May 2017 Regional Learning Session Slides

Regional Learning Session Working with Employers to Increase Healthcare Value

Friday, May 12th, 2017

Thank you to our funders!

Lead Supporter

Major Supporters

AHC Enterprises, LLC

Supporters

Additional Supporters • OhioHealth • 100% of our Board of Directors & Staff • Individual & Corporate Donations

Today’s Agenda 8:30am: Welcome & HCGC Update

• Carrie Baker, President & CEO, HCGC 9:00am: Employer Efforts to Improve Healthcare Value Across the Country • Kristof Stremikis, Associate Director for Policy, Pacific Business Group on Health 9:45am: Employer Efforts to Improve Healthcare Value in our Region

• Kenny McDonald, Senior Vice President, Columbus Partnership 10:20am: Employer Efforts to Improve Healthcare Value Across the State • Monica Juenger, Director of Stakeholder Relations, Governor's Office of Health Transformation 10:50am: Open Discussion

45+ Partner Meetings: Learning Themes • HCGC is trusted resource for health and healthcare information and projects • Data is a challenge to get to increasing value

Learning Themes • Consumer and employer engagement conversations needed • HCGC face to face meetings continue; partners want to keep conversations going in between face to face meetings • Integration of primary care, behavioral health, social services, payer, employer learnings requested

Learning Themes • Energy around CPC+, questions about Ohio CPC; systems are “building from within” to meet payment reform challenges but see a need to partner

Collaborative Learning Results

Medical Neighborhood

Medical Neighborhood Referral Project:

Advancing accountable care coordination across clinical and social service organizations

Organizations Exchanging Referrals • Alliance Healthcare Partners

• La Clinica Latina

• Central Ohio Area Agency on Aging • LifeCare Alliance • Central Ohio Diabetes Association • Central Ohio Primary Care • Charitable Pharmacy of Central Ohio

• Lower Lights Christian Health Center • Metropolitan Family Care • Physicians CareConnection

• Clintonville-Beechwold Community • PrimaryOne Health Resource Center • Ripple Life Care Planning • Columbus Free Clinic • Southeast, Inc. • Equitas Health (formerly ARC Ohio)

• Syntero

• Helping Hands Health and Wellness • The Breathing Association Center • YMCA of Central Ohio • Kroger Pharmacy

Referral Infrastructure Learning • Utilize knowledge and experience from Great Lakes Health Connect • We obtained the same number of referrals in the first year ~500 • 5 years later Michigan is currently exchanging 196,000 referrals • Best practices to help partners to adopt the process/culture change • Asking partners the right questions • Process mapping to find opportunities to eliminate waste

2017 Medical Neighborhood Objectives • Expanding provider partners, social services, local government, and increasing payer participation • Emergency Rooms • Public Health • Emergency Services/Community Paramedicine • Care Coordinators/Social Workers in PCP • Providing technical assistance to existing referral partners to identify ways to more efficiently utilize the system • Develop pilots across partners • Share how referral network is achieving better health and patient outcomes as well as decreasing costs

Quality Transparency

Quality Transparency PURPOSE: Based on nationally endorsed measures, compile and share all-payer quality data from electronic medical records to: • Help health care professionals identify opportunities for improvement, enable consumers to make more informed choices about their health and healthcare, and allow purchasers to know the value of the healthcare that they are buying.

• Align work with existing national, state, and regional quality improvement efforts.

• Share and apply learning to catalyze the adoption and spread of best practices.

Quality Transparency Project Participants: Berger Health Partners

Mount Carmel Medical Group

Central Ohio Primary Care Physician

OhioHealth Physician Group

CompDrug Concord Counseling Services Heart of Ohio Family Health Centers

Lower Lights Christian Health Center

The Ohio State University Wexner Medical Center Primary Care PrimaryOne Health Southeast, Inc.

Syntero

HCGC Quality Measures Controlling High Blood Pressure: Percent of patients ages 18-85 with hypertension and whose blood pressure is adequately controlled (<140/90) Tobacco Use: Percent of adult patients who were screened for tobacco use and who received cessation counseling intervention.

Colorectal Cancer Screening: Percent of patients ages 50-75 who had appropriate screening for colorectal cancer.

Diabetes Care: Percent of patients ages 18-75 with diabetes whose most recent HbA1c level was reported as in control.

Diabetes Care: Percent of patients ages 18-75 with diabetes who received a nephropathy screening test or had evidence of nephropathy.

Depression Utilization of PHQ-9: Percent of adult patients with major depression or dysthymia who had a PHQ-9 administered during a 4-month period Depression Remission at 12 months: Percent of adult patients with major depression or dysthymia and initial PHQ-9 >9 who demonstrate remission at 12 months.

Depression Response at 12 months: Percent of adult patients with major depression or dysthymia and initial PHQ-9 >9 who demonstrate response to treatment at 12 months.

Managing Diabetes A1C

Managing Blood Pressure

Screenings for Colon Cancer

Additional measures Early results: Comprehensive Diabetes Care – 82% of adults with diabetes received medical attention for nephropathy Tobacco Screening and Cessation – 89% of adults were screened and received cessation counseling for tobacco use if identified Depression – 75% of adults with major depression were screened in order to monitor progress

Today’s Agenda 8:30am: Welcome & HCGC Update • Carrie Baker, President & CEO, HCGC 9:00am: Employer Efforts to Improve Healthcare Value Across the Country • Kristof Stremikis, Associate Director for Policy, Pacific Business Group on Health 9:45am: Employer Efforts to Improve Healthcare Value in our Region • Kenny McDonald, Senior Vice President, Columbus Partnership 10:20am: Employer Efforts to Improve Healthcare Value Across the State • Monica Juenger, Director of Stakeholder Relations, Governor's Office of Health Transformation 10:50am: Open Discussion

Kristof Stremikis, MPP, MPH Associate Director for Policy Pacific Business Group on Health

The Changing Health Care Payment Landscape Whatâ&#x20AC;&#x2122;s Happening Nationally and How Are Employers Reacting?

PBGH Members

25

Three Questions • What’s changing?

• How are employers reacting?

• Increasing engagement?

26

Repeal and Replace is About Public Coverage â&#x20AC;˘ Most employers remember thisâ&#x20AC;Ś

27

Repeal and Replace is About Public Coverage • But not this…

28

Public Sector Health Care Payment is Changing

29

Private Sector Health Care Payment is Changing

75% of all business activity will be in alternative payment model contracts with triple aim goals by 2020.

30

Vital roles for employer-purchasers

31

•

Provide input to policy leaders on APM definitions, metrics, methods; MIPS measures

•

Influence CMS and major health plans

•

Expand purchaser education/awareness of APMs and payer initiatives

•

Increase number of purchaser voices in payment policy process

•

Increase number of purchasers taking steps to change payment or benefit design

One Reaction

32

Another

33

What Are Other Employers Doing?

34

Maternity Care Improvement Campaigns

Successful campaign completed Piloting value-based payment

Regional coalition meetings held

35

Improving Maternity Care

36

37

1. Meeting with hospitals â&#x20AC;˘ Asking for reports of low-risk C-section rates directly to them and/or adopt a QI improvement initiative !!

2. Implementing VBP through health plan

1. Blended Case Rate Reimburse the same for C-sections and vaginal births 2. Episode-Based Bundle Pay one bundled fee for prenatal, delivery and postpartum care 3. Denial of Payment Deny payment for medically inappropriate care

38

3. Reviewing benefits package • Ensure coverage of less utilized services that can improve outcomes and patient experience.

• Midwives • Birth centers • Doulas • Group prenatal care

39

4. Changing beneficiary incentives • Tiered or narrow networks • Link to hospital C-section rates in online provider directories • Reference pricing • Patient engagement materials and tools

40

Employer Centers of Excellence Network

41

42

ECEN CoE Locations

Virginia Mason Medical Center Seattle, WA Mercy Hospital, Springfield Springfield, MO Kaiser Permanente Irvine Medical Center Irvine, CA Johns Hopkins Bayview Medical Center Baltimore, MD Geisinger Medical Center Danville, PA Scripps Mercy Hospital San Diego, CA

Charlotte, NC spine CoE & San Antonio, TX bariatric CoE launching Summer 2017

Joints Spines Bariatrics

43

ECEN Program Snapshot by Condition

Launch Date Number of CoEs Bundled Price (average discount)

Format

Site of care Other features

Volume

Joint Replacement

Spine Procedures

Bariatric Surgery

January 1st, 2014

April 1st, 2015

January 1st, 2016

4

4

3

20-30%

20-30%

30-40%

Virtual evaluation Travel for surgery

Virtual review, travel for in-person evaluation and/or surgery (one trip)

Virtual review, travel for in-person evaluation and/or surgery (two trips*)

All inpatient procedures

Inpatient and ambulatory procedures

All inpatient procedures

Includes initial outpatient physical therapy

All patients receive comprehensive inperson assessment

One year standardized virtual follow up

Completed Cases: 1645

Completed Cases: 269

Data Reporting starting mid-2017

44

Loweâ&#x20AC;&#x2122;s Improved Outcomes through ECEN $600,000 savings in 2014 from ECEN higher quality Quality Metric

2014 Carrier

ECEN

Discharge to Skilled Nursing Facility

9.1%

0.0%

Readmissions < 30 Days

6.6%

0.4%

Revisions within 6 months

1.1%

0.0%

*Results of a claims analysis of primary joint replacement (DRG 470) patients who received usual care via Loweâ&#x20AC;&#x2122;s carrier benefit versus ECEN patients

Boeing Direct ACO Contracting Model Preferred Partnership (ACO) • Improve Quality • Enhance Member Experience • Reduce Cost Delivery Goals • Incentive Only • Maintain Employee Choice • Simplified Approach Markets • Puget Sound (2015): • Providence-Swedish Health Alliance & their partners • UW Medicine Accountable Care Network & their partners • St. Louis (2016): Mercy Health Alliance & their partners • Charleston (2016): Roper St. Francis & their partners

45

ACO Plan Structure Program Design • Mixed Model • Designated – Employee elects program during Annual Enrollment • Attributed – Majority of care is delivered at ACO Partner • ACO Network is ‘In-Network’ • PCP encouraged, but not required • No Gatekeeper Financial Incentives for Employees • Lower Employee Premiums • Higher Company Funded HSA • $0 Primary Care Office Copay

• $0 Generic Drugs

46

Preliminary Results Improve Quality • Improvement in most metrics • Better controlling Blood Pressure, Diabetes, Cholesterol • Increased Screening Rates • Performance Improving on Depression Management • Higher Generic Fill Rates Enhance Member Experience • 15% - 35% employees enrolled • Rating of 8.5 out of 10 Reduce Cost • Results available later in 2017 • Partner Commitment • Long term Investment

47

What Else?

• High needs, high cost patients (including behavioral health) • Challenge grants for regional pilots • Employer ACO assessments

48

Enhanced CCM Services for HC/HN • Working directly with plans and providers, embedding within ACO contracts, integrated into onsite/near site medical clinics • Identification: prospective risk modeling and retrospective identification • Structure: NCQA Level III starting point, enhanced access, interoperable HIT • Model: dedicated coordinator, face-to-face, referral to vetted community supports • Payment: Two-sided risk, P4P on specific CCM measures • Measures: Process and Outcome (member experience, evidencedbased care, activation and engagement—referred to and using services)

49

Enhanced CCM Services for HC/HN • What’s worked: • Evidence of modest cost savings in working age adult and Medicare population; now being expanded to Medicaid • Process measures (getting recommended care) • Referral and uptake of onsite wellness and community services • Member satisfaction/rating

• Ongoing challenges: • Deeper savings • Movement on health status measures (BMI, depression) • Interoperable EHR

50

PVN Payment Reform Challenge Grants

• • • • •

Maternity care Primary care Avoidable ED use Cardiac care Joint replacement

Awarded Under development

51

Health Plansâ&#x20AC;&#x2122; Self-Reported ACO Results

52

Employers looking “under the hood”

53

Key Domains for ACO Assessment • Leadership and governance • Member identification and engagement • Provider engagement and feedback • Quality measurement and improvement • Care management and population health • Network management and financial model • Prescription drug management • Health IT, data integration, and reporting

54

Engaging Employers in Payment and Delivery Reform • More outreach needed (everywhere) • Executive leadership crucial • Carriers can lead softly • Target senior exec in company • Personalities matter • “Neutral” state convener helpful • Federal support crucial

55

“Above all, try something.”

56

Questions?

Kenny McDonald Senior Vice President Columbus Partnership

HCGC REGIONAL LEARNING SESSION May 12, 2017

ABOUT COLUMBUS 2020 Mission Generate opportunity and build capacity for economic growth in the Columbus Region Goals to achieve by the year 2020  Add 150,000 net new jobs  Increase personal per capita income by 30 percent  Generate $8 billion of capital investment  Be recognized as a national leader in economic development Plan  Retain and expand companies and industries that call the Columbus Region home today  Attract economic base employers to the Columbus Region  Accelerate high-growth enterprises by connecting entrepreneurs with the economic development system  Improve civic infrastructure to enhance the economic development environment

10-YEAR GOALS NET NEW JOBS

CAPITAL INVESTMENT

PER CAPITA INCOME

Current: 136,783

Current: $7.6B

Current: 21.5%

Goal: 150,000 Pace: 190,589

Goal: $8B Pace: $10.3B

Goal: 30% Pace: 47.6%

Source: Bureau of Labor Statistics, LAUS, seasonally adjusted by Columbus 2020, January 2010 – March 2017

Source: Columbus 2020, as of May 2017

Source: Bureau of Economic Analysis, 2010 – 2015

OPPORTUNITY GENERATION 165 ACTIVE PROJECTS Attraction/Expansion

81

25%

Sales 36

75%

Attraction

Stage

Expansion

Deal

30

Offer

18

App/Accept

OPPORTUNITY GENERATION 36

47% FOREIGN-OWNED COMPANIES

OPPORTUNITIES CREATING 200+ JOBS

42%

16%

33%

9%

MANUFACTURING PROJECTS

LOGISTICS PROJECTS

OFFICE PROJECTS

OTHER PROJECTS

2017 RESULTS

1362

$68.7M Payroll

Jobs

27 Announced Projects

23 Domestic 4 International

20 Expansion 7 Attraction

$244M Investment

13

8

3

2

1

HQ/BO

MFG

L&D

IT

R&D

2017 YTD RESULTS BUSINESS AGILITY

COMPETITIVENESS AGENDA

Meet the workforce challenge

Increase global trade and investment

Generate high-growth opportunities

Develop competitive infrastructure

Increase manufacturing competitiveness

THANK YOU COLUMBUSREGION.COM

Questions?

Monica Juenger Director of Stakeholder Relations Office of Health Transformation

Overview of the Ohio Comprehensive Primary Care Program (CPC) Model May 12, 2017 WORKING DOCUMENT

Preliminary pre-decisional working draft; subject to change

Objectives for today’s discussion

▪ Overview of Ohio CPC care delivery transformation ▪ Integration of CPC+ practices into Ohio CPC ▪ Program requirements ▪ Program infrastructure ▪ Shared savings and payment ▪ Timeline and next steps on Ohio CPC

▪ Appendix

Confidential and Proprietary

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Preliminary pre-decisional working draft; subject to change

Ohioâ&#x20AC;&#x2122;s vision for PCMH is to promote high-quality individualized, continuous and comprehensive care

Confidential and Proprietary

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Preliminary pre-decisional working draft; subject to change

Ohio CPC “Early Entry” Practice Eligibility (January 1, 2017 to December 31, 2017) Required



• Eligible provider type and specialty • One of the following characteristics: 

Practice with 5,000+ members and national accreditation1



CPC+ practices with a minimum of 500 attributed/assigned Medicaid members by Medicaid group ID



Practice with 500+ members with claims-only attribution AND PCMH accreditation1

• Commitment:

Not required





To sharing data with contracted payers/ the state Not required



To participating in learning activities2



To meeting activity requirements in 6 months

• Planning (e.g., develop budget, plan for care delivery improvements, etc.)

• Tools (e.g., e-prescribing capabilities, EHR, etc.)

1 Eligible accreditations include: NCQAII/III, URAC, Joint Commission, AAAHC 2 Examples include sharing best practices with other CPC practices, working with existing organizations to improve operating model, participating in state led CPC program education at kickoff Confidential and Proprietary

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Preliminary pre-decisional working draft; subject to change

Ohio CPC Practice Eligibility (January 1, 2018 and beyond) Required

• Eligible provider type and specialty



• Minimum size: 500 attributed/assigned Medicaid members by Medicaid group ID at each attribution period • Commitment:

 To sharing data with contracted payers/ the state  To participating in learning activities1 Not required

 To meeting activity requirements in 6 months Not required • Accreditation (e.g., e-prescribing capabilities, EHR, etc.)



• Planning (e.g., develop budget, plan for care delivery improvements, etc.)

• Tools (e.g., e-prescribing capabilities, EHR, etc.)

1 Examples include sharing best practices with other CPC practices, working with existing organizations to improve operating model, participating in state led CPC program education at kickoff

Confidential and Proprietary

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Preliminary pre-decisional working draft; subject to change

Overview of the 92 â&#x20AC;&#x153;Early Entryâ&#x20AC;? Ohio CPC practices

# Practices Attributed Lives

Practice Size (Members)

> 25,000 29 practices have >5,000 attributed lives, representing 468k CPC members

10,000 to 25,000

5,000 to 10,000

# Ohio CPC Practices

4

Attribution as of December 1, 2016

Not enrolled in CPC+

CPC+ Track 1

CPC+ Track 2

3

1

0

164k

30k

0

1

4

5

16k

67k

84k

10

1

4

69k

8k

29k

55

2

6

145k

5k

18k

69

8

15

~394k

~110k

~131k

194,757

10

166,715

15

Under 5,000

Total

Attributed members

106,271

63

92

168,684

~636k

Confidential and Proprietary

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Preliminary pre-decisional working draft; subject to change

Contents

▪ Overview of Ohio CPC care delivery transformation ▪ Integration of CPC+ practices into Ohio CPC ▪ Program requirements ▪ Program infrastructure ▪ Shared savings and payment ▪ Timeline and next steps on Ohio CPC

▪ Appendix

Confidential and Proprietary

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Preliminary pre-decisional working draft; subject to change

Eligible CPC+ practices are invited to enroll in Ohio CPC ▪ Decision was made in 2016 that CPC+ practices would be eligible to join Ohio CPC model this year, for any CPC+ practice with 500+ attributed members based on claims

▪ ODM performed a cross-walk from the CPC+ practice Tax ID (TIN) to the Medicaid Billing ID (the unit of a practice for Ohio CPC)

▪ 69 practices were newly eligible for Ohio CPC (based on Medicaid billing IDs), due to their CPC+ status and attributed members (500+)

– 571 CPC+ sites were mapped to 453 practices based on Medicaid billing ID1

– 91 of these practices have 500+ attributed members based on claims – 69 of this group are not yet participating in Ohio CPC – The 69 newly-eligible practices represent approximately ~275,000 attributed lives These CPC+ practices may enroll into Ohio CPC by May, ensuring they are aligned as possible with the 2017 cohort (e.g., receiving Q2 reports and Q3 PMPM payments) 1 Based on mapping of Tax IDs to Billing IDs. CPC+ uses Tax IDs at the site level, while CPC uses billing IDs at the aggregate practice level SOURCE: CPC+ practice data as of 2017, CPC data reflects attribution as of December 1, 2016 Confidential and Proprietary | 77

Preliminary pre-decisional working draft; subject to change

Ohio’s CPC program aligns with Medicare CPC+ Ohio CPC Program

Medicare CPC+ Program

Care model

 Care Model based on key principles of access,  Similar principles coordination, care management, patient engagement, population health management

Eligible practices

 Open provider enrollment and inclusive of most primary care practice types

 Application process and excludes pediatrics and FQHCs

Definition of practice

 Defined as Medicaid Billing ID

 Defined at the site level

PMPM

 Risk-adjusted PMPM based on patient health status

 Track 1 vs. 2 have different riskadjusted PMPMs

Incentive

 Shared savings based on cost and quality

 Pay for performance bonus

Alt. to FFS

 Episode-based payment model

 Track 2 includes partial capitation

EHR

 EHR not required

 EHR required

Activities

 8 activity requirements

 Similar activity requirements

Clinical quality

 20 clinical quality measures

 14 clinical quality measures (7 overlap with Ohio CPC)

Efficiency

 4 efficiency measures

 2 efficiency measures (1 overlaps with Ohio CPC)

Payment streams

Program Requirements

Confidential and Proprietary

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Preliminary pre-decisional working draft; subject to change

Ohio application of CPC+ payment streams by line of business

Payer

Ohio Medicaid FFS

Ohio Medicaid Managed Care

Medicare FFS

ODM

MCP2

CMS

Commercial / Medicare Advantage Plan

500 (across all Medicaid members)

500 (across all Medicaid members)

150 Medicare FFS members

Determined by plan

Track 11

$3-5 average

$3-5 average

$15 average

Determined by plan

Track 21

$3-5 average

$3-5 average

$28 average

Determined by plan

Track 1

50% gain-sharing rate on TCC3

50% gain-sharing rate on TCC3

$2.50 PMPM pay for performance

Determined by plan

Track 2

65% gain-sharing rate on TCC

65% gain-sharing rate on TCC

$4.00 PMPM pay for performance

Determined by plan

Track 2 Only

Episodes only

Episodes only

Partial capitation

Determined by plan

Minimum panel size

PMPM payments

Incentive payments

Alternative to FFS

1 Single payment reflects both CPC+ and CPC; in no instance would there be double payment 2 MCP administers payment in all cases; PMPM payment would be supported through ODM 3 Practices would have potential opportunity to earn the higher gain-sharing rate due to highest performance on total cost of care during the performance year Confidential and Proprietary

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Preliminary pre-decisional working draft; subject to change

Update on CPC+ practice enrollment into Ohio CPC

▪ 23 CPC+ practices1 applied to participate, 16 of which meet Ohio CPC eligibility requirements

▪ These 16 practices represent ~101k attributed lives ▪ 6 practices have over 5,000 attributed lives and will potentially be eligible for shared savings

▪ Of the 16 practices, 6 are Track 2 CPC+ practices, while 10 are Track 1 practices

▪ Enrollment of these practices into Ohio CPC will be finalized this week

1 At the Medicaid Billing ID level Confidential and Proprietary

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Preliminary pre-decisional working draft; subject to change

Geographic distribution of Ohio CPC Practices 92 "Early Entry" CPC practices 16 Newly-eligible CPC+ practices

Confidential and Proprietary

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Preliminary pre-decisional working draft; subject to change

Contents

▪ Overview of Ohio CPC care delivery transformation ▪ Integration of CPC+ practices into Ohio CPC ▪ Program requirements ▪ Program infrastructure ▪ Shared savings and payment ▪ Timeline and next steps on Ohio CPC

▪ Appendix

Confidential and Proprietary

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Preliminary pre-decisional working draft; subject to change

How the Ohio CPC activity requirements were selected

Examined activity requirements of nationally-recognized PCMH programs

▪

▪

Leading PCMH programs, including Arkansas Medicaid’s PCMH program, and CPCi Expert accreditation standards (e.g., NCQA, Joint Commission, URAC)

Gathered stakeholder feedback

Resulted in 8 priority activity requirements for Ohio CPC

▪

Multi-step, collaborative stakeholder process

▪

Consistent with other national programs

▪

Input shared by primary care practices, payers, and other stakeholders

▪

In use in leading PCMH models

▪

Specific to Ohio’s needs

Confidential and Proprietary

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Preliminary pre-decisional working draft; subject to change

Ohio Comprehensive Primary Care (CPC) Program Requirements and Payment Streams Requirements

8 activity requirements

▪ Same-day ▪ ▪ ▪ ▪ ▪ ▪ ▪ Payment Streams

PMPM

Shared Savings

appointments 24/7 access to care Risk stratification Population management Team-based care management Follow up after hospital discharge Tracking of follow up tests and specialist referrals Patient experience

4 Efficiency measures

▪ ED visits ▪ Inpatient admissions ▪ ▪

for ambulatory sensitive conditions Generic dispensing rate of select classes Behavioral health related inpatient admits

20 Clinical Measures

Total Cost of Care

▪ Clinical measures aligned with CMS/AHIP core standards for PCMH

Must pass 50% Must pass 50%

Must pass 100%

All required

Based on selfimprovement & performance relative to peers

All required

Confidential and Proprietary

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Preliminary pre-decisional working draft; subject to change

Ohio CPC Activity Requirements Must pass 100%

▪ The practice provides same-day access, within 24 hours of initial request, including some weekend hours to a

Same-day appointments

PCMH practitioner or a proximate provider with access to patient records who can diagnose and treat

24/7 access to care

▪ The practice provides and attests to 24 hour, 7 days a week patient access to a primary care physician, primary care physician assistant or a primary care nurse practitioner with access to the patient’s medical record

▪ Providers use risk stratification from payers in addition to all available clinical and other relevant information to risk

Risk stratification

stratify all of their patients, and integrates this risk status into records and care plans

▪ Practices identify patients in need of preventative or chronic services and implements an ongoing multifaceted

Population health management

outreach effort to schedule appointments; practice has planned improvement strategy for health outcomes

▪ Practice defines care team members, roles, and qualifications; practice provides various care management

Team-based care management

strategies in partnership with payers and ODM for patients in specific patient segments; practice creates care plans for all high-risk patients, which includes key necessary elements

Follow up after hospital discharge

Tests and specialist referrals

▪ Practice has established relationships with all EDs and hospitals from which they frequently get referrals and consistently obtains patient discharge summaries and conducts appropriate follow-up care

▪ ▪ ▪ ▪ ▪

The practice has a documented process for tracking referrals and reports, and demonstrates that it: Asks about self-referrals and requests reports from clinicians Tracks lab tests and imaging tests until results are available, flagging and following up on overdue results Tracks referrals until the consultant or specialist’s report is available, flagging and following up on overdue reports Tracks fulfillment of pharmacy prescriptions where data is available

▪ The practice assesses their approach to patient experience and cultural competence at least once annually Patient experience

through quantitative or qualitative means; information collected by the practice covers access, communication, coordination and whole person care and self-management support; the practice uses the collected information to identify and act on improvement opportunities to improve patient experience and reduce disparities. The practice has process in place to honor relationship continuity.

Detailed requirement definitions are available on the Ohio Medicaid website: http://medicaid.ohio.gov/Providers/PaymentInnovation/CPC.aspx#1600563-cpc-requirements Confidential and Proprietary

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Preliminary pre-decisional working draft; subject to change

Example of a detailed activity requirement : Same day appointments Provider requirement

Payer role

Start-up and ongoing: ▪ The practice provides same day (within 24 hours of initial request) appointments with a practitioner (primary care physician, primary care PA/NP) connected to the CPC practice (i.e. who can access patient records) who can diagnose and treat the patient. This must include some weekend hours that are sufficient to meet patient demand.

▪ Practice can implement this through arrangements with other proximate providers (primary care physician, primary care PA/NP) who have access to the patients’ records (other arrangements may include open scheduling, group visits, and expanded hours)

▪ Validate that the CPC practice offers same day appointments (e.g., extended weekday hours, weekend hours, etc.) in order to ensure accurate information and appropriate guidance is provided by member facing departments to attributed members.

Acceptable evidence

▪ Monitoring entity can successfully schedule a same-day ▪ ▪

appointment in person per specifications above Evidence of weekend hours (e.g., weekly schedule) Additional evidence deemed reasonable by payer

Note: Telemedicine was removed from definition to ensure consistency with existing Ohio regulation Confidential and Proprietary

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Preliminary pre-decisional working draft; subject to change

Activity requirement monitoring will begin after July 1, 2017

• Structured assessment questionnaire • Phone discussion and review of relevant documents

Desk reviews

1 Reporting 2

4 • Practices not passing onsite reviews must Provider submit a performance response improvement plan • Practices may contest the results of the monitoring reports through a reconsideration process

Activity requirement monitoring Onsite reviews 3

• Written report from each desk review • Detailed discussion of how activity requirements are or are not being met

• Opportunity to observe and learn from innovative practices, or observe activities for practices where desk reviews indicate improvement is needed

Confidential and Proprietary

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Preliminary pre-decisional working draft; subject to change

Ohio CPC Clinical Quality Requirements Must pass 50% Category

Pediatric Health (4)

Women’s Health (5)

Adult Health (7)

Behavioral Health (4)

Population health priority

Measure Name

Population

NQF #

Well-Child Visits in the First 15 Months of Life

Pediatrics

1392

Well-Child visits in the 3rd, 4th, 5th, 6th years of life

Pediatrics

1516

Adolescent Well-Care Visit

Pediatrics

HEDIS AWC

Weight assessment and counseling for nutrition and physical activity for children/adolescents: BMI assessment for children/adolescents

Pediatrics

Obesity, physical activity, nutrition

0024

Timeliness of prenatal care

Adults

Infant Mortality

1517

Live Births Weighing Less than 2,500 grams

Adults

Infant Mortality

N/A

Postpartum care

Adults

Infant Mortality

1517

Measures will evolve over time

Breast Cancer Screening

Adults

Cancer

2372

▪

Cervical cancer screening

Adults

Cancer

0032

Measures will be refined based on learnings from initial roll-out

Adult BMI

Adults

Obestiy

HEDIS ABA

▪

Controlling high blood pressure (starting in year 3)

Adults

Heart Disease

0018

Hybrid measures that require electronic health record (EHR) may be added to the list of core measures

▪

Hybrid measures may replace some of the core measures

▪

Reduction in variability in performance between different socioeconomic demographics may be included as a CPC requirement

Med management for people with asthma

Both

1799

Statin Therapy for patients with cardiovascular disease

Adults

Heart Disease

HEDIS SPC

Comprehensive Diabetes Care: HgA1c poor control (>9.0%)

Adults

Diabetes

0059

Comprehensive diabetes care: HbA1c testing

Adults

Diabetes

0057

Comprehensive diabetes care: eye exam

Adults

Diabetes

0055

Antidepressant medication management

Adults

Mental Health

0105

Follow up after hospitalization for mental illness

Both

Mental Health

0576

Preventive care and screening: tobacco use: screening and cessation intervention

Both

Substance Abuse

0028

Initiation and engagement of alcohol and other drug dependence treatment

Adults

Substance Abuse

0004

Detailed requirement definitions are available on the Ohio Medicaid website: http://medicaid.ohio.gov/Providers/PaymentInn ovation/CPC.aspx#1600563-cpc-requirements

Note: All CMS metrics in relevant topic areas were included in list except for those for which data availability poses a challenge (e.g., certain metrics requiring EHR may be incorporated in future years) Confidential and Proprietary

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Ohio CPC Efficiency Measure Requirements

Tied to payment

Must pass 50% Metric

Rationale

Generic dispensing rate (all drug classes) Ambulatory caresensitive inpatient admits per 1,000 Emergency room visits per 1,000 Behavioral healthrelated inpatient admits per 1,000 Episodes-related metric

▪ Strong correlation with total cost of care for large practices ▪ Limited range of year over year variability for smaller panel sizes ▪ Aligned with change in behavior that the program wants to incentivize ▪ Strong correlation with total cost of care for large practices ▪ PCPs have a stronger ability to influence the measure, compared to all inpatient admissions

▪ Limited range of year over year variability for smaller panel sizes ▪ Aligned with change in providers’ behavior that the program wants to incent ▪ Reinforces desired provider practice patterns, with focus on behavioral health ▪ ▪

population Relevant for a significant number of smaller practices Stronger correlation to total cost of care than other behavioral health-related metrics

▪ REPORTING ONLY (not tied to payment) ▪ Links CPC program to episode-based payments ▪ Based on CPC practice referral patterns to episodes principle accountable providers

Detailed requirement definitions are available on the Ohio Medicaid website: http://medicaid.ohio.gov/Providers/PaymentInnovation/CPC.aspx#1600563-cpc-requirements Confidential and Proprietary

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Quality and Efficiency Measure Thresholds Category Pediatric Health (4)

Womenâ&#x20AC;&#x2122;s Health (5)

Adult Health (7)

Behavioral Health (4)

Measure Name

Threshold

Well-Child Visits in the First 15 Months of Life Well-Child visits in the 3rd, 4th, 5th, 6th years of life Adolescent Well-Care Visits BMI assessment for children/adolescents Timeliness of prenatal care Live Births Weighing Less than 2,500 grams Postpartum care Breast Cancer Screening Cervical cancer screening Adult BMI Assessment Controlling high blood pressure1 Medication management for people with asthma Statin Therapy for patients with cardiovascular disease Comprehensive Diabetes Care: HgA1c poor control Comprehensive diabetes care: HbA1c testing Comprehensive diabetes care: eye exam Antidepressant medication management Follow up after hospitalization for mental illness tobacco use: screening and cessation intervention

11% 41% 15% 10% 56% <= 11% 41% 52% 36% 10% 10% 24% 28% <=90% 75% 35% 47% 32% 10%

Initiation of alcohol and other drug dependence treatment

34%

ED Visits / 1,000 Members Efficiency metrics

<=73

IP Admits for Ambulatory Conditions /1,000 Members

<=7

Generic Dispensing Rate

78%

Behavioral Health-related IP Admits /1,000 Members

<=1.2 Confidential and Proprietary

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Contents

▪ Overview of Ohio CPC care delivery transformation ▪ Integration of CPC+ practices into Ohio CPC ▪ Program requirements ▪ Program infrastructure ▪ Shared savings and payment ▪ Timeline and next steps on Ohio CPC

▪ Appendix

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Overview of the Ohio CPC practice journey

Attribution

Payment

Reporting

Determining the patients for which an Ohio CPC practice is responsible

Quarterly permember-permonth (PMPM) payments

Summary of performance at the Ohio CPC Practice level and detailed member level

Q2 payment for MCP members in progress

May 4 Q1 CPC provider report shared

Key upcoming dates: April 4 â&#x20AC;&#x201C; Q2 attribution and payment files shared on MITS July 6 - Q3 attribution and payment files shared on MITS

The practice journey through the Ohio CPC program is intended to transform care delivery and support primary care practices in effectively managing patientsâ&#x20AC;&#x2122; health needs

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Patient attribution is determined prior to each quarter

Payment and reporting period

Attribution date

Timeframe reports are shared with CPCs

January to March

September 1 of the prior year

April

April to June

December 1 of the prior year

July

July to September

March 1

October

October to December

June 1

January of the following year

Winter (Q1)

Spring (Q2)

Summer (Q3)

Fall (Q4)

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Attribution for the Ohio CPC program is based on three criteria Attribution logic for FFS and MCP members 1▪ First criteria: assign members based on member choice

2▪ Second criteria: if member choice isn’t expressed, attribute member based on claims from visits 3▪ Third criteria: if neither member choice nor visit claims are available – Assign member based on non-claims considerations1

Member choice is the most direct way for members to be attributed to an Ohio CPC Claims-based attribution is based on a plurality of E&M visits with a practice

Patients may be attributed to your practice even if you have not seen them in the past

Attribution can be changed based on member preference (i.e. member exhibits new or changed choice) or member behavior as determined through claims

1 MCPs may use other factors to conduct non-claims based attribution Confidential and Proprietary

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Ohio CPC Practice Reports for Q1 have been shared with practices 1 PDF Summary of practice performance

2 CSV file with detailed patient-level data

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Practice Webinar dates and tentative topics for 2017

Webinar topic

Date

1 Attribution and payment

April 6, 2017

2 Best practices in meeting activity requirements

April 25, 2017

3 Ohio CPC Provider Reports

May 9, 2017

4 Risk tiers and shared savings under the Ohio CPC model

June 13, 2017

5 Best practices in improving quality measure performance

July 11, 2017

6 Behavioral health integration

August 8, 2017

7 Practice partnerships in 2018

September 12, 2017

8 Model design changes and supporting new enrollment for 2018

October 10, 2017

9 Feedback on payment and reporting in 2017

November 14, 2017

10 Feedback on year in review

December 12, 2017

Note: dates and topics are preliminary and subject to change Confidential and Proprietary

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Contents

▪ Overview of Ohio CPC care delivery transformation ▪ Integration of CPC+ practices into Ohio CPC ▪ Program requirements ▪ Program infrastructure ▪ Shared savings and payment ▪ Timeline and next steps on Ohio CPC

▪ Appendix

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Per member per month (PMPM) payment calculation The PMPM payment for a given Ohio CPC practice is calculated by multiplying the PMPM for each risk tier by the number of members attributed to your practice in each risk tier

Ohio CPC PMPM Tier 1

Ohio CPC PMPM Tier 2

Ohio CPC PMPM Tier 3

3M CRG health statuses ▪ Healthy

Example of 3M CRG

▪

Healthy (no chronic health problems)

▪

History of significant acute disease

▪

Chest pains

▪

Single minor chronic disease

▪

Migraine

▪

Minor chronic diseases in multiple organ systems

▪

Migraine and benign prostatic hyperplasia (BPH)

▪

Significant chronic disease

▪

Diabetes mellitus

▪

Significant chronic diseases in multiple organ systems

▪

Diabetes mellitus and CHF

▪

Dominant chronic disease in 3 or more organ systems

▪

Diabetes mellitus, CHF, and COPD

▪

Dominant/metastatic malignancy

▪

Metastatic colon malignancy

▪

Catastrophic

▪

History of major organ transplant

2017 CPC PMPM

$1

$8

▪

Your practice will receive payments prospectively and quarterly

▪

Risk tiers are updated quarterly, based on 24 months of claims history with 6 months of claims run-out

$22

Detailed requirement definitions are available on the Ohio Medicaid website: http://medicaid.ohio.gov/Providers/PaymentInnovation/CPC.aspx#1600562-cpc-payments Confidential and Proprietary

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Patients and services included in total cost of care Inclusions

Patients



▪ All adults and pediatrics ▪ All behavioral health members ▪

including SPMI Members with exclusively dental or vision TPL coverage

▪ All non-excluded medical and

Services

▪

prescription spend including: – Case management – DME – Home health – First 90 days of LTC Quarterly Ohio CPC PMPMs

1 Defined as Nursery level 3 and 4

Exclusions



▪ Duals (included as operationally ▪ ▪

feasible, priority for MyCare) Members with limited benefits (e.g., family planning) All other members with TPL coverage

▪ Waiver ▪ Currently underutilized services ▪

(dental, vision, transportation) All spend for members: – With a NICU1 stay – With > 90 days of LTC claims – That are outliers within each risk band (top and bottom 1%)

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Ohio CPC shared savings payment calculation ▪ Annual retrospective payment based on total cost of care (TCC) ▪ Activity requirements and quality and efficiency metrics must be met for

▪ ▪

the CPC practice to receive this payment CPC practice must have 60,000 member months to calculate TCC CPC practice may receive either or both of two payments:

1. Total Cost of Care RELATIVE TO SELF

2. Total Cost of Care RELATIVE TO PEERS

Payment based on a practice’s improvement on total cost of care for all their attributed patients, compared to their own baseline total cost of care Payment based on a practice’s low total cost of care relative to other CPC practices

CY17 Shared Savings will be determined in Q3 2018 after a 6-month claims run-out period Detailed requirement definitions are available on the Ohio Medicaid website: http://medicaid.ohio.gov/Providers/PaymentInnovation/CPC.aspx#1600562-cpcpayments

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Ohio CPC shared savings: self-improvement Shared savings payment based on self-improvement on total cost of care (TCC) Methodology for determining self-improvement on TCC High TCC baseline 50% Gainsharing rate 8,500 8,000 7,500 7,000 6,500 6,000 5,500 5,000 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0

Low TCC baseline 65% Gainsharing rate Low-TCC threshold

•

All attributed members’ costs are risk-adjusted for both a 1year baseline and for the performance period – 3M CRG tool used for risk-adjustment – Baseline year is 2015 for the 2017 performance year

•

A benchmark is established for each practice using baseline average risk-adjusted TCC, adjusted for programmatic changes – Practices achieve at least 1% savings to be eligible to receive shared savings payments

•

The savings percent is calculated as the difference between the performance period average risk-adjusted TCC and the benchmark TCC, divided by the benchmark

•

Risk-adjusted savings percent is applied to performance year total cost (not risk-adjusted) to determine savings

Two tiers for Ohio CPC Shared Savings payments

•

CPC practices receive 50 or 65% of their savings over their own baseline as a Shared Savings payment

•

The 65% tier is accessed in one of two ways:

– Enrolling in CPC+ Track 2 – Having a low baseline TCC (threshold PMPY of $3,100)

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Ohio CPC shared savings: performance relative to peers

Shared savings payment based on total cost of care (TCC) relative to peers Distribution of CPC TCC

Bonus for lowest-cost practices

Lowestcost 10%

Receive Bonus

 Practices with the 10% lowest TCC across all Ohio CPC practices receive a bonus payment regardless of whether or not they save over their own baseline  This payment will be in addition to shared savings payments for self-improvement, if applicable  The 10% threshold is determined at the end of the performance period, and is based on TCC from the 2017 performance year  Payment will be a lump sum amount calculated and paid annually

Risk Adjusted TCC

 Payment is calculated by multiplying the number of members attributed to the CPC practice during the performance period by $5

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Contents

▪ Overview of Ohio CPC care delivery transformation ▪ Integration of CPC+ practices into Ohio CPC ▪ Program requirements ▪ Program infrastructure ▪ Shared savings and payment ▪ Timeline and next steps on Ohio CPC

▪ Appendix

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Ohio’s Comprehensive Primary Care (CPC) Timeline 2015

CPC “Classic”

Ohio CPC Program

Medicare CPC+

Year 3

▪

▪ ▪ ▪

Ohio’s SIMsponsored PCMH model

2016

Year 4

Design

Medicare-sponsored Payers apply by region Practices apply within regions

Early Entry into the Ohio CPC Program ▪ CPC+ practices with 500+ Medicaid members ▪ Practices with 500+ Medicaid members with claims-only attribution AND NCQA III ▪ Practices with 5,000+ Medicaid members and national accreditation

2017

2018

▪

2020

2019

Southwest Ohio’s federally-sponsored, multi-payer PCMH model

Year 1 (early entry)

Year 1 (CMS-selected)

Year 2 (open entry)

Year 3 … (open entry)

Year 2 (CMS-selected)

Year 3 … 5 (CMS-selected)

Ongoing Enrollment in the Ohio CPC Program ▪ Any practice with 500+ Medicaid members that meets Ohio CPC program activity, efficiency and clinical quality requirements

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Select upcoming activities on Ohio CPC implementation

▪ Complete integration of CPC+ practices into Ohio CPC ▪ Solicit feedback from stakeholders on Practice Partnership design for 2018 and begin implementation

▪ Begin practice monitoring of Ohio CPC practices on activity requirements

▪ Implement changes to the MITS portal to accommodate enrollment of CPC practices and Practice Partnerships for 2018

▪ Prepare for open enrollment for 2018 cohort of new CPC practices

▪ Continue provider engagement through monthly webinars and in-person learning opportunities

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Contents

▪ Overview of Ohio CPC care delivery transformation ▪ Integration of CPC+ practices into Ohio CPC ▪ Program requirements ▪ Program infrastructure ▪ Shared savings and payment ▪ Timeline and next steps on Ohio CPC

▪ Appendix

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24/7 access to care Provider requirement

Payer role

Start-up and ongoing: ▪ In order to reduce unnecessary use of the emergency room, the practice must provide interactive clinical advice to patients by telephone or secure electronic video conferencing or messaging. A primary care physician, primary care PA/NP who has access to the patient’s medical record, by telephone (for urgent requests) or secure electronic communication (for routine requests) must respond to patients seeking clinical advice when the office is both open and closed.

▪ Practice makes patient clinical information available 24/7 to on-call staff, external facilities, and other clinicians outside the practice when the office is closed through paper or electronic records or telephone consultation ▪ The CPC practice must provide a response to requests for clinical advice received after hours in accordance with the CPC practice's written policy, and within a reasonable time frame ▪ All clinical advice is documented in the patient records in accordance with the written policy of the CPC practice not to exceed 1 business day

▪

Validate that the CPC practice offers 24/7 access to care in order to ensure accurate information and appropriate guidance is provided by member facing departments to attributed members.

Acceptable evidence

▪ ▪

▪ ▪

Monitoring entity would try to access after-hours advice and confirm that the provider has access to the patients’ clinical records, and that they can receive advice by telephone for urgent needs Documented process for sharing patient records with relevant parties who work with practice to provide 24/7 access, if relevant Office policies for documentation Additional evidence deemed reasonable by payer

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Risk stratification Provider requirement

Payer role

Start-up: Practice has developed a method for documenting patient risk level that is integrated with overall patient record, and have a clear approach to implement this across their patient panel ▪ Ongoing: – Providers use risk stratification from ODM and contracted MCPs in addition to all available clinical and other relevant information such as cost data or screening results, tobacco use, health risk behaviors to risk stratify all of their patients and communicate this information back to ODM and contracted MCPs as requested – Patient risk status is fully integrated into patient records and used to drive decisions around patient treatment, including development of individualized care management plans – Providers update their risk stratification periodically (whenever updated information is available from payers or when the practice is informed of a significant change event e.g. hospitalization for the patient) and correspondingly update care plans to reflect changes in risk status

▪

Acceptable evidence

▪ ▪ ▪

▪

Care plans for high-risk patients, showing explicitly how risk status was used in their development Health records showing risk status incorporated List of additional factors considered in supplementing risk stratification information from payers Additional evidence deemed reasonable by payer

▪

▪

▪

Generate and provide a list of risk-stratified members attributed to each CPC practice on a regular basis and whenever there is a change in risk status.

Review the risk stratified list with the CPC practice and provide additional data for high priority patients in order to assist the CPC practice with ongoing care management responsibilities.

Timely notify the CPC practice of significant change events (IP hospitalizations, ED visits, etc.) that could impact the assigned risk stratification level.

Update the MCP’s care management system to reflect changes to the risk stratification level that are initiated and communicated by the CPC practice.

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Population health management Provider requirement

Payer role

Start-up: Practices identify who needs preventative or chronic services and begins outreach to those (either patients or their families/caregivers) who have not been recently seen in order to schedule an appointment or identify additional services to meet the needs of the patient ▪ Ongoing: All of the above, plus – Practices identify patients with gaps in care (e.g., high-risk patient, children who have not had well-checks, and patients who take specific medications), and implement an ongoing multifaceted outreach effort to schedule appointments (independently or through partnership with payers and community) – Practices have a planned improvement strategy for health outcomes and business processes; the practice devotes staff resources and time to quality improvement activities with goal of improving health outcomes for the entire patient population – Billing process includes appropriate detailed coding for health risk factors (e.g., ICD-10 code Z59.0 for lack of housing)

▪ Provide information about MCP-

▪

▪

Acceptable evidence

▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Practice’s overall plan for population health management List of conditions that are being tracked Methodology for outreach Quality improvement strategy Workplan outlining payer and provider responsibilities for population health management Transition of care plans Job descriptions of staff involved in population health and quality improvement Additional evidence deemed reasonable by payer

▪

administered specialized services and resources as part of the MCP’s model of care for which a CPC practice can refer and link members to with assistance by the MCP. Assist with identification of preventive or chronic services that members have not received in order to identify gaps in care.

Assist in coordinating services as needed (e.g., schedule appointments, arrange transportation, facilitate referrals and linkages to MCP health and wellness programs, etc) in order to assist with improving health outcomes.

Share timely, meaningful, actionable data with the CPC practice that can facilitate population health activities.

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Team-based care management Provider requirement

Payer role

Start-up: Practice has designated and begun to train individual(s) to fill care manager role, which is to help overcome the barriers to the patient getting the evidence-based treatment that they need ▪ Ongoing: All of the above, plus – Practice defines who is on the care team (including the payer(s) and a quality improvement lead as appropriate), care team member qualifications, how team members function in relationship to other providers, ODM and/or contracted MCPs outside the care team; provides orientation and ongoing education and training to staff and holds scheduled patient care team meetings.

– The practice provides various care management strategies in partnership with ODM and/or contracted MCPs including coordination with practitioners and external care agencies, integration of behavioral health, self-management support for patients with at least three high risk conditions, medication management, and linkage to community-based resources – Practice creates care plans for all high-risk patients, which includes key necessary elements, including at minimum patient preferences and functional/lifestyle goals, treatment goals, potential barriers to meeting goals, self-management plan; and is easy to understand and provided in writing to the patient/family/caregiver.

– The practice identifies and flags key activities that require action/follow-up by ODM and/or the contracted MCP

▪ Work with each CPC practice to

Acceptable evidence

▪

▪ ▪ ▪ ▪

Example care plans Job descriptions of care team members Minutes from care team meetings Additional evidence deemed reasonable by payer

▪

▪

▪

▪

delineate roles and responsibilities for high priority patients to assure there are no gaps in or duplication of services.

Designate points of contact for each CPC practice to clearly identify who will participate in CPC practice-led patient care team meetings and who will assist the CPC practice with effectively and efficiently navigating MCP processes (e.g., facilitating prior authorizations).

Participate in CPC practice-led patient care team meetings, when requested.

Respond timely to requests from the CPC practice for action and follow up by the MCP (e.g., arranging transportation, performing outreach to a patient).

Receive and integrate critical CPC practice data elements (e.g., social determinants of health identified by the CPC practice) into the MCP’s care management system and use the information when interacting with members.

Share timely, meaningful, actionable data with the CPC practice that can facilitate effective team based care management activities (e.g., resolution of CPC practice requests for MCP follow up)

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Follow-up after hospital discharge Provider requirement

Payer role

▪

▪

▪

Start-up: Practice has established relationships with all EDs and hospitals from which they frequently get referrals and has established process to ensure a reliable flow of information Ongoing: All of the above, plus – Practice proactively and consistently obtains patient discharge summaries from hospitals and other facilities – Practice tracks patients receiving care at hospitals and EDs, proactively contacts patients/families for appropriate follow-up care given the cause of admission within an appropriate period following a hospital admission or emergency department visit.

– Follow-up care may include an in-person visit, physician counseling, referrals to community resources, and disease or case management or self-management support programs

▪

▪ ▪

Acceptable evidence

▪ ▪ ▪

Evidence of ongoing outreach to/contact with local EDs and hospitals Patient discharge summaries, evidence of appointments scheduled or calls made as follow-up, evidence of patient presence on calls or at appointments Additional evidence deemed reasonable by payer

▪

Notify the CPC practice of ED visits or IP admissions for high priority patients.

Participate in discharge planning activities with the CPC practice and inpatient facility in order to support a safe discharge placement and to prevent unplanned or unnecessary readmissions, ED visits, and/or adverse outcomes.

Support the post discharge services as specified in the discharge/transition plan.

Facilitate clinical hand offs, upon request from the CPC practice, between the discharging facility and other providers (e.g., home health, community behavioral health agencies).

Share timely, meaningful, and actionable data with the CPC practice that can facilitate effective care transitions.

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Tests and specialist referrals Provider requirement

Payer role

▪ Start-up: Practice has established bidirectional communication with

▪ When requested assist with

▪

specialists, pharmacies, labs and imaging facilities necessary for referral tracking Ongoing: All of the above, plus the practice has a documented process for and demonstrates that it: – Asks about self-referrals and requests reports from clinicians – Tracks lab tests and imaging tests until results are available – Tracks referrals until the consultant or specialist’s report is available, flagging and following up on overdue reports – Tracks fulfillment of pharmacy prescriptions where data is available

▪

bi-directional communication between the CPC practice and specialists, pharmacies, labs and imaging facilities, as needed, in order to facilitate timely exchange of information.

Share timely, meaningful, and actionable data with the CPC practice that can facilitate tracking and follow up of tests and referrals (e.g., when patients self-refer).

Acceptable evidence

▪ ▪ ▪ ▪

Contact list for common referrals Documented process for referral tracking Example referral track for a specific patient Additional evidence deemed reasonable by payer

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Patient experience Provider requirement

Payer role

Start-up: The practice has a process to orient all patients to the CPC practice and incorporates patient preference in the primary care provider selection process. The practice builds the continuity of patient relationships through the entire care process.

▪ Ongoing: All of the above plus – The practice assesses their approach to patient experience and cultural competence at least once annually through quantitative or qualitative means (e.g., a patient/family advisory council, focus groups, or a patient survey), and integrates additional data sources into its assessment where available – Information collected must cover access, communication, coordination, and whole person care and self-management support – The practice uses the information collected to identify improvement opportunities, and take action via concrete initiatives with dedicated staff time to improve overall patient experience and reduce disparities in patient experience

▪ Facilitate a warm hand off

Acceptable evidence

▪ ▪ ▪ ▪

Results from patient feedback (survey, focus group, advisory council, etc) Action plan resulting from patient feedback Documented process for patient orientation to CPC practice Additional evidence deemed reasonable by payer

▪

▪

between the MCP care manager and the CPC practice when care management responsibility transitions from the MCP to the CPC practice.

Provide quantitative or qualitative data with the CPC practice that can improve the patient experience (e.g., results from the MCP’s member advisory groups, member satisfaction surveys, grievances and complaints, member preferences, etc).

Participate in the CPC practice’s improvement opportunities, as requested, that are aimed at improving overall patient experience and reducing disparities in patient experience.

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Questions?

Please Mark Your Calendar August 25th Regional Learning Session • Doug Houg, Economist, Johns Hopkins University Author, Irrationality in Healthcare November 7th Care Coordination Forum • Full day conference focused on improving care coordination in Central Ohio December 8th Regional Learning Session • To be determined