Oregon’s health system transformation • Oregon began implementing the coordinated care model in 2012 within CCOs • CCOs are networks of all types of health care providers (physical health, addictions and mental health, and dental care) who work together to serve Oregon Health Plan (Medicaid) members • 423,325 children in Oregon enrolled in Medicaid (August 2017, under age 18) 27
Oregon’s Coordinated Care Model 28
CCO Accountability to OHA CCO Incentive Measures • Annual assessment of CCO performance on selected measures. • Measures selected by public Metrics & Scoring Committee. • CCO performance tied to bonus $ • Compare annual performance against prior year (baseline), to see if CCO met benchmark or demonstrated certain amount of improvement Measure specifications and guidance documents online at: http://www.oregon.gov/oha/analytics/Pages/CCO-Baseline-Data.aspx 29
Quality Pool Structure • CCOs must meet either the benchmark or an improvement target annually for each of the incentive measures to earn quality pool funds. • Quality pool = percentage of actual CCO paid amounts during calendar year. • Pool has generally increased annually: • 2% in 2013 • 3% in 2014 • 4% in 2015 • 4.25% in 2016 • 4.25% in 2017 30
Quality Pool Distribution To earn their full quality pool payment for 2017, CCOs must: ✓ Have at least 60 percent of their members enrolled in a patient- centered primary care home (PCPCH); and, ✓ Meet the benchmark or improvement target on at least 12 of the 16 remaining measures. Money left over from the quality pool goes to a challenge pool . To earn the challenge pool payments, CCOs have to meet the benchmark or improvement target on the challenge pool measures (a subset of full measure set). All money in the pool is distributed every year. Quality Pool methodology (reference instructions) online at: http://www.oregon.gov/oha/analytics/Pages/CCO-Baseline-Data.aspx 31
Metrics and Scoring Committee • 2012 Senate Bill 1580 established committee • Nine members serve two-year terms. Must include: 3 members at large 3 members with expertise in health outcome measures 3 representatives of CCOs • Committee uses public process to identify objective outcome and quality measures and benchmarks. 32
CCO Measure Selection: A Public Process Health Plan Quality Metrics Committee Public Testimony: advocates, Metrics & Scoring Committee organizations, CCOs, providers Stakeholder Input: Metrics Technical Advisory Providers, CAPs, CACs, Workgroup community 33
Measures should… • Address multiple domains o Health outcomes, patient experience, quality, and access • Represent services CCOs provide o Ambulatory care, inpatient care, chemical dependency and mental health treatment, oral health care, care coordination, prevention, etc… • Represent populations CCOs serve o Adults, children, demographics such as race, ethnicity, disability, SPMI • Align with Quality Improvement Focus Areas from Oregon’s 1115 Medicaid demonstration waiver (2017 – 2022 goals below) o Stronger behavioral, oral, and physical health integration o Address social determinants of health and promote equity o Health related services and value-based purchases for a sustainable rate of growth o Increase duals’ involvement in CCO model 34
Measures should… • Be national / standardized measures o Though to push health transformation, the Committee has developed and adopted non-standardized measures (smoking cessation; drug and alcohol screening [SBIRT]; children in DHS custody; effective contraceptive use) • Fit within the operational parameters of the program o Metric is sensitive to improvement efforts and can change in a 12 month period o Consistently reportable at the CCO level on at least an annual basis o Reportable for the measurement period of each program year (CY) 35
Measure Selection Criteria • Transformative potential • Consumer engagement • Relevance • Consistency with national and state measures (with room for innovation) • Attainability • Accuracy • Feasibility of measurement (data source, timing) • Reasonable accountability Across the SET of measures: • Range / diversity of measures • Right number of measures http://www.oregon.gov/oha/HPA/ANALYTICS/MetricsScoringMeetingDocuments/Measure_selection_crit 36 eria.pdf
CCO Incentive Measures since 2013 CCO Incentive Measures 2013 2014 2015 2016 2017 2018 Adolescent well-care visits x x x x x x Alcohol or other substance misuse screening (SBIRT) x x x x Ambulatory care: Emergency department (ED) visits x x x x x x CAHPS composite: Access to care x x x x x x CAHPS composite: Satisfaction with care x x x x x Childhood immunization status x x x Cigarette smoking prevalence x x x Colorectal cancer screening x x x x x x Controlling high blood pressure x x x x x x Dental sealants x x x x Depression screening and follow-up plan x x x x x x Developmental screening (0-36 months) x x x x x x Disparity measure: ED visits among members with mental illness x Early elective delivery x x Diabetes: HbA1c poor control x x x x x x Effective contraceptive use x x x x Electronic health record adoption x x x Follow-up after hospitalization for mental illness x x x x x Follow-up for children prescribed ADHD medication x x Health assessments within 60 days for children in DHS custody x x x x x x Patient centered primary care home enrollment x x x x x x Timeliness of prenatal care x x x x x x 37 Weight assessment and counseling for children and adolescents x
2018 Incentive Measures Access to care (CAHPS survey) Dental sealants for kids Adolescent well-care visits Depression screening and f/u plan Emergency department utilization Developmental screenings Assessments for kids in DHS custody Diabetes HbA1c poor control Disparity measure: ED utilization for Childhood immunization status members with mental illness Cigarette smoking prevalence Effective contraceptive use Colorectal cancer screening PCPCH enrollment Weight assessment and counseling Controlling high blood pressure for kids and adolescents Timely prenatal care Bold: Measures related to early childhood and family well-being ****=challenge pool, additional bonus $ (challenge pool focuses on early childhood health; Committee ultimately wants a measure of kindergarten readiness) 38
CLAIMS-based measures Access to care (CAHPS survey) Dental sealants for kids Depression screening and f/u plan Adolescent well-care visits Emergency department utilization Developmental screenings Diabetes HbA1c poor control Assessments for kids in DHS custody Disparity measure: ED utilization for Childhood immunization status members with mental illness Cigarette smoking prevalence Effective contraceptive use Colorectal cancer screening PCPCH enrollment Weight assessment and counseling for Controlling high blood pressure kids and adolescents Timely prenatal care 39
EHR and other data sources Access to care (CAHPS survey) Dental sealants for kids Adolescent well-care visits Depression screening and f/u plan Emergency department utilization Developmental screenings Assessments for kids in DHS custody Diabetes HbA1c poor control Disparity measure: ED utilization for Childhood immunization status members with mental illness Effective contraceptive use Cigarette smoking prevalence Colorectal cancer screening PCPCH enrollment Weight assessment and counseling Controlling high blood pressure for kids and adolescents Timely prenatal care 40
Measure specifications Developmental Screening in the First Three Years of Life Measure Basic Information Measure Details Name and date of specifications used: Data elements required denominator: Children who turn 1, 2, or 3 years of age in the measurement Core set of Children’s Health Care Quality Measures, Updated June 2017 year and had continuous enrollment in a CCO for the 12 months prior to their birthdate in the measurement year, regardless if they had a medical/clinical visit or not in the measurement year. See URL of Specifications: https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By- Core Set of Children’s Health Care Quality Measures for details. Topics/Quality-of-Care/Downloads/Medicaid-and-CHIP-Child-Core-Set-Manual.pdf Required exclusions for denominator: None. Measure Type: HEDIS PQI Survey Other Specify: NCQA & CAHMI (Children and Health Measurement Deviations from cited specifications for denominator: None. Initiative) Measure Utility: Data elements required numerator: Children in the denominator who had a claim with CPT code 96110 CCO Incentive State Quality Measure CMS Adult Core Set CMS Child Core Set in the 12 months preceding the birthday in the measurement year. See new Clarification section below. Other Specify: Required exclusions for numerator: N/A Data Source : MMIS/DSSURS Deviations from cited specifications for numerator: If the claim was for CPT 96110, the claim was Measurement Period: January 1, 2018 – December 31, 2018 included regardless of the inclusion of any modifiers. This deviates from published specifications. 2013 Benchmark: 50%; from Metrics and Scoring Committee consensus What are the continuous enrollment criteria: Enrollment must be continuous for one year prior to the 2014 Benchmark: 50%; from Metrics and Scoring Committee consensus 2015 Benchmark: 50%; from Metrics and Scoring Committee consensus birthday in the measurement year, with a maximum of a 45 day gap. 2016 Benchmark: 50%; from Metrics and Scoring Committee consensus 2017 Benchmark: 60.1%; 2015 CCO 75 th percentile What are allowable gaps in enrollment: No more than one gap in continuous enrollment of up to 45 2018 Benchmark: 74.0%; 2016 CCO 90 th percentile days in the 12 months prior to the birthday in the measurement year. 2018 Improvement Targets: Minnesota method with 3 percentage point floor Define Anchor Date (if applicable): Child’s birth date. Clarification for coding and billing for developmental screening Incentive Measure changes in specifications from 2017 to 2018: To review, developmental screening is defined by the American Academy of Pediatrics as “the none. administration of a brief, standardized and validated tool that aids the identification of children at risk Member type: CCO A CCO B CCO G for developmenta l, behavioral or social delays.” Federal Bright Futures Recommendations call for children to be screened, using a global developmental screening tool, at three different times in the first Specify claims used in the calculation: three years of life in the context of routine well-child visits or when a concern is raised through standardized developmental surveillance. The CCO incentive metric is intended to operationalize Claim from matching DS CCO Denied claims included whether that Bright Futures recommended care is provided for young children. Numerator event Y Y 41
Questions? Sara Kleinschmit, OHA (sara.kleinschmit@state.or.us) 42
Arriving at the Scope of Our Workgroup 43
Vision • What is the vision for improving school readiness in Oregon? • How does the health sector impact kindergarten Interest readiness? • How might we improve kindergarten readiness in Oregon through the health system? • What is a feasible scope for this workgroup Scope that will bring us closer to our vision for achieving kindergarten readiness in Oregon? 44
Vision Every child in Oregon arrives at school ready to learn. All sectors — health, education, human services, and beyond — collectively support children, parents, caregivers, and communities to achieve kindergarten readiness. Long-term goal: Shared accountability and collective action for kindergarten readiness across sectors 45
Interest in Measures of Health Sector’s Role in Kindergarten Readiness • 2014 – 2015: T he Child and Family Well-being Measures Workgroup developed initial measurement recommendations for child and family well-being, including kindergarten readiness. • 2015 – 2017: T he Metrics and Scoring Committee (M&SC) remained engaged on the topic of developing a kindergarten readiness metric. • May 2017: T he M&SC voted to sponsor a KR metric technical workgroup, launching an innovative partnership between OHA and Children’s Institute. • July 2017: T he Health Plan Quality Metrics Committee received a presentation on the proposed KR workgroup and approved its formation, with a request for further details within 120 days. • Ongoing: Deep engagement on the developmental screening metric and exploration of referral and follow-up practices has highlighted challenges and opportunities with cross- sector collaboration and continues to ignite interest. 46
Interest Has Led to Our Opportunity • Seizing demand and buy-in from within the health sector • Leveraging the transformative power of metrics • CCO incentive metrics have been powerful levers for focusing attention, driving quality improvement, and promote collaboration • Making progress that will bolster Oregon’s broader early learning system 47
Scope What is the health sector’s role and responsibility for achieving kindergarten readiness for Oregon’s children? Then, given that role, what are specific short-term and Health long-term metrics that would operationalize whether the Sector’s health system is playing that role? Role Recommend a health system quality measure that: • drives health system behavior change, quality improvement, and investments that meaningfully Kindergarten Readiness contribute to improved kindergarten readiness • catalyzes cross-sector collective action necessary for achieving kindergarten readiness • aligns with the intentions and goals of the CCO metrics program 48
Shared accountability and cross-sector collective action to achieve kindergarten readiness Phase 3 Phase 1 Phase 2 • Explore integrating the • Recommend a quality • Pilot/test the measure health system quality measure of the health • Explore additional measure into the early system’s role in recommendations, i.e., learning system data kindergarten readiness data sharing or new dashboard to be applied as a CCO measure development • Explore opportunities for incentive measure • Explore potential to joint accountability and • Consider other shared measurement apply the measure to recommendations to other health plans and achieve desired goals payers 49 Engagement and coordination with the ELD, ELC, and other sectors to ensure alignment and impact
Phase I Within Scope • Adopting a conceptual framework for the health sector’s role in kindergarten readiness • Identifying metrics that can operationalize components of the health sector’s role • Identify metrics that can be applied and measured at the CCO level in the short- and long- term • Identifying recommendations for future phases i.e., data sharing or new measure development Outside of Scope • Joint accountability with the Early Learning System • Health sector developing a new definition of kindergarten readiness • Health sector adopting a metric that measures child-level outcomes and abilities within health care 50
Work Plan March Establish workgroup role, process, and workplan Review key background information April – May Establish conceptual framework for health sector’s role in kindergarten readiness Discuss and adopt principles for measure recommendations Review spectrum of potential recommendations, generate additional options June – August Measure exploration and prioritization based on framework and principles Seek and incorporate input from stakeholders, including Metrics and Scoring Committee September Finalize measure recommendations with group consensus Present recommendations to Metrics and Scoring Committee October Debrief presentation of recommendations Discuss next steps and future work 51
Key Considerations • Short timeline for Phase 1 • Priority focus for Phase 1 is Metrics and Scoring and CCOs • Feasible sources for annual data collection and reporting • Constraints of measure selection criteria and operational requirements • Desire for transformation 52
Hearing From Families: Kindergarten Readiness Focus Group Findings
Children’s Institute contracted with the Center for Improvement of Child & Family Services at Portland State University to conduct 8 focus groups with parents and caregivers statewide to inform the Health Aspects of Kindergarten Readiness Technical Workgroup. THE PSU RESEARCH TEAM Callie Lambarth Heidi McGowan Diane Reid Ron Joseph Beth Green Project Director Lead Facilitator & Co-Facilitator & Translator & Consultant & Analyst Analyst Analyst Co-Facilitator 54
The project purpose is to: • Ensure that family voice is informing discussions about how to measure the health sector’s role in kindergarten readiness. -Inform adoption of a working definition of KR and definition of health sector’s role in KR -Inform thinking about principles for measure recommendations to reference and apply during all workgroup discussions 55
Parent focus groups were designed to explore specific questions • What does school readiness mean to you? • What health services and early learning supports have you participated in? • How have these helped you and your child be ready for school? • What do you wish health services and early learning supports would do differently to better support you and your child to be ready for school? 56
Communities and participants were identified with purpose 87 total parents/caregivers with children ages 0-8 • Targeted recruitment of families experiencing poverty, families belonging to racial and ethnic minority groups, and families of children with special health needs 18 participated in Spanish with simultaneous English translation 69 participated in English Identified communities had primary local contacts with existing relationships with Children’s Institute, PSU, or stakeholder partners, in order to convene parent focus groups on a short timeline 57
Participants came from communities across the state, including rural and urban locales 11 Baker City 9 Enterprise 5 Eugene 8 Grants Pass 16 Gresham-Fairview 16 Medford 14 Portland 8 Yoncalla 58
Although the majority of participants identified as White, the project actively sought participation of Black/African American and Latino parents/caregivers 89% Focus Groups Oregon 61% 28% 12% 11% 6% 4% 3% 3% 2% 1% 1% Asian Native American Black/African Latino White Hawaiian/Pacific Indian/Alaska American Islander Native 59
Most participants utilized publicly-funded health coverage in the past year, as well as additional early childhood, family, and community supports Public library 84% OHP 70% WIC 59% SNAP 54% EI/ECSE 29% TANF 24% Head Start 21% Early Head Start 17% 60
What does school readiness mean to families? 61
What does it mean for children to be ready for school? 62
What does it mean for your child to be ready for school? Having social-emotional skills were most important to most families • Sharing • Being able to identify and verbalize feelings • Caring for others • Making friends • Enjoying playing with other children 63
What does it mean for your child to be ready for school? Having social-emotional skills were most important to most families “ Being able to recognize their emotions and how they feel and verbalize them to friends, and recognize people in need. ” 64
What does it mean for your child to be ready for school? Having strong executive functioning skills was also very important • Being able to focus attention • Remembering instructions • Being able to self-regulate 65
What does it mean for your child to be ready for school? Having strong executive functioning skills was also very important “ That my children are able to listen to and receive instructions from their teachers, so teaching them to have listening skills is, for some of my children, a challenge. ” 66
What does it mean for your child to be ready for school? Being familiar with the school and understanding classroom and school routines • How to sit in a circle, stand in a line • Know where the bathroom is • Where to go at recess • How to ride the bus 67
What does it mean for your child to be ready for school? Pre-academic skills were not as big of a concern to most families but were more important for families whose home language was Spanish • Letters • Numbers • Shapes • Colors 68
What does it mean for your child to be ready for school? Pre-academic skills were not as big of a concern to most families but were more important for families whose home language was Spanish “ Que sepan por lo menos algo como escribir su nombre. Sabiendo el abecedario y los números de 1 al 20 de contar. [They should at least know something like how to write their name. Know the ” alphabet and count from 1 to 20.] 69
What does it mean for your child to be ready for school? Some parents described additional skills • Be able to be independent and comfortable being away from parents • Be able to do personal care, e.g., tie shoes, use the bathroom on their own • Have fine motor skills, e.g., can use scissors, pencils, crayons • Discover their interests and have a love for learning 70
What does it mean for families to be ready for school? 71
What does it mean for families to be ready for school? Develop ways to support children’s learning at home from birth • Being attuned and reflexive to support their child’s individual needs and strengths • Provide variety of play and learning opportunities • Read at home regularly 72
What does it mean for families to be ready for school? Develop ways to support children’s learning at home from birth “ I think as a parent, it is important to understand where your child is at and what you need. ” 73
What does it mean for families to be ready for school? Establish routines • Set regular bed and waking times • Limit screen time 74
What does it mean for families to be ready for school? Health supports are in place • Monitor child development with routine screenings and get connected to needed supports • Ensure that health and safety plans are in place in early learning and elementary school settings • Work with health providers to address needs of children with special health needs in early learning and elementary school settings 75
What does it mean for families to be ready for school? Health supports are in place “ Putting together a patchwork of different medical specialists, therapists, in different settings…The [health care provider] is thinking about the medical side and also about when [child] gets to school, how to ” learn to do [her own medical care]. 76
What does it mean for families to be ready for school? Build relationships and talk with early learning providers and teachers • Gain comfort talking with them about child’s learning at school • Understand how to support child’s learning at home and connect to learning in the classroom 77
What does it mean for families to be ready for school? Obtain information about kindergarten transition and expectations • Learn when kindergarten registration happens • Know when immunizations are due • Understand teacher expectations for them and their child • Know what elementary school options exist in the community, e.g., public, charter, private schools • Meet school staff • Talk with child about kindergarten 78
What does it mean for families to be ready for school? Some parents described additional needs • Provide tangible materials such as school supplies, uniforms • Learn about and access existing supports and programs • Connect with other parents to understand and accept that there is a range of parenting values, strategies, and challenges that families face 79
What kind of health services have you participated in? 80
Types of Health Services Families described accessing a variety of health services • Health insurance means families can more easily access care • Preventative health services such as well-child checks, dental services, and developmental screenings • Specialized health services such as speech and language therapy • “Alternative” medicine such as acupuncture, massage, homeopathic treatments • Emergency medical services 81
Types of Health Services Families also described accessing health services in home, school, and community- based settings • Home visiting through CaCoon, Early Intervention, Healthy Birth Initiative, Healthy Start • Breastfeeding and nutrition supports through WIC, SNAP • School-based health services • Mobile clinics and community health fairs 82
How do health services support school readiness? 83
Health services help children and families be ready for school Most importantly, through providers who take the time to build trust and listen • Consistently, parents shared that the parent-provider relationship is the most important and foundational aspect of accessing health services for their child • Parents and caregivers want providers to take the time to build relationships, hear parents’ concerns, and answer questions 84
Health services help children and families be ready for school Most importantly, through providers who take the time to build trust and listen “ [My child’s pediatrician] didn’t rush through any appointment. If I had questions, she’d explain it thoroughly. She’d explain everything, even if I had a question about another kid – behavior ” problems, developmental problems. 85
Health services help children and families be ready for school Most importantly, through providers who take the time to build trust and listen “ It’s a really healthy mix of conversation, resources, handouts, websites, Apps. It opens doors. You establish a relationship [with health care provider] and then you know you can call and get help if you need ” it. 86
Health services help children and families be ready for school Comprehensive prenatal and postpartum care, and parental health services, give families a healthy and stable foundation • Families valued timely, locally accessible, and routine prenatal and postpartum care • Families connected their own mental and physical health to their ability to parent and meet the needs of their children 87
Health services help children and families be ready for school Comprehensive prenatal and postpartum care, and parental health services, give families a healthy and stable foundation “ When I found out I was pregnant, I started classes right away with [health care provider]. They did pregnancy care, then infant care. They work with you on any issue. ” 88
Health services help children and families be ready for school Comprehensive prenatal and postpartum care, and parental health services, give families a healthy and stable foundation “ Sometimes I have a hard time leaving the house, just going to the park is hard for me because of my anxiety. I already know that I’m not being the best parent I could be for my kids. I am trying to find a program to help me [but] I don’t see anything that has been easy to ” get access to. 89
Health services help children and families be ready for school Conducting developmental screenings and monitoring child development • Doing the ASQ with health care providers, home visitors, and in early learning settings • Going beyond doing the ASQ, to talking about it and learning how to help child reach milestones was most important. This was described by many parents as a missing step. • Parents liked when ASQs were shared between providers, e.g., health and early learning settings 90
Health services help children and families be ready for school Conducting developmental screenings and monitoring child development “ I love [the ASQ] because it has opened up a lot of questions for me at the doctor’s appointment. Like, ‘Wait, is [child] supposed to ” be doing this?’ 91
Health services help children and families be ready for school Conducting developmental screenings and monitoring child development “ Thinking about the well-child checks I took my kids to before starting school, there wasn’t a whole lot of conversation about what types of gross motor activities they should be doing or fine motor skills. I think there needs to be more conversations taking place and opportunities for parents to really understand the why and the how and the impact of ” the importance of those things for later in school. 92
Health services help children and families be ready for school Provide additional kinds of developmental supports • Timely immunizations • Nutrition supports, such as those offered through WIC, were frequently mentioned as important for child development and readiness • Encouraging literacy, book giveaways 93
Health services help children and families be ready for school Provide additional kinds of developmental supports “ [WIC] makes sure they have proper nutrition and will be able to think and be physically able to participate in activities. ” 94
Health services help children and families be ready for school Make referrals to other health, early learning, and family supports • Being knowledgeable about additional supports and making referrals • Warm-hand offs are more effective, either directly through the health care provider, or someone in a service coordination role, e.g., nurse, social worker 95
Health services help children and families be ready for school Make referrals to other health, early learning, and family supports “ One thing we have benefitted from in the clinical environment…clinics include a social worker, so having someone there to say have you tried this, have you tried this and they can name off all the different resources available. That care coordinator, or nurse who specializes in making referrals to the community. Someone who can ” orient you and point you in the right direction. 96
How can Health Services continue to improve to support school readiness? 97
Health services could continue to improve to help children and families be ready for school Spend more time with families and develop trusting relationships • Develop relationships over time • Continuity of providers was important to building trust • Help families feel comfortable asking questions • Approach families nonjudgmentally 98
Health services could continue to improve to help children and families be ready for school Spend more time with families and develop trusting relationships “ I feel that [health care providers] haven’t necessarily made it a safe environment for parents to ask. If I don’t feel I’m accepted that is not someone I would go to and ask [about parenting], because that takes a ” relationship. 99
Health services help children and families be ready for school In the context of a trusting relationship, share expertise, information, and guidance • Provide concrete information, tools, and resources for families to support their child’s development 100
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