Provider Insider

Leadership message

A message from Dr. Austin Bailey

The sole purpose of a Clinically Integrated Network—in its simplest terms—is to make life better. Better for providers. For payers. And, most importantly, for the individuals and families we care for.

In our short existence, we have focused on creating a blueprint for success that benefits everyone, and we’re making tremendous progress. This achievement is driven by strategy and tactical implementation, which, in turn, is driven by talented people.

Speaking of incredibly talented people, Coordinated Care is thrilled to have Dr. Jenny Bajaj join us as vice president of clinical integration and operations. It is essential that we develop infrastructure and processes that serve our providers, payers and patients, and Dr. Bajaj is the right person at the right time to lead us forward.

“I am excited to be at UCHealth because I believe we are on the cutting edge of health care,” says Dr. Bajaj. “Value-based care has the potential, when done right, to truly deliver on our promise to provide the very best care possible—and when patients need us most.”

I couldn’t have said it better myself. This is an important time in the evolution of health care, and Coordinated Care is even better positioned now to be an industry leader.

Prior to joining our leadership team, Dr. Bajaj served as chief medical officer for Paladina Health and president of Paladina Health Medical Group, a subsidiary of DaVita Health Care Partners, where she helped design and implement clinical informatics and operational systems for the rapidly growing direct primary care practice.

She also led population health and care management programs at Kaiser Permanente, both in the Colorado region and at the national level. As medical director of population health, she helped design and implement programs in care coordination, behavioral health integration, community programs for special needs populations, and transitions of care and informatics/decision support. During her tenure at Kaiser, Dr. Bajaj was responsible for:

• Orchestrating year-over-year improvements in blood pressure and diabetes control, achieving an overall 5-star quality rating
• Developing a protocol for automatic ordering of routine preventive and chronic condition care labs, as well as a results management program that vastly decreased the need to order labs or review normal results
• Training over 200 people in process improvement, and launching more than 40 quality improvement projects
• Designing a national physician process improvement workshop to train physician leaders

We’re already making significant progress in the acquisition and analysis of data that will lead to transformative changes in the care of complex patients. The addition of Dr. Bajaj’s expertise only accelerates our ability to make a difference along the Front Range.

I am confident Dr. Bajaj will take Coordinated Care to an even higher level of performance. Her wealth of experience in population data analysis and identifying opportunities for strategic and tactical improvements will drive our Quadruple Aim.

Our future is in good hands.

Austin Bailey, MD
Medical Director, Population Health, UCHealth

Practice spotlight

Meet Dr. Vu & the Matthews-Vu Medical Group

Practice: Matthews-Vu Medical Group

Location: Colorado Springs

Coordinated Care member since: 12/20/2017

Website: www.matthewsvu.com

Specialties: Pediatrics, family medicine, internal medicine

Dr. Richard Vu’s specialty is caring for adults with complex medical conditions. By focusing on health maintenance and disease prevention, he helps patients enjoy healthy and productive lives. Compassion, skill and the ability to treat the whole person are the hallmarks of his practice.

Dr. Richard Vu and his wife, Dr. Shabnum Matthews-Vu, founded Matthews-Vu Medical Group in 2004. They work with a group of physicians who have a deep commitment for patient-centered health care.

Matthews-Vu Medical Group’s vision is to provide exceptional health care for children and adults while providing a high level of exemplary service. Staff members are professional, courteous and friendly—they are driven to deliver a warm and welcoming practice environment.

Expansion: Matthews-Vu Medical Group opened a NEW medical building in 2018

Their pediatricians are now practicing in this location, on the same campus. The population health department at Mathews-Vu Medical Group, which assists all patients with coordinating their medical care, has expanded. This team focuses on the acute and chronic needs of patients who are medically complex, and facilitates transition of care. Urgent Care is now open seven days a week to offer same-day access for patients.

Population health strategy: Medicare CPC+ program

Participation in the CPC+ program through the Coordinated Care improves health care access for patients, addressing barriers to medical care, improving workflow, and facilitating communication between providers and patients. The perpetual goal is to increase value of care and improve quality of life for all patients.

Transformation insight

CU Trust is taking its commitment a step further

The University of Colorado (CU), CU Medicine and UCHealth formed the University of Colorado Health and Welfare Trust (CU Trust) in 2010 to help mitigate the rising costs of health care, tailor health plans to specific needs based on evidence-based approaches to health care, and emphasize a commitment to wellness.

CU Trust is taking its commitment a step further by entering into a Management Services Organization (MSO) agreement with Coordinated Care. Effective July 1, 2018, Coordinated Care will provide population health services to the three employer groups in the CU Trust. The agreement focuses on enhanced services that will improve quality, reduce cost and enrich the patient experience for employees and their dependents.

Below are the applicable product lines selected by each of the employer groups. These product lines are administered by the CU Trust’s third party administrator–Anthem Blue Cross and Blue Shield.

“We believe Coordinated Care is uniquely positioned to deliver enhanced population health services that would support these employer groups in achieving their mission,” says Kelly Henry, senior director, payer strategies and value-based contracting at Coordinated Care. “Many of our providers will contribute to this endeavor, and we look forward to everyone’s collective participation and impact.”

Planning is underway for the CU Trust program rollout in July 1, 2018. If you have any questions, please call Kelly Henry at 720.553.1643 or send an email to [email protected].

Quadruple Aim progress report

KPI dashboard delivers valuable insight

One of the major accomplishments of the Clinical Committee and Clinical Transformation Workgroup has been coming together to align on key performance indicators (KPIs) for clinical quality. Last fall, we implemented the initial KPIs. Now, all Coordinated Care providers have access to the KPI dashboards so that we can track our progress. At the provider and department level, the dashboards are available through Epic, while organizational, regional, city/location and network level summaries are available via PowerBI for members of the Clinical Transformation Workgroup.

We are very excited for this cross collaboration to define metrics, and the learning that follows for how we can all improve together for the health of our patients. We’ll be adding additional KPIs in the future as determined by the Clinical Transformation Workgroup and the Clinical Committee.

As we progress with Coordinated Care, we are in the process of building a balanced scorecard, which will include cost and utilization, access, patient experience and pharmacy. As we add new data elements, we will be able to better monitor our progress toward achieving the Quadruple Aim.

Coordinated Care’s Clinical Committee is comprised of stakeholders and leaders from UCHealth, UCHealth Medical Group, Associates in Family Medicine, Family Medicine Center and CU Medicine.

This committee analyzes data and prioritizes key program development to lower total cost of care while improving health outcomes. We encourage each of our provider partners to reach out with questions, suggest new ideas and share best practices. By working together, we can achieve the Quadruple Aim more efficiently.

If you have any questions regarding KPIs, the dashboard or the Clinical Committee’s efforts, please call Austin Bailey, MD, at 720.848.9332 or send an email to [email protected].

Pharmacy integration insights

2017 American College of Cardiology/American Heart Association Hypertension Guidelines: Lower blood pressure goals recommended for most patients

Coordinated Care provides access to clinical experts, and we are privileged to have hypertension expertise from Joseph Saseen, PharmD, professor and vice chair with the University of Colorado Skaggs School of Pharmacy.

In the very first episode of our “Clinical Pharmacy Insights” podcast, I ask Dr. Saseen to share his thoughts on the important changes to hypertension guidelines and how the changes might impact clinical practice.

Dr. Saseen holds an appointment with the University of Colorado School of Medicine, Department of Family Medicine, and has practiced as a clinical pharmacist at UCHealth A.F. Williams Family Medicine Clinic – Stapleton for nearly 20 years. He is a nationally and internationally recognized speaker on the topic of hypertension, has authored multiple book chapters on hypertension, and he has served as a clinical expert reviewer for the 2017 ACC/AHA hypertension guidelines.

Expert recommendations for best use of medication and appropriate clinical targets for chronic disease management are routinely updated as new evidence and clinical information become available. Clinical pharmacists can help providers stay updated to ensure treatment adheres to guideline recommendations.

The American College of Cardiology and American Heart Association recently published an updated guideline for the treatment of hypertension.¹ The previous standard of care hypertension guidelines were from JNC 7 and were published in 2003. Since that time, there have been other expert recommendations for important changes based on recent studies, most notably the SPRINT Trial, “A Randomized Trial of Intensive versus Standard Blood-Pressure Control.”² The following are important takeaways from the updated 2017 guidelines:

• New blood pressure (BP) goal of <130/80 mmHg for most patients with hypertension
• Change in BP classification; notably ≥130/80 mmHg is now used to define hypertension
• Greater emphasis on verifying hypertension diagnosis, utilizing both in-office strategies and home BP measurements to ensure accuracy
• No change in first-line therapy options: ACE inhibitor, ARB, thiazide diuretic and CCB

For more detailed information, here are links to documents summarizing the 2017 ACC/AHA hypertension guidelines. These provide tables and figures with blood pressure recommendations and treatment algorithms.

Click here to view the Brief Summary Document

Click here to view the Detailed Summary Document

Finally, I encourage you to watch the video below with Dr. Saseen showing the proper blood pressure measurement technique developed with support from the AHA Million Hearts Campaign. The proper blood pressure measurement technique is emphasized in the updated 2017 guidelines.

I look forward to sharing more “Clinical Pharmacy Insights” during our podcast next quarter. If you have any suggestions for future episodes, please reach out to me with your thoughts.

Thank you for listening!

Joseph Vande Griend, PharmD, BCPS, BCGP
Director of Population Health Pharmacy
UCHealth
[email protected]

Special thanks to Kristi Smith, PharmD student; Scott Pearson, PharmD, PGY2 pharmacy resident; and Joseph Saseen, PharmD, and professor of clinical pharmacy, all with the University of Colorado Skaggs School of Pharmacy, for their contributions to this article.

References:

1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017; doi: 10.1161/HYP.0000000000000065. [Epub ahead of print].
2. SPRINT Research Group. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2015. 373(22): 2103-16.

Network news

An update about what is happening within the Integrated Network

Welcome to Coordinated Care!

CMS SNF Three-Day Rule Waiver accepted

Our Provider Portal is on the horizon–connecting with providers is about to get easier

Did you know …

Welcome to Coordinated Care!

Beyond the original Coordinated Care members—UCHealth Medical Group, CU Medicine, Associates in Family Medicine and Family Medicine Center—30 additional practices have joined us, including locations in Steamboat Springs, Fort Collins, Colorado Springs and Pueblo. These equally committed providers will help improve patient accessibility and expand our footprint in Colorado:

CMS Skilled Nursing Facilities (SNF) Three-Day Rule Waiver accepted

We are pleased to share the wonderful news: The Centers for Medicare & Medicaid Services (CMS) accepted our application to participate in the CMS SNF 3-Day Rule Waiver, to review the details. MSSP patients no longer are required to spend three days in an acute hospital setting prior to admission to a skilled nursing facility.

Following an evaluation of a MSSP beneficiary and the decision to place the eligible patient in an approved SNF, the physician will place the order in Epic. The care manager will then assist with transferring the eligible patient to an approved SNF.

“This is incredibly exciting for Coordinated Care, as it will enhance patient care and lower hospital costs,” says Jenny Bajaj, MD, MPH, vice president, clinical integration, and operations.

Improving communication between Coordinated Care and participating providers is critical to achieving our quality health care goals.

“We’re encouraging all providers to share their ideas and best practices so everyone can benefit from our collective expertise,” says Dr. Austin Bailey, medical director, population health, UCHealth. “And I’m excited to share that communication is about to get even better.”

To ensure the timely distribution of essential information, Coordinated Care is developing a Provider Portal. The target completion date is the end of April 2018. Once live, the portal will deliver the following functionality:

• Secured access to Network providers/practices
• Provider directory
• Document repository (i.e., access to policies and procedures, forms, reports, etc.)
• Network provider/practice custom reports
• Secured messaging between and among Network providers/practice

We look forward to providing this necessary resource. More details on the Provider Portal and how to access it will be sent to you in an email before it goes live.

“… if an initial blood pressure reading is elevated, rechecking after resting five minutes and using proper technique, the blood pressure will be in control 70—80% of the time?”

—Dr. Jenny Bajaj

“… Coordinated Care’s composite quality performance for our Cigna population improved from an initial 18% to 56% over the past year?”

—Dr. Austin Bailey