities makes it difficult to address misconceptions. Though some data indicate that rates of mental illness are lower in the RGV than in other parts of the state and the country, a 2001 health assessment by Perkins, et. al. noted that these data are confounded by underreporting “due to differences in cultural beliefs, expression of symptoms and health/help seeking behaviors.” Many residents will only seek help as a last resort. This problem is often exacerbated by a mistrust of professionals offering assistance. In many cases, these social and cultural misperceptions are not likely to be resolved unless the service provider is able to meet the person to be served in the local community. Our mobile clinics will be an innovative approach to delivering community-based behavioral health services to residents of the colonias, a segment of the population contending with often overwhelming challenges to accessing healthcare due to poverty and isolation. They will improve access to services, allow more people to get the right care at the right time in the right setting, increase utilization of evidence-based preventive care, improve health outcomes and the experience of care for those served and reduce avoidable costs associated with delays in accessing care. This project addresses the following community needs identified in the RHP 5 Plan:

• CN.2: Shortage of behavioral healthcare professionals and inadequate access to behavioral healthcare

• CN.3: Inadequate integration of care for individuals with co-occurring medical and mental illness or multiple chronic conditions

• CN.4: Lack of patient-centered care Project Core Components: The RHP Planning Protocol does not identify additional core components for project option 1.12.3, however, per HHSC’s recommendation to clearly identify Continuous Quality Improvement as a required core component for all healthcare transformation projects, we will complete the following:

a) Conduct quality improvement for project using methods such as rapid cycle improvement. This will be accomplished through our through TTBH’s Quality Management (QM) and Utilization Management (UM) structures and through planned learning collaborative activities with regional partners and other community mental health centers through the consortia sponsored


by the Texas Council of Community Centers. Our QM/UM programs utilize several internal committees supported by data made available through our Management of Information Systems (MIS) Department and electronic health record to continuously monitor performance indicators related to service quality, health outcomes and business performance through a plan, do, study, act quality improvement process. In addition to specified Category 3 outcome targets, related data will be evaluated regularly against our past performance, national benchmarks, state mandated performance targets and applicable accreditation standards to drive performance improvement activities as indicated.

Customizable Process or Improvement Milestones: NA Related Category 3 Outcome Measure(s): IT-11.27.d: Adult Needs and Strengths Assessment (ANSA) The ANSA is an effective multi-purpose assessment tool that supports care planning and level of care decision-making for adults with behavioral health (mental health or substance use) challenges, facilitates quality improvement initiatives, and allows for the monitoring of service outcomes. Beginning in September 2013, the Texas Department of State Health Services (DSHS) replaced the Texas Recommended Assessment Guidelines (TRAG) with the ANSA as the instrument used to conduct uniform assessments of individuals seeking behavioral health care through the DSHS system. As it relates to this project, we would use the instrument to measure outcomes associated with improved functioning as a result of this intervention across a range of assessment domains including strengths, needs, behaviors and history of psychiatric crises and hospitalizations, in the manner described by the Praed Foundation, developers of the ANSA Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): The implementation of mobile behavioral health clinics will support our project to expand access to comprehensive behavioral health services throughout the RGV as a whole and to more people with requiring specialized co-occurring psychiatric and substance use disorders (Projects 138708601.1.1 and 138708601.1.2). Contacts by the staff of the mobile clinics are also likely to identify individuals needing referral for medical concerns appropriate for treatment through our co-located primary care clinics and/or chronic care management services (projects 138708601.2.1 and 138708601.2.4). We will collaborate with South Texas Health Systems to share information and lessons learned as it pertains to their project to implement mobile primary care services in the region (project 094113001.1.104) and with any other regional partners as indicated, to advance the RHP’s goal to transform the region’s health care delivery system to a more coordinated and integrated delivery model for addressing chronic disease and health disparities in the region. Plan for Learning Collaborative: TTBH will make its website available for web-based information sharing and reporting. We will request that the Texas Council of Community Centers consider coordinating bi-annual face-to-face meetings between LMHAs involved in similar healthcare transformation projects to promote sharing of challenges and testing of new ideas and solutions. Project Valuation:


• Jail Diversion is a key component of our proposed project. According to the Treatment Advocacy Center, 40% of individuals with serious mental illnesses have been in jail or prison at some time in their lives. In DY 3 TTBH expects to realize a savings of $10,960 per jail diversion based on an average duration of incarceration of 80 days at a cost of $137/day. As such, the overall value of jail diversions is calculated to be $2,176,656 by the end of DY 5.

• Homelessness: Five percent (5%) of the individuals in our mental health service population were identified as homeless or at imminent risk for homelessness by our PATH (Projects for Assistance in Transition from Homelessness) and Supported Housing programs. A two-year University of Texas survey of homeless persons found that the cost to taxpayers attributed to a single homeless person was $14,480 per year. As such, we calculated the overall value related to avoidance of homelessness to be $359,466 the end of DY 5.

• Hospital: According to the Hogg Foundation, 18.6% of admissions to medical hospitals are related to mental health conditions. Our data indicate that approximately 1.2% of our service population is admitted to a medical hospital while an estimated 17.4% are kept out of the hospital. The Texas Hospital Association sponsors Texas Price Point as a resource for information on Texas hospitals. From this resource, we obtained data pertaining to psychiatric care delivered in the counties of our local service area. We arrived at a weighted average hospital stay of 5.3 days and a weighted average collection cost of $678. Therefore, the overall value related to hospital admissions was calculated to be $310,437 the end of DY 5.

• Emergency Room Utilization: Individuals in our service population who are admitted to hospitals are frequently served in emergency departments prior to admission. Accordingly, based on our review of cost data from local hospitals we arrived at a estimated cost per emergency department visit of $986, and a total valuation attributed to emergency department utilization of $85,182 by the end of DY 5.

• The valuation estimate for the Category 3 measure was established based on the required minimum percentage of the total project valuation for each of DYs 3, 4 and 5 prescribed in the Program Funding and Mechanics Protocols (10%, 10% and 20% respectively). At this time the total valuation for the proposed Category 3 outcome measure for this project is $546,195.45.

• The overall project valuation is $3,477,936.


THREE-YEAR DSRIP PROJECT SUMMARY RHP 05

Unique Project Identifier: 112716902.2.100 Provider Name/TPI: Rio Grande Regional Hospital / 112716902 Brief Project Description 2.6.1 - Implement Evidence Based Health Promotion Programs - Rio Grande Regional Hospital (Rio) intends to implement evidence based health promotion in Hidalgo County, Texas to target reducing the incidence of diabetes in school-aged residents through school-based interventions. Rio will provide guidance to at-risk community members to accomplish the goal of prevention and management of diabetes for at-risk patients, particularly young residents in our low-income and Medicaid eligible communities. Establishing self-management and wellness programs for our targeted population will provide the best opportunity for positive results and ongoing outcomes.

Description of Intervention Rio will repurpose a dietician, nutritionist, and administrative staff to establish community outreach and school-based interventions for diabetic children, and the patient population susceptible to diabetes (specifically the overweight / obese population in the surrounding school districts. This program will focus on evaluation, education, nutrition, and ongoing assessment to reduce the incidence of diabetes and help our diabetic population better manage their disease. Additionally, Rio intends to conduct school visits and home visits with the targeted patient population. This project will address the core requirement of this project option which is to establish self-management programs and wellness using evidenced-based designs. This project will be comprised of the following milestones: P‐2: Development of evidence‐based projects for targeted population based on distilling the needs assessment and determining priority of interventions for the community. P-8: Participate in face-to-face learning (i.e. meetings or seminars) at least twice per year with other providers and the RHP to promote collaborative learning around shared or similar projects. I‐8: Increase access to health promotion programs and activities through this project.

• Total patient impact: 3,060 patient encounters; Medicaid and Uninsured patient impact: 2,448 patient encounters.

This project will conduct quality improvement using methods such as rapid cycle improvement. Activities may include, but are not limited to, identifying project impacts, “lessons learned,” opportunities to scale all or part of the project to a broader patient population, and key challenges associated with expansion of the project, including special considerations for safety‐net populations.


Need for the project The RHP 5 plan notes diabetes and obesity as its first “key health challenge.” (RHP 5 Plan, Page 7). The plan cites diabetes and obesity as the third leading cause of mortality in this region behind heart disease and cancer, and an underlying component of over half of hospital admissions for heart attack, hypertension, sepsis and stroke. (RHP Plan, Page 29-30). The lack of primary care in the community (CN.1) means that providers must try more innovative approaches to addressing the region’s top health challenge, including community outreach and school-based programs. Two additional community needs identified in the RHP 5 plan include the inadequate integration of care and the lack of patient-centered care. (CN3 and CN4). This project will attempt to target a more patient centered model and integrate care and address one of the biggest health challenges in the region. Target population The target population is the school aged population of the surrounding school districts, which have a very high Medicaid-eligible and uninsured population. Currently, the McAllen area pediatric population is 79% Medicaid and uninsured. Rio’s pediatric patient population is 84% Medicaid and uninsured. As such, Rio expects this project to reach approximately 80% Medicaid and uninsured pediatric patients. At the scale of the project, Rio expects approximately 4,080 patient encounters over the three remaining years of the demonstration.

Category 1 or 2 expected patient benefits Rio expects to reduce the onset and complications of diabetes for targeted pre-diabetics in the community through provider-furnished education and management about lifestyle choices, medications, and risks. Additionally, Rio expects a higher rate of controlled diabetes among community members with this chronic disease. Over the three remaining years of the demonstration, Rio expects the following patient impact:

DY3: 360 total patient encounters, of those 288 will be from the Medicaid/uninsured population DY4: 1,080 total patient encounters, of those 864 will be from the Medicaid/uninsured population DY 5: 1,620 total patient encounters, of those 1,296 will be from the Medicaid/uninsured population

Category 3 outcomes expected patient benefits IT‐1.11 Diabetes care: BP control (<140/80mm Hg)234 – NQF 0061 (Standalone measure) – helping patients control their blood pressure. Rio aims to improve the percentage of patients in Hidalgo County with uncontrolled blood pressure by educating the diabetic community on diabetes medication and diet management tactics, leading to better control of diabetic conditions. Patient education, follow-up, and management will result in better overall health outcomes for the targeted population, including increased quality of life, reduced use of acute care, and slower progression of this chronic disease. Achieving this outcome will require Rio to not only communicate with the target population, but to affect their lifestyle choices. Patients will need to reduce poor eating habits, increase physical activity, and manage their medications (when applicable), which Rio cannot force patients to do on a regular basis. Rio intends to reach out to the community through innovative methods (including social media, creating coalitions, and other methods of community outreach) to create support networks and community engagement in accomplishing this outcome, which is meant to benefit individuals at-risk and the community as a whole.


Project Narrative


• Title of Project: Implement Evidence Based Health Promotion Programs – Diabetes Education


• Performing Provider name/TPI: Rio Grande Regional Hospital (Rio) / 112716902



• Overview of Project: Rio will implement evidence based health promotion in Hidalgo County, Texas to target reducing the incidence of diabetes in school-aged residents through school-based interventions. Rio will provide guidance to at-risk community members to accomplish the goal of prevention and management of diabetes for at-risk patients, particularly young residents in our low-income and Medicaid eligible communities. Establishing self-management and wellness programs for our targeted population will provide the best opportunity for positive results and ongoing outcomes. Rio will repurpose a dietician, nutritionist, and administrative staff to establish community outreach and school-based interventions for diabetic children, and the patient population susceptible to diabetes (specifically the overweight / obese population in the surrounding school districts. This program will focus on evaluation, education, nutrition, and ongoing assessment to reduce the incidence of diabetes and help our diabetic population better manage their disease. Additionally, Rio will to conduct school visits and home visits with the targeted patient population. This project will address the core requirement of this project option which is to establish self-management programs and wellness using evidenced-based designs.

• Project Goals: This project will focus on educating school-aged residents on the prevention and management of diabetes and its complications. This project aims to impact approximately 3,060 patient encounters over the course of the Waiver, 80% of which should be Medicaid or uninsured patients.

• Challenges or issues faced by the Performing Provider: 26% of Rio Grande Valley residents are diabetics. Hidalgo County's rates are double the statewide average of hospital admissions for long-term diabetes complications, according to the Texas Department of State Health Services. Rio faces challenges from patients ill-equipped to recognize the signs of diabetic conditions, address necessary lifestyle changes to reduce the risk of diabetes, or manage the disease once they are diagnosed. As a result, Rio sees numerous avoidable hospitalizations and patient encounters for diabetes-related condition and complications. Additionally, Rio has a high readmission rate for patients with diabetes because diabetic patients and families can be resistant to dietary restrictions and exercise and sometimes have difficulty complying with consistent blood-sugar monitoring.


• How the project addresses those challenges: This project implements early intervention for our region’s school-aged children to reduce the incidence and complication of diabetes. This project will better inform community residents to recognize the signs of diabetes, make necessary lifestyle changes to reduce the incidence of diabetes, and better manage the disease once diagnosed.

• 3-year expected outcome for Performing Provider and patients: This project aims to impact approximately 3,060 patient encounters over the course of the Waiver, 80% of which should be Medicaid or uninsured patients.

• How the project is related to the regional goals: The RHP 5 plan notes diabetes and obesity as its first “key health challenge.” (RHP 5 Plan, Page 7). The plan cites diabetes and obesity as the third leading cause of mortality in this region behind heart disease and cancer, and an underlying component of over half of hospital admissions for heart attack, hypertension, sepsis and stroke. (RHP Plan, Page 29-30). The lack of primary care in the community (CN.1) means that providers must try more innovative approaches to addressing the region’s top health challenge, including community outreach and school-based programs. Two additional community needs identified in the RHP 5 plan include the inadequate integration of care and the lack of patient-centered care. (CN3 and CN4). This project will attempt to target a more patient centered model and integrate care and address one of the biggest health challenges in the region.


• Starting Point/Baseline: Rio has not established a baseline because this is a new initiative. Rio expects

to have 360 patient encounters in the first year (80% of which should be Medicaid or uninsured).

• Quantifiable Patient Impact: Rio will measure the number of patient encounters of individuals receiving services or using the intervention. Rio expects to reduce the onset and complications of diabetes for targeted pre-diabetics in the community through provider-furnished education and management about lifestyle choices, medications, and risks. Additionally, Rio expects a higher rate of controlled diabetes among community members with this chronic disease. Over the three remaining years of the demonstration, Rio expects the following patient impact:

o DY3: 360 total patient encounters, of those 288 will be from the Medicaid/uninsured population

o DY4: 1,080 total patient encounters, of those 864 will be from the Medicaid/uninsured population

o DY 5: 1,620 total patient encounters, of those 1,296 will be from the Medicaid/uninsured population

• Rationale: The RHP 5 plan notes diabetes and obesity as its first “key health challenge.” (RHP 5 Plan, Page 7). The plan cites diabetes and obesity as the third leading cause of mortality in this region behind heart disease and cancer, and an underlying component of over half of hospital admissions for heart attack, hypertension, sepsis and stroke. (RHP Plan, Page 29-30). The lack of primary care in the community (CN.1) means that providers must try more innovative approaches to addressing the region’s top health challenge, including community outreach and school-based programs. Two additional community needs identified in the RHP 5 plan include the inadequate integration of care and the lack of patient-centered care. (CN3 and CN4). This project will attempt to target a more


patient centered model and integrate care and address one of the biggest health challenges in the region. This is a new project for Rio.

[Please note you will need to select either P-7 or P-8 but do not need both. The choice is either weekly internal reviews (P-7) or semi-annual regional reviews (P-8)].

Rio selected the following three milestones:

o P-2: Development of evidence-based projects for targeted population based on distilling the needs assessment and determining priority of interventions for the community;

o P-8: Participate in face-to-face learning (i.e. meetings or seminars) at least twice per year with other providers and the RHP to promote collaborative learning around shared or similar projects. At each face-to-face meeting, all providers should identify and agree upon several improvements (simple initiatives that all providers can do to “raise the floor” for performance). Each participating provider should publicly commit to implementing these improvements; and

o I-8: Increase access to health promotion programs and activities through this project.

Rio selected these milestones because they most closely align with the hospital’s potential to develop a meaningful intervention with this region’s school-aged children. This project addresses multiple community needs and the most pervasive health challenge in the region. Rio aims to reduce the incidence and complication of diabetes in school-aged children, which should benefit the overall community.


o Rio will accomplish the CQI core components through its participation in face-to-face meetings at least twice per year with other providers and the RHP to promote collaborative learning around shared or similar projects. Rio will help identify and agree upon several improvements (simple initiatives that all providers can do to “raise the floor” for performance). Rio will publicly commit to implementing these improvements.

o Additionally, Rio will internally evaluate the success or failure of each project at each reporting

opportunity to evaluate what improvements can make the project more effective.


• Related Category 3 Outcome Measure(s): IT-1.11 Diabetes care: BP control (<140/80mm Hg)234 – NQF 0061 (Standalone measure) – helping patients control their blood pressure. Since diabetes-related complications are a substantial issue for this region, this outcome matches the intent of the project and an important area where this region could show improvement. Rio has not established a baseline for this measure yet, but 26% of Rio Grande Valley residents currently suffer from diabetes, indicating there is a substantial need for providers to focus on these issues. Rio aims to improve the percentage of patients in Hidalgo County with uncontrolled blood pressure by educating the diabetic community on diabetes medication and diet management tactics, leading to better control of diabetic conditions. Patient education, follow-up, and management will result in


better overall health outcomes for the targeted population, including increased quality of life, reduced use of acute care, and slower progression of this chronic disease. Achieving this outcome will require Rio to not only communicate with the target population, but to affect their lifestyle choices. Patients will need to reduce poor eating habits, increase physical activity, and manage their medications (when applicable), which Rio cannot force patients to do on a regular basis. Rio intends to reach out to the community through innovative methods (including social media, creating coalitions, and other methods of community outreach) to create support networks and community engagement in accomplishing this outcome, which is meant to benefit individuals at-risk and the community as a whole.

• Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): Diabetes and diabetes related complications are one of the key health challenges in this region, leading some other providers to submit projects that touched on diabetes related issues. However, only two current projects in the region address diabetes issues: one project for a region-wide disease registry and one for gestational diabetes. This project addresses a key health need in this part of the region, Hidalgo County, and is the only project in this county that proposes this type of intervention. One other provider submitted a similar project for Cameron County, but both areas could equally benefit from this type of intervention and there will not be an overlap in the target population.

• Plan for Learning Collaborative: Rio looks forward to participating in RHP 5’s learning collaborative once the Anchor develops the plan for the learning collaborative. For this project, the reduction of diabetes-related complications should lead to substantial benefits across the region. This is one of the region’s highest health priorities and many providers are implementing projects aimed at reducing the number of patients with diabetes and reducing the complications of that disease. A regional learning collaborative should focus on determining the most effective means of implementing change with this region’s population, particularly its school-aged population.

• Project Valuation: Rio valued this project at $2,900,000 over the 3 remaining years of the Waiver. This value is based on the substantial need for this project and the impact on over 3,000 patient encounters. Since this project targets school-aged children, Rio expects this project’s patient impact to be approximately 80% Medicaid and uninsured patients. This project meets a key community need concerning diabetes-related illnesses. This is a large scale project that should reduce long-term costs by helping younger patients address diabetes and its related complications before they become serious problems.

PROPOSED THREE YEAR DSRIP PROJECT RHP 05

Unique Project Identifier: 112716902.2.101


Provider Name/TPI: Rio Grande Regional Hospital / 112716902 Project Description 2.6.1 - (Implement Evidence Based Health Promotion Programs) – Rio Grande Regional Hospital (Rio) intends to implement evidence based health promotion in Hidalgo County, Texas to target reducing the complications of asthma in school-aged residents through school-based interventions. Rio will provide guidance to at-risk community members to accomplish the goal of prevention and management of asthma for at-risk patients, particularly young residents in our low-income and Medicaid eligible communities. Establishing self-management and wellness programs for our targeted population will provide the best opportunity for positive results and ongoing outcomes. This project will involve asthma screenings, counseling, referrals to specialists, and ongoing education regarding disease management.

Description of Intervention Rio will transition a respiratory therapist and potentially hire a social worker to establish community outreach and school-based interventions for asthmatic children, and the patient population susceptible to asthma in the surrounding school districts. This program will focus on evaluation, education and ongoing assessment to reduce the complications of asthma and help our population better manage their disease. This project will address the core requirement of this project option which is to establish self-management programs and wellness using evidenced-based designs. This project will be comprised of the following milestones: P‐2: Development of evidence‐based projects for targeted population based on distilling the needs assessment and determining priority of interventions for the community. P-8: Participate in face-to-face learning (i.e. meetings or seminars) at least twice per year with other providers and the RHP to promote collaborative learning around shared or similar projects. I‐8: Increase access to health promotion programs and activities through this project.

• Total patient impact: 3,060 patient encounters; Medicaid and Uninsured patient impact: 2,448 patient encounters.


Need for the project


Region 5’s community needs include inadequate integration of care for individuals with multiple health issues (CN.3), and a lack of patient-centered care (CN.4). Children in our community are not receiving early intervention to address potential asthma issues, which can be controlled with regular maintenance. Unfortunately, because such a large portion of our patient population does not have sufficient primary care (CN.1), their children often do not receive adequate early intervention for this condition. As such, Rio expects to have a significant impact on reducing incidence of asthma related admissions to the ED through this project. Target population The target population is the school aged population of the surrounding school districts, which have a very high Medicaid-eligible and uninsured population. Currently, the McAllen area pediatric population is 79% Medicaid and uninsured. Rio’s pediatric patient population is 84% Medicaid and uninsured. As such, Rio expects this project to reach approximately 80% Medicaid and uninsured pediatric patients. At the scale of the project, Rio expects approximately 4,080 patient encounters over the three remaining years of the demonstration.

Category 1 or 2 expected patient benefits Rio expects to educate a large section of its pediatric patient population regarding asthma related issue, prevention, and management. Rio will likely have two practitioners working in area schools to improve disease recognition and options. Over the three remaining years of the demonstration, Rio expects the following patient impact:

DY3: 360 total patient encounters, of those 288 will be from the Medicaid/uninsured population DY4: 1,080 total patient encounters, of those 864 will be from the Medicaid/uninsured population DY 5: 1,620 total patient encounters, of those 1,296 will be from the Medicaid/uninsured population

Category 3 outcomes expected patient benefits IT‐9.3 Pediatric/Young Adult Asthma Emergency Department Visits‐ NQF 1381273 – Rio expects to improve the rates of emergency department visits by pediatric patients and young adults caused by asthma related complications.


Project Narrative


• Title of Project: Implement Evidence Based Health Promotion Programs – Asthma Education





• Overview of Project: Rio intends to implement evidence based health promotion in Hidalgo County, Texas to target reducing the complications of asthma in school-aged residents through school-based interventions. Rio will provide guidance to at-risk community members to accomplish the goal of prevention and management of asthma for at-risk patients, particularly young residents in our low-income and Medicaid eligible communities. Establishing self-management and wellness programs for our targeted population will provide the best opportunity for positive results and ongoing outcomes. This project will involve asthma screenings, counseling, referrals to specialists, and ongoing education regarding disease management. Rio will transition a respiratory therapist and potentially hire a social worker to establish community outreach and school-based interventions for asthmatic children, and the patient population susceptible to asthma in the surrounding school districts. This program will focus on evaluation, education and ongoing assessment to reduce the complications of asthma and help our population better manage their disease. This project will address the core requirement of this project option which is to establish self-management programs and wellness using evidenced-based designs.

• Project Goals: This project will focus on educating school-aged residents on the prevention and management of asthma and its complications. This project aims to impact approximately 3,060 patient encounters over the course of the Waiver, 80% of which should be Medicaid or uninsured patients.

• Challenges or issues faced by the Performing Provider: Rio has a large number of admissions to its ED for young people with asthma-related complications. Many of these conditions are preventable with education and better disease management. A large portion of our patient population does not have sufficient access to primary care that could prevent these admissions with early intervention.

• How the project addresses those challenges: This project implements early intervention for our region’s school-aged children to reduce the incidence and complication of asthma. This project will better inform community residents to recognize the signs of asthma, make necessary lifestyle changes to reduce the incidence of asthma, and better manage the disease once diagnosed.


• 3-year expected outcome for Performing Provider and patients: This project aims to impact

approximately 3,060 patient encounters over the course of the Waiver, 80% of which should be Medicaid or uninsured patients.

• How the project is related to the regional goals: Region 5 wants to improve access to primary care (CN.1), integration of care (CN.3), patient centered care (CN.4). Many children in our community have asthma issues that could be treated and managed with a minimal increase in effort. This project will improve this area through education and health promotion.




• Quantifiable Patient Impact: Rio expects to educate a large section of its pediatric patient population regarding asthma related issue, prevention, and management. Rio will likely have two practitioners working in area schools to improve disease recognition and options. Over the three remaining years of the demonstration, Rio expects the following patient impact:




• Rationale: Region 5’s community needs include inadequate integration of care for individuals with multiple health issues (CN.3), and a lack of patient-centered care (CN.4). Children in our community are not receiving early intervention to address potential asthma issues, which can be controlled with regular maintenance. Unfortunately, because such a large portion of our patient population does not have sufficient primary care (CN.1), their children often do not receive adequate early intervention for this condition. As such, Rio expects to have a significant impact on reducing incidence of asthma related admissions to the ED through this project. This is a new project for Rio. Rio selected the following three milestones:


o P-8: Participate in face-to-face learning (i.e. meetings or seminars) at least twice per year with other providers and the RHP to promote collaborative learning around shared or similar projects. At each face-to-face meeting, all providers should identify and agree upon several improvements (simple initiatives that all providers can do to “raise the floor” for performance). Each participating provider should publicly commit to implementing these improvements; and



Rio selected these milestones because they most closely align with the hospital’s potential to develop a meaningful intervention with this region’s school-aged children. This project addresses multiple community needs in a health area that could show improvement with targeted intervention. Rio aims to reduce the incidence and complication of asthma in school-aged children, which should benefit the overall community.






• Related Category 3 Outcome Measure(s): IT-9.3 Pediatric/Young Adult Asthma Emergency Department Visits- NQF 1381273 – Rio expects to improve the rates of emergency department visits by pediatric patients and young adults caused by asthma related complications.

• Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): Driscoll Children’s submitted a project with the original RHP plan to help pregnant women combat chronic diseases like asthma. This is the only new 3-year project in the RHP targeting asthma. This is an important health issue for our region’s youth and Rio has proposed the only project to address asthma in young people in RHP 5.

• Plan for Learning Collaborative: Rio looks forward to participating in RHP 5’s learning collaborative once the Anchor develops the plan for the learning collaborative. Since this is the only project addressing asthma in young people, Rio expects to contribute information regarding successes and failures helping young people address health challenges generally, rather than specific issues related to this disease.

• Project Valuation: Rio valued this project at $2,900,000 over the 3 remaining years of the Waiver. This value is based on the substantial need for this project and the impact on over 3,000 patient encounters. Since this project targets school-aged children, Rio expects this project’s patient impact to be approximately 80% Medicaid and uninsured patients. This is a large scale project that should reduce other costs by helping younger patients avoid admission to the ED with asthma-related issues.


Project Title: Develop, implement, and evaluate standardized clinical protocols and evidence-based care delivery model to improve care transitions. Unique RHP Project ID number: 154504801.2.101 Performing Provider/TPI: Harlingen Medical Center / 154504801 Project Option: 2.12.1 Project Core Components: 2.12.1.a-g

PROJECT SUMMARY Provider Description

Harlingen Medical Center is a 112-bed general acute care and Level IV Trauma Designated hospital that specializes in bariatric, cardiology, emergency, gastroenterology, imaging, neurology, pediatric, obstetrics and gynecology, orthopedic, sleep apnea treatment, vascular and endovascular surgery, and wound healing care. Located in Cameron County, the hospital serves a population of 139,392 of which approximately 57.6% are covered by Medicare, 14.2% Medicaid, 16.4% by HMO or PPO, and 11.8% are indigent and/or low income underinsured.

Project Description

This project will improve care transitions so that patients receive appropriate and timely follow-up care and avoid being re-hospitalized for reasons that could have been prevented. This project will adopt a proven care transitions model for patients at risk of readmission, develop standardized clinical protocols and a care delivery model, implement optimum hospital discharge planning and processes, connect patients to outpatient settings for timely access to care following a hospitalization, use data and information to drive decision-making and promote care coordination, and conduct quality improvement. We plan to utilize nurses specifically in charge of care transitions to meet with patients from the time they are admitted through their discharge. After discharge, the nurses make home calls, ensuring medications and discharge instructions are being followed and patients are attending follow-up appointments with primary care physicians. The overall goal of this project is to implement smooth transitions of care from inpatient to outpatient settings so that patients being discharged understand the care regimen, have follow-up care scheduled, and are at reduced risk of avoidable readmissions.

Intervention(s)

We have selected Project Option 2.12.1 Implement/Expand Care Transitions Programs: Develop, implement, and evaluate standardized clinical protocols and evidence-based care delivery model to improve care transitions. This project improves care transitions from inpatient to outpatient settings in order to reduce unplanned readmissions.


As cited in the community needs assessment, the region experiences: a shortage of primary and specialty care providers (CN.1), inadequate integration of care for individuals with multiple health issues (CN.3), and a lack of patient-centered care (CN.4). Many patients do not receive appropriate, ongoing care in community-based settings. This project would improve care transitions from the hospital so that patients receive the post-hospitalization care they need, reducing the risk of re-hospitalizations.

Target population


This project will serve 5,459 unique individuals in DY 4 and 5,500 unique individuals in DY 5 according to care transitions guidelines. Of those patients, we estimate approximately 26% would be Medicaid, indigent, or uninsured. Expected impact (total patients per year): DY3-0, DY4-5,459, DY5-5,500 unique individuals

Category 1 or 2 expected patient benefits

The project seeks to improve care transitions from acute care to community-based settings, as evidenced by an anticipated total of 5,459 unique individuals in DY 4 and 5,500 unique individuals in DY 5 receiving care according to care transitions guidelines. We will implement care transitions evidence-based protocols and standardized care transition processes and increase the number of patients in the target population receiving standardized, evidence-based care according to the approved clinical protocols and care transitions policies. Patients would benefit from:

• Improved hospital discharge processes • Timely post-hospitalization care • Reduced risk of needing acute care services 30-60 days post-discharge • Right care at the right time in the right setting • Improved patient health

Quantifiable patient impact milestones are to provide: DY3-0, DY4-5,459, DY5-5,500 unique individuals with care transitions services

Category 3 outcomes expected patient benefits

We have selected outcome measure IT-3.1 Hospital-Wide All-Cause Unplanned Readmission Rate – (Standalone measure). This project would reduce the 30-day readmission rate by 20% over baseline by DY 5.


Project Title: Develop, implement, and evaluate standardized clinical protocols and evidence-based care delivery model to improve care transitions. Unique RHP Project ID number: 154504801.2.101 Performing Provider/TPI: Harlingen Medical Center / 154504801 Project Option: 2.12.1 Project Core Components: 2.12.1.a-g Project Description: This project will improve care transitions so that patients receive appropriate and timely follow up care and avoid being re-hospitalized for reasons that could have been prevented. This project will adopt a proven care transitions model for patients at risk of readmission, develop standardized clinical protocols and care delivery model, implement optimum hospital discharge planning and processes, connect patients to outpatient settings for timely access to care following a hospitalization, use data and information to drive decision-making and promote care coordination, and conduct quality improvement. We plan to utilize nurses specifically in charge of care transitions to meet with patients from the time they are admitted through their discharge. After discharge, the nurses make home calls, ensuring medications and discharge instructions are being followed and patients are attending follow-up appointments with primary care physicians. The overall goal of this project is to implement smooth transitions of care from inpatient to outpatient settings so that patients being discharged understand the care regimen, have follow-up care scheduled, and are at reduced risk of avoidable readmissions. Specific project goals include: patients leave the hospital with a printed and reconciled medication list and a printed care plan; patients have follow-up care appointment(s) scheduled at the time of hospital discharge; patients are seen within 24 hours, 48 hours, or 5 days, depending on the patient’s risk of re-hospitalization and care needs; the patient’s primary care provider has the discharge summary in hand at the time of the first post-hospitalization visit; patients receive a reminder call prior to their first post-hospitalization visit; and patients can teach-back their medication regimen, including dosage and time. This project aligns with all of the regional goals to:

• Leverage and improve existing programs and infrastructure; • Increase access to primary and specialty care services; • Nurture a culture of ongoing quality improvement; and • Transform health care delivery to a patient-centered, coordinated and integrated model.

Starting Point/Baseline: Our readmission rate is 15.5%, which is too high and represents re-hospitalizations that could have been avoided through improved discharge processes and post-hospitalization care. We did not have a care transitions program prior to the DSRIP program, so we do not have a baseline. Quantifiable Patient Impact: We have selected QPI metric I-11.2: Number of patients in target population receiving standardized, evidence-based care according to the approved clinical protocols and care transitions policies, consistent with HHSC’s recommended QPI measure for this project option. Rationale: Identifying and implementing best practices to reduce avoidable readmissions have been shown to improve quality, reduce unnecessary health care utilization and costs, promote patient-centered care, and increase value in the health care system. Moreover, as some individuals are at greater risk of readmission, care coordination targeted to particular groups of patients can reduce readmissions and may help eliminate disparities in care. A proven method for reducing avoidable readmissions is to improve transitional care, which ensures proper coordination and continuity of care as patients move between various locations or levels of care within the health care system. Hundreds of hospitals across the nation are adopting care transitions models suited for their


unique populations with promising results.1 Studies show that care transitions intervention coaching can result in reduced 30-day readmits.2 Milestones & Metrics: The following milestones and metrics were chosen for the care transitions initiative based on the core components and the needs of the target population:

• Process Milestones and Metrics: P-1 (P-1.1) and P-2 (P-2.1) to implement care transitions evidence‐based protocols and standardized care transition processes.

• Improvement Milestones and Metrics: I-11 (I-11.2) to increase the number of patients receiving standardized, evidence-based care transitions.

Unique community need identification number the project addresses: • CN.1 – Shortage of primary and specialty care providers and inadequate access to primary or preventive

care • CN.3 – Inadequate integration of care for individuals with co-occurring medical and mental illness or

multiple chronic conditions • CN.4 – Lack of Patient-Centered Care How the project represents a new initiative or significantly enhances an existing delivery system reform initiative: This is a new initiative with no related activities that are funded by HHS. Project Core Components: We will be addressing all of the project core components: a. Review best practices from a range of models (e.g., RED, BOOST, STAAR, INTERACT, Coleman, Naylor,

GRACE, BRIDGE, etc.). We have already begun this review in DY 3, and based on that, have decided to use the widely acclaimed RED model.

b. Conduct an analysis of the key drivers of 30‐day hospital readmissions using a chart review tool (e.g., the Institute for Healthcare Improvement’s (IHI) State Action on Avoidable Re‐hospitalizations (STAAR) tool) and patient interviews). Based on patient interviews as well as a chart review tool, we plan to analyze key drivers of 30-day hospital readmissions.

c. Integrate information systems so that continuity of care for patients is enabled. We will be activating an information portal to provide information to discharge facilities, expanding an information repository and increasing EMR access to physician’s offices, as an addition to the Truven care system to improve tracking of performance and 30-day readmit patient identification.

d. Develop a system to identify patients being discharged potentially at risk of needing acute care services within 30‐60 days. We plan to use the LACE Risk tool to identify patients.

e. Implement discharge planning program and post discharge support program. We plan to begin policy development and implementation to coordinate with case management inpatient services and outpatient support programs.

f. Develop a cross‐continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers. We are compiling a team to include the above-mentioned representatives, including from the community.

g. Conduct quality improvement for project using methods such as rapid cycle improvement. Activities may include, but are not limited to, identifying project impacts, identifying “lessons learned,” opportunities to scale all or part of the project to a broader patient population, and identifying key challenges associated with

1 Ness, D. and Kramer, W. “Reducing Hospital Readmissions: It’s About Improving Patient Care,” Health Affairs Blog (August 16, 2013). 2 See A Look at Care Transitions article: http://nashville.medicalnewsinc.com/reducing-unplanned-hospital-readmissions-cms-2426 and Coleman EA, Parry C, Chalmers S, Min SJ, “The Care Transitions Intervention: Results of a Randomized Controlled Trial,” Arch Intern Med. 2006 Sep 25;166(17):1822-8. RHP Plan for [RHP 5/South Texas] 36

http://nashville.medicalnewsinc.com/reducing-unplanned-hospital-readmissions-cms-2426

expansion of the project, including special considerations for safety‐net populations. We plan to conduct quality improvement using PDSA cycles on data collected during patient interviews and chart reviews.

Customizable Process or Improvement Milestones: N/A Related Category 3 Outcome Measure(s): We have selected from outcome domain 3: Potentially Preventable Readmissions (PPRs) – 30‐day Readmission Rates: IT‐3.1 Hospital‐Wide All‐Cause Unplanned Readmission Rate – (SA). The implementation of a proven care transitions model has demonstrated again and again good results; for example, studies show that care transitions intervention coaching can result in a significant reduction in 30-day hospital readmits, as well as a potential reduction in 90-day and 180-day readmits.3 Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): Relationship to Other Projects: Our other DSRIP project is improving medication management, which intersects with care transitions. Additionally, this project would support population health improvements in Category 4 by reducing Potentially Preventable Readmissions (PPRs). Relationship to Other Performing Providers’ Projects in the RHP: This project meets the community needs and operates in conjunction with RHP-wide initiatives. Many RHP5 performing provider projects also focus on addressing community needs through complementary work. The RHP5 plan as of April 2013 lacks a care transitions project. Two other providers submitted new project summaries related to care transitions in Hidalgo County; the only other provider proposing to implement care transitions in Cameron County is Valley Regional Medical Center, but their program is targeted to patients with diabetes. As such, this proposed project meets the needs of specific populations and will not duplicate services of other Performing Provider projects in the RHP. Plan for Learning Collaborative: We plan to participate in the statewide learning collaborative to facilitate sharing of challenges and testing of new ideas and solutions to promote continuous improvement in our health care system. Project Valuation: We have valued this project based on the following factors: Achieves Waiver Goals: The care transitions project will: • Improve quality: Effective care transitions will emphasize warm hand-offs between providers that promote

care coordination, improve medication reconciliation, increase follow-up care, and improve patients’ ability to self-manage their condition(s).

• Improve health status: The implementation of a proven care transitions model has demonstrated again and again good results; for example, studies show that care transitions intervention coaching can result in a significant reduction in 30-day hospital readmits.4 Care transition programs are often applied to high-risk patient groups with proven, positive results. Moreover, care transitions programs can help reduce disparities in care, since certain patient groups are at higher risk of falling through the cracks after a hospital discharge (e.g., elderly, minority, uninsured patients).

3 See A Look at Care Transitions article: http://nashville.medicalnewsinc.com/reducing-unplanned-hospital-readmissions-cms-2426. 4 See A Look at Care Transitions article: http://nashville.medicalnewsinc.com/reducing-unplanned-hospital-readmissions-cms-2426 and Coleman EA, Parry C, Chalmers S, Min SJ, “The Care Transitions Intervention: Results of a Randomized Controlled Trial,” Arch Intern Med. 2006 Sep 25;166(17):1822-8. RHP Plan for [RHP 5/South Texas] 37



• Improve patient experience: Based on focus groups and interviews for the Always Events initiative, patients, families, providers, and experts agreed that success in care transitions is one of two key areas at the heart of patient-centered care.5

• Improve coordination: The predominant care transitions models focus on improving care coordination specific to the period during and after a hospitalization.

• Improve cost-effectiveness: Readmissions are costly – though a small number of patients are readmitted, the cost is disproportionally high and can be avoided through better follow-up and ongoing care in a community-based, clinic setting. Researchers have estimated that inadequate care coordination, including inadequate management of care transitions, was responsible for $25-45 billion in wasteful spending in 2011 through avoidable complications and unnecessary hospital readmissions.6 Results of a randomized controlled trial showed that the mean hospital costs were lower for care transitions intervention patients ($2,058) vs. controls ($2,546).7

Addresses Community Need(s): As cited in the community needs assessment, the region experiences: a shortage of primary and specialty care providers (CN.1), inadequate integration of care for individuals with multiple health issues (CN.3), and a lack of patient-centered care (CN.4). Many of these patients end up needing more acute care and may not receive the appropriate, ongoing care in community-based settings. This project would improve care transitions from the hospital to community-based settings so that patients receive the post-hospitalization care they need, reducing the risk that the patients may need further acute care services. • Community Benefit: RHP5 has long been a health professional shortage area with particular difficulty in

recruiting and retaining primary care and specialist physicians, nurses and physician assistants.8 providing effective care transitions post-hospitalization will be important to promoting ongoing care and care coordination for this underserved population.

Patient Outcomes & Impact: This project would reduce the 30-day readmission rate by 20%. This project seeks to improve care transitions from acute care to community-based settings for an anticipated total of 5,459 unique individuals in DY 4 and 5,500 unique individuals in DY 5 receiving care according to care transitions guidelines.

5 Picker Institute, “Always Events: Creating an Optimal Patient Experience,” (October 2011). 6 "Health Policy Brief: Care Transitions," Health Affairs, September 13, 2012. 7 Coleman EA, Parry C, Chalmers S, Min SJ, “The Care Transitions Intervention: Results of a Randomized Controlled Trial,” Arch Intern Med. 2006 Sep 25;166(17):1822-8. 8 According to the report, “U.S./Mexico Border Health Issues: The Texas Rio Grande Valley” and in concurrence with the community needs assessment, the Texas Rio Grande Valley is one of the poorest and most underserved areas of the U.S. and the problems of its uninsured remain more persistent and intense than nearly anywhere else in the nation. Public health issues are more complicated given the high level of migration between the U.S. and Mexico. HRSA has a history of prioritizing the U.S./Mexico border in order to promote primary care and ensure quality health care services for the underserved. RHP Plan for [RHP 5/South Texas] 38

Category 2: Innovation and Redesign Performing Provider Name: University of Texas Health Science Center Houston Project Title: Implement medical homes in HPSA Brownsville Community Health Center Unique RHP Project Identification Number: 111810101.2.100 Performing Provider/TPI: University of Texas Health Science Center- Houston/ 111810101 Project Option: 2.1.3 Implement medical homes in HPSA and other rural and impoverished areas using evidence-based change concepts for practice transformation developed by the Commonwealth Fund’s Safety Net Medical Home Initiative: Medical Home

Project Summary

Provider:

The University of Texas Health Science Center Houston (UT Health) serves the South Texas area through its UT School of Public Health Campus and its mobile van located in RHP 5. It trains students and provides primary health care to indigent patients through its mobile services. Additionally, students being trained in medicine and public health have border experiences providing care in South Texas.

Intervention: UT Health proposes to implement a certified patient centered medical home (PCMH) model of care to provide safety net primary healthcare services to targeted patients who live in HPSA, rural, and impoverished areas of Cameron and Willacy County. This will be achieved through a partnership with Brownsville Community Health Center, a primary care clinic that serves the poor and underserved in RHP5.

Need for the Project: Over 70% of the population has one or more chronic condition. A similar proportion has currently no health insurance. This means that preventive care and intervention is largely neglected and patients often only present when they develop severe disease requiring Emergency Department or Inpatient care. No integrated chronic care management programs are provided currently available in RHP5. Therefore there is a need to eliminate fragmented and uncoordinated care, which can lead to emergency department and hospital over-utilization. The PCMH model is viewed as a foundation for the ability to accept alternative payment models under payment reform.

Target Population: The target population includes the uninsured and under-served, those below 200% of poverty, migrant and seasonal farmworkers, Hispanics, women and children. Approximately 77.34% of our patients are at or below 100% of Poverty, 96.09% are at or below 200% of Poverty. Of the over 21,000 patients, over 60% are uninsured, about 20% are on Medicaid/CHIP or Medicare. All patients are expected to benefit from the Patient Centered Medical Home model and from the meaningful exchange of health information.

Category 1 or 2 expected patient benefits:

The key functional element of the project is to become a certified patient centered medical home for primary care access so that the clinic can have a lasting and meaningful impact on over 21,000 patients, and reduce the growth in health care costs by working collaboratively with other healthcare partners.The project meets the following regional goal: Transform health care delivery from a disease-focused model of episodic


care to a patient- centered, team-based model.

Description of the Category 3 measure(s):

Once process and implementation milestones are reached, the clinic expects a decrease in the percentage of diabetic patients whose HbA1c levels are greater than 9.0% (poor control).

PROJECT DESCRIPTION The UTHSC Houston School of Public Health Campus-Brownsville (UTHealth) proposes to work with Brownsville Community Health Center to implement a certified patient centered medical home (PCMH) model of care to provide safety net primary healthcare services to targeted patients who live in HPSA, rural, and impoverished areas of Cameron County. The project would improve access to comprehensive, primary and preventive care through the implementation of the medical home model. The project would cover 2 existing service sites located in Brownsville. These sites touch 21,000 medical and dental patients, equating to approximately 4% of the total population of Cameron County and a larger % (~6-8% of those who have limited access to health services).

The project greatly enhances the current comprehensive, primary health and wellness services for Cameron County in South Texas by developing a medical home model that will improve the service to patients and greatly improve the efficiency and effectiveness of helping them control their chronic health conditions. The clinic responds to the needs of the community by providing quality primary care and prevention services regardless of ability to pay. The community clinic is accredited by the Joint Commission. The target population includes the uninsured and under-served, those below 200% of poverty, migrant and seasonal farmworkers, Hispanics, women and children. The clinic’s service area ranks as one of the poorest in the nation.

The Provider partnership between UT HEALTH SCIENCE CENTER HOUSTON and BCHC consists of the following Full Time Equivalents (FTEs): Primary Care Physicians (10.5 FTE); Other providers including Nurse Practitioners/Physician Assistants/Certified Nurse Midwives/Podiatrist (5 FTE); Dentists and Dental Hygienists (4 FTE). Services include: pediatrics, internal medicine, family practice, OB/GYN, Behavioral Health, Dental, minor surgery, podiatry, pharmacy, and rheumatology services. Outreach, Lab & x-ray, 24-hour on-call hospital coverage, health professions training, nutrition, health education, social services, case management, integrated eligibility screening, and specialty referral coordination round out the core services. It also includes project coordinators, data managers, data analysts, expertise in health promotion, communications and health information exchange, and community health workers. The BCHC currently serves 3,231 patients who have been diagnosed with type 2 diabetes. The patient centered medical home model will be able to provide a more effective means of care focused on prevention and a patient/medical team concept that will lower risk of severe sequelae from diabetes and reduce visits to emergency departments and hospitalization. Most of the patients served would go to an emergency room, often with more advanced symptoms, if they did not have access to this clinic. Goal: RHP 5 is a medically underserved area with a population that is 40-60% uninsured and that has no public hospital or hospital district. All of the hospitals are private for-profit and are therefore limited in their ability to meet the needs of the population for primary and specialty care, based on current


reimbursement/financing mechanisms and levels of insurance. Furthermore, the population suffers from very substantial health disparities, particularly obesity, diabetes and related conditions as described and documented in detail in the needs assessment. The primary goal of this 3 year program is to create functional, patient centered medical homes in the clinics of BCHC that will be eligible for NCQA certification and to apply for certification. Two additional goals of the project are to: • Develop meaningful digital health information collection and exchange between providers of care for this

demographic segment, and • Develop actionable health information and analytical capability for reporting project performance,

patient risk stratification and population management.

The key functional element of the project is to become eligible for certification as patient centered medical home for primary care access. By achieving patient centered medical home status, the 2 clinics can have a lasting and meaningful impact on the over 21,000 patients, while reducing the growth in health care costs through working collaboratively with other healthcare partners, and increase patient satisfaction with the healthcare system.

The project meets the following regional goals: • Transform health care delivery from a disease-focused model of episodic care to a patient-centered, team-

based model • Build a regional, coordinated source of care designed to reduce costs, lower duplicative work, and increase

patient satisfaction. Challenges: The transformation to a new model of integrated patient centered care is a substantial undertaking involving the redesign of service delivery, the creation of care teams and reorientation of care team thought processes. The entire organization must undergo a coordinated transformation that addresses the simultaneous conversion of the health system to electronic health records, new government regulations, and revised reimbursement criteria. Strong leadership from all partners, the UTHealth SPH campus and BCHC administration and clinical team are essential for success. Just as important, the patient must also be educated in the new system and must buy in to the PCMH method of care. Staff must be retrained and work processes must be revised, all while maintaining productivity and reducing costs. Finally, implementing comprehensive change within a population that is overwhelmingly Hispanic and Spanish speaking with low health literacy is a challenge. 3-Year Expected Outcome for Provider and Patients: • Creation of a Patient Centered Medical Home through transformation of the delivery of health services at

Brownsville Community Health Center. • Application to NCQA for certification as a patient centered medical home. • Improvements in coordination with area hospitals are expected through the implementation of the Health

Information Exchange. • Involvement of internal medicine residents and psychiatry residents in caring for patients in a Patient

Centered Medical Home environment.


• A measurable decrease in the percentage of diabetic patients whose HbA1c levels are greater than 9.0% (poor control).

STARTING POINT/BASELINE: • There are no PCMH programs in region 5. Currently another FQHC is also going through the process of

transformation into a PCMH under another waiver project. Working with the UTHealth SPH Campus the clinics of BCHC will be among the first such programs in the region.

• The community clinics currently use an electronic medical records system and have already participated in a number of training opportunities regarding the patient centered medical home. However they are not connected to the larger HIE that will allow sharing of records across RHP5.

• The Administrative Leadership Team is knowledgeable of patient centered medical home concepts and has integrated the goal of PCMH certification into the organization’s board approved strategic plan.

• Currently, no RHP5 sites, including BCHC sites have been certified as a patient centered medical home so the baseline is zero in DY3.

• With respect to diabetes, the clinic collects data on the percentage of patients with HbA1c greater than 9% (poor control of diabetes). For the baseline year of 2011, that percentage with HbA1c >9% was 34.27%.

QUANTIFIABLE PATIENT IMPACT: When the PCMH process is completed at least 21,000 people per year will be served, and we anticipate to increase that by 5-10% based on the efficiency and organization of the PCMH. Over 60% of those served by this program will be people on Medicaid or Medicaid/Medicare or with no insurance. 12,399 patients seen at BCHC are below poverty level, of which 7,256 individuals are uninsured. RATIONALE: Federal, state, and local health care providers share goals to promote more patient-centered care focused on wellness and coordinated care. In addition, the PCMH model is viewed as a foundation for the ability to accept alternative payment models under payment reform. PCMH development is a multi-year transformational effort and is viewed as a foundational way to deliver care aligned with payment reform models and the Triple Aim goals of better health, better patient experience of care, and ultimately better cost-effectiveness. 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. These projects all are focused on the concepts of the PCMH model; but they are adapted by providers depending on the local circumstances, and in this case we are looking at a population considered by the US Census Bureau as the poorest in the nation. This initiative would transform and expand the current health care delivery in RHP5 since this provider currently is not a PCMH. It aims to eliminate fragmented and uncoordinated care, which can lead to emergency department and hospital over-utilization. The projects associated with Medical Homes establish a foundation for transforming the primary care landscape in Texas by emphasizing enhanced chronic disease management through team-based care. Finally, this program will provide an example to other providers in RHP5 for development of the PCMH model. With respect to the concept of the Patient Centered Medical Home, the National Committee for Quality Assurance (NCQA) found the following:


• Primary care is a foundation of the health care system. The NCQA PCMH standards reflect

elements that make primary care successful. Primary care clinicians are often the first point of contact for an individual; thus, patient access to care is an important issue. Just as patient-centeredness is an integral part of the program, so too is a practice’s ability to track care over time and across settings. The amount of clinical information for some patients—particularly those with chronic illnesses—and the fragmented nature of the U.S. health system make this aspect of primary care challenging. Merely having an electronic health record system in a practice is not enough. The health information system itself must achieve meaningful use to improve quality of care.

Implementing a patient centered medical home model in an area of the state with the highest uninsurance rates, high rates of diabetes, high percentage of Hispanic population, and lowest incomes in the nation will have a positive effect on reducing health disparities within the region. This is a new project for the performing provider and for RHP5 as no certified PCMH currently exists.

REQUIRED CORE PROJECT COMPONENTS: a) Empanelment: Assign all patients to a primary care provider within the medical home. Understand practice supply and demand, and balance patient load accordingly. b) Restructure staffing into multidisciplinary care teams that manage a panel of patients where providers and staff operate at the top of their license. Define roles and distribute tasks among care team members to reflect the skills, abilities, and credentials of team members. c) Link patients to a provider and care team so both patients and provider/care team recognizes each other as partners in care. d) Assure that patients are able to see their provider or care team whenever possible. e) Promote and expand access to the medical home by ensuring that established patients have 24/7 continuous access to their care teams via phone, e-mail, or in-person visits. f) Conduct quality improvement for project using methods such as rapid cycle improvement. Activities may include, but are not limited to, identifying project impacts, identifying “lessons learned,” opportunities to scale all or part of the project to a broader patient population, and identifying key challenges associated with expansion of the project, including special considerations for safety-net populations. This project addresses the following needs: Community Need 3: Inadequate integration of care for individuals with co-occurring medical and mental illness or multiple chronic conditions Community Need 4: Lack of Patient-Centered Care

RELATED CATEGORY 3 OUTCOME MEASURE: We are considering the following category 3 outcome measure but will await final designation of approved outcome measures. IT-1.10 HbA1c poor control (standalone measure). The Category 3 goal considered for this project is to reduce the percentage of community clinic patients with Type 1 or 2 diabetes whose most recent hemoglobin A1c (HbA1c) is greater than 9% (poor control) to 27%.

Providing a patient centered medical home where a diabetic patient has a direct relationship with a provider and care team has shown a correlation with decreased use of inpatient and emergency care (see Rationale above). Community clinics offer a variety of services in one location, including medical, dental, podiatry,


nutrition counseling, social services, behavioral health, care management, and social services. Combining the power of the medical home model with the community oriented patient navigator services offered by the UTHealth SPH Campus community health workers, we believe we can have a positive, early impact on helping diabetic patients control their HbA1c. Through a host of national projects funded by the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid, it has been shown that the implementation of a Health Information Exchange among hospitals, providers, and related healthcare providers can have a positive impact on health care coordination, patient satisfaction, and total healthcare costs. RHP5 is characterized by being home to a number of small communities and metropolitan areas strung along a 90 mile stretch of highway along the U.S. – Mexico border. The resident population is very mobile and often lives in one community, works in another, and gets their healthcare/hospital care in another. Having the ability to effectively share health information in a secure manner among providers will prove beneficial to all. The UTHealth SPH Campus will assure the development of the connection between the PCMH and the Rio Grande Valley HIE. As stated above, RHP5 is among the highest poverty regions in the nation. Over 70% of patients served by our clinic are at or below 100% of poverty.

RELATIONSHIP TO OTHER PROJECTS: This project reinforces the projects being proposed by other UT System partnerships with RHP5 hospitals and other performing providers by strengthening the network of care, particularly those services aimed at the lowest income and highest uninsured groups in the region. This project will complement the chronic disease management project by providing a long term home for patients with underlying chronic disease who have gone through an intense 180 day period of education and orientation to control their condition, but who need a long term PCMH for ongoing management. This project also meshes with other initiatives currently under way in the region such as the development of Accountable Care Organizations, development of a fully functioning medical school, and increased medical research on a variety of topics including obesity, nutrition, and diabetes among Hispanic populations.

RELATIONSHIP TO OTHER PERFORMING PROVIDERS’ PROJECTS IN THE RHP: A major aim of this project is to work with Brownsville Community Health Center to create a PCMH at each 2 BCHC clinic sites. In addition, other clinics are likely to pursue this goal and the UTHealth SPH Campus will work with those clinics along with BCHC to share progress, best practices, and lessons learned throughout the project period.

PLAN FOR LEARNING COLLABORATIVE: With the UTHealth School of Public Health (SPH) Campus as the facilitator, we will develop the learning collaborative during the project period. The UTHealth SPH Campus will also work with the HIE and BCHC to create a seamless access to patient data to facilitate management of patients enrolled in the PCMH. All of the partners in the project have the capacity to host online and videoconference interactive meetings that will be organized and facilitated by the UTHealth SPH Campus. This will provide ample opportunity for a robust learning collaborative.

The UTHealth SPH Campus has an advanced data collection, data management and data analysis operation. Working with the BCHC Information Technology team and the Rio Grand Valley HIE will create a robust system of data for evaluation, management and decision making. Furthermore it will provide the foundation to expand the IT interaction with hospitals and other clinics in the region.

PROJECT VALUATION: RHP Plan for [RHP 5/South Texas] 44

The project will be valued based upon the successful attainment of the following expected results: • Develop and implement action plans for a application to NCQA as a patient centered medical home. • Restructure staffing into multidisciplinary care teams that manage a panel of patients where providers and

staff operate at the top of their license. • Collaborate with the RGV Health Information Exchange to develop the capacity to use EMR for effective

patient management across hospitals, PCMHs, community clinics, and other clinics. • Management and coordination for shared, high-risk patients. • Impact on control of diabetes.


Expanding Service Capacity at the HOPE Clinic 160709501.1.101 Doctors Hospital at Renaissance / 160709501 Project Option: 1.1.2 Project Description: Doctors Hospital at Renaissance (DHR) is partnering with the Hope Family Health Center to expand its facilities and increase services. HOPE is a nongovernmental nonprofit organization who is sustained through grants, individual donations, volunteer services and fundraisers. DHR is wanting to greatly increase the Hope clinic’s service capacity in efforts of maintain a clinic to refer to that are serviced within DHR and are considered high-risk and in-need of follow-up healthcare to help manage their chronic conditions. By doing this, an invaluable service is being provided to the community helping to improve the overall quality of life and moving towards a sustainable health care model as frequent, high-risk, ED users have access to follow-up care. As a result, these efforts create the opportunity forthe patient to stabilize and improve on their chronic conditions preventing further advancement and readmissions. Goals: The primary goal of this project is to expand the medical service capacity of the HOPE clinic. This is accomplished by collaborating with the clinic and providing the necessary resources to expand its hours, personnel, and supplies. Long-term goals that build off of the immediate expansion of availability is creating an outlet for emergent patients to turn to for follow-up care that would not have anywhere else to turn once released. As the HOPE clinic is able to offer increased primary healthcare, it serves as a chance at a better quality of life, and DHR in collaboration with the HOPE clinic will move closer towards a sustainable health care model. Challenges/Issues: Within RHP5, approximately 1 in 3 people are without any type of insurance, and 40% of the families live below the federal poverty line9. Nearly half of all uninsured, non-elderly adults report having a chronic condition, and these people are less likely to visit a health professional than their insured counterparts10. Within these circumstances, the only option for health care falls on the county indigent program, emergency rooms, or the few clinics that offer free health care such as the HOPE clinic. The HOPE clinic is a nonprofit organization that provides medical and counseling care to the uninsured living in RHP5. Its current personnel is comprised of volunteer medical providers that treat patients at no charge. With a team of volunteer health care providers the availability of healthcare is uncertain. Additionally, the clinic solely operates on a donation basis that severely limits the capacity of services. When services simply cannot be provided, patients are forced to forgo treatment often leading to emergent conditions that often lead to poor outcomes11. Addressing the challenges:

9 RHP5 Community Needs Assessment 10 National Health Interview Survey: http://www.urban.org/UploadedPDF/411161_uninsured_americans.pdf. Note: information stated is regarding the nation as whole. 11 Mathematica Policy Research, Inc.: http://www.mathematica-mpr.com/publications/PDFs/health/reformhealthcare_IB1.pdf RHP Plan for [RHP 5/South Texas] 46

http://www.urban.org/UploadedPDF/411161_uninsured_americans.pdf

http://www.mathematica-mpr.com/publications/PDFs/health/reformhealthcare_IB1.pdf

DHR will partner with the HOPE clinic significantly enhancing their service capabilities. Such enhancements include expanding the clinics hours of operation, creating a full-time primary care schedule, and creating the availability to see more uninsured, poverty stricken patients. 3-Year Expected Outcomes/Benefits: Provider: As health care providers, all endeavors made by the HOPE clinic and DHR revolve around creating a sustainable model that provides safe, quality health care for the surrounding patient population. By enhancing this invaluable resource through collaboration, DHR is increasing the availability of primary healthcare for high-risk patients that have no other options once stabilized and released. The HOPE clinic represents an opportunity for patients to receive health care at the right time within the right setting helping to reduce readmissions. The HOPE clinic benefits through collaboration with DHR by positioning itself to continuously bolster its capabilities and expand its outreach within the community. Patient: Over the three years, patients are expected to benefit by receiving the education and healthcare needed to help stabilize and manage their conditions (diabetes, hypertension, high cholesterol, asthma, and heart disease). Improved availability within this resource allows opportunities for follow-up health care, decreased admissions/readmissions, and improving on potentially preventable conditions further increasing the quality of life for the benefiting patient base. How this project is related to regional goals: This project aligns itself with the regional goal of increasing healthcare availability to the indigent population. Increasing the service capacity of the HOPE clinic directly supports community need 1 (CN1), “Access to primary and specialty healthcare”. Increased access to primary health care supports the right care in the right setting methodology that improves overall admission and readmission rates. Additionally, the HOPE clinic offers free/donation based counseling services at to patients and community members in need. Through this waiver, behavioral services can become more available which also supports community need 2 (CN2), “Shortage of behavioral health care professionals and inadequate access to behavioral health care”. Starting Point/Baseline: In FY11 the HOPE Clinic provided approximately 3000 patient encounters. This will be the baseline as the project gets off the ground within DY3 and continues to expand services through DY5. Quantifiable Patient Impact: One of the primary goals of the project is increasing primary care availability through making available permanent healthcare providers modifying the current model that operates through volunteer based staffing. Once clinical service capacity has expanded, there will be a minimum of a 10% increase in patient encounter volumes in DY4 and a 15% increase in patient encounter volumes in DY5. Rationale: RHP5 is historically considered a medically underserved area with high levels of indigent population living at or below the federal poverty line. As a result, this segment of the population is often at the highest risk for developing chronic diseases due to a lack of available primary and preventative healthcare. Under these circumstances, family clinics such as the HOPE clinic serve as the last alternative for any type of healthcare for those disenfranchised patients that do not quality for any type of government subsidized healthcare. To magnify the efforts this clinic, project open 1.1.2, “Expand existing primary care capacity”, has been selected.


This project option contains three core components: a.) Expand primary care clinic space, b.) Expand primary care clinic hours and c.) Expand primary care clinic staffing. Milestone 1, P-2, “expand hours in the existing community clinic”, addresses core component “b”. Milestone 2, P-5, “Documentation of increased number of providers and staff”, addresses core component “c”. Improvement milestone, milestone 3 (I-12), has been selected to support the prime objective of this project which is improving on CN1, “Access to primary and specialty healthcare”. Each of the milestones within the selected project option has been selected to further improve access for the uninsured, poverty stricken patients that have nowhere else to turn. Core Components:

• Expand primary care clinic space: Given the time frame of the project, expanding clinical space is not being sought after through this collaboration. The focus of this project is increasing the availability of services within the clinic in which space is not a limitation.

• Expand primary care clinic hours: The clinic is currently closed on Mondays and does not keep any type of evening or weekend hours. Through waiver assistance the clinic is able to expand these hours and provide healthcare to the working poor who cannot otherwise take time off of work to seek primary health care.

• Expand primary care staffing: The clinic is comprised of volunteer healthcare providers. Through collaboration with DHR using the waiver, funding will be allocated towards acquiring part-time and full-time healthcare providers to strengthen the availability schedule and provide more services to the surrounding population.

Related Category 3 Outcome Measures: OD-3: IT-3.3 Diabetes 30-day Readmission Rate Relationship to other Projects: For those patients that qualify for other programs that are being implemented for the waiver, collaboration will expand to these services as well to improve the outcomes for high-risk patients. Such services include:

• Pharmaceutical Care Services [160709501.2.102] • Chronic Disease Registry [160709501.1.105] • Joslin Clinic Expansion [160709501.1.102] • Diabetes Mental Health Expansion [160709501.1.108]

Collaboration within these projects allows for a continuum of health for high-risk patients moving them from primary to specialty care, and making diabetes specific behavioral health available. Qualifying patients will be managed through the chronic disease registry to initiate follow-up care is initiated and kept track of. Plan for Learning Collaborative: Doctors Hospital at Renaissance will participate in the statewide learning collaborative that is being organized by the Texas Health and Human Services Commission. Every effort will be made to collaborate with the RHP5 anchor in providing any and all results from the implemented projects including lessons learned. All findings will be supported by data and provided in a meaningful manner so that other participating providers can contribute as well. Project Valuation:


When placing a value on this project the targeted patient population represented the most important factor. The clinic serves a 100% uninsured patient population that will be granted an increased availability to primary healthcare to help prevent the advancement of any comorbidities meanwhile keeping these patients out of the emergency department. Another variable that plays on the valuation of the project is the hard costs that come with expanding services by bringing in full-time staffing. . As volumes increase with the presence of full-time providers the costs of supplies and medications also increases. We believe that the costs of this project are far exceeded by the opportunity to provide quality, appropriate, and timely healthcare to a population that traditionally would go without.




Provider Name/TPI: Columbia Valley Healthcare System, L.P. d/b/a Valley Regional Medical Center / 020947001

Project Description 1.9.2 - Expand Specialty Care Capacity – Improve Access to Specialty Care – Diabetes Clinic - Valley Regional Medical Center (Valley Regional) intends to improve access to specialty care by expanding the hours of availability for its diabetes clinic. This region has had deficient service availability to diabetics and the patient population susceptible to diabetes. Valley Regional has had success with a diabetes clinic, but has had limited availability because of financial constraints. The objective of this project is to increase the capacity to provide specialty care services. This project will increase service availability with extended hours.

Description of Intervention Valley Regional will expand the services provided at the diabetes outpatient clinic. This program will focus on evaluation, education, nutrition, and ongoing assessment to reduce the complications of diabetes and help our diabetic population better manage their disease. This project will be comprised of the following milestones. P-11 – Expand specialty care clinic P-20: Review project data and respond to it every week with tests of new ideas, practices, tools, or solutions. This data should be collected with simple, interim measurement systems, and should be based on self-reported data and sampling that is sufficient for the purposes of improvement; and I‐22.2 - Increase the number of clinic hours available for the diabetes clinic. Total patient impact: 4,500 patient encounters; Medicaid and Uninsured patient impact: 1,800 patient encounters. Activities may include, but are not limited to, identifying project impacts, identifying “lessons learned,” opportunities to scale all or part of the project to a broader patient population, and identifying key challenges associated with expansion of the project, including special considerations for safety-net populations.

Need for the project The RHP 5 plan notes diabetes and obesity as its first “key health challenge.” (RHP 5 Plan, Page 7). The plan cites diabetes and obesity as the third leading cause of mortality in this region behind heart disease and cancer, and an underlying component of over half of hospital admissions for heart attack, hypertension, sepsis and stroke. (RHP Plan, Page 29-30). Two community needs identified in the RHP 5 plan include the inadequate integration of care and the lack of patient-centered care. (CN3 and CN4). This project will attempt to target a more patient centered model and integrate care and address one of the biggest health challenges in the region.

Target population Valley Regional expects to have a large impact on the Medicaid and uninsured population in the region. Currently, Valley Regional serves a patient population that is at least 47% Medicaid eligible or uninsured. Valley Regional expects this project’s impact to be at 40% for the Medicaid and uninsured population.



Valley Regional to increase treatment for Type II diabetes for targeted pre-diabetics in the community through provider-furnished education and management about lifestyle choices, medications, and risks. Additionally, Valley Regional expects a higher rate of controlled diabetes among community members with this chronic disease. Valley Regional intends to provide 1000 patient encounters in DY3, 1,500 patient encounters in DY4, and 2,000 patient encounters in DY5 for a total intervention of 4,500 patient encounters in DY3-DY5.


IT‐1.11 Diabetes care: BP control (<140/80mm Hg)234 – NQF 0061 (Standalone measure) – helping patients control their blood pressure. Valley Regional aims to improve the percentage of patients in Cameron County with uncontrolled blood pressure by educating the diabetic community on diabetes medication and diet management tactics, leading to better control of diabetic conditions. Patient education, follow-up, and management will result in better overall health outcomes for the targeted population, including increased quality of life, reduced use of acute care, and slower progression of this chronic disease. Achieving this outcome will require Valley Regional to not only communicate with the target population, but to affect their lifestyle choices. Patients will need to reduce poor eating habits, increase physical activity, and manage their medications (when applicable), which Valley Regional cannot force patients to do on a regular basis. Valley Regional intends to reach out to the community through innovative methods (including social media, creating coalitions, and other methods of community outreach) to create support networks and community engagement in accomplishing this outcome, which is meant to benefit individuals at-risk and the community as a whole.


Project Narrative


• Title of Project: Expand Specialty Care Capacity – Improve Access to Specialty Care – Diabetes Clinic





• Overview of Project: Valley Regional intends to improve access to specialty care by expanding the hours of availability for its diabetes clinic. This region has had deficient service availability to diabetics and the patient population susceptible to diabetes. Valley Regional has had success with a diabetes clinic, but has had limited availability because of financial constraints. The objective of this project is to increase the capacity to provide specialty care services. This project will increase service availability with extended hours.

• Project Goals: Valley Regional will expand the services provided at the diabetes outpatient clinic. This program will focus on evaluation, education, nutrition, and ongoing assessment to reduce the complications of diabetes and help our diabetic population better manage their disease.

• Challenges or issues faced by the Performing Provider: Valley Regional has a high readmission rate for patients with diabetes because diabetic patients and families can be resistant to dietary restrictions and exercise and sometimes have difficulty complying with consistent blood-sugar monitoring.

• How the project addresses those challenges: By expanding the availability of care in an outpatient setting, Valley Regional aims to reduce the complication of diabetes. This project will better inform community residents to recognize the signs of diabetes, make necessary lifestyle changes to reduce the complications of diabetes, and better manage the disease once diagnosed. Additionally, greater availability of outpatient services for diabetics should help improve overall health goals for our diabetic patients.


• How the project is related to the regional goals: The RHP 5 plan notes diabetes and obesity as its first “key health challenge.” (RHP 5 Plan, Page 7). The plan cites diabetes and obesity as the third leading cause of mortality in this region behind heart disease and cancer, and an underlying component of over half of hospital admissions for heart attack, hypertension, sepsis


and stroke. (RHP Plan, Page 29-30). Two community needs identified in the RHP 5 plan include the inadequate integration of care and the lack of patient-centered care. (CN3 and CN4). This project will attempt to target a more patient centered model and integrate care and address one of the biggest health challenges in the region.

• Specialty care information (for projects from project option 1.9): All specialty projects should provide

answers to the following questions: 1) Does the project include a clear description of specialties that the initiative is focusing on? This project focuses on health issues affecting diabetics in an outpatient setting. 2) Are selected specialty areas in high need for the Medicaid/uninsured population? Diabetes is RHP 5’s greatest health challenge. Additionally, this region lacks adequate primary and specialty care options for diabetics. 3) Are high-intensity specialties in areas of high need for the Medicaid/uninsured population? Many Medicaid and uninsured patients cannot get adequate services

In addition, 1.9 projects are required to have two (2) QPI metrics:

• Metric representing total QPI (all patients served): 4,500 total patients encounters • QPI for the Medicaid/low-income uninsured population: 1,800 patient encounters

• Starting Point/Baseline: Valley Regional has not established a baseline because this is a new initiative.

Valley Regional expects to have 1000 patient encounters in the first year (40% of which should be Medicaid or uninsured).

• Quantifiable Patient Impact: Valley Regional will increase the number of specialty care encounters provided. Valley Regional expects an increase care for Type II diabetes for targeted pre-diabetics in the community through provider-furnished education and management about lifestyle choices, medications, and risks. Additionally, Valley Regional expects a higher rate of controlled diabetes among community members with this chronic disease. Valley Regional intends to provide 1000 patient encounters in DY3, 1,500 patient encounters in DY4, and 2,000 patient encounters in DY5 for a total intervention of 4,500 patient encounters in DY3-DY5.



o DY 5: 2,000 total patient encounters, of those 800 will be from the Medicaid/uninsured population

• Rationale: The RHP 5 plan notes diabetes and obesity as its first “key health challenge.” (RHP 5 Plan, Page 7). The plan cites diabetes and obesity as the third leading cause of mortality in this region behind heart disease and cancer, and an underlying component of over half of hospital admissions for heart attack, hypertension, sepsis and stroke. (RHP Plan, Page 29-30). The lack of primary care in the community (CN.1) means that providers must try more innovative approaches to addressing the region’s top health challenge, including community outreach and school-based programs. Two additional community needs identified in the RHP 5 plan include the inadequate integration of care and the lack of patient-centered care. (CN3 and CN4). This project will attempt to target a more


patient centered model and integrate care and address one of the biggest health challenges in the region. This is a new project for Valley Regional. Valley Regional selected the following three milestones: P-11 – Expand specialty care clinic; P-20: Review project data and respond to it every week with tests of new ideas, practices, tools, or solutions. This data should be collected with simple, interim measurement systems, and should be based on self-reported data and sampling that is sufficient for the purposes of improvement; and I-22.2 - Increase the number of clinic hours available for the diabetes clinic. Valley Regional selected these milestones because they most closely align with the hospital’s potential to develop a meaningful intervention. This project addresses multiple community needs and the most pervasive health challenge in the region. Valley Regional aims to reduce the complication of diabetes through greater access to specialty care.


o Valley Regional will accomplish the CQI core components by increase the number of clinic hours available for the diabetes clinic.

o Valley Regional will also accomplish the CQI core components by reviewing project data and responding to it every week with tests of new ideas, practices, tools, or solutions, which will collect data with simple, interim measurement systems, and based on self-reported data and sampling that is sufficient for the purposes of improvement.


• Related Category 3 Outcome Measure(s): IT-1.11 Diabetes care: BP control (<140/80mm Hg)234 – NQF 0061 (Standalone measure) – helping patients control their blood pressure. Since diabetes-related complications are a substantial issue for this region, this outcome matches the intent of the project and an important area where this region could show improvement. Valley Regional has not established a baseline for this measure yet, but 26% of Rio Grande Valley residents currently suffer from diabetes, indicating there is a substantial need for providers to focus on these issues. Valley Regional aims to improve the percentage of patients in Cameron County with uncontrolled blood pressure by educating the diabetic community on diabetes medication and diet management tactics, leading to better control of diabetic conditions. Patient education, follow-up, and management will result in better overall health outcomes for the targeted population, including increased quality of life, reduced use of acute care, and slower progression of this chronic disease. Achieving this outcome will require Valley Regional to not only communicate with the target population, but to affect their lifestyle choices. Patients will need to reduce poor eating habits, increase physical activity, and manage their medications (when applicable), which Valley Regional cannot force patients to do on a regular basis. Valley Regional intends to reach out to the community through innovative methods (including social media, creating coalitions, and other methods of community outreach) to create support


networks and community engagement in accomplishing this outcome, which is meant to benefit individuals at-risk and the community as a whole.

• Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): Diabetes and diabetes related complications are one of the key health challenges in this region, leading some other providers to submit projects that touched on diabetes related issues. However, only two current projects in the region address diabetes issues: one project for a region-wide disease registry and one for gestational diabetes. This project addresses a key health need in this part of the region, Cameron County, and is the only project in this county that proposes this type of intervention. One other provider submitted a similar project for Hidalgo County, but both areas could equally benefit from this type of intervention and there will not be an overlap in the target population.

• Plan for Learning Collaborative: Valley Regional looks forward to participating in RHP 5’s learning collaborative once the Anchor develops the plan for the learning collaborative. For this project, the reduction of diabetes-related complications should lead to substantial benefits across the region. This is one of the region’s highest health priorities and many providers are implementing projects aimed at reducing the number of patients with diabetes and reducing the complications of that disease. A regional learning collaborative should focus on determining the most effective means of implementing change with this region’s population, particularly its school-aged population.

Project Valuation: Valley Regional valued this project at $2,800,000 over the 3 remaining years of the Waiver. This value is based on the substantial need for this project and the impact on 4,500 patient encounters. Valley Regional expects this project’s patient impact to be approximately 40% Medicaid and uninsured patients. This project meets a key community need concerning diabetes-related illnesses and expands access to specialty care.


Project Title: Expand Mobile Clinic: Expand existing primary care capacity. Unique RHP Project ID number: 94113001.1.100 Performing Provider/TPI: South Texas Health System / 094113001 Project Option: 1.1.3

PROJECT SUMMARY

Provider Description South Texas Health System consists of McAllen Medical Center, McAllen Heart Hospital, Edinburg Regional Medical Center/Edinburg Children’s Hospital, and South Texas Behavioral Hospital (STBHC), a 134 bed inpatient, acute care hospital in Edinburg, TX. In addition, STHS is associated and works closely with Cornerstone Regional Hospital (50:50 JV local physicians) & McAllen Medical Center Physicians (501A). As a system, STHS is one licensed hospital with four campus locations. Total licensed beds are 848. The primary market area is Hidalgo County in South Texas on the US/Mexico border. Secondary market are includes the surrounding counties of Cameron, Brooks, and Starr.

Project Description Through the development of a mobile primary care unit, the surrounding rural and McAllen/Edinburg communities will have the opportunity to access a variety of health resources in a timely and cost effective manner. Specifically, STHS will equip the mobile unit with capabilities that will offer preventive screenings particular to the RHP population. These screenings will begin with cardiac related studies to include: High Blood Pressure, Peripheral Arterial Disease, and Abdominal Aortic Aneurysm screenings. Radiology technicians capable of performing these studies will staff the clinic along with mid-level support. Radius of travel and clinic hours will be dependent on capabilities of the unit. The mobile clinic will look to expanding capabilities once implemented and will look at increasing its primary care capabilities in order to reach a bigger population within RHP 5.

Intervention(s) We have selected Project Option 1.1.3 Expand Primary Care Capacity: Expand mobile clinics. The Mobile Health Clinic will serve STHS’ primary service area, along with outreaching communities that might not have access to primary care services. STHS will identify a service area in which to deploy the mobile clinic in order to be most effective in reaching a larger population. The clinic will be set up to offer various primary care services, including screenings recommended by the American Heart Association.

Need for the Project As sited in the community needs assessment (CN.1), there is inadequate access to primary and preventive care. Many patients have to drive long distances for medical services making distance a barrier. While the supply is lacking, the need is great: More than half of RHP 5 Mexican-American adolescents and 76% of the region’s adults are overweight or obese. As a result, chronic disease rates are high: heart failure is among the top diseases resulting in hospitalization in RHP 5, renal disease is the second leading cause of hospitalization in RHP 5, South Texas has one of the highest rates of chronic liver disease in the country, 31% of survey respondents reported high cholesterol, and researchers estimate that 273,831 Mexican Americans in the RHP 5 have diabetes, for which 56% are not being treated; 292,271 have hypertension for which 50% are not being treated; and 441,634 have elevated cholesterol for which 85% are not receiving treatment (RHP 5 Community Health Needs Assessment).


Target Population The target population will be patients within our primary and secondary services areas that are unable to access appropriate care due to distance. We expect to provide 1,000 encounters through the mobile clinic in DY 3; 1,200 in DY 4 and 1,400 in DY 5; of which we expect approximately 40%, will be Medicaid, indigent or uninsured.

Category 1 or 2 Expected Patient Benefits Patients that would otherwise not have access to care due to distance; will now have the opportunity to receive primary care services, as evidenced by 1,000 encounters in DY 3 through the mobile clinic, 1,200 in DY 4 and 1,400 in DY 5. We expect patients to benefit from increased access to preventive and primary care, increased screenings and vaccinations/immunizations, more chronic care, improved health outcomes and fewer hospitalizations.

Category 3 Outcomes Expected Patient Benefits We have selected the following outcome:

• IT- 12.6 Influenza Immunization – Ambulatory (NSA) Percentage of patients aged 6 months and older seen for a visit between October 1 and the end of February who received an influenza immunization OR patient reported previous receipt of an influenza immunization. To increase the amount of patients that receive influenza vaccines by 10% by educating them on the importance of vaccine administration, baseline is 20%. • IT – 1.21 Comprehensive Diabetes Care Lipid Testing (NSA) Percentage of patients 18 – 75 years of age with diabetes (type 1 and type 2) who received an LDL-C test during the measurement year. Drop A1c Hemoglobin below 9% for the poorly control population by 10%, baseline is 34.3% • IT – 1.22 Preventive Care & Screening: BMI Screening & Follow Up (NSA)

Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside of normal parameters, a follow-up nutrition plan that is documented within during the current visit, baseline 10%.


Project Title: 1.1.3 Expand Mobile Clinic: Expand existing primary care capacity. Unique Project ID: 094113001.1.100 Performing Provider Name/TPI: South Texas Health System / 094113001 Project Components: 1.1.2.a-c

Project Description: Through the development of a mobile primary care unit, the surrounding rural and McAllen/Edinburg communities will have the opportunity to access a variety of health resources in a timely and cost effective manner. Specifically, STHS will equip the mobile unit with capabilities that will offer preventive screenings particular to the RHP population. These screenings will begin with cardiac related studies to include: High Blood Pressure, Peripheral Arterial Disease, and Abdominal Aortic Aneurysm screenings. Radiology technicians capable of performing these studies will staff the clinic along with mid-level support. Radius of travel and clinic hours will be dependent on capabilities of the unit. The mobile clinic will look to expanding capabilities once implemented and will look at increasing its primary care capabilities in order to reach a bigger population within RHP 5. In our current system patients receive services in urgent and emergent care settings for conditions that could be managed in a more coordinated manner if provided in the primary care setting. This often results in more costly, less coordinated care and a lack of appropriate follow-up care. Patients may experience barriers in accessing primary care services secondary to transportation, cost, lack of assigned provider, physical disability, inability to receive appointments in a timely manner and a lack of knowledge about what types of services can be provided in the primary care setting. By making it more convenient for patients to receive the care they need by providing primary care services in a mobile unit this allows patients to receive the treatment they need without having to travel. Project Goals The project goal is to expand the capacity of primary care, specifically using mobile clinics Hidalgo County area. This expansion would better accommodate the needs of the regional patient population and community, as identified by the RHP needs assessment, so that patients have enhanced access to services that they may not be able to travel to, allowing them to receive the right care at the right time in the right setting. Regional Goals This project would meet the region’s first two goals – to leverage existing infrastructure to meet the region’s primary care needs, and to increase access to primary care.

Challenges The clinic would help a market currently struggling to meet the care they need do to long travel, lack of transportation and lack of access to medical facilities or medical care. The patient’s long distance drive at times prevents them from getting the medical care that they need. The area that the patient lives in does not provide access to primary care services that need to receive the medical care that every patient needs. The 3-year expected outcome(s): As a result of expanded mobile unit services, we expect to provide at least 1,000 encounters in DY 3, 1,200 encounters in DY 4 and at least 1,400 encounters in DY 5. Starting Point/Baseline. Hidalgo County is a medically underserved region. Preventative services/cares and primary care falls under that category. While the supply is lacking, the need is great: More than half of RHP 5 Mexican-American adolescents and 76% of the region’s adults are overweight or obese. As a result, chronic disease rates are RHP Plan for [RHP 5/South Texas] 58

high: heart failure is among the top diseases resulting in hospitalization in RHP 5, renal disease is the second leading cause of hospitalization in RHP 5, South Texas has one of the highest rates of chronic liver disease in the country, 31% of survey respondents reported high cholesterol, and researchers estimate that 273,831 Mexican Americans in the RHP 5 have diabetes, for which 56% are not being treated; 292,271 have hypertension for which 50% are not being treated; and 441,634 have elevated cholesterol for which 85% are not receiving treatment (RHP 5 Community Health Needs Assessment). Rationale The region faces a shortage of primary care professionals to serve a growing population, lagging behind Texas in the supply of patients reeving the care they need due to travel and lack of medical care. Some patients do not have the transportation they need in order to receive the medical care due to this barrier. Others face the obstacle that they cannot get proper medical care because of the convenience of having studies done because the locations for these test are far from their home. Providing the mobile clinic will allow patients to receive the care they need and the test that need to be performed so that medical care is made convenient for the patient. The patients want convenience, getting the medical care they need in areas that are hard to come by will ensure patient health needs are being met and the medical attention is being given. The community needs mobile clinic to service the area in surrounding Hidalgo County that the population is in dire need to medical primary care attention. The current PCP payer mix is 70% Medicaid, indigent, and self-pay. Much of the region is medically underserved. Low-income and minority women and children tend to suffer from poorer health. Project Core Components: This project will address the three required core components in Project Option 1.1.4, as detailed in the RHP Planning Protocol: a) Reopen the labor and delivery service line – We plan to expand current space to accommodate additional practitioners. The new service will have 12 LDRs, 13 bed nursery, 2 C-section suites and 13 postpartum rooms. b) Expand OBGYN practices- This will be evaluated and revised with the additional case load to provide further access. Additional physicians will be added. c) Expand primary care clinic staffing- we plan to hire 2 OB/GYNs. Project milestones: We plan to implement the following process and improvement milestones: Year 3: P-1: Establish additional or expand existing primary care clinics

P-1.1: Number of additional clinics P-2: Implement/expand a community/school-based clinics program

P-2.2: Expanded hours in the existing community/school based clinics program Year 4: P-5: Train/hire additional primary care providers and staff

P-5.2: Documentation of relevant training for new and/or existing provider and staff. Year 5: I-11: Patient satisfaction with primary care services

I-11.1: Patient Satisfaction scores: Average reported patient satisfaction scores, specific ranges and items to be determined by assessment tool scores Unique Community Need Identification Numbers the Project Addresses: CN.1 Inadequate access to primary or preventive care.


How the Project Represents a New Initiative or Significantly Enhances an Existing Delivery System Reform Initiative: This is a new initiative with no related activities that are funded by the U.S Department of Health and Human Services. Related Category 3 Outcome Measure: We have selected three outcome measures:

• IT- 12.6 Influenza Immunization – Ambulatory (NSA) Percentage of patients aged 6 months and older seen for a visit between October 1 and the end of February who received an influenza immunization OR patient reported previous receipt of an influenza immunization. • IT – 1.21 Comprehensive Diabetes Care Lipid Testing (NSA) Percentage of patients 18 – 75 years of age with diabetes (type 1 and type 2) who received an LDL-C test during the measurement year. • IT – 1.22 Preventive Care & Screening: BMI Screening & Follow Up (NSA)

Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside of normal parameters, a follow-up plan is documented within the past six months or during the current visit. Relationship to Other Projects. One of our other DSRIP projects is also focused on improving primary care by implementing the medical home model. Additionally, this project would support population health improvements in Category 4.

Relationship to Other Performing Providers’ Projects in the RHP. STHS has ensured that all project plans meet the community needs and operate in conjunction with the RHP-wide initiatives. Furthermore, our proposed projects meet the needs of specific populations and will not duplicate services of other Performing Provider projects in the RHP. This project focuses on the expansion of Primary Care Expanded Mobile Clinics with these other Category 1 projects in our RHP: 121805903.1.1-Establish More Primary Clinics-Pediatrics; 121805903.1.2 - Establish More Primary Care Clinics-Primary Care;112671602.1.1-Expand Existing Primary Care Capacity; 1328296208.1.1-Establish More Primary Care Clinics.

Plan for Learning Collaborative. Many of the projects chosen by RHP 5 shift from traditional models of care delivery to more patient-focused, community-based, coordinated points of access and care transitions. As the region’s providers implement these new models of care delivery it is important that we share and learn from each other’s successes and challenges. Our collective learning will help in the transformation of our region towards better health and improved coordination. Our shared learning will also help in the identification of best practices and enhance the equity of services across the region. Project Valuation: The addition of the mobile clinics we will expand the capacity of primary care to better accommodate the needs of the regional patient population and community, as identified by the RHP needs assessment, so that patients have enhanced access to services, allowing them to receive the right care at the right time in the right setting. In our current system, more often than not, patients receive services in urgent and emergent care settings for conditions that could be managed in a more coordinated manner if provided in the primary care setting. This often results in more costly, less coordinated care and a lack of appropriate follow-up care. By adding mobile clinics, patients will be able to receive the care they need without having to travel, bring patient awareness of preventative measures they can take, patients and their families will align themselves with the primary care system resulting in better health outcomes, patient satisfaction, and appropriate utilization and reduced cost of services. Providing the targeted population with proactive care RHP Plan for [RHP 5/South Texas] 60

early on in their pregnancy will result in savings if the condition is managed and does not require expensive ED visits, inpatient hospitalization, or other extensive treatments. With proactive education, monitoring and treatment, STHS anticipates a reduction in Comprehensive Diabetes Care Lipid Testing (NSA), Preventive Care & Screening: BMI Screening & Follow Up (NSA) and Influenza Immunization – Ambulatory (NSA.)


Project Title: Workforce enhancement initiatives will be developed to increase access to inpatient and outpatient services. Unique RHP Project ID number: 94113001.1.101 Performing Provider/TPI: South Texas Health System / 094113001 Project Option: 1.14.1

PROJECT SUMMARY

Provider Description South Texas Health System consists of McAllen Medical Center, McAllen Heart Hospital, Edinburg Regional Medical Center/Edinburg Children’s Hospital, and South Texas Behavioral Hospital (STBHC), a 134 bed inpatient, acute care hospital in Edinburg, TX. In addition, STHS is associated and works closely with Cornerstone Regional Hospital (50:50 JV local physicians) & McAllen Medical Center Physicians (501A). As a system, STHS is one licensed hospital with four campus locations. Total licensed beds are 848. The primary market area is Hidalgo County in South Texas on the US/Mexico border. Secondary market are includes the surrounding counties of Cameron, Brooks, and Starr.

Project Description South Texas Behavioral Health Center, a facility within South Texas Health System, proposes to hire 2 full time Board Certified Psychiatrists to treat adults and children in the inpatient and outpatient setting and 1 full time licensed clinical Psychotherapist to fill the vast void in availability of psychiatric specialists.

Intervention(s) Project Option: 1.14.1 has been selected. Workforce enhancement initiatives will be developed to increase access to inpatient and outpatient services. The 2 Psychiatrists and one licensed clinician (i.e., LPC, LCSW) will serve indigent behavioral health consumers in HPSA areas and in localities within non-HPSA counties which do not have equal access to county programs. The project will enhance current psychiatric services by hiring 2 full time Board Certified Adult and Child Psychiatrists.

Need for the Project As cited in the community needs assessment (CN.2), there is a shortage of behavioral health providers including Psychiatrists. Currently, this region has 13 actively practicing Psychiatrists with a waiting period of approximately 6 months for appointments. Of the 13, only 54% are taking new patients for outpatient treatment covering a population of 1.3 million. The lack of Psychiatrists available to treat patients in the inpatient setting results in current staff Psychiatrists carrying high volume case loads. In the outpatient setting, not having an adequate number of Psychiatrists who provide services, leads to crisis situations resulting in the need for costly and lengthy inpatient treatment.

Target Population The target population is the estimated 298,500 (28.6%) people in the RHP5 adult population with a measurable level of depression based on a random population survey. This excludes the Veteran’s Administration population and children and adolescents in the region. Expected impact (total patients per year): DY3-2,000, DY4-2,500, D35-3,500 additional individuals receiving behavioral health services available due to the provider enhancements created under this initiative.

Category 1 or 2 Expected Patient Benefits


It is expected that 2,000 individuals with behavioral health illnesses will be served in DY3; 2,500 in DY4 and 3,500 in DY5 translating to a 5% reduction in inappropriate use of emergency room and medical floor care. Patients would greatly benefit from increased availability of outpatient services at the critical time it is needed—before a potentially life threatening crisis occurs. Patients who require 7 day post discharge appointments will be seen in the required time frame which reduces the likelihood of relapse. Patients in the inpatient setting will benefit from Psychiatrists being able to divide high volume caseloads more evenly. Quantifiable patient impact milestones are to provide: DY3-2,000, DY4-2,500, DY5-3,500 additional individuals receiving behavioral health services available due to the provider enhancements created under this initiative (I-17.1 (QPI) Metric: Increase in number of individuals accessing behavioral health services due to the workforce enhancement initiatives).

Category 3 Outcomes Expected Patient Benefits The following outcomes have been selected from outcome domain 14: IT-2.4 Behavioral Health/Substance abuse (BH/SA) Admission Rate (Standalone Measure). An approximate cost savings of $4,500 per inpatient psychiatric hospitalization will be accomplished by increasing the availability of outpatient psychiatric treatment. Outpatient services will increase the probability of prolonged stabilization of symptoms and avoidance of crisis. IT.14.3 Number of practicing psychiatrist per 1000 individuals in HPSA’s or MAU’s (Standalone measure). Currently, there are an estimated 298,500 adults with a measurable level of depression based on a random population survey excluding Veterans and children and adolescents in the region. Of the 13 psychiatrists, 9 serve the adult population leaving each one to serve a potential patient case load of 33,111 patients—clearly un an unattainable feat. Data regarding identified potential children and adolescents suffering from an untreated mental illness is not available at this time, but the demand is equally unattainable for the 4 remaining Psychiatrists who treat children and adolescents. By DY3, 2000 individuals will be served in the region for outpatient services; DY4 2500; DY5 3500. This projection includes all age categories.


Project Option 1.14.1: Workforce enhancement initiatives will be developed to increase access to inpatient and outpatient services. Unique Project ID: 94113001.1.101 Performing Provider Name/TPI: South Texas Health System/094113001 Project Components: 1.14.1.a-c Project Description: STBHC is the largest provider of inpatient psychiatric services in the region. This has placed us at the forefront of identification of the dire need of Psychiatrists. Efforts to recruit Psychiatrists to the area have not been successful due to the close proximity to the Mexico and the increase in border violence along the Rio Grande River. This has forced stakeholders to explore more creative ways of psychiatric specialist to the region including Psychiatrist and Psychotherapists. The new initiative is to offer full time employment and incentives to such eligible professionals. The STBHC workforce expansion initiative will allow for the employment of 2 full time Board Certified Psychiatrists and 1 full time licensed master’s level Psychotherapist to treat patients in underserved markets in the region. An outpatient practice will be established to offer access to outpatient medication management and psychotherapy providing more opportunity for outpatient stabilization. Increased access to outpatient psychiatric services will allow for patients to avoid crisis situations and subsequent inpatient admissions. The 2 Psychiatrists will also be available to treat patients in an inpatient setting at STBHC. An existing 2400 square foot office space owned by STBHC will be completed to provide these outpatient services. Goals and Relationship to Regional Goals The goal of the workforce expansion project is to increase access to outpatient and inpatient psychiatric services benefiting the indigent public health consumer in HPSA areas. Structured incentive programs to attract and retain these providers will be implemented. Challenges

1. Physician and Psychotherapist recruitment. 2. Demands for behavioral health care services are outweighing the availability of Psychiatrists in the

inpatient and outpatient settings. Starting Point/Baseline Currently, baseline data is not available since we do not offer outpatient Psychiatric services. Quantifiable Patient Impact: We have selected QPI metric I-17.1: Increase in number of individuals accessing behavioral health services due to the workforce enhancement initiatives. Projected outcome is a timely provision of access to outpatient and inpatient services. In DY3 2000; DY4 2500; 3500 DY5. This will provide 5% reeducation in inappropriate use of emergency room care and medical floor care. Patients will greatly benefit from increased availability of outpatient psychiatric services. Rationale The addition of 2 Psychiatrists and a licensed Psychotherapist will increase access to inpatient and outpatient services for members in the region in need of behavioral health services. The limited number of available providers leaves patients needing services in limbo while available appointments are secured. This lapse of services leads to patients seeking treatment in emergency rooms. Patients who are not treated in a timely manner may engage in at risk behavior including suicidal and homicidal attempts. Such outcomes have severe and lasting negative effects on families and friends which further exacerbates the need for psychiatric services.


Of the 13 psychiatrists in the region, 9 serve the adult population leaving each one to serve a potential patient case load of 33,111 patients—clearly an unattainable feat. Data regarding identified potential children and adolescents suffering from an untreated mental illness is not available at this time, but the demand is equally unattainable for the 4 remaining Psychiatrists who treat children and adolescents. By DY3, 2000 individuals will be served in the region for outpatient services; DY4 2500; DY5 3500. This projection includes all age categories. Project Milestones Year 1: Milestone P-1: Conduct gap analysis P-1.1 Metric: Baseline analysis of behavioral health patient population which may include elements such as consumer demographics, proximity of sources of specialty care, utilization of emergency departments, other crisis and inpatient services including state hospital services use by residents of the region, incarceration rates, most common sites of mental health care, most prevalent diagnosis, comorbidities; existing provider case load, provider demographics and other factors of regional significance. Milestone I-10: Emergency Department Use I-10.1 Metric: Reduction in inappropriate use of Emergency Department Care by individuals with mental illness or substance use disorders. Baseline will be established in DY3 and measured improvement to be reported in DY4 and DY5. Year 2: Milestone I.11: Consumer satisfaction with Care I-11.1 Metric: Percentage of patients reporting satisfaction with care Year 3: Milestone I.17: Improve access to behavioral health services I-17.1 Metric: Increase in number of individuals accessing behavioral health services due to the workforce enhancement initiatives. Unique Community Need Identification Numbers the Project Addresses CN.2 Shortage of behavioral health care professionals and inadequate access to behavioral health care.

How the Project Represents a New Initiative: This is a new initiative with no related activities that are funded by the U.S Department of Health and Human Services. Project Core Components The core components of psychiatric workforce expansion include: a) Conduct a qualitative and quantitative gap analysis to identify needed behavioral health specialty vocations lacking in the health care region and the issues contributing to the gaps. In order to meet this component, we will hold meetings with various community entities in the behavioral healthcare provision of services will be organized to identify the number of patients who are underserved would benefit from outpatient psychiatric services. The impact of providing such services on admission rates will also be projected. b) Develop plan to remediate gaps identified and data reporting mechanism to assess progress toward goal. The STBHC plan will specifically identify:


• A detailed plan will outline how to resolve the severity of shortages of Psychiatrists and licensed Psychotherapists in the community to service behavioral health patients with no access to psychiatric treatment. Outreach efforts will be explored, outlined and implemented. • A plan will be drafted to identify where Psychiatrists and Psychotherapists can be recruited from including target dates for employment. • STBHC will work with an existing network of inpatient and outpatient providers who are part of the Universal Health Services Behavioral Health Division. Psychiatric recruiters will be identified and utilized. • Psychiatric practitioners will complete continuing education licensure requirements on a yearly basis. A needs assessment will be conducted to identify areas of beneficial education based on the patient needs and prevalence of illness and resources for obtaining education in these areas will be enlisted. c) Assess and refine strategies implemented using quantitative and qualitative data. We will compile data to summarize the number of patients served and the types of diagnosis treated. Analysis will be conducted on the number of inpatient hospitalizations that were avoided due to the provision of implemented outpatient services. A cost quotient will also be totaled to review the economic impact on service provision. Best practices will be compiled and implemented to assure quality and consumer satisfaction. Customizable Process or Improvement Milestones: N/A Related Category 3 Outcome Measure(s) IT-2.4 Behavioral Health/Substance abuse (BH/SA) Admission Rate (Standalone Measure). A cost savings of $4,500 per inpatient psychiatric hospitalization will be accomplished by increasing the availability of outpatient psychiatric treatment. Outpatient services will increase the probability of prolonged stabilization of symptoms and avoidance of crisis. IT-14.3 Number of practicing Psychiatrists per 1,000 individuals in HPSA’s. By recruiting 2 Psychiatrists, the region will have increased access to Psychiatric treatment. Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): Relationship to Other Projects: Other related STHS projects supported by the workforce enhancement project will be Telemedicine 94113001.2.100 and Patient Care in Medical Home Model 94113001.2.101. Relationship to other Performing Providers in the RHP South Texas Health System has ensured that all project plans meet the community needs and operate in conjunction with the RHP-wide initiatives. Border Region Behavioral Health in RHP05 is another Performing Provider doing this project (121989102.1.2); however, demographically they are located 228 miles from the area this project proposed to encompass. Our proposed projects meet the needs of specific populations and will not duplicate services of other Performing Provider projects in the RHP. Project Valuation Approach/Methodology Providing increased psychiatric staff for inpatient and outpatient treatment will:

1. Serve approximately 5,000 new behavioral health patients for the duration of the waiver who otherwise would not be served in the region.

2. Will reduce overutilization of emergency rooms and medical floors in DY3 20%; DY4 25%; DY5 35%. 3. Lower the percentage rate of preventable inpatient psychiatric admissions. 4. Suicide and homicide rates will decrease in the area due to access to services which provide early

intervention and prevention of crisis. Baseline data will be explored since it is unavailable at this time.



Unique Project Identifier: 112716902.2.102 Provider Name/TPI: Rio Grande Regional Hospital (Rio) / 112716902

Project Description 2.12.2: Implement Pilot Intervention – Emergency Department Care Transitions: This project is twofold and focuses on improving the efficiency of operations of Rio’s Emergency Department – from a patient’s initial triage and coordination efforts upon arrival to the ED through follow up care and partnership with community providers. The project first focuses on patients brought to the ED from the scene of an accident or home – typically patients are brought to Rio with very little lead-time or detailed information on the severity of the injury or condition of the patient; therefore, every moment is critical in getting the patient the right care by the right personnel. Case management staff will partner with first responders to get ED physicians as much information as possible prior to arrival, and ensure that ED protocols are followed, which will result in a support staff framework ready to accept the patient. The second part of this project focuses on the patient’s transition to post-acute care – whether that is to the home, or to another local community provider for more comprehensive follow up care. This project will add at least 3 new staff to the ED care team to manage patients throughout the continuum of care (including a social worker, a community provider liaison, and an additional case manager, as well as training for current ED personnel and physicians to more efficiently guide patients through an acute injury. This project will also include investment in technology, including connecting the ED staff with follow up care providers through HealthPost – a software that aids in finding a follow up appointment in a non-acute setting. This follow up care will reduce readmissions by providing patients a resource for questions and issues after a hospital stay, as well as better identification of patients with persistent chronic conditions that are high-risk for readmission.

Intervention(s) In DY3, Rio plans to develop a staffing and implementation plan and implement standardized care transition processes in specified patient populations. This project will create a more efficient emergency response from the time the patient presents to the ED through the patient’s discharge and follow up care. This project will include the following milestones:

• P-7 Develop a staffing and implementation plan to accomplish the goals/objectives of the care transitions.

• P-12: Participate in face-to-face learning (i.e. meetings or seminars) at least twice per year with other providers and the RHP to promote collaborative learning around shared or similar projects.

• I-14 Implement standard care transition processes in specified patient populations • I-11 Increase % of patients and families in defined population receiving standardized communication

per developed protocols.

Need for the project This region experiences a lack of patient-centered care (CN.4), and inadequate integration of care for individuals with multiple health issues (CN.3). Efficient response to emergent conditions, as well as early identification and intervention of chronic conditions has been shown to lead improved patient outcomes and decreased overall healthcare costs. Addressing health concerns specific to this population should help reduce overall costs by providing ongoing treatment to this population.


In addition to receiving delayed or inappropriate care, patients relying on the emergency department for primary care services and chronic care case management do not receive care coordination and case management that is proven to improve patient health and outcomes. Uncoordinated care can lead to bad health outcomes, particularly when when test results are not communicated to the patient or providers, patients receive prescription medications that cause serious reactions, or patients fail to receive necessary follow-up care when dismissed from a hospital. It also adds to duplicative services that increases costs and exposes patients to unnecessary risks associated with certain services. According to a study published in the American Journal of Managed Care, roughly 30 percent of annual health care spending is estimated to be unnecessary. This project, focused on reducing readmission rates for chronically ill patients, supports the overall goal of the Waiver to implement strategies to decrease health care costs through the provision of preventative medicine and delivery of care in the appropriate setting. The Region has a high rate of patients suffering from chronic illnesses, and these patients are frequently readmitted for avoidable reasons. Evidence indicates that appropriate follow-up care and monitoring of patients with chronic illnesses is a key component to reducing readmission rates and lowering health care costs associated with repetitive readmissions. This project (focused on efficient operations including reducing readmission rates for chronically ill patients) supports the overall goal of the Waiver to implement strategies to decrease health care costs through the provision of preventative medicine and delivery of care in the appropriate setting. This project is a new initiative because it creates a new process establishing contact with post-discharged chronically ill patients.

Target population The target population consists of: (1) patients transitioned to the ED from first responders and local EMS providers, and (2) the patient population with a high-risk of readmission due to chronic disease or other factors. This project will target these populations in order to effectuate better health outcomes, which will benefit the overall healthcare delivery system, as well as individual patient outcomes. Approximately 64% of the ED patient population is Medicaid eligible or uninsured. We expect that this project will reflect a similar benefit to Medicaid eligible and indigent patients.

Category 1 or 2 expected patient benefits Rio expects to develop standardized protocols for patients that come through the ED, and increase the percentage of patients that are receiving care under those standardized protocols over the three remaining years of the demonstration. Rio expects the following patient impact in each remaining demonstration year: DY3: 4,653 total patient encounters, of those 2,978 will be from the Medicaid/uninsured population; DY4: 18,615 total patient encounters, of those 11,913 will be from the Medicaid/uninsured population; DY 5: 24,820 total patient encounters, of those 15,884 will be from the Medicaid/uninsured population

Category 3 outcomes expected patient benefits IT 3.1 – Reduce the all-cause 30-day readmission rate - Populations affected by frequent readmissions include patients with chronic diseases, complex medical and social needs and patients with little or no funding resources for post-acute care needs. Evidence suggests that the rate of avoidable re-hospitalization can be reduced by improving core discharge planning and transition processes out of the hospital, and by improving transitions and care coordination at the interfaces between care settings. A measurable reduction in Rio’s all-cause 30-day readmission rate will indicate that Rio has made progress towards these goals.


Project Narrative


• Title of Project: Implement Pilot Intervention – Emergency Department Care Transitions





• Overview of Project: This project is twofold and focuses on improving the efficiency of operations of Rio’s Emergency Department – from a patient’s initial triage and coordination efforts upon arrival to the ED through follow up care and partnership with community providers. The project first focuses on patients brought to the ED from the scene of an accident or home – typically patients are brought to Rio with very little lead-time or detailed information on the severity of the injury or condition of the patient; therefore, every moment is critical in getting the patient the right care by the right personnel. Case management staff will partner with first responders to get ED physicians as much information as possible prior to arrival, and ensure that ED protocols are followed, which will result in a support staff framework ready to accept the patient. The second part of this project focuses on the patient’s transition to post-acute care – whether that is to the home, or to another local community provider for more comprehensive follow up care. This project will add at least 3 new staff to the ED care team to manage patients throughout the continuum of care (including a social worker, a community provider liaison, and an additional case manager, as well as training for current ED personnel and physicians to more efficiently guide patients through an acute injury. This project will also include investment in technology, including connecting the ED staff with follow up care providers through HealthPost – a software that aids in finding a follow up appointment in a non-acute setting. This follow up care will reduce readmissions by providing patients a resource for questions and issues after a hospital stay, as well as better identification of patients with persistent chronic conditions that are high-risk for readmission.

• Project Goals: Rio plans to develop a staffing and implementation plan and implement standardized care transition processes in specified patient populations. This project will create a more efficient emergency response from the time the patient presents to the ED through the patient’s discharge and follow up care. By the conclusion of the project, Rio aims to impact the vast majority of its ED population to improve provision of care in the right setting, by the right personnel, as quickly as possible. This project, focused on reducing readmission rates for chronically ill patients, supports the overall goal of the Waiver to implement strategies to decrease health care costs through the provision of preventative medicine and delivery of care in the appropriate setting.


• Challenges or issues faced by the Performing Provider: In addition to receiving delayed or inappropriate care, patients relying on the emergency department for primary care services and chronic care case management do not receive care coordination and case management that is proven to improve patient health and outcomes. Uncoordinated care can be unsafe for patients, such as when test results are not communicated to the patient or providers, patients receive prescription medications that cause serious reactions, or patients fail to receive necessary follow-up care when dismissed from a hospital. It also adds to duplicative services that increases costs and exposes patients to unnecessary risks associated with certain services. Rio has a high rate of patients suffering from chronic illnesses, and these patients are frequently readmitted for avoidable reasons.

• How the project addresses those challenges: Evidence indicates that appropriate follow-up care and monitoring of patients with chronic illnesses is a key component to reducing readmission rates and lowering health care costs associated with repetitive readmissions. This project (focused on efficient operations including reducing readmission rates for chronically ill patients) supports the overall goal of the Waiver to implement strategies to decrease health care costs through the provision of preventative medicine and delivery of care in the appropriate setting. This project is a new initiative because it creates a new process establishing contact with post-discharged chronically ill patients.

• 3-year expected outcome for Performing Provider and patients: Rio expects to develop standardized protocols for patients that come through the ED, and increase the percentage of patients that are receiving care under those standardized protocols over the three remaining years of the demonstration. Rio expects the following patient impact in each remaining demonstration year: DY3: 4,653 total patient encounters, of those 2,978 will be from the Medicaid/uninsured population; DY4: 18,615 total patient encounters, of those 11,913 will be from the Medicaid/uninsured population; DY 5: 24,820 total patient encounters, of those 15,884 will be from the Medicaid/uninsured population.

• How the project is related to the regional goals: This region experiences a lack of patient-centered care (CN.4), and inadequate integration of care for individuals with multiple health issues (CN.3). Efficient response to emergent conditions, as well as early identification and intervention of chronic conditions has been shown to lead improved patient outcomes and decreased overall healthcare costs. Addressing health concerns specific to this population should help reduce overall costs by providing ongoing treatment to this population.



to have 4,653 patient encounters in the first year (2,978 of which should be Medicaid or uninsured).

• Quantifiable Patient Impact: Rio expects the following patient impact in each remaining demonstration year: DY3: 4,653 total patient encounters, of those 2,978 will be from the Medicaid/uninsured population; DY4: 18,615 total patient encounters, of those 11,913 will be from the Medicaid/uninsured population; DY 5: 24,820 total patient encounters, of those 15,884 will be from the Medicaid/uninsured population.


• Rationale: Efficient response to emergent conditions, as well as early identification and intervention of chronic conditions has been shown to lead improved patient outcomes and decreased overall healthcare costs. Addressing health concerns specific to this population should help reduce overall costs by providing ongoing treatment to this population. This region experiences a lack of patient-centered care (CN.4), and inadequate integration of care for individuals with multiple health issues (CN.3). This is a new project for Rio. Rio selected the following milestones:

o P-7 Develop a staffing and implementation plan to accomplish the goals/objectives of the care transitions;

o P-12: Participate in face-to-face learning (i.e. meetings or seminars) at least twice per year with other providers and the RHP to promote collaborative learning around shared or similar projects. At each face-to-face meeting, all providers should identify and agree upon several improvements (simple initiatives that all providers can do to “raise the floor” for performance). Each participating provider should publicly commit to implementing these improvements;

o I-14 Implement standard care transition processes in specified patient populations; and

o I-11 Increase % of patients and families in defined population receiving standardized communication per developed protocols.

Rio selected these milestones because they most closely align with the hospital’s potential to develop a meaningful intervention and demonstrate improvement through operationalizing that intervention.






• Related Category 3 Outcome Measure(s): IT 3.1 – Reduce the all-cause 30-day readmission rate - Populations affected by frequent readmissions include patients with chronic diseases, complex medical and social needs and patients with little or no funding resources for post-acute care needs. Evidence suggests that the rate of avoidable re-hospitalization can be reduced by improving core discharge planning and transition processes out of the hospital, and by improving transitions and care coordination at the interfaces between care settings. A measurable reduction in Rio’s all-cause 30-day readmission rate will indicate that Rio has made progress towards these goals.


• Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): This is the only project in the region focusing on ED care transitions. Two other providers have projects for care transitions related to diabetics, but this is the only large scale intervention for emergency-services transformation in the region.

• Plan for Learning Collaborative: Rio looks forward to participating in RHP 5’s learning collaborative once the Anchor develops the plan for the learning collaborative. Integration of care and patient centered care are important RHP goals; this project should provide insight into a large-scale intervention targeting our region’s sickest population and those most likely to seek emergency care when other avenues of care could be more appropriate. This initiative should provide insights into cost savings and improvement of care region-wide.

• Project Valuation: Rio valued this project at $13,500,000 over the 3 remaining years of the Waiver. This value is based on the substantial need for this project and the impact on over 24,820 total patient encounters. Rio expects 15,884 of those encounters to be with Medicaid or uninsured patients. This project has a significant impact on our region’s low-income and needy patient population, justifying the value of this project.


Project Option 2.16.1: Implement a telemedicine program with Psychiatric specialists. Unique Project ID: 094113001.2.100 Performing Provider Name/TPI: South Texas Health System/094113001

PROJECT SUMMARY

Provider Description South Texas Behavioral Health Center (STBHC), a facility in the South Texas Health System (STHS), is a 134 bed inpatient, acute care hospital in Edinburg, TX. STBHC serving a population of approximately 1.5 million encompassing 10 counties including: Hidalgo, Cameron, Willacy, Zapata, Starr, Webb, Brooks, Jim Hogg, Kennedy, Duval. South Texas Health System consists of McAllen Medical Center, Edinburg Regional Medical Center, Edinburg Children’s Hospital, and South Texas Behavioral Health Center. Additionally, STHS is associated and works closely with Cornerstone Regional Hospital (50:50 JV local physicians and McAllen Medical Center Physicians (501A). As a system, STHS is a licensed hospital with four campus locations. Total licensed beds are 848. The primary market area is Hidalgo County and South Texas on the US/Mexico border. Secondary market includes surrounding counties of Cameron, Brooks, and Starr.

Project Description A telemedicine program will be established with Psychiatrists making themselves available to consult, evaluate and treat patients at remote sites. South Texas Behavioral Health Center (STBHC), one of 5 hospitals in the South Texas Health System, will contract with 2 Psychiatrists who will provide access to psychiatric services to hospitals, agencies and patients in the region. Currently, South Texas is grossly underserved with the number of Psychiatrists. The telemedicine program would expand the availability of Psychiatrists ultimately improving hospital services and outpatient treatment.

Intervention(s) Project Option: 2.16.1 has been selected. The Telemedicine Program would provide remote consultations to determine treatment options and remote outpatient treatment. The remote consultation will facilitate a face-to-face interview whereby a Psychiatrist can make medication recommendations as well as determine an appropriate level of care as required to meet the patient’s mental health needs while a patient is being treated medically. Outpatient remote services would allow for medication management and crisis intervention.

Need for the Project As cited in the community needs assessment (CN.2), there is a shortage of behavioral health providers as well as an inadequate integration of care for individuals with co-occurring medical and mental illness conditions (CN.3). Texas has the lowest per capita spending rate on mental health services in the country and the community needs assessment finds that the entire South Texas region has a shortage of mental health professionals including Psychiatrists. The lack of psychiatric services in Texas has impacted the state economically as evidenced by overcrowded jail systems since mentally ill individuals are eight times more likely to be incarcerated rather than treated in behavioral health hospitals.

Target Population


The target population will increase and have improved access by providing 1,500 tele-psychiatry consults in DY 3; 2,000 consults in DY 4; and 2,500 in DY 5. It is estimated that 50% of the consults provided will be patients insured by Medicaid, indigent or uninsured individuals. Expected impact (total patients per year): DY3-1,500, DY4-2,000, DY5-2,500 tele-psychiatry consults

Category 1 or 2 Expected Patient Benefits Patients and hospital emergency rooms and medical floors will benefit from increased access to behavioral health services provided directly by a Psychiatrist expeditiously. Patients will no longer have to wait for months to see a Psychiatrist on an outpatient basis. Timely psychiatric interventions will be facilitated for patients at hospital Emergency Rooms and medical floors. Quantifiable patient impact milestones are to provide: DY3-1,500, DY4-2,000, DY5-2,500 tele-psychiatry consults (I-12.2. Metric (QPI): Number of virtual consultations provided)

Category 3 Outcomes Expected Patient Benefits The following outcome has been selected: IT‐2.4 Behavioral Health/Substance Abuse (BH/SA) Admission Rate (Standalone Measure) Emergency room and medical floor length of stay are often extended due to no access to a Psychiatrist to conduct the consult for behavioral health patients. A behavioral health patient who occupies an emergency room or medical floor bed requires more specialized care including the potential need for one-on-one supervision to ensure safety. Additionally, this diverts time and energy from the treatment of other medically ill patients. By giving physician and staff access to specialists, they can determine appropriate treatment and level of care necessary to reduce admission rate. Patients admitted require more intense services such as one-on-one supervision with limited staff resources who need to tend to more medically compromising emergencies. The program proposes to decrease acute admission rates by 5%.


Project Option 2.16.1: Implement a telemedicine program with Psychiatric specialists.

Unique Project ID: 094113001.2.100 Performing Provider Name/TPI: South Texas Health System/094113001 Project Components: 2.16.1.a-j Project Description: The STBHC Telepsychiatry Expansion Program (STEP) will provide virtual psychiatric and clinical guidance and treatment to all participating primary care providers delivering services to behavioral patients regionally. Psychiatrists will make themselves available to consult, evaluate and treat patients at remote sites. South Texas Behavioral Health Center (STBHC), one of 5 hospitals in the South Texas Health System, will contract with 2 Psychiatrists who will provide access to psychiatric services to hospitals, agencies and patients in the region. Currently, South Texas is grossly underserved with the number of Psychiatrists. The telemedicine program would expand the availability of Psychiatrists ultimately improving hospital services and outpatient treatment. As part of this project, we plan to hire a consulting firm that provides Psychiatric treatment via teleconference. Procure equipment and connectivity to enrolled sites including hospital emergency rooms and medical floors and Primary Care Physicians in region. The components of STEP will be implemented as follows:

1. Purchase supplies, equipment and secure networking capability. 2. Provide timely patient consultations at emergency rooms and medical floors by Board Certified

Child/Adolescent and General Psychiatrists via teleconference. 3. Provide outpatient Psychiatric services for the community and post discharged patients. 4. Conduct continuous quality improvement activities. 5. Gather data of daily encounters and outcomes. 6. Protocols and policies will be outlined for the use of STEP.

Starting Point/Baseline: Since this is a new program, we do not have baseline data for tele-psychiatry consults. Our Behavioral Health/Substance Abuse Admission Rate is 300 admissions per month. Quantifiable Patient Impact: We have selected QPI metric I-12.2: Number of virtual consultations provided, consistent with HHSC’s recommended QPI measure for this project option. The projected project outcome is a timely provision of access to Psychiatrists for consultation, evaluation, and treatment. We expect 1,500 tele-psychiatric consults in DY3, 2,000 consults in DY4 and 2,500 consults in DY5. Rationale: The use of Telepsychiatry will greatly increase the access to psychiatric services resulting in efficient designation of disposition, treatment, and mental health stability. Since those seeking services resort to presenting to emergency rooms due to a lack of providers, this adversely affects the operation of the ER in terms of safety, staffing, resources and bed occupancy. Delay in services can lead to misuse of the emergency room and inadequate treatment interventions such as physical restraints. With increased access to Psychiatrists in the inpatient and outpatient setting, the quality of care for patients will improve, inpatient admission decline will reduce costs, and hospital emergency and medical services will be better utilized. This project will benefit the following:


Hospital Emergency Rooms - The remote consultation and evaluation component of the project will allow Psychiatrists located remotely to provide consultations in emergency rooms for behavioral health patients. Currently, there are no Psychiatrists in this region who are available to provide face to face evaluations in emergency rooms. This adversely affects the services provided in the emergency room. Behavioral health patients often require one to one supervision to ensure safety and are in an environment where such supervision cannot be provided due to staffing capability. Emergency room staff commonly are ill equipped to manage the behavior of behavioral health patients and have to resort to supervision by a security officer and at times the use of physical restraints. Emergency room physicians are limited in their ability and comfort level in treating psychiatric disorders. Access to a Psychiatrist may free a bed best suited for a medical emergency with life and death on the line. Hospital Medical Floors – Remote access to Psychiatrists will allow for patients admitted to medical floors to receive timely intervention for their mental health needs. Patients admitted to medical floors may be experiencing medical symptoms that could be more accurately diagnosed as a mental illness such as Anxiety Disorder for a patient complaining of chest pain. Also, patients admitted for medical reasons and are not eligible for a transfer to a behavioral health hospital may need psychotropic interventions while their medical issues are resolved. STEP would allow for determination of the appropriate medications that would begin the mental health stabilization process; provide clearance for discharge; and outline the appropriate level of care for discharge (i.e., nursing home referral). This would also assist families by reducing stress levels that too often are left to wait unnecessarily for appropriate treatment recommendations. Outpatient Services – The demand for outpatient services exist for the community and patients discharged from STBHC. Currently, the lack of outpatient providers in the community results in limited availability for medication management. STBHC offers free intake assessments to determine treatment needs. Adult patients who need outpatient medication management have to wait approximately 6 months for an outpatient appointment. The lapse in services may lead to a crisis that results in the need for an inpatient admission that could be avoided. Families and friends are also adversely affected due to being ill equipped in managing behaviors associated with mental illness (i.e. aggression, substance abuse, etc.) Child and Adolescent Psychiatrists are limited. Of the 2 Board Certified Child Psychiatrists, only one accepts new patients under the age of 12. Additionally, patients who are discharged from inpatient STBHC services are required to follow up with a Psychiatrist within 7 days. The lack of outpatient Psychiatrists in the community makes it very challenging to find a provider who can facilitate medication management within that time frame. The local Mental Health Authority has waiting lists of 6 months. The referral to a Primary Care Provider (PCP) is at times considered. PCP’s may elect to defer psychotropic medication management to a Psychiatrist. Goals and Relationship to Regional Goals STEP’s goals are twofold. First, providing telepsychiatric consults and evaluations in the emergency rooms and medical floors will decrease the wait time, allow for the provision of appropriate and timely treatment of symptoms, and facilitate efficient recommendations for the next level of care. Safety will be enhanced as a result of timely interventions of uncontrollable behaviors (i.e. aggression). Second, patients needing first time outpatient services or post discharge follow up care will be seen in a timely manner resulting in more success in stabilization of symptoms and less need for inpatient treatment. Challenges STBHC is the largest provider of inpatient Psychiatric services in the region. This has placed us at the forefront of identification of the dire need of Psychiatrists. Efforts to recruit Psychiatrists to the area have not been successful due to the close proximity to the Mexico and the increase in border violence along the Rio Grande Valley. This has forced stakeholders to explore more creative ways of servicing the behavioral health


population. Providing private psychiatric services via teleconference will be the first effort made in this geographic area. Challenges include:

3. Physician recruitment. 4. Demands for behavioral health care services are outweighing the availability of Psychiatrists in the

inpatient and outpatient settings. 5. The increasing prevalence of medical issues being part of a behavioral health patient’s treatment needs

has increased the complexity of care and the need for collaboration with mental health professionals in the acute care setting.

6. The lack of available Psychiatrists in the community providing outpatient services, patients resort to presenting themselves in emergency rooms with symptoms that are best suited for treatment in the outpatient setting.

Project Milestones DY3: Milestone 1 [P.3.] Enroll primary care settings into the remote behavioral health consultation services.

Metric 1 [P-3.1] description and number of project documentation Milestone 2 [P.7] Review project data and respond to it every week with tests of new ideas, practices, tools, or solutions.

Metric 1 [P-7.1] Description of the number of new ideas, practices, tools, or solutions tested by each provider Brief description of the idea, practice, tool, or solution tested by each provider each week Milestone 3 [I-12]

Metric I-12.2 provide 1,500 of virtual consultations DY4: Milestone 1 [I-12]

Metric I-12.2 provide 2,000 of virtual consultations DY5: Milestone 1 [I-12]

Metric I-12.2 provide 2,500 of virtual consultations Unique Community Need Identification Numbers the Project Addresses

• CN.2 Shortage of behavioral health care professionals and inadequate access to behavioral health care • CN.3 Inadequate integration of care for individuals with co‐occurring medical and mental illness or

multiple chronic conditions How the Project Represents a New Initiative This is a new initiative with no related activities that are funded by the U.S Department of Health and Human Services in this region. Project Core Components: a) Establish the infrastructure and clinical expertise to provide remote psychiatric consultative services. The assistance of the STHS Information Services Department will be solicited to design and implement the technological component of STEP. A needs assessment of current technology available at participating sites will be conducted. b) Determine the location of primary care settings with a high number of individuals with behavioral health disorders (mental health and substance abuse) presenting for services, and where ready access to behavioral health expertise is lacking. A summary of current available data regarding the origin of referral sources will be RHP Plan for [RHP 5/South Texas] 77

compiled. A final list of resources with the highest number of referrals will be examined and feasibility of connectivity with STEP will be explored. Identify what expertise primary care providers lack and what they identify as their greatest needs for psychiatric and/or substance abuse treatment consultation via survey or other means. A needs assessment will be conducted with providers to identify level of knowledge in treating behavioral health patients. A prioritized list will be compiled of identified needs in assisting them with such patients. c) Assess applicable models for deployment of virtual psychiatric consultative and clinical guidance models. A research initiative will be conducted to identify existing programs with a goal of adapting best practices. d) Build the infrastructure needed to connect providers to virtual behavioral health consultation. This may include: Procuring behavioral health professional expertise (e.g., Psychiatrists, Psychologists, Psychiatric Nurses, Licensed Professional Counselors, Masters level Social Workers, Licensed Chemical Dependency Counselors, Licensed Marriage and Family Therapists, Certified Peer specialists, and Psychiatric Pharmacists,). This will include expertise in children and adolescents (e.g. Child and Adolescent Psychiatrists, Psychologists, Nurses, and Pharmacists); expertise in psychotropic medication management in severe mental illness. This will be accomplished with the assistance of STHS Information Services and required contractors. e) Ensuring staff administering virtual psychiatric consultative services are available to field communication from medical staff on a 24-hour 7 day per week basis. Contract requirements will stipulate the need for 24/7 access. A contract will only be established with an agency that can meet this requirement. f) Identify which medical disciplines within primary care settings (nursing, nursing assistants, pharmacists, primary care physicians, etc.) could benefit from remote psychiatric consultation. A review of current available data will assist with the identification of settings in which access is most needed. g) Provide outreach to medical disciplines in primary care settings that are in need of telephonic behavioral health expertise and communicate a clear protocol on how to access these services. Meetings will be scheduled to review and train methods of accessing the system. h) Identify clinical code modifiers and/or modify electronic health record data systems to allow for documenting the use of telephonic behavioral health consultation. STBHC will work with the STHS Health Information Management, Information Services and Business Office to determine how telephonic services can be coded. STBHC will collaborate with Information Services to outline integration with current electronic medical record system. i) Develop and implement data collection and reporting standards for remotely delivered behavioral health consultative services. Stakeholders will identify the type of data that will need to be collected and determine a reporting methodology. j) Review the intervention(s) impact on access to telephonic psychiatric consults and identify “lessons learned,” opportunities to scale all or part of the intervention(s) to a broader patient population, and identify key challenges associated with expansion of the intervention(s), including special considerations for safety-net populations Data regarding the impact of services will be gathered and reviewed. At the onset of the project, daily meetings will be held to problem solve any glitches in the system. Challenges will be identified and remediated in a timely manner. A communication process will be outlined to share lessons learned to all program participants. Customizable Process or Improvement Milestones: N/A Related Category 3 Outcome Measure(s): IT‐2.4 Behavioral Health/Substance Abuse (BH/SA) Admission Rate (Standalone Measure). Implementing direct tele-psychiatric services in the emergency rooms, medical floors, and private offices will accomplish two benefits for the patients. First, in the hospital environment, psychiatric consultation times will be reduced and treatment will begin in a timely manner. Second, patients will receive direct psychiatric outpatient treatment at the time it is critically needed. Overall, the need for inpatient stabilization admission rates will be reduced resulting in cost savings and consumer satisfaction.


Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): Relationship to Other Projects: This project would support RHP05 94113001.1.100-1.1.3 as well as support population health improvements in Category 4 by reducing Potentially Preventable Admissions and Readmissions (PPAs and PPRs). Relationship to other Performing Providers in the RHP South Texas Health System has ensured that all project plans meet the community needs and operate in conjunction with the RHP-wide initiatives. Our proposed projects meet the needs of specific populations and will not duplicate services of other Performing Provider projects in the RHP. STEP will uniquely serve patients located in private hospital emergency rooms and medical floors; Primary Care Physician offices; Nursing Homes; and patients in underserved areas. These patients will benefit from direct and immediate access to Psychiatrists.

Plan for Learning Collaborative: We plan to participate in the statewide learning collaborative. Our participation in a collaborative will facilitate sharing of challenges and testing of new ideas and solutions to promote continuous quality improvement in our health care system. Project Valuation: Approach/Methodology Providing Telepsychiatry will be a regional asset due to the following:

1. Behavioral health patients will have improved access to Psychiatrists in the emergency room, medical floor, and on an outpatient basis.

2. The accommodation of having a patient in the emergency room seen by a Psychiatrist will reduce consultation wait time by 50%.

3. Telepsychiatry will allow for the reduction of length of stay by 33% in the medical floor since patients will receive a timely face to face consult with a Psychiatrist who can start psychotherapeutic treatment.

4. A cost savings of $4,500 per inpatient psychiatric hospitalization will be accomplished by increasing the availability of outpatient psychiatric treatment. Outpatient services will increase the probability of prolonged stabilization of symptoms and avoidance of crisis.

The estimated total cost for running this program includes personnel; purchased services including regulatory compliance, psychiatric professional services, equipment and supplies; service agreements and repairs; office and administrative supplies; office equipment and furniture; and travel and education. DY 3 costs will be $614,314; DY4 $582,737; DY5 $690,332 totaling $1,887,383 over the three year period.


Project Option 1.2.4 - Establish Primary Care/Preventive Medicine Residency Program Unique Project ID: 160709501.1.100 Performing Provider/TPI: Doctors Hospital at Renaissance / 160709501 PROJECT DESCRIPTION: Doctors Hospital at Renaissance proposes to establish a primary care/Preventive Medicine residency training program. This project is designed to improve patient access to primary care by increasing the physician workforce in RHP 5, a designated health care provider shortage area (HPSA) and improve the health of the community by training physicians who specialize in health promotion and disease prevention. Doctors Hospital at Renaissance (DHR) will establish a new primary care/Preventive Medicine residency training program in partnership with The University of Texas Health Science Center at San Antonio’s Regional Academic Health Center (UTHSCSA RAHC). The new faculty, the resident trainees, and the graduates of the training program will expand the primary care workforce. Allaying the shortage of primary care providers will increase access to care in the appropriate time and place, reduce inappropriate and costly emergency department utilization, increase patient satisfaction, and improve the health of the community. In addition, the Preventive Medicine faculty, trainees, and graduates will help to address the systemic health factors afflicting the residents of RHP 5. These factors include a disproportionate rate of chronic and infectious diseases amenable to preventive medicine and public health interventions. For example, the tuberculosis disease rates in RHP 5 are twice the state rate and over 2.5 times the national rate; additionally, the major populated metropolitan area in RHP 5 is the most obese in the country. When fully implemented in 2017, the new Preventive Medicine residency will have the capacity to train as many as 6 residents – 3 residents in each of two classes. Preventive Medicine is a two-year training program for residents who have already completed one year of residency in another accredited program. The DHR Preventive Medicine training program will complement other new residency programs at DHR, as well as existing, expanding and new programs at other hospitals in RHP 5. Goals and Relationship to Regional Goals:

• To create a Preventive Medicine Residency program with faculty, residents, and graduates who will increase patients’ access to care;

• To create and implement an innovative curriculum that incorporates population health management, chronic disease management, patient-centered medical home, and clinical safety and effectiveness training;

• To transition Doctors Hospital at Renaissance to be a primary teaching hospital for UTHSCSA RAHC in South Texas;

• To infuse the RHP 5 medical community with primary care specialists who will focus on prevention and the root causes of morbidity, thereby improving the overall public health of the community;

• To conduct quality improvement projects to continuously improve clinical outcomes and efficiency; and

• To collaborate with other new and expanding residency training programs in the region to transform the delivery system and the health status of the South Texas community.

This project meets the following regional goals:

• By combining the resources of DHR as a major safety net hospital and The University of Texas, leverage and improve on existing programs and infrastructure to ensure that the health care delivery system will be adequately developed to meet the primary care needs of residents throughout a rapidly growing, yet historically underserved region.


• Increase access to primary care services in the short-term with new faculty, in the intermediate term with resident trainees, and in the long-term with graduate physicians, with a focus on individuals with chronic conditions, to ensure they have access to the most appropriate care for their condition.

• Nurture a culture of ongoing quality improvement and innovation that maximizes the use of technology and best practices to improve access and timely utilization of appropriate care.

• Transform health care delivery to a patient-centered, coordinated and integrated delivery model that improves patient satisfaction and health outcomes, reduces unnecessary emergency department use and duplicative services, and expands on the existing health care system.

• Address the public health issues of the fast-growing, economically and educationally disadvantaged RHP 5 population.

• Address clinical preventive services at the individual patient and community levels to include primary, secondary and tertiary prevention.

Challenges and issues: Creating a new residency program from the ground up is time consuming and requires approval of the Accreditation Council on Graduate Medical Education (ACGME). The Preventive Medicine Residency Review Committee (RRC) meets to review proposals only two times each year. Residency programs must be accredited before the programs can begin to recruit first-year residents who will enter the training program in the following academic year. Addressing the challenges: DHR will partner with UTHSCSA RAHC. UTHSCSA will provide the Program Director and core faculty for the Preventive Medicine Residency Program. UTHSCSA faculty and staff have extensive experience with the accreditation process. DHR and UTHSCSA will work together collaboratively to establish an innovative curriculum including the patient-centered medical home model and chronic care disease management to address the unique needs of RHP 5. 3-year expected outcome for Performing Provider and patients: By the end of the Demonstration Period in September 2016, the first cohort of up to three Preventive Medicine residents will start in July 2016. The initial cohort of residents will complete the two-year program and enter practice in 2018. Supervised residents will begin providing care to patients in 2016. As soon as they are recruited (late DY 3/early DY 4, the Program Director and core faculty members will dedicate 50-75% of their time to clinical care and public health activities. To comply with the ACGME program requirements, residents will demonstrate proficiency in several core competencies – notably for RHP 5, mobilizing community partnerships to identify and solve health problems. In addition to direct patient care requirements, residents must also be assigned to health departments, non-governmental organizations and community-based organizations. Residents must have a minimum of two months experience at a governmental public health agency. At the outset, we project that we will fill two of the maximum three second-year training slots in DY5. By the end of DY5, we expect 2 PGY2 Preventive Medicine residents in training at DHR. The residents will provide patient care in half-day clinic sessions as required by RRC standards. The number of clinic sessions and the number of patient visits per session will increase from DY4 to DY 5 as the number of residents increase along with the maturity of their experience. QUANTIFIABLE PATIENT IMPACT Primary care capacity and patients’ access to primary care will increase as the program matures to full, maximum build-out of 6 Preventive Medicine residents at DHR (3 PM1/PGY2 and 3 PM2/PGY3). The patient access metrics related to faculty practice are limited to incremental access provided by imported faculty physicians new to RHP 5. Accordingly, we project that 500 primary care visits will be provided by new faculty physicians and residents in DY 4 and an additional 750 visits in DY 5 for a cumulative total of 1,250. We


project that 75% of these visits will be with Medicaid and low-income uninsured patients. Public health activities, for which there are no defined QPI metrics, will impact the Medicaid and low-income uninsured population almost exclusively. STARTING POINT/BASELINE DHR currently hosts no residency programs. In all of RHP 5, as of October 2013, existing UTHSCSA-sponsored residency training programs include an Internal Medicine program at Valley Baptist in Cameron County and a Family Medicine program at McAllen Medical Center in Hidalgo County. Valley Baptist also sponsors directly a separate Family Medicine program. Approved DSRIP projects to create new residency training programs are underway currently as noted below. DHR is a 506-bed general acute care hospital located in South Texas. Our hospital was founded to serve over 1.2 million residents and improve health care access in a region that lacked any public or county hospitals. Today, we are working to forge a new integrated health care delivery model that incorporates patient navigation, electronic medical records, population-based care, and superior quality and efficiency to meet every patient’s health needs. DHR offers some of the most comprehensive medical care on the U.S. Southern Border. We are located in a community that Forbes Magazine recently listed as one of the poorest areas in the United States. Despite these challenges, DHR has excelled in the delivery of care and was recently recognized, for the third straight year, by Thompson Reuters as one of the Top 100 Hospitals in the nation. RATIONALE In RHP 5, the shortage of and need for primary care physicians is amply addressed in the community needs assessment of this Plan. The University of Texas’ Board of Regents and the Texas Legislature have authorized the development of UTHSCSA RAHC into a future medical school in RHP 5. In order to retain the future graduates of the new medical school in RHP 5 for eventual community practice, new residency training programs must be established and existing programs must be expanded. The 2011 State Physician Workforce Data Book published by the AAMC Center for Workforce Studies shows that among students who complete both their undergraduate and graduate medical education in Texas, 80% remained in the state to practice. Project components:

• Identify high impact services and gaps in care, coordination, ambulatory and public health • Recruit Preventive Medicine Program Director and core faculty in DY 3 and DY 4

o Program Director: 50% academic time for program development/accreditation activities and 50% patient care/public health time

o Core faculty: 25% academic time and 75% clinical and public health time • Create innovative curriculum including population health management, chronic disease registries, team-

based community care, data analytics, and quality improvement projects using the PDSA and other methodologies contained in the UT System CS&E course

• Provide Clinical Safety & Effectiveness (CS&E) training to faculty and DHR staff • Develop and organize inpatient and ambulatory clinical training/patient care opportunities for Preventive

Medicine at DHR • Complete and submit the Program Information Form (PIF) to the RRC by January 2015 • Attain ACGME approval for the program via RRC meeting in March 2015 • Recruit prospective Preventive Medicine residents in the fall of 2015 • Enroll the first class of Preventive Medicine residents in July 2016

Unique community need identification number the project addresses:

• CN.1 – Shortage of primary and specialty care providers and inadequate access to primary or preventive care


How the project represents a new initiative or significantly enhances an existing delivery system reform initiative: In the area of Texas most in need, south of Austin and west of Houston, there is no Preventive Medicine training program. Meanwhile, a rapidly growing number of Texas medical students are choosing to complete a dual MD/MPH program (Master of Public Health). Having already demonstrated a passion for public health by completing the curriculum that is a core component of the Preventive Medicine program, these students are uniquely qualified for further training and service in RHP 5. They will enter the Preventive Medicine program prepared to hit the ground running, impacting direct patient care and impacting the root causes of poor health in RHP 5 through collaborations with local health departments, as mandated by ACGME Preventive Medicine program requirements. Data Driving this Project: In addition to the staggering prevalence of diabetes and the resurgence of tuberculosis discussed in the community needs assessment, the 2013 County Health Rankings promulgated by Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute highlight the dire condition of public health in RHP 5.

2013 County Health Rankings 232 Texas counties ranked

Cameron Hidalgo Starr Willacy

Health Outcomes 59 41 108 26

Mortality 24 18 41 21

Morbidity 162 144 218 104

Health Factors 213 228 232 227

Health Behaviors 22 74 63 15

Clinical Care 189 191 232 150

Social & Economic Factors 227 229 231 232

Physical Environment 109 189 222 69

www.countyhealthrankings.org

The key factors in RHP 5’s clinical care ranking are the 38% uninsured rate, the shortage of primary care physicians and dentists, the high rate of preventable hospital stays, and the low rate of mammography screening. The key social and economic factors are the low level of college achievement, the high unemployment rate, and the 47% of children living in poverty compared to the state rate of 27%. The relevant physical environment factors are drinking water safety and limited access to healthy foods. Given these statistics, we are certain that a Preventive Medicine training program will make a significant positive impact on the RHP 5 community. Related Category 3 Outcome Measure(s): OD-14 Primary Care Workforce Stand-alone: IT - 14.1 Number of practicing primary care physicians per 100,000 individuals in HPSA or MUA Rationale for selecting the outcome measures: It is challenging to select outcome measures in the early stages of planning the residency program, given the lack of clarity and complete plans about when and where faculty will practice, the part-time nature of that practice, and the fact that three or more years of training are required before the first-matriculated residents will


http://www.countyhealthrankings.org/

begin independent clinic practice. However, because the Program Director and core faculty will be recruited and in place even before the programs are accredited and will dedicate 50-75% of their time to clinical care and public health activities, they will have an impact on the number of practicing primary care physicians per 100,000 individuals in RHP 5. Relationship to other DHR Projects:

• 160709501.1.1 Establish Primary Care/Internal Medicine Training Program; • 160709501.1.2 Establish Primary Care/Family Medicine Training Program; • 160709501.1.3 Establish Primary Care/Obstetrics & Gynecology Training Program; and • 160709501.1.4 Expand high impact specialty care capacity in most impacted medical specialties

(Establish General Surgery Training Program). Relationship to UTHSCSA Projects in RHP 5:

• 085144601.1.1 Expand Primary Care/Internal Medicine Training Program at Valley Baptist - Harlingen;

• 085144601.1.2 Expand high impact specialty care capacity in Adult and Child Psychiatry at Valley Baptist - Brownsville; and

• 085144601.1.3 Increase faculty to support the Family Medicine residency program at McAllen Medical Center.

Plan for Learning Collaborative: All of the new and existing residency training programs in RHP 5 will be/are directed by UTHSCSA faculty. The University of Texas System and UTHSCSA, specifically, have a nationally known Clinical Safety & Effectiveness (CS&E) training program embedded in their medical schools and clinical facilities. CS&E is a training course with PDSA (Plan Do Study Act, rapid cycle improvement) at the heart of the curriculum; a strategic improvement project is required as part of the course. Many faculty and staff adopt CS&E into their ongoing activities after graduation from the training. In addition, UTHSCSA requires all new resident trainees to complete the core curriculum of the IHI Open School prior to joining the training programs. All of the residency training programs will feature innovative curriculum components focused on patient-centered medical home, population health management, team-based community care, integrating primary and specialty care, the use of patient registries, and the application of data analytics. The Program Directors will meet quarterly to discuss and share quality improvement efforts within the context of the CS&E program as well as the common core curriculum components noted above. UT will provide opportunities for DHR physicians and staff to participate in the CS&E course and projects. Project Valuation: In addition to increasing access to primary care, the Preventive Medicine program can positively impact the serious public health issues that increase the burden and cost of poor health in RHP 5. Therefore, we believe that this project’s value is equivalent to the value of other already approved DSRIP residency programs.


Project Title: Conduct Medication Management Unique RHP Project ID number: 154504801.2.100 Performing Provider/TPI: Harlingen Medical Center / 154504801 Project Option: 2.11.2 Project Core Components: 2.11.2.a-c


Harlingen Medical Center is a 112-bed general acute care and Level IV Trauma Designated hospital that specializes in bariatric, cardiology, emergency, gastroenterology, imaging, neurology, pediatric, obstetrics and gynecology, orthopedic, sleep apnea treatment, vascular and endovascular surgery, and wound healing care. Located in Cameron County, the hospital serves a population of 139,392 of which approximately 57.6% are covered by Medicare, 14.2% Medicaid, 16.4% by HMO or PPO, and 11.8% are indigent and/or low income underinsured.

Project Description

This project will implement a medication management program using an outpatient pharmacist, electronic medical records, and computerized physician order entry (CPOE). The medication management program will conduct medication reconciliation, track medications being taken by patients (including use of printed lists), and monitor medication administration. Medication management can help increase patient compliance with an appropriate medication related treatment. Such a program improves patient safety and clinical outcomes because proper medication usage helps patients to control health conditions and improve health outcomes, as well as prevent readmission due to non-adherence to the prescribed medication regimen.

Intervention(s)

We have selected Project Option 2.11.2 Conduct Medication Management: Evidence‐based interventions that put in place the teams, technology and processes to avoid medication errors. This project implements medication management, CPOE, and pharmacist-led chronic disease medication management in order to promote appropriate use of medications to improve health and control conditions.


As cited in the community needs assessment, the region experiences inadequate integration of care for individuals with multiple health issues (CN.3) and a lack of patient-centered care (CN.4). Many patients do not understand their care regimen or may be receiving contradicting information from various providers. This project would improve medication management so that patients – particularly those with multiple health issues – are appropriately and safely using medications to improve their health and avoiding re-hospitalization.

Target population

This project will provide medication management services to 5,459 unique individuals in DY 4 and 5,500 unique individuals in DY 5. Of those patients, we estimate approximately 26% would be Medicaid, indigent, or uninsured. Expected impact (total patients per year): DY3-0, DY4-5,459, DY5-5,500 unique individuals



The project seeks to improve medication management through evidence‐based interventions that put in place the teams, technology, and processes to avoid medication errors and prevent readmissions, as evidenced by an anticipated total of 5,459 unique individuals in DY 4 and 5,500 unique individuals in DY 5 receiving medication management services. Medication management is especially important for patients taking multiple medications to address chronic illness and co-occurring diseases such as acute myocardial infarction (AMI) and congestive heart failure (CHF). This project will increase the number of unique patients that have medications reconciled as a standard part of the discharge process. Patients would benefit from:

• Improved medication reconciliation • Medication orders • Pharmacist consultation • Patient-centered and better coordinated care • Increased understanding of and compliance with the medication regimen • Higher quality health care • Improved health status • Improved patient safety • Reduced risk of re-hospitalization

Quantifiable patient impact milestones are to provide: DY3-0, DY4-5,459, DY5-5,500 unique individuals with medication management services


This project will reduce the rate of readmission for high-risk patients: 1) IT-3.2 Congestive Heart Failure (CHF) 30-day Readmission Rate (Standalone measure) – our goal is to reduce

this rate by 20% over baseline by DY 5 2) IT-3.5 Acute Myocardial Infarction (AMI) 30-day Readmission Rate (Standalone measure) – our goal is to

reduce this rate by 20% over baseline by DY 5 As a result of improved medication management services, we expect CHF and AMI readmission rates to go down as evidence that patients are following the medication regimen needed for their condition.


Project Title: Conduct Medication Management Unique RHP Project ID number: 154504801.2.100 Performing Provider/TPI: Harlingen Medical Center / 154504801 Project Option: 2.11.2 Project Core Components: 2.11.2.a-c Project Description: This project will implement a medication management program using an outpatient pharmacist, electronic medical records, and computerized physician order entry (CPOE). The medication management program will conduct medication reconciliation, track medications being taken by patients (including use of printed lists), and monitor medication administration. Medication management can help increase patient compliance with an appropriate medication related treatment. Such a program improves patient safety and clinical outcomes because proper medication usage helps patients to control health conditions and improve health outcomes, as well as prevent readmission due to non-adherence to the prescribed medication regimen. The overall goal of this project is to implement effective medication management so that patients follow recommended use of medications for optimal control of health conditions, reducing the need for readmission to the hospital environment. Specific project goals include: patients receive clinical pharmacist consultation; patients leave the hospital with a printed and reconciled medication list; medication lists and instructions are maintained in the patient’s medical record; physicians electronically enter instructions for the treatment of patients; physician orders are communicated over a computer network to the medical staff/outpatient pharmacist responsible for fulfilling/re-filling the order; patients are reminded to take their medications; patients can teach-back their medication regimen, including dosage and time; and patients refill prescriptions in the outpatient setting. This project aligns with three of the four regional goals to:

• Leverage and improve existing programs and infrastructure; • Nurture a culture of ongoing quality improvement; and • Transform health care delivery to a patient-centered, coordinated and integrated model.

Starting Point/Baseline: Our CHF 30-day readmission rate is 23.5%; and our AMI 30-day readmission rate is 17.3%. We did not have a medication management program prior to the DSRIP program, so we do not have a baseline. Quantifiable Patient Impact: We have selected QPI metric I-9.1: Increase the number of patients (meeting criteria for chronic condition) contacted or receiving medication management, consistent with HHSC’s recommendation. Rationale: Chronic diseases currently affect 45% of the population (133 million Americans), account for 81% of all hospital admissions, 91% of all prescriptions filled, and 76% of physician visits.12 Chronic disease rates are high among our patient population, and it is recommended that many of these patients take multiple medications to adequately control their diseases. Once a patient leaves our hospital, the lack of access to primary care can put at risk the patient’s adherence to the necessary drug regimen. Pharmacists are not always integrated in patient care, even though medications are involved in 80% of all treatments and impact every aspect of a patient’s life.13 Different providers may prescribe duplicative or contradicting medications to patients. Patients

12 Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care. September 2004 Update. Available at: http://www.rwjf.org/files/research/Chronic%20Conditions%20Chartbook%209-2004.ppt. Accessed on April 17, 2007. 13 Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec 2011. RHP Plan for [RHP 5/South Texas] 87

often do not understand what their medications are, why they are taking them, and how and when to take certain medications. All of these factors negatively affect patient safety, quality of care, patient experience and clinical outcomes. Our readmission rate for high-risk patients is too high and represents readmissions that could have potentially been avoided through better medication management. Medications taken properly can significantly enhance a patient’s health and life; however, patients who take multiple medications, have difficulty understanding the medication regimen or receive confusing information from different providers can actually suffer from an increased health risk. AHRQ finds that medication errors are a frequent cause of adverse drug events, including: missed dose (7%); wrong technique (6%); illegible order (6%); duplicate therapy (5%); drug-drug interaction (3-5%); equipment failure (1%); inadequate monitoring (1%); and preparation error (1%).14 Many readmissions and resulting hospital costs can be reduced if hospitals make changes to their systems for medication reconciliation and patient education on medications. Milestones & Metrics: The following milestones and metrics were chosen for the medication management initiative based on the core components and the needs of the target population:

• Process Milestones and Metrics: P-1 (P-1.1) to implement/expand a medication management program and/or system; P-4 (P-4.1) to implement an evidence based program based on best practices for medication reconciliation to improve medication management and continuity between acute care and ambulatory setting; and P-7 (P-7.1) to implement CPOE to allow providers to enter medical orders directly via computer, replacing the more traditional paper, verbal, telephone, and fax methods.

• Improvement Milestones and Metrics: I-9 (I-9.1) to increase the number of targeted patients consistently receiving medication management counseling at the point of care.

Unique community need identification number the project addresses: • CN.3 – Inadequate integration of care for individuals with co-occurring medical and mental illness or

multiple chronic conditions • CN.4 – Lack of Patient-Centered Care How the project represents a new initiative or significantly enhances an existing delivery system reform initiative: This is a new initiative with no related activities that are funded by the U.S Department of Health and Human Services. Project Core Components: This project option could include one or more of the following components: a) Implement a medication management program that serves the patient across the continuum of care targeting one or more chronic disease patient populations. We will be coordinating with community pharmacy and physicians to improve medication reconciliation and medication management with pharmacist oversight. We will be targeting high-risk patients, defined as patients at risk for readmission for AMI or CHF. b) Implement Computerized Physician Order Entry (CPOE). We expect to implement CPOE by January/February 2014. c) Implement pharmacist-led chronic disease medication management services in collaboration with primary care and other health care providers. We will be using pharmacy review of medication reconciliation and medication management during hospitalization and on discharge for allergies, incompatibilities and duplication of pharmacology. As stated above, these will be part of the patient’s continuum of care, and we will be collaborating with community pharmacy and physicians to improve medication reconciliation and medication management with pharmacist oversight. Customizable Process or Improvement Milestones: N/A

14 AHRQ, “Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs,” http://www.ahrq.gov/research/findings/factsheets/errors-safety/aderia/index.html. RHP Plan for [RHP 5/South Texas] 88

http://www.ahrq.gov/research/findings/factsheets/errors-safety/aderia/index.html

Related Category 3 Outcome Measure(s): We have selected from outcome domain 3: Potentially Preventable Readmissions (PPRs) – 30‐day Readmission Rates, the following two outcome measures:

1. IT‐3.2 Congestive Heart Failure (CHF) 30‐day Readmission Rate – (SA) 2. IT‐3.5 Acute Myocardial Infarction (AMI) 30‐day Readmission Rate – (SA)

Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): Relationship to Other Projects: Our other DSRIP project is improving care transitions, which intersects with medication management. Additionally, this project would support population health improvements in Category 4 by reducing Potentially Preventable Readmissions (PPRs). Relationship to Other Performing Providers’ Projects in the RHP: This project meets the community needs and operates in conjunction with the RHP-wide initiatives. Many of the RHP5 performing provider projects also focus on addressing community needs through complementary work. The RHP5 plan as of April 2013 lacks a project specifically focused on medication management. Doctors Hospital at Renaissance submitted three new DYs 3-5 project summaries related to medication management to RHP5, but those projects would take place in Hidalgo, not Cameron, County. As such, this proposed project meets the needs of specific populations and will not duplicate services of other Performing Provider projects in the RHP. Plan for Learning Collaborative: We plan to participate in the statewide learning collaborative. Our participation in a collaborative effort will facilitate sharing of challenges and testing of new ideas and solutions to promote continuous improvement in our healthcare system. Project Valuation: We have valued this project based on the following factors: Achieves Waiver Goals: The medication management project will: • Improve quality: Effective medication management will improve medication reconciliation, increase

pharmacist involvement, increase the use of medication lists in medical records, increase computerized physician order entry, improve patients’ compliance with medication regimens, and improve patient safety.

• Improve health status: Medication management including CPOE and clinical pharmacists has been shown to reduce patient safety risks.15 Properly taking a managed medication regimen can help control diseases and improve outcomes.

• Improve patient experience: HCAHPS includes medication-related questions. The use of pharmacists in providing medication counseling upon discharge increased the Cleveland Clinic’s medication-related HCAHPS scores by 64%.16

• Improve coordination: Medication management using CPOE and electronic medical records communicates recommended medications, doses and usage to other departments of the hospital, like pharmacy, as well as to outpatient providers.

• Improve cost-effectiveness: Effective medication management can help patients control their chronic illnesses in the outpatient setting, reducing avoidable and costly readmissions.

Addresses Community Need(s): As cited in the community needs assessment, the region experiences inadequate integration of care for individuals with multiple health issues (CN.3) and a lack of patient-centered

15 AHRQ, “Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs,” http://www.ahrq.gov/research/findings/factsheets/errors-safety/aderia/index.html. 16 http://www.pharmacytimes.com/news/Pharmacists-Help-Hospitals-Improve-Patient-Satisfaction-Scores RHP Plan for [RHP 5/South Texas] 89

http://www.ahrq.gov/research/findings/factsheets/errors-safety/aderia/index.html

http://www.pharmacytimes.com/news/Pharmacists-Help-Hospitals-Improve-Patient-Satisfaction-Scores

care (CN.4). Many of these patients may not be following optimal medication regimens: they may be prescribed duplicative or contradicting medications by different providers; they may not understand how and when to properly take medications; or they may not comply with care plan instructions. As a result, patients’ health conditions may not be receiving optimal treatment, and high-risk patients may be frequently readmitted. This project would improve medication management so that patients receive safer, higher quality, more coordinated and patient-centered care and education. • Addressing Priority Community Need: Participants in the focus groups that were part of the PRC

community health needs assessment were asked individually to identify their top five health priorities for their community. They emphasized a strong need for patients to get more follow up support about their medications.17

• Patient Outcomes & Impact: This project would reduce the rate of readmission of high-risk (AMI & CHF) patients by 20%. The project seeks to improve medication management through evidence‐based interventions that put in place the teams, technology and processes to decrease readmission rate of high-risk patients, as evidenced by an anticipated total of 5,459 unique individuals receiving medication management services in DY 4, and 5,500 n DY 5.

Project Scope/Size: The project seeks to improve medication management through evidence‐based interventions that put in place the teams, technology and processes to avoid decrease readmission rate of high-risk patients, as evidenced by an anticipated total of 10,959 unique individuals receiving medication management services in DYs 4-5. • Services Provided: The medication management program would provide the following services: patients

receive clinical pharmacist consultation; patients leave the hospital with a printed and reconciled medication list; medication lists and instructions are maintained in the patient’s medical record; physicians electronically enter instructions for the treatment of patients; physician orders are communicated over a computer network to the medical staff/outpatient pharmacist responsible for fulfilling/re-filling the order; patients are reminded to take their medications; patients can teach-back their medication regimen, including dosage and time; and patients refill prescriptions in the outpatient setting.

• Project Investment: We will be implementing CPOE and using clinical pharmacists.

17 2011 PRC Community Health Report. RHP Plan for [RHP 5/South Texas] 90

Category 2: Innovation and Redesign Performing Provider Name: University of Texas Health Science Center Houston Project Title: Implement innovative Evidence-based Strategies to Reduce and Prevent Obesity in Children and Adolescents. Unique RHP Project Identification Number: 111810101.2.101 Performing Provider/TPI: University of Texas Health Science Center- Houston/111810101 Project Option: 2.7.5 Implement Evidence-based Disease Prevention Programs

Project Summary Provider:

The University of Texas Health Science Center Houston (UTHealth) is part of the medical center in Houston (outside of RHP 5) but serves the South Texas area (RHP 5) through its UT School of Public Health Brownsville Campus and its mobile clinical van. It trains students and provides primary health care to indigent patients through its mobile services. Additionally, students being trained in medicine and public health have border experiences providing care in South Texas. UTHealth does not have a hospital in RHP 5.

Intervention: This project is designed to implement the MEND Community Based Obesity Prevention Program to address the youth obesity epidemic by applying a nationally recognized and scientifically sound method for supporting and coaching underserved and minority families to achieve better nutrition and physical activity habits.

Need for the Project: The need for this project in RHP 5 is vital. Over 50% of youth are above a healthy weight for their age and gender. Over 70% of the adult population has one or more chronic conditions. A similar proportion currently has no health insurance.

Target Population: The target population is youth patients and their families living in the RHP 5. The project will establish baseline numbers in DY 3 and show incremental increases through DY 5. 1000 children will be served by project. Approximately 50% of those reached will be CHIP / Medicaid eligible or indigent. They will benefit from the MEND project through increase quality of life and decreased BMI leading to prevention of chronic diseases.


[I-5.1]: Our goal is to have 4% annual incremental improvements in number of eligible patients in the CHIP / Medicaid population receiving MEND program.


IT-10.1.a.ii – PedsQL.

Our goal is to have 360 children (30%) of the program participants show an improvement in the PedsQL score at 3 or 6 month follow-up of the program.


PROJECT DESCRIPTION: UTHealth proposes to implement the MEND Community Based Obesity Prevention Program to address the obesity epidemic by applying a nationally recognized and scientifically sound method for supporting and coaching underserved and minority families to achieve better nutrition and physical activity habits. For the intervention in Cameron and Hidalgo County, we will use one of the most thoroughly researched 129 and proven obesity prevention programs in the world: MEND (Mind, Exercise, Nutrition ... Do It!). MEND was developed in the United Kingdom in 2001 and has since then been delivered and evaluated in Europe, Australia, Canada and the United States. In Texas, MEND is currently being delivered in Austin, Dallas and Houston, where it is the focus of a large randomized control trial (RCT) study funded by a US Childhood Obesity Research Demonstration Project (CORD) grant from the U.S. Centers for Disease Control and Prevention (CDC). The Texas research team includes senior faculty from the University of Texas Health Science Center Houston (UTHealth) School of Public Health at Austin, and the U.S. Department of Agriculture/Agricultural Research Service and the Children's Nutrition Research Center at Baylor College of Medicine in the Texas Medical Center.

MEND's evidence base, clinical rigor and academic links are significant differentiators in a healthcare marketplace that demands measureable outcomes and clinical effectiveness. In the area of community-based child weight management, MEND is the only program with a completed successful RCT showing efficacy on a wide range of health and psychosocial outcomes. Evaluation of over 10,000 children in the UK and 1,660 in the US has demonstrated similar effectiveness when the program was delivered at scale by leaders from diverse backgrounds and varied settings 130. This replicability is highly unusual.

The RCT results 131 demonstrated that children who attended the MEND 7-13 year old program, compared to controls, had a statistically significantly reduced waist circumference, BMI score for their sex, age and height and increased their cardiovascular fitness, physical activity levels and self-esteem at 3 and 6 months. Half the children were then followed up at 12 months where the majority of outcomes were either improved or sustained.

The evaluation of the US children concluded that: • Physical activity increased by 5 hours per week • Screen time and sedentary activity decreased by 3.5 hours per week • Cardiovascular fitness was improved (recovery heart rate after a step test: 5.1 beats per minute) • Body image and self-esteem improved (measured using validated questionnaires) • Dietary behaviors and nutritional intake improved • All results are highly statistically significant

Evaluated against the U.S. Preventive Services Task Force's recommendations for healthy lifestyles for children, MEND proved to be highly successful.

The evaluation of the US children concluded that: • Physical activity increased by 5 hours per week • Screen time and sedentary activity decreased by 3.5 hours per week • Cardiovascular fitness was improved (recovery heart rate after a step test: 5.1 beats per minute) • Body image and self-esteem improved (measured using validated questionnaires) • Dietary behaviors and nutritional intake improved • All results are highly statistically significant

Percent of Children Before MEND / After MEND • Participation in the recommended 60 minutes of physical activity per day: 53% / 83% • Sedentary for more than 2 hours per day: 24% / 10% • Consuming sugar sweetened beverages a few times per day: 13%/ 2% RHP Plan for [RHP 5/South Texas] 92

• Rarely consumed sugar sweetened beverages: 26% / 47% • Eating 4-5 fruits and vegetables per day: 9% / 24% • Eating less than two fruits and vegetables per day: 33%/ 12%

Implementation in RHP 5 UTHealth will implement the MEND program in close collaboration with community partners that have a long track record for promoting and nurturing diabetes prevention and self-management programs in the community. The program will focus on two age groups: ages 2-5 and ages 7-13 and their parents. MEND 2-5 is a healthy lifestyle program for children ages 2 to 5 and their parents. It involves a 90-minute session once a week for ten weeks. MEND 2-5 is adapted for use in the US was launched in select communities in the US in 2012. MEND years 2-4 is currently running in Alberta, Canada.

MEND 7-13 is a healthy lifestyle program for 7 to 13 year olds who are above a healthy weight and their parents. Meetings are held twice a week for ten weeks and involve nutrition education for the family, parenting support strategies and fun, group exercise for kids to support and promote an active, healthy, lifestyle. It is available currently in seven US states and in Alberta, Canada.

PROJECT GOAL: The project goals include increased patient self-esteem and motivation, increased physical activity and healthy eating and decrease in weight and overall body mass index all in support of a healthier lifestyle avoiding medical complications and/or the onset of chronic conditions. This project also supports the overall regional goals of providing preventative care and education as well as increased awareness and access to appropriate levels of care in the right settings. This project ties to CN.1 by addressing shortages of primary care / preventive services in RHP 5 by making preventive information and lifestyle changes easily accessible and actionable to youth and families through an evidenced based program.

Challenges and issues facing this project: Some of the challenges will include community education and consistent participation with both children and their parents required to be involved with the program. The programs will focus on the communities in Cameron and Hidalgo County with the highest need. In the planning, the program team will visit with all the potential partners for the delivery of the program, including, but not limited to day cares, elementary schools, middle schools, places of worship, and community based organizations that are participating in diabetes self-management programs or weight loss programs.

Participants in the MEND program will be referred to the program by their health care providers, school professionals or self-referred via community promotions. Medical matters that arise in the course of the program will be referred to the appropriate primary care team. If patients and providers mutually consent blood pressure, cholesterol and blood sugar control measures will be tracked.

STARTING POINT / BASELINE: This project represents a new initiative for this region as currently in Texas, MEND is only being delivered in Austin, Dallas and Houston. Currently, MEND is not being offered in RHP 5 and to our knowledge there are no other evidence-based programs in this region that address youth obesity. Baseline for this project is 0 (zero) youths being served by the MEND project in RHP 5.

Participants will be evaluated at baseline, at 10 weeks post program completion, 3 months, 6 months and 12 months against the following domains: • Quality of life: PedsQL • Patient-centered: Self-Esteem Score


• Behaviors: physical activity, healthy eating • Biometrics: abdominal circumference, BMI score for sex, age and height 132, Recovery Heart Rate

QUANTIFIABLE PATIENT IMPACT: The project will launch in DY3 of 2014 with training of providers followed by the roll out of the program.

The proposed DSRIP project will be using the recommended QPI measure of the “Number of unique individuals receiving services/ intervention.” We are proposing to serve 1200 unique children with this intervention project across the life of the project (DY 3 150, DY 450, DY 5 600). Our goal is to have 4% annual incremental improvements in number of eligible patients in the CHIP / Medicaid population receiving MEND program.

Other information that provides the full scope of the impact of this project includes: • Total MEND 7-13 programs: 75 • Total MEND 2-5 programs: 48 • Families served by MEND programs: 1200 • Direct beneficiaries (1 caregiver per child): 2400 • Total family beneficiaries: 4800

RATIONALE: Recent data from RHP 5 indicate that approximately 32 percent of adults in RHP 5 are overweight and 50 percent are obese. In addition to being tied to diabetes, obesity also increases the risk for certain types of cancer, heart disease, stroke, arthritis and other diseases 133.

We estimate that 31% of the population of adults in RHP 5 has diabetes. While there are many causes for diabetes, obesity is a major contributing factor. It been established that 90% of obesity can be prevented. Rather than developing a program that addresses adult obesity, we have chosen to aggressively prevent and reduce childhood obesity. Addressing obesity among participants in the Medicaid program is particularly relevant. A 2006 study by Thompson Medstat reviewed Medicaid claims data from 2004 and found that 134: • Children covered by Medicaid are nearly six times more likely to be treated for a diagnosis of obesity than children covered by private insurance. • Children treated for obesity are roughly three times more expensive for the health system than the average insured child. • Annual healthcare costs are about $6,700 for children treated for obesity covered by Medicaid and about $3,700 for obese children with private insurance. • The national cost of childhood obesity is estimated at approximately $11 billion for children with private insurance and $3 billion for those with Medicaid. • Children diagnosed with obesity are two to three times more likely to be hospitalized. • Children who receive Medicaid are less likely to visit the doctor and more likely to enter the hospital than comparable children with private insurance.

• Children treated for obesity are far more likely to be diagnosed with mental health disorders or bone and joint disorders than non-obese children.

5 year expected outcomes: By implementing this internationally recognized and evidence based program in RHP 5, we expect to: • Improve the effectiveness of obesity prevention and care among RHP residents who are medically underserved • Increase program participants' knowledge of healthy eating and lifestyle habits • Improve patient and community health


PROJECT CORE COMPONENTS The core component required for project 2.7.5 is 1) Conduct quality improvement for project using methods such as rapid cycle improvement. Activities may

include, but are not limited to, identifying project impacts, identifying “lessons learned,” opportunities to scale all or part of the project to a broader patient population, and identifying key challenges associated with expansion of the project, including special considerations for safety-net populations.

We have proposed metrics to implement this core component and will meet this requirement.

The project will also include the following core components as dictated by past research regarding its implementation 1) Project will be delivered with fidelity in regards to MEND intervention curriculum 2) Project will be delivered with fidelity in regards to MEND post program elements 3) Project will be delivered with fidelity to project evaluation and follow-up of participants.

RELATED CATEGORY 3 OUTCOME MEASURE(S) AND RATIONALE FOR SELECTING: The related Category 3 outcome measure is taken from the revised Category 3 menu protocol to measure pediatric populations. The outcome measure is the new “Pediatric Quality of Life InventoryTM IT-10.1.a.ii – PedsQL. Description of Inventory: The PedsQLTM Measurement Model is a modular approach to measuring health-related quality of life (HRQOL) in healthy children and adolescents and those with acute and chronic health conditions. The 23-item PedsQL scale measures across four scales: physical functioning, emotional functioning, social functioning, and school functioning. This tool measures areas that past MEND results have shown to improve and will be used in this project to assess outcomes. Our goal is to have 360 participants (30%) have an improvement in their PedsQL score at 3 or 6 month follow-up. In addition, we will also be tracking IT-1.20 Other Outcome Improvement Target: Body Mass Index (BMI) for age, gender and height, the most appropriate metric for investigating impact of obesity intervention programs targeting children according to The Cochrane Collaboration135.

RELATIONSHIP TO OTHER PROJECTS: No other performing provider is implementing this same youth obesity prevention project in RHP5. However, this project will work in coordination with all other performing providers in the region to refer youth patients who are obese and present with health risks to the program for follow-up and comprehensive care. We are fully committed to working with the other performing providers to ensure the triple aims are achieved. RHP 4 is implementing the MEND project (unique project id 17460005857016.2.2 and 130958505.2.2). We will coordinate as possible with this project and other youth obesity prevention projects in the state.

RELATIONSHIP TO OTHER PERFORMING PROVIDERS’ PROJECTS AND PLAN FOR LEARNING COLLABORATIVE: UTHealth will serve as the facilitator to encourage the development of a learning collaborative during the project period. Working together to develop and implement a prevention project and with other projects implementing youth and family projects will bring to light many similarities among performing providers and will also highlight those areas where challenges can be overcome. Our experience with preventive care, health communication, and support for lifestyle changes will be resources we plan to bring to the learning collaborative. We anticipate a strong working relationship among universities, hospitals, and private performing providers. We also plan to work with RHP 4 who is implementing a similar MEND project.

PROJECT VALUATION: The project will be valued based upon the successful attainment of the following expected results: • Develop and implement action plans for a youth obesity prevention project • Improved early screening of health risks among low income, low health insurance populations RHP Plan for [RHP 5/South Texas] 95

• Prevention and early intervention among high-risk youth and families • Collaborate with other performing providers to efficiently refer at risk youth patients into care.

In addition the valuation is based on cost savings for preventing obesity. It is expected that 65% of the 1200 children participating in the MEND program will complete the 10 weeks of classes. If 50% of these youth keep their BMI below 30 or reduce it below 30, then the potential annual savings in costs in medical care and drugs would amount to $4,284136 per child or $1,670,760. This number would of course increase when the participant sustains the health behavior changed by MEND and a conservative estimate of 5 year cost savings would be $8.3 million dollars, well beyond the valuation of this project. Excluded from this valuation are the lifetime savings from a MEND program participant avoiding or postponing the onset of obesity in adulthood. Furthermore, there would also be potential benefits from the 1200 parents or caregivers who will join their children or adolescents at the training classes. While many of them will change their lifestyles towards improved eating habits and increased exercise, we do not have data to estimate the "spill-over effect" to parents and other family members (another parent, siblings) who do not participate in the program.

_____________________________

129 MEND International Research Group, Research Summary. August 7, 2012 130 Ibid. 131 Ibid.

132 zBMI = Age-and sex-standardized BMI 133 Fisher-Hoch,S.P., Vatcheva,K.P., Laing,S.T., Hossain,M.M., Rahbar,M.H., Hanis,C.L., Brown,H.S., III,

Rentfro,A.R., Reininger,B.M., and McCormick,J.B. (2012). Missed opportunities for diagnosis and treatment of diabetes, hypertension, and hypercholesterolemia in a mexican american population, cameron county Hispanic cohort, 2003-2008. Prev. Chronic. Dis. 9, E135.

134 Thompson Medstat. "Childhood Obesity: Costs, Treatment Patterns, Disparities in Care, and Prevalent Medical Conditions". 2006. http://www.medstat.com/pdfs/childhood_obesity.pdf 2

135 Waters E, de Silva-Sanigorski A, Hall BJ, Brown T, Campbell KJ, Gao Y, Armstrong R, Prosser L,

Summerbell CD. Interventions for preventing obesity in children (Review). The Cochrane Collaboration. 2011.

136 Thompson Medstat. "Childhood Obesity: Costs, Treatment Patterns, Disparities in Care, and Prevalent Medical Conditions". 2006. http://www.medstat.com/pdfs/childhood_obesity.pdf 2


Unique Project Identifier: 112716902.1.100 Provider Name/TPI: Rio Grande Regional Hospital / 112716902


http://www.medstat.com/pdfs/childhood_obesity.pdf/

http://www.medstat.com/pdfs/childhood_obesity.pdf/

Project Description 1.1.2 - Expand Primary Care Capacity: Expand Obstetrical and Gynecological Care Capacity - Rio Grande Regional Hospital (Rio) intends to expand the provision of primary care in the region by adding to its OB/GYN care capacity in the existing community clinics by recruiting one (1) new primary care provider for OB/GYN Care Capacity, and at least one (1) additional patient navigator serving the 5 existing OB/GYN clinics. Rio plans to provide more access to essential health services to this target population. The Region faces a shortage of primary care physicians. This project aims to increase access to primary care. This project will improve access to primary care in the Region through a variety of measures, including identifying the locations most in need of primary care services, enhancing educational outreach to ensure members of the community know that they have access to these critical OB/GYN services for prenatal care and follow up visits. This project, focused on primary care providers, supports the overall goal of the RHP to provide increased access and availability of primary care trained physicians to meet the healthcare needs of the area and to provide more integrated care.

Intervention(s) Rio will meet the core requirements of this project by expanding the hours of primary clinic service and increasing primary care staffing by one additional provider in its community clinics. Additionally, Rio anticipates hiring additional administrative or support staff to improve the provision of care and adjust to the added patient load. This project will focus on the following milestones:

• P-4: Expand the hours of a primary care clinic, including evening and/or weekend hours. • I-12: Increase primary care clinic volume of visits and evidence of improved access for patients

seeking services

Need for the project This region experiences a shortage of primary and specialty care providers and inadequate access to primary or specialty care (CN.1), inadequate integration of care for individuals with multiple health issues (CN.3), and a lack of patient-centered care (CN.4). Additionally, The supply of physicians in OB/GYN lags behind Texas by 25%. To address this severe shortage in the Rio Grande Valley, we have actively engaged in marketing and incentive strategies to recruit physicians into our community. Early detection of healthcare problems results in earlier medical intervention, and earlier identification and intervention has been shown to lead improved patient outcomes and decreased overall healthcare costs. Addressing women’s health concerns specific to this region should help reduce overall costs by providing ongoing treatment and care management. The current shortage in primary care OB/GYN services often leads to long wait time for appointments, particularly in rural areas served by Rio’s clinics. This project seeks to add health accessibility for women in our region and increase the availability of primary care.

Target population Rio expects to have a large impact on the Medicaid and uninsured population in the region. Currently, Rio’s outpatient OB/GYN clinics serve a patient population that is at approximately 97% Medicaid eligible or uninsured. Rio expects this project will serve a similar percentage of patients that are Medicaid – eligible or uninsured.



Rio expects that, by recruiting additional OB/GYN providers to the community to maintain and expand obstetrical and gynecological care access for the patient population, patient satisfaction and health outcomes will improve. These healthcare providers are able to provide primary care in the form of annual checkups for women of reproductive age in the community, and also to provide services for women with specific gynecological and obstetric needs. Improving patient access to these services in a preventative and ongoing capacity is expected to result in improved health outcomes for pregnant women and women at risk for gynecological conditions, and to result in reduced long-term costs for treating women in need of regular gynecological and obstetric services.

Patient impact DY3: 480 total patient encounters, of those 465 will be from the Medicaid/uninsured population DY4: 960 total patient encounters, of those 931 will be from the Medicaid/uninsured population DY 5: 960 total patient encounters, of those 931 will be from the Medicaid/uninsured population

Category 3 outcomes expected patient benefits IT 8.2 – Percentage of Low Birth‐ weight births (CHIPRA/NQF # 1382) - Rio intends to reduce the number of low-weight births to its clinic clients by reducing the number of unhealthy pregnancies and early deliveries through regular access to OB/GYN care. Those reductions should increase the infants’ short- and long-term health outcomes, and reduces the cost of providing care to the mothers and infants.


Project Narrative


• Title of Project: Expand Primary Care Capacity: Expand Obstetrical and Gynecological Care Capacity





• Overview of Project: Rio intends to expand the provision of primary care in the region by adding to its OB/GYN care capacity in the existing community clinics by recruiting one (1) new primary care provider for OB/GYN Care Capacity, and at least one (1) additional patient navigator serving the 5 existing OB/GYN clinics. Rio plans to provide more access to essential health services to this target population. The Region faces a shortage of primary care physicians. This project aims to increase access to primary care. This project will improve access to primary care in the Region through a variety of measures, including identifying the locations most in need of primary care services, enhancing educational outreach to ensure members of the community know that they have access to these critical OB/GYN services for prenatal care and follow up visits. This project, focused on primary care providers, supports the overall goal of the RHP to provide increased access and availability of primary care trained physicians to meet the healthcare needs of the area and to provide more integrated care.

• Project Goals: Rio will meet the core requirements of this project by expanding the hours of primary clinic service and increasing primary care staffing by one additional provider in its community clinics. Additionally, Rio anticipates hiring additional administrative or support staff to improve the provision of care and adjust to the added patient load. Rio intends to add one new primary care provider and one new patient navigator to impact services provided in over 2,700 patient encounters.

• Challenges or issues faced by the Performing Provider: Rio has greater demand for women’s health services than it can provide and a shortage of OB/GYN services. The current shortage in primary care OB/GYN services often leads to long wait time for appointments, particularly in rural areas served by Rio’s clinics.

• How the project addresses those challenges: This project seeks to add health accessibility for women in our region and increase the availability of primary care. Early detection of healthcare problems results in earlier medical intervention, and earlier identification and intervention has been shown to lead improved patient outcomes and decreased overall healthcare costs. Addressing women’s health concerns specific to this region should help reduce overall costs by providing ongoing treatment and care management.


• 3-year expected outcome for Performing Provider and patients: Rio expects that, by recruiting additional OB/GYN providers to the community to maintain and expand obstetrical and gynecological care access for the patient population, patient satisfaction and health outcomes will improve. These healthcare providers are able to provide primary care in the form of annual checkups for women of reproductive age in the community, and also to provide services for women with specific gynecological and obstetric needs. Improving patient access to these services in a preventative and ongoing capacity is expected to result in improved health outcomes for pregnant women and women at risk for gynecological conditions, and to result in reduced long-term costs for treating women in need of regular gynecological and obstetric services.

• How the project is related to the regional goals: This region experiences a shortage of primary and specialty care providers and inadequate access to primary or specialty care (CN.1), inadequate integration of care for individuals with multiple health issues (CN.3), and a lack of patient-centered care (CN.4). Additionally, the supply of physicians in OB/GYN lags behind Texas by 25%. To address this severe shortage in the Rio Grande Valley, we have actively engaged in marketing and incentive strategies to recruit physicians into our community.



to have 480 patient encounters in the first year (465 of which should be Medicaid or uninsured).

• Quantifiable Patient Impact: Rio expects 2,730 total patient encounters, 2,327 of those encounters will be with Medicaid or uninsured patients. Rio expects the following patient impact over the three remaining years of the Waiver:

• DY3: 480 total patient encounters, of those 465 will be from the Medicaid/uninsured population

• DY4: 960 total patient encounters, of those 931 will be from the Medicaid/uninsured population

• DY 5: 960 total patient encounters, of those 931 will be from the Medicaid/uninsured population

• Rationale: This region experiences a shortage of primary and specialty care providers and inadequate access to primary or specialty care (CN.1), inadequate integration of care for individuals with multiple health issues (CN.3), and a lack of patient-centered care (CN.4). Additionally, The supply of physicians in OB/GYN lags behind Texas by 25%. To address this severe shortage in the Rio Grande Valley, we have actively engaged in marketing and incentive strategies to recruit physicians into our community. This is a new project for Rio. Early detection of healthcare problems results in earlier medical intervention, and earlier identification and intervention has been shown to lead improved patient outcomes and decreased overall healthcare costs. Addressing women’s health concerns specific to this region should help reduce overall costs by providing ongoing treatment and care management. The current shortage in primary care OB/GYN services often leads to long wait time for appointments, particularly in rural areas served by Rio’s clinics. This project seeks to add health accessibility for women in our region and increase the availability of primary care. Rio selected the following milestones:


o [P-4]: Expand the hours of a primary care clinic, including evening and/or weekend hours; and o [I-12]: Increase primary care clinic volume of visits and evidence of improved access for patients

seeking services. Rio selected these milestones because they most closely align with the hospital’s potential to develop a meaningful intervention and demonstrate improvement through operationalizing that intervention.

• Project Core Components: Rio will accomplish the CQI core components by expanding primary care clinic hours as described in Milestone P-4 and increasing primary clinic volumes as described in Milestone I-12; this will result in an increased number of primary care encounters provided.


• Related Category 3 Outcome Measure(s): IT 8.2 – Percentage of Low Birth- weight births (CHIPRA/NQF # 1382) - Rio intends to reduce the number of low-weight births to its clinic clients by reducing the number of unhealthy pregnancies and early deliveries through regular access to OB/GYN care. Those reductions should increase the infants’ short- and long-term health outcomes, and reduces the cost of providing care to the mothers and infants.

• Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): One other project (proposed by South Texas Health System) relates to increasing primary care services for women’s health. The shortage of women’s health services in this region is a substantial problem, indicating there is significant demand for increased access to women’s health primary care services. Rio’s project expands clinic services, which provides greater access for women’s health than services exclusively provided in a hospital setting, which appears to be the goal of STHS’s project. Rio will provide greater health access in rural areas as well, which is an area of particular need for this region since many patients lack sufficient transportation options to visit a hospital for primary care services.

• Plan for Learning Collaborative: Rio looks forward to participating in RHP 5’s learning collaborative once the Anchor develops the plan for the learning collaborative. This project addresses three significant community needs, the lack of primary care services (CN.1), the lack of integration of care (CN.3), and the lack of patient-centered care (CN.4). Rio expects its experience implementing this project will benefit all providers in the region through the sharing of lessons learned in the collaborative.

Project Valuation: Rio valued this project at $2,200,000 over the 3 remaining years of the Waiver. This value is based on the substantial need for this project and the impact on the Medicaid uninsured population. Rio expects 2,730 total patient encounters, 2,327 of those encounters will be with Medicaid or uninsured patients. This project has a significant impact on our region’s low-income and needy patient population, justifying the value of this project.


Expanding Clinical Outreach for the Joslin Diabetic Clinic 160709501.1.102 Doctors Hospital at Renaissance / 160709501 Project Option: 1.9.2 Project Description: Joslin Diabetic Clinic is one of the largest clinics that is dedicated to the treatment and study of diabetes. With a growing population, diabetes continues to be on the rise and Joslin will eventually meet the limit of patients it can service. Doctors Hospital at Renaissance is expanding the Joslin Diabetes Clinic by opening another location in a strategically located area providing optimal access to the surround population. The new location would include the recruitment of endocrinologists, RN’s, diabetic educator(s), and integration of a diabetic registry through EMR to enhance population studies. This project targets the diabetic population regardless of their insurance status (private, Medicare, Medicaid, indigent). Goals: Through the availability presented within an additional Joslin Diabetes Clinic, the goal of the project directly focuses on increasing the availability of specialized healthcare to the surrounding community. Josline Diabetes Clinics specializes in the treatment of diabetes from stabilizing the adverse affects of the condition and studying the underlying behaviors associated with diabetes. In addition to the clinical and behavioral care that is specific to diabetes, an education component is also used to provide a multifaceted treatment regime. The education component includes the following:

o Dietary Intervention o Exercise Intervention o Cognitive Behavioral Intervention (group behavioral support sessions are conducted) o Medication Management Intervention (there is a major language barrier preventing many

learning how to properly take their medications) The secondary goal of the project is to increase the in-depth research opportunities that are available it this diabetes saturated population. RHP5 represents a unique population that is stricken by vast levels of poverty, lack of healthcare availability, and a stigma for medication adherence creating a wealth of research to be conducted leading to truly transformative healthcare delivery. Challenges/Issues: The cost of diabetes has increased 41 percent over a five year period to $245 billion in 2012 from $174 billion in 2007 (this includes $167 billion in direct medical costs and $69 billion in reduced productivity)18. According to the RHP5 community needs assessment, the primary health issues within the region are rooted in extreme levels of economic and health disparities and unprecedented epidemics of chronic disease, particularly diabetes and related chronic conditions. Of the many studies identifying regions such as Texas as an area with a high population percentage affected by diabetes19, there are very little studies done in any concentrated areas. One such area is RHP5 where approximately 30% of the population is on Medicaid, and approximately 31% of the population is affected by

18 American Diabetes Association. http://www.diabetes.org/advocate/resources/cost-of-diabetes.html 19 http://www.cdc.gov/diabetes/pubs/factsheets/hispanic.htm RHP Plan for [RHP 5/South Texas] 102

http://www.diabetes.org/advocate/resources/cost-of-diabetes.html

http://www.cdc.gov/diabetes/pubs/factsheets/hispanic.htm

diabetes20. Joslin Diabetes Center is the world’s largest diabetes research and clinic care organization. RHP5 serves as a wealth of knowledge and foundation for innovation towards outreach and general understanding of the diabetic condition as it relates to such a unique population. Diabetes helps promote other major chronic conditions such as obesity (estimated $190 billion in national healthcare costs21), heart conditions (estimated $444 billion in healthcare costs22), hypertension, premature low-weight births, and organ failure to name a few. A lack of expansion of specialized diabetes care is especially damaging to the unique at-risk, poverty stricken uninsured population in this region. This community resource will serve as a wealth of prevention services and education that can encourage true health care transformation. Addressing the challenges: The Joslin Diabetes Center addresses the lack of specialty care by expanding its presence within a new clinic. The clinic will be developed around optimal accessibility according to the needs of the community. Its core components include increased hours of operation, increased specialty providers, and a referral system that allows patients an increase of access that was not available prior to the 1115 Medicaid Transformation Waiver. 3-Year Expected Outcomes/Benefits: The project falls under the categorization of 1.9.2, expanding specialty care. The primary patient benefit will stem from a new location in a location that is strategically located to optimize patient outreach and convenience. Once the services have been established patients, the region, and the healthcare system will benefit by having improved specialty healthcare services that is focused on a morbidity that has spread to pandemic proportions. How this project is related to regional goals: According to the RHP5 community needs assessment, diabetes has affected the population on a scale that is proportionate to that of an epidemic. When combined with a high level of Medicaid and uninsured population (approximately 63% combined), this epidemic can be the single most influential factor in perpetuating an unsustainable healthcare delivery system. The Joslin Diabetes Clinics offers an invaluable opportunity to offer a resource that is solely dedicated to the treatment and study of diabetes within a region that has been historically medically underserved and disenfranchised. This project improves on Community Need 1 (CN.1), “lack of primary and specialty healthcare”, by not only expanding clinical locations, but creating the foundation around accessibility for the Medicaid population. Starting Point/Baseline: Within FY12, the Josline Diabetes Clinic provided services to approximately 2000 patients. This number will serve as the baseline moving forward into DY3 – DY5. Quantifiable Patient Impact:

20 RHP5 Community Needs Assessment 21 Forbes. http://www.forbes.com/sites/rickungar/2012/04/30/obesity-now-costs-americans-more-in-healthcare-costs-than-smoking/ 22 Centers for Disease Control and Prevention. http://www.forbes.com/sites/rickungar/2012/04/30/obesity-now-costs-americans-more-in-healthcare-costs-than-smoking/ RHP Plan for [RHP 5/South Texas] 103

http://www.forbes.com/sites/rickungar/2012/04/30/obesity-now-costs-americans-more-in-healthcare-costs-than-smoking/



Through waiver funding, DHR will have the capabilities to fortify the current Joslin Diabetes Clinic to ensure that an increase of patients continue to be seen. Once the second location is fully functional, DHR can expect to see at least a 15% increase of patients serviced within DY4 and 20% increase within DY5. Rationale: RHP5 is historically considered a medically underserved area with high levels of indigent population living at or below the federal poverty line. As a result, this segment of the population is often at the highest risk for developing chronic diseases due to a lack of available primary, preventative healthcare. Under these circumstances, the Joslin Diabetes Clinic is one of the few, if not the only, clinic that is designed not only to treat but also study the dynamics surround diabetic patients within this region. To magnify the efforts this clinics project option 1.9.2, “Improve access to specialty care”, has been selected. This project option contains four core components:

a.) Increase service availability with extended hours: Milestone 2, P-11, launch a specialty care clinic, will be founded around optimal patient access from hours to its location which also caters to core component “b”. b.) Increase number of specialty clinic locations: The Josline clinic is currently located on the DHR campus, and its expansion clinic is planned to be located within an area of which a resource of this kind would have a profound effect. c.) Implement standardized referrals across the system: Milestone 1, P-2, trains providers on the processes and guidelines for implementing and utilizing a standardized referral system within the clinic. d.) Conduct quality improvement for the project: Quality improvement remains at the forefront of this endeavor as it relates to the patients’ safety, outcomes, and overall experience.

Once the clinic has been established in a strategic location with accessible hours its goal will be to increase the volume of visits throughout DY4 and DY5 and continuously improving its research and treatment methods. Core Components: a) Increase service availability with extended hours: To ensure that the those patients who are not available during normal working hours to receive specialty care, extended hours will be available on selected days to ensure that the best possible amount of patients are granted access. b) Increase number of specialty clinic locations: The Joslin Diabetic Clinic is expanding clinic locations by one additional location that is strategically placed for optimal community outreach and accessibility. c) Implement transparent, standardized referrals across the system: Within RHP5 approximately 1 in 3 people (1 in 2 within Starr County) are either diagnosed with or are affected by Diabetes. As a result, much of the community physicians know to refer to the Joslin Diabetes Clinic as it is the only resource of its kind within the area. With the expansion in a new area, best practices will be adopted in creating a standardized referral system to ensure that the patients have timely access to primary and specialty care according to their needs. d) Conduct quality improvement: Quality improvement will become necessary once patient analytics are in place to ensure that optimal services are being provided within the time allotted. Employee observations, trends that become apparent within aggregated data and physician recommendations will all be accumulated within a “lessons learned” approach to develop improvements when discovered. This will allow for the clinic to make adjustments where necessary to provide a safe, quality, and positive patient experience.


Related Category 3 Outcome Measures: IT-1.10 Diabetes care: HbA1c poor control (>9.0%) - NQF 0059 (Standalone measure) This category 3 measure serves as one of the fundamental goals in treating patients. These goals include:

• Education • Self-Management (through education) • Studies • HbA1c control (as a product of education, self-management, and adjusted outreach according to results

stemming from the clinic’s research)

Relationship to other Projects: The clinical expansion will collaborate with any projects that cater to the diabetic population within its community outreach. The goal is increasing service capacity and serving as a beacon for referrals from other providers who feel that patients need a focused approach on stabilizing their diabetes and maintaining a healthy condition. Specific projects that relate to the clinic expansion are the following:

• Pharmaceutical Care Services Expansion (160709501.2.102) • Maternal Fetal Medicine Clinic Implementation (160709501.1.106) • Diabetic Behavioral Services Expansion (160709501.1.108) • Diabetic Ambulatory Eye Clinic Implementation (160709501.1.103) • PCMH Implementation (160709501.2.100)

Plan for Learning Collaborative: Doctors Hospital at Renaissance will participate in the statewide learning collaborative that is being organized by the Texas Health and Human Services Commission. Every effort will be made to collaborate with the RHP5 anchor in providing any and all results from the implemented projects including lessons learned. All findings will be supported by data and provided in a meaningful manner so that other participating providers can contribute as well. Project Valuation: The approach for evaluating the projects value comes about through assessing the costs of establishing a clinic and fully staffing it. When opening a clinic of this stature, staffing includes many clinical providers, case management, and electronic medical records including a chronic disease registry. The second component of valuation stems from the patient demographic that this clinic caters to (Medicaid and uninsured primarily). These patients typically do not have access to this type of specialized treatment that focuses not only stabilizing a patient’s condition, but also maintenance through follow-up care and education. Such methods have been shown to improve outcomes and decrease patients admissions and readmissions into emergent care settings.

THREE YEAR DSRIP PROJECT SUMMARY RHP 05



Provider Name/TPI: The University of Texas Health Science Center at San Antonio / 085144601

Provider Description The University of Texas Health Science Center at San Antonio serves San Antonio and the 50,000 square-mile area of South Texas. It extends to campuses in the metropolitan border communities of Laredo and the Rio Grande Valley. More than 3,000 students a year train in an environment that involves more than 100 affiliated hospitals, clinics and health care facilities in South Texas.

Intervention(s) Project Option 1.2.4 Establish Primary Care/Pediatric Residency Training Program, with emphasis in communities designated as health care provider shortage areas (HPSAs) The University of Texas Health Science Center at San Antonio (UTHSCSA) Regional Academic Health Center (RAHC) proposes to create an ACGME-accredited primary care Pediatrics residency training program in Hidalgo County in collaboration with Doctors Hospital at Renaissance and Edinburg Children’s/McAllen Medical Center. This project is designed to improve patient access to primary care by increasing the physician workforce in RHP 5. The new faculty, the resident trainees, and the graduates of the training program will expand the primary care workforce. Allaying the shortage of primary care providers will increase access to care in the appropriate time and place, reduce inappropriate and costly emergency department utilization, increase patient satisfaction, and improve the health of the community.

Need for the project In RHP 5, there are only 55 primary care physicians per 100,000 population, as noted in the community needs assessment of this Plan. This compares to 70 per 100,000 statewide. Although RHP 5 has 13.8 pediatricians per 100,000 population (compared to 12.8) statewide, RHP 5 has a younger population than the rest of the state. In Hidalgo County, the median age is 28.3 years compared to 33.6 years for Texas. If one calculates the number of active pediatricians per 100,000 children (persons 0 to 19), the ratio for RHP 5 is 39.8, compared to 46.0 for Texas as a whole and a national average of 67 pediatricians per 10,000 children. In addition, the four counties of RHP 5 have among the highest proportion of children living in poverty, ranging from 45% to 55%. More than half of RHP 5 adolescents are overweight or obese, which contributes to diabetes and other health issues throughout youth and into adulthood. More adolescents are obese than overweight. Texas has a high retention rate for residents who train in a community to practice in that community. This project will greatly increase the pipeline for new primary care physicians and provide near-term relief with faculty physicians. Community need addressed by the project: CN. 1 Shortage of primary and specialty care providers and inadequate access to primary or preventive care

Target population The target population for this project will be children, especially children enrolled in Medicaid and low income uninsured children. In RHP 5, approximately 55% of children are enrolled in Medicaid and another 15% live in households with income at or below 200% FPL.

Category 1 or 2 expected patient benefits RHP Plan for [RHP 5/South Texas] 106

New program faculty will increase access to care in the early years of the project. After the residency program is accredited in 2015, residents will be recruited to begin training and providing care to patients in 2016. In addition, the program will feature an innovative curriculum incorporating PCMH, population health analytics, chronic disease management, and quality improvement. QPI: DY 4: Provide 2,000 patient care encounters by new providers DY 5: Provide 4,000 patient care encounters by new providers At least 70% of the patients served will be Medicaid enrollees or low income uninsured.

Category 3 outcomes expected patient benefits OD 14 Workforce IT-14.1 Our goal is to increase the number of practicing primary care physicians per 100,000 people in HPSA/MUA of RHP 5.


Project Option 1.2.4 - Establish Primary Care/Pediatrics Residency Training Program Unique Project ID: 085144601.1.100 Performing Provider/TPI: The University of Texas Health Science Center San Antonio / 085144601 PROJECT DESCRIPTION: The University of Texas Health Science Center San Antonio proposes to establish a primary care/Pediatrics residency training program. This project is designed to improve patient access to primary care by increasing the physician workforce in RHP 5, a designated health care provider shortage area (HPSA). The University of Texas Health Science Center at San Antonio’s Regional Academic Health Center (UTHSCSA) will establish a new primary care/Pediatrics residency training program in partnership with Doctors Hospital at Renaissance (DHR) and Edinburg Children’s Hospital (EC), part of South Texas Health System. The new faculty, the resident trainees, and the graduates of the training program will expand the primary care workforce. Allaying the shortage of primary care providers will increase access to care in the appropriate time and place, reduce inappropriate and costly emergency department utilization, increase patient satisfaction, and improve the health of the community. When fully implemented in 2018, the new Pediatrics residency will have the capacity to train as many as 24 residents – 8 residents in each of three classes. The UTHSCSA Pediatrics training program will complement other approved DSRIP residency programs in RHP 5. UTHSCSA is establishing a new Adult and Child Psychiatry residency at Valley Baptist-Brownsville (VBMC-B), expanding the Internal Medicine residency training program at Valley Baptist-Harlingen (VBMC-H), and strengthening its existing Family Medicine program affiliated with McAllen Medical Center (MMC), part of South Texas Health System. DHR has approved DSRIP projects to establish residency programs in Family Medicine, Internal Medicine, Obstetrics & Gynecology, and General Surgery. Goals and Relationship to Regional Goals: This project has the following goals:

• To create a Pediatrics Graduate Medical Education (GME) program with faculty, residents, and graduates who will increase patients’ access to care;

• To create and implement an innovative curriculum that incorporates population health management, chronic disease management, and clinical safety and effectiveness training;

• To create a continuity clinic for the residency program to focus on transitions of care, reduce hospital readmissions and function as a patient-centered medical home;

• To conduct quality improvement projects to continuously improve clinical outcomes and efficiency; and

• To form a learning collaborative with other new and expanding residency training programs in the region to transform the delivery system for the South Texas community.

This project meets the following regional goals: • By combining the resources of The University of Texas, DHR and ECH, leverage and improve on existing

programs and infrastructure to ensure that the health care delivery system will be adequately developed to meet the primary care needs of residents throughout a rapidly growing, yet historically underserved region;

• Increase access to primary care services in the short-term with new faculty, in the intermediate term with resident trainees, and in the long-term with graduate physicians, with focus on prevention and on children with chronic conditions to ensure they have access to the most appropriate care for their condition;


• Nurture a culture of ongoing quality improvement and innovation that maximizes the use of technology and best-practices to improve access and timely utilization of appropriate care; and

• Transform health care delivery to a patient-centered, coordinated and integrated care system that improves patient satisfaction and health outcomes, reduces unnecessary emergency department use and duplicative services, and expands on the existing health care system.

Challenges and issues: Creating a new residency program from the ground up is time consuming and requires approval of the Accreditation Council on Graduate Medical Education (ACGME). The Pediatrics Residency Review Committee (RRC) meets to review new program proposals only two to three times each year. Residency programs must be accredited before the programs can begin to recruit fourth-year medical students through the National Residency Match Program (NRMP) to enter the residency training program in the following academic year. As a result of the increasing complexity of the pediatric GME program requirements and the program scale necessary for compliance, the number of pediatric residency programs is falling nationally, with a net loss of eleven pediatric residency programs over the past decade. The RHP 5 faces an additional challenge in that no single hospital has the pediatric patient volume, diversity and complexity in all the service lines required by ACGME to sustain a self-contained pediatric residency program. Addressing the challenges: UTHSCSA will partner with DHR and ECH to work together collaboratively to establish an innovative curriculum including the patient-centered medical home model and chronic care disease management to address the unique needs of RHP 5. Based on current patient data, we plan to have resident rotations in Term Nursery, Neonatal Intensive Care Unit, and Pediatric Hematology/Oncology at DHR and rotations in Emergency Medicine and Pediatric Intensive Care Unit at ECH. Inpatient rotations will likely occur at both DHR and ECH. The required Pediatric Subspecialty training rotations will take place at both hospitals and in subspecialist physicians’ offices. Over time, actual rotations will align with patient volume and complexity to ensure that residents have the opportunity to develop proficiency in all the domains of clinical competency. UTHSCSA will recruit the Program Director and Associate Program Director as well as necessary administrative support staff for the Pediatrics program. UTHSCSA, DHR, ECH, and the RHP 5 community will work collaboratively to recruit core faculty, including the ACGME-required pediatric subspecialists in adolescent medicine, developmental-behavioral pediatrics, neonatal-perinatal medicine, pediatric critical care, pediatric emergency medicine, and subspecialists from five other distinct pediatric medical disciplines. When possible, faculty will be recruited from the existing population of community physicians who meet the ACGME requirements for board certification, licensure, and scholarship. Given the overwhelming prevalence of obesity and diabetes in the community and the absence of community resources currently, critical recruitments from outside will be needed in pediatric endocrinology. UTHSCSA faculty and staff will apply their extensive experience with the accreditation process. 3-year expected outcome for Performing Provider and patients: The Program Director, Associate Program Director and the Program Coordinator will be recruited by UTHSCSA to McAllen/Edinburg. Subsequently, additional requisite faculty will be recruited. The accreditation application known as the Program Information Form (PIF) will be submitted to the Pediatrics Residency Review Committee by early in calendar year 2015. The RRC decision to accredit the program will be received by the fall of 2015. The South Texas Pediatrics Residency Program will participate in the National Residency Match Program that recruits fourth-year medical students from September 2015 to March 2016. In July 2016, the first cohort of as many as eight Pediatrics residents will begin their training in RHP 5. This initial cohort of residents will complete the program and enter clinical practice in 2019. Supervised residents will begin RHP Plan for [RHP 5/South Texas] 109

providing care to patients in 2016. The Program Directors and core faculty members will dedicate 25-75% of their time to clinical care. Primary care capacity and patients’ access to primary care will increase as the program matures to full, maximum build-out of 24 Pediatrics residents (8 PGY1; 8 PGY2; and 8 PGY3). STARTING POINT/BASELINE As of October 2013, residency programs in RHP 5 include an existing UTHSCSA internal medicine program with 15 residents at VBMC-H and a family medicine program with 18 residents at MMC. Valley Baptist also sponsors directly a separate family medicine program with 15 residents. Approved DSRIP projects for new residency training programs are underway currently as noted above. In 2010, approximately 1,000 ill children were transferred for care out of RHP 5. The nearest children’s hospitals are Driscoll Children’s in Corpus Christi and CHRISTUS Santa Rosa in San Antonio - distances of 160 and 250 miles, respectively. This creates a tremendous hardship for sick children and their families. QUANTIFIABLE PATIENT IMPACT Because some of the faculty for the new training program will be recruited from the existing, local supply of culturally competent physicians, the patient access metrics related to faculty practice are limited to incremental access provided by imported faculty physicians new to RHP 5. Accordingly, we project in the metrics that an additional/incremental 2,000 patient care visits will be provided by new faculty physicians in DY4 and 4,000 in DY 5 and that 70% of the visits will be provided to children who are either enrolled in Medicaid or low-income uninsured. Due to the constraints of the accreditation process/timeline, the Pediatrics residency program will be brand new in DY 5. Therefore, we project that we will fill six of the maximum eight first-year training slots in July 2016, and we will not include residents’ patient care visit numbers in the QPI for this project. Nonetheless, the residents will provide patient care in half-day clinic sessions as required by RRC standards. The number of sessions will increase as the number of residents increases along with the maturity of their experience. RATIONALE In 2010, Texas had 176 patient care physicians per 100,000 population and 70 primary care physicians per 100,000 population with a state ranking of 46 and 47, respectively. (Comparable ratios for US Total are 220 and 91, respectively.) From 2001 to 2011, the Texas primary care physician workforce grew only 25%, barely keeping pace with population growth. From 2002 to 2011, Texas increased medical school enrollment 31% from 1,342 to 1,762, in line with the national call by the Association of American Medical Colleges (AAMC) to increase medical school enrollments by 30%. In 2011, there were 1,445 medical school graduates in Texas. Coincidentally, there were 1,445 allopathic entry-level GME positions offered in Texas in the annual National Resident Matching program. (There were 31 osteopathic slots.) The Texas Higher Education Coordinating Board recommends a ratio of 1.1 entry-level GME positions for each Texas medical school graduate. The number of Texas medical school graduates is expected to peak at over 1,700 in 2015. This implies a need for 400 additional GME positions in 2015. The shortage of GME positions or residency slots may be the single most problematic bottleneck in Texas’ efforts to alleviate the state’s physician shortage. In RHP 5, there are only 55 primary care physicians per 100,000 population, compared to 70 per 100,000 statewide, as noted in the community needs assessment of this Plan. For children in RHP 5, the situation is even more severe. The number of pediatricians per 100,000 population (all ages) in RHP 5 is 14.4, compared to 13.6 for Texas as a whole. However, it must be noted that the median age of the population in RHP 5 is lower than that for the state. If one calculates the number of active pediatricians per 100,000 children (persons 0 to 19), the ratio for RHP 5 is 39.8, compared to 46.0 for Texas as a whole and a national average of RHP Plan for [RHP 5/South Texas] 110

67 pediatricians per 10,000 children. (Data sources: 2012 Texas Department of State Health Services’ Health Professions Resource Center; 2012 American Community Survey; and UnitedHealth Center for Health Reform & Modernization) The University of Texas’ Board of Regents and the Texas Legislature have authorized the development of UTHSCSA RAHC into a full medical school in RHP 5. In order to retain the future graduates of the new medical school for eventual community practice in RHP 5, new residency training programs must be established and existing programs must be expanded. The 2011 State Physician Workforce Data Book published by the AAMC Center for Workforce Studies shows that among students who complete both their undergraduate and graduate medical education in Texas, 80% remained in the state to practice. Project components:

• Identify high impact services and gaps in care, coordination, and ambulatory capacity • Recruit Pediatrics Program Director and core faculty in DY 3 and DY 4 • Create innovative curriculum including population health management, chronic disease registries,

team-based community care, data analytics, and quality improvement projects using PDSA and other methodologies contained in the UT System CS&E course

• Provide Clinical Safety & Effectiveness (CS&E) training to faculty and DHR and ECH staff • Develop and organize inpatient and ambulatory clinical training/patient care opportunities • Complete and submit the Program Information Form (PIF) to the RRC in early calendar 2015 • Attain ACGME approval for the program by fall 2015 • Recruit prospective Pediatrics residents fall 2015 to early spring 2016 • Enroll the first class of Pediatrics residents in July 2016



How the project represents a new initiative or significantly enhances an existing delivery system reform initiative: Currently, RHP 5 has very few residency programs, and no Pediatrics residency training programs. The faculty for the Pediatrics residency program will collaborate with the faculty for the other new and existing residency training programs underway through DSRIP to expand primary care delivery in RHP 5. Data Driving this Project: The 2013 County Health Rankings promulgated by Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute highlight the dire health conditions in RHP 5.

2013 County Health Rankings 232 Texas counties ranked

Cameron Hidalgo Starr Willacy

Health Outcomes 59 41 108 26


Mortality 24 18 41 21

Morbidity 162 144 218 104

Health Factors 213 228 232 227

Health Behaviors 22 74 63 15

Clinical Care 189 191 232 150

Social & Economic Factors 227 229 231 232

Physical Environment 109 189 222 69

www.countyhealthrankings.org

The key factors in RHP 5’s clinical care ranking are the 38% uninsured rate, the shortage of primary care physicians and dentists, the high rate of preventable hospital stays, and the low rate of mammography screening. The key social and economic factors are the low level of college achievement, the high unemployment rate, and the 47% of children living in poverty compared to the state rate of 27%. The relevant physical environment factors are drinking water safety and limited access to healthy foods. Given these statistics, we are certain that a Pediatrics training program will make a significant positive impact on the nearly 500,000 children in the RHP 5 community. Related Category 3 Outcome Measure(s): OD-14 Primary Care Workforce Stand-alone: IT - 14.1 Number of practicing primary care physicians per 100,000 individuals in HPSA or MUA Rationale for selecting the outcome measures: It is challenging to select outcome measures in the early stages of planning the residency program, given the lack of clarity and complete plans about when and where faculty will practice, the part-time nature of that practice, and the fact that three or more years of training are required before the first-matriculated residents will begin independent clinic practice. However, because the Program Directors and core faculty will be recruited and in place even before the programs are accredited and will dedicate 25-75% of their time to clinical care, they will have an impact on the number of practicing primary care physicians per 100,000 individuals in RHP 5. Relationship to other UTHSCSA Projects: This project is related to two UTHSCSA projects expanding and strengthening residency programs in primary care – Family Medicine and Internal Medicine – and one project establishing a new residency program in adult and child Psychiatry. The faculty and residents will be part of the GME learning collaborative. This project is undertaken as a compliment to all the Category 2 UTHSCSA projects implementing PCMH and implementing chronic disease interventions at the patient level. Relationship to DHR’s Projects in the RHP: This project is related to the five DHR projects establishing residency programs: in primary care – Family Medicine, Internal Medicine, Obstetrics/Gynecology, and Preventive Medicine – and in the high impact specialty area of General Surgery. The faculty and residents will be part of the GME learning collaborative. Plan for Learning Collaborative: All of the new and existing residency training programs in RHP 5 will be/are directed by UTHSCSA faculty. The University of Texas System and UTHSCSA, specifically, have a nationally known Clinical Safety & Effectiveness (CS&E) training program embedded in their medical schools and clinical facilities. CS&E is a training course with PDSA (Plan Do Study Act, rapid cycle improvement) at the heart of the curriculum; completing a strategic improvement project is required as part of the course. Many faculty and staff adopt CS&E into their ongoing


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activities after course completion. UTHSCSA requires all new resident trainees to complete the core curriculum of the IHI Open School prior to enrollment. All residency training programs will feature innovative curriculum components on population health management, team-based community care, integrating primary and specialty care, using patient registries, and applying data analytics. The Program Directors will meet quarterly as a learning collaborative to share quality improvement efforts within the context of the CS&E program as well as the common core curriculum components noted above. UT will provide opportunities for physicians and staff at affiliated hospitals to participate in the CS&E course and projects. Project Valuation: This project’s impact on Medicaid and low income uninsured children and their families in RHP 5 will be profound. Academic medicine and resident training programs have a long tradition of providing significant portions of care to safety net populations. Expanding access to primary care will allow patients to get the right care at the right time in the right place, avoiding costly emergency room visits and hospital admissions. Creating residency training programs in RHP 5 that will attract graduates of the new local medical school who are highly likely to remain in the area post-residency will positively impact the long-term number of practicing primary care physicians per 100,000. With innovative curricula designed to meet community needs, UT faculty will train new physicians for practice, engage community physicians as preceptors, and embed the UT Clinical Safety & Effectiveness program in local hospitals. Therefore, we believe that this project’s value is equivalent to the value of other already approved DSRIP residency programs.



Provider Name/TPI: Rio Grande Regional Hospital / 112716902

Project Description


2.6.1 - Implement Evidence Based Health Promotion Programs – Lactation Program

Rio Grande Regional Hospital (Rio) intends to implement evidence based health promotion in Hidalgo County, Texas to target new mothers and provide education surrounding the benefits of breastfeeding and supply additional support through additional lactation consultations and follow up calls to encourage continuing to breastfeed. This project is aimed at increasing the percentage of new mothers that report breastfeeding upon follow-up calls after they have been discharged. Establishing this additional support system will help young mothers understand the benefits and potential consequences of choosing not to breastfeed, which is a growing problem among low income and teen mothers in our community.

Intervention(s) Rio will utilize its current lactation specialist and trained RNs to increase encounters with women who have delivered in the hospital to increase the new mother’s exposure to the education material surrounding the benefits of breastfeeding. Rio intends to establish new clinic space within the hospital to focus these efforts. This project would include a supplemental visit from the lactation outreach team, as well as an enhanced presentation on the benefits to the infant. Additionally, the hospital-based team will perform follow-up calls and provide in-home support on a case-by-case basis to encourage new mothers to breastfeed their newborns. This project will be comprised of the following milestones:

• P‐2: Development of evidence‐based projects for targeted population based on distilling the needs assessment and determining priority of interventions for the community.

• P-8: Participate in face-to-face learning (i.e. meetings or seminars) at least twice per year with other providers and the RHP to promote collaborative learning around shared or similar projects.

• I‐8: Increase access to health promotion programs and activities through this project. This project will conduct quality improvement using methods such as rapid cycle improvement. Activities may include, but are not limited to, identifying project impacts, “lessons learned,” opportunities to scale all or part of the project to a broader patient population, and key challenges associated with expansion of the project, including special considerations for safety‐net populations.



Region 5’s community needs includes a lack of patient-centered care (CN.4). Texas, and Hidalgo County in particular, have relatively low rates of breastfeeding in the first year of a baby’s life. This is due to a variety of factors including being separated from the baby for long periods immediately after birth, lack of education, lack of support materials, inconvenience, and in some cases, pain or sensitivity. Many studies have found that there are significant benefits to breastfeeding including a decreased risk of death between 28 days and 1 year, increased immune system, which can prevent disease, a reduction in the risk of some childhood cancers, as well as protection from diseases that occur later in life, such as diabetes, high cholesterol, and Crohn’s disease. Rio expects that an increase in community education and support to new mothers will have a significant impact on increasing the rate of mothers that report exclusively breastfeeding on follow up calls from the lactation specialist and trained personnel.

Target population The target population is patients that deliver in the hospital, which includes a high percentage of Medicaid-eligible and uninsured patients. Currently, of the total births at Rio in a given year, over 78% of the patients are Medicaid and uninsured. As such, Rio expects this project to reach approximately 78% Medicaid and uninsured pediatric patients.

Category 1 or 2 expected patient benefits Rio expects to provide education and support to new mothers that deliver in the hospital to encourage breastfeeding. Based on the research in this area, it is clear that breastfeeding has significant benefits to both mother and baby. Rio is seeking to triple the encounters that each new mother has with a lactation specialist or specifically trained RN or nurse practitioner. Over the three remaining years of the demonstration, Rio expects the following patient impact:

DY3: 776 new patient encounters, of those 535 will be from the Medicaid/uninsured population DY4: 3,105 new patient encounters, of those 2,142 will be from the Medicaid/uninsured population DY 5: 4,140 new patient encounters, of those 3,229 will be from the Medicaid/uninsured population

Category 3 outcomes expected patient benefits IT‐8.15b – Rate of Exclusive Breastfeeding – Rio expects to improve the rates of new mothers that report exclusive breastfeeding upon follow up calls from the lactation outreach team.


Project Narrative


• Title of Project: Implement Evidence Based Health Promotion Programs – Lactation Program





• Overview of Project: Rio Grande Regional Hospital (Rio) intends to implement evidence based health promotion in Hidalgo County, Texas to target new mothers and provide education surrounding the benefits of breastfeeding and supply additional support through additional lactation consultations and follow up calls to encourage continuing to breastfeed. This project is aimed at increasing the percentage of new mothers that report breastfeeding upon follow-up calls after they have been discharged. Establishing this additional support system will help young mothers understand the benefits and potential consequences of choosing not to breastfeed, which is a growing problem among low income and teen mothers in our community.

• Project Goals: Rio will utilize its current lactation specialist and trained RNs to increase encounters with women who have delivered in the hospital to increase the new mother’s exposure to the education material surrounding the benefits of breastfeeding. Rio intends to establish new clinic space within the hospital to focus these efforts. This project would include a supplemental visit from the lactation outreach team, as well as an enhanced presentation on the benefits to the infant. Additionally, the hospital-based team will perform follow-up calls and provide in-home support on a case-by-case basis to encourage new mothers to breastfeed their newborns.

• Challenges or issues faced by the Performing Provider: Many women who deliver at Rio do not attempt breastfeeding or abandon breastfeeding shortly after leaving the hospital. Texas, and Hidalgo County in particular, have relatively low rates of breastfeeding in the first year of a baby’s life. This is due to a variety of factors including being separated from the baby for long periods immediately after birth, lack of education, lack of support materials, inconvenience, and in some cases, pain or sensitivity.

• How the project addresses those challenges: Rio will provide educational support and early intervention to encourage breastfeeding. Additionally, Rio will follow-up with women in the hospital and after they go home to attempt to encourage maintenance of breastfeeding efforts.

• 3-year expected outcome for Performing Provider and patients: This project aims to impact approximately 8,021 patient encounters, 5,906 of which should be Medicaid patients or uninsured. Rio expects that an increase in community education and support to new mothers


will have a significant impact on increasing the rate of mothers that report exclusively breastfeeding on follow up calls from the lactation specialist and trained personnel.

• How the project is related to the regional goals: Region 5’s community needs includes a lack of patient-centered care (CN.4). Many studies have found that there are significant benefits to breastfeeding including a decreased risk of death between 28 days and 1 year, increased immune system, which can prevent disease, a reduction in the risk of some childhood cancers, as well as protection from diseases that occur later in life, such as diabetes, high cholesterol, and Crohn’s disease. This project will help provide mothers of newborns greater options and education for positively impacting the life of their children.



to have 776 patient encounters in the first year (535 of which should be Medicaid or uninsured patients).

• Quantifiable Patient Impact: Rio expects to provide education and support to new mothers that deliver in the hospital to encourage breastfeeding. Based on the research in this area, it is clear that breastfeeding has significant benefits to both mother and baby. Rio is seeking to triple the encounters that each new mother has with a lactation specialist or specifically trained RN or nurse practitioner. Over the three remaining years of the demonstration, Rio expects the following patient impact:

• DY3: 776 new patient encounters, of those 535 will be from the Medicaid/uninsured population

• DY4: 3,105 new patient encounters, of those 2,142 will be from the Medicaid/uninsured population

• DY 5: 4,140 new patient encounters, of those 3,229 will be from the Medicaid/uninsured population

• Rationale: Region 5’s community needs includes a lack of patient-centered care (CN.4). Texas, and

Hidalgo County in particular, have relatively low rates of breastfeeding in the first year of a baby’s life. This is due to a variety of factors including being separated from the baby for long periods immediately after birth, lack of education, lack of support materials, inconvenience, and in some cases, pain or sensitivity. Many studies have found that there are significant benefits to breastfeeding including a decreased risk of death between 28 days and 1 year, increased immune system, which can prevent disease, a reduction in the risk of some childhood cancers, as well as protection from diseases that occur later in life, such as diabetes, high cholesterol, and Crohn’s disease. Rio expects that an increase in community education and support to new mothers will have a significant impact on increasing the rate of mothers that report exclusively breastfeeding on follow up calls from the lactation specialist and trained personnel. Rio selected the following three milestones:



o P-8: Participate in face-to-face learning (i.e. meetings or seminars) at least twice per year with

other providers and the RHP to promote collaborative learning around shared or similar projects. At each face-to-face meeting, all providers should identify and agree upon several improvements (simple initiatives that all providers can do to “raise the floor” for performance). Each participating provider should publicly commit to implementing these improvements; and


Rio selected these milestones because they most closely align with the hospital’s potential to develop a meaningful intervention with this region’s new mothers. This project addresses multiple community needs in a health area that could show improvement with targeted intervention.






• Related Category 3 Outcome Measure(s): IT-8.15b – Rate of Exclusive Breastfeeding – Rio expects to improve the rates of new mothers that report exclusive breastfeeding upon follow up calls from the lactation outreach team.

• Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): This is the only project in RHP 5 targeting improvement in breastfeeding.

• Plan for Learning Collaborative: Rio looks forward to participating in RHP 5’s learning collaborative once the Anchor develops the plan for the learning collaborative. Since Rio is the only provider with a project in this area, we hope to provide insight for other providers who are targeting other initiatives in women’s health and neonatal care.

• Project Valuation: Rio valued this project at $3,600,000 over the 3 remaining years of the Waiver. This value is based on the substantial need for this project and the impact on 8,021 patient encounters, 5,906 of which should be Medicaid patients or uninsured. This project will provide a substantial impact for our Medicaid and uninsured community and help facilitate better health outcomes for newborns.

PROPOSED THREE YEAR DSRIP PROJECT

RHP 05


Unique Project Identifier: 020947001.2.101 Provider Name/TPI: Columbia Valley Healthcare System, L.P. d/b/a Valley Regional Medical

Center / 020947001

Project Description

2.6.1 - Implement Evidence Based Health Promotion Programs – Diabetes Education - Valley Regional Medical Center (Valley Regional) intends to implement evidence based health promotion in Cameron County, Texas to target reducing complications of diabetes in school-aged residents through school-based interventions. Valley Regional will provide guidance to at-risk community members to accomplish the goal of prevention and management of diabetes for at-risk patients, particularly young residents in our low-income and Medicaid eligible communities. Establishing self-management and wellness programs for our targeted population will provide the best opportunity for positive results and ongoing outcomes.

Description of Intervention Valley Regional will hire a health promotion specialist to establish community outreach and school-based interventions for diabetic children, and the patient population susceptible to diabetes (specifically the overweight / obese population in the surrounding school districts. This program will focus on evaluation, education, nutrition, and ongoing assessment to reduce complications of diabetes and help our diabetic population better manage their disease. This project will address the core requirement of this project option which is to establish self-management programs and wellness using evidenced-based designs. This project will be comprised of the following milestones: P‐2: Development of evidence‐based projects for targeted population based on distilling the needs assessment and determining priority of interventions for the community; P-7: Review project data and respond to it every week with tests of new ideas, practices, tools, or solutions. This data should be collected with simple, interim measurement systems, and should be based on self-reported data and sampling that is sufficient for the purposes of improvement; and I‐8: Increase access to health promotion programs and activities through this project.

• Total patient impact: 3,750 patient encounters; Medicaid and Uninsured patient impact: Valley Regional is currently working with the surrounding school districts to determine the potential Medicaid / uninsured patient population to be impacted the overall project.




The RHP 5 plan notes diabetes and obesity as its first “key health challenge.” (RHP 5 Plan, Page 7). The plan cites diabetes and obesity as the third leading cause of mortality in this region behind heart disease and cancer, and an underlying component of over half of hospital admissions for heart attack, hypertension, sepsis and stroke. (RHP Plan, Page 29-30). Two community needs identified in the RHP 5 plan include the inadequate integration of care and the lack of patient-centered care. (CN3 and CN4). This project will attempt to target a more patient centered model and integrate care and address one of the biggest health challenges in the region. Target population This program intends to target students in the surrounding school districts. Valley Regional expects to have a large impact on the Medicaid and uninsured population in the region. Currently, Valley Regional serves a patient population that is at least 47% Medicaid eligible or uninsured. Valley Regional expects this project’s impact to be at least that level for the Medicaid and uninsured population of Cameron County.

Category 1 or 2 expected patient benefits Valley Regional expects to increase care for Type II diabetes for targeted pre-diabetics in the community through provider-furnished education and management about lifestyle choices, medications, and risks. Additionally, Valley Regional expects a higher rate of controlled diabetes among community members with this chronic disease. Valley Regional intends to provide 500 patient encounters in DY3, 1,250 patient encounters in DY4, and 2,000 patient encounters in DY5 for a total intervention of 3,750 patient encounters in DY3-DY5.


IT‐1.11 Diabetes care: BP control (<140/80mm Hg)234 – NQF 0061 (Standalone measure) – helping patients control their blood pressure. Valley Regional aims to improve the percentage of patients in Cameron County with uncontrolled blood pressure by educating the diabetic community on diabetes medication and diet management tactics, leading to better control of diabetic conditions. Patient education, follow-up, and management will result in better overall health outcomes for the targeted population, including increased quality of life, reduced use of acute care, and slower progression of this chronic disease. Achieving this outcome will require Valley Regional to not only communicate with the target population, but to affect their lifestyle choices. Patients will need to reduce poor eating habits, increase physical activity, and manage their medications (when applicable), which Valley Regional cannot force patients to do on a regular basis. Valley Regional intends to reach out to the community through innovative methods (including social media, creating coalitions, and other methods of community outreach) to create support networks and community engagement in accomplishing this outcome, which is meant to benefit individuals at-risk and the community as a whole.


Project Narrative


• Title of Project: Implement Evidence Based Health Promotion Programs – Diabetes Education





• Overview of Project: Valley Regional will implement evidence based health promotion in Cameron County, Texas to target reducing the complications of diabetes in school-aged residents through school-based interventions. Valley Regional will provide guidance to at-risk community members to accomplish the goal of prevention and management of diabetes for at-risk patients, particularly young residents in our low-income and Medicaid eligible communities. Establishing self-management and wellness programs for our targeted population will provide the best opportunity for positive results and ongoing outcomes. Valley Regional will hire a health promotion specialist to establish community outreach and school-based interventions for diabetic children, and the patient population susceptible to diabetes (specifically the overweight / obese population in the surrounding school districts. This program will focus on evaluation, education, nutrition, and ongoing assessment to reduce the complications of diabetes and help our diabetic population better manage their disease. This project will address the core requirement of this project option which is to establish self-management programs and wellness using evidenced-based designs.

• Project Goals: This project will focus on educating school-aged residents on the prevention and management of diabetes and its complications. This project aims to impact approximately 3,750 patient encounters over the course of the Waiver, 50% of which should be Medicaid or uninsured patients.

• Challenges or issues faced by the Performing Provider: Valley Regional has a high readmission rate for patients with diabetes because diabetic patients and families can be resistant to dietary restrictions and exercise and sometimes have difficulty complying with consistent blood-sugar monitoring.

• How the project addresses those challenges: This project implements early intervention for our region’s school-aged children to reduce complication resulting from diabetes. This project will better inform community residents to recognize the signs of diabetes, make necessary lifestyle changes to reduce the complications of diabetes, improve overall care, and better manage the disease once diagnosed.



• How the project is related to the regional goals: The RHP 5 plan notes diabetes and obesity as its first “key health challenge.” (RHP 5 Plan, Page 7). The plan cites diabetes and obesity as the third leading cause of mortality in this region behind heart disease and cancer, and an underlying component of over half of hospital admissions for heart attack, hypertension, sepsis and stroke. (RHP Plan, Page 29-30). The lack of primary care in the community (CN.1) means that providers must try more innovative approaches to addressing the region’s top health challenge, including community outreach and school-based programs. Two additional community needs identified in the RHP 5 plan include the inadequate integration of care and the lack of patient-centered care. (CN3 and CN4). This project will attempt to target a more patient centered model and integrate care and address one of the biggest health challenges in the region.


• Starting Point/Baseline: Valley Regional has not established a baseline because this is a new initiative.

Valley Regional expects to have 500 patient encounters in the first year (50% of which should be Medicaid or uninsured).

• Quantifiable Patient Impact: Valley Regional will measure the number of patient encounters of individuals receiving services or using the intervention. Valley Regional expects to increase care and reduce the complications of diabetes for targeted pre-diabetics in the community through provider-furnished education and management about lifestyle choices, medications, and risks. Additionally, Valley Regional expects a higher rate of controlled diabetes among community members with this chronic disease. Over the three remaining years of the demonstration, Valley Regional expects the following patient impact:

o DY3: 500 total patient encounters, of those 250 will be from the Medicaid/uninsured population o DY4: 1,250 total patient encounters, of those 625 will be from the Medicaid/uninsured population


• Rationale: The RHP 5 plan notes diabetes and obesity as its first “key health challenge.” (RHP 5 Plan,

Page 7). The plan cites diabetes and obesity as the third leading cause of mortality in this region behind heart disease and cancer, and an underlying component of over half of hospital admissions for heart attack, hypertension, sepsis and stroke. (RHP Plan, Page 29-30). The lack of primary care in the community (CN.1) means that providers must try more innovative approaches to addressing the region’s top health challenge, including community outreach and school-based programs. Two additional community needs identified in the RHP 5 plan include the inadequate integration of care and the lack of patient-centered care. (CN3 and CN4). This project will attempt to target a more patient centered model and integrate care and address one of the biggest health challenges in the region. This is a new project for Valley Regional. Valley Regional selected the following three milestones:



o P-7. Milestone: Review project data and respond to it every week with tests of new ideas, practices, tools, or solutions. This data should be collected with simple, interim measurement systems, and should be based on self-reported data and sampling that is sufficient for the purposes of improvement; and

o I-8: Increase access to health promotion programs and activities through this project. Valley Regional selected these milestones because they most closely align with the hospital’s potential to develop a meaningful intervention with this region’s school-aged children. This project addresses multiple community needs and the most pervasive health challenge in the region. Valley Regional aims to reduce the complication of diabetes in school-aged children, which should benefit the overall community.


o Valley Regional will accomplish the CQI core components by reviewing project data and responding to it every week with tests of new ideas, practices, tools, or solutions, which will collect data with simple, interim measurement systems, and based on self-reported data and sampling that is sufficient for the purposes of improvement.

o Additionally, Valley Regional will internally evaluate the success or failure of each project at

each reporting opportunity to evaluate what improvements can make the project more effective.


• Related Category 3 Outcome Measure(s): IT-1.11 Diabetes care: BP control (<140/80mm Hg)234 –

NQF 0061 (Standalone measure) – helping patients control their blood pressure. Since diabetes-related complications are a substantial issue for this region, this outcome matches the intent of the project and an important area where this region could show improvement. Valley Regional has not established a baseline for this measure yet, but 26% of Rio Grande Valley residents currently suffer from diabetes, indicating there is a substantial need for providers to focus on these issues. Valley Regional aims to improve the percentage of patients in Cameron County with uncontrolled blood pressure by educating the diabetic community on diabetes medication and diet management tactics, leading to better control of diabetic conditions. Patient education, follow-up, and management will result in better overall health outcomes for the targeted population, including increased quality of life, reduced use of acute care, and slower progression of this chronic disease. Achieving this outcome will require Valley Regional to not only communicate with the target population, but to affect their lifestyle choices. Patients will need to reduce poor eating habits, increase physical activity, and manage their medications (when applicable), which Valley Regional cannot force patients to do on a regular basis. Valley Regional intends to reach out to the community through innovative methods (including social media, creating coalitions, and other methods of community outreach) to create support networks and community engagement in accomplishing this outcome, which is meant to benefit individuals at-risk and the community as a whole.


• Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): Diabetes

and diabetes related complications are one of the key health challenges in this region, leading some other providers to submit projects that touched on diabetes related issues. However, only two current projects in the region address diabetes issues: one project for a region-wide disease registry and one for gestational diabetes. This project addresses a key health need in this part of the region, Cameron County, and is the only project in this county that proposes this type of intervention. One other provider submitted a similar project for Hidalgo County, but both areas could equally benefit from this type of intervention and there will not be an overlap in the target population.

• Plan for Learning Collaborative: Valley Regional looks forward to participating in RHP 5’s learning collaborative once the Anchor develops the plan for the learning collaborative. For this project, the reduction of diabetes-related complications should lead to substantial benefits across the region. This is one of the region’s highest health priorities and many providers are implementing projects aimed at reducing the number of patients with diabetes and reducing the complications of that disease. A regional learning collaborative should focus on determining the most effective means of implementing change with this region’s population, particularly its school-aged population. Project Valuation: Valley Regional valued this project at $2,200,000 over the 3 remaining years of the Waiver. This value is based on the substantial need for this project and the impact on 3,750 patient encounters. Since this project targets school-aged children, Valley Regional expects this project’s patient impact to be approximately 50% Medicaid and uninsured patients. This project meets a key community need concerning diabetes-related illnesses. This is a large scale project that should reduce long-term costs by helping younger patients address diabetes and its related complications before they become serious problems.


• Tropical Texas Behavioral Health • Enhance service availability of appropriate levels of behavioral health care • 138708601.1.101 Provider: A brief description of the provider, including the provider’s size and role as a provider in the region’s health care infrastructure.


Intervention(s): Clearly state the intervention(s). This project will expand the infrastructure and extend operating hours at our Weslaco outpatient clinic to better serve the residents of the many surrounding communities, an area referred to locally as the Mid-Valley.


The limitations posed by a shortage of clinic space (only 4,000 square ft.), inefficient building design and a lack of adequate parking required that we restrict the hours of operation and the number of persons and quantity of services we could reasonably and safely deliver from our existing Weslaco clinic.


The project will serve 100 unique persons who would not have been served prior to project implementation and provide transportation to services for 26 low income uninsured persons in DY 3; 179 unique individuals served and 29 provided with transportation to services in DY 4; and serve at least 259 individuals and transport 32 in DY 5. We estimate 40% of persons served will be Medicaid eligible and 52% will be low-income uninsured.


TTBH will expand the availability of behavioral health and substance abuse treatment services for the communities in the Mid-Valley. The expansion of our Weslaco clinic will allow the residents of these areas, many of whom currently have to travel 30 miles or more in order to receive care, to receive behavioral health care closer to home. We will increase the number of unique persons receiving services in Weslaco by at least 100 over our FY 13 baseline of 796 in DY 3, by 179 over baseline in DY 4, and by 259 above baseline by the end of DY 5. served through the project from 300 in DY 3, to 360 in DY 4 and 420 by DY 5. We will increase the number of service encounters delivered out of the clinic by at least 10%, 20% and 30% over our FY13 baseline in DYs 3, 4 and 5 respectively. We will increase the number of unique individuals provided with transportation services annually and from at least 26 in DY 3, to at least 29 in DY 4, and at least 32 by the end of DY 5.

Description of Category 3 measure(s): IT-11.27.d: Adult Needs and Strengths Assessment (ANSA)


The ANSA is an effective multi-purpose assessment tool that supports care planning and level of care decision-making for adults with behavioral health (mental health or substance use) challenges, facilitates quality improvement initiatives, and allows for the monitoring of service outcomes. Beginning in September 2013, the Texas Department of State Health Services (DSHS) replaced the Texas Recommended Assessment Guidelines (TRAG) with the ANSA as the instrument used to conduct uniform assessments of individuals seeking behavioral health care through the DSHS system.


Identifying Project and Provider Information: 1.12 Enhance Service Availability of Appropriate Levels of Behavioral Health Care Unique RHP Project identification number: 138708601.1.101 Performing Provider/TPI: Tropical Texas Behavioral Health/138708601 Project Option 1.12.1 Enhance service availability (i.e., hours, locations, transportation, mobile clinics) of appropriate levels of behavioral health care. Project Description: Positive healthcare outcomes are impacted by the ability of individuals to obtain routine and preventive healthcare services as soon as possible after the need for care has been identified. The lower Rio Grande Valley (RGV), including Hidalgo, Cameron and Willacy Counties, continues to contend with a shortage of qualified behavioral health providers in relation to the rapidly expanding population and health care needs of the region. The increasing need for specialty care that is readily accessible to the many communities throughout the RGV has also outpaced the expansion in infrastructure to adequately accommodate the need. Anything that delays or limits an individual’s ability to access health care services, or any break or disruption in services, can result in functional loss and worsening of symptoms. Through improvements to clinic infrastructure and operations funded by this project, Tropical Texas behavioral Health (TTBH) will eliminate existing limitations on the availability of readily accessible behavioral health and substance abuse care for large segment of the Valley’s population. Building on our current efforts to improve availability of behavioral health and substance abuse services throughout the Valley, TTBH will extend the days and hours of operation at our Weslaco outpatient clinic. We will also increase available clinic space, add clinical program staff and implement transportation services prioritizing the needs of low-income and uninsured persons served, who have the greatest need for assistance accessing care. The combination of expanded hours and staffing, improved infrastructure and transportation assistance for our clients most in need will have a significant positive impact on the availability of care, experience of care and health-related outcomes for the residents of the many communities of the “Mid-Valley” who must currently travel 30 or more miles East or West to receive care at our clinics in the cities of Edinburg or Harlingen. This will promote the Center for Medicare and Medicaid Services’ (CMS) objectives of ensuring access to the right care at the right time in the right setting and reducing unnecessary healthcare costs associated with barriers to receiving preventive health care. This project will also accelerate our efforts to reduce and ultimately eliminate waiting lists for behavioral health and substance abuse services. Project goals:

• Expanded capacity to deliver readily accessible behavioral health and substance use treatment services to the residents of the communities around our Weslaco outpatient clinic through the expansion of clinic space, the addition of at least nine (9) new clinic staff positions, and the extension of the days and hours of operation of medication clinic services from 2 days/16 hours per week to 5 days/40 hours per week.

• The addition of a dedicated Mobile Crisis Outreach Team (MCOT) to serve the communities of the Mid-Valley.

• Increase the number of unique persons receiving behavioral health and substance abuse treatment services at our Weslaco clinic. We will increase the number of unique individuals served annually and by at least 100 over our FY13 baseline (796) in DY 3, by at least 179 over baseline in DY 4, and by at least 259 over baseline in DY 5.

• Increase the number of behavioral health and substance abuse treatment service encounters delivered at our Weslaco clinic. We will increase the number of service encounters annually and by at least 10%


over our FY13 baseline (16,588) or 1,659 encounters in DY 3, by at least 20% over baseline or 3,318 encounters in DY 4, and by at least 30% over baseline or 4,976 encounters in DY 5.

• Implementation of scheduled services to assist low-income and uninsured clients with transportation to appropriate levels of behavioral health care. We will increase the number of unique individuals provided with transportation services annually and from at least 26 in DY 3, to at least 29 in DY 4, and at least 32 by the end of DY 5.

The project meets the following regional goals: • Increase the availability of and access to behavioral health services by expanded mental health

workforce capacity to help prevent admission/readmission to inpatient psychiatric care. • Leverage and improve on existing programs and infrastructure to ensure that the health care delivery

system will be adequately developed to meet the primary and specialty care needs of residents throughout a rapidly growing, yet historically underserved region.


• Increase the capacity of safety net providers in the region to provide patient-centered care and care management, particularly for patients with chronic conditions, to improve health literacy, self-care management skills, and more effectively access or navigate the health care system appropriately.

Challenges: • Acquiring appropriate and necessary infrastructure and equipment to achieve the proposed expansion

of service capacity at our Weslaco clinic operations. • Recruitment and retention of additional clinic staff.

Addressed by: • Steady progress in the planning and implementation of the proposed expansion through the efforts of

our Executive Management Team. • Staff recruitment and retention challenges will be addressed using existing strategies including:

o Competitive hiring and salary structure based on years of experience o Structured career ladder advancement opportunities for each position o Productivity incentive opportunities o Recruitment incentives through the agency’s Health Professional Shortage Area (HPSA)

designation with the National Health Service Corps. o Tuition reimbursement opportunities o Re-location reimbursement o Opportunities for training and education to enhance staff competencies and promote

professional development. 3-Year Expected Outcome for Provider and Patients: We will increase the number of unique persons receiving services in Weslaco by at least 100 over our FY 13 baseline of 796 in DY 3, by 179 over baseline in DY 4, and by 259 above baseline by the end of DY 5. served through the project from 300 in DY 3, to 360 in DY 4 and 420 by DY 5. We will increase the number of service encounters delivered out of the clinic by at least 10%, 20% and 30% over our FY13 baseline in DYs 3, 4 and 5 respectively, and we will increase the number of low-income uninsured clients who receive assistance with scheduled transportation to appointments in each of the demonstration years. Doing so will enhance access to the right care at the right time in the right setting and the experience of care for those served at this clinic; increase utilization of routine behavioral health services and reduce the need for more costly emergency interventions. This expansion will also support our efforts to eliminate our existing waiting lists and avoid the use of waiting lists in the future. Using a validated standardized outcome measure (consideration is being given to the Adult Needs and Strengths Assessment (ANSA) and the Addiction Severity Index (ASI) and Teen-


ASI) we expect to show that enhancing the availability of and access to behavioral health and substance abuse services including dedicated crisis outreach services, will yield improvements in a variety of functioning and quality of life domains for our clients from the communities in the Mid-Valley. Starting Point/Baseline: 796 unique individuals received behavioral health services at our existing Weslaco outpatient clinic in FY 2013, and 16,588 service encounters were completed. Scheduled services to assist low-income uninsured persons with transportation to behavioral health care were not available at our Weslaco clinic in FY 2013. Quantifiable Patient Impact: We will increase the number of unique persons receiving behavioral health services at our expanded Weslaco clinic who would likely not have received services at the clinic prior to implementation of the project, by at least 100 over our FY13 baseline in DY 3, by at least 179 over baseline in DY 4 and by at least 259 over baseline by the end of DY 5. We will increase the number of behavioral health service encounters delivered from our expanded clinic 1,659 over our FY13 baseline in DY 3, by at least 3,318 over baseline in DY 4 and by at least 4,976 over baseline by the end of DY 5. We will also provide routine and scheduled transportation services to appropriate behavioral health services at the Weslaco clinic to at least 26 unique individuals identified as low-income uninsured in DY 3, to at least 29 unique individuals in DY 4 and to at least 32 unique individuals in DY 5. Rationale: Residents of the Mid-Valley contend with the same obstacles to seeking routine health care that impact individuals and families across the Rio Grande Valley including inadequate access to reliable transportation due to the disabling effects of poverty and the problems associated with using public transit systems with limited routes and coverage areas. Furthermore, individuals with mental illness often don’t know about available transportation services or how to use them, and low-income uninsured persons with mental illness often do not benefit from transportation programs that are limited to those with Medicaid or other insurances. In July 2012, 2,150 adults served by TTBH responded to survey questions concerning patterns of health care use and ability to access care. Forty-three percent (43%) reported that they lacked health insurance; more than 25% indicated their home was 10 or more miles from the nearest medical facility; 30% reported that they had only occasionally reliable transportation or none at all; only 3% reported using public transportation to get to their appointments; and although a majority of respondents said they relied on personal vehicles or the support of family or friends to get to their appointments, nearly half (48%) indicated they did not access routine checkups or preventive care on a regular basis. As mentioned previously, delays in access appropriate behavioral health care have been linked to disproportionately high rates of negative outcomes for people mental illness including disability, unemployment, homelessness, substance abuse, incarceration, hospital emergency department visits, psychiatric and medical inpatient hospitalization, complications of co-morbid illnesses and suicide. There is ample evidence indicating that delays in accessing community-based mental health services often results in more expensive emergency and crisis-related interventions. In 2011, a study by Health Management Associates of proposed budget cuts to community-based mental health services in Texas found the average per day cost of community-based services was $12 for adults and $13 for children, compared to $401/day for a state hospital bed, $137/day to incarcerate a person with mental illness and $986 for an emergency room visit.


This project will improve the infrastructure and extend operating hours at our Weslaco outpatient clinic to better serve the residents of the surrounding communities, an area referred to locally as the Mid-Valley. The limitations posed by a shortage of clinic space (only 4,000 square ft.), inefficient building design and a lack of adequate parking required that we restrict the hours of operation and the number of persons and quantity of services we could reasonably and safely deliver from our existing Weslaco clinic. As a result, many individuals and families from the cities of Weslaco, Donna, Mercedes, Progreso, Alamo, Edcouch, Elsa, Monte Alto, La Feria, La Blanca and La Villa, and the many unincorporated colonias in the area, must travel 30 or more miles to the East or West to access care at our Edinburg or Harlingen clinics, presenting a potentially significant barrier to accessing care. We will resolve the barriers caused by these limitations and expand our capacity to deliver readily accessible behavioral health and substance use treatment services to the residents of these communities. We will accomplish this through the expansion of clinic space, the addition of new clinic staff including a dedicated MCOT and the extension of the days and hours of operation of our medication clinic from 2 days/16 hours per week to 5 days/40 hours per week. Our data indicate that we served 3,000 unduplicated persons from Mid-Valley communities in FY 2013. This number does not include the many individuals who, for a variety of reasons, do not provide us with accurate information regarding their city of residence. Given the potential number of people from the Mid-Valley needing access to conveniently located behavioral health and substance abuse treatment services, and the evidence pointing to the elevated risk of devastating outcomes for individuals with mental illness when routine care is not readily available, this project to enhance the availability of appropriate levels of behavioral health care for these communities has the potential to make a significant contribution to transforming the healthcare delivery system and improving healthcare related outcomes in our region. This project addresses the following community needs identified in the RHP 5 Plan:

• CN.2: Shortage of behavioral healthcare professionals and inadequate access to behavioral healthcare • CN.3: Inadequate integration of care for individuals with co-occurring medical and mental illness or

multiple chronic conditions • CN.4: Lack of patient-centered care

Project Core Components:

a) Evaluate existing transportation programs and ensure that transportation to and from medical appointments is made available outside of normal operating hours. If transportation is a significant issue in care access, develop and implement improvements as part of larger project. This project will not address transportation services outside of normal operating hours at this time. We have and will continue to gather information on the transportation issues facing the population we serve. Through the project, transportation to necessary behavioral health care will be made available to low-income uninsured persons served from the Mid-Valley, whose access to services is most seriously impacted by a lack of reliable transportation.

b) Review the intervention(s) impact on access to behavioral health services and identify “lessons learned,” opportunities to scale all or part of the intervention(s) to a broader patient population, and identify key challenges associated with expansion of the intervention(s), including special considerations for safety-net populations. This will be accomplished through our existing Quality Management and performance improvement structures as explained in the project description; through planned learning collaborative activities with regional partners as appropriate; and through the collaborative activities of the Community Mental Health Center consortia sponsored by the Texas Council of Community Centers.

Customizable Process or Improvement Milestones: RHP Plan for [RHP 5/South Texas] 130

NA Related Category 3 Outcome Measure(s): IT-11.27.d: Adult Needs and Strengths Assessment (ANSA) The ANSA is an effective multi-purpose assessment tool that supports care planning and level of care decision-making for adults with behavioral health (mental health or substance use) challenges, facilitates quality improvement initiatives, and allows for the monitoring of service outcomes. Beginning in September 2013, the Texas Department of State Health Services (DSHS) replaced the Texas Recommended Assessment Guidelines (TRAG) with the ANSA as the instrument used to conduct uniform assessments of individuals seeking behavioral health care through the DSHS system. As it relates to this project, we would use the instrument to measure outcomes associated with improved functioning as a result of this intervention across a range of assessment domains including strengths, needs, behaviors and history of psychiatric crises and hospitalizations, in the manner described by the Praed Foundation, developers of the ANSA. Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): Enhancing the availability of appropriate levels of behavioral health care is fundamental to the success of our projects to expand and enhance TTBH’s behavioral health services including projects to provide necessary behavioral health services to an increasing number of individuals diverted from the criminal justice system (Project 138708601.2.2), to persons with co-occurring substance use disorders (Project 138708601.1.2) and/or to persons with co-occurring Intellectual and Developmental Disabilities (Project 138708601.2.9). We will work with Border Region Behavioral Health Center, the LMHA serving Starr County, and other regional partners as indicated, to develop and participate in learning collaborative activities related to our respective projects to enhance the availability of behavioral health care services. Plan for Learning Collaborative: TTBH will make its website available for web-based information sharing and reporting. We will request that the Texas Council of Community Centers consider coordinating bi-annual face-to-face meetings between LMHAs involved in similar healthcare transformation projects to promote sharing of challenges and testing of new ideas and solutions. Project Valuation:

• Jail Diversion is a key component of our proposed project. According to the Treatment Advocacy Center, 40% of individuals with serious mental illnesses have been in jail or prison at some time in their lives. In DY 3 TTBH expects to realize a savings of $10,960 per jail diversion based on an average duration of incarceration of 80 days at a cost of $137/day. As such, the overall value of jail diversions is calculated to be $3,909,176 by the end of DY 5.

• Homelessness: Five percent (5%) of the individuals in our mental health service population were identified as homeless or at imminent risk for homelessness by our PATH (Projects for Assistance in Transition from Homelessness) and Supported Housing programs. A two-year University of Texas survey of homeless persons found that the cost to taxpayers attributed to a single homeless person was $14,480 per year. As such, we calculated the overall value related to avoidance of homelessness to be $692,258 the end of DY 5.

• Hospital: According to the Hogg Foundation, 18.6% of admissions to medical hospitals are related to mental health conditions. Our data indicate that approximately 1.2% of our service population is admitted to a medical hospital while an estimated 17.4% are kept out of the hospital. The Texas Hospital Association sponsors Texas Price Point as a resource for information on Texas hospitals. From this resource, we obtained data pertaining to psychiatric care delivered in the counties of our local


service area. We arrived at a weighted average hospital stay of 5.3 days and a weighted average collection cost of $678. Therefore, the overall value related to hospital admissions was calculated to be $772,119 the end of DY 5.

• Emergency Room Utilization: Individuals in our service population who are admitted to hospitals are frequently served in emergency departments prior to admission. Accordingly, based on our review of cost data from local hospitals we arrived at a estimated cost per emergency department visit of $986, and a total valuation attributed to emergency department utilization of $206,226 by the end of DY 5.

• The valuation estimate for the Category 3 measure was established based on the required minimum percentage of the total project valuation for each of DYs 3, 4 and 5 prescribed in the Program Funding and Mechanics Protocols (10%, 10% and 20% respectively). At this time the total valuation for the proposed Category 3 outcome measure for this project is $1,059,303.31.



Performing Provider Name: University of Texas Health Science Center Houston Project Title: Implement a Chronic Disease Management Registry; Implement/enhance and use chronic disease management registry functionalities. Unique RHP Project Identification Number: 111810101.1.100 Performing Provider/TPI: University of Texas Health Science Center- Houston/111810101 Project Option: 1.3.1 Implement/enhance and use chronic disease management registry functionalities Required core project components:

Project Summary

Provider:

The University of Texas Health Science Center Houston (UTHealth) serves the South Texas area through its UT School of Public Health Campus and its mobile clinical van located in RHP 5. It trains students and provides primary health care to indigent patients through its mobile services. Additionally, students being trained in medicine and public health have border experiences providing care in South Texas.

Intervention: This project is designed to implement a chronic disease registry, specifically diabetes, in RHP5. In doing so it will sustain and expand the Rio Grande Valley Health Information Exchange and create the first network of providers connected through the new HIE in RHP5, and provide a means to give integrated care to patients across a range of RHP5 providers. The registry will provide integrated management and intervention in a population where 31% of the adults have diabetes. This project will allow for the creation and oversight of a diabetes management registry through the integration of an electronic medical record (EMR) system in community diabetes self-management education (DSME), diabetes self-management support (DSMS) programs, independent non-hospital-based community health centers (FQHC), and integrated chronic disease management programs in hospitals, in public health clinics and implementation of a health information exchange (HIE) system. This centralized data will provide invaluable support to designing customized treatment plans, setting self-management goals, and improving quality of care (QI).

Need for the Project:

Over 70% of the adult population has one or more chronic conditions. Over 50% of the adult population is obese and another 30% are overweight. Diabetes is present in 31% of adults, of whom less than half are diagnosed and only about 50% of those who know they have diabetes are on adequate treatment. Thus the need for a much improved system of registry, tracking and management. Diabetes results in $227million in lost wages in RHP5 region. For all chronic disease, especially diabetes, prevention and intervention is largely neglected and patients often only receive care when they develop severe disease requiring Emergency Department or Inpatient care. So continuous and integrated care is vital to controlling diabetes in RHP5.

Target Population:

The RGVHIE covers 26 hospitals, clinics and other organizations that provide primary care, that covers about 500,000 population. We will target those with diabetes identified in these institutions and create a registry that will be available across the set of institutions so that patients with diabetes, identified in the RGVHIE, will be part of the disease registry. This will make their data available to all of the participating institutions in order to improve the integration and continuity of care and reduce redundant tests and evaluations.


Our goal is to make the registry functional for at least 60% of the participating organizations by end of year 3, and to increase enrollment in the registry by 10% over baseline for each subsequent year.



1-20. Improve diabetes control in registry patients by 5% by year 4 and another 10% by year 5.

PROJECT DESCRIPTION: This project will allow for the creation and oversight of a diabetes management registry through the integration of an electronic medical record (EMR) system in community diabetes self-management education (DSME), diabetes self-management support (DSMS) programs, independent non-hospital-based community health centers (FQHC), and integrated chronic disease management programs in hospitals, in public health clinics and implementation of a health information exchange (HIE) system. The EMR is an electronic version of a patient's medical history that is maintained, over time, by the provider and may include all of the key data relevant to that person's care under a particular provider, including demographics, diagnoses, progress notes, medication, vital signs, past medical history, immunizations, laboratory data, and radiology reports. Additionally, the EMR contains data that support other activities such as quality management, and outcomes reporting. For the patient, this translates into the availability of pertinent information and coordination of services between any potential providers. Importantly for this Data relating to diabetes is also available from the EMR to create the diabetes registry. This centralized data will provide invaluable support to designing customized treatment plans, setting self-management goals, and improving quality of care (QI).

Goals and Relationship to Regional Goals: The goals for this project include: • Enhancement of chronic disease management through implementation of an EMR system and strengthening and expansion of the HIE. • Creation of a registry for diabetes using EMR data.

Chronic diseases, highlighted by diabetes, are a major problem identified in the RHP5 needs assessment. Implementation of an EMR system and expansion of the HIE will provide the foundation for creating a diabetes patient registry that will greatly enhance the capacity of RHP5 to address the issue of management and control of diabetes, a major need of RHP5.

Challenges: Among the most significant problems identified in the needs assessment of RHP5 is the lack of access to health services primarily because of poverty and lack of insurance. These factors result in patients not having regular access to primary health care services and lead to the use of emergency room services for chronic care management. This produces fragmented management of chronic disease and in the case of diabetes poorly controlled blood sugar and greatly increased risk of complications. The need for greater care coordination, communication between health care providers, and resources to decrease these barriers is clear.

3-Year Expected Outcome for Provider and Patients: We expect to see: • An increase in the number of patients recorded in the registry relative to the baseline number of 0 with 500 patients entered each of the years DY3, DY4 and DY5. • An increase in the number of patients enrolled in the registry which should reflect an annual increase with more clinics and providers participating.


STARTING POINT/BASELINE: The current status of zero functionality of the HIE and no diabetes registry will serve as the project baseline.

QUANTIFIABLE PATIENT IMPACT: We will increase the registry by 500 patients per year for each of the 3 years of operation for a total of at least 1500 patients into the registry by end of DY5.

RATIONALE: Diabetes and obesity are at the root of many of the chronic conditions dominating RHP5 and therefore top of the list of needs. Self-reported obesity approaches 35% but measured obesity in the Cameron County Hispanic Cohort (CCHC: consisting of over 2,000 adults randomly recruited in the community) is 49%.4;5 Disturbingly, though self-reported diabetes is 13.7% objectively measured diabetes in adults over 18 years is more than twice at 30.7% and half are untreated, leaving a very large pool of undiagnosed as well as untreated people.4 The costs for these two conditions alone runs into the hundreds of millions of dollars for RHP5. Underlying diabetes is present in over 50% of hospital admissions in RHP5 for serious conditions.1 The RHP5 cost in lost wages alone from diabetes is $227 million a year.6

Twelve percent of the population in Health Region 11 (from which some of the counties in RHP 5 are drawn) reported that they had diabetes in 2010 based on the Texas behavioral risk factor surveillance system, showing that the 4 counties rate of self- reported diabetes is 9.1% with a range from 11% to 18% of the adult population.5 However, the prevalence of diabetes in a randomly selected group of 2,000 people from the CCHC in whom the actual level of measured diabetes is in fact just shy of 31%.4 The same figure shows that self-reported diabetes is 14.7% consistent with the BFRSS data. However population in RHP5 is poor with little access to healthcare. Among Mexican-Americans nationally more are more overweight than obese whereas local published data show that more are obese than overweight. Similarly undiagnosed diabetes is 13.7% compared to 10.4% in Mexican-Americans nationally. The overall prevalence of self-reported diabetes nationally is 8.3% but in our population 17% of the total adult population has diabetes and is unaware of it; that is more people are undiagnosed than diagnosed with diabetes.4

The impact of diabetes on hospital care shows the proportion of patients with the major causes of hospital admission who also have diabetes to be 57% of heart attacks, strokes and sepsis to 90% of those with leg ulcers and retinopathy. The impact of diabetes on length of hospitalization in RHP5 is substantial and accounts for 2,126 extra days in the ICU, and 14,087 days of excess hospitalization. The estimated cost ranges from $48 million to $82 million.

While EMR systems are being implemented in providers offices, hospitals and large clinics, the HIE program in RHP5 is in its infancy. Without an HIE, the EMR system will be very limited in its potential to create true delivery system reform. The UT School of Public Health recognizes the potential for public/community based health benefits, particularly in effective management of chronic disease such as diabetes and is therefore taking the lead in this project to ensure that hospitals, the nascent Rio Grande Valley HIE, and multiple providers including larger public clinics are vested in the process.

The community health clinics, hospitals and diabetes education programs in RHP5 have a large population of low-income, uninsured, and medically underserved people. Moreover, the UTSPH in partnership with the


participant clinics and hospitals and the RGVHIE will create a registry to collect, analyze and disseminate data related to diabetes. Ultimately the RGVHIE will be developed to the point that it can take on the responsibilities for the HIE and disease registry process for all chronic diseases.

Based on current guidelines for EMR data the patient will have the ability to authorize who would be permitted access to the information. Ultimately, every provider designated on the patient's care team would be able to share notes, coordinate treatments, consider diagnostics and medication regimens refer to inpatient and emergency department records, and review adjunct protocols and action plans from services such as diabetes self-management education and support.

EMRs, HIE and their use for chronic disease management and broader purposes of health service delivery comprise potent tools of efficiency, cost saving and improved patient safety and outcome. The data and its timeliness and availability, will enable providers to make better decisions based on a more comprehensive patient record, provide better care, avoid duplication of diagnostics, and at the same time empower the patient to be an adherent participant in the process. Development of the RGVHIE will also enhance collection and reporting of other chronic diseases as well as other illnesses such as those caused by infections. PROJECT COMPONENTS: Through the Chronic Disease Management Registry project we propose to meet all required project components listed below. The selected milestones and metrics relate to project components.

a) Enter patient data into the diabetes (chronic disease) registry.

b) Use registry data to help patients to manage their diabetes by identifying those with diabetes, especially those at risk for poor control. We will provide that information to the appropriate providers (hospital or clinic) for follow up. Thus, we will identify the disease status (controlled, marginal, not controlled), the risk of marginal or uncontrolled status (hi, medium, low) and provide that information to the provider (hospital or clinic) to help guide patient management and entry into an evidence based diabetes education and self-management program.

c) We will provide registry reports to assist providers to develop and implement targeted plan for diabetes management. We will provide a blueprint and training to provider on an evidence based system for diabetes management based on a companion project aimed at chronic care management. Thus the registry and the chronic care management blueprint will provide a means for providers to use the registry data to identify and enter patients with diabetes into an evidence based diabetes management program.

d) We will conduct quality improvement by holding 6 monthly meetings to identify project impacts, identify “lessons learned,” and identifying key challenges associated with expansion of the project, particularly to the large population of safety net patients in RHP5.

MILESTONES AND METRICS: The following milestones and metrics have been chosen for the Chronic Disease Management Registry project based on the core components and the needs of the target population: Process Milestones and Metrics: P-1 (P-1.1); P-2 (P2.1), P-4 (P-4.1) P-7 (P-7.1) P-15 (P-15.1)


Improvement Milestones and Metrics: 1-15 (15.2 QPI measure number of individuals managed in the registry); I-16 (I-16.1)

Unique community need identification number the project addresses: • CN.3 Inadequate integration of care for individuals with co-occurring medical and mental illness or multiple chronic conditions • CN.4 - Lack of Patient-Centered Care

RELATED CATEGORY 3 OUTCOMES MEASURE(S): We will consider the related Category 3 outcome measure IT-1.10, Diabetes care: HbAlc poor control (>9.0%). The availability of each patient's accurate and timely medical information to the care team should allow for the early identification and prevention of emerging medical problems. So we will document The percentage of patients 18-75 years of age with diabetes whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year. These data will be given to providers along with a blueprint for an evidence based method of diabetes patient education and management that is being implemented in another project.

RELATIONSHIP TO OTHER PROJECTS: This project is directly related to other projects aimed at reducing the burden and improving the management of chronic disease, particularly diabetes in RHP5:

[085144601].2.1 Implement medical homes in HPSA and other rural and impoverished areas.

[085144601].2.2 Expand Model of Management of Chronic Diseases in Lower Valley of RHP 5

[085144601].2.3 Establish/Expand a Patient Care Navigation Program based on a Mobile Clinic model

[085144601].2.4 Implement Evidence-based Health Promotion Programs

This project is related to all of the above projects because it will interact with each of the programs in potentially providing access to patient information by each of the entities in these projects aimed at reducing the burden of chronic disease in RHP5.

Additionally, the implementation of an HIE system will be a catalyst for improved outcomes and coordination amongst health care providers, educators and outreach workers, strengthening the projects related to medical homes and chronic care management.

RELATIONSHIP TO OTHER PERFORMING PROVIDERS’ PROJECTS AND PLAN FOR LEARNING COLLABORATIVE: The UT School of Public Health will facilitate the development of a learning collaborative during the project period. Working together to develop and implement a Health Information exchange will bring to light many similarities among performing providers and will also highlight those areas where challenges can be overcome.


PROJECT VALUATION: RHP5 has a population of 1,260,000 with 60% or more uninsured (756,000), with 31% of the adult population having diabetes, this calculates to over 250,000 adults with diabetes, 60% (150,000) who have diabetes but no health insurance, many who do not qualify for county indigent health care. These patients along with the underinsured receive their health care in community-based health centers and hospital emergency departments (ED). The Federally Qualified Health Clinics in RHP5 alone have more than 25,000 patients with diabetes. Often, patient populations such as the working poor, undocumented immigrants and those at the edge of RHP5 society seek medical care within the non-hospital based community health centers, public health centers and support programs. These community based providers do not have access to patient records electronically; hence, as a person seeks treatment and services at whichever site that is most immediately affordable there is no continuity of treatment records. This is reciprocal for the local hospital systems when the aforementioned patient population presents as a hospital or emergency room admission.

While all of the clinics have EMRs they are not connected through the nascent RGVHIE. This project seeks to utilize the availability of EMR in each of the community based sites and interface each site with the RGVHIE a Health Information Exchange (HIE). The RGVHIE HIE recently received approval from the Texas Department of State Health Services. The timing of this proposed community based project is a natural fit to the ongoing efforts to connect individual health providers, hospital systems, diagnostic facilities and ancillary clinics with the HIE. As the HIE uses well established software vendor to gather information from a variety of sources, but it also requires services. These tools will also enhance coordination of care throughout many clinics and hospitals in RHP5.

Workflows in the HIE are scalable and accommodate the increasing number of chronically ill patients. The EMR and HIE together offer the capacity to create a patient registry specific to chronic diseases such as diabetes, so that as a patient moves from one point of care to the next, each provider has access to critical information. What ensues is a level of proactive and preventative care that can reduce complications and the need for hospital and/or emergency room visits. One analysis conducted with the North Carolina Medicaid system found that significant cost savings may be derived if these interventions are associated with even modest improvements in the appropriateness of care. With only 5% of non-urgent, emergency department encounters redirected to the more appropriate care setting, there will be substantial savings in monthly cost to the State's Medicaid system.

Using HIE's to improve care, enhance coordination among members of the care team, enable regular and frequent interventions can help to lower overall health care costs and produce a substantial ROI for a community or organization. For example in RHP5 patients with diabetes admitted to the ICU or medical or surgical services had 1-1.5 days longer hospitalizations which result in over $40 million per year in increased costs. Reduction by 10% would save at least $4 million per year. Diabetes is one of the most common causes of visits to ED and emergency hospital admissions in RHP5. Furthermore the level of disability in RHP5 is one of the highest in Texas. All of these add millions of dollars to the cost burden of diabetes and justify all of the efforts to identify and manage the disease in a much more organized, comprehensive an integrated manner. The use of EMR in combination with an HIE in RHP5 will greatly facilitate this effort and far more than pay for itself.


Medicaid Eye Care Clinics 160709501.1.103 Doctors Hospital at Renaissance / 160709501 Project Option: 1.9.2 Project Description: Doctors Hospital at Renaissance (DHR) proposes to establish a diabetic-focused ambulatory eye clinic and outreach education program for Medicaid-eligible and indigent patients. The project is designed to increase the accessibility of optometry care for at-risk populations in RHP 5, a designated healthcare provider shortage area (HPSA). Doctors Hospital at Renaissance will establish a new clinic that will provide access to comprehensive eye care that can detect, prevent, and/or treat many common eye conditions in partnership with the University of Houston, College of Optometry (UHCO). Clinic staff; faculty; students and residents; and new graduates from UHCO who participate in the clinic will help expand the primary care workforce and lead to enhanced eye care services. The key tenants of this project are centered on access to primary eye care, prevention of ocular morbidity as it relates to eye diseases and general health and detection of systemic diseases such as diabetes, vascular disease and hypertension. In addition, this project will address vision needs as they relate to correction of refractive conditions. The project will target individuals that are Medicaid-eligible or indigent. Priority will be given to patients that are diagnosed with type 1 or 2 diabetes due to the increased risks of eye complications associated with diabetes.

The project will provide/expand comprehensive eye care to an at-risk, Medicaid population affected by diabetic complications (approximately 1 in 3). Common eye conditions impacting diabetic patients include23:

• Diabetic retinopathy – a leading cause of blindness in American adults • Cataract – clouding of the eye’s lens. • Glaucoma – increase in fluid pressure inside the eye that leads to optic nerve damage and loss of vision.

Goals and Relationship to Regional Goals: The overall goal of the project is to expand the availability of ocular service for a population that has traditionally lacked access to necessary eye care. Access to preventative care and follow-up treatments for diabetic eye conditions will allow for opportunities in patient self-management as vision plays a crucial within medication adherence24 and glycogenic control. To accomplish this, Doctors Hospital at Renaissance will:

• Create a primary eye care clinic staffed with optometrist, faculty, optometry students, and optometric residents;

• Create and implement an innovate eye care center that will be capable of providing the latest in comprehensive eye care, including annual dilated fundus examinations on diabetic patients; and

• Create an innovative outreach program that engages the community and helps resolve healthcare barriers for indigent and Medicaid patients.

23 National Eye Institute: http://www.nei.nih.gov/health/diabetic/retinopathy.asp 24 National Eye Institute: http://www.nei.nih.gov/lowvision/content/medication.asp RHP Plan for [RHP 5/South Texas] 139

Additionally, to ensure long-term success DHR will work:

• To infuse the RHP 5 medical community with primary care optometry care specialist who will focus on prevention and root causes of diabetic retinopathy;

• To conduct quality improvement projects to continuously improve clinical outcomes and efficiency; and • To collaborate with the University of Houston, College of Optometry to expand overall eye care services

in the region to transform the delivery system and the health status of the South Texas community. This project meets the following regional goals:

• By combining the resources of DHR as a major safety net hospital, the University of Houston, College of Optometry, and the Joslin Clinic at Renaissance this project will improve on existing programs and infrastructure to ensure that the healthcare delivery system will be adequately developed to meet the eye care and diabetic needs of residents throughout the a rapidly growing, yet historically underserved region.

• Increase access to primary eye care services with new care providers, residents, and faculty. • Transform healthcare delivery to a patient-centered, coordinated and integrated delivery model that is

capable of providing the latest in comprehensive eye care, including annual dilated fundus examinations on diabetic patients.

• Facilitate a culture of ongoing quality improvement and innovation that maximizes the use of technology and best practices to improve access and timely utilization of appropriate care.

• Assist patients with chronic conditions in a manner that enhances quality of life and prevents vision impairment. This is a central mission as vision impairment leads to a dramatic increase in care needs and makes self-management25 of health conditions increasingly difficult and prompts an escalation of preventable conditions, admission, and readmissions.

• Address the public health issues of the fastest-growing, economically and educationally disadvantaged RHP 5 population.

• Address clinical preventive services at the individual patient and community level. Unique community need identification number the project addresses:

• CN.1 – Shortage of primary and specialty care providers and inadequate access to primary or preventative care.

Challenges/Issues: Creating a new diabetic-centered eye care center from the ground up is time consuming and requires specialized training and evidence-based clinical guidelines. To ensure success, it will be necessary to recruit new and train current eye care providers and to actively engage the community to participate in the clinic’s programs. Addressing the challenges: DHR will partner with University of Houston, College of Optometry (UHCO). UHCO will provide faculty, students, residents, and training to help meet key needs required to fully implement the project. Additionally, DHR will work with the Joslin Diabetes Center at Renaissance to structure new clinical protocols, patient

25 European Journal of Clinical Pharmacology: http://link.springer.com/article/10.1007/BF00226324 RHP Plan for [RHP 5/South Texas] 140

engagement programs, and other training that will reduce cultural, clinical, and socioeconomic barriers that frequently exist in low income populations. DHR, UHCO, and the Joslin Center will work together collaboratively to establish an innovative eye clinic that creates new and effective care protocols, increases access to eye care services, and implements a robust disease management program to meet the unique needs of RHP 5. 3-Year Expected Outcomes/Benefits: By the end of the Demonstration Period in September 2014 (DY3), key staff will be recruited, required care providers will be employed, clinic operations will have commenced. The measures of expected outcomes and benefits will include the number of patients participating in routine eye examinations, the percentage of patients returning for regularly scheduled follow-up exams, the percentage of patients accepting referrals for advanced testing and vision services, the prevalence of diabetes related retinopathy and glaucoma, and the percentage of patients enrolled through other clinics who have received routine eye exams within the last year. Quantifiable Patient Impact: General and diabetic eye care services will increase as the program matures and care protocols are fully developed and implemented. Once the clinic becomes fully operational, we project that 300 unique patients will be served by clinic providers, faculty, and rotating residents. Given that optometry exams take on average between 30 minutes to an hour depending on the experience of the provider and the complexity of the case, patient encounters will not reflect the volume experienced in general medicine primary care clinics. We project that over 60 percent of patients will be Medicaid-eligible or low income uninsured patients. If there is any availability within the clinic, any and all populations will have an access to this specialty care. Educational and outreach public health initiatives will be almost exclusively aimed at low-income uninsured or Medicaid-eligible populations. Starting Point/Baseline: DHR currently does not operate a diabetic-centered eye care center. The starting baseline for care services and patient access will be set at the end of DY3 once the clinic has been established and staffed. Rationale & Data Driving Project: In RHP 5, the shortage of and need for diabetic-centered care is thoroughly addressed in the community needs assessment of this plan. The prevalence rate of diabetes in the Rio Grande Valley is particularly high at 26 percent, or 1 in 3.8 people. Hidalgo County's rates are double the statewide average of hospital admissions for long-term diabetes complications, according to the Texas Department of State Health Services. That means if current trends continue, 1 of every 2 Hispanic children born today will face a lifetime with this disease.26 Every person with diabetes is at risk of developing diabetic retinopathy27. More than 75% of people who have diabetes for more than 20 years will have some form of diabetic retinopathy. While diabetic retinopathy is not currently

26 Hidalgo County, “November is Diabetes Awareness Month”, 2013. http://www.co.hidalgo.tx.us/index.aspx?NID=1033 27 World Health Organisation (WHO), ‘Prevention of Blindness from Diabetes Mellitus’, (2005), available at: http://www.who.int/blindness/Prevention%20of%20Blindness%20from%20Diabetes%20Mellitus-with-cover-small.pdf. RHP Plan for [RHP 5/South Texas] 141

http://www.who.int/blindness/Prevention%20of%20Blindness%20from%20Diabetes%20Mellitus-with-cover-small.pdf

http://www.who.int/blindness/Prevention%20of%20Blindness%20from%20Diabetes%20Mellitus-with-cover-small.pdf

the primary cause of avoidable blindness, it has the capacity to become the leading cause of blindness in the next 20 years and it will affect the poorest people with a greater frequency28. Project Core Components: Each milestone has been selected for the purpose of increasing diabetic eye care for the Medicaid population within RHP 5. The time period within DY3 is being used to establish the clinic making certain that all proper staffing, supplies, and protocols are in place to maintain a safe clinical setting promoting patient satisfaction. Once the clinics have been established and a baseline has been set, increasing the clinical volumes will be sought after within DY4, DY5, and onward. Community need 1, expansion of primary and specialty care, is being improved on with direct expansion of specialty care. Primary care physicians will have the ability to refer their patients that meet criteria out to the clinic to receive follow-up care increasing the quality of care that is available within the continuum.

• Increase service availability with extended hours: To ensure that the those patients who are not available during normal working hours to receive specialty care, extended hours will be available on selected days to ensure that the best possible amount of patients are granted access.

• Increase number of specialty clinic locations: The eye clinic is establishing its location within

strategically placed areas for optimal community outreach and accessibility.

• Implement transparent, standardized referrals across the system: Establishing eye clinics that are focused on providing services with a diabetic focus is a new endeavor that will be established with a referral procedure that emulates best practices.

• Conduct quality improvement: Quality improvement will become necessary once patient analytics are

in place to ensure that optimal services are being provided within the time allotted. Employee observations, trends that become apparent within aggregated data and physician recommendations will all be accumulated within a “lessons learned” approach to develop improvements when discovered. This will allow for the clinic to make adjustments where necessary to provide a safe, quality, and positive patient experience.

Related Category 3 Outcome Measures: IT-1.12 Diabetes care: Retinal eye exam235—NQF 0055 (Non- standalone measure) a.) Numerator: An eye screening for diabetic retinal disease as identified by administrative data. This includes diabetics who had one of the following:

• A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year, or

• A negative retinal exam (no evidence of retinopathy) by an eye care professional in the year prior to the measurement year b.) Denominator: Members 18 to 75 years of age as of December 31 of the measurement year with diabetes (type 1 and type 2)

28 International Diabetes Federation, IDF World Atlas Fifth Edition, ‘The Global Burden’, (2011), available at: http://www.idf.org/diabetesatlas/5e/the-global-burden. RHP Plan for [RHP 5/South Texas] 142

http://www.idf.org/diabetesatlas/5e/the-global-burden

Relationship to other Projects: Doctors Hospital at Renaissance (DHR) is implementing a series of projects that include residency programs, diabetes clinical expansions, medication reconciliation, and pharmaceutical care services. The primary morbidity that DHR is seeking to improve on is diabetes. As patient volumes increase within each of the projects, those that need specialty ocular care will have the ability to receive such care through the eye clinic that specializes in diabetic complications. This project represents an opportunity to add a comprehensive method of care within the healthcare delivery continuum. Plan for Learning Collaborative: Doctors Hospital at Renaissance will participate in the statewide learning collaborative that is being organized by the Texas Health and Human Services Commission. Every effort will be made to collaborate with the RHP5 anchor in providing any and all results from the implemented projects including lessons learned. All findings will be supported by data and provided in a meaningful manner so that other participating providers can contribute as well. Project Valuation: The project’s impact on children and families in RHP 5 can be substantial. In addition to increasing access to eye care, this project can positively impact the serious conditions that develop in diabetic patients and reduce the burden of cost of poor health in RHP 5. Several forms of preventable blindness exist in higher incidence in the Hispanic population in general and RHP 5 in particular, including diabetic retinopathy and glaucoma. Both of these diseases are manageable and, if detected early, can decrease the incidence of blindness or decreased visual function. The provision of regular eye examinations on the project’s targeted population will result in early identification and intervention of these diseases. In addition, other diseases that affect visual function or are signs of systemic disease, such as systemic hypertension and vascular disease can be detected and triaged to the appropriate healthcare resource. Diabetic patients have a significant risk of developing diabetic retinopathy with potentially catastrophic ocular complications including blindness. Early intervention on these and other conditions can significantly decrease the incidence of blindness and reduce significant long-term health costs. Also, it is well established that compromised visual function can lead to mental health issues such as depression. Although detection and intervention in ocular disease is paramount, the identification of refractive errors and binocular vision problems such as nearsightedness, farsightedness, crossed eyes and lazy eye can have a significant impact on a child’s ability to learn and perform in school. It is not uncommon that undiagnosed vision problems have translated to behavioral issues in the classroom. This project will help address a number of these health needs and reduce long term care costs for a vulnerable population. Therefore, we believe that this project’s value is in-line with the value of other already approved DSRIP projects of a similar nature.


Category 2: Innovation and Redesign Performing Provider Name: University of Texas Health Science Center Houston Project Title: Expand Model of Management of Chronic Diseases in Upper Valley of RHP 5 Unique RHP Project Identification Number: 111810101.2.102 Performing Provider/TPI: University of Texas Health Science Center- Houston/111810101 Project Option: 2.2.1 Redesign the outpatient delivery system to coordinate care for patients with chronic diseases

Project Summary Provider:

The University of Texas Health Science Center Houston (UTHealth) serves the South Texas area through its UT School of Public Health Campus and its mobile clinical van located in RHP 5. It trains students and provides primary health care to indigent patients through its mobile services. Additionally, students being trained in medicine and public health have border experiences providing care in South Texas.

Intervention(s): This project is designed to expand proactive, ongoing chronic care management to keep patients with chronic diseases healthy. This project will include elements of the Chronic Care Model (CCM) for ambulatory care that have been shown to lead to the greatest improvements in health outcomes.

Need for the project: The need for this project in RHP 5 is vital. Over 70% of the population has one or more chronic condition. A similar proportion currently has no health insurance. This means that preventive care and interventions are largely neglected and patients often only seek care when they develop severe disease requiring Emergency Department or inpatient care. No chronic care management programs are currently provided among the proposed partners.

Target population: The target population is adult diabetic patients. The project will reach at least 1500 patients over the life of project. Of these people, at least 950 will receive diabetes self-management education programs. Approximately 60% of those reached will be Medicaid eligible or indigent. They will benefit from the chronic care management services associated with this project through better control of HbA1c.


[I-17.1]: Our goal is to have 1500 patients receiving care under the chronic care management program

Category 3 outcomes:

IT-1.10 Our goal is to have a 5% decrease in percentage of patients with HbA1c control > 9.0% over baseline (at least 75 patients)

PROJECT DESCRIPTION: This project is designed to expand proactive, ongoing chronic care management to keep patients with chronic diseases healthy. It will also empower them to self-manage their conditions. The ultimate goal is to prevent worsening health precipitating the need for Emergency Department or inpatient care. Most chronic diseases fall into the category of non-communicable diseases (NCDs). NCDs are the pandemic of the 21st century, and the World Health Organisation reported in 2010 that they now account for more disability and death globally RHP Plan for [RHP 5/South Texas] 144

than all other causes combined(World Health Organisation, 2011). In 2011 the World Economic Forum estimated that by 2030 they will cost $47 Trillion globally (Bloom DE et al., 2011). Texas, particularly South Texas, is among the leaders in our nation in prevalence of NCDs. To meet this growing threat in RHP5, our chronic disease management initiative will use population-based approaches to create practical, supportive, evidence-based interactions between patients and providers to improve the management of chronic conditions and identify symptoms early, with the goal of preventing complications and managing utilization of acute and emergency care. Chronic disease management also enhances the ability to identify one or more chronic health conditions or co-occurring chronic conditions that merit intervention across a patient population. This ability is based on assessment of patients’ risk of developing complications, comorbidities or likelihood of utilizing acute or emergency services. These chronic health conditions include, prominently, diabetes, congestive heart failure, chronic obstructive pulmonary disease, renal disease, non-alcoholic fatty liver disease (NAFLD), all of which are liable to progress to complicating health conditions and a range of severe or end-stage diseases, such as renal failure or cancer. With this project we will begin by focusing on diabetes. Effective management of this chronic disease is imperative because it is more prevalent in our RHP than nationally.

This project will include elements of the Chronic Care Model (CCM) for ambulatory care that have been shown to lead to the greatest improvements in health outcomes:

1) Delivery system redesign (changes in the organization of care delivery)

2) Self-management support strategies (increase patients’ involvement in their own care)

3) Decision support (guidelines, education, and expertise to inform care decisions)

4) Information systems (changes to facilitate use of information about patients, their care and their outcomes)

5) Community linkages (activities increasing community involvement)

6) Health system support (leadership, practitioner, and financial support).

We will implement an outcome evaluation and a ‘plan, do, study, act’ (PDSA) strategy. Quality improvement cycles will ensure long-term health benefits are achieved and that improvement processes are incorporated throughout the funding period. Based on meta-analysis findings for Chronic Care Management models, this approach does improve outcomes, but it can take years to see true improvements (Coleman et al., 2009). However, we believe that by using CCM and the PDSA cycles we will see sustained improvements as we proceed to further dissemination of the model across our partner organizations during the life of this project. To further this end, we plan to incorporate Information system changes including computerized reminders and communication (clinical information systems), involvement of practitioners on quality improvement teams (delivery system redesign), guidelines supported by clinician education or computer support (decision support), formal self-management programs (self-management support), a registry (clinical information systems), and community health workers health promotion support (community linkages for lifestyle changes and navigation).

All services implemented through this initiative will be monitored by two oversight entities that cut across the partners in anticipation of creating greater collaboration for clinical care in the RHP 5. These will be a clinical care and a clinical information management team. The clinical care team will be comprised of medical


personnel appointed from participating providers, clinics and community partners. The clinical information management team will be comprised of health information exchange representatives and appointed health information representatives from clinical and community based partners. The University of Texas will be responsible for ensuring actions of these entities are in line with project milestones and that PDSA and evaluation activities are continuous and reported to the two teams. In addition to specified Category 3 Waiver outcome targets, relevant data will be evaluated regularly against past performance, national benchmarks, state mandated performance targets and applicable accreditation standards to drive performance improvement activities when indicated. Validation of this approach can be found in “Evidence on the Chronic Care Model in the New Millennium” available at http://content.healthaffairs.org/content/28/1/75.full), (Coleman et al., 2009).

PROJECT GOAL: The goal of this project is to create multidisciplinary care teams coordinated by HIE to provide culturally appropriate and comprehensive chronic care management to patients in RHP 5. We will initially focus on persons with diabetes.

Project goals include:

• To design and implement comprehensive chronic care teams who can efficiently respond to patients’ health needs

• Ensure that patients can access care teams in person, via phone or email

• Increase patient engagement in their health care treatment

• Implement projects that empower patients to make lifestyle choices

• Conduct quality improvement projects to continuously improve impact and efficiency.

Relationship of the project to regional goals This project substantially contributes to delivery system transformation in RHP 5 by furthering each one of the region’s goals:

• Leverage and improve on existing programs and infrastructure to ensure that the health care delivery system will be adequately developed to meet the primary and specialty care needs of residents throughout a rapidly growing, yet historically underserved region.


• Nurture a culture of ongoing quality improvement and innovation that maximizes the use of technology and best-practices to improve access and timely utilization of appropriate care, including behavioral health services, particularly in our rural communities.

• Transform health care delivery to a patient-centered, coordinated and integrated delivery model that improves patient satisfaction and health outcomes, reduces unnecessary emergency department use and duplicative services, and expands on the accomplishments of our existing health care system.


http://content.healthaffairs.org/content/28/1/75.full

Challenges and issues facing this project 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. These 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

In RHP 5, preventive care and intervention is largely neglected and patients often only seek care when they develop severe disease requiring Emergency Department or inpatient care. No navigation services are in place for those in these rural areas. The current delivery model is designed to react to patients with chronic conditions upon presentation at the hospital and then to treat within the confines of the hospital setting. With the high prevalence of patients with chronic conditions, the demand for treatment is heavy and ongoing. There is a need for greater connectivity among hospital and primary care providers and community based chronic disease management resources so that patients are able to learn and have support for creating lifestyle changes that can effectively achieve wellness. Additionally, multidisciplinary care teams are not established to focus on managing and supporting patients with chronic conditions outside the hospital setting.

Facing the Challenges Overcoming these deficiencies will require nothing less than a transformation of health care, from a system that is essentially reactive - responding mainly when a person is sick - to one that is proactive and focused on keeping a person as healthy as possible. To speed the transition, we will build an evidenced program based on the effectiveness of the Chronic Care Model that has recently been summarized. We also have assembled a team of committed organizations that will contribute to the chronic care management team model: Universal Health Services, Inc. McAllen Medical Center, Migrant Health Promotion, and UTHealth. We will also work closely with Projects 2.2 and 2.1 in RHP 5 and its patient centered medical home.

3-year expected outcome for Performing Provider and patients of the Chronic Care Management (CCM) Program:

• Transformation of chronic care into an integrated management program conducted by all of the partner institutions.

• Institutionalization of health information exchange in the partner institutions that will facilitate integrated management

• Once process and implementation milestones are reached, 5% fewer type 2 diabetic patients enrolled in the CCM program will have HbA1c levels above 9.0% (poor diabetes control).

STARTING POINT/BASELINE: No project of this kind is currently implemented in the RHP 5 area or with these partners. Patients in RHP5 are currently not receiving the CCM model services at any clinical care facility. As such, there is also no data to


establish a baseline for number of patients with uncontrolled diabetes. This will be established in the first year. Data from a clinic in the same region indicate nearly 35% of patients have uncontrolled diabetes (Su Clinica data, 2011).

QUANTIFIABLE PATIENT IMPACT: The project will use the proposed impact measures suggested by HHSC. For this project we will use the QPI of the number of unique individuals receiving care under the chronic care model in the upper valley of RHP 5. We will serve 1500 unique individuals during the 3 years of this project (DY 3 200, DY 4 500, DY5 800).

RATIONALE: Reasons for Selecting the Project Option: Chronic diseases are the leading health threat to the RHP5 region. A well characterized cohort study locally conducted shows 70% of the population has one or more chronic conditions, with obesity being the underlying and exacerbating issue for most (Fisher-Hoch, et al, 2012). These data also show 31% of adults have diabetes in the region with over half unaware of their condition (Fisher-Hoch, et al, 2012). Creating a comprehensive chronic care model directly addresses the population management care needs of the population and creates more comprehensive and cost effective approaches to support self-management among the population.

The proposed project is a multi-year transformational effort and is viewed as a foundational way to deliver care aligned with payment reform models and the Triple Aim goals of better health, better patient experience of care, and, ultimately, better cost-effectiveness. 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. This initiative aims to eliminate fragmented and uncoordinated care, which can lead to emergency department and hospital over-utilization. The project emphasizes enhanced chronic disease management through team-based care.

We will implement quality improvement activities for this proposed project. We will conduct a rapid cycle improvement (PDSA) process to identify problems, and study and implement solutions.

PROJECT COMPONENTS: We will implement all the required core project components for this project option (listed below). We have assembled the partner institutions that are committed to working together to implement this project and redesign the outpatient delivery system to coordinate care for patients with chronic diseases. They will:

a) Design and implement care teams that are tailored to the patient’s health care needs, including non-physician health professionals, such as pharmacists doing medication management; case managers providing care outside of the clinic setting via phone, email, and home visits; nutritionists offering culturally and linguistically appropriate education; and health coaches helping patients to navigate the health care system

b) Ensure that patients can access their care teams in person or by phone or email

c) Increase patient engagement, such as through patient education, group visits, self-management support, improved patient-provider communication techniques, and coordination with community resources

d) Implement projects to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions


e) Conduct quality improvement for projects using methods such as rapid cycle improvement. Activities may include, but are not limited to, identifying project impacts, identifying “lessons learned,” opportunities to scale all or part of the project to a broader patient population, and identifying key challenges associated with expansion of the project, including special considerations for safety-net populations.

In summary, implementing a chronic care management model project in an area of the state with the highest uninsured rates, a high rates of diabetes, a high percentage of Hispanic people, and the lowest incomes in the nation will be challenging but will have a positive effect on health and reducing health disparities within the state of Texas.

Unique community need identification number the project addresses. CN.1 Shortage of primary and specialty care providers and inadequate access to primary or preventive care CN.2 Shortage of behavioral health care professionals and inadequate access to behavioral health care CN.3 Inadequate integration of care for individuals with co-occurring medical and mental illness or multiple chronic conditions CN.4 Lack of Patient-Centered Care

How the project represents a new initiative: There is currently no coordinated approach to management of chronic disease in RHP5. With published rates of the uninsured as high as 70%, the community receives inadequate care even for diagnosed chronic disease. This project is therefore unique for this region, which is one of the poorest and least served in our nation. It will therefore be developed for patients who currently have little or no care. The project is also unique in that it seeks to coordinate with other DSRIP proposals in a network of projects designed to reach those at need, provide comprehensive management of chronic diseases, empower the patient and in the long term reducing the needs for Emergency Room or inpatient care.

Data Driving this Project: In RHP 5, 70% of the population has one or more chronic condition (Fisher-Hoch et al, 2012). A similar proportion currently has no health insurance. The whole population (88% Hispanic) of RHP 5 suffers from substantial health disparities including 1) over 50% of the adult population is obese; 2) 31% of the adult population has diabetes; 3) Over 70% of adults have a chronic condition of diabetes, hypertension, hypercholesterolemia, heart disease, or other condition. Many people with diabetes (55.5%) and hypertension (50.0%) are untreated as are 85% of those with hypercholesterolemia (Fisher-Hoch et al., 2012). Health along the entire US border with Mexico is among the worst in the nation (Diaz-Apodaca et al., 2010). Multiple complications of diabetes and obesity include renal failure requiring dialysis and heart failure. The underlying conditions are essentially preventable or treatable, and the long term cost of their neglect will be huge.

RELATED CATEGORY 3 OUTCOME MEASURE(S): The Category 3 goal for this project is to reduce the percentage of CCM patients with Type 2 diabetes whose most recent hemoglobin A1c (HbA1c) is greater than 9% (poor control). We will serve 300 patients in DY 3, increasing each subsequent year and our goal will be to decrease the percent of patients with poorly controlled diabetes by 5%. 2009 Data from the Centers for Disease Control indicates that the Age-Adjusted

Estimates of the Percentage of Adults Diagnosed with Diabetes in South Texas was as follows:

Based on previously mentioned data where only 50% of the population with diabetes is aware of their diagnosis, the above mentioned rates under estimate actual disease in RHP 5. Providing patients with comprehensive care and support from a chronic care management team has shown a relationship with decreased use

County Percentage Cameron 8.5% Hidalgo 10.2% Starr 8.5% Willacy 8.8%


of inpatient and emergency care. We believe we can have a positive, early impact on helping diabetic patients control their HbA1c.

Through a host of national projects funded by the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid, it has been shown that the implementation of a Health Information Exchange among hospitals, providers, and related healthcare providers can have a positive impact on health care coordination, patient satisfaction, and total healthcare costs. RHP5 is characterized by being home to a number of small communities and metropolitan areas strung along a 90 mile stretch of highway along the U.S. – Mexico border. The resident population is very mobile and often lives in one community, works in another, and gets their healthcare/hospital care in another. RHP5 is among the highest poverty regions in the nation. Over 70% of patients served by our clinic are at or below 100% of the poverty level. Having the ability to effectively share health information in a secure manner among providers will prove beneficial to all.

RELATIONSHIP TO OTHER PROJECTS: This project reinforces the projects being proposed by RHP5 hospitals and other performing providers by strengthening the network of care, particularly those services aimed at the lowest income and highest uninsured groups in the region. Underpinning the pioneering proposals from the hospital community with a strong and vibrant medical home model has proven, in many communities, to increase the coordination of care and reduce the burden on hospitals caused by unnecessary emergency department visits. Any project that strengthens the cooperative relationships among healthcare providers and reduces unnecessary delays and waste, can only prove beneficial to the region.

This project also meshes with other initiatives currently under way in the region such as the community wide campaign (project 2.4), development of a fully functioning medical school, and increased medical research on a variety of topics including obesity, nutrition, and diabetes among Hispanic populations. This project is related to project 2.1 and its proposed development of a patient centered medical home. This project also ties directly with project 085144601.2.2 that is implementing a CCM project in the RHP 5 lower valley with different performing providers, clinic and hospital partners and outreach organizations. We will be working with this project closely to coordinate services and develop learning collaborative. Patients from the lower valley project will not be shared by the upper valley project.

RELATIONSHIP TO OTHER PERFORMING PROVIDERS’ PROJECTS IN THE RHP: University of Texas Health Science Center San Antonio (UTHSCSA) is another provider approved to implement a chronic care management project in another county within this same RHP 5 (lower valley project). Both the UTHealth and UTHSCSA projects have multiple organizations, some of which are performing providers on other projects, involved in their implementation. Both institutions are fully committed to working with other performing providers to share progress, best practices and lessons learned.

PLAN FOR LEARNING COLLABORATIVE: We plan to work with the UT School of Public Health as the facilitator to encourage the development of a learning collaborative during the project period. Working together to develop and implement a Health Information Exchange will identify similarities among performing providers and will highlight those areas where challenges can be overcome.

PROJECT VALUATION: The project will be valued based upon the successful attainment of the following expected results:

• Develop and implement action plans for a chronic care management model


• Collaborate with the RGV Health Information Exchange to develop and use EMR for effective patient management across the partner hospitals, PCMHs, community clinics in this project

• Improve data exchange between hospitals and affiliated partners and clinical sites

• Restructure staffing into multidisciplinary care teams that manage a panel of patients

• Management and coordination of high-risk patients across the partners in this project and related projects

References:

1. Bloom DE, Cafiero ET, Jane-Llopis E, et al The Global Economic Burder of Non-communicable Diseases. 1-46. 10-9-2011. Geneva, Switzerland, World Economic Forum.

2. Coleman,K., Austin,B.T., Brach,C., and Wagner,E.H. (2009). Evidence on the Chronic Care Model in the new millennium. Health Aff. (Millwood. ) 28, 75-85.

3. Diaz-Apodaca,B.A., Ebrahim,S., McCormack,V., de Cosio,F.G., and Ruiz-Holguin,R. (2010). Prevalence of type 2 diabetes and impaired fasting glucose: cross-sectional study of multiethnic adult population at the United States-Mexico border. Rev. Panam. Salud Publica 28, 174-181.

4. Fisher-Hoch,S.P., Vatcheva,K.P., Laing,S.T., et al (2012). Missed opportunities for diagnosis and treatment of diabetes, hypertension, and hypercholesterolemia in a Mexican American population, cameron county Hispanic cohort, 2003-2008. Prev. Chronic. Dis. 9, E135.

5. World Health Organisation. Global Status Report on non-communicable diseases. Alwan A. 1-176. 4-1-2011. Italy, World Health Organisation


Patient Centered Medicaid Home 160709501.2.100 Doctors Hospital at Renaissance / 160709501 Project Option: 2.1.3 Project Description: Doctors Hospital at Renaissance is proposing to expand access to primary health care by implementing a clinic that is founded around the “Patient Centered Medical Home” (PCMH) model. This clinic will be amongst the first of its kind within the region and will serve as a model clinic for others to follow once its effectiveness has been demonstrated within this unique patient demographic. Although the clinic will be built around the PCMH model, its focus will be that of providing optimal accessibility for the Medicaid population that it’s intended to provide services to. Through this endeavor, traditional primary care is transformed into a medical home that can lead to higher quality and lower costs, and can improve patients’ an providers’ experience of care. Goals: The driving goal of this project is implementing the PCMH from the ground up allocating resources and a patient base that sets the clinic on a solid foundation for success. Success is determined by the ability to not only increase primary health care accessibility, but also improve patient outcomes more efficiently than the traditional outpatient model of health care. To ensure that this success is met patients are assigned a health care team who tailors services to a patient’s unique health care needs, effectively coordinates the patient’s care across inpatient and outpatient settings, and proactively provides preventive, primary, routine and chronic care. Through this model of health care patient outcomes are expected to improve as they move through the continuum of care and transition into self-management in-between routine follow-up care. Challenges/Issues: A major issue in RHP5 is the cost of health care that is largely driven by the high prevalence of chronic disease and poor access to health services by this population with major health disparities. This leads to people developing advanced chronic diseases particularly obesity, diabetes, heart disease and related conditions. Many are first seen with manifestations of advanced disease in emergency departments of hospitals, resulting in costly hospitalizations. Furthermore, the lack of comprehensive follow up care due to lack of access, inadequate number of health professionals in RHP5, and virtually no programs targeting the prevention or systematic control of chronic disease such as diabetes insures that those with chronic diseases are not well managed with education and prevention programs. Within this region the leading health concerns stem from non-communicable diseases (NCDs), mainly chronic diseases, which have reached pandemic proportions and are considered to be the greatest threat to the global economy and health at this time, with a total predicted cost by 2030 of $47 trillion (nationally). The leading NCDs are mostly obesity driven, particularly diabetes and cardiovascular diseases. Throughout RHP5 obesity and diabetes affects a disproportionate percentage of population versus the national and state averages. The greatest challenge is presented by those patients that face large gaps in primary and specialty healthcare. These patients typically represent the Medicaid and indigent population and have increased percentages of being diagnosed with multiple comorbidities such as hypertension, obesity, diabetes, and heart failure. Patients that fall into these categories each need a unique approach to their healthcare regime that is not available in any one physician office. Rather, a comprehensive approach is needed to tailor a specific healthcare regimen according to the individual patient’s needs. Addressing the challenges:


The PCMH directly addresses the challenges of customized care plans for individual patients. The PCMH model is founded on integrated primary and specialty care in collaboration with a care team that focuses on the unique necessities that are represented by any combination of comorbidities. This approach to addressing multiple facets of the patient’s healthcare has proven to achieve the Triple Aim of improved patient outcomes, improved patient experience, and improved value29. 3-Year Expected Outcomes/Benefits: This PCMH is focusing on category 2 type benefits as this model of health care is relatively new in this area where the traditional model of a single physician’s clinic will undergo a major redesign to offer comprehensive healthcare to the patient base. Benefits will include:

• Care that is designed around the patients chronic conditions • Better follow-up care through a team approach • Enhanced condition (such a diabetes) education

As a healthcare system, emergency room visits and hospital admissions are expected to decrease demonstrating effective plans of care within the patient centered medical home. These outcomes will be demonstrated through EMR records. For those that do experience an emergency room visit or hospital admission, the PCMH will be notified so that the care team can readjust / bolster their plan of care to ensure a better outcome for this individual. How this project is related to regional goals: This project is related to regional goals in that it strives to increase the availability of primary healthcare to the Medicaid population all while meeting the Triple Aim of healthcare. According to the community needs assessment for RHP5, community need 1 states that there is a lack of primary and specialty healthcare. This has continued to create a gap in healthcare causing many patients to go without any type of real preventive care. These circumstances result in people developing advanced chronic diseases particularly obesity, diabetes, heart disease and related conditions. As the PCMH is implemented within RHP5 and provides efficient quality outcomes with a positive patient and provider experience, regional goals will have been met and exceeded. Starting Point/Baseline: The starting point of the project will be set at the end of DY3 once the organizational realignment of resources has been completed to ensure all measures are in place for increased patient outreach. The patient baseline is based off of the number of patient encounters as a result of increased primary care availability upon clinic functionality. Quantifiable Patient Impact: Once the clinic becomes fully operational, 300 unique patients will be impacted per year. The clinic is focused on comprising its capacity with the Medicaid and indigent population. Increases in individual patient volumes will be dependent on capacity of overall medication management program to maintain a responsible, manageable patient panel.

29 US Health and Human Services : http://pcmh.ahrq.gov/page/evidence-and-evaluation RHP Plan for [RHP 5/South Texas] 153

http://pcmh.ahrq.gov/page/evidence-and-evaluation

Rationale: The PCMH model of health care has not taken a foothold with in RHP5 since the idea was introduced. The physician market is vastly segregated into single-physician private practices in which any and all resources have been allocated within that particular location. DHR is now in position to collaborate with the physician community in an effort to implement this new, evidence based model of healthcare. RHP5 has been shown to have a high prevalence of chronic disease and poor access to health services by its predominant Medicaid/Indigent population. Patients have also been shown to have multiple comorbidities such as obesity, diabetes, and heart disease, each of which requires a unique approach in addressing the related complications within those diseases. Through this alignment of resources and process improvements the PCMH model can flourish within these circumstances to encourage improvement in patient outcomes. The core measures that are in place are being developed so that the PCMH will be developed on a solid foundation for long-term growth and outreach. Each milestone that is selected will demonstrate the implementation process of the PCMH (P-1 & P-2) and the improvement of patient access that this project represents (I-12 & I-17). Core Components: a) Empanelment: Assign all patients to a primary care provider within the medical home. Understand practice supply and demand, and balance patient load accordingly: Doctors Hospital at Renaissance will either collaborate with a community physician to transform the established practice into a PCMH, or implement a stand-alone PCMH with staffing, policies and procedures, that emulate accreditation standards. b) Restructure staffing into multidisciplinary care teams that manage a panel of patients where providers and staff operate at the top of their license. Define roles and distribute tasks among care team members to reflect the skills, abilities, and credentials of team members: The clinic will be structured in this fashion from the very beginning. This staffing structure will be incorporated into the policies, procedures, and any contracting for future recruitment within the clinic. c) Link patients to a provider and care team so both patients and provider/care team recognizes each other as partners in care: Providers and individuals within the care team will work closely together to develop partnerships that remain flexible as care team individuals change according to the needs of the patient. d) Assure that patients are able to see their provider or care team whenever possible: The PCMH upholds patient quality as its foremost value. Building accessibility within the PCMH model remains a core component of this value and will be strategically adjusted if need be to optimize the patients’ ability to see their care team. e) Promote and expand access to the medical home by ensuring that established patients have 24/7 continuous access to their care teams via phone, e-mail, or in-person visits: To help achieve this core metric, on-call schedules will be created with various methods of communication in place so that patients will have 24/7 communication capabilities with their team. f) Conduct quality improvement for project using methods such as rapid cycle improvement. Activities may include, but are not limited to, identifying project impacts, identifying “lessons learned,” opportunities to scale all or part of the project to a broader patient population, and identifying key challenges associated with expansion of the project, including special considerations for safety-net populations: Quality improvement will become necessary once patient analytics are in place to ensure that optimal services are being provided within the time allotted. Employee observations, trends that become apparent within aggregated data and physician recommendations will all be accumulated within a “lessons learned” approach to develop improvements when discovered. This will allow for the clinic to make adjustments where necessary to provide a safe, quality, and positive patient experience. Related Category 3 Outcome Measures: IT-3.3 Diabetes 30 day readmission rate (Standalone measure)


a.) Numerator: The number of readmissions (for patients 18 years and older), for any cause, within 30 days of discharge from the index diabetes admission. If an index admission has more than 1 readmission, only first is counted as a readmission. b.) Denominator: The number of admissions (for patients 18 years and older), for patients discharged from the hospital with a principal diagnosis of diabetes and with a complete claims history for the 12 months prior to admission. Diabetes has turned into an epidemic within RHP5 affecting well over 30% of the population within the region. For this cause DHR is strongly committed to utilizing multiple fronts of resources in combating this disease and increasing the quality of life for the surrounding community. Relationship to other Projects: Doctors Hospital at Renaissance is embarking on various projects including expansion of behavioral health, diabetes specific care, and a patient centered medical home each of which will need the services of medication management for a percentage of their patient population. Collaboration amongst these projects within the DHR system enhances their capabilities promoting a continuum of care transformation and improved outcomes. Plan for Learning Collaborative: Doctors Hospital at Renaissance will participate in the statewide learning collaborative that is being organized by the Texas Health and Human Services Commission. Every effort will be made to collaborate with the RHP5 anchor in providing any and all results from the implemented projects including lessons learned. All findings will be supported by data and provided in a meaningful manner so that other participating providers can contribute as well. Project Valuation: The approach for evaluating the project revolves around start-up expenses that are involved with opening a clinic and each of the associated assets required for efficient operational capabilities. Assets include clinical supplies, administrative supplies, furnishings, and EMR. Additional funding is required for providing clinical provider salaries to ensure provider availability regarding patient access. The last component that is involved with valuation is the target patient population that this clinic is intended to serve. Program funding is an essential part of clinical longevity due to the high levels of Medicaid and indigent high-risk patients that will comprise the empanelment.


Project Title: Establish more primary care clinics Unique RHP Project ID number: 135035706.1.100 Performing Provider/TPI: Knapp Medical Center/135035706 Project Option: 1.1.1


Knapp Medical Center is a 227-bed not-for-profit, acute care hospital in Weslaco, South Texas (Hidalgo County). For five decades, Knapp has been providing exceptional health care services to the residents of the Rio Grande Valley. Our primary service area includes a population of 75,000 people residing in the area referred to as the Mid-Valley. Knapp Medical Center’s payor mix is as follows: Medicare 44%, Medicaid 25%, HMO/PPO 16%, and self-pay/uninsured 15%. As a percentage of net revenue, Knapp Medical Center has the highest percentage of uninsured patient volume than any other hospital in Hidalgo County. Services include 24-Hour Emergency Department, Advanced (Level III) Trauma Center, Adult Medicine, Cardiology, Critical Care/ICU, Inpatient and Outpatient Surgery, Pediatrics, Women’s Health, Obstetrics/Gynecology, Neonatal Care and an Outpatient Center that provides over 400 services. Knapp works hard to provide state-of-the-art technology, progressive diagnostic and treatment options, and patient-focused care.

Project Description

We propose to establish a new primary care clinic. This clinic would provide Mid-Valley residents with primary care services so that residents would not need to use the ED for primary care, or forgo seeking care altogether. This clinic will also serve a key community benefit role in participating in the new primary care residency program that is desperately needed in the Rio Grande Valley, given the area’s severe primary care workforce shortage (anticipated program start date July 2015). Finally, this clinic will further enhance Knapp Medical Center’s ability to provide needed prevention, primary and chronic care services. The clinic will be promoting ongoing, evidence-based screenings and tests so that patients’ care is proactive, managed and patient-centered. The new clinic will be operated based on the medical home model.

Intervention(s)

We have selected Project Option 1.1.1 Expand Primary Care Capacity: Establish more primary care clinics. This project establishes a primary care clinic in Mid-Valley for a low-income patient population.



As cited in the community needs assessment, the region experiences: a shortage of primary and specialty care providers (CN.1), inadequate integration of care for individuals with multiple health issues (CN.3), and a lack of patient-centered care (CN.4). Many Mid-Valley residents do not receive timely, ongoing and patient-centered care in community-based settings. The clinic would help a market struggling to meet the primary care needs of its population. South Texans experience extreme levels of economic and health disparities that are exacerbated by low levels of health insurance, including a lack of access to and utilization of needed health care services. The South Texas area faces a shortage of primary care professionals to serve a growing population, with only half to three‐quarters of the physician‐to‐population ratios of Texas for primary care specialists (e.g., family practice, general practice, OB/GYN). The current delivery system does not have the capacity to identify individuals with or at risk for chronic conditions and to navigate them into appropriate programs to help prevent, diagnosis and manage their health conditions. The region has an unprecedented epidemic of chronic disease – particularly diabetes and related chronic conditions – that is fueled by high levels of adult and childhood obesity. Many residents seek primary care in the ED, or let their conditions go untreated, which puts the patient at increased risk of needing ED or acute care services. This project would establish a new primary care clinic so that patients can receive more preventative, primary and chronic care in order to stay healthy and out of the ED/hospital.

Target population

This project would provide 2,500 primary care encounters in DY 4 and 3,000 in DY 5. Of those patients, we estimate approximately 25% would be Medicaid, indigent or uninsured individuals. Expected impact (total patients per year): DY3-0, DY4-2,500, DY5-3,000 primary care encounters


The project expands primary care capacity so that Mid-Valley residents have increased access to primary care services, as evidenced by an anticipated total of 2,500 primary care encounters in DY 4 and 3,000 in DY 5. Patients would benefit from:

• Increased access to preventative, primary and chronic care • Reduced risk of delayed or forgone needed treatment • Right care at the right time in the right setting • Improved preventative tests/screening/vaccination rates • Improved chronic care management • Improved patient care • Improved health outcomes • More patient-centered care • Reduced need for ED/hospital services

Quantifiable patient impact milestones are to provide: DY4-2,500, DY5-3,000 primary care encounters (12.1 to increase the number of primary care visits)


We have selected outcome measure IT‐1.10 Diabetes care: HbA1c poor control (>9.0%) – (Standalone measure). As a result of expanding primary care capacity, we expect to reduce the number of diabetics with HbA1c levels out of control, signifying improved health and better managed care.


Project Title: Establish more primary care clinics Unique RHP Project ID number: 135035706.1.100 Performing Provider/TPI: Knapp Medical Center/135035706 Project Option: 1.1.1 Project Description: We propose to establish a new primary care clinic. This clinic would provide Mid-Valley residents with primary care services so that residents would not need to use the ED for primary care, or forgo seeking care altogether. This clinic will also serve a key community benefit role in participating in the new primary care residency program that is desperately needed in the Rio Grande Valley, given the area’s severe primary care workforce shortage (anticipated program start date July 2015). Finally, this clinic will further enhance Knapp Medical Center’s ability to provide needed prevention, primary and chronic care services. The clinic will be promoting ongoing, evidence-based screenings and tests so that patients’ care is proactive, managed and patient-centered. The new clinic will be operated based on the medical home model. Starting Point/Baseline: This would be a new clinic, so there is no baseline data for this population or clinic. Quantifiable Patient Impact: We have selected QPI metric I-12.1: Documentation of increased number of visits, consistent with HHSC’s recommended QPI measure for this project option. The project expands primary care capacity so that Mid-Valley residents have increased access to primary care services, as evidenced by an anticipated total of 2,500 primary care encounters in DY 4 and 3,000 in DY 5. Rationale: Hidalgo County is a Health Professionals Shortage Area (HPSA) for primary medical care and a Medically Underserved Area/Population as designated by the federal government.30 Primary care is the backbone of preventive health care, and has been associated with reduced health care costs and improved quality. Indeed, a wealth of evidence shows that primary care helps prevent illness and death, including that health is better in areas with more primary care physicians, people who receive care from primary care physicians are healthier, and the characteristics of primary care are associated with better health.31 Adequate access to primary care can improve care coordination and reduce the frequency of avoidable hospitalizations. Conversely, lack of adequate access to primary care, as is the case in the Mid-Valley area currently, results in patients delaying or foregoing treatment until illnesses are so bad that urgent, emergent or acute care services are needed. Such health care system utilization results in poorer patient outcomes as well as increased costs. This project will help alleviate the primary care shortage by establishing a new primary care clinic that will also serve a key role in the launching of a new primary care residency program. Thus, this project will increase patient access to primary care services during the waiver, as well as help to set the stage for increasing the primary care workforce post-waiver. Milestones & Metrics: The following milestones and metrics were selected based on the needs of the target population:

• Process Milestones and Metrics: P-1 (P-1.1) to establish a new primary care clinic and P-5 (P-5.1) to train/hire additional providers/staff.

• Improvement Milestones and Metrics: I-12 (I-12.1) to increase the number of primary care visits. Unique community need identification number the project addresses:

30 Hidalgo County Comprehensive Economic Development Strategy 2011-2015 31 Starfield B., L. Shi, and J. Macinko, “Contribution of Primary Care to Health Systems and Health,” The Milbank Quarterly, Vol. 83, No. 3, 2005 (pp. 457–502). RHP Plan for [RHP 5/South Texas] 158


• CN.3 – Inadequate integration of care for individuals with co-occurring medical and mental illness or multiple chronic conditions

• CN.4 – Lack of Patient-Centered Care How the project represents a new initiative or significantly enhances an existing delivery system reform initiative: This is a new initiative with no related activities that are funded by the U.S Department of Health and Human Services. Project Core Components: N/A Customizable Process or Improvement Milestones: N/A Related Category 3 Outcome Measure(s): We have selected from outcome domain 1: Primary Care and Chronic Disease Management, the outcome measure: IT‐1.10 Diabetes care: HbA1c poor control (>9.0%) – (Standalone measure). As a result of expanding primary care capacity, we expect to reduce the number of diabetics with HbA1c levels out of control, signifying improved health and better managed care. The regional community health needs assessment finds that diabetes contributes to more than 16,000 extra bed days per year at an additional cost of $49 million to $83 million annually. The importance of glycemic control is particularly well documented32, and HbA1c testing is a well-established strategy to monitor glycemic control in patients with diabetes (NCQA, NQF, PQRI, PCPI). Measuring HbA1c values >9.0% among patients aged 18 to 75 years identifies those patients who are in poor control and at highest risk for major health complications. We can measure whether care improvements designed to reduce this rate are working, as well as identify the high-risk patients we should target for focused care improvement. The new primary care clinic will be actively managing patients’ conditions and keeping those conditions under control, so that patients do not experience an acute episode or need emergent or acute care. Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): Relationship to Other Projects: This project would support population health improvements in Category 4 by reducing Potentially Preventable Admissions and Readmissions (PPAs and PPRs).

Relationship to Other Performing Providers’ Projects in the RHP: This project meets the community needs and operates in conjunction with the RHP-wide initiatives. Many of the RHP5 performing provider projects also focus on addressing community needs through complementary work of expanding access to primary and specialty care services, better coordinating and integrating care, and improving delivery of care through use of care management and navigation models. The RHP5 plan as of April 2013 includes a new primary care clinic in Starr County, increases primary care training in multiple areas of the region and adds primary care providers to behavioral health care teams, but currently lacks a primary care expansion project in the Mid-Valley area. Additionally, new RHP5 projects proposed for DYs 3-5 include expanding existing clinics’ capacity and access, developing mobile clinics, recruiting PCPs, and creating school-based clinics, but our project remains the only new primary care clinic in the Mid-Valley area. As such, this proposed project meets the needs of specific populations and will not duplicate services of other Performing Provider projects in the RHP.

32 Ousman Y, Sharma M: The Irrefutable Importance of Glycemic Control. Clinical Diabetes 19-2:71-72, 2001. RHP Plan for [RHP 5/South Texas] 159

Plan for Learning Collaborative: We plan to participate in the statewide learning collaborative. Our participation in a collaborative will facilitate sharing of challenges and testing of new ideas and solutions to promote continuous quality improvement in our health care system. Project Valuation: We have valued this project based on the following factors: Achieves Waiver Goals: The primary care clinic will: • Improve quality and health status: There is strong evidence that primary care helps prevent illness and

death, and is associated with a more equitable distribution of health in populations. Three lines of evidence show that primary care improves health: (1) health is better in areas with more PCPs; (2) people who receive care from primary care physicians are healthier; and (3) the characteristics of primary care are associated with better health.33

• Improve patient experience: The primary care clinic can serve as a medical home and offer patient-centered care, oriented to whole-person health needs and working to improve overall health. Through a longitudinal relationship, the clinic can improve the patient’s experience.

• Improve coordination: Our primary care clinics’ use of the medical home and chronic care models improve coordination of patients’ care.

• Improve cost-effectiveness: Many residents seek primary care in the ED, or let their conditions go untreated, which puts the patient at increased risk of needing ED or acute care services. The regional community health needs assessment finds that diabetes contributes to more than 16,000 extra bed days per year at an additional cost of $49 million to $83 million annually. Use of emergent and acute care services is costly to the health system. Having the clinic as a source of care is a cost-effective option for patients and the health care system.

Addresses Community Need(s): As sited in the community needs assessment, the region experiences: a shortage of primary and specialty care providers (CN.1), inadequate integration of care for individuals with multiple health issues (CN.3), and a lack of patient-centered care (CN.4). Many of these patients as a result end up needing more acute care and may not receive the appropriate, ongoing care in community-based settings. This project would establish a new primary care clinic in the Mid-Valley area. • Addressing Priority Community Need: The primary care clinic will increase access to preventative, primary

and chronic care for residents who desperately need those services. South Texans experience extreme levels of economic and health disparities that are exacerbated by low levels of health insurance, including a lack of access to and utilization of needed health care services. The current delivery system does not have the capacity to identify individuals with or at risk for chronic conditions and to navigate them into appropriate programs to help prevent, diagnose and manage their health conditions. The region has an unprecedented epidemic of chronic disease – particularly diabetes and related chronic conditions – that is fueled by high levels of adult and childhood obesity. South Texas also has a greater incidence of infectious diseases.34

• Community Benefit: RHP5 has long been a health professional shortage area with particular difficulty in recruiting and retaining primary care and specialist physicians, nurses and physician assistants. According to the report, “U.S./Mexico Border Health Issues: The Texas Rio Grande Valley” and in concurrence with the community needs assessment, the Texas Rio Grande Valley is one of the poorest and most underserved areas of the U.S. and the problems of its uninsured remain more persistent and intense than nearly anywhere else in the nation. Public health issues are more complicated given the high level of migration between the

33 Starfield B, Shi L, Macinko J. “Contribution of Primary Care to Health Systems and Health,” Milbank Q. 2005; 83(3): 457-502. 34 RHP-5 community health needs assessment and “Texas in Focus: South Texas, Health Care,” http://www.window.state.tx.us/specialrpt/tif/southtexas/healthcare.html#28. RHP Plan for [RHP 5/South Texas] 160

http://www.window.state.tx.us/specialrpt/tif/southtexas/healthcare.html%2328

U.S. and Mexico. HRSA has a history of prioritizing the U.S./Mexico border in order to promote primary care and ensure quality health care services for the underserved.35

• Patient Outcomes & Impact: This project would reduce the number of diabetics with HbA1c levels out of control by expanding primary care capacity so that Mid-Valley residents have increased access to primary care services, as evidenced by an anticipated total of 2,500 primary care encounters in DY 4 and 3,000 in DY 5.

35 Warner, D. and Jahnke, L., “U.S./Mexico Border Health Issues: The Texas Rio Grande Valley,” Regional Center for Health Workforce Studies Center for Health Economics and Policy The University of Texas Health Science Center at San Antonio (April 2003). RHP Plan for [RHP 5/South Texas] 161

Project Title: Patient Centered Medical Home to provide primary care to rural and impoverished areas of Hidalgo County using evidence‐approached change concepts for practice transformation developed by the Commonwealth Fund’s Safety Net Medical Home Initiative Unique RHP Project ID number: 094113001.2.101 Performing Provider/TPI: South Texas Health System / 094113001 Project Option: 2.9.1 Project Core Components: 2.9.1.a-f

PROJECT SUMMARY

Provider Description South Texas Health System (STHS) consists of McAllen Medical Center, McAllen Heart Hospital, Edinburg Regional Medical Center/Edinburg Children’s Hospital, and South Texas Behavioral Hospital. In addition, STHS is associated and works closely with Cornerstone Regional Hospital (50:50 JV local physicians) & McAllen Medical Center Physicians (501A). As a system, STHS is one licensed hospital with four campus locations. Total licensed beds are 848. The primary market area is Hidalgo County in South Texas on the US/Mexico border. Secondary market are includes the surrounding counties of Cameron, Brooks, and Starr.

Project Description

South Texas Health System and propose to work with Nuestra Clinica (a nine-clinic network) to implement a certified patient centered medical home (PCMH) model of care to provide safety net primary health care services to targeted patients who live in HPSA, rural, and impoverished areas of Hidalgo County. As such, this project would improve access to comprehensive, primary, preventative and chronic care through the implementation of the medical home model.

Intervention(s) This project will implement a certified patient centered medical home (PCMH) model of care to provide safety net primary healthcare services to targeted patients who live in HPSA, rural, and impoverished areas of Hidalgo County. This will be achieved through a partnership with Nuestra Clinica, a primary care clinic that serves the poor and underserved of Upper Valley.

Need for the project As cited in the community needs assessment, RHP5 suffers from a shortage of primary care (CN.1), inadequate integration of care for individuals with multiple chronic conditions (CN.3), and a lack of patient-centered care (CN.4). Over 70% of the population has one or more chronic conditions. A similar proportion currently does not have health insurance. This means that preventive care and intervention is largely neglected and patients often only present when they develop severe illnesses requiring Emergency Department or Inpatient care. There is a lack of chronic care management programs currently available in RHP5. Therefore, there is a need for ongoing, coordinated care, including preventative, primary and chronic care. The PCMH model is viewed as a foundation for such care by providing patients with a regular source of care. This project would convert nine Nuestra Clinica sites into patient-centered medical homes in order to provide more preventative and proactive primary and chronic care that is both coordinated and patient-centered.

Target population


The target population includes the uninsured and under-served, those below 200% of poverty, migrant and seasonal farm workers, Hispanics, women and children. Approximately 77.34% of our patients are at or below 100% of Poverty, 96.09% are at or below 200% of Poverty. Of the 31,415 patients, 51.17% are uninsured, 34.85% are on Medicaid/CHIP, 5.62% are on Medicare, and 8.36% are covered by other 3rd party forms of payment. All patients are expected to benefit from the Patient Centered Medical Home model and from the meaningful exchange of health information. Expected impact (total patients per year): DY3-3,000, DY4-6,000, DY5-9,000 unique individuals.


The key functional element of the project is to become a certified patient centered medical home for primary care access for approximately 9,000 patients over the 3 year project period. Patients will benefit from a regular source of preventative, primary and chronic care that is proactive and coordinated. As such, patients can better manage their conditions, staying healthy and out of the ED/hospital. Thus, this project will improve patient care and reduce health system costs. For example, prevented hospitalizations is an area where we expect to reap cost savings since diabetics when hospitalized tend to have at least one extra day in the hospital and an extra ½ day in the ICU (RHP 5 assessment data). Quantifiable patient impact milestones are to assign: DY3-3,000, DY4-6,000, DY5-9,000 unique individuals to medical homes (metric I-12.2: Number of patients assigned to medical homes)

Category 3 outcomes expected patient benefits By DY 5, the clinic expects a 10% decrease in the percentage of diabetic patients whose HbA1c levels are greater than 9.0% (poor control) (IT-1.10 – Standalone measure). For the baseline year of 2011, that percentage was 34.27%. We estimate that the expected 10% reduction in uncontrolled HbA1c levels for 4,000+ patients with diabetes will mean potential savings of several millions of dollars.


Project Title: 2.9.1 Implement medical homes in HPSA and other rural and impoverished areas using evidence-approached change concepts for practice transformation developed by the Commonwealth Fund’s Safety Net Medical Home Initiative. Unique Project ID: 094113001.2.101 Performing Provider Name/TPI: South Texas Health System / 094113001 Project Components: 2.9.1.a-f Project: South Texas Health System and The UTHSCSA Regional Academic Health Center (RAHC) propose to work with Nuestra Clinica to implement a certified patient centered medical home (PCMH) model of care to provide safety net primary healthcare services to targeted patients who live in HPSA, rural, and impoverished areas of Hidalgo County.The project would improve access to comprehensive, primary and preventive care through the implementation of the medical home model. . These sites touch 31,000 medical and dental patients, equating to approximately 6.0% of the total population of Hidalgo County. The project greatly enhances the current comprehensive, primary health and wellness services for Hidalgo County in South Texas by developing a medical home model that will improve the service to patients and greatly improve the efficiency and effectiveness of helping them control their chronic health conditions. The 9 partner clinics currently serve 4,373 patients who have been diagnosed with diabetes. The patient centered medical home model will be able to provide a more effective model of care focused on prevention and a patient/medical team model that will lower risk of severe consequences from diabetes and reduce visits to emergency departments and hospitalization. Although Nuestra Clinica is a Federally Qualified Health Center and receives grantfunding to help with operations, no federal grant dollars will be expended for the positions budgeted for in the 1115 waiver contract. These positions are vital to the successful progression to a level three PCMH certification and to the improvement in health care outcomes for the population in RHP 5. Patient benefit DY4: Goal: At least 50% of Nuestra Clinica patients assigned to medical homes including at least 50% of those 4000+ with diabetes and related chronic conditions, which translates to 6000 unique individuals. Of these, an estimated 82 % would be Medicaid, indigent or uninsured. Patient benefit DY5: At least 75% of Nuestra Clinica patients assigned to medical home including 100% of those with diabetes and related chronic conditions, which translates to appropriately 9000 unique individuals. Of these, an estimated 82 % would be Medicaid, indigent or uninsured. Project Goals The key functional element of the project is to become a certified patient centered medical home for primary care access. By achieving patient centered medical home status, the 9 clinics can have a lasting and meaningful impact on the more than 31,000 patients, reduce the growth in health care costs by working collaboratively with other healthcare partners, and increase patient satisfaction with the healthcare system. Regional Goals RHP 5 is a medically underserved area with a population that is 40-60% uninsured and that has no public hospital or hospital district. All of the hospitals are private for profit and are therefore limited in their ability to meet the needs of the population for primary and specialty care, based on current reimbursement/financing mechanisms and levels of insurance. Furthermore, the population suffers from very substantial health disparities, particularly related to obesity, diabetes and related conditions as described and documented in detail in the needs assessment. As such, this project meets all of the regional goals, as described in the RHP5 plan. Challenges


As cited in the community needs assessment, RHP5 suffers from a shortage of primary care (CN.1), inadequate integration of care for individuals with multiple chronic conditions (CN.3), and a lack of patient-centered care (CN.4). The transformation to a new model of integrated, patient-centered care is not trivial, as it involves the redesign of service delivery and reorientation of care team thought processes. The entire organization must undergo a coordinated transformation at the same time that clinical systems are being converted to electronic health records, new government regulations are being implemented, and reimbursement systems revised. Strong leadership from all partners, the RAHC and Nuestra Clinica administration and STHS clinical team are essential for success. Just as important, the patient must also be educated in the new system and must buy in to the new system of care. Staff must be retrained and work processes must be revised, all while maintaining productivity and reducing costs. Finally, implementing comprehensive change within a population that is overwhelming Hispanic and Spanish speaking with low health literacy can be a challenge. Starting Point/Baseline • There are no PCMH programs in the Upper Valley area of Region 5. Working with the RAHC the

clinics of Nuestra Clinica will become the first such programs in Hidalgo County. • The community clinics currently use an electronic medical records system and have already

participated in a number of training opportunities regarding the patient centered medical home. • The Administrative Leadership Team is knowledgeable of patient centered medical home concepts

and has integrated the goal of PCMH certification into the organization’s board approved strategic plan.

• Currently, no RHP5 sites, including Nuestra Clinica sites have been certified as a patient centered medical home so the baseline is zero in DY2.

• With respect to diabetes, the clinic collects data on the percentage of patients with HbA1c greater than 9% (poor control). For the baseline year of 2011, that percentage with HbA1c >9% was 34.27%.

Patient Impact: We have selected QPI metric I-12.2: Number of patients assigned to medical homes, consistent with HHSC’s recommended QPI measure for this project option. We expect to serve at least 3,000 unique individuals in DY 3, 6,000 in DY 4, and 9,000 in DY 5 under the patient-centered medical home model. Rationale: Federal, state, and local health care providers share goals to promote more patient-centered care focused on wellness and coordinated care. In addition, the PCMH model is viewed as a foundation for the ability to accept alternative payment models under payment reform. PCMH development is a multi-year transformational effort and is viewed as a foundational way to deliver care aligned with payment reform models and the Triple Aim goals of better health, better patient experience of care, and ultimately better cost-effectiveness. 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. These projects all are focused on the concepts of the PCMH model; yet, they take different shapes for different providers. This initiative aims to eliminate fragmented and uncoordinated care, which can lead to emergency department and hospital over-utilization. The projects associated with Medical Homes establish a foundation for transforming the primary care landscape in Texas by emphasizing enhanced chronic disease management through team-based care. With respect to the concept of the Patient Centered Medical Home, the National Committee for Quality Assurance (NCQA) found the following: Primary care is a foundation of the health care system. The NCQA PCMH standards reflect elements

that make primary care successful. Primary care clinicians are often the first point of contact for an


individual; thus, patient access to care is an important issue. Just as patient-centeredness is an integral part of the program, so too is a practice’s ability to track care over time and across settings. The amount of clinical information for some patients—particularly those with chronic illnesses—and the fragmented nature of the U.S. health system make this aspect of primary care challenging. Merely having an electronic health record system in a practice is not enough. The health information system itself must be achieve meaningful use to improve quality of care.

Implementing a patient centered medical home model in an area of the state with the highest uninsured rates, high rates of diabetes, high percentage of Hispanic population, and lowest incomes in the nation will have a positive effect on reducing health disparities within the region and therefore the state of Texas. This is a new project for the performing provider and for RHP5 as no PCMH currently exists.

Project Milestones & Metrics We plan to implement the following process and improvement milestones:

• Process Milestones and Metrics: • Improvement Milestones and Metrics: I-12 (I-12.2) to increase the number of patients assigned to

medical homes For DY 3

P-2 Establish/expand a health care navigation program to provide support to patient populations who are most at risk of receiving disconnected and fragmented care

P-2.1 Number of people trained as patient navigators, number of navigation procedures, or number of continuing education sessions for patient navigators

P-4 Increase patient engagement, such as through patient education, self-management support, improved patient-provider communication techniques, and/or coordination with community resources

P-4.1 Description of and the number of classes and/or initiations offered, or number or percent of patients enrolled in the program

P-8 Participate in face-to-face learning (i.e. meetings or seminars) at least twice per year with other providers and the RHP P-8.1 Participate in semi-annual face-to-face meetings or seminars organized by the RHP. For DY 4 I-6 Increase empanelment in primary care settings for patients without a medical home who use the ED, urgent care, and/or hospital services I-6.1 Increase medical home empanelment of patients referred from navigator program I-7 Reduce average number of ED visits and/or avoidable hospitalizations for patients enrolled in the navigator program I-7.1 ED visits and/or avoidable hospitalizations For DY 5 I-8 Reduction in ED use by identified ED frequent users receiving navigation services I-8.1ED visits pre- and post-navigation services by individuals identified as ED frequent users I-9Improved adherence to recommended care regimens for patients in Navigator program I-9.1Improved compliance with recommended care regimens Unique Community Need Identification Numbers the Project Addresses:

• CN.1: Shortage of primary and specialty care providers and inadequate access to primary or preventive care



• CN.4: Lack of Patient-Centered Care How the Project Represents a New Initiative or Significantly Enhances an Existing Delivery System Reform Initiative: This is a new initiative with no related activities that are funded by the U.S Department of Health and Human Services. Project Core Components: a) Develop the model that allows patients in need to be assigned to a PCMH home. This plan will involve a slow rollout plan to allow for development of a process that would allow for understanding of practice supply, demand and balancing of patient loads. Tracking of volumes would come from HIE, including volumes of services.b) Structure of staffing to a multidisciplinary care team that maximizes the effectness of of meeting the needs of the patients to ensure maximum patient benefit. Tracking of this information will be monitor by the care team bimonthly and evaluate the need for adjustments. c) Develop the education plans that empower the patients for their own health. This information will be gathered from patient care audits that patient improvement and compliance with their plans of care d) Develop a plan of patient contact with their care providers to promote increased self management of disease processes. This information we be tracked by patient contacts and decreased emergencies room visits. Customizable Process or Improvement Milestones: N/A Related Category 3 Outcome Measure: We have selected IT-1.10 Diabetes care: HbA1c poor control (>9.0%). The Category 3 goal for this project is to reduce the percentage of community clinic patients with Type 1 or 2 diabetes whose most recent hemoglobin A1c (HbA1c) is greater than 9% (poor control) from 34.27% to 24%, or a10 % reduction, by DY 5. Providing a patient centered medical home where a diabetic patient has a direct relationship with a provider and care team has shown a relationship with decreased use of inpatient and emergency care (see Rationale above). Community clinics offer a variety of services in one location, including medical, dental, podiatry, nutrition counseling, social services, behavioral health, care management, and social services. Combining the power of the medical home model with the community oriented patient navigator services offered by the RAHC community health workers, we believe we can have a positive, early impact on helping diabetic patients control their HbA1c. Relationship to Other Projects This project relates to our DSRIP project to increase OB/GYN capacity, as both projects are improving primary care. Additionally, this project would support population health improvements in Category 4. Relationship to Other Performing Providers’ Projects in the RHP A major aim of this project is to have patients without medical care assigned to a primary medical home for improved health it is related to OB/GYN increased primary care. Plan for Learning Collaborative: South Texas Health System through the RAHC as the facilitator will develop the learning collaborative during the project period. The RAHC will also work with the HIE and Nuestra Clinica to create a seamless access to patient data to facilitate management of patients enrolled in the PCMH. All of the partners in the project have the capacity to host online and videoconference interactive meetings that will be organized and facilitated by the UTHSCSA RAHC. This will provide ample opportunity for a robust learning collaborative.


The RAHC has an advanced data collection, data management and data analysis operation. Working with the Nuestra Clinica Information Technology team and the Rio Grand HIE will create a robust system of data for evaluation, management and decision making. Furthermore it will provide the foundation to expand the IT interaction with hospitals and other clinics in the region. We also plan to participate in the statewide learning collaborative for DSRIP. Project Valuation: The project will be valued based upon the successful attainment of the following expected results:

• Develop and implement action plans for a patient centered medical home. • Restructure staffing into multidisciplinary care teams that manage a panel of patients

where providers and staff operate at the top of their license. • Management and coordination for shared, high-risk patients.

This project will impact patients and health costs through addressing chronic conditions with a specific focus on diabetes. We estimate that a 10% reduction in uncontrolled to controlled A1c results on over 4,000+ patients with diabetes (out of the 31,000 Nuestra Clinica patients) which is a potential long term savings of several million dollars based on data extrapolated from previous studies. Additional cost savings are found in our expected improvement of A1c results for another 50% of the PCMH diabetic population (<9.0% but still above 6.0%). We estimate those savings to be $1-2 million per year. Prevented hospitalizations is another area where we will reap cost savings since diabetics in RHP5 when hospitalized have at least one extra day in the hospital and an extra ½ day in the ICU (RHP 5 assessment data). We estimate savings that could reach $5-7 million / year from averted ICU and regular stay hospitalizations. Finally, our program will also likely improve hypertension and hypercholesterolemia because of its comprehensive approach as a PCMH. As we have shown with other chronic care management programs we will establish a program that achieves significant savings from preventing the onset of other chronic conditions and especially achieving control of diabetes.


Medication Reconciliation 160709501.2.101 Doctors Hospital at Renaissance / 160709501 Project Option: 2.11.2 Project Description: Doctors Hospital at Renaissance (DHR) is implementing evidence-based interventions that put into place teams, technology and processes to avoid medication errors. Through this project DHR will significantly enhance its capabilities for medication management processes in an effort to facilitate the appropriate use of medications, leading to improving outcomes. The specific purpose of this project is to provide the platform to conduct medication reconciliation, thus reducing reduce errors, improving patient adherence, and reducing adverse effects that stem from medication errors. This project option will focus on the following method:

• Implement pharmacist ‐led ch

primary care and other health care providers.

DHR is one of the most technologically advanced hospitals within South Texas. It followed aggressive timelines while implementing its current electronic medical record system, aligning its resources with key physicians to share electronic information, and has sought to introduce CPOE amongst its providers in an effort to improve patient outcomes. Through utilizing funding made available within the waiver, resources will be effectively leveraged when implementing a pharmacist-led chronic disease medication management program as the next step towards increased medication management capabilities. This is accomplished by aligning resources within DHR’s pharmacy and case-management outreach. Through this endeavor high-risk readmission patients are identified and contacted, with the goal of enrolling them in a follow-up program. Once enrolled, medication management in collaboration with case management will work together in efforts of improving medication adherence by each patient.

Goals: The primary purpose of this project is to facilitate the appropriate use of medications in order to control illness and improve long-term health. Underlying objectives that need to be met in order to achieve this goal are the following:

a) Implement pharmacist led chronic disease medication management services in collaboration with primary

care and other health care providers; b) Create the criteria to identify high-risk patients that would benefit the most from medication

management, and c) Enhance current case-management services to identify and contact to high-risk patients that meet the

criteria for being enrolled in the medication management program.

Through project implementation the following goals will be achieved:

• Tools and criteria will be used to identify patients that are at the highest risk for deviating from medication adherence.

• The increase of access will address the most common causes of medication error in patients including (a) language barrier, (b) lack of education towards the purpose of the medication, (c) improper medication administration, (d) lack of care coordination and follow-up, and (e) complex treatment regimens

• Improved outcomes that determine the management of diabetes such HbA1c levels


• Improved readmission rates of those patients that previously required stabilization within the emergency department.

Challenges/Issues: Medication errors account for over $17 billion in costs throughout the healthcare system. The most common errors are improper doses of medicine, inaccurate prescriptions, and erroneous routes of administration. In RHP5, over half of the population is either uninsured or on Medicaid and is subject to higher risks for comorbidities such as hypertension, obesity or diabetes, each of which result in one more type of prescription medication in order to help manage and improve their condition. The most at-risk patients are those with multiple chronic conditions since they are on a panel of prescription medications. Other common causes of medication error stem from:

• High out-of-pocket costs, especially for patients on multiple prescriptions for chronic conditions • Lack of care coordination and follow-up • Personal factors, including lifestyle, culture and belief system

Through the implementation of the medication reconciliation program resources will be made available to reach out to qualifying patients addressing each of the major issues identified. Addressing Challenges: Medication management within a high-volume hospital such as Doctors Hospital at Renaissance provides opportunities to vastly reduce medication errors. Through the program high-risk readmission Medicaid patients will be identified in pursuit of ensuring that their current medication panel is not conflicting, and assisting the patient with education on medication adherence to avoid adverse effects that are associated with medication errors. 3-Year Expected Outcomes/Benefits: Expected outcomes that come with implementing a medication management projects:

• Decrease overall medication errors for those patients enrolled with the program. • Decrease of hospital readmissions for those patients enrolled • Increased patient education and ability to self-manage their pharmaceutical panel.

Each of the expected outcomes support each other in improving long-term outcomes for those impacted patients increasing their overall quality of life and decreasing preventable hospital readmissions. How this project is related to regional goals: A major issue in RHP5 is the cost of health care that is largely driven by the high prevalence of chronic disease and poor access to health services by this population with major health disparities. These circumstances result in people developing advanced chronic diseases particularly obesity, diabetes, heart disease and related conditions. In combination with diet and exercise, medication adherence remains a crucial role in managing any chronic disease. With the challenges that are present within RHP5, medication management will serve as


an important facet within the healthcare continuum to improve patient outcomes reducing hospital readmissions and associated adverse affects that comes with medication errors. Starting Point/Baseline: The starting point of the project will be set at the end of DY3 once the organizational realignment of resources has been completed to ensure all measures are in place for increased patient outreach. The patient baseline is based off of the number of patient encounters that are serviced by the program expansion to demonstrate an increase of medication reconciliation throughout the community. Quantifiable Patient Impact: Once the clinic becomes fully operational, 300 unique patients will be impacted per year. The clinic is focused on comprising its capacity with the Medicaid and indigent population. Increases in individual patient volumes will be dependent on capacity of overall medication management program to maintain a responsible, manageable patient panel. Rationale: This project option has been selected to increase access to behavioral health to a specific patient demographic that is afflicted by the predominant underlying comorbidity, diabetes. Collaboration with the University of Houston and DHR enables the program to be developed efficiently so that the patient population seen within DHR (over 50,000 patients a year) and within the Josline Diabetes Clinic will have access to services by the end of DY3 creating a patient panel. By DY4, patient panels can be improved on within the limitations of the provider capacity. Although HHSC did not stipulate any type of core components for this project option, hours and location has been selected to increase the availability of access to the targeted patients. Milestones have been chosen to demonstrate project implementation and will be reported on to demonstrate an improved access to healthcare. Core Components: This project does not have any mandated core components. Related Category 3 Outcome Measures: The medication management program will derive a large percentage of its empanelment from patients that have been admitted to the hospital. The goal of the project is to contact eligible patients and enroll them within the program so that necessary care is given to their medication regimen, and literacy adjusted tools / education is provided to improve on 30 day readmission percentages. With these goals in mind, the category 3 outcome measure that best relates to this project is IT-31, “All cause 30 day readmission rate”. Due to various adverse effects that take place due to medication error, any specific focus on readmission, such diabetes 30 day readmission, becomes difficult to maintain. Relationship to other Projects: Doctors Hospital at Renaissance is embarking on various projects including expansion of behavioral health, diabetes specific care, and a patient centered medical home each of which will need the services of medication management for a percentage of their patient population. Collaboration amongst these projects within the DHR system enhances their capabilities promoting a continuum of care transformation and improved outcomes.


Plan for Learning Collaborative: Doctors Hospital at Renaissance will participate in the statewide learning collaborative that is being organized by the Texas Health and Human Services Commission. Every effort will be made to collaborate with the RHP5 anchor in providing any and all results from the implemented projects including lessons learned. All findings will be supported by data and provided in a meaningful manner so that other participating providers can contribute as well. Project Valuation: The project valuation is derived from two variables, the hard costs of expanding service capacity, and the targeted patient empanelment. The hard costs of expanding service capacity include increased staffing to handle proper data management for reporting, clinical case managers, pharmacists, and increased equipment and supplies to ensure the availability of services. The targeted patient population is high-risk patients that fall within Medicare or are uninsured which have increased probabilities of being readmitted into the hospital.


PROPOSED THREE YEAR DSRIP PROJECT

RHP 05


Provider Name/TPI: Rio Grande Regional Hospital / 112716902 Project Description 1.1.2: Expand Primary Care Capacity – Primary Care Physician Recruitment. Rio Grande Regional Hospital (Rio) seeks to increase primary care capacity at its local outpatient clinics. This project will allow Rio to recruit and retain a primary care physician to support primary care services in the North Central and Northwest areas of the Region entail implementing creative strategies for attracting the needed practitioners to the community. We have an ongoing mission to draw talented, qualified physicians to our facility. In addition to current efforts, we continue to seek and develop innovative ways to attract physicians to the area. We will develop a plan for adding additional incentives to the recruitment and retention efforts and implement strategies we have identified.

Intervention(s) Rio plans to hire an additional primary care physician to expand access to primary care. This increase in provider presence will result in an increase in primary care clinic volume. This project will focus on the following milestones:

• P‐5: Train/hire additional primary care providers and staff and/or increase the number of primary care clinics for existing providers.

• I‐12: Increase primary care clinic volume of visits and evidence of improved access


Region 5 ranked the shortage of primary and specialty care providers and inadequate access to primary or preventive care as its most prevalent community need (CN.1) as well as inadequate integration of care for individuals with multiple health issues (CN.3), and a lack of patient-centered care (CN.4). The community needs assessment utilized by Region 5 shows that the Region has only half the rate of general practitioners per 100,000 population compared to Texas. To address this severe shortage in the Rio Grande Valley, we have actively engaged in marketing and incentive strategies to recruit physicians into our community. This project will increase the number of physicians and scope of services offered in the community by facilitating the recruitment of primary care physicians to the area. This increase in the primary care workforce will result in strengthen and integrated health care system and play a key role in implementing disease management programs, which a strong primary care framework is necessary. The goal of this project is to recruit more workforce members to serve as primary care providers and clinicians to address the substantial primary care workforce shortage.

Target population

The target population is the patient population with the need for a primary care physician, new families moving into the area and patients who are in need of annual screenings and other preventative care to maintain healthy lives. About 35% of the patients that will benefit from this project are Medicaid eligible or indigent.



The increased availability of primary care resources should reduce inappropriate usage of hospital Emergency Departments for basic medical services. An additional primary care physician will promote comprehensive health care outside of the Emergency Department, which will help in achieving the Waiver aim of providing the right care in the right setting. Expanding access to primary care is a foundational issue for transforming the delivery of care and improving patient outcomes in the Region.

By implementing this intervention, Rio plans to have 4,300 patient encounters over the course of the Waiver, 1,505 of which should be for Medicaid or uninsured patients. Rio anticipates the following patient impact: DY3: 1,000 total patient encounters, of those 350 will be from the Medicaid/uninsured population; DY4: 1,500 total patient encounters, of those 525 will be from the Medicaid/uninsured population; DY 5: 1,800 total patient encounters, of those 630 will be from the Medicaid/uninsured population.

Category 3 outcomes expected patient benefits IT 2.11 – Reduce Ambulatory Care Sensitive Conditions Admissions Rate – Rio expects that the improved accessibility to primary care will cause a reduction in non-emergent ED admissions for the target population. Rio believes patients in the targeted outlying communities will have better access to primary care through the recruitment of an additional primary care practitioner.


Project Narrative


• Title of Project: Expand Primary Care Capacity – Primary Care Physician Recruitment





• Overview of Project: Rio seeks to increase primary care capacity at its local outpatient clinics. This project will allow Rio to recruit and retain a primary care physician to support primary care services in the North Central and Northwest areas of the Region entail implementing creative strategies for attracting the needed practitioners to the community. We have an ongoing mission to draw talented, qualified physicians to our facility. In addition to current efforts, we continue to seek and develop innovative ways to attract physicians to the area. We will develop a plan for adding additional incentives to the recruitment and retention efforts and implement strategies we have identified.

• Project Goals: Rio plans to hire an additional primary care physician to expand access to primary care. This increase in provider presence will result in an increase in primary care clinic volume. By implementing this intervention, Rio plans to have 4,300 patient encounters over the course of the Waiver, 1,505 of which should be for Medicaid or uninsured patients.

• Challenges or issues faced by the Performing Provider: Rio has greater demand for primary care services in its clinics than it can currently provide. As a result, many patients are forced to seek primary care in Rio’s ED, which diverts resources away from patients with the greatest need.

• How the project addresses those challenges: By adding primary care capacity, Rio will alleviate patient backlogs and allow greater access to care in its clinics. The increased availability of primary care resources should reduce inappropriate usage of hospital Emergency Departments for basic medical services. An additional primary care physician will promote comprehensive health care outside of the Emergency Department, which will help in achieving the Waiver aim of providing the right care in the right setting. Expanding access to primary care is a foundational issue for transforming the delivery of care and improving patient outcomes in the Region.

• 3-year expected outcome for Performing Provider and patients: This project will increase the number of physicians and scope of services offered in the community by facilitating the recruitment of primary care physicians to the area. This increase in the primary care workforce will result in strengthen and integrated health care system and play a key role in implementing disease management programs, which a strong primary care framework is necessary. The goal


of this project is to recruit more workforce members to serve as primary care providers and clinicians to address the substantial primary care workforce shortage.

• How the project is related to the regional goals: Region 5 ranked the shortage of primary and specialty care providers and inadequate access to primary or preventive care as its most prevalent community need (CN.1) as well as inadequate integration of care for individuals with multiple health issues (CN.3), and a lack of patient-centered care (CN.4). The community needs assessment utilized by Region 5 shows that the Region has only half the rate of general practitioners per 100,000 population compared to Texas. To address this severe shortage in the Rio Grande Valley, we have actively engaged in marketing and incentive strategies to recruit physicians into our community.



to have 1,000 patient encounters in the first year (350 of which should be Medicaid or uninsured).

• Quantifiable Patient Impact: The increased availability of primary care resources should reduce inappropriate usage of hospital Emergency Departments for basic medical services. An additional primary care physician will promote comprehensive health care outside of the Emergency Department, which will help in achieving the Waiver aim of providing the right care in the right setting. Expanding access to primary care is a foundational issue for transforming the delivery of care and improving patient outcomes in the Region. By implementing this intervention, Rio plans to have 4,300 patient encounters over the course of the Waiver, 1,505 of which should be for Medicaid or uninsured patients. Rio anticipates the following patient impact: DY3: 1,000 total patient encounters, of those 350 will be from the Medicaid/uninsured population; DY4: 1,500 total patient encounters, of those 525 will be from the Medicaid/uninsured population; DY 5: 1,800 total patient encounters, of those 630 will be from the Medicaid/uninsured population.

• Rationale: Region 5 ranked the shortage of primary and specialty care providers and inadequate access to primary or preventive care as its most prevalent community need (CN.1) as well as inadequate integration of care for individuals with multiple health issues (CN.3), and a lack of patient-centered care (CN.4). The community needs assessment utilized by Region 5 shows that the Region has only half the rate of general practitioners per 100,000 population compared to Texas. To address this severe shortage in the Rio Grande Valley, we have actively engaged in marketing and incentive strategies to recruit physicians into our community. Rio selected the following milestones:

o [P-5]: Train/hire additional primary care providers and staff and/or increase the number of primary care clinics for existing providers; and


o [I-12]: Increase primary care clinic volume of visits and evidence of improved access for patients seeking services.

Rio selected these milestones because they most closely align with the hospital’s potential to develop a meaningful intervention and demonstrate improvement through operationalizing that intervention.

• Project Core Components: Rio will accomplish the CQI core components by training/hiring additional primary care providers and staff as described in Milestone P-5 and increasing the primary care clinic volume as described in Milestone I-12, which will increase the number of primary care encounters provided.


• Related Category 3 Outcome Measure(s): IT 2.11 – Reduce Ambulatory Care Sensitive Conditions Admissions Rate – Rio expects that the improved accessibility to primary care will cause a reduction in non-emergent ED admissions for the target population. Rio believes patients in the targeted outlying communities will have better access to primary care through the recruitment of an additional primary care practitioner.

• Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): While other RHP 5 projects touch on issues related to primary care, this project specifically targets the addition of clinic availability in outlying areas of Hidalgo County. As such, this project provides a unique opportunity to expand primary care access and capacity to an underserved area of this region.

• Plan for Learning Collaborative: Rio looks forward to participating in RHP 5’s learning collaborative once the Anchor develops the plan for the learning collaborative. This project addresses three significant community needs, the lack of primary care services (CN.1), the lack of integration of care (CN.3), and the lack of patient-centered care (CN.4). Rio expects its experience implementing this project will benefit all providers in the region through the sharing of lessons learned in the collaborative.

Project Valuation: Rio valued this project at $3,300,000 over the 3 remaining years of the Waiver. This value is based on the substantial need for this project and the impact on the Medicaid uninsured population. By implementing this intervention, Rio plans to have 4,300 patient encounters over the course of the Waiver, 1,505 of which should be for Medicaid or uninsured patients. This project has a significant impact on our region’s low-income and needy patient population, justifying the value of this project.


Increasing Mental Health Access 160709501.1.104 Doctors Hospital at Renaissance / 160709501 Project Option: 1.12.2 Project Description: DHR is proposing to expand the behavioral health service line through creation of an additional outpatient clinic. Outpatient clinics will help increase patient access to partial hospitalization programs and follow-up support management programs. Inpatient availability will be created and allow for medical supervision and unit stabilization. Additionally, a post-discharge support system will be created to help self-management and avoid episode reoccurrence. Target population is the Medicaid community in need of mental health services. This project will primarily focus on currently diagnosed, at-risk, patients that are in need of follow-up care. This care will in turn help reduce readmissions. Goals:

The goals of the expansion clinic include the following:

• Increasing access to behavioral health on an individual and group level depending on the circumstances of the patients (such as a diabetic support group; or a geriatric anxiety session; or other behavioral needs).

• Increasing overall behavioral health care access to the public with a focus on the Medicaid population. • Provide follow-up services to encourage stabilization and prevent episode reoccurrence further

preventing readmissions. • The clinic will also dramatically increase access to substance and addiction support programs.

Challenges/Issues: Hidalgo County is considered a Health Professional Shortage Area. This project expands the accessibility of services by creating additional clinical space and the recruitment of professionals to allow for more patients to been seen. Population focus is directed towards the Medicaid population throughout the community that typically has difficulties accessing professional behavioral help. According to the RHP 5 Community Needs Assessment an estimated 28.6% of people have a measurable level of depression. An additional 30% of adults have been surveyed as having a measurable level of anxiety. These levels are expected to be further exacerbated when applied to the diabetic population due to conflicts of medication management. Some anti-psychotics and anti-depressants may increase the risk of diabetes or diabetic control by promoting weight gain, glucose intolerance and insulin resistance36. Within the Doctors Hospital at Renaissance spectrum of services there are no designated follow-up clinics that are designed specifically for mental health. Once patients leave the inpatient setting, DHR currently has limited resources to assist an individual in maintaining a healthy lifestyle and to avoid further and unnecessary hospitalizations. These additional outpatient-based services will allow DHR to provide enhanced resources to the patient that will help them maintain a healthy condition and keep up with their mental healthcare needs.

36Arizona Dept. of Health Services – Division of Behavioral Health Services: http://www.azdhs.gov/bhs/qhi/files/qhi9_provider.pdf RHP Plan for [RHP 5/South Texas] 178

http://www.azdhs.gov/bhs/qhi/files/qhi9_provider.pdf

Addressing the challenges: To help meet the demand for behavioral health services, DHR is expanding their current capabilities by implementing an ambulatory behavioral follow-up clinic. This allows for an access point of continued mental health services once patients have been released from the Behavioral Center at Renaissance helping to decrease behavioral health readmissions and inappropriate emergency department utilization. 3-Year Expected Outcomes/Benefits: Hidalgo County, within RHP5 is identified as a Healthcare Professional Shortage Areas (HPSA). This project directly addresses the problem by increasing service availability (community need 2). Patients will have increased access to mental health care services in both the inpatient and outpatient care setting. Through these services, hospital readmissions will be reduced and preventable mental health care needs will be addressed in the right setting in the right time. Without these services, patients will experience an elevation in their current condition, a diminished quality of life, and can lead to an emergent situation. How this project is related to regional goals: This project directly addresses community need 2 (CN.2), “shortage of behavioral health care professionals and inadequate access to behavioral healthcare”. A lack of behavior health care settings further exacerbates gaps in care as these patients are also often affected by chronic diseases such as diabetes. When a patients mental condition becomes unstable, adherence to treatment plans become difficult increasing the chances for emergency department utilization. The goal is to reduce fragmented and inadequate behavioral health care once the patient leaves the primary care setting. Improving access through addressing CN.2 promotes the right care in the right setting building a sustainable healthcare model in which appropriate care is available increasing quality for the patient and efficiencies for the provider. Starting Point/Baseline: The clinic is scheduled to be operational within DY3. Patients seen within this year is the baseline that will be used for comparison within DY4 and DY5. If there is available capacity within the clinic by the end of DY3 due to a lack of time to fully utilize its resources it will be noted within the reporting. Quantifiable Patient Impact: Given that DY3 is being used to establish the clinic, approximately 100 patients can be seen within the clinic. Given a full year of operation, 300 patients will be impacted by this increase of service line, an increase of 200 over the prior year. With the complexities of behavioral health, maintaining a manageable patient panel size is crucial building a behavioral healthcare model that is founded on quality, safety, and a positive patient experience. Within DY5, 500 patients (200 additional patients over DY4) will be the benchmark for patient impact as new patients come through the clinic and others discontinue the need for the services. Rationale: RHP5 is historically considered a medically underserved area with high levels of Medicaid and indigent population living at or below the federal poverty line. As a result, this segment of the population is often at the highest risk for being admitted into the emergency department as behavioral health service availability and follow-up care is limited. Given these regional circumstances this expansion project is included within Doctors Hospital at Renaissance’s (DHR) menu of projects. DY3 will allow the expansion clinic to be established RHP Plan for [RHP 5/South Texas] 179

(milestone 2, P-6) and fully staffed (milestone 1, P-4). Once this has occurred and policies and procedures have been adopted, services can be utilized by the community where availability was not possible before (milestone 3, I-11). As an effect of this increased access, frequent emergency department users will have an outpatient clinic to be referred to allowing for the appropriate care to be received within a more adequate setting (milestone 4, I-12). The improvement targets include: increased community clinic utilization (I-11) and a decrease of inappropriate emergency department usage (I-12). Core Components: This project, 1.12.2, has no HHSC mandated core components. The primary object of this project is to expand the number of community based settings where behavioral health services may be delivered in underserved areas. The project’s main core component focuses on increasing clinical locations and providers. Related Category 3 Outcome Measures: IT-9.2 ED appropriate utilization (Standalone measure) • Reduce all ED visits (including ACSC)271 • Reduce pediatric Emergency Department visits (CHIPRA Core Measure)272 • Reduce Emergency Department visits for target conditions

o Congestive Heart Failure o Diabetes o End Stage Renal Disease o Cardiovascular Disease /Hypertension o Behavioral Health/Substance Abuse o Chronic Obstructive Pulmonary Disease o Asthma

Many times behavioral patients are left with no type of follow-up care after being stabilized and released. Patients digress from their current state back into on that demands immediate emergent care. Access to behavioral follow-up care allows patients that have historically used the ED as a method of care to have their conditions treated in an appropriate setting alleviating inappropriate utilization of the emergency department. Relationship to other Projects: Due to the nature of this project and Doctors Hospital at Renaissance being the primary provider without any type of collaboration, the expansion of behavioral services will act on its own without any real relation to other projects. Behavioral health is a standalone community need which inadvertently affects all other projects in the sense that behavioral patients often have chronic diseases due to their lack of available primary care and rehabilitating conditions. Plan for Learning Collaborative: Doctors Hospital at Renaissance will participate in the statewide learning collaborative that is being organized by the Texas Health and Human Services Commission. Every effort will be made to collaborate with the RHP5 anchor in providing any and all results from the implemented projects including lessons learned. All findings will be supported by data and provided in a meaningful manner so that other participating providers can contribute as well. Project Valuation: RHP Plan for [RHP 5/South Texas] 180

Project valuation is based off of the costs of establishing an expansion clinic that is fully staffed and meets all accreditation standards. Additional consideration is given to the Medicaid and indigent patient population that this clinic is intended to serve which typically receive services that aren’t reimbursed in a manner that covers costs and patients have no way to consistently pay.


Implementing a Chronic Disease Registry 160709501.1.105 Doctors Hospital at Renaissance / 160709501 Project Option: 1.3.1 Project Description: Doctors Hospital at Renaissance (DHR) is a 500+ bed facility with a busy ED, over 500 on-staff physicians, and is home to one of the Joslin Diabetic Clinics. Although electronic medical records (EMR) are heavily integrated throughout the hospital, there is no developed chronic disease registry. DHR, through the assistance of the 1115 waiver, is now in a position to develop a comprehensive, meaningful, chronic disease registry. The registry is going to serve as a tool to provide reports about how well overall provider organizations within DHR are doing in delivering evidenced based care to specific patient populations. The registry is intended to stratify patients into risk categories in order to target interventions towards patients with the highest needs. Implementation is targeted towards the ED department, the Cancer Center at Renaissance, Joslin Diabetes Clinic, and will be integrated within the oncoming residency programs (160709501.1.1 through 160709501.1.4). This project will target all available patient demographics with a special emphasis on the Medicaid population. More specifically this project’s most valuable asset is data and being able to categorize it in a meaningful way. The more patients that are added within the registry the better the socioeconomics of RHP5 will be understood. Goals: DHR is the largest hospital organization in the county with high volumes of patients that come from a stratified payor mix (primarily Medicaid). The goal is to build a user friendly registry that is used to register the various conditions and circumstances of these patients in which this registry. The registry can be disseminated throughout the communities healthcare providers to be further populated and create evidence based researched that is specific to this region. RHP5 has been long identified as an underserved area yet there has been little to no in-depth studies focused on this fast growing Medicaid population. A patient registry creates an opportunity to take a look at the patient demographics on a scalable level in efforts to adjust outreach and treatment methods. The implementation and complete adoption of a chronic disease registry will assist in the following: • Prompt physicians and their teams to conduct appropriate assessments and deliver condition-specific

recommended care; • Provide reports about how well individual care teams and overall provider organizations are doing in

delivering recommended care to specific patient populations; • Stratify patients into risk categories in order to target interventions toward patients with highest needs. Challenges/Issues: Within RHP5 non-communicable diseases (NCDs), mainly chronic diseases, have reached pandemic proportions and are considered to be the greatest threat to the global economy and health at this time, with a total predicted cost by 2030 of $47 trillion. The leading NCDs within RHP5 are mostly obesity driven,


particularly diabetes and cardiovascular diseases.37 The implementation and complete adoption of a chronic disease registry will assist in the following: A continued lack of chronic disease registry prohibits meaningful outreach and treatment adjustments due to quantifiable patient metrics not being accessible on a large scale. Currently, evidence based practices that are utilized within this region where not specifically designed for this unique patient population which can lead to a lack of optimal efficiencies and effectiveness. Addressing the challenges: Implementation of a chronic disease registry will allow data analysts to collaborate with the physician/provider community to use aggregated real-time data to better assess the effectiveness of treatment plans for patients. Trends can be seen through historical data made available through registry and treatment plans can be adjusted accordingly. Once wide spread adoption has occurred within the provider community, a majority of patients will have their data input within the registry to create an in-depth tool that can be used to transform the healthcare delivery methodology within RHP5. 3-Year Expected Outcomes/Benefits: Once the changes have been within the providers’ facilities, patients will benefit by receiving adjusted healthcare according to their chronic condition. The research that will be available through this project will also increase awareness of the patient demographics unique situations so that outreach can be altered to best meet the needs of the hospitals inpatient population, participating outpatient populations, and the overall community. How this project is related to regional goals: RHP5 is a region that is comprised of purely safety-net hospitals and providers. With a large percentage of the patient population falling into either a Medicaid or uninsured population, hospitals operate within an intricate financial structure. A tool such as the registry will allow the regions providers to have access to real-time outcomes to adjust current strategies allocating resources where they are needed the most. This new available method of healthcare ensures that attention is given where most needed creating an efficient healthcare delivery system encouraging improved outcomes for RHP5. Through successful development and integration of this tool community need 1 is essentially enhanced by improving the delivery of care once meaningful data has been made available. Starting Point/Baseline: The starting point for this baseline will be at the end of DY3. This allows enough time for the resources to be put into place throughout the installment of the disease registry so that patient information can be inputted. Quantifiable Patient Impact: DHR, on-average provides care for over 200,000 patient encounters per year. This patient base will provide for the creation if an in-depth patient registry. To maintain proper integration, and allow for flexibility in altering the database to increase efficiencies, the quantifiable impact will be 15,000 patients within DY3, and a 10% increase every year thereafter, resulting in approximately 49,000 patients populating the tool over the 3 years.

37 RHP5 Community Needs Assessment RHP Plan for [RHP 5/South Texas] 183

Once the data base has proven itself to be affective and has been adopted by the DHR provider community, patient impact is projected to be in the hundreds of thousands. Rationale: RHP5 is historically considered a medically underserved area with high levels of indigent population living at or below the federal poverty line. As a result, this segment of the population is often at the highest risk for developing chronic diseases due to a lack of available primary, preventative healthcare. While this circumstance represents a valuable segment to undergo studies that revolve around gaps of care, large Medicaid populations and the effect it has on outcomes and what safety-net providers are doing to stay operational in these demographics, there is really no available resource to capture this information. The chronic disease registry provides an opportunity to capture and aggregate large amounts of real time data to accurately stratify patient demographics and the various treatment methods that apply accordingly. DY3 is dedicated towards implementing the registry (milestone 1, P-2) and ensuring that key staff is trained to accurately utilize the tool (milestone 2, P-7). DY4 and DY5 is focused on increasing the percent of patients enrolled within the registry (I-15) and how well each participating provider utilizes the tool through follow-up monitoring of patient program adherence (I-18). Core Components: a) Enter patient data into unique chronic disease registry: Once the registry is functional and each participant is able to utilize the tool, patients’ information will populate continuously to ensure a large aggregate in efforts to enhance community outreach. b) Use registry data to proactively contact, educate, and track patients by disease status, risk status, self-management status, community and family need: Once there is enough patient information within the tool to use in a meaningful way, each participant can set their criteria that would determine patient outreach according to available resources. c) Use registry reports to develop and implement targeted QI plans: Given delicate financial structures, an increased amount of patient information demonstrating trends in their outcomes according to their care plan allows strategic quality improvement plans to various patient demographics as each segment can differ from one to the next. d) Conduct quality improvement: Quality improvement will become necessary once patient analytics are in place to ensure that optimal services are being provided within the time allotted. Employee observations, trends that become apparent within aggregated data and physician recommendations will all be accumulated within a “lessons learned” approach to develop improvements when discovered. This will allow for the clinics utilizing the registry to make adjustments where necessary to provide a safe, quality, and positive patient experience. Related Category 3 Outcome Measures: IT-1.11 Diabetes care: BP control (<140/80mm Hg)234 – NQF 0061 (Standalone measure) Blood pressure is monitored during hospital treatment because it’s arguably one of the quickest ways to tell a patient’s current health. As a sudden rise or drop in blood pressure signals a major problem monitoring a patient’s blood pressure can give doctors and nurses the fastest notification that a patient is in crisis. It’s definitely not the most precise measurement, but it is one of the most important to monitor. Being able to pull


up patient’s recent BP screen, apply it to the historical screenings, and create a trend will be an indicator if the treatment plans are working or not. Patients benefit by keeping record of their BP and various other tests such as HbA1c which enables the care team to readjust their treatment plan within and outside of the clinic to improve outcomes. Using the patient registry, BP trends as well as other important factors of a patient’s health are able to be assessed and treatment strategies adjusted. Relationship to other Projects: This project is to be incorporated within many branches of the Doctors Hospital at Renaissance. Such areas include the Joslin Diabetes Clinic, residency programs, patient centered medical home, each of which are dedicated waiver projects. The chronic disease registry serves as a cornerstone in evolving the health care model into one that focuses on real time evidence based outcomes to constantly evolve care plans and improving patient quality throughout the system. Plan for Learning Collaborative: Doctors Hospital at Renaissance will participate in the statewide learning collaborative that is being organized by the Texas Health and Human Services Commission. Every effort will be made to collaborate with the RHP5 anchor in providing any and all results from the implemented projects including lessons learned. All findings will be supported by data and provided in a meaningful manner so that other participating providers can contribute as well. Project Valuation: Project valuation is determined through the assessment of overall involvement that goes into creating tool that is meant to be integrated so heavily throughout the organization. Programmers will have to be brought on board to create a custom tool that fits the organization, equipment will need to be expanded on to handle the increase of data usage, providers will require training on the tool, and staff will be need to be reinforced to handle the reporting analytics of the tool. The most important factor that influences the valuation of the project is the vast patient population that this tool is intended to serve. Although the initial QPI is minimal to allow for further development, its purpose to aggregate the information of every patient that is seen within the system equating to a monumental amount of meaningful, usable data.


Project Title: Emergency Department Patient Navigator Program Unique RHP Project ID number: 0941130012.102 Performing Provider/TPI: South Texas Health System / 094113001 Project Option: 2.9.1 Project Core Components: 2.9.1.a-e

PROJECT SUMMARY


Project Description

The overall goal of this project is to increase the number of patients seen in a more appropriate level of care through implementation of patient navigation services and ED triage protocol. South Texas Health System’s 3-year goal is to increase the number of primary care provider referrals for patients without a primary care provider who use the ED.

Intervention(s) We have selected Project Option 2.9.1 Establish/Expand a Patient Care Navigation Program: Provide navigation services to targeted patients who are at high risk of disconnect from institutionalized health care. South Texas Health System will develop a patient navigator program to track, follow-up on and help manage care for chronically ill patients who have a history of frequently visiting the ED. A team of patient navigators would connect patients from our hospital to physicians so that patients can receive regular care in the primary care setting. In addition the patient navigator could assist patients without health insurance coverage to acquire appropriate coverage through Medicaid, the federal Health Care Exchange program, and other venues. The patient navigators would remotely monitor patients via frequent telephone check-ups to detect early signs of changes in a patient’s condition as well as to make appropriate interventions and referrals to prevent unnecessary and costly ED and/or hospital visits.



As sited in the community needs assessment, RHP5 suffers from a shortage of primary care (CN.1), inadequate integration of care for individuals with multiple chronic conditions (CN.3), and a lack of patient-centered care (CN.4). Over 70% of the population has one or more chronic conditions. A similar proportion currently does not have health insurance. This means that preventive care and intervention is largely neglected and patients often only present when they develop severe illnesses requiring Emergency Department or Inpatient care. There is a lack of chronic care management programs currently available in RHP5. The patient navigator model will provide patients with resources to help them manage their chronic conditions in appropriate care settings less costly than the Emergency Department and to help patients receive regular check-ups to ensure proper treatment is followed.

Target population The target population is non-urgent ED patients that do not have sufficient access to primary care. We expect to enroll at least 250 targeted patients in DY 3; 500 patients in DY 4 and 1,000 targeted patients in DY 5 into the patient navigator program. Of these enrollees, we expect approximately 60% will represent low-income (Medicaid, indigent and uninsured) patients.


STHS’ 3-year goal is to increase the number of primary care provider referrals for patients without a medical home who use the ED. We expect to enroll at least 250 targeted patients in DY 3; 500 patients in DY 4 and 1,000 targeted patients in DY 5 into the patient navigator program. Patients will benefit from access to a primary care provider and follow-up care, resulting in better patient outcomes and the prevention of avoidable ED visits. The expected benefits would include:

• Help patient better navigate the health care system to receive right care, right time, right place; • Increase patient access to ongoing primary and chronic care; • Provide care management and coordinated care; • Provide access to health insurance coverage via Medicaid, Health Insurance Exchanges, etc. • Improve at-risk patients’ health conditions; and

Reduce preventable ED and/or hospital visits.


IT-9.2.d ED Diversion. Decrease utilization of ED for patients in the navigation program by 65% by helping them receive care through a primary care physician in the appropriate care setting.


Project Title: 2.9.1 Emergency Department Patient Navigator Program Unique Project ID: 094113001 2.102 Performing Provider Name/TPI: South Texas Health System / 094113001 Project Components: 2.9.1.a-e Project Description:

South Texas Health System proposes to implement a patient navigator program to assist patients in receiving care in appropriate non-emergent settings as well as providing assistance with obtaining health insurance.

Each year South Texas Health System (STHS) Emergency Departments (EDs) have approximately 1,500 patients who come to the ED in excess of three times per year. The majority of these patients present with chronic conditions such as diabetes, kidney disease, and respiratory disorder or other conditions not meriting the higher and more costly level of care offered in an ED.

Patient navigators would serve to identify these patients upon their arrival to the ED, help patients

know how to receive care in a more appropriate setting outside the ED, and help the patient to obtain health insurance as necessary. Once the patient is enrolled in the patient navigation system, the patient navigation team would continue to provide follow-up phone calls to ensure that the patient is able to make appointments with primary care physicians, fill medication prescription orders, and help the patient maintain their chronic condition more effectively.

This project greatly enhances the current comprehensive, primary health and wellness services for Hidalgo County in South Texas by developing a patient navigation model that will improve the service to patients and greatly improve the efficiency and effectiveness of helping them control their chronic health conditions. STHS emergency departments contribute to the needs of the community by providing quality primary care and prevention services regardless of ability to pay. All emergency departments are accredited by the Joint Commission. The target population includes the uninsured and under-served, those below 200% of poverty, migrant and seasonal farm workers, Hispanics, women and children. The service area ranks as one of the poorest in the nation.

The staffing requirement for this project will include the following full-time equivalents (FTEs): Financial Counselor Supervisor (1 FTE); Certified Application Counselors/Patient Navigators (10 FTEs allocated between McAllen Medical Center, Edinburg Regional Medical Center, Edinburg Children’s Hospital, and McAllen Heart Hospital). Patient navigators will have the following core duties: (1) identifying patients in the ED who qualify to be in the patient navigation program, (2) assisting patients to procure a primary care physician, (3) assisting patients to apply and qualify for health insurance, and (4) providing follow-up phone calls to ensure patient follow through on physician appointments, filling of medication prescriptions, and other care goals.

Once patients are identified to be enrolled in the patient navigation program, they will be referred to either an existing primary care physician or to a designated primary care physician aligned with the navigation program. STHS has recently formed a partnership with the University of Texas Health Science Center at San Antonio’s Regional Academic Health Center to run a family practice residency clinic in McAllen that would be able to provide care for patients enrolled in the patient navigation program without primary care doctor. The family practice clinic is run by 7 faculty and 18 residents. The family practice clinic addresses medical provider shortages by providing medical residents and medical students a unique opportunity to gain frontline experience in treating many of the perplexing medical conditions prevalent along the U.S.-Mexico border.


Given the low income levels, high uninsured rates, and high percentage of Hispanics living in RHP 5, we propose to serve 34 of the following zip codes through this project: 78501 through 78599. Patient benefit DY4: Goal: Have at least 500 patients enrolled in the patient navigator program. Patient benefit DY5: Have at least 1,000 patients enrolled in the patient navigator program. Of these, an estimated 80 % would be Medicaid, indigent, or uninsured. Project Goals RHP 5 is a medically underserved area with a population that is 40-60% uninsured and that has no public hospital or hospital district. All of the hospitals are private for profit and are therefore limited in their ability to meet the needs of the population for primary and specialty care, based on current reimbursement/financing mechanisms and levels of insurance. Furthermore, the population suffers from very substantial health disparities, particularly related to obesity, diabetes and related conditions as described and documented in detail in the needs assessment. Two supplementary goals of the project are to:

• Develop meaningful digital health information collection and exchange between providers of care for

this demographic segment, and

• Develop actionable health information and analytical capability for reporting project performance, patient risk stratification and population management.

The key functional element of the project is to develop a structured patient navigation program with the ability to organize patient information to help improve population health and provide increased access to primary care and health insurance. Enrolling patients in this program will also reduce unnecessary ED visits, help patients better navigate the healthcare system to receive right care, right time, right place; increase patient access to ongoing primary and chronic care; provide care management and coordinated care; and improve at-risk patients’ health conditions. Regional Goals The project meets all of the regional goals: • Leverage and improve on existing programs and infrastructure to ensure that the health care delivery

system will be adequately developed to meet the primary and specialty care needs of residents throughout a rapidly growing, yet historically underserved region.


• Nurture a culture of ongoing quality improvement and innovation that maximizes the use of

technology and best-practices to improve access and timely utilization of appropriate care, including behavioral health services, particularly in our rural communities.

• Transform health care delivery to a patient-centered, coordinated and integrated delivery model that

improves patient satisfaction and health outcomes, reduces unnecessary emergency department use and duplicative services, and expands on the accomplishments of our existing health care system.


Challenges As cited in the community needs assessment, RHP5 suffers from a shortage of primary care (CN.1), inadequate integration of care for individuals with multiple chronic conditions (CN.3), and a lack of patient-centered care (CN.4). Developing a new care model to appropriately identify patients needing to be redirected to a primary care physician setting, provide education and assistance with health insurance, and provide direct follow-up phone calls to patients will require significant resources as well as coordination within the health system. The entire organization must undergo a coordinated transformation at the same time that clinical systems are being converted to electronic health records, new government regulations are being implemented, and reimbursement systems revised. Strong leadership from all partners including the UTHSC Family Practice Clinic and STHS clinical team are essential for success. In addition, the patient must also be educated in the new system and must buy in to the new system of care. Implementing this comprehensive change within a population that is overwhelming Hispanic and Spanish speaking with low health literacy will be a challenge requiring both time and resources. The 3-year expected outcome(s): We expect to serve at least 1,750 unique individuals in DY3, DY4, and DY5. In addition, we plan on reducing unnecessary ED visits within this group by 65%. Starting Point/Baseline. • STHS EDs currently have approximately 1,500 unique patients making three or more visits to the ED

per year. This represents a large population in need of proper primary care and a system to help them manage their chronic conditions.

• There are currently no Emergency Department-based patient navigator programs in the Upper Valley area of Region 5. Working with the UTHSC Family Practice will make this model the first such programs in Hidalgo County.

• STHS implemented a new electronic medical records system in March 2013 and has the baseline capability of tracking unique patient visits to the ED and integrate all medical records pertaining to each individual.

• The Administrative Leadership Team is knowledgeable of patient navigator programs and is committed to making such a program successful.

Rationale Patients who are underserved or have Medicaid health insurance are disproportionately seen in emergency departments. Many of these patients seek emergency care for medical conditions that should be treated in primary care settings. Unnecessary visits to the emergency department by underserved patients are much more expensive than primary care visits and result in an inefficient use of medical resources. Patients without a regular source of primary care often rely on the emergency room for routine care. We need to invest more resources to increase primary care capacity and help underserved patients avoid unnecessary emergency department visits. This initiative aims to eliminate fragmented and uncoordinated care, which can lead to emergency department and hospital over-utilization. This patient navigator project establishes a foundation for transforming the primary care landscape in South Texas by emphasizing enhanced chronic disease management through team-based care focused around the individual patient’s needs. Project core components: a) Establish Patient Navigator role is an integrated part of the ED and care management team. b) Develop link between patient navigator program, ED, and primary care physicians in the community – specifically those physicians in the UTHSC Family Practice clinic.


c) Link patients to a provider and care team so both patients and provider/care team recognizes each other as partners in care. d) Assure that patients are able to see their provider or care team whenever possible. e) Promote and expand access to the patient navigation program by ensuring that established patients have 24/7 continuous access to their patient navigator team via phone, e-mail, or in-person visits. f) Conduct quality improvement for project using methods such as rapid cycle improvement. Activities may include, but are not limited to, identifying project impacts, identifying “lessons learned,” opportunities to scale all or part of the project to a broader patient population, and identifying key challenges associated with expansion of the project, including special considerations for safety-net populations. Project milestones: Year 3 P-2. Establish/expand a health care navigation program to provide support to patient populations who are most at risk of receiving disconnected and fragmented care.

▪ (P-2.1) Number of people trained as patient navigators, number of navigation procedures, or number of continuing education sessions for patient navigators

P-2. Establish/expand a health care navigation program to provide support to patient populations who are most at risk of receiving disconnected and fragmented care.

▪ (P-2.2) Develop outreach plan to enroll patients in navigation program Year 4 P-4. Increase patient engagement, such as through patient education, self-management support, improved patient-provider communication techniques, and/or coordination with community resources ▪ (P-4.1) Description of and the number of classes and/or initiations offered, or number or percent of patients enrolled in the program. I-10. Improvements in access to care of patients receiving patient navigation services

▪ (I-10.1) Increase percentage of target population reached I-7. Reduce average number of ED visits and/or avoidable hospitalizations for patients enrolled in the navigator program

▪ (I-7.1) Number of ED visits and/or avoidable hospitalizations during the reporting period for patients enrolled in the navigator program

Year 5 I-8. Reduction in ED use by identified ED frequent users receiving navigation services

▪ (I-8.1) ED visits pre- and post-navigation services by individuals identified as ED frequent users I-9. Improved adherence to recommended care regimens for patients in Navigator program ▪ (I-9.1) Improved compliance with recommended care regimens Unique Community Need Identification Numbers the Project Addresses:

• CN.1: Shortage of primary and specialty care providers and inadequate access to primary or preventive care


• CN.4: Lack of Patient-Centered Care How the Project Represents a New Initiative or Significantly Enhances an Existing Delivery System Reform Initiative: This is a new initiative with no related activities that are funded by the U.S Department of Health and Human Services.


Related Category 3 Outcome Measure: We have selected IT-9.2.d ED Diversion. Decrease utilization of ED for patients in the navigation program by 65% by helping them receive care through a primary care physician in the appropriate care setting. Relationship to Other Projects. This project relates to our DSRIP project to increase OB/GYN capacity, as both projects are improving primary care. Additionally, this project would support population health improvements in Category 4. Relationship to Other Performing Providers’ Projects in the RHP. A major aim of this project is to work with the UTHSC Family Practice residency program to help improve patient access to primary care. The aim is to ensure the improved health care for the impoverished population of the area. These individuals are not receiving primary care at present, only seeking health care in emergency situations at higher costs with increased complications. Plan for Learning Collaborative. South Texas Health System through the UTHSC Family Practice residency program as the facilitator will develop the learning collaborative during the project period. The UTHSC Family Practice residency program will also work with the HIE to create a seamless access to patient data to facilitate management of patients enrolled in the patient navigator program. All of the partners in the project have the capacity to host online and videoconference interactive meetings that will be organized and facilitated by the UTHSCSA RAHC. This will provide ample opportunity for a robust learning collaborative. The RAHC has an advanced data collection, data management and data analysis operation. Working with the Nuestra Clinica Information Technology team and the Rio Grand HIE will create a robust system of data for evaluation, management and decision making. Furthermore it will provide the foundation to expand the IT interaction with hospitals and other clinics in the region. Project Valuation: The project will be valued based upon the successful attainment of the following expected results:

• Help patient better navigate the healthcare system to receive right care, right time, right place • Increase patient access to ongoing primary and chronic care • Provide care management and coordinated care • Provide access to health insurance coverage via Medicaid, health Insurance Exhanges, etc. • Improve at-risk patients’ health conditions • Reduce prefentable ED and/or hospital visits

The estimated total cost for running this program across the four EDs within STHS includes salaries for the patient navigators and financial counselor supervisor, medical office supplies, technology (computer, printer, etc.), and training for employees. DY3 costs will be $1,295,802, DY4 costs will be $1,360,747, and DY5 costs will be $1,796,447 for a total of $$4,452,996 over the three year period. We estimate savings that could reach $ 5-7 million / year from averted ICU and regular stay hospitalizations. Finally, our program will also likely improve hypertension and hypercholesterolemia because of its comprehensive approach as a patient navigator program. As we have shown with other chronic care management programs we will establish a program that achieves significant savings from preventing the onset of other chronic conditions.


Implementing Maternal Fetal Medicine Clinics 160709501.1.106 Doctors Hospital at Renaissance / 160709501 Project Option: 1.9.2 Project Description: Doctors Hospital at Renaissance is proposing to open maternal fetal medicine (MFM) woman’s clinics. MFM Clinic provides high quality, comprehensive obstetrical (Ob) outpatient care for women who have a maternal, fetal, or obstetric complication. Such complications derive from the high prevalence of diabetes and obesity within the region leading to high-risk pregnancies. The MFM doctors can provide consultations, co-manage prenatal care with the referring physician, or provide all prenatal care at the referring physician’s request. Goals: This project is designed to improve access to women that are identified as high-risk pregnancies and are in need of specialized Ob services available through MFM care. The clinical staff includes specialty-trained physicians, registered nurses, nutritionists and social workers who provide the following services:

• High-risk obstetrics care • Medical consultation • Diabetes in Pregnancy Program

Through the implementation of the MFM clinic, improved access to specialized care will be granted for the Medicaid and uninsured population. The object of increasing access to this targeted population is promoting a healthy pregnancy, carrying the fetus to full-term, and reducing overall birth complications such as a very low birth weight. Additional goals that are sought after through increasing access to this subspecialty include the management / prevention of the following conditions: • Uncontrolled blood glucose levels: High blood glucose levels can be harmful to babies during the first

few weeks of pregnancy. This is the time when a baby’s brain, heart, kidneys and lungs begin to form.

• Birth Defects: Babies of women with preexisting diabetes are more likely than other babies to have a birth defect, including heart defects and neural tube defects. The neural tube is the part a developing baby that becomes the brain and spinal cord.

• Very Low Birth Weight Babies: Extremely preterm infants (less than 29 weeks gestational age) are at increased risk for childhood impairments in brain function due to brain injury and disruptions in early brain development.38

• Stillbirth: Women with preexisting diabetes are more likely than women who don’t have diabetes to have a miscarriage or stillbirth. Miscarriage is the death of a baby in the womb before 20 weeks of pregnancy. Stillbirth is the death of a baby in the womb after 20 weeks of pregnancy but before birth.

Challenges/Issues: Besides age playing the most prominent role of categorizing a pregnancy “high-risk”, the second most common cause leading to high-risk pregnancies is diabetes. In 2010 RHP5 had a population of 1.26 million of which 31% (388,000) of adults were affected by diabetes. Due to large gaps in primary care for Medicaid and the

38 deRegnier RA. Neurophysiologic evaluation of brain function in extremely premature newborn infants. Seminars in Perinatology. 20087; 32:2-10. RHP Plan for [RHP 5/South Texas] 193

http://www.womenandinfants.org/womenandinfants/highriskpregnancy/index.cfm

http://www.womenandinfants.org/womenandinfants/Services/Diabetes-Management-Diabetes-in-Pregnancy-Program.cfm

http://www.marchofdimes.com/baby/birth-defects.aspx

http://www.marchofdimes.com/baby/congenital-heart-defects.aspx

http://www.marchofdimes.com/baby/neural-tube-defects.aspx

http://www.marchofdimes.com/loss/miscarriage.aspx

http://www.marchofdimes.com/loss/stillbirth.aspx

uninsured, disease management is not often sought after. A large percent of high-risk pregnancies stem from these gaps of disease control and an overall lack of health education. Due to the region’s high poverty rates, elevated levels of diabetes, a historically underserved region, and a growing population an increase of obstetrical and MFM care is essential within the community.

Access to MFM care not only benefits the patients but it helps create a more sustainable healthcare. The effects of low birth weight and prematurity strain the community as a whole. In 2001, hospital costs for preterm birth/low birth weight births, during the first year of life, totaled $5.8 billion, representing 47 percent of all infant hospitalization costs and 27 percent of all pediatric hospital costs. Preterm/low birth weight infant hospital stays have an average cost of $15,000 and an average length of 12 days, versus $600 and 1.9 days for full-term, normal birth weight babies. In 50 percent of cases, private/commercial insurance is the designated payer. Medicaid is the designated payer in 42 percent of cases.39 Addressing the challenges: Access to MFM clinics helps address the shortage of specialty care for the Medicaid population regarding MFM and OB. Patients receiving services within the clinic will have increased probabilities of carrying their pregnancy to full-term helping prevent defects that are often present in premature births. The challenge of addressing increased levels of high-risk pregnancies will have been improved on dramatically through a dedicated resource that is focused solely on improving patient outcomes. 3-Year Expected Outcomes/Benefits: The focus of this project is expanding high impact specialty care capacity for an at-risk population. There is a high female diabetic and obese population within RHP5 that are in need of this specialty throughout the term of their pregnancies. When the clinics are opened a strong referral base will come from Doctors Hospital at Renaissance. DHR delivers, on average, over 700-800 babies a month. With this type of high volume, MFM clinics provide an invaluable benefit to this population as this specialty promotes pregnancies coming to full-term and delivering the healthiest baby possible. Access to these clinics will give first time mothers the clinical support they need to make educated lifestyle decisions throughout their pregnancy to encourage healthy fetus development. Such support will include dietary interventions providing the patient with an overview of vital nutritional needs. Other vital support stems from diabetic education and informing the mother of the importance of strict glucose control and the detrimental affect it will have on the baby otherwise. MFMs will be able to access the baby’s development throughout the course of the pregnancy to determine if treatment plans need to be adjusted. The benefits not only affect the mother, but directly impact the baby as a healthy baby has greater percentages of living a healthier life overall as compared to those born into complications and typically accrue higher healthcare costs versus that of a healthy newborn. How this project is related to regional goals: The most prominent community need within RHP5 is CN1, increasing primary and specialty care capacity, for every insurance classification: Private, Medicare, Medicaid, and uninsured. The majority of the population ages 18-64 falls within the scope of either Medicaid (25%) or uninsured (38%). This project supports the

39 Ruseell R, et al. Cost of hospitalization for preterm and low birth weight infants in the United States. Pediatrics. 2007; 120(1): e1-e9 RHP Plan for [RHP 5/South Texas] 194

regional goal of improving accessibility to specialty care (Community Need 1) by increasing the availability of subspecialty care for women that fall into high-risk pregnancies (approximately 31%). This resource is invaluable to the region as high-risk pregnancies can cause irreversible damage to the child being born vastly reducing his/her quality of life. Starting Point/Baseline: There is currently no available data to provide for a starting point. The clinic will be implemented on an aggressive time attainting operational capabilities within DY3. Once this has been accomplished, the MFM Clinic is projected to provide at least 1250 patient encounters. Quantifiable Patient Impact: Given that the starting point and baseline is set at 1250 patient encounters, the clinic can expect to see a 15% increase in patient encounters in DY4 and a 25% baseline increase within DY5. Over the three years, the QPI is estimated to be over 4000 patient encounters. Rationale: RHP5 is historically considered a medically underserved area with high levels of indigent population living at or below the federal poverty line. As a result, this segment of the population is often at the highest risk for developing comorbidities such as obesity, hypertension, heart failure, and diabetes; diabetes playing the most influential factor in the percentages of high-risk pregnancies. This project addresses community need 1 by increasing specialty care within a highly impactful specialty such as maternal fetal care. Each core component is being built into the MFM Clinic to optimize patient accessibility. Each milestone that is listed within the RHP5 workbook focuses exclusively on creating the clinic within DY3 and increasing rendered services throughout DY4 and DY5. Core Components: a) Increase service availability with extended hours: To ensure that the those patients who are not available during normal working hours to receive specialty care, extended hours will be available on selected days to ensure that the optimal amount of patients are granted access. b) Increase number of specialty clinic locations: Maternity/MFM clinics are not being expanded upon throughout the demonstration years. Due to limited MFM providers within the region the current number of clinics will remain consistent to maintain a schedule that is optimal for accessibility. c) Implement transparent, standardized referrals across the system: Doctors Hospital at Renaissance, on average, births over 800 babies per month with a substantial amount of on-staff gynecological/obstetrical physicians within the community. This will allow patients of all insurance identifications in need of MFM care to be referred out and receive guidance throughout their pregnancy to encourage a healthy development. d) Conduct quality improvement: Quality improvement will become necessary once patient analytics are in place to ensure that optimal services are being provided within the time allotted. Employee observations, trends that become apparent within aggregated data and physician recommendations will all be accumulated within a “lessons learned” approach to develop improvements when discovered. This will allow for the clinic to make adjustments where necessary to provide a safe, quality, and positive patient experience.


Related Category 3 Outcome Measures: IT-8.2 Percentage of Low Birth-Weight births (CHIRPA/NQF # 1382) (Standalone measure)

a. Numerator: The number of babies born weighing < 2,500 grams at birth b. Denominator: All births

Data Source: HER, claims Relationship to other Projects: Relationships to other projects include collaboration with the following DSRIP projects:

• Ob/Gyn Residency Program: 160709501.1.3 • Joslin Diabetes Clinic Expansion: 160709501.1.102 • Chronic Disease Registry: 160709501.1.105 • Pharmaceutical Care Services: 160709501.2.102

Plan for Learning Collaborative: Doctors Hospital at Renaissance will participate in the statewide learning collaborative that is being organized by the Texas Health and Human Services Commission. Every effort will be made to collaborate with the RHP5 anchor in providing any and all results from the implemented projects including lessons learned. All findings will be supported by data and provided in a meaningful manner so that other participating providers can contribute as well. Project Valuation: Project valuation was assigned by taking into account the hard costs of implementing a fully operational clinic including leasing, staffing, equipment, supplies, informatics, and insurance. The most variable that has been assessed is the target population which is a predominant Medicaid population of which prevention services will be provided. Due to the average increase of healthcare cost associated with birth complications and life-long treatment for that patient the long-term value of the project far exceeds the immediate valuation of the project


Establishing School Based Primary Care Clinics 160709501.1.107 Doctors Hospital at Renaissance / 160709501 Project Option: 1.1.2 Project Description: The development of this project is in response to the need for primary health care (PCP) for the Edinburg Consolidated Independent School District (“Edinburg CISD”) employee community as a whole while focusing on increasing ease of accessibility and limiting the amount of time an employee must be away from their work in order to receive needed healthcare. School-based health care centers play a critical role in efforts to reduce disparities in health care access and child health status by providing a consistent source of primary health care in the most accessible environment. The goal will be to establish a centralized school district clinic with the location to be chosen by the district leadership and board. These clinics with streamlined to create access and reduced costs at private physician clinics located in strategic areas in Hidalgo County. The majority of the school districts have an increasing trend of Medicaid enrollment rates that exceed 50%. The clinic will be open to treat and care for the school district’s employees, their covered dependents, and the Medicaid student population. Electronic medical records (EMR) will be implemented at the clinic. To ensure that these patients have the most efficient care, and in any response to necessary specialty care, health information exchange technology (HIE) will also be adopted so that a consulting physician has immediate access to the patient’s information. These clinics are intended to meet the “triple aim” of healthcare; reduce costs, improve quality and create an excellent patient experience. The clinic will administer vaccines, intercept early onset of chronic diseases through wellness screenings/labs, provide education on chronic disease management, and directly increase access to a primary care physician and nurse practitioner. An expected outcome will be reduced costs to the district in both funds paid for emergency care, funds paid to treat chronic conditions, and decreases in lost work productivity including absenteeism. Specific attention will be given to those staff and students that have been diagnosed with diabetes and morbid obesity, as these two conditions have been the underlying cause of half of the admissions to hospitals in the Rio Grande Valley. Preferred access will be given at The Joslin Center at Renaissance for the newly diagnosed diabetic patients. The clinics will also be open to the Medicaid population that is in need of primary healthcare. Goals: The primary goal of this project is to establish a school district clinic that will be centrally located for easy access, provide preferred access in certain private physician clinics, reduce absenteeism, and improve health preventative health information. Additionally we are proud to offer access to the Joslin Diabetes Center at Renaissance the only one of its kind in South Texas. The Center treats diabetic patients with protocols development at the world renowned Harvard Medical School as well as provides our community with access to research not otherwise available in our area. The secondary goals of this project will focus on preventable conditions (such as preventing Type II diabetes progressing to Type I diabetes), hospital admissions, and hospital readmissions. Improvement in preventable


conditions and admissions will be facilitated through vaccine administration to help reduce the number of patients coming down with the flu. Hospital readmissions will be reduced through the use of a chronic disease registry that is in place within DHR, electronic medical records (EMR), and a health information exchange tool (HIE), each of which enhance the abilities of primary care providers to manage necessary follow-up care. Challenges/Issues: With thousands of employees and students, maintaining a healthy school district population becomes a challenge through multiple barriers. These include:

• Cost of office co-pays • Inconvenient office hours and locations • General lack of understanding towards a healthy style and preventative healthcare • Parents unable to take time off of work to take their child to a physicians clinic • Lack of follow-up care capability for patients • Apprehension and discomfort discussing personal problems affecting health.

A school-based health center care has been shown to be an important option for reducing these financial and non-financial barriers to health care. These clinics will provide a special attention to obesity as it serves as the major underlying cause of the majority of chronic diseases such as diabetes and hypertension. With such a large percent being disenfranchised from traditional primary health care, chronic conditions are left unmanaged/untreated, vaccinations are not given, and overall healthcare is forgone. Addressing the challenges: DHR is collaborating with the school districts in creating readily accessible primary healthcare clinics. These clinics are founded around the unique barriers that are faced within large school districts to ensure that accessibility, quality, safety, and satisfaction are always at the forefront of healthcare delivery. Primary healthcare will now be made available for those staff members that do not qualify employer provided insurance, students who have no readily available outpatient healthcare, and for those school district members that simply cannot afford to take time off from work to seek primary healthcare. 3-Year Expected Outcomes/Benefits: Expected patient benefits include an expansion of available health care via a consistently available clinic that is designed to reduce the disparities and gap of health care for the staff and children that don’t normally have reliable access to a primary care physician. Community health benefits include a healthier student population, a healthier academic staff, and a model of healthcare that is accessible to thousands from those affiliated within the Edinburg CISD, their dependents. How this project is related to Regional Goals: According to the RHP5 community needs assessment, diabetes has affected the population on a scale that is proportionate to that of an epidemic. When combined with a high level of Medicaid and uninsured population (approximately 63% combined), and a decreased amount of accessibility to primary healthcare, this epidemic can be the single most influential factor in perpetuating an unsustainable healthcare delivery system. Approximately 40% of the families within RHP5 live at or below the federal poverty limit resulting in a working poor social class that is typically disenfranchised and resorts to emergent care as the only means of RHP Plan for [RHP 5/South Texas] 198

healthcare. Within these circumstances, on average, the majority of the school districts within RHP5 have a 50% student Medicaid population. School clinics represent an opportunity for students to receive primary care at the right time within the right setting when they would otherwise forgo this type of care due to financial situations. Increasing primary care access to large school districts addresses community need 1 (CN.1), "expanding primary and specialty care", for a large percentage of disadvantaged students and the surrounding Medicaid population. Starting Point/Baseline: Starting point would begin at the end of DY3 once the clinics have been established and the school district population size can be taken into account. Quantifiable Patient Impact: The QPI will be 1,000 unique patients visits per year which will account for approximately 3,000 patient encounters within the clinics for primary care services. Rationale: RHP5 is historically considered a medically underserved area with high levels of indigent population living at or below the federal poverty line. As a result, this segment of the population is often at the highest risk for developing chronic diseases due to a lack of available primary, preventative healthcare. To improve these conditions Doctors Hospital at Renaissance (DHR) has elected to move forward in collaborations with school districts to create school-based clinics that offer timely, accessible care to those who would otherwise forgo primary care. Each core component is built into the milestone P-2, “Implement a community school-based clinic program”, where hours and locations are taken into consideration so that services remain readily available. Within DY4 and DY5, goals will be to increase patient utilization of the clinics (I-12). This is accomplished through patient population management through the use of EMR. Those patients that have been diagnosed with a chronic disease or symptoms will prioritized to ensure they have the necessary tools available to stabilize and improve. Core Components: a). Expanded Clinic Hours: To ensure that patients can receive care outside normal working hours extended hours will be available on selected days to ensure that the best possible amount of patients are granted access. b). Expand Clinic Locations: School clinics will be established in strategic, readily accessible areas so that students, faculty, and the surrounding population can receive primary healthcare in a convenient manner. c). Expand Clinical Staff: Clinical staff will be established according to the current necessity of the school district's faculty and student population. After DY3, expansion of clinical staff throughout the clinics must be assessed to match the demand for the primary care services and health education. Related Category 3 Outcome Measures: IT-9.2 ED appropriate utilization (Standalone measure)

• Reduce all ED visits (including ACSC) • Reduce pediatric Emergency Department visits (CHIPRA Core Measure)


Measures would be taken to compare the patient base available within Edinburg CISD and compare those patients identification within the EMR at DHR to see who has used the ED within the past two years (FY11 & FY12) to create a trend and baseline.

Relationship to other Projects: This project represents an increase of primary care and an introduction into a type of medical home for the staff/students who wouldn’t otherwise have timely access to these medical services. As this project is established and expands, it will serve as an opportunity for cooperation with other projects such as the residency programs that will have their first cohort of medical residents within 2015, the Joslin Diabetes Clinic, populating the chronic disease registry. The school clinic presents an in depth opportunity for the Medicaid population to receive serves within the numerous specialties available in the DHR system such the Bariatric Institute, Urology Institute, Joslin Diabetes Clinic, Behavioral Center, Rehab Center, and the Cancer Center. Plan for Learning Collaborative: Doctors Hospital at Renaissance will participate in the statewide learning collaborative that is being organized by the Texas Health and Human Services Commission. Every effort will be made to collaborate with the RHP5 anchor in providing any and all results from the implemented projects including lessons learned. All findings will be supported by data and provided in a meaningful manner so that other participating providers can contribute as well. Project Valuation: The scope of the project is main factor taken into consideration when valuing these clinics. Multiple clinical sites will be developed each of which will need clinical and administrative staffing, EMR, supplies, lease agreements, professional liability insurance, etc, etc. The second component of valuation comes from taking into account that majority of students are covered through Medicaid and will be given priority access to these clinics as their method of primary/preventative care. Patients within the clinic will have access to timely vaccinations, medical education on subjects such as diabetes and obesity, each of which can lead to a lifetime of increased, chronic medical conditions.




Provider Name/TPI: Rio Grande Regional Hospital / 112716902 Project Description

1.9.1 - Expand Specialty Care Capacity – Expand Urological Service Capacity Rio Grande Regional Hospital (Rio) intends to expand the provision of specialty care in the region by recruiting one (1) new Urologist. Increased Urological specialty care capacity will allow patients to be seen with less wait times, which will result in better patient outcomes. The Region faces a severe shortage of specialty care physicians. This project aims to increase access to that care, regardless of a patient’s ability to pay.

Intervention(s)

Rio will meet the core requirements of this project by identifying high impact / most impacted specialty service gaps and recruiting a specialist to meet those needs. An additional specialist will provide expanded access to these critical patients. This project will focus on the following milestones:

• [P-1]: Conduct specialty care gap assessment based on community need. • [I-22]: Increase the number of specialist providers in targeted specialties. • [I-23]: Increase specialty care clinic volume of visits and evidence of improved access for patients seeking

services.


This region experiences a shortage of primary and specialty care providers and inadequate access to primary or specialty care (CN.1), inadequate integration of care for individuals with multiple health issues (CN.3), and a lack of patient-centered care (CN.4). An increase of one Urologist will allow more patients to receive care on a more timely basis. Early detection of healthcare problems results in earlier medical intervention and earlier identification and intervention has been shown to lead improved patient outcomes and decreased overall healthcare costs. Addressing this specific shortage in the region should help reduce overall costs by providing ongoing treatment and care management. The current shortage in Urology services often leads to long wait time for appointments.

Target population

This project targets the patient population in the hospital in need of Urology services, regardless of ability to pay. Rio’s Urology department payor mix is comprised of about 40% Medicaid and uninsured patients. Rio expects that this project will have a similar impact on the Medicaid and uninsured population.



Rio expects that, by recruiting an additional Urology provider to the community to expand specialty serve capacity will increase access for the patient population, patient satisfaction and health outcomes will improve.

Patient impact DY3: 90 total patient encounters, of those 36 will be from the Medicaid/uninsured population DY4: 180 total patient encounters, of those 72 will be from the Medicaid/uninsured population DY 5: 180 total patient encounters, of those 72 will be from the Medicaid/uninsured population


IT 3.1 – All Cause 30-day Readmission Rate - Rio expects that increase capacity for Urology services will increase patient interaction with a physician and increased coordination of care; therefore, Rio expects that the patient outcomes will improve and have less risk of readmission. A reduction in the readmission rate will allow the hospital to serve more patients overall, and decrease costs to the overall healthcare delivery system.


Project Narrative


• Title of Project: Expand Specialty Care Capacity – Expand Urological Service Capacity





• Overview of Project: Rio intends to expand the provision of specialty care in the region by recruiting one (1) new Urologist. Increased Urological specialty care capacity will allow patients to be seen with less wait times, which will result in better patient outcomes. The Region faces a severe shortage of specialty-care physicians. This project aims to increase access to that care, regardless of a patient’s ability to pay.

• Project Goals: Rio will recruit one (1) new Urologist, which will expand the provision of specialty care. Through this project, Rio expects to serve 450 additional patient encounters over the course of the Waiver; 40% of those encounters should be with Medicaid or uninsured patients. Rio expects that, by recruiting an additional Urology provider to the community to expand specialty serve capacity will increase access for the patient population, patient satisfaction and health outcomes will improve.

• Challenges or issues faced by the Performing Provider: Rio’s patients often face long wait times for urology appointments. Additionally, there is a greater volume of demand for urology services that Rio can currently provide. Urology is a high acuity area of service for Rio and we do not have sufficient services to cover our demand.

• How the project addresses those challenges: By expanding the availability of specialty care, Rio expects to provide more patient encounters and reduce patient wait-times for appointments.

• 3-year expected outcome for Performing Provider and patients: This project aims to impact approximately 450 patient encounters over the course of the Waiver, 40% of which should be Medicaid or uninsured patients.

• How the project is related to the regional goals: This region experiences a shortage of primary and specialty care providers and inadequate access to primary or specialty care (CN.1), inadequate integration of care for individuals with multiple health issues (CN.3), and a lack of patient-centered care (CN.4). An increase of one Urologist will allow more patients to receive care on a more-timely basis. Early detection of healthcare problems results in earlier medical intervention and earlier identification and intervention has been shown to lead improved patient outcomes and decreased overall healthcare costs. Addressing this specific shortage in the region should help reduce overall costs by providing ongoing treatment and care


management. The current shortage in Urology services often leads to long wait time for appointments.

• Specialty care information (for projects from project option 1.9): All specialty projects should provide

answers to the following questions:

1) Does the project include a clear description of specialties that the initiative is focusing on? This project focuses on increasing urological health services. 2) Are selected specialty areas in high need for the Medicaid/uninsured population? Our disabled and elderly patient population who are eligible for Medicaid have a significant need for urological services. Additionally, uninsured patients often do not have access to a urologist because of high demand. 3) Are high-intensity specialties in areas of high need for the Medicaid/uninsured population? Many Medicaid and uninsured patients cannot get adequate services

In addition, 1.9 projects are required to have two (2) QPI metrics:

• Metric representing total QPI (all patients served): 450 total patients encounters • QPI for the Medicaid/low-income uninsured population: 180 patient encounters



• Quantifiable Patient Impact: Rio will increase the number of specialty care encounters provided. Rio expects that, by recruiting an additional Urology provider to the community to expand specialty serve capacity will increase access for the patient population, patient satisfaction and health outcomes will improve.

o DY3: 90 total patient encounters, of those 36 will be from the Medicaid/uninsured population o DY4: 180 total patient encounters, of those 72 will be from the Medicaid/uninsured population

o DY 5: 180 total patient encounters, of those 72 will be from the Medicaid/uninsured population

• Rationale: This region experiences a shortage of primary and specialty care providers and inadequate

access to primary or specialty care (CN.1), inadequate integration of care for individuals with multiple health issues (CN.3), and a lack of patient-centered care (CN.4). An increase of one Urologist will allow more patients to receive care on a more-timely basis. Early detection of healthcare problems results in earlier medical intervention and earlier identification and intervention has been shown to lead improved patient outcomes and decreased overall healthcare costs. Addressing this specific shortage in the region should help reduce overall costs by providing ongoing treatment and care management. The current shortage in Urology services often leads to long wait time for appointments. This is a new project for Rio. Rio selected the following three milestones:

o [P-1]: Conduct specialty care gap assessment based on community need. o [I-22]: Increase the number of specialist providers in targeted specialties.


o [I-23]: Increase specialty care clinic volume of visits and evidence of improved access for patients seeking services.

Rio selected these milestones because they most closely align with the hospital’s potential to develop a meaningful intervention. This project addresses multiple community needs.


o Rio will accomplish the CQI core components by increase the number of specialist providers, which will increase the number of specialty care encounters provided.


• Related Category 3 Outcome Measure(s): IT 3.1 – All Cause 30-day Readmission Rate - Rio expects that increase capacity for Urology services will increase patient interaction with a physician and increased coordination of care; therefore, Rio expects that the patient outcomes will improve and have less risk of readmission. A reduction in the readmission rate will allow the hospital to serve more patients overall, and decrease costs to the overall healthcare delivery system.

• Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): One other project in the region is focused on increasing urology specialty care, but that project is aimed at pediatric urology and only seeking to add a urologist who will travel to the region five times per month. Rio is trying to recruit a permanent urologist, who will provide services full time in this region. This is the only such project in RHP 5.

• Plan for Learning Collaborative: Rio looks forward to participating in RHP 5’s learning collaborative once the Anchor develops the plan for the learning collaborative. For this project, Rio expects to contribute to discussions regarding improving specialty care and recruiting providers to our region, which are both significant challenges for hospitals in this area.

• Project Valuation: Rio valued this project at $975,000 over the 3 remaining years of the Waiver. This valuation is based on the high acuity and complication rate associated with these specialty services, and cost associated with implementing this project. Rio expects this project’s patient impact to be approximately 40% Medicaid and uninsured patients. This project also meets a key community need concerning access to specialty care.


Tropical Texas Behavioral Health (TTBH) Three Year Projects – Category 2: • Tropical Texas Behavioral Health • Enhance service availability of appropriate levels of behavioral health care • 138708601.2.100

Provider: A brief description of the provider, including the provider’s size and role as a provider in the region’s health care infrastructure.


Intervention(s): Clearly state the intervention(s). This project will expand the availability of substance abuse detox and aftercare services in our local service area through contracts with experienced treatment providers in the Rio Grande Valley (RGV). By supporting the crisis stabilization of medical detox through outpatient substance abuse follow-up care that is integrated with ongoing mental health services, we expect to improve outcomes in the treatment of Co-Occurring Psychiatric and Substance use Disorders (COPSD) for adolescents and adults in the RGV with chronic impairments due to substance use or who experience substance use related crises.


The risk for developing COPSD is elevated for individuals with severe mental illness in comparison to rest of the population and their prognosis significantly worse. The availability of detox and aftercare services in the RGV continues to fall well short of the level of service need. Data from The National Survey on Drug Use and Health and the Texas Department of State Health Services reflect increases in the use of many illicit substances in adolescents and adults throughout the country and the state of Texas, with even higher rates of usage reported in the communities along the U.S./Mexico border, while access to treatment comparatively poor for those living in Southmost Texas.


The project will serve 300 unique persons in DY 3, 360 in DY 4 and 420 unique individuals in DY 5. We estimate 40% of persons to be served will be Medicaid eligible and 52% will be low-income uninsured.


The project seeks to provide necessary routine behavioral health services to individuals waiting for services prior to implementation. The project will serve at least 250 individuals from our waiting lists in DY2, at least 500 individuals by DY3, at least 775 individuals by DY4 and at least 1,050 individuals from our waiting lists by DY5. We will provide transportation to appropriate levels of care to 1,200 individuals in DY 3, 1,400 individuals in DY 4 and 1,600 individuals in DY 5.

Description of Category 3 measure(s): Two outcome measures are being considered pending final information from HHSC and CMS regarding


Category 3: IT-11.27.f: Addiction Severity Index (ASI) and Teen Addiction Severity Index (T-ASI) The ASI is a standardized and validated semi-structured interview that evaluates seven potential problem areas in adult substance-abusing patients. It has been used extensively for treatment planning and outcome evaluation of clinical outcomes. The T-ASI is a valid and reliable standardized instrument for the evaluation of psychoactive substance use in adolescents. It assess changes in the severity ratings of seven age appropriate domains or problem areas in response to the treatment intervention. IT-11.27.d: Adult Needs and Strengths Assessment (ANSA) The ANSA is an effective multi-purpose assessment tool that supports care planning and level of care decision-making for adults with behavioral health (mental health or substance use) challenges, facilitates quality improvement initiatives, and allows for the monitoring of service outcomes. Beginning in September 2013, the Texas Department of State Health Services (DSHS) replaced the Texas Recommended Assessment Guidelines (TRAG) with the ANSA as the instrument used to conduct uniform assessments of individuals seeking behavioral health care through the DSHS system.


Identifying Project and Provider Information: 2.13 Provide an intervention for a targeted behavioral health population to prevent unnecessary use of services in a specified setting (i.e., the criminal justice system, ER, urgent care etc.). Unique RHP Project identification number: 138708601.2.100 Performing Provider/TPI: Tropical Texas Behavioral Health/138708601 Project Option 2.13.1 This project will provide prompt access to inpatient substance abuse detox treatment for individuals with co-occurring mental illness and substance abuse issues in need of acute detoxification; facilitate discharge from inpatient care and a smooth transition to outpatient substance abuse aftercare and integrated mental health and primary care services; and increase opportunities for successful maintenance of abstinence from use of illicit substances and recovery from mental illness. Project Description: This project will expand the availability of substance abuse detox and aftercare services in our local service area through contracts with experienced treatment providers in the Rio Grande Valley (RGV). Upon discharge and referral from inpatient detox, TTBH will coordinate continuity of care referrals to outpatient aftercare service providers and will provide comprehensive outpatient mental health services including specialized services integrating treatment of Co-Occurring Psychiatric and Substance use Disorders (COPSD). Additionally, integrated primary care services may be available to individuals served by this project who lack a medical home. Project goals:

• Increase the number of unique individuals receiving detox services supported by follow-up aftercare and integrated mental health services annually and to at least 420 by DY 5.

• Improve access to the right care at the right time in the right setting. • Improve health outcomes, functional status and the experience of care for persons served. • Decrease utilization of costly emergency interventions including mobile crisis teams, law enforcement

and hospital emergency departments. The project meets the following regional goals:

• Increase the availability of and access to behavioral health services by expanded mental health workforce capacity to help prevent admission/readmission to inpatient psychiatric care.

• Leverage and improve on existing programs and infrastructure to ensure that the health care delivery system will be adequately developed to meet the primary and specialty care needs of residents throughout a rapidly growing, yet historically underserved region.


• Improve the integration of care for people with multiple chronic diseases, including those with co-occurring physical and behavioral health conditions as part of our region’s transformation to a quality-based health care system.

Challenges: Historically the RGV has had a shortage of local detox and aftercare providers in relation to the level of service need, frequently resulting in the requirement that individuals travel outside of the Valley to receive treatment, away from their families and communities; a condition that persists today. The principle challenge to the success of this project is to foster interest in and execute contracts with enough experienced treatment providers to achieve the level of service capacity expansion and continuity of care required to best address the needs of our population locally. Addressed by:


Continuing to leverage longstanding collaborative relationships with local treatment providers. Emphasizing shared goals for those served and the region. Discussing opportunities for training and education between TTBH and contracting partners in areas of shared interest to enhance staff competencies and promote quality improvements. Issuing Requests For Information (RFIs) and Requests For Proposals (RFPs). 3-Year Expected Outcome for Provider and Patients: Through the funding associated with this project we will collaborate with interested and experienced substance abuse treatment providers in the RGV to increase the availability of medical detox services. Upon discharge and referral from inpatient detox we will coordinate continuity of care referrals to outpatient aftercare providers for substance abuse follow-up services. We will also resume delivery of the routine mental health services appropriate for the individual’s level of care. Individuals without a primary care physician or medical home will be assessed to receive integrated primary care services as well. We will increase the number of unique persons served through the project from 300 in DY 3, to 360 in DY 4 and 420 by DY 5. The project will increase access to the right care at the right time in the right setting; increase utilization of routine behavioral health services; and decrease the need for costly and repetitive emergency interventions by mobile crisis teams, law enforcement and hospitals. Using a validated and reliable measure (consideration is being given to the Adult Needs and Strengths Assessment (ANSA) and the Addiction Severity Index (ASI)) we expect to see that reinforcing the stabilizing effects of medical detox with outpatient substance abuse follow-up care that is integrated with comprehensive mental health and primary care services will result in significant improvements in functioning, quality of life and the experience of care for adolescents and adults with chronic and acute co-occurring disorders. Starting Point/Baseline: The baseline for these services is zero. This represents a new initiative for TTBH. Quantifiable Patient Impact: We will increase the number of unique persons receiving inpatient detox and integrated aftercare and COPSD services through the project from 300 in DY 3, to 360 in DY 4 and 420 by the end of DY 5. Rationale: Evidence of an increasing need for substance abuse detox and follow-up services among adolescents and adults across the country, in the state of Texas, and in the state’s border regions including the Rio Grande Valley has been chronicled time and again. In the spring of 2012, the Texas Department of State Health Services, in conjunction with the Public Policy Research Institute at Texas A&M University, conducted its thirteenth biennial Texas School Survey of Substance Use. About 47,791 students in grades 4-6 and 87,293 students in grades 7-12 from 78 school districts across the State were asked to report on their use of alcohol, tobacco, inhalants, illicit drugs, and over-the-counter and prescription-type drugs, as well as student attitudes, extracurricular involvement, sources of information, and other related behaviors. While the report found that use of alcohol, tobacco and illicit drugs such as inhalants, hallucinogens and methamphetamines decreased among Texas youth from 2010 to 2012, marijuana use remained level, with 26.2 percent of secondary school students in 2010 and 2012 reporting lifetime use of marijuana, and nonmedical use of narcotic prescription drugs such as oxycodone and hydrocodone products increased during this period. The same survey conducted in 2010 revealed important regional differences, with students from the border schools reporting higher lifetime and past-month use of tobacco, inhalants, cocaine/crack, Ecstasy, and Rohypnol, and higher current use of alcohol than students living elsewhere in the state. The National Survey on Drug Use and Health (NSDUH) sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) is an annual survey of more than 67,000 persons and the primary source of information on the use of illicit drugs, alcohol, and tobacco in the civilian, non-institutionalized population of the United States aged 12 years old or older. In 2012 the NSDUH reported that from 2008 to 2012, rates of RHP Plan for [RHP 5/South Texas] 209

current drug use among persons aged 12 or older increased from 8.1 percent to 9.2 percent, and from 19.7 percent to 21.3 percent among adults aged 18 to 25, driven largely by an increase in marijuana use. The annual number of persons with substance dependence or abuse rose from 20.6 million in 2011 to 22.2 million in 2012. In 2012, 23.1 million persons aged 12 or older needed treatment for an illicit drug or alcohol use problem (8.9 percent of the population aged 12 or older). Of these, only 2.5 million or 1.0 percent received treatment at a specialty facility. Of the 20.6 million persons aged 12 or older in 2012 who were classified as needing substance use treatment but did not receive treatment at a specialty facility in the past year, 1.1 million (5.4 percent) reported that they felt they needed treatment for their illicit drug or alcohol use problem. Of these 1.1 million persons who felt they needed treatment, 347,000 (31.3 percent) reported that they made an effort to get treatment. Based on combined 2009-2012 data, the primary reason for not receiving treatment among this group of persons was a lack of insurance coverage and inability to pay the cost (38.2 percent). According to FY 2009 data from the Behavioral Health Integrated Provider System (BHIPS), the web-based computer system developed by the Texas Department of State Health Services (DSHS) to track and report demographic, service utilization, and clinical data about substance abuse patients in Texas, of the 1,250 total waitlist entries for residential detoxification services for the 11 healthcare regions across the state, region 11, comprised of 19 counties in Southmost Texas including Hidalgo, Willacy and Cameron Counties, accounted for 79% of the waitlist entries for residential detox services. The gender differential for rates of COPSD in region 11 was 58% female and 42% male, and of the 11 healthcare regions statewide region 11 had the 5th highest number of wait list entries for intensive residential substance abuse services specialized for females. Region 11 ranked 5th out of the eleven regions statewide for the number of adult female substance abuse screenings in the state, 3rd for the number of male youth screenings, was 5th highest for the overall total number of substance abuse screenings (combined screenings for male and female youth and adults) and while the statewide average rate for persons relapsing and being readmitted to COPSD services in 2009 was 10.5%, the rate for region 11 was 13%. Finally, of the 247 counties that reported the number of adult residents admitted to residential or inpatient substance abuse facilities in 2009 Cameron, Starr and Hidalgo Counties ranked 15th, 30th and 32nd respectively. Of the 161 counties that reported the number of adolescent residents with substance abuse admissions in 2009, Hidalgo, Cameron and Starr Counties ranked 10th, 11th and 29th respectively. Aftercare, or continuing care, is the stage following discharge, when the client no longer requires services at the intensity required during primary treatment. Clients continue to reorient their behavior to the ongoing reality of a pro-social, sober lifestyle. Aftercare is essential to recovery. Aftercare enables an individual to remain vigilant as they work toward repairing damaged relationships and achieving life goals. Aftercare programs for adolescents recovering from substance abuse focus on the unique needs of the individuals recovering from drug and/or alcohol abuse/dependence and who need to accept personal responsibility. Such aftercare programs emphasize recovery from the substance abuse/dependence, academic components, responsibility as an integral part of young adulthood, and recreation as an important element of a healthy, balanced life free of drugs or alcohol. In a 2008 report entitled “Promoting continuing care adherence among substance abusers with co-occurring psychiatric disorders following residential treatment” DeMarce, Lash, Stephens, et al. provided support for their assertion that there is growing evidence that continuing care adherence interventions positively impact substance abuse treatment outcomes, especially for individuals with co-occurring psychiatric and substance use disorders. They studied 150 veterans who had received recent residential substance abuse treatment, 51% of whom had one or more co-occurring Axis I or Axis II psychiatric disorders in addition to a substance use diagnosis. The individuals were randomized to receive either a behavioral continuing care adherence intervention (essentially aftercare) involving contracting, prompting and reinforcing attendance (CPR), or standard treatment. They reported that “among individuals RHP Plan for [RHP 5/South Texas] 210

http://www.ncbi.nlm.nih.gov/pubmed/18573617


with co-occurring disorders, those who received the CPR intervention show increased duration of treatment and improved 1-year abstinence rates compared to those who received standard treatment.” They went on to report that “effects of the CPR intervention were generally more pronounced among persons with co-occurring Axis I and/or Axis II disorders than those without these disorders.” The risk for developing of co-occurring substance abuse and dependence disorders is elevated for individuals with severe mental illness in comparison to rest of the population. Evidence also indicates that outcomes for individuals with co-occurring mental and substance use disorders are significantly worse than for those with a mental illness or substance use disorder alone, including higher rates of relapse, medical illness, violence, hospitalization, work and school problems, incarceration, suicide and early death. While the treatment of the mental illness or the substance abuse disorder separately may reduce the risk, lessen the severity or increase a person’s willingness to engage in treatment of the co-occurring disorder, navigating separate and complex systems of care can result in barriers to treatment access and recovery and contribute to relapse. A growing body of evidence has demonstrated that integrated treatment of both disorders results in the best possible outcomes for those with co-occurring disorders. Upon discharge from detox services, in addition to aftercare services TTBH clients served by this project will receive COPSD services that integrate substance use related services with services including psychosocial rehabilitation; cognitive behavioral therapy; prescription medications; supported employment and housing services; and peer supports as clinically indicated. This project addresses the following community needs identified in the RHP 5 Plan:

• CN.2: Shortage of behavioral healthcare professionals and inadequate access to behavioral healthcare • CN.3: Inadequate integration of care for individuals with co-occurring medical and mental illness or

multiple chronic conditions • CN.4: Lack of patient-centered care

Project Core Components:

a) Assess size, characteristics and needs of target population. We will complete a needs assessment to more accurately identify the characteristics and needs of the population in the Rio Grande Valley that will benefit most from improved access to substance abuse detox and aftercare services.

b) Review literature / experience with populations similar to target population to determine community-based interventions that are effective in averting negative outcomes and promote correspondingly positive health and social outcomes/quality of life. We will continue to review literature pertaining to community-based interventions identified as effective in treating co-occurring psychiatric and substance use disorders in populations with characteristics similar to those of our service area.

c) Develop project evaluation plan using qualitative and quantitative metrics to determine outcomes. TTBH will participate in learning collaboratives with the other community centers across the state proposing similar projects and utilize existing internal quality management structures to ensure that qualitative and quantitative metrics are used to measure outcomes.

d) Design models which include an appropriate range of community-based services and residential supports. TTBH will implement a substance abuse treatment model that incorporates inpatient detox combined with outpatient aftercare services to provide the follow-up needed to support the individual's efforts to achieve and maintain abstinence from substances. This will be accomplished by the expanding the availability of these services locally through contracts with experienced treatment providers in the Rio Grande Valley. We will evaluate the interventions using information from stakeholders, other community centers, evaluation metrics, functional assessments and internal reports to determine if they are sufficient in capacity and scope and make quality improvement recommendations to service providers as indicated.


e) Assess the impact of interventions based on standardized quantitative measures and qualitative analysis relevant to the target population. We will research applicable standardized measures for implementation to assess community impact and identify and respond to lessons learned

Customizable Process or Improvement Milestones: NA Related Category 3 Outcome Measure(s): At this time, the following outcome measures are being considered for implementation with this project pending final information from HHSC and CMS regarding Category 3: IT-11.27.f: Addiction Severity Index (ASI) and Teen Addiction Severity Index (T-ASI) According to the National Institutes of Health (NIH), the ASI is a standardized and validated semi-structured interview that can be used effectively to explore problems within any adult group of individuals who report substance abuse as a major problem. It has been used with psychiatrically ill, homeless and prisoner populations. The ASI evaluates seven potential problem areas in substance-abusing patients: medical status, employment and support, drug use, alcohol use, legal status, family/social status, and psychiatric status. The T-ASI is reported to have high clinical utility (Inter-rater reliability of R=.78) and uses a multidimensional approach of assessment as an age-appropriate modification of the ASI. IT-11.27.d: Adult Needs and Strengths Assessment (ANSA) The ANSA is an effective multi-purpose assessment tool that supports care planning and level of care decision-making for adults with behavioral health (mental health or substance use) challenges, facilitates quality improvement initiatives, and allows for the monitoring of service outcomes. Beginning in September 2013, the Texas Department of State Health Services (DSHS) replaced the Texas Recommended Assessment Guidelines (TRAG) with the ANSA as the instrument used to conduct uniform assessments of individuals seeking behavioral health care through the DSHS system. As it relates to this project, we would use the instrument to measure outcomes associated with improved functioning as a result of this intervention across a range of assessment domains including strengths, needs, behaviors and history of psychiatric crises and hospitalizations, in the manner described by the Praed Foundation, developers of the ANSA. Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): Enhancing the availability of substance detox and aftercare services will directly support our project to expand access to comprehensive behavioral health services to more people with co-occurring substance use disorders (project 138708601.1.2) and co-occurring Intellectual and Developmental Disabilities (project 138708601.1.3). Enhancing the availability of medical detox services may lead to the identification of medical issues appropriate for referral to our developing co-located primary care clinics and chronic care management services (projects 138708601.2.1 and 138708601.2.4). Evidence suggests that many of the individuals requiring detox and/or aftercare could have law enforcement involvement and may be eligible for diversion to treatment though our Mental Health Officer Task Force (project 138708601.2.2). The detox and aftercare focus of this project is unique within RHP 5. We will, however, collaborate with Border Region Behavioral Health Center, the Local Mental Health Authority (LMHA) for Starr County; the Rio Grande Valley Council, the local substance abuse Outreach, Screening, Assessment and Referral (OSAR) services provider; and other regional partners as indicated to share information and lessons learned. Plan for Learning Collaborative: TTBH will make its website available for web-based information sharing and reporting. We will request that the Texas Council of Community Centers consider coordinating bi-annual face-to-face meetings between LMHAs involved in similar healthcare transformation projects to promote sharing of challenges and testing of new ideas and solutions. RHP Plan for [RHP 5/South Texas] 212

Project Valuation: • Quality of Life is a key component of our proposed project. According to the Journal of Internal

Medicine, substance abuse treatment services can translate to as much as a 22% improvement in the quality of life of the person served. The quality of life standard value is 50,000 per individual served. Accordingly, the overall value for the proposed integration of substance abuse detox, aftercare and mental health services is calculated to be $11,622,600 by DY 5.

• The valuation estimate for the Category 3 measure was established based on the required minimum percentage of the total project valuation for each of DYs 3, 4 and 5 prescribed in the Program Funding and Mechanics Protocols (10%, 10% and 20% respectively). At this time the total valuation for the proposed Category 3 outcome measure for this project is $1,907,400.



Identifying Project and Provider Information: Title (should include the project option # and description as found in the RHP Planning Protocol): 2.2.1 Redesign the outpatient delivery system to coordinate care for patients with chronic diseases - Implementing HCV Screening and Linkage to Care for Baby Boomers in Primary Care Performing Provider: University of Texas Health Science Center at San Antonio Performing Provider TPI: 085144601 Project ID: 085144601.2.100 Project Summary: Brief provider description, including size of the provider and the role of the provider in the healthcare delivery system in a particular RHP Description of the intervention, Need for the project, Target population including the number of people that will be served by the project and percent that are expected to be Medicaid/low income uninsured individuals, Category 1 or 2 expected patient benefit and a description of the QPI [Quantifiable Patient Impact] metric(s), Description of the Category 3 measure(s) Provider Description: This HCV screening and linkage to care program for baby boomers will build on the developmental work conducted in an ongoing CDC-funded project implementing HCV testing in patients admitted to a safety net hospital. From 12/1/13-9/15/13, this program screened 2,182 boomers with HCV antibody (anti-HCV) and identified 195 (9%) as anti-HCV+. Of these 195 patients, 109 (56%) were HCV RNA+, 60 (32%) HCV RNA-, 23 (13%) HCV RNA not yet done. Of the 109 chronically infected patients, 86% have been linked to primary and/or specialty care. These individuals have received counseling about the adverse effects of alcohol consumption, risky medications (e.g., excessive acetaminophen), and risk reduction in regards to transmitting the disease. They are also tested for HIV and receive immunizations if needed against hepatitis A and B. All of these approaches can slow the progression of disease. In South Texas, our group is one of the first in the country to implement a hepatitis C virus (HCV) screening program for hospitalized baby boomers but we now aim to implement a multifaceted, novel outpatient-based baby boomer HCV screening program and evaluate it in regards to cost and quality outcomes. The settings for this implementation project include 4 diverse primary care practices throughout region 5 serving a varied patient population. Intervention(s): For this project, we will translate tools and lessons learned from this inpatient screening project to implement HCV testing for baby boomers in outpatient primary care practices. This outpatient project is also informed by a CDC funded HCV screening project in an outpatient resident clinic in Atlanta, Georgia where over 2,000 patients have been tested and 65% have received follow-up HCV RNA testing. First, we will educate all providers in the 4 practices participating in this project about the need for and processes to achieve HCV screening of baby boomers. These presentations and educational materials have already been developed. Second, we will develop an electronic medical record (EMR) algorithm to screen patients in a practice for HCV testing eligibility including: birth year 1945-65 and no prior record in the EMR of HCV testing or HCV diagnosis. Eligible individuals will be flagged in the EMR or a list generated of upcoming visits of eligible patient as part of their routine health maintenance requirements and we will develop systems for the practice team to order anti-HCV screening. Third, patients will be informed about national guidelines for HCV screening from posters, flyers, and given the opportunity to opt out of testing. In our current hospital-based program. This approach has resulted in < 10% of patients opting out. Fourth, in 2 of these practices, patients with an anti-HCV+ test will be provided a mobile App RHP Plan for [RHP 5/South Texas] 214

educational program in English or Spanish about HCV infection and its care. In 2 practices, we will offer a web-based version of the educational program to anti-HCV + patients that can be viewed in the practice or logging into a website in the community, or home. We will compare the impact on acceptance of follow-up HCV RNA testing between these two educational approaches. For all practices, personal counseling by a bilingual case manager/counselor will be available to answer questions about HCV and to address alcohol consumption, depression, and barriers to specialty care. A bilingual patient navigator will telephone patients to coordinate follow-up testing and linkage to HCV specialty care. The case manager will ensure that all patients receive recommended preventive care interventions on-site in clinic and counseling for substance abuse and care for depression. All of this will be coordinated closely in conjunction with primary care practice as in the model of the patient-centered medical home. Need for the project: Hepatitis C virus (HCV) is the most common chronic blood borne infection in the U.S (1). An estimated 4 million persons are chronically HCV infected in the U.S. (1).The Centers for Disease Control and Prevention (CDC) and the United States Preventive Services Task Force (USPSTF) both recommend one-time testing of all baby boomers (born 1945 - 1965) for hepatitis C virus (HCV) infection. In the U.S., the majority of persons with chronic HCV infection are baby boomers because an estimated 1.5 M (1.9%) of the 79 M baby boomers have undiagnosed chronic HCV and 3/4 of HCV-infected persons are in this age range. The CDC estimates that baby boomer screening could diagnose >800,000 persons with chronic HCV and prevent 121,000 deaths through anti-viral therapy and other lifestyle changes. HCV testing has been found in several studies to be cost effective due to averting serious, costly complications, most notably end-stage liver disease, liver cancer, and the need for liver transplant. Here in Texas, HCV is the primary reason for liver transplant. Serious complications of chronic HCV infection such as cirrhosis and hepatocellular carcinoma can be mitigated or eliminated by addressing factors that accelerate disease progression such as excessive alcohol use, immunization against hepatitis A and B, and treatment with much more effective “new era” HCV drugs (2). New infections are declining (1, 3) so HCV is concentrated in baby boomers (1945 through 1965). Two recent studies based largely on data estimates from experts support cost-effectiveness of screening baby boomers for HCV infection (4, 5). However, cost-effectiveness studies have not been conducted using data from real-world implementation of new recommendations for one-time screening of baby boomers by both the CDC and the USPSTF (6, 7). This project will address RHP 5 Community Needs (CN) 1, 2 and 6 (see section below for description of how the project will address these needs). Target population (% Medicaid and % Low Income, Uninsured and number of people): Target population includes individuals born from 1945-65. Exclusions include prior HCV diagnosis, any HCV test in the system, dementia, unstable psychiatric disease, or poor prognosis (e.g. metastatic cancer). This project will test at least 30% of the eligible Medicaid or low-income uninsured patients across all these practices. The study sites include group practices and solo practices in the RHP 5 region. Category 1 or 2 expected patient benefits (include Quantifiable Patient Impact metric for each year): Category 2 expected benefits include identifying undiagnosed HCV infection to modify the course of the disease through behavioral changes and if you will eventually to cure the disease through effective HCV therapy. Our goal is to screen 500 baby boomers for HCV antibody in each of our four clinics the first year (QPI DY3 = 2,000). Our goal is to screen 750 baby boomers for HCV in each of our four clinics in the second and third years (QPI DY4 = 3,000; QPI DY5 = 3,000). We will also provide outreach to patients who test positive for HCV antibody. We conservatively expect to find RHP Plan for [RHP 5/South Texas] 215

that 2% of tested persons are positive for anti-HCV. We will provide outreach and engage at least 50% of these individuals in testing for HCV RNA to confirm active infection. We expect to provide outreach through prevention counseling and linkages to care, treatment, and prevention services to approximately 150 patients who are both anti-HCV+ and HCV RNA+ (QPI DY3 = 30; QPI DY4 = 60; QPI DY5 = 60). These 150 patients are targeted because only those who are positive on both the anti-HCV antibody and HCV RNA tests are chronically infected with hepatitis C. Patients who are positive on the anti-HCV antibody test and not positive on the HCV RNA test will be asked to get tested for HCV through the RNA test in three months to confirm that they are clear of the virus. Category 3 outcomes: IT-5.1C: Cost Effectiveness Analysis (CEA); IT-5.1D: Cost Utility Analysis (CUA); IT-5.2: Per episode cost of care Project Description: Describe project, including project goal(s) and challenges or issues faced by the Performing Provider, how the project addresses those challenges, and 3-year expected outcome for Performing Provider and patients. Also describe how the project is related to the regional goals. Project Description: This HCV screening and linkage to care program for baby boomers will build on the infrastructure of an ongoing CDC-funded project to implement HCV testing for inpatients in a safety net setting. For this project, we will translate tools and lessons learned from our team’s inpatient screening project to implement HCV testing for baby boomers in outpatient primary care practices. This outpatient project is also informed by a CDC funded HCV screening project in an outpatient resident clinic in Atlanta, Georgia where over 2,000 patients have been tested and 65% have received follow-up HCV RNA testing. Based on experience and lessons learned from these projects, we will be able to: 1) train staff in HCV screening in the context of the Chronic Care Model, including the essential components of a team-based delivery system that supports high quality clinical and chronic disease care and 2) train appropriate staff on evidence-based clinical protocols for HCV testing within DY3. To facilitate identification of eligible baby boomers, our informatics team will assist the practices in utilizing their electronic medical record (EMR) to include screening protocols. We will also offer practices patient educational materials about HCV have already been developed, including posters and flyers and a mobile app posttest counseling program (all in Spanish and English). A web-based version of this counseling program is under development. We have protocols for the HCV counselors to support patients who were newly identified as being anti-HCV + to promote necessary follow-up HCV RNA testing and, if positive, linkage to specialty care. Our team also has substantial expertise in conducting the cost analyses that will be performed to evaluate cost-effectiveness of this intervention. Project Goals Goal 1) To educate providers about baby boomer HCV screening and processes to achieve this in clinic. Goal 2) To increase the proportion of baby boomers who are aware of being HCV antibody positive. Goal 3) To increase the proportion persons with a HCV RNA+ result who receive prevention counseling and are linked to care, treatment, and prevention services. Challenges and overcoming challenges Challenges include lack of insurance, transportation problems, poor health literacy, mental health disorders (depression) and substance abuse (especially alcohol). We have substantial experience in overcoming these barriers to care including providing patients with reimbursement for transportation through transportation vouchers. We are also addressing poor health literacy with clear explanations about the meaning of HCV infection and the value of taking care of it either by changing risky behaviors or by taking medications to eliminate it. We are providing substance RHP Plan for [RHP 5/South Texas] 216

abuse counseling for those patients who have substance abuse disorders and refer patients with mental health disorders to a mental health specialist. Three-year expected outcome

1) Educate 90% of providers about baby boomer HCV screening and processes to achieve this in clinic.

2) Increase the proportion of baby boomers that are aware of their HCV infection by screening at least 30% of baby boomers with the HCV+ Antibody test

3) Increase the proportion of baby boomers who are tested for HCV through the HCV RNA test who are positive on the anti-HCV+ test

4) Provide 70% of patients with a HCV RNA+ result linkage to care

Related to the regional goals This project is related to numerous RHP 5 goals. It will leverage existing primary care practice infrastructure to ensure that the health care delivery system will be adequately developed to meet the primary and specialty care needs of residents throughout a rapidly growing, yet historically underserved region. This project will increase access to primary and specialty care services for persons with newly diagnosed with a chronic disease through screening individuals born from 1945 – 1965 for Hepatitis C. If tested positive, we will ensure they have access to the most appropriate care for their condition, regardless of where they live or their ability to pay. This project will also transform health care delivery to a patient-centered, coordinated and integrated delivery model that improves patient satisfaction and health outcomes, reduces unnecessary emergency department use and duplicative services, and expands on the accomplishments of our existing health care system. Specialty Care Information: Applies only to projects from project option 1.9. N/A Starting Point/Baseline: e.g., number of clients currently served by project (applies to the existing initiatives, e.g. primary care clinic is already in the existence but the provider will add one more physician to increase access to care and serve more patients); percent of providers trained in project; number of encounters. Indicate time period for baseline. The clinics in South Texas that we will be working with provide comprehensive, primary health and wellness services for Nueces, Cameron and Willacy counties. The clinics respond to the needs of the community by providing quality primary care and prevention services regardless of ability to pay. The target population includes the uninsured and under-served, those below 200% of poverty, migrant and seasonal farmworkers, Hispanics, women and children. The service area ranks as one of the poorest in the nation. As of January, 2013, Su Clinica’s Provider Team consisted of the following Full Time Equivalents (FTEs): Primary Care Physicians (26.65 FTE); Other providers including Nurse Practitioners/Physician Assistants/Certified Nurse Midwives/Podiatrist/Nutritionist/Dietician (13.86 FTE); Dentists and Dental Hygienists (10.41 FTE). Including the Provider Team, Su Clinica has a total staff complement of 380.37 FTEs providing services at six delivery sites (Harlingen, Raymondville [2], Brownsville, and Santa Rosa [2]). Services include: pediatrics, internal medicine, family practice, OB/GYN, Behavioral Health, Dental, minor surgery, podiatry, pharmacy, and WIC services. Outreach, Lab &


x-ray, 24-hour on-call hospital coverage, health professions training, nutrition, health education, social services, case management, integrated eligibility screening, and specialty referral coordination round out the core services. In 2012, Su Clinica served 34,465 unique patients in 1181,413 encounters. Approximately 60% of patients in these participating practices are enrolled in Medicaid or uninsured. Currently, less than 10% of patients in these clinics are estimated to have been screened for HCV. Quantifiable Patient Impact: Description of the project's impact (e.g. how many people a year will be served due to the project). The list of recommended QPI measures can be found at HHSC’s website: http://www.hhsc.state.tx.us/1115-docs/QPImetrics.pdf. If a provider selects a different measure for QPI, the narrative should include a description of why HHSC’s recommended measure does not work for the project. The QPI for this project is related to the number of unique individuals receiving care under chronic care model. We will be impacting approximately 2,000 patients. This includes 30% of patients being screened for HCV with the antibody test, 20% of patients who are tested for HCV through the HCV RNA test after being tested positive on the anti-HCV+ test and the 70% of patients with a HCV RNA+ result who are linked to care. Rationale: In Texas in 2010, there were 5,899,576 baby boomers, very few of whom are unaware of their HCV status. Our inpatient screening program has found that 9% of tested patients are anti-HCV+ and 5% of all tested patients have undiagnosed chronic HCV infection based on both anti-HCV+ and HCV RNA+ tests but no knowledge of this fact. Thus if even 2% of Texas baby boomers have undiagnosed HCV infection, that means 117,991 persons remain to be diagnosed with chronic HCV infection. Among these persons, it takes averting only a small number of liver transplants and care for liver cancer to make the program worthwhile and cost-effective. Current anti-HCV therapy is now much shorter and much more effective – curing over two-thirds of patients. Thus, we can definitely change the course of disease in patients. Explain why the community needs addressed by this project are most pressing and/or the extent to which the identified community need will be addressed by this project. CN.1 – Texas ranks last in the nation in health care quality. This project will implement a new recommended standard preventive care intervention – universal one-time HCV screening of baby boomers. Evaluating a state-of-the-art implementation program and then disseminating it widely will move Texas to the forefront of HCV screening and prevention. CN.2 - A high prevalence of chronic disease and related health disparities require greater prevention efforts and improved management of patients with chronic conditions. Our project will address CN2 by implementing a new standard of care as determined by the USPSTF. An estimated 1.5 million baby boomers in the US have chronic HCV infection and don’t know it. Many of the individuals who were infected come from vulnerable populations. We have found that 5% of baby boomer inpatients in a safety-net hospital have newly diagnosed chronic HCV infection in San Antonio. Therefore, we have excellent evidence that we require greater prevention efforts. CN.6 - High rates of communicable disease and potential for vaccine preventable diseases. HCV is a communicable disease and as noted, we have found that a substantial proportion of baby boomers have undiagnosed HCV infection as predicted by the CDC. It is critical that these individuals be immunized against other forms of hepatitis which can rapidly precipitate more aggressive hepatitis and lead to liver failure. There are important public health implications also because these individuals need to be educated about modifying risky behaviors such as sharing RHP Plan for [RHP 5/South Texas] 218

http://www.hhsc.state.tx.us/1115-docs/QPImetrics.pdf

toothbrushes and rough unprotected sex. Describe how this project addresses one or more of the triple aim goals. This project will address two goals of the Triple Aim goals including improving the patient experience of care (including quality and satisfaction) and reducing the per capita cost of health care. Improving the patient experience of care will be addressed because this project has patient navigation as a component. This project will target patients newly diagnosed with Hepatitis C. We will train and guide case managers and patient navigators (promotoras) to assist these patients with coordinated, timely, and site appropriate health care services. By improving patient navigation, the patient experience will also be improved. Additionally, team-based care will facilitate receipt of necessary preventive services and address barriers to HCV specialty care. Reducing the per capita cost of health care will be addressed by this project as HCV screening and confirmatory testing and education/linkage to care is expected to be at least as cost-effective as routine screening for hypertension or colorectal cancer (4). Averting only a few liver transplants can pay for a substantial number of patients to be treated for HCV infection. With the advent of effective short-term anti-HCV pill-based regimens (70% cure rates), HCV testing becomes very worthwhile. We will conduct a cost-effectiveness analysis of universal one time HCV screening in diverse outpatient settings using primary data to fill the identified gaps in evidence, and also to provide policymakers and stakeholders with information on the costs and health benefits of HCV screening through a refined screening system in such settings. Our analyses will include: primary data from inpatient settings, published literature, public databases, and expert opinion. The primary measure of cost-effectiveness will be incremental costs per QALY gained from the health care system’s perspective because it is paying for the costs of the program. To explore uncertainty around health and cost outcomes, a comprehensive sensitivity analysis will be conducted, including both deterministic (one-way/multi-way and scenario analysis) and probabilistic sensitivity analysis. The findings of the analysis will be highly valuable to guide the implementation and sustainability of HCV testing in similar inpatient settings. We expect to find the cost to be $35,000-$60,000 per QALY gained, from the health care perspective, and a range of $50,000-$100,000 per QALY gained as conventional willingness-to-pay (WTP) thresholds.

Project Core Components: We will apply evidence-based care management models to patients identified as having high risk health care needs. Our HCV screening and linkage to care program has several components. First, we will have an electronic medical record (EMR) algorithm to screen patients for HCV screening eligibility including: birth year 1945-65 and no prior HCV testing or HCV diagnosis in our system. Patients are informed about our HCV screening initiative from posters, flyers, and our promotoras. Based on past experience, we expect <10% refuse our testing program. Patients with an anti-HCV+ test will receive personal counseling by our bilingual counselor and learn about HCV from a mobile App program in English or Spanish developed for this project. Lastly, a bilingual promotora will help chronic HCV+ patients to successfully access needed services and addresses barriers to care including lack of insurance, no usual source of care, transportation, poor health literacy, and substance abuse. Customizable Process or Improvement Milestones: N/A


Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): A narrative describing how this project is similar to other projects implemented or proposed by the same provider, or similar projects by other providers. The narrative should also include a detailed description if the proposed project is similar to another project by the Performing Provider in a different RHP. Providers should specify the differences in the projects.) Please list the related Category 1 and 2 projects with the unique RHP project identification number. Describe how this project supports/complements another RHP 5 project or how it fills a need not otherwise addressed by other RHP 5 projects.

In relation to other projects and interventions within the RHP plan, this project supports, reinforces and enables Increase Training of Primary Care Workforce (1.2), Primary Care Redesign(2.3) and Redesign for Cost Containment (2.5), Patient Navigation (2.9) and Patient Experience (2.4)

Increase Training of Primary Care Workforce (1.2): This project is likely to be unique in our region. Developing a team-based infrastructure to promote recommended screening of baby boomers for chronic HCV, fills a training gap in the implementation of a new expert guideline sanctioned preventive care intervention. We will be training the practice providers, and newly training case managers, and promotoras to support patients in achieving care goals for this challenging condition. Primary Care Redesign(2.3) - This primary care practice redesign project will develop new EMR protocols and reminders as well as team-based protocols to facilitate screening, counseling, and linkage to care of newly diagnosed HCV patients. We are implementing this screening program in diverse types of practices including solo and group practices so that we can develop models that will be generalizable to other settings. Redesign for Cost Containment (2.5): The CDC has found that baby boomer screening for HCV is likely to be cost effective so that this redesign effort is integrating a new preventive care intervention that is likely to contain costs. A major focus of this project will be evaluating in the cost-effectiveness of this approach. Patient Navigation (2.9): This project will target patients who have been newly diagnosed with Hepatitis C. Once these patients are identified, we will train and guide patient navigators (promotoras) to assist the patients at greatest need and provide at-risk patients with coordinated, timely, and site appropriate health care services. By improving patient navigation, the patient experience (2.4) will also be improved. Plan for Learning Collaborative: Describe plans for participating in an RHP-wide and/or statewide learning collaborative with other providers with similar projects. Describe how the learning collaborative will promote sharing of challenges and testing of new ideas and solutions between providers implementing similar projects. The learning collaborative will be formed such that organizations are able to share ideas, challenges and develop solutions. A learning collaborative will bring together participating sites via conference calls once a quarter where project-level goals are discussed and other projects are able to learn. During these meeting, those belonging to the learning collaborative along with others outside of the region are able to share knowledge and participating sites are able to learn from the successes/challenges of other sites. Metrics will be used to measure success of the learning collaborative (e.g. Network affinity, rate of spread). We propose to develop linkages to other groups in the state that are targeting our same population and diseases including St. Luke’s Health System and Scott & White Healthcare in Temple. We will also reach out to other institutions nationwide that have implemented a hepatitis C screening program for baby boomers to learn


from their experiences and to guide our initiatives to improve clinical outcomes: these include Emory University, Baylor University, and other University of Texas institutions. We will continue to collaborate with the Texas Department of State Health Services – TB/HIV/STD/ viral hepatitis unit (Mr. Larry Cuellar). We gave a lecture at a statewide meeting regarding HCV prevention and treatment in convened by the DSHS November 2013. Project Valuation: A narrative that describes the approach for valuing each project and rationale/justification (e.g. size factor, project scope, populations served, community benefit, cost avoidance, addressing priority community need, estimated local funding). Supporting information may be included in the addendums. Cat 1 or 2: Based on previous research, the estimated annual health care costs for patients with chronic hepatitis C infection are approximately $21,453. The average annual cost among patients with end-stage liver disease is $59,995 (8). Health care costs for HCV-infected patients with end-stage liver disease are nearly 2.5 times higher than those in the early stages, according to a Henry Ford Hospital study. If we are able to diagnose even one patient with HCV and stop them from developing end-stage liver disease, we will save thousands of dollars in health care costs. Averting one liver transplant will save nearly half a million dollars (9). Cat 3: Determining the cost effectiveness of this new standard of care as determined by the Institute of Medicine informs clinicians and the general population about the importance of HCV screening and the economic burden that this chronic disease carries. This project meets a key need of chronic disease control and management, fills a gap in the RHP5 DSRIP program for controlling chronic disease by addressing need in Hidalgo County. Lastly, we will serve primarily Medicaid/ low income uninsured population that suffers excessively with chronic disease and poor access to health services.


Pharmaceutical Care Services 160709501.2.102 Doctors Hospital at Renaissance / 160709501 Project Option: 2.11.1 Project Description: Doctors Hospital at Renaissance (DHR) proposes to establish ambulatory care clinics for Medication Therapy Management (MTM) for patients with Type I & II diabetes. The project is designed to improve collaboration among pharmacists, physicians, and other healthcare professionals; enhance communication between patients and their healthcare team; and optimize medication use for improved patient outcomes. The medication therapy management (MTM) services described in this model empower patients to take an active role in managing their medications. The services are dependent upon pharmacists working collaboratively with physicians and other healthcare professionals to optimize medication use in accordance with evidence-based guidelines40. Doctors Hospital at Renaissance in collaboration with the University of Houston will create ambulatory care sites throughout the region in strategically positioned areas that will be ideal for accessibility. Patients with a confirmed diagnosis of Type I and II diabetes will be eligible to receive services. Academic clinical pharmacist faculty, as well as community ambulatory-care clinical pharmacists, will be trained in a diabetes certificate program. After training, these individuals will enroll type I and II diabetic patients to receive pharmaceutical care services. Clinical interventions will include long-term follow-up led by academic clinical pharmacist faculty and ambulatory-care clinical pharmacists using scheduled consultations, clinical assessment, goal setting, monitoring, and collaborative drug therapy management. Goals and Relationship to Regional Goals: The project has the following goals:

• To create ambulatory care sites that provide innovative Medication Therapy Management services • Establish a diabetic medication management certification program. • Have all of the providers within the ambulatory sights complete a diabetes certificate program. • To serve as an access point for medical education, medication assessment, and drug therapy

management. • Increase medication treatment compliance and decrease medication errors.


• By combining the resources of DHR as a major safety net hospital, Joslin Diabetes Center, and The University of Houston, leverage and improve on existing programs and infrastructure to ensure that the pharmaceutical health care delivery system will be properly developed to support the wellbeing of the region as the population continues to grow.

• Nurture ongoing quality improvement and innovation that maximized the use of technology and best-practices to improve access of appropriate care as well as patient compliance with treatment.

• Increase the understanding of socioeconomic barriers that decrease treatment compliance, medication utilization, and increase medication errors.

• Facilitate a culture of ongoing quality improvement and innovation that maximizes the use of technology and best practices to improve access to medication management services.

• Assist patients with chronic conditions in a manner that enhances quality of life and prevents errors in medication management. This is a central mission as medication errors lead to a dramatic increase in

40 American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication therapy management in community pharmacy practice: core elements of an MTM service (version 1.0). J Am Pharm Assoc. 2005;45:573-9. RHP Plan for [RHP 5/South Texas] 222

care needs and makes management of health conditions increasingly difficult and prompts an escalation of preventable conditions, admission, and readmissions.

• Address the public health issues of the fastest-growing, economically and educationally disadvantaged RHP 5 population.

• Address clinical preventive services at the individual patient and community level. Challenges and Issues: Creating a new diabetic-centered Medication Therapy Management program from the ground up is time consuming and requires specialized training and evidence-based clinical guidelines. To ensure success, it will be necessary to recruit new and train care providers and to actively engage the community to participate in the clinic’s programs. Addressing the challenges: DHR and Joslin Diabetes Center will partner with The University of Houston. The University of Houston will provide key faculty throughout the ambulatory care sites including an ambulatory-care clinical pharmacist to manage the collaborative drug therapy. As the patients are admitted into the program, there will be a diabetes certified faculty that will engage in clinical assessments, long-term follow-up, and goal setting that will be monitored to ensure quality improvement within the facility’s patient population. Once the patients are established within the program, barriers to medication compliance can be addressed and medication errors reduced. 3-year expected outcome for Performing Provider and patients: By the end of Demonstration Year 5 (DY5) in September 2016, the ambulatory care sites would have been established and have a large diabetic patient panel would have been enrolled into the medication therapy management program. Through the establishment of these sites, proper technological systems, such as health information exchange, will be in place so that the pharmacist can be in contact with the specialists that are also treating the patients. The creation of a diabetic medication therapy management certification program would have helped local care providers become better informed on the needs of diabetic patients. Patients would have been engaged and become active participants in their overall healthcare needs and medication therapy regiments. As a result, overall medication errors will be decreased as barriers to compliance are addressed, and management programs continue to improve in each of the ambulatory sites. It is our goal that preventable conditions, admissions, and readmissions from medication errors will be greatly reduced for patients enrolled in the program. Additionally, public health events sponsored throughout the community would have led to increase in awareness on the need for medication compliance and patient responsibility. Starting Point/Baseline Doctors Hospital at Renaissance currently operates the Joslin Diabetes Center at Renaissance where patients are referred for endocrinology care. Medication compliance studies will be run on the existing patient panel served by both the Joslin Center and Doctors Hospital at Renaissance. Based on patient encounter data derived from DHR’s combined patient history from FY12, estimates will be calculated on the projected number of patients that can be served by the project. The baseline will be set according to the historical numbers while maintaining a manageable population size. Rationale More than 3.5 billion prescriptions are written annually in the United States, and four out of five patients who visit a physician leave with at least one prescription. Medications are involved in 80 percent of all


treatments and impact every aspect of a patient’s life. The two most commonly identified drug therapy problems in patients receiving comprehensive medication management services are: (1) the patient requires additional drug therapy for prevention, synergistic, or palliative care; and (2) the drug dosages need to be titrated to achieve therapeutic levels that reach the intended therapy goals. When combined with the communication/literacy barriers throughout this region, it can be seen how the indigent population (which is most at risk for diabetes) would have difficulty adhering to drug therapy41. According to the World Health Organization, adherence to therapy for chronic diseases in developed countries averages 50 percent, and the major consequences of poor adherence to therapies are poor health outcomes and increased health care costs. Within RHP5, 30% of the population is Diabetic with over 55% not on any treatment what so ever. According to the American Diabetes Association42, patients for whom diabetes medication was prescribed were poor compliers with treatment, including both oral hypoglycemic agents and insulin. Project Components • Implement a medication management program that serves the patient across the continuum of care

targeting one or more chronic disease patient populations. • Implement pharmacist-led chronic disease medication management services in collaboration with

primary care and other health care providers. • Train the providers in a diabetes certificate program such as the programs offered by the American

Association of Diabetes Educators

Establish an ambulatory clinic that integrates the five core elements recommended by the American Pharmacists Association and the National Association of Chain Drug Stores Federation for the delivery of MTM services in an ambulatory setting. Every core element is integral to the provision of MTM; however, the sequence and delivery of the core elements may be modified to meet an individual patient’s needs. • Medication Therapy Review: The medication therapy review (MTR) is a systematic process of

collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them.

• Personal Medication Record: The personal medication record (PMR) is a comprehensive record of the patient’s medications (prescription and nonprescription medications, herbal products, and other dietary supplements).

• Medication-Related Action Plan: The medication-related action plan (MAP) is a patient centric document containing a list of actions for the patient to use in tracking progress for self-management.

• Intervention and/or Referral: The pharmacist provides consultative services and intervenes to address medication-related problems; when necessary, the pharmacist refers the patient to a physician or other healthcare professional.

• Documentation and Follow-up: MTM services are documented in a consistent manner, and a follow-up MTM visit is scheduled based on the patient’s medication-related needs, or the patient is transitioned from one care setting to another.

Unique community need identification number the project addresses: • CN.1 – Diabetes & Obesity: This project will be focused on the medication management and treatment

programs for the diabetic population with Type I and Type II Diabetes.

41 Department of Medicine, University of Virginia: http://www.ncbi.nlm.nih.gov/pubmed/12032108 42Yale University School of Medicine: http://care.diabetesjournals.org/content/27/5/1218.long RHP Plan for [RHP 5/South Texas] 224


http://care.diabetesjournals.org/content/27/5/1218.long

How the project represents a new initiative or significantly enhances an existing delivery system reform initiative: Currently RHP5 has limited comprehensive care initiatives regarding patients, especially diabetics. One of the best comprehensive care models that is available to diabetic patients within this region is the Joslin Diabetes Center which brings in the patients, clinically assesses them, educates them, maintains follow-ups, and tries to address the barriers to treatment compliance. This project will significantly enhance that model on the medication front by expanding availability through multiple sites that are aimed specifically towards clinical assessments, monitoring, and collaborative drug therapy management. Data Driving this Project: Medication-related problems are a significant public health issue within the healthcare system. Incidence estimates suggest that more than 1.5 million preventable medication-related adverse events occur each year in the United States, accounting for an excess of $177 billion in terms of medication-related morbidity and mortality43,44. The Institute of Medicine advocates that healthcare should be safe, effective, patient-centered, timely, efficient, and effective to meet patients’ needs and that patients should be active participants in the healthcare process to prevent medication-related problems.45, 46 In its 2003 report on medication adherence,47 the World Health Organization (WHO) quoted the statement by Haynes et al that “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.” The need for enhanced care services for Hispanic populations is extensively documented. Data published by the United States Census Bureau in 2012 show that 88% (Cameron County) and 91% (Hidalgo County) of the population is Mexican American or Latino in origin and that 35% live below the poverty line, compared with 17% for Texas and 14% nationally (http://quickfacts.census.gov/qfd/states/00000.html). Currently about 65% of RHP 5 residents have health insurance of some kind, more than half of which is Medicare or Medicaid. Obesity is the underlying and exacerbating issue. Published data (Fisher-Hoch et al, 2012) from UT’s locally recruited, randomized community cohort show that the prevalence of obesity is 48% and that 8% are morbidly obese. The prevalence of diabetes is an alarming 31% in adults 18 years or over. Eighty-four percent of those with hypertension are diagnosed, but only half of those with diabetes or hypercholesterolemia are diagnosed and under care. Many participants with diabetes (55%) and hypertension (50%) are untreated as are 85% of those with hypercholesterolemia. Multiple complications of diabetes and obesity include renal failure requiring dialysis, and heart failure, and at least 12% have evidence of liver disease associated with obesity and diabetes leading to liver failure and liver cancer. Given these alarming health statistics, it is clear that a medication management program that helps one of the largest concentrations of diabetic patients will have a substantial impact on overall health of RHP 5. Related Category 3 Outcome Measure(s): IT-1.10 Diabetes Care: HbA1c poor control (>9.0%) – Stand-alone measure Rationale for selecting the outcome measure:

43 Ernst FR, Grizzle AJ. Drug-related morbidity and mortality: updating the cost-of-illness model. J Am Pharm Assoc. 2001;41:192-9. 44 Institute of Medicine. Report Brief: Preventing Medication Errors. Washington, DC: Institute of Medicine; July 2006. http://www.iom.edu/~/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.pdf 45 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: Institute of Medicine; 2001. 46 Institute of Medicine. Report Brief: Preventing Medication Errors. Washington, DC: Institute of Medicine; July 2006. http://www.iom.edu/~/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.pdf 47 Sabaté E, editor. , ed. Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization; 2003. RHP Plan for [RHP 5/South Texas] 225

http://www.iom.edu/%7E/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.pdf



While this project focuses on the medication side of diabetes control, studies show that poor adherence to therapies lead to poor health outcomes and increased healthcare costs. The diabetic population that this project is serving is the indigent and Medicaid population, which is also the population segment that has a higher prevalence of diabetes. With improved management over medication therapy plans, education, and long-term follow-ups, patients will have the tools and support necessary to improve on their conditions thereby improving on the HbA1c levels. Relationship to other Projects: This project ties into the following projects:

• Diabetic Behavioral Health: 160709201.1.108 • Diabetic Eye Clinic: 160709501.1.103 These projects are each related to each other in the fact that they are all intended to support each other’s goals of improving overall outcomes for diabetic patients. If any one of their patient bases is in need of other projects services a referral relationship will have been established so services are rendered in a timely fashion.

Plan for Learning Collaborative: This project serves as a point of access to pharmaceutical treatment, clinical assessment, and long-term management. It also serves as part of a bigger picture in which other projects test innovative models of care that move away from episodic treatment toward a more integrated and coordinated approach centered on the patient’s whole-person needs and health outcomes. Such projects will come together with other related projects that take this approach. Projects that revolve behavior health and understanding why patients deviate from treatment plans will be able to learn from each-other to address these issues in efforts to accelerate true transformation. Once patient referral patterns are established and significant data is collected, quarterly meeting will be able to be facilitated with other healthcare providers across the state in an effort for shared learning.

Project Valuation: This project’s impact on children and families in RHP 5 will be profound. Medication Therapy Management programs in RHP 5, one of the most literacy-challenged and diabetic regions in the nation have the potential to permanently alter the healthcare landscape in the Rio Grande Valley. Once established, healthcare teams will be able to use advanced insulin therapies and other medication regiments presently unavailable for countless patients due to low-literacy levels and socioeconomic barriers. Increased medication adherence will help avoid costly re-admissions, increased morbidity of chronic conditions, and preventable admissions. Together, healthcare providers and patients can work together to deliver the right care, at the right time, in the right setting. Therefore, we believe that this project’s value is equivalent to that of other already approved DSRIP projects.


Behavioral Health Expansion for Diabetic Population 160709501.1.108 Doctors Hospital at Renaissance / 160709501 Project Option: 1.12.2 Project Description: Doctors Hospital at Renaissance (DHR) in combination is proposing to collaborate with the University of Houston (UH) in expanding behavioral health services focused on the prevention and treatment of diabetes, and diabetes related illness. These services will also be provided to the surrounding community with a special focus on the Medicaid population depending on program availability. The University of Houston (UH) will be collaborating on the project through utilizing their resources within the Graduate College of Social Work, the Department of Health and Human Services, the Texas Obesity Research Center, and the Department of Psychology at the University of Houston, and the Behavior Analysis Program at the University of Houston-Clear Lake. Each of these groups has expertise related to behavioral aspects of health maintenance and disease prevention related to diabetes and to comorbid conditions that affect management of patients with diabetes. These groups will work together along with the physicians at DHR and the Joslin Diabetes Center to develop customized behavioral interventions for patients with Type I and Type II diabetes to address the myriad social, behavioral, and social factors that affect treatment, treatment compliance, and disease progression. Once said patients are placed within this system of care, underlying behavior causalities will be assessed to determine root causes for uncontrolled diabetes such as eating habits/disorders, exercise routine, and adherence to medication treatment plans. Goals:

The primary goal of this project is expanding behavioral health specifically for the diabetic patient population. Studies show that there is a relation of depression and diabetes self-care, medication adherence, and preventive care48, however there are not many in-depth studies regarding the mental condition of a diabetic patient within the RHP5 sociodemographic and how it relates to depression, denial, anger, and anxiety. This outreach project improves access to behavioral care to an at-risk Medicaid / Indigent care population and provides invaluable information on how providers can better treat patients. Thus, expansion of behavioral health provides an over-arching framework for the intervention by which cognitive-behavioral strategies can be implemented to improve diabetic individuals’ ability to identify stressors, appraise the level of changeability, and match this level with an appropriate coping response, ultimately leading to a reduction in depressive and anxious symptoms. After patients have had an opportunity for behavioral health evaluations, set criteria will determine the next plan of action for each patient. After addressing the primary goal of behavioral health expansion, the secondary goal of this project is to increase patient outcomes as it relates to the primary care treatment plans. Outcomes include improved medication compliance, HbA1c levels, and hospital admission rates for those patients enrolled within the program.

48 American Diabetes Association: http://care.diabetesjournals.org/content/27/9/2154.full


http://care.diabetesjournals.org/content/27/9/2154.full

Challenges/Issues: The population of the Rio Grande Valley region of Texas experiences significant health risks due to the high incidence of diabetes and obesity. Prevention and treatment of these conditions is most effective when both medical, behavioral, and social factors are taken into consideration. At the same time, there is a shortage of professionals in the region who can address the behavioral and social components of treatment, and a shortage of personnel in some medical professions. The University of Houston and University of Houston-Clear Lake are uniquely qualified and poised to partner with Doctors Hospital at Renaissance (DHR) to offer comprehensive programs to treat these conditions and to develop programs for prevention and education to help lower their incidence in this population, and thereby increase the cost-effectiveness of health care in the valley. The Centers for Disease Control and Prevention (CDC) continue to report an increasing prevalence of Type 2 Diabetes in the United States. In 2008, the number of patients diagnosed with Type 2 diabetes rose sharply across Texas, perhaps suggesting a worsening epidemic, but also a greater awareness of diabetes risks and more aggressive diagnosing. Patients diagnosed with diabetes often have their own mental health care issues apart from the general population. The most common diagnosis within the diabetic population is depression and obesity eating disorders. Depression occurs among individuals with diabetes twice as frequently as in the general population (NIMH), and diabetes and depression are believed to have a reciprocally influencing relationship to each other. Depression among patients with diabetes is associated with suboptimum glycemic control, poorer treatment adherence, and increases in diabetes complications, thus exacerbating diabetic and related conditions. Typically depression is developed through patient-initiated behaviors that are difficult to maintain such as exercise, diet, and medication adherence. This creates a strain on behavioral health care demand as many behavioral providers do not have the background to fully comprehend the issues at hand regarding diabetes. This project aims to help increase access to this patient base and better understand the mental conditions of patients that have been diagnosed with diabetes to better understand this disease in efforts to treat it. Addressing Challenges: Diabetic patients face unique circumstances that affect their mental health. Often times there are a gap between healthcare availability working together with their primary healthcare. This project focuses on closing that gap by providing diabetic healthcare in collaboration with the specialty care that is provided within the Joslin Diabetes Clinic. Realignment of these resources in combination with process improvements will promote better outcomes through the treatment regimes prescribed to each individual patient. 3-Year Expected Outcomes/Benefits: This project is unique as not only does it increase the accessibility of mental health care, it is segmented towards understanding behaviors that are associated with diabetic patients. This increase of access and understanding will allow the providers determine the root causes of these behaviors to help patients cope with their conditions and eventually move towards a model of


self-management. Benefits of this project are derived from an increased availability of behavioral health care in efforts to understand and influence patient’s behavior in regards to eating, exercise, and medication plan adherence. By the end of DY3 key staff and protocols will be in place so that qualifying patients can be enrolled in the program. Within DY4 and DY5 patient services will continue to expand in volume to demonstrate an increased availability of behavioral health services for the Medicaid/indigent patient population. How this project is related to regional goals: According to the RHP5 community needs assessment, diabetes has affected it's population on a scale that is proportionate to that of an epidemic. When combined with a high level of Medicaid and uninsured population (approximately 63% combined), this epidemic can be the single most influential factor in perpetuating an unsustainable healthcare delivery system. Behavioral health is often left untreated with primary care, creating gaps in care that are often left unknown and untreated by the providers. Through organizational realignment and process improvement, behavioral health is integrated within the primary/specialty point of care to address underlying issues that may be hindering patient adherence to care plans. As access to the type of care model increases, patient outcomes are expected to improve, hospital admissions decrease, inappropriate use of the emergency department decreases, and patients’ comorbidities become manageable improving their quality of life. Starting Point/Baseline: The starting point of the project will be set at the end of DY3 once the behavioral service line has been established and staffed. The patient baseline is based off of the number of patient encounters that are serviced by the behavior health provider to demonstrate an increase of service availability. Quantifiable Patient Impact: Once the clinic becomes fully operational, 300 qualifying patients will be impacted per year. The clinic is focused on comprising its capacity with the Medicaid and indigent population. Increases in individual patient volumes will be dependent on capacity of the behavioral health providers to maintain a responsible, manageable patient panel. Rationale: This project option has been selected to increase access to behavioral health to a specific patient demographic that is afflicted by the predominant underlying comorbidity, diabetes and improved on community need 2, expansion of behavioral health services. Collaboration with the University of Houston and DHR enables the program to be developed efficiently so that the patient population seen within DHR (over 50,000 patients a year) and within the Joslin Diabetes Clinic will have access to services by the end of DY3. UH proposes to provide training to appropriate health professionals at the Joslin Center to increase the availability of depression-related mental health services in the region. The psychologists will provide a range of individual


and group based services that are evidence based, while health professionals at the Joslin Center will be trained in group based Cognitive Behavioral Stress Management (CBSM). CBSM will address the following domains: (a) overview of stress and depressive and anxious symptoms; (b) selection and implementation of appropriate coping strategies; (c) provide depression and anxiety reduction skills; (d) modify cognitive appraisals of stressful situations using cognitive restructuring; (e) improve interpersonal communication and conflict resolution skills; (f) increase utilization of social support resources; and (g) relaxation training. By DY4, patient panels can be improved on within the limitations of the provider capacity. Although HHSC did not stipulate any type of core components for this project option, hours and location has been selected to increase the availability of access to the targeted patients. Milestones have been chosen to demonstrate project implementation and will be reported on to demonstrate an improved access to healthcare. Core Components: This project does not have any mandated core components. Related Category 3 Outcome Measures: The patient population that primarily comprises project utilization stems from patients seen within DHR and at the Joslin Diabetes Clinic including those patients that have turned to the emergency department (ED) as a method of primary care and condition stabilization. Through the use of electronic medical records, those patients that have inappropriately utilized ED services will be managed and tracked to assess the effectiveness of their participation within this new program. The following represents the HHSC language that reviews the category 3 outcome measure: IT-9.2 ED appropriate utilization (Standalone measure) • Reduce all ED visits (including ACSC)271 • Reduce pediatric Emergency Department visits (CHIPRA Core Measure)272 • Reduce Emergency Department visits for target conditions

o Congestive Heart Failure o Diabetes o End Stage Renal Disease o Cardiovascular Disease /Hypertension o Behavioral Health/Substance Abuse o Chronic Obstructive Pulmonary Disease o Asthma

Relationship to other Projects: Expanding behavioral health services for the diabetic patients directly impacts and is related to the following projects:

• Joslin Diabetes Clinical Expansion [160709501.1.102]


• Pharmaceutical Care Services for Diabetic Patients [160709501.2.102] • Diabetic Eye Clinic [160709501.1.104]

Each project is intended to expand services to the Medicaid diabetic population. Within these projects, it is projected that a percentage of the patients will have a necessity for behavioral health services to improve their overall outcomes. Plan for Learning Collaborative: Doctors Hospital at Renaissance will participate in the statewide learning collaborative that is being organized by the Texas Health and Human Services Commission. Every effort will be made to collaborate with the RHP5 anchor in providing any and all results from the implemented projects including lessons learned. All findings will be supported by data and provided in a meaningful manner so that other participating providers can contribute as well. Project Valuation: Project valuation is derived from the hard costs of implementing and running a fully functional clinic that is equipped, supplied, and staffed to ensure that patient services can be expanded over the years to influence more positive outcomes. The most important variable taken into consideration throughout project valuation is scope of the patient population which this project is intended to serve. These patients include diabetic patients that are on Medicaid and those that are uninsured.


Project Title: Expand Primary Care Capacity: Expand existing primary care capacity Unique RHP Project ID number: 094113001.1.102 Performing Provider/TPI: South Texas Health System / 094113001 Project Option: 1.1.2 Project Core Components: 1.1.2.a-c

PROJECT SUMMARY

Provider Description

South Texas Health System (STHS) consists of McAllen Medical Center, McAllen Heart Hospital, Edinburg Regional Medical Center/Edinburg Children’s Hospital, and South Texas Behavioral Hospital. In addition, STHS is associated and works closely with Cornerstone Regional Hospital (50:50 JV local physicians) & McAllen Medical Center Physicians (501A). As a system, STHS is one licensed hospital with four campus locations. Total licensed beds are 848. The primary market area is Hidalgo County in South Texas on the US/Mexico border. Secondary market are includes the surrounding counties of Cameron, Brooks, and Starr.

Project Description

Under project Option 1.1.2, the goal of this project is to increase primary care access and capacity by expanding and restructuring clinic hours, decreasing the amount of time for patients to obtain appointments, and by enhancing same‐day walk‐in clinics to accommodate patients with acute illnesses and/or in need of preventive care. This project will expand the capacity of primary care to better accommodate the needs of the regional patient population and community. Expanding providers in our extended hour clinics will improve access and care for patients. Valley Care Clinics is the area’s preferred multi-specialty medical group, 85 physicians and mid-levels representing 6 specialties in 17 clinic locations. VCC provides almost 24,000 visits and 41,000 procedures, Medicaid and self-pay represents nearly 24% of VCCs total volume, and the costs to treat those patients was over $3 million. Intervention(s)

Goal is to expand and enhance primary care with a minimum of 10 full time providers, physicians and mid-levels, to open access and lower wait time. Clinic hours and additional locations will be enhanced based on the demand for services, access to providers, wait time for appointments, and gap analysis providing additional new access capacity.



Shortage of primary care providers has resulted in a waiting list for Medicaid and Medicare patients and extremely limited access for uninsured patients. As cited in the community needs assessment, the region experiences: a shortage of primary and specialty care providers (CN.1), inadequate integration of care for individuals with multiple health issues (CN.3), and a lack of patient-centered care (CN.4). The clinic would help a market struggling to meet the primary care needs of its population. South Texans experience extreme levels of economic and health disparities that are exacerbated by low levels of health insurance, including a lack of access to and utilization of needed health care services. The South Texas area faces a shortage of primary care professionals to serve a growing population, with only half to three-quarters of the physician-to-population ratios of Texas for primary care specialists (e.g., family practice, general practice, OB/GYN). Many residents seek primary care in the ED, or let their conditions go untreated, which puts the patient at increased risk of needing ED or acute care services. This project would establish a new primary care clinic so that patients can receive more preventative, primary and chronic care in order to stay healthy and out of the ED/hospital.

Target population

We anticipate at least 1,000 additional patient visits will be achieved by DY 3. Openings will be available to all patients with an expectation that 40% of the patient population will be Medicaid and/or uninsured. Expected impact (total patients per year): DY3-1,000, DY4-1,250, DY5-1,500 primary care encounters.


VCC will hire 10 additional physicians and mid‐level staff by DY 3, and will increase extended hours during the evenings and weekends. Space availability will be determined and measures implemented to best accommodate the patient population. Additional expansion will occur using current providers who will extend their work days. As the largest provider of primary care in Region 5 this will address the need for additional primary care capacity. For reporting purposes the following visits are anticipated patients would benefit from increased access to preventative, primary and chronic care, reduced risk of delayed or forgone needed treatment, right care at the right time in the right setting, improved preventative tests/screening/vaccination rates, improved chronic care management, Improved patient care, improved health outcomes, more patient-centered care and reduced need for ED/hospital services. Quantifiable patient impact milestones are to provide: DY3-1,000; DY4-1,250, DY5-1,500 primary care encounters (QPI metric I-12.1: Documentation of increased number of visits).


IT‐6.1 Percent improvement over baseline of patient satisfaction scores is the outcome measure.

Surveys provide feedback on accessing care in our facilities, set benchmarks, and trends over time. Our goal will be to identify predictors of patient satisfaction and experience with access to primary care using the M3 survey.


Project Title: 1.1.2 Expand existing primary care capacity. Unique Project ID: 094113001.1.102 Performing Provider Name/TPI: South Texas Health System / 094113001 Project Components: 1.1.2.a-c

Project Description: Under project option 1.1.2, the goal of this project is to increase primary care access and capacity by expanding and restructuring clinic hours, decreasing the amount of time for patients to obtain appointments, and by enhancing same‐day walk‐in clinics to accommodate patients with acute illnesses and/or in need of preventive care. This project will expand the capacity of primary care to better accommodate the needs of the regional patient population and community. Expanding providers in our extended hour clinics will improve access and care for patients. Valley Care Clinics is the area’s preferred multi-specialty medical group, 85 physicians and mid-levels representing 6 specialties in 17 clinic locations. VCC provides almost 24,000 visits and 41,000 procedures, Medicaid and self-pay represents nearly 24% of VCCs total volume, and the costs to treat those patients was over $3 million. Project Goals: The project goal is to expand the capacity of, and access to primary care in the clinic setting for residents of Hidalgo County. This expansion would better accommodate the needs of the regional patient population and community, as identified by the RHP needs assessment, so that patients have enhanced access to services, allowing them to receive the right care at the right time in the right setting. Regional Goals: This project would meet the region’s first two goals – to leverage existing infrastructure to meet the region’s primary care needs, and to increase access to primary care.

Challenges: The primary care initiative would help a market that is deficient in primary care providers, and maintains a high level of Medicaid and/or unfunded population. As a result, the population suffers from access to primary care, a lack of patient compliance with treatment plans, and an epidemic of disease states such as obesity, and diabetes. These challenges can be addressed by making access to care available in an inviting atmosphere that encourages the development of the patient/physician relationship relating to the patient’s culture and language. Starting Point/Baseline: Hidalgo County is a medically underserved region with primary care falling under that category. GMNEC data statistics support the need for additional PCPs in our service area. We currently only have 3 Family Practice Physicians and 1 Family Practice Midlevel. An aggressive physician recruitment plan has been approved and recruitment efforts are under way. The additional PCPs will be recruited to an existing practice. The clinic provides 10,000 primary care encounters per year (as of 2013). Quantifiable Patient Impact:


We have selected QPI metric I-12.1: Documentation of increased number of visits, consistent with HHSC’s recommended QPI measure for this project option. The project expands primary care capacity so that residents have increased access to primary care services, as evidenced by an anticipated additional 1,000 primary care encounters in DY 3, 1,250 primary care encounters in DY 4 and 1,500 in DY 5. Rationale: The region faces a shortage of primary care professionals to serve a growing population, lagging behind Texas in the supply of PCPs. The current PCP payer mix is 70% Medicaid, indigent, and self-pay. Much of the region is medically underserved. Low-income and minority women and children tend to suffer from poorer health. Following national trends, we intend to open access to healthcare to that segment of the population that has previously not developed a relationship with a PCP. Milestones & Metrics: We plan to implement the following process and improvement milestones: DY3: P-1.1: Establish additional or expand at least 1 primary care clinic. P-1.2: One clinic with expanded primary care space. P-2.2: Expand into 1 community/school-based clinic program. I-12 (I-12.1): provide at least 1,000 primary care visits. DY 4: P-5.1: At least 5 additional PCP providers. I-11.1: Maintain at least 95% satisfaction overall rating with primary care services. I-12 (I-12.1): provide at least 1,250 additional primary care visits. DY5: P-1: Establish additional or expand at least 1 primary clinic. P-5.2- Documentation of training in diabetes and obesity for PCPs. I-12 (I-12.1): provide at least 1,500 additional primary care visits. Unique Community Need Identification Numbers the Project Addresses:


• CN.3 – Inadequate integration of care for individuals with co-occurring medical and mental illness or multiple chronic conditions

• CN.4 – Lack of Patient-Centered Care How the Project Represents a New Initiative or Significantly Enhances an Existing Delivery System Reform Initiative: This is a new initiative with no related activities that are funded by the U.S Department of Health and Human Services. Project components:


This project will address the required core component in Project Option 1.2.1, as detailed in the RHP Planning Protocol: a) P-1- (Establish additional, or expand existing primary care clinics)

b) P-2 ( Implement/expand a community/ school-based clinics program) c) I-11 ( Patient satisfaction with primary care services)

Customizable Process or Improvement Milestones: N/A Related Category 3 Outcome Measure: We have selected the following outcome measure: IT‐6.1 Percent improvement over baseline of patient satisfaction scores is the outcome measure. Surveys provide feedback on accessing care in our facilities, set benchmarks, and trends over time. Our goal will be to identify predictors of patient satisfaction and experience with access to primary care using the M3 survey. Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): Relationship to Other Projects: One of our other DSRIP projects is also focused on improving primary care by adding addition Family Practice Physicians and Mid-levels. Additionally, this project would support population health improvements in Category 4.

Relationship to Other Performing Providers’ Projects in the RHP: This project focuses on the expansion of labor and delivery capacity along with these other Category 1 projects in our RHP: 121805903.1.1-Establish More Primary Clinics-Pediatrics. Plan for Learning Collaborative. We plan to participate in the statewide learning collaborative. Our participation in a collaborative will facilitate sharing of challenges and testing of new ideas and solutions to promote continuous quality improvement in our health care system.

Project Valuation: The addition of Primary Care will expand our capacity to better accommodate the needs of the regional patient population and community, as identified by the RHP needs assessment, so that patients have enhanced access to services, allowing them to receive the right care at the right time in the right setting. In our current system, more often than not, patients receive services in urgent and emergent care settings for conditions that could be managed in a more coordinated manner if provided in the primary care setting. This often results in more costly, less coordinated care and a lack of appropriate follow-up care. By enhancing access points, available appointment times, and patient awareness of available services patients and their families will align themselves with the primary care system resulting in better health outcomes, patient satisfaction, and appropriate utilization and reduced cost of services. Texas has the highest percentage of uninsured in the nation at 23.8%. Hidalgo County is the 4th fastest growing and is among the largest counties in Texas. Hidalgo County Medicaid population is 107,000 with the uninsured population just over 80,000. The Community Needs Assessment clearly supports the needs for this project. Access Barriers (lack of personal resources and lack of


insurance), and primary care physician shortage. Because of the demonstrated need of primary care, high Medicaid population, and explosive growth in the community – it was evident that this addition would add value to the community.



Unique Project Identifier:

085144601.1.101

Provider Name/TPI: The University of Texas Health Science Center at San Antonio/085144601

Provider Description The University of Texas Health Science Center at San Antonio serves San Antonio and the 50,000 square-mile area of South Texas. It extends to campuses in the metropolitan border communities of Laredo and the Rio Grande Valley. More than 3,000 students a year train in an environment that involves more than 100 affiliated hospitals, clinics and health care facilities in South Texas.

Intervention(s) Cancer Grand Rounds and Consults Project Option 1.7.5 Use telehealth services to provide medical education and specialized training for targeted professionals in remote locations. We will also incorporate Project Option 1.7.6 Implement an electronic consult or electronic referral processing system to increase efficiency of specialty referral process by enabling specialists to provide advice and guidance to primary care physicians that will address their questions without the need for face-to-face visits when medically appropriate. This project is designed to educate health professionals in RHP 5 with regard to early diagnosis and treatment of cancer, especially those cancers which have a higher incidence and mortality rate among Hispanics. Primary care professionals will be the focus but the programs will also be open to all local health care providers. Using telehealth (teleconferences, video conferences, online transmission), experts from the Cancer Treatment and Research Center (CTRC) at UTHSCSA will conduct Grand Rounds for physicians, physician assistants, and nurses in RHP 5. Videoconferences will take place at sites in Cameron and Hidalgo Counties using facilities at UT Brownsville, UT Pan Am and the UT Regional Academic Health Center. We will open the conferences to local health departments, FQHCs and other safety net clinics, as well as physicians in private practice. The conferences will meet the requirements for professional Continuing Education for nurses, physician assistants, and physicians. The videoconferences will also be available on the internet for health professionals in Starr and Willacy Counties. In addition, CTRC and UTHSCSA physicians will make themselves available for electronic consults and commit to performing necessary diagnostic or therapeutic procedures as necessary after electronic consults.



In Fall 2013, “A Comprehensive Report on Cancer among Hispanics in Texas” was published in the Texas Public Health Journal. The report found that “rates of newly diagnosed cancer of the liver and stomach were twice as high in both Hispanic men and women.” Fewer Hispanics are diagnosed at the earliest and most treatable stage than non-Hispanic Whites. Hispanic men and women have higher mortality rates than non-Hispanic Whites with cancer of the stomach and liver. In addition, in the Border Area of Texas, breast, cervical and colorectal cancer screening rates for Hispanics are significantly lower than the rates for non-Hispanic whites. Community need addressed by the project: CN. 1 Shortage of primary and specialty care providers and inadequate access to primary or preventive care Target population The target population for this project will be the general population in RHP 5, with a special focus on Hispanics who are either enrolled in Medicaid or low income uninsured.

Category 1 or 2 expected patient benefits Increase number of electronic “curbside consults” provided by specialists to primary care physicians through electronic consults or electronic referral processing system. QPI: DY 3: Provide 15 electronic consults related to cancer DY 4: Provide 30 electronic consults related to cancer DY 5: Provide 40 electronic consults related to cancer At least 50% of the patients served will be Medicaid enrollees or low income uninsured. If follow up care related to these consults cannot be provided in the home community, UTHSCSA specialty providers commit to performing necessary diagnostic or therapeutic procedures as medically necessary after electronic consults.

Category 3 outcomes expected patient benefits OD 12 Primary Care and Primary Prevention IT-12.1 Breast Cancer Screening IT-12.2 Cervical Cancer Screening IT-12.3 Colorectal Cancer Screening IT-12.11 HPV Vaccine for Adolescents


Project Option 1.7.5 – Implement or expand medical education and specialized training programs via telehealth program for targeted professionals in remote locations Unique Project ID: 085144601.1.101 Performing Provider/TPI: The University of Texas Health Science Center at San Antonio / 085144601 PROJECT DESCRIPTION: The University of Texas Health Science Center at San Antonio proposes to implement a medical education program via telehealth for targeted professionals in remote locations and implement an electronic consult system to provide advice and guidance to primary care physicians that will address their questions without the need for face-to-face visits when medically appropriate. This project is designed to educate health professionals in RHP 5 with regard to early diagnosis and treatment of cancer, especially those cancers which have a higher incidence and mortality rate among Hispanics. Primary care professionals will be the focus but the programs will also be open to local specialists. Using teleconferences and video conferences, experts from the Cancer Treatment and Research Center (CTRC) at UTHSCSA will provide quarterly Grand Rounds to physicians, physician assistants, and nurses in RHP 5. Videoconferences will take place at sites in Cameron and Hidalgo Counties using facilities at UT Brownsville, UT Pan Am and the UT Regional Academic Health Center. We will open the conferences to local health departments, FQHCs and other safety net clinics, as well as physicians in private practice. The conferences will meet the requirements for professional Continuing Education for nurses, physician assistants, and physicians. The videoconferences will also be available on the internet for health professionals in Starr and Willacy Counties. UTHSCSA will also add features from project option 1.7.6 to project option 1.7.5. CTRC and UTHSCSA physicians will make themselves available for electronic consults and commit to performing necessary diagnostic or therapeutic procedures as medically necessary after electronic consults. Goals and Relationship to Regional Goals: This project has the following goals:

• To educate professional primary care providers to improve cancer knowledge, especially with regard to the Hispanic population

• To offer appropriate electronic consults and access to medically necessary specialty care • To conduct continuous quality improvement activities to improve the education process

as well as the consult process

This project meets the following regional goals: • Improve primary care provider knowledge with regard to cancer prevention, diagnosis,

and treatment among Hispanics • Improve access to cancer specialists, especially for the low income and Medicaid

populations


• Improve clinical outcomes • Improve the efficiency and effectiveness of health care

Challenges and issues: UTHSCSA RAHC will need to develop a more proactive role in professional outreach to health care providers across the entirety of RHP 5. Similarly, this project presents an outreach challenge and opportunity for UTHSCSA’s Cancer Therapy and Research Center (CTRC), the National Cancer Institute designated Cancer Center in San Antonio. Addressing the challenges: UTHSCSA will partner with local health departments, FQHCs, and other community safety net providers to develop the implementation and marketing plans and to select the topics and dates for the Grand Rounds events. UTHSCSA will develop a patient registry to track all consults, testing, results communication, referrals, and follow up with primary care providers and patients. 3-year expected outcome for Performing Provider and patients: UTHSCSA will leverage developing local partnerships by the RAHC and the clinical expertise of the CTRC to develop and implement cancer-focused continuing medical education to be delivered to primary care and safety net providers. Through this professional outreach and networking, UTHSCSA cancer specialists will provide electronic consults to primary care providers in RHP 5 and follow up care to Medicaid and low income patients as appropriate. STARTING POINT/BASELINE UTHSCSA does not currently conduct Grand Rounds for the RHP 5 provider community nor is there a standard protocol for electronic consults. RATIONALE AND DATA DRIVING THIS PROJECT In the fall of 2013, the Texas Public Health Association published “A Comprehensive Report on Cancer among Hispanics in Texas,” produced by the Comparative Effectiveness Research on Cancer in Texas (CERCIT) Project, funded by the Cancer Prevention and Research Institute of Texas (CPRIT). CERCIT is a consortium of investigators from UT Medical Branch, UT MD Anderson Cancer Center, the UT School of Public Health, Rice University, Baylor College of Medicine, and the Texas Department of State Health Services. The report finds that cancer has surpassed heart disease to become the leading cause of death for Hispanics in Texas. The report echoes the description of the RHP 5 population, noting that Hispanics in Texas are disadvantaged compared to non-Hispanic Whites with regard to educational attainment, poverty, and access to health care. The incidence rates of common cancers - breast, colon and lung cancer - appear to be lower in Hispanics. However, cancers for which infectious diseases are an important risk factor are more commonly diagnosed in Hispanics. According to the report, “rates of newly diagnosed cancer of the liver and stomach were twice as high in both Hispanic men and women, and cancer of the cervix in Hispanic woman was nearly 50% higher.” Further, Hispanic men as well as women are more than twice as likely to die of cancers of the stomach and liver, and Hispanic women have a 50% higher mortality rate for cervical cancer as


compared to non-Hispanic Whites. Hispanics are somewhat more likely to be diagnosed with various cancers at a later disease stage than non-Hispanic whites. This would seem to indicate more limited access to cancer screening and care. The findings of the CERCIT report are driving this project. We want to increase the cancer health literacy of the RHP 5 provider community with specific emphasis on the cancers for which their patients are most at risk – those related to infectious diseases – cancers of the stomach, liver and cervix. We will provide specific provider education with regard to screening for H. pylori. H. pylori is noted by the National Cancer Institute as a major cause of stomach cancer. We will also offer provider education with regard to the use of HPV vaccinations, as appropriate, for prevention of cervical cancer. With respect to overutilization of cancer screening, the report notes some findings inconsistent with the evidence-based screening recommendations of the United States Preventive Services Task Force (USPSTF). Annual, routine cancer screenings, specifically mammography and colonoscopy, occur for Hispanics older than 75 as they do for non-Hispanic Whites despite the USPSTF guidelines to the contrary. The report finds that routine Prostate Specific Antigen (PSA) screening continues despite the USPSTF guideline that no PSA-based screening for prostate cancer occur for men of any age. UTHSCSA will promote and disseminate the USPSTF guidelines and recommendations through professional education. How the project represents a new initiative or significantly enhances an existing delivery system reform initiative: The UTHSCSA response to the CERCIT report will have two dimensions in RHP 5. The telehealth Grand Rounds and consults project will seek to provide cancer-focused continuing medical education for primary care physicians and other providers and provide access to electronic consults and referrals with CTRC specialists in San Antonio. The health fairs project will seek to increase the general population’s health literacy with a specific focus on cancer screening and prevention among low-income Hispanics. UTHSCSA will provide outreach and education both on the road with the general public and on-line with health care providers throughout the four counties of RHP 5. Project components:

• Conduct needs assessment to identify needed medical education • Create innovative telehealth medical education that will engage provider community

members, promote appropriate cancer screenings and appropriate vaccinations • Conduct pre- and post-evaluations among remote health care providers demonstrating

they gained knowledge and capacity on key areas of cancer care knowledge • Develop electronic consult process to connect primary care providers and UTHSCSA

specialists • Establish and use patient registry to track consults, screenings, results, referrals, and

follow up


• Required core components: a) Conduct quality improvement for project using methods such as rapid cycle improvement. Activities may include, but are not limited to, identifying project impacts, identifying “lessons learned,” opportunities to scale all or part of the project to a broader patient population, and identifying key challenges associated with expansion of the project, including special considerations for safety-net populations. Conduct continuous quality improvement to improve and refine the Grand Rounds telehealth sessions and to improve the electronic consult protocols

Unique community need identification number the project addresses: • CN.1 – Shortage of primary and specialty care providers and inadequate access to

primary or preventive care Quantifiable Patient Impact The Cancer Grand Rounds and electronic consults project will provide health education to an increasing number of primary care providers in RHP 5. The annual target numbers of providers will be determined in the course of the DY 3 needs assessment and planning process. UTHSCSA specialty providers will provide 15 electronic consults related to cancer care in DY 3, 30 in DY 4, and 40 in DY 5. If follow up care related to these consults cannot be provided in the home community, UTHSCSA specialty providers commit to performing necessary diagnostic or therapeutic procedures as medically necessary after electronic consults. At least 50% of the people served will be either enrolled in Medicaid or low-income uninsured. Related Category 3 Outcome Measure(s): OD-12 Preventive Services Rationale for selecting the outcome measures: Pending HHSC and CMS finalization of Category 3 metrics, we believe the Preventive Services Outcome Domain is most appropriate for this project. Relationship to other UTHSCSA Projects: The other UTHSCSA projects in RHP 5 mirror the multi-dimensional and intertwined aspects of the cancer health fairs and cancer Grand Rounds projects. On the community-focused dimension, UTHSCSA is engaged in projects to promote chronic disease management, care navigation, patient engagement and self-care as well as spreading the patient-centered medical home model in community clinics. On the provider-focused dimension, UTHSCSA is engaged in projects to increase the physician workforce in primary care and much-needed, high impact specialties to increase access to care for Medicaid and low-income uninsured persons. Relationship to Other Performing Providers’ Projects in the RHP: The UTHSCSA health fairs project complements other outreach projects in RHP 5 that intend to improve health literacy among the population. By providing continuing medical education and electronic consults to primary care providers, the Grand Rounds project compliments the many RHP 5 projects that intend to enhance access to primary care and increase the number of


primary care providers including the primary care residency projects at Doctors Hospital Renaissance and the projects to integrate primary care and behavioral care led by Tropical Texas Behavioral Health. In concert, the two UTHSCSA cancer-related projects intend to improve cancer prevention and care in RHP 5. More importantly, the projects intend to improve the health system infrastructure through education and by opening dialogues on several fronts among the patient population, health care providers, and academia. Plan for Learning Collaborative: Together with the Anchor, UTHSCSA will convene semi-annual learning collaborative sessions to improve the quantity and quality of its outreach efforts. UTHSCSA will present the results and findings of the community needs assessment as well as the feedback from the health fairs and Grand Rounds to key collaborators in the safety net – hospitals, clinics and local health departments. The purpose will be to identify lessons learned from successes and challenges and to plot improvements to the educational strategies. Through its continuous quality improvement activities, UTHSCSA will continually monitor its processes to ensure screening results are communicated timely and electronic consults are completed timely. UTHSCSA will take advantage of the semi-annual learning collaborative meetings to engage patients and providers to improve timely communication. Project Valuation: The health fairs project and the Grand Rounds project together can have a significant impact on the Medicaid and low income uninsured population of South Texas. UTHSCSA will engage the community’s population directly through the health fairs, improving overall health literacy with a special emphasis on cancer screening and prevention. To ensure that the primary care provider community is in step with increased patient awareness with respect to cancer, the Grand Rounds project will provide the requisite continuing medical education as well as electronic consults with specialists at CTRC, a NCI-designated center. The projects will provide, at no cost to participants, audience-appropriate health education, general and cancer-specific screenings and preventive vaccinations, referrals for appropriate screenings (mammograms and colonoscopies), electronic consults to health professionals, and follow up care as needed.



Unique Project Identifier:

085144601.2.101

Provider Name/TPI: The University of Texas Health Science Center at San Antonio/085144601

Provider Description

The University of Texas Health Science Center at San Antonio serves San Antonio and the 50,000 square-mile area of South Texas. It extends to campuses in the metropolitan border communities of Laredo and the Rio Grande Valley. More than 3,000 students a year train in an environment that involves more than 100 affiliated hospitals, clinics and health care facilities in South Texas.

Intervention(s)

Health Fairs with Cancer Focus Project Option 2.7.1 Implement innovative evidence-based strategies to increase appropriate use of technology and testing for targeted populations. This project is designed to improve appropriate use of cancer screenings primarily among the Hispanic population in RHP 5. The University of Texas Health Science Center at San Antonio will conduct several health fairs annually in RHP 5 to increase health literacy about cancer. Health fairs will take place in or near schools, grocery stores, FQHCs and other safety net providers such as local county health departments. Nurses and nursing students, medical students, and community health workers will educate attendees about cancer prevention, risk reduction, appropriate screening, treatment and survivorship. Health fair attendees will be offered, as appropriate, HPV vaccines, FIT tests, and tests to detect Helicobacter pylori. Attendees will be referred to local providers if needed for cervical cancer screenings, mammograms, and follow-up. Flu and pneumonia inoculations will also be provided as appropriate.


In Fall 2013, “A Comprehensive Report on Cancer among Hispanics in Texas” was published in the Texas Public Health Journal. The report found that “rates of newly diagnosed cancer of the liver and stomach were twice as high in both Hispanic men and women.” Fewer Hispanics are diagnosed at the earliest and most treatable stage than non-Hispanic Whites. Hispanic men and women have higher mortality rates than non-Hispanic Whites with cancer of the stomach and liver. In addition, in the Border Area of Texas, breast, cervical and colorectal cancer screening rates for Hispanics are significantly lower than the rates for non-Hispanic whites. Community need addressed by the project: CN. 1 Shortage of primary and specialty care providers and inadequate access to primary or preventive care Target population


The target population for this project will be Hispanic women, men and children in RHP 5 who are either enrolled in Medicaid or low income uninsured.


QPI: DY 3: Provide health fair education and appropriate screenings/inoculations to 500 people DY 4: Provide health fair education and appropriate screenings/inoculations to 1,500 people DY 5: Provide health fair education and appropriate screenings/inoculations to 2,500 people


OD 12 Primary Care and Primary Prevention IT-12.1 Breast Cancer Screening IT-12.2 Cervical Cancer Screening IT-12.3 Colorectal Cancer Screening IT-12.4 Pneumonia vaccination status for older adults IT-12.6 Influenza immunization- ambulatory IT-12.11 HPV Vaccine for Adolescents


Project Option 2.7.1 – Implement innovative evidence-based strategies to increase appropriate use of technology and testing for targeted populations. Unique Project ID: 085144601.2.101 Performing Provider/TPI: The University of Texas Health Science Center at San Antonio / 085144601 PROJECT DESCRIPTION: The University of Texas Health Science Center at San Antonio proposes to conduct health fairs for the purpose of improving appropriate use of cancer screenings in the target population. This project is designed to improve appropriate use of cancer screenings primarily among the low-income Hispanic population in RHP 5. The University of Texas Health Science Center at San Antonio (UTHSCSA) Regional Academic Health Center (RAHC) will conduct several health fairs annually in RHP 5 to increase health literacy about cancer. Health fairs will take place in or near schools, grocery stores, community event centers, FQHCs and other safety net providers such as local county health departments. Nurses and nursing students, medical students, and community health workers will educate attendees about cancer prevention, risk reduction, appropriate screening, treatment and survivorship. Health fair attendees will be offered, as appropriate, HPV vaccines, FIT tests, and test to detect Helicobacter pylori (H. pylori). Attendees will be referred to local providers if needed for cervical cancer screenings, mammograms, and follow-up. Flu and pneumonia inoculations will also be provided as appropriate. Goals and Relationship to Regional Goals: This project has the following goals:

• To develop and implement an innovative evidence-based project to increase health literacy about cancer among the Hispanic population

• To educate and train culturally competent team members to staff health fairs at various venues that are easily accessible to the community

• To educate health fair attendees to improve health literacy, especially with regard to cancer

• To offer appropriate screening tests, especially FIT tests and tests to detect H. pylori • To offer vaccinations for HPV as well as flu and pneumonia, as appropriate • To refer health fair attendees to local healthcare providers for cervical cancer

screenings, mammograms, and follow-up as appropriate • To conduct continuous quality improvement activities to improve health fair outcomes.


• Increase access to preventive services and cancer screening for low-income Hispanic men and women.

• Improve health literacy broadly and specifically with regard to cancer among Hispanics


Challenges and issues: Although UTHSCSA RAHC has a close working relationship with providers (Su Clinica FQHC and the VA clinic) in close geographic proximity in Harlingen, it will need to develop a more proactive role in outreach across the entirety of RHP 5. Similarly, this project presents an outreach challenge and opportunity for UTHSCSA’s Cancer Therapy and Research Center (CTRC), the National Cancer Institute designated Cancer Center in San Antonio. Addressing the challenges: UTHSCSA will partner with local health departments, FQHCs, and other community safety net providers to develop the implementation and marketing plans and to select the sites for the health fairs. Using the expertise of CTRC staff, UTHSCSA will engage various academic components at UT Brownsville and UT Pan American, including the School of Public Health, Nursing, Social Work, Pharmacy, and the Physician Assistant Studies Program to encourage participation by students and active engagement with the curriculum, first as learners and second as peer educators. UTHSCSA will develop a patient registry to track all contacts, testing, results communication, referrals, and follow up with health fair attendees. 3-year expected outcome for Performing Provider and patients: UTHSCSA will leverage developing local partnerships by the RAHC and the clinical expertise of the CTRC to develop and implement culturally competent, cancer-focused health literacy curriculum to be delivered to the low income Hispanic population of RHP 5. Through the health fairs and the accompanying patient registry, UTHSCSA will increase cancer screening appropriately through a combination of FIT tests, H. pylori tests, and referrals for cervical cancer screenings, mammograms, and colonoscopies. Referrals for appropriate follow up after screening results will also be achieved. In addition, UTHSCSA will promote cancer prevention by offering HPV vaccinations to appropriate individuals. Additional health promotion activities will include flu and pneumonia vaccinations. STARTING POINT/BASELINE UTHSCSA does not currently conduct health fairs for the RHP 5 community nor is there a standard protocol for health fairs operations. RATIONALE AND DATA DRIVING THIS PROJECT In the fall of 2013, the Texas Public Health Association published “A Comprehensive Report on Cancer among Hispanics in Texas,” produced by the Comparative Effectiveness Research on Cancer in Texas (CERCIT) Project, funded by the Cancer Prevention and Research Institute of Texas (CPRIT). CERCIT is a consortium of investigators from UT Medical Branch, UT MD Anderson Cancer Center, the UT School of Public Health, Rice University, Baylor College of Medicine, and the Texas Department of State Health Services. The report finds that cancer has surpassed heart disease to become the leading cause of death for Hispanics in Texas. The report echoes the description of the RHP 5 population, noting that Hispanics in Texas are disadvantaged compared to non-Hispanic Whites with regard to educational attainment, poverty, and access to health care. The incidence rates of common cancers - breast, colon and lung cancer - appear to be lower in Hispanics. However, cancers for which infectious diseases


are an important risk factor are more commonly diagnosed in Hispanics. According to the report, “rates of newly diagnosed cancer of the liver and stomach were twice as high in both Hispanic men and women, and cancer of the cervix in Hispanic woman was nearly 50% higher.” Further, Hispanic men as well as women are more than twice as likely to die of cancers of the stomach and liver, and Hispanic women have a 50% higher mortality rate for cervical cancer as compared to non-Hispanic Whites. Hispanics are somewhat more likely to be diagnosed with various cancers at a later disease stage than non-Hispanic whites. This would seem to indicate more limited access to cancer screening and care. The findings of the CERCIT report are driving this project. We want to increase the health literacy of the RHP 5 Hispanic population with specific emphasis on the cancers for which they are most at risk – those related to infectious diseases – cancers of the stomach, liver and cervix. We will offer onsite screening for H. pylori. H. pylori is noted by the National Cancer Institute as a major cause of stomach cancer. We will also offer onsite HPV vaccinations, as appropriate, for prevention of cervical cancer. With respect to overutilization of cancer screening, the report notes some findings inconsistent with the evidence-based screening recommendations of the United States Preventive Services Task Force (USPSTF). Annual, routine cancer screenings, specifically mammography and colonoscopy, occur for Hispanics older than 75 as they do for non-Hispanic Whites despite the USPSTF guidelines to the contrary. The report finds that routine Prostate Specific Antigen (PSA) screening continues despite the USPSTF guideline that no PSA-based screening for prostate cancer occur for men of any age. UTHSCSA will promote and disseminate the USPSTF guidelines and recommendations through the cancer health fairs. How the project represents a new initiative or significantly enhances an existing delivery system reform initiative: The UTHSCSA response to the CERCIT report will have two dimensions in RHP 5. The health fairs project will seek to increase the general population’s health literacy with a specific focus on cancer screening and prevention among low-income Hispanics. The telehealth Grand Rounds and consults project will seek to provide cancer-focused continuing medical education for primary care physicians and other providers and provide access to electronic consults and referrals with CTRC specialists in San Antonio. UTHSCSA will provide outreach and education both on the road with the general public and on-line with health care providers throughout the four counties of RHP 5. Project components:

• Identify high impact preventive services and gaps in health literacy • Create innovative health fair protocol that will engage community members in a

culturally competent manner, promote appropriate cancer screenings and appropriate vaccinations

• Establish and use patient registry to track screenings, results, referrals, and follow up • Develop referral process for cervical cancer screenings and mammograms


• Develop process for communicating screening results and referring for follow up as appropriate

• Required core components: a) Conduct quality improvement for project using methods such as rapid cycle improvement. Activities may include, but are not limited to, identifying project impacts, identifying “lessons learned,” opportunities to scale all or part of the project to a broader patient population, and identifying key challenges associated with expansion of the project, including special considerations for safety-net populations. Conduct continuous quality improvement to improve and refine the health fairs protocols and increase community participation



Quantifiable Patient Impact The health fairs project will provide health education and appropriate screenings and vaccinations (HPV, flu and pneumonia) as well as screening referrals and follow up to at least 500 people in DY 3, 1,500 people in DY 4, and 2,500 people in DY 5. At least 60% of the people served will be either enrolled in Medicaid or low-income uninsured. Related Category 3 Outcome Measure(s): OD-12 Preventive Services Rationale for selecting the outcome measures: Pending HHSC and CMS finalization of Category 3 metrics, we believe the Preventive Services Outcome Domain is most appropriate for this project. Relationship to other UTHSCSA Projects: The other UTHSCSA projects in RHP 5 mirror the multi-dimensional and intertwined aspects of the cancer health fairs and cancer Grand Rounds projects. On the community-focused dimension, UTHSCSA is engaged in projects to promote chronic disease management, care navigation, patient engagement and self-care as well as spreading the patient-centered medical home model in community clinics. On the provider-focused dimension, UTHSCSA is engaged in projects to increase the physician workforce in primary care and much-needed, high impact specialties to increase access to care for Medicaid and low-income uninsured persons. Relationship to Other Performing Providers’ Projects in the RHP: The UTHSCSA health fairs project complements other outreach projects in RHP 5 that intend to improve health literacy among the population. By providing continuing medical education and electronic consults to primary care providers, the Grand Rounds project compliments the many RHP 5 projects that intend to enhance access to primary care and increase the number of primary care providers including the primary care residency projects at Doctors Hospital Renaissance and the projects to integrate primary care and behavioral care led by Tropical


Texas Behavioral Health. In concert, the two UTHSCSA cancer-related projects intend to improve cancer prevention and care in RHP 5. More importantly, the projects intend to improve the health system infrastructure through education and by opening dialogues on several fronts among the patient population, health care providers, and academia. Plan for Learning Collaborative: Together with the Anchor, UTHSCSA will convene semi-annual learning collaborative sessions to improve the quantity and quality of its outreach efforts. UTHSCSA will present the results and findings of the community needs assessment as well as the feedback from the health fairs and Grand Rounds to key collaborators in the safety net – hospitals, clinics and local health departments. The purpose will be to identify lessons learned from successes and challenges and to plot improvements to the educational strategies. Through its continuous quality improvement activities, UTHSCSA will continually monitor its processes to ensure screening results are communicated timely and electronic consults are completed timely. UTHSCSA will take advantage of the semi-annual learning collaborative meetings to engage patients and providers to improve timely communication. Project Valuation: The cancer health fairs project and the Grand Rounds project together can have a significant impact on the Medicaid and low income uninsured population of South Texas. UTHSCSA will engage the community’s population directly through the health fairs, improving overall health literacy with a special emphasis on cancer screening and prevention. To ensure that the primary care provider community is in step with increased patient awareness with respect to cancer, the Grand Rounds project will provide the requisite continuing medical education as well as electronic consults with specialists at CTRC, a NCI-designated center. The projects will provide, at no cost to participants, audience-appropriate health education, general and cancer-specific screenings and preventive vaccinations, referrals for appropriate screenings (mammograms and colonoscopies), electronic consults to health professionals, and follow up care as needed.


Project Title: Expand Primary Care Capacity: Expanding existing primary care capacity Unique RHP Project ID number: 094113001.1.103 Performing Provider/TPI: South Texas Health System / 094113001 Project Option: 1.1.2 Project Core Components: 1.1.2.a-c

PROJECT SUMMARY


Project Description This is the expansion of primary care services via increasing access to OB/GYNs, improved prenatal care, and education to the uninsured and underserved portion of our community. OBGYSs typically serve as the PCP provider for most women. We expect to provide 1,300 incremental visits in DY 4 and 1,365 incremental visits in DY 5 as evidence of increased access to OB/GYN services. Patients will receive preventative, primary, and maternal care. As a result, we expect to improve patient outcomes, specifically reducing early elective deliveries and increasing safe delivery practices in accord with HRU standards.

Intervention(s) This project will expand the capacity of primary care services – particularly obstetrics and gynecological services – in the community, prenatal care management, and education that can be provided in the most appropriate setting in a timely manner. OBGYNs often serve as the primary care provider for women.

Need for the project The region faces a shortage of primary care professionals to serve a growing population, lagging behind Texas in the supply of OB/GYN physicians by 25% (CN.1). South Texas Health System currently has 8 OB/GYNs who are at or beyond capacity. Their patient population is 70% Medicaid, indigent, and self-pay. Much of the region is medically underserved.


Target population The target population will increase and have improved access as evidenced by 1,300 OBGYN encounters provided in DY 4 and 1,365 in DY 5. Currently 70% of the payor mix in the labor and delivery unit is Medicaid, Indigent, and Self Pay. Hidalgo County has a significant number of Medicaid and uninsured. Medicaid enrollees total 107,000 and the uninsured population is 80,000. Expected impact (total patients per year): DY3-1,235, DY4-1,300, DY5-1,365 primary care/OBGNY encounters.


Patients will benefit from increased access to OB/GYN services, improved prenatal care, and education on various healthcare needs. We expect to provide 1,300 incremental visits in DY 4 and 1,365 incremental visits in DY 5 as evidence of increased access to OB/GYN services. Patients will receive preventative, primary, and maternal care. As a result, we expect to improve patient outcomes, specifically reducing early elective deliveries and increasing safe delivery practices in accord with HRU standards. Quantifiable patient impact milestones are to provide: DY4-1,300, DY5-1,365 primary care/OBGYN encounters (12.1 to increase the number of primary care visits)

Category 3 outcomes expected patient benefits We have selected two outcomes: 1) IT-8.3 Early Elective Delivery – (Standalone measure), therefore promoting improved health for both the mother and baby. A decrease in early elective deliveries will result in fewer complications, healthier infants, and lower healthcare costs. The goal will be to see a 10% reduction in elective deliveries by DY5 from the baseline numbers established in DY 3. 2) IT-12.1 High Reliability Unit – (Non-standalone measures). By DY 5 we also anticipate improving the safety of all deliveries by implementing HRU standards and decreasing the high risk rate by 10% for Medicaid, indigent, and uninsured individuals within the community. Studies have shown that low socioeconomic status is an important predictor associated with low rates of regular mammography screening and delayed diagnosis and treatment of breast cancer resulting in poor outcomes.


Project Title: 1.1.2 Expand Labor and Delivery Capacity: Expand existing primary care capacity. Unique Project ID: 094113001.1.103 Performing Provider Name/TPI: South Texas Health System / 094113001 Project Components: 1.1.2.a-c

Project Description: This project will expand the capacity of OB/GYN primary care services to better accommodate the needs of the regional patient population and community, as identified by the RHP needs assessment, so that patients have enhanced access to services, allowing them to receive the right care at the right time in the right setting. The focus would be on the residents residing in the following zip codes: 78539, 78541, 78501, 78503 and 78504. OB/GYNs will provide community education on the importance of prenatal care and wellness to promote health and wellness for the patient and baby. We have a largely low-income population in the community. Expanding access to primary care in the community can help better serve this population as many primary care providers are no longer taking Medicaid patients. In our current system patients receive services in urgent and emergent care settings for conditions that could be managed in a more coordinated manner if provided in the primary care setting. This often results in more costly, less coordinated care and a lack of appropriate follow-up care. Patients may experience barriers in accessing primary care services secondary to transportation, cost, lack of assigned provider, physical disability, inability to receive appointments in a timely manner and a lack of knowledge about what types of services can be provided in the primary care setting. By enhancing access points, available appointment times, patient awareness of available services and overall primary care capacity, patients and their families will align themselves with the primary care system resulting in better health outcomes, patient satisfaction, and appropriate utilization and reduced cost of services. With the additional OB/GYNs, STHS will be able to provide appropriate healthcare access to an increasing number of women and expectant mothers in the right setting. Prenatal care would be provided in the most appropriate setting in a timely fashion. Project Goals The project goal is to expand the capacity of and access to primary care, specifically OB/GYN services, in the clinic setting for residents of Hidalgo County. This expansion would better accommodate the needs of the regional patient population and community, as identified by the RHP needs assessment, so that patients have enhanced access to services, allowing them to receive the right care at the right time in the right setting. Regional Goals This project would meet the region’s first two goals – to leverage existing infrastructure to meet the region’s primary care needs, and to increase access to primary care. Challenges The clinic would help a market currently struggling to meet the labor and delivery needs of its population. As cited in the community needs assessment (CN.1), there is a critical shortage of obstetric capacity and access. As a result, women’s health care and health outcomes are suboptimal. Specific


challenges include: 1) Physician Recruiting – it has been challenging to recruit experienced OB/GYNs to fill the need in the community; 2) Patient compliance with prenatal care – this can be overcome by providing education in basic lay terms, having a bilingual caregiver in the clinic, and improving patient access to care. Starting Point/Baseline. Hidalgo County is a medically underserved region. OB/GYN primary care falls under that category. GMNEC data statistics support the need for 4 additional OB/GYNs in our service area. We currently only have 8 OB/GYNs. An aggressive physician recruitment plan was approved and recruitment efforts are under way. The additional OB/GYN will be recruited to an existing practice where the baseline of patient visits for DY2 was 2,000. We currently provide 1,200 OB/GYN visits per year. Almost 70% of the payor mix in the labor and delivery unit is Medicaid and Self Pay. Quantifiable Patient Impact: We have selected QPI metric I-12.1: Documentation of increased number of visits, consistent with HHSC’s recommended QPI measure for this project option. As a result of expanded OB/GYN services, we expect to provide at least 1,300 incremental primary care encounters in DY 4 and at least 1,365 incremental primary care/OBGYN encounters in DY 5. Rationale The region faces a shortage of primary care professionals to serve a growing population, lagging behind Texas in the supply of OB/GYN physicians by 25% (CN.1). South Texas Health System currently has 6 OB/GYNs who are at or beyond capacity. Their patient population is 70% Medicaid, indigent, and self-pay. Much of the region is medically underserved. Low-income and minority women tend to suffer from poorer women’s health outcomes: Maternal mortality rates have not improved in recent years, and studies indicate that as many as half of all deaths from pregnancy complications could be prevented if women had better access to health care, received better quality care, and made positive changes in their health and lifestyle habits. A woman’s race, ethnicity, country of birth, and age can be associated with her risk of dying of pregnancy complications, ability to avoid unintended pregnancy, access to adequate medical care, or practice of healthy behaviors.49 Disparities in screening mammography persist among racial/ethnic minorities and low-income women. Uninsured women and those with no usual care have the lowest rates of reported mammogram use. As a result, vulnerable populations continue to bear a disproportionate burden of breast cancer mortality.50 Project milestones: Year 1: P-5: Train/hire an additional OB/GYN provider P-1: Expand the clinic space Year 4: P-5: Train/hire an additional OB/GYN provider

49 CDC Report, “Safe Motherhood: Promoting Health for Women Before, During, and After Pregnancy,” February 2008. 50 Peek M, Han J, “Disparities in Screening Mammography: Current Status, Interventions, and Implications,” J Gen Intern Med. 2004 February; 19(2): 184–194.


I-12: Increase primary care clinic volume of visits Year 5: I-12: Increase primary care clinic volume of visits Unique Community Need Identification Numbers the Project Addresses: CN.1 Shortage of obstetricians and inadequate access to primary or preventive care. How the Project Represents a New Initiative or Significantly Enhances an Existing Delivery System Reform Initiative: This is a new initiative with no related activities that are funded by the U.S Department of Health and Human Services. Project Core Components: This project will address the three required core components in Project Option 1.1.2, as detailed in the RHP Planning Protocol: a) Reopen the labor and delivery service line – We plan to expand current space to accommodate additional practitioners. The new service will have 12 LDRs, 13 bed nursery, 2 C-section suites and 13 postpartum rooms. b) Expand OBGYN practices- This will be evaluated and revised with the additional case load to provide further access. Additional physicians will be added. c) Expand primary care clinic staffing- we plan to hire 2 OB/GYNs. Related Category 3 Outcome Measure: We have selected two outcome measures: 1) IT-8.3: Early Elective Delivery (Standalone measure): Studies have shown that babies born two to three weeks before their due date have a higher risk of health problems. Studies have also shown that a baby’s brain at 35 weeks weighs only two-thirds of what it will weight at 39 to 40 weeks. Elective deliveries can also lead to higher healthcare cost due to being medically riskier. With an additional OB/GYNs, STHS anticipates more appropriate and timely prenatal care management as well as care being delivered and offered in the most appropriate setting. We anticipate with prenatal care management and education there will be a 10% reduction in Early Elective Deliveries. 2) IT-12.1 Breast Cancer Screening (Non-standalone measure): Women whose breast cancer is detected early have more treatment choices and better chances for survival. Mammography screening has been shown to reduce mortality by 20-30% among women 40 and older. With increased access to OB/GYN services, we expect to increase the screening rate by 10%. Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): One of our other DSRIP projects is also focused on improving primary care by implementing the medical home model. Additionally, this project would support population health improvements in Category 4.

Relationship to Other Performing Providers’ Projects in the RHP. This project focuses on the expansion of labor and delivery capacity along with these other Category 1 projects in our RHP: 121805903.1.1-Establish More Primary Clinics-Pediatrics; 121805903.1.2 - Establish More Primary Care Clinics-Primary Care; 112671602.1.1-Expand Existing Primary Care Capacity; 1328296208.1.1-Establish More Primary Care Clinics, which focuses on the overall primary


care shortage. STHS has ensured that all projects plans meet the community needs and operate in conjunction with the RHP-wide initiatives.

Plan for Learning Collaborative. We plan to participate in the statewide learning collaborative. Our participation in a collaborative will facilitate sharing of challenges and testing of new ideas and solutions to promote continuous quality improvement in our health care system. Project Valuation: • The addition of the OB/GYNs will expand the capacity of primary care to better accommodate the needs of

the regional patient population and community, as identified by the RHP needs assessment, so that patients have enhanced access to services, allowing them to receive the right care at the right time in the right setting. In our current system, more often than not, patients receive services in urgent and emergent care settings for conditions that could be managed in a more coordinated manner if provided in the primary care setting. This often results in more costly, less coordinated care and a lack of appropriate follow-up care. By enhancing access points, available appointment times, patient awareness of available services and overall OB/GYN primary care capacity, patients and their families will align themselves with the primary care system resulting in better health outcomes, patient satisfaction, and appropriate utilization and reduced cost of services.

• Providing the targeted population with proactive care early on in their pregnancy will result in savings if the condition is managed and does not require expensive ED visits, inpatient hospitalization, or other extensive treatments. With proactive education, monitoring and treatment, STHS anticipates a reduction in Early Elective Deliveries (IT.8.3). Education will also help to increase the number of Breast Cancer Screenings in the county especially among the Hispanic population which has a high incidence rate of breast cancer (IT-12.1).

Category 3: Quality Improvements Outcome Measure Title: IT- 8.3 Early Elective Delivery (Standalone measure) Performing Provider: South Texas Health System / 094113001 Outcome Identification Number: 094113001.3.1 Outcome Domain: OD-8 Perinatal Outcomes and Maternal Child Health Measure Description: We selected outcome measure IT-8.3 Early Elective Delivery, which assesses patients with elective deliveries between 37-39 weeks of gestation completed.51 Offering increased availability and access to individuals to receive the appropriate care in the right setting and in a timely fashion can result in

51 Numerator: Patients with elective deliveries with a Principal Procedure Code or an Other Procedure Codes for one or more of the following: • Medical induction of labor as defined in Appendix A, Table 11.05 available at: http://manual.jointcommission.org; or • Cesarean section as defined in Appendix A, Table 11.06 while not in Active Labor or experiencing Spontaneous Rupture of Membranes available at: http://manual.jointcommission.org. Denominator: Patients delivering newborns with ≥ >= 37 and < 39 weeks of gestation completed. EXCLUSIONS: • Principal Diagnosis Code or Other Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation as defined in Appendix A, Table 11.07; • Less than 8 years of age; • Greater than or equal to 65 years of age; • Length of Stay >120 days; • Enrolled in clinical trials


http://manual.jointcommission.org/

http://manual.jointcommission.org/

proper prenatal care management and reduction in costly medical expenses. We will be expanding OB/GYN capacity and increasing access to those services, as evidenced by 1,300 visits in DY 4 and 1,365 visits in DY 5.In DY 3, we will establish the baseline. By DY 5, we expect to see a 7% reduction in Early Elective Deliveries. Rationale: The region faces a shortage of primary care professionals to serve a growing population, lagging behind Texas in the supply of OB/GYN physicians by 25% (CN.1). As a result, many women are not receiving sufficient prenatal care. With expanded OB/GYN capacity, we expect to provide increased access to prenatal care. Part of this service includes education on the importance of full-time pregnancies. Early elective deliveries account for 10-15% of all deliveries. Numerous studies show early elective deliveries are associated with increased maternal and neonatal complications for both mothers and newborns, compared to deliveries occurring beyond 39 weeks and women who go into labor on their own.52 By reducing this rate, we can improve maternal outcomes, improve infant outcomes, and lower medical costs. Outcome Measure Valuation The expansion of the OB/GYN clinic will fill the need for OB/GYN primary care services in community. Additional primary care services will allow individuals to receive services in a timely manner in the most appropriate setting. The project will promote education and prenatal care management so that individuals will be less likely utilizes more expensive healthcare option such as the ED, urgent care, or inpatient admissions. Hidalgo County is the 4th fastest growing and is among the largest counties in Texas. By adding an additional OB/GYN to the community, individuals will be able to stay close to home while alleviating some of the demands on our current OB/GYN practitioners. The Community Needs Assessment clearly supports the needs for this project. Access Barriers (lack of personal resources and lack of insurance), primary care physician shortage, and high chronic disease are proven factors within the community. Because of the demonstrated need of primary care, high Medicaid population, and explosive growth in the community – it was evident that this addition would add value to the community. Category 3: Quality Improvements Outcome Measure Title: IT-12.1 Breast Cancer Screening (Non-standalone measure) Performing Provider: South Texas Health System / 094113001 Outcome Identification Number: 094113001.3.2 Outcome Domain: OD-12 Primary Prevention Measure Description: We selected outcome measure IT-12.1 Breast Cancer Screening, which measures the percentage of women aged 40-74 who received an annual mammogram.53 Offering increased availability and access

52 CMS, “Strong Start for Mothers and Newborns Initiative: Effort to Reduce Early Elective Deliveries,” http://innovation.cms.gov/initiatives/Strong-Start-Strategy-1 (Accessed September 28, 2013). 53 Numerator: Number of women aged 40 to 69 74 that have received an annual mammogram during the reporting period. Denominator: Number of women aged 40 to 69 74 in the patient or target population. Exclusion: Women who have had a bilateral mastectomy are excluded.


http://innovation.cms.gov/initiatives/Strong-Start-Strategy-1

to individuals to receive the appropriate care in the right setting and in a timely fashion can result in better prevention and population-based health and reduction in costly medical expenses. We will be expanding OB/GYN capacity and increasing access to those services, as evidenced by 1,300 visits in DY 4 and 1,365 visits in DY 5. In DY 3, we will establish the baseline. By DY 5, we expect to see at least a 5% increase in the screening rate over baseline. Rationale: The region faces a shortage of primary care professionals to serve a growing population, lagging behind Texas in the supply of OB/GYN physicians by 25% (CN.1). As a result, many women are not receiving sufficient preventative care. Breast cancer is the second most common type of cancer among American women, with approximately 178,000 new cases reported each year. Women whose breast cancer is detected early have more treatment choices and better chances for survival. Mammography screening has been shown to reduce mortality by 20-30% among women 40 and older. Disparities in screening mammography persist among racial/ethnic minorities and low-income women. Uninsured women and those with no usual care have the lowest rates of reported mammogram use. As a result, vulnerable populations continue to bear a disproportionate burden of breast cancer mortality.54 Outcome Measure Valuation The project will promote education and prenatal care management so that individuals will be less likely utilizes more expensive healthcare option such as the ED, urgent care, or inpatient admissions. Hidalgo County is the 4th fastest growing and is among the largest counties in Texas. By adding an additional OB/GYN to the community, individuals will be able to stay close to home while alleviating some of the demands on our current OB/GYN practitioners. The Community Needs Assessment clearly supports the needs for this project. Access Barriers (lack of personal resources and lack of insurance), primary care physician shortage, and high chronic disease are proven factors within the community. Because of the demonstrated need of primary care, high Medicaid population, and explosive growth in the community – it was evident that this addition would add value to the community. Providing the targeted population with proactive care early on in their chronic condition, this will result in savings if the condition is managed and does not require expensive ED visits, inpatient hospitalization, or other extensive treatments. With proactive prenatal education, monitoring and treatment, ADHD anticipates a reduction in Early Elective Deliveries.

54 Peek M, Han J, “Disparities in Screening Mammography: Current Status, Interventions, and Implications,” J Gen Intern Med. 2004 February; 19(2): 184–194.


Project Title: Expand Trauma Care Capacity: Expand existing trauma care capacity Unique RHP Project ID number: 094113001.1.104 Performing Provider/TPI: South Texas Health System / 094113001 Project Option: 1.9.2 Project Core Components: 1.9.2.a-d



Project Description STHS will pursue designation as an American College of Surgeons Level II Trauma Center at McAllen Medical Center. This project will require the development and implementation of new trauma care processes, expansion and renovation of current trauma care clinical facilities, improved access to specialty physicians to care for an expanded population of injured patients, and the development of a comprehensive care system in the local community that brings together ground and air EMS, the emergency department, referring hospitals, freestanding emergency centers, trauma surgeons, multiple subspecialties and rehabilitation facilities.

Intervention(s) We have selected Project Option 1.9.2 Expand Specialty Care Capacity: Improve access to specialty care. This project will expand access to specialized trauma services through the development and implementation of new trauma care processes, expansion and renovation of current trauma care clinical facilities, and improved access to specialty care physicians.

Need for the project As cited in the community needs assessment, the region experiences a shortage of specialty care (CN.1) and a lack of patient-centered care (CN.4). The need for additional trauma care has been recognized by community stakeholders as one of the most significant health care issues facing the Rio Grande Valley (RGV). Because there currently is no Level I or Level II trauma centers in the RGV, many trauma patients must be transported to San Antonio or Corpus Christi, which takes 120 to 240 minutes by ground (depending on the starting location within the RGV) to receive the needed trauma care services. The additional time required to be transported to a Level I or Level II trauma center or to remain at a lower or non-designated facility can result in increased morbidity and mortality for trauma patients. Currently, McAllen Medical Center (MMC), which is part of STHS, is currently designated by the Texas Department State of Health Services as a Level III Trauma Center. In 2012, MMC Emergency Department received an average of 1457 trauma patients per month. Of these, approximately 2% were admitted and an additional 1% were transferred to a higher level of care due to subspecialty services that are not readily available in the local community. These statistics do not include patients transported to higher levels care from the scene or those transferred from other area health care facilities.


Target population The target population is trauma care patients who reside in the primary and secondary service areas. McAllen Medical Center had approximately 17,483 trauma patient encounters last year, and approximately 40% of these encounters were with Medicaid or uninsured patients. Therefore, we are expecting that a similar number of trauma patients will benefit from the enhanced trauma services each year and a similar percentage of the patients benefiting from this project will be Medicaid or uninsured patients each year. Expected impact (total patients per year): DY3-17,833, DY4-18,190, DY5-18,554 trauma care encounters (estimated 40% Medicaid or uninsured patients)

Category 1 or 2 expected patient benefits The development and implementation of a Level II Trauma Center at McAllen Medical Center will enhance specialty care services in Hidalgo County while reducing the number of patients transferred to higher level Trauma Centers outside the area, as evidenced by an anticipated 17,833 trauma care encounters in DY 3, 18,190 encounters in DY 4 and 18,554 encounters in DY 5. This project will increase service availability with extended hours, increase the number of specialty service locations, implement standardized referrals and conduct quality improvement. The increased access to trauma care services in Region 5 will result in:

• Higher patient satisfaction • Reduction in time to definitive care • Improved patient outcomes • Expanded availability of specialty care in the local community • Reduction of health system costs.

Quantifiable patient impact milestones are to provide: DY3-17,833, DY4-18,190, DY5-18,554 trauma care encounters (estimated 40% Medicaid or uninsured patients)

Category 3 outcomes expected patient benefits This project will reduce potentially preventable complications for trauma care patients, as measured by IT ‐4.6 Incidence of Hospit – (SA). As a result of more accessible and timely trauma care services, we expect the incidence of hospital-acquired VTE to go down.


Project Title: Expand Trauma Care Capacity: Expand existing trauma care capacity Unique RHP Project ID number: 094113001.1.104 Performing Provider/TPI: South Texas Health System / 094113001 Project Option: 1.9.2 Project Core Components: 1.9.2.a-d Project Description: This project will expand the capacity of trauma care services to better accommodate the needs of the regional patient population and community, as identified by the RHP needs assessment, so that patients have enhanced access to services, allowing them to receive the right care at the right time in the right setting. The focus would be on the residents residing in the following zip codes: 78501, 78503, 78504, 78539, and 78541. McAllen Medical Center’s trauma care staff will provide community education on the importance of the increase trauma services provided to the community that would reduce patients and families from having to leave their home community to obtain needed trauma care, importance in providing needed specialties for the trauma patients, and improve patient outcomes. Hidalgo County have a large low-income population in the community; thus, expanding trauma care access to this community can help better serve this population for currently, the closest Level II trauma center is a 2 to 4 hour drive time from this community. Project Goals The project goal is to expand the capacity of and access to a higher level of trauma care for residents of Hidalgo and surrounding counties. This expansion would better accommodate the needs of the regional patient population and community, as identified by the RHP needs assessment, so that patients have enhanced access to services, allowing them to receive the right care at the right time in the right setting. Regional Goals This project would meet the region’s first two goals – to leverage existing infrastructure to meet the region’s primary trauma care needs and to increase access to primary trauma care. Starting Point/Baseline: We currently do not have a Level II Trauma Center in our service area. As a Level III Trauma Center, we provided 17,483 trauma encounters at McAllen Medical Center in 2012. An aggressive physician recruitment plan to recruit trauma surgeons and trauma subspecialties that are required in order to be designated as a Level II Trauma Center has been in effect for the past year. Also, increase the Trauma Services Department to meet the ACS requirements was approved and appropriate staff has been hired. Our current Incidence of Hospital‐acquired VTE for trauma patients is less than .03%. Providing a higher skilled level of care for the trauma patients will continue to reduce the likelihood of Hospital-acquired VTE incidents. Quantifiable Patient Impact: 1.9 projects are required to have two (2) QPI metrics: 1 metric representing total QPI (all patients served) and 1 metric for the Medicaid/low-income uninsured population. Consistent with HHSC recommended QPI metrics for this project, we have selected:

• I-23.1: Documentation of increased number of visits over prior reporting period (over baseline for DY3); and


• I-34.1: Documentation of increased number of visits for Medicaid and Uninsured patients over prior reporting period (over baseline for DY3).

Rationale: Hidalgo and surrounding counties represent a medically underserved region. The Rio Grande Valley (RGV) region faces a shortage of high level of trauma care. The State Trauma Designation Division supports the need for designating our facility from a Level III Trauma Center to a Level II Trauma Center in our service area. The need to transfer trauma patients outside the RGV area is due to lack of not having the specialty services needed to care for the trauma patients. By providing this higher level of trauma care at our facility, trauma patients will be able to stay in the RGV area and near loved ones, have improved access to the specialty services needed, experience improved care transitions and coordination, be able to be more compliant with follow-up post discharge care since all the providers would be available in the RGV area, and be better able to receive the support necessary to improve recovery at a reduced cost to the patient and others. DY3 Project Milestones & Metrics: We plan to implement the following process and improvement milestones:

• Process Milestones and Metrics: o P-2 (P-2.1): Train care providers and staff on processes, guidelines and technology for

referrals and consultations into selected medical specialties; Baseline/Goal: Our goal is to train evidence based trauma care processes to all the

existing and for all newly hired ED and ICU staff.

o P-11 (P-11.1): Establish/expand specialty care clinics by constructing a helipad just outside the medical center ED doors for accepting air transported trauma patients; and

Baseline/Goal: Expand the number of trauma cases arriving by air by 10% DY3

o P-17 (P-17.1): Implement the re-design of medical specialty clinics in order to increase operational efficiency, shorten patient cycle time and increase provider productivity by establishing a closed ICU so that all patients admitted will be under the care of a critical care intensivist. Our current medical center has three trauma surgeons who are trauma critical care intensivists. This implementation will reduce LOS in the ICU as well as improve the delivery of critical care services that are ordered and rendered timely.

Baseline/Goal: Establish care consistency that will reduce complications by 10% DY3

Improvement Milestones and Metrics: period (establish DY3 baseline); and o I-34 (I-34.1): Documentation of increased number of visits for Medicaid and Uninsured

patients over prior reporting period. Baseline/Goal: Increase Medicaid and uninsured patients’ trauma encounters by

2% over prior year to establish DY3 baseline

o I-23 (I-23.1): Documentation of increased number of visits over prior reporting year Baseline/Goal: Increase trauma encounters by 2% over prior reporting year to

establish baseline for DY3.


DY4 Project Milestones & Metrics: We plan to implement the following process and improvement milestones:

• Process Milestones and Metrics: o P-2 (P-2.1): Train care providers and staff related to processes, guidelines and technology

for referrals and consultations into selected medical specialties; Baseline/Goal: Our goal is to train evidence based trauma care processes to all

newly hired ED/ICU staff.

o P-11 (P-11.1): Establish/expand specialty care clinics by increasing air transported trauma patients to the Level II Trauma Center; and

Baseline/Goal: Expand the number of trauma cases arriving by air by 5% (over baseline for DY3)

o P-17 (P-17.1): Implement the re-design of medical specialty clinics in order to increase operational efficiency, shorten patient cycle time and increase provider productivity by maintaining a closed ICU so that all patients admitted will be under the care of a critical care intensivist. Our trauma surgeons are trauma critical care intensivists. This continued concept will continue to aid in the reduction of LOS in the ICU as well as improve the delivery of critical care services that are ordered and rendered timely.

Baseline/Goal: Establish care consistency that will reduce trauma related complications by 5% over baseline DY3.

Improvement Milestones and Metrics: period (over baseline for DY3); and o I-34 (I-34.1): Documentation of increased number of visits for Medicaid and Uninsured

patients over prior reporting period (over baseline for DY3). Baseline/Goal: Increase Medicaid and uninsured patients’ trauma encounters by

2% DY4 (over baseline for DY3) o I-23 (I-23.1): Documentation of increased number of visits over prior reporting

Baseline/Goal: Increase trauma encounters by 2% DY4 (over baseline for DY3). DY5 Project Milestones & Metrics: We plan to implement the following process and improvement milestones:

• Process Milestones and Metrics: o P-2 (P-2.1): Train care providers and staff related to processes, guidelines and technology

for referrals and consultations into selected medical specialties; Baseline/Goal: Our goal is to train evidence based trauma care processes to all

newly hired ED and ICU staff.

o P-11 (P-11.1): Establish/expand specialty care clinics by increasing air transported trauma patients to the Level II Trauma Center; and

Baseline/Goal: Expand the number of trauma cases arriving by air by 5% over baseline for DY3

o P-17 (P-17.1): Implement the re-design of medical specialty clinics in order to increase operational efficiency, shorten patient cycle time and increase provider productivity by maintaining a closed ICU so that all patients admitted will be under the care of a critical care intensivist. Our medical center has three trauma surgeons who are trauma critical


care intensivists. This concept will reduce LOS in the ICU as well as improve the delivery of critical care services that are ordered and rendered timely.

Baseline/Goal: Establish care consistency that will reduce trauma related complications by 5% over baseline for DY3

Improvement Milestones and Metrics: period (over baseline for DY3); and o I-34 (I-34.1): Documentation of increased number of visits for Medicaid and Uninsured

patients over prior reporting period (over baseline for DY3). Baseline/Goal: Increase Medicaid and uninsured patients’ trauma encounters by

3% DY5 (over baseline for DY3)

o I-23 (I-23.1): Documentation of increased number of visits over prior reporting Baseline/Goal: Increase trauma encounters by 2% DY5 (over baseline for DY3).

Unique Community Need Identification Numbers the Project Addresses:

• CN.1 – Shortage of primary and specialty care providers and inadequate access to primary or preventive care.

• CN.4 – Lack of patient-centered care. How the Project Represents a New Initiative or Significantly Enhances an Existing Delivery System Reform Initiative: This is an expanded initiative with related activities that are funded by the U.S Department of Health and Human Services through the state trauma programs. Project Core Components: This project will address all four of the required core components in Project Option 1.9.2, as detailed in the RHP Planning Protocol: Increase service availability with extended hours: To become a Level II Trauma Center, there has to be 24/7 trauma surgeons that live in the facility or are within 15 minutes response time for any Trauma Codes. McAllen Medical Center has four trauma surgeons who now live within the facility and are immediately available for all Trauma Alerts and Trauma Codes which makes for immediate specialty care at the bedside to assist the ED physician perform primary and secondary assessments of the patient. Other specialty physicians that MMC has recruited on-call and available to extend trauma care services are as follows:

• Plastic surgeon, Otolaryngology physician, Oral/maxillofacial surgeon, Neurosurgery, Orthopedic surgeon, Pediatric Intensivists, Thoracic surgery, Obstetric/Gynecologic surgery, Ophthalmology, and Urology.

• MMC has provided the infrastructure needed to function as a Level II Trauma Center that will facilitate the increase in total trauma services/procedure needed and available to service the Hidalgo and surrounding counties 24/7.

With a trauma surgeon immediately available, this will improve arrival time to the ED and reduce wait time for the trauma surgeon to be available. MMC also has quarterly meetings with all EMS services to review the cases brought to their facility, what was positive and what opportunities were identified on both sides in order to overall improve the care provided to the patient and the services available to the community.


Implement transparent, standardized referrals across the system: A referral system will be used to ensure that patients receive timely access to appropriate trauma care services. This will be accomplished by meetings with community physicians, the community, regular scheduled meeting with transport companies, public educational learning programs, and participating on the region’s trauma board – Trauma Regional Advisory Council Region V (TRAC V). Related Category 3 Outcome Measure: We have selected from outcome domain 4: Potentially Preventable Complications, Healthcare Acquired Conditions, and Patient Safety, measure IT‐4.6 Incidence of Hospital‐acquired Venous Thromboembolism (VTE) – (SA). Studies have reported evidence of trauma complications including deaths related to VTEs. VTE can also lead to higher health care cost due to longer LOS, increase risk of mortality, and more care required. Having trauma critical care intensivists caring for the trauma patients will provide more appropriate and timely care management as well as care being delivered and offered in the most appropriate setting. We anticipate a 10% reduction in diagnosed VTE. Relationship to other Projects (including Other Performing Providers’ Projects in the RHP): Relationship to Other Projects: Our other DSRIP projects are focused on providing right care, right care, and right place with improved access to needed services. We have another DSRIP projects that focus on improving access to trauma care services, preventing overcrowded EDs, and establishing free standing EDs. Additionally, this project would support population health improvements in Category 4.

Relationship to Other Performing Providers’ Projects in the RHP: This project meets the community needs and operates in conjunction with the RHP-wide initiatives. The RHP5 plan as of April 2013 as well as proposed new projects lack a project specifically focused on a trauma center designation below Level III. As such, this proposed project meets the needs of specific populations and will not duplicate services of other Performing Provider projects in the RHP. Plan for Learning Collaborative: Many of the projects chosen by RHP 5 shift from traditional models of care delivery to more patient-focused, community-based, coordinated points of access and care transitions. As the region’s providers implement these new models of care delivery, it is important that we share and learn from each other’s successes and challenges. Participating with the TRAC V counsel with other facilities will help our collective learning in the transformation of our region towards better trauma care services, improved initiatives, and improved coordination. Our shared learning will also help in the identification of best practices and enhance the equity of services across the region. We also plan to participate in the statewide learning collaborative(s) as they become available.

Project Valuation: The addition of a Level II Trauma Center at McAllen Medical Center will expand the capacity of primary trauma care offered to better accommodate the needs of the regional patient population and community, as identified by the RHP needs assessment, so that patients have enhanced access to services, allowing them to receive the right care at the right time in the right setting. As a Trauma Level III designated facility, we often have to transfer patients outside our service area to receive services that could be provided in their own community with a Trauma Level II designated facility if provided in the


primary care setting. This often results in more costly, less coordinated care and a lack of appropriate follow-up care. By enhancing access points, available appointment times, patient awareness of available services, patients and their families will align themselves with the primary trauma care system resulting in better health outcomes, patient satisfaction, and appropriate utilization and reduced cost of services. Information specific to projects from project option 1.9 - Expand Specialty Care Capacity: 1) Does the project include a clear description of specialties that the initiative is focusing on?

• Recruitment of trauma surgeons that are critical care intensivists, recruitment of subspecialty physicians/surgeons (Plastics, Otolaryngology, Oral/Maxillofacial, Neurosurgery, Orthopedics, Ophthalmology, Urology, Cardiothoracic surgeons), train/hire trauma critical care nurses, establish a closed ICU for higher level of care delivery, improve trauma patients transport services (ground, fixed wing, air) access to MMC, & educate the public on trauma care and services available – promote staying within RGV

2) Are selected specialty areas in high need for the Medicaid/uninsured population? • Yes as provided in target population on page 1 – we expect to exceed 40%. Currently, several of

the Medicaid and uninsured trauma patients are transferred out of the area in order to receive the higher level of care they need which results in an increase financial burden to the patient/family. Having this higher level of care available in their own service area will be a financial benefit for these patients.

3) Are high‐intensity specialties in areas of high need for the Medicaid/uninsured population? • Yes, this high intensity specialty trauma level service is in high need for the Medicaid/uninsured

population for currently, there is Trauma Level II designated center in the targeted population area which results in the Medicaid/uninsured patients needing this higher level of care to be transferred out of their service area to obtain such specialty services.


Project Title: Expand Trauma Care Capacity: Expand existing trauma care capacity Unique RHP Project ID number: 094113001.1.105 Performing Provider/TPI: South Texas Health System / 094113001 Project Option: 1.9.2 Project Core Components: 1.1.2.a-c



Project Description

STHS will pursue designation as an American College of Surgeons Level III Trauma Center at Edinburg Regional Medical. This project will require the development and implementation of new trauma care processes, expansion and renovation of current trauma care clinical facilities, improved access to specialty physicians to care for an expanded population of injured patients, and the development of a comprehensive care system in the local community that brings together ground and air EMS, the emergency department, referring hospitals, freestanding emergency centers, trauma surgeons, multiple subspecialties and rehabilitation facilities.

Intervention(s) This project will expand access to specialized trauma services through the development and implementation of new trauma care processes, expansion and renovation of current trauma care clinical facilities, and improved access to specialty care physicians at Edinburg Regional Medical Center. Need for the project Currently, Edinburg Regional Center which is part of STHS is designated by the Texas Department State of Health Services as a Level IV Trauma Center. Year to date in 2012, ERMC received 740 trauma patients per month. Of these, approximately 2% were admitted and an additional 1% were transferred to a higher level of care because subspecialty services are not readily available in the local community. These statistics do not include patients transported to higher levels care from the scene or those transferred from other area health care facilities.


Target population The target population is trauma care patients who reside in STHS’s primary and secondary service areas. ERMC had approximately 8,880 trauma patient encounters last year, and approximately 76% of these encounters were with Medicaid or uninsured patients. We are expecting to provide 9,058 trauma care encounters in DY 3; 9,239 encounters in DY 4 and 9,425 encounters in DY 5, with a similar percentage of Medicaid or uninsured patients. Category 1 or 2 expected patient benefits

The development and implementation of a Level III Trauma Center at Edinburg Regional Medical Center will enhance specialty care services in Hidalgo County while reducing the number of patients transferred to higher level Trauma Centers. This will result in:

• Higher patient satisfaction • Reduction in time to definitive care • Improved patient outcomes • Expanded availability of specialty care in the local community • Reduction of health system costs.

Our goal is to increase Trauma Services (via Trauma Registry) up to 9,058 patients for DY 3, 2% improvement of DY 3 patients for DY 4, and 2% improvement of DY 4 patients for DY 5. As part of this increase, we expect Medicaid and uninsured patients to increase 2% per year.

Category 3 outcomes expected patient benefits IT-4.14. Potentially Preventable Complications, Healthcare Acquired conditions and Patient Safety-Intensive Care: Incidence of Hospital-acquired Venous Thrombembolism (VTE) (SA)-Our goal is to initiate prophylaxis from intake to disposition to prevent VTE. Total Valuation Cat 1 - 4: DY 3: $2,725,764 DY 4: $2,935,163 DY 5: $3,809,109 TOTAL: $9,470,036


Project Title: 1.9.2 Expand Trauma Care Capacity: Expand existing trauma care capacity at Edinburg Regional Medical Center. Unique Project ID: 094113001.1.105 Performing Provider Name/TPI: South Texas Health System / 094113001 Project Components: 1.1.2.a-c

Project Description: STHS will pursue designation as an American College of Surgeons Level III Trauma Center at Edinburg Regional Medical Center. This project will require the development and implementation of new trauma care processes, expansion and renovation of current trauma care clinical facilities, improved access to specialty physicians to care for an expanded population of injured patients, and the development of a comprehensive care system in the local community that brings together ground and air EMS, the emergency department, referring hospitals, freestanding emergency centers, trauma surgeons, multiple subspecialties and rehabilitation facilities. The target population is trauma care patients who reside in the primary and secondary service areas. Edinburg Regional Medical Center had approximately 8,880 trauma patient encounters last year, and approximately 40% of these encounters were with Medicaid or uninsured patients. Therefore, we are expecting that a similar number of trauma patients will benefit from the enhanced trauma services each year and a similar percentage of the patients benefiting from this project will be Medicaid or uninsured patients each year. This project will involve the following core 1.9.2 project components as these relate to the development and expansion of trauma care clinical facilities: a. Increase specialty trauma service availability with extended trauma care services/procedure

hours. We will facilitate the increase in total specialty care trauma services/procedure hours by recruiting additional specialty care physicians in targeted specialty areas.

b. Increase/expand specialty trauma care clinical facilities. The specialty care physicians will be located in new and/or enhanced trauma facilities. The new/enhanced trauma facilities will have space for the new physicians to provide specialty trauma care services to patients in the community.

c. Implement transparent, standardized referrals across STHS’ trauma system. A referral system will be used to ensure that patients receive timely access to appropriate trauma care services.

d. Conduct quality improvement for project using methods such as rapid cycle improvement. STHS’ quality improvement activities will include implementing a comprehensive performance improvement review process for trauma and create actions plans to address deficiencies in criteria, coverage or performance.

This project will expand the capacity of trauma care services to better accommodate the needs of the regional patient population and community, as identified by the RHP needs assessment, so that patients have enhanced access to services, allowing them to receive the right care at the right time in the right setting. The focus would be on the residents residing in the following zip codes: 78539, 78540, 78541, and 78542. Residents north of McAllen in the areas of Elsa, Edcouch, and Falfurrias will also benefit from increased trauma services in Edinburg.


ERMC is currently designated as a level IV trauma center. Expanding this designation to a level III will provide several important improvements in the core trauma services provided to the community. As a level III trauma center, ERMC would provide the following services to the community in addition to what is already provided:

• General Surgery coverage within 30 minutes of patient arrival to ED with trauma activation • Orthopedic surgery coverage within 30 minutes of patient arrival to ED with trauma

activation. • Required education for trauma physicians focused on trauma care • Enhanced structure for quality improvement with designated Trauma Coordinator

ERMC’s trauma care staff would provide education to the outlined communities regarding the expanded trauma services provided, the reduced need for patients and families to have to leave their home community to obtain needed trauma care, the addition of new specialties for trauma patients, and improved patient outcomes. Edinburg Regional Medical Center would be the first level III designated trauma center in the city of Edinburg. In the current Level IV trauma service at ERMC, patients receive services in urgent and emergent care settings for conditions that could be managed in a more coordinated manner that would be provided in a Level III trauma care setting. Having to transfer the trauma patient outside their local community, these results in more costly, less coordinated care and a lack of appropriate follow-up care due to the distance of where the patient’s care would be provided. Patients may currently experience barriers due to in accessing needed trauma care services secondary to having to be transferred outside their community resulting in added transportation cost, inability to receive follow-up care without having to travel outside their community, and a lack of knowledge about what types of services can be provided in their current community setting. By enhancing trauma access, increased specialties, available appointment times, patient awareness of available services and overall improved trauma care capacity, patients and their families will align themselves with the local higher trauma care system resulting in better health outcomes, patient satisfaction, and appropriate utilization and reduced cost of services. With ERMC becoming a designated Level III Trauma Center, STHS will be able to provide appropriate healthcare access to an increasing number of trauma patients being cared for in the right setting in their own community. Project Goals The project goal is to expand the capacity of and access to a higher level of trauma care for residents of Hidalgo and surrounding counties. This expansion would better accommodate the needs of the regional patient population and community, as identified by the RHP needs assessment, so that patients have enhanced access to services, allowing them to receive the right care at the right time in the right setting. Regional Goals This project would meet the region’s first two goals – to leverage existing infrastructure to meet the region’s primary trauma care needs and to increase access to primary trauma care. Challenges ERMC would help a market currently struggling to meet the trauma care needs of its population. As sited in the community needs assessment (CN.4), there is a critical need to increase a higher


level of trauma services and access. As a result, trauma patients will receive the needed specialty trauma care within their own community that will result in improved health outcomes. Specific challenges include: 1) Physician Recruiting – it has been challenging to recruit experienced trauma subspecialists to fill the need for ERMC to become a Level II Trauma Center in the community; 2) Patient’s understanding of available trauma care services – this can be overcome by providing trauma education in lay terms, having a bilingual interrupter available to provide this education to both English and Spanish speaking persons for improving patient access to trauma care. The 3-year expected outcome(s): As a result of expanded trauma care services, we expect to provide service to at least 9,058 trauma patients in DY3, 9,239 trauma patients in DY4, and 9,425 trauma patients in DY5. 76% of these patients are expected to be uninsured or Medicaid. Starting Point/Baseline. Hidalgo and surrounding counties are defined as being a medically underserved region. Trauma care services falls under this category. The State Trauma Designation Division supports the need for designating ERMC from a Level IV Trauma Center to a Level III Trauma Center in our service area. We currently do not have a Level III Trauma Center in the city of Edinburg. An aggressive physician recruitment plan to bring in trauma surgeons and trauma subspecialties that are required to be designated as a Level III Trauma Center has been in effect for the past year. In addition, trauma-specific training will need to be provided to current physicians that will be providing trauma coverage. An increase in the Trauma Services Department will be needed to meet the ACS requirements for Trauma III designated hospitals. Rationale The Rio Grande Valley (RGV) region faces a shortage of high level of trauma care (CN-4). . There are eleven (11) acute care facilities in the RGV with six (6) being designated as Level III Trauma Centers and four (4) being designated as Level IV Trauma Centers. Throughout the state of Texas 185 hospitals are designated as Level IV Trauma while only 49 are designated as Level III Trauma. Having ERMC upgrade from a Trauma designated Level IV Trauma Center to a Level III Trauma Center would provide improved trauma care services in the RGV since much of the region is medically underserved. The need to transfer trauma patients outside the RGV area is due to lack of not having the specialty services needed to care for the trauma patients. By providing this higher level of trauma care at ERMC, the trauma patients will be able to stay in the RGV more frequently, receive the right care in the right place at the right time, receive the specialty services needed, and be able to be compliant with follow-up post discharge care since all the providers would be available in the RGV area. Overall, the patients would have family members and others nearby that could provide the injured patient the support necessary to improve recovery at a reduced cost to the patient and others. Project Core Components: This project will address the three required core components in Project Option 1.9.2, as detailed in the RHP Planning Protocol: This project will address the following core 1.9.2 project components as these relate to the development and expansion of trauma care clinical facilities:

e. Increase specialty trauma service: To become a Level III Trauma Center, there has to be 24/7 emergency physician coverage in the facility to participate in the resuscitation and treatment of trauma patients of all ages. ERMC currently has 24/7 emergency department


physicians on staff and recently separated its services from others in the community by adding pediatric fellowship trained emergency physicians to the adjacent Edinburg Children’s Hospital ED.

• ERMC has provided the infrastructure needed to function as a Level III Trauma Center that will facilitate the increase in total trauma services/procedure needed and available to service the Hidalgo and surrounding counties 24/7.

f. Increase/expand EMS/Air transport specialty services. ERMC has a helipad located directly outside the Emergency Department entrance to aid in receiving all emergency patients. With a general trauma surgeon immediately available, this will improve arrival time to the ED and reduce wait time for the trauma surgeon to be available. ERMC also has quarterly meetings with all EMS services to review the cases brought to their facility, what was positive and what opportunities were identified on both sides in order to overall improve the care provided to the patient and the services available to the community.

g. Implement transparent, standardized referrals across the STHS trauma system. A referral system will be used to ensure that patients receive timely access to appropriate trauma care services. This will be accomplished by meetings with community physicians, the community, regular scheduled meeting with transport companies, public educational learning programs, and participating on the region’s trauma board – RAC V.

h. Conduct quality improvement projects using PDCA and rapid cycle improvement methodology. The Trauma Department staff reviews 100% of the ERMC trauma cases and identifies any areas of concern or opportunities for improvement. These quality cases are taken to the Trauma M&M committee for further review which demonstrates a comprehensive performance improvement review process for trauma and create actions plans to address deficiencies in criteria, coverage or performance.

Project milestones: Year 3: I-22. Increase the number of specialist providers for the high impact/most impacted medical specialties

• (I-22.2). Increase clinic hours and/or procedure hours in targeted specialties (includes evening and/or weekend)

I-23. Increase specialty care clinic volume of visits and evidence of improved access for patients seeking services

• (I-23.1) Documentation of increased number of visits. Demonstrate improvement over prior reporting period (baseline for DY3).

Year 4: I-27. Patient satisfaction with specialty care services.

• (I-27.1) Patient satisfaction scores: Average reported patient satisfaction scores, specific ranges and items to be determined by assessment tool scores. Demonstrate improvement over prior reporting period (baseline for DY3).




I-34. Documentation of increased number of visits for Medicaid and Uninsured patients over prior reporting period (over baseline for DY3).

• (I-34.1) Baseline/Goal: Increase Medicaid and uninsured patients’ trauma encounters by 2% over baseline for DY3

Year 5: I-27. Patient satisfaction with specialty care services.

• (I-27.1) Patient satisfaction scores: Average reported patient satisfaction scores, specific ranges and items to be determined by assessment tool scores. Demonstrate improvement over prior reporting period (baseline for DY3).



I-34. Documentation of increased number of visits for Medicaid and Uninsured patients over prior reporting period (over baseline for DY3).

• (I-34.1) Baseline/Goal: Increase Medicaid and uninsured patients’ trauma encounters by 2% over baseline for DY4.

Unique Community Need Identification Numbers the Project Addresses: CN.4: Lack of patient centered care as it related to trauma patients. How the Project Represents a New Initiative or Significantly Enhances an Existing Delivery System Reform Initiative: This is an expanded initiative with related activities that are funded by the U.S Department of Health and Human Services through the state trauma programs. Trauma Level III services would be new to the Edinburg area and strengthen the network of emergency care available to residents of the Rio Grande Valley. Related Category 3 Outcome Measure: IT-4.14. Initiate prophylaxis from intake to disposition to prevent VTE: Studies such as Potentially Preventable Complications, Healthcare Acquired Conditions and Patient Safety-Intensive Care have reported evidence of trauma complications including deaths related to VTEs: Incidence of Hospital-acquired Venous Thromboembolism (VTE) (SA). VTE can lead to higher healthcare cost due to longer LOS, increase risk of mortality, as well as increase in care required. With having trauma critical care intensivists caring for the trauma patients will provide more appropriate and timely care management as well as care being delivered and offered in the most appropriate setting. We anticipate with improved care management and education of ICU staff, there will be a 10% reduction in diagnosed VTEs. Relationship to Other Projects. One of our other DSRIP projects is to build freestanding Emergency Departments. Trauma Level III designation will provide these freestanding Emergency Departments a higher level of care facility for those consumers that required such level of care services. Relationship to Other Performing Providers’ Projects in the RHP. This project focuses on the expansion on Trauma Level III care services in order to provide this higher level of care to consumers in the Rio Grande Valley. STHS has ensured that these project plans meet the community needs and operate in conjunction with the RHP’s wide initiatives.


Furthermore, our proposed projects meet the needs of specific population and will not duplicate services of other performing provider projects in the RHP. Plan for Learning Collaborative. Many of the projects chosen by RHP 5 shift from traditional models of care delivery to more patient-focused, community-based, coordinated points of access and care transitions. As the region’s providers implement these new models of care delivery it is important that we share and learn from each other’s successes and challenges. Participating with the RAC V counsel and other facilities that participate in the RAC V will help our collective learning in the transformation of our region towards better trauma care and improved coordination. Our shared learning will also help in the identification of best practices and enhance the equity of services across the region. To support our shared learning in RHP 5, we will participate in the regional learning collaborative that is based on similar health or delivery challenges/projects and that focus on sharing knowledge, experience, and expertise. Project Valuation: The project will be valued based upon the successful attainment of the following expected results higher patient satisfaction, reduction in time to definitive care, improved patient outcomes, expanded availability of specialty care in the local community, & reduction of health system costs. The estimated total cost for expanding to a Trauma Level III facility includes salary expenses for a Trauma Program Coordinator, Trauma analysts, and a Trauma QA/PI analyst. Incremental equipment and supplies necessary to upgrade to Trauma Level II as well as education for staff are also included as necessary expenses. In addition, incremental specialty physician call pay will be required to provide necessary coverage in the ED. DY3 costs will be $2,725,764, DY4 costs will be $2,935,163, and DY5 costs will be $3,809,109 for a total of $9,470,036 over the three year period. The addition of a Level III Trauma Center at ERMC will expand the capacity of primary trauma care offered to better accommodate the needs of the regional patient population and community, as identified by the RHP needs assessment, so that patients have enhanced access to services, allowing them to receive the right care at the right time in the right setting. As a Trauma Level IV designated facility, ERMC often has to transfer patients outside its service area to receive services that could be provided in their own community with a Trauma Level III designated facility if provided in the primary care setting. This often results in more costly, less coordinated care and a lack of appropriate follow-up care. By enhancing access points, available appointment times, patient awareness of available services, patients and their families will align themselves with the primary trauma care system resulting in better health outcomes, patient satisfaction, and appropriate utilization and reduced cost of services. Information specific to project option 1.9

(1) This project will require the addition of general surgery coverage as well as orthopedic coverage for trauma patients in order for the facility to be upgraded to Trauma Level III.

(2) Trauma services are a high need for the Medicaid and uninsured population in ERMC’s primary service area. During the past year 76% of the 8,880 trauma patients arriving at ERMC were classified as being Medicaid or uninsured. This is a very significant population with acute needs that requires a larger scope of available specialty services and demands large amounts of hospital resources for treatment.

(3) High-intensity services are in high need for the Medicaid and uninsured population especially in the Edinburg area as there is currently no Level III designated Trauma facility to ensure needed coverage for patients with higher level trauma needs.


Project Title: Expand existing primary care capacity Unique RHP Project ID number: 094113001.1.106 Performing Provider/TPI: South Texas Health System / 094113001 Project Option: 1.1.2 Project Core Components: 1.1.2.a-c

PROJECT SUMMARY


Project Description Increase primary care access via the development Freestanding Emergency Departments which serve as the PCP for many of our populations indigent and uninsured. The target population will increase and have improved access as evidenced by a 20,000 visits in DY 3; 25,000 visits in DY 4; and 27,500 visits in DY 5. This project may also serve as an educational opportunity for the Family Practice Residency Program as well as the UTPA’s PA school, who regularly rotate students through STHS Emergency Departments. The project will supplement the access to the Medical Home Initiative by providing clinical resources necessary to patients 24/7. The project focuses on expanding emergency services to remote communities that are on the outside border of our primary service area. The FEDs expand the reach of advanced care programs/providers, including Cardiology, Psychiatry, Endocrinology, Substance Abuse, Pediatric Care, etc. In addition, services such as mammography, diagnostic imaging, vaccinations, preventive medicine, occupational medicine will be available to the underserved and uninsured populations.

Intervention(s) This FED project will expand the capacity of emergency care and primary care services and provide occupational medicine to community employees that need medical care 24 hours per day, 7 days per week. This project will supplement the development of the STHS Medical Home initiative by expanding the footprint of subacute, acute, diagnostic and educational access in the community.



South Texas Health System currently sees almost 90,000 patients through our Emergency Departments annually. We have identified that upward of 25% of these patients do not have a PCP and are not followed for appropriate aftercare. A third party community needs assessment show that Hidalgo County has a deficit of 78 PCPs, putting a burden on the existing emergency care systems to manage chronic and subacute conditions. Development of Freestanding Emergency Departments in the community expands all of the services STHS offers to a greater percent of the service area and address CN.1, the shortage of primary care and specialty care providers/access to primary care.

Target population The target population will increase and have improved access as evidenced by a 20,000 visits in DY 3; 25,000 visits in DY 4; and 27,500 visits in DY 5. Improved access to emergency and primary care will also help in the prevention of unnecessary hospital admissions, improved rate of annual vaccinations and the expansion of advanced emergency care (cardiovascular, trauma, orthopedic, etc) to populations that may not have access to these services on a 24 hour basis. Expected impact (total patients per year): DY3-20,000, DY4-25,000, DY5-27,500 primary care level I, level II and level III (subacute) patient encounters.


To increase emergency and primary care clinic access and evidence of improved access to the Medical Home initiative. The target population will increase and have improved access as evidenced by a 20,000 visits in DY 3; 25,000 visits in DY 4; and 27,500 visits in DY 5. This project may also serve as an educational opportunity for the Family Practice Residency Program as well as the UTPA’s PA school, who regularly rotate students through STHS Emergency Departments. The project will supplement the access and operation of the Medical Home Initiative by providing clinical resources necessary to patients 24/7. Quantifiable patient impact milestones are to provide: DY3-20,000, DY4-25,000, DY5-27,500 primary care encounters (metric I-12.1: Documentation of increased number of visits)

Category 3 outcomes expected patient benefits OD-1 Primary Care and Chronic Disease Management. This project expands primary care and chronic disease care by expanding access to medical providers/facilities/education 24 hours/day, 7 days/week via Freestanding Emergency Departments. The expansions of these services address IT-1.6 cardiovascular management, IT1.11/IT1.12IT1.13 diabetic care.


Project Title: 1.1.2 Expand Existing Primary Care Capacity

Unique Project ID: 094113001.1.106 Performing Provider Name/TPI: South Texas Health System 094113001 Project Core Components: 1.1.2.a-c

Project Description: This project will expand the capacity of primary care and chronic disease management services as well as provide occupational medicine to community employees that need medical care 24 hours/day, 7 days/week. South Texas Health System currently sees almost 90,000 patients through our Emergency Departments annually. We have identified that upward of 25% of these patients do not have a PCP and are not followed for appropriate aftercare. A third party community needs assessment show that Hidalgo County has a deficit of 78 PCPs, putting a burden on the existing emergency care systems to manage chronic and subacute conditions.This project will supplement the development of the STHS Medical Home initiative by expanding the footprint of subacute, acute, diagnostic and educational access in the community. Development of Freestanding Emergency Departments in the community expands all of the services STHS offers to a greater percent of the service area and address CN.1, the shortage of primary care and specialty care providers/access to primary care. GOAL: To increase emergency and primary care clinic access and evidence of improved access to the Medical Home initiative. The target population will increase and have improved access as evidenced by a 20,000 visits in DY 3; 25,000 visits in DY 4; and 27,500 visits in DY 5. This project may also serve as an educational opportunity for the Family Practice Residency Program as well as the UTPA’s PA school, who regularly rotate students through STHS Emergency Departments. The project will supplement the access and operation of the Medical Home Initiative by providing clinical resources necessary to patients 24/7. The project focuses on expanding emergency services to remote communities that are on the outside border of our primary service area. The expansion of access to emergency and primary care 24 hours per day, 7 days per week provides STHS the opportunity to expand the reach of its advanced care programs/providers, including Cardiology/Chest Pain, Orthopedic, Trauma, Psychiatry, Endocrinology, Substance Abuse, Pediatric Care, etc. In addition, services such as mammography, diagnostic imaging, vaccinations, preventive medicine, occupational medicine will be available to the underserved and uninsured populations.

Challenges Some anticipated challenges are as follows: 1) Starting capital – This project will require a significant amount of capital to construct the facilities. 2) Physician recruitment – The recruitment of trained Emergency Medicine physicians is difficult given our market and the growing need for EM providers nationally. STHS believes that participation in local programs, such as the Residency Programs will foster local physicians and develop a pipeline of well-trained practitioners in the future; however immediate physician demand remains constant. The 3-year expected outcome(s):


Over the 5 year demonstration period it is expected that with the expansion of Emergency Services in the community will reduce the number of unnecessary admissions and increase the utilization of Emergency Services to baseline by 20,000 visits in DY3, 25,000 visits in DY4 and 27,500 visits in DY 5. Regional goals The Regional goal is expanding access to emergency and primary care services 24 hours per day, 7 days per week providing STHS the opportunity to expand the reach of its advanced care programs/providers, including Cardiology/Chest Pain, Orthopedic, Trauma, Psychiatry, Endocrinology, Substance Abuse, Pediatric Care, etc. In addition, services such as mammography, diagnostic imaging, vaccinations, preventive medicine and occupational medicine will be available to the underserved and uninsured populations. Starting Point/Baseline. Hidalgo County is a medically underserved region. Emergency services falls in line with the lack of access and lack of primary care providers. As a result 35-45% of the population do not have a primary care provider, despite the prevalence of chronic disease such as diabetes, obesity, hypertension, etc. The uninsured and/or underinsured population make up the majority of the patients that do not have a PCP. Emergency Departments typically serves as the first line of medical care, particularly in pediatrics and diabetes. The development of the STHS Medical Home project will be supplemented by the expansion of Emergency Services. The two proposed Freestanding Emergency Departments are novel and have no volume at baseline. Rationale Hidalgo County is underserved in regard to primary care providers and access. The lack of PCP access has relegated the community’s underserved and uninsured to rely on Emergency Departments for basic, sub-acute care. South Texas Health System currently sees almost 90,000 patients through our Emergency Departments annually. We have identified that upward of 25% of these patients do not have a PCP and are not followed for appropriate aftercare. A third party community needs assessment show that Hidalgo County has a deficit of 78 PCPs, putting a burden on the existing emergency care systems to manage chronic and sub-acute conditions. Required core project components: 1.1.2 Expand existing emergency and primary care capacity. Required core project components: a) Expand emergency & primary care space – We plan to expand current space to accommodate additional practitioners. The new space will be approximately a total of 27,000 sq/ft. b) Expand emergency & primary care hours- The Freestanding Emergency Departments will be operational 24 hours per day, 7 days per week. c) Expand emergency & primary care staffing- The addition of 8 Emergency Medicine physicians. To meet these requirements we plan to implement the following process and improvement milestones: Year 3: Milestone P.2.1: Expand the number of additional clinics or expanded space.


Metric: Number of additional clinics. a. Data Source: Documentation of detailed expansion plan and provider schedule. b. Rationale: Providing access to emergency care in underserved communities has been shown to be

effective in reaching patients limited by hours of availability and resources. Milestone P.5.1: Documentation of utilization of emergency services and the enrollment in aftercare programs. Metric: Enrollment in Medical Home program a. Data Source: Documentation of completion of all items described by the RHP plan for this measure. Hospital or other Performing Provider report, policy, contract or other documentation b. Rationale: The accessibility of clinicians and services will expand the reach of the Medical Home program. Year 3: P-8: Utilize evidence based training material for medical homes based on the model change concepts. Metric: P-8.1. Use evidence based material to promote successful use of Medical Home. a. Data Source: Clinic documentation b. Rationale/Evidence: The implementation of a Medical Home will provide the support our patients that suffer chronic diseases require to prevent unwanted readmission and drive down the cost of care. I-12. Milestone: Increase primary care clinic volume of visits and evidence of improved access for patients seeking services. I-12.1. Metric: Documentation of increased number of visits. Demonstrate improvement over prior reporting period (over baseline for DY3). ) a. Total number of visits for reporting period b. Data Source: Registry, EHR, claims or other Performing Provider source c. Rationale/Evidence: This measures the increased volume of visits and is a method to assess the ability for the Performing Provider to increase capacity to provide care. Year 4 and 5: I-14: Increase primary care clinic volume of visits and evidence of improved access for patients seeking services Metric I-14.1: Documentation of increased Medical Home registrations. Demonstrate improvement over prior reporting period. a. Total number of Medical Home registrations for reporting period b. Data Source: Registry and clinical documents c. Rationale/Evidence: This initiative will provide access to patients seeking medical care and those that qualify should be registered into the Medical Home for support, education and clinical follow up that prevent more costly intervention. This Project addresses the following needs: CN.1: Access Barriers: Lack of Personal Resources CN.2: Access Barriers: Lack of Insurance CN.3: Primary Care Physician Shortage CN.8: Mid-Level Provider Shortage


CN 10: High ED Utilization

Related Category 3 Outcome Measure. IT-1.6: Cholesterol Management Improvement Target: Improve the access to emergent care related to chronic disease management such as blood pressure and cholesterol management. Data Source: Medical records The lack of primary care physicians and access to medical care at peak times and days has driven up the cost of emergent care via a lack of preventive interventions. The construction of Freestanding Emergency Departments expands the reach of STHS and the already developed programs, physicians, educational resources, etc that may help drive down the overutilization of services. IT-1.11/IT-1.12/IT-1.13: Diabetes care Improvement Target: Improve the access to emergent care related to chronic disease management such as diabetes. Data Source: Medical records The lack of primary care physicians and access to medical care at peak times and days has driven up the cost of emergent care via a lack of preventive interventions. The construction of Freestanding Emergency Departments expands the reach of STHS and the already developed programs, physicians, educational resources, etc that may help drive down the overutilization of services. Relationship to Other Projects. This project is related to the expansion of the Medical Home initiative by supplementing and increasing access to patient lives on the outer boundaries of the County.

Plan for Learning Collaborative. We plan to participate in the statewide learning collaborative. Our participation in a collaborative will facilitate sharing of challenges and testing of new ideas and solutions to promote continuous quality improvement in our health care system.

Project Valuation: • The expansion of emergency services provides increased access to uninsured and underserved

patients seeking emergent medical attention to do so conveniently and 24 hours per day, 7 days per week. The expanded access to emergent care also allows STHS to reach a greater number of patients with chronic conditions and enroll them in programs, such as the Medical Home and manage their condition in a more efficient, less costly manner. The common result is less coordinated care and lack of appropriate follow-up care. By enhancing access points, available appointment times, patient awareness of available services and overall OB/GYN primary care capacity, patients and their families will align themselves with the primary care system resulting in better health outcomes, patient satisfaction, and appropriate utilization and reduced cost of services.


C. Category 3: Quality Improvements Narratives for Category 3 measures will not need to be submitted at this time with the 3-year projects. Once revisions to Category 3 of the RHP Planning Protocol are approved, HHSC will ask providers to submit narratives for Category 3. For now, providers will indicate the value of the Category 3 measures in the Milestones and Metrics Table Excel file.


D. Category 4: Population-Focused Improvements (Hospitals only)


Performing Provider Name: Valley Regional Medical Center (“Valley”) Performing Provider TPI #: 020947001

Domain 1: Potentially Preventable Admissions (8 measures)

• Description – Valley will report on the 8 measures in this domain in an effort to gain information on and understanding of the health status of its patients with regard to potentially preventable admissions, which are often linked with poor chronic disease management and lack of access to appropriate outpatient healthcare.

• Valuation Rationale/Justification – The value Valley placed on this domain is based upon the value the hospital attributes to understanding the causes of and health/financial impacts of potentially preventable admissions. The goals of the Waiver are to reduce the cost of providing care and to improve patient access and health outcomes. Understanding our starting point and tracking our improvement is essential to making progress. PPAs negatively impact patient outcomes (including overall health, satisfaction, and quality of life), which can have short- and long-term consequences for the cost of delivering care to patients. The potential result of tracking and reducing PPAs in at Valley will have a beneficial impact on individual patient outcomes and significantly reduce the financial burden of paying for PPAs.

Domain 2: Potentially Preventable Readmissions – 30 days (7 measures)

• Description – Valley will report on the 7 measures in this domain in an effort to gain information on and understanding of the health status of patients it has treated, discharged, and then readmitted for the same principal diagnosis. Too many patients are released from the hospital into the community with no follow-up or support, and end up back in the hospital inpatient setting soon thereafter.

• Valuation Rationale/Justification - The value Valley placed on this domain is based upon the value the hospital attributes to understanding the causes of and health/financial impacts of 30-day readmissions. Specifically, the measures are targeted towards prevalent chronic diseases and then allow for a broad measure of readmissions, which will allow the hospital to gauge the potential causes of these rates in conjunction with each other and as a whole. The goals of the Waiver are to reduce the cost of providing care and to improve patient access and health outcomes. Understanding our starting point and tracking our improvement is essential to making progress. The potential result of tracking and reducing PPRs for Valley patients will have a beneficial impact on individual patient outcomes and significantly reduce the financial burden of paying for PPRs.


Domain 3: Potentially Preventable Complications (64 measures)

• Description – Valley will report on the 64 measures in this domain in an effort to understand the most prevalent causes of PPCs and to use the information to make institutional reforms toward reducing the rates. Hospitals suffer from shortages of space, staffing, equipment, and protocols for preventing complications like the measures in this domain, and Valley is dedicated to assuring that it takes all possible steps to improve its provision of healthcare where indicated.

• Valuation Rationale/Justification - The value Valley placed on this domain is based upon the value the hospital attributes to understanding the causes of and health/financial impacts of potentially preventable complications. Reporting on this domain will require the hospital to evaluate its own performance, and will allow for institutional change that will be invaluable for the hospital’s patients and the hospital’s operating costs. The goals of the Waiver are to reduce the cost of providing care and to improve patient access and health outcomes. Understanding our starting point and tracking our improvement is essential to making progress.

Domain 4: Patient-Centered Healthcare (2 measures)

• Description – Valley will report on Patient Satisfaction and Medication Management under this domain in an effort to gauge how well the hospital is serving its patients. How a patient perceives his/her care often affects that patient’s willingness to engage in follow-up, self-management, and honest interactions with practitioners. As a consequence of patient dissatisfaction, patients may experience negative health outcomes and become even more disillusioned with the healthcare delivery system. Valley is committed to preventing this from happening.

• Valuation Rationale/Justification - The value Valley placed on this domain is based upon the value the hospital attributes to understanding how patients perceive the care they receive from Valley and how well Valley performs its function of promoting medication management. Valley is committed to improving patient outcomes, and therefore places a high value on these measures. The goals of the Waiver are to reduce the cost of providing care and to improve patient access and health outcomes. Understanding our starting point and tracking our improvement is essential to making progress. Prevalent chronic disease and lack of care coordination for traditionally underserved patients in the Rio Grande Valley is costly to patients’ health and to the delivery system, and Valley believes that its hospital services must leave these patients satisfied and confident in the healthcare delivery system, in order for the expansion of primary care to have the maximum beneficial impact for the community.


Domain 5: Emergency Department (1 measure)

• Description – Valley will measure the admit decision time to ED departure time for admitted patients. This measure is important because patients often languish in hospital EDs due to lack of systemic cooperation between hospitals, their departments, and other types of providers, and the patients experience poor health outcomes as a result.

• Valuation Rationale/Justification - The value Valley placed on this domain is based upon the value the hospital attributes to knowing how well it is currently performing in the ED and to making goals for self-improvement. Long ED wait times can lead to complications, poor outcomes, and patient dissatisfaction with their care. The goals of the Waiver are to reduce the cost of providing care and to improve patient access and health outcomes. Understanding our starting point and tracking our improvement is essential to making progress.


Performing Provider Name: Rio Grande Regional Hospital (“Rio”) Performing Provider TPI #: 112716902

Domain 1: Potentially Preventable Admissions (8 measures)

• Description – Rio will report on the 8 measures in this domain in an effort to gain information on and understanding of the health status of its patients with regard to potentially preventable admissions, which are often linked with poor chronic disease management and lack of access to appropriate outpatient healthcare. Rio expects that its expansion of OB/GYN services in its community clinics will have a positive impact on the number of PPAs for women with manageable obstetric/gynecological conditions that can be treated and/or managed outside of the hospital setting with proper access to primary care. Additionally, the physicians providing the OB/GYN care can provide patients with detection and management of other conditions that lead to PPAs for clients who are otherwise unable to access primary care. Rio also expects its asthma project to improve the status of PPAs.

• Valuation Rationale/Justification – The value Rio placed on this domain is based upon the value the hospital attributes to understanding the causes of and health/financial impacts of potentially preventable admissions. The goals of the Waiver are to reduce the cost of providing care and to improve patient access and health outcomes. Understanding our starting point and tracking our improvement is essential to making progress. PPAs negatively impact patient outcomes (including overall health, satisfaction, and quality of life), which can have short- and long-term consequences for the cost of delivering care to patients. The potential result of tracking and reducing PPAs in at Rio will have a beneficial impact on individual patient outcomes and significantly reduce the financial burden of paying for PPAs.

Domain 2: Potentially Preventable Readmissions – 30 days (7 measures)

• Description – Rio will report on the 7 measures in this domain in an effort to gain information on and understanding of the health status of patients it has treated, discharged, and then readmitted for the same principal diagnosis. Too many patients are released from the hospital into the community with no follow-up or support, and end up back in the hospital inpatient setting soon thereafter.

• Valuation Rationale/Justification - The value Rio placed on this domain is based upon the value the hospital attributes to understanding the causes of and health/financial impacts of 30-day readmissions. Specifically, the measures are targeted towards prevalent chronic diseases and then allow for a broad measure of readmissions, which will allow the hospital to gauge the potential causes of these rates in conjunction with each other and as a whole. The


goals of the Waiver are to reduce the cost of providing care and to improve patient access and health outcomes. Understanding our starting point and tracking our improvement is essential to making progress. The potential result of tracking and reducing PPRs for Rio patients will have a beneficial impact on individual patient outcomes and significantly reduce the financial burden of paying for PPRs.

Domain 3: Potentially Preventable Complications (64 measures)

• Description – Rio will report on the 64 measures in this domain in an effort to understand the most prevalent causes of PPCs and to use the information to make institutional reforms toward reducing the rates. Hospitals suffer from shortages of space, staffing, equipment, and protocols for preventing complications like the measures in this domain, and Rio is dedicated to assuring that it takes all possible steps to improve its provision of healthcare where indicated.

• Valuation Rationale/Justification - The value Rio placed on this domain is based upon the value the hospital attributes to understanding the causes of and health/financial impacts of potentially preventable complications. Reporting on this domain will require the hospital to evaluate its own performance, and will allow for institutional change that will be invaluable for the hospital’s patients and the hospital’s operating costs. The goals of the Waiver are to reduce the cost of providing care and to improve patient access and health outcomes. Understanding our starting point and tracking our improvement is essential to making progress.

Domain 4: Patient-Centered Healthcare (2 measures)

• Description – Rio will report on Patient Satisfaction and Medication Management under this domain in an effort to gauge how well the hospital is serving its patients. How a patient perceives his/her care often affects that patient’s willingness to engage in follow-up, self-management, and honest interactions with practitioners. As a consequence of patient dissatisfaction, patients may experience negative health outcomes and become even more disillusioned with the healthcare delivery system. Rio is committed to preventing this from happening.

• Valuation Rationale/Justification - The value Rio placed on this domain is based upon the value the hospital attributes to understanding how patients perceive the care they receive from Rio and how well Rio performs its function of promoting medication management. Rio is committed to improving patient outcomes, and therefore places a high value on these measures. The goals of the Waiver are to reduce the cost of providing care and to improve


patient access and health outcomes. Understanding our starting point and tracking our improvement is essential to making progress. Prevalent chronic disease and lack of care coordination for traditionally underserved patients in the Rio Grande Valley is costly to patients’ health and to the delivery system, and Rio believes that its hospital services must leave these patients satisfied and confident in the healthcare delivery system, in order for the expansion of primary care to have the maximum beneficial impact for the community.

Domain 5: Emergency Department (1 measure)

• Description – Rio will measure the admit decision time to ED departure time for admitted patients. This measure is important because patients often languish in hospital EDs due to lack of systemic cooperation between hospitals, their departments, and other types of providers, and the patients experience poor health outcomes as a result. Rio hopes that its care transition project will help improve this domain.

• Valuation Rationale/Justification - The value Rio placed on this domain is based upon the value the hospital attributes to knowing how well it is currently performing in the ED and to making goals for self-improvement. Long ED wait times can lead to complications, poor outcomes, and patient dissatisfaction with their care. The goals of the Waiver are to reduce the cost of providing care and to improve patient access and health outcomes. Understanding our starting point and tracking our improvement is essential to making progress.


Performing Provider Name: Harlingen Medical Center (HMC) Performing Provider TPI #: 154504801 Related Category 1 or 2 Project: 154504801.2.100 – Medication Management and 154504801.2.101 – Care Transitions Domain 1: Potentially Preventable Admissions (8 measures) Domain Description: Our projects focus on making sure that patients who are admitted receive medication management and smooth care transitions in order to avoid preventable readmissions. As such, we do not expect our projects to have a direct impact on PPAs. Although we do not expect any direct project impact in Domain 1, HMC is dedicated to reducing PPAs. Domain 2: Potentially Preventable Readmissions (PPRs) – 30 days (7 measures) Domain Description: Our projects focus on making sure that patients who are admitted receive medication management and smooth care transitions in order to avoid preventable readmissions. As such, we expect significant reductions in readmissions for those patients who are targeted for the medication management and care transitions programs. Domain 3: Potentially Preventable Complications (64 measures) Domain Description: As our projects focus more on discharge and post-hospitalization follow-up care, we do not expect our project to influence PPCs. Although we do not expect any direct project impact in Domain 3, HMC is dedicated to implementing evidence-based practices and improving patient safety thereby preventing hospital-acquired conditions. Domain 4: Patient‐Centered Healthcare (2 measures) Domain Description: As our projects focus on discharges, it is possible we may expect our projects to influence targeted inpatients’ satisfaction with care. Domain 5: Emergency Department (1 measure) Domain Description: As our projects focus on non-ED patients, we do not expect our projects to influence admit decision time to ED departure time for admitted patients. Although we do not expect any direct project impact in Domain 5, HMC is committed to improving the patient transfer process.


Category 4 Population‐Focused Improvements McAllen Hospitals LP dba South Texas Health System Performing Provider Name: McAllen Hospitals LP dba South Texas Health System Performing Provider TPI #: 094113001 Related Category 1 or 2 Project:

• 94113001.1.100/102/103/106 – Expand Existing Primary Care Capacity; • 94113001.1.101 – Workforce Enhancement Initiatives to Increase Access; • 94113001.1.104/105 – Expand Trauma Care Capacity; • 94113001.2.100 – Implement a Telemedicine Program with Psychiatric Specialists • 94113001.2.101 – Patient Centered Medical Home to Rural & Impoverished Areas • 94113001.2.102 – Emergency Department Patient Navigator Program

IGT Entity for DYs 3‐5: Hidalgo County via LPPF Domain 1: Potentially Preventable Admissions (PPA) ‐ 8 Measures Through the development of a Mobile Primary Care Unit (#94113001.1.100), the surrounding rural and Mcallen/Edinburg communities will have the opportunity to access a variety of health resources in a timely and cost effective manner. The mobile units will offer preventative screenings which include: High Blood Pressure, Peripheral Arterial Disease, and Abdominal Aortic Aneurysm screenings. Through the Expanded Primary Care Capacity of this project, the target population will be patients within our primary and secondary service areas that are unable to access appropriate care due to distance issues.

• CHF Admission Rate • Diabetes Admission Rates • Hypertension Admission Rate • Bacterial Pneumonia Immunization • Influenza Immunization

Through the development of Psychiatry Access (#94113001.1.101), we are planning to increase capacity to provide Psychiatry services through the addition of two full time Board Certified Psychiatrists and one full time licensed clinical Psychotherapist that will treat adult & children in both an inpatient & outpatient setting. The shortage of behavioral health providers leads to situations resulting in need for costly and lengthy inpatient treatments.

• Behavioral Health and Substance Abuse Admission Rate The goal of the Primary Care Expansion project (#94113001.1.102) is to increase primary care access and capacity by expanding and restructuring clinic hours, decreasing the amount of time for patients to obtain appointments, and by enhancing same-day walk-in clinics to accommodate patients with acute illnesses and/or or in need of preventative care. Anticipated benefits include increased access to preventative, primary and chronic care, reduced risk of delayed or forgone needed treatments,


improved preventative tests/screening/vaccination rates, improved chronic care management, improved health outcomes, and reduced ED/hospital services.

• Pediatric Asthma • Bacterial Pneumonia Immunization • Influenza Immunization • Diabetes Admission Rates • CHF Admission Rate • Behavioral Health and Substance Abuse Admission Rate

The expansion of OB/GYN services (#94113001.1.103) will expand access for primary care services; improve prenatal care, and education for uninsured and underserved populations in the community. Resulting expectation include improved patient outcomes, reduced early elective deliveries, and increases safe delivery practices. Additionally reduced need for services to be provided in an urgent and emergent care settings.

• Hypertension Admission Rate • Diabetes Admission Rate • Bacterial Pneumonia Immunization • Influenza Immunization

STHS will purse designation as an American College of Surgeons Level II Trauma Center at McAllen Medical Center (#94113001.1.104). The improved trauma care, expansion and renovation , improved access to specialty facilities, and the development of a comprehensive care system will bring together ground and air EMS, emergency services, referring hospitals, free-standing emergency centers, trauma surgeons, subspecialty physicians and rehabilitation facilities. The increased access to trauma care services will result in: higher patient satisfaction, reduction in time to definitive care, improved patient outcomes, expanded availability of specialty care in the local community, and reduction in health inpatient services.

• CHF Admission Rate • Diabetes Admission Rate • Behavioral Health and Substance Abuse Admission Rate • COPD Admission Rate • Hypertension Admission Rate • Pediatric Asthma • Bacterial Pneumonia Immunization • Influenza Immunization

STHS will purse designation as an American College of Surgeons Level III Trauma Center at Edinburg Regional Medical Center (#94113001.1.105). The improved trauma care, expansion and renovation , improved access to specialty facilities, and the development of a comprehensive care system will bring together ground and air EMS, emergency services, referring hospitals, free-standing emergency


centers, trauma surgeons, subspecialty physicians and rehabilitation facilities. The increased access to trauma care services will result in: higher patient satisfaction, reduction in time to definitive care, improved patient outcomes, expanded availability of specialty care in the local community, and reduction in health inpatient services.


Through the development of Free-Standing Emergency departments (#94113001.1.106), the project will increase primary care access for patients that use emergency services as the PCP. This project will serve as an educational opportunity for the Family Practice Residency program as well as UTPAs PA school who rotate students the Emergency department. The project will supplement the access to the Medical Home initiative by providing clinical resources necessary to patients 24/7. FEDs will expand advanced care in Cardiology, Psychiatry, Endocrinology, Substance Abuse, Pediatric Care, etc.


The Telemedicine Program (#94113001.2.100) will be establishing Psychiatrists availability for consultation, evaluation and treatment for patients in remote sites. STHS will contract local Psychiatrists who will be providing access to hospitals, agencies and patients in the region. Outpatient remote services will allow for medication management and crisis intervention.

• Behavioral Health and Substance Abuse Admission Rate The goal of the Patient Centered Medical Home project (#94113001.2.101) is to provide safety net primary health care services to targeted patients who live in HPSA, rural and impoverished areas of Hidalgo County. Project would improve access to comprehensive, primary, preventative and chronic care through the implementation of the medical home model. The project would convert nine Nuestra Clinica sites into patient-centered medical homes in order to provide more preventative and proactive primary and chronic care that is both coordinated and patient-centered.



The goal of project (#941130012.102), Patient Navigation, is to increase the number of patients seen in a more appropriate level of care through the implementation of a patient navigation services and ED triage protocol. The expected benefits include: helping patients better navigate the health care system, increase patient access to on-going primary and chronic care, provide care management and coordinated care, provide access health insurance coverage via Medicaid, Health Insurance Exchanges, improve at-risk patients health conditions and reduce preventable ED and/or hospital visits.


Domain 2: Potentially Preventable Readmissions (PPRs) – 30 days (7 measures) Through the development of a Mobile Primary Care Unit (#94113001.1.100), the surrounding rural and Mcallen/Edinburg communities will have the opportunity to access a variety of health resources in a timely and cost effective manner. The mobile units will offer preventative screenings which include: High Blood Pressure, Peripheral Arterial Disease, and Abdominal Aortic Aneurysm screenings. Through the Expanded Primary Care Capacity of this project, the target population will be patients within our primary and secondary service areas that are unable to access appropriate care due to distance issues.

• CHF 30-Day Re-admissions • Diabetes 30-Day Re-admissions • Behavioral Health and Substance Abuse 30-Day Re-admissions • COPD 30-Day Re-admissions • Stroke 30-Day Re-admissions • Pediatric Asthma 30-Day Re-admissions


• All Cause 30-Day Re-admissions Through the development of Psychiatry Access (#94113001.1.101), we are planning to increase capacity to provide Psychiatry services through the addition of two full time Board Certified Psychiatrists and one full time licensed clinical Psychotherapist that will treat adult & children in both an inpatient & outpatient setting. The shortage of behavioral health providers leads to situations resulting in need for costly and lengthy inpatient treatments.

• Behavioral Health and Substance Abuse 30-Day Re-admissions The goal of the Primary Care Expansion project (#94113001.1.102) is to increase primary care access and capacity by expanding and restructuring clinic hours, decreasing the amount of time for patients to obtain appointments, and by enhancing same-day walk-in clinics to accommodate patients with acute illnesses and/or or in need of preventative care. Anticipated benefits include increased access to preventative, primary and chronic care, reduced risk of delayed or forgone needed treatments, improved preventative tests/screening/vaccination rates, improved chronic care management, improved health outcomes, and reduced ED/hospital services.

• CHF 30-Day Re-admissions • Diabetes 30-Day Re-admissions • Behavioral Health and Substance Abuse 30-Day Re-admissions • COPD 30-Day Re-admissions • Stroke 30-Day Re-admissions • Pediatric Asthma 30-Day Re-admissions • All Cause 30-Day Re-admissions


• Diabetes 30-Day Re-admissions • Stroke 30-Day Re-admissions • All Cause 30-Day Re-admissions




STHS will purse designation as an American College of Surgeons Level III Trauma Center at Edinburg Regional Medical Center (#94113001.1.105). The improved trauma care, expansion and renovation , improved access to specialty facilities, and the development of a comprehensive care system will bring together ground and air EMS, emergency services, referring hospitals, free-standing emergency centers, trauma surgeons, subspecialty physicians and rehabilitation facilities. The increased access to trauma care services will result in: higher patient satisfaction, reduction in time to definitive care, improved patient outcomes, expanded availability of specialty care in the local community, and reduction in health inpatient services.




The Telemedicine Program (#94113001.2.100) will be establishing Psychiatrists availability for consultation, evaluation and treatment for patients in remote sites. STHS will contract local


Psychiatrists who will be providing access to hospitals, agencies and patients in the region. Outpatient remote services will allow for medication management and crisis intervention.

• Behavioral Health and Substance Abuse 30-Day Re-admissions The goal of the Patient Centered Medical Home project (#94113001.2.101) is to provide safety net primary health care services to targeted patients who live in HPSA, rural and impoverished areas of Hidalgo County. Project would improve access to comprehensive, primary, preventative and chronic care through the implementation of the medical home model. The project would convert nine Nuestra Clinica sites into patient-centered medical homes in order to provide more preventative and proactive primary and chronic care that is both coordinated and patient-centered.




Domain 3: Potentially Preventable Complications (64 measures) Each of our projects will focus on reducing Potentially Preventable Complications for the 64 Risk-Adjusted Measures Through the development of a Mobile Primary Care Unit (#94113001.1.100), the surrounding rural and Mcallen/Edinburg communities will have the opportunity to access a variety of health resources in


a timely and cost effective manner. The mobile units will offer preventative screenings which include: High Blood Pressure, Peripheral Arterial Disease, and Abdominal Aortic Aneurysm screenings. Through the Expanded Primary Care Capacity of this project, the target population will be patients within our primary and secondary service areas that are unable to access appropriate care due to distance issues. Through the development of Psychiatry Access (#94113001.1.101), we are planning to increase capacity to provide Psychiatry services through the addition of two full time Board Certified Psychiatrists and one full time licensed clinical Psychotherapist that will treat adult & children in both an inpatient & outpatient setting. The shortage of behavioral health providers leads to situations resulting in need for costly and lengthy inpatient treatments. The goal of the Primary Care Expansion project (#94113001.1.102) is to increase primary care access and capacity by expanding and restructuring clinic hours, decreasing the amount of time for patients to obtain appointments, and by enhancing same-day walk-in clinics to accommodate patients with acute illnesses and/or or in need of preventative care. Anticipated benefits include increased access to preventative, primary and chronic care, reduced risk of delayed or forgone needed treatments, improved preventative tests/screening/vaccination rates, improved chronic care management, improved health outcomes, and reduced ED/hospital services. The expansion of OB/GYN services (#94113001.1.103) will expand access for primary care services; improve prenatal care, and education for uninsured and underserved populations in the community. Resulting expectation include improved patient outcomes, reduced early elective deliveries, and increases safe delivery practices. Additionally reduced need for services to be provided in an urgent and emergent care settings. STHS will purse designation as an American College of Surgeons Level II Trauma Center at McAllen Medical Center (#94113001.1.104). The improved trauma care, expansion and renovation , improved access to specialty facilities, and the development of a comprehensive care system will bring together ground and air EMS, emergency services, referring hospitals, free-standing emergency centers, trauma surgeons, subspecialty physicians and rehabilitation facilities. The increased access to trauma care services will result in: higher patient satisfaction, reduction in time to definitive care, improved patient outcomes, expanded availability of specialty care in the local community, and reduction in health inpatient services. STHS will purse designation as an American College of Surgeons Level III Trauma Center at Edinburg Regional Medical Center (#94113001.1.105). The improved trauma care, expansion and renovation , improved access to specialty facilities, and the development of a comprehensive care system will bring together ground and air EMS, emergency services, referring hospitals, free-standing emergency centers, trauma surgeons, subspecialty physicians and rehabilitation facilities. The increased access to trauma care services will result in: higher patient satisfaction, reduction in time to definitive care, improved patient outcomes, expanded availability of specialty care in the local community, and reduction in health inpatient services.


Through the development of Free-Standing Emergency departments (#94113001.1.106), the project will increase primary care access for patients that use emergency services as the PCP. This project will serve as an educational opportunity for the Family Practice Residency program as well as UTPAs PA school who rotate students the Emergency department. The project will supplement the access to the Medical Home initiative by providing clinical resources necessary to patients 24/7. FEDs will expand advanced care in Cardiology, Psychiatry, Endocrinology, Substance Abuse, Pediatric Care, etc. The Telemedicine Program (#94113001.2.100) will be establishing Psychiatrists availability for consultation, evaluation and treatment for patients in remote sites. STHS will contract local Psychiatrists who will be providing access to hospitals, agencies and patients in the region. Outpatient remote services will allow for medication management and crisis intervention. The goal of the Patient Centered Medical Home project (#94113001.2.101) is to provide safety net primary health care services to targeted patients who live in HPSA, rural and impoverished areas of Hidalgo County. Project would improve access to comprehensive, primary, preventative and chronic care through the implementation of the medical home model. The project would convert nine Nuestra Clinica sites into patient-centered medical homes in order to provide more preventative and proactive primary and chronic care that is both coordinated and patient-centered. The goal of project (#941130012.102), Patient Navigation, is to increase the number of patients seen in a more appropriate level of care through the implementation of a patient navigation services and ED triage protocol. The expected benefits include: helping patients better navigate the health care system, increase patient access to on-going primary and chronic care, provide care management and coordinated care, provide access health insurance coverage via Medicaid, Health Insurance Exchanges, improve at-risk patients health conditions and reduce preventable ED and/or hospital visits. Domain 4: Patient‐Center Healthcare (2 measures) Through the development of a Mobile Primary Care Unit (#94113001.1.100), the surrounding rural and Mcallen/Edinburg communities will have the opportunity to access a variety of health resources in a timely and cost effective manner. The mobile units will offer preventative screenings which include: High Blood Pressure, Peripheral Arterial Disease, and Abdominal Aortic Aneurysm screenings. Through the Expanded Primary Care Capacity of this project, the target population will be patients within our primary and secondary service areas that are unable to access appropriate care due to distance issues.

• Patient Satisfaction (Inpatient Setting Only) DOES NOT APPLY, OUTPATIENT PROJECT • Medication Management (Inpatient Setting Only) DOES NOT APPLY, OUTPATIENT PROJECT.

Through the development of Psychiatry Access (#94113001.1.101), we are planning to increase capacity to provide Psychiatry services through the addition of two full time Board Certified Psychiatrists and one full time licensed clinical Psychotherapist that will treat adult & children in both an inpatient & outpatient setting. The shortage of behavioral health providers leads to situations resulting in need for costly and lengthy inpatient treatments.


• Patient Satisfaction (Inpatient Setting Only) • Medication Management (Inpatient Setting Only)

The goal of the Primary Care Expansion project (#94113001.1.102) is to increase primary care access and capacity by expanding and restructuring clinic hours, decreasing the amount of time for patients to obtain appointments, and by enhancing same-day walk-in clinics to accommodate patients with acute illnesses and/or or in need of preventative care. Anticipated benefits include increased access to preventative, primary and chronic care, reduced risk of delayed or forgone needed treatments, improved preventative tests/screening/vaccination rates, improved chronic care management, improved health outcomes, and reduced ED/hospital services.






STHS will purse designation as an American College of Surgeons Level III Trauma Center at Edinburg Regional Medical Center (#94113001.1.105). The improved trauma care, expansion and renovation , improved access to specialty facilities, and the development of a comprehensive care system will bring together ground and air EMS, emergency services, referring hospitals, free-standing emergency centers, trauma surgeons, subspecialty physicians and rehabilitation facilities. The increased access to trauma care services will result in: higher patient satisfaction, reduction in time to definitive care, improved patient outcomes, expanded availability of specialty care in the local community, and reduction in health inpatient services.





The Telemedicine Program (#94113001.2.100) will be establishing Psychiatrists availability for consultation, evaluation and treatment for patients in remote sites. STHS will contract local Psychiatrists who will be providing access to hospitals, agencies and patients in the region. Outpatient remote services will allow for medication management and crisis intervention.


The goal of the Patient Centered Medical Home project (#94113001.2.101) is to provide safety net primary health care services to targeted patients who live in HPSA, rural and impoverished areas of Hidalgo County. Project would improve access to comprehensive, primary, preventative and chronic care through the implementation of the medical home model. The project would convert nine Nuestra Clinica sites into patient-centered medical homes in order to provide more preventative and proactive primary and chronic care that is both coordinated and patient-centered.




Domain 5: RD‐5. Emergency Department Projects below address NQF 0497 – Admit decision time to ED departure time for admitted patients:

• 94113001.1.104/105/106 – Expand Trauma Care Capacity; • 94113001.2.102 – Emergency Department Patient Navigator Program


STHS will purse designation as an American College of Surgeons Level II Trauma Center at McAllen Medical Center (#94113001.1.104). The improved trauma care, expansion and renovation , improved access to specialty facilities, and the development of a comprehensive care system will bring together ground and air EMS, emergency services, referring hospitals, free-standing emergency centers, trauma surgeons, subspecialty physicians and rehabilitation facilities. The increased access to trauma care services will result in: higher patient satisfaction, reduction in time to definitive care, improved patient outcomes, expanded availability of specialty care in the local community, and reduction in health inpatient services. STHS will purse designation as an American College of Surgeons Level III Trauma Center at Edinburg Regional Medical Center (#94113001.1.105). The improved trauma care, expansion and renovation , improved access to specialty facilities, and the development of a comprehensive care system will bring together ground and air EMS, emergency services, referring hospitals, free-standing emergency centers, trauma surgeons, subspecialty physicians and rehabilitation facilities. The increased access to trauma care services will result in: higher patient satisfaction, reduction in time to definitive care, improved patient outcomes, expanded availability of specialty care in the local community, and reduction in health inpatient services. Through the development of Free-Standing Emergency departments (#94113001.1.106), the project will increase primary care access for patients that use emergency services as the PCP. This project will serve as an educational opportunity for the Family Practice Residency program as well as UTPAs PA school who rotate students the Emergency department. The project will supplement the access to the Medical Home initiative by providing clinical resources necessary to patients 24/7. FEDs will expand advanced care in Cardiology, Psychiatry, Endocrinology, Substance Abuse, Pediatric Care, etc. The goal of project (#941130012.102), Patient Navigation, is to increase the number of patients seen in a more appropriate level of care through the implementation of a patient navigation services and ED triage protocol. The expected benefits include: helping patients better navigate the health care system, increase patient access to on-going primary and chronic care, provide care management and coordinated care, provide access health insurance coverage via Medicaid, Health Insurance Exchanges, improve at-risk patients health conditions and reduce preventable ED and/or hospital visits.


Performing Provider Name: Knapp Medical Center (KMC) Performing Provider TPI #: 135035706 Related Category 1 or 2 Project: 135035706.1.100 – Expand Primary Care Capacity Domain 1: Potentially Preventable Admissions (8 measures) Domain Description: Our project focuses on expanding primary care capacity so that more patients can receive ongoing care in the outpatient setting, thereby improving their ability to prevent and manage health conditions. As such, we would expect our project to potentially have some impact on reducing PPAs. Improved outpatient care can improve patient outcomes and quality of life, reduce the need for emergency/acute care, reduce the potential for complications associated with hospitalization and reduce health care costs. These factors also contribute to patient satisfaction. Domain 2: Potentially Preventable Readmissions (PPRs) – 30 days (7 measures) Domain Description: Our project focuses on expanding primary care capacity so that more patients can receive ongoing care in the outpatient setting, thereby improving their ability to prevent and manage health conditions. As such, we would expect our project to potentially have some impact on reducing PPRs, assuming that patients post-hospitalization utilize the primary care clinic being established through our project. Improved outpatient care can improve patient outcomes and quality of life, promote self-management and ongoing care, and reduce the risk of readmission. These factors also contribute to patient satisfaction. Domain 3: Potentially Preventable Complications (64 measures) Domain Description: As our project focuses on outpatients, we do not expect our project to influence PPCs. Although we do not expect any direct project impact in Domain 3, KMC is dedicated to implementing evidence-based practices and improving patient safety thereby preventing hospital-acquired conditions. Domain 4: Patient‐Centered Healthcare (2 measures) Domain Description: As our project focuses on outpatients, we do not expect our project to influence inpatients’ satisfaction with care. Although we do not expect any direct project impact in Domain 3, KMC is dedicated to improving the patient experience. Domain 5: Emergency Department (1 measure) Domain Description: As our project focuses on non-ED outpatients, we do not expect our project to influence admit decision time to ED departure time for admitted patients. Although we do not expect any direct project impact in Domain 5, KMC is committed to improving the patient transfer process.


Section IV. RHP Participation Certifications Each RHP participant that will be providing State match or receiving pool payments must sign the following certification. For the December 20, 2013 submission of new three-year projects, this certification only needs to be signed by the IGT Entities and Performing Providers for the proposed three-year projects along with any IGT Entities/Performing Providers that were not included in the December 2012 RHP Plan submission that joined the RHP between then and now. By my signature below, I certify the following facts:

• I am legally authorized to sign this document on behalf of my organization; • I have read and understand this document; • The statements on this form regarding my organization are true, correct, and complete

to the best of my knowledge and belief.

Signature Name Organization

The following RHP Participation Certifications are included in the plan:

• Columbia Valley Healthcare Systems, LP, dba Valley Regional Medical Center

• Rio Grande Regional Hospital

• Harlingen Medical Center

• University of Texas Health Science Center Houston

• McAllen Hospital LP dba South Texas Health System

• Knapp Medical Center


REGIONAL HEALTHCARE PARTNERSHIP

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