SIM Cohort 3 Application Instructions and Questions

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1 SIM Cohort 3 Application Instructions and Questions Overview, Instructions & Resources: SIM Cohort 3 Application Overview: Thank you for your interest in the Colorado State Innovation Model (SIM) Initiative and interest in applying for SIM Cohort 3. By completing this online application the Practice Site is demonstrating interest in participating in SIM Cohort 3. Please note all completed applications will be reviewed by a multi-stakeholder review committee that will provide recommendations to the Colorado SIM Office who will make the final selection of practices offered the opportunity to participate in the final cohort of SIM, anticipated to begin June Instructions: (Abbreviated) The SIM Cohort 3 Application consists of nine sections: Practice Site Information Practice Site Demographics Practice Site Key Contacts Practice Site Provider Roster Health Information Technology (HIT) Behavioral Health & Practice Transformation Practice Site Narratives Participation Attestation Application Completion Status The SIM Cohort 3 Application should be completed at the Practice Site level and reflect the demographics, key contacts, and information unique to the Practice Site. For more information on the SIM Initiative, visit the Colorado SIM Office website: Additional information regarding SIM can also be found at the University Practice Innovation Program Colorado website: For technical and programmatic questions related to this application please contact: PracticeInnovation@ucdenver.edu PRACTICE SITE INFORMATION This section collects basic information regarding the Practice Site and Practice Site Healthcare System or Multi-Site Organization (if applicable). Not all questions are required but Practice Sites are encouraged to complete as much information as possible in order to create a more comprehensive practice profile. 1) Has this Practice Site previously applied to participate in SIM? PRACTICE SITE NAME(S) Please confirm the Practice Site Name(s) below. Some fields have auto-populated based on your previous responses. Please modify where appropriate. The Official Practice Site Name is the formal name, and often the same as the Legal Practice Name. The Preferred Practice Name is the name the Practice Site would like used in SIM communications. 2) Practice Site Name(s): Preferred Name Legal Name Doing Business As (DBA) (Optional) PRACTICE SITE ADDRESS & PHONE NUMBER(S) Please enter information regarding the Practice Site address and contact information. 3) Practice Site Physical Address: Street Address, City, State, Zip Code 4) Practice Site County 5) Practice Site Phone Number(s) (Ex ): Main Phone Number, Other Phone Number (Optional)

2 PRACTICE SITE BILLING & IDENTIFICATION INFORMATION Please enter information regarding the Practice Site: Taxpayer Identification Number (TIN), Medicaid Billing ID Number(s), and Practice National Provider Identifier (NPI) for [Practice Site]. 6) List the TINs this Practice Site uses to bill services (Ex. XX-XXXXXXX): 7) Practice Site Group National Provider Identifier (NPI): 8) List the Medicaid Billing IDs this Practice Site uses for Medicaid primary care services: 9) Is this Practice Site contracted with Medicaid as a Primary Care Medical Provider (PCMP)? 9a) Is the Medicaid Billing ID # this Practice Site is contracted under as a PCMP the same as the one provided in question eight (8)? 9b) Under what Medicaid Billing ID # is this Practice Site contracted as a PCMP? HEALTHCARE SYSTEM OR MULTI-SITE ORGANIZATION INFORMATION Please indicate if this Practice Site is a part of a Healthcare System or Multi-Site Organization. If applicable complete the additional fields below. 10) Does this Practice Site belong to a larger Healthcare System or Multi-Site Organization? 10a) Healthcare System or Multi-Site Organization Name: (Some participating Healthcare Systems and Multi-Site Organizations are listed below. Please select the correct name within the list or choose 'Other' and type in the appropriate Healthcare System or Multi-Site Organization name your Practice Site belongs to.) 10ai) Please specify the 'Other' Healthcare System or Multi-Site Organization Name: 10b) Healthcare System or Multi-Site Organization Address: 10c) Healthcare System or Multi-Site Organization Phone Number(s) (Ex ): Practice Site Key Contacts This section aims to collect necessary information regarding [Practice Site] Key Contacts and Healthcare System or Multi-Site Organization Contacts, if applicable. Practices are encouraged to fill out this section as completely and accurately as possible. PRACTICE SITE & MULTI-SITE ORGANIZATION KEY CONTACTS Please provide information regarding key contacts for this Practice Site. As an individual may fill multiple roles within a Practice Site and they can also be identified in more than one key contact role. 11a) Primary SIM Practice Site Contact 11b) Practice/Office Manager 11c) Provider Champion 11d) Lead Clinician/Provider 11e) Contact for Payers or Insurance Companies (Contact can be based at the Practice Site or at the Healthcare System or Multi-Site Organization level.) 11g) Healthcare System or Multi-Site Organization Contact 1 11h) Healthcare System or Multi-Site Organization Contact 2 (Optional) 11i) Healthcare System or Multi-Site Organization Contact 3 (Optional) Practice Site Demographics This section collects basic demographics regarding the Practice Site and the Practice Site's Healthcare System or Multi- Site Organization if applicable. Practice Sites are encouraged to complete as much information as possible in order to create a more comprehensive practice profile. PRACTICE SITE DEMOGRAPHICS Please complete all information regarding this Practice Site's general demographics, including Provider information. 12) Which of the following best describes this Practice Site's Organizational Structure? Federal (Veterans Administration, Department of Defense, etc.) Federally Qualified Health Center Federally Qualified Health Center Look-Alike Freestanding Urgent Care Center Health Maintenance Organization (Ex. Kaiser Permanente, etc.)

3 Hospital or Health System Owned Mental Health Center Non-Federal Government Clinic (Ex. State, County, City, etc.) Primary Care Residency Practice Private Solo or Group Practice Public Health Service Rural Health Clinic School-Based Clinic 12a) Please specify 'Other' Practice Site Organizational Structure: 13) Which of the following describes this Practice Site type? (Select all that apply.) Family Medicine General Internal Medicine Primary Care Pediatrics Nurse-Led Primary Care School-Based Clinic Non-Traditional (Specify) 13a) If this Practice Site is a 'Non-Traditional' Primary Care Practice, it must still meet the Institute of Medicine (IOM) definition of primary care, "Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." An applicant primary care Practice Site must be capable of providing a majority of its patients comprehensive primary, preventive, chronic, and urgent care. Please describe how this Practice Site meets the Institute of Medicine (IOM) definition of primary care as outlined above: 13b) If this Practice Site is an 'Other' Primary Care Practice, it must still meet the Institute of Medicine (IOM) definition of primary care, "Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." An applicant primary care Practice Site must be capable of providing a majority of its patients comprehensive primary, preventive, chronic, and urgent care. Please describe how this Practice Site meets the Institute of Medicine (IOM) definition of primary care as outlined above: 14) Is this Practice Site engaged in training future primary care practitioners and staff? 14a) Describe this Practice Site's training engagement below. PRACTICE SITE PATIENT POPULATION Please complete all questions regarding this Practice Site's patient population by entering estimates for each. Percentage totals must add up to 100%. 15) Total number of patient visits per year at this Practice Site: 16) Percentage of patients in this Practice Site in the following age ranges: 0-17: 18-64: 65+: Total: 17) Percentage of patients in the following payer categories for this Practice Site: Approximate % of Medicare: Approximate % of Medicaid/CHIP: Approximate % of Commercial or Private Insurance: Approximate % with No Insurance: Approximate % of Other Payer Category: Total:

4 18) Practice Site Formal Designations for Serving Undeserved Populations: Federally Qualified Health Center Federally Qualified Health Center Look-Alike Rural Health Clinic Indian Health Services Center Colorado Indigent Care Program Community Safety Net Clinic Health Profession Shortage Area Not Applicable 18a) Please specify 'Other' formal designations for serving underserved populations: PRACTICE SITE PROVIDER/STAFF CATEGORIES & COUNTS Reference the following table to provide approximate Practice Site totals for each of the provider and staff categories. The values provided in this roster will be used to calculate completion rates for the SIM Clinician & Staff Experience Survey that participating practice sites complete annually. 19) Enter approximate Practice Site totals for the provider/clinician and staff categories listed: Providers/Clinicians Clinical Practice Staff Allied Health Professional Support & Office Staff Other Practice Staff Practice Site Provider Roster This section aims to collect necessary information regarding the Practice Site's Providers/Clinicians. Practice sites are required to include roster information for their providers. This information can help determine if this Practice Site is eligible for additional financial support from payers participating in SIM. Please include all Providers at this Practice Site who have an NPI. Common Specialty/Taxonomy Codes for Primary Care Providers: Pediatric Medicine: X General Practice: 208D0000 Adult Medicine: 207QA0505X Family Medicine: 207Q00000X Internal Medicine: 207R00000X Geriatric Medicine: 207RG0300X The SIM Taxonomy Code List can be found here: Please use the link to view a complete list of taxonomy codes for Primary Care Providers. PRACTICE SITE PROVIDER ROSTER For each Primary Care Provider/Clinician at the Practice Site enter the following: First Name, Last Name, , Provider/Clinician Type, NPI, and Taxonomy Code. Complete the following information for all licensed providers and clinicians at the Practice Site: First Name, Last Name, NPI, Provider/Clinician Type, Taxonomy 1, Taxonomy 2 Health Information Technology (HIT) This section aims to collect details on the Practice Site's Electronic Health Record (EHR) and use of Health Information Technology (HIT). ELECTRONIC HEALTH RECORD (EHR) SYSTEM Provide the following details regarding this Practice Site s Electronic Health Record (EHR) System. 20a) Select the Practice Site Electronic Health Record (EHR) System/Product Name: 20ai) Specify 'Other EHR System/Product' name: 20b) Specify EHR version used by the Practice Site:

5 MEANINGFUL USE ATTESTATION Please answer the following questions regarding attestation of Meaningful Use. 21) Have providers at this Practice Site attested to Meaningful Use? 21a) Please indicate the highest stage of Meaningful Use achieved. CLINICAL QUALITY MEASURES (CQMS) 22) Is this Practice Site currently able to report SIM CQMs per the timeline outlined in the SIM CQM Reporting Requirements, within the RFA document? To review the SIM CQM Reporting Requirements please reference the SIM Clinical Quality Measure (CQM) Reporting Requirements document ( 22a) What resources does this Practice Site need to develop in order to report SIM CQMs? Behavioral Health & Practice Transformation This section collects details about the Practice Site's participation in Behavioral Health and Practice Transformation activities. BEHAVIORAL HEALTH 23) Does this Practice Site have access to a Behavioral Health Provider (BHP)? 23a) What type of access to a BHP does this Practice Site have? Full-time Onsite Part-time Onsite Full-time Telehealth Part-time Telehealth Consult Only 23ai) Specify 'Other' type of access to a BHP that this Practice Site has: 23b) What are the degrees(s) or license(s) of the BHP(s) this Practice Site has access to? 23bi) Specify 'Other' degree or license: OTHER PRACTICE TRANSFORMATION INITIATIVE PARTICIPATION & WORK 24 Is this Practice Site recognized as a Patient-Centered Medical Home? 24a) Please indicate the organization(s) that recognizes this Practice Site as a 'Medical Home:' 24ai) Specify the standard year for National Committee for Quality Assurance (NCQA-PCMH): 24aii) Specify State-Based Recognition Program name and recognition level received: 24aiii) Specify the recognition level received for Utilization Review Accreditation Commission (URAC): 24aiv) Specify the 'Other Organization' that recognizes this Practice Site as a 'Medical Home': 25) Is this Practice Site participating in CPC+ currently? 26) Has this Practice Site participated in any quality improvement (QI) activities or practice transformation initiatives with Practice Facilitators and/or Quality Improvement Coaches? 26a) Identify which of the following quality improvement (QI) activities or practice transformation initiatives this Practice Site has previously or is currently participating in: 26ai) Specify the 'Other' quality improvement (QI) activities or practice transformation initiatives: 27) Identify which of the following non-fee-for-service payments from a payer in the last 24 months this Practice Site has participated in? (Ex. Shared Savings, PMPM, Global Payments, Episode of Care Payments, etc.) 27a) Specify 'Other Medicare ACO Program': 27b) Specify non-fee-for-service payment 'Other Program': Practice Narratives This section provides the opportunity for Practice Sites to share their practice transformation goals and reasons for applying to the SIM Initiative. Please answer each question thoroughly and distinctively for this Practice Site. 28) Explain why this Practice Site is interested in participating in SIM: 29) Identify the benefits anticipated from participation in SIM: 30) Describe this Practice Site's Leadership, provider and staff commitment to Practice Transformation. Please discuss how leadership will support transformational change and identify resources required for sustainable change. 31) Identify the existing or planned processes this Practice Site has for supporting behavioral health integration. 32) Please provide any additional information you would like us to consider or any comments you would like to share.

6 SIM Participation Attestation The section below documents the Practice Site s attestation to the accuracy of the information provided in the SIM Cohort 3 Application and an understanding of the general expectations of participation in SIM. The attestation below is NOT a commitment to participate in SIM. Practice's selected for SIM Cohort 3 will have the opportunity to accept or decline participation after the offer. 33) By signing this application to be considered for participation in SIM Cohort 3, this Practice Site attests: a. Practice Leadership and/or Healthcare System or Multi-Site Organization Leadership, supports the intention to move toward increasing integrated primary care and behavioral health. b. The SIM Cohort 3 Application was completed by the staff and/or providers at the Practice Site with approval of the Healthcare System or Multi-Site Organization, if applicable. c. Commitment to participate in one year of practice transformation and agrees to: Identify a cross-functional Quality Improvement Team to implement improvements Complete a set of practice assessments to identify key areas of focus for improvement Collect, report, and review SIM Clinical Quality Measures on a quarterly basis Attend two Collaborative Learning Sessions and/or for CPC+ participating practices, participate in CPC+ Learning System and activities Participate in SIM evaluation activities Achieve selected SIM building blocks through achievement of key milestones d. This Practice Site has the ability and willingness to account for funding received from SIM. e. This Practice Site has the ability and interest to participate in alternative payment models such as Per Member Per Month (PMPM), Bundled Payments, Global Payments, Shared Savings, etc. 34) Please upload your completed University W9 Template here: REQUIRED 35) Please upload any additional materials: 36) Please provide the name and contact information for the person who should be contacted with questions regarding this application: First & Last Name, Practice Role, Contact, Phone Number 36a) In addition to the previously person identified, Practice Sites can enter up to three additional contacts to receive an confirming the submission of a SIM Cohort 3 Application for [Practice Site Name]: First Name, Last Name,