SAN FOA-12052014.pdf

Transforming Clinical Practice Initiative (TCPI) i

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

Center for Medicare and Medicaid Innovation

Initial Announcement Cooperative Agreement

Transforming Clinical Practice Initiative (TCPI) Support and Alignment Network (SAN)

Funding Opportunity Number CMS-1L1-15-002

CFDA 93.639

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

Support and Alignment Network (SAN) 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 SAN 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 Award 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 III.8 Anticipated Substantial Involvement by Awarding Office

IV. Eligibility Information

IV.1 Eligible Applicants IV.2 Eligible Applicants – Legal Status IV.3 System for Award Management Registration (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

V.2.1 Letter of Intent to Apply V.2.3 Format Requirements of Application Submission V.2.4 Overview of Cooperative Agreement Application Structure and Content

Centers for Medicare & Medicaid Services Table of Contents

Support and Alignment Network (SAN) 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

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

Appendix B. Practice Transformation Networks (PTNs) will be responsible for the following activities:

Appendix C. Sample Budget and Narrative Justifications

Appendix D. Application and Submission Information

Appendix E. Application Check-Off List Required Contents

Centers for Medicare & Medicaid Services

Support and Alignment Network (SAN) iv

List of Figures

Figure 1: Pathway to a Transformed Healthcare System

Figure 2: Illustration of Model Framework

List of Tables

No table of figures entries found.

Centers for Medicare & Medicaid Services Eligibility Information

Support and Alignment Network (SAN) 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 help as they prepare and conduct 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 Support and Alignment Network (SAN)

Announcement Type New

Funding Opportunity Number CMS-1L1-15-002

Catalog of Federal Domestic Assistance 93.639

Letter of Intent (highly encouraged) Due Date 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

Period of Performance

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 $30 Million, pending availability of funds

Estimated Number and Type of Awards 30 Cooperative Agreements

Estimated Award Amount $1 Million up to $3 Million

Estimated Award Date May 1, 2015

Eligible Applicants Organizations that serve as medical professional associations, specialty societies, and

Support and Alignment Network (SAN) 6 organizations that are: 1) involved in generating evidence-based guidelines for clinical practice;

2) promoting measurement through clinical registries and electronic health records; and 3) effectively incorporating safety and patient and family engagement.

II. Funding Opportunity Description

II.1 Purpose

This Funding Opportunity Announcement (FOA) is intended for the SANs. Applicants that are selected as SAN cooperative agreement awardees will work to leverage primary and specialist care transformation work and learning in the field. The action by PTNs and SANs is planned to contribute to the overall operational efficiency and movement of the clinician practices through the 5 Phases of Transformation and their achievement of the TCPI goals. They will utilize their unique and established channels (peer reviewed journals, registries, accreditation and licensure refinement, continuing medical education, maintenance of certification, annual conferences, task forces, newsletters, etc.) with their members, consumers and others to support TCPI action and related results from clinicians and their practices.

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 with the goal of reducing spending under Medicare, Medicaid, or CHIP while also preserving or enhancing the quality of care furnished to beneficiaries under those programs. The TCPI is a service delivery model that tests whether providing technical assistance in a specific, complex, and adaptive manner will enable clinicians and their practices to rapidly transform the way they deliver care to patients, thereby resulting in improved health outcomes and reduced costs.

The authority for the TCPI model is section 1115A of the Social Security Act (the Act). Under §1115A(d)(1) of the Act, the Secretary of Health and Human Services may waive such requirements of Titles XI and XVIII and of §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 §1115A(b). For this model and consistent with this standard, the Secretary may consider issuing waivers of certain fraud and abuse provisions in §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 sub awardees must comply with all applicable laws and regulations, except as explicitly provided in any such separately documented waiver issued pursuant to §1115A(d)(1) specifically for the TCPI model. Any such waiver would apply solely

Support and Alignment Network (SAN) 7 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 change. To date, the Innovation Center has supported model tests 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.

Information available from these models, coupled with the growing evidence gathered from a body of published literature, 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.

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

Support and Alignment Network (SAN) 8

II.4 Initiative Goals The Transforming Clinical Practice Initiative Model will fund successful applicants as Support and Alignment networks (SANs) that propose the most compelling approaches to assisting clinicians in transforming their practices and that commit themselves and their communities of practice to 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 other 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 model design. Their aligned efforts toward assisting providers with quality improvement activities resulted in decreases in hospital-acquired infections (HAI), hospital-acquired conditions (HAC), and 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

Support and Alignment Network (SAN) 9 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. PTNs will be required to perform an initial and periodic ongoing environmental scans of such APM initiatives that TCPI participating clinicians in their networks may have joined.

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 clinicians and their practices (including but not limited to clinicians in rural health clinics, rural community health centers, and health professional shortage areas (HPSA) 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 demanded from 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.

Support and Alignment Network (SAN) 10

Figure 1: Pathway to a Transformed Healthcare System

Figure 2: Illustration of Model Framework

Support and Alignment Network (SAN) 11

II.4.2 Clinician Practice Alignment with TCPI Aims and CMS Programs The TCPI model will hold awardees to the bold aims that they submit as a part of their application. It is important that the SAN awardees work effectively with the National Support Contractors and Practice Transformation Networks. The TCPI model seeks to have SAN awardees focus their work on the stated TCPI aims and related milestones. Practice Transformation Networks will commit to generating results through their supported clinicians/practices based on these aims. SANs will support clinician members and play an active role in the alignment of new learning into continuing medical education, certifications, and other quality improvement opportunities. Clinicians participating in the TCPI model will commit to participate in the Physician Quality Reporting Program 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.

II.4.3 Key Attributes

The TCPI SANs will be an invaluable asset in attaining the TCPI goals. Examples of the types of organizations that could serve as Support and Alignment Networks include, but are not limited to, medical professional associations and specialty societies, organizations involved in generating evidence-based guidelines for clinical practice, and organizations promoting measurement and improvement through clinical registries and electronic health records. As part of the TCPI technical assistance infrastructure, SANs will work in tandem with the Practice Transformation Networks (PTNs) and facilitate achievement of the following TCPI national milestones:

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/

Support and Alignment Network (SAN) 12

• Ensure alignment of TCPI National Support Contractor (NSC) content with national evidence-based guidelines of care and best practices;

• Promote evidence-based quality measures that can be collected via registries and Electronic Health Records and Systems;

• Ensure alignment with other public and private entities working in the area of quality improvement and transformation;

• Ensure their support is in alignment with PTNs and participating practices within the context of their medical neighborhoods and communities;

• Promote rural and urban clinician participation in TCPI and work to sustain their active engagement over the life of the model;

• Support their members and practices in work to reduce unnecessary testing and procedures;

• Incorporate TCPI-related content into continuing medical education and ongoing clinician training programs, in their discretion and if they determine the content is appropriate;

• Incorporate TCPI- related content into maintenance of certification requirements, in their discretion and if they determine the content is appropriate;

• Ensure leadership and collaboration in the fomenting and fostering support to integrate patient and family engagement and measurement in the transformed care delivery system;

• Mobilize the professional community on improvement topics and goals;

• Publicize and call attention to best practices and the results of high performing practices in the TCPI;

• Focus on specialty topics by providing high quality advice and guidelines to practices about these “specialty” conditions and how to manage them appropriately (e.g., primary care providers work with diabetes, patients with hypertension, cancer, gastrointestinal problems and heart disease);

• Interface with specialists (e.g. gastroenterologists, cardiologists, and endocrinologists) to assist with registry data for example to improve quality which should overlap with aspects of Choosing Wisely;

• Offer supportive and evolving ideas to create, improve, and expand specialists’ interactions with primary care providers to make these relationships work better in the community; and

• Use their unique and established channels (peer reviewed journals, registries, annual conferences, task forces, newsletters, etc.) with members to support action and results on the initiative, as they determine appropriate.

One goal of this process is for each SAN to expand its current involvement in transformation. In each of the applicable above areas, the SANs should detail their current processes, develop a strategy and implementation plan to achieve target goals over the funding period, and detail a roadmap that links the two.

The TCPI Practice Transformation Networks (PTNs) will coach, mentor, and assist clinicians in developing core competencies to assist them in moving through the TCPI Phases of Transformation. 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

Support and Alignment Network (SAN) 13 the clinicians and practices which are more likely to lead to sustained efforts after the TCPI technical assistance (service delivery) model tests are complete. Specifics regarding TCPI PTN responsibilities can be found in Appendix B.

The SANs should actively utilize the following description of the Phases of Transformation, and the characteristics and milestones associated with them as they work with PTNs and their participating clinicians/practices.

Table 1: 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 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

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-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.

Support and Alignment Network (SAN) 14 patient and family engagement in care.

Phase 2:

Reporting and using data to generate improveme nts

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 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.

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.

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 reducing unnecessary tests and hospitalizations.

Practice develops plan to incorporate Meaningful use into their operational redesign.

The 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.

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

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 will include updating information about the practice’s risk stratification methodology, empanelment status, risk stratification data, and other activities.

Practice will incorporate regular improvement methodology to execute change ideas in a rapid cycle. Use a

Support and Alignment Network (SAN) 15 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 behaviors and self-management.

Demonstrates improvement on select quality measures.

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

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 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

Support and Alignment Network (SAN) 16 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 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 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 decreases 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 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.

The 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 demonstrat ed 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

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

Support and Alignment Network (SAN) 17 meaningful use objectives might consider and how to evaluate the pros and cons for the population they serve.

Table 2: TCPI Phases of Practice Transformation:

Specialists’ descriptive characteristics and associated milestones.

Phases of Practice Transfor mation

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 which they operate.

Learns and integrates best practices for care coordination and patient co-management with multidisciplinary and inter-professional 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

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 and lessons learned.

Practice starts to perform an assessment of the clinical practice and starts to collect baseline data on comorbidities, referral patterns, utilization, quality and outcome measures, and identifies problem areas for improvement.

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

Support and Alignment Network (SAN) 18 systems are optimized using this knowledge by redesigning all of these processes toward developing a leaner and higher performing organization that produces better outcomes.

Phase 2:

Reporting and using data to generate improveme nts

Same as those listed in Primary Care

Develops care coordination agreements with other care providers that cover 15% of their patients and defines co-management responsibilities with other care providers.

The practice identifies ways to improve care transitions, care processes, workflow; and ways to eliminate waste and decrease costs that are enabled through the exchange of essential health information (electronically or otherwise).

Phase 3:

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

with other care providers that cover 30% of their patients their and defines co-

Practice routinely exchanges essential health information (electronically or otherwise) with other members of care team outside of practice.

Practice has reduced unnecessary hospitalizations, tests, procedures by at least 15% from baseline.

Support and Alignment Network (SAN) 19

Phase 4:

Getting to benchmark status with other care providers that cover 50% of their patients and defines co-

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

Phase 5:

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

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

The goal of reaching the TCPI aims will include use of a core set of measures to inform monitoring, evaluation and performance improvement across all clinician practices participating in TCPI. In addition to a menu set of measures 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.

Each SAN applicant must clearly include quantifiable means for generating and documenting their projected impact on the overall initiative and the five key aims outlined in Section II.4. For example, SAN proposals should clearly delineate how they will support participating clinicians and their PTNs in reducing the costs of unnecessary testing and procedures. Strong proposals will establish quantitative targets for overall cost reductions achieved as a result of the activity and work of the SAN. Similar approaches to quantitative targets in other areas will make SAN applications even stronger. CMS will use actual performance on projected SAN impacts to inform judgments on future funding in option years. Some examples of additional items for SAN applicants to potentially address include:

• Demonstrated improvement in the aggregate increase in number of clinician members supported, Support and Alignment Network (SAN) 20

• Demonstrated improvement achieved through implementation of alignment activities conducted with clinicians and their practices,

• Effective support provided to primary and specialty care clinicians to promote and sustain their active involvement with their PTNs and in the overall initiative,

• Number and type of SAN programs and activities used to support progress towards the aims of the TCPI (continuing medical education offerings, maintenance of certification, journal articles, newsletter articles, alignment with professional standards, more);

• Increasing the number of participating clinicians,

• Providing supportive learning for clinicians’ success in adapting to changes in national standards and guidelines, and

• Improved integration of primary and specialty care clinicians in patient and family engagement and other outreach efforts.

Each SAN applicant will be responsible for monitoring, evaluating, and reporting on the progress and impact of their improvement program goals and success each quarter. In addition to this self-evaluation, CMS contractors will conduct an independent evaluation. These evaluations will be used in determining the SANs’ eligibility for further funding.

The PTNs will focus on the recruitment and coaching of practices and provide intensive technical assistance, facilitation, and support to those practices. CMS will share aggregate data received from the Practice Transformation Networks recruitment efforts and performance reports with the SANs. SANs will support primary and specialty care clinicians with tailored services.

CMS will also share aggregate PTN performance data on an ongoing basis with the SANs. This may include comparative performance information for each PTN relative to others in the model, and may be stratified by characteristics that are thought to affect performance. The SANs are expected to use this data to continue internal improvement and implement adaptive mechanisms to further advance clinicians and practices through the Phase of Transformation and in achieving the goals of TCPI. SANs will support clinicians in aligning their practice delivery actions to national standards and guidelines and support their learning to adapt to the changes that they will work to incorporate into specialty board exams and other mechanisms as they determine appropriate.

SANs will be required to provide access and data to CMS or its contractors as may be needed for evaluation purposes. The evaluation will include multi-pronged data collection to understand the context of the programs and to capture the nuances occurring at the sites. Data for the analyses will come from sources including, but not limited to: the practice application and readiness assessment; Medicare claims; EHR measures, Choosing Wisely® measures as reported by practices, patient experience surveys; site visits with practices; focus groups with beneficiaries and their caregivers, practice staff, technical assistance providers, and others (e.g., payers); and observation of technical assistance sessions.

II.4.5 Learning and Diffusion The TCPI is a service delivery model test of 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. Learning and diffusion

Support and Alignment Network (SAN) 21 methods are central to transforming clinical practices on a large scale to achieve measurable improvements quickly. Methods such as those utilized in Partnership for Patients and collaborative learning models will be applied to achieve the desired results over a four year period. This will include setting clear and measurable aims across both PTNs and SANs using Plan, Do, Study, Act (PDSA) quality improvement methods within and across practices. A key activity will be to identify and showcase practices that are already successful in implementing changes that lead to full transformation in learning sessions.

Lessons learned from other transformation collaboratives and improvement activities will inform the implementation and management of TCPI. Existing tools (specific to practice transformation;

patient safety; effective use of health information and related technology for clinical and operational improvement, patient and family engagement; and other knowledge management resources, communication and related tools utilized in primary, tertiary and specialty care practices) will be employed in this Initiative, while taking into account practices’ local context and regional market characteristics. The learning and diffusion strategy across PTNs and SANs will be supported by TCPI Learning Sessions and Change Packages. A change package is a set of improvement tools and implementation instructions for a specific area of improvement that reflects the current knowledge base regarding successful interventions for achieving breakthrough improvements that can be sustained over time. The TCPI Change Package will guide the changes tested and implemented at participating practices and will consist of: common change concepts, interventions and tools. Change Packages when used in combination with small test of change by the clinicians and their practices will serve as one mechanism to allow the networks to operate as a collective through a Transforming Clinical Practice Community of Practice (TCP-CoP). It will also help ensure effective implementation of improvement tools and processes and highlight unique factors that generate success or failure.

Across the networks, TCPI will support communities of practice to: 1) share and generate best practices to support changes across primary and specialty care practice; 2) facilitate communication through Listservs and forums with all participating clinicians; 3) access TCPI generated resources and tools; and 4) foster new tests of changes through rapid cycle evaluation as well as spread of interventions demonstrated to drive results in achieving overall TCPI aims.

TCPI will utilize a customized Content and Knowledge Management (KM) Tool similar to the tool used by the Partnership for Patients initiative and QIO program.

II.4.6 Key Personnel CMMI desires a balanced team of key personnel to ensure the success of the TCP Initiative model. Applicants must propose required key personnel and identify the relevant titles and qualifications for these positions. Applicants must identify whether the proposed personnel that are part of the primary awardee and those that are subcontractors. The following personnel are designated as “key”:

• Program Manager:

Provide overall management and accountability for meeting TCPI goals and commitments made in the applicant’s submission.

• Quality Improvement Advisors:

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These individuals will have expertise in quality improvement across several areas to include clinical, operational including finance and business process redesign, patient and family engagement and broad quality improvement including lean methodology.

• Clinical Personnel:

Extensive experience in producing results both within their practice (primary and specialty care) and in support of other practices and organizations.

The Awardee is encouraged to dedicate key personnel full-time to this effort, unless otherwise specified by the SAN and agreed to by CMS. Key personnel may be assigned to more than one functional area but their time may not exceed on Full Time Equivalent (FTE). Any staff identified as key personnel must have a backup who is properly trained and qualified to act as a fully functioning replacement in the temporary absence of the key person. Key personnel shall be assigned for a minimum of the 12-month base period barring circumstances outside the control of the awardee, e.g., death, and disability. Should any key personnel choose to leave for another reason (e.g., higher pay, job dissatisfaction), their replacement shall be equal or superior qualifications and provided within 30 calendar days of their known departure.

II.5 Restrictions on Award

• An applicant can only be funded to serve as a Practice Transformation Network or a Support and Alignment Network. An entity or subcomponent of an entity may not perform as both a PTN and a SAN.

• Funds shall be used to implement, manage toward results, and evaluate models that support system transformation toward higher quality care at lower costs. Additionally, the funds shall further healthcare design improvements to support both primary and specialty care. This would include innovations that have been tested and shown to reduce unnecessary testing and eliminate other inefficiencies in specialty care that are of primary interest in the SANs’ work.

• Award dollars cannot be used for specific components, devices, equipment, or personnel that are not integrated into the entire service delivery model proposal.

• Funds shall not be used to build or purchase health information technology or other information technology that exceed more than 10% of total costs of the applicant’s proposed budget.

• CMS will not fund proposals that replicate models that CMS is currently testing in other initiatives.

• CMS will not review applications that merely restate the text within the FOA.

Applicants should detail their approach to achieving the TCPI goals and milestones.

Reviewers will note evidence of how effectively the applicant includes these in their overall implementation plan.

• Award dollars may be used for specific components, devices, equipment, software, analytical tools, or personnel provided that they are integrated into the service delivery and payment model.

• Award dollars cannot be used to make permanent improvements to property not owned by the federal government; minor alterations and renovations are permissible under

Support and Alignment Network (SAN) 23 certain circumstances that will be described in the financial plan template to be provided at a later date.

II.6 Alignment of Awardees CMS expects significant proactive alignment and coordination among PTN and SAN awardees.

The awardees will likely have differing specialties and strengths, so coordination will enable best practices found in one area to diffuse into other PTNs and SANs. SANs are expected to lead and participate in regular weekly webinars, pacing events, and office-hours events with CMS, PTNs and each other throughout the four-year model of work.

II.7 Technical Assistance and Information for Potential Applicants

Prior to the application deadline, CMS will host a series of Open Door Forums or webinars to provide details about this initiative and to answer any questions from potential applicants.

Information about the forums will be posted on the Innovations Center website at http://innovations.cms.gov.

II.8 Preventing Duplication of Effort TCPI participants will work collaboratively with the CMS Quality Improvement Organizations (QIOs), State Innovation Model, Regional Extension Centers, and other HHS programs for alignment and synergy, and to prevent duplication of efforts. Based on more than two years of collaboration and work between CMS Quality Improvement Organizations (QIOs) and Partnership for Patients (PfP) Hospital Engagement Networks (HENs), the following three proven strategies will be used to maximize synergy and prevent duplication of effort:

• CMS delineates how work funded as part of the Transforming Clinical Practice Initiative is distinct and different from other federally-funded work toward practice improvement with similar aims. CMS has worked extensively with program leads from AHRQ, ONC, HRSA, and the QIO program to offer technical assistance that complements but does not duplicate the work of other initiatives at the program-level as well as at the provider-level. Because TCPI focuses on total practice transformation rather than specific isolated topics (such as assessment and support of the practice’s performance in meeting Meaningful Use measures) it is much broader in topic than other large scale technical assistance programs geared toward clinicians. TCPI aims to transform 150,000 clinicians and including specialists and non-physicians, TCPI reaches more types of clinicians on a much larger scale than other clinical, operational, and financial transformation efforts that have targeted between 500 to 8,000 clinicians/practices. In addition, the QIO program is integrally interwoven into TCPI for the specific function of practice assessments. These unique characteristics make TCPI larger in scope than previous clinician transformation initiatives.

• CMS established clear aims for the Transforming Clinical Practice Initiative that helps others (private and public) who want to contribute to this work to self-align their tools, resources, people, and funding in ways that are non-duplicative and maximize synergy.

http://innovations.cms.gov/

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• CMS requires three actions by federally funded PTN and SAN cooperative agreement recipients that may contribute to this work:

a. Contact other regional, State, local or…