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

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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

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SIM PTO TRAINING JANUARY 23, 2019 9:00 AM

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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
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COLORADO SIM PTO TRAINING

REVIEW BUILDING BLOCKS AND MILESTONES TO DATE & DISCUSS CHALLENGES

JANUARY 23, 2019

Presenters: Marjie Harbrecht, MD Stephanie Kirchner, MSPH, RD Kelly Pearson, RN, MSN

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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

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REMAINING BUILDING BLOCKS & MILESTONES

NOV 1, 2018 – JAN 31, 2019 COHORTS 2 & 3

▪ BB3 – Empaneling Patient Population ▪ BB6 – Risk Stratification/Actively Manage Patients ▪ BB7 – Screen and Link to BH/SUD Resources

FEB 1 – JUNE 30, 2019 COHORTS 2 & 3

▪ BB8 – Prompt access to care, including BH ▪ BB9 – Care coordination for primary care/BH ▪ BB10 – Fully integrated BH/whole person care

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PHASED APPROACH TIMELINE: COHORT 2 - YEAR 2

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PHASED APPROACH TIMELINE: COHORT 3 – YEAR 1

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SLIDE 7 WHERE TO START? PATIENT POPULATION ("ACTIVE" PATIENT PANEL)

POSITIVE BH/SUD

BB6 - RISK STRATIFICATION Year 2: Risk stratify at least 75% of population

LOW RISK MEDIUM RISK HIGH RISK

BB6 - CLOSELY MANAGE at least 75% of HIGH RISK PATIENTS

SIM COHORT 2 MILESTONE OPERATIONAL ALGORITHM (OVERVIEW)

COORDINATED and/or INTEGRATED CARE

EXPAND and MAINTAIN EFFORTS ALL PATIENTS CONTINUE BB1, BB2, BB4, BB5 BB6 - HIGH RISK PATIENTS Year 2: Risk stratify, use data to manage care gaps/track outcomes, develop care plans for 75% of high-risk patients PATIENTS WITH BH ISSUES BB8 - ACCESS TO BH CARE Year 2: Bi-directional data sharing BB9 - CARE COORDINATION TO REDUCE COSTS AND IMPROVE CARE BB10 - BH REFERRAL PATHWAY WITH 24/7 EHR ACCESS; CARE PLANS, TRACK BH PATIENT OUTCOMES USE REGIONAL HEALTH CONNECTORS TO ASSIST YOU WHEN POSSIBLE

BUILD INFRASTRUCTURE

BB1 - ENGAGED LEADERSHIP Year 1: Establish agreements with payers, set up budget, QI team, champion attends CLS, set vision for behavioral health (BH) integration and pathway UNDERSTAND THE MAKEUP OF YOUR POPULATION
  • IMPROVE CONTINUITY
THROUGH EMPANELMENT
  • SCREEN FOR BH/SUD
  • USE DATA TO
CLOSE GAPS & IMPROVE CARE BB3 - EMPANEL AT LEAST 75% of PATIENT POPULATION ______________ BB7 - SCREEN UP TO 90% FOR BH/SUD Connect to BH/Community

Prevent Low and Medium Risk patients from becoming High Risk

STRATEGICALLY MANAGE YOUR POPULATION BY RISK STRATIFYING TO DETERMINE WHO NEEDS ADDITIONAL ATTENTION/SERVICES
  • BUILD COLLABORATIVE
AGREEMENTS WITH BEHAVIORAL HEALTH (EITHER ONSITE OR OFFSITE) TO IMPROVE COORDINATION AND MANAGEMENT

Improve Quality of Care Reduce Costs Improve Experience for Patients & Healthcare Teams

BUILD INFRASTRUCTURE BB2 - USE DATA TO DRIVE CHANGE Year 1: Data, care gaps, CQMs, cost drivers BB4 - TEAM-BASED CARE Year 2: Workflows for three CQMs (at least 1BH) BB5 - PARTNERSHIP WITH PATIENTS Year 1: Establish PFAC Year 2: Shared decision-making aids and self-management support tools BB8, BB9 and BB10 - BEHAVIORAL HEALTH ISSUES Year 1: Start building infrastructure to address BH Year 2: Develop collaborative care agreements with BH providers
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BUILD EXPAND

SUSTAIN

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POLLING & REVIEWING TO ASSESS CHALLENGING MILESTONES

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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)

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PHASE 1 & 2: BUILDING AN INFRASTRUCTURE

BB1 – ENGAGED LEADERSHIP BB2 – USE DATA TO DRIVE CHANGE BB4 – PROVIDE TEAM-BASED CARE BB5 - BUILD PATIENT PARTNERSHIPS

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BB1 – ENGAGED LEADERSHIP

GOAL: Practice establishes agreement(s) with payer

  • rganization(s) that cover at least 150 patients across

payers, for value-based payment program(s) to support practice transformation under SIM.

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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

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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.

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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

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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

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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

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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.

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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

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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

  • n practice transformation activities and progress.

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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

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PHASE 3 - MANAGING A POPULATION

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

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BB3 - EMPANEL THE POPULATION

Goal: Practice has, and maintains, empanelment for at least 75% of its patient population.

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POLLING QUESTION #5: BB3 – EMPANEL THE POPULATION

From the milestones listed below, please select those you and/or your practices are struggling with:

COHORT 3: YR 1

a) Practice has assessed patient panel and assigned primary care providers/care teams to 75% of patient population. b) Practice reviews payer attribution lists monthly (when available). c) Practice designs and implements process for validating primary care provider/care team assignment with patients. d) None

COHORT 2: YR 2

a) Practice maintains 75% empanelment of patients with provider/care teams. b) Practice develops policies to support empanelment, including definitions, changing PCPs, assigning new patients, and ensuring continuous coverage. c) None

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BB6 - RISK STRATIFY AND ACTIVELY MANAGE POPULATION USING DATA

GOAL: Practice uses population-level data to manage care gaps, develop care management care plans and implement those plans for high-risk patients and families.

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POLLING QUESTION #6: BB6 – RISK STRATIFY AND ACTIVELY MANAGE POPULATION USING DATA

From the milestones listed below, please select those you and/or your practices are struggling with:

COHORT 3: YR 1 a) Practice identifies, documents a risk stratification methodology. (Recommended, but not required for pediatric practices) b) Practice identifies strategy to identify care gaps (e.g. patient registry, data aggregation tool) and prioritize high-risk patients and families. c) none COHORT 2: YR 2 a) 75% of empaneled patients are risk-stratified. (Recommended, but not required for pediatric practices). b) 75% of high-risk patients/families have a documented care plan. c) Practice implements proactive care gap management and tracks outcomes. d) Practice embeds care plan template in EHR.

e) None

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BB7 – SCREEN FOR BH & SUD, AND LINK PRIMARY CARE TO BH AND SOCIAL SERVICES

Goal: Practice screens at least 90% of appropriate patients/families for substance use disorder (SUD) and/or behavioral health (BH) needs, and includes BH and community services as part of care management strategies.

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POLLING QUESTION #7: BB7 – SCREEN FOR BH & SUD,

AND LINK PRIMARY CARE TO BH AND SOCIAL SERVICES

From the milestones listed below, please select those you and/or your practices are struggling with:

COHORT 3: YR 1

a) Identify BH resources for patients/families, including support from SIM health plans and RHCs. b) Identify screening tool to report on at least two BH screening measures (depression, maternal depression, developmental disorders, obesity, and substance use disorders - unhealthy alcohol use, other drug dependence, and tobacco use); Screens 25% of patients. c) Document process for connecting patients/families with BH resources (from screening), including standing orders/protocols and follow-up. d) None

COHORT 2: YR 2

a) Screen 50% of patients for BH condition(s). b) Perform assessment of community resources to assist patients/families with social needs (such as food, housing, transportation). c) Identify and connect 50% of patients identified with BH need to resource. d) None

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POLLING QUESTION #8

What would be most helpful in addressing the challenging areas discussed today?

a) Sharing “tips and tricks” with each other. b) Getting expert(s) to talk about a specific topic identified by majority. c) Covering specific topics at upcoming Learning Session? d) Other – please add comments in chat box

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NEXT PHASE: MOVING TOWARD FULL BH INTEGRATION BB8 – BB9 – BB10

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REMINDERS

▪ USE MILESTONE ATTESTATION CHECKLIST

▪ As ongoing guide for where to concentrate efforts. Don’t wait until formal evaluation!

▪ USE SIM IMPLEMENTATION GUIDE ▪ To review building blocks and milestone tips ▪ USE RESOURCE HUB – for great tools and resources ▪ ATTEND SPLIT MONTHLY OFFICE HOURS

▪ Register through CHES Newsletter or online calendar

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Making Connections

How the Regional Health Connector workforce can support you

February 28, 2017

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UPCOMING DUE DATES

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Reporting Activity Cohort 2 Cohort 3

Practice Roster Updates 12/17/2018 – 1/31/2018 12/17/2018 – 1/31/2018 SIM CQM Reporting Q4 (Reported to Payer)

(Cohort 1, 2 & 3 Practices). Required for those using extended CHITA services

Jan 31, 2019 Jan 31, 2019 Final Assessments – Part 1

(IPAT , HIT , Clinician/Staff Survey)

March 1, 2019 – April 1, 2019 March 1, 2019 – April 1, 2019 Final Assessments – Part 2

((Monitor, MAC, Practice Closeout Survey & Practice Final Progress Report (Previously referred to as “Final Field Note”))

April 1, 2019 – May 15, 2019 April 1, 2019 – May 15, 2019 SIM CQM Reporting Q1 2019 (FINAL)

(Cohort 1 2& 3 Practice Sites)

April 1, 2019 April 30, 2019 April 1, 2019 April 30, 2019 PF Field Notes Report Monthly

(must be submitted within one week of the last day of the month)

Report Monthly

(must be submitted within one week of the last day of the month)

CHITA Field Notes Report Monthly

(must be submitted within one week of the last day of the month)

Report Monthly

(must be submitted within one week of the last day of the month)

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FUTURE PTO EVENTS

January 2019

▪ 1/24 -- SPLIT Office Hours; 9-10 am

February 2019

▪ 2/12 – TCPi PTO Touchbase; 9-10 am ▪ 2/19 -- CHITA Learning Community; 3-4 pm ▪ 2/20 -- MGMA Practice Webinar; noon-1 pm ▪ 2/21 – Learning Features; APMs, Making sense of the alphabet soup; Stephanie Gold 10 - 11 am ▪ 2/26 – CO QPP Coalition Webinar; “Kick-Start to 2019” noon- 1 pm ▪ 2/27 – SIM PTO Training; 9-10 am ▪ 2/28 -- SPLIT Office Hours: 9 - 10 am

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SAVE THE DATE DENVER METRO SIM CLS THURSDAY MARCH 7, 2019 WESTERN SLOPE SIM CLS FRIDAY MARCH 8, 2019

REGISTRATION LINK COMING SOON; HTTP://WWW.PRACTICEINNOVATIONCO.ORG/

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University Practice Innovation Team Contact Information

Practice Transformation – Stephanie.Kirchner@ucdenver.edu Learning Community - Kellyn.Pearson@ucdenver.edu CQMs & SPLIT/Data Related – support-split@ucdenver.edu ENSW & IT MATTTRs 2 – Daniel.Pacheco@ucdenver.edu TCPi - Kristin.Crispe@ucdenver.edu or Allyson.Gottsman@ucdenver.edu SIM – PracticeInnovation@ucdenver.edu Invoicing – Natalie.Buys@ucdenver.edu All Other Questions – PracticeInnovation@ucdenver.edu

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QUESTIONS?

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