Project Option 2.12.2: Implement one or more pilot intervention(s) in care transitions targeting one or
more patient care units or a defined patient population: IMPLEMENT/EXPAND CARE TRANSITIONS
PROGRAMS
Unique Project ID: 130601104.2.1
Performing Provider Name/TPI: Providence Memorial Hospital / TPI: 130601104
Project Description:
This project will provide discharge planning assessment and intervention for targeted patients with a
high risk of readmission.
This project will involve identification and targeting of patients with the highest risk of readmission. This
project will support and enhance discharge planning assessment and intervention, with the
development of tools that assist case managers to identify and target those patients at risk for
readmission to the hospital within 30 to 60 days. The intent of this project is to improve the core
discharge planning function and support a safe, effective, and efficient transition to post-acute care. The
ultimate goal will be to reduce preventable readmissions by identifying and developing comprehensive
discharge plans that meet the needs of the high-risk population early in the patient stay. A
comprehensive and reliable discharge plan, along with post‐discharge support, can reduce readmission
rates, improve health outcomes, and ensure quality transitions.
Following the implementation of the project, quality improvement activities will be conducted to foster
continued learning by staff regarding the most effective methods for ensuring quality care transitions.
High-risk assessment will be integrated into an existing assessment, increasing the time a case manager
must have with the patient/family, making implementation of the project somewhat challenging.
Goals and Relationship to Regional Goals:
Project Goals: The goal of such this project is to ensure that the hospital discharge is accomplished
appropriately and that care transitions occur effectively and safely, as evidenced by identification and
targeting of patients that are high risk for re-admission and development of a discharge plan based on
the individualized patient needs. Through high-risk assessment at the point of admission, patients will
be identified and targeted and interventions will promote an individualized, effective and safe
transition. Transitions from inpatient care to the home setting will be supported and readmissions or
revisits within 30 to 60 days will be reduced.
This project meets the following regional goals: Implementing a tool to assess patients who are at a high
risk for readmission, would allow PMH to provide this patient population with a comprehensive
discharge/transition plan that will promote self-management of a chronic disease, and attainment of
community resources to support the patient in the appropriate health setting or home and avoid
preventable readmissions. This project would support the Regional goal of improvement management
of patients with chronic diseases and the goal of prevention of unnecessary readmissions. The project
would support the goal of getting patients the care they need to prevent, self-manage, and address in
an appropriate setting; The comprehensive transition plan from these high risk screenings would
facilitate the Regional goals of the provision of patient education to ensure the population is accessing
the right care in the right setting, assist in removing barriers to accessing healthcare resources in the
region; and Increase patient satisfaction through delivery of high-quality, effective healthcare services.
Challenges:
A major challenge facing the successful implementation of this project is the difficulty inherent in
ensuring that patients properly follow discharge instructions.
5-Year Expected Outcome for Provider and Patients:
Providence expects timely identification and targeting of patients with the highest risk of readmission
will support and enhance discharge planning assessment and intervention, with the development of
tools that assist case managers to identify and target those patients at risk for readmission to the
hospital within 30 to 60 days. PMH expects the improvement of the core discharge planning function.
The expectation then is to ultimately reduce preventable readmissions by identifying and developing
comprehensive discharge plans that meet the needs of the high-risk population early in the patient stay.
PMH believes that a comprehensive and reliable discharge plan, along with post‐discharge support, can
reduce readmission rates, improve health outcomes, and ensure quality transitions.
Starting Point/Baseline:
Evaluation of readmissions tied to identified diagnostic groups will provide the baseline data to
determine the starting point for case management training.
Rationale:
According to the Medicare Payment Advisory Committee, 76 percent of re-hospitalizations occurring
within 30 days in the Medicare population are potentially avoidable. Other populations affected include
patients with chronic diseases, complex medical and social needs and patients with little or no funding
resources for post-acute care needs. Evidence suggests that the rate of avoidable re-hospitalization can
be reduced by improving core discharge planning and transition processes out of the hospital, and by
improving transitions and care coordination at the interfaces between care settings.
Project Components:
This project will accomplish the following project components:
a) Implement one or more pilot intervention(s) in care transitions targeting one or more
patient care units or a defined patient population.
o
Providence will improve the core discharge planning function and support a safe,
effective, and efficient transition to post-acute care.
b) Conduct quality improvement for the project using methods such as rapid-cycle
improvement. Activities may include, but are not limited to, identifying project impacts,
“lessons learned,” opportunities to scale all or part of the project to a broader patient
population, and key challenges associated with expansion of the project, including special
considerations for safety-net populations.
o
Providence will continue to improve its discharge planning interventions by
conducting quality improvement activities following the implementation of the
interventions.
Unique community need identification numbers the project addresses:



CN-1: Primary Care
CN-2: Secondary and Specialty Care
CN-6: Other Projects
How the project represents a new initiative or significantly enhances an existing delivery system
reform initiative:
Implementing a tool to assess patients who are at a high risk for readmission, would allow PMH to
provide this patient population with a comprehensive discharge/transition plan that will promote selfmanagement of a chronic disease, and attainment of community resources to support the patient in the
appropriate health setting or home and avoid preventable readmissions. This will enhance the current
discharge planning process.
Related Category 3 Outcome Measures:
OD-3 Potentially Preventable Re-Admissions—30-Day Readmission Rates (PPRs)
IT-3.1: All-cause 30-day readmission rate
130601104.3.4
Reasons/rationale for selecting the outcome measures:
Providence anticipates that the enhanced discharge interventions for high-risk patients will create a
more effective post-discharge health management strategy. Through increased focus on these high-risk
patients, Providence will reduce the potentially, preventable readmissions rate at its facility.
Relationship to Other Projects: This project is part of Tenet’s larger plans to expand and develop
primary care and specialty care services in the El Paso community, while improving access to care and
containing the costs of care. Specifically, this project will complement Tenet’s Expand Primary Care
Access project (130601104.1.1) and Enhance Interpretation Services and Culturally Competent Care
project (130601104.1.2); each of these projects is intended to improve the patient experience by
providing care in more effective and efficient ways.
Relationship to Other Performing Providers’ Projects and Plan for Learning Collaborative:
This project complements Sierra Providence East Medical Center’s similar care transitions project.
Performing Providers, IGT entities, and the Anchor for Region 15 have held consistent monthly meetings
throughout the development of the Waiver. As noted by HHSC and CMS, meeting and discussing Waiver
successes and challenges facilitates open communication and collaboration among the Region 15
participants. Meetings, calls, and webinars represent a way to share ideas, experiences, and work
together to solve regional healthcare delivery issues and continue to work to address Region 15’s
community needs. UMC, as the Region 15 Anchor anticipates continuing to facilitate a monthly
meeting, and potentially breaking into workgroup Learning Collaboratives that meet more frequently to
address specific DSRIP project areas that are common to Region 15, as determined to be necessary by
the Performing Providers and IGT entities. UMC will continue to maintain the Region 15 website, which
has updated information from HHSC, regional projects listed by Performing Provider, contact
information for each participant, and minutes, notes and slides from each meeting for those parties that
were unable to attend in-person.
Region 15 participants look forward to the opportunity to gather annually with Performing Providers
and IGT entities state-wide to share experiences and challenges in implementing DSRIP projects, but also
recognize the importance of continuing ongoing regional interactions to effectuate change locally.
Through the use of both state-wide and regional Learning Collaborative components, Region 15 is
confident that it will be successful in improving the local healthcare delivery system for the low-income
and indigent population.
Project Valuation
$6,717,071. In determining the value of this project, Tenet considered the extent to which newlyimplemented or expanded care transitions programs will address the community’s needs, the
population which this project will serve, the resources and cost necessary to implement the project, and
the project’s ability to meet the goals of the Waiver (including supporting the development of a
coordinated care delivery system, improving outcomes while containing costs, and improving the
healthcare infrastructure). Specifically, the valuation of this project takes into account the potential of
better care transition management to improve quality of care and thereby improve patient satisfaction
and patient outcomes. The valuation of this project also takes into account the challenges that
Providence will face in implementing this project in the hospital setting.
Tenet plans to implement a similar Category 2 project at its Sierra Providence East Medical Center
location, serving a different geographic area of the city. The disparity in valuation between this
Providence project and the similar Sierra East project is due to the fact that Providence is a much larger
facility than Sierra East (with 508 beds, compared to 110 at Sierra East) and accounts for 270% more
Medicaid and uninsured days than Sierra East.
130601104.2.1
2.12.1.X
Providence Memorial Hospital
130601104.3.4
IT-3.1
Related Category 3
Outcome Measure(s):
Year 2
(10/1/2012 – 9/30/2013)
Milestone 1: Establish baseline for
metrics P-2.1, P-7.1, and I-11.1.
Metric 1: Establish baseline for future
years.
Milestone 1 Estimated Incentive
Payment: $1,6,42,757
2.12.1
IMPLEMENT/EXPAND CARE TRANSITIONS PROGRAMS
130601104
All cause 30 day readmission rate
Year 3
(10/1/2013 – 9/30/2014)
Milestone 2 [P-2]: Implement
standardized care transition
processes.
Metric 1 [P-2.1]: Care transitions
policies and procedures.
Baseline/Goal: n/a
Data Source: Policies and
procedures of care transitions
program materials.
Milestone 2 Estimated Incentive
Payment: $896,080
Milestone 3 [P-7]: Develop a staffing
and implementation plan to
accomplish the goals/objectives of
the care transition program.
Year 4
(10/1/2014 – 9/30/2015)
Year 5
(10/1/2015 – 9/30/2016)
Milestone 4 [I-11]: Improve the
percentage of patients in defined
population receiving standardized care
according to the approved clinical
protocols and care transitions policies.
Milestone 5 [I-11]: Improve the percentage of
patients in defined population receiving
standardized care according to the approved
clinical protocols and care transitions policies.
Metric 1 [I-11.1]: Number over time of
those patients in target population
receiving standardized, evidencebased interventions per approved
clinical protocols and guidelines.
Baseline/Goal: 15% improvement.
Data Source: Registry or EHR
report/analysis.
Milestone 4 Estimated Incentive
Payment: $1,797,370
Metric 1 [I-11.1]: Number over time of those
patients in target population receiving
standardized, evidence-based interventions
per approved clinical protocols and
guidelines.
Baseline/Goal: 25% improvement.
Data Source: Registry or EHR
report/analysis.
Milestone 5 Estimated Incentive Payment:
$1,484,784
Metric 1 [P-7.1]: Documentation of
the staffing plan.
Baseline/Goal: n/a
Data Source: Staffing and
implementation plan.
Milestone 3 Estimated Incentive
Payment: $896,080
Year 2 Estimated Milestone Bundle
Amount: $1,642,757
Year 3 Estimated Milestone Bundle
Amount: $1,792,160
Year 4 Estimated Milestone Bundle
Amount: $1,797,370
TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD: $6,717,071
93835.7
Year 5 Estimated Milestone Bundle Amount:
$1,484,784