Great Lakes Practice Transformation Network Gregory J. Makris, MD – Clinical Lead, Michigan

CMS Disclaimer The Great Lakes Practice Transformation Network is supported by Funding Opportunity Number CMS-1L from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Agenda Current Health System Landscape TCPI and the Great Lakes Practice Transformation Network Clinical Quality Improvement in Action

The Problem: Increasing Healthcare Costs

CMS shifting to value-based payments

3 major changes to payment regulations Physicians are measured in four performance categories scored 0-100

Agenda Problem: Current Health System Landscape TCPI and the Great Lakes Practice Transformation Network Clinical Quality Improvement in Action

The Solution: TCPI Support more than 140,000 clinicians in their practice transformation work Improve health outcomes for millions of Medicare, Medicaid and CHIP beneficiaries and other patients Reduce unnecessary hospitalizations for 5 million patients Generate $1 to $4 billion in savings to the federal government and commercial payers Sustain efficient care delivery by reducing unnecessary testing and procedures Transition 75% of practices completing the program to participate in Alternative Payment Models Build the evidence base on practice transformation so that effective solutions can be scaled

TCPI Five Phases of Practice Transformation Set aims Use data to drive care Achieve progress on aims Achieve benchmark status Thrive as a business via pay-for- value approaches

Great Lakes Practice Transformation Network 33 healthcare partners 7 universities $46.4M received $1B in cost savings Indiana, Michigan, Illinois, Ohio, Kentucky, West Virginia 15,000+ clinicians (35% over goal!) 10+ million lives impacted 52 on-site, on-demand Quality Improvement Advisors

Optimizing use of EHR Custom workflow evaluation and coaching Support for aligning and streamlining existing quality and data reporting efforts Implementation of Chronic Care Management Preparation for value-based payment models Free CME and MOC Part IV

Support and Alignment Networks 10 Support and Alignment Networks (SANs) offer personalized resources and best practices to help clinicians integrate evidence-based care to improve value for patients.

Agenda Current Health System Landscape TCPI and the Great Lakes Practice Transformation Network Clinical Quality Improvement in Action

6 Clinical Quality Areas of Focus Medication Management Controlling high blood pressure Anticoagulation therapy in patients with atrial fibrillation Unnecessary Testing Advanced diagnostic imaging Esophageal-gastric-duodenoscopy (EGD) Colonoscopy Prevention Influenza vaccination rates Behavioral Health Depression screening and follow-up Chronic Disease Management Diabetes Chronic Obstructive Pulmonary Disorder (COPD) Congestive Heart Failure (CHF) Reducing Preventable Hospitalizations

Goals for CME and MOC Part IV Activities Chosen topics are of interest to a majority of potential participants Requirements are easily attainable Activities align with GLPTN TA value proposition QI measures help support PQRS reporting requirements

Depression Suicide is the 10 th leading cause of death Prevalent Decreased Productivity Increased risk for other issues Screening is not enough

QI Supported by CME/MOC part IV *Baseline period is 1 month prior to participation/training *Post-Intervention period is month 3 of participation *Post-Adjustment period is months 5 and 6 of participation

Hypertension The most common condition seen in primary care, HTN leads to: – Heart Attack (Myocardial Infarction, MI) – Stroke (Cerebrovascular Accident, CVA) – Kidney Failure (Chronic Renal Failure, CRF or CKD) – Death “But how bad is it really, doc?” – Heart disease and stroke are the 1 st and 4 th causes of death in the United States. – “Silent Killer”

QI needs to be meaningful. Providers are busy. Challenges, Barriers and the Future

Thank you! Questions? Website: glptn.org