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5-Year PRIME Project Plan

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5-Year PRIME Project Plan Public Hospital Redesign and Incentives in Medi-Cal (PRIME) 5-Year PRIME Project Plan Application due: by 5:00 p.m. on April 4, 2016 1 Table of Contents Table of Contents....................................................................................................................................... 2 General Instructions................................................................................................................................... 3 Scoring....................................................................................................................................................... 3 Section 1: PRIME Participating Entity Information............................................................................... 4 Section 2: Organizational and Community Landscape ........................................................................ 4 Section 3: Executive Summary ................................................................................................................ 8 SECTION 4: PROJECT SELECTION...................................................................................................13 Section 4.1 -- Domain 1: Outpatient Delivery System Transformation and Prevention.........................15 Section 4.2 -- Domain 2: Targeted High-Risk or High-Cost Populations .................................................23 Section 4.3 – Domain 3: Resource Utilization Efficiency........................................................................34 Section 5: Project Metrics and Reporting Requirements ...................................................................47 Section 6: Data Integrity..........................................................................................................................47 Section 7: Learning Collaborative Participation...................................................................................48 Section 8: Program Incentive Payment Amount..................................................................................48 Section 9: Health Plan Contract (DPHs Only) .....................................................................................48 Section 10: Certification ..........................................................................................................................49 Appendix Infrastructure Building Process Measures .........................................................................50 References................................................................................................................................................64 2 General Instructions Thank you for your interest in the Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program. Your response to this 5-Year PRIME Project Plan (“Plan”) will enable the Department of Health Care Services (DHCS) to assess if your entity can meet the requirements specified in the waiver Special Terms and Conditions (STCs) and has the capacity to successfully participate in the PRIME program. This 5-Year PRIME Project Plan is divided into 10 sections which are structured around the Medi-Cal 2020 Waiver’s Special Terms and Conditions (STCs). Additional information about the PRIME program requirements can be found in the PRIME Projects and Metrics Protocol (Attachment Q) and Funding Mechanics (Attachment II) of the STCs. Scoring This Plan will be scored on a “Pass/Fail” basis. The state will evaluate the responses to each section and determine if the response is sufficient to demonstrate that the applicant will be able to effectively implement the selected PRIME Projects while simultaneously conducting the regular business of operating the hospital system. In the event that a response to a Plan section is not sufficient and fails to meet review criteria, the applicant will have an opportunity to revise the response(s) to meet the state’s satisfaction. Applicants will have three (3) days to complete the revisions upon receiving feedback from the state. Please complete all sections in this 5-Year PRIME Project Plan, including the Appendix (the infrastructure-building process measure plan as applicable), and return to Tianna Morgan at [email protected] no later than 5:00 p.m. on April 4, 2016. 3 Section 1: PRIME Participating Entity Information Health Care System/Hospital Name Palomar Health (PH) Health Care System Designation (DPH or DMPH) DMPH Section 2: Organizational and Community Landscape The purpose of this section is to provide DHCS with an understanding of the demographic makeup of the community the applicant serves, the target population that will benefit from the PRIME activities, and any other relevant information that will help inform the state’s review of this Plan. 2.1 Community Background. [No more than 400 words] Drawing on available data (e.g., DHCS, Office of Statewide Health Planning and Development, U.S. Census Bureau), summarize the health care needs and disparities that affect the health of your local community. Palomar Health (PH) is a healthcare district hospital, as defined by State law, which serves the North Inland Region of San Diego County (SDC). An analysis of the North Inland Region conducted by the HHSA in 2012 found that the high prevalence of chronic disease and high rates of obesity were top concerns for the Region. Similarly, the Hospital Association of San Diego & Imperial County’s 2013 Community Health Needs Assessment (CHNA) found that cardiovascular disease and obesity were among the top health needs in the region. In addition to the top health needs, the 2013 CHNA identified five broad categories of recommendations for hospitals to improve community health including access to care or insurance, care management, education, screening services, and collaboration. Access and chronic disease management were also identified as a common barrier for the SDC community. Cardiovascular Disease: Nearly 7% of adults in the North Inland Region have been diagnosed with heart disease, compared to 6.0% in SDC. Additionally, 22.6% have been diagnosed with high blood pressure in the Region. “Diseases of the heart” is the second leading cause of death in the Region, accounting for 21% of deaths in the North Inland Region. Obesity: More than half of the adults in the North Inland Region are overweight or obese. Additionally in the Region, 12.9 % of children age 2-11 are overweight and 27.1% of adolescents age 12-17 are overweight or obese. Health Disparities: Nearly two thirds of the communities in the North Inland Region are considered to be high or very high need by the Dignity Health Community Need Index, 4 which provides a high-level assessment of community health needs based on income, culture and language, educational levels, insurance and housing. According to the 2013 American Community Survey, the two large North Inland communities of Escondido and San Marcos had a higher percentage of residents who are eligible for public programs, speak only Spanish, have not attained a high school degree and spend greater than 30% of their income on housing compared to the rest of the North Inland Region and SDC overall. These are all factors known to adversely impact health and hinder access to preventable care. Coverage: With a shortage of physicians (77.5 in San Diego County per 100,000 population) and overall poverty (27.5% are uninsured) in the Region, PH is challenged to meet the healthcare needs of the community it serves. From Fiscal Year 2014 to Fiscal Year 2015, PH experienced a 49.5% increase in the number of Medi-Cal patients accessing care. 2.2 Population Served Description. [No more than 250 words] Summarize the demographic make-up of the population included in your hospital’s service area, including information about per capita income, age, race, ethnicity, primary language, etc. The total population in SDC is 3,138,265 with the population density estimated at 746 persons per square mile. The North Inland Region is the largest region geographically within the County and home to 581,849 residents (approximately 18% of the county). The communities of the North Inland Region include urban, suburban, rural and remote areas and represent a low population density of 246.2 persons per square mile. Income: Within the North Inland Region, 11.1% of the population has an income below 100% of the Federal Poverty Level (FPL) compared to 19.3% in California. Additionally, 27.5% are uninsured, and 14.1% of residents over 25 lack a high school diploma or equivalent. The average per capita income in the North Inland Region is $32,342 compared to $29,527 for California. Race/Ethnicity & Language: North Inland is predominately white (53.89%), Hispanic (29.85%) and Asian/Pacific Islander (10.74%). While the majority of residents report speaking English (66.5%) only or being bilingual (16.5%), there remains a significant percentage (12.08%) of the population that report speaking Spanish only at home. Age: Average age of North Inland Region residents is 37.5 years old, higher than the SDC median of 34.8. The age breakdown is as follows: • 0-18 years: 26.9% • 19-64 years: 59.3% • 65 years+: 13.4% 5 2.3 Health System Description. [No more than 250 words] Describe the components of your health care system, including license category, bed size, number of clinics, specialties, payer mix, etc. Palomar Health is the largest healthcare district by geographic area in California and serves communities in an 850-square mile area and has a trauma center that covers more than 2,200 square miles. As of April 4, 2016, the health system includes
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