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NASHP Learning Collaborative: From Engagement to Evidence:

Using PCOR and CER to Inform State Policymaking

October 31, 2016 Site Visit Notes

Participants Colorado:

Kimberley Smith

Judy Zerzan

Gabriel Kaplan

Paul Barnett

Gregory Tung

Donald Nease

Shannon Secrest

Kevan Scott

Petrina Stamatopoulos

Elizabeth Haskell

Ann Renaud

Joann Ginal

Tiffany Madrid

Jessica Corvinus

Jennifer Lopez

Tara Smith

Eric Kurtz

Zach Lynkiewicz

Curt Curnow Center for Evidence-based Policy

Jane Beyer

Adam Obley NASHP

Felicia Heider

Session II. Moving from Evidence to Policy Permanent Supportive Housing (PSH) Discussion

Adam: We often hold SDOH programs to a double standard. Would we expect an ROI from cancer drugs? 2 Quotes from PSH studies demonstrate this concept.

Gabriel: we talk about a utility ROI in public health. An individual can benefit from a program tremendously but not be able to show that in cost or cost savings

Jane: what kind of performance measures do you use to show outcomes for these programs? When it comes to things like PSH, HEDIS measures don’t cut it. We want to know about things like employment outcomes, community integration, have they been arrested? Are we keeping people safe, out of jail, out of the hospital?

Adam: based on PSH findings, my confidence in outcomes for PSH programs is at a 7 or 8 on 10-point scale. Not as sure about ROI but it makes real impacts on people’s lives

Jane: not about spending less money but about spending money better

Jessica: don’t have a way to monetize reducing homelessness from Results First perspective. Being able to standardize quality of life is difficult

Gabriel: when it comes to value judgments, there are a lot of tradeoffs. If you shift money away from hospitals (e.g. reduce emergency department use), the hospitals can’t sustain themselves

Kimberley: in the area of value judgments, there’s also ignorance playing into this. How worthy is evidence if you can’t clearly communicate it to people?

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o This gets at the why use Evidence-informed Health Policy (EiHP) EiHP and communicating the vale of EiHP

Adam: Interesting model in Oregon where hospitals are investing $40 million in housing

Jane: The evaluations for PSH show ED usage, psychiatric services usage, criminal justice, etc. But how can we really measure the impact of the program? Think more broadly about PSH impact on use of other programs like child welfare, cash and food assistance use, etc.

Session III. Building a Collaborative Agency Structure for EiHP Discussion of state models in Oregon, Minnesota, New York, and Washington State Oregon Health Evidence Review Commission (HERC)

Tiffany: can someone take the topic nomination twice, as a consumer and public servant for example?

o HERC topic nomination survey goes to public and state officials. We ask people to identify themselves on the survey – e.g. consumer advocacy vs. state official vs. manufacturer, etc. So they only count once.

Zach: is it just medical technologies? o Medical technologies, services, treatments, initiatives like primary care and

behavioral health integration

Joann: what happens when something like Hepatitis C comes up? o We prioritize types of HEP C. There can be variations in severity of Hep C. This is

something Oregon is actively struggling with and the ability to prioritize the stages of Hep C is a unique process in Oregon.

Joann: how do you communicate with public? o Post on website and through listserv

Tiffany: do you look at state data to measure the relevance of the topic in the state? o Yes, look at claims data for example

New York Medicaid Evidence-based Benefits Review Advisory Committee (EBBRAC)

Focus on Medicaid as opposed to HERC model, which is used to inform public and private insurance. EBBRAC does not prohibit sharing work with other payers.

Joann: who chooses legislative members participating in EBBRAC? o Legislature

Curt: do they only review things that aren’t covered yet or do they review things that are currently covered but maybe shouldn’t be?

o Both – can also make adjustments to cover things under certain circumstances

HERC decisions are binding on Medicaid program and other state purchased health care programs (e.g. state employee benefits) besides workers comp

EBBRAC is not binding, its advisory, but the state generally trusts the EBBRAC recommendations

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Minnesota Health Services Advisory Commission (HSAC)

There is a cross-state HTA group – WA, OR, TX, NY, MN to coordinate the HTA work

Gabriel: how does coverage policy audit work in Minnesota? o They go to the managed care organization (MCO) and say we have a requirement

you cover this services, show us your coverage policy – demonstrate that you are or not covering a particular service

Gabriel: is it a random audit or routine? o Not sure

Zach: have these programs saved money for the state? o Will get to that but the short answer is yes

Example of HSAC work: Minnesota used HSAC as a way to have a discussion on what EPSDT services should be for Autism Spectrum Disorder (ASD) children. MN didn’t have a lot of evidence but decided to implement and evaluate ASD treatment simultaneously

Jessica: how is the state doing the evaluation for ASD services? o State programs set up markers of ASD progress and view that as an indication

services should be covered

Tiffany: how specifically do you measure given ASD is a spectrum? o Not sure exactly in MN. Its been a challenge to figure out how to collect this data o Judy: MN is not using claims data they are using clinical data through prior

authorization process. Funding for evaluation was included in legislation. It was a directive from legislature cover ASD services while doing evidence development.

Washington Health Technology Assessment

Example of an incremental approach to EiHP - can be helpful for Colorado to think about in terms of building from benefits collaborative

HTA started first in 2006 – originally decisions were advisory but legislature revised a few years later to make it binding once they saw the work happening

HTA has a ton of public input and public involvement

Joann: are contracted researchers in state or out of state? o 2-3 different contractors. One is Institute for Clinical and Economic Review

(ICER). Also have local group in Seattle, CEbP does some work o AHRQ designates evidence-based practice centers around the country

Bree Collaborative was 5 years after HTA and this was the legislature trying to think broader than state funded health care and multi-payer approaches.

Bree is advisory – talking about public/private partnerships. Include health care purchasers in collaborative

Elizabeth: does this control cost of Medicaid? o WA looks at cost avoidance. Measure how much it has limited services like

expensive imaging, etc. One study showed $20 million cost avoidance. o As of last year they are projecting $47 million in savings sine they started o Kansas saved $11 million in 2003 in Medicaid prescription drug costs –through

DERP participation

Elizabeth: does this work mean people are going without care?

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o No. For example, if we have evidence a class of medications is equally effective, why pay for the most expensive drugs? Choosing the medicine that is equally effective but less expensive

o Judy: and CO does this in terms of paying for drugs.

Jane: imaging example. We have CT scans, MRI, X-rays, etc. HTA took on the challenge of when do you really need an MRI (more expensive) vs. CT scan. Example of when alternative treatments are available.

Judy: back pain is a good example of the types of issues CO is facing. CO is strong on imaging. There’s a lot of evidence that surgery for back pain isn’t necessarily effective in reducing pain but we don’t currently have any limitations on this.

Adam: HERC took on back pain and made big decision opioids wouldn’t be covered for lower back pain – took input from many stakeholders. These types of evidence review entities are looking at unwarranted variations in care.

Elizabeth: how do providers react? o It’s a cultural change. We do expect controversy when we take on a topic. We do

take in clinical experts and bring them in at the beginning stages. o Try to be as inclusive as possible and let everyone voice their opinion.

Kimberley: another use for these types of evidence review entities is when thinking about new technologies where people don’t have preferences yet. For example, genetic testing with 4 different companies providing services. Wouldn’t you want to cover the least expensive option if they’re all equally effective?

Joann: if a physician really pushes on this, would they ultimately get what they want? o It depends on the policy. For example, HERC is binding. o How this worked in the past before HERC existed: Let’s say OHA decides not to

cover a service based on the evidence. If a physician really believed that patient would benefit from the services (e.g. Medicaid patient) the patient could appeal. In the past, the court would go with the treating physicians opinion as opposed to state physician. Now what happens, the state shows the treating physician the thorough HERC process and it becomes a bigger decision for the court.

Judy: I’ll add a lot of recommendations I’ve seen from WA and OR are varied and depend on the specific population. E.g. Here are the instances where it seems to have a benefit and when it does not have a benefit. They are not one size fits all decisions.

o Adam: an example is type of patient who really benefits from bariatric surgery.

Judy: I think these processes help in a lot of ways. One study estimated it takes clinicians 20 years from being in the evidence to following it. These kinds of groups can help identify new evidence, gaps in the evidence, etc. Sometimes clinicians aren’t always up to date on the most recent technology.

Shannon: what mechanism do we have in Colorado other than the medical services board?

o Kimberley: we have benefits collaborative processes that engages stakeholders in policymaking process. In addition, HCPF has some discretion over particulars of what’s covered e.g. dosage – this falls under Dr. Zerzan’s purview – wouldn’t it be nice if she had more help?

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o Shannon: so yes, we don’t currently do this work to the full extent

Joann: drug utilization review board is exception. CO has very involved process for pharmacy.

Judy: we sort of have this covered for drugs but this is more about the rest of the medical benefits side and health technology

Shannon: with Medicaid expansion I’m surprised we haven’t done this yet

Jane: yes, and there’s a lot more discussion on mental health/SUD treatments now so there is a lot of opportunity in this area. For example, when there’s a shortage of behavioral health providers and a limited ability to reach patients in need, we need to think about where we want to invest based on the evidence.

Curt: the benefits collaborative is potentially in an evolutionary stage. What are the key differences between programs like HERC and benefits collaborative? What do we need to take the benefits collaborative to this level?

Kimberley: we are missing resource. When we tackle a topic, we do some preliminary research on it but we have a small budget ($25K a year) to contract out to researchers. We are great about opening that process out to the public and clients and collecting evidence from them. We have some basic structure to allow the public to bring research to our attention that we consider based on our guiding principles. We have input of councils like NightMAC.

o Example: we ran benefits collaborative for genetic testing. We were able to understand in house that we should cover pre-natal genetic testing for down syndrome. There’s clinical validity and utility in that. But there are 4 different pre-natal genetic tests. We don’t know which are better or worse and we don’t have capacity to determine which are best. But there’s a huge difference in price. We opened up a code so anyone can bill for any of them but at a single price which we’ve heard is too low. We really rely on volunteer experts. We could be making much better decisions.

Jane: credibility is another issue. Who put the evidence together and who looked at it? In these other state, a neutral third party person looks at it.

o Judy: so an approach like HERC or HTA programs put our current benefits collaborative process on steroids – it adds structure, depth, and speed. Right now our process takes 2 years. I think it would also be helpful to have outside stakeholders that provide the same neutral perspective for all issues.

Shannon: from the public perspective, it’s still not a consensus model. It’s still HCPF that still has the ultimate say. In other states it’s not advisory – it’s a decision making board (e.g. HERC and HTA). They do listen to us but they don’t really have to listen to us in CO.

Session IV. What could work for Colorado? Defining a purpose statement What aspects of other state purpose statements ring true to you? (from MN, OR, NY, WA)

Still have to focus on quality of care long term to help reduce costs down the road

Use of scientific evidence

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Consider definition of scientific evidence

Think about including future and long-term evidence on health outcomes – long-term benefits for patients

Value assessment from patient perspective

Public transparency

Credibility of who’s doing the research, acceptance it’s a valid process is important, especially from a legislative standpoint

Curt: zach asked if we can piggy back off of other states but I think its important that it be a state driven process so that we get buy in early. We don’t just want to do what’s working in Washington.

Can also consider other states’ work from a Colorado lens

Zach: also think about consistency across agencies. Agencies have different coverage guidances. Maybe that should be a goal to the extent possible to be consistent across agencies.

Jane: maybe is consistent with clear exceptions.

Tara: “systematic” process really resonates with me – both within organizations and then across organizations

Structure systematic process

Gabriel: struggling with consistency. That might be second to where the literature is going and where science is going. For example, there could be a new intervention and if it’s a fiscally minded administration, they might direct the agencies to stay out of it.

Jane: in terms of topic nomination, it’s often an agency director who makes ultimate decision about what services and technology are going to be reviewed.

Gabriel: thorny example, hepatitis C treatment and the stage at which you intervene – when they’re 40 and asymptomatic, 50 and slightly symptomatic, or 65 and full-blown? In our environment, we are limited to a 1-year time horizon in our fiscal planning. When you look at a 1-year payback period you make very different choices than when looking at 10-year payback. So an entity like this could ask legislature to think long term about specific issues. Ask for a tax increase from voters or ask for legislature to shift funds. Maybe even social impact bonds – these are all examples of areas where the state agencies are very limited. Need to think beyond involving just agency leadership.

Joann: I think the interagency structure is great collaboratively. You’d want a third party involved and it ultimately goes back to interagency group to make ultimate decision.

o Kimberley: it’s possible. We haven’t reached consensus on a model. I think we are moving toward a third party for that key recommendation stage.

Joann: I think it’s important to have outside unbiased voice - a third party so that people are less skeptical and more able to trust and agree.

Jane: you can have 3 levels of unbiased review. You can have entity that does actual review and analysis of the evidence. Then agencies would bring in clinical expertise. Then the third party group would inform agencies decisions.

So 1 independent group to review evidence and 1 committee to make recommendations.

In OR, members of HERC are subject to conflict of interest disclosures.

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Jane: maybe this group could have longer-term view that’s not limited.

Some topics are very cross-agency – for example dental caries or obesity in schools

Elizabeth: so would this group just look at Medicaid or issues in other agencies? o Looking at it over all agencies

Kimberley: yes, HERC looks at all agencies but has Medicaid subcommittee.

Joann: but don’t you think everything comes back to Medicaid?

Kimberley: I think there are example where CDPHE tries to push out an initiative but Medicaid is payer so we could be working together better

Other potential partners? o State employee health benefits – dept. of personnel o Department of insurance

Gabriel: HCPF has less flexibility than some other private groups when it comes to policymaking

Zach: can you elaborate on how CDPHE fits into this? What decisions are you making that come into play here?

Gabriel: tobacco cessation for example, we’re all interested in tobacco cessation and USPSTF recommendation is to refer patients to treatment. The understanding is the initial conversation between the doctor and the patient is covered and the cessation treatment. But how many attempts are covered and which treatments are covered? We might experience a lot of variation across health plans in coverage options. So the group could make a recommendation to streamline coverage. Could outline a minimum benefit interpretation. Could have plans saying that they follow the EBRACC or whatever the CO program name is - we support their approach to treatment. Colorectal cancer screening is another recommended screening but you have multiple types of screening with varying levels of evidence so what is the approach we could recommend? For example, Walmart plan might mail you a kit and its on you to complete it or Saks Fifth Avenue plan might cover transportation to hospital, lodging, etc.

Outside of Medicaid coverage these groups have a lot to bring to the table. Other ideas for what you want to see incorporated?

Kimberley: agencies coming together to leverage resources and expertise to the extent we can.

Curt: in states that involve private insurance in their process, do private insurers help finance the process?

o Not sure o HERC does not include any private funding – bree might because of public

private partnership

Donald: Minnesota and Michigan program - institute for clinical improvement notion that various payers were spending their own dollars on quality improvement and prevention efforts and not feeling like they were hitting the mark on so they pooled some resources for areas like behavioral health integration.

Summary of key concepts/key words to include in a purpose statement: o Best available scientific evidence

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o Quality of care o Long-term benefits o Future costs o Interagency coordination (CDPHE, UB, HCPF, OBH) o Leveraging and combining agency resources o Public involvement/transparency o Credible/valid process o Consistency (systematic, non-random

Review and discussion of Colorado models A. Options for identifying topics of mutual interest

Zach: if the state could only tackle 4-6 subjects, it makes sense to me that there’s a very transparent process for selecting topics

Kimberley: it feels right to me that wed involve public to some degree. In our benefits collaborative we have stakeholder interest as 1 of 4 criteria. Not sure how much public dictates what we select but they should be involved in suggesting topics

Joann: if we leverage work of existing inter-agency workgroups, that doesn’t include public

need a prioritization matrix especially for public involvement

Donald: what other sorts of stakeholders do we want to bring into the process?

Jane: do you actively solicit input or have a very transparent process and invite folks to join and participate?

Judy: maybe of a first time meeting for the public that’s a kick off and once this process is in place then those meetings and that process takes into account how we have more topics

Kimberley: so are you saying for first iteration we throw out a half dozen topics and then see who wants to participate and go from there?

Judy: something like that. I think it could be controversial in terms of how we go about determining coverage benefits, etc. so want to invite public.

Judy: also is there any connection between what we’re interested in and what the other 4 groups have already done that we can borrow from? This could be a starting point?

Jane: evidence reviews are on website and you want to be sure to include topics that are new enough

Kimberley: we’ve had some tentative conversation about 3-4 topics we know are of mutual interest to the agencies. Should we start there? I think the public would really need to see this in action to wrap their brains around what it is we’re trying to do. I don’t know how much interest there would be from public at the beginning.

3-4 ideas we currently have: o colon cancer screening o from obh – integrating assertive community treatment with supportive

employment o permanent supportive housing

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o some of the most effective treatment for folks with mental illness especially as their coming out of the hospital

Do you want to start with areas that are rich with sufficient evidence? There are some areas that have more clear evidence than others. Where do you want to start?

Donald: are there places we want to go in the other direction – things we currently pay for where there isn’t really any evidence. Should we start there?

Paul: we have an evidence-based supportive employment program. Colorado is an employment first state and in the vision we have IPS in all health services but no funding. So one option is for providers to use indigent funding but that may or may not work. It’s an unfunded mandate.

Adam: Oregon HERC process still takes on some controversy. So it may be helpful to think about starting with a less controversial issue. Colonoscopy could be a challenging process to start with.

Zach: within rate review advisory committee, one of the constraints is decisions aren’t binding. We are grappling with that this year. From the HCPF perspective we’d sometimes agree with their decisions but couldn’t include in our budget due to budget constraints. So how do we make sure folks know their voices are being heard even if the outcome doesn’t reflect that?

Kimberley: maybe in first year we come to the table with some topics and let them know about prioritization matrix and let them know it would be a more open process in the future.

Curt: I’m concerned if its driven by public input you would end up doing research on things advocates and industry wanted to add instead of looking at issues where there could be cost savings.

Kimberley: maybe public identified topics are in one part of the matrix that get taken into consideration with others

Kimberley to kevan: thoughts on how topic should be involved in the topic nomination process?

Kevan: It’s hard to get public involved without them being part of the group. Shannon and I are part of the group. You have to be careful in the way you invite the public because you’d get a lot of comments on what we should nominate and that might impede process. If I were to pick something I want to nominate and members of the public comment on that and they submit things to nominate and you may get an overload of what you actually want. On the other hand, since Shannon and I are stakeholder reps, maybe there’s a way for comments to come to us and we sort through them for most common comments. And then we’d submit most common 5-10 topics.

Kimberley: it’s tricky. I think we should involve public most heavily when group makes policy make recommendations. Then again we’ve been having a lot of discussion on PCOR. But maybe it’s more about having public shape the research framework than selecting the topic.

Donald: We have a really engaged group of consumers at the table that help us identify issues going on in the community. They put things on our radar we wouldn’t have prioritized without them – for example opioids. So there has to be a balance.

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Kimberley: so maybe a topic nomination committee? Doesn’t have to be outside folks. Could be folks from our agencies and maybe members of the public as well. Is that too complex?

o Judy: Potentially too complex. I think public engagement is already a strength

Jane: maybe make prioritization matrix very public and transparent. Then people have to think if the topic they put forward is consistent with priorities.

Gabriel: if we try to have a collaborative and open process for agenda items and we don’t have prioritization tool we’re likely to get swamped. But even with it I’m not sure we have the staff capacity to go through all the topics and sort through them and see what’s most common. If we pick agenda items we think are of mutual interest to agencies we can start there.

Kimberley: we can see we’re in beta testing phase with intent of making more public as we work out the kinks

Joann: what if each interagency group recommends 1-3 topics to add to the table?

Adam: can involve public in making sure you assign the right rankings to check work

Kimberley: more information on prioritization matrices and how it work?

Jane: can do this on future TA call.

Kimberley: recap: o Lets be limited in year 1. Come to the table with topics. Haven’t closed the door

on the public nominating topics but we are going to more be transparent about topics we’ve picked and have them gut check us a little and help with prioritization criteria.

Jane: if it were a prioritization matrix, in terms of initial topics state proposed, you want to make sure topics submitted by the state meet the criteria in the matrix.

Kimberley: this conversation could be either: do we want to put in a legislative budgeting request? But I think the conversation is lending to a more iterative build up approach.

Joann: how much money did this cost in HERC? o 4 OHA FTE o money to produce evidence reports. For 8-10 evidence reports it costs around

$250 to $300K.

Zach: Medicaid is driving over $9 billion of state budget. When you think of things Medicaid is covering but it shouldn’t I think you can make up for the cost of investment by generating cost savings.

B. Options for conducting research

Tara: what would be the role for existing research projects? For example there’s a robust evaluation of primary care and behavioral health integration through initiatives like SIM. Is that something that could be fed through this body?

Kimberley: yes, want to augment what SIM is already doing. Is this idea that we’re already collaborating and building a body of evidence for things like SIM together so how could we use this collaborative to feed into that?

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Tara: how are we translating what we are seeing SIM demonstrating, whether it’s working or not working, to implement a coordinated state policy. It’s combining evidence that already exists on primary care and behavioral health integration. What does SIM show? How can we incorporate that?

Joann: I think the intern program is great. I use that as a state legislator. My biggest concern is bias. Are the students biased?

Petrina: from my perspective as a student I think that’s always a question but there’s a way, a process to prevent bias from occurring so we could have students do that.

Adam: there are various programs we can share to train people do unbiased review.

Kimberley: my preference would be to get money for an outside group like MED or something conduct a systematic review and then have a third party group review and make recommendations

Curt: could you have interns do work and have outside group do quality check to cut some costs?

Zach: is there a problem using students in the first year in terms of giving it authority and then asking the legislature to fund it? Could this hurt us in the log run? Need to establish credibility first before asking for funding.

Jane: great point. I think the idea of using very recent reviews by the other states that can apply to Colorado might be a good way for Colorado to pilot this on lower costs. Maintains external, third party perspective. Helps create the value.

Judy: I think we agree our preferred strategy is to contract evidence reviews out but maybe we work with combination of other approaches realizing our limitations.

Kimberley: maybe use some of the research from other states (e.g. OR, WA) similar to processes we want to create as a beta test. Then at the same time we work on legislative or budget proposal when we come across areas without evidence.

Donald: yes, tiered approach. What percentage of issues that have already been covered apply to Colorado? What problems are we facing that don’t have existing evidence reviews?

Joann: maybe we need to pull other entities together.

Judy: pulling pieces of people might be a possibility but we don’t have full extra FTE to spare. It would be challenging to free up additional FTEs.

Zach: what would governance structure be? If you have pooled FTE they remain in their department but it could be complicated otherwise. Where does this program exist? Who manages it? If it’s broad enough to encompass all 3 agencies or private insurance where do you put it?

Kimberley: summary: o Start with research that’s already there for the first year (e.g. HERC research) and

then in the future put in a legislative request. Is that what we want or ask for money sooner?

Jane: can also ask legislature to fund something smaller (maybe $50K) with proposal for how this program would work with commitment from the agencies. Pull together a workgroup to think about this and at the same time think about putting together an implementation plan for legislature.

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Kimberley: I think it would be helpful in that case to ask for the $50K with 1 FTE.

Joann: last session we had trouble with just $5000 budget amounts.

Jane: could ask for federal match for this.

Zach: If this were specific to Medicaid and impacts services we currently provide that we shouldn’t be, wouldn’t savings in the first year offset the costs? It would be contingent on picking the right things in the beginning.

Adam: HERC and HTA might be able to point you in the direction of picking right topics.

Jane: just be careful not to overpromise and under-deliver.

Gabriel: also consider the point that if we do this program on a shoestring budget the legislature might say you can make it work now, why do you need more money?

Kimberley: team will think about all of this this, let it percolate and continue this conversation on our next TA call.

Session V. Communicating about the value of EiHP and cross-agency approach

Communicating about the evidence in a nutshell: you have 3 groups of people interested in EiHP aproach: people who are impacted, people who want to be good stewards of taxpayer dollars, and then the group of people who are interested in long-term investments.

There is a strong relationship between Medicaid and other state programs and I’m not sure everyone things of the other agencies that this impacts. Working on one issue will impact the other systems

Look at evidence not just from perspective of Medicaid program but from the perspective of impact on other programs.

When you look at risk factors for children in foster care – it touches a lot of different programs and agencies

Summary of what the model could look like in Colorado – 3 approaches

1. Iterative/build up approach: Consider implementing a limited model in year 1. Come to the table with topics identified by agencies or, perhaps even better, go after topics that have already been reviewed by OR HERC or WA HTA with the goal of targeting low-hanging fruit to demonstrate an early ROI. Emphasize important role the public could play in future years for the topic nomination process once more capacity is established. In the meantime for year 1, be very transparent with public about topics we’ve picked and have them gut check us a little and help with prioritization criteria. Pursue legislative allocation for funding in future years after demonstrating success/importance in year 1.

2. Legislation approach: Wait to implement the model. Submit to legislators for a budget request to hire outside contractors to conduct research and author systematic reviews of topics identified.

3. Combined approach: can also ask legislature to fund something smaller (maybe $50K plus 1 FTE for first year) with proposal for how this program would work with commitment from the agencies. Pull together a workgroup to think about this and at the same time think about putting together an implementation plan for legislature.

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Other key considerations and next steps o Be careful to consider impacts of implementing a smaller/pilot project in year 1

on a shoestring budget o On future TA calls, dig into: prioritization matrix for topic selection process, topic

nomination process, ideas for low-hanging fruit o Work on a project proposal by original date of December 16