BCBSM Physician Group Incentive Program Organized Systems of Care Initiatives Interpretive Guidelines 2012-2013 V. 4.0 Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Table of Contents 15.0 OSC Integrated Patient Registry Initiative... 2 16.0 OSC Integrated Performance Measurement Initiative... 9 17.0 OSC Integrated Processes of Care Initiative... 12 2
Blue Cross Blue Shield of Michigan Physician Group Incentive Program Organized Systems of Care Initiatives Interpretive Guidelines An Organized System of Care (OSC) is a community of caregivers consisting of primary care practices, specialists, hospitals and other providers that measure performance, set goals, track progress, and coordinate care across the continuum for the primary care-attributed patient population. The OSC assumes responsibility for establishing shared information systems and care processes, and accepts accountability for delivering effective and efficient patient care over time and across settings of care. Under Blue Cross Blue Shield of Michigan s (BCBSM) Physician Group Incentive Program (PGIP), OSC infrastructure and care processes are organized into three Domains of Function : OSC Integrated Patient Registry OSC Integrated Performance Measurement OSC Processes of Care OSC Initiatives have been collaboratively developed by BCBSM and PGIP Physician Organizations (POs), identifying the capabilities to be implemented within each OSC domain of function. These OSC Interpretive Guidelines were likewise developed collaboratively by a BCBSM-PO team The OSC Interpretive Guidelines will be reviewed annually and updated as needed, based on feedback from PGIP OSCs. The OSC Initiatives provide a roadmap to a state-of-the-art vision that will be incrementally implemented over the course of five to ten years. Organizations are not expected to have all of these capabilities initially. Through the PGIP program, BCBSM will reward OSCs for implementing these capabilities. Any capability reported to BCBSM as in place must be fully in place and in use by all care partners in the OSC on a routine and systematic basis. Capabilities are not necessarily listed in sequential order and may be implemented in any sequence the OSC feels is most suitable to their practice transformation strategy. 15.0 OSC Integrated Patient Registry Initiative 16.0 OSC Integrated Performance Measurement Initiative 17.0 OSC Processes of Care Initiative Total Capabilities 24 6 12
15.0 OSC Integrated Patient Registry Initiative (OSC Information Technology for Comprehensive Population Management) The purpose of the OSC Integrated Patient Registry Initiative is to assist nascent OSCs in the development of a health information system that will be used to collect, track, use and store patient health data sets. The aim is to enable the OSC and all of its associated providers in all settings of care to have the right information at the right time to effectively manage its patient population with the goal of high quality, cost-effective care. Use of the term registry is not intended to limit OSCs to current industry tools; the goal is to catalyze OSCs to extend beyond practice-specific registry tools and create health information systems with population management functionality that integrate information across settings and providers. This initiative builds upon the foundational capabilities in the PCMH Patient Registry Initiative and will enable OSC providers to perform OSC-wide management of their primary care-attributed patient population and reduce disparities in healthcare. General a. Patient Registry is a database that contains relevant clinical data on patients to enable the OSC to manage its patient population b. Patient Registry linkages must be compliant with HIPAA/HITECH 1 patient protection regulations, where applicable c. Patient Registry data sources may include: Electronic Medical Records (EMRs), payer-provided data (e.g., claims), e-prescribing/medication data, data feeds from other providers of care (e.g., laboratory, radiology, hospitals, home health care, physical therapy) and patient-generated data (e.g., health risk appraisals) d. Patient Registry should include a functional source of truth/master patient index (e.g., practice management system) that will perform demographic and clinical reconciliation (i.e., refreshing and cleaning data) e. Patient Registry is expected to be electronic, not paper-based, so that it can efficiently handle the volume of patients associated with the providers who are participants in the care of the OSC patient population 1 Health insurance Portability and Accountability Act of 1996, Public Law 104-191 ( HIPAA ), the Health Information Technology for Economic and Clinical Health Act, Public Law 111-005 ( the HITECH Act ), and regulations promulgated thereunder by the U.S. Department of Health and Human Services (the HIPAA Regulations ) and other applicable laws. 2
15.1 OSC has completed a plan to integrate patient registries of all PCPs in the OSC a. OSC has completed a detailed project plan, with milestones and dates, to establish an integrated registry that links all PCPs within the OSC and aggregates clinical data at the OSC level to support OSC-wide reporting and population management i. The plan defines the format (CCR/CCD, XMA, XML), model and architecture required to integrate all information b. Plan includes provisions for linking the registries of all newly associated PCPs that join the OSC in the future 15.2 The patient registries of 50% of established PCP practices in the OSC are electronically linked/integrated a. OSC has completed the integration of the registries of at least 50% of current PCP practice units so that the capability to conduct OSC-wide PCP patient management exists 15.3 The patient registries of 95% of established PCP practices in the OSC are electronically linked and integrated a. OSC has completed the integration of at least 95% of established PCP practice units registries 15.4 The patient registries of new practice units joining the OSC are electronically linked and integrated within 12 months of joining the OSC a. A process is in place to ensure that the patient registries of new practice units are electronically linked to the OSC-level patient registry within 12 months of joining the OSC. 15.5 All data in the integrated patient registry can be aggregated and analyzed at the OSC population level, as well as segmented by meaningful sub-units a. Data can be aggregated and analyzed at the OSC level 3
b. Data can be segmented by meaningful sub-units such as geographic area, practice unit or physician and by patient demographics and health conditions to allow the OSC to manage patient populations in aggregate and by segment 15.6 Integrated patient registry includes all patients attributed to the OSC s PCPs under BCBSM s attribution methodology; registry is not limited to patients with chronic diseases a. Integrated patient registry incorporates clinical information on all BCBSM attributed patients including those with and without chronic diseases b. Individual members attributed to a PCP practice unit who are unrecognized by the practice or who have only tangential contact with the practice are not required to be included in the registry c. Clinical information relevant to preventive care as well as management of chronic diseases is included in the integrated patient registry 15.7 Integrated patient registry is all-payer, and includes all insured and uninsured patients in all OSC PCP practices a. Integrated patient registry includes patients of all payers and patients without insurance (including non-attributed BCBSM patients) 15.8 All data in the integrated patient registry is updated through automatic electronic feeds and incorporated into the registry at clinically relevant intervals, at least monthly a. Processes and interfaces have been developed to enable the registry to electronically receive data from OSC providers on a daily basis where possible, and generally within a reasonable timeframe to enable appropriate and efficient management of the population as well as individual patient management at the point of care 15.9 Integrated patient registry contains patient self-reported data on individual goal setting a. OSC recognizes that patient self-reported data is an important component of overall population management and uses patient self-reported data to complement provider-developed registry data b. Integrated patient registry accepts self-reported data from patients either electronically (such as via patient portal) or by manual data entry 4
c. Patient self-reported data is updated as frequently as possible d. Patient self-reported data is updated during each encounter at which new data on individual goal-setting is obtained 15.10 Integrated patient registry contains imported structured patient Health Risk Appraisal data a. Reference 15.9(a), (b) and (c) b. Patient self-reported data is updated r upon receipt of newly-completed health risk appraisal form c. Patient self-reported health and functional status measures are collected and incorporated into the integrated patient registry (e.g., activities of daily living, important elements as determined by OSC that impact health and receiving healthcare such as behavioral health, living arrangements/home situation, caregiver availability, and advanced directives) 15.11 Integrated patient registry contains patient self-reported data from systematic application of validated screening tools (e.g., PHQ2 2, PHQ9) a. Reference 15.9(a), (b) and (c) b. Patient self-reported data is updated during each encounter at which data from screening tools are obtained 15.12 PO has a process in place to identify key care partners and sources for their data to be included in the integrated patient registry a. Information-sharing capabilities enable all providers in the OSC to access and update the patient health record to share information and coordinate the care of the OSC s patients b. Electronic interfaces are bi-directional where appropriate (e.g., medication history, HIEs) c. Linkage may be with registry or data warehouse or clinical database or EMR (whichever data collection/reporting tool the provider uses) d. Linkages are compliant with HIPAA/HITECH3 patient protection regulations 2 Patient Health Questionnaire-2 (PHQ-2) - this questionnaire is used as the initial screening test for major depressive episodes; PHQ9 is used for screening, diagnosing, monitoring and measuring the severity of depression. 3 Health insurance Portability and Accountability Act of 1996 5
15.13 Integrated patient registry is electronically linked to the health information technology of those specialty types that most commonly collaborate with the OSC s PCPs, and within those types, to those specialists who have executed a Primary Care- Specialist Agreement and have been nominated for an uplift a. Reference 15.12 15.14 Integrated patient registry is electronically linked to the health information technology of those specialty types that most commonly collaborate with the OSC s PCPs, and within those types, to those specialists who have executed a Primary Care- Specialist Agreement but have NOT been nominated for an uplift ( a. Reference 15.12 15.15 Integrated patient registry is electronically linked to the health information technology of key specialists (across all specialty types) engaged in caring for at least 95% of the OSC s patient population a. Reference 15.12 15.16 Integrated patient registry is electronically linked to the health information technology of key hospitals engaged in caring for the OSC s patient population a. Reference 15.12 15.17 Integrated patient registry is electronically linked to the health information technology of key laboratories engaged in caring for the OSC s patient population a. Reference 15.12 6
15.18 Integrated patient registry is electronically linked to the health information technology of key electronic prescribing systems or PBMs that are used in caring for the OSC s patient population a. Reference 15.12 15.19 Integrated patient registry electronically captures relevant health information from key community agencies and public institutions engaged in caring for the OSC s patient population, including but not limited to food banks, shelters, counseling centers, youth development centers a. Reference 15.12 15.20 Integrated patient registry is electronically linked to the health information technology of key non-hospital facilities engaged in caring for the OSC s patient population a. Examples of non-hospital facilities include home health care agencies, physical therapists and occupational therapists b. Reference 15.12 15.21 Integrated patient registry incorporates basic patient information that will allow the OSC to identify and address disparities in care a. Basic patient information includes: i. primary language ii. gender iii. race iv. ethnicity v. date of birth vi. occupation vii. date of death viii. disability status 7
15.22 Integrated patient registry incorporates advanced patient information that will allow the OSC to identify and address disparities in care a. Advanced patient information includes: i. measures of level of social support (e.g., disability, family network) ii. health literacy limitations iii. type of payer (e.g., uninsured, Medicaid) iv. relevant behavioral health information o Systems are in place to operationalize regulatory protection regarding behavioral health data on a minimum necessary, need to know basis, with necessary permission granted v. Information about preliminary cause of death should be included when available 15.23 Integrated patient registry electronically exchanges key clinical information among providers of care and patient authorized entities a. Key clinical information may include: problem list, medications list, medication allergies, diagnostic test results b. Linkages must be compliant with HIPAA/HITECH3 patient protection regulations 15.24 Integrated patient registry incorporates claims data from health plans and non-osc providers a. This data supplements data received from key providers in the care of the OSC patient population b. Relevant data may include: facility and professional medical claims, pharmacy claims data on filled prescriptions c. Registry incorporates data from the health plans that provide health care coverage for the preponderance of the OSC s patients 8
16.0 OSC Integrated Performance Measurement Initiative The OSC Integrated Performance Measurement Initiative builds on the foundational capabilities in the PCMH Performance Reporting Initiative and enables OSCs to generate OSC-wide performance reporting for all patients. Initially, performance reports will be for internal use, but in the longer-term, OSCs will collaborate to define a common set of measures that can be used to provide external entities with information for payment and public reporting. OSCs should actively collaborate on working toward the development of a consistent set of performance metrics relevant to key stakeholders to which they are collectively accountable (e.g., local and regional health plans, CMS, Aligning Forces for Quality collaboratives). General a. Performance reports are systematic, routine reports that provide current, clinically meaningful health care information on the entire OSC population of patients and allow comparison across the population of patients at a single point of time b. Performance reports should be produced and made available via an OSC portal or other online method on a regular basis to all key participants in the care of the OSC patient population c. Specific measures should include performance measures designed to measure quality and efficiency of care provided by all key participants in the care of the OSC patient population for entire OSC patient population 16.1 OSC performance measures are reliable and actionable and are used for the development of internal quality improvement efforts a. Input and testing have been conducted to ensure measures are reliable and actionable, including b. Developing, implementing and testing the internal reliability of performance measurement methodologies c. Ensuring that the results derived from these performance measures are meaningful and actionable with regard to patterns of illness within the population 16.2 OSC performance measures are aligned with nationally or regionally-recognized performance measures 9
a. Examples of sources of recognized measures include CMS Medicare Shared Savings Program, HITECH Meaningful Use standards, PQRS measures, HEDIS measures, U.S. Preventive Services Task Force b. Performance measures are updated annually to reflect most recent research and findings regarding optimal clinical outcomes (such as the increasing evidence that pushing to high rates of control in diabetes and blood pressure, especially for those who are older and with other comorbidities, can lead to unanticipated, negative consequences (e.g., complications of hypoglycemia; increased mortality, and that population level health improves more with moving the A1c of people with diabetes from 9 to below 8, rather than below 7). 16.3 OSC performance reports address a range of population segments and incorporate risk stratification and other methods to identify populations most in need of intervention and with the greatest opportunity for improvement a. Range of population segments includes but is not limited to patients segmented by age, gender, chronic disease status, history of use of healthcare resources, and characteristics that are related to potential disparities in care including race, gender and measures of level of social support (e.g., disability, family network, percent of low birth weight infants). 16.4 OSC performance reports measure transitions across care settings and over time a. Standards are established for key care transitions, based on patient diagnoses and needs (e.g., timeframe for PCP visit after hospital discharge) b. Performance reports measure actual performance against established standards c. Additional information about care transitions available at www.caretransitions.org 16.5 OSC performance measures address patient experience a. Assessment of patient and caregiver engagement in the care process generally and the medical home relationship in particular is conducted in a systematic fashion using standardized measurement approaches 16.6 OSC performance reports should include measures that incorporate health plan claims data 10
a. When available, the performance reports should include key clinical information provided by health plan claims data; for example: i. Inpatient and emergency department use ii. Ambulatory care sensitive admissions iii. Potentially preventable complications iv. Primary care sensitive emergency department visits v. Data on filled prescriptions vi. Services received from providers outside of the OSC 11
17.0 OSC Integrated Processes of Care Initiative The OSC Processes of Care Initiative builds on the foundational capabilities in the PCMH Initiatives, catalyzing the OSC to ensure that care partners communicate, coordinate, and collaborate to achieve clinical integration at the OSC level. Given the large number of specialty types and practices with which PCPs may share patients, the OSC Integrated Processes of Care Initiative is constructed to allow a phased approach. First Phase: Nominated Specialists applies to those specialty types that most commonly collaborate with the OSC s PCPs, and within those types, to those specialists who have executed a Primary Care-Specialist Agreement and have been nominated for an uplift Second Phase: Agreement Only applies to those specialty types that most commonly collaborate with the OSC s PCPs, and within those types, to those specialists who have executed a Primary Care-Specialist Agreement but have NOT been nominated for uplift. Third Phase: All Remaining applies to all remaining specialty types with whom the OSC s PCPs collaborate. 17.1 Patient-Provider Partnership a. OSC ensures that a system is in place to track implementation of patientprovider partnership capabilities in member PCP offices 17.2 Individual Care Management a. OSC ensures that for each patient or category of patient, lead responsibility for individual care management is clearly defined and accepted by either the PCP, the specialist, or via a centralized process at the OSC level b. OSC provides training and support and ensures that this domain s capabilities are actively utilized in member PCP offices and in partner specialist offices c. OSC ensures that care partners communicate, coordinate, and collaborate to achieve clinical integration of this domain s capabilities at the OSC level 12
17.3 Extended Access a. Reference 17.2(b) and (c) i. For example, when a patient contacts a specialist with a primary care issue, the specialist ensures that the patient makes contact with the primary care provider 17.4 Test Results Tracking & Follow-up a. OSC ensures that when patient is co-managed by PCP and specialist, the provider ordering the test is responsible for all follow-up and for clearly communicating information about test orders and test results to partner provider. b. Reference 17.2(b) and (c) 17.5 Preventive Services a. OSC ensures that for each patient or category of patient co-managed by PCP and specialist, lead responsibility for preventive services is clearly defined and accepted by either the PCP or the specialist b. Reference 17.2(b) and (c) 17.6 Linkage to Community Services a. OSC ensures that for each patient or category of patient, lead responsibility for linkage to community services is clearly defined and accepted by either the PCP, the specialist, or via the OSC through a centralized process b. Reference 17.2(b) and (c) 13
17.7 Self-Management Support a. OSC ensures that for each patient or category of patient, lead responsibility for self-management support is clearly defined and accepted by either the OSC, the PCP, or the specialist b. Reference 17.2(b) and (c) 17.8 Patient Web Portal a. Reference 17.2(b) and (c) 17.9 Coordination of Care a. OSC ensures that for each patient or category of patient, lead responsibility for coordination of care is clearly defined and accepted by either the OSC, the PCP, the specialist or facility b. OSC provides training and support and ensures that coordination of care capabilities are actively utilized in member PCP offices, in partner specialist offices or in partner facilities (e.g., hospitals, extended care facilities, rehab facilities) c. Reference 17.2 (c) 17.10 Specialist Referral Process a. Reference 17.2(b) and (c) 17.11 Access to Specialists 14
a. OSC has processes in place to ensure that patients have timely and appropriate access to specialty care i. Waiting time for specialty care appointments is tracked, and measured 17.12 Access to Behavioral Health Care a. OSC has processes in place to ensure that patients have timely and appropriate access to behavioral health care i. Waiting time for behavioral health care appointments is tracked, and measured 15