American Samoa

More to come...

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

Summary by Focus Area:

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

Financing Population Health:
  • Enhancing capacity for payment reform among integrated and behavioral health providers by increasing access to data and providing funding to accelerate organizations’ ability to enter into modernized payment structures, which will extend to non-Medicaid/Medicare lines of business as experience grows. (p. 13).
  • Arizona Health Care Cost Containment System (AHCCCS) will ensure competitive incentive payments that reward high performance. (p. 15)
  • Implement multi-payer, value-based payment reform programs to align incentives toward high quality, cost-efficient health care and improved population health. (p. 30)

Transforming Clinical Care:
  • Improving access and coordination of care identified as one of three overarching priorities in the assessment, and includes facilitating a team-based approach to care. (p. 2)

Disparities:
  • The delivery system for American Indians is among the most fragmented. The Plan will enhance and expand American Indian Health Program (AIHP) care coordination infrastructure and data sharing capacity, and create member health literacy material for American Indians. (p. 10-11)
  • AHCCCS has already established a tribal consultation process. The State has discussed care coordination for the American Indian population in tribal consultation and connected its effort to the national Improving Patient Care initiative. (p. 21)

Behavioral Health:
  • A State Health Assessment and identified 15 leading health issues, including access to behavioral health services and others impacted by behavioral health needs, such as obesity, tobacco use, diabetes and unintentional injury. (p. 2)
  • Grants to major providers that partner with community-based behavioral health providers to improve the capability to integrate care. (p. 7)
  • State’s largest insurer – AHCCCS – was helpful in connecting existing efforts and identifying the missing link – behavioral health. (p. 20) Behavioral health is key in improving population health and decreasing per capita spending. (p. 4)

Data:
  • Accelerate use of HIT/HIE in the delivery system. (p. 7, pp. 15-19)
  • Develop formal electronic exchange of information (including IT infrastructure) necessary to improve care coordination for individuals that transition to/from qualified health plans (QHPs) and Medicaid. (p. 10)
  • Leveraging Health Information Technology (HIT) solutions for delivery system reform (p. 15) to expand opportunities for the use of electronic measures and data reporting. (p. 24)

Workforce:
  • Several programs are well-positioned to support the proposed SIM workforce efforts to analyze and assess the effectiveness of various models and expand provider training and education opportunities. (p. 8)
  • Develop an integrated behavioral health workforce and training for a variety of providers, including community-based behavioral health providers. (p. 8)

CHNA & Community Benefits
  • Arizona is using multiple regulatory authorities to facilitate delivery system reform. Overall, Arizona has few regulatory restrictions impeding reform efforts. It has a very competitive commercial insurance market as well as limited certificate of need (CON) requirements, extending CONs only to ambulance services to ensure service delivery in rural areas. (p. 13)
  • Arizona is now using the results of the Assessment to develop the State Health Improvement Plan (SHIP), a state-wide plan to improve population health, which provides a 5-year strategy for partners to work together toward a healthier Arizona. ADHS is assembling a Steering Committee and workgroups, including representatives from the legislature, the Arizona Health Care Cost Containment System (AHCCCS), business community, academia, healthcare, small business, public health, human services, non-profit and faith-based organizations to formulate the draft plan by December 31, 2014.2 The State Health Assessment (see footnote 1) documents the numerous opportunities for CDC collaboration on these efforts. (p. 2)
Other
  • M&E plan will continually monitor based on a set of Key Performance Indicators (KPIs). (pp. 24-28)

California
State's SIM website
State's SIM overview

More to come...

District of Columbia
State's SIM website
More to come...

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

Summary by Focus Area:

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

Financing Population Health:
  • Payment and/or Service Delivery Model, transitioning from a fee-for-service payment system to a model based on outcomes. (p. 9)

Transforming Clinical Care:
  • Patient-centered medical homes (PCMH) provide the necessary platform for developing behavioral care enhancements, and is a dominant model for Hawaii's primary care practices. (p. 3)
  • Health Care Delivery System Transformation Plan. (p. 5-9)

Disparities:
  • Plan stratifies payment to encourage attention to disparities. (p. 3)
  • The Population Health Plan (PHP) will address health disparities and the underlying social determinants of health. (p. 3)

Behavioral Health:
  • Round Two proposal builds upon the behavioral health gap identified in Round One. (p. 1)
  • The PHP will include the payment and delivery model interventions and goals related to behavioral health. (p. 3)

Data:
  • The statewide HIE network is expanding services to enable providers to share information. (p. 3, pp. 10-11)
  • The state plans to build data planning, aggregation, and dissemination capabilities to help public and private stakeholders assess and improve population health. (p.11)

Workforce:
  • Developing an interprofessional workforce center to serve as a data repository and neutral authority on workforce data with behavioral health provider data as its first priority. (p. 7)
  • Supporting state-owned academic institutions and rural hospitals to expand interprofessional medical education residency programs that integrate behavioral with primary care practice. (p. 7)

Other

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

Summary by Focus Area:

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

Financing Population Health:
  • KY Medicaid initiative to begin January 2015 to increase reimbursement rates for certain high-value prevention services that have been demonstrated to provide a strong ROI. (p. 9)
  • Kentucky has identified four broad goals for payment reform: 1) Incentivize Greater Prevention to Improve Population Health Outcomes, 2) Improve Chronic Disease Prevention & Management with Innovative Payment Models, 3) Incentivize Adoption of Integrated and Coordinated Care Models, 4) Align Payments with Quality of Care. (p. 9)

Transforming Clinical Care:
  • Kentucky intends to provide a detailed roadmap for more effective measurement of quality and quantifiable improvement in clinical outcomes for all state citizens. (p. 14)
  • LHDs are already working toward integration of the public health and health care delivery systems through programs such as Community Health Workers (CHWs) (per Section 5313 of the ACA), public health dental hygienists, school health programs, and local diabetes education and prevention programs. (p. 4)
  • The guiding vision of Kentucky’s health care delivery system transformation plan is to achieve the Triple Aim – improved value, patient care and population health outcomes – in the context of an interconnected and comprehensive health care ecosystem. (p. 5)
  • Three broad goals for delivery reform and important strategies to support each: 1) Increase access; 2) Increase integrated and coordinated care models; 3) Expand HIT infrastructure. (See Figure 2, p. 6)

Disparities:
  • The Model Design will incorporate specific analysis of the projected impact of proposed interventions on health disparities across the Commonwealth. (p. 18)

Behavioral Health:
  • As of April 1, 2014, Kentucky has been developing a Health Home Planning Model and currently plans to include chronic disease(s) and behavioral health. (p. 16)
  • Balancing Incentive Program (BIP) enhanced match rate will fund a total of 1,203 1915(c) waiver slots serving individuals with intellectual or developmental disability, or acquired brain injury. (p. 16)

Data:
  • New MMS system will be flexible, modular, and provide near real-time interfaces and access to information, and will interface with the other systems within the QHI framework and enable automation of Kentucky’s data reporting to CMS. (p. 11)
  • The APCD will support three key objectives: improve public health and quality of care delivery, support health care reform initiatives, and provide a foundation for transparency in cost and delivery of health care. The APCD will provide the necessary information repository to catalog and measure the utilization and outcomes of all health care in Kentucky, and will help integrate predictive modeling capabilities into health care projections. (p. 11)
  • Kentucky Health Information Exchange (KHIE): Supports transition to electronic health records (EHRs) within CHFS and with private providers via KHIE. Works with all KY providers to connect their EHR systems to the state for the exchange of patient clinical information. KHIE has on-boarded over 800 provider locations/points of care, and 80% of Kentucky hospitals are currently live on KHIE, which has also successfully completed interfaces to the KY Immunization & Cancer Registries, CDC/BioSense and National Electronic Disease Surveillance System. Forthcoming work of KHIE, which will be incorporated in the Model Design as appropriate, involves development of an individually accessible patient portal/personal health record (PHR). (p. 11)

Workforce:
  • Strategically assess workforce needs to leverage existing state-level, multi-stakeholder effort (e.g., NGA Academy). Transform state’s health care workforce scope and pipeline to provide modernized, holistic approach to health care in view of shifting models of care delivery. (p. 6)
  • Kentucky was one of seven states selected to participate in the National Governors Association Policy Academy "Building a Transformed Health Care Workforce: Moving From Planning to Implementation." (p. 9)

CHNA & Community Benefits
  • Kentucky will leverage the Certificate of Need program (located in the Office of Health Policy (OHP) to support systemic innovation. (p. 8)
  • Kentucky’s Model Design Population Health Improvement Plan (PHIP) will build upon the Commonwealth’s Affordable Care Act (ACA) implementation, Governor Beshear’s kyhealthnow initiative, and state population health plans in development. The PHIP will form the foundation of any and all progress the Commonwealth makes with health care reform. (p. 2)

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

Summary by Focus Area:

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

Financing Population Health:
  • Integrated delivery systems will be evaluated on both their current state of progress toward, and their ability to achieve during the Model Test period, the following characteristics: Financial plan: costs for target population reduced to equal/exceed pilot funding; Multi-payer: direct contract with the State, commercial plans and Medicare; and Provider incentives: Distributes outcomes-based payments, rewards efficiency. (p. 8)
  • By the end of 2016, the integrated delivery networks developed through participation in the Pilots, will have begun covering Medicare enrollees and be ready to begin contracting with commercial health plans. Illinois’ Model is designed to ensure that patients moving between Medicaid and commercial coverage experience minimal disruptions in care and have access to the same effective, highly integrated delivery networks regardless of their health insurance coverage. (p. 10)
  • Tested payment reforms will include: Patient-Centered Primary Care Home (PCPCH) payments; Bundled payments, including case rates, fee-for-service (FFS) with risk-sharing, and episode payments; Risk and gain-sharing arrangements; Service agreements aligning incentives for specialty and primary care physicians; 11 Quality bonuses or other performance incentives; and Coverage of non-medical services. This may include bonuses for stable housing, removing allergens from the home of an asthmatic person or helping individuals with disabilities prepare for employment. (p. 11)
  • Through the work of the Integrated Delivery System Reform subcommittee, on which health plans and providers participate, the Model Test will align the Pilot measures and targets with commercial health plan value-based payment structures. (p. 12)

Transforming Clinical Care:
  • Illinois began implementing the following programs in 2013 to accelerate the development of integrated delivery systems and reformed payment models in Medicaid: Care Coordination Entities (CCEs), Accountable Care Entities (ACEs), CountyCare (Cook County). (see p. 8 for more details)
  • Specific integrated delivery systems will serve as Model Test Pilots and will be identified through an application process during the pre-implementation year. They will encompass broad geographic and demographic diversity in the populations covered. In their applications, integrated delivery systems will be evaluated on both their current state of progress toward, and their ability to achieve during the Model Test period, a list of ten characteristics. (see p. 9 for this list).
  • Realistic measures and targets, including both quality and value metrics, will be set during the pre-implementation period for each Pilot based on the current Alliance work group process. Pilots will be required to demonstrate how they will achieve cost savings over the Test period. Quality metrics will incorporate HEDIS measures and those already established for Medicaid care coordination programs, including well-child and adolescent well-care visits, medication management for people with asthma, and frequency of prenatal care. Examples of value metrics are ambulatory care follow-ups after an emergency department visit or inpatient discharge, and inpatient psychiatric 30-day readmission rates. (p. 12)
  • Tobacco use, diabetes, and obesity and their underlying social determinants are key drivers of poor health outcomes and rising health care costs. Performance improvement related to these three priority areas will be tracked. Team-based health care will foster redesigned workflows for patient care and referral management, better transitions of care, and increased family and patient involvement. (p. 4)

Disparities:
  • The overarching goal of Illinois’ Plan for Improving Population Health (Plan for Pop Health) is to consider the health outcomes of the entire population and focus on reducing health disparities. (p. 2)
  • Telehealth and remote patient monitoring are critical tools used to enable care coordination,
    address disparities and improve outcomes. (p. 16)

Behavioral Health:
  • In their applications, integrated delivery systems will be evaluated on both their current state of progress toward Health homes: Primary care and behavioral health that meet Federal criteria. (p. 8)
  • Illinois will develop a common care IT platform during the pre-implementation year that includes all relevant data necessary and is accessible to all members of the patient care team. The common care platform will leverage the ILHIE services already in use by behavioral health and long-term care providers, and the Medicaid ACE requirements for connectivity across provider networks to expand the adoption of health IT among long-term care and behavioral health providers. (p. 18)

Data:
  • The various population health datasets, such as the Behavioral Risk Factor Surveillance System (BRFSS), the Hospital Discharge Dataset, I-Query, and PopHealth, will be key resources for tracking performance on CMS Core Measures and for monitoring overall population health. (p. 3)
  • Illinois has invested significant resources in health information technology as a powerful strategy to achieve the Triple Aim. The Innovation Plan leverages these initial investments to accelerate the adoption of health IT among a wide range of health providers and incentivize them to use IT to achieve clinical integration and improve population health. (p. 14)
  • Health Information Technology Plan contains the following strategies/components: Governance and current state of health IT adoption/use, Policy levers to accelerate standards-based, interoperable technology, Using data and analytics, telehealth and remote monitoring to improve care, Federal investments in IL for interoperable health/human service IT infrastructure, Integration of public health IT systems in Plan for Pop Health, Leveraging of health IT to implement common quality and cost measures across payers, and Engaging long-term care, behavioral health providers and patients. (See p. 14-18)

Workforce:
  • Ensure an adequate workforce with the appropriate education,
    training and compensation. (p. 1)
  • In the area of workforce (Plan objective # 4), Illinois has passed legislation to improve the effectiveness and efficiency of the health care workforce. The community health worker advisory board (HB5412) will develop recommendations for the certification process of community health workers. Clinical psychologists who have met specific training requirements can now prescribe controlled substances (Public Act 98-0668). A three-year pilot program for certified nursing assistants to also become certified medication aides (SB 2958) has been created. Telehealth services can be covered by insurance as if the services were rendered onsite (SB647). Dentists, with the appropriate training, can administer the flu vaccine to individuals 18 years of age and older. (Public Act 98-665). These laws expand the scope of practice, and allow Illinois residents in rural areas to receive better access to health care. (p. 13)
  • Illinois proposes to use the following outcome measure to monitor the impact of the Model: # of community health workers working in Model Test pilot sites. (p. 27)

CHNA & Community Benefits
  • The Innovation and Transformation Resource Center (ITRC) will work with IDPH to support community capacity development to conduct needs assessments, certifications, and monitoring and support of community-based services. (p. 5)
  • In their applications, integrated delivery systems will be evaluated on both their current state of progress toward, and their ability to achieve during the Model Test period: an Integrated care model based on community needs assessment and broad service array. (p. 8)
  • Illinois’ Certificate of Need (CON) process is designed to ensure access to necessary health services. The Health Facilities and Services Review Board is in the process of determining whether alternative care models, which will streamline the CON process in order to ensure timely approvals, denials and appeals can be established, via administrative rule, and/or by legislation. The newly developed rules will address the need for services, facility size, staffing, payer mix, travel time, patient transfer, emergency care, and contractual relationships. (p. 13)
  • The Illinois Department of Public Health (IDPH) appoints a planning team every five years to lead a state health assessment and publish a SHIP. (see p. 2-3 for SHIP process).
  • Each of the 89 local health departments engages in a local IPLAN process, a community health assessment conducted every five years. (p. 3)

Maryland:
State's SIM website

More to come....

Montana

More to come....

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

Summary by Focus Area:

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

Financing Population Health:
  • Payments to providers and/or service vendors are tied to value and performance that lead to better controlled costs. (p. 5)
  • DHCFP is continuing to collaborate with payer and health care systems across the state. This work effort will identify additional populations that may be addressed by this initiative. Based on an initial assessment of the potential payer system collaboration, we have identified the potential population target groups as the following: Medicaid, CHIP, Indian Health Services (IHS), Public Employees Benefit Plan (PEBP), and the Culinary Unions Self-Funded Plan. This target population includes approximately 700,781 beneficiaries, or 25 percent of the State's population. Nevada is encouraging commercial plans to participate as well and will continue toward that goal. At this time, we are not considering Medicare population participation, but we are open to reconsidering if desired by CMS. (p. 8)
  • DHCFP is committed to designing a state health plan that includes multi-payer payment innovation and measure alignment. (p. 11)

Transforming Clinical Care:
  • Based on Governor Sandoval 's priorities and the State's overall health care objectives, Nevada will work with a broad range of stakeholders to transform health care delivery in the state. DHCFP has identified guiding principles for transforming health care delivery, many of which are consistent with CMS' characteristics of a transformed system. Models considered for this initiative will apply these guiding principles. (see p. 5 for list of principles)

Behavioral Health:
  • The Governor's Behavioral Health Strategic Initiatives Council is reviewing initiatives on community capacity for mental health services, crisis prevention, adequate hospital beds, stable housing, and workforce development. (p. 15)
  • A plan will be developed to engage stakeholders to obtain data such as vital records, workforce development, and behavioral/mental health records. (p. 13)

Data:
  • The Division will assess the availability and reliability of data needed using HealtHIE, which is a not-for-profit statewide community-based health information exchange (HIE). This initiative will capitalize on the Division's electronic health record (EHR) program that went "live" on August 6, 2012. It includes incentive payments for Eligible Professionals (EP), Eligible Hospitals (EH), and critical access hospitals (CAH) for Adopt/Implement/Upgrade (AIU) and Meaningful Use (MU). As of June I 0, 2014, the Nevada DHCFP reported payments to 340 providers and 27 hospitals, with incentive payments totaling more than $34 million. (p. 10)
  • The State's executive leadership team will direct the planning and oversight of design and development activities and utilize policy and regulatory levers to accelerate standards based health information technology adoption to facilitate improvement in delivery system care. Effective communication, planning and project management will be used for promoting patient engagement and shared-decision making; and for developing multi-payer strategies to enable and expand the use of health information technology to make data driven decisions to coordinate and improve care across the state. (p. 10)

Workforce:
  • Health care workforce listed as one of three categories of innovation and systematic improvement areas. (p. 2)

CHNA & Community Benefits
  • DHCFP is committed to designing a state health plan that includes multi-payer payment innovation and measure alignment. (p. 11)

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

Summary by Focus Area:

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

Financing Population Health:
  • Improvements in communication and IT will improve the dynamic of health care delivery and decrease pre-capita health care spending. (p. 3)
  • Payment and/or Service Delivery Model includes discrete payment methodologies, expanding Medicaid and other strategies that will result in short, medium and long-term cost savings. (p. 8-9)

Transforming Clinical Care:
  • Incorporate psycho-social determinants of health, health outcomes, patient experience of care, and population health into clinical practice. (p. 8)
  • DHHS-funded grants to hospitals, health systems, and/or community providers to form pilots related to improving the delivery and coordination of treatments and services and improving population health. (p. 16)

Disparities:
  • RHCE improvement initiatives to ensure that issues needing a broader perspective, for example addressing disparities in health, are addressed and that transparency and accountability are maintained. (p. 6)

Behavioral Health:
  • RHCEs will explore multiple determinants of health, including social, environmental and behavioral determinants and integrate health services and community resources in developing local strategies to improve population health. (p. 13)

Data:
  • SIM Model Design will focus on mechanisms to increase the collection, exchange, and use of data. (p. 3-4), such as improving registries and disease surveillance. (p. 9)
  • Population health improvements will be data driven and initially target tobacco use, obesity, and diabetes, as well as be guided by the State Health Improvement Plan (SHIP). (p. 7)

Workforce:
  • Eliminate waste and improve the efficiency and effectiveness of health care delivery through health care systems engineering (HSE) and implementation, evaluate workforce adequacy and use (p. 7)

CHNA & Community Benefits
  • Regional Healthcare Cooperative Extensions (RHCE) population health improvements will be data-driven and initially target tobacco use, obesity, and diabetes, as prescribed, as well as be guided by the New Hampshire State Health Improvement Plan (SHIP), produced by the Division of Public Health Services (DPHS). (p. 7)

New Jersey
State's SIM website
More to come...

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

Summary by Focus Area:

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

Financing Population Health:
  • New Mexico will use grant funds to explore development of a community paramedicine program to support health promotion and disease management. (p. 6)
  • NM is reducing reliance on high-cost services through improved disease management programs, greater use of health information technology, and new payment models that focus on effectiveness and efficiency (p. 5).
  • New payment models are expected to complement the PCMH initiative and Centennial Care innovations. These innovations include an array of payment options that can work within the capitated payments made to the Managed Care Organizations (MCOs), but will also be applicable for payers and systems outside of Medicaid. New Mexico Medicaid is in the early stages of piloting several payment reform models, including bundled payments, pay-for-performance, shared-savings models, and payments for episodes of care. (p. 6)

Transforming Clinical Care:
  • Patient-centered care that features enhanced roles for health care paraprofessionals and expansion of services to rural and underserved populations; development
    and utilization of multi-disciplinary community health teams that focus on evidence-based care and connecting patients with social services. (p. 4)
  • New Mexico will enhance the patient experience of care by increasing physician and patient awareness of community resources, encouraging patient engagement in care through care coordination and technology, and coordinating with providers to implement policies that encourage self-management. (p. 4)

Disparities:
  • Project ECHO at the University of New Mexico (UNM) to improve access to specialty care for rural and underserved individuals, and PLACE MATTERS programs through the New Mexico Health Equity Partnership (NMHEP) to address the social conditions that lead to poor health. (p. 4)

Behavioral Health:
  • Increased availability of behavioral health services for all age groups. The state will support integration of behavioral health services into primary care, in part through expanding programs like the NM Screening, Brief Intervention and Referral to Treatment (NM-SBIRT) Collaborative to more sites and partners and supporting training and education of the behavioral health workforce. (p. 4)
Data:
  • Reports and analyses based on APCD data will improve health care quality and reduce costs. Standardized metrics can generate provider performance data that will inform the development of alternative payment models. (p. 7)

Workforce:
  • Assessment of regulatory approaches to improve the health care workforce. (p. 8)
  • Greater use of CHWs is one key to improving the delivery system. One goal of statewide CHW certification is to provide opportunities for reimbursement through Medicaid for CHW services, thereby promoting growth of this critical component of the state’s healthcare workforce. As part of the Model Design plan, strategies will be developed with key stakeholders to link CHWs to primary care providers, to explore dual-training options and multiple CHW roles, to explore options to integrate public health essential services and primary care services, and to create a cohesive and integrated CHW workforce. Alternative reimbursement streams for CHWs will also be explored. (p. 5)
  • Community Health Workers (CHWs) provide services that span the life continuum. (p. 2)

CHNA & Community Benefits
  • New Mexico’s Current Health Council System: The system is comprised of 33 county-based health councils and five tribal health councils. Many of these health councils were originally established under provisions of the 1992 Maternal and Child Health Plan Act. The New Mexico Department of Health provides training, coordination, technical assistance, and other kinds of support to the health councils. The existing health councils have varying degrees of resources and infrastructure. New Mexico’s community health councils have achieved a number of positive changes in their communities that in turn result in improved community health. (p. 11)

Other:
  • New Mexico will explore how the Centennial Rewards model can be expanded to other system payers and populations. One possibility is to adopt the program for the NM State Risk Management Division to incentivize state employees to improve their overall health, leading to a healthier workforce, improved job performance and reduced costs. (p. 6)

Commonwealth of the Northern Mariana Islands

More to come...

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

Summary by Focus Area:

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

Financing Population Health
  • The OSIM will engage and strategize with private businesses and public and private payers to develop a health system transformation plan that targets value-based insurance design. (p. 8)
  • The OHIP Coalition will also align and leverage existing innovative payer efforts that are ongoing. For example, the OSIM plans to leverage and align efforts with the Comprehensive Primary Care (CPC) initiative, which includes Blue Cross Blue Shield of Oklahoma (BCBSOK), CommunityCare of Oklahoma, and the Oklahoma Health Care Authority (OHCA), as well as OHCA’s Health Access Networks (HANs) and Patient-Centered Medical Homes (PCMH) initiatives. (p. 17)
  • Healthcare Financing Workgroup – will work with the actuarial contractor to integrate state-purchased insurance into a new value-based payment model and pay-for-success, and perform actuarial analysis of OSIM interventions and ROI evaluations. (p. 28)

Transforming Clinical Care
  • The scope of work for the outside consultants will encompass research and analysis for the development and selection of alternative multi-payer, outcomes-based health system delivery model(s) that fairly compensate providers for care, incentivize healthy behaviors, and reinforce quality, value and evidence-based best practices. Health Access Networks (HANs), Coordinated Care Organizations (CCOs), Health Homes, Patient-Centered Medical Homes (PCMHs), Comprehensive Primary Care (CPC) initiatives, and others will be assessed with a focus on the defined health topics. (p. 8)
  • The OSIM design will integrate healthcare and public health, with an emphasis on chronic and co-morbid conditions, and the reduction of preventable hospitalizations, avoidable readmissions and inappropriate emergency department utilization. (p. 8)

Disparities
  • The analysis and presentation of data will be stratified to highlight health disparities and the impacts of social determinants on health status. (p. 4)
  • OSIM seeks to accomplish the health system triple aim of better health, better care, and lower costs across Oklahoma populations, including populations that lack access to care and are most impacted by socioeconomic inequities and disparities. (p. 16)

Behavioral Health
  • The Oklahoma Health Improvement Plan (OHIP) Coalition is chaired by Oklahoma’s Cabinet Secretary of Health and Human Services and includes representation by behavioral health providers (p. 3)

Data
  • In phase 3, stakeholders will identify strategies to increase adoption levels of Electronic Health Records (EHR) and attainment of Meaningful Use (MU) among providers; initiate planning for the development of a Value-Based Analytics Tool (VBA) for healthcare data analysis; determine benchmarks aimed at improving clinical and population health outcomes; and identify potential savings across multi-payer structures. (p. 1)
  • Objectives and strategies will be focused on reducing primary healthcare cost drivers, as well as reducing access to care barriers and other challenges to be identified through a gap analysis. The gap analysis will be accomplished by integrating data across a number of surveillance sets that include both quantitative and qualitative data. Relevant data sets and reports used for the gap analysis will include, but are not limited to, the 2014 Oklahoma State of the State’s Health Report, hospital and county health assessments, OHIP community chats and tribal consultations, OHIP Business Survey information, workforce data, medical claims data and health information exchange (HIE) data. (p. 4)
  • Consultants and the OSIM staff will mobilize key stakeholders to determine the benefits, feasibility, and sustainability of developing a Value-Based Analytics tool (VBA) to increase health systems data transparency by providing statewide population-based information on patient demographics, diagnoses, procedures and use of hospital services, as well as enhancing the collection of medical school, continuing education, and health workforce data. The VBA will provide opportunities to measure population and public health, social determinants of health, and provide analytics for the development of more targeted culturally and linguistically appropriate care. The VBA will also enable a shift from responding to episodes of care to emphasizing whole-person, population-based care with a focus on wellness. (p. 8-9)
  • In order to achieve statewide health transformation, the OSIM will focus its efforts on two Health Information Technology (HIT) areas: leverage public and private partners to design a VBA to act as a common service quality and cost measure instrument used for monitoring and reporting across providers and payers; and to strengthen acceleration and adoption of EHR and MU to create a robust, interoperable health IT-oriented environment. (p. 11)

Workforce (Plans for CHWs italicized)
  • One of the OHIP health transformation goals is to collect, host and analyze standard workforce data on healthcare professionals. This initiative seeks to create a repository accessible by all involved partners, which would provide capacity for data analysis and enhance the understanding of current workforce needs and strengths. A workforce repository could be provided by the VBA and would enable the identification of opportunities and allow for strategic planning efforts as health professional shortage areas emerge or recede. The implementation of this OSIM healthcare workforce project will receive added support in its alignment with the healthcare workforce goals and objectives identified by the Oklahoma National Governors Association Policy Academy (NGA). (p. 12)
  • $225,000 Health Workforce Assessment: The Contractor will conduct an assessment of and catalog health workforce data, to include: a description of various issues and influences affecting the health workforce, including the state’s legislative and regulatory history and its current programs, financing and policies affecting health professions, education, service placement and reimbursement, planning and monitoring, and licensure/regulation. The Contractor will also perform an assessment of the state’s internal capacity and existing strategies for addressing the above workforce issues and influences, and will provide a policy analysis on the implications of the current workforce data, issues, capacity and strategies. (p. 22)

CHNA & Community Benefits
  • The OSIM activities will be aligned with the state’s Healthy People 2020 health improvement plan (OHIP). (p. 16)
  • Health Alert Networks (HANs) operating in Oklahoma expand on the PCMH model by creating community-based, integrated networks intended to increase access to healthcare services, enhance quality and coordination of care, and reduce healthcare costs. (p. 10)

Other

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

Summary by Focus Area:

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

Financing Population Health
  • The Department of Public Welfare (DPW) will hold contracted insurers accountable for advancing alternative payment models including Accountable Provider Organizations (APOs) and PCMHs in order to drive outcomes-based performance. In Years 1 and 2, DPW will advance its value-based payment models with the Medicaid managed care and new waiver eligible population. In Year 3, these initiatives will be expanded to dually-eligible consumers, including aging waiver participants. (p. 10-11)

Transforming Clinical Care
  • To meet our target of 65% of PCPs having attained specified PCMH skills by the end of 2018, 2000 additional practices need to transform the way they deliver care. (p. 6)
  • To provide the knowledge, expertise and peer learning opportunities needed to achieve transformation, a principal component of Pennsylvania’s SIM Model Test initiative is a Health Care Transformation Support Center (Transformation Center). The Transformation Center will be a multi-faceted resource to build organizational and professional capacity in support of a wide array of providers and thereby accelerate delivery system transformation. (p. 6)
  • Pennsylvania has identified four inter-related delivery models and payment methodologies that support delivery system transformation: 1. APOs with shared savings and risk assumption opportunities; 2. PCMHs with shared savings opportunities; 3. Episodes of care (EOC) with budgeted reconciled or prospective payments, and 4. Community-based Care Management Teams (CMT). (p. 8-9)
  • Pennsylvania intends to pilot four additional reforms to address other elements of the care continuum, with the potential to expand after evaluation of effectiveness: · use pharmacists to provide patient counseling to conduct medication reconciliation, increase medication adherence, reduce unnecessary poly-pharmacy, and improve transitions of care. Pharmacists may be placed on CMTs and in high-volume community health centers; · test the CDC evidence-based Diabetes Prevention Program through grants to YMCAs and other community centers, specifically for Medicaid beneficiaries; · hire registered nurses to join county mental health teams to enhance integration, and · create mobile, multi-disciplinary community care teams to provide interventions for people with high physical and/or behavioral health needs in settings where consumers live. (p. 10)
  • Pennsylvania’s HealthChoices program promotes selection of a primary care provider as part of a beneficiary’s plan selection and enrollment. In addition, under Pennsylvania’s pending Medicaid 1115 Waiver Demonstration, Healthy Pennsylvania Private Coverage Organizations will require that all newly eligible adults have access to a primary care provider. (p. 9)
  • To promote greater adoption of the APO and PCMH models, the State will utilize its health care coverage programs – Medicaid, CHIP and the pending 1115 Demonstration – to help drive system transformation. DPW, through its contractual relationship with the HealthChoices MCOs and Healthy Pennsylvania Private Coverage Organizations, will drive system transformation by incentivizing approaches tied to quality, outcomes-based performance measures. (p. 10)

Disparities
  • Health disparities listed as one of the core population measurements. (p. 19). For performance improvement targets, see table on p. 22.
  • The stakeholder-oriented process uses evidence-based practices occurring locally to address health disparities as well as state and local health priorities. (p. 2)

Behavioral Health
  • Department of Public Welfare’s (DPW) Office of Mental Health and Substance Abuse Services (OMHSAS) is working with DOH to expand mental health and substance use screening strategies within PCMHs and establish PCMH options for individuals with serious mental illness (SMI) to improve the coordination of physical health and behavior health care for individuals with SMI and other behavioral health disorders. (p. 4)
  • Pennsylvania will create community-based care management teams to provide highly-coordinated behavioral and physical health services to high-risk Medicaid members. (p. 1)
  • The Department of Public Welfare’s (DPW) Office of Mental Health and Substance Abuse Services (OMHSAS) is engaged in a stakeholder-centered planning process to address behavioral health service needs including those identified in the SHA. (p. 3)
  • Behavioral health providers are piloting PCMH models that utilize nurse navigators, PCP co-location and physical health consultation. The State will continue to encourage these options to facilitate better integrated care coordination activities and the sharing of appropriate clinical data. (p. 6)
  • Support EHR functionality and connectivity for behavioral health and long-term care providers. (p. 7)
  • To meet the workforce needs of PCMHs and APOs, Pennsylvania will implement an enhanced Loan Repayment Program for geriatricians and behavioral health providers – physicians, nurse practitioners and physician assistants – serving underserved populations. (p. 8)
  • Within HealthChoices, DPW will start to align pay-for-performance measures so that both the physical and behavioral health MCOs share common quality parameters, including preventable readmissions. (p. 12)

Data
  • Pennsylvania will leverage SIM to: 1) further strategic collaboration among State agencies by developing a unified HIT strategy; 2) significantly increase use of HIT by providing incentives and technical assistance to providers in rural areas, providers with high Medicaid volume and those not eligible for Meaningful Use incentives to adopt electronic health records (EHRs), connect to a regional health information exchange (HIE), and use telemedicine as appropriate; 3) streamline the flow of information by helping providers efficiently report and access performance data; and 4) inform performance improvement and accountability through implementation of analytical tools and dissemination of performance data. (p. 12)
  • To promote accountability, the Pennsylvania Health Care Cost Containment Counsel (PHC4) will provide regional reports using both population health and provider-supplied clinical data enabling the Steering Committees to track change, and identify and address issues. (p. 4-5)
  • To enable localities to easily identify available resources, DOH is currently developing extensive geo-mapping databases that will enable consumers and providers to enter geographic information and receive community-based resource information. The geo-mapping program is initially focusing on chronic conditions, Accountable Provider Organizations (APO) and PCMH locations, pharmacy networks and super-utilizer communities with an overlay of Care Management Teams (CMT). (p. 5)

Workforce (Plans for CHWs italicized)
  • To meet the workforce needs of PCMHs and APOs, Pennsylvania will implement an enhanced Loan Repayment Program for geriatricians and behavioral health providers – physicians, nurse practitioners and physician assistants – serving underserved populations. (p. 8)
  • The DOH Center for Practice Transformation and Innovation (CPTI) , with direction from the Advisory Committee, will oversee the central office’s performance of the following functions: a) guiding the direction of the transformation process and overseeing the activities of the hubs; b) developing training materials and practice tools that promote capacity development; c) developing an interactive website to share materials and build a learning community; d) planning and holding regularly scheduled peer learning conferences for provider and APO staff, including care managers, medical assistants, data analysts, and clinicians; e) disseminating a monthly e-newsletter spotlighting transformation successes, summarizing relevant literature, and promoting upcoming training opportunities; f) training practice facilitators on effective coaching skills and elements of the transformation models, and g) evaluating hub and provider performance data to identify issues and make strategic and program adjustments. (p. 7)

CHNA & Community Benefits
  • Pharmacists may be placed on Care Management Teams (CMTs) and in high-volume community health centers (p. 10).

Puerto Rico

More to come...

Utah
State's SIM website

More to come...

Virginia
Click Here for SIM Proposal Abstract
State's SIM website

More to come...

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

Summary by Focus Area:

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

Financing Population Health
  • Table 1 (p. 2) illustrates the distribution of two subgroups of the WV population that experience multiple chronic conditions and have the greatest impact on the health care system. Tier 1 targets the highest cost beneficiaries; Tier 2 is comprised of the larger segment of the respective coverage groups with chronic conditions or other “modifiable” conditions that result in avoidable costs or utilization of health care services. The target of this model design is to focus on these tiers as high cost and impactable populations and then generalize to a broader patient population. (p. 2)
  • The design team will continue to work with representatives of Medicaid, CHIP, Public Employee Insurance and participating commercial and managed care payers through the Collaborative and other initiatives to coordinate the alignment of payment models with the health care transformation plan. Our intention is to encourage the phased progression from the current fee-for-service and cost-based reimbursement model to a value-based compensation arrangement. (p. 8)
  • The target of the model design is to start with high cost and impactable populations based upon claims analysis and then spread to a broader patient population. This is consistent with the approach taken by the WV Medicaid program in launching the health homes project and by Public Employees Insurance Agency (PEIA) and Highmark WV in implementing and incentivizing PCMH models. (p. 8)

Transforming Clinical Care
  • Stakeholders involved in the Collaborative and other initiatives will design a model that is: 1) highly effective and efficient; 2) targets the primary care system and encourages effective, patient-centered care; 3) emphasizes value; 4) is integrated at the state level to share resources such as training, expertise, devices and problem solve challenges as they arise; 5) is evidence-based; and 6) regionally-coordinated but community-based as needed to combat the rural, underserved setting while providing flexibility to providers based on local needs. (p .4)

Behavioral Health
  • Promote team-based, patient-centered care; Emphasize full array of medical, social, behavioral, and oral health as well as cultural, environmental, and socioeconomic factors. (p. 6)

Data
  • Integrated Care and Use of HIT: Advance evidence-informed clinical decision making using electronic health record (EHR) decision support, shared decision making tools, and provider quality and cost data at the point-of-care; Improve consumer-directed care decisions. Objectives: Encourage care coordination across settings using health information exchange tools and data availability to care teams (claims and clinical data) to assist in measuring utilization, outcomes, cost and effectiveness of clinical interventions; Promote use of population-based data to understand practice sub-populations, panel, and individual risk, and to inform care coordination. (see table, p. 7 for interventions and targeted outcomes).
  • WV will leverage the infrastructure and analytic resources of a new Medicaid data warehouse with business intelligence tools; the WV Medical Institute, a Medicare Quality Improvement Organization (QIO); the schools of public health; and consultants to analyze multi-payer administrative and clinical data to inform the design process. A comprehensive state HIT plan will be developed through a structured project management process to harmonize the Medicaid state health information technology plan (SMHP), the WVHIN’s operational plan, the State Office of Technology strategic plan and those of providers to support the new SIM model. (p. 10)

Workforce (Plans for CHWs italicized)
  • Invest in resources/programs to prepare professional; support continuous learning for providers; create virtual practice transformation support program. (p. 15)

CHNA & Community Benefits
  • The preliminary goals, objectives, and supported interventions (see pages 6-7) are based on results from population health and health care system needs assessments conducted in 2012 and planning efforts of the Collaborative and other stakeholder groups. (p. 5)
  • The WV Health Care Authority, also a participant in the Collaborative, regulates acute care hospital rates as well as the need for capital expenditures of covered services for health facilities through the rate review and certificate of need (CON) programs. (p. 10)

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

Summary by Focus Area:

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

Financing Population Health
  • The DHS and the SVC LC will engage providers, payers, purchasers, and consumers across the state to assess priorities for payment models to support the targets for care delivery transformation identified under the process described in § (2). Wisconsin will build on existing payment models and experiments in the state (e.g., public designation of centers of value, pay-for-performance, expansion of risk-based contracting, bundled payments for acute procedures, reference pricing, Medicare and private sector accountable care organizations [ACOs]). Wisconsin’s strategy will be to choose highest priority areas of care delivery redesign (described in § 2), and develop payment strategies to support sustainable, cost-effective, equitable improvements in care. Wisconsin will seek to align with ongoing and emerging Medicare value-based payment strategies to ensure that the state has a pathway to reach the target of 80% of payments from all payers in value-based alternatives to fee-for-service. (p. 6-7)
  • Wisconsin has ensured access to coverage for all residents through a waiver covering childless adults up to 100% FPL, with those above 100% FPL receiving care in the federal Health Insurance Marketplace. Medicaid now covers approximately 17% of the state’s population. Stakeholders participating in the SVC touch the preponderance of providers and members across the state to reach the target of 80% of payments through value-based arrangements. (p. 7)
  • Examples of models that will be reviewed include tying payments to outcomes (value-based payments), examining Medicaid health home payment models, and using incentive payments to promote the adoption of electronic health records (EHRs) and health information exchange (HIE) for providers not eligible for meaningful use payments and/or implementation of best practices. (p. 8)

Transforming Clinical Care
  • Wisconsin will select targeted health improvement priorities for care delivery transformation, beginning with identification of health care services with the greatest variation in quality and cost effectiveness, health conditions and health care services that are major cost drivers in the state, and clinical conditions with the most severe disparities in health outcomes. (p. 3-4)
  • The DHS and the SVC LC will identify barriers to adoption of best practices and recommend evidence-based models for dissemination and adoption by providers throughout the state, while considering the needs of providers in different settings (e.g. rural, urban, independent, tribal, safety net, community.) Based on the lessons learned from current innovations, Wisconsin will also establish strategies for assisting providers in adapting clinical workflows and processes to incorporate new approaches. (p. 4-5)

Disparities
  • As part of the development of aligned health improvement priorities, Wisconsin proposes to build on these efforts to develop a plan to close two major gaps: access to care and a lack of care coordination between behavioral health and medical care. (p. 5-6)

Behavioral Health
  • Behavioral health has been examined in Wisconsin through efforts that include nonprofit hospitals’ community health needs assessments, a special Assembly Speaker’s Task Force on Mental Health convened during the 2013-14 legislative session, and a recent investment of $30 million in Medicaid for mental health care redesign. As part of the development of aligned health improvement priorities, Wisconsin proposes to build on these efforts to develop a plan to close two major gaps: access to care and a lack of care coordination between behavioral health and medical care. (p. 5-6)
  • During the SIM design award year, the DHS and the SVC LC will identify possible solutions to expand access to clinical and community behavioral health services, including addressing workforce needs (including both para-professional and advanced licensed providers), expanding and enhancing the use of telehealth (e.g. supporting a Child Psychiatry Consultation Line) and identifying best practices in incorporating behavioral health screenings and trauma-informed care into primary care and other firstline care settings. (p. 6)
  • To improve care coordination across settings, the DHS and the SVC LC will identify best practices and models in incorporating both medical and behavioral health to ensure comprehensive care is delivered for patients. Wisconsin will identify barriers to sharing data across providers (including behavioral health providers in clinical and community settings) and will also develop strategies to accelerate adoption and implementation of these models with special emphasis on regional approaches. (p. 6)

Data
  • Wisconsin will develop a HIT Plan focused on: 1) creating incentives, policies, and other strategies to close the remaining gaps in existing data sets; 2) establishing mechanisms to consolidate and streamline reporting, abstraction, and retrieval of clinical and administrative data for providers, payers, and purchasers, thereby leading to reduced administrative burden and cost; 3) supporting expanded access to more comprehensive data with analytic services and supports, particularly for smaller provider practices; 4) linking clinical, administrative and socioeconomic data to better identify cost-drivers, challenges and opportunities related to the targeted interventions; and 5) ensuring coordination of effort across all existing statewide data assets. (p. 10)
  • Wisconsin’s HIT plan will also provide a pathway for providers to adopt best practices, including 1) opportunities to enable telehealth and remote patient monitoring to advance the health improvement priorities; 2) consideration of incentives to promote HIT adoption and interoperability by providers not currently eligible for the Medicaid and Medicare EHR Incentive Programs (e.g., behavioral health and long term care); and 3) technical assistance and analytic support to ensure that available data can be transformed into actionable information at the point of care. (p. 10)

Workforce (Plans for CHWs italicized)
  • The DHS and the SVC LC will identify possible solutions to expand access to clinical and community behavioral health services, including addressing workforce needs (including both para-professional and advanced licensed providers). (p. 6)

CHNA & Community Benefits
  • Behavioral health has been examined in Wisconsin through efforts that include nonprofit hospitals’ community health needs assessments (p. 5)
  • The PHIP developed during the SIM design period will support greater alignment in local efforts to improve population health, as well as inform the efforts of the DHS and Statewide Value Committee Leadership Council to align clinical and community health improvement strategies to realize the bold vision of the state public health agenda, Healthiest Wisconsin 2020: “Everyone living better, longer.” This vision reflects the state health plan’s twin goals: 1) improve health across the lifespan, and 2) eliminate health disparities and achieve health equity. (p. 2)

Other
  • The SVC LC will serve as the primary advisory council, collaborating partner and lead convener of private sector health care systems and purchasers throughout the award period. The SVC is a cross-section of major health care leaders representing all areas of the state, including national and local health plans, health care systems, providers and associations, employers and employer health care purchasing organizations, the DHS (Medicaid, mental health, long term care, public health), state employee health benefits, Wisconsin’s statewide health information exchange, all-payer administrative data database, quality reporting and technical assistance organizations, and other private sector organizations promoting health care transformation and payment reform. (p. 11)
New Mexico’s Current Health Council System: The system is comprised of 33 county-based health councils and five tribal health councils. Many of these health councils were originally established under provisions of the 1992 Maternal and Child Health Plan Act. The New Mexico Department of Health provides training, coordination, technical assistance, and other kinds of support to the health councils. The existing health councils have varying degrees of resources and infrastructure. New Mexico’s community health councils have achieved a number of positive changes in their communities that in turn result in improved community health. (p. 11)