SECTION II: PROJECT-LEVEL: Bi-Directional Care. Project Selection & Expected Outcomes (2,000 words) Project Description and Justification

Transcription

1 2A Bi-Directinal Care Integratin Prject DRAFT Nv 13, 2017 SECTION II: PROJECT-LEVEL: Bi-Directinal Care Menu f Transfrmatin Prjects Dmain 2: Care Delivery Redesign 2A: Bi-Directinal Integratin f Physical and Behaviral Health thrugh Care Transfrmatin (required) 2B: Cmmunity-Based Care Crdinatin 2C: Transitinal Care 2D: Diversins Interventins Dmain 3: Preventin and Health Prmtin 3A: Addressing the Opiid Use Public Health Crisis (required) 3B: Reprductive and Maternal and Child Health 3C: Access t Oral Health Services 3D: Chrnic Disease Preventin and Cntrl Prject Selectin & Expected Outcmes (2,000 wrds) Prject Descriptin and Justificatin Abstract Bi-directinal care integratin is the integratin f behaviral health services int the primary care setting and the integratin f primary care services int the behaviral health setting. CPAA intends t address the physical and behaviral health needs f children and adults thrugh an integrated system f care that fcuses n whle-persn health. Mving int an integrated system, based n Cllabrative Care principles, will change the dynamics f health care teams such that prviders will use shared care plans, track treatments in new patient registries, use new evidence-based screening tls and treatment, and receive reimbursement fr quality f care and clinical utcmes thru value-based payment. Medicaid beneficiaries will benefit frm these practice transfrmatins by receiving whlepersn care that is dedicated t cvering physical and behaviral health cnditins as well as imprving care crdinatin t address the scial determinants f health. By implementing Cllabrative Care principles, we aim t clse the gap between primary care and behaviral health, imprve health utcmes and wellbeing fr the mst vulnerable ppulatins, and create sustainable, transfrmatinal change t the health care system. Justificatin fr Selecting Prject and Hw It Addresses Reginal Pririties Bi-directinal care integratin is necessary fr achieving full health system transfrmatin, as integrated care will serve as the fundatin fr imprving primary care and access t behaviral health services, lwering health care csts, and imprving health utcmes. Thrugh a whle-persn apprach t care, prviders will be able t vercme health sectr sils by having an integrated netwrk f prviders and imprved care crdinatin acrss the entire health care spectrum. Behaviral health cnditins ften g untreated and get verlked due t stigma, lack f screening, and lack f access t apprpriate care. Research shws that peple wh suffer frm a chrnic disease are mre likely t suffer frm depressin, which highlights the need fr integrated care as this c- 1 P age

2 2A Bi-Directinal Care Integratin Prject DRAFT Nv 13, 2017 mrbidity results in an estimated tw t three times higher health care csts. 1,2 Fr example, research shws that depressin is fund t c-ccur in 17% f cardivascular cases, 23% f cerebrvascular cases, and 27% f patients with diabetes and mre than 40% f individuals with cancer. 3 In state rankings, Washingtn ranked third fr the percent f adults with any mental illness (AMI) and secnd fr the percent f adults with serius mental illness (SMI) at 23.7% and 6.7%, respectively. 4 These rates are even higher in the CPAA regin. In FY , individuals within the CPAA regin diagnsed with mental illness, serius mental illness, and c-ccurring substance-use disrder and mental illness (SUD + MI) were 30.6%, 23%, and 9.3%, respectively. 5 Prviding whle-persn care in the setting in which individuals are mst likely t seek care is a key building blck fr CPAA t achieve its verarching gals f imprved health, better quality, and lwered csts. Thrugh lcal frums in the CPAA regin and in cllabratin with partnering prviders, cmmunity members, and managed care rganizatins (MCOs), five reginal health pririties were identified. Fur ut f five f these reginal pririties address reginal needs and cmmunity interests specific t this prject: imprving access t health care (including adult and pediatric primary care and behaviral health), imprving care crdinatin & integratin, preventing & managing chrnic disease, and preventing and mitigating adverse childhd experiences (ACEs). CPAA has elected t use all f the mdels put frward in the prject tlkit t ensure the full cntinuum f primary care and behaviral health settings are wrking n integratin appraches. Within the primary care setting, CPAA will utilize the Cllabrative Care Mdel (CCM) and the Bree Cllabrative Behaviral Health Integratin Recmmendatins as the evidence-based appraches fr bidirectinal care integratin. In the primary care setting, research supprts the effectiveness f the CCM in imprving utcmes and lwering csts fr patients with cmmn mental disrders such as depressin when cmpared t usual care. 6,7 In behaviral health settings, primary care integratin appraches fcus n implementing ff-site, enhanced cllabratin; c-lcated, enhanced cllabratin; r c-lcated, integrated care, alng with the cre principles f cllabrative care. We anticipate implementing the afrementined appraches in primary care and behaviral health settings will result in imprvements t a number f the metrics related t this prject and shared acrss ther prject areas, ultimately imprving care and wellbeing fr the residents f the CPAA regin. Hw Prject Will Supprt Sustainable Health System Transfrmatin fr the Target Ppulatin Bi-directinal care integratin will supprt sustainable health system transfrmatin fr the chsen 1 Centers fr Disease Cntrl and Preventin. Mental Health and Chrnic Diseases. NCCDPHP Issue Brief N. 2, Octber Accessed: Nvember Available: 2 Bree Cllabrative. Behaviral Health Integratin Reprt and Recmmendatins, Accessed: Nvember Available: 3 Centers fr Disease Cntrl and Preventin. Mental Health and Chrnic Diseases. NCCDPHP Issue Brief N. 2, Octber Accessed: Nvember Available: 4 Washingtn State Institute fr Public Plicy. Inpatient Psychiatric Capacity and Utilizatin in Washingtn State, February Accessed: Nvember Available: State_Reprt.pdf 5 Healthier Washingtn, Department f Scial and Health Services Research and Data Analysis (RDA) ACH Prfiles. Accessed: Nvember Available: 6 Health Hme Infrmatin Resurce Center. The Cllabrative Care Mdel: An Apprach fr Integrating Physical and Mentalh Health Care in Medicaid Health Hmes, May Accessed: Nvember Available: 7 Archer J, Bwer P, Gilbdy S, Lvell K, Richards D, Gask L, Dickens C, Cventry P. Cllabrative care fr depressin and anxiety prblems. Cchrane Database f Systematic Reviews 2012, Issue 10. Art. N.: CD DOI: / CD pub2 2 P age

3 2A Bi-Directinal Care Integratin Prject DRAFT Nv 13, 2017 target ppulatin by assisting prviders t adpt a whle-persn apprach t care that is patientcentered and fcused n prviding accuntable care. This will require changes in partnering prviders wrkflws, business practices, and staffing patterns t supprt team-based care, treatment t target, and ppulatin-based care. Investments in this prject will be supprted by the ther prjects that the CPAA is implementing, including Cmmunity Care Crdinatin (Reginal Pathways HUB), Transitinal Care, Reprductive and Maternal/ Child Health, Chrnic Disease Preventin and Cntrl, and Opiid Respnse. The prject metrics and ppulatins targeted by these ther prject areas verlap thse served under this prject, and many f their strategies will supprt success in this initiative as well. Fr example, the Chrnic Care Mdel has served as the cnceptual base fr several integrated care mdels by prviding a clinical framewrk that ffers direct cnnectins t cmmunity resurces, better chrnic disease educatin, and use f patient registries t mnitr and track patient data. CPAA anticipates interventins and resurces develped in this prject als will be shared acrss ther prjects, therefre, benefiting target ppulatins in multiple prject areas. Fr example, implementing pediatric integrated behaviral health care will aid in early identificatin f behaviral health cnditins. Once these investments have been made, they will becme permanent, as the care systems have becme permanently reriented t these new nrms and standard prcesses and prcedures. CPAA and its administrative partner, CHOICE Reginal Health Netwrk, have a prven track recrd transitining pilt prjects, similar t this ne, t nging prgrams in the regin. CHOICE has accmplished this by using cllective impact and demnstrating cst-effectiveness t participating funders, wh then maintained funding fr these effrts n a cntinuing basis. CPAA will apply this apprach t assure sustainability f bi-directinal care integratin pst Transfrmatin. Hw CPAA Will Ensure Prject Crdinates With and Des Nt Duplicate Existing Effrts CPAA and CHOICE have wrked clsely with the cmmunity fr ver 20 years and are thus familiar with bth health care needs and existing services prvided in the regin. CPAA s gvernance and advisry structure bring t the table a wide-range f service prviders, stakehlders, and rganizatinal leaders in the CPAA regin, including the tw Behaviral Health Organizatins and all five Managed Care Organizatins that serve Medicaid beneficiaries. This brad range f partner representatin already in place thrughut the CPAA structure enables us t hear real-time cncerns abut health issues, including implementatin f bi-directinal care integratin. There is a high level f understanding in the Bi-Directinal Care Integratin Wrk Grup f the need fr mre streamlined, crss-system crdinatin withut duplicating existing services, alng with guidance n transfrming individual rganizatins t meet standards utlined in the Prject Tlkit. CPAA is taking great care t build upn ur regin s cllective wrk t imprve bi-directinal care integratin and avid duplicative effrts and capacity fr this prject. This is in keeping with ne f CPAA s fundatinal principles, namely t build upn existing assets in the regin and strengthen existing infrastructure and care systems t the greatest extent pssible. Therefre, ne f the first implementatin steps in this prject area will be t cmplete a current state assessment f integrated care acrss the regin by the end f Q that will serve t prvide a baseline understanding f the levels f integrated care at ur partnering prviders. In additin, CPAA will cntinue crdinating with Qualis Health t cmpile their integrated care data already being cllected frm the Patient Centered Medical Hme-A (PCMH-A) and Maine Health Access Fundatin (MeHAF) assessments that identify the current state f care integratin in primary care clinics and behaviral health settings, respectively (see Appendix XX). Data frm these assessments will assist with capacity building and be used t track, mnitr, and crdinate implementatin effrts. 3 P age

4 2A Bi-Directinal Care Integratin Prject DRAFT Nv 13, 2017 CPAA began taking stck f prject areas in which partnering prviders are planning t implement interventins by pening a Request fr Qualificatins (RFQ) prcess that prmpted prviders t describe new prject ideas, hw new prjects will avid duplicating effrts, and which partners are wrking in cllabratin. It has been well-cmmunicated thrugh prject wrk grups and crrespndence with partners that Transfrmatin funding can nly be used fr new prjects and/r enhancing current prjects. T date, we have received 38 RFQ respnses, f which 17 pertain t the bi-directinal care integratin prject area (see Appendix XXX). Additinally, CPAA cnducted a landscape analysis f majr Medicaid prviders and payers, as well as public health departments in the regin (see Appendix XXX). Fr prviders, this includes dental, primary care, FQHCs, hspitals, and majr health systems. The purpse f this assessment is t better understand wh the majr stakehlders are in the CPAA regin, wh is already engaged in the Transfrmatin prjects, and wh CPAA still needs t engage in the Transfrmatin wrk. During a review f this tl by the CPAA Cuncil and Dmain 2 Wrk Grup, a number f key prviders yet t be engaged were identified. T ppulate this tl, we used Prvider data supplied by the HCA and included prviders in the table wh served apprximately 90% f Medicaid beneficiaries in By analyzing the prvider landscape, CPAA is able t facilitate new partnerships between prviders, keep track f individual prvider s initiatives, and create new tls t mnitr existing prject effrts. CPAA is well psitined t develp versight, mnitring, and cntinuus quality imprvement (CQI) mechanisms t assure timely implementatin f prject interventins, and prmte fidelity t evidence-based practices that d nt duplicate effrts. Anticipated Prject Scpe Anticipated Target Ppulatin Bradly, bi-directinal care integratin has the ptential t serve all Medicaid beneficiaries, bth children and adults, with behaviral health cnditins. In the primary care setting, this means particularly patients suffering frm depressin r anxiety as well as serius mental illness, and in the behaviral health setting, patients suffering frm serius mental illness. In bth settings, subset ppulatins will be patients with depressin r serius mental illness wh have ne r mre chrnic cnditins such as diabetes, asthma, heart disease, r besity. Ppulatins with behaviral health cnditins and c-mrbidities will verlap with the target ppulatins frm Prject 3A, 3B, and 3D. CORE has cnducted an analysis fr CPAA that highlights sub-regins and subgrups with prer health utcmes r mre limited access t services (see Appendix XX). CPAA reviewed these CORE findings with the prject wrk grups and asked members t identify additinal subgrups and sub-regins fr further cnsideratin. Based n wrk grup members feedback, we cmpiled the fllwing qualitative list: peple wh are hmeless, individuals new t the area, thse withut a PCP using the ED as their main access pint fr care, thse with transprtatin barriers in urban and rural settings, patients in hspice seeking care, Hispanic families with fear arund accessing care, elderly individuals, yung parents ages 18-24, and the gegraphic area f East Lewis Cunty. In FY , a ttal f 170,627 Medicaid beneficiaries, bth children and adults, were served jintly by HCA-DSHS in the CPAA regin. Based n a review f this data, we anticipate a maximum reach wuld include just under 115,000 Medicaid beneficiaries with the fllwing diagnses: 52,175 diagnsed with mental illness (MI); 39,298 diagnsed with serius mental illness (SMI); 4 P age

5 2A Bi-Directinal Care Integratin Prject DRAFT Nv 13, ,310 with SUD treatment need. 8 One additinal analysis t estimate the reach f this prject fcuses n crss-referencing data frm the HCA with utilizatin measures required fr the Transfrmatin. As described abve, 115,000 individuals were diagnsed with MI, SMI r SUD treatment need. In the CPAA regin, 74% f adult Medicaid beneficiaries accessed preventive/ambulatry health services. As a prxy measure, implementatin f this prject has the ptential t reach 85,000 adults and children accessing preventive/ambulatry services. CPAA ntes that bi-directinal care integratin represents several gradatins f effrt, ranging frm better crdinatin between distinct primary care and BH practices, t n-site integratin f PCP and BH services. We estimate that, by the end f the prject perid, apprximately 85,000 ptential patients will receive sme level f integrated care. Invlvement f Partnering Prviders CPAA is keenly aware that we need t engage the right prviders in rder t meet ur regin s transfrmatin gals. With that in mind, CPAA has cnducted three effrts t identify partnering prviders: 1) a Request fr Qualificatins (RFQ) t identify and engage partnering prviders; 2) a table that includes prviders wh served apprximately 90% f Medicaid beneficiaries in 2016; and 3) a table that includes cmmunity-based rganizatins and scial services in each cunty that have already been engaged (see Appendix XXX). There is strng supprt frm mst f the majr Medicaid prviders in the CPAA regin fr implementing bi-directinal care integratin including ur regin s three Federally Qualified Health Centers (FQHCs). The clinical prviders identified in the CORE analysis represent the main clinical access pints fr Medicaid beneficiaries. With strng invlvement frm ur clinical partners acrss the regin, we can expect t serve a large ppulatin f Medicaid beneficiaries, specifically the target ppulatins detailed abve, which is critical fr the success f this prject. Many f ur clinical partners have engaged with CPAA frm the start and have been invlved in wrk grups t design this prject applicatin. This prject prmtes and supprts specific changes in clinical delivery that have a strng evidence base fr imprving patient utcmes. Additinally, ur clinical partners implementing this prject will fllw the evidence-based mdels utlined in the Prject Tlkit, which are the prven strategies fr achieving care delivery redesign. CPAA cntinues t engage nn-clinical partners with the understanding that their invlvement will play a key rle in achieving the required level f integrated care. Future wrk will invlve strengthening partnerships between ur clinical and nn-clinical partners. Level f Impact When cnsidering the level f impact fr this prject s anticipated target ppulatin, ur initial analysis fcused n identifying prviders that serve 90% f Medicaid beneficiaries in the CPAA regin. By utlining the prviders that are serving the majrity f Medicaid beneficiaries, we expect t reach the maximum number f patients, and therefre maximizing the level f impact. Further analysis f the CPAA regin allwed us t better understand diagnstic data related t this prject and t highlight health trends in specific demgraphics and individual cunties. Fr example, ED utilizatin per 1000 member mnths is highest in Masn, Grays Harbr, Lewis, and Pacific cunties, 9 which may crrelate 8 Healthier Washingtn, Department f Scial and Health Services Research and Data Analysis (RDA) ACH Prfiles. Accessed: Nvember Available: 9 Healthier Washingtn Data Dashbard. Accessed: Nvember Available: 5 P age

6 2A Bi-Directinal Care Integratin Prject DRAFT Nv 13, 2017 with a subgrup f patients presenting in the ED withut a PCP r a lack f access t primary care. By fcusing n these cunties t reduce ED utilizatin, we can maximize the level f impact fr Medicaid beneficiaries and reduce cunty metrics t match the State average. Additinally, CPAA harnessed the lcal knwledge f ur prvider netwrks t suggest subgrups and sub-regins within each cunty that suffer frm health disparities and lack f access t care. Frm this lcal knwledge, we learned that East Lewis Cunty in particular is disprprtinately affected by limited access t care. One additinal methd that helped us understand this prject s level f impact was detailed by ur partnering prviders in their RFQ respnses. Fr each RFQ respnse, prviders listed the anticipated target ppulatin that wuld be served, allwing us t further identify regins and ppulatins suffering frm the greatest health disparities. Up t this pint, all f the activities and analysis regarding target ppulatins were designed t give us the mst cmprehensive picture f where the health care needs and the patient ppulatins are the greatest. Further refinement f ur target ppulatin will take place during the planning phase thrugh cntinued wrk with ur partnering prviders, supprted by further analysis by ur data cntractr, CORE. Hw CPAA Will Ensure Health Equity is Addressed in the Prject Design Addressing health equity has been built int the CPAA s general apprach t the Medicaid Transfrmatin prjects. CPAA is develping an adaptatin f health equity tls used by ther rganizatins such as King 10 and Multnmah 11 cunties that will infrm the methds behind finalizing target ppulatins and implementing specific prject area interventins. By analyzing health utcme data with ur clinical and nn-clinical partners in the prject wrk grups, we are able t fcus ur interventin effrts n reaching ppulatins that experience gegraphic barriers and thse underserved by the health care system. The prcess by which we gathered lcal knwledge n subgrups and subregins speaks t ur effrt t better understand health disparities in ur regin. Fr example, we learned that patients receiving treatment fr a chrnic disease may have an undiagnsed mental health cnditin, which untreated, can result in the increased use f emergency departments. We are engaging cnsumers in ur regin t help with the identificatin and selectin f the right target ppulatin/s fr this and ur ther prject areas. In late Octber, cnsumers frm thrughut the seven-cunty regin came tgether within the CPAA Cnsumer Advisry Cmmittee t advise n prject planning methds and activities t date. We are cnsulting with ur Tribal partners, sme f whm have been invlved in ur wrk grups, t ensure health equity is thrughly cnsidered in ur prject planning and implementatin. Fr instance, we recently met with the health directr f the Nisqually Indian Tribe, t learn abut the Tribe s greatest health needs. As a result f these nging cnsultatins, the list f pririty target ppulatins and interventins may change, reflecting mre fully health equity cnsideratins. dashbard 10 Healthy King Cunty Calitin. Accessed: Nvember Available: Assessment-Tl_FINAL-1+%284%29.pdf 11 Multnmah Cunty. Equity and empwerment Lens. Accessed: Nvember Available: 6 P age

7 2A Bi-Directinal Care Integratin Prject DRAFT Nv 13, 2017 Prject s Lasting Impacts and Benefit t the Regin s Overall Medicaid Ppulatin During DY 2, CPAA will frmalize cmmitments with partnering prviders n implementing prjectspecific interventins. Implementing bi-directinal care integratin will have lasting practice transfrmatin effects that will result frm a shift in practice as usual. Mving int an integrated system will change the dynamics f health care teams such that prviders will start using shared care plans, tracking treatments in new patient registries, using new evidence-based screening tls and treatment, and receiving reimbursement fr quality f care and clinical utcmes thrugh value-based payment. Medicaid beneficiaries will benefit frm these practice transfrmatins by receiving whlepersn care that is dedicated t cvering physical and behaviral health cnditins as well as imprving care crdinatin t address the scial determinants f health. CPAA will be a driving frce behind this cllective effrt by tracking prject implementatin prgress and individual prject metrics. As prviders implement integrated care thrughut the Transfrmatin, the dr will pen fr further crss-prject cllabratin that will mre effectively serve Medicaid patients entering the health care system frm different access pints. Building n infrastructure already in place, prviders have the pprtunity t demnstrate hw systemwide transfrmatin in care delivery will result frm investments in wrkfrce, value-based payment, and ppulatin health management. Investments in the three Dmain 1 areas will directly translate int lasting impact fr patients. After the Transfrmatin perid, these investments will result in verarching infrastructure and capacity changes necessary t supprt care delivery redesign lng-term. Additinally, the change t fully integrated managed care will cincide with care integratin effrts at the clinical level, and CPAA anticipates that nce these majr changes are made t bth business and clinical practices, the system will be permanently reset and interventins will be sustained beynd the Transfrmatin perid. CPAA and CHOICE have prven track recrds fr develping innvative prjects with pilt funding and develping ways t sustain these effrts int the future. Key t ur success is ur ability t demnstrate t stakehlders, including hspitals and CBOs, that the prject has enabled the stakehlders t achieve efficiencies, imprve utcmes, r avert future csts. We expect this experience, alng with the trusted relatinships we have already built with prviders in ur regin, will supprt ur ability t a develp path tward sustainability fr this prject. Implementatin Apprach and Timing (Supplemental Wrkbk Tabs) See 2A Implementatin Apprach tab in ACH Prject Plan Supplemental Data Wrkbk fr a brief descriptin f hw CPAA will accmplish each set f prject milestnes in Stage 1, Stage 2, and Stage 3. Partnering Prviders (500 wrds + Supplemental Wrkbk Tabs) Hw CPAA Has Included Partnering Prviders That Cllectively Serve a Significant Prtin f the Medicaid Ppulatin CPAA is well psitined t bring majr partnering prviders in the regin tgether t create cllective impact. A principal asset in this engagement prcess is the well-established prvider relatinships CHOICE has cultivated ver the last tw decades; a number f key Medicaid prviders are members f 7 P age

8 2A Bi-Directinal Care Integratin Prject DRAFT Nv 13, 2017 CHOICE, including tw f the regin s three Federally Qualified Health Centers (Valley View Health Center and Sea Mar) and all f the regin s hspitals in five f the seven cunties cvered by CPAA, including ur largest tertiary hspital, Prvidence St. Peter Hspital. Frm the beginning, CPAA has included a brad range f prviders in its wrk acrss ur seven-cunty regin, including prviders that cllectively serve a significant prtin f the Medicaid ppulatin. CPAA cnvened a Bi-Directinal Care Integratin Wrk Grup and has been meeting at least mnthly t cllect infrmatin and design the prject plan. The wrk grup includes representatives frm mental health, substance abuse treatment, and primary care rganizatins frm every cunty in the regin. Members have played an active rle in prject design and n the develpment f this applicatin and are fully engaged in the bi-directinal care integratin prject. T ensure a significant prtin f the Medicaid ppulatin will be served in this Transfrmatin, CPAA partnered with CORE t analyze prvider claims data prvided by the HCA t develp a landscape analysis f the majr Medicaid prviders and payers as well as public health departments in the CPAA regin. This list has been crss-referenced with RFQ respnses received frm partners t ensure a significant prtin f Medicaid recipients can be reached thrugh the partners engaged in each prject. Fr prviders, this includes dental, primary care, FQHCs, hspitals, and majr health systems. The purpse f this tl is t better understand wh the majr stakehlders are in the CPAA regin, wh is already engaged in Transfrmatin prjects, and whm we still need t cntact fr engagement. T ppulate this tl, we used Prvider data supplied by HCA and included prviders wh cllectively served apprximately 90% f Medicaid beneficiaries in By analyzing the prvider landscape, CPAA can engage and cnnect stakehlders with the gal f creating new partnerships and crdinating interventin effrts. The CPAA is well psitined t facilitate new partnerships between prviders, keep track f individual prvider initiatives, and create new tls t mnitr existing prject effrts. Prcess fr Ensuring Partnering Prviders Cmmit t Serving the Medicaid Ppulatin As previusly mentined, CPAA cnducted a Request fr Qualificatins (RFQ), prmpting prviders t describe the target ppulatin and estimated number f Medicaid lives served. This preliminary infrmatin is the first step in understanding which Medicaid ppulatins will be served and will allw us t further the cnversatin abut chsing specific target ppulatins. In DY 2, we will secure frmal cmmitments frm ur partnering prviders t implement the evidence-based appraches utlined in the prject tlkit that will include a cmmitment t serve specific Medicaid ppulatins. These cmmitments will be made in the frm f cntracts with partnering prviders that specify the specific scpe f wrk fr each implementatin partner, reprting requirements, and payment arrangements. CPAA will mnitr these cmmitments by tracking prgress n prject implementatin and utcmes fr perfrmance metrics per agreed upn cntracts with partnering prviders. Additinally, CPAA will ensure prviders interested in participating in the Transfrmatin that have a lwer than average Medicaid ppulatin cmmit t increasing their access t the Medicaid ppulatin. Prcess fr Engaging Partnering Prviders That are Critical t the Prject s Success, and Ensuring That a Brad Spectrum f Care and Related Scial Services are Represented CPAA engages key partnering prviders in the Transfrmatin in varius ways. A number f key implementatin partners already serve n ur prject wrk grups. Wrk grups cnsist f individuals frm partnering rganizatins, including large and small, urban and rural clinical prviders that encmpass behaviral health and primary care, scial services, cmmunity-based rganizatins, MCOs, and public health departments. 8 P age

9 2A Bi-Directinal Care Integratin Prject DRAFT Nv 13, 2017 At wrk grup meetings, we identify gaps in ur partner participatin by asking ur members t identify missing rganizatins and individuals t ensure thrugh representatin frm all necessary health and scial service rganizatins. One methd we have emplyed t identify key service prviders yet t engage is a cmparisn f RFQ respnses received and majr Medicaid prviders identified in the regin. This has allwed us t make cnnectins with new prviders as well as prmpt existing partnering prviders t submit a RFQ respnse fr bi-directinal care integratin. T date, we have received 38 RFQ respnses, f which 17 pertain t the bi-directinal care integratin prject area. Finally, the CPAA Cuncil includes members frm different health and scial services rganizatins. CPAA des extensive utreach t rganizatins that need t be invlved and is asking existing partners, including ur Prvider Champins clinicians wh have agreed t assume a leadership rle in liaising with ur prvider cmmunity t bring ther prviders t the table that are essential t prject success. CPAA s apprach t gvernance and prject management relies n strng prvider engagement. All five wrk grups, the Supprt Team, and the Cuncil include key partners representing different practices and rganizatins. Hw CPAA is Leveraging MCO s Expertise in Prject Implementatin, and Ensuring There is N Duplicatin MCOs have been active participants in the all wrk grups, the Clinical Advisry Cmmittee, and the CPAA Cuncil and Bard f Directrs. MCO representatives have cntributed t the identificatin f reginal health pririties, have prvided input int the prject planning prcess, and will cntinue t be key partners thrughut Transfrmatin implementatin. CPAA encurages MCO representatives t share develpments in their rganizatins regarding VBP strategies, mving t fully integrated managed care, and any additinal guidance fr wrking with prviders at the clinical level n integrated care. MCOs are critical t the success f this prject, as we need t ensure payment mechanisms are aligned with and supprt ur prject interventins. All five MCOs that serve ur regin have participated in the CHOICE-led reginal health imprvement wrk ver the years and, mving frward, we anticipate that the MCOs will play an active rle in the Medicaid Transfrmatin prject planning and implementatin. This will ensure there is gd crdinatin between payers, their expertise is leveraged, and duplicatin will be avided. Appendix TK lists MCO representatives and the rganizatins they represent. Reginal Assets, Anticipated Challenges and Prpsed Slutins (1,000 wrds) Assets CPAA and Reginal Partnering Prviders Will Bring t the Prject One f the principal assets CPAA brings t this prject is CHOICE s brad and well-established netwrk f psitive, cllegial relatinships with clinical prviders, cmmunity-based rganizatins, and health plans develped ver mre than tw decades f cmmunity-led health imprvement and cllective actin. In its prject planning and implementatin, CPAA can readily build n this strng, trusting fundatin. Partnering prviders thrughut the CPAA regin bring a wealth f knwledge frm many different sectrs f health care, urban and rural perspectives, and small clinics t large hspital systems. The amunt f in-kind time cntributed thrugh wrk grups and advisry grups is substantial and demnstrates the deep cmmitment f ur partners. Our implementatin partners have shwn 9 P age

10 2A Bi-Directinal Care Integratin Prject DRAFT Nv 13, 2017 cnsistent engagement in prject wrk grups, advisry cmmittees, and the cuncil and bard f directrs. Additinally, the majr Medicaid prviders in the CPAA regin cntinue t express their cmmitment t this nging cllabrative effrt. Several f ur partnering prviders already have VBP cntracts in place; this creates a fundatinal platfrm fr increasing the number f cntracts in value-based arrangements. Partners currently implement aspects f integrated care t varying degrees. Fr example, Valley View Health Center began implementing the Cllabrative Care Mdel in 2009 and has demnstrated success in peratinalizing the mdel, shwn ability t scale the mdel, and reflects satisfactin with utcmes frm implementatin. In additin t Valley View implementing cllabrative care, they are als wrking with the largest behaviral health prviders in the CPAA regin t partner in c-lcatin and shared learning arund integratin. Valley View is sharing clinic space with Behaviral Health Resurces and Cascade Mental Health. Prvidence St. Peter Hspital ffers behaviral health integratin as part f their Family Medicine Residency Prgram which fllws the Cllabrative Care Mdel and uses a patient registry prvided by the AIMS Center. Cwlitz Family Health Center has prvided integrated behaviral health care in its primary care practice since 2009, and bi-directinal primary care and substance use disrder treatment since CPAA will wrk with these partners t help facilitate infrmatin sharing with ther prviders n their experiences and expertise with implementing cllabrative care. Anther key asset supprting prject readiness is that all partnering prviders wh are interested in implementing cllabrative care principles have existing EHR systems, sme f which may have interperability with ther data systems. Challenges t Imprving Outcmes and Lwering Csts fr Target Ppulatin and Strategy t Mitigate Risks and Overcme Barriers There are a number f challenges and barriers t vercme in rder t achieve the intended prject utcmes. Bradly speaking, these fall int tw categries: (1) general challenges and barriers, and (2) prject-specific challenges and barriers. General Challenges and Barriers All Transfrmatin prjects require: Data: CPAA must have access t timely, accurate data t: Identify/refine target ppulatins, partnering prviders, and interventins, and Mnitr the perfrmance f ur partnering prviders under the Transfrmatin t determine partner cmpensatin, curse crrect if milestnes and perfrmance metrics are nt being achieved, and cnduct cntinuus quality imprvement effrts. Health Infrmatin Systems: Our partnering prviders must have the ability t exchange infrmatin abut patients and care plans in rder t avid care gaps and duplicatin f services. Currently, there is n cnsistent standard and/r IT system fr infrmatin sharing in ur regin, especially between prviders that serve patients with multiple chrnic illnesses and behaviral health cnditins. Wrkfrce: Our partnering prviders must have access t the right wrkfrce t implement the evidence-based interventins in the chsen prject areas. This includes persnnel with the right general prfessinal qualificatins, expertise and experience in the prject area, and training in 10 P age

11 2A Bi-Directinal Care Integratin Prject DRAFT Nv 13, 2017 the specific methds and appraches f the chsen interventins. Ensuring ready access t this wrkfrce is a majr cncern, especially in rural, under-resurced areas. Finances: Our partners need t be clear n: Fund flws, i.e., they need t understand when, hw and hw much they will be paid in rder t infrm their decisin-making abut investments in the Transfrmatin. Financial sustainability, i.e., they need t understand what payment mechanisms are being develped t sustain their investments beynd the Transfrmatin. The principal barrier in this arena is the fact that the vast majrity f purchasing activities ccur in ther venues and are cntrlled by ther parties. Mst medical purchasing is cnducted by MCOs, while behaviral health services are currently purchased under the rubric f BHOs. Prject-Specific Challenges and Barriers In additin t these general challenges and barriers, there are a number f prject-specific challenges and barriers t vercme. The fllwing is a list f selected key challenges and barriers specific t bidirectinal care integratin: Wrkflw Changes Restructuring care teams t fit the Cllabrative Care Mdel; Establishing a starting pint fr implementing integrated care; Establishing clear language arund gals, mutual trust, effective cmmunicatin, and measurable prcesses and utcmes within care teams; Behaviral health prviders finding physical space fr c-lcated, integrated care; Primary care prviders enhancing their level f care arund behaviral health services; Establishing effective change management techniques fr rganizatins and clinicians. Health Infrmatin Technlgy Access t timely, accurate data n prject metrics t allw fr mre immediate quality imprvement; Lack f interperability between partnering prviders different EHR systems; Data tracking and reprting deficiencies f EHR systems; Dcumenting and tracking behaviral health infrmatin due t deficiencies with EHRs; Implementing and managing new patient registries fr Cllabrative Care and determining lgistics f data entry; Using technlgy fr effective team-based care. Lack f Prvider Capacity Recruitment Lng vacancies fr necessary psitins include registered nurses, medical assistants, mental health cunselrs, clinical scial wrkers, and substance abuse/behaviral health cunselrs; 12 Lack f attractive hiring incentives; Specific shrtages in primary care physicians, psychiatrists, and behaviral health clinicians, particularly in rural areas; 12 Washingtn Sentinel Netwrk. Health Wrkfrce Cuncil 2016 Annual Reprt. Accessed: Nvember Available: 11 P age

12 2A Bi-Directinal Care Integratin Prject DRAFT Nv 13, 2017 Lack f funding t supprt new staff. Retentin Prvider dissatisfactin; Limited nging training; Nt clearly managing changes t rles and respnsibilities. Training Develping wrkfrce training plans tailred t supprt the implementatin f each prject; Crdinating retraining effrts fr prviders t meet the demands f wrkflw/care delivery redesign; Ensuring that varius training needs are being met acrss all prviders and hspital administratrs; Establishing effective scheduling methds between behaviral health clinicians and PCPs; Crdinating training effrts with HCA, DOH, Qualis Health, and the AIMS Center. Value-based Purchasing (VBP) Understanding the prvider capacity gaps in effectively engaging in VBP cntracts; Develping methds t supprt prviders in increasing VBP cntracts in primary and behaviral health care; Ensuring rganizatins and clinicians are trained n implementing new cllabrative care cdes fr Medicaid; Understanding what the critical VBP cmpetencies are acrss different VBP arrangements; Develping a smth transitin t fully-integrated managed care. CPAA Strategy fr Mitigating the Identified Risks and Overcming Barriers The fllwing table lists varius mitigatin strategies t address the identified challenges and barriers. As new infrmatin is released frm the HCA and MCO partners, CPAA will cntinue t develp additinal mitigatin strategies with ur prject wrk grups and advisry cmmittees. Barrier Data Health Infrmatin Systems Wrkfrce Finances Ptential Slutins Partner with CORE, state and prviders t identify/refine target ppulatins, partnering prviders, and interventins (underway) Partner with prviders and MCOs t btain clse t real-time prvider perfrmance infrmatin; explre cntracting with a third-party data aggregatr with data analytics capabilities (underway). Partner with state, MCOs, prviders, and ther ACHs in develping interperability between health infrmatin systems; expedite planning fr and implementatin f clinical integratin f behaviral health. Invest in training f partnering prviders in evidence-based methds/mdels Explre shared wrkfrce ptins, e.g., thrugh telehealth Funds Flws: Wrk with CPAA Finance Cmmittee t clarify funds flws 12 P age

13 2A Bi-Directinal Care Integratin Prject DRAFT Nv 13, 2017 Wrkflw Changes Health Infrmatin Technlgy Lack f Prvider Capacity Value-based Purchasing (underway) Financial Sustainability: Wrk with payers (health plans and state) t supprt transitin t value-based purchasing; state needs t adjust cntracting w/ MCO wh in turn mdify prvider payment appraches accrdingly Cntract with the AIMS Center t prvide training and technical assistance fr implementing cllabrative care principles, restructuring care teams, and using patient registries Crdinate with Qualis Health n implementing PCMH-A and MeHAF assessments that lead t quality imprvement and wrkflw changes (underway) Establish cllabrative care champins at each partnering prvider t establish a clear plan fr integrating care Develp guidance n change management principles fr partnering prviders Develp an inventry f partnering prviders EHR systems t help CPAA and partners develp creative slutins t data sharing challenges Develp guidance n vercming restrictins f behaviral health infrmatin fr care teams Wrk clsely with the AIMS Center n evaluating ptins fr patient registries, effectively using patient registries, and understanding lgistics f data entry (underway) Develp guidance n effective ways t restructure care teams and mdify rles and respnsibilities f care team members Ensure prviders have the necessary training and expertise t effectively manage wrkflw changes assciated with cllabrative care Cntinue prmting VBP acrss the regin particularly fr VBP cntracts in relatin t cllabrative care Cmmunicate clear guidance n transitining frm fee-fr-service cntracts t VBP cntracts Identify prvider capacity gaps in effectively engaging in VBP cntracts Target Transfrmatin resurces t supprt develpment f VBP arrangements Mnitring and Cntinuus Imprvement Plan fr Mnitring Prject Implementatin Prgress, Including Addressing Delays in Implementatin CPAA will implement a rigrus prject mnitring apprach t implementatin f the prject. The same apprach will be emplyed acrss the entire prtfli f prjects. This includes entering int cntracts that clearly spell ut partnering prviders respnsibilities, including reprting requirements, and supprts CPAA can ffer as well as emplying prject planning sftware and tls t lay ut required deadlines, key tasks, subrdinate tasks, and milestnes. Each prject implementatin plan will define critical paths and key dependencies. Key 13 P age

14 2A Bi-Directinal Care Integratin Prject DRAFT Nv 13, 2017 indicatrs will be determined fr each prject area that will serve as an early warning system t detect when implementatin challenges are encuntered. A mnthly perfrmance dashbard reprt will cmpare actual perfrmance f key indicatrs against targets within and acrss all prject areas. This will allw the prject managers as well as the CPAA Supprt Team, which includes the chairs f each prject wrk grup, t identify bth implementatin prblems and early wins. CPAA has hired dedicated supprt staff fr each prject area (prgram managers). It is the respnsibility f the prgram managers t stay in clse cntact with all partnering prviders in their respective prject area. Specifically, the prject managers are respnsible fr: Identifying supprt needs f partnering prviders thrughut the duratin f the Transfrmatin; Serving as subject matter experts fr partnering prviders r, if additinal expertise is required, identify and facilitate external subject matter experts prviding enhanced technical assistance t partnering prviders; and Mnitring verall partnering prvider perfrmance tward milestnes and perfrmance metrics (see belw fr details). Prject implementatin mnitring is clsely tied t perfrmance mnitring f partnering prviders. The next sectin f the prject plan discusses in detail hw CPAA will mnitr the perfrmance f individual partnering prviders. The data reprting and analytics tls used t hld individual partnering prviders accuntable t agreed upn deliverables will prvide CPAA als with a clear sense abut the prject s verall implementatin prgress, as individual prvider perfrmance data rlls up int a regin-wide perfrmance summary. See next sectin fr details. Plan fr Mnitring Cntinuus Imprvement, Supprting Partnering Prviders, and Determining Whether r Nt CPAA is n Track t Meet Expected Outcmes CPAA will set up a prgressive implementatin and perfrmance mnitring structure with tiered interventins up t terminatin f partnering prvider cntracts. This will include regular meetings with ur partnering prviders t assess implementatin prgress and challenges. If prject implementatin prgress becmes questinable r is delayed, the prject manager will infrm his r her immediate supervisr (Clinical Directr r Care Crdinatin & Educatinal Prgrams Directr) f the cncern. The senir prject management team will assess the severity f the situatin. When pssible, we will seek t mitigate the risk r delay by prviding technical assistance t help the partnering prvider/s t get back n track. This will include seeking advice frm clinical experts, including Prvider Champins serving n the CPAA Clinical Prvider Advisry Cmmittee. The partnering prvider and CPAA will agree n an actin plan (Perfrmance Imprvement Plan) t reslve the issue r renegtiate the cntract deliverables, if necessary. In severe cases r if the technical assistance des nt crrect the prblem, we will escalate the issue t ur Clinical Prvider Advisry Cmmittee fr a mre cmprehensive review. The cmmittee may identify additinal prblem slutin strategies, ask ur Prvider Champins t intervene, help access additinal external technical assistance resurces, r engage ther key stakehlders in additin t affected prviders t remedy the cause f delays. If the prblem cannt be reslved, is f a majr magnitude r invlves key partners that serve large numbers f Medicaid beneficiaries, the CPAA Cuncil and Bard will be infrmed. The bard will make the final decisin abut mdifying r terminating cntracts with partnering prviders. Access t timely and relevant data will be critical t ur ability t mnitr prject implementatin and 14 P age

15 2A Bi-Directinal Care Integratin Prject DRAFT Nv 13, 2017 supprt cntinuus imprvement. Measurement is an integral part f quality imprvement. We will enter int a cntract with each partnering prvider that will detail the prvider s respnsibilities, including the nature and scpe f investments t be made; implementatin f the key cmpnents f each selected apprach; adherence t prject guidelines, plicies and prcedures, and prtcls; the target ppulatin(s) and any gegraphic sub-regins n which the interventins will be fcused; reprting requirements (milestnes and utcme metrics as well as frequency f reprts); participatin in peer learning cllabratives; and payment mdalities. Partnering prviders will be required t submit perfrmance infrmatin mnthly. We are explring utilizing the Washingtn Hspital Assciatin s (WSHA) updated QBS business intelligence system t capture and analyze prvider data that is nt already reprted thrugh ther systems. Our gal is t place minimal reprting burdens n ur partnering prviders while prviding CPAA with an effective perfrmance mnitring tl that prvides us with timely perfrmance data, s that we can actively mnitr and track partnering prvider perfrmance. QBS is easy t ppulate by ur partners (including autmated data uplads) and easy fr us t analyze (inbuilt reprting tls, including cmparisn f actual achievement against gals, trend infrmatin ver time, and cmparative perfrmance evaluatin acrss prviders). We plan t augment this infrmatin system thrugh less frequent regin wide data reprts n key reginal perfrmance measures, including claims-based data. The latter may require us t cntract with a third-party data aggregatr with sufficient data analytics capability t validate and augment the perfrmance infrmatin reprted by ur prviders thrugh the QBS system. CPAA will be using data frm the abve surces and analytical tls t issue regular reprts t participating prviders. These reprts will serve tw purpses: 1) infrm prviders n where t target their effrts; and 2) advise prviders n prgress tward meeting required bjectives. CPAA r its designated partner will prvide regular reprts (e.g., quarterly) t prviders fr this purpse. When a prvider r a grup f practices is nt making adequate prgress n meeting key milestnes and metrics, CPAA will reach ut t the prvider in questin and develp a plan f actin with the prvider t remedy identified gaps r barriers. Fr example, CPAA and the prvider might agree t additinal wrkfrce training t assure best practices are fully emplyed in wrking with the target ppulatin. Additinally, CPAA will cnvene all partnering prviders nce per quarter t participate in a peer learning cllabrative. Partnering prviders will have the pprtunity t share successes as well as t raise implementatin challenges that the partners can then engage n jintly t reslve. Likely, these meetings will result in the identificatin f additinal technical assistance needs f partnering prviders, n which CPAA will fllw up accrdingly. This learning cllabrative will prvide an imprtant peer supprt functin t ur partnering prviders and prve essential fr the cntinuus imprvement f ur prject. Plan fr Addressing Strategies That are Nt Wrking r Nt Achieving Outcmes A similar apprach will be used t assess verall prgress f prject initiatives and the efficacy f strategies within thse initiatives. CPAA will use its quarterly perfrmance reprts alng with semiannual reprts prvided by the state with key metrics t determine whether the prject initiative as a whle is n track and/r whether specific strategies within prject areas are wrking as intended. If the reprts indicate ne r mre strategies within the prject area are nt wrking, CPAA will cnvene key stakehlders t assess the reasns fr the lack in effectiveness. This will include partnering prviders, Prvider Champins (Clinical Prvider Advisry Cmmittee), cnsumers (Cnsumer Advisry Cmmittee), and subject matter experts (e.g., technical assistance prviders). Based n this analysis, a recmmendatin will be made whether t cntinue the strategy in questin with a revised apprach r whether t discntinue the strategy in favr f a different ne. The decisin t change the apprach r pursue a different strategy altgether rests with the CPAA Bard based n a discussin and 15 P age