Meeting 1 Brownsville Regional Campus

NameOrganizationContact John Susan Anaelle Pablo Andrew LombardoRio Grande Valley Janie MartinezRio Grande Valley Kelley Emily AlpertBrownsville Community Health Humberto GonzalezSu Judith PerezSu Michael PaezValley Baptist Health Justin RockValley Baptist Health Brownsville Regional Campus School of Public Health

Brownsville Regional Campus School of Public Health 1115 Waiver Background 2011 Texas Health and Human Services Commission (HHSC) 1115 waiver Preserve Upper Payment Limit (UPL) Expand Medicaid managed care services in Texas 1115 waiver goes into 2 statewide pools of funding ($29 billion over five years) 1. Uncompensated care pool to reimburse hospitals for the cost of Medicaid and uninsured patients 2. Delivery System Response Incentive Payment (DSRIP) pool Incentive payments to providers for transforming healthcare practices Enhance access to health care Increase quality of care, coordination, and cost-effectiveness

Brownsville Regional Campus School of Public Health Regional Healthcare Partnership 5 Regional healthcare partnerships (RHPs) DSRIP delivered through RHPs 20 RHPs in Texas We are RHP5 Cameron, Hidalgo, Starr, Willacy

Brownsville Regional Campus School of Public Health High Prevalence of Diabetes in RHP5 RHP5 Needs Assessment (August 2012) 31% (388,00) adults with diabetes 51% (197,000) undiagnosed 56% (216,500) untreated Underlying diabetes present in >50% of hospital admissions

Brownsville Regional Campus School of Public Health 8 DSRIP Projects University of Texas Health Science Center at San AntonioUniversity of Texas Health Science Center at Houston 1.Implement patient-centered medical home (PCMH) at Su Clinica Familiar 1.Implement a Chronic Disease Management Registry 2.Expand Model of Management of Chronic Diseases in Lower Valley of RHP 5: Salud y Vida program 2.Implement patient-centered medical home (PCMH) at Brownsville Community Health Center 3.Expand a Patient Care Navigation Program based on a Mobile Clinic model 3.Implement innovative Evidence-based strategies to reduce and prevent obesity in Children and Adolescents: MEND program (Mind, Exercise, Nutrition, Do it) 4.Implement Evidence-based Health Promotion Programs through a community wide campaign to promote healthy lifestyles 4.Expand Model of Management of Chronic Diseases in Upper Valley of RHP 5: Salud y Vida program

Chronic Disease Registry Goals Short-term: Create use cases for chronic disease registry Populate the chronic disease registry with patient data Implement the chronic disease registry service for participating providers Identify provider needs Evaluate practice workflows Leverage Wellcentive to fill provider needs Evaluate the potential performance of the chronic disease registry Brownsville Regional Campus School of Public Health

Chronic Disease Registry Goals Long-Term Reduce the prevalence of diabetes in the Lower Rio Grande Valley Create chronic disease registry best practices Evaluate the effectiveness of the chronic disease registry tool Evaluate the adoption of the chronic disease registry Evaluate the impact of the chronic disease registry Brownsville Regional Campus School of Public Health

Brownsville Regional Campus School of Public Health

The Registry Review Background Brownsville Regional Campus School of Public Health 1.Milestone 3: Develop a cross-functional team to evaluate registry program. Metric #1: P-4.1: Documentation of roles and number of personnel (clinical, IT, administrative) assigned to evaluate registry program. a.Baseline: 0. b.Goal: Establish a cross functional team with at least 5 members to evaluate the registry c.Data Source: Team roster and minutes from team meetings. d.Metric Measure: Number and role of personnel assigned to evaluate the registry. e.Metric Type: Number. f.Numeric Goal: 5. g.QPI Metric: No.

The Registry Review Purpose Brownsville Regional Campus School of Public Health Identify provider needs. Evaluate existing workflows. Identify where the chronic disease registry will fit in. Evaluate the potential performance of the chronic disease registry. Create use case documents for the chronic disease registry. Create chronic disease registry best practice documents. Evaluate the efficacy of the chronic disease registry. Evaluate the adoption of the chronic disease registry. Evaluate the impact of the chronic disease registry. Evaluate the accuracy/reliability of the data inside of the chronic disease registry.

The Registry Review Member Roles Brownsville Regional Campus School of Public Health a.Metric Measure: Number and role of personnel assigned to evaluate the registry. Roles based on expertise and organization affiliation? NameOrganization John BenderUTHealth Susan Fisher-HochUTHealth Anaelle MoalUTHealth Pablo SanchezUTHealth Andrew LombardoRio Grande Valley HIE Janie MartinezRio Grande Valley HIE NameOrganization Kelley ChesterWellcentive Emily AlpertBrownsville Community Health Center Humberto Gonzalez Su Clinica Judith PerezSu Clinica Michael PaezValley Baptist Health System Justin RockValley Baptist Health System

The Registry Review Future Meetings Pushing back reporting to April, 2014 Need for weekly meetings in September? Push back to every two weeks? Future meeting coordination 1. Decide on regular meetings now? Doodle poll? Adobe connect poll? 2. Decide in the future? Doodle poll? Adobe connect poll? Brownsville Regional Campus School of Public Health

Chronic Disease Registry/HIE Updates Salud y Vida patients populated Demographic and lab data Currently evaluating workflows and using Wellcentive to fill gaps Kickoff call 8/29: Needs Identified Need a calendar “A1c due” reminder for 3, 6, and 9 months Patient-information compliant secure communication Patient-level view for Promotoras. Su Clinica Meeting 8/29 to establish buy-in Next step: Implementation Brownsville Regional Campus School of Public Health

Questions/Next Meeting Questions: How can we make these meetings better? Format, topics, perspectives, etc. Any other questions? Next Meeting: What reports would be helpful for hospitals? How can Salud y Vida use Wellcentive most effectively? Any other proposed topics? Brownsville Regional Campus School of Public Health

Thank you! Brownsville Regional Campus School of Public Health