PTN FOA-12052014.pdf

Centers for Medicare & Medicaid Services

Transforming Clinical Practice Initiative (TCPI) i

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Center for Medicare and Medicaid Innovation

Initial Announcement Cooperative Agreement

Transforming Clinical Practice Initiative (TCPI) Practice Transformation Networks (PTNs)

Funding Opportunity Number CMS-1L1-15-003

CFDA 93.638

Applicable Dates:

FOA Posting Date: October 23, 2014 Letter of Intent to Apply Due Date: November 20, 2014 Electronic Cooperative Agreement Application Due Date: February 5, 2015

(3:00 p.m. Eastern - Baltimore MD -Time.

Anticipated Issuance of Notices of Award: April 10, 2015 Anticipated Cooperative Agreement Period of Performance: May 1, 2015 – April 30, Centers for Medicare & Medicaid Services Table of Contents

Practice Transformation Networks (PTNs) ii

Table of Contents I. Executive Summary

II. Funding Opportunity Description

II.1 Purpose II.2 Authority II.3 Background II.4 Initiative Requirements

II.4.1 Model II.4.2 Clinician Practice Alignment with TCPI Aims and CMS Programs II.4.3 Key Attributes II.4.4 Evaluation and Monitoring PTN support of clinicians and practices through

TCPI Phases of Transformation and Milestones II.4.5 Learning and Diffusion II.4.6 Key Personnel

II.5 Restrictions on Awards II.6 Alignment of Awardees II.7 Technical Assistance and Information for Potential Applicants II.8 Preventing Duplication of Effort

III. Award Information

III.1 Total Funding III.2 Award Amount III.3 Anticipated Award Date III.4 Period of Performance III.5 Number of Awards III.6 Type of Award III.7 Termination of Award

IV. Eligibility Information

IV.1 Eligible Applicants IV.2 Eligible Applicants – Legal Status IV.3 System for Award Management (SAM) Requirement IV.4 Cost Sharing or Matching IV.5 Foreign and International Organizations IV.6 Faith-Based Organizations

V. APPLICATION AND SUBMISSION INFORMATION

V.1 Address to Request Application Package V.2 Application Content and Required Form Submission Deadline Dates

V.2.1 Letter of Intent to Apply V.2.2 Application Materials V.2.3 Format Requirements for Applications V.2.4 Overview of Cooperative Agreement Application Structure and Content

Centers for Medicare & Medicaid Services Table of Contents

Practice Transformation Networks (PTNs) iii

V.3 Intergovernmental Review V.4 Funding Restrictions

VI. APPLICATION REVIEW INFORMATION

VI.1 Evaluation and Selection Criteria VI.2 Review and Selection Process VI.3 Anticipated Announcement and Award Dates

VII. AWARD ADMINISTRATION INFORMATION

VII.1 Award Notices VII.2 Administrative and National Policy Requirements VII.3 Reporting (Frequency and Means of Submission)

VII.3.1 Progress Reports VII.3.2 Project Monitoring VII.3.3 Evaluation VII.3.4 Federal Financial Report VII.3.5 Transparency Act Reporting Requirements VII.3.6 Audit Requirements VII.3.7 Payment Management Requirements

VII.4 Terms and Conditions

VIII. Agency Contacts

VIII.1 Programmatic Contact Information:

VIII.2 Administrative Questions

Appendices - please note that appendices contain information that is crucial to the submission of the application. In order to ensure eligibility and correct submission please follow all directions provided in the appendices.

Appendix A. Example of measures to be considered for performance improvement and model evaluation

Appendix B. SAMPLE BUDGET AND NARRATIVE JUSTIFICATIONS

Appendix C. Application and Submission Information

Appendix D. Application Check-Off List Required Contents

Acronyms

Practice Transformation Networks (PTNs) iv

List of Figures Figure 2: Three levels of clinician support

List of Tables No table of figures entries found.

Practice Transformation Networks (PTNs) 5

I. Executive Summary

The Transforming Clinical Practice Initiative (TCPI) model will test whether a three-pronged approach to national technical assistance will enable large scale transformation of thousands of clinician practices to deliver better care and result in better health outcomes at lower costs for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) enrollees. This technical assistance design includes: (1) aligned federal and state programs and resources moving toward common transformation goals; (2) Practice Transformation Networks (PTN) formed by group practices, health care systems, and others that join together to serve as trusted partners to provide clinician practices with quality improvement expertise, best practices, coaching and assistance as they prepare and begin clinical and operational practice transformation; and, (3) Support and Alignment Networks (SANs) formed by professional associations and others that align their memberships, communication channels, continuing medical education credits and other work to support the PTNs and clinician practices.

Funding Opportunity Title Practice Transformation Network (PTN)

Announcement Type New

Funding Opportunity Number CMS-1L1-15-003

Catalog of Federal Domestic Assistance 93.638

Letter of Intent Due Date (link) November 20, 2014

Cooperative Agreement Application Due Date February 5, 2015; 3:00 p.m. Eastern (Baltimore MD) time

Anticipated Notice of Award April 10, 2015

Performance Period May 1, 2015 – April 30, 2016; May 1, 2016 – April 30, 2017; May 1, 2017 – April 30, 2018; May 1, 2018 – April 30, 2019. Maximum 4 years

Anticipated Total Available Funding Up to $670 Million, pending availability of funds

Estimated Number and Type of Awards 35 cooperative agreements

Estimated Award Amount $2 Million to $50 Million

Estimated Award Date May 1, 2015

Eligible Applicants

Organizations that have pre-existing relationships with multiple clinician practices (primary care and/or specialists) that include data sharing capabilities. See section IV.

Practice Transformation Networks (PTNs) 6

II. Funding Opportunity Description

II.1 Purpose

This Funding Opportunity Announcement (FOA) is intended for the PTNs. Applicants that are selected as PTN cooperative agreement awardees will collaboratively lead clinicians and their practices through the TCPI phases of transformation, achieve the TCPI goals, and through adaptive redesign, position these clinicians and their practices to be sustainable components within the changing care delivery system.

II.2 Authority

Section 1115A of the Social Security Act (the Act), as added by § 3021 of the Affordable Care Act, authorizes the Center for Medicare & Medicaid Innovation (CMMI or the Innovation Center) to test innovative payment and service delivery models to reduce spending under Medicare, Medicaid, or CHIP, while preserving or enhancing the quality of care furnished to beneficiaries under those programs. The TCPI model is a service delivery model under section 1115A that tests whether providing technical assistance in a specific complex adaptive manner will enable clinicians and their practices to rapidly transform the way they deliver care to patients, resulting in improved health outcomes and reduced costs.

Under section 1115A(d)(1) of the Act, the Secretary of Health and Human Services may waive such requirements of Titles XI and XVIII and of sections 1902(a)(1), 1902(a)(13), and 1903(m)(2)(A)(iii) as may be necessary solely for purposes of carrying out section 1115A with respect to testing models described in section 1115A(b). For this model and consistent with this standard, the Secretary may consider issuing waivers of certain fraud and abuse provisions in sections 1128A, 1128B, and 1877 of the Act. Waivers are not being issued in this document; waivers, if any, would be set forth in separately issued documentation. Thus, notwithstanding any other provision of this Funding Opportunity Announcement, awardees and subawardees must comply with all applicable laws and regulations, except as explicitly provided in any such separately documented waiver issued pursuant to section 1115A(d)(1) specifically for the TCPI model. Any such waiver would apply solely to the TCPI model and could differ in scope or design from waivers granted for other programs or models.

II.3 Background

The Innovation Center is charged with testing and evaluating innovative payment and service delivery models to reduce program expenditures under Medicare, Medicaid and CHIP while preserving or enhancing the quality of care furnished to program beneficiaries. Models that support providers in transforming care are consistent with this charge. To date, the Innovation Center has supported this care transformation effort through an array of initiatives that are listed on the Innovation Center’s website. The initiatives cover a broad range of payment and service delivery models, including accountable care organizations; bundled payment; primary care transformation;

initiatives to accelerate the development of new payment and service delivery methods; and initiatives to speed the adoption of best practices.

http://innovation.cms.gov/initiatives/index.html#views=models

Practice Transformation Networks (PTNs) 7

Information available from these models, coupled with the growing evidence gathered from a body of published literature including the Commonwealth Fund ‘s 2008 ‘Organizing the US Health Care Delivery System for High Performance’ , indicates that a focused effort on health delivery redesign through clinician practice transformation can improve the quality of care for patients and prepare clinicians to participate in new payment models. This redesign requires a simultaneous change in many independent processes to create a more efficient and effective care delivery system.

Depending on the nature and circumstances of each clinician, there are many possible paths to transformation. Successful clinician practices possess a number of similar traits that include the following variables: committed leadership; an operational culture that emphasizes the use of data to drive decision making; practice redesign, and a focus on integrating clinical, administrative, and financial systems as central aspects of implementing quality and process integration as a business strategy.

II.4 Initiative Goals

The Transforming Clinical Practice Initiative model will fund successful applicants as Practice Transformation Networks (PTNs) that propose the most compelling approaches for assisting clinicians in transforming their practices, and commit to meeting quantifiable outcomes. These outcomes must be aligned with the overall aims of the TCPI model, including:

1. Support more than 150,000 clinicians in work to achieve practice transformation;

2. Build the evidence base on practice transformation so that effective solutions can be scaled, if successful.

3. Improve health outcomes for 5 million Medicare, Medicaid and CHIP beneficiaries.

4. Reduce unnecessary hospitalizations and overutilization of other services for 5 million

Medicare, Medicaid and CHIP beneficiaries.

5. Sustain efficient care delivery for Medicare, Medicaid and CHIP beneficiaries by moving at least 75% of clinicians that complete the TCPI phases of transformation to participate in incentive programs and practice models that reward value upon completion of TCPI; and

6. Generate savings to the federal government over a period of 4 years through reduced Medicare, Medicaid and CHIP expenditures. In addition, we believe commercial payers may experience savings as a result of this model.

II.4.1 Model

The Transforming Clinical Practice Initiative model will assist clinicians in changing the way they deliver care by integrating quality and process improvement to build on and spread existing change methodologies, practice transformation tools, published literature, key learnings, and technical assistance programs. For the TCPI model, clinicians include primary care and specialty physicians, nurse practitioners, physician assistants, clinical pharmacists, and their respective practices.

Through a combination of service delivery refinements and innovative technical assistance, the Partnership for Patients (PfP) initiative and the Quality Improvement Organization (QIO) program have together shown promise in making dramatic improvements in quality, outcomes and cost efficiency in the hospital setting using an adaptive quality improvement approach to program design.

Their aligned efforts toward assisting providers with quality improvement activities resulted in decreases in hospital-acquired infections (HAI), hospital-acquired conditions (HAC), and

Practice Transformation Networks (PTNs) 8 readmission rates. TCPI will use a similar approach to providing technical assistance to transform clinician practices to deliver high-quality care that is evidence based, efficient, coordinated and patient-centered. We expect that practice transformation will result in improvements in patient health outcomes and reduced health care costs.

As TCPI wishes to structure participation in the model so as to avoid confounding effects of possible overlap, it will be necessary to track clinician participation in such other models and programs that involve comprehensive practice transformation, cease technical assistance in these circumstances, and to account for this in the evaluation of savings and other program impacts. We believe that significant overlap between TCPI and the other model/program would exist with the following: the Medicare Shared Savings Program, the Pioneer ACO program, the Multi-payer advanced primary care program, and the Comprehensive primary care initiative. Potential participation in other payment models that have a specific scope/topic (e.g. bundled payment models, and models that cover specific chronic diseases or settings) will need to be evaluated on a clinician-by-clinician basis to see if a substantial proportion (i.e.: 20% or more) of their total estimated payments for clinical services provided to Medicare, Medicaid and CHIP beneficiaries are covered by the model. In order to facilitate the tracking of clinician participation in such other models or programs, PTNs will be required to perform an initial and periodic ongoing environmental scans of such initiatives that TCPI participating clinicians in their networks may have joined, and to report the results to CMS.

The TCPI implementation design is centered on a multifactorial approach that will encompass the following:

1) Identify, engage, and deploy expert faculty;

2) Develop and continuously refine improvement guides and TCPI Change Package for implementation in practices;

3) Establish relationships with other public and private entities;

4) Establish and support a national infrastructure that is funded through cooperative agreements and contracts; and

5) Assist participating primary care and specialists clinicians and their practices (including clinicians in rural health clinics, rural community health centers, and health professional shortage areas (HPSAs), and those clinicians supporting medically underserved populations such as community and migrant health centers), in progressing through various phases of transformation.

By participating in TCPI, practices will be able to receive the technical assistance and peer-level support they need to deliver care in a patient-centric and efficient manner, which is increasingly being demanded by health care payers and purchasers as part of a transformed care delivery system.

Participating clinicians will thus be better positioned for success in the health care market of the future - one that rewards value and outcomes rather than volume. The following two figures provide additional perspective and context on the overall design of the TCPI model.

Figure 1. Pathway to a Transformed Healthcare System

Practice Transformation Networks (PTNs) 9

Figure 2: Three levels of clinician support

Practice Transformation Networks (PTNs) 10

II.4.2 Clinician Practice Alignment with TCPI Aims and CMS Programs The TCPI model seeks to have PTN applicants to focus their work on the stated TCPI aims and related milestones. Practice Transformation Networks will commit to generating results based on the aims of TCPI. Continuation of PTN funding in future years of the model will be contingent upon producing tangible results that flow from these aims. Clinicians participating in the TCPI model will commit to participate in the Physician Quality Reporting System and Value-Based Payment Modifier Programs. Additional detail about these programs can be found at www.cms.gov or by clicking on the names of each program.

Figure 3 below begins to illustrate the manner in which the TCPI model will hold awardees to the bold aims that they submit as a part of this FOA application in Section VI.1.

Figure 3

Improvement Area Within first 12 months of award

By the end of the 4 year period of performance

Enter percentage improvement on quality measures:

Clinical Outcomes (Note: applicants can Diabetes Enter % Enter % http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS/ http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html http://www.cms.gov/

Practice Transformation Networks (PTNs) 11 add rows to more fully describe and delineate project results in this area)

Asthma Enter % Enter %

Heart Failure Enter % Enter %

Reduction of unnecessary testing Enter number Enter number

Cost savings

Sample formula: Cost savings = Total dollars saved divided by total number of patients

Provide $ value or $ value per patient

Provide $ value or $ value per patient

Unnecessary hospitalizations avoided Enter number Enter number

II.4.3 Key Attributes

The TCPI infrastructure will include a group of national faculty experts that will support TCPI improvement activities. The national faculty will be supported through a TCPI contract. The national faculty in collaboration with the PTNs will coach and mentor clinicians in developing core competencies to assist them in moving through the TCPI Phases of Transformation and TCPI Change Package. Coaching allows for the clinical practices to become actively engaged in the transformation rather than as the recipient of the transformation. Coaching builds the skills of the clinicians and practices that are more likely to lead to sustained efforts after the TCPI technical assistance (service delivery) model tests are complete. The PTNs will be responsible for the following activities:

• Recruiting clinician practices and building strategic partnerships o Perform environmental scans to identify and collaborate with community partners that can help to achieve common goals;

o Collaborate with partners, such as QIOs, to assess and ensure clinician/practice readiness;

o Recruit clinicians/practices to participate in the Practice Transformation Networks;

Emphasize the recruitment of clinicians/practices with the greatest need for technical assistance

Emphasize the recruitment of clinicians whose patients include Medicare, Medicaid or CHIP beneficiaries

Emphasize the recruitment of clinicians serving in:

• medically underserved areas (including those practicing in community, migrant, and Indian health centers),

• health professional shortage areas,

• rural areas (including rural health clinics, rural community health centers and

Indian Health Centers), and

• Small, rural practices of 9 or fewer clinicians.

Practice Transformation Networks (PTNs) 12 o Develop collaborative relationships with purchasers and payers to facilitate multi-payer alignment of financial incentives, quality measures, and methods;

o Collaborate with states (including public health and mental health agencies), regional and community based organizations, and private entities that are participating in transformation activities to ensure synergy and prevent duplication; and o Develop effective partnerships among clinicians and their respective patients/families.

• Serving as champions for continuous improvement, culture change, and patient and family engagement o Support culture change in clinician practices through engaged leadership, team building, and patient engagement;

o Identify top-performing practices in the network and showcase their work to network members;

o Provide ongoing coaching, facilitation and technical assistance to practices including support in the systematic inclusion of patient and family engagement;

o Disseminate and spread quality improvement (QI) and change methodologies, tools, published literature, best practices, and lessons learned on practice transformation through TCPI learning sessions; and o Create community based peer groups that can share QI resources and expertise to improve specific aspects of their practices and coordinate care in a common medical neighborhood, achieving measurable improvements in care and efficiency through rapid cycle evaluation:

Improve partnerships among primary and specialty care clinicians that support their medical neighborhood.

Integrate local and community resources with team-based care that supports access to care and patient self-management support.

• Facilitating improved clinical practice management o Identify ways clinician practices can improve quality and access to care.

Provide training to clinician practices on how to establish care plans that are sensitive to the language, values, and culture of their patients with complex care needs, while promoting self-management and shared decision making with patients and their family members;

Provide exposure to new systems of care and alternative payment models;

Coach practices to optimize scheduling so that same day appointments can be offered, and after-hours access to clinician advice is available; and Offer information regarding certification and training requirements as well as CMS program requirements, and ways in which clinicians may effectively meet them.

o Connect primary care practitioners (PCP) with specialty and ancillary providers in their medical neighborhood that can serve their patient panel;

Expand the capacity for team-based practice and optimal integration of non-physician practitioners (including nurse practitioners, physician assistants, clinical pharmacists) into care teams;

Promote the use of tools specific to primary and specialty care coordination (such as formalized agreements for care coordination, referrals and co-management plans) that clearly specify roles, responsibilities and expectations in care planning and

Practice Transformation Networks (PTNs) 13 management across practices (e.g. timely communication of test results and exchange of clinical information with patients and other providers);

Provide information to clinician practices on planning for and facilitating transitions of their patients across care settings and time, including the transfer from pediatric to adult practices; and

Explore the use of patient navigators, parent partners, and peer support services in effecting patient engagement and care coordination.

o Use technology to enhance the effective use of administrative, financial and clinical systems Participate in national TCPI webinars and other offerings specific to practice transformation and the use of administrative, financial, and clinical systems Offer frequent webinars on a variety of quality improvement topics and practices; for example, webinars showing providers how to use clinical and other data to risk stratify their population and identify patients at high-risk for hospitalization or complications from chronic conditions, as well as instruction on how to perform timely interventions and monitoring.

Offer information regarding certification and training requirements as well as CMS program requirements, and ways they may effectively meet them.

• Using quality measures and data for improvement o Support improvement on a core set of clinical, operational, quality, and care experience measures;

o Facilitate practice data reporting as needed, especially for clinicians in small practices or rural settings who may require additional assistance from their PTN;

o Use practice data for clinical and operational quality improvement, improve practice flow and care management and identify methods to reduce health care disparities;

o Provide ongoing monitoring and feedback regarding participating practice performance based on the data;

o Promote the interoperability and effective use of registries, Electronic Health Records, and other practice management systems, while maintaining privacy and security of patient health information, to improve coordination of care delivery between primary and specialty practices, facilitating improved patient outcomes; and o Assess the practices’ progress in addressing Meaningful Use (MU). More information on meaningful use can be found via the following hyperlink - What is Meaningful Use?

Collaborating with CMS on transformation activities and provide ongoing feedback on the progress toward goals.

o Work with practices to collect data on progress toward goals and facilitating improvement activities when the need for assistance is detected.

o Work with practices to display and communicate progress with their peers across the TCPI community of practice at learning sessions events at least twice each performance period.

o Provide aggregate data to CMS through the specified data collection tools on at least a quarterly basis that shows results by month.

o Provide feedback for improvement on the specified data collection processes to ensure the collection of accurate information without undue burden.

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html

Practice Transformation Networks (PTNs) 14

Funding Targeted to Applicants that Commit to Specific Results

Although the awards under this FOA are for a four-year period of performance, CMS is interested in sustainability beyond the initial period of federal investment. CMS is interested in information from applicants regarding sustainability, such as evidence of public-private partnerships or shared savings agreements directly with other payers.

CMS is interested in funding Practice Transformation Networks who will commit to:

• PTNs that support specialty care practices must explain in their applications their plans, milestones and aims for how the specialists would reduce unnecessary testing and procedures.

• Pursue and achieve the aims of the TCPI model;

Ensure support from a robust number of practices willing to participate with the network, including a minimum of 20% of clinicians from practices that are small in size, located in rural areas, and/or that serve medically underserved populations;

• Conduct pre-assessment and on-going assessment of practices’ clinical and operational health;

• Engage practice leadership to commit to the goals of TCPI and to dedicate a specific improvement team of individuals;

• Participate and support clinicians participation in PTN-based and national TCPI training events;

• Project clinician enrollment and achievement targets aligned with the TCPI model aims;

• Develop collaborative relationships with purchasers and payers to facilitate multi-payer alignment of financial incentives, quality measures, and program methods;

• Serve as champions for continuous improvement and culture change through engaged leadership, team building, and patient engagement;

• Receive and utilize monthly reporting of results/outcomes from clinicians/ practices for quality improvement, with an intent to converge on core clinical, operational process, outcome, and financial measures over time;

• Collaborate with partners such as other PTNs, QIOs, states (e.g. public health and mental health agencies), rural communities and private entities that are participating in transformation activities to ensure synergy and prevent duplication;

• Provide data to CMS about the clinicians and their practices’ performance;

• Work with the clinician practices they serve to ensure compliance with HIPAA;

• Continuously assess patients/families’ care experiences;

• Leverage telehealth and other technology to enhance care coordination and link rural participants with more distant urban specialists;

• Provide ongoing coaching, facilitation and technical assistance to practices;

• Disseminate and spread quality improvement and change methodologies, tools, published literature, best practices, and lessons learned on team-based care delivery and other aspects of practice transformation;

• Conduct and ensure clinicians report regular, rapid small tests of change as part of Quality Improvement work;

Practice Transformation Networks (PTNs) 15

• Create community-based peer groups that can share quality improvement resources and expertise to improve specific aspects of their practices and coordinate care in a common medical neighborhood, achieving measurable improvements in care and efficiency through rapid cycle evaluation;

• Facilitate improved clinical practice management by connecting primary care practitioners (PCP) with specialty and ancillary providers in their medical neighborhood that can serve their patient panel, and encouraging the use of tools specific to primary and specialty care coordination, such as formalized agreements for care coordination, referrals and co-management plans that clearly specify roles, responsibilities and expectations in care planning and management across practices;

• Use data and results for improvement on a core set of clinical and operational quality measures (improve practice flow and care management, quality and care experience);

• Provide ongoing monitoring and feedback regarding participating practice performance to improve coordination of care delivery between primary care and specialty practices, facilitating improved patient outcomes; and

• Sustain practice changes and improvements beyond the formal clinician engagement.

Responsive proposals will include specific discussion and explanation of how applicants will address these points.

Applicants must demonstrate established data sharing capabilities with clinical providers that include the ability to collect, hold, and evaluate personally identifiable information (PII). PII in the TCPI model is defined as “…information which can be used to distinguish or trace an individual's identity, such as their name, Social Security number (SSN), biometric records, etc. alone or when combined with other personal or identifying information which is linked or linkable to a specific individual, such as date and place of birth, mother’s maiden name, etc...” 1 PTNs,at a minimum, will provide CMS and its support contractors with aggregate data on clinician/practice clinical, operational and financial improvement results/outcomes at least quarterly. The CMS support contractor will conduct further analysis of TCPI improvements across the cohort of PTNs. This will allow CMMI to compare results across the model with minimal delay. Additionally CMS will use data already being reported by participating clinicians/practices that are captured from other CMS and HHS reporting systems.

The PTNs and the clinician practices that they assist under TCPI are responsible for ensuring compliance with all applicable laws, including HIPAA, with regard to data used or disclosed in connection with the TCPI model.

II.4.4 Evaluation and Monitoring PTN support of clinicians and practices through TCPI Phases of Transformation and Milestones

How will the TCPI model utilize measurement for results through quality improvement?

1 From: OMB Memorandum M-07-16, Safeguarding Against and Responding to the Breach of Personally Identifiable

Information.

Practice Transformation Networks (PTNs) 16

CMS expects PTN applicants to have established systems and measures in place for collecting, assessing, and sharing monthly quality improvement data and results from participating practices.

CMS understands PTNs will in many cases be recruiting new clinician practices that may be using the PTN measurement systems for the first time. The TCPI will require ongoing reporting of key metrics, such as population based health improvement measures, quality indicators, cost, and utilization metrics, patient-centered outcomes, and patient satisfaction. Each PTN must have a measurement strategy in place that is designed with consideration of the diverse set of measures and collection methodologies that clinician practices currently may be using. Applicants must propose their initial core set of measures as part of their application. There are a number of national efforts to align measures across programs in both the public and private sector so that practices can report once and satisfy some of the various requirements of multiple programs. PTNs and their participating clinicians/practices should align their measurement strategies with these existing measures and programs. Over time, PTNs and their participating practices will be expected to increasingly converge on the use of a common set of core measures and have an adaptable reporting system that can capture these measures. In addition, a central set of measures will be used by the CMS support contractor to evaluate the TCPI model.

CMS will continuously review PTN progress in achieving outcomes aligned with the model aims and objectives using both qualitative and quantitative metrics. TCPI methodology will include readiness assessments to be completed by all clinician practices that apply to join a PTN, continuous measurement and assessment of “advancing” through the various phases (employing a flexible design that allows for measurement across phases), and measurement of the clinician practices’ performance on quality of care and cost metrics as they progress through the phases. Quality Improvement Organizations (QIOs) are anticipated to play a key role in assisting PTNs and their practices with the administration of clinical practice readiness assessment and on-going periodic assessments to determine progress through the 5 transformational phases (see Figure 4 on following page).

The CMS TCPI model implementation team will lead the real-time improvement assessment function. PTNs will provide CMS and its support contractors with aggregate data on clinician/practice clinical, operational and financial improvement results/outcomes at least quarterly The CMS support contractors will include an evaluation and a data, feedback and monitoring contractor that will track implementation for the TCPI model and will provide CMS continuous feedback and timely findings of model results achieved.

A core set of measures will be used to inform monitoring, evaluation, and performance improvement across all clinician practices participating in TCPI. The initial set of core measures will be proposed by the PTNs and may be the same measures that PTNs are currently collecting from clinicians. In addition, a menu set of measures established by CMS will be used that can allow for practice and/or region specific measures to drive improvement on a local level. These will likely include measures consistent with the Million Hearts™ initiative and American Board of Internal Medicine’s (ABIM) Choosing Wisely® Initiative. The total cost of care will be derived using methods similar to those utilized for the physician value-based payment modifier under the Medicare Physician Fee Schedule.

Patient satisfaction will be measured through the survey and methods from the Consumer Assessment of Healthcare Providers and Systems (CAHPS).

Practice Transformation Networks (PTNs) 17

How will PTNs support practices and their clinicians through TCPI Phases of Transformation and related milestones?

PTNs will coach and mentor clinicians in developing core competencies to assist them in moving through the TCPI Phases of Transformation. Clinicians and their practices will complete an assessment tool facilitated by the QIOs to determine their current practice state, as defined by the phases described below. PTNs will be accountable to provide the appropriate technical assistance to assist clinicians and their practices with progress through the phases. Periodic assessments will also occur to gauge the progress of practices as the TCPI model matures.

Assessment: Practice transformation is a set of discrete changes in the way a practice operates. The degree to which a practice is transformed is dependent on the practice’s capacity to provide high quality health care at lower cost in a coordinated manner. Clinicians and their practices will be assessed by CMS through QIOs in partnership with PTNs to determine their current practice state.

A baseline assessment will be conducted for clinicians recruited to participate in practice transformation and will be followed by reassessments throughout the period of performance by the Practice Transformation Networks in partnership with the QIOs. The initial assessment tool completed by practices and reviewed by QIOs and PTNs will include assessments of quality improvement methodologies currently employed by the practice, as well as assessments of patient population, clinical results, effective use of health information and related technology for clinical and operational improvement, team-based care delivery models (including roles and services provided by all team members), current business models, and related financial and administrative practices and community resources. The initial assessment results will be used to determine readiness for transformation, and position of the clinician/practice on a continuum of transformation defined by distinct phases that directly map to achievement of the larger goals for the TCPI.

The periodic reassessments will be managed by the QIOs and PTNs and used to determine the clinician/practice’s progress in moving upward through the phases, and will be based upon achievement of both quantitative and qualitative milestones. The tables below for primary care and specialists contain a description of the phases of transformation, the activities and characteristics associated with each phase and the performance milestones that clinician practices must meet in order to advance to the next phase. As indicated in the tables, many of the phase descriptions and milestones are the same for primary care and specialists, although there is some variation.

Figure 4A: TCPI Phases of Practice Transformation:

Primary Care descriptive characteristics and associated milestones.

Phase Description Phase Milestones Phase 1:

Setting aims and developing basic capabilities

The practice has the full support of leadership for transformation and develops and commits to a clear statement that outlines the specific goals of transformation, why they are important to the practice and the community they serve, what

Practice will submit a detailed plan that addresses the specific goals of transformation—what is important to the practice and the aims. This will be submitted within one month of practice joining PTN.

Practice starts to perform a self-

Practice Transformation Networks (PTNs) 18 changes will be made, and how progress will be measured.

Learns and integrates a planned care model which includes understanding the intersection of administrative, financial, and clinical systems and uses this knowledge to redesign all of these processes toward a leaner and higher performing organization that produces better outcomes.

Uses data to better understand practice flow. Implements improvement strategy that relies on routine performance measurement to identify opportunities for improvement and uses rapid cycle change methods to test ideas for change. Intentionally minimizes unnecessary testing and procedures, and measures, and reports impact of these changes.

Participates in learning collaborative to share its best practices and lessons learned and to benefit from the learning of others.

Practice recognizes importance of patient and family engagement in care.

assessment and starts to collect baseline data on utilization and other quality and outcome measures and identifies problem areas for improvement.

Practice starts to train at least 50% of staff in improvement methods and tools.

Staff starts to understand the process of improvement and how to test changes in daily workflows. Staff is trained on optimal team-based practice.

Practice has a process in place for training staff on data quality problems when they are detected.

Practice establishes measures, plans and a baseline for intentionally minimizing unnecessary testing and procedures.

Practice has in place mechanisms for addressing the needs of their patients/families to be active partners in care.

Phase 2:

Reporting and using data to generate improvements

Acquires core capabilities in improving the health of populations through more cost-effective systems of care. Establishes new relationships within the community and expands the care team.

Produces real time reports on how practices, providers and care teams are meeting quality, financial and utilization goals to enhance patient experience of care, eliminate waste and decrease costs.

Shares outcomes of quality and clinical measures for the patient population with the PTN. Uses data to analyze potential disparities in care and develops action plans—this

Practice starts to capture and analyze population, disease specific, and relevant quality measures for utilization, billing data and tests ordered from their registry, practice management or EHR system to drive clinical practice improvement and resulting in reduced unnecessary tests and hospitalizations.

Practice has identified community partners and other points of care that their patients are using and has a formal agreement in place with these partners.

Practice has defined improvements in care transition and processes enabled through exchange of essential health information to eliminate waste and decrease costs.

Practice Transformation Networks (PTNs) 19 allows practices to identify individual patients needing intervention to improve overall practice performance.

Practice has integrated specialty care through agreements.

The practice identifies ways to increase patient and family engagement in care and identifies barriers to patient and family engagement in care.

The practice tracks patients obtaining outside services.

Eligible clinicians assess their ability to meet Meaningful Use objectives and develop an EHR integration plan to meet Meaningful Use objectives in Phase 5.

At least 50% of the practice’s patients have a main clinical point of contact at the practice for their health care needs (i.e. empanelment to provider and care teams).

The practice provides care management to at least 50% of highest risk patients (those that are clinically unstable).

The practice implements at least three specific care management strategies for patients in higher risk cohorts, samples may include, but are not limited to:

o Integration of behavioral health, o Self-management support for at least three high risk conditions o Medication management and review.

Monthly reporting includes updating information about the practice’s risk stratification methodology, empanelment status, risk stratification data, and other activities.

Practice incorporates regular improvement methodology to execute change ideas in a rapid cycle. Use a plan-do-study-act (PDSA) quality improvement cycle of small scale tests of change in the practice setting.

Phase 3:

Achieving aims of lower costs, better care, and better health

Optimizes care team and utilizes technology to track patient improvements via population based management (use of information on clinical grouping of patients to improve their care and clinical outcomes). Matches and allocates care team functions based on skill, abilities, and credentials to support efficient care delivery.

Obtains feedback from patients and family members about their health care experience and uses this information for quality improvement. Provides incentives to care team based on performance.

Proactively engages patients and families to expand their role in decision making, health-related

Practice is optimizing reports in registry, practice management, or EHR system to drive clinical practice improvement on a monthly basis.

Practice has reduced unnecessary tests and hospitalizations by at least 25% from baseline.

Practice has involved patients, families and staff in quality improvement initiatives.

Practice sets clear expectations for each team member’s functions and responsibilities to optimize efficiency, outcomes, and accountability.

Practice routinely creates and/or maintains shared care plans and utilizes shared decision making tools to incorporate patient preferences and goals in care management processes.

Practice Transformation Networks (PTNs) 20 behaviors and self-management.

Demonstrates improvement on select quality measures.

Practice identifies patient risk stratification by disease, health risk and other conditions.

Practice routinely exchanges essential health information with other members of care team outside of the practice.

Practice has increased the number of patients who have received the appropriate health screenings and completion of referrals.

Practice has identified high risk patients and has ensured they are receiving appropriate care and case management services.

Practice has a formal written vision related to care coordination.

Practice links a patient to a provider and care team so both the patients and team recognize each other as partners in care.

Practice ensures that patients are able to see their provider or care team whenever possible.

Practice links patients with community resources to facilitate referrals.

Practice tracks and supports patients when they obtain services outside the practice.

Practice follows up with patients within 24 hours after an emergency room visit or hospital discharge.

Phase 4:

Getting to benchmark status

Manages populations of patients through a panel with significant demonstration of care coordination, including coordinating follow up appointments with patient after emergency room visits or hospitalizations.

Provides patients with community resources, tracks and supports patients obtaining outside services.

Integrates advanced access to eliminate waits, minimize “no show” rates and streamline workflow, such as 24/7 access to the care team, and scheduling options.

Continues to demonstrate improved performance on quality measures

Practice uses utilization reports on a monthly basis and continuously makes clinical improvement changes such as 24/7 access to care, ‘same as’ tracking number of patient triaged after hours, number of same day appointments for emergent problems, number of patients being discharged from the hospital and needing an appointment with 24 hours after discharge, and the practice continues to decrease the “no show” rate over time.

Practices submit utilization reports to PTN on a monthly basis. Feedback is submitted back to the practice.

Practice has reduced unnecessary tests and hospitalizations by at least 20% from baseline.

Practice Transformation Networks (PTNs) 21 and seeks to improve performance relative to local and national benchmarks.

Has knowledge of the health status of other populations in the medical neighborhood and contributes to the success of the over health of the community served.

Practice has a process in place for identifying 90% of high risk patients on a monthly basis and has ensured that 75% are receiving appropriate care and case management services as part of their continuous practice improvement plan.

Practice tracks patients, on a monthly basis, when they obtain services outside of the practice.

Practice has a process in place to link the patient to a care provider and care team so both the patients and team recognize each other as partners in care.

Phase 5:

Practice has demonstrated capability to generate better care, better health at lower cost.

Practice has documented substantial performance improvements. Practice generates significant quality improvements in patient health outcomes and experience of care.

Eligible clinicians have completed implementing their integration plans for meeting meaningful use objectives.

Practice sustains prior improvements in key metrics for at least one year.

Practice has developed business acumen in the various types of alternative payment models including understanding of shared savings models with and without risk, various contracting arrangements that a practice might consider, and how to evaluate the pros and cons for the population they serve.

Figure 4B: TCPI Phases of Practice Transformation:

Specialists’ descriptive characteristics and associated milestones.

Phases of Practice

Transformation Description Milestones

Phase 1:

Setting aims and developing basic capabilities

The specialty clinician/practice has the full support of leadership for transformation and develops and commits to a clear statement of action with specific goals and metrics for delivering well-coordinated, timely, efficient care as part of a patient’s care team, that defines their role and responsibilities with respect to the larger medical neighborhood in

Specialty clinician/practice will submit a detailed plan that addresses how they will increase access to care, negotiate co-management of patients with other providers, coordinate care with other providers, reduce unnecessary hospitalizations, testing and procedures, and deliver patient-centered care.

Participates in multidisciplinary learning collaborative to benefit from the learning of others, share best practices

Practice Transformation Networks (PTNs) 22 which they operate.

Learns and integrates best practices for care coordination and patient co-management with multidisciplinary and interprofessional patient care teams.

This includes understanding the intersection of primary care, specialty care, behavioral health, and patient self-management, in providing patient-centered care, and producing optimal patient outcomes.

Engages in effective electronic, standards-based, bi-directional communication with other providers caring for the same patient. Administrative, financial and clinical systems are optimized using this knowledge by redesigning all of these processes toward developing a…