Overview

In September 2015, the Centers for Medicare and Medicaid Services (CMS) awarded funding to 29 Practice Transformation Networks (PTNs)^[1]to improve care through use of electronic health records, care coordination, and patient monitoring.  The goals of the PTNs are to improve health outcomes and reduce unnecessary hospitalizations for five million patients.  CMS expects the PTNs to generate one to four billion dollars in savings to the federal government and commercial payors.  The New Jersey Innovation Institute (NJII) was awarded a four-year $50M PTN cooperative agreement from CMS.  The Maryland Health Care Commission (MHCC), MedChi, The Maryland State Medical Society (MedChi), and the University of Maryland School of Medicine Department of Family and Community Medicine (MLC) partnered with NJII in May 2016 to complete the CMS defined practice transformation activities in Maryland.  

The PTNs will support 140,000 clinicians in achieving large-scale health transformation by providing hands-on support to develop the skills and tools needed to improve care delivery and transition to alternative payment models.  The funding aims to support transformation of care in PTN practices, and establish peer-based learning networks to provide peer coaching and share best practices to transform care.  CMS defines PTNs as peer-based learning networks designed to coach, mentor, and assist practitioners in developing core competencies specific to practice transformation, such as improving patient care, organization, and workflow.  The PTN approach to care allows practices to become actively engaged in the transformation. The peer based learning networks ensure collaboration among a broad community of practices that creates, promotes, and sustains learning and improvement across the health care system.  

Key activities of the Maryland PTN partners include:

• MLC – Prime on the subcontract and is responsible for practice transformation, education and coaching, quality improvement, health information technology optimization, and recruitment
• MedChi – Provider recruitment
• MHCC – Convener, consultant, program monitor, and coordinator

Leading Accomplishments

• Enrolled and oriented practices to PTN support and services, and programmatic requirements
• Evaluated select health IT capabilities of enrolled practices through in-person interviews with practice transformation coaches  
• Performed baseline practice assessments to identify the baseline level for transformation areas such as patient and family engagement, team based relationships, and population health management  
• Created a tracking database for enrolled practices and practitioners
• Educated practices on CMS and PTN data requirements and data collection options; data may be sent by the practice to the NJII PTN or extracted from the EHR by the PTN
• Established data collection methodology by practice
• Worked with practices to report Physician Quality Reporting System (PQRS) data for 2016
• Supporting practices meaningful use (MU) reporting for 2016

Upcoming Initiatives

• A MACRA education symposium that offers continuing medical education credits in partnership with MedChi on January 18th
• Finalize quarterly learning collaborative meetings aimed at peer learning
• Create individual work plans for all existing practices using the interview and assessment results to assist practices in obtaining clinical improvement goals
• Create dashboard reports to track program metrics and progress of practices through five stages of practice transformation
• Implement the CMS Change Package with practices to educate practices and achieve programmatic goals
• Promote the use of CRISP, the State-Designated HIE, to facilitate data exchange and support optimization of health IT
• Implement transition of care and chronic care management billing code support to help practices increase revenue
• Implement a measures management process to track program metrics and progress of practices through the five stages of practice transformation
• Provide monitoring of quality measures to track program metrics and progress of practices through the five stages of practice transformation
• Monitoring and remediation of practices with deficiencies to support practices to meet established clinical improvement goals
• Continue to recruit, enroll, and orient new practices to PTN support and programmatic requirements

Current Enrollment

• Enrolled - 807 practitioners, 87 practices
• Interested - 400 practitioners, 65 practices (estimated)