1. Progress on the Healthcare Transformation Waiver in RHP 2
Craig S. Kovacevich, MA
Associate Vice President
Waiver Operations & Community Health Plans
Office of the President
The University of Texas Medical Branch at Galveston
Wednesday, August 20, 2014

2. Regional Health Partnership: Region 2
UTMB 2

3. Regional Health Partnership: Region 2
Galveston
Brazoria
Nacogdoches
Angelina
Shelby
Sabine
San Augustine
Jefferson
Orange
Jasper
Newton
Liberty
Hardin
Tyler
Polk
San Jacinto
UTMB
16 counties
Population of nearly 1.5 million people
Covers nearly 14,500 square miles
Urban and rural with varying infrastructure challenges
25% of population is uninsured
27% of population is on Medicaid or Medicaid/Medicare (dual eligible)
More than 50% of the region is designated as Health Professional Shortage Area in Primary Care and/or Mental Health
85 total projects (including the 10 newly approved 3-year projects)
DY3 Category 1/2 valuation = $78,488,310.45
Major Project Topics:
15 are to Establish/Expand Primary Care
5 are to expand Behavioral Health to Underserved Areas
5 are for crisis stabilization
6 are to Expand Specialty Care Access
4 are on Care Transitions
10 are on Evidence-Based Interventions for Behavioral Health

4. RHP 2 Community Needs Assessment
Access barriers
Personal resource challenges (i.e. transportation)
Lack of insurance coverage
Health care workforce shortages
Physicians (primary and specialty care)
Mental/behavioral health providers
Allied health professionals (mid-level providers, nurses, etc.)
Dentists
Community Health Workers/Patient Navigators
High ED utilization and 30-day readmission rate
Chronic disease Incidence
Diabetes
Heart & vascular related diseases
Mental health related morbidity and mortality

5. RHP 2 Regional Goals and Objectives
Expand access to and coordination of:
Patient-centered primary care
Behavioral health care services
Health promotion and disease prevention
Specialty care services
Chronic disease management
Improve quality of care through:
Continued process improvements
Collaborative learning opportunities
Development of innovative solutions
Grow health system resources by:
Expanded and enhanced healthcare workforce training
Educate future healthcare professionals through interdisciplinary training that contemplates tomorrow’s delivery system

6. RHP 2 Readmissions Learning Collaborative
Goals:
Expand quality improvement reporting capacity by improving utilization of people, processes and technology…with an end goal of reducing as many avoidable readmissions as possible
Share best practices, provide education and training to clinical and administrative staff and design more timely and efficient data collection systems…with an end goal of reducing as many avoidable readmissions as possible
Learn about content and about rapid cycle improvement from subject matter experts, project staff/learning collaborative coaches and each other…with an end goal of reducing as many avoidable readmissions as possible
Incorporate the BOOST model (Better Outcomes for Older adults through Safe Transitions) from the Society for Hospital Medicine as a framework for addressing Preventable Readmissions…with an end goal of reducing as many avoidable readmissions as possible
Readmissions Collaborative
January 23, 2014 Attendees:
Angleton, Baptist, Brazosport, CHRISTUS, HHSC, Memorial Health System of East Texas, Region 3, Region 6, Sabine County Hospital, Society for Hospital Medicine, Spindletop, The Gulf Coast Center, UTMB
May 14, 2014 Attendees:
Angleton, Baptist Brazosport, CHRISTUS, Gulf Coast Center, Harris Health-Region 3, Memorial Medical Center of East Texas, Nacogdoches Memorial Hospital, Sabine County Hospital, Spindletop, Tyler County Hospital, UTMB

7. RHP 2 Readmissions Learning Collaborative
Three “In-Person” Meetings: January, May and August 2014
14 different organizations have actively participated, including Public and Private Hospitals, Critical Access Hospitals, Physician Group Practices and Behavioral Health Centers
Sharing of challenges and successes by all participating organizations – even if they do not have DSRIP projects directly tied to readmissions
Calls are held twice a month (first call of the month: project status updates; second call of the month: “push” of information on performance improvement topics)
BOOST Model “Areas of Focus”
8P Risk Scale - Prior Hospitalization, Problems with Medications, Psychological, Principal Diagnosis, Physical Limitations, Poor Health Literacy, Patient Support and Palliative Care
General Assessment of Preparedness (GAP) Tool for Clinical Assessment -Done at minimum on three (3) occasions: admission, nearing discharge and discharge
Patient Preparation to Address Situations Successfully (Patient PASS) - Patient’s perception of their condition(s) and requirements for self-management
Teach-back - To discover what the patient really understands about their condition, hospitalization, home treatment and follow-up care
Readmissions Collaborative
January 23, 2014 Attendees:
Angleton, Baptist, Brazosport, CHRISTUS, HHSC, Memorial Health System of East Texas, Region 3, Region 6, Sabine County Hospital, Society for Hospital Medicine, Spindletop, The Gulf Coast Center, UTMB
May 14, 2014 Attendees:
Angleton, Baptist Brazosport, CHRISTUS, Gulf Coast Center, Harris Health-Region 3, Memorial Medical Center of East Texas, Nacogdoches Memorial Hospital, Sabine County Hospital, Spindletop, Tyler County Hospital, UTMB

8. RHP 2: Our “Shared” Opportunities
Development of competencies for new reimbursement models and population health management
Establishment of new affiliations and community relationships to improve coordination of and access to healthcare services
Engagement of regional stakeholders, including additional providers, community organizations and patients
Advancement of the “Triple Aim” in through enhanced collaboration:
Improve the patient experience via quality and overall satisfaction
Advance the health outcomes of populations
Reduce the per capita cost of care

9. Readmissions Case Study #1
57 year old male with a history of COPD
Medicare patient
Five (5) admissions in a six (6) week span (totaling 11 inpatient days)
All admissions for shortness of breath/COPD exacerbation
Teach-back and clear discharge plan documented for each discharge
Follow-up phone calls made
Were any of the readmissions preventable?

10. Readmissions Case Study #1 (continued)
57 year old male with a history of COPD
Six (6) previous admissions in 2014
History of Medication non-compliance
Limited funds spent on cigarettes and marijuana
History of non-compliance with fluid restrictions and dietary recommendations
Home Health (HH) and Community Health Program (CHP) referrals were made
The readmissions were not avoidable
Patient deemed hospital dependent due to:
Non-compliance of medical orders and recommendations
Rapid disease progression
Determination of hospital dependency allows for:
More appropriate use of inpatient resources and planning
Recognition that HH and CHP are sometimes not able to solve readmissions due to patient non-compliance

11. Readmissions Case Study #2
30 year old female with a history of Crohn’s Disease
Managed Medicaid patient
Five (5) day index (initial) admission
Teach-back and clear discharge plan documented for discharge
Follow-Up phone call(s) made
Patient discharged with Narco for pain (40 tab)
Patient readmitted after 10 days for Abdominal pain (before outpatient follow-up visit could occur)
Was the readmission preventable?

12. Readmissions Case Study #2 (continued)
30 year old female with a history of Crohn’s Disease
Documentation shows that she had severe disease
Pain was uncontrolled
Patient was not hospital-dependent
Patient referred to Community Health Program (CHP) during readmission
This readmission was avoidable
Determination of non-hospital dependency made:
Patient initially discharged with inadequate pain medication
Documentation of pain indicated a stronger Rx required
Referral to CHP should have been made at initial discharge vs. at readmission discharge
During follow-up call, patient indicated concerns with pain that should have triggered an ambulatory appointment or outreach visit by CHP personnel.

13. Please visit our regional website at:
Thank You
Please visit our regional website at: