Colorado SIM Operational Plan Award Year 3 Update
The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S Department of Health and Page Human Services (HHS), Centers for Medicare & Medicaid Services (CMS). The Colorado State Innovation Model (SIM), a four-year initiative, is funded by up to $65 million from CMS. The content provided is solely the responsibility of the authors and does not necessarily represent the official views of HHS or any of its agencies.
1 of 239
Contents A. SIM background
4
a. Summary of model test
4
b. End state vision
8
c. Updated driver diagrams
11
d. Updated master timeline
25
B. General SIM policy and operational areas a. SIM governance
43 43
1. Management structure and decision-making authority
43
2. Leveraging regulatory authority
57
3. Stakeholder engagement
61
b. Health care delivery system transformation plan
71
1. Payment model(s) and service delivery model(s)
71
2. Quality measures alignment
91
3. Plan for improving population health
93
4. Health information technology
122
5. Workforce capacity
187
c. SIM alignment with state and federal initiatives
193
Coordination between SIM and other federal initiatives
193
Quality payment program (MACRA)
193
Comprehensive Primary Care Initiative (CPCi)
194
Comprehensive Primary Care Plus Initiative (CPC+)
194
Coordination with non-federally funded initiatives
236
C. Program evaluation and monitoring
240
a. State-led evaluation
240
b. Federal evaluation, data collection and sharing
246
c. Program monitoring and reporting
248
d. Fraud abuse prevention, detection and correction
260
D. Sustainability plan
265
E. Conclusion
269
Page 2 of 239
A. SIM background a. Summary of model test The Colorado State Innovation Model (SIM) operational plan charts a path to achieving SIM’s overarching goal: To improve the health of Coloradans by improving access to integrated physical and behavioral healthcare services in coordinated community systems, with value-based payment structures, for 80% of Colorado residents by 2019. To turn this vision into a reality, SIM will leverage a model test award from the Center for Medicare and Medicaid Innovation (CMMI) to implement and expand activities outlined in Colorado’s State Health Innovation Plan (SHIP), which was created with support from a CMMI Model Design Award. Colorado will work with 400 practices and four community mental health centers to integrate behavioral and physical health in primary care settings and test alternative payment models from 2015 through 2019. Practice sites have two years (with the exception of cohort 3, which has one year) to work with practice coaches who help them revise processes and enhance care teams to deliver this "whole-person care," which has been proven to improve outcomes and lower costs. During this second year of the test award, which is the first practice implementation year, the SIM team gained insights into practical challenges associated with integrating care using stakeholder interviews as well as evaluation reports and data analysis as a guide. Initial successes identified during the first implementation year are attributed to strong collaboration among stakeholders and a shared vision among state leaders for healthcare transformation. A few examples of success to date: ●
Broadband capability expanded by 80 sites across the state;
●
47 primary care practice sites awarded small grants are using funds to integrate care;
●
80% of practice sites reported on all required SIM measures;
●
There is a 92% retention rate for SIM participation;
●
82% of cohort-1 practices that responded to a SIM survey say they would recommend participation to their colleagues; and
●
Strong provider interest in SIM value: 226 practices applied for cohort 2 (150 open slots).
●
Continued strong stakeholder interest in the SIM initiative.
Challenges that SIM is addressing. ● ● ● ● ● ● ●
Provider initiative fatigue; Provider burnout; Reporting burden; Shortage of behavioral health providers; Financial support to sustain gains realized through SIM; Technology challenges software challenges; and Barriers to information sharing that would ensure that providers have access to all relevant patient information. Page 3 of 239
Progress-to-date The SIM team collected feedback throughout the first implementation year and has completed work to refine implementation for the initiative to ensure future success. Changes allow practices to report short-and long-term successes during their two-year SIM experiences with a focused progression along an integration pathway. The team also worked to align clinical quality measures and other aspects of the initiative to ensure that SIM would be complementary, not competitive, to CPC+. The team engaged its stakeholders to vet ideas and tweak SIM milestones to create guideposts for sustainable success for practices at all levels of care integration. The work has already proven to be successful as evidenced by strong provider interest and ongoing support for the initiative. One example: The team received 226 applications for a stated 150 open spots in cohort 2 and has fielded questions from practices that are interested in applying for cohort 3. Details about changes to the initiative are outlined in the Service Delivery Models section of the plan.
Roadshow The team is working with a vendor to schedule meetings across the state, engage stakeholders and share the work that the regional health connectors and local public health agencies are doing to improve community connections, reduce stigma related to mental health and facilitate the integration of behavioral and physical health for practices across the state. Staff continue to develop a self-insured employer communication outreach strategy and have seen increased interest from that group in future collaboration. Outreach to date includes a presentation to the Colorado Business Group on Health, which prompted requests for lists of SIM providers that members could publish on their websites. Members of the SIM team have conferred with a group from Health Care Strategies for help engaging the self-insured employer market and gained valuable insights from the conversations, which have been used in the SIM strategy in Colorado. The team continues to build its social media presence, publishes two newsletters (a general, monthly SIM newsletter and a bimonthly practice newsletter), has started a podcast series, published a video series, and regularly updates its website to share information about integrated care and testing alternative payment models. Analytics show that these efforts are reaching new audiences: ●
The SIM website had 4,355 unique page views in January (1,272 more than December).
●
10,600 Twitter impressions (sixth consecutive month of increases) ●
70 mentions
●
24 new followers
●
693 profile visits
Monthly SIM newsletter ●
38.8% open rate (22.93% industry average)
●
188 (or 35.5% of all who opened) clicked on one or more links.
SIM provider newsletter ●
38.6% open rate (22.93% industry average) Page 4 of 239
●
33 (or 29.5% of all who opened) clicked on one or more links.
Action plan The activities outlined in this operational plan directly reflect Colorado’s commitment to engage stakeholders from across the healthcare spectrum to integrate physical and behavioral healthcare, improve population health by leveraging public health and community resources, and help SIM practices shift from fee-for-service reimbursement structures to prospective value-based payment models that reward better care outcomes. This plan outlines Colorado’s four-pillar approach to healthcare innovation: 1. Providing access to integrated physical and behavioral health services in coordinated community systems; 2. Applying value-based payment structures; 3. Expanding information technology efforts including telehealth; and 4. Finalizing a statewide plan to improve population health.
The plan leverages practice transformation, payment reform, health information technology (HIT) and public health efforts to build upon the success of existing initiatives, such as the Comprehensive Primary Care Plus Initiative (CPC+) and the Medicaid Accountable Care Collaborative (ACC). The plan also details how SIM will engage consumers, develop workforce capacity, and use a range of policy and regulatory levers to address current systemic barriers and pave the way for future innovation and transformation. Finally, the document addresses how a dynamic evaluation plan, which aligns clinical quality measures (CQMs) with population-based data and focuses on rapid-cycle feedback, will allow SIM to identify areas that need improvement in real time and build on existing strategies. 4
When fully implemented, the plan is projected to generate $126.6 million in total cost of care savings by 2019 with annual savings of $85 million thereafter to help sustain Colorado’s model. By expanding access to integrated care, SIM is intended to improve the experience of care for consumers as well as the health of the overall population. In short, the Test Award will accelerate Colorado’s progress toward becoming the healthiest state in the nation. We are thankful for the opportunity and look forward to sharing the lessons we learn along the way.
Project Summary Goal: The goal is to improve the health of Coloradans by providing access to integrated physical and behavioral healthcare services in coordinated community systems, with value-based payment structures, for 80% of Colorado residents by 2019. Approach: SIM has synthesized payment reform, practice transformation, public health, and HIT strategies into a “four-pillar” approach to achieving this goal in Colorado. The SIM office will welcome 163 cohort-2 practices in September, which maps to its goal of working with 400 practice sites and four community mental health centers during its four-year time frame. The goal, as stated earlier, is to help practices integrate behavioral and physical health in primary care settings and to test alternative payment models from 2015 through 2019. The team continues to refine its approach with stakeholder input and an ongoing assessment that has helped identify areas of
Page 5 of 239
vulnerability that have been addressed in cohort-2 and will continue to be assessed to ensure that the SIM initiative provides practice sites with a sustainable plan for integration.
Page 6 of 239
b. End state vision Multi-payer participation The SIM team has worked with the Multi-Payer Collaborative (MPC) every step of the way to redesign the program for the second and third cohorts so that it ensures sustainable integration of physical and behavioral healthcare. Team members present data during monthly meetings, identify priorities for payers when it comes to the accomplishment of milestones and collaborate with the group to identify which practice activities might warrant additional financial support in the future. The team continues its work to improve communication between payers and providers to identify and explain value-based payments that are used to “support” the work practices do in SIM and to provide data aggregation tools that will help providers negotiate mutually-beneficial contracts that reward value-based care. The team launched a Multi-Stakeholder Symposium in January 2017 to bring payers and providers together to discuss ways they can improve relationships and streamline communication to develop a mutual understanding and appreciation for what it takes to transform medical practices and integrate care. In year 3, cohort-1 practices will use a data aggregation tool (Stratus™) that will help them identify cost and utilization trends and improve their ability to look at patient populations through a preventive care lens. This tool will complement the coaching practices receive from practice facilitators (PFs) and clinical health information technology advisors (CHITAs), which helps them translate data into actionable information as they deliver whole-person care that improves patient outcomes and lowers or helps avoid costs, a goal that appeals to payers and provider alike. The SIM team will continue to develop its plan to design business supports that help providers succeed in APMs. This was outlined in the original plan and is part of the contract with the University of Denver Department of Family Medicine. The team continues to hear about a need for help with practice budgets, recognizing how you prove return-on-investment and the ways in which practices can successfully negotiate value-based contracts with health plans as well as practice vendors. The team will continue to revise the business support offered to SIM cohorts to ensure value. The SIM team is also pursuing electronic health record (EHR) affiliate groups and exploring ways to help practices capitalize on their EHR investments, which will help with this effort since the need for help with contract negotiation spans all aspects of practice management. We believe this is a key component to helping providers succeed in APMs. The SIM team is also investing in a new consumer engagement strategy to help build awareness among consumers about the move from volume- to value-based healthcare. The goal is to engage consumers differently in their healthcare so they seek providers who integrate care and are active participants in the care plans that are developed and the healthcare that is received. Our goal is to empower consumers so they play a larger role in the process of practice transformation by participating as informed leaders in SIM workgroups, etc.
Value-based payment models The SIM initiative, which will reach 400 primary care practices and four community mental health centers (CMHCs) during its four-year timeline, has extended its influence through local public health agencies and regional health connectors. More information about this can be found in the Practice Transformation and evaluation sections.) SIM will measure its ability to influence the expansion of alternative payment models (APMs) by working with payers to obtain the number of practice sites participating in alternative payment models and the percentage of patients in each level of APM. This has been a struggle for the SIM team though ongoing efforts are proving fruitful. The SIM team published a payer framework online this year that outlines the different APMs that payers are using to support SIM practices. Page 7 of 239
Coordinated care from providers who are accountable for quality and total cost SIM practices receive monthly coaching support from PFs and CHITAs, who help care teams assess processes and approaches to ensure they deliver the highest quality of care. One coach described herself as a translator because, she said, she helps practices “prove” that they deliver high-quality care by assessing data and processes to identify areas for improvement as well as celebration as teams make improvements that will help them sustain their efforts. SIM practices are required to report clinical quality measures (CQMs) (Appendix S3), and the SIM team has learned a great deal about the challenges practices face when it comes to using electronic health records (EHRs) to support these efforts. In year 3 the team hopes to dig into this issue and identify ways to help support practices in their ongoing quest to use EHRs as effective tools to help them collect, report, and analyze their CQMs. These CQMs were streamlined in year-two to align with other federal initiatives and reduce provider reporting burden. These efforts have been well received by providers, who cite ongoing challenges with the time it takes to report data in different ways, and has helped providers recognize synergies between federal programs. The SIM team is also investigating how to use health information technology funds to support a statewide repository for the collection and use of CQMs, which is outlined in detail in the HIT section. This will contribute to the team’s ongoing efforts to create a sustainability plan. SIM practices received their first customized cost and utilization reports in April 2017, and licenses to the Stratus™ data aggregation tool in May. These two complementary tools help SIM practices assess their costs and compare them with groups in their specialties and regions. A comparison of these tools (Appendix B1) helps identify their unique value.
Population health and health system transformation The SIM initiative continues to expand its reach across the state through its investments in local public health agencies (LPHAs) and regional health connectors (RHCs), a new healthcare workforce that helps care teams identify and connect patients to community resources (see plan for improving population health section).The SIM initiative also serves as a model for new state initiatives, such as the TeamBased Care (TBC) Initiative, and others. For example, a representative from the TBC reached out to the SIM team to ask for guidance with integration efforts. A meeting has been set for May. SIM will be able to measure and align efforts for the greatest collective impact through a “Coordinated Community Systems Index” that will be created by TriWest, the state’s independent evaluator, in the fall of 2017. This index will combine data from these sources: key informant interviews with LPHAs, behavioral health transformation behavioral health transformation collaboratives (BHTCs), and RHCs, monthly RHC report data from CHI, quarterly LPHA and BHTC grantee report data from CDPHE, network analysis from CHI, environmental scan findings from HMA, as well as population health indicators and Colorado Health Access Survey data. Themes will focus on collaboration efforts and ratings at the community level. Data will be associated with SIM practice sites and CMHCs in communities to assess the degree of coordination between population health partners and efforts and SIM practice sites and CMHCs. More information about the index can be found in the defining and measuring coordinated community systems part of the evaluation section. SIM’s population health workgroup has also commissioned a research project to identify behavioral health integration initiatives in the state, which will help align efforts and build a list of best practices that will help sustain the delivery of whole-person care in the future. More information about this work can be found in the plan for improving population health section.
Page 8 of 239
Transformed health information technology and analytics statewide The SIM office has spent a significant amount of time researching the needs and challenges of creating a health information technology (HIT) strategy that will help SIM practices achieve their goals and contribute to a statewide solution. The team works with several state agencies, including the Office of eHealth Initiatives, the Office of Information Technology and others to align efforts and build on existing frameworks. The HIT strategy will include a telehealth plan that will help extend patient access to integrated care. The SIM team has gathered a group of subject matter experts to hear about successes and challenges with existing telehealth programs across the state and will collaborate on a solution that fits SIM’s goals and helps pave the way for sustainability. The SIM office's HIT work acknowledges the challenges with information sharing and data sharing that can help or hinder payment reform (alternative payment models) and delivery reform efforts. The HIT programs related to data extraction and aggregation emphasize interoperability, and leverage existing technology and infrastructure to promote a sustainable and modular solution that meets and adapts to changing needs that will continue to be addressed after the SIM initiative ends. With the eCQM and data aggregation solutions that SIM has funded and developed, we can expect to see the following results: Providers can share their data with minimal effort; Payers are able to trust the data and release performance-based payments; Behavioral and physical health providers can share data (with patient consent) to provide care that is appropriate and effective. Learn more about these ongoing efforts, which will take shape in year 3 of the initiative, in the HIT section.
Overall summary The SIM office has worked closely with a large group of stakeholders to ensure that the four-year initiative to integrate behavioral and physical health and help providers succeed in alternative payment models lays the groundwork for sustainable success. The team continues to work closely with providers, health plans, and practice transformation organizations to improve communication about what it takes to integrate care, how integration improves health outcomes and avoids or lowers healthcare costs and the ways in which practices can collect, report and use data to negotiate mutually-beneficial, valuebased contracts with health plans. Success in each of these categories relies on developing new skill sets and redesigning traditional approaches to delivering healthcare. The first year and a half of implementation has helped the team identify areas for improvement, which were addressed for cohort2. and reinforced the value of the multi-stakeholder approach to practice transformation work. The Colorado team is in a unique position to create a model that can be replicated across the country because of its scope of work, which encompasses all aspects of the healthcare delivery system, and the involvement of public and private payers. Each payer is using its own APM to support the work that SIM practices are doing, and their involvement in the MPC, commitment to streamlining quality metrics and providing access to data aggregation opens new doors for effective dialogue between these two partners will help ensure sustainability of these integration efforts. Providers recognize the value of integrated care, which they describe as the “right way to care for patients,” and acknowledge that delivering “whole-person care” helps improve outcomes, reduce or avoid costs, and enhance the morale of care teams. Strong demand for cohort-2 illustrates continued interest in this approach to healthcare reform that puts providers in the driver’s seat and enhances the partnership between providers and payers. This integration work forges new pathways in healthcare circles because it prompts providers, payers and patients to reevaluate their traditional roles and Page 9 of 239
embrace change, which is difficult to do and harder to sustain. The SIM team continues to see data that reinforces early signs of success and believes that as healthcare providers see the rewards of providing integrated care — in healthier patients who are more engaged in their care — the term “whole-person care” will become nationally recognized as the best way to deliver healthcare. The team also believes that early indications of a positive financial return-on-investment for SIM practices in the first six months of the initiative will lead health plans to embrace this approach to care as they expand their payment models.
Page 10 of 239
c. Updated driver diagrams
SIM TRIPLE AIM SIM GOAL Improve the health of Coloradans by providing access to integrated physical & behavioral healthcare services in coordinated systems, with valuebased payment structures, for 80% of Colorado residents by 2019.
Better Experience of Care Provide access to integrated physical and behavioral healthcare services in coordinated systems with value-based payment structures for 80% of Colorado residents
PRIMARY DRIVER All drivers support each element of the triple aim
Payment Reform Develop and implement value-based payment models that incent integration and improve quality of care
Practice Transformation
Lower Costs
Support practices as they accept new payment models, deliver more comprehensive care, and integrate behavioral and physical health care
$126.6 million in cost savings/avoidance by 2019; $85 million in annual savings thereafter
Engage communities to reduce stigma, promote coordination of health systems, and remove barriers to accessing care
Population Health
Improved Population Health Improvements in 14 practicereported clinical quality measures and aligned population health indicators
Health Information Technology Promote the secure and efficient use of technology in order to advance SIM goals
Page 11 of 239
SECONDARY DRIVER
PRIMARY DRIVER Practice Transformation Support practices as they accept new payment models and integrate behavioral and physical health care
Technical Assistance Provide technical assistance, business consulting, and additional training to primary care and behavioral health practices to promote advancement along a continuum of integrated care Access to Capital Provide improved access to capital via achievement-based payments and competitive small grants designed to mitigate up-front costs of integration Workforce Development Undertake efforts to ensure current and future workforce has training and capacity to support integrated care delivery models Regulation/Oversight Coordinate and align the state’s regulatory and oversight structures, and remove barriers to integrated care and alternative payment models
KEY ACTIVITIES Support 400 primary care practices in advancing integration of behavioral health care Support four Community Mental Health Centers in advancing integration of primary care Disseminate achievement-based payments to primary care practices Disseminate competitive small grants to primary care practices Determine and implement process for sharing list of practices that are in “good standing” in SIM with payers
Identify and address workforce pipeline issues Provide guidance on behavioral health information sharing (including HIPAA and 42 CFR Part 2) to integrated care providers Examine state regulations that impede integrated care delivery and recommend appropriate policy revisions
Page 12 of 239
Primary driver: Practice transformation Support 400 primary care practices in advancing integration of behavioral healthcare TECHNICAL ASSISTANCE
Continue to support 92 SIM-participating primary care practices from SIM cohort 1. Onboard at least 150 primary care practices to participate in SIM cohort 2 in September 2017. Release Request for Applications in Spring 2018 to recruit approximately 150 additional primary care practices to participate in SIM cohort 3. Train Practice Transformation Organizations to provide practice facilitation, Clinical Health Information Technology Advisors, and other technical support to SIM-participating primary care practices. Focus PTO support on implementation of the revised set of 10 Practice Transformation Building Blocks. Hold twice-yearly Collaborative Learning Sessions for participating practices. Update the practice transformation implementation guide and toolkits to assist practices in advancing toward the revised set of 10 Practice Transformation Building Blocks for Cohorts 2 and 3. Align SIM practice transformation support with support offered by CPC+ for practices participating in both initiatives. Disseminate online training modules to support SIM-participating practices in achieving greater integration. Support four Community Mental Health Centers in advancing integration of primary care Colorado Behavioral Health Council to continue supporting four community mental health centers, including progression along the revised Practice Transformation Building Blocks. Sites to implement reporting recommendations and processes suggested by Health Management Associates during the no-cost extension. Sites continue to support patients that are enrolled in the integrated care model. Sites to propose sustainable alternative payment models.
Page 13 of 239
ACCESS TO CAPITAL
Disseminate achievement-based payments to primary care practices Create system to attest to completion of key practice transformation activities and milestones tied to achievement-based payments of up to $13,000 for cohort-2 practices and disseminate payments to practices via The University of Colorado. Determine achievement-based payment structure for Cohort 3 practices. Disseminate competitive small grants to primary care practices Continue to disseminate payments to cohort-1 practices that were selected to receive Small Grants during Award Year 2 and collect final reports from grantees. Work with partners at The Colorado Health Foundation and other key stakeholders to revise the Small Grants Request for Application (RFA) based on feedback from cohort 1. Release small grants RFA in early winter 2017 and fund approximately 30 cohort-2 practices with small grants of up to $40,000 to implement behavioral health integration goals outlined in their practice improvement plans.
WORKFORCE TRAINING AND DEVELOPMENT
Determine and implement process for sharing list of practices that are in “good standing” in SIM with payers Work with payers and practice transformation stakeholders to determine process for attesting that practices are in “good standing” (based on progress toward achieving practice transformation milestones identified as priorities by payers and achievement of other key activities). Provide list of practices that are not in good standing to payers on a quarterly basis. Individual payers will determine how practice standing may affect payments. Identify and address workforce pipeline issues Use the new Colorado Department of Public Health and Environment (CDPHE) Provider Directory to identify key workforce pipeline issues. Participate in the Colorado Workforce Development Council's Healthcare Sector Partnership monthly check in calls, work with governor’s Workforce Cabinet, and continue partnering with DORA and NGA to develop strategies to best address identified issues.
Page 14 of 239
REGULATION/ OVERSIGHT
Provide guidance on behavioral health information sharing to integrated care providers Create interactive webinar presentation and discussion with panel that comprises an expert in behavioral health information sharing policy, a behavioral health provider, and a primary care provider. HIEs can separate the relevant 42CFRII data in operation, and only release that data where a release is present. This technology has been demonstrated in a pilot that is intended to be expanded into a statewide plan. More information about all of this is in the white paper (appendix H3). CO is working on a state definition of the 42CFRII rule. Definitions are steeped in legislative actions, which would involve Kyle Brown in the governor's office. Goal: Consensus driven, research informed, recommendations to come from the SIM office, which is coordinating with the Office of eHealth Innovation (OeHI) and the Health Information Office (HIO) in this effort. OeHI might address the issue of uniformly with the eHealth Commission rolling out guidance about how stakeholders in the state should interpret 42 CFR Part 2. The SIM Policy and HIT workgroups will continue to engage members to solicit stakeholder feedback on how a uniform interpretation would be useful, as necessary. Respond to community needs by hosting webinars with an equally qualified panel to provide robust information and explore issues brought forth by the integrated care community. Examine state regulations that impede integrated care delivery through telehealth and recommend appropriate policy revisions. Examine state regulations that impede integrated care delivery and recommend appropriate policy revisions Monitor scope of practice and licensure requirements. Compile and disseminate resources that providers can use to address policies that impede delivery of integrated care. Work with Colorado Department of Health Care Policy and Financing (HCPF) to evaluate the need for potential Medicaid waivers or state plan amendments (i.e., Section 2703 Health Homes).
Page 15 of 239
KEY ACTIVITIES SECONDARY DRIVER PRIMARY DRIVER Population Health Engage communities to reduce stigma, promote coordination of health systems, and remove barriers to accessing care
Provider Education Develop educational opportunities for providers that focus on screening, prevention, and special populations
Support for Community-Level Health Promotion Efforts Support communities to coordinate with health systems and employ strategies to reduce stigma, raise awareness, and promote health, based on local needs
Population Health Monitoring Use public health data to track trends in the behavioral and physical health of the population
Disseminate online Provider Education Modules to primary care providers Identify and address key barriers to implementing SBIRT Disseminate resources for Behavioral Health Providers integrating into the primary care setting Deploy Regional Health Connectors to coordinate activities between providers, the public health system, and community resources Fund Local Public Health Agencies and Behavioral Health Transformation Collaboratives to implement strategies that reduce stigma, increase screening, or promote behavioral health Issue a call to action based on results of an environmental scan of behavioral health initiatives, for the purposes of sustainability and planning for future efforts Work with state and local public health agencies to jointly advance regulatory initiatives that improve population health Monitor health outcomes on a population health level related to areas of behavioral and physical health aligned with 14 clinical quality measures
Page 16 of 239
Primary driver: Population health
PROVIDER EDUCATION
Disseminate online Provider Education Modules to primary care providers CDPHE to disseminate online training modules that address pregnancy-related depression, obesity & depression, and depression in men to at least 100 primary care providers. Office of Behavioral Health (OBH) to disseminate online courses related to substance use disorders, behavioral health in the senior population, and trauma-related issues, to at least 100 primary care providers. Identify and address key barriers to implementing SBIRT OBH to conduct an environmental scan of practices to determine key barriers to implementing SBIRT and make recommendations on how to address these barriers. Disseminate resources for Behavioral Health Providers integrating into the primary care setting OBH to compile a resource outlining best practices for behavioral health providers working in the primary care setting. OBH to develop a voluntary certificate program for behavioral health providers working in the primary care setting, to be completed by a minimum of 50 providers.
SUPPORT FOR COMMUNITYLEVEL HEALTH PROMOTION EFFORTS
Deploy Regional Health Connectors (RHCs) Colorado Health Institute will support and provide technical assistance to 21 RHCs. Continue to develop standardized training for RCHs. After selecting host organizations to house RHCs in local communities, work with hired RHCs to develop and set three priority areas of focus for their region. Fund Local Public Health Agencies (LPHAs) and Behavioral Health Transformation Collaboratives (BHTCs) to implement strategies that reduce stigma, increase screening, or promote behavioral health CDPHE to continue disseminating funds to eight (8) LPHAs and two (2) regional BHTC awardees and monitor progress toward goals. The SIM office will continue to create and support collaboration between funded LPHAs, RHCs, and SIM practices regarding coordination of complementary activities and initiatives. Page 17 of 239
CDPHE will work with Health Management Associate to conduct an environmental scan to assess non-SIMrelated behavioral health initiatives across the state. This scan will serve to inform the population health workgroup of gaps or overlapping efforts and inform future efforts of the workgroup and program planning. Issue a call to action based on results of an environmental scan of behavioral health initiatives for sustainability and planning for future efforts The SIM office will contract with Health Management Associates to produce a call to action, based on gaps identified in the environmental scan conducted during the NCE. The population health workgroup will advise on the best way to disseminate the call to action and convene interested partners to discuss next steps. Advance regulatory initiatives that improve population health Partner with CDPHE to implement/achieve policy objectives outlined in the Healthy Colorado: Shaping a State of Health- Colorado’s Plan for Improving Public Health and the Environment 2015-2019 report. Coordinate and align the administration and funding of prevention services.
Monitor health outcomes on a population health level related to 12 areas of behavioral and physical health POPULATION HEALTH MONITORING
CDPHE to provide SIM with updates on all population health metrics listed in the “Core Progress Metrics and Accountability Targets” section of the operational plan as they become available. CDPHE, in collaboration with the SIM Office, will continue to update an electronic, interactive display of population health metrics (VISION tool: https://www.colorado.gov/pacific/cdphe/vision-data-tool) that divides data based on demographics (county, age, etc.) for practices, LPHAs, and other relevant organizations to identify areas of high need.
Page 18 of 239
KEY ACTIVITIES SECONDARY DRIVER PRIMARY DRIVER Health Information Technology Promote the secure and efficient use of technology in order to advance SIM goals
Acquisition and Aggregation of Data From Various Sources Create systems for collecting and aggregating clinical, behavioral health, and claims data
Reporting Develop processes and systems to generate actionable reports that can guide future efforts
Redevelop Shared Practice Learning and Improvement Tool (SPLIT) to house data on practice progress toward practice transformation goals Collect Clinical Quality Measures via Clinical Quality Measures Reporting Tool (QMRT) Support SIM practices and bidirectional health homes in connecting to Health Information Exchanges Create an HIT solution that builds on QMRT to integrate clinical data with claims data Provide baseline and benchmark reports of Clinical Quality Measures and cost and utilization information to practices Clarify state and federal regulations around data sharing, privacy and confidentiality, and patient consent
Telehealth Increase use of telehealth as a means of improving access to care
Expand telehealth for behavioral health services for adult and pediatric populations
Support expansion of broadband to 300 sites throughout the state
Page 19 of 239
Primary driver: Health information technology Redevelop Shared Practice Learning and Improvement Tool (SPLIT) to house data on practice progress toward ACQUISITION practice transformation goals AND Work with IEQ Technologies to redevelop and support the Shared Practice Learning Improvement Tool (SPLIT). AGGREGATION Train Practice Transformation Organizations on use of redeveloped SPLIT. OF DATA FROM Cohorts 1 and 2 practices submit assessments and relevant data via SPLIT. VARIOUS Collect Clinical Quality Measures via Clinical Quality Measures Reporting Tool (QMRT) SOURCES Collect Clinical Quality Measures (CQMs) from SIM-participating practices via QMRT on quarterly basis. Create an HIT solution that builds on QMRT to integrate clinical data with claims data and provides a mechanism for eCQM reporting Convene subject matter experts to make a recommendation on infrastructure design. Issue RFP to select vendor responsible for development of solution(s) that accomplish the above. Work with data architect and vendor to inform design of new solution(s) and inform implementation. Support practices in connecting to Health Information Exchanges (HIEs) Use results of SIM HIE assessment conducted during the no-cost extension to inform development of an HIE strategy for SIM practices. Work with Quality Health Network and CORHIO to promote increased connectivity between SIM practices and HIEs.
Page 20 of 239
REPORTING
Provide baseline and benchmark reports of Clinical Quality Measures to practices Train clinical health information technology advisors to support practices in accessing and interpreting benchmark reports. Continue to provide practices with their clinical quality measures, including a comparison to practice baseline over time. Continue to provide practices with a benchmark report that compares practice with performance of their peers. Create an HIT solution that builds on QMRT to integrate clinical data with claims data Work with stakeholders to determine fields that are most useful to include in for reporting back to practices. Build display capabilities into QMRT+ solution. Clarify state and federal regulations around data sharing, privacy and confidentiality, and patient consent Evaluate policy actions including, but not limited to: Subscription subsidies to health technology platforms and improving a patient centric approach to data sharing across public and private care settings.
TELEHEALTH
Expand telehealth for behavioral health services for adult and pediatric populations Continue to convene a telehealth sub-workgroup to determine how to best implement recommendations outlined in qualitative reports produced by Spark Policy Institute, including the Telehealth Vision and Telehealth Implementation Reports. Release RFP to select a vendor that will implement telehealth work with a focus on behavioral health integration for adult and pediatric populations (various modalities, including but not limited to electronic consultation and collaborative care models will be considered). Support SIM primary care practices in advancing integration of behavioral healthcare through telehealth in addition to in-person patient touches. Support expansion of broadband to 300 sites throughout the state Colorado Telehealth Network (CTN) to identify potential sites from cohort 2 for expanded broadband. CTN to assist sites in acquiring subsidies and navigating process of expanding broadband access.
Page 21 of 239
KEY ACTIVITIES SECONDARY DRIVER PRIMARY DRIVER
Engagement of Public, Private, and Self-Funded Payers Coordinate efforts and garner commitments from a mix of payers throughout the state
Payment Reform Develop and implement valuebased payment models that incent integration and improve quality of care
Movement toward Value-Based Payment Models Payers align to move, in a coordinated fashion, away from fee-for-service reimbursements to value-based payments
Alignment of Metrics Create a common set of measures for value-based payments
Coordinate and align private insurer and Medicaid approaches to payment reform Continue efforts to secure commitments from Medicare, self-insured employers, VA and TRICARE to participate in SIM Leverage State Employee Health Plan to expand state adoption of alternative payments models and drive employer demand for value-based payments Work with Department of Health Care Policy and Financing to align Medicaid payment approaches with SIM initiatives and objectives Ensure that payers support SIM-participating practices with alternative payment models Engage SIM providers in dialogue with payers to inform continued implementation of alternative payment models Ensure that participating payers have access to a common set of clinical quality measures (CQMs) and cost & utilization measures
Page 22 of 239
Primary driver: Payment reform
ENGAGEMEN T OF PUBLIC, PRIVATE, AND SELF-FUNDED PAYERS
Coordinate and align private insurer and Medicaid approaches to payment reform Leverage Multi Payer Collaborative and Multi-Stakeholder Symposiums to align efforts of public and private payers involved in SIM. Payers to continue working toward goals stated in Memorandum of Understanding with SIM office outlining commitment to alternative payment models during bimonthly meetings of the Colorado Multi Payer Collaborative. Continue efforts to secure commitments from Medicare, self-insured employers, VA and TRICARE to participate in SIM Engage in ongoing conversations with CMS regarding Medicare participation in the state in unique ways, in collaboration with their all-payer unit Continue engaging the Colorado Business Group on Health, an organization representing more than 30 selffunded groups from across the state, to explore the expansion of integrated care and alternative payment models (APMs) to this market segment. Leverage state employee health plan to expand state adoption of APMs and drive employer demand for value-based payments Continue to work with the Department of Personnel Administration (DPA) regarding the use of contractual language/stipulations regarding integrated care and APMs as part of the state employee health plan reprocurement process.
Page 23 of 239
MOVEMENT TOWARD VALUEBASED PAYMENT MODELS
Work with Department of Health Care Policy and Financing to align Medicaid payment approaches with SIM initiatives and objectives The SIM office will participate in HCPF planning and discussions around proposed payment models for ACC Phase II and the CCBHC grant, and other proposed initiatives as they arise. Engage SIM providers in dialogue with payers to inform continued implementation of alternative payment models Convene quarterly in-person Multi Stakeholder Symposiums that provide payers, practice transformation organizations, and providers with an opportunity to discuss and inform implementation of APMs. Continue to address payment reform topics during bi-annual Collaborative Learning Sessions. Payers support SIM participating practices with APMs The SIM office will engage with the University of Colorado and payers around selection processes for practices in cohorts 2 and 3. Payers to review practices accepted into SIM cohorts to determine which practices within their provider networks they will support with APMs. Payers to reach out to supported practices and negotiate agreements around APMs. All participating payers utilize common set of clinical quality measures (CQMs) and cost & utilization measures
ALIGNMENT OF METRICS
Payers will continue work with internal informatics teams, SIM office, SIM Evaluation Specialist, and the selected SIM evaluation vendor to establish accountability targets for the number of lives covered by APMs through SIM. The SIM office will report SIM CQMs to payers annually. Report cost and utilization measures to each practice site. Work with members of the multi-payer collaborative to provide a data aggregation solution to SIM- primary care practices and community mental health centers that reflects payer data. Work with payers to collect data for state and federal evaluation needs.
Page 24 of 239
d. Updated master timeline Governance, Management and Decision Making
NCE (Feb. 2017 – Jul. 2017)
Year 2 (Feb. 2016 – Jan. 2017)
Year 3 (Aug. 2017 – Jul. 2018)
Year 4 (Aug. 2018 – Jul. 2019) Changes, Short Description
Goal: Oversee, coordinate and ensure success of all SIM project deliverables Q1
Q2
Q3
Q4
Q5
Q6
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Convene Advisory Board Meetings
x
x
x
x
x
x
x
x
x
x
X
x
x
x
Convene Steering Committee Meetings
x
x
x
x
x
x
x
x
x
x
X
x
x
x
Convene SIM Workgroup Meetings
x
x
x
x
x
x
x
x
x
x
X
x
x
x
Stakeholder Engagement
NCE (Feb. 2017 – Jul. 2017)
Year 2 (Feb. 2016 – Jan. 2017)
Year 3 (Aug. 2017 – Jul. 2018)
On track; Advisory Board will continue to meet every other month in AY3 On track; Steering Committee will continue to meet every other month in AY3 On track; all workgroups continue to meet quarterly (with exception of Payment Reform workgroup, which has been changed to Multi-Stakeholder symposiums as described in the governance section)
Year 4 (Aug. 2018 – Jul. 2019)
Goal: Ensure the active engagement of all stakeholders, including but not limited to payers, providers and key contractors Q1 Monthly SIM Newsletter (all stakeholders)
x
Q2 x
Bimonthly Newsletter to Providers SIM Charter outlining stakeholder workgroup objectives posted to SIM website (https://www.colorado.gov/healthinnovation/workgroups)
Q3
Q4
Q5
Q6
Q1
Q2
Q3
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Q4 x
x
SIM to co-host Medical Home Community Forum
x
Articulation of SIM Strategies
x
Q1
Q2
Q3
Q4
x
x
x
x
x
x
x
x
On track (changed from quarterly to monthly based on stakeholder feedback) On track (New activity added since original Operational Plan) Complete
x
x
x
x
x
x
x
x
x
On track; the forum continues to convene quarterly. Population Health Program Manager will take point on coordinating forums in AY3 Complete
Page 25 of 239
SIM Outreach Tour
Outreach tour postponed to align with delayed launch of Cohort 2. Stops to be made in non-metro locations throughout 2017. While outreach was conducted throughout 2016 on an ad hoc basis, a formal tour was not executed during this time, The SIM Office is in the process of selecting a vendor to complete work that will directly engage consumers, including recruitment of consumers for the Consumer Engagement Workgroup. SIM Conference planned for late 2017 to convene all workgroup stakeholders. Conference was not held in Year 2 due to start of multi-stakeholder symposiums (see addition to payment reform section). On track, public comment logs continued.
x x
Identification of strategies to Directly Engage Consumers (e.g. during SIM Outreach Tour, consumer section of SIM website, via existing consumer groups etc.)
x
x
Convening of Annual SIM Conference
Public Comment Logs (include a list of comments submitted via the SIM website and public comment made at meetings) maintained by SIM Office
x
x
Population Health Plan
x
x
x
Year 2 (Feb. 2016 – Jan. 2017)
x
x
x
NCE (Feb. 2017 – Jul. 2017)
x
x
x
Year 3 (Aug. 2017 – Jul. 2018)
x
x
X
x
x
Year 4 (Aug. 2018 – Jul. 2019) Changes, Short Description
Goal: To develop and execute on a plan for improving population health with Governor’s Office, key state agencies and stakeholders Q1
Q2
Q3
Q4
Q5
Q6
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Regional Health Connectors (RHCs) First RHC Cohort Selected Second RHC Cohort Selected
Complete
x
Third RHC Cohort Selected
RHC Annual Workplan
Complete
x
Complete
x
x
x
x
Y2 Workplan complete. Due to the NCE, the annual workplan for Y3 and Y4 were moved back six months.
Page 26 of 239
RHC Quarterly Meetings
x
x
x
x
Convening of RHC Technical Advisory Group
RHC Quarterly Reports
x
x
x
x
x
x
x
x
x
x
x
X
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
X
x
x
RHC Final Report and Sustainability Plan
x
Grants to Local Public Health Agencies (LPHAs) Announcement of selected LPHAs
x
Awards made to selected LPHAs
x
LPHAs implement award-funded activities
x
x
x
x
x
x
x
x
x
X
x
x
x
x
x
x
x
x
x
x
X
x
x
Grants to Population Health Collaboratives Announcement of selected First Cohort Collaboratives
x
Awards made to selected First Cohort Collaboratives
x
Collaboratives implement award-funded activities
x
On track On track, the TAG consists of RHCs and key stakeholders. Meets regularly to provide guidance on implementation On track; reports include key metrics. As of May 31, reports will include updates on RHC priority areas and progress made toward those On track; annual workplans are due annually, as noted above, whereas this activity will occur once during close out and is noted as such in 2019 Delay of funding release from CMMI pushed timelines related to grantees back in Y2. (Budgets were submitted to OAGM, but took over four months for unrestriction to occur. Delays were in part due to challenges resolving what defined “unallowable” expenses. Additionally, the volume of requests coming in to OAGM from other states created substantial delays). Work is now on track.
Provider Education CDPHE Provider Education Plan reviewed and finalized Launch of Obesity and Depression, Depression in Men, and Pregnancy-Related Depression (PRD) modules
Dissemination of online training modules
Complete
x x
x
x
x
x
x
x
x
x
x
x
X
x
x
PRD module released, others delayed due to contracting issues (further detailed in the Plan for Improving Population Health) PRD module released, others delayed due to contracting issues (further detailed in the Plan for Improving Population Health)
Page 27 of 239
Provide information and resources about pregnancy and substance use to all providers involved in the SIM initiative
Distribute state guidelines for psychotropic medications for children
Develop an on-line substance use disorder course for primary care providers
Complete x Psychotropic medication module complete and hosted on CU eLearning website. New 2017 guidelines awaiting approval from CDHS Director. Substance abuse module complete and expected to go live on CU eLearning platform by end of August 2017.
x
x
x
Enhance and expand the work of SBIRT
x
Develop an education course to address trauma and trauma related issues
x
Develop on-line course for senior behavioral health issues and intervention strategies
x
Develop a voluntary certificate for Integrated Behavioral Health Staff
x
x
x
x
x
x
x
x Shifted to December 2017 due to complexity of subject.
x
x On track; contract for AY3 will include specific intermediary steps for planning, including an analysis of other existing programs and stakeholder engagement regarding the ultimate format of the end product On track
x
Develop a set of Best Practice Guidelines for Behavioral Health staff working in Health Settings.
x
Convene best practices symposium for Behavioral Health
x
New activity added since original Operational Plan. On track; SIM Office currently exploring possibility of aligning with the Collaborative Family Health Care Association Annual Conference, which may be held in Denver
Environmental Scan and Call to Action CDPHE to identify vendor and scope of work for environmental scan
x
Complete. New activity added since original Operational Plan
Page 28 of 239
Vendor to conduct key information interviews and a literature review and report out on the environmental scan that identifies gaps and opportunities for sustainability of SIM goals Prepare a written call to action that addresses multiple sectors and potential resources for recommended activities
Complete x
x
x On track x
CDPHE and SIM Office to support adoption of call to action and identify appropriate actions that promote sustainability based on findings of the environmental scan
x
Practice Transformation Plan
NCE (Feb. 2017 – Jul. 2017)
Year 2 (Feb. 2016 – Jan. 2017)
x
x
Year 3 (Aug. 2017 – Jul. 2018)
On track; specific steps will be identified based on results from activity above
x Year 4 (Aug. 2018 – Jul. 2019)
Status Goal: Provide intensive support to practices to integrate behavioral health and primary care Q1
Q2
Q3
Q4
Q5
Q6
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Practice Transformation Organizations (PTOs) Onboarding and training for PTOs
x
PTOs matched to primary care practices
x
x
PTOs conduct readiness assessments using Shared Practice Learning Improvement Tool (SPLIT)
PTOs deploy practice facilitators and Clinical Health Information Technology Advisors (CHITAs) to support practices
x
SIM Office convenes regular PTO Office Hours
x
Complete. All PTOs have been selected and trained. No new PTOs will be accepted. Complete for Cohort 1. PTO matching for Cohorts 2 and 3 has been postponed in accordance to the delayed start of these Cohorts. Complete for Cohort 1. Assessments for Cohorts 2 and 3 has been postponed in accordance to the delayed start of these Cohorts. The Readiness Assessment for Cohort 1 is included as Appendix T1.
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
On track; all Cohort 1 practices are currently matched with a PTO On track; new activity added since original Operational Plan
Practice Transformation Primary Care Cohorts x
Update Project Management/Operational Plan Practice Cohort 1 practices selected and onboarded
x
x
Postponed until end of NCE Complete
Page 29 of 239
SIM Implementation Guide and Toolboxes available to Cohort 1 practices
x
Complete x
Revisions made to Implementation Guide and Toolboxes to reflect revised Practice Transformation Building Blocks
x E-Learning courses disseminated (released incrementally)
x
Practices convene for Collaborative Learning Sessions (CLS)
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x Define method of determining which practices are in “good standing” under revised SIM framework and milestones
Clinical Quality Measures reporting
x
x
x
x
x
Conduct Open Door Forum/Webinar for cohort 2
x
RFA for Practice cohort 2
x
Practice cohort 2 selection
Practice cohort 2 begins
List of cohort-2 practices “in good standing” provided to payers.
x
x
x
x
x
X
x
x
x
x
x
New activity added since original Operational Plan. Marjie Harbrecht has been contracted to support this work and a practice algorithm for implementation has been drafted On track; six modules live on SIM e-learning website. SIM practices also have access to 4 HIT modules and 12 PCMH modules On track; Cohort 1 practices have attended two CLS events thus far. Cohort 2 practices will begin attending CLS events in November, 2017. On track; the SIM Office is working with partners at the University to outline this criteria. An explanation will be included in all notification packets to accepted Cohort 2 practices in July. On track All activities for Cohort 2 were postponed by six months to account for the NCE and to avoid conflicting with CPC+. An in-depth explanation of the decision to delay is provided in the Health Care Service and Delivery section of the plan. The SIM Office is working with members of the multi-payer collaborative to determine the best process for sharing this list.
Page 30 of 239
With stakeholder input, identify a patient experience of care measure.
Added since initial draft of AY3 plan. All activities for Cohort 3 have been postponed by six months to align with the NCE On track; the SIM Office is currently working with partners at the University of Colorado to determine an exact timeline for Cohort 3 recruitment and implementation that will allow for sufficient time to close out the SIM cooperative agreement. Timeline anticipated by end of NCE.
x
Conduct Open Door Forum/Webinar for cohort 3
x
RFA for Practice cohort 3 Practice cohort 3 selection Practice cohort 3 begins
x x x
Small Grants to Primary Care Practices
RFA for Practice Transformation Small Grants Released
x
Funds distributed to awardees
x
x
x
Awardees submit annual reports to SIM Office
On track for Cohort 1 (47 awardees have received funds). Release of RFA and funds for Cohort 2 and 3 postponed to align with delayed starts of these cohorts.
x
x
x
x
x
New activity added since original Operational Plan.
Bi-Directional Health Homes Health Home Pilot Sites begin Health Homes Peer-Supported Learning Groups
Complete
x x
x
x
x
Health homes patient enrollment and initial primary care visits
x
x
x
Patient-specific and population-based data collection underway
x
x
x
x
x
x
x
x
x
x
x
On track Complete (though working with Health Management Associates to determine final count) The SIM Office is working with HMA to identify a strategy for data collection, as outlined in the narrative of the Health Care Service Delivery Models section of the plan
Page 31 of 239
Health Home sites fully operational and the model in full implementation
Health Home Clinical Quality Metrics reporting
CBHC conducts site visits to CMHCs
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
CMHCs complete assessments and practice improvement plans with Practice Facilitator
x
CMHCs complete project plans outlining specific goals and next steps
x
Health Home sites develop and submit final reports on all defined performance metrics, outcomes, cost savings, and lessons learned Payment Reform
NCE (Feb. 2017 – Jul. 2017)
Year 2 (Feb. 2016 – Jan. 2017)
Year 3 (Aug. 2017 – Jul. 2018)
x
x
x
x
Changes, Short Description
Q1
Q2
Q3
Q5
Q6
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4 Complete Challenges encountered by payers in running attribution delayed identification of practices until May, 2016. Complete
x
Payers submit description of payment models that will be used to support SIM practices to the SIM office as an addendum to MOU.
Payers determine: 1) whether they can report attributed lives in practice based on four LAN framework categories; 2) whether they can report attributed lives in non-SIM participating practices.
Q4
x
Payers identify SIM practices they will support with alternative payment models (APMs), in conjunction with SIM office selection of initial cohort.
Engage in ongoing conversations with CMS regarding Medicare participation in the state in unique ways, in collaboration with its all-payer unit.
On track
Year 4 (Aug. 2018 – Jul. 2019)
Goal: By 2019, payers serving a majority of Coloradoans will reimburse practices for integrated physical health and behavioral health services in shared risk and savings programs
Payers sign Memorandum of Understanding with SIM Office
On track; previous delays due to release of funds Delayed; after HMA facilitates consensus among CMHCs for reporting, CQM reporting will begin in year 3 Added since initial draft
x
x
x
x
x
x
x
x
x
x
The SIM Office is still in communications with CMS. Competing priorities around CPC+ roll out and changes in administration extended the anticipated timeframe for discussion into Y3 Complete; final data collection template sent to payers in Oct 2016
Page 32 of 239
x
Payers report on the following, annually: # of SIM and statewide practices in each APM category; # of attributed lives in SIM and statewide practices, by each APM category; payments to SIM and statewide providers in each APM.
x
x
x
Determine expansion of RISE and Stratus tool licenses to practices participating in first SIM cohort.
x
x
x
x
x
x
Continue outreach/engagement with self-insured employers, VA, and TriCare.
x
x
x
x
x
x
x
x
x
x
Work with HCPF to align Medicaid payment approaches with SIM initiatives/objectives; explore need for additional federal authorities as part of ACC Phase II, including Section 2703 Home Health or other waivers.
x
x
x
x
x
x
x
x
x
x
x
x
Support ongoing dialog with state employee health plan administrators to expand/drive adoption of integrated care delivery and value-based payments.
x
x
x
x
x
x
x
X
Work with payers and the University of Colorado to establish processes, criteria for the selection of practices for SIM cohorts 2 and 3.
Leveraging Regulatory Authority
x
x x
Year 2 (Feb. 2016 – Jan. 2017)
x
NCE (Feb. 2017 – Jul. 2017)
Year 3 (Aug. 2017 – Jul. 2018)
x
Delayed; updated annually; clarified data points; some payers have submitted CY2015 baseline data and the SIM Office is working with others to report baseline and year 1 2016 data Contracting delays with Best Doctors (the vendor for Stratus) extended this process. Cohort 1 practices are now on track to receive licenses by the end of NCE On track re: self-insured plans (the SIM Office continues to make progress with the Colorado Business Group on Health) Delayed re: TriCare and the VA (competing priorities with the MultiPayer Collaborative have delayed this outreach. The new SIM Strategy and Policy Manager will conduct outreach to the VA and TriCare to determine next steps) On track; conversations are ongoing. The SIM office is currently working to address issues related to eCQM reporting of alternative payment models Activity adjusted from original Operational Plan to reflect current goals Payers are on track to indicate support of Cohort 2 practices by July 2017. Delayed start of Cohort 2 RFA postponed this process accordingly.
Year 4 (Aug. 2018 – Jul. 2019)
Page 33 of 239
Changes, Short Description Goal: Use a range of legislative, regulatory, and policy levers to advance SIM goals and objectives and the achievement of the Triple Aim Q1
Q2
Q3
Q4
Q5
Q6
Develop a sustainability plan to ensure successful implementation and impact beyond the term of the cooperative agreement
Monitor policy barriers identified by SIM workgroups and analyze and recommend potential policy actions utilizing the SIM policy framework
Q1
Q2
Q3
Q4
x
x
x
x
Q1
Q2
Q3
Q4
x
x
x
x
x
x
x
x
x
x
Monitor legislative activities at state and federal level to identify risks/opportunities related to SIM initiatives
x
x
x
x
x
x
x
x
x
x
x
X
x
x
Work with state agencies and other organizations to coordinate/align legislative agendas
x
x
x
x
x
x
x
x
x
x
x
X
x
x
Work with state agencies to consolidate/streamline the fragmented oversight of physical, mental, and substance use providers and programs
x
x
x
x
Identify non-rule barriers (differing payment structures/philosophies, disease-based model of care, operational barriers) to integrated care and recommend policy solutions
x
x
x
x
Clarify state and federal rules regarding information sharing between providers, specifically related to patient privacy and confidentiality and consent
x
x
Use policy levers to remove barriers and advance opportunities for integrated care delivery systems
x
x
x
x
Use policy levers to remove barriers and advance opportunities for alternative payment models
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
X
x
x
x
x
x
x
x
x
x
X
x
x
The SIM Office will fill the vacant Policy and Strategy Manager position during NCE. The Position Description has been adjusted to make the sustainability plan a top priority for AY3. (New activity added to timeline since original Operational Plan) On track (New activity added since original Operational Plan) On track On track Oversight has not been identified as a key priority, however the SIM Office will continue to align and coordinate between these providers and programs On track (timeframe extended to allow for continued consideration of alignment with CPC+ and Medicare Collaborative Care Models) On track (timeframe extended to respond to stakeholder interest in extending webinar series, which began during NCE, that addresses this topic) On track On track
Page 34 of 239
Leverage state resources and capacity as a payer and regulator to advance SIM goals and objectives (state employee health plan, QHP certification requirements) x
x
Evaluate levers advancing health information sharing (i.e., investments in expanding health information data infrastructure, subscription subsidies to health technology platforms, improving a patient centric approach to data sharing among care settings, public and private)
x
x
x
x
x
Monitor federal health IT policy, programs, and standards recommendations and disseminate state-wide
x
x
x
x
x
Evaluate telehealth regulations identifying potential barriers for widespread adoption - reimbursement, prescribing, and home monitoring
Address scope of practice laws, credentialing and/or licensing to accommodate changing workforce
Strategy and Policy Manager to research and identify possible
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
X
x
x
x
x
X
x
x
x
x
x
x
x
x
x
Delayed; The SIM Office is engaged in ongoing conversations with the DOI and DPA, but political uncertainties have hindered headway with these agencies On track (currently partnering with the Office of eHealth Innovation to create a statewide HIT roadmap, which will address this topic). The SIM Office anticipates that this roadmap will be available by the end of June and can be shared with CMMI at that point. On track Delayed. Anticipated completion by end of NCE to inform the Telehealth RFP (see HIT section) SIM Office has decided to narrow focus of this activity to supporting the behavioral health workforce. The SIM Office will work with the Office of Behavioral Health and Workforce Workgroup to address this topic. This is a new activity that has been added since the original submission
Page 35 of 239
Workforce Development Monitoring
NCE (Feb. 2017 – Jul.2017)
Year 2 (Feb. 2016 – Jan. 2017)
Year 3 (Aug. 2017 – Jul. 2018)
Year 4 (Aug. 2018 – Jul. 2019) Changes, Short Description
Goal: Build a workforce that is sufficient in capacity, training, efficiency and effectiveness to provide 80% of all Coloradans with access to comprehensive primary care that integrates physical and behavioral health by 2019 Q1
Perform environmental scan of practices, training and education programs, and workforce partners throughout the state to understand their respective activities for integrated care and create map of these efforts.
Generate policy recommendations as they relate to health workforce innovation throughout the state
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
x
x
x
x
x
x
x
x
x
x
x
X
x
x
x
x
x
x
x
x
x
x
x
X
x
x
x
x
x
x
x
x
Develop resources for SIM-funded practices to support partnerships between primary care and behavioral health providers
Health Information Technology
NCE (Feb. 2017 – Jul. 2017)
Year 2 (Feb. 2016 – Jan. 2017)
Year 3 (Aug. 2017 – Jul. 2018)
Q3
x
Q4
x
On track. Workgroup Co-chair held symposium in November 2016 to address this topic. SIM Office will continue to disseminate findings and use them to inform strategy in AY3 and AY4 On track (recommendations made on an ad hoc basis) On track. The Workforce Workgroup has prioritized this area of work, and will specifically give input on deliverables due from the Office of Behavioral Health (see Practice Transformation – Provider Education section). New activity added since original Operational Plan
Year 4 (Aug. 2018 – Jul. 2019) Changes, Short Description
Goal: Develop a seamless IT infrastructure and data hub that supports the needs of communities in direct clinical care and population health Q1
Q2
Q3
Q4
x
x
x
x
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
x
x
x
x
x
x
x
x
Telehealth Expand Broadband State-wide
Develop State-wide Strategy
x
x
x
x
x
x
x
On track Spark Policy (the vendor for the Statewide Strategy) required extra time to complete deliverables. The Telehealth Strategy was finalized during the NCE
Page 36 of 239
x
Release RFP for implementation of telehealth strategy
Implement Telehealth Strategy to Expand Broadband Statewide
Shared Practice Learning and Improvement Tool Training for Practice Transformation Organizations on use of SPLIT Initial use of SPLIT with first cohort practices
x
x
x
x
x
x
x
Complete
x
Complete
x
Enhancement of SPLIT
x
Continued use of SPLIT to assess practice progress and establish readiness of practices in subsequent cohorts
On track. New activity added since original Operational Plan Extensions of timeframe to complete telehealth strategy pushed back implementation of the strategy accordingly. Timeframe was extended to align with the federal timeline that dictates use of subsidies.
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
The original vendor for SPLIT, Intervision Media, went out of business. A new vendor, IEQ, was selected to redevelop SPLIT and will continue to make enhancements to the original version and support implementation.
Quality Measurement Tool Development (QMRT) Vendor selected for design of short-term QMRT Short Term Solution operational
CQM benchmark report to SIM cohort practice sites
Quarterly collection of Clinic Quality Measures via QMRT
Data Acquisition and Aggregation with QMRT+
Complete
x
Complete
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
On track; DartNet “Practice Performance Registry” report available to practices with their CQM data and aggregate SIM cohort data each quarter. SIM Office is currently collecting feedback from SIM practices regarding these reports and will use it to make adjustments in the future. Continued use of QMRT will be in effect until development of QMRT+ Based on work with HIT stakeholders the longterm QMRT+ may not be a central data hub, but rather a combination of
Page 37 of 239
Develop and implement practice HIT assessment to understand data extraction and reporting, use of registries and HIE connectivity to inform the QMRT + solution
Working with the Colorado data architect, develop Infrastructure Design Recommendation
x
x
RFP process for development of QMRT+
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
QMRT+ Design and Implementation
Quarterly collection of Clinical Quality Measures via QMRT+
Work with payer partners to support data aggregation across payers, including practice level reporting of cost and utilization data to inform care management and identify gaps in care Partners with Colorado Medicaid to maximize connectivity to state HIEs utilizing 90-10 matching dollars when available
x
x
X
X
X
X
X
x
x
x
x
x
x
x
x
x
x
x
x
x
solutions, that will address clinical quality measures and claims data. Work with contractor during NCE will inform what structure the solution(s) take. This topic is further addressed in the HIT narrative of this plan. On track. (New activity since original Operational Plan) Delays hiring a Data Architect resulted in delays in determining design recommendations. The SIM Office, in conjunction with the Office of E-Health, anticipate hiring the Data Architect by the end of NCE and receiving initial design recommendations by Q1 of Y3. Delayed due to lack of Data Architect; SIM office working with vendor to write RFP – anticipated to be released during first two quarters of AY3 Delayed due to lack of Data Architect and initial recommendations Delayed due to lack of QMRT+ development. QMRT will be used to collect CQMs until QMRT+ is available. New activity added since original Operational Plan). See Payment Reform section for more details. On track. (New activity added since original Operational Plan)
Page 38 of 239
Program Monitoring and Reporting
Goal: Develop both process and outcomes measures to track progress toward the Triple Aim All Payer Claims Database & Medicare Data (CIVHC)
Q1
Q2
Quarterly APCD Data extracts for state-led evaluator and actuary
x
Annual APCD data extracts for federal evaluator
x
Establish, test, implement primary care attribution methodology
x
x
Bi-annual primary care attribution update
Establish, test, implement CMHC attribution methodology
NCE (Feb. 2017 – July 2017)
Year 2 (Feb 2016 – Jan 2017)
Q3
x
x
x
Q6
x
Q1
x
Q2
x
Q3
x
Q4
x
Year 4 (Aug. 2018 – Jul. 2019)
Q1
x
Q2
x
Q3
x
x
x
x
x
x
x
x
x
x
x
x
x
X
x
Bi-annual CMHC attribution update
Claims-based clinical quality measure proxy development and calculations
Q5
x
x
x
Q4
Year 3 (Aug. 2017 – Jul. 2018)
x
x
x
x
x
Changes, Short Description Q4
x
On track; listed as “APCD data pull” in original Ops Plan timeline, added clarity On track; extracts were originally scheduled for 3x per year; federal evaluation confirmed only need once annually Complete; listed as “Attribution strategy identified” in original Ops Plan timeline, added clarity; delivered final attribution methodology in Sep 2016 On track; CIVHC will run attribution for each new cohort and after each annual practice roster update with NPIs Delayed; ran preliminary CMHC attribution Jun 16; will finalize after HMA facilitates consensus during NCE Delayed; will run biannually after final methodology established during NCE, to align with primary care schedule Development complete, reporting on track; delivered breast and colorectal cancer screening measures for CMMI and 2015 baseline proxy measure report in Jan 2017; will update with Medicaid BHO encounter data during NCE; will deliver
Page 39 of 239
CIVHC annual work plan update CIVHC monthly report
x
x
x
x
x x
x
Medicare data extract for SIM data aggregation
annually when full calendar year data becomes available On track
x x
x
x
x
x x
x
x
x
x
x
x
x
x
x
x
x
On track Pending CMS approval of strategy
Actuarial Reporting (Milliman) Quarterly aggregate SIM cohort cost & utilization reporting
x
x
x
x
x
x
x
x
x
x
x
x
Quarterly individual SIM practice site cost & utilization reporting
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Semi-annual Actuarial Cost & Utilization Reporting
x
APCD analysis reporting
x
Pooling Reporting
x
x
x
Credibility Reporting
x
x
X
Member Attribution Logic Testing
x
x
x
X
x
Risk Adjuster Model Reporting
x
Projected Cost & Utilization Report
X
Cost Savings/Avoidance & ROI Analyses Report MACRA report
x
x x
x
x
X x
x
On track; will report to CMMI when full CY2015 baseline data available (Q1 2017 report) On track; rolling out to practices Apr 2017 with full baseline data On track; contain additional actuarial measures that feed into cost savings/ROI analysis Complete; ran analysis during year 1 and Y2Q1 Delayed; combined with credibility reporting for Y2Q1; will resume annual reporting schedule after NCE Delayed; combined with pooling reporting for Y2Q1; will resume annual reporting schedule after NCE Complete; CIVHC will run bi-annual attribution moving forward Delayed; delivered preliminary report in year 1; will resume annual report after NCE, if payers and stakeholders want to pursue common risk adjustment methodology On track; informs subsequent cost savings/ROI calculation On track; first report Jun 2017 Complete; ad hoc report to get landscape of
Page 40 of 239
Predictive Model Reporting
x
x
x
Payment Model Reform Reporting
x
x
x
Annual Summary Reporting
x
x
x
practices participating in various APM initiatives Delivered general report Apr 2016 and depression predictive model Jan 2017; will resume annual report after NCE, if payers and stakeholders want to pursue On track; will resume annual report after NCE On track; will resume annual report after NCE
x
State-led Evaluation (TriWest) External Evaluation Vendor Contracted
Complete
x
Initial work plan
x
Complete
Revised evaluation framework
x
Complete
Revised logic model
x
Complete
Revised methodology
x
Complete
Initial central repository of measures
x
On track; delivered first report Y2Q3 and will update annually Complete
Plan for capturing baseline data
x
Complete
Annual Data Analysis Plan
x
Initial establishment of baseline
x
Quarterly rapid-cycle feedback report
x
x
x
x
x
X
Annual report
x
Draft sustainability plan
x
x
x
x
x
x
x
x
x
X
x
x
Final sustainability plan
x
Final SIM evaluation report
x
Delivered draft; will update with full CY2015 APCD data On track; listed as “quarterly report” in original Ops Plan timeline, added clarity; delivered report structure Aug 2016 and first Q3 rapid-cycle report Oct 2016 Delayed; will maintain Feb 2016 - Jan 2017 annual report timeframe, but won't deliver until Aug 2017 (after NCE) On track; will deliver preliminary Aug 2017 and revise May 2019 On track; will deliver Jun 2019 On track; will deliver final evaluation report at end of grant period
Page 41 of 239
eCQM technical assistance (Mathematica)
Development of 4 non-eCQM measure specifications and guidance
x
x
Complete; moving forward with developmental screening measure in 2017 On track
x
Feasibility assessment for eCQM reporting and training/TA for CHITAs
x
x
Data aggregation
Stratus licenses for SIM cohort 1 practice sites, quarterly data refresh
x
x
Re-procurement of data aggregation tool for SIM cohorts 2 and 3
x
x
x
x
x
x
x
x
x
On track; cohort 1 practice sites will receive licenses May 2017 through end of participation in SIM On track;
CMMI Reporting Clinical quality measure reporting
x
x
x
x
x
x
Cost and utilization reporting
x
Access to care reporting
x
Population health reporting
x
x
x
Payer/payment model participation reporting
Model participation reporting (practice transformation, population health, HIT)
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
X
x
x
x
x
x
x
x
x
X
x
x
On track Delayed; waiting on full CY2015 baseline data from APCD; will deliver measures to CMMI in Y2Q1 report Delayed; waiting on full CY2015 baseline data from APCD; will deliver measures to CMMI in Y2Q1 report On track; report annually as part of Q3 CMMI report Delayed; working with payers to collect CY2015 baseline data and year 1 2016 data; will collect annually On track
Page 42 of 239
B. General SIM policy and operational areas a. SIM governance 1. Management structure and decision-making authority Governor’s office engagement The Colorado State Innovation Model (SIM) office was established by an executive order issued by Governor John Hickenlooper in March 2015. Since this time, the governor’s office continues to play a crucial role in overseeing and providing guidance for implementation of the SIM initiative. While the Colorado Department of Health Care Policy and Financing (HCPF) serves as the fiscal administrator for SIM and employs SIM staff, the governor’s office directly employs Barbara Martin, RN, MSN, ACNP-BC, MPH, SIM director. David Padrino, chief of staff to the lieutenant governor, and deputy chief operating officer, meets regularly with Barbara to provide guidance and leadership for the initiative. The SIM office has an interagency agreement with the governor's office to evaluate the SIM director’s performance, which ensures a direct line of sight into SIM progress. It also ensures an alignment of strategic goals and that SIM complements the state’s broader healthcare agenda. View the updated milestones (adult and family; pediatric) which were amended after evaluating its first implementation year. The governor’s office will also manage a SIM request for proposal and contract for a vendor that will assist with consumer engagement this year. The governor appoints members of the SIM advisory board, which provides “advice, oversight, and guidance for the operation of the SIM office and the management of grant funds… [and] recommendations about how to better integrate behavioral and physical health in Colorado.”1 Four of the 13 seats2 are reserved for members of the governor’s cabinet – the executive director of Colorado Department of Human Services (CDHS), executive director of the Colorado Department of Public Health and Environment (CDPHE), executive director of HCPF, and the commissioner of insurance. In Award Year3 (AY3), the SIM office will work with Romaine Pacheco, director of the governor’s Office of Boards and Commissions, to fill any vacancies on the advisory board (including the vacancy created when Cara Beatty left UnitedHealthcare) and to ensure its ongoing success. The SIM initiative is also closely connected with the office of the lieutenant governor. Donna Lynne, DrPH, was sworn in as Colorado’s 49th lieutenant governor and chief operating officer May 12, 2016. Prior to assuming her roles in Colorado state government, Dr. Lynne served as executive vice president of Kaiser Foundation Health Plan Inc. and Kaiser Foundation Hospitals, and as group president responsible for its Colorado, Pacific Northwest and Hawaii regions. Since taking office, Dr. Lynne has leveraged her expertise in the healthcare sector to offer crucial strategic guidance to the SIM team. In January 2017, Dr. Lynne participated in the inaugural SIM Multi-Stakeholder Symposium, which convened more than 80 representatives from SIM payers, practices, and practice transformation organizations. Later, Dr. Lynne met with Colorado SIM payers to discuss key payment reform efforts and gain a better understanding of the Multi-Payer Collaborative (MPC). In AY3, Dr. Lynne will continue to meet with SIM payers and key stakeholders to ensure that SIM efforts are aligned with other payment reform efforts throughout the states.
1
Executive Order B 2015-001. The Executive Order creating the Advisory Board (EO B 2015-001) was amended September 2015, to increase the number of members from 9 to 13. 2
Page 43 of 239
Kyle Brown, the governor’s senior health advisor, will continue to serve as the chair of the consumer engagement workgroup, sit on the steering committee, and act as a liaison between the Governor’s office and SIM throughout AY3. Barbara Martin, RN, MSN, ACNP-BC, MPH, SIM director, regularly participates in meetings of the governor’s healthcare cabinet. These meetings provide a crucial forum to create synergies between state agencies and health policy priorities including those outlined in the governor’s State of Health report. Barbara will continue to participate in these meetings throughout AY3. Multiple points of intersection between the SIM team and Governor’s office ensure that the Governor maintains a direct line of contact, communication, and input into the initiative, which is a natural convener of state agencies and other stakeholders to reach consensus and alignment around the state’s healthcare priorities and overall goals.
Governance, decision-making and stakeholder representation In AY3, The SIM office will continue operating under the following governance structure, designed to engage stakeholders, create avenues for constituent groups that implement the objectives of the program to provide input and sustain a collaborative environment for the initiative:
SIM office The SIM office oversees the initiative and is responsible for coordinating efforts with other state agencies, including HCPF, CDHS, CDPHE, the Colorado Department of Regulatory Agencies (DORA), and The Department of Personnel and Administration (DPA); consulting with all relevant stakeholders, including representatives from public, private, and nonprofit healthcare sectors; and facilitating and coordinating communications between state departments, external stakeholders, and the Centers for Medicare and Medicaid Services (CMS). SIM office roles and responsibilities include: Page 44 of 239
●
Coordinating with Center for Medicare & Medicaid Services (CMS), Office of the National Coordinator (ONC) and the Colorado governor’s office to ensure all deliverables are met; ● Establishing standards for the SIM initiative; ● Executing and monitoring vendor contracts; ● Reporting on progress toward SIM goals and objectives; ● Ensuring all legal, regulatory, and administrative requirements are met; and ● Hiring or contracting staff, as needed, to fulfil the work outlined above. In AY3, the SIM office will continue to oversee and support stakeholder workgroups, the steering committee and the advisory board. Each workgroup has an assigned SIM office staff member, who is responsible for: providing administrative support; answering SIM-related questions (e.g. project scope, program policies, and procedures); and facilitating communication and collaboration within and across workgroups. Collectively, the SIM office staff works to ensure that stakeholders engaged at each level of the governance structure have the resources and support needed to successfully meet their defined goals and objectives so the SIM initiative can advance in a timely and efficient manner.
Workgroups SIM workgroups continue to form the core of the SIM governance structure. The workgroups are designed to provide a forum for stimulating ideas and discussions on how to advance SIM’s goals and objectives. Workgroup members are tasked with identifying specific activities and/or action items, and making recommendations to the steering committee, advisory board, and ultimately the SIM office. The SIM office, as the sponsoring authority for the SIM initiative, holds ultimate decision-making authority, and is responsible for executing the recommendations made by any entity within the governance structure. Each workgroup continues to be led by two co-chairs and supported by a program manager from the SIM office. (Please see the stakeholder engagement section of the operational plan for a detailed description of the workgroups and their charters.) While the SIM initiative has achieved a high-level of retention for workgroup members, in AY3 the SIM office will continue to fill vacancies created when workgroup members transition off workgroups or when workgroups identify an area of expertise needed by the group. The process for recruiting workgroup members will continue to be conducted via a competitive application process based on the candidates’ subject-matter expertise.
Repurposing of the payment reform workgroup Since drafting the original operational plan, the SIM office decided to disband the payment reform workgroup. The addition of quarterly multi-stakeholder symposiums that convene payers and practices (see stakeholder engagement section for more information) to the initiative’s stakeholder engagement process, combined with ongoing bimonthly meetings of the MPC (See payment models and service delivery models section for more information) created significant opportunities to discuss payment reform strategies and issues. As a result, members of the payment reform workgroup were no longer clear on a distinct role and purpose of their group and expressed a need for more payment reform expertise on other SIM workgroups. Some members also expressed a concerned about stakeholder burnout due to the overlap between other groups. After speaking with key stakeholders, including the co-chairs of the payment reform workgroup, the SIM office decided to dissolve the workgroup and asked members to participate in the Multi-Stakeholder Symposium, as appropriate, as well as fill key vacancies on other workgroups. The co-chairs agreed to continue participating in steering committee meetings to ensure that a payment reform perspective was still represented on that group.
Page 45 of 239
Steering committee This group is made up of the co-chairs of each workgroup, and is charged with: ● Reconciling issues and timeline dependencies identified by the SIM office or workgroups; ● Establishing quality metrics for the SIM initiative; ● Developing mitigation strategies for identified risks; and ● Ensuring that information is communicated across workgroups. The committee plays a critical role in coordinating the activities across SIM workgroups. The SIM office created separate workgroups for each of the model’s key components so each group could focus on its area of expertise. The office was aware of the risk that each group could become isolated from the greater mission and had the potential to duplicate efforts. The steering committee is tasked with identifying key dependencies between workgroups and ensuring they are moving forward in a coordinated and complementary fashion. In addition to discussions on cross-cutting issues, this committee also serves as a forum to address topics that cannot be resolved at a workgroup level. It can also refer difficult issues to the advisory board for further guidance and recommendations. The steering committee will continue to meet every other month in AY3.
SIM advisory board This group provides oversight and guidance for the operation of the SIM office and management of SIM grant funds. Members are appointed by the governor to serve four-year terms. As initially outlined in the March 2015 executive order, the board had nine positions: ● The director of the SIM, who will serve as the chairperson; ● A representative with experience or knowledge of behavioral health; ● A representative with experience or knowledge of primary healthcare; ● A representative with experience or knowledge of healthcare delivery; ● A representative with experience or knowledge of Health Information Technology (HIT); ● The executive director of HCPF, or his or her designee; ● The executive director of the CDHS, or his or her designee; ● The executive director of CDPHE or his or her designee; and ● The Commissioner of Insurance, or his or her designee. The board added the following four positions in November 2015: ● A representative of a statewide health insurance carrier; ● A representative of the statewide association of hospitals; and ● Two representatives of consumer interests. A list of current advisory board members is attached as Appendix G1. It will continue to meet every other month in AY3.
Quality Assurance Committee The University of Colorado has convened a Quality Assurance Committee to review practice and Practice Transformation Organization (PTO) progress. While not convened by the SIM office, this committee provides critical recommendations to the SIM office on quality assurance processes and a crucial avenue for ensuring sufficient achievement in the area of practice transformation. More information about the committee is detailed in the Quality Assurance Section. A roster of committee members is attached as Appendix Q.
Statewide Health Insurance Carrier Representation: In March 2017, Dr. Cara Beatty, a representative of a statewide health insurance carrier, resigned from Page 46 of 239
the advisory board after leaving her position with UnitedHealth Group and taking the role of president and chief medical officer (CMO), SCL Physicians (SCLP), for SCL Health. However, Dr. Beatty plans to stay involved throughout AY3. While the change in position precludes her from officially sitting on the board, she will continue to attend meeting in a liaison capacity. In the first quarter of AY3, the SIM office will work with the Governor’s Office of Boards and Commissions to fill Dr. Beatty’s vacancy.
Programmatic, Financial and Communications Oversight HCPF is the designated fiscal agent for SIM Model Test award. All vendor contracts to implement the SIM model must therefore go through HCPF’s procurement process. All vendors must abide with terms and conditions contained in the SIM Notice of Award and the CMS Standard Grant/Cooperative Agreement, as well as any additional state agency requirements imposed by HCPF. Contracts for SIMrelated work are primarily deliverable-based and contain a detailed description of a vendor’s responsibilities for implementation of specific program components, costs/finances for activities, and expectations regarding ongoing communication with the SIM office. As sponsoring authority for the SIM initiative, the SIM office maintains ultimate responsibility for the execution and monitoring of all vendor contracts, and ensuring successful and timely completion of all project deliverables. The SIM office will continue to coordinate implementation activities across key program areas with state agencies involved in the administration or regulation of Colorado’s healthcare system, including HCPF, which administers Medicaid; CDPHE, which provides public health and environmental protection services; CDHS, which oversees behavioral health and social services; DORA, which oversees the regulation of insurance and professional licensing; the Division of Insurance (DOI), which regulates the health insurance marketplace; and DPA, which administers state employees’ health benefits.
Coordination of Private and Public Efforts The SIM office will continue to engage private and public stakeholders in all stages of planning and implementation of the test model. The SIM governance structure purposely includes representatives of public and private organizations in all workgroups, the steering committee and advisory board. Examples of private efforts with which the SIM office collaborates are outlined by primary driver below.
Practice transformation The SIM office was awarded a $3 million grant from The Colorado Health Foundation to provide SIM primary care practices with competitive small grants to advance behavioral health integration. The SIM office has made awards to 27 practices with funds from The Colorado Health Foundation, and will continue to make new awards throughout AY3. The SIM program implementation manager regularly meets with The Colorado Health Foundation to ensure that the continued evolution of the small grants program aligns with the strategic goals of both organizations. Staff from The Colorado Health Foundation have attended practice transformation workgroup meetings and receive regular rapid-cycle feedback reports on the SIM initiative. Key leaders from the SIM office and the foundation jointly make decisions regarding use of funds. The SIM office remains in close contact with other foundation partners via the Early Childhood Mental Health Funders network. SIM received a $200,000 grant from a group of funders (The Colorado Health Foundation, Rose Community Foundation, Aloha Foundation, and Community First Foundation) to advance its multi-payer approach. Funders dictated that the SIM initiative included a focus on pediatrics populations, including that at least 15% of the first cohort must be pediatric practices. While the grant concluded in July 2016, the SIM director continues to present at monthly meetings of this network to ensure that the initiative is aligned with other state efforts. Throughout AY3, the SIM director will leverage this group to identify other potential avenues for public-private partnership. Page 47 of 239
Payment reform In February, 2016 seven public and private payers signed a Memorandum of Understanding (MOU) with the SIM office indicating their commitment to working collaboratively with SIM to transform the way physical and behavioral healthcare are delivered and financially supported in the practice sites selected for SIM within these networks. These payers include: ● Anthem Blue Cross Blue Shield ● Cigna ● Colorado Choice Health Plans ● Health First Colorado (Medicaid) ● Kaiser Permanente ● Rocky Mountain Health Plans ● UnitedHealthcare These payers are collaborating to: ● ●
Focus on primary care practice sites and behavioral health settings seeking to integrate care; Support providers in delivering and coordinating integrated care that improves population health, and increases quality while reducing costs; ● Increase providers’ abilities to manage whole-person care; ● Develop necessary infrastructure to support integration and delivery of whole-person care; and ● Encourage practice sites to continually evolve towards higher-levels of integration through transformation of care delivery support by alternative payment models (APMs). These payers come together during monthly meetings of the MPC, a self-funded, self-governing entity voluntarily formed by payers to develop organizational alignment and consistency around the support of SIM as well as the Comprehensive Primary Care Plus (CPC+) initiative. While a more comprehensive picture of SIM’s work with the MPC is detailed in the Payment models and service delivery models section of this plan, Colorado’s ongoing engagement of payers via the MPC, as outlined in the MOU, represents a crucial strategy for coordinating private and public efforts around key test model components. The MPC will continue to meet on a bimonthly basis in AY3. In AY3, SIM will continue to conduct broad outreach to the state’s largest payers, and engage the selffunded business community to drive demand for integrated behavioral health in the Administrative Service Organization/Third Party Administrator market. In AY2, the SIM office presented to the Colorado Business Group on Health (CBGH), a non-profit organization that serves as the voice of market-based, employer driven approaches to lowering costs and improving quality. The organization engages more than 30 public and private members. In AY3, the SIM office will continue to communicate with the CBGH to educate the group about the benefits of driving employees to providers who deliver “whole-person care,” and finding ways to engage the self-insured market. The SIM Strategy and Policy manager will outline a strategy no later than May 2018 to engage state employer health plans and other self-insured plans in SIM-related efforts, including outlining the health and cost benefits of integrated care and practice transformation. Within this strategy, SIM will lay out action steps and a timeline for the following: 1) SIM will continue to engage with the Colorado Business Group on Health (CBGH), including setting up a meeting with its new leadership to discuss potential areas of collaboration between the SIM office and self-insured plans. 2) A member of the SIM team will continue to attend CBGH monthly meetings as necessary. 3) SIM will schedule a follow-up meeting with the DPA to assess next steps for engagement and will draft three goals for this outreach 4) In addition, SIM will invite SEHP representatives to the appropriate SIM workgroup meetings. 5) The SIM team will reach out to selfinsured employers that are actively involved in encouraging employees to access integrated care and to tackle mental health stigma in their offices, and the team will align with the Page 48 of 239
National Behavioral Health Innovation Center efforts to engage employers in the state. The SIM team will continue to reach out to TA and other partners for guidance on this complicated issue. In regard to data submission to the APCD, we will continue to monitor discussions between self-insured plans and CIVHC, as this is related to SIM efforts but out of our specific scope of work.
Population health Establishing a strong and ongoing partnership between Colorado’s public health system and the behavioral health and primary care sectors remains crucial to SIM’s efforts to address factors outside the clinical setting – including social, economic, and environmental influences – that influence health outcomes. The plan for improving population health section of the operational plan outlines how CDPHE has created a public-private partnership with the Denver Foundation to issue a joint Request for Application (RFA) that supports population health collaboratives, which include both public and private agencies working together to address behavioral health in their communities. Grants to collaboratives are underway and staff from CDPHE continue to meet with members of the Denver Foundation to align efforts. The Plan for Improving Population Health details how CDPHE has contracted with Health Management Associates (HMA) to conduct an environmental scan and gap analysis of behavioral health initiatives by public and private sectors in Colorado. In AY 3, HMA, in coordination with CDPHE and the SIM office, will issue a call to action designed to activate public and private entities to address unmet needs and determine how to sustain current progress.
Page 49 of 239
Health information technology A central component of SIM is the expansion of the state’s HIT infrastructure to support practice transformation, improve population health, develop shared care planning resources, expand telehealth, and coordinate public health services. As SIM works to create a fully-integrated electronic health care system with statewide reach, public and private collaboration remains essential to achieving our goals.
Office of eHealth Innovation The Office of eHealth Innovation, housed within the governor’s office, will play an important role in strengthening public-private collaboration around HIT initiatives within the state. The Office of eHealth Innovation is tasked with promoting and advancing “the secure efficient and effective use of health information” and coordinating “relevant public and private stakeholders and Health IT programs across state agencies and between state and federal projects.”[1]3 The office, along with a Commission appointed by the governor, will serve as Colorado’s designated entity to participate in the programs of the Office of the National Coordinator for HIT and other federal HIT programs. Public and private collaboration and coordination will figure prominently in several SIM HIT initiatives, including: ● Data Acquisition, Aggregation, & Integration – SIM will be working to collect, aggregate, and integrate clinical, behavioral health and claims data from multiple sources, both public and private, to analyze and report quality and cost measurements and to assess the completeness of the initiative’s integrative efforts and ability to produce predictive analysis. All laws and rules regarding patient privacy will be followed; ● Analytical Reporting – Data extraction, analysis and reporting capabilities created under SIM will need the capacity to provide analytics and reporting for multiple end users, both private and public, including providers, payers, policymakers, and researchers; ● Governance – Policies, procedures, and protocols regarding the overall management of the availability, usability, integrity, and security of health information data in Colorado, developed through the SIM project in conjunction with the Office of eHealth Innovation and in accordance with federal standards and requirements, will apply to both public and private entities; and ● Sustainability - Colorado received federal, state and community funding to build and strengthen local HIT infrastructure, test innovations, and build Health Information Exchange (HIE) capacity; as these sources of grant funding come to an end, the state will need to find a financial mechanism for supporting and sustaining HIT and HIE systems, which will likely include contributions from public and private sources. A more detailed discussion of the Office of eHealth Innovation can be found in the HIT section.
Integration/alignment with existing legislative and executive authority SIM is well aligned with executive and legislative authority. The SIM office was formed with an executive order, and there is statewide support for the work SIM is doing through the legislative branch.
Executive authority Governor John Hickenlooper signed Executive Order B 2015-001 in March of 2015, creating the SIM office and establishing the SIM advisory board. Four of the 13 seats on the advisory board are reserved for members of the governor’s cabinet (as outlined above.) Governor Hickenlooper also signed Executive Order B 2015-008 in October of 2015, creating the Office 3 [1]
Executive Order B 2015-008
Page 50 of 239
of Office of eHealth Innovation (OeHI) and the eHealth Commission. In executive order B 2015-008, OeHI is charged with collaborating with SIM to integrate physical and behavioral health, establish foundational HIT in support of value-based payment, and continue to further define priorities through the state’s HIT roadmap efforts. The OeHI State Health IT Coordinator serves as a co-chair of the SIM HIT workgroup, and advises SIM telehealth efforts.
Legislative authority The SIM office is aware of and in alignment with state legislation that sets the stage for successful healthcare integration in Colorado. Key legislation enacted since the inception of SIM was included in the original operational plan. Since that time, the SIM office is attempting to align with the bills outlined below. In AY3, the SIM strategy and policy manager will review these bills and identify ways in which legislative authority can help sustains SIM’s progress and goals beyond the initiative. HB16-1047 - Interstate Medical Licensure Compact – Removes barriers to providers seeking licensure in Colorado, which had been a major barrier to recruiting and training behavioral health providers in the state. [Workforce workgroup] HB16-1103 - License Pathways for Mental Health Workforce - Clarifies the licensing process for a range of behavioral health providers. [Workforce workgroup] HB16-1168 - Sunset Rural Alcohol & Substance Abuse Treatment Program - Extends the rural alcohol and substance abuse prevention and treatment program (a critical component of behavioral healthcare) through Sept. 1, 2025. [Workforce, Practice Transformation workgroups] HB16-1407 - Extend Medicaid Payment Reform and Innovation Pilot - Removes the date by which HCPF must select payment projects for the Medicaid payment reform and innovation pilot program. This allows HCPF to select new payment projects for the pilot program and removes end dates for pilot programs. [Policy workgroup] HB16-1408 - Cash Fund Allocations for Health-related Programs - Modifies the allocation of cash fund revenues from the tobacco settlement and marijuana taxes to increase access to primary care services across the state (without supplanting general fund appropriations). [Practice transformation workgroup] SB16-069 - Community Paramedicine Regulation – Creates a framework and measures to provide community-based out-of-hospital medical services, and makes an appropriation – expanding access to care. [Practice Transformation] SB16-169 – GOVERNOR VETOED - Emergency 72-hour Mental Health Procedures – The process of vetoing this bill prompted the governor to direct the CDHS to create a taskforce and develop solutions to the problems with using jails to hold mental health patients. It produced this report: https://drive.google.com/file/d/0B5VYtOtGTnaxZ1NCY1A1Rndjem8/view. SB16-169 is relevant to SIM, even though no law was put into effect, because it protects people in mental health crisis from incarceration without treatment. [Policy workgroup] SB16-202 - Increasing Access Effective Substance Use Services – increases access to effective substance use disorder services, a component of behavioral healthcare. [Practice transformation workgroup]
2017 Legislative progress (bills signed into law as of April 10, 2017): HB17-1094 - Telehealth Coverage Under Health Benefit Plans – Clarifies telehealth parity with traditional (in person) services. Legislation passed in 2015 went into effect Jan. 1 and this bill provides context. [Health Information Technology, Telehealth] Page 51 of 239
HB17-1173 - Healthcare Providers and Carriers Contracts – protects health providers when they disagree with, report, or participate in investigations of carriers. These protections are to be explicitly stated in contracts between carriers and providers. [Practice Transformation, Payment Reform] SB17-065 - Transparency in Direct Pay Health Care Prices - Requires healthcare professionals and facilities to publish prices for directly-billed services. The act also prohibits penalties for anyone participating in direct-pay services. (Goes into effect Jan. 1, 2018) [Payment Reform]
Roles and responsibilities of staff and contractors SIM office SIM director Since submission of the original operational plan, the SIM office hired a new director following Vatsala Pathy’s departure in February 2016. Barbara Martin, RN, MSN, ACNP-BC, MPH, has stepped into the role. Ms. Martin has more than 15 years of clinical and leadership experience in healthcare delivery, care coordination, and working across complex systems of care. She received a master’s degree in public health with a focus on population-based policy and systems change work to enhance and improve systems of care delivery in 2013. Ms. Martin has been engaged with the SIM initiative since 2013. As director of the Health Systems Unit at CDPHE, she served on the core SIM team during the grant planning process and led state public health efforts to implement population health strategies to support SIM. She joined the SIM office in 2015 as director of the Transforming Clinical Practices initiative (TCPi) to lead statewide efforts to build a program that helps clinicians and practices transition into new care delivery and payment models. She stepped in as interim director for SIM in March 2016 and was promoted to the director role in September.
SIM staff The roles and responsibilities for all SIM office staff (full-time, temporary and contract) are outlined below. As part of the onboarding and orientation process, staff members have one-on-one meetings with the SIM office director and staff to whom they report directly to review and clarify job responsibilities and expectations. Those responsibilities are outlined in the chart below and in staterequired position descriptions maintained by the HCPF’s Human Resources department and the state’s human resources department. When the last operational plan was filed the SIM office employed nine full-time (1.0 FTE) positions. Since that time, the office has created new staff positions and hired employees to meet needs identified during AY1 and AY2. The SIM office has 11 full-time (1.0 FTE) positions: ● Two were vacated and will be filled by the end of the no-cost-extension (NCE) ● One was previously filled by a contracted employee and will be a full-time SIM office role ● Six partial FTE positions ● Three temporary positions (hourly) We hope to add two more full-time (1.0 FTE) staff positions and one part-time (0.1 FTE) position by the end of the NCE. These positions will ensure support in the following areas throughout AY3. Descriptions:
Page 52 of 239
Delineated Roles and Responsibilities for Existing Full-Time Staff Roles for Existing Staff
(1) SIM Director
(2) Program Implementation Manager (Formerly SIM Operations Manager)
(3) Strategy and Policy Manager (hired—person to start in June)
(4) Administration and Contracts Manager
(5) Population Health and Workforce Program Manager
(6) Data Analyst
(7) Stakeholder Engagement Assistant (8) Administration and Contracts Program Assistant II (9) Communications Coordinator (10) Small Grants Administrator Coordinator (11) HIT Program Manager (previously contract role – vacant)
Responsibilities Oversees the coordination and administration of all aspects of SIM including planning, organizing, staffing, leading, and guiding activities. Ensures implementation and achievement of all planned initiative activities and essential goals. Develops relationships with and creates boards and committees that comprise stakeholders, advisors, healthcare organizations, state and federal agencies as well as representatives from the governor’s office that effectively steer the initiative and help achieve desired outcomes. Determines needs for external vendors to assist with implementation and auditing of the SIM initiative. Represents SIM and publicly communicates goals and opportunities. Holds signing and appointing authority for the office and is accountable for all initiative outcomes. Reports directly to governor’s office.
Oversees implementation of SIM initiative activities. Manages relationships with and between staff and partners, including stakeholders, SIM boards and committees, advisors, workgroup leaders and other entities and individuals who support implementation of the initiative (initiative partners). Manages processes and workflow of the SIM office as they relate to progress of initiative implementation. Oversees development and implementation of a comprehensive shared knowledge database for all initiative partners. Presents on initiative progress to the SIM office, initiative partners and public audiences. Publicly communicates the goals and opportunities offered by SIM. Manages multiple SIM office vendor contracts. Manages the population health and workforce program manager, the stakeholder engagement assistant and the small grants administrator. Reports directly to the SIM director. Develops and maintains expertise on healthcare policy issues related to the SIM initiative, stays abreast of substantive literature and ongoing political and policy developments. Participates in policy-relevant research, analysis and advice on complex policy and regulatory issues in healthcare focusing on policy and regulatory issues that pertain to the integration of physical and behavioral health, data sharing, collection, aggregation, and reporting, and HIT. Analyzes policy and regulatory issues associated with state agencies involved with SIM as well as their federal counterparts. Develops reports, policy documents and other written materials for a wide range of audiences and purposes. Presents to the SIM office, program partners and public audiences. Builds an effective and credible government affairs strategy that identifies and meets the needs of the initiative. Manages the data coordinator, policy analyst and HIT coordinator. Reports directly to the SIM director. Oversees administrative functions of the SIM initiative. Manages continual improvement process for SIM office projects, operations and workflows with the goal of maximum efficiency. Oversees procurement, contract management, and performance for the SIM office. Manages contractual budgets to ensure appropriate expenditures within allocations, identifies additional fiscal needs and prepares appropriate budget requests. Works with appropriate state and federal governmental offices to obtain necessary contract and budget approvals. Manages the administration and contracts manager program assistant and reports directly to the SIM Director. Manages workforce, population health and consumer engagement stakeholder workgroups and sub-workgroups. Serves as workgroup liaison between the SIM office and stakeholders working on physical and behavioral health integration. Partners with healthcare organizations to build, strengthen, and coordinate efforts in the healthcare community. Manages multiple SIM office vendor contracts. Designs strategy, systems, processes, guidelines, rules, and standards that are mission critical and directly affect SIM’s operation and policy. Reports directly to the program implementation manager. Works closely with the evaluation specialist. Researches, reviews, cross-references, and compiles reports from multiple data streams relating to SIM. Helps develop and improve data collection and reporting mechanisms. Presents reports to SIM office workgroups, manages SIM vendor contracts and reports directly to the SIM strategy and policy manager. Works closely with SIM office program managers assigned to each workgroup to ensure appropriate content, communication presentation and documentation of all SIM workgroup meetings. Reports directly to the SIM program implementation manager. Acts as liaison with HCPF contracts and accounting departments. Maintains tracking and archival systems for all SIM office contracts, deliverables and invoices and contract amendments. Manages operating expenditures, such as office supplies. Reports directly to the SIM administration and contracts manager. Provides technical and content development assistance for the public SIM office website. Maintains SIM office SharePoint site, provides design and technical assistance for SIM board and committee meetings and presentations. Performs ad-hoc writing and editing assignments. Reports to SIM communications director. Manages the SIM small grants program. This salary is funded by a grant from the Colorado Health Foundation. Reports directly to the SIM program implementation manager. Provides expertise, support in HIT strategy and coordination. Reports to HIT data strategy program manager.
The five part-time positions: Page 53 of 239
Delineated Roles and Responsibilities for Existing Partial FTE Staff Roles for Existing Staff (1) Communications Manager (0.7 FTE) SIM, .3 FTE TCPI)
(2) Accounting Technician (0.8 FTE)
(3) Evaluation Specialist (.5 FTE SIM)
(4) Purchasing Agent II (0.5 FTE)
(5) Grants Administrator (0.1 FTE)
(6) Budget Analyst (0.1 FTE –vacant)
Responsibilities Manages internal and external communications for SIM including managing media relations, improving and managing external stakeholder communications, managing SIM-related meetings and conferences, and creating communications materials in conjunction with the Governor's Office and HCPF staff and other program partners. Provides management and oversight of the SIM external website, newsletters and other public communications. Manages communications coordinator and reports directly to the SIM director. Works closely with the administration and contracts manager and program assistant. Maintains the accounting setup for the SIM initiative and other SIM program funding sources. Creates accounting reports and ensures that Grant Solutions has been updated to reflect SIM office expenditures in a timely manner. Reports directly to the HCPF Accounting department. Works with external evaluation contractor and external data contractors to analyze the metrics of SIM performance for multiple key performance indicators. Acts as a liaison between various SIM office workgroups and employees to establish clear metrics for reporting. Presents to SIM workgroups boards and committees. Manages multiple SIM vendor contracts and manages the SIM data analyst. Reports directly to the SIM director and to the HCPF chief medical officer and Client and Clinical Care Office director. Works closely with the administration and contracts program manager and other SIM staff managing contracts and purchase orders. Prepares purchasing documents, solicitations and contracts issued by the department. Maintains compliance with state/federal laws, rules, and contracting standards to ensure that contracts protect the interests of the department, the SIM office and the federal government. Reports directly to the HCPF Purchasing and Contracts Department. Oversees the SIM initiative. Will be trained by the SIM administration and contracts manager. Uses the federal grants management portal, Grant Solutions, for SIM purposes. Assists the SIM team with the writing and submission of grant applications, troubleshooting grant issues during implementation and writing and submitting grant reports. Reports directly to the HCPF Grants department. Develops a tracking methodology for the grant award and includes accounting coding, the approved budget, expenditure tracking and other relevant information. Works closely with grant staff to ensure that the budget is not overspent and that there is a mutual understanding of when funds are to be spent. Responsible for reviewing clearance items (contracts, budget submittals, and expenses reports). Works with program and grant staff to develop budget tables and summary documentation for new grant applications. Ensures that calculations are accurate, timely and reflect the needs of the program. Remains updated on the progress of grant implementation once approval is received and provides budget support as needed to implement the initiative. Reports directly to the administration and contracts manager.
Three temporary (hourly) positions:
Delineated Roles and Responsibilities for Existing Temporary Staff Roles for Existing Staff (1) Policy Analyst (this position ends once the new Policy and Data Analyst position is filled) (2) Data Strategy Coordinator (this position will end when the newly created HIT Program Data Strategy Manager position is filled)
(3) Scheduler
Responsibilities Provides policy research and writing support. Reports directly to the strategy and policy manager. Manages the HIT workgroup and sub-workgroup meetings. Serves as workgroup liaison between the SIM office, the office of eHealth commission and stakeholders working to integrate physical and behavioral data. Partners with healthcare organizations to build, strengthen, and coordinate efforts in the healthcare community through effective exchange of clinical and claims data. Manages multiple SIM HIT vendor contracts. Takes actions and issues expert opinions that provide direction for future action. Designs strategies, systems, processes, guidelines, rules, and standards that help SIM meeting its HIT goals. Reports directly to the SIM director. Responsible for scheduling SIM office events between staff and stakeholders. Maintains the HCPF calendar as well as the SIM office calendar to ensure that rooms, necessary equipment for meetings, and supplies are available for the SIM office. Tracks SIM office supply needs and coordinates with the administration and contracts manager for purchasing and invoicing. Reports directly to the SIM director.
Page 54 of 239
The three newly-created positions (to be filled by the end of NCE): Delineated Roles and Responsibilities for Newly-Created Staff Positions (to be filled by the end of May 2017) Newly Created Roles
(1) HIT Data Strategy Program Manager (1 FTE)
(2) Data and Policy Analyst (1 FTE)
(3) Health IT Data Architect (1 FTE)
Responsibilities
Manages the HIT workgroup and sub-workgroup meetings as needed. Serves as workgroup liaison between the SIM office, the Office of eHealth commission and stakeholders working to integrate physical and behavioral data. Partners with healthcare organizations to build, strengthen, and coordinate efforts in the healthcare community through effective exchange of clinical and claims data. Manages multiple SIM HIT vendor contracts. Takes actions and issues expert opinions that provide direction for future action by others. Designs strategies, systems, processes, guidelines, rules, and standards that bring SIM closer to meeting its HIT goals. Reports directly to, the SIM director.
Researches, reviews, cross-references, and compiles reports from multiple data streams as they relate to the functions of SIM. Identify available data resources and gaps in current data, coordinate and/or assist in the development of mechanisms for data collection and reporting, perform advanced dataset manipulation functions (aggregation, normalization), conduct ongoing data quality monitoring, develop presentation of data for end users, act as a direct resource for questions and identifying trends, and coordinate with internal and external evaluators for SIM- related data pools. Provide accurate and timely analysis of policy and programmatic topics that affect the SIM initiative with a focus on practice transformation, payment reform, data sharing, governance and HIT. The Health IT Data Architect will work on the SIM long-term data solution, which requires collaboration with stakeholders, including the OIT, the OeHI, SIM office, and HCPF. This involves meeting with stakeholders, researching and developing architecture, and presenting to business executives. Work will include defining technical requirements and HIT architecture, developing data models, and overseeing the implementation and sustainment of this solution. This work must integrate OIT's statewide architecture and align with OeHI's future vision for HIT in Colorado.
A current organizational chart, list of key staff members, and list of contractors are included in Appendix G2.
External contractors The roles and responsibilities of the vendors/contractors retained to support SIM work are articulated in the executed contract between the state and vendor/contractor. All contracts go through the state procurement process, and are reviewed and approved by CMMI.
Recruitment of staff in support of SIM activities SIM office The SIM office follows state agency protocols to recruit and hire new staff. The SIM office also contacts local education institutions to recruit master’s degree candidates interested in internships with the SIM office (e.g. achieving practicum credits). For state staff who contribute to SIM work as a percentage allocation of their overall work duties (100% or less), specific roles and responsibilities related to SIM are determined by the SIM office and the state agency of employment. They include: ● ● ● ●
Creation of a detailed position description; Posting the description on the state’s jobs website for the requisite time period; Reviewing applications received and identifying top candidates for phone and in-person interviews; and Conducting interviews to evaluate skills and subject matter expertise.
Page 55 of 239
External Contractors External contractors have been identified through the state’s competitive procurement process. In instances in which a specific vendor has unique qualifications to execute specific SIM deliverables within a required time frame, a sole source model might be pursued, as allowed by state guidelines.
Staff Training and Support SIM office All new staff members undergo human resources orientation at HCPF and receive mandatory training on the Colorado Open Records Act, Americans with Disabilities Act, Health Insurance Portability and Accountability Act, and cybersecurity, among others. Staff are also encouraged to take advantage of the free HCPF trainings that help them improve technological, presentation, project management and facilitation skills using new software tools. Program managers also select and attend economical subject matter trainings (approved by the SIM director) to stay current in their fields of expertise. SIM staff receive “on the job” training by attending workgroup, advisory board and steering committee meetings, reading background materials, and shadowing other staff members. The SIM office has developed a set of office policies and procedures, which are stored online and detail the protocols for common daily tasks (e.g. setting up meetings, reserving conference lines, etc.) New staff members are encouraged to reach out to SIM’s extensive network of stakeholders and to other individuals, agencies, and organizations in the state that are pursuing similar initiatives to gain background knowledge and additional subject-matter expertise. The SIM office offers a constant learning environment in which staff regularly share key academic articles, news stories, and research findings with the team. The office also holds biweekly staff meetings, during which team members share information learned at conferences and webinars and update the team on the status of their work projects. Staff are also directed to the technical assistance resources available through CMMI.
External Contractors External contractors are expected to abide by all contract terms, which describe requirements and expectations regarding ongoing engagement with the SIM office in the form of weekly status calls/updates, attending workgroup meetings, and incorporating feedback from SIM stakeholders into contract execution and deliverables, as applicable. In AY3, the administration and contracts program assistant will continue to document contracting processes and develop resources for external contractors.
Monitoring of Continuous Quality Improvements Efforts The SIM office regularly submits metrics to the governor’s office, which used them to help populate the governor’s dashboard, which is monitored by the state’s Performance Management & Operations Division. The SIM office submits metrics on a quarterly basis to HCPF’s department performance plan. A detailed description of SIM’s methods for monitoring quality improvement efforts can be found in the Program monitoring and reporting section of the operational plan.
Page 56 of 239
2. Leveraging regulatory authority SIM remains committed to developing a policy and regulatory framework that supports the integration of comprehensive physical and behavioral health services, strengthens population health, and promotes the expansion of value-based payment structures. The team believes that this will pave the way for innovation, help reach SIM’s goals and advance the Triple Aim. The SIM office plans to engage with multiple regulatory authorities to advance initiatives in the domains outlined below.
Reinforcing accountable care and delivery system transformation The SIM team strives to bend the cost curve by providing Coloradans with access to integrated physical and behavioral health that addresses the health needs of all residents, particularly those with chronic, co-morbid physical and behavioral health issues. Colorado law specifies the type of healthcare entities that must be licensed prior to providing services in the state and requirements for licensure or certification.40 Colorado uses DORA to house nearly all licensing regulations for healthcare providers to minimize regulatory burden, keep licensing costs low, and facilitate collaboration among autonomous licensing boards. The Health Facilities and Emergency Medical Services Division (HFEMS) of the CDPHE issues licenses for the operation of state healthcare entities, inspects entities that serve Medicare/Medicaid clients in Colorado and makes recommendations to CMS regarding certification.41 The goal is to ensure that healthcare entities meet minimum standards of service and quality in compliance with state law and regulations, and measure a provider’s ability to deliver care that is safe and adequate in accordance with state and federal law and regulations. State statute includes a performance incentive for facilities that cooperate with investigations and have minimal or no deficient practices.42 Colorado’s licensing and certification processes do not contain any requirements or incentives aimed at reducing state healthcare costs or promoting coordinated planning around new services and facility construction. The team investigated the use of facility licensing requirements as a mechanism to control healthcare costs and decided not to take this approach, after conferring with stakeholders, which was acknowledged as outside the SIM framework scope last year. SIM is moving forward with its plans to link clinical care to public health and community resources with its local public health agencies and regional health connectors to address “upstream” issues. Learn more about these efforts in the plan for improving population health section. SIM is also engaged with the Colorado Commission on Affordable Health Care, a three-year commission created through bipartisan legislation (SB 14-187) that is analyzing state healthcare costs and will make recommendations to the state legislature. The SIM team will continue to follow the commission’s work, provide comments as appropriate, and ensure the initiative is aligned with its recommendations. The SIM team was a founding member of the Colorado Quality Payment Program Coalition, a group of state organizations that are committed to helping providers succeed with new payment models and gain the skills they need to collect, report and analyze data: http://www.cms.org/communications/coloradoqpp-coalition.
Page 57 of 239
Improving effectiveness, efficiency, and mix of the healthcare workforce Building a healthcare workforce with the capacity, training, efficiency, and effectiveness to support the Colorado Framework integrated care model will be a critical component of SIM’s success. While the overall size of the workforce is appropriate by some measures, rural and frontier regions face shortages of primary and behavioral healthcare providers. In addition, Colorado has a deficit of providers in specific behavioral health specialty areas including psychiatry and professionals with pediatric expertise. Integrated care, the foundational element of SIM, requires a different set of skills, knowledge, and attitudes than those required in traditional models. [Read more about this in the practice transformation article series: http://bit.ly/2kqPCRA.] Most primary and behavioral health providers are not trained to provide integrated, team-based care and might not have the correct competencies. To transform today’s primary care and behavioral health workforce, providers need training and ongoing support to successfully work in integrated settings. Helping tomorrow’s workforce succeed in integrated, team-based care settings requires education, training and residency approaches. Colorado boasts a long legacy of thoughtful and low-burden regulation to achieve public health priorities. SIM continues to work with DORA to build a team-based healthcare workforce that is responsive to patient needs. Other agencies that SIM partners with to ensure that Colorado’s legislative and regulatory infrastructure supports sustainable, long-term integrated care models include: the Division of Professions and Occupations at the Colorado DORA, which regulates more than 50 professions, occupations, and businesses in the state; the Health Equity and Access Branch of CDPHE, which addresses healthcare workforce, planning, and prevention needs in underserved communities; the Colorado Association of Local Public Health Officials (CALPHO), which is the statewide organization representing LPHAs in Colorado; the Colorado Behavioral Healthcare Transformation Council within the CDHS, which addresses issues related to the behavioral health workforce; the Department of Labor and Employment’s Colorado Workforce Development Council (CWDC); the Colorado Public Health Association; HCPF; and professional guilds and provider associations. During the SIM planning process, several barriers were identified in regulatory structures that inhibit collaboration among providers, particularly at financial and operational levels. Statutory provisions regulate providers without reference to their collaboration with other professionals and regulations differ significantly among professions even if they provide similar patient services. In some circumstances, professional regulation differs by the type of practice facility, which causes unnecessary confusion. Current law does not clearly provide the authority to create new facility types that might be necessary for or help facilitate integrated care. Separate authorities for licensing, payment, and compliance of the physical structure often promote “siloed” decision-making by facility type. SIM continues to review statutory and regulatory structures and work with the aforementioned organizations to address barriers, workplace administrative inefficiencies and promote development of an oversight structure that helps deliver team-based care in which practice members – including primary care clinicians, behavioral health providers, care coordinators, community health workers and other non-licensed providers, and non-medical staff – work collaboratively at the top of their licensures and/or scopes of practice, to meet the needs of their practice populations. SIM has also explored mechanisms for strengthening Colorado’s workforce pipeline by developing and expanding provider education and training, and creating additional academic collaborations and programs that support the education of physical and behavioral healthcare providers in integrated environments. To address provider shortage issues, SIM will continue to explore legislative options, such Page 58 of 239
as loan payment programs that incent providers to pursue certain occupations or practice in high needs areas. In alignment with Colorado Public Health Act of 2008 (C.R.S. 25-1-501 et seq.), SIM is funding regional health connectors (learn more in plan for improving population health section) to connect providers with community resources.
Aligning state regulations and requirements for health insurers The Colorado Division of Insurance (DOI) within DORA, is the primary regulator of health insurance carriers in the state, which is structured around key functions, including company licensing, producer licensing, product regulation, market conduct, financial regulation, and consumer services. The DOI’s regulatory role varies across insurance market segments and includes four major responsibilities: rate regulation; consumer protection; financial solvency; and market regulation. There is a unique collaboration between health plans in Colorado and a spirit of collaboration that will help the SIM team make progress toward its goals. Colorado health plans have had an established framework to align efforts since the “Alignment Bill” (HB 13-1266) was passed in 2013 and seven participate in a MultiPayer Collaborative (MPC) that supports SIM. The SIM team works closely with MPC payers to help communicate the benefits of supporting integrated care through data collection and analysis to show how integrated care improves patient outcomes and lowers costs. Colorado SIM will build on public and private payers’ commitments, demonstrated though individual initiatives and joint participation in CPCI and CPC+ to help providers succeed with alternative payment models and ultimately move toward prospective, non-volume based payments. The MPC offers a unique forum for voluntary collaboration and alignment of the state’s major payers around transformation activities, including the provision of enhanced financial, technical, and data support to practices.
Assurance of payment reform alignment The SIM office continues to align clinical quality measures and building blocks that help improve partnerships between health plans and providers. The team recently completed a contract for cohort-1 practices that provides a common data aggregation tool that provides claims utilization data to assure quality and alignment of measures. This type of work helps build a sustainability framework for integrated care because it will help providers use data in effective ways to identify costs of care and highlight ways that providers can tweak processes to improve outcomes and lowers costs. As Colorado payers embrace value-based reimbursement models, the ability for practices to access and use data effectively will become increasingly important. The SIM team has worked closely with HCPF on its Accountable Care Collaborative (ACC) model, which shifts payment from capitation to fee-for-service for behavioral health benefits and represents a significant departure from the current payment for behavioral health. The plan is to move financing for physical and behavioral health benefits under a single framework and address a key issue of payment fragmentation in the system. Members of the SIM team continue to be involved in these discussions, and plans for the second phase of ACC, which beings in 2018. The reimbursement structure would allow for some potential utilization and outcome-oriented elements, including quality metrics, incentive payments, and shared savings arrangements. Another important element of ACC Phase II is to increase collaborative care that takes place beyond the walls of the PCMP office through the creation of health neighborhoods, which would include specialists, hospitals, oral health providers, and other ancillary providers. CDHCPF has started moving toward value-based payments. Page 59 of 239
Integrating value-based principles in health insurance plans Commercial payer commitments to alternative payment models are voluntary though MPC members have pledged continued cooperation for SIM. While the initiative’s approach to payment reform does not require or promote specific payment strategies, such as bundled payments or episodes of care, SIM recognizes existing alternative payment models (APMs—as outlined in the payment models and service delivery models section.). The goal is to help providers succeed in these APMs with coaching that helps them with practice transformation as well as data use so they can progress toward shared savings/shared risk models, and ultimately to prospective, outcome-based payments based on patient populations. Colorado statutes and regulations neither prohibit nor encourage APMs or the use of value-based insurance designs. The SIM team will work with the DOI to identify best practices from the model test and ways to accelerate the adoption of successful approaches.
Integrating transformation-based teachings into medical education programs Colorado has a robust academic training environment of universities, colleges, and educational institutions with two medical schools, a school of public health, two physician assistant programs, seven doctoral psychology programs, four schools offering master of social work degrees, and numerous programs in nursing that add to the capacity of whole-person healthcare teams across the state. Many schools have already developed special training programs or initiatives to support team-based primary care, behavioral health integration, and interdisciplinary training of health professionals. The University of Colorado Department of Family Medicine is a primary partner in advocating this work, and SIM will continue to be a resource for these programs in award year 3.
Page 60 of 239
3. Stakeholder engagement Convening SIM stakeholder workgroups The principal avenue for engaging stakeholders is through these seven, topic-specific workgroups: ● Consumer engagement; ● Evaluation; ● Health information technology (HIT); ● Policy; ● Population health; ● Practice transformation and service delivery; and ● Workforce development. Charters outlining workgroup objectives are published: https://www.colorado.gov/healthinnovation/workgroups. The Colorado State Innovation Model (SIM) is in the process of reassessing its workgroup structure to ensure effective use of time and resources. The team has proposed moving some meetings to bimonthly and has reassigned some volunteers to different workgroups to cross-pollinate ideas and ensure greater buy-in for foundational changes proposed through SIM stakeholders. Four workgroups meet at least once per month while three meet once every other month to disseminate information to stakeholders and encourage stakeholders to make recommendations to the SIM office. Dozens of workgroup meetings were held before and after the award date of Feb. 1, 2015, to refocus stakeholders’ attention to implementation rather than design of the SHIP. All workgroups continue to refine their goals and objectives to align with SIM program implementation as it evolves throughout years two and three. Between June 1, 2015, and Nov. 30, 2015, about 70 stakeholder workgroup meetings were held. From December 2015 through November 2016, roughly 75 additional meetings were held. Moving forward, there are about 66 workgroup meetings planned for 2017. Workgroups currently consist of about 17 members each for a total of 137 participants. Members were initially selected in an open and competitive application process based on their subject-matter expertise and ability to represent key stakeholder groups across the state. The workgroup membership application remains open to ensure continued access to participating in SIM. Membership has been limited to underscore the importance of participation (members are required to attend 75% of all workgroup meetings) and support the nimbleness required to thoughtfully operationalize SIM. During the past year, workgroups have taken time to look at their respective membership rosters and identify areas of expertise that might be lacking. There has been some membership turnover, due to job transition, inability to attend meetings, changing priorities, workgroups have taken the opportunity to ensure that the right people are at the table. In collaboration with the SIM office, new members have been identified. Workgroups are cognizant of the importance of diversity in the room (geographic, background, expertise, etc.) Additional details about workgroup structure and interface with the SIM governance model, see the SIM governance section.
SIM payment reform workgroup update As referenced in the Governance section of the plan, the SIM office decided to repurpose the payment reform workgroup because quarterly meetings of the Multi-Stakeholder Symposium (detailed later in this section) and Multi-Payer Collaborative were sufficient forums through which to address the aims of the stakeholder group. Members of the payment reform workgroup were asked to participate on one of Page 61 of 239
the other seven workgroups that best aligned with their expertise. The goal is to ensure that payment reform discussions are woven throughout the fabric of all SIM discussions to ensure ongoing success of integration efforts. SIM office staff made personal phone calls to each workgroup member to explain the change and to determine what workgroup could best use their expertise. For example, one member of the Payment Reform workgroup who represents a private foundation now sits on the Practice Transformation workgroup, which previously did not have any representation from the philanthropic community. Furthermore, the chair and co-chair of the payment reform workgroup still participate in SIM steering committee meetings to ensure that all workgroups can engage with payment-reform related issues. Finally, many members of the payment reform workgroup will participate in MultiStakeholder Symposium meetings.
Demonstration of diversity The following table demonstrates the distribution of agencies with at least one representative on a SIM stakeholder workgroup. The agencies have a healthcare focus and represent broader topics and interests that support the overall objectives of SIM. The SIM office makes every effort to preserve diversity of workgroup membership as new members are added. Commercial payers/purchasers Colorado Access Kaiser Permanente Rocky Mountain Health Plans UnitedHealth Group Community-based and long-term support providers Community Health Partnership Colorado Community Managed Care Network Colorado Community Health Network Grand County Rural Health Network Greater Metro Denver Healthcare Partnership North Colorado Health Alliance Servicios de la Raza The Chronic Care Collaborative Consumer advocacy organizations Alliance Colorado Center for Health Progress Colorado Center on Law and Policy Colorado Health Initiative The Arc of Colorado Health systems and providers AllHealth Network Arapahoe House Centennial Mental Health Center, Inc. Centura Health Children‘s Hospital Deb Parsons, MD, LLC Denver Health
Page 62 of 239
High Plains Community Health Center Jefferson Center for Mental Health Kaiser Permanente Mental Health Center of Denver Salud Family Health Centers Swedish Family Medicine The Denver Hospice University of Colorado Health (UCH) Higher education University of Colorado College of Nursing University of Colorado School of Medicine Red Rocks Community College Regis University University of Denver, Graduate School of Social Work Local public health agencies Boulder County Public Health El Paso County Public Health Health District of Northern Larimer County Jefferson County Public Health Tri-County Health Department State agencies Colorado Department of Human Services Office of Governor John Hickenlooper Colorado Department of Health Care Policy and Financing State Senate Colorado Department of Labor and Employment Colorado Department of Public Health and Environment Colorado Department of Regulatory Affairs Other Caring for Colorado Foundation Center for Improving Value in Healthcare Colorado Academy of Family Physicians Colorado Association of Addiction Professionals Colorado Behavioral Healthcare Council Colorado Medical Society Colorado Nurses Association Colorado Regional Health Information Organization (CORHIO) Engaged Public Consulting Early Milestones Colorado – LAUNCH Together HealthTeamWorks Health Systems Development, LLC. Milliman Physician Health Partners
Page 63 of 239
Quality Health Network Rose Community Foundation ValueOptions
(For a complete list of SIM workgroup members, see Appendix G3)
Strategy for future engagement The SIM office will continue to convene workgroups at least once a quarter and more often when needed until the end of the initiative. In the first year, the SIM office convened most workgroups at least once per month. In the first implementation year, workgroup convening has changed as outlined above.
Tracking progress and key dependencies across workgroups The SIM office hired a stakeholder engagement program assistant, who tracks progress and key dependencies across workgroups. This position provides day-to-day support for all workgroups and stakeholder engagement events, the steering committee, and advisory board. With a unique vantage point to monitor all work across the diverse workgroups, this staff member can identify areas of potential collaboration and dependency. The program assistant documents and monitors workplans across all groups to identify areas of overlap and potential synergy. In addition, each SIM office staff member who supports a workgroup completes a monthly status summary that outlines progress. The report includes information on areas of collaboration with other workgroups, and identifies possible risks and mitigation strategies. This program assistant also compiles monthly reports and assists in identifying key dependencies across workgroups. These summaries are shared with all workgroup members via email and the designated file-sharing platform (Basecamp) to increase transparency about work done in each workgroup.
SIM multi-stakeholder symposium While payment reform workgroup members were added to other groups to voice the payer perspective across SIM, the SIM team recognized the need to open dialogue between SIM providers, practice transformation organizations, and insurance companies. The inaugural Multi-Stakeholder Symposium took place in January 2017. SIM plans to host these stakeholder meetings regularly to gather as many people as possible, including virtual attendance options. The first meeting was dedicated to focused discussions among attendees, who were seated at tables of eight to encourage open dialogue among representatives from insurance companies, providers and practice transformation organizations (PTOs). Participants were asked to write down ideas—concerns and hopes—for improvements in the following content buckets, which will be compiled by the SIM team for ongoing discussion: ● ● ● ● ● ● ● ● ● ●
Payment Patient experience Resources Practice transformation Social determinants of health Data and evaluation Communication Achieving change Integration Burnout
Page 64 of 239
Representatives from the SIM office collected this feedback, identified themes, and developed target areas to address in the future. The SIM office will address areas of concern for stakeholders and will continue to do so as future meetings take place and themes surface.
Leveraging other stakeholder groups The SIM office recognizes that a wide array of stakeholders has been convened to help accelerate statewide health transformation. Rather than relying entirely on SIM workgroups and events, the SIM office also seeks to collaborate with and leverage these existing forums for stakeholder engagement.
Current state SIM staff members regularly participate in a wide range of stakeholder groups convened by other organizations. Key examples include: ● ● ● ● ● ●
Health cabinet meetings (convened by the governor’s office); Workforce cabinet meetings (convened by the governor’s Office); Colorado Health Extension System (convened by University of Colorado, Department of Family Medicine); MPC meetings (in conjunction with CPC+); State-designated entity (SDE) action committee (state HIT steering committee); and eHealth Commission meetings (convened by the Office of eHealth Innovation).
Strategy for future engagement In addition to continuing engagement in the meetings above, the SIM office will seek to expand its partnership with other stakeholder groups. Key examples of future collaboration include:
Medical home community forum This group, convened by CDPHE, meets quarterly to engage Colorado agencies, families, medical facilities, organizations and policymakers as they implement patient-centered medical home (PCMH) model. To promote alignment between Colorado PCMH initiatives and SIM integration efforts, the SIM office has committed to presenting at all community forum meetings during the initiative. Since the inaugural meeting, SIM office and CDPHE staff continue to meet and partner with CDPHE to run these forums into award year 3. The following list includes tentative topics for the 2017 forums: ●
●
●
March 14, 2017, 4:30-6:30 PM; Lead(s): Caitlin (Evrard) Loyd, Sue Williamson, Bridget Burnett, Molly Yost. o Panel/presentation on the integration of behavioral health into primary care settings with a focus on young children and pregnant women. June 13, 2017, 4:30-6:30 PM; Lead(s): Ellen Kaufmann, Nicole King, Barbara Martin, Kyle Knierim. SIM Evaluation; cohort 1; planning for cohort 2. o CQM data sharing this data with payers (stakeholder key informant interview data and PTO practice facilitators); o How practices are working to meet the CQM, get PTO perspectives; o Panel of CHITAS and PTO Facilitators to share experiences and their perspectives; o Graph that shows the reach of SIM with the LPHAs and practices; and o Update on TCPi. Sept. 12, 2017, 4:30-6:30 PM; Lead(s): Jacqueline Laundon, Ashlie Brown, Caitlin Loyd, Jennie Munthali. Community based connections: LPHAs (MCH and SIM grantees), Regional Health Connectors, RCCOs. Page 65 of 239
●
Dec. 12, 2017, 4:30-6:30 PM; Lead(s): TBD (Susan Mathieu will provide HCPF contact). LTSS alignment with ACC 2.0 implementation.
Engaging consumer groups The SIM office is working with a dedicated team of volunteers on the consumer engagement workgroup, who possess expertise in the field of consumer advocacy. The team has recognized a need to incorporate a wider perspective from the consumer population, particularly those who are insured by Health First Colorado. The team is working on a contract to create a community-driven stakeholder engagement program that would build a base of community leaders who would bring a health equity lens to the ongoing conversations about transforming healthcare delivery systems. With support from the SIM office through July 2017, the applicant or vendor will be able to identify two to three communities with a threshold of SIM practices, active local public health agency grantees and a regional health connector to enable close collaboration to engage consumers as active healthcare leaders in their communities. Community liaisons will be recruited from these target communities and will use a community strengths-based perspective to help patients and community members identify barriers to health, educate them on health systems transformation efforts in their communities, develop their leadership so they engage in SIM’s workgroup structure to influence SIM activities. We will target community members who are participating in value-based payment reform programs and accessing integrated behavioral and physical healthcare. Proposed activities would include: 1) Community identification and initial relationship building; and 2) Intensive community outreach. The scope of work is being reviewed and finalized by the SIM office. The consumer engagement workgroup has given feedback on the direction of this work.
Engaging tribes and the American Indian population Coordination with Denver Indian Health and Family Services, Inc. The SIM office recognizes the importance of engaging tribes and the American Indian Population throughout Colorado in its work.
Strategy for future engagement While the SIM office will maintain its relationship with Denver Indian Health and Family Services, it seeks to expand its engagement beyond the Denver metro area. Further efforts will focus on engaging the Southern Ute and Ute Mountain Ute tribes.
Tribal consultations To date, CDHCPF, CDHS, and CDPHE have signed agreements with the two tribes to hold regular tribal consultations, defined by the State-Tribal Consultation Guide as “the open and mutual exchange of information integral to effective collaboration, participation, and informed decision making, with the goal of reaching consensus on issues.”4 The consultations will help develop a relationship based on trust an effort to understand and consider any effects an undertaking may have on the consulting parties.4 The SIM program implementation manager participated in one tribal consultation with the Southern Ute and Ute Mountain Ute tribes. In the future, the population health program manager will continue to
4
Department of Health and Human Resources, Health Resources Services Administration. “Tribal Consultation Policy.” http://www.hrsa.gov/publichealth/community/indianhealth/tribalconsultationpolicy.pdf
Page 66 of 239
participate in tribal consultations and develop strategies to coordinate and engage with this population.
Engaging the public SIM website The SIM office continues to update and maintain its website: www.colorado.gov/healthinnovation, which serves as a central platform for public-facing information, including: ● ● ● ● ● ● ● ●
Articles about SIM and its mission; Videos and podcasts about the work practices are doing to integrate care and test alternative payment models; Advisory board and workgroup charters; Open funding opportunities (RFAs, RFPs, RFIs, etc.); SIM resources (FAQs, one-page overviews, informational presentations, etc.); SIM newsletters and other healthcare transformation news; Data published by the SIM office; and Public meeting information (detailed below).
Public meetings All workgroup, steering committee, and advisory board meetings are open to the public. The SIM office commits to maintaining the following process for communicating information about meetings: ●
● ● ●
Notification: All public meetings are posted on the calendar section of the SIM website at least two weeks in advance of the meeting. Interested parties can receive updates to the SIM calendar by subscribing to Rich Site Summary (RSS) feed or syncing calendars with the SIM calendar via iCal. In addition, anyone is welcome to sign up for event invites through the public interest form located on the SIM website. Statewide participation: All public meetings have a phone and webinar option so workgroup members and members of the public who live outside the Denver metro area can participate. Public comment period: All public meetings include a time for public comment, and in certain cases, members of the public may be invited to participate throughout the meeting. Meeting recordings and minutes: Minutes and an audio recording of every meeting are posted on the SIM website within one week of each meeting.
SIM videos In addition to a video featuring Governor John Hickenlooper and others active in SIM provided an overview of SIM and its importance to the state in October 2015. In October 2016, the SIM office published the first in a series of three videos that outlines SIM’s mission, its goals and a few of its success stories. The short videos feature many of the faces and voices of people who have been integral in creating, supporting and furthering SIM's mission to integrate behavioral and physical health. They talk about why it matters to healthcare providers, patients and insurance companies that are working with SIM to create sustainable pathways to integration. The most current video series features: ●
What is the Colorado State Innovation Model (SIM)? o https://www.youtube.com/watch?v=6yCxJpMomOg&feature=youtu.be ● Practice transformation and the Colorado State Innovation Model (SIM). o https://www.youtube.com/watch?v=JNInICY9oMw&feature=youtu.be ● Payers on board - Colorado State Innovation Model o https://www.youtube.com/watch?v=_2ZcOr3Gg9I&feature=youtu.be More videos are planned in the coming year, including videos featuring the work of the RHCs.
Page 67 of 239
SIM social media, newsletters, and podcasts SIM has bolstered social media efforts during the past several months. The team maintains an active Twitter account (@SIM_Colorado), a LinkedIn account (https://www.linkedin.com/companybeta/15244374/?pathWildcard=15244374) and a Facebook page (https://www.facebook.com/colorado.sim.7) to engage diverse audiences. Social media analytics have been compiled since October of 2016. The full reports can be seen in Appendix G4. The SIM office emails a monthly stakeholder newsletter via Constant Contact to a list of more than 1,500 subscribers. It is intended for a wide range of SIM stakeholders and communicates key updates, such as the release of RFPs and upcoming deadlines. In addition, a provider newsletter is published every other month and focuses on pertinent information for SIM practices. Archived copies of these newsletters are available: https://www.colorado.gov/healthinnovation/news-7. The SIM office also launched a podcast series “Innovation Insights” that provide brief, informative and informal information for SIM stakeholders and practices. The first podcast overview: “What are local public health agencies (LPHAs) and how do they help Colorado State Innovation Model (SIM) practices integrate behavioral health and primary care? Get details on how LPHAs are laying the foundation for better health throughout Colorado in this discussion with Jackie Laundon, CDPHE, and Heather Grimshaw, SIM.” All podcasts are available: https://soundcloud.com/user-118904494.
Logging public comment The public can submit questions or comments through the SIM website and during public meetings. In addition, the SIM office created a public comment log to track these comments, allow staff members to identify trends or themes to address and ensure that timely responses are received.
Annual SIM outreach tour The SIM office has committed to implementing an annual SIM Outreach Tour in which key members of the SIM staff will engage stakeholders outside of the Denver metro area in their local communities.
Future SIM outreach tour approach We are evolving the original SIM outreach concept to involve regional health connectors (RHCs), local public health agencies (LPHAs) and SIM cohort-1 practices that will tell their stories about how SIM has worked in their practices. The intent is to dovetail with existing meetings scheduled by partners or medical societies and coordinate scheduling with RHC and LPHA partners. This approach is also meant to foster a sense of collaboration and coordination among SIM partners to showcase the wide-reaching aspects of SIM. The SIM office is reaching out to medical societies to identify dates for upcoming meetings, and partners at CDPHE are helping connect team members with the LPHA administrative lead to identify upcoming events across the state for possible presentation opportunities. The goal is to identify a unique element of the SIM initiative to highlight for each outreach efforts. For example, the Delta Medical Society has invited SIM to talk at its monthly meeting. There are plans to highlight the work that LPHAs and RHCs are doing during the May 4 event and highlight provider resources. RHCs completed their environmental scans in March 2017 and we plan to leverage each RHC’s three Page 68 of 239
goals to customize future presentations. The SIM office is also exploring the idea of having SIM booths/exhibits at appropriate conferences in Colorado and will continue to collaborate with LPHAs and RHCs who can talk about their work to highlight unique aspects of SIM that are being implemented in the community.
SIM conference The SIM office will convene an annual conference of SIM stakeholders in a central location to gather representatives from the HIT, public health, primary care, and behavioral health sectors as well as other relevant parties. The conference invitees will comprise workgroup members as well as those who represent efforts that align with SIM, such as the ACC. The focus will be on sharing lessons learned and promoting partnership and coordination between agencies. The initial SIM narrative indicated that a conference would be convened every six months but feedback from the first SIM Outreach Tour indicated that regional meetings that address local needs would be more effective than centralized conferences. To balance the need for local flexibility with overall program standardization, the SIM office will continue to conduct outreach tours yearly and host a SIM conference in Denver once a year.
Incorporating the consumer perspective The SIM office is committed to incorporating consumer needs, wants, and preferences in all aspects of its work. SIM has taken the following steps to ensure that the consumer voice is included and heard throughout decision-making processes.
Consumer representation on the SIM advisory board At the first SIM advisory board meeting in June 2015, members of the public were asked to weigh in on whether the advisory board needed to include greater representation of a specific group or interest. The SIM office collected responses and identified common themes. The most commonly identified need was inclusion of consumer representatives on the board. As a result, the SIM executive order was amended to add four new positions to the advisory board, two of which were reserved for people who represented consumer interests. The governor’s office of Boards and Commissions ran a competitive application process and selected the following representatives to fill these slots: ▪ Consumer Representative: Carol Meredith, executive director, Arc of Arapahoe & Douglas County; and ▪ Consumer Representative: Carol Pace, FACMPE, volunteer advocate for AARP and the Colorado Consumer Health Initiative. (For a complete list of SIM Advisory Board Members, see Appendix G1.) The SIM office believes that these two consumer representatives will help ensure that consumer perspectives are considered in all major decisions moving forward. The team has invested more energy in social media posts that have attracted attention from patient advocacy groups and a growing number of “followers,” who are spreading the message about the value of integrated health to patients across the state. The team also participated in the HCPF patient advisory council several times and will seek new ways to use this group in the future. Staff continues to seek patient stories to share online and is connecting with different state Page 69 of 239
organizations dedicated to consumer engagement efforts to align efforts. With limited staff, we are trying to optimize relationships as possible and will continue to pursue the contract with a vendor (outlined above) to help us address the consumer engagement piece of the SIM puzzle in the future.
Requirements of participating payers Please see the Payment and Service Delivery Models section.
Requirements of participating providers Please see the Health Care Delivery System Transformation Plan section.
Agreement between payers and providers Please see the Payment and Service Delivery Models section.
Page 70 of 239
b. Health care delivery system transformation plan 1. Payment model(s) and service delivery model(s) Payment model(s) Payment reform is a key component of the State Innovation Model (SIM’s) efforts to provide 80% of Coloradans with access to integrated physical and behavioral healthcare in coordinated community systems, with value-based payment structures, by 2019. Current payment systems, which reimburse care primarily through fee-for-service (FFS) payments and use a range of payer-specific measures to evaluate outcomes, compound the fragmented nature of care delivery in the state and create a significant barrier to integrated care. To achieve lasting and sustainable change, payment reform must go together with efforts to transform healthcare delivery.
Overview of payment reform in Colorado In the last year, the state has seen tremendous shifts in the health insurance market - on and off the exchange. Rocky Mountain Health Plans was acquired by UnitedHealthCare, potential national mergers that would have affected Colorado were proposed but did not occur, and multiple payers reduced regions or plan offering on the individual exchange, or exited entirely. While competition is considered one of the strengths of the Colorado marketplace, this activity has created an uncertain market. Additionally, significant variation exists among payers, which range from small, local non-profit organizations to large, publicly-traded health insurance companies and sophisticated integration systems. This fragmentation within the marketplace as well as the significant changes in the last year on a local and national level, makes the spread of value-based payments across payers with varying resources, capacities, and strategies, an ambitious enterprise. Despite these challenges, multiple public and private value-based payment initiatives are underway in the state. During the planning period for SIM, payers indicated a high degree of interest in pursuing value-based payment models, many expressed a need for state guidance and leadership around key issues, including a common or standardized set of performance metrics; minimum reporting standards, based on “best practices” and new processes and support for data sharing. The SIM initiative has played a leading role in addressing these issues, and other barriers to the adoption of value-based payments through its work with the Multi-Payer Collaborative (MPC).
SIM approach to payment reform Engagement with public and private payers SIM has worked with payers and providers during the last two years to develop a payment reform strategy that meets these industry players where they are and works to move them away from FFS reimbursement toward alternative payment models that incent quality and value rather than volume. SIM is committed to supporting payment reform through participation in initiatives including Comprehensive Primary Care Plus (CPC+), the Colorado Medicaid Accountable Care Collaborative program (ACC), and independent projects supported by commercial insurers to capitalize on payers’ previous time investments, infrastructure development, and philosophical alignment. Using this platform of existing work will ensure maximum payer participation in SIM, and catalyze SIM’s efforts to reach 80% of state residents by 2019. The MPC represents public and private payers that share a commitment to support and expand accountable, whole person, patient-centered care transformation through a variety of initiatives. Seven payers signed a Memorandum of Understanding (MOU) with the SIM office (Appendix S1), in which they Page 71 of 239
committed to work with SIM to transform the way physical and behavioral healthcare is delivered and financially supported in practices selected for SIM within their networks. These payers are collaborating to: 1. Focus on primary care practices and behavioral health settings seeking to integrate care; 2. Support providers who deliver and coordinate integrated care that improves population health, and increases quality while reducing costs; 3. Increase providers’ abilities to manage whole-person care; 4. Develop necessary infrastructure to support care integration and delivery of whole-person care; and 5. Encourage practices to continually evolve towards higher-levels of integration via transformation of care delivery support through alternative payment models (APMs). The launch of SIM cohort-1 practices in the spring of 2016 provided an opportunity for providers and payers to partner around shared goals for the patients they serve. Shortly after the launch of the first cohort, it became clear that there was a disconnect between providers and payers in terms of payment for SIM practices. Because of this, the SIM office embarked on a process to better understand expectations between providers and payers. Colorado payers recognize the value of integrating physical and behavioral health. They also recognize and have invested in value-based payment models in the state. Payers participating in SIM were told that their existing value-based payment models would be acknowledged as support for SIM practices as outlined in the SIM proposal. For some payers, these models include behavioral health. For this reason, practices that were part of a value-based initiative or model might not have received a new contract or increase in financial reimbursement for their participation in SIM. The team has spent considerable time with SIM provider and practice stakeholders, as well as the MPC to develop messaging and communication about the work that was done to identify how the disconnect in expectations for SIM “payment” occurred to ensure that future cohorts would have a clear understanding of this agreement. We have made it clear that the SIM initiative does not offer one payment model. The initiative helps create better relationships between payers and providers by helping them use and communicate data in ways that show how changes in process and patient interactions can reduce costs and improve health outcomes. During the continuous quality improvement process of evaluating the model to support practice transformation, it became evident that while cohort-1 milestones were comprehensive, they were too expansive. With no accountability metrics or goals, and an expansive list of activities across 10 building blocks, it was hard for practices to focus and for payers to see how SIM participation would help providers transform. To rectify the issue, the team worked with the MPC to simplify the SIM Framework using the “Bodenheimer Building Blocks of High-Performing Primary Care,” aligning with CPC+, and identifying goals with milestone metrics for each year of SIM participation. This allows practices and payers to move forward with a shared understanding and expectation of practice-level achievements in SIM. The payers also came together to identify a high-level framework that outlines SIM payer support in Colorado. They also amended the SIM-Payer MOU (Appendix S1) to include descriptions of each payer’s value-based payment model for SIM practices. The following is an overview of payer support for SIM. Payers that support SIM have agreed to apply organization-specific payment model(s) and establish Page 72 of 239
their own agreements with practices selected for SIM cohort-2. Payers have APMs in place with many practices in their networks to support primary care transformation. For SIM, value-based payments received through a payer-specific APM will support practice work around behavioral health integration. As noted in the SIM MOU addendum, the payers in Colorado have adopted the Healthcare Payment Learning Action Network (HCP LAN) payment category framework (Appendix S2). Payers’ existing APMs are tied to performance measures and they are working collaboratively to align measures that support behavioral health integration. Additionally, there is payer support for the SIM clinical quality measures and claims-based measures that will help practices identify how their efforts affect healthcare quality, utilization, and costs. After the MACRA/QPP final rules were published and CPC+ was announced, the SIM office recognized the need to evaluate and align the SIM CQMs with these innovative programs. A simplified and aligned measure set (Appendix S3) was developed with stakeholder input and approved by the payers. Despite the commitment to the SIM measurement set, there continues to be a reporting burden on practices that must report measures that are not included in the simplified measure set, and this is recognized as an area of focus moving forward. Participating payers have aligned practice expectations to the SIM Practice Transformation Building Blocks. Payers’ payment methodologies are designed to support practice capacity and infrastructure to achieve the milestones within these building blocks during the initiative. While each payer is using its own payment model to support SIM’s transformation goals, the payment model(s) that payers will apply to SIM practices all include the following basic elements that comprise the SIM payment framework: 1. Fee-for-service payments; 2. Payments that include behavioral health integration through one of the following mechanisms: a. Upfront payments; b. Population-based payments (e.g., PMPM); c. Care coordination payments; or d. Payment for additional codes. 2. Shared savings opportunities OR incentive payments based on performance and/or outcomes linked to quality. Additionally, the MPC has agreed to aggregate claims data in a singular reporting and analytics tool to help practices understand care gaps and utilization patterns. The payers are supporting the Stratus™ data sharing tool that aims to enhance and improve delivery of care to Colorado residents and reduce overall cost of care. Prior to this project, providers received multiple reports from each health plan and had to log on to several websites to access patient data, which made it cumbersome and inefficient to coordinate a patient’s care. Stratus™ allows care providers to access patient claims data from one website. Rise Health has partnered with Colorado’s Center for Improving Value in Healthcare and other state and local entities to build the tool and help ensure a comprehensive approach to data aggregation. During year three of the initiative (the second performance year), SIM will re-procure a data aggregation tool to support SIM practices. The SIM office will select cohort-2 during the summer of 2017. Payers will be notified of SIM cohort-2 Page 73 of 239
practices during this time and will continue to direct their own investments toward the source of care that is most likely to produce a return associated with intermediate and advanced practice competencies identified in the revised SIM framework. Colorado payers are also working to align their payment, measurement and data sharing processes in a way that will help practices that is similar to what the MPC accomplished with the CPC initiative. It is anticipated that Colorado practices that participate in SIM, and advance through components of the model, will greatly improve the likelihood of receiving enhanced funding from private and public payers.
Self-funded plans and employer purchasers The SIM office has reached out to self-funded plans and purchasers during the NCE period to gain perspectives on how the team might engage with this group and to educate these healthcare purchasers about the goal of the initiative, and explain how whole-person care can improve outcomes and reduce costs. The team presented to the Colorado Business Group on Health (CBGH) in March. There was a lively discussion among the group, and the presentation resulted in requests for SIM providers in their areas. One request the SIM team made was whether CBGH members would suggest that their employees seek care from providers who offer integrated behavioral and physical health. This idea was well-received, as evidenced by the requests for SIM providers. The SIM team continues discussions with the CBGH to test different ways to incent employees to select SIM providers or those who offer integrated care. The team has also engaged professionals at the National Behavioral Health Innovation Center to discuss ways to partner and work with this group to identify a return-on-investment for employers who actively encourage employees to select integrated care providers. The team will have more information to share about these overtures in the coming months.
Leverage MPC and multi-stakeholder symposium The Colorado MPC includes public and private healthcare payers working to strengthen primary care. Established in the spring of 2012, the MPC originated as part of the Centers for Medicare and Medicaid’s Comprehensive Primary Care (CPC) initiative. At its inception, the MPC included 10 payer organizations, regional and national as well as public and private, that coordinated efforts and supported CPC practices. The MPC now includes every public and private payer operating in Colorado. It is committed to building on initial efforts to expand and support primary care transformation throughout Colorado, and is focused on supporting SIM, CPC+, and regional data aggregation. Not all payers participate in each project supported by the MPC but all payers are committed to payment and practice transformation in Colorado. Membership includes: ● ● ● ● ● ● ● ●
Anthem Blue Cross/Blue Shield of Colorado Centers for Medicare and Medicaid/Center for Medicare and Medicaid Innovation CIGNA Colorado Choice Health Plans Colorado Department of Health Care Policy and Financing Kaiser Permanente Rocky Mountain Health Plans UnitedHealthcare
The MPC uses the following definition of success to guide their work together: A shared commitment to increased quality, improved efficiency, higher value, and continuous improvement and diffusion of innovative and successful strategies through increased system accountability, improved health outcomes Page 74 of 239
and experiences for patients and providers, and decreased total cost of care.
Relationship between the MPC and SIM The MPC will serve as the primary forum for SIM’s engagement with public and private payers throughout the implementation of the model test. However, the SIM Office will continue to engage with payers and other stakeholders outside of this setting, to inform and direct payment reform activities, as outlined below.
Service delivery models Colorado State Innovation Model (SIM) has committed to achieve its goal of providing access to integrated physical and behavioral healthcare services in coordinated systems, with value-based payment structures, to 80% of Colorado residents by 2019 through these mechanisms: ● Providing practice transformation support to approximately 400 primary care practices during the three-year grant implementation period; and ● Supporting a Bi-Directional Integration Demonstration Pilot that will create integrated health homes in four community mental health centers (CMHCs). The SIM practice transformation and service delivery stakeholder workgroup continues to provide guidance on all aspects of practice transformation by providing thought leadership, promoting synergy with payment reform efforts, and ensuring alignment with other components of the initiative.
Practice transformation in the primary care setting Status of practice transformation cohorts: The SIM office remains on track to select the following three cohorts of primary care practices for inclusion in practice transformation activities during a three-year period: ● ● ●
Cohort 1: 100 practices accepted; two years of practice transformation support; Cohort 2: 150 practices; two years of practice transformation support; and Cohort 3: 150 practices; one year of practice transformation support.
The SIM office continues to contract with the University of Colorado (the university) to lead practice transformation efforts across the state.
Cohort 1 The SIM office selected 100 primary care practices to join the first SIM cohort in December 2015, and primary care practices began transformation efforts in March 2016. To date, 92 of the original 100 practices are participating in the first cohort. Five of the eight practices were acquired by a national healthcare system and the internal quality improvement process precluded them from participating in SIM. The other three practices withdrew for a variety of reasons, including insufficient support from payers and changes in practice leadership that reduced practice capacity for participation. Six of the eight practices that withdrew were accepted into Comprehensive Primary Care Plus (CPC+).
Practice satisfaction survey results The university conducted a practice satisfaction survey with cohort-1 practices to solicit feedback regarding levels of satisfaction with the initiative and the support from practice facilitators (PFs) and/or clinical health information technology advisors (CHITAs) through their practice transformation organizations (PTOs). The semi-structured satisfaction survey consisted of 15 questions. All questions, except for the unstructured items, were required. The survey was sent to three key individuals in each of the 92 cohort-1 practices and yielded the following results:
Page 75 of 239
● ● ● ● ●
●
●
A total of 114 responses were received across 71 (77%) of the 92 SIM practices. 98.2% of respondents agreed/strongly agreed that PFs helped them accomplish practice goals. 82.4% respondents agreed/strongly agreed that CHITAs helped them accomplish practice goals. 87% of respondents stated that they would recommend SIM participation to a colleague and/or other practice. 13% of respondents) said they would not recommend SIM participation for these reasons: ● CQM reporting burden (1 respondent) ● Time commitment required is too much (2) ● The burden of participating in multiple practice transformation initiatives (3) ● Payment was not what was expected (3) ● Inadequate support from the PF and/or CHITA (5) Responses to an open-ended item regarding advantages and value of SIM included: ● Networking ● Increased focus on integrated behavioral health ● Optimized use of Electronic Health Record (EHR) ● Structured goal setting ● Grants and funding access Responses to an open-ended question regarding implementation challenges included: ● Communication about funding ● Lack of quarterly checklists or due dates ● Time and staffing ● Work performed in relation to funding received ● Unclear expectations
The SIM office used survey feedback to improve its practice transformation model for Cohorts 2 and 3, as described in the sections below.
Cohort 2 The SIM office delayed release of the request for applications (RFA) for cohort 2 from summer 2016, as originally anticipated, to February 2016. This decision was made based on several factors, including: ●
●
●
Timing with release of CPC+ applications: The delayed release of the SIM RFA avoided a conflict with the open application window for CPC+. The team received feedback from key stakeholders that applying to two Centers for Medicare and Medicaid Innovation (CMMI)-funded initiatives concurrently might be overly burdensome for practices and create confusion. Additionally, the SIM office needed time to work with CMMI leadership to determine how to align the two initiatives without duplicating efforts. Alignment with No Cost Extension (NCE): Due to the budgetary and programmatic implications of the six-month NCE, the SIM office delayed the start of practice transformation efforts for cohort 2 until Award Year 3 (AY3). Improvement of the model: After gathering feedback from cohort-1 practices and stakeholders, the SIM office delayed the cohort-2 RFA to refine the practice transformation model.
Cohort 2 recruitment The RFA for Cohort 2 was released Feb. 16, 2017 (https://www.colorado.gov/healthinnovation/cohort2), and we received 226 applications by the close of the application March 31, 2017. The SIM office is working with payers and a review panel convened by the university to select approximately 150 practices to begin transformation activities in September 2017. The RFA included several key changes Page 76 of 239
from cohort 1 that were made based on stakeholder feedback and were designed to improve the experience of cohort-2 practices and maximize the effects of the model.
Feedback
Change to Cohort 2
Reporting burden too high
Streamlined set of Clinical Quality Measures (CQMs)
Difficulties implementing SIM at individual practice sites instead of across groups/systems
All practices in a group/system are now encouraged to apply
Confusion regarding support from payers
Inclusion of clarifying language plus links to the payer Memorandum of Understanding (MOU), addendum, and payment model summaries are published in the RFA
$5,000 insufficient/$40,000 grants were difficult to apply for
Achievement based payments of up to $13,000 will be available, and additional grant funds will exclusively be provided via The Colorado Health Foundation
Insufficient Health Information Technology (HIT) support
Inclusion of Health Information Exchange (HIE) support in RFA, more clearly defined information regarding broadband expansion. (See HIT section for more information)
Revised practice transformation building blocks: SIM adopted a building block model based on Dr. Thomas Bodenheimer’s conceptual framework of the “Building Blocks of High-Performing Primary Care” to advance change. The framework includes: engaged leadership, data-driven improvement, patient empanelment, team-based care, patient and family engagement, population health, continuity of care, prompt access to care, comprehensive care management and care coordination and integration of primary care and behavioral health. Cohort-1 practices received a set of activities associated with the 10 building blocks and chose which milestones to work on based on priorities they selected and outlined in their practice improvement plans. However, the SIM office received feedback that, while this approach provided ample flexibility, it did not provide clear enough guidance regarding the number and type of activities practices had to achieve to be successful in SIM. Additionally, variance in activities among practices made it difficult to evaluate the effects of the model. Finally, the SIM office recognized the need to ensure that activities were aligned with payer priorities. As a result, the SIM office worked with members of the multi-payer collaborative (MPC) to revise activities associated with the building blocks, and create a SIM framework and milestones which will be used by SIM cohort-2 and -3 practices. The SIM framework includes a set of adult and family milestones as well as a set of pediatric milestones that are appropriate for practices serving only pediatric patients. Cohort-1 practices are not required to adopt the new framework, but are encouraged to pick activities within the old framework that align with new milestones that have been identified as priorities. The university prepared a building blocks crosswalk (included as Appendix S4) to help cohort-1 practices and the PTOs that support them identify activities from the revised framework that map to those in the cohort-1 framework. Page 77 of 239
Practice sites in Cohorts 2 and 3 are expected to maintain “good standing” with the behavioral health focus of the initiative through successful completion of identified building blocks and achievement of key milestones in the SIM Framework. If practice sites are not in good standing, payers will determine how that affects their programs and the payment a practice receives. The SIM office will work with PTOs and the university to support transformation and to determine a practice site’s standing. Practice standing information will be shared with payers to inform practice eligibility for payment. The SIM office, in conjunction with the university, is updating the SIM Implementation Guide and Toolkit to provide practices with the resources and supports to advance through the milestones based on the revised framework. Key assessments, such as the practice improvement plan, are being revised to capture progress made by practices within the new framework, which will be implemented in AY3. Copies of the implementation guide and associated documents will be made available to CMMI when complete, likely in the first quarter of AY3.
Behavioral health integration: Behavioral health integration is a key component of SIM, as reflected by building block 10 of the framework referenced above: “Practice has fully integrated behavioral healthcare to provide wholeperson care.” In addition to the activities associated with building block 10, activities that promote integration are woven throughout the building blocks (for example, the goal of building block 7 states that the “practice screens at least 90% of patients for substance use disorder/other behavioral health needs; includes behavioral health and community services as part of care management strategies.”) Each practice completes the Integrated Practice Assessment Tool (IPAT) at baseline and periodically throughout the initiative to gauge progress. PFs use the tool in conjunction with an assessment of where practices are with implementing the SIM framework and milestones to complete practice improvement plans. Practices must select one goal focused on behavioral health for practice improvement plans. Recognizing that some practices are farther along the pathway of achieving fully-integrated care than others and that each practice has unique needs, the SIM office will align its support with the CPC+ Behavioral Health Integration Menu of Options so practices can choose to focus on care management for mental illness or the primary care behaviorist model.
Technical assistance to practices: Practices in all SIM cohorts will be provided with technical assistance and support via three avenues: ● ● ●
In-person facilitation and assistance Collaborative Learning Sessions E-learning modules
In-person facilitation and assistance Practice sites are provided with a PF and a CHITA as well as linked with regional health connectors (RHC) to deliver a comprehensive, personalized package of in-office support that helps them achieve the SIM framework and milestones and connects them with community and state resources. The PF and CHITA are provided by one or more PTOs selected by a rigorous procurement process to ensure that practices benefit from highly-skilled personnel. Currently, 17 contractors provide PTO services. The broad range of PTOs ensures that practices in all sections of the state have an adequate number of PTOs to choose from (as some PTOs work in specific areas of the state) as well as allows practices the opportunity to work with organizations through whom they have already received practice transformation support. Because the number and reach of PTOs was considered to be sufficient for Cohort 1, the SIM office chose not to recruit more PTOs for Cohort 2 and 3, but rather to work with the existing list. RHCs are deployed Page 78 of 239
through local organizations selected for their existing, trusted relationships in the communities they serve (see plan for improving population health section for more information). An overview of each role is provided below. 1. PF role: a. Support implementation of an ongoing change and quality improvement process through quality improvement teams; b. Contribute to the development and updating of a SIM practice improvement plan (PIP); c. Facilitate quality improvement team activities to focus on PIP objectives; d. Identify and help resolve challenges in achieving objectives; e. Facilitate the development of sustainable quality improvement techniques and processes; and f. Coordinate and facilitate practice site access to additional practice transformation resources, including coordination with the local RHC. 2. CHITA role: a. Assist in the development and updating of a SIM data quality plan (DQA), including identification and assessment of current HIT resources; b. Support the enhancement of practice capacity to implement data-driven quality improvement; c. Assist with the development and implementation of practice workflow for data collection, reporting, validation and analysis; d. Facilitate data-driven quality improvement priorities; and e. Link practice sites with technical assistance through various HIT resources (some SIM-related). 3. RHC role: a. Provide information regarding state and regional transformation and community health resources; b. Facilitate the connection of practice site to local public health and other community resources; and c. Establish ongoing supportive relationships with practice sites that can be sustained beyond the two years of active practice transformation support.
Page 79 of 239
All cohort-1 practices have been working with a PF and CHITA. All RHCs are now hired and deployed. During AY3, the SIM office will work with the university to make the following adjustments and improvements to the ways in which these roles deliver support. ●
●
●
Re-scope of the CHITA role: The SIM office and university are developing a core set of CHITA competencies in response to feedback that CHITA support was insufficient, training guidelines were inconsistent and payment was too low to support expectations. Additionally, the CHITA scope of work has been expanded to include conducting a formal assessment of each practice’s health information technology needs as well as their ability to submit CQMs. This HIT assessment will help to provide greater consistency in how CHITAs identify practice challenges and needs. CHITAs will also be required to provide documentation of progress they have made with each practice, in relation to the practice improvement plan. The SIM office will support their expanded work with increased payment. Addition of Stratus™ support: As the SIM office rolls out licenses to this data aggregation tool that includes clinical and claims data across payers, PFs will be trained on how to support practices with accessing this tool in AY3 and using it to guide changes in clinical practice. (More information can be found in the HIT section). Connections between practices and other areas: The SIM office will continue to make connections between SIM-funded entities now that RHCs have been hired, collaboratives of local public health agencies (LPHAs) (see plan for improving population health section) are implementing health systems coordination work, and cohort-2 practices will soon join cohort 1 practices in the initiative. Connections will be made during targeted outreach events across Colorado, via webinars that include multiple partners, and during Collaborative Learning Sessions (CLS) (see below).
The SIM office and university will continue to update the SIM Implementation Guide and Toolkit for practices throughout AY3 to address the new milestone framework and provide more clarity for PTOs and practices on expectations and available resources.
Collaborative learning sessions One of the key SIM objectives is to identify what works and disseminate these best practices as broadly as possible. The university has convened four CLS events, two in the Denver metro area and two on the western slope. Two more will be held in June during the NCE. During these events, cohort-1 practices, PTOs, bi-directional health homes, and other stakeholders share general knowledge, identify lessons learned, and disseminate best practices. Twice-yearly CLS events will continue throughout the SIM Initiative. Feedback from rapid cycle feedback reports, as well as the SIM practice transformation and Page 80 of 239
service delivery workgroup, will be used to inform CLS topics. The first CLS events for AY3 are scheduled for Nov. 3 2017, in the metro Denver area and Dec. 8, 2017, on the western slope. These sessions will include practices from both cohorts as well as the four bi-directional health home sites.
E-learning modules During AY2, the university developed these modules for its patient-centered medical home e-learning program: ● ● ● ● ● ● ● ●
1: Introduction to SIM and Practice Transformation Module; 2: Patient and Family Centered Care Module; 3: Integrated and Coordinated Care Module; 4: Team-Based Primary Care Module; 5: Quality Improvement Module; 6: Patient Self-Management Support Module; 7: Population Management Module; and 8: Leadership Skills for SIM and Practice Transformation.
While these modules are available to cohort-1 practices, the SIM office has not been able to gauge use, due to challenges with hosting the modules. E-learning modules will be migrated to a new platform by the start of AY3 and disseminated to primary care practices. The Office of Behavioral Health (OBH) is working with the university to assess whether SIM-funded provider education opportunities (see plan for improving population health section) can be hosted on the same platform to ensure convenient access for SIM practices. Alignment of provider education opportunities will be a key priority for AY3.
Access to capital: While SIM practices will benefit from the technical assistance outlined earlier in this section, the initial costs of integration efforts can be prohibitive. Larger-scale investments in infrastructure (such as building out a private exam room for a behavioral health provider), HIT (such as adapting an existing EHR to include behavioral health records), or personnel (such as hiring a behavioral health provider) can present substantial barriers to participation.
Access to resources for cohort-1 practices To mitigate the costs of integration and provide incentives for practices to make high-impact changes, the SIM office is taking a three-pronged approach to providing resources for cohort 1.
Page 81 of 239
Payments to practices – Cohort 1 SIM cohort-1 practices qualified for payments of up to $5,000 for completing key activities, such as reporting on CQMs and attending twice-yearly CLS events. The university will continue to disburse these payments to cohort-1 practices throughout AY3. In addition to these non-competitive payments, the SIM office created competitive grants of up to $40,000 and established a Practice Transformation Fund with approximately $3 million in federal SIM funds from CMMI plus approximately $3 million in funds from the Colorado Health Foundation (CHF) to fund these competitive small grants. The small grants are intended to help SIM practices advance toward greater integration of behavioral healthcare and to implement practice improvement plans. Page 82 of 239
SIM small grants – Cohort 1 A request for applications (RFA) for the small grants was issued in April of 2016. Practices applied for small grants from a SIM or a CHF funding stream (not both). A total of 66 practices submitted applications, 42 to the CHF funding stream and 24 to the SIM funding stream. A total of 27 practices were selected to receive funds through the CHF funding stream, and 20 were selected to receive funds through the SIM funding stream. The SIM office anticipates disbursing $926,448.00 in grants from the CHF funding stream and $578,543.00 from the SIM funding stream to cohort-1 practices, which leaves approximately $4.5 million in the Practice Transformation Fund to support future cohorts. In cohort 1, SIM small grant awardees are using grant funds to (1) train new and existing practice staff (including methods to better coordinate referral to specialty mental health settings), (2) upgrade existing technology to support integrated care, and (3) support methods to foster patient and family engagement in integrated care. CHF grant awardees are using grant funds for (1) seed funding to support behavioral health clinicians, (2) capital costs to support renovations that foster integrated care, and (3) technological solutions to support systematic screening for behavioral health problems. The following charts show the distribution of cohort-1 funding requests from each funding stream:
The SIM small grants manager, hired during AY2, will continue to support small grant awardees throughout AY3. Practices will submit final reports and outline the impact of grant funds.
Page 83 of 239
Access to capital for cohorts 2 and 3 The SIM office will continue to offer $5,000 practice payments and CHF competitive grants of up to $40,000. In response to feedback from PTOs and practices, the SIM office is planning to repurpose approximately $2.4 million of the SIM transformation funds. Instead of using the funds for competitive small grants to a targeted number of SIM practices, the SIM office will use the funds to provide noncompetitive payments of up to $8,000 that tie directly to a SIM practice’s successful completion of activities related to the SIM Framework and Milestones.
Page 84 of 239
A table outlining payments to practices in AY3 follows:
Removal of low-interest loans from SIM strategy The SIM office planned to include access to low-interest loans to provide practices with access to capital but decided not to pursue this strategy for the following reasons: ● ● ●
Conversations with CMMI indicated that a partnership with Vital Healthcare Capital (the proposed lender), might present issues of supplanting that might prohibit SIM involvement; The SIM office was unable to collect sufficient evidence that demand for low-interest loans would justify the program; and The proposed loan term extended beyond the initiative and the team couldn’t operationalize how effects would be measured or accountability maintained for the final years of the loans.
The CHF will offer Colorado practices an opportunity to partner with Vital Healthcare Capital. SIM practices will be informed of these opportunities, but the SIM office will not actively promote or encourage practices to apply for loans.
Practice assessments and data driven improvements: The university selected a battery of assessments for SIM cohort-1 practices to complete. The assessments are intended to provide evidence of practice progress and to provide practices with useful information to help them adjust approaches to better achieve their goals. While the university is adjusting certain assessments to reflect the revised SIM framework and milestones for the second and third cohorts and is considering changes to the frequency of reporting, the SIM office anticipates continuing to use the following assessments throughout AY3.
Page 85 of 239
Assessment Name
Purpose
Timing
Medical Home Practice Monitor
Practice self-assessment of level of implementation of core aspects of advanced primary care.
Baseline & Annually
IPAT (Integrated Practice Assessment Tool)
Assesses current methods BHI along levels of coordination, co-location and integration.
Baseline & Annually
Clinician and Staff Experience Survey
Individual provider and staff survey that assesses two subscales – Clinician & Staff Experience, and Burnout.
Baseline & Annually
SIM Milestone Activity Inventory
Assesses practice's current implementation of SIM milestone activities, helps identify gaps and prioritizes practice's next steps.
Baseline, 12 Month, 24 Month 18 Month TBD
Data Quality Assessment
Assesses practice's current state of data quality including accuracy of data element capture, validity of CQM reports and desired next HIT steps.
Baseline, 12 Month, 24 Months. 18 Month TBD
Practice Improvement Plan
Specific, Measurable, Achievable, Responsible, Time-Related (SMART) goals related to practice transformation as it relates to milestone activities.
Baseline & Every 6 Months
Clinical Quality Measures
Track patient and process outcomes achieved by practices.
Every calendar quarter starting Q2 2016.
Additional information about data-driven improvements used by practices, particularly through the Stratus™ tool and via cost and utilization reports, is provided in HIT section and within the program monitoring and reporting section.
Quality Assurance: During AY2, the university convened a Quality Assurance Committee, which meets on a bimonthly basis to discuss and monitor progress among primary care practices and PTOs. This committee mapped out a process for identifying and addressing practices and PTOs that might not be meeting expectations (see: Appendix S5). This process will continue throughout AY3 and this committee will continue to build and refine a practice and PTO dashboard through AY3 that flags potential issues in implementation. While the Quality Assurance Committee is not convened by the SIM office, the SIM program implementation manager sits on the committee. Committee findings are regularly shared with the SIM team and used to identify successes and challenges within the initiative. Furthermore, workgroup chairs are aware that this committee is available to examine issues in greater detail that may be identified at the workgroup level. Committee documents are shared with SIM staff. In this manner, the Quality Assurance Committee is incorporated into the SIM governance and decision-making structure. In AY3, the SIM office will submit regular reports to payers regarding which SIM practices are in “good standing.” Practice standing will be gauged by progress through the priority milestones, as outlined in Page 86 of 239
the SIM Framework and Milestones (see Appendix S6). The SIM office and the university will draft a process for attesting to practice standing during the NCE and vet it with members of the Multi-Payer Collaborative by the end of Q1 of AY3. The process will be implemented for practices in cohorts 2 and 3.
Patient engagement: Patient engagement is a key component of the SIM model. Practice Building Block 5: “Practice has built partnership with patients” includes use of shared decision-making aids in practices as well as quarterly Patient Family Advisory Council meetings as key activities. The university collects data on milestone progress through the Medical Home Practice Monitor assessment and Practice Improvement Plans. Practices are supported in achieving Milestone 5 with resources from the SIM Implementation Guide. Trainings presented at CLS events will focus on patient engagement during AY3. Finally, in AY3 the SIM office will work with key stakeholders to determine an experience of care measurement for the initiative. The Consumer Engagement workgroup has taken a more active role in providing feedback to the university and PTO, and will provide a platform for consumer and patient engagement input.
Alignment with CPC+: A total of 62 CPC+ practices applied to SIM cohort 2. Recognizing this substantial overlap, the SIM office is seeking ways to increase programmatic and operational alignment between SIM and CPC+ to help minimize provider burnout and frustration. In AY2, the SIM office began to develop an alignment strategy and engaged in robust conversations with a wide range of stakeholders, including providers, payers, and practice transformation experts. Stakeholders were agreed to seek a strategy that would: ● ● ● ●
Maintain the multi-payer focus of the SIM initiative; Ensure diversity in the type of practices engaged in SIM; Reduce the burden on practices that might want to participate in both initiatives; and Preserve SIM’s unique focus on the integration of physical and behavioral health.
Stakeholders arrived at a consensus that the interrelated goals and objectives of SIM and CPC+ create natural synergies and create a true benefit for practices, providers, and payers electing dual participation. This would mitigate the risk of practices choosing between the two initiatives and accentuate the complementary nature of the initiatives. The vision of alignment coordinated practice requirements, such as practice transformation support, learning collaborative offerings, and quality measure reporting to reduce provider burden and preserve SIM’s focus on the integration of physical and behavioral health, coordination of primary care, public health and community health organizations. The SIM office differentiated requirements for cohort-2 practices in SIM and those in CPC+ and SIM: SUMMARY OF SIM PARTICIPATION EXPECTATIONS Shared Expectations of All SIM Practice Sites 1) Identify a cross-functional quality improvement team to implement improvements based on the SIM Practice Transformation Building Blocks. 2) Complete a set of practice assessments to identify key areas of focus for improvement. 3) Participate in SIM evaluation activities. Expectations of practice sites in SIM-Only
Expectations of practice sites in CPC+ and SIM
Page 87 of 239
4) Required to attend the SIM CLS events. 5) Collect, report, and review SIM Clinical Quality Measures on a quarterly basis. 6) Complete a foundational subset of building blocks through achievement of key milestones.
4) Encouraged to attend the SIM CLS but not required to do so. 5) Collect, report, and review only the SIM Clinical Quality Measures that align with CPC+ requirements on a quarterly basis. 6) Complete an advanced subset of building blocks through achievement of key milestones. ** Practice sites in CPC+ and SIM will be expected to adhere to all expectations of CPC+
During AY3, the SIM office will continue conversations with the CPC+ team to ensure alignment of key areas including delivery of practice transformation support and the timing and content of CLS events.
Practice transformation in bidirectional health homes SIM recognizes that successful care integration should not only occur within primary care settings but should also include settings that patients themselves identify as their primary locus of care. Community behavioral health settings are an excellent example where many individuals are better served beyond traditional primary care, including populations with severe, co-occurring mental health, substance use, and chronic health conditions. As a result, SIM contracted with the Colorado Behavioral Healthcare Council (CBHC) to facilitate and manage an initiative that supports integrated health homes within four Community Mental Health Centers (CMHCs). In 2015, CBHC selected four CMHCs to participate via an independently managed, Request for Proposal (RFP) process There were significant delays in implementation due to a delay in release of funds. The original RFP to which the CMHCs responded was based on a vision and activities articulated in the original SIM application and concept documents, but that included some line items that were ultimately determined unallowable within CMMI funding parameters (for example, direct services and capital construction). Through dedicated and consistent partnership between CMMI, the SIM Office, the CMHCs, and CBHC, all sites were able to re-scope activities to more specifically focus on capacity building, transformation and system redesign. All sites are operational and a description of how CMHCs are using SIM dollars to support bi-directional integration follows: Community Reach Center (CRC), a private, nonprofit community mental health center, is one of the premier integrated health providers in the north Denver area. For the bi-directional pilot program, CRC is partnering with Salud Family Health Centers, a Federally Qualified Health Center (FQHC) serving communities in northeastern Colorado, and Dental Lifeline Network. CRC and Salud Family Health Centers placed a fully functional medical clinic in CRC’s Commerce City Outpatient Clinic in December 2014. SIM funds are used to transform this clinic into a fully integrated health home with the goal of serving 1,200 patients with a focus on those with severe mental illness and high health needs. SIM funding supports several new activities that are crucial to advancing integration of behavioral and physical healthcare at the site, including use of feedback informed treatment, which comprises an outcome rating scale and session rating scale to guide patient care. Through this process, information will be shown to consumers through a graph in the EHR to put the patient “in the driver seat” of his or her care. CRC will adopt SAMHSA’s Four Quadrant Clinical Integration Model to improve care coordination. Jefferson Center for Mental Health (Jefferson Center) is a private, nonprofit community mental health center serving Jefferson, Gilpin, and Clear Creek counties. Jefferson Center is partnering with Metro Page 88 of 239
Community Provider Network (MCPN), the local federally qualified health center to develop the Jefferson Plaza Family Health Home (JPFHH). JPFHH is the third in a series of shared, integrated health homes between the three partners. SIM funds build on the existing health home infrastructure to move beyond co-location and advance the level of bidirectional integration and cross-organizational system transformation and culture change in pursuit of a sustainable model of bidirectional integration that effectively achieves and demonstrates quadruple aim outcomes. While Jefferson Center has a long history of partnership with these agencies, JPFHH marks a new endeavor that aims to serve 3,000 patients by year four with a focus on children, adolescents, young adults, homeless families and individuals, and individuals with severe mental illness and high health needs. SIM funds support increased levels of coordination between partners, establishment of new processes and procedures to ensure coordinated care, and includes a new focus on preparing for a shift to value-based payment. Mental Health Partners (MHP) is a private, nonprofit community mental health center that has provided mental healthcare for more than 50 years to the local underserved population in Boulder and Broomfield counties. With SIM funding, MHP is partnering with Clinica Family Health Services, the local FQHC, and Dental Aid, to create Boulder Health Integration Partners (BHIP), a multi-agency collaborative partnership. This partnership is developing an integrated health home that proposes to serve 1,000 patients by year four with a focus on those with severe mental illness and high physical health needs. Because the site endeavors to reach underserved patients in the community who do not access care and will be conducting outreach to populations, as well as incorporating new services into the health home, a SIM-funded full-time-equivalent position will be exclusively devoted to completion of new activities that advance SIM goals, not to support existing operations. Southeast Health Group (SHG) is the private, nonprofit community mental health center providing mental health, substance use, primary care, and wellness services to the six-county, rural and frontier region in the southeastern corner of Colorado. SHG will use SIM funding to support the creation of an integrated health home model in two of its practice sites (Rocky Ford and Lamar) as well as to expand existing bidirectional services offered at its La Junta site. Establishing a health home model in two new sites requires new processes and procedures, training additional staff, tailored outreach to distinct communities, and implementation of resources specifically designed to meet the unique needs of patients at each site. Other organization-wide changes anticipated include modifications to SHG’s EHR that will support integrated care, improved tracking of pain management patients, and increased training on Suboxone treatment. Throughout AY3, CBHC will provide support to the four sites and the additional practice transformation vendors. It will continue to facilitate regular phone calls between sites and create other opportunities for peer-to-peer learning such as quarterly in-person collaborative visits. CBHC will also provide technical assistance to sites, conduct site visits, and report successes and challenges to the SIM office. CBHC will continue to maintain and manage all contracting and subcontracting processes related to the bi-directional pilot program. During AY3, CBHC staff will maintain close involvement with the broader SIM initiative to ensure alignment. The CBHC SIM Project Lead will continue to serve as chair of the SIM policy workgroup and have representation on the SIM Steering Committee. In addition, in AY3, CBHC staff will maintain a strong presence and engagement with the other six SIM workgroups and advisory board.
Alignment with practice transformation efforts in primary care During the NCE, CMHCs filled out a series of baseline and repeat assessments designed to align with those used by primary care practices that participate in SIM. This included the IPAT, the Practice Improvement Plan (PIP), the Data Quality Assessment, the Milestone Inventory, and the Practice Page 89 of 239
Monitor: CMHC Version. In addition, the staff and clinicians at each awarded site are completing the Clinician and Staff Experience Survey. Minor modifications have been made in partnership with the CMHCs, the University of Colorado, and other partners to ensure the assessments reflect some of the unique aspects of the bi-directional effort. For example, in their Practice Improvement Plans, CMHCs were required to identify one Physical Health Goal (instead of a Behavioral Health Goal required for the primary care practices). In AY3, each CMHC will continue work with their assigned PF and Clinical Health Information Technology Advisor (CHITA). The services provided to the sites for practice facilitation and CHITA support is similar to the scope for the broader cohorts of participating primary care practices in SIM, creating alignment between the activities and milestones for these different models and settings of integrated care. In AY2, each health home site participated in CLS events described in the section above as well as the first MultiStakeholder Symposium. The sites also participated in and helped to drive two separate Learning Collaborative sessions hosted specifically for the CMHCs by their practice facilitators. Sites will continue to participate in these activities in AY3 to learn from and share best practices with primary care sites.
Measuring impact Recognizing that CMHCs have different capacity and needs than primary care practices, the SIM office contracted with Health Management Associates (HMA) during the NCE to recommend data collection and reporting strategies and to identify a uniform method of consistently reporting attribution, clinical quality measures, and participating providers. By AY3, HMA will have conducted focus groups with all participating sites as well as TriWest, the SIM office, and other key stakeholders. Based on information gathered, HMA will draft, prepare and present a guidance document to the SIM office with specific recommendations and action steps for data collection. Participating sites will begin collecting this data based on the recommendations in the guidance document in AY3.
Page 90 of 239
2. Quality measures alignment As SIM cohort-1 practice sites reported clinical quality measures (CQM) data during the first year of implementation, the SIM office received feedback from practice representatives and clinical health information technology advisors (CHITAs) about challenges with CQM reporting. The biggest challenge is working with electronic health record (EHR) vendors to build the necessary data fields and reports to capture and report CQM data, and will require a longer-term strategy. The SIM office made significant changes to reduce reporting burden and align with other initiatives.
Measurement period The SIM office worked with key stakeholder partners and CHITAs to change the measurement period for SIM CQM reporting. SIM practice sites will still report on a quarterly basis to have real-time, actionable data that informs internal quality improvement efforts, but a quarterly (90-day) lookback period for CQM reporting is not feasible and does not produce trustworthy data for most practices. Different EHR vendors and versions have different capabilities, and there is not one common measurement period methodology across all systems. Therefore, the SIM office provided guidance to practice sites to report CQMs using a rolling 12-month measurement period. If that preferred methodology is not available, practice sites were encouraged to use a year-to-date measurement period. There are a few cases in which neither a rolling 12-month nor a year-to-date methodology were available and practices used a quarterly lookback period. Starting in Q1 2017, updated CQM reports through Qualtrics will collect more detailed data about the measurement period used for each practice site. These reports will provide insights into data quality because practice sites will be asked to describe what they reported if they did not report the exact CMS eCQM measure specifications.
Simplified CQMs In addition to changing the measurement period, the SIM office (with input from university partners, CHITAs, and key stakeholders) simplified the CQM measure set that practices are required to report. There are now fewer CQMs that are required, and some measures were prioritized as “primary” CQMs. In addition, the group identified target areas where SIM could move the needle over time, and developed a more focused measure set for practices in January 2017. Practice sites are required to phase-in primary measures during their first year of SIM participation. If they cannot report on a given primary measure it can be replaced with a secondary measure to meet requirements. The practice is expected to work with its CHITA to report all primary measures over time. Practice sites are encouraged to report on primary and secondary measures during their two-year participation in SIM.
CQM alignment The SIM office ensured that all measures within the simplified CQM set aligned with existing initiatives (CPC+ and TCPI) and MACRA’s Quality Payment Program. Practice sites will not be asked to build new measures into EHRs if they do not have value outside of SIM. The one exception is the developmental screening, which is a key SIM behavioral health measure for pediatric practice sites. The SIM office contracted with Mathematica to develop guidance and deliver technical assistance related to developmental screening, aligning with the OHSU measure under development. In addition to aligning measures with other initiatives, the SIM office set out to ease the reporting burden for practice sites in SIM and CPC+. The SIM office will accept the CQMs that practice sites already report for CPC+. For example, the SIM office will accept the depression remission at 12-months measure from CPC+ practice sites in lieu of SIM’s depression screening and follow-up measure. Additionally, CPC+ practice sites will not be required to report on SIM’s adult obesity measure as it is not aligned with a CPC+ measure.
Page 91 of 239
The SIM office prepared reporting schedules for cohort 1 and cohort 2 that specify reporting requirements for pediatric and adult practice sites, as well as SIM practice sites that participate in CPC+. The SIM office also updated the CQM guidebook to reflect the simplified set of measures and provide detailed guidance to practice sites and CHITAs. The amended payer MOU included an appendix with this simplified set of CQMs.
Adult clinical quality measure set Measure Condition Primary CQMs Depression
Diabetes: Hemoglobin A1c
Hypertension
Obesity: Adult
Substance Use Disorder: Alcohol and Other Drug Dependence Substance Use Disorder: Tobacco
SIM Metric Title
Citation
Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan Diabetes: Hemoglobin A1c Poor Control
NQF 0418 CMS 2v6 NQF 0059 CMS 122v5 Controlling High Blood NQF Pressure 0018 CMS 165v5 Preventive Care and Screening: NQF Body Mass Index (BMI) 0421 Screening and Follow-up Plan CMS 69v5 Initiation & Engagement of NQF Alcohol & Other Drug 0004 Dependence Treatment CMS 137v5 Preventive Care and Screening: NQF Tobacco Use: Screening and 0028 Cessation Intervention CMS 138v5
CPC+
QPP
TCPI
Depression Remission at 12 Months
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
No obesity measure (not required for SIM if in CPC+)
✓
✓
✓
✓
✓
Secondary CQMs Asthma
Fall Safety
Maternal Depression
Substance Use Disorder: Alcohol
Medication Management for People with Asthma (replaced to align with QPP) Falls: Screening for Future Fall Risk
NQF 1799 CMS n/a NQF 0101 CMS 139v5 Maternal Depression NQF Screening 1401 CMS 82v4 Preventive Care and Screening: NQF Unhealthy Alcohol Use: 2152 Screening & Brief Counseling CMS n/a
✓
✓
✓
✓ Alcohol & Other Drug Dependence measure (above)
✓
✓
Page 92 of 239
Measures reported via APCD claims data automatically Breast Cancer
Colorectal Cancer
Breast Cancer Screening
Colorectal Cancer Screening
NQF 2372 CMS 125v5 NQF 0034 CMS 130v5
✓ (clinical)
✓ (clinical)
✓ (clinical)
✓ (clinical)
✓
Pediatric clinical quality measure set Measure Condition Primary CQMs Depression
Development Screening Maternal Depression Obesity: Adolescent Secondary CQMs Asthma
Metric Title
Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan Developmental Screening in the First Three Years of Life (developed by Mathematica) Maternal Depression Screening Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Medication Management for People with Asthma (replaced to align with QPP)
Citation
NQF 0418 CMS 2v6 NQF 1448 CMS – under development NQF 1401 CMS 82v4 NQF 0024 CMS 155v5
NQF 1799 CMS n/a
QPP
TCPI
✓
✓
No developmental screening measure
✓
✓
✓
✓
✓
✓
3. Plan for improving population health State health needs assessment and priority setting Leveraging population health assessments The state of Colorado is large and geographically diverse, as outlined in the previous operation plan. As of 2016, there are 5.54 million people living in Colorado’s 64 counties and two tribal nations. Approximately 85% of the population is concentrated on 20% of the state’s land primarily in the 200mile stretch of land along the eastern side of the Rocky Mountains known as the Front Range. The remaining 15% of the population is spread across the state’s 24 rural and 23 frontier communities and 21 of Colorado’s 64 counties have more than 25,000 people. Colorado remains one of the fastest growing states in the nation with a 10.2% population increase from 2010 to 2016.5 As of 2015, 68.7% of Colorado’s population is non-Hispanic white, 21.3% is Hispanic, 4.5% 5
U. S. Census Bureau. QuickFacts: Colorado. “Population, % change - April 1, 2010 (estimates base) to July 1, 2016, (V2016).” https://www.census.gov/quickfacts/table/PST045216/08
Page 93 of 239
is Black, 3.4% is Asian or Pacific Islander and 1.6% is Native American or Alaska Native, with 2.9% of the population identifying as two or more races. Nearly 17% of Coloradans ages five years or older speak a language other than English at home.6 Colorado’s diverse geographic and cultural landscapes lead to broad health needs and related issues among its residents, which can be compounded by barriers to accessing care due to geographic barriers (e.g. mountain passes) or low population density. From the outset, SIM aimed to address these unique healthcare challenges and improve population health through two primary vehicles – an improved public health system and a transformed healthcare delivery system that integrate physical and behavioral health services – to create an effective and sustainable community-based system. Based on the social determinants of health model, the plan leverages the work of public health to reinforce improvements in the clinical health delivery system. The two systems seek to build a collaborative and outcomes-oriented model of healthcare and public health integration that helps reach the SIM goal, which is to improve the health of Coloradans by providing access to integrated physical and behavioral healthcare services in coordinated systems, with valuebased payment structures, for 80% of Colorado residents by 2019. ●
SIM defines population health as the health of a population, including the distribution of health outcomes and disparities in the population.7 The SIM plan to improve population health continues to build on statewide efforts, including numerous local, state and national health assessments and plans outlined in the previous operational plan.
Resources to determine areas of high burden and cost As shown in the previous operational plan in the 2011-2015 period, 27 LPHAs prioritized mental health and 22 prioritized substance use issues as a pressing public health need in their communities. Colorado has the seventh highest suicide rate in the nation at 20.9 suicides per 100,000, and suicide is the second leading cause of death for Coloradans ages 10-34 years old. In 2015 there were 1,093 suicide deaths in Colorado, the highest recorded number. It exceeds other causes of death including diabetes, motor vehicle crashes, breast cancer, and homicide.8 As of 2014, 17.5% of Colorado adults classified for the rate of binge-drinking, which is higher than the national average of 16.0 %.9 In addition, as of 2014, the drug poisoning death rate was 16.3 per 100,000, which is higher than the national rate of 14.7.10 While one in 10 Coloradans report eight or more days of poor mental health in the last 30 days,11 many Colorado residents are unable to access the behavioral health services they need. Despite an increase in the number of mental health and substance use disorder (SUD) providers in Colorado in recent years, there is a workforce shortage of providers with specialized skills to serve those with complex behavioral health needs. The greatest deficit of providers is in rural and frontier areas of the state. In fact, 82% of practicing psychiatrists, 86% of child psychiatrists, and almost all psychiatrists specializing in SUD
6
Ibid.
7
Adapted from definition of Population Health in Kindig D., Stoddart G. What is population health? Am J Public Health.2003:93(3):380-383 8 CDPHE. Office of Suicide Prevention Annual Report: Suicide Prevention in Colorado 2015-2016. https://www.colorado.gov/pacific/sites/default/files/PW_ISVP_OSP-2015-2016-Legislative-Report.pdf. November 1, 2016. 9 CDC and Prevention: Sortable Risk Factors and Health Indicators. http://sortablestats.cdc.gov/#/summary. 2015. Accessed April 10, 2017. 10 Ibid. 11 Colorado Health Institute. Colorado Health Access Survey. http://www.coloradohealthinstitute.org/uploads/downloads/2015_CHAS_for_Web_.pdf. September 2015.
Page 94 of 239
treatment are based out of the Denver and Colorado Springs metro areas.12 Additionally, more than a third (22 of 64) of the counties in Colorado have zero licensed psychologists.13 Colorado’s statewide priorities and initiatives relating to SIM goals have been established through the assessments and plans described in the previous operational plan. The goals include reducing substance use (including alcohol, prescription drugs, and smoking); preventing suicide; promoting mental health; expanding healthcare access and capacity; improving health system integration and quality; and overall promotion of prevention and wellness. Addressing these important and pressing behavioral healthcare needs continues to require a strategic approach of incorporating systematic, coordinated interventions at various levels. Using the three buckets of prevention framework14 as outlined by John Auerbach at the Centers for Disease Control and Prevention, areas of preventive care include: ● Traditional clinical approaches; ● Innovative patient-centered care and funding models and/or community-clinical linkages; and ● Total population or community-wide approaches. Traditional clinical approaches include increasing preventive care and screening activities in healthcare settings, such as clinics and hospitals. These approaches are often reimbursed by insurers but are underutilized and, therefore, have low impact. Public health plays a role in supporting clinical interventions by providing data and technical assistance from public health agencies, which varies by intervention and site, and includes examples of screening tools and their proper use, resources for clinical workflow restructuring, referrals to community resources, and others. The second approach to prevention includes innovative approaches and evidence-based strategies to address community health needs. These approaches generally occur in clinical or health systems operating with value-based payment structures, and include integrating clinical and community resources. Interventions at this level are typically not reimbursed in the traditional fee-for-service model. Examples include embedding patient navigators (PNs) as part of care teams to reduce patients’ barriers to care and using health education to promote health literacy and patient self-management. Community-wide approaches focus on factors that affect the health of a population and include systemwide interventions. These approaches seek to address factors, including social and environmental, that affect a person’s health and well-being. Examples include supporting chronic disease self-management groups, promoting tobacco cessation, and addressing the stigma of mental health. CDPHE is funded to handle tobacco cessation efforts in the state and has a full team dedicated to this work. The SIM team continues to provide practices with resources through its regional health connector program and track CQMs, which include this measure. In quarter 1 of 2017, 53 primary care SIM practice sites reported an average of 88.4% of their patients were screened for tobacco use and if the screen was positive received a tobacco cessation intervention. SIM continues to address the state’s health needs by acting on these approaches to prevention and organized this plan based on that framework. Most of the activities operate at more than one level.
12
The Mental Health Funders Collaborative. The Status of Behavioral Health in Colorado: Advancing Colorado’s Mental Healthcare. http://www.caap.us/pages/documents/2011StatusofHealthCareColoradoReport.pdf. 2011. 13 Colorado Health Institute 14 Auerbach, John. The 3 Buckets of Prevention. J Public Health Management Practice, 2016, 22(3), 215–218.
Page 95 of 239
Existing capacity and efforts aimed at population health SIM population health strategies and activities SIM designed its population health plan to align with other population health efforts in the state. This section outlines interventions that are underway or planned to support the integration of behavioral and physical health. SIM can build off the state’s momentum and buy-in to achieve SIM goals and the governor’s goal to become the healthiest state in the nation.
Traditional clinical approaches The Colorado Department of Public Health and Environment (CDPHE) was charged with developing and disseminating three courses to enhance behavioral health delivery on the topics of pregnancy-related depression, depression in men, and obesity and depression. These topics were chosen because of the demonstrated need to increase provider knowledge and skills in these areas. In fall 2016, after working with the University of Colorado Department of Family Medicine, CDPHE’s Maternal and Child Health (MCH) unit distributed a Perinatal Mood and Anxiety Disorder Training to MCH and SIM contacts. As of January 2017, 125 providers had viewed and completed the perinatal mood disorders training. The MCH unit also developed a provider education course on Adverse Childhood Experiences (ACEs), which was disseminated to the same contacts. As of April 2017, three providers and 11 practice facilitators had completed it. The SIM and university teams will continue to encourage participation in the course. There have been numerous delays and obstacles with executing the contract with the entity chosen to develop the courses regarding depression in men and obesity and depression. CDPHE identified and selected a vendor to design and host the courses given their expertise in curriculum development, and a long-standing cooperative relationship for similar course development. There were significant and protracted delays in executing the contract between CDPHE and the vendor, due to disagreement regarding contract structure, timelines, and workplan, as well as the seven-month delay in the federal release of funds. The delay of funding release from CMMI pushed timelines related to grantees back. (Budgets were submitted to OAGM, but took more than four months for “unrestrictions” to occur. Delays were in part due to challenges resolving what defined “unallowable” expenses. Additionally, the volume of requests coming in to OAGM from other states created substantial delays). Despite the delays, CDPHE is taking steps to ensure that provider education materials are developed for these two topics with the hope of completion by July 2017. Should further delays persist, CDPHE will identify an alternate plan of action. All three courses are expected to reach a minimum of 100 providers each who practice in the fields of primary care, family practice, behavioral health, pediatrics, public health, and dietetics. CDPHE developed a provider education and evaluation plan in late 2015 that includes descriptions of providers that will receive the education, the type of education to be provided, including the topics covered, a description of the communication strategies to disseminate the availability of the trainings, and an education evaluation plan. The provider education plan will be updated in the summer of 2017 to reflect the progress made. CDPHE continues to work with other SIM-funded entities, including the Office of Behavioral Health and the University of Colorado, School of Medicine, to align and leverage the educational opportunities available for providers, practices, and other relevant staff to support the integration of behavioral health into primary care. These partnerships, which provide relevant, evidence-based, and up-to-date education, began prior to and will continue beyond the life of the SIM grant. Please see the workforce capacity section of the plan for information on how CDPHE will coordinate with the Office of Behavioral Health to advance training opportunities.
Page 96 of 239
Population health monitoring will provide the structure for monitoring and surveillance and inform the SIM evaluation. CDPHE developed SIM’s behavioral health population health measure set, which is detailed in the previous operational plan. Measures were based on existing Colorado population health measures and are intended to fill gaps in existing data. Selected measures align with the SIM clinical quality measures (CQMs), define the population’s burden of a health condition, and are timely and sustainable. Ideally, they will be available at the state and county levels. CDPHE focused on traditional physical and behavioral health measures, which are not as robustly monitored in our public health system. CDPHE successfully added depression-specific questions to the 2016 Behavioral Risk Factor Surveillance System that will enable increased behavioral health tracking in Colorado, and the SIM team worked with the Colorado Health Institute to add questions to the Colorado Health Access Survey. There are 18 behavioral and 16 physical health measures providing corollary population-level data to the SIM-required CQMs. The population health measures are informed by the Behavioral Risk Factor Surveillance System, the Colorado Child Health Survey, the Healthy Kids Colorado Survey, the Pregnancy Risk Assessment Measurement Survey, the Prescription Drug Monitoring Program, the National Survey on Drug Use and Health, the Colorado Hospital Utilization Data, and Vital Statistics.
Innovative patient-centered care and funding models and/or community clinical linkages Regional health connectors The Patient Protection and Affordable Care Act authorized The Agency for Healthcare Research and Quality (AHRQ) to create a national Primary Care Extension Program (PCEP). The program deploys community-based health extension agents to help providers “improve the accessibility, quality, and efficiency of primary care systems” and “collaborate with local health departments … and other community agencies to identify community health priorities and … address the social and primary determinants of health.”15 SIM saw this model as an opportunity to create synergy between its primary vehicles for improving population health – an improved public health system and a transformed healthcare delivery system with integrated physical and behavioral health services. The previous operational plan includes a detailed history of the grant and model for the health extension agents. Since the submission of that plan, Colorado has launched a new workforce of 21 regional health connectors (RHCs) across the state. Inspired by the PCEP model, a RHC is a local resident whose full-time job is to improve the coordination of services to advance health and address the social determinants of health. RHCs promote connections among clinical care, community organizations, public health, human services, and other partners. They implement activities to improve clinical-community linkages, remove barriers to healthcare, and address factors that influence health. RHCs, who work with practice transformation efforts funded by SIM, support providers and their patients by: •
Connecting practices with resources to improve health, such as community tobacco cessation groups, chronic disease management programs, school-based health services, and mental health response trainings. • Assessing the need for practice transformation support and making connections to appropriate programs, such as SIM, including EvidenceNOW Southwest (ENSW), the Transforming Clinical Practice Initiative, and Regional Care Collaborative Organizations. The Colorado RHC program is supported by two federally funded initiatives: SIM and ENSW, which is one of seven regional cooperatives funded by AHRQ to provide small primary care practices with support to improve heart health in their patients using the latest medical evidence. EvidenceNOW Southwest is a collaborative effort of the University of Colorado, the Colorado Health Extension System, the New 15
Phillips, Robert. “The Primary Care Extension Program: A Catalyst for Change” Annals of Family Medicine. 2013; 11(2) 173-178
Page 97 of 239
Mexico Health Extension Rural Offices, and multiple other organizations. As shown in Figure 1, the Colorado RHC Program was developed and is managed by the Colorado Health Institute (CHI) and the Colorado Foundation for Public Health and the Environment (CFPHE) under contract with the SIM office (SIM funding) and the University of Colorado (ENSW funding). CHI is responsible for delivering on SIM contractual components related to RHC services. CHI was selected to oversee this work due to its track record of success serving as the fiscal agent for major initiatives in Colorado, including the planning and building of Colorado Regional Health Information Organization (CORHIO) and the state’s health insurance exchange, as well as its experience conducting research in local areas across the state related to behavioral health integration. For more information, please see the RHC Program Structure, Administration, and Funding handout in Appendix S7.
Figure 1. Colorado Regional Health Connector program coordination and oversight relationships
In the summer of 2017, CMMI and AHRQ approved a braided funding strategy proposed by the SIM office, the University of Colorado, CHI, and CFPHE. Under this strategy, SIM provides 70% of the funding for each RHC and ENSW provides the remaining 30% of the funding with specific contractual requirements to ensure that funding is not comingled. The approved funding allocation functions similarly to a pay-for-value payment model for providers. Rather than paying for a specific number of meetings with specific stakeholders, the RHC Program pays RHCs to develop and implement three community-specific projects through milestone-based contracts. RHC community-specific projects are directly linked to the SIM and ENSW statewide target areas shown in the tables below. RHCs choose appropriate target areas from these lists, which are based on unique community needs and develop a locally-relevant project to address those needs. Each RHC must develop one project related to ENSW target areas and two projects related to SIM target areas:
Page 98 of 239
1. Each RHC will choose a community-specific project that can be directly linked to one of the ENSW target areas around heart health. The ENSW target areas and a few hypothetical projects are shown in Table 1 below. A variety of projects could satisfy this requirement, depending on the specific needs of the community. Quarterly reports submitted to the SIM office by CHI will include an inventory of local priorities (anticipated in the Q2 report) and projects (anticipated in the Q3 report) and will be shared with CMMI. Table 1. ENSW Target Areas and Example RHC Projects ENSW Target Area
Example RHC Projects
Cardiovascular Disease
● Help practices implement evidence-based clinical-community linkages for smoking cessation ● Disseminate patient engagement materials about cardiovascular health ● Increase access to local community college fitness facility
Cholesterol Hypertension Obesity Substance Use – Tobacco
1. RHCs choose community-specific projects linked to SIM target areas on behavioral health. The SIM behavioral health target areas and a few projects examples are shown in Table 2. A variety of projects can satisfy this requirement, depending on a community’s needs. Table 2. SIM Behavioral Health Target Areas and Example RHC Projects SIM Behavioral Health Target Area Anxiety
Child Development Screenings
Depression
Substance Use – Alcohol
Substance Use – Prescription Drugs
Example RHC Projects ● Connect primary care to statewide early intervention resources ● Disseminate stigma reduction materials from SIM LPHA grantees to primary care ● Facilitate coalition between law enforcement, substance use providers, and primary care ● Improve access to behavioral health services in rural communities via coordinating transportation networks and/or supporting adoption of telehealth.
Page 99 of 239
2. Each RHC will choose a community-specific project that can be directly linked to any of the SIM target areas, as long as this intervention supports the project linked to behavioral health area in Project 2. The goal of this project must be to address comorbidities or other linkages between the SIM target area chosen in Project 2 and another SIM target area. This project could address two behavioral health comorbidities OR comorbidities between behavioral and physical health. For example, if an RHC proposes a project that addresses depression in Project 2, he/she could focus Project 3 on addressing co-occurring disorders of depression and substance use disorders or depression and obesity. SIM target areas and a few examples supporting projects are shown in Table 3. This requirement could be satisfied by a wide variety of projects that address comorbidities or other linkages between SIM target areas. Table 3. All SIM Target Areas and Example RHC Projects SIM Target Area Anxiety Child Development Screenings Depression Substance Use – Alcohol Substance Use – Prescription Drugs Asthma Diabetes Hypertension Obesity Prevention – Breast and Colon Cancer Prevention – Flu Safety – Falls Substance Use – Tobacco
Example RHC Projects ● Facilitate community social support network to address comorbidity between depression and obesity ● Implement follow-up referral to BH specialist after positive result from cancer screening ● Help practices establish referral networks that include support for comorbidities (e.g., joint referral for home assessment for falls and social support evaluation)
In addition to the three community-specific projects described above, the RHC Statement of Work outlines specific responsibilities to be completed on an as-needed basis to support each initiative. For example, an RHC might be asked to engage practices in their region for the SIM initiative or to participate in a SIM evaluation site visit. These as-needed, initiative-specific responsibilities are expected to constitute a small portion of the total RHC workload, and the braided funding structure enables the RHC to fully support both initiatives. To ensure work is locally driven, each RHC is hosted by an organization or collaboration with existing relationships and a history of community-based work in the region. The host organization or collaboration (host) receives funding to hire and manage an RHC for the region. The host enables the RHC to coordinate stakeholders and mobilize action to address local priorities by: ●
Ensuring the RHC is engaged in existing relationships and forging new relationships with local partners. ● Supporting the RHC as he/she develops and implements three specific regional projects. ● Expanding the scope of the host’s work and joining a statewide network to develop the RHC workforce. ● Enabling the RHC to serve communities across the region and address local priorities rather than focusing on organization-specific projects. Through a competitive procurement process, CHI and CFPHE have selected local organizations across the state to host an RHC in their regions. The RHC regions largely map to the 21 Health Statistics Regions Page 100 of 239
(HSRs) in Colorado. Adjustments to move Grand county from region 12 to 11 and Teller County from region 17 to 4 were proposed by potential hosts and approved during a procurement process. The final RHC regions and selected hosts for each region are shown in the map and table below:
Regio n
Host Organization or Collaboration
1
Centennial Area Health Education Center
2 3 4 5
Health District of Northern Larimer County Tri-County Health Department Community Health Partnership Centennial Area Health Education Center
6
Otero County Health Department
7
Pueblo City-County Health Department
8
San Luis Valley Behavioral Health Group
9
Southwest Colorado Area Health Education Center
10
Tri-County Health Network
11
Northwest Colorado Community Health Partnership
Counties Logan, Morgan, Phillips, Sedgwick, Washington, Yuma Larimer Douglas El Paso, Teller Elbert, Lincoln, Kit Carson, Cheyenne Baca, Bent, Crowley, Huerfano, Kiowa, Las Animas, Otero, Prowers Pueblo Alamosa, Conejos, Costilla, Mineral, Rio Grande, Saguache Archuleta, Dolores, La Plata, Montezuma, San Juan Delta, Gunnison, Hinsdale, Montrose, Ouray, San Miguel Grand, Jackson, Moffat, Rio Blanco, Routt
Page 101 of 239
12 13 14 15 16 17 18 19 20 21
West Mountain Regional Health Alliance Chaffee County Health Coalition Tri-County Health Department Tri-County Health Department City and County of Broomfield Health and Human Services Central Colorado Area Health Education Center North Colorado Health Alliance Mesa County Health Department Mile High Health Alliance Jefferson County Public Health
Eagle, Garfield, Pitkin, Summit Chaffee, Custer, Fremont, Lake Adams Arapahoe Boulder, Broomfield Clear Creek, Gilpin, Park Weld Mesa Denver Jefferson
More information about the RHC program is available: http://www.practiceinnovationco.org/rhc/. In AY3, the SIM office will continue to support CHI implementation of the RHC program with opportunities for coordination between host organizations, SIM-funded local public health agencies and behavioral health transformation collaboratives, and SIM practices. The office is working with TriWest to evaluate the RHC program and suggest improvements for the future. And the population health workgroup will continue to provide guidance.
Behavioral health transformation collaboratives In addition to the population health-facing work of the RHCs, SIM seeks to influence population health efforts through a joint effort between CDPHE and The Denver Foundation. In September 2015, the two entities released a joint request for application (RFA) for a public-private partnership designed to eliminate overlap and redundancies and leverage funding opportunities focused on behavioral health and wellness in Colorado. While the original intent had been to have multiple cohorts of BHTCs, similar to practice cohorts, the SIM Office and CDPHE made the decision to combine cohorts into one group of awardees. This funding opportunity supports existing collaboratives that are formally working together to meet shared behavioral health goals. The collaboratives comprise community organizations and government agencies (including LPHAs) that have a formal partnership of three or more unrelated organizations, resident groups, and/or public entities (such as behavioral health organizations). By working together in ways that make sense for their communities, the collaboratives seek to bring assets and resources together in unique ways to increase access to behavioral health prevention and care and strive to improve behavioral health outcomes. The Denver Foundation is supporting 40 projects related to increasing access to behavioral health treatment and CDPHE supports two collaboratives focused on behavioral health prevention and screening with SIM funding. The goals of the treatment-focused funding are: 1. Reduce and remove barriers for Coloradans with high behavioral healthcare needs in accessing behavioral healthcare; 2. Build on innovations and investments in place around behavioral healthcare and support strategies for sustainability within the communities; 3. Support solutions that will benefit and meet the needs of the local community, as well as explore how those solutions could be replicated and/or scaled to meet the needs of communities across the state; and 4. Widely share solutions and approaches that improve access to behavioral healthcare, as well as openly convey “lessons learned.” The goals of the prevention-focused funding include: Page 102 of 239
1. Behavioral health outreach and education focused on behavioral health wellness and prevention; 2. Stigma-reducing programs and campaigns; 3. Community-based training and resources focused on behavioral health prevention; and 4. Improved coordination of systems that improve behavioral health screening and referral, with a focus on assessment of community-based resources and gaps.
Community-wide approaches Local public health agencies (LPHAs) Based on an RFA released in October 2015, CDPHE funded eight LPHAs across the state to support activities that promote behavioral health and improve community-based awareness, prevention, and screening of behavioral health disorders. This effort will improve the health of Coloradans by building capacity and support for the implementation of behavioral health promotion and the prevention of behavioral health disorders. These activities will also complement corresponding SIM activities to increase access to integrated physical and behavioral healthcare services in coordinated systems of care. The two focus areas that grantees must address are: 1. Behavioral health promotion, outreach, education, and/or stigma reduction focused on evidence-based/research-informed behavioral health, wellness, and prevention strategies; and 2. Coordination of systems that improve integration of behavioral and physical health services. LPHAs designed projects to influence behavioral health at a population health level based on their community and regional needs. LPHAs regularly report on progress, successes and barriers to CDPHE in quarterly reports, monthly check-in calls, and correspondence (e.g. e-mail, phone calls as needed). While eight LPHAs were selected as funded agencies, work conducted by the agencies affects 31 of Colorado’s 64 counties as many of the host agencies are working as regional collaboratives to ensure wide-ranging impact of their work. A map of host agency locations with surrounding counties is shown below. SIM Colorado LPHA host agencies and counties involved
Page 103 of 239
The following table includes details about host agencies that received SIM funding to conduct population health activities, counties involved, and the priority areas for population health activities. SIM Colorado-Funded LPHA, with Areas of Focus, Goals, and Expected Results
Page 104 of 239
Grantee Name
County(ies) included
Health Issue(s) Addressed
Goals
El Paso County Public Health
El Paso
Youth Depression
Reduce the incidence of depression among youth in El Paso County.
Mesa County Health Department
Mesa
Suicide
Increase community awareness of risk and protective factors related to suicide to decrease the stigma associated with seeking behavioral health services in Mesa County.
Northeast Colorado Health Department
Logan, Morgan, Phillips, Sedgwick, Washington, Yuma
Child Health Development
To promote behavioral health, wellbeing and prevention in a six-county region in northeast Colorado using evidence-based strategies and improving integration of behavioral health and primary care services.
Expected Results of Activity(s) 1. Decrease in youth suicide, youth suicide attempts 2. Increase in youth depression screening, referral to treatment, coordination of care and follow-up 3. Increase in trust and communication among partner agencies to better support youth at-risk for suicide 4. Decrease in stigma among adults and youth to encourage help seeking behavior for youth depression 5. Increase in awareness of resources to support youth with depression or at risk for suicide 1. Increased community member awareness of suicide risk and protective factors. 2. Increased community awareness of resources to support people who are contemplating suicide. 3. Reduction in stigma associated with suicide and seeking behavioral health services. 4. Increased awareness of resources, gaps, and overlaps between behavioral health and primary care. 5. Increased capacity of primary care providers to engage clients in behavioral assessments. 6. Increased connection to services for individuals identified as high risk through the screening. 1. Greater awareness in the region about pregnancy-related depression and depression in men 2. Better integration between behavioral health and primary care providers in Logan, Morgan, Phillips, Sedgwick, Washington and Yuma counties.
Page 105 of 239
Ouray County Public Health
Delta Gunnison Hinsdale Montrose Ouray San Miguel
Reduction of stigma associated with behavioral health
Improve behavioral health help-seeking attitudes and practices of the low socioeconomic (SES) status population of the West Central Public Health Partnership (WCPHP) region. Maximize access to behavioral health preventive services for low SES populations through assessment, partnerships, systems building and community-clinical linkages in the WCPHP region.
1. Decrease in behavioral health stigma among low SES populations in WCPHP region. 2. Increase in low SES populations screened, identified and referred for behavioral health issues. 3. Improved understanding of resources and gaps in behavioral health and primary care system and service integration.
Pueblo CityCounty Health Department
Pueblo
Integrated primary care
Improve access to integrated primary care and behavioral healthcare services in coordinated community systems for Pueblo County residents.
1. Improvement of Pueblo County’s behavioral health status through outreach, engagement and community development designed to systematically integrate primary care and behavioral health services. 2. Improved awareness and understanding of the link between chronic disease and behavioral health. 3. Decreased stigma and increased utilization of behavioral healthcare among community members and healthcare providers in Pueblo city and county.
Rio Grande County Public Health Agency
Alamosa Conejos Costilla Mineral Rio Grande Saguache
Preventive Services
Increase access to preventive services in San Luis Valley by integrating behavioral health and primary care.
1. Increase in patients screened, identified, referred and documented for behavioral health concerns from baseline provided in the patients’ health records. 2. Increase in community member and provider knowledge of behavioral healthcare services available in Rio Grande County. 3. Decrease in behavioral healthcare stigma among community members in San Luis Valley.
Page 106 of 239
San Juan Basin Health Department
Archuleta La Plata San Juan
Vulnerable Individuals and Families
Improve the health of vulnerable individuals and families by increasing access to integrated primary care and behavioral health services in coordinated community systems.
1. Increased collaboration with San Juan Basin Health Department around behavioral health issues by collaborators partners and stakeholders in Archuleta, La Plata, and San Juan counties. 2. Increased knowledge of behavioral health needs, gaps, target populations, and potential strategies 3. Increased community-level awareness of behavioral health issues
TriCounty Health Department
Denver Adams Arapahoe Douglas Boulder Broomfield Jefferson
Increase access to screening and integrated treatment for behavioral health issues for low-income people
Reduce stigma of behavioral health issues and increase openness to behavioral healthcare help-seeking attitudes and behaviors in low-income populations in the seven county Denver metro region.
1. One organization will pilot the stigma reduction messaging campaign. 2. The Common Messaging Campaign will be shared with at least eight community organizations the first year reaching approximately 150,000 residents in the Denver metro region. 3. Community assessments and gap analyses will be conducted in conducted in the seven counties of the Denver metro region. A plan to address gaps found in the community assessments to be implemented in years two and three of the grant in the seven counties of the Denver metro region. 4. All organization that participate in the screening access and referral assessment will be invited to participate in the plan to address gaps.
Increase access to behavioral health screening and treatment for low-income populations in the seven-county Denver metro region, through coordination of systems that improve integration of behavioral health services and primary care.
Page 107 of 239
Population health workgroup The SIM population health workgroup comprises 17 individuals from community and governmental agencies across Colorado with subject matter expertise. It convenes monthly to provide expert input and feedback to ensure that SIM interventions improve health outcomes at the community and population level and align and synergize with other population health and SIM efforts in Colorado. This workgroup continues to provide input and work with TriWest, the contracted SIM evaluator, to assess the population health effects of SIM. In March 2017, CDPHE worked with the population health workgroup to begin an environmental scan and gap analysis of existing population level behavioral health initiatives in Colorado. CPDHE contracted with the Denver office of Health Management Associates (HMA), a national healthcare consulting firm, to conduct the scan and gap analysis. The purpose is to identify efforts related to behavioral health, identify where efforts might be lacking, compare these findings to best practices in behavioral health prevention and promotion, and use this information to drive future decision-making, resource alignment and program activities for the population health workgroup and the state. The scan is anticipated to conclude in July 2017. The workgroup anticipates using this scan to inform a community strategy or call to action for improving behavioral health in Colorado with an anticipated second project phase to begin in fall 2017. This second phase, expected to be contracted to HMA, will build on the scan and gap analysis findings. With input from the workgroup, HMA will prepare a document with recommendations for how Colorado can expand its work in population-based behavioral health with programs for prevention and promotion, distribution of funding, and policy development and structure.
Population health data SIM is committed to addressing social determinants of health by encouraging and requiring LPHAs to address health disparities in local communities. CDPHE already tracks, monitors, and maps population health data and can break down this data by location, zip code, age, gender, income, and other demographic categories, depending on the population health measure, to identify and understand issues related to social determinants of health. In November 2016, CDPHE launched its Visual Information System for Identifying Opportunities and Needs (VISION) data tool, which provides consumers with interactive data visualization so they can create and extract data reports. CDPHE and SIM have frequently shared opportunities for training and presentations on the VISION tool to encourage widespread use and encourage RHC, funded LPHAs, and SIM practices to use the tool to focus and guide their efforts.
Additional SIM opportunities Funding opportunities for behavioral health transformation collaboratives and LPHAs outlined above allow awardees to select evidence-based or research-informed strategies that best address community needs. Grantees have strategically aligned their first-year grant activities with other non-SIM program activities, including maternal and child health, the Nutritional Program for Women, Infants and Children (WIC), Communities that Care, Aging and Disability Resources Centers (ADRCs), or their county health assessment (CHA) process to expand the reach of their SIM work and improve their community’s health. The SIM-funded CDPHE team will continue to encourage program alignment and consideration of new needs within the communities. SIM endeavors to consistently seek new partnerships and leverage emerging opportunities that might advance SIM goals. SIM staff have started to assess involvement or collaboration between local program coordinators for SIM activities and for maternal and child health activities. The CDPHE team is talking with different agency staffers to gauge awareness and collaboration with SIM staff to learn best practices (if an agency has high levels of coordination) and disseminate them. SIM-funded CDPHE staff also work to align programmatic work in CDPHE, including Page 108 of 239
participation in workgroups on mental health and substance use, and teen suicide. As grant activities continue to progress, SIM staff will continue to assess the ability to partner with new or existing efforts to reflect the changing needs and healthcare landscape in Colorado to improve the overall health of the state, and advance SIM goals.
Roadmap to improve population health Colorado’s population health activities summarized above provide a platform to leverage healthcare system strategies and broader public health goals and community efforts to improve population health in the state. Colorado’s strategic behavioral health population health roadmap illustrates the work underway to improve the behavioral health and wellness of the population. Given that behavioral health affects the overall health of the population, our roadmap represents an inventory of behavioral health strategies that align with advancing SIM goals and represents opportunities to support Colorado’s health delivery system and behavioral health integration efforts. These approaches are categorized into three approaches to prevention including the traditional clinical, innovative patient-centered care and funding models and/or community-clinical linkages, and community-wide approaches. The roadmap represents a more detailed overview of behavioral health priorities, strategies and work that can be leveraged to help achieve SIM goals. It was updated to reflect future SIM activities. Inputs include: ● Shaping a State of Health: Colorado’s Plan to Improve Public Health and Environment 2015-2019 ● Colorado’s MCH 2016-2020 Needs Assessment ● The State of Health: Colorado’s Commitment to Become the Healthiest State These were selected based upon their applicability to SIM and their potential reach. The list is not exhaustive, but is representative of Colorado’s behavioral health population health work as it relates to SIM. The behavioral health population health roadmap is organized by priority area and identifies proposed strategies and approaches to meet the goals along with proposed indicators and metrics to track impact. Each strategy is classified into one of three identified approaches to prevention. SIM priority areas and associated strategies and metrics are presented in the table to demonstrate alignment of SIM with other population health efforts. The roadmap serves as a guide for SIM activities for the next two years. Identified SIM goals, activities, and measures will be a part of the population health evaluation and contribute to the broader SIM evaluation. SIM goals and associated strategies and metrics will continuously be evaluated for progress and effectiveness, and collaboration with partners will continue to ensure aligned efforts surrounding SIM goals, strategies, and measures. The roadmap allows SIM staff to monitor other population health efforts in the state that relate to SIM, and tracking these efforts will continue for the duration of SIM. CDPHE staff will report on SIM-identified metrics and indicators to the SIM office on an annual basis. Colorado has made great strides in its population health efforts, and SIM has made great progress in building a behavioral health integration and health systems delivery infrastructure. During the next two years, SIM funding will allow targeted integration of physical and behavioral health in more than 400 primary care practices and community mental health centers (CMHCs) with about 1,600 primary care providers. Initiative staff is working with the Multi-Payer Collaborative to encourage most payers to adopt more shared risk and savings programs by 2019, is working to expand information technology, including telehealth, and launched a robust evaluation program that measures processes and outcomes. The population health efforts are poised and ready to help SIM achieve its stated goal.
Page 109 of 239
Behavioral health population health roadmap KEY MCH State of Health State PHIP SIM
Colorado Maternal and Child Health 2016-2020 Needs Assessment The State of Health: Colorado’s Commitment to Become the Healthiest State Shaping a State of Health: Colorado’s Plan to Improve Public Health and the Environment, 2015-2019 Colorado SIM
Goals
Proposed Approach/Strategy
Priority Area: Behavioral and Mental Health 1. Advance policy and Expand comprehensive social community approaches and emotional health screening to improve the social of caregivers by increasing and emotional health of adoption of depression mothers, fathers, screening codes for caregivers caregivers, and children at the child’s visit Support efforts designed to increase access to high quality mental and behavioral health care Develop and expand the behavioral health workforce
2. Increase the number of children in Colorado receiving age-
Change the reimbursement structure for mental health services by increasing incentives Promote best practice mental health integration in all publicly funded primary care Identify and implement policy/systems changes that improve developmental
Progress
Proposed Metric/Indicator
Source
Level of Impact
TBD
State PHIP
Traditional clinical approaches
On track. Not a chosen approach for SIM, but CDPHE’s Maternal Wellness unit is focusing on this.
TBD
State PHIP
Traditional clinical approaches
On track.
TBD
State PHIP
Traditional clinical approaches
TBD
State PHIP
Traditional clinical approaches
TBD
State PHIP
# of state agency leaders and statewide partners who develop and endorse key
MCH
Innovative patientcentered care and/or community linkages Innovative patientcentered care and/or community linkages
On track. SIM Workforce Development leading effort. On track. Colorado’s Accountable Care Collaborative (ACC) rebid addressing this. On track. Work of some LPHAs funded by SIM. On track. SIM LPHA work; work of MCH unit in CDPHE.
Page 110 of 239
appropriate developmental screening and increase the number of children who are evaluated and who receive services among those with identified needs
screening, referral and services for children ages 10 through 71 months
Support individualized technical assistance to LPHAs, community and health care partners on best practices in early childhood developmental screening, referral and interventions services 3. Reduce the burden of depression in Colorado, especially among pregnant women, men of working age, and individuals who are obese
Improve screening and referral practices
Reduce stigma of seeking help for depression
Partner with stakeholders and the Governor’s office to share consistent messages focused on mental health as a part of overall health, and the importance of integrated care delivery systems
recommendations for improved policies and coordination of services related to developmental screening, referral, and intervention services # of statewide organizations or systems that implement developmental screening, referral and intervention recommendations # of LPHAs, community and/or health care partners in Colorado that have implemented internal processes that support optimal early childhood development through a family centered approach Percent of adults who reported taking medication or receiving treatment from a doctor or other health professional for any type of mental health condition or emotional problem Percent of adults who report experiencing symptoms of depression (increase implies reduced stigma) Number of partnerships sharing consistent messaging focused on mental health as a part of overall health, and the importance of integrated care delivery systems
MCH
Innovative patientcentered care and/or community linkages
On track. SIM LPHA work; work of MCH unit in CDPHE.
MCH
Innovative patientcentered care and/or community linkages
On track. SIM LPHA work; work of MCH unit in CDPHE and SIM staff within CDPHE.
State PHIP
Traditional clinical approaches
On track. SIM LPHA work.
State PHIP
Community-wide strategies
On track. SIM LPHA work.
State PHIP
Community-wide strategies
On track. SIM LPHA work and work of SIM staff at CDPHE.
Page 111 of 239
3a. Reduce the burden of depression among pregnant and postpartum women
Develop competencies for providers and hospitals to more adequately address pregnancy related depression (PRD)
Strengthen referral networks for providers to address pregnancy-related depression
Develop and implement a public awareness initiative to address stigma 3b. Reduce the burden of depression among men of working age
Reduce the stigma of seeking help for depression
Increase access to an online cognitive behavior therapy tool
% of mothers reporting that a doctor, nurse or other health care worker talked with them about what to do if they felt depressed during pregnancy or after delivery % of mothers who are appropriately screened and treated for depression
State PHIP
Traditional clinical approaches
On track. SIM LPHA work; work of MCH unit in CDPHE and SIM staff within CDPHE.
State PHIP
Traditional clinical approaches
# of providers and/or hospitals in Colorado that implement key PRD competencies into standard work # of pregnant and postpartum women with PRD symptoms referred for treatment
MCH
Traditional clinical approaches
MCH
Innovative patientcentered care and/or community linkages
# of Medicaid providers who screen pregnant or postpartum women for PRD
MCH
Innovative patientcentered care and/or community linkages
% of providers who talk to a woman about what to do if they experience signs and symptoms of depression % of pregnant and postpartum women who understand that PRD is common and that it is okay to ask for help # of men who access and use Mind Master, the online cognitive behavior therapy tool on Mantherapy.org Percent of men who report experiencing symptoms of
MCH
Innovative patientcentered care and/or community linkages
MCH
Community-wide strategies
State PHIP
Innovative patientcentered care and/or community linkages
State PHIP
Community-wide strategies
On track. SIM LPHA work; work of MCH unit in CDPHE and SIM staff within CDPHE. On track. SIM LPHA work; work of MCH unit in CDPHE and SIM staff within CDPHE. On track. SIM LPHA work; work of MCH unit in CDPHE and SIM staff within CDPHE. On track. SIM LPHA work; work of MCH unit in CDPHE and SIM staff within CDPHE. On track. SIM LPHA work; work of MCH unit in CDPHE and SIM staff within CDPHE. On track. SIM LPHA work; work of MCH unit in CDPHE and SIM staff within CDPHE. On track. SIM LPHA work; work of VIP-MHP unit in CDPHE and SIM staff within CDPHE. On track. SIM LPHA work; work of VIP-MHP
Page 112 of 239
through access to the Man Therapy campaign and website
3c. Reduce the burden of depression among individuals who are obese
Provide best practices, tools, and guidelines to primary care and behavioral health providers on screening and referral for depression and physical health care needs for obese patients
Priority Area: Substance Abuse 1. Reduce prescription Improve usability and drug overdose death appropriate accessibility of the rates of Coloradans prescription drug monitoring ages 15 and older program (PDMP) system 2. Decrease the percent through the use of information of women ages 18-44 technology, increased who used an illicit drug stakeholder access, and (including marijuana or increase use as a public health non-medical use of tool prescription drugs) during the past 30 days
Ensure all physicians and dentists receive continuing education about safe prescribing practices, including the use of the PDMP
depression (an increase implies reduction in stigma) Number of visitors to Mantherapy.org
State PHIP
Community-wide strategies
# of viewers of online training about the relationship between depression and obesity that describes best practices and tools to improve screening and referral for depression and physical health care needs for obese patients
State PHIP
Traditional clinical approaches
Ratio of queries of the prescription drug monitoring program database per filled controlled substance prescription
State PHIP
Innovative patientcentered care and/or community linkages
Ratio of queries to PDMP per high-dose opioid prescriptions dispensed to women age 1844
MCH
Innovative patient centered care and/or community linkages
Rule(s) promulgated for all DORA-licensed prescribers to include pain management guidelines and require
State PHIP
Traditional clinical approaches
unit in CDPHE and SIM staff within CDPHE. On track. SIM LPHA work; work of VIP-MHP unit in CDPHE and SIM staff within CDPHE. On track. SIM LPHA work; work of VIP-MHP unit in CDPHE and SIM staff within CDPHE.
On track. Not a chosen focus area for SIM. CDPHE’s VIP-MHP branch, DORA, the Colorado Consortium for the Prescription Drug Abuse Prevention are addressing through pilot projects to improve PDMP access for providers. On track. Not a chosen focus area for SIM, but a focus area for CDPHE Children, Youth and Families branch and VIP-MHP branch. Not a chosen focus area for SIM. DORA issued opioid prescribing guidelines, but not “pain
Page 113 of 239
continuing education on safe prescribing practices
Increase access to permanent disposal sites for controlled substances
management guidelines.” There is no continued education that is required.
Statement issued to physicians by the Colorado State Board of Health, Board of Medicine, Department of Regulatory Affairs, or other statewide medical recommending body (e.g. CO AAP) regarding medical marijuana use during pregnancy or post-partum # of partners enlisted to offer provider trainings regarding safe and effective pain management practices, including the use of the PDMP
MCH
Traditional clinical approaches
Not a chosen focus area for SIM. Materials for clinical guidance around medical marijuana during pregnancy previously developed in 2015.
State PHIP
Traditional clinical approaches
# of healthcare providers who provide care to pregnant, post-partum, or women of reproductive age that complete prescription drug continuing medical education training or that receive marijuana education
MCH
Traditional clinical approaches
# of permanent drug disposal sites for controlled substances
State PHIP & MCH
Community-wide strategies
On track. Not a chosen activity for SIM. Focus area for CDPHE VIPMHP branch and the Colorado Consortium for Prescription Drug Abuse Prevention. On track. Not a chosen activity for SIM. CDPHE’s VIP-MHP and Children Youth and Families branch are focusing on this objective. Of note: prescription drug training and marijuana education are separate program activities. On track. Not a chosen activity for SIM. Focus area for CDPHE’s VIPMHP and Environmental Health and Sustainability
Page 114 of 239
Division and the Colorado Consortium for Prescription Drug Abuse Prevention. Work with partners to inform Perception of “no risk” of and disseminate mass reach harm from daily or near daily health education campaigns use of marijuana among that target pregnant and postwomen ages 18-44, and partum women with substance specifically for pregnant and abuse prevention messages postpartum women Priority Area: Health Care Access, Coverage, Integration and Quality 1. Align state and local Standardize and connect public Number of sites reporting public health with health data systems to allow successful ongoing submission health care reform for appropriate electronic of appropriate public health efforts to increase public health and clinical data tracking data access to and utilization exchange through the Health of health care and Information Exchange Number of public health related services agencies able to engage in real-time data sharing with Health Information Exchange Increase collaboration among clinical care, public health and payers to build a more integrated, effective health care system Develop policy and systems change strategies that support a medical home approach within their communities
MCH
Community-wide strategies
On track. Not a chosen activity for SIM, but CDPHE’s VIP-MHP is working on this.
State PHIP
Innovative patientcentered care and/or community linkages
State PHIP
Innovative patientcentered care and/or community linkages
State plan for investment in workforce development for primary, oral and mental health providers who care for medically underserved Coloradans % of children ages 1-14 who receive care within a medical home
State PHIP
Innovative patientcentered care and/or community linkages
On track. Not a chosen activity for SIM but CDPHE’s Health Systems Unit is working on this. On track. Not a chosen activity for SIM but CDPHE’s Health Systems Unit is working on this. On track. Not a chosen activity for SIM but CDPHE’s Primary Care Office is working on this.
State PHIP
Innovative patientcentered care and/or community linkages
% of children and youth with special health care needs (CYSHCN) ages 1-14 who receive care within a medical home
State PHIP
Innovative patientcentered care and/or community linkages
On track. Not a chosen activity for SIM but CDPHE’s MCH / HCP is working on this. On track. Not a chosen activity for SIM but CDPHE’s MCH / HCP is working on this.
Page 115 of 239
Identify and implement policy/systems changes that support communication and collaboration between programs that provide care coordination for children and youth Identify and implement policy and systems changes that enhance statewide access to pediatric specialty care for CYSHCN
% of CYSHCN who receive HCP Care Coordination services that have an inter-agency plan of care
MCH
Innovative patientcentered care and/or community linkages
On track. Not a chosen activity for SIM but CDPHE’s MCH / HCP is working on this.
MCH
Innovative patientcentered care and/or community linkages
On track. Not a chosen activity for SIM but CDPHE’s MCH / HCP is working on this.
MCH
Innovative patientcentered care and/or community linkages
On track. Not a chosen activity for SIM but CDPHE’s MCH / HCP is working on this.
State of Health State of Health
Traditional clinical approaches
On track. SIM Workforce Development lead. On track. Not a chosen activity for SIM but HCPF and Connect for Health Colorado continue to enroll members under the expansion.
State of Health
Innovative patientcentered care and/or community linkages
2. Expand health care access
Close gaps in access to primary care and other health services
Development of an implementation and funding plan based on the key recommendations identified by the interagency pediatric specialty care partners Identification and prioritization of evidence based transition strategies for state and local implementation to strengthen transition for CYSHCN # of new providers recruited and retained
3. Improve health care coverage
Expand public and private health insurance
# of Coloradans who are insured
4. Improve health system integration and quality
Expand use of patient-centered medical homes for Colorado adults
Number of Colorado adults connected to a patientcentered medical home
Identify and implement policy and systems changes that strengthen transitions for CYSHCN
Community-wide strategies
On track. Focus area for ACC/ RCCOs.
Page 116 of 239
5. Enhance value and strengthen sustainability
Support better behavioral health through integration
TBD
State of Health
Innovative patientcentered care and/or community linkages
On track.
Reduce Medicaid costs by expanding and developing new care delivery platforms
ACC cost savings per year
State of Health
Innovative patientcentered care and/or community linkages
On track. Focus area for HCPF and ACC.
Invest in HIT
# of Coloradans served by providers with EHRs and connected to Health Information Exchange
State of Health
Innovative patientcentered care and/or community linkages
On track. Focus area for CDPHE’s CHED and the Governor’s Office of E-Health Innovation.
Advance payment reform in the public and private sectors
# of payment reform pathways in Colorado
State of Health
Innovative patientcentered care and/or community linkages
On track. Focus area for HCPF; CDPHE coordinating efforts.
State PHIP, MCH, Vision 2018 MCH
Innovative patientcentered care and/or community linkages
Not a chosen approach for SIM; focus area of CDPHE’s ECOP team.
Innovative patientcentered care and/or community linkages
Not a chosen approach for SIM; focus area of CDPHE’s ECOP team.
MCH
Traditional clinical approaches
Not a chosen approach for SIM; focus area of CDPHE’s ECOP and HEAL teams.
Priority Area: Healthy Eating, Active Living and Obesity Prevention 1. Increase the Develop and support policies # of hospitals designated as percentage of infants and programs that protect, baby-friendly who are ever breastfed, promote and support and exclusively breastfeeding-friendly breastfeed through six environments months Marketing and distribution of a toolkit of resources and training opportunities to strengthen breastfeeding support 2. Improve nutrition Implement cross-sector use # of partners reporting and physical activity among providers of consistent dissemination and/or use of environments for messaging related to early ECOP messages in their children younger than childhood obesity prevention practice, programs and 18 years via early (ECOP) evidence-based activities childhood education practices
Page 117 of 239
centers and schools, especially those that serve low-income populations
Expand access to the child and adult care food after-school program
# of meals distributed
State PHIP
Community-wide strategies
Implement evidence-based physical activity interventions in select child care centers through a network of state and local partners
# of providers representing child care centers that have integrated structured physical activity into center lesson plans, curriculum and/or policy # of worksites that have adopted worksite wellness policies combining healthy eating, lactation accommodation, and physical activity # of adults ages 18 and older with pre-diabetes and/or at high risk of developing type 2 diabetes enrolled in the Diabetes Prevention Program
MCH
Community-wide strategies
State PHIP
Innovative patientcentered care and/or community linkages
Not a chosen approach for SIM; focus area of CDPHE’s HEAL team.
State PHIP
Innovative patientcentered care and/or community linkages
Not a chosen approach for SIM; focus area of CDPHE’s DPP team.
# of local governments that have adopted and/or implemented policies and environmental strategies to increase safe, equitable access to physical activity through the built environment
State PHIP
Community-wide strategies
Not a chosen approach for SIM; focus area of CDPHE’s HEAL and OHE teams.
Source
Level of Impact
3. Increase access to worksite wellness programs and to healthy foods and beverages in worksite and government settings
Develop a statewide strategic plan for worksite wellness that includes a network to assess, implement, communicate, and deliver national best practices in worksite wellness Increase referrals to, use of, and reimbursement for the Diabetes Prevention Program
4. Advance ‘health in all policies’ as a widespread philosophy for actively engaging in state and local land use, transportation, agriculture and community development initiatives
Develop policy and environmental strategies that focus on increasing access to physical activity and promoting health equity
Not a chosen approach for SIM; focus area of CDPHE’s Nutrition Services team. Not a chosen approach for SIM; focus area of CDPHE’s HEAL team.
SIM-Specific Activities Goals
Proposed Approach/Strategy
Proposed Metric/Indicator
Progress
Priority Area: Behavioral and Mental Health
Page 118 of 239
1.Increase provider knowledge surrounding behavioral and mental health issues with emphasis on vulnerable populations
2. Improve behavioral health screening and referral
3. Improve upon traditional public health surveillance to incorporate behavioral health measures
4. Increase LPHA capacity to support community-based behavioral health integration
Develop provider education on pregnancy-related depression, obesity and depression, depression in men, senior behavioral health, and behavioral health trauma/trauma related issues Develop provider education and evaluation plan to outline the education and evaluation that will be delivered following the successful delivery of the first three modules Develop state guidelines for psychotropic medications for children and distribute to providers and practices, specifically emphasizing practices that serve foster care and welfare children Enhance and expand the work of SBIRT and work to increase the knowledge about the behavioral health needs of special populations Develop an inventory of public health surveillance measures and identify physical and behavioral population health measures that align with the SIM CQMs and are available at the state and county levels Increase number of LPHAs who participate in a collaborative or coalition focused on behavioral health and wellness and prevention of chronic disease
# of providers who complete the courses (evaluation plan to be determined)
SIM
Traditional clinical approaches
On track.
# of providers who complete the courses (evaluation plan to be determined)
SIM
Traditional clinical approaches
On track.
Document created and # of SIM practices reporting use of guidelines
SIM
Traditional clinical approaches
On track.
# of sites implementing SBIRT
SIM
Traditional clinical approaches
On track.
SIM population health measures inventory and tracking system created
SIM
Traditional clinical approaches
On track.
# of LPHAs funded through SIM funding who participate in a collaborative or coalition with community partners
SIM
Innovative patientcentered care and/or community linkages
On track.
Page 119 of 239
Build capacity and support in LPHAs for the implementation of behavioral health promotion and the prevention of behavioral health disorders through technical assistance and learning collaboratives Distribute SIM funding to LPHAs to support activities that promote behavioral health and improve community based awareness, prevention and screening of behavioral health disorders Priority Area: Substance Abuse 1. Increase provider Develop and disseminate SUD knowledge surrounding education to enhance SUDs integrated behavioral health Develop and disseminate pregnancy and SUD education to enhance integrated behavioral health
Technical assistance provided (evaluation plan to be determined)
SIM
Community-wide strategies
On track.
# of LPHAs funded (evaluation plan to be determined)
SIM
Community-wide strategies
On track.
# of providers who complete the courses and the number of courses offered # of providers who complete the courses and the number of courses offered
SIM
Traditional clinical approaches
On track.
SIM
Traditional clinical approaches
On track.
SIM
Traditional clinical approaches
On track.
SIM
Innovative patientcentered care and/or community linkages
On track.
Priority Area: Health Care Access, Coverage, Integration, and Quality 1. Increase provider and Develop best practice Guidelines created clinic/hospital guidelines for behavioral health competencies about staff working in health settings behavioral health and primary care integration 2. Increase community Deploy Regional Health # of Regional Health capacity to support Connectors across the Colorado Connectors deployed behavioral health to facilitate linkages among the various components of the health and health care delivery system
Page 120 of 239
3. Strengthen community-based behavioral health collaboratives
Improve the accessibility, quality, and efficiency of primary care systems by collaborating with local health departments and other community agencies Increase access to behavioral health care by funding projects that increase access to behavioral health prevention, screening and treatment
# of partnerships formed
SIM
Innovative patientcentered care and/or community linkages
On track.
# of projects funded by SIM
SIM
Innovative patientcentered care and/or community linkages
On track.
Fund existing collaboratives comprised of community organizations and government agencies including LPHAs in a formal partnership of three or more unrelated organizations to meet shared goals around behavioral health
# of collaboratives funded
SIM
Community-wide strategies
On track.
Page 121 of 239
4. Health information technology Operational Plan Update Purpose and Requirements Colorado is focused on leveraging and enhancing current HIT infrastructure and integrating and aligning new technology in a systematic manner to advance payment reform and care delivery. The SIM team and other state-led groups have made significant progress in these critical areas through transformation programs. In award year (AY) 2 of the SIM grant, the SIM Office, Office of eHealth Innovation (OeHI), and the Health Information Office (HIO) of the Department of Health Care Policy and Financing (HCPF) continued to advance SIM’s HIT operational plan. The team recognized that the conceptual HIT plans required additional input from providers, payers, policy makers, technical experts, and partner organizations to assess capabilities, enable infrastructure, and funding to move the plans forward. During AY2, the SIM Office contracted with the following companies/individuals: Mede Analytics to complete a use case prioritization, Kate Keifert (independent contractor) to complete a feasibility analysis, and Deloitte Consulting to determine business and functional requirements for the top two prioritized use cases with a focus on the second use case. OeHI has continued along a parallel, complementary process to prioritize HIT through development of an HIT roadmap for the state. The SIM work, and the clinical quality measures (eCQM) implementation roadmap that Deloitte will produce by July 2017, is meant to fit into the larger state roadmap and connect the SIM use cases to the larger ecosystem of HIT. Working with these contractors during the last year has illustrated the shifting landscape of HIT and the fact that many providers, payers and systems have invested in their own solutions and do not want duplicative technology. Significant investments have also been made in the state, such as the All Payer Claims Database (APCD) and health information exchanges (HIEs), which should be leveraged in the future. We also learned that there is no one-size-fits-all, nor is there the political will to invest in largescale technology that has not shown a return-on-investment (ROI) for key stakeholders. A modular approach has been recommended—begin with foundational investments that can be scaled. Continued partnership between the SIM office, OeHI, HCPF, and the state’s Office of Information Technology (OIT) will enable this modular approach to meet the SIM HIT objectives, and build a foundation for effective data sharing in Colorado. The AY3 HIT operational plan will outline the implementation strategy for AY3. While there are many unknowns and dependencies, the AY3 plan will identify decision points throughout the year that allow the reader to understand the SIM HIT roadmap with a decision tree to guide HIT investments. To further refine the HIT year-3 operational plan, SIM is committed to developing and delivering the following deliverables to CMMI: ●
Workplan (1-2 pages) with key action decisions/discussions for SIM HIT YR 3 operational plan with dates developed by SIM and OeHI that will be submitted to CMMI by July 15 ● Conceptual framework of eCQM solution developed by Deloitte submitted to CMMI by the end of June ● Quality measurement and reporting implementation timeline and roadmap developed by Deloitte and submitted to CMMI by the end of July ● Refined data flows developed by SIM and OeHI with input from Deloitte and Health Tech Solutions submitted to CMMI by the end of August While Colorado has made significant investments in HIT and HIE infrastructure, plans for statewide enterprise architecture to aggregate claims and clinical information and integrate behavioral and physical health information require careful consideration from a political, technical, financial, and social Page 122 of 239
perspective. As noted above, a modular approach of foundational HIT investment has been identified as the path to take for SIM, OeHI and its partners. With shifting federal and state policy related to payment reform, existing HIT/HIE investments, and the need for more trust in existing information sharing and data systems, stakeholders encourage the SIM team to leverage HIT/HIE efforts underway and further define a longer-term HIT/HIE vision for data aggregation, integration, and governance with OeHI and its eHealth Commission’s Health IT Roadmap efforts. From a policy perspective, the state is interested in the transparency of cost and quality for consumers and aligning quality measurement and reporting to reduce provider burden and improve quality and financial outcomes. The SIM AY 3 operational plan is organized by prioritized use cases, both of which fit into the broader framework developed for the OeHI roadmap to ensure sustainability. We initially believed that aggregating claims and clinical in one location would be ideal, but stakeholders have said they would prefer a modular implementation approach that culminates in aggregation and integration of clinical and claims data but starts with incremental and foundational investments. SIM’s AY 3 HIT operational plans focuses on two key use cases identified and prioritized by stakeholders to advance service delivery and payment reform: 1- Promote statewide health information and data sharing 2. Enhance quality measurement reporting and analytics For the first use case, SIM is working with OeHI, HCPF, the Colorado Department of Health and Human Services (CDHS), the Colorado Department of Public Health and Environment (CDPHE), OIT, and the state HIEs - the Colorado Regional Health Information Organization (CORHIO) and Quality Health Network (QHN) – to promote statewide health information and data sharing. SIM is working with OeHI and the eHealth Commission to define plans and funding in Colorado’s HIT roadmap. This includes ongoing discussions and planning for federal HIT/HIE funding requests and a new joint-budget request from the state legislature in November 2017 for funds in 2018. Planning is underway and the final plans will to be delivered to the governor’s office in October 2017. For the second use case, SIM is working with Deloitte, OeHI, and OIT to develop an implementation roadmap and timeline, which includes business, functional and technical requirements for a quality measurement and reporting solution by mid-July 2017. These plans will be presented to SIM’s HIT workgroup and steering committee as well as the eHealth Commission for review in August 2017. Upon approval, SIM will move forward with development of a request for proposal (RFP) and procurement of a quality measurement and reporting solution that supports value-based payment and is more automated than SPLIT, the current portal for manual reporting of clinical quality measures. For both use cases, key decisions will need to be made related to the following to ensure alignment and sustainability of SIM’s HIT/HIE investments with the following: HCPF Decisions with OeHI/SIM support o o
How will HCPF require providers to report on quality for clinical, structural, and performance measures in the new alternative payment model (APM)? How will the new Accountable Care Collaborative 2.0 contract combine accountable care and behavioral health organizations into one entity that leverages SIM’s efforts?
Page 123 of 239
o o
What is the timeline and plan for leveraging the new Health First Colorado (Medicaid) systems once fully implemented? HCPF in the process of addressing questions, plans, and timeline of new APM and how to best leverage systems and resources. SIM and OeHI are working with Deloitte to support HCPF and define the roadmap and timeline as it relates to quality measurement and reporting. Readiness of HCPF’s system and providers will be considered in SIM/OeHI plans for eCQM solution. Specific recommendations will be provided June 15 and finalized by Deloitte in July 2017. Any delay in decisions might affect funding and procurement of new systems.
Multi-Payer Collaborative Decisions with SIM/OeHI support o o
What is the plan for Stratus™ and continued investment from the payers and Multi-Payer Collaborative (MPC) after completion of SIM and CPC+? The MPC is implementing a claims aggregation solution for SIM cohort 1 and new CPC+ providers. Further input from the MPC and the governor’s office is needed to determine appropriate steps for the collaborative decision-making process. SIM is working with Deloitte to define recommendations and impact of decisions.
OeHI and SIM with eHealth Commission and SIM stakeholder input o o
How will Colorado fund ongoing operations and maintenance for a quality measurement and reporting solution? OeHI and the eHealth Commission are developing initiatives for Colorado’s HIT roadmap, which includes defining new and existing programs and funding strategies. This effort aligns directly with SIM’s eCQM solution. Any delay in decisions might affect funding and procurement of new systems.
Moving into AY 3, the SIM Office, OeHI, and HIO have committed to weekly tactical implementation meetings to process these questions, currently considered dependencies or considerations that have not yet been fully flushed out. In June of 2017, we will develop agreed upon governance structure for meetings, budget, and initiatives. These decisions will impact the modular investments in technology, yet as with many large-scale decisions, in the setting of implementing a new MMIS BIDM system, the state was not prepared to answer these questions in AY 2.
SIM Year 3 Operational Plan Award year 3 of the SIM initiative is focused on continuing to operationalize and implement SIM’s HIT plans for the two, key use cases:
Use Case 1— Promote Statewide Health Information and Data Sharing Goals and Objectives: o
Promote sharing of information ▪ Continue to increase the number of SIM practices connected to HIEs- 50% SIM practices connected to an HIE ▪ Implement “Shared Care” report pilot with HIEs and SIM several practices JuneJuly 2017 and develop plan to expand innovation effort. ● Outcome of the pilot will affect how SIM and OeHI advance efforts with this type of report. We will need to further align with ACC 2.0 and get approval from executive leadership at HCPF to expand to Health First Colorado populations. Preliminary planning funds are being consideredPage 124 of 239
o
o
o o
but the master patient index (MPI)/master patient database (MPD) and eCQM solutions are higher priority for HCPF and OeHI in FY 2018. An update to the IADP in fall 2017 might be considered if pilot is successful. ▪ Define technical requirements for MPI/MPD and release RFP in fall 2017. ▪ Leverage SIM dollars to support OeHI procurement of MPI/MPD due to timing of requests and available 90/10 funds. Provide resources for adoption and implementation ▪ HIT/HIE assessment of SIM practices, community mental health centers (CMHC), and ACC practices’ HIT/HIE capabilities- assessment to be completed in July 2017-and to inform SIM and state funding decisions. ● HCPF/OeHI/SIM plan to share assessment outcomes with stakeholders for input and will determine how to invest and align funds for SIM, CMHCs, and RCCOs. ● It is also being considered in OeHI/SIM’s joint budget request for 2018/2019 and development of Colorado’s HIT roadmap initiatives. ▪ Further define technical assistance and practice transformation support needed for SIM practices. Statement of work (SOW) being revised to further define competencies and deliverables for clinical health information technology advisors (CHITAs) — to be included in final SIM workplan July 2017. Harmonized consent for the sharing of information ▪ Leverage ONC’s Advanced Interoperability Grant efforts-completed in June 2017. ▪ Use Colorado’s roadmap planning effort to determine the strategy for sharing consent broadly across the state. ▪ The eHealth Commission Planning Work Group is working on a definition of harmonized consent with direct input from SIM and consideration of the HIT/HIE assessments for CMHCs, RCCOs, and SIM practices. Scope and budget being finalized in summer 2017 for inclusion in SIM’s Year 3 HIT operational plan and Colorado HIT Roadmap. Accelerate adoption of telehealth and digital health innovations ▪ Telehealth requirements for RFP in progress. RFP to be released October 2017. Aggregation of clinical and claims data for value-based payment ▪ Support MPC efforts to aggregate claims data for CPC+ and SIM practices by attending working sessions. ▪ Support the MPC pilot to integrate clinical and claims information integration for three CQMs (Diabetic HbA1c, Depression Screening, and Depression Remission). Pilot is pulling in clinical information from HIEs CORHIO and QHN. ▪ Define statewide plans for the aggregation of clinical and claims information through Colorado HIT Roadmap efforts and as it relates to the second use case. Final plan delivered to the governor’s office in October 2017.
Page 125 of 239
Use Case 2- Enhance Quality Measurement Reporting and Analytics Goals and Objectives: o
o
o
o
Provide venue for easy, efficient, effective, consolidated eCQM reporting for providers ▪ Deloitte conducting stakeholder interviews and technical assessment of capabilities and feasibility; will define objectives when the implementation plan and roadmap are delivered in July 2017. Simplify reporting requirements and processes for quality and value in healthcare. ▪ Leverage SIM-aligned CQMs by developing a plan through Colorado HIT Roadmap efforts. ▪ Partner with the MPC to further define opportunities for measure alignment across initiatives and value-based payment programs. Provide more efficient, streamlined processes and tools for providers to report on required healthcare metrics. ▪ Deloitte is conducting stakeholder interviews and technical assessment of capabilities and feasibility- will define objectives when implementation plan and roadmap are delivered in July 2017. Strengthening HIT/HIE infrastructure to support eCQM reporting: ▪ Deloitte is conducting stakeholder interviews and technical assessment of capabilities and feasibility (defined objectives in implementation plan/roadmap). Anticipate RFP December 2017 to begin work February 2018. Data extraction validation target is SIM/Health First Colorado practices. ● Colorado is committed to submitting a final report to ONC by July 30, 2017. Deloitte will present initial recommendations June 15 and share preliminary recommendations after SIM and OeHI reviews. Stakeholder interviews are still in progress.
Page 126 of 239
Start Date
Milestone
Deliverables
Deliverable Due Date 8/1/2017
Utilization/penetration ALL Health First Colorado Primary Care Medical Providers + All SIM provider practices
Budget/Funding Source HCPF/CHITA scope
4/1/2017
Complete HIT/HIE assessment: SIM and Health First Colorado RCCO practices
Aggregated Assessment of SIM/RCCO practice HIT/HIE capabilities
5/1/2017
HIE Shared Care report pilot: final report delivered to practices with feedback
Summary of impact of Shared Care report on care coordination to inform expansion of pilot
8/1/2017
5% of SIM cohort-1 practices for pilot, expand to additional SIM and HCPF practices during AY3. The aim is to expand to all SIM practices but the decision to fund expansion will be made on completion of pilot.
$96,000
06/01/17
SIM HIT Workplan for CMMI
1-2 Page Workplan with AY3 decisions, action items, and discussions to track progress
08/31/17
N/A
SIM
Decision Tree HIT/HIE assessments will inform practice readiness for eCQM extraction and necessary requirements for the RFP HIE Shared Care pilot to inform medical neighborhood and care gaps—pilot practices to inform continuation of this to broader cohort of practices. Upon completion of the pilot decisions will be made on how to fund and expand to other SIM practices and Health First Colorado. How to integrate and track decisions for each use case and governance of OeHI/SIM/HCPF planning efforts. Combine workplan component table, milestones timeline (built from original ops plan) and
Page 127 of 239
06/01/17
Refined data flows
Define data flows for care delivery and data integration in support of payment reform for SIM’s HIT use cases.
9/15/2017
N/A
SIM/HCPF
2015
ONC Advanced Interoperability white paper: Informs data sharing and consent management for BH/LTSS Enhance CHITA scope of work and funding to enhance data quality reporting and practice support
Recommendations to the eHealth Commission and SIM HIT workgroup
8/1/2017
CAII grant assessed 500 eligible providers and connect: 338 eligible providers and 30 TPAC, piloted two different consent efforts from CORHIO/QHN
TBD
SOW with activities and deliverables for CHITAs
9/2017 Go Live
257 practices--SIM Cohort 1 and Cohort 2 practices
See practice transformation budget
Establish baseline for SIM cohort-1 practices connected to HIE
List of SIMconnected practices from CORHIO and QHN
10/1/2017
Identified that 48 practices or 50%—
HITECH
5/1/2017
2/1/2017
timeline budget table) Future state role of BIDM and HIEs, Current and future state of the integration of behavioral and physical health, State quality measurement and reporting State data aggregation for use cases 1, 2 Partners producing white paper planned summer 2017 will inform SIM office and OeHI next steps to implement broader consent model. AY2 CHITAs could only focus on quarterly reporting not data quality and workflow— enhanced investment will enable more effective data quality and validation HIE technology must be maximized—if cannot reach critical threshold of practice
Page 128 of 239
03/01/2017
Business and functional requirements for MPI/MPD development
Final draft of functional and business requirements delivered to OeHI and eHealth Commission
04/12/2017
Phased requirements focus on SIM and Health First Colorado populations for Phase One.
HITECH
05/19/17
State budget request initiated in partnership with SIM, HCPF and OeHI in discussions with governor’s office
Healthy Coloradan: MPI/MPD Quality Measurement Program-TBD
7/1/2018
SIM, Health First Colorado, and state populations
See eCQM section for more detailsHITECH, SIM, and 90/10 Funds leveraged and requested
connectivity will impact requirements for eCQM extraction Additional specificity on use cases for SIM and Health First Colorado are needed. Will be determined during development of technical assessments. Due to timing of RFP release, we will need to determine how to fund MPI/MPD with SIM, HITECH, and state funds. Requested 1.5 million for MPI/MPD for Fy2017/2018 from CMS. Will need to ask for additional state funds to leverage for additional 90/10 in 2018/2019, leverage SIM funds due to timing, and determine sustainable funding for ongoing operations and maintenance.
Page 129 of 239
05/19/17
Project plan for MPI/MPD
Initial project plan delivered to SIM/OeHI for review
06/01/17
SIM, Health First Colorado, and state populations
HITECH
6/19/2017
Technical requirements for MPI/MPD developed
Draft RFP including technical requirements for MPI/MPD
08/01/2017
Use cases for MPI/MPD focused on SIM and Health First Colorado populations in initial phase, future phases may include DORA, and CDPHE. Use cases will be further defined in this process.
OeHI/HCPF requested HITECH funds for 1.5 million
9/1/2017
MPI/MPD RFP released
RFP posted
11/30/2017
10/1/2017
Increase SIM practices connected to HIE from 70%
Phased goal of connecting rest of cohort 1 and initial outreach to cohort-2 practices
2/1/2018
SIM: 443,462 + 500,000 IAPD 17/18: 1.5 million
Increase use of HIE to 70% and plan for additional onboarding
HITECH
Project plan finalized upon onboarding of new HIT vendor Health Tech Solutions in June 2017. Health Tech developing technical requirements when onboarded to OeHI as new vendor. Planned for June 14, 2017. Timeline and strategy for developing RFP technical requirements will be finalized. Date of RFP released depends on new Health Tech Solution Vendor completing technical requirements, input from stakeholders on requirements during this process, Public Knowledge drafting RFP, and Colorado procurement rules. Based on connectivity will need to refine approach and strategy
Page 130 of 239
3/1/2018
MPI/MPD vendor identified
Review committee recommendations
04/1/2018
SIM, Health First Colorado, and state populations
TBD-OeHI will work with Health Tech Solutions in June 2017 on technical requirements and project scope. TBD-OeHI will be working with Health Tech Solutions in June 2017 to determine technical requirements and project scope.
05/01/2018
MPI/MPD vendor(s) start
06/01/2018
SIM, Health First Colorado, and state populations
5/01/207
Telehealth SME group meets biweekly to advise telehealth expansion
Develop strategy and timeline for implementation and operations of MPI/MPD of phased approach of specific use cases for Health First Colorado, SIM, DORA, and CDPHE Framework with strategy recommendations based on five strategies
11/1/2017
SIM/ Health First Colorado /behavioral health providers
$572,160 carry forward + $672,160 AY3
11/1/2017
Telehealth RFP
Draft telehealth RFP released
TBD—to be coordinated with other HIT RFPs
SIM/Public Knowledge
See above
Dependent on specific use cases defined during technical requirements, procurement timelines, and input from new vendors. Initial recommendation for hub and spoke implementation strategy not recommended by SMEs and stakeholders, recommendations need to expand access and build on existing and potential investments with payment models, payer support Decision related to technical and business requirements that complement existing infrastructure will be
Page 131 of 239
key to successful RFP —stakeholders acknowledge competition and that one size does not fit all
Page 132 of 239
Use Case One Details The exchange of health information, including behavioral health information, across providers will lay the foundation for the advancement of improved health outcomes at lower costs across the state. As noted in the Health Care Payment and Learning Action Network’s (HCPLAN) Data Sharing Draft White Paper: “Data sharing lies at the heart of two important and ambitious goals of Population-Based Payments (PBP) and Alternative Payment Models (APMs).” In general: 1) It promotes the availability and use of real-time comprehensive, patient-level data and information to inform clinical care, decision making, enable true integration of care, and improve care delivery and outcomes; and 2) It improves the healthcare marketplace, such that care is purchased on the basis of transparent and reliable assessment of cost and quality performance.”16 The first use case lays the foundation for the advancement of HIT/HIE in Colorado and is the foundation for sharing health information to advance the integration of behavioral and physical health in support of value-base payment. As mentioned earlier this use case is focused on broadly sharing health information across the state by increasing HIE connectivity and establishing enterprise-level infrastructure to advance the state’s efforts. One core component of this infrastructure is identity management. OeHI is working collaboratively with SIM and other stakeholders to advance these efforts. Maximizing Health Information Exchange Onboarding SIM providers to HIEs for data submission continues to be a priority for SIM HIT investment. Approximately 50% of practices in the initial SIM cohort are not connected to HIEs. Those that are connected have varying degrees of connectivity. Extending HIE services to SIM cohort practices has been the first step in promoting the secure and efficient exchange of data across providers and laying ground work for other key use cases, including increased data sharing and care coordination. The SIM office is working with the state’s two HIEs – CORHIO and QHN – and HCPF to enhance state information exchange infrastructure, provide practices with more clinical information about their patients through the prioritization of onboarding SIM practices to the HIEs using HITECH funds. SIM is also promoting the use of HIEs through the Shared Cared Report pilot, which provides visibility into where a practice’s patients are receiving care, regardless of practice connection to the HIE. It also provides an opportunity for stakeholders to identify where data is not readily available in the HIE and develop targeted action-plans to onboard those practices that are not connected. This level of connectivity is a significant challenge and the state of Colorado is committed to working collaboratively with CORHIO and QHN to advance the broad sharing of health information. Colorado is leveraging HITECH funds for onboarding providers to bridge this gap by paying for onboarding fees; however high costs of system interfaces, practice resources, and ongoing HIE subscription costs requires additional consideration. Advancing information sharing by leveraging HIEs is one of the core components of SIM’s use case one, and an objective of the broader Colorado HIT roadmap. Plans are underway to further define strategies and initiatives through this state roadmap and the foundational work with HCPF and the HIEs using HITECH dollars to enhance connectivity is essential. To ensure integrated health information is shared broadly, especially with restrictions from 42 CFR, consent management is needed. In 2015 HCPF was awarded the ONC Advanced Interoperability grant for the two state HIEs to pilot different methodologies for behavioral health consent management to enable sharing substance use data. The grant period ends in June 2017. Upon conclusion of the grant, 16
Health Care Payment Learn Action Network Page 133 of 239
CORHIO and QHN will create a white paper on their recommendations for advancing these efforts statewide. Upon review of the whitepaper, SIM intends to work collaboratively with OeHI, HCPF, the Office of Behavioral Health (OBH), and the HIEs to develop a strategy and plans. In addition, recent Colorado legislature SB17-019 requires OBH to develop a plan and budget request for sharing medication formulary lists and health information of individuals with mental illness in the criminal justice system to reduce recidivism. This plan will require a consent mechanism and innovative approach to sharing medication formularies and health information that will require cross-agency collaboration and input from SIM and OeHI on the best strategy. SIM Practices SIM’s practices are on the front line of advancing effective sharing and use of data in Colorado. During AY2 an assessment of the practice transformation framework based on Bodenheimer building blocks of advance primary care was completed. The framework was refined and streamlined to ensure practice success is aligned with payer expectations. Milestones of progress and goals for each building block were identified and will be expected of cohorts 2 and 3 moving forward. The follow building block expectations will support practice readiness for technology adoption and identify practices that are ready and prepared to move to data extraction and reporting. Please note the SIM framework with more details about the building blocks milestones and assessments can be found in the payment models and service delivery models section. Building Block 2: Practice Uses Data to Drive Change AY 3 Milestones: ●
Practices successfully submit eCQMs quarterly;
●
Practices review data with PF/CHITA quarterly;
●
Uses data for quality improvement; and
●
Uses data aggregation tool for cost and utilization.
Building Block 3: Practice population is empaneled AY 3 Milestones: ●
Practice has assessed patient panel and assigned primary care providers/care teams to 75% of patient population; and
●
Practice reviews payer attribution list monthly.
Building Block 4: Practice Provides Team-based Care AY 3 Milestones (preparing for AY4 workflow development for at least 3 of the eCQMs): ●
Practice uses established tools to assess baseline team relationship;
●
Practice has written job descriptions; and
●
Practices implements a team-based care strategy.
SIM practices that develop these skills and capabilities within their practices and systems will be well poised to maximize opportunities to effectively share data and use data within value-based payment models. Both QHN and CORHIO have undergone an assessment of their capacity to extract eCQM data in multiple formats. CORHIO is undertaking a pilot this summer to assess the feasibility of taking data from HL7 and CCDA formats and merging them into a single document that would allow users to pull out discrete data points. Upon completion of the pilot, CORHIO will continue efforts to expand capacity to Page 134 of 239
extract eCQM data from practices for analytic and reporting purposes, which will positively contribute to both use care one, effectively sharing data, and use case two below. If this pilot is not successful, other options that Deloitte identifies in its implementation roadmap will be explored. MPI and MPD OeHI has drafted initial functional and business requirements for an MPI and MPD. OeHI plans to develop technical requirements with Health Tech Solutions in the Summer of 2017 with plans to release an RFP this fall. SIM leadership has been asked to provide direction on how practices can access and use this technology. These tools were identified as underlying technical solution components for all priority uses cases. The two components are included as part of a master data management (MDM) strategy that will be developed by HCPF and OeHI. By implementing a MPI and MPD as the foundation for its MDM, HCPF will achieve a unified view of Health First Colorado providers and member data across HIE networks, which will improve the quality of data, collaboration, and reducing costs, and will also create a suite of data records and services that will allow HCPF to link and synchronize member, provider, and organization data to HIE sources.17 The future phases of MDM will include a consents and disclosures repository as part of the Health First Colorado provider directory that will support precision for information sharing consents and disclosures across medical, behavioral, and substance use disorder information. The strategy and plans for statewide consent is being defined through Colorado’s HIT Roadmap process and completion of Colorado’s ONC Advanced Interoperability grant work. Creating a strong and legally sound consent framework will reduce barriers to information exchange, improve interoperability, and enhance care coordination.18 The initial RFP is focused on MPI/MPD phases and future phases of MDM will include consent management and other complementary technologies. Although the MDM will initially be focused on the needs of Health First Colorado and SIM providers, HCPF is working with OeHI to research and define a scalable MDM strategy that can be coordinated and aligned with other HIT efforts. OeHI is Colorado’s state-designated entity responsible for coordinating strategic HIT initiatives and establishing data sharing and HIT governance through its eHealth Commission. To date, Colorado does not have a MDM plan for sharing and exchanging health information, nor does it have a statewide identity management or provider directory system that healthcare providers can access. OeHI has led efforts to gather information about various business needs and use case objectives that will benefit from an integrated MDM platform that includes an MPI and MPD and identifies functional requirements that must be included in the MDM for these objectives to be achieved. The needs of SIM have figured prominently in these efforts. Three distinct program phases have been proposed to define the implementation and rollout schedule of the MDM. Base requirements in later stages might optionally be implemented in an earlier stage, as some requirements in phases 2 and 3 might need to be implemented earlier depending on the timing of SIM and APD rollouts. ●
Year-1 base requirements: Support Health First Colorado business needs and use cases by aligning data sources for MPI/MPD. Support SIM needs for clinical care, HIE use cases, and eCQM solution use case. Optionally, year 2 base requirements needed for SIM (dependent on SIM direction and
17
Colorado Office of eHealth Innovation Master Data Management (MDM) Draft Business and Functional Requirements for Public Comment, October 12, 2016. Available at: 18
? Page 135 of 239
solution requirements), APD or other services could be implemented in this phase. Funding for these efforts is being provided by HITECH, SIM, and the state due to timing of project and funding restrictions for a scalable statewide solution that includes Health First Colorado and other payers. ●
Year-2 base requirements: Begin data source integration for the Department of Regulatory Agencies (DORA) and CDPHE, integrate SIM/MPI/MPD solutions with Health First Colorado MPI/MPD efforts. Year 3 base requirements needed for APD or other services could be implemented in this phase.
●
Year-3 base requirements – Include other public/private partner and social determinants use cases. Note all requirements were developed with stakeholder input and will be reassessed with Health Tech Solutions and Solutions Architect from OIT during the summer of 2017.
Data Aggregation The aggregation of clinical and claims information is a core component of the SIM operational plan. As mentioned earlier, SIM is taking a phased approach to the aggregation of clinical and claims information due to stakeholder input, efforts underway through the Colorado HIT Roadmap, and investment by multi-payers in a process and solution to help CPC+ and SIM practices understand performance measures required for value-based payments. The SIM office is partnering with the MPC to use Stratus™ during the SIM initiative to provide aggregated cost and utilization data to cohort 1 practices to better understand cost, utilization, and gaps in care to advance value-based payments. Discussions and decisions will need to be made on how to leverage this process and tool beyond the SIM initiative. This data sharing is essential for understanding population health needs and gaps in care. The SIM office contracted with Best Doctors to provide this tool to cohort-1 practices for one year, and is assessing the need to procure a data aggregation tool to ensure that cohort-2 and -3 practices have access to aggregated cost and utilization data. The MPC includes public and private healthcare payers working to strengthen primary care. Established in the spring of 2012, the MPC originated as part of the Centers for Medicare & Medicaid Service (CMS) Comprehensive Primary Care (CPC) initiative. At its inception, the MPC consisted of 10 payers, regional and national, public and private, working together to coordinate efforts and support CPC practices. The MPC includes a majority of public and private payers in Colorado, and is committed to building on initial efforts to expand and support primary care transformation in the state. The MPC is focused on supporting CPC, SIM, CPC+, and regional data aggregation and is convened by the Center for EvidenceBased Policy out of Oregon Health Sciences University. In Colorado, payers participating in CPC – including six private payers and Health First Colorado – joined together to procure and finance a data aggregation and analytics tool, known as Stratus™. In March of 2016, CMS executed a data use agreement (DUA) with Best Doctors (formerly known as Rise Health) to include Medicare data in Stratus™ to give CPC payers and practices an unprecedented opportunity to test and measure reductions in the total cost of care for CMS beneficiaries. Practice feedback has indicated that the addition of Medicare data to Stratus™ has significantly increased the value of the tool as practices have a more comprehensive view of their patient panel and related cost and utilization data, trends, and gaps in care. The SIM office has worked with Best Doctors and payers to provide Stratus™ licenses to SIM practice sites. SIM cohort-1 received licenses in May 2017, and have access to aggregated data from six SIM participating payers (Health First Colorado, Anthem, United, Rocky Mountain Health Plans, Colorado Choice, and Cigna). The SIM office is working with CMMI and CIVHC on potential solutions for including Page 136 of 239
Medicare data for SIM practices. In addition to supporting data aggregation of claims data, the MPC has initiated a clinical data integration pilot using state HIEs to send three eCQM data points to Stratus™ to integrate with cost and utilization data. Additionally, Stratus™ can calculate Healthcare Effectiveness Data and Information Set (HEDIS) claims-based measures. This will be used as a validation/comparison mechanism so practices and payers can compare HEDIS with eCQMs and develop a shared trust in the data. Governance: The MPC has developed several policy and governance policies to guide effective aggregation and sharing of data for CPC and SIM. The data governance panel meets the first Tuesday of each month, and is facilitated by the Center for Evidence-Based Policy. The governance panel comprises one payer representative and one alternate from each payer partner supporting data aggregation as well as a SIM office representative. Each payer organization has one vote in decision-making processes, and vendors and other contractors do not vote. The governance panel is intended to provide management, operational guidance, and oversight for Stratus™. The objectives of the governance panel are to ensure project deadlines are met, make decisions regarding changes to Stratus™, and identify strategies for improving use of data regionally. The panel is informed by MPC meetings, the data workgroup, and user subgroup. It has decision-making authority for Stratus™. The data workgroup, which meets the third Tuesday of each month and is facilitated by Best Doctors, comprises payer and practice representatives with Stratus™ licenses. This may include members of payers’ data and project management teams, practice care managers or data specialists, and providers. The objectives of the workgroup are to provide feedback on user experiences, discuss opportunities to improve Stratus™ and support practice use, and identify innovative project solutions to drive the use of data regionally. The workgroup operates with the following core principles: ▪ ▪ ▪ ▪ ▪ ▪
Communicate clearly, coordinate closely; Make data accessible to and actionable by CPC+ and SIM practices; Build on existing market resources; Focus on the goal and stay grounded; Achieve business requirements; and Explore multiple approaches, test, and innovate.
The data workgroup provides the data governance panel with recommended changes, but does not have decision-making authority or oversight of Stratus™. A user subgroup meets every Friday, facilitated by Rocky Mountain Health Plans, with a focus on the clinical and administrative data integration pilot. The subgroup comprises a limited group of payer and practice representatives to inform discussion at the data workgroup and decisions at the governance panel. The objectives of the subgroup are to identify use cases, discuss user experiences, and identify opportunities for improvement.
Telehealth The vision for a statewide strategy for telehealth supports the SIM goal by using telehealth as a facilitator, expanding its use, adoption, and uptake to support increased access to integrated care supported by payment and delivery reform. In this vision, patients access the telehealth system through various entry points such as a primary care facility, hospital, emergency room, community mental health center, at home or via a mobile device. A robust stakeholder-driven process illuminated several key strategies necessary for a coordinated Page 137 of 239
statewide approach to telehealth expansion. Several potential leverage points, or actionable strategies to operationalize the vision, have been identified. These five final strategies, as illustrated by Figure 1, work in concert and combine in a broader system change framework. Figure 1. Five strategies to support the SIM goal Three of the strategies are structural in nature: ● Establish a governance structure; ●
Support a coordinated network approach; and
●
Establish provider and consumer- specific
support centers. The final two strategies work to affect the overarching environment in which the strategies are operating and support the structural changes: ● Ensure the policy environment is supportive of telehealth; and ● Leverage and integrate existing payment and delivery reform and integration of care efforts.
Collectively, these strategies support a vision in which telehealth improves access to integrated care in several key ways, regardless of setting or reason patients are seeking services. It will change the structure of the system by creating a coordinated network approach, allowing investments already made in telehealth infrastructure and provider training to thrive, while supporting continued expansion across the state. One of the key strategies is to increase information, which will ensure providers in the networks have adequate support and training and recruit and cultivate providers, providing information and resources to overcome barriers to entry. It will also grow capacity of the system by increasing the size and connected capacity of the telehealth network facilitating integrated care through coordinated networks, thereby increasing access to care. During the no-cost extension (NCE), a subject matter expert group was convened to meet biweekly to provide actionable recommendations to the SIM office on how to invest in the strategies highlighted above. A telehealth investment framework will be developed with support from Public Knowledge, and will be submitted with the SIM finalized HIT workplan in July 2017. The SME group has committed to meeting through October 2017 to provide expert recommendations that will inform the RFP. The RFP and technical requirements will be detailed by Public Knowledge during the first three months of AY 3. The tentative timeline for RFP release is October/November 2017. Additionally, e-consultation, a core concept of telehealth, is being explored as a strategy to increase access to specialty care and behavioral health. The Health First Colorado office has a pilot with primary care and rheumatology. Several private payers, including Kaiser, have robust e-consult programs. The SIM office is assessing feasibility of convening payer and provider leaders to consider targeted econsultation expansion, the potential rules, legislation, funding, and platform necessary.
Page 138 of 239
Use Case Two Details SIM has made significant efforts to align and advance the reporting and measurement of CQMs. Through a collaborative process SIM established a list of eCQMs that meet SIM requirements and align with other quality payment programs such as the Quality Payment Program (QPP), Accountable Care Collaborative (ACC), and Alternative Payment Models (APMS). The SIM office developed a collaborative agreement with each payer participating in SIM to outline the data governance around sharing eCQM data from SIM practices with payers. Five of the seven payers have signed a cooperative agreement. One payer does not accept eCQMs from practices and the second payer is undergoing a buy-out and plans to move forward with the cooperative agreement once the purchase is complete. The collaborative agreement is meant to ensure rules of engagement so payers will not share practice-identifiable data publicly or use it for purposes not included in their contractual relationships. The first annual cohort year-1 2016 eCQM data was shared with payers as baseline data in April 2017. This was a manual process of developing reports from SPLIT/QMRT with practice data only going to the payers that support that practice as part of SIM. Although a manual process, the initial feedback from payers has been positive and all payers have indicated they will use the eCQM data as part of their internal evaluation of SIM cohort-1 practices. This is an important development since many commercial payers are not using eCQMs as part of their value-based performance evaluation. It is essential to continue to develop trust and ensure accuracy of the data. Payers have requested that any future investment in eCQM reporting include a feedback loop and mechanism to validate the data. The second use case provides SIM practice cohorts with an opportunity to advance methods for extracting and reporting CQMs beyond the manual entry of numerators and denominators. As noted above, the process for reporting SIM CQMs is manual. Practices enter numerators and denominators into the Quality Measuring and Reporting Tool (QMRT) that is developed and administered by the University of Colorado Department of Family Medicine. Many SIM practices extract clinical quality data from their electronic health records (EHRs) and aggregate, visualize, and report for federal requirements using their own systems and other qualified registries. For example, The University of Colorado Hospital and the University of Colorado have developed their own mechanisms for extraction and reporting. Several other practices are using registries such as the Prime Registry supported by the American Association of Family Physicians. As the QPP is implemented, there is an increased demand for practice support and technology solutions. Additionally, the Health First Colorado program will begin its APM reporting system using 2018 as a baseline performance year. This will enable practices to choose eCQMs for reporting. In some cases, practices are incorporating HIE data to build a more comprehensive quality measure. In numerous stakeholder interviews, providers expressed a need for reduced administrative burden in reporting CQMs to multiple entities, especially considering outcomes improvement and reporting requirements for QPP. The SIM office is partnering with the MPC and Health First Colorado to align eCQMs for SIM, CPC+, TCPi, QPP and the Health First Colorado APM program. Providers have expressed appreciation for this alignment, but also report continued administrative burden related to additional measures from commercial plans that do not align. Many health plans do not use eCQMs and continue to use HEDIS data and other data sources for value-based payment model contracts. During AY3, strategic planning with OeHI will determine a process for continued alignment. There is no political will to move towards alignment and integration of clinical and administrative data. The modular approach will enable investments in foundational data extraction, while strategic policy work lays the ground work for continued support for a Colorado combined measure set. Additional details about SIM’s eCQM Implementation Roadmap and timeline will be developed by Deloitte. Page 139 of 239
The following two options were identified for eCQM extraction and reporting: ● Option 1: Create a central, shared, reusable technology solution for SIM-specific HIT technology supporting SIM objectives and develop a strategy to connect to broader HIT ecosystem. A central technology solution: ● Benefits: o Fills a technology need for SIM objectives with scalability potential for additional uses o Supports a long-term integrated technical system strategy ● Disadvantages: o Will take planning to identify regional and state-level technology solutions and how they can be built for efficient development and use ● Considerations: o Will require considerable governance and coordination o Will require multiple levels of data normalization and implementation/operational resources o Planning and implementation timing must be considered with SIM time frame ● Actions needed: o Build roadmap for current, developing, and future data sources and use case scalability o Determine how providers, payers, and public sector will see, receive, use information for clinical and business purposes ● Option 2: Use and extend existing technology capability and coordinate with other data networks for prioritized use cases and sequencing that extends and uses existing technology investments: ● Benefits: o Reuse existing HIT investments; o Can be aligned with other public and private infrastructure and functionality development; and o Build information integration strategy to reduce data user burdens on submitting data and accessing information. ● Disadvantages: o Existing HIT investments might not have technical capabilities to sufficiently meet all SIM HIT objectives; o Will require significant data governance; o Will require significant coordination across vendors/organizations through strong business agreements and processes; and o Will require accountable oversight responsibility across vendors and organizations. This must align to broader governance structures beyond SIM. ● Actions needed: o Build roadmap for current, developing, and future data sources and use case scalability; o Determine how providers, payers, and public sector will see, receive, use the information for clinical and business purposes; o Confirm state procurement options; o Assess feasibility and capabilities of existing technology solution components to reuse; and
Page 140 of 239
o
Understand limitations on using data from specific technology assets in Colorado (e.g., legislated use for policy and research will not support operational uses without policy change).
After careful consideration and input from HCPF and other key stakeholders, Colorado has determined that option 2 offers the best possibility to maximize existing efforts and state infrastructure. Leveraging HIEs and investments made for meaningful use and 90/10 federal financial participation dollars to support quality measure extraction and reporting will enable a modular and functional HIT solution that can be scaled to fit the ongoing and expanding needs of the state. To provide the state with the tactical steps required to successfully develop and implement the technology infrastructure that accomplishes option 2, the SIM office identified the need for a SIM HIT implementation strategy and roadmap that would cite tactical HIT/HIE business and functional requirements to support CQM extraction and reporting. Deloitte Consulting was contracted during the AY2 NCE to work with the SIM office and OIT technical architect team to develop this implementation roadmap that would be informed by the feasibility analysis and a robust stakeholder process to determine alignment of use case with the business and technical needs of providers and payers in the state. The key informant interviews, to be completed in May 2017, will inform the eCQM implementation roadmap that will be delivered in July for review by the SIM HIT workgroup, the eHealth Commission, and the SIM steering committee. The SIM office contracted with Deloitte Consulting to develop an eCQM implementation strategy and roadmap.
SIM Measure Alignment and Advancement of data extraction and Use The SIM Office has initiated conversations at the MPC about alignment of measures beyond the initiatives mentioned above. Additionally, the SIM Office shared its first baseline eCQM data report with payers in April of 2017, providing an opportunity for payers to determine how they might incorporate this data into their programs. eCQMs are essential tools to enable population health management. The SIM office worked with key partners to advance the use of accurate and actionable data at the practice and systems level. The QMRT tool was developed for SIM cohort-1 practices to report eCQMs. Moving into AY3, SIM cohort-1 and -2 practices will continue to report eCQMs via the QMRT tool while laying the foundation for developing automatic data extraction and reporting capabilities. The first step in effective reporting and use of eCQMs is developing technology that effectively produces accurate and trusted data. The SIM office partnered with HCPF in the spring of 2016 to develop an enhanced HIT assessment to assess practice ability to extract and use data. The assessment complements the annual data quality assessment completed by practices via the SPLIT tool that is used to guide CHITAs working with practices. Once practice sites completed initial assessment tools, results are used to develop a Practice Improvement Plan (PIP). The PIP tool in SPLIT required practice sites to select at least one (and no more than two) milestone activity from the 10-building-block framework as a goal in each of the following three SIM program focus areas: ● Practice transformation; ●
Behavioral health; and
●
HIT.
Page 141 of 239
The figure on the next page lists the building blocks and activities practice sites could choose for their initial goals. The numbers and percentages on the right side of the table indicate the number of practices in each program area that selected goals in a building block or activity. For example, the first section of the table on the following page (figure 10) shows 12 of the total practice sites (4%) selected goals address Building Block 1, “Engaged Leadership.” Specific goals are further distributed among the four activities that make up that block. At the time of this writing, analysis is being competed to assess which HIT building block activities cohort one practices were most successful in achieving. However, the following summary provides a snapshot of practices’ achievements. ● ● ● ●
Practices that did not formally work on their HIT goal = 5 practice sites; Stopped work before achieving their HIT goal = 3 practice sites; Started and continue to work on their HIT goal = 53 practice sites; and Worked on and achieved their HIT goal = 31 practice sites.
More detail will be provided in the Q2 quarterly report, after further analysis of the PIP data. Cohort-1 PIP
➊ Building Block One: Engaged Leadership
10
1
1
1 2
A: Practice completes all SIM practice assessments
1
0
1
(4%)
B: Training on continuum of behavioral health services & integration
3
1
0
6
0
0
0
0
0
22
12
6 7
101
5
8
4 8
(34% )
B: 50% of staff trained on quality improvement IQI) tools and forms a QI team who meets regularly
17
2
2
C: Selects the CQM group that best aligns with patient population transformation priorities
0
2
1 4
D: At least quarterly, use data hub benchmark reports to inform QI process on at least three core measures
0
0
3
➌ Building Block Three: Empanelment
12
0
2
A: Documents strategy to achieve and maintain empanelment to provider and care teams
11
0
2
B: Periodically reviews attribution lists provided by payers and works with payer(s) to reconcile discrepancies
1
0
0
C: Practice completes annual budget or forecast with projected new SIM revenue and implementation costs D: Engage with ongoing evaluation and technical assistance deliverables
➋ Building Block Two: Data-driven Improvement Using Computerbased Technology A: Completes baseline assessments to begin to determine data capacity
1 4 (5%)
Page 142 of 239
➍ Building Block Four: Team-based care
19
8
4
3 1
A: Periodically (baseline and at least annually) reviews assessment of distribution of patient care tasks by role
5
4
1
(10% )
12
2
1
2
2
2
0
0
0
B: Implements at least one of the following strategies: Daily team huddles, Collaborative care planning sessions, Standing orders C: Demonstrate that individualized patient treatment plans that include both physical and behavioral health goals and are accessible in the HER D: Participate in SIM Collaborative Learning Sessions as peer presenter at Learning Collaboratives when requested
Page 143 of 239
No. of selections across all three target areas Health Information Technology Behavioral Health Practice Transformation
➎ Building Block Five: Patient-Team Partnership
8
9
1
1 8
A: Implement self-management support for at least three high-risk conditions
1
4
1
(6%)
4
5
0
3
0
0
0
0
0
19
45
2 0
8 4
1
1
0
(28% )
7
2
0
C: In primary care, attest that 90% of patients are screened for at least one behavioral health (BH) condition for which the practice has a documented workflow to assist patients who screen positive
7
35
8
D: Practice uses a registry system to track outcomes of at least two subpopulations of patients
4
7
1 2
➐ Building Block Seven: Continuity of Care
2
3
0
5
A: Track continuity with primary care provider and/or care team
2
3
0
(2%)
➑ Building Block Eight: Prompt Access to Care
1
0
0
1
B: Implement shared decision-making tools in two health conditions C: Implement one of the following: regular patient and family surveys (at least quarterly) or patient and family advisory council (meet at least quarterly) D: Implement shared decision-making tools or aids in two health conditions
➏ Building Block Six: Population Management A: Indicate methodology used to assign risk status to every empaneled patient B: Provide care management to at least 80% of highest risk patients
Page 144 of 239
A: Provide and attest to 24 hour, 7 days a week patient access to a practice representative with access to practice’s medical record, including BH records if a BH professional is fully integrated in practice
1
0
0
B: Enhance access by implementing at least one asynchronous form of communication (e.g., patient portal, email, text messaging)
0
0
0
(0%)
Page 145 of 239
No. of selections across all three target areas Health Information Technology Behavioral Health Practice Transformation
➒ Building Block Nine: Comprehensiveness and Care Coordination
5
6
5
16
A: Detail where patients access BH services outside of primary care practice. For bi-directional health homes, detail where patients access primary care
0
5
1
(5 %)
B: Enact care compacts/collaborative agreements with at least two groups of high-volume specialists (including one BH provider group for primary care sites)
3
1
2
C: Demonstrate active engagement and care coordination across the medical neighborhood by creating and reporting on suggested quality measures to assess impact and guide improvements
2
0
2
➓ Building Block Ten: Integration and compensation reform
2
16
0
18
A: Practice leadership receives education on implementing models of advanced access to BH services that includes financial, and operational considerations of the different options
2
11
0
(6 %)
B: Practice accepts non-fee-for-service payments
0
0
0
C: Practice engages at least one public health or community organization to make improvements in a mutual population health goal
0
5
0
Additional Data Sources for Population Health Management Because of the lag in receiving a full calendar year baseline report on practice-level eCQMs, The Center for Improving Value in Health Care (CIVHC) developed methodologies and programming for claimsbased proxy measures for each CQM to serve as a mechanism for baseline and comparison reporting. Baseline calendar year (CY) 2015 measures were delivered during the no-cost extension period, and claims-based proxies will be delivered on an annual basis in quarter (Q)2 of year 3 and Q2 of year 4. Claims-based proxy measures will be developed for the new simplified CQMs when full CY 2016 data is available. These proxy measures serve as benchmarks for the CQMs and will be reported to CMMI in the core metrics template annually. These have become an important data source for SIM as well as other stakeholder interested in using state level clinical data for population health. The practice and aggregate Page 146 of 239
data will be compared to our SIM eCQM data to better understand the comparison between practicedriven eCQM reporting and claims-based data. CDPHE has partnered with CORHIO, Denver Health and numerous other partners in the state on the Colorado Health Observation Regional Data Service (CHORDs) project to develop a federated model for clinical data extraction. This data can be used for population health surveillance and population health programming. Taking a long-term perspective, this will be included as a key opportunity for HIT connectivity on the HIT roadmap. Stakeholders have continued to support conceptually the integration of data and use for population health purposes, but AY3 will focus on clinical data extraction for the use case of supporting practices and payers in value based programs. Because this will include data quality and validation, it is an essential building block of programs like CHORDS, that use clinical data for population health surveillance and planning. CDPHE has developed a dashboard of SIM-identified population health measures, derived from the Behavioral Risk Factor Surveillance System (BRFSS) and other survey-based data sources, to track the effects at a population (of Colorado) level. This data will be combined with the county level eCQM data to better understand population impacts of SIM participation. At this time, there is no plan to integrate BRFSS data into the QMRT + solution. This dashboard has not been used by anyone outside of the SIM office and evaluation contractor, but during AY 3 the Sim office plans to combine the dashboard data with the CIVHC proxy data and the eCQM baseline data from 2016.
Page 147 of 239
HIT Modular Components In alignment with ONC’s HIT Modular Components, SIM has outline how Colorado is working on these modular components. Many of these modular components (below) exist.
HIT Modular Component Legend
Yellow: Currently functionalOeHI/SIM assessing functionality for use case 1 and 2, Stratus, MMIS/BIDM, HIE/HIT Assessment
Orange: Currently operational- SIM/OeHI leverage as is for use case 1 and 2: SPLIT/QMRT, PEAK-CO eligibility APP, CIVHC/APCD, Public Health Reporting, Payer attribution, Empanelment
The HIT Modular Component Legend on the right shows projects and status currently underway. The specific interconnected relationships are being defined through Deloitte and OeHI’s Roadmap efforts for use case 1 and 2. The broad sharing of information across Colorado is based on our state HIE foundation and intends to connect data sources through identity and data management. On page 43, the diagram outlines the modular HIT functionality needed for a eCQM solution. Decisions must be made on how to leverage and implement infrastructure.
Green: SIM/OeHI Planning/Implementation AY 3; Public Health Data, CAII, Colorado HIT Roadmap defining HIT initiatives based in alignment with SIM’s efforts, Stratus™: Clinical Integration Pilot, eHealth Commission
Funding: SIM, HITECH 90/10, State, Payer, and Provider funds are being leveraged to implement and sustain use case 1 and 2
Page 148 of 239
GovernanceAccountable Oversight/Rules of Engagement, Financing, Policy/Legal, and Business Operations
Governance, financing, policy/legal, and business operations for SIM’s two use cases are currently being assessed. Use Case 1: Planning- MPI/MPD requirements and Colorado HIT Roadmap in progress. The Colorado Health IT Roadmap is currently in development. Roadmap objectives attached in the Governance section. Final version completed in Fall of 2017. Use Case 2: Planning- Deloitte eCQM Implementation Roadmap in progress
Identity Management & Provider Directory
Identify management for individual and providers is core to both use cases. Use Case 1: MPI/MPD requirements and HIT/HIE assessment in progress. See Use Case 1 Details section for more specifics. Use Case 2: Planning- Deloitte eCQM Implementation Roadmap in progress
Security Mechanism Consent Management
Currently assessed in reference to the two use cases
Currently being assessed to the two use cases. Upon completion of the Advanced Interoperability Grant will have more strategic input and alignment. Advancing the integration of physical and behavioral health data by continuing efforts of the ONC Advanced Interoperability behavioral health consent pilots and standardizing data sharing agreements between state agencies to improve care delivery and support payment reform. See Use Case 1 for more details.
Data Quality and Provence
Currently being assessed in reference to the two use cases. Stratus, QMRT/SPLIT, HIE and CHITA efforts are actively working through data quality issues. Decisions will need to be made on how to address issues for each use case and through statewide planning efforts in Colorado’s Health IT Roadmap.
Data Extraction, Transformation,
Data extraction and transformation is occurring in several health system and regions throughout Colorado. Decisions will need to be made about the second use case. Use Case 2: Planning- Deloitte eCQM Implementation Roadmap in progress
Data Aggregation
Initial phases of data aggregation are focused on leveraging the MPC’s claims and clinical aggregation is being assessed for each use case. Connecting SIM practices to Stratus™, a claims data aggregator and analytics tool designed and implemented by the MPC. Continuing efforts to integrate clinical and claims information by integrating clinical data from state HIEs CORHIO and QHN into Stratus™ for three clinical quality metrics. Efforts support of payment reform. Phased approach is recommended by stakeholders.
Page 149 of 239
Decisions will need to be made in reference to the second use case. Use Case 2: Planning- Deloitte eCQM Implementation Roadmap in progress Notification Services
Practices and Providers connected to HIEs receive a variety of notification services. Decisions will need to be made in reference to the use cases and what notifications might need to be provided to compliment efforts.
Provider Tools
For SIM, providers are using SPLIT/QMRT for eCQM reporting, CIVHC’s APCD for claims information, and Stratus™ for cost and utilization data. Decisions will need to be made in reference to the use cases and what provider tools need to be leveraged to complement efforts.
Exchange Services
SIM and HCPF- conducting HIT/ HIE Assessment of the technical and adoption capabilities for SIM practices, regional accountable care organization (RCCO) practices, and community mental health center (CMHC) capabilities. HIT/HIE asset assessment in Colorado and key stakeholder interviews from payers, providers, technology partners, state agencies and officials to inform technical investments for integrated care delivery and support payment reform. This effort will inform investments for two use cases. The Office of Broadband was launched in April of 2017. This Office is focused on expanding broadband coverage from 70% to 100% by 2020. SIM will connect 300 sites to broadband by the end of the grant period in 2019. Comprehensive data and cellular coverage is essential for exchange services. See Use Case 1 for more specifics on HIE efforts.
Patient Attribution
SIM supports multi-payer attribution. Both use-cases are assessing requirements needs to accommodate multiple attribution methods.
Consumer Tools
Many consumer tools are available. PEAK is a consumer app for Colorado’s eligibility system that is currently operational. Decisions will need to be made on how to leverage this tool and/or align with other consumer tools to integrate care and prepare for value-based payment.
Analytics and Reporting Services
Currently being assessed in reference to the two use cases Public health, cost and transparency, and HIE reports available-statewide analytics are an area that SIM and OeHI are investigating for two use cases. SIM Reports: https://www.colorado.gov/healthinnovation/sim-data-hub
Page 150 of 239
Objectives of SIM HIT Implementation Strategy and Roadmap In the summer of 2016, SIM completed a feasibility analysis to identify necessary technological and business requirements for implementing the selected use cases. In addition to deciding how SIM HIT funds should be invested, the technical infrastructure architecture must meet long-term needs and goals in Colorado. A key consideration for functionality will involve thinking through whether the solution should be built on existing technical investments or new, stand-alone investments connected to disparate data networks. Additionally, the technical architecture approach will influence how the end users and stakeholders benefit and gain value from these added technical services Considering the goal of the SIM initiative and the use cases prioritized for HIT innovation, the strategy and roadmap, which is due in July 2017, will provide a detailed and tactical plan for investing in and launching HIT initiatives that will achieve the two prioritized use cases with SIM funding and infrastructure and be sustainable after the initiative. OeHI and eHealth Commission are providing input into the implementation strategy and ensuring alignment with Colorado’s Health IT Roadmap. The project will reflect: ●
Analysis of existing technologies, methodologies, and best practices leveraged by the state;
●
Input from stakeholders reflecting the perspective of healthcare payers and providers regarding the value and challenges to collecting and reporting eCMQs;
●
Timelines and milestones for procuring HIT solutions and tools, and/or system integration services to implement and operate solutions; and
●
High-level business and functional eCQM requirements to inform the aligned state RFP process.
Principles Used in Development of Implementation Strategy and Roadmap To achieve the above objectives, Deloitte will closely collaborate with the SIM office, OeHI, and eHealth Commission, as well as other stakeholders. Existing HIT plans, tools, and technologies in Colorado will be reviewed, validated, and taken into account as this plan is developed. The SIM HIT Roadmap will be developed in alignment with Colorado’s HIT Roadmap and SIM’s HIT operational plan. Other states that have gone through similar HIT planning processes may serve as a point of reference, and the final strategy will be tailored to Colorado’s healthcare operating environment. Furthermore, Deloitte will adhere to the following principles in the development of the plan: ●
Leverage innovations and promising practices used in other SIM states based on vendor experience and expertise;
●
Be action-oriented, tactical and detailed enough so that the SIM office can build technology requirements based on recommendations;
●
Consider original SIM plan vision and stakeholder input, yet outline practical recommendations with a realistic timeline reflecting Colorado payers and providers’ operating environment, their willingness and capabilities to adopt and use HIT;
●
Be synchronized with other state HIT planning efforts and reflect federal policy and funding imperatives; and
●
Use advances in business processes and technology solutions that can fulfill the objectives of the prioritized use cases.
Building off initial key informant interviews conducted in the summer of 2016, Deloitte will complete targeted key informant interviews with partners at key organizations that have state infrastructure as
Page 151 of 239
well as provider and payer partners to determine their use case and business requirements to ensure alignment with the future HIT modular strategy by May of 2017 by May of 2017. In Spring 2017, HCPF unveiled its APM methodology that includes an option for Health First Colorado (Medicaid) providers to report CQMs as part of the value-based payment model program. HCPF seeks to improve the HIE data collection foundation to support the transition to automated meaningful use (MU) reporting for Health First Colorado providers. HCPF is planning to leverage infrastructure at the HIE to support CQM reporting to CMS and to implement CQM analytics for its providers and other care coordination organizations participating in its Accountable Care Collaborative (ACC). The approach includes updating infrastructure to collect existing CQM data, additional data elements, and support MU reporting directly from the clinical health record from Medicaid providers. Specific data acquisition and aggregations plans are in development. One option includes: data will be aggregation, normalization, and validation at the HIE Foundation, and ultimately shared as appropriate with MMIS-BIDM, the Medicaid enterprise data management solution. Other options may include leveraging existing registries and creating a phased approach for reporting quality measures. Discussion/decisions will need to be made in 2017 on how providers measure and report for HCPF in 2018/2019. Ideally, this improvement of data will be used to support advanced risk stratification analysis, enhance care coordination infrastructure and activities, and measure provider performance and outcomes in Health First Colorado programs. Updated CQM reporting will support transitions of care (ToC), CCDs, and the capability to run analytics on the CQMs submitted by EPs and EHs with enhanced reporting and data validation services. As part of the roadmap process, Deloitte will focus on eCQM extraction and reporting that supports providers in the Health First Colorado APM incentive program. Additionally, key informant interviews will expand the value of eCQM reporting for commercial payers in the state. SIM QMRT eCQM reporting has begun, and payers have voiced positive feedback about using the data to understand care delivery and performance. However, many payers are not yet incorporating eCQMs, or the QRDA format, into their data and business models. An additional benefit to a modular implementation plan is that it will enable incremental scaling and expansion. The draft table (below) lists capabilities that will be considered essential, and sequential components to the foundational infrastructure necessary for data extraction and reporting. Additionally, an assessment of current and potential capabilities enables us to understand potential solutions. This list of capabilities and foundational infrastructure is a draft deliverable from Deloitte. Additional details of the capabilities and potential solutions will be delivered in July. SIM is currently working with Deloitte to review and further define the assessment. Also note the list of capabilities, reflect technical capabilities only. Assumptions/Caveats: 1) This list reflects "ideal state" of capabilities needed to extract and report eCQMs. 2) No consideration has been given to budgetary constraints or timing needed to implement these capabilities. 3) Priority is defined as follows: 1= critical, 2=important, 3=desirable
SIM is determining the best strategy on how to provide practices with funding and resources to advance their extraction and reporting of eCQMs.
Page 152 of 239
Legend: Y: Capability currently meets eCQMs reqs D: Capability could be developed to meet eCQM reqs C: Believe capability is present, but unconfirmed Page 153 of 239
Capability Definitions
Page 154 of 239
eCQM Extraction and Registry Potential Barriers Potential barriers to the SIM plan for aggregating and sharing clinical quality measure data relate to stakeholder buy-in and sustainability. Several factors are concurrently at-play, which makes modular decision making essential. As noted above, Deloitte will complete key informant interviews with key stakeholders, including payers. Although they were positive about the eCQM reports submitted for SIM cohort 1, it is not yet known if they will continue to rely on HEDIS data or plan to move towards eCQM reporting. Additionally, the state budget and legislative session runs December through May of each year. Our budget request that we plan to submit in December will not be approved until May, and potential dollars will not available until after July 2018. Thus, we need a sound investment of current state and SIM dollars to lay the foundation for development of an MPI/MPD and eCQM extraction in incremental stages that will be scalable statewide over time once funding is secured. Refer to the eCQM registry project plan timeline and budget on page 22 for more details.
Operational Plan Requirements Use Case #2 As outlined in section A, use case 2 is focused on eCQM extraction, reporting, data quality and analytics. Deloitte will complete the SIM eCQM implementation roadmap, and identify necessary business and functional requirements. Concurrently during the NCE, the Office of Information Technology (OIT) is supporting SIM with access to its team of technical architects, who will help develop technical requirements in AY3, in partnership with Public Knowledge. The diagrams below illustrate the as-is state as well as potential future state flow diagrams for use case 1 and use case 2. The later use cases illustrate current and future state efforts for use case 2.
Colorado Health IT Modular Functions for APM Data Infrastructure Included in this section are several data flows that show the data relationships and decisions that need to be made to implement the prioritized use cases. All documents can be accessed online, viewed, and downloaded in larger detail in the google folder here and are also PDF included as a separate attachment. In the Summer of 2016, SIM convened stakeholder with technical assistance support from the Office of the National Coordinator (ONC). As a result, two high-level uses cases with data flows and critical path questions were developed. See the graphics on the following two pages.
Page 155 of 239
High Level Data Flows and Critical Path Questions SIM Use Case 1 Information Data Sharing
Page 156 of 239
SIM Use Case 2 QM Reporting and Analytics
Page 157 of 239
To address the questions/decisions and further define Colorado’s SIM HIT operations and implementation strategy, several key initiatives were launched and are ongoing. This includes: Use case 1-Information Sharing ●
SIM/OeHI leveraging MPC and performance measurement tool Stratus to improve data quality efforts and prep for AMP – not clear if long term solution but contracted through CPC+ ● SIM/OeHI worked with HIEs to advance data sharing through prioritized onboarding and planning for quality measurement and reporting. Use case 2-Quality Measurement and Reporting ●
SIM convened HIT stakeholders to provide SIM with preliminary recommendations for the questions posed for use case #2. Recommendations for data extraction and integration of clinical quality measures were submitted and accepted by SIM’s HIT workgroup and steering committee. ● SIM/OeHI/OIT contracted skilled data/solutions architects to define technical requirements. ● SIM contracted with Deloitte to determine preliminary requirements and strategies for data sharing and quality measurement. ● SIM continues to partner Office of eHealth Innovation and the eHealth Commission to begin to define data governance and data sharing for the State. o Colorado HIT Roadmap efforts identified data governance and data sharing as key priorities and are working with SIM to define specific initiatives. Final Roadmap will be delivered to the governor’s office in fall of 2017. o eHealth Commission will review Deloitte’s recommendations. ● SIM/OeHI mapped out more granular current and future state data flows for data sharing and quality measurement in support of APM. See below for data flows. To address the questions/decisions and further define Colorado’s SIM HIT operations and implementation strategy, several key initiatives were launched. This includes the following: ●
● ● ● ●
● ●
SIM convened stakeholders to provide SIM with recommendations for the questions posed. Recommendations were submitted and accepted by SIM’s HIT workgroup and Steering Committee. SIM/OeHI worked with HIEs to advance data sharing through prioritized onboarding and planning for quality measurement and reporting. SIM/OeHI/OIT contracted skilled data/solutions architects to define technical requirements. SIM contracted with Deloitte to determine preliminary requirements and strategies for data sharing and quality measurement. SIM continues to partner Office of eHealth Innovation and the eHealth Commission to begin to define data governance and data sharing for the State. o Colorado Health IT Roadmap efforts identified data governance and data sharing as key priorities and are working with SIM to define specific initiatives. Final Roadmap will be delivered to the Governor’s Office in Fall of 2017. o eHealth Commission will review Deloitte’s recommendations. SIM/OeHI leveraging MPC and performance measurement tool Stratus to improve data quality efforts and prep for AMP – not clear if long term solution but contracted through CPC+. SIM/OeHI mapped out more granular current and future state data flows for data sharing and quality measurement in support of APM. See below for data flows.
Page 158 of 239
Current/Future State: Performance Measure Reporting First diagram is current state-SIM HIT Year 3 claims/clinical data aggregation and reporting for Use Case 2. All grey images represent database or warehouses and aggregation. Blue boxes represent reporting and analytics but for is part of Stratus™. Green represents the practices and purple represents the clinical integration. Future state is listed below the black line. Note the future of Stratus for SIM and the State is being determined. Click here for larger image.
Page 159 of 239
Current/Future State: Data Extraction to SIM Primary Care Practices Use Case 2 First diagram is current state-SIM HIT Yrs 3 eCQM reporting for Use Case 2. All grey images represent database or warehouses and aggregation. Blue boxes represent reporting and analytics. Green represents the practices and payers. Future state is listed below the black line. Note the BIDM is still being implemented. Decisions/Discussions will need to be made on BIDMs role in statewide eCQM reporting. Click here for larger image
Page 160 of 239
Page 161 of 239
Data Flow and Capabilities needed for Quality Measurement and Reporting Below is an initial conceptual data flow and capabilities required for eCQM reporting. This workflow was developed via stakeholder input and technical assessment. Rule of engagement on the flow of clinical and claims and where and how it will be staged and normalized are still to be determined. Deloitte is developing more granular concepts based on white boarding with SIM/OeHI on June 15. The “To-Be” list represents all the capabilities that must be present for statewide eCQM extraction and reporting.
Population Health Management
HEALTH CARE ORGANIZATIONS Hospitals (74) Practices (520+) Labs (9)
Clinical Data
HEALTH INFORMATION EXCHANGES (HIE) CORHIO & QHN
TO-BE HEALTH DATA SYSTEM(S) Aggregated & Normalized Clinical Data
COMMERCIAL PAYERS
Claims Data
STRATUS Best Doctors
Claims Data
PUBLIC PAYERS Medicaid Medicare
Claims Data
ALL PAYER CLAIMS DATABASE (APCD) Center for Improving Value in Health Care (CIVHC)
Aggregated & Normalized Claims Data
Examples of capabilities: • Data storage & management • Data analytics • Patient matching • Provider attribution • Clinical & claims data aggregation • eCQM analytics • eCQM reporting • Measure validation • Provider portal • Consent management
eCQMs
Quality Measurement Reporting
Additional data flows in development through end of July 2017. Below are a few examples of the data flows that SIM will develop include: ● ● ● ● ●
Future State Care Delivery Transformation; Future state role of BIDM and HIEs in SIM’s HIT use cases; Current and Future State of the Integration of Behavioral and Physical Health; Future State Quality Measurement and Reporting; and Future State Data Aggregation for Use Case 1 and Use Case 2.
Page 162 of 239
Health IT Optimization B1. Detail how the awardee will optimize new and leverage current HIT at the provider, payer and state levels to achieve the statewide infrastructure needed to implement delivery system and payment reform, including telehealth.
HIT Functionality
Information, Purpose and Location
Current Barriers
Funding
Policy Levers Utilized
QMRT
A portal used by SIM- practices to enter data related to required practice CQMs and receive feedback on their performance.19
new SPLIT vendor on-boarded, separate portal for providers, working through issues with new version to improve reporting and collaboration New SPLIT vendor onboarded Spring 2017. Continue to expand access to new users
SIM
Other federal initiative alignment (ENSW, TCPi)
8/2017
Medicaid Management Information System (MMIS)
The Colorado InterChange20 will provide the core MMIS and supporting services, which include: ● Fiscal Agent Operations Services ● Provider Web Portal ● Online Provider Enrollment ● Claims Processing and Payment ● Electronic Data Interchange ● Electronic Document Management System ● Provider Call Center ● Help Desk ● General IT functionality and business operations
New system implementation begins March 2017 and HCPF continues to onboard providers for the next couple months. Deloitte is currently researching and defining barriers/components for each component as it relates to SIM’s Use Case 2 Use Case and OeHI is assessing for the first Use Case.
Health First Colorado (Medicaid)
ACC 2.0, PCMH
TBD
19
SIM Year 1 Operational Plan, published 1/6/16
20
The Colorado InterChange: https://www.colorado.gov/pacific/hcpf/colorado-interchange-faqs, accessed 4/5/17
Fully Operational Dates
Page 163 of 239
Business Intelligence and Data Management (BIDM)
A state, enterprise-wide data warehouse that collects, consolidates, and organizes data from multiple sources, and fully integrates Health First Colorado eligibility and claims data for reporting and business process analysis. The objective is to offer HCPF the ability to evaluate programs and health benefit plans, and establish provider rates by forecasting utilization, cost, and caseload and modeling scenarios based on those analytics21.
New system implementation in progress, plans to incorporate 80+ data sources of claims, health, and human services data. Specific use cases are in development. BIDM team focused on initial implementation. More details to come in fall 2017.
Health First Colorado/ Medicaid
State privacy and security policies, accountable care arrangements- New ACC 2.0 and APM requires reporting of performance and quality measures, planning discussions are underway on how BIDM will accept the files and share data with other systems.
Stratus
A reporting and analytical tool provided by Best Doctors allowing care providers to access their patients’ claims data from one website using payergenerated attribution. This is the same data with the same attribution the payers are using to evaluate performance in VBP models. Data is refreshed monthly-quarterly allowing closer to real time analysis (currently the APCD continues to have a significant lag). Additionally, the tool has interactive capabilities that allow the user to analyze and develop registries based on risk, diseases, utilization. Best Doctors has partnered with CIVHC and other state and local entities to build the tool and help ensure a
Accessing Health First Colorado/Medicaid data, not all payers in state participate-not as comprehensive as CIHVC APCD, Medicare providing data for CPC+ practices only, CIHVC is providing claims for Medicaid and Cigna- SIM practices and will provide Medicare data for SIM practices now that a Qualified Entity.
Payers/SIM
Advanced primary care arrangements, APCD, federal or state grants,
TBD
21
Truven Health Analytics: https://truvenhealth.com/news-and-events/press-releases/detail/prid/167/truven-health-awarded-colorado-hcpfcontract-worth-$86m-, published 6/16/15 Page 164 of 239
comprehensive approach to data aggregation.22 Colorado Community Managed Care Network (CCMCN)
Colorado Community Managed Care Network (CCMCN) is a Health Center Controlled Network (HCCN) comprised of 19 Community Health Centers with more than 90 clinic sites. CCMCN was founded as a non-profit organization in 1994 to respond to the advent of mandatory Medicaid managed care. Areas of focus include managed and accountable care, health information technology, and clinical quality improvement programming. Governed by executive leadership from FQHCs
Leveraging technology and trust established with FQHCs for use case 1 and 2, this includes connecting all FQHCs to HIEs, leveraging eCQM efforts, aligning HIE/HIT infrastructure, and understanding how new ACC 2.0 will impact partnerships for sharing data and reporting quality measures
Individual organization or RCCO partner
Federal or state grants-HRSA-available dollars, advanced primary care arrangements, governed by FQHC Board of Directors, 1/3 partner in Colorado Access, and partner of ICHP RCCO 4. FQHCs have identified CCMCN as their trusted partner for data extraction and analytics, will need to consider with long term investments how to leverage and support these partnerships
2016
Multiple sources
Federal or state grants— HITECH/IAPD-available dollars, advanced primary care arrangements, former state designated entity, HIE oversight, RCCO partnerships, REC program administrator
2012
May be a data contributor on behalf of the FQHCs and/or technology partner for use case 1 and 2,
Currently providing eCQM aggregation, reporting, and analytics for FQHCsreporting on behalf of SIM practices
CCMCN is providing data aggregation, normalization, validation, reporting and analytics for FQHCs. Colorado Regional Health Information Organization (CORHIO)
22
As an independent, nonprofit organization, CORHIO is one of the two HIEs in Colorado, providing advisory services to help healthcare professionals use technology and improve care delivery, and supply health plans and accountable care organizations with data that enhance
Continue to gain provider and hospital buy-in on the front range. Developing connectivity to QHN for specific use cases (use case one— data sharing; use case two—data extraction and reporting) and XCA connection for patient-centered data home efforts. Use cases for data sharing will be developed as needed. Discussion are underway
The Colorado Multi-Payer Collaborative: http://www.cms.org/uploads/SIM_Payer_Collaborative_FAQ.pdf, accessed 4/5/17 Page 165 of 239
analytics and population health programs23.
through Colorado’s HIT Roadmap to further define standards and requirements for sharing data in the state. On May 5th 2017, CORHIO announced use of FHIR APIS for access to clinical data. Piloting technology to extract and combine data from HL7 and CCD into a single document, break down discrete data points, and inform quality of data across multiple sources. More details will be available soon. This would enable eCQM extraction and potential development of registry capabilities and aligns directly with SIM’s Use Case 2.
Quality Health Network (QHN)
QHN is a not-for-profit community partnership that was established in 2004 to support the adoption of health information technology, provide HIE services and promote innovative uses of electronic health information for improved healthcare outcomes.
Expanding patient-centered data home model beyond western slope and expanding interoperability between CORHIO/QHN. Western slope HIE is live and fully functional. Subscription model well received by stakeholders.
Broadband/Telehealth
With the passage of HB 15-1029, which requires carriers to reimburse providers who use telemedicine to deliver care, the SIM office is working to develop and implement a statewide telehealth strategy, which aims to expand access to and improve quality of integrated physical and behavioral health care. SIM has entered an agreement with Colorado Telehealth Network (CTN) to expand access to broadband services to
Cost, infrastructure
23
SIM
Federal or state grants— HITECH/IAPD-available dollars, advanced primary care arrangements, HIE oversight, RCCO partnerships
2010
Newly-created Office of Broadband- Governor John Hickenlooper declared 100% connectivity by 2020 in State of the State address to legislature in 2017
2020
CORHIO, About Us: http://www.corhio.org/about, accessed 4/5/17 Page 166 of 239
approximately 300 underserved urban and rural healthcare facilities throughout Colorado by 2018. Based on the SIM HIT workgroup progress as of April 2017, Spark Policy was engaged to deliver a telehealth implementation report to inform the RFP process. The priority will be to enhance behavioral health integration through telehealth for adult and pediatric populations.24 All Payer Claims Database (APCD)
The APCD (www.comedprice.org) is a secure database that includes claims data from commercial health plans (large group, small group, and individual), Medicare and Health First Colorado. Created by legislation in 2010 and administered by CIVHC, the CO APCD is the most comprehensive source of health claims data from public and private payers in the state25.
Transitioning to new vendor, sustainability, applying to be qualified entity for CMS data. Potential to expand cost information. Not funded directly by the state. The sustainability model is based on selling data for research.
CIVHC
Long-term eCQM registry
Support integration of clinical, behavioral and administrative data to enable better provider decision-making at the point of care
Sustainability, buy-in
SIM, 90/10, payer, providers
Federal or state grants, advanced primary care arrangements, state designated entity, HIE oversight, APCD, qualified entity rules
2013
2019-2020
Leverage standards (C-CDA) for sharing clinical summaries to meet Meaningful Use Stage 2 requirements Enhance HCA ability to report on common measure set and analyze clinical quality measures, which will 24
SIM HIT Workgroup Meeting presentation material, presented 4/6/17
25
Colorado All Payer Claims Database: http://www.civhc.org/All-Payer-Claims-Database.aspx/, accessed 4/20/17 Page 167 of 239
impact payment models and service delivery. Provide mainstream reporting and analytics capabilities with custom and pre-configured reports Establish data store for future extracts to support advanced analytics MPI/MPD
OeHI is moving forward with plans to release an RFP for MPI/MPD in the fall 2017. In 2016 developed business and functional requirements and will be working with Health Tech Solutions to define technical requirements. Goal is to build for Health First Colorado and leverage for other payers focused on SIM use case and Health First Colorado use cases.
Procurement process and contracting, timing of available funds
90/10 and might use SIM funds due to timing and the amount of funds initially requested in the IAPD
Public Health Data Integration
BIDM will be incorporating more than 80 plus data sources- Health First/Medicaid Colorado’s data warehouse and analytics platform. This includes public health and human services data. BIDM is in the early stages of implementation, currently funded by state and HITECH. Goal is to integrate public health and human services data in 2017. Stage I of the implementation begins March 2017 and stages II and II of the implementation will continue through the end of 2017.
Funded by state and HITECH- IAPDU, II and III stage of implementation in progress, Public Health data is part of stage III implementation
90/10, 75/25, and state funding
2019-2020
ACC 2.0, APM
2017
Page 168 of 239
Telehealth Current plans and requirements for telehealth in development. Activity (telehealth functionality or activity) ●
Policy work group to evaluate multi-payer structure for telehealth e-consultation in rural and urban areas. Legislation implemented in 2017 to increase access to telehealth required of all health plans
●
The telemedicine/telehealth SME workgroup is prioritizing telehealth modalities to support access to behavioral health services and supports, and identify the training and resources necessary to support platform development and expansion, based on the 5 strategies listed in the narrative above.
●
Public Knowledge will facilitate the SME group and convene stakeholders to determine final functional and business requirements for the telehealth RFP.
Colorado Coordinated Telehealth Network Plan Geographic/Policy Barriers Limitations ● Buy-in to model—might not ● Multiple be one-size-fits-all for CAHs, platforms FQHCs/RHCs. Plan: Convene available SME group that comprises ● Work with representatives from systems, existing partners urban, rural, provider mix to and referral make recommendations patterns ● Lack of reimbursement for e● Varying payer consults. Plan: convene mix across the payer/provider group to state develop framework ● Multiple existing platforms and competition among systems. Plan: One size statewide platform will not fit Colorado, enhance existing infrastructure by focusing on expanding access to services and supports for BH, training and resources for providers and consumers key
Funding Source SIM / providers and systems/public and private payers
Timeline 2017
Population Health B.2. Detail how the awardee will utilize new and current health IT at the provider, payer and state level to support the information/data needs for integration of population health into the activities, including e-performance measurement
Page 169 of 239
HIT Domains of OP Purpose & Location CDPHE Population Health Website
CDPHE Public health reporting / registry ● CIIS/Immunizations ● Syndromic Surveillance ● Birth/Fetal data ● Trauma registry ● Cancer registry ● Death Registry
HIT functionality Live on a CDPHE website/Tableau
None
Funding source
SIM
Multi-payer policy levers used
Federal or State Grants
9/30/2016
MU/State, Financial-provider time and Federal Incentives resources to complete for providers to integration effort is limited. work through CIIS AY3 CDPHE Cerner integration and Integrating CIIS into EHRs via implementation and EHR Project CDPHE and CORHIO and integration dependent on Management Mental Health Institute and CDHS Mental InstituteSkills for Local Public Health Agency Federal or state grants/MU/90/10 Cerner implementation development EHR Cerner project which has delayed go-live build of Cerner several times and has not project, planning set a new go-live date. New for Cerner go-live date will be implementation determined in June 2017 for in progress, goboth projects. live scheduled for 2018
Evaluation of reporting of provider performance measures / MU measures via a statewide eMIPP system / MU Tracker registry system could leverage key population health data for population health.
eCQM reporting via QMRT
Current barriers
Performance measure reporting
Manual process, trust in data
HITECH / MMIS initial investment/SIM
None, transition plans need to be developed in AY3 from manual process to automated once eCQM SIM implementation Roadmap and timeline are finalized in July 2017.
Start date/ Fully operational date
AY3 – AY4
eCQM reporting
1/2018 12/20
eCQM Reporting; CPC+, MACRA
4/2016 4/2017
Page 170 of 239
Common measure set – A goal for SIM program, aligning with CPC+, QPP, and ACC 2.0
Performance measure reporting
eCQM alignment has occurred across public and private payers. Payers continue to rely on HEDIS/claims performance for VBP. Longer term goal to SIM / Agency convene conversation around common Colorado performance measure set to include eCQM and admin measures
CIVHC statewide quality measure proxy
Data dashboards
None, in alignment with SIM common quality measure SIM set
eCQM Reporting
1/2018
eCQM reporting
Live 7/2016
Federal or state grants
Start 11/2016 – live 1/2017
Contracting /Adoption of Tool CHORDS is a collaborative, regional pilot project that uses EHR data to monitor public health trends, and measure the efficacy of public health interventions. CHORDS project
Population Health Tool
SIM CHORDS is operational and on the eHealth roadmap. It is in a pilot phase—several systems participate but data extraction work of SIM/OeHI will need to discuss how to leverage and advance effort. Potentially enable great penetration
Page 171 of 239
Prescription Drug Monitoring Program (PDMP)
Supporting registries using HITECH funding. We can use 90/10 funding. DOH also has an ADP to look at registry architecture. Strategy and planning to happen in AY3.
PDMP integration, HIE, EHR integration, mobile apps
Registries
Improved data sharing for individuals with mental illness in HIE / EMR/data criminal justice system. sharing/Interoperability
and true population level data. MPI will enable deduplication of patient-level results, a current issue. PDMP application transitioning to new vendor (APRIS) in July 2017, several grant efforts through Bureau of Justice Assistance and CDC to improve use of HITECH system through UC Health ED direct integration, CORHIO/QHN pilot integration, and RX Assure application.
Funding
MMIS / Agency
Multi-state agency project (DHS, HCPF, CDPS, DOC, OIT, State funds to OEHI) working with MICJSbegin efforts and Mental Illness in Criminal plans to request Justice Task Force to additional funds determine plan for and leverage information sharing by 2018 HITECH funds. and present to legislators.
HIE Advisory Council / Oversight Board Top priority on governor’s dashboard
TBD
Medicare and Medicaid EHR Incentive Program ('Meaningful Use')
TBD
SB17-019: Medication Consistency Bill information sharing to improve care coordination of individuals with mental health illness in criminal justice system. Requires state to come up with a plan and funding strategy by 2018 legislative session
Page 172 of 239
Subscription model for HIE access by jails, or entities with no revenue, etc. Investigating HIE / EMR whether we can use federal funding for EHRs in jails/prisons and to identify safety concerns.
TBD
TBD
Funding / implementation, Updated details requested from HIEs to evaluate –this is part of the OeHI roadmap and aligns with current TBD efforts for SIM use cases
HIE Advisory Council / Oversight Board State purchasing/contracting of healthcare services
TBD
It is currently not on the HIT workplan Planning / Implementation CMS
Approx. Medicaid waivers & demonstrations 1/1/2017 start
Note: All TBDs listed in the chart above will be addressed in SIM’s Finalized Workplan submitted July 2017
Page 173 of 239
Governance Structure To support health transformation, a coordinated HIT/HIE and data governance structure is needed to align health programs, unify technology investments, and advance data integration among state agencies and private health partners. In October 2015, through Executive Order B 2015-008, the eHealth Commission and OeHI were created under the Office of the Governor to strengthen coordination of HIT governance and provide strategic oversight to support Colorado’s health transformation trajectory. The eHealth Commission and OeHI provide governance and strategic oversight on Colorado’s HIT initiatives. The eHealth Commission has members from both HIEs, the public and private payer community, several state agencies that influence healthcare, providers, and other organizations related to healthcare. OeHI performs the role of the SDE and governs Colorado’s eHealth HIE operating model. OeHI is led by an office director who was selected by the governor’s office and is supported by the state HIT coordinator. The State Health IT Coordinator is responsible for coordinating all health IT projects in Colorado to ensure alignment in efforts and budgets. The State Health IT Coordinator also serves as an honorary member of the eHealth Commission and directly supports the SIM project through consultation and collaboration, co-chairs the SIM HIT WORKGROUP, and aligns SIM with OeHI’s Roadmap effort. The eHealth Commission, formed as a committee within OeHI, is responsible for creating and coordinating specific initiatives and workgroups, including those essential to establish ehealth standards (e.g., privacy and security, interoperability, information, technology) for each strategic initiative. The department is the state Medicaid agency (SMA) and serves as the fiscal agent managing funding requests, procurements, contracts, and payments to vendors on behalf of the SDE. Funding requested in Appendix D will be used to continue supporting the SDE’s strategic planning (Colorado HIT Roadmap) and DDI of infrastructure to support Colorado’s HIE Statewide Shared Services. OeHI and the eHealth Commission works collaboratively with the department, CDPHE, OIT, and other public and private stakeholders to develop strategies and best practices for infrastructure development and the continuous improvement of the Colorado health ecosystem. This ensures that project initiatives, including the projects detailed in this IAPD-U, have strategic foundation and alignment, are coordinated to other related projects, and optimize resources and enterprise assets.
Page 174 of 239
OeHI and the eHealth Commission consists of three major groups. The full-time staff of OeHI is outlined above. The two staff members work for the governor’s office to goals outlined in the State of Health. The office is supported by HCPF, which serves as the fiscal administrator and provides financial management of federal and state funds. HCPF will process funding awards in the state as well as contract management services for dissemination to partners, vendors and qualified entities. Second, the eHealth Commission consists of nine to 15 volunteers appointed by the governor who have experience and knowledge in: i. Primary health care delivery; ii. Behavioral health care delivery; iii. Health insurance; iv. Non-profit HIT-related community organizations; v. Interoperability and data exchange; vi. Consumer engagement in healthcare; and vii. Health care quality measures. The eHealth Commission includes private sector and consumer representation along with the public sector ensuring a holistic approach to the future of HIT in Colorado. OeHI and the eHealth Commission are developing Colorado’s HIT Roadmap that leverages and continues SIM’s efforts beyond the term of the initiative. Through a process of stakeholder input from key stakeholders and the SIM office, several HIT objectives were identified and make up the goals of the plan. OeHI is in the process of defining initiatives for each objective in Summer of 2017. Data governance and policy were a few of the top priorities and are listed explicitly as objectives in Colorado’s Health IT Roadmap. The Roadmap process will address how OeHI and State leadership work across state agencies and with multi-payers in directing and overseeing the funding, implementation, and operations of the data health IT governance. OeHI intends to work with SIM to refine plans and a vision for the state. The Colorado HIT Roadmap Objectives are shown below. Objectives that align with SIM’s year 3 Use Cases for information sharing and eCQM reporting are highlighted.
Page 175 of 239
Page 176 of 239
Data Governance Structure
Multi-Stakeholder Structure for health IT in Support of Service Delivery Reform ● OeHI convenes the eHealth Commission, which has the following principles: o Establish an open and transparent statewide collaborative effort to develop common policies, procedures, and technical approaches that will enhance the state’s HIT network; o Promote and advance data sharing by reducing barriers to effective information sharing; o Support health innovation and transformation by enhancing Colorado’s information infrastructure; and o Improve health in Colorado by promoting meaningful use of HIT. ● OeHI completes its strategic state HIT roadmap, which includes data governance as a key priority, and will influence SIM initiatives. SIM is working with OeHI to determine strategies and rules of engagement for each use case. ●
SIM has a comprehensive governance structure that includes an advisory board, steering committee (which comprises the co-chairs from eight workgroups), and an HIT workgroup. The focus of SIM’s HIT Operational plan is to review/approve Deloitte’s eCQM Implementation Plan, requirements for the MPI/MPD and eCQM solution, CHITA SOW, and Colorado HIT Roadmap initiatives as it relates to SIM’s use cases. For AY 3 the SIM steering committee and HIT workgroup will focus on the following: o o
Data governance around sharing eCQM data in the long-term solution Data governance related to
Multi-Stakeholder Structure Related to e-Performance Metrics and Value-Based Payment Reform ●
●
● ● ●
For SIM’s Uses Cases for specific roles of each committee and advisory board will need to be further defined based on their existing charter and recommendations from SIM/OeHI. Requirements will be added to RFP to help facilitate these discussions/decisions. eHealth Commission was established to provide data governance recommendations and they are providing recommendation, as needed. The Colorado Health IT Roadmap is further defining how data governance will be performance statewide and what the rule of engagement entails for data sharing and quality measurement and reporting. ●
Health IT Governance Structure
The governor’s office oversees SIM and OeHI, creating shared leadership and guidance on implementing statewide strategies to maximize HIT.
The Accountable Care Collaborative Program Improvement Advisory Committee makes recommendations to the ACC program on KPIs and performance metrics. They inform efforts to align across programs. Includes broad provider and community stakeholder input The SIM Steering Committee is tasked with approving any changes to the performance metrics for SIM and also will approve accountability metrics. They make recommendations to the SIM office and the advisory board. Several steering committee members also sit on the eHealth Commission eHealth Commission is currently developing the HIT roadmap. Will be the informing body for data governance The MPC currently governs the data aggregation tool Governing Data Advisory Board (GDAB)
A government data governance structure for common measure set is being explored. The MPC has aligned measures for SIM and CPC+ and the SIM office simplified the measure set to align with QPP and the ACC 2.0 APM measure set. Working with key partners, the SIM office is leading efforts to understand viable options for developing a Colorado common measure set. Decisions/discussions Colorado has a shared vision for aligning eCQMs, however these are just one
Page 177 of 239
●
●
●
Risks as a result of the barriers and action plan with timeline to mitigate risks, including interdependencies
One of the primary risks is the delay in developing the data governance strategy. Although the commission was created in December of 2015, it has taken some time to develop the strategic roadmap, a key primary activity. Once complete, we anticipate that rules of engagement will be informed by recommendations from the commission. OeHI has initiated streamlined data sharing agreements between health agencies. ● EHR capabilities may be lacking the traditional “plug-and-play” functionality, making EHR integrations more costly and lengthy than expected ● Provider readiness and technical capabilities may be lacking, especially in underserved and rural areas of the state ● Multiple requests of providers for data ● Resource constraint for individual practice connectivity Continued barriers to sharing substance use disorder and behavioral health data
●
●
●
●
component used in value based payment models. Determining a path forward to align administrative and claims-based measures will need to occur to determine which structure will govern the Colorado quality measure set strategic planning. This is not something that can be achieved quickly without leadership and engagement. SIM HIT Workplan to define strategy and plan for AY3.
Since 2016, OeHI has worked across state agencies to develop a singular data use agreement to foster and enhance effective data sharing at a state agency level. As of May 2017, several key health agencies (OeHI/ HCPF/CDHS/CDPHE) have agreed to use a standard format for data sharing. Efforts continue to finalize process and expand to other agencies via GDAB. It will be key to document what data governance decisions have been adopted (or agreed to) and apply the findings to SIM as well as state policies and procedures. Work with HIEs to negotiate with vendors on behalf of providers in the state. Additional strategies and support needed by practices to share concerns with vendors on current capabilities of electronic health records. SIM is working with the University of Colorado and OeHI to develop a plan. Support measure alignment and the advancement of data extraction and reporting capabilities to reduce reporting burden Work with policy workgroup to determine education and TA around 42CFR part 2 rules
Page 178 of 239
SIM and OeHI Decision Governance The following depicts the decision making for the SIM initiative, which may inform or be informed by the Office of eHealth Innovation. There is currently a collaborative partnership in place based on the shared location of the two offices within the Governor’s Office with shared leadership.
Note the impact of the decisions in SIM’s YR 3 Operational plans are broader than SIM and OeHI and will require input from other stakeholders and governing organizations. The governor’s office will continue to play a crucial role in alignment.
Page 179 of 239
HIT Policy Note all items listed in table below that mention AY3 will be further defined and tracked in SIM’s HIT Workplan. HIT Policy Lever
Impact Topic focus: Governance/data sharing and HIT infrastructure Mechanism for implementation: Statutory/regulatory Target of the policy lever: Provider, population health, and Health First Colorado programs State Designation of the Status of whether the policy lever is operational or planned: It is operational. Will develop data governance structure in the OeHI as the SDE state and guide rules of engagement. Impact of lever to assure HIT statewide: Planning for operationalizing data governance AY3 will have broad impact on HIT data governance Topic focus: Governance/policy and payment incentives Mechanism for implementation: statutory/regulatory, public program contracts, payer contracts Medicare and Medicaid Target of the policy lever: provider, population health or Health First Colorado programs EHR Incentive Program Status of whether the policy lever is operational or planned: Operational for EPs and planned for IPs. ('Meaningful Use') Impact of lever to assure HIT statewide: Through the Medicaid EHR Incentive Program, states support provider adoption of interoperable, certified HIT. In AY3 to be spread to previously ineligible providers. Topic focus: Payment incentives, policy, etc. Mechanism for implementation: Public program contracts, waiver-specific funding contracts Target of the policy lever: Providers, population health Medicaid Waivers & Status of whether the policy lever is operational or planned: Planned for AY3 Demonstrations Impact of lever to assure health IT statewide: States can promote HIT and interoperability through Medicaid waivers and demonstrations. In AY3 Colorado will embark on a planning phase for its 1115b waiver to assess whether there would be a positive impact on HIT investment Topic focus: Governance/policy Mechanism for implementation: TBD-Colorado HIT Roadmap to be completed with eCQM initiative defined by SIM in Fall of 2017 and Deloitte Implementation plan to be delivered with specific in July 2017. Target of the policy lever: Colorado payers have voluntarily aligned around a common set of eCQMs for CPC+ and SIM. The SIM office has worked with Health First Colorado and other key stakeholders to align measures across state programs and initiatives. Providers feel burdened by additional measurement reporting r benchmarking outside of these programs. eCQM Reporting Collaborative discussions are under way to identify possible mechanisms to reduce provider burden. Status of whether the policy lever is operational or planned: TBD eCQM measurement alignment is the first step but Colorado will spend the first two quarters of AY3 assessing the environment to expand alignment to administrative and claims-based measures. With the current Federal uncertainty in the health care landscape there has been a diminished ability to convene new conversations. Impact of lever to assure health IT statewide: Goal to require Colorado common measure set for reporting.
Page 180 of 239
Topic focus: Payers, providers, and state government > toward payment incentives Mechanism for implementation: Statutory/regulatory Target of the policy lever: Colorado's APCD legislation (Colorado House Bill 10-1330) went into effect in late summer 2010. The legislation set a number of required actions and milestones. CIVHC was appointed the administrator of the APCD and, through its work with an appointed APCD advisory committee, has successfully met its statutory milestones on or before deadlines. APCD policies allow data to be used for an expansive set of use cases that advance interoperability. This includes the aggregation of claims and clinical data as well as use of the data to support clinical care. The APCD adheres to national All Payer Claims Database interoperability standards and uses common infrastructure to identify beneficiaries. This data from CIVHC is used to inform a (APCD) Policies TCOC report for SIM practices and provides a comprehensive picture of the total cost of care for individuals that can be used to support initiatives focused on improving healthcare quality and efficiency. Such data could potentially be used for decision making by providers in APMs who require enhanced understanding of patients’ total cost of care. Status of whether the policy lever is operational or planned: Operational AY3 to provide Medicare Claims data to Stratus for SIM practices and claims proxy measures to the SIM Office for performance measures. Practices received their first report April 2017, will be updated quarterly Impact of lever to assure health IT statewide: The CIVHC APCD data is used to inform SIM practices of historical cost and utilization patterns to support VBP. Topic focus: Payment Incentives / Workforce Mechanism for implementation: Statutory / regulatory, public program contracts State Target of the policy lever: providers/population (CDPHE, CDHS) Purchasing/Contracting Status of whether the policy lever is operational or planned: Planned for AY3. SIM working with OeHI and HCPF to develop of Health IT joint budget request for 2018 funds. Specific incentives and policy levers will be determined through Colorado’s Health IT Infrastructure (nonRoadmap process. Medicaid) Impact of lever to assure health IT statewide: States directly purchase information systems as part of their operations outside of Medicaid or their direct provision of care. This can include EHRs for their group homes, mental health institutes, prisons, public health reporting systems, non-MMIS claims processing systems, etc. Topic Focus: HIT adoption LTSS Mechanism for implementation: Grant funding Target of the policy lever: Providers/population — In March 2014, CMS awarded planning grants to nine qualified states to test quality measurement tools and demonstrate e-health in Medicaid community-based long-term services and supports (LTSS). Federal or State Grants The grant program, known as TEFT, is designed to field test an experience survey and a set of functional assessment items, demonstrate personal health records, and create a standard electronic LTSS record. The state grantees will have an opportunity to extend the grant period to a total of four years. The total grant program is almost $42 million, and marks the first time that CMS promotes HIT in the community-based LTSS system. Status of whether the policy lever is operational or planned: Operational and ongoing Prescription Drug Topic Focus: Statewide prescription drug monitory program Monitoring Programs Mechanism for implementation: Statutory/regulatory (PDMP) Target of the policy lever: payers, providers, and state government
Page 181 of 239
HB 14-1283, signed into law May 21, 2014, modified the state’s PDMP. Some of the modifications allow "push notices" to prescribers and pharmacists, mandatory PDMP registration for pharmacists and DEA registered prescribers, direct access to PDMP by CDPHE, and permission authority for federally owned and operated pharmacies to submit controlled substance data into the PDMP. SB17-146, signed into law April 06, 2017, modifies provisions relating to licensed health professionals' access to the electronic prescription drug monitoring program to allow a healthcare provider who has authority to prescribe controlled substances, or the provider's designee, to query the program regarding a current patient, regardless of whether the provider is prescribing or considering prescribing a controlled substance to that patient. Status of whether the policy lever is operational or planned: Pending new PDMP vendor For AY3 SIM practices will have enhanced PDMP systems through the new vendor and CDC pilots to increase access to the PDMP. Pilots include HIE integration and direct EHR integration. The goal is to bring utilization to 70%. Topic Focus: Public health surveillance Mechanism for implementation: statutory/regulatory Target of the policy lever: payers, providers, state government, population Colorado HIO and the health department have implemented three pilot implementations to support exchange between healthcare providers and the public health department. They include the Electronic Lab Reporting, Immunization Reporting, and Newborn Screening Orders & Results Delivery. The HIO and health department are also partnering to pilot population health Public Health Surveillance data sharing into the cancer registry and for syndromic surveillance data. The state has not mandated electronic reporting or public health messaging policy, but there is an increasing trend and preference toward that approach considering MU2 requirements. Status of whether the policy lever is operational or planned: Operational. Impact of lever to assure HIT statewide: State partnership with Health First Colorado, public health and the HIEs has enabled effective sharing of data to assure population health activities. Topic Focus: Care coordination, reduced recidivism Mechanism for implementation: Statutory/regulatory Target of the policy lever: Providers, payers, state government, population SB17-019, sent to the governor for signature requires additional planning from OBH, DHS, OIT, HCPF and other agencies to Medication Mental Illness develop a legislative budget request and HIT plan to share health information for individuals in the criminal justice system that in Justice Systems includes medication formulary and other health information with health and justice system providers. Status of whether the policy lever is operational or planned: Planned. In AY3 data flows and funding request will be submitted to legislature for approval. Impact of lever to assure HIT statewide: Improves care through interoperability and data sharing between state systems, care providers, criminal justice providers, and HIEs. Topic of focus: Sharing behavioral health data Mechanism for implementation: Statutory/regulatory State privacy and security Target of the policy lever: Payers, providers, state government, population policies Behavioral Health Information Exchange - The Colorado Division of Behavioral Health Code of Colorado Regulations (2 CCR 5022) includes a confidentiality stipulation that states written consent must be acquired and held on file for one year to share
Page 182 of 239
certain client information (and renewed for additional one-year periods). This regulation affects behavioral health organizations that provide outbound formation to an HIE. This does not limit receiving data through the HIE, such as labs, hospital discharge information, imaging results, care summaries, etc. Status of whether the policy lever is operational or planned: Operational until 6/17 – not operational in AY3. Colorado was awarded the Colorado Advanced Interoperability Initiative to pilot two models of consent for sharing BH/SUD data. The pilot ends June 2017 and will inform future efforts. In AY3 SIM will incorporate state privacy and security requirements into RFPs for use case 1: MPI/MPD and use case 2 eCQM. Impact of lever to assure health IT statewide: Governs privacy and security of information sharing
Page 183 of 239
Performance Measurement/Quality Reporting Systems Note all items listed in table below that mention AY3 will be further defined and tracked in SIM’s HIT Workplan. Performance Metrics and Quality Reporting Systems Enabled by HIT Modular Functions SIM has aligned its measures set with QPP, CPC+ and the Health First Colorado ACC program. This is the first step to support quality measurement while reducing administrative burden for providers The governor’s office is building a consumer portal for information about health care quality and value. This platform will be operational in October 2017. It will initially report publicly available consumer-facing data points. There may be an opportunity to use this platform to expand the conversation around measure alignment across the state for all value-based payment models—as noted above these are delicate conversations and the focus in the current environment is on coverage and maintaining the exchange. It is our goal to move forward the collaborative conversation over the first two quarters of AY3. Moving towards a Colorado list of agreed upon measures will greatly reduce administrative burden and allow coordinated efforts to support quality improvement.
Governance & Financing State decisions/discussions on measurement alignment in AY3 will define measures, governance, and process for the state. The SIM office and MPC have committed to align eCQMs, an initial conversation about broader measure alignment occurred at both the MPC and the Multi-stakeholder symposium. Since most payers in Colorado are national payers this is not a simple step process but one that starts with building collaborative trust and a shared vision. There is a plan in place to convene the conversation during the first two quarters of the AY3. Recommendations will be made to the governor’s office and the eHealth Commission at that time. The SIM steering committee and HIT workgroup approved the SIM simplified measure set and provide guidance and recommendations to SIM. AY3 plans are to implement a consumer cost and quality portal. Specifics being planned through the governor’s office. As the conversation broadens around an infrastructure to share data, OeHI and the eHealth Commission will provide recommendation and guidance. State HIT Roadmap includes one objective focused on measure alignment. Specific initiatives to be defined by October 2017.
Page 184 of 239
Technical Assistance Note all items listed in table below that mention AY3 will be further defined and tracked in SIM’s HIT Workplan. Targeted Provider Type26 SIM Primary Care Providers
SIM Primary Care Providers and 4 bidirectional health home site providers
All SIM providers and care team members
All SIM practices CMHC
HIT TA to Be Provided & Funding 27 Train Practice Transformation Organizations (PTO) to provide practice facilitation, clinical health information technology advisors (CHITAs), and other technical support to SIM practices. Focus PTO support on implementation of the revised set of 10 practice transformation building blocks. Each practice will develop one HIT practice improvement goal per year to support progress in data-driven quality improvement. Annual data quality assessment and HIT/HIE assessment to be completed by the practice with CHITA guidance, results used to inform PIP as well as to inform HIT infrastructure and data extraction needs. (HIT assessment data being collected by CHITA, aggregated and analyzed in the SIM Office to be provided to CHITAs in monthly Office Hours) Bi-annual collaborative learning sessions with targeted training for practice improvement tactics, including maximizing HIT for population health, data extraction, using Stratus™, aligning with QPP—hosted in two regions every six months. Planned for November 2017 and June 2018. Data extraction validation long term CMHC assessment conducted by independent consultants to define technical needs and additional TA and funding needs currently being review by HCPF.
Funding $15,000 practice facilitation for cohort-2 practices; $10,000 for cohort-1 practices $3,250 CHITA support for cohort-2 practices; $1,750 CHITA support for cohort-1 practices Total: Practice facilitation: $3,395,000 Total: CHITA: $697,250 Included in above budget
Included in University of Colorado budget $200,000 for AY3 to host four regional collaborative learning sessions for all SIM practices.
Currently DARTNET $55,000; planned as part of the longterm solution Funded by HCPF
26
Specify the provider type and date for health IT TA that will be provided in Year 3. Please explicitly address now the timing of the TA correlates to the implementation of new health IT and re-use of current health IT in a different way. 27
Indicate by provider type the TA that is planned, the means by which it will be provided (in person, web, etc.),
Page 185 of 239
SIM/Medicaid providers All providers CHITAs and PFs
Mathematica targeted technical assistance around newly developed eCQMs Data extraction techniques –part of long term HIT solution Training and education to PFs and CHITAS in quarterly in-person training and monthly Office Hours plus scheduled monthly webinars.
TBD based on HIT/HIE assessment TBD Part of University budget
Page 186 of 239
5. Workforce capacity Stakeholder Engagement A robust stakeholder engagement process is the foundation of SIM’s workforce development efforts.
Workforce Workgroup This workgroup regularly engages a wide range of experts representing organizations throughout Colorado, including academic medical centers, community colleges, professional associations and trade groups. Workgroup members represent the organizations listed below:
●
Caring for Colorado Foundation
●
Colorado Association of Addiction Professionals
●
Colorado Department of Health Care Policy and Financing
●
Colorado Department of Regulatory Affairs
●
Colorado Department of Public Health and Environment
●
Colorado Division of Labor and Employment
●
Colorado Hospital Association
●
Colorado Nurses Association
●
Denver Health
●
Greater Metro Denver Healthcare Partnership
●
Health Systems Development, LLC.
●
Jefferson Center for Mental Health
●
Regional Collaborative Care Organization 6
●
Red Rocks Community College
●
Swedish Family Medicine
●
University of Colorado School of Medicine
●
University of Colorado, College of Nursing
●
University of Denver, Graduate School of Social Work
These members help guide the overall strategy and agenda of the workgroup and offer the SIM office powerful opportunities to partner with these agencies to help advance initiatives that address training needs and workforce shortages throughout the state. For example, the SIM Alignment with Federal and State Initiatives section outlines how the SIM office is supporting the University of Denver School of Social Work’s application to the Health Resources and Services Administration Behavioral Health Workforce Education and Training Program funding opportunity. If either grant is awarded, the Page 187 of 239
workforce workgroup will play a role in advising program implementation.
Workforce & Education Working Group The SIM population health and workforce program manager sits on the Workforce & Education Working Group, which consists of state agencies convened by the Colorado Department of Labor and Employment to align workforce needs with the educational system in Colorado. The group is looking beyond traditional postsecondary education to programs such as registered apprenticeships, workbased learning opportunities, and certificate programs to create a pipeline that is responsive to and meets the needs of the Colorado labor market. In AY3, the population health and workforce program manager will continue to take findings from and issues raised by this group to SIM office staff and the workforce workgroup to guide implementation of initiatives. This group will likely influence development of the behavioral health endorsement program discussed later in this section.
Identification of Barriers and Priorities Integrated Behavioral Health Consortium In November of 2016, the University of Denver’s Center for Professional Development and the Graduate School for Social Work collaborated with the Colorado Health Foundation to host an inaugural meeting of an “Integrated Behavioral Health (IBH) Training Consortium” to discuss the status and future of IBH training across the state. Four main themes were presented for consideration: ● Current strengths within the IBH training landscape; ● Current gaps and identified areas for improvement; ● Potential opportunities for resource collaboration; and ● Goals and action items to support IBH training. The IBH Training Consortium focused on two efforts that will support ongoing training in integrated healthcare settings across Colorado. The primary effort was to complete an in-depth assessment of all current IBH training initiatives, plans, opportunities, and curricula in Colorado. This information will be used to create a master, interactive matrix with that information. The design will allow the information to be easily updated, revised, and shared. The second intended goal was to convene a consortium of IBH stakeholders and representatives for information sharing on current training opportunities. The consortium was asked to complete three tasks: ● ●
Discuss results of the statewide data collection on the status of IBH training; Share lessons learned from current and previous approaches to training in integrated healthcare; and ● Actively participate in breakout sessions with consortium attendees to discuss and develop actionable steps designed to improve Colorado’s IBH training efforts. The SIM workforce workgroup co-chairs were participated in the IBH consortium. Michael Talamantes, LCSW, acted as a facilitator for the consortium and Benjamin Miller, Psy.D., presented on the Eugene S. Farley, Jr. Health Policy Center and the University of Colorado School of Medicine’s plans to develop an interactive, online database with survey data. They discussed the importance of incorporating a standard set of competencies into integrated healthcare training using an accessible database that healthcare professionals across the state can access to locate, register for, and participate in postgraduate educational opportunities. This is aligned with the SIM goals of creating a centralized data and analytics hub and a common curriculum that trains our workforce to understand how working together is essential to achieving success and sustainability for Colorado’s innovative healthcare delivery strategies. This also clearly aligns with the workgroup’s charge of partnering with educational institutions to identify workforce competencies and trainings that allow personnel to achieve high Page 188 of 239
performance in IBH settings. Co-chairs Talamantes and Miller are key stakeholders to lead the SIM workforce workgroup and provide guidance to align with other training initiatives around the state. Several lessons learned from developing training in integrated health settings were presented to the group and included: ●
The need to integrate health resources in rural areas. There is a need to foster partnerships between primary care agencies and behavioral healthcare specialists to share resources and aid in practice transformation. Challenges include limited funding and insufficient numbers of behavioral health (BH) providers in rural areas to serve as partners. ● Need to consider integrated care from a population health lens and consider integration from a diagnostic and normative perspective. Two challenges included the lack of clarity in billing for services within integrated models and sustainability for integrated practices. ● The need for the team to learn and practice together as a cohesive, process-oriented, and nonhierarchical unit and create a universal training approach. Challenges to this lesson include an insufficient number of models that promote integration of substance use and oral health into primary care models. ● The need to include cultural competencies training in integrated care training models and the value added when exposing providers and trainees to cross-disciplinary communication and different settings. One recommendation is to ask medical professionals to collaborate earlier in the process to promote engagement, role modeling, and respect for multi-disciplinary approaches to treatment. ● The importance of a multileveled and multilayered approach to training in an integrated system was highlighted. It was noted that a conceptual understanding of why and how integrated care is different from other treatment approaches is necessary to transform the system. One challenge to this lesson is the need for professionals to unlearn and/or modify components of their formal training and education to accommodate an integrated care approach. Shadowing is a possible method for re-training. Current strengths within the landscape were identified by a small working group. The group reported a strong desire and willingness to collaborate among disciplines in the community environment. This is aligned with the SIM workforce workgroup’s charge to develop a plan for change management that will engage providers, administrators, and educators before, during, and after the innovation. Other identified strengths include the number of healthcare professionals participating in the consortium as evidence of collaboration, optimism regarding the number of trainings offered and under development, and the breadth of trainings that align with the priorities of the state’s vision. Finally, The Colorado Health Foundation identified possible funding for the development of IBH training programs. Three major themes arose from the discussion on gaps and growth areas in the current landscape and include infrastructure, access, and content. Attendees noted that the overarching infrastructure and approach to IBH training needs improvement. Specifically, there seems to be a disconnect between healthcare training and educational programs. One recommendation is to develop a standardized approach that includes the core competencies to training that will provide requisite skills and knowledge necessary to begin a career in integrated healthcare. The group noted there is inconsistency in the appropriate and relevant training content. There is a dissonance related to the limitation in accessible, available, and transitional training between educational programs and direct service delivery. The lack of training for the delivery of integrated pediatric services was identified by the group as a specific content gap. The group also identified challenges for billing and reimbursement and suggests training modules that include policy and billing Page 189 of 239
practices. When asked to identify potential opportunities for resource collaboration the group clearly emphasized the importance of continuing to meet as a community to build solutions and discuss ongoing improvement of IBH training in Colorado. The SIM workforce workgroup and future IBH training consortiums are venues for these community discussions to continue. Goals were categorized as either short- or long-term and fell into five diverse domains: standardization, pre-professional training, practice-based approaches, accessibility, and advocacy. Examples of shortterm goals include: ●
Create a single governing body whose purpose is to maintain a precedent for Colorado-based IBH training content and quality; ● Develop ongoing evaluation methods of integration efforts; ● Promote cross-disciplinary graduate-level education based in the practicalities of IBH practice; ● Encourage cross-disciplinary supervision and training; ● Expand access to currently available courses and develop new webinars; and ● Continue advocating for funding. Examples of long-term goals identified by the group include: ●
Enact an agnostic governing body whose purpose would be to organize and coordinate all training efforts; ● Pilot a new paradigm that requires healthcare professionals to transition from a ‘unidisciplinary’ practicum model to one that is multidisciplinary; ● The need to address substance use in integrated care; ● Establish a mentorship program for urban and rural clinics; ● Hold a IBH training consortium in a rural location; and ● Research in integrated care efficacy is a long-term goal. At the end of the day, the IBH Consortium was asked to identify specific action steps to demonstrate efforts of achieving the short-term and long-term goals. The actionable items are listed as such: ●
● ●
● ● ● ● ● ●
Convene a second consortium with the goals of creating a detailed action plan to be shared with the SIM workforce workgroup and identify delegates to develop training in specialized content areas; Develop a mentorship program with rural clinics for information and sharing and training collaboration; The Eugene S. Farley, Jr. Health Policy Center will develop a website with a database of available training programs for providers that will be shared with organizations and graduate training programs across Colorado; Identify specific funding sources for sustainability; Establish a core set of integrated healthcare training competencies; Increase communication with graduate programs to promote organizations that provide training in integrated care; Host an integrated healthcare symposium; Establish a system for accreditation of integrated healthcare training programs; and Provide incentives for hiring individuals who have completed accredited training programs.
Workforce Training The state of Colorado is committed to developing a fully Integrated Behavioral Healthcare system that would fully integrate behavioral health and primary care. This change in status quo requires a different Page 190 of 239
type of workforce. It is imperative to create an integrated training model to ensure that team-based integrated care delivery is a top training priority for all behavioral health and primary care providers. SIM’s close partnership with the Colorado Department of Human Services (CDHS) Office of Behavioral Health (OBH) provides an integral mechanism for addressing many of the priorities that have been identified by the SIM workforce workgroup and the Workforce & Education Working Group. The SIM office has contracted with OBH for several key SIM initiatives related to training the integrated behavioral health workforce. In grant year 1, OBH developed and provided information and resources about pregnancy and substance abuse use for SIM practices. Resources were made available at A Mother’s Connection; http://mothersconnection.com/. A letter containing materials identifying a contact person at OBH who practices can contact for more information was distributed to key stakeholders, health organizations, and professionals in the behavioral health and primary care sectors. OBH continues to share this information as new health organizations and practices are identified. CDHS is working with the Office of Children Youth and Family (OCYF) to distribute new state guidelines on psychotropic medications for children. OBH created a video for the new guidelines and distributed to SIM and all applicable OBH contacts. The final report, State Guidelines for Psychotropic Medications, is scheduled for release in July 2017. The OBH video module will be functional on the new University of Colorado Learning Management System platform in July 2017. In grant year 2, CDHS will focus on training and provider education and will develop an online substance use disorder course for primary care practices. CDHS is partnering with the University of Colorado Department of Family Medicine to create a platform for the training module. This is targeted to be completed by July 2017. CDHS is also working to develop an online educational course and course materials using the most appropriate format for trauma and trauma-related issues. An outline for this work has been completed and the final product is anticipated in December 2017. CDHS is also tasked with enhancing and expanding the work of Short Brief Intervention, Referral and Treatment (SBIRT), a national model for behavioral health screening and referral that increases knowledge regarding behavioral health needs for unique populations. OBH will identify barriers to implementation, encourage non-participating sites to implement SBIRT, and collaborate with Peer Assistance to develop and online substance use disorder treatment resource directory. This is targeted for completion in December 2017. CDHS is also working on a third online course for education and training for senior behavioral health issues that encompasses intervention strategies. It will be distributed to SIM practices and practices that have a large proportion of seniors. The targeted completion is December 2017. In grant year 3, CDHS will focus on best practices and certification. CDHS will develop a set of best practice guidelines for behavioral health staff in healthcare settings that will build on the competencies developed by the SIM workforce workgroup. They will also be based on national best practice information and the collective wisdom of those working in integrated settings. CDHS will also be publicizing and distributing Colorado’s behavioral health resources. CDHS will also develop a voluntary endorsement for integrated behavioral healthcare staff. CDHS will convene a workgroup to determine a process for obtaining voluntary certificates and create a process for obtaining the certificate. Ongoing conversations with key stakeholders will help create an effective framework to better serve the behavioral health community. Finally, CDHS is tasked with convening a Page 191 of 239
best practices symposium to share guidelines and educational opportunities. This symposium will be open to all behavioral health consultants in primary care to promote the adoption of best practices for behavioral health staff working in health settings and pursuit of the certificate. Discussions to define the scope of the symposium are underway. The work CDHS is embarking on directly correlates with the objectives of the workforce workgroup, which will offer recommendations regarding minimum qualifications, credentialing and training as CDHS develops training modules for providers. The workgroup will also offer guidance on the best ways of delivering training to providers. CDHS/OBH will work to support practices as they integrate behavioral health and primary care through training, resource development and sharing, certification and collaboration.
Page 192 of 239
c. SIM alignment with state and federal initiatives SIM leverages a strong foundation of federal, state, and private sector investments in primary care transformation and integration. The team builds on these initiatives to consolidate and align statewide efforts to sustain long-term comprehensive healthcare innovation. At the highest level, SIM acts as a focal point for aligning the philosophical vision of healthcare transformation in Colorado. In the State of Health report, Governor Hickenlooper wrote: “Our vision is a future where health and well-being are as much a part of Colorado’s way of life as our mountains, clear skies, and pristine environment. Instead of only focusing on sickness, we will support Coloradans in their efforts to stay healthy or become healthier. Our health delivery networks will be comprehensive, personcentered, high-quality, and affordable. They will integrate physical, behavioral, oral, and environmental health with community-based long-term services and supports, and support individual health with HIT.” The SIM office recognizes that no one initiative can achieve the goals of the entire state, but strives to ensure that the initiative is visible, accessible, and influential throughout the state. To maximize its effects, the SIM office (1) Coordinates with and builds upon existing initiatives and (2) Ensures that federal funding will not be used for duplicative activities, or to supplant current federal or state funding. Coordination between SIM and other federal initiatives SIM builds on, and aligns with, numerous CMMI, HHS, and federal initiatives that support highperforming primary care and integrated behavioral health. Examples include, but are not limited to: Quality payment program (MACRA) As detailed in the quality measures alignment section, the SIM initiative streamlined its clinical quality measures for cohort 2 to better align with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Furthermore, the sustainability plan outlines how SIM used its cohort-2 RFA to present SIM participation as an opportunity to prepare for long-term changes in the payment reform landscape, principally MACRA. At the September 2016 collaborative learning session Pam Ballou-Nelson, RN, MA, MSPH, PhD, PCMH CCE, principal consultant with the Medical Group Management Association (MGMA) gave a presentation entitled “Understanding and Executing the MIPS Four Domains: How do they apply to my practice,” in which she discussed alignment between work with SIM and preparation for the Quality Payment Program (QPP). Click here to download presentation slides. The SIM office and the University of Colorado Department of Family Medicine (University), a practice transformation partner, will continue to keep QPP and MACRA as a training topic at future collaborative learning sessions. SIM’s health information technology (HIT) plan, which is reported separately, outlines the steps that the state is taking to support practices as they prepare to report clinical quality measures for QPP. Practice data from 2017 will be used to calculate performance starting in 2019. For this reason, the team’s HIT investments are focused on practice-level data extraction, validation and reporting. We continue to hear concerns from our provider partners about data accuracy and questions about whether the data is actionable and represents the quality of care delivered.
Colorado QPP coalition The SIM team was a founding member of the Colorado QPP coalition (CQPPC), which comprises healthcare leaders in the state, and helps create and disseminate education and tools to help providers Page 193 of 239
prepare for and succeed in the QPP. The team participates in monthly meetings, helps design and give presentations to provider audiences, and shares CQPPC materials through SIM publication channels. Learn more about the coalition: http://www.cms.org/communications/colorado-qpp-coalition. The CQPPC28 started with 14 member organizations and is dedicated to (1) Increasing QPP awareness among Colorado healthcare providers using common messaging, (2) organizing education efforts, and (3) coordinating effective and efficient technical assistance for physician practices. The CQPPC began providing training in January of 2017 and intends to continue at least through the end of 2018. SIM has a leadership role in the CQPPC and creates messaging and education for member organizations to disseminate to their stakeholders throughout Colorado. In February 2016, the SIM program implementation manager participated in an informational webinar hosted by the CQPPC and Telligen about how MACRA and SIM align. The SIM office will continue to offer content for future events. Comprehensive Primary Care Initiative (CPCi) Colorado was one of seven markets selected by CMS to participate in CPCi, a multi-payer initiative designed to test practice redesign models and a supportive multi-payer payment model from 2012 to 2016. In many ways, CPCi served as a foundation for SIM, which built off its work in the following ways: ●
●
●
Continuation of the Multi-Payer Collaborative (MPC): Public and private payers came together under CPCi, which led to creation of the MPC, a self-funded, self-governing entity formed by payers to develop organizational alignment and consistency around the support of CPCi practices. Payers elected to continue using the MPC as a primary forum to develop support for SIM and continue to use Oregon Health & Science University as a facilitator (see the Payment Reform section for more information). Building upon the MPC’s foundational work under CPCi, SIM continued to leverage private payers’ commitments to migrate toward prospective, nonvolume payments, as providers become capable of adopting these new payment models. We anticipate that practices selected for SIM will advance through components of the payment models established under CPCi, which will improve likelihood of receiving enhanced funding from public and private payers. We also expect that participation in CPCi, SIM, or both will increase practices’ capacity to serve larger groups of patients more effectively and efficiently, which will contribute to sustainability. SIM initially used the basic CPCi measure set as a foundation for its CQMs. Data aggregation: SIM’s HIT plan builds on the Stratus™ tool developed by payers participating in CPCi. SIM is extending Stratus™ licenses to all cohort-1 practices. The HIT section includes information about how Stratus™ has informed the initiative’s HIT strategy and provides data aggregation opportunities for SIM cohorts 2 and 3. Practice transformation: The SIM office and payers recruited CPCi practices to join SIM. In total, 32 of the first 100 practices to participate in SIM participated in CPCi. The SIM office adopted 10 practice transformation building blocks to align with the CPCi milestones. These milestones have since been revised for cohort 2 to better align with payer priorities and reflect SIM’s focus on behavioral health information, but they were designed based on CPCi milestones. See the Healthcare Delivery Transformation section for more information about the building blocks.
Comprehensive Primary Care Plus Initiative (CPC+) SIM recognizes that aligning with and complementing the work of CPC+ is critical to the success of both initiatives. As discussed in the Healthcare Delivery Transformation section of the plan, the SIM office 28
http://www.cms.org/coqpp Page 194 of 239
decided to delay the start of cohort 2 to allow sufficient time to outline a plan for how the initiatives would work together and give practices an opportunity to learn if they were participating in CPC+ before applying to SIM. Sixty two of the 226 applications for SIM cohort 2 are enrolled in CPC+. Before releasing the request for applications (RFA) for cohort 2, the SIM office submitted a proposal to CMMI entitled “Colorado State Innovation Model (SIM) Proposed Alignment with the Comprehensive Primary Care Plus (CPC+) Initiative,” which was reviewed by the CPC+ team and approved by Joshua Traylor, SIM’s project officer at the time. The proposal outlined a comprehensive plan for alignment with CPC+ and is included as Appendix S8. Furthermore, the RFA for cohort 2 provided information about what participation in both initiatives would mean for practices. A table summarizing the information is included in the Healthcare Delivery Transformation section of the plan. In AY3, the SIM office will continue to work closely with the CPC+ team to refine alignment between the two initiatives. In April 2017, the two teams had an initial phone call to discuss alignment and decided to continue meeting quarterly by phone to discuss questions as they arise. The SIM office will seek ways in which training and resources can be shared among participants in both initiatives.
Medicaid-led transformation efforts Accountable Care Collaborative (ACC) The ACC is the primary care delivery system for Health First Colorado (Colorado Medicaid). ACC clients have access to medical homes that provide primary care, preventive services, specialist referrals, and health education. Primary care medical providers (PCMPs) are considered a client’s medical home. Starting on July 1, 2014, the Colorado Department of Health Care Policy & Financing (HCPF) took steps to recognize and reimburse PCMPs who offer services beyond the traditional fee-for-service (FFS) primary care service delivery model through the enhanced PCMP (EPCMP) program. EPCMPs can earn an additional $0.50 per member per month (PMPM) by meeting at least five of nine enhanced primary medical home factors. The nine factors29[1] are based on the medical home standards from National Committee on Quality Assurance (NCQA), recommendations from the regional care collaborative organizations (RCCOs), Colorado Senate Bill 07-130 (which defined the criteria for medical homes for children), and other key HCPF initiatives designed to incentivize quality improvement. These factors closely align with SIM milestones, and two (bolded in footnote1) directly relate to integrating behavioral
29
[1] The nine factors are: Extended Hours, Timely Clinical Advice, Data Use and Population Health, Behavioral Health Integration, Behavioral Health Screening, Patient Registry, Specialty Care Follow-Up, Consistent Medicaid Provider, and Patient-Centered Care Plans Page 195 of 239
health. The state is divided into seven RCCOs that help develop a network of providers, support providers with coaching and information, manage and coordinate member care, connect members with non-medical services, and report on the costs, utilization, and outcomes for their client populations. ACC clients are attributed to a RCCO based on the county in which they live. RCCOs help ACC clients find a PCMP and access appropriate services. The SIM office coordinates with RCCO representatives regarding delivery of payment support to SIM practices. Recognizing the RCCOs are the primary point of contact for many SIM practices, the SIM office will provide RCCOs with standardized training about the SIM initiative to help onboard cohort-2 practices in in AY3. The SIM office will provide stock language for communications from RCCOs to SIM practices to ensure message consistency. RCCO representatives will also participate in quarterly Multi Stakeholder Symposiums (outlined in the Stakeholder Engagement section of the plan). ACC participation in SIM has been described by HCPF leaders as a “central component of the department’s behavioral and physical health integration strategy.” Through SIM, the RCCOs make payments to selected primary care medical practices to help them integrate physical and behavioral healthcare and progress with through the milestones. HCPF provides financial and administrative oversight for SIM, and has key staff in each of the eight SIM workgroups to ensure continuity of support and to facilitate alignment and synergy with the ACC. The department also serves as a payer supporting Health First Colorado practices participating in SIM. From February 2016 through February 2018, the department has committed to supporting SIM’s goal of recruiting 400 primary care practices and helping them transition to care delivery models that integrate physical and behavioral healthcare. To do so, SIM is collaborating with ACC providers to implement models of integrated care with the objective of providing consumers access to behavioral and physical healthcare services in coordinated systems of care. Through the involvement of ACC primary care practices, HCPF receives benefits of SIM practice transformation that include SIM-funded education for providers that supports practice integration and transformation, and connection between communities and practices. HPCF leaders say, “These and other aspects of our participation in SIM are helping us prepare providers to integrate physical and behavioral health in FY 2018-19 when the new ACC contract begins (ACC Phase II).”
Page 196 of 239
ACC phase II: The next phase will further advance the ACC’s proven success as a vehicle for Medicaid reform innovations that incentivize care coordination and the wise use of health services. Combining administration of physical health and behavioral health under one regional entity (the regional accountable entity or RAE) will establish a cohesive network of physical and behavioral health providers who can more effectively coordinate healthcare services for clients across disparate providers including long-term services and supports (LTSS), specialty care, oral health, and social agencies. The department issued a request for proposals (RFP) for RAE contractors in May 2017, following a draft RFP public comment period in fall 2016-Winter 2017. Contract awards for the seven regional RAEs will be announced during fall 2017, with contracts scheduled to be executed in winter 2018. There will be overlapping contracts for current and new ACC vendors during Spring 2018 as the new RAEs prepare to begin operations on July 1, 2018. During the start-up period, the RAEs will establish their provider networks, policies and procedures, and technology systems to ensure the seamless delivery of services to clients. The department will also perform a readiness review of each RAE in compliance with federal regulations to ensure the new vendors are fully ready to begin operations. HCPF is also developing alternative payment methodologies that will give providers the opportunity to receive a higher rate for certain codes billed if they demonstrate that they have met pre-selected structural criteria or are meeting targets for clinical performance or service utilization. Practices will receive full credit for a period of time for SIM participation.
Behavioral health organizations (BHOs) There are currently five BHOs in Colorado (map inset) that align efforts with physical health providers in preparation of ACC Phase II. For example, they are working to evaluate the behavioral health needs of PCMPs clients in several regions, engage in strategic planning processes with PCMPs, promote integrated services in school-based settings, and encourage colocation of mental health and substance use disorder services with PCMPs. One example of how SIM has contributed to state healthcare policies was provided by one of the policy workgroup members: When you assemble a diverse crosssection of stakeholders to look at policy issues, that sharing of information will have an impact on the policies developed when stakeholders return to their "home bases." He downstream lobbying efforts of the various organizations that become more informed about the issue of integration because of their exposure to a diverse set of perspectives. A specific example the policy workgroup had on this member’s work that, as he said, “will translate to better care for our clients.” “One of the reoccurring areas of discussion has been how the Medicaid program can fail to fully meet Page 197 of 239
the needs of clients with dual behavioral health and developmental disability diagnosis,” due to the bifurcated delivery system between fee-for-service and managed care. “In some cases, people fall through the cracks when the managed care entity denies payment for services.” As someone who is responsible for payment reform initiatives and managed care rate setting, “my exposure and discussion with the policy workgroup allowed me to partially solve for this problem when I probably wouldn't have even fully understood it otherwise. In the most recent round of contracting with the BHOs, I was able to have a performance metric (tied to payment) included that should improve the outcome for individuals with dual diagnosis. The performance metric essentially requires the BHO to ensure that a care followup plan is done every time they deny payment for services for individuals with dual diagnoses if the reason for denied payment was a primary diagnosis of developmental disability. The intent is to ensure clients are connected to care regardless of whether the services are paid for by the BHO or in fee-forservice rather than falling through the cracks completely. This won't solve all of the problems we have in this area but should make things somewhat better and will provide insight through the care planning process to show where there are gaps in system capacity that need to be addressed.
Colorado Medicare-Medicaid program: Duals integration In June 2014, HCPF received a $13.6 million grant from CMS to implement the State Demonstration to Integrate Care for Medicare-Medicaid Enrollees (Demonstration), which is designed to integrate and coordinate physical, behavioral, and social health needs for Medicare-Medicaid members. Colorado Health First Colorado clients who are eligible for Medicare and Medicaid comprise approximately 7% of the department’s Medicaid enrollment, but accounted for 29% of the state’s costs.30 More than 50% of Medicare-Medicaid beneficiaries are older than 65, and more than 605 of them have multiple, chronic health conditions.31 HCPF built on the ACC’s infrastructure, resources and provider networks to implement the program, and in September 2014 began enrolling approximately 30,000 full benefit Medicare-Medicaid enrollees into the ACC program. Early results have highlighted the need for the ACC to formally expand its network and coordinate with agencies such as Single Entry Points (SEPs) and Community Centered Boards (CCBs). As the program evolved, it provided HCPF and other state agencies and organizations with valuable feedback regarding the best ways to achieve the goal of person- and family-centered care, and placing clients or patients at the center of their care planning and delivery.
Medicare advanced primary care Colorado does not participate in the CMS Multi-Payer Advanced Primary Care Practice initiative.
Medicare shared savings programs The following accountable care organizations (ACOs) are participating in the Medicare Shared Savings Program and include Colorado in their service areas: Name Physician Health Partners, LLC Community Health Provider Alliance San Juan Accountable Care Organization, LLC 30
HCPF press release
31
ibid
ACO Agreement Renewal Initial Initial
Track 1 1 1
Page 198 of 239
Rocky Mountain Accountable Care Organization, LLC UCHealth Integrated Network Banner Network Colorado, LLC Clinical Partners of Colorado Springs, LLC Colorado Accountable Care, LLC Physicians Accountable Care Solutions Mountain Prairie ACO
Initial Initial Initial Renewal Renewal Initial Initial
1 3 2 1 1 1 1
ACO Investment Model The following Colorado ACOs are also participating in the ACO investment model: ● San Juan Accountable Care Organization, LLC Grand Junction, CO ● Rocky Mountain Accountable Care Organization, LLC Grand Junction, CO Practices within these organizations are eligible and encouraged to apply for SIM.
Pioneer/NextGen ACO Model No ACOs in Colorado participate in CMMI’s Pioneer or NextGen ACO Models.
Healthcare innovation awards These eight projects received Healthcare Innovation Award funding and include Colorado in their reach: Denver Health and Hospital Authority Project Title: “Integrated model of individualized ambulatory care for low income children and adults” Description: The goal of the project is for Denver Health to transform its primary care delivery system to provide individualized care to more effectively meet its patients’ medical, behavioral, and social needs. Institute for Clinical Systems Improvement Project Title: “Care management of mental and physical co-morbidities: A Triple Aim bulls-eye” Description: Award to improve care delivery and outcomes for high-risk adult patients with Medicare or Medicaid coverage who have depression and diabetes or cardiovascular disease. Rutgers, The State University of New Jersey (The Center for State Health Policy) Project Title: “Sustainable high-utilization team model” Description: Award to expand and test team-based care management strategy for high-cost, high-need, low-income populations served by safety-net provider organizations in Allentown, PA, Aurora, CO, Kansas City, MO, and San Diego, CA. Southeast Mental Health Services Project Title: “TIPPING POINT: Total Integration, Patient Navigation and Provider Training Project for Prowers County, Colorado” Description: Southeast Mental Health Services received an award to coordinate comprehensive, community-based care for high-risk, high-cost, and chronically ill residents of rural Prowers County, Colorado. Trustees of Dartmouth College Project Title: “Engaging patients through shared decision making: using patient and family activators to meet the triple aim” Page 199 of 239
Description: The High Value Healthcare Collaborative (HVHC) received an award led by The Trustees of Dartmouth College to implement patient engagement and shared decision-making processes and tools across its 15 member organizations for patients considering hip, knee, or spine surgery and complex patients with diabetes or congestive heart failure. The program will hire and train 48 health coaches across the 15 member organizations to engage patients and their families in their healthcare and health decisions. University of North Texas Health Science Center Project Title: “Brookdale Senior Living (BSL) Transitions of Care Program” Summary: The University of North Texas Health Science Center (UNTHSC), in partnership with BSL, is developing and testing the Brookdale Senior Living Transitions of Care Program, which is based on Interventions to Reduce Acute Care Transfers (INTERACT), an evidenced-based assessment tool for residents living in independent living, assisted living, and skilled nursing facilities in Florida, Colorado, Kansas, and Texas. Upper San Juan Health Service District Project Title: “Southwest Colorado Cardiac and Stroke Care” Description: The Upper San Juan Health Service District is improving care for cardiovascular disease and risk through a multifaceted approach to reduce costs and to improve the quality of care in rural and remote areas of southwestern Colorado. National Association of Children’s Hospitals and Related Institutions Project Title: "Coordinating All Resources Effectively (CARE) for Children with Medical Complexity" Description: The National Association of Children’s Hospitals and Related Institutions is testing Coordinating All Resources Effectively (CARE) for children with medical complexity (CMC), which aims to inform sustainable change in healthcare delivery through new payment models that support improved care and reduced costs for CMC. All projects align with SIM’s vision and goals. However, no direct collaboration has occurred to date. The SIM strategy and policy manager will research opportunities to work with these initiatives in AY3.
Bundled payment initiatives Bundled payment arrangements are being tested and implemented in Colorado through various federal and state initiatives. Federal test models include: ●
Bundled Payments for Care Improvement Initiative (BPCI) - 16 sites in Colorado including hospitals, orthopedic practices, skilled nursing facilities, and home healthcare agencies – are participating in CMMI’s BPCI Model 2 and Model 3 demonstrations.
Organization Panorama Orthopedics and Spine Center PC Golden, CO Penrose-St. Francis Health Services Colorado Springs, CO Colorado Springs Orthopedic Group Colorado Springs, CO Orthopedic & Spine Center of The Rockies, A Professional Corp, Ft Collins, CO Centura Health - Porter Adventist Hospital Denver, CO Emeritus at Roslyn Long Term Care Community Denver, CO Encompass Home Health of Colorado Denver, CO
Model 2 2 2 2 2 3 3
# of Episodes 1 1 2 2 1 1 1
Page 200 of 239
Encompass Home Health of Colorado Fort Collins, CO Emeritus at Bear Creek Long Term Care Community Colorado Springs, CO Glenwood Investments & Associates, LLC Glenwood Springs, CO Paonia Investments & Associates, LLC Paonia, CO Encompass Home Health of Colorado Springs, CO Northglenn Operations, LLC Northglenn, CO Brighton Operations, LLC Brighton, CO Emeritus at Green Mountain Long Term Care Community Lakewood, CO Rocky Ford Healthcare, LLC Rocky Ford, CO
●
3 3 3 3 3 3 3 3 3
1 3 8 17 5 29 29 1 21
Comprehensive Care for Joint Replacement Model (CJR) – two Colorado metropolitan statistical areas are implementing the CRJ model in Colorado: o Boulder MSA – including Boulder county o Denver-Aurora-Lakewood MSA – including Adams, Arapahoe, Broomfield, Clear Creek, Denver, Douglas, Elbert, Gilpin, Jefferson and Park Counties.
The University of Colorado Hospital (UCH), one of 22 hospitals in the Denver-Boulder metro area that is participating in CJR has built on its work around bundled payments to create new care delivery strategies, such as the development of “care pathways” that standardize the services patients receive based on evidence and experience. In addition, UCH is also piloting an Enhanced Recovery After Surgery (ERAS) program to improve outcomes and reduce hospital readmissions and costs. This program was developed in partnership with the Institute for Healthcare Quality, Safety, and Efficiency (IHQSE), UCH, Children’s Hospital Colorado, and the US School of Medicine and College of Nursing, and started enrolling pancreatic cancer patients in April 2017. Colorado’s state level bundled payment initiatives include: ●
PROMETHEUS - a bundled payment pilots for chronic conditions with self-insured employers in Alamosa, Colorado Springs, and Boulder, sponsored by Colorado’s employer purchasing coalition, the Colorado Business Group on Health ● Center for Improving Value in Health Care (CIVHC) - As Colorado’s Regional Health Improvement Collaborative, CIVHC is developing bundled payments for acute care episodes with physician groups and hospitals in metro Denver. ● Colorado Public Employees Retirement Association (PERA) - PERA offers fixed-cost hip or knee replacement procedures to pre-Medicare retirees and their dependents enrolled in a plan called PERACare Select, administered by Anthem Blue Cross Blue Shield. PERA contracted with a select group of doctors and facilities in the Denver metro area to establish a fixed price for a “suite” of services, from intake to discharge, that includes the surgery, hardware, anesthesia, and pain block and management. Plan enrollees who chose one of PERACare Select’s designated providers may have their co-payments or other cost-sharing requirements waived, resulting in out-of-pocket savings of up to $13,000. PERA officials are using the hip and knee replacement program as a pilot to evaluate the viability and efficacy of using fixed costs in future negotiations for healthcare services. The Colorado Health Commission, created through bi-partisan legislation in 2014, has been conducting an ongoing analysis of healthcare cost drivers in the state, to identify policy priorities and recommendations for the legislature and governor. In the “2016 Report to the Colorado General Assembly and Colorado Governor,” the commission recommended a pilot, using state employees, to further test the effect that bundled payments and value-based purchasing might have on employer healthcare costs. The commission will submit a final report in late 2017. Page 201 of 239
The SIM approach to payment reform allows payers and providers to work together to develop alternative payment models that are tailored to meet their respective needs. SIM anticipates that bundled payments will continue to be included as a component of alternative payment models, and will align with and incorporate best practices from past and ongoing bundled payment initiatives in the state. SIM’s bidirectional pilot project, administered through the Colorado Behavioral Health Council (CBHC) will explore the use of performance-based incentive payments, braided funding, and bundled, risk-adjusted payment mechanisms within CMHCs. (Please see the Healthcare Delivery Transformation section for additional details on this program.) Health First Colorado might also include bundled payments as part of its reimbursement structure the phase II of the ACC. Bundled payments, particularly as developed and utilized by health plans, hospitals and specialty physicians around acute care episodes, may serve as an important interim prospective payment strategy on the path toward global payments.
Accountable health communities There are two Accountable Health Communities (AHC) in Colorado: Rocky Mountain Health Plans (RMHP) serving the western slope, and the Denver Regional Council of Governments (DRCOG) in the Denver region.
RMHP In April 2017, the community received a $4.5 million grant from CMS for its AHC efforts. RMHP has committed AHC funds towards: ●
Administering a social needs screening beginning in 2018 for most Medicare and Medicaid enrollees. ● Enabling practices to access to a community resource inventory for referrals. ● Providing access to patients with high needs (who have had more than two emergency room visits in the last year) to community-based navigation support. ● Coordinating and collaborating with community-based organizations to provide services ● Tracking data in a CMS-compliant way to prove program effectiveness ● Provide opportunities for community-based organizations to participate in the advisory committee to identify gaps in services and plan and prioritize a strategy to address those gaps For more information on the RMHP AHC model, visit: https://www.rmhpcommunity.org/ahcm/accountable-health-communities-model. As a payer that participates in SIM, a PTO that provides support to SIM practices, and a sponsor of the Collaborative Learning Sessions held on the western slope, RMHP is in close and frequent communication with the SIM office.
DRCOG The DRCOG is a planning organization in which local governments32 collaborate to establish guidelines, set policy and allocate funding in the areas of: ● Transportation and personal mobility ● Growth and development ● Aging and disability resources DRCOG was awarded a $4.5 million AHC grant from CMS in April 2017 to bridge the gap between clinical and community service providers. DRCOG will serve as a hub for 16 regional partners addressing health32
https://www.drcog.org/about-drcog/member-governments Page 202 of 239
related social needs including housing instability, food insecurity, domestic violence, and transportation. By addressing these social needs, the model aims to reduce unnecessary healthcare use and spending by improving health outcomes and quality of care for patients. DRCOG will also coordinate and monitor providers to ensure responsiveness. During the five-year period, clinical and community partners will report on services provided and patient outcomes helping inform best practices for the industry. For more information on the DRCOG AHC model, visit: https://www.drcog.org/sites/drcog/files/resources/2017DRCOG_CMS.pdf
Potential opportunities for alignment and collaboration The SIM office intends to meet with key leaders from RMHP and DRCOG to operationalize potential avenues for alignment and explore: ● ● ● ●
●
Opportunities for regional health connectors (RHCs) to share priorities with AHC initiative leaders to avoid duplication of efforts and use resources to achieve complementary goals. Opportunities for RHCs to connect SIM practices with key resources developed by or for an AHC, such as the community resource inventor for referrals. Avenues by which SIM-funded local public health agencies and behavioral health transformation collaboratives might engage in AHC efforts. Ways in which ACH efforts might help practices achieve practice transformation building block 7: Practice has linked primary care to behavioral health and social services. Year 2 milestones within this building block include: o 50% of patients are screened for behavioral health condition(s). o Practice performs an assessment of community resources to assist patients/families with social needs (such as food, housing, transportation). o 50% of patients identified with a behavioral health need are connected with resources. ACH efforts might be particularly useful to help practices achieve these milestones. Identification of key staff who may be able to serve on a SIM stakeholder workgroup (particularly population health) to ensure that SIM, DRCOG, and RMHP are apprised of each other’s efforts to avoid duplication and take advantage of natural synergies.
Transforming Clinical Practice Initiative (TCPi) The Colorado Practice Transformation Network offers tools and resources for up to 2,000 Colorado providers to be successful in value based payments. As of April 2017, there are 1,446 providers involved in TCPi. (For more information visit: https://www.colorado.gov/pacific/healthinnovation/tcpi.
Alignment of oversight TCPi is hosted in the SIM office and the SIM director oversees both initiatives. TCPi staff participate in regular SIM office staff and management meetings. This structure encourages close coordination while helping ensure that efforts are not duplicated. TCPi is also supported by the Colorado Health Extension System (CHES). Many of the PTOs that support SIM also support TCPi. CHES provides a central structure to ensure that PTOs align, but do not duplicate, efforts. For more information on CHES, visit http://www.ucdenver.edu/academics/colleges/medicalschool/departments/familymed/research/practi ce_transformation/Pages/practice_transformation.aspx.
Page 203 of 239
Programmatic alignment The TCPi application narrative was designed to align with, not duplicate SIM efforts. TCPi complements other statewide initiatives that address how healthcare is delivered and reimbursed. A substantial part of the work will involve supporting practices as they change operations so they optimize care teams and use data effectively to help deliver higher-quality, lower cost care. However, while SIM is focused on primary care, 85% of participating TCPi providers are specialists. No SIM practices participate in TCPi, which helps ensure that funds are not supplanted and that efforts are not duplicated in any practice. The graphic below compares the two initiatives and demonstrate how these opportunities build a comprehensive and person-centered statewide system that addresses a broad range of health needs.
Page 204 of 239
Meaningful use and HIT for economic and clinical health (HITECH) The HITECH Act outlines the plans for adoption of EHRs through MU of HIT. CMS Medicare and Medicaid EHR incentive programs support state efforts through three stages of MU. MU requires providers to show how they are using their certified-EHR technology to measure quality and quantity. As Colorado evolves from MU to MACRA practices and hospitals need to have certified 2015 EHRs at a minimum to be able to extract and report clinical quality metrics automatically from their EHRs. Colorado SIM HIT work is largely focused on understanding, supporting, and advancing practices toward achieving this goal as well as working to align quality outcomes across the state with a better understanding of EHR contracts and operability. HCPF recognizes the importance of expanding HIT across the state of Colorado to enhance interoperability and improve care coordination, which will significantly reduce healthcare costs and improve patient outcomes. With the passage of the HITECH Act in 2009, the department could be supported by 90% federal financial participation to help providers become meaningful users of EHRs. The HIE network continues to prove its success with the provider onboarding program expanding outreach efforts and technical services to Medicaid EPs who were ineligible for the ONC regional extension center program. This will continue to boost MU numbers and milestones in Colorado to enhance the HIT vision. In addition to Adopt Implement Upgrade and MU education and technical services, the program will continue to assist providers in meeting MU Stage 2 and Stage 3 through onboarding provider interfaces and providing the capabilities to automatically meet several MU measures.
Initiatives from related agencies such as CDC, ONC, SAMHSA, HRSA, and AHRQ CDC The Plan for Improving Population Health section outlines how SIM aligns with CDC Winnable Battles. The SIM approach to population health is partially informed by Colorado's 10 Winnable Battles, which was developed by the Colorado Department of Public Health and Environment (CDPHE) and aligns with several CDC Winnable Battles. Two of Colorado's Winnable Battles are mental health and substance abuse, and injury prevention; these priority areas are the predominant focus of the population health activities funded by SIM around the state.
ONC A central component of the Colorado initiative is the expansion of the state’s health information technology (HIT) infrastructure to support practice transformation, improve population health, develop shared care planning resources, expand telehealth, and coordinate public health services. As SIM works to create a fully-integrated electronic healthcare system with a statewide reach, public and private collaboration will be essential to achieving our goals. This work could not be accomplished without close alignment and coordination to leverage existing and available resources. The Office of ehealth Innovation (OeHi), the SIM office, and the HCPF Health Information Office (HIO) meet weekly to coordinate project plans and leverage opportunities to complement funding for shared HIT objectives. OeHi, like the SIM office, is housed within the governor’s office to ensure close partnership with coordinated leadership input. OeHi will play an important role in strengthening public-private collaboration around HIT initiatives within the state. It is tasked with promoting and advancing the secure efficient and effective use of HIT and coordinating “relevant public and private stakeholders and
Page 205 of 239
HIT programs across state agencies and between state and federal projects.”33 The office, along with a commission appointed by the governor, will serve as Colorado’s designated entity to participate in the programs of the Office of the National Coordinator (ONC) for HIT and other federal HIT programs. Public and private collaboration and coordination will figure prominently in several SIM HIT initiatives, and is fully detailed in the HIT section. The following is a summary of coordinated efforts: HCPF and OeHi, as well as the SIM office, have prioritized a master data management (MDM) strategy for a shared master patient index and master provider directory to leverage enhanced federal funding match and develop a statewide solution for identity management and other MDM needs. This is a core component of the SIM HIT use case one and SIM will leverage the investments made to develop an MDM, potentially using SIM providers to test the technology. HCPF was awarded the ONC Advanced Interoperability grant in the summer of 2015 for the two state health information exchanges (HIEs) to pilot different methodologies for behavioral health consent management and enable sharing substance use data. The grant is slated to end in June 2017, and will inform future SIM efforts to support integrating behavioral health with physical health data. Additional Implementation Advanced Planning Documents (IAPD) funding leveraged by HIO and the OeHi maximizes the commitment to improving effective sharing and data utilization in Colorado. This funding will cover provider onboarding, as well as the strategic development and implementation of core infrastructure and technical solutions to create and enhance sustainable solutions for Health First Colorado providers serving clients and supporting Medicaid-eligible professionals’ (EPs) and eligible hospitals’ (EHs) achievement of Meaningful Use (MU). HCPF will submit its annual IAPD-Update (IAPD-U) this month, which aligns the department’s strategy for advancing HIT and HIE in Colorado by supporting the design, development, testing, and implementation of core infrastructure and technical solutions promoting HIE for EPs and EHs aligned with Colorado’s Medicaid Electronic Health Record (EHR) Incentive Program authorized by the American Recovery and Reinvestment Act of 2009 (ARRA). Although many states are struggling to create a sustainable HIE model, the Colorado HIE Network is sustainable to continue operations without support from ONC grantee funding.
Substance Abuse and Mental Health Services Administration (SAMHSA) Colorado was one of 24 states to receive a planning grant for the Certified Community Behavioral Health Clinics program from SAMHSA in conjunction with CMS and the Assistant Secretary of Planning and Evaluation (ASPE). HCPF used the funds to develop a process for certifying community behavioral health clinics, soliciting input from stakeholders, establishing prospective payment systems for demonstration reimbursable services, and preparing an application to participate in the demonstration program. This has informed the process of aligning CBHCs with HCPF needs, especially as the ACC 2.0 is finalizing and determining Regional Accountable Entity statements of work. This is in full alignment with SIM efforts.
Health Resources and Services Administration (HRSA): The SIM office intends to provide a letter of support for the University of Denver School of Social Work’s application to the Behavioral Health Workforce Education and Training Program funding opportunity, which aims to expand the mental health and substance abuse (jointly referred to as behavioral health throughout the funding opportunity announcement) workforce serving children, adolescents, and transitional-age youth at risk for developing or who have a recognized behavioral health disorder. If the application were to be funded, the SIM workforce workgroup would provide guidance on 33
Executive Order B 2015-008
Page 206 of 239
implementation in AY3. The SIM director and workforce program manager are talking with the co-chair of the workforce workgroup to coordinate details of the application and the letter of support.
Agency for Healthcare Research and Quality (AHRQ): SIM transformation efforts are aligned with existing opportunities and resources that AHRQ presents, particularly with EvidenceNOW Southwest (ENSW), an initiative aimed at “transforming healthcare delivery by building critical infrastructure to help smaller primary care practices apply the latest medical research and tools to improve heart health.” ENSW will serve up to 260 primary care practices in Colorado and New Mexico with practice transformation and quality improvement support, including onsite practice facilitation and coaching, expert consultation, shared learning collaboratives, and electronic health record support. ENSW is led by the Practice Innovation Program at the University of Colorado, Department of Family Medicine, which has been contracted to lead practice transformation activities for SIM primary care practices as well as TCPi. The fact that one department is responsible for implementation of all three initiatives helps to ensure operational alignment between the three. While the focus of ENSW is on cardiovascular health and the focus of SIM is on behavioral health integration, the two initiatives promote development of complementary practice transformation competencies. As a result, SIM and ENSW have hosted joint collaborative learning sessions (with breakout sessions specific to each initiative’s focus) and continue to share resources. Additionally, many of the PTOs that provide support to ENSW practices also provide support to SIM practices. Because many of the applicants to SIM cohort 2 are participating in ENSW, the flexibility to request a PTO via SIM means that practices may be able to work with the same practice facilitator for each initiative. This can help ensure that practices meet the goals of each initiative while steering practices toward resources and activities that support success in both. As previously described under the TCPi portion of this plan, CHES will play a key role in assuring the PTOs are not duplicating efforts between the initiatives. SIM and ENSW braided funds to support the state’s RHC workforce. A detailed diagram explaining the braided funding structure as well as a discussion of how the work of the RHCs was designed to support the goals of each initiative is available in the plan for improving population health.
Coordination with non-federally funded initiatives Regional Health Improvement Collaboratives (RHIC) Center for Improving Value in Healthcare (CIVHC) CIVHC is the only RHIC in Colorado officially recognized by the RHIC and is a SIM vendor. For more information on CIVHC’s role in SIM, see the Bundled payment initiatives section.
Community benefit programs sponsored by non-profit hospitals/businesses Colorado has numerous institutions and organizations engaged in community benefit programs, including non-profit hospitals, payers, businesses, state agencies, and philanthropic organizations. Although Colorado law does not require non-profit hospitals to report community benefits to state agencies, these entities are bound by the Patient Protection and Affordable Care Act and Internal Revenue Service (IRS) requirements to report on the community benefits they provide. The Colorado Hospital Association (CHA) conducts an annual statewide community benefits survey of its member hospitals and health systems to promote transparency and improve the visibility of unique community health programs throughout the state. The CHA also provides toolkits and communication Page 207 of 239
materials to members to help promote their community benefit activities. While the SIM office has not directly collaborated with community benefit programs to date, RHCs might work with community benefit programs in AY3. More information will be available by the end of NCE after RHCs submit their project plans.
Local public health department activities (LPHAs) and local health education activities SIM is committed to aligning with the activities undertaken by LPHAs throughout the state. The Plan for Improving Population Health section provides information on LPHA priorities, locally-identified strategies to address those priorities, and SIM-funded avenues of support.
Community needs assessment completed by not for profit hospitals and health systems When identifying community priorities, RHCs were asked to review community health needs assessments and select topics that aligned, where possible. Community needs assessments will also play an important role in guiding RHC project plans.
Other key local initiatives sponsored by city, county or regional public health commissions/agencies, foundations, large employers, academic institutions, community organizations, etc. Numerous private organizations in Colorado support collaboration efforts to improve health at the community and regional level. Examples of such activities are outlined below.
Denver Foundation The Denver Foundation offers community grants to address basic human needs, including basic physical and behavioral medical care. The organization prioritizes innovative, collaborative projects and proposals that work across systems to build on community assets, improve access to services, offer longer-term access to necessary support, and ensure the safety net better meets our community’s needs. The Colorado Health Access Fund (Fund), created within the Denver Foundation with support from SIM as a Field of Interest fund in 2014, supports programs and activities that generally increase access to healthcare and strive to improve health outcomes for populations in Colorado with high healthcare needs. SIM and the Denver Foundation jointly released a RFA in September 2015 for behavioral health transformation collaboratives. For more information, see the Plan for Improving Population Health.
Colorado Project LAUNCH Project LAUNCH seeks to improve coordination across child-serving systems, build infrastructure, and increase access to high-quality prevention and wellness promotion services for children and their families. The SIM Program Implementation Manager participated in “LAUNCH Together Retreat State/Local Systems Panel Presentation” in December, 2016, and participated in an evaluation of Project Launch. Molly Yost, technical assistance and policy manager for Project LAUNCH is on the SIM population health workgroup and presented at a Medical Home Community Forum meeting, which was co-sponsored by SIM. We will continue seeking opportunities to partner and align throughout AY3.
BC3 – Better Care, Better Costs, Better Colorado BC3 is a collective effort to improve healthcare in Colorado by bringing a diverse group of stakeholders together in a new way to reach shared goals by aligning activities, engaging communities and supporting and building on existing initiatives. The initiative was started in 2014 by the Colorado Health Foundation and is supported through a 10-year funding commitment. Participating organizations and individuals Page 208 of 239
commit to aligning efforts and supporting each other through regular meetings. Participants also commit to measuring effectiveness of both the collective effort and its activities, as well as partnering with the most influential entities and organizations in Colorado. A steering committee that consists of public and private leaders representing providers, payers, and consumers has established goals and a structural foundation for activities, focusing on shared “Triple Aim” goals. Eight building blocks were identified to ensure success, including: connections to community; practice transformation; patient engagement; transparency and reporting; HIT and exchange; workforce; payment reform; and policy and regulatory changes. While goals and activities are expected to evolve over time, initial short-term goals identified by the steering committee included: ●
Improving transitions between care settings with the goal of enhancing coordination and communication among providers and care settings, and improving performance on key metrics by 20% by 2020; ● Reducing unnecessary emergency room visits, with the goal of reducing avoidable emergency department volume by 10% by 2020; and ● Increasing access to integrated physical and behavioral healthcare services, with the goal of providing 80% of Coloradans with access to integrated physical and behavioral healthcare by 2020. BC3 supports the SIM initiative, and has purposely aligned its activities with SIM by establishing similar goals. Six of the eight building blocks identified by BC3 match the subject matter areas addressed in SIM workgroups. BC3’s goal around integrated care delivery also matches SIM’s stated objective. The SIM office looks forward to a continued partnership with BC3 and is committed to working with other BC3 member organizations to maximize the collective impact of efforts to transform the state’s healthcare system. The SIM director continues to regularly engage with BC3.
The Colorado Opportunity Project This joint initiative was recently launched by HCPF, CDPHE, and CDHS to provide low-income Coloradans with economic opportunities for upward mobility and a pathway to the “middle class” that ends their reliance on safety net programs. A key aim is to create a shared understanding of what opportunity looks like in Colorado and coordinate and align the efforts of government, private, non-profit, and community partners around that vision to support economic opportunity for Coloradans in a streamlined and efficient way. This includes aligning key state agency initiatives, including CDPHE’s 10 Winnable Battles, CDHS’s Two-Generation Approach,34 and HCPF’s ACC, as well as the Cross-Agency Collaborative on Quality Measurement to drive progress towards a common goal of ensuring Coloradans have access to economic opportunities. The goal of the Opportunity Project is to deliver evidence-based initiatives that help Coloradans reach middle class¹ by middle age. To track and measure social mobility and help ensure Coloradans stay on the path towards self-sufficiency and economic success, the Opportunity Project developed a set of “indicators” or milestones across various life stages from family formation through early and middle childhood, adolescence, the transition to adulthood, and adulthood. SIM supports the life stages approach adopted by the Opportunity Project, which builds on the Brookings Institution’s Social Genome Project framework, as a mechanism for addressing the social determinant of health. SIM’s activities to increase prevention and screening for behavioral health conditions will complement the 34
Two-Generation approaches focus on creating opportunities for addressing the needs of vulnerable children and their parents together; CDHS is currently partnering with Ascend/The Aspen Institute to apply Two-Generation approaches in Colorado
Page 209 of 239
efforts of the Opportunity Project by identifying challenges that individuals face that might negatively affect their ability to meet selected benchmarks and achieve social mobility during any life stage. In addition, SIM’s initiatives to bolster public health and community resources will provide Colorado Opportunity Project partners with a broader range of tools to design interventions, and develop “course corrections” that allow individuals to progress along that pathway to economic opportunity. In AY3, the SIM office will focus on how to align efforts between Colorado Opportunity Project Liaisons and RHCs as both positions have similar aims.
Colorado Office of Early Childhood – Early childhood mental health strategic plan The 2015 Early Childhood Mental Health Strategic Plan (ECMHSP) was developed to guide strategic visions for early childhood mental health efforts in Colorado. This overarching plan encompasses the range of work in Colorado that focuses on social emotional development and early childhood mental health, which will collectively contribute to the plan’s outcomes. The ECMHSP is closely aligned with the 2015 Colorado Early Childhood Framework developed by the Early Childhood Leadership Commission within CDHS’ Office of Early Childhood, and focuses on the health and well-being domain. Building on previous work in the state, the ECMHSP identifies three priority areas: a sustainable financing approach system, coordination and alignment across system and sectors, and a competent workforce that is well-trained and well supported. Each priority is associated with specific goals, which include improvements at the family, provider and systems level. The SIM office has worked with the Early Childhood Mental Health director in the Office of Early Childhood to help ensure alignment of goals and objectives around child mental and behavioral health, and to identify ways the SIM initiative can contribute to the achievement of the ECMH strategic vision. Most recently, the SIM team with the Early Childhood Mental Health director to provide more insights into challenges that practices face when billing for maternal depression screenings, particularly when administered in pediatric practices. The Office of Early Childhood is coordinating with SIM PTOs that have dealt with this issue and will work with the SIM office to propose a set of possible solutions in AY3.
Page 210 of 239
C. Program evaluation and monitoring a. State-led evaluation Evaluation approach SIM onboarded TriWest Group, the state-led evaluation team, in April 2016, after a competitive bid procurement process. An updated logic model is included as Appendix E1 and updated evaluation methodology, data analysis plan, repository of measures, and baseline data report are available upon request. These are “living” documents that are updated continually in response to program developments and rapid-cycle findings. SIM’s evaluation approach comprises three major components: formative/implementation, summative/outcomes, and rapid-cycle feedback. TriWest provides quarterly rapid-cycle feedback reports that contain a progress implementation dashboard, some consistent measures such as clinical quality measures (CQMs), and a special focus each quarter. Quarterly rapid-cycle reports will continue to be delivered throughout the life of SIM and will contain key process measures and practice Shared Practice Learning & Improvement Tool (SPLIT) assessment data analysis as available. The reports also contain practice vignettes that take a deeper dive into qualitative data and field notes for a sample of practices to highlight key issues, challenges, and best practices. These rapid-cycle reports facilitate a continuous quality improvement process for the SIM office and partners to identify short-term successes, challenges, opportunities for course correction, and continued or additional support. In year 3, the SIM office will create a system for dissemination and utilization of these rapid-cycle findings with stakeholder workgroups and key partners.
Formative / Implementation
Summative / Outcome
Rapid Cycle Feedback TriWest will also deliver annual reports and a final evaluation report that contain outcomes data and summative findings. In the final year of SIM implementation, TriWest will deliver a sustainability plan for state-led evaluation efforts that specifies the systems, data, and other mechanisms to continue to monitor the effects of SIM efforts after completion of the initiative. In addition to the streams of data from various partners, practices, and payers (detailed in the program monitoring and reporting section), TriWest is conducting three rounds of key informant interviews with: 1) key stakeholders and partners, 2) Practice transformation organizations (PTOs), and 3) SIM practice sites, community mental health center (CMHC) bi-directional health homes, regional health connectors (RHCs), and local public health agency (LPHA) and behavioral health transformation collaborative (BHTCs) grantees. This qualitative data supplements the SPLIT assessment data and provides real-time, Page 211 of 239
in-depth insights into SIM implementation. Stakeholder interviews will be completed again at the end of the program, and PTO/LPHA/RHC interviews will be completed annually, to demonstrate progress during SIM. TriWest will conduct several interviews with practices from each cohort and the CMHC bidirectional health homes to develop case studies related to the cost of transformation and other themes.
Approach for measuring overarching goal The primary goal of the SIM project is to “Improve the health of Coloradans by providing access to integrated physical and behavioral health care services in coordinated community systems, with valuebased payment structures, for 80% of Colorado residents by 2019.” There are three components within this “80%” goal. Each component is represented as a sphere in the diagrams below. SIM is implementing a series of efforts supporting the state’s progress towards a healthcare system that improves the measures in each of these three components or spheres. Access to integrated healthcare Colorado Population
Access to Integrated Care
Healthcare supported by Alternative Payment Models Colorado Population
Supported by alternative payment models
Healthcare in Communities with Coordinated Systems Colorado Population In communities with coordinated systems
Each component of the overall goal is an ambitious undertaking when considered alone, and each is important in making progress towards integrating primary and behavioral healthcare with the goal of affecting 80% of Colorado’s population. These three distinct “spheres” are mutually supportive but usually thought of separately, as illustrated above. SIM seeks to evaluate both changes within each sphere separately and changes to the intersection of the three spheres. Therefore, the evaluation will focus on 1) documenting progress made in each of these three spheres during SIM implementation and 2) examining changes to the overlap of the three spheres.
Defining and measuring access to integrated care Access to care most generally will be measured by use of All Payer Claims Database (APCD) data as defined in the SIM evaluation plan using standardized Agency for Healthcare Research and Quality (AHRQ) access to care metrics. Other sources of access data include SIM-specific questions added to the Colorado Health Access Survey (CHAS). Integrated care will be assessed using SPLIT data, specifically the Integrated Practice Assessment Tool (IPAT) and the milestone activity inventory, and the medical home practice monitor. One measure of increased access to integrated care will use the number of patients served by providers scoring a specific integration threshold level on the IPAT, milestone inventory, practice monitor and access estimates from APCD data analysis. TriWest is working with the University of Colorado Department of Family Medicine (the University) and the SIM office to identify thresholds that indicate integration across various assessments and data sources. TriWest is defining the scores for the IPAT, practice monitor behavioral health integration Page 212 of 239
questions, overall practice monitor score, and the various behavioral health integration questions from the milestone inventory, which signify that a practice is integrated. They are also estimating the correlations between these various scores to assess consistency across the assessments and to create a more comprehensive picture of integration. In addition to the data sources listed above, increased provider access to telehealth capabilities, use of EHRs and health information exchanges (HIEs) to track patient outcomes, and data sharing among primary care providers will also be considered when estimating access to integrated care.
Defining and measuring value-based payment The SIM office is working with participating payers to provide data on practice sites participating in alternative payment models (APMs) and the percentage of patients in each HCP-LAN defined category of APMs. TriWest will use this payer-reported data to estimate increased use of APMs as demonstrated by an increase in the number of practices supported by APMs and an increase in the number of patients attributed to practices supported by APMs. In addition to Milliman’s cost of care calculations, TriWest will estimate cost decreases associated with increased use of APMs (compared with non-SIM practices). While Milliman is calculating return on investment (ROI) from the CMMI federal initiative perspective, TriWest will leverage key informant interviews with practices to obtain provider perspectives of ROI for participating in APMs and identify challenges encountered by practices adopting APMs. TriWest will also describe payer perspectives of ROI in moving toward greater use of APMs.
Defining and measuring coordinated community systems To estimate progress in the third sphere of the 80% goal, TriWest is working with key partners and stakeholders to develop a coordinated community systems index that will combine data from key informant interviews with LPHAs, BHTCs, and RHCs, monthly RHC report data from the Colorado Health Institute (CHI), quarterly LPHA and BHTC grantee report data from the Colorado Department of Public Health and Environment (CDPHE), environmental scan findings from Health Management Associates (HMA), population health indicators and CHAS data. Themes will focus on collaboration efforts and ratings at the community level. Data will be associated with SIM practice sites and CMHCs to assess the degree of coordination between population health partners and efforts and SIM practice sites and CMHCs.
Defining sub-populations TriWest is working with University partners and population health partners to define various populations for sub-analyses. Potential subgroups include adult and pediatric practice sites, rural, urban, suburban, and frontier geographic locations, practice size, practice type, and county level analysis. TriWest will calculate various measures according to these sub-populations as part of the summative evaluation in the annual and final reporting. TriWest will conduct analyses between cohorts to consider various changes to implementation for each cohort. For example, cohort 2 will use the streamlined set of building blocks and metrics as well as the simplified set of CQMs. Some cohort-1 practice sites participated in the Clinical Primary Care Initiative (CPCi) while a different subset participated in CPC+ starting in the second year of SIM implementation. Cohort-3 practice sites will only have one year of SIM participation versus the two years that cohorts 1 and 2 had. TriWest will examine impacts across the SIM program and aggregate cohort of 400 practice sites, as well as specific considerations for each cohort individually.
Identifying comparison data Pending CMMI approval of a proposal submitted in year 2, TriWest will execute a strategy for identifying
Page 213 of 239
data from practice sites that are not part of the SIM cohorts. The state-led evaluation has two general goals that require use of such data. One is to assess movement toward, and achievement of the SIM goal that 80% of Coloradans have access to integrated care that is supported by APMs in coordinated community systems. Estimating the proportion of Coloradans who are supported by APMs and those in coordinated community systems will be done through comparisons using ACPD and geographic-based community-level data, not at the practice site level. However, estimating access to integrated care requires data at the practice-site level on integration for practice sites outside the SIM cohorts. A random sample of practices selected on a stratified basis to ensure representation across the state could be used to create an estimate of how many non-SIM practices are providing a level of integrated care as defined by measures of integration used by SIM practices. The number of patients served, and overall practice-site capacity within a general geographic area could then provide a foundation for calculating an estimate of how many individuals have access to integrated care. Starting in year 3, TriWest aims to engage and collect IPAT and milestone activity inventory data, and perhaps conduct an interview with practice sites that are not participating in SIM. The other goal is to associate observed outcomes to SIM-specific efforts by eliminating external factors. The attribution to SIM drivers of changes in outcome measures such as utilization, cost, or quality will be more credible if a comparison group of non-SIM cohort practice sites is developed. For measures that are calculated from the APCD, comparison groups can be matched based on known APCD (claims) characteristics.
Actuarial analyses Milliman, SIM’s contracted actuary partner, calculates various cost and utilization measures on a regular basis. The nine core SIM cost and utilization measures are calculated quarterly on an aggregate basis and reported to CMMI. In addition to the aggregate calculations, Milliman prepares a cost and utilization report for each individual SIM practice site. The first quarterly reports with baseline CY2015 data were distributed to primary care practice sites in April 2017. Reports for each of the four participating CMHCs will be created and distributed once patient lists are reported to the Center for Improving Value in Health Care (CIVHC) for attribution purposes (by the end of the no-cost extension period). These reports will continue to be delivered to individual sites on a quarterly basis throughout the SIM program. In addition to the core SIM cost and utilization measures, Milliman calculates actuarial cost and utilization measures on an aggregate and individual practice site basis. These reports are delivered semiannually (every 6 months) and feed into the cost projections, cost savings/avoidance, and ROI calculations. To calculate ROI, Milliman delivers projected cost and utilization reports once annually. The first report was delivered in Q4 of year 2 and future reports will be delivered in Q2 of year 3 and Q2 of year 4. Milliman then compares projected cost and utilization with actual cost and utilization to develop cost savings/avoidance and ROI each year. The first cost saving/avoidance and ROI report will be delivered during the no-cost extension period in July 2017, and future reports will be delivered in Q4 of year 3 and Q4 of year 4. Milliman also develops reports to inform payment reform and practice transformation efforts for SIM. Pooling and credibility reports discuss criteria for success of pooling models and approaches under provider payment model reforms, including approaches for determining credibility of insured member groups, and illustrative results from detailed commercially insured data in Colorado. The first report was delivered in Q1 of year 2, and future reports will be delivered annually in Q2 of year 3 and Q2 of year 4. Risk adjustment reports discuss certain potential value-based payment models, risk adjustment Page 214 of 239
methodology considerations, risk adjustment model selection issues, and the application of risk adjustment models in value-based payment models. The first report was delivered in Q4 of year 1, and future reports will be delivered annually in Q1 of year 3 and Q1 of year 4. Predictive modeling reports use technology and statistical methods to search through large amounts of information, analyze it to predict outcomes for individual patients, and attempt to identify patients at risk for specific medical or behavioral conditions. The first general report was delivered in Q1 of year 2, and a report focusing on predictive modeling for depression was delivered in Q4 of year 2. Future reports will be delivered annually in Q1 of year 3 and Q1 of year 4. Payment reform reports focus on criteria for success of payment model reforms, transitioning options for different practices, and plans for implementing various models and methodologies in Colorado during the pre-implementation period and test years. The first report was delivered in Q1 of year 2, and future reports will be delivered annually in Q3 of year 3 and Q3 of year 4.
APCD data and analyses CIVHC is the administrator of Colorado’s APCD and provides quarterly claims data refreshes to TriWest and Milliman for evaluation and actuarial analyses. CIVHC also provides an annual data refresh to the federal evaluation team that have all claims data for submitting payers in the state dating back to 2011. In addition to providing claims data to key evaluation partners, CIVHC worked with stakeholders to develop a standard attribution methodology to run through APCD data for SIM reporting and evaluation purposes. CIVHC runs attribution and provides this data as a supplementary file to the full APCD data refresh on a semi-annual basis. As SIM primary care practice sites update their National Provider Identifier (NPI) information annually, CIVHC provides updated attribution data to TriWest, Milliman, and the federal evaluation team. Following the no-cost extension period, CIVHC will provide attribution files for participating CMHCs based on self-reported patient lists every six months. Read more information in the program monitoring and reporting section. CIVHC has developed methodologies and programming for claims-based proxy measures for each of the CQMs. Baseline CY2015 measures were delivered during the no-cost extension period, and claims-based proxies will be delivered on an annual basis in Q2 of year 3 and Q2 of year 4. Claims-based proxy measures will be developed for the new simplified CQMs when full CY2016 data is available. These proxy measures serve as benchmarks for the CQMs and will be reported to CMMI in the core metrics template annually. In year 3 the SIM office will work with CIVHC to identify a path for providing Medicare data to the SIM practice data aggregation tool. Other data collection and reporting partners and processes for CMMI core metrics and other reporting are detailed in the program monitoring and reporting section.
Page 215 of 239
b. Federal evaluation, data collection and sharing All Payer Claims Database (APCD) data The Center for Improving Value in Health Care (CIVHC) provides annual APCD data extracts to the federal evaluation team with data from all payers who submit data to the APCD, including the seven private and public payers participating in SIM. It includes claims data for all lines of business, age groups, regions, provider types and settings, and procedure codes. CIVHC creates a composite person identification to serve as a common identifier across payers. The first extract and data element dictionary were delivered in August of 2016 and contained data from January 2012 through November 2015 (Medicare FFS through December 2014 and Medicare Rx through December 2013). These extracts will continue to be delivered every August on an annual basis throughout the life of SIM unless the federal evaluation team identifies a different timeline or process to conduct federal evaluation activities.
Attribution The annual APCD extract includes beneficiaries attributed to SIM practice sites as well as all other beneficiaries in the APCD for comparison purposes. CIVHC runs the standardized attribution methodology developed for SIM reporting and evaluation purposes on a semi-annual basis (for more information, see the program monitoring and reporting section. Through the attribution process, CIVHC associates every beneficiary in the APCD with a provider National Provider Identifier (NPI). Provider NPIs that are self-reported in the SIM practice roster are rolled up to the SIM practice site level to attribute beneficiaries to each SIM practice site. CIVHC provides a supplementary attribution file to the federal evaluation team with each annual APCD data extract. CIVHC provides the more frequent, semi-annual updates to attribution to the federal evaluation team upon request.
Payment support data The SIM office continues to work with participating payers to provide data for SIM reporting and evaluation. Pending the receipt of CY2015 baseline data from all payers, the SIM office shared a list of payers supporting each SIM cohort 1 practice site with an APM. In preparation for sharing 2016 eCQM data with payers, the SIM office asked each payer to update the list of SIM cohort 1 practices they support through an APM. Once the SIM office receives updated information from each payer, the team will share the comprehensive list with the federal evaluation team. The SIM office is also in the process of collecting payment support information for each of the practice sites that applied for cohort 2. Once the team receives a final list from payers, the SIM office will share the list of payers supporting each practice site that is accepted into cohort 2.
Consumer focus groups Early in SIM year-1 implementation, the SIM office collaborated with HCPF to provide Health First Colorado (Medicaid) client information to the federal evaluation team to conduct consumer focus groups. HCPF’s data team pulled data for beneficiaries attributed to SIM cohort 1 practice sites, stratified by behavioral health organization (BHO) members and “non-BHO” members. The data contained the beneficiary’s phone number, address, sex, and age. The SIM office worked with the federal evaluation team and HCPF to ensure that all appropriate data sharing agreements and consent forms were in place, as well as appropriate incentives and communications to Health First Colorado clients. The SIM office will continue to cooperate with the federal evaluation team to provide data needed for future focus group activities.
Page 216 of 239
Key informant interviews Early in SIM year-1 implementation, and again during the no-cost extension period, the SIM office provided SIM provider and key stakeholder information to conduct key informant interviews. The SIM office worked with the federal and state-led evaluation teams to coordinate key informant interview outreach and efforts. While the federal evaluation team was unable to share data or findings, the team coordinated timelines so key stakeholders and providers were not contacted back-to-back by both evaluation teams. The SIM office will continue to cooperate with the federal evaluation team to provide data needed for future key informant interview activities.
Coordination with state-led evaluation efforts The SIM office evaluation program manager and a representative from TriWest’s state-led evaluation team join monthly calls with the federal evaluation team to discuss updates and to inform the federal evaluation team’s efforts. The SIM office provides data and information as requested and shares the state-led evaluation quarterly rapid-cycle feedback reports. The SIM office will continue to participate in these regular communication opportunities and bring in program staff to provide subject matter expertise as needed. The SIM office has obtained appropriate data sharing agreements for all data sharing needs with the federal evaluation team. The SIM office will continue to work with the federal evaluation team to understand future data needs and work with identified partners to execute the necessary data sharing agreements. The SIM office agrees not to receive additional reimbursement for providing data or other reasonable information to CMS or another government entity or contractor.
Page 217 of 239
c. Program monitoring and reporting Model participation metrics In year 3, the SIM office will continue to collect data from vendor partners, practice sites, and payers for internal program monitoring, reporting core metrics to CMMI, and evaluation. The SIM office has developed the processes for collecting core metrics data from vendor partners on a quarterly basis. For example, the Colorado Telehealth Network (CTN) reports on the number of sites enabled for telehealth, and the Office of Behavioral Health (OBH), The Colorado Department of Public Health and Environment (CDPHE), and the University of Colorado Department of Family Medicine (University) each report on the number of provider education activities conducted. The SIM office conducts quality assurance, aggregates the data, and reports these model participation metrics to CMMI each quarter. The SIM office and partners will continue to follow this process during year 3, reporting on calendar year quarters. Calendar year quarter 3 (July - September) data will be reported to the SIM office by the end of October, and will in turn be reported to CMMI in the November quarterly report. Some process measures are reported biennially. The Center for Improving Value in Health Care (CIVHC) runs attribution, utilizing a standardized methodology developed by SIM stakeholders for reporting and evaluation purposes, twice per year. All payer claims database (APCD) attribution is run once at the onset of each cohort, and then again after practice sites update their SIM practice rosters after the first year, reflecting updated NPI information. The SIM office provides guidance for each SIM practice roster update to ensure practice sites report the most complete and accurate list of NPIs possible, to allow for more complete and accurate data, such as patient attribution and cost and utilization measures. Since the standardized attribution methodology applies only to primary care practice sites, participating Community Mental Health Centers (CMHCs) plan to self-report their patient lists to CIVHC twice per year.
Model performance metrics In addition to the process metrics reported by vendor partners, the SIM office has the processes in place to report key model performance measures. Milliman is calculating the core aggregate cost and utilization metrics on a quarterly basis. TriWest is using AHRQ methodology to report the access to care prevention quality composite measures annually. CIVHC is calculating claims-based proxy measures for each of the Clinical Quality Measures (CQMs). They delivered baseline 2015 data on the set of 2016 CQMs, and data for those that align with the 2017 simplified set of CQMs will be added to the year 3 core metrics template (attached in Appendix P1). Data for the full set of simplified CQMs, including data for measures that were added or replaced old measures, will be reported once full calendar year 2016 data is available in the APCD.
Page 218 of 239
Colorado SIM measure summary table This table provides a high-level summary of the core metrics reported to CMMI on a regular basis, as well as a sample of measures the state-led evaluation team is monitoring.
CQMs
Population health
Cost and utilization
Model participation (process)
Depression Screening
Anxiety disorders among adults
Total cost of care
Diabetes: Hemoglobin A1c
Adults being treated for mental health
Payment reform (practices/ben eficiaries in APMs)
Hypertension
Prenatal care counseling about maternal depression
Obesity: Adult and adolescent Developmental Screening Maternal Depression Substance use disorder: Alcohol and other drug dependence, tobacco Asthma Fall safety
Adults who are currently depressed Suicide death rate Developmental screening for children Binge drinking Current smoking among adults Heavy alcohol consumption Non-medical opioid use
Out of pocket expenditures for consumers Admissions Psychiatric admissions Readmissions Psychiatric readmissions Emergency department (ED) rate Psychiatric ED rate Follow-up after hospitalization for mental illness Actuarial calculations
Practice transformation (practices, providers, beneficiaries in cohort) Population health (LPHAs, RHCs, provider education) HIT (broadband, CQM reporting)
Access to care Prevention quality chronic composite Prevention quality acute composite Pediatric quality overall composite Prevention quality overall composite
Additional evaluation measures Access to integrated care (IPAT, CHAS) Client experience of care Payer/provider ROI Coordinated Community Systems Index Collaboration, stakeholder engagement Workforce and policy efforts SPLIT assessment data Key informant interviews (challenges, successes, lessons learned)
Page 219 of 239
The population health indicators were selected to align with the CQMs that SIM practice sites report on a quarterly basis. These indicators provide a statewide population-level benchmark; however, as these measures tend to remain stagnant overtime, Colorado SIM does not expect to see much movement over the course of the grant. SIM regional health connectors (RHCs) have aligned their target areas with the CQMs, which in turn, align with the population health indicators (please see the Population Health Improvement Plan section). CDPHE is collecting and reporting the core SIM population health indicators once annually. During the first year of implementation, the SIM office worked with CDPHE to focus in on the behavioral health indicators that align with SIM behavioral health CQMs. The populations health indicators that align with SIM primary care CQMs are still being reported to the SIM office by CDPHE, and used for internal monitoring with the population health workgroup; however, they are no longer reported to CMMI. As existing population health survey data (from BRFSS, vital statistics, etc.) becomes available at different points throughout the year, CDPHE reports all the indicators to the SIM office once per year, and will be reported to CMMI as part of the November quarterly report.
Practice-level data The SIM office will continue to collect CQM data from practices on a quarterly basis, and aggregate the data for reporting to CMMI. Cohort-1 primary care practice sites have been reporting quarterly CQM data for over a year. Following the release of funding for CMHCs, the SIM office contracted with Health Management Associates (HMA) to facilitate consensus among the four participating CMHCs to ensure consistent data reporting related to attribution, CQM reporting, and number of providers participating in SIM. HMA will complete this work during the no cost extension, and CMHCs will start reporting CQM data in year 3. Aggregate CMHC CQM data will be reported separately from primary care practice site CQM data. In year 3, as part of the November quarterly report, the SIM office will add additional rows to the core metrics table to report aggregate cohort-2 CQM data separately from cohort-1 CQM data. This will allow the SIM office to monitor progress and outcomes data for each cohort separately, given the changes to implementation over time. In addition to the CQM data reported by primary care practice sites and CMHCs, each site reports baseline and annual/semi-annual data for a set of assessments via the shared practice learning and improvement tool. The University, TriWest, and the SIM office each have a role in analyzing the SPLIT assessment data to report back to practice sites, inform program implementation, and feed into the state-led evaluation.
Participating payer data The SIM office has been working closely with the Multi-Payer Collaborative (MPC) to identify and define the key data elements necessary for CMMI reporting and state-led evaluation. Together with participating payers, the SIM office finalized a data collection template, detailed definitions and guidance, and hosted a webinar in October. The SIM office aligned the data request and guidance with the national HCP-LAN data collection effort wherever possible. Payers were asked to submit CY2015 baseline data for cohort-1 practice sites by December 31, 2016. To date, the SIM office has received at least partial data from three participating payers and continues to follow-up with each payer individually to understand the challenges and provide guidance. While some payers were able to submit data for the national effort, it is a manual process for payers to pull this data at the state level. It is a further manual process to pull the data at the cohort level of SIM practice sites. Payers are still working to understand, categorize, and pull their data, according to the relatively new HCP-LAN APM categories. Finally, some payers are hesitant to provide payment data (dollar amounts) to the state. The SIM office plans to Page 220 of 239
request this data on an annual basis, with CY 2016 data for cohort-1 requested by July 31, 2017. The SIM office has begun sharing eCQM data with payers. As practice sites and clinical health information technology advisors (CHITAs) have provided feedback related to data quality issues, and that they do not trust the data until the measures reflect a full calendar year’s worth of data, the SIM office is sharing the data once annually. The measures that practice sites report in Q4 should cover the full calendar year (January – December) of the previous year. The eCQM data is shared with payers only for the practice sites that they support with an alternative payment model. Cohort-1 practice sites were provided with an option to opt-out of the SIM office sharing their eCQM data with payers on their behalf. For the next annual report, and for cohorts 2 and 3, practice sites will not have the opportunity to opt-out. The SIM office also drafted and executed cooperative agreements with each payer that prevents payers from sharing practice-identifiable data without the practice site’s permission, and allows payers to use the data only for purposes contained within existing payment agreements or contracts.
Gaps in data The SIM office continues to work on identifying and developing strategies to address gaps in existing data. For example, behavioral health data is lacking in the APCD. To supplement the analysis TriWest, Milliman and CIVHC conduct for SIM evaluation activities, the SIM office has been working with the Department of Health Care Policy and Financing (HCPF) to provide the Behavioral Health Organization (BHO) encounter data flat file to these partners. Because the file contains substance use disorder data, the SIM office and HCPF identified an exception to 42 CFR part 2, and draft the necessary data sharing agreements with each vendor. This data will help provide a more comprehensive picture of the impact SIM is having on cost, utilization and other claims-based measures. The SIM office continues to work with CMMI to identify a way to obtain Medicare data for inclusion in the data aggregation tool for SIM practice sites, as well as for reporting and evaluation purposes. The SIM office provided a concept paper to CMMI outlining use cases for all three purposes and has followed-up with CMMI on the various data sharing agreements in place and potential paths forward. In year 3, the SIM office will continue to pursue CIVHC as a qualified entity to pass Medicare data through to the data aggregation tool. The SIM office has also worked with TriWest and Milliman to identify the reports available via ResDAC and will submit a request for research (SIM evaluation and reporting) purposes.
Care experience measure The SIM office has pursued several strategies to identify a care experience measure to monitor over the course of the program. The SIM office attempted to incorporate commercial beneficiaries into HCPF’s annual CAHPS survey administration, as well as leverage a HCPF pilot to administer the clinician and group PCMH CAHPS survey with a small sample of practices. While the SIM office was unable to leverage these existing efforts, we will continue to work with payers and HCPF partners to explore opportunities for future years. For year 3, TriWest is developing a strategy to identify the various care experience instruments that SIM practice sites already implement and assess whether there are common data elements that can be used for reporting and evaluation purposes. Additionally, TriWest has worked with the consumer engagement workgroup to develop survey questions that address identified priority areas. This survey will be administered with a sample of SIM practice sites and may include retrospective questions to estimate progress over time. The evaluation methodology and data analysis plan will be updated once the strategy is finalized, and the identified measure will be added to the core metrics reporting template. Page 221 of 239
Accountability targets During year 2, the SIM office worked with key partners and stakeholders, and conducted research to identify existing benchmarks, to set accountability targets for core metrics reported to CMMI. For many of the metrics, baseline data was not available until early 2017. Since the SIM office and stakeholders wanted to make data-driven decisions based on baseline data and existing benchmarks, accountability targets were included in the Q1 2017 report. Some accountability targets are not yet determined, such as new CQMs and payer/payment metrics, as we are waiting to have more complete baseline data to make appropriate projections. Any additional accountability targets will be added to the CMMI core metrics reporting template as they are determined.
Proposed changes to core metrics table The SIM office is making several additions and replacements to the core metrics table for reporting to CMMI. An updated core metrics table is included in Appendix P1; retired metrics are noted in the status column, new proposed metrics are highlighted in yellow, and modifications are included in the notes section. Working together with reporting partners, the SIM office proposes the following changes for year 3: ● Retire local public health agencies (LPHAs) “implementing strategies” - this measure reflects when the LPHAs received their funding, and since all 8 have received their funding, this goal has been achieved. Replace with community members participating in behavioral health and wellness education. ● Retire behavioral health transformation collaboratives (BHTCs) “implementing strategies” - this measure reflects when the BHTCs received their funding, and since both have received their funding, this goal has been achieved. Replace with participant referrals to behavioral health community resources. ● Add HIE connectivity for primary care and CMHC sites ● Add small grant project implementation for primary care sites ● Add cost savings to cost and utilization metrics (tracking toward ROI goals) ● Add claims-based proxy measures that align with simplified CQMs (will add remaining with 2016 annual refresh) ● Modify utilization measures to better align with actuarial calculations and create consistency among utilization measures o Admissions – revise from per 100,000 to per 1,000 members o ED rate – revise from per 100,000 to per 1,000 members o Psychiatric readmissions – include only 30 days to align with all-cause readmissions o Follow-up after hospitalization for mental illness – include only 30 days to align with allcause readmissions Previous changes to the core metrics template included the 2017 simplified CQM measure set, parsing out pediatric obesity into 3 separate components as measure is structured, and paring down the population health indicators to include only behavioral health indicators that align with SIM COMs.
Monitoring newly-identified risks The SIM office continues to monitor the risks identified in the original operational plan and provide updates via quarterly reports to CMMI. The risk mitigation section of the most recent quarterly report is included as Appendix P2. However, the following risks have emerged since the submission of the original operational plan. The SIM office will continue to monitor and address these risks throughout AY3.
Page 222 of 239
Practice transformation: Lack of consistency in support delivered by practice transformation organizations (PTOs): cohort-2 practices can choose between 18 PTOs to deliver practice transformation support to their practices, and may work with two separate PTOs for SIM alone - one to provide a practice facilitator (PF) and one to provide a CHITA. While this model maximizes flexibility for practices, affording larger health systems the opportunity to offer in-house support and allowing practices to select a PTO with whom they may have previously worked, it has also presented challenges in making sure that all PTOs are performing up to a common standard and consistently disseminating information. Mitigation strategy: The SIM office is working with the University to determine a standard, minimum set of competencies for CHITAs that will be adopted across all PTOs. Additionally, the SIM office and University are working to revise the field note structure that PFs and CHITAs use to record interactions with practices. Instead of being entirely made up of a free text field, the note will include more discrete fields to capture information that will allow the SIM office to better assess consistency. Finally, during the NCE, the SIM office began to host monthly PTO office hour webinars, during which the SIM office can communicate key messages directly to PFs, CHITAs, and other representatives from PTOs as well as offer them a forum in which to ask questions of the SIM office. Partners at the University are adjusting the training that they provide via webinars and collaborative learning sessions based on findings from rapid-cycle feedback reports from TriWest and suggestions made in surveys completed by practices.
Population health: Low ratio of RHCs to SIM practices: The SIM office supports 21 RHCs throughout the state, one in each health statistics region (see the plan for improving population health section for a detailed description of the program). Given the high number of practices participating in SIM and the large geographic regions that some RHCs are expected to cover, concerns have been raised that RHCs will not have the time or capacity to support each practice and may be spread too thin to have a substantial impact. For the stateled evaluation, TriWest is relying on the Colorado Health Institute (CHI) to collect data from each of the RHCs. CHI will share the monthly report and social network analysis data with TriWest, which will feed in to the coordinated community systems index. TriWest will also conduct annual key informant interviews with the RHCs (please see program evaluation and monitoring section for more information). The SIM office will continue to monitor progress based on the metrics table that CHI submits to SIM on a monthly basis (included as Appendix P3). Mitigation strategy: RHCs will meet with PFs, many of whom support multiple practices in a region, as well as review practice improvement plans from each practice, to identify common needs and themes. RHCs will select common themes that align with the priorities they have selected for their region and focus their efforts in those areas. RHCs will then be able to more efficiently disseminate information by bringing together groups of PFs or practices that have a common interest for trainings, webinars, and meetings. Additionally, because RHCs will be sharing information with each other across regions, there may be opportunities for a practice in one region to be matched with training or practices addressing similar issues in another region. The SIM office will continue to monitor this risk as the RHC program moves further into implementation.
Health information technology (HIT): Delayed hiring and contracting of key personnel to complete HIT activities: The SIM office completed a stakeholder-driven process to identify the top two prioritized use cases during the summer and fall of 2016. The plan was to hire a technical architect, housed within the state Office if Information Technology (OIT), to determine the technical requirements and specifications Page 223 of 239
required to support the prioritized use cases. Additionally, Deloitte Consulting was contracted to complete a SIM HIT implementation roadmap, meant to link the use cases to the technical requirements and ensure that the business case for providers and payers was clearly articulated in the roadmap. Due to delays in contracting, Deloitte did not begin work until April 2017. Additionally, despite months of interviewing candidates, the SIM office was not able to secure a technical architect at the salary range offered. These delays have impacted the SIM timeline for procuring the HIT long-term solution. Mitigation strategy: SIM negotiated with the state OIT to utilize their existing technical architecture staff for the remainder of the NCE period to work with Deloitte on the implementation roadmap and start outlining the technical requirements and technology specifications to support an eCQM registry. OIT will start with an assessment of exiting technology and assess format and capacity. The Office of eHealth Innovation (OeHi) has supported the SIM office, providing consultation and guidance during this period. They will work with OIT on a project plan and ensure SIM is maximizing the resources available during the NCE. Additionally, HCPF has secured a master HIT consultant. After discussion with HCPF HIT experts and OeHi, SIM will include a request for a technical/data architect within that contract. This will enable SIM to maximize resources available to support the year-three HIT goals.
Payment reform: Insufficient avenues for communication between payers and practices that participate in SIM: The SIM office has received feedback from several cohort-1 practices that communications with payers have been insufficient and confusing. Several practices have spoken with payer representatives that were unfamiliar with SIM or provided misinformation about the terms of the initiative. Looking ahead to cohort-2, the SIM office endeavors to ensure that practices have clear information regarding the details of APMs provided to them by SIM-participating payers. However, the fact that the SIM office must be blind to the specific details of private payers’ models presents a challenge to clear communications. Mitigation strategy: The SIM office has worked with members of the MPC to review and vet language that will be provided to cohort-2 practices regarding which payers have indicated support for that practice. This language includes a payer-specific contact to whom practices can direct questions. For cohort-1 practices, many payers identified a high-level director or other leader in the organization as the contact for practices. However, many times these individuals did not have the time to respond to practice questions. Additionally, some practices found that their existing contact at a payer, responsible for the day-to-day details of contracting, was unfamiliar with SIM. For cohort-2, the SIM office has asked each payer to identify a contact or contacts that have the capacity to respond to a high volume of practice inquiries. The SIM office is also compiling talking points about SIM, a list of frequently asked questions, and protocols for who to contact in the SIM office with additional questions. These resources will be disseminated to all payer contacts as a means of ensuring that all payers provide consistent information and messaging to SIM practices.
Project management structure HCPF serves as the fiscal agent for the Colorado SIM office. The SIM initiative receives funds from both CMMI (up to $65 million via a cooperative agreement) and from the Colorado Health Foundation (up to $3 million via a grant). An accounting technician (0.8 FTE), purchasing agent II (0.5 FTE), budget analyst (0.1 FTE), and grants administrator (0.1 FTE) who work elsewhere in HCPF, but not directly within the SIM office, help to provide financial and administrative oversight to the SIM initiative, ensuring accountability of the SIM office staff. (See Roles and responsibilities of staff and contractors section for detailed job descriptions of each position). Page 224 of 239
The SIM office directly monitors the work of multiple vendors. The diagram following this section names the vendors with which the SIM office intends to contract in AY3, as well as delineates their major responsibilities by primary SIM driver. Since submission of the original operational plan, the SIM office identified the need to have a dedicated staff member with knowledge of state procurement processes to streamline efforts around drafting, renewing, monitoring, and executing contracts. As a result, the SIM office hired Joseph Rodriguez as the administration and contracts program assistant II. With this role filled, the SIM office worked to identify staff roles and responsibilities related to contracts, as outlined in the chart below.
Administration and contracts program assistant ● Initiates drafting request and coordinates to contract point person to start drafting Statement of Work (SOW) ● Completes required supplementary documents for contracts and amendments ● Creates and maintains deliverable and substitution/amendment tracking system ● Receives and processes invoices ● Uploads contract/procurement documents to SharePoint ● Tracks deliverables and deliverable substitutions ensures deliverable tracker is updated ● Ensures deliverables are approved on time ● Point for contractor to resolve any invoicing issues
Content expert ● ● ● ●
Reviews and approves SOW Reviews and approves contract amendments Reviews and approves deliverables Participates in regular check ins (weekly calls, etc.) to provide guidance to vendor and ensure alignment with other components of SIM
Vendor liaison ●
●
Main point of contact for procurement – drafts SOW and amendments; leads iterative process with procurement to answer questions, make edits, and finalize contract Schedules meetings, coordinates requests for information across vendors
While the administration and contracts program assistant II performs tasks that are standard to all contracts, such as processing invoices, each contract is also assigned a content expert (generally a manager), who possesses the subject-matter expertise necessary to guide the overall content of the contract and to review submitted deliverables for accuracy. Additionally, when needed, a secondary point person, called a vendor liaison, may be appointed to assist the content expert in his/her interactions with a particular vendor and handle the more time-consuming details of contract monitoring. This structure ensures that there is sufficient capacity within the SIM office to monitor all contracts across various work streams. The SIM office has several methods for monitoring contracts. Because HCPF compensates vendors according to deliverable-based contracts, in which a vendor is paid a set amount for a given work product, accountability mechanisms are built into each contract. Tangible work products that are critical Page 225 of 239
to the success of SIM are expressed as deliverables and included in these contracts. Vendors turn in deliverables, generally on a monthly basis, which are reviewed by SIM management. If a deliverable fails to demonstrate sufficient progress toward SIM goals, the SIM content expert assigned to the contract requests revisions or changes. If revisions are deemed unacceptable, payment for the deliverable is withheld and is not be disbursed unless a sufficient product is provided. Deliverables take on a variety of forms such as quarterly progress reports meant to provide a summary of successes and challenges to more programmatic products, such as a recording of a training webinar that was produced. Most vendors are also required to provide metrics to the SIM office, which the SIM team uses to populate quarterly reports to CMMI. All SIM contracts also include standard deliverables, which include a communications plan and business continuity plan, which outline mitigation strategies for common risks, such as turnover in key personnel. In addition, the SIM office holds regularly-scheduled meetings with all vendors to ensure continued progress. For example, key staff from the University meet with key SIM staff for a one-hour call each week to discuss accomplishments and challenges. Agendas are drafted and action items are tracked across meetings. The SIM office might schedule longer meetings to address issues around program implementation. For example, the SIM and university teams will convene for a retreat in June to plan for AY3 and ensure that both teams understand expectations moving forward. Similarly, SIM staff sit on advisory groups for several vendors. For example, in addition to meeting regularly with CHI for contract monitoring, the SIM program implementation manager sits on the RHC administrative workgroup that convenes monthly to provide guidance on the program rollout. These advisory groups provide SIM staff with an additional avenue for monitoring contract implementation while engaging with individuals from outside the SIM office. Additionally, the SIM team meets with vendors to ensure they have sufficient processes in place for monitoring subcontracts. For example, the SIM office and university drafted a survey of SIM practices with questions about overall experience in SIM and satisfaction with the PTOs with whom they were matched. The PTOs are subcontractors of the University. Raw data from the survey was provided to the SIM office to gain an understanding of the university’s performance as well as its contracted PTOs. In addition, the quality assurance committee convened by the University drafted a process to identify and address PTO performance issues. See Appendix S5 for more information. All SIM vendors are expected to regularly participate on SIM stakeholder workgroups and, when necessary, to present challenges to the SIM steering committee and advisory board. For example, the population health workgroup has played an active role in ensuring that CHI meets its contractual obligations to the SIM office and that each deliverable is addressed in a manner that best serves the overall aims of SIM. Similarly, the practice transformation workgroup is a key forum through which the University and the Colorado Behavioral Health Care Council garner feedback on elements of implementation. While stakeholder workgroups are not directly responsible for holding vendors accountable, conversations that take place during these meetings ensure that a broader group of experts, beyond SIM office staff, provide guidance on key areas of implementation. These conversations may, in turn, guide the content of new contracts or initiate amendments to existing contracts. The SIM evaluation manager shares quarterly rapid-cycle feedback reports produced by TriWest with all SIM staff, including program managers (who generally serve as content experts for contracts). Program managers are required to include rapid-cycle findings as standing items during workgroup meetings, looping in both vendors and other key stakeholders on progress made toward addressing issues identified in the rapid-cycle reports. (For more information about Rapid Cycle feedback reports, see the state-led evaluation section). Page 226 of 239
In AY3, the SIM office will continue to assess its strategy around contracting processes and adjust as necessary. The administration and contracts program assistant II will continue developing and improving processes and sharing these changes with the team.
Page 227 of 239
Page 228 of 239
Maintenance of program operations beyond SIM funding period: The SIM office has established strong partnerships with organizations and groups that will continue to sustain progress beyond the SIM funding period. Practice transformation: Facilitated by the practice innovation program at the University, the Colorado Health Extension System (CHES) convenes numerous PTOs across the state for the purpose of achieving better population health, lower costs, and an improved experience of care for patients, families and the healthcare team. PTOs that support SIM practices participate in CHES, as does CHI, who deploys RHCs. The Colorado SIM director and program implementation manager regularly participate in CHES meetings, including meetings of the CHES steering committee. CHES has played a key role in coordinating PTOs prior to SIM for initiatives such as the Comprehensive Primary Care Initiative (CPCi) and EvidenceNOW Southwest. As PTOs continue to support practices in Colorado via new initiatives, CHES will possess the institutional knowledge needed to ensure that lessons learned from the SIM initiative are incorporated into statewide practice transformation efforts moving forward. Payment reform: The Colorado MPC (described in further detail in SIM approach to payment reform section) was initially convened as a means of supporting the aims of CPCi. The group now plays a critical role in advancing the objectives of Colorado SIM as well as CPC+. As funding comes to an end for the SIM initiative, the group will continue to convene to coordinate support for CPC+. Furthermore, members of the MPC are currently exploring avenues to formalize an ongoing partnership with Oregon Health Sciences University, which facilitates MPC meetings, beyond the term of SIM. As payers have identified behavioral health integration as a key priority under SIM, it is anticipated that the MPC will continue to focus on efforts that sustain progress toward integration in the long-term. Population health: CDPHE plays a leadership role in guiding the population health efforts of Colorado SIM. Dr. Tista Ghosh, deputy chief medical officer at CDPHE, chairs the SIM population health workgroup. Under Dr. Ghosh’s leadership, the population health workgroup recommended that CDPHE contract with HMA to undertake an environmental scan of efforts related to behavioral health across the state and to issue a call to action based on identified needs and gaps (more information about the environment scan is provided in the plan for improving population health). CDPHE leadership is committed to providing an ongoing forum for sustaining progress made under SIM and will continue to coordinate efforts with statewide partners beyond the term of SIM funding. HIT: The SIM office has partnered closely with OeHI in developing and implementing its HIT strategy. Carrie Paycok, Colorado’s HIT coordinator, serves as the co-chair of the SIM HIT workgroup and is closely involved with all SIM HIT efforts. Carrie has played a crucial role in the guiding efforts at creating a state HIT roadmap and building the foundation for a long-term statewide HIT solution or solutions that will aggregate clinical and claims data. As a permanent employee, the HIT coordinator will ensure that the progress made under SIM is sustained beyond the SIM funding period. Additionally, SIM is in the process of funding a data architect, who will be shared with HCPF Health information Office (HIO) through the master HIT consultant contract. While the primary responsibility of this individual will be to build the foundation for a long-term HIT solution under SIM, HIO will continue to fund this position beyond the term of the SIM initiative and continue to partner with OIT, ensuring continuity in implementing the solution.
Page 229 of 239
d. Fraud abuse prevention, detection and correction Colorado has a robust set of statutes, programs, and processes to prevent, detect, and correct health insurance fraud and abuse. The Colorado State Innovation Model (SIM) office anticipates that payment reform and other initiative activities will fit into the statutory and regulatory mechanisms outlined here.
Medicaid State statute The State of Colorado has adopted a Medicaid anti-fraud statute to prevent the submission of false and fraudulent claims to the Health First Colorado (Medicaid). The Colorado Medicaid False Claims Act (CMFCA), enacted in 2010, makes it unlawful for any person to knowingly present a false claim to Medicaid, make a false representation of a material fact in connection with a claim; present a cost document the person knows contains a false material statement; or make a claim for services payable by Medicaid with knowledge that the individual who furnished the services was not licensed to provide such services. Person(s) who violate state statute are subject to civil penalties of not less than $5,500 and not more than $11,000 plus three times the amount of damages the state sustains.
Colorado healthcare divisions Colorado Department of Health Care Policy and Financing (HCPF) HCPF has multiple programs and resources to combat fraud, waste, and abuse. The department’s Program Integrity Section is primarily charged with detecting and deterring fraud, waste, and abuse in the Colorado Medical Assistance program, monitors Medicaid providers for compliance with Medicaid statutes and rules to recover inappropriate payments. A staff of nurse reviewers, claims reviewers, and data analysts conducts compliance monitoring, which involves reviewing a provider’s paid claim and comparing it with that of their peers to identify those who are significantly above the norm. Compliance monitoring also includes educating the employees of providers about false claims. The program integrity section also conducts preliminary investigations of suspected fraud, a process that involves extensive claims review and some medical records review. If a suspicion seems warranted, the matter is assigned to an internal post-payment claims review for audit or referred to the Colorado Medicaid Fraud Control Unit (MFCU), which is housed within the state’s attorney general’s office for a formal investigation and/or prosecution. Several other sections within HCPF are also engaged in fraud prevention and detection: ●
The Benefits Coordination Section works to recover money and avoid unnecessary costs, and ensures that Medicaid is the payer of last resort when clients have other insurance, per federal regulations;
●
The Nursing Facility Section works to detect and reduce fraud, waste, and abuse associated with Medicaid Nursing Facilities in Colorado;
●
The Compliance Section works to reduce fraud, waste, and abuse committed by recipients of HCPF programs; and
●
The Client Over-Utilization Program (COUP), also known as “Lock-In,” is a statewide surveillance and utilization control program that safeguards against unnecessary or inappropriate use of care or services. The program uses a post-payment review process to identify excessive patterns of utilization to rectify over-utilization practices of clients. Potential COUP client’s usage is reviewed on a quarterly basis. Medicaid clients whose Page 230 of 239
utilization of benefits without medical necessity have exceeded certain program parameters (i.e., use of 16 or more prescriptions, use of three or more pharmacies, excessive emergency room and physician visits) in a three-month period might be restricted to one designated pharmacy and one primary care physician when there is documented evidence of abuse or over-utilization of allowable medical benefits. In addition to staff efforts, HCPF has a diagnosis review contract in place and has a recovery audit contract with Health Management Systems, Inc. Colorado will continue to consult with the Centers for Medicare and Medicaid Services (CMS) for conducting post-payment compliance reviews and audits. Finally, HCPF participates in the Payment Error Rate Measurement (PERM) program developed by CMS to comply with the Improper Payments Information Act (IPIA) of 2002 (amended in 2010 by the Improper Payments Elimination and Recovery Act or IPERA). PERM measures improper payments in Medicaid and Children’s Health Insurance Program (CHIP) and produces error rates for each program, based on reviews of the Fee-for-Service (FFS), managed care, and eligibility components of Medicaid and CHIP in the fiscal year (FY) under review.
Colorado Medicaid Fraud Control Unit (MFCU) - State of Colorado Office of the Attorney General The MFCU is tasked with investigating and prosecuting cases of Health First Colorado provider fraud. MFCU’s mission is to protect state and federal funds from fraud against Medicaid by individuals or companies that provide services and to protect residents of long-term care facilities from physical or threatened abuse, mental or emotional abuse, sexual abuse, criminal neglect, and financial abuse. MFCU employs a professional staff of criminal investigators, an auditor, a nurse investigator, and prosecutors experienced in criminal and financial investigations. The MFCU’s abuse jurisdiction extends to all personal care boarding homes, adult day care facilities, hospitals, skilled nursing centers, rehabilitation centers, long-term facilities, and some assisted living centers – regardless of whether the patient is a Health First Colorado client or not. The unit does not investigate abuse in the home or in non-Medicaid facilities. MFCU fraud jurisdiction covers all Health First Colorado providers. The MFCU has authority to hold individuals or entities accountable through criminal prosecution and/or civil litigation. It also makes recommendations to the U.S. Department of Health and Human Services, Office of the Inspector General to exclude individuals or entities from participating in federally funded programs.
Colorado Department of Human Services (CDHS) While the MFCU investigates and prosecutes cases of provider and facility fraud, CDHS has authority over individuals who receive services as part of the Health First Colorado program. CDHS’s county offices investigate suspected cases of recipient fraud, and the local district attorney’s office prosecutes individuals who practice fraudulent schemes. CDHS’s jurisdiction also encompasses inappropriate or fraudulent activity by CDHS employees, CDHS management, CDHS appointees, and community partners, including contractors, grantees, vendors, and other sub-recipients. The department has authority to examine all relevant records, financial statements, and client information and to conduct interview of involved to complete investigations.
Commercial Insurance State statute Colorado state law requires any licensed insurance company doing business in the state to “prepare, Page 231 of 239
implement, and maintain an insurance anti-fraud plan.” The anti-fraud plan, which is required to be submitted annually to the Colorado Department of Insurance (DOI), must outline specific procedures to: “(I) Prevent, detect, and investigate all forms of insurance fraud, including fraud by the insurance company‘s employees and agents, fraud resulting from false representations or omissions of material fact in the application for insurance, renewal documents, or rating of insurance policies, claims fraud, and security of the insurance company‘s data processing systems; (II) Educate appropriate employees about fraud detection and the company‘s anti-fraud plan; (III) Provide for the hiring of or contracting for one or more fraud investigators; (IV) Report suspected or actual insurance fraud to the appropriate law enforcement and regulatory entities in the investigation and prosecution of insurance fraud.” Additionally, insurance companies are required to include an anti-fraud statement on all insurance applications, policies, or claim forms, language substantially similar to: “It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.”
Colorado Department of Insurance (DOI) – Department of Regulatory Affairs The DOI is authorized to conduct market examinations of commercial insurance carriers in Colorado according to Colorado statues and regulations. Colorado was one of seven states that adopted the National Association of Insurance Commissioner’s (NAIC) “Market Conduct Surveillance Model Law,” and large sections of the model have been incorporated into state statute. Market conduct examiners, when possible, use the NAIC Market Regulation Handbook and follow NAIC guidance when conducting exams. Company anti-fraud plans are regularly reviewed as part of market conduct exams, to ensure compliance with state laws. Exams may also investigate fraud allegations, either against companies for committing fraudulent activities, or against consumers accused of committing fraud against a company. The attorney general has jurisdiction to prosecute insurance fraud throughout the state of Colorado.
Guarding against new fraud and abuse exposures As previously noted, the SIM Office relies on statutory and regulatory mechanisms to protect against fraud and abuse exposures that may occur in relation to payment reform activities. As an additional safeguard, the SIM office will include a clause (or something like it) in SIM practice contracts: Each participant must comply with all applicable Colorado and federal laws and regulations; such compliance includes but shall not be limited to, compliance with all applicable federal laws and regulations designed to prevent fraud, waste, and abuse, including but not limited to applicable provisions of Federal criminal law, the False Claims Act (31 U.S.C. 3729 et seq), and the anti-kickback statute (42 U.S.C. section 1320a-7b(b)). Page 232 of 239
SIM will also ensure that payers participating in the model comply with state and federal anti-trust laws. All payers participating in SIM payment reform models are part of the self-funded and self-governing Colorado Multi-Payer Collaborative (MPC). All meetings of the MPC begin with a reading of, and agreement to, the following anti-trust statement: “Payers participating in the Colorado Payer Collaborative agree that all activities are in compliance with federal and state antitrust laws. In the course of discussion, no financial information from participating payers will be shared with other payers or the general public. During meetings and other activities, including all formal and informal discussions, each participant will refrain from discussing or exchanging information regarding any competitively sensitive topics. Such information includes, but is not limited to: ●
Per-member per-month (PMPM);
●
Shared savings; and
●
Information about market share, profits, margins, costs, reimbursement levels, or methodologies for reimbursing providers, or terms of coverage.
Plan for existing fraud and abuse protections that may pose barriers The SIM Office has not identified any existing fraud or abuse protections that would prevent the implementation of Colorado’s model. The scope of the SIM initiative focuses first on enhancing primary care and does not explicitly address the role of specialty or hospital-based care because systems based on primary care are best positioned to improve overall health and control costs. Specialty care, including care for those with severe mental illness and significant substance abuse issues, will continue to be referred to specialists. In addition, our proposed payment reform models will not hold providers accountable for costs incurred outside the walls of the primary care practice. As Colorado’s healthcare delivery system moves toward more coordinated systems of care and accountable care organizations, it will become more feasible to transition providers into outcome-based payment arrangements that reflect the total cost of care across the patient care spectrum. Once SIM has successfully integrated behavioral health into a primary care setting and has moved to value-based payment for primary care, it will have the basic infrastructure to create larger coordinated systems of care. These systems will include the full spectrum of care including bidirectional physical and behavioral health integration, public health, oral health, and long-term services and supports. The SIM office recognizes that the introduction of new payment models will present opportunities for improved care and cost savings, and new forms of fraud and abuse. The evaluation of SIM’s payment reform activities will serve a dual function: identifying program successes that can potentially be replicated and scaled up and identifying problems or issues, including incentives that are not properly aligned with care delivery goals or other inefficiencies or areas of weakness that might be vulnerable to gaming or abuse. As the use of data is central to the implementation of value-based payments, the SIM office will work closely with the Office of eHealth Innovation to help ensure the safety, integrity and accuracy of data sharing and transfers within the state. SIM will also work with payers, providers, CIVHC (APCD), Stratus, and other data sources to ensure that the data collected to support payment delivery models is accurate, complete and timely. SIM is committed to working with state and federal officials to monitor the development of new Page 233 of 239
payment models, identify potential areas of risk, and implement safeguards against any new threats. Through this ongoing dialogue, SIM hopes to identify potential opportunities for fraud and abuse, and address any issues that arise during the Model Test as expeditiously and effectively as possible.
Page 234 of 239
D. Sustainability plan The State Innovation Model (SIM) office has worked with its stakeholders to ensure that the initiative is designed for long-term sustainability and success. With the revision of milestones and the alignment of clinical quality measures (CQMs) for cohort-2 practices, SIM helps practices prepare for success with alternative payment models (APMs) that reward value versus volume. The three cohorts that will progress along the integration pathway through SIM will gain knowledge, skills and tools that enable them to deliver whole-person care and negotiate more effectively with health plans. The team continues to reach out to the self-insured employer market to round out the involvement of all payers in the state, and has had initial success with education efforts that highlight the value of investing in preventive care that avoids or reduces the cost of care and improves patient health and wellness. These efforts will continue and be led by the new SIM Strategy and Policy Manager, who starts June 5, 2017, and will lead the creation of a comprehensive sustainability plan for the SIM initiative. This plan will be designed with input from key SIM stakeholders and developed in close coordination with Center for Medicare and Medicaid Innovation (CMMI) and technical assistance partners. The plan will build on the following strategies to secure short- and long-term sustainability of the SIM initiative.
Mitigating changes in personnel and administration During the first two award years (AY), the SIM office faced several changes in key personnel including a change of SIM director. Vatsala Pathy, director, resigned in February 2016, and Barbara Martin, RN, MSN, ACNP-BC, MPH, assumed the title of interim director in March and was promoted to the director position in September. There were also several key changes occurred in the governor’s office. Lieutenant Governor Joe Garcia stepped down and Donna Lynne took office in May 2016. This transition prompted a subsequent change in the lieutenant governor’s chief of staff, who guides and evaluates the SIM director. In addition to these changes, and several staff changes outlined in earlier sections, there have been several changes in CMMI representatives for the SIM team. Despite these transitions, the SIM office has sustained its operations with minimal disruptions. The following mechanisms have proven successful in mitigating issues caused by changes in personnel and will continue to ensure the success of the initiative during AY3 and AY4.
Stakeholder engagement process Since its inception, the SIM office has relied heavily on the expertise of SIM stakeholders to provide guidance to the initiative. The robust stakeholder engagement process described in the SIM governance section has allowed the SIM office to gain buy-in from a wide range of leaders in practice transformation, payment reform, health information technology (HIT), and population health. By regularly engaging more than 140 workgroup members from both the public and private sectors, the SIM office has ensured that changes in one role or organization do not derail the initiative’s progress. When the SIM office needs to onboard a new leader, incoming staff members tap a wide variety of subject matter experts who are intimately familiar with the initiative for guidance. The SIM stakeholder engagement program assistant archives recordings and minutes from each meeting and updates goals and objectives for each workgroup and sends monthly summaries to all stakeholders to keep the groups apprised of what’s happening across the SIM spectrum. This type of robust stakeholder engagement has helped ensure the existence of institutional knowledge despite changes in leadership.
Page 235 of 239
Engagement with multiple state agencies The SIM office works with multiple state agencies. The governor’s office oversees the initiative, the Department of Health Care Policy and Financing (HCPF) is the fiscal agent, and physical work space is split between HCPF and the Colorado Department of Public Health and Environment (CDPHE). This structure ensures that the team interacts with multiple agencies and that leadership changes at any one agency does not unduly affect SIM operations and the SIM office can tap resources to sustain progress.
Continued financing to support sustained healthcare transformation beyond the SIM funding period Continued commitments from payers Through their work with SIM, members of the Multi-Payer Collaborative (MPC) identified behavioral health integration as a priority for the collaborative. As the SIM initiative comes to a close, payers will continue to participate in the MPC to maintain progress made under Comprehensive Primary Care Plus (CPC+) (for more information on the continuation of the MPC beyond SIM, (see the program monitoring and reporting section). Due to the substantial overlap between SIM and CPC+ practices (CPC + practices represent 42 of the 92 practices participating in SIM cohort 1, 66 of the 226 applicants to cohort 2, and are anticipated to make up a significant number of cohort 3 practices), many SIM practices will have the opportunity to use funds generated through participation in CPC+ to sustain progress toward their goals and objectives for SIM. The SIM initiative is expected to demonstrate value to payers, which will lead them to extend APMs to new practices or to develop new payment models that are focused on behavioral health integration. In this manner, the SIM initiative is building a foundation for sustainable, ongoing financing to support transformation of the healthcare delivery system.
Collaboration with foundation partners The SIM office has built strong ties with philanthropic partners. The team administers a $3 million grant from The Colorado Health Foundation to provide competitive small grants to SIM practices (see the payment models and service delivery models section for more information). The SIM office received a $200,000 grant from a consortium of four funders, including the Colorado Health Foundation, Rose Community Foundation, Community First Foundation and the Aloha Foundation to support facilitation of the MPC. The SIM director regularly participates in meetings of the Early Childhood Mental Health Funders Network and several representatives of philanthropic organizations sit on SIM workgroups to facilitate ongoing discussion and participation in the SIM initiative. SIM office staff will continue to work with foundation partners to identify possible areas in which funding strategies can align with priorities and ongoing needs identified during the initiative.
Adaptability of payment and delivery models The SIM initiative was designed to allow for adaptations and rapid-cycle improvements based on lessons learned. Recruiting SIM practices in three discrete cohorts has allowed program staff to make changes based on feedback collected via practice surveys, TriWest rapid cycle feedback reports, and conversations with key stakeholders. Between cohorts 1 and 2, the SIM office revised its practice transformation building blocks, streamlined its clinical quality measures, changed the structure of grants and payments to practices, and laid the foundation for increasing its HIT support (a table detailing changes made to the cohort-2 model is provided in the payment models and service delivery models section). Furthermore, the SIM office is working with payers to provide greater clarity and frequency for communications to SIM practices regarding the type of support or APMs that practices can expect. These adjustments to the SIM model have secured the short-term sustainability of the initiative, and the Page 236 of 239
team believes that improvements made to the model contributed to recruiting 226 applicants for a target of 150 practices in cohort 2. While payers signed a memorandum of understanding (MOU) with the SIM office outlining a common set of goals and commitments, the SIM initiative affords payers a significant amount of flexibility in how they design and adapt their payment models. The three-cohort structure allows payers to support cohort-2 practices with different APMs than they used for cohort-1 practices. By allowing payers the flexibility to adjust their payment models between cohorts, the SIM office ensured that payers can quickly adapt to changes in the market. For example, the insurance market in Colorado faced significant consolidation when UnitedHealthcare and Rocky Mountain Health Plans finalized a merger in March 2017. The flexibility to adjust support in response to the evolving landscape has contributed to retention of SIM payers in the initiative and created an opportunity for payers to test their own models throughout the initiative. Payers plan to use lessons learned through SIM to inform future support for practices and sustain progress toward promoting greater integration of behavioral healthcare. Prior to releasing an application for SIM cohort 3, the SIM office will consider additional lessons learned and make further adjustments to the model as needed to maximize practice recruitment and long-term success. As the initiative comes to a close, the SIM office will compile a final list of lessons learned across each of the primary drivers that can be shared with organizations listed in the program monitoring and reporting section that will continue operations beyond SIM funding to ensure sustainability of the project.
Long-term funding and support for population health improvement activities Environmental scan and call to action The plan for improving population health section outlines work undertaken by CDPHE to identify partners that will sustain work under the SIM initiative and address gaps in behavioral health efforts. This work will inform SIM strategy for sustaining population health improvement activities beyond SIM funding.
Regional health connectors The braided funding structure used to finance the regional health connector (RHC) program (detailed in the plan for improving population health section) was pursued to ensure the short-term sustainability of the program, as the term of EvidenceNOW Southwest (ENSW) funds were scheduled to end before the SIM funds. Braiding the funds extended the term of RHCs. Looking toward long-term sustainability, RHC program staff have convened a technical advisory group (TAG) to provide feedback and advice on the development and delivery of the RHC program. The TAG provides guidance on communication, sustainability, governance, and leadership. Program staff will work with the TAG to develop a sustainability plan During the summer and fall 2017.
Expansion of health information technology and analytic infrastructure SIM’s HIT strategy is focused on expanding HIT infrastructure long-beyond SIM. The HIT section outlines the SIM strategy for ongoing infrastructure expansion and the program monitoring and reporting section details how the SIM office is working with HCPF’s HIT office to ensure sustainability of operations.
Alignment with Quality Payment Program (MACRA) The SIM office has aligned with the priorities of the Medicaid Access and Chip Reauthorization Act Quality Payment Program (MACRA/QPP). The revised SIM Framework and Milestones (included as Page 237 of 239
Appendix S6) was designed to help practices build the competencies necessary to succeed under QPP. In defining and prioritizing the framework’s practice transformation activities, the SIM office created a crosswalk of expectations under MACRA with the original set of SIM practice transformation milestones used for cohort 1 and adjusted milestones to ensure that SIM practices were focused on activities that would prepare them for QPP. Details of how SIM aligned its measures with QPP are in the Quality Measure Alignment section. These intentional efforts to complement expectations for MACRA allowed the SIM office to frame participation in SIM cohort 2 as an opportunity to prepare for success under QPP. The Request for Application (RFA) for cohort 2 contained the following language: Participation in SIM helps providers prepare for a changing healthcare landscape that has been shaped by the Medicare Access and CHIP Reauthorization Act (MACRA), a bipartisan piece of legislation signed in 2015 that was designed to pay providers for the quality and effectiveness of the care they provide Medicare beneficiaries. Other payers have also implemented value-based payment models. This shift from volume-based to value-based payment puts the onus on practices to demonstrate higher-quality care that improves outcomes while reducing costs. Success in this value-based reimbursement world requires different skills and processes that allow providers to integrate behavioral health and primary care. The SIM Initiative helps guide practice sites along this path with intensive coaching to implement integrated care and turn data into actionable information that helps build sustainable models. These efforts help focus SIM practice efforts on successful participation in SIM and on identifying and pursuing a long-term strategy for sustaining success within an evolving healthcare landscape. SIM was one of the founding members of the Colorado Quality Payment Program Coalition (http://www.cms.org/communications/colorado-qpp-coalition), and will continue to disseminate pertinent resources to participating practices.
Page 238 of 239
E. Conclusion Since the original submission of the State Innovation Model (SIM) operational plan, the SIM initiative has demonstrated key successes in each of its primary drivers; throughout Award Year 2 (AY2) and the nocost extension (NCE), the SIM office and its partners finalized a Memorandum of Understanding (MOU) with seven public and private payers, recruited 225 primary care practices to apply for SIM cohort 2, funded population health efforts via local public health agencies (LPHAS) and behavioral health transformation collaboratives (BHTCs) covering 31 counties, fielded a new workforce of 21 regional health connector (RHCs), and collected clinical quality measures (CQMs) from all SIM practice sites. The update to the operational plan reflects SIM’s substantial achievements as well as details for how the team has identified challenges, cultivated lessons learned, and made key improvements to its model to ensure success. The updated plan reflects how the SIM team continues to adjust its program to ensure long-term success by soliciting feedback from practices in the three cohorts, using rapid-cycle evaluation feedback from TriWest, the initiative’s independent evaluator, to adjust its approach to practice transformation efforts, and engage stakeholders at every step of the way to ensure buy-in, support and to solicit feedback. The team has received positive feedback from healthcare providers, who appreciate the team’s willingness to adjust the initiative for cohort-2 so that it aligns with other value-based initiatives in the state, provides a more focused pathway to integrating behavioral and physical health and shows a more direct correlation between what payers want to see providers accomplish to earn value-based reimbursements. In AY3, the SIM office will continue to balance careful planning with the flexibility to respond to new opportunities and challenges within an evolving healthcare landscape. In doing so, the SIM initiative looks forward to forging a sustainable path toward a healthier Colorado.
Page 239 of 239
