MARCH 27, 2019 9:00 AM Call Instructions: Please Mute your phone, - - PowerPoint PPT Presentation

SIM PTO TRAINING MARCH 27, 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

COLORADO SIM PTO TRAINING

REVIEW AMA BH HIGHLIGHTS FOR BH INTEGRATION REVIEW MAC FOR BB8, BB9 & BB10

MARCH 27, 2019

Presenters: Marjie Harbrecht, MD Kelly Pearson, RN, MSN Kristen Owens

TRAINING OBJECTIVES

▪ Achievement Payments - Invoicing in SPLIT ▪ Due Dates for Assessments ▪ Review highlights from AMA Webinar on BH Integration ▪ MAC Review for BB8, BB9, BB10 – moving toward behavioral health integration. ▪ Upcoming Events

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COMING DOWN TO THE WIRE…. YOU CAN…..

SIM FINAL REPORTING SUMMARY INSTRUCTIONS

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Posted on the Practice Innovation Program Resource Hub and can be found by searching SIM - Final Reporting Summary & Instructions (http://bit.ly/PracticeInnovationSupport) Reference this document for the following:

• SIM Assessment & Reporting Due Dates
• General Assessment Instructions for SPLIT
• Clinician & Staff Survey Expectations
• Practice Site Invoicing Dates & Process
• PTO Completion Report & Invoicing

SIM ASSESSMENT & REPORTING DUE DATES

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Task/Assessment Name Assessment Timeframe

Final Assessments – Part 1

(IPAT, HIT, Clinician & Staff Survey)

March 1st – March 31st SIM CQM Reporting for Q1 - 2019 April 1st – April 30th Final Assessments – Part 2

(Monitor, MAC, Practice Closeout Survey)

April 1st – May 15th PF & CHITA Monthly Field Notes

(Last Monthly Field Note due June 8, 2019)

Report Monthly thru May/June 2019

(Submitted within one week of the last day of the month )

Final Practice Site Progress Report

(Previously known as ‘Final Field Note’)

April 1st – May 15th SIM Practice Invoice Submission April 26th – June 30th PTO Invoice Submissions April 1st – June 30th

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SIM Assessment/Activity Approximate Time Completed By PDF

Integrated Practice Assessment Tool 15 – 30 mins Practice Site Team & PF IPAT Medical Home Practice Monitor 45 – 60 mins Practice Site Team & PF Monitor Health Information Technology Assessment 45 – 60 mins Practice Site Team & CHITA HIT Milestone Attestation Checklist 60 – 90 mins Practice Site Team & PF MAC Clinician & Staff Experience Survey 5-10 mins Practice Site Clinician & Staff CSES Practices Closeout Questions 45-60 mins Practice Site Team Closeout Final Practice Site Progress Report 15-30 mins PF & CHITA Final Report CQM Reporting for Q1 -2019 15-30 mins Practice Site Team & CHITA ―

SIM ASSESSMENTS & REPORTING ACTIVITIES

SIM CLINICIAN & STAFF EXPERIENCE SURVEY

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As a part of participation in the SIM Initiative providers and staff have the opportunity to provide valuable input about their practice site(s) by completing a Clinician & Staff Experience Survey. All individual responses remain confidential, and only aggregated summary reports will be shared with the practice and the SIM Initiative. The survey takes approximately 5 to 10 minutes to complete, and the anticipated due date can be found in SPLIT.

Practice completion expectations for the SIM Clinician & Staff Experience Survey:

• Practice sites have a unique survey link for that can be distributed to providers and staff.
• Completion rates are calculated with the values provided on the practice site roster.
• The goal is for each practice site to achieve a 70% or greater survey completion rate.
• If >70% completion is achieved, the primary practice contact will receive an email notification.

SIM CLINICIAN & STAFF EXPERIENCE SURVEY

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Additional information regarding the SIM Clinician & Staff Experience Survey:

• Practice site administrators and/or PTO partners are responsible for sharing the survey link

with practice site’s clinician and staff – some potential ways to distribute the survey include:

• Practice site manager or PTO partner can email the unique link to providers and staff.
• Designate a computer in the practice site break room for staff to complete the survey.
• At a practice site staff meeting have providers and staff present complete the survey.
• The reusable unique survey link for a practice sites can be referenced within the ‘Reference

Clinician & Staff Survey’ task on the ‘Assessments’ page in the ‘My Tasks’ section in SPLIT.

• The task will remain available on the ‘Assessments’ page until the survey is officially closed.

SIM CLINICIAN & STAFF EXPERIENCE SURVEY

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REMAINING BUILDING BLOCKS & MILESTONES

PHASE 4: 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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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

HTTPS://WWW.YOUTUBE.COM/WATCH?V=HL4RPBOK MQO

PSYCHOLOGISTS IN INTEGRATED HEALTHCARE

INTRODUCTION VIDEO SPECIFIC SETTINGS VIDEO

https://www.apa.org/health/psychologists-integrated-care

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UPCOMING DUE DATES – FINAL ASSESSMENTS PART 2

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Reporting Activity Cohort 2 Cohort 3

SIM CQM Reporting Q4

(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

(Cohort 1 2& 3 Practice Sites)

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

MILESTONE ATTESTATION CHECKLIST (MAC) REQUIRED MILESTONES

MOVING TOWARD FULL BH INTEGRATION

BB8 - BB9 - BB10

COHORT 3 - YEAR 1 COHORT 2 - YEAR 2

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BUILDING BLOCK 8 - PROVIDE PROMPT ACCESS TO CARE, INCLUDING BH CARE

Goal: Practice (at minimum), has established collaborative care management agreements with BH providers in the community and members of the care team can articulate how to use those agreements. Practice has ability to share clinical data based on collaborative care management agreements with BH providers bi-directionally within 7 days.

COHORT 3 - MAC BB8.Y1 - PROVIDE PROMPT ACCESS TO CARE, INCLUDING BH

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1) Practice representative with 24/7 EHR access 2) Assess referral pathways and after-hours BH support (work with RHCs) 3) Identify data sources and technology needed for bi-directional data sharing

COHORT 2 - MAC BB8.Y2 - PROVIDE PROMPT ACCESS TO CARE, INCLUDING BH

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1) Establish a collaborative agreement with at least one BH health provider 2) Develop plan for bi-directional data sharing with BH health provider

POLLING QUESTION #1: BB8 - PROVIDE PROMPT ACCESS TO CARE, INCLUDING BH CARE

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

COHORT 3: YR 1

a) Practice representative with 24/7 EHR access b) Assess referral pathways and after-hours BH support (work with RHCs) c) Identify data sources and technology needed for bi-directional data sharing d) None

COHORT 2: YR 2

a) Establish a collaborative agreement with at least one BH health provider b) Develop plan for bi-directional data sharing with BH health provider c) None

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BUILDING BLOCK 9 - COMPREHENSIVE CARE COORDINATION FOR PRIMARY CARE/BH

Goal: Practice has reduced total cost of care while maintaining or improving quality of care for patients, including those with depression and substance abuse disorders, compared with non- SIM practices.

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COHORT 3 - MAC BB9.Y1 - COMPREHENSIVE CARE COORDINATION FOR PRIMARY CARE/BH

• 1. Identify total cost of care for panel, and subset of those with BH

conditions

• 2. Identify/implement policy and procedures for timely follow-up

for ED visits/hospital admissions

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COHORT 2 - MAC BB9.Y2 - COMPREHENSIVE CARE COORDINATION FOR PRIMARY CARE/BH

• 1. Contact 50% of patients within 7 days of hospitalization/ED visit, including medication

reconciliation

• 2. Identify cost drivers for patients with BH conditions and incorporate in QI processes
• 3. Create/report a measurement to assess impact and guide improvement on at least one of the

following:

• Notification of ED visit in timely fashion
• Completed medication reconciliation within 72 hours
• Notification of admission and clinical information exchange at time of admission
• Information exchange between primary care and specialty care related to referrals

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POLLING QUESTION #2: BB9 - COMPREHENSIVE CARE COORDINATION FOR PRIMARY CARE/BH

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

COHORT 3: YR 1

a) Identify total cost of care for panel, and subset of those with BH conditions b) Identify/implement policy and procedures for timely follow-up for ED visits/hospital admissions c) None

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POLLING QUESTION #2: BB9 - COMPREHENSIVE CARE COORDINATION FOR PRIMARY CARE/BH

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

COHORT 2: YR 2

a) Contact 50% of patients within 7 days of hospitalization/ED visit, including medication reconciliation b) Identify cost drivers for patients with BH conditions and incorporate in QI processes c) Create/report a measurement to assess impact and guide improvement on at least one of the following:

• Notification of ED visit in timely fashion
• Completed medication reconciliation within 72 hours
• Notification of admission and clinical information exchange at time of admission
• Information exchange between primary care and specialty care related to referrals

d) None

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BUILDING BLOCK 10 - PROVIDE FULLY INTEGRATED BH FOR WHOLE-PERSON CARE

Goal: Patient BH outcomes are systematically measured over time and treatment is adjusted as needed, as measured by outreach, registry and other information readily available for purpose of monitoring and adjustment.

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COHORT 3 - MAC BB10.Y1 - PROVIDE FULLY INTEGRATED BH CARE FOR WHOLE-PERSON CARE

• 1. Use identified referral pathways for BH needs (including available after-hours

support and a representative with 24/7 EHR access).

• 2. Systematically measure and track BH outcomes
• 3. Develop care plans that include patient actions to manage BH conditions

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COHORT 2 - MAC BB10.Y2 - PROVIDE FULLY INTEGRATED BH CARE FOR WHOLE-PERSON CARE

• 1. Systematically measure and track patient BH outcomes
• 2. Document/implement protocols to identify and manage care

for high-risk BH populations

• 3. Identify/implement at least 2 opportunities to adjust protocols

to improve BH health status of patients

• 4. Demonstrate advanced access to BH services

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POLLING QUESTION #3: BB9 - COMPREHENSIVE CARE COORDINATION FOR PRIMARY CARE/BH

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

COHORT 3: YR 1

a) Use identified referral pathways for BH needs (including available after-hours support and a representative with 24/7 EHR access). b) Systematically measure and track BH outcomes c) Develop care plans that include patient actions to manage BH conditions d) None

COHORT 2: YR 2

a) Systematically measure and track patient BH outcomes b) Document/implement protocols to identify and manage care for high-risk BH populations c) Identify/implement at least 2 opportunities to adjust protocols to improve BH health status of patients d) Demonstrate advanced access to BH services e) None

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POLLING QUESTIONS – TOPICS AND VENUE FOR APRIL & MAY

Question #4: We have 2 more PTO Trainings left and will concentrate on those topics you have identified as the most challenging. Please select how you would like those topics delivered:

a) By an expert in the field – please add name if you have someone in mind (i.e., Alex Schmidt) b) By a few practice facilitators presenting their experiences c) By informally sharing tips/tricks among each other d) Other – please write in

Question #5: Do you want either PTO Training to be in person?

a) April 24th – Yes/No b) May 22nd – Yes/No

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UPCOMING TRAININGS

▪ 3/28 -- SPLIT Office Hours; 9 – 10 am April 2019 ▪ 4/3 -- CQM Quarterly Update; 10-11 am ▪ 4/4 – Virtual Colorado MAT Learning Forum; MAT Selection: Naltrexone, Buprenorphine or Methadone (including CO-SLAW introduction) 12:30 – 1:30 pm ▪ 4/9 – TCPi PTO Touchbase; 9-10 am ▪ 4/16 – CHITA Learning Community; 3-4 pm ▪ 4/18 – Learning Features Call; Social Determinants of Health 10-11 am ▪ 4/23 – CO QPP Coalition Office Hours; 2019 Eligibility Parameters 12- 1 pm ▪ 4/24 – MGMA Practice Webinar; Connect the Dots: Contracts to Revenue Cycle, Moving Into Value-Based Models 12-1 pm ▪ 4/24 – SIM PTO Training; Cohort 2 & 3, DISCUSS/REVIEW BB8, BB9, BB10; 9-10 am ▪ 4/25-- SPLIT Office Hours 9-10 am

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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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