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Summary by Focus Area:

Prevention & Population Health:
  • Accountable Care Communities. (p. 27-32)
  • 2-3 Pilots focused on cardiovascular disease

Financing Population Health:
  • Wellness Trust Funds for Accountable Care Communities
  • Develop Impact Equation (total savings = target population x engagement rate x savings/person/year)
  • ROI Accountable Care Communities goes back to the Trust

Transforming Clinical Care:
  • Improve maternity care (decrease electives, increase VBACs). (p. 16-19)
  • Health Homes for Complex Patients
  • Integrate palliative care into primary care

  • TA for EHR/HIE for health homes, application of telehealth/mobile-health
  • Develop All-Payer Claims Database

  • Community Health Workers (CHW): Plan focuses on CHWs or "front-line workers," as essential to primary care teams in 3 of the plan's 4 initiatives: ACOs, Health homes for complex patients, and palliative care integration into primary care.
  • The plan refers to leveraging the state's primary care office to focus on underserved communities, training for cultural competency and supporting the 4 initiatives.

  • Integrated Health Association (IHA) to lead incubation of payment reforms centered on pay for performance (P4P)

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Summary by Focus Area:

Prevention & Population Health:
  • “Health Extension System” – clinician technical assistance to support transformation and linkages to public health, linkages between providers and linkages to Community Health Improvement (CHI) initiatives.
  • Community health to connect with Health Information Exchange (HIE).
  • Need to strengthen and modernize Public Health workforce.

Financing Population Health:
  • Public health to join Accountable Care Organizations (ACOs) and bill insurance carriers for services (e.g., community health workers).

Transforming Clinical Care:
  • Colorado Medicaid has established 7 Regional Coordinated Care Organizations (RCCOs) which receive out-come based payments, along with the participating primary care providers within the RCCOs.
  • Primary care providers use “Medical Neighborhood” approach to partner with selected specialists and to leverage telehealth opportunities.
  • Incremental approach to care coordination/shared savings and risk/ global budgets. (p. 79-88)

  • Special attention to tribes, homeless, children/youth.

Behavioral Health:
  • Integration (bidirectional) of behavioral health and public health is the cornerstone of Colorado’s transformation vision. (p. 55-78)
  • One Regional Coordinated Care Organization (RCCO) is integrating behavioral health and primary care in its global payment from Medicaid.
  • Moving primary care and behavioral health providers to teams to share patients. A lot of provider support to accomplish integration.
  • Recognizes essential contribution of public health to the “Health Extension System” aimed at supporting behavioral health integration.
  • Most of expected savings likely to come from behavioral health integration with chronic disease complex patients.

  • Serious workforce shortages, especially in rural and frontier areas, for primary care and behavioral health clinicians. The plan presents medically underserved shortage area data for primary care and behavioral health.
  • Community Health Workers (CHWs): references a pilot (Rocky Mountain Health Plan) that integrates Community Health Workers into Primary Care/Behavioral Health team. Work is underway by the Colorado Trust to standardize Community Health Worker training.
  • Good chart of examples of an integrated Primary Care/Behavioral Health team functions and personnel responsibilities. (p. 112-115)

  • Summary of short and long-term legal barriers to behavioral health/primary care integration. (p. 178-182)

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Summary by Focus Area:

Prevention & Population Health:
  • Two initiatives to develop a “Community Integrated Health System:
    1. “Designated Prevention Service Centers (DPSC)”: Evidence-based primary and secondary prevention supporting Advanced Medical Homes. Initial focused of Designated Prevention Service Centers is on indoor environmental quality and healthy behaviors, staffed with certified Community Health Workers. Initial targets include: diabetes prevention program, asthma home assessment, and falls prevention.
    2. “Health Enhancement Communities (HEC)”: multi-sector coalitions to improve public health and reduce disparities of communities 10,000-80,000. Strong existing collaborations will be intensified, will be linked to local clinical reforms, will have common measures, and will have state leadership.
  • 3-5 Health Enhancement Community grants will be competitively awarded.
  • Each Health Enhancement Community will use evidence-based initiatives toward 4 priorities: tobacco, nutrition, physical activity and diabetes care. Interventions based on policy-, systems- and environmental-level change. (p. 70-84)

Financing Population Health:
  • Start-up 1-2 years for Designated Prevention Services Centers to come from foundations or SIM funds, and thereafter from billing to Primary Care Providers.
  • Anticipates legislation to establish the Health Enhancement Communities with a permanent Health Enhancement Community reserve fund. A portion of savings accrued in the Health Enhancement Communities will be returned to the Fund. Also, tax credits and other benefits to providers, etc. to invest in Health Enhancement Communities.

Transforming Clinical Care:
  • Advanced Medical Homes for Primary Care, with financial incentives for pay-for-performance.
  • Incremental shift from fee-for-service to value-based payment (rewards for quality and care experience), then moving to shared savings.
  • Must align payers to adopt similar rewards and common scorecard.

  • Plan states that eliminating disparities is a priority in every aspect of the Plan.
  • Strong existing culture to fight disparities. (p. 51-52)
  • Establish an Equity and Access Council to develop metrics/analytics to guard against under-service.

Behavioral Health:
  • Studying regulatory barriers to behavioral health/primary care integration. (p. 158)

  • Information Technology elements of Plan initially focused on developing and enhancing provider and payer analytics: patient attribution, risk stratification, risk adjusted cost comparisons, quality and utilization metrics. In Year 3, plan focuses on integration with public health systems. (p. 108)
  • Developing an All Payer Claims Database (APCD).

  • Develop a “Connecticut Service Track” to promote population health and inter-professional teams within professional training.
  • Develop training and certification standards for Community Health Workers (CHWs) with careful attention to assuring linguistic/cultural competency and creating a career pathway for existing workers and those from underserved areas.
  • Primary Care Graduate Medical Education (GME) changes to align with transformation.
  • Develop articulation agreements between entry- and advanced level colleges to allow mobility for healthcare workers.
  • Include transformation concepts in Graduate Medical Education (GME) and residency programs.

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Summary by Focus Area:

Prevention & Population Health:
  • “Healthy Neighborhoods” (p. 82-87): Neighborhood Councils, led by a full-time ‘Champion” to develop shared database of resources, develop (with hospitals) common goals and scorecard, develop cross-trained Community Health Workers (CHWs) to eliminate barriers external to delivery system and care coordinators to eliminate barriers internal to healthcare system.

Financing Population Health:
  • No mention of long-term sustainability.

Transforming Clinical Care:
  • Elements of clinical reform: patient registries, risk stratification, clinical guidelines, care coordination, multi-dimensional teams, patient engagement, performance review.

  • No mention, all sub-populations defined by age or medical condition.

Behavioral Health:
  • Primary care Graduate Medical Education (GME) changes to align with transformation.

  • Very high Health Information Exchange adoption rate.

  • References roles of care coordinators (largely based in ambulatory care settings with complex patients), and Community Health Workers (CHWs) working in the Healthy Neighborhoods to promote wellness. (p. 97)
  • Very detailed plan for a “Delaware Health Professions Consortium” high-graduate school levels, emphasizing team care, flexibility, etc. Delaware does not have a medical school, therefore “opportunities for state to invest in teams.” (p. 99-104)

  • Interesting graphics to evaluate community vs. clinical interventions, utilization and costs (p. 46, 48, 49)
  • Graphic derived from Institute of Medicine (IOM) analysis of sources of healthcare waste. (p. 123)

Click Here for Full State Plan

Summary by Focus Area:

Prevention & Population Health:
  • No reference to broad, primary community health improvement beyond various types of care coordination with Patient Centered Medical Home (PCMH).

Transforming Clinical Care:
  • Expand Patient Centered Medical Homes (PCMHs).
  • Care coordination for high-risk: Medicaid Health Homes.
  • Community Care Networks reimbursed by all payers and focusing on those at risk of a chronic disease or already with complex chronic disease, 3 pilots for super-utilizers: Behavioral Health, Community Paramedicine, and Department of Public Safety. Emergency Medical Technicians (EMTs) may be extenders for Federally Qualified Health Centers (FQHCs) (EMTs in rural areas provide post-acute care with statewide Electronic Medical Record (EMR) and single contract for service delivery).
  • Also, a focus on recidivating inmates with chronic diseases in partnership with the Department of Public Safety.

  • Plan expresses a 4th objective to the “Triple Aim (+1)”: to reduce health disparities.

Behavioral Health:
  • Behavioral Health/Primary Care integration is a focal point of Plan, with strategies to: increase primary care telemedicine consults with behavioral health, screening for depression, behavioral health policy analysis to develop further advances, co-locate behavioral health and Primary Care, Develop learning collaboratives. (p. 46)

  • Establish career pathway for the state’s 243 school health aides to become medical assistants, Community Health Workers (CHWs), or receive their bachelor’s degree in Public Health.
  • Community Health Workers (CHWs): Currently there is a 2-yr Community Health Worker program at the University of Hawaii. Legislators are looking to increase cultural competency training and explore certification.
  • For substance abuse, certified peer specialists and substance abuse counselors can bill Medicaid for services. SIM grant would expand trainings for certified peer specialists.
  • Establish an advanced practice registered nurse educational program.

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Summary by Focus Area:

Prevention & Population Health:
  • No discussion of any SIM investments in social or environmental determinants or in stare or local public health/prevention infrastructures. The Plan calls for local health departments to share the findings of community health needs assessments with the Regional Collaboratives, who will integrate these needs/resources with those of local Patient Centered Medical Homes (PCMHs). Regional Collaboratives will also ‘recruit practitioners and medical neighborhood participation…” (pg. 34)

Financing Population Health:
  • No discussion of financing population health, just financing reforms to medical care – moving from fee-for-service to shared savings with quality incentives.

Transforming Clinical Care:
  • This is a very medically-oriented (not community-oriented), private (nongovernmental) model. Focus of most of the Plan is to move to Patient Centered Medical Homes (PCMHs) across the State, led by a new non-profit, the Idaho Healthcare Coalition and Regional Collaboratives. (It was decided that local public health would not be the chosen structure for the Regional Collaboratives. Regional Collaboratives would be newly developed extensions of the Idaho Healthcare Coalition in order to be faster and more consistent.) (p.23)
  • Places all coordination responsibilities, including those with entities in the “medical neighborhood”, with the Patient Centered Medical Home (PCMH), as well as on-going population health management. (Pg. 32).

  • 2 of Idaho’s 5 tribes gave input, focusing on behavioral health and specialty coordination needs.

Behavioral Health:
  • Provides for behavioral health integration in Patient Centered Medical Home (PCMH) with the goal of “10X10”: increase life expectancy of those with serious mental illness by 10 years in 10 years.

  • Idaho has very low Health Information Exchange participation and no Statewide Health Improvement Plan. A first priority for the new Coalition is to develop baseline metrics for population health improvement and uniform measuring capability.

  • Virtually all of Idaho is a behavioral health workforce shortage area and most is also a primary care shortage area. Key strategies are: the model of a “virtual Patient Centered Medical Home”, using Community Health Workers (CHWs) and community emergency medical personnel to perform key primary care functions.
  • Also, telemedicine for behavioral health consults.

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Summary by Focus Area:

Prevention & Population Health:
  • Key goal #3 of the Plan is to enhance public health efforts to address social and environmental factors influencing the health of specific populations. (pg. 21)
  • Four key values underlying public health improvements:
    • health equity,
    • integration
    • continuous learning, and
    • sustainability.
  • Proposed public health innovations:
    • Regional public health hubs bring together state and local public health, communities and the Alliance (a government-appointed group of providers, public health, businesses, payers, community development advocates).
    • Community assessments will be aligned across local public health, hospitals and others, with shared metrics and data support from the Hubs.
    • Convening stakeholders will be a Hub activity, to shield hospitals from anti-trust as they collaborate on assessments, etc.
    • Planning interventions will be supported by the Hubs which will advise on evidence-based interventions and try to get communities to link interventions for maximum collective impact.
    • Hubs will also have roles in evaluation, data collection, dissemination, and capacity building.
  • Uses Asset-Based Community Development method and seeks to improve broad quality measures, including quality of life, community health, along with medical outcomes.

Financing Population Health:
  • Plan proposes to engage health economists to estimate monetary value of Hub interventions and ensuing return on investment. Then they will attempt to structure a sustainable funding model, taking into account the value of public health efforts to all community stakeholders, including employers. The idea is for regional wellness trusts to be funded by investments by regional stakeholders. (pg. 24).
  • Also, the Alliance is exploring social impact bonds for public health application.

Transforming Clinical Care:
  • Key goal #1 of the Plan is to develop integrated delivery systems of providers serving identified patient populations and linked by shared governance, performance management, Health Information Technology systems, shared savings payments, and practice-level care coordinators. Begins with Medicaid, to advance to Medicare, large employers including the state, and commercial plans. Plan expects to eventually develop standardized pay-for-performance targets across all payers – Medicaid, Medicare, commercial.

  • Key goal #2 of the Plan is to assure needed services and supports for people with special needs: mental illness, homeless, old and frail, justice-system involved, HIV/AIDS, intellectually or developmentally disabled. Primary care providers and specialists roles, composition of medical homes, care teams, Community Health Workers (CHWs) will all be redefined to care for special needs people.

Behavioral Health:
  • Plan recommends behavioral health integration into primary care via Screening, Brief Intervention, and Referral to Treatment (SBIRT), adding types of behavioral health providers able to direct bill Medicaid, establishing a core set of behavioral health services that various providers could deliver, develop metrics for quality outcomes and shared savings in behavioral health.
  • Use peer mental health counselors.

  • Plan is to establish All-Payer Claims Database (APCD).

  • 4 approaches to workforce reform:
    • Create new roles, including Community Health Workers (CHWs),
    • Standardize curriculum and research to evaluate effectiveness and resulting economic development associated with Community Health Workers,
    • Enhance training for home care aides and community paramedics in chronic disease management, and
    • Plans to expedite pathway for veterans to work in civilian roles.
  • Ensure that medical professionals work at the top of their license.
  • Expand capacity training for primary care, specialists, and behavioral health.

  • The Plans goal is to maintain continuous quality improvement throughout the health system.
  • Governor's Office of Health System Transformation comprised of senior health policy advisor, Office of Health Information Technology, agency heads, and an academic partner to establish Innovation and Transformation Center which provides technical assistance to agencies and partners to accelerate information technology, rapid-cycle feedback, and economic modeling for payment innovation.

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Summary by Focus Area:

Prevention & Population Health:
  • Plan will establish patient-centered, value-based delivery system through Regionalized Accountable Care Organizations (ACOs) that will begin with a Accountable Care Organization with phasing in of behavioral health and long-term care services and supports. The proposal plans for 6 regions. (pgs. 22-23, 124)

Financing Population Health:
  • Multi-payer Accountable Care Organization (ACO); Value-based payment reforms using the Wellmark Value Index Score (VIS) as the main framework and then building out to add behavioral health, and long-term care services and supports measures. (pgs. 10-11,15, 114, 134). Accountable Care Organizations (ACOs) will be responsible for the total cost of care but will receive financial incentives (bonus to providers for enrollees receiving prevention/assessment services and rewards to providers). (pg. 12)

Transforming Clinical Care:
  • Using a request for proposal (RFP) process the state will detail the deliverables of the Accountable Care Organizations (ACOs) but will not dictate what type of entity can be an Accountable Care Organization. This is to better manage the high-cost, high need population and cut down on unnecessary emergency room usage and hospital admissions and days, care coordination, and appropriate use of services. To ensure, that this is not the only population, specific measures will also be added for children. (pg. 135) Will also continue to explore metrics for holding Accountable Care Organizations to performance standards related to social determinants of health. See page 146 for a detailed diagram of cost reduction and population health improvement goals.

  • There are plans to specifically address the needs of the children, and the planned disparities in the future as a result of the demographics of the Iowa population changing from increased needs of the aging population, variance in the racial make-up. Identifies the need for supports for children diagnosed with serious emotional disturbance (SED) being greater in the African American Population.

Behavioral Health:
  • Plans to phase in behavioral health during phase 2 of 3. Behavioral health issue/barriers (pg. 53); Serious Emotional Disturbance (pg. 73)

  • Adoption of Health Information Exchange and Electronic Health Record use. (pg. 97)

  • Workforce needs/analysis are detailed on page 47; additional information is available pages 138-143

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Summary by Focus Area:

Prevention & Population Health:
  • “Community Health Hubs” (CHHs) will cover a county or region and provide community-based care prevention and care coordination. CHHs will be selected on a competitive basis (may be hospitals, local health coalitions, LHDs, other non-profits) and will contract with Patient Centered Medical Homes (PCMHs) to define roles, data sharing, tracking, and performance monitoring. CHHs will deploy community health teams to provide non-medical community supports and to work closely with hospital discharge planners.
  • CHHs will have standard discharge measures
  • CHHs must focus on Medicare and Dual Eligibles and also may add another superutilizer group eg., HIV, children with rare conditions.
  • CHH services will be available to other payers.

Financing Population Health:
  • Funding for the “Community Health Hubs” (CHHs) will be on a “pay and/or play basis: "Play": payer enrolls their superutilizers into the full Community Integrated Medical Home (CIMH) model.
  • “Pay and Play”: payer chooses to enroll in a partial set of CHH services; for example, just non-medical supports but not care coordination, if that is already provided in the Patient Centered Medical Home (PCMH).
  • “Pay”: Payer chooses to continue to offer its own services.
  • All fees for community interventions will be paid out of SIM grant funds in first 3 years. “Pending a positive ROI, payers will pay for services in year 4 and beyond.” (pg. 60)
  • Payers choosing not to play will be evaluated based on established benchmarks. At the end of year 2, if their performance does not meet the benchmark, they must participate in year 3 and beyond with their own funds.
  • CHHs will be paid on a severity-adjusted capitated basis and will bill fee for service (FFS) to those payers who are purchasing only limited services.

Transforming Clinical Care:
  • Community Integrated Medical Homes (CIMHs) will be certified by the state, using the multiple eligibility and performance criteria already in use across different payers.
  • Goal is for 80% of the population to receive care from a CIMH by the end of the SIM grant.
  • Initial focus is on getting Medicare and dually-eligible people into CIMHs to support the 5-year Medicare cost savings goal of the Maryland' hospital waiver. Also, Medicare enrollees are more likely to be superutlizers and are the least managed of all groups.
  • Medicare will HAVE to participate in monitoring, bonuses, etc of the CIMH, if the Maryland plan is funded.

Behavioral Health:
  • Behavioral Health integration into services of the Community Integrated Medical Home (CIMH), including in large practices the addition of onsite social workers and addiction counselors, is essential since over 50% of Maryland superutilizers have a behavioral health co-morbidity.
  • Analysis of behavioral health integration through the “Four Quadrant Clinical Integration Model,” (pg. 46).

  • Currently a strong Health Information Technology (HIT) foundation, including an All-Payer Claims Database (APCD), Health Information Exchange (HIE), and integrated public health data.
  • To be added: Operational Management System: for Community Health Hubs (CHHs) to track the fidelity to community evidence-based interventions (EBIs) and their outcomes. Will also track the efficiency of various CHHs.
  • Uniform consent form to be developed.

  • Community Health Workers (CHWs_ to be used in Patient Centered Medical Homes (PCMHs) and community teams.
  • Maryland will develop standardized CHW training and certification and leverage existing partnerships with community colleges.
  • Will establish an Advisory Board to draft CHW and CHW supervisor curriculum and (perhaps phased) implementation.
  • The Maryland State Health Agency will oversee all policy development and certification of CHWs and keep a registry of CHWs.

  • Asserts 2 unique features of Maryland's plan: (1) The state’s unique hospital waiver, approved by CMS, which creates strong financial incentives for hospitals to increase quality, not quantity and (2) leadership for SIM planning is with the state public health agency.

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Summary by Focus Area:

Prevention & Population Health:
  • The major components of the Blue Print are: Patient Centered Medical Homes (PCMHs), Accountable Systems of Care, Community Health Innovation Regions, Payment Reforms, and Infrastructure (pg. 6)
  • Creates "Community Health Innovation Regions" where, "partners act cohesively with a broad-based vision for region-wide impact, to make the environment healthier and to connect health services with relevant community services." First steps are needs assessment and action plan (pgs. 93-95)

Financing Population Health:
  • Payment Reform: test models on a pay-for-performance continuum including shared savings, global payments, and partial capitation. (pgs. 96-107)
  • Community Health Innovation Regions must secure financial support from local public and private funding sources. (pg. 107)

Transforming Clinical Care:
  • "Patient Centered Medical Homes (PCMHs) are the core of the blueprint: expanding existing PCMH project by promoting interprofessional teams, increasing the number of providers and payers participating, and maintaining the support of existing payers. (pgs. 4, 10, 30-32, 80-82)"
  • Creates "Accountable Systems of Care" to promote integration, provider communication, and share in investments in data and Health Information Technology (HIT). (pgs. 83-93)

  • Part of overarching aim-"reduced health disparities associated with race, ethnicity, income, geography or source of insurance.” (pg. 71)
  • "Provides Accountable Systems of Care and Community Health Innovation Region incentives to address environmental and social determinants of health.” (pg. 11) Three of Governor Snyder’s initiatives – the Regional Prosperity Initiative, Early Childhood Education, and Pathways to Potential – emphasize integration, coordination, and collaboration needed to address social determinants and are mainstays of Michigan’s Blueprint. (pgs. 38-39)

Behavioral Health:
  • Behavioral health integrated into Patient Centered Medical Homes (PCMHs) and Accountable Systems of Care (pgs. 83-85)
  • Convened a " privacy work group to examine consent issues that will help facilitate appropriate information exchange between physical and behavioral health care providers." (pg. 118)

  • Chapter F provides thorough overview of Health Information Technology (HIT) plan. (pg. 113)
  • Data enhancements include a health provider directory to track provider affiliations to Patient Centered Medical Homes (PCMHs) and Accountable Systems of Care; collection and aggregation of cost and quality data from multiple payers and sources; mechanisms to prominently display progress towards overall State Innovation Model (SIM) goals; mechanisms to provide ratings and non-financial rewards to top-performing Accountable Systems of Care and Community Health Innovation Regions; and, public recognition programs that include profiling and performance rating of Patient Centered Medical Homes, Accountable Systems of Care, and Community Health Innovation Regions. (pg. 110)

  • Community Health Workers (CHWs): "Michigan’s Blueprint includes support for greater use of community health workers… " Includes, "efforts to define the roles and skill sets of community health workers...this may include development of a registry within the Health Professions Licensing Division in the Bureau of Health Care Services, at the Department of Licensing and Regulatory Affairs" (pg. 131). Also discusses CHWs as integral parts of health teams in Patient Centered Medical Homes (PCMHs) and potentially Community Health Innovation Regions.
  • Reviewing graduate medical education (GME) funding to figure out how best to address provider shortages. (pg. 130). Provides for training on team-based care. Scope of practice - Blue Print will "include identification and elimination of potential barriers that prevent health team members from practicing at the highest competency level of their license and training". (pg. 127)

New Hampshire:
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Summary by Focus Area:

Prevention & Population Health:
  • Transform the Long Term Services and Support Systems of Care in the State. Focus will be to expand services to those that may be at risk for needing services, but also to really target care coordination to the "superutilizers", as well as another subset (just below superutilizers) in order to prevent or delay worsening of conditions and needed demand for additional supports or use of unneeded services. Plans align with other public health programs and goals to further address chronic conditions. (pg. 41)

Financing Population Health:
  • Spending will be projected for this population along with a projected savings amount. If saving's goal is met, the incentive pool savings will be distributed to payers, providers, and reinvested to further enhance the systems, such as Health Information Technology (HIT). (pg. 5) Four Step Approach - access, empowerment, payment reform, and incentives. (pg. 28)

Transforming Clinical Care:
  • Pg. 29 for flow diagram. Will also expand Life Plan Coordination to those that may not meet criteria, such as those that are 21 and seniors. Families/Individuals will also have a long term services and supports (LTSS) budget in order to expand access to services, increase choice, and assist in managing costs of the system. In addition, because many in the target group receive supports from many programs and payers, efforts of the care coordination and medical home will be to assure the correct payer and decreased duplication of services. (pgs. 52-54)

  • Focus was mainly on utilization of services amongst the target population of individuals in need of or at-risk for needing long term services and supports (LTSS).

Behavioral Health:
  • "We plan to use this model as a means for incentivizing the provision of certain types of substance use disorders (SUD) treatment, as well as adding a broader array of this targeted care into the Life Plan itself. We recognize that incorporating screening for SUDs during the initial assessment phase for each of these populations (developmentally disabled, elderly, and behavioral health) is an important step to inform the individual’s Life Plan creation and its periodic updates. we also recognize the role of the Team Coordinator in this area. Specifically, we have identified a role for SUD treatment in both the training and evaluation components of the Team Coordinator function." (Pg. 43)

  • Plans to develop a robust, database-driven , web-based system to allow access to Life Plan, activities, long term services and supports (LTSS) budgets (family/individual), health outcomes, and consumer access. For use by consumers, state systems, and provider systems. (pg. 44)

New York:
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Summary by Focus Area:

Prevention & Population Health:
  • Plan uses State Health Department’s Prevention Agenda 2013 – 2017 as a guide for building healthy communities. Plan will work to strengthen links between primary care, hospitals, long-term care providers, local health departments, and a variety of community stakeholders.
  • Focus on the prevention of chronic illnesses – cancer, diabetes, heart disease, hypertension, smoking, and colorectal cancer. (pg. 17)
  • Promotion of healthy women, infants, and children.
  • Provision of effective mental health and substance use prevention and treatment services.
  • Prevention of HIV, sexually transmitted diseases, and vaccine-preventable diseases.
  • Link with “Regional Health Improvement Collaboratives” (RHICs) – promote regional health planning (11 RHICs).
  • Plan discusses the importance of care coordination. (pg. 65 and pg. 69)
  • Plan discusses the preventive care integration. (pg. 71)
  • Plan details its MCH focus. Providing and coordinating age and developmentally appropriate child care, including vaccinations, developmental screening, and preventive oral health practices, for all children, in accordance with AAP/Bright Futures guidelines. Integrating routine preconception and interconception care in routine primary care delivered to women of reproductive age (including screening and follow up for risk factors, management of chronic medical conditions, and use of contraception to plan pregnancies). (pg. 72)

Financing Population Health:
  • Couple the "Advanced Primary Care" (APC) model with innovative, tiered payments that cover cost of registries, care coordination, and care management; a variety of gain-sharing incentives for better managing care and costs and up front funding to help support technical assistance for practice transformation.
  • Harmonize with 1115 waiver and DSRIP program.
  • Value-based payment models (also focused on targeted populations).
  • Pg. 96 – Establish a flexible framework for value-based payment for APC – 1. Pay for performance; 2. Shared Savings; 3. Risk Sharing; 4. Care Coordination PMPM Payments.
  • Delivery System Reinvestment (pg. 166) and Program Investments. (pg. 167)
  • Net Savings – generate nearly $17B in gross value creation over five years. (pg. 168)

Transforming Clinical Care:
  • Advanced Primary Care (APC) – new care model defined as an augmented patient centered medical home (PCMH) that provides patients with timely, well-organized and integrated care, and enhanced access to teams of providers. (pg. 5) Built on 3 progressively advanced levels of integrated care: 1. Pre-APC, includes most primary care practices; 2. Standard APC, practice which meets and exceeds NCQA’s current standards for PCMH recognition; and, 3. Enhanced APC, practices in which behavioral health care is integrated into the primary care setting & practice participates in initiatives focused on improving broader community health.
  • Focus on primary prevention at the clinical and community level, and implementing effective linkages between primary care and community-based organizations.
  • Patient centered care measured by chronic disease management (diabetes and cardiovascular care) with specific focus on higher-risk populations and a spotlight on secondary & tertiary prevention. (pg. 27)
  • Make care more accessible through extended hours, same day appointments, and use of technology (telehealth, video, online/phone based consultations).

  • Plan states that “first critical step is to ensure that New Yorkers have access, without disparity, to quality health care.”
  • Prevention agenda also prioritizes addressing local health disparities.

Behavioral Health:
  • Behavioral health integration (pg. 70) - The Collaborative Care approach aims to detect and manage common mental health conditions in primary care settings, with an initial focus on depression
  • This approach is widely recognized as best practice, including by the Substance Abuse and Mental Health Services Administration (SAMHSA). It has demonstrated improved outcomes for mental health and other chronic health conditions such as diabetes, hypertension, and high cholesterol. Savings, over time, principally accrue in reduced high intensity medical services, including emergency departments and inpatient medical care (i.e., not mental health services).
  • Advanced Primary Care (APC)' practices also identify and respond to the needs of patients who use alcohol and other drugs at risky levels, and engage in behavior associated with health consequences, disease, accident, and injury. They will use techniques like Screening, Brief Intervention and Referral to Treatment (SBIRT)
  • Integrated licensing program. (pg. 80)
  • Dual-eligible work. (pg. 80)

  • Goal is to achieve 80% primary care provider (PCP) participation in the all-payer claims database (APCD) and/or Health Information Exchange (HIE). Second goal is to engage 20% of consumers in active use of their patient portal.
  • Work with county health departments and regional planning entities to develop & maintain registries of local organizations that provide care, support and education to improve community health and well-being.
  • Role of transparency and data sharing. (pg. 65)
  • More details on Health Information Technology. (pg. 124)

  • Targeted health care workforce strategy – building on those of New York's Medicaid Redesign Team (MRT). Four focus areas – recruitment & retention of primary care workforce (health care workers who support delivery of primary care) and update standards and educational programs.
  • Specific workforce details - accessible entry points for most consumers – LPNs, RNs, and NPs – who then coordinate with specialists. (pg. 107 and 115)
  • Collaborative care approach that supports individuals with 2 or more chronic conditions.
  • For mild to moderate behavioral health conditions, primary care-led screening and treatment that incorporates remote psychiatric consultant support.
  • All consumers – prevention through primary care screenings & involvement of health workers focused on consumer education.

  • System level goals: achieving top quartile performance among states in prevention and public health; greater than 20 percent improvement in avoidable admissions and readmissions; and 2 percent annual cost reduction against trend resulting in $5-10 billion in cumulative savings over 10 years.
  • State will use Rate Review process as a core mechanism to encourage payer innovations & investments in implementation of advanced primary care (APC) models developed in collaboration with participating providers.

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Summary by Focus Area:

Prevention & Population Health:
  • Integration between primary care and public health will connect clinicians with community services; build community health teams to empower patients to successfully manage illness and maximize resources.
  • Development of connections between community health and primary care - Ohio is working across public and private agencies and partners to implement a 28-point agenda for addressing the most common and preventable causes for infant mortality. These efforts tie in closely to the state’s efforts to improve care through the Patient Centered Medical Home (PCMH) model and increase efficiency through a perinatal episode of care model.
  • Approaches considered include the development of community health teams to connect patients with community resources to reduce risk and improve disease management for illnesses and injuries related to episodes of care. Expanding collaboration among providers, public health, community organizations, and health care insurers through the Ohio Patient-Centered Primary Care Collaborative (OPCPCC) was also discussed as a means to develop integrated community health approaches.

Financing Population Health:
  • Launching two models statewide – patient centered medical home and episode-based payments.
  • Value-based payment system.
  • Goal is to reach 50% of population in selected markets within 3 years and 80-90% of Ohio’s population.
  • Ohio plans to make a sizeable investment to launch and support both PCMH and episode-based payment models. Investments include the infrastructure required for payment innovation, as well as provider incentive dollars and funds for provider support as they shift care delivery to succeed under new models. (Pgs. 50-51)
  • Combined, the state is estimating projected costs to range from $35–75 million, depending on the path forward for implementation.
  • Expected cost savings will be reinvested in the model in the form of incentives for providers delivering cost-efficient, high quality, and well-coordinated treatment.

Transforming Clinical Care:
  • Improve the use of clinical data to assess and monitor population health, and create greater capacity to reach into more neighborhoods and improve health outcomes in whole populations.
  • Mention integration of clinical services and population health.
  • Patient Centered Medical Home (PCMH) Model - Integration of primary care, public health, and community health.
  • Episode-based payment model – encourages providers to coordinate patient care throughout the duration of an episode rather than on specific visits or procedures; increases coordination of care among multiple providers
  • Five episodes identified include: perinatal, asthma acute exacerbation, Chronic Obstructive Pulmonary Disease (COPD) exacerbation, joint replacement, and percutaneous coronary intervention. Ohio’s plan is to design, with payer and provider input, 20 episodes over the next three years.

  • Ohio’s plan highlights the Preventive Health and Health Services Block Grant (PHHSBG), which is administered by Ohio Department of Health. PHHSBG’s goals are to: achieve health equity and eliminate health disparities by impacting social determinants of health; decrease premature death and disabilities due to chronic diseases and injuries by focusing on the leading preventable risk factors; support local health programs, systems, and policies to achieve healthy communities; and provide opportunities to address emerging health issues and gaps. (pg. 17)
  • The plan also notes - disparities are often due to differences in access to health care and other social services, availability of community resources (e.g., safe places to be active, healthy food options, etc.) and economic and educational opportunities. To address this significant burden, Ohio is developing a cross-cutting approach to improve health and reduce disease. Developed by more than 40 statewide partners, the plan will leverage activities ongoing through the state’s expansion of PCMH, adoption of HIT, integration of clinical services and population health and development of connections between community health and primary care. (pg. 9-10)

Behavioral Health:
  • Focusing on mental health and developmental disabilities populations (as well as long term services and supports (LTSS). Pursuing managed care model with dual population (integrated care delivery system (ICDS). The ICDS will address the fragmented nature of services offered through the two separate entities by taking a person-centered approach to care coordination and providing a single point of contact across both Medicare and Medicaid.
  • Launched severe and persistent mental illness (SPMI) medical homes in 5 counties – plan to roll model out statewide in 2014.

  • Capitalize on existing in-state data and Health Information Technology (HIT) to regularly assess the progress of the models toward their specific goals of improving quality and patient care and lowering costs. These measures will, unlike now, be standardized to a much greater degree across payers and providers throughout the state and tracked on a more regular basis to evaluate the state’s performance across three main categories:
  • Goal achievement in overall program components: tracking the state’s progress toward reaching scale in patient centered medical homes (PCMHs) and episodes;
  • Specific program outcomes: achieving improvement in health system transformation, and improved risk reduction; and,
  • Stakeholder engagement: measuring satisfaction and level of involvement.
  • Plan calls for increasing adoption and use of HIT and electronic health information exchanges
  • Leverage Medicaid incentives for meaningful use; electronic health record adoption; and provider portal
  • Health Information Exchanges (HIE) – two exchanges in Ohio.

  • Coordinate health sector workforce & training – provider training programs to reinforce PCMH and episode based care delivery; build education opportunities for new providers; align incentives to encourage participation in education & training opportunities; enhance workforce infrastructure; enable workforce changes through regulatory policy
  • To support these models, Ohio will increase its number of primary care providers, improve the effectiveness of its interdisciplinary heath care teams and build its health care workforce in underserved areas. The new model will also require support from the entire health care community.

  • Prevention strategies include - help expecting mothers have healthy pregnancies through perinatal interventions to reduce low birth weight. (pg. 22)

Click Here for Full State Plan

Summary by Focus Area:

Prevention & Population Health:
  • Development of a community health improvement plan and implementation of improvements through the state’s ten county and municipal-based health departments and local health improvement coalitions.
  • Supporting the Healthy Pennsylvania health literacy initiative through Pennsylvania’s Family Place Libraries.
  • Utilizing technology to map chronic disease incidence to improve prevention and self-management of chronic conditions.
  • Maximizing patient engagement in behavior change to better manage chronic conditions and adopting healthy behaviors through acceptance of shared decision-making processes and tools and through the application of skills such as motivational interviewing .
  • Transformation Support Center – population roadmap for improvement focusing on the below items at practice level– 1. planned care and risk assessment at every visit using proactive team-based care, 2. patient self-management support, education, and activation, and 3. care coordination (hospital-based networks).
  • “Strengthening Public Health” – section (pg. 138)
  • Increase health literacy through Pennsylvania libraries. (pg. 143)
  • Utilize technology to address public health needs. (pg. 146)

Financing Population Health:
  • Focus on two priority payment models – Accountable Provider Organizations (APOs) and Patient-Centered Medical Homes (PCMHs) with a specific focus on providing intensive care management services to high-risk consumers, and a third pilot – Episodes of Care (EOCs).
  • PCMH core competencies. (pg. 44)
  • APO core competencies. (pg. 48)
  • Descriptions of models with linkages and strategies. (pg. 69)
  • EOCs – HealthChoices managed care organzations (MOCs) implement EOC models with their APOs as a means to align payer-APO-provider incentives. More details on pg. 77.
  • APOs - Larger organizations that have already developed PCMHs and which possess other necessary infrastructure will develop APOs and will be able to realize greater financial rewards by assuming downside risk.
  • An APO is an organized group of providers which contracts with a commercial insurer, CHIP or Medicaid managed care organization, or with a plan administrator for self-funded employers on a population-based payment basis and thereby assumes responsibility for the cost, health and health care of a defined group of patients. “APO” differs from the ACO term used by CMS since Pennsylvania stakeholders envision a more flexible concept whose design and execution will not be in lock-step with the Medicare Shared Savings or Pioneer ACO Programs. (pg. 70)
  • PCMHs (pgs. 74-76)
  • Net savings to Medicaid are estimated at $13 million in the first year and $185 million in the fifth year. Some of the savings will likely be returned to providers as part of planned risk-sharing arrangements.
  • Cost savings plan (pg. 212)

Transforming Clinical Care:
  • Chronic Care Initiative – this was launched in 2009.
  • Create a Healthcare Transformation Support Center (Transformation Support Center) – provide training courses, offer on-site technical assistance and link practices with community resources. Allows for dissemination of best practices throughout the state and provide instruction on how to engage in practice transformation. (pg. 40 and pgs. 43-44)
  • Special focus on patient engagement (pg. 51)
  • Regional Hubs as part of this initiative (pg. 56)
  • Expand telemedicine – provide additional specialty consultation services in outpatient (telepsychiatry) & inpatient settings throughout state.
  • Provide office-based care coordination and care management services throughout Pennsylvania through Accountable Provider Organizations (APOs) and Patient-Centered Medical Homes (PCMHs). (pg. 14)
  • Targeting the top 5% of Medicaid’s high risk consumers, community-based Care Management Teams (CM Teams) will provide services to two key populations:
    1. Medicaid consumers with complex medical needs who receive care from practices that are too small to maintain their own care management resources;
    2. Medicaid consumers not affiliated with an APO who have very complex psycho-social-physical needs that exceed the capability of primary care practice-based care management.
  • (Pg. 80) - The following disparity measures, for which Pennsylvania ranked 28th or below out of 50, indicate lack of good chronic care management:
    • hospital admissions for pediatric asthma (ranked 36th)
    • potentially avoidable hospitalizations from respiratory disease among adults (ranked 32nd);
    • potentially avoidable hospitalizations from complications of diabetes among adults (ranked 30th), and
    • percentage of adults who smoke (ranked 28th).
  • These and other indicators of health disparities, such as higher complications from poor chronic disease management in non-Hispanic black and Hispanic/Latino populations, will be directly addressed by the components of the Innovation Plan.
  • Access issues also noted – telemedicine as an approach to increase access. (pg. 107)

Behavioral Health:
  • Expand telemedicine – provide additional specialty consultation services in outpatient (telepsychiatry).
  • Transformation Support Center will provide support to primary care providers (PCPs) with identifying and coordinating referrals for mental health services.
  • Community-based Care Management Teams (pg. 77) - studies have indicated that many high utilizers have both physical and behavioral health co-morbidities. The diagnoses for many of the highest utilizers suggest that their conditions can be positively impacted by aggressive interventions. This is the target population that intensive care management programs have successfully impacted, resulting in reduced hospitalizations and emergency department visits.

  • Accountable Provider Organizations (APOs) and Patient-Centered Medical Homes (PCMHs) report common quality measures from electronic health records (EHRs) to Pennsylvania Health Care Cost Containment Council (PHC4), which will aggregate the data and make info available to providers, insurers and consumers.
  • Use data to inform performance improvement; insurers will use data for accountability & to modify payment; consumers will use data to inform provider choice.
  • Detailed Plan (pg. 100)
  • Enhanced collection, analysis and dissemination of claims-related data from hospitals.
  • integration of claims and clinical data. (pg. 111)

  • More extensive educational and training programs for clinicians and providers.
  • Obtaining an adequate supply of primary care providers and behavioral health providers – to do so:
    • Enhanced loan forgiveness for primary care and behavioral health (physician and non-physician) and dentists
    • More robust medical home training through Transformation Support Center
    • Redesign of medical school curriculum to focus on evidence-based practices, team-based delivery models, and creation of Pennsylvania Health Learning Network using telemedicine infrastructure
    • Detailed Plan (pg. 129)
  • Redefining roles for Medical Assistants (MAs), community health workers (CHWs) and Licensed Practical Nurses (LPNs) will be essential to achieve practice transformation. (pg. 132)

  • Overarching goal of plan to connect activities (including current reform activities) towards a common goal of reducing delivery system fragmentation and improving delivery system coordination thereby improving population health – so plan focused on:
    1. Care transformation support
    2. High Risk Care Management
    3. Medicaid as a value based purchaser
    4. Standardized, transparent performance measurement

Rhode Island:
Click Here for Full State Plan

Summary by Focus Area:

Prevention & Population Health:
  • 3 levels of measurement to improve the health of Rhode Islanders:
    1. Indicators of overall health – population-wide basis, years of potential life lost
    2. Prevalence of specific diseases & conditions that contribute to a population’s health
    3. Behavioral & lifestyle indicators that impact the health of the population
  • Focus on Population Health Management – 3 key strategies:
    1. Empowering and enabling primary care providers to be the central coordinator of care
    2. Supplementing primary care with robust, patient-centered care management tools & resources based on a modernized data infrastructure
    3. Leveraging those care management tools & resources to effectively engage people in their own health
  • (Pg. 79):
    1. Social and community service resource directory
    2. Through planning, encourage the state, cities and towns to understand social determinants of health
    3. Communication – Public Service Announcements (PSAs) & social media
    4. Create a sustainable, commonly available fund for prevention activities – could include vaccination, tobacco cessation, obesity prevention
    5. Targeted sustainable health promotion efforts:
      • Smoking
      • Obesity
      • Diabetes care management

Financing Population Health:
  • Goal is for 80% of Rhode Islanders to have access to care that functions in value-based payments such as Pay for Performance, Bundled Payments, & Shared Savings, Patient-Centered Medical Homes & Population-Based payment (global payment that must include behavioral health and ideally oral health in models).
  • Value-based care continuum (pg. 57)
  • Use regulatory and purchasing powers to set payment standards.
  • Total cost of care reductions (versus the trend) of over $1.25B over a five year period – primary driver of this will be increased care management that effectively reducse preventable utilization and improves health.

Transforming Clinical Care:
  • Integrate primary care with community groups, hospitals & specialists.
  • Full, statewide availability of Patient Centered Medical Homes – including pediatrics; involve specialists and hospitals also.
  • Expand use of Community Health Teams (CHTs) – using Vermont's Blueprint for Health as model – use CHTs for care coordination and management outside of clinical setting. Also, focus on needs of high-risk and rising-risk populations. Using specialized CHTs to focus on specific needs of persons with behavioral health needs. (pg. 63)
  • Use Community Health Teams as Patient Centered Medical Home (PCMH) enabler
  • Have nurse as care manager and clinical coordinator, as well as "stable" of care professionals.
  • Intermediary services for high emergency department (ED) utilizers – Rhode Island Medicaid has implemented “Communities of Care” which identifies high end ED utilizers, offers a progressive array of case management services and tracks utilization. (pg. 65)
  • Use of care transitions to reduce hospital readmissions. (pg. 68)

  • Pg. 104-105 describes specific plans.
  • Establish interagency education and information programs that articulate impact of social determinants of health on different agencies. Information will be routed in improved data collection and research on the social determinants of health of Rhode Islanders, and will include robust reporting on the economic and social implications of the relevant social determinants of health to each department.
  • Creation of a Health Care Innovation Trust Fund.
  • Access through Accountable Care Organization (ACO)-like organizations, common care protocols/guidelines and incentives will improve access and outcomes.

Behavioral Health:
  • Intermediary services for high emergency department (ED) utilizers – Rhode Island Medicaid has implemented “Communities of Care” which identifies high end ED utilizers, offers a progressive array of case management services and tracks utilization. (pg. 65)
  • Effective, meaningful integration with other parts of the system of care resulting in improved health (pg. 66)
    1. Include behavioral health payments in coordinated and integrated payment models
    2. Co-location of behavioral health and primary care – use Screening, Brief Intervention, and Referral to Treatment (SBIRT) and co-locate primary care at community mental health centers (CMHCs).
    3. Community Health Teams
  • Technology solutions to allow for effective coordination of care – information sharing and tracking of critical health factors.
  • Engaging patients in their health requires an effective patient interface.
  • Payment models that are based on costs of care for a population require provider organizations to understand and address trends of the costs of their population.
  • Technical systems that effectively and accurately record and report outcomes.
  • Use of Health information technology (HIT) in practice; centralized information. (pgs. 68 and 73)
    1. Enable real-time and point of care patient data – expand the presence & usability of electronic health records (EHRs).
    2. Offer technical assistance (TA), training and shared analytic resources to providers.
    3. Align quality, cost and utilization measures among payers & government.
    4. Use data to drive state health policy.
  • Establish a statewide authoritative Provider Directory. (pg. 77)

  • Community Health Workers (CHWs) under-recognized (however, plan noted a successful program within the Department of Health), but awareness and function low among providers.
  • The Rhode Island Care Transformation and Innovation Center (RICTIC) will focus on workforce development
    • develop uniform credentials and requirements for CHWs. (pg. 71)
    • conduct a workforce assessment
    • develop curricula for in-service training for professionals as well as students

CHNA & Community Benefits
  • In addition to regulatory authority, DOH also leverages existing policies and practices to drive healthcare facilities and professionals towards a Value-Based Care Paradigm. An example is adding conditions to the licenses of health care facilities to improve public health outcomes. This authority has most recently been used in the Certificate of Need process with several hospital acquisitions and the introduction of Minute Clinics. Conditions include setting clear expectations for the community assessment plans that IRS requires from non-profit hospitals through their 990H and conducting a joint public hearing process for health facilities. This is currently underway for hospitals. (p. 12)

  • Rhode Island Transformation and Innovation Center (RICTIC) provide technical assistance (TA) to providers and community-based organizations. (pg. 67 )

Click Here for Full State Plan

Summary by Focus Area:

Prevention & Population Health:
  • Patient Centered Medical Home (PCMH) model focused on primary prevention for healthy or at-risk patients and coordination of care for chronically ill.
  • Monitor population health status through tracking process indicators and indicators on intermediate outcomes.
  • Population models that emphasize prevention and wellness by design. PCMH models that reward providers based on their patient’s total cost of care provide new incentives to providers to make changes to their practice to ensure more patients receive preventive care. PCMH models also promote and support providers to counsel individuals to adopt healthy behaviors, such as encouraging treatment adherence, physical activity, tobacco cessation, and healthy eating.
  • More details on pg. 56.

Financing Population Health:
  • 3 strategies to payment & delivery reform:
    1. Expansion and alignment of patient-centered medical homes & other population-based models to reward health care providers who care for their patients on an ongoing basis, promote prevention, treat chronic conditions, and coordinate care over time.
    2. Episode-based payment that rewards providers for delivering high quality and efficient care for an acute health care event.
    3. Payment and delivery system reform to address the specific needs of populations that require long term services and supports.

  • Patient Centered Medical Homes (PCMH):
    1. Major payers in Tennessee have agreed to “Population-Based Models Charter” committing to have 80% of members across books of business cared for through a population-based model within 5 years.
    2. The major payers in Tennessee have agreed to launch a multi-payer initiative in 1-2 metropolitan areas, characterized by investment into the same practices and a common approach to quality, provider enrollment and payment methodology. This initiative could be scaled statewide, if successful.
    3. The state will lead by example by increasing enrollment in PCMH models with their managed care organizations (MCO) and administrative services organizations (ASO) partners, and by developing common definitions and alignment of the PCMH approaches of the TennCare MCOs.
    4. The state will make targeted investments to accelerate PCMH adoption across all insurers in Tennessee. The state will determine the best manner to invest in infrastructure to support PCMH expansion, for example, through shared care coordination capacity or the development of uniform PCMH provider reporting.
  • Episodes of Care:
    • This approach seeks to reward high-quality care, promote the use of clinical pathways and evidence-based guidelines, encourage coordination, and reduce ineffective and/or inappropriate care. Episode-based payment is applicable for most procedures, hospitalizations, acute outpatient care (e.g., broken bones), behavioral health conditions (e.g., ADHD, depression, substance abuse treatment), and some forms of treatment for cancer.
    • The initiative has completed design and is on track for multi-payer implementation of a first wave of three episodes in Tennessee: perinatal care, total joint replacements, and acute asthma exacerbations. The initiative will begin reporting actionable information on the first wave of episodes to providers for commercial (including Benefits Administration members), TennCare, and CoverKids members in January 2014. Additional episodes will be designed and introduced thereafter; 75 episodes will be implemented in Tennessee over the next five years.

Transforming Clinical Care:
  • Care coordination included in Patient Centered Medical Home (PCMH) model
  • (Pg. 27) PCMH Care delivery model: The care delivery model is the centerpiece of the PCMH strategy. In Tennessee, the care delivery model will have several significant features:
    • Tailored care plans based on patient need: PCMH providers will be encouraged to develop individualized care plans for high-risk patients. Plans will focus on coordination of care and the improvement of a patient’s health status over time. Risk-stratification of patients will ensure that all high-needs patients are proactively engaged in care, while encouraging appropriate stewardship of resources. TennCare payers already risk-stratify their Medicaid membership for TennCare’s Population Health programs using proprietary algorithms and share that information with payers.
    • Team-based care with care coordination: A PCMH provides care through a multi-disciplinary team, with the PCP at the center. Teams will collaborate to develop care plans, improve diagnosis and treatment, and deliver appropriate patient coaching. Many PCMHs will have dedicated care coordination staff.
    • Evidence-informed pathways: Care will reflect known standards for the most appropriate care for superior outcomes and cost-effectiveness. Care will also be patient-centered, guided by the patient’s specific needs and preferences.
    • Improved access: Enhancements in access may include 24/7 phone support, evening and weekend hours, or same-day appointments for high-needs patients. Specific access improvements will be left to the discretion of individual providers and payers.

  • Social factors such as income, educational attainment, and employment are significant determinants of health. Low incomes can result in unhealthy living conditions and can render care unaffordable. Tennesseans with low income may delay needed care or forgo preventive care, often increasing complications over the long term. Education levels impact economic opportunity, but also directly influence overall health and health literacy. In this sense, most of the activity of government and the private sector has an impact on health.
  • Improvements in health and health care can also have a positive impact on the economy. By reducing future health care costs, the initiative will reduce the pressure on the state budget that can then be invested into addressing these other determinants of health. Government resources saved through the initiative can be reallocated to support education, housing, and employment programs.

Behavioral Health:
  • Episode-Based Payments:
    • Wave 2: Wave 2 will expand episode-based payment to additional service lines (e.g., behavioral health, cardiology, and/or oncology). Payers are scheduled to begin reporting in July 2014; the initial performance period will begin in January 2015. Initial gain- and risk-share payments under the current plan will be made in April of 2016.
    • Wave 3: Wave 3a will accelerate the pace of episode introduction, with an emphasis on rapid introduction of reporting followed by a more moderate phase-in of episode-based payment. Wave 3a is scheduled to include an infusion of 16 episodes, including BPCI episodes and additional medical/behavioral health episodes. Payers will begin reporting on these episodes in January 2015. Over the following 18 months, payers will implement a phased rollout of performance periods for Wave 3a episodes. Wave 3b will consist of 3 episodes focused on LTSS and behavioral health. Payers will begin reporting in July 2015; the initial performance period will begin in January 2016.
    • Wave 4: Building on Wave 3a and further accelerating episode introduction, Wave 4a will consist of an infusion of 32 episodes, including BPCI episodes and additional medical/behavioral health episodes. The reporting period for Wave 4a will begin in January 2016, with performance periods rolled out over the following 18 months. Wave 4b will consist of 3 additional medical, behavioral health, and/or quality- and acuity-based episodes.
  • Engage stakeholders in designing solutions to expand the use and adoption of health information technology (HIT). Central to the state’s plan is to utilize existing HIT initiatives that are serving the dual objectives of improving quality and lowering costs. The state plans to utilize direct secure messaging under both Patient Centered Medical Home (PCMH) and episodes.
  • The state will also invest in infrastructure; future plans may include performance reporting to all primary care providers in the state leveraging the All-Payer Claims Database, as well as development of a multi-payer portal.
  • More details on pg. 63

  • Tennessee may require additional care coordination or primary care capacity. Reforms will also create the need for new skills and behaviors in the existing workforce, particularly around health information technology/health information exchange (HIT/HIE) and care coordination. To meet these needs, Tennessee will focus on strategic levers including education, recruitment, training, and regulation.
  • More details on pg. 68

Click Here for Full State Plan

Summary by Focus Area:

Prevention & Population Health:
  • Community‐Based Public Health Innovations (Model 4): Public Health‐Medicaid Managed Care Diabetes Education Project, Scaling the National Diabetes Prevention Program in Texas (pg.166-172)
  • The Texas SIM initiative will expand the reach of these programs to more communities, while also promoting their sustainability where the evidence shows promising outcomes (pg. 133)
  • Programs to measure the quality of care delivered by physicians and clinicians to manage patients suffering from chronic conditions, e.g. Bridges to Excellence and Blue Cross Blue Shield of Texas programs (pg.74 & 75)
  • Department of State Health Services (DSHS) is supporting a reorientation of the service delivery models to focus on resiliency and disease management, behavioral and physical health integration of services and continuity of care (pg.70)

Financing Population Health:
  • Transition Away from Fee‐for‐service to Quality‐based Payment and adopt payment models that reward quality rather than volume of care (pg. 9 & 131)
  • "Health and Human Services Commission (HHSC) focus on ensuring an effective, comprehensive quality strategy within the managed care organization (MCO) contracting model e.g. STAR and STAR+PLUS (pg. 101)
  • Significant and meaningful investments in health IT technology, practice transformation, public health innovations and a wide variety of dissemination and collaboration activities (pg.191)
  • The Texas Health Services Authority (THSA) would convene a Finance Task Force to encourage the support of all public and private payers charged with overseeing the planning for the first two HIE sustainability strategies, provider payments for HIE utilization and HIE connectivity payment programs (pg.144)

Transforming Clinical Care:
  • Clinical Care Transformation Programs – Medical Home Training Program, Medical Home Recognition Program, Chronic Disease Care Recognition Program (Model 2) (pg.145-153)
  • Sustaining Practice Transformation in Medicaid Managed Care (Model 3, Innovation 2) (pg. 171)
  • Multi‐Payer Engagement and Alignment (Model 5, Innovation 1 & 2): Building Capacity for Multi‐payer Collaboration, Multi‐payer Alignment on Diabetes Care Transformation and Prevention (pg. 174-178)
  • Build Capacity for Continuous, Ongoing Improvement and Innovation throughout the Health Care and Public Health Systems in Texas - foster collaboration in spreading and sustaining best practices in service delivery and payment, and closing the gap between the demand for and capacity of primary care (pg. 9, pg. 187)
  • Patient‐Centered Medical Home Programs and Specialty Practices - six clinics in Texas becoming NCQA-recognized patient-centered specialty practices. Accountable Care Organizations (ACO) are gaining popularity in Texas due in large part to the availability of federal funding (pg. 76-79)

  • "Racial, ethnic, and urban-rural disparities identified as factors impacting health status” (pg. 44)
  • Healthy Babies Initiative focuses on provider education to reduce disparities in birth outcomes between racial and ethnic groups (pg.61)

Behavioral Health:
  • "Model 1 EHR Adoption Incentive Program would target small, rural and behavioral health and LTSS providers.” (pg. 11)
  • Increase in behavioral health integration in existing and proposed initiatives. The innovation models are designed to have an impact on these outcomes for targeted populations, including people with chronic conditions, chronic conditions with behavioral health comorbidities and pregnant women (pg. 3)
  • Under the transformation of the Delivery System to Models of Patient‐centered Care, patients with a chronic condition and an accompanying behavioral health co-morbidity will receive high quality care that integrates and coordinates physical and behavioral health services based on their needs (pg.30)

  • Expand electronic health records (EHR) adoption and meaningful use, health information exchange (HIE) participation and sustainability (Model 1). The proposed initiatives will include coordinated research, governance, planning and marketing (pg.138-144)
  • Texas Health Care Innovations Tracking Center (Model 3, Innovation 3) (pg. 164)
  • "Collaboration for Public‐Private Data Sharing (Model 5, Innovation 3)” (pg. 178)
  • State legislature created the THSA to support improvement of the Texas healthcare system by promoting and coordinating HIE and Health IT (HIT) throughout the state, the Office of e-Health Coordination (OeHC) serves as a single point of coordination for HIT initiatives in the State of Texas etc. (pg. 98-107)
  • Improved patient satisfaction is a key outcome for the Texas SHIP. The Texas SIM initiative will track improvement on satisfaction with overall health care, personal doctor and specialist seen most often (pg.133)
  • SIM initiative will act as a resource for technical assistance and incentives for practice transformation and EHR adoption, particularly in rural areas and among select provider types (pg. 130)

  • Health Innovation Learning Network (Model 3, Innovation 1) ( pg. 157, pg. 180)
  • Establishment of the Texas Institute for Health Care Quality and Efficiency (Institute) (pg. 18)
  • Numerous delivery system reform incentive programs to improve health care delivery systems (pg. 183) Table on pg. 184 of projects
  • Recent state legislation created several new programs to support medical and graduate medical education designed to bolster the primary care provider pipeline (pg. 195)
  • SIM initiatives to improve workforce efficiencies without physician workforce expansion (pg.186-187) and create a statewide Learning Exchange for disseminating best practices on health care delivery system and payment reforms linked with state and federal Medicaid and public health initiatives (pg. 130)

  • The Texas State Health Care Innovation Plan (SHIP) proposes five innovation models to achieve the long term goal meet the state’s goals for health care delivery and payment (pg. 1)
  • Establish SIM Council to coordinate with the Texas Institute for Health Care Quality and Efficiency objectives of improving the quality and efficiency of health care delivery but particularly, drive transformation and innovation in the areas of EHR and HIE Expansion, Clinical Care Transformation and adoption of best practices, community based public health and multi-payer engagement and alignment (pg. 128-130)

Click Here for Full State Plan

Summary by Focus Area:

Prevention & Population Health:
  • The state’s goal for improving care, population health, and reducing health care cost were the drivers for the selection of the two aims being proposed in the area of community health. The two aims are: the use of Community Health Workers (CHWs) and the implementation of a common wellness agenda (CWA) at the community level.
  • The strategy to include CHWs in the health care work force will increase effectiveness, efficiency, and appropriate mix of the health care workforce. When CHWs work collaboratively with primary care physicians there is an increase in effectiveness and efficiency because there is a greater likelihood that the patient will take their medications as prescribed and follow the physician’s directions (e.g., adopt new health behaviors like eating more nutritious foods, obtaining and maintaining a healthful weight, getting regular physical activity, not consuming tobacco products). CHWs could tackle not only behavioral health but also substance abuse (which impacts the patient’s ability to implement behavioral health changes), children’s dental health (which is integral to healthful eating), and long term services and support (such as supporting older adults and people with disabilities to maintain independence and maximize self-determination).
  • If CHWs and primary care physicians work effectively together to optimize patient health then it might be easier to move away from health care provider payment based on volume and move towards a payment system based on outcomes. Use of CHWs allows for an increase in primary care capacity because the physician, nurse, and CHW can work at the top of their licensure thereby containing cost and increasing patient support simultaneously.
  • Optimally, health care organizations would have policies to integrate CHWs into their care mode thereby working towards a more effective and less expensive workforce.
  • The CWA was developed to engage communities in bringing together and better coordinating available resources and services. The CWA will address all sectors of the community where people learn, work, live, play, and pray. (pg. 66)

Financing Population Health:
  • Payment reform will directs reimbursement from a fee-for-service model to a fee-for-results environment. Training in Quality Improvement methods, leadership and culture change to support team-based care will use adult learning models across practice setting and types of staff. Approaches to provide technical assistance should integrate the Utah SIM Plan elements so they do not compete with each other for provider attention. A holistic program or at least close coordination across programs will allow providers to make the most progress and not become overwhelmed.
  • Utah Medicaid has worked with its managed care plans to develop Utah Medicaid Accountable Care Organizations (ACOs) that receive capitated payments for covering enrollees each month. Over the last year, Utah Medicaid has met with the ACOs and interested stakeholders to develop quality measures that will be included in the ACO contracts. We believe the process and measures from the Utah Medicaid ACO quality effort will help serve as a basis for work that will be done under the Plan.
  • The Plan will pursue an approach that will allow these existing VBP efforts to progress and then use research techniques to identify what features or factors the most successful plans have in common. In addition, the research approach may also be able to identify which features or factors work better in different environments. This process of allowing existing VBP efforts to progress is consistent with the Governor’s general philosophy that private innovations should be encouraged and that they are more likely to be successful than government-created solutions.

Transforming Clinical Care:
  • Aim 2 focuses on helping patients designate their own life sustaining treatments. Subaims under Aim 2 look to make sure that physician ordered life sustaining treatments (POLSTs) and patient advanced directives are electronically available to ensure that patient wishes regarding end-of-life care are honored. Additionally, providers will be taught how to have crucial conversations with patients regarding end of live care and how to assist patients in the development and institutionalization of POLSTs and advanced directives.
  • Utah’s plan addresses end of life preferences in three ways. These ways include: 1) the use of information technology as an infrastructure to improving access to the end of life directives, 2) training physicians on crucial conversations, and 3) conducting community outreach and educational activities. The goal of such interventions is to create a cultural shift towards the expression of end of life preferences, documentation of such preferences, and access to those preferences at the right time. If conducted with dignity and respect, an overall decrease in end of life institutional spending should decrease with subsequent increases in home based comfort care.
  • Utah aims to model the successful teamwork approach to healthcare delivery.

Behavioral Health:
  • AIM 3 of Utah’s plan: To increase access to primary care and behavioral health
  • The goal is to provide these critical services to more Utahns through increased behavioral health screenings, training and use of interdisciplinary teams, and use of telehealth services.
  • Provide behavioral health services via telehealth services:
    • Working to address limited access to psychiatrists, a pilot project was created to improve access to pediatric mental health services in Utah. This early pilot project is known as GATE Utah, Giving Access to Everyone, a novel, web-based consultation model. Their goals are to improve access to mental health services for children and adults, improve collaboration between primary care physicians and mental health professionals, and enhance knowledge of how to manage mental health conditions in the primary care setting. As opposed to the traditional psychiatric clinic, GATE Utah believes they can influence the greatest number of people with the GATE Utah system by providing high quality care to families and children, while at the same time lowering costs and maintaining the majority of the treatment in the medical home.
  • Aim 1 details how Utah will adapt and perform in a VBP environment through improved utilization of health information technology tools and the development of value- based metrics which will inform providers’ and payers’ purchasing decisions.
    1. Subaim 1.1: Increase Utah stakeholder use of key health information technology (HIT)-enabled tools by 60 percent to support timely and accurate information for value-based delivery of care and payment reform.
    2. Subaim 1.2: Improve security measures of key HIT enabled tools.

  • A fundamental element of developing VBP systems is the ability of those systems to follow patients across time and sectors. Subaims 1.1 and 1.2 will increase stakeholder use of a state-wide master person index (sMPI),
  • improve the use of electronic medical records (particularly in rural areas), provide a more secure clinical health information exchange, and increase the accessibility and usefulness of the All-Payer Claims Database (APCD).
  • It is the goal of the sMPI to act as the definite master person index for all healthcare activities in Utah. Utah Department of Health (DOH) will be responsible for the sMPI.
  • The Plan includes a technical assistance intervention program to help providers in areas and stages that will not be covered by other programs. Through the intervention program, providers with high Utah Medicaid patient volumes can continue to receive subsidized support in order to meet the demands of state and federal requirements as they increase and become more challenging over time.

  • Aim 4 will create community-clinical linkages through increasing the use of community health workers within health systems and plans. The Plan envisions training programs for community health workers which will teach them to incorporate general healthy behaviors in patient interactions with emphasis on tobacco cessation, diabetes control and management and overall weight and nutrition training.
  • The Plan outlines how providers will be assisted and trained in adapting and performing well in a value-based payment (VBP) environment. Such an environment has multiple characteristics of practice delivery that may be new to current practitioners. Practicing well in a VBP environment requires such skills as care coordination and coaching, care management, population management, use of information technology, motivational interviewing, behavioral health screening, collecting and reporting quality metrics, providing medical homes for geriatric populations, the chronically ill or those with complex medical conditions, and team collaboration.
  • Subaim 1.4: Align supply/demand workforce projection methodologies with a value-based purchasing environment.
  • Subaim 1.5: Prepare/train providers to perform in a VBP environment.
  • Using current and new training methods, providers will be taught to serve in a value-based purchasing environment utilizing care management training and care coordinators to facilitate the use of quality measures and health information technology. Improving access to behavioral health services and integrating them with primary care particularly in rural areas will require more advanced and regular use of technologies such as telehealth and advanced practice providers whenever possible.
  • The strategy to create a common wellness agenda (CWA) at the community level will help to develop community awareness and engagement in state efforts to achieve better health, better care, and lower cost through improvement of all segments of the population. This will be accomplished by demonstrating how a community can come together to tackle health disparities within their community. (pg. 64-65)
  • Encompassed within the CWA aim is the charge to develop a community coalition, a community-level CWA, develop and implement effective community-based initiatives to improve health outcomes and develop effective reporting mechanisms for these outcomes. The focus of the CWA will be created by reviewing state and local-level data and considering national and state plans (e.g., Health People 2020, National Prevention Strategy,National Quality Strategy, Million Hearts Campaign). This will enable the final CWA to align with national and state health objectives.

  • Four Aims of Plan:
    • AIM 1: To adapt to and perform well in a value-based purchasing environment (value = quality outcomes/cost).
    • AIM 2: To facilitate end-of-life preferences for Utah citizens so they receive care with dignity, respect and efficiency.
    • AIM 3: To increase access to primary care and behavioral health.
    • AIM 4: To create community-clinical linkages and healthful environments.

Click Here For Full State Plan

Summary by Focus Area:

Prevention & Population Health:
  • One of the three key strategies in the overall plan includes, improving health overall by building healthy communities and people through prevention and early mitigation of disease throughout the life course. (pg. 49)
  • Leveraging community-based, public-private collaboratives to bring together key stakeholders to link, align, and act on achieving health improvement goals, support local innovation, and enable cross-sector resource sharing, development, and investment.
  • Amplifying a Health in All Policies approach across State agencies and within communities, with a focus on healthy behaviors, healthy starts for children, prevention and mitigation of adverse childhood experiences, clinical-community linkages, and social determinants of health. (pg. iii)
  • Using geographic information systems-mapping and hot-spotting resources to drive community decisions.
  • Designing a toolkit for communities seeking to finance innovative regional projects.
  • Create Accountable Communities of Health - leverages innovation and collaboration already occurring in local communities by formalizing regionally governed public-private collaboratives to address shared health goals. These new partnership organizations will support communities, sectors, and systems in their regional service areas, and implement health improvement plans primarily focused on prevention strategies. (pgs. 30 and more details on pg. 52)

Financing Population Health:
  • One of three key strategies in the overall plan includes, Washington will move away from a largely fee-for-service reimbursement system to an outcomes-based payment system that delivers better health and better care at lower costs. Specifically, within five years, Washington aims to move 80 percent of its State-financed health care to outcomes based payment and work in tandem with other major purchasers to move at least 50 percent of the commercial market to outcomes-based payment. (pg. iii) See pg. 42 for more details.
  • Requiring all providers of State-financed health care to collect and report common measures, implement evidence-based guidelines, and enable use of patient-decision aids.
  • Implementing accountable care organization models, reference pricing, and tiered/narrowed networks for State-financed health care.
  • Aligning public and private purchasing expectations with flexible benefit design efforts.
  • Generating actionable commitments in support of a well-defined strategy that will align payment and delivery system transformation across multiple payers, purchasers, and providers.
  • Accountable Communities of Health also will help structure and oversee Medicaid purchasing. They will partner with the State to bring order and synergy to programs, initiatives, and activities based on unique regional and local characteristics.
  • Potential to generate more than $730 million in return on investment. Financial Analysis begins on pg. 67

Transforming Clinical Care:
  • One of three key strategies in the overall plan, improving chronic illness care through better integration of care and social supports, particularly for individuals with physical and behavioral co-morbidities. (pg. 56)
  • Spreading adoption of the Chronic Care Model.
  • Supporting the integration of physical and behavioral health care at the delivery level through expanded data accessibility and resources, practice transformation support, increased workforce capabilities, and reduction of administrative and funding silos on a phased basis.
  • Restructuring Medicaid procurement into regional service areas to support integrated physical and behavioral health care and linkages to community resources.
  • The State will create a Transformation Support Regional Extension Service that operates at the state and community levels. This entity will ensure providers receive the necessary support in Washington’s rapidly changing health care environment. (pg. 3) See pg. 34 for more details.

  • The Innovation Plan recognizes health is a complex interplay of physical health; behavioral health; basic needs such as food, housing, education and employment; personal and family supports; welcoming communities; and quality of life—beginning at birth. Health and recovery services, without a strong foundation of equitable system supports and community services geared to sustain health, do not serve individuals as whole people. Additionally, without supports, such as payment models that incentivize outcomes, the system responsible for health cannot effectively deliver it. (pg. 14)
  • Improve health equity. Eliminating health and health care disparities will drive improved health outcomes and reduce costs. Broader coverage afforded through the Medicaid expansion and other health reforms is a necessary but insufficient step toward ensuring equitable access to care and other services. The strategies and infrastructure supports outlined in the Innovation Plan are directed to areas of particular inequity and anticipate resources devoted to monitoring access and outcomes for diverse individuals and populations across the state. (pg. 20)

Behavioral Health:
  • Supporting the integration of physical and behavioral health care at the delivery level through expanded data accessibility and resources, practice transformation support, increased workforce capabilities, and reduction of administrative and funding silos on a phased basis. More details on pg. 57
  • Restructure Medicaid procurement to support integrated physical and behavioral health care with links to community resources. (pg. 61)

  • Leverage and align state data capabilities. (pg. 33)
  • Washington will partner with the Institute for Health Metrics and Evaluation and local public health to develop new data capabilities and technical assistance to support community population health management.

  • Increase workforce capacity and flexibility (pg. 37)
  • "Work in teams to engage individuals and families and provide care effectively for those with complex and chronic conditions. Provide education and practice support for team-based and coordinated care, and extend workforce capacity through telehealth and telemonitoring.” (pg. 39)
  • Encourage workforce capacity for the transformed system by building educational and career progression opportunities.
  • Expand model testing sites and build on successful methods for Community Health Workers. (pg. 38)
  • Washington will convene a specific workforce team to focus on CHWs and develop a timeline outlining the steps each stakeholder must take to establish an effective CHW workforce for Washington State.
  • Train primary care and behavioral health providers to address the needs of whole person. (pg. 39)
  • Build and Expand Primary Care Residencies in Washington. (pg. 40)
  • Leverage Washington State’s Progressive Scope of Practice Laws to Improve Patient Management and Mitigate the Shortage of Primary Care Providers. (pg. 40)

  • Recognizing that health and health care are influenced by local needs, the State and regional leaders (including counties) will work together to determine regional service areas that drive increased collaboration between clinical and population health efforts. These regional service areas also will define Medicaid purchasing boundaries and make it easier to support health improvement and prevention at the local and regional levels. Most importantly, this regional approach will empower local entities, such as counties and public health jurisdictions, to shape a health and social services system tailored to the needs of their communities and aligned with key statewide priorities.