Medicaid 1115 Waiver Program
Catherine Gibson, Chief Waiver Officer
University Medical Center of El Paso
Anchor Hospital -- Region 15
Mano y Corazón Binational Conference of Multicultural Health Care Solutions, El Paso, Texas, September 27-28, 2013
2. Texas Healthcare Transformation and Quality
Improvement Program 1115 Waiver
On December 11, 2011, CMS formally approved this program for Texas
5 year Waiver – 2011-2016
Purpose: To transform and improve healthcare to the Medicaid and
Under-Funded Patients in Texas by:
Better access to health-care services
Improving the quality of health-care and health systems
Cost effectiveness of services and health systems
Regional collaboration and coordination
Each Region forms a Regional Healthcare Partnership Plan (RHP)
Project Categories include:
Infrastructure Development
Program Innovation and Redesign
Patient Outcomes
Hospital Core Measure Reporting
4. RHP Regions of Texas
20 Regions Developed in Texas
We are Region 15 comprised of:
El Paso and Hudspeth Counties
Region 15 holds monthly Public Meetings
On or around the last Wednesday of each month
Location: El Paso First Health Plans
Contact: Cathy Gibson, Chief Waiver Officer cgibson@umcelpaso.org
Region 15’s RHP plan is developed and located on the Region 15 RHP
Website:
www.umcelpaso.org
Region 15–RHP (link on webpage)
Contains all information and documents from Region 15 Public
meetings to date.
5. Region 15 Community Needs Assessment
Regional Strategic Health Framework Needs Assessment Report
Phase 1 – Needs Assessment
Phase 2 – Priority Ranking
Region 15 formally adopted the Paso del Norte Regional Health
Assessment
Top Priorities
Diabetes / Obesity Behavioral Health
Primary Care
Secondary / Specialty Care
Behavioral Health
Region 15 projects will center around these priority areas
6. Region 15 RHP Plan
Approved by HHSC on 3/2/13
CMS is in the process of approving all RHP Plans for Texas
Texas Medicaid 1115 Waiver Program has 1300 Projects under
review by CMS
Region 15 has 53 Projects
UMC
EHN
El Paso Health Department
El Paso Childrens Hospital
Texas Tech
HCA
Tenet
7. Region 15 Projects
DSRIP
UMC – 17 Projects
Adding Residents and Fellows to New and Existing Hospital Services
Electronic Medical Record Programs
UMC Neighborhood Health Clinics
Expanding clinic hours in 3 clinics to include evening and weekend
Performance Enhancement
Establishing Certified Medical Homes
Chronic Care Models
Coumadin Clinic
Inserting Medical Treatment in the Shelters
Expanding Hospice Program
Comprehensive Discharge Navigation Program
Nurse Advise Call Lines and Surgery Guidebooks for Pre and Post
Surgeries
Psychiatric Liaison Inpatient Services
Emergency Department / Inpatient LEAN Efficiency
Graduate Nursing Simulation Lab Primary and Specialty Care
8. Region 15 Projects
DSRIP
Texas Tech – 9 Projects
Enterprise-wide Disease Management Registry
NCQA Designation as Medical Home
Addition of Child Psychiatry Fellowships
Expanding Neurology Care
Enhancing & Expanding Comprehensive Breast Care Services
Increasing Access to Surgical Services
Establishing a Minimally Invasive Surgery Fellowship Program
Increasing Access to Ocular Care
Expanding Pediatric Primary Care
9. Region 15 Projects
DSRIP
Emergence – 5 Projects
Increase number of Psychiatrists and Licensed Behavioral
Health Providers in El Paso
Develop an Extended Observation Unit (EOU)
Develop a Crisis Respite Unit
Crisis Continuum for Intellectual Developmental Disability (IDD)
Evidence-based Practices are Empirically Based Treatment
Modalities that are Proven to Result in Positive Outcomes
10. Region 15 Projects
DSRIP
Tenet (Providence and Sierra East) – 8 Projects
Discharge Planning Assessment and Intervention
Develop Program to Improve Cultural Competency of Staff
Establishing New Urgent Care Centers
Form 2 Specialty Clinics
11. Region 15 Projects
DSRIP
Las Palmas Del Sol – 7 Projects
Establish Outpatient Women’s Centers
Establish a Diabetes Information system
Tele-Psychiatric Consultation in the Emergency Department
Clinical Information Registry for Heart Disease Patients
Develop Strategies for Recruiting and Retaining Primary Care Providers
Recruit 2 Specialists or Expand 2 Specialty Clinics
Implement Hospitalist Model
12. Region 15 Projects
DSRIP
Health Department – 5 Projects
El Paso Childrens Hospital - 1 Project
Health Department
Establish a Community Health Atlas
Establish Mobile Dental Clinics
Automated Emergency Dispatch
Regional Data Validation of HIE
Disease Management Registry
EPCH
Pediatric Hospitalist Model
13. UMC Neighborhood Health Clinics
DSRIP Projects
Opening a new Primary Care Clinic at Crossroads and Mesa with expanded evening and weekend hours serving
the Westside of the City of El Paso.
# Providers
Hours/Days
The placement of this new clinic will create between 10,000 and 20,000 visits by the end of the Waiver term
in 2016.
The outcome improvement target is to improve patient satisfaction and also to adequately control patients on
blood pressure monitoring medication
Expansion of current services - This project will expand access to primary and urgent care in the RHP Region,
and more specifically the East area of El Paso County by relocating and expanding the Montwood Clinic to a
much larger site offering many additional services including additional primary care staff, evening and Saturday
hours, Women’s Health Services including ultrasound, a regional laboratory and a pharmacy.
We expect to have approximately 50,000 visits which also include lab, pharmacy and ultrasound services by
the end of the Waiver term in 2016.
The outcome improvement target is to improve patient satisfaction and also to adequately control patients on
blood pressure monitoring medication
Expansion of current services- This project will expand access to primary and urgent care in the RHP Region,
and more specifically El Paso County. UMC will expand primary and urgent care staffing, services and hours at
two existing Neighborhood Health Centers at Ysleta and Fabens helping them to become minor hub sites which
provide lab in addition to primary care.
There are currently no evening or weekend hours at either the Ysleta or Fabens Neighborhood Healthcare
Centers. Many providers are extremely busy with third next available appointments out over a month.
The outcome improvement target is to improve patient satisfaction
14. UMC Neighborhood Health Clinics
DSRIP Projects
Improve the quality of care given at the UMC neighborhood health centers (NHCs) by upgrading the
EMR system to better document and track disease progressions and provide a scorecard to measure
improvement.
electronically prescribe medications, meeting meaningful use standards, and tracking HEDIS measures
UMC will add key staff to enhance and interpret reporting methodologies that enable quality improvement and rapid-
cycle change.
By 2016, this quality of care initiative will impact 63,500 patients
The outcome improvement target is decrease the hemoglobin A1c measurement to 8% or below for patients
discharged to the NHCs with diabetes within 1 year
Implement the Medical Home Model in the UMC neighborhood health centers, resulting in better
coordination of care, greater access, and enhanced quality of patient care. Development of a patient
registry including layered reporting of performance measures and decision support so that cost, access
and quality are measurable and improvement can be demonstrated.
Currently care at NHC is reactive instead of proactive and planned. Multiple studies have shown that increased
access to planned, proactive primary care and support staff and greater involvement of the patient in making their
own health care decisions improve total health care costs.
By providing the right care at the right time and in the right setting, over time, patients may see their health improve,
rely less on costly ED visits, incur fewer avoidable hospital stays, and report greater patient satisfaction.
NHC will obtain Medical Home Recognition 300 new patients assigned to medical home will be contacted for their
first patient visit within 60-120 days.
We expect this project to improve the quality of care given by establishing a medical home for 31,775 patients by the
end of the Waiver in 2016.
The outcome improvement target is to reduce the 30 readmission rates for these diabetic patients
15. UMC Neighborhood Health Clinics
DSRIP Projects
Diabetes Chronic Care - This project will redesign the outpatient delivery system to coordinate care for patients
with chronic diseases and improve patient outcomes, with a focus on diabetic patients.
We will coordinate an appointment for Diabetic patients within 4 days from discharge at UMC to UMC-NHC for
patients without a PCP or NHC patients.
Utilizing the Chronic Care Model and a team approach including PCP, Pharmacist, Registered Dietitian, Social
Worker and Exercise Physiologist we will create a comprehensive medical home for Diabetic patients, track their
process in a registry system and help the patient increase their understanding of diabetes and establish their own
self-management goals.
UMC-NHC are currently not utilizing the Chronic Care Model nor has a specialized diabetic program upon discharge
from UMC despite having a large number of diabetic patients who would benefit from a more systematic approach to
helping them manage their diabetes.
The outcome improvement target is to reduce 30 diabetes readmission rates
Establish a Coumadin Clinic – Basic Services to be provided include:
establishment of a medical home, patient assessment, monitoring of anticoagulation, dosage adjustment, medication
education and management, patient education (including nutrition counseling and self-management), and follow-up
care.
This clinic goes well beyond the traditional Coumadin Clinic to get to the root causes of what caused the patient to
have the problems so severe that they were hospitalized and that then needed Coumadin as part of the medication
plan. The clinic will treat the whole patient and work on helping the patient get under control the underlying conditions
that caused their hospitalization.
The clinic uses a team approach including physician, NP, clinical pharmacist, nutritionist, social worker, physical
therapist and exercise physiologist to health the patient regain their health. The clinic will increase patient well-being
and satisfaction, and reduce the number of readmissions to treat stroke and coronary artery disease and related
bleeding.
Currently there is no Coumadin Clinic in the El Paso area for uninsured/ Medicaid patients. UMC currently is
discharging 6-10 patients every week in this category or patients who do not have an established Primary Care
Provider. This is a very dangerous situation due to the complexity of the patient’s health status following discharge
on this medication. Currently 80% of the patients being discharged from UMC are on Medicaid or are Uninsured with
only 20% having Medicare or private insurance.
This population has had a high readmission rate due to lack of appropriate primary care. The outcome improvement
16. Expand Resident and Fellowship Programs
and Establish a Graduate Nurse Residency
Program
Additional Resident and Fellowship slots for Cardiology, Nephrology, Radiology,
and GI will be provided by UMC to increase access to services at the hospital.
The outcome improvement target is to survey graduating residents and fellows and
improve retention of these specialties in the El Paso area.
Development of a comprehensive graduate nursing program including a
simulation lab and specialty care focused training
The outcome improvement target is to survey graduating nurses and improve
retention of these specialties in the El Paso area.
17. Insert Medical Care and Wellness into the
El Paso Shelters
This project will provide nursing care and an in-house wellness program to residents at the Salvation
Army.
Diabetes treatment will be a large portion of care provided for this target population; however, the residents will
receive any ongoing medical care they need via RN’s who are located in the Salvation Army.
This project will develop a program for clients to gain control of their healthcare through disease management,
medication compliance, appropriate diet and nutrition, and lifestyle changes.
Under this project, UMC will contract with VNA to develop and implement an evidence-based nursing program in
order to provide primary and preventive healthcare to residents of the Salvation Army shelter in El Paso.
Annually, this bilingual, culturally sensitive program will serve approximately 350 homeless families with children
(over 1,000 unique individuals) by educating the population about preventative healthcare and wellness (including
education on nutrition, fitness, counseling, and health management—including management of chronic diseases).
The wellness program will directly provide for a nutritionist, a chef, and kitchen equipment, supplemental nutritious
foods including fresh produce, a wellness counselor, fitness resources, and prescription drug vouchers.
The outcome improvement target is to reduce hospital admission rates for this patient population
This project will provide nursing care to residents at the Rescue Mission.
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.
Clients will receive nursing care in the shelter to better address ongoing maintenance of chronic conditions and to
treat urgent conditions as they arise.
This project will develop innovative strategies to reduce, prevent and manage chronic diseases in children and
adults. 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 outcome improvement target is to reduce hospital admission rates for this patient population
18. Emergency Department Throughput and
Psychiatric Liaison Nursing on the Hospital
Units
ED Lean Project – To increase access to care and provide more timely and quality care to UMC
patients, multiple teams and processes are being implemented to reduce the wait time for a patient to
be seen in the ER, and the wait time to admit a patient waiting in the ED to a hospital bed.
Improvement in our processes will also improve the discharge process for inpatients who are ready for
discharge home.
The outcome improvement target is to prevent patients from leaving the emergency room without being seen by a
doctor and the reduce the wait times for admission
Nurse Psychiatric Liaison – UMC is not a psychiatric institution, but treats a large number of patients in
the EL Paso community for medical conditions (who may also have a secondary psychiatric diagnosis.
Those patients will be identified and consulted for follow-up psychiatric care upon discharge from the
hospital.
The outcome improvement target is to reduce readmission rates for this patient population
Discharge Navigators – This project will create a coordinated system of care upon discharge within the
hospital to ensure the continuity of health care as patients transfer between different locations.
Patient care navigators / case management positions will discharge our Medicaid and Unfunded patients with
chronic conditions to appropriate medical homes for follow-up healthcare treatment utilizing other UMC projects that
will provide for clinic growth and expansion, as well as appropriate home health care services, and finally
coordinating homeless and transient patients to our partner homeless residential facilities.
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.
The outcome improvement target is to reduce the 30 day readmission rate for this patient population
19. Addressing Surgical Patients Needs and
EMR Programs to Improve Patient Care
Surgery Guidebook and Nurse Advise Line
UMC will develop an educational guidebook for surgical patients, including resources for pre-
surgery, intra-surgery, post-surgery, discharge, and follow-up. UMC will create a 24/7 nurse
advice line for surgical patients to access with questions and concerns. We 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.
Outcome improvement target is to reduce readmission rates for this patient population due to
complications
EMR - UMC will participate in nationally validated, risk-adjusted, outcomes-based
programs to measure and improve the quality of trauma and surgical care (TQIP
and NSQIP).
UMC will implement robust electronic medical record (EMR) and data collection systems to
provide the infrastructure for improving patient care and decreasing the incidence of Potentially
Preventable Complications and Healthcare Acquired Conditions.
The target population is our surgical and trauma patients which are at a higher risk for
contracting a complication. However, the implementation of a robust EMR along with
participation in an outcomes-based program will benefit all of our patients.
Hire/train quality improvement staff in well-proven quality and efficiency improvement principles,
tools, and processes to measure improvement and trends
Outcome improvement target is to reduce catheter associated urinary tract infection rates of
hospital patients
20. Region 15 Learning Collaborative
Diabetes
Plan for Learning Collaborative for Diabetes in
Region 15 will be submitted October, 2013 for the
next 3 years
DSRIP projects and subcontracts addressing
Diabetes:
UMC
30 Day Readmission Rates for Diabetes
Discharge Navigation
Primary Medical Care in Salvation Army and Rescue Mission in
collaboration with VNA Nursing
High intensity chronic care disease management –Tendercare
Home Health Care
Neighborhood Health Clinics