1. Transforming Clinical Practices Grant Opportunity Sponsored by CMS

2. Transforming Clinical Practices Initiative Designed with the intention to help clinicians achieve large-scale health transformation. The initiative is designed to support 150,000 clinician practices over the next four years in sharing, adapting and further developing their comprehensive quality improvement strategies. The initiative is one part of a strategy advanced by the Affordable Care Act to strengthen the quality of patient care and spend health care dollars more wisely. It aligns with the criteria for innovative models set forth in the Affordable Care Act: – Promoting broad payment and practice reform in primary care and specialty care, – Promoting care coordination between providers of services and suppliers, – Establishing community-based health teams to support chronic care management, and – Promoting improved quality and reduced cost by developing a collaborative of institutions that support practice transformation.

3. Background Since the launch of the Affordable Care Act, CMS has launched numerous programs and models to help health providers achieve large-scale transformation. Programs and models striving to help clinicians and hospitals move from volume- based towards patient-centered quality health care services. Some examples: – Hospital Value-Based Purchasing Program, – Accountable Care Organizations, – Partnership for Patients initiative with Hospital Engagement Networks, To date, there has been no large–scale investment in a collaborative peer-based learning initiative designed– an investment that ensures that clinicians who participate will be part of leading and creating positive change for the entire health care system. CMS estimates that only about 185,000 of the nation’s clinicians currently participate in existing programs, models, and initiatives that facilitate practice transformation. The Transforming Clinical Practice Initiative is one of the largest federal investments uniquely designed to support clinician practices through nationwide, collaborative, and peer-based learning networks that facilitate large-scale practice transformation.

4. CMS will award cooperative agreement funding for two network systems under this initiative Practice Transformation Networks Peer-based learning networks designed to coach, mentor and assist clinicians in developing core competencies specific to practice transformation. This approach allows clinician practices to become actively engaged in the transformation and ensures collaboration among a broad community of practices that creates, promotes, and sustains learning and improvement across the health care system. Must have pre-existing relationships with multiple clinician practices (primary care and/or specialists) that include data sharing capabilities. Successful applicants will collaboratively lead clinicians and their practices through the transformation process, achieve the initiative’s goals, and ensure that clinicians and their practices can maintain and sustain these activities in a dynamic care delivery system. Support and Alignment Networks Will provide a system for workforce development utilizing national and regional professional associations and public-private partnerships that are currently working in practice transformation efforts. Utilizing existing and emerging tools (e.g., continuing medical education, maintenance of certification, core competency development) these networks will help ensure sustainability of these efforts. successful applicants that may include eligible medical professional associations, specialty societies, and other organizations that are involved in aligning their programs with the aims of the initiative; generating evidence- based guidelines for clinical practice; promoting measurement for improvement; supporting members and practices in work to reduce unnecessary testing and procedures; and, effectively incorporating safety and patient and family engagement.

5. SAN CRL - MU SAN - CME SAN - Surveys SAN Pharmacy Services

6. TWC Vision for the PTN Lead at least 20 practices in transformation – 20 % small practices (1-3 physicians) – Working with no less than 120 physicians Mostly within NEPA Tapping those in the CRL project, CCI, and Residency Training Sites

7. Change Package Practice Coaching and Patient Engagement 1.To increase the capacity of the members of the health care team through redistributing work to the patients: – Check In Process Progress Note Creation – Check Out Process 2. To redesign work that is leaner and avoids duplication: – Care Compacts with Specialists and Hospitalists – CRL

8. As work capacity is created… 3.To invest in care management strategies: – Risk Stratification – Templates Decrease ED Visits Decrease Hospitalizations

9. Collaborative Learning Sessions Practices (2 times a year) Physicians (monthly) Medical Assistants – Emerging Leaders (monthly) Care Managers (monthly) Patients (monthly)

10. Incentive for Participation Increasing capacity of the workforce through tapping patients abilities, team building, and leaner referral process; CME Faculty Development (TCMC) EMR Meaningful Use achievement NCQA metrics for PCMH certification Customer Satisfaction Coaching / Collaborative Costs

11. Incentives Continued Establishment of Patient Engagement / Volunteerism services; Billing Infrastructure: Care Management TOC

12. Consultants Connie Sixta Dr. John Norcross

13. Awards PTN Up to $670 million – Each $2 million to 50 million SAN Up to 30 million – Each $1 million to 3 million  Both 4 year period – one 12 month period followed by 3 additional 12 month periods based on performance.  Initial period 5/1/15 – 4/30/16