Accountable Care Atlas

Accountable Care Atlas

MEDICAL PRODUCT MANUFACTURERS SERVICE CONTRACRS Accountable Care Atlas Overview Map Competency List by Phase Detailed Map Example Checklist What is the Accountable Care Atlas? The Accountable Care Atlas (Atlas) is a collection of over 160 competencies organized into a logical sequence to aide providers in their transformation efforts. Cross-industry representatives convened by the Accountable Care Learning Collaborative identified the competencies, which are viewed as essential for provider organizations successfully providing value-based care. The ACLC is managed by Leavitt Partners, LLC. Provider organizations will use the Accountable Care Atlas to: Identify their position on the path to value Understand important next steps Navigation Use the overview map on page 2 to navigate within the document. Click on a hexagon to jump to the page with the corresponding competencies. Tips and Considerations Recognize areas they have overlooked Prioritize resource allocation PROVIDER ORGANIZATIONS REGULARS Many of the competencies describe ongoing efforts rather than a one-time event. The Atlas lists all competencies according to when they should begin, not necessarily end. The placement of the competencies suggests that multiple competencies may begin and be developed concurrently. The three phases and four work areas (i.e., Governance, Finance, Care Delivery, and Health IT) are identified to orient the reader, rather than to dictate absolute timing or strict ownership. INSURERS ASSOCIATIONS ACADEMIC INSTRUCTIONS The Atlas does not intend all competencies to be managed by the provider. In some instances, partners, such as payers, may be best positioned to fulfill the need. The Atlas is suggestive, not prescriptive. Each provider organization is unique, each market is different, and strategies and timing are varied. Organizations should customize the Atlas to fit their own needs. 1

Overview Map PRE-CONTRACT PHASE 1 PHASE 2 PHASE 3 GOVERNANCE Commit to pursue valuebased care Set objectives at the board level Design governance structure Identify value-oriented leaders Ensure multistakeholder input Identify and engage provider network Educate providers and staff Establish quality and leadership teams Report system and provider performance FINANCE HEALTH IT CARE DELIVERY Assess financial requirements Gain access to needed capital Create legal structure for financial collaboration READY FOR RISK-BASED CONTRACTS Build systems to track financial performance Asses current IT strategy Align incentives with value-based objectives Identify gaps in IT infrastructure Assess needs of the covered population Organize internal data assets Ensure access to care Develop strategy to assess individual needs Aggregate external data assets Identify individual patient needs Develop platform to house and analyze data Design systems to address patient needs Enable data sharing and access by care team Establish and maintain use of care guidelines Design care team Establish care team protocols Provide care team with data access and support Conduct ongoing patient outreach Implement shared care-planning and decision-making Monitor performance of financial contracts Monitor and report care delivery effectiveness Enable reporting and feedback INCREASING RISK OVER TIME 2

Competency List by Phase: Pre-Contract PRE-CONTRACT Commit to pursue value-based care G1 Align your organization s mission, vision, and strategy with value-based care and patient-centeredness objectives G2 Set clear goals and strategies for the board and organization to achieve within 12-18 month timeframes Set objectives at the board level G3 G4 G5 Set cost, quality and risk migration targets for the portfolio of business Include the quality improvement program in the strategic plan of the organization, including representation in the budgeting process Align quality improvement initiatives with ethical obligations G6 Set meaningful and appropriate goals for your quality improvement efforts and monitor and communicate your progress towards achieving those goals GOVERNANCE Design governance structure Identify value-oriented leaders G7 G8 G9 G10 G11 G12 Adjust board structure and bylaws to advance value-based agenda Document decision-making processes that align with the organization s value-based objectives Drive high value outcomes by providing adequate resources, monitoring return on investments, and directing the flow of funds Identify leaders who have proven reputation and abilities among peers to achieve value outcomes, carry out quality-improvement initiatives, and manage risk Invest in and monitor leadership development programs to build leaders who will propel the adoption of a value -based strategy Ensure that there is sufficient representation, through an advisory board or other means, of clinicians, community members, and patients throughout the governance structure of the organization G13 Ensure meaningful participation from providers currently practicing within the health system on steering committees G14 Select clinical and administrative champions that demonstrate a commitment to lead quality improvement efforts Ensure multistakeholder input G15 G16 Assign care provider champions to technology implementations Ensure meaningful participation from patient representatives on steering committees G17 Establish formal policies related to patient rights and responsibilities G18 Ensure meaningful representation from representatives of local community health organizations on steering committees G19 Ensure meaningful participation from payer partners on steering committees FINANCE Assess financial requirements F1 F2 F3 Understand the financial investment required to support the transition to value-based payment models Calculate the burn rate and break-even points for contracts under consideration Analyze and understand the potential for short- and long-term return on investment for risk-bearing contracts 3

Competency List by Phase: Pre-Contract, Continued PRE-CONTRACT, CONTINUED FINANCE GOVERNANCE FIN. Gain access to needed capital Identify and engage provider network Create legal structure for financial collaboration F4 G20 G21 G22 G23 G24 G25 F5 F6 F7 F8 Have access to the capital required to support the transition to value-based payment models Develop a strategy for provider membership and participation, including physician, hospital and service providers Identify resources to support providers and health care professionals in offering value-driven care Ensure meaningful participation from payer partners on steering committees Commit to a transparent organizational communication strategy related to improvement efforts for all stakeholders Collaborate and communicate frequently and effectively with value-focused partners across the healthcare spectrum Engage providers and health care leaders throughout all levels of the organization to carry out and drive value-based objectives Establish legal structures to receive and distribute shared savings payments to participating providers Develop the ability to distribute shared savings and performance-based payments to providers Prepare for and mitigate insurance risk to protect against catastrophic claims or expenses Align provider contracts with the aims of a value-based health system Secure value-based contracts F9 Negotiate value-based contracts that are informed by quality and cost performance data with payers and employers 4

Competency List by Phase: Phase 1 PHASE 1 G26 Offer care providers education concerning the aims and core characteristics of a value-based delivery system GOVERNANCE Educate providers and staff G27 G28 G29 G30 Offer leadership training for care providers assigned to leadership roles Offer patient experience training for providers and staff Offer training on team-based care for care providers on multi-disciplinary teams Train all types of providers and employees in improvement culture, improvement methodology, and their own role in quality G31 Develop leaders who are focused on patient-centered improvement efforts at all levels of the organization F10 Establish and maintain systems to track utilization, revenues, and costs when bearing financial risk FINANCE Build systems to track financial performance F11 F12 F13 Track encounter data across the organization Compare expected revenue to actual revenue from each source within, and outside of, the organization Calculate spending at an individual patient level HEALTH IT Assess current IT strategy HT1 HT2 HT3 Align the health IT strategy with overall organizational goals and objectives Assess the health IT strategy and infrastructure across the organization Analyze and mitigate privacy and security risks GOVERNANCE Establish quality and leadership teams G32 G33 G34 G35 Develop formal processes whereby interdisciplinary clinical and administrative teams integrate with one another Establish the organizational framework with the staff necessary to manage quality programs and support improvement activities Develop organizational expertise in a specific and actionable improvement model Build a team of clinical quality improvement experts to guide the work of improvement teams in your organization F14 Create, evaluate, and modify operation metrics, including financial incentives for executive leadership and providers, to reflect your value-driven strategy FINANCE Align incentives with value-based objectives F15 F16 F17 Design financial measures for a master population and important sub-populations using key clinical, socioeconomic and demographic factors Incentivize attention to the patient s overall health care experience Ensure all staff are in alignment with incentives to improve quality F18 Align executive compensation policies with value-based performance measures 5

Competency List by Phase: Phase 1, Continued PHASE 1, CONTINUED FIN. Align incentives with value-based objectives F19 F20 Align care provider compensation and incentives with value-based performance measures Reward quality improvement successes throughout the organization HEALTH IT Identify gaps HT4 HT5 HT6 HT7 Identify gaps in health IT infrastructure necessary to meet organizational goals and objectives Identify data and data sources needed for clinical care, priority programs, and processes Build appropriate staffing to maintain IT infrastructure Define platform requirements to support value based objectives CM1 Adapt risk assessment models in response to patient need, business use, or payment incentives CARE Assess the needs of the covered population CM2 CM3 Support multiple levels of analysis, such as population, provider, and individual patient levels of analysis Anticipate the care needs of the entire population CM4 Understand the unique cultural characteristics of the population served to implement changes in the organization to provide high-value care HIT Organize internal data assets HT8 Aggregate and normalize internally available data and information to allow for the provision of useful information 6

Competency List by Phase: Phase 2 PHASE 2 CM5 Provide convenient and timely access to care based on the needs of patients CM6 Increase access to primary care services (e.g., extended hours, nurse call lines, virtual visits, telehealth, and other non-visit based care and support) CM7 Provide 24/7 patient access to a clinician who can evaluate the patient s level of urgency and facilitate a timely and appropriate intervention Ensure access to care CM8 CM9 Offer access to and integrate with behavioral health services Offer access to palliative and hospice care services CARE DELIVERY CM10 CM11 CM12 CM13 Facilitate access to community resources and social support services Develop a process to leverage resources across the health care and social service spectrum based on the needs of your patient population Develop relationships on behalf of patients with community-based organizations and services Anticipate the care needs of individual patients Develop patient risk assessment strategy CM14 CM15 CM16 Identify the purpose and goals of patient risk assessment and develop a strategy for support which incorporates multiple data types, including administrative, clinical, socio-economic, social determinant and patient-reported data Develop a strategy for effectively assessing patient risk and supporting stratified care management and care coordination Determine which patients are appropriate for risk assessment based on the patient s health and utilization history, behavioral or mental health history, functional status, cognitive and physical abilities CM17 Establish a single, formal coding methodology across all organizations in the system and accurately code clinical services provided HT9 Develop a strategy to gather data and information from multiple sources, including structured and unstructured data HT10 Develop and implement processes to acquire and ingest claims data from all relevant payers HEALTH IT Aggregate external data assets HT11 HT12 HT13 HT14 Ensure access to critical data generated outside of the organization s network (e.g. hospital and commercial clinical laboratories, PH laboratories, and information on medications dispensed) Develop and implement process to acquire and ingest multiple data types such as: SDH, PGDH, VS from monitoring devices, PH, Social services, etc. Participate in data exchanges with local, state, and federal public health registries Ensure data and information is shared in accordance with all applicable privacy and security laws and regulations HT15 Ensure the data acquisition process continues uninterrupted HT16 Monitor data integrity and conduct periodic data quality audits to ensure accurate data 7

Competency List by Phase: Phase 2, Continued PHASE 2, CONTINUED CARE DELIVERY Identify individual patient needs CM18 CM19 CM20 CM21 CM22 Identify the rising risk index of patients and sub-populations on an on-going basis Identify diagnoses and patients health care and social support needs that both drive spending and are modifiable Evaluate factors that may increase patient risk, such as functional, cultural, socioeconomic and behavioral determinants of health, as well as health literacy, emotional support, and family/caregiver resources Use patient assessment tools that are tailored to the capabilities of the patient Enable user-defined variable weights and models for multiple care models or programs to address the diversities of populations served HEALTH IT CARE HEALTH IT Develop platforms to house and analyze data Design systems to address patient needs Enable data sharing and access by care team HT17 HT18 HT19 CM23 CM24 CM25 HT20 HT21 HT22 HT23 HT24 Develop a stable platform for information systems that is consistent and aligned with the organization s health IT strategy Establish a data repository that has timely clinical process and outcome data, cost data, and patient experience and safety data Create capability to leverage the data repository for quality improvement activities Identify opportunities for intervention that target modifiable behaviors and interventions based on specific patient needs and the organization s program model(s) Integrate patient risk data with appropriate clinical evidence-based guidelines Design care management systems that address both medical and social determinants of health Share patient specific data among authorized clinicians internal to the organization s network using any HIE, Direct messaging, shared screens, or any other available mechanism Share patient specific data among authorized clinicians, both internal and external to the organization s network through various HIE structures or direct messaging Ensure that all data use agreements and technical requirements are in place to enable sharing of patient specific health data between organization and external entities Utilize secure e-communications effectively with authorized patient and family/caregivers when not co-located Utilize secure e-communications effectively with the internal care team when not co-located HT25 Utilize secure e-communications effectively with external partners and stakeholders when not co-located CM26 Use evidence-based care guidelines to manage patients based on clinical severity CARE Establish and maintain use of care guidelines CM27 CM28 Use guidelines to avoid adverse drug events Use guidelines to avoid adverse impacts due to gaps in care CM29 Actively monitor whether clinical services correspond with nationally endorsed guidelines 8

Competency List by Phase: Phase 2, Continued PHASE 2, CONTINUED CM30 Develop care teams with well-defined roles and responsibilities for planning, coordinating, and assuming accountability for continuity of patient care across the continuum CM31 Ensure that the patient is at the center of the care team, which includes family/caregivers, multi-disciplinary health professionals, and community members who are focused on meeting the patient s goals Design care teams CM32 CM33 CM34 Ensure members of the care team have the necessary communication skills and cultural competencies to understand and collaboratively establish the patient s/caregiver s medical or non-medical goals and priorities Designate a primary coordinator of care to assure continuity throughout the continuum of care Implement methods for the care team to receive reliable and timely feedback on the functioning of the team and achievement of the patient s goals CM35 Ensure that staff-members are adequately trained on the use of evidence-based care protocols CM36 Ensure that patients, families, providers, and care team members are involved in quality improvement activities CM37 Assess and collaborate to reduce adverse events, prevent patient s functional decline, and prepare a streamlined, evidence-based plan of care CARE DELIVERY Establish care team protocols CM38 CM39 CM40 CM41 CM42 Ensure coordinated and seamless care for patients across all sites and care events Develop care transition protocols to reduce unnecessary emergency room visits and hospital admissions Provide continuity of care in a way that organizes services around the patient s physical, emotional and social needs Provide culturally competent care Develop, document, and follow effective communication protocols within and across care teams and partnering organizations CM43 Provide care teams with a single, comprehensive patient health record Provide care team with data access and support CM44 CM45 CM46 CM47 Integrate patient reported outcomes in clinical pathways Notify the care team of key patient activities (admission or discharge from a care setting, presents at ED, does not fill prescription, does not keep a referral) Provide point-of-care decision support tools for care providers Use up-to-date information on clinical findings, evidence-based research, and public health issues to guide interventions and activities CM48 Make risk assessment data available at the point of care (e.g. discrete, searchable fields and/or on the problem list in the EMR) Implement shared careplanning and decision making CM49 CM50 CM51 Assure the care plan is accessible by the care-team and contains the patient s most updated goals, preferences, advanced directives, results, and other relevant information Involve patients in all decisions relevant to their care Incorporate patients values, preferences, expressed needs, concerns and feedback into all care 9

Competency List by Phase: Phase 2, Continued PHASE 2, CONTINUED CARE DELIVERY Implement shared care-planning and decision making Conduct ongoing patient outreach CM52 CM53 CM54 CM55 CM56 CM57 CM58 CM59 CM60 CM61 CM62 CM63 CM64 CM65 Engage in a collaborative partnership approach for care decision-making and social support planning with patients and their family/caregivers Integrate appropriate legal procedures into operations (e.g. patient legal capacity for decision making, guardianship, consent, etc.) Identify gaps in patients understanding of conditions and treatments and empower patients with tools and strategies (e.g. disease-specific patient support services) to promote self-management Educate patients on wise use of health care services before and after clinical encounters Provide patients with personally relevant health education materials Provide patients with all relevant cost and coverage information at appropriate decision points Provide a comprehensive care summary to patients Conduct ongoing patient outreach programs to improve the health of the targeted population Encourage and enable patients to carry out self-management by providing HIPAA compliant information and tools Ensure that patients have secure access to their personal health information and care plans Develop monitoring system to track patient out-of-network utilization Share information with patients about gaps in care and suboptimal outcomes Offer or facilitate access to ongoing wellness classes and lifestyle change support groups Align with relevant public, community and employer health interventions to improve population health 10

Competency List by Phase: Phase 3 PHASE 3 GOV. Report system and provider performance G36 G37 Capture and report data relevant to cost, processes of care delivery, health outcomes, and patient experience in a standard manner Report quality performance to payers and other stakeholders F21 Monitor performance in current value-based contracts FINANCE Monitor performance of value-based contracts F22 F23 F24 Evaluate provider referral patterns Evaluate spending relative to quality performance Provide feedback to care providers on value-based performance measures that are outlined in compensation agreements CARE Monitor and report care delivery effectiveness CM66 CM67 Continually monitor care model effectiveness, leveraging data as well as feedback from care teams and patients Use clinical quality measures for performance management HT26 Assess effectiveness of current reports and modify as deemed necessary by internal users HT27 Identify key reports that various organizational stakeholders need to monitor the progress of their programs and processes HT28 Develop internal reports to monitor key indicators of quality, utilization, and costs HT29 Analyze data to create useful and/or actionable information that simultaneously supports performance improvement HEALTH IT Enable reporting and feedback HT30 HT31 HT32 Integrate cost, clinical data, and patient demographics into actionable reports Create a user-friendly report profile which is interactive and easily modifiable Allow segmentation by filters (e.g. payer, provider, health condition, psychosocial or behavioral health, etc.) HT33 Provide role-based access to transparent risk reports HT34 Share detailed reports, whether data and/or information at either a population, provider, or patient level, with authorized internal and external stakeholders HT35 Develop or purchase a reporting tool, such as a dashboard, that captures appropriate deviations and benchmarks, and share reports with the care team, patients and public HT36 Provide transparent cost, quality, and process data to internal and external stakeholders 11

Detailed Map ACCOUNTABLE CARE ATLAS PRE-CONTRACT PHASE 1 PHASE 2 Align your organization s mission, vision, and strategy with value-based care and patient-centeredness objectives GOVERNANCE FINANCE HEALTH IT CARE DELIVERY Set clear goals and strategies for the board and organization to achieve within 12-18 month timeframes Set cost, quality and risk migration targets for the portfolio of business Include the quality improvement program in the strategic plan of the organization, including representation in the budgeting process Adjust board structure and bylaws to advance valuebased agenda Document decision-making processes that align with the organization s value-based objectives Drive high value outcomes by providing adequate resources, monitoring return on investments, and directing the flow of funds Understand the financial investment required to support the transition to value-based payment models? Calculate the burn rate and break-even points for contracts under consideration Analyze and understand the potential for short- and longterm return on investment for risk-bearing contracts Identify leaders who have proven reputation and abilities among peers to achieve value outcomes, carry out qualityimprovement initiatives, and manage risk Align quality improvement initiatives with ethical obligations Set meaningful and appropriate goals for your quality improvement efforts and monitor and communicate your progress towards achieving those goals Ensure that there is sufficient representation, through an advisory board or other means, of clinicians, community members, and patients throughout the governance structure of the organization Invest in and monitor leadership development programs to build leaders who will propel the adoption of a value -based strategy Ensure meaningful participation from providers currently practicing within the health system on steering committees Ensure meaningful participation from patient representatives on steering committees Ensure meaningful representation from representatives of local community health organizations on steering committees Ensure meaningful participation from payer partners on steering committees Gain access to the capital required to support the transition to value-based payment models Select clinical and administrative champions that demonstrate a commitment to lead quality improvement efforts Assign care provider champions to technology implementations Ensure meaningful participation from payer partners on steering committees Ensure internal communication strategy that effectively aligns with organizational values and optimize operational processes Develop strategy for provider membership and participation, including physician, hospital and service providers Identify resources to support providers and health care professionals in offering value-driven care Establish legal structures to receive and distribute shared savings payments to participating providers Commit to a transparent organizational communication strategy related to improvement efforts for all stakeholders Collaborate and communicate frequently and effectively with value-focused partners across the healthcare spectrum Engage providers and health care leaders throughout all levels of the organization to carry out and drive value-based objectives Develop the ability to distribute shared savings and performance-based payments to providers Prepare for and mitigate insurance risk to protect against catastrophic claims or expenses Establish formal policies related to patient rights and responsibilities Negotiate value-based contracts with payers and employers that are informed by quality and cost performance data READY FOR RISK-BASED CONTRACTS Offer care providers education concerning the aims and core characteristics of a value-based delivery system Establish and maintain systems to track utilization, revenues, and costs when bearing financial risk Align the health IT strategy with overall organizational goals and objectives Offer leadership training for care providers assigned to leadership roles Offer patient experience training for providers and staff Offer training on team-based care for care providers on multidisciplinary teams Train all types of providers and employees in improvement culture, improvement methodology, and their own role in quality Develop leaders who are focused on patient-centered improvement efforts at all levels of the organization Track encounter data across the organization Compare expected revenue to actual revenue from each source within, and outside of, the organization Calculate spending at an individual patient level Adapt risk assessment models in response to patient need, business use, or payment incentives Assess the health IT strategy and infrastructure across the organization Analyze and mitigate privacy and security risks Develop formal processes whereby interdisciplinary clinical and administrative teams integrate with one another Establish the organizational framework with the staff necessary to manage quality programs and support improvement activities Support multiple levels of analysis, such as population, provider, and individual patient levels of analysis Identify gaps in health IT infrastructure necessary to meet organizational goals and objectives Develop organizational expertise in a specific and actionable improvement model Create, evaluate, and modify operation metrics, including financial incentives for executive leadership and providers, to reflect your valuedriven strategy Anticipate the care needs of the entire population Identify data and data sources needed for clinical care, priority programs, and processes Build appropriate staffing to maintain IT infrastructure Define platform requirements to support value based objectives Build a team of clinical quality improvement experts to guide the work of improvement teams in your organization Design financial measures for a master population and important subpopulations using key clinical, socioeconomic and demographic factors Incentivize attention to the patient s overall health care experience Ensure all staff are in alignment with incentives to improve quality Understand the unique cultural characteristics of the population served to implement changes in the organization to provide high-value care Aggregate and normalize internally available data and information to allow for the provision of useful information Align executive compensation policies with value-based performance measures Align care provider compensation and incentives with value-based performance measures Reward quality improvement successes throughout the organization Provide convenient and timely access to care based on the needs of patients Develop a strategy to gather data and information from multiple sources, including structured and unstructured data Increase access to primary care and specialty care (e.g., extended hours, nurse call lines, virtual visits, telehealth, and other non-visit based care and support). Provide 24/7 patient access to a clinician who can evaluate the patient s level of urgency and facilitate a timely and appropriate intervention Offer access to and integrate with behavioral health services Offer access to palliative and hospice care services Facilitate access to community resources and social support services Develop and implement processes to acquire and ingest claims data from all relevant payers Ensure access to critical data generated outside of the organization s network (e.g. hospital and commercial clinical laboratories, PH laboratories, and information on medications dispensed) Ensure data and information is shared in accordance with all applicable privacy and security laws and regulations Ensure the data acquisition process continues uninterrupted Monitor data integrity and conduct periodic data quality audits to ensure accurate data Develop a process to Develop relationships leverage resources across on behalf of patients the health care and social with community-based service spectrum based on organizations and the needs of your patient services population Identify the rising risk index of patients and Anticipate the care sub-populations on an needs of individual on-going basis patients Identify the purpose and goals of patient risk assessment and develop a strategy for support which incorporates multiple data types, including administrative, clinical, socioeconomic, social determinant and patient-reported data Develop a strategy for effectively assessing patient risk and supporting stratified care management and care coordination Determine which patients are appropriate for risk assessment based on the patient s health and utilization history, behavioral or mental health history, functional status, cognitive and physical abilities Establish a single, formal coding methodology across all organizations in the system and accurately code clinical services provided Participate in data exchanges with local, state, and federal public health registries Develop and implement process to acquire and ingest multiple data types such as: SDH, PGDH, VS from monitoring devices, Develop a stable platform PH, Social services, etc. for information systems Establish a data repository that is consistent that has timely clinical and aligned with the process and outcome data, organization s health IT cost data, and patient strategy experience and safety data Create capability to leverage the data repository for quality improvement activities INCREASING RISK OVER TIME Identify diagnoses and patients health care and social support needs that both drive spending and are modifiable Evaluate factors that may in-crease patient risk, such as functional, cultural, socioeconomic and behavioral determinants of health, health literacy, emotional support, and family/caregiver resources Use patient assessment tools that are tailored to the capabilities of the patient Enable user-defined variable weights and models for multiple care models or programs to address the diversities of populations served Identify opportunities for Design care management intervention that target systems that address modifiable behaviors and both medical and social interventions based on determinants of health specific patient needs and the organization s program model(s). Integrate patient risk data with appropriate clinical evidence-based guidelines Share patient specific data among authorized clinicians internal to the organization s network using any HIE, Direct messaging, shared screens, or any other available mechanism Share patient specific data among authorized clinicians, both internal and external to the organization s network through various HIE structures or direct messaging Ensure that all data use agreements and technical requirements are in place to enable sharing of patient specific health data between organization and external entities Utilize secure e-communications effectively with authorized patient and family/caregivers when not co-located Utilize secure e-communications effectively with the internal care team when not co-located Utilize secure e-communications effectively with external partners and stakeholders when not colocated Use evidence-b guidelines to m patients based o severit Develop care te well-defined ro responsibilities fo coordinating, and accountability for of patient care a continuu 12

Detailed Map, Continued PHASE 2 PHASE 3 Capture and report data relevant to cost, processes of care delivery, health outcomes, and patient experience in a standard manner Report quality performance to payers and other stakeholders Monitor performance in current value-based contracts Provide feedback to care providers on value-based performance measures that are outlined in compensation agreements Align executive compensation policies with value-based performance measures Align care provider compensation and incentives with value-based performance measures Evaluate provider referral patterns Evaluate spending relative to quality performance Reward quality improvement successes throughout the organization Provide convenient and timely access to care based on the needs of patients Increase access to primary care and specialty care (e.g., extended hours, nurse call lines, virtual visits, telehealth, and other non-visit based care and support). Provide 24/7 patient access to a clinician who can evaluate the patient s level of urgency and facilitate a timely and appropriate intervention Use evidence-based care guidelines to manage patients based on clinical severity Use guidelines to avoid adverse drug events Actively monitor whether clinical services correspond with nationally endorsed guidelines Assure the care plan is accessible by the care-team and contains the patient s most updated goals, preferences, advanced directives, results, and other relevant information Provide a comprehensive care summary to patients Offer access to and integrate with behavioral health services Offer access to palliative and hospice care services Facilitate access to community resources and social support services Develop a process to leverage resources across the health care and social service spectrum based on the needs of your patient population Develop relationships on behalf of patients with community-based organizations and services Use guidelines to avoid adverse impacts due to gaps in care Involve patients in all decisions relevant to their care Incorporate patients values, preferences, expressed needs, concerns and feedback into all care Engage in a collaborative partnership approach for care decision-making and social support planning with patients and their family/caregivers Develop a strategy to gather data and information from multiple sources, including structured and unstructured data Develop and implement processes to acquire and ingest claims data from all relevant payers Ensure access to critical data generated outside of the organization s network (e.g. hospital and commercial clinical laboratories, PH laboratories, and information on medications dispensed) Ensure data and information is shared in accordance with all applicable privacy and security laws and regulations Ensure the data acquisition process continues uninterrupted Monitor data integrity and conduct periodic data quality audits to ensure accurate data Identify the rising risk index of patients and Anticipate the care sub-populations on an needs of individual on-going basis patients Identify the purpose and goals of patient risk assessment and develop a strategy for support which incorporates multiple data types, including administrative, clinical, socioeconomic, social determinant and patient-reported data Develop a strategy for effectively assessing patient risk and supporting stratified care management and care coordination Determine which patients are appropriate for risk assessment based on the patient s health and utilization history, behavioral or mental health history, functional status, cognitive and physical abilities Establish a single, formal coding methodology across all organizations in the system and accurately code clinical services provided Participate in data exchanges with local, state, and federal public health registries Develop and implement process to acquire and ingest multiple data types such as: SDH, PGDH, VS from monitoring devices, Develop a stable platform PH, Social services, etc. for information systems Establish a data repository that is consistent that has timely clinical and aligned with the process and outcome data, organization s health IT cost data, and patient strategy experience and safety data Create capability to leverage the data repository for quality improvement activities INCREASING RISK OVER TIME Identify diagnoses and patients health care and social support needs that both drive spending and are modifiable Evaluate factors that may in-crease patient risk, such as functional, cultural, socioeconomic and behavioral determinants of health, health literacy, emotional support, and family/caregiver resources Use patient assessment tools that are tailored to the capabilities of the patient Enable user-defined variable weights and models for multiple care models or programs to address the diversities of populations served Identify opportunities for Design care management intervention that target systems that address modifiable behaviors and both medical and social interventions based on determinants of health specific patient needs and the organization s program model(s). Integrate patient risk data with appropriate clinical evidence-based guidelines Share patient specific data among authorized clinicians internal to the organization s network using any HIE, Direct messaging, shared screens, or any other available mechanism Share patient specific data among authorized clinicians, both internal and external to the organization s network through various HIE structures or direct messaging Ensure that all data use agreements and technical requirements are in place to enable sharing of patient specific health data between organization and external entities Utilize secure e-communications effectively with authorized patient and family/caregivers when not co-located Utilize secure e-communications effectively with the internal care team when not co-located Utilize secure e-communications effectively with external partners and stakeholders when not colocated Develop care teams with Ensure coordinated Provide care teams well-defined roles and and seamless care for with a single, responsibilities for planning, patients across all sites comprehensive patient coordinating, and assuming and care events health record accountability for continuity of patient care across the continuum Ensure that the patient is at the Develop care transition Integrate patient reported center of the care team, which protocols to reduce unnecessary outcomes in clinical includes family/caregivers, emergency room visits and pathways multi-disciplinary health hospital admissions professionals, and community members who are focused on Notify the care team of key meeting the patient s goals Provide continuity of care in patient activities (admission a way that organizes services or discharge from a care around the patient s physical, setting, presents at ED, does emotional and social needs not fill prescription, does Ensure members of the care not keep a referral) team have the necessary communication skills and Provide culturally cultural competencies to competent care Provide point-of-care understand and collaboratively decision support tools for establish the patient s/ care providers Develop, document, and follow caregiver s medical or nonmedical goals and priorities effective communication protocols within and across care teams and partnering Designate a primary organizations Use up-to-date information coordinator of care to assure on clinical findings, continuity throughout the evidence-based research, continuum of care and public health issues to guide interventions and activities Implement methods for the care team to receive reliable and timely feedback on the Make risk assessment data functioning of the team available at the point of care and achievement of the (e.g. discrete, searchable patient s goals fields and/or on the problem list in the EMR) Ensure that staff-members are adequately trained on the use of evidence-based care protocols Ensure that patients, families, providers, and care team members are involved in quality improvement activities Assess and collaborate to reduce adverse events, prevent patient s functional decline, and prepare a streamlined, evidence-based plan of care Integrate appropriate legal procedures into operations (e.g. patient legal capacity for decision making, guardianship, consent, etc.) Identify gaps in patients understanding of conditions and treatments and empower patients with tools and strategies (e.g. disease-specific patient support services) to promote self-management Conduct ongoing patient outreach programs to improve the health of the targeted population Encourage and enable patients to carry out selfmanagement by providing HIPAA compliant information and tools Ensure that patients have secure access to their personal health information and care plans Develop monitoring system to track patient out-of-network utilization Share information with patients about gaps in care and suboptimal outcomes Offer or facilitate access to ongoing wellness classes and lifestyle change support groups Align with relevant public, community and employer health interventions to improve population health Educate patients on wise use of health care services before and after clinical encounters Provide patients with all cost and coverage information at appropriate decision points Continually monitor care model effectiveness, leveraging data as well as feedback from care teams and patients Assess effectiveness of current reports and modify as deemed necessary by internal users Use clinical quality measures for performance management Identify key reports that various organizational stakeholders need to monitor the progress of their programs and processes Develop internal reports to monitor key indicators of quality, utilization, and costs Create a user-friendly report profile which is interactive and easily modifiable Allow segmentation by filters (e.g. payer, provider, health condition, psychosocial or behavioral health, etc.) Provide role-based access to transparent risk reports Develop or purchase a reporting tool, such as a dashboard, that captures appropriate deviations and benchmarks, and share reports with the care team, Integrate cost, clinical data, patients and public and patient demographics into actionable reports Provide transparent cost, quality, and process data to internal and external stakeholders Share detailed reports, whether data and/or information at either a population, provider, or patient level, with authorized internal and external stakeholders Analyze data to create useful and/or actionable information that simultaneously supports performance improvement 13

Example Checklist: Care Delivery PHASE 1 Assess the needs of the covered population CM1 CM2 CM3 CM4 PHASE 2 Ensure access to care CM5 CM6 CM7 CM8 CM9 Adapt risk assessment models in response to patient need, business use, or payment incentives Support multiple levels of analysis, such as population, provider, and individual patient levels of analysis Anticipate the care needs of the entire population Understand the unique cultural characteristics of the population served to implement changes in the organization to provide high-value care Provide convenient and timely access to care based on the needs of patients Increase access to primary care services (e.g., extended hours, nurse call lines, virtual visits, telehealth, and other non-visit based care and support) Provide 24/7 patient access to a clinician who can evaluate the patient s level of urgency and facilitate a timely and appropriate intervention Offer access to and integrate with behavioral health services Offer access to palliative and hospice care services CM10 Facilitate access to community resources and social support services CM11 Develop a process to leverage resources across the health care and social service spectrum based on the needs of your patient population CM12 Develop relationships on behalf of patients with community-based organizations and services Develop patient risk assessment strategy CM13 Anticipate the care needs of individual patients CM14 Identify the purpose and goals of patient risk assessment and develop a strategy for support which incorporates multiple data types, including administrative, clinical, socio-economic, social determinant and patientreported data CM15 Develop a strategy for effectively assessing patient risk and supporting stratified care management and care coordination This is a portion of a checklist for the Care Delivery competencies CM16 Determine which patients are appropriate for risk assessment based on the patient s health and utilization history, organized behavioral by phase. or mental Complete health history, functional status, cognitive and checklists physical abilities for each or the four Work Areas can be found at CM17 Establish a single, formal coding methodology across all organizations in the system and accurately code clinical www.accountablecarelc.org/atlas services provided Identify individual patient needs CM18 Identify the rising risk index of patients and sub-populations on an ongoing basis CM19 Identify diagnoses and patients health care and social support needs that both drive spending and are modifiable CM20 Evaluate factors that may increase patient risk, such as functional, cultural, socioeconomic and behavioral determinants of health, as well as health literacy, emotional support, and family/caregiver resources CM21 Enable user-defined variable weights and models for multiple care models or programs to address the diversities of populations served CM22 Use patient assessment tools that are tailored to the capabilities of the patient Design systems to address patient needs CM23 Identify opportunities for intervention that target modifiable behaviors and interventions based on specific patient needs and the organization s program model(s) CM24 Integrate patient risk data with appropriate clinical evidence-based guidelines CM25 Design care management systems that address both medical and social determinants of health Establish and maintain use of care guidelines CM26 Use evidence-based care guidelines to manage patients based on clinical severity CM27 Use guidelines to avoid adverse drug events 14

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