1. Heart of Virginia Healthcare Kick-off
March 2, 2016
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2. The Heart of Virginia Healthcare is one of seven cooperatives funded by the Agency for Healthcare Research and Quality’s (AHRQ) EvidenceNOW initiative. Through this $10.6 million grant initiative, participating practices will have the opportunity to participate in a prestigious learning collaborative to improve quality, team function, satisfaction and revenue.
Benefits to Signature Partners include:
Clinical Integration facilitation by expert faculty from George Mason University
Consultative expert medical faculty from Virginia Commonwealth University
Process improvement and practice resources from our state’s quality improvement organization, VHQC, and the American Medical Association
Additional reporting resources on clinical quality measures that we are already targeting and required to report to CMS
Financial incentives to the network and providers

3. SPN Infrastructure Agenda Introductions/attendance – 5 min
Quality and Clinical Integration Coordinators – 10 min
The Case for the Heart of Virginia Healthcare Cooperative – 15 min
Required Data for the HVH Evaluation – 15 min
Measuring the ABCS: Current Recommendations to Prevent Control Cardiovascular Disease – 30 min
Joy in Practice – 45 min
Closing and additional resources
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4. SPN Infrastructure Signature Partners Snapshot (as of January 2016)
Innovation Health
180,000 total members; 50,000 from HIX
21,000 attributed to SPN
Goal: increase to 43,000 attributed by end of 2016
MSSP
31,000 attributed
Medicare Advantage
4700 total in Aetna MA plan; approximately 500 attributed to SPN
Intent to shift to Innovation Health MA product in 2018 with aggressive marketing
Hospitals 12
5 Inova hospitals
6 Valley Health hospitals (4 Critical Access Hospitals)
Fauquier (effective March 2016)
Primary Care Physicians (peds/adult): 288
Employed PCPs: 92 (65 Inova, 27 Valley)
Independent PCPs: 196
Specialists 586
IMG Employed: 151
Valley employed: 113
Independent: 322
Hospital/facility based: 2,000
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5. Signature Partners Quality and Clinical Integration Program and the Heart of Virginia Healthcare

6. Quality and Clinical Integration Coordinator Role
Practice-based quality subject matter experts
Aligns Signature programs, initiatives, grant work, etc. to the goals of the practice
Facilitates clinical data integration to the network
Assists in data interpretation in order to create meaningful, practice-based, quality improvement projects

7. SPN Quality Initiatives
Medicare Shared Savings Program – 34 accountable care organization measures
Innovation Health - narrow network – clinical and efficiency measures
The Advanced Illness Model (C-TAC/VQHC) - to improve care for patients with advanced illness and their families.
- Virginia’s Physician Orders for Scope of Treatment
Diabetes: Together 2 Goal® - AMGA program
- Retinal Group of Washington Diabetic Eye Exam pilot
Million Hearts® Campaign
COPD, Early Diagnosis and Appropriate Management
- American Association of Respiratory Care Spirometry Training
Heart of Virginia Healthcare (George Mason University and VCHI/VQHC)

8. HVH Practice Coaches/SPN Quality Coordinators
Our Quality Coordinators will work cooperatively with HVH Practice Coaches and provide all of the necessary documentation EXCEPT for the surveys (addressed later in the presentation) which must be submitted directly to George Mason University
We will use the HVH Toolkit
AMA STEPS Forward modules
VCU expert faculty are available to discuss practice improvement techniques
We will schedule on-site visits with each practice’s manager and physician/clinical leaders and continue to touch base weekly (or more frequently if necessary)
We will help facilitate EvidenceNow Advancing Heart Health in Primary Care MOC which may be applied to ABFM and ABIM through August 2017

9. HVH Kick-Off
The video excerpts that follow were originally recorded on February 13, 2016, in Williamsburg, VA by the Heart of Virginia Healthcare Team and featured the following speakers:
Kurtis Elward, MD, MPH is Co-Chair, VAFP Practice Improvement Committee. He has extensive experience in practice redesign and quality improvement and maintains a full scope family medicine practice near Charlottesville.
Mark Greenawald, MD is Vice Chair for Academic Affairs and Professional Development, Department of Family and Community Medicine at the Virginia Tech Carilion School of Medicine. He has presented at both VAFP and AAFP meetings on strategies to improve professional well-being and practice culture.
Stephen Horan, PhD is the founding president of Community Health Solutions, bringing more than 25 years of professional experience to each client and project. Under Steve’s leadership Community Health Solutions has helped hundreds of organizations achieve better results through focused assessment, design, capacity building, and execution.
James Jenkins, MD is the managing partner for Fairfax Family Practice Centers and has presented many times at regional and statewide meetings on keys to maximizing reimbursement for office care.
Alex Krist, MD, MPH is an Associate Professor of Family Medicine and Population Health at Virginia Commonwealth University. He is a member of the US Preventive Services Task Force and has been active in the creation and dissemination of evidence based guidelines for many years.
Anton Kuzel, MD, MHPE is Professor and Chair of Family Medicine and Population Health at Virginia Commonwealth University and the principal investigator for Heart of Virginia Healthcare. He has worked for years to identify innovations in primary care practice that lead to better outcomes, better care, lower costs, and more enjoyable practice. He has published on practice transformation and practice team function in Family Practice Management.
Susan Miller, MD has championed transforming VCU Family Medicine clinics to idealized designs and is an Institute for Healthcare Improvement Idealized Design of Clinical Office Practice trainer.
Christine Sinsky, MD and Thomas Sinsky, MD are general internists from Dubuque, Iowa and have developed much of the practical strategies for practice redesign that is part of the Heart of Virginia Healthcare curriculum. Christine was one of the authors of “Finding Joy in Primary Care”.

10. The Case for the Heart of Virginia Healthcare Cooperative

11. Required Data for the HVH Evaluation

12. SPN Infrastructure 2 Research Expectations
Data Collection for 4 measures
Signature is already collecting the necessary data, so we will provide this data to George Mason University/HVH in a de-identified aggregated state
We will working with George Mason University/HVH to help facilitate data collection for newer practices that have not yet become clinically integrated
Surveys
Providers will receive financial incentives when they complete the set of surveys:
One-time survey is a little longer and best completed by your practice manager as it collects information about structural HIT, practice characteristics, and QI capacities
Interval Surveys (total of 3/staff member over the 3 year grant) very short surveys that assess the perceptions of change management
TIMELINE: NOW, then 12 months and then 9 months from then
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13. SPN Infrastructure ABCS Clinical Quality Measures
A: Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic.
Percentage of patients aged 18 years and older with IVD with documented use of aspirin or other antithrombotic
B: Hypertension (HTN): Controlling High Blood Pressure.
Percentage of patients aged 18 through 85 years who had a diagnosis of HTN and whose blood pressure was adequately controlled (<140/90) during the measurement year
C: Preventive Care and Screening: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease.
Percentage of high-risk adult patients 21 and older who were previously diagnosed with, or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR adult patients 21 and older with a fasting or direct Low-Density Lipoprotein Cholesterol (LDL-C) level >= 190 mg/dL; OR patients aged years with a diagnosis of diabetes with a fasting or direct LDL-C level of mg/dL; who were prescribed or are already on statin medication therapy during the measurement year
S: Preventive Care and Screening: Tobacco Use.
Percentage of patients aged 18 years and older who were screened about tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user
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14. SPN Infrastructure
Surveys
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15. Measuring the ABCS: Current Recommendations to Prevent and Control Cardiovascular Disease

16. Joy in Practice

17. Additional Resources

18. SPN Infrastructure Additional Videos
Contact Signature Partners Quality Director, Darlene Almanza, RN, MPH, for more information at or
The Journey to Joy in Practice
Optimizing Teamwork: Building Personal Resilience and Creating Culture by Design
Optimizing the Financial Picture
Optimizing Key Workflows
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19. SPN Infrastructure 2016 MSSP Information 2016 MSSP Program Information
Attachment A
Attachment B
Attachment C
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20. SPN Infrastructure 2016 Innovation Health CQMs
Innovation Health Attribution Methodology
Innovation Health Quality Measures
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21. SPN Infrastructure Together 2 Goal Together2Goal Campaign
Together2Goal Measure Specifications
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22. SPN Infrastructure Advance Care Planning C-TAC Advance Care Measures:
1) % of Enrollees with Advance Directive
N = Enrollees with documented advance directive in the EMR
D = All active enrollees
2) % of Enrollees with POLST
N= Enrollees with POLST documentation in the EMR
D= All active enrollees
3) % of Patients with Care Goals and Preferences Documented in the EMR and Updated Monthly
N= Enrollees with monthly documentation of care goals and preferences
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