1 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK CLARION

1 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK CLARION Interprofessional Case Competition The Heart of the Matter INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

2 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Nathaniel Arnold Medical Director of the Heart Failure Clinic at Central Hospital Natalie Nguyen Head of WestPlans health plan Disease and Case Management Program Darshan Pandya Head of WestPlans Home Care and Hospice Andrew Rock Nurse Manager from Central Hospital Our Team INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

3 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK The Heart of the Matter: Chronic Heart Failure (CHF) Demands improvements in quality of care and patient safety for CHF Hospital Readmissions Reduction Program 50% CHF patients are readmitted 50% mortality within 5 years 5.1 million INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS To recognize and eliminate the gaps and failure points that prevent optimal heart failure care at WestPlan Our Purpose

4 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Chronic Heart Failure & WestPlan 1,817 WestPlan members have CHF 184 (10.2%) members participate in our Disease and Case Management Program Central Hospital treated 2,346 patients with CHF in 2013 Inpatient Admissions: 1,644Outpatient Visits: 1,105 (87 ER Visits) Visits per patient 1 to 21,513 (92%)1 to 2984 (89%) 3 to 5125 (7.6%)3 to 5111 (10%) More than 57 (0.4%)More than 515 (1.3%) INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

5 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK 69 Years Old Insured by Medicare Robert & Lisa Reeves Retired Mechanic Smoking & Drinking Margie Reeves Stressors Sedentary Lifestyle & Poor Diet Sedentary Lifestyle & Poor Diet Family History Harlan Reeves INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

6 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

7 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

8 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Fragmented health records 8 Development/dx of DM II (12 years ago) Unhealthy Lifestyle Low health literacy Smoking/drinking to deal with stressors No regular medical checkups Diabetic and Cardiac Events in the 7 months following MI/Rushed to the ER (3 weeks ago) Hospitalization for deteriorating condition and admitted as an inpatient to the transitional care unit (2 weeks ago) MI at home/placement of stent/pacemaker at Central Hospital (7months ago) Development/dx of Grade III CHF (14 months ago) Unmanaged DM II FH of heart disease Continued smoking and sedentary lifestyle Rejected palliative care 7 months ago Inadequate home care Never referred to Heart Clinic or transferred to Transitional Care High BMI due to poor lifestyle Family History of DM II Poor handling of CHF dx 14 mos. ago Poor coordination of care for DM II and CHF Non-adherence to cardiac medication regimen Admitted only for observation 3 weeks ago no Transitional Care Margie and Lisa now physically unable to care for Harlan Age/gender: 69 y/o M INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS The system failed Harlan Reeves

9 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Harlans Health Care Access to Needed Care Optimal Evidence-based Disease Management Prevention of Disease State Interdisciplinary Coordination INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

10 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS Our Recommendations 1. Achieve Advanced Certification in Heart Failure by The Joint Commission 2. Partner with the Dunnelly community to implement population health management Images retrieved from: http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx Institute of Healthcare Improvementhttp://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx

11 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Recommendation 1 Advanced Certification in Heart Failure INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

12 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Recommendation Strategy Cardiac Care Checklist Hospital Stay Hospital Discharge Post-Acute Care Outpatient Home Care & Hospice [ ] Joint Commission Core Measures in Heart Failure [ ] Joint Commission requirements for Advanced Certification in Heart Failure: INPATIENT and OUTPATIENT [ ] WestPlan considerations for Standards of Care

13 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Pathway to Advanced Certification for CHF Integrate and improve Health Information Technology Tactic 1 Coordinated Transitions of Care Tactic 2 Medication Management Tactic 3 Optimize Home Care and Hospice services for CHF patients Tactic 4 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

14 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Tactic 1 : Information Technology Existing EHR Clinical Decision Support Tool Cardiac Care Checklist CHF Risk Assessment Checklist Oregons Health Information Exchange program (Care Accord) Integrating health records from WestPlan and outside of WestPlan networks INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

15 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Tactic 2: Transition Coordinators Transform discharge planners into Transition Coordinators Ensures smooth transition from hospital to next care setting Follow-up by post-discharge day 7 & connect with Home Care and Hospice services Goals to achieve: 80% patient follow-up with PCP, cardiologist, or Heart Failure Clinic or other WestPlan Service 100% of medications prescribed are filled at discharge with medication instructions understood by the patient Reduce CHF readmissions by 15% within year 1 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

16 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Tactic 3: Medication Management Medication Reconciliation Obtaining medication histories Reconciling patients home medications with updated medication action plans Interdisciplinary effort Improving medication safety across the continuum of care Inpatient stays Outpatient appointments Updated personal patient medication lists INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

17 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Tactic 3: Medication Management Medication Regimen Dose Optimization Adding a clinical pharmacist to the WestPlan Heart Failure Clinic to help optimize heart failure regimens in the most critical and complex patients Medication Therapy Management (MTM) Adding an MTM pharmacist to the Disease and Case Management Program to help improve medication safety for patients not regularly seen in the WestPlan Heart Failure Clinic INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

18 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK P4: Home Care and Hospice Why is Home Care and Hospice important for CHF patients? Quality of Life Patient Safety Reducing hospital re-admissions! WestPlans Home Care and Hospice services are underutilized. Why? Stigma Access Our current team: Geriatricians, Nurse Practitioners, Nurses, Social Workers, Assisted Living specialists (home aides), Chaplains Which roles do we want to add or enhance? Transition Coordinators Dietician Clinical pharmacist INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

19 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK P4: Home Care and Hospice How will our improved interdisciplinary team help CHF patients? Health Professionals Roles in Patient Safety Transition coordinators Medicare resources Coordination amongst the teamSharing medical information NPs/Nurses Medication management Fluid volumes Preventing medication errors Monitoring any sudden changes Social workers and Chaplains Family meetingsIndividualized patient care Dieticians Menu planningPatient-specific dietary needs Home aides Assistance with ADLs Preventing accidents and reducing caregiver burden Geriatricians and Pharmacists Effective and personalized care and medication plansIndividualized patient care INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

20 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Recommendation 2 Population Health Management INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

21 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK 10% Level 3 High risk Multiple Chronic Illnesses 20% Level 2 Moderate risk Single Chronic Illness or Risk Factors 70% Level 1 Low Risk Intensive Case & Disease Management Chronic disease self-management Increased enrollment through electronic medical records (EMR) Health Coaching & Lifestyle Management Coaching lifestyle choices Programs for modifying risk factors Health Education & Promotion Raising health awareness Health promotion programs Community Partnerships Incentives Screening & Annual Visits Outreach & Awareness OUR COMMUNITY INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS Information Technology Population Health Management

22 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK CHF RISK STRATIFICATION Risk LevelsRisk Criteria HIGH RISK 1.Any cardiac condition or hospitalization for a cardiac condition 2.Valvular Heart Disease 3.MI 4.Cardiomyopathy 5.Left Ventricular Hypertrophy 6.CHF Grade II, III, IV MODERATE RISK Conditions: 1.CHF Grade I 2.Diabetes 3.Hypertension 4.High cholesterol One or more of the following: 1.Smoking 2.Alcohol use-due to impact on risk factor conditions for CHF 3.Poor Diet 4.Stress 5.Low Physical Activity 6.Overweight LOW RISK Defined by exclusion of all of the above Community All those who have not come into contact with our healthcare system, not currently patients, or we do not have any health assessment information Risk Stratification INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

23 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK WestPlan Community Care-a-Van Interdisciplinary Team (Allocated Part Time) 1 Public Health Specialist (Epidemiologist) 2 Registered Nurses 1 Social Worker Services provided Blood Pressure and Blood Glucose Readings BMI Assessments Tobacco and Alcohol Use Assessments (ASSIST) Individual Health Risk Assessments Referrals to WestPlan providers Care-a-Van operations would partner with the Million Hearts Campaign INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

24 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Raising Health Awareness WestPlan Community Care-a-Van Honoring Choices Onsite patient counseling Health Education and Promotion Classes on various health topics Specialized for inpatients, outpatients, or the general public Community Partnerships Health Fairs Engagement with community stakeholders INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

25 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS Recommendations 1. Achieve Advanced Certification in Heart Failure by The Joint Commission 2. Partner with the Dunnelly community to implement population health management Images retrieved from: http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx Institute of Healthcare Improvementhttp://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx

26 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Tactic 1-4 Expenses Table E: Salary Expense Annual Salary Monthly SalaryAllocated for Central Hospital Registered Nurse(RN)** $ 69,000.00 $ 5,750.00 $ 51,750.00 9 months Registered Nurse(BSN)** $ 73,000.00 $ 6,083.33 $ 54,750.00 9 months Social Worker (MSW)** $ 58,233.00 $ 4,852.75 $ 43,673.00 9 months Epidemiologist (MPH)** $ 86,132.00 $ 7,177.67 $ 71,776.67 10 months Dietician (RDN) $ 57,034.00 $ 4,752.83 Clinical Pharmacist (PharmD) $ 109,974.00 $ 9,164.50 Pharmacist (PharmD) $ 105,049.00 $ 8,754.08 Social Worker Manger (MSW) $ 65,000.00 $ 5,416.67 Total Salary Expense and Training and Orientation Time $ 623,422.00 $ 31,171 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

27 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Tactic 1-4 Cost Savings INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS Intervention Total Savings Cardiac Rehabilitation $ 671,381.50 Guideline Directed Medical Therapy $ 161,349.60 Multidisciplinary Teams $ 3,661,981.80 Transitional Care Coordination $ 4,401,682.50 Enhanced Medication Management by Pharmacist $ 2,929,585.44 Discussions about Advanced Directives HCAPS Increase

28 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Care-a-Van Pro Forma Analysis Scenario 3 Care-a-Van Volume (low performance) YearPatient Volume 2015480 2016528 2017581 2018639 2019703 (1day x 48weeks x 10patients) (10% annual growth) Table E: Salary Expense Annual Salary Monthly SalaryAllocated for Care-a-Van Registered Nurse(RN) $ 69,000.00 $ 5,750.00 $ 17,250.00 3 months Registered Nurse(BSN) $ 73,000.00 $ 6,083.33 $ 18,250.00 3 months Social Worker (MSW) $ 58,233.00 $ 4,852.75 $ 14,558.25 3 months Epidemiologist (MPH) $ 86,132.00 $ 7,177.67 $ 14,355.33 2 months Total Salary Expense $ 64,413.58 Table B : Cash Savings from Heart Attack Prevention 20152016201720182019 Number of M.I. prevented58101215 Cost per M.I. = $14,00014,000 Annual Cost Savings $ 70,000.00 $ 112,000.00 $ 140,000.00 $ 168,000.00 $ 210,000.00 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

29 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Care-a-Van Pro Forma Analysis Assumption of Scenario 3 - Low performance conservative estimates. Care-a-Van Pro Forma201420152016201720182019 aInitial Capital Outlay $ (75,000.00) bCash Savings ( M.I. prevention) $ 70,000 $ 112,000 $ 140,000 $ 168,000 $ 210,000 cDonations $ 1,200 $ 1,320 $ 1,452 $ 1,597 $ 1,757 dNet Revenue (earned and saved) $ 71,200 $ 113,320 $ 141,452 $ 169,597 $ 211,757 eLess: Salary Operating Expense $ 64,414 $ 65,702 $ 67,016 $ 68,356 $ 69,723 fLess: Supply Operating Expense $ 868 $ 955 $ 1,050 $ 1,155 $ 1,271 gLess: Depreciation Expense $ 14,000 hNet Operating Income $ (8,081) $ 32,664 $ 59,386 $ 86,086 $ 126,763 iAdd: Depreciation Expense $ 14,000 jNet Operating Cash Flow $ 5,919 $ 46,664 $ 73,386 $ 100,086 $ 140,763 kAdd: Salvage Value $ 5,000 lProject Cash Flows $ 5,919 $ 46,664 $ 73,386 $ 100,086 $ 145,763 mCost of Capital3% nPresent Value Interest Factors0.97090.94260.91510.88850.8626 oAnnual Present Value of Cash Flows $ (75,000.00) $ 5,746.35 $ 43,985.03 $ 67,155.55 $ 88,926.32 $ 125,735.15 pNet Present Value $ 331,548.39IRR51% INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

30 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Harlan Reeves Development/dx of DM II (12 years ago) Poor lifestyle management Lack of education Smoking/drinking to deal with stressors No regular medical checkups Diabetic and Cardiac Events in the 7 months following MI/Rushed to the ER (3 weeks ago) Hospitalization for deteriorating condition and admitted as an inpatient to the transitional care unit (2 weeks ago) MI at home/placement of stent/pacemaker at Central Hospital Development/dx of Grade III CHF (14 months ago) Unmanaged DM II FH of heart disease Continued smoking and sedentary lifestyle Rejected palliative care 7 months ago Margie suffering from caregivers burden Never referred to Heart Clinic or transferred to Transitional Care High BMI due to poor lifestyle FH of DM II Poor handling of CHF dx 14 mos. ago Poor coordination of care for DM II and CHF Non-adherence to cardiac medication regimen Admitted only for observation 3 weeks ago no Transitional Care Margie and Lisa now physically unable to care for Harlan Age/gender: 69 y/o M Disease & Case Management Home Care & Hospice INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS Community Care Partners Health Promotion & Education Health Coaching & Lifestyle Management The system failed Harlan Reeves

31 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK Thank You INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET OUTLOOK & TAKEAWAYS

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1 INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK INTROTHE CASERCA RECOMMENDATIONS IMPLEMENTATIONBUDGET BARRIERS & OUTLOOK CLARION