Changing the Care Paradigm at Connecticut’s FQHCs

1. Changing the Care Paradigm at Connecticut’s FQHCs Connecticut Practice Transformation Network

2. What is Transforming Clinical Practices Initiative (TCPi)? • Innovative model to strengthen the quality of patient care and spend health care dollars more wisely • Promoting broad payment and practice reform in primary care and specialty care • Promoting care coordination between providers of services and suppliers • Establishing community-based health teams to support chronic care management • Promoting improved quality and reduced cost by developing a collaborative of institutions that support practice transformation

3. Transforming Clinical Practice Initiative • PTN Change Programs Move Enrolled Practices and Clinicians Through Seven Levels of Transformation • Enrolled Practices Change: • Culture • Operations • Infrastructure • Measurement • Business model • Performance

4. CHCACTs Role in TCPi • Support Health Centers in their migration away from encounter-based reimbursement toward an Alternate Payment Model (APM) • Paying for quality rather than quantity • Support Health Centers in primary drivers; • Patient & Family Engagement • Continuous Data Driven Quality Improvement • Sustainable Business Operations

5. TCPi Network II. Practices Enrolled & Assessed I. Clinicians Enrolled by PTN There is a strong network of support available for these PTN Change Programs: • SANs • QIN-QIOs • TCPI National Faculty TCPI National Faculty Seven Levels of TCPI Performance III. PTN Delivers TA to Practices QIN-QIOs IV. Practices Transform (5 Phases) V. Practices Achieve Aims Set with PTN 29 PTN and 2 SAN 2.0 Programs VI. PTN Performance on 7 Aims SAN Action Partnerships with PTNs 10 SANs VII. Practices in APM

6. A Major Force within Connecticut State-wide geographic coverage 1 in 14 state residents impacted 90% of all Federally Qualified Health Centers (FQHCs) in CT

7. Activities to Transform Health Centers • Focus on the practice and their performance to improve the clinical experience for the patient • Monthly in-person meetings with CHCACT QI Advisors • Transformation Plan assistance • Data monitoring • Share information among participants to accelerate best practices and new learning • Quarterly in-person Quality Forums • Annual Summit • National Network • Gain reductions in cost through performance improvements • Data monitoring • Cost data sharing with CHN

8. Improving Diabetes Care Our Bold Aim: Our goal is to increase controlled Diabetics from 19.81% to 31.68%. Controlled Diabetic = Optimal Diabetes Care Composite 19,556 adult with diabetes

9. Optimal Diabetes Care: Our Progress % of adults with diabetes, with BP, LDL, and A1c in Control

10. PTN Cost Per Member Months by Quarter • Member months are the number of months each patient on Husky is covered. The Maximum per patient if 12. • As Member months have increased over the past 5 quarters, PMPM cost has decreased, which is a trend that we hope continues for the remainder of the grant. • Please note that the State reducing qualifying income levels can also affect member months.

11. Keys to Success • Encourage and use evidence-based best practices • Develop standards and tool to close performance gaps • Measure and track outcomes • Shared resources brought together (no silos) • Engaging national resources