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

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

3. Healthcare reimbursement framework is changing

5. 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.

6. 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

7. 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

8. PTN: Phases of Transformation

9. 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

10. 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

11. Self Management

12. Risk Level Stratification

13. Community Referral Systems

14. 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

15. Special Projects Coordinator
Your Kansas PTN Team
Kendra Tinsley
Executive Director
Rosanne Rutkowski
Program Director
Karlen Haury
Quality Improvement
Advisor
Mary Monasmith
Quality Improvement
Advisor
Josh Mosier
Quality Improvement
Advisor
Craig Concannon, MD
PTN Clinical Lead
Rhonda Lassiter
Executive Assistant
Eric Cook-Wiens
Data and
Measurement Manager
Jonathan Smith
Quality Improvement
Advisor
Jill Daughhetee
Quality Improvement
Advisor
Amanda Prosser
Special Projects Coordinator
Alyssa Miller
Project Coordinator

16. Thank you.