SIM PTO TRAINING - Practice Innovation Program Coloradoresourcehub.practiceinnovationco.org/wp-content/... · SIM PTO TRAINING JANUARY 24, 2018 9:00 AM 1 Call Instructions: Please

SIM PTO TRAINING

JANUARY 24, 2018 9:00 AM

1

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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)

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INTEGRATED PRACTICE ASSESSMENT TOOL (IPAT)

STEPHANIE KIRCHNER

5

6

7

DEFINITIONS OF BH COORDINATION TO INTEGRATION

MEDICAL HOME PRACTICE MONITOR

STEPHANIE KIRCHNER

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MEDICAL HOME PRACTICE MONITOR

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HEALTH INFORMATION

TECHNOLOGY ASSESSMENT (HIT)

ANDREW BIENSTOCK

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HEALTH INFORMATION TECHNOLOGY (HIT) ASSESSMENT

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CQM SPECIFIC RESPONSES

12

HIT BARRIERS RANKING

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HIE / TELEHEALTH / BROADBAND

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COHORT 2 REGISTRY ACCESS AND USE FOR CQM COUNTS

15

COHORT 2 EHR DISTRIBUTION

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MILESTONE ATTESTATION CHECKLIST (MAC)

STEPHANIE KIRCHNER

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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

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MAC RESULT SUMMARY

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REPORT BY EACH BUILDING BLOCK AND MILESTONES

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QUESTIONS

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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

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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.

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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.

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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)

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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/

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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

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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

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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

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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

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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

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University Practice Innovation Team Contact Information

Practice Transformation – Stephanie.Kirchner@ucdenver.edu

Learning Community - Kellyn.Pearson@ucdenver.edu

CQMs – Andrew.Bienstock@ucdenver.edu

SPLIT/Data Related – Lauren.Shviraga@ucdenver.edu

ENSW – Daniel.Pacheco@ucdenver.edu

TCPi - Kristin.Crispe@ucdenver.edu or Allyson.Gottsman@ucdenver.edu

SIM – Taryn.Bogdewiecz@ucdenver.edu or Heather.Stocker@ucdenver.edu

Invoicing – Natalie.Buys@ucdenver.edu

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QUESTIONS?

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