Transformation Plan Final Report

Transcription

1 PacificSource Columbia Gorge Coordinated Care Organization Transformation Plan Final Report March 2018

2 Transformation Area 1: Integration of Care Benchmark 1.1 (Baseline to ) Benchmark 1.2 (Baseline to ) Benchmark 1.3 (Baseline to ) Transformation Plan Final Report PacificSource Community Solutions Columbia Gorge Building capacity for social and behavioral health integrated services in primary care clinics through enhanced staffing model. Policy documented. Number of clinics participating. Number of members assigned to participating clinics. Policy approved to establish a financial model outlining a sustainable model for integrated behavioral and/or social health services in primary care. Target support for clinics that do not currently have the infrastructure. Gorge CCO financially supports integrated behavioral health services in primary care. At least two (2) primary care clinics participate. Integration between dental, behavioral health, and physical health providers for all members including those with SPMI Establish baseline of current availability of primary care or dental health in specialty behavioral health facilities. Document increase in access to integrated services. SPMI population will receive dental, physical and mental health services as appropriate to their health status at levels equal to or better than the global CCO population. Integrate physical health services into at least one (1) of MCCFL s specialty behavioral health facilities that may include use of the dental van at MCCFL sites. Develop an expedited path to Substance Use Disorder (SUD) treatment for identified members Completed service map of SUD services including policy and/or data on access. Members with SUD will receive SUD services as appropriate to their need (e.g. counseling, medication assisted treatment) and those services will meet the best practice guidelines for access based on assessment of need, urgency, and readiness/choice of the member. The elements of the treatment continuum for youth and adults are available with documented access standards and process for accessing services. Page 1 of 26

3 a. Please describe the actions taken or being taken to achieve milestones and/or benchmarks in this transformation area. For each activity, describe the outcome and any associated process improvements, as well as the associated benchmark number (e.g. 1.1 or 1.2). Associated Benchmark # Page 2 of 26 Activity (Action taken or being taken to achieve milestones or benchmarks.) 1.1 PacificSource staff created a payment model for integrated behavioral health services as described in the following policy: Financial Model for Sustainable Reimbursement of Integrated Behavioral Health in Patient Centered Primary Care Homes. PacificSource developed a dashboard to track the progress of implementation. Provided assistance to Patient Centered Primary Care Homes (PCPCH) in the Columbia Gorge to understand this care model and approved billing processes. Hired independent consultant to perform structured site visits to evaluate the quality of integration at each clinic. Resourced internal staff to conduct technical assistance with clinics to act on the recommendations developed by the independent consultant. 1.2 Developed an internal PacificSource analytics tool to track and monitor the level of care provided to members with Severe and Persistent Mental Illness (SPMI). Encouraged and supported Mid-Columbia Center for Living (MCCFL) the local Community Mental Health Program, in their effort to develop integrated care. Outcome to Date The PacificSource policy was approved and implemented in June Seven (7) clinics in the Columbia Gorge are participating as Integrated Behavioral Health sites: o One Community Health: The Dalles, Hood River, Hood River School-Based Clinic o Deschutes Rim Clinic o Mid-Columbia Medical Center: Waters Edge, Family Medicine, Pediatrics Approximately ¾ of the Columbia Gorge CCO members are served by primary care clinics with integrated behavioral health. The independent consultant identified both areas of strength and gaps in how clinics have implemented the model. PacificSource trained internal staff to provide technical assistance to clinics. The number of members served and services provided have significantly increased over (See Figures 1 & 2) Data from the internal analytics tool shows that members with SPMI utilize primary care, dental, emergency department, and behavioral health services at a much higher rate than the general population. (See Figure 3) Data from the internal analytics tool show that members with SPMI are receiving some screenings at higher rates than members with no SPMI and Process Improvements PacificSource has implemented a reimbursement model for integrated behavioral health in PCPCH clinics. PacificSource is actively improving evaluation methods to ensure that high quality integrated care is provided at participating clinics. PacificSource is offering technical assistance to address identified areas of improvement. PacificSource has continued to refine contract language and payment models for integrated behavioral health in primary care. The PacificSource Analytics team now maintains a standard reporting tool that will allow ongoing monitoring of disparities among the member population with SPMI. Leadership from PacificSource and MCCFL have established a monthly

4 1.3 Amended contract with Substance Use Disorder (SUD) service provider to include measurement and reporting of access timelines as part of the performance withhold. Identify gaps in SUD service array and work with providers to develop an improvement plan if necessary. Reopened the Behavioral Health provider panel in early 2017 to expand the service array and the availability of services. other screens at lower rates. (See Figure 4) MCCFL was certified as a Certified Community Behavioral Health Clinic (CCBHC) which required attestation to the provision of integrated care. MCCFL has taken steps toward providing integrated care for all members: o Hired nursing staff to conduct medical intakes with new and existing clients, initiate referrals for specialty care, and monitor medication compliance. o Established routine written communication process to inform PCPs on patient engagement in services. o Expanded EHR to include a Doctor s Homepage that tracks BMI, vital signs, allergies, medical conditions, and medication management. o Established routine process of accessing medical records through Reliance Health Information Exchange (HIE). o Initiated monthly client review meeting with local Federally Qualified Health Center (FQHC) to coordinate care. o Trained existing staff as OHP enrollment specialists to assist clients in applying for benefits. PacificSource addressed the two identified gaps in the SUD service array in the Columbia Gorge Region: o Intensive Outpatient Care - MCCFL is meeting this need by individualizing treatment plans to meet the needs of members. o Medication Assisted Treatment (MAT) - MCCFL is working closely with One Community Health, the region s FQHC to provide MAT for members. The agencies meet weekly for coordinated case management. conference call to allow for open communication regarding all facets of service delivery. PacificSource added new behavioral health providers outside of MCCFL to the network available to CCO members and allows members open access for assessments by any network provider. Page 3 of 26

5 b. Please note which Benchmarks have been met and which have not. 1.1 MET 1.2 MET 1.3 MET c. Please describe any barriers to achieving your milestones and/or benchmarks in this Transformation Area. 1.1 In the Financial Model for Sustainable Reimbursement of Integrated Behavioral Health in Patient Centered Primary Care Homes policy at PacificSource, clinics must administer the Integrated Practice Assessment Tool (IPAT) to establish evidence of the level of integrated care being provided. It became apparent that some clinics could benefit from assistance in assessing their level of integration. 1.2 Mid-Columbia Center for Living (MCCFL) is the local mental health authority operating in the Columbia Gorge Region. MCCFL s facility capacity limits the pace at which they can expand services in Wasco County. In 2016, they received a Community Development Block Grant to build a new facility and they also joined a statewide initiative to become a Certified Community Behavioral Health Clinic (CCBHC). These two large initiatives contribute to building capacity for MCCFL to develop a fully integrated care model. 1.3 The small population of the Columbia River Gorge region impairs the capacity of local organizations to offer some types of high-intensity services. d. Describe any strategies you have developed to overcome these barriers and identify any ways in which you have worked with OHA (including through your Innovator Agent or the learning collaborative) to develop these alternate strategies. 1.1 PacificSource contracted with a consultant to work with clinics to evaluate the level to which services were fully integrated. The consultant also worked closely with staff at PacificSource to develop an internal resource to provide ongoing technical assistance for clinics in the region. 1.2 In order to provide members with more integrated care, MCCFL has relied on strong community partnerships, collaboration, and nurse case management to develop a system that is meeting the needs of members. MCCFL did receive approval to operate as a CCBHC, which required attestation to elements of integrated care. For example, the implementation of an Electronic Medical Record (EMR) system and screening process for physical health of all new patients. MCCFL is also working closely with One Community Health, a local FQHC in the area, to staff cases that require care which is not currently provided by MCCFL directly. 1.3 MCCFL has adapted to serving this small population through customizing individual care plans and partnering with other health care providers in the region. Page 4 of 26

6 Figure 1: Behavioral Health Services Integrated in Primary Care Settings by Unique Members and Visits (Report includes Central OR CCO and Columbia Gorge CCO statistics): Page 5 of 26

7 Figure 2: Behavioral Health Services Integrated in Primary Care Settings by Month and Provider Group (Report includes Central OR CCO and Columbia Gorge CCO statistics): Page 6 of 26

8 Figure 3: Utilization Comparison: SPMI Page 7 of 26

9 Figure 4: Screening Rates Page 8 of 26

10 Transformation Area 2: Patient Centered Primary Care Home Benchmark 2.1 (Baseline to ) Page 9 of 26 Implement and develop PCPCH model of care under 2017 standards. Number of clinics offered consultation. Number of clinics accepting consultation. Change in PCPCH points score of all contracted primary care clinics. Consultation on meeting 2017 PCPCH standards offered directly to administration at 100% of recertifying CCO clinics. Fifty percent (50%) of recertifying primary care clinics receive technical assistance on 2017 PCPCH standards and/or maintain or improve their PCPCH points score. a. Please describe the actions taken or being taken to achieve milestones and/or benchmarks in this transformation area. For each activity, describe the outcome and any associated process improvements, as well as the associated benchmark number (e.g. 2.1 or 2.2). Associated Benchmark # Activity (Action taken or being taken to achieve milestones or benchmarks.) 2.1 PacificSource hired a Practice Facilitator in the Columbia Gorge. b. Please note which Benchmarks have been met and which have not. 2.1 MET Outcome to Date The Practice Facilitator has offered technical assistance to 100% of clinics that were due for PCPCH recertification. Six (6) clinics in the Columbia Gorge region recertified in Of those clinics, two (2) maintained their Tier 3 status, and four (4) clinics upgraded from Tier 3 to Tier 4 status. c. Please describe any barriers to achieving your milestones and/or benchmarks in this Transformation Area. Process Improvements The Practice Facilitator communicates with clinics regularly regarding quality standards, including PCPCH certification requirements. The Clinical Advisory Panel of the CCO receives monthly status reports on the PCPCH Quality Incentive Measure. 2.1 A barrier to improvement in the PCPCH status of individual clinics is a perception that the effort required to increase PCPCH status may not yield adequate financial or quality benefit to the clinic or its patients. d. Describe any strategies you have developed to overcome these barriers and identify any ways in which you have worked with OHA (including through your Innovator Agent or the learning collaborative) to develop these alternate strategies. 2.1 PacificSource hired a Practice Facilitator in the Columbia Gorge to work with clinics to understand and improve their overall quality performance as well as specific quality measures, such as PCPCH status.

11 Transformation Area 3: Alternative Payment Methodologies Benchmark 3.1 (Baseline to ) Benchmark 3.2 (Baseline to ) Benchmark 3.3 (Baseline to ) Develop a process for tracking and evolving CCO contracts to ensure the implementation of Alternative Payment Methodologies & CGHC contracting principles Establish baseline for APM usage within the Columbia Gorge CCO system. Benchmark will measure the performance toward the improvement target and in comparison to the baseline. By : 1. Establish a prior year baseline measure 2. Achieve endorsement from CGHC on 2017 improvement targets for APM, consistent with APM guiding principles. 3. Produce an inventory tracking tool for APM contracts to measure impact and spread of value based reimbursement activities. Report progress on APM contracts to the CGHC Finance Committee. Achieve the 2017 improvement targets established as part of the 2016 milestone; in particular, progress in integrating the currently separate reimbursement mechanisms for physical, behavioral, and oral health. (Examples of improvement targets may be to increase contracts with APM by 10% or to ensure that 75% of Global Budget is delivered through APM contracts.) Establish a framework for evaluating, awarding & integrating new CCO services and funding streams into the CCO Global Budget that will leverage value-based reimbursement, consistent with CGHC contracting principles Documentation of process. Number of contracts executed that reflect CCO priorities. Develop a rubric for evaluating & prioritizing funding streams for newly integrated benefits coming into the global budget. Ensure CGHC contracting principles and other community priorities (Community Health Assessment and Improvement Plan, Transformation Plan, Quality Metrics, etc.) are reflected in executed contracts. Provide documentation that any funding streams for newly integrated benefits (TCM, NEMT, Adult Residential MH) have been evaluated & awarded consistent with this rubric, At least 80% of newly executed contracts abide by established rubric. Undergo a community process for evaluating the global budget allocation & process for distributing Flexible Service funds Documentation of new process and reporting system. Through a community process, determine whether a percentage of the global budget should be allocated for the provision of Flexible Services; document findings and adjust benchmarks if necessary. If a Flexible Services fund is formally established, develop a reporting system to monitor the volume, type & beneficiary impact of services that have been funded. Page 10 of 26

12 a. Please describe the actions taken or being taken to achieve milestones and/or benchmarks in this transformation area. For each activity, describe the outcome and any associated process improvements, as well as the associated benchmark number (e.g. 3.1 or 3.2). Associated Benchmark # Page 11 of 26 Activity (Action taken or being taken to achieve milestones or benchmarks.) 3.1 Produced a contract tracking tool to measure impact and spread of value based reimbursement activities. Obtained input and endorsement of the summary and tracking tool from the CGHC board and Finance Committee. Utilized input to develop the following improvement targets. o PacificSource will develop standard contract language on sharing provider-specific information about clinical performance and utilization with the Health Council and CCO participants and will provide opportunity for input from providers and the Health Council during the process. o PacificSource will develop contracting strategies that maintain or improve volume of high-value care provided to members and limit low-value care and will provide opportunity for input from providers and the Health Council during the process. o PacificSource will work with providers and the Health Council committees to develop a measure definition and reporting strategy for access to care and member experience. o PacificSource will track and show increased utilization of services provided by behavioral health professionals working in primary care settings. Improvement targets were approved by the Finance Committee and CGHC board. Create access reporting tools for the Columbia Gorge CCO based on successful data collection and analysis originally conducted in Central Oregon CCO. Outcome to Date Created a summary of payment methods in the CCO for the OHA. Created a tracking tool that includes a baseline description of all provider contracts with the CCO and received endorsement of the tool from CGHC board and Finance Committee. Developed standard contract language on sharing provider-specific information about clinical performance and utilization with the Health Council and CCO participants. Formalized contracting strategies that maintain or improve volume of high-value care provided to members and limit lowvalue care. o Moved preventive care codes to fee-forservice, out of Primary Care capitation payment, to create clear financial incentive for increased access and utilization of these services. o Added behavioral health providers to Medicaid network in addition to those working for the Community Mental Health Program and changed authorization process so that members have open access for their initial visit with any contracted provider. o Updated dental contracts to include financial incentives tied to quality performance. o Transitioned Mid-Columbia Medical Center to a contract that includes incentives for quality performance and cost control. PacificSource and community partners at the Health Council have adopted the Consumer Assessment of Healthcare Process Improvements Developed a rubric for value-based contracts that will be used internally in contract goal-setting and negotiation. The rubric tracks the following elements: risk, cost, value, access, quality, experience, and participation in regional health improvement activities.

13 3.2 Developed rubric for evaluating and prioritizing funding streams for newly integrated benefits coming into the global budget. Ensured that rubric is inclusive of CGHC contracting principles and other community priorities (Community Health Assessment, Community Health Improvement Plan, Transformation Plan, and Quality Metrics). Used the rubric that was developed for new funding streams during contract year. Formalized rubric and solicited revisions and endorsement from CGHC board. 3.3 Developed PacificSource Flexible Funds Policy. Requested approval from OHA and made appropriate revisions. Received approval from the CGHC board for funding the flexible services line item in the 2016 and 2017 CCO global budgets. Page 12 of 26 Providers and Systems (CAHPS) measurements of Access and Member Experience and developed a strategy for accountability and reporting to be implemented in Analytics staff created an access report for Columbia Gorge CCO members. Developed a contracting model to support behavioral health services in primary care and a standard report to track utilization. (See Transformation Area 1, Figures 1 &2) The rubric was used for integration of Non- Emergency Medical Transportation (NEMT). It was endorsed by the CGHC board in October 2015 and again in June The revised PacificSource Flexible Funds policy has been approved by OHA and implemented in the Columbia Gorge CCO. The Community Advisory Council, Finance Committee, and Governing Board of the CCO receive scheduled reporting on flexible funds requests and expenditures. Approximately 111 requests for Flexible Services were approved in This rubric is in place as a template for any future funding integrations that occur. The Flexible Services policy is in place and the implementation process has been defined. A reporting system has been designed and implemented to monitor the volume, type & beneficiary impact of services that have been funded. PacificSource is receiving regular requests for flexible services from multiple providers in the Columbia Gorge.

14 b. Please note which Benchmarks have been met and which have not. 3.1 MET 3.2 MET 3.3 MET c. Please describe any barriers to achieving your milestones and/or benchmarks in this Transformation Area. 3.1 The sub-capitation model for behavioral health that we inherited from pre-cco Oregon Health Plan has made it difficult to move to a payment model that is grounded in objective valuations of services being provided by those programs. We are addressing this by adding more contracted behavioral health providers outside of the CMHP and establishing an access model where members may see the provider of their choice. In addition, we are actively engaged with our CMHP in negotiations around a payment model that aligns incentives for quality care, good member experience, and cost containment. The payment model, under Oregon Medicaid, for rural hospitals is entirely based on fee-for-service payments. The level of payment and incentives in the feefor-service model are a barrier to hospitals voluntarily negotiating other contract arrangements. CCOs need the continued collaboration of the OHA to move hospitals from Type A/B reimbursement to models that better align with the system s overall goals, while maintaining the financial viability of rural hospitals. d. Describe any strategies you have developed to overcome these barriers and identify any ways in which you have worked with OHA (including through your Innovator Agent or the learning collaborative) to develop these alternate strategies. 3.1 PacificSource is currently working to refine the payment model with Community Mental Health Programs. Columbia Gorge hospitals remain on a fee-forservice payment model tied to Oregon s Type A/B payment model, but we continue to discuss and offer other contracting models on an annual basis. Page 13 of 26

15 Transformation Area 4: Community Health Assessment and Community Health Improvement Plan Benchmark 4.1 (Baseline to ) Benchmark 4.2 (Baseline to ) Benchmark 4.3 (Baseline to ) Contractor will ensure that provider contracts require appropriate participation in and response to focus areas outlined in the Community Health Improvement Process (CHIP) and contributing input for the Community Health Assessment (CHA) Documentation of baseline and improvement target. Performance toward improvement target. Establish a tracking tool, report out bi-annually to CCO Governance, and establish a 2017 improvement target based on goal. Achieve improvement target established for 2016 milestone. (Examples may be to increase contracts with CHA/CHIP participation/response by 25% or to ensure that 75% of Global Budget is delivered through contracts inclusive of CHA/CHIP priorities). Developing a structured process to establish partnerships and measure progress to advance CHIP priorities Number of written, shared agreements, outlining milestones and metrics, between stakeholders in relation to CHIP priorities. Prioritize and establish milestones with metrics and community commitments through a Declaration of Cooperation or equivalent for 2 or more CHIP topics in partnership with CGHC as described in the Joint Management Agreement. Metrics are to be integrated into CHA and are reviewed at least bi-annually. As above for 4 or more CHIP topics. Contractor, in partnership with CGHC as described in the Joint Management Agreement, will participate in a regional, collaborative CHA and CHIP process to align with regulatory requirements for CCO s, hospitals and other agencies Document participation in regional CHIP process. Coordinate and participate in a regional collaborative CHA that meets or exceeds the scope of the 2013 Gorge CHA. Evaluate the ability to include the following additional information: 1. Types of prevalence of adverse childhood experiences (ACE s) 2. Data from electronic health records across the region, such as ED utilization 3. Data from CAHPS surveys. Coordinate and participate in a regional collaborative CHIP that meets or exceeds the scope of the 2014 Gorge CHIP. Page 14 of 26

16 a. Please describe the actions taken or being taken to achieve milestones and/or benchmarks in this transformation area. For each activity, describe the outcome and any associated process improvements, as well as the associated benchmark number (e.g. 4.1 or 4.2). Associated Benchmark # Page 15 of 26 Activity (Action taken or being taken to achieve milestones or benchmarks.) 4.1 Establish a baseline that includes the percentage of provider contracts that currently require appropriate participation and response to focus areas outlined in the Community Health Improvement Plan (CHIP) and contributing input for the Community Health Assessment (CHA). o Baseline 100% PCP, 100% of contracted specialists, 90% of behavioral health, 50% of hospital, 0% of dental, 0% of transportation, 0% of public health. Established improvement targets for 2017 as endorsed by the CGHC board. o Maintain current high baseline o Offer CHA/CHIP participation provision in contract negotiations through July 2017 as contracts without this provision are re-negotiated. Within the contract tracking tool that was developed for Benchmark 3.1, measure the degree to which provider contracts require participation in CHA/CHIP activities. 4.2 The Community Health Improvement Process was completed in June It outlined priority focus areas in three categories: social and economic conditions, direct healthcare services, and health and health ecosystem. Oregon Solutions conducted two local planning processes that developed agreements on how to proceed as documented in signed Declarations of Cooperation. Providence Hood River Memorial Hospital partnered to fund a Collective Impact Health Specialist who has coordinated grant applications and proposals communitywide, in order to align initiatives that are focused on improvements in the prioritized focus areas of the CHIP. Outcome to Date Developed standard contract language for participation in CHA/CHIP planning and implementation. Standard contract language for CHA/CHIP has been implemented at the following rates: 100% of primary care; 100% of contracted specialists; 100% of hospitals; 100% of dental; 100% of transportation; 100% of public health Housing & Food: an Oregon Solutions project resulted in a Declaration of Cooperation to develop a regional Gorge Food Security Coalition. Coordination across healthcare and social services: the CGHC designed and began operation of Bridges to Health, a care coordination hub using the Pathways model, as detailed in a preexisting Declaration of Cooperation. Supporting Development in the Early Years: an Oregon Solutions project resulted in a Declaration of Cooperation to form an obesity prevention coalition, now named Fit in Wasco. Process Improvements Adding CHA/CHIP participation to contracts elevates the importance of this activity. It has also provided a model for writing other expectations for participation into provider contracts; such as data sharing and governance. The CCO has established a collaborative model for creating a joint CHA and CHIP across the entire region. This results in coordinated efforts and grant requests to address needs throughout communities in the Gorge.

17 4.3 Completion of the CHA and CHIP was delegated to the Columbia Gorge Health Council (CGHC) through a joint management agreement. PacificSource staff participate in the processes convened by CGHC. The CGHC aspires to lead a regional, collaborative CHA process. The Community Advisory Council (CAC) was instrumental in developing and distributing the CHA survey, which is collected and analyzed by the Providence Center for Outcomes Research and Education. Physical & Mental Health Together: the Hood River High School-Based Health Clinic accessed state funds, using evidence from the CHIP and CHA, to add two behavioral health professionals to their staff. Mental Health Access for Children & Youth: PacificSource established a policy and payment model to allow PCPCH clinics to bill for providing integrated behavioral health services. Coordination Across the Spectrum of Healthcare (physical, mental, dental, pharmacy): the CCO has led a collaborative process resulting in implementation of Health Information Exchange technology across the region in outpatient settings, inpatient settings, and social service organizations. The 2016 CHA survey included questions related to trauma history as well as access and satisfaction with health services. In addition, the CHA incorporated CCO utilization data, CAHPS data, and data from the Oregon Healthy Teen Survey. The 2016 CHA and 2017 CHIP are complete and can be found on the CGHC website at: The CGHC has established a collaborative process for implementing the CHA and CHIP that is inclusive of CAC and multiple community partners across the Columbia Gorge region. b. Please note which Benchmarks have been met and which have not. 4.1 MET 4.2 MET 4.3 MET Page 16 of 26

18 c. Please describe any barriers to achieving your milestones and/or benchmarks in this Transformation Area. 4.1 Provider contracts have historically focused on financial and compliance items. 4.2 The CGHC has developed a collaborative approach to completing a region-wide CHA. For this collaboration to be successful, the CHA must be completed every three years to meet the timing needs of the hospitals that partner in the effort. Therefore, the CCO spent most of 2016 and 2017 conducting a new CHA and developing a new CHIP. 4.3 The CGHC has developed a collaborative approach to completing a region-wide CHA. This is a huge benefit for the community. However, it does present challenges in accessing data that is adequate to define the needs in the entire region. For example, the region includes two counties in Washington State and Sherman County in Oregon, which are outside of the CCO region. d. Describe any strategies you have developed to overcome these barriers and identify any ways in which you have worked with OHA (including through your Innovator Agent or the learning collaborative) to develop these alternate strategies. 4.1 The CCO s Finance Committee has been a useful venue to develop ideas and educate both PacificSource staff and provider partners on the role of explicit, contractual agreements in care transformation. 4.2 While the new CHA/CHIP were being developed the community continued to work on priority areas outlined in the previous CHIP. Several of these activities were aided by Oregon Solutions processes and resulted in community agreements. 4.3 The CGHC utilized several sources to validate the CHA survey data. Page 17 of 26

19 Transformation Area 5: Electronic Health Records, Health Information Exchange and Meaningful Use Benchmark 5.1 (Baseline to ) Continue development and implementation of HIT/HIE to support Triple Aim outcomes in the Columbia Gorge CCO and region overall Document increase in HIT functionality and meet associated improvement targets around 1) Usage and impact of Emergency Department utilization and 2) CCO and provider access to Jefferson Health Information Exchange (JHIE) Continuity of Care Documents (CCD) for enhanced care coordination and 3) evaluate member access to their own data Upon implementation of emergency department diversion technology: 1. Establish a baseline for high ED utilization for Columbia Gorge members. 2. Establish improvement target based on baseline and submit to OHA for inclusion in Transformation Plan benchmark Ensure the CCO s ability to effectively utilize Jefferson HIE through the integration of eligibility data. Achieve access to 100% of Gorge OHP CCDs populated in Jefferson HIE. Benchmark 5.2 (Baseline to ) Ensure at least 50% of PCP providers have access to Gorge CCDs (OHP members, uninsured and commercial) populated in Jefferson HIE. Develop a plan to utilize access and through the development of a strategic work plan, set specific goals around case management and cost savings inclusive of members having access to or exchange with providers and the health plan. By July 2016, submit 2017 benchmark to OHA for inclusion in Transformation Plan. Achieve improvement target established in 2016 in relation to implementation of Emergency Department technology. Meet benchmark/improvement target(s) as submitted in 2016 in relation to utilization of CCD data. Impact Quality and Patient Outcomes through improved health analytics and provider information exchange. Descriptive process analysis, provider qualitative feedback. Integrate 2016 CCO claims information into PacificSource Enterprise HEDIS reporting solution to support calculation of administrative measures and QIM s and lay the foundation for the development of a Patient Profile tool to support providers toward enhanced quality improvement capability. Pilot quarterly delivery of PacificSource Patient Profiles to at least one (1) provider partner. Page 18 of 26

20 a. Please describe the actions taken or being taken to achieve milestones and/or benchmarks in this transformation area. For each activity, describe the outcome and any associated process improvements, as well as the associated benchmark number (e.g. 5.1 or 5.2). Associated Benchmark # Activity (Action taken or being taken to achieve milestones or benchmarks.) 5.1 The Columbia Gorge CCO has worked with Reliance ehealth Collaborative to implement Health Information Exchange (HIE) in provider clinics (dental, physical, mental health) and social service providers across the region. The Columbia Gorge CCO has established a 2017 target of ensuring that 1/3 of Medicaid members will be served in a clinic with Emergency Department (ED) diversion technology actively in use PacificSource refined and enhanced the Member Insight Report to act as a Patient Profile Tool for clinic use in monitoring QIM performance and better managing target populations. Outcome to Date There are 39 sites in the Columbia Gorge region that currently have HIE capacity through Reliance ehealth Collaborative. Of these, 24 organizations are currently active using ereferrals only, and five are using ereferrals and sharing data through the community health record. Training and installation of HIE has been completed for all primary care clinics for use of secure messaging and referrals. At the end of the 4 th Quarter of 2017, PreManage ED Diversion Technology is live at the following clinics: o One Community Health o Mid-Columbia Outpatient Clinics o Columbia Gorge Family Medicine o Deschutes Rim Clinic o Providence Hood River Family and Internal Medicine These five clinics serve 85.8% of the CCO s members. The Columbia Gorge CCO finished 2017 with an ED Utilization rate of 39.8 per 1,000 member months. This will be substantially better than the state CCO metric benchmark of 42.9 per 1,000 member months. The following clinics are currently receiving the Member Insight Report: o One Community Health o Mid-Columbia Medical Center o Columbia Gorge Family Medicine o Summit Family Medicine, LLC o Providence Hood River Process Improvements The Columbia Gorge CCO is continuing to offer training and technical assistance to support the use of HIE and is working toward integrating the service with existing data systems. PacificSource will continue to refine the Member Insight Report based on feedback from providers. Page 19 of 26

21 b. Please note which Benchmarks have been met and which have not. 5.1 MET 5.2 MET c. Please describe any barriers to achieving your milestones and/or benchmarks in this Transformation Area. 5.1 In order to prevent avoidable ED use, the CCO has focused on increasing the use of ED diversion technology by offering clinics access to PreManage. One barrier to doing this work is customizing and then implementing workflows that use the technology in clinics that are already working at maximum capacity. 5.2 The Member Insight Report has been distributed to providers for some time, and the feedback has been very positive overall. The biggest challenge is determining how clinics can process the large volume of information in the report and put it to use. d. Describe any strategies you have developed to overcome these barriers and identify any ways in which you have worked with OHA (including through your Innovator Agent or the learning collaborative) to develop these alternate strategies. 5.1 PacificSource hired a full time Emergency Department Improvement Coordinator who has made significant progress in assisting clinics to utilize PreManage ED Diversion technology. The ED coordinator has been able to work with clinics to understand their current workflows and staffing resources, in order to assist with training, onboarding of the technology, and develop workflows that are amenable to each clinic s capacity and resources. 5.2 PacificSource has hired a full time Practice Facilitator who works directly with providers in the Columbia Gorge to improve clinical quality. Transformation Area 6: Communications, Outreach and Member Engagement Benchmark 6.1 (Baseline to ) PacificSource will ensure use of plain language in all member communications, in English, Spanish and other languages as needed, and assist community partners with plain language communication to members Review of materials completed. Improvement documented. Columbia Gorge Consumer Members and other local groups as identified by the CAC will review three key member materials for ease of comprehension and usability. Based on the group s review and feedback, PacificSource will update at least one (1) of the key materials, as long as proposed changes do not increase reading level above the 6th grade requirement or alter state-required or plan-required language. PacificSource will invest in plain language training for at least two appropriate employees. PacificSource will provide community partners with relevant examples of and resources for training in plain language and/or access to the consumer member review structure described above, as facilitated by the CAC. Page 20 of 26

22 a. Please describe the actions taken or being taken to achieve milestones and/or benchmarks in this transformation area. For each activity, describe the outcome and any associated process improvements, as well as the associated benchmark number (e.g. 6.1 or 6.2). Associated Benchmark # Activity (Action taken or being taken to achieve milestones or benchmarks.) 6.1 Improve the knowledge and skill of PacificSource and community partners staff in use of plain language. Incorporate feedback from CCO members into the design of memberfacing materials. b. Please note which Benchmarks have been met and which have not. 6.1 MET Outcome to Date PacificSource co-sponsored the Legacy Health Literacy Conference Several partners from the Columbia Gorge region attended the event as did staff from the PacificSource Marketing and Communications departments. PacificSource Marketing and Communications staff have incorporated what they learned from the Plain Language training in the revision process for multiple documents as well as in the preparation of new materials. PacificSource recently updated its CCO website for enhanced functionality for members with lower literacy levels and easier navigation: Process Improvements PacificSource Marketing and Communications has worked to incorporate feedback from Community Advisory Councils in the design and content of member-facing materials. c. Please describe any barriers to achieving your milestones and/or benchmarks in this Transformation Area. 6.1 The Community Advisory Council (CAC) meeting agendas are typically full, given the inclusion of the group in multiple decision-making and input processes. Due to the tight agendas there is not always time for the CAC to review materials on a set schedule. d. Describe any strategies you have developed to overcome these barriers and identify any ways in which you have worked with OHA (including through your Innovator Agent or the learning collaborative) to develop these alternate strategies. 6.1 PacificSource prioritizes key member materials for review and solicits member feedback simultaneously on multiple products. Page 21 of 26

23 Transformation Area 7: Meeting the culturally diverse needs of Members Benchmark 7.1 (Baseline to ) Benchmark 7.2 (Baseline to ) Page 22 of 26 Increasing access to in-person qualified or certified interpreters Number of qualified/certified interpreters employed by health care facilities in Gorge CCO. Number of claims submitted for interpreter services. Capture a baseline of clinics that employ qualified or certified interpreters. CGHC and CCO establish support protocol for clinics to increase qualified or certified interpreters. Increase the number of qualified or certified interpreters available on staff at participating clinics by at least 20%. Increase the utilization of interpreter service from baseline by 10%. Workforce Diversity Baseline established. Descriptive narrative of process and partner engagement. Number of partners engaged. Complete baseline assessment on overall health care workforce diversity, with a specific focus on Native American and Hispanic/Latino workforce across all disciplines (e.g. mental/behavioral health, physical health, etc.). Identify and outline strategies that leverage partnerships with K-12 and community colleges to develop workforce development strategy. Through the formation of a workgroup, CCO/CGHC to establish formal ties with education partners (e.g. K-12, Community College) to develop health care workforce strategy. Program partners have convened, program plan developed, begin implementation of program if partners have secured needed resources. a. Please describe the actions taken or being taken to achieve milestones and/or benchmarks in this transformation area. For each activity, describe the outcome and any associated process improvements, as well as the associated benchmark number (e.g. 7.1 or 7.2). Associated Benchmark # Activity (Action taken or being taken to achieve milestones or benchmarks.) 7.1 Ensure providers have options and access to certified/qualified interpreter services. Encourage providers to bill for services provided by certified/qualified staff interpreters. Support providers in training staff to become certified or qualified as health care language interpreters. Outcome to Date The baseline of clinics that employed qualified or certified interpreters was one (1). In June, 2017 PacificSource surveyed providers again to determine the number of qualified/certified interpreters on staff at clinics in the region and found that five (5) clinics have qualified/certified interpreters on staff. In the fall of 2017, PacificSource sponsored a free program for Health Care Language Interpreters in the Process Improvements PacificSource provides technical assistance to clinics to help them initiate billing for interpreter services.

24 7.2 Assess Workforce Demographic data. Engage in partnership with K12 and higher education to initiate workforce development strategies. community to receive the required 60 hours of training to obtain state certification. More than 30 staff members from organizations in the region completed the training. The U.S. Census Bureau, Center for Economic Studies, Longitudinal Employer-Household Dynamics (LEHD) provides the following information from their 2014 report Demographics of Health Care and Social Assistance Workers. Wasco County: AI/AN: 1.3% (Q1 2016: 1.7%) Hispanic/Latino: 12.8% (Q1 2017: 12.5%) Hood River County: AI/AN: 1.3% (Q1 2016: 1.7%) Hispanic/Latino (Q1 2017: 22%) PacificSource staff joined the Regional Achievement Collaborative, a local initiative convened by K-12 and community colleges to develop strategies for enhancing workforce development and promoting Science, Technology, Engineering and Math education in the region. PacificSource and the CGHC have made a conscious effort to ensure that there is diversity in the Community Advisory Council, and that the voices of minority populations are well represented. PacificSource staff continue to be active with the Regional Achievement Collaborative and East Cascades Workforce Development Board to create a process for training and recruiting a diverse health care workforce for the region. b. Please note which Benchmarks have been met and which have not. 7.1 MET 7.2 MET c. Please describe any barriers to achieving your milestones and/or benchmarks in this Transformation Area. 7.1 Clinics in the Columbia Gorge have worked to hire and train staff who are bilingual and bi-cultural. Clinics expressed a desire to have these staff complete the requirements to become qualified or certified Health Care Language Interpreters. However, meeting the training requirement required staff to travel to the Portland Metro area or further to complete the 60 hours of required training. Page 23 of 26

25 7.2 PacificSource surveyed the community to find current efforts in workforce development and began participating in the Regional Achievement Collaborative and the 4-Rivers Early Learning Hub. The Regional Achievement Collaborative has struggled with lack of funding and staff. The group has suffered some stagnation as a result. d. Describe any strategies you have developed to overcome these barriers and identify any ways in which you have worked with OHA (including through your Innovator Agent or the learning collaborative) to develop these alternate strategies. 7.1 PacificSource used shared savings from the prior year s budget to fund a 60-hour Health Care Language Interpreter training locally in the Columbia Gorge. The response was overwhelming. More than 30 existing staff members from clinics in the Columbia Gorge received the required training and are in the process of filing paperwork with OHA to become qualified/certified. 7.2 PacificSource is working with the East Cascades Workforce Investment Board to initiate new workgroups in the region. Transformation Area 8: Eliminating racial, ethnic and linguistic disparities Benchmark 8.1 (Baseline to ) Benchmark 8.2 (Baseline to ) QI project to reduce disparities in access to medical and/or dental preventive care The percentage of pregnant women with a dental visit during pregnancy determined through internal Medicaid and PCP Pregnancy Report and global claims data. Identified pregnant women on OHP as target population experiencing disparity in receipt of dental care. Baseline from Medicaid and PCP Pregnancy Report: 31.3% Baseline from global claims data: 21.4% Increase by 3% the rate of pregnant women with a dental visit during pregnancy. Community-based quality improvement process to reduce health disparities. Narrative description of completed activities, participants, and resulting agreements or goals. Complete process with partner agencies, community members, and care providers to assess CHA data, PacificSource disparities reporting, and input from members of affected groups. A minimum of 4 sessions will be convened with interim work defined and delegated to CCO or other institutions. Page 24 of 26

26 a. Please describe the actions taken or being taken to achieve milestones and/or benchmarks in this transformation area. For each activity, describe the outcome and any associated process improvements, as well as the associated benchmark number (e.g. 8.1 or 8.2). Associated Benchmark # Activity (Action taken or being taken to achieve milestones or benchmarks.) Outcome to Date Process Improvements 8.1 Launched a project to initiate a performance withhold in the dental contracts that includes performance on dental care during pregnancy. (Q3-Q4 2016). Launched a collaborative effort with PS analytics to commission a pregnancy measure dashboard using Minnesota Method improvement targets applied to each DCO, by region. Launched monthly mailings to newly identified pregnant women encouraging dental care. Collaborated with contracted DCOs to undertake improvement activities. Increased dental care during pregnancy (YTD 12/31/17) to 51.9% in the Columbia Gorge. (TARGET was 46.2%) Advantage Dental has a hygienist who provides oral health education, prevention and stabilization services, and referral pathways at community sites in Hood River & Wasco County. Advantage also conducts extensive outreach to pregnant women. Implemented contract amendments to include performance withhold arrangements. Developed and improved reporting for the pregnancy measure dashboard. PacificSource continues to support and monitor DCO outreach activities. 8.2 Convened analytics workgroup study claims data and better define health disparities among the PacificSource Medicaid population. Hosted OHA Health Equity technical assistance session with Ignatius Bau and community partners and initiated a local dialog. Partnered with the CGHC to conduct a series of listening sessions (focus groups) with multiple special interest populations to gather qualitative information about member experiences. b. Please note which Benchmarks have been met and which have not. 8.1 MET 8.2 MET Columbia Gorge Health Council commissioned ten listening sessions with special interest groups in the Columbia Gorge Region for the purpose of adding qualitative data to the quantitative information in the CHA Surveys conducted in A final CHA and CHIP were published in Page 25 of 26