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: DEVELOP SURGERY GUIDEBOOK FOR PATIENTS AND CORRESPONDING NURSE ADVICE LINE

Unique Project ID: 138951211.2.8

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 will develop an educational guidebook for surgical patients and a corresponding nurse advice line.

Under this project, UMC will develop an educational guidebook for surgical patients, including resources for pre-surgery, intra-surgery, post-surgery, discharge, and follow-up.

Additionally, UMC will create a 24/7 nurse advice line for surgical patients to access with questions and concerns. UMC will tailor the nurse advice line to be able to give more detailed support regarding the same issues and questions addressed by the surgery guidebook.

This project will target the population of surgery patients at UMC, providing them with the information and resources that are crucial for effective pre-surgery and post-surgery care transitions.

Following the development of the surgery guidebook materials and the implementation of the nurse advice line, UMC will conduct quality improvement activities to ensure that the services provided to UMC surgery patients through this project are of the highest quality.

Goals and Relationship to Regional Goals:

Project Goals: The goals of this project are to develop a surgery guidebook and to implement a corresponding nurse advice line.

This project meets the following regional goals: This project meets the regional goal of establishing more effective care navigation upon discharge. While the surgery guidebook will contain information relevant to both pre-surgery and post-surgery patients, this project will be particularly useful to post-discharge patients, because it will allow them to obtain answers to their questions either by consulting the guidebook or by speaking with a knowledgeable nurse via the 24-hour nurse advice line. It will not be necessary for patients to return to the hospital or its ED in order to obtain this information.

Challenges:

UMC will need to assess and anticipate patient questions and concerns in order to develop appropriate and relevant material for inclusion in the guidebook and in the advice line documentation. UMC will also need to evaluate resources available to patients in order to recommend them to patients through the guidebook and advice line. UMC will have to hire new staff or reschedule existing staff in order to properly staff the advice line on a 24/7 basis. Finally, the implementation of these information-sharing initiatives will be made more difficult by the language barriers faced by some groups within the population to be targeted by this project.

5-Year Expected Outcome for Provider and Patients:

UMC expects that this project will result in an improvement in pre-surgery and post-surgery self-care within the targeted patient population, as well as greater patient awareness of risks, benefits, and best practices when undergoing surgical procedures. UMC also expects that the project will reduce readmissions for preventable conditions associated with surgery.

Starting Point/Baseline:

UMC does not currently provide a surgery guidebook to its surgery patients, nor does it provide them with access to a 24/7 nurse advice line.

Rationale:

Beyond the risks associated with surgical procedures in and of themselves, there is a great risk that patients will suffer from conditions secondary to the surgery, such as infection. It is important that patients understand the general risks of surgery and the benefits of following a strict regimen of self-care pre-surgery and post-surgery. There are a host of resources in the El Paso community through which patients can access support for pre-surgery and post-surgery self-care. However, this information is not being effectively communicated to the patients who could benefit most from such resources, because there is no comprehensive guide providing such information. This is especially detrimental for elderly and indigent patients who are less likely to have access to online resources and who are less able to travel outside their homes for outpatient care. Beyond the guide, for patient-specific questions or for those people who cannot use the guidebook for various reasons, patients currently do not have access to providers in the region for questions regarding pre-surgery and post-surgery best practices

Project Components:

This project will accomplish the following project component:

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 following the initial implementation of the project, to ensure that patients receive high-quality care under this project.

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:

This project will significantly enhance the care provided to UMC patients undergoing surgery by providing them with information which they need in order to experience effective pre-surgery and post-surgery care transitions. Currently, this information either does not exist or is not provided to the patients who need it in an organized and accessible way.

Related Category 3 Outcome Measures:

OD-3 Potentially Preventable Re-Admissions – 30 Day Readmission Rate

IT-3.12 Other Readmission Rate (Post Surgical Patients Discharged from UMC) – 30 Day Readmission Rate

Reasons/rationale for selecting the outcome measures:

This outcome measure was chosen to measure the improvement in readmission rates for patients receiving information and self-care support through the surgery guidebook and the corresponding nurse advice line. Because the purpose of the project is ultimately to reduce complications associated with a pre-surgery and post-surgery lack of proper self-care and of effective care transitions, UMC believes the success of the project can be accurately measured by the readmission rate for the population of patients which receive services under the project.

Relationship to other Projects: Like UMC’s Discharge Navigation and Electronic Medical Records projects (138951211.2.3; 138951211.1.2), this project is primarily aimed at improving care transitions for a designated population of patients in the El Paso community. Additionally, this project is one of several which is intended to make primary care resources more accessible in the El Paso community; these related projects include Establishing the Crossroads Clinic in Southwestern El Paso (138951211.1.3); Expanding Primary Care at Ysleta and Fabens (138951211.1.5); and Expansion and Enhancement of Medical Homes at UMC NHCs (138951211.2.4).

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 care and specialty care in the community.

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

In determining the value of this project, UMC considered the extent to which the more effective and accessible provision of pre-surgery and post-surgery self-care information and support will address the community’s needs, the population served, 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). This project will focus on achieving the Waiver goal of improving outcomes while curbing healthcare costs, because the services to be provided under the project will reduce or eliminate the need for post-surgery patients to seek care for their chronic conditions in an ED or inpatient setting, and reducing the likelihood of readmission for those patients who have been discharged and enrolled in chronic care at an NHC. Additionally, providing these services at the appropriate time and an appropriate place makes it more likely that a patient’s chronic health problems will be addressed before greater complications can develop, leading to better outcomes and less costly treatment.

138951211.2.8	2.12.2	2.12.2	Develop Surgery Guidebook for Patients and Corresponding Nurse Advice Line
University Medical Center of El Paso	138951211
Related Category 3 Outcome Measure(s): OD - 3	IT-3.125	138951211.3.16	OD-3 Potentially Preventable Re-Admissions – 30 Day Readmission Rate IT-3.12 Other Readmission Rate (Post Surgical Patients Discharged from UMC) – 30 Day Readmission Rate
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]: Develop or implement best practices or evidence-based protocols for effectively communicating with patients and families during and post-discharge to improve adherence to discharge and follow-up care instructions. Metric 1 [P-1.1]: Care transitions protocols. Baseline/Goal: Develop care transitions protocols. Data Source: Care transition protocols and materials. Milestone 1 Estimated Incentive Payment: $1,018,279 Milestone 2 [CQI P-10]: 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 1 [P-10.1]: Number of bi-weekly meetings, conference calls, or webinars organized by the RHP that the provider participated in. Baseline/Goal: n/a 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: $1,018,279	Milestone 3 [P-2]: Implement standardized care transition processes. Metric 1 [P-2.1]: Care transition policies and procedures. Baseline/Goal: Develop care transitions policies and procedures. Data Source: Policies and procedures of care transitions program materials. Milestone 3 Estimated Incentive Payment: $1,110,888 Milestone 4 [CQI P-10]: 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 1 [P-10.1]: Number of bi-weekly meetings, conference calls, or webinars organized by the RHP that the provider participated in. Baseline/Goal: n/a 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: $1,110,888	Milestone 5 [I-11]: Improve the percentage of patients in defined population receiving standardized care according to the approved clinical protocols and care transitions policies. Metric 1 [I-11.1]: Number over time of those patients in target population receiving standardized, evidence-based interventions per approved clinical protocols and guidelines. Numerator: Number of patients that receive all recommended education, care, and services as dictated by approved and evidence-based care guidelines. Denominator: Number of patients discharged or eligible for care transition services. Baseline/Goal: 30% improvement over of starting point of patients enrolled in post surgical discharge program Data Source: Registry; EHR report/analysis. Milestone 5 Estimated Incentive Payment: $2,228,235	Milestone 6 [I-14]: Implement standard care transition processes in specified patient populations. Metric 1 [I-14.1]: Measure adherence to processes. Numerator: Number of patients in defined population receiving care according to standard protocol. Denominator: Number of population patients discharged. Baseline/Goal: 40% improvement over of starting point of patients enrolled in post surgical discharge program Data Source: Hospital administrative data and the patient medical record. Milestone 6 Estimated Incentive Payment: $1,840,716
Year 2 Estimated Milestone Bundle Amount: $2,036,558	Year 3 Estimated Milestone Bundle Amount: $2,221,776	Year 4 Estimated Milestone Bundle Amount: $2,228,235	Year 5 Estimated Milestone Bundle Amount: $1,840,716
TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD: $8,327,285

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