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Live Well, Dubuque Proposal_Health Innovation Grant Program Round 2Masterpiece on the Mississippi Dubuque band AI- America City 11111r 2007 • 2012 • 2013 TO: The Honorable Mayor and City Council Members FROM: Michael C. Van Milligen, City Manager SUBJECT: Health Innovation Grant Program Round 2 - Live Well, Dubuque Proposal DATE: August 15, 2013 Assistant City Manager Teri Goodmann and Public Health Specialist Mary Rose Corrigan are recommending that the City submit a $8.0 million Live Well, Dubuque Federal grant application. I concur with the recommendation and respectfully request Mayor and City Council approval. Michael C. Van Milligen MCVM:jh Attachment cc: Barry Lindahl, City Attorney Cindy Steinhauser, Assistant City Manager Teri Goodmann, Assistant City Manager Mary Rose Corrigan, RN, Public Health Specialist THE CITY OF Dui Masterpiece on the Mississippi TO: Mike Van Milligan, City Manager Dubuque band AI- America City 11111r 2007 • 2012 • 2013 FROM: Teri Goodmann, Assistant City Manager Mary Rose Corrigan, Public Health Specialist SUBJECT: Health Innovation Grant Program Round 2 - Live Well, Dubuque Proposal DATE: August 15, 2013 Introduction The purpose of this memo is to provide you with information on the Health Innovation Grant Program Round 2 - Live Well, Dubuque proposal for $8.0 million that was submitted to the Centers for Medicare and Medicaid Services. Background Dubuque seeks to be one of the healthiest cities in America. The City is working cooperatively with hospitals, clinics and health care providers to help connect the dots to improve health outcomes and reduce costs. The proposed Live Well, Dubuque project's key components include: • Community Health Collaborative — Dubuque hospitals and clinics are interested in forming a Community Health Collaborative. The Collaborative will provide member organizations with higher levels of efficiency and effectiveness by allowing them to implement some consistent community -wide practices and models to address some of the most important health care challenges today. The Collaborative will also work with physicians and other providers throughout the region to assist them in strengthening their practices. The collaboration can provide information technology, community resources and supply chain management, and health care provider education and support. • Care Coaches — Care Coaches will combine health coaching and case management skills to support healthier patients, reducing Medicare, Medicaid and Children's Health Insurance Program (CHIP) costs. Each Care Coach will serve approximately 200 clients annually, and provide a conduit for residents to understand and access Dubuque's existing health programs, services and other infrastructure. • Education and Marketing Campaign — Dubuque is interested in launching a community - wide, coordinated health education and marketing campaign, focused on preventive measures. Raising the awareness of Dubuque's available health tools and resources will further help to improve health outcomes and reduce costs. Specifically, the Collaborative, Care Coaches and education and marketing campaign will help connect patients with the existing health programs, services and other infrastructure across Dubuque, including the Crescent Community Health Center, preventive health services, the Wellness Center, diabetic education programs, tobacco cessation counseling and assistance, healthy food opportunities and community gardens, the City's Green & Healthy Homes Initiative, recreational opportunities such as the area's extensive trail network, and other programs that help address the social determinants of health. What makes this model unique is that it effectively leverages existing local, state, federal and private resources. While there are many preventive health services available in the Dubuque community, the Live Well, Dubuque model is inventive because it helps to streamline and better connect residents with those programs, thereby reducing overlap and optimizing health care delivery. Dubuque will shift to a comprehensive care or total cost of care (TCoC) payment model to reduce costs. A total cost of care model involves providing a single risk - adjusted payment for the full range of health care services needed by a specified group of people for a fixed period of time. The benefits associated with this model are improved flexibility for providers in terms of care delivery; greater potential for innovation in delivery design (including use of community resources, programs and public health initiatives); incentives to deliver care efficiently; better collaboration among providers who serve a particular population; and stronger emphasis on maximizing health. Action: This memo is for information only. No action is required. TG:sv Attachments 2 Masterpiece ��" ^ Mississippi ' on the l�/1J�5/��l7Y�1 August 15, 2013 Dubuque ric e- zmr'zmz'zma Ms. Mary Greene Grants Management Officer Office ofAcquisition and Grants Management Ceriters for Medicare and Medicaid Services U.S. Department of Health and Human Services Mail Stop B3-30-03 7500 Security Boulevard Baltimore, Maryland 21218 Dear Ms. Greene, City Manager's Office City Hall oo West 13th Street Dubuque, IA 52001'4805 Office (563) 589-4110 Fax (563) 589-4149 TTY (563) 690-6678 ctymgr@cityofdubuque.org www.cityofdubuque.org On behalf of the City of Dubuque, | am pleased to submit the enclosed Live Well, Dubuque proposal to the Centers for Medicare and Medicaid Services. Dubuque seeks $8 million in Health Care Innovation Award funding to improve health outcomes and reduce Mediomne. Medicaid and Children's Health Insurance Program costs in the region. The project will produce better health outcomes and reduce costs by establishing a Community Health Collaborative, deploying Care Coaches to work with high-risk patients, and developing an education and marketing campaign to encourage healthier lifestyles. These service delivery improvements will be combined with a total cost of care payment model that will provide a single risk-adjusted payment for a full range of health care services needed by a specified group of people for a fixed period of time. The project will be administered through the City's Health Services Department. The primary contact is: Mary Rose Co i an, RN Public Health Specialist City of Dubuque Health Services Department 1300 Main Street Dubuque, IA 52001 Phone: 503589 4181 Fax: 563 589 4299 Thank you for your consideration. 8incmraly, Michael C. Van Milligen City Manager MCVM: ds SECTION ONE: DESIGN 1.1 Model Goals and Targeting The City of Dubuque, Iowa, is applying for Health Care Innovation Award (HCIA) Innovation Category: #4 — Models that Improve the Health of Populations through Activities Focused on Engaging Beneficiaries, Prevention, Wellness, and Comprehensive Care that Extend Beyond the Clinical Service Delivery Setting. In particular, the proposed "Live Well, Dubuque" service delivery and payment model will address the following Centers for Medicare & Medicaid Services (CMS) priority areas: • Models that Lead to Better Prevention and Control of Cardiovascular Disease, Hypertension, Diabetes, Chronic Obstructive Pulmonary Disease, Asthma, and HIV /AIDS • Models that Promote Behaviors that Reduce Risk for Chronic Disease, including Increased Physical Activity and Improved Nutrition • Models that Promote Medication Adherence and Self - Management Skills • Broader Models that Link Clinical Care with Community -Based Interventions Dubuque seeks to be one of the healthiest cities in America. The City is working cooperatively with hospitals, clinics and health care providers in the region to help connect the dots to improve health outcomes and reduce costs. The Live Well, Dubuque project's key components include: • Community Health Collaborative — Dubuque hospitals and clinics are interested in forming a Community Health Collaborative. The Collaborative will provide member organizations with higher levels of efficiency and effectiveness by allowing them to implement consistent community -wide practices and models to address some of the most 1 important health care challenges today. The Collaborative will also work with physicians and other providers throughout the region to assist them in strengthening their practices. The collaboration can provide community resources, health care provider education and support, information technology sharing, and supply chain management. • Care Coaches — The Collaborative will deploy Care Coaches to work one -on -one with 2,400 high -risk individuals (see 1.3 Participant Recruitment and Enrollment for description of high -risk individuals) during the three -year project period. Care Coaches will combine health coaching and case management skills to support these patients, reducing Medicare, Medicaid and Children's Health Insurance Program (CHIP) costs. Each Care Coach will serve approximately 200 clients annually, and provide a conduit for residents to understand and access Dubuque's existing health programs, services and other infrastructure. • Education and Marketing Campaign — Dubuque will launch a community -wide, coordinated health education and marketing campaign, focused on preventive measures. Raising the awareness of Dubuque's available health tools and resources will further help to improve health outcomes and reduce costs. Specifically, the Collaborative, Care Coaches and education/marketing campaign will help connect patients with the existing health programs, services and other infrastructure across Dubuque, including the Crescent Community Health Center, preventive health services, the Wellness Center, diabetic education programs, tobacco cessation counseling and assistance, healthy food opportunities and community gardens, the City's Green & Healthy Homes Initiative, recreational opportunities such as the area's extensive trail network, and other 21 Page programs that help address the social determinants of health. What makes this model unique is that it effectively leverages existing local, state, federal, and private resources. While there are many preventive health services available in the Dubuque community, the Live Well, Dubuque model is inventive because it helps to streamline and better link residents with those programs, thereby reducing confusion and overlap and optimizing health care delivery. Dubuque will shift to a comprehensive care or total cost of care (TCoC) payment model to reduce costs. A TCoC model involves providing a single risk- adjusted payment for the full range of health care services needed by a specified group of people for a fixed period of time. The benefits associated with this model are improved flexibility for providers in terms of care delivery; greater potential for innovation in delivery design (including use of community resources, programs and public health initiatives); incentives to deliver care efficiently; better collaboration among providers who serve a particular population; and stronger emphasis on maximizing health. An innovation that Dubuque seeks to test is the dedication of a portion of the model's shared savings, as well as some of the fees that Dubuque will generate from participation in the State's 1115B Medicaid waiver to provide incentives to people who are actively working with Care Coaches to improve their health. For example, a patient that is actively enrolled in Iowa's Health and Wellness Plan and is taking responsibility for their health would be able to take advantage of incentives that would address the social determinants of health, such as an air conditioning unit for someone suffering from heart disease. The program's sustainability will depend on health improvements that generate savings to support these incentives. 3 P age The health service delivery and payment model will be phased in during the HCIA project period. During the first year of the project, the Crescent Community Health Center will pilot and measure the performance of the proposed innovations. In year two, Dubuque will expand the model to private providers and emergency room deferment. Finally, year three will include full implementation with area hospitals, clinics and other providers. The goals of the Live Well, Dubuque delivery and payment model include: • Connecting patients with health programs and services throughout the Dubuque region — Care Coaches will consult with high -risk individuals and provide health, wellness and lifestyle management training. Directing patients to Dubuque's available health programs, services and other infrastructure will improve health outcomes and reduce Medicare, Medicaid and CHIP costs. • Decreasing the number of emergency room visits — Better engagement between patients and Care Coaches will reduce the number of emergency room visits for the region. Eliminating unnecessary emergency room visits will help to drastically cut Medicare, Medicaid and CHIP expenditures. • Increasing the physical activity of CMS beneficiaries — Better education and marketing efforts will help Dubuque residents to get active. Greater physical activity will lead to healthier citizens. • Improving healthy eating — Direct coaching with participants, as well as effective education and marketing campaigns, will help to increase healthy eating habits across the population. Healthier eating can reduce the risk of obesity, heart disease, diabetes, and other chronic conditions. 4 Page ® Reducing smoking — Care Coaches will help to direct patients to existing smoking cessation programs. People who quit smoking will be at a lower risk for cancer, heart disease and other chronic conditions. ® Lowering obesity — Coaching and outreach will help to leverage health programs designed to reduce obesity rates in the Dubuque area. Lower body mass indexes (BMI) will reduce the risk for diabetes, heart disease and other chronic conditions. • Boosting prescription drug adherence — Among patients with chronic illness, approximately 50% do not take medications as prescribed. Care Coaches will work with high -risk individuals to ensure that they take their medications as prescribed, which will improve health outcomes and decrease Medicare, Medicaid and CHIP costs. ® Growing the number of individuals with a "medical home" — Health care in Dubuque too often addresses immediate, acute problems rather than examining the root causes of patients' concerns. Dubuque seeks to grow the medical home model in the region, which encourages preventive services such as annual physical exams, developmental screening, health education, immunizations, well -child care, and other medical and community - based services to help maintain optimal health. ® Decreasing the incidence of and prevalence of chronic diseases — Efforts to improve healthy eating, active living, reduced smoking, and prescription drug adherence will result in the decrease of chronic diseases across the Dubuque region, thereby reducing health care costs. The provider partners involved in developing the Live Well, Dubuque service delivery and payment model include: 5 Page • The City of Dubuque Health Services Department, which collaborates in community health assessment, assurance and policy development to ensure the public's health. Its prime responsibility is to plan programs, develop and implement policies and ordinances based on community health needs, and respond to related health issues and emergencies as required, all in collaboration with community partners. • Crescent Community Health Center, a Federally Qualified Health Center (FQHC) located in Dubuque, is a medical and dental clinic providing basic primary medical and oral health care. Crescent Community Health Center offers high - quality and affordable care to anyone needing a medical and/or dental home, including individuals and families who are uninsured, underinsured and those with various types of insurance. • Mercy Medical Center - Dubuque is a general medical and surgical hospital, with 272 beds. It is one of two hospitals in Dubuque. According to the American Hospital Association, survey data for the latest year available shows that 21,737 patients visited the hospital's emergency room. The hospital had a total of 8,864 admissions, and its physicians performed 2,398 inpatient and 4,741 outpatient surgeries. • Finley Hospital is a general medical and surgical hospital with 119 beds. According to the American Hospital Association, survey data for the latest year available shows that 30,608 patients visited the hospital's emergency room. The hospital had a total of 4,669 admissions. Its physicians performed 1,385 inpatient and 4,826 outpatient surgeries. • Medical Associates Clinic is a multi- specialty medical group practice that provides quality, accessible and cost - effective primary and specialty health care services to residents of the tri -state area. Medical Associates Clinic provides medical care at locations including Dubuque, Bellevue, Cascade, Dyersville, Elkader, and Monona, 6 Page Iowa; Cuba City, and Platteville, Wisconsin; and Elizabeth and Galena, Illinois. The group was founded in 1924 and is Iowa's oldest multi- specialty group practice, with over 165 providers and a staff of over 1,000 health care professionals and support personnel. ® Dubuque Internal Medicine was founded in 1955 by Dr. Eugene Coffinan. Now, more than five decades later, the group has grown to over 35 physicians and over 300 employees. Dubuque Internal Medicine is the largest internal medicine group practice in Iowa. • Tri -State Independent Physicians Association is a multi - specialty group practice serving patients in northeast Iowa, northwest Illinois and southwest Wisconsin. Founded in 1987, the Tri -State Independent Physicians Association has grown to over 160 physicians representing a full array of primary care and surgical specialties. The targeted geographic area for the Live Well, Dubuque service delivery and payment model is Dubuque County, Iowa. The U.S. Census Bureau estimates the population of Dubuque County at 95,097 people as of 2012. The targeted population of the Live Well, Dubuque project will be approximately 10,375 residents who suffer from chronic diseases. The targeted population by age group includes: ® Infants (1 -12 months): 75 people • Children (1 -11 years): 300 people ® Adolescents (12 -18 years): 1,500 people • Young Adults (19 -25 years): 500 people • Adults (26 -64 years): 6,500 people • Elderly (65 -74 years): 1,400 people 71Pabe • Elderly (75+ years): 100 people The breakdown of the targeted population by insurance types includes: • Medicaid: 7,000 people • CHIP: 500 people • Medicare Advantage: 1,500 people • Uninsured: 1,375 people The project will serve the entire targeted population through the Collaborative and education/marketing efforts. During the first year of the project, a pilot group of high -risk patients will be identified and paired with Care Coaches. Individuals served by the Crescent Community Health Center who have been hospitalized, use area hospitals' emergency rooms inappropriately or meet other selection criteria (see 1.3 Participant Recruitment and Enrollment for description of high -risk individuals) will be recruited for the Care Coaches pilot in year one (approximately 1,000 people, or 150 Medicare beneficiaries, 840 Medicaid beneficiaries and 10 CHIP beneficiaries). In years two and three, the Care Coaches pilot will be expanded to serve the patients of area hospitals, clinics and other providers (approximately 2,400 total people by year three, or 300 Medicare beneficiaries, 2,050 Medicaid beneficiaries and 50 CHIP beneficiaries). According to the 2011 Iowa Health Fact Book, among the major causes of death in Iowa are diabetes, heart disease, cancer, and stroke. The complementary efforts of launching a Collaborative, deploying Care Coaches to work with high -risk patients and improved 81 Page educational/and marketing activities will help Dubuque to reduce the incidence and prevalence of these chronic diseases, and thereby significantly reduce Medicare, Medicaid and CHIP costs. The Live WcU, Dubuque project complements the City's Sustainable Dubuque initiative, a community-wide, citizen-led movement to create a more viable, livable and equitable community. Sustainable Dubuque focuses on economic prosperity, socinKouhundvibronuy and environmental integrity, and has gained recognition nationally because it serves as a replicable model for communities under 200,000 in population, where over 40% of the country lives. The proposed Live Well, Dubuque project will serve as a similar model for small to medium-sized communities nationwide. While healthy living has been an undercurrent of the Sustainable Dubuque plan (through principles including Healthy Local Foods, Healthy Air and Clean Water, among others), the planned introduction of a standalone Health & Safety princi le this fall gives further recognition to the community's ambitions to improve the health of its residents. Sustainable Dubuque will be represented in the CoUuhootive, and will help to monitor community indicators related to health, such as healthy local food, clean air and water, alternative transportation, etc. 91Page 1.2 Comprehensive Description of the Model and Supporting Evidence Base Innovation Category: #4 — Models that Improve the Health of Populations through Activities Focused on Engaging Beneficiaries, Prevention, Wellness, and Comprehensive Care that Extend Beyond the Clinical Service Delivery Setting Priority Areas: Models that Lead to Better Prevention and Control of Cardiovascular Disease, Hypertension, Diabetes, Chronic Obstructive Pulmonary Disease, Asthma, and HIV /AIDS; Models that Promote Behaviors that Reduce Risk for Chronic Disease, including Increased Physical Activity and Improved Nutrition; Models that Promote Medication Adherence and Self - Management Skills; and Broader Models that Link Clinical Care with Community -Based Interventions Dubuque's health service delivery model will include the formation of a Collaborative, the deployment of Care Coaches to serve high -risk residents and a community -wide education/marketing campaign that will help to improve health outcomes and reduce costs: Community Health Collaborative — Dubuque seeks to establish a Community Health Collaborative to deliver common health programs and services across the region. The Collaborative will help to improve health care, lower costs and move best practices out to the provider community. The Collaborative will focus on four high - volume, high -cost, high - variation health conditions, including: heart disease, cancer, stroke and diabetes. The primary chronic condition that the project will focus on is diabetes. 101 Page Functionally, the Collaborative will be managed by the Crescent Community Health Center. Participants will include at least one area hospital and additional health care providers, primarily family care, pediatric and obstetric practices. The Collaborative will work to eliminate the duplication of health programs and services across the region, and provide member organizations with higher levels of efficiency and effectiveness by allowing them to implement consistent community -wide practices and models to address some of the most important health care challenges today. The Collaborative will be open to all health care providers on a voluntary basis. Specifically, the Collaborative will: • Appoint an "Efficiency Coordinator" to identify areas of overlap and duplication across existing health programs and services, and make best practices recommendations to the member organizations; • Reduce the burden and cost of high -risk patients through Care Coaches, who will work one -on -one with individuals to help them better meet their health care needs; • Connect Medicare, Medicaid and CHIP beneficiaries with healthy living opportunities (e.g., preventive health services, the Wellness Center, diabetic education programs, tobacco cessation counseling and assistance, healthy food opportunities and community gardens, the City's Green & Healthy Homes Initiative, recreational opportunities); • Promote the medical home concept across the region; • Develop educational materials for health care providers and staff; • Produce a community -wide marketing campaign to teach residents how to live healthier lives; and 111P g_ • Identify and implement information technology and supply chain management improvements that can increase efficiencies and save costs. A challenge for successful implementation of the Collaborative will be to enroll hospitals, as well as providers, who typically view each other as challengers. Existing rivalries in Dubuque have discouraged meaningful collaboration. One of the primary goals of the Collaborative is to demonstrate how better working relationship's can help to improve medical outcomes and save money. Dubuque acknowledges that competing hospitals and providers may not initially enroll together. However, if the Collaborative can demonstrate significant efficiencies and financial savings, the City expects that rivals will decide to join the Collaborative and work alongside each other to achieve the same benefits. Care Coaches — Many people feel unable to navigate the health care system in this country. Diseases are complex, treatment options are confusing and the byzantine organization of health care delivery defies logic. For those individuals facing poor or declining health, these obstacles cost lives and money. In the early 2000's, health coaching appeared as a relatively novel discipline which addressed the challenge clients had in achieving and sustaining health behavior changes. Health coaching has since emerged as a new approach of partnering with patients to enhance self - management strategies for the purpose of preventing exacerbations of chronic illness, and demonstrated variable efficacy with regard to helping individuals' lead healthier lifestyles. 121Page Health coaching combines health education and health promotion within a coaching context to enhance the well -being of individuals and to facilitate the achievement of their health - related goals. Health coaching effectively motivates behavior change through a structured, supportive partnership between the participant and the coach. The coach helps the participant to clarify goals and provides insight into goal achievement through inquiry, collaboration and personal discovery. 1 Care Coaches will meet with patients when they most need the support (e.g., diagnosed with a new illness, being discharged from the hospital, non - compliant with medication usage, co- occurring mental health/physical health diagnosis). They will provide support, information and connections to community resources and conduct motivational interviewing to assist the patient in taking advantage of community offerings to improve their health and reduce expensive medical care. Dubuque will employ evidence -based health coaching techniques during the study. Traditional methods of providing one -way health information to patients have been demonstrated to be ineffective. The goal of evidence -based health coaching is to guide patients to discover their own ambivalence toward health behavior change, and to impact their ability to better self - manage their condition. Health behavior change must come from within the client. Values, beliefs, culture, and birth generation affects health care decisions. Research has shown that providing care in patients' homes affords providers with enhanced opportunities to improve health outcomes. Patients typically feel safer and more secure in their own homes. This 1 Palmer, S., Tubbs, I. & Whybrow, A. (2003). Health coaching to facilitate the promotion of healthy behavior and achievement of health - related goals. International Journal of Health Promotion and Education, 41 (3), 91 -93. 131;P_ge provides an environment to develop trust between patients and caregivers. This also sets the stage for determining what is important to the patient, what the patient wants to accomplish relative to their disease, and how active the patient is in caring for their self. During the first year the project, Care Coaches will work with approximately 1,000 Medicare, Medicaid and CHIP patients of the Crescent Community Health Center who have chronic health conditions (e.g., heart disease, cancer, stroke, diabetes), been hospitalized, use area hospitals' emergency rooms inappropriately, or meet other selection criteria (see 1.3 Participant Recruitment and Enrollment for description of high -risk individuals). During years two and three of the project, Care Coaches will serve additional patients of area hospitals and health care providers (approximately 2,400 total people by year three, or 300 Medicare beneficiaries, 2,050 Medicaid beneficiaries and 50 CHIP beneficiaries). Each Care Coach will serve approximately 200 clients, and will combine health coaching and case management skills to support healthier patients, reducing Medicare and Medicaid costs. Dubuque expects to bring on five Care Coaches in year one, three additional Care Coaches in year two, and another four Care Coaches in year three. Care Coaches will receive medical coaching certification, motivational interviewing training and other training as identified to meet patients' needs. Care Coaches will promote healthier lifestyles (e.g., exercising, healthy eating, smoking cessation), encourage prescription medication adherence, discourage emergency room visits for services that could be administered at home, and help to improve the treatment of chronic diseases. Improving lifestyles, reducing emergency room visits and treating chronic diseases will lead to better health outcomes and reduce payments from CMS. 141 Page Care Coaches will ensure that patients adhere to medical appointments, lab tests and medication compliance. For example, a Care Coach could work with a diabetic patient to schedule regular appointments with their physician, have hemoglobin Alc and glucose test conducted as recommended, and work with the patient and provider to develop a healthy lifestyle care plan. These actions will help to reduce waste, unnecessary tests, general non - compliance and poor health outcomes. Dubuque will measure a variety of health outcomes and indicators (e.g., emergency room visits, physical activity, eating habits) during the project. At the end of the first year, Crescent Community Health Center staff will evaluate what worked, and make adjustments as more Care Coaches are introduced throughout the community. Education and Marketing Campaign — Dubuque will focus on two audiences for its education and marketing campaign: health care providers and the target population. Initial outreach efforts will describe the opportunities available from the Collaborative and the Care Coaches. After year one of the project, Dubuque will determine what worked in its pilot with the patients of Crescent Community Health Center, identifying the lessons learned from establishing and providing health care services through the Collaborative, as well as the best practices developed through the interactions between Care Coaches and the targeted population. The educational effort for health care providers will include: • Informing providers how they can improve efficiency and reduce costs through the Collaborative; 151 P ng ve • Highlighting the successes of the Care Coaches to improve health outcomes and reduce costs with high -risk patients; and • Educating providers about community health programs and services (e.g., preventive health services, the Wellness Center, diabetic education programs, tobacco cessation counseling and assistance, healthy food opportunities and community gardens, the City's Green & Healthy Homes Initiative, recreational opportunities) that are available across the region. The education and marketing campaign will also focus on the target population of high -risk patients (10,375 residents who suffer from chronic diseases), and provide additional benefit to the community at- large. Specifically, the community education and marketing campaign will: • Help patients understand their health care conditions; • Identify steps that individuals can take to develop personalized health plans; • Highlight community health programs, services and resources that patients can use to implement their health plans; • Encourage businesses to provide health insurance to their employees; and • Promote healthy behaviors and preventive measures that can improve health outcomes and reduce medical costs. Dubuque's education and media campaign will connect with residents through a variety of media, including: • Fact sheets and brochures; • Web sites; 161Page • Social media such as Facebook and Twitter; and • Radio and television advertisements. Competing forces in the community include fitness and education programs that aren't connected with an overall care plan for an individual (and often offer promising quick fix solutions). Lack of transportation alternatives to connect with the wellness resources profiled in the education and marketing campaign is also an obstacle. Dubuque is conducting a complementary analysis of its bus transit system to determine if its routes link the community to opportunities to lead healthier lifestyles. Alternate Payment Model — Dubuque will shift to a TCoC payment model to reduce costs. A TCoC model involves providing a single risk - adjusted payment for the full range of health care services needed by a specified group of people for a fixed period of time. The benefits associated with this model are improved flexibility for providers in terms of care delivery; greater potential for innovation in delivery design (including use of community resources, programs and public health initiatives); incentives to deliver care efficiently; better collaboration among providers who serve a particular population; and stronger emphasis on maximizing health. Presently a major impediment to TCoC implementation is the high cost and limited access to community care management. While a provider may know exactly how to treat a child's asthma episode, he /she may not know how to remove the environmental factors contributing to those episodes. Participating in a TCoC model, where providers are rewarded or penalized based upon 17 1 '. -^ a, g e the overall improving health of the population they serve, is not an easy decision for these providers when they control only a portion of the health "risk" the patient faces. The Live Well, Dubuque model will reduce the cost of and improve the access to community care management. CMS funding will be used to create and /or coordinate local care management assets. An innovation that Dubuque seeks to test is the dedication of a portion of the model's shared savings, as well as some of the fees that Dubuque will generate from participation in the State's 1115B Medicaid waiver, to provide incentives to people who are actively working with Care Coaches to improve their health. For example, a patient that is actively enrolled in Iowa's Health and Wellness Plan and is taking responsibility for their health would be able to take advantage of incentives that would get at the social determinants of health, such as an air conditioning unit for someone suffering from heart disease. The program's sustainability will depend on health improvements that generate savings to support these incentives. 18 1 P a 1.3 Participant Recruitment and Enrollment The project will serve the entire targeted population of 10,375 residents with chronic diseases through the Collaborative and education/marketing efforts. Individuals will be recruited to participate with Care Coaches in stages. During the first year, the pilot group will include the patients served by the Crescent Community Health Center. This pilot group will include patients suffering from chronic diseases (e.g., heart disease, cancer, stroke, diabetes), been hospitalized or who use area hospitals' emergency rooms inappropriately (approximately 1,000 people, or 150 Medicare beneficiaries, 840 Medicaid beneficiaries and 10 CHIP beneficiaries). In particular, participants will be identified and recruited if they: • Have a history of non - compliance with medications; • Frequently miss doctor's appointments; • Are obese; • Do not comply with diet recommendations; • Have a baby; • Acquire a new chronic disease diagnosis; and • Receive Medicare, Medicaid or CHIP benefits. Dubuque expects to bring on five Care Coaches in year one; each Care Coach will serve approximately 200 clients. The participant group will be expanded in years two and three. In year two, Dubuque will grow the model to include private providers and seek to address emergency room deferment. The project team will identify and recruit participants that use the emergency room for acute care, 19IPage complications from chronic disease and sick child care. Three additional Care Coaches will be hired in year two. These Care Coaches will serve an additional 600 patients of area hospitals and health care providers (approximately 1,600 total people in year two, or 200 Medicare beneficiaries, 1,380 Medicaid beneficiaries and 20 CHIP beneficiaries). In year three, the model will be fully available to all area hospitals, clinics and other providers. Four additional Care Coaches will be hired in year three. These Care Coaches will serve an additional 800 patients (including 100 additional Medicare beneficiaries, 670 additional Medicaid beneficiaries and 30 additional CHIP beneficiaries) in year three. Upon project completion, 12 Care Coaches will be serving a population of 2,400 patients (including 300 Medicare beneficiaries, 2,050 Medicaid beneficiaries and 50 CHIP beneficiaries). Incentives will be built into the model to keep participants engaged, including, for example: • Transportation assistance; • Preferred scheduling; • Use of a personal trainer; and • Coupons for healthy foods if patients go to nutrition/cooking classes or are successful at reducing cholesterol, decreasing weight, etc. In addition, Dubuque will work on policy and environmental changes to improve the health of its citizens. Using models such as the Centers for Disease Control and Prevention's (CDC) Action Communities for Health, Innovation, and Environmental Change (ACHIEVE) program, the City will address policy and environmental changes from several perspectives: schools, work site, 201 Page restaurants, institutions, churches, neighborhood associations, etc. Changing the community culture to one that values and promotes health and wellness will further encourage patients to adopt healthier lifestyles. Z1|Page 1.4 Education and Outreach Dubuque plans to target two audiences for its education and marketing campaign: health care providers and the target population. Initial outreach efforts will describe the opportunities available from the Collaborative and the Care Coaches. After year one of the project, Dubuque will determine what worked in its pilot with the patients of Crescent Community Health Center, identifying the lessons learned from establishing and providing health care services through the Collaborative, as well as the best practices developed through the interactions between Care Coaches and the targeted population. The education effort for health care providers will include: • Informing providers how they can improve efficiency and reduce costs through the Collaborative; • Highlighting the successes of the Care Coaches to improve health outcomes and reduce costs with high -risk patients; and • Educating providers about community health programs and services (e.g., preventive health services, the Wellness Center, diabetic education programs, tobacco cessation counseling and assistance, healthy food opportunities and community gardens, the City's Green & Healthy Homes Initiative, recreational opportunities) that are available across the region. The education and marketing campaign will also focus on the target population of high -risk patients (10,375 residents who suffer from chronic diseases), and provide additional benefit to the community at- large. Specifically, the community education and marketing campaign will: 221 Page • Help understand —'`,-_'_ , • Identify steps that individuals can take to develop personalize health plans; • Highlight community health programs, services and resources that patients can use to implernent their health plans; • Encourage businesses to provide health insurance to their employees; and • Promote healthy behaviors and preventive measures that can improve health outcomes and reduce medical costs. Dubuque's education and media campaign will connect with residents through a variety of media, including: • Fact sheets and brochures; , • Web sites; • Social media such as Facebook and Twitt r; and • Radio and television advertisements. 23 1P age 1.5 Community Integration The Live Well Dubuque project will involve a number of community health partners, including: • The City of Dubuque Health Services Department, which collaborates in community health assessment, assurance and policy development to ensure the public's health. Its prime responsibility is to plan programs, develop and implement policies and ordinances based on community health needs, and respond to related health issues and emergencies as required, all in collaboration with community partners. • Crescent Community Health Center, a Federally Qualified Health Center (FQHC) located in Dubuque, is a medical and dental clinic providing basic primary medical and oral health care. Crescent Community Health Center offers high - quality and affordable care to anyone needing a medical and/or dental home, including individuals and families who are uninsured, underinsured and those with various types of insurance. • Mercy Medical Center - Dubuque is a general medical and surgical hospital, with 272 beds. It is one of two hospitals in Dubuque. According to the American Hospital Association, survey data for the latest year available shows that 21,737 patients visited the hospital's emergency room. The hospital had a total of 8,864 admissions, and its physicians performed 2,398 inpatient and 4,741 outpatient surgeries. • Finley Hospital is a general medical and surgical hospital with 119 beds. According to the American Hospital Association, survey data for the latest year available shows that 30,608 patients visited the hospital's emergency room. The hospital had a total of 4,669 admissions. Its physicians performed 1,385 inpatient and 4,826 outpatient surgeries. • Medical Associates Clinic is a multi- specialty medical group practice that provides quality, accessible and cost - effective primary and specialty health care services to 241 Page residents of the tri -state area. Medical Associates Clinic provides medical care at locations including Dubuque, Bellevue, Cascade, Dyersville, Elkader, and Monona, Iowa; Cuba City, and Platteville, Wisconsin; and Elizabeth and Galena, Illinois. The group was founded in 1924 and is Iowa's oldest multi - specialty group practice, with over 165 providers and a staff of over 1,000 health care professionals and support personnel. • Dubuque Internal Medicine was founded in 1955 by Dr. Eugene Coffman. Now, more than five decades later, the group has grown to over 35 physicians and over 300 employees. Dubuque Internal Medicine is the largest internal medicine group practice in Iowa. • Tri -State Independent Physicians Association is a multi - specialty group practice serving patients in northeast Iowa, northwest Illinois and southwest Wisconsin. Founded in 1987, the Tri -State Independent Physicians Association has grown to over 160 physicians representing a full array of primary care and surgical specialties. Health partners will play an active role in helping to develop the Collaborative, hire and train the Care Coaches, and develop education/marketing materials. A steering committee of executives from these organizations will meet monthly to provide guidance and direct the project. Working teams composed of staff from the organizations will implement the project components. In addition, the project will involve a number of organizations and stakeholders that help to support healthy lifestyles in the Dubuque region, including: • Health non - profits; • Health educators at area schools and colleges; 25 Page • Community gardening organizations; • Healthy eating advocates; • Recreation associations; • Staff from the City's Green & Healthy Homes Initiative, which seeks to improve living conditions for low - income households; and • Fitness facilities. Representatives from these community organizations will be invited to serve on the steering committee and working teams. The Community Health Needs Assessment and Health Improvement Plan (CHNA -HIP) identified many of the above mentioned groups. Committee members will also be recruited from the CHNA -HIP healthy behaviors committee, the County Wellness Coalition, Tri -State Trails Organization, the Life Healthy Dubuque steering committee, the Dubuque Community School District and workplace wellness providers. High community engagement will be critical in helping to establish the Live Well, Dubuque model and market it throughout the region. Continuing community participation will also be critical in ensuring the sustainability of the model beyond the project period. The City's Health Services Department and Crescent Community Health Center will continue to take the lead in expanding the Live Well, Dubuque model following the CMS project period. Project partners will continue to attract new providers into the Collaborative, and expand the use of Care Coaches across the region. Educational and marketing efforts will also continue indefinitely in order to continue informing providers and patients about the available 26jPage opportunities to improve health outcomes and reduce costs through the Live Well, Dubuque program. The vision for Live Well, Dubuque is to create a culture of health and wellness in the community through policy and environmental change that fosters and enables patients and health care providers to achieve improved health outcomes for the individual and community. 27 I P e 1.6 Targeting Medicaid and CHIP Populations The model includes a strong focus on Medicare, Medicaid and CHIP beneficiaries. The project will serve the entire targeted population (10,375 patients) through the Collaborative and education/marketing efforts. Care Coaches will work with pilot groups of high -risk patients, including: • In year one, approximately 1,000 patients of the Crescent Community Health Center, or 150 Medicare beneficiaries, 840 Medicaid beneficiaries and 10 CHIP beneficiaries, will be recruited to participate in the Care Coaches project. • In year two, the project will serve an additional 600 patients of area hospitals and health care providers (including 50 additional Medicare beneficiaries, 540 additional Medicaid beneficiaries and 10 additional CHIP beneficiaries). • Finally, in year three, full implementation of the project will involve area hospitals, clinics and other providers, and serve an additional 800 patients (including 100 additional Medicare beneficiaries, 670 additional Medicaid beneficiaries and 30 additional CHIP beneficiaries). Upon project completion, a population of 2,400 patients (including 300 Medicare beneficiaries, 2,050 Medicaid beneficiaries and 50 CHIP beneficiaries) will have been served by the Care Coaches. 281 Page 1.7 Mu Engagement The p 'cct will include patients dependent on Medi Medicaid and CHIP, as well as those who are uninsured. The entire target population of 10,375 patients with chronic diseases will be served by the Collaborative and education/marketing efforts. A pilot group of 2,400 total patients will be served by Care Coaches, including: • In year one, the targeted population will include Crescent Community Health Center patients suffering from chronic diseases, that have been hospitalized or who use area hospitals' emergency rooms inappropriately. • In year two, Dubuque will expand the model to private providers and seek to address ernergency room deferment. An additional 600 patients of area hospitals and health care providers will be served by the Care Coaches. • In year three, full implementation of the project will involve area hospitals, clinics and other providers, and serve an additional 800 patients with Care Coaches. The goa of the project iutohuvcthoLheWeU Dubuque model work for all payers. The team is interested in cons how individuals with private insurance could participate in years two and three of the project. 29|Page SECTION TWO: ORGANIZATION CAPACITY The Live Well, Dubuque model will be administered by the City of Dubuque's Health Services Department, which collaborates in community health assessment, assurance and policy development to ensure the public's health. Its prime responsibility is to plan programs, develop and implement policies and ordinances based on community health needs, and respond to related health issues and emergencies as required, all in collaboration with community partners. The Health Services Department is directed by Mary Rose Corrigan. Mary Rose received a Bachelor of Science degree in Nursing from Mount Mercy College in Cedar Rapids, Iowa, and a Master of Science degree in Nursing from Clarke College in Dubuque, Iowa. She has worked for the City's Health Services Department since 1985, and in her current role as Public Health Specialist since 1989. She has been involved in developing and delivering many public health programs and services, including the Crescent Community Health Center, the City's childhood lead poisoning prevention program and most recently, the Green & Healthy Homes Initiative. Mary Rose works with local, state and federal partners on public health policy and programs, including health promotion and disease prevention, community emergency preparedness education and planning. She also serves on several community -based organization boards and hosts nursing and public health students for public health experience and internships. A key partner and co -lead of the Live Well, Dubuque project is the Crescent Community Health Center. The Crescent Community Health Center will help to administer the Collaborative, and will support the hiring, training and deployment of Care Coaches. The Executive Director of the Crescent Community Health Center is Julie Woodyard. Julie has served as Executive Director 30 1? age since 2008. Previously, Julie was the Assistant Executive Director /Chief Operating Officer of Hillcrest Family Services in Dubuque, Iowa. She received a Bachelor of Arts degree from the University of Northern Iowa and a Master of Arts degree in Education and Counseling from the University of Iowa. The Live Well, Dubuque project complements the City's Sustainable Dubuque initiative, a community -wide, citizen -led movement to create a more viable, livable and equitable community. Sustainable Dubuque focuses on economic prosperity, social/cultural vibrancy and environmental integrity, and has gained recognition nationally because it serves as a replicable model for communities under 200,000 in population, where over 40% of the country lives. The proposed Live Well, Dubuque project will create a similar model for small to medium -sized communities nationwide. While healthy living has been an undercurrent of the Sustainable Dubuque plan (through principles including Healthy Local Foods, Healthy Air, and Clean Water, among others), the planned introduction of a standalone Health & Safety principle this fall gives further recognition to the community's ambitions to improve the health of its residents. The Dubuque community has a strong record of delivering results on federally funded projects. In particular, the Crescent Community Health Center has received a number of grants to support health projects, including: • A $758,930 Section 330 FQHC Operational Grant from the Health Resources and Services Administration's (HRSA) Bureau of Primary Health Care (BPHC); • A $260,320 Immediate Facility Improvement Grant from HRSA to expand clinic operational space /service; 315Pag • An $83,321 Outreach and Enrollment Grant from HRSA to enroll/educate on the Affordable Care Act (ACA); • $161,534 in American Recovery and Reinvestment Act (ARRA) Increased Demand for Services funding to provide additional services due to increased demand (from downturn in economy); and • $390,315 in ARRA CIP funding for record storage, generator and Wellness Center build out. The City has also successfully implemented multiple projects with the U.S. Department of Housing and Urban Development, the U.S. Department of Energy, the U.S. Environmental Protection Agency, the U.S. Department of Transportation, the Economic Development Administration, and many others. The Live Well, Dubuque project focuses on those health conditions that most seriously affect the city's residents. According to the 2011 Iowa Health Fact Book, diabetes, heart disease, cancer, and stroke are among the major causes of death in Iowa. The complementary efforts of launching a Collaborative, deploying Care Coaches to work with high -risk patients and improved educational/marketing activities will help Dubuque to reduce the incidence and prevalence of these chronic diseases, and thereby significantly reduce Medicare, Medicaid and CHIP costs. To administer and implement the project, the City will establish two organizational bodies composed of strong health and community stakeholder representation. A steering committee consisting of senior executives of area hospitals and health care providers, as well as community 321 Page health stakeholders and advocates, will help to provide guidance and direct the project. This steering committee will meet once a month. Working teams will also be established to develop and implement the project's components. These working teams will be composed of staff from area hospitals and health care providers, as well as community health stakeholders and advocates. The working teams will meet at least once a month, with heavier engagement in year one when the project is launched. Working teams and the steering committee will help with monitoring and analyzing progress. The working teams will develop measures and data collection procedures to help determine the success of the Live Well, Dubuque model. Project staff will help to analyze the collected data, and present those findings to the steering committee at regular intervals. The steering committee will be responsible for making mid - course corrections to ensure that CMS investment is producing results. The Crescent Community Health Center will be responsible for managing the Collaborative. The specific tasks required for establishing the Collaborative include: ® Establish a steering committee; ® Recruit providers and community stakeholders for Collaborative working team; ® Hire a consultant to help develop the payment model; ® Hire an IT consultant to help develop a data collection and tracking system; ® Establish an inventory of all community health programs, services and infrastructure; ® Establish framework and policies for the Collaborative; and 33 1 a g e • Recruit hospitals and providers into the Collaborative. The stability and sustainability of the Collaborative following the project period will be built on the involvement and financial contributions of area hospitals and health care providers. The recruitment, hiring and training of Care Coaches will be managed by the City's Health Services Department and Crescent Community Health Center. The specific tasks required to deploy Care Coaches include: • Recruit providers and community stakeholders for Care Coaches working team; • Develop hiring requirements for Care Coaches; • Identify training needs of Care Coaches; • Conduct regional and national outreach, and work with local and regional colleges and universities with health care education, to hire Care Coaches; • Identify and recruit high -risk patients; • Assign Care Coaches to patients; and • Conduct one -on -one meetings between Care Coaches and patients to develop and implement self - management plans. The education and marketing campaign will be directed by the City's Health Services Department. The specific tasks required to launch the education and marketing campaign include: • Recruit providers and community stakeholders for Education and Marketing Campaign working team; 34I Page 6 Establish an inventory of all community health programs, services and infrastructure; Decide key messages for education/marketing campaign; and 6 Develop and distribute education/marketing materials. Dubuque is submitting the design of a payment model, rather than a detailed and fully developed payment model, with this application. Dubuque and its partners have the ability to develop a fully developed payment model during the project period. Development of the payment model will be supported by the working teams and steering committee, as well as outside consultants and experts. 35 1 ::age SECTION THREE: RETURN ON INVESTMENT 3.1 Financial Plan The Live Well, Dubuque model is expected to generate significant health care savings, and produce a net reduction in the total cost of care. However, data was not available from project partners to complete the Financial Plan. Dubuque will work with health care consultants during the project period to develop the Financial Plan. A full accounting of project costs is included in the attached Budget Narrative. 361 Page 3.2 Model Sustainability Plan Dubuque will lead the shift away from fee - for - service, episodic care toward TCoC payment model which can reduce costs through leveraging of shared local assets. A TCoC model involves providing a single risk - adjusted payment for the full range of health care services needed by a specified group of people for a fixed period of time. The benefits associated with this model are improved flexibility for providers in terms of care delivery; greater potential for innovation in delivery design (including use of community resources, programs and public health initiatives); incentives to deliver care efficiently; better collaboration among providers who serve a particular population; and stronger emphasis on maximizing health. Presently a major impediment to TCoC implementation is the high cost and limited access to community care management. While a provider may know exactly how to treat a child's asthma episode, he /she may not know how to remove the environmental factors contributing to those episodes. Participating in a TCoC model, where providers are rewarded or penalized based upon the overall improving health of the population they serve, is not an easy decision for these providers when they control only a portion of the health "risk" the patient faces. The Live Well, Dubuque model will reduce the cost of and improve the access to community care management. CMS funding will be used to create and /or coordinate local care management assets. Those assets will be sustained into the future by a series of capital sources, including but not limited to: 1. Continued public health investments by Local governmental entities, including personnel, facilities, equipment, etc. — The community of Dubuque invests significant 371Page resources in public health assets. This takes the form of annual direct investment. By year three of the program, direct public investment would contribute to the ongoing costs of the shared community health services. 2. Revenue generated from the utilization of shared community health services — Communities have a long history of providing access to critical, shared community services (such as water, electricity, gas, sewer, etc). They provide it without cost as needed to support societal needs, but also at cost for improved economic opportunities. While a business may pay to purchase water from the local municipal utility, it will be able to do so for a fraction of the cost of developing that water infrastructure independently. Early societal needs supported by this infrastructure, without additional direct cost, would include public programs such as Medicare, Medicaid and Hawk -I (the Iowa CHIP program). Early economic users supported by this infrastructure at direct cost would include area employers (particularly those who "self- fund" for health care costs), area insurance carriers who are looking for a lower cost of service for their area insureds and area health care providers extending their services (particularly if they are moving toward risk - bearing status with an Accountable Care Organization (ACO) or similar structure). A goal would be by year three of the program to be covering a portion of the recurring annual costs of these shared community health services through direct compensation. 3. TCoC analysis allows for the ability to project a specific population's per member, per month (PMPM) anticipated cost of health claims, and to then attribute any increases or decreases in that PMPM to actions taken within the health care system. For Medicaid, Medicare and other public programs, the City would propose completing that analysis for 381 Page those Dubuque populations, providing access to the shared community health services without up- front charge, and then sharing in the projected savings occurring through decreased PMPM claims after three years. A goal would be that by year three of the program, the shared community health services would be covered by some of the TCoC shared savings. 4. Dubuque would propose to utilize some of the fees that Dubuque will generate from participation in the State's 1115B Medicaid waiver to further support the shared community health service by providing incentives to people who are actively working to improve their health and participating with Care Coaches within the system. For example, a patient that is actively enrolled in Iowa's Health and Wellness Plan and is taking responsibility for their health would be able to take advantage of incentives that would get at the social determinants of health, such as an air conditioning unit for someone suffering from heart disease. The program's sustainability would depend on health improvements that generate savings to support these incentives. 39 1 g e SECTION FOUR: MONITORING, REPORTING AND EVALUATION 4.1 Reporting and Evaluation Working teams and the steering committee will help with monitoring and analyzing progress. The working teams will develop measures and data collection procedures to help determine the success of the Live Well, Dubuque model. Project staff will help to analyze the collected data, and present those findings to the steering committee at regular intervals. The steering committee will be responsible for making mid - course corrections to ensure that CMS investment is producing results. The project team's self - monitoring plan will include the collection and analysis of data in three distinct areas: quality of care received, health care outcomes and costs, and patient satisfaction. Specifically, the model will track the following measures from the CMS' Recommended Awardee Self - Monitoring Measures: STRUCTURE otboti Structure Health IT Ref. #6 Adoption of Medication e- Prescribing Ref. #8 Ability for Providers with HIT to Receive Laboratory Data Electronically Ref. #9 PCMH Certification II. PROCESS accinations Ref. #10 Childhood Immunization Status Ref. #11 Influenza Vaccination Ref. #12 Pneumonia Vaccination Status for Older Adults 401 Page 2. Screening Ref. #13 Measure Pair: A) Tobacco Use Assessment, B) Tobacco Cessation Intervention Ref. #14 Colorectal Cancer Screening Ref. #15 Cervical Cancer Screening Ref. #16 Preventive Care and Screening: BMI Screening and Follow-Up Ref. #17 BMI 2 through 18 Years of Age 3. Wellness Visits & Prenatal Care Ref. 819 Well-Child Visits in the First 15 Months of Life B. Clinical Care 1. Diabetes Ref. #22 Eye Exam Ref. #23 Foot Exam Ref. #24 Medical Attention to Nephropathy Ref. #25 Diabetic Lipid and Hemoglobin Al c Profile 2. Coronary Artery Disease Ref 429 Lipid Control 5. Asthma & COPD Ref. #38 Medication Management for People with Asthma 6. Hyperlipidemia Ref. #43 Hyperlipidemia (Primary Prevention) — Lifestyle Changes and/or Lipid Lowering Therapy 8. Dental Ref. #55 Annual Dental Visit 13. Miscellaneous Ref. #78 Therapeutic klonitoring: Annual Monitorintt for Patients on Persistent Medications III. OUTCOME A. Morbidity & Mortality 2. Morbidity: Diabetes Ref. #93 Comprehensive Diabetes Care 41 I 2 age 3 orbidity: Cardiovascular Ref. #141 Congestive Heart Failure Admission Rate Morbidity: Pulmonar Ref. #102 Asthma: Percent of Patients Who Have Had a Visit to an Emergency Department/ Urgent Care Office for Asthma in the Past Six Months IV. PATIENT & CAREGIVER EXPERIENC] eneral Patient Satsfact Ref. #127 CARPS Ref. #143 ED Visit Rate The project team will collect and analyze data quarterly, and submit a description of progress made in all measures with its quarterly reports to CMS. 421 Page SECTION FIVE: FUNDING 1 SUST ABILITY 5.1 Budget Form SF 424A and Budget Narrative See attached SF 424A and Budget Narrative. SECTION SIX: SUPPLEMENTARY MATE 6.1 Operational Plan See attached Operational Plan. 6.2 Executive Overview See attached Executive Overview. 431Page GRANTS.GOV' Opportunity Title: Offering Agency: CFDA Number: CFDA Description: Opportunity Number: Competition ID: Opportunity Open Date: Opportunity Close Date: Agency Contact: Grant Application Package Health Care Innovation Awards Round Two Centers for Medicare & Medicaid Services 93.610 Health Care Innovation Awards (HCIA) CMS- 1C1 -14 -001 CMS- 1C1 -14- 001 - 017996 05/15/2013 08/15/2013 OAGMGrantsBaltimore @cros.hhs.gov This opportunity is only open to organizations, applicants who are submitting grant applications on behalf of a company, state, local or tribal government, academia, or other type of organization. Application Filing Name: Health Care Innovation Award Round Two - Live Well, Dubuque Model Select Forms to Complete Mandatory Application for Federal Assistance (SF -424) Disclosure of Lobbying Activities (SF -LLL) Project Abstract Summary Project Narrative Attachment Form Budget Narrative Attachment Form Budget Information for Non - Construction Programs (SF -424A) Assurances for Non - Construction Programs (SF-424B) Optional Other Attachments Form ❑ Project/Performance Site Location(sl Instructions Show Instructions » This electronic grants application is intended to be used to apply for the specific Federal funding opportunity referenced here. If the Federal funding opportunity listed is not the opportunity for which you want to apply, close this application package by clicking on the "Cancel" button at the top of this screen. You will then need to locate the correct Federal funding opportunity, download its application and then apply. OMB Number: 4040 -0004 Expiration Date: 03/31/2012 Application for Federal Assistance SF-424 * 1. Type of Submission: ❑ Preapplication Application * 2. Type of Application: * If Revision, select appropriate letter(s): X New ❑ Continuation * Other (Specify): X Application El Changed /Corrected NI Revision * 3. Date Received: 4. Applicant Identifier: 08/15/2013 5a. Federal Entity Identifier: 5b. Federal Award Identifier: State Use Only: 6. Date Received by 7. State Application Identifier: State: 8. APPLICANT INFORMATION: * a. Legal Name: City of Dubuque * b. Employer/Taxpayer Identification Number (EIN/TIN): * c. Organizational DUNS: 42- 6004596 0931053020000 d. Address: * Streetl: Street2: * City: County /Parish: * State: Province: *Country: * Zip / Postal Code: 50 West 13th Street Dubuque IA: Iowa USA: UNITED STATES 52001 -4805 e. Organizational Unit: Department Name: Division Name: f. Name and contact information of person to be contacted on matters involving this application: Prefix: Middle Name: * Last Name: Suffix: * First Name: Mary Rose Corrigan Title: Public Health Specialist Organizational Affiliation: * Telephone Number: 563- 589 -4181 Fax Number: * Email: Mcorriga @cityofdubuque.org Application for Federal Assistance SF -424 * 9. Type of Applicant 1: Select Applicant Type: C: City or Township Government Type of Applicant 2: Select Applicant Type: Type of Applicant 3: Select Applicant Type: * Other (specify): * 10. Name of Federal Agency: Centers for Medicare & Medicaid Services 11. Catalog of Federal Domestic Assistance Number: 93.610 CFDA Title: Health Care Innovation Awards (HCIA) * 12. Funding Opportunity Number: CMS- 1C1 -14 -001 *Title: Health Care Innovation Awards Round Two 13. Competition Identification Number: CMS- 1C1 -14- 001 - 017996 Title: 14. Areas Affected by Project (Cities, Counties, States, etc.): Add Attachment Delete Attachment ; Uiew Attachment * 15. Descriptive Title of Applicant's Project: Health Care Innovation Awards Round Two - Live Well, Dubuque Model Attach supporting documents as specified in agency instructions. Add Attachments Delete Attachments View Attachments Application for Federal Assistance SF -424 16. Congressional * a. Applicant Districts Of: IA -001 b. Program /Project IA -001 Attach an additional list of Program /Project Congressional Districts if needed. Add Attachment Delete Attachment View Attachment 17. Proposed * a. Start Date: Project: 04/01/2014 * b. End Date: 03/31/2017 18. Estimated Funding ($): *a. Federal * b. Applicant * c. State * d. Local * e. Other * f. Program Income *g. TOTAL 8, 020, 770.00 0.00 0.00 0.00 0.00 0.00 8,020,770.00 * 19. Is Application El a. This application b. Program Subject to Review By State Under Executive was made available to the State under is subject to E.O. 12372 but has not been selected is not covered by E.O. 12372. Order 12372 Process? the Executive Order 12372 Process for review on by the State for review. © c. Program * 20. Is the Applicant 0 Yes If "Yes ", provide Delinquent On Any Federal Debt? (If "Yes," provide explanation in attachment.) © No explanation and attach Add Attachment Delete Attachment View Attachment 21. *By signing herein are true, comply with any subject me to this application, I certify (1) to the statements contained in the list of certifications ** and (2) that the statements complete and accurate to the best of my knowledge. I also provide the required assurances ** and agree to resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001) and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency X ** I AGREE ** The list of certifications specific instructions. Authorized Representative: Prefix: Middle Name: * Last Name: Suffix: * First Name: Teri Goodmann * Title: Assistant City Manager *Telephone Number: 563 -589 -4110 Fax Number: * Email: tgoodman @cityofdubuque.org * Signature of Authorized Representative: Teri Goodmann * Date Signed: 08/15/2013 DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C.1352 Approved by OMB 0348 -0046 1. * Type of Federal Action: Ela. contract b. grant ❑ c. cooperative agreement El d. loan e. loan guarantee f. loan insurance 2. * Status of Federal Action: El a. bid/offer /application b. initial award Elc. post -award 3. * Report Type: a. initial tiling 0 b. material change 4. Name and Address of Reporting Entity: ES * Name ' Street 1 City Prime 0SubAwardee City of Dubuque 50 West 13th Street Dubuque Congressional District, if known: State Street 2 IA: Iowa Zip 52001 -4805 5. If Reporting Entity in No.4 is Subawardee, Enter Name and Address of Prime: 6. * Federal Department/Agency: Centers for Medicare and Medicaid Servic 7.* Federal Program Name /Description: Health Care Innovation Awards (HCIA) CFDA Number, if applicable: 93.610 8. Federal Action Number, if known: 10. a. Name and Address of Lobbying Registrant: Prefix ' Last Name * Street 1 * City Seth ' First Name 9. Award Amount, if known: Andrew Middle Name 500 New Jersey Avenue, NW Washington State Street 2 Suffix Suite 500 DC: District of Columbia Zip 20001 b. Individual Performing Services (including address if different from No. 10a) Prefix * Last Name * Street 1 * City First Name Andrew Middle Name Seth State Street 2 Suffix Zip 11. Information requested through this form is authorized by title 31 U.S.C. section 1352, This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when the transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi - annually and will be available for public inspection. Any person whb fails to tile the required disclosure shall be subject to a civil penalty of not less than 510,000 and not more than 5100,000 for each such failure. * Signature: *Name: Prefix • Last Name Teri Goodmann Title: First Name Teri Middle Name Goodmann Telephone No.: Suffix Date: 08/15/2013 Authorized for Local Reproduction Standard Form - LLL (Rev. 7 -97) OMB Number: 0980 -0204 Expiration Date: 08/31/2012 Project Abstract Summary Program Announcement (CFDA) 93.610 Program Announcement (Funding Opportunity Number) CMS- 1C1 -14 -001 Closing Date 08/15/2013 Applicant Name City of Dubuque Length of Proposed Project 36 Application Control No. Federal Share Requested (for each year) Federal Share 1st Year Federal Share 2nd Year Federal Share 3rd Year $ 2,372,256 $ 2,649,507 $ 2,999,007 Federal Share 4th Year Federal Share 5th Year $ 0 $ 0 Non Non - Federal Share Requested (for - Federal Share 1st Year each year) Non- Federal Share 2nd Year Non- Federal Share 3rd Year $ 0 $ 0 $ 0 Non - Federal Share 4th Year Non - Federal Share 5th Year $ 0 $ 0 Project Title Health Care Innovation Awards Round Two - Live Well, Dubuque Model Project Abstract Summary Project Summary Dubuque seeks to be one of the healthiest cities in America. The City is working cooperatively with hospitals, clinics and health care providers in the region to help connect the dots to improve health outcomes and reduce costs. The proposed Live Well, Dubuque project's key components include: • Community Health Collaborative - Dubuque hospitals and clinics are interested in forming a Community Health Collaborative. The Collaborative will provide member organizations with higher levels of efficiency and effectiveness by allowing them to implement some consistent community -wide practices and models to address some of the most important health care challenges today. The Collaborative will also work with physicians and other providers throughout the region to assist them in strengthening their practices. The collaboration can provide information technology, community resources and supply chain management, and health care provider education and support. • Care Coaches - Care Coaches will combine health coaching and case management skills to support healthier patients, reducing Medicare, Medicaid and Children's Health Insurance Program (CHIP) costs. Each Care Coach will serve approximately 200 clients annually, and provide a conduit for residents to understand and access Dubuque's existing health programs, services and other infrastructure. • Education and Marketing Campaign - Dubuque is interested in launching a community -wide, coordinated health education and marketing campaign, focused on preventive measures. Raising the awareness of Dubuque's available health tools and resources will further help to improve health outcomes and reduce costs. Specifically, the Collaborative, Care Coaches and education and marketing campaign will help connect patients with the existing health programs, services and other infrastructure across Dubuque, including the Crescent Community Health Center, preventive health services, the Wellness Center, diabetic education programs, tobacco cessation counseling and assistance, healthy food opportunities and community gardens, the City's Green & Healthy Homes Initiative, recreational opportunities such as the area's extensive trail network, and other programs that help address the social determinants of health. What makes this model unique is that it effectively leverages existing local, state, federal and private resources. While there are many preventive health services available in the Dubuque community, the Live Well, Dubuque model is inventive because it helps to streamline and better connect residents with those programs, thereby reducing overlap and optimizing health care delivery. Dubuque will shift to a comprehensive care or total cost of care (TCoC) payment model to reduce costs. A total cost of care model involves providing a single risk - adjusted payment for the full range of health care services needed by a specified group of people for a fixed period of time. The benefits associated with this model are improved flexibility for providers in terms of care delivery; greater potential for innovation in delivery design (including use of community resources, programs and public health initiatives); incentives to deliver care efficiently; better collaboration among providers who serve a particular population; and stronger emphasis on maximizing health. Estimated number of people to be served as a result of the award of this grant. 10375 Project Narrative File(s) Mandatory Project Narrative File Filename: Add andatoi ec Dubuque HCIA Project Narrative.pdf Narrative File Delete Mandatory Project Narrative File View Mandatory Protect Narrative File To add more Project Narrative File attachments, please use the attachment buttons below. Add Optional Project Narrative File Delete Optional Project Narrative File. View Optional Project Narrative File Budget Narrative File(s) Mandatory Budget Narrative Filename: Add Mandato Budget Narrative Dubuque HCIA Budget Narrative.pdf Delete Mandatory Budget Narrative View Mandatory Budget Narrative To add more Budget Narrative attachments, please use the attachment buttons below. Add Optional Budget Narrative Deiet Optional Budget Narrative View Optional Budget Narrative BUDGET INFORMATION - Non - Construction Programs OMB Number: 4040 -0006 Expiration Date: 06/30/2014 SECTION A - BUDGET SUMMARY Grant Program Function or Activity (a) Catalog of Federal Domestic Assistance Number (b) Estimated Unob igated Funds New or Revised Budget Federal (c) Non - Federal (d) Federal (e) Non - Federal (f) Total (g) 1. Health Care Innovation Awards Round Two 93.610 $ $ $ $ $ 2. 3. 4. 5. Totals $ $ $ $ $ Standard Form 424A (Rev. 7- 97) Prescribed by OMB (Circular A -102) Page 1 SECTION B - BUDGET CATEGORIES 6. Object Class Categories GRANT PROGRAM, FUNCTION OR ACTIVITY Total (5) (1) (2) (3) (4) Health Care Innovation Awards Round Two a. Personnel $ 3,481,720.00 $ $ $ $ 3,481,720.00 b. Fringe Benefits 819,050.00 819,050.00 c. Travel 110,000.00 110,000.00 d. Equipment 100,000.00 100,000.00 e. Supplies 50,000.00 50,000.00 f. Contractual 3,050,000.00 3,050,000.00 g. Construction 0.00 h. Other 410,000.00 410,000.00 i. Total Direct Charges (sum of 6a -6h) 8,020,770.00 $ 8,020,770.00 j. Indirect Charges $ k. TOTALS (sum of 6i and 6j) $ 8,020,770.00 $ $ $ $ 8,020,770.00 7. Program Income $ $ $ $ $ Authorized for Local Reproduction Standard Form 424A (Rev. 7- 97) Prescribed by OMB (Circular A -102) Page 1A Authorized for Local Reproduction Standard Form 424A (Rev. 7- 97 Prescribed by OMB (Circular A -102) Page 2 SECTION C - NON - FEDERAL RESOURCES (a) Grant Program (b) Applicant (c) State (d) Other Sources (e)TOTALS 8. $ $ $ $ 9. 10. 11. 12. TOTAL (sum of lines 8 -11) $ $ $ $ SECTION D - FORECASTED CASH NEEDS 13. Federal Total for 1st Year 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter $ 2,372,256.00 $ 593,064.00 $ 593,064.00 $ 593,064.00 $ 593,064.00 14. Non - Federal $ 15. TOTAL (sum of lines 13 and 14) $ 2,372,256.00 $ 593,064.00 $ 593,064.00 $ 593,064.00 $ 593,064.00 SECTION E - BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT (a) Grant Program FUTURE FUNDING PERIODS (YEARS) (b)First (c) Second (d) Third (e) Fourth 16. Health Care Innovation Awards Round Two $ 2,372,256.00 $ 2,649,507.00 $ 2,999,007.00 $ 17. 18. 19. 20. TOTAL (sum of lines 16 - 19) $ 2,372,256.00 $ 2,649,507.00 $ 2,999,007.00 $ SECTION F - OTHER BUDGET INFORMATION 21. Direct Charges: 22. Indirect Charges: 23. Remarks: Authorized for Local Reproduction Standard Form 424A (Rev. 7- 97 Prescribed by OMB (Circular A -102) Page 2 OMB Number: 4040 -0007 Expiration Date: 06/30/2014 ASSURANCES - NON - CONSTRUCTION PROGRAMS Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348- 0040), Washington, DC 20503. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY. NOTE: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified. As the duly authorized representative of the applicant, I certify that the applicant: 1. Has the legal authority to apply for Federal assistance and the institutional, managerial and financial capability (including funds sufficient to pay the non - Federal share of project cost) to ensure proper planning, management and completion of the project described in this application. 2. Will give the awarding agency, the Comptroller General of the United States and, if appropriate, the State, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the award; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives. 3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain. 4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency. 5. Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. § §4728 -4763) relating to prescribed standards for merit systems for programs funded under one of the 19 statutes or regulations specified in Appendix A of OPM's Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F). 6. Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88 -352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. § §1681 - 1683, and 1685 - 1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U. S.C. § §6101- 6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92 -255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91 -616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) § §523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. § §290 dd -3 and 290 ee- 3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. § §3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and, (j) the requirements of any other nondiscrimination statute(s) which may apply to the application. 7. Will comply, or has already complied, with the requirements of Titles I I and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91 -646) which provide for fair and equitable treatment of persons displaced or whose property is acquired as a result of Federal or federally- assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in purchases. 8. Will comply, as applicable, with provisions of the Hatch Act (5 U.S.C. § §1501 -1508 and 7324 -7328) which limit the political activities of employees whose principal employment activities are funded in whole or in part with Federal funds. Previous Edition Usable Standard Form 424B (Rev. 7 -97) Authorized for Local Reproduction Prescribed by OMB Circular A -102 9. Will comply, as applicable, with the provisions of the Davis - Bacon Act (40 U.S.C. § §276a to 276a -7), the Copeland Act (40 U.S.C. §276c and 18 U.S.C. §874), and the Contract Work Hours and Safety Standards Act (40 U.S.C. § §327- 333), regarding labor standards for federally- assisted construction subagreements. 10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93 -234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more. 11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91 -190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project consistency with the approved State management program developed under the Coastal Zone Management Act of 1972 (16 U.S.C. § §1451 et seq.); (f) conformity of Federal actions to State (Clean Air) Implementation Plans under Section 176(c) of the Clean Air Act of 1955, as amended (42 U.S.C. § §7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended (P.L. 93 -523); and, (h) protection of endangered species under the Endangered Species Act of 1973, as amended (P.L. 93- 205). 12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. § §1271 et seq.) related to protecting components or potential components of the national wild and scenic rivers system. 13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. §470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. § §469a -1 et seq.). 14. Will comply with P.L. 93 -348 regarding the protection of human subjects involved in research, development, and related activities supported by this award of assistance. 15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89 -544, as amended, 7 U.S.C. § §2131 et seq.) pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities supported by this award of assistance. 16. Will comply with the Lead -Based Paint Poisoning Prevention Act (42 U.S.C. § §4801 et seq.) which prohibits the use of lead -based paint in construction or rehabilitation of residence structures. 17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act Amendments of 1996 and OMB Circular No. A -133, "Audits of States, Local Governments, and Non - Profit Organizations." 18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations, and policies governing this program. 19. Will comply with the requirements of Section 106(g) of the Trafficking Victims Protection Act (TVPA) of 2000, as amended (22 U.S.C. 7104) which prohibits grant award recipients or a sub - recipient from (1) Engaging in severe forms of trafficking in persons during the period of time that the award is in effect (2) Procuring a commercial sex act during the period of time that the award is in effect or (3) Using forced labor in the performance of the award or subawards under the award. * SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL * TITLE Teri Goodmann Assistant City Manager * APPLICANT ORGANIZATION * DATE SUBMITTED City of Dubuque 08/15/2013 Standard Form 424B (Rev. 7-97) Back Other Attachment File(s) Mandatory Other Attachment Filename: Add Mandatory her Att achmen Dubuque HCIA Operational Plan.doc e andatory Other Attachment View Mandatory Other Attachmen To add more "Other Attachment" attachments, please use the attachment buttons below. Add Optional Other Attachment Delete Optional Other Attachment View Optional Other Attachment CMS CENT. FOR MEDICARE b MEDICAM SERVICES CENTER FOR MEDICARE 6 MEDICAID INNOVATION LIth Care Innovations Awards- Round Two (HCIA) Executive Overview Please complete all fields unless directed otherwise. tr Letter of' Mtent Contivniatlon [Agrnber H-8558MC Organization Name City of Dubuque Hearth Services Department Street Address 50 VVest 13th Street My Dubuque Organization TIN State !A Organization NPI Number (if applicable) Zip Code 52001 First Name Bus. Phone Primary TIK (if applicable) Mary Rose 563-589-4181 Last Name Corrigan Bus. Email RP! Number (if applicable) mcorriga@cityofdubuque.or First Name Teri Bus. Phone 563-589-4110 Last :lame Goodmann Bus. Email tgoodman@cityofOubuque.o Type of Organization Local/Reg. Collaborative or Health Dept. Organization Status Year Established/ Incorporated Government 1837 ) ro Other Revenue $50,000,001-$500,000,000 (.• nt ' - r) CMS MEDICTRI &MEDICAID SERVICES CENTER TOR MEDICARE & MEDICAID INNOVATION Project Title should reflect the design of your model. Please do not propose a generic-sounding title such as "Health Care Innovation Project". (Max 150 characters) Project Title Live Well, Dubuque Primary Clinical Condition to be Addressed Diabetes Other or Additional Conditions or Objectives Heart disease, cancer, stroke, obesity Primary Innovation Category Type Models to improve health of populations Additional Innovation Category Type(s) Please mark an 'X' next to additional Categories your proposal will address, excluding Primary Category above.) Models that are designed to rapidly reduce Medicare, Medicaid, and/or CHIP costs in outpatient and/or post-acute settings. Models that improve care for populations with specialized needs. Models that test approaches for specific types of providers to transform their financial and clinical models. Models that improve the health of populations — defined geographically (health of a community), clinically (health of those with specific diseases), or by socioeconomic class — through activities focused on engaging beneficiaries, prevention (for example, a diabetes prevention program or a hypertension prevention program), wellness, and comprehensive care that extend beyond the clinical service delivery setting. Priority Areas to be Addres (as referenr in Funding Opportu n ' next to an are. Category 1: diagnostic seivices Category 1: high-cost physician- administered drugs Category 1: therapeutic services Category 2: high-cost pediatric populations Category 2: children at high risk for dental disease Category 2: persons with Alzheimer's disease Category 2: persons requiring long-term support and services Category 1: outpatient radiology Category 1: home based services Category 1: post-acute services Category 2: children in foster care Category 2: adolescents in crisis Category 2: persons living with HIV/AIDS (in particular, efforts to link and retain patients in care and improve medication adherence that lead to viral suppression) Category 2: persons with serious behavioral health needs 21 S rOR 6,1f010,117 SERVICES. CENTER FOR MEDICARE & MCIDOOD INNOVATION • ' • • • . . • • ••. -Hi. • X Category 3: models designed for physician specialties and subspecialties (for example, oncology and cardiology) Category 4: models that promote behaviors that reduce risk for chronic disease, including increased physical activity and improved nutrition Category 4: models that prevent falls among older adults Category 4: broader models that link X clinical care with community-based interventions Other Enter text here. Category 3: models designed for pediatric providers who provide services to children with complex medical issues (including but not limited to care for children with multiple medical conditions, behavioral health issues, congenital disease, chronic respiratory disease, and complex social issues) Category 4: models that lead to better prevention and control of cardiovascular X disease, hypertension, diabetes, chronic obstructive pulmonary disease, asthma, and HIV/AIDS X Category 4: models that promote medication adherence and self-management skills Provide a brief summary of the population(s) and their needs that you propose to address in your project. Be sure to include a description of the problem and/or gap in care being addressed, the size of the population, and the opportunities to improve care and/or health and to lower cost. (300 word / 2500char max) Dubuque seeks to be one of the healthiest cities in America. The City is working cooperatively with hospitals, clinics and health care providers to help connect the dots to improve health outcomes and reduce costs. The targeted geographic area for the Live Well, Dubuque model is Dubuque County, lovva. The U.S. Census Bureau estimates the population of Dubuque County at 95,097 people as of 2012. The targeted population of the project will be approximately 10,375 residents who suffer from chronic diseases. The targeted population by age group includes: • infants (1-12 months): 75 people • Children (1-11 years): 300 people • Adolescents (12-18 years): 1,500 people • Young Adults (19-25 years): 500 people • Adults (26-64 years): 6,500 people • Elderly (65-74 years): 1,400 people • Elderly (75+ years): 100 people s FOR 1.103.11£ .1:11CAID SERVICES According to the 2011 Iowa Health Fact Book, among the major causes of death in Iowa are heart disease, cancer, stroke and diabetes. The complementary efforts of launching a Collaborative, deploying Care Coaches to work with high -risk patients and improved educational and marketing activities will help Dubuque to reduce the incidence and prevalence of these chronic diseases, and thereby significantly reduce Medicare, Medicaid and CHIP costs. The Collaborative will work to eliminate the duplication of health programs and services across the region, and provide member organizations with higher levels of efficiency and effectiveness by allowing them to implement some consistent community -wide practices and models to address some of the most important health care challenges today. Care Coaches will provide support, information and connections to community resources and conduct motivational interviewing to assist the patient in taking advantage of community offerings to improve their health and reduce expensive medical care. Finally, the education and marketing campaign will raise the awareness of Dubuque's available health tools and resources will further help to improve health outcomes and reduce costs. Provide a brief summary of your proposed intervention. Be sure to describe how it will address and /or improve the problem and /or gap in care for the population identified above. Briefly summarize the evidence which suggests your intervention has a likelihood of success. (300 word / 2500char max) Community Health Collaborative — Dubuque seeks to establish a Community Health Collaborative to deliver common health programs and services. The Collaborative will be managed by the Crescent Community Health Center, and include at least one area hospital and additional providers. The Collaborative will: • Identify areas of overlap and duplication, and make "best practices" recommendations to member organizations; • Reduce the burden and cost of high -risk patients through Care Coaches; • Connect Medicare, Medicaid and CHIP beneficiaries with healthy living opportunities; • Promote the medical home concept; • Develop educational materials for providers; • Produce a community -wide marketing campaign to teach residents how to live healthy lives; Care Coaches — Care Care Coaches will promote healthier lifestyles, encourage prescription medication adherence, discourage emergency room visits, ensure that patients adhere to medical appointments, and help to improve the treatment of chronic diseases. These actions will help to reduce waste, unnecessary tests, general non - compliance and poor health outcomes. Education and Marketing Campaign — Dubuque will target two audiences for its education and marketing campaign: providers and the community at- large. The educational effort for providers will include: • Informing providers how they can improve efficiency and reduce costs through the Collaborative; • Highlighting the successes of the Care Coaches to improve health outcomes and reduce costs; and • Educating providers about community health programs and services that are available across the region. The education and marketing campaign will also target the community at- large. Specifically, the community education and marketing campaign will: • Help patients of understand their health care conditions; CMS CE.F. TOR M1IFOICAR, 6 MED.'S SERVICES CENTER FOR MEDICARE E MEDICAID INNOVATION • Identify steps that individuals can take to develop personalized health plans; • Highlight community health programs, services and resources that patients can use to implement their heath plans; • Encourage businesses to provide health insurance to their employees; and • Promote healthy behaviors and preventatives measures that can improve health outcomes and reduce medical costs. =-1.711==_a_. Provide a brief summary of the improvements you expect from this project, and the measures that will quantify improved health/care and lower costs in the proposed model. Quantify the improvement opportunities and quantify the cost drivers that be different as the result of the intervention described above. (300 word / 2500char max) The project's goals inciude: • Connecting patients with health programs and services — Care Coaches will consult with patients and provide health, wellness and lifestyle management training, which will improve health outcomes and reduce Medicare, Medicaid and CHIP costs. [Measure: Use of wellness programs and services] « Decreasing the number of emergency room visits — Better engagement between patients and Care Coaches will reduce the number of unnecessary emergency room visits. [Measure: ER Visits] • Increasing the physical activity of CMS beneficiaries — Better education and marketing efforts will help Dubuque residents to get active. [Measure: Physical activity] • Improving healthy eating — Coaching, as well as effective education and marketing, will help to increase healthy eating, reducing the risk of obesity, heart disease, diabetes, and other chronic conditions. [Measure: Diet/food consumption] o Reducing smoking — Care Coaches will help to direct patients to existing smoking cessation programs. People who quit smoking will be at a lower risk for cancer, heart disease and other chronic conditions. [Measure: Tobacco use screening] • Lowering obesity — Coaching and outreach will help to leverage programs designed to reduce obesity rates. Lower body mass indexes (BM!) will reduce the risk for heart disease, diabetes and other chronic conditions. [Measure: BM[ screening] • Boosting prescription drug adherence — Care Coaches will work with patients to ensure that they take their medications as prescribed. [Measure: Medication management] • Growing the number of individuals vvith a "medical home" — Dubuque seeks to grow the medical home model in the region, which encourages preventive services such as annual physical exams, developmental screening, health education, immunizations, well-child care, and other medical and community-based services. [Measure: PCMH Certification] • Decreasing the incidence of and prevalence of chronic diseases — Efforts to improve healthy eating, active living, reduced smoking, and prescription drug adherence will result in the decrease of chronic diseases. [Measure: Health screenings] Provide a brief summary of the -proposed payment model that will support your p'oject. Please be sure to address how the model will be sustained. (300 word / 2500,.ohar m'aix) Owls C OR MEDICARE & MEDICAID INNOVATION Dubuque will shift from fee - for - service, episodic care toward a total cost of care (TCoC) payment model. The Live Well, Dubuque model will reduce the cost of and improve the access to community care management. CMS funding will be used to create and /or coordinate local care management assets. Those assets will be sustained by a series of capital sources, including but not limited to: 1. Continued public health investments by local governmental entities, including personnel, facilities, equipment, etc. 2. Revenue generated from the utilization of shared community health services — Communities have a long history of providing access to critical, shared community services (such as water, electricity, etc). They provide it without cost as needed to support societal needs, but also at cost for improved economic opportunities. Early societal needs supported by this infrastructure, without additional direct cost, would include public programs such as Medicare, Medicaid and Hawk -I. Early economic users supported by this infrastructure at direct cost would include area employers, area insurance carriers who are looking for lower cost of service and area health care providers extending their services. 3. TCoC analysis allows for the ability to project a specific population's per member, per month (PMPM) anticipated cost of health claims, and to then attribute any increases or decreases in that PMPM to actions taken within the system. For Medicaid, Medicare and other public programs, the City would propose completing that analysis for those Dubuque populations, providing access to the shared community health services without up -front charge, and then sharing in the projected savings occurring through decreased PMPM claims. 4. Dubuque proposes to utilize some fees that generated from participation in the State's 1115B Medicaid waiver to further support the shared community health service by providing incentives to people who are actively participating with Care Coaches to improve their health. All applicants must submit, as part of their application, the design of a payment model that is consistent with the new service delivery model funded by this second round of Health Care Innovation Awards. Alternatively, applicants may choose to submit, as part of their application, a detailed and fully developed payment model as well as a list of payers interested in testing the new payment and service delivery model. If they have not already done so as part of the application, awardees must deliver, during or by the conclusion of the cooperative agreement period, a detailed and fully developed version of the payment model required above, as well as a list of payers interested in testing the payment and service delivery model. Does the application include a detailed and fully developed payment model? No If Yes above, when will the payment model be ready for launch? MM/YY (Note: '»hile CMS encourages awardees to implement new payment models within the award period, C :S'is not obligated to implement paz-ment policy changes di ing or after the award period.) Do you currently have commitment / interest from payers (other than Medicare, Medicaid, and CHIP) to participate in the payment model? If Yes above, please list any payers committed to testing the model in the table below. Yes CMS (INTERS FOR MMICARE 6 Alf 01,113 SMVICES CENTER FOR MEDICARE MEDIC/LIR INNOVATION Payer Name Crescent Community Health Center Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text Click here to enter text. Commqment? Yes Select Select Select Select Select Select Select Net Savings Projection- for CMS Beneficiaries after Deducting In-in:, Costs From financial elan Year 1 Year 2 Year 3 Total $0 $0 $0 $0 Please list all Partner Organizations below applying with Applicant Include any participating payer organizations. Partner Organization Name Crescent Community Health Center Mercy Medical Center- Dubuque Unity Point-Finley Hospital Medical Associates Clinic Dubuque Internal Medicine Tri-State Independent Physicians Association CoOpportunity Health Partner Organization Type FQHC/Community Health Center Hospital Hospital Physician Gorups/IPAs/Phys. Office Physician Gorups/IPAs/Phys. Office Physician Gorups/IPAs/Phys. Office Payers/Health Plans Partner Role Proj Mgmt/Admin Clinical Clinicafi Clinical Clinical Clinical Proj Mgmt/Admin (#-:frls [EWERS FOR MEMO.. /.0.10 SMICES CENTER FOR MEDICARE & MEDICAID INNOVATION Click here to enter text. Click here to enter text. Click here to enter text. • „ Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. If more space is needed to add partner organizations, please use the space below to list each organization, organization type, and role. Ex. Partner Organization Name, Partner Organization Type, Partner Role Click here to enter text. der Typ mark an X X Emergency Medical Technician (EMT) X Licensed practical nurse (LPN / LVN) X Non-clinical health workers Intervention that apply.) X X NP,PA, and other advance practice RN X Other Click here to enter text. Pharmacist Physician, primary care Registered Nurse Physician, specialist (indicate below) Adolescent Medicine Anesthesiology Chiropractic Medicine Dermatology Endocrinology Gastroenterology Geriatric Medicine Hospice and Palliative Care Medical Toxicology Neurology Oncology Allergy and Immunology X Cardiology and Vascular Medicine Dentistry Emergency Medicine X Family Practice X General Practice Hematology Infectious Disease Medicine Nephrology X Obstetrics and Gynecology Ophthalmology 8 CMS MT. MEE MEM,. Mr01,En III SERVICES CENTER FOR MEDICARE . MEDICAID INNOVATION Optometry Orthopedics Otolaryngology Pain Management Pathology X Pediatrics Physical Medicine and Rehabilitation X Preventative Medicine Psychiatry Radiology Sports Medicine Urology Podiatry Primary Care, General Practice, and X Family Practice X Pulmonary Medicine Rheumatology Surgery Other Click here to enter text. Target Number of Intervention Sites Target Number of Participants (If applicable) (Regardless of insurance status) Year 1 Year 2 Year 3 Total Year 1 (by Quarter) Year 2 (Total) Year 3 (Total) Total r Targeted Number of Participants by [new-mice Status (Please provide targets by status for each year) Medicaid* Children's Health Insurance Program (CHIP)* Medicare Fee for Service or Medicare Unspec.* Medicare Advantage Dually Eligible (Medicare + Medicaid) Private/Commercial Health Ins./Health Plan VA Health System (Veterans of Armed Forces) TRICARE (Armed Forces) Year 1 Year 2 CENTER FOR MEDICARE MEDICAID INNOVATION Indian Health Service Uninsured Other Unknown *Excludes Du '[= sacias -armaal. MIMS Please describe the source data to be used for Participant Recruitment. (200 word max) Crescent Community Health Center records, data from area hospitals and providers Provide estimated date 111m911111m91111111 06/01/2014 04/01/2014 Please indicate if you will require CMS data, if awarded, during the course of your projects. While CMS cannot make any commitment to provide this data, we are assessing each award's requirements. For operational purposes please consider alternatives that do not rely on receiving this data. Medicaid and CHIP data will not be available due to limited availability of this data at CMS. This is a brief initial assessment only. You will be required to provide more detailed paperwork and data use agreements at a later time including a formal written request from your award lead. 572=EZZIZSISZ64.2ZEME Will you need CMS Medicare FFS data for your project? (Please indicate selection with an x) Yes Please complete Claims Data section, then proceed to Existing Grants Information. X No Please proceed to Existing Grants Information section. What is the reason for the data request? (Please mark an 'X' next to any areas that apply.) Cost Analysis for Payment Arrangement Sustainability Model Patient and/or Risk Segmentation for Intervention Self-Monitoring and Reporting Identification of Patients for Intervention Other How soon will data be needed? Choose an item. 10l CMS CENTERS FOR MEDIC/Ma MOM SERVICE, CENTER FOR MEDICARE R MEDICAID INNOVATION Are patiepA: identifiabe data recwired? Yes If you selected Yes above, please keep in mind CMS cannot provide identifiable claims data on mental health or substance abuse service for many research grants. Please explain in the box provided any impact this would have on your project. (max 500 char) The proiect does not seek mental health or substance abuse data MEMMEEMEZ-- . Do you have an alternative plan i CMS data cannot be provided? No (Note: Medicaid and CHIP data will not be available to due limited availability at CMS.) If you selected Yes above, please describe any impact to the project in lieu of data. .H1-:; 5C0 I-) Click here to enter text. Does your proposal involve the provision of services c.o participants? Yes If you selected Yes above, please indicate if your organization (and partners) have processes and procedures to capture the following information: Provider Tax IDs Yes Practitioner NPIs Yes Medicare Participant H1CNs Yes Medicaid Participant IDs Yes CHIP Participant IDs Yes Other Payer IDs Yes Social Security Numbers (if awardee already collects SSN) Yes Participant Name Yes Date of Birth of Participants Yes Home Address of Participants Yes Counts by participant demographic characteristics Yes Service Types Yes Dates of Service Yes Existing Grant, Information Please describe any grants or other federal contracts that your organization or partner organizations currently receive or will receive during the period of performance which overlap and /or complement this proposal due to staff and /or subject area similarities. (If more space is needed to add Existing Grants /Contracts, please submit on a supplemental Word document and attach with the application.) Title of Grant/Contract Org / Federal Agency Name Lead Hazard Control HUD Grant/Contract # Award Amt. IALHH0217 -10 Dates of Award Type of Award Key Staff (MM /YY - MM /YY) (000p Agreement, Grant, etc.) Overlap? $3,099,948 01/11 -06/14 grant Yes Brief Summary of Objectives (Ha >:'��C clr:us? Removing lead hazards in 185 residential units to reduce lead exposure risk to children, community education and contractor certification. This is our 4th Lead Hazard Control grant from HUD Title of Grant/Contract Healthy Homes Production Org / Federal Agency Name Grant/Contract # HUD Brief Summary of Objectives (Max 500 chars) To address multiple residential health and safety hazards KIMICAWASEREAMONNial Title of Grant/Contract IALHH0217 -10 Org / Federal Agency Name Grant/Contract # Immediate Facility HRSA Improvement Grant Brief Summary of Objectives iMa ;; 50o chars) Expand clinic operational space /service Award Amt. Dates of Award Type of Award (MM /YY - MM /YY) (CoOp Agreement, Grant, etc.) $999,973 01/11 -06/14 grant Key Staff Overlap? Yes Award Amt. Dates of Award Type of Award Key Staff — mi,l/YYi (C,.;Oi_ ."-,,;Ireeri1ent, Grant. etc.) Overlap? C8BCS23865 $260,320 05/12 grant Yes Title of Grant/Contract Org / Federal Agency Name Grant/Contract # Brief Summary of Objectives (Max 500 chars) Award Amt. Dates of Award Type of Award Key Staff (MM /YY - MM /YY) (CoOp Agreement, Grant, etc.) Overlap? Yes 121 CMS CIN....1.011 MIDI( API ,111Y1,111,1,1CI5 Please complete the following tables with full and complete information as to the identity of each person or entity with an ownership or control interest in the applicant, including all officers, directors, and partners. If the applicant is a new entity that has been formed by one or more existing entities, please reflect this in the entity table below. (If roof 4 �ei-neededtoaddExisUngGronta/Contraots.p|oasesubmitonaaupp|emenLa|VVorddocumentandottaohvviththeapp|iuodon) For Persons with ownership or control interests in the applicant: First Name Last Name NPI (if applicable) Address (City,Shate,7ip) For Entities with ownership or controt interests in the applicant: Legal Name NPI (if applicable) Address (City,State.Zip) Role Relationship % Ownership (� �rn|ir�k� % Ownership (If apolicable === The applicant must report investigations of, and sanctions, penalties, or corrective action plans imposed against, the applicant and any person or entity with an ownership or control interest in the applicant, including all officers, directors, and partners. Please provide information from the previous three year period. Person / Entity Federal or state agency or accrediting body (e.g., DOJ, OIG) Description of infraction Resolution status CENTERS FOR AlF0.1, MEDICAID SERVICES Is your organization or partner organization(s) currently participating in a CMS demonstration model or the Medicare Shared Savings Program? If you selected Yes above, please explain below. (max 500 char) Click here to enter text. No W Please describe generally below any financial relationships between or among health care providers and payers and /or patients that may be used in implementing the proposed service delivery and payment models. N/A Do you anticipate the need for IRB approval from your institution for any aspect of your intervention, including but not limited to collecting patient - identifiable data and providing that data to CMS? If you selected Yes above, please explain below. (max 500 char) Click here to enter text. No mummammazars If you are a provider organization, does your organization use an Electronic Health Record system? Select CMS is sometimes requested by others to provide the name of a contact at our applicants. Does your organization desire to be contacted for information on your HCIA project (if awarded) and /or your HCIA proposal (if not awarded) by other organizations? (Please indicate selection with an `X') X Yes, OK to share our contact information with other government agencies. Yes, OK to share our contact information with other HCIA applicants and awardees. No, please do not release our contact information to anyone outside CMS and its contractors for this application (such as evaluators) Note that CMS may request additional information from you after review of your responses in this Executive Overview and /or in any other submissions you make in connection with your application and proposal. 14 I CMS CENTE. FOR MM.., 4040:11[..VICF5 CENTER FOR MEDICARE 6 MEDICAID INNOVATION Health Care Innovations Awards- Round Two (HCIA) Operational Plan — Live Well, Dubuque Sectio n A Strategies, Aims, and Drivers ary Drivers r 41111" econda rwprs Increase participation rates of health, wellness and lifestyle training programs by 25% by March 31, 2017 High-quality education and training Availability Promotion Ease of understanding Engaging instructors Care Coaches Reduce all-cause readmissions within 30 days at participating hospitals by 25% by March 31, 2017 Target high-risk patients Focus on patients with diseases with high likelihood of readmission (diabetes, heart failure, infection etc.) Focus on patients with multiple chronic diseases/risk factors Patient engagement and education for self-management Care Coaches Self-management plans Proactive counseling Provide early post-discharge services Care Coaches Multidisciplinary home visits Follow up calls/communication Home telemonitoring 50% of high-risk patients participate in at least 150 minutes of moderate to vigorous physical activity per week by March 31, 2017 Exercise regimen Care Coaches Fitness trainers Gyms/exercise facilities Exercise classes Outdoor recreation activities/trails 50% of high-risk patients will eat 5 servings of fruits and vegetables daily, reduce fast food/low nutrient dense food consumption and plan healthy diets by March 31, 2017 Healthy food awareness Care Coaches Education/dieticians Cooking classes Healthy food access and availability Locally grown food Farmers markets Community gardens Health food stores Healthy food affordability School lunches/senior center lunches/event food healthy choices SNAP Transportation choices Food purchasing education Reduce smoking among high-risk patients by 30% by March 31, 2017 Nicotine dependence Care Coaches Cessation treatments Cessation medications CENTER FOR MEDICARE I.< MEDICAID INNOVATION 1 o idary lltive Reduce patient BMI to 28 or lower by March 31, 2017 Calories in Care Coaches Prepared meals versus fast food /purchased meals Alcohol consumption Protein/carbohydrate /fat content of food Consumption of sugary beverages Calories out Care Coaches Intensity /frequency /durations of physical activity Increase metabolism rate for increased calorie bum Reduce TV /screen/sedentary time Improve drug adherence by 40% among high -risk patients by March 31, 2017 Complexity of medication regimens Care Coaches Simple instructions Improved communication Pharmacists Comprehension of treatment benefits Care Coaches Education Side effects Care Coaches Improved communication Pharmacists Costs Care Coaches Government subsidies Grow the number of high -risk patients with a medical home by 40% by March 31, 2017 Patient - centered care management Care Coaches Coordinated teams of medical professionals Training Improved payment model Patient Centered Medical Home certification Decrease the incidence and prevalence of chronic diseases by 5% by March 31, 2017 Health care Access to care Quality of care Healthy behaviors Diet /nutrition and exercise Tobacco use Alcohol use High -risk sexual behavior Violence Stress management Socioeconomic factors Ethnicity Education Income Physical environment Air quality Water quality Lead risk/other home environmental health hazards (ITT. .4 MM.. S. MEDICAID SMVIC. CENSER S-012 MEDICARE E. ME01101110 INNOVATION Primary rivers ec°11darY rivers Access to physical activity options, healthy foods Reduce costs of providers through the Community Health Collaborative by 10% by March 31, 2017 Administrative costs Information technology Supply chain management Preventive education costs Care Coaches Shared programs Community-wide marketing/education CMS [EMUS KIP AIMICAM L MEDICAID SMILES CENTER FOR MEDICARE &MEDICAID INNOVATION Project Set-Up Requested Content Needs Driver Diagram Strategy Project Set-up Actions and Potential. Risks • Processes to routinely review driver diagram and revise as appropriate • Engage stakeholders, clarify and align population and target measures with self-monitoring plan Actions Required to Implement (w/in 6 Months starting 04/01/14) (Max 500 chars),. the projeEt s s eering commi tee and *wolikingteamswill...rneetm_onthl.y to VItaliretd rivegliagrlam*Awalkwa4 —1,i1Wappropriate. The project tearniitlApAsalt the driver diagram strategy as it identifies participants for Thew roject. teutsideistakeholders will also be kept apprised of thrargsjsL ItoWgEl eeting the projettaims. The Live Well Dubliciite project will be —inistered by the City of Dubuque's Health firiVites'i,=t-Department:- A -conecriu:ttlp exec utive*.of area hospitals and health care providers, as well as community ' 'ehorders, will help to provide -guidance.,Tlesteering corrirnitte-e wrl meet once-az'ttiionth. Working teams, Leadership and Governance Structure • Description of governance roles, policies and procedures; organizational charts; committee structures and composition; meeting frequency Potential Risks (Max 500 chars) Proposed Mitigation Strategies for Risks (Max 500 chars) tje,44r4ng com ":tteela, to a eqa dtifrange sr -Akcirkin tevisj Rote fat- "sks' for improvement, as well as realistic the project's aims .are difficulty collecting data'totf:----assess local data and make -support progress toward Erver;diagram aims • ■ • health staff and, __community -StUelioldersimillIalsowbe!e-sta v.,;clevelop.,aftd implement the project. Working will meet at least once a moth- -Rortential risks include health earprdyi,der buy in, local changes accordingly. The project team will:also' identifi upon project launch how it will collect data to measure progress toward Dubuque will utilize existing partnerships merits to participate - - from steering committee and 757-1<rngaaiifPTAT413eiT h e r jegtwill-alsb include- , interested community stakeholders thr6ughotit-th''' committee _and works = - - - 4 1 Intervention ^�.�� Development and Deploym; S CENTERS FOR MEDICA^MEDICAI.SERVICES CENTER FOR MEDICARE a MEDICAID INNOVATION Project Set-Up Needs Requested Content _____ itse Actions Required to Implement Potential Risks (w/in 6 Months starting 04/01/14 (Max 50Nchars) • Could you deliver your intervention or service today? O When will the service or intervention be ready to be deployed to patients /recipients? o What is needed to have your service or intervention ready to be deployed within thefirst six months? The Collaborative, Care Coaches and education/marketing campaign will need some time to develop. Within six -months, a framework for the -Collaborative will be established and health providers will begin working to increase efficiency and reduce costs. CareCooche�can trained and beginning work with patients. The first sta of the education and marketing campaign U begin. Each health organization will need to designate a champion/point staff. � (Max B0chars) Potential risks include provider disinterest in the Collaborative, hiring and training delays for the Care Coaches, appropriate community-wide messaging for the education and marketing campaign, prompt education of providers, willingness toimplement model in a chariging health care environment. Proposed Mitigation Strategies for Risks (Max 500 chars) -- '+.`. . - —=^x~�� Dubuque has already engaged community health providers and has developed support for the ' Collaborative. The City and Crescent Community Health Center will develop a hiring and training strategy for the Care Coaches that builds contingencies for delays. Brainstorming sessions will also be conducted at project Iaunch to develop a clear understanding of the education/ marketing goals. o Do you intend to develop/operate an alternate payment model during the award period? ° If not, when will it be submitted? o What are the key actions in developing payment model? • Who are the key payers engaged in the payment model and when will their involvement start? The U�� prepared and submitted during the project period. It is anticipatedthata- fully fully develo pd ready by January 2015. Financial experts be hired to help develop the payment model. Prticipants include area clinics,_hospitals and providers. :kp!otentiaI risk is that partners-do riot understand nrcannntaccountforthe' complexity the payment model. The team will work with experts to d ine how the payment model will improve outcomes and reduce costs. • How will the outreach and communication to patient be deployed? ° What data orpartnerships are required to recruit patients? Are memorando of understanding and data sharing agreemerlts required? In year one, high-risk patients will be ,recruited from the Crescent and fro uninsured/underinsured patients who could use Crescent Community Health Center as their medical home. Years Potential risks include low- patient interes in participating, partner engagement with the Collaborative. r� A large pool of high-risk already exists at Crescent CommunhYHeahhCente[and will be identified tnensure that the team meets its recruitment goals. Dubuque has also already 5| S 11N7t. ICA ALLVICAllt L1,1E01,110 RAVIUS CENTER FOR MEDICARE & MEDICAID INNOVATION Project Set-up Actions and Potential Risks Project Set-Up Needs Actions Required to Implement (w/in 6 Months starting 04/01/14) (Max 500 chars) • Will a consent policy need development? • What is the coordination with related interventions or dependencies? wo andriVetrtilrierePtuting atients'fibm emergent rooms, hospitals an allri r-fti...:Pi.ea hospitals *and proyideVrJr3MMartners of he CollaboriatimeThe partners will oordinate With'Care Coaches va implement the model to improve Potential Risks (Max 500 chars) tia Proposed Mitigation Strategies for Risks (Max 500 chars) Staffing (Admin and Clinical) Subcontract Management and Procurement • What are the components of your staffing plan? • How will you address recruitment if staffing lags? • What are your strategies for training? • What contractors are needed and for what capabilities? • When will each contract be executed by quarter and date? Please address oversight of all engaged community health providers taptitias-, eveidpedgowii port f Collaborative. health outcomes and reduce costs. The Live Well,,,D_ubuque project will be PotergaVrisks include staff Mary Rose and Julie-will support administered by Mary Rose Corrigan, turnove.RsaS-a-.weil..asIC-ace4-iz-a,-,--.TAhe:;Ptbject rnanagen::,‘Ah.e City t e PA.iblic Health Specialist for hiring and training Djuque's HealthtSer-Vices- challenges Department. She will be sa.pported by uli podyard, theiXeCutive Director of CrescerAtCoarnunity Health Center. Care Co eke..:s:IfftWatifitftqlfe'project rperiod, along with a project manager-, •=1ericl.intherAe,y staff. Training will be fl7e7itired for Care Coaches and Crescent are committed to the project and will assure ongoing commitment to staffing. Dubuque will conduct regional and national outreach, - and workmithdoCal..and regional colleges and universities with'it-- i tea ithcareiedu.catiorttoThrre.,,-r_,_ Care Coaches, ensuring that arl sizallelabor pooklearns of the „ job oppatunity„The CollaboratiVe explore in training Care Coaches. '71-The:Coljahorative will hire contractors A potential risks includes —Dubuque will conduct regional to help suppostSIWykallament of A:173-failingtcrattract qualified and national Putreaci-seekin --tfie-payrnent-Jnodelzastwellyasitolrair..;—corftrattors. qua lifiedcorrtractorsenSto Care'Coaches-and,develop>education„ contractor pooi 61 Project Set -up Actions and Potential Risks Project Set -Up Requested Content Needs required contracts, planned start -up timelines, procurement policies and procedures ® Who are the Payer participants as of the time of application? In what capacity are they participating? ® What other payers do you intend to add, when and in what capacity? • When all targeted payers are engaged what is the geographical service area and market share of each? ® Identification and oversight of major health IT procurement and implementation activities and associated timelines 6 Summary of major legal or regulatory dependencies and estimated timelines, including but not limited to certification, licensure and IRB approval. Actions Required to Implement (w /in 6 Months starting 04/01/14) (Max 500 chars) and marketing materials. Contractors will be hired upon the launch of the project. The Collaborative will manage all subcontracts, and follow local procurement policies and procedures. Potential Risks (Max 500 chars) Crescent Community Health Center will pilot the payment model in year one of the project. Additional participants, including area hospitals and providers, will join in years two and three. All participants will have the ability to serve the Dubuque region. The Collaborative will seek to share information technology investments among providers, and engage local,_ partners (i.e., IBM and McKesson) in developing technology for the. Collaborative. Proposed Mitigation Strategies for Risks (Max 500 chars) A potential risk includes failure to attract participants in years two and three. A potential risk is the possibility that providers do not identify common information technology needs /time to develop. learns of the project opportunity. Dubuque has already engaged hospitals and community health providers and has developed support for the Collaborative, Care Coaches, education/ marketing campaign, and supporting payment model. Dubuque will work with providers at the launch of the project to identify areas where shared information technology could produce better health outcomes and reduced costs. The establishment of the _Collaborative . will require legal arrangements between the partners, as well approval by the directors of the participating organizations. Participants are expected to review and approve participation in the Collaborative by January 2015. Apotential risk includes low- partner interest /willingness to participate in the Collaborative. Dubuque has already engaged hospitals and community health providers and has developed support for the Collaborative, with a long, strong history of collaboration for improving community health. 7 CMS CENTERS FOR MEDICO. Z. MEING117 SE11,C13 CENTER FOR MEDICARE & MEDICAID INNOVATION Project Set-Up Needs Capacity for Monitoring and Measurement Project Set-up Actions and Potential Risks Requested Content • Will you have the required ability to track patient identifiers? • Will you have the required ability to track payments and tie those to providers? • What are the key supporting analysis contracts, and processes for sharing and reviewing the data? Actions Required to Implement (w/in 6 Months starting 04/01/14) (Max 500 chars) liTprojnriatIllVdMiti variety of measures Data will be collected from Crescent Community Health C-efifeTiear one, who already '6blect e Ith ou ti&-bedtt'a - for their patients asmell as area emergency rocms7hOspitals and providersjrbgearts.twp.andzthree,Jb,e project tearrYWill'establiSh-policies and processes to collect and manage that data. Potential Risks (Max 500 chars) AVdretffrartMlifttlrb - of provide 07.0 idea/utilize IT system for c Max roposed Mitigation trategies for Risks I 500 chars) ,,, ._„..... 'articipating providers W* agree share appropriate -,aggregate data with the projer ..,„ Other project set-up priorities • Other examples reflective of your project N/A N/A Please list the Key Personnel who will be assisting you with the leadership and implementatiorio Mary Rose Corrigan, RN, MSN • y • JulieWoodyard Project Lead City of Dubuque--?7:,' 1300 Main Street, Dubuque, IA Health.,S&Vitee ;75200i,-- - — eityofdubuque.org,, Department — mcorriga@ Community H e a Ith„(.0_ ritew4 1789 Elm Street, Dubuque, IA jwoodyard@ h'or- rescen 56-3589-4181 8 I Ms Section C Implementation Milestones and Work Plan 0.1 Establish steering committee Supports all project - aims P1 for Firs._.6 Months. ...a _, Fes. , y r :all '§:"m•" .. •.f , +. .. �'a': �'N'.%? n .t:.a.....y. _. r'7,'n " , ' Leadership and- Governance Structure City of Dubuque, Dubuque Health- Services Department Crescent Community Health Center, area business leaders, other community leaders Q1 Recruit providers and community stakeholders for working teams Supports all project aims Leadership and Governance Structure 04/01/14 05/31/14 City of Dubuque, - Dubuque Health Services Department Crescent Community Health Center, community based organizations. Hire project director and key- staff Supports all project aims Leadership and Governance Structure -- 04/01/14 05/31/14 City of Dubuque, Dubuque Health Services Department -_ - Crescent Community Health Center, community based organizations Q1 Hire consultant to help develop payment mode( Supports all project aims Payment Model 04/01/14 05/31/14 Dubuque - Health Services Department, steering:—=_r _ committee Crescent Community Health Center, Iowa Primary Care Association 01 Hire IT consultant to help develop data collection and tracking system Supports all-project aims Capacity for Monitoring and Measurement - .04/01/14 05/31/14 Dubuque Health Services Department steering committee Crescent Community Health Center,-lowa Primary Care Association Q1 Establish an Supports all project Intervention 04/01/14 05/31/14 Dubuque Health Crescent Community Health 91 CINTritS,0114.11,11C, M1.1[1,11,10 CENTER FOR MEDICARE & MEDICAID INNOVATION - - , inventory of all CoMmunity„hea, It. programs, - --g, services-And -infrastructure aims DevelopmenLand Deplo merit Develophiringa requirernents Care Coaches-- - — Supports all project Staffing 'AIMS Services Departmen -'---'CHNA HIP* -steering iicom m itteet.4, 1021:73671'47' tenter Q1 Identify training e edsfor '..ta re Coaches Supports all project ---Staffing0. 04/01/14 04/30/14 _ 'DO'buque Heaith ,Services Department Dubuque Health ervices Department Supports all project- ir: Intervention., Development-and messages for aims educaonJ marketing . _ . campaign. Deployment Dubuque Health Department, steeringt committee Q1 Finalize criteria to -1Supports all project Patient Recruitment 5/01 Identify'high:TisleT--aimsp,-; Crescent Community Hea CenterAwalAelthicare7-'_'-i' provide Crescent ConnintinitwHealth Center CrescenfCommunity HeAlth „Center Dubuque Health I trIgartieCtiMiiiunity Health evices Iowa Primary Care Department Association v iptervention 05/01/ DeVelqi:irrient and Deployment- Of_.3431/14_ Dubuque Halth _ . _grescent:CotrinAiiiilf-124alifi Services Center 'Department, steering committee- 05/01/14 07/31/14 Crescent . . Community Dubuque- Health Services Department 10 1 CMSFORN1MIMMICE ENTERMRAIEDWAREM , Q1, Q2 Finalize payment Supports all project '_ model aims -^`-~ Model "`- Health Center - 07/31/14 DUbuq-Cle-Health Services -,'` finance consultant 'CrescnntCornmun�yHoahh` Conte[ Q2 Recruit high-risk patients -_,,-._,r-'__ aims *__',`.,,�' Patient Recruitment 07/01/14 03/31/17 Crescent ' -- Community Health Center Dubuque Health Services Department Q2 Assign Care Coaches to patients Supports .- aims .� ; o8/31/14 Crescent HealCenter . Dubuque Health Department Q2 Q2 One-on-one meetings_ _ between Care Coaches and' patients to develop and implement self- managennent plans Develop and distribute ' ' education/ marketing materials Supports all project aims Intervention Development and Deployment -� Supports all project Intervention ..' aims Deve�pmeOtand Deployment ` 08/01/14 03/34/17 06/30/14 — '^ Crescent Community� Health Dubuque Health Department '�_ ^`'` Dubuque Servicem-' Department, steering committee,^�'`�� Crescent Community Heafth - Center, h' kh care organizations C FOR MEDICARE &E MEDICAID INNOVATION Milestone Work Plan for First 6 Months marketing staff Recruit hospitals'' °and providers into Collaborative: Supports all project aims Intervention Development an _Deploymen 4.03,341007 bubuque Health Services De ar-tm e community leaders Section D Measurement and Self- Monitoring D.1 Describe how self - measurements will be used Working teams and the steering committee will help with monitoring andy anal yzing progress., procedures.to =<help determine the success of the - Live Well, Dubuque- model.__Health Services present those findingsto the_ steeringcorrimittee_at regular intervals. The steering _co�.,mrnit� teams--will develop measures anddatacollection Department staff will help to analyze.., #iecollected data, and e respo si prmakrng "mid- course corrections D.2 Beneficiary Identifiers As the data collection and IT systems are developed, agreed upon identifiers will be named. "' D.3 Programmatic and Operational Measures 12 1 CM., /OR MEDICARE ^MEDICAID 3,11,CES CENTER FOR MEDICARE A. MEDICAID INNOVATION Measure Domain An Litio FTE Counts for Hiring and Staffing No problems Unique Participant Counts by Insurance Type (Medicare, Medicaid, CHIP, etc.) No problems Unique Participant Counts by Age No problems Quarterly Expenditures No problems Counts of Encounters (CIinicaI visits etc.) o problems Payments to Providers if applicable No problems Add other measures as needed No problems D,4 Process and Outcome Measure Selection from Suggested CMS List (found athttp:/&nnovatimm.�u�.r�� ^= Outcome Measure Selection from Suggested CMS List Number from Suggested Measures List 6 _'~--8~'_~��:�� 9 10 11 12 Aim or Driver From Driver Diagram Reduce the Collaborative by 10% by March 31, 2017+�'-� �Redoce costs of= -~— _the.Collaborative by `'-°-�'` '- Grow �-^ patients with a medical March-31, 2017 incidence and -prevalence of _ -chronic diseases by 10% by March 31, --- Domain from Structure7Uther Structure /Other �^n Pro-6_s/- Decrease the incidence and ^ prevalence of ch[onicd 10% by March 31 2017 _— - Process/ -� Decrease incidence and prevalence of p pce chronic d by 10/ by March 31, .2017 -p l3 | CMS CENTERS FOR MMICAPEZ PIELIKAIDSMICE CE ER FOR MEDICARE & MEDIU. INNOVATION Measures List Measure Name Text Description Inclusion /Exclusion Criteria Data Source Structure /Health IT -; ea 'sure Selection from Suggested, Structure /Health IT Structure /Health IT Preventive Ca_ re/ Vaccinations Preventive4C- are/ 4Preventive Care/ Vaccinations1 _ _ - Vaccinations. option o Medication e Prescribing Ability for Provide-0 PCM H Certification with HIT to Receivell aboratory Data Electronically Documents whether provider as adopted a ualified e- Documents the etentgto which a provider uses r.. Ice hied /qualified" Frequency of CrescentCle-Scent OrriThiliitty Health Center, Hospitals and Health Providers :Cluarte.rly HR system that incorporates'an electronic ata interchangenv�ut `oe ormore. laborato ies a llovving direcl electronic Ira nsmission:= tabor-atorry data into Childhood Immunization Status Influenza Vaccination /proof participating practices with NCQA patient Centered medical home certification.— EHR -as discrete sears abledata = ;elements one Measure calculates a rate forreach- recommend vacelnes -and nine separate combination rates Pneumonia.- neumonia - ' Vaccination Status + r. J ervAdults Percentage of patients aged 6 months and older seen for a visi'° between October �anil�the�end�of ��'- .February -.who received an ir.►flueaz-a -_. immunization ORS'' p tient reported fevious receipt of an influenza inlmunlzatlon Percentage of patients 65 years of age and older who ever received pneumococcal vaccinationw F= -Crescent.: Community Health-- e ter' Hospitals and Flalt roviders =Cre=scent Community Healthy Cente Hospita nd, Health roviders r.Crescent ommunity Health-- enter, Hospitals and Wealth-- Providers.: Quarterly�` • Quarterly... Crescent Community Health Center, Hospitals .µ and Health rouider -s -,- -None -t9 'Crescent ' -_` Community Health Center, Hospitals sand Health Providers. =� Quarterly‘' Quarterly 'Quarterly 14 CMS Measurement Limitations Comments Sampling Strategy (if Applicable) None None N/A None None N/A None -:None N/A - None None None N/A None N/A N/A Mode of Administration (if Applicable) N/A N/A N /A- -N /A None None N/A N/A Number from Suggested Measures List Aim or Driver From Driver Diagram Reduce smoking among high -risk patients by 30 %. by March 31,2017 Decrease the - incidence and prevalence of chronic diseases by 10% by March 31,-- 2017 Decrease the incidence and - prevalence of chronic diseases by 10% by March 31, 2017 Reduce high-risk patient BMI to 28 or lower by March 31, 2017 Reduce high- risk patient BMI to 28 or lower by March 31, 2017 - Increase participation rates of health, wellness and lifestyle training programs by 25% by March 31, 2017 Domain from Measures List Process / Preventive Care/ Screening Process/ Preventive Care/ Screening Process/ Preventive Care/ Screening Process/ Preventive Care/ Screening "Process/ :- Preventive Care Screening Process / Preventive Care / Wellness Visits and Prenatal Care Measure Name Measure Pair: A Colorectal Cancer - Cervical Cancer. . Preventive Care and Body Mass Index Well -Child Visits in 15 1 [Nal, ARDICARE n...1.10 SERV4,5 CENTER FOR RIEDICARR 01.113 INNOVATOR •• 'SS - - . (8„utmMeasLfreSeIectIonfom , uggested! *Lit4(contiritee Tit[ISSCCOUse. - --Assessment, B) Tobacco Cessation Intervention r4Sereening- Screening ereening: Body I x( MI) Screening a Follow-Up (BM1) 2 through48:- theTitsr Months.' Y ars f e of Life • Text Description A)-15-ercentageicof Kit* patients whqiwAr,e, queried about tobacco.,usePne.iPr--* ni-erdirri the two-year measurement ,-perioc1;- 43)Percentage of patients identified as tobacco users Avhd!.received Aiiitervention,clurmg ,theitwoo.,,ear measuremer,ft period Inclusion/Exclusion Criteria None Percentage of - 'Percentage-of— -7_.T ,ereeritage o - ,i-Percentage - ifiuertentagelo, emembers 50- 5 women-21=64-yeaW-p-atierits'aged 1FP- children, 2 thr ughl;;:._,-=mmbers-who - 4y,earsloftage'w,ho7'""' Pflterreeireedneri""rrettealid o I d e r 18 years of age; .101-ifed-15-finOnth'5",!'* , - had appropriate or more Pap tests with a calculated whose weight is old during the --'''-- screening foroittio,to-screen 4WILdocumented in -Classified based on _,,measurement Oar colorectal cancer cervical cancer _ - the rrfeditallrectitc1LP'N3M'IVertentirefOr— and who had the ANDifthe most recent BMI is utside the parameters,,a, w up plan is documented age and gender -::F-R440,- ii-roptaglogroptg.,k;: foI]�wing number of weil-child _visits with.7atpcP4during'-'-' thei r*firsr157.--.?-wo onths fatikrag None None Data Source Crescent Community Health Center Hospitals and Health Providers ekent Crescent Community.Health_„Corn_rn,unity_Health Community Health Center Hospitals Center „Hospitals Center Hospitals_ - - - 'Crescent Community Healt1-1,-,;;‘, „Center;'‘I-rirsiiita Is - Crescent Community Health-, Center, HospitaI s and 'Health'. and Health--- and Health and Health !and Health-- Providers, - -PrOViders Prait'lers Providers Frequency of Measurement Limitations Quarterly , None- None uarterly arterIy- Quartert' • one one NOne_ 16 1 CMS [INIti, FUR 411.1,I1[ M1IMILA.10 SERVIM CENTER FOR AIEDICARE MEDICAID INNOVATION Outcome Measure Selection from Suggested CMS List (continued) Project Meas Comments None None None Sampling Strategy -N/A- (if Applicable) N/A - --N/A None N/A None None N/A N/A N/A Mode of Administration (if Applicable) N/A _ N/A N/A - N/A _N/A - Outcome Measure Selection from Suggested CMS List (continued) Number from Suggested Measures List 22 24 25 29 38 Aim or Driver From Driver Diagram Decrease the incidence and - prevalence of chronic diseases by 10% by March 31, 2017 Decrease the Decrease the incidence and incidence and prevalence of prevalence of - chronic-diseases by - 10% by March 31, 2017 chronic diseases by 10% by March 31, 2017 Domain from Measures List Process/ Clinical Care/ Diabetes Process/ Clinical Care/ Diabetes Process/ Clinical Care/ Diabetes Decrease the incidence and -prevalence of — chronic diseases by 10% by March 31, 2017 Process/ Clinical Care/ Diabetes Decrease the incidence and prevalence of chronic diseases by 10% by March 31, 2017 Process/ Clinical Care/ Coronary Artery Disease Improve drug adherence by 40% among high-risk patients by March 31, 2017 Process/ Clinical Care/ Asthma & COPD Eye Exam Measure Name Foot Exam Medical Attention - -Diabetic Lipid and to Nephropathy Hemoglobin A1c Profile - - - - Lipid Control Medication Management for People With Asthma 17 1 CENTER FOR MEDICARE a MEDICAID INNOVATION Text Description Inclusion /Exclusion Criteria IT -;"% g 1'I.s y be 'i+ ,2 fir' • tt /... <u ome eaSureNSel'ectilorli froth Percentage of adult patients with d• iabetes aged 18- years who §_ received an eye • eentng1for diabetic retinal disease during the m easurernent. ear Percentage of adult 'patientnvith diabetes aged 18,75. years who received a foot exanl�i7 t inspection, sensory exam with monofilament, or triffajritirt Percentage #of ?mbe s -years ofage wit diabetes (type 1 1.-2) who -received a nephropathy screening- testxor+• . adrevtdertcey of- nephropathy during _e-measurement -year Pereerttage of adult amts with iabetes aged 18 -75 years who'received "a' hemoglobin A1c and - lipid prp assessment durin the measurement, ear pulse exam) Percentage of patients aged 18 years and old'e ithpatdiaghos s`of CAD seen within a 'tat n, tpeio_ who have a LDL-C ti result <100 mg /dL OR- patients who have a LDL -C resu4•t > =100 mg /dL ancf Thepercentage of patients 5. -r64 ears o ge duringthe Measurement period who were identified a"�aviilg persistent asthma and.were dispensed appropriate 4medlcatier ti at they remained on have a documented plan of care- tow_ achieve LDL -C_;:_ <100mg /dL, ncluding`at_a -_: minimum the prescription of a statin during the ' treatment period Data Source None ,:.,Crescent 'Community Health Center€Hospitals and HeaIth -Provders Frequency of Measurement Quarteay rescent. -- Community, Health Center, Hospitals and Health Provrders None Crescent'' Community-Health Cente HOs and Health Providers Crescent Community,Health Ce. ter, Hospitals nd Nealth Providers` ' `'` Nang None- Zrzescent- Community Health Center, Hospitals and.Health„r_. Providers aCrescent Community Health Center, Community and Health •Providers .. Quarterly-" Quarterly Quarterly J uarterly — Quarterly Limitations No None ;None None on None Comments MNone �:w.. :None : w — -None None None Sampling Strategy N/A N 181 CMS CENTERS FOR MEDICARE 6 MEDICAID SERVICES CENT. FOR MEDICARE A PATOICAID INNOVATION Outcome Me Lute Selection from Suggested CMS List (if Applicable) Mode of Administration (if Applicable) N/A N/A N/A N/A N/A N/A Outcome Measure Selection from Suggested CMS List (continued) Number from Suggested Measures List 55 78 141 102 Aim or Driver From Driver Diagram Decrease the incidence and prevalence of chronic diseases by 10% by` March `31, ,- 2017 Decrease the incidence and prevalence of chronic diseases by 10% by March 31, 2017 Improve drug adherence by among high-risk -_ patients by March 31, 2017 Decrease the incidence and prevalence of chronic_ diseases =by 10% by March 31, 2017 Decrease the incidence and- _ prevalence of chronic= diseases by 10% by March 31, 2017 Reduce all -cause readmissions within 30 days at participating hospitals by 25% by March 31, 2017 Domain from Measures List Process/ Clinical Care / Hyperlipidemia Measure Name Hyperlipidemia (Primary Prevention) - Lifestyle Changes and/or Lipid - Lowering Therapy Process/ Clinical Care/ Dental Annual Dental Visit Process/ Clinical Care/ Miscellaneous`` Outcome /Morbidity & Mortality/ Diabetes Outcome /Morbidity & Mortality/ Cardiovascular Outcome /Morbidity & Mortality/ Pulmonary Therapeutic Monitoring: Annual Monitoring for Patients on- Persistent Medications Comprehensive Diabetes Care Congestive Heart Failure Admission Rate Asthma: Percent of Patients Who Have Had a Visit to an Emergency Department (ED) /Urgent Care Office for Asthma in 19 I ni...x...uosravi<6 ICEN7111 111It .131C.E11.1.111CAM INNOVIVIION , " • • utcome Measure Selection from Suggested CMS Lust (continued) . . ; the Past Six Months Text Description Percentage of Percentage of patients age4,1R,Okii,...,:*,,ogambers.:2721.- years and older eaVOtragewho,------ with riskjactors tor had at least one coronaryartery,------dentalwisitcluring--- disease Whbilhave,-----themeasgenent- an elevatedLID_-C year 'and who are taking a lipid owe 4 .gent or have initiated therapeutelifestyle - changes Percentage f patients 18 years and older who received at least Fw, yi. The percentage of individuA1s187-75 years of agetiVitht, diabetes (type 1 ha d eacko.f.,the folio • HbA1c poor '-'180fda'yVpply of medication therap. for the selected ra %alga g ent hereceived annuallmonitorin rid f8r- grt h e iapeutic agent CO 0 Percent of county_ population with mixy --.admissions for C 9.0%) e-iHbAlc control (<8.0%) o-HbAlc control - • Eye exam (retinal This measure is used to assess-,,,,," opercent of p_atten who-h a ve_140,a ,vift4to _ - Emergentyws..- - Dena rtnielt (ED)/Lirgent Care -officebrasthma in the past six ms „ .• • LDL-C screening • LDL-C con -61 OYdL MedicaIattention nephropathy itOP co noi 140/90 mm Hg) • Smoking status__, d/Cessation dvice or treatment Inclusion/Exclusion Criteria -- No . None None None - Data Source Crescent Crescent Cresce t Crescent Crescentiv- Crescent- emtrp5-----, Community Health- - Community Health— Zommunity-Health Community Health Communityailtb ComnnunityVIth -Ceiltel-rHo-s-pital§"15'Cerite'r-OrspitalsCenterlqIiospitals Center, HOgiSitals'**Center-5.Hospitals 'Center,-Hospda.rs---- 20 M5 CENTER MR MEDICARE MEDICAID INNOVATION and Health Providers 1?.. ice. u re:Selectaon f m Su gg este' and Health Providers S:Lis ct l tinued� ,< and Health Providers and Health Providers Frequency of Measurement Quarterly Quarterly Quarterly Quarterly Limitations None None None None Comments Sampling Strategy (if Applicable) None None N/A None None N/A N/A N/A Mode of Administration (if Applicable) N/A N/A and Health Providers Quarterly None None -N /A N/A and Health Providers Quarterly None None N/A N/A Number from Suggested Measures List Aim or Driver From Driver Diagram Domain from Measures List 127 Outcome Measure Selection from Suggested CMS List (continued) Increase participation rates of health, wellness and lifestyle training programs by 25% by March 31, 2017 Patient & Caregiver Experience/ 143— Reduce all -cause readmissions within 30 days at participating hospitals by by March 31, -2017 Cost & Resource Use/ ED Utilization CMS CENTER FOR MEDICARE N MEDICAID INNOVATION • utcome Measure Selection from Suggested CMS List (continued Measure Name Text Description Inclusion /Exclusion Criteria Data Source Frequency of Measurement Limitations Comments Sampling Strategy (if Applicable) General Patient Satisfaction --- ,,Consur i Assessiient`oF =# =`�� "Ffealthcai-e Providers and Systems (CAMPS") . surveys ask - consurners and patients to report on and evaluateryi their-experiences with health care None - ED- Visit .Rate„,„...„„„, Hospital ED Visit Rate, - -by Conditio as,.appropriate) -Crescent Community Health CenterHospitaIs and Health_ Rrovrd ersL Quarterly AP he, IoN None' Crescent: Corliniunity Health Center, Hoitals r an -Health _ Providers -y. aQdarterly 22 1 Is CEMITIIS CA 17 MEDIU, 1...11V,S CCDTFR FOR MEDICARE & MEDICAID INNOVADON -1: utconie Measure Selection from Suggested CMS Listfcontinueot''r Mode of Administration (if Applicable) N/A D5 Custom Process and Outcome Measures Selection (Not from Suggested CMS Ust) Aim From Driver Diagram Encourage 50% of Encourage 50% of high-risk patients to high-risk patients to conduct at least eat 5 servings of 150 minutes of fruits and moderate to vegetables daily, vigorous physical reduce fast food activity per week by consumption and March 31, 2017 plan healthy diets by March 31, 2017 Domain from Measures List N/A N/A Measure Name Text Description Physical Activity Healthy Diet-- Amount of Change from poor _ moderate to eating habits to vigorous physical healthy diet activity per week 23 I CMS CIXTERS FOR 1.91. ID MANUS CENTER FOR MEDICARE k MEDICAID INNOVATION Custom Outcome Measure Selection. Technical Definition (Numerator and Denominator) Inclusion /Exclusion Criteria Data Source Frequency of Measurement Limitations Comments N/A Crescent Crescent eommuniWHealth= =Community Healtl - Center, Hospitals _ _ Center, Hospitals and Health and Health --; =- Providers prow er Quarterly Quarterly None None' Sampling Strategy (if Applicable) 24 1 CMS CENTER FOR MEDICARE 6 hIEDIGAID INNOVATION Custom Outcome Measure Selection ft- Mode of Administration (if Applicable)