ACC Request for Information - RCCO RFP Process
Colorado Department of
Health Care Policy and Financing
REQUEST FOR INFORMATION
RFI UHAA 2015000017
Accountable Care Collaborative Request for Information
THIS IS A REQUEST FOR INFORMATION (RFI) ONLY
THIS IS NOT A FORMAL BID SOLICITATION.
NO AWARD WILL RESULT FROM THIS RFI.
Page 2 of ii
Table of ContentsSECTION 1.0OVERVIEW31.1.PURPOSE OF THIS REQUEST
FOR INFORMATION (RFI)31.2.DEPARTMENT BACKGROUND31.3.PROGRAM
BACKGROUND31.4.VISION FOR THE NEXT RCCO RFP4SECTION
2.0ADMINISTRATIVE INFORMATION52.1.RFI TERMS AND
CONDITIONS52.2.POINT OF CONTACT62.3.NOTICES AND
COMMUNICATIONS62.4.TIMELINE6SECTION
3.0RESPONSES73.1.INQUIRIES73.2.PROTECTED HEALTH
INFORMATION73.3.RESPONSE FORMAT7 RESPONSE WORKSHEET` 8-32APPENDIX:
DEFINITIONS AND ACRONYMS 33-35
OVERVIEW
PURPOSE OF THIS REQUEST FOR INFORMATION (RFI)
The Colorado Department of Health Care Policy and Financing
(Department) is issuing this Request for Information (RFI) to
solicit input on the next phase of the Accountable Care
Collaborative (ACC).
Information provided to the Department in response to this
Request for Information will inform the Departments Request for
Proposals (RFP) for the Regional Care Collaborative Organizations
(RCCO) and the future design of the ACC Program.
Anyone interested in responding is welcome to submit a reply
(persons or entities responding to this RFI are called respondents
throughout this document). The Department encourages everyone with
ideas about the ACC to respond.
DEPARTMENT BACKGROUND
The Department serves as the Medicaid Single State Agency, as
defined by Code of Federal Regulations (CFR) Title 45 Section
205.100 (45 CFR 205.100). The Department develops and implements
policy and financing for Medicaid and the Children's Health
Insurance Program, called Child Health Plan Plus (CHP+) in
Colorado, as well as a variety of other publicly funded health care
programs for Colorado's low-income families, children, pregnant
women, the elderly, and people with disabilities. For more
information about the Department, visit www.Colorado.gov/HCPF.
PROGRAM BACKGROUND
The Accountable Care Collaborative (ACC) Program started in May
2011 with around 500 clients. Since that time, the ACC has grown in
many ways. Today, the program covers over 700,000 people. The
current phase of the ACC is focused on developing a strong network
of contracted providers that can serve as medical homes for
Medicaid clients. At the start of the program, enrollment was
comprised largely of adults, and the pay-for-performance measures
were designed for an adult population.
Over the course of the last three years, the ACC has expanded
its focus from the medical home to the whole neighborhood of
providers, such as specialists. Program enrollment expanded,
increasing the number of children to mirror the overall Colorado
Medicaid population. To continue developing the ACC, the Department
updated pay-for-performance measures to include children and
changed the payment model to support improved medical homes.
The ACC strives to provide the Colorado Medicaid program with a
client and family-centered, whole-person approach that improves
health outcomes and ensures savings. The program design includes a
focus on clinically-effective and cost-effective utilization of
services. The ACC works to identify the needs of clients and to use
local resources to meet those needs.
The ACC was designed as a platform to transform the Colorado
Medicaid program. The upcoming request for proposals (RFP) will
build upon the successes of the current program by further
developing the ACC to serve more people through greater efficiency
and other incremental improvements. In addition to these updates to
the program, this RFP will also seek to make bolder,
more-comprehensive changes to the ACC through deeper integration,
new payment reforms, and the promotion of whole-person/whole-family
health.
These improvements will also be strengthened by significant
investments in technology, as with the forthcoming Business
Intelligence and Data Management (BIDM) system. These new platforms
will allow for enhanced program monitoring and evaluation, and will
give all parts of the ACC Program better data to improve care and
decision-making.
As one of the major parts of the ACC, the RCCOs leverage local
infrastructure, relationships, and community resources. The RCCOs'
main responsibilities in the first RFP were:
Provider network development: developing a formal contracted
network of primary care providers and an informal network of
specialists and ancillary providers;
Care coordination: the RCCOs must ensure that every client has
access to an appropriate level of medical management and care
coordination;
Provider support: supporting providers in delivering efficient,
high-quality care by offering clinical tools, client materials,
administrative support, practice redesign, etc.; and
Accountability and reporting: the RCCOs are responsible for
reporting to the Department on the region's progress, and meeting
programmatic and Departmental goals.
The RCCOs are responsible for assisting clients with every
aspect of their care. This means that they have to assist clients
with their physical health and their behavioral health. The state
pays providers directly for physical health services. In Colorado,
Medicaid behavioral health services are managed by five Behavioral
Health Organizations (BHOs) statewide. RCCOs frequently work with
the BHOs to coordinate care. Almost all Medicaid clients are
enrolled in a BHO when they receive Medicaid. The BHOs get a set
amount of money to manage the care for Medicaid clients, and the
BHOs reimburse their network of providers for delivering services
to those clients. The five regions that the BHOs manage do not
match the regions managed by the RCCOs.
Today, there are seven RCCOs, each working in a specific part of
Colorado. Each RCCO has adopted a different approach that works in
its region. The RCCOs and their leadership play a vital role in the
ACC and offer customized and local health care experience to the
program. The ACC leverages personal, human connections to build on
the strengths of local and regional partners.
Just as the first RCCO RFP initiated the ACC Program in
Colorado, this second RFP will launch the next iteration of the
ACC. What the program looks like in the future depends upon the
RFP, and the content of the RFP depends upon the insight and
guidance you offer through opportunities such as this Request for
Information.
For more information on the ACC Program, click here
VISION FOR THE NEXT RCCO RFP
The next phase of the ACC Program will build on the strengths
and the lessons learned during the first iteration. There are three
main goals of the next RFP. The Department welcomes input on these
goals and how to achieve them.
1. Transforming our system from a medical model to a health
model.
A person's health is impacted by his or her social situation
(for example housing, income, transportation, nutrition, presence
of supportive family and friends) as well as medical care. The next
phase of the ACC Program aims to promote health by developing
systems that support healthy lives, rather than just medical
care.
2. Moving toward person-centered, integrated, and coordinated
supports and services.
Person-centered care means that the individual/family/caregiver
is an equal participant with the provider in defining health goals
and developing treatment plans. These both must address the whole
person and be achievable within the context of the person's life.
To accomplish this, RCCOs must also be able to coordinate
more-closely with non-medical services and other state agencies. In
order to do this, RCCOs must understand the community and culture
where the person lives.
Part of a whole-person or person-centered approach is addressing
both a person's physical and behavioral health needs in a way that
is coordinated and cohesive, often referred to as integration.
Taking steps towards integration or better coordination of physical
and behavioral health care for Medicaid clients is a primary goal
of the next RFP. Behavioral health care refers to all services to
treat health conditions that primarily present as alterations in
thinking, mood or behavior and changes in emotional (mood),
psychological (thinking), or social well-being (behavior) and
conditions related to addictions. To create the infrastructure for
this integration, the Department seeks input on whether or how the
Behavioral Health Organization (BHO) or RCCO maps or functions
should be adjusted so that they are aligned.
This next RFP will aim to continue to build on local strengths
of each community. This RFP aims to be sensitive to the diverse
needs of clients with Medicaid coverage and will develop specific
expectations around meeting the unique needs of subpopulations such
as children, adults, the elderly, persons with disabilities,
clients involved in the criminal justice system, and all
others.
Incorporating clients' perspectives is an ongoing process. The
next RFP aims to strengthen opportunities for clients and advocates
to provide input and play an important role in program design and
ongoing improvement.
3. Leveraging efficiencies to provide better quality care at
lower costs to more people.
The next RFP aims to capture efficiencies and save money through
enhanced technology and by supporting a diverse and changing health
care workforce.
The RFP endeavors to align the financial drivers for all
elements of the Medicaid delivery system. Through the RFP process,
the Department will explore different ways to pay for care, bend
the cost curve, and be as cost-effective as possible.
ADMINISTRATIVE INFORMATION
RFI TERMS AND CONDITIONS
This RFI is issued solely for information and planning purposes
and does not constitute a solicitation. Information about costs and
pricing is submitted voluntarily and is non-binding on the
respondent. Responses to this RFI will not be considered legal
offers nor will they result in an award of any type of
contract.
The Department is not responsible for any costs incurred by any
respondents for the development and provision of a response to this
RFI.
The Department is subject to strict accountability and reporting
requirements as a recipient of funds from public sources. Responses
to this RFI are subject to disclosure by the Department as required
by the Colorado Open Records Act (CORA). The Department plans to
make responses to this RFI available for review online.
The Department reserves the right to copy any information
provided by respondents for the purposes of facilitating the
Departments review of / use of the information.
The Department reserves the right to use information or ideas
that are provided by respondents. By submitting information in
response to this RFI, the entity or individual represents that such
copying or use of information will not violate any copyrights,
licenses, or other agreements with respect to information
submitted.
The responses received from this RFI may be used for the
development of a future solicitation. Should a solicitation be
issued, further details on the solicitation process will be
provided.
POINT OF CONTACT
The Departments point of contact for this RFI is:
Kevin Dunlevy-Wilson (note: other Department staff may address
e-mails or phone calls)
Department of Health Care Policy and Financing
Accountable Care Collaborative Strategy Unit
1570 Grant Street
Denver, CO 80203-1818
Phone: 303-866-5351
[email protected]
NOTICES AND COMMUNICATIONS
Communication with respondents will be via various methods
including, but not limited to, e-mail, phone, mail, the
Department's ACC RFP Web site
at:https://www.colorado.gov/pacific/hcpf/regional-care-collaborative-organizations-rccos-request-proposals-rfp
and notices on the CORE Web site
at:https://codpa-vss.hostams.com/webapp/PRDVSS1X1/AltSelfService;jsessionid=00007DX5IavpsnQoNcRwuPiYmie:189n1q4b1.
Respondents can view information posted on CORE by clicking on the
Public Access button. It is the respondents responsibility to
periodically check the Colorado CORE Web site or the ACC RFP Web
site for notices, changes, additional documents or amendments that
pertain to this RFI.
TIMELINE
The timeline for this RFI is as follows:
ACTIVITY
DATE
RFI RELEASE DATE
OCTOBER 21, 2014
INQUIRIES REGARDING THE RFI ACCEPTED UNTIL
OCTOBER 31, 2014
11:00 AM MOUNTAIN TIME
DEPARTMENT RESPONSES TO RFI INQUIRIES (ESTIMATED)
NOVEMBER 10, 2014
RFI RESPONSE SUBMISSION DUE DATE
NOVEMBER 24, 2014
3:00 PM MOUNTAIN TIME
RESPONSES
INQUIRIES
For inquiries about this RFI, you may send an email to:
[email protected]. If preferred, you may also contact the ACC RFP
team by phone at: 303-866-5351. Include the RFI number and title
listed in the e-mail subject line.
The Department will track the questions that it receives and
aggregate the questions into an Inquiries and Answers document.
Inquiries received by the Department by the Inquiry Deadline
will be responded to by the Department via a posting of the
Inquiries and Answers document on the CORE Web site and the ACC RFP
Web site. Inquiries received after the Inquiry Deadline may not be
included in the Departments response.
PROTECTED HEALTH INFORMATION
Do not include Protected Health Information (PHI) in your
response.
If the Department discloses the responses online or via a CORA
request, unless the responder explicitly requested otherwise,
responses by all Medicaid clients will be identified only by first
initial and county of residence. Example: John Doe would be listed
as: "'J.' Weld County." Requests for pseudonyms will generally be
granted if requested.
RESPONSE FORMAT
The RFI is broken into the following sections:
Basic information about you, the respondent.
General Questions
Behavioral Health Integration
Care Coordination
Program Structure
Stakeholder Engagement
Network Adequacy and Creating a Comprehensive System of Care
Practice Support
Payment Structure and Quality Monitoring
Health Information Technology
The Department is requesting respondents to send any comments or
answers, no matter how minor, to the Department. Respondents are
encouraged to address the questions listed in the Response
Worksheet, but you do not have to reply to all of the questions in
a section.
Please note that early responses are appreciated. Respondents do
not need to wait until SUBMISSION DATE (see Section 2.4) to submit
comments. The Department appreciates receiving any and all comments
from respondents.
Reponses should be emailed to [email protected]. Your answers
may be submitted as an attachment or an email. If they cannot be
emailed, they may also be sent, in hard copy, to: Colorado
Department of Health Care Policy and Financing, Attention: ACC
Team, 1570 Grant St., Denver, CO 80203. Following receipt of your
response, you should receive a confirmation email within three (3)
business days.
RESPONSE WORKSHEET
Basic Questions for All Respondents to this Request for
Information:
Please provide your name and location:
Name:Julie Reiskin
Location:Denver, CO
If you are a member of (or affiliated with) an association,
business, or other similar entity, please provide the name and
location of that organization:
Name of organization:Colorado Cross-Disability Coalition
Location:Denver, CO
Please check if you are answering on behalf of this entity
Please choose the best description for you, your organization,
or the person on the behalf of whom this response is being
submitted Check all that apply:
Client
Client's family member
Client advocate
Medical provider / PCMP / other provider
i. Type or specialty: Click here to enter text.
ii. Area of practice: Click here to enter text.
Provider advocate (e.g. medical society)
Potential bidder for RCCO contract
Behavioral Health Organization
Data or HIT entity
Foundation
Educational or research institution
Another public or private program
Legislator or elected official
Other (please describe): Click here to enter text.
Are you currently involved in the ACC program?
Yes
No
I don't know
If you answered "yes" above, how long?
Less than one year
1-2 years
2-3 years
3-4 years
Since before the program was implemented.
How have you been involved in the ACC program and what
interaction have you had with RCCOs:
Worked with two RCCO on disability issues and with one on client
engagement. Worked with HCPF on similar issues. Involved in Duals
Demonstration.
Please briefly describe your involvement with Medicaid, either
in Colorado or another state:
CCDC has been deeply involved with Medicaid and HCPF since the
department was formed. We are on numerous advisory and stakeholder
committees, and have had a member on the MSB since its inception.
We are a key group that brings the client voice to HCPF. We have
developed programs such as CDASS and have been very active in all
areas of community based LTSS and have been involved with Olmstead
and transition. We have been active in benefit collaborative work.
We were active in the managed care contract, which was the
predecessor to the ACC/RCCO program. We also provide individual
advocacy for clients and applicants on both eligibility and service
related issues. We represent people with appeals and complaints as
needed. We work with most of the provider groups both in an
advocacy role and when appropriate as a collaborator on projects. A
significant part of the work of our organization is directly
involved with Medicaid.
If you are a client, provider, or potential bidder, what is the
likelihood that you will seek to participate in the program?
Very likely
Likely
Reserved (waiting to see the RFP)
Unlikely without significant changes
Will not seek to participate
N/A
The program is here and we support this program as a way to
coordinate and manage care without using a capitation model, which
does not work well for the population we represent. We think the
program is showing promising results, even though the data for
disability groups is less promising, we are eager to see it move
forward.
General Questions
1) What is working best in the Accountable Care Collaborative
(ACC) right now?
There are two RCCO organizations that are actively working with
the disability community and seeking our involvement and input.
Rocky is doing some innovative care coordination and starting a
payment reform pilot project. We are pleased that the Duals demo
will include Independent Living Philosophy.
2) What is not working well in the ACC Program?
Physician attribution and poor mailing list addresses are making
it very hard for the RCCOs to do appropriate early outreach. They
are getting bad information from HCPF. The opt out rate at least
for duals is concerning. The data on disability shows that there
needs to be more attention paid to disability and that is not
surprising given only one RCCO is really paying close attention to
this population in a meaningful way and figuring out why there are
not the same gains in terms of reduction of ER, imaging, etc. for
this population.
3) What is working best in the Behavioral Health Organization
(BHO) system right now?
Very little is working well in this system except that there are
a few good providers and the people lucky enough to be in those
clinics are getting quality services. These clinics are those that
stay small enough to do a good job. Denver Health does a good job
for the people in their clinic who are able to manage to show up at
appointments and follow their rules. CHARG is fantastic.
4) What is not working well in the BHO system?
Access to care remains a VERY serious problem. People are
reporting a 3-6 month wait and access to medications and
psychiatrists is the biggest problem. People who move or who come
out of jail are forced to decompensate because they cannot get
services and many cannot get into a primary care doctor either.
The data for whatever reason is not capturing this serious
access problem. Clients that come to the attention of the system
may get an appointment but most clients just wait and for some
reason it is not showing that they are waiting as long as they are.
We do not see a lot of good innovative treatment in the public
mental health system. We do not see strong client engagement,
meaningful recovery markers, etc. There seems to be little to no
mental health advocacy that is client focused.
The system remains very punitive and harsh, despite great
language in the HCPF contract and great promises by the BHOs
clients continue to get kicked out of treatment for not showing up,
unless they commit crimes and get into some special program. If the
client is just disorganized and unable to manage their lives to be
where they are supposed to be are being left out in the cold.
5) What is working well with RCCO and BHO collaboration right
now?
We have not seen evidence of anything working well, this does
not mean that nothing is working, only that we have not seen it.
There may be some ability in Colorado Access to make referrals more
easily but we have not seen that result in quicker access to actual
care. In Colorado Access there is ability of case managers to come
together because they work for the same company.
6) What is not working well with RCCO and BHO collaboration
right now?
The silo mentality is still alive and well so not much is
happening. The lack of access to mental health care and
continuation of the mental health center monopoly for Medicaid
clients creates a huge access issue. Our information is that most
preventable emergency room care is due to behavioral health
emergencies, but the RCCOs are not allowed to interfere and do
anything about the problem. They are required to collaborate with
the BHOs and are not in a place politically (and in one case
structurally) to report to HCPF areas where the BHO is not
fulfilling their contractual obligations. For this to work it is
imperative that HCPF do some independent enforcement OR put the
RCCO in a position of authority over the BHO (preferably the
former).
Behavioral Health Integration
7) What should be the next steps in behavioral health
integration in Colorado?[footnoteRef:1] [1: Many terms and
definitions can be found in the Appendix at the end of this
document.]
Until the behavioral health system can handle the client needs
nothing more can or should be done. We should not assume that
primary care doctors cannot and should not do any behavioral health
prescribing. The model that has been in place has not worked. We
need to admit that and move on. We have a few areas that have
produced results (Denver Health, CHARG, etc) and we should figure
out why they work and replicate. It is disturbing that the crisis
contract was not given to a company that has innovation experience
in other states but that was not a HCPF decision. Access to even
basic psychiatric care is a crisis in Colorado in the public
system.
Co-location is OK for some clients in some situations. There are
varying needs amongst the large Medicaid population and the system
should not assume that all clients have the same needs. Some
clients need ONLY a psychiatrist and medication management and do
not need therapy. Others may need ONLY therapy and no medications.
Still others need case management and psychosocial supports.
It is important to NOT assume that all people with mental
illness have substance abuse problems and to make sure that the two
populations are not dumped together as there may be victimization
against those with serious mental illness by substance abusers.
Moreover, the clinical needs are different. People with both drug
and alcohol abuse and mental illness have a different set of needs
and need to be treated for both problems.
Of course, the complete lack of behavioral health for people
with developmental disabilities still continues to be a
problem.
ACC Request for Information
CORE ID # RFI UHAA 2015000017 Page 2
8) Barriers to the integration of behavioral health and physical
health services. Using the table below, please explain which issues
are barriers, and how they can be addressed:
Barrier?
Factor:
Yes
No
If yes, please provide details of the barrier and how to address
it:
Community Mental Health Center financing
structure[footnoteRef:2] [2: More information about these rules,
payment types, and entities can be found in the Appendix at the end
of the document.]
This is a problem but not a barrier, they are getting paid for
every man, woman and child on Medicaid and expected to provide
specific services but have no consequences for failure to do so
Community Behavioral Health Services Rule
Not sure if the rule is really the problem, but the lack of
consequences for failure to meet access standards is a problem.
Covered diagnoses list
We need to add autism on because people with autism use the same
medications and need behavioral health interventions. The BHOs also
Must be forced to stop denying services to people with TBI and
I/DD
Different behavioral / physical health reimbursement
I do not know enough about the details to know if reimbursement
is a problem, but there seems to be enough money in the system.
Institutions for Mental Diseases exclusion
Please do not eliminate this, we need to make sure there are
strong incentives against putting people in state institutions. If
someone needs a hospitalization to address a medical problem they
should be on a psych ward but in a regular hospital with medical
backup like Denver Health or Porternot in a stand alone psychiatric
facility especially a state run institution.
OBH rules, reporting, or financing (regulatory differences
between agencies)
We need one enforceable standard and increased enforcement of
access standards and increased quality oversight
PCMP financing structure
Not sure how this affects behavioral health care, however there
is a problem with not enough primary care doctors and clients with
mental health or other disabilities are at risk for not having any
PCP
Per-member per-month amount
If this amount is not adequate the BHO should not sign a
contract.
Physical space constraints
Unsure but with the huge increase in Medicaid clients this might
be a problem
Privacy Laws (HIPAA, 42 CFR)
This is a problem everywhere and in mental health it becomes
worse this seems to come up more when people want to avoid
involvement of families and advocates. HIPAA rules do cause
problems with law enforcement and mental health but it is probably
a good civil rights protection to have the restrictions.
Professional / cultural divisions
Lack of disability cultural competency is an issue for surethere
is lack of cultural competency in other arenas as well. This
includes lack of respect for Native people in SW CO, lack of
cultural competency in rural resort communities, etc.
RCCO or BHO contracts
The contracts themselves are pretty good, the enforcement is the
problem.
Staff capacity
This is a HUGE issue in the behavioral healthcare arena. It is
also a problem with primary care. Everyone knew that the Medicaid
roles would be exploding after ACA so there should have been more
preparation. Now that the ACA has been in place, contractors that
have not addressed the problem should be replaced. If there is
really no way to have adequate staff then something else needs to
happen, such as using other doctors to prescribe. Telling people
with genuine mental illnesses to wait months, or even weeks, to get
medication is unacceptable.
State/Federal rules or reporting requirements
As a client advocacy organization we are not aware of
requirements that are a problem.
Technical resources / data sharing
We know the RCCO organizations are not getting accurate
information for new clients which makes outreach hard.
Training
There is a lack of training on disability accessibility,
disability cultural competence, ADA compliance and how to provide
appropriate services and effective communication to the population
we represent. There is a lack of clinical expertise on how to work
with people with I/DD and the few that are able to do this seem to
be excluded from provider networks.
Others
Please type your response here.
The Medicaid roles have exploded due to the implementation of
ACA. This is great, however we need to make sure those with the
greatest need are not cast aside to serve those with lesser needs.
The access issues have become extreme especially with behavioral
health care. There is no one enforcing the contracts and the data
is not showing the problems, but everywhere people report the same
thing.
Some of the people that have a great need for integrated care
are those not served by the BHO system such as people with TBI,
autism, Alzheimers, etc. Since the BHO system is unlikely to serve
them well (given the track record with other disabilities) funds
paid on behalf of these populations should be diverted to a system
willing and able to provide the care. In some instances this could
be the RCCO.
While co-location is OK that will only work if clients have
access to both the psychiatrist and the physician. Just having two
provider types at the same location is not going to cause
integration. Integration will only occur if there is a go to
person, such as a social worker or medical care manager that can
really know the client and carry info between both provider types.
It is important that these care coordinators NOT be treated like
doctors. Doctors go to medical school for a reason and having
nurses and others prescribe drugs, at least to people with complex
conditions has had devastating results.
For many clients a shared electronic portal where the client
could write information or even a system where a client could
self-report symptoms and health issues that both the medical and
behavioral providers could also access could be a great tool and
would mitigate the need for co-location and even can work if the
PCP and mental health professional are in different places. Some
clients have good doctors and get mental health elsewhere and these
systems work for the most part and should not be disrupted.
Clients that have both mental and physical disabilities need
personalized care and do not do well in large clinics where there
is a lot of confusion and many rules to follow. They need ONE go to
person that can connect them to the right person, in a
compassionate, humane, ethical manner.
9) What characteristics are necessary for the State to recognize
a clinic as providing integrated, whole-person/whole-family
physical and behavioral health care?
a) Every client is assigned to ONE person with clinical skills
who will have access to medical and psychiatric expertise as
needed. The client will have a direct phone number and email and
can communicate with the go to person as needed. The case load will
be such that same day response will be the norm for issues that
require it.
b) All clients on psychiatric medication have complete annual
physicals and quarterly blood work.
c) All clients on psychiatric medication are OFFERED (but not
required) support for weight management. This needs to be done in a
non-judgmental, kind manner, and cannot be about lecturing or
shaming clients.
d) Clients who are opposed to taking psychiatric medication can
still get other behavioral health care services such as
therapy.
e) Physicians are trained in mental health and are graded by
clients with mental illness about compassion and listening ability.
There are measures to assure that physicians take seriously medical
complaints of people with mental illness and do not assume that
complaints are psychosomatic in origin.
f) There is emotional support for caregivers even if they are
not on Medicaid. Medicaid services that ease the life of a
caregiver are considered medically necessary and not an item of
convenience (within reason of course) and all providers are trained
on long term caregiver stress.
g) It becomes standard practice to prescribe supports so that
there is no longer an expectation that parents continue to bathe,
dress, and toilet a child, or provide 24 hour line of sight
supervision, or deal with sleep deprivation without support once
doing these tasks is no longer age appropriate. For example after
toddlerhood a parent should not have to deal with nighttime
interruptions, once a child is 10 or older parents should not be
involved with bathing and dressing unless they are a compensated
attendant (and never should the parent be the only attendant). It
is the doctor that needs to be having these conversations with the
family at an early age.
h) Prevention and health promotion are for everyone. This means
that ALL clients are screened for things like pain management,
sleep regularity, nutrition, etc.
i) Doctors are encouraging clients to have a meaningful day and
act as active advocates and promote/prescribe whatever supports are
necessary to make that happen. This means the doctor or someone at
the office needs to know about LTSS and other resources. For
example that might be a referral to CDASS or IHSS, encouraging
someone to volunteer, refer to DVR, assure that the client has a
wheelchair that is appropriate for outdoor use, etc. There is
support to help clients pursue.
j) Doctors and staff understand and can articulate the
Independent Living Philosophy and Olmstead.
10) Please share any other general advice or suggestions you may
have about behavioral health integration.
Until HCPF holds the BHOs accountable for access standards,
there will not be successful integration of behavioral health. The
RCCOs are in an awkward position in that they are supposed to
coordinate but if they have to work as partners with the BHOs they
cannot really report to HCPF or actively advocate. People have been
saying there are access problems for years, and there continues to
be data problems. This should tell HCPF that either the data
collection is a problem or they are not collecting the right data
or something else is wrong. Otherwise this would not continue to be
a problem. Simply the behavioral health emergency room visits
should be enough to prove there is a problem.
HCPF should hire clients to be secret shoppers to test access
and other aspects of the system. This might require HCPF to give
clients dummy ID numbers.
Clients do not know what to expect so they do not complain when
they do not get adequate access. If they decompensate due to lack
of medication by the time they can get help they are often in such
bad shape that they cannot complain. Perhaps having the RCCO give
clients information on what they should expect in terms of access
to behavioral health could help. That may be a conflict of interest
for some, but at least it should be tried. Contracting with other
organizations such as Independent Living Centers or organizations
like Family Voices could get the word out about access standards
and also help clients understand what they should expect regarding
quality would also help. Even providing information on these issues
to application assistance sites might help.
Care Coordination
11) Care coordination is an important part of the ACC
Program.
a. What is the best definition of care coordination? The below
definition is about long-term care coordination but is relevant for
all care coordination, specific tasks are outlined in footnote
#2.
Long Term Care Coordination is a consumer-directed, team
approach to the integration of care, services and support for
optimizing health and social outcomes.
Those outcomes include:
Care coordination(1) must allow people to maintain control to
the greatest extent possible.
Care coordination and activities of care coordination2 must
recognize people may require different levels of support based upon
individual strengths and/or desires.
Care coordination must allow people to change care coordinators
upon request.
Care coordination provides tools and supports for people to take
increased levels of personal responsibility.
Care coordination encompasses person centered care(3),
self-determination (4) and consumer direction(5)
. 1 Care coordination is the facilitation on behalf of the
person to obtain or retain medical and non-medical services to meet
their goals and needs.
2 Activities include finding providers, scheduling appointments,
helping problem solve to mitigate any barriers such as
transportation, copays, assisting with applications,
redeterminations, prior authorizations, appeals processes and all
ancillary care. It provides referrals to resources to assist the
person in meeting their other life needs and goals, including
offering referrals to advocacy organizations and peer-to-peer
support
3 Person Centered care focuses on the preferences, strengths,
capacities, needs and desired outcomes or goals expressed by the
person. Any planning process, regardless of the persons choice of
service delivery must be an interactive process that supports and
enhances the individuals stated preferences. Any discussion related
to an individual or event supporting an individual must focus on
the Person-Centered approach and should utilize the values of
Self-Determination.
4 Freedom to decide how one wants to live his or her life;
Authority over a targeted amount of dollars; Supports to organize
resources in ways that are life enhancing and meaningful to the
person; Responsibility for the wise use of public dollars;
Recognition of the contribution individuals across Disability and
aging can make to their communities and Confirmation of the
important roles that individuals must play in the newly designed
system
5 People with disabilities assess their own needs and make
choices about what services would best meet those needs. It makes a
statement that consumers can and should have options:
- to choose the personnel or provider entities that deliver
their services,
- manage the how, when, and where of delivery of services, and-
monitor the quality of services.
Choice is guaranteed including the choice of how much to direct
or not direct services.
THE ABOVE DEFINITION HAS BEEN AGREED UPON AND VETTED BY MANY
ORGANIZATIONS AND INDIVIDUALS WITHIN THE DISABILITY COMMUNITY.
Please see www.INDIVISIBLE-CO.org
b. How should RCCOs prioritize who receives care coordination
first?
First, it should be based on anyone that asks for care
coordination. CCDC has been disappointed in a couple of situations
where a client self-identified the need and was denied meaningful
or any care coordination. Even if the client is difficult and time
consuming, the RCCO should absolutely be required to provide this.
Literature and HCPF/RCCO web sites should provide specific email
and contact information for people to make this request.
Second, should be based on data. They currently are doing this
with high ER utilizers and this is OK but they should also be
prioritizing in other areas including: All of these are situations
where the client should be OFFERED care coordination but not
required. It should be stated clearly what care coordination is,
what the offer is and that there is no consequence to saying no.
Clients should be allowed to meet with someone to discuss and there
should be something written given to the clients to explain what it
is an expectations.
-People with no known address
-People with no PCP especially if they have specialty needs
-People who have been taken off HCBS for any reason
-Anyone that has been in a rehab center if not on HCBS
-People with multiple medical testing or more than 10
medications should be offered it
c. How should RCCOs identify clients and families who need care
coordination?
-They should do outreach and allow as many clients as possible
to self identify. This includes web sites with clear info on what
it is and how to access.
-They should have an easy process for other agencies, including
advocacy and provider organizations to refer for care coordination.
This should be an online process and should allow for the
submission of a release if the provider or advocacy organization
wants to be kept in the loop (and the client wants this also). The
process should explain clearly what to expect (e.g. if you make a
referral the client will receive an email or call within X days and
should be able to have an in person meeting at an office in X town
within X days. It should tell us how to access Medicaid
transportation for the first appointment. There should be a place
for our clients to ask questions before agreeing to care
coordination.
-Using claims data to do outreach and offer care
coordination.
d. How should RCCOs track care coordination when the care
coordination takes place at a delegated Medical provider?
There should be a very easy to use standard tracking program, if
a medical provider office is not willing to use that form then they
should ask for reporting in whatever way the provider will do it
and try to incorporate into their system.
Tracking should include both outcomes and outputs and should not
assume quantity will be the same for all clients. Tracking should
help inform decisions like appropriate caseload size for a care
coordinator. It should also have a way to incorporate client
feedback.
12) What services should be coordinated and are there services
that should not be a part of care coordination?
Finding providers, scheduling appointments, helping problem
solve to mitigate any barriers such as transportation, copays,
assisting with applications, redeterminations, prior
authorizations, appeals processes and all ancillary care. It
provides referrals to resources to assist the person in meeting
their other life needs and goals, including offering referrals to
advocacy organizations and peer-to-peer support
It should include advocacy to get into LTSS and perhaps advocacy
if client has a problem with the LTSS care manager but should not
include that at this time since that is a different system (at some
point we can address this but not right now).
It SHOULD include helping people with problems that affect
health such as housing advocacy e.g. advocating that a local
housing authority do appropriate pest control. They should also be
doing things like writing reasonable accommodation letters for
housing issues.
It SHOULD help people get services and supports to have a
meaningful day (e.g. move to CDASS so they can get an attendant
mid-day) but should NOT be involved in any way with employment or
even volunteer work or education. These are areas where ones health
care has no business.
It SHOULD help people get resources for healthier living (access
to gyms or rec centers, getting transportation to said places,
etc.) but should NOT engage beyond that or engage with family
issues or psychosocial issues unless there is a health
connection.
It SHOULD do whatever is appropriate to help a child stay in
school, especially if the child has school avoidance behaviors.
13) What pieces of information are most important to have about
someone in order to know what care coordination he or she
needs?
-What are current services and are they working well (IF SO
LEAVE IT ALONE)
-Does person have unmet health goals? If so what?
-Does person have things that they do during the day that are
meaningful? If not that will lead to bad health.
Do they have other stresses that are too much (caregiving on top
of a job, etc)
-Do they eat enough and have choices of what they eat (or do
they have to eat government cheese and lots of 99 cent fast
food)?
-Do they sleep well?
-Do they have a primary care physician and if so are they
comfortable with the person?
-Do they have dental care?
-Do they have untreated or unmanaged pain?
14) Many clients and their families have access to a number of
different care coordinators. These coordinators often work in
different systems.
a. What care coordination is going on today?
-LTSSall waiver clients have a care manager
-Mental health-some BHO clients have a care manager
-Clients in some housing programs have a care manager
-Some clients have care managers from other places like
Independent Living Centers, AAAs, Arcs (ILC and ARC do not do case
management but often end up doing the same things because no one
else is doing it and their client needs it).
-EPSDT (rare but some people have it)
-People on probation
b. What care coordination takes place outside of the RCCO or
ACC, and what makes that coordination different?
See above, each is different. For example HCBS coordinates ONLY
LTSS. In the DD system it is different and more involved but in the
EBD system it is more gatekeeping (which is OK) and setting up
services, does not really deal with health.
Mental health case management when it happens is the closest to
what the RCCO should be doing.
Housing/homeless programs often help people deal with benefits,
sometimes they are transitional and go away after a specific amount
of time.
c. How can the ACC avoid duplicating or disrupting current care
coordination relationships?
Ask each client who else they work with and if they already have
a case manager bow out unless the client wants them to be involved.
Make sure that there is NO interference with LTSS but should be
strong referral to LTSS. RCCO CM should be able to advocate for
client with the LTSS CM (example, the client is getting sick
because the house is not clean enough and client needs more
homemaking hours, client needs to be getting out of the house and
needs non-medical transportation)
d. What are the gaps in care coordination across the continuum
of care?
-People with complex or high needs but who do not abuse the ER
and do not abuse drugs or alcohol are completely left out and are
not getting their needs met. Also people who are may not have high
needs but who have needs and are unable to access care without help
need care coordination.
-People who need help with cross-systems issuesfor example they
need medical letters for housing purposes, or need help moving due
to a medical problem, or need transportation to get to a probation
appointment need coordination.
-People with disabilities that want to engage in healthier
habits and lifestyle have no one to help them navigate and find
resources to help make it happen.
-People with communication barriers including but not limited to
people with speech impairments, traumatic brain injury, mental
illness, learning disability and people with cognitive impairment
who do not have guardians.
15) RCCOs' roles in addressing clients' and their families'
non-medical needs. Please complete the table below, keeping in mind
adults, children, and families:
Non-medical need:
Should the RCCO have a role?
Should the RCCOs coordinate with community supports and
services?
Should the RCCOS have an additional role beyond coordinating
with these supports? If so, what should that role be?
Yes
No
Yes
Abuse, neglect, and trauma
Unless client wants counseling or there are medical issues as a
result. They should understand and practice trauma informed care.
They should understand that some in the disability community
experienced abuse by medical professionals.
Affordability (assistance with prescriptions or co-pays)
Medicaid co-payments are minimal, however they should still try
to help if someone is unable to follow medical advice due to these
payments.
Daycare / childcare
This is a challenge for all low income parents. CDHS runs a
program which is not terribly client friendly.
Economic stability & employment
Economic stability is a need for everyone and while poor health
and poverty are correlated, the RCCO cannot be all things to all
people. The one exception is that they should encourage people to
work and make sure providers are supporting what people need to
work in terms of DME, pain management, etc.
Education
They may want to coordinate with school based health clinics in
some situations. However education is something all kids need and
is very important, but again, this is a health program and cannot
be all things to all people. Providers should make sure they are
prescribing and advocating for what kids and young adults need to
be successful like DME, assistive technology, etc. Kids with IEPs
should not be forced to spend half their school day getting therapy
and losing important educational time.
Environment
Not sure exactly what this is about but if it is about things
like bed bug mitigation or asbestos they should be involved as
advocates and perhaps even helping clients access financial
resources.
Food access / nutrition
People cannot be healthy without food, they should give people
information and refer to community resources. Some clients may need
advocacy. RCCO case managers should help clients get as many
medical deductions as possible to increase food stamps.
Health literacy
This is absolutely a perfect fit for RCCOs.
Housing
Housing and health are connected but it is important that
housing and services are NOT connected. I checked yes ONLY because
there is a need for case managers to help with advocacy, reasonable
accommodation letters, etc. RCCO should not provide it directly but
should refer and be involved with advocacy as often clients need a
medical professional especially if they deal with housing
authorities.
Language or translation services
This is a requirement under CMS for LEP
Literacy
Literacy is important for all, it is not a health issue in
general. RCCOs should refer to community resources.
Transportation
RCCO should not provide it directly but should refer and help
people use Medicaid transportation and should also refer and fill
out paperwork for paratransit or mobility training as needed. The
case managers should understand local transportation options so
they can encourage and support clients.
Other
Please type your response here. Feel free to list as many
non-medical factors as you want, and please explain how the RCCO
should be involved.
16) Requirements about who should be doing care coordination.
Care coordination is often a team effort with several people with
different skills working together to serve Clients and families.
Please use the table below to describe who should be a part of
coordinating care and what roles those different people should
play:
Type:
Coordinate care?
In what capacity should these individuals coordinate care in the
ACC Program?
Yes
No
Advanced Practice (Registered) Nurses
For medical care only but not social care
Certified Addiction Councilors
Certified Nurse Midwives
For pregnancy and infancy related care only
Community Health Workers
Need more info about what this means but they should be able to
help with community referrals and advocacy
Generalists (BA/BS/MA/MS)
Would need more info as to qualifications, having a degree alone
is not enough
Health Coaches
Licensed Clinical Social Workers
Ideal for care coordination if properly trained
Licensed Marriage and Family Therapist
Licensed Mental Health Counselors
Licensed Professional Counselor
Masters of Public Health
Medical Doctors / Doctors of Osteopathic Medicine
Only for some medical coordination for example coordination of a
complex medical procedure only but not social or supportive follow
up
Nurse Practitioners
Should focus on medical aspects
Patient Navigators
If properly trained should be able to do all aspects of care
coordination and do it well
Peer Advocates
If properly trained should be able to do all aspects of care
coordination and do it well
Promotoras
If properly trained should be able to do all aspects of care
coordination and do it well
Psychiatrists
Psychologists
Registered Nurses
Only for health related aspects
Social Workers
Only if licensed
Wraparound facilitators
Other
Please type your response here.
Contracts with Independent Living Centers or other advocacy
organizations like Family Voices could be used to do specialized
care coordination.
Some LTSS care management organizations especially some of the
ones that have worked with CHCBS might be good care
coordinators.
17) Care coordination requirements for specific populations.
Please use the table below to describe if any of the following
populations require unique care coordination requirements, or if
general requirements are sufficient:
Population
Specific
General
If specific, please describe
Newborns and infants
Children
Children who are healthy, but in socially-complex
environments
Depends on situations but if parents want it or if DHS is
involved
Children involved in the foster care system
Absolutely legal knowledge is imperative for issues like medical
records
Children with a chronic illness
If no one else is doing it-should have family systems
training
Children with a serious emotional disturbance
If no one else is doing it-should have family systems
training
Children with medical complexity
Should be medical management if no one else is doing itshould
have family systems training
Children or youth with a behavioral health diagnosis or
substance use disorder
Transition-age adolescents
Parents and families
Pregnant women
Adults
Adults who are healthy, but in socially-complex situations
Only if client wants it
Adults with a chronic illness
Adults with a behavioral health diagnosis or substance use
disorder
Depends on needs
Clients involved in the criminal justice system
Yes definitely
Clients with a disability
Depends on needs
Clients in a nursing facility
Oversight to make sure medical care is OK and for MFP
Elderly clients
Depends on needs
Frail elderly clients
Yes but already should have through LTSS
Clients in palliative care
They would have this through palliative care already
Other populations, please comment:
18) How do you envision the RCCOs working with child-serving
agencies in the state to deliver care for medically or socially
complex children or for children involved in the foster care
system?
Would defer to Family Voices and Parent to Parent and EMPOWER on
this question.
19) How should care coordination be evaluated? How should its
outcomes be measured?
What is client goal? Did CC help client meet goal?
Are more adults with disabilities working or volunteering
without interruption due to preventable medical problems (pressure
sores or contractures) or failed systems (broken wheelchair) or
inability to get care when they need it (mental health)?
Reduced hospitalizations
Are more adults taking action to improve health (going to
dentist, losing weight, increasing activity, etc.) after receiving
care coordination support?
20) Today, RCCOs receive $8-$9 per member per month (PMPM) to
cover care coordination and other expenses, like developing and
supporting a network of providers.
a. What is the PMPM cost for providing care coordination
services?
We are not a provider so cannot answer.
b. Is it advisable to have the PMPM vary by specific population?
If so, what would be the recommended PMPM cost by population?
Yes it would be advisable as some populations require people who
are culturally and otherwise competent to work with them (e.g,.
Deaf) but we are not provider so cannot answer cost.
We will say that people with complex needs need a LOW client to
case manager ratio.
21) Should there be care coordinator to client ratio
requirements in the next RFP? How should this vary by client acuity
or population?
YES and should vary by population and level of service
expected
a. Care coordinator to client ratios. If you answered yes to the
previous question: with roughly 45% adults, 55% children, and with
6% of covered clients having disabilities, please estimate how many
clients one care coordinator can serve. Please use the table below
for your response:
Clients
Fewer than 25
26-50
51-100
101-200
201-500
501-1,000
1,001-1,500
1,501-2,000
2,001-3,000
3,001-4,000
4,001-5,000
More than 5,000
THIS IS VERY HARD TO ANSWER BECAUSE ONE DOES NOT KNOW WHAT THE
NEEDS ARE--
22) How should care coordination outcomes be evaluated by the
Department? Which metrics are most important?
Reduction of preventable ER and hospital visits
For adults with disabilities days lost from usual activity and
increase in having a usual activity, getting to a baseline will
take some time.
Weight loss of people with obesity
Other health measures such as reduced smoking, drinking,
etc.
23) Please share any other general advice or suggestions you
have about care coordination in the ACC.
Care coordination is the key of how this whole thing will work.
For those whose needs are the greatest (may not be most expensive
in system) a low client ratio is important. Care coordination
should not have rigid limits and should be about doing whatever it
takes to get the job done. For some clients that will be wildly non
traditional. For example some clients may need to have a
relationship with a care coordinator before they will feel
comfortable listening. It might be something like having the client
call the care coordinator and get together each time the client
wants to use the ERthat might mean Sundays or late at night.
Lasting behavior change comes from a close relationship and ability
to make small changes, get positive reinforcement, then more
changes. A few clients might need this forever.
Program Structure
24) If you could require all RCCOs to implement certain
functions in the same way across the state (or across all regions),
what functions would you consider most important? (The Department
has heard examples such as: care coordination requirements, data
reporting to the RCCOs, data reporting from the RCCOs, provider
contracting, and payment methodologies).
-Data should be the same so we can measure apples to apples
-Care coordination should have some of the same elements but
RCCO should be allowed to experiment also
-Required client engagement that is meaningful each one should
do what works in their community but each should be able to point
to specific activities and give client names and advocacy
organizations for references
25) What should be required of a bidder to ensure that, as a
RCCO, it could form community relationships and understand
community strengths and needs?
-References from several community organizations including
advocacy and client run organizations
-Proof that they have worked cooperatively on joint projects
with community organizations including advocacy organizations and
organizations other than medical providers.
-Demonstration on how they have reached out to the community to
determine client needs
-Proof that they have supported community activities including
local non-profits. Did they participate in local fairs, Veteran
Stand Down, etc.
26) The Department has received suggestions that, in the next
RFP, PCMPs should be allowed to choose the RCCO to which that
practice's clients are enrolled. Please comment on this
proposal.
-Not sure how this would work since clients are assigned based
on where they live. Would this mean that there would be more than
one RCCO per area? While CCDC always supports choice, we are not
sure there is enough data to demonstrate a need to have more than
one at this time.
27) Should the RCCO region maps change? Why or why not? If so,
how? We have no reason to think they should be changed at this
time.
28) Should the BHO region maps change? Why or why not? If so,
how?
Yes they should match the RCCO regions so if needed the RCCO can
take over this function if the BHOs cannot be fixed.
29) Based on the current scope of work for RCCOs, how many
months of transition would new vendors require? What needs to
happen during the transition period? What are the expenses involved
in this transition?
We are not providers and could not comment with much knowledge,
but if there were new vendors client communication would be
imperative so it would be important that communications are not
held up in clearance at HCPF.
30) What legislation, policy, rules, or changes in procedure are
needed to make the ACC more effective?
No legislation is needed, not sure rule changes are needed other
than in definitions, Enforcement of existing rules and
implementation of what is already promised is most important.
-Defining care coordination and then enforcing provision of it
for complex clients
-Enforce access standards on BHOs
-Fix the problems with addresses and attribution and fix CBMS
problems that kick people off Medicaid inappropriately.
-Need more primary care doctors to work with Medicaid clients
especially those with disabilities and particularly those with pain
management needs.
31) What are the limitations of the current benefit structure
and what if any changes are needed?
The Medicaid benefit structure in CO is pretty good. Coverage of
glasses and hearing aids for adults would be terrific.
32) Should there be multiple RCCOs per region? This would
involve two or more entities operating in the same region and
competing for clients and providers. If so, why? If so, how many
and where? What issues would this address?
This might be a good thing for the future but for right now we
should get the program off the ground morewe have not had
complaints from clients wanting a different RCCO. We have had a
couple complaints about the care coordination being inadequate or
non existing and that might be solved with ability to move to
another RCCO. However requirements about care coordination and
forcing them to work with disabled and complex clients and allowing
all clients to choose and change the specific care coordinator
should suffice with less administrative hassle.
33) If you or your practice provide services to clients referred
through a BHO, but you are not a Medicaid provider, would you be
willing to become a Medicaid provider? If so, what has prevented
you from becoming a provider in the past? If not, why not?
NA
34) What role should RCCOs play in attributing clients to their
respective PCMPs?
They should help find a PCP practice at request of the client.
This means there have to be enough doctors to take the clients.
They would need to make sure the PCP could meet the client
needs.
35) What types of collaboration should exist between the ACC
Program and the Colorado Department of Public Health and
Environment?
CDPHE should meet with care coordinators to ascertain what are
REAL threats to health and safety. They should also ask questions
about what hospitals may need additional oversight particularly in
terms of inappropriate discharges.
36) What types of collaboration should exist between the ACC
Program and the Colorado Department of Human Services?
CDHS should meet with RCCO care coordinators to hear about how
programs are or are not working such as their child care program,
need for additional medical exemptions for the food stamp
program
37) What types of collaboration should exist between the ACC
Program and the insurance marketplace / Connect for Health
Colorado?
Unsure
38) What types of collaboration should exist between the ACC
Program and the Colorado Department of Regulatory Agencies or the
Division of Insurance?
Unsure
Stakeholder Engagement
39) What should be required of the RCCOs in terms of stakeholder
engagement with clients, clients' families, and client
advocates?
Meaningful client engagement, this means a real process, not a
pro forma advisory group that never meets or that only hears
presentations. Each RCCO should have a written plan about client
engagement and that should involve some external group in a
meaningful way. This should include a communication plan.
Ongoing education about client populations provided by client
run organizations for cultural competency.
Hiring clients or advocacy organizations to help do satisfaction
surveys.
Engaging clients and advocacy organizations for what should be
on websites, testing and working on client facing communications,
etc.
40) What specific requirements should RCCOs have for stakeholder
engagement with providers, community organizations, social service
providers, and others in their region?
Not sure about providers but they should make sure to include
advocacy organizations.
41) Many of the successes of the ACC Program can be attributed
to the involvement of local communities. How can enhanced community
engagement be created in the ACC?
If there is adequate and appropriate client and provider and
community organization engagement that will happen organically.
42) How should the Department structure stakeholder engagement
for the ACC as a whole?
Require each RCCO to have written plan as above, HCPF should
have a statewide oversight group that has staff to make sure it
well run. There should be contracts for advocacy groups to assure
client participation and to get information to clients and from
clients to the department.
Network Adequacy and Creating a Comprehensive System of Care
43) Does the current network of PCMPs, specialists, behavioral
health providers, hospitals, pharmacies, dental, home health, and
non-medical providers adequately serve the ACC population?
NO
a. If no, what are the gaps?
Primary care for people with complex needs and pain management
is biggest medical gaps
Lack of choice of DME and NO complex rehab in some parts of
state
PDN for kids and adults
Specialists access varies regionally
b. Please address gaps for the population as a whole, and for
specific subpopulations such as children/families and individuals
with disabilities.
We are only able to speak for people with disabilities of all
ages
44) ACC Clients and the RCCOs interact with many parts of the
Medicaid program, as well as with service entities and other types
of providers or facilities.
a. What role should hospitals play in the next iteration of the
ACC Program?
Hospitals are important. In Montrose there was a lot of praise
for the local hospital what are they doing and how can it be
replicated? All hospitals should remain open to Medicaid
clients.
b. What role should pharmacies play in the next iteration of the
ACC Program?
Currently almost all pharmacies serve the Medicaid population
and this should continue
c. What role should specialists play in the next iteration of
the ACC Program?
d. What role should home health play in the next iteration of
the ACC Program?
Home health is becoming less relevant in LTSS as most LTSS is
now done through IHSS or CDASS but it is still important for two
reasons: If IHSS requires most services to be unskilled people will
stay in home health because it will be financially impossible to
use iHSS. Also if parents cannot be paid paid under personal care
via CDASS parent C.N.A.s will have to stay in home health. Finally,
home health is important for acute care to help people leave
hospitals earlier.
e. What role should hospice care play in the next iteration of
the ACC Program? Hospice is an essential wonderful service that
should be available to all people if they are in a terminal
situation. Hospice should be available without requiring people to
forgo all curative treatment.
f. What role should Single Entry Points (SEPs) and Community
Centered Boards (CCBs) play in the next iteration of the ACC
Program?
There should be some coordination but we need to be careful to
avoid duplication. Also LTSS is NON medical and while there is some
overlap most people want to keep some separation between every day
life and medical care.
g. What role should counties play in the next iteration of the
ACC Program?
NONEwe should get eligibility to eligibility sites and the
SEPs
h. What role should local public health agencies play in the
next iteration of the ACC Program?
They are very important for EPSDT and in rural communities but
we do not have specific information other than that they should be
involved.
i. What role should community organizations and non-profits play
in the next iteration of the ACC Program? Are there potential
partnerships with these organizations which have been overlooked in
the past?
A couple RCCOs do not appear to have any contracts with
disability rights organizations to help them with client engagement
and cultural competency. RCCOs should contract with client run
organizations to help them in this regard. The ones that do so
should be commended and rewarded. They should also be involved with
other organizations such as Homeless outreach groups, Veteran
advocacy groups, etc.
45) How can RCCOs help to support clients and families in making
and keeping appointments?
Common sense, implement effective communication protocols and
use reasonable modification of policy, practice and procedure.
Reminder calls/emails, help with transportation advocacy if
needed.
46) Community Health Workers are lay members of a community who
provide coordination or help people to navigate the health care
system in that community. Should the Department require Community
Health Workers or Patient Navigators as part of the next RFP?
No, it should not be required but there should be funds for
those who want to use it. Ideally the RCCO should make the system
work so that clients do not need yet ONE MORE person in our lives
to help us navigate the system. Just make the system understandable
and customer friendly. However we are so far from that in some
systems that something like this might be needed but should happen
in conjunction with systems change.
47) Community Health Worker reimbursement. Please use the table
below to detail how Community Health Workers should be
reimbursed:
Reimbursement process
(Please check all that apply)
Independently bill
On staff (salary) at Primary Care Medical Provider Clinic
On staff (salary) at RCCO
Per Member Per Month Payment
48) Oral health is an important part of overall health for both
children and adults. Oral health benefits in Colorado are currently
structured through an administrative services organization. What
should be the RCCO's role in coordinating dental care and ensuring
an adequate network of providers?
None other than encouraging clients to use the service.
49) Cultural competence among providers is important to ensure a
Client-centered, effective system that supports the health and
well-being of clients and families.
a. What does cultural competence mean to you?
[1] Culturally Competent: The ability to interact effectively
with people of different cultures, including different disability
cultures, and socioeconomic backgrounds.
b. What RCCO requirements would ensure cultural competency?
That all staff including administrators have training by people
from the affected populations (not by others talking about us) and
that they have implemented the recommendations from those
trainings. For disability that means policies in place to assure
effective communication as required by ADA and process for
requesting and receiving reasonable modification to policy,
practice and procedure. It also means adherence to the IL
philosophy.
c. What skills must providers and staff have in order to provide
culturally and linguistically-responsive care to all
Clients/families including those with low health literacy?
Effective Communication
d. Low heath literacy, different cultural health beliefs, and
language barriers make communicating about health complicated. What
RCCO requirements would help address these and reduce inequality in
health outcomes?
Need to have staff who are members of various cultural groups,
for low incidence groups they should hire consultants to help.
50) Should the next RFP allow for preferred networks for
specialty, facility, or ancillary care?
NOneed to keep this FFS and any willing provider.
51) Nationally, rates of emergency room utilization are on the
rise. This presents challenges in terms of cost and coordination of
care. What should the ACC do to address this trend?
Some of this needs to be HCPF and maybe the legislature to get
more primary care doctors. HCPF also needs to enforce the access
standards in the BHO contracts. The RCCO can find out why clients
are using the ER and report to HCPF so there can be joint
solutions.
52) Please feel welcome to share other general advice,
suggestions, and information you may have about network adequacy,
PCMPs, specialists, pharmacies, or hospitals.
Most ER visits are for uncontrolled pain, dental emergencies,
and behavioral health emergencies. Dental emergencies should be
reduced now that there is a benefit for Medicaid clients.
Practice Support
53) Support for practices. Please use the table below to
describe the types of support RCCOs should offer to practices and
other providers. Please check boxes to indicate if specific tools
should be provided, and if the state, rather than the RCCOs, should
offer a platform of support:
Type of support
Should a specific tool be required?
Should the state provide?
Yes
No
Administrative support
Network provider education
Assistance with practice redesign
Assistance with efficiency-enhancing activities
Provide web-based resources and directories
Provide practice-specific data reports
Provide clinical care guidelines and best practices.
Provide clinical screening tools
Provide health and functioning questionnaires
Provide chronic care templates
Provide registries
Offer client reminders
Offer client self-management tools
Offer educational materials about specific conditions
Supply behavioral health surveys
Supply other self-screening tools
Administer behavioral health surveys
Administer other self-screening tools
Prepare client action plans
Provide training on providing culturally-competent care
Provide training to supporting staff
Provide training on motivational interviewing
Provide tools and software for phone call and appointment
tracking
Provide tools and resources for tracking labs, referrals,
etc.
Provide referral and transitions of care checklists
Provide visit agendas or templates
Provide standing pharmacy order templates
Provide comprehensive directory of community resources
Provide directory of other resources
Provide materials regarding Nurse Advice Line
Ensure all tools and resources are centrally located on
RCCO-specific website
Others
Resources for ADA compliance
54) If you checked any of the boxes in the column entitled
"should a specific tool be required" from the table above, please
provide details about the specific process, tool, or product that
should be required.
Only checked it because in those areas it would be confusing to
have different tools or lists
55) What RCCO requirements or services should be required to
support practices in practice transformation or to assist practices
in becoming more efficient and robust medical homes?
Not sure anything should be required, there is too much
variation and if things are required practices will not want to
join.
56) What is the most effective way to recognize and reimburse
PCMPs based on their capacity to serve as a client's medical
home?
Not sure but increased dollars for complex or difficult clients
are needed.
57) Should the Department require that PCMPs utilize disease
registries to manage the health of their population?
NO
58) Please share any other advice or suggestions about provider
support in the ACC.
PLEASE do not mandate anything for providers regarding reporting
or how they have to practice; we have enough shortage as it is and
cannot afford to lose more Medicaid providers.
Payment Structure and Quality Monitoring
59) Does the current payment structure support the goals of the
ACC? How can financial incentives be further aligned to support
these goals?
Unsure perhaps financial incentives for specific outcomes but
this has to be done VERY carefully. Incentives should be given for
providers to treat people who no one else will treat such as
chronic pain patients.
60) If PCMPs could voluntarily elect to receive capitation
payments rather than fee-for-service, would your practice be
interested in participating? Under what parameters? What services
should be included in a primary care capitation?
NA but CCDC does NOT support capitation as that always is bad
news for our population.
61) Do providers have the infrastructure to be successful in an
environment where payments are tied to value? If not, what are the
barriers to developing that infrastructure?
Not sure
62) The Department is evaluating various financial and
administrative arrangements that may involve licensure by the
Division of Insurance (DOI). Licensure may require financial
reserves or the fulfillment of other regulatory requirements. For
potential RCCO bidders: is your organization licensed by the DOI
with an LSLPN, HMO, or other license? Would the requirement to
obtain a Limited Service Licensed Provider Network (LSLPN) license
or a Health Maintenance Organization (HMO) license preclude your
organization from bidding?
NA but CCDC opposes ANY movement towards capitation or HMO
model.
63) What role if any should the RCCOs play in the distribution
of payments to providers?
They should be allowed to distribute bonuses only if they have
no conflict of interest.
64) Please feel welcome to add any further thoughts or
suggestions pertaining to payment reform within the ACC.
We should not make any changes until we see results of the
payment reform demonstration.
65) What types of measures should be tied to payment in order to
ensure the program improves the quality of care, satisfaction of
clients and providers, and health outcomes?
Client satisfaction
No dumping of clients
Willingness to take clients that are labeled as difficult or
unpopular or clients that need a lot of support.
66) Measuring Client experience. Please complete the table below
to indicate how the Department should measure Client/patient
experience:
Tool:
Should it be used?
Comments:
Yes
No
Consumer Assessment of Healthcare Providers and Systems
(CAHPS)
This is fairly useless and does not measure much that is
important or that means good care.
SF-12 Health Survey
Do not know what this is
Other types of client interviews / surveys
We should find something meaningful
Patient Activation Measure
Yes patient activation is tied to health
Focus groups
Yes good way to get info
Other
Please type your response here.
67) Knowing that, at this time, the Department only has claims
data, how should population health be measured?
Specific measures such as ER and inpatient claims (why and were
they preventable), dental claims (are people going for
preventative), physician claims (preventative)
Look at specific codes
68) How should quality and performance data be reported to the
RCCOs, PCMPs, and the public?
Via HCPF web site, RCCO WEB SITES, news releases, social
media,
69) Measures for payment. Please use the table below to describe
how many measures should be tied to payment at one time. These
could function similarly to Key Performance Indicators, but they do
not necessarily have to do so. Please assume that the Department
will try to align measures with other programs to the extent
possible.
Measures
1-7
8-10
11-20
21-30
31-40
41-50
51+
None
70) What percent of RCCO payments should be tied to measures or
performance?
Percentage
10-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
91%+
71) Should all RCCOs, across each region of the state, be paid
on the same Key Performance Indicators (KPIs)? Should providers and
RCCOs be paid on the same KPIs?
Yes
72) Should RCCOs be reimbursed based on their performance
compared to national standards or based on improvement?
National Standards
73) Should the Department only tie payment to measures where
data can be provided on a monthly or regular basis (as opposed to
annually or bi-annually)? This will mean that, for a period of
time, we may be constrained to only tying payment to claims-based
measures.
No
74) Incentive payment frequency. Please use the table below to
answer how frequently the Department should make incentive
payments:
Monthly
Quarterly
Annually
Other
If you checked the "Other" box, please describe payment
frequency below: maybe twice a year but no more
75) For potential offerors and other similar organizations:
please describe the fixed costs of operating a RCCO.
NA
76) For practices and community providers, what are you
currently measuring to assess the quality of your care delivery?
Are you being reimbursed on any of these measures?
NA
Health Information Technology (HIT)
77) Types of communication. For clients with Medicaid coverage,
please use the table below to rank each by whether or not you would
use it to communicate with your provider or RCCO:
Type of Communication
No, I wouldn't use
Yes, I would use
Phone call / phone number
Text message
Web portal
Email
Telemedicine / Video chat
Face-to-face meeting
Smartphone app
Other:
All are important and should be options
78) HIT investments by organizations. For all organizations,
including potential bidders, networks, practices, and others: the
table below asks about what HIT your organization has invested in
and what it plans to invest in over the next two years. Please
complete the table below:
Tool
Own / Operate
Plan to Operate in next 2 years
Population analytics / reporting
Digital care management tool
Care transitions alerts
Electronic Health Records (EHRs)
Health risk assessment software
Practice assessment tools
Practice management tools (scheduling, billing)
Client web portal for communicating care plan, services, benefit
enrollment
Patient education/wellness tools
Provider/case manager directory
Shared decision-making tools
Telemedicine software
Other:
Other:
79) Importance of technology by type. The Department is working
to determine what technology is in place, what technology is
needed, and what technology should be standardized. For RCCOs,
providers, and other organizations, use the table below to answer
what HIT infrastructure outside of the SDAC your organization would
use to perform population health management activities. Tools are
scored from 1-5, where 1 are those items least-likely to be used,
and 5 are items most-likely to be used:
Tool
1Least
2
3
4
5Most
Population analytics / reporting / dashboard
Care management tool
Care transitions alerts
Electronic Health Records (EHRs)
Practice assessment tools
Health risk assessment software
Practice management tools (scheduling, billing)
Client web portal for communicating care plan, services, benefit
enrollment
Patient education wellness tools
Provider/case manager directory
Shared decision-making tools
Telemedicine
Other:
80) What are the primary barriers to RCCOs and providers
increasing their use Health Information Technology to improve the
performance of Primary Care Practices?
NA
81) How can Health Information Technology support Behavioral
Health Integration?
NA
82) In the next iteration of the ACC, should there be a shared
resource for data and analytics? Please describe the basic criteria
for what a shared data and analytics platform needs to contain in
order for it to be useful.
If this can be connected to the all Payer Claim Database and if
there is external funding, do not divert scarce Medicaid dollars
for this.
83) Should there be a shared care management tool? Please
describe the basic criteria for what a care management tool would
need to contain in order for it to be useful.
Without seeing a specific tool hard to say, if so there MUST be
extensive client engagement before adopting to make sure the tool
is useful and not too intrusive.
84) Should there be a shared population health management tool?
Please describe the basic criteria for what a population health
management tool would need to contain in order for it to be
useful.
Would need more info
85) Please describe the functionality that a common Medicaid
provider directory would need to contain in order for it to be
useful.
Search by county, if they are taking new patients, what services
they provide, if they take Medicare also, if they are accessible,
and address (if they are on public transit line would be great but
anyone can figure that out with specific address). Hours would be
good also
86) How can the RCCOs support providers' access to actionable
and timely clinical data?
Unsure
87) What are the HIT solutions that would benefit clients,
providers, and RCCOs? Please comment on the parameters these tools
or platforms would need to possess and the ways in which they could
be used.
Web based portal where client can see and comment on all medical
records, make requests for prescriptions, or other things that need
to be signed would be great
Any ability to self schedule appointments would be awesome for
clients
88) What technical assistance or resources related to HIT
infrastructure should the RCCOs supply? This assistance or these
resources could be for providers, social service organization,
clients/families, or for others.
Unsure
89) What role should health information exchange platforms like
CORHIO or QHN play in the next iteration of the ACC?
Unsure
90) Please share any information, advice, and suggestions you
have about health information technology in the ACC Program.
Appendix: Definitions and Acronyms
The following words have been defined for the purpose of this
RFI.
42 CFR is a federal regulation outlining when information about
someone's Substance Use Disorder (SUD) treatment may be disclo
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