Primary Care Coalition. Discussion Document April 27 th, 2015

Transcription

1 Primary Care Coalition Discussion Document April 27 th, 2015

2 Meeting Objective To brief the Primary Care Coalition on the SIM Innovation Model Test, including a detailed review of the CCIP program, and seek input into the design and implementation of the CCIP program 2

3 Agenda Overview of SIM and CCIP Program 30 minutes Collaborative Work Session 20 minutes Potential Next Steps 10 minutes 3

4 Our Vision Connecticut s State Healthcare Innovation Plan Establishes a Blueprint for Transformation. Connecticut s Current Health System: As Is Our Vision for the Future: To Be Despite a rich array of healthcare, public health, and support services, healthcare in Connecticut falls short in several respects: insufficient access to care, a fragmented delivery system that often fails to educate and inform consumers, a lack of transparency about cost and performance, and payment methods that reward volume of service rather than quality, access and overall health improvement. Establish a whole-person-centered healthcare system that improves population health and eliminates health inequities; ensures superior access, quality, and care experience; empowers individuals to actively participate in their healthcare; and improves affordability by reducing healthcare costs 4

5 Our Vision Connecticut s State Healthcare Innovation Plan Establishes a Blueprint for Transformation. Connecticut s Current Health System: As Is Our Vision for the Future: To Be Despite a rich array of healthcare, public health, and support services, healthcare in Connecticut falls short in several respects: insufficient access to care, a fragmented delivery system that often fails to educate and inform consumers, a lack of transparency about cost and performance, and payment methods that reward volume of service rather than quality, access and overall health improvement. Establish a whole-person-centered healthcare system that improves population health and eliminates health inequities; ensures superior access, quality, and care experience; empowers individuals to actively participate in their healthcare; and improves affordability by reducing healthcare costs 5

6 Our Journey from As Is to To Be : Four Components Fragmented to Integrated Transform Healthcare Delivery System Better Healthcare to Better Health Evaluate Results, Learn, Adjust Build Population Health Capabilities Periodic to Continuous Reform Payment & Insurance Design Reward Value Integration with Other State Initiatives (BHH, Wrap-Around, etc) 6

7 Our Journey from As Is to To Be : Four Components Transform the healthcare delivery system to make it more coordinated, integrate clinical and community services, and distribute services locally in an accessible way. Transform Healthcare Delivery System Build population health capabilities that reorient the healthcare toward a focus on health promotion and wellness for the whole community Evaluate Results, Learn, Adjust Build Population Health Capabilities Evaluate the results, learn from each other in an ongoing, active manner, and adjust strategies as appropriate Reform Payment & Insurance Design Integration with Other State Initiatives (BHH, Wrap-Around, etc) Reform payment & insurance design to incent value over volume, engage consumers, and drive investment in community wellness. 7

8 SIM Model Test Initiatives Primary Care Advanced Medical Home (AMH) Community and Clinical Integration Program (CCIP) Learning Collaboratives Healthcare Workforce Community health workers PCP survey & analysis HIT Measure production Direct Messaging Consent Registry Reporting: Implementation Population health Healthcare Quality Care Experience Per Capita Spend Evaluate Results, Learn, Adjust Transform Healthcare Delivery System Reform Payment & Insurance Design Build Population Health Capabilities Integration with Other State Initiatives (BHH, Wrap-Around, etc) Population Health Plan Tailored State Health Assessment Population Health Council Health Enhancement Communities (HEC) Prevention Service Centers (PSC) MQISSP (1) Quality Measure Alignment Value-Based Insurance Design Health Rewards and Reinvestments (1) MQISSP is Connecticut s planned Medicaid Quality Improvement and Shared Savings Program that is intended to provide incentives for providers, as well as accompanying tools and techniques through CT SIM funding to improve care and reduce costs. 8

9 Each Component of SIM Involves Fundamental Change Transform Healthcare Delivery System Build Population Health Capabilities Reform Payment & Insurance Design As Is Fragmented Healthcare Volume To Be Integrated Health Performance Cost Value Evaluate Results, Learn, Adjust Periodic Continuous 9

10 ... Which in Turn Requires Intermediate Steps As Is The Bridge To Be Transform Healthcare Delivery System Build Population Health Capabilities Reform Payment & Insurance Design Fragmented Healthcare Volume Integrated Health Performance Cost Value Evaluate Results, Learn, Adjust Periodic Continuous 10

11 Characterization of Each Component at Each Phase As Is The Bridge To Be Transform Healthcare Delivery System Fragmented & Poorly Distributed Practice Advancement Community and Clinical Integration Build Population Health Capabilities Centered Around Healthcare Services Whole Person and preventive care processes Community Engagement in Health Promotion Reform Payment & Insurance Design Pay for Volume of Services Reward providers and consumers for better care Reward communities for better health Evaluate Results, Learn, Adjust Periodically Assessing Results of Programs Monitoring Outcomes in an Integrated Way Actively Learning on an Ongoing Basis 11

12 Transform Healthcare Delivery System 12

13 Advanced Medical Home Program -Practice Advancement Our initial focus on practice advancement led to the development of the Advanced Medical Home Program with the following key features. NCQA standards based Additional requirement elements and factors o Health equity o Integrated behavioral health o Person-centered/care experience o Oral health o Prevention Learning collaborative Special focus on improving primary care team satisfaction 13

14 Advanced Medical Home Program Vanguard Pilot We are piloting the AMH program model in five Advanced Networks and 45 practices throughout the state beginning in May 2015 Qualidigm - lead practice transformation team Planetree - focus on patient centered care NCQA as key partner in piloting improvements in the PCMH recognition process Pre- and post-evaluation to inform development of our transformation model SIM grant will support transformation of 360 additional practices (2016 to 2018) 14

15 Community and Clinical Integration Program Objective The overall objective of the Community and Clinical Integration Program (CCIP) work is to define the design of the programs and capabilities for which Advanced Networks can receive technical assistance and grant funding. The CT SIM grant technical assistance and matching grant funding will be provided at the enterprise level to Advanced Networks 1 committed to pursuing programs and associated measurement and reporting enablers 2 that will further clinical and community integration. The infrastructure built through this assistance will serve as the framework for a more distributed and geographically focused approach to population health management. Notes: 1 Advanced Networks includes IPAs, PHOs, Health Systems, Large Physician Groups, FQHCs. 2 Measurement and reporting enablers include capabilities that will allow measuring for health equity gaps, identifying complex patients ( super utilizers ), actionable quality metrics, and measuring patient experience for vulnerable populations 15

16 Community and Clinical Integration Program Participation CCIP program participation will be required of all Advanced Networks and FQHCs that participate in the MQISSP CCIP program requirements will be included in the MQISSP selection process MQISSP selection process may begin as soon as fourth quarter 2015 Notes: 1 Advanced Networks includes IPAs, PHOs, Health Systems, Large Physician Groups, FQHCs. 2 Measurement and reporting enablers include capabilities that will allow measuring for health equity gaps, identifying complex patients ( super utilizers ), actionable quality metrics, and measuring patient experience for vulnerable populations 16

17 CCIP Vision The CCIP Vision 17

18 CCIP: Overall Timeline The CCIP Timeline PTTF Meeting Chartis Supported Research HISC Meeting CCIP Design Group Meetings Chartis Supported CCIP Report Development MAPOC CMC Meeting 18

19 Subject Matter Expert Interviews Interviewee(s) Topic(s) Status Pat Baker & Elizabeth Kraus, Connecticut Health Foundation Measuring Health Equity Gaps Community Health Workers Complete Bernadette Keleher Community Linkages Complete Bruce Gould and Petra Clark Dufner, UCONN Health/AHEC Community Health Workers Complete Camden Coalition Community Health Workers Identification of complex patients Complete Terri DiPietro, Middlesex Identification of complex patients Scheduled Suzanne Lagarde, CEO Fair Haven Community Health Center Steve Ruth, Systems and Management Consulting Primary Care Coalition of Connecticut Grace Damio, Hispanic Health Council, Director of Research and Training E-consults Care Transitions Identification of complex patients Community Linkages Care Transitions Community Health Workers Scheduled Scheduled Scheduled Pending Marie Smith Medication Therapy Management Dynamic Clinical Teams Pending Dawn Lambert & Kate McEvoy, DSS Long Term Support Services Pending Daren Anderson, Community Health Center, Inc. E-consults Pending Molly Gavin, CT Community Care, Inc. Long Term Support Services Pending CT SIM State Program Experience (CMMI Technical Assistance) All Ongoing 19

20 Agenda Overview of SIM and CCIP Program 30 minutes Collaborative Work Session 20 minutes Potential Next Steps 10 minutes 20

21 Key Questions for Discussion Collaborative Brainstorming Session on Care Coordination and Super Utilizers 1. What are the biggest challenges/barriers to clinical and community integration in Connecticut today? 2. What solutions to improving clinical and community integration has this group explored in the past (e.g.; ED and hospitalist care transitions and hand offs, access to health information to stratify patients, and communicate and monitor patient progress/outcomes) that may help inform our approach or could be tested? 3. Which community and clinical integration solutions do you think would be most impactful for Advanced Networks participating in the Medicaid Quality Improvement and Shared Savings Program? 21

22 Key Questions for Discussion Existing Clinical and Community Integration Models 1. Are there working models that could be applied/drawn on to inform the CT SIM CCIP work (i.e.; existing protocols, standards, and approaches)? 2. What are the key CT agencies that are involved in this work and how is/should the relationship with the Advanced Networks be structured? 3. Are there individuals in this group that would like to be involved in the development/design of the CT SIM CCIP program protocols/standards? 22

23 Agenda Overview of SIM and CCIP Program 30 minutes Collaborative Work Session 20 minutes Potential Next Steps 10 minutes 23

24 Next Steps Seek opportunities to incorporate the input of the Primary Care Coalition Provide updates through the design and implementation process Others? 24