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CTC-RI: Practicing with Value - Transforming Care and Collaborative Improvement in Rhode Island

CTC-RI is a program focused on care transformation and collaborative improvement in Rhode Island, aiming to reduce in-patient admissions and improve the quality of care. This article highlights the evidence of value-based practices and their impact on cost, clinical quality, customer experience, and integrated behavioral health. It also discusses the development of community health teams and the future plans for sustainability and expansion.

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CTC-RI: Practicing with Value - Transforming Care and Collaborative Improvement in Rhode Island

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  1. Care Transformation Collaborative of Rhode IslandEvidence of Practicing with Value: CTC-RI Perspective Debra Hurwitz, MBA, BSN, RN CTC-RI Co-director October 20, 2016

  2. CTC-RI Practicing with Value: Making a Difference in Cost of Care: Reducing In-Patient Admissions

  3. All-Cause Admissions: All CTC-RI Cohorts** Reduced IP Admission Rates vs. Comparison *Includes BCBS-RI, UHC, NHP data. Does not include Medicaid FFS or Medicare FFS data or RHO Dual Eligible NHP members. **Refer to Appendix for list of practices per cohort

  4. All-cause Inpatient Admissions per 1000 Member Months…..CTC Target= 5% Observation: the longer the practice cohort has been in CTC, the greater the relative reduction in IP admissions …….suggesting that transformation is hard work and takes time.

  5. CTC-RI Practices DemonstrateIn-Patient Savings > than program costs for FY2015 *Cost per Admission = 60th percentile; vs mean=$14k; Median=$10k **Total Program Cost include CTC Admin, CHTs and Practice Payments paid by health plans

  6. CTC-RI Practicing with Value: Making a Difference with Quality

  7. Clinical QualityCTC Outperform Regional Benchmarks

  8. CTC-RI Practicing with Value: Making a Difference with Customer Experience

  9. 2014 MAPCP CAHPS Patient Experience DataProvider Communication statistically significant and Better Than All Other States – Note: This measure is a performance incentive in the CTC contract

  10. 2014 MAPCP CAHPS Patient Experience Data-Access Approaching Statistical Significance and Better Than All Other States

  11. CTC-RI Practicing with Value: Integrated Behavioral Health

  12. Integrated Behavioral Health Pilot* (Phase1): 12 Practices • Assessment of Behavioral Health Integration • Intervention : monthly on site consultation provided by Dr. Burdette • Evaluation: Practices used the Maine Site Assessment to re-measure behavioral health integration in primary care *Made possible through funding from Tufts health care

  13. Maine Site Assessment -Evidence Based Tool Average for All Dimensions (18)

  14. Integrated Behavioral Health Phase 2* – 12 practices Intervention On Site embedded Behavioral Health Staff Monthly on site consultation Staff training : universal screening for depression; anxiety and substance use disorder • Patient Care: • BH providers provides counseling mild to moderate depression; anxiety and SUD • Referral and care coordination for more complex cases to specialty BH • NCM Coordination with complex patients *Made possible through Rhode Island Foundation and Tufts Health Car Funding

  15. CTC-RI Practicing with Value: Community Health Teams

  16. Community Health Teams: Program Development • 2014 -Implemented Pilot with 2 teams • 2015 -Evaluation of Pilot* • 2016 - Phase 2 : Centralized Management and IT ( *Formative Evaluation conducted by Brown University Faculty)

  17. What Did Patients Say? • Whatever was needed: • Food, clothing, furniture, medication…… • Assistance with medical system and getting benefits • Behavioral Health • Moral Support and anxiety reduction • Encouragement to ask for help

  18. Community Health Team Phase 2 • Right Patient: Use of Standardized Triage Tool • Right Time: Direct Alert Notification; Health plan communication • Right Data: Common data base to track results

  19. Rhode Island: Practicing with Value: Moving Forward: OHIC Sustainability Payment 2017 CTC Expansion Comprehensive Primary Care Plus Accountable Care Organizations Transforming Clinical Practice Initiative

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