1. Janet Hurley MD Operational Chief of Primary Care, CHRISTUS® Trinity Mother Frances Health System

2.  Early efforts toward medical home transformation ◦ National Demonstration Project ◦ Texas Medical Home Initiative Pilot  Interim Learning ◦ Employee Health Plan ◦ Payer Pilots  Department transformation

3.  EMR (Centricity)  Regular review of quality dashboards for HEDIS measures with physician quality bonus  Cost saving measures with a local employer to prescribe generics, but did not share in the savings

4.  Refill protocol  Team-Based care with daily huddles  Virtual office visits

5.  Achieved NCQA Level 3 designation  Began secure email communication with patients  More active team-based care model in the clinic

6. 6 NCQA PPC-PCHM Recognition  CERTIFIED 2011 LEVEL III  RECERTIFIED 2014 LEVEL III

7.  Began using RN Nurse Navigators to target high risk patients (BCBS)  Began using LVN Care Coordinators to do previsit planning and care gap closures  Quarterly best practice meetings  Started measuring customer service via CGCAHPS

8.  Did not have access to claims data

9.  Health Plan members given financial incentives to: ◦ Choose a PCP ◦ Have an annual wellness visit and biometric labs ◦ Engage with Nurse Navigator, Care Coordinator, or Case Manager if contacted  Financial disincentives to seek care outside of the system  Focused Care Coordination on the highest risk and rising risk/cost members

10.  Case Management ◦ Manage high costs ◦ Help members navigate the system ◦ Close Care Gaps  Disease Management and monitoring ◦ Monitor compliance rates ◦ Manage risk factors  Diabetes Grant program

11.  Via Nurse Navigator, Care Coordinator, Web Tools, and Provider Office ◦ Tobacco Cessation Counseling ◦ Weight Management Coaching ◦ Physical Activity Coaching ◦ Dietary Counseling ◦ Stress Coaching ◦ Nurse Advice Line

12.  HEDIS metrics ◦ Met or exceeded our goals in 11/12 metrics  Cost ◦ Payouts per member per year had been going up steadily from 2010-2013 ◦ Reduction in health care costs by $400 per member per year between 2013-2014  Comparison to Cohort (11 total members) ◦ TMFHC excelled compared to our peers in quality and cost measures

13.  Exposed some high-cost products ◦ Compounded creams $2,000-$14,000/mo  We CAN manage patients better to improve quality and reduce costs, but…  We cannot achieve cost and quality metrics without a strong and engaged Primary Care Base

14. Primary Care Chief 18 sites, approx.100 providers

17. Primary Care Chief RN Nurse Navigators (2-3) LVN Care Coordinators (2- 3) IT Analyst (part-time) Physician Champion

19.  Creation of the Primary Care Leadership Infrastructure  Modernization of Primary Care Practice Sites  Recruiting ◦ Increased new physician salary guarantee ◦ $125,000 loan repayment ◦ $10,000 referral bonus if physician is later hired ◦ Educational stipends for residents that sign on early ◦ More proactive engagement with local residency program  Retention ◦ $2 million salary increase to Primary Care Jan 2016

20.  Emphasis on Primary Care Revitalization  EHR clinical decision support tools that assist with achieving quality goals  Quarterly best practice meetings at each site to share quality, discuss system achievements and share best practices  Specialists are encouraged to release standing orders for care gaps if they are due

21.  Address physician concerns ◦ EMR Efficiency Classes ◦ Primary Care Revitalization Committee  Provide Staff and Physician Leadership Development  Address Physician Burn-Out

22.  Quality Committee responsible for assigning goals for the Physician Quality Bonus ◦ Primary Care—Goal to achieve 90 th percentile of HEDIS metrics ◦ Specialty Care—specialty specific goals  Care Gap lists are now embedded in the EMR  Each site responsible for setting goals and formally documenting a plan to achieve them  LVN Care Coordinators are assigned to each site to assist with care gaps  New compensation plan has10% of physician salary tied to achieving quality, access, and customer service metrics

23.  Purpose ◦ Provide a multidisciplinary care management program for highly complex patients, especially those who had frequent hospitalizations or ER visits  Team Members ◦ Physician ◦ Advanced Practice Provider ◦ Nurse Navigator ◦ Licensed Professional Counselor ◦ Pharmacist ◦ Dietician

24. 24  ACO/MSSP: 21,000 covered lives  Medicare Advantage: 8,000 covered lives  Commercial: 21,000 covered lives

25.  PMPM care management fees  Quality achievement rewards  Shared savings

26.  Sustaining Medical Home Changes within a large organization does not occur without effort  Large organizations should commit to making a functional leadership structure for their primary care departments  Large organizations should make a financial investment in primary care