065086301.1.2 1.5.3 1.5.3 (Quality Improvement) Project Title: el Paso community health atlas Performing Provider Name: City of El Paso Department of Public Health TPI: 065086301 Related Category 3 Outcome Measures: OD-11 Addressing Health Disparities in Minority Populations 065086301.3.2 IT-11.6 Outcome Improvement Target (TBD) Year 2 (10/1/2012 – 9/30/2013) Year 3 (10/1/2013 – 9/30/2014) Year 4 (10/1/2014 – 9/30/2015) Year 5 (10/1/2015 – 9/30/2016) Process Milestone P-4 Implement standardized policies and procedures to ensure the consistent and accurate collection of data Process Metric P-4.1 Description of elements of the system Goal: Inventory data sources; identify gaps in geo-coded data; identify opportunities for standardization of REAL data collection; develop policies, as needed; develop business plan for collection of biomarker data; spec equipment, supplies, furnishings Process Milestone P-4 Implement standardized policies and procedures to ensure the consistent and accurate collection of data Process Metric P-4.1 Description of elements of the system Goal: Continue data source inventory; identify gaps in data; identify opportunities for standardization of REAL data collection; develop policies, as needed; refine business plan for collection of biomarker data; procure mobile health unit and Improvement Milestone I-12 Implement intervention to make improvements in REAL data collection and use Improvement Metric I-12.1 Documentation of increased number of unique patients with documented REAL data using innovative program option. Demonstrate improvement over prior reporting period (baseline for DY 2) Goal: Continuation of biomarker data collection; interface collected Improvement Milestone I-12 Implement intervention to make improvements in REAL data collection and use Improvement Metric I-12.1 Documentation of increased number of unique patients with documented REAL data using innovative program option. Demonstrate improvement over prior reporting period (baseline for DY 2) Goal: Continuation of biomarker data collection/analysis; interface
for mobile health unit for collection of de-identified biomarker data Data Source: Policies and procedures; evidence of business plan Estimated Incentive Payment: $475,000 Process Milestone P-8 Participate in face-to-face learning, i.e., meetings of seminars, at least twice per year with other providers and the RHP to promote collaborative learning around shared or similar projects. At each face-to-face meeting, all providers should identify and agree upon related equipment, supplies, furnishings for collection of biomarker data. Recruit/retain staff for field deployment for collection of biomarker data; initiate data collection Data Source: Policies and procedures; evidence of business plan, furnished/deployable health screening van. Availability of staff. Estimated Incentive Payment: $434,670 Process Milestone P-8 Participate in face-to-face learning, i.e., meetings of seminars, at least twice per year data with other data sources/systems; develop reporting formats; analyze and report health status data by zip code Data Source: Evidence of biomarker data collection, analysis, and reporting Estimated Incentive Payment: $465,005 Process Milestone P-8 Participate in face-to-face learning, i.e., meetings of seminars, at least twice per year with other providers and the RHP to promote collaborative learning around shared or similar projects. At each face-to-face meeting, all collected data with other data sources/systems; refine reporting formats; develop tailored reports for healthcare providers, policy makers, and general public; report health status data by zip code Estimated Incentive Payment: $505,438 Process Milestone P-8 Participate in face-to-face learning, i.e., meetings of seminars, at least twice per year with other providers and the RHP to promote collaborative learning around shared or similar projects. At each face-to-face meeting, all providers should identify and agree upon several improvements
several improvements (simple initiatives that all providers can do to “raise the floor” for performance). Each participating provider should publicly commit to implementing these improvements. Process Metric P-8.1 Participate in semi-annual meetings organized by the RHP P-8.2 Implement the the floor” improvement initiatives established at the semi-annual meeting Goal: Participate in face-to-face learning with other providers and the RHP to promote collaborative learning around shared or similar projects. At each face-to-face meeting, all providers should identify and agree upon several improvements (simple initiatives that all providers can do to “raise the floor” for performance). Each participating provider should publicly commit to implementing these improvements. Process Metric P-8.1 Participate in semi-annual meetings organized by the RHP P-8.2 Implement the “raise the floor” improvement initiatives providers should identify and agree upon several improvements (simple initiatives that all providers can do to “raise the floor” for performance). Each participating provider should publicly commit to implementing these improvements. Process Metric P-8.1 Participate in semi-annual meetings organized by the RHP P-8.2 Implement the “raise the floor” improvement initiatives established at the semi-annual meeting (simple initiatives that all providers can do to “raise the floor” for performance). Each participating provider should publicly commit to implementing these improvements. Process Metric P-8.1 Participate in semi-annual meetings organized by the RHP P-8.2 Implement the “raise the floor” improvement initiatives established at the semi-annual meeting Goal: Participate in face-to-face learning
Data Source: Documentation of semi-annual face-to-face meetings; evidence of “raise the floor” initiative. Estimated Incentive Payment: $475,000 established at the semi-annual meeting Goal: Participate in face-to-face learning Data Source: Documentation of semi-annual face-to-face meetings; evidence of “raise the floor” initiative. Estimated Incentive Payment: $434,670 Goal: Participate in face-to-face learning Data Source: Documentation of semi-annual face-to-face meetings; evidence of the floor” initiative. Estimated Incentive Payment: $465,004 Data Source: Documentation of semi-annual face-to-face meetings; evidence of the floor” initiative. Estimated Incentive Payment: $505,438 Year 2 Estimated Milestone Bundle Amount: $950,000 Year 3 Estimated Milestone Bundle Amount: $869,340 Year 4 Estimated Milestone Bundle Amount: $930,009 Year 5 Estimated Milestone Bundle Amount: $1,010,876 TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD (add milestone bundle amounts over Years 2-5): $3,760,225
Biomarkers are patient and consumer characteristics that are measured and evaluated. Risk factors are variables that predict outcomes and are composed of biomarkers and social and environmental factors. The of a risk factor depends on the degree to which it can predict an event. Lastly, there are endpoints which include biomarkers, alone or in combination with clinical events. Below are the biomarkers to be collected in this project. Biomarkers Description Associated health outcome Body Mass Index Indicator of the balance between energy intake and energy expenditure Cardiovascular disease, diabetes mellitus, stroke, mortality, osteoarthritis, and some forms of Cancer. Fasting Glucose Measures the amount of sugar in blood; indicator of diabetes Diabetes, CHD, poor cognitive functioning, and mortality Diastolic Blood Pressure Index of cardiovascular activity; lowest pressure in an artery when the heart is resting Cardiovascular disease, stroke, Coronary Heart Disease, mortality Systolic Pressure Index of cardiovascular activity, maximum pressure in an artery when the heart is pumping blood throughout the body Coronary Heart Disease, stroke, CVD, mortality High Density Lipoprotein Protective cholesterol risk of arthrosclerosis CVD Low Density Lipoprotein Transports cholesterol from the liver to be incorporated into cell membrane tissues arthrosclerosis, stroke, peripheral vascular disease, CHD Cholesterol Aids in the synthesis of bile and steroid hormones In middle ages individuals CHD and all-cause mortality are present. In older age, U shaped relation to death. Triglycerides Fat substance stored for energy use Heart attack, CHD, coronary artery disease, pancreatitis Resting pulse Indicator of functioning and measure of overall fitness CHD, mortality Single lead EKG Measurement of electrical impulses in the heart Cardiovascular risk, stroke, mortality Po2 Measure of blood oxygenation Risk factor of cardiopulmonary and pulmonary disease Forced expiratory pressure Measure of lung capacity Risk factor of pulmonary disease/conditions Cystatin C Measure of GFR Decreased function, kidney failure Urinalysis Measure of metabolism, tubular and glomerular function Alteration I renal function, and metabolic alteration,
065086301.3.2 3.IT-11.6 Other Outcome Improvement Target (TBD) Performing Provider: City of El Paso Department of Public Health TPI: 065086301 Collect Valid and Reliable Race, Ethnicity, and Language (REAL) Data to Reduce Disparities: Unique Category 1 Identifier: 065086301.1.2 Starting Point/Baseline: 0 OD-11: Addressing Health Disparities in Minority Populations Year 2 (10/1/2012 – 9/30/2013) Year 3 (10/1/2013 – 9/30/2014) Year 4 (10/1/2014 – 9/30/2015) Year 5 (10/1/2015 – 9/30/2016) Category 3 Process Milestone P-1 Project Planning-engage stakeholders, identify current capacity and needed resources, determine timelines and document implementation plans Process Milestone Metric Goal: Inform stakeholders and broader community the El Paso Community Health Atlas initiative; assess availability of health data from traditional and non-traditional sources; prepare related index; assess and address issues of inter-operability of databases; identify data gaps; prepare plan to collect biomarker data through Category 3 Process Milestone P-3 Develop and test data systems Process Milestone Metric Goal: Conduct integrated analysis of existing REAL health data by zip code; supplement database, as needed, with biomarker data collected through mobile health screening van; identify trends and outlier results by zip code; begin mapping of results with data Category 3 Outcome Improvement Target IT-11.6 Other Improvement Target: Must be evidence-based, appropriate for the proposed project, and meet the definition of an outcome measure Goal: TBD Data Source: Performing Provider Estimated Incentive Payment: $310,003 Category 3 Outcome Improvement Target IT-11.6 Other Improvement Target: Must be evidence-based, appropriate for the proposed project, and meet the definition of an outcome measure Goal: TBD Data Source: Performing Provider Estimated Incentive Payment: $336,959