SIM PTO TRAINING NOVEMBER 28, 2018 9:00 AM Call Instructions: - - PowerPoint PPT Presentation

SIM PTO TRAINING NOVEMBER 28, 2018 9:00 AM

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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 TRAINING

BB3 – EMPANELING THE POPULATION BB6 – RISK STRATIFICATION – ACTIVE MANAGEMENT BB7 – SCREENING AND LINKING FOR BH/SUD

NOVEMBER 28, 2018

Presenters: Marjie Harbrecht, MD Stephanie Kirchner, MSPH, RD Kelly Pearson, RN, MSN Andrew Bienstock, MHA

TRAINING OBJECTIVES

▪ Review Assessment Results for Cohort 2 – Year 1 ▪ Review “Good Standing”, invoicing, and other associated issues ▪ PHASE 3 – Population Management

▪ BB3 – Empanel Patient Population ▪ BB6 – Risk Stratify and Actively Manage Patients ▪ BB7 – Screen and Link to BH/SUD Resources

▪ Upcoming Events and Due Dates

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COHORT 2 - YEAR 1 ASSESSMENT RESULTS

ANDREW BIENSTOCK

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CLINICIAN & STAFF SURVEYS: COHORT 2 - YEAR 1

MAC RESULTS: COHORT 2 - YEAR 1

GOOD STANDING, INVOICING AND OTHER ASSOCIATED ISSUES

ANDREW BIENSTOCK

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GOOD STANDING: COHORT 2 - YEAR 2

▪ SIM-Only Practices:

▪ Achieve a rating of (4) for at least 75% of activities in Year 2 Building Blocks 1, 2, 3, 4, and 7, and any two additional Year 2 building blocks (Building Blocks 5, 6, 8, 9, and 10) and a rating of (3) for remainder of activities.

▪ CPC+ Practices:

▪ Achieve a rating of (4) for at least 75% of activities in Year 2 Building Blocks 1, 2, 3, 4, 7, 8, 9 and 10, and a rating of (3) for remainder of activities.

NOTE: Though not required for good standing, Cohort 2 practices should be scored on Year 1 BBs/Milestones on the MAC at baseline and at end of project period.

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GOOD STANDING: COHORT 3

▪ SIM-Only Practices:

▪ Achieve a rating of (4) for at least 50% of activities in Year 1 Building Blocks 1, 2, 3, 4, and 7, and a rating of (2) or (3) for the remainder of the activities.

▪ CPC+ Practices:

▪ Achieve a rating of (4) for at least 50% of activities in Year 1 Building Blocks 1, 2, 3, 4, 7, 8, 9 and 10, and a rating of (2) or (3) for the remainder of the activities.

NOTE: Though not required for good standing, Cohort 3 practices should be scored on Year 2 BBs/Milestones on the MAC.

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ACHIEVEMENT-BASED PAYMENTS: COHORT 2 - YEAR 2

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Tier 1: If practice achieves the following scores on the MAC they will receive the achievement-based payments for all Year 2 Building Blocks: ▪ SIM-Only Practices:

▪ Achieve a rating of (4) for at least 75% of activities in Year 2 - BBs 1, 2, 3, 4, & 7 and any two additional Year 2 building blocks (BBs 5, 6, 8, 9, & 10) and rating of (3) for remainder of activities.

▪ CPC+ Practices:

▪ Achieve rating of (4) for at least 75% of activities in Year 2 BBs 1, 2, 3, 4, 7, 8, 9 & 10, and a rating of (3) for remainder of activities.

Tier 2: If practice does not reach requirements in Tier 1, they can still be eligible for achievement-based payments for all BBs if they meet the following:

▪ SIM-Only Practices: ▪ Achieve rating of (4) for at least 75% of activities in Year 2 - BBs 1, 4 & 7, and rating of (3) for remainder. ▪ CPC+ Practices: ▪ Achieve rating of (4) for at least 75% of activities in Year 2 - BBs 4, 7, and two of BBs 8, 9 or 10, and rating of (3) for remainder. ▪ *CPC+ Practices only select two building blocks to work on from 8, 9, and 10. Because of small numbers of milestones in individual building blocks, we have combined BBs for SIM-Only and CPC+ Practices.

Tier 3: If a practice does not receive their achievement-based payment based on the criteria in Tiers 1 or 2 we will default to the following methodology:

▪ SIM-Only Practices: ▪ Achieve rating of (4) for at least 75% of activities in Year 2 BB1, and rating of (3) for remainder of activities = Payment for BB1. ▪ Achieve rating of (4) for at least 75% of activities in Year 2 BB4, and rating of (3) for remainder of activities = Payment for BB4. ▪ Achieve rating of (4) for at least 75% of activities in Year 2 BB7, and rating of (3) for remainder of activities = Payment for BB7. ▪ CPC+ Practices: ▪ Achieve rating of (4) for at least 75% of activities in Year 2 BB4, and rating of (3) for remainder of activities = Payment for BB4. ▪ Achieve rating of (4) for at least 75% of activities in Year 2 BB7, and rating of (3) for remainder of activities = Payment for BB7. ▪ Achieve rating of (4) for at least 75% of activities in at least two of Year 2 - BBs 8, 9, or 10, and rating of (3) for remainder of activities = Payment for those Building Blocks.

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ACHIEVEMENT-BASED PAYMENTS: COHORT 2 - YEAR 2

ACHIEVEMENT-BASED PAYMENTS: COHORT 3

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Tier 1: If a practice achieves the following scores on the MAC they will receive the achievement-based payments for all Building Blocks:

• SIM-Only Practices:

 Achieve rating of (4) for at least 50% of activities in Year 1 - BBs 1, 2, 3, 4, & 7, and rating of (2) or (3) for remainder.

• CPC+ Practices:

 Achieve rating of (4) for at least 50% of activities in Year 1 - BBs 1, 2, 3, 4, 7, 8, 9 & 10, and a rating of (2) or (3) for remainder.

ACHIEVEMENT-BASED PAYMENTS: COHORT 3

Tier 2: If a practice does not reach the requirements in Tier 1, they can still be eligible for the achievement-based payments for all Building Blocks if they meet the following requirements:

• SIM-Only Practices:
• Achieve rating of (4) for at least 50% of activities in Year 1 - BBs 1, 4 & and 7, and rating of (2) or (3) for remainder.
• CPC+ Practices:
• Achieve rating of (4) for at least 50% of activities in Year 1 - BBs 4, 7, & two BBs from 8, 9 and 10, and a rating of (2) or (3) for

remainder. ▪ *CPC+ Practices only select two BBs to work on from 8, 9, and 10. Because of small numbers of milestones in individual building blocks we have combined building blocks for SIM-Only Practices, and CPC+ Practices. Tier 3: If a practice does not receive their achievement-based payment based on the criteria in tiers 1 or 2 we will default to the following methodology:

• SIM-Only Practices:

 Achieve rating of (4) for at least 50% of activities in Year 1 BB1, and rating of (2) or (3) for remainder of activities = Payment for BB1.  Achieve rating of (4) for at least 50% of activities in Year 1 BB4, and rating of (2) or (3) for remainder of activities = Payment for BB4.  Achieve rating of (4) for at least 50% of activities in Year 1 BB7, and rating of (2) or (3) for remainder of activities = Payment for BB7.

• CPC+ Practices:

 Achieve rating of (4) for at least 50% of activities in Year 1 BB4, and rating of (2) or (3) for remainder of activities = Payment for BB4.  Achieve rating of (4) for at least 50% of activities in Year 1 BB7, and rating of (2) or (3) for remainder of activities = Payment for BB7.  Achieve rating of (4) for at least 50% of activities in at least two of Year 1 - BBs 8, 9, or 10, and rating of (2) or (3) for remainder of activities = Payment for those Building Blocks.

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DOCUMENTS FOR ACHIEVEMENT BASED PAYMENTS AVAILABLE AT: COHORT 2 YEAR 2:

HTTP://RESOURCEHUB.PRACTICEINNOVATIONCO.ORG/2018/11/ 27/PRACTICE-ACHIEVEMENT-BASED-PAYMENT-COHORT-2- YEAR-2/

COHORT 3:

HTTP://RESOURCEHUB.PRACTICEINNOVATIONCO.ORG/2018/11/ 27/PRACTICE-ACHIEVEMENT-BASED-PAYMENT-COHORT-3/

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COHORT 3 & COHORT 2 – YEAR 2 MILESTONES

PHASE 3 MANAGING A POPULATION BB3 – BB6 – BB7

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NOVEMBER 1, 2018 - JANUARY 31, 2019

COHORT 3

▪ BB3 – Empaneling Patient Population ▪ BB6 – Risk Stratification/Actively Manage Patients ▪ BB7 – Screen and Link to BH/SUD Resources

COHORT 2 – YEAR 2

▪ BB3 – Empaneling Patient Population ▪ BB6 – Risk Stratification/Actively Manage Patients ▪ BB7 – Screen and Link to BH/SUD Resources

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PHASED APPROACH TIMELINE: COHORT 3

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PHASED APPROACH TIMELINE: COHORT 2 - YEAR 2

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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 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

COHORT 3 & COHORT 2 – YEAR 2

BB3 – EMPANEL THE POPULATION BB6 - RISK STRATIFY & ACTIVELY MANAGE USING DATA BB7 – SCREEN FOR BH/SUD & LINK TO RESOURCES

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BB3 - EMPANELING THE POPULATION

Goal: Practice has, and maintains, empanelment for at least 75% of its patient population.

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BB3.Y1 - COHORT 3

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. *Active population = seen by primary care within last 12 to 24 months.

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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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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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BB3.Y2 – COHORT 2

• 1. Practice maintains 75% empanelment of patients

with provider/care teams.

• 2. Practice develops policies to support empanelment,

including definitions, changing PCPs, assigning new patients, and ensuring continuous coverage.

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QUESTIONS?

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BB6 -RISK STRATIFY AND ACTIVELY MANAGE POPULATION USING DATA

GOAL: Practice uses population-level data to manage care gaps, develop care management care plans and implement those plans for high-risk patients and families.

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BB6.Y1 - COHORT 3

• 1. Practice identifies, documents a risk stratification
• methodology. (Recommended, but not required for pediatric

practices)

• 2. Practice identifies strategy to identify care gaps (e.g.

patient registry, data aggregation tool) and prioritize high-risk patients and families.

BB6.Y2 – COHORT 2

• 1. 75% of empaneled patients are risk-stratified.

(Recommended, but not required for pediatric practices).

• 2. 75% of high-risk patients/families have a

documented care plan.

• 3. Practice implements proactive care gap

management and tracks outcomes.

• 4. Practice embeds care plan template in EHR.

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QUESTIONS?

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BB7 – 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 (SUD) and/or behavioral health (BH) needs, and includes BH and community services as part of care management strategies.

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BB7.Y1 – COHORT 3

• 1. Practice identifies BH resources for patients/families, including

support from SIM participating health plans and Regional Health Connectors (RHCs).

• 2. Practice identifies screening tool for reporting on at least two BH

screening measures for SIM (depression, maternal depression, developmental disorders, obesity, and substance use disorders - unhealthy alcohol use, other drug dependence, and tobacco use); Screens 25% of patients.

• 3. Practice has documented process for connecting

patients/families with BH resources (from screening), including standing orders/protocols and follow-up.

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BB7.Y2 - COHORT 3

• 50% of patients are screened for behavioral health

condition(s).

• Practice performs an assessment of community

resources to assist patients/families with social needs (such as food, housing, transportation).

• 50% of patients identified with behavioral health

need are connected to resource.

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PATHWAYS TO CONNECT PCP & BH RESOURCES

• 1. Inside Practice

a) Co-Location b) Integration

• 2. Outside Practice

a) Collaboration

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Making Connections

How the Regional Health Connector workforce can support you

February 28, 2017

SCREENING, BRIEF INTERVENTION, REFERRAL TO TREATMENT (SBIRT) RESOURCES-TRAINING-PUBLIC AWARENESS

Available online and as a mobile app (Apple and Android) at www.shifttheinfluence.org

Hi, I’m Jordan!

I enjoy y partying tying, , but my my drink nking ing and d smoking ing weed have been getting ing in the way ay of keepin ing my job.

Hi, I’m Donna!

I'm deali ling ng with h a lot these day ays, s, and I use alcohol cohol to cope pe with h stress. .

www.sbirtcolorado.org

HTTPS://WWW.COLORADO.GOV/LADDERS

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HTTPS://WWW.SAMHSA.GOV/FIND-HELP/NATIONAL-HELPLINE

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PSYCHOLOGY TODAY

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QUESTIONS?

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POLLING QUESTION #1

• 1. Since our next PTO Training is on December 26th, we

are rescheduling it for Wednesday, December 19th from 9am to 10am. Will you be able to attend by phone?

a) Yes b) No c) Not sure but will check and get back to you ASAP

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POLLING QUESTION #2

• 2. From the Building Blocks listed below (and any

associated milestones), please select those you and/or your practices are struggling with: (see screen for milestones)

a) BB1 – Leadership b) BB2 – Using Data To Drive Change c) BB3 – Empaneling The Population d) BB4 – Team Based Care e) BB5 – Partnership With Patients f) BB6 – Risk Stratify and Actively Manage Patients

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BUILDING BLOCK YEAR-1 MILESTONES YEAR-2 MILESTONES

G O A L

POLLING QUESTION #3

• 3. Please select from the following options for content:

a) Discuss any issues you and/or your practices are struggling with from Question #2, including Q&As and sharing of “tips and tricks” with each other. b) Get expert(s) to talk about a specific topic from Question #2 that a majority

• f you want more help with. Please list any specific milestones in chat box

associated with Building Blocks selected (see screen). c) Other – please add comments in chat box

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COHORT 1 EXTENDED CHITA SERVICES

▪ Timeline is December 1st, 2018 – March 15th 2019. ▪ Monthly meeting with practice ▪ Practice must submit 2018 CQMs for SIM ▪ Meeting between HDCO partners, practice and CHITA to discuss eCQM tool ▪ CHITAs can start meeting with practices on December 1st ▪ All practices should be linked to PTOs in SPLIT ▪ Extended CHITA Services field note is now in SPLIT as well

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RESOURCES

▪ Building Block 3: Practice Population is Empaneled

▪ Panel Size: How Many Patients Can One Doctor Manage? Empanelment: Establishing Patient-Provider Relationships Addressing Staff Pushback for Empanelment

▪ Building Block 6: Practice Risk Stratifies and Actively Manages Patient Population Using Data

▪ Predict, Prioritize, Prevent. Nine Things Practices Should Know About Risk Stratification and Panel Management AAP Population Management Strategies Practice-Based Population Health: Information Technology to Support Transformation to Proactive Primary Care Risk-Stratified Care Management and Coordination

▪ Building Block 7: Practice Identifies Behavioral Health Resources for Patients/Families, Including Support from SIM Participating Health Plans and Regional Health Connectors (RHCs)

▪ Center for Adolescent Substance Abuse Research (CeASAR) Screening, Brief Intervention, Referral and Treatment (SBIRT): A Step-by-Step Guide for Screening and Intervening for Unhealthy Alcohol and Other Drug Use Final Recommendation Statement – Depression in Adults: Screening The US Preventive Services Task Force

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VALUE PROPOSITION OPPORTUNITY FOR SIM PRACTICES - INDIVIDUALIZED SUPPORT

▪ There are less than 15 spots remaining!

▪ Pam Ballou-Nelson, Senior consultant with MGMA, will provide practice specific, one-on-one consulting for 48 SIM practices to help the practice demonstrate and articulate their unique value to payers, patients, ACOs, IPAs and others. The final work product after working with Ms. Ballou Nelson is the practice’s unique story to take to payers to aid in contract negotiations. ▪ Flyers were emailed to SIM practices on Wednesday, November 7. Please contact Allyson Gottsman if you have a practice that has questions or send them the link to register here. There are two flyers for you to share with practices; one to use electronically with a direct registration link and one can be printed and taken to practices, and includes a link for practice registration. ▪ The target for this opportunity is independent practices in all cohorts, both adult and pediatric practices. It is not appropriate for FQHCs or practices

• wned by a health system.

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REMINDERS

▪ USE MILESTONE ATTESTATION CHECKLIST

▪ As ongoing guide for where to concentrate efforts. Don’t wait until formal evaluation!

▪ USE SIM IMPLEMENTATION GUIDE ▪ To review building blocks and milestone tips ▪ USE RESOURCE HUB – for great tools and resources ▪ ATTEND SPLIT MONTHLY OFFICE HOURS

▪ Register through CHES Newsletter or online calendar

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UPCOMING DUE DATES

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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

UPCOMING EVENTS

▪ December 2018 ▪ 12/11 – TCPi PTO Touch base 9-10 am ▪ 12/12 – TCPi Regional CLS Grand Junction 1 to 4 pm ▪ 12/13 – TCPi Regional CLS Montrose 9 to noon ▪ 12/13 – SIM Office Hours-10-11 am ▪ 12/14 – SIM CLS Western Slope registration open ▪ 12/15 – MGMA Skills Development Practice Webinar - 12-1 pm ▪ 12/18 - CHITA Learning Community-3-4 pm ▪ 12/20 – Learning Features Call – - CANCELLED Due to Holidays 10-11 am ▪ 12/25 - Colorado QPP Coalition Office Hours webinar- CANCELLED Due to Holidays ▪ 12/26 – SIM PTO Training Tentative date Dec 19th ▪ 12/27- SPLIT Office Hours 9-10 am CANCELLED Due to Holidays

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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

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