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

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 • 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

COLORADO SIM PTO TRAINING JANUARY 24, 2018 PHASE 3: Presenters: BB3 – EMPANELING THE POPULATION Marjie Harbrecht, MD Stephanie Kirchner, MSPH, RD BB7 – SCREENING AND LINKING FOR Kelly Pearson, RN, MSN BH/SUD Andrew Bienstock

TRAINING OBJECTIVES ▪ Review Practice Feedback Reports ▪ Introduce PHASE 3 – Population Management ▪ BB3 – Empaneling Patient Population ▪ BB7 – Screening and Linking BH/SUD ▪ Questions 3

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) 4

INTEGRATED PRACTICE ASSESSMENT TOOL (IPAT) STEPHANIE KIRCHNER 5

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DEFINITIONS OF BH COORDINATION TO INTEGRATION 7

MEDICAL HOME PRACTICE MONITOR STEPHANIE KIRCHNER 8

MEDICAL HOME PRACTICE MONITOR 9

HEALTH INFORMATION TECHNOLOGY ASSESSMENT (HIT) ANDREW BIENSTOCK 10

HEALTH INFORMATION TECHNOLOGY (HIT) ASSESSMENT 11

CQM SPECIFIC RESPONSES 12

HIT BARRIERS RANKING 13

HIE / TELEHEALTH / BROADBAND 14

COHORT 2 REGISTRY ACCESS AND USE FOR CQM COUNTS 15

COHORT 2 EHR DISTRIBUTION 16

MILESTONE ATTESTATION CHECKLIST (MAC) STEPHANIE KIRCHNER 17

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 18

MAC RESULT SUMMARY 19

REPORT BY EACH BUILDING BLOCK AND MILESTONES 20

QUESTIONS 21

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

USE THE MAC TO GUIDE YOUR WORK – PHASE 3 24

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. 25

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. 26

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.

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) 28

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

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/ 31

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 other behavioral health needs, and includes behavioral health and community services as part of care management strategies 32

TWO MAIN ASPECTS 1. Mental Health Issues ▪ Depression, anxiety, severe mental illness (SMI), etc 2. Behavioral Issues associated with chronic disease and other conditions ▪ Tobacco/drug/alcohol cessation, weight control, physical activity 33