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INNOVATE

INTEGRATE

TRANSFORMBarbara Martin, RN, MSN, ACNP-BC, MPH,

Colorado State Innovation Model Director

CHA Patient Safety Conference, Oct. 23, 2018

Fund: The Colorado State Innovation Model (SIM) and Transforming Clinical

Practice Initiative are funded by the Centers for Medicare & Medicaid

Services with up to

$76 million to reform health care payment and delivery systems.

Collaborate: Colorado was the only SIM state to focus on integrated

behavioral and physical health in primary care settings with support from

public and private payers to help providers succeed with APMs.

TCPi rounds out the equation of providers, who have access to health reform

support and 80% are specialists working on business supports, process

changes for success with APMs.

Systems change: These Governor’s office initiatives are investing in

hundreds of providers, community mental health centers and local public

health agencies to set the stage for future success.

HEALTH REFORM

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WHY INTEGRATION MATTERS

> 50%

80%50%

Of referrals from primary care to an outpatient behavioral

health clinic do not make the 1st appointment

Of people with a behavioral

health disorder visit a primary

care at least once a yearOf behavioral health

disorders are treated in

primary care

WHY IT MATTERS TO YOU

Sources: https://www.cdc.gov/nchs/fastats/mental-health.htm

https://www.hcup-us.ahrq.gov/reports/statbriefs/sb216-Mental-Substance-Use-Disorder-ED-Visit-Trends.jsp

• Number of visits to physician offices with mental disorders as the primary

diagnosis: 59.8 million

• Number of visits to EDs with mental disorders as primary diagnosis: 5.7 million

• Between 2006 and 2013, the rate of ED visits increased across mental and

substance use disorders, but the increase was higher for mental disorders

(55.5% for depression, anxiety or stress reactions and 52.0% for psychoses

and bipolar disorders) than for SUDs (37.0%)

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BEHAVIORAL HEALTH IN THE HOSPITAL

Sources: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb225-Inpatient-US-Stays-Trends.pdf

https://www.hcup-us.ahrq.gov/reports/statbriefs/sb216-Mental-Substance-Use-Disorder-ED-Visit-Trends.jsp

• From 2005-2014 the total number of hospital stays for mental

health/substance use conditions

rose 12.2% in the U.S. In comparison, overall hospital stays for all conditions

dropped by 6.6%

• Driving the increase in hospitalizations were patients from 0-17 and 45-64

years of age

• In 2005 mood disorders were not found in the top 5 reasons for

hospitalization in these

populations yet in 2014 mood disorders were the top reason for

hospitalizations for these

ages 0-17 as well as 18-44 and it’s number 3 for 45-64

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System barrier and facilitators can influence

communication, collaboration and coordination

▪ Financing

▪ Data exchange

▪ A culture of communication collaboration and

coordination

▪ Recognizing an evolving landscape—older population, co-

morbid disease, increasing severity of behavioral health

BREAKING THE CYCLE

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SYSTEM BARRIERS

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Effective communication exists when each clinician or treatment

provider caring for patients shares needed treatment information

with other clinicians and providers caring for that patient.

Information can be shared verbally, manually in writing or through

information technology, such as a shared electronic health record.

Collaboration is multidimensional and requires the aggregation of

several behaviors, including:

▪ A shared understanding of goals and roles

▪ Effective communication

▪ Shared decision making

CHANGING THE SYSTEM

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THE SIM APPROACH

Public

Health

Behavior

al Health

Providers

Consumers

Consumer Engagement Policy Workforce Evaluation

Practice

Transformation

Payment

ReformPopulation

HealthHIT

Increase access

to integrated care in coordinated

systems supported by value-based payment

Support for

practices as they

accept new

payment models

and integrate

behavioral and

physical healthcare.

Engaging

communities in

prevention,

education, and

improving access

to integrated

care.

Development and

implementation of

value-based

payment models

that incentive

integration and

improve quality

of care.

Secure and

efficient use of

technology across

health and non-

health sectors in

order to advance

integration and

improving health.

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KEY

RHC = Regional Health

Connector

CHITA = Clinical HIT Advisor

PF = Practice Facilitator

Grants to Practices

Each practice can apply for

competitive small grants of up

to $40,000 to offset initial costs

of integration. Alternative Payment Models

Each practice will be supported

with value-based payments from

at least one of the seven payers

that signed the SIM MOU.

Achievement-Based Payments

Each practice participating in

SIM is eligible to receive

achievement-based payments.

Regional Health Connectors

Each SIM practice will be

matched with a regional health

connector, who will serve as a

dedicated resource for

connecting the practice to

relevant resources.

Business Consultation

MGMA provides resources and

assistance to help practices

improve business processes and

accept alternative payment

models.

Practice Facilitators and CHITAs

Each SIM practice is matched

with an appropriate practice

transformation organization that

provides them with a practice

facilitator (PF) and/or a clinical

health information technology

advisor (CHITA), as well as other

technical assistance.

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BI-DIRECTIONAL PILOT

SIM is helping providers integrate behavioral and physical

health in primary care settings to ID all health issues

early and help ensure that patients get the care when

and where they need it.

The key is effective collection, analysis and use of data.

REFORMING CARE

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▪MACRA/QPP and other emerging alternative payment models include measures of cost control, either as an adjustment to practice payments or through shared savings and/or shared risk

▪ Practices have had little to no data to help

them work on this

▪ It is critically important for practices to begin

to learn how to use cost data to reduce

unnecessary costs and improve patient care

and safety

HELPING PROVIDERS USE DATA

COST & UTILIZATION MEASURES

▪ Out of Pocket Expenditures for Consumers

▪ Total Cost of Care Population based Per member per-month (PMPM) Index

▪ Admissions

▪ Emergency Department (ED) Rate

▪ Follow-Up after Hospitalization for Mental Illness

▪ Readmissions

▪ PsychiatricAdmissions

▪ Psychiatric ED Rate

▪ Psychiatric Readmissions

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APCD DATA ATTRIBUTION

▪ All Payer Claims Database (APCD) data

▪ Medicare, Medicaid, commercial claims

▪ Includes detailed membership and claims data for inpatient facility, outpatient facility, professional services, ancillary services and prescription drugs (all healthcare costs)

▪ Attribution based on NPIs reported by practices on SIM practice roster

USING DATA EFFECTIVELY

▪ Sample SIM practice cost and utilization report

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OTHER DATA SOURCES

Milliman cost & utilization reports StratusTM data aggregationtool

APCD data Payers submit directly or via APCD

All payers 6 payers that support the tool

SIM standard attribution methodology Proprietary payer attribution

Methodology

9 SIM cost and utilization measures

(aligned with CMMI report)

3 HEDIS measures; filters & custom reports

on claims data; gaps in care

6 month – 1 year time lag Might be more recent if payers submit

directly

Quarterly reports Monthly – quarterly data refreshes

IMPROVING PATIENT HEALTH

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SIM practices are screening more patients to ID and

address issues early. In 2017 SIM practices screened:

• 59% of eligible moms for maternal depression

• 81% of eligible children for developmental issues

• 86% of eligible adolescents for obesity

• 98% of eligible patients for tobacco use

• 20% of patients with diabetes had poor HBA1c levels*

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49.71%56.32%

65.71%

36.02%

61.2…62.49%

52%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

2017 Q2 2017 Q3 2017 Q4 2018 Q1 2018 Q2

Cohort 2 Cohort 3 CMHCs Primary care target

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Aggregate percent of eligible patients screened for depression

as reported by the CMHCs and cohorts 2 and 3

37.50%

28.64% 32.17%

8.98%

21.70%

22.80%

29.80%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

2017 Q2 2017 Q3 2017 Q4 2018 Q1 2018 Q2

Cohort 2 Cohort 3 CMHCs Primary care targets

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Lower values are desired for this measure

Aggregate percent of patients with diabetes and who have poor HbA1c

control in cohort practices sites and CMHCs

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595.14

568.15

550.00

555.00

560.00

565.00

570.00

575.00

580.00

585.00

590.00

595.00

600.00

Q4 (2015) Q4 (2016)

ED rate for primary care disorders for patients attributed to

SIM cohort-1 primary care practices (per 1,000 population)

▪ SIM launched a service to help primary care practice sites extract electronic clinical quality measures (eCQMs) once and report to several approved entities.

▪The first phase includes 11 practices and 90 providers and the second phase will include 190 practices.

▪The application for phase 2 of the SIM eCQM solution is open: www.surveymonkey.com/r/5CYV5CW.

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SIM SUPPORTS

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ECQM PROJECT

▪ Three organizations contracted with SIM and formed Health Data Colorado (HDCo)

▪ CORHIO (front range, eastern plains)

▪ QHN (western slope)

▪ CCMCN (safety net providers)

▪ Phase 1 — Initial phase

▪ Completed July 31, 2018

▪ All 3 organizations worked with about 12 practices in total

▪ Collected 3 eCQMs

▪ Phase 2 — full implementation — HDCO will work with CHITAs

▪ Working with SIM practices — open to 190

▪ Collecting 9 SIM measures

▪ Field-level data through custom extracts or other methods

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While SIM is helping primary care providers deliver whole-

person care, TCPi is focused on helping providers (mainly

specialists) ensure the delivery of patient-centered, team-

based care.

By intervening early—patients avoid unnecessary ED visits

that do not lead to better health outcomes and have a

negative effect on your bottom line.

SIM is also investing in local public health agencies and

created a new workforce to help ensure that providers know

about community resources to avoid duplication of efforts.

EFFECTIVE, EFFICIENT CARE

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Q3 AND Q4 2017 FEEDBACK

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11.8%

29.4%

52.9%

5.9%

4.2%

45.8%

37.5%

12.5%

0% 20% 40% 60% 80% 100%

Awareness

Cooperating

Coordinating

Integrating

LPHA/BHTC

SIM-funded LPHAs, BHTCs and RHCs

report positive progress:

▪ RHCs are forming important

partnerships in their communities

that link health systems with

community partners

▪ LPHA education/outreach efforts

reached 12,108,987 individuals

during Q2–Q3 2017

▪ BHTCs referred 3,283 participants

to behavioral health resources

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• Commitment: 2,000 clinicians

• Enrolled: 1,972

• 99% progress toward goal

Aim 1: Engagement

• Commitment: Improve 28,904 lives

• Lives Improved: 24,823 lives

• 85% progress toward goal

Aim 2:Improve health

outcomes

• Commitment: 1,704

• Admissions avoided: 6,169

• 360% progress toward goal

Aim 3: Reduce unnecessary

hospitalizations

TCPI COMMITMENTS AND RESULTS

• Commitment: $85.6 million

• $42 million

• 49% progress toward goal

Aim 4: Save dollars for the health care system

• Commitment: 4,000 tests reduced

• Test reduced: 3,267

• 85% progress toward goal

Aim 5: Reduce unnecessary tests and procedures

• Commitment: 410 clinicians

• Graduated: 363 clinicians to CPC+ and MSSP Track 3 (18%)

• 20% progress toward goal

Aim 6: Graduate to APM

TCPI COMMITMENTS AND RESULTS

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PROVIDER SPECIALTIES

Anesthesiology

Bariatric Medicine

Behavioral Health

Cardiology

Colon and Rectal

Surgery

Dermatology

Emergency Medicine

Family Medicine

Fetal Medicine

Gastroenterology

General Surgery

Hospice

Infectious Disease

Internal Medicine

Interventional

Radiology

Nephrology

Neurology

Neurosurgery

OB/GYN

Oncology

Ophthalmology

Orthopaedics

Otolaryngology

Pain Management

Pediatric Medicine

Pediatric Surgery

Physical Therapy

Plastic &

Reconstructive

Surgery

Podiatry

Psychiatry

Pulmonology

Radiology

Rheumatology

Surgery

Urology

Primary Care Other Specialists

Behavioral Health

204 Practices

1,972 Clinicians

87% Specialty Care

USING DATA TO BRIDGE THE GAP

▪ Colorado providers have recognized the value of effective communication (and the processes that back it up)

▪ Optimization of EHRs, health information exchanges

▪ Effective huddles, actionable referrals

▪ Patient education, discussion, follow-up

▪ Working as a team that extends beyond the four-walls of a clinic, providers and hospitals can improve patient outcomes, lower costs and succeed financially

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INFLUENCING PATIENT CARE, SAFETY

▪ TCPi helps providers retool processes, which results in cost-savings and cost avoidance. One example:▪ A small, specialty practice improved access via same-day appointments

and “special alert” phone protocols, which helped endocrine patients avoid more than 300 ED visits per year

▪ Avoided unnecessary duplicative testing by routine use of HIE

▪ Provided ongoing patient education, teach-back and shared decision making, medication management and use of patient portal for communication and follow-up

SUCCESS WITH APMS

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• Prepare providers for success in the Medicare Quality Payment Program

and Merit-Based Incentive Program

• 323 MIPS- eligible providers in 2017 reporting year

• More than 97% of Colorado TCPi eligible providers reported

• Practices are preparing for alternative payment models (APMs) and using

TCPi to understand data

• Expect to transition 400+ providers to APMs

• TCPi national goal of to move 75% of providers into value-based

contracts

• Limited availability of APMs for specialists could affect Colorado’s

ability to transition specialists to APMs

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• Solo Obstetrics/Gynecology

• Serving 4,189 patients

• Avoided 302 ED visits, which saved $257,908 annually

by offering same-day appointments

• Saved $120,000 per year by assessing surgical trays;

went from $3,000 to $106 per surgery

EXEMPLAR PRACTICE

• Largest retina practice in the Rocky Mountain region

• Number of patients served: 18,046

• 12 providers

• Reduced ED visits by 231

• $197,914 in savings by offering same day appointments

• Saved $20 million by changing injectables compared with national average of peers

EXEMPLAR PRACTICES

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• Part of large safety-net health system

• 3,500 patients served per year

• 4 providers

• Reduced ED visits <14 days of surgery by 33%

• Estimated cost savings: $16,275/year

• Successful process change spreading to other clinics in the system

EXEMPLAR PRACTICES

LESSONS LEARNED

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SUSTAINING INNOVATION

Payment reform to achieve a healthier Colorado

Support for value-based payments and coordination across providers and stakeholders to encourage patient-centered, team-based care that improves

health outcomes and reduces or avoids unnecessary costs

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• Advance primary care engagement and success in alternative payment models; incremental steps toward participation

• Support integration of physical and behavioral health

• Bolster primary care infrastructure and build off success and lessons learned in SIM and CPC+

Multi-payer advanced alternative payment model for primary care

• Provide flexibility and financial stability for hospitals to best serve their communities and align with other service providers

• Population health objectives and health goals related to quality and performance

• Voluntary participation for rural hospitals

Global budgets for some rural hospitals

TELEHEALTH: EXPANDING ACCESS TO CARE

▪ SIM will fund three health systems with up to $250,000 each to develop an implementation model for an e-Consult program.

▪ Up to $100,000 can be spent on technology.

▪ RFP released by the Department of Health Care Policy & Financing Oct. 18: https://lnkd.in/ee_HAZ6. Interested parties must apply by Nov. 19, 2018.

▪ UHAA 2019000083 e-Consult Planning and Implementation Project seeks a Contractor to solicit competitive, responsive proposals from experienced and financially sound health care entities to plan for and test electronic consultations (e-Consults).

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QUESTIONS AND DISCUSSION

The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S Department of Health and Human

Services (HHS), Centers for Medicare & Medicaid Services (CMS). The Colorado State Innovation Model (SIM), a four-year initiative, is

funded by up to $65 million from CMS. The content provided is solely the responsibility of the authors and does not necessarily

represent the official views of HHS or any of its agencies.