Project Option 2.9.1 Establish/Expand a Patient Care Navigation Program – Provide navigation services to targeted patients who are at high risk of disconnect from institutionalized healthcare: DISCHARGE FACILITATION / NAVIGATION FOR HIGH-RISK PATIENTS

Unique Project ID: 138951211.2.3

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 develop a patient care navigation system to facilitate discharges for high-rick patients to assist in self-management education and coordination with local community groups and resources.

This project will identify high-risk patients based on chronic conditions and history of readmissions, and create/amend staff positions to facilitate the discharge of these patients to include RNs, physicians, case managers, social workers, and other appropriate practitioners in the hospital setting. The project will specifically target patients with diabetes, renal disease, history of stroke, obesity, and other populations with a history of readmissions. Establish a process for hospital-based case managers to follow up with identified patients hospitalized related to the top chronic conditions to provide standardized discharge instructions and patient education, which address activity, diet, medications, follow-up care, weight, and worsening symptoms; and, where appropriate, additional patient education and/or coaching as identified during discharge.

Goals and Relationship to Regional Goals:

Project Goals: Ensure that hospital discharges are accomplished appropriately and that care transitions occur effectively and safely. Dedicate full-time RNs to facilitate discharge for high-risk patients, in an effort to assure that these patients receive instructions and education about self-care, and support for social and emotional issues related to discharge; engage UMC social workers to use the Cerner system to consult with high-risk patients, and their physicians and nurses, to review and identify needs at discharge; coordinate with local community groups to place patients after discharge, thus keeping track of the targeted patients subsequent to discharge to provide support and monitor health status; finding community members to coordinate the discharges with in the community.

This project meets the following regional goals: This project meets several regional goals, including increased access to primary care through the expansion of medical homes, primary care clinics, and more effective care navigation upon discharge; better managing patients with chronic diseases, such as Diabetes, CHF, Asthma, COPD, Epilepsy, Dementia, and Renal disease to help prevent unnecessary readmission and get patients the care they need to prevent, self-manage, and address in an appropriate setting; and providing patient education to ensure the population is accessing the right care in the right setting.

Challenges:

Hospital readmissions are both costly and common. Health care professionals are all tasked with treating the patient quickly and moving the patient through the system and discharging as soon as possible. This is done to reduce cost, prevent complications, and even aide in customer satisfaction. Unfortunately, many times the patient is discharged with a list of instructions to do and necessary follow up, but for many reasons, they are unable to complete the necessary follow up and return to the emergency room and possibly end up back in the hospital. Patients who have a clear understanding of their discharge instructions and home care, including how to take their medications and when to follow up with their primary care physician do not return to the emergency room Knowing that they have an appointment in a short period of time give the patient and family the sense of security they will have the necessary follow up they need.

5-Year Expected Outcome for Provider and Patients:

This project twill create a coordinated system of care upon discharge within the hospital. UMC expects that the effective targeting and navigation of high-risk and chronic care patients will greatly reduce or eliminate return emergency room visits while also reducing hospital inpatient days for this population. This project will also increase patient awareness of self-care best practices and increase support inside and outside of the hospital for discharged patients.

Starting Point/Baseline:

Nurse Discharge Navigators can coordinate with the local community to obtain appropriate placement of discharged patients with chronic diseases requiring management and monitoring; target patients with diabetes, renal disease, history of stroke, obesity, and other populations with a history of readmissions. Once the assessment determines the need to hire Discharge Navigators, patients will be identified and enrolled in the care transition protocol developed in this project. Baseline will be determined.

Rationale:

Patients with chronic disease are often at high risk for hospital readmission due to an inability to engage in self-care and/or a lack of psycho-social support upon and after discharge from an inpatient stay. RNs can provide discharge instructions and education about the physical components of leaving the hospital (including diet, medication management, wound care, worsening symptoms, etc.), and can facilitate the use of case managers and/or social workers to provide support to discharged patients for the non-physical aspects of their recovery and/or maintenance of health status. Social workers can, in turn, use the Cerner system to integrate a patient’s full electronic records and seek the involvement of the appropriate hospital practitioners to provide guidance during the discharge process. The Discharge Navigation Nurse (DNN) would also be able to assist the patient in obtaining a clinic appointment if they were not able to do so within one month of discharge.

Project Components:

The implementation of this project at UMC El Paso will accomplish the following core project components (a-e):

Identify frequent ED users and use navigators as part of a preventable ED reduction program. Train health care navigators in cultural competency.

In DY 2 UMC will provide report identifying the following (P-1.1)

Targeted patient population characteristics (e.g., patients with no PCP or medical home, frequent ED utilization, homelessness, insurance status, low health literacy).

Gaps in services and service needs.

How program will identify, triage and manage target population (i.e. Policies and procedures, referral and navigation protocols/algorithms, service maps or flowcharts).

Ideal number of patients targeted for enrollment in the patient navigation program

Number of Patient Navigators needed to be hired

Available site, state, county and clinical data including flow patients, cases in a given year by race and ethnicity, number of cases lost to follow-up that required medical treatment, percentage of monolingual patients

Deploy case managers/workers as patient navigators.

In DY 3, UMC with hire patient navigators (P-2.1)

Connect patients to primary and preventive care.

In DY 3, UMC will establish a patient navigator program (P-3.1)

Increase access to care management and/or chronic care management, including education in chronic disease self-management.

As a part of the navigator program, UMC will include education in self-management and increase access to chronic care management for these patients.

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 care navigation program established under this project.

Unique community need identification numbers the project addresses:

CN-2: Secondary and Specialty Care

CN-3: Diabetes

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

This project will establish a patient care navigator program. UMC will hire and train care navigators to target and manage high-risk patients with chronic diseases. This new program will identify these patients and ensure that they are receiving the follow-up care, self-management instructions, and support they need in the community.

Related Category 3 Outcome Measures:

OD-11 Addressing Health Disparities in Minority Populations

IT-11.5 Other Outcomes Target (30 Readmission Rate for Patients enrolled in care transitions protocol under the Discharge Navigation Program

Reasons/rationale for selecting the outcome measures:

UMC believes that when patients with chronic diseases are put in contact with a nurse-navigator, the outcome will include better follow-up care, better self-management, and a greater awareness of resources in the community. This knowledge base will cause the patients to seek the appropriate care in the appropriate setting, rather than utilizing the Emergency Department as their first point of contact. This will lower the rate of potentially preventable readmissions for those that are enrolled in the patient navigator program.

Relationship to other Projects: UMC has several other projects focused on patients with chronic conditions and high-risk patients, including expanding the chronic care management model at UMC’s Neighborhood Health Clinics (138951211.2.5)

Relationship to Other Performing Providers’ Projects and Plan for Learning Collaborative: Texas Tech is also proposing a project to better-manage this population through a disease management registry (084597603.1.3). Las Palmas Del Sol also has a project for a diabetes management registry (094109802.1.1).

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 challenges in establishing a new program, hiring additional personnel to support the navigation program, and ongoing costs associated with managing this high-risk patient population. This project also has a potential savings to the overall healthcare delivery system because there are significant costs and health complications that can be avoided when a patient population receives the right care in the right setting, rather than utilizing the Emergency Department as its primary healthcare resource. This project will significantly address the needs of the El Paso community by providing high-risk patient with chronic diseases information on self-management and existing resources in the community.

UMC also evaluated this project based on the patient and community benefit that is enhanced by providing ongoing care after the patient with a chronic condition is discharged in order to prevent costly readmissions and ER visits, as well as preventing a decline in the patient’s condition. The amount of patients in the community with chronic conditions (e.g. Diabetes) is extraordinarily high and managing this condition alone would create a healthier community and one empowers to manage their condition effectively. Providing focused assistance and care after hospital discharge to the underfunded community is a valuable benefit that will lead to healthier lifestyles for this target population.

138951211.2.3	2.9.1	138951211.2.3.a-e	Discharge Facilitation/Navigation to High-Risk Patients
University Medical Center of El Paso	138951211
Related Category 3 Outcome Measure(s): OD-11	IT-11.6	138951211.3.11	Other Outcomes Target (30 Readmission Rate for Patients enrolled in care transitions protocol under the Discharge Navigation Program)
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]: Conduct a Needs Assessment to identify the patient population(s) to be targeted with the Patient Navigator Program Metric [P-1.1]: Provide report identifying targeted patient population characteristics; how the program will identify, triage, and manage patient population; number of navigators needed to be hired Data Source: Program documentation, EHR, claims, needs assessment survey Milestone 1 Estimated Incentive Payment: $1,527,419 Milestone 2 [CQI P-6]: Participate in at least bi-weekly interactions (meetings, conference calls, or webinars) with other providers and the RHP to promote collaborative learning around shared or similar projects. Metric[CQI P-6.1]: 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: $1,527,419	Milestone 3 [P-2]: Establish/expand a health care navigation program to provide support to patient populations who are most at risk of receiving disconnected and fragmented care including program to train the navigators, develop procedures and establish continuing navigator education. Metric [P-2.1]: Number of people trained as patient navigators, number of navigation procedures, or number of continuing education sessions for patient navigators. Data Source: Workforce development plan for patient navigator recruitment, training and education Milestone 3 Estimated Incentive Payment: $1,110,888 Milestone 4 [P-3]: Provide care management/navigation services to targeted patients. Metric 1 [P-3.1]: Increase in the number or percent of targeted patients enrolled in the program Numerator: Number of targeted patients enrolled in the program Denominator: Total number of targeted patients identified Baseline/Goal: Baseline of 0 people enrolled. Increase number of patients enrolled in program by 10%. Data Source: Enrollment reports Milestone 4 Estimated Incentive Payment: $1,110,888 Milestone 5 [CQI P-6]: Participate in at least bi-weekly interactions (meetings, conference calls, or webinars) with other providers and the RHP to promote collaborative learning around shared or similar projects. Metric[CQI P-6.1]: 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 5 Estimated Incentive Payment: $1,110,888	Milestone 6 [I-10] Improvements in access to care of patients receiving patient navigation services using innovative project option. Metric [I-10.1] Increase percentage of target population reached: Numerator: Number of individuals of target population reached by the Patient Navigator Program. Denominator: Number of individuals in the target population Baseline/Goal: Increase target population reached by 20% Data Source: Documentation of target population reached, as designated in the project plan. Milestone 6 Estimated Incentive Payment: $3,342,352	Milestone 7 [I-10] Improvements in access to care of patients receiving patient navigation services using innovative project option Metric [I-10.5] Improved compliance with recommended care regimens: Numerator: % compliance with [recommended care regimen] (TBD by provider) of patients participating in Navigator program. Denominator: % compliance with [recommended care regimen] (TBD by provider) of all patients. Baseline/Goal: Increase compliance with recommended care regimen by 20%. Data Source: EHR, claims Milestone 7 Estimated Incentive Payment: $2,761,073
Year 2 Estimated Milestone Bundle Amount: $3,054,838	Year 3 Estimated Milestone Bundle Amount: $3,332,664	Year 4 Estimated Milestone Bundle Amount: $3,342,352	Year 5 Estimated Milestone Bundle Amount: $2,761,073
TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD (add milestone bundle amounts over Years 2-5): $12,490,927

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