Testing States

Colorado

Click Here for Updated State Plan
State's SIM website

  • Focus on 12 core population health target areas. (p.1)
  • Winnable Battles provide a framework for progress across a broad set of public health goals. Led by the Colorado Department of Public Health and Environment (CDPHE), multiple state agencies and community partners have prioritized Colorado’s 10 Winnable Battles – focus areas such as obesity, substance use and mental health, tobacco, unintended pregnancy, and oral health – in which Colorado can make population-level progress in a relatively short period of time. (chart with focus area and targets on p.3-4)
  • Governor John Hickenlooper set the stage in 2013 for Colorado to become the healthiest state in the nation when he unveiled the administration’s sweeping health agenda, The State of Health: Colorado’s Commitment to Become the Healthiest State. (p.2); a listing of The State of Health metrics that align with Colorado's SIM efforts are included on p.5.
  • Population Health Transformation Collaboratives will be comprised of community health leaders and will disseminate evidence-based strategies, assist with setting priorities and goals, support collaboration toward population health goals using established metrics, and distribute resources to local agencies. Collaboratives will work with our newly created Health Extension Service to strengthen work underway at the local level and will be defined around existing state divisions to maximize shared resources. (p.6)
  • The core objective of the measures that will be used in the Colorado SIM minimum dataset is to leverage and consolidate existing measures that are agreed upon by public health experts, providers, and CPCi payers, including Colorado Medicaid. To demonstrate this alignment, the following table details the 12 core population health target areas we will use in SIM and how each maps across other initiatives, including Colorado’s Winnable Battles, USPSTF A & B Recommendations, CDC Recommendations, and CPCi measures. (p.7-9)
  • Colorado’s Chronic Disease Plan - one of the efforts upon which we will build for our Plan for Improving Population Health - adopted the CDC framework for organizing public health initiatives into five domains: epidemiology and surveillance; policy and environmental change; health systems transformation; community clinical linkages; and media and education. (p.10)

Connecticut

Click Here for Full State Plan
State's SIM website

  • Led by the DOH, the plan is for Prevention Service Centers (PSC) to be created to support clinical practice and for Health Enhancement Communities (HECs) to be formed around multi-sector coalitions to address social determinant of health in particularly burdened communities. PSCs will focus on healthy homes and healthy behaviors. PSC will be competitively procured among LHDs, community organizations and FQHCs and will be staffed with host agency staff and CHWs. HECs will focus on community prevention as well as job training and community development. HECs be financed through state funds, new Medicaid reimbursement for non-clinical services or through other innovative approaches. (p.3)

Delaware

Click Here for Full State Plan
State's SIM website

  • Governor’s Council on Health Promotion and Disease Prevention brings together statewide leaders to address important health challenges. (p. 2)
  • "Healthy Neighborhoods" - local communities that come together to form a multi-stakeholder coalition to address Delaware's pressing health needs (includes schools, employers, and community organizations, primary care physicians, behavioral health providers, FQHCs, and at least one health system). Statewide program that will offer funding and resources for individual communities to: convene forums of community leaders; align priority health areas of focus; assess existing resources; facilitate targeted interventions and track progress. (p. 3) Goal is to scale to 10 Neighborhoods statewide. (p. 4)
  • Plan for Improving Population Health will be based on Healthy Neighborhoods strategy. (p. 6)

Idaho

Click Here for Full State Plan
State's SIM website

  • Health promotion and wellness are central tenets of Idaho’s healthcare redesign. (p. 1)
  • Recruit public health districts to serve as Regional Collaboratives, integrating public health and physical health at the local level. (p. 2)
  • The Public Health Division within the Idaho Department of Health and Welfare (IDHW) will work with Idaho’s 7 regional public health districts to develop and implement a state-wide plan for improving population health. (p. 2)
  • Timeline for Idaho's Health Improvement Plan (IHIP). Based on the plan, the IHIP will be completed in early May 2015. (p. 2-3)
  • The IHIP will address the core measures of tobacco use and the incidence of obesity and diabetes. Additional measures may be selected based on Idaho needs identified in the IHA. (p. 3)
  • The Regional Collaboratives (RCs) will serve as the public health/physical health integrator in local communities. Idaho’s 7 regional public health districts (PHDs) will contract with IDHW to serve as the RCs. The RC will assist local PCMHs by establishing formal referral and communication protocols within the broader medical neighborhood to facilitate coordinated care, support local innovation and expand evidence-based practices. (p. 8)
  • Performance Measures for Population Health. (p. 26-27)

Iowa

Click Here for Full State Plan
State's SIM website

  • Specific Population Health Improvement Initiative within 6 Priority Areas - targeting ACOs and local delivery systems and integrating health care & PH. Some initiatives driven through ACO and others through LPHA. Population Health Initiatives Table. (p. 3)
  • The LPHAs will link members to community-based resources and will use the data collected through the HRA to define gaps and provide public health programming. Iowa will use the SIM rapid-cycle evaluation process to further develop the Healthy Behaviors requirements, expand the program to the full Medicaid population, and test the ability to collect, refine, and use SDH data to improve population health. (p. 5)
  • The SIM Initiative will test the provision of a shared support system through the development of Community Care Teams. Community Care Teams will act as a platform to connect ACOs to resources available in the community and will ignite the population health strategies outlined in the SIM. (p. 12)
  • Community interventions focused on obesity; patient engagement; tobacco use. (p. 4)

Michigan

Click Here for Full State Plan
State's SIM website

  • Plan for Improving Population Health is a key objective. The Blueprint for Health Innovation along with the State Health Improvement Plan (2012) provides a foundation for improving population health. (p.1-5)

New York

Click Here for Full State Plan
State's SIM website

  • "Prevention Agenda" (PA) details goals in 5 areas: chronic disease, MCH, environmental health, vaccination-preventable diseases, behavioral health. The PA will be integrated into the SIM and the new Medicaid waiver. Public Health consultants will work in 11 regional entities to link Advanced Primary Care (APC) practices with community resources. APC is the foundation of care transformation; the highest level of APC will include community-facing coordination and care agreements w community partners. (p.1)

Ohio

Click Here for Full State Plan
State's SIM website

  • Incorporate population health measures into regulatory and payment systems, and use those measures to align population health priorities across clinical services, public health programs, and community-based initiatives. (p. 1)
  • Prioritized expanding patient centered primary care, reducing tobacco use and exposure, preventing obesity and chronic disease, and reducing infant mortality. (p. 2)
  • Systematically incorporate population health measures into all regulatory and payment programs. (p. 3)
  • Align Community Health Needs Assessment and population health planning to identify clear population health priorities across regions. (p. 4)
  • Convene population health leadership team through the Governor’s Office of Health Transformation (OHT) to develop a broader statewide population health plan. (p. 4)
  • Three existing Regional Health Improvement Collaboratives (RHIC) provide statewide leadership for payment and practice transformation. (p. 21)

Rhode Island

State's SIM website
Click Here for Full State Plan

  • Population Health Plan will be directed by a Senior Public Health Epidemiologist from the Department of Health (DOH) and a Chief of Transformation from BHDDH. They will oversee the work of two vendors we will hire to develop the Population Health Plan. (p. 4-5)
  • Based on the FOA directions and our efforts on the State Health Innovation Plan, Rhode Island aspires to focus population health in the following areas: chronic disease treatment and prevention, preventable utilization, infectious disease prevention, behavioral health, child and infant health, and end of life care and palliative care. (p. 4)
  • Rhode Island’s vision is to ensure that all Rhode Islanders have the opportunity to achieve the best possible mental health and well-being within healthy local communities that promote empowerment, inclusion, and shared responsibility. (p. 5)
  • Rhode Island envisions a population health model that: is based on the need and demand for behavioral health services across the continuum of age groups from infancy through older adults; embraces decision-making based on evidence based practices for each age cohort to create effective prevention and treatment delivery; and ensures effective action through the collaborations with state agencies, private partners and community participants. (p. 5)
  • The development of the Population Health Plan will be supported by several existing initiatives. Among these is a study on the demand, supply and cost of behavioral health treatment that will be completed within the pre-implementation period as well as existing and continuing community health assessments and already available data. (p. 6)

Tennessee

Click Here for Full State Plan
State's SIM website

  • The Department of Health is legislatively mandated to maintain and update a State Health Plan. The Plan will be enhanced through the development of specific and measurable goals, an increased focus on population health improvements and addressing disparities, and specific commitments from stakeholders to actions that support the goals. (p. 13-14)
  • Tennessee regulates the establishment and modification of health care institutions, facilities and services through Certificate of Need (CON). CON applications are reviewed on whether the proposed project is consistent with the State Health Plan, as required by the Tennessee Health Services and Planning Act. (p. 15)

Washington

Click Here for Full State Plan
State's SIM website

  • Prevention Framework is jointly run with Department of Health and Health Care Authority. Accountable Communities for Health (ACH) will rely on the Prevention Framework, convening multiple sectors to invest in evidence-based practices, evaluate, spread to scale and capture savings to reinvest. (p.5-6)
  • "Visualize Health in Communities" is an enhanced local mapping of health and social determinant data. (p.18)

Design States


American Samoa

More to come...

Arizona:
Click Here for Full State Plan
State's SIM website

  • Improving population health is one of the three components of Arizona's strategy. The plan will assess the overall health of the state and identify measureable goals, objectives and evidence-based interventions. (p.1)
  • The super-utilizer initiative will improve care coordination around members whose health outcomes are particularly impacted by a fragmented delivery system, with the long-term goals of improving provider and member engagement and developing a prevention model. (p. 9)
  • Overhaul of State regulations that allows providers to offer integrated health services under one license, eliminating regulatory barriers for the integrated whole person care that is a cornerstone of Arizona’s SIM strategies. (p. 14)

California

More to come...

District of Columbia

More to come...

Hawaii:
Click Here for Full State Plan
State's SIM website

  • Hawaii's Health Care Transformation Office (HCTO) will lead the effort to develop and implement a Population Health Plan (PHP). (p. 4)
  • Health Information Exchange (HIE) interfaces, delivery system tools and other functionality will help providers manage population health and coordinate. (p. 11)

Kentucky
Click Here for Full State Plan
State's SIM website

  • The Model Design will build on a number of reforms already underway or under discussion in Kentucky in the arenas of coordinated care delivery, chronic disease management and prevention, expanded use of health data and technology and leadership by local health entities. Kentucky will develop, in close concert with stakeholders, a population health plan that facilitates integration of population health strategies and metrics with public health officials and health care delivery systems, with particular attention to narrowing health disparities, expanding access to care at the local level and improving chronic disease prevention and management. (p. 1)
  • Kentucky’s PHIP will also have a strong focus on child wellness and prevention issues (ongoing work supported in part by a CDC 1305 Grant), particularly prevention of tobacco initiation and childhood obesity, including through ongoing school, childcare and community-based strategies, which will be synthesized with the PHIP. (p. 5)
  • Kentucky’s Model Design Population Health Improvement Plan (PHIP) will build upon the Commonwealth’s Affordable Care Act (ACA) implementation, Governor Beshear’s kyhealthnow initiative, and state population health plans in development. (p. 2)

Illinois
Click Here for Full State Plan
State's SIM website
  • The SHIP establishes priorities and strategies for health status and public health system improvement, with a focus on prevention. (p. 2)
  • The overarching goal of Illinois’ Plan for Improving Population Health (Plan for Pop Health) is to consider the health outcomes of the entire population and focus on reducing health disparities. This will be done by leveraging and enhancing existing State infrastructure to implement innovative approaches and further integrate population health strategies into the health care delivery system. (p. 2)
  • A revised State health assessment and Illinois’ Plan for Pop Health will be completed by January 2016, and the monitoring of CMS Core Measures and the implementation of public health strategies will be integrated into the health delivery system as proposed in the Innovation Plan. (p. 2)
  • The Innovation and Transformation Resource Center (ITRC) will also be established to provide technical assistance to integrated delivery systems, Pilots, and Regional Hubs. This ensures there is access to granular population health data to monitor the success of transformation efforts related to clinical care and population health. The ITRC will work with IDPH to support community capacity development to conduct needs assessments, certifications, and monitoring and support of community-based services. (p. 5)
  • The Plan for Pop Health will support the implementation of evidence-based clinical interventions recommended by the U.S. Preventive Services Taskforce and community interventions recommended by the Community Preventative Services Taskforce, Community Guide. (p. 3)

Maryland:
State's SIM website

More to come....

Montana

More to come...

Nevada
Click Here for Full State Plan
State's SIM website

  • Nevada's plan will integrate strategies that address Governor Sandoval 's core health care priorities as well as child wellness and prevention priorities such as reducing childhood obesity, preventing early childhood dental caries, and maternal depression to foster healthy child development. (p. 2)
  • The Nevada Division of Health Care Financing and Policy (DHCFP) is pursuing the State Innovations Model grant to design a statewide plan to improve the population health in Nevada. To accomplish this objective, DHCFP will leverage broad statewide support from health care providers, public health officials, industry associations, consumer advocacy groups, medical centers and researchers and all stakeholders to design and develop an innovation model that reflects the unique characteristics of Nevada's health care environment and population. Nevada will collaborate with Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) in developing our strategy. Nevada's plan will address the core measures identified in the population health metrics (i.e., tobacco use, obesity, and diabetes) as well as a selection of Nevada measures based on goals that are specific, measurable, achievable and realistic. (p.1-2)

New Hampshire:
Click Here for Full State Plan
State's SIM website

  • Plan for Improving Population Health includes a focus on prevention priorities. (p. 7) Updates will be provided on a NH Quality Indicators website. (p. 11)
  • Create a Regional Healthcare Cooperative Extensions (RHCE) Trust to sustain regional population health improvement initiatives through legislation. (p. 10)

New Jersey

More to come...

New Mexico
Click Here for Full State Plan
State's SIM website

  • NMDOH uses the SHA and SHIP to increase its focus on prevention in alignment with the National Prevention Strategy, and to refine and expand population based approaches to priority health indicators. (p. 1)
  • NMDOH has established successful population-based approaches to improving health outcomes at all life stages. These approaches include the Healthy Kids Healthy Communities program that targets, in part, childhood obesity; school-based health centers (SBHCs) that address adolescent health by expanding access to the uninsured and integrating behavioral health services; and the Tobacco Use Prevention and Control Program to address adult smoking behaviors. (p. 2)

Commonwealth of the Northern Mariana Islands

More to come...

Oklahoma
Click Here for Full State Plan
State's SIM website

  • The OSIM Population Health Plan (PHP) will be incorporated into the state’s overall Oklahoma Health Improvement Plan (OHIP) redesign process. As such, the PHP will be adopted by the OHIP Access to Services workgroup as an OSIM action plan with the goal of integrating state healthcare delivery systems with population-based primary prevention strategies, such as those found across the three flagship issues. (p. 3)
  • The PHP will use a socioecological framework for the delivery of evidence-based interventions across influencing environments. A primary goal will be to restructure healthcare investments in the state from a tertiary prevention focus toward increased adoption of secondary and primary prevention to yield maximum ROI related to healthcare costs, disease burden and premature death. (p. 4)
  • The OSIM project will strategically align population-based health outcomes with clinical quality measures using National Quality Forum (NQF) Measures and Clinical Quality Measures (CQM) for the targeted areas of tobacco, obesity, diabetes, hypertension and other health topic focus areas as defined by stakeholders and data analysis. (p. 7-8, see Table 1, p. 5)

Pennsylvania
Click Here for Full State Plan
State's SIM website

  • The goal is to improve population health by coordinating the health care delivery system and public health initiatives to reduce the prevalence of obesity and diabetes, as well as reduce tobacco use, improve childhood dental care, improve mental health service delivery, and improve service access for people with Alzheimer’s and Related Disorders. (p. 1, see Table on p.21-23)
  • Leveraging the State Health Assessment (SHA) findings and through the State Health Innovation Plan (SHIP), communities will be using a data-driven and community-preference approach to identify priority initiatives and to strategically deploy evidence-based resources that directly impact population health. (p. 3)
  • The core measure set will be developed with twin objectives of a) focusing providers and communities on key population health priorities and b) aligning Accountable Provider Organizations (APOs) and Patient-Centered Medical Homes (PCMH) contractual incentives on population health (and other) measures. These data will be collected and reported by Pennsylvania Health Care Cost Containment Council (PHC4) and used by providers, payers and the Transformation Center to identify gaps and implement targeted initiatives to close the identified gaps. (p. 19)

Puerto Rico

More to come...

Utah

More to come...

Virginia

More to come...

West Virginia
Click Here for Full State Plan
State's SIM website

  • Efforts have been made to overcome the isolation of services as technology and training have become more accessible, including: legislation for an All Payer Claims database, comprehensive state health plans (Health Care Authority, Bureau of Public Health), collaborative projects among Academic Health Centers, and development of the WV Health Information Network (WVHIN). The WVDHHR, home to the Bureau for Public Health, the Bureau for Behavioral Health and Health Facilities and the Bureau for Medical Services, takes an active, integrated approach to improving the health and well-being of the state. (p. 2)
  • The WV Health Innovation Collaborative (the Collaborative) has provided individual agencies, providers, and other stakeholders the opportunity to present their individual programs, success stories, metrics, and outcomes. These discussions have led to increased collaborations, thoughtful planning about common resources, additional training, and shared quality measures that had not taken place prior. (p. 3)
  • Through the Collaborative, stakeholders from both the public and private sector are reviewing state health statistics and available health care services, programs and providers to align quality measures throughout the state. In addition to developing an inventory of existing initiatives, the work groups are also leveraging current projects with the National Academy of State Healthcare Policy and the National Governors Association to develop a compendium of best practices for improving population health and providing better care at lower costs. (p. 12-13)
  • The current stratification of chronic disease throughout the state requires the evaluation to target select populations in terms of improvements in outcomes, health care procedures, reimbursement plans, and cost/utilization. It will be necessary to create a discrete set of quality outcome and cost and utilization measures that will show measureable progress towards the achievement of project goal. The Collaborative has started to develop standard quality measures for those health issues identified across the various age groups within WV. The design team will continue to work with members of the Collaborative to expand this process by developing outcome measures and model comparisons that map the population health indices and quality measures. (p. 13-14)

Wisconsin
Click Here for Full State Plan
State's SIM website

  • The Population Health Improvement Plan (PHIP) developed during the SIM design period will support greater alignment in local efforts to improve population health, as well as inform the efforts of the Wisconsin Department of Health Services (DHS) and Statewide Value Committee Leadership Council (SVC LC) to align clinical and community health improvement strategies to realize the bold vision of the state public health agenda, Healthiest Wisconsin 2020: “Everyone living better, longer.” This vision reflects the state health plan’s twin goals: 1) improve health across the lifespan, and 2) eliminate health disparities and achieve health equity. (p. 2)
  • Wisconsin will use the grant to support a multi-stakeholder planning process that will: 1) establish a common agenda for improving population health, and examine all focus areas identified in the SIM population health metrics document, along with state-specific priority areas; 2) identify a menu of evidence-based or emerging strategies that have the potential to demonstrate improvement in health, quality of health care and decreased costs in three to five years and that are measurable at the state and local/regional level; 3) secure commitments from local and state leaders across all sectors to support implementation of a comprehensive plan for population health improvement; and 4) disseminate these priorities and recommended action strategies by engaging public and private sector stakeholders at the local and state level, including policymakers.(p. 3)
  • Many population health improvement metrics identified in the SIM FOA align with focus areas in the state health plan, Centers for Disease Control (CDC) grants, clinical metrics currently tracked by the Wisconsin Collaborative for Healthcare Quality (WCHQ) and the SVC’s value measures (e.g., cancer screening, diabetes, childhood immunization, hypertension control, and health care acquired infections). (p. 13)