SIM PTO TRAINING FEBRUARY 28, 2018 9:00 AM Call Instructions: - - PowerPoint PPT Presentation

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SIM PTO TRAINING FEBRUARY 28, 2018 9:00 AM Call Instructions: - - PowerPoint PPT Presentation

Feb 24, 2024 185 likes •674 views

SIM PTO TRAINING FEBRUARY 28, 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

FEBRUARY 28, 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

FEBRUARY 28, 2018

Presenters: Marjie Harbrecht, MD Stephanie Kirchner, MSPH, RD Kelly Pearson, RN, MSN Ashlie Brown – RHC Director Bethany Pace-Danley-Peer Assistance Services, Inc. SBIRT Program Manager

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TRAINING OBJECTIVES

▪ Review recent survey results throughout ▪ Review PHASE 3 – Population Management

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

▪ Discuss March 28 Tips & Tricks in-person meeting ▪ Questions

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SURVEY RESULTS

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PHASED APPROACH TIMELINE

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USING SIM TIMELINE, INDICATE PROGRESS YOUR PRACTICES ARE MAKING ON MILESTONES IN GENERAL

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SELECT ALL MILESTONES YOU/PRACTICES ARE STRUGGLING WITH - BB1.Y1 – ENGAGED LEADERSHIP

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BB2.Y1 – USE DATA TO DRIVE CHANGE

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BB4.Y1 – PROVIDE TEAM-BASED CARE

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BB5.Y1 – BUILD PATIENT PARTNERSHIPS

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FOR BB3.Y1 – EMPANEL 75% OF PATIENT POPULATION, SELECT ALL MILESTONES YOU/PRACTICES ARE STRUGGLING WITH

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POLLING QUESTION

  • 1. What is the issue with payer attribution lists?

a) Practices are not receiving them. b) Practices get them but we don’t know how to use them.

  • 2. Do you feel comfortable helping practices with the PROCESS
  • f empaneling their population?

a) YES b) NO

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FOR BB7.Y1 – SCREEN FOR BH/SUD AND LINK TO RESOURCES, SELECT ALL MILESTONES YOU/PRACTICES ARE STRUGGLING WITH

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PHASE 3 BB3.Y1 – EMPANELING POPULATION BB7 – SCREENING FOR BH/SUD & LINKING TO RESOURCES

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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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BB3.Y1 – EMPANELING POPULATION

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

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

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

Goal: Screen at least 90% of appropriate patients/families for SUD and/or BH needs, and include BH and community services as part of care management strategies

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,

  • besity, 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 QUESTION FROM JANUARY

1.What percentage of your practices have a CLEAR IMPLEMENTABLE VISION that outlines how they will approach behavioral health?

0% -25% 26% – 50% 51% - 75% 76% - 100%

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POLLING QUESTIONS - OUT OF 7

RESPONSES

  • 1. What have the majority of your practices selected as the BH

pathway to work on NOW?

a) Collaboration - 2 b) Co-location – 2 c) Collaboration/Co-location - 1 d) Integration – 2

  • 2. What have the majority of your practices selected as the BH

pathway to work toward in the FUTURE?

a) Collaboration b) Co-location - 1 c) Integration - 6

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Making Connections

How the Regional Health Connector workforce can support you

February 28, 2017

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Three Takeaways

  • 1. Regional Health Connectors (RHCs) help connect

the systems that keep us healthy

  • 2. RHC work may support Building Block 7 milestones
  • 3. Each RHC has selected three local priorities to focus
  • n while serving the surrounding region
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RHCs work across systems

PF – Practice Facilitator CHITA – Clinical Health Information Technology Advisor

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Building Block 7: Continuity of Care

Year 2 Milestones

  • 50% of patients are screened for behavioral health condition(s).
  • Practice performs an assessment of community resources to assist

patients/families with social needs (such as food, housing, transportation).

  • 50% of patients identified with behavioral health need are

connected to resource. Goal Practice screens at least 90% of appropriate patients/families for substance use disorder and/or other behavioral health needs, and includes behavioral health and community services as part of care management strategies.

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Real World Examples

In Region 3 (Front Range), RHC Laura Don connected a primary care practice with a behavioral health provider in the same office building! In Region 11 (Western Slope), RHC Stephanie Monahan is convening care coordinators, case managers, and community service providers to identify referral opportunities and gaps

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Local Priorities are Connected to CQMs

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http://regionalhealthconnectors.org

  • Interactive map of RHC regions and projects
  • Downloadable list with RHC for each SIM Practice
  • RHC Success Stories

RHC Website Resources

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Thank you!

RHConnectors@Coloradohealthinstitue.org @RHConnectors

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The Project described is supported by Funding Opportunity Number CMS -1G1-14- 001 from the US Department of Health and Human Services (HHS), Centers for Medicare and Medicaid Services (CMS) and by contract/grant number 1R18HS023904-01 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services (HHS). Opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ, CMS, or HHS.

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SCREENING, BRIEF INTERVENTION, REFERRAL TO TREATMENT (SBIRT) RESOURCES-TRAINING-PUBLIC AWARENESS

Available online and as a mobile app (Apple and Android) at www.shifttheinfluence.org

Hi, I’m Jordan!

I enjoy y partying tying, , but my my drink nkin ing and d smokin ing weed have been getting ing in the way ay of keepin ing my my job.

Hi, I’m Donna!

I'm deali ling ng with h a lot these day ays, s, and I use alcohol cohol to cope pe with h stress. .

www.sbirtcolorado.org

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HTTPS://WWW.COLORADO.GOV/LADDERS

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PSYCHOLOGY TODAY

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HTTPS://WWW.SAMHSA.GOV/FIND-HELP/NATIONAL-HELPLINE

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MARCH 28TH PTO TRAINING – TIPS & TRICKS COPIC BUILDING: COLORADO MEDICAL SOCIETY CONFERENCE ROOM

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WILLING TO SHARE TIPS/TRICKS BB3 - EMPANELMENT

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REMINDER - USE THE MAC TO GUIDE YOUR WORK

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REMINDERS

▪ USE MILESTONE ATTESTATION CHECKLIST

▪ Ongoing guide for where to concentrate efforts ▪ Start considering what you will be doing for year 2

▪ 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 Clinical Quality Measures Final submission (Q1 2018) due 4/30/18. Q1 2018 due 4/30/18. Cohort 1 Final Assessments (IPAT , Practice Monitor, HIT Assessment, Milestone Inventory, SIM close out questionnaire) Now open. Due 3/31/18 NA Final Field Note/Progress Report Due 4/30/18. NA Cohort 2 Six Month Assessments (MAC & HIT Assessment) NA Open 3/15/18. Due 4/30/18. PF Field Notes monthly monthly CHITA Field Notes monthly monthly

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UPCOMING EVENTS

February 2018

▪ 2/28 -- SPLIT Training for SIM Cohort 1 Final Assessments 12-1 pm

▪ March 2018

▪ (Scheduled) ▪ 3/7 -- SPLIT Training for SIM Cohort 1 Final Assessments 8-9 am ▪ 3/8– Learning Features Call – Collaborative Care Model 9:30-11 am ▪ 3/13 – TCPi PTO Touchbase- 9-10 am ▪ 3/13 – CMGMA Practice Webinar; Ransomware and Your Practice 11-12 noon ▪ 3/20 – CHITA Learning Community 3-4 pm ▪ 3/21 -- MGMA Practice Webinar – Reimbursement Models; What works today and preparing for tomorrow 12-1 pm ▪ 3/22 --SPLIT Office Hours 9-10 am ▪ 3/27 –CO QPP Coalition Webinar 12- 1 pm ▪ 3/28 –SIM PTO Training Phase 3: BB3 – empaneling population; BB7 – screening AND LINKING for BH/SUD 9-10 am at COPIC Building in the Colorado Medical Society Conference Room ▪ 3/28 --SPLIT Training for SIM Cohort 2 Assessments 12-1 pm

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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 – Heather.Stocker@ucdenver.edu or Taryn.Bogdewiecz@ucdenver.edu Invoicing – Natalie.Buys@ucdenver.edu SPLIT Technical Support -- support-split@practiceinnovationco.org

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QUESTIONS?

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