SIM PTO TRAINING FEBRUARY 27, 2019 9:00 AM Call Instructions: - - PowerPoint PPT Presentation

▶
sim pto training february 27 2019 9 00 am
SMART_READER_LITE
LIVE PREVIEW

SIM PTO TRAINING FEBRUARY 27, 2019 9:00 AM Call Instructions: - - PowerPoint PPT Presentation

Dec 11, 2022 222 likes •608 views

SIM PTO TRAINING FEBRUARY 27, 2019 9:00 AM 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

slide-1
SLIDE 1

SIM PTO TRAINING FEBRUARY 27, 2019 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
slide-2
SLIDE 2

COLORADO SIM PTO TRAINING

REVIEW BB8, BB9 & BB10 REVIEW COST/UTILIZATION KEY DRIVER DIAGRAM

FEBRUARY 27, 2019

Presenters: Marjie Harbrecht, MD Stephanie Kirchner, MSPH, RD Kelly Pearson, RN, MSN Lauren Shviraga

slide-3
SLIDE 3

TRAINING OBJECTIVES

▪ Invoicing in SPLIT ▪ Review BB8, BB9, BB10 – moving toward behavioral health integration. ▪ Review Cost/Utilization Driver Diagram ▪ Upcoming Events and Due Dates for Assessments

3

slide-4
SLIDE 4

INVOICING IN SPLIT

LAUREN SHVIRAGA

SPLIT PROJECT COORDINATOR & SIM RESEARCH ASSISTANT

4

slide-5
SLIDE 5

INITIATIVE ASSESSMENTS & DUE DATES

5

Task/Assessment Name Assessment Timeframe

Final Assessments – Part 1

Integrated Practice Assessment Tool (IPAT) Health Information Technology Assessment (HIT) Clinician & Staff Experience Survey (CSES)

March 1st – March 31st Updates to SIM CQM Reporting for Q4 – 2018

(Opportunity for practices to update CQM data for Payer Reports, if issues were encountered during the Q4-2018 reporting period)

Updated Data Due March 15th SIM CQM Reporting for Q1 - 2019 April 1st – April 30th Final Assessments – Part 2

Medical Home Practice Monitor (Monitor) Milestone Attestation Checklist (MAC) SIM Practice Closeout Questions (Closeout)

April 1st – May 15th PF & CHITA Monthly Field Notes

(Last Monthly Field Note due June 8, 2019)

Report Monthly thru May/June 2019

(Submit within one week of the last day of the month – Last field note will document work completed after May 15th)

Final Practice Site Progress Report

(Previously known as ‘Final Field Note’ and to be completed by PFs & CHITAs)

April 1st – May 15th

slide-6
SLIDE 6

CQM REPORTING FOR Q4 – 2018

  • Practice sites that were unable to submit CQMs due to a vendor or other issue

were required to complete the CQM reporting survey in SPLIT by January 31st

  • In the survey select ‘Unable to Report this Quarter’ response for CQMs usually reported
  • In the survey select ‘EHR vendor issue’ on the last page and supply details related to the issue(s)

and include a date when the practice site anticipates being able to report Q4 – 2018 CQMs

  • Practice sites that are unable to report CQM due to a vendor issue will be able

to update reported the CQM values used in SIM Payer Reports until March 15th

  • Reminder – failing to submit CQMs or failing to indicate that they are unable

to by January 31st , may prevent a practice site from receiving payment

6

slide-7
SLIDE 7

PTO INVOICING PROCESS

Practice Transformation Organizations (PTOs) are responsible for submitting invoices to the Practice Innovation Program team upon completion of all SIM reporting activities/assessments for all practice sites assigned to the PTO. Required deliverables can be referenced in the appropriate PF or CHITA Statement of Work (SOW). To assist PTOs in tracking the completion of deliverables a ‘PTO Deliverable Completion Reports’ will be posted in SPLIT on a biweekly schedule March 29th to June 10th. Listed are important due dates, additional submission instructions, and PTO invoices/payments details:

  • All SIM work and activities related to PTO deliverables must be completed no later than June 8, 2019.
  • To receive payment for completed work PTO invoices must be submitted no later than June 30, 2019.
  • Completion reports will be generated and posted in SPLIT on Fridays biweekly starting March 29, 2019.
  • The final completion reports for work completed will be generated and posted in SPLIT on June 10, 2019.
  • PTO invoices will be created and submitted by the PTO, and are not generated by or available in SPLIT.
  • PTO invoices should be submitted by email to Natalie.Buys@ucdenver.edu.
  • Payments are typically processed and issued within 30 days of submission.

7

slide-8
SLIDE 8

PTO COMPLETION REPORTS

Completion reports will summarize the following activities by practice site for PTOs:

  • Practice Site Assessments
  • CQM Reporting
  • Monthly Field Notes
  • Deliverable Completion

8

slide-9
SLIDE 9

9

slide-10
SLIDE 10

QUESTIONS?

Contact the Support Team http://bit.ly/PracticeInnovationSupport

10

slide-11
SLIDE 11

REMAINING BUILDING BLOCKS & MILESTONES

PHASE 4: FEB 1 – JUNE 30, 2019 COHORTS 2 & 3

▪ BB8 – Prompt access to care, including BH ▪ BB9 – Care coordination for primary care/BH ▪ BB10 – Fully integrated BH/whole person care

11

slide-12
SLIDE 12

PHASED APPROACH TIMELINE: COHORT 2 - YEAR 2

12

slide-13
SLIDE 13

PHASED APPROACH TIMELINE: COHORT 3 – YEAR 1

13

slide-14
SLIDE 14

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 INFRASTRUCTURE

BB1 - 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 patients from 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

slide-15
SLIDE 15

MOVING TOWARD FULL BH INTEGRATION

BB8 - BB9 - BB10

COHORT 3 - YEAR 1 COHORT 2 - YEAR 2

15

slide-16
SLIDE 16

BUILDING BLOCK 8 - PROVIDE PROMPT ACCESS TO CARE, INCLUDING BH CARE

Goal: Practice (at minimum), has established collaborative care management agreements with BH providers in the community and members of the care team can articulate how to use those agreements. Practice has ability to share clinical data based on collaborative care management agreements with BH providers bi-directionally within 7 days.

slide-17
SLIDE 17

MAKING CONNECTIONS

How the Regional Health Connector workforce can support you

February 28, 2017

slide-18
SLIDE 18

COHORT 3 BB8.Y1 - PROVIDE PROMPT ACCESS TO CARE, INCLUDING BH

  • 1. Practice representative with 24/7 EHR access
  • 2. Assess referral pathways and after-hours BH

support (work with RHCs)

  • 3. Identify data sources and technology needed for

bi-directional data sharing

18

slide-19
SLIDE 19

COHORT 2 BB8.Y2 - PROVIDE PROMPT ACCESS TO CARE, INCLUDING BH

  • 1. Establish a collaborative agreement with at least
  • ne BH health provider
  • 2. Develop plan for bi-directional data sharing with

BH health provider

19

slide-20
SLIDE 20

BUILDING BLOCK 9 - COMPREHENSIVE CARE COORDINATION FOR PRIMARY CARE/BH

Goal: Practice has reduced total cost of care while maintaining or improving quality of care for patients, including those with depression and substance abuse disorders, compared with non-SIM practices.

20

slide-21
SLIDE 21

COHORT 3 BB9.Y1 - COMPREHENSIVE CARE COORDINATION FOR PRIMARY CARE/BH

1.Identify total cost of care for panel, and subset

  • f those with BH conditions

2.Identify/implement policy and procedures for timely follow-up for ED visits/hospital admissions

21

slide-22
SLIDE 22

COHORT 2 BB9.Y2 - COMPREHENSIVE CARE COORDINATION FOR PRIMARY CARE/BH

1.Contact 50% of patients within 7 days of hospitalization/ED visit, including medication reconciliation 2.Identify cost drivers for patients with BH conditions and incorporate in QI processes 3.Create/report a measurement to assess impact and guide improvement on at least one of the following:

  • Notification of ED visit in timely fashion
  • Completed medication reconciliation within 72 hours
  • Notification of admission and clinical information exchange at time of admission
  • Information exchange between primary care and specialty care related to referrals

22

slide-23
SLIDE 23

KEY COST DRIVERS

▪ Avoidable Emergency Department Visits

▪ Increase Access to Primary Care/BH ▪ Patient Education/Engagement ▪ Care Coordination/Care Management

▪ Hospital Admissions/Readmissions

▪ Increase Access to Primary Care/BH ▪ Patient Education/Engagement ▪ Care Coordination/Care Management

▪ Referrals and Coordination of Care Issues

▪ Specialists/Behavioral Health/Hospitals ▪ Unnecessary tests, pharmacy costs ▪ Not using available community resources (i.e., Pharmacists, BH related, etc)

23

slide-24
SLIDE 24

AVOIDABLE ER VISITS AND HOSPITALIZATIONS

▪ Increase Access to Primary Care/BH

▪ Understand and address supply/demand issues ▪ Provide after-hours coverage ▪ Build bridge with hospitalists/care coordinators at hospital ▪ Follow up after ER visit/hospitalization

▪ Patient Education/Engagement

▪ Education materials re PCMH, services offered, after hours coverage, urgent care ▪ Ensure patients understand their conditions and what to do when in trouble (Action Plan). ▪ Provide patients copy of care plan, help them set/achieve self-management goals, use shared decision making ▪ Assess patient’s adherence to medication - ensure they understand reasons for and how to take their medications ▪ Use teachable moments whenever possible ▪ Have patients notify PCP when they go to specialist, ER, Hospital, urgent care, etc.

24

slide-25
SLIDE 25

CARE COORDINATION/CARE MANAGEMENT

▪ Care teams identify/assist high risk patients to prevent ED/hospital admissions. Help patients create/implement care plans using motivational interviewing or other techniques for:

▪ complex chronic disease management (DM, CVD, COPD, CHF , Asthma) ▪ special needs or need for social support systems ▪ frequent ED/hospital visits ▪ financial considerations for meds/appointments or work issues ▪ medication reconciliation and adherence

▪ F/U after ER/hospital admission to prevent readmissions ▪ Coordinate care for transitions between healthcare facilities

25

slide-26
SLIDE 26

BUILDING BLOCK 10 - PROVIDE FULLY INTEGRATED BH FOR WHOLE-PERSON CARE

Goal: Patient BH outcomes are systematically measured over time and treatment is adjusted as needed, as measured by outreach, registry and other information readily available for purpose of monitoring and adjustment.

26

slide-27
SLIDE 27

COHORT 3 BB10.Y1 - PROVIDE FULLY INTEGRATED BH CARE FOR WHOLE-PERSON CARE

  • 1. Use identified referral pathways for BH needs

(including available after-hours support and a representative with 24/7 EHR access).

  • 2. Systematically measure and track BH outcomes
  • 3. Develop care plans that include patient actions to

manage BH conditions

27

slide-28
SLIDE 28

COHORT 2 BB10.Y2 - PROVIDE FULLY INTEGRATED BH CARE FOR WHOLE-PERSON CARE

  • 1. Systematically measure and track patient BH outcomes
  • 2. Document/implement protocols to identify and manage

care for high-risk BH populations

  • 3. Identify/implement at least 2 opportunities to adjust

protocols to improve BH health status of patients

  • 4. Demonstrate advanced access to BH services

28

slide-29
SLIDE 29

29

slide-30
SLIDE 30

BH RELATED RESOURCES

▪ https://www.cms.gov/Medicare/Medicare-Fee-for-Service Payment/PhysicianFeeSched/Care-Management.html ▪ https://www.integration.samhsa.gov/financing/billing-tools ▪ https://aims.uw.edu/sites/default/files/CMS_FinalRule_BHI_CheatSheet.pdf ▪ https://www.colorado.gov/pacific/hcpf/accphase2 ▪ https://www.aafp.org/practice-management/transformation/cpc-plus.html

slide-31
SLIDE 31

UPCOMING DUE DATES

31

Reporting Activity Cohort 2 Cohort 3

SIM CQM Reporting Q4

(Cohort 1, 2 & 3 Practices). Required for those using extended CHITA services

Jan 31, 2019 Jan 31, 2019 Final Assessments – Part 1

(IPAT , HIT , Clinician/Staff Survey)

March 1, 2019 – April 1, 2019 March 1, 2019 – April 1, 2019 Final Assessments – Part 2

((Monitor, MAC, Practice Closeout Survey & Practice Final Progress Report (Previously referred to as “Final Field Note”))

April 1, 2019 – May 15, 2019 April 1, 2019 – May 15, 2019 SIM CQM Reporting Q1 2019

(Cohort 1 2& 3 Practice Sites)

April 30, 2019 April 30, 2019 PF Field Notes Report Monthly Report Monthly CHITA Field Notes Report Monthly Report Monthly

slide-32
SLIDE 32

32

COHORT 3 - REDUCED TIME OVERALL COHORT 2 - SELECT 2 ADDITIONAL MILESTONES FOCUS ON “TROUBLE” AREAS SOONER THAN LATER! USE MAC TO GUIDE WHERE TO CONCENTRATE EFFORTS, DON’T WAIT UNTIL FORMAL EVALUATION

REMINDER: TIMELINES ARE SHORT

slide-33
SLIDE 33

PTOS AND PRACTICES

THURSDAY, MARCH 7: DENVER METRO SIM COLLABORATIVE LEARNING SESSION REGISTER & DRAFT AGENDA (REGISTRATION CLOSES 2/28/19) FRIDAY, MARCH 8: WESTERN SLOPE SIM COLLABORATIVE LEARNING SESSION REGISTER & DRAFT AGENDA MONDAY, MARCH 18: ALTERNATIVE PAYMENT MODEL CONVENING 12:00 PM – 4:30 PM DEVELOPED FOR TCPI PRACTICES AND PTOS BUT ALL ARE WELCOME REGISTER

slide-34
SLIDE 34

FUTURE PTO EVENTS

February 2019 ▪ 2/28 – SPLIT Office Hours: 9 - 10 am March 2019

  • 3/7 – Virtual Colorado MAT Learning Forum 12:30 – 1:30 pm
  • 3/7 – SIM CLS Denver; 8 am – 4 pm
  • 3/8 – SIM CLS Grand Junction; 9 am – 4 pm
  • 3/12 – TCPi PTO Touchbase; 9-10 am
  • 3/15 – QPP Coalition; MIPS 101 11 am - noon
  • 3/18 – TCPi APM Convening Mtg
  • 3/19 – CHITA Learning Community; 3-4 pm
  • 3/20 -- MGMA Practice Webinar; 12-1 pm
  • 3/21 -- Learning Features Call; Value Based Payment/Cost & Utilization:10 -11 am

34

slide-35
SLIDE 35

University Practice Innovation Team Contact Information

Practice Transformation – Stephanie.Kirchner@ucdenver.edu Learning Community - Kellyn.Pearson@ucdenver.edu CQMs & SPLIT/Data Related – support-split@ucdenver.edu ENSW & IT MATTTRs 2 – Daniel.Pacheco@ucdenver.edu TCPi - Kristin.Crispe@ucdenver.edu or Allyson.Gottsman@ucdenver.edu SIM – PracticeInnovation@ucdenver.edu Invoicing – Natalie.Buys@ucdenver.edu All Other Questions – PracticeInnovation@ucdenver.edu

35

slide-36
SLIDE 36

QUESTIONS?

36