Reflection Look Forward Practice Transformation Initiative Share Learn

Reflection & Look Forward Practice Transformation Initiative Share & Learn Webinar December 13, 2017 2/15/2022

Hello and welcome!

Zoom Tips • Attendees are automatically UNMUTED upon entry • Refrain from using the hold button • Use the chat box, raise your hand, or unmute yourself and jump in if you have questions or would like to participate • Direct messages to Jen if you have any technical issues • Sit back and enjoy – this meeting is being recorded; slides & a recording will be included in the PTI Weekly Communications email on Thursday! Practice Transformation Initiative

Share & Learn Webinars • Monthly opportunity to Share & Learn alongside your PTI colleagues: • on technical content or learn new concepts, • to share your successes and promising practices, • to thought partner with your peers about the challenges you’re facing in this work. • Each webinar will have a different focus and will vary in its target audience, but is open to all of you (project team members or practice coaches). 2/15/2022

Today’s Agenda 1. 2. 3. 4. 5. 2/15/2022 Introductions 2017 Reflection Look Forward to 2018 Practice Engagement Strategy Wrap-up

Presenters / PO Partners Alex Stack Rashi Hemnani 2/15/2022 Juliane Tomlin Celida Madrid Peter Robertson Pam Laidley Sam Monks Yvette Salas

Question: Reflecting on your PTI work in 2017: What is one word to describe what you’re feeling right now? Practice Transformation Initiative, a program of: 2/15/2022

2017 Reflection Practice Transformation Initiative, a program of: 2/15/2022

2/15/2022

Performance on 2017 Focus Areas Diabetes Management • 45% of practices (850/1900) showing improvement • 48, 500 people with diabetes receiving better care Patient Family Engagement 39% of clinicians receiving quarterly patient experience feedback 9 out of 13 PTI organizations have an updated aim statement that includes a patient family engagement goal Joy in Work (Milestone 24) • 44% of practices have shown improvement over baseline; the average score increased from 1. 25 to 1. 77 at follow-up. 2/15/2022

Celida Madrid Practice Facilitator & QI Administrative Manager EPIC Management Practice Transformation Initiative, a program of: 2/15/2022

Question: What is your biggest PTI Bright Spot in 2017? Practice Transformation Initiative, a program of: 2/15/2022

Look Forward to 2018 Practice Transformation Initiative, a program of: 2/15/2022

4 -Year Aims CMS TCPi Aims PTI Aims 1. Support more than 140, 000 clinicians in their practice transformation work. 1. Support 4, 800 clinicians in practice transformation by working with 16 provider organizations 2. Improve health outcomes for millions of Medicare, Medicaid and CHIP & other patients. 2. Improve health outcomes for approximately 3. 5 million Californians through 20% relative improvement across our clinical quality measures 3. Reduce unnecessary hospitalizations for 5 million patients. 3. Reduce hospital and ED utilization by 5% (44, 361 fewer inpatient bed days and 35, 340 fewer ED visits) 4. Sustain efficient care delivery by reducing unnecessary testing and procedures. 4. Sustain efficient care by reducing unnecessary testing by 5% (17, 469 patients avoiding unnecessary tests) 5. Generate $1 to $4 billion in savings to the federal government and commercial payers 5. Generate $242 million in savings 6. Transition 75% of practices completing the program to participate in Alt. Pay. Models 6. 75% of clinicians participate in Value Based Payment programs 7. Build the evidence based on practice transformation so that effective solutions can be scaled 7. Build the evidence on scaling transformation through a collaborative model with provider organizations that hire practice facilitation coaches to work with various types of practices

2018 Practice Transformation Initiative Goals By December 31, 2018…. . Program Goals • Realize 20% relative improvement toward the 90 th percentile on high impact outcome measures (Hb. A 1 c <8; Hb. A 1 c >9; HTN control). • Record at least $202 million in cumulative cost savings across the 4 utilization measures (ED visits, hospital bed days, imaging for LBP and cervical cancer overscreening). Organization Goals Practice Goals • 100% of practices will have been actively engaged with a Practice Facilitation Coach. • 80% of practices are actively building Quality Improvement infrastructure and capability, reflected by % scoring 2 or higher on specific PAT milestones. • Each organization will have a documented return on investment for sustainability of the Practice Transformation work including program components that will continue beyond 2019. • 80% of practices have implemented the PFE tactics of shared decisionmaking and patient activation. • Each organization will support Team-Based Care in the practices by establishing clinician-approved standing orders and trainings for care team staff. • 80% of practices use performance reports for Quality Improvement, reflected by % scoring 2 or higher on specific PAT milestones.

PTI Training 2018 DRIVERS MEASURES • 4 – Patient Family Engagement in Care • 5 – Patient Family Engagement in QI • 6 - Team Member Functions • 10 - Care Management for High Risk • 15 - Behavioral Health • 17 - Appointment Access • 19 - QI Approach • 20 - QI Capability • 21 - Performance Reports Sharing Stories 2/15/2022 Culture Change • Clinical • Diabetes Good Control • Diabetes Poor Control • Diabetes Blood Pressure Control • Hypertension Blood Pressure Control • Utilization • Inpatient Bed Days • Emergency Department Visits Sustainability Enabling Factors

Practice Engagement Strategy Organizational Level Goal: By the end of 2018, 100% of practices will have been actively engaged with a Practice Facilitation Coach. Practice Transformation Initiative, a program of: 2/15/2022

PTI Practice Engagement Strategy • By March 31, 2018, Provider Organizations will have developed an engagement strategy for 100% of PTIenrolled practices. • This will include a definition of “engagement” for each practice, including… • Details about prioritization or sequencing • Frequency of meetings with practice facilitator • Depth of QI activity • Etc. Practice Transformation Initiative

Some Examples from your Peers… Rashi Hemnani PTI Project Manager Health. Care Partners Practice Transformation Initiative Pam Laidley & Yvette Salas Practice Facilitators Sutter Pacific

Health Care Partner’s Practice Engagement Strategy Prioritization Criteria: • High panel size • High engagement (physician buy-in) • High opportunity (who would benefit the most from the effort? Where can we push the needle? ) 2/15/2022

Sutter Pacific’s Practice Engagement Strategy 2/15/2022

Some other ideas… • Consider your criteria for prioritization • • Volume of your patients Readiness / engagement of practice Current performance Provider champion identified • Categorize practices into “engagement tiers” • High, Medium, Low • Categorize practices based on sequence of engagement Define EACH category, including… • details about prioritization or sequencing • frequency of meetings w/ practice facilitator • depth of QI activity Practice Transformation Initiative

And Remember… • High-priority practices will follow this general coaching trajectory… Priority level can change… High-touch/priority practices should move in to “maintenance or “graduated” level • Lower priority could become higher priority (as readiness increases, for example) • 100% of practices will be… • completing PATs every 6 months • using data to monitor performance regularly Practice Transformation Initiative

Question: Based on what you’ve heard, what do you want to learn more about? Practice Transformation Initiative, a program of: 2/15/2022

Wrap Up Practice Transformation Initiative, a program of: 2/15/2022

Question: What will you apply to your work as a result of today’s discussion? Practice Transformation Initiative, a program of: 2/15/2022

• Jan 24 @ 10 am: Share & Learn Webinar – Data &Performance Stories UPCOMING EVENTS • Feb 1 @ 10 am: Practice Facilitation Workshop – Case Study; Team Based Relationships & Coordinated Care Delivery • Feb 21 -22 @ Irvine Marriott: PTI Annual Convening

SURVEY: The meeting was a good use of my time? Practice Transformation Initiative, a program of: 2/15/2022

Thank you for participating! Share your topic ideas and how we can improve: Share & Learn Feedback Form 2/15/2022 29