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

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
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
All 3 Components of Diabetes Composite Measure must be met for practice to receive credit for numerator being met as controlled.
Bold Aim was made in initial RFP

9. Optimal Diabetes Care: Our Progress
% of adults with diabetes, with BP, LDL, and A1c in Control
Our Diabetes Care Composite results have enjoyed consistent, incremental improvement from quarter to quarter. The incremental improvement translates into over 1,400 more patients becoming “controlled”, which is a 53% increase from baseline. We are also experiencing high levels of patient engagement, as at least 68% of our 19k plus diabetic patients are being seen quarterly.
So how have we done this?
This measure included as one of the AIMS for all of our practices – so all practices are working on this composite measure. As their efforts to improve Diabetes Care evolve, some practices are standing out:
Diabetes Clinic (19% - 25%) - Urban Health Center
All patients with A1c>9 are referred by their PCP to the clinic
The “clinic” is comprised of a care team (APRN, MA, Nutritionist, Pharmacist) dedicated to Diabetes Care
Patient meet quarterly with both the APRN & Nutritionist, and sometimes with the Nutritionist between visits
Patient graduate when they meet all 3 of the composite components
When patients graduate, their success is celebrates with a certificate of accomplishment.
Care Management (6.14% %!) – Rural Health Center
Partner with Quest Diagnostics to receive a list of patients with A1c>9
Patient are assigned Case Management services, where a shared care plan is developed either over the phone or in person
Health Center Nutritionist runs a monthly Diabetes Support Group AND a monthly Nutrition & Cooking class .

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