JANUARY 23, 2019 9:00 AM Call Instructions: Please Mute your - PowerPoint PPT Presentation

SIM PTO TRAINING JANUARY 23, 2019 9:00 AM Call Instructions: Please • Mute your phone, microphone, and speakers on your computer/device • Turn off the zoom video feature • Enter your name/organization in the chat box feature for attendance • Submit questions via the chat box feature • Questions will be answered following the presentation Time to ask questions via audio will be offered for those on the phone • 1

JANUARY 23, 2019 COLORADO SIM PTO TRAINING Presenters: Marjie Harbrecht, MD REVIEW BUILDING BLOCKS AND MILESTONES TO Stephanie Kirchner, MSPH, RD DATE & DISCUSS CHALLENGES Kelly Pearson, RN, MSN

TRAINING OBJECTIVES ▪ Review all Building Blocks and Milestones to date. Use polling to identify and discuss those that continue to be challenging for practices and/or practice facilitators. ▪ Upcoming Events and Due Dates 3

REMAINING BUILDING BLOCKS & MILESTONES NOV 1, 2018 – JAN 31, 2019 FEB 1 – JUNE 30, 2019 COHORTS 2 & 3 COHORTS 2 & 3 ▪ BB8 – Prompt access to care, ▪ BB3 – Empaneling Patient including BH Population ▪ BB6 – Risk Stratification/Actively ▪ BB9 – Care coordination for primary Manage Patients care/BH ▪ BB7 – Screen and Link to BH/SUD ▪ BB10 – Fully integrated BH/whole Resources person care 4

PHASED APPROACH TIMELINE: COHORT 2 - YEAR 2 5

PHASED APPROACH TIMELINE: COHORT 3 – YEAR 1 6

SIM COHORT 2 MILESTONE OPERATIONAL ALGORITHM (OVERVIEW) BUILD INFRASTRUCTURE BB1 - ENGAGED LEADERSHIP WHERE TO START? Year 1: Establish agreements with payers, set up budget, QI team, champion attends CLS, set vision for behavioral health (BH) integration and pathway PATIENT POPULATION BUILD INFRASTRUCTURE UNDERSTAND THE ("ACTIVE" PATIENT PANEL) BB2 - USE DATA TO DRIVE CHANGE MAKEUP OF YOUR Year 1: Data, care gaps, CQMs, cost drivers POPULATION ------------ BB4 - TEAM-BASED CARE IMPROVE CONTINUITY Year 2: Workflows for three CQMs (at least 1BH) THROUGH BB3 - EMPANEL AT LEAST 75% of EMPANELMENT BB5 - PARTNERSHIP WITH PATIENTS PATIENT POPULATION ------------ Year 1: Establish PFAC SCREEN FOR BH/SUD Year 2: Shared decision-making aids and self-management support ______________ ------------ tools USE DATA TO BB7 - SCREEN UP TO 90% FOR BH/SUD POSITIVE BH/SUD CLOSE GAPS & BB8, BB9 and BB10 - BEHAVIORAL HEALTH ISSUES Connect to BH/Community IMPROVE CARE Year 1: Start building infrastructure to address BH Year 2: Develop collaborative care agreements with BH providers BB6 - RISK STRATIFICATION EXPAND and MAINTAIN EFFORTS Year 2: Risk stratify at least 75% of population STRATEGICALLY MANAGE ALL PATIENTS YOUR POPULATION BY CONTINUE BB1, BB2, BB4, BB5 RISK STRATIFYING TO LOW RISK MEDIUM RISK HIGH RISK DETERMINE WHO NEEDS BB6 - HIGH RISK PATIENTS ADDITIONAL Year 2: Risk stratify, use data to manage ATTENTION/SERVICES care gaps/track outcomes, develop care Prevent Low and Medium Risk patients plans for 75% of high-risk patients from becoming High Risk COORDINATED -------------- PATIENTS WITH BH ISSUES and/or BB8 - ACCESS TO BH CARE BUILD COLLABORATIVE BB6 - CLOSELY MANAGE at INTEGRATED Year 2: Bi-directional data sharing AGREEMENTS WITH least 75% of HIGH RISK BEHAVIORAL HEALTH CARE PATIENTS BB9 - CARE COORDINATION TO REDUCE (EITHER ONSITE OR COSTS AND IMPROVE CARE OFFSITE) TO IMPROVE BB10 - BH REFERRAL PATHWAY WITH COORDINATION AND 24/7 EHR ACCESS; CARE PLANS, MANAGEMENT TRACK BH PATIENT OUTCOMES USE REGIONAL HEALTH CONNECTORS TO ASSIST YOU WHEN POSSIBLE Improve Quality of Care Reduce Costs Improve Experience for Patients & Healthcare Teams

SUSTAIN EXPAND BUILD 8

POLLING & REVIEWING TO ASSESS CHALLENGING MILESTONES TIMELINE IS SHORT, ESPECIALLY FOR COHORT 2 (NEED TO SELECT 2 ADDITIONAL MILESTONES FOR YEAR 2) FOCUS ON “TROUBLE” AREAS SOONER THAN LATER! (USE MAC REPORT AND EXPERIENCES TO DATE) 9

PHASE 1 & 2: BUILDING AN INFRASTRUCTURE BB1 – ENGAGED LEADERSHIP BB2 – USE DATA TO DRIVE CHANGE BB4 – PROVIDE TEAM-BASED CARE BB5 - BUILD PATIENT PARTNERSHIPS 10

BB1 – ENGAGED LEADERSHIP GOAL: Practice establishes agreement(s) with payer organization(s) that cover at least 150 patients across payers, for value-based payment program(s) to support practice transformation under SIM. 11

POLLING QUESTION #1: BB1 - ENGAGED LEADERSHIP From the milestones listed below, please select those you and/or your practices are struggling with: COHORT 3: YR 1 a) Establish value-base agreements with payers b) Complete an annual budget c) Develop QI Team d) Leadership/Champion attend meetings/CLS e) Set VISION for BHI f) None COHORT 2: YR 2 a) Leadership allocates appropriate resources to complete QI work b) Design plans to evaluate effects of value-based payments c) None 12

BB2 – USE DATA TO DRIVE CHANGE GOAL: Practice uses EHR clinical quality measures to provide quarterly panel reports on all SIM measures not extracted through claims data; uses claims data provided through a data aggregation tool to inform QI processes. 13

POLLING QUESTION #2: BB2 – USE DATA TO DRIVE CHANGE From the milestones listed below, please select those you and/or your practices are struggling with: COHORT 3: YR 1 a) Submit CQM’s quarterly b) Review data with PF/CHITA quarterly c) Begin using model for improvement and identify opportunities for improvement using CQM data d) Use data aggregation tool to review cost/utilization data e) None COHORT 2: YR 2 a) Review CQM data to inform rapid cycle improvement processes b) Develop process for providing performance feedback to providers (CQMs/cost) c) Conduct regular QI activities based on CQMs d) None 14

COST/UTLIZATION DATA ▪ CAN USE VARIOUS COST DATA REPORTS INCLUDING STRATUS, MILLIMAN OR OTHER REPORTS AVAILABLE TO PRACTICE . ▪ Attend/Download SIM webinars by Pam Ballou-Nelson and Milliman MILLIMAN REPORTS: Available mid to late February 2019 ▪ Milliman webinar; SIM PTO Training – Cost & Utilization Reports Presentation, 8- 16-17 http://resourcehub.practiceinnovationco.org/2017/08/24/sim-pto- training-cost-utilization-reports-8-16-17/ Milliman Cost and Utilization Webinar 8-30-2017 ▪ http://resourcehub.practiceinnovationco.org/2017/09/25/milliman-cost- utilization-webinar-8-30-2017/ ▪ Milliman slides from Nov CLS 2017; Understanding and Using the CMMI and Actuarial Cost and Utilization Reports http://resourcehub.practiceinnovationco.org/wp- content/uploads/2017/11/Milliman-Presentation-2017-11- 03_Matthews_Cedar.pptx 15

COST/UTLIZATION DATA – KEY DRIVER DIAGRAM ▪ HealthTeamWorks Multi-payer PCMH Pilot: http://resourcehub.practiceinnovationco.org/wp- content/uploads/2019/01/FINAL-Key-Driver-Diagram-for-Mulit-Payer-Pilot-7-13-11-Practice.pdf 16

BB4 – PROVIDE TEAM-BASED CARE GOAL: The care team uses shared operations, workflows, and protocols to facilitate collaboration and consistently implements specific shared workflows rather than informal processes for at least three measures, including at least one behavioral health measure. 17

POLLING QUESTION #3: BB4 – PROVIDE TEAM-BASED CARE From the milestones listed below, please select those you and/or your practices are struggling with: COHORT 3: YR 1 a) Use established tools to assess baseline team relationships b) Develop written job descriptions, including clear roles and responsibilities c) Identify/implement team-based care strategy (team huddle, collaborative care planning, etc) d) None COHORT 2: YR 2 a) Re-evaluate team relationships using tools from Year 1 b) Develop protocols for shared workflows (for 3 CQMs with at least one BH measure) c) Review roles/responsibilities for team-based care activities to ensure accountability d) None 18

BB5 – BUILD PATIENT PARTNERSHIPS GOAL: Practice has established use of evidence-based shared decision-making aids or self-management support tools for at least one, preference-sensitive condition, and tracks the use of these tools. Practice has established a PFAC to provide input and feedback on practice transformation activities and progress. 19

POLLING QUESTION #4: BB5 – BUILD PATIENT PARTNERSHIPS From the milestones listed below, please select those you and/or your practices are struggling with: COHORT 3: YR 1 a) Identify 1 preference-sensitive condition appropriate for decision aids/SMS support tools b) Select evidence-based decision aids/SMS tools for identified conditions c) Establish Patient and Family Advisory Council (PFAC) that meets at least quarterly d) None COHORT 2: YR 2 a) Identify patients/families eligible for selected decision aids/SMS tools b) Implement decision aids/SMS tools and establish protocol and workflow for use c) Track/evaluate use of decision aids/SMS tools d) Use Patient and Family Advisory Council (PFAC) to evaluate care experience e) None 20

PHASE 3 - MANAGING A POPULATION BB3 – EMPANEL THE POPULATION BB6 - RISK STRATIFY & ACTIVELY MANAGE USING DATA BB7 – SCREEN FOR BH/SUD & LINK TO RESOURCES 21

BB3 - EMPANEL THE POPULATION Goal: Practice has, and maintains, empanelment for at least 75% of its patient population. 22