Project Option: 1.9.

2- Improve access to specialty care: Wound Care Program Unique RHP Project Identification Number: 133355104.1.18 Performing Provider Name/TPI: Harris Health System / 133355104 Project Description: Harris Health System proposes to improve access to specialty care through implementation of a program that improves access to wound care services delivered by skilled professionals in strategically placed locations based on regional needs. Wound care cost has increased from $5 to $7 billion annually, which is an increase of 10% per year1. The scope of the project is implementation of a Harris Health system wide initiative to ensure patients have access to specialty wound care services that are geographically convenient and provide comprehensive services to include debridement, treatment, dressing changes, assessment and placement of wound vacutainers and ostomy care. Harris Health patients today have access to only 2 locations for wound care services which are on acute care campuses. Wound care is fragmented in the sense that physical therapists, nurses, physicians and home care nurses provide a variety of treatment options. Access is limited by skilled wound ostomy continent nurses to provide the comprehensive services necessary post discharge and to secure supplies and referrals to specialty care required. Harris Health patients discharged from acute care are attending the emergency center for supplies, education related to ostomy, and wound care systems. Sepsis is of concern when patients attend the Harris Health community health centers with infected wounds due to lack of timely follow-up due to transportation barriers and finances to procure the necessary supplies. Patients that are fitted with wound drainage systems across the system today without access to a specialist for appropriate placement, management and tracking for outcomes and removal. The 4 new locations will be staffed with registered nurses, nurse practitioners and physician evidence based portico oversight. Language barriers will be addressed via the use of bilingual staff and immediate access to patient interpretation services either on site or telephonically. Literature related to patient self-management wound care will mitigate the need for home care services which was greater than $600,000 for the last fiscal year (Harris Health financial data). Wound drainage systems accounted for over $1.5 million in cost the last fiscal year with staff not always cognizant of status or need to remove when treatment is complete (Harris Health financial data). Access to care that is patient centered, timely, and delivered by certified skilled professionals, will promote healing, decrease cost, and provide quality skilled care at a convenient location. Continuity of care is essential for the proactive identification of potential wound complications. This program will develop additionally a transition acute care (to include surgical patients) to the ambulatory setting by ensuring a peer to peer hand off is initiated as part of the discharge plan (to the nurses in the new centers). The transition plan will ensure the patient is
1

Junkin, J.(n.d.). Failure to thrive in wounds: Prevention and early intervention. Infection Control Resource 1 (2). Available from http://www.infectioncontrolresource.org/Past_Issues/IC2.pdf

monitored post discharge and the ambulatory new centers will be proactive in reaching out to the patient and developing the rapport required, for the necessary follow-up to promote healing and decreased inappropriate utilization of acute care services and unnecessary supplies and equipment. Project Goal(s) and Relationship to Regional Goals 1. Providing geographically convenient access to an increased provider and nurse specialist for wound care will promote access and quality 2. Access to timely wound care services will decrease the cost of home care and wound drainage 3. Decreasing EC visits aids in cost containment and improved quality for the patient who can access the services 5-6 days weekly, a minimum of 8 hours per day. 4. Specialized certification and evidence based wound care treatment, aids in recovery and decreased expense related to infection and dehiscence. The project is related to the regional goals below: Transform health care delivery from a disease-focused model of episodic care to a patient-centered, coordinated delivery model that improves patient satisfaction and health outcomes, reduces unnecessary or duplicative services, and builds on the accomplishments of our existing health care system, and Develop a regional approach to health care delivery that leverages and improves on existing programs and infrastructure, is responsive to patient needs throughout the entire region, and improves health care outcomes and patient satisfaction. Challenges: Culturally diverse population to include Hispanics and African American who are predisposed to diabetes, hypertension, and obesity (Harris Health System Fact Sheet 2012) with a propensity for development of wounds based on such disease processes relative to venous stasis, peripheral neuropathies and metabolic syndromes. o Hispanic 57.4% o African American 26.3% o Caucasian 9.2% o Asian 4.8% o Other 2.2% o American Indian 0.2% Inability to track and monitor patients across the continuum of wound care services Lack of resources and appropriate equipment to be utilized for delivery of quality wound care by skilled professionals Lack of education for primary and specialty care physicians as to how to assess and refer for wound care concerns and potential treatment Geographically limited access to wound care services resulting in emergency center visits for non-emergent treatment How the Project Addresses those Challenges: The project will address the above challenges by providing timely geographically convenient patient centered care that is delivered by skilled professionals. Improved access will
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promote a decrease in overall cost of emergency room visits, infections, admissions, readmissions and provide education to providers to promote the timely referral to wound care services professionals. Wound care nurses will be co-located in 4 of the Harris Health community health centers and work collaboratively with the primary care and specialty providers to educate regarding evidence based wound care. The nurses will be either bilingual or have access to timely interpretation services and an array of comprehensive services will be available in each of the locations to include: debridement, sterile technique dressings, removal and initiation of wound drainage systems, and access to specialty patient chairs, equipment, and ostomy consultation and assistance services. 5-Year Expected Outcome for Provider and Patients: Through increasing coordination of services for wound care treatment, patients with wounds and ostomy relevant needs will have improved access to geographically convenient care that is appropriate for the level of care they need. Through improved training of providers, services will be delivered and monitored by skilled professionals who will be able to track and monitor the wound care incidence, prevalence, and outcomes across the continuum of patient care within the Harris Health System. Costs for non-emergent visits and readmissions will be decreased as will the incidence of infection related to timely access to care2. Starting Point/Baseline: This is a new initiative for Harris Health. We currently do not have a geographically sensitive comprehensive wound care program, so the baseline is 0 patients. Rationale: Project option 1.9.2 is selected based on the need to implement a best practice, geographically convenient strategy for improving access to wound care services. Project Components: The project will address all project components below, except item a). a) Increase service availability with extended hours- This project will not expand hours for service availability; rather it will meet the current demand for services during regular business hours. b) Increase number of specialty clinic locations c) Implement transparent, standardized referrals across the system. d) Conduct quality improvement for project using methods such as rapid cycle improvement. Unique community need identification number the project addresses: CN.2- Inadequate access to specialty care CN.8- High rates of inappropriate emergency department utilization
1

Junkin, J.(n.d.). Failure to thrive in wounds: Prevention and early intervention . Infection Control Resource 1 (2). Available from http://www.infectioncontrolresource.org/Past_Issues/IC2.pdf

CN.9- High rates of preventable hospital readmissions CN.10- High rates of preventable hospital admissions How the project represents a new initiative or significantly enhances an existing delivery system reform initiative: The project is a new initiative for Harris Health and wound care programs improve patient outcomes at reduced costs1. Wound care services provided in the current system are fragmented and uncoordinated, and are available only within a limited geographic area and from a limited number of providers. This initiative will greatly improve the existing delivery system process by coordinating services among regional providers and ensuring patients receive the best care possible in the most appropriate setting available. The new initiative creates 4 new locations of services within the Harris Health community health centers and each of the 4 locations will be geographically patient convenient and access will be enhanced via the addition of skilled nursing staff who will be available for at least 8 hours per day, 5-6 days per week. Related Category 3 Outcome Measure(s): OD-9 Right Care, Right Setting IT-9.4 Other outcome improvement target: Decrease acute care and emergency center utilization related to wound dehiscence or infection Reasons/rationale for selecting the outcome measure: OD-9 IT-9.4 is relevant to the goals of improving patient access to quality specialty wound care services, at a geographically convenient location and to be served by either bilingual staff or staff with ready access to interpretive services. The ability to improve access, promotes the decrease in cost of inappropriate utilization for acute care and emergency room visits. Co-location of wound care services at Harris Health community health centers promotes the ability for patients to receive care within their community and educate the primary care physicians and patients relative to identification of wound complications. Relationship to other Projects and Other Performing Providers Projects in the RHP: This projects focus on improved patient care for high-need services supports expansion of primary care services, specialty services and via the project of disease registry can readily identify patients with chronic illness at risk based on zip code, disease process, inappropriate utilization and acute care discharge. The referral to wound care services will be tracked electronically and monitored for patient safety and utilization, and cost per episode of care. Other related projects include transition of care, predictive modeling and expansion of primary care service locations. Plan for Learning Collaborative: We plan to participate in a region-wide learning collaborative(s) as offered by the Anchor entity for Region 3, Harris Health System. Our participation in this collaborative with other Performing Providers within the region that have similar projects will facilitate sharing of challenges and testing of new ideas and solutions to promote continuous improvement in our Regions healthcare system

1.9.2(B-D) Harris Health Related Category 3 [unique Category 3 IT IT-9.4 Outcome Measure(s): identifier(s)] Year 2 Year 3 (10/1/2012 9/30/2013) (10/1/2013 9/30/2014) Milestone 1 [P-1]: Conduct specialty care gap assessment based on community need Metric 1 [P-1.1]: Documentation of gap assessment. Goal: Provide documentation of gap analysis for Wound Care Program Data Source: Completed Needs Assessment report Milestone 1 Estimated Payment Incentive: $2,140,932 Milestone 2 [P-21]: Participate in facetoface learning at least twice per year with other providers and the RHP to promote collaborative learning around shared or similar projects. Metric 1 [P-21.1]: Participate in semi annual facetoface meetings or seminars organized by the RHP. Goal: Participate in meetings Data Source: Documentation of meeting attendance Milestone 2 Estimated Payment Incentive: $503,749 Milestone 3 [P-2]: Train care providers and staff on processes, guidelines and technology for referrals and consultations into selected medical specialties Metric 1 [P-2.1]: Training of staff and providers on referral guidelines, process and technology Baseline: 0 providers and staff trained in DY2 Goal: Train all targeted providers and staff Data Source: Log of specialty care personnel trained and Curriculum for training.

133355104.1.18

1.9.2

IMPROVE ACCESS TO SPECIALTY CARE: WOUND CARE PROGRAM 133355104 Other: Decrease acute care and emergency center utilization related to wound dehiscence or infection Year 4 Year 5 (10/1/2014 9/30/2015) (10/1/2015 9/30/2016) Milestone 5 [I-23]: Increase specialty care clinic volume of visits and evidence of improved access for patients seeking services. Metric 1 [I-23.1]: Documentation of increase number of visits. Demonstrate improvement over prior reporting period baseline DY3 Baseline: DY 3 Goal: Increase volume of patients by 15% over DY3 baseline Data source: Nurse schedules, patient appointments, EHR, utilization reports Milestone 6 [I-23]: Increase specialty care clinic volume of visits and evidence of improved access for patients seeking services. Metric 1 [I-23.1]: Documentation of increase number of visits. Demonstrate improvement over prior reporting period baseline DY 3 Baseline: DY 3 Goal: Increase volume of patients by 20% over DY3 baseline Data source: Nurse schedules, patient appointments, EHR, utilization reports Milestone 6 Estimated Payment Incentive: $1,435,684

Milestone 5 Estimated Payment Incentive: $1,889,057

1.9.2(B-D) Harris Health Related Category 3 [unique Category 3 IT IT-9.4 Outcome Measure(s): identifier(s)] Year 2 Year 3 (10/1/2012 9/30/2013) (10/1/2013 9/30/2014) Milestone 3 Estimated Payment Incentive: $503,749 Milestone 4 [P-11]: Launch/expand a specialty care clinic Metric 1 [P-11.1]: Establish/expand specialty care clinics. Baseline: zero for all 4 quadrants of the Harris county. Goal: Establish wound care clinics in targeted facilities Data source: Evidence of clinic availability in 4 quadrants of the county based on needed access to care; Recruitment of registered nurses, increased number of referrals and patients seen with wound care specialty needs. Milestone4 Estimated Payment Incentive: $503,749 Milestone 5 [P-X]: Establish baseline volume of completed Wound Care visits Metric 1 [P-X.1]: Documentation of baseline Goal: Document baseline number of completed visits to Would Care Program Data Source: EHR

133355104.1.18

1.9.2

IMPROVE ACCESS TO SPECIALTY CARE: WOUND CARE PROGRAM 133355104 Other: Decrease acute care and emergency center utilization related to wound dehiscence or infection Year 4 Year 5 (10/1/2014 9/30/2015) (10/1/2015 9/30/2016)

1.9.2(B-D) Harris Health Related Category 3 [unique Category 3 IT IT-9.4 Outcome Measure(s): identifier(s)] Year 2 Year 3 (10/1/2012 9/30/2013) (10/1/2013 9/30/2014) Milestone 5 Estimated Payment Incentive: $503,749

133355104.1.18

1.9.2

IMPROVE ACCESS TO SPECIALTY CARE: WOUND CARE PROGRAM 133355104 Other: Decrease acute care and emergency center utilization related to wound dehiscence or infection Year 4 Year 5 (10/1/2014 9/30/2015) (10/1/2015 9/30/2016)

Year 2 Estimated Milestone Bundle Amount: (add incentive payments amounts from each milestone): $2,140,932

Year 3 Estimated Milestone Bundle Amount: 2,014,994

Year 4 Estimated Milestone Bundle Amount: $1,889,057

Year 5 Estimated Milestone Bundle Amount: $1,435,684

TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD (add milestone bundle amounts over Years 2-5): $7,480,667

Title of Outcome Measure (Improvement Target): IT- 9.4 Other outcome improvement target: Decrease acute care and emergency center utilization related to wound dehiscence or infection Unique RHP Outcome Identification Number(s): Outcome Measure Description: IT-9.4 Other outcome improvement target will measure acute care and emergency center utilization related to wound dehiscence or infection. The measure must be evidenced based, appropriate for proposed project, and meet the definition of an outcome measure

The implementation of a comprehensive wound care program is to promote access to quality specialty care that will decrease costs of acute care utilization and decrease emergency center visits. Comprehensive specialty services will be geographically convenient so as to provide patients with ready access to a wound care specialist which promotes healing, and decreases the incidence of infection 1. The Harris county population is comprised of 9% patients with diabetes and a 28% of the populous are patients who are obese and physically inactive2 which are risk factors for wound dehiscence that can result in as much as a 14-50% surgical mortality rate for wounds resulting from abdominal surgeries 3. Process Milestones: DY2: P-1; P-2 DY3: P-4 Outcome Improvement Target(s) for each year: DY4: o IT9.4 Decrease acute care and emergency center utilization related to wound dehiscence or infection among patients served by the Wound Care Program o decrease utilization by 3% of DY2 baseline DY5: o IT-9.4 Decrease acute care and emergency center utilization related to wound dehiscence or infection among patients served by the Wound Care Program o decrease utilization by 5% of DY2 baseline Rationale: Process improvement milestones of P -1 and P-2 were selected as a means to permit time for engagement of stakeholders to discuss, collaborate, and implement a comprehensive wound care program and associated services, at 4 locations convenient to the patient population. The provision of planning to secure supplies, equipment and stakeholder involvement in the types of services to be offered is essential, to promote the necessary collaboration required as part of a primary care multidisciplinary approach to wound care1 .Project planning will also include the necessary education of

Centers for Disease Control and Prevention. (2012). Diabetes public health resource 2011. Available from http://www.cdc.gov/diabetes/pubs/references11.htm 3 Sorensen, L., Hemmingsen, U., Kallehave,F., Wille-Jorgensen, P., Kjoergaard, J.,Moller, L., et al. (2005). Risk factors for tissue and wound complications in gastrointestinal surgery. Annals of Surgery,241(4), 654- 658. 1 Junkin, J.(n.d.). Failure to thrive in wounds: Prevention and early intervention. Infection Control Resource 1 (2). Available from http://www.infectioncontrolresource.org/Past_Issues/IC2.pdf

providers, existing staff, recruited staff, and also development of patient materials in the healthcare language of patient choice, and at the 5th grade literacy level, specifically for Harris Health patient population. Additionally the ability to secure key performance indicators required as part of the project and the reporting required to evaluate the outcomes delineated in DY 3, 4, 5 is paramount to tracking and monitoring quality, access, and cost of care. Improvement targets were placed in DY4-5 in order to collect data and improve upon the established baseline determined in DY3. Outcome Measure Valuation: TBD

[Unique Category 3 outcome measure identifier(s], e.g. [TPI] IT .5.3

IT-9.4

Other: Decrease acute care and emergency center utilization related to wound dehiscence or infection 133355104

Harris Health System Related Category 1 or 2 Projects:: Starting Point/Baseline: DY 2 Year 2 (10/1/2012 9/30/2013) Process Milestone 1 [P-1]: Project planning engage stakeholders, identify current capacity and needed resources, determine timelines and document implementation plans Data Source: Project planning documentation/report Year 3 (10/1/2013 9/30/2014) Process Milestone 3 [P-4] Conduct PDSA cycles to improve data collection and intervention activities To be established in DY3 Year 4 (10/1/2014 9/30/2015) Outcome Improvement Target 2 [IT 9.4]: Decrease acute care and emergency center utilization related to wound dehiscence or infection among patients served by the Wound Care Program Improvement Target: Decrease by 3% of DY2 baseline Data source: cost accounting and utilization reports

Year 5 (10/1/2015 9/30/2016) Outcome Improvement Target 3 [IT 9.4]: Decrease acute care and emergency center utilization related to wound dehiscence or infection among patients served by the Wound Care Program Improvement Target: Decrease by 5% of DY2 baseline Data source: cost accounting and utilization reports

Data source: EHR, utilization and financial reports

Process Milestone 1 Estimated Incentive Payment (maximum amount): $134,000

Process Milestone 3 Estimated Incentive Payment: $267,999

Process Milestone 2 [P-2]: Establish baseline acute care and emergency center utilization related to wound dehiscence or infection

Outcome Improvement Target 2 Estimated Incentive Payment: $401,999

Outcome Improvement Target 3 Estimated Incentive Payment: $884,397

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[Unique Category 3 outcome measure identifier(s], e.g. [TPI] IT .5.3

IT-9.4

Other: Decrease acute care and emergency center utilization related to wound dehiscence or infection 133355104

Harris Health System Related Category 1 or 2 Projects:: Starting Point/Baseline: DY 2 Year 2 (10/1/2012 9/30/2013) Data Source: EHR, utilization reports Year 3 (10/1/2013 9/30/2014) To be established in DY3 Year 4 (10/1/2014 9/30/2015)

Year 5 (10/1/2015 9/30/2016)

Process Milestone 2 Estimated Incentive Payment: $134,000

Year 2 Estimated Outcome Amount: (add incentive payments amounts from each milestone/outcome improvement target): $267,999

Year 3 Estimated Outcome Amount: $267,999

Year 4 Estimated Outcome Amount: $401,999

Year 5 Estimated Outcome Amount: $884,397

TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD (add outcome amounts over DYs 2-5): $1,822,394

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