DSRIP and RHP3’s Direction Nina Kavarthapu – Health System Strategy Analyst Sonyia Sandhu – Regional Operations Analyst

Region 3 Anchor Team, Harris Health System TEXAS 1115 WAIVER

2 Original Texas 1115 Waiver (DY1-6)

“Allows the state to expand Medicaid managed care while preserving hospital funding, provides incentive payments for health care improvements and directs more funding to hospitals that serve large numbers of uninsured patients.”1

RHP Plan includes: • DSRIP (Delivery System Reform Incentive Payment Program) • UC (Uncompensated Care)

DY1 DY2 DY3 DY4 DY5 DY6 (2011-2012) (2012-2013) (2013-2014) (2014-2015) (2015-2016) (2016-2017) Texas $500 M $2.3 billion $2.67 billion $2.85 billion $3.1 billion $3.1 billion DSRIP RHP3 $101 M $465 M $539 M $577 M $626 M $639 M

1 https://hhs.texas.gov/laws-regulations/policies-rules/waivers/medicaid-1115-waiver 3 1115 Waiver renewal - Waiver “2.0” • Approved 12/21/17: 5 year renewal (DY7-11) • Emphasis of DSRIP Program evolves:

DY1-6 DY7-11 • Infrastructure • Population health development across systems • Program innovation and redesign • Quality improvement

DY7 DY8 DY9 DY10 DY11 (2017-2018) (2018-2019) (2019-2020) (2020-2021) (2021-2022) Texas DSRIP $3.1 billion $3.1 billion $2.91 billion $2.49 billion $0 RHP3 $639 M $639 M TBD TBD $0

4 DY7-8 RHP PLAN UPDATE

5 Category Funding Distribution DY7 % of DY8 % of Program platform platform Element Description value value Submit RHP Plan Regional plan submission 20% 0% Maintain unique *MLIU Category B patient volume in “system” 10% 10% Category C Achieving quality goals 55% 75% System/population Category D performance reporting 15% 15% Qualitative reporting, Category A Core Activities 0% 0%

6 RHP3 SYSTEMS AND VOLUME

7 RHP Plan Update in Region 3 - DSRIP Key: CMHC = Community Mental Health Center LHD = Local Health Department M = Million K = Thousand

$4.2 M at 2 Hospitals $599.9 M at: $284 K at 1 Hospital • 12 Hospitals - $376.7 M • 2 Physician Practices - $92.6 M • 1 CMHC - $83.9 M $2.8 M at 1 Hospital • 2 LHDs - $46.7 M

$28.7 M at: • 1 Hospital - $4.2 M $2.2 M at 1 Hospital • 1 CMHC - $11.3 M • 1 LHD - $5.6 M

9 Counties 25 DSRIP Performing Providers

∗ Several organizations’ services extend beyond the home-base county 8 RHP3 Performing Providers Hospitals (18) . West Houston Medical Center . CHI St. Luke’s Health . Columbus Community . St. Joseph Medical Center Hospital . Oak Bend Medical Center . El Campo Memorial Hospital . Bayshore Medical Center . Tomball Regional Medical . UT MD Anderson Cancer Center Center . Methodist Willowbrook . Memorial Hermann Hospital . Memorial Medical Center System . Matagorda Regional Medical . Memorial Hermann The Center Woodlands . Rice Medical Center . Texas Children's Hospital . Houston Methodist Hospital . Harris Health System

9 RHP3 Performing Providers, cont. Physician Practices (2) . Baylor College of Medicine . UT Physicians Local Health Departments (3) . Harris County Public Health . City of Houston . Fort Bend County Community Mental Health Centers (2) . Texana Center . The Harris Center for Mental Health and IDD

10

Common Patient Service Locations Local Health Departments • Clinics • Immunization locations “In the broadest sense, Community Mental Health Centers the system is defined by • Home-based services the location(s) where • Office/clinic patients are served by • Contracted inpatient beds the performing provider and the types of services Physician Practices patients are receiving.” • Owned/operated primary care clinics - HHSC • Owned/operated specialty care clinics Hospitals • Inpatient services • Emergency Department • Maternal department • Owned/Operated outpatient clinics

11 Patient Population by Provider System • At Regional level: • Aggregate all-payer patients = 3.17 million • Aggregate MLIU patients = 1.16 million

• Goal is to maintain volume of MLIU patients (10% of Provider valuation) • Volume goals calculated using average of DY5 and DY6 system patient populations

12 DY5&6 MLIU Volume & Percent of MLIU Patients Per County

8,225 33% MLIU

1,072,369 36% MLIU 7,061 51,038 45% MLIU 40% MLIU

15,859 61% MLIU

6,380 34% MLIU

13 RHP3 OUTCOME SELECTIONS

14 Category C Background

• Emphasis on system quality improvement • Allocated 55% (DY7) and 75% (DY8) of Provider valuation • For hospitals and physician practices, related measures are bundled • Some measures in a bundle are required while others are optional • CMHC and LHD menus have solitary measures • Some measures align with hospital/physician practice bundles

15 DY7-8 Measure Bundle Valuations in Region 3* $140 7 Numbers above each bar indicate the number of Providers who have selected the bundle. $120 7

$100

7 $80 4 6 7 $60 5 7 Millions ($$) 7 4 6 $40 7 3 4 6 $20 3 4 3 2 2 2 1 2 1 1 $0

*Measures for LHDs and CMHCs were sometimes found in more than one bundle and so were added to each bundle. The total valuation does not reflect the total valuation for the Region.

16 140 DY7-8 Topic Area Valuations

8 14 CMHC LHD 120 7 6 Physician Practice Hospital

100 Numbers above each bar indicate the number of Providers who have selected the bundle. 80 6 9

60 8 6 8 Valuations in Millions ($$) in Millions Valuations 8 - 40 4 DY7

20 4 5 4 1 1 0

Topics

17 CORE ACTIVITIES

18 Core Activities – Region 3

Frequency of Core Activity Grouping Selection 16 14 14

12 11 10 10 10 9 9

8 Frequency 6 5

4 3 3 2 2 1

0 Access to Expansion of Availability of Other Chronic Care Prevention Maternal and Behavioral Expansion or Patient Access to Primary Care Patient Care Appropriate Management and Wellness Infant Health Health Crisis Enhancement Centered Specialty Care Services Navigation Levels of Care Stabilization of Oral Health Medical Services and Transition Behavioral Services Services Home Services Health Care Services

19 MEETING COMMUNITY HEALTH NEEDS

20 Continuing Community Health Needs • Insufficient access primary and specialty care • Inadequate transportation options • High prevalence of chronic disease and poor health • Behavioral Health needs continue • Patient services remain fragmented and uncoordinated • Disparities in health outcomes across diverse population

21 Key Points • Diverse range of outcome selections • Alignment between DY7-8 outcome selections, core activities, and community needs • More opportunities for collaboration!

22 BREAK

23 Housekeeping • Make sure presenters are at the presentation table before their block starts • Presentations will be strictly timed – all presenters will be given a one-minute warning • Use the clicker by pressing the right arrow to advance the slide and the left arrow to go to a previous slide • Reserve audience questions until after the presentation block is complete

24 ROUND 1 PRESENTATIONS

MATAGORDA REGIONAL MEDICAL CENTER ST. JOSEPH MEDICAL CENTER HCA BAYSHORE AND WEST HOUSTON TOMBALL HOUSTON METHODIST HOSPITAL METHODIST WILLOWBROOK BAYLOR COLLEGE OF MEDICINE THE HARRIS CENTER FOR MENTAL HEALTH AND IDD

25 1. When did Texas receive approval for the 1115 Waiver? a) December 2011 b) December 1995 c) April 2010 d) April 2013 e) September 1776

26 2. How large is the state pool for DYs7-8? a) $ 2.49 billion b) $ 2.91 million c) $ 3.1 billion d) Very very large

27 3. Which bundle has the highest valuation in Region 3? a) J1: Hospital Safety b) C1: Primary Care Prevention – Healthy Texans c) E2: Maternal Safety d) A1: Chronic Disease Management: Diabetes 28 4) What was the third webinar in the Region 3 summer webinar series last year? a) “How to survive Waiver 2.0” b) “MCOs 101” c) “Finding a job outside of DSRIP” d) “Multidisciplinary Approach to DSRIP Cost Analysis”

29 Matagorda Regional Medical Center

LaToya Rivers-Azanga, Chief Quality & Patient Safety Officer Matagorda Regional Medical Center

Celeste Harrison, Chief Executive Officer Matagorda Episcopal Health Outreach Program (MEHOP) At a Glance… • Service area - Matagorda County • Rural County - Population 36,183 • Health Outcomes Ranking - 164 of 243 • Highest poverty rate • Lowest median income • Second lowest insurance coverage • Highest percentage of adults with poor health

• Hospital & FQHC DSRIP Collaboration • History of DSRIP Focus • Primary Care access utilizing nights & weekends • Patient Navigation engagement in the Emergency Department • Specialty Care access for high prevalence chronic diseases

31 Category B • Total PPP • 26,004

• MLIU PPP • 15,859 • 60.08% • Medicaid, Low Income, Uninsured, Charity Care

32 System Definition System Component Description Hospital 58 Staffed Beds – General & ICU Ancillary Departments – Radiology, Wound Care, Oncology & Nuclear Medicine Maternal Department

Emergency Department Level III Trauma Center

Outpatient Clinics – Owned/Operated Medical Assistance Program (MAP)

Outpatient Clinics – Partnership MEHOP – PCMH Certified FQHC Urgent Care – Owned/Operated 9am – 6pm Saturday & Sunday Advanced Nurse Practitioner

33 Category C • MPT: 6 • A1 – Improved Chronic Disease Management – Diabetes Care • A1-112 - Comprehensive Diabetes Care: Foot Exam • A1-115 - Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) • A1-207 - Diabetes care: BP control (<140/90mm Hg)

34

Category C, cont. • Hospital Based • A1-500 - PQI 93 Diabetes Composite (Adult short- term complications, long-term complications, uncontrolled diabetes, lower-extremity amputation admission rates) • A1-508 - Reduce Rate of Emergency Department visits for Diabetes

35 Next Steps… • Primary Care Expansion project continues utilizing partnership with MEHOP

• Discontinue Patient Navigation & Specialty Care Expansion

• Update MEHOP contract to value-based care with upside & downside risk

36 Next Steps… • Initiate Quality Process Improvement efforts • Action plan development using Rapid Cycle methodology • Performance dashboard development to better monitor quality & process metrics • Community Based Organization engagement

• Core Activities implementation • Diabetes Education & Outreach • Medication Management Best Practices

37 Contact Us

Matagorda Regional Medical Center LaToya Rivers-Azanga Chief Quality & Patient Safety Officer [email protected]

Matagorda Episcopal Health Outreach Program (MEHOP) Celeste Harrison Chief Executive Officer [email protected]

38 39 St. Joseph Medical Center

Amanda Simmons, DSRIP Richard Kuehn LPC-S, Clinical Program Director Provider Information • A Steward Family Hospital • Two Locations • St. Joseph Parkway • 358 Staffed Beds (75 Behavioral Health) • 12 Bed Med Psych Unit • The Heights • 46 Staffed Beds (4 ICU) • Service Area • Houston & surrounding sub-burbs • DY 7 & 8 • Valuation: $8.4M / year • MPT: 17

41 Category B • Total PPP • 51,920 • MLIU PPP • 22,383 • 43.11% • MLIU population consists of Medicaid, Dual Eligible, CHIP, Low Coverage Option, Insured on the Exchange, Low Income, and Uninsured

42 System Definition

System Description Component

Inpatient Short term acute care facility that includes 248 staffed beds utilizing sub-specialties Services (cardio, medicine, ortho, gynecology, surgery) - general & ICU. Facility includes ancillary departments of Behavioral Health, Sports Rehabilitation, Wound Care, and Radiation Oncology.

Emergency SJMC has 2 emergency departments - one is located at the downtown campus and one Department is located at the Heights campus. The ED is a certified Level 3 trauma center, certified primary stroke center, and provides telemedicine partnerships with the UT neuroscience department for stroke victims. The ED has 26 patient rooms and treats 2500-2800 patients per month.

Outpatient SJMC has several ambulatory clinics including a wound center, radiation oncology, and Clinics sports rehabilitation.

Maternity SJMC has a robust maternity service which offers classes for perspective parents Department (breastfeeding, childbirth, newborn etc.), neonatal ICU, OBGYN care, and labor and delivery.

43 Category C • H2 Bundle: Behavioral Health and Appropriate Utilization • Core Activity: Med/Psych Unit • Utilize the Med/Psych 10 bed unit to the bridge the gap in care between behavioral health and physical health needs for inpatients and ensure discharge instructions and follow-up care is provided for both sets of diagnoses • Implement Best Practices for Behavioral Health full Continuum of Care

44 Next Steps…

• Continuation of the Med : Psych Unit • Discontinuation of the Partial Hospitalization Program • Continue The Roadmap to Peace of Mind • Planning & development to “Close the Gap” for behavioral health patients to ensure continued care post hospital services • Implement Process Improvement Program aligned with hospital quality strategies • Refine data analytics process utilizing new EMR implementation • Partner with Southwest General Hospital (San Antonio) for BH best practice implementation • Establish Community Based outreach & education for BH awareness • Identify best practices for Social Determinants of Health that impact BH quality outcomes

45 Amanda Simmons [email protected] (713) 859-9683 Richard Kuehn, LPC-S [email protected] (713) 756-8098

46 HCA Gulf Coast Division Bayshore Medical Center, West Houston Medical Center & Tomball Regional Medical Center Shannon Evans, Division Director DSRIP Provider Information • HCA Gulf Coast Division • Organizational and DSRIP mission statement • “Above all else, we are committed to the care and improvement of human life.” • $18.5 million, MPT-37 • Bayshore Medical Center • West Houston Medical Center • Tomball Regional Medical Center

48 Category B • All RHP3 Facilities • 214,229 • MLIU PPP • 118,753 • 55.4% • Medicaid, Uninsured, Self Pay, CHIP, Dual Eligible, Low-Income

49 System Definition

System Component Description

Inpatient Services Bariatrics, Cardiology, Wound Care, Geriatric Behavioral Health, ICU, NICU, etc.

Owned or Operated Outpatient Clinics Bayshore Medical Center is the only organization that has an owned an operated Midwife clinic

Emergency Department Combination of free standing EDs and on- campus EDs

50 Category C • HCA Gulf Coast Division • Bundle B2: Patient Navigation & ED Diversion • Bayshore Medical Center & West Houston Medical Center • Care Coordination and Navigation • Case Manager/CHW education, appointment scheduling, follow up for key conditions and patients without a PCP

51 Category C • HCA Gulf Coast Division • Bundle E2: Maternal Safety • Bayshore Medical Center • Maternal and Infant Health Care • Healthy Babies are Worth the Wait Campaign • Nurse Family Partnerships • Centering Pregnancy

52 Category C • HCA Gulf Coast Division • Bundle J1: Hospital Safety • Bayshore Medical Center & West Houston Medical Center • Implement standardized evidence based identification and care management protocols for sepsis patients for any patient of BMC that is identified with sepsis or has the potential to develop sepsis. • Quality Metric Tracking, Review, and Education

53

Category C • HCA Gulf Coast Division • Bundle K2: Rural Emergency Care • Tomball Regional Medical Center • ER Throughput Intensive • ED Surge Planning • Discharge Communication Education and Tool Development

54 SHANNON EVANS, HCA GULF COAST DIVISION DIRECTOR DSRIP

[email protected] 713-852-1563

55 Houston Methodist Hospital & Methodist Willowbrook Hospital Dr. Heather Chung, Director of Psychiatry Houston Methodist Hospitals

“To provide high quality, cost-effective health care + million that delivers the best value 1.27 to the people we serve in a Patient visits annually 22,247 6,700 4,500 spiritual environment of Employees Active Nurses Physicians caring in association with internationally recognized teaching and research.” - Methodist Mission 2,034 100k+ Patient Statement admissions Operating beds

The goal at our 3 DSRIP sites is to improve the health outcomes of our patients and community by focusing on the delivery, quality, as well as addressing patient needs with a holistic view.

57 MPT 9 points HMH/SJ Category B Our MLIU PPP is comprised of Medicaid, Dual HMH/SJ System by Unit/Dept HMH/SJ Total PPP Eligible, CHIP, Self- Pay, and 4, 1% 6, 2% Uninsured patients 39538, 8% 66, 19%

432710, 92% 278, 78%

ED Maternal Units Inpatient Units Outpatient Clinics DY6 MLIU PPP DY6 Other PPP

58 HMH/SJ Category C

Follow-Up After Transitions of care Hospitalization for Telehealth home visits Mental Illness Pilot Residency Clinic

Assignment of PCP and Identification/ ILS Assessment to connection to Individuals with resources and Bundle H2: Behavioral Schizophrenia screening Health and Appropriate Utilization Child, Adolescent, and Screening and Adult MDD Suicide Risk connection with Assessment resources

Bipolar Disorder and Major Screening with PHQ 9, Audit C Depression: Appraisal for and substance abuse alcohol or chemical screening; connection with substance use resources

59 HMH/SJ Category A: Core Activity for H2

• Utilization of Care Management function that integrates primary and behavioral health Secondary needs of individuals Drivers

• Teach-back method is a way of checking understanding by asking patients to state in their own words what they need to know or do about their health; it confirms that you have taught patients in a way that they understand. We will use teach back for social workers scheduling appointments to ensure patients are aware of the key information taught.​ Drivers • Social workers will schedule follow-up appointments with patients in primary care setting

• We will use an EPIC report to measure teach back completion Change • EPIC documentation through social workers in "discharge summary" flowsheet Ideas

60 WB Category B (MPT 3) Our MLIU PPP is Methodist WB System definition by comprised of Medicaid, Dual Unit/Departments Methodist WB PPP Eligible, CHIP, Self- Pay, and Uninsured patients

3, 13% 1, 4% 17,414, 15%

96,356, 85%

20, 83%

DY6 MLIU PPP DY6 Other PPP ED Maternal Inpatient

61 WB Category C

Develop super utilizer meeting Community Resources

Reduce Rate of ED visits for Substance Abuse and Behavioral Health D2S2 (Discharge Decision Support Bundle B2: System) utilization Patient PHQ 9 and other MH screening Navigation Utilize evidenced based protocol Reduce ED visits for Acute Identification and Connection to Ambulatory Care Sensitive appropriate resources Conditions (ACSC) Utilize FQHC per zip code

62 WB Category A: Core Activity for B2 Change Idea

Social workers will schedule follow-up appointments for patients and include EPIC documentation through social workers in "discharge summary" flowsheet

Secondary Drivers

Social workers will identify super utilizers, assess social determinants, and strategize patient navigation

Primary Driver/ Core activity Identification of frequent ED users and use of care navigators as part of a preventable ED reduction program, which includes a connection of ED patients to primary and preventive care.

63 The End • Heather Chung: Director Psychiatry [email protected] 281-755-5391 • Hailey Stein, Social Worker [email protected] 321-514-9804 • Marshall Getz, Sr Training Specialist [email protected]

64 Baylor College of Medicine Teen Health Clinics Allyssa Abacan, MPH: Project Manager Meghna Sebastian, MD: Adolescent Medicine Director Andrea Vick, MSN, RN: Operations Nurse Manager Peggy Smith, MA, PhD: CEO Ruth Buzi, LCSW PhD: Social Services Director Mariam Chacko, MD: Medical Director

Teen Health Clinics

• The clinic’s DSRIP goal is to provide access to primary and preventive health care services to uninsured adolescents and young adults through delivery of high quality medical and gynecological services in order to enhance the health of patients and families it serves. • 11 clinics: 2 hospital, 3 free standing, 5 HISD and 1 charter school and free standing • DSRIP DY7-8 valuation: $742,000 • MPT: 1

66 Category B • Total PPP: 22,000 • MLIU PPP • 21,700 • 98.5% • MLIU population composition: self-pay, low- income, Medicaid, uninsured

67 System Definition

System Component Description Owned or Operated Primary Care Clinics 11 Clinics affiliated with Baylor College of Medicine-provide preventative primary health care services in high schools and free standing clinics Owned or Operated Specialty Care Clinics serve primarily east and south Clinics east side of Houston (1 central Houston) provide reproductive health care, Adolescent Medicine and Sports Medicine services

68 Category C • D1: Pediatric Primary Care • D1-211: Weight assessment and counseling for nutrition and physical activity • D1-212: Appropriate testing for children with Pharyngitis • D1-284: Appropriate treatment for children with URI • D1-400: Tobacco use and help with quitting among adolescents • D1-389: Human Papillomavirus Vaccine • D1-503: Acute composite • D1-T01: Innovative Measure- Behavioral health counseling for childhood obesity

69 Category C • Antibiotic Resistance • D1-212 and D1-284 • Documentation is important

• D1-389: HPV • Low rates • No immunization records

70 Category C • D1-400: Tobacco use and help with quitting among adolescents • Low rates of smokers • Increased educational materials for patients

• D1-503: Acute composite • Low rates among our patient population • Working with Ben Taub ER to get adolescents in the ER plugged into our clinics if appropriate

71 Category C • Core Activity (Prevention and Wellness) • Innovation Measure- Behavioral Health Counseling for Childhood Obesity: • BMI Follow-up • Minimum of 2 counseling sessions with provider (NP or MD) and licensed medical social worker (LMSW). • Use Motivational Interviewing to promote healthy weight • Determine eligibility by meeting metric D1-211: Weight Assessment

72 Data Collection • Limitations with EMR and Billing Software • Labor intensive • Smart phrases to improve documentation • Creation of data points within billing software to capture data • Generate reports every two weeks to troubleshoot any issues

73 The End For logistics and operations questions: Allyssa Abacan, MPH [email protected] O: 713-873-3601

For medical/clinical questions: Meghna Sebastian, MD Adolescent and Sports Medicine Department O: 832-822-3666

74 The Harris Center for Mental Health & IDD

Jeanne Wallace, LMSW, DSRIP Project Director The Harris Center Information • Transform the lives of people with behavioral health and IDD diagnosis • Improving lives through accessible, integrated and a comprehensive recovery oriented system of care • DY7-8 valuation: $83,923,377.76 • MPT: 40 points • Harris County

76 Patient Population • Total PPP • Total PPP number: 43,356 • MLIU PPP • MLIU PPP number: 37,561 • MLIU PPP percentage: 86.63% • MLIU population composition: Medicaid, Medicare, CHIP, Low Income Uninsured

77 System Definition System Component Description

Office/Clinic We provide services in 4 MH clinics located in SE, SW, NE, NW sections of Houston Home-Based (services in the MH & Crisis Services are provided in the community) community. Our Crisis services division has 11 programs provided 24 hours a day (Hotline, PES, ICC, CSU, CRU, CIRT, COD, MCOT, CTI, CCSI, PATH) School-based Clinic We have programs in 24 schools in a number of school districts within Harris County Hospital: Contracted Inpatient Beds; Harris County Psychiatric Hospital, West State-funded Community Hospital; State Oaks Psychiatric, Rusk State Hospital Mental Health Facility

78 Category C Measures 27 Measures have been selected divided into the following categories: 1. Initiation of MH Treatment 2. Substance Use 3. Health Improvement 4. Diagnostic Driven 5. Hospitalizations

79 Initiation of Treatment M1-342: Time to Initial Evaluation within 10 days of initial contact M1-390: Time to Initial Evaluation Mean Days M1-263: Assessment of Psychosocial Issues of Psychiatric Patients at intake

80 Substance Use M1-105:Tobacco Use: Screening and Cessation M1-261: Assessment for Substance Abuse Problems for Psychiatric Patients M1-317: Preventative Care: Unhealthy Alcohol (ETOH) Use, Screening, and Brief Counseling M1-340: Substance Use Disorder: Current Diagnosis of Opioid Use and Counseling on Psychosocial and Pharmacological Options

81

Substance Use M1-341: Substance Use Disorder: Current Diagnosis of Alcohol (ETOH) Use and Counseling on Psychosocial and Pharmacological Options M1-405: Bipolar and Depression Appraisal for Alcohol or Substance Use M1-257: Care Planning for Dual Diagnosis (mental disorder and substance abuse disorder)

82

Health Improvement M1-147: Preventative Care: BMI Assessment and Follow-Up M1-210: Preventative Care: Screening for High Blood Pressure and Follow-Up M1-260: Annual Physical Exam M1-287: Documentation of Current Medications in the Medical Record

83 Diagnostic Driven: Depression M1-146: Preventative Care for Depression, Screening and Treatment Planning M1-256: Initiation of Depression Treatment M1-262: Assessment for Risk to Self/Others M1-305: Child & Adolescent Major Depressive Disorder Suicide Risk Assessment M1-319: Adult Mental Health Major Depressive Disorder Suicide Risk Assessment

84 Diagnostic Driven: Schizophrenia M1-259 Assignment of PCP to Pts with Schizophrenia M1-264 Vocational Rehabilitation for Pts Schizophrenia M1-265 Housing Assessment for Individuals with Schizophrenia M1-266 Independent Living Skills Assessment for Individuals with Schizophrenia

85 Diagnostic Driven: Intellectual Developmental Delay

M1-385: Functional Status Assessment M1-386: Improvement in Functional Status

86 Hospitalizations M1-160: Follow-Up After Hospitalization for Mental Illness (7 & 30 Day) M1-124: Medication Reconciliation Post- Discharge

87 Category C Measures

Initiation of Health Diagnostic Substance Use Hospitalizations Treatment Improvement Driven • M1-342 • M1-105 • M1-147 • Depression • M1-160 • M1-390 • M1-261 • M1-210 • M1-146 • M1-124 • M1-263 • M1-317 • M1-260 • M1-256 • M1-262 • M1-340 • M1-287 • M1-305 • M1-341 • M1-319 • M1-405 • Schizophrenia • M1-257 • M1-259 • M1-264 • M1-265 • M1-266 • Intellectual Developmental Delay • M1-385 • M1-386

88 Core Activities 1. Utilization of Care Management function that integrates primary and behavioral health needs of individuals M1 -147 M1-210 M1-259 M1-260

M1-287

89 Core Activities 2. Utilization of telehealth/telemedicine in delivering behavioral services M1 - 124 M1-147 M1-160 M1-210 M1 -256 M1-261 M1-262 M1-263 M1 -264 M1-265 M1-305 M1-319 M1-342 M1-405 M1-105 M1-146 M1-266 M1-287 M1-317 M1-340 M1-341 M1-385 M1-386 M1-390

90 Core Activities 3. Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model M1-147 M1-160 M1-305 M1-319

M1-342 M1-105 M1-146 M1-287

M1-317

91 Core Activities 3. Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model proposed revisions M1-124 M1-147 M1-160 M1-210 M1-256 M1-261 M1-262 M1-263 M1-264 M1-265 M1-305 M1-319 M1-342 M1-405 M1-105 M1-146 M1-266 M1-287 M1-317 M1-340 M1-341 M1-390

92 The End • Keena Pace, COO • Michael Downey, VP MH Services 713-970-7245 • Kim Kornmayer, VP Crisis Services 713-970-7455 • Robert Stakem, VP IDD Services 713-970-3871 • Mona Lisa Jiles, VP Forensic Services 713-970-3361 • Jeanne Wallace, DSRIP Director 713-970-3971

93 BREAK

94 ROUND 2 PRESENTATIONS

CHI ST. LUKE'S COLUMBUS COMMUNITY HOSPITAL EL CAMPO MEMORIAL HOSPITAL CITY OF HOUSTON TEXANA CENTER UT MD ANDERSON CANCER CENTER

95 1. Who is the current U.S Secretary of Health and Human Services?

a) Tom Price b) Eric Hagar c) John Scott d) Alex Azar

96 2. How many counties are in Region 3?

a) 7 b) 1 c) 10 d) 9 e) 20

97 3. When was Region 3’s last Learning Collaborative?

a) December 10, 2017 b) February 7, 2018 c) January 31, 2018 d) September 8, 2017

98 4. According to the last CHNA, what is the population of Region 3?

a) 5.2 million b) All I know for sure is that traffic is terrible c) 5.8 million d) 4.4 million

99 Baylor St. Luke’s Medical Center

Seth Stephens, DNP, APRN, ACNP-BC; Nurse Practitioner- Medical Quality Jonathan Gecomo, MSN, RN; Lead – Clinical Informatics

Provider Information • Baylor St. Luke’s Medical Center (BSLMC) • Founded in 1954 • Academic medical center caring for more than one hundred thousand unique patients each year • One of the top 20 heart centers in the nation • Member of Catholic Health Initiatives (CHI), a national nonprofit health system that ranks as the nation’s third-largest faith-based health system • An acute-care, non-profit, inpatient hospital system • BSLMC DY7-8 plan: • Further DY2-6 Care Transitions Model • Utilize a multi-disciplinary approach to improve Hospital Safety measures • DSRIP DY7-8 valuation – $7,601,866.00 • DSRIP MPT – 15 Points

101 Category B • Total PPP • 104,590 • MLIU PPP • 20,625 • 19.72% • Includes Medicaid, Dual-eligible, Insured on Exchange, Indigent Care Plan, Patient Financial Assistance (PFAP) Program, and Self-Pay

102 System Definition System Component Description

Inpatient Services Hospital inpatient 879 licensed beds Inpatient Rehabilitation 24-bed Unit Inpatient Diagnostic and Therapeutic Radiology Departments

Emergency Department Baylor St. Luke's Medical Center's Emergency Department & 3 Community Emergency Departments

Owned or Operated 3 Outpatient Ambulatory Surgical Centers Outpatient Clinics Outpatient Diagnostic and Therapeutic Radiology Departments Outpatient Cardiac Rehab Center 6 Specialty Care Outpatient Clinics

103 Category C • Bundle B1 – Care Transitions and Hospital Readmissions • Acute Care Process Improvement • Implement a CHF Pathway for standardizing utilization of CHF Guideline-Driven Medical Therapy • Create a committee to follow operational outcomes related to CHF care • Implement enhanced Transition Record in the discharge process • Implement Operational Work Group for process improvement identification and implementation • Implement Report Builds and DASHBOARD for DSRIP success tracking and reporting

104 Category C • Bundle B1 – Care Transitions and Hospital Readmissions • Post-Acute Care Coordination • Improve selection of interventions for successful and efficient discharge planning through a risk- stratification model that utilizes the BSLMC EMR. • Align the model with triggers for early identification and mitigation of patient risk. • Identify and coordinate follow-up care for at-risk patients with appropriate medical homes

105 Category C • Bundle B1 – Care Transitions and Hospital Readmissions • Post-Acute Care Coordination • Investigate strategies for extremely high-risk patients for intense post-discharge support • Implement a pilot of Home Health and Skilled Nursing Facility Preferred Providers • Train Preferred Providers in high-risk diseases and required post-acute care processes

106 Category C • Bundle J1 – Hospital Safety • Implement processes to measure and improve the patient experience • Utilize a multi-disciplinary approach to improve Hospital Safety measures, thus improving the patient experience by avoiding unnecessary infection or patient safety occurrences that lengthen hospital stay, increase healthcare costs, and negatively affect patient outcomes

107 Contacts • Bernie Chance • [email protected] • 713-325-1341 • Valerie Baron • [email protected]

108 Columbus Community Hospital

Betty Hajovsky, Columbus Community Hospital Waiver Coordinator Provider Information • Columbus Community Hospital (CCH) is a rural 40 bed hospital • CCH serves Colorado, Fayette and Austin Counties • Measure Point Threshold is 3

110 Category B • Total PPP • Total Patient Population is 16,340 • MLIU PPP • MLIU PPP is 5,193 • MLIU PPP percentage is 31.78% • MLIU population is composed of Medicaid, Self- Pay, and Managed Care Programs

111 System Definition

System Component Description

Inpatient Services The system component are the Inpatient units including the Medical/Surgical unit and Obstetrical unit at Columbus Community Hospital (CCH).

Emergency Department The system component is the Emergency Room at CCH.

Owned & Operated Outpatient Units The system component are the 2 Rural Health Clinics owned & operated by CCH.

Maternal Unit The system component is the Obstetrical unit at CCH

112 Category C • Bundle K1: Rural Preventive Care

• K1-105: Preventive Care & Screening: Tobacco Use: Screening Cessation Intervention • K1-268: Pneumonia vaccination status for older adults • K1-285: Advance Care Plan

• Strategies to impact measures: • Implementation of strategies to prevent lung diseases and to give patients a choice of medical care. • Train personnel to do the screening • Educate patients on tobacco use and cessation, pneumonia risk, and benefits of advance care plan. • Deploy educational material to patients via EHR on Tobacco Cessation, Pneumonia and Advance Care Planning.

113

Thank You • Betty Hajovsky, CCH Waiver Coordinator 979-493-7577

114 El Campo Memorial Hospital

David Mak, CFO Sherrie Hardin, Manager of Quality Improvement Provider Information • Our overall DSRIP goals include a) Clinical outcome improvement with metric measured to show positive impacts on patient outcomes. b) Population focused improvements to specifically target result towards MLIU population.

• ECMH is classified as a rural hospital with sole community hospital status, serves El Campo City and the adjacent areas in West Wharton County.

• DSRIP DY7-8 valuation: $284,520 (per year)

• MPT: 1

116

Category B • Total PPP = 15,674 • MLIU PPP = 7,061 • MLIU PPP % = 45.05% • MLIU population composition • Self-Pay • Self-Pay after insurance • Medicaid • Managed Medicaid

117 System Definition

System Component Description Inpatient general medical/surgical 26 inpatient beds and swing beds, including 4 ICU beds. Services provided include surgeries, advanced imaging, lab, pulmonary, cardiology, sleep lab, dialysis and other ancillary services.

Emergency Room Level 4 ER unit with 11 patient beds.

Rural Health Clinic 14 primary care and specialists including GYN, Ortho, GI, and general surgery.

118 Category C

Measures • K1-105 Tobacco use screen and cessation counseling • K1-268 Pneumonia vaccination status for older adult • K1-285 Advanced Care Plan

Core Activities • Training - multiple levels of healthcare providers, including physicians, mid- levels, and nurses to perform screening and counseling as documented in hospital's clinical protocols. • Education – educational material to be identified and provided to patients to improve patient’s healthcare awareness. • Documentation - Utilize new EMR to build screener templates, allowing reportable data to be captured.

119

The End

• Contact Information:

David H. Mak, CFO [email protected]

Sherrie Hardin, Manager of Quality Improvement [email protected]

120 City of Houston William F. Bryant, Jr., Senior Staff Analyst Provider Information • The City of Houston Health Department (HHD) works in partnership with the community to promote and protect the health and social well-being of all Houstonians.

• Our overall DSRIP goals are to: • Help clients navigate the healthcare arena and address barriers • Employ prevention strategies to improve health • Improve the quality of services • Provide cost-savings to the overall health system and clients

• HHD serves the 2.3 million residents of the City of Houston. Our scope and impact reaches beyond the city limits and extends to Harris County’s population of 4.6 million people

• Our DSRIP DY7-8 valuation is $37,818,349 with a MPT of 20.

122 Category B • Our total patient population by provider (PPP) is 44,401. • Our Medicaid Low-income Uninsured (MLIU) PPP is 39,461 which is 95.31% of our PPP. • Our MLIU population is composed of Medicaid, Dual Eligible, CHIP, Low-Income (FPL below 200%), Uninsured and self-pay

123 System Definition

System Component Description Clinics (Required) Four (four) safety-net clinics throughout Houston. Services offered are dental, family planning, TB, STD, and immunizations. Mobile Outreach Non-clinical services that include, but are not limited to, chronic disease and diabetes self-management education, client navigation, and transitional care services.

124 Category C • We selected measures geared towards the three core functions of public health: Prevent, Promote, and Protect • Measures selected also aligned with the priorities identified by HHSC, i.e. the Healthy Texans Bundle. • A total of 10 measures were selected to achieve our MPT of 20.

125 Category C • Expansion or Enhancement of Oral Health Services • Expand use of existing dental clinics for underserved populations • L1-224 – Dental Sealant: Children • L1-225 – Dental Caries: Children • Increase outreach in community • Workforce Development • Improvements to patient follow-up

126 Category C • Access to Primary Care Services • Provision of screening and follow up services • L1-235 – Post-Partum Follow-Up and Care Coordination • L1-105 –Tobacco Use: Screening and Cessation Intervention • L1-280 – Chlamydia Screening in Women • L1-147 – BMI Screening and Follow-Up • L1-210 – Screening for HBP and Follow-Up Documented • Strengthen screening and follow-up protocols • Increase PCP relationships • Increase outreach in community

127 Category C • Access to Primary Care Services • Establishment of care coordination and active referral management that integrates information from referrals into the plan of care • L1-115 – Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) • L1-207 – Diabetes care: BP control(<140/90mg Hg) • Increase partnerships with PCP • Enhance bi-directional referral protocols with providers

128 Category C • Chronic Care Management • Management of targeted patient population • L1-347 – Latent TB Infection treatment rate • Identify high risk populations through testing and contact investigations • Improve education through linguistic support • Mitigate transportation barriers

129 Category C • Prevention and Wellness • Implementation of evident-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions • L1-115 – Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) • L1-207 – Diabetes care: BP control (<140/90mm Hg) • L1-147 – BMI Screening and Follow-Up • L1-210 – Screening for HBP and Follow-Up documented • Expand educational services and offerings by HHD • Collaboration with local resources

130 Category C Slide • Expansion of Patient Care Navigation and Transition Services • Provision of navigation services to targeted patients • L1-105 – Tobacco Use: Screening & Cessation Intervention • L1-147 – BMI Screening and Follow-Up • L1-210 – Screening for HPB and Follow-Up Documented • House navigation units within each clinic

131 City of Houston 1115 Waiver Contact

William F. Bryant, Jr. [email protected] 832.393-4612

132 Texana Center

Brian Gurbach, UM/QM Manager Provider Information

• Texana Center is a Local Mental Health Authority (also known as a Community Mental Health Center ) serving individuals with Mental Illness and individuals with an Intellectual or Developmental Disability. Overall DSRIP goals are to continue to operate the Crisis Center for those experiencing a mental health crisis and to improve the lives of those served. • Texana serves 6 counties: Fort Bend, Austin, Waller, Matagorda, Colorado and Wharton. • Texana’s DSRIP DY7-8 valuation is $11,331,617 each year and MPT is 23.

134 Category B • Total PPP • 10,223 • MLIU PPP • 6,818 • 66.69% • The MLIU population composition consists of Medicaid, Low Income, Uninsured, CHIP and Dual Eligible (Medicare and Medicaid)

135 System Definition

System Component Description Home-Based Services provided in-vivo in the home in the six county service area for those with mental illness and IDD.

Office/Clinic Six Behavioral Healthcare Outpatient Clinics in the six county area served providing behavioral healthcare services including psychiatric evaluations and pharmacological management as well as services for those with autism and other IDD.

Contracted Inpatient Hospital Beds Beds contracted for those in mental health crisis. Includes West Park Springs in Fort Bend and other psychiatric hospitals in Houston.

136 Category C

• M1-105 Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention • Smoking/nicotine used to self medicate with the population that we serve. By screening, educating and providing cessation information, our hope is to reduce tobacco use.

• M1-147 Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow Up • We have always performed height and weight and BMI but have now added the follow up/education.

• M1-160 Follow-Up After Hospitalization for Mental Illness • This is our only 3 point measure. We are used to performing this measure with QMHP-CS staff but now have licensed staff completing the follow up. This measure assists with engaging individuals into ongoing outpatient services to avoid hospitalization.

• M1-182 Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD-AD) • Undiagnosed diabetes is common among the population we serve. We screen those with these MI diagnoses and refer to primary care for treatment.

• M1-203 Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk • The population we serve is at high risk of Hepatitis C.

• M1-210 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented • Undiagnosed and uncontrolled hypertension are also common to the population we serve.

137 Category C • M1-211 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents • Proper nutrition and lack of physical activity are common with this population. Our child and adolescent psychiatrists have long been concerned about this but now a systematic process is in place to screen and educate all children.

• M1-257 Care Planning for Dual Diagnosis • This is also common among those that we serve and important to make appropriate referrals for substance abuse treatment that we do not provide.

• M1-264 Vocational Rehabilitation for Schizophrenia • This measure was chosen as it in in line with other services that we provide (i. e. supported employment)

• M1-305 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-CH) • As a Suicide Safe Care Center, Texana is committed to the goal of zero suicides and had recently implemented this assessment as part of this initiative.

• M1-317 Preventative Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling • Alcohol is another substance used by the population we serve to self medicate.

• M1-319 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (eMeasure) • As a Suicide Safe Care Center, Texana is committed to the goal of zero suicides and had recently implemented this assessment as part of this initiative.

• M1-400 Tobacco Use and Help with Quitting Among Adolescents • As with Adults, youth use to self medicate but also to fit in especially with the new forms of nicotine (e- cigs and vaping.)

138 The End • Texana Center does not have individuals dedicated to DSRIP. These responsibilities are shared by members of the existing team. • Shena Timberlake, Director of Behavioral Healthcare Services 281-239-1384 • Brian Gurbach, UM/QM Manager 281-239- 1383

139 The University of Texas MD Anderson Cancer Center

Sonia Gilmore, Program Manager Mehwish Javaid, Program Manager Provider Information • MD Anderson’s overall mission is to eliminate cancer in Texas, the nation, and the world through outstanding programs that integrate patient care, research and prevention, and through education for undergraduate and graduate students, trainees, professionals, employees and the public. • We serve all of RHP3, mainly Harris and Ft. Bend counties

DY7 Valuation DY8 Valuation MPT $23,750,000 $23,750,000 46

141 Category B • Total PPP • 159,480 • MLIU PPP • 18,187 • 11.40% of total PPP • Comprised of Medicaid/CHIP, Low-income, Self- Pay and Indigent

142 System Definition

System Component Description Inpatient Services MD Anderson provides inpatient care to cancer patients at its hospital in the Texas Medical Center (TMC). Emergency Services Emergency Department is located at the hospital in TMC. Owned or Operated Outpatient Clinics 4 Houston Area Locations : 1) Bay Area 2) Katy, 3) Sugar Land and The Woodlands Contracted Clinics Spring Branch Community Health Centers (4 locations): 1) Hillendahl 2) Pitner 3) West Houston 4) Cy-Fair

143 Category C

Measure Bundle Name System Components

B1- Care Transitions and Hospital MD Anderson Cancer Center Readmissions C2 – Primary Care Prevention- Cancer MD Anderson Cancer Center and Spring Screening Branch Community Health Centers F1 – Improved Access to Adult Dental Care MD Anderson Cancer Center and Spring Branch Community Health Centers G1- Palliative Care MD Anderson Cancer Center

J1 – Hospital Safety MD Anderson Cancer Center

144 Category C • Bundle B1: Care Transitions & Hospital Readmissions • Objective: Implement improvements in care transitions and coordination of care from inpatient to outpatient, post‐acute care, and home care settings in order to improve health outcomes, and prevent increased health care costs and hospital readmissions. • Target Population: Individuals admitted to an inpatient setting • Project Access • Timely access to appointments by consistent use of established Medical Acceptance Criteria within each center • Efficient template management to facilitate new patient appointments

145 B1 Bundle Driver Diagram

Documentation of a Implement Enhancement in primary physician, other checklist in system Expansion of coordination between health care professional for providers to B1: Care Transitions Patient Care primary care, urgent care, or site designated for use in and Hospital and Emergency follow-up care. documenting that Navigation and Readmissions (6 Departments to increase the specified required measures) Transition communication and elements of the Services improve care transitions Transition Record for patients are included in the

patient's record.

146 Category C

• Bundle C2: Primary Care Prevention-Cancer Screening • Objective: Increase access to cancer screening in the primary care setting. • Target Population: DSRIP attributed individuals age 18 or older • Fit/Flu CRC screening and follow-up • Fit-testing and follow-up with diagnostic colonoscopy for those testing positive • Project VALET • Mobile mammography screening and diagnostic follow-up

147 C2 Primary Care Prevention-Cancer Screening Driver Diagram

Use patient Provision of screening and reminder calls follow-up services: This core to decrease the activity is comprised of Continue offering breast no-show rates C2 – Primary Care screening, diagnostic follow- cancer screening and for screening Access to appropriate diagnostic Prevention up and navigation to services in the Primary Care follow-up through Project Cancer Screening (3 treatment for cancer as mobile Services VALET mobile mammography required measures) appropriate for breast and mammography program. colorectal cancers. This core van. activity will be conducted at MD Anderson Hospital as well as four locations of Spring Continue screening patients Provide Branch Community Health for colorectal cancer using Centers. Providers dedicated take-home FITs and provide refresher to the intervention are two appropriate diagnostic trainings for physicians and one follow-up to patients who clinic staff radiologist. test positive and are regarding FIT diagnosed with cancer. testing guidelines and procedures.

148 Category C • Bundle F1: Improved Access to Adult Dental Care • Objective: Increase access to timely, appropriate dental care. • Target Population: Adults 18+ with one or more dental encounter during the measurement year

149 F1 Improved Access to Adult Dental Care Driver Diagram

Documentation of community outreach activities Expanded use of Provide patients at F1 – Adult Dental existing dental FQHCs with information including Care clinics for on the importance of oral distribution of (3 required underserved health and oral cancer education materials measures) population screening at community dental clinics

150 Category C • Bundle G1: Palliative Care . Objective: Provide palliative care services to patients and their families and/or caregivers to improve patient outcomes and quality of life with a focus on relief from symptoms, stress, and pain related to serious, debilitating or terminal illness. . Target Population: Individuals enrolled in palliative or hospice care program during the measurement year or the year prior to the measurement year per measure specifications. . End-of-Life Care • Supportive psychosocial care based on patient-specific needs • Discussions and transitions to end-of-life care as appropriate to each patient

151

G1 Palliative Care Driver Diagram

Document findings of a comprehensive Utilization of pain assessment for services G1 – Palliative patients taking assisting Implement a system for Care opioids individuals pain management in (6 required with pain patients taking opioids. measures)* management Actively engage patients in decision making to find effective alternatives for pain management. * Two additional measures are for a cancer hospital

152 Category C • Bundle J1: Hospital Safety • Objective: Improve patient health outcomes and experience of care by reducing the risk of health-care associated infections, and reducing hospital errors. • Target Population: Individuals receiving inpatient care . Eliminate adverse outcomes by following effort prevention and safety guidelines including: • Surgical checklists • CLABSI Bundle • CAUTI Bundle • Hand Hygiene

153 J1- Hospital Safety Driver Diagram

Feedback on Other – 1) Maintain Hand Hygiene inpatient Catheter- rates for both associated Urinary Tract CLAUTI and Infections (CAUTI) rates CLABSI J1: Hospital Other- Patient and 2) maintain inpatient Compliance with Hand Hygiene without MBI Safety (5 for CLAUTI and CLABSI without Central Line Associated required Infection MBI Bloodstream Infections measures) Control Electronic without mucosal barrier Health Record injury or MBI (CLABSI) data capture rates in OneConnect system

154 For more information, please contact: • Diane Benson [email protected] • Sonia Gilmore [email protected] • Mehwish Javaid [email protected]

155 LUNCH

156 ROUND 3 PRESENTATIONS

HARRIS COUNTY PUBLIC HEALTH RICE MEDICAL CENTER TEXAS CHILDREN'S HOSPITAL UT PHYSICIANS

157 1. Which Anchor team member was featured on the cover of the 2017 Community Health Needs Assessment?

a) Michelle Eunice b) Sonyia Sandhu c) Giovanni Rueda d) Those were just stock photos!

158 2. How many DSRIP RHPs are there in the state of Texas?

a) 18 b) 20 c) 34 d) 10

159 3. Where can you find new HHSC documents?

a) The bulletin board on HHSC’s reporting tool b) Just call John Scott’s cellphone c) CMS website d) Texas Department of Public Safety website

160 4. How many Local Health Departments participate in DSRIP in RHP 3?

a) 9 b) 1 c) 5 d) 3

161 RICE MEDICAL CENTER

NANCY CASTILLO, PROJECT MANAGER MARY JO SPANIHEL, PRACTICE MANAGER

212060201 - RICE MEDICAL CENTER • EAGLE LAKE, TEXAS • 25-BED CRITICAL ACCESS HOSPITAL • TRAUMA LEVEL IV ED • 1,100 SQUARE MILE AREA/POPULATION 20,000 • COLORADO, WHARTON AND AUSTIN COUNTIES • RICE MEDICAL ASSOCIATES • TWO RURAL HEALTH CLINICS: EAGLE LAKE AND EAST BERNARD • PRIMARY CARE CLINIC: WALLIS

163 212060201 – RICE MEDICAL CENTER

• GOAL–TO IMPROVE THE OVERALL HEALTH IN THE COMMUNITY FOR PATIENTS ASSOCIATED WITH CHRONIC DISEASES.

• DY7-8 VALUATION: $3,962,1177.00 • MPT: 23

164 CATEGORY B • TOTAL PPP • 17,232 • MLIU PPP • 6,065 • 35.20% • INCLUDES MEDICAID, LOW-INCOME, DUAL ELIGIBLE, SELF-PAY, CHIP, UNINSURED AND LOCAL COVERAGE OPTION.

165 SYSTEM DEFINITION

System Component Description

INPATIENT SERVICES MEDICAL NURSERY OBSTETRICS SURGICAL SWING BED

EMERGENCY DEPARTMENT TRAUMA LEVEL IV 800 PATIENTS PER YEAR

OWNED OR OPERATED OUTPATIENT EAGLE LAKE CLINICS EAST BERNARD WALLIS FASTTRACK

MATERNAL DEPARTMENT 30 PATIENTS PER YEAR.

166 CATEGORY C • BUNDLE A1 CHRONIC DISEASE MANAGEMENT: DIABETES CARE • CORE ACTIVITY-DIABETES EDUCATION PROGRAM • IMPROVE PATIENT OVERALL HEALTH • IDENTIFY PATIENTS DUE FOR SCREENING/TESTING. • PROVIDE PATIENTS WITH EDUCATION

167 CATEGORY C • BUNDLE C2 PRIMARY CARE PREVENTION: CANCER SCREENING • CORE ACTIVITY-PROVISION OF SCREENING AND FOLLOW-UP SERVICES • REVIEW PROCESS OF HOW OFTEN PATIENTS ARE SCREENED. • PROPERLY IDENTIFY PATIENTS DUE FOR SCREENING/TESTING • CONFIRM THE NEED FOR IDENTIFIED SCREENING/TESTING

168 CONTACT INFO

MARY JO SPANIHEL, RHIA NANCY CASTILLO PRACTICE MANAGER PROJECT MANAGER RICE MEDICAL ASSOCIATES RICE MEDICAL CENTER 610 S AUSTIN RD 610 S. AUSTIN RD. EAGLE LAKE, TX 77434 EAGLE LAKE, TX 77434 979-234-2551 979-234-5571 [email protected] [email protected]

169 “Our Family Caring For Yours”

170 Texas Children’s Hospital

Bethany Lowe, Senior Project Manager Provider Information • Texas Children’s overall DSRIP goals center on implementing delivery system reforms that increase access to health care, improve quality of care, and enhance the health of the patients and families that we serve. Implementing these delivery system reforms also aligns with the Institute for Healthcare Improvement’s (IHI) triple aim, to improve patient experience, enhance population health, and reduce the per capita cost of care. • Texas Children’s DSRIP efforts aim to address the needs outlined in the Southeast Texas RHP - Region 3 Community Needs Assessment, which closely align with the needs identified in Texas Children’s Community Health Needs Assessment. • DY7-8 valuation = $32.4M • MPT = 65

172 System Definition System Component Description Inpatient Services TCH Medical Center, West Campus (Katy), Woodlands, and the Texas Children’s Pavilion for Women Emergency Department Emergency Center at The Woodlands, West Campus, and West Tower (Medical Center) Owned or Operated Outpatient Clinics Texas Children's Hospital provides care in more than 40 pediatric subspecialties at all 3 hospital locations and at 7 specialty centers across the Greater Houston area Maternal Department Texas Children’s Pavilion for Women OB/GYN practices (BCM, POGC, WSH, Pearland) Owned or Operated Urgent Care Clinics 9 Texas Children’s Urgent Care sites

173 174 Category C Measure Bundles

D5: Diabetes D3: Hospital Safety 8 points 10 points DY7: $2,042,225.79 DY7: $2,553,228.92 DY8: $2,784,853.35 DY8: $3,481,675.80

D4: Asthma G1: Palliative Care 9 points 6 points DY7: $2,297,727.35 DY7: $1,531,222.66 DY8: $3,133,264.57 TCH DSRIP System DY8: $2,088,030.90 • IP/OP • PFW IP/OP D1: Primary Care E1: Maternal Care • TCP & Urgent Care 11 points 16 points DY7: $2,806,943.76 DY7: $4,084,451.58 DY8: $3,827,650.58 DY8: $5,569,706.70 I1: Specialty Care E2: Maternal Safety 2 points 8 points DY7: $509,216.40 DY7: $2,042,225.79 DY8: $694,386.00 DY8: $2,784,853.35

175 Contact Information

Bethany Lowe, Senior Project Manager, [email protected]

Karen Rose, Senior Project Manager, [email protected]

176 Yen-Chi Le, Assistant Director Sharif Mansur, Assistant Director Provider Information • UT Physicians, the practice plan of UT Health, provides primary and specialty care to patients of all ages in an ambulatory, outpatient setting. • Service areas: Harris, Fort Bend & Jefferson • DY7-8 valuation: $91.84 million • MPT: 75

178 Category B • Total PPP • 304,655 • MLIU PPP • 53,111 • 17.43% MLIU PPP rate • MLIU comprises: Medicaid, Low-Income, Medicaid/Medicare Dual-Eligible, CHIP and Uninsured

179 System Definition • High-level overview System Component Description Owned or Operated Outpatient Clinics All primary care (e.g., family medicine, internal medicine, pediatrics) clinic locations owned by UT Physicians. All multi-specialty (e.g., behavioral health, psychiatry, obstetrics/gynecology, endocrinology, cardiology, hepatology) clinic locations owned by UT Physicians.

180 Category C Measure Measure Bundle Bundle ID Measure Bundle Name Base Points A1 Improved Chronic Disease Management: Diabetes 11 C1 Primary Care Prevention - Healthy Texans 12 C2 Primary Care Prevention - Cancer Screening 6 C3 Hepatitis C 4 D1 Pediatric Primary Care 14 E1 Improved Maternal Care 10 Integration of Behavioral Health in a Primary or Specialty H1 Care Setting 12 Total Overall Selected Points (including optional and PBCOs) 87

181 A1: Diabetes Care

182 C1: Healthy Texans

183 C2: Cancer Screening

184 C3: Hepatitis C

185 D1: Pediatric Primary Care

186 E1: Improved Maternal Care

187 H1: Integrated Behavioral Health

188 Development of DSRIP Measure Guides • Clinical components • Documentation components • Clinical workflows • Performance dashboards

189 Clinical Workflow for D1-108; D1-211; D1-237; D1-271; D1-400)

190 Clinical Workflow for A1-112 (foot); A1-115 (A1c); A1-209 (BP)

191 The End

Contact information:

Yen-Chi Le, Assistant Director, Healthcare Transformation Initiatives [email protected]

Sharif Mansur, Assistant Director, Healthcare Transformation Initiatives [email protected]

192 BREAK

193 ROUND 4 PRESENTATIONS

HARRIS HEALTH SYSTEM FORT BEND COUNTY OAKBEND MEDICAL CENTER MEMORIAL HERMANN HOSPITAL: SOUTHWEST, WOODLANDS

194

1. How many bundles are on the Category C Measure Bundle menu?

a) 15 b) 24 c) 31 d) 37

195 2. Which animal was used by HHSC to represent Category 3 in the October DY6 Reporting Webinar?

a) Giraffe b) Wildebeest c) Cat d) Eagle

196 Joe Dygert – Director, Health System Strategy Project Management Office Stephen Orrell – Operations Manager, Health System Strategy Project Management Office

Provider Information Goals • To transform healthcare delivery from a disease-focused model of episodic care to a patient-centered, coordinated delivery model that improves patient satisfaction and health outcomes, reduces unnecessary or duplicative services and builds on the accomplishments of our existing healthcare system. • To promote a culture of ongoing transformation and innovation that maximizes the use of technology and best-practices, facilitates collaboration and sharing, and engages patients, providers, and other stakeholders in the planning, implementation and evaluation processes.

Service Area: Harris County DSRIP DY7-8 valuation: $221,291,770.07 MPT: 75

198 Category B • Total PPP • 307,236 • MLIU PPP • 248,396 • 80.85% • Medicaid, CHIP, Local Coverage Option (Below 200% FPL), Insured on the Exchange (Below 200% FPL), Low-Income (Below 200% FLP), Self-Pay, and Uninsured

199 System Definition System Component Description Inpatient Services Patients formally admitted to a hospital with a doctor’s order, i.e. care of patients whose condition requires admission to a hospital.

Emergency Department Provides triage, treatment and support for trauma, and emergency patients of all ages in an acute care setting. Owned or Operated Outpatient Clinics Part of the hospital and designed for patients who do not require a bed or admission for overnight care. Maternal Department Provides care for women during pregnancy and childbirth. Also provides care for newborn infants. School-based Clinics Clinics located on school campuses that provide preventive and primary health care services to children and adolescents.

200 Bundle A1: Diabetes Care

Metrics • A1-112 Comprehensive Diabetes Care: Foot Exam • A1-115 Comprehensive Diabetes Care: HbA1c (>9.0%) • A1-207 Diabetes care: BP control (<140/90mm Hg) • A1-500 PQI 93-ST/LT comp, uncontrolled DM, amput. adm rate • A1-508 Reduce Rate of ED visits for Diabetes

Core Activities • Patient education and care coordination for DM patients that promotes self-management • Telephone follow-up within 48-72 hours post-intervention to assist with patient compliance • Outreach to patients to address barriers such as eligibility and medication adherence. • Drill-down of patient lists at clinic sites to stratify and direct recommended interventions to clinic leadership and DM programs (DMP & Home Visits)

201 Bundle B1: Care Transitions & Hospital Readmissions

Metrics • B1-124 Medication Reconciliation Post-Discharge • B1-141 Risk Adj AC Readm: CHF • B1-217 Risk Adjusted AC Readmission • B1-252 Transition Record with Specified Elements (ED) • B1-253 Transition Record with Specified (Inpatient) • B1-287 Documentation of Current Medication • B1-352 Post-Discharge Appointment (HF w/ scheduled) B1-352 Post-Discharge Appointment (7 days) Core Activities • Automated best practice alerts that are triggered by specific diagnoses to remind providers to place orders or referrals that positively impact the measures. • Utilize workbench reports Inpatient prevent CHF and All-cause readmissions • Update Inpatient discharge summary print groups • New workflows to streamline measure interventions.

202 Bundle C2: Cancer Screening & Follow Up

Metrics • C2-106 Cervical Cancer Screening • C2-107 Colorectal Cancer Screening • C2-186 Breast Cancer Screening

Core Activities • Commitment from clinic administration for daily pre-clinic chart reviews • Dedicated LVN/MA at each location to review health maintenance before appointment • New workflows to streamline measure interventions • Development of fall-out reports for patient chart monitoring

203 Bundle D1: Pediatric Primary Care Metrics • D1-108 Childhood Immunization Status (CIS) • D1-211 BMI • D1-211 Nutrition Counseling • D1-211 Physical Activity • D1-212 Appropriate Testing for Children With Pharyngitis • D1-237 WC Visits in the 1st 15 Months (6 or more visits) • D1-271 Immun for Adolescents- Tdap/TD, HPV and MCV • D1-284 Appropriate Treatment for Children with URI • D1-400: Adoloscent Tobacco Use and Help Quitting • D1-503: PDI 97 Gastroenteritis, UTI Admit Rate Core Activities • Automated best practice alerts that are triggered by specific diagnoses to remind providers to place orders or referrals that positively impact the measures • Additional Pedi Orders Smart Sets • New workflows to streamline measure interventions.

204 Bundle E1: Improved Maternal Care

Metrics • E1-232 Timeliness of Prenatal Care (Medicaid) • E1-235 PP Follow-Up and Care Coordination • E1-300 BH Risk Assessment (dep, alcohol, violence)Core Activities

Core Activities • Modification of provider templates to expand appointment availability • Addition of Postpartum visit type for scheduling • Epic documentation flowsheets that capture required components • New workflows to streamline measure interventions • Address Eligibility barrier

205 Bundle G1: Palliative Care

Metrics • G1-276 Palliative Care – Pain assessment • G1-277 Palliative Care – Treatment Preferences • G1-278 Beliefs/Values - Spiritual/religious concerns • G1-361 Patients on Opioid given a Bowel Regimen • G1-362 Palliative Care -- Dyspnea Treatment • G1-363 Palliative Care -- Dyspnea Screening

Core Activities • Automated best practice alerts that are triggered by specific diagnoses to remind providers to place orders that will positively impact the measures • Epic Smart Forms for discrete data capture

206 Bundle H4: Integrated Care for People with Serious Mental Illness

Metrics • H4-182 DM Screen for SCZ or BP pt on Antipsychotic • H4-260 Annual Physical pts with Mental Illness • H4-258 LDL-C for pts with CV disease and SCZ

Core Activities • Automated best practice alerts that are triggered by specific diagnoses to remind providers to place orders or referrals that positively impact the measures • New workflows to streamline measure interventions

207 Contact

Joe Dygert: [email protected]

Stephen Orrell: [email protected]

208 Fort Bend County

Kaye Reynolds, DrPH Deputy Director, Fort Bend County Health & Human Services

M. Connie Almeida, PhD Director, Fort Bend County Behavioral Health Services

Provider Information

• Fort Bend County Health & Human Services Department and Behavioral Health Services Department jointly created a government, community agency and private provider collaboration to improve the health outcomes of residents using innovative programs. The collaboration includes formal contractual agreements, sub-county department partnerships, and community agency referrals, shared resources and partnerships. • The overall DSRIP goals are based on the Fort Bend County vision for health care transformation to Right Care, Right Place, Right Time. The objective is to develop a system of care, collaborated through the various community programs and agencies that identifies clients and families needing health improvement and to provide the coordinated and appropriate level of care and support, addresses social determinants of health, supports ongoing recovery and wellness, reduces episodic crisis care, incarceration and unnecessary hospitalization. • DY7 Valuation: $5,649,979 • DY8 Valuation: $5,649,979 • Minimum Point Threshold: 11

210 Category B • Total PPP • Total PPP number - 41,323 • MLIU PPP • MLIU PPP number - 27,256 • MLIU PPP percentage - 65.96% • The MLIU population is composed of : • Medicaid • Dual eligible for Medicaid and Medicare • CHIP • Uninsured • Low-income (below 200% FPL) • Local coverage option (below 200 FPL) • Insured on the exchange (below 200% FPL) • Self-pay

211 System Definition

• Fort Bend County system components include our local Federally Qualified Health Center (FQHC), mobile units, and behavioral health crisis response system as well as recovery and support programs.

System SystemComponent Component DescriptionDescription Clinics 2 FBC Clinical Health Services (CHS) locations provide TB prevention and control, STD List your selected system components.treatment and partner elicitation,Provide and a HIVbrief risk reductiondescription. services. Immunization Locations 3 FBC Clinical Health Services (CHS) immunization locations provide vaccines by the Texas Vaccines for Children program are offered only to individuals who are uninsured or Medicaid recipients. Only flu vaccine purchased by the county is offered without restriction to payer type. MobileEx: Owned Outreach or Operated OutpatientThe Mobile Outreach componentEx: 14 consists primary of Crisis care Intervention clinics Services throughout (CIT) and EMS o CIT involves law enforcement officers trained in mental health crises that redirect mental Clinics health issues away fromthe the criminal greater justice Houston system and towardarea. appropriate Provide mental healthcare. variety of preventive services and o Fort Bend County’s emergency medical services respond to 911 health emergencies. Fort Bend County considers EMSscreenings. pre-hospital care and transportation to care. Access Health FQHC Adult Family Practice FBC contracts with Access Health FQHC in Richmond and Missouri City for adult care only. Clinics in Richmond and Missouri City FBC Behavioral Health Services Department FBC Behavioral Health Services Department is part of Fort Bend County’s Administration of Justice Division and provides the following services: o Recovery and reintegration: for adults with mental health disorders who are involved in criminal justice and need intensive case management and wrap around services. o Juvenile diversion: same as above but for children. o Crisis Intervention Team: jointly administered with the FBC Sherriff’s office.

212 Category C Measure Selections Measure L1-105 - Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention • Core Activity - Implementation of strategies to reduce tobacco use for patients not ready to quit • SBIRT (Screening, Brief Intervention, Referral to Treatment) • Systematically screen all clients to identify those who need further intervention • Reduce tobacco, drug and alcohol use in identified patients

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Category C Measure Selections Measure L1-107 - Colorectal Cancer Screening • Core Activity - Implement Evidence-based Disease Prevention Programs • Colonoscopy Screening • Assess and reduce patient barriers to completion of screening procedure • Leverage the Health Information Technology Systems

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Category C Measure Selections Measure L1-115 - Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) Measure L1-207 - Diabetes care: BP control (<140/90mm Hg) • Core Activity - Provision of navigation services to targeted patients • Care Coordination • Establish engagement with referred clients by enrolling them into a navigation team approach to improve health outcomes for the client • Improving chronic disease understanding and self- management • Community Health Worker assessment and referral for mitigation of health impacting social determinants

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Category C Measure Selections Measure L1-115 - Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) Measure L1-207 - Diabetes care: BP control (<140/90mm Hg) • Core Activity - Identification of frequent ED users and use of care navigators as part of a preventable ED reduction program, which includes a connection of ED patients to primary and preventive care. • Community Paramedics • Engage clients in chronic illness self- management, healthy lifestyles, preventive care, and positive healthcare decisions • Identify patients who are at risk for inequalities in social determinants of health that are impacting their health through coordination of care, referrals for service provision

216 Category C Measure Selections Measure - L1-205 - Third next available appointment • Core Activity - Expanded Practice Access • Expanded Hours • Same day appointment availability slots to expand access • Maintain a full provider team dedicated to the expanded clinic hours

217 Category C Measure Selections Measure L1-241 - Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons • Core Activity - Provision of crisis stabilization services based on the best practices • Crisis Intervention Team • Specialized Crisis Intervention Team (CIT) that is trained and supported to address behavioral health crises, in the community. • A network of needed clinical and support services, in the community, for individuals and families.

218 Category C Measure Selections Measure L1-241 - Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons • Core Activity - Provision of services to individuals that address social determinants of health and/or family support services. • Recovery and Reintegration • Juvenile Diversion • Screen clients (youth and adults) enrolled in Behavioral Health Services for social determinants of health. • Intensive case management services provided to clients.

219 Category C Measure Selections Measure L1-241 - Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons • Core Activity - Implement models supporting recovery of individuals with behavioral health needs. • Recovery and Reintegration • Juvenile Diversion • Complete the CANS (Child and Adolescents Needs and Strengths) and ANSA (Adult Needs and Strengths Assessment) to assess needs and strengths. • Patient support/continuity of care of services for clients enrolled in the program

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Fort Bend County Contact Information • M. Connie Almeida, PhD 301 Jackson St., Ste 520 Richmond, TX 77469 [email protected] 281-238-3078 • Kaye Reynolds, DrPH 4520 Reading Road, Suite A-100 Rosenberg, TX 77471 [email protected] 281-238-3519 • M. desVignes-Kendrick, MD, MPH, FAAP 4520 Reading Road, Suite A-100 Rosenberg, TX 77471 [email protected] 281-238-3589 • DeAndrea M. Newton 301 Jackson St., Ste 520 Richmond, TX 77469 [email protected] 281-238-3046

221 OakBend Medical Center

Jason Todd, Special Projects Coordinator Ebony Buckner, Community Health Coordinator Lawauna Budwine, Director of Perinatal Services LaToya Bates, Quality Coordinator Jonathan Ray, DSRIP Data Analyst

Provider Information • OBMC is focused on providing exceptional, compassionate health care for our community, regardless of ability to pay. • We serve the population of Fort Bend County and surrounding communities. • DY7-8 combined valuation: $23,477,483 • Minimum Point Threshold: 23

223 Category B • Total PPP • 75,978 individuals • MLIU PPP • 17,292 individuals • 22.76% of total population • Our MLIU population consists of individuals on Medicaid, Dual Eligible, and CHIP as well as Self- Pay and Uninsured community members.

224 System Definition

System Component Description Inpatient Services 3 hospitals focused on providing care for serious ailments and trauma as well as an inpatient surgical facility

Emergency Department 3 hospital ED’s and 1 freestanding, including level III and IV trauma centers, RN and EMT clinical rotations, and air ambulance services

Outpatient Clinics 6 Primary Care clinics, 7 Specialty Care clinics, 4 Ambulatory Surgical Centers, and 21 Physical Therapy Clinics Maternal Department Includes L&D, Post Partum, Anti Partum, and a level II NICU

225 Bundle B-1 • Measures 124 and 287 are already required under hospital record keeping policy. • Measures 252 and 253 require a change in discharge process policy to include a procedure and lab result summary. • Measures 141, 217, and 352 are assisted by a care transition team for ED discharges and our Community Health Coordinator for inpatients.

226 Bundle E-2 • For measure A01, Oak Bend has enrolled in TexasAIM Plus. This enrollment entails additional quality measures and further collaborative efforts. • Measures 150 and 151 are subject to physician decisions on a case by case basis.

227 Bundle J-1 • Statistics for all J-1 measures are constantly tracked by the Quality department. Any issues are identified and addressed in a monthly meeting between managerial staff.

228 Contact Information • Jason Todd • Farah Awan • (281)341-2804 • (281)341-3005 • [email protected] • [email protected]

• Ebony Buckner • Jonathan Ray • (281) 341-3006 • (281) 341-2808 • [email protected] • [email protected]

229 Memorial Hermann Health System

Kord Quintero, Project Manager • Memorial Hermann Health System operates two DSRIP Performing Providers anchored by: • Memorial Hermann Texas Medical Center (TMC) (137805107) • The “4-Plex” – Memorial Hermann Southwest, Southeast, Greater Heights, and The Woodlands Hospitals (020834001) • Memorial Hermann cares for patients throughout all counties in the Greater Houston area. DY 7 DY 8 MPT TMC $26,607,454 $26,607,454 53 4-Plex $31,729,977 $31,729,977 63

231 MH “4-Plex” Category B • Total PPP • 323,206 • MLIU PPP • 122,555 • 37.92% • MLIU population includes Medicaid, Dual eligible Medicare & Medicaid, Self-Pay, CHIP, and Uninsured Patients

232 MH TMC Category B • Total PPP • 192,287 • MLIU PPP • 73,252 • 38.10% • MLIU Population includes Medicaid, Dual Eligible Medicare & Medicaid, Self-Pay, CHIP, and Uninsured Patients

233 MH “4-Plex” System Definition System Component Description Inpatient Services Memorial Hermann Greater Heights, Southwest, Southeast, The Woodlands Hospitals

Emergency Department Memorial Hermann Greater Heights, Southwest, Southeast, The Woodlands Hospitals

Owned or Operated Outpatient Clinics Memorial Hermann Medical Group Clinics (MHMG) - 49 locations throughout the Houston MSA

Maternal Department Memorial Hermann Greater Heights, Southwest, Southeast, The Woodlands Hospitals

234 MH TMC System Definition System Component Description Inpatient Services Memorial Hermann Texas Medical Center

Emergency Department Memorial Hermann Texas Medical Center

Maternal Department Memorial Hermann Texas Medical Center

School Based Health Clinics All MH School Based Health Centers located within five school districts in the Houston MSA. Includes 10 clinics and a Mobile Dental Van. Mental Health Crisis Clinics Three MH Mental Health Crisis Clinic Locations

235 Memorial Hermann Category C • Bundle B2: Patient Navigation & ED Diversion • System: 4-Plex • Targeted utilization of the 24-Hour Nurse Triage Line • Expanded coordination with care & case management • Utilizing CHW “navigators” for coordination of care

236 Memorial Hermann Category C • Bundle G1: Palliative Care • System: 4-Plex • Utilize palliative care MDs and mid-level providers for comprehensive Palliative Care services. • Improve patient/family relations with end of life decisions and quality of life for the patient.

237 Memorial Hermann Category C • Bundle H1: Integration of Behavioral Health in a Primary or Specialty Care Setting • System: 4-Plex • Pilot program that provides psychiatric services to patients in a primary care setting • Currently in four locations with plans for expansion • Still undergoing the proof of concept process and staffing models are not yet finalized

238 Memorial Hermann Category C • Bundle D1: Pediatric Primary Care • System: TMC • Utilize existing School Based Health Centers • Allows students to see a primary care provider during the school day • Reduces the amount of time missed from class • Provides immunizations and other wellness checks free of charge

239 Memorial Hermann Category C • Bundle F2: Preventive Pediatric Dental • System: TMC • Utilizes a mobile dental van as part of the School Based Health Centers • Includes screening and preventative dental services to improve long term oral health • Reduces costs by preventing the need for more intensive treatment in the future • Operates on a rolling schedule throughout all School Based Health Centers

240 Memorial Hermann Category C • Bundle B1: Care Transitions & Hospital Readmissions • System: TMC & 4-Plex • Targeted utilization of the 24-Hour Nurse Triage Line • Expanded coordination with care & case management • Utilizing CHW “navigators” for coordination of care and post-discharge appointment

241 Memorial Hermann Category C • Bundle H2: Behavioral Health & Appropriate Utilization • System: TMC & 4-Plex • Utilize our Mental Health Crisis Clinics & Case Management Program to drive improvement within this population • The Case Management program coordinates services and care outside of the hospital • The Crisis Clinics offer appropriate services outside of the Emergency Department

242 Memorial Hermann Category C • Bundle J1: Hospital Safety • System: TMC & 4-Plex • Continue to create a health care environment that: • Anticipates problems • Promotes early detection • Makes early responses

243 Contact Info: Kord Quintero – Project Manager [email protected] Michael Dsouza – Palliative Care [email protected] Deborah Ganelin – Community Benefit [email protected] Theresa Fawvor – Behavioral Health [email protected]

244 BREAKOUT ACTIVITY

245 Breakout Activity • Pick a table with a topic related to your outcomes. • At your table, introduce yourself to your colleagues and grab an index card. • Spend some time discussing the question with your colleagues – when you’re done, grab another card and keep going! • After 30 minutes, rotate to another table.

246 ADJOURN

THANK YOU!

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