DSRIP Plan: Kern Medical Center
Page 1
CATEGORY 1: Infrastructure Development
Project
Increase Primary Care
Capacity



Description
Increase clinic hours to evenings and weekends
Triage patient appointments to ensure that same
day appointment slots are available for the most
urgent patients
Provide urgent appointments within 3 calendar
days of request
Y1:
Y2:
Y3:
Y4:
Y5:
Implement and Utilize
Disease Management
Registry Functionality



Design disease registry reporting plan and
structure
Train at least 10 champions on populating and
using the registry functionality
Expand the use of the registry to all areas of KMC
with diabetic patients, including the primary care
clinics, diabetic clinic, eye clinic, podiatry clinic
and inpatient floors
Y1:
Y2:
Y3:
5-Year Goals
Develop a plan to expand the hours of primary care clinic to include
evenings and weekends, as measured by (a) identification of current
patient volume (b) Assessment of new patient waiting list (c)
development of plan to expand the hours and (d) a plan to re-integrate
urgent appointments into primary care clinics, including triaging
patients so that patients can be seen by their primary care provider
teams
(1) Implement a nurse triage software system to assist nurses in
determining the acuity of patients; (2) Hire and train at least 2
additional primary care nurses; (3) Provide 20% of patients that request
urgent appointments, an appointment in the primary care clinic (instead
of having to go to the ED or an urgent care clinic) within 3 calendar days
of request
(1) Expand the hours of the primary care clinic by at least 8 hours per
week; (2) Provide 40% of patients that request urgent appointments, an
appointment in the primary care clinic (instead of having to go to the ED
or an urgent care clinic) within 3 calendar days of request
(1) Expand the hours of the primary care clinic by at least 16 hours per
week; (2) Patient access to primary care by reducing days to third nextavailable appointment within 30 calendar days
Patient access to primary care by maintain 30 calendar days to third
next-available appointment
Demonstrate and design registry reporting ability to track and report on
patient demographics, diagnoses, patients in need of services or not at
goal and preventive care status
(1) Expand registry report services to provide on-demand, operational
and historical capabilities, inclusive of reports to care providers,
managers and executives; (2) Conduct staff training for at least 10 staff
on populating and using the registry
(1) Spread registry functionality and training to inpatient floors and 6
outpatient clinic site that provide continuity of care for the diabetes
population; (2)Enter patient data into the registry for at least 50% of
patients with diabetes who are assigned to a KMC primary care clinic as
their medical home
Enhance Urgent Medical
Advice

Expand Specialty Care
Capacity

DSRIP Plan: Kern Medical Center
Page 2
Y4: Enter patient data into the registry for at least 65% of patients with
diabetes who are assigned to a KMC primary care clinic as their medical
home
Y5: Enter patient data into the registry for at least 65% of patients with
diabetes who are assigned to a KMC primary care clinic as their medical
home
Y1: (1) Establish baseline and metrics of the 24/7 Nurse Line and Health
Provide urgent medical advice so that patients
Information Library. Includes at least the following metric baselines: (a)
who need it can access it telephonically so that
number of patients that access the nurse advice line and (b) number of
avoidable utilization of urgent care and the ED
patients that called the nurse advice line and reported intent to go to
can be reduced
the ED for non-emergency conditions; (3) Inform and educate 5,000
patients on the nurse advice line
Y2: (1) Inform and educate an additional 5,000 (10,000 total) patients on
the nurse advice line; (2) Increase the number of patients that accessed
the nurse advice line by 10% over baseline established in Year 1; (3)
Develop and distribute 5,000 patient-focused newsletters with
proactive health information and reminders based on nurse advice line
data / generated report identifying common areas addressed by the
nurse advice line and topics searched for in the Health Information
Library
Y3: (1) Increase in the number of patients that accessed the nurse advice
line by 25% over baseline established in Year 1; (2) Develop and
distribute 10,000 patient-focused newsletters with proactive health
information and reminders based on nurse advice line data / generated
report identifying common areas addressed by the nurse advice line and
topics searched for in the Health Information Library; (3) Increase the
number of patients that called the nurse advice line with intent to go to
the ED for non-emergency conditions who were redirected to non-ED
resources by 10% over baseline established Year 1.
Y4: (1) Increase in the number of patients that accessed the nurse advice
line by 40% over baseline established in year 1; (2) Increase the number
of patients that called the nurse advice line with intent to go to the ED
for non-emergency conditions who were redirected to non-ED
resources by 25% over baseline established Year 1.
Y5: Increase the number of patients that called the nurse advice line with
intent to go to the ED for non-emergency conditions who were
redirected to non-ED resources by 25% over baseline established Year 1.
Conduct a gap analysis to determine the specialty Y1: (1) Collect baseline data for wait times, backlog and now show rates in
at least 8 specialty clinics; (2) Train 25 primary care providers and/or
care needs of the community


Enhance Interpretation
Services and Culturally
Competent Care






DSRIP Plan: Kern Medical Center
Page 3
staff on processes, guidelines and technology for referrals and
Implement specialty care guidelines for the
consultations; (3) Launch a musculoskeletal clinic
highest demand specialties.
Expand the number of current specialty providers Y2: (1) Conduct a specialty care gap analysis based on community need by
assessing specialty clinic supply and demand, capacity and productivity;
and/or specialty clinic hours for the highest need
(2) Based on results of gap analysis, increase the number of specialist
specialties to expand the supply of specialty care
providers and/or clinic hours available for at least 2 high impact / most
impacted medical specialties identified in the gap analysis; (3) Establish
3 specialty care guidelines for the high impact / most impacted medical
specialties identified in the gap analysis
Y3: (1) Establish 3 additional (6 total) specialty care guidelines for the high
impact / most impacted medical specialties identified in the gap
analysis; (2) Based on the results of gap analysis, increase the number of
specialist providers and / or clinic hours available for at least 1
additional (3 total) high impact / most impacted medical specialties
Y4: Based on results of gap analysis, increase the number of specialist
providers and/or clinic hours available for at least 1 additional (4 total)
high impact / most impacted medical specialties
Y5: No milestones identified
Y1: (1) Conduct an analysis to determine gaps in language access through a
Identification of language access needs and/or
survey to determine availability of interpretative equipment within the
gaps in language access
hospital and its outpatient clinics; (2) Expand capacity of qualified
Addition of interpreter technology in inpatient
healthcare interpretation workforce to 2 full time staff on HCIN; (3)
and outpatient areas
Establish baseline data of qualified interpreter encounters and number
Expansion of certified qualified healthcare
of video or audio conferencing points of access and/or units within
interpreters by 50%
inpatient and outpatient areas of the hospital.
Increased training related to language access
Y2:
(1) Train 50% of direct patient care staff and/or providers in patient
Training of staff “ champions” related to cultural
areas to appropriately utilize health care interpreters (via video, phone
competency / sensitivity
or in person); (2) Develop and implement a training program for 10
Improving language access through an increase in
“champions” to improve cultural competency; (3) Develop a plan to
qualified healthcare encounters
expand the interpreter technology to additional patient care areas
within the hospital and its outpatient clinics; (4) Improve language
access through a 5% increase from baseline in qualified interpreter
encounters per month
Y3: (1) Train 50% of direct patient care staff and/or providers in outpatient
care areas to appropriately utilize health care interpreters (via video,
phone, or in person; (2) Train 10 additional (20 total) designated
champions / staff to improve cultural competency in outpatient areas;
(3) Expand the interpreter technology (video or audio units) by 5% over
baseline in year 1; (4) Improve language access through a 10% increase
DSRIP Plan: Kern Medical Center
Page 4
from baseline in qualified interpreter encounters per month.
Y4: (1) Expand the interpreter technology (video or audio units) by 5% from
previous year; (2) Improve language access through a 15% increase from
baseline in qualified interpreter encounters per month
Y5: (1) Improve language access through a 20% increase from baseline in
qualified interpreter encounters per month
CATEGORY 2: INNOVATION AND REDESIGN
Expand Medical Homes


Redesigning Primary
Care



60% of new patients assigned to county medical
homes that are contacted for their first patient
visit within 120 days
75% of patients per year who need to receive a
screening exam will be provide with reminders
for Chlamydia screenings, cancer screenings and
cholesterol screenings
Increasing efficiency in clinics through the
implementation of the patient visit redesign
model
Improving appointment access and convenience
through patient-centered scheduling
Improving scheduling and registration efficiency
through the implementation of a practice
management system
Y1: Determine the appropriate panel size for primary care provider teams,
potentially based on staff capacity, demographics and disease
Y2: (1) Put in place policies and systems to enhance patient access to the
medical home; (2) Assign at least 1,500 of eligible patients(where
eligible is defined as eligible for Kern County’s LIHP program) to medical
homes; (3) At least 40% of new patient assigned to medical homes will
be contacted for their first patient visit within 120 days
Y3: (1) Assign at least 2,500 of eligible patients(where eligible is defined as
eligible for Kern County’s LIHP program) to medical homes; (2) At least
60% of new patient assigned to medical homes will be contacted for
their first patient visit within 120 days
Y4: Medical home provides population health management by identifying
and reaching out to 50% of patients who need to be brought in for
preventive and ongoing care
Y5: Medical home provides population health management by identifying
and reaching out to 75% of patients who need to be brought in for
preventive and ongoing care
Y1: Establish implementation plan and collect baseline data for patient
appointment “no show” rates, days to third-next available appointment,
and primary care visit cycle time
Y2: (1) Implement patient visit redesign in primary care clinics; (2)
Implement the patient-centered scheduling model in primary care
clinics; (3) Implement practice management system
Y3: (1) Reduce patient appointment no-show rate to 25%; (2) Reduce
average visit cycle time for at least 2 primary care clinics to 60 minutes
or less – without reducing the time a patient spends with his/her
provider from baseline Year 1
Y4: (1) Reduce patient appointment no-show rates to 15%; (2) Reduce
average visit cycle time for at least 2 additional (total 4) primary care
clinics to 60 minutes or less – without reducing the time a patient
spends with his/her provider from baseline Year 1
Integrate Physical and
Behavioral Health Care


Establish a Patient Care
Navigation Program


DSRIP Plan: Kern Medical Center
Page 5
Y5: (1) Maintain patient appointment no-show rates at 15%; (2) Maintain
average visit cycle time for primary care clinics to 60 minutes or less –
without reducing the time a patient spends with his/her provider from
baseline Year 1
Y1: (1) Train at least 15 primary care clinicians on primary care management
60% of patients discharged from an inpatient
of behavioral health conditions; (2) Establish, implement and distribute
psychiatric unit will be assigned a medical home
referral guidelines for referring to the behavioral health care provider
45 % increase in patients who have access to
behavioral health services amount those patients Y2: (1) Train at least 20 additional (35 total) primary care clinicians on
primary care management of behavioral health conditions; (2) Co-locate
identified as having a behavioral health need
behavioral health and primary care, as measured by at least 2
behavioral health providers in primary care clinics; (3) Development of a
tracing mechanism of referrals from primary care providers to on-site
behavioral health professionals
Y3: (1) Establish policies and procedures for a more robust inpatient
discharge coordination with outpatient medical home providers for
patients with behavioral health needs; (2)Increase from baseline 15% of
patients with a behavioral health care need as identified by the primary
care provider, who have access to behavioral health care (e.g. , visits
with social workers, case managers or psychiatrists), as needed
Y4: (1) Assign 40% of patients discharged from the inpatient psychiatric unit
to a medical home; (2) Increase from baseline 25% of patients with a
behavioral health care need as identified by the primary care provider,
who have access to behavioral health care (e.g. visits with social
workers, case managers or psychiatrists), as needed
Y5: (1) Assign 60% of patients discharged from the inpatient psychiatric unit
to a medical home; (2) Increase from baseline 45% of patients with a
behavioral health care need as identified by the primary care provider,
who have access to behavioral health care (e.g. visits with social
workers, case managers or psychiatrists), as needed
Y1: (1) Establish care navigation program to provide support to patient
Implement a navigation program with 2 care
populations who are at most risk of receiving disconnected and
navigators for populations most at risk of
fragmented care; (2) Provide care management and navigation services
receiving disconnected care (patients with high
to 60 targeted patients who are high utilizers of the Emergency
past utilization of inpatient and emergency
Department and/or inpatient services
services)
Y2: (1) Increase patient engagement by completing 5 patient engagement
Implement an ED navigator program to educate
initiatives; (2) Expand program to include ED navigator who educates
patients on the importance of primary care and
patients on the importance of primary care; connects patients to a new
coordinate with other community clinics and the
Primary Care Clinic and/or assists patient in getting following
county primary clinics to provide appointment
appointment with established PCP.
slots for patients upon discharge from the ED
DSRIP Plan: Kern Medical Center
Page 6
Y3: (1) Provide navigation services to patients using ED for episodic care; (2)
Measure ED visits and/or avoidable hospitalizations for patients
enrolled in the care management / navigator program for high utilizers
of the Emergency Department and/or inpatient services
Y4: (1) Provide navigation services to patients using ED for episodic care; (2)
Measure Ed visits and/or avoidable hospitalizations for patients enrolled
in the care management / navigator program for high utilizers of the
Emergency Department and/or inpatient services
Y5: Provide a primary care appointment to 30% of the patients who need a
follow-up primary care appointment after being discharged from the ED
CATEGORY 4: URGENT IMPROVEMENT IN CARE
Improve Severe Sepsis
Detection and
Management

Central Line Associated
Blood Stream Infection
(CLABSI) Prevention



implement Sepsis Management and Resuscitation
Bundle
Reduce avoidable harm or deaths due to severe
sepsis to patients receiving inpatient services
improve compliance with central line insertion
bundle
Reduce avoidable harm or deaths and costs of
care due to central-line associated blood stream
infections
Y1: Implement a sepsis bundle data collection and reporting method
Y2: (1) Complete a gap analysis of current processes re: sepsis; (2) Develop
a formalized inter-professional protocol based on Sepsis Resuscitation
Bundle; (3) Participate in Patient Safety First Collaborative of
Sacramento and Central Valley Region for Sepsis; (4) Implement
education on treatment of sepsis in both critical and non-critical patient
care settings; (5) Report at least 6 months of data collection on Sepsis
Resuscitation Bundle to SNI for baseline / benchmarks; (6) Report
results to the state
Y3: (1) achieve TBD% compliance with sepsis resuscitation bundle; (2) share
data and practices with SNI for benchmarking across public hospitals; (3)
Report results to the state
Y4: (1) achieve TBD% compliance with sepsis resuscitation bundle; (2) share
data and practices with SNI for benchmarking across public hospitals; (3)
Report results to the state
Y5: (1) achieve TBD% compliance with sepsis resuscitation bundle; (2) share
data and practices with SNI for benchmarking across public hospitals; (3)
Report results to the state
Y1: Implement a central line insertion practice (CLIP) data collection and
reporting method
Y2: (1) Complete a gap analysis of current processes; (2) Develop a
formalized inter-professional “Central-line Treatment Protocol”; (3)
Participate in Patient Safety First Collaborative of Sacramento and
Central Valley Region; (4) Implement education on treatment and
management of CLIP; (5) Report at least 6 months of data collection on
CLIP to SNI for baseline / benchmarks; (6) Report at least 6 months of
data collection on CLABSI to SNI for baseline / benchmarks ; (7) Report
Surgical Site Infection

Hospital-acquired
Pressure Ulcer (HAPU)
Prevention

Stroke Management
Venous
Thromboembolism (VTE)
Prevention & Treatment

DSRIP Plan: Kern Medical Center
Page 7
CLIP results to state
Y3:
(1)achieve TBD% compliance with CLIP; (2) share data and practices
with SNI; (3) report CLIP and CLABSI results to State
Y4:
(1) achieve TBD% compliance with CLIP; (2) reduce central line
bloodstream infections by TBD%; (3) share data and practices with
SNI; (4) report CLIP and CLABSI results to State
Y5:
(1) achieve TBD% compliance with CLIP; (2) reduce central line
bloodstream infections by TBD%; (3) share data and practices with
SNI; (4) report CLIP and CLABSI results to State
Not a selected intervention by Kern Medical Center
improve surgical site infection prevention

Y1: Implement a HAPU data collection and reporting method
Use a multi-disciplinary team approach to the
Y2: (1) Share data, promising practices and findings with SNI to foster
prevention of pressure ulcers using evidenceshared learning and benchmarking across the California public hospitals;
based recommendations from the national
(2) Report HAPU prevalence results to the state
Pressure Ulcer Advisory Panel
Y3: (1) Achieve HAPU prevalence of less than 5.5%: (2) Share data,
promising practices and findings with SNI to foster shared learning and
benchmarking across the California public hospitals; (3)Report HAPU
prevalence to the state.
Y4: (1) Achieve HAPU prevalence of less than 3.2%: (2) Share data,
promising practices and findings with SNI to foster shared learning and
benchmarking across the California public hospitals; (3)Report HAPU
prevalence to the state.
Y5: (1) Achieve HAPU prevalence of less than 1.1%: (2) Share data,
promising practices and findings with SNI to foster shared learning and
benchmarking across the California public hospitals; (3)Report HAPU
prevalence to the state.
Not a selected intervention by Kern Medical Center
Prevent VTE by checking patients for risk of blood Y1: Implement a VTE data collection and reporting method
Y2: (1) Complete a gap analysis of current processes for assessment and
clots and taking appropriate steps to prevent
prophylactic treatment of VTE; (2) Develop a formalized interthem
professional VTE Prevention Treatment Protocol based on AHRQ; (3)
Implement education on VTE prevention and treatment; (4) Report at
least 6 months of data to SNI for baseline / benchmarks; (5) Report the
5 VTE process measures to the state
Y3: (1) increase by TBD rate the rate of patients who received VTE
prophylaxis or documentation why no VTE prophylaxis given the day of
or day after hospital admission or surgery end date; (2) increase by TBD
rate the rate of patients who received VTE prophylaxis or
Falls with Injury
Prevention

DSRIP Plan: Kern Medical Center
Page 8
documentation why no VTE prophylaxis given the day of or the daty
after initial admission to ICU or surgery end date; (3) increase by TBD
rate the rate of patients diagnosed with confirmed VTE who received
and overlap of parenteral IV or subcu anticoagulation and warfarin
therapy; (4) increase by TBD rate the rate of patients diagnosed with
confirmed VTE who received IV UFH therapy dosages AND had platelet
counts monitored using defined parameters; (5) increase by TBD rate
the rate of patients diagnosed with confirmed VTE that are discharged
to home, home care, court/law enforcement or home on hospital care
on warfarin with written discharge instructions that address all criteria;
(6) share data and findings with SNI; (7) report 5 VTE process measures
to State
Y4: Same as Y3 with adjusted rates
Y5: Same as Y4 with adjusted rates
Not a selected intervention by Kern Medical Center