Strategies for Success:

Strengthening Rural Partnerships

JULY 18, 2018

LCDR Fred Butler Jr MBA MPH

Senior Advisor for Integration and Quality

Quality Improvement and Innovation Group

Center for Clinical Standards and Quality

Centers for Medicare and Medicaid Services

U.S. Department of Health & Human Services

2

For your hard work & commitment

For your leadership and contributions to rural health

For the strategic thinking of everyone in the room

For being part of the continued evolution and

innovation of community-based healthcare

3

Purposes of Session

Share Powerful Leadership and Management Models & Mindsets

Net Forward Energy

Accountability for Bold Goals

Change Management

Resilience

Choice

Real Work, Requests, Offers, Networking, Deal-making & Action

Review potential opportunities for Community-Based Organizations

Generating Results to Address the Opioid Crisis

QIO 11th and 12th Scopes of Work

Gain your perspectives, insights and feedback

4CMS has established large-scale, action-focused networks

to spread quality improvement and generate results on a

national scale

Partnership for Patients

4,000+ Hospitals

Transforming Clinical Practices Initiative

120,000+ Clinicians

End Stage Renal Disease Networks

6,000 Dialysis Facilities

Quality Innovation Networks –Quality Improvement Organizations

390+ Communities

12,000+ Nursing Homes

3,800 Home Health Organizations

300 Hospice

1,700 Pharmacies

MACRA and Quality Payment Program - Small, Underserved, Rural Support (SURS)

Up to 200,000 Clinicians

CMS Strategic GoalsTHE CMS STRATEGY WILL BE BUILT ON ONE MAIN GOAL:

PUT PATIENTS FIRST

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Centers for Medicare and Medicaid Services:

Strategic Goals

1. Empower patients and doctors to make decisions about their

health care.

2. Usher in a new era of state flexibility and local leadership.

3. Support innovative approaches to improve quality,

accessibility, and affordability.

4. Improve the CMS customer experience.

7A Continuum of Energy, Thoughts,

Statements

Positive (+) | Negative (-)

What Works What Doesn’t Work

Good Stories Bad Stories

Opportunities Problems

What We Can Do What We Can’t Do

What I Do Have What I Don’t Have

Acting Analyzing, Wishing

Taking Responsibility Blame

8Cultivating a Mindset of Net

Forward Energy

Assertions

Declarations

Requests & Offers

Acknowledgements

“Yes, and”

Effective Questions

Leadership Happens Through Language-- Leadership Speech Acts --

Gossip

Complaints

Worries

Frets

Ineffective Questions

Not Leadership Speech Acts

11

11

“I believe that this nation should commit itself to achieving the

goal, before this decade is out, of landing a man on the moon

and returning him safely to the earth.”

--- President John F. Kennedy,

Delivered in person before a joint session of Congress

May 25, 1961

Bold Aims Create Systems; Systems Create Results

12Partnership for Patients

Focused on 2 Breakthrough Aims

13National Hospital-Acquired Conditions (HACs) Rate:

HACs per 1,000 Discharges

145 142132

121 121

9894

90

0

20

40

60

80

100

120

140

160

2010 2011 2012 2013 2014 2015 2016*

Historical Trend 2014 Rebaselined HAC Rate*preliminary

data

Source: AHRQ, National HAC Scorecard 2014 and 2016

14National Results on Patient Safety:

Substantial Progress Thru 2015

Source: Agency for Healthcare Research & Quality. “Saving Lives and Saving Money: Hospital-Acquired

Conditions Update. Interim Data From National Efforts To Make Care Safer, 2010-2014.” December 1, 2015.

125,000 lives saved

$28B in cost savings

3.1M fewer harms

15Pause for Reflection

and Discussion

1. What is your main insight from this

material so far?

2. What are some of your own

experiences with these kinds of

leadership and management

approaches?

167 Key Goals of CMS Transforming

Clinical Practice Initiative

1

6

1791% of 22,656 Enrolled TCPI Practices are small, rural or operating in medically underserved areas

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DesignationNumber of Practices

Percent of Total Enrollment

Medically Underserved Areas 11,913 52.58%

Rural Areas 3,872 17.09%

Small Practices 17,420 76.88%

Small, Rural, OR Medically

Underserved Practices20,642 91.11%

Small, Rural, AND Medically

Underserved Practices1,997 8.81%

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CCWV Service

Area by zip code

(shaded area)• 15 Health Centers

• 1 Dental Clinic

• 8 Pharmacies

• Behavioral Health

• Pain Management

• 50 School-Based Centers

19Framing the Opioid Problem for

a High Performing Practice in WV

In 2016, the five states with the highest rates of death due to drug overdose were:

• West Virginia (52.0 per 100,000)

• Ohio (39.1 per 100,000)

• New Hampshire (39.0 per 100,000)

• Pennsylvania (37.9 per 100,000)

• Kentucky (33.5 per 100,000)

20Community Care of WV’s Integrated Pain Care model

All patients with pain complaints are welcomed at any practice location

1. Patients are assessed and a determination is made if opioid prescriptions in excess of 30 days is a likely treatment path.

2. CDC guidelines are considered.

3. The patient receives education about the integrated program and a sample controlled substances contract is discussed with the patient.

4. Internal referral to our “specialty” program is made.

5. Patients are contacted by the pain management clinic to begin pre-visit planning including Opioid Risk Assessments, PDMP education, SDoH, SBIRT, psychiatric assessments for comorbidities, etc.

6. The PCP and pain management team develop a shared care plan for treatment after the patient is assessed by the chronic pain team.

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The opioid program data that CCWV does know

Program Result

Patients entering the program since 2013 2692

Active users today 1057

Overdoses from our program users 0

39% of the total hospitals are identified as rural/CAH

23Hospital Improvement Innovation

Network—Minnesota

24Hospital Association of New York State

HIIN: Improvement in Sepsis

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We were taught….

That People Are

Resistant to Change

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In fact…

People Are Not Resistant to Change

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In fact…

People Are Not Resistant to Change

We Change All the Time!

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In fact…

People Are Not Resistant to Change

We Change All the Time!

However…

People Are Resistant to Being Changed.

29Lead Change by Helping People

Invent Their Own Changes

What is working?

What is causing it to work?

What is our objective here?

What could we do…More of?

Better?

Differently?

30Pause for Reflection

and Discussion

1. What is your main insight from this latest

material?

2. What are some of your own experiences

opioids and change management?

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“Real Work” is:

• Making Commitments

• Delivering on Commitments

• Securing Commitments from others

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Work is not…

Talking About Commitments

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Together, Doing Real Work,

We Can Make the World Turn

200 people at the Rural Health Care Improvement Collaboration Meeting

engage repeatedly in making requests and offers….say, 5-10 commitments

each:

That could be 1,000 to 2,000 commitments!

What we ask of you:

Embrace Change!

Seek Out Innovation, New Experiences, New Partners!

Think About Data Differently!

33

“The antidote to exhaustion

…is wholeheartedness.”

-- David Whyte

“Crossing the Unknown Sea”

Fostering Resilience in

Ourselves and Others

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What Are the Sources of Resilience?

Wholeheartedness

Purpose

Embracing Change; Leading Change

Partners

Choice

Perspective

A Powerful Model

Stimulus Response

Choice: The Most Powerful Model

Stimulus CHOICE Response

Viktor E. Frankl

Made Extraordinary Choices

Seminal Book:

Man’s Search for

Meaning

39

Pause for Reflection and Discussion

As a leader, what might you do more

of, better or differently today, and

going forward?

40Our “Way” of

Operating to Achieve Results

Bold, Clear Aims -- Implemented at Scale

Focus on Results

Do More of What Works

Make Best-In-Class Performance, Common

Performance

Tight About the “What” Outcome; Flexible on

the “How”

Foster and Foment Joy in Work

41Emerging Key Priority Areas to Guide

Our Improvement Work Through 2024

Opioids & Behavioral Health Nursing Home Quality

Burden Reduction Supporting Patients Through Care Transitions

Patient Safety Chronic Disease Management/Self-Management

Rural Health, Vulnerable Populations and

Patient & Family Engagement

are Cross-cutting Priorities

42CMS Quality Improvement Work Is Anticipated to

Align With Priorities Across Healthcare Settings

Priority Focus AreasClinicians in Clinical

Practices

Hospitals (acute care,

specialty, LTACs, IRFs)Nursing Homes Community Coalitions

Opioids & Behavioral

Health

Burden Reduction

Patient Safety

Chronic Disease Self-

Management

Care Transitions

Nursing Home Quality

Rural Health, Vulnerable Populations and Patient & Family Engagement are Cross-cutting Priorities

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Intended Approach

Less reporting, fewer deliverables, and more

improvement work

Maximize competition

Continue testing promising innovations through

the Strategic Innovation Engine

Advance and scale up promising innovations from

innovation projects and other successful

initiatives on the front lines

Sustain and expand continuous quality

improvement based on data from Beneficiary and

Family Centered Care functions

Reward Value

Use of CMS datasets for impact evaluation

Be flexible on the “how” methods and tight on the

“what” outcomes

Perform work at National Scale across all key

healthcare settings, including: clinical practices,

hospitals, nursing homes and communities

Work in close partnership with both patients &

providers – put patients over paperwork

Align with Administration priorities, other federal

programs/agencies, and team with private partners

Align with and implement CMS Meaningful

Measures: fewer, more important measures with a

focus on outcomes/results

Strong use of self-reported QI data, with validation, to

drive improvement work

44Questions for Discussion & Feedback

What are your insights and reactions to these

CMS priorities?

What opportunities does this work potentially

create for HRSA rural partners?

What else?

45

Thank you!

LCDR Fred Butler Jr MBA MPH

Senior Advisor for Integration and Quality

Quality Improvement Innovation Group

Centers for Clinical Standards and Quality

Centers for Medicare and Medicaid Services

Fred.butler@cms.hhs.gov