Project Option 2.7.6: Implement innovative evidence-based strategies to reduce, prevent and manage chronic diseases (including but not limited to diabetes, obesity, hepatitis C, cirrhosis / liver disorders, and hypertension), in children and adults.

Rescue Mission / VNA Shelter Program for the Homeless

Unique Project ID: 138951211.2.2

Performing Provider Name/TPI: The El Paso County Hospital District d/b/a University Medical Center of El Paso (UMC) / TPI: 138951211

Project Description:

Under this project, UMC El Paso will enter into a contract to transition all Rescue Mission discharges into the VNA Nursing Shelter Program.

The Rescue Mission’s Nursing Program will be designed to provide primary and preventive healthcare to residents living at the Rescue Mission, a homeless shelter in El Paso. This is a population that generally encounters difficulty accessing healthcare, preventive services, and especially coordination of care. This program also delivers education and support to empower them to gain control of their lives through disease management, medication compliance, appropriate diet and nutrition, and lifestyle changes. VNA will provide the nursing and support services for the Rescue Mission’s residents to prevent them from using the County Hospital or other EDs for their primary care or for non-emergent care needs. The Shelter will provide the space and VNA will provide the nursing and support staff where we will be able to monitor the chronic health conditions of those residing at the shelter. Also patients identified as at-risk for chronic diseases need interventions to change behavior and lifestyle choices so the development of chronic conditions can be decreased or prevented. VNA will also conduct surveillance for communicable disease and problems common in shelters. Our infection control nurse is experienced in the prevention, education and control of infections in the home setting and will bring this knowledge to this program for application in shelter settings. Residents will have access to nursing services 5 days a week and adjusted as necessary to meet the needs of the patient population.

Goals and Relationship to Regional Goals:

Project Goals: Implement innovative evidence-based strategies in disease prevention areas including the following: diabetes, obesity, prenatal care, and health screenings. Improve the health of the local homeless population, increase health awareness and knowledge, reduce the use of area emergency rooms, and implement the principles of preventative healthcare to the homeless population. Reduce the number of patients who are admitted to the hospital as a result of difficulty managing chronic health conditions such as diabetes, obesity, hepatitis C, cirrhosis / liver disorders and hypertension. Reduce the use of emergency room visits by those in the homeless shelters by successfully managing their care on-site. Cost savings are also an expected benefit to the community by reducing the need for expensive inpatient care, unnecessary ambulance calls, or utilization of the ED as a first choice for care.

This project meets the following regional goals: This project meets the regional goals of overcoming language, socio-economic, and monetary barriers to accessing healthcare resources in the region, and of increasing patient satisfaction through delivery of high-quality, effective healthcare services. The project will expand the provision of primary and urgent care service to socio-economic groups which previously did not have access to such care by providing care which is appropriate to the needs of the homeless patient population.

Challenges:

Challenges faced by this project include but are not limited to a transient population, high rates of diabetes and related issues, and cultural biases related to dietary and fitness habits. Many living in shelters have not only been displaced from their homes but in many cases they have been displaced from their usual access to care. Coordination of care for a transient population is always difficult as well as health literacy. Housing instability often detracts from regular medical attention and the lack of consistent care aggravates their health conditions, making their episodes more dangerous and much more costly.

5-Year Expected Outcome for Provider and Patients:

UMC expects that the transition of UMC homeless patients to VNA Shelter Nursing Program at the Rescue Mission will greatly reduce or eliminate return emergency room visits while also reducing hospital inpatient days for this population. These patients will receive nursing care in the shelter to better address ongoing maintenance of chronic conditions and to treat urgent conditions as they arise. The cost of care and the cost burden on UMC will be reduced. This program will manage chronic conditions in a clinic setting and provide primary and urgent care services to the residents of the Rescue Mission.

Starting Point/Baseline:

Services at the Rescue Mission start with a comprehensive assessment by a nurse and include a frequency of visits to monitor the patient’s condition and progress. Baseline data assessment includes at a minimum: A Risk Profile, vitals, physical assessment, assessment of ongoing healthcare needs, nutrition, glucose and oxygen saturation monitoring, and evaluate their knowledge of their disease for education and self-management goals. This assessment will serve as the starting baseline data for collection.

Rationale:

Disease management emphasizes prevention of disease-related exacerbations and complications using evidence-based guidelines and patient empowerment tools. It can help manage and improve the health status of a defined patient population over the entire course of a disease.1

The homeless experience higher rates of chronic disease than the general U.S. population. Most homeless have at least one chronic disease and with age, the risk of chronic disease rises. Although homeless shelters have the capacity to provide many necessary services, they do not have the formal capacity to provide medical care. Eliminating barriers to medical care for this population and through the provision of evidence-based interventions will reduce the chances for those who reside at shelters to have their conditions worsen. Ongoing patient-centered care monitoring allows interventions before exacerbations require and emergency room visit and/or hospitalization. Delivery Mechanisms: (note this list is not inclusive of all delivery mechanisms)

Establish and use patient registry systems to enhance the provision of patient follow-up, screenings for related risk factors and to track patient improvement.

Establish and implement clinical practice guidelines.

Adopt the Chronic Care Model

Develop a mapping process linking patients treated in the emergency rooms within RHP to improve the continuum of care and standardized procedures and outcome measures.

Promote RHP health system supports such as reminders of care, development of clinical performance measures, and the use of case management services to increase patient’s adherence to health care guidelines.

Establish evidence-based disease and disability prevention programs for targeted populations to reduce their risk of disease, injury, and disability.

People experiencing homelessness are more likely to access the most costly health care services. According to a Texas hospital information source, Price Point, the average charge at UMC from October 2009 through September 2010 was $4,461 per day, with other hospitals in El Paso averaging $8,959. Offering healthcare services in the shelter will prove to be a valuable tool in reducing costs and improving the health outcomes of this population. VNA nurses will provide preventive screening, monitoring, and non-emergent care, supported by three medical directors which will be critical for the needs of this population. The provision of nursing services on-site will prevent individuals from getting acutely ill or flooding the ED for their primary care needs which is a growing trend. These services offer a continuum of care throughout the year, improving on preventive measures and education. The Rescue Mission estimates that the residents at their shelter average 250-270 ambulance calls that may not result in transfer to ER. Also many emergency room visits occur each month by residents of the Rescue Mission. Of the emergency room visits, approximately 10% are admitted to the hospital for at least one night.

Project Components: 2.7.6 Other Project Option. Implement innovative evidence-based strategies to reduce, prevent and manage chronic diseases (including but not limited to diabetes, obesity, hepatitis C, cirrhosis / liver disorders, and hypertension), in children and adults.

The implementation of this project at UMC El Paso will accomplish the following core project components:

Development of innovative evidence-based project for targeted population.

UMC will contract with VNA to develop a program to manage chronic conditions in a clinic setting and provide primary and urgent care services to the residents of the Rescue Mission.

Transition UMC homeless patients from acute hospital care into the VNA Shelter Nursing Program at the Rescue Mission

UMC will transition homeless patients from UMC hospital care to the care of VNA of El Paso.

Implement a nursing program at Rescue Mission to provide a comprehensive assessment by a nurse and include a frequency of visits to monitor the patient’s condition and progress.

UMC will contract with VNA to provide for nursing services that begin with a

baseline data assessment includes at a minimum: A Risk Profile, vitals, physical assessment, assessment of ongoing healthcare needs, nutrition, glucose and oxygen saturation monitoring, and evaluate their knowledge of their disease for education and self-management goals. This assessment will serve as the starting baseline data for collection.

Conduct quality improvement for project using methods such as rapid cycle improvement. Activities may include, but are not limited to, identifying project impacts, identifying “lessons learned,” opportunities to scale all or part of the project to a broader patient population, and identifying key challenges associated with expansion of the project, including special considerations for safety-net populations.

UMC will conduct quality improvement activities as part of the VNA Nursing Shelter program established under this project.

Unique community need identification numbers the project addresses:

CN-2: Secondary and Specialty Care

CN-3: Obesity and Diabetes

CN-6: Other Projects

How the project represents a new initiative or significantly enhances an existing delivery system reform initiative:

The provision of nursing services on-site will prevent individuals from getting acutely ill or flooding the ED for their primary care needs which is a growing trend. These services offer a continuum of care throughout the year, improving on preventive measures and education.

Related Category 3 Outcome Measures:

OD-11 Addressing Health Disparities in Minority Populations; IT-11.5 (PPR 30 Day Readmissions for target homeless population discharged to the Rescue Mission with chronic conditions that include but not limited to diabetes, obesity, hepatitis C, cirrhosis / liver disorders and hypertension)

Reasons/rationale for selecting the outcome measures:

This outcome measure was chosen to measure the improvement in all-cause readmission rates for patients discharged to the VNA Nursing Shelter program at the Rescue mission. Because the purpose of the project is ultimately to improve the delivery of care in the setting where it is most appropriate, UMC believes this outcome measure will accurately track whether or not the project has been successful in its primary goal, from the perspective of the patients to whom the services are provided.

Relationship to other Projects UMC plans to cooperate with VNA in implementing a similar program at the Salvation Army, another homeless shelter in El Paso (138951211.2.1; Discharge Navigation 138951211.3).

Relationship to Other Performing Providers’ Projects and Plan for Learning Collaborative: Providence and Sierra East are also developing projects to support the expansion of access to primary or specialty care in the community for those patients who currently experience financial, geographic, or other barriers to accessing the care they need.

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

The valuation of each UMC project takes into account the degree to which the project accomplishes the triple aim of the Waiver, the degree to which the project addresses community needs, the acuity and number of patients served by the project, and the investment required to implement the project. This project also takes into account the costs and health complications that can be avoided when a patient population receives the right care in the right setting, rather than being forced to utilize the Emergency Department as its primary healthcare resource. This project will significantly address the needs of the El Paso community by providing uninsured and underinsured patients with hospice care which is currently unavailable to them.

138951211.2.2	2.7.6	138951211.2.10.1	Rescue Mission / VNA Shelter Program for the Homeless
University Medical Center of El Paso	138951211
Related Category 3 Outcome Measure(s): OD-11 Addressing Health Disparities in Minority Populations	IT-11.6 (PPR 30 Day Readmissions for target homeless population discharged to the Rescue Mission with chronic conditions that include but not limited to diabetes, obesity, hepatitis C, cirrhosis / liver disorders and hypertension)	138951211.3.10	OD-11 Addressing Health Disparities in Minority Populations IT-11.6 (PPR 30 Day Readmissions for target homeless population discharged to the Rescue Mission with chronic conditions that include but not limited to diabetes, obesity, hepatitis C, cirrhosis / liver disorders and hypertension)
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 P-1: Development of innovative evidence-based project for targeted population. Metric P-1.1: Document innovational strategy and plan. Data Source Performing Provider evidence of innovational plan Milestone 1 Estimated Incentive Payment (maximum amount): $678,853 Milestone 2 CQI P-5: Participate in at least bi-weekly interactions with other providers and the RHP to promote collaborative learning around shared or similar projects. Metric P-5.1: Number of bi-weekly meetings, conference calls, or webinars organized by the RHP that the provider participated in. Data Source Documentation of weekly or bi-weekly phone meetings, conference calls, or webinars, including agendas for phone calls, slides from webinars, and/or meeting notes. Milestone 2 Estimated Incentive Payment: $678,853	Milestone 3 P-3: Execution of learning and diffusion strategy for testing, spread and sustainability. Metric P-3.1: Document learning and diffusion strategic plan Data Source Performing Provider contract or other documentation of implementation TBD by Performing Provider. Milestone 3 Estimated Incentive Payment: $740,592 Milestone 4 CQI P-5: Participate in at least bi-weekly interactions with other providers and the RHP to promote collaborative learning around shared or similar projects. Metric P-5.1: Number of bi-weekly meetings, conference calls, or webinars organized by the RHP that the provider participated in. Data Source Documentation of weekly or bi-weekly phone meetings, conference calls, or webinars, including agendas for phone calls, slides from webinars, and/or meeting notes. Milestone 4 Estimated Incentive Payment: $740,592	Milestone 5 I-7: Increase access to disease prevention programs using innovative project option. The following metrics are suggested for use with an innovative project option to increase access to disease prevention programs but are not required. Metric I-7.2: Increased number of encounters as defined by intervention (e.g., screenings, education, outreach, etc.). Total number of visits for reporting period. Data Source VNA, Rescue Mission, UMC Registry Data Registry, EHR, claims or other Performing Provider source Milestone 5 Estimated Incentive Payment: $1,485,490	Milestone 6 I-7: Increase access to disease prevention programs using innovative project option. The following metrics are suggested for use with an innovative project option to increase access to disease prevention programs but are not required. Metric I-7.2: Increased number of encounters as defined by intervention (e.g., screenings, education, outreach, etc.) Increase patients enrolled in VNA Shelter Nursing Program at Rescue Mission by 20% Data Source Registry, EHR, claims or other Performing Provider source Milestone 6 Estimated Incentive Payment: $1,227,144
Year 2 Estimated Milestone Bundle Amount: $1,357,706	Year 3 Estimated Milestone Bundle Amount: $1,481,184	Year 4 Estimated Milestone Bundle Amount: $1,485,490	Year 5 Estimated Milestone Bundle Amount: $1,227,144
TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD: $5,551,524

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