CONGESTIVE HEART FAILURE CLINIC

Identifying Project and Provider Information: Category 2: Expand Chronic Care
Management Models; Project Option 2.2.2: Apply evidence-based care management
model to patients identified as having high-risk health care needs; 0941090802.2.2;
HCA Las Palmas Del Sol (0941090802).

Project Description: We propose to implement a Chronic Care Management Model
relating to patients with Congestive Heart Failure (CHF). The Congestive Heart
Failure Initiative will consist of a multi-disciplinary team of expert health
professionals to deliver optimal patient care through the utilization of current
evidence-based guidelines and the development and implementation of new
initiatives to meet service delivery gaps. The multi-disciplinary care team will be
composed of physicians, physician extenders, educators, behavioral health
professionals, pharmacological advisors, dieticians, nursing staff, and health care
navigators. This initiative will also enable the hospital to collaborate with communitybased home-health agencies whereby the home-health agencies will provide timely
feedback to help the prevention of unnecessary readmissions. The model will also
include a Clinical Information System (registry) to structure, organize, and trend
patient data for registries, performance measurements, and prevention services.
This registry we are considering is called CDEMS and is used by community health
centers, primary care practices, rural clinics, hospitals, and quality improvement
projects across the United States and in Canada, India, Haiti, and South Africa. This
program was developed and is shared by the Washington Diabetes Prevention and
Control Program. Using a registry that is widely utilized will better allow our
organization to report on patient populations with chronic health conditions.
Applications of self-management principles through patient-centered interventions
will include education resources, skill training, tele-scales, and psychosocial support.
By applying self-management principles, the support will empower and prepare
patients to manage their health and healthcare. Finally, this program will commit to
the education and training of healthcare professionals to include physicians, nurses,
ancillary staff, and community-based partners; such training will provide awareness
of the resources available.
o Goals: Utilizing current evidence-based guidelines to create hospital wide
standard protocols/pathways for the prevention, detection and management of
heart failure will result in healthier patients, decreased readmissions and cost
savings. Delivering optimal patient care in line with current evidence-based
guidelines to decrease complications and meet delivery gaps related to CHF due
to lack of collaborative management and lack of understanding, by the patient.
Promoting self-awareness and self-management with the result of improved
outcomes and increased continuity of care. Developing a centralized approach to
CHF management based upon clinical practice guidelines, which will result in
improved overall health for the hypertensive patient.
o Challenges: It will be difficult to notify the public of this available resource. ED
discharge and wrap-up of outpatient visits will be the best patient-care
opportunities to notify patients with Congestive Heart Failure of this outpatient
resource designed specifically for their needs.

Starting Point/Baseline: Las Palmas Del Sol is using protocols designed by the
American Heart Association “Get With the Guidelines” program and CMS core
measures that allows for in-house concurrent reviews by Quality management
personnel. There is no centralized program that brings these protocols together.

Rationale:
o The leading cause of death in the United States among all ethnicities is heart
disease; it is also a common cause of illness and disability. The principal form of
heart disease is coronary heart disease (CHD), also called ischemic heart
disease. It is caused by buildup of cholesterol deposits in the coronary arteries
that feed the heart. In the U.S. there are about 1.1 million persons who have a
heart attack or myocardial infarction every year. According to the Texas
Department of Health, in 1999 the death rate in El Paso County due to heart
disease was 203.5 per 100,000 population per year, compared to a rate of 272.7
per 100,000 population per year for Texas as a whole. While Hispanics have a
CHD death rate that is less than that of the U.S. population as a whole, it is still
the number one cause of death among Hispanics. The rate for CHD for the U.S.
population as a whole is 216 per 100,000 population per year compared to 151
per 100,000 population per year for Hispanics.
o There are many definitions of “chronic condition,” some more expansive than
others. We characterize it as any condition that requires ongoing adjustments by
the affected person and interactions with the health care system. The most
recent data show that more than 145 million people, or almost half of all
Americans, live with a chronic condition. That number is projected to increase by
more than one percent per year by 2030, resulting in an estimated chronically ill
population of 171 million. Almost half of all people with chronic illness have
multiple conditions. As a result, many managed care and integrated delivery
systems have taken a great interest in correcting the many deficiencies in current
management of diseases such as diabetes, heart disease, depression, asthma
and others. Those deficiencies include:
 Rushed practitioners not following established practice guidelines
 Lack of care coordination
 Lack of active follow‐up to ensure the best outcomes
 Patients inadequately trained to manage their illnesses

Related Category 3 Outcome Measure(s): OD-3: Potentially Preventable ReAdmissions—30 day Readmission Rates; IT-3.2: Congestive Heart Failure 30 day
readmission rate; (094109802.3.7).

Relationship to Other Projects: This project is part of LPDS’s larger plans to
expand and develop primary care and specialty care services, while improving
access to care and containing the costs of care. Specifically, this project will
complement LPDS’s Diabetes Management Registry project (094109802.1.3); both
of these projects are targeted towards patient populations for whom delivery system
reform could result in great improvements in the cost and quality of care, as well as
improvements in overall patient population health.

Relationship to Other Performing Providers’ Projects in the RHP: TBD

Plan for Learning Collaborative: TBD

Project Valuation: $7,663,758. The valuation of each LPDS project takes into
account the transformational impact of the project, the population served by the
project (both number of people and complexity of patient needs), the alignment of
the project with community needs, and the magnitude of costs avoided or reduced
by the project. In particular, this project has been valued based on the need for
these services for this patient population (i.e., congestive heart failure patients), and
the possibility of significant cost and quality improvement when the project is
implemented.
094109802.2.2
2.2.2.X
HCA Las Palmas Del Sol
094109802.3.7
IT-3.2
Related Category 3
Outcome Measure(s):
Year 2
(10/1/2012 – 9/30/2013)
Milestone 1: Establish baseline for
metrics P-2.1, P-3.1, P-4.1, P-9.1, and I17.1.
Metric 1: Establish baseline for future
years.
Milestone 1 Estimated Incentive
Payment: $1,874,284
2.2.2
Year 3
(10/1/2013 – 9/30/2014)
Milestone 2 [P-2]: Train staff in the
Chronic Care Model, including the
essential components of a delivery
system that supports high-quality
clinical and chronic disease care.
Metric 1 [P-2.1]: Increase percent of
staff trained.
Baseline/Goal: 10% increase over
DY 2 baseline.
Data Source: HR; training program
materials.
Milestone 2 Estimated Incentive
Payment: $511,186
Milestone 3 [P-3]: Develop a
comprehensive care management
program.
Metric 1 [P-3.1]: Documentation of
care management program. Best
practices such as the Wagner Chronic
Care Model and the Institute of
Chronic Illness’s Care Assessment
Model may be utilized in program
development.
Baseline/Goal: n/a
Data Source: Program materials.
Milestone 3 Estimated Incentive
Payment: $511,186
Milestone 4 [P-4]: Formalize multidisciplinary teams, pursuant to the
chronic care model defined by the
Wagner Chronic Care Model or
CONGESTIVE HEART FAILURE CLINIC
094109802
Congestive Heart Failure 30 day readmission rate
Year 4
(10/1/2014 – 9/30/2015)
Year 5
(10/1/2015 – 9/30/2016)
Milestone 6 [I-17]: Apply the Chronic
Care Model to targeted chronic
diseases which are prevalent locally.
Milestone 7 [I-17]: Apply the Chronic Care
Model to targeted chronic diseases which are
prevalent locally.
Metric 1 [I-17.1]: X additional patients
receive care under the Chronic Care
Model for a chronic disease or for
MCC.
Baseline/Goal: 10% increase over
DY 2 baseline.
Data Source: Registry.
Metric 1 [I-17.1]: X additional patients receive
care under the Chronic Care Model for a
chronic disease or for MCC.
Baseline/Goal: 10% increase over DY 4.
Data Source: Registry.
Milestone 6 Estimated Incentive
Payment: $2,050,687
Milestone 7 Estimated Incentive Payment:
$1,694,064
094109802.2.2
2.2.2.X
HCA Las Palmas Del Sol
094109802.3.7
IT-3.2
Related Category 3
Outcome Measure(s):
Year 2
(10/1/2012 – 9/30/2013)
2.2.2
CONGESTIVE HEART FAILURE CLINIC
094109802
Congestive Heart Failure 30 day readmission rate
Year 3
(10/1/2013 – 9/30/2014)
Year 4
(10/1/2014 – 9/30/2015)
Year 5
(10/1/2015 – 9/30/2016)
similar.
Metric 1 [P-4.1]: Increase the number
of multi-disciplinary teams or number
of clinic sites with formalized teams.
Baseline/Goal: 1 additional site.
Data Source: TBD by provider.
Milestone 4 Estimated Incentive
Payment: $511,186
Milestone 5 [P-9]: Develop program
to identify and manage chronic care
patients needing further clinical
intervention.
Metric 1 [P-9.1]: Increase the number
of patients identified as needing
screening test, preventative tests, or
other clinical services.
Baseline/Goal: 10% increase over
DY 2 baseline.
Data Source: EHR; patient registry.
Milestone 5 Estimated Incentive
Payment: $511,185
Year 2 Estimated Milestone Bundle
Amount: $1,874,284
Year 3 Estimated Milestone Bundle
Amount: $2,044,743
Year 4 Estimated Milestone Bundle
Amount: $2,050,687
TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD: $7,663,758
91317
Year 5 Estimated Milestone Bundle Amount:
$1,694,064