SIM PTO TRAINING JANUARY 24, 2018 9:00 AM Call Instructions: - - PowerPoint PPT Presentation

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SIM PTO TRAINING JANUARY 24, 2018 9:00 AM Call Instructions: - - PowerPoint PPT Presentation

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SIM PTO TRAINING JANUARY 24, 2018 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 24, 2018 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

PHASE 3: BB3 – EMPANELING THE POPULATION BB7 – SCREENING AND LINKING FOR BH/SUD JANUARY 24, 2018

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

Andrew Bienstock

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TRAINING OBJECTIVES

▪ Review Practice Feedback Reports ▪ Introduce PHASE 3 – Population Management

▪ BB3 – Empaneling Patient Population ▪ BB7 – Screening and Linking BH/SUD

▪ Questions

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COHORT 2 BASELINE PRACTICE FEEDBACK REPORT OVERVIEW

The following SIM baseline assessments are summarized in these reports: ▪ 1) Integrated Practice Assessment Tool (IPAT) ▪ 2) Medical Home Practice Monitor (Monitor) ▪ 3) Health Information Technology Assessment (HIT) ▪ 4) Milestone Attestation Checklist (MAC)

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INTEGRATED PRACTICE ASSESSMENT TOOL (IPAT)

STEPHANIE KIRCHNER

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DEFINITIONS OF BH COORDINATION TO INTEGRATION

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MEDICAL HOME PRACTICE MONITOR

STEPHANIE KIRCHNER

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MEDICAL HOME PRACTICE MONITOR

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HEALTH INFORMATION TECHNOLOGY ASSESSMENT (HIT)

ANDREW BIENSTOCK

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HEALTH INFORMATION TECHNOLOGY (HIT) ASSESSMENT

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CQM SPECIFIC RESPONSES

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HIT BARRIERS RANKING

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HIE / TELEHEALTH / BROADBAND

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COHORT 2 REGISTRY ACCESS AND USE FOR CQM COUNTS

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COHORT 2 EHR DISTRIBUTION

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MILESTONE ATTESTATION CHECKLIST (MAC)

STEPHANIE KIRCHNER

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MILESTONE ATTESTATION CHECKLIST (MAC)

▪ GOOD STANDING for both SIM Only and SIM-CPC+ Practices:

▪ NS= Not Started (1) ▪ JB= Just Beginning (2) ▪ AA= Actively Addressing (3) ▪ C= Completed (4) ▪ Not Possible (0) for milestone activities BB1.1.1 and BB8.2.2, are included in the Not Started (1) count at this time.

▪ GOOD STANDING GOALS

▪ Completed (4) for at least 75% of required milestones AND at least ▪ Actively Addressing (3) for all other required milestones

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MAC RESULT SUMMARY

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REPORT BY EACH BUILDING BLOCK AND MILESTONES

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QUESTIONS

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PHASED APPROACH TIMELINE

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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

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USE THE MAC TO GUIDE YOUR WORK – PHASE 3

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BUILDING BLOCK 3 – EMPANELING POPULATION

Goal: Practice has, and maintains, empanelment for at least 75% of its patient population. Empanelment is the act of assigning individual patients* to individual primary care providers (PCP) and care teams with sensitivity to patient and family preference. Empanelment will take time, is an ongoing process requiring ongoing monitoring.

*Active population - primary care within last 12 to 24 months.

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WHY DO IT?

▪ Empanelment is the basis for population health management and the key to continuity of care between patients and the provider/care team. ▪ Empanelment improves patient and care team satisfaction, increase preventative services, and can reduce hospital admissions and ED visits.

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MILESTONES BB3.Y1 – EMPANELING THE POPULATION

  • 1. Practice has assessed patient panel and assigned

primary care providers/care teams to 75% of patient population.

  • 2. Practice reviews payer attribution lists monthly

(when available).

  • 3. Practice designs and implements process for

validating primary care provider/ care team assignment with patients.

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GETTING “YOUR ARMS” AROUND YOUR POPULATION

▪ Who’s in my population? ▪ How complex are they (age, chronic conditions, BH/SUD, social determinants, etc)? ▪ Do I have enough staff/resources to manage them? ▪ How do I adjust my work to best address my population?

A “VISIT” DOES NOT ALWAYS NEED TO BE IN PERSON (secure emails, e-visit, phone visit, video visits)

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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

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NEXT PHASE: BB6 RISK STRATIFICATION AND ACTIVE MANAGEMENT OF POPULATION

▪ While you’re empaneling, include or at least start thinking about: a) Methodology for risk stratification b) Who will need BH for mental health or complex chronic disease management

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QUESTIONS?

FOR DETAILED INFORMATION ABOUT EMPANELMENT

  • Learning Features January 18: (resource hub)

http://resourcehub.practiceinnovationco.org/2018/01/22/ learning-features-webinar-1-18-18/

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BUILDING BLOCK 7 – 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 and/or

  • ther behavioral health needs, and includes behavioral

health and community services as part of care management strategies

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TWO MAIN ASPECTS

  • 1. Mental Health Issues

▪ Depression, anxiety, severe mental illness (SMI), etc

  • 2. Behavioral Issues associated with chronic disease and
  • ther conditions

▪ Tobacco/drug/alcohol cessation, weight control, physical activity

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MILESTONES BB7.Y1 - SCREEN FOR BH & SUD, AND LINK PRIMARY CARE TO BH AND SOCIAL SERVICES

1. Practice identifies BH resources for patients/families, including support from SIM participating health plans and Regional Health Connectors (RHCs). 2. Practice identifies a screening tool for reporting on at least two behavioral health screening measures for SIM (depression, maternal depression, developmental disorders, obesity, and substance use disorders [i.e., unhealthy alcohol use, other drug dependence, and tobacco use]); screens 25% of patients. 3. Practice has documented process for connecting patients/families with behavioral health resources (from screening), including standing orders and or/protocols and follow-up.

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PATHWAYS TO CONNECT PCP AND BH RESOURCES

OUTSIDE PRACTICE

Collaboration

INSIDE PRACTICE

Co-Location Integration

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POLLING QUESTIONS

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REMINDERS

▪ USE MILESTONE ATTESTATION CHECKLIST

▪ Ongoing guide for where to concentrate efforts

▪ USE SIM IMPLEMENTATION GUIDE ▪ To review building blocks and milestone tips ▪ USE RESOURCE HUB

▪ To get and share great tools and resources

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UPCOMING DUE DATES

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Activity Cohort 1 Cohort 2 SUBMIT CQMs January 31, 2018 January 31, 2018 Final Assessments (IPAT , Monitor, DQA, MAC) Release Mid February NA Final Field Note/Progress Report April, 2018 NA 6 Month Assessments (HIT , MAC) NA April, 2018 (Open/available March 2018) PF Field Notes monthly monthly CHITA Field Notes monthly monthly

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UPCOMING EVENTS

January 2018

▪ 1/25 – MGMA Face to Face session; Thrive in the Value Based World; Financial Keys to Succeed 8 am - noon

February 2018

▪ 2/1 -- SIM SPLIT Office Hours 9-10 am ▪ 2/8 – SIM Office hours – 10-11 am ▪ 2/13 – TCPi PTO Touchbase 9-10 am ▪ 2/13 -- CMGMA Practice webinar 11-noon ▪ 2/15 – Learning Features – Cost & Utilization Reports 10 – 11 am ▪ 2/20 – CHITA Learning Community 3-4 pm ▪ 2/21-- MGMA Practice Webinar – What Do I Bring to the Table? Develop your value proposition noon-1 pm ▪ 2/27 – Cost/Utilization workshop (TCPi & 1 non TCPi person/PTO) ▪ 2/27 – CO QPP Coalition Webinar The basics and guidance on how to report - noon- 1 pm ▪ 2/28 – SIM PTO Training 9-10 am – Phase 3

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University Practice Innovation Team Contact Information

Practice Transformation – Stephanie.Kirchner@ucdenver.edu Learning Community - Kellyn.Pearson@ucdenver.edu CQMs – Andrew.Bienstock@ucdenver.edu SPLIT/Data Related – Lauren.Shviraga@ucdenver.edu ENSW – Daniel.Pacheco@ucdenver.edu TCPi - Kristin.Crispe@ucdenver.edu or Allyson.Gottsman@ucdenver.edu SIM – Taryn.Bogdewiecz@ucdenver.edu or Heather.Stocker@ucdenver.edu Invoicing – Natalie.Buys@ucdenver.edu

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QUESTIONS?

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