Yale Medicine met approximately 90% of its goals on the final practice assessment of the Transforming Clinical Practices initiative (TCPi), showing substantial improvements since it began participating in the program three years ago.
TCPi is a service delivery innovation model launched by the Centers for Medicare and Medicaid Services (CMS) to help clinicians and health care organizations transition from traditional fee-for-service payment models to a system where payments are tied to value, quality, and outcomes. Participating organizations are part of a peer learning network where members work to achieve aligned clinical quality goals.
When Yale Medicine began participating in TCPi in 2016, the practice met 33% of milestones for primary care and 42% of milestones for specialty care. On the most recent practice assessment, conducted in May and June 2019, Yale Medicine met 90% of TCPi milestones for primary care and 91% for specialty care, indicating steady progress during the three years that YM has been participating in TCPi.
The TCPi milestones measure a wide range of clinical quality goals in such areas as patient access, patient safety, chronic disease management and prevention, patient and family engagement, transparent sharing of data, efforts to reduce unnecessary tests and hospitalizations, and readiness to engage in alternative payment models.
The TCPi program will end after this month. Yale Medicine is considering participating, in partnership with Northeast Medical Group (NEMG), in a similar practice transformation network offered by CMS, called Clinician Quality Improvement Contractor (CQIC), after TCPi comes to an end.
Integrating Primary and Behavioral Health Care
Among the TCPi milestones that Yale Medicine has been working to achieve in recent months are improvements in behavioral health outcomes and integration of primary and behavioral health care.
In April, YM began piloting a team-based collaborative care model for care coordination and behavioral health integration within Yale Internal Medicine Associates (YIMA). A behavioral health coordinator was hired, who regularly screens YIMA patients for depression. When a patient is diagnosed with depression, the behavioral health coordinator (who is a psychologist) may treat the patient herself, enroll him/her in an appropriate care program, and/or work with a psychiatrist and the patient’s primary care provider to initiate medical treatment. She can also refer patients to an online cognitive-behavioral health therapy program that is available through TCPi.
In addition to the behavioral health coordinator, YIMA has also added a social worker and a nursing care coordinator to its staff to create a true collaborative care model. The social worker assists YIMA patients with such issues as mental health, financial support, emotional support, and connecting to community-based resources. The nursing care coordinator provides a variety of services, such as helping patients manage chronic medical conditions, making sure that patients are up-to-date on preventive care screenings, and checking in with patients who were recently seen in the emergency department or recently discharged from the hospital.
The goal of this collaborative care model is to reduce unnecessary emergency department visits, hospitalizations, and readmissions; increase rates of screening for and remission of depression; and improve blood pressure and diabetes control.