Board of Trustees Medicaid Transformation...Reduce opioid drug misuse through cross sector collaboration in Clark , Skamania, Klickitat counties. Community Care Coordination. Individuals

Project OverviewsMay 11, 2018

Board of TrusteesMedicaid Transformation

19/21/2018

9/21/2018 2

MEDICAID TRANSFORMATION PROJECTS

VisionA healthy southwest

Washington region where all people have equitable access to quality whole person care and live in connected and thriving communities without barriers to wellness

Health Information Exchange / Health Information Technology

Partners across the SWACH region have consistent communication and connectivity for improved whole-person, integrated care

Opioid ResponseReduce opioid drug misuse through cross sector

collaboration in Clark, Skamania, Klickitat counties

Community Care CoordinationIndividuals with health and/or social needs connect

to quality, coordinated care interventions and services to improve their overall health outcomes

Bi-Directional Clinical IntegrationIndividuals receive Behavioral Health and Physical Health services in each setting along SAMSHAs Six

Levels of Integration

Value Based PaymentProvide support to the region to transition from a volume based payment structure to

a value based payment structure to promote whole person care

Workforce DevelopmentSupport the development of an

empowered, compassionate, and sustainable workforce that is responsive to

community health needs in our region

Trauma Informed Care

Chronic CareProvide support for effective complex care and

disease management for targets utilizing CBOs and clinical providers to support interventions

Collaborative Shared LearningReduction of StigmaHealth Equity

DOM

AIN

ON

E

CARE SETTINGS

Emergency Department

Behavioral Health

Primary Care

Community Based Organizations

CORN

ERST

ON

ES

Community Engagement

Medicaid Transformation Project Overviews: Summary

9/21/2018 3

Project Overview: Bi-Directional Clinical Integration SWACH Lead: Daniel Smith

Aim Statement Individuals receive Behavioral Health and Physical Health services in each setting along SAMSHAs Six Levels of Integration

Target Population

All Medicaid beneficiaries (children and adults), particularly those at risk for behavioral health conditions, including mental illness and/or substance use disorder

Issues / Risks

Description Mitigation

Clinical Integration workgroup does not currently have representation from all involved parties.

Plan to re-charter workgroup and membership by September

Transformation Plan timeline is condensed Provider input at least three times during development. Build in extensions to deadlines as a contingency plan.

Changes from the State and risk that info will not flow to the ACH and providers timely

SWACH staying connected with HCA, legislature, WSHA, WA Academy of Pediatrics, Governor's office, and other ACH’s. Communicate changes to providers.

Unknown of 3rd payer launching in 2019 SWACH available to help providers navigate and align. Including potential new payers in meetings in SWACH meetings

Consolidation of the market - health system affiliations, payer arrangements and impact to the behavioral health market.

SWACH available as resource to support providers in making partnership and contracting decisions

Approach and Tactics

Work with partner organizations to develop their transformation plans, which will support the regional implementation plan developed by SWACH to achieve end state

Physical Health settings providing Behavioral Health services• Universal Screening for behavioral health• BH specialist as part of clinical team• Data systems to track outcomes and population health• Collaborative Care Model• Key elements of Bree Collaborative Model• Evidence Based treatment

Behavioral Health settings providing Physical Health services• Universal Screening for physical health• Medical services onsite or enhanced care link and shared

care planning with primary care• Data systems to track outcomes• Milbank Model of Care• Key elements of Bree Collaborative Model• Evidence Based treatment

Measures

Pay for Performance (P4P) Pay for Reporting (P4R)

• All-Cause Emergency Department (ED) Visits

• Inpatient Hospital Utilization• Follow up after ED visit for mental

health• Follow up after hospitalization for

mental illness• Follow-up after ED visit for alcohol or

drug dependence• Mental health treatment penetration• Percent homeless• Plan All-Cause Readmissions• Substance use disorder treatment

penetration• Child and Adolescents’ Access to

Primary Care Practitioners• Comprehensive Diabetes Care: Eye

Exam performed• Comprehensive Diabetes Care: HbA1c

testing • Comprehensive Diabetes Care:

Medical Attention for Nephropathy• Medication Management for People

with Asthma (5-64 years)• Antidepressant Medication

Management

• Assessment of integration of physical and behavioral health care (MeHAF Site Self Assessment tool-under HCA review)

G

9/21/2018 4

Project Overview: Bi-Directional Clinical Integration – Partner and Community Engagement

Partner Engagement

Clinical Integration Committee includes representatives from:• Catholic Community Services• Center for Community Health and Evaluation• Child and Adolescent Clinic• Children’s Center• Community Health Plan of Washington• Comprehensive Healthcare• Daybreak Youth Services• Klickitat Valley Health• Kaiser • Legacy Health Services• Lifeline Connections• Molina Healthcare• NAMI SW Washington• PeaceHealth• Providence Health and Services• Qualis• Rose Clinic• SeaMar Community Health Services• Skamania County• Skyline Hospital and Family Medicine• The Vancouver Clinic


• Our approach: Engage the community where they are through:

• SWACH initiated community discussions• Attendance at existing community groups• Launch of a Community Voices Council

Stakeholder Review

• Regular updates will be shared with RHIP and the Board

• RHIP will have opportunities to review and provide input prior to taking major final products to the Board

• e.g. Transformation Plan, Implementation Plan, Funds Flow, Workgroup Charters

9/21/2018 5

Project Overview: Opioid Response SWACH Lead: Eric McNair Scott

Aim Statement Reduce opioid drug misuse through cross sector collaboration in Clark, Skamania, Klickitat counties

Target Population

Medicaid beneficiaries, including youth, who use, misuse, or abuse prescription opioids and/or heroin

Issues / Risks


Waiting on process to fund initial pilot ideas which are ready to move forward; risk of partner disengagement if delayed

Working on funds flow model and initial grant process

Need plan to support and sustain momentum of Opioid task force, including definition of the role of SWACH staff

Working with Public Health, ACES Action Alliance, and provider champions on longer term model



Prevention Strategies• Disposal and secure storage of opioids• Use of PMP• Training and support for providers• TeleHealth (i.e. Project Echo)

OD Treatment Strategies• Increased distribution of naloxone• Increased access to naloxone

Treatment Strategies• Team model of engagement and care• Number of MAT providers in care settings outside of SUD

(Primary Care, Hospitals, ED, Specialists, etc)• Increased MAT initiation sites (Primary Care, ED’s,

Hospitals, HRC, etc)• Increased Tx access points in clinical and community

settings

Recovery Strategies• Increased peer support services• Peer access in clinical settings

Measures



• Inpatient Hospital Utilization

• Patients on high-dose chronic opioid therapy

• Patients with concurrent sedatives prescriptions

• Substance use disorder treatment penetration (opioids)

• Providers are trained on guidelines on prescribing opioids for Pain

• Practice/clinic site has EHRs or other systems that provide clinical decision support for the opioid prescribing guidelines

• Mental health and SUD providers deliver acute care and recovery services for people with OUDs

• ED has protocols in place for providing overdose education, peer support and take-home naloxone to individuals seen for opioid overdose

• Organization site connects persons to MAT providers

• Organization site received technical assistance to organize or expand syringe exchange programs

G

9/21/2018 6

Project Overview: Opioid Response – Partner and Community Engagement

Partner Engagement

Opioid Crisis Response Committee includes representatives from:• Clark County• Clark County Public Health• Clark County Sheriff’s Office• Columbia River Mental Health Services• Community Health Plan of Washington• Community Voices are Born• Comprehensive Healthcare• Cowlitz Tribal Treatment• ESD112• KLASAC• Klickitat Valley Health• League of United Latin American Citizens• Lifeline Connections• Molina Healthcare• Northshore Medical• PeaceHealth• SeaMar Community Health Services• Share Vancouver• United Health Care• Current email distribution includes 80 contacts • Anticipate moving forward with an Opioid task force and close

alignment with the Clinical Integration Committee




• Holding three events in May focused on:• Opioid prevention • Treatment• Addressing stigma

Stakeholder Review



• E.g. Transformation Plan, Implementation Plan, Funds Flow, Workgroup Charters

9/21/2018 7

Project Overview: Chronic Care SWACH Lead: Daniel Smith

Aim Statement Provide support for effective complex care and disease management for targets utilizing CBOs and clinical providers to support interventions

Target Population

Medicaid beneficiaries (adults and children) with, or at risk for, arthritis, cancer, chronic respiratory disease (asthma), diabetes, heart disease, obesity and stroke, with a focus on those populations experiencing the greatest burden of chronic disease in the region.

Issues / Risks


Lack of central hub for chronic disease self management education

Consider role of SWACH and potential community needs in implementation planning

Ensuring alignment with current initiatives and current contracts

Focus with providers on enhancing current interventions and supporting scaling to Medicaid



Chronic Disease Self Management Education programs• Partner commitment and resources to support patient

engagement• Best practices for patient retention• Central coordinating entity• Provider, environment, and patient readiness• Community clinical linkages to education and services

Community Paramedicine programs• ED / Hospital diversion and community education• Transition – follow up in community after acute episodes• Best and highest use of EMS resources• Community Health Worker developments

Measures



• Inpatient Hospital Utilization• Mental health treatment penetration• Substance use disorder treatment

penetration• Child and Adolescents’ Access to Primary

Care Practitioners• Comprehensive Diabetes Care: Eye Exam

performed• Comprehensive Diabetes Care: HbA1c

testing • Comprehensive Diabetes Care: Medical

Attention for Nephropathy• Medication Management for People with

Asthma (5-64 years)• Antidepressant Medication Management • Statin Therapy for Patients with

Cardiovascular Disease

• None

G

9/21/2018 8

Project Overview: Chronic Care – Partner and Community Engagement

Partner Engagement

Chronic Care is included in the Clinical Integration Committee, which includes representatives from:• Catholic Community Services• Center for Community Health and Evaluation• Child and Adolescent Clinic• Children’s Center• Community Health Plan of Washington• Comprehensive Healthcare• Daybreak Youth Services• Klickitat Valley Health• Legacy Health Services• Lifeline Connections• Molina Healthcare• NAMI SW Washington• PeaceHealth• Providence Health and Services• Qualis• SeaMar Community Health Services• Skamania County• Skyline Hospital• The Vancouver Clinic




Stakeholder Review




9/21/2018 9

Project Overview: Community Care Coordination SWACH Lead: Louise Nieto

AimStatement

Individuals with health and/or social needs connect to quality, coordinated care interventions and services to improve their overall health outcomes

Target Population

Medicaid beneficiaries (adults and children) with one or more chronic disease or condition (e.g. arthritis, cancer, chronic respiratorydisease, diabetes, obesity, stroke), or mental illness/depressive disorders, or moderate to severe substance use disorder and at least one risk factor (e.g., unstable housing, food insecurity, high EMS utilization)

Issues / Risks


Shared services contract with CCS on behalf of multiple ACH’s

Seeking collective alignment with other ACHs • Program Evaluation• Data • Security• Programmatic• Policy and Advocacy

Track closely and participate in the process; expect this to result in more cost efficient contract

Legal and technology expertise needed for Pathways Hub contracting process

Collective alignment with ACHs for legal and technology resources. Formalize shared services agreements for IT security



Pathways Community HUB• Reduce duplication of care coordination efforts• Measure and track outcomes• Value Based Paying contracting with MCO’s and payors

Support Rural care coordination needs

Support current coordination and referral efforts, e.g. 2-1-1

Measures



• Inpatient Hospital Utilization• Follow up after ED visit for mental health• Follow up after hospitalization for mental

illness• Follow-up after ED visit for alcohol or drug

dependence• Mental health treatment penetration• Percent homeless• Plan All-Cause Readmissions• Substance use disorder treatment

penetration

• None

Y

9/21/2018 10

Project Overview: Community Care Coordination – Partner and Community Engagement

Partner EngagementCommunity Care Coordination Workgroup includes representatives from:• 211 Info• Area Agency on Aging and Disabilities• Beacon Health Options• Community Health Plan of Washington• Community Voices are Born• Council for the Homeless• DSHS• EOCF of Washington• Free Clinic of SW Washington• Klickitat Valley Health• Legacy Health Services• Molina Healthcare• Northwest Justice Project• PeaceHealth• Providence Health and Services• SeaMar Community Health Services• Skamania County• United Health Care• Vancouver Housing Authority

• Engaged potential partner organizations and community on Pathways Hub model in Fall 2017 through RFA and education sessions for Care Coordinating Agencies (CCA) and Referral Agencies (RA)




Stakeholder Review




Opioid Taskforce

9/21/2018 11

Community Care Coordination

Clinical Integration Chronic Disease Opioid

SWACH Workgroup Structure

Current State –Project Workgroups

Potential Future State for Implementation –Shared Learning Collaboratives

Clinical Integration

Community Care

Coordination

LINKAGES

Key Milestones

Activity Target Date Status

Clinical Partner Assessment closed. COMPLETE G

Funds flow model for DY2 – 3 (2018 – 2019) finalized. TBD G

Provider partner payment (tied to assessment). 6/29/18 G

Develop Transformation Plan requirements and Tools for Regional Participants (draft distributed by June 11).

7/2/18 Y

Semi Annual Report #1 submitted to HCA. 7/31/18 G

Partners submit Transformation Plans. 8/17/18 G

Provider partner payment (tied to transformation plans). 10/1/18 G

SWACH Implementation Plan submitted to HCA. 10/1/18 G

Provider contracts/MOU executed. 12/31/18 G

SWACH Dashboard: Medicaid Transformation May 2018

Success Metrics

Description Target Actual Comments

Clinical Partner Assessment Participation

100% BH 69%PC 52%

Extensions to 5/18% indicates complete survey.

Transformation Plans complete

100% N/A

P4R HCA Measures being finalized

For 2019 reporting2A under HCA review 12

Overall Status

Area Status Notes

By C

are

Sett

ing

Primary Care Y Realigning primary care representation consistent with re-chartering Clinical Integration Committee

Behavioral Health Y Realigning behavioral health representation consistent with re-chartering Clinical Integration Committee

ED Y Little penetration from two ED departments as work has been focused on BH/PC settings.

CBO Y Defining approach for CBO transformation plans to include CBOs in all planning and development.

By P

roje

ct

Clinical Integration G

Opioid Response G Three Opioid focused community events in May.

Chronic Care G

Care Coordination Y Contract with CCS for Pathways Hub technology and Healthy Gen for consulting. Align with 5 ACHs implementing Pathways.

Issues / Risks


Changes from the State and risk that info will not flow to the ACH and providers timely

SWACH coordinating with providers and stakeholders (e.g. providers, WHA, Governor’s office)

Unknown of 3rd payer launching in Q1 2019 SWACH available to help providers navigate and align. Including potential new payers in SWACH meetings

Consolidation of the market - health system affiliations, payer arrangements and impact to the behavioral health market.

SWACH available as resource to support providers in making partnership and contracting decisions

In jeopardy, intervention requiredNo concerns to escalate Some risk, monitor closelyG Y

R

Vision A healthy southwest Washington region where all people have equitable access to quality whole person care and live in connected and thriving communities without barriers to wellness

9/21/2018 13

SWACH Dashboard: Operations May 2018

HR Finance Contracting IT

Status Yellow Yellow Green Green

Updates Posted positions: • Community

Engagement Coordinator

• Finance Director• Contracted for interim

Communications Lead• Contracting for AP/AR

function with local company

• Reviewing organizational roles and staffing models

• Phase 2 Funds flow being finalized

• Initial community engagement for FIMC priorities

• Mid Adopter incentive payments pending to support Klickitat County

• Interim Finance support being provided by Pierce and will transition AP/AR to local contracted agency

• HCA Contract Amendment• Point B SOW updated to

include additional capacity for transformation plan support

• VALO SOW executed for Website redesign

• Contract IT support in place• Updated, secure network

infrastructure (Wi-Fi) deployed in SWACH offices

• SharePoint collaboration site in development

• Website redesign / updates in progress

Issues / Risks • Finance Director application pool not as robust as expected. Potentially extend recruitment window

• Organizational needs review needs further inputs

• Knowledge transfer from Pierce to in house for AP/AR

149/21/2018

Recommendationsto the Board

• Nominate Klickitat County representative

RECENT DECISIONS

Workgroup RHIP Board

• Re-Charter Clinical Integration Committee by 9/1

• Input for transformation plan at three different points

• Data and Learning Workgroup under review

• Opioid Workgroup under review• Care Coordination workgroup

under review

• Review and make recommendations for charter update

• Approved funds flow for Phase I-Transformation Planning and Assessments

Recommendations and Decisions

Measure Date SWACH Performance

Statewide Performance

Relative to State

All-cause Emergency Department Utilization (per 1,000 member months) * MY 2017 53 50

Antidepressant Medication Management – Acute MY 2017 51% 49%

Antidepressant Medicaid Management – Continuation MY 2017 36% 33%

Child and Adolescent Access to Primary Care (12-24 months) MY 2017 89% 93%

Child and Adolescent Access to Primary Care (2-6 years) MY 2017 81% 84%



Comprehensive Diabetes Care: Eye Exam MY 2017 38% 31%

Comprehensive Diabetes Care: HbA1c Testing MY 2017 83% 84%

Comprehensive Diabetes Care: Medical Attention for Nephropathy MY 2017 86% 86%

Follow up after Discharge from ED for Alcohol or Other Drug Dependence (7 day) MY 2017 31% 23%

Follow up after Discharge from ED for Alcohol or Other Drug Dependence (30 day) MY 2017 40% 31%

Follow up after Discharge from ED for Mental Health (7 day) MY 2017 58% 60%

Follow up after Discharge from ED for Mental Health (30 day) MY 2017 72% 71%

Follow up after Hospitalization for Mental Health (7 day) MY 2017 84% 80%

Follow up after Hospitalization for Mental Health (30 day) MY 2017 91% 87%

Inpatient Hospital Utilization (per 1,000 member months) * MY 2017 63 65

Pay for Performance (P4P) Measure DashboardMeasurement Period: July 2016 – June 2017 (MY 2017)

Legend

Data Sources

Data sources used include:Healthier Washington Data Dashboard + RDA Measure Decomposition Reports

SWACH performance is at or above statewide

SWACH performance is below statewide

SWACH is the lowest performing ACH region

15

May 2018

Improvement over Self

Gap to Goal

*lower rate indicates better performance

Legend

About P4P Measures

The first year ACHs will be held accountable for P4P measures is CY 2019. Performance in CY 2019 will be compared to baseline (CY 2017). Official ACH baseline performance will be calculated for CY 2017; the state intends to release baseline results in October 2018. Official improvement targets and benchmarks for measures will also be released in October 2018. SWACH performance reported here is preliminary.

Benchmarks for gap to goal measures will likely be the national Medicaid 90th percentile; ACHs must close the gap between baseline and benchmarks by 10%. Targets for improvement over self measures will be based on 1.9% improvement from baseline.

Future updates of the P4P Measure Dashboard will include official baseline and benchmarks / improvement targets. The P4P Measure Dashboard will be updated quarterly where possible; however, some measures are only available annually or semi-annually.

SWACH performance is at or above statewide

SWACH performance is below statewide

SWACH is the lowest performing ACH region

16

May 2018

Measure Date SWACH Performance

Statewide Performance

Relative to State

Medication Management for People with Asthma MY 2017 34% 31%

Mental Health Treatment Penetration MY 2017 47% 46%

Percent Homeless * MY 2017 4% 5%

Plan All-Cause Readmission* MY 2017 11% 14%

Substance Use Disorder Treatment Penetration MY 2017 31% 28%

Patients on High Dose Chronic Opioid Therapy

Data for these P4P measures are not yet available. Patients with Concurrent Opioid and Sedative Prescriptions

Statin Therapy for Patients with Cardiovascular Disease

Substance Use Disorder Treatment Penetration (Opioids)

Improvement over Self

Gap to Goal

*lower rate indicates better performance

Pay for Performance (P4P) Measure DashboardMeasurement Period: July 2016 – June 2017 (MY 2017)

9/21/2018 17

SWACH Partnering Providers MCO’sASSESSMENT• Deploy a portfolio of current state assessment(s)

TRANSFORMATION PLANNING• Develop Transformation Plan requirements and

Tools for Regional Participants • Submit to HCA MTP Regional Implementation Plan• Ensure partners meet Transformation Plan

requirements• Support regional continuous improvement process• Identify regional workforce shortages and capacity

building solutions • Review local HIE/HIT assessment results • Based on current state assessment results develop

regional strategy to address HIE/HIT

TRANSFORMATION INVESTMENT PLANNING• Review regional transformation plans to identify

regional capacity investments and implementation

ASSESSMENT• Complete portfolio of current state assessments

(HIE/HIT, PH and BH)

TRANSFORMATION PLANNING• Review and provide input into transformation plan

template and guidance• Participate in transformation plan webinar• Develop an organizational level plan to meet

transformation requirements to include identification of target populations, equity/stigma/Trauma Informed supports, partner development, continuous improvement plan, workforce and HIE/HIT needs.

• Ensure leadership sponsor is identified to transformation plan milestones

• Submit Transformation Plan• Ongoing active participation in Clinical Integration

Committee

TRANSFORMATION BUDGET• Identify initial transformation Plan Budget and

Capacity needs

• Support continuous improvement • Support regional HIE/HIT strategy at the state level• Support each provider to move into VBP contracts• Support data needs for providers• Performance metrics/measurement developments• Assist providers to asses and develop a sustainable

business model to whole person care requirements and VBP

Roles: Transformation Planning

Documents

Board of Trustees Medicaid Transformation...Reduce opioid drug misuse through cross sector collaboration in Clark , Skamania, Klickitat counties. Community Care Coordination. Individuals