Regional Healthcare Partnership Planning Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver Activities And Workgroup Participation

Waiver Introduction In an effort to reduce costs, the 2011 Texas Legislature directed the Texas Health and Human Services Commission to expand managed care and preserve hospital access to UPL (Upper Payment Limit) funding In response, HHSC applied for an 1115 waiver 5 year waiver was approved by CMS in December 2011, and became effective immediately Waiver authorizes Texas’ expansion of managed care (which took effect March 1st) and creates a new methodology for continuing UPL hospital funding

New Hospital Payment Methodology Under the new waiver, trended historic UPL funds and additional new funds are distributed to hospitals through two pools: Uncompensated Care (UC) Pool Costs of care provided to individuals who have no third party coverage for the services provided by hospitals or other providers Delivery System Reform Incentive Payments (DSRIP) Support coordinated care and quality improvements through Regional Healthcare Partnerships (RHPs) to transform care delivery systems .

Transition Period UPL payments have a one year transition through September 2012 Funding to hospitals remains largely the same during the first year. Effective October 2012, payments to hospitals from the former UPL program will be made only through Uncompensated Care Pool and DSRIP Pool

What is DSRIP? The Delivery System Reform Incentive Payment Pool provides “incentive” payments for health-care related projects and investments to increase or improve: Access to health-care services Quality of health-care and health systems Cost/effectiveness of services and health systems Regional collaboration and coordination

Qualifying for DSRIP and UC – Regional Healthcare Partnerships Development To qualify for UC and DSRIP funds, local entities that currently receive UPL funds are required to collaborate in regions with other local entities, hospitals, and other key stakeholders to create RHPs. The RHP anchor (Harris County Hospital District) serves as the primary point of contact for the region, coordinate RHP activities and provides administrative oversight. RHP regions should reflect deliver systems and geographic proximity. HHSC has developed a map with suggested regions, but final decisions have not yet been made. .

RHP Activities RHPs bring participants and stakeholders together to develop an RHP Plan for public input and review Participants with IGT matching funds (a unit of local government including a public hospital, hospital district, county, city, or local mental health authority) will make final decisions regarding the selected incentive projects included in the RHP plan The anchor does not decide which projects other IGT entities will select

RHP Plan Requirements RHP Plans are developed by each RHP, but the general requirements are determined by HHSC and CMS and will include: Regional health needs assessments Participating local entities Identification of hospitals receiving incentives Incentive projects by DSRIP categories Yearly performance measures

Workgroup Activities Based on a review of more than 30 community needs assessment documents, topical Stakeholder Workgroups have been created to assist in the development of potential DSRIP performance activities. The primary focus is to identify innovative healthcare initiatives to improve access to care, quality of care, cost of care, and the overall health of our community population. Each workgroup will collaborate with other members to develop specific recommendations that will be submitted to the Regional Advisory Council for review and consideration. IGT entities will make the final determination of which DSRIP measures they will include in their program. .

DSRIP Plan Options HHSC is developing a list of DSRIP initiative options from which workgroups will select projects for consideration Group of “clinical champions” is advising HHSC on menu options List is scheduled to be released April 1st HHSC will select a at least limited number of projects that all hospitals will be required to include in their RHP plan HHSC also is developing metrics for measuring progress in reaching project goals, but we do not know how specific the metrics will be or how much flexibility RHP entities will have

DSRIP Category 1: Infrastructure Development Expand behavioral health care access Provide culturally competent care Expand primary and specialty care access Enhance health promotion and disease prevention Improve urgent and emergent care Improve performance and reporting capacity

DSRIP Category 2: Program Innovation and Redesign Create and implement: Strategies to implement Potentially Preventable Events Behavioral health delivery systems Delivery models using telemedicine Financing mechanisms for providers Health promotion and disease prevention improvements Strategies to reduce inappropriate ED use Medical Home Model Disease registry management

DSRIP Category 3: Quality Improvements Improvements in prevention and/or management of: Behavioral health admissions Obesity Congestive heart failure Potentially preventable admissions Asthma Pre-39 week elective induction Diabetes Birth trauma rate Healthcare-acquired infections Central line-associated bloodstream infections HIV Surgical site infections Hypertension Stroke/chest pain Medication management

DSRIP Category 4: Population-focused Improvement Patient/care giver experience Care coordination Preventative health At-risk populations

Timeline of Key Dates Task Responsibility Due Date UC Protocol Due to CMS HHSC 3-1-2012 DSRIP Project Menus for Categories 1,2,3,4 Due to RHPs 4-1-2012 DSRIP Payment Protocols Due to RHPs 6-1-2012 RHP Urban Regions Due to HHSC Urban RHPs RHP Rural Regions Due to HHSC Rural RHPs 7-1-2012 RHP Regions Due to CMS 8-1-2012 Final Urban RHP DSRIP Plans Due to HHSC DSRIP Payment Protocols and Project Menus Due to CMS 8-31-2012 Final Rural RHP DSRIP Plans Due to HHSC 9-1-2012 Final DSRIP Plans Due to CMS 10-31-2012

Goals for Workgroup Planning Brainstorm project ideas in workgroup areas for each DSRIP category (preferably no more than 5-10 ideas for all 4 categories) Identify goal of projects Identify expected outcomes Identify challenges/issues Identify metrics

Things to keep in mind Projects must have an IGT partner to provide the non-federal share Projects must be something you are not currently doing today; may be projects that you planned to do Outcomes must be measurable. Metrics will determine if you have achieved goals in each year (and payment). Make them a stretch, but doable. Advance payments are not available, so initiatives need to be something that can be financed in the first year. Federal match payments available at the end of year one will provide some working capital in year two.

Ground Rules Listen actively to others Practice meeting courtesy -- one person talks at a time; do not interrupt; no side conversations All ideas are welcome Express yourself completely and concisely Participate enthusiastically and fully but do not “over-participate” Mute cell phones and other devices; stay focused on conversation in the room

Project Example – Infrastructure (From California DSRIP Plan) Implement Disease Registries Five Year Goals: Primary Care providers and staff of all primary care clinics will be trained in the use of disease management registry, panel management and the chronic care model Providers will receive monthly registry reports on their patients with diabetes and hypertension Providers at all primary care clinics will meet monthly with a panel manager and the care team to coordinate care Process Milestones: Year 1 - Develop curriculum and initiate training of providers and staff at facility’s primary care clinics in the use and principles of disease management registry, including training in the chronic care model and panel management Metrics: Training logs, agendas, curricula, presentations and participant learning survey Year 2 - Train 75% of providers and staff at all primary care clinics in the use and principles of disease management registry. Include training in the chronic care model and panel management Metrics: Training logs, agenda, presentations and participant learning survey Year 3 – Integrate 2-hour refresher training into annual training plans of all primary care clinic clinical staff, and achieve a minimum of 75% completion of training by clinical staff Metrics: Document that annual competency plans for primary care clinics include chronic disease training; document attendance rate; training logs

Project Example –Innovation and Redesign (From California DSRIP plan) Improve Patient Flow in the Emergency Department Five Year Goals Reduce overall ED length-of-stay for both low acuity patients and for patients admitted to the hospital by 20% compared to the 2010 baseline 2010. Process Milestones: Year 1 - Develop and disseminate monthly med-surgical ED flow report that identifies average ED length-of-stay for both low acuity patients (level 4&5) and for patients admitted to the hospital, and establish an organizational baseline for 2010. Metrics: Average length-of-stay for the two populations as measured by electronic time stamps in ED information system Year 2 – Identify and implement three improvement interventions and monitor and report their impact on flow Metrics: Reports documenting interventions and results Year 3 – Reduce overall ED length-of-stay for both low acuity patients(level 4 and 5) and for patients admitted to the hospital by 10% compared to baseline 2010 Metrics: Average length-of-stay for the two populations as measured by electronic time stamps in ED system Year 4 – Reduce overall ED length of stay for both low acuity patients and for patients admitted to the hospital by 20% compared to baseline 2010 Metrics: Average length of stay for the two populations as measured by electronic time stamps in ED system