The Frederick Integrated Healthcare Network (FIHN) Care Transformation Organization (CTO) has been in existence since 2015. FIHN supports practices in achieving transformation in the following areas depending upon practice-specific needs and MDPCP Track: care management, data analytics, connectivity and information sharing, practice EHR workflow optimization, linkage to community agencies, and non-traditional care providers. The FIHN CTO also helps with understanding, operationalizing, and meeting MDPCP care transformation and reporting requirements.

As a CTO in MDPCP, FIHN can assist primary care providers through economies of scale not available to independent practices. FIHN enables practices to remain viable and independent in a sustainable fashion that reduces provider burnout, overutilization, and the total cost of care in Maryland. We are excited about this opportunity to improve care for patients and continue to support our local independent physician partners.

Care Management
FIHN care managers prioritize their work based on patient risk stratification and care team referrals. They collaborate with care team members and patients to develop patient specific plans of care that focus on the patient’s needs, barriers, lifestyle and set realistic expectations for self-management that meet that patient’s desired goals. Care managers provide coaching between clinical visits and linkage between providers and community agencies to maximize efficient use of available resources. Care management teams are multidisciplinary and flexible depending upon the needs of patients. RNs, LPNs, Medical Assistants, Licensed Clinical Social Workers, Pharmacists, Nutritionists, Behavioral Health Specialists and Community Health Workers are represented. Practices have found their care manager to be an asset to the care team and patients. References regarding practice experience with FIHN Care Management are available upon request.

The FIHN Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) has care managers embedded in Primary Care and select Medical Specialty practices in Frederick County serving over 9,000 Medicare beneficiaries. Serving as a CTO for MDPCP allows for continuity of care management for physician practices and patients. The FIHN approach to Care Management has been successful in reducing physician practice workload, improving quality and reducing avoidable utilization and costs for Medicare which has sustained community momentum for change due to shared goals and incentives. FIHN works across communities with our partners participating in the Regional Grant for Care Transformation with the Trivergent hospitals to our west. We plan to supplement CTO functions by collaborating with other systems in the Advanced Health Collaborative (a coalition of 5 Maryland hospitals) to reduce the cost of CTO supporting tools such as telemonitoring, behavioral health telemedicine, and other initiatives.

IT Analytics
The CTO’s analytics team makes use of Medicare claims, EHR data, CRISP tools, and Care Management screening tools to risk stratify patients and prioritize work starting with the highest risk population. They produce dashboards to monitor progress and provide patient specific actionable data for care managers and practices. Our analysts regularly visit practices and educate staff on workflows for integrating data into discrete EHR fields for ease of reporting, quality improvement tracking, and daily huddle reports to reduce gaps in care. Our analysts are experienced working with over 19 different EHR vendors. They also provide support to link to CRISP connectivity to utilize hospital encounter notifications to provide transitional care, and bidirectional flow of documents.

Practice Transformation
FIHN has trained Practice Transformation Specialists who assist with practice workflows, LEAN process development and working at the top of license to increase quality of outcomes and efficiency. The Transformation Specialists participated in best practice training through our CMS QIO that trained practices under the Maryland Primary Care Medical Home initiative. The FIHN medical directors review population-level reports by practice with physicians and discuss performance and priorities quarterly. Our teams look forward to expanding current efforts using national CPC+ best practice Program tactics to drive further transformation.

Please contact Christian Gomes, FIHN Director of Operations at 240-566-3713 or CGomes@fmh.org for more information.

SAMPLE CTO ARRANGEMENT

Frederick Integrated Healthcare Network CTO Public Reporting Page