The 1115 Waiver application submitted to CMS outlines important goals for the program that seeks to transform the health care delivery system. Through the program, Texas plans to integrate systems of care to ensure patients receive the right care, at the right time, and in the right setting; deliver high-quality care that can serve as a model for ongoing improvement in quality, safety, and efficiency; provide prevention and primary care services for all patients through expansion of the primary care workforce; provide a positive health care experience for patients; offer medical home care from a multidisciplinary team that effectively manages chronic diseases; and provide equitable care that takes into account patient-specific health care needs and backgrounds.
UTMB not only has clinical programs that can be a strong part of the provider and hospital network in the region to directly address health needs, it is an organization that is at the forefront of innovation. UTMB has made much progress in the four categories outlined in the waiver application, and has developed expertise that will help guide the creation of a delivery system reform incentive plan for the region. Further discussion of these categories follows, for consideration:
The development of a robust infrastructure is the foundation for delivery system transformation and requires an investment in people, places, processes, and technology. UTMB has already embarked upon a plan to enhance and grow its own infrastructure for delivery system reform in a number of ways. The work already underway at UTMB can serve as a model for partners in the region and as a foundation for further progress in the region in partnership with those other stakeholders.
Electronic Health Record:
UTMB has a long history as an early adopter of automation of documentation, having developed our own integrated electronic obstetric record across our distributed geography and advocated the use of computerized provider order entry over a decade ago. In our most recent generation of work, we began implementation of our Epic electronic health record in 2005, and by the end of 2012 will complete installation of final components in specialty clinic settings. In June, 2011 we completed the implementation of e-prescribing in all live Epic sites, including payer formulary checking (using Sure Scripts). We enjoy communicating with more than 9,000 of our patients using the MyChart electronic patient portal, fostering patient engagement and improving and speeding communication with patients.
This track record has positioned UTMB well in contemporary imperatives for transparency of performance and accountability. In September, 2011 we made application, notifying the Office of the National Coordinator of our attestation, under TX Medicaid rules, of adoption and implementation of our certified electronic health record for both UTMB hospital and the eligible professionals in our faculty practice plan. We simultaneously declared our intent to submit evidence of compliance with health information technology Meaningful Use objectives and quality measures to CMS in its fiscal year 2012. We have implemented all required features/functions and will make this available to all clinical services by the end of 2012. We have completed our validation and while UTMB performs well in almost all elements (objectives) and measures, we have begun initiatives to improve performance in the very few meaningful use measures that are not performing to goal. Our hospital is now using the EMR to report on 15 quality measures related to ischemic stroke, VTE prophylaxis, and Emergency Department throughput. For each eligible provider, we are reporting three core measures and, a somewhat more demanding task, identifying the three additional quality measures from among 38 approved additional quality measures under meaningful use, that best represent their practice. We will continue to submit data for all eligible professionals as their practice settings complete implementation during 2012.
Group Practice Reporting Option/Physician Quality Reporting System:
During 2011, enabled by these efforts at deploying a robust EMR, the UTMB faculty group practice plan first submitted quality performance data to the CMS Physician Quality Reporting System under its group practice reporting option (GPRO) and the eRX GRPRO e-prescribing value based purchasing imperatives. The faculty group practice organization consists of just fewer than 550 specialty and primary care physicians. Having accumulated a few years of performance data for our primary care providers via the electronic medical record, we were prepared to supply the GPRO performance indicators in chronic disease management and preventive primary care and can now benchmark against other physicians nationally. UTMB’s performance on the 26 quality indictors in GPRO 1 varied in benchmarking recently performed by CMS for the 2010 cohort of 35 medical groups, 11 of which were academic. We performed between the 50th to 80th percentile on the four coronary artery disease quality indicators, oral anti-platelet therapy prescribed, lipid-lowering therapy prescribed, beta-blocker therapy with previous MI, and diabetes or LVEF < 40% prescribed ACE inhibitor or ARB therapy. Our performance was more variable in the other categories of diabetes (8), heart failure (7), hypertension (3), and preventative (4), ranging from the 10th to the 90th percentile. We are actively working to improve our scores on these quality indicators in the future.
Health Information Exchange:
In 2008, UTMB began cultivating relationships for the purpose of sharing patient health information among the following stakeholders in Galveston County: the Gulf Coast Center (MHMR), St. Vincent’s Hope Clinic, and the Galveston County Health District “4C’s” FQHCs as the Galveston County Health Information Exchange (HIE). UTMB created a web-based clinical data repository (CDR) that stores patient demographic and encounter information for uninsured and/or underserved patients to be utilized by Galveston County HIE partner medical providers in making patient care decisions. GCHIE successfully applied for and received a Texas Department of Health and Human Services Commission Local HIE Grant Program planning grant to cover Galveston and parts of Brazoria county to create a HIE. Galveston County HIE later agreed to merge under the Greater Houston HIE (GHHIE) comprised of 14 counties of which Galveston and Brazoria are included. UTMB is actively involved on the Greater Houston HIE Board of Directors and various workgroups. Greater Houston HIE would like to assess a Galveston County pilot using the UTMB web-based CDR to exchange emergency department encounters between UTMB and another hospital within the county. [more]
In the fall of 2010, after survey by the American College of Surgeons, UTMB regained Level I Trauma provider status, having met all performance standards and sufficiently demonstrated volumes of trauma cases. We serve an expansive service area in southeast Texas, Trauma Service Area R. Among the many indicators we track and benchmark using the Trauma Quality Improvement Program database, UTMB performed best in class with the lowest observed to expected rate of mortality among all trauma centers reporting in the national TQIP database (National Trauma Data Bank), and has been in the top 10 for mortality (Trauma Level I, 401-600 bed size hosp) for the last decade. [more]
Regional Maternal Child Health Program and OB Network:
The Regional Maternal and Child Health Program operates clinics in 31 sites across east and southeast Texas providing a network of care to over 100,000 women, infants and children, especially those with greater needs. The Maternal Fetal Medicine Division accepts inpatient maternal transfers with high risk maternal and fetal conditions from a significant number of hospitals to provide a higher level of care. Outcomes of the Obstetrics and Gynecology division of UTMB are routinely reviewed by its quality committee and compared against published evidence and other academic health centers using risk adjusted benchmarks. UTMB rates for cesarean section and vaginal birth after cesarean are as good as or better than the region and the nation. For example, our primary C-section rate was 16.9% for the 12 months ending August, 2010, up slightly from the year before. The obstetrics department routinely evaluates evidence-based care practice compliance as well as outcomes (e.g. vaginal birth after caesarean), including complications of care (e.g. C-section hysterectomy). UTMB provides both low and high-risk perinatal care to both mothers and infants, with an advanced maternal fetal medicine service, prenatal ultrasound and prenatal diagnosis, a 24 hour CNM service, and more than 40 infant special care beds. Our department of pediatrics routinely monitors the delivery of specialized services to high risk and pre-term infants, using comparative performance data we share with the Vermont Oxford Network (a national collaborative of health care professionals dedicated to improving the quality and safety of medical care for newborn infants and their families). [more]
Regulatory Accreditation & External Reporting:
UTMB monitors compliance with regulatory standards, has launched a scorecard of results in measures associated with external standards and routinely engages staff in the conduct of tracers to monitor performance and identify areas for improvement. In the past year, we have been involved with ample accreditation and certification activity:
Disease Specific Certifications submitted and awaiting on site survey: –
Regional systems of care that encourage increased primary care capacity in rural areas or in underserved areas that are integrated with increased access to tertiary care in urban areas is one of the strategies outlined for focus in the early years of the program. Additionally, developing pilots for innovative care models or payment systems that can be clearly measured and then replicated if successful are a key component to delivery system reform.
UTMB has developed its plans for the clinical enterprise using the approach outlined above. Growth of primary care through additional providers, staff, and facilities as needed to address the needs of the region are part of the infrastructure investment that UTMB is making. This is being complemented by targeted investment in specialties that are needed in the region. Clearly, one organization cannot provide all that is needed in a region, and the development of the regional partnership in Southeast Texas will enhance collaborative planning among health care providers, allowing for a more deliberate and well thought out plan to address prevention, primary care and specialty care needs of the region based on the expertise and capabilities of various providers and organizations.
UTMB is a leader in the development of innovative models of patient care, and many of these are now being replicated on a larger scale across the institution. Some of these programs are outlined in the following paragraphs.
Community Health Program:
UTMB Community Health Program (CHP), or Outpatient Care Management Program is an integrated care and disease management model that focuses on high risk, unsponsored UTMB patients with chronic diseases. Examples of the chronic diseases currently followed by the CHP are Diabetes, Hypertension, Congestive Heart Failure, Coronary Artery Disease and Chronic Obstructive Pulmonary Disease. The primary goals of the program include: improved disease state management, reduced complications from chronic disease, improved quality of life and decreased acute care utilization while using a multi-disciplinary approach with registered nurses, community health workers, social workers, and nutritionists. Patients are established with a medical home either at the Galveston County Health District FQHC’s or at St. Vincent’s Hope Clinic. Group and one-on-one education is provided to diabetics regarding diet modification, including how to shop for and prepare nutritious foods with the objective of lowering their Hemoglobin A1C’s and teaching them how and when to check their blood glucose level. The program additionally provides UTMB Multi-Share Plan members with acute chronic diseases outpatient care management services.
The Community Health Program was provided an additional SSBG award of $373,000 to pilot a program to provide 120 unfunded chronic disease patients inpatient-to-outpatient care management for improved transition from the acute setting to the home setting and to reduce complications. The care manager provided resources such as home health care, medical equipment & supplies, referral to follow-up and primary care and assistance acquiring medications to ensure compliance with the provider’s treatment plan and improve continuity of care. The patients were also instructed on “red flags” that would signal potential complications as well as when and how to contact their physician in an effort to reduce the need for acute care. The care manager also provided instruction related to chronic disease management to enable and empower individuals to care for themselves and maintain an improved quality of life. Care Management services were provided via home visits, telephone follow-ups and joint clinic visits with the patient. The goal of these interventions was to decrease the chance for readmission to the hospital and/or further complications. [more]
St. Vincent’s Hope Clinic:
St. Vincent’s Hope Clinic (STV Hope Clinic) is an innovative primary care practice that provides health care to Galveston’s vulnerable populations through a nurse managed health clinic. In partnership with UTMB School of Nursing, St. Vincent's House, and UTMB Health Policy and Legislative Affairs, STV Hope Clinic opened in October 2008. The STV Hope Clinic offers a unique nursing focus that emphasizes the comprehensive and continuous nature of primary health care practice. The practice focuses on health care maintenance and management of chronic illnesses for all ages. A partnership with UTMB Community Health Program allows access to nurse case management services and a recent partnership with Family Services Center provides access to counseling and mental health services. In the fall of 2010, the Health Resources and Services Administration of the U.S. Department of Health and Human Services awarded a $1.5 million federal grant to UTMB School of Nursing that allowed the STV Hope Clinic to expand services. The STV Clinic has implemented an electronic health record, expanded its comprehensive primary care services to children and the elderly and has begun accepting insured patients. New partnerships with The Children's Center shelter for homeless families with children, The Gulf Coast Center and the Salvation Army (under development) have allowed the clinic to bring services to residents of homeless centers and people with chronic mental health problems. [more]
Primary Care Medical Home:
The Primary Care Medical Home (PCMH) is also under development at UTMB in a two-pronged fashion. The Family Medicine department has started a PCMH at an outpatient clinic site on Stewart Road in Galveston. UTMB is seeking NCQA recognition for the work in this clinic. Additionally a pilot program has just begun with the purpose of training Medical Assistants to become health care coaches for patients. As a patient comes into the clinic they are assigned to a physician’s panel of patients. In addition, a primary nurse and a Medical Assistant are assigned to the patient so that they have a team of providers to access. The Medical Assistant serves as that first point of contact for patients, guiding them between visits and helping them manage wellness rather than illness. As a part of this pilot, UTMB has developed a partnership with College of the Mainland for UTMB to serve as a clinical experience site for students working through the certification program to become a Medical Assistant. To determine the success of this pilot through the patients’ perspective, a pre and post survey will be conducted to assess general health and wellness of the patient and satisfaction with care. The goal is to implement the Medical Assistant as the health care coach more widely after the completion of the pilot program.
Telemedicine is one of the most successful efforts to provide access to care in rural areas of Texas, and remote areas of the world. The UTMB Telehealth program began at UTMB over 16 years ago in its correctional care and maternal child wellness programs, and has been expanded into numerous settings including community health clinics, community mental health centers, corporate employee health programs, cruise ships, off-shore industries, and remote areas of the world like the South Pole. To date, more than 600,000 synchronous physician-to-patient telehealth encounters have been conducted.
UTMB Health was awarded a Frew Advisory Committee sponsored contract to implement and operate telemedicine clinics specifically for pediatric tele-psychiatry with community partners for children enrolled in the Texas Medicaid program in 2009. This program provided more than 7,775 real-time clinical encounters through the program and demonstrated reduced ER visits for patients in the program and a lower no-show rate for visits than traditional psychiatric care clinics. This project was a clear demonstration of how telemedicine can improve access to specialists, reduce emergency room utilization, and create cost savings in the system.
Telemedicine for School-Based Mental Health was established to meet the mental health needs of Galveston County’s adolescents and youth through a collaborative framework—involving the University of Texas Medical Branch (UTMB), the Robert Wood Johnson Foundation (RWJ), the Galveston Independent School District and the city’s philanthropic community—for mental health care in area primary and secondary schools. This undertaking is driven by a simple but powerful goal: to close the gaps in access to mental health services for adolescents and youth in the Galveston County community. The initiative currently operates in the Galveston, Dickinson, La Marque and Santa Fe Independent School Districts, in addition to a clinic at the Galveston County Juvenile Justice facility in Texas City (a total of 10 clinics operating through a collaborative with the school systems and community-based partners) to deliver services to underserved youth and adolescents. This system provides a virtual “one-stop shop” for primary care, mental health care, social support groups and other services aimed at coordinating a system of care around children and their families and engaging the Galveston County community-based providers and school districts in the provision of an evidence-based, model of holistic mental health care. This system has a few notable developments: easy access to care at the appropriate level and with the appropriate provider; information continuity through the use of an integrated EMR; a system of coordinated care and transitions in care between separate community-based providers; shared accountability between partner agencies; peer review and teamwork based care; and, continuous innovation. Over the last five years this program has provided over 11,780 patient contacts that might not have otherwise happened. Over the last year, we are also pleased to report that we have continued to demonstrate a democratized access to care: 40% White, non-Hispanic, 32% African-American, 27% Hispanic and 1% Asian. This statistic is of additional significance given that the Galveston population demographics post-Ike have shifted dramatically from what was approximately 1/3 Hispanic, 1/3 African-American, 1/3 White, non-Hispanic to approximately 45% Hispanic, 27% African-American, 27% White, non-Hispanic. Our results continue to indicate progress in improving paths of access to mental health services taken by minority racial/ethnic groups and massive efforts to affect parent attitudes, knowledge and opinions related to the use of mental health services. [more]
Utilization and Operating Efficiency:
In anticipation of CMS’s readmission reduction program, we have commissioned a number of improvement efforts. One such effort is the creation of a medical home for patients with COPD (one chronic illness population with a recurring admission challenge for UTMB) to improve quality of life and reduce hospitalizations. Tests of change for improving this care include a systematic review of mechanism for gathering and displaying EMR information on current care; deploying enabling clinical decision support; and enhancing the likelihood of follow-up outpatient visits. Similar EMR hard-wiring of changes has been undertaken to improve care for patients with community-acquired pneumonia and heart failure, including discharge instructions and work flows, medication reconciliation, and vaccine compliance. As a result of such changes, November, 2011 was the first month UTMB could boast 100% compliance with all surgical care improvement core measures.
A systematic effort was undertaken this past year to enhance Emergency Department throughput. Our internal medicine group assigned an attending physician to directly evaluate and initiate treatment for patients with an admission order. As a result of their effort, we have reduced overall patient ED wait time by almost half, reduced number of patients who left without being seen by 66%, and reduced hours on ambulance diversion because of capacity problems from 170 min. (Sept.) to 8 min. (current).
Evidence Based Practice:
In early 2011, UTMB Health implemented a software application (Provation/UpToDate) to support the review of evidence to assure that order sets built in our Epic EMR are based on the best available scientific evidence. Subject matter experts approved initial target order sets in every clinical department by September, 2011. We are hard-wiring this evidence content using clinical decision support tools in the EMR. For example, after initiating Venous Thromboembolic Event (VTE/DVT) prophylaxis changes in Epic, 91% of eligible adult Med/Surg patients and 96% of OB/Gyn patients had active orders had DVT prophylaxis orders.
Care Management for uninsured population:
In 2007, UTMB received a grant from the Houston Endowment Inc. to create a cohesive health care management plan for the uninsured in Galveston County so that health care is provided in an accessible, organized and systematic manner with better health outcomes and the hope that this model can be replicated in other communities across the state. The health care management plan included offering a 3-Share Plan (two year pilot) to the working uninsured, developing a Galveston County Clinical Data Repository (CDR) that provides electronic health information for the unfunded population, and aggressively manages a selected population of unfunded patients who suffer from chronic diseases in order to improve disease state management, establish a medical home, and decrease acute care utilization through the Community Health Program (CHP). [more]
UTMB 3-Share/Multi-Share Plan:
In July of 2009, the 3-Share Plan or health benefits program was offered to 500 members who work for small business (2-50 employees) within Galveston County with a total premium of $180 per member per month (PMPM). The plan was designed to follow an HMO model with a provider network primarily made up of UTMB physicians. The 3-Share Plan became a model for five other multi-share concept programs within the state. Together, the six multi-share plans formed the Texas Communities Health Care Coalition (TexHealth Coalition) to collaborate on ways to promote optimum health and cost efficiency through plan designs that emphasize primary and preventative care. One of the primary goals of the TexHealth Coalition is to provide vitally needed health care benefits to the working uninsured in Texas, while paying special attention to the impact that these uninsured workers have on the bottom-lines of small businesses. After a successful two year pilot program and additional grant dollars secured by the Texas Department of Insurance, the 3-Share Plan was reviewed and modified to the Multi-Share Plan in August 2010 with a premium of $250 PMPM. The new Multi-Share Plan was offered to the original 3-Share Plan members as a new benefit program. Currently, the plan offers a premium subsidy of $75 PMPM for those qualifying members earning wages at or below 300% of the federal poverty level to reduce which reduces the premium cost for both the employer and employee. [more]
Galveston and Brazoria County 2009-2011 Hurricane Ike Recovery: Social Service Block Grant (SSBG) Collaborative:
Houston Galveston Area Council (HGAC) through funds provided by Texas Department of Health and Human Services Commission administered awards and contracts to provide recovery funds to address social and health services for individuals, and for repair or construction of social and health services facilities affected by hurricanes. The Galveston/Brazoria County SSBG Collaborative was awarded $35 million dollars among four lead agencies: Catholic Charities, Gulf Coast Center, Lutheran Social Services, and UTMB Health to serve 152,000 clients. UTMB Health as a lead agency managed $6.7 million and provided 425,000 actual service counts as compared to a goal of 152,000. The Community Health Program was awarded $817,000 to double the existing program to accommodate 300 unfunded chronic disease patients. CHP served 332 patients and provided medicine vouchers, patient navigation, enrollment in pharmacy assistance programs, and disease education.
These are examples of the work UTMB participates in and leads in order to approach health care delivery from a population health perspective. Much of the work that is being done in infrastructure investment described above also supports the long term goal of managing the health of populations. Being able to collect, extract, analyze, and report on clinical data of different patient populations is key to all facets of population-focused improvement. With culture of safety and quality and Health IT systems as a foundation, the organization can make improvements at the population level. UTMB already measures the patient experience through Press Ganey satisfaction surveys. This information drives continuous improvement in patient care across the continuum.
UTMB looks forward to working with counties, other hospitals, providers, and communities to build a regional health care partnership in the Southeast Texas region. UTMB is committed to improving access to and quality of care for all patients throughout Texas, and believes that through the Regional Health Care Partnership in the Southeast Region of Texas the needs of the patient populations can be addressed.