Bi-Directional Clinical Integration Committee May 24, 2018 · 2018-08-22 · P4R Requirements-Bi-Directional Integration-Updated •Practice/Clinic Site—Project 2A-Bi Directional

Bi-Directional Clinical Integration Committee

May 24, 2018

Clinical Partner Assessment closed 5/18/18 COMPLETE

Develop Transformation Plan requirements and Tools for Regional Participants (draft by June 11) 7/2/18

Community Based Organizations defined and ‘assessment’ process determined and community partner review process underway

7/1/18

Providers Registered in PCG Portal 7/1/18

Partners submit Transformation Plans 8/17/18

Clinical Integration Committee re-chartering complete 9/1/18

SWACH implementation plan submitted to HCA 10/1/18

Establish Clinical Integration implementation cohorts (based upon partners with similar transformation plans) 12/31/018

Provider contracts/MOU executed 12/31/18

Promote whole person health and wellness within Clark, Skamania, and Klickitat counties, including focus on integration of physical and behavioral health, care for chronic disease, and addressing the opioid epidemic. Individuals receive elements of Behavioral Health and Physical Health in each setting, along the SAMSAH 6 levels of integrationcontinuum while also creating community care linkages are developed across settings.

Bi-Directional Clinical Integration Committee

Objectives

Issue: Clinical Integration workgroup does not currently have representation from all involved parties. Resolution: Plan to re-charter workgroup and membership by September

Risk: Changes from the State and risk that info will not flow to the ACH and providers timely. Mitigation: SWACH staying connected with HCA, legislature, WSHA, WA Academy of Pediatrics, Governor's office, and other ACH’s. Communicate changes to providers.

Risk: 3rd payer launching in 2019. Mitigation: SWACH available to help providers navigate and align. Including potential new payers in meetings in SWACH meetings.

Risk: Consolidation of the market - health system affiliations, payer arrangements and impact to the behavioral health market. Mitigation: SWACH available as resource to support providers in making partnership and contracting decisions

Issues/Risks

Decisions Success Metrics

Milestones Target date Status

Description Target Actual Comments

Clinical Partner Assessment Participation

100% PH est. 81%BH est. 88%

Transformation Plans complete 100%

P4R HCA Measures being defined HCA clarified/updated

Target date in jeopardy; intervention required No concerns about target dateTarget date at some risk; monitor closely

Transformation Plan touch points between 5/24 and 7/2 Provider reporting system/structure for partners and SWACH Determine Funds flow at partnering provider level-Phase 2 of Funds Flow Pre-Manage implementation for third cohort of behavioral health providers (Fall 2018)

P4R Requirements-Bi-Directional Integration-Updated

• Practice/Clinic Site—Project 2A-Bi Directional Integration

It is not required that all project 2A partnering providers use the MeHAF tool.

• MeHAF allows for a targeted understanding of Project 2A progress, and is therefore an appropriate fit for Project 2A reporting.

• ACHs are welcome to and encouraged to proceed with PCMH-A use (as well as other assessment activities), which can be complementary to the MeHAF

• ACHS are will not be required to submit the assessments to HCA.

P4R Requirements-Opioids-Updated• Practice/Clinic Site—Project 3A-Opioids

• Providers are trained on guidelines on prescribing opioids for Pain • Practice/clinic site has EHRs or other systems that provide clinical decision

support for the opioid prescribing guidelines• Mental health and SUD providers deliver acute care and recovery services for

people with OUDs• ED has protocols in place for providing overdose education, peer support and

take-home naloxone to individuals seen for opioid overdose

• CBO—Project 3A-Opioids• Organization site connects persons to MAT providers• Organization site received technical assistance to organize or expand syringe

exchange programs

MEDICAID TRANSFORMATION PROJECTS

VisionA healthy southwest

Washington region where all people have equitable access to quality whole person care and live in connected and thriving communities without barriers to wellness

Health Information Exchange / Health Information Technology

Partners across the SWACH region have consistent communication and connectivity for improved whole-person, integrated care

Opioid ResponseReduce opioid drug misuse through cross sector

collaboration in Clark, Skamania, Klickitat counties

Community Care CoordinationIndividuals with health and/or social needs connect

to quality, coordinated care interventions and services to improve their overall health outcomes

Bi-Directional Clinical IntegrationIndividuals receive Behavioral Health and Physical Health services in each setting along SAMSHAs Six

Levels of Integration

Value Based PaymentProvide support to the region to transition from a volume based payment structure to

a value based payment structure to promote whole person care

Workforce DevelopmentSupport the development of an

empowered, compassionate, and sustainable workforce that is responsive to

community health needs in our region

Trauma Informed Care

Chronic CareProvide support for effective complex care and

disease management for targets utilizing CBOs and

clinical providers to support interventions

Collaborative Shared Learning

Reduction of StigmaHealth Equity

DO

MA

IN O

NE

CARE SETTINGS

Emergency Department

Behavioral Health

Primary Care

Community Based Organizations

CO

RN

ERST

ON

ES

Community Engagement

Medicaid Transformation Project Overviews: Summary

Transformation Goals – Where & What?

SWACH

Community Clinical

Linkages

Clinical Physical & Behavioral

Health

Pharmacy

Dental

Addiction Medicine

Emergency Medical

Response

Law Enforcement

& Criminal Justice

Community Based

Organization

Emergency Department,

Acute and Post Acute

Care

• Use improvement methodology to work

in and across settings to implement

key system change and standards of

care for:– Whole Person Integrated Care

– Community and Clinical Care Coordination

– Patient outcomes, Provider Experiences,

and Access

Transformation Goals – How?

Identify the sites of care and providers those populations rely most heavily upon for care and infuse resources and supports to transform those settings.

– Quality Improvement Technical Assistance

– Value Based Payment Support

– Workforce Development

– Authentic Community Voice

– Tools and Technology for Population Health Management

– Health Equity Policies, Procedures and Capacity Building, Anti-Stigma Policies, Trauma Informed Care

– Community Clinical Linkages

– Partnership Development

Individuals receive Behavioral Health and Physical Health

services in each care setting along SAMSHAs Six Levels of

Integration

Physical Heath settings providing Behavioral Health

services

Universal Screening

BH specialist as part of clinical team

Data systems to track outcomes

Collaborative Care Model

Behavioral Health settings providing Physical Health

services

Universal Screening for physical health

Medical services on site

Enhanced coordination and collaboration with PCValue Based Purchasing

Community Clinical Linkages via Pathways

Data systems for Population Health

Management

Workforce Development

Performance Measurements

Increased Screening for BH Needs in Primary

Care Settings

PRIMARY DRIVERS SECONDARY DRIVERS CHANGE IDEAS

Increased Screening for Physical Health needs in

BH Settings

Standardized Protocols and procedures for close

loop referrals

Integrated team based services

Enhanced coordination with CBOs

Standardized HIE protocols

Performance Based Contracting

Bi-Directional Clinical Integration

Evidence Based Treatment

Shared Learning Collaboratives

Transformation Plan

• Goals of the Transformation Plan are to:o Help SWACH gain an understanding of and align with partner work towards Medicaid Transformationo Highlight the partners’ work and resource needs in order to facilitate investmento Gather information to meet HCA’s needs in the Implementation Plan

• Our guiding principles for the template include:o Provide enough structure to facilitate partner entry of key informationo Identify tactics that are important for the health of the Medicaid populationo Ensure that partners have flexibility to suggest innovative tactics

• The Transformation Plan template is under development

Project Overview: Bi-Directional Clinical Integration SWACH Lead: Daniel Smith

Aim Statement Individuals receive Behavioral Health and Physical Health services in each setting along SAMSHAs Six Levels of Integration

Target Population

All Medicaid beneficiaries (children and adults), particularly those at risk for behavioral health conditions, including mental illness and/or substance use disorder

Issues / Risks

Description Mitigation

Clinical Integration workgroup does not currently have representation from all involved parties.

Plan to re-charter workgroup and membership by September

Transformation Plan timeline is condensed Provider input at least three times during development. Build in extensions to deadlines as a contingency plan.

Changes from the State and risk that info will not flow to the ACH and providers timely

SWACH staying connected with HCA, legislature, WSHA, WA Academy of Pediatrics, Governor's office, and other ACH’s. Communicate changes to providers.

3rd payer launching in 2019 SWACH available to help providers navigate and align. Including potential new payers in meetings in SWACH meetings

Consolidation of the market - health system affiliations, payer arrangements and impact to the behavioral health market.

SWACH available as resource to support providers in making

partnership and contracting decisions

Approach and Tactics

Work with partner organizations to develop their transformation plans, which will support the regional implementation plan developed by SWACH to achieve end state

Physical Health settings providing Behavioral Health services• Universal Screening for behavioral health• BH specialist as part of clinical team• Data systems to track outcomes and population health• Collaborative Care Model• Key elements of Bree Collaborative Model• Evidence Based treatment• Community Clinical linkages developed

Behavioral Health settings providing Physical Health services• Universal Screening for physical health• Medical services onsite or enhanced care link and shared

care planning with primary care• Data systems to track outcomes• Milbank Model of Care• Key elements of Bree Collaborative Model• Evidence Based treatment• Community Clinical linkages developed

Measures

Pay for Performance (P4P) Pay for Reporting (P4R)

• All-Cause Emergency Department (ED) Visits

• Inpatient Hospital Utilization• Follow up after ED visit for mental

health• Follow up after hospitalization for

mental illness• Follow-up after ED visit for alcohol or

drug dependence• Mental health treatment penetration• Percent homeless• Plan All-Cause Readmissions• Substance use disorder treatment

penetration• Child and Adolescents’ Access to

Primary Care Practitioners• Comprehensive Diabetes Care: Eye

Exam performed• Comprehensive Diabetes Care: HbA1c

testing • Comprehensive Diabetes Care:

Medical Attention for Nephropathy• Medication Management for People

with Asthma (5-64 years)• Antidepressant Medication

Management

• Assessment of integration of physical and behavioral health care

G

Project Overview: Bi-Directional Clinical Integration – Partner and Community Engagement

Partner Engagement

Clinical Integration Committee includes representatives from:• Catholic Community Services• Center for Community Health and Evaluation• Child and Adolescent Clinic• Children’s Center• Community Health Plan of Washington• Comprehensive Healthcare• Daybreak Youth Services• Klickitat Valley Health• Kaiser • Legacy Health Services• Lifeline Connections• Molina Healthcare• NAMI SW Washington• PeaceHealth• Providence Health and Services• Qualis• Rose Clinic• SeaMar Community Health Services• Skamania County• Skyline Hospital and Family Medicine• The Vancouver Clinic

Community Engagement

• Our approach: Engage the community where they are through:• SWACH initiated community discussions• Attendance at existing community groups• Launch of a Community Voices Council

Stakeholder Review

• Regular updates will be shared with RHIP and the Board

• RHIP will have opportunities to review and provide input prior to taking major final products to the Board • e.g. Transformation Plan, Implementation

Plan, Funds Flow, Workgroup Charters

Project Overview: Opioid Response SWACH Lead: Eric McNair Scott

Aim Statement Reduce opioid drug misuse through cross sector collaboration in Clark, Skamania, Klickitat counties

Target Population

Medicaid beneficiaries, including youth, who use, misuse, or abuse prescription opioids and/or heroin

Issues / Risks

Description Mitigation

Waiting on process to fund initial pilot ideas which are ready to move forward; risk of partner disengagement if delayed

Working on funds flow model and initial grant process

Need plan to support and sustain momentum of Opioid task force, including definition of the role of SWACH staff

Working with Public Health, ACES Action Alliance, and provider champions on longer term model

Approach and Tactics

Work with partner organizations to develop their transformation plans, which will support the regional implementation plan developed by SWACH to achieve end state

Prevention Strategies• Disposal and secure storage of opioids• Use of PMP• Training and support for providers• TeleHealth (i.e. Project Echo)

OD Treatment Strategies• Increased distribution of naloxone• Increased access to naloxone

Treatment Strategies• Team model of engagement and care• Number of MAT providers in care settings outside of SUD

(Primary Care, Hospitals, ED, Specialists, etc)• Increased MAT initiation sites (Primary Care, ED’s,

Hospitals, HRC, etc)• Increased Tx access points in clinical and community

settings

Recovery Strategies• Increased peer support services• Peer access in clinical settings

Measures

Pay for Performance (P4P) Pay for Reporting (P4R)

• All-Cause Emergency Department (ED) Visits

• Inpatient Hospital Utilization

• Patients on high-dose chronic opioid therapy

• Patients with concurrent sedatives prescriptions

• Substance use disorder treatment penetration (opioids)

• Providers are trained on guidelines on prescribing opioids for Pain

• Practice/clinic site has EHRs or other systems that provide clinical decision support for the opioid prescribing guidelines

• Mental health and SUD providers deliver acute care and recovery services for people with OUDs

• ED has protocols in place for providing overdose education, peer support and take-home naloxone to individuals seen for opioid overdose

• Organization site connects persons to MAT providers

• Organization site received technical assistance to organize or expand syringe exchange programs

G

Project Overview: Opioid Response – Partner and Community Engagement

Partner Engagement

Opioid Crisis Response Committee includes representatives from:• Clark County• Clark County Public Health• Clark County Sheriff’s Office• Columbia River Mental Health Services• Community Health Plan of Washington• Community Voices are Born• Comprehensive Healthcare• Cowlitz Tribal Treatment• ESD112• KLASAC• Klickitat Valley Health• League of United Latin American Citizens• Lifeline Connections• Molina Healthcare• Northshore Medical• PeaceHealth• SeaMar Community Health Services• Share Vancouver• United Health Care

• Current email distribution includes 80 contacts • Anticipate moving forward with an Opioid task force and close

alignment with the Clinical Integration Committee

Community Engagement

• Our approach: Engage the community where they are through:• SWACH initiated community discussions• Attendance at existing community groups• Launch of a Community Voices Council

• Holding three events in May focused on:• Opioid prevention • Treatment• Addressing stigma

Stakeholder Review

• Regular updates will be shared with RHIP and the Board

• RHIP will have opportunities to review and provide input prior to taking major final products to the Board • E.g. Transformation Plan, Implementation

Plan, Funds Flow, Workgroup Charters

Project Overview: Chronic Care SWACH Lead: Daniel Smith

Aim Statement Provide support for effective complex care and disease management for targets utilizing CBOs and clinical providers to support interventions

Target Population

Medicaid beneficiaries (adults and children) with, or at risk for, arthritis, cancer, chronic respiratory disease (asthma), diabetes, heart disease, obesity and stroke, with a focus on those populations experiencing the greatest burden of chronic disease in the region.

Issues / Risks

Description Mitigation

Lack of central hub for chronic disease self management education

Consider role of SWACH and potential community needs in implementation planning

Ensuring alignment with current initiatives and current contracts

Focus with providers on enhancing current interventions and supporting scaling to Medicaid

Approach and Tactics

Work with partner organizations to develop their transformation plans, which will support the regional implementation plan developed by SWACH to achieve end state

Chronic Disease Self Management Education programs• Partner commitment and resources to support patient

engagement• Best practices for patient retention• Central coordinating entity• Provider, environment, and patient readiness• Community clinical linkages to education and services

Community Paramedicine programs• ED / Hospital diversion and community education• Transition – follow up in community after acute episodes• Best and highest use of EMS resources• Community Health Worker developments

Measures

Pay for Performance (P4P) Pay for Reporting (P4R)

• All-Cause Emergency Department (ED) Visits

• Inpatient Hospital Utilization• Mental health treatment penetration• Substance use disorder treatment

penetration• Child and Adolescents’ Access to Primary

Care Practitioners• Comprehensive Diabetes Care: Eye Exam

performed• Comprehensive Diabetes Care: HbA1c

testing • Comprehensive Diabetes Care: Medical

Attention for Nephropathy• Medication Management for People with

Asthma (5-64 years)• Antidepressant Medication Management • Statin Therapy for Patients with

Cardiovascular Disease

• None

G

Project Overview: Chronic Care – Partner and Community Engagement

Partner Engagement

Chronic Care is included in the Clinical Integration Committee, which includes representatives from:• Catholic Community Services• Center for Community Health and Evaluation• Child and Adolescent Clinic• Children’s Center• Community Health Plan of Washington• Comprehensive Healthcare• Daybreak Youth Services• Klickitat Valley Health• Legacy Health Services• Lifeline Connections• Molina Healthcare• NAMI SW Washington• PeaceHealth• Providence Health and Services• Qualis• SeaMar Community Health Services• Skamania County• Skyline Hospital• The Vancouver Clinic

Community Engagement

• Our approach: Engage the community where they are through:• SWACH initiated community discussions• Attendance at existing community groups• Launch of a Community Voices Council

Stakeholder Review

• Regular updates will be shared with RHIP and the Board

• RHIP will have opportunities to review and provide input prior to taking major final products to the Board • E.g. Transformation Plan, Implementation

Plan, Funds Flow, Workgroup Charters

Project Overview: Community Care Coordination SWACH Lead: Louise Nieto

AimStatement

Individuals with health and/or social needs connect to quality, coordinated care interventions and services to improve their overall health outcomes

Target Population

Medicaid beneficiaries (adults and children) with one or more chronic disease or condition (e.g. arthritis, cancer, chronic respiratorydisease, diabetes, obesity, stroke), or mental illness/depressive disorders, or moderate to severe substance use disorder and at least one risk factor (e.g., unstable housing, food insecurity, high EMS utilization)

Issues / Risks

Description Mitigation

Shared services contract with CCS on behalf of multiple ACH’s

Seeking collective alignment with other ACHs • Program Evaluation• Data • Security• Programmatic• Policy and Advocacy

Track closely and participate in the process; expect this to result in more cost efficient contract

Legal and technology expertise needed for Pathways Hub contracting process

Collective alignment with ACHs for legal and technology resources. Formalize shared services agreements for IT security

Approach and Tactics

Work with partner organizations to develop their transformation plans, which will support the regional implementation plan developed by SWACH to achieve end state

Pathways Community HUB• Reduce duplication of care coordination efforts• Measure and track outcomes• Value Based Paying contracting with MCO’s and payors

Support Rural care coordination needs

Support current coordination and referral efforts, e.g. 2-1-1

Measures

Pay for Performance (P4P) Pay for Reporting (P4R)

• All-Cause Emergency Department (ED) Visits

• Inpatient Hospital Utilization• Follow up after ED visit for mental health• Follow up after hospitalization for mental

illness• Follow-up after ED visit for alcohol or drug

dependence• Mental health treatment penetration• Percent homeless• Plan All-Cause Readmissions• Substance use disorder treatment

penetration

• None

Y

Project Overview: Community Care Coordination – Partner and Community Engagement

Partner Engagement

Community Care Coordination Workgroup includes representatives from:• 211 Info• Area Agency on Aging and Disabilities• Beacon Health Options• Community Health Plan of Washington• Community Voices are Born• Council for the Homeless• DSHS• EOCF of Washington• Free Clinic of SW Washington• Klickitat Valley Health• Legacy Health Services• Molina Healthcare• Northwest Justice Project• PeaceHealth• Providence Health and Services• SeaMar Community Health Services• Skamania County• United Health Care• Vancouver Housing Authority

• Engaged potential partner organizations and community on Pathways Hub model in Fall 2017 through RFA and education sessions for Care Coordinating Agencies (CCA) and Referral Agencies (RA)

Community Engagement

• Our approach: Engage the community where they are through:• SWACH initiated community discussions• Attendance at existing community groups• Launch of a Community Voices Council

Stakeholder Review

• Regular updates will be shared with RHIP and the Board

• RHIP will have opportunities to review and provide input prior to taking major final products to the Board • E.g. Transformation Plan, Implementation

Plan, Funds Flow, Workgroup Charters

Measure DateSWACH

PerformanceStatewide

PerformanceRelative to

State

All-cause Emergency Department Utilization (per 1,000 member months) * MY 2017 53 50

Antidepressant Medication Management – Acute MY 2017 51% 49%

Antidepressant Medicaid Management – Continuation MY 2017 36% 33%

Child and Adolescent Access to Primary Care (12-24 months) MY 2017 89% 93%

Child and Adolescent Access to Primary Care (2-6 years) MY 2017 81% 84%

Child and Adolescent Access to Primary Care (7-11 years) MY 2017 86% 89%

Child and Adolescent Access to Primary Care (12-19 years) MY 2017 86% 90%

Comprehensive Diabetes Care: Eye Exam MY 2017 38% 31%

Comprehensive Diabetes Care: HbA1c Testing MY 2017 83% 84%

Comprehensive Diabetes Care: Medical Attention for Nephropathy MY 2017 86% 86%

Follow up after Discharge from ED for Alcohol or Other Drug Dependence (7 day) MY 2017 31% 23%

Follow up after Discharge from ED for Alcohol or Other Drug Dependence (30 day) MY 2017 40% 31%

Follow up after Discharge from ED for Mental Health (7 day) MY 2017 58% 60%

Follow up after Discharge from ED for Mental Health (30 day) MY 2017 72% 71%

Follow up after Hospitalization for Mental Health (7 day) MY 2017 84% 80%

Follow up after Hospitalization for Mental Health (30 day) MY 2017 91% 87%

Inpatient Hospital Utilization (per 1,000 member months) * MY 2017 63 65

Pay for Performance (P4P) Measure DashboardMeasurement Period: July 2016 – June 2017 (MY 2017)

Legend

Data Sources

Data sources used include:Healthier Washington Data Dashboard + RDA Measure Decomposition Reports

SWACH performance is at or above statewide

SWACH performance is below statewide

SWACH is the lowest performing ACH region

May 2018

Improvement over Self

Gap to Goal

*lower rate indicates better performance

Legend

About P4P Measures

The first year ACHs will be held accountable for P4P measures is CY 2019. Performance in CY 2019 will be compared to baseline (CY 2017). Official ACH baseline performance will be calculated for CY 2017; the state intends to release baseline results in October 2018. Official improvement targets and benchmarks for measures will also be released in October 2018. SWACH performance reported here is preliminary.

Benchmarks for gap to goal measures will likely be the national Medicaid 90th percentile; ACHs must close the gap between baseline and benchmarks by 10%. Targets for improvement over self measures will be based on 1.9% improvement from baseline.

Future updates of the P4P Measure Dashboard will include official baseline and benchmarks / improvement targets. The P4P Measure Dashboard will be updated quarterly where possible; however, some measures are only available annually or semi-annually.

SWACH performance is at or above statewide

SWACH performance is below statewide

SWACH is the lowest performing ACH region

May 2018

Measure DateSWACH

PerformanceStatewide

PerformanceRelative to

State

Medication Management for People with Asthma MY 2017 34% 31%

Mental Health Treatment Penetration MY 2017 47% 46%

Percent Homeless * MY 2017 4% 5%

Plan All-Cause Readmission* MY 2017 11% 14%

Substance Use Disorder Treatment Penetration MY 2017 31% 28%

Patients on High Dose Chronic Opioid Therapy

Data for these P4P measures are not yet available. Patients with Concurrent Opioid and Sedative Prescriptions

Statin Therapy for Patients with Cardiovascular Disease

Substance Use Disorder Treatment Penetration (Opioids)

Improvement over Self

Gap to Goal

*lower rate indicates better performance

Pay for Performance (P4P) Measure DashboardMeasurement Period: July 2016 – June 2017 (MY 2017)