CSI/RI Extension contracts. W I T N E S S E T H: WHEREAS, the Plan and the Provider desire to enter into an agreement for the funding toward the Rhode.

CSI/RI

Extension contracts

W I T N E S S E T H:

WHEREAS, the Plan and the Provider desire to enter into an agreement for the funding toward the Rhode Island Chronic Care Sustainability Initiative (“CSI-RI”) on the terms and conditions set forth herein; and

  WHEREAS, CSI, a Multi-Payer Demonstration of the

Patient-Centered Medical Home (“PCMH”), a model of primary care that will improve the care of chronic disease and lead to better overall health outcomes for Rhode Islanders.

  NOW, THEREFORE, in consideration of the mutual

covenants, promises and undertakings hereinafter set forth and for other good and sufficient consideration, the receipt of which is hereby acknowledged, the parties hereto agree as follows:

Participating Practices

University Medicine Foundation, Inc. –Governor St. 285 Governor Street, Suites 200 and 300 Providence, RI 02906  Coastal Medical, Inc. - Smithfield 41 Sanderson Road Smithfield, RI 02917 Family Health & Sports Medicine 725 Reservoir Avenue Cranston, RI 02910  Hillside Family and Community Medicine 727 East Avenue Pawtucket, RI 02860  Thundermist Health Center - Woonsocket 450 Clinton Street Woonsocket, RI 02895

Compensation

Contract Year 1: $5.50 PMPM Contract Year 2: scaled rate based upon performance in Contract Year 1:

$5.00 PMPM if 0-1 Target is met$5.50 PMPM if Target #1 is met along with one other Target (Target #2 or Target #3)

$6.00 PMPM if 3 Targets are met Attribution methodology

Nurse Care manager – lynchpin for success

“It is the expectation that the Provider will have a dedicated NCM retained to sufficiently support these types of functions listed in Attachment A”

Nurse Care manager – lynchpin for success Attachment A: Nurse Care Manager Role and Responsibilities

Complete initial patient assessment, including a comprehensive medical, psychosocial, and functional assessment of the patient, including in the home setting if needed.

Provide detailed education about patient’s specific chronic illness, including the pathology, signs and symptoms, complications, and medications used in treatment.

Assure that screening tests are up to date.

Utilize a multi-disciplinary team approach to address opportunities to plan and coordinate care.

Establish care management plans, Interventions, treatment goals – including self-management goals, and contact schedules.

Help to arrange contact with ancillary personnel.

Promote compliance with chronic care plan.

Coordinate care and communicate with multiple providers, both within and external to the practice

Review test results and tracks outcomes.

Review patient compliance issues.

Work one-on-one with patients.

Arrange group visits.

Leverage EMR / chronic disease registry reporting to prioritize patient follow-up.

Identify and utilize cultural and community resources.

Develop reporting (to be defined) on service volume, distribution of patients by plan, and types of services provided.

Ensure open communication, regarding patient status, with physicians and office staff.

Provide training to non-RN Quality Assistant and other practice staff as needed.

Act as liaison to hospital, long-term care, specialists and home health representatives.

Attend required training and collaboration sessions [i.e., learning sessions, outcomes congress, care management collaboration meetings, and practice team meetings] as scheduled.

Train staff on motivational interviewing

Interact and coordinate with hospital and other provider staff, when applicable in caring for the patients within the Patient Centered Medical Home.

Performance targets

Target #1: Utilization Metric Target #2: Quality and member

satisfaction metric Target #3: Process Improvement metric

Target

#1:

Utilization

Metric:

CSI Providers will achieve a five percent (5%) relative reduction in hospital admissions per thousand as compared to similar, non –PCMH providers

CSI Providers will achieve ten percent (10%) relative reduction in ED visits per thousand as compared to similar, non –PCMH provider

{(or) 1% above target on one and 75% of other target}

Target #2: Quality and member satisfaction metric Provider will achieve the target on three

out of the six CSI clinical quality measures

Provider will conduct member satisfaction survey that demonstrates achievement of greater than 80% average “satisfied” or “very satisfied” rate (at end of year one)

Target #3: Process Improvement: Provider’s After Hours Protocol Participation in hospital – outpatient

transitions best practices Compacts with high volume specialists NCM activity reporting

Training and reporting

Participation in training program Chosen by steering group “Participation” determined by steering

group The Provider shall endeavor to engage

its patients in the CSI-RI program Provider and plan* agree to participate

in evaluation Plan reporting requirements…

Plan reporting requirements

Hospital Emergency Department (ED) visits / 1000 - Quarterly

Percentage of Eligible Subscribers with greater than two (2) ED visits within ninety (90) days - Quarterly

Hospital admissions / 1000 – Quarterly Subscriber Panels – Quarterly Subscriber Inpatient and ED Utilization –

Weekly Other reports as agreed to by the Plan

Plan reporting requirements (2) Beginning Quarter 5, Plan will contribute

to the RI “All Payer” data base Beginning Quarter 6, Plan will provide

Provider, if applicable, quarterly high dollar imaging activity. Plan will include the number of tests ordered by category

Beginning Quarter 5, Plan will report to Provider three (3) additional measures selected through statewide “harmonization”

Term and termination

“prompt and equitable settlement of all disputes or grievances “

“Negotiate directly and in good faith” If resolution not possible “refer to CSI RI

Steering Committee for review and comment”

Ways CSI-RI Could Fail (1)

No practices are willing to become pilot sites under tenets of the project

Plans and practices do not come to agreement on contract amendments

Champions at pilot sites are unable to convince colleagues/administration at their organizations the value of participation

Ways CSI-RI Could Fail (2)

Physicians at pilot sites are unsuccessful at transforming practices into PC-MHs

Patients do not take advantage of additional services offered by the PC-MH

Patient and physician utilization of PC-MH features does not result in improvements in outcomes

Ways CSI-RI Could Fail (3)

PC-MH supported improvements in clinical outcomes are modest, and insufficient to motivate change by others Other practices Other payers/same payers in other venues Purchasers

PC-MH supported improvements in clinical outcomes are significant, but too costly