CERTAIN Projects to Drive Improvement in WWAMI Practice Transformation Network

Wednesday, October 14, 2015

Funded by the Centers for Medicare & Medicaid Services, the Transforming Clinical Practice Initiative (TCPI) is a national effort designed to support clinicians in achieving large-scale health care transformation. UW Medicine is one of 39 health care collaborative networks selected to participate and will receive about $30 million to develop a Practice Transformation Network (PTN) across the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region. This WWAMI-region PTN will provide technical assistance to help equip more than 6,700 clinicians who serve 1.9 million patients with tools, information, and network support needed to improve quality of care, increase patients’ access to information, and spend health care dollars more wisely. To accomplish this, the PTN will:

Support an infrastructure comprised of rapid-cycle performance surveillance and benchmarking of quality measures, a telemedicine grid, support for coordinated care for patients with chronic conditions, and data and information sharing across practices.
Train primary and specialty care practitioners using a hybrid model of web-based and in-person learning, including on site coaching to support practice transformation.
Deploy targeted programs to drive performance improvement linked to endpoints of interest to the PTN and TCPI, including patient-reported outcomes, hospital readmissions, unnecessary testing and procedures, and healthcare costs.


CERTAIN Medical Director Dr. David Flum led efforts to develop the WWAMI-region PTN building on lessons learned from the development of statewide networks in quality improvement (Surgical Care and Outcome Assessment Program) and learning healthcare research (CERTAIN).  The PTN will leverage several successful CERTAIN programs aimed at improving patient outcomes and reducing unnecessary procedures:

PROS in Practice

The collection of patient-reported outcomes (PROs) gives clinicians a unique opportunity to incorporate patient-centered data into clinical practice. This improves patient-provider communication, patient satisfaction, and when used in shared decision-making can reduce the use of invasive procedures or testing.  While PRO data is starting to appear in emerging health information technology platforms, most healthcare practitioners have little experience interpreting PROs or incorporating PROs into practice transformation activities. PROs in Practice provides convenient and systematic mechanisms for capturing PROs directly from patients ensuring timely and accurate PRO data and meaningful reporting to support the delivery of patient care as efficiently as possible. Expanding PROs in Practice across the PTN is expected to reduce unnecessary procedures by as much as 30% through:

  • Data collection, benchmarking and reporting on novel patient-centered outcomes for Dr. Robert Bree Collaborative recommended procedures.

  • Training on use of patient-centered outcomes in preference sensitive care planning.

  • Quarterly forums to share best practices and guide practice change.



An increasing number of patients are being discharged to skilled nursing facilities following acute care admissions, but a large proportion of these patients (more than 25%) have unplanned re-hospitalizations, and care coordination with primary care clinicians has been a challenge. INFORM (Improving Nursing Facility Outcomes using Real-time Metrics) is a collaborative of specialty care clinicians, primary care clinicians, and skilled nursing facilities using performance benchmarking and best practices to improve the health of patients receiving specialized post-acute care following hospitalization. INFORM evaluates the variability in patient, structural, and process factors that contribute to readmission and focuses on improving transitions in care from hospital to skilled nursing facilities to primary care.  INFORM is expected to reduce re-hospitalizations by 20% across the PTN through:

  • Performance benchmarking and reporting on acute care discharges and readmissions, and CMS Minimum Dataset measures for patients discharged from network practices to skilled nursing facilities.

  • Monthly teleconference forums to share best practices and guide practice change.  


Surgical site infection is a major source of preventable morbidity, mortality, and healthcare expense.  Infections can cost $20,000 per diagnosed case and are a top contributor to costs due to healthcare-associated infections. With shorter hospital stays, most surgical site infections now occur after discharge when patients are particularly vulnerable and there are no established standardized or reliable methods for detection. mPOWEr is an innovative mobile health platform designed to improve post-surgical discharge care by enabling patient-initiated monitoring of surgical wounds and facilitating patient-provider communication during transition back to primary care.  mPOWEr is expected to reduce emergency room visits and re-hospitalizations by 25% through:

  • Performance benchmarking and reporting on elective surgeries and readmissions.

  • Deploying innovative mobile store-and-forward application for patients leaving the hospital and returning to primary care practice


WWAMI PTN by the Numbers

  • UW Medicine will receive up to $5.5 million for the first year, and then will receive up to $30.2 million over a four-year period.
  • 6,739 clinicians in the WWAMI-region PTN provide care for over 1.9 million patients annually across a region that is one quarter of the land mass of the United States.
  • The WWAMI-region PTN leverages existing collaborations and relationships among the 8 owned and operated entities of UW Medicine, 9 additional member organizations comprising the UW Medicine Accountable Care Network, and 24 organizations of UW’s WWAMI-region Practice and Research Network.
  • The WWAMI-region PTN will accomplish significant and sustained practice transformation with an expected $425 million in cost savings.