PRACTICE TRANSFORMATION NETWORK 2/24/16

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3 Transforming Clinical Practice Initiative (TCPI) Practice Transformation Network (PTN)  $18.6 million – 4 year time period  Broader focus of Practice Transformation  Includes Pediatric & Adult Practices, Specialists

4 BOLD AIM Statement By September 2019, we will engage and support 3000 clinicians across North and South Carolina in transforming their practices for success in a value-based healthcare environment. These clinicians will achieve sustained improvement in practice efficiency and quality of care, and demonstrate savings through reduction of unnecessary testing and avoidable hospital use. Their patients will use more preventive services, engage in better management of chronic conditions, experience better health outcomes, and report greater satisfaction with care received. Empowering Practices for Success in a Value Based Healthcare Environment

5 Practices Will Be Supported With….  On–site practice transformation coach with expertise in QI methodologies, practice facilitation, population management, care coordination and self-management; and how to use data and analytics to support transformation  Expert resources for implementing behavioral health integration and medication management strategies  Technical tools for rapid-cycle measurement and feedback and patient registries for identifying gaps in care and tracking outcomes  Assistance with proactive, data-driven identification of patients most likely to benefit from targeted interventions

6 CORE Measure Set Includes…  Preventive—adult and pediatric  Disease Management---adult and pediatric  Patient Experience---adult and pediatric  Cost and Utilization

7 You are not alone in this work….let us help! We will meet you where you are at You don’t have to work on all measures at once Focus on what is applicable to your patient populations Measures align with our Clinically Integrated Network and Heart Health Now Transformation stages align well with PCMH work

8 We Can Help You With…..  Implementing daily team huddles  Pre-visit planning  Improving medication adherence  Working better as a team  Tracking, coordinating, closing the loop on referrals  Optimizing the space you have  Avoiding over testing  Managing your panel of patients  Lowering your “no show” rate  Self-management strategies/resources  Behavioral health integration

9 You and Your Practice: What PTN expects  Commit to do this work and dedicate resources  Create Quality Improvement Team with a provider champion  Engage with your PTN Coach at least twice a month  Participate in practice assessments, rapid cycle small tests of change  Report, review, and use your data to drive improvement  Share best practices  Engage in collaborative learning activities such as webinars (whenever possible)  Participate in PQRS (Physician Quality Reporting System) reporting, as applicable Patient Experience Cost and Utilization

10 PTN Coach: What you can expect  Mentor, guide and provide assistance to support your practice through the “five phases of transformation”  Visit your practice on-site a minimum of (2) times per month  Meet you where you are at and help you develop goals and a plan to move forward  Provide free QI tools and resources to assist with your QI work.  Teach you how to conduct rapid cycle small tests of change and identify best practices  Train you on QI methodologies and tools  Help you review, analyze and interpret your data to determine quality of care and to identify problems, patterns, and high- risk activities. Patient Experience Cost and Utilization

11 Questions?