CONGESTIVE HEART FAILURE CLINIC

Identifying Project and Provider Inforation! Category 2: Expand Chronic Care

Management Models; Project Option 2.2.2: Apply evidence-ased care management
model to patients identi!ied as having high-ris" health care needs; #$%&#$#'#2.2.2;
(CA )as Palmas *el +ol ,#$%&#$#'#2-.
Project "e#cri$tion! .e propose to implement a Chronic Care Management Model
relating to patients /ith Congestive (eart 0ail1re ,C(0-. 2he Congestive (eart
0ail1re 3nitiative /ill consist o! a m1lti-disciplinary team o! expert health
pro!essionals to deliver optimal patient care thro1gh the 1tili4ation o! c1rrent
evidence-ased g1idelines and the development and implementation o! ne/
initiatives to meet service delivery gaps. 2he m1lti-disciplinary care team /ill e
composed o! physicians5 physician extenders5 ed1cators5 ehavioral health
pro!essionals5 pharmacological advisors5 dieticians5 n1rsing sta!!5 and health care
navigators. 2his initiative /ill also enale the hospital to collaorate /ith comm1nity-
ased home-health agencies /herey the home-health agencies /ill provide timely
!eedac" to help the prevention o! 1nnecessary readmissions. 2he model /ill also
incl1de a Clinical 3n!ormation +ystem ,registry- to str1ct1re5 organi4e5 and trend
patient data !or registries5 per!ormance meas1rements5 and prevention services.
2his registry /e are considering is called C*EM+ and is 1sed y comm1nity health
centers5 primary care practices5 r1ral clinics5 hospitals5 and 61ality improvement
projects across the 7nited +tates and in Canada5 3ndia5 (aiti5 and +o1th A!rica. 2his
program /as developed and is shared y the .ashington *iaetes Prevention and
Control Program. 7sing a registry that is /idely 1tili4ed /ill etter allo/ o1r
organi4ation to report on patient pop1lations /ith chronic health conditions.
Applications o! sel!-management principles thro1gh patient-centered interventions
/ill incl1de ed1cation reso1rces5 s"ill training5 tele-scales5 and psychosocial s1pport.
8y applying sel!-management principles5 the s1pport /ill empo/er and prepare
patients to manage their health and healthcare. 0inally5 this program /ill commit to
the ed1cation and training o! healthcare pro!essionals to incl1de physicians5 n1rses5
ancillary sta!!5 and comm1nity-ased partners; s1ch training /ill provide a/areness
o! the reso1rces availale.
o Goa%#! 7tili4ing c1rrent evidence-ased g1idelines to create hospital /ide
standard protocols9path/ays !or the prevention5 detection and management o!
heart !ail1re /ill res1lt in healthier patients5 decreased readmissions and cost
savings. *elivering optimal patient care in line /ith c1rrent evidence-ased
g1idelines to decrease complications and meet delivery gaps related to C(0 d1e
to lac" o! collaorative management and lac" o! 1nderstanding5 y the patient.
Promoting sel!-a/areness and sel!-management /ith the res1lt o! improved
o1tcomes and increased contin1ity o! care. *eveloping a centrali4ed approach to
C(0 management ased 1pon clinical practice g1idelines5 /hich /ill res1lt in
improved overall health !or the hypertensive patient.
o C&a%%enge#! 3t /ill e di!!ic1lt to noti!y the p1lic o! this availale reso1rce. E*
discharge and /rap-1p o! o1tpatient visits /ill e the est patient-care
opport1nities to noti!y patients /ith Congestive (eart 0ail1re o! this o1tpatient
reso1rce designed speci!ically !or their needs.
Starting Point'(a#e%ine! )as Palmas *el +ol is 1sing protocols designed y the
American (eart Association :;et .ith the ;1idelines< program and CM+ core
meas1res that allo/s !or in-ho1se conc1rrent revie/s y =1ality management
personnel. 2here is no centrali4ed program that rings these protocols together.
Rationa%e!
o 2he leading ca1se o! death in the 7nited +tates among all ethnicities is heart
disease; it is also a common ca1se o! illness and disaility. 2he principal !orm o!
heart disease is coronary heart disease ,C(*-5 also called ischemic heart
disease. 3t is ca1sed y 1ild1p o! cholesterol deposits in the coronary arteries
that !eed the heart. 3n the 7.+. there are ao1t &.& million persons /ho have a
heart attac" or myocardial in!arction every year. According to the 2exas
*epartment o! (ealth5 in &$$$ the death rate in El Paso Co1nty d1e to heart
disease /as 2#>.? per &##5### pop1lation per year5 compared to a rate o! 2@2.@
per &##5### pop1lation per year !or 2exas as a /hole. .hile (ispanics have a
C(* death rate that is less than that o! the 7.+. pop1lation as a /hole5 it is still
the n1mer one ca1se o! death among (ispanics. 2he rate !or C(* !or the 7.+.
pop1lation as a /hole is 2&A per &##5### pop1lation per year compared to &?&
per &##5### pop1lation per year !or (ispanics.
o 2here are many de!initions o! :chronic condition5< some more expansive than
others. .e characteri4e it as any condition that re61ires ongoing adj1stments y
the a!!ected person and interactions /ith the health care system. 2he most
recent data sho/ that more than &%? million people5 or almost hal! o! all
Americans5 live /ith a chronic condition. 2hat n1mer is projected to increase y
more than one percent per year y 2#>#5 res1lting in an estimated chronically ill
pop1lation o! &@& million. Almost hal! o! all people /ith chronic illness have
m1ltiple conditions. As a res1lt5 many managed care and integrated delivery
systems have ta"en a great interest in correcting the many de!iciencies in c1rrent
management o! diseases s1ch as diaetes5 heart disease5 depression5 asthma
and others. 2hose de!iciencies incl1de:
B1shed practitioners not !ollo/ing estalished practice g1idelines
)ac" o! care coordination
)ac" o! active !ollo/1p to ens1re the est o1tcomes
Patients inade61ately trained to manage their illnesses
Re%ated Category ) O*tcoe +ea#*re,#-! O*->: Potentially Preventale Be-
AdmissionsC># day Beadmission Bates; 32->.2: Congestive (eart 0ail1re ># day
readmission rate; ,#$%&#$'#2.>.@-.
Re%ation#&i$ to Ot&er Project#! 2his project is part o! )P*+Ds larger plans to
expand and develop primary care and specialty care services5 /hile improving
access to care and containing the costs o! care. +peci!ically5 this project /ill
complement )P*+Ds *iaetes Management Begistry project ,#$%&#$'#2.&.>-; oth
o! these projects are targeted to/ards patient pop1lations !or /hom delivery system
re!orm co1ld res1lt in great improvements in the cost and 61ality o! care5 as /ell as
improvements in overall patient pop1lation health.
Re%ation#&i$ to Ot&er Perforing Provider#. Project# in t&e RHP! 28*
P%an for Learning Co%%a/orative! 28*
Project Va%*ation! E@5AA>5@?'. 2he val1ation o! each )P*+ project ta"es into
acco1nt the trans!ormational impact o! the project5 the pop1lation served y the
project ,oth n1mer o! people and complexity o! patient needs-5 the alignment o!
the project /ith comm1nity needs5 and the magnit1de o! costs avoided or red1ced
y the project. 3n partic1lar5 this project has een val1ed ased on the need !or these
services !or this patient pop1lation ,i.e.5 congestive heart !ail1re patients-5 and the
possiility o! signi!icant cost and 61ality improvement /hen the project is
implemented.
094109802.2.2 2.2.2 2.2.2.X CONGESTIVE HEART FAILURE CLINIC
HCA Las Palmas Del Sl 094109802
Rela!e" Ca!e#$%
& O'!(me
)eas'$e*s+,
094109802.3.7 IT-3.2
C-#es!./e Hea$! Fa.l'$e &0 "a% $ea"m.ss.- $a!e
Year 2
(10/1/2012 9/30/2013)
Year 3
(10/1/2013 9/30/2014)
Year 4
(10/1/2014 9/30/2015)
Year 5
(10/1/2015 9/30/2016)
Milestone 1: Establish
baseline for metrics P-2.1, P-
3.1, P-4.1, P-9.1, and I-17.1.
Metric 1: Establish baseline for
ftre !ears.
Milestone 1 Estimated Incenti"e
Pa!ment: #1,$74,2$4
Milestone 2 %P-2&: 'rain sta(
in the )hronic )are Model,
incldin* the essential
com+onents of a deli"er!
s!stem that s++orts hi*h-
,alit! clinical and chronic
disease care.
Metric 1 %P-2.1&: Increase
+ercent of sta( trained.
-aseline./oal: 101
increase o"er 23 2
baseline.
2ata 4orce: 567 trainin*
+ro*ram materials.
Milestone 2 Estimated
Incenti"e Pa!ment: #811,1$9
Milestone 3 %P-3&: 2e"elo+ a
com+rehensi"e care
mana*ement +ro*ram.
Metric 1 %P-3.1&:
2ocmentation of care
mana*ement +ro*ram. -est
+ractices sch as the :a*ner
)hronic )are Model and the
Institte of )hronic Illness;s
)are <ssessment Model ma!
be tili=ed in +ro*ram
de"elo+ment.
-aseline./oal: n.a
2ata 4orce: Pro*ram
materials.
Milestone 3 Estimated
Incenti"e Pa!ment: #811,1$9
Milestone 6 %I-17&: <++l! the
)hronic )are Model to tar*eted
chronic diseases >hich are
+re"alent locall!.
Metric 1 %I-17.1&: ? additional
+atients recei"e care nder the
)hronic )are Model for a
chronic disease or for M)).
-aseline./oal: 101 increase
o"er 23 2 baseline.
2ata 4orce: 6e*istr!.
Milestone 9 Estimated
Incenti"e Pa!ment: #2,080,9$7
Milestone 7 %I-17&: <++l! the
)hronic )are Model to tar*eted
chronic diseases >hich are +re"alent
locall!.
Metric 1 %I-17.1&: ? additional
+atients recei"e care nder the
)hronic )are Model for a chronic
disease or for M)).
-aseline./oal: 101 increase o"er
23 4.
2ata 4orce: 6e*istr!.
Milestone 7 Estimated Incenti"e
Pa!ment: #1,994,094
094109802.2.2 2.2.2 2.2.2.X CONGESTIVE HEART FAILURE CLINIC
HCA Las Palmas Del Sl 094109802
Rela!e" Ca!e#$%
& O'!(me
)eas'$e*s+,
094109802.3.7 IT-3.2
C-#es!./e Hea$! Fa.l'$e &0 "a% $ea"m.ss.- $a!e
Year 2
(10/1/2012 9/30/2013)
Year 3
(10/1/2013 9/30/2014)
Year 4
(10/1/2014 9/30/2015)
Year 5
(10/1/2015 9/30/2016)
Milestone 4 %P-4&: @ormali=e
mlti-disci+linar! teams,
+rsant to the chronic care
model deAned b! the :a*ner
)hronic )are Model or similar.
Metric 1 %P-4.1&: Increase the
nmber of mlti-disci+linar!
teams or nmber of clinic
sites >ith formali=ed teams.
-aseline./oal: 1 additional
site.
2ata 4orce: '-2 b!
+ro"ider.
Milestone 4 Estimated
Incenti"e Pa!ment: #811,1$9
Milestone 5 %P-9&: 2e"elo+
+ro*ram to identif! and
mana*e chronic care +atients
needin* frther clinical
inter"ention.
Metric 1 %P-9.1&: Increase the
nmber of +atients identiAed
as needin* screenin* test,
+re"entati"e tests, or other
clinical ser"ices.
-aseline./oal: 101
increase o"er 23 2
baseline.
2ata 4orce: E567 +atient
re*istr!.
Milestone 8 Estimated
Incenti"e Pa!ment: #811,1$8
094109802.2.2 2.2.2 2.2.2.X CONGESTIVE HEART FAILURE CLINIC
HCA Las Palmas Del Sl 094109802
Rela!e" Ca!e#$%
& O'!(me
)eas'$e*s+,
094109802.3.7 IT-3.2
C-#es!./e Hea$! Fa.l'$e &0 "a% $ea"m.ss.- $a!e
Year 2
(10/1/2012 9/30/2013)
Year 3
(10/1/2013 9/30/2014)
Year 4
(10/1/2014 9/30/2015)
Year 5
(10/1/2015 9/30/2016)
3ear 2 Estimated Milestone
-ndle <mont: #1,$74,2$4
3ear 3 Estimated Milestone
-ndle <mont: #2,044,743
3ear 4 Estimated Milestone
-ndle <mont: #2,080,9$7
3ear 8 Estimated Milestone -ndle
<mont: #1,994,094
TOTAL ESTMATE! "#E"T$E %AYME"TS &O' 4(YEA' %E'O!) #7,993,78$
91317