SIM PTO TRAINING
JANUARY 24, 2018 9:00 AM
1
Call Instructions:
Please
• Mute your phone, microphone, and speakers on your computer/device
• Turn off the zoom video feature
• Enter your name/organization in the chat box feature for attendance
• Submit questions via the chat box feature• Questions will be answered following the presentation
• Time to ask questions via audio will be offered for those on the phone
COLORADO SIM PTO
TRAININGPHASE 3:
BB3 – EMPANELING THE POPULATION
BB7 – SCREENING AND LINKING FOR
BH/SUD
JANUARY 24, 2018
Presenters:
Marjie Harbrecht, MD
Stephanie Kirchner, MSPH, RD
Kelly Pearson, RN, MSNAndrew Bienstock
TRAINING OBJECTIVES
▪ Review Practice Feedback Reports
▪ Introduce PHASE 3 – Population Management
▪ BB3 – Empaneling Patient Population
▪ BB7 – Screening and Linking BH/SUD
▪ Questions
3
COHORT 2 BASELINE PRACTICE FEEDBACK REPORT OVERVIEW
The following SIM baseline assessments are summarized in these reports:
▪ 1) Integrated Practice Assessment Tool (IPAT)
▪ 2) Medical Home Practice Monitor (Monitor)
▪ 3) Health Information Technology Assessment (HIT)
▪ 4) Milestone Attestation Checklist (MAC)
4
INTEGRATED PRACTICE ASSESSMENT TOOL (IPAT)
STEPHANIE KIRCHNER
5
6
7
DEFINITIONS OF BH COORDINATION TO INTEGRATION
MEDICAL HOME PRACTICE MONITOR
STEPHANIE KIRCHNER
8
MEDICAL HOME PRACTICE MONITOR
9
HEALTH INFORMATION
TECHNOLOGY ASSESSMENT (HIT)
ANDREW BIENSTOCK
10
HEALTH INFORMATION TECHNOLOGY (HIT) ASSESSMENT
11
CQM SPECIFIC RESPONSES
12
HIT BARRIERS RANKING
13
HIE / TELEHEALTH / BROADBAND
14
COHORT 2 REGISTRY ACCESS AND USE FOR CQM COUNTS
15
COHORT 2 EHR DISTRIBUTION
16
MILESTONE ATTESTATION CHECKLIST (MAC)
STEPHANIE KIRCHNER
17
MILESTONE ATTESTATION CHECKLIST (MAC)
▪ GOOD STANDING for both SIM Only and SIM-CPC+ Practices:
▪ NS= Not Started (1)
▪ JB= Just Beginning (2)
▪ AA= Actively Addressing (3)
▪ C= Completed (4)
▪ Not Possible (0) for milestone activities BB1.1.1 and BB8.2.2, are included in the Not Started (1) count at this time.
▪ GOOD STANDING GOALS
▪ Completed (4) for at least 75% of required milestones AND at least
▪ Actively Addressing (3) for all other required milestones
18
MAC RESULT SUMMARY
19
REPORT BY EACH BUILDING BLOCK AND MILESTONES
20
QUESTIONS
21
PHASED APPROACH TIMELINE
WHERE TO START?
PATIENT POPULATION
("ACTIVE" PATIENT PANEL)
POSITIVE BH/SUD
BB6 - RISK STRATIFICATION
Year 2: Risk stratify at least 75% of
population
LOW RISK MEDIUM RISK HIGH RISK
BB6 - CLOSELY MANAGE at
least 75% of HIGH RISK
PATIENTS
SIM COHORT 2 MILESTONE OPERATIONAL ALGORITHM (OVERVIEW)
COORDINATED
and/or
INTEGRATED
CARE
EXPAND and MAINTAIN EFFORTS
ALL PATIENTS
CONTINUE BB1, BB2, BB4, BB5
BB6 - HIGH RISK PATIENTS
Year 2: Risk stratify, use data to manage
care gaps/track outcomes, develop care
plans for 75% of high-risk patients
PATIENTS WITH BH ISSUES
BB8 - ACCESS TO BH CARE
Year 2: Bi-directional data sharing
BB9 - CARE COORDINATION TO REDUCE
COSTS AND IMPROVE CARE
BB10 - BH REFERRAL PATHWAY WITH
24/7 EHR ACCESS; CARE PLANS,
TRACK BH PATIENT OUTCOMES
USE REGIONAL HEALTH CONNECTORS
TO ASSIST YOU WHEN POSSIBLE
BUILD INFRASTRUCTUREBB1 - ENGAGED LEADERSHIP
Year 1: Establish agreements with payers, set up budget, QI team,
champion attends CLS, set vision for behavioral health (BH)
integration and pathway
UNDERSTAND THE
MAKEUP OF YOUR
POPULATION
------------
IMPROVE CONTINUITY
THROUGH
EMPANELMENT
------------
SCREEN FOR BH/SUD
------------
USE DATA TO
CLOSE GAPS &
IMPROVE CARE
BB3 - EMPANEL AT LEAST 75% of
PATIENT POPULATION
______________
BB7 - SCREEN UP TO 90% FOR BH/SUD
Connect to BH/Community
Prevent Low and Medium Risk patientsfrom becoming High Risk
STRATEGICALLY MANAGE
YOUR POPULATION BY
RISK STRATIFYING TO
DETERMINE WHO NEEDS
ADDITIONAL
ATTENTION/SERVICES
--------------
BUILD COLLABORATIVE
AGREEMENTS WITH
BEHAVIORAL HEALTH
(EITHER ONSITE OR
OFFSITE)
TO IMPROVE
COORDINATION AND
MANAGEMENT
Improve Quality of Care
Reduce Costs
Improve Experience for Patients & Healthcare Teams
BUILD INFRASTRUCTURE
BB2 - USE DATA TO DRIVE CHANGE
Year 1: Data, care gaps, CQMs, cost drivers
BB4 - TEAM-BASED CARE
Year 2: Workflows for three CQMs (at least 1BH)
BB5 - PARTNERSHIP WITH PATIENTS
Year 1: Establish PFAC
Year 2: Shared decision-making aids and self-management support
tools
BB8, BB9 and BB10 - BEHAVIORAL HEALTH ISSUES
Year 1: Start building infrastructure to address BH
Year 2: Develop collaborative care agreements with BH providers
USE THE MAC TO GUIDE YOUR WORK –PHASE 3
24
BUILDING BLOCK 3 – EMPANELING POPULATION
Goal: Practice has, and maintains, empanelment for at
least 75% of its patient population.
Empanelment is the act of assigning individual patients*
to individual primary care providers (PCP) and care
teams with sensitivity to patient and family preference.
Empanelment will take time, is an ongoing process requiring ongoing monitoring.
*Active population - primary care within last 12 to 24 months.
25
WHY DO IT?
▪ Empanelment is the basis for population health management and the key to continuity of care between patients and the provider/care team.
▪ Empanelment improves patient and care team satisfaction, increase preventative services, and can reduce hospital admissions and ED visits.
26
MILESTONESBB3.Y1 – EMPANELING THE POPULATION
1. Practice has assessed patient panel and assigned primary care providers/care teams to 75% of patient population.
2. Practice reviews payer attribution lists monthly (when available).
3. Practice designs and implements process for validating primary care provider/ care team assignment with patients.
GETTING “YOUR ARMS” AROUND YOUR POPULATION
▪ Who’s in my population?
▪ How complex are they (age, chronic conditions, BH/SUD, social determinants, etc)?
▪ Do I have enough staff/resources to manage them?
▪ How do I adjust my work to best address my population?
A “VISIT” DOES NOT ALWAYS NEED TO BE IN PERSON (secure emails, e-visit, phone visit, video visits)
28
WHERE TO START?
PATIENT POPULATION
("ACTIVE" PATIENT PANEL)
POSITIVE BH/SUD
BB6 - RISK STRATIFICATION
Year 2: Risk stratify at least 75% of
population
LOW RISK MEDIUM RISK HIGH RISK
BB6 - CLOSELY MANAGE at
least 75% of HIGH RISK
PATIENTS
SIM COHORT 2 MILESTONE OPERATIONAL ALGORITHM (OVERVIEW)
COORDINATED
and/or
INTEGRATED
CARE
EXPAND and MAINTAIN EFFORTS
ALL PATIENTS
CONTINUE BB1, BB2, BB4, BB5
BB6 - HIGH RISK PATIENTS
Year 2: Risk stratify, use data to manage
care gaps/track outcomes, develop care
plans for 75% of high-risk patients
PATIENTS WITH BH ISSUES
BB8 - ACCESS TO BH CARE
Year 2: Bi-directional data sharing
BB9 - CARE COORDINATION TO REDUCE
COSTS AND IMPROVE CARE
BB10 - BH REFERRAL PATHWAY WITH
24/7 EHR ACCESS; CARE PLANS,
TRACK BH PATIENT OUTCOMES
USE REGIONAL HEALTH CONNECTORS
TO ASSIST YOU WHEN POSSIBLE
BUILD INFRASTRUCTUREBB1 - ENGAGED LEADERSHIP
Year 1: Establish agreements with payers, set up budget, QI team,
champion attends CLS, set vision for behavioral health (BH)
integration and pathway
UNDERSTAND THE
MAKEUP OF YOUR
POPULATION
------------
IMPROVE CONTINUITY
THROUGH
EMPANELMENT
------------
SCREEN FOR BH/SUD
------------
USE DATA TO
CLOSE GAPS &
IMPROVE CARE
BB3 - EMPANEL AT LEAST 75% of
PATIENT POPULATION
______________
BB7 - SCREEN UP TO 90% FOR BH/SUD
Connect to BH/Community
Prevent Low and Medium Risk patientsfrom becoming High Risk
STRATEGICALLY MANAGE
YOUR POPULATION BY
RISK STRATIFYING TO
DETERMINE WHO NEEDS
ADDITIONAL
ATTENTION/SERVICES
--------------
BUILD COLLABORATIVE
AGREEMENTS WITH
BEHAVIORAL HEALTH
(EITHER ONSITE OR
OFFSITE)
TO IMPROVE
COORDINATION AND
MANAGEMENT
Improve Quality of Care
Reduce Costs
Improve Experience for Patients & Healthcare Teams
BUILD INFRASTRUCTURE
BB2 - USE DATA TO DRIVE CHANGE
Year 1: Data, care gaps, CQMs, cost drivers
BB4 - TEAM-BASED CARE
Year 2: Workflows for three CQMs (at least 1BH)
BB5 - PARTNERSHIP WITH PATIENTS
Year 1: Establish PFAC
Year 2: Shared decision-making aids and self-management support
tools
BB8, BB9 and BB10 - BEHAVIORAL HEALTH ISSUES
Year 1: Start building infrastructure to address BH
Year 2: Develop collaborative care agreements with BH providers
NEXT PHASE: BB6 RISK STRATIFICATION AND ACTIVE MANAGEMENT OF POPULATION
▪ While you’re empaneling, include or at least start thinking about:
a) Methodology for risk stratification
b) Who will need BH for mental health or complex chronic disease management
QUESTIONS?
FOR DETAILED INFORMATION ABOUT EMPANELMENT
- Learning Features January 18: (resource hub)http://resourcehub.practiceinnovationco.org/2018/01/22/learning-features-webinar-1-18-18/
31
BUILDING BLOCK 7 – SCREEN FOR BH & SUD AND LINK PRIMARY CARE TO BH AND SOCIAL SERVICES
Goal: Practice screens at least 90% of appropriate
patients/families for substance use disorder and/or
other behavioral health needs, and includes behavioral
health and community services as part of care
management strategies
32
TWO MAIN ASPECTS
1. Mental Health Issues
▪ Depression, anxiety, severe mental illness (SMI), etc
2. Behavioral Issues associated with chronic disease and other conditions
▪ Tobacco/drug/alcohol cessation, weight control, physical activity
33
MILESTONESBB7.Y1 - SCREEN FOR BH & SUD, AND LINK PRIMARY CARE TO BH AND SOCIAL SERVICES
1. Practice identifies BH resources for patients/families, including support from SIM participating health plans and Regional Health Connectors (RHCs).
2. Practice identifies a screening tool for reporting on at least two behavioral health screening measures for SIM (depression, maternal depression, developmental disorders, obesity, and substance use disorders [i.e., unhealthy alcohol use, other drug dependence, and tobacco use]); screens 25% of patients.
3. Practice has documented process for connecting patients/families with behavioral health resources (from screening), including standing orders and or/protocols and follow-up.
34
PATHWAYS TO CONNECT PCP AND BH RESOURCES
OUTSIDE PRACTICE
Collaboration
INSIDE PRACTICE
Co-Location
Integration
35
POLLING QUESTIONS
REMINDERS
▪ USE MILESTONE ATTESTATION CHECKLIST
▪ Ongoing guide for where to concentrate efforts
▪ USE SIM IMPLEMENTATION GUIDE
▪ To review building blocks and milestone tips
▪ USE RESOURCE HUB
▪ To get and share great tools and resources
37
UPCOMING DUE DATES
38
Activity Cohort 1 Cohort 2
SUBMIT CQMs January 31, 2018 January 31, 2018
Final Assessments (IPAT, Monitor, DQA,
MAC)
Release Mid
February
NA
Final Field Note/Progress Report April, 2018 NA
6 Month Assessments (HIT, MAC) NA April, 2018
(Open/available
March 2018)
PF Field Notes monthly monthly
CHITA Field Notes monthly monthly
UPCOMING EVENTSJanuary 2018▪ 1/25 – MGMA Face to Face session; Thrive in the Value Based World; Financial Keys to Succeed
8 am - noon
February 2018▪ 2/1 -- SIM SPLIT Office Hours 9-10 am
▪ 2/8 – SIM Office hours – 10-11 am
▪ 2/13 – TCPi PTO Touchbase 9-10 am
▪ 2/13 -- CMGMA Practice webinar 11-noon
▪ 2/15 – Learning Features – Cost & Utilization Reports 10 – 11 am
▪ 2/20 – CHITA Learning Community 3-4 pm
▪ 2/21-- MGMA Practice Webinar – What Do I Bring to the Table? Develop your value proposition
noon-1 pm
▪ 2/27 – Cost/Utilization workshop (TCPi & 1 non TCPi person/PTO)
▪ 2/27 – CO QPP Coalition Webinar The basics and guidance on how to report - noon- 1 pm
▪ 2/28 – SIM PTO Training 9-10 am – Phase 3
39
University Practice Innovation Team Contact Information
Practice Transformation – [email protected]
Learning Community - [email protected]
CQMs – [email protected]
SPLIT/Data Related – [email protected]
ENSW – [email protected]
TCPi - [email protected] or [email protected]
SIM – [email protected] or [email protected]
Invoicing – [email protected]
40
QUESTIONS?
41
