Community Care Collaborative Expand Specialty Care Capacity for Gastroenterology 307459301.1.6 Pass 3 Provider: The Community Care Collaborative (CCC) is a new multi-institution, multi-provider, integrated delivery system. Launched in 2012 by Central Health, Travis County’s Healthcare District, and the Seton Healthcare Family, Central Texas’ largest hospital system, and now joined by Austin Travis County Integral Care, the County’s Local Mental Health Authority, this 501(c)3 will integrate safety net providers in Travis County in a ACO-like model. Patients will receive navigated, patient-centered care that will lead to better health outcomes, increased satisfaction with the system, efficient delivery of services, and lower costs. Intervention(s): This project will contract with or hire additional gastroenterologists and support staff to practice in community based settings. A new multi-specialty clinic, to be known as the Southeast Health and Wellness Center, in a low-income area of Travis County will also be developed as a new location to provide these services. Need for the project: People with low-incomes and/or public insurance programsoften have to wait four months for a gastroenterology appointment. Wait times for gastroenterology liver services are close to one year. The only clinic option available is located in a hospital in downtown Austin. Among Travis County residents, colon cancer is one of the top two causes of cancer-related deaths. According to analysis of the safety net patient population in Region 7 and surrounding counties, Hepatitis C related visits increased approximately 16% between 2009 and 2010. Data from a recent survey of local safety net providers show that only 34% of needed GI referrals are able to obtain care. Preventive colonoscopies are not available to the target population at this time.
Target population: The target population will be CCC enrollees who need gastroenterology services. All CCC enrollees have incomes under 200% of the Federal Poverty Level and/or have multiple chronic conditions. Over the course of the waiver, this project is expected to serve nearly 1,800 patients. New providers will be located at community based settings that serve a high proportion of Medicaid patients, and all CCC related provides will also serve Medicaid patients as part of their practices. Category 1 or 2 expected patient benefits: The project seeks to expand the number of gastroenterologists available to serve the population and offer those services in locations that are better connected with patients’ medical homes. The project will also support the development of a new multispecialty clinic site in Southeast Travis county, an area consistently identified as very high need. Category 3 outcomes: The outcomes of this project are to reduce wait times for gastroenterology services, effectively manage the longterm medications of patients with Hepatitis C and ensure these patients are tested and treated for depression, a known side effect of Hepatitis C treatment. IT-1.1 Third Next Available Appointment IT-1.8 Depression Management: Screening and Treatment Plan for Clinical Depression IT-1.20 Other Outcome Improvement Target – Annual Monitoring for Patients on Persistent Medications – boceprevir or telaprevir in combination with peginterferon alfa and ribavirin (Class 1, Level A)
IT-12.3 Colorectal Cancer Screening (HEDIS 2012)
Title of Project: Expand Specialty Care Capacity for Gastroenterology Category / Project Area / Project Option: 1.9.2 Expand Access to Specialty Care RHP Project Identification Number: 307459301.1.6 Pass 3 Performing Provider Name: Community Care Collaborative
Performing Provider TPI: 307459301 Project Description The Community Care Collaborative (CCC) is a 501(c)3 public-private partnership that will redesign the Travis County indigent healthcare delivery system. The CCC was created in 2012 by Central Health, the taxpayer-funded Travis County Healthcare District, and the Seton Healthcare Family, Travis County’s largest hospital system. Austin Travis County Integral Care, the designated provider of community-based behavioral health and development disorder services for Travis County, has also recently joined the CCC as a partner. The CCC’s overarching goal is to provide high quality, cost effective, patient centered care that improves health outcomes for its targeted population. The CCC, through its contracted provider network, will initially serve a defined patient population of 50,000 uninsured individuals at or below 200%
of the Federal Poverty Level and who meet other established eligibility requirements.
The operational objectives of the CCC are to create effective coordination between providers across the continuum of care; increase and integrate capabilities of providers’ Electronic Health Record (EHR) and the system’s Health Information Exchange; and aligns payments with outcomes, rather than outputs. With significant public investment in the transformation of the indigent healthcare system, the CCC will develop and implement accountable care organization (ACO) and patient-centered medical home principles by establishing a strong, comprehensive primary care base, collective responsibility for care of patients across the delivery continuum, payments linked to quality improvements, and reliable and progressively stronger
This project will expand access to Gastroenterology (GI) services by contracting with and/or hiring two additional GI physicians and related support staff to serve within the CCC’s constellation of community-based care settings. With these providers, the project will seek to reduce wait times for care, expand capacity for colorectal cancer screening, and improve adherence to Hepatitis C drug treatments. CCC patients will benefit from expanded access to gastroenterology services as described in this project, but also the thirteen other DSRIP projects that the CCC is proposing. These thirteen projects are:
STD & HIV Screening and Treatment &
GI specialty services for the target population are offered primarily at one hospital-based specialty clinic located at University Medical Center Brackenridge (UMCB) in downtown Austin. A local Federally Qualified Health Center (FQHC) provides a two GI clinic sessions per week at a north Austin site. Even with some GI care available in the community, wait times for GI appointments at the UMCB specialty clinic remain an average 121 days, or approximately four months. Patients who need to see a GI for liver
concerns, including Hepatitis C infection, often have to wait nearly a year for care. Data from a recent survey of local safety net providers show that only 34% of needed GI referrals are able to obtain care. Long wait times for gastroenterology care are of particular concern given the prevalence of GI related chronic diseases in Region 7 and in Travis County. Among Travis County residents, colon cancer is one of the top two causes of cancer-related deaths. Yet, there are no screening colonoscopies provided for the CCC population, and the existing UMCB facility has no capacity to expand colonoscopy services. This leaves the target population with a significant gap in preventive care designed to address this leading cause of cancer death. According to projections from the Texas State Data Center, the population in Region 7 grew dramatically between 2000 and 2010. Travis County’s population is expected to grow by another 7% during the waiver period. Population growth will place even more demand on already scarce GI resources. Additionally, demand for GI services is expected to increase due to guidelines recently issued by the Centers for Disease Control and Prevention (CDC) that recommend that all people born during 1945-1965 be tested for Hepatitis C. Hepatitis C infection is a growing concern for low-income Travis County residents. According to analysis of the safety net patient population in Region 7 and surrounding counties, Hepatitis C related visits increased approximately 16% between 2009 and 2010. This project addresses current unmet need and anticipated future needs for GI services by expanding GI services into multiple community based clinics that currently serve the target population. Additional clinic sessions with new GI providers are expected to reduce wait times for care. Expansion into community- based settings is expected to transform the health system by offering specialty services in the context of the patient’s medical home, minimizing the need to travel to a separate clinic. Care provided in a familiar location that is likely closer to home is expected to achieve better adherence to appointment schedules and treatment plans. As part of the community-based care expansion for GI services, a new multispecialty clinic site in southeast Travis County will be developed to provide this care. Southeast Travis County has consistently been identified as an area with high levels of poverty and limited healthcare infrastructure. Approximately 270,000 people reside within a 5-mile radius of the proposed Southeast Health and Wellness Center, and 46% live below 200% of the Federal Poverty Level. In addition to expanding care, this project will evaluate the potential to perform screening colonoscopies at this new care site and contract with local providers to perform screening colonoscopies for CCC patients within their facilities. Project Goals
Increase the number of GI providers offering services in community-based settings to low-income,
uninsured, and publicly insured patients.
Develop the Southeast Health and Wellness Center to provide community-based GI care and
expand capacity for colorectal cancer screenings
Decrease the time until third next available appointment to see a GI specialist Increase the rate of Hepatitis C patients who successfully adhere to their treatment regimen.
Challenges or Issues Faced by the Performing Provider
Lack of available workforce is a challenge to the implementation of this project because specialty providers are difficult to recruit and retain. Additionally, potential providers must be willing to serve a potentially challenging patient population that will likely suffer from multiple chronic diseases. Integrating specialty care into settings that have traditionally offered primary care may prove to be a challenge at initial
implementation. Due to the side effects of the medications, many do not complete the treatment regimen needed to decrease the viral load. How the Project Addresses those Challenges
The CCC and its membership organizations have existing relationships with area medical schools and residency programs. We will build on these relationships and aim to retain as many of these providers as we can to provide GI services to our low-income populations. The CCC will also work with the UT- Austin school of nursing to ensure an adequate supply of nurses and other medical support staff that can support the work of expanded specialty care services. To manage care coordination and co-location of primary care and specialty care services, the CCC will develop and implement a standard set of care protocols that will manage the care of the entire target population under a uniform set of guidelines. The CCC will build in specific strategies to screen and treat Hepatitis C patients for depression to minimize non-compliance with Hepatitis C treatment drugs. How the Project is Related to RHP Goals 1. Prepare and develop infrastructure to improve the health of the current and future Region 7 populations. – This project enhances and expands existing specialty care infrastructure to better meet the demand of low-income populations. This infrastructure expansion will allow the target population to access needed preventive screenings and better management of care for GI related chronic conditions. 2. Reduce health system costs by expanding opportunities for patients and families to access the most appropriate care in the most appropriate setting. By expanding opportunities to receive gastroenterology services in a timely manner, patients will be able to have their medical concerns addressed more quickly and before problems escalate to more serious issues. Services offered in community-based medical home settings will allow the patient access to care in a more comfortable, appropriate setting. Starting Point/Baseline Between January and December, 2011, people served in the safety net received 1,343 GI visits at the UMCB Specialty Clinic. Time Period for Baseline
January-December, 2011 Rationale Reason for Selection of Project Options and Components
Project option 1.9.2 – Expand Specialty Care Capacity was chosen to address the extended wait times CCC patients experience when they need to access GI services. Long delays in accessing specialty care result in delayed GI related screenings, such as colonoscopies, which can prevent cancer. Additionally, expansion of GI capacity will allow local providers to enhance screening practices for Hepatitis C. Health screenings that can detect potentially serious health conditions before they worsen could significantly improve patient health outcomes and reduce costs to the health system. Travis County residents who are low-income, uninsured or have public insurance coverage such as Medicaid, CHIP, or the local Medical Access Program (MAP) struggle with access to specialty care services due to lack of care capacity within the existing provider network serving this population. At the same time, the population in Central Texas is growing dramatically, placing a growing burden on the already strained network of specialty care providers dedicated to providing care to underserved populations. Option 1.9.2 includes four required components:
a) Increase service availability with extended hours. Currently, GI clinic sessions are offered
only three days per month to the existing MAP population at the UMCB specialty clinic. A limited
number of clinic sessions are offered through a community-based setting. After a series of planning tasks, this project will begin by hiring providers to offer more care in community-based, outpatient settings. Hiring of additional providers will allow additional hours of care to be provided beginning in DY 2.
b) Increase number of specialty clinic locations. The project will increase the number of specialty
clinic locations by placing newly hired providers at existing community-based outpatient settings that serve the population but do not yet provide GI services. The project will also develop a portion of the Southeast Health and Wellness Center, under renovation in southeast Austin, which will serve as a new specialty care site. Care offered at the new location will be in addition to care expanded at existing sites.
c) Implement transparent, standardized referrals across the system. GI specialty care will be
provided within the context of the newly formed Community Care Collaborative (CCC). The CCC’s function will be to monitor and coordinate care for the entire covered population. A robust referral system will be developed that will have standard operations across the entire network of care.
d) Conduct quality improvement. Expanded GI capacity will require careful planning, monitoring,
and revision of expansion plans to ensure highest quality care to the patient population. Specialty providers will conduct continuous quality improvement activities that will be evaluated quarterly.
Reason for Selection of Milestones & Metrics
During DY 2, it is critical for the performing provider to complete a planning process (P-X: Complete a planning process) to understand how much additional capacity is needed and where it should be located to achieve the greatest expansions in care capacity. While this planning is occurring, the performing provider will begin the recruiting and hiring process (I-22: Increase the number of specialty providers) with a goal to provide additional patient visits (I-23: Increase specialty care volume of visits) as early as DY 2. New providers will be located at existing community-based sites. In DY 3, to be launched in DY 4, the provider will complete a planning process (P-X: Complete a planning process) to prepare and then work to renovate the Southeast Health and Wellness Center to provide GI specialty care services to the target population. The Southeast Health and Wellness Center will be tailored to meet the specific care and cultural needs of the patient population. During this planning process, the CCC will evaluate adding additional capacity for preventive colorectal cancer screenings at the new location. In DY 2, 3, 4, and 5, the provider will hire providers and provide care to additional patients. These milestones will grow over time as care is expanded at existing clinic sites and at the new site to open in DY 4.
Unique Community Need Identification Number
CN.2 Inadequate access to specialty care. How the project represents a new initiative for the Performing Provider or significantly enhances an existing delivery system reform initiative
GI services are offered to the target population on a limited basis through the UMCB Specialty Clinic (hospital-based) and on a limited basis at a local FQHC. This project will build on and expand GI services offered in community-based settings to increase capacity in this area to benefit the target population. Related Activities Funded by U.S. Dept. of Health and Human Services (DHHS) N/A
Related Category 3 Outcome Measure(s) Category 3 Outcome Measures(s) Selected
IT-1.20 Other Outcome Improvement Target – Annual Monitoring for Patients on Persistent Medications – boceprevir or telaprevir in combination with peginterferon alfa and ribavirin (Class 1, Level A)1 IT-1.8 Depression Management: Screening and Treatment Plan for Clinical Depression IT-12.3 Colorectal Cancer Screening (HEDIS 2012) Reasons/Rationale for Selecting the Outcome Measure(s) IT-1.1 Third Next Available Appointment: A primary goal of this project is to expand access to care as measured by reduced wait times for services, hence the selection of Third Next Available Appointment as an outcome measure. IT-1.20 Other Outcome Improvement Target: Monitoring adherence to treatment protocols for patients on prescribed medication therapy – boceprevir or telaprevir in combination with peginterferon alfa and ribavirin (Class 1, Level A). Hepatitis C is a growing concern for Travis County safety net populations, yet treatment regimens are difficult to follow because treatment times last many weeks and the drugs have difficult side effects. The CCC’s goal is to improve Hepatitis C treatment through better management of adherence to Hepatitis C drug regimens among newly-diagnosed patients, for which the above treatment regimen is recommended. The CCC expects that a majority of its Hepatitis C patients will not have had access to these treatments in the past, hence the choice of a drug regimen for newly- diagnosed patients. IT-1.8 Depression Management: Screening and Treatment Plan for Clinical Depression: Depression is common among patients with Hepatitis C and this condition may worsen during treatment. Screening for depression before treatment is crucial and may improve treatment outcomes. (Papafragkakis et al. “Depression and pegylated interferon-based hepatitis C treatment” International Journal of Interferon, Cytokine, and Mediator Research.March 2012, Volume: 2012:4, Pages 25-35). The CCC’s goal is to ensure all patients diagnosed with hepatitis C are screened for depression and treated if necessary. IT-12.3 Colorectal Cancer Screening (HEDIS 2012): In expanding capacity to provide colorectal cancer screening to the patient population, the CCC aims to catch colorectal cancer early to improve health outcomes. Relationship to Other RHP Projects How Project Supports, Reinforces, Enables Other Projects
This project reinforces other projects proposed by the CCC, including expanded access to primary and specialty care, and the development of standard protocols for the management of chronic diseases in the CCC population. The following projects are related most directly
307459301.1.2: Expanded Primary Care Hours at Community-Based Outpatient Settings 307459301.1.7: Expanded Specialty Care Services at Community-Based Outpatient Settings:
307459301.1.5: Expanded Specialty Care Services at Community-Based Outpatient Settings:
307459301.1.3: Mobile Health Clinics 307459301.2.2: Chronic Care Management Protocols
List of Related Category 4 Projects (RHP Project ID Number)
1 American Association for the Study of Liver Diseases – 2011 Practice Guideline. http://www.aasld.org/practiceguidelines/Documents/2011UpdateGenotype1HCVbyAASLD24641.pdf The drug combination noted here is recommended for patients who have never received therapy for HCV.
RD-4: Medication management Relationship to Other Performing Providers’ Projects in the RHP List of Other Providers in the RHP that are Proposing Similar Projects 176692501.1.1: Expanding Access to Specialty Care Plan for Learning Collaborative Plan for Participating in RHP-wide Learning Collaborative for Similar Projects
RHP 7’s performing providers, IGT entities, and anchor recognize the importance of learning from each other’s implementation experiences and will make regular efforts to share ideas and solve problems. Region-wide, anchor-led meetings will be held at least annually and will offer an opportunity to share, listen, and learn what providers have encountered while implementing their DSRIP projects. RHP 7 envisions continuing the regular, anchor-led calls that are open to all performing providers and IGT entities, as launched during plan development. These calls have brought value to the process, and will be continued on a schedule that will be helpful throughout the waiver period. Further, the region will continue to use its website (www.texasregion7rhp.net) to share information, updates and best practices as has been done during this first waiver year. As useful, Central Health, as RHP’s anchor, will foster the development of topical learning collaboratives – smaller meetings than the annual regional summit – that will bring together all levels of stakeholders who are involved in DSRIP projects that share common goals, outcomes, themes or approaches. This multi- pronged approach should allow for continuous improvement of regional projects, which will in turn better serve RHP 7’s low-income population and transform its healthcare delivery system. Project Valuation In valuing its projects, the Community Care Collaborative considered the extent to which the project fulfilled the Triple Aim, supported Waiver goals and addressed community needs. The size of the required investment was also considered, which included considerations of personnel, equipment, time and complexity. Finally, the CCC reflected on the scope of the project: the number of patients that would be affected, including the type of patients; the number of patient visits or encounters; how many providers or staff members would be added; the costs that would be avoided as a result of the project; and the “ripple effect” the project would have on all members of the healthcare system. These factors were weighed against the amount of funding available. Valuations for Category 3 projects associated with this Category 1 project are weighted according to the number of people expected to benefit from a particular outcome. 307459301.1.6 1.9.2 1.9.2.A EXPAND SPECIALTY CARE CAPACITY FOR GASTROENTEROLOGY 307459301 Related Category 3 Outcome Measure(s): Depression management: Screening and Treatment Plan for Clinical Depression Other Outcome Improvement Target: Monitoring adherence to treatment protocols for patients on prescribed medication therapy – boceprevir or telaprevir in combination with peginterferon alfa and ribavirin (Class 1, Level A).Colorectal Cancer Screening (HEDIS 2012) (10/1/2012 – 9/30/2013) (10/1/2013 – 9/30/2014) (10/1/2014 – 9/30/2015) (10/1/2015 – 9/30/2016) Milestone 1 [P-X]: Complete a Milestone 4 [P-X]: Complete a Milestone 7 [P-11]: Launch/expand a Milestone 10 [I-22]: Increase the
gastroenterology service capacity across
Payment (maximum amount): $984,002
Payment (maximum amount): $1,065,386
Milestone 5 [I-22]: Increase the Milestone 8 [I-22]: Increase the Milestone 2 [I-22]: Increase the
Payment (maximum amount): $1,165,266
Milestone 11 [I-23]: Increase specialty 307459301.1.6 1.9.2 1.9.2.A EXPAND SPECIALTY CARE CAPACITY FOR GASTROENTEROLOGY 307459301 Related Category 3 Outcome Measure(s): Depression management: Screening and Treatment Plan for Clinical Depression Other Outcome Improvement Target: Monitoring adherence to treatment protocols for patients on prescribed medication therapy – boceprevir or telaprevir in combination with peginterferon alfa and ribavirin (Class 1, Level A).Colorectal Cancer Screening (HEDIS 2012) (10/1/2012 – 9/30/2013) (10/1/2013 – 9/30/2014) (10/1/2014 – 9/30/2015) (10/1/2015 – 9/30/2016)
Payment (maximum amount): $984,002
Payment (maximum amount): $961,807
Payment (maximum amount): $1,065,386
Milestone 6 [I-23]: Increase specialty Milestone 9 [I-23]: Increase specialty
Payment (maximum amount): $1,165,265
Milestone 3 [I-23]: Increase specialty
Payment (maximum amount): $984,002
Payment (maximum amount): $961,806
Payment (maximum amount): $1,065,385 Year 2 Estimated Milestone Bundle
Amount: (add incentive payments amounts from each milestone): $3,196,157 TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD (add milestone bundle amounts over Years 2-5): $11,364,114
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