Health Share of Oregon Transformation Plan 3/8/2013

Health Share of Oregon Transformation Plan 3/8/2013

Contents Introduction... 1 Community Health Integration... 2 Goal 1: Improve Equity and Population Health Reduce health disparities, improving the quality of life for all members of Health Share and the tri-county community....2 Initiative #1: A Systemic Strategy for Cultural Competence...2 Initiative #2: Non-Traditional health workers for cultural groups...6 Goal 2: Prevent Chronic Disease Ensure that prevention-focused health care and community prevention efforts and services are available, integrated, and mutually enforcing....7 Initiative #1: Assess and align chronic disease prevention programs including evidence-based chronic disease self-management; tobacco use prevention; and weight management...7 Initiative #2: Develop a comprehensive chronic disease and health promotion action plan inclusive of addictions, mental health, physical health, and community health....8 Goal 3: Stimulate Innovation and Integration...9 Initiative #1: Facilitate systemic integration between patient-centered health homes and community-based public health and social services and resources to support healthy individuals and families....9 Initiative #2: Collaboration with First Responders in local jurisdictions in the tri-county area (Fire, Police, Ambulance, Crisis Response)... 10 Initiative #3: Collaborate with affordable housing stakeholders and assess supportive services for vulnerable populations and people with special health care needs.... 12 Initiative #4: Collaboration with school districts, early learning councils, other education-based organizations... 13 Goal 4: Engage and empower the community to impact health outcomes for OHP members and the population of the tri-county area.... 14 Initiative #1: Convene Health Share s Community Advisory Council (CAC)... 14 Initiative #2: Conduct a Community Health Needs Assessment and generate a Community Health Improvement Plan with CAC and community partners... 15 Initiative #3: Develop formal partnerships and with social and support services in the tri-county area... 16 Goal 1: Leverage the Health Commons Grant... 18 Initiative #1: Interdisciplinary Community Care Teams... 19 Initiative #2: Care Transitions Innovation... 20 Initiative #3: The Intensive Transition Team (ITT)... 20

Initiative #4: The ED Guides Program... 21 Initiative #5: The Transitions Standardized Discharge Program... 21 Goal 2: Identifying Additional Opportunities for Partner Organizations... 22 Initiative #1: The Regional Coordinated Care Management System... 22 Initiative #2: Patient Centered Primary Care Homes... 23 Goal 3: Behavioral Health Integration... 24 Goal 4: Building Community Partnerships... 27 Initiative #1: Incorporating Emergency Management Services... 27 Goal 5: Enhancing the Provider Network... 27 Goal 6: Simplifying the Ancillary Network... 29 Regional Health Information Technology... 31 Overview... 31 Expansion of Membership... 31 Delivery System Transformation... 32 Goal 1: Leverage the Health Commons Grant... 32 Goal 2: Support Partner Alignment Opportunities and Community Partnerships... 41 Goal 3: Support Behavioral Health Integration... 42 Goal 4: Enhance Risk / Payment Transformation... 42 Goal 5: Supplement Administrative Simplification Efforts... 43 Accountability... 44 Section 1- Reporting and Informatics... 44 Goal: As efficiently as possible, collect and accumulate data in order to effectively measure, analyze and report performance at multiple levels across the system to inform action and transformation 44 Section 2- Integration of the Quality Assessment and Performance Improvement System... 47 Goal: Develop a fully integrated quality improvement program that is in compliance with federal and state requirements while meeting the Triple Aim objectives utilizing a plan, do, study act (PDSA) methodology... 47 Section 3- Risk Transformation... 52 Goal: Create a global risk system and alternate payment methodologies that will enable Health Share to reward the transition from volume to value in order to achieve the Triple Aim... 52 Section 4- Administrative Simplification... 55 Goal: Develop an administrative system that minimizes duplication and cost while increasing performance and enhancing service to our members and providers... 55

Section 5-Standardized Regional Behavioral Health System... 61 Conclusion... 62 In development.... 62

Introduction Health Share s goal is to create a regional system of self-regulating and aligned service providers (physical, behavioral, addictions, oral and social service) who are committed to achieving the same Triple Aim measureable targets, but provide flexibility to achieve those targets based on creativity and knowledge of the needs of the members in their community. We envision a patient centric eco-system focused on the member to identify and align the service needs in the tri-county communities. Health Share defines Transformation for the Tri-County region as providing a community based, patient-centered system that members can access through any door, which opens a gateway and connection to all services. Working together, this community-based approach will define how to pay for value and how to maximize finite health care resources. This in turn will deliver the anticipated outcomes that will bend the cost curve and support the best possible health for all members. Due to the complexity and dependencies of the work Health Share is trying to accomplish, we have chosen to organize our transformation initiatives into four areas of focus: Community Health Integration Delivery System Transformation Regional Health Information Technology Accountability The over-arching goal is to deliver the best possible outcomes through the management of finite resources. This will be accomplished by aligning all of the community resources physical, capital, and human to make the necessary system, process, and engagement changes to address the cost, quality, access and equity challenges we face in today s health care environment. NOTE: Health Share will work collaboratively with the Oregon Health Authority to agree upon the final set of metrics/benchmarks to be used for accountability and status reports. Benchmarks listed in the Transformation Plan are illustrative and require refinement and calculation of baseline measurements. 3 February 2015 Page 1 of 62

Community Health Integration Goal 1: Improve Equity and Population Health Reduce health disparities, improving the quality of life for all members of Health Share and the tri-county community. (CCO Elements 1, 6, 7, 8) Initiative #1: A Systemic Strategy for Cultural Competence (CCO Elements 6, 7, 8) Current State: Each affiliate within Health Share has its own approach to providing culturally competent care. The types of health outcomes that Health Share is attempting to accomplish are dependent on these competencies. Currently there is no alignment on approaches or minimum standards for cultural competence and appropriate attention to health literacy in member collateral, patient educational materials, and trainings for providers and staff of the Coordinated Care Organization. Future State: Health Share will implement a Systemic Strategy for Cultural Competence with input and participation from cultural competence thought leaders from community organizations and coalitions, Health Share affiliates, members of the Community Advisory Council, members of the Quality Improvement Committee, Cultural Competence Workgroup, CMO Workgroup, Health Share s leadership team, and Health Share members. Because of the geographic diversity and subsequent cultural diversity of the region served by Health Share s providers, the approaches to cultural competence for providers in Health Share s network will necessarily be different across the network, but will meet standards set out by the CCO to ensure that member communications and engagement are tailored to cultural, linguistic and health literacy needs. The core outcomes of the strategy will be: 1. Improved outcomes across specific metrics that demonstrate impact on health disparities 2. Alignment on mission, goals, and outcomes concerning cultural competence and health equity across Health Share affiliates and sub-contracted organizations 3. Integration of culturally competent practices within all of Health Share s activities and programs including community health strategies, member education and assistance, patient-centered primary care homes, and the integration of cultural competency in the evaluation metrics of existing programs 4. Data collection, analysis, and sharing agreements to improve understanding of Health Share s member population to guide development of strategies 5. Development or identification of culturally competent recruitment policies, training curriculum, performance expectations, and quality improvement systems that ensure accountability for the delivery of culturally sensitive and linguistically appropriate care and reduction of health disparities 3 February 2015 Page 2 of 62

6. Diverse community representation and participation on planning and advisory groups Benchmarks: CAHPS composite (access to care and satisfaction with plan customer service) and CAHPS functional status (member health status); Reduction of disparities; Ratio of members of the health plan to members participating in services measured by race and ethnicity; Number of services received (visits) by race and ethnicity by diagnostic code; Initial engagement New diagnosis for selected chronic diseases presentation for follow-up care within a 4-6 or 12 month time frame, analyzed by race/ethnicity; % of new employees trained in cultural competence, and % of employees receiving annual continuing education in cultural competence; Complaints driven in any part by care and services that did not meet members cultural and linguistic needs. Contract Benchmark: CAHPS Cultural Competence Item Set Process: Health Share staff will initiate the following strategic actions: 1. Convene a tri-county Cultural Competence Workgroup and develop a Cultural Competence Workgroup Charter to facilitate formal collaborative partnerships with cultural competence thought leaders, coalitions, organizations, and stakeholders. Outcomes: The Cultural Competence Workgroup will provide collective leadership from partner organizations, community organizations and leaders, and consumers for the cultural competency and health equity work of Health Share. The work group will be actively involved in the development of strategies relating to the Systemic Strategy for Cultural Competence. Timeline: October 2012: A small committee of representatives from each county s health and/or mental health departments who work on cultural competency met twice with Health Share staff to facilitate development of the Cultural Competence Workgroup s Charter, tasks and responsibilities, and membership. November-December 2012: 25 workgroup members were recruited from affiliate organizations, culturally specific provider groups, and culturally-specific community based organizations and the charter was finalized. February 26, 2013: Workgroup convenes. Key staff, partners, or committees: Health Share leadership and community partners, affiliate organizations designated internal champions and staff with dedicated time in their work plans to implement the work across the system. 2. Conduct a cultural competence needs assessment. No current community-wide standards exist to evaluate whether or not health care organizations are providing care that is adequately tailored to members cultural, linguistic, or health literacy needs. In conjunction with action #3 below, Health Share s Cultural Competence Workgroup will conduct a cultural competence needs assessment across affiliate organizations to identify areas in which affiliate partners need to improve in order to meet community-wide cultural competence standards. Based on this needs assessment, affiliate organizations will develop strategies to address gaps in current cultural competence activities, and meet the minimum standards for affiliate organizations 3 February 2015 Page 3 of 62

Outcomes: Health Share s contract with OHA describes responsibilities related to culturally and linguistically appropriate care in several areas, including Patient Rights and Responsibilities, Engagement, and Choice; Access to Care; Delivery System and Provider Capacity; Delivery System Features; Delivery System Dependencies; Health Promotion and Prevention; and Health Equity and Elimination of Disparities. In order to assess the current state of cultural competency within Health Share, an environmental scan and assessment of needs at the organizational level is necessary. Examples of areas of focus include workforce diversity and culturally-specific clinical health providers, member engagement activities and communications, and other areas of interest where mutually identified goals amongst Health Share s affiliates will be beneficial. Coordination of this task will be among the first actions taken by the Cultural Competence Workgroup, which will be comprised of leaders from each of Health Share s affiliates as well as members and other community stakeholders. Timeline: January 2013 - June 2014: planning and coordination with the Cultural Competence Workgroup to identify the goals, process, and outcome of the organizational environmental scan and needs assessment and administer the assessment. By July 2014, each organization will have developed plans to address areas of poor performance. Key staff, partners or committees: Health Share leadership, Cultural Competence Workgroup, affiliate organizations designated internal champions and staff with dedicated time in their work plans to implement the work across the system. 3. Develop and reach consensus on definitions, principles, and benchmarks associated with providing culturally competent Member-centered care, adopt community wide cultural competence standards. Outcomes: Alignment is reached concerning definitions, principles, benchmarks to serve as a baseline for agreement on future actions conducted by Health Share and our partners to improve health equity and cultural competency. These will be recommended to the CAC and Board for approval and adoption. The result is that performance standards for functions are uniform for all entities performing the function within Health Share. Health Share supports all its affiliate organizations in achieving cultural competency, as well as supporting culturally specific programs and agencies. Timeline: The Cultural Competence Workgroup will lead this effort beginning in March 2013 and complete a document or tool by end of 2013. Key staff, partners or committees: Health Share staff, Cultural Competency Workgroup, affiliate organizations designated internal champions and staff with dedicated time in their work plans to implement the work across the system, CAC, Board 4. Survey members who file complaints regarding interactions with Providers/Plan/Staff, Consumer Rights, and Plan/Provider Bias Measures to garner additional information about care and services that did not meet their cultural and linguistic needs. Outcomes: Survey developed to garner further information from members who file complaints to determine how many complaints were driven in any part by care and services that did not meet 3 February 2015 Page 4 of 62

members cultural and linguistic needs. Mechanism is developed for addressing member complaints having to do with care and services not being tailored to members cultural and linguistic needs. Complaints are tracked and frequency of complaints and their resolution is reported quarterly, Health Share is able to identify areas of need within partner organizations and develop strategies to address those needs. Reports issued quarterly to Health Share s Quality Assurance and Performance Improvement Committee. Timeline & Process: July 2013-July 2014: Survey developed to garner further information from members who file complaints to determine how many complaints were driven in any part by care and services that did not meet members cultural and linguistic needs. Any member who filed a complaint will receive survey. Concurrently, a mechanism will be developed for addressing member complaints having to do with care and services not being tailored to members cultural and linguistic needs, and tracking and reporting on frequency and resolution of these complaints. Key staff, partners or committees: Health Share Quality Improvement and Performance Management staff, Cultural Competency Workgroup, affiliate organizations designees, CAC. 5. Ensure that Health Share member data including racial, ethnic, educational attainment, sexual orientation, disability and socio-economic information are comprehensively collected in a culturally competent manner. Outcomes: Standardized race/ethnicity/language (REL) data collection and/or the development of disparities-sensitive measures or tools (such as consumer surveys, disease prevalence data analyzed by race and ethnicity, etc.) are used to assess cost, quality and access to track health disparities, justify initiatives to advance health equity, and adopt payment reforms that use data-driven equity performance measures. Quality improvement systems ensure that Health Share provides evidencebased care in a culturally and linguistically appropriate manner. Established metrics are appropriate for culturally-specific communities. Timeline: Health Share staff has consulted with multiple community partners and our affiliates to gain an understanding of quality improvement activities around data gathering and best practices currently in use. In December 2012, Health Share leadership met with staff from the Oregon Health Authority s Office of Equity and Inclusion and co-chairs and the project manager of the 4-County Community Health Needs Assessment to gather information about measures and tools that will align with OHA s plans for promoting culturally competent care across CCOs. Following this, planning and coordination between Health Share s leadership and the Cultural Competence Workgroup and outreach among additional community partners will be ongoing. Goals and actions will be identified by June 2013 with a specific work plan mapped by December 2013. Key staff, partners or committees: Health Share leadership staff including Chief Information Officer, Compliance Manager; Cultural Competence Workgroup, affiliate organizations designated internal champions and staff with dedicated time in their work plans to implement the work across the system. 5. Identify and implement culturally competent recruitment and cultural competence training for Health Share employees and infuse cultural competence measures and standards in performance reviews. 3 February 2015 Page 5 of 62

Outcomes: Health Share Leadership team and Office Manager will coordinate to ensure health equity and cultural competency is a component of Health Share s employee training plans and performance reviews. Health Share will assess its strategy for recruiting and retaining a culturally diverse workforce and enhance or adjust its procedures to achieve this objective. Timeline: Training curriculum, a self-assessment tool or other assessments will be identified prior to June 2013. Adoption of the tool will begin following approval by CEO by December 2013. Key staff, partners or committees: Health Share Leadership, Office Manager. 6. Design or identify Member-centered cultural competence curriculum. Outcomes: Curriculum will be identified and initial pilot projects developed during 2013 with both clinical and non-clinical staff, beginning with using data on which culturally-specific populations are served by individual provider networks in order to create tools for communication with members in a culturally appropriate way about care coordination and provider and member responsibilities in assuring effective communication. Curricula will be at or above national standards for culturally and linguistically appropriate services (CLAS). Health Share will provide support to increase diversity of primary care providers, recruit and train community health works to provide education and outreach to diverse communities. Health Share will provide health equity data and cultural competence education for planning and to inform and educate groups including the Community Advisory Council (CAC). Timeline: Planning and scoping initiated by second quarter of 2013, following the results of the organizational environmental scan and assessment, and additional planning and scoping of project through December 2013. Key staff, partners or committees: Health Share s CAC, staff, Cultural Competence Workgroup, affiliate organizations designated internal champions and staff with dedicated time in their work plans to implement the work across the system. Initiative #2: Non-Traditional health workers for cultural groups (CCO Elements 1, 6, 7, 8) Current State: Many of Health Share s affiliate organizations employ non-traditional health workers (NTHWs), some of whom do targeted work with culturally-specific communities. However, there are currently no culturally specific workers that can be deployed across the system as a whole to coordinate care for members from specific cultural groups. There are still many unanswered questions about how CCOs will be able to pay for the services of or directly employ non-traditional health workers, as well as how data will be shared amongst and between community-based organizations and providers. Future State: Community Health Workers and other non-traditional health workers, including those based in culturally-specific community organizations, will coordinate care for high-utilizing Medicaid patients with chronic conditions, providing patient education about disease management, treatment plan development, appointment scheduling, assistance in navigating Mental Health and health-care systems, family-centered support, and addressing social determinants of health. 3 February 2015 Page 6 of 62

Benchmarks: Non-Traditional health workers will appropriately reflect the cultural groups being served. Process: Health Share staff will work with affiliates, the State Office of Equity and Inclusion, NTHW professional associations, and partner organizations that employ NTHWs to assess current programming across our community partners and affiliates. Health Share will pilot the use of culturally-specific Community Health Workers based on lessons learned from the Interdisciplinary Community Care Teams, clinical data on health outcomes across the community, and the Community Health Needs Assessment. Timeline: October - December 2012: Health Share staff met with key informants from the Oregon Community Health Worker Association, the State Office of Equity and Inclusion, Culturally Specific Community Based Organizations, the tri-county Public Health Departments and Mental Health Authorities and affiliates who currently employ culturally specific Community Health Workers to design a pilot project. By March, 2013: Pilot project will be reviewed by Health Share s Community Care Team, Clinical leadership, Cultural Competence Workgroups and Compliance and Quality Improvement Committee. Pilot initiated June of 2013 with plans for additional planning and scoping of project later in 2013. Key staff, partners or committees: Health Share staff, Cultural Competence Workgroup, culturallyspecific Community-based organizations, Oregon Community Health Worker Association, affiliate organizations designated internal champions and staff with dedicated time in their work plans to implement the work across the system. Goal 2: Prevent Chronic Disease Ensure that prevention-focused health care and community prevention efforts and services are available, integrated, and mutually enforcing. (CCO Elements 4, 6, 7) Initiative #1: Assess and align chronic disease prevention programs including evidencebased chronic disease self-management; tobacco use prevention; and weight management. (CCO Element 4) Current State: Four of the most prominent chronic diseases cardiovascular disease (CVD), cancer, chronic obstructive pulmonary disease (COPD) and type 2 diabetes are linked by common and preventable biological risk factors, notably high blood pressure, high blood cholesterol and overweight, and related major behavioral risk factors. These include unhealthy diet, physical inactivity, and tobacco use. Action to prevent these major chronic diseases among Health Share members should focus on controlling these and other key risk factors in a well-integrated manner. Future State: Chronic Disease Self-Management, Tobacco Use Prevention, and Weight Management Programs are available in areas of highest need, and are covered benefits for Health Share members. Benchmarks: Rate of tobacco use; obesity and adolescent well-care visits; optimal diabetes care; weight assessment and counseling for nutrition and physical activity for children/adolescents. 3 February 2015 Page 7 of 62

Process: Health Share Staff will identify stakeholders from affiliate and community partner organizations and convene a team to assess and evaluate current community initiatives available to members or covered under RAE s benefits. Health Share staff will recommend actions to facilitate access and promotion of programs across Health Share s affiliates/raes and create a policy requiring a certain level of coverage of these services across our affiliate provider network. Timeline: Health Share staff met with key informants in the Helping Benefit Oregon Smokers Collaborative in September 2012 to initiate a partnership to address tobacco cessation coverage. Staff met with Oregon Public Health Division s Center for Prevention and Health Promotion staff in November of 2012 to align Health Share prevention efforts with statewide planning around chronic disease prevention and self-management. Within the first quarter of 2013 Health Share staff will convene chronic disease prevention experts from the tri-county local public health authorities to gather information about resources available in the community and best practices. By June 2013, Health Share staff will work with RAEs to administer self-assessments of benefits available to Health Share Members. Following completion of assessments, Health Share Staff will convene appropriate staff from RAEs to analyze self-assessments, available resources and best practices and recommend strategic actions to be taken across the system, completed by end of 2013. Initiative #2: Develop a comprehensive chronic disease and health promotion action plan inclusive of addictions, mental health, physical health, and community health. (CCO Elements 6, 7) Current State: Chronic diseases are the leading causes of death and disability worldwide. Modifiable health risk behaviors such as lack of physical activity, poor nutrition, tobacco use, excessive alcohol consumption, and the environmental factors that contribute to them are linked to the causes of these preventable diseases. Future State: Health Share will engage key stakeholders to develop a comprehensive chronic disease and health promotion action plan inclusive of multiple areas of health in order to assure appropriate strategies and messaging. Health Share staff will utilize an evidence-based public health (EBPH) approach that seeks to integrate science-based interventions with community preferences for improving population health. Key elements of EBPH are engaging the community in assessment and decisionmaking, using data and information systems systematically, making decisions on the basis of the best available peer-reviewed evidence (both quantitative and qualitative), applying program-planning frameworks, conducting sound evaluation, and disseminating what is learned. Through utilizing this framework, the comprehensive action plan will be inclusive of mental and physical health and addictions and will align where appropriate with the chronic disease and health promotion plans identified by the Oregon Health Authority. Initiatives will include Alcohol and Drug Abuse Prevention and Early Identification and Intervention Programs. Prevention strategies for members with co- or tri-morbidities and/or a history of trauma will use a trauma-informed framework. All strategies will be communitybased and will involve key stakeholders including members. The action plan will also align with the Systemic Strategy for Cultural Competence, and will include health disparities-sensitive measures and outcomes. 3 February 2015 Page 8 of 62

Partnerships with community organizations to draft and/or enact the comprehensive action plan are a key component for successfully impacting chronic disease at the community level. Please refer to Goal 4 Initiative 3 for the strategy for community partnerships. Benchmarks: Rate of tobacco use; obesity and adolescent well-care visits; optimal diabetes care; weight assessment; and counseling for nutrition and physical activity for children/adolescents; rate of SBIRT or referrals for addictions or mental health treatment. All benchmarks would ideally be calculated based on member s Race, Ethnicity, Language (REL) or presence of Serious and Persistent Mental Illness (SPMI). Process: Health Share Staff will identify stakeholders from affiliate and community partner organizations and convene a team to assess and evaluate current community initiatives available to members or covered under RAE s benefits. Health Share staff will recommend actions to facilitate access and promotion of programs across Health Share s affiliates/raes and create a policy requiring a minimum level of coverage of these services across our affiliate provider network. Timeline: Within the first quarter of 2013 Health Share staff will convene chronic disease prevention experts from the tri-county local public health authorities to gather information about resources available in the community and best practices. Health Share Staff will convene appropriate staff from RAEs to analyze self-assessments, available resources and best practices and recommend strategic actions to be taken across the system, completed by end of 2013. A comprehensive action plan will be completed by end of 2013. Goal 3: Stimulate Innovation and Integration (CCO Elements 1, 6) Initiative #1: Facilitate systemic integration between patient-centered health homes and community-based public health and social services and resources to support healthy individuals and families. (CCO Elements 1, 6) Current State: Health Share is informally involved with local initiatives that are convening to coordinate health, mental health, addictions and social services in high needs neighborhoods within the tri-county region where Health Share members live. Health Share staff have begun a partnership with United Way of the Columbia Willamette and Northwest Health Foundation with the goal of fostering the success of community-based initiatives designed to improve health outcomes through the integration of medical care, social services, and other upstream supports by developing a learning community, identifying the core elements of success, such as data sharing across systems, and a common narrative about the benefits to families and individuals and cost savings to the community associated with integration. Health Share Staff have also begun to facilitate conversations in neighborhoods that are hot spots such as Old Town/China Town in Portland, to identify opportunities where data sharing, collaboration, and alignment of funding and/or programming activities between agencies could produce more personcentered delivery of services, reduce emergency room visits and use of other high acuity settings and reduce cost of care. 3 February 2015 Page 9 of 62

Future State: Health Share members and providers that serve members, including non-traditional health workers and peer support workers, benefit from coordination and integration of medical care, mental health and addictions care, social services, and other upstream supports. Efficient and effective referrals processes are used to refer members across medical, mental and behavioral health and social services systems. Information exchange between health and social service providers is a core element of service coordination. Benchmarks: All cause readmission rate; primary care sensitive hospital admissions; care plan for members with long-term care benefits; planning for end-of-life care; follow up after hospitalization for mental illness. Process: United Way and Northwest Health Foundation have hired a consultant to engage in a mapping exercise to identify existing initiatives intended to coordinate services and areas where there is interest in developing collaborations across service providers but no firm plans in place to do so. From this mapping process, will develop a collaborative learning environment comprised of initiatives working toward the goal above, to support cross pollination of ideas, create a common language, and foster their success. Timeline: The mapping process is currently being drafted by consultants, with input from Health Share and our partners and took place in the last quarter of 2012. Convening geographically-based integration initiative project leads will begin in the first quarter of 2013. A rapid-cycle improvement process within and across initiatives willing to participate is planned for the second quarter of 2013. Initiative #2: Collaboration with First Responders in local jurisdictions in the tri-county area (Fire, Police, Ambulance, Crisis Response) (CCO Element 1) Current State: People in crisis in the region often experience unnecessary, preventable police contact, and are often transported to emergency departments for care, which could be provided in a more appropriate setting. Studies show that violent incidents are strongly correlated with intoxication independent of mental illness, which is one example of the complexity of the work of crisis responders and health care providers serving those in crisis. People with unmet health and social needs are often transported to the hospital by First Responders when their needs could be met in primary care, urgent care, mental health, or community settings. Future State: Increased coordination among partners will improve services to people in crisis by providing appropriate care management support services and reducing contact with First Responders. There will be increased ability for First Responders to appropriately triage people in mental health crisis, including those related to substance use, resulting in decreased inappropriate ED use, diversion from hospitalization, and reducing police contact and jail. People with unmet health and social needs will be connected with ED Navigators or ICCT staff to support their engagement in more appropriate health care delivery settings. 3 February 2015 Page 10 of 62

Benchmarks: Total emergency department utilization; potentially avoidable emergency department visits; follow-up after hospitalization for mental illness; alcohol or other substance misuse screening (SBIRT); Process: Health Share staff have begun gathering information and building relationships with city and county crisis responders in the region and identifying potential areas of collaboration that will include possible data sharing between systems, identification of hot spots where Health Share members are utilizing emergency services and encountering first responders in ways that could be prevented through more coordinated care and service provision. Additionally, an Emergency Medical Services Workgroup has been formed, with the following preliminary objectives; 1. Review data to understand frequent users of EMS and assess current activities focused on that population in order to align efforts, develop and share best practices, and solve system wide challenges. a) Share current needs, gaps and best practices within each county b) Recommend strategy for leveraging opportunities with Health Commons grant. 2. Understand the needs of low acuity users of the EMS system. Identify, plan and test chosen system adaptations that address the needs of low acuity users of the EMS system. a) Identify and study the low acuity Medicaid population medical acuity, service needs, transport patterns, hospital evaluation/cost, outcome of calls, and follow up care b) Based on findings from above, identify potential EMS system adaptations, ways to coordinate with other providers, and determine demonstration projects within four meetings. c) Deploy a minimum of two demonstration projects within six months that focus on alternative triage, response and/or transport of low acuity clients. d) Analyze demonstrations to determine medical and social outcomes along with costs impacts on the system and individual providers. e) Discuss current pilots or innovations in the region to study, learn and explore spreading of best practices. 3. Establish data and information sharing agreements with hospitals and other health care providers to improve coordination and quality of care and to study the continuum of care provided to low acuity users of EMS within six months. Timeline: Workgroup kickoff, January 2013 Identify and analyze adaptation recommendations, March-April 2013 Partners decide on demonstration project, May 2013 Demonstration launched, June 2013 Adapt demonstration, August 2013 and ongoing 3 February 2015 Page 11 of 62

Initiative #3: Collaborate with affordable housing stakeholders and assess supportive services for vulnerable populations and people with special health care needs. (CCO Element 1) Current State: Preliminary data indicates that some of the highest rates of crisis calls come from affordable housing sites. Reducing unnecessary acute and crisis care is a key strategy in achieving Health Share's goal of reducing cost and improving care and health outcomes. Affordable housing includes rent subsidized housing (Section 8, etc.), transitional shelter, permanent supportive housing, group homes, assisted living facilities, or any other housing provided with financial or other assistance. Supportive services for people living in affordable housing are not aligned system-wide, and may not be provided at all in some cases. Some housing sites benefit from a wide array of social services, while others have very few if any. An integrated approach is necessary to assure that vulnerable people in affordable housing are supported to maximize their health and well-being. Future State: Vulnerable community members living in affordable housing have the services they need to have the best possible health outcomes and the least possible need for acute care services. Starting in 2014 through ACA expansion, Health Share anticipates that its membership will grow significantly, including the expansion of OHP coverage to almost all people who are homeless or living in affordable housing. Through assessment and coordinated provision of care for this unique population, Health Share will be better prepared to meet the needs of our community, including those who are not insured or who may be eligible for OHP in the future, while reducing demand for acute and emergency services. Benchmarks: Total emergency department utilization; potentially avoidable emergency department visits; follow-up after hospitalization for mental illness; alcohol or other substance misuse screening (SBIRT); primary-care sensitive hospital admissions; Patient Centered Primary Care Home enrollment; Process & Timeline: A Supportive Housing Workgroup was convened in August 2012 and now meets monthly. Initial work focuses on identifying sites where vulnerable people are living (as indicated by high levels of acute care utilization), and engaging in systems improvements to provide more comprehensive and effective care. Given the complexity and acuity of the individuals who live in affordable housing, the premise of the group is that a significant number of these crises may be due to lack of available lower acuity social and clinical services. Working in partnership with the affordable housing community, the group will test this premise by doing an exploratory assessment of the use of crisis services in 6-10 housing units across the Tri County Area. This exploratory assessment will take place from December 2012 to March 2013 or earlier. The workgroup will present its findings and recommendations for possible interventions to the Health Share executive leadership and the CMO Workgroup by March 2013. In addition to the exploratory assessment, the Supportive Housing Workgroup will address the following three areas for strategic planning in alignment with Health Share s triple aim objectives over the next 18 months (through June 2014): 3 February 2015 Page 12 of 62

1. Explore the potential for re-purposing of existing affordable housing units for Health Share members with special health care needs or who are identified as high utilizers of acute medical services needing supportive housing. 2. Establish a path or strategy to align investments in housing with the imperatives of Health Share by coordinating and communicating with housing funders and providers in the tri-county. 3. Establish future housing development goals for high need, high impact populations including Health Share members and the high risk uninsured anticipated to become members through ACA expansion in 2014. Outcomes: Health Share coordinates with affordable housing providers to implement a traumainformed and culturally appropriate mechanism for assessing and identifying ongoing health care needs for vulnerable people, particularly those with special health care needs, who live in affordable housing. Increased coordination between affordable housing stakeholders and Health Share leadership results in better mechanisms for providing care, resulting in better health outcomes for vulnerable people and saved money due to decrease in demand for acute and emergency medical services. Health Share coordinates with affordable housing providers and funders to establish a mechanism for alignment in investments in housing, resulting in better coordination and efficient use of funds. Existing affordable housing units are utilized more appropriately for members with high needs, resulting in reduced use of acute and emergency medical services and better health outcomes. Health Share coordinates with affordable housing providers and funders to develop a set of goals and initiatives for 2014. Initiative #4: Collaboration with school districts, early learning councils, other education-based organizations (CCO Element 1) Current State: Health Share staff has met with leadership from school districts, leadership from the Governor s Early Learning Councils and other organizations and coalitions with a stake in education and school health to develop relationships and begin assessing opportunities for collaboration and understanding our stakeholders throughout the tri-county region. Future State: Partnering with families while incorporating the resources of the Early Learning Councils in the tri-county region, collaborating with organizations supporting health in schools such as partners involved with the Healthy Kids Learn Better Coalition, partnering with school nurses, school-based health centers, and Oregon Pediatric Improvement Project; identifying projects or opportunities for ongoing partnerships where goals align between partners to improve the health outcomes of youth, particularly those who are Health Share members. Increased coordination of mental health services and youth peer support with educational systems. Benchmarks: Developmental screening by 36 months; adolescent well care visits; childhood immunization status; well-child visits and adolescent well-care visits; follow-up care for children prescribed attention deficit hyperactivity disorder medication; CAHPS 4.0H (children with chronic conditions supplemental items); 3 February 2015 Page 13 of 62

Process & Timeline: Planning meetings to initiate pilot project between school nurses and pediatric providers occurred in October and November of 2012. Planning will continue through first quarter of 2013. Early Learning Council and Oregon Pediatric Improvement Project representatives met with Health Share leadership to identify areas of collaboration to benefit Health Share members in the last quarter of 2012. Pilot project planning and implementation will take place through 2013. Goal 4: Engage and empower the community to impact health outcomes for OHP members and the population of the tri-county area. (CCO Elements 1-8) Initiative #1: Convene Health Share s Community Advisory Council (CAC) (CCO Elements 1, 4, 6, 7, 8) Current State: Chartered by the Health Share Board of Directors, the CAC is comprised of nine Medicaid consumer members and eight community members, including an appointed representative from each county. Members represent the diversity of the community, including: race/ethnicity, age, gender identity, sexual orientation, disability, and geographic location. The CAC has regular monthly meetings open to the public and allow for public comment during a specified time. The Council is guided by an Executive Committee. The CAC Chairperson serves on the Health Share Board of Directors by virtue of the office. Health Share has designated a Community Engagement Program Coordinator to serve as the primary, supportive liaison between the organization and the CAC. Future State: The CAC provides advice and recommendations to the Health Share Board of Directors on the strategic direction of the organization, including Health Share s: Strategic Plan, Quality Improvement Plan and Transformation Plan. The CAC is represented in workgroups/committees that influence the strategic direction of the organization, including: Communications Workgroup, CMMI Oversight Team, CMMI Steering Committees, CMO Workgroup, Community Health Needs Assessment Regional Workgroup, Cultural Competence Workgroup, Operations Workgroup and the Supportive Housing Workgroup. Additionally, the CAC will regularly: identify and advocate for Health Share preventative care practices, maximize engagement of those enrolled in the OHP, provide feedback to Health Share about strategies to engage the community in CCO planning, help Health Share link the community s medical and non-medical services, and provide a link back to community constituents to aid in achieving the Health Share Mission, Vision and Goals. In order to achieve its goals, the CAC will also convene temporary and/or permanent sub-committees to deal with specific projects and subject matters. Benchmarks: Community Advisory Council initiatives are sustained and membership is expanded as appropriate; satisfaction surveys of CAC members report high degrees of satisfaction. Process: As Health Share convenes strategic workgroups and committees, the Community Engagement Program Coordinator will work with Health Share staff to assess and define roles for the CAC and facilitate CAC connection to Health Share planning and operations activities. CAC will broaden membership as necessary to round out the expertise of members to include areas not currently represented. The CAC has approved the creation of a Mental Health and Addictions standing subcommittee and is working to establish membership, purview and procedures. The CAC has also 3 February 2015 Page 14 of 62

approved first-round recommendations to Health Share s Transformation Plan and will continue to review drafts and provide feedback as it is finalized into contract amendment. Timeline: The Council was formed in July 2012 and meets once monthly. In September 2012, a CAC Executive Committee was formed to build capacity and develop processes and procedures to oversee the Community Health Needs Assessment through June 2013. Planning for the resulting Community Health Improvement Plan development and subsequent report will take place following June 2013 through the end of the year. A Mental Health and Addictions standing sub-committee was formed in October 2012, and its membership will be finalized was finalized in January 2013. The CAC began submitting feedback and comments on Health Share s draft Transformation Plan in October and has continued to be involved in its evolution. Policies and procedures for CAC representation on Health Share work groups will be established by end of first quarter 2013. Initiative #2: Conduct a Community Health Needs Assessment and generate a Community Health Improvement Plan with CAC and community partners (CCO Elements 1, 4, 6, 7, 8) Current State: A group of partners consisting of four county health departments (Clackamas, Clark, Multnomah, & Washington) and fourteen hospitals (including Adventist, Kaiser, Legacy, OHSU, Providence, PeaceHealth, and Tuality) have convened to work on the community health needs assessment, which will inform the development of a community health improvement plan. The process is being co-led by Kate O Leary, Washington County s Director of Public Health who serves as a county representative on Health Share s Community Advisory Council. Health Share s CAC continues to work on its approach to overseeing the CHNA and the process for adopting a community health improvement plan. Future State: Approval of CHNA and CHIP by the CAC and adoption of recommended actions and strategies by Health Share and partners as appropriate. Clinical data is aggregated and shared with Public Health epidemiologists so that Local Public Health Authorities are able to plan and implement systems and policy changes that impact population health outcomes. Benchmarks: Community Health Improvement Plan is completed on time, is relevant to the community and reflects appropriate systems and policy changes that impact population health Contract Benchmark: Community Health Improvement Plan is completed on time; accepted by RAEs, Community Advisory Council and Board of Directors. Process & Timeline: Through December 2012: Assessment model and work plan developed; website with documents links, and other items identified (to be launched by Healthy Communities Institute - contractor through the 4-county CHNA Workgroup ; criteria for selecting community health needs proposed (first step to capture community input); assessment of capacity to address community health issues. Health Share staff and the 4-county CHNA Workgroup co-chairs are currently proposing a methodology by which Health Share and Family Care, the region s other Coordinated Care Organization can participate as a formal partner in the assessment process through 2014 and ongoing. 3 February 2015 Page 15 of 62

January 2012-May 2013: Prioritize community health needs; select the prioritized community health needs for which strategies will be developed; solicitation of community feedback; community health needs and community ideas for strategies (second step to capture community input); develop strategies to address community health needs; develop regional materials if desired; partners will develop reports and continue updating web pages/other info for sharing. Initiative #3: Develop formal partnerships and with social and support services in the tri-county area (CCO Elements 1-8) Current State: Through projects Health Share is in the process of initiating with community service providers such as social service providers, first responders, educational systems, and housing providers etc., partnerships are forming between Health Share and community partners. In some cases formal agreements exist, while many others are informal and just beginning to gain structure. Future State: As Health Share develops and matures, an ongoing effort will be made to reach out to social and support service providers who serve Health Share members, and to initiate activities that serve shared goals. Where appropriate, Memoranda of Understanding (MOUs) or other formal partnership agreements will be established. Benchmarks: Prenatal care; mental and physical health assessment for children in DHS custody; effective contraceptive use; reduction of disparities; care plan for members with long-term care benefits; Chlamydia screening in women age 21-24; Process & Timeline: Memoranda of Understanding (MOUs) or other formal partnership agreements have been or will be established and utilized between Health Share and multiple partners including Tricounty DHS field offices, the Oregon Youth Authority and Juvenile Justice departments, Departments of Corrections and local community corrections and law enforcement, local court systems and restorative justice systems, school districts, ESDs and other departments addressing the special needs populations, developmental disabilities programs, tribal organizations, urban Indian organizations, services provided for the benefit of Native Americans and Alaska Natives, housing programs, community-based family and peer support organizations, and culturally specific organizations. In 2012, Health Share developed MOUs with Multnomah, Clackamas, and Washington County Public Health, Aging, and Mental Health authorities. These MOUs will serve as a basis for development of future agreements and MOUs with the above named community partners. Health Share s MOU with the three Local Public Health Authorities includes agreements about the following health system components: Public Health Infrastructure for Immunizations, Sexually Transmitted Diseases (STD), and Other Communicable Diseases; Point of Contact Services and Access to Testing, Treatment, Special Medications, and Vaccines; Payment Models that Support Best Practices, Coordination, and Prevention; Continuity and Coordination of Care; Evidence-Based, Culturally Competent Health & Prevention Programming; 3 February 2015 Page 16 of 62

Training and Specialty Consult Services; Care Model Development; Data and IT Infrastructure and Outcome and Quality Metrics. Health Share s MOUs with the three Local Mental Health Authorities include agreements about the following: Development of a Mutually Supportive System of Care; Governance, Community Planning and Participation, and Coordination of the LMHA and Health Share; Member Engagement and Family Partnerships; Provider Network Development and Contracts; Coordination, Transition and Care Management; and Health Information Systems. Health Share s MOUs with the three Local Medicaid Long Term Care Authorities include agreements about the following: Prioritization of High-Needs Members in Long Term Care; Development of Individualized Care Plans; Transitional Care Practices; Member Engagement and Preferences; Establishing Member Care Teams; Use of Best Practice; Use of Health Information; Member Access and Provider Responsibilities; Outcome and Quality Measures; Governance Structure; Learning Collaborative; Role of Patient Centered Primary Care Home; and Safeguards for Members. Partnership development with community organizations and agencies will be achieved through: Information-gathering and information-sharing to assess common goals, gaps in services, and areas of potential collaboration (last quarter 2012 and ongoing as needed through 2013); Regular review of standing MOUs to assure that commitments are being upheld and to serve as the basis for continuing partnership and/or partnerships with new organizations or entities; Facilitation of ongoing processes and for decreasing fragmentation and confusion among organizations (ongoing). 3 February 2015 Page 17 of 62

Delivery System Transformation Goal 1: Leverage the Health Commons Grant (CCO Elements 1, 2, 6, 7, 8) Current State: The Tri-County Health Commons innovation grant aims to create a regionally integrated patient-centered system to improve care coordination, care quality, and health outcomes among highcost, high-acuity adult Medicaid patients while reducing overall costs. We will reach this goal in three primary ways: by altering utilization patterns and reducing costs, by improving health management and health outcomes, and by improving the patient experience for our target population. Through the implementation and/or expansion of five separate but coordinated care model interventions across the community, we will achieve smarter utilization management, improved care coordination, enhanced systems for learning and collaboration, and a sustainable system of care delivery for our population. Together, these interventions will help our community achieve the Triple Aim of reducing costs as well as ED visits and hospitalizations, improving overall health and patients health self-efficacy, and improving our patients care experience both broadly and with respect to care transitions. The total population impact for the three-year program is 19,000 and the expected three-year savings is $32,542,913. Future State: An agile learning and development methodology that has been used by CareOregon over the past nine months during the creation of the ICCT pilot program will be used more broadly by the CMMI Oversight Team to assure all five interventions are being appropriately cultivated and are evolving successfully. This method involves regularly identifying critical programmatic best practices and challenges by soliciting front-line staff input, conducting weekly patient case conferences, and conducting regular programmatic team meetings. Best practices and challenges are then explored with all stakeholders using an open inquiry process informed by programmatic data when appropriate. The intended objectives of this methodology are: (1) best practices are agreed upon, formalized and become standard work, and metrics are established in order to monitor adherence to these practices, (2) challenges are acknowledged and mitigation or resolution strategies are developed, tested, and implemented, and (3) staff become empowered to continuously strive for process and programmatic improvement in their work. Ultimately this method takes into account that we are creating transformative care models without an existing blueprint, and assures a set of interventions that is much more likely to meet our Triple Aim goals. The Health Commons will measure the success of these care innovations with both process and outcome measures utilizing qualitative interview methods and standardized quantitative metrics. Broadly, we will monitor hospital, ED, and primary care utilization (rates, time between events, and lengths of stay) as well as total cost for this high-acuity adult Medicaid population. Indicators reflecting medical and behavioral health clinical status will be monitored as intermediate population health metrics. Patient (and provider) satisfaction as well as timely access to services will be captured at regular intervals to demonstrate that our targeted patients are receiving a higher quality care experience. More narrowly, several functional and health status assessments (e.g. Outcome Star, EQ- 3 February 2015 Page 18 of 62

5D, Life Space Assessment) will be used to periodically measure patient and worker-perceived changes in health status within the population served by the ICCT intervention. Patient-report self-management efficacy will also be assessed. Finally, a collection of process measures including (but not limited to) caseload capacity, frequency and type of contact, and length of program enrollment will be measured across interventions to inform program feasibility and scaling efforts. This information will support concurrent learning and testing cycles (PDSA) to help us tailor and refine our interventions over time. As the effectiveness of these initiatives is established, the partners of the Tri County Medicaid Collaborative have agreed to implement them across their systems as part of the new Coordinated Care Organization model of care. Their sustainability will be supported by new payment methodologies being developed. A CCO Transformation Fund has been established and initial capital committed to support the launch and further spread of these initiatives as well. Benchmarks: Vary by Initiative The five care model interventions are intended to address the deficiencies in our current system regarding the transition out of the hospital and ongoing case management of high utilizers as follows: Initiative #1: Interdisciplinary Community Care Teams (ICCT) (CCO Element 1, 8) Outcomes: Interdisciplinary Community Care Teams (ICCT) provide high intensity engagement, coaching, health literacy, and care coordination support to patients with high ED and hospital utilization, and who struggle with socio-behavioral challenges and co-existing medical conditions. The model enhances primary and specialty practice teams with a non-traditional outreach worker who provides support to these patients outside the walls of the health care setting, in the community or in patients homes. The help these enhanced teams provide may range from one-to-one collaboration with patients on improving self-care and following treatment plans to assistance with social skills and basic needs, such as housing. Process & Timeline: CareOregon will oversee this intervention based on its existing Community Care pilot program. The process for this initiative involves meeting with partner clinics to clarify needs and expectations. The results of these conversations will help determine what infrastructure will be provided by each clinic and what infrastructure will be provided by CareOregon. Clinic administrators and providers will collaborate with the team to establish protocols and contracts will be executed between CareOregon and the partner clinics. Each clinic will be asked to identify a provider champion and one administrative champion. A major component of the work will be hiring the outreach workers, qualified mental health specialists, social workers, peer wellness specialists and RN based upon the need of the clinics. The hiring, contracting and training timeline began in the 4 th quarter of 2012. Throughout the program, the team will perform ongoing program monitoring and improvement through process and outcomes evaluation feedback. The ICCT initiative began seeing patients in November 2012. Additional staff will be hired to supplement clinics in Q1, Q2, and Q3 of 2013. The final staff will be hired in Q3 of 2014. The potential impact is 1,078 patients in Year 1. 3 February 2015 Page 19 of 62

Benchmarks: Total emergency department utilization; outpatient and emergency department utilization; potentially avoidable emergency department visits; primary-care sensitive hospital admissions; all-cause readmissions; comprehensive care for diabetes, high blood pressure Initiative #2: Care Transitions Innovation (C-Train) (CCO Element 2, 6, 7, 8) Outcomes: C-TraIn provides intensive nurse management and clinical pharmacist support for medical patients who are at high risk for readmission to the hospital. The intervention begins with risk assessment and individualized discharge planning while the patient is hospitalized and then proceeds with home visits and telephone calls immediately following discharge. A critical component of the intervention is facilitating a high quality, timely connection with primary care follow-up. This was piloted at Oregon Health & Science University, which will join with Legacy Health to oversee the expansion. Process & Timeline: The project team began working with leadership at OHSU to identify and train clinic champions and physician and pharmacy leads in Q4 of 2012. Transitional care nurses will be hired for the clinics involved in the project. The team has been working with the leads to identify and map current workflow changes and will remap with C-TraIn additions at OHSU in Q4 2012 and at Legacy in Q1 2013. Once the workflow is complete, IT will be brought in to map and implement IT solutions for workflow and reporting/evaluation. The OHSU pilot project began in Q4 2012 and through the use of PDSA evaluation changes will be made to workflow and IT needs prior to implementation at Legacy in Q2 2013. The potential impact is 520 patients in Year 1. Benchmarks: Medication reconciliation post-discharge; timely transmission of transition record; care plan for members with long-term care benefits; reducing readmissions; total emergency department utilization. Initiative #3: The Intensive Transition Team (ITT) (CCO Element 1, 6, 7, 8) Outcomes: The Intensive Transition Team (ITT) provides short-term intensive case management and mental health services to psychiatric inpatients and emergency room users discharging to the community. The goal is to assure the engagement of high-risk individuals into appropriate communitybased services and supports in order to divert inpatient psychiatric admissions and prevent readmissions. This intervention is based on a model implemented in Washington County, where it reduced readmissions by 26 percent. Providence will subcontract with each county to administer this project. Process & Timeline: The ITT Implementation Workgroup, which includes representatives for all three counties and community providers began meeting in Q4 2012. This group will be responsible for solidifying the ITT Model of Care and evaluation metrics for ongoing performance management. The counties will then either amend or develop new contracts with the community providers. Six qualified mental health specialists will be hired across the counties in Q4 2012 and the initiative will begin seeing patients during that same time. The ITT Workgroup will continue to meet to monitor program success and ensure fidelity of model. The potential impact is 660 patients in Year 1. 3 February 2015 Page 20 of 62

Benchmarks: Follow-up after hospitalization for mental illness; reducing readmissions; emergency department utilization; timely transmission of transition record. Initiative #4: The ED Guides Program (CCO Element 2, 6, 7, 8) Outcomes: The ED Guides Program uses non-traditional workforce members to reduce the use of emergency department services for non-emergent issues. These guides link patients to primary care homes and support services, including referral to the Community Care Team intervention and selfmanagement resources. Providence has piloted ED Guides in several of their facilities and will oversee the expansion of the program to additional hospitals. Process & Timeline: An interdisciplinary workgroup has been formed to develop workflows and policies. The group will also be responsible for preparing the facility for guide stations, creating patient materials, and identifying community resources and referrals. Education of existing staff about the program will begin in Q4 2012. At the same time, an ED guide for Providence St. Vincent will be will be hired and trained. The educating phase of this project began in Q4 2012 followed by performance monitoring and improvement. The guiding phase will begin in Q2 2013. The potential impact for this program is 500 patients in Year 1. Benchmarks: Emergency department utilization; patient centered primary care home enrollment; primary care sensitive hospital admissions. Initiative #5: The Transitions Standardized Discharge Program (CCO Element 2, 6, 7, 8) Outcomes: The Transitions Standardized Discharge Program aim is to create a standardized hospital discharge summary format to be used in all area hospitals for effective communication of critical admission history and discharge instructions to primary care providers. The anticipated outcomes are an improvement of the hospital transition process and a reduction in hospital readmissions. This informational technology intervention will rely on a new technology solution that will transfer the standardized discharge summary within 24 hours of discharge to each primary care system s EMR. Legacy, Providence and OHSU are key partners in this effort. This program is aligned with other TCMC work around health homes that will ensure this information is acted upon in primary care. Process & Timeline: The project team will identify and recruit stakeholders from partner organizations to guide the development of the standardized discharge summary form and process, and provide feedback on project execution. In Q4 2012, a beta version of the assessment and discharge summary template was developed. The group will identify a data sharing process and notification system. At the pilot sites, the configuration and uplink processes will be completed. Training of staff on the discharge summary process began at the pilot sites in Q4 2012. After the go-live, the workgroup will perform ongoing program monitoring and improvement through process and outcomes evaluation feedback. The program will be expanded to OHSU sites in Q2 2014 and Providence sites in Q3 2013 assuming that the prior pilot activation is a success and the outcomes are as expected. The potential impact for this initiative is 400 patients in Year 1. 3 February 2015 Page 21 of 62

Benchmarks: Care transition record transmitted to health care professional; reducing readmissions; medication reconciliation post-discharge; timely transmission of transition record. Goal 2: Identifying Additional Opportunities for Partner Organizations (CCO Elements 1, 2, 6, 7, 8) Current State: The CMMI Grant has always been considered a springboard or catalyst for transformation and its limitations are recognized. First, while the CMMI Health Commons initiatives are designed to better meet the needs of high acuity Health Share members who have socio behavioral challenges driving high utilization, the member population needing those supportive services is far greater than the number of members covered under Grant funding. Second, there are clearly other model of care delivery system transformation issues, particularly those around increasing the effectiveness of Patient Centered Primary Care Homes, the integration of physical health, mental health and addictions, and addressing issues of maternal child and family health which are such a large part of Medicaid health care. Additionally, Health Share can support other partnership opportunities, to drive clinical transformation. Each of these will need to be addressed to reach the larger goal of Triple Aim Transformation. Future State: The Chief Medical Officer (CMO) Work Group, comprised of the executive clinical leads from each of the partner organizations, serves as the convening entity for regional coordinated transformation initiatives focused on clinical care. Delivery system transformation can only be accomplished through the alignment of strategic initiatives and coordination of effort of each of the participating groups; in effect, large system change will occur if all of the large (and small) systems themselves change. This group meets monthly and is chartered to lead and coordinate the delivery system Transformation efforts. Benchmarks: This goal will work to address the quality of and access to care for individuals enrolled in CCOs and for the community at large. Process: The first step for the group was for each organization to bring to the table their current strategic Medicaid initiatives to find areas for alignment. It was clear after this exercise that all organizations were doing some form of care management around populations similar to that of the CMMI Grant and that there was an opportunity to create a coordinated system of high acuity care management across systems. To this end, a Care Management Taskforce was convened in November 2012. Initiative #1: The Regional Coordinated Care Management System (CCO Elements 1, 2, 6, 7, 8) Outcomes: The Care Management Taskforce is chartered to create a CCO wide coordinated system to ensures that no matter where a high acuity Health Share member at risk for high acute care utilization driven by socio behavioral issues enters or receives care they will be reliably identified, assessed and offered appropriate supportive services. For those who need the highest level of service, the ICCT intervention of the CMMI grant or equivalent community based care will be provided; for those who 3 February 2015 Page 22 of 62

need office or centralized telephonic care management, that will be available; for those whom peer support services would be the most effect, those will be available. This will effectively take the CMMI initiatives to scale. Process and Timeline: The Care Management Taskforce has agreed to assess each organization s current process and capacity for care management functionally defined as all non episodic / non clinical treatment efforts where staff are assigned to improve health outcomes in partnership with high risk / high acuity members. This will identify best practices that can be spread and gaps that need to be addressed. It will also help establish common definitions of the target population, agreement on accountabilities for providing care management services and implementation, and commitment to tracking organizational and aggregate effort. Health Share hired staff will support this work. The initial formulation of targets and accountabilities is to occur in the Q1 2013. Benchmarks: Total emergency department utilization; outpatient and emergency department utilization; potentially avoidable emergency department visits; primary-care sensitive hospital admissions; all-cause readmissions; comprehensive care for diabetes, high blood pressure. Initiative #2: Patient Centered Primary Care Homes (CCO Elements 1, 2, 6, 7, 8) Outcomes: There has already been significant work done in the Tri County region to transform primary care practices into a patient centered primary care homes (PCPCH) model. The shift from visit / encounter based practice to outcomes based practice will be largely driven by new payment models that increasingly reward performance over volume. The first formulation of new incentive payments will follow the finalization of the CCO pay-for-performance (P4P) metrics due from the State as part of its agreement with CMS for additional funding. Process and Timeline: The CMO Work Group has been discussing the draft P4P metrics and the required Process Improvement Projects (PIPs). It has been agreed that as soon as the CMS required metrics are finalized the group will begin discussion of a quality incentive program for primary care practices to ensure Health Share meets performance targets. It is anticipated that this will be the focus of the December CMO WG meeting. Health Share will also encourage those practices which have not achieved PCPCH certification to participate in the training opportunity offered by the QCorps Institute. One of the Health Share partners, CareOregon, has already been designated as lead for one of the regional Institute collaborative to start in Q1 2013. Benchmarks: Enrollment in patient centered primary care homes; colorectal cancer screening, development screening and child/adolescent well-care visits; controlling high blood pressure, optimal diabetes care; CAHPS composite (access to care); potentially avoidable emergency department visits; primary-care sensitive hospital admissions; effective contraceptive use. Contract Benchmark: Percent of Health Share members receiving care in a State Certified PCPCH, by Tier 1/2/3. 3 February 2015 Page 23 of 62

Initiative #3: Maternal Child Family Health (CCO Elements 6, 7, 8) Outcomes: A new model of maternity care focused not simply on the medical issue of ensuring a safe delivery of a healthy child but also on supporting families at risk so that the child successfully develops to be school ready has been under discussion between public health and medical providers for the past year. The full scope of such a model has now been mapped under the leadership of public health, starting with preconception counseling and continuing through school entry. Implementation of this model will involve working across the continuum, from up skilling primary care to provide counseling (e.g. using One Key Question) and effective (including long acting) contraception, to creating a demedicalized, bio-psychosocial maternity model that can screen and case management at risk moms / families and provide early parenting support, to building capacity in pediatric practices to identify and respond to developmental or family issues, and to aligning public health and other resources when parenting supports are needed. Process & Timeline: The Providence Health System is piloting a new model of maternity care through their Midwifery practice based at Providence Portland Medical Center, which began in January 2013. This model will use group visits as the predominant method for delivering prenatal care, a methodology now strongly evidence supported. The practice will include both care managers to identify and intervene around risk issues and doulas for pregnancy and labor support. The pilot will test whether the cost of this increased staff support will be offset by shorter in hospital length of stays because of adequate preparation for labor and delivery supports. Other maternity providers have expressed interest in implement this kind of model, particularly in partnership with public health resources to support families with parenting challenges. A Maternal Child Program Manager is being hired by Health Share to work with those providers to start other similar pilots and create a learning collaborative between them. Dialogue has also begun with those interested in both the upstream preconception issues and the downstream developmental screening and intervention issues. Benchmarks: Timeliness and frequency of pre-natal care; elective delivery before 39 weeks; low birth weight; postpartum care rate; cesarean rate for Nulliparous Term Singleton Vertex. Goal 3: Behavioral Health Integration (CCO Elements 1, 2, 6, 7, 8) Initiative #1: Establish Behavioral Health Homes (CCO Elements 1, 2, 6, 7, 8) Current State: Individuals with mental illness die 25 years earlier than their non-mentally ill age-mates. Community Mental Health programs have spotty attention to the prevention and treatment of chronic health conditions, preventative care, or coordination with primary care. Given the impact of undiagnosed and untreated physical health problems among those who use Mental Health providers as their health home there is a need for co-locating physical health staff in behavioral health settings. Some pilot projects are underway; some providers have received grants for new projects. These existing efforts need to be strengthened and coordinated. Development of effective co-location models have been identified. 3 February 2015 Page 24 of 62

Future State: Individuals with disabling mental health conditions have access to basic preventative health screening and follow up care for chronic conditions in the setting they most strongly affiliate with: the Community Mental Health Center. Mental Health Professionals are dually-trained in interventions that promote both health and recovery. Strong coordination with Primary Care is wellestablished. Process: Behavioral Health Home Work group has been convened, developed a charter, and is finalizing goals and work plan. Monthly meetings are scheduled and workgroup membership established. Workgroup consists of physical health plan and behavioral health providers, and behavioral health RAE sponsors from across the region. Outcomes: The co-location of behaviorists has been widely adopted as a best practice as part of the PCPCH health home model in the region. While work remains to be done both in spreading and standardizing the practice, both providers and clinic leaderships have acknowledged the effectiveness of this intervention. It is also acknowledged that adding training on addictions for behaviorists is critical given the impact of substance abuse, including prescription opioids, on the population. A few clinics are piloting co location of trained additions staff (CADC), particularly in clinics with larger impacted Medicaid populations. Given the impact of undiagnosed and untreated physical health problems among those who use Mental Health providers as their health home there is interest in similarly co locating physical health staff in those clinics. Multiple pilot projects have been done; several providers have received grants for new projects. Development of effective co location models has been established as a key goal for Health Share s Transformation process. Process & Timeline: Over the past 3 years, a Regional Behavioral Health Workgroup has been working to centralize, standardize or align the policies and procedures of the three Behavioral Health RAEs. They have now created a sub Workgroup focused on integrating physical health capacity into mental health. They are to build on work already done or in progress in the community as well as learn from other national models with a goal of presenting a proposal for next steps to the Regional group in Q1 2013. A provider led Addictions Workgroup is also in the process of formation; its scope of work is to be defined and presented to Health Share and the CMO Workgroup also in Q1 2013. The Care Management Workgroup has already identified access to mental health and addictions treatment as the highest priority challenge they face in helping the clients they care/ case manage and that they need to work closely in conjunction with the Behavioral Health groups on these issues. Benchmarks: Initiation and engagement of alcohol and other drug dependence treatment; emergency department utilization; screening for clinical depression and follow-up plan; alcohol or other substance misuse screening; reduction of disparities; antidepressant medication management; adherence to antipsychotics for individual with schizophrenia; annual monitoring for patients on persistent medications; New Behavioral Health Home pilots implemented. Increase in routine health screening and chronic disease management for seriously mentally ill adults. 3 February 2015 Page 25 of 62

Contract Benchmark: Hospitalization rate for individuals with SPMI. Initiative #2: Behavioral Health and Primary Care Integration (CCO Elements 1, 2, 6, 7, 8) Current State: The co-location of behaviorists within primary care has been widely adopted in the region as a best practice as part of the PCPCH health home model. Work remains to be done both in spreading and standardizing the practice. Addiction Training for behaviorists is critical given the impact of substance abuse, including prescription opioids, on the population. A few clinics are piloting colocation of trained additions staff (CADC), particularly in clinics with larger impacted Medicaid populations. Bi-directional coordination with the behavioral specialty care delivery system is inconsistent and can benefit from standardized approaches. Future State: Improved care and reduced costs associated with mental health and addictions issues via standardized practices and protocols within high density primary care providers including expanded co-location of behaviorists in primary care with standardized roles and functions, routine screening for depression and substance abuse, standardized protocols for referral to behavioral health specialty care and vice versa, shared care plans, telephonic psychiatric consultation for primary care, protocols for communication frequency and content, and health information interconnectivity. Process: Primary Care Integration work group has begun meeting and has developed a work plan. Membership includes health systems, primary care, counties, and behavioral health providers. Work group will meet monthly. Outcomes/Benchmarks: SBIRT and PhQ-9 or other tools are implemented in high volume primary care sites; Referral criteria and protocols implemented (bi-directional); Telephonic psychiatric consultation for primary care (OPAL-K, OPAL-A) implemented Timeline: Recommendations to be completed by mid 2013. Full implementation by early 2014 Initiative 3: Behavioral Health Acute Care System Management (CCO Elements 1, 6, 7, 8) Current State: Hospitals and plans operate in a county-specific vendor relationship with plans and inpatient care is often disconnected from crisis and outpatient services. Future State: Regionally coordinated policies, procedures and services will be in place which divert Behavioral Health Emergency Department admissions, reduce inappropriate holds, divert admissions from the ED, avoid readmissions, and reduce lengths of stay through a cooperatively managed regional system. Process: A Behavioral Health Acute Care work group has begun meeting and has developed a work plan. Membership includes regional psychiatric inpatient, Behavioral Health RAE, involuntary commitment, outpatient and crisis program staff. Outcomes/Benchmarks: Reduced psychiatric inpatient bed days; reduced readmissions; reduced ED census; reduced involuntary holds. 3 February 2015 Page 26 of 62

Timelines: Work group recommendations to be implemented mid-2013. Goal 4: Building Community Partnerships (CCO Elements 1, 6, 7, 8) Initiative #1: Incorporating Emergency Management Services Current State: At the same the Health Share partners were discussing how to respond to the CMMI Grant RFA, emergency response leaders in the region were developing their own proposal. They proposed a number of innovations within the crisis system to address the issue that the majority of 911 transports do not require Emergency Department care. While not funded, their proposal highlighted both the opportunity for addressing issues of health care cost and quality by partnering with the EMS system, as well as the complexity of maintaining a high reliability crisis system. Further exploration of this proposal and work already being done within the crisis system has led to an emerging partnership between the EMS providers and Health Share. Areas of mutual interest and joint effort are actively being explored. Future State: Non-medical resources, such as housing or social services, are particularly critical for a vulnerable population in poverty. Health Share s delivery system Transformation Plan prioritizes creating strategic community partnerships to address that issue, as described in Goal 3, Stimulate innovation and integration with Community Service Providers/Agencies. Goal 5: Enhancing the Provider Network Current State: Each RAE currently manages its own provider network. Each RAE must show that they have enough capacity for their membership for primary care, medical and surgical specialties and for inpatient services. Health Share has ensured that the provider networks of each RAE will meet the need for their assigned Members. Future State: Health Share believes that in order to reduce unnecessary acute and high cost care and encourage better health outcomes that services should be delivered in natural systems of care by the best providers. A natural system of care includes primary care providers, behavioral health providers, specialists, ED and hospital providers, social service agencies, and advocates in a local ecosystem and encourages them to interact and coordinate the member s care. This means that a Member will be able to receive the care they need close to home and that all the providers needed for a member s care are connected within the system to ensure proper referrals and effective communication. These natural systems will be supported by non-traditional and community health workers who can integrate themselves either into the clinic or community setting and provide additional support beyond the medical model of care. Additionally, Health Share believes in provider accountability and using process and outcomes measures to evaluate performance. We also believe that this evaluation should be done transparently and that we should work with those providers in our network who, regardless of their RAE affiliation, need assistance in improving performance. Additionally, with the entry of the fee-for-service population into 3 February 2015 Page 27 of 62

managed care, Health Share will evaluate this population and their needs and consider expanding its network to potentially include naturopaths who currently care for some Members of this population. Benchmarks: Numerous measures including incentives; core performance; adult core measures; CHIPRA measures. Process: Supply/Demand Analysis: Health Share is partnering with the Center for Outcomes Research (CORE) at Providence Health and Services in order to do extensive and detailed mapping, which will allow us to look at the needs of the population by neighborhood as well as the current supply of providers by specialty and where our Members are located. The researchers at CORE have done extensive surveys and research on the demographics and characteristics of the Tri-county area, which can be overlaid on Health Share s Member information to provide an even clearer view of the needs of each community. Health Share will assist CORE in this work and once the mapping results of and analysis are complete, Health Share will work with the CMO Workgroup and Health Share Board of Directors to determine an action plan for addressing any deficiencies in provider availability by geography. Provider Performance: Health Share in collaboration with the CMO workgroup, the Quality Management Council and the IT Oversight Committee will develop a performance measures for providers. These measures will need to consider the complexity of the individual patient and other complicating factors. The IT Oversight Committee will need to develop the ability to capture this information and reporting capacity. Provider performance evaluation will require investment by the RAEs, delivery systems and community providers as well as Health Share. We will need to evaluate how to implement this given those limitations, while realizing that it is in Health Share s best interest to maintain a network of providers who are providing superior quality and service to our Members. The initial area of focus will be aligning with the state s incentive measures. Pilot Project: With the entrance of the FFS population into managed care beginning in November. Health Share will need to work with the state to learn more about these members and how they currently receive services. Health Share has previously met with the Oregon Association of Naturopathic Physicians. If we learn that many of the FFS members are currently cared for by naturopaths, rather than disrupt their care, Health Share may consider conducting a pilot to evaluate adding naturopaths to its network. Timeline: Supply/Demand Analysis: This work with CORE is currently underway and initial results are expected in Q1 2013. This evaluation will also be used by the Health Commons grant. During the subsequent three months, the CMO workgroup will evaluate the results and determine recommendations, which will be presented for approval by the Health Share Board of Directors. These changes will need to be phased in and implemented with an emphasis on the highest need areas. 3 February 2015 Page 28 of 62

Performance measurement: We anticipate that this project may take up to a year to implement completely due to the complexity of choose measures that are agreed to be valid and meaningful by not only Health Share, but also the RAEs and community providers. Additionally, it will take significant IT infrastructure development and coordination across the Tri-county to develop these reports. Pilot Project: Health Share has already reached out to the state to receive data. We began analyzing this information in late-september. Health Share continues to have discussions with naturopath association leadership and representatives from primary care. We are evaluating different types of pilot projects. Depending on the outcomes of this pilot, Health Share will either contract directly with the naturopaths or will ask them to contract with an existing RAE. Goal 6: Simplifying the Ancillary Network Current State: Contracting ancillary services is delegated to the RAEs, which are each responsible for managing their own services and networks. Future State: Health Share would like to increase efficiency and develop the most cost effective ancillary network as possible in order to reduce the cost of services and the administrative overhead. The role of Health Share is to look to reduce administrative overhead and seek out opportunities to take advantage of economies of scale with our large membership. Additionally, the opportunity for consolidation will also have a positive impact on our Members and network providers. The ancillary services in question include services such as durable medical equipment (DME), vision services, imaging and lab. Benchmarks: Numerous measures including incentives; core performance; adult core measures; CHIPRA measures. Process: Health Share will create a RAE network workgroup, which will be made up of the point people at each organization for contract and network issues. Health Share and the RAE representatives will collaboratively discuss how to prioritize each service for consolidation. Special attention will be paid to focusing on the high-cost services initially. Health Share will then work with work with each RAE to understand their current arrangement for the service, the duration of their existing contract and the associated costs. After all the information is gathered, Health Share will work with the RAE network workgroup to identify potential providers or solutions and Health Share will then put out a request for proposals if there are multiple options. In weighing responses, input will be sought from content experts. For example, when considering longterm care providers, Health Share will consult with our counties AAA/APD partners to evaluate options for identifying the best partners. Health Share and the network workgroup will weigh each response and ultimately select one or more vendors. Health Share and the RAE network workgroup will then develop a work plan for each RAE to handle the transition. Special attention will be paid throughout the process to the different needs of physical and behavioral health, but one benefit of developing a single network will be better integration and less confusion for Members and providers. 3 February 2015 Page 29 of 62

Timeline: Health Share will convene the network workgroup beginning in Q2 of 2013. We anticipate the prioritization process to take two months in order to gather proper input from the RAEs. We anticipate that each service will require approximately one month of information-gathering and comparative analysis followed by another month to request proposals, concluding with two months of work to determine the appropriate vendor and subsequently time will be needed to develop the appropriate contractual relationships. Also due to the variability in contract terms of current relationships, we will need to develop an individual work plan and timeline for implementation with each of the RAEs. Changes will need to be accompanied by communications to our providers and implemented in a way that is least disruptive to our members. Risks: Both Providence and Kaiser are part of regional systems and may not have the latitude to change ancillary service providers due to arrangements with the larger corporate entity. Health Share will work with them to ensure alignment across the system regardless of service provider. 3 February 2015 Page 30 of 62

Regional Health Information Technology Overview A tremendous investment has been made to date in the regional health information technology (HIT) landscape underlying Health Share of Oregon 1. The information systems and technology comprising this landscape enable health plan operations, member services, provider services, and the delivery of healthcare services to Health Share members 2. However, as these investments have understandably been made separately by individual Health Share affiliates and partners, their use is scoped to each organization s distinct business. As a result, there is both redundancy and variance among the information systems comprising the HIT landscape underlying Health Share. In some cases, redundancy proves advantageous; in other cases, redundancy provides opportunities for consolidation. In any case, Health Share s IS/IT Strategy is predicated on optimizing and leveraging existing information systems and technology where practical and introducing and integrating new information systems and technology where and when required. Fundamentally, information systems and technology enable business processes and related, desired changes aimed at achieving the Triple Aim objectives: better care, better health, and lower costs. The following subsections summarize Health Share s 12-18 month plan to manage an expanding membership assigned by OHA 3 to Health Share and how existing and new information systems and technology will enable three key dimensions of Health Share Transformation Plan: delivery system, risk/payment, and administrative simplification. Expansion of Membership Health Share acknowledges that its assigned membership will expand over time as follows: Daily: New enrollments (and terminations) 11/1/12: ¾ of existing fee-for-service (FFS) members (30,000 state-wide), including a special needs population, were enrolled in CCOs TBD: Remaining ¼ of the FFS members (10,000 state-wide), will be incrementally enrolled in CCOs 1/1/14: Affordable Care Act (ACA) Medicaid Expansion With the exception of daily new enrollments (and terminations), each expansion of membership requires enhancements to Health Share s master member enrollment / assignment system and global budget management algorithm which Health Share will introduce coincidental with each expansion. This work will be accomplished by the EDI Workgroup which is staffed, directed, and overseen by the Health Share IT Oversight Team. 1 See Appendix A Health Share IT Inventory 2 See Appendix B Health Share Member Engagement Process (As Is) 3 OHA=Oregon Health Authority 3 February 2015 Page 31 of 62

Delivery System Transformation As described previously, the Delivery System Transformation Plan comprises four goals: 1. Leverage the Health Commons Grant 2. Identify Additional Opportunities for Partner Alignment; 3. Behavioral Health Integration; and 4. Build Community Partnerships The manner by which information systems and technology will enable each strategy is described below. Goal 1: Leverage the Health Commons Grant (CCO Element 5) Current State: The delivery system underlying Health Share spanning physical health, behavioral health, community and social services, and dental health settings is a constellation of disparate, independent organizations utilizing information systems and technology unique and, often, limited to their distinct organization. Multiple instances of various electronic health record systems and health information exchange solutions have been implemented to support each organization s business operations. Information is often documented inconsistently by providers within a shared instance of an electronic health record (EHR) and duplicated across multiple instances of EHRs used throughout the delivery system. The community serviced by the delivery system lacks a comprehensive and integrated electronic health record (EHR) in which a member s complete health history is summarized. 3 February 2015 Page 32 of 62

Figure 2 EHRs and HIEs (current state) Integral to Epic System s EHR is health information exchange (HIE) functionality known as Care Everywhere. Care Everywhere enables the sharing of PHI and event notifications among appropriately privileged stakeholders using Epic s EHR (utilizing Epic s Care Epic module) as well as between privileged stakeholders using non-epic EHRs (utilizing Epic s Care Elsewhere module). Within each instance of Epic implemented by Health Share s Affiliates and Partners, Care Everywhere is inconsistently and/or non-optimally configured to support desired health information exchange. Furthermore, information regarding a patient s care team is inconsistently and haphazardly documented within each patient s chart. While Care Everywhere is used to share PHI between providers using different instances of Epic, PHI is most often exchanged between Epic users and non-epic users via FAX. 3 February 2015 Page 33 of 62

Figure 3 HIE using Epic Care Everywhere Care Epic and FAX (current state) Today, two complementary systems notify providers of events related to Health Share members. Care Everywhere is currently configured in the context of all Epic instances to broadcast events in real-time when they are documented; however, only a few instances are configured to receive and deliver notifications to applicable providers. Independent of Epic, an event notification system implemented by CareOregon informs a targeted subset of providers by delivering a daily report of emergency department (ED) visits by CareOregon members within the last 24 hours. Notifications include information summarizing the date/time of the event, the type of event, the place of the event, and the person for whom the event pertains. 3 February 2015 Page 34 of 62

Future State: Health Share agrees to participate in OHA s upcoming process to assess the next phase of statewide HIE development (including assessing the scope, financing and governance of statewide HIE services). In particular, Health Share will make appropriate executive and staff resources available for an interview with an OHA consultant, and will participate in a brief series of stakeholder workgroup meetings, if requested OHA. After the OHA process concludes and the next phase of statewide HIE services are defined, Health Share will update this HIE component of our transformation plan at the next update cycle. The prevalence of Epic within the delivery system underlying Health Share, coupled with the fact that more than 74% of physical health care services provided to Health Share members arise within settings using Epic 4, provide motivation to optimize the configuration and use of Care Everywhere existing and expected future 5 capabilities - to support HIE among all providers servicing Health Share members. Furthermore, the use of FAX as a means of exchanging health information can be streamlined by leveraging web-based, read-only access to an instance of Epic (via EpicCare Link) or by utilizing secure Provider-Provider Messaging (e.g. CareAccord). Secure Provider-Provider Messaging predicated on the Direct Project 6 standard protocols will soon be seamlessly available within EHRs certified as meeting Meaningful Use Stage 2 requirements 7 at which point we anticipate greater adoption and use among providers. And, to embrace the distributed nature of PHI pertaining to any individual Health Share member documented within multiple Epic and non-epic EHRs, Health Share will formally evaluate TBD 3 rd party HIE Gateways 8 predicated on a federated architecture to enable real-time assimilation of distributed clinical information regarding a Health Share member at the point of care. In addition, a 3 rd party HIE Gateway may enable Health Share to aggregate clinical (administrative, and financial) data into a data warehouse intended to facilitate provider performance and member utilization measurement, analysis, and reporting as well as business intelligence activities. 4 Based on analysis of CareOregon physical health claims arising 6/2011-7/2012 related services delivered by contracted providers in the tri-county area. 86% of claims related to inpatient services, 84% of claims related to outpatient services, and 63% of claims related to ambulatory (primary care) services arose in physical health care settings using Epic s EHR for an average of 74% of all physical health claims. When taking into consideration services delivered at Kaiser related to its members, the average is expected to increase. 5 E.g. Ability to automate queries coinciding with upcoming scheduled visits to update a local instance of an individual s chart with remote information; more granular event notification send/receive options; etc. 6 See www.directproject.org. 7 See http://www.healthit.gov/policy-researchers-implementers/meaningful-use-stage-2-0 8 E.g. Certify HealthLogix, Medicity Novo Grid and inexx, Optum Health Information Exchange (previously Axolotl) Harris Community Information Exchange (previously CareFx), Caradigm ehealth Information Exchange, etc. 3 February 2015 Page 35 of 62

Figure 4 HIE using Epic Care Everywhere Care Epic, EpicCare Link, and Provider-Provider Messaging 3 February 2015 Page 36 of 62

Figure 5 HIE using an HIE Gateway 3 February 2015 Page 37 of 62

To ensure that interested providers are informed when members visit ED, get admitted, or are discharged from a hospital, we intend to enhance and leverage the functionality of the event notification system implemented by CareOregon to: Embrace three event types: ED visit, Hospital Admission, and Hospital Discharge; Receive notifications regarding Health Share members from all hospital-based delivery systems; and Deliver notifications to a broader audience of healthcare providers interested in receiving them. This functionality will complement real-time event notification facilitated by Care Everywhere which we intend to consistently and optimally configure across all instances of Epic implemented within the delivery system. Figure 6 Event Notification System 3 February 2015 Page 38 of 62

To provide privileged providers with a longitudinal summary of encounters that transpired within the delivery system for each Health Share member, Health Share intends to leverage an emerging community-wide care coordination registry, PopIntel, predicated on administrative claims data related to Health Share members being implemented by CareOregon 9. This registry permits: Subpopulations of interest to be defined and aligned with intervention programs; Outreach workers to be assigned members and to be notified of ED visits and hospital admissions and discharges related to assigned members; Encounters between outreach workers and members to be documented; and Various measures to be viewed in dashboards and reports. Figure 7 Community Care Coordination Registry (PopIntel) 9 Note: Use of PopIntel initially restricted to program interventions comprising the Health Commons grant wherein experience and lessons learned will inform a future decision as to whether broader use of PopIntel or transitioning to a more comprehensive 3 rd party population health management / case management system is warranted. 3 February 2015 Page 39 of 62

In support of the Transitions initiative of the CMMI Health Commons grant, a standardized discharge summary document will be implemented across the hospitals comprising the delivery system. The event notification system and HIE capabilities described above will inform relevant providers of discharge events and enable them to access or receive related discharge summaries. Figure 8 Standardized Discharge Summary Flow Finally, Health Share intends to leverage the aggregated claims data repository enabling PopIntel as a source of administrative claims information required to support the Center for Outcomes Research and Education (CORE) reporting and analysis objectives related to the CMMI Health Commons grant. Benchmarks: As related to, and determined by the Health Commons Oversight Committee to coincide with Delivery System Transformation benchmarks and metrics. Contract Benchmarks: % of members receiving care in multiple healthcare settings whose EHRs are successfully/unsuccessfully connected across contracted providers EHR implementations; % of contracted providers exchanging secure messages. Process: In collaboration with Health Share Affiliates and Partners and led by the Health Share IT Oversight Team, Health Share intends to establish and propagate a consistent and optimal set of configuration options governing Care Everywhere as implemented across the CCO to enable health information exchange (HIE). Similarly, Health Share intends to establish and promote a consistent data model underlying the documentation and best practices regarding the maintenance of defined care team relationships within all EHR, Population Health, and Care Coordination/Case Management systems in which information regarding its membership is documented. 3 February 2015 Page 40 of 62

In collaboration with the CMO Workgroup and the Transitions Sub-Workgroup, Health Share intends to establish and implement a standard discharge summary document across all hospitals and related EHRs beginning with Legacy. In collaboration with Health Share s Affiliates, Partners and CareOregon, Health Share will implement and deploy the event notification system and PopIntel solutions. Health Share will also collaborate with CORE to provide them with administrative (claims) data enabling them to achieve reporting and analysis objectives related to the CMMI Health Commons grant. The above collaboration will occur within the Care Coordination Workgroup formed, staffed, and directed by the Health Share IT Oversight Team. Timeline: The following Gantt chart summarizes the high-level activities that have been completed and are required to deliver the technology cited above enabling the intervention programs comprising the CMMI Health Commons grant. Key: Green=Completed; Yellow=In Progress; Red=At Risk; Gray=Not Started Figure 9 CMMI Health Commons Grant IT Timeline Goal 2: Support Partner Alignment Opportunities and Community Partnerships There is no incremental technology investment beyond that cited above required to enable and support the partner alignment opportunities and community partnerships cited within the Delivery System Transformation Plan. These opportunities will utilize existing health information technology e.g. 3 February 2015 Page 41 of 62

Electronic Health Records in use within Health Share today and leverage emerging technology cited above as it becomes available. Goal 3: Support Behavioral Health Integration (CCO Element 1) Incremental technology investment beyond that cited above will be required to support the integration of behavioral care and primary health, specifically the implementation of: SBIRT and PhQ-9 or other desired assessments in primary care settings EHRs; and Referral criteria and protocols in both settings. Goal 4: Enhance Risk / Payment Transformation (CCO Element 3) OHA expects all CCOs to be represented as one integrated CCOb 10 and one CCOe for as long as each CCO services fee-for-service (FFS) mental health only beneficiaries. The following information systems are required to enable Health Share to consolidate from its current representation as four CCObs and one CCOe to one CCOb and one CCOe thereby meeting OHA s expectations: Implementation of a new member assignment algorithm predicated on an agreed upon definition of equitable distribution of members across Health Share risk bearing organizations Implementation of a revised algorithm governing the management and disbursement of the global budget aligned with the new member assignment algorithm Implementation of a new member enrollment/eligibility verification system enabling Health Share providers to determine a Health Share member s enrollment/eligibility status and the risk bearing entity to which the member s been re-assigned. Completing the above activities is a pre-requisite to enabling the Risk / Payment Transformation Plan contemplating new risk bearing organizations. And lastly, we will require a revised algorithm governing the management and disbursement of the global budget inclusive of provisions for: RAE-specific surplus distribution 11 RAE-specific deficit management RAE-specific medical-loss budgets Reciprocity rates; Pay or play model 10 CCOb = CCO bearing risk and responsibility for managing and delivering physical and mental health services to its assigned members; CCOe = CCO bearing risk and responsibility for delivering mental health services only 11 Surplus distribution predicated on TBD pay-for-performance (P4P) measures 3 February 2015 Page 42 of 62

Goal 5: Supplement Administrative Simplification Efforts TBD once the administrative simplification plan solidifies. 3 February 2015 Page 43 of 62

Accountability Section 1- Reporting and Informatics Goal: As efficiently as possible, collect and accumulate data in order to effectively measure, analyze and report performance at multiple levels across the system to inform action and transformation As noted throughout Health Share of Oregon s transformation plan, Health Share and its affiliates and partners must become adept at population risk, population health, coordinated care, and complex case management. To achieve its objectives, comply with contractual obligations, and successfully complete quality improvement programs (QIPs), Health Share of Oregon must continuously measure, analyze, and report specific provider performance and member utilization metrics across the CCO. The Oregon Health Authority (OHA) will hold Health Share of Oregon accountable for specific performance measures and related targets. OHA formed the Scoring and Metrics Committee which has identified over 80 measures of cost, quality, access, patient experience, and health status that could be tracked over delivery settings and populations 12. OHA intends to analyze administrative claims data and survey results to calculate performance across all measures to compare against defined targets 13. OHA will report most measures quarterly on their website and all measures annually. A subset of the performance measures comprise an incentives measures set that will be tied to quality pool funding for CCOs. The performance measures identified by OHA are a subset of those currently being measured, analyzed, and reported by Health Share s Affiliates and Partners for a variety of purposes today. As directed by Health Share s CMO Workgroup and Quality Management Council, Health Share s CIO will lead the Health Share IT Oversight Team in embracing prioritized requirements regarding provider performance and member utilization metrics and identifying and implementing health information technology (HIT) solutions enabling the measurement, analysis, and reporting of required metrics. Current State: Today, data required to continuously measure, analyze, and report provider performance and member utilization of health care services across the CCO is housed in separate, distinct repositories created and administered by Health Share s Affiliates and Partners: risk accepting entities (RAEs) and health care delivery systems. Each partners ability and propensity to measure, analyze, and report provider performance and member utilization varies. As Health Share s entitlement to protected health information surrounding its membership only began on September 1, 2012, it currently lacks sufficient accumulation of data - in both type and quantity - required to continuously measure, analyze, and report provider performance and member utilization metrics. 12 See Oregon Measurement Strategy 13 See Incentives measures list with specifications and targets 3 February 2015 Page 44 of 62

Two organizations aggregate administrative claims information received from Health Share s RAEs today: OHA, specifically its Actuarial Services Unit (ASU), and Oregon Health Care Quality Corporation (Q-Corp). ASU s gold data set is used by OHA/ASU to establish and revise CCO payment rates. Using Milliman s MedInsight healthcare analytics product 14, Q-Corp calculates specific provider performance metrics and publishes them in two quality reports intended for providers and consumers respectively. Future State: Health Share s IT team is analyzing and intends to recommend and implement health care information technology (HIT) enabling the following functions to occur across its entire membership and contracted provider network: Population Risk Management Population Health Management Administrative and Clinical Data Aggregation Member Utilization Measurement, Analysis, and Reporting Provider Performance Measurement, Analysis, and Reporting Health Share IT team s strategy is to identify solutions used by its partners today and, where applicable, evaluate the feasibility and appropriateness of using them more broadly and effectively across the CCO. When it s determined that the CCO lacks certain solutions, Health Share IT s strategy is to appropriately evaluate HIT vendors solutions, recommend one for purchase, and, pending approval from Health Share s Board of Directors, purchase and implement the recommended solution in a manner integrated with and thereby complementing existing HIT comprising the IT landscape underlying Health Share. Aggregating administrative and clinical data from multiple sources, particularly when related to multiple, distinct organizations and differing HIT systems, is very challenging. None of Health Share s affiliates or partners is experienced in doing so today, although some are experienced in aggregating one data type or the other source from within their respective organizations. It is likely that Health Share will require a proven solution(s) from experienced HIT vendor. Once the functions cited above are enabled, dashboard and detailed reports summarizing specific metrics of interest time-based snapshots and historical trends - will be implemented and made available to interested, privileged stakeholders. Such dashboards and reports should enable stakeholders to assess the impact of QIPs and identify where and when new QIPs are required. Benchmarks: Metrics will tie to those required to achieve incentive payments from OHA. Current benchmarks and related targets to be established by OHA. Process: Formed and led by the Health Share IT Oversight Team, the Care Coordination and Data Analysis and Reporting Workgroups, Health Share s CMO Workgroup and Quality Management Council, will author requirements, evaluate existing and, when necessary, HIT vendors solutions, and make 14 See Milliman MedInsight. Note: Providence Health Plan has recently implemented MedInsight and both Covisint and The Advisory Board have licensed and integrated MedInsight is a population risk management solution into their respective product suites. 3 February 2015 Page 45 of 62

recommendations as to how best to enable the following functions to occur across its entire membership and contracted provider network: Population Risk Management Population Health Management Administrative and Clinical Data Aggregation Member Utilization Measurement, Analysis, and Reporting Provider Performance Measurement, Analysis, and Reporting Foundational to these functions is expected to be one or more comprehensive aggregated data warehouses. In accordance with recommendations and approval from Health Share s BOD, these workgroups will formulate and execute requisite project plans in collaboration with Health Share s Affiliates and Partners to enable the above functions required for Health Share to achieve its objectives and comply with contractual obligations. In terms of member utilization measurement, analysis, and reporting, it s likely that two complementary strategies will be progressively pursued: Rely upon Health Share s RAEs to measure, analyze, and report member utilization pertinent to each RAE s assigned membership Implement a comprehensive Population Risk Management solution In terms of provider performance measurement, analysis, and reporting, it s likely that two complementary strategies will be progressively pursued: Rely upon Affiliates and Partners to consistently report upon a defined set of performance measures Measure, analyze, and report upon quality process measures predicated on administrative claims data as Health Share accumulates a sufficient volume of adjudicated claims reported by its RAEs. Timeline: TBD; however it s recognized that member utilization measurement, analysis, and reporting is required ASAP to enable emerging strategies 15 comprising the delivery system component of Health Share s transformation plan. 15 E.g. Comprehensive, consistent Care Management 3 February 2015 Page 46 of 62

Section 2- Integration of the Quality Assessment and Performance Improvement System Goal: Develop a fully integrated quality improvement program that is in compliance with federal and state requirements while meeting the Triple Aim objectives utilizing a plan, do, study act (PDSA) methodology (CCO Element 8) Health System transformation includes improving access and quality of care to our members while simultaneously reducing the growth rate per capita cost and advancing the measures of the Triple Aim. The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI s belief that new designs must be developed to simultaneously pursue three dimensions: Enhance the patient care experience (including access, quality and reliability) Improve the health of the defined population Reduce or at least control the per capita cost of care Health Share of Oregon s (Health Share) goals as a regional CCO is to: Deliver coordinated, high-quality services at the right place at the right time by engaging members, the high-risk uninsured, providers and community resources in meaningful partnerships. We will work to eliminate health disparities, focus on excellent customer service and satisfaction and achieve a cost savings while creating a sustainable system. Fully integrate physical, behavioral and oral health and minimize the fragmented care delivered in today s siloed environment. Current State: Prior to the formation of CCOs, the methodology for measuring performance and quality in the Fully-Capitated Health Plan (FCHP) contract included oversight and reporting quarterly to DMAP and contracted External Quality Review (EQRO) in compliance (every 3 years), information systems capability assessments (every 2 years) and performance measures and performance improvement projects (yearly). Compliance review included: Enrollee Rights Delivery Network Primary care and coordination of services Coverage and authorization of services Provider selection Sub contractual relationships and sub delegation Practice guidelines QAPI program rules and elements- Performance Measurement Detect over and under utilization 3 February 2015 Page 47 of 62

Assess quality and appropriateness of care Grievance system In the Mental Health Organization (MHO) contract, while the EQRO reviews were the same, the focus was domain centered: Domain: Access to services Domain: Quality of services Domain: Integration and Coordination Domain: Outcomes Domain: Prevention, education and outreach Domain: Quality Management Domain: CSCI: Children s Intensive Treatment Services Planning by MHO Performance measures: Post-acute care hospital follow up in 7 and 14 days Inpatient admits PTMPM Average LOS Initiation and engagement Readmission rates to acute care ISA screening within 3 days Penetration rate by age group and ethnicity MH clients seen by a PCP within the last year At the end of the contract, each FCHP and MHO maintained separate Quality Assurance Performance Improvement (QAPI) programs and developed performance initiatives in the following areas: Performance Improvement Projects (PIPs) All four physical health risk accepting entities (RAEs) have been involved in the Assuring Better Childhood Development (ABCD III) initiative. The remaining four clinical PIPs include: Childhood Immunizations Reducing childhood and adolescent obesity Adolescent well child visits Integrating Physical Health for Children transitioned by placement of primary care providers into mental health clinic to managing antipsychotics for children In the mental health arena six PIPs were in the process of development and implementation in the three counties: 3 February 2015 Page 48 of 62

Increasing primary care engagement for children with Serious and Persistent Mental Illness (SPMI ) Improve the documentation of the healthcare status for individuals on antipsychotic medications Measuring outcomes of informed care utilizing the ACORN assessment tool Reducing no show rates in outpatient mental health clinics Improved cultural competency in the delivery system Changes in utilization of mental health services by clients being served in an Assertive Community Treatment program Future state: The goal is to collaboratively develop the Quality Assessment and Performance Improvement program in executing the transformation of the healthcare delivery system. A focus on provider accountability and member engagement will facilitate utilizing process and outcomes measures to evaluate performance of initially reducing and ultimately eliminating health disparities in our population. Our initial steps will be the development of a process for standardizing data collection from our Risk Accepting Entities. We will then review our data demographics for race, ethnicity and language. We have received data from the state with regards to comorbidity files. We will begin by an analysis of this data as well. We will identify and map high-need/disparity areas. We will use the data to develop a comprehensive plan to coordinate local disparities reduction activities. Health Share will improve access to care and provide availability of language services to our members in the interim. Health Share Risk Accepting Entities are required to monitor access and availability to care. Health Share will develop and initiate a strong surveillance system that monitors trends in as well as availability and access to care health and quality of care measures through routine RAE reports on access and availability to care. Health Share s leadership and workgroups (the Chief Medical Officer Workgroup, the Information Technology Workgroup, Care Management Workgroups, Quality Assessment and Performance Improvement Workgroups. etc. ) will promote responsiveness to the cultural diversity member needs and preferences to RAE leadership thus driving the example and expectation of improving quality of care and their experience of care to members. Health Share will review the Community Needs Assessment and conduct a gap analysis to identify disparities identified in the Needs Assessment. We will review complaint and grievance reports. The complaint and grievance reports will help to identifythe number of complaints related to equity issues. Conducting an analysis of identified issues will provide more information to validate the disparity exists and will provide one measurement process to track improvement. Health Share will review programs and develop diversity training to be given to staff at Health Share of Oregon and our Risk Accepting Entities. Our measure of improvement in this processes will be tracked by the number of staff trained. A RAE provider assessment will becompleted by each RAE and the results will be provided to Health Share. The CAHPs survey measurement will be reviewed in relation to REL and experience of care. This data combined with analysis will identify the top three disparet conditions for Health Share to target for elimination of disparities and improved outcomes. 3 February 2015 Page 49 of 62

We will also conduct an analysis of REL data on the performance measures to identify disparities specific to condition. This will provide confirmation regarding the existence of certain disparities on health conditions identified. We will use the tools from the RWJF Roadmap for ending disparities, the CMS MCO Roadmap for ending disparities to assist us. We will be creating partnerships with the community, patients, and families. We plan to reach out to consult with the Office of Equity and Inclusion regarding how to choose disparities for elimination. We plan to establish measures for equitable care through the analysis of the Community Needs Assessment by the develop ment of an effective community engagement strategy through the Community Advisory Committee and the Cultural Competence Workgroup findings. Our analysis of of provider capacity to meet language needs of members; meet their needs for culturally appropriate care will enable Health Share to develop an assessment tool in which to complete organizational assesments and complete a gap analysis of provider organizations by July 2014. We will analyze the results of the above assessments as well as any provider assessments conducted to develop a plan specifically related to the gaps identified for eliminating disparities. The health conditions identified will continue to be followed and measured with expectation of at minimum 10% improvement in outcomes, screenings etc. related to the conditions identified. Once these have been accomplished, we feel we will have been able to identify our top three disparet measures and develop benchmark targets for reducing the disparities. Our Risk Accepting Entities have integrated patient centered health homes in their networks. Working with the PCPCHs to improve care coordination will involve coordination of disease prevention services, management of transitions between providers and provide a source of primary care access. Benchmarks: Ambulatory care sensitive hospital admissions ; reducing preventable re-hospitalizationsencompasses all cause readmissions; medication reconciliation post discharge; integrating primary and behavioral care; alcohol misuse-screening, brief intervention, and referral for treatment; initiation & engagement in alcohol and drug treatment; deploying care teams to improve care and reduce unnecessary costly utilization; addressing population health issues for example; diabetes, hypertension, depression screening-; member satisfaction and access to care as measured by the CAHPS; health and functional status among enrollees; rate of tobacco use, obesity rate; outpatient and ED utilization; potentially avoidable emergency department visits; mental health assessment for children in DHS custody; follow up after hospitalization for mental illness; effective contraceptive use among women who do not desire pregnancy; low birth weight; developmental screening by 36 months; reduction in disparities in the above benchmarks in relation to race and ethnicity. Contract Benchmark: Health Share will develop a process for standardization of the data collection categorized by R/E/L categories initially. Compare REL data with comorbidity files to identify and map high need/ disparity areas; and develop a quality improvement plan to coordinate local disparities reduction activities. Process: Initially the RAE Quality Improvement Coordinators (QICs) have collaborated via teleconference to share ideas regarding the development of the QAPI program and performance improvement projects. There is enthusiasm and a willingness to share ideas and provider tools in the transformation process. Alignment in the focus areas of the Health Commons grant projects; the OHA Incentive Measures and the OHA required Performance Improvement Projects has been embraced by all the RAEs. There has 3 February 2015 Page 50 of 62

also been keen interest in focusing on reducing the cost curve by ensuring members are receiving appropriate care in the appropriate setting while ensuring the care they receive is of the highest quality. The RAE QICs reviewed their existing data and programs internally and provided Health Share with their recommendation of PIPs to conduct in 2013. The Chief Medical Officer (CMO) Workgroup then met and discussed their ideas for PIPs based on their charter and transparency activities on November 16 th. The ideas from both groups were reviewed internally at Health Share and presented to the Governance and Quality Committee in December for approval. Outcomes: Health Share formed the QAPI Committee and meetings began in December 2012. Health Share notified OHA with which PIPs have been identified at the end of December. Health Share of Oregon will utilize existing community-based research to prioritize a minimum of three documented health disparities affecting our members. A plan for addressing these disparities will be developed by Q3 2013 with the goal of eliminating these disparities within our membership by 2018. Health Share envisions a collaborative workgroup of QI representatives working together across the table to improve outcomes for our members at the point of care. We envision sharing of best practices and tools to standardize as many processes as possible while maintaining the individuality and accountability of each RAE in their efforts to improve care at the individual RAE management of care. Timeline: RAE QIC identify preference of PIPs to conduct November 20 CMO input received November 16 Governance and Quality Committee presentation and approval, December 4 QAPI Committee initial meeting December Compliance Committee initial meeting December Risks: Too aggressive of a timeline. 3 February 2015 Page 51 of 62

Section 3- Risk Transformation Goal: Create a global risk system and alternate payment methodologies that will enable Health Share to reward the transition from volume to value in order to achieve the Triple Aim (CCO Element 3) Current State: Health Share of Oregon s mission is to develop an integrated health system that achieves better care, better health, and lower costs for the Medicaid population and the Tri-County community. In order to achieve this goal, Health Share is committed to risk payment transformation. Currently, Health Share contracts with seven Risk Accepting Entities (RAEs). Four RAEs deal with physical health (CareOregon, Providence, Kaiser, and Tuality) and three RAEs deal with mental health (Multnomah, Washington, and Clackamas Counties). This transitional RAE structure was created to allow Health Share of Oregon to begin operations on September 1, 2012 and to allow the organization to properly evaluate risk payment model alternatives. Three of the four physical health RAE s function as integrated delivery systems with health plan and provider relationships organizationally combined. One of the four physical health RAE s utilizes contractual provider network relationships on a fee for service basis. The three mental health RAE s use a combination of owned and contracted provider relationships. While all of the RAE s are fully capitated for their services, their relationships with their providers vary. The current configuration also drives a requirement of fully redundant restricted reserves. Health Share engaged Kaufman Hall to assist with the development of a risk payment transformation plan for the organization. Kaufman Hall has conducted interviews with each of Health Share s member organizations in addition to a conversation with the Oregon Health Authority. Among the topics explored in those interviews was the member organization s experience in taking full risk as well as tolerance for full risk. Those findings were summarized and presented to both the Health Share Board Finance Committee as well as the Health Share Board of Directors. Kaufman Hall, in conjunction with Health Share leadership, then developed three potential overall risk payment models for consideration. These models were presented and discussed by both the Health Share Board Finance Committee and the Health Share Board of Directors. Future State: At this time, an overall risk model for Health Share of Oregon has not been determined. Based on the results of the Kaufman Hall risk payment transformation work and discussions, Health Share is planning a phased approach to this work going forward. The phases of this approach include leveraging of existing relationships, exploring natural systems of care, and expanding mutual risk. Our initial focus (the next 12-18 months) will center on the first phase aimed at leveraging existing relationships. Leveraging existing relationships will involve defining a transitional reimbursement model for those organizations less experienced in managing full risk for the cost of care, one which will move them forward in a staged manner and provide the appropriate financial incentives to effectively manage 3 February 2015 Page 52 of 62

the care of their assigned Medicaid population. This effort is focused on the physical health RAE that is currently operating with a contracted network on a fee for service basis. This work will include alternate payment methodologies to engage and incentivize the delivery system to pursue transformation activities. This initial phase will also involve defining acceptable levels of administrative retention and medical loss ratio policies and standards by which each RAE will be held accountable. RAE contracts as well as downstream provider contracts will dictate incentive language for performance metrics and outcome measures. This will be accomplished by working with all RAEs to articulate a meaningful set of metrics and benchmarks to define a performance-based reimbursement model, within the context of the Health Share s selected quality metrics and risk distribution methods. Specifically, our areas of emphasis for the first phase include the following: 1. Medical-Loss Budget: Establish the target medical-loss budgets for the membership allocated to each RAE. 2. TPA Services: Define the Third Party Administrator services needed in each RAE. 3. Health Share Withholds: Establish the appropriate Health Share withholds for administration of special needs members, social programs and reserves. 4. Surplus Distribution: Establish a method for the distribution of potential Health Share surpluses to all risk-pool participants. 5. Reciprocity Rates: Establish standard provider (physician and hospital) draw rates for services rendered to members within this healthcare delivery pod. 6. Financial Model: Develop financial model which projects the financial results of each RAE based various revenue, expense and enrollment assumptions. 7. Risk Reserves: Restricted reserve requirements for fully capitated entities. Benchmarks: Compare traditional insurance metrics, including administrative rate, medical loss ratio, and utilization statistics with access and outcomes measures to ensure the risk and payment methodologies are encouraging appropriate clinical transformation. Contract Benchmark: Percent of Health Share providers participating in alternative payment methodologies aimed at improving quality and reducing costs aligned with State CCO incentive metrics. Process/Timelines: As mentioned above, the initial focus of risk payment transformation will center on leveraging of existing relationships which will occur over the next 12-18 months. While we embark on this first phase of transition, timeframes will be defined with milestones to transition to an increasingly capitated model of reimbursement, while maintaining fairness and transparency across the Health Share member entities as we move towards exploring natural systems of care and expanding mutual risk across all Health Share member organizations. 3 February 2015 Page 53 of 62

Initiative 1: Adopt Alternative Payment Methodology for Mental Health (Case Rate) Current State: The Regional Behavioral Health Steering Committee has agreed upon a unified Level of Care system for the region supported by LOCUS and CASII/ECSII. The current fee for service system needs to be transitioned to a new payment methodology that will allow greater flexibility in service delivery and align incentives for value versus volume. Future State: A standardized case rate will be paid for each outpatient level of care based on the expected intensity of service delivery for each level. A risk corridor will act as a governor for under or overutilization and a performance incentive will be included to reward identified outcomes utilizing treat to target. Process: Dale Jarvis, CPA, a national expert in alternative payment methodology, has been hired to consult on this initiative. A Case Rate Workgroup is meeting with Dale to develop the methodology, with Behavioral Health RAEs and provider participation. Outcomes/Benchmarks: Recommendations to the Behavioral Health Steering Committee are expected by March 2013. Timeline: Target date for implementing case rate payments is April 2013. 3 February 2015 Page 54 of 62

Section 4- Administrative Simplification Goal: Develop an administrative system that minimizes duplication and cost while increasing performance and enhancing service to our members and providers Current State: Health Share of Oregon s mission is to develop an integrated health system that achieves better care, better health, and lower costs for the Medicaid population and the Tri-County community. In order to achieve this goal, Health Share is committed to administrative simplification. Our goal for administrative simplification is to identify near and long-term opportunities, (including responsibilities, accountabilities, and timelines) that integrate the best in class systems and experience that our respective member and partner organizations have to minimize duplication, cost, and risk and accelerate performance in meeting our mission and the needs of our members. Currently, Health Share contracts with seven Risk Accepting Entities (RAEs). Four RAEs deal with physical health (CareOregon, Providence, Kaiser, and Tuality) and three RAEs deal with mental health (Multnomah, Washington, and Clackamas Counties). This transitional RAE structure was created to allow Health Share of Oregon to begin operations on September 1, 2012 and to allow the organization to properly evaluate administrative simplification opportunities and priorities. Current State Health Share Quality & Compliance Data Exchange and Consideration Clackamas County Multnomah County Washington County Kaiser CareOregon Providence Tuality Permanente Enrollment Communications Network Contracting Medical Management Claims Administration Customer Service Quality & Compliance Data Analysis and Reporting To achieve our goal of administrative simplification, Health Share engaged Optum Solutions to assist with the development of an administrative simplification plan for the organization. Optum Solutions has conducted interviews with each of Health Share s member organizations, the Oregon Health Authority, 3 February 2015 Page 55 of 62