Together 2 Goal Innovator Track: Cardiovascular Disease Cohort. Call for Participation

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1 Together 2 Goal Innovator Track: Cardiovascular Disease Cohort Call for Participation

2 Cardiovascular Disease (CVD) and Diabetes Approximately 28 million Americans are living with Type 2 diabetes. Due to the complications associated with diabetes, such as high blood sugar, high blood pressure, and obesity, cardiovascular disease (CVD) is the leading cause of death for those with diabetes. People with diabetes are two to four times more likely to develop CVD than people without diabetes. In the United States, healthcare costs for managing cardiovascular conditions in people with diabetes totaled more than $23 billion in About the Innovator Track CVD Cohort The Innovator Track is the most advanced track within AMGA Foundation s Diabetes: Together 2 Goal campaign. There are two cohorts within the Innovator Track: the CVD Cohort and the Eye Exam Cohort. The Together 2 Goal Innovator Track s CVD Cohort offers groups the opportunity to team with other high-performing organizations to be on the leading edge of cardiovascular management in people with diabetes. The objective of this program is to develop a framework and success metrics for cardiovascular management in patients with diabetes based on cardiovascular risk. Participating organizations will work alongside an Advisory Committee of clinical experts and the AMGA team to help develop and refine the framework and metrics. AMGA will accept 10 organizations to participate in the CVD Cohort, and the program will run for 12 months. 2

3 Key Programmatic Components Population-based intervention strategies they will implement Participants will be asked to: Develop protocols to identify, stratify, and manage patients with diabetes based on CVD risk and symptoms Construct a collaboration between primary care and specialists for management of patients based on CVD risk Optimize pharmacotherapy management for patients with diabetes and CVD Develop a patient lifestyle modification action plan Provide smoking cessation counseling and create a patient action plan Create or distribute patient education resources about CVD risk scores Program evaluation Participants will be asked to: Develop strategies/tools for capturing CVD risk data Create quality success metrics for tracking outcomes in patients with diabetes and CVD Business case for participation Participants will be asked to: Identify staffing, resources, and key skills required to manage CVD in patients with diabetes Document provider and staff education needed to sustain work Develop an implementation plan 3

4 Criteria for Participation Participating organizations will: Create an internal CVD Cohort team that will include: Clinical Champion: Affiliated physician/clinical champion identified as team lead Administrative Champion: Administrator with operational responsibilities in a related area Project Manager: Individual to manage the project plan and timeline Data/IT Analyst: Team member to retrieve and submit project data Commit to contributing to the development and implementation of the framework and measures Obtain high-level organizational leadership approval on project, and anticipated or budgeted resources Report on developed measures in addition to the Together 2 Goal campaign s Core Track measures Submit periodic updates/action plans to AMGA Participate in all relevant CVD Cohort activities and to meet regularly with peers, experts, and AMGA staff by: Attending two in-person meetings (two team members are required to attend each meeting) Joining bi-monthly webinars on CVD hot topics for patients with diabetes Hosting AMGA staff for site visits Although not a requirement for participation, AMGA strongly recommends that participants consider the patient perspective when developing programs in order to improve patient engagement and health literacy. 4

5 Core Track Participation Requirement The Innovator Track is designed for groups who are looking to elevate their diabetes care to a new level. Groups who are currently reporting data to Together 2 Goal on the Core Track or who are willing to commit to reporting on the Core Track are eligible to participate. DATA REPORTING TRACKS Basic HbA1C control < 8 percent BP control < 140/90 mmhg 3 3 Lipid management 3 3 Medical attention for nephropathy 3 3 CVD outcomes measures 3 Eye exam measures 3 Note: Innovator Track participants only report measures within their specific cohort. Core (Bundle) Innovator Responsibilities Team Members CVD Cohort Team Member Responsibilities Clinical Develop protocol to identify, stratify, and manage patients with diabetes based on CVD risk and symptoms Construct a collaboration plan with specialty care for management of patients based on CVD risk Optimize pharmacotherapy management for patients with diabetes and CVD Primary care physician, advanced practice clinician, nurse, pharmacist, endocrinologist, cardiologist Lifestyles Develop a patient lifestyle modification action plan Provide smoking cessation counseling and create patient action plan Develop or distribute patient education resources about CVD risk scores Care manager, quality improvement specialist, social worker, nutritionist, behavioral health specialist, exercise physiologist, health coach Data/IT Analyze data Implement, test, and refine success metrics Report data Data/IT analyst Operations/ Finance Plan the project Manage billing and coding compliance, insurance, marketing, staffing, operations, and physical space requirements Quality improvement specialist, billings and coding manager, project manager 5

6 Benefits of Participation $7,500 to support the initiative for each organization participating in the CVD Cohort Reimbursement for travel and hotel expenses for two in-person meetings for two representatives from each participating organization Customized assistance with the development of a sustainable population health management approach to CVD management in patients with diabetes, including implementation plans based on your organization s structure and size Care redesign that will improve quality and value Support and coaching from the CVD Advisory Committee and AMGA staff Participation in the development and testing of the framework and measures alongside national experts in CVD and diabetes Ability to benchmark performance with similar organizations Opportunity to present data as posters or podium presentations at AMGA and other national conferences Public recognition of participation (announcements made at AMGA conferences, on AMGA s website, press releases, etc.) Opportunity to apply for national awards Considerations before Applying Your organization must be a current member of AMGA and must sustain membership throughout the length of Innovator Track. One Tax I.D. per group (per AMGA membership status) is permitted. Potential members of AMGA are encouraged to contact Bill Baron at wbaron@amga.org for more information. Small to large medical groups, IPAs, academic practices, and integrated delivery systems that are committed to improving the management of CVD in patients with diabetes are encouraged to submit an application. Organizations are welcome to apply for one or both Innovator Track cohorts. However, in making selections, the committee will pay close attention to an organization s ability to tackle two quality improvement projects simultaneously. 6

7 Evaluation Criteria Applications will be evaluated based upon: 1. Committed Resources Ability to dedicate staffing and resources to CVD Cohort Ability and commitment to develop framework and measures IT plan and ability to identify targeted populations, track data, and meet reporting requirements 2. Potential Impact Number of patients impacted Openness to innovation and quality improvement Feasibility and scalability Willingness to change organizational structure and processes 3. Implementation and Sustainability Intent Funds/resources/staff available to implement and sustain CVD risk management program beyond completion of CVD Cohort Ability to monitor program to ensure ongoing effectiveness CVD Cohort Timeline Date January 22, 2018 February 28, 2018 March 1-14, 2018 March 15, 2018 April 11, 2018 May 2018 May 16-17, 2018 March 2018 April 2019 September 2018 April 2019 September 2018 February 2019 April 2019 TBD April 2019 Activities Call for Participation distributed Applications due to AMGA Review and selection of participants by Advisory Committee Applicants notified of selection; MOU agreements signed Introductory webinar Baseline reporting In-person kick-off meeting Hot topics webinars Quarterly reporting AMGA site visits Case study development In-person wrap-up meeting 7

8 Instructions for Preparing Your Application 1. Complete the Innovator Application Template. Include an organizational profile that gives the reader an understanding of the size and scope of your organization without revealing your organization. 2. Complete the cover sheet template and include: Organization name Innovator Track Cohort of interest Primary contact information (name, title, , phone, address) IT contact information (name, title, , phone, address) Sponsor signature (CEO, medical director, department head) and contact information (name, title, , phone, address) 3. Submit one electronic copy of the application to Applications are due by 5:00 p.m. PST on February 28, For further information or questions, contact or visit together2goal.org. CVD Cohort Advisory Committee Frank Colangelo, M.D., M.S.-HQS, FACP, Chief Quality Officer, Premier Medical Associates (Lead Advisor) Parag Agnihotri, M.D., Medical Director, Sharp Rees-Stealy Medical Group Beth Averbeck, M.D., Senior Medical Director, Primary Care, HealthPartners Medical Group Laura Balsamini, Pharm.D., BCPS, Director of Pharmacy Services, Summit Medical Group, P.A. Yates Lennon, M.D., Chief Quality Officer, Wake Forest Baptist Health Liana Spano-Brennan, D.O., FACC, Cardiologist, Summit Medical Group The CVD Cohort of the Innovator Track is sponsored by the BI-Lilly Diabetes Alliance.