(El Paso) Tenet DSRIP-Care Transitions Programs High Risk Transition Care Plan Sierra Providence

Project Option 2.12.2: Implement one or more pilot intervention(s) in care transitions targeting one or more patient care units or a defined patient population: IMPLEMENT/EXPAND CARE TRANSITIONS PROGRAMS

Unique Project ID: 196829901.2.1

Performing Provider Name/TPI: Sierra Providence East Medical Center / TPI: 196829901

Project Description:

This project will provide discharge planning assessment and intervention for targeted patients with a high risk of readmission. This project will involve identification and targeting of patients with the highest risk of readmission. This project will support and enhance discharge planning assessment and intervention, with the development of tools that assist case managers to identify and target those patients at risk for readmission to the hospital within 30 to 60 days. The intent of this project is to improve the core discharge planning function and support a safe, effective, and efficient transition to post-acute care. The ultimate goal will be to reduce preventable readmissions by identifying and developing comprehensive discharge plans that meet the needs of the high-risk population early in the patient stay. A comprehensive and reliable discharge plan, along with post‐discharge support, can reduce readmission rates, improve health outcomes, and ensure quality transitions. Following the implementation of the project, quality improvement activities will be conducted to foster continued learning by staff regarding the most effective methods for ensuring quality care transitions. High-risk assessment will be integrated into an existing assessment, increasing the time a case manager must have with the patient/family, making implementation of the project somewhat challenging. Goals and Relationship to Regional Goals: Project Goals: The goal of such this project is to ensure that the hospital discharge is accomplished appropriately and that care transitions occur effectively and safely, as evidenced by identification and targeting of patients that are high risk for re-admission and development of a discharge plan based on the individualized patient needs. Through high-risk assessment at the point of admission, patients will be identified and targeted and interventions will promote an individualized, effective and safe transition. Transitions from inpatient care to the home setting will be supported and readmissions or revisits within 30 to 60 days will be reduced. This project meets the following regional goals: Implementing a tool to assess patients who are at a high risk for readmission, would allow SPEMC to provide this patient population with a comprehensive discharge/transition plan that will promote self-management of a chronic disease, and attainment of community resources to support the patient in the appropriate health setting or home and avoid preventable readmissions. This project would support the Regional goal of improvement management of patients with chronic diseases and the goal of prevention of unnecessary readmissions. The project would support the goal of getting patients the care they need to prevent, self-manage, and address in an appropriate setting; The comprehensive transition plan from these high risk screenings would facilitate the Regional goals of the provision of patient education to ensure the population is accessing the right care in the right setting, assist in removing barriers to accessing healthcare resources in the region; and Increase patient satisfaction through delivery of high-quality, effective healthcare services. Challenges: A major challenge facing the successful implementation of this project is the difficulty inherent in ensuring that patients properly follow discharge instructions.

5-Year Expected Outcome for Provider and Patients: Sierra Providence East expects timely identification and targeting of patients with the highest risk of readmission will support and enhance discharge planning assessment and intervention, with the development of tools that assist case managers to identify and target those patients at risk for readmission to the hospital within 30 to 60 days. SPEMC expects the improvement of the core discharge planning function. The expectation then is to ultimately reduce preventable readmissions by identifying and developing comprehensive discharge plans that meet the needs of the high-risk population early in the patient stay. SPEMC believes that a comprehensive and reliable discharge plan, along with post‐ discharge support, can reduce readmission rates, improve health outcomes, and ensure quality transitions. Starting Point/Baseline: Evaluation of readmissions tied to identified diagnostic groups will provide the baseline data to determine the starting point for case management training. Rationale: According to the Medicare Payment Advisory Committee, 76 percent of re-hospitalizations occurring within 30 days in the Medicare population are potentially avoidable. Other populations affected include patients with chronic diseases, complex medical and social needs and patients with little or no funding resources for post-acute care needs. Evidence suggests that the rate of avoidable re-hospitalization can be reduced by improving core discharge planning and transition processes out of the hospital, and by improving transitions and care coordination at the interfaces between care settings. Project Components: This project will accomplish the following project components: a) Implement one or more pilot intervention(s) in care transitions targeting one or more patient care units or a defined patient population. o Sierra East will improve the core discharge planning function and support a safe, effective, and efficient transition to post-acute care. b) Conduct quality improvement for the project using methods such as rapid-cycle improvement. Activities may include, but are not limited to, identifying project impacts, “lessons learned,” opportunities to scale all or part of the project to a broader patient population, and key challenges associated with expansion of the project, including special considerations for safety-net populations. o Sierra East will continue to improve its discharge planning interventions by conducting quality improvement activities following the implementation of the interventions. Unique community need identification numbers the project addresses:  CN-1: Primary Care  CN-2: Secondary and Specialty Care  CN-6: Other Projects How the project represents a new initiative or significantly enhances an existing delivery system reform initiative: Implementing a tool to assess patients who are at a high risk for readmission, would allow SPEMC to provide this patient population with a comprehensive discharge/transition plan that will promote self- management of a chronic disease, and attainment of community resources to support the patient in the appropriate health setting or home and avoid preventable readmissions. This will enhance the current discharge planning process. Related Category 3 Outcome Measures: OD-3 Potentially Preventable Re-Admissions—30-Day Readmission Rates (PPRs)

IT-3.1: All-cause 30-day readmission rate

196829901.3.4

Reasons/rationale for selecting the outcome measures: Sierra East anticipates that the enhanced discharge interventions for high-risk patients will create a more effective post-discharge health management strategy. Through increased focus on these high-risk patients, Sierra East will reduce the potentially, preventable readmissions rate at its facility. Relationship to Other Projects: This project is part of Tenet’s larger plans to expand and develop primary care and specialty care services in the El Paso community, while improving access to care and containing the costs of care. Specifically, this project will complement Tenet’s Expand Primary Care Access project (196829901.1.1) and Enhance Interpretation Services and Culturally Competent Care project (196829901.1.2); each of these projects is intended to improve the patient experience by providing care in more effective and efficient ways.

Relationship to Other Performing Providers’ Projects and Plan for Learning Collaborative: This project complements Providence Memorial Hospital’s similar care transitions project. Performing Providers, IGT entities, and the Anchor for Region 15 have held consistent monthly meetings throughout the development of the Waiver. As noted by HHSC and CMS, meeting and discussing Waiver successes and challenges facilitates open communication and collaboration among the Region 15 participants. Meetings, calls, and webinars represent a way to share ideas, experiences, and work together to solve regional healthcare delivery issues and continue to work to address Region 15’s community needs. UMC, as the Region 15 Anchor anticipates continuing to facilitate a monthly meeting, and potentially breaking into workgroup Learning Collaboratives that meet more frequently to address specific DSRIP project areas that are common to Region 15, as determined to be necessary by the Performing Providers and IGT entities. UMC will continue to maintain the Region 15 website, which has updated information from HHSC, regional projects listed by Performing Provider, contact information for each participant, and minutes, notes and slides from each meeting for those parties that were unable to attend in-person. Region 15 participants look forward to the opportunity to gather annually with Performing Providers and IGT entities state-wide to share experiences and challenges in implementing DSRIP projects, but also recognize the importance of continuing ongoing regional interactions to effectuate change locally. Through the use of both state-wide and regional Learning Collaborative components, Region 15 is confident that it will be successful in improving the local healthcare delivery system for the low-income and indigent population. Project Valuation

$3,771,290. In determining the value of this project, Tenet considered the extent to which newly- implemented or expanded care transitions programs will address the community’s needs, the population which this project will serve, the resources and cost necessary to implement the project, and the project’s ability to meet the goals of the Waiver (including supporting the development of a coordinated care delivery system, improving outcomes while containing costs, and improving the healthcare infrastructure). Specifically, the valuation of this project takes into account the potential of better care transition management to improve quality of care and thereby improve patient satisfaction and patient outcomes. The valuation of this project also takes into account the challenges that Sierra East will face in implementing this project in the hospital setting.

Tenet plans to implement a similar Category 2 project at its Providence Memorial Hospital location, serving a different geographic area of the city. The disparity in valuation between this Providence project and the similar Sierra East project is due to the fact that Providence is a much larger facility than Sierra East (with 508 beds, compared to 110 at Sierra East) and accounts for 270% more Medicaid and uninsured days than Sierra East. 196829901.2.1 2.12.2 2.12.2.X IMPLEMENT/EXPAND CARE TRANSITIONS PROGRAMS Sierra Providence East Medical Center Related Category 3 196829901.3.4 IT-3.1 All cause 30 day readmission rate Outcome Measure(s): Year 2 Year 3 Year 4 (10/1/2012 – 9/30/2013) (10/1/2013 – 9/30/2014) (10/1/2014 – 9/30/2015) (10/1/2015 – 9/30/2016) Milestone 1: Establish baseline for Milestone 2 [P-2]: Implement Milestone 4 [I-11]: Improve the Milestone 5 metrics P-2.1, P-7.1, and I-11.1. standardized care transition percentage of patients in defined patients in defined population receiving processes. population receiving standardized care standardized care according to the approved Metric 1: Establish baseline for future according to the approved clinical clinical protocols and care transitions policies. years. Metric 1 [P-2.1]: Care transitions protocols and care transitions policies. policies and procedures. Metric 1 [I-11.1]: Number over time of those Milestone 1 Estimated Incentive Baseline/Goal: n/a Metric 1 [I-11.1]: Number over time of patients in target population receiving Payment: $922,324 Data Source: Policies and those patients in target population standardized, evidence-based interventions procedures of care transitions receiving standardized, evidence- per approved clinical protocols and program materials. based interventions per approved guidelines. clinical protocols and guidelines. Baseline/Goal: 25% improvement. Milestone 2 Estimated Incentive Baseline/Goal: 15% improvement. Data Source: Registry or EHR Payment: $503,103 Data Source: Registry or EHR report/analysis. report/analysis. Milestone 3 [P-7]: Develop a staffing Milestone 5 Estimated Incentive Payment: and implementation plan to Milestone 4 Estimated Incentive $833,630 accomplish the goals/objectives of Payment: $1,009,131 the care transition program.

Metric 1 [P-7.1]: Documentation of the staffing plan. Baseline/Goal: n/a Data Source: Staffing and implementation plan.

Milestone 3 Estimated Incentive Payment: $503,103

Year 2 Estimated Milestone Bundle Year 3 Estimated Milestone Bundle Year 4 Estimated Milestone Bundle Year 5 Estimated Milestone Bundle Amount: Amount: $922,324 Amount: $1,006,206 Amount: $1,009,131 $833,630 TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD: $3,771,290 93812.6