CARE COORDINATION SUBCOMMITTEE PRESENTATION TO INTEGRATED DELIVERY - - PDF document

Governor’s Office of Health Innovation and Transformation

CARE COORDINATION SUBCOMMITTEE MEETING PRESENTATION TO IDS Meeting Minutes 10/28/14

All meetings will be accessible to handicapped individuals in compliance with pertinent state and federal laws upon notification of anticipated

• attendance. Handicapped persons planning to attend and needing special accommodations should contact GOHIT at least five business days

prior to the meeting so that we may best accommodate their needs. Governor’s Office of Health Innovation and Transformation 100 W Randolph St, Chicago, IL 60601 Suite 2-201 312.814.1600

CARE COORDINATION SUBCOMMITTEE PRESENTATION TO INTEGRATED DELIVERY SYSTEMS SUBCOMMITTEE MEETING MINUTES

Meeting Date: 10/28/14 Meeting Location: Chicago, Springfield, conference call Approval: FINAL

Governor’s Office of Health Innovation and Transformation

CARE COORDINATION SUBCOMMITTEE MEETING PRESENTATION TO IDS Meeting Minutes 10/28/14

All meetings will be accessible to handicapped individuals in compliance with pertinent state and federal laws upon notification of anticipated

• attendance. Handicapped persons planning to attend and needing special accommodations should contact GOHIT at least five business days

prior to the meeting so that we may best accommodate their needs. Governor’s Office of Health Innovation and Transformation 100 W Randolph St, Chicago, IL 60601 Suite 2-201 312.814.1600

ATTENDANCE

Name Title Organization Peter Eckart Director of Health and Information Technology IPHI-Illinois Public Health Institute Chuck Feerick Associate Whitaker Kinne Group, LLC Laura Furlong CEO Marcfirst Blair Jones The Alliance of Chicago Community Health Centers Dejan Jovanov PHN System Architect IDPH Ellen Kaufmann Program Coordinator IPHI-Illinois Public Health Institute Alexander Martell Intern GOHIT Xenia Okalibe Program Assistant IPHI-Illinois Public Health Institute Susanne Schnell

• Dr. Joseph West

Chief Population Health Officer NextLevel Health Partners Michael Gelder Co-Chair, Delivery System Reform GOHIT Elissa Bassler CEO IPHI-Illinois Public Health Institute Kathleen Monahan Illinois Framework Jayne Antonacci IDHS/DASA Sonia Bhagwakar General Counsel IDoA - Illinois Department on Aging David Billingham Associate Director Maine Center, Inc. Michael Brave Vice President Southern Illinois Living Centers, Inc - SILC Kelly Carter Chief Operating Officer Illinois Primary Health Care Association Craig Cathcart Director of Legislative Affairs and Advocacy Swedish Covenant Hospital Gerri Clark Associate Director for Program Services UIC-Division of Specialized Care for Children Cathy Cumpston IDHS/Division of Mental Health Selma D'Souza Government Affairs Director GOHIT Laura Furlong CEO Marcfirst Art Jones IDSR SME Health Management Associates Janice Gambach President Mental Health Centers of Central Illinois /System Administrator, Behavioral Health, Memorial Health System Ramon Gardenhire Deputy Policy Director SEIU Healthcare Christine Hammond Project Manager IDHS - Illinois Department of Human Services Jill Hayden Director of Medicaid Policy BlueCross BlueShield of Illinois Daniel Hoodin Vice President - Managed Care Strategy /Development HSHS- Hospital Sisters Health System Nadeen Israel Policy Director EverThrive Illinois

Governor’s Office of Health Innovation and Transformation

CARE COORDINATION SUBCOMMITTEE MEETING PRESENTATION TO IDS Meeting Minutes 10/28/14

All meetings will be accessible to handicapped individuals in compliance with pertinent state and federal laws upon notification of anticipated

• attendance. Handicapped persons planning to attend and needing special accommodations should contact GOHIT at least five business days

prior to the meeting so that we may best accommodate their needs. Governor’s Office of Health Innovation and Transformation 100 W Randolph St, Chicago, IL 60601 Suite 2-201 312.814.1600

Michael Jones Special Assistant to the Director IDHFS - Illinois Department of Healthcare and Family Services Keith Kudla CEO Family Health Network John Lewis President

• J. Lewis & Associates

Marie Lindsey Illinois Society for Advanced Practice Nursing Rajnish Mandrelle VP - Organizational Development and HR Association for Individual Development Kimberly Matthews Policy Analyst Illinois Framework Peter McLenighan Executive Director Stepping Stones, Inc. Robert Mendonsa IDHFS - Illinois Department of Healthcare and Family Services Pat Merryweather Co-Chair, Data and Technology Executive Director, Telligen Helen Michelassi Executive Director Prairieland Service Coordination, Inc. Laura Minzer State Government Affairs Cigna Mary McGinnis Director of Operations GOHIT Teressa Perdieu Melissa Picciola Staff Attorney Equip for Equality Jim Runyon Vice President, Strategic Initiatives & Gov’t. Affairs Easter Seals Peoria-Bloomington Ken Ryan Vice President of Member Advocacy Illinois State Medical Society Al Shehadi Deb Shipley Chief of Staff - Operations IDoA - Illinois Department on Aging John Smolen Director Consilink, LLC Lora Thomas Executive Director NAMI Illinois Jen McGowan Policy Analyst GOHIT Leonor Vanik PhD Candidate University of Illinois at Chicago (UIC) Charles Watkins Marketplace Regional Outreach Coordinator Governor's Office Sharyn Elman Director of Communications GOHIT Sharron Matthews Assistant Director IDHFS - Illinois Department of Healthcare and Family Services Carole Schwartz Senior Policy Advisor IDoA - Illinois Department on Aging

MEETING LOGISTICS

Building: James R. Thompson Center 100 W. Randolph Street, 16th Floor Conference Room: Chicago, 16th Floor 16-504 / Springfield, 2nd floor 205 Video Conference Room Remote Access Tools Used: Dial-In: (888) 494-4032, code: 738-916-388#

Governor’s Office of Health Innovation and Transformation

CARE COORDINATION SUBCOMMITTEE MEETING PRESENTATION TO IDS Meeting Minutes 10/28/14

All meetings will be accessible to handicapped individuals in compliance with pertinent state and federal laws upon notification of anticipated

• attendance. Handicapped persons planning to attend and needing special accommodations should contact GOHIT at least five business days

prior to the meeting so that we may best accommodate their needs. Governor’s Office of Health Innovation and Transformation 100 W Randolph St, Chicago, IL 60601 Suite 2-201 312.814.1600

MEETING START

Meeting Schedule Start: 1:00 pm Meeting Actual Start: 1:00pm Meeting Scribe: Xenia Okalibe

AGENDA

WELCOME AND INTRODUCTIONS – Michael  IDS has not met since September 10  All meeting minutes are available on the GOHIT website What is an integrated delivery system? – Michael  The delivery should work with different payers  Systems are not insurers  Need to move from fee-for-service to an outcome-based payment methodology  Primary care, behavioral health, substance abuse, and other community based services to address the social needs of the members of the integrated delivery system  Care coordination is a key component of this system IDS RECAP AND LEVEL-SETTING - Michael IDS Subcommittee  Developed consensus on criteria for integrated delivery system pilots  Developed consensus on criteria for health plan participation in integrated delivery system pilots  Evaluating ways Regional Health Improvement Collaboratives should be connected to IDS pilot sites  Visit GOHIT website for full list of criteria Additional IDS Subcommittee Work Plan Topics - Michael  A risk stratification system  We have created a work group on health care for the undocumented to look at a system of care for people who are not entitled to federal discounts IDS – Care Coordination Alignment - Michael  We want to figure out how the portable care plan would be met by applicants for the integrated delivery systems pilot sites CARE COORDINATION PRESENTATION CARE COORDINATION INTRODUCTION -- Mary  The Care Coordination Subcommittee has about 60 members, and their primary goal is to create a system that will be accessible to all types of consumers and providers, not limited to medical care providers.

Governor’s Office of Health Innovation and Transformation

CARE COORDINATION SUBCOMMITTEE MEETING PRESENTATION TO IDS Meeting Minutes 10/28/14

All meetings will be accessible to handicapped individuals in compliance with pertinent state and federal laws upon notification of anticipated

• attendance. Handicapped persons planning to attend and needing special accommodations should contact GOHIT at least five business days

prior to the meeting so that we may best accommodate their needs. Governor’s Office of Health Innovation and Transformation 100 W Randolph St, Chicago, IL 60601 Suite 2-201 312.814.1600

 The Portable Care Plan refers to an action-oriented document that includes a focused sub-set of the full electronic health record and social determinants that are necessary to effectively manage and coordinate a consumer’s care.  The Common Care Platform is a set of the technological standards to support access, storage and secure sharing of comprehensive consumer-specific health information.  We need to further discuss the Common Care Platform within the Care Coordination subcommittee.  Our Portable Care Plan survey showed us that we should not exclusively focus on EHR data. The Portable Care Plan will be actionable and will leverage existing systems and standards. PORTABLE CARE PLAN Mary  Draft Components of the Portable Care Plan

• 3 components: (1) Clinical Data (2) Person-centered Planning Team Members (3) Clinical and

Social/Behavioral Goals  We want to move towards a patient/consumer centered approach Peter  How do we provide detail and context for the Portable Care Plan?  The model being proposed represents a level of alignment with what people are thinking, based on the survey results.  The Portable Care Plan will be available to anyone who has a clinical record and interacts with the health care and human services enterprise. CLINICAL DATA – Joseph West  Care plans are not a novel idea - so what can be considered innovative?  The patient/member owns the care plan and is actively engaged.  The care plan will have applications across systems. There will be inputs and outputs.  Clinical data will highlight the major issues, that we will be the focus of coordinated care.  Social determinants are very important and are sometimes barriers to receiving adequate health care.  The top care goal is asking the member/owner what their main issue is, what they are concerned about.  Rationale: Basic, accessible information.  As we think about the IDS pilots as they relate to the Portable Care Plan, think about portability and access.

• Where would this clinical data come from? How do you gather information and make it

actionable and usable? PERSON-CENTERED PLANNING – Joseph  Michael –Q: How do the Home Community Based Services relate to the example of Juan that was presented?  Peter-A: The new person-centered planning rules being promulgated from federal CMS will have specific

• requirements. One of the reasons we identified these specific data elements was to capture this

information in order to be ready for the new person-centered planning requirements from CMS.  Joseph – Remember in the example of Juan, he has a disability but also wants to go to college, how do we help him accomplish these goals?

Governor’s Office of Health Innovation and Transformation

CARE COORDINATION SUBCOMMITTEE MEETING PRESENTATION TO IDS Meeting Minutes 10/28/14

All meetings will be accessible to handicapped individuals in compliance with pertinent state and federal laws upon notification of anticipated

• attendance. Handicapped persons planning to attend and needing special accommodations should contact GOHIT at least five business days

prior to the meeting so that we may best accommodate their needs. Governor’s Office of Health Innovation and Transformation 100 W Randolph St, Chicago, IL 60601 Suite 2-201 312.814.1600

 Q: How privacy will be addressed? Would this be done by legislative action or consent by the individual? How would Juan feel/what say would he have with his housing or school having access to his clinical data?

• Joseph-A: The subcommittee is beginning to discuss this question. Some stakeholders indicated

that since the Portable Care Plan is consumer-owned, there is initial consent of what can be shared and with whom. In the proposed Portable Care Plan, the full patient record is not revealed to everyone, only the action-oriented, front-facing Portable Care Plan.  Comment: We need to realize that for adolescents certain clinical data needs to be protected. The adolescent needs to decide if they want the parent to see it. CLINICAL AND SOCIAL AND BEHAVIORAL GOALS - Joseph  The individuals that comprise the care team will assist in defining these goals. QUESTIONS  Q: Who is responsible for the care plan? The Managed Care Organization? The primary physician? What happens when care occurs across state lines? How will different state laws/rules such as DMH rule 132 be considered?  Joseph-A: That is part of what we are trying to work through. Who will own the plan? We need to be forward thinking and look at rules coming down the pipeline now.  Michael-A: We want to first figure out what we think should be in the plan and then sort out what the legal barriers may be.  Comment: This could be a good opportunity to coordinate with Healthcare and Family Services about the Integrated Eligibility System.  Q: Have you involved the providers and health plans in your conversations?  Joseph – We have a few insurers on the committee and they brought up how we will reconcile against established systems. Can the proposed Portable Care Plan be reconciled using the architecture in existing systems? We looked at the CCEs and ACEs and their technical requirements as common ground to start with.  Q: Do you feel like you are moving towards consensus?  Peter-A: From a process standpoint, this is the first presentation of the Portable Care Plan. This is step 3 of 7; it’s too early to represent that consensus has been reached. The charge of Care Coordination subcommittee is to assist in the identification of the technical aspects for the IDS model test sites.  Q: So who will be responsible for assessing consensus?  Michael-A: We are still at the stage where consensus can be assumed by ‘head nods’ rather than people signing on the dotted line. The more people we engage in the process, the more people we can get to be

• n board.

 Joseph- There was consensus in the subcommittee and that is a common starting point.  Q: Are you using Health Risk Assessment (HRA) data? The HRA is a screening tool that takes 5-7 minutes.  Joseph-A: The Uniform Assessment Tool (UAT) could be used.  Michael – UAT would only be applied to HCBS.  Q: We need to prioritize tasks. Will your committee talk about this?  Q: Do you have an electronic tool to measure care management ratios and monitoring whether or not the case manager is getting their tasks done?

Governor’s Office of Health Innovation and Transformation

CARE COORDINATION SUBCOMMITTEE MEETING PRESENTATION TO IDS Meeting Minutes 10/28/14

All meetings will be accessible to handicapped individuals in compliance with pertinent state and federal laws upon notification of anticipated

• attendance. Handicapped persons planning to attend and needing special accommodations should contact GOHIT at least five business days

prior to the meeting so that we may best accommodate their needs. Governor’s Office of Health Innovation and Transformation 100 W Randolph St, Chicago, IL 60601 Suite 2-201 312.814.1600

 Joseph- A: Care gaps did come up within our discussions but we do not have definitive recommendations about this at this time. STAKEHOLDER DISCUSSION  Mary – We are looking for feedback from IDS on what we presented and whether there were gaps in the

• presentation. Our main purpose today is to acquire feedback.

 Q: How will each model test site show that the work that they do accounts for the cost of that architecture?  Mary-A: There are dollars in the proposal to CMMI to develop the Innovation Transformation Resource

• Center. We want to first leverage what exists.

 Comment: Commonality and consensus is important as we talk to providers.  Michael – We are not underestimating the complexity/challenge of what we are trying to do.  Comment: I suggest we look at what other states are using for Health Homes. Missouri has a statewide system (available online) that all providers feed into. I’m sure that they have had the same cost issues we are having.  Mary- There are opportunities to learn from others and we do plan to do so. We also plan to contract with an external consulting vendor to take advantage of technical expertise that is available in the marketplace. NEXT STEPS  Mary – We will be discussing the technical and functional components of the Common Care Platform at the November 20th Care Coordination meeting. Members of the IDS subcommittee are welcome to attend.  Michael – The idea of case study (Juan) is good and helps us provide some context as we explain the idea to others.  Steering Committee is meeting tomorrow 10/29 from 1-3pm.

MEETING END

Meeting Scheduled End: 2:30 PM Meeting Actual End: 2:32 PM