1. The Care Transitions Network
August 31, 2016
National Council for Behavioral Health Montefiore Medical Center Northwell Health New York State Office of Mental Health Netsmart Technologies

2. Transforming Clinical Practice Initiative
Practice Transformation Networks (PTNs)
The Care Transitions Network for People with Serious Mental Illness is part of the CMS-funded Transforming Clinical Practice Initiative.
Improve patient and population-level health outcomes
Reward the delivery of high value care
Increase long-term financial sustainability
The Care Transitions Network is one of 29 CMS-funded Practice Transformation Networks across the country, but the only one designed to help primary health and behavioral health practices who serve people with serious mental illness.

3. Five “Phases of Transformation”
Set Aims
Use Data to Drive Care
Achieve Progress on Aims
Benchmark Status
Thrive as a Business Through Value-Based Payment Systems
All 29 Practice Transformation Networks will support more than 140,000 clinicians to progress through the “phases of transformation”
Achieve the triple aim: to improve patient experience, improving health outcomes and reduce per capita health care costs.

4. Change Package Family and Patient-Centered Care Design
1.1 Patient and family engagement
1.2 Team-based relationships
1.3 Population management
1.4 Practice as a community partner
1.5 Coordinated care delivery
1.6 Organized, evidence based care
1.7 Enhanced access to care
Continuous, Data-Driven Quality Improvement
2.1 Engaged and committed leadership
2.2 Quality improvement strategy supporting a culture of quality and safety
2.3 Transparent measurement and monitoring
2.4 Optimal use of HIT
Sustainable Business Operations
3.1 Strategic use of practice revenue
3.2 Workforce vitality and joy in work
3.3 Capability to analyze and document value
3.4 Efficiency of operation

5. CMS Alternative Payment Model Framework

6. Clinical Practice Improvement Activities
15% of the MIPS composite score linked to CPIA’s
Participation in the TCPI project
24/7 access to MIPS eligible clinicians
Integrated behavioral and mental health
Screening for social determinants of health

7. How do we prepare today for transformation tomorrow?

8. Thank you! www.CareTransitionsNetwork.org
The project described was supported by Funding Opportunity Number CMS-1L from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services.
Disclaimer: The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.