SIM PTO TRAINING SEPTEMBER 26, 2018 9:00 AM Call Instructions: - - PowerPoint PPT Presentation

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SIM PTO TRAINING SEPTEMBER 26, 2018 9:00 AM Call Instructions: - - PowerPoint PPT Presentation

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SIM PTO TRAINING SEPTEMBER 26, 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

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SIM PTO TRAINING

SEPTEMBER 26, 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: COHORT 2 – BB1, BB2, BB4, BB5 COHORT 3 – BB1, BB2, BB4, BB5

SEPTEMBER 26, 2018

Presenters:

Marjie Harbrecht, MD Andrew Bienstock, MHA Stephanie Kirchner, MSPH, RD Kelly Pearson, RN, MSN

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TRAINING OBJECTIVES

▪ Review MAC Requirements ▪ Cohort 3 – Year 1 - (Reviewed in August)

▪ BB1, BB2, BB4, BB5

▪ Cohort 2 – Year 2

▪ BB1, BB2, BB4, BB5

▪ Review Preliminary Results – Andrew Bienstock

▪ CQM and Other Results To Date ▪ Extended CHITA Services

▪ Upcoming Events and Due Dates

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MILESTONE REQUIREMENTS

“Good standing” is defined as the following for each project year:

▪ Practice Sites participating in SIM-Only: ▪ Project Year 1 (Cohort 3): Practice sites must achieve Year 1 milestones within BBs: 1, 2, 3, 4, and 7. ▪ Project Year 2 (Cohort 2): Practice sites must achieve Year 2 milestones within BBs: 1, 2, 3, 4, 7, and any two additional building blocks. ▪ Practice Sites participating in SIM and CPC+: ▪ Project Year 1 (Cohort 3): Practice sites must achieve Year 1 milestones within BBs: 1, 2, 3, 4, 7, 8, 9, and 10. ▪ Project Year 2 (Cohort 2): Practice sites must achieve Year 2 milestones within BBs: 1, 2, 3, 4, 7, 8, 9, and 10.

NOTE: Though not required for good standing, Cohort 3 practices should be scored on Year 2 BBs/Milestones on the MAC.

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USE MAC TO GUIDE ONGOING PRACTICE WORK

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NOW THROUGH OCTOBER 31, 2018

COHORT 3 – YEAR 1

▪ BB1 – Engaged Leadership ▪ BB2 – Using data to drive change ▪ BB4 – Team-based care ▪ BB5 – Partnership with patients

COHORT 2 – YEAR 2

▪ BB1 – Engaged Leadership ▪ BB2 – Using data to drive change ▪ BB4 – Team-based care ▪ BB5 – Partnership with patients

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PHASED APPROACH TIMELINE – COHORT 3 – YEAR 1

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PHASED APPROACH TIMELINE – COHORT 2 - YEAR 2

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SLIDE 9 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

SIM OPERATIONAL ALGORITHM – COHORT 3 & 2

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BUILD EXPAND

SUSTAIN

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COHORT 3 MILESTONES

BUILDING INFRASTRUCTURE BB1 - BB2 - BB4 - BB5 REVIEWED YEAR 1 MILESTONES IN AUGUST (ANY QUESTIONS??)

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COHORT 2 MILESTONES

YEAR 2 – EXPANDING INFRASTRUCTURE BB1 - BB2 - BB4 – BB5

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COHORT 2 – YEAR 2 BB1.YR 2 - ENGAGED LEADERSHIP

  • 1. Leadership allocates appropriate resources to

complete QI work 2.Design plans to evaluate effects of value-based payments (Review VISION for any adjustments needed)

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COHORT 2 – YEAR 2 BB2.Y2 - USE DATA TO DRIVE CHANGE

  • 1. Review CQM data
  • 2. Develop process for providing performance feedback to

providers (CQMs/cost)

  • 3. Conduct regular QI activities based on CQMs

(Continue to submit CQM’s quarterly – next DUE Oct 31st)

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POLLING QUESTION RE COST/UTILIZATION

1. How many of your practices are using Stratus to assist with cost/utilization information?

a) All of them b) Half or more c) Less than half d) None

2. For your practices using Stratus, in general what feedback are you receiving about it?

a) Overall very positive b) Overall positive but they need more training on it c) Overall negative d) They don’t have access to it

  • 3. What other tool(s) beside Stratus are they using for cost/utilization information? (Mark all that

apply)

a) Medicaid's Statewide Data Analytics Contractor (SDAC) b) Milliman Reports c) QRUR reports from Medicare d) Other (explain) e) They’re not using anything

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BB2.Y1.4. PRACTICE BEGINS USING A DATA AGGREGATION TOOL PROVIDED BY SIM TO REVIEW COST AND UTILIZATION DATA.

▪ Practice Attestation Anchor: Demonstrate through attestation of use of a tool that provides cost and utilization data, such as Medicaid's Statewide Data Analytics Contractor (SDAC), Stratus, QRUR reports from Medicare, etc. ▪ Practice Facilitator Attestation Methodology: Attest if practice is learning to review and use a utilization aggregation tool. Document in monthly field notes.

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COHORT 2 - YEAR 2 BB4.Y2 - PROVIDE TEAM-BASED CARE

  • 1. Re-evaluate team relationships using tools from Year 1
  • 2. Develop protocols for shared workflows

(for 3 CQMs with at least one BH measure)

  • 3. Review roles/responsibilities for team-based care

activities

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BB4.Y2.1. PRACTICE REEVALUATES TEAM RELATIONSHIP USING TOOL FROM YEAR 1

Action Items: Re-evaluate how practice teams are functioning by reviewing distribution of patient care tasks by role used in Year 1.

▪ Practice Attestation Anchor: Repeat assessment/discussion of team relationships ▪ Practice Facilitator Attestation Methodology: Confirm review of MAC, Medical Home Practice Monitor and Clinician/Staff Experience Survey results, plus other similar tools used, including comparison to baseline results.

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BB4.Y2.2. PRACTICE DEVELOPS PROTOCOLS FOR SHARED WORKFLOWS FOR 3 QUALITY MEASURES (AT LEAST ONE BH MEASURE)

▪ Action Items:

  • 1. USE STANDING ORDERS

a) Screening for developmental, substance use, cancer, depression b) Disease-based testing (i.e., A1C, PHQ-9, monofilament exams)

  • 2. Develop a written protocol
  • 3. Review with providers/staff
  • 4. Train staff on using standing order protocols, including NEW staff
  • 5. Review/update standing orders/protocols regularly and

retrain/update with any new information.

▪ Practice Attestation Anchor: Demonstrate protocols/workflows ▪ Practice Facilitator Attestation Methodology: Confirm practice implementation of protocols/workflows.

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EXAMPLE: DEPRESSION SCREENING

▪ GOAL: How do we increase depression screening in practice to ensure patients with depression get appropriate treatment and care to improve depression symptoms (and consequences of that – missing work, unable to enjoy things, etc) ▪ Standing Order: Every patient screened for depression at least once per year ▪ Written Protocol (workflow) and who does what

▪ What test do you use? ▪ Who will administer it? ▪ What is done if results are positive? ▪ What follow up is recommended? How often? Who ensures patient gets follow up? ▪ For physicians – what therapy or medications are first line, second line, etc? When do we refer? What happens if patient has risks for harming self or others? ▪ When do we get patient back to normal follow up?

▪ Review Standing Order/Protocol/Workflow as needed

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BB4.Y2.3. PRACTICE REVIEWS ROLES/RESPONSIBILITIES FOR TEAM-BASED CARE ACTIVITIES TO ENSURE ACCOUNTABILITY FOR VARIOUS TASKS ASSIGNED.

▪ Action Items:

  • 1. Build “team culture”, empower staff to take on new roles, act

independently, and communicate effectively. Provide protected time for teams to interact/plan activities.

  • 2. Distribute workload throughout team to make optimal use of each

member’s training and skill set, with training for new skills if needed.

  • 3. Help patients understand what they can expect from the team-

based care model

▪ Practice Attestation Anchor: Document roles/responsibilities for various team-based activities. ▪ Practice Facilitator Attestation Methodology: Confirm implementation

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CARE MANAGEMENT SERVICES

▪ Advance Care Planning

  • Advance Care Planning Services Fact Sheet
  • Advance Care Planning Services FAQs

▪ Behavioral Health Integration

  • Behavioral Health Integration Fact Sheet
  • Behavioral Health Integration FAQs

▪ Transitional Care Management

  • Transitional Care Management Services Fact

Sheet

  • Transitional Care Management Services FAQs

▪ Chronic Care Management

  • Changes to Chronic Care Management Services

for 2017 Fact Sheet

  • Chronic Care Management Services Fact Sheet
  • Chronic Care Management Services FAQs
  • Chronic Care Management Outreach Campaign on

Geographic and Minority/Ethnic Health Disparities

  • Chronic Conditions in Medicare
  • Chronic Conditions Data Warehouse

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Care- Management.html

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COHORT 2 – YEAR 2 BB5.Y2 BUILD PATIENT PARTNERSHIPS

  • 1. Identify patients eligible for decision aids or Self-

Management Support (SMS) tools

  • 2. Implement decision aids or SMS tools and establish

protocol and workflow

  • 3. Track/evaluate use of decision aids or SMS tools
  • 4. Use Patient and Family Advisory Council (PFAC) to

evaluate care experience

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PRELIMINARY RESULTS

ANDREW BIENSTOCK, MHA

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DEPRESSION CQM

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DEVELOPMENTAL SCREENING

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MAC RESULTS

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COHORT 1 EXTENDED CHITA SERVICES

▪ Emails went out to PTOs and Practices ▪ Timeline is December 1st, 2018 – March 15th 2019. ▪ Monthly meeting with practice ▪ Practice must submit 2018 CQMs for SIM ▪ Meeting between HDCO partners, practice and CHITA to discuss eCQM tool ▪ Practices need to sign up by October 12th ▪ Link on Practice Innovation CO website https://bit.ly/2QrqDgE

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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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UPCOMING DUE DATES

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Reporting Activity Cohort 2 Cohort 3

SIM CQM Reporting Q 3

(Cohort 1 2& 3 Practice Sites)

Oct 31, 2018 Oct 31, 2018 Cohort 2 12 mon Assessments

(IPAT , Monitor, HIT , MAC)

Aug 15 to Sept 30, 2018

N/A

Cohort 3 Initial Assessments

(IPAT , Monitor, HIT , MAC)

N/A

Completed Aug 15, 2018 PF Field Notes Report Monthly Report Monthly CHITA Field Notes Report Monthly Report Monthly

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UPCOMING EVENTS –

9/27— SPLIT Office Hours 9-10 am October 2018 10/2 -- CQM Update 11 to noon 10/9 -- TCPi PTO Touch base 9-10 am 10/9 -- CMGMA Practice Webinar; The Business of Medicine - Career Alternatives & Opportunities 11-12 noon 10/11-- SIM Office Hours 10-11 am 10/16 -- CHITA Learning Community-3-4 pm 10/17 -- MGMA Practice Webinar; Reimbursement Models: What Works Today and Preparing for Tomorrow. 12-1 pm 10/18 –- Learning Features Call – CANCELLED due to CLS 10/23 -- Colorado QPP Coalition Office Hours webinar- What changes can I anticipate for 2019 Performance Year. 12-1 pm 10/24 -– SIM PTO Training: BB3, BB6, BB7 10/25 -- SPLIT Office Hours 9-10 am 10/26 –SIM/TCPi Collaborative Learning Session - Omni Broomfield – Registration Now Open

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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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REFLECTIONS AND QUESTIONS