Strategic Plan for the Clinical Enterprise

Clinical Enterprise – Goal 1

• Continue to develop innovative models of care delivery focusing on a patient-centered and collaborative approach to care delivery that is responsive and flexible to address the needs of the population we serve.
Strategies
• Facilitate patient accessibility through expansion of clinic hours, increased number of care providers and locations. A new patient navigation structure will be implemented to enhance online and virtual care.
• Expand the use of home visits for physical, behavioral and social health interventions.
• Identify and develop intervention plans for the clinically vulnerable at-risk populations in the primary care setting including the frail elderly, patients experiencing depression, alcoholism, obesity, tobacco addiction and substance abuse.
• Demonstrate a clear institutional leadership position as an advocate for improved vaccination compliance across Texas.
• Use and improve chronic disease dashboards to monitor physician and overall system performance.
• Increase collaborative and coordinated patient care across the six schools of the UTHealth Houston system in Houston through an improved referral system and patient navigation tools.
• Continue to enhance the use of Epic as the electronic health record for the clinical practice plan of UT Physicians.
• Improve patient access and care coordination by further developing the multi-disciplinary and collaborative patient care center at Bellaire Station.
• Establish an Urgent Care center for daily after-hours patient care at the UT Bayshore Clinic in Clear Lake.
• Expand the tele-medicine programs for physical and behavioral health services through development of a McGovern Medical School at UTHealth Houston Center for Telemedicine.
• Use Nurse Triage lines available 24 hours a day as a point of rapid contact.
• Enhance patient and care team contact with patients between clinic visits through novel applications of technology including wearable monitoring devices and enhanced use of new care team members such as Clinical Pharmacists.
• Increase the percentage of patients receiving care coordination services via a Care Team, (clinical pharmacists, community health worker, social workers, diabetic educator and others).
• Increase the number of home care visits by Advanced Care Practitioners and Social Workers
• Increase the percentage of clinics offering pre-visit planning, post-visit planning and / or standing orders protocols.
• Develop and implement a centralized transitions of care team for high-risk patients.

Outcomes

• Increased numbers of patients accessing care outside of traditional clinic hours including nights and weekends.
• Expanded disease prevention strategies with measurable increase in frequency of use.
• Reduction of avoidable Emergency Department visits, hospital admissions, readmissions, and length of stay.
• Increased identification and appropriate clinical follow up of depression, falls, obesity, nicotine use, substance abuse, and health harming social needs through comprehensive screening tools, appropriate treatment measures, and prevention strategies.
• Increased number of rapid follow up appointments, 90% of which will occur within thirty days, throughout all UTP clinics. Improve the effectiveness of case managers, community health workers in coordinating post-hospital care.
• Increased participation in educational programs relating to Health System Science, Informatics and Artificial Intelligence in patient Care.
• Increased collaborative programs in biomedical informatics among all UTHealth Houston schools.
• Enhanced reputation for clinical excellence, relevance and influence in population health care delivery locally and beyond.
• Increased rates of vaccinations in both pediatric and adult populations served.
• Increased volume of service requests, referrals or patient touches.
• Increased number of patients receiving transitions of care services, increased percentage of patients completing a post hospital discharge clinic visit with a Primary Care provider.
• Decreased number of avoidable Emergency Department visits and admissions.

Clinical Enterprise – Goal 2

• Improve opportunities for Behavioral Health services for both inpatient and outpatient care including substance abuse.

Strategies

• Improve access to inpatient and outpatient care through operation of a new psychiatric hospital.
• Develop and implement behavioral health online interactive programs for patient education and self-management.
• Establish a physician hotline for behavioral health outpatient consultations as well as real time tele-psychiatry for patients.
• Educate and train psychiatric advanced care providers.

Outcomes

• Decrease in wait times for patient access to psychiatric care.
• Improved patient behavioral health outcomes using both self-reported measures as well as standardized screening tools.

Clinical Enterprise – Goal 3

• Develop community-based programs benefiting the overall health of the population.

Strategies

• Reduce health disparities through development of new community outreach programs using a multi-sector collaborative approach including mobile health screening, healthy lifestyle education, chronic disease management, medication adherence, programs to address smoking, obesity, substance abuse, medication adherence, enhanced immunization rates and addressing the health harming legal needs of our patients.
• Expand and enhance existing programs for wellness, diabetes education and self-management, hypertension, physical fitness and behavioral health.
• Partner with existing community-based programs to enhance our outreach to an increased proportion of the population.
• Develop, study/research, and initiate innovative projects to address the social determinants of health that impact our patients.
• Provide programs that address social determinants of health.
• Continue to develop the pediatric PATH program for children having a medical illness with coexisting psychosocial factors as an intensive outpatient approach

Outcomes

• Increased number of patients participating in wellness-oriented programs, including diabetes education, exercise, Tai Chi, healthy meal selection and cooking, gardening, and health fairs.
• Improved disease management measures and improved patient self-reporting of overall health satisfaction and well-being.
• Improvement in our employees’ health using self-reporting and standardized screening tools.
• Needs assessments by clinic.
• Actual number and type of programs available.
• Number of patients screened.
• Number of patients who screened positive and received services.
• Decreased patient no show or non-adherence to treatment.

Clinical Enterprise – Goal 4

• Promote stronger, more integrated and patient focused affiliations with our major academic and community partners while aligning our strategic and financial goals with the stakeholders.

Strategies

• Establish criteria for mutually negotiated goals for patient care and outcomes for the clinical and financial enterprise.
• Work with Managed Care Organizations and payers to improve clinical outcomes and reduce costs.
• Partner with other UTHealth Houston schools to identify and secure new funding to improve infrastructure and patient outcomes.

Outcomes

• Maintain a top 10% ranking as a provider of patient care and superior ranking in hospital quality measures on the Vizient index and Press Gainey Surveys.
• Increase our funded and philanthropic research awards by at least 5% yearly.
• Increased participation and increased performance in quality and shared savings programs.
• Increased data exchange via supplemental data feed or FTP (File Transfer Protocol).

Clinical Enterprise – Goal 5

• Demonstrate continuous improvement of patient safety and quality measures through use of new and existing enhanced reporting mechanisms.

Strategies

• Expand the certification of the NCQA Patient Centered Home to all clinical sites.
• Enhance and facilitate the use of the Patient Safety Reporting Module.
• Initiate methods to improve and enhance ease of error reporting.
• Provide continuing education programs for error reduction and patient safety for students, staff and faculty.
• Implement Population Health measures to create and sustain systemic improvement through development of performance tools that allow multi-level tracking.

Outcomes

• Absolute reduction in serious and non-serious safety events.
• Absolute reduction in care errors, near misses, as well as omissions in care management.
• National recognition as leaders in patient quality and safety.
• Databases that will track quality and clinical outcomes, modelling to stratify risk, including tools for gaps in care analysis.

Clinical Enterprise – Goal 6

• Develop and enhance Interprofessional Education (IPE) programs focused on a team-based approach to patient care and disease prevention.

Strategy

• Improve collaboration between all the UTHSC schools in IPE at all levels, undergraduate, graduate and professional CME activities.

Outcome

• Increased number of IPE programs among the schools with a continuous increase in the number of students, staff and faculty participating.

Clinical Enterprise – Goal 7

Focus on recruitment and retention of outstanding clinical faculty. Expand and monitor programs designed to promote faculty wellbeing, including tools and strategies to identify and reduce clinician burnout, and enhanced career-long programs for faculty development.

Strategies

• Expansion of programs for faculty development, including mentoring and coaching programs.
• Support for faculty participation in the Clinical Safety and Effectiveness (CS&E) and Leadership development courses through UTHealth Houston and McGovern Medical School as well as participation in national leadership development courses.
• Use tools to survey workplace satisfaction to identify areas for improvement.

• Encourage use of screening tools to aid in identification of individuals at risk and provide appropriate management options.

Outcomes

• Recruitment of outstanding clinical faculty.
• All newly-hired faculty will have a designed faculty mentor.
• Improved work satisfaction as measured by improved satisfaction scores for faculty, trainees, staff.
• Improved retention of faculty and staff.