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An IDS That Runs Like Clockwork

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Screamer Co

on 17 September 2014

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Transcript of An IDS That Runs Like Clockwork

Post-Acute Care
Palliative Care
Primary Care
Health Promotion
Expand health care focus to include wellness
and prevention strategies

• Initiate workgroup

• Identify goal and milestones to support CCC clinical efforts

• Implement process for integrating health promotion practices

• Individual Level

• Organizational Level

• Community Level

• Institutional Level

• Policy Level

Facilitate access to com
unity-based medical,
dental, and behavioral health care services

• Continue implementation of DSRIP projects

• Increase primary care screening rates

• Improve diabetic
care management
Ensure sufficient capacity for medical and behavioral health
urgent/emergent needs to:

•Stabilize and treat acute, time-sensitive issues

•Refer to appropriate level of care

• Reduce inappropriate ED utilization

• Monitor use of psychiatric ED

Implement changes to care network/service availability to
facilitate treatment of non-emergent conditions in
appropriate settings

Ensure access to standardized, cost-effective pharmaceutical
services across CCC network

• Implement and monitor a shared, cost-effective formulary

• Create a community-wide pharmacy and therapeutics committee

• Facilitate distribution of pharmacy-related
information across provider network
• Monitor appropriateness of formulary and revise as needed

• Develop protocols that support the delivery of clinical
pharmacy services and appropriate medication therapy

Advance quality and safety of inpatient services in alignment
with best practices and in conjunction with the development
of the new teaching hospital and medical school

• Continued coordination with CH, UT, and Seton on development of new
teaching hospital and reuse and redevelopment of UMCB/Central Health
Downtown campus

• Reduce IP visits in alignment with reduction of ED utilization

• Work with community stakeholders to
increase access to behavioral health
inpatient services

Ensure access to appropriate care for individuals with
serious illnesses

• Continued implementation/expansion of Seton
DSRIP Program

• Increase access to primary palliative care

• Implement specialty palliative care, as possible

Create/add capacity to facilitate access to:
Rehabilitation, Skilled Nursing, and Long-Term Acute Care
services for medical and behavioral health needs

• Medical: Create plan to develop resources for IDS population

• Behavioral Health: Work with community partners on strategic plan to
define service gaps and prioritize needs

Facilitate appropriate access to shared data throughout network
and track outcomes

Shared, Evidence-Based Protocols
Develop and implement shared, evidence-based care protocols that
are regularly reviewed and updated based on demonstrated outcomes
and/or national standards

• Establish an effective, standardized process for protocol training
and implementation

• Develop process for protocol revisions and version control

• Expand areas for shared protocol development and create linkages
between CCC protocols and other care delivery networks
Care Coordination
Create consistent approach to coordination of patient care
activities between service lines

• Create a shared platform of tools for use by all providers in
care coordination

• Create alignment between care coordination and navigation
services to best support individual health and healthcare service
delivery across the IDS
Performance Improvement
Design and implement a network-wide Performance
Improvement (PI) Program

Build capacity within CCC administration and contracted network providers to define
and conduct PI efforts

Offer PI consulting services to CCC member organizations that:

• Assist in the identification of performance gaps/waste and development of related
improvement projects

• Assist in the prioritization of PI projects

• Lead/facilitate PI efforts as needed
• Finalize Data Governance Structure

• Define and begin implementation of shared care plan

• Stabilize relationship with ICC and ICare

• Define One Button Interface

• Plan CCC Analytics Platform
• Implement 4 completed Primary Care protocols

• Continue development of Primary Care protocols for priority conditions

• Monitor implemented Specialty Care Protocol

• Use shared care plan to inform work

• Strengthen linkages between various service lines

• Engage Seton on transitional care program outcomes
• Hire staff

• Promote services across IDS

• Implement program
Patient Experience
Levels to be Addressed
Medical ED:
Psychiatric ED:
Work with community stakeholders to increase access to
behavioral health services to reduce need for emergency care
Design and implement multi-level interventions
to most effectively impact population health
• Implement Primary Care Medical Home (PCMH)
model across network

• Emphasize team-based care

• Promote person-centered care and patient engagement

• Implement a comprehensive chronic care
management program

• Expand and enhance integration of behavioral
health services in PCMHs

Specialty Care
Facilitate access to medical, dental, and behavioral health specialty services that are well-coordinated with primary care homes
• Continue to implement Gastroenterology (GI) and Pulmonology DSRIPs to
expand access to these services

• Improve diabetic care management

• Identify additional specialty care needs

• Use data to prioritize the addition of new specialty
care services

• Expand specialty care access in primary care settings

• Increase supply of specialists via collaboration with
Dell Medical School

• Work with community stakeholders to increase
access to behavioral health specialty services


Support, and coordinate with, community efforts to create a medical health district in downtown Austin with the
Seton Medical Center at The University of Texas and the new
Dell Medical School as foundational elements

Increase access to primary palliative care

• Manage symptoms

• Discuss treatment goals and prognosis

Implement specialty palliative care

• Manage refractory symptoms

• Assist with conflict resolution regarding treatment goals
or methods of treatment

• Assist in addressing cases of near futility

After transformational goals are achieved and resources allow, develop plan to address post-acute medical needs
Behavioral Health:
Work with community stakeholders to increase access to
behavioral health post-acute services
Governance Structure:
Create an Organized Healthcare Arrangement to facilitate ability to share health information among all CCC participants
Collaborative Care Plan:
Create ability for each CCC provider team to push their care plan to the community HIE and design look of aggregate care plan with providers
One Button:
Create easy access to patient care provided across the CCC network for all care provider teams
CCC Analytics Platform:
Build a data warehouse, along with corresponding functionalities to house data, report progress, and help analyze system impact
Establish a network-wide system to assist
patients/families in accessing all services across the
continuum of care throughout the network

• Develop relationships with community organizations to
facilitate access to needed services

• Develop shared protocols

• Expand outreach to MAP population

• Develop and implement services for
frequent ED utilizers
Implement/expand navigation services according to the following principles:

• Connect, coordinate, and follow up for services in a timely manner

• Partner with the person to guide them through the continuum of care

• Provide culturally and linguistically appropriate support with an awareness of
individual needs and sensitivities

• Educate and connect people to appropriate levels of care, community
resources, and available coverage

• Promote the health and well-being of the person at all contacts

• Anchor healthcare safety net system across Central Texas while
providing advanced medical care to the community

• Increase the supply of local physicians and other healthcare professionals

• Improve opportunities for interdisciplinary teams to cultivate higher quality
while refining the healthcare experience for patients

• Maximize the ability for patients to receive a broad array of care in the
most appropriate and accessible locations

• Enable medical educators to more efficiently teach healthcare professionals
and researchers to discover and establish new standards of care

• Reduce the need to travel to other cities for treatment

• Ensure a variety of inpatient needs are accessible for the community
Specifically, the Seton Medical Center
at The University of Texas will:
Full transcript