Natividad Medical Center (NMC)

ADDENDUM TO DSRIP FIVE-YEAR PLAN SUBMITTED on 2/18/2011

CATEGORY 3: POPULATION-FOCUSED IMPROVEMENT REPORTING MEASURES

Revised April 25, 2011

Based on the changing community demographics of Monterey County, increasing chronic diseases reflecting health disparities by income and ethnicity, and the enactment of comprehensive health care reform that has the potential to stabilize and strengthen the local health care safety net, NMC’s goals over the next five years will focus on providing safe, reliable, quality health care that is integrated, comprehensive, and coordinated. NMC is placing a high priority on expanded access and capacity, strengthening the medical home implementation, and fostering team based care with an emphasis on population health.

In order to strengthen the safety net continuum of care in the ambulatory setting, NMC is planning the expansion of the medical home in two clinics: Natividad Medical Group and Laurel Family Practice Clinic, operated by the Monterey County Health Department (MCHD). Central to this development is better understanding of the patient experience. The deployment of a patient experience survey including the CG CAHPS’ questions will provide NMC with valuable information to shape organizational improvement strategies in how the patient experiences the care and satisfaction with the care in the defined ambulatory settings.

A focus on population health improvement requires access to information on valid health care indicators to inform and find improvements in population health. A requirement for success will be the building of capacity for reporting on a comprehensive set of population health metrics providing information and understanding on health status of key populations. The development of systems to assure the availability of patient data at the point of care and across the care continuum is of critical importance. The Laurel Family Practice Clinic has an electronic medical record (EMR). NMC’s EMR for the hospital and Natividad Medical Group is in development. A strategic goal for NMC and MCHD is to integrate robust EMR’s linking patient health information for data exchange between all County health services. This comprehensive and timely integration of patient health information between the hospital and the ambulatory settings will reduce redundant patient information gathered at multiple sites, increase continuity of care opportunities, aid in the prevention of medical errors, provide clinical decision support, foster population health management, and aid in the improvement of the patient experience.

With these system improvements, NMC is prepared to measure and report on the defined set of Category 3 milestones across the four domains as outlined in this plan.

1 Patient/Care Giver Experience Year 1 Year 2 Year 3 Year 4 Year 5 1. Undertake the 2. Report results of CG CAHPS questions 7. Report results of CG 12. Report results of CG necessary for “Getting Timely Appointments, CAHPS questions for CAHPS questions for planning, Care, and Information” theme for at “Getting Timely “Getting Timely redesign, least data from the last two quarters Appointments, Care, Appointments, Care, translation, of the demonstration year to the and Information” and Information” training and State theme to the State theme to the State contract 3. Report results of CG CAHPS questions 8. Report results of CG 13. Report results of CG negotiations in for “How Well Doctors Communicate CAHPS questions for CAHPS questions for order to With Patients” theme for at least “How Well Doctors “How Well Doctors implement CG- data from the last two quarters of the Communicate With Communicate With CAHPS in DY8. demonstration year to the State Patients” theme to Patients” theme to 4. Report results of CG CAHPS questions the State the State for “Helpful, Courteous, and 9. Report results of CG 14. Report results of CG Respectful Office Staff” theme for at CAHPS questions for CAHPS questions for least data from the last two quarters “Helpful, Courteous, “Helpful, Courteous, of the demonstration year to the and Respectful Office and Respectful Office State Staff” theme to the Staff” theme to the 5. Report results of CG CAHPS questions State State for “Patients’ Rating of the Doctor” 10. Report results of CG 15. Report results of CG theme for at least data from the last CAHPS questions for CAHPS questions for two quarters of the demonstration “Patients’ Rating of “Patients’ Rating of year to the State the Doctor” theme to the Doctor” theme to 6. Report results of CG CAHPS questions the State the State for “Shared Decisionmaking” theme 11. Report results of CG 16. Report results of CG for at least data from the last two CAHPS questions for CAHPS questions for quarters of the demonstration year to “Shared “Shared the State Decisionmaking” Decisionmaking” theme to the State theme to the State

2 Care Coordination Year 1 Year 2 Year 3 Year 4 Year 5 1. Report results of the 3. Report results of the 7. Report results of the 11. Report results of the Diabetes, short-term Diabetes, short-term Diabetes, short-term Diabetes, short-term complications measure complications measure complications measure complications measure to the State to the State to the State to the State 2. Report results of the 4. Report results of the 8. Report results of the 12. Report results of the Uncontrolled Diabetes Uncontrolled Diabetes Uncontrolled Diabetes Uncontrolled Diabetes measure to the State measure to the State measure to the State measure to the State 5. Report results of the 9. Report results of the 13. Report results of the Congestive Heart Failure Congestive Heart Failure Congestive Heart Failure measure to the State measure to the State measure to the State 6. Report results of the 10. Report results of the 14. Report results of the Chronic Obstructive Chronic Obstructive Chronic Obstructive Pulmonary Disease Pulmonary Disease Pulmonary Disease measure to the State measure to the State measure to the State

Care Coordination Denominator:

The following are the DPH system primary care clinic(s):

1. Natividad Medical Group

2. Laurel Family Practice Clinic

Additionally, in order for there to be consistent reporting across DPH systems, the “past 12 months” for all care coordination measures will be defined as the prior demonstration year (July 1 – June 30 of the prior year).i

3 Preventive Health Year 1 Year 2 Year 3 Year 4 Year 5 1. Report results of the 3. Report results of the 8. Report results of the 13. Report results of the Mammography Screening Mammography Screening Mammography Screening for Mammography Screening for Breast Cancer measure for Breast Cancer measure Breast Cancer measure to the for Breast Cancer measure to the State to the State State to the State 2. Reports results of the 4. Reports results of the 9. Reports results of the 14. Reports results of the Influenza Immunization Influenza Immunization Influenza Immunization Influenza Immunization measure to the State measure to the State measure to the State measure to the State 5. Report results of the Child 10. Report results of the Child 15. Report results of the Child Weight Screening measure Weight Screening measure to Weight Screening measure to the State the State to the State 6. Report results of the 11. Report results of the 16. Report results of the Pediatrics Body Mass Index Pediatrics Body Mass Index Pediatrics Body Mass Index (BMI) measure to the State (BMI) measure to the State (BMI) measure to the State 7. Report results of the 12. Report results of the Tobacco 17. Report results of the Tobacco Cessation measure Cessation measure to the Tobacco Cessation measure to the State State to the State

Preventive Health Denominator:

1. Natividad Medical Group

2. Laurel Family Practice Clinic

Additionally, in order for there to be consistent reporting across DPH systems, the “past 12 months” for all preventive health measures will be defined as the prior demonstration year (July 1 – June 30 of the prior year).i

4 At-Risk Populations Year 1 Year 2 Year 3 Year 4 Year 5 1. Report results of the 3. Report results of the Diabetes 10. Report results of the 17. Report results of the Diabetes Mellitus: Low Mellitus: Low Density Lipoprotein Diabetes Mellitus: Low Diabetes Mellitus: Low Density Lipoprotein (LDL-C) (LDL-C) Control (<100 mg/dl) Density Lipoprotein (LDL-C) Density Lipoprotein (LDL-C) Control (<100 mg/dl) measure to the State Control (<100 mg/dl) Control (<100 mg/dl) measure to the State 4. Report results of the Diabetes measure to the State measure to the State 2. Report results of the Mellitus: Hemoglobin A1c Control 11. Report results of the 18. Report results of the Diabetes Mellitus: (<9%) measure to the State Diabetes Mellitus: Diabetes Mellitus: Hemoglobin A1c Control 5. Report results of the 30-Day Hemoglobin A1c Control Hemoglobin A1c Control (<9%) measure to the State Congestive Heart Failure (<9%) measure to the State (<9%) measure to the State Readmission Rate measure to the 12. Report results of the 30-Day 19. Report results of the 30-Day State Congestive Heart Failure Congestive Heart Failure 6. Report results of the Readmission Rate measure Readmission Rate measure Hypertension (HTN): Blood to the State to the State Pressure Control (<140/90 mmHg) 13. Report results of the 20. Report results of the measure to the State Hypertension (HTN): Blood Hypertension (HTN): Blood 7. Report results of the Pediatrics Pressure Control (<140/90 Pressure Control (<140/90 Asthma Care measure to the State mmHg) measure to the State mmHg) measure to the State 8. Report results of the Optimal 14. Report results of the 21. Report results of the Diabetes Care Composite for at Pediatrics Asthma Care Pediatrics Asthma Care least data from the last two measure to the State measure to the State quarters of the demonstration 15. Report results of the 22. Report results of the Optimal year to the State Optimal Diabetes Care Diabetes Care Composite to 9. Report results of the Diabetes Composite to the State the State Composite for at least data from 16. Report results of the 23. Report results of the the last two quarters of the Diabetes Composite to the Diabetes Composite to the demonstration year to the State State State

At-Risk Populations Denominator:

1. Natividad Medical Group 5 2. Laurel Family Practice Clinic

Additionally, in order for there to be consistent reporting across DPH systems, the “past 12 months” for all at-risk populations measures will be defined as the prior demonstration year (July 1 – June 30 of the prior year).i

6 Category 3 Five-Year Incentive Payment Table

DY 6 DY 7 DY 8 DY 9 DY 10 Category 3 Patient/Care Giver - $965,250 $1,287,000 $1,930,500 $2,252,250 Experience Care Coordination - $1,018,875 $1,358,500 $2,037,750 $2,377,375

Preventive Health - $1,018,875 $1,358,500 $2,037,750 $2,377,375

At-Risk Populations - $965,250 $1,287,000 $1,930,500 $2,252,250

7 i “The past 12 months” is defined as the prior demonstration year (July 1 – June 30 of the prior year) because:

 This definition allows the DPH system’s year-end DSRIP report to build on the 6-month DSRIP report by using the same population in the denominator, which is consistent with the program mechanics and therefore, with how the other categories are being reported.

 The visit/admission/discharge in which the numerator event occurred (e.g., LDL recorded, admission for diabetes complications) will have occurred after the 2 visits to primary care, which is consistent with the reason for defining the population as patients for whom the health system has had sufficient opportunity to provide good care and influence good health.