Practice Transformation Network KHC/KDHE Community Work Group Rosanne Rutkowski, MPH, BSN, RN Kansas Healthcare Collaborative

Transforming Clinical Practice Initiative (TCPI) Practice Transformation Network (PTN)

Healthcare reimbursement framework is changing

Chronic Care Model Health System Community Health Care Organization Self-Management Support Delivery System Design Decision Support Clinical Information Systems Community Resources, Systems & Environments Productive Interactions Chronic Care Model Informed, Activated & Connected Patient Prepared Proactive Practice Team Population Health Outcomes / Clinical Outcomes And if we think back to the chronic care model, we’re really talking about this area of patient self-management support. This is a natural bridge for us to build between providers and community.

What is TCPI? And where does TCPI fit into this change? TCPI is the major initiative designed to “provide hands-on support to 140,000 physicians and other clinicians for developing the skills and tools needed to improve care delivery and transition to alternative payment models.” -HHS Secretary Sylvia M. Burwell

Kansas PTN Practices 1,352 Providers 272 practices (unique ZIP+4, TIN & Specialty) 148 are rural 22 part of FQHC organizations 234 in areas designated as Medically Underserved *Enrollment is ongoing 14

PTN: Phases of Transformation

PTN: Drivers Patient & Family Engagement Team Based Relationships Population Management Practice as a Community Partner Coordinated Care Delivery Organized Evidence- based Care Enhanced Access Engaged & Committed Leadership Quality Improvement Strategy to Support a Culture of Quality & Safety Transparent Measurement & Monitoring Optimal Use of HIT Strategic Use of Practice Revenue Workforce Vitality & Joy in Work Capability to Analyze & Document Value Efficiency of Operation

Compass PTN data system Web portal developed by Telligen Aggregate monthly numerator and denominator Entered by hand or through QRDA Type-3 file Optional patient-level tracking for clinics without EHR Transformation Plan Practice Assessment Tool

Self Management

Risk Level Stratification

Community Referral Systems

Takeaway 1422/1305 clinical strategies are aligned with the PTN drivers Most practices have are at an early stage of transformation Providers will be financially accountable for providing quality and value (lots of pressure) To impact their performance on outcome measures, they will need greater integration with resources outside of the clinic Change takes time and this change is monumental

Special Projects Coordinator Your Kansas PTN Team Kendra Tinsley Executive Director ktinsley@khconline.org Rosanne Rutkowski Program Director rrutkowski@khconline.org Karlen Haury Quality Improvement Advisor khaury@khconline.org Mary Monasmith Quality Improvement Advisor mmonasmith@khconline.org Josh Mosier Quality Improvement Advisor jmosier@khconline.org Craig Concannon, MD PTN Clinical Lead Rhonda Lassiter Executive Assistant rlassiter@khconline.org Eric Cook-Wiens Data and Measurement Manager ecook-wiens@khconline.org Jonathan Smith Quality Improvement Advisor jsmith@khconline.org Jill Daughhetee Quality Improvement Advisor jdaughtee@khconline.org Amanda Prosser Special Projects Coordinator aprosser@khconline.org Alyssa Miller Project Coordinator amiller@khconline.org

Thank you.