Strategic Plan artworkStrategic Plan for the Clinical Enterprise (FY 2018-2022)

Strategic Plan artworkPractice Plan – Mission

The mission of the clinical practice at McGovern Medical School is to provide excellent, compassionate and patient centered care based on quality, safety and accessibility while demonstrating measurable effectiveness in primary and specialty services. Our mission will be accomplished through the development of targeted objectives, strategies and outcomes over the next five years.

Core Values

• Providing the highest quality of medical care that is patient centered, compassionate and collaborative, and focused on the population that we serve.
• Provide and maintain an environment where patients, providers, students and staff will be treated with dignity and respect.
• Commitment to a mission embracing social responsibility and promotion of a culture of transparency, diversity, growth and innovation.

Practice Plan – Goal 1
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 system in Houston through an improved referral system and patient navigation tools.
• Expand the tele-medicine programs for physical and behavioral health services through development of a UTHealth McGovern Medical School 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 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 six UTHealth 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.
• Number of patients receiving transitions of care services, percentage of patients completing a post hospital discharge clinic visit with a Primary Care provider.
• Decreased number of avoidable ER visits and admissions.

Practice Plan – Goal 2
Complement Behavioral Health services for both inpatient and outpatient care including substance abuse.

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.

OUTCOMES
• Improvement in health outcomes including 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.

Practice Plan – 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.

OUTCOMES
• Improvement in health outcomes including 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.

Practice Plan – 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 UT 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).

Practice Plan – 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 nonserious 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.

Practice Plan – Goal 6
Develop and enhance Interprofessional Education (IPE) programs focused on a team based approach to patient care and disease prevention.

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

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

Practice Plan – 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 careerlong 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 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, with a measurable increase in recruitment of women and underrepresented minorities.
• 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.

MEASURED OUTCOMES TO 2019
• Same-day appointments, evening and weekend hours added at all Community Based Clinics totaling an additional 424 hours per month for patient care
• Care coordination and transitions of care team received over 15,000 referrals since inception. The care coordination team currently consists of financial counselors, clinical pharmacists, diabetes educators, medical social workers, community health workers, behavioral health providers, nurses, advanced care practitioners and physicians.
• Pediatric high-risk care program has resulted in a 47-69% reduction in ED visits, admissions, PICU admissions and length of stay.
• Medicaid payments were reduced by $6,243/child-year with care coordination.
• Social workers have received over 10,000 referrals since inception.
• Diabetic educators have received over 6,000 referrals since inception.
• Clinical pharmacist referrals have identified and resolved over 300 drug therapy problems.
• The EHR integrated Patient Safety Reporting Module has received over 100 instances of potential patient safety events that have been evaluated and remedial actions taken.
• Nurse triage line operating 24/7 answered 349,000 patient calls in 2019.
• Behavioral health is now integrated in all primary care clinics.
• Approximately 40 clinical care measures for primary ,secondary and tertiary prevention have been established each with a measureable performance dashboard.
• All primary care patients are now screened annually for depression, falls, obesity, nicotine and alcohol use.
• Over 50 Wellness Programs for patients are currently available in conjunction with 30 community partners. Caring for the community programs include chronic disease management, nutrition and lifestyle, physical fitness, maternal and child care, and patient education and support.
• Strong Foundations for Motherhood uses community health workers to decrease severity and duration of postpartum depression showing a 50% decrease is psychological distress and achieved depression remission.
• Pediatric and adult vaccination rates have increased significantly.
• Construction on a new psychiatric hospital has commenced.
• A new physician to physician telephone consultation line for psychiatric patients is now operational.
• The Department of Psychiatry has enrolled students in a program to education Psychiatric Advanced Care Practitioners.
• UTP is leading a 60 member consortium to address food insecurity and clinical outcomes of intervention.
• NCQQA PCMH certification of 11 clinics with an additional 7 anticipated in 2020.
• IPE activities including mass casualty drills twice per year with participants from all health science disciplines participating in mock disaster simulations, Innovation Challenge interprofessional teams compete to find the best solution to active problems in health care, collaborative care continuing education in all clinical settings.

Practice Plan – Oversight
• The plan will be monitored semiannually for successful outcomes completion by a multidisciplinary team representing clinical, research and education champions, these updates will be available for general faculty review and comment.
• Outcomes that are identified as not meeting anticipated goals will be brought to the Medical Directors, Section Chiefs or Department Chairs for discussion and implementation of methodologies for improvement.
• Periodic re-assessment and adjustments to the plan will be required over time. Responding to and anticipating future clinical challenges will be a necessary task of the plan oversight committee.
• Performance dashboards, retrospective and prospective analysis will be employed to track the performance in each of the identified areas.

Strategic Plan artwork