Transforming Clinical Practice Initiative (TCPI) Summary of Awards

Practice Transformation Networks

Awardee:  Arizona Health-e Connection

Geographic area: Arizona

Summary: The network aims to engage 2,000 clinicians over the next four years. The network will provide direct technical assistance and coaching to participating providers and practices, as well as information technology support and assistance for travel and communications.

Awardee: Baptist Health System, Inc.

Geographic area: Alabama

Summary: The network aims to engage 1,350 clinicians over the next four years in improving outcomes for diabetes, asthma, and heart failure by 10 percent and reducing unnecessary testing and avoidable hospitalizations by 25 percent. The network will place trained quality improvement advisors in clinician practices, support clinicians through the Patient- Centered Medical Home and Patient-Centered Specialty Practice Recognition process, and link data systems to a centralized registry.

Awardee: Children's Hospital of Orange County

Geographic area: Southern California

Summary: The network aims to engage 1,450 pediatric primary care providers and specialists to lower the cost of care for six common pediatric conditions: asthma, bronchiolitis, community-acquired pneumonia, headaches, acute gastroenteritis, and acne. The conditions oftentimes result in unnecessary emergency department visits and hospitalizations, testing, and specialist referrals. The network will train, support, and provide technical assistance to transform pediatric primary care and specialty practices by cultivating a culture of quality to reduce variation in care and to build an infrastructure of rapid-cycle deployment of performance improvement tools, data, and metrics. The network will use evidence-based clinical care pathways throughout practices to improve healthcare outcomes and streamline healthcare delivery to reduce costs. The network will create culturally-sensitive care plans, employ strategies to improve access to and satisfaction with care, and facilitate a mutually beneficial learning environment that supports providers and increases accountability for healthcare outcomes through a regional interdependent healthcare system.

Awardee: Colorado Department of Health Care Policy & Financing

Geographic area: Colorado

Summary: The network aims to engage 2,000 clinicians in practice and clinician transformation. The network will provide on-the-ground health information technology assistance, practice facilitators for in-practice assistance with the transformation process, regional learning collaborative sessions twice a year, and a-learning modules and webinars to provide clinicians and staff with added opportunities to share experiences and learn important concepts, skills, and information.

Awardee: Community Care of North Carolina, Inc.

Geographic area: North Carolina

Summary: The network aims to engage 3,000 clinicians, including small, rural, independent, and safety net providers. The network will focus on addressing a range of physical and behavioral health needs for patients through this reformed health care model.

Awardee: Community Health Center Association of Connecticut, Inc.

Geographic area: Nationwide

Summary: The network aims to engage more than 1,500 clinicians, focusing on clinicians in health professional shortage areas and targeting underserved populations with high prevalence of diabetes, asthma, and hypertension. The network will support assessments of health centers and practices, creation of a transformation dashboard, readiness coaching, leadership development, learning collaborative development, practice transformation support, and management clinical tools and resources.

Awardee: Consortium for Southeastern Hypertension Control

Geographic area: Alabama, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia

Summary: The network aims to engage nearly 3,500 clinicians by the end of initiative through a distance-learning platform to train and educate providers. The network will be supported by centralized resources that include data warehousing, analytics, transformation experts, care management strategies, evidence-based guideline development, and web-based educational tools.

Awardee: Health Partners Delmarva, LLC

Geographic area: Delaware, Maryland

Summary: The network aims to engage at least 1,600 clinicians to increase physician alignment, improve quality, and share health information technology. The network will provide participating clinicians direct technical support to make the required transformation. The network will also provide clinicians with access to problem-solving, peer-directed groups to share in and learn about quality improvement and cost reduction, access to nationally-recognized faculty, and access to robust data, analytic, and care management.

Awardee: Iowa Healthcare Collaborative

Geographic area: Georgia, Iowa, Kansas, Nebraska, Oklahoma, South Dakota

Summary: The network aims to engage 7,046 clinicians including 4,665 primary care and 2,381 specialty care providers. The network will use a centralized infrastructure of education, data management and supporting resources to deploy local transformation activities through four-month transformation cycles and in• person learning sessions. Core functions of the network will include recruitment of clinicians, technical assistance, patient and family engagement, leadership engagement and practice-based education.

Awardee: Local Initiative Health Authority of Los Angeles County

Geographic area: Los Angeles, California

Summary: The network aims to engage 3,100 clinicians and will use funding to enhance routine care for patients with diabetes and/or depression at high risk for hospitalization, optimize transitions to community care settings after acute hospitalization, increase frequency of medication reconciliation, and improve patient medication education and management in all care settings. Strategic use of key technologies at the point of care in support of these priorities will help prevent initial and repeat hospitalizations, and coaches will provide onsite and remote support to all practices in performing activities and achieving milestones detailed for each phase of transformation.

Awardee: Maine Quality Counts

Geographic area: Maine, New Hampshire, Vermont

Summary: The network aims to engage over 1,300 primary care and specialty clinicians in 400 or more practices across the region. By working with a wide range of in-state organizations and using a cooperative extension model of local service delivery, the network will provide support physician practices need in order to achieve sustainable practice transformation. The network will provide quality improvement assistance from on-site practice facilitators and from expert faculty in a peer-oriented learning community, supplemented by practical tools and a wide range of additional resources and support.

Awardee: Mayo Clinic

Geographic area: Iowa, Minnesota, Wisconsin

Summary: The network aims to engage 1,231 clinicians with extensive experience in implementing key components of the proposed care delivery model, including the delivery of team-based care, care transitions program to reduce readmissions, collaborative care models for behavioral health, medication therapy management programs, and shared decision making. The network will use the principles of minimally disruptive medicine to help clinicians reduce unnecessary care while engaging patients in treatment decisions and helping them build the capacity to manage their care.

Awardee: National Council for Behavioral Health

Geographic area: New York

Summary: The network aims to engage 4,000 clinicians, focusing on clinicians who provide services to patients with severe mental illness (specifically those with schizophrenia, psychotic disorders, bipolar disorder, and chronic depression in the high risk post-discharge period for psychiatric or medical hospitalization). The network will help clinicians in using a centralized care management program that coordinates care for patients in the post-discharge period for psychiatric or medical hospitalization and a robust technology platform that ensures communication between providers and across organizations. The network will provide a data- driven learning collaborative to support clinicians in implementing evidence-based practices to best serve the target population.

Awardee: National Rural Accountable Care Consortium

Geographic area: California, Michigan, Missouri, Iowa, Illinois, Indiana, Oklahoma, Texas, Washington

Summary: The network aims to engage more than 5,500 rural clinicians and provide them with tools necessary to transition into successful accountable care organization structures. Leveraging the technical systems, recruitment methodology, and quality improvement programs currently in place, the network will assess, prepare, educate, and provide on•site, peer-supported education, and training to participating clinicians.

Awardee: New Jersey Innovation Institute

Geographic area: New Jersey

Summary: The network aims to engage more than 15,000 clinicians to gather and use clinical quality measures, improve chronic care management, and improve costs and efficiency.

Awardee: New Jersey Medical & Health Associates dba CarePoint Health

Geographic area: New Jersey

Summary: The network aims to engage 800 clinicians, including primary and specialty care clinicians. The network will establish a framework to ensure successful planning, development, and implementation throughout the transformation process.

Awardee: New York eHealth Collaborative

Geographic area: New York

Summary: The network aims to engage up to 11,193 eligible clinicians statewide (7,275 primary care clinicians and 3,918 specialty care clinicians). The network will target and track improvement of key program indicators, including measures related to wellness, high blood pressure and diabetes control, physician quality reporting system enrollment and reporting, health information technology meaningful use, tobacco use screening and cessation interventions, and improvements in transitions of care following hospital admission.

Awardee: New York University School of Medicine

Geographic area: New York

Summary: The network aims to engage roughly 1,900 clinicians by providing practice facilitation, information technology and data management support, as well as project management, oversight, and training. The network will use the 10 Building Blocks of High- Performing Primary Care model and the Chronic Care Model to guide transformation efforts from foundational stages of leadership engagement and team-based care towards advanced stages of population management, care coordination, and patient and community engagement. The network will engage clinicians in learning collaboratives, peer coaching, and best practice dissemination.

Awardee: Pacific Business Group on Health

Geographic area: California

Summary: The network aims to engage nearly 5,000 primary care and specialty clinicians by leveraging an existing multi-payer, multi-stakeholder network system. The network will provide two tiers of coaching and peer-to-peer network support for provider organization leaders leading transformation within their systems and for practice coaches hired by the provider organizations to work intensively with a sub-set of clinicians. The network will also provide two tiers of data feedback on a set of triple-aim measures common across Medicare, commercial and Medicaid payers, and support provider organizations in strengthening technology and human-operated systems.

Awardee: PeaceHealth Ketchikan Medical Center

Geographic area: Alaska, Oregon, Washington

Summary: The network aims to engage nearly 600 employed clinicians through the implementation of team-based care models within the practices. These teams will work in tandem to integrate clinical findings, health metrics data and chronic disease registry outcomes in a shared effort to identify high risk populations, validate success of interventions, and determine opportunities for further intervention. Through the network, the teams will improve management of care transitions to ensure proper clinical follow-up and remove barriers to appropriate care. The goals behind this evolution are to improve clinical outcomes, improve overall individual and community health, and prevent unnecessary health expenditures.

Awardee: Rhode Island Quality Institute

Geographic area: Rhode Island

Summary: The network aims to engage 1,500 primary care and specialty clinicians by providing assessments to test the effectiveness of and identify valuable practice transformation strategies, curricula, and resources. The network will also work with participating practices to improve care team experience, patient experience, and quality of care, reduce hospital readmissions, and move at least 1,125 clinicians into value-based payment models.

Awardee: The Trustees of Indiana University

Geographic area: Illinois, Indiana, Michigan

Summary: The network aims to engage 11,500 clinicians through learning practices capable of providing better health and improved care at a lower cost for a population of more than 10 million Americans. The network will train and deploy 52 quality improvement advisors to coach clinicians through the five phases of patient-centric practice transformation, provide direct technical assistance in meaningful use, Physician Quality Reporting system, and local quality improvement efforts to help prepare clinicians for participation in value-based payment systems.

Awardee: VHA/UHC Alliance Newco, Inc.

Geographic area: Arizona, California, Connecticut, Florida, Kentucky, Massachusetts, Michigan, Missouri, New York, Ohio, Pennsylvania, South Carolina, Texas, Washington

Summary: The network aims to engage more than 26,000 clinicians. The network will focus on improving access to care, quality of care, efficiency, patient satisfaction, and outcomes. The network will provide guidelines and checklists, assessment resources with clear action steps, tracking tools to measure progress, and policies and guidelines to facilitate improvement throughout participating organizations. The network will adopt a multi-pronged strategy that includes oversight (advisory, individual organization coaching and facilitation), engagement (leadership and project involvement), and use of data for decision-making and evaluation, as well as collaboration to improve outcomes for all participants.

Awardee: University of Massachusetts Medical School

Geographic area: Connecticut, Massachusetts

Summary: The network aims to engage approximately 5,400 clinicians through the readiness phases of practice transformation, preparing participants to adopt new payment models that reward improved clinical outcomes, and reduce hospitalizations and other unnecessary testing. Quality improvement advisors will train, educate, and coach practices in the transformation phases. The network will create shared learning experiences that emphasize the value of collaboration, innovation and data-driven, evidence based decision making. The network will focus on clinical measures related to diabetes, asthma, heart failure, and key aspects of geriatric care, targeting measurable and significant improvement.

Awardee: University of Washington

Geographic area: Alaska, Idaho, Montana, Washington, Wyoming

Summary: The network aims to engage more than 6,700 clinicians in practice transformation, impacting over 1.9 million patients. The network will leverage existing collaborations and relationships, and deploy an infrastructure comprising of rapid-cycle performance surveillance and benchmarking of quality metrics, a telemedicine grid, support for coordinated care for patients with chronic conditions, and data and information sharing across practices. The network will train primary and specialty care practitioners using a hybrid model of web-based and in-person learning, including on site coaching to support practice transformation. The network will also deploy targeted programs to drive performance improvements, including patient-reported outcomes where appropriate, hospital readmissions, unnecessary testing and procedures, and healthcare costs.

Awardee: Vanderbilt University Medical Center

Geographic area: Arkansas, Michigan, Tennessee

Summary: The network aims to engage 34 academic and community hospitals, over 330 small and large primary care and specialty practices with over 4,300 clinicians reaching over 3 million patients. The network will leverage current and planned informatics capacity, prior experience in training and performing quality improvement, and community/stakeholder engagement. The network will also rely on an array of informatics tools that have been developed at Vanderbilt to enhance collection and management of clinical data, provide clinical decision support, and collect patient reported data.

Awardee: Virginia Health Quality Center

Geographic area: Virginia

Summary: The network aims to engage 1,250 primary care clinicians, with the goal of improving care for more than 1 million patients. The network will develop and conduct the learning collaborative, analyze and report data, and recruit and support independent practices that participate in the network. Funds will be paid to subawardees on the basis of attaining transformation milestones, and will support the costs of practice transformation personnel and modifications to existing data systems for incorporating practice transformation measures that are not currently being collected and reported.

Awardee: VHS Valley Health Systems, LLC

Geographic area: Texas, North Carolina, Pennsylvania

Summary: The network aims to engage 1,200 participating physicians by the end of the initiative. The network will enhance the practice outreach, educational offerings, analytic ability, and process improvement capabilities of physician practices. The network will develop a strategy for clinical and practice efficiency education and lead analysis of opportunities related to chronic disease management, inpatient and emergency room encounters, and duplicative or unprovided care both at a local level and based on shared best practices across regions. The network will also develop clinical outreach teams, consisting of on-the-ground clinical resources designed to provide intervention for high-risk patients, facilitate and provide education to practices as directed by the clinical quality team, and act as primary liaisons for practices to address major educational or operational needs. The network will include an analytics and reporting team to facilitate reporting of quality and claims data from payers and providers, develop data into regular operational reporting, and report information back to the practices to inform greater transformation.

Awardee: Washington State Department of Health

Geographic area: Washington

Summary: The network aims to engage 5,600 pediatric primary and specialty clinicians by the end of the initiative. The network will provide an innovative approach by combining primary care and behavioral health clinicians, moving these solo practices into an integrated practice transformation network.

Support and Alignment Networks

Awardee: American Board of Family Medicine

Geographic area: Nationwide

Summary: Two organizations, collectively representing over 100,000 family physicians, will partner on the Family Medicine Support & Alignment Network. This network will help recruit 25,000 family practices into existing practice transformation networks, develop a member interest group learning collaborative, provide maintenance of certification and continuing medical education credit to participating practices, offer developed practice performance coaching guides, use unique, established communication and engagement channels (publications, national meetings, state chapter sessions) to disseminate learning among practices, provide access to the Family Medicine Registry to support practice quality measure extraction and management, and develop modules to translate practice transformation successes.

Awardee: American College of Emergency Physicians

Geographic area: Nationwide

Summary: The network will focus on reducing unnecessary care and testing, improving clinical outcomes and early identification and for treatment of patients with sepsis, and reducing hospitalizations and improving the value of emergency department care for patients with chest pain. The network will engage providers by developing eCME modules and Maintenance of Certification Assessment of Performance in Practice activities in collaboration with the American Board of Emergency Medicine. The network will also support emergency department practice transformations by developing quality improvement toolkits and leading learning collaboratives, and will align clinical practice guidelines. The network aims to engage over 2,000 emergency departments and over 33,000 emergency clinicians, and to impact the care of over 16 million patients.

Awardee: American College Physicians

Geographic area: Nationwide

Summary: The network will work with key partners – including regional chapters, American Board of Internal Medicine, Stanfords Clinical Excellence Research Center, National Partnership for Women and Families, and Institute for Patient- and Family-Centered Care – to recruit clinicians, communicate key messages, and develop and disseminate tools for inclusion in a learning session and change package. The network will develop and refine tools to help practices improve patient access to care, engage patients and families in collaborative efforts to improve the experience of care, decrease rates of unnecessary tests and procedures, decrease overuse of emergency department and hospital-level services, increase the delivery of guideline- based preventive care, and increase the number and quality of advance care discussions in the ambulatory setting. The network aims to reach over 200,000 practicing physicians and prepare 30,000 clinicians to participate in practice transformation.

Awardee: American College of Radiology

Geographic area: Nationwide

Summary: The network will help at least 24,000 member radiologists and their referring physician colleagues to reduce unnecessary testing and procedures. The network will coach participants in data collection, educational intervention, and assessment of effectiveness. The network will use R-SCAN, which will prepare participants for data registry activities surrounding appropriate use and Physician Quality Reporting System and for adoption of a clinical decision software tool (to be provided free to participants). Moving through these phases will ultimately enable 75 percent participants to initiate value-based practices.

Awardee: American Medical Association

Geographic area: Nationwide

Summary: The network will engage the national physician community in healthcare transformation through network projects, change packages, success stories, training modules for use by over 140,000 participating clinicians and the broader healthcare community including physicians, clinicians and practice staff across geographies, specialties and practice settings. The network will accelerate the maturation of clinical data registries to meet related requirements by providing coordination, resources and tools needed by registries to continue to mature in a direction and at a pace consistent with large-scale transformation. The network will also elevate the collective capability and capacity of various transformation networks by bringing together relationships, expertise, and channels of the country’s largest physician association to increase the ability, readiness, and effectiveness of all participating clinicians. Toward this end, American Medical Association will develop content and provide nationally recognized adjunct faculty for 16 collaborative learning events.

Awardee: American Psychiatric Association

Geographic area: Nationwide

Summary: The network will train and support a national workforce of consulting psychiatrists who will partner with Practice Transformation Networks and participating practices to implement evidence-based, population-focused, integrated behavioral healthcare programs. The network will work closely with the University of Washington to train a network of psychiatrists in collaborative care and will provide those psychiatrists with the clinical and leadership skills needed to support primary care practices that are implementing integrated behavioral health programs. Training for consulting psychiatrists will include topics, such as population health management and the use of registries and real-time clinical outcome data to improve quality and outcomes of behavioral healthcare at the individual patient and practice level. Clinical skills taught will include in-person, telephonic, tele-video, and caseload-focused psychiatric consultation methods, primary care team coordination, and evidence-based methods utilization for managing patients with common mental disorders in primary care. The network aims to engage 3,500 psychiatrists.

Awardee: HCD International

Geographic area: Nationwide

Summary: The will network will bring the collaborative infrastructures of the National Hispanic Medical Association, National Council of Asian Pacific Islander Physicians, Association of American Indian Physicians, and National Minority Quality Forum together as strategic partners. These physicians and quality focused organizations make up the core panel of 60,000 physicians and represent, in large percentages, medically underserved, rural and urban areas from across the nation. Through referral and recruitment process, the network will obtain baseline data on their practices and clinical outcomes. Based upon this, the network will provide educational and outreach on best practices and evidence based strategies to reduce hospitalizations. The network aims to engage 10,000 clinicians.

Awardee: National Nursing Centers Consortium

Geographic area: Nationwide

Summary: The National Nursing Centers Consortium, in partnership with the American Association of Nurse Practitioners, will implement a network dedicated to helping the nation’s nurse practitioners align their practices with large-scale transformation. The network will promote nurse practitioners participation in practice transformation networks and provide for a wider representation of primary care providers, increase the initiatives capacity to reach underserved and other vulnerable populations, and expand evidence-base practice. The network aims to recruit over 7,000 nurse practitioners, support approximately 2.6 million patients, and support value-based contracting or other incentive programs for over 6,000 nurse practitioners.

Awardee: Network for Regional Healthcare Improvement

Geographic area: Nationwide

Summary: The network aims to improve outcomes, reduce inappropriate utilization and overutilization. The network will design a multi-faceted high-value care learning program to increase awareness around total cost of care and high-value care, and provide a care plan with evidence-based quality improvement treatments or activities that have been successfully adopted by communities in response to the cost drivers. The network will disseminate a learning program through a mix of mediums, including in-person meetings, video-conferencing, and other virtual events, as well as one-on-one coaching and a shared on-line platform. The network will explore and develop a common core set of meaningful activities related to reducing total cost of care/improving high-value care that could qualify physicians for maintenance of certification credit.

Awardee: Patient-Centered Primary Care Foundation

Geographic area: Nationwide

Summary: The network will support over 140,000 clinicians to define and promote best practices for inter-professional, team-based primary care; to expand and support patient/practice partnerships; and to establish clinic to community linkages. The network will leverage their existing membership, which includes over 1,300 organizations representing more than 1 million patients, health professionals, health plans, employers, industry, and community- based organizations.