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 • 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
FEBRUARY 28, 2018 Presenters: COLORADO SIM PTO TRAINING Marjie Harbrecht, MD Stephanie Kirchner, MSPH, RD PHASE 3: Kelly Pearson, RN, MSN BB3 – EMPANELING THE POPULATION Ashlie Brown – RHC Director BB7 – SCREENING AND LINKING FOR BH/SUD Bethany Pace-Danley-Peer Assistance Services, Inc. SBIRT Program Manager
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 3
SURVEY RESULTS 4
PHASED APPROACH TIMELINE
USING SIM TIMELINE, INDICATE PROGRESS YOUR PRACTICES ARE MAKING ON MILESTONES IN GENERAL 6
SELECT ALL MILESTONES YOU/PRACTICES ARE STRUGGLING WITH - BB1.Y1 – ENGAGED LEADERSHIP 7
BB2.Y1 – USE DATA TO DRIVE CHANGE 8
BB4.Y1 – PROVIDE TEAM-BASED CARE 9
BB5.Y1 – BUILD PATIENT PARTNERSHIPS 10
FOR BB3.Y1 – EMPANEL 75% OF PATIENT POPULATION, SELECT ALL MILESTONES YOU/PRACTICES ARE STRUGGLING WITH 11
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 of empaneling their population? a) YES b) NO 12
FOR BB7.Y1 – SCREEN FOR BH/SUD AND LINK TO RESOURCES, SELECT ALL MILESTONES YOU/PRACTICES ARE STRUGGLING WITH 13
PHASE 3 BB3.Y1 – EMPANELING POPULATION BB7 – SCREENING FOR BH/SUD & LINKING TO RESOURCES 14
PHASED APPROACH TIMELINE
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 Year 2: Risk stratify at least 75% of EXPAND and MAINTAIN EFFORTS 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 AGREEMENTS WITH Year 2: Bi-directional data sharing least 75% of HIGH RISK BEHAVIORAL HEALTH CARE PATIENTS (EITHER ONSITE OR BB9 - CARE COORDINATION TO REDUCE OFFSITE) COSTS AND IMPROVE CARE 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
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. 17
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) 18
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 Year 2: Risk stratify at least 75% of EXPAND and MAINTAIN EFFORTS 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 AGREEMENTS WITH Year 2: Bi-directional data sharing least 75% of HIGH RISK BEHAVIORAL HEALTH CARE PATIENTS (EITHER ONSITE OR BB9 - CARE COORDINATION TO REDUCE OFFSITE) COSTS AND IMPROVE CARE 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
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
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, 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. 21
PATHWAYS TO CONNECT PCP AND BH RESOURCES OUTSIDE PRACTICE Collaboration INSIDE PRACTICE Co-Location Integration 22
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% 23
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 24
Making Connections How the Regional Health Connector workforce can support you February 28, 2017
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