MPA Reference Guide. Millennium Collaborative Care

Transcription

1 Millennium Collaborative Care

2 1. MPA Provider Types Primary Care Practices Pediatric Practices Behavioral Health Acute Care Post-Acute Care Engagement and Reporting Workforce Value-Based Payment Data-Related Deliverables Patient Engagement Transformation Requirements Health Literacy Survey Enhanced Primary Care Linkage from Acute Care Non-Utilizer Management SBIRT Crisis Stabilization Participation in Behavioral Health Workgroups Transformation with Performance Emergency Department Care Triage Program Health Home Integration Medical Neighborhood Best Practice Behavioral Health 7- and 30-Day Follow-Up Depression Best Practice MPA Exhibits DSRIP Timeframes / 37

3 1. Master Participation Agreement Resources This site is intended to be used by providers affiliated with the Millennium Collaborative Care PPS ( Millennium ) and to offer guidance around DSRIP projects and achievement of associated metrics. This site was created as an accompaniment to the Master Participation Agreements (MPAs) for DY3 (April 1, 2017 through June 30, 2018) to provide helpful resources and best practice recommendations relating to achievement of MPA deliverables and overall DSRIP goals. The site will be updated with additional resources and best practice recommendations through the year. Click on a provider type to see the related requirements and resources: Primary Care Practices Pediatric Practices Acute Care (Hospitals) Behavioral Health, Inpatient and Outpatient Post-Acute Care (Skilled Nursing Facilities and Home Health Agencies) Maternal & Child Health Please note: This site is not meant to serve as a comprehensive list of all activities required under the MPA. Partner expectations, responsibilities, and deliverables have been provided in the MPA exhibits and associated billing templates. 2. Provider Types 2.1. Primary Care Practices This page pertains to primary care practices (all sizes). See also: Pediatric practices Engagement and Reporting 3 / 37

4 Category Participant Activity Substantiation Workforce Data Data Data Enter required staffing impact data into HWApps on biannual basis. Provide updated roster of providers on annual/biannual basis. Execute MCC-developed managed care organization data consent form (small, medium, and large practices). Provide claims data (extra large practices). Successful upload of practice workforce data in HWApps (biannually). Submission of updated provider roster (annually/biannually). Provide copy of signed data consent form. Submission of electronic claims to MCC for PPS attributed lives. Data Implement CCDAs. CCDAs successfully implemented as evidenced by activity on the HEALTHeLINK monthly reporting dashboard. Engagement Engagement Value-Based Payments ( VBP ) Transformation Provide quarterly engagement reporting for behavioral health and cardiovascular disease ( CVD ). Meet with MCC at least quarterly (all practice locations). Topics for discussion may include Patient Activation Measure ( PAM ) training (if applicable) and behavioral health best practices. Create a VBP transition plan to include the following required minimum elements: 1. Technology and analytics 2. Utilization and care management tactics 3. Staffing expertise 4. Financial feasibility and impact 5. Timeline for implementing VBP Successful upload of all quarterly engagement reports as indicated by MCC project managers. Provide sign-in sheets, meeting minutes, and workflows (if applicable). Submission of report. For entities with multiple provider types, each shall be required to provide either a separate report or to have a specific portion of the report dedicated to each provider type. 4 / 37

5 Category Participant Activity Substantiation Health Literacy and Survey Participate in MCC PCP office training and workgroup sessions on MCC specific CG-CAHPS survey measures. Develop and implement work plan including strategies for improvement based on survey results. Minutes from training and working session that include identification of strategies to improve results. Provide copy of work plan. Provide revised patient-facing materials. Medical Record Review Non-Utilizer Management Screening, Brief Intervention and Referral to Treatment ( SBIRT ) Screening, Brief Intervention and Referral to Treatment ( SBIRT ) PAM Revise patient facing materials to improve and enhance patient literacy according to CG-CAHPS standards. Attend MCC-led education on documentation requirements. appropriate documentation and at least 75% documentation accuracy of blood pressure control and depression screen with follow-up. Contact Non-Utilizers via new phone call or letter to attempt to schedule preventative appointment. If outreach is unsuccessful and/or scheduled Non-Utilizer fails to show for new preventative appointment, provide a list of outstanding Non- Utilizers to MCC-contracted community-based organizations ( CBOs ). Accept Non-Utilizer referrals from MCC-contracted CBOs. 90% of Non- Utilizer referrals must be scheduled for appointments within 30 days of referral. Non-utilizers are patients with no preventive visit in previous 12 months Train at least one clinical staff member per site. Implement SBIRT. Administer PAM surveys in PCP offices. Participants must perform PAMs on a minimum of 10% of Medicaid visits. Sign-in sheets reflecting training attendance. MCC shall conduct initial medical review audit. If original findings by MCC indicate less than 75% documentation accuracy, then MCC will re-audit again at a later time. Provide Non-Utilizer list to MCC. Completion of MCC sampling audit on documentation of Non-Utilizer outreach efforts. Non-Utilizer referral appointments substantiated by MCC-contracted CBO reports. Demonstrate completion of training (e.g., certificates or sign-in sheets). Provide workflow and quarterly reporting on number of screenings. Provide workflow and quarterly reporting on number of PAM surveys administered. Transformation with Performance 5 / 37

6 Category Participant Activity Substantiation Type Substantiation Primary Care Access Adherence Rate Improvement Run 12-month annual visit adherence report and establish baseline.* Develop management plan for improvement of adherence rate and submit adherence rate reports. Produce report and plan. Submit reports. Primary Care Access Adherence Rate Improvement CVD Best Practice CVD Best Practice *See Section 1.2 of Exhibit A for additional details on establishing baselines and reporting requirements. Improve 12 month visit adherence rate over historical baseline.** **Participants are only eligible for an award for achieving one of the performance benchmarks listed in the Substantiation column. So, for example, if at yearend a Participant had achieved 15% improvement, they would be eligible for a single allocation as further outlined in the billing templates. PCPs will develop the following registry (or develop an alternate reporting/identification process) Patients with: HbA1c >= 7% Blood pressure >= 140/90 ASCVD risk score >= 7.5% OR provide a documented process demonstrating how the practice will calculate the ASCVD risk score and record in EMR Improve number of patients with controlled blood adherence rate improvement >=10% over baseline OR adherence rate improvement >=15% over baseline OR adherence rate improvement >=20% over baseline OR Demonstrate overall adherence rate >=94% (over 18 years) and >=98% (under 18 years) with maintenance use of registry or alternate process (i.e. Category 2 codes) to automate case identification in electronic medical record. Produce registries. Produce documented process/plan to calculate and record the ASCVD risk score (if unable to produce registry only). achievement of metric. 6 / 37

7 pressure by 10%. CVD Best Practice Improve to or maintain 75% CAD patients on a statin. achievement of metric. Medical Neighborhood Review and revise care coordination policy to include the following: Address linkages with behavioral health, CBOs, health home, and hospitals; Participate in a facilitated meeting with MCC project manager regarding policy revisions. Submit revised care coordination policy with all required elements. Confirm bi-directional communication with all relevant hospitals and highvolume specialists; Evaluate and revise criteria and process for follow-up visits and calls; Enable ADTs with HEALTHeLINK; and Incorporate process to act upon and ensure outreach and follow-up. Medical Neighborhood Conduct outreach to and schedule follow-up visits for acute inpatients that are discharged from a hospital with one of the following avoidable admission principal diagnoses ( Target Conditions ): Provide hospital patient follow-up log substantiated by MCC sample audit of logs. COPD and related complications; diabetes and related complications; asthma; and other practice-specific avoidable admission diagnosis driver as identified by MCC analytics. Maintain hospital patient follow-up log. Medical Neighborhood Enroll and/or refer patients Report number and 7 / 37

8 Medical Neighborhood Medical Neighborhood Depression Best Practice Depression Best Practice eligible for care coordination and/or health home services consistent with internal policies and applicable health home guidelines. Reduce practice-specific avoidable admission rate (including readmissions) for Target Conditions by 5% when compared to historical baseline. Reduce practice-specific preventable emergency department visit rate by 10% when compared to historical baseline. Participate in MCCfacilitated education and training on depression best practices. Develop and implement practice workflow to care manage newly diagnosed depressed patients prescribed an antidepressant. Improve patient Major Depression Medication Adherence to antidepressant medications, acute phase (12 weeks). percentage of patients with target conditions enrolled in care coordination. Report number and percentage of patients referred to health homes. Report can be satisfied by practice or health home. achievement of metric. achievement of metric. Sign-in sheets for education and training sessions. Report on number and percent of patients that were care managed. improvement in patients Major Depression Medication Adherence to anti-depressant medications, acute phase (12 weeks) by 10%; OR If current Major Depression Medication Adherence is at or above 60%, maintain. Depression Best Practice Improve patient Major Depression Medication Adherence to antidepressant medications, chronic phase (6 months). improvement in patients Major Depression Medication Adherence to anti-depressant medications, chronic phase (6 months) by 10%; OR If current Major Depression Medication Adherence is at or above 44%, maintain. 8 / 37

9 2.2. Pediatric Practices Engagement and Reporting Category Participant Activity Substantiation Workforce Data Data Enter required staffing impact data into HWApps on biannual basis. Provide updated roster of providers on annual/biannual basis. Execute MCC-developed managed care organization data consent form. Successful upload of practice workforce data in HWApps (biannually). Submission of updated provider roster (annually/biannually). Provide copy of signed data consent form. Data Implement CCDAs. CCDAs successfully implemented as evidenced by activity on the HEALTHeLINK monthly reporting dashboard. Engagement Value-Based Payments ( VBP ) Transformation Provide quarterly engagement reporting for behavioral health. Create a VBP transition plan to include the following required minimum elements: 1. Technology and analytics 2. Utilization and care management tactics 3. Staffing expertise 4. Financial feasibility and impact 5. Timeline for implementing VBP Successful upload of all quarterly engagement reports as indicated by MCC project managers. Submission of report. For entities with multiple provider types, each shall be required to provide either a separate report or to have a specific portion of the report dedicated to each provider type. 9 / 37

10 Category Participant Activity Substantiation Medical Record Review Attend MCC-led education on documentation requirements. Sign in sheets reflecting training attendance. Non-Utilizer Management Provide documentation evidencing at least 75% of patients with full immunization panel and percentage of two-year-olds with lead screenings. Contact Non-Utilizers via new phone call or letter to attempt to schedule new preventative appointment. If outreach is unsuccessful and/or scheduled Non-Utilizer fails to show for new preventative appointment, provide a list of outstanding Non- Utilizers to MCC-contracted community-based organizations ( CBOs ). Accept Non-Utilizer referrals from MCC-contracted CBOs. 90% of Non- Utilizer referrals must be scheduled for appointments within 30 days of referral. Non-utilizers are patients with no preventive visit in previous 12 months MCC shall conduct initial medical review audit. If original findings by MCC indicate less than 75% documentation accuracy, then MCC will re-audit again at a later time. Provide Non-Utilizer list to MCC. Completion of MCC sampling audit on documentation of Non-Utilizer outreach efforts. Non-Utilizer referral appointments substantiated by MCC-contracted CBO reports. Transformation with Performance Category Participant Activity Substantiation Type Substantiation Primary Care Access Adherence Rate Improvement Run 12-month annual visit adherence report and establish baseline.* Produce report and plan. Submit reports. Primary Care Access Adherence Rate Improvement Develop management plan for improvement of adherence rate and submit adherence rate reports. Improve 12-month visit adherence rate over historical baseline.** adherence rate improvement >=10% over baseline OR adherence rate improvement >=15% over baseline OR adherence rate 10 / 37

11 improvement >=20% over baseline OR Demonstrate overall adherence rate >=98% with maintenance ADHD Best Practice Produce registries for children 6 12 years with ADHD on ADHD medication. Produce registry. ADHD Best Practice Develop process for ADHDrelated bi-directional communication with behavioral health practices. Establish workflow with behavioral health providers for provision of care for patients with ADHD. Provide policies and workflows. ADHD Best Practice Improve to or maintain at least 52% patients with behavioral health visit within 30 days of starting ADHD medication. improvement or maintenance. ADHD Best Practice Improve to or maintain at least 61% patients with behavioral health visit within 9 months of starting ADHD medication. improvement or maintenance. Hospital Utilization and Reducing Avoidable Admissions Review and revise care coordination policy to include the following: 1. Confirm bi-directional communication with all relevant hospitals. 2. Evaluate and revise criteria and process for follow-up visits and calls. 3. Enable ADTs with HEALTHeLINK. 4. Incorporate process to act upon and ensure outreach and follow-up. Participate in a facilitated meeting with MCC project manager regarding policy revisions. Submit revised care coordination policy with all required elements. Hospital Utilization and Reducing Avoidable Admissions Conduct outreach to and schedule follow-up visits for acute inpatients that are discharged from a hospital with one of the following avoidable admission principal diagnoses ( Target Conditions ): achievement of >=75% metric. Hospital patient follow-up log substantiated by MCC sample audit of logs. asthma; 11 / 37

12 dehydration; and other practice-specific avoidable admission diagnosis driver as identified by MCC analytics. maintain hospital followup log. Hospital Utilization and Reducing Avoidable Admissions Enroll and/or refer patients eligible for care coordination and/or health home services consistent with internal policies and applicable health home guidelines. Report number and percentage of patients with target conditions enrolled in care coordination. Report number and percentage of patients referred to health homes. Report can be satisfied by practice or health home. Hospital Utilization and Reducing Avoidable Admissions Reduce practice-specific avoidable admission rate (including readmissions) for Target Conditions by 5% when compared to historical baseline. achievement of metric. Hospital Utilization and Reducing Avoidable Admissions Identify patients with preventable emergency department diagnoses and develop workflows and processes to manage these patients. Provide copies of workflow and process documents. Hospital Utilization and Reducing Avoidable Admissions Reduce practice-specific preventable emergency department visit rate by 10% when compared to historical baseline. achievement of metric. Increase Well Visits within 15 Months Identify number of children that had five or more well visits within their first 15 months and establish this as practice baseline.* Produce report and plan. Increase Well Visits within 15 Months Improve practice-specific rate of five or more well visits. Improvement in practicespecific rate of five or more well visits in first 15 months Behavioral Health Engagement and Reporting 12 / 37

13 Behavioral Health Provider Type Category Participant Activity Substantiation Outpatient Workforce Enter required staffing impact data into HWApps on biannual basis. Outpatient Data Submit performance data (e.g., PSYCKES and/or managed care organization data) to MCC. Outpatient Engagement Provide quarterly engagement reporting for behavioral health. Outpatient Inpatient Transformation Behavioral Health Provider Type Outpatient Value-Based Payments ( VBP ) Participation in Regional Behavioral Health Workgroups Create a VBP transition plan to include the following required minimum elements: 1. Technology and analytics 2. Utilization and care management tactics 3. Staffing expertise 4. Financial feasibility and impact 5. Timeline for implementing VBP Attend and participate in MCC regional behavioral health workgroups. Successful upload of practice workforce data in HWApps (biannually). Submission of required data. Successful upload of all quarterly engagement reports as indicated by MCC project managers. Submission of report. For entities with multiple provider types, each shall be required to provide either a separate report or to have a specific portion of the report dedicated to each provider type. Sign-in sheets evidencing workgroup attendance. Category Participant Activity Substantiation Participation in Regional Behavioral Health Workgroups Attend and participate in MCC regional behavioral health workgroups. Outpatient Non-Utilizer Management Link closed/discharged cases with primary care, health home, or other provider; or, if no linkage, provide name of patients to MCC-contracted community-based organizations ( CBOs ). Provide monthly list of closed patients with linkages requiring HbA1c or LDL lab work to followup provider. Non-utilizers are patients with no preventive visit in previous 12 months Sign-in sheets evidencing workgroup attendance. Provide MCC with monthly list indicating number of Non-Utilizer patient referrals to MCCcontracted CBO. Provide MCC with monthly list indicating number of patients requiring HbA1c or LDL lab work sent to followup provider. 13 / 37

14 Transformation with Performance Behavioral Health Provider Type Outpatient Outpatient Outpatient Outpatient Outpatient Category Participant Activity Substantiation Type Substantiation 7- and 30-Day Follow-Up for Outpatients 7- and 30-Day Follow-Up for Outpatients 7- and 30-Day Follow-Up for Outpatients 7- and 30-Day Follow-Up for Outpatients Substance Abuse Treatment Attempt outreach utilizing the Sinnissippi model for patients discharged from acute care prior to appointment. Perform outreach for 75% or more patients. Produce historical show rate for 7- and 30-day follow-up appointment* Improve show rate for 7-day follow-up appointments over historical baseline.** Improve show rate for 30-day follow-up appointments over historical baseline.** Participate in MCC best practice Provide report of number of attempted contacts vs. scheduled patients. Report must evidence 75% or more outreaches attempted. Provide PSYCKES and/or internal report to MCC. show rate improvement >=5% over baseline OR show rate improvement >=10% over baseline OR show rate improvement >=15% over baseline OR Exceed/maintain current rate if baseline number already shows >=74%. show rate improvement >=5% over baseline OR show rate improvement >=10% over baseline OR show rate improvement >=15% over baseline OR Exceed/maintain current rate if baseline number already shows >=74%. Sign-in sheets evidencing 14 / 37

15 workgroup and implement workflows created in workgroup. workgroup attendance and documentation of employee training and distribution of training materials. Outpatient Substance Abuse Treatment Produce historical compliance rate for substance abuse treatment metrics.* Provide PSYCKES and/or internal report to MCC. Outpatient Substance Abuse Treatment Increase number of patients with timely initiation of substance abuse treatment (within 14 days) over historical baseline.** improvement of >=5% in number of patients with timely Substance Abuse Treatment initiative OR improvement of >=10% in number of patients with timely Substance Abuse Treatment initiative OR improvement of >=15% in number of patients with timely Substance Abuse Treatment initiative OR Exceed/maintain current number if baseline number already shows >=57%. Outpatient Substance Abuse Treatment Increase number of patients engaged in ongoing substance abuse treatment (2 or more visits over 30 days) who have a diagnosis of substance abuse issues over historical baseline.** improvement of >=5% in number of patients with timely Substance Abuse Treatment initiative OR improvement of >=10% in number of patients with timely Substance Abuse Treatment initiative OR improvement of >=15% in number of patients with timely 15 / 37

16 Substance Abuse Treatment initiative OR Exceed/maintain current number if baseline number already shows >=57%. Outpatient Cardiovascular and Diabetic Monitoring for Patients with Schizophrenia Produce historical compliance rate for HbA1c and LDL testing among schizophrenic patients.* Provide PSYCKES and/or internal report to MCC. Outpatient Cardiovascular and Diabetic Monitoring for Patients with Schizophrenia Improve compliance rate for HbA1c testing for patients with schizophrenia and diabetes over historical baseline.** Improve compliance rate >=5% over baseline OR Improve compliance rate >=10% over baseline OR Improve compliance rate >=15% over baseline OR Exceed/maintain current compliance rate if baseline number already shows >=90%. Outpatient Cardiovascular and Diabetic Monitoring for Patients with Schizophrenia Improve compliance rate for LDL testing for patients with schizophrenia and diabetes or CVD over historical baseline.** Improve compliance rate >=5% over baseline OR Improve compliance rate >=10% over baseline OR Improve compliance rate >=15% over baseline OR Exceed/maintain current compliance rate if baseline number already shows >=92%. Outpatient Medication Adherence for Patients with Schizophrenia Participate in MCC best practice workgroups and implement workflows created in workgroups. Sign-in sheets evidencing workgroup attendance and documentation of employee training and distribution of training materials. Outpatient Medication Adherence for Patients with Produce historical compliance rate for Medicaid schizophren Provide PSYCKES and/or internal report to MCC. 16 / 37

17 Schizophrenia ia-diagnosed patients years who remained on antipsychotic medication for 80% of treatment period.* Outpatient Medication Adherence for Patients with Schizophrenia Improve compliance rate over historical baseline.** Improve compliance rate >=5% over baseline OR Improve compliance rate >=10% over baseline OR Improve compliance rate >=15% over baseline OR Exceed/maintain current compliance rate if baseline number already shows >=76%. Inpatient Substance Abuse Patient Follow-up Secure follow-up appointment with mental health facility at discharge within 14 days for 80% or more of substance abuse patients. Provide number of monthly discharges with log of patient appointments. Inpatient 7- and 30-day Follow-up Secure follow-up appointment with mental health facility at discharge within 7 days for 80% or more of patients. Implement warm handoff workflow to engage patient during discharge process. Provide monthly log of patient follow-up visits Provide workflow and process that includes patient participation in scheduling of appointment (e.g., participation in call with follow-up agency or discussion and documentation of patient input and/or feedback regarding appointment). Inpatient 7- and 30-day Follow-up Successful outreach/handoff to designated outpatient mental health facility relationship manager for 90% or more of patients. Develop patientfacing material to include comprehensive information relating to MCC shall substantiate via audit (e.g., evidence of , fax or phone call). Provision of patientfacing material that includes these elements. 17 / 37

18 follow-up appointment: Name of provider; Full address; Date and time; Why the appointment is important. *See Section 1.2 of Exhibit A for additional details on establishing baselines and reporting requirements. ** Participants are only eligible for an award for achieving one of the performance benchmarks listed in the Substantiation column. So, for example, if at year-end a Participant had achieved 10% improvement, they would be eligible for a single allocation as further outlined in the billing templates Acute Care Engagement and Reporting Category Participant Activity Substantiation Workforce Enter required staffing impact data into HWApps on biannual basis. Successful upload of practice workforce data in HWApps (biannually). Data Provide claims data. Submission of electronic claims to MCC. Data Value-Based Payments ( VBP ) Emergency Department Care Triage ( EDCT ) Transformation Implement CCDAs. Continue to consent patients with HEALTHeLINK consistent with developed workflows and HEALTHeLINK utilization. Implement ADT messaging for admission, discharge or transfer to HEALTHeLINK. Create a VBP transition plan to include the following required minimum elements: 1. Technology and analytics 2. Utilization and care management tactics 3. Staffing expertise 4. Financial feasibility and impact 5. Timeline for implementing VBP Create lists of PCPs accepting EDCT referrals and appointments. Listing of PCPs must include physician name, license number and address. CCDAs and ADTs successfully implemented as evidenced by activity on the HEALTHeLINK monthly reporting dashboard. active consenting and query activity as per MCC HEALTHeLINK reports. Submission of report. For entities with multiple provider types, each shall be required to provide either a separate report or to have a specific portion of the report dedicated to each provider type. Provide required lists. 18 / 37

19 Category Participant Activity Substantiation Health Literacy ( HL ) and Survey Identify H-CAHPS/HL Champion. Participate in MCC training and workgroup sessions on H-CAHPS survey measures. Documentation identifying an H- CAHPS/HL Champion. Sign-in sheets reflecting attendance at workgroup sessions. Develop and implement work plan for improvement based on survey results. Revise patient-facing materials to improve and enhance patient literacy according to H-CAHPS standards. Report results to MCC of the following survey questions: Submission of H-CAHPS work plan and updated patient-facing discharge material. Evidence of distribution of workflow and training of key staff. Report ongoing survey results to MCC as available. Enhanced Primary Care Acute Linkage Enhanced Primary Care Acute Linkage Non-Utilizer Management Crisis Stabilization: #23: Staff took preferences of patient/caregiver into account in deciding patient s health care needs for discharge. #24: Upon discharge patient had good understanding of responsibilities and discharge instructions. #25: Patient clearly understood purpose for taking each of patient s medications. Create enhanced linkages to PCPs for patients discharged from acute care. Revise patient-facing materials to include written documentation of when/where follow-up appointment is and reason for appointment. Provide copy of materials to patients when PCP visit is scheduled. Refer patients who fail to follow up with PCP visits after EDCT intervention or an acute admission to MCC-contracted community-based organizations ( CBOs ). Non-utilizers are patients with no preventive visit in previous 12 months Attend MCC-led workgroups focused on: Provide workflow and processes demonstrating patient linkage with PCPs. Provide copies of revised patientfacing materials. Provide total number of patients referred to MCC-contracted CBOs Sign-in sheets reflecting attendance at workgroup sessions. 19 / 37

20 Identifying accessible behavioral health crisis services that allow access to appropriate level of service and providers. Copy of protocols, date of training, and material distribution to relevant staff. Transformation with Performance Developing and implementing protocols to divert patients from emergency department ( ED ) and inpatient services when medically appropriate. Category Participant Activity Substantiation Type Substantiation Emergency Department Care Triage (EDCT) Implementation Implement EDCT program if not already established. Provide patient-facing materials including written documentation of when/where appointment is and reason for appointment. Identify Medicaid patients with low acuity triage levels in the ED. Enhance Primary Care Linkage for ED patients via assistance and scheduling of immediate follow-up appointment after discharge with outreach to PCP office. Review monthly EDCT program report from MCC and report improvement opportunities to MCC. Copy of materials distributed to patients when PCP visit is scheduled. Provide monthly report of Key Performance Indicators with the following: Number of patients with EDCT acuity triage level 3 5. Number of EDCT patients engaged with Patient Navigator. Number of patients completing Patient Activation Measure survey. Number of patients linked to primary care and percentage of patients who attended their PCP appointment. Minutes of meetings evidencing improvement opportunities. Emergency Department Care Triage (EDCT) Implementation Hospitals with existing EDCT programs must increase engagement of Medicaid patients by at least 5%. Hospitals that are new participants in EDCT programs must engage at least 5% of Medicaid low- For hospitals with existing EDCT programs: year-end report demonstrating increased engagement of low-acuity Medicaid patients by at least 5% over previous year. For hospitals that are new participants in EDCT 20 / 37

21 acuity patients. programs: year-end report demonstrating engagement of at least 5% of low-acuity patients. Health Home Integration Prepare workflow supporting health home s clinical integration within hospital ED. Provide documentation of workflow. Health Home Integration Integrate health homes within hospital setting. Increase health home referrals by 10% over previous year. Report on number of patients referred to health homes the previous year demonstrating increase. Medical Neighborhood Participate in MCC-led workgroups and develop an at risk process or tool, to include both medical and social factors, that identifies patients at risk for readmission. Sign-in sheets reflecting attendance at workgroup sessions. Provide copy of at risk process or tool development materials. Medical Neighborhood Develop comprehensive care transition policy with the following minimum required elements: Provide care transition policy with all required elements. Address linkages and confirm bi-directional communication with postacute entities (including behavioral health, home care, skilled nursing facilities, PCPs, and specialists), health homes, and CBO partners. Expand CBO integration guidelines and linkages with key agencies identified in facilitated workgroups. Utilize thorough Medication Reconciliation including patient and family education on medication prior to discharge. Incorporate process to act upon and ensure outreach and follow-up. Manage Hospital Utilization Establish Medicaid-specific reports and baselines for the following:* Provide ongoing monthly report to MCC, including principal diagnosis (and 21 / 37

22 30-day readmission rate (PPR); PPV visits (ambulatory sensitive conditions); and PQI measures. *See Section 1.2 of Exhibit A for additional details on establishing baselines and reporting requirements. Medical Neighborhood Reduce PPV rate by 10% compared to historical baseline. Medical Neighborhood Medical Neighborhood Reduce PQI admission rate by 5% compared to historical baseline. Reduce 30-day readmission rate by 5% compared to historical baseline. DRG for acute discharges) for PQI, PPV, and PPR (including both the initial admission and the 30-day readmission). Provide reports evidencing reduction. Provide reports evidencing reduction. Provide reports evidencing reduction Post-Acute Care Engagement and Reporting Category Participant Activity Substantiation Workforce Data Value-Based Payments ( VBP ) Engagement Enter required staffing impact data into HWApps on biannual basis. Execute MCC-developed managed care organization data consent form. Create a VBP transition plan to include the following required minimum elements: 1. Technology and analytics 2. Utilization and care management tactics 3. Staffing expertise 4. Financial feasibility and impact 5. Timeline for implementing VBP Provide quarterly engagement reporting for INTERACT relating to emergency department and inpatient utilization impact. Successful upload of practice workforce data in HWApps (biannually). Provide copy of signed data consent form with all participating payers. Submission of report. For entities with multiple provider types, each shall be required to provide either a separate report or to have a specific portion of the report dedicated to each provider type. Successful upload of all quarterly engagement reports as indicated by MCC project managers. 3. Engagement and Reporting 22 / 37

23 3.1. Workforce Provider Types The deliverables described in this section are required by the following types of participants: Primary care practices Pediatric practices Planned Parenthood Acute care Behavioral health outpatient Developmental disability organizations Skilled nursing facilities Home health agencies Description Current workforce statistics must be compiled and given to the state to measure the effect DSRIP initiatives are having on the healthcare workforce over the time of the program. Projections on staffing need, bed reductions (or additions), and utilization trends are generated from workforce data. In addition to meeting state requirements, workforce data collected from participants is used for the following objectives: To inform education and training requirements for PPSs and their partners To guide retraining for redeployed workers and employee support programs To advance healthcare workforce research and policy development while demonstrating DSRIP impact Partners will enter required workforce staffing impact data into HWApps. The purpose of the Compensation and Benefits Survey is to capture a snapshot in time and examine workforce trends within each PPS. The survey was first conducted in DY1, and NYS requires PPS to repeat the survey in DY3 and DY5. This data is collected and aged in accordance with antitrust regulations. The Workforce Compensation and Benefits Survey was sent to each partner by Millennium s workforce vendor, Rural AHEC. Resources HWApps 3.2. Value-Based Payment Provider Types The deliverables described in this section are required by the following types of participants: Primary care practices (including pediatric practices) Planned Parenthood Acute care Behavioral health outpatient Developmental disability organizations Skilled nursing facilities Home health agencies 23 / 37

24 Description One of the key objectives of DSRIP is to prepare for the transition from fee-for-service (FFS) to value-based payment (VBP) arrangements. Partners will create a VBP Transition Plan which will include the following required elements: Type of agreement(s) Technology and analytics Utilization and care management tactics Staffing expertise Financial feasibility and impact Timeline Additional outreach and support, as well as a template, will be provided Data-Related Deliverables Provider Types The deliverables described in this section are required by the following types of participants: Partner Type Primary care practices (including pediatric practices) Extra large primary care practices Planned Parenthood Acute care Skilled nursing facilities Home health agencies Behavioral health outpatient Requirements Managed care organization data consent form HEALTHeLINK: CCDAs Claims data HEALTHeLINK: CCDAs Managed care organization data consent form Claims data HEALTHeLINK: CCDAs, patient consent, ADT messaging Managed care organization data consent form Managed care organization data consent form Performance data (e.g., PSYCKES and/or MCO data) Description Patient-level data is required for Millennium s population health management tool to provide a 360 view of the patient and our community s health. Primary care (including pediatrics and Planned Parenthood) and post-acute partners will sign a release to have their paid claims data from Managed Care Organizations (MCOs) shared with Millennium for the purpose of population health management and ensuring a 360 view of the patient. The data consent form is under development by Millennium s legal team and will be made available to partners. Acute care partners and extra large primary care practices will electronically submit claims data to the PPS. 24 / 37

25 Use of HEALTHeLINK is critical for clinical interoperability and sharing of patient data across providers and systems in order to provide informed, appropriate care. Primary care and acute care partners will share CCD-As with HEALTHeLINK Acute care partners will demonstrate continued use of HEALTHeLINK through patient consenting workflows and query utilization Acute care partners will implement ADT messaging with HEALTHeLINK for admission, discharge, or transfer of patient Millennium will receive monthly utilization reports directly from HEALTHeLINK. Millennium will be available to assist with strategy development to increase individual partner site usage as identified from the monthly reports. Behavioral health (outpatient) partners will be required to share performance data, potentially in the form of PSYCKES data or MCO data Patient Engagement Provider Types The deliverables described in this section are required by the following types of participants: Primary care practices (including pediatric practices) Planned Parenthood Behavioral health outpatient Skilled nursing facilities Home health agencies Description Participants must provide Millennium with regular documentation and reports showing the success of their patient engagement throughout the course of DSRIP. Patient engagement criteria are determined by NYS and outlined in Exhibit B of the DY3/MY4 Master Participation Agreement. Patient engagement registries must be in the approved Millennium standard format (using the correct Microsoft Excel template). Since these registries contain protected health information (PHI), they must be transmitted to Millennium using a secure file transfer method. Millennium s approved secure file transfer platform is WatchDox. Submissions are always due the 15th of the month following the end of the DSRIP quarter: July 15, October 15, January 15, and April 15. Resources More information about patient engagement: DY3 MPA Exhibit B Instructions for reporting patient engagement Instructions for reporting patient engagement (behavioral health only) Instructions for WatchDox Secure File Transfer System for Patient Engagement Links to patient engagement templates (coming soon) 4. Transformation Requirements 25 / 37

26 4.1. Health Literacy Survey Provider Types The deliverables described in this section are required by the following types of participants: Primary care practices (excluding pediatric practices): CG-CAHPS survey Acute care: H-CAHPS survey Description Partners will develop an organizational plan that will focus on reducing health disparities and improving health outcomes with at-risk populations. This will be done through effective and culturally sensitive communication with patients across the health disciplines. Emphasis will be placed on improving patient health literacy and the use of health literacy interventions by providers, such as the teach-back method. Ultimately, this strategy will support the pay-for-performance measures related to Clinics & Groups Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS), Hospital Consumer Assessment of Healthcare Providers and Systems (H-CAHPS), and care transitions. Primary Care Practices The DSRIP measures related to the CG-CAHPS survey span several patient experience and quality of care topics, which include two composite measures and eleven individual questions. CG-CAHPS composite measures and questions: Percent with always/usually timely access, composed of the following CG-CAHPS questions: Question 6: In the last 6 months, when you contacted this provider s office to get an appointment for care that you needed right away, how often did you get an appointment as soon as you needed? Question 8: In the last 6 months, when you made an appointment for a checkup or routine care with this provider, how often did you get an appointment as soon as you needed? Question 10: In the past 6 months, when you contacted this provider s office during regular business hours, how often did you get an appointment as soon as you needed? Percent with care coordination, composed of the following CG-CAHPS questions: Question 13: In the last 6 months, how often did this provider seem to know the important information about your medical history? Question 22: In the last 6 months, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider s office follow up to give you those results? Question 24: In the last 6 months, how often did you and someone from this provider s office talk about all the prescription medicines you were taking? CG-CAHPS individual questions: Question 2: Is this the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt? Question 3: How long have you been going to this provider? Question 18: In the last 6 months, how often were the provider s instructions easy to understand? Question 19: In the last 6 months, how often did this provider ask you to describe how you were going to follow these instructions? Question 20: In the last 6 months, how often did this provider explain what to do if this illness or health condition got worse or came back? Question 30: Have you had a flu shot or flu spray in the nose since September 1, 2015? Question 32: In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health care provider? 26 / 37

27 Hospitals Question 33: In the last 6 months, how often was medication recommended or discussed by a doctor or health care provider to assist you with quitting smoking or using tobacco? Question 34: In the last 6 months, how often did your doctor or health care provider discuss or provide methods and strategies other than medication to assist you with quitting smoking or using tobacco? Question 35: Do you take aspirin daily or every other day? Question 37: Has a doctor or health care provider ever discussed with you the risks and benefits of aspirin to prevent heart attack or stroke? The three DSRIP performance measures related to the H-CAHPS survey fall under the Care Transitions section, questions as stated below: Question 23: During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left. Question 24: When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. Question 25: When I left the hospital, I clearly understood the purpose for taking each of my medications. Each acute care partner will identify at least one H-CAHPS champion to represent the organization. The H- CAHPS champion must participate in monthly workgroup meetings (subject to change as H-CAHPS scores increase). Intended audience for workgroup meetings include but are not limited to identified H-CAHPS project champions. Each hospital and primary care practice will develop and implement an individualized work plan for improvement based on survey results. Hospitals and primary care practices will revise patient-facing material to improve and enhance patient literacy according to H-CAHPS/CG-CAHPS standards. Hospitals will report H-CAHPS results as they relate to transitions of care according to the following schedule: July 1 September 30: Scores are due no later than November 15 October 1 December 31: Scores are due no later than January 15 January 1 March 31: Scores are due no later than April 15 April 1 June 30: Scores are due no later than July Enhanced Primary Care Linkage from Acute Care Provider Types The deliverables described in this section are required by the following types of participants: Acute care Description Ensuring definitive, timely linkages are made to primary care following a hospital stay is crucial for follow-up and maintenance of health conditions in the community setting. Primary care needs to be the center of care coordination strategies. Patients must be given appropriate resources to be successful in their linkage to primary care. Partners are expected to develop a workflow and process demonstrating patient linkage with PCP. 27 / 37

28 Acute care partners will create timely linkage to primary care for patients prior to discharge Revise patient-facing materials that demonstrate components of health literacy with inclusion of written documentation of when/where follow-up appointment is and reason for appointment Provide copy of materials to patient when primary care provider (PCP) visit is scheduled 4.3. Non-Utilizer Management Provider Types The deliverables described in this section are required by the following types of participants: Primary care practices (including pediatric practices) Acute care Behavioral health outpatient Description Hospitals For hospitals, the objective of NU management is to successfully link ED Care Triage patients who fail to attend their primary care follow-up visit to primary care services. As part of the EDCT program, Medicaid patients are linked with a primary care appointment prior to leaving the ED. The Patient Navigator will follow up with the EDCT patient within 48 hours of upcoming primary care visit. This is to ensure the patient is aware of their appointment and to identify any barriers to getting to their appointment. The Patient Navigator will confirm and document the patient s compliance to their PCP scheduled appointment. Hospitals will track patient s outcome either in SalesForce or their own electronic medical record (EMR): Primary Care For hospitals using Salesforce for EDCT documentation, Millennium will pull SalesForce data of patients with No Show and submit the patients to the Millennium-contracted non-utilizer (NU) vendor For ECMC hospitals using their own EMR for EDCT documentation, Millennium will assist ECMC with reporting requirements of patients with a No Show to PCP The intent of non-utilizer (NU) management within primary care is to provide additional support with locating patients that have become disconnected from primary care practices. Millennium s contracted community-based organizations (CBOs) will be providing that support to primary care. Millennium recognizes that primary care practices are currently spending significant resources on telephonic outreach and mailings to bring patients in for routine services. The NU management program is intended to attempt another form of outreach for hard-to-reach patients. Once a patient is located, the contracted CBO will navigate the patient back to his or her primary care provider for an appointment. Primary care practices will partner with one of Millennium s regional contracted CBOs to receive their NU lists. The practice will run reports which identify non-utilizing patients throughout the engagement and send these reports to Millennium s vendor. The vendor will attempt additional forms of outreach to connect with the patient and get the patient back to primary care. Primary care practices must accept referrals from NU vendors and schedule 90% of appointments within 30 days of referral. 28 / 37

29 Behavioral Health For behavioral health providers, the objective of NU management is to successfully connect patients with behavioral health diagnoses to primary care. Behavioral health practices will report (monthly) the number of patients referred to the NU vendor who require HbA1c or LDL lab work. All Applicable Partners Participants will report the total number of patients referred to the NU program monthly. Millennium may request an audit at any time. In order to exchange patient data, participants must execute a Business Associate Agreement with the NU vendor. Patient lists must be exchanged using a secure file transfer method. Resources Sample BAA from HHS 4.4. Screening, Brief Intervention, and Referral to Treatment (SBIRT) Provider Types Primary care practices (excluding pediatric practices) Planned Parenthood Description Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a set of guidelines that recognize the important role for primary care services in screening for nicotine, alcohol, and other drug use, fostering healthy changes in use, and in linkage to further services when appropriate. All patients seen in primary care settings should be screened for use and misuse of alcohol, nicotine, and other drugs. Resources SBIRT Best Practices for Primary Care Substance Abuse Algorithm 4.5. Crisis Stabilization Provider Types The deliverables described in this section are required by the following types of participants: Acute care Description It is imperative that Millennium partners have established diversion management protocols to prevent unnecessary ED visits and hospitalizations for patients with a crisis episode. Diversion management protocols document how readily accessible behavioral health services would be accessed by patients getting them to the 29 / 37