Blue Cross & Blue Shield of Rhode Island (BCBSRI) Advanced Primary Care Program Policies

Blue Cross & Blue Shield of Rhode Island (BCBSRI) Advanced Primary Care Program Policies Effective 1/1/2016 The following program policies are applicable to all contracted providers and practices participating in Patient Centered Medical Home and/or System of Care arrangements. Unless otherwise stated, all communications for stated deliverables should be sent to PCMH@bcbsri.org or submitted via an established Secure File Transfer Protocol (SFTP) connection. All stated policies are subject to change at the discretion of BCBSRI Management. BCBSRI Management reserves the right to expand the scope of policies documented. Contracted practice sites will be notified of any changes in deliverables and/or requirements with sixty (60) calendar days written notice. Revised 11/30/2015 1

1. National Patient Centered Medical Home (PCMH) Recognition Standards Blue Cross & Blue Shield of Rhode Island (BCBSRI) believes that nationally recognized Patient Centered Medical Homes (PCMHs), such as those qualified by the National Committee for Quality Assurance (NCQA), can lead to higher quality and lower costs, and can improve patients and providers experience of care. The National Committee for Quality Assurance (NCQA) PCMH Recognition program is the most widely-used way to transform primary care practices into medical homes. The PCMH care delivery model is a way of organizing primary care that emphasizes care coordination and communication to transform and enhance primary care through achievement of key performance and accreditation standards. 1 Transformation Level NCQA recognizes three levels of PCMH Recognition, with each level requiring progressively advanced practice transformation activities. BCBSRI requires that all contracted PCMH practice sites achieve and maintain a minimum of NCQA PCMH Level 2 Recognition to participate in PCMH and/or Shared Savings arrangements. Contracted PCMH practice sites who reach NCQA PCMH Level 2 must achieve NCQA PCMH Level 3 within 12 months of achieving initial NCQA rating. Initial Recognition Contracted PCMH practice sites must submit a written project plan detailing the proposed timeline and activities related to NCQA submission within two (2) months of the contract effective date. Updated project plans will be required every three (3) months after the initial submission. Contracted PCMH practice sites must achieve at least NCQA PCMH Level 2 Recognition within twelve (12) months of the contract effective date. Contracted PCMH practice sites must submit the final NCQA application at least sixty (60) calendar days prior to the above-noted deadline to allow processing and review by NCQA. o Any site at risk of not meeting the submission deadline must submit a written explanation for the delay and a corrective action plan, including a projected timeframe for submission, to the attention of Director, Clinical Programs at least sixty (60) calendar days prior to the submission deadline. Contracted PCMH practice sites must notify the BCBSRI PCMH Team of the level achieved and dates of recognition by the above-noted deadline. Maintenance Contracted PCMH practice sites must submit a written project plan detailing the proposed timeline and activities related to NCQA renewal at least twelve (12) months prior to their NCQA expiration date. Updated project plans will be required every three (3) months after the initial submission. Contracted PCMH practice sites must achieve subsequent NCQA PCMH Level 3 Recognition within twelve (12) months of achieving Level 2 Recognition; contracted PCMH 1 http://www.ncqa.org/programs/recognition/practices/patientcenteredmedicalhomepcmh.aspx#sthash.2fahm6m1.dpuf Revised 11/30/2015 2

practice sites who have achieved NCQA PCMH Level 3 Recognition must achieve subsequent NCQA PCMH Level 3 Recognition by their current NCQA expiration date. Contracted PCMH practice sites must submit their final NCQA application at least 60 calendar days prior to the above-noted deadline to allow processing and review by NCQA. o Any site at risk of not meeting the submission deadline must submit a written explanation for the delay and a corrective action plan, including a projected timeframe for submission, to Director, Clinical Programs at least sixty (60) calendar days prior to the submission deadline. Contracted PCMH practice sites must notify the BCBSRI PCMH Team of the level achieved and dates of recognition by the above-noted deadline. Contracted PCMH practice sites must achieve and maintain at least NCQA PCMH Recognition as stated to be considered a PCMH practice and eligible PCMH providers. PCMH designation has both provider and member impacts. Failure to do so, or allowing a lapse in recognition dates, may result in any combination of the following: o Rescinding of PCMH designation by Payer; o Reduction or cessation of Case Management (CM) and/or infrastructure funding by Payer; o Recoupment of funds previously paid for the provision of CM services and/or additional financial penalties at the discretion of the Payer. Revised 11/30/2015 3

2. Active Provider Reporting Participation in the Patient Centered Medical Home (PCMH) and System of Care (SOC) value-based programs offers both provider and member level benefits, which may include enhanced payment and/or reduced member liability. Eligible providers must meet the following requirements: 1. Provider must be credentialed in an eligible specialty, as defined by the provided EHR Payment Policy; 2. Provider must utilize a qualified EHR, as defined by the provided EHR Payment Policy; 3. Provider or provider group must meet documented BCBSRI Access Standards, as defined by the BCBSRI Participating Provider Manual and the provided Access Policy; 4. Provider must achieve NCQA PCMH Recognition as applicable per contractual requirements and the provided National Patient Centered Medical Home (PCMH) Recognition Standards Policy; 5. Provider must develop and maintain a high risk registry, as defined by NCQA PCMH Standards and the provided National Patient Centered Medical Home (PCMH) Recognition Standards Policy; 6. Provider or provider group must work collaboratively with BCBSRI to deliver on PCMH and SOC program expectations, as defined by the provided Practice/Payer Collaboration Policy. Exceptions to the identified criteria must be reviewed and approved by the Director, Clinical Programs and/or the Managing Director, Health Systems Management and documented in the applicable contract(s). Contracted practice sites are required to submit notice when providers join the site using BCBSRI s Practitioner Change Form or System of Care Provider Change Form at least sixty (60) calendar days in advance of the intended change. If a provider ends his/her affiliation with a contracted practice site or group affiliation, it is the responsibility of the site to notify BCBSRI of the change and the provider(s) who will assume the impacted patients through written notice on practice letterhead. Please follow the submission requirements documented in the form and submit a copy of the completed form or written notice to the BCBSRI PCMH Team. Revised 11/30/2015 4

3. Nurse Care Manager (NCM) Roles and Responsibilities A Nurse Care Manager (NCM) plays an integral role in the success of a PCMH practice site. The NCM has direct, frequent and often face-to-face contact with all of the identified high risk members, as well as frequent interactions with clinical and non-clinical staff in the practice and in the community. BCBSRI delegates Care Management (CM) activities to practice-based NCMs only if the practice site is compliant with the provided National Patient Centered Medical Home (PCMH) Recognition Standards Policy and has a practice-based NCM. BCBSRI members attributed to a contracted PCMH site that does not yet possess NCQA PCMH Recognition will be managed by BCBSRI s internal CMs. BCBSRI CMs will always assist a BCBSRI member who requests, or is referred, for CM services to address an immediate need; if BCBSRI CMs provide CM services to an identified PCMH member, the CM will notify the identified NCM when s/he begins working with the member and communicate any clinically significant changes in health status. Hiring: Contracted PCMH practice sites must employ a practice-based NCM to provide CM services to identified high risk members. The NCM must meet the following minimum criteria, with additional education and/or experience requirements at the discretion of the practice: o Maintain an active, unrestricted Rhode Island Registered Nurse license o Minimum of 3-5 years of active RN experience o Designation as a Certified Case Manager (CCM) is preferred. If the candidate does not have CCM recognition, it is recommended within two years of employment. o Experience with Electronic Health Records and Microsoft Excel preferred Contracted PCMH practice sites must have a NCM employed within ninety (90) calendar days of the contract effective date, unless otherwise stated in the contract. Contracted PCMH practice sites must notify the BCBSRI PCMH Team once the NCM position is filled and at any time there is a vacancy or change in employment. Written notification, along with a coverage plan and recruitment plan, is required for any vacancy in excess of thirty (30) calendar days. All identified NCMs must have their own practice-provided email address and provide a direct telephone number for clinical transitions. BCBSRI will not provide Protected Health Information (PHI) to public domain email addresses. Training: NCM candidates should have extensive experience in clinical case management, including active Certified Case Manager credentials. At a minimum, NCMs are expected to be prepared to fulfill the following roles and responsibilities: o Provide primary care management services for identified high risk members, including assessment, care plan development, and member education; Revised 11/30/2015 5

o Act as a liaison between members, providers, community resources, and Payers; o Facilitate effective transitions of care through timely communication of necessary information for patient care and discharge planning; o Conducts medication reconciliation as appropriate and communicates any needed adjustments to care team and providers; o Appropriately documents member engagement for high risk engagement reporting. NCMs must participate in clinical trainings in accordance with the Office of the Health Insurance Commissioner (OHIC) guidelines for NCM education. BCBSRI reserves the right to audit NCM education at any time; if requested, contracted practice sites must provide requested documentation within thirty (30) calendar days of the request for documentation. Reporting: See provided High Risk Engagement Reporting policy for detailed requirements for reporting NCM engagement with identified high risk members. Contracted PCMH practice sites must provide updated NCM contact information, in writing, upon NCM placement, reassignment, or any vacancy within thirty (30) days of said change. Required information includes: o NCM full name o State(s) of licensure and RN License # o CCM status o Primary practice assignment and hours of availability o Practice assignment may include practice site and/or assigned clinicians o Any additional practice assignments and hours of availability, if applicable o Direct telephone number o If NCMs have multiple practice assignments, please provide a direct line (i.e. cell phone, forwarded line) to reach the NCM at any of his/her practice assignments. o Professional e-mail address for exchange of Protected Health Information (PHI) Due to the clinical importance and financial support of the role, BCBSRI will regularly conduct audits to ensure these positions are filled and the NCMs are meaningfully engaging with identified high risk members. Failure to hire a NCM within the first ninety (90) calendar days of the contract, a position vacancy of more than thirty (30) calendar days, or hiring a NCM who does not meet the outlined requirements may result in any combination of the following: o Rescinding of PCMH designation by Payer; o Reduction or cessation of Case Management (CM) and/or infrastructure funding by Payer; o Recoupment of funds previously paid for the provision of CM services and/or additional financial penalties at the discretion of the Payer. Revised 11/30/2015 6

4. High Risk Engagement Reporting Practice-based Nurse Care Managers (NCMs) are responsible for case management of identified high risk members in delegated Patient Centered Medical Home (PCMH) practice sites. As NCMs are case managing active BCBSRI members on behalf of BCBSRI, NCMs are expected to provide engagement reports indicating their involvement with BCBSRI-identified high risk members and Transitions of Care members. High risk members are determined by the Johns Hopkins Adjusted Clinical Groups (ACG) System, which is used to stratify active BCBSRI patients. This system assigns a Resource Utilization Band (RUB) score ranging from 1, low risk, to 5, high risk. To further assist PCMH partners in identifying the highest risk members for intervention, members are assigned a risk category. The criterion for each category is as follows: Red is as follows: o Patients identified as RUB 4 or RUB 5 with at least one of the following criteria: Predicted inpatient probability 30% or greater Total cost of $100,000+ o Patients identified as RUB 3 with a diagnosis of CHF o New Medicare Advantage members with an HCC score of 2.5 or greater New to BCBSRI following CMS Annual Enrollment Period and/or as members age-in to Medicare coverage Orange is as follows: o 3+ IP in last 6 months o 3+ ED in last 6 months o 3+ Chronic Conditions High Risk Transitions of Care members, as identified in the daily Transitions of Care (TOC) discharge reports. Monthly patient panels of active, attributed BCBSRI members, provided on the last business day of the calendar month, and daily Transitions of Care reports are provided via a Secure File Transfer Protocol (SFTP) site and/or via the BCBSRI Population Health Registry. Practices in the process of establishing an SFTP connection may receive the monthly patient panels via secure email to approved emails at the discretion of BCBSRI s Chief Privacy Officer. NCMs are expected to actively engage at least forty percent (40%) of BCBSRI-identified high risk members, as defined above, unless otherwise stated in an executed contract. Engagement rate targets will be updated annually; it is the expectation that contracted PCMH practice sites will demonstrate increased rates of engagement year over year. Engagement is defined as members who have agreed to participate with the NCM and have a documented active care plan in place. Revised 11/30/2015 7

NCMs will document the following minimum data elements for identified high risk members and Transitions of Care cases: a. Open: Date referral was received by NCM b. Participating: Date of engagement (i.e. the date the member consents to participate or work with the NCM) c. Closed: Date member was discharged from ongoing CM services; d. Closed Reason: Expired, Declined, Unable to Contact, Goals Met, LTC Resident, Inappropriate for CM e. Intervention Type/Level: Measurement of low-moderate-high level intensity. The following are recommendations on how to classify intensity of CM services provided: Complex: Requires 60+ days of active CM services; Transitions of Care/Moderate: Requires 30-59 days of active CM services, such as moderate-term case management for TOC or other CM events; Short-Term/One-Time Touch: May be a specific request for social, transportation, welfare, or referrals that will not require NCM management after addressing of immediate need. High Risk Engagement Reports will be provided to BCBSRI by the 20 th of every month, or closest business day, for activity completed in the previous calendar month. Files will be returned via the same mechanism as received by the practice. High Risk Engagement Reports should be saved using the following file naming format: Contracted Group_Practice Site_NCM Engagement_MMYYYY. If submitting via secure email, please submit via secure/encrypted email according to organizational requirements for exchanging PHI, to PCMH@bcbsri.org, with the email subject line in the same format as the file name. Timeline Example: PCMH Practice A will receive an updated monthly panel from BCBSRI by December 31 st. PCMH Practice A will provide the high risk engagement report, documenting services provided during the month of January, by no later than February 20 th. Sites that do not adhere to timely submission requirements will be contacted by Director, Clinical Programs. Repeated noncompliance with required NCM reporting may result in any combination of the following: o Rescinding of PCMH designation by Payer; o Reduction or cessation of Case Management (CM) and/or infrastructure funding by Payer; o Recoupment of funds previously paid for the provision of CM services and/or additional financial penalties at the discretion of the Payer. Revised 11/30/2015 8

5. Practice/Payer Collaboration Policy Blue Cross & Blue Shield of Rhode Island (BCBSRI) partners with select primary care practices to facilitate practice transformation efforts aligned with NCQA PCMH Recognition. BCBSRI is committed to assisting contracted PCMH practice sites with practice transformation activities that are designed to improve clinical outcomes, increase patient and provider care team satisfaction, and optimize efficiency within the practice-setting. To this extent, BCBSRI provides the services of a highly trained PCMH Practice Facilitation (PF) Team, which is available to offer in-kind support to contracted PCMH practice sites. Who They Are BCBSRI s PCMH PFs have extensive clinical and business leadership experience, making them ideal candidates to assist in the primary care office setting. Our PFs have active Rhode Island nursing licenses and/or Master s Degrees in a healthcare related field. Areas of specialization include: Certified Content Experts in NCQA s PCMH Recognition program, Certified Professionals in Electronic Health Records, and Certified Case Managers. Additional areas of expertise include office workflow redesign, medical terminology, and customer service. Services Provided The PF team completes an initial onsite assessment within three (3) months of the contract effective date, unless an alternate date is agreed upon by the practice and BCBSRI leadership. The initial assessment includes at least two (2) BCBSRI PFs and will take one (1) business day to complete. Additional PFs and/or additional hours may be required depending on the size of the practice. It is the expectation that contracted PCMH practice sites will engage with these facilitators in a timely manner. This will be communicated to the practice during the planning process. The initial assessment will include: Initial staff meeting to introduce PFs and explain the onsite process Individual interviews with office manager, all providers, and all staff members Shadow of office staff, including front/back office and Medical Assistants Perform at least two (2) complete patient pathways A detailed transformation report, highlighting strengths and opportunities in key areas of PCMH practice transformation, will be provided following the initial assessment. Completed reports will be delivered to practices within eight (8) weeks of the initial onsite assessment, unless an alternate date is agreed upon by the practice and BCBSRI leadership. Ongoing practice Facilitation services offered include, but are not limited to: Communication Strategies Enhanced Access High Risk Case Management Guidance, including Transitions of Care workflows NCM Practice Integration NCQA Revised 11/30/2015 9

Practice Workflow Optimization Pre-visit Planning Quality Improvement including Plan-Do-Study-Act (PDSA) Team Building Practice Facilitators will engage with the contracted PCMH sites at least quarterly; contracted PCMH sites that are new to the PCMH program may have more frequent interactions, at least monthly. Additional interactions will occur as needed and/or as requested by the PCMH practice site. Interactions may occur via in person meetings, telephone calls, and/or attendance at community meetings or events. PFs will report engagement with practices to external organizations (i.e. CTC leadership) as contractually required. Revised 11/30/2015 10

6. Value-Based Programs Payment Contracted Patient Centered Medical Home (PCMH) practice sites and Systems of Care (SOC) are eligible to receive payments in accordance with the executed contracts. Payments are designated for use related to practice transformation, infrastructure, care coordination, and earned incentives. Unless otherwise documented, payments will be made by the end of the first month of each calendar quarter. Payments are calculated based on the previous month s attributed membership for contracted PCMH/SOC providers. Please refer to the executed contract(s) for attribution methodology, member eligibility, and payment terms. Revised 11/30/2015 11

7. Access Contracted PCMH practice sites are expected to meet all documented BCBSRI Access Standards at all times. Please refer to Section 3.4 Access in BCBSRI s Physician/Provider Agreement Administrative Policies for the minimum requirements in the following areas: Access for new and established patients; Timeliness of returned phone calls; Timeliness of provision of medical services in urgent and non-urgent situations; Physical accessibility to and within the practice site. Contracted PCMH practice sites will submit documentation detailing active providers accepting new patients, and the third next available new patient appointment, quarterly throughout the active contract period. Reports are due to BCBSRI by the 10 th,or closest business day, of the first month of each calendar quarter. PCMH practice sites must improve access beyond the BCBSRI network requirements. PCMH practice sites must meet the following access requirements: Baseline: Within forty-five (45) days of contract execution, contracted practice sites will provide documentation demonstrating both the third next available appointment for established patients and the next available appointment for new patients for the first thirty days of the contract period to serve as the access measurement baseline. Contracted practice sites will also provide the average weekly clinical hours for each of the affiliated providers. Year 1: It is the expectation that contracted practice sites will meet the following access requirements within twelve (12) months of the contract execution date: New Patients First available appointment time with any provider in the practice will be available within thirty (30) calendar days; Established Patients Third next available routine appointment time with any provider in the practice will be available within seven (7) calendar days. Contracted practice sites will provide both documentation demonstrating the third next available appointment for established patients and first available appointment for new patients the last thirty (30) calendar days of the first twelve (12) months of the contract period to demonstrate improvement on outlined access measures. Contracted practice sites will also provide the average weekly clinical hours for each of the affiliated providers. Reports must be submitted within thirty (30) calendar days of the reporting period. Subsequent Contract Years: It is the expectation that contracted practice sites will improve access requirements for each subsequent contract year meeting, if not exceeding, the following access standards by 12/31/2018: New Patients First available appointment time with any provider in the practice will be available within seven (7) calendar days; Revised 11/30/2015 12

Established Patients Third next available routine appointment time with any provider in the practice will be available within two (2) calendar days; Implementation of open access scheduling; Access seven (7) days per week, including at least two (2) evenings; Access to providers through use of alternative sites such as retail clinics, urgent care or telemedicine services. Timeline Example: PCMH Practice A s contract period begins January 1, 2016. Baseline data, as outlined above, will be due by February 14, 2016. Year 1 data, as outlined above, will be due by January 31, 2017. Subsequent reporting years will be due by January 31 st of each subsequent contract year. Note: All PCMH and SOC practice sites contracted prior to 1/1/2016 will follow the Baseline reporting requirements for 2016. Revised 11/30/2015 13

8. Quality Performance Quality improvement activities are central to the Patient Centered model of care in both contracted Patient-Centered Medical Home (PCMH) and System of Care (SOC) practice sites. As such, providers participating in a contracted PCMH or System of Care practice site must participate in all BCBSRI s quality improvement programs for which they are eligible. At a minimum, contracted practice sites must meet the following: Annual participation in Clinicians and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS), including providing required patient level information as requested, educating patients on the survey process and timeframes, and encouraging participation; Annual participation in BCBSRI Pay-for-Performance (P4P) program, achieving results in the 95 th percentile or higher, unless otherwise stated in an active contract. Contracted practice sites must access and submit reports in the stated manner and within all specified timeframes to be eligible for participation. Additional quality reporting as required by an active contract. Quality reports must be submitted in accordance with program and contractual requirements. BCBSRI reserves the right to deny contracted practices from participating in these programs if reports are not received by stated deadlines, in the manner specified in program materials, or if a Corrective Action Plan (CAP) is in place. Revised 11/30/2015 14

9. Utilization Management Contracted Patient-Centered Medical Home (PCMH) and System of Care (SOC) practice sites have the unique opportunity to impact utilization of healthcare services, ensuring the appropriate care is provided in the appropriate setting and at the appropriate time. Enhanced practice site access and patient education will improve utilization management and performance. Contracted practice sites must participate in BCBSRI utilization review, meet contractual requirements regarding utilization metrics, and participate in BCBSRI and State-led cost containment strategies, which will be communicated in detail as programs launch and/or expand. Contracted practice sites will be provided with daily Transitions of Care reports that identify active BCBSRI patients who have been discharged from a participating facility and/or facility type to assist in identifying patients who require outreach to coordinate discharge planning and provide education about accessibility in the primary care setting, when applicable. - Revised 11/30/2015 15

Glossary of Terms BCBSRI Blue Cross & Blue Shield of Rhode Island CTC Care Transformation Collaborative, the statewide PCMH program CM(s) Case Management services, Case Managers CCM Certified Case Manager NCM Nurse Care Manager NCQA National Committee for Quality Assurance PCMH Patient Centered Medical Home PF(s) Practice Facilitation/Practice Facilitators RN Registered Nurse SOC System(s) of Care SS Shared Savings arrangement Revised 11/30/2015 16