Click Here for Updated State Plan
State's SIM website

Summary by Focus Area:

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

Financing Population Health:
  • Project total cost of care savings of $126.6 million over the course of the SIM program, with annual savings of $85 million thereafter to help sustain Colorado’s model. (p. 1)
  • A Health Transformation Investment Fund will provide early incentives to both payers and providers as they make the necessary changes toward integrating behavioral health and primary care, both financially and clinically. (p. 18)
  • Colorado proposes to use one-third of actuarially projected savings to support ongoing activities related to the project. We also anticipate that changes in payment models will become permanent and ongoing after the grant period. (p. 19)
  • Aligning provider payment with financial outcomes (total net reduction in healthcare costs) is a key element of our proposal. Goal is by 2019 (fourth year of the SIM grant), payers serving a majority of Coloradans will reimburse practices for integrated physical health and behavioral health services in shared risk and savings programs. Furthermore, a significant number of integrated practices will receive a global or capitated payment for comprehensive primary care. (p. 19)
  • Colorado has received firm commitments from six private payers to:
    -Continue care coordination payments;
    -Move to shared savings opportunities;
    -Move to prospective, non-volume payments;
    -Use the SIM minimum data set; and
    -Support the aggregation of clinical and claims data.
  • The cornerstone of this payment reform glide path is the readiness and ability of primary care practices to move from a fee for service environment. This approach contemplates a gradual transition to new payment models that allows for long-term adaptation, rather than an immediate switch that could result in market instability. (p. 25)
  • Example of reforms (p.33) and descriptions of phases. (p. 28-29)
  • Grant Budget and Narrative (p. 75)
  • Colorado’s SIM most closely resembles the PCMH payment model, rather than the ACO model, and aligns with the CPCi approach to payment reform. (p. 22-25)

Transforming Clinical Care:
  • Integrate physical and behavioral health care in more than 400 primary care practices and community mental health centers (CMHCs) with about 1,600 primary care providers. (p. 1)
  • By 2016, connect an additional 555,000 Coloradans with a patient-centered medical home through the Accountable Care Collaborative. (p. 5)
  • Colorado’s public health infrastructure, including CDPHE and the Colorado School of Public Health, has been a driver of the development of Colorado’s Health Extension Service (HES). The HES is a central part of our SIM model’s ability to facilitate practice transformation and community coordination statewide and will rely heavily on state and local public health agencies for support. (p. 10)
  • Coordinating with social service agencies is a crucial component of ensuring SIM is successful in integrating community-based social services with clinical care. Colorado's approach to securing firm commitments from local social services agencies. Partner with existing and emerging population health transformation collaboratives (PHTCs) across Colorado, we will support them in identifying and engaging local social service organizations most appropriate to leveraging SIM work and connecting with clinical care. This grassroots approach for engaging social services best suits the Colorado environment and our belief that all health is local. (p. 12-13)
  • Health care delivery system transformation plan, called “The Colorado Framework” and outlined in the SHIP, leverages a strong foundation of federal, state and private sector investments in primary care transformation and integrated care. (p. 14)

  • Based on the social determinants of health model, the Colorado SIM proposal leverages the efforts of public health to support the clinical health transformation. (p. 1)
  • Our state agencies are collaborating to support progress on the social determinants of health. CDPHE, the Department of Human Services (CDHS), and the Department of Health Care Policy and Financing (HCPF) are collaborating to align system infrastructure, integrate health services in Colorado, and work together to address social determinants of health. (p. 11)
  • In order to adequately address the broad context of the social determinants of health, Colorado is taking a “life stages” approach that targets resources, programs, services, and quality measurement based on critical points in life, beginning at pre-conception and progressing to older adulthood. This initiative is based on the Brookings Institute’s “Social Genome Project” framework and crosses social, economic, and cultural contexts to acknowledge the physical, social, and emotional developments throughout the life cycle that affect chronic disease and long-term health risks. (p. 11)

Behavioral Health:
  • The overarching goal of Colorado SIM is to improve the health of Coloradans by providing access to integrated primary care and behavioral health services in coordinated community systems, with value-based payment structures, for 80 percent of state residents by 2019. (p. 2)
  • Mental health and substance abuse "winnable battles and targets." (p. 3)
  • A Child Mental Health Coordinator will be tasked with developing targeted population health initiatives for prevention and early intervention of mental health problems in very young children. (p. 6-7)
  • The Colorado Framework envisions three stages of integrated primary care and behavioral health (see Figure 1 on p. 14)
  • Bidirectional approaches that bring primary care into behavioral health settings for those with severe and persistent mental illness are a priority. We will also spur integration in long-term services and supports (LTSS), schools and jails. (p. 15)
  • The state has committed to integrating primary care across the behavioral health system, as demonstrated in the latest Behavioral Health Organization (BHO) RFP, where organizations were specifically asked to articulate their plans for integration, including care coordination and supportive services. (p. 22)
  • As currently structured, the BHOs are contracted to cover Medicaid clients with a covered diagnoses of major mental illness, and they currently provide services to approximately 10% of the Medicaid-covered population (88,715 in 2012). Medicaid clients served by the RCCOs are also served by BHOs. Coordination of services in support of integration is currently a contract requirement for both BHOs and RCCOs, and future iterations of the RCCOs will enhance requirements for integration of care between the organizations. RCCOs and BHOs strive for ‘whole person care” by focusing on care coordination; bi-directional referrals; screening for major issues that fall under either provider; sharing information to coordinate care; alignment of some quality and performance measures such as reduction of ER visits, hospital readmissions, and increase in follow-up care; and sharing data. (p. 23)

  • By 2015, provide network access to more than 400 hospitals, behavioral health providers, clinics, and other providers throughout rural and urban Colorado. (p. 5)
  • Enhanced connectivity through Health Information Technology (HIT) and state Health Information Exchanges (HIEs), will build upon and expand the Comprehensive Primary Care initiative (CPCi) centralized data hub that integrates clinical and claims data, and use other sources of shared information. (p. 7)
  • Overseen by the Governor’s Office, the state SIM office will provide planning and oversight and will manage HIT contracts for tasks, such as the provision of technical assistance to practices, done at the regional level. The state SIM office also will manage the contract for a centralized data hub with the State Designated Entity (SDE), Colorado Regional Health Information Organization (CORHIO). (p. 40)
  • The SDE will support the SIM initiative in the following ways:  Provide administration support for coordination and oversight of the SIM HIT proposed programs.  Facilitate HIT architecture development supporting SIM clinical and cost data hub.  Oversee data governance through statewide expert workgroups and committees. Create, distribute, and vendor selection for additional technology investments.  Distribute funding to the HIT partners supporting Colorado’s SIM proposal. (p. 41)

  • By 2015, recruit and retain 148 primary care and dental providers through the Colorado Health Service Corps. (p. 5)
  • Workforce Initiatives - Conducting a comprehensive review of current Colorado health professional practice acts, statutes regarding provider credentialing and empanelment and related issues. This will help clarify the perceived and real barriers to collaboration among professions and increases in administrative cost. As part of this effort, a Governor-appointed task force is in the final stages of an analysis of requirements for advance practice nurses to obtain prescriptive authority. It is likely they will recommend a statutory change to reduce barriers to entry for this authority. (p. 35)
  • Gathering data on the readiness level of Colorado’s practicing behavioral health workforce to be trained to work in an integrated primary care setting in order to inform the scope and level of training efforts undertaken across the state, and help to target efforts. (p. 35)
  • Assessing the workforce needed for both clinical needs and non-clinical needs, such as IT, administration and billing, discharge planning and health navigator services that may be needed to support the system. Creating learning opportunities for both primary care and behavioral health providers to learn how to best work with one another in both settings. Integrating providers requires addressing cultural elements; as such, we will offer opportunities for providers for team-based training, both in educational and “real world” settings. (p. 27)
  • Colorado is one of seven states selected by the National Governors Association to implement a health workforce development plan that will create a centralize data and analytics hub, use data to drive statewide workforce planning that is responsive to local needs and build on Colorado’s nationally recognized loan repayment program to expand recruiting and retraining efforts. The Governor’s Office will work with the Colorado Department of Higher Education, the Community College System, and key health professions’ educators to ensure that team- based, integrated care delivery is a training priority. (p. 27)


Click Here for Full State Plan
State's SIM website

Summary by Focus Area:

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

Financing Population Health:
  • Many innovative approaches are mentioned in the proposal including state funding, assessments on insurance carriers/payers, wellness trusts, innovative Medicaid and possibly commercial insurance reimbursement policies, payments by entities such as hospitals and payers which derive benefit from community prevention. (p. 3)

Transforming Clinical Care:
  • Focus is on moving a large percentage of PCPs to Advanced Primary Care (APC) and providers participating in the new Medicaid waiver. The "Advanced Medical Home Glide Path" will move PCPs to APC designation (National Committee for Quality Assurance patient-centered medical home plus certain CT-specific indicators) using practice transformation vendors providing support for 9-18 months (p. 19). A clinical integration team will help practices integrate behavioral and oral health, address community prevention and health equity issues, medication therapy management, e-consults, team-delivered care, community linkages for wrap-around supports and identification of super-utilizers.
  • Emphasis on moving primary care practices to be accountable for quality, care experience and costs through shared savings programs. This is aligned with Medicare's ACOs, in which few FQHCs or small practices currently participate. Insurance plans are encouraged to promote value-based insurance designs. The plans will be conducting an independent evaluation of the outcomes of VBID. Insurance plans were assessed $3.2 million/year to support the SIM project management office. (p. 39)

  • Measures of health equity at the community and clinical levels will be developed and publicly reported. (p. 3)
  • The Health Enhancement Communities are coalition-based efforts to improve health disparities. (p. 7)

Behavioral Health:
  • Integration of behavioral health (BH) within advanced primary care is a goal of the CT Plan. All quality and outcome measures developed by CT's SIM team will eventually include BH measures. (p. 24)
  • Looking at various policy levers to advance BH, including promoting integrated plans to be sold on the State Insurance Exchange, and reviewing current Medicaid policies that prohibit physical and BH services from being billed on the same day. (p. 11 , 24)

  • A common provider scorecard based on the Medicare ACO reports plus peds, behavioral health and health equity measures is planned. Similarly, CT will work with all plans to develop a uniform set of measures for all plans to use to determine practices' shared savings. A consistent survey of consumer experience will also be developed to be used for all practices. (p. 41)
  • CT does not currently have a statewide HIE (Health Information Exchange), but the SIM proposal includes provision for building integration of the high level of electronic medical records (EMRs) operating in hospitals and private practices, development of extensive data-sharing agreements, and better data sharing between clinicians and community. Enhanced data sharing will allow for improved public health disease registries and various mobile apps. An all-payer claims database (APCD) is under development but because current state law prohibits the sharing of much commercial data, the State is committed to seeking statutory changes to allow necessary data exchange. (p. 58)

  • On-going education and support of primary care practitioners. A Learning Collaborative will focus on the transformation needs of PCPs working with Medicaid patients and with federally qualified health centers (FQHCs). There is an extensive plan for community health workers (CHWs) and other team members, based in Area Health Education Centers. There is a plan for CT colleges and universities to produce and retain more PCP team members. (p. 13)

CHNA & Community Benefits
  • Enhanced Behavioral Risk Factor Surveillance Survey (BRFSS) sampling will provide baseline and ongoing capability to conduct small area analyses for tobacco, obesity and diabetes and other identified health priorities. Other data sources include mortality data, hospital and ED discharge data and existing community health needs assessments. (p. 2)
  • Each of the five counties awarded Community Transformation Grant funding created a comprehensive Needs Assessment (p. 6)
  • A health and wellness district jointly sponsored by Charter Oak Communities, City of Stamford and Stamford Hospital is aimed at revitalizing the economic health and well-being of Stamford’s West Side residents. Informed by a local Community Health Needs Assessment (CHNA) and a collaborative strategic planning process, the initiative is well underway and has achieved a number of accomplishments (p. 8)
  • The plan for improving population health will utilize and build upon the DPH’s recent State Health Assessment, State Health Improvement Plan (Healthy Connecticut 2020) and the state Chronic Disease Prevention Plan. This revised plan will be completed during Years 1 and 2 of the Test Grant. (p. 48)
  • DPH will also seek capable vendors that have prior experience developing the state’s Healthy Connecticut 2020 State Health Improvement Plan. In this way the contractor will have knowledge of Connecticut’s structure and environment, experience working with sectors and partners involved in initial planning, and demonstrated skills in community engagement, facilitation of diverse groups discussing complex issues, and statewide health improvement planning. (p. 73)

  • An "Underservice Monitoring" effort aimed at assuring that shared savings programs do not result in under-service: cost-shifting, less than ideal care levels or other cost-cutting steps with negative health impacts. An Equity and Access Council, including consumers, will guard against this risk. (p. 20)
  • Very high level of consumer involvement in all governing entities related to SIM. (p. 34-35)


Click Here for Full State Plan
State's SIM website

Summary by Focus Area:

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

Financing Population Health:
  • Attribute all patients to primary care physicians (PCPs) and incentivize PCPs to address specific measures (obesity screening, smoking, diabetes control) as well as total cost, Delaware’s payers are shifting incentives to support population health. (p. 3)
  • Transition to value-based payment models that support integrated care delivery - create flexibility for many different types of provider organizations to participate in new models, allowing providers to innovate how they integrate with organizations focused on improving population health. (p. 7-8, 14)
  • Population Health and Common Provider scorecards – align measures so that providers and community organizations have common areas of focus (p. 8); align measures across payers (p. 18)
  • All payers introduce one Pay for Value (P4V, with bonus tied to quality and utilization management for a panel of patients) and one Total Cost of Care (TCC, with shared savings linked to quality and total cost management for panel of patients) payment model option to eligible PCPs (p. 17-18)

Transforming Clinical Care:
  • Plan emphasizes the role of primary care in the system and prioritizes integrated care (including behavioral health) for high-risk individuals and more effective diagnosis and treatment for all.
  • Flexible framework to support independent providers and health systems in adoption of existing models including: co-location of services, population-specific care coordination, Patient Centered Medical Homes, Accountable Care Organizations. (p. 10)
  • Specific components of plan: voluntary participation, practice transformation support, expansion of learning collaboratives, transition to value-based payment, care coordination support paid by payers to PCPs, improved access to information, engaging clinical leaders around clinical best practices, engaging patients. (p. 13-15)

  • Develop community-specific datasets that quantify and assess local health needs and track health performance/outcomes over time. (p. 5)
  • Cross-agency collaboration to address social determinants of health. (p. 8)

Behavioral Health:
  • Proposal compliments existing value-based models: “PROMISE” program for severe and persistent mental health, Medicaid managed care for long-term care, strengthened Home and Community Based Services. (p. 19)
  • Provide EHR adoption incentives to support integration of behavioral health. (p. 26)

  • Delaware Health Information Network (DHIN, HIE) provides Admit Discharge Transfer (ADT) notifications which support providers in coordinating care. (p. 14)
  • DHIN aggregate common measures to provide one integrated view of provider performance across all payers, with single access point for reports. (p. 14, 25)
  • Expand clinical information in DHIN from ambulatory providers, nursing homes, and home care facilities. (p. 25)
  • Build on existing and planned investment in Medicaid/State-employee claims databased to create multi-payer data warehouse (government, commercial, and non-reimbursable claims). (p. 25-26)
  • Develop consumer engagement tools (e.g., portal, mobile apps) to enable patients to access health information, building on Meaningful Use. (p. 26)

  • Healthy Neighborhoods will create an inter-professional forum that brings together workforce responsible for coordinating care, including care coordinators and community health workers. (p. 4)
  • Retraining current workforce, building sustainable workforce planning capabilities, training future workforce in skills needed to deliver integrated care. (p. 16)
  • Academic and healthcare communities will collaborate on multi-year curriculum that includes: simulation-based learning modules, facilitated workshops on team-based care, development of core competencies for new roles, symposia. (p. 16)
  • Statewide Telehealth Coalition: expanding practices for individuals with disabilities, mental health disorders, and chronic conditions. (p. 26)

CHNA & Community Benefits

  • Delaware will conduct a needs assessment, finalize details for Healthy Neighborhoods’ structure and process, build DPH resources to support communities and local data collection, and select pilots. (p. 6)
  • A review of health needs identified by hospital community health assessments, the Division of Public Health’s (DPH) State Health Improvement Plan, and comparisons against national averages and goals set by the CDC shows that Delaware’s most pressing health needs include: rising obesity, in particular for children (14.2% vs. 13.7% nationally); tobacco use; diabetes (9.6% prevalence; 7.6% pre-diabetes); cardiovascular disease; behavioral health (9th highest death rate from overdoses in U.S.); and dental care. (p. 1)
  • Healthy Neighborhoods: Neighborhoods will agree on an initial plan for health improvement, including overall goals, 1-2 priority interventions, and existing assets. (p. 3)
  • Delaware has a series of federal programs, including funding for the DHIN and CDC funding for public health initiatives (e.g., assessment and planning for DPH’s State Health Improvement Plan). (p. 39)


Click Here for Full State Plan
State's SIM website

Summary by Focus Area:

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

Financing Population Health:
  • Align payment mechanisms across payers to transform payment methodology from volume to value. Idaho’s 3 largest commercial insurers in the State will participate in the model: Blue Cross of Idaho, Regence BlueShield, and PacificSource. Together, these three payers account for approximately 92% of the individual market, 95% of the small group market, and 97% of the large group market. (p. 6)
  • Financial analysis indicates that Idaho’s healthcare system costs will be reduced by $89M over 3 years through new public and private payment methodologies that incentivize providers to focus on appropriateness of services, improved quality of care and outcomes rather than volume of service. (p. 7)
  • Idaho projects a ROI for all populations of 197% for five years. (p. 7)
  • Idaho’s Model Test both drives and supports the transformation to the new delivery system by utilizing grant funding to support start-up costs for PCMH transformation, and to incentivize higher levels of PCMH recognition. Payer-provided PMPMs and shared savings payments will cover the practice costs associated with ongoing care coordination and patient management, as well as the costs of collecting quality and performance measures. (p. 7-8)
  • The new payment model components will include Per Member Per Month (PMPMs) payments to support care coordination and other PCMH functions, total cost of care shared savings arrangements, and quality incentives. (p. 9)
  • PCMH Practice Transformation Incentives & PCMH National Recognition Incentives. (more details p. 10-11)

Transforming Clinical Care:
  • Deliver integrated, efficient, and effective primary care services through the patient-centered medical home (PCMH), which is integrated within the local Medical Neighborhood. (p. 1)
  • The broader healthcare system is organized at the regional level as a robust Medical Neighborhood, integrating a spectrum of ancillary healthcare providers with primary care. (p. 1)
  • Create a virtual PCMH to bring high quality healthcare to extremely rural communities (p. 2). Develop 75 virtual PCMHs. (p. 5)
  • Build 180 PCMH primary care practices with 900 primary care providers serving 1.3M Idahoans (80% of state population). Idaho’s new PCMH model builds on the activities of the Idaho Medical Home Collaborative (IMHC), but expands from the current 27 PCMH pilot sites to statewide primary care provider engagement. The Model Test will also expand the PCMH model to all patients, not just those with chronic conditions. (p. 4)
  • Establish 7 Regional Collaboratives to support the integration of each PCMH with the broader Medical Neighborhood. At the local level, Idaho’s 7 Public Health Districts (PHDs) will serve as Regional Collaboratives (RCs) which will support practices as they transform to a PCMH and support existing PCMHs as they further expand their capacity and enhance their performance. (p. 5)

Behavioral Health:
  • The virtual PCMH model will also allow for integration of behavioral health services in remote communities via telehealth services. (p. 5)

  • Improve care coordination through adoption and use of EHRs and HIE connections among the 180 Model Test PCMHs, and across the Medical Neighborhood. (p. 4)
  • Idaho’s proposal include significant investment in connecting PCMHs to the Idaho Health Data Exchange (IHDE), enhancing care coordination through improved sharing of patient information. This Model Test also includes technical assistance to improve practices’ use of EHRs. EHRs in primary care settings are proving to be an essential tool to quality and care coordination. (p. 5)
  • Build a statewide data analytics system. Grant funds will support data collection training at the PCMH level, and development of a state-wide data analytics system to track, analyze and report feedback to individual providers on selected performance and outcome measures to improve their practice. The data analytics system will also report to the RCs on regional population management metrics which will be used to identify and address regional population management issues. (p. 6)
  • The HIT Plan calls for the development and/or expansion of EHR and IHDE technology to support: 1) statewide data collection and performance analysis needed to improve quality and establish value-based payments; 2) shared data to facilitate coordinated care, and; 3) patient portals to increase patient–provider communication and patient self-management. Telehealth technology will also be developed to expand access to healthcare and extend the healthcare work force in underserved areas, and to integrate behavioral health with PCMHs. Finally, the HIT plan will coordinate with Idaho’s new Time Sensitive Emergency (TSE) system to leverage improved care coordination for people who experience trauma, stroke or heart attack. (p. 16)

  • The IHC will join forces with the Idaho Health Professions Education Council, Idaho Area Health Education Center, and the Idaho Telehealth Council to support workforce expansion efforts and develop innovative strategies to maximize the capacity of the State’s limited healthcare workforce. Some barriers caused by the State’s workforce shortages will be addressed through the use of multi-disciplinary teams in the PCMH. Each PCMH team member will practice at the top of their license and achieve efficiencies by delivering care at the appropriate level. (p. 4)
  • Physicians will be able to focus their time on clinical care requiring physician-level intervention while other staff, such as nurses and community health workers (CHWs), provides care within the appropriate scope of their practice. (p. 4)
  • Train over 550 CHWs and community health emergency medical services (CHEMS) to assist in providing rural patient access via virtual PCMHs. (p. 5)
  • Proposed CHW and CHEMS training programs will include staff training and on-site technical assistance to assure successful integration of these staff into the PCMH team. (p. 5)

CHNA & Community Benefits
  • Communities will participate in community needs assessments and will work with the Regional Collaboratives (RCs) to align specific performance metrics for the PCMHs in their region with identified areas of need. (p. 21)
  • Model Transformation and Patient Experience of Care Measures includes Regional Health Needs Assessments: % of PCMHs who receive results of community health needs assessments to guide development of quality initiatives within their practice. (p. 28)
  • Division management has been meeting since June of 2014 to design the Idaho Health Assessment (IHA) which will inform the Idaho Health Improvement Plan (IHIP), Idaho’s plan for improving population health. The IHIP will integrate population health with the healthcare delivery system. Between November 2013 and April 2014, the Division of Public Health developed a set of Leading Health Indicators for Idaho. The indicators provide a framework for describing the health of all Idahoans and provide direction for the IHIP. The workgroup has an aggressive timeline, targeting completion of the assessment in December 2014, and completion of the IHIP in May 2015. (p. 2)
  • The foundation of the IHIP will be a thorough statewide health assessment with the following timeline (see p. 2-3).

  • The Idaho Healthcare Coalition (IHC), established by Governor Otter through executive order, and composed of key stakeholders from around the state, will guide the statewide implementation of the model. (p. 9)
  • Idaho’s 2014 legislature also passed two concurrent resolutions that promote key aspects of Idaho’s healthcare system transformation. First, HCR046 recognizes the importance of telehealth in a rural state like Idaho, directing IDHW to convene a Telehealth Council. A second concurrent resolution (HCR 049) directs IDHW to convene a workgroup to study collection of hospital discharge data and to study creation of a comprehensive system of healthcare data, including inpatient, outpatient and other care services. (p. 13-14)


Click Here for Full State Plan
State's SIM website

Summary by Focus Area:

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

Financing Population Health:
  • Iowa has expanded Medicaid through the Iowa Health and Wellness Plan (IHAWP), which began on January 1, 2014, and provides comprehensive health care coverage to low-income, uninsured Iowans ages 19 to 64.8 Part of the IHAWP is the Healthy Behaviors Program, which emerged as a SIM concept during the SIM Design and incentivizes all IHAWP members to work with providers to be healthy and stay healthy. Members who achieve the Healthy Behaviors requirements will not be responsible for a monthly premium. Medicaid has designed payment levers for both the primary care provider and the IHAWP ACOs that align with the member healthy behaviors. (p. 4).
  • Development of multi-payer ACOs is a key driver of system transformation. Iowa's delivery system is characterized by a relatively small number of large entities that already work together, including several large health systems that deliver the majority of acute care services and employ more than half of the primary care physicians. This multi-payer foundation creates a powerful opportunity to align accountable pay-ment structures to enhance providers’ ability to achieve critical mass and catalyze transformation. (p. 8-10)
  • Currently, one commercial payer is committed to participating in this payment model, Wellmark, which accounts for 41% of the Iowans who are covered by commercial insurance. (p. 14)
  • A value-based payment model closely aligned with Wellmark and similar to Medicare is a key strategy in Iowa’s SIM. See table with keey components of payment structure in full Medicaid ACO (p.14). The State is also open to testing payment reform pilots such as partial and full capitations for ACOs that prove effective at transforming them into a value-based entity. (p. 15)
  • IME, in conjunction with Wellmark, will work with Treo Solutions to develop, simulate, and test the appropriate and most effective way to embed incentives that will further drive ACOs to invest in the required tools, capability, and capacity to address SDH without increasing risk avoidance. (p. 17)
  • For the state-wide Medicaid ACO strategy laid out in this proposal, DHS intends to submit a Payment Methodology State Plan Amendment (SPA) to CMS and move Medicaid into a 1915(b) waiver for choice and PCP assignment. In addition, the State will leverage ACO con-tracts to expand the ACOs into a community setting with a population health focus (p. 26).

Transforming Clinical Care:
  • ACOs - organically-derived from local communities and are able to leverage the diversity & strengths of each local delivery system. (p. 3)
  • Population Health Initiatives Table (p. 4)
  • Clinical interventions focused on obstetric adverse events; healthcare associated infections; diabetes. (p. 11)
  • The SIM Initiative will provide significant support for ACOs and public health/primary care integration. the SIM Initiative will expand these quality improvement processes to the entire spectrum of care offered through the ACOs. This process will focus on aligning resources toward a common vision that expands current healthcare delivery into the community setting, developing local champions to serve as faculty of best practice, and aligning measurement strategies to track community progress toward population health initiatives. Community Care Teams provide an opportunity to partner with hospitals or physician clinics not contracted in an ACO, to ensure smaller providers are able to participate in new care models. (p. 12-13)

  • Plan introduction notes - Health disparities were especially high related to income, race, and ethnicity, with 68.5% of low-income adults unable to access recommended primary care, a rate about 25% higher than the overall state total and a primary driver for Iowa’s Medicaid expansion. Rural access to care issue. (p. 1)
  • Addressing disparities between rural and urban areas is a significant reason for implementing Accountable Care Organizations (ACOs), and the Iowa Medicaid Enterprise (IME) expects that ACOs will naturally facilitate a focus on the areas of greatest need, while capitalizing on local strengths. One of three mechanisms for accelerating transformation - supporting the ACO delivery system to integrate with communities and social services to address the social determinants of health (p. 6).
  • The SIM Initiative will address the SDH in three ways: first, by developing improved community infrastructure and linkages through community-based transformation activities, as well as integration from public health to support healthy lifestyles (as described in Part 1); second, through practice transformation activities that provide healthcare providers and systems with the knowledge and tools to evaluate the SDH and address them as a routine part of the healthcare encounter; and third, through developing risk adjustment payment structures that provide additional resources for members significantly impacted by the SDH (described further in Part 3) The State also plans to focus efforts by issuing SDH grants at the community level as a means to accelerate capacity of these teams to address SDH issues specific to their communities. (p. 49)

Behavioral Health:
  • Full Medicaid ACO contracts, using guidance from stakeholders during the SIM model design, will involve partnerships with a broad range of community-based providers moving to a more organized delivery system that includes other behavioral health providers (including both mental health and substance use). (p. 7-8)
  • Initially, ACOs will coordinate care with existing BH and LTCSS; over time, ACOs will as-sume financial and clinical accountability for BH and LTCSS services. Core sets of ACO quality measures will be expanded in phases and include BH and LTCSS quality of care, access, integration with physical health services, and ratio of community-based vs. institution-based services. (p. 8)
  • (Also aligns with workforce) - Iowa has developed three post graduate training programs to provide specialized training in mental health for Physician Assistants, Nurse Practitioners and Psychologists. Two programs funded by the state and administered through the IDPH involve post graduate training that enable these professions to have a certification in mental health. Practitioners who matriculate through these programs can provide mental health services in a variety of primary and mental health clinical settings. The third program works to provide a post graduate training program for doctoral level psychologists that meets their supervised rotation requirements similar to a residency. (p. 46)

  • Data collection and analysis efforts will focus around existing data such as the Behavioral Risk Factor Surveillance Survey (BRFSS), hospital discharge data, and additional data collection efforts when required. Whenever possible, LPHAs will facilitate the connection between ACOs and other community-based health improvement efforts. (p. 3-4)
  • Medicaid is using the AssessMyHealth HRA tool10 developed by Treo Solutions.11 The tool collects information about members’ self-activation, social determinants of health (SDH), and basic clinical risk information that a provider can integrate into an individualized plan of care (p. 4).
  • The 2013 Iowa Health and Wellness Plan (IHAWP) legislation establishes a framework for exchange of member health information to improve care and reduce costs. DHS is required to provide the health care claims data of attributed members to each ACO. (Every ACO contract contains a HIPAA-compliant business associate agreement to protect patient confidentiality). The Medicaid environment is a safe place for ACOs to share data and identify efficiencies without the legal concern of collective bargaining for rate setting that can be found with the private market. (p. 16)
  • IME’s HIT planning and roadmap centers around four goals central to supporting the health of Medicaid populations and Iowa’s overall reform goals. These goals and objectives, as articulated in IME’s State Medicaid HIT Plan (SMHP)17 most recently submitted and approved by CMS, are to: 1) increase provider adoption of electronic health records and health information exchange; 2) improve administrative efficiencies and contain costs; 3) improve quality outcomes for members; and 4) improve member wellness. Health Information Exchange Information. (p. 18)

  • Population health improvement plan - some of it will be driven by LPHAs, who will provide resources and collaborate with the ACOs through a community health worker/care coordination model. (p. 3)
  • Growing competition between ACOs should generate new workforce models that utilize lower levels of licensure. Expanding the team to include social workers, pharmacists, community health workers, nurses, and others, will mitigate access to care challenges resulting from medical provider shortages. IDPH also manages a variety of loan repayment and recruitment and retention programs supporting community delivery systems and will use the case studies to better inform policies. (p. 13)
  • During early SIM workgroup meetings, ACOs indicated that they have already begun re-training their workforce to engage in team-based care, telehealth, and practices that support a more effective system. IME supports the use of telemedicine and will work to identify levers to expand workforce reach. (p. 46)

CHNA & Community Benefits
  • During the SIM Initiative, IDPH will draw together an expert panel to expand upon the state-wide Heath Improvement Plan to improve population health, and use that to guide SIM activities. Specific initiatives have already been identified (Table 1), along with major efforts to train ACOs in the tools, processes, re-sources, and culture of public health. IDPH, with assistance from the Iowa Health Collaborative (IHC) will implement these initiatives and monitor their outcomes. (p. 3)
  • One important responsibility of Iowa’s local public health agencies (LPHAs) is coordinating the development of community health needs assessments and health improvement plans for their local jurisdictions. While IDPH requires these be developed every five years, adjustments to this schedule are being made to enable LPHAs to coordinate more effectively with local hospital partners, allowing achievement of their IRS requirements to conduct these same local planning efforts on a three-year basis. (p. 17-18)
  • The model test proposed in Iowa uses these newly formed Community Care Teams to address social determinants of health by sharing community needs assessment data, and sharing data gathered from the HRA Assess My Health. (p. 49)

  • ACOs envisioned in the SIM include all three major payers – Wellmark, Medicaid, and Medicare, covering 86% of Iowans. (p. 3)
  • Through SIM, Iowa will seek a waiver to move Medicaid fee for service into the PCCM model of assignment so that all of the Medicaid population is assigned a PCP of their choice. (p. 8)
  • As part of regulatory powers - IDPH will investigate opportunities to align Certificate of Need application questions that would support strategies in this proposal. (p. 17)
  • The ACO TA strategy moves these systems into a community setting that focuses on the goals and measures of the Population Health Improvement Plan. This approach promotes relation-ship building with community partners, including local public health (LPH), Maternal and Child Health Agencies (MCH) agencies and the newly formed Community Care teams. Presently, LPH/MCH agencies do not have a clear role in the ACO infrastructure. Through this delivery system transformation, LPH/MCH agencies will have the opportunity to be innovative and respon-sive by aligning with the ACOs and coming together to define what they could offer to the ACO, therefore reducing the number of contractual agreement ACOs would have to make with LPH/MCH agencies. We propose a venue in which the local agencies would actively participate in the development of the integration into primary care and ACOs. One of the venues proposed to create this integration will be the community level learning collaborative that will bring community healthcare leaders together to create community level responses. (p. 48)


Click Here for Full State Plan
State's SIM website

Summary by Focus Area:

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

Financing Population Health:
  • Payment Service Delivery Models : Patient Centered Medical Homes, Accountable Systems of Care, and Community Health Innovation Regions. (p.7-11)
  • Patient Centered Medical Home transformation is well underway in Michigan. (p.7-11)

Transforming Clinical Care:
  • Health care delivery transformation plan is central to innovating service delivery. (p.5-7)

  • Focus on low income and minority groups. (p.1)

Behavioral Health:
  • Create financial incentives for plan for enrollees who demonstrate improved health outcomes or maintain healthy behaviors. (p.15)
  • CareConnect360 is a Medicaid web-based platform that is improving communication between behavioral health and physical health providers, and convening stakeholders to establish vendor-neutral behavioral health exchange. (p.15)
  • Behavioral Risk Factor Surveillance System will be used to monitor social determinants. (p. 27)

  • Health Information Technology uses a collaborative approach to data exchange promotes shared public-private state-level services and data infrastructure (p. 14-18)

  • Verify that health care professionals practice at the top of their training and licensure, review the overall licensing scheme, while being attentive to the goal of avoiding unnecessary regulation. (p. 12)
  • A policy objective of the Blueprint is to incorporate Incorporate non-traditional professions, such as Community Health Workers, into service coordination while also supporting standards for the training and skill sets of these occupational groups. (p.12)

CHNA & Community Benefits

  • The Blueprint proposes that Community Health Innovation Regions organize partners based on the collective impact model. They will leverage community benefit and public health accreditation requirements to conduct collaborative community health needs assessments that will identify key health concerns, illuminate root causes of poor health outcomes, and set strategic priorities. (p. 4)
  • Some communities in Michigan have already developed sustainable funding mechanisms to support the backbone organization for a Community Health Innovation Region, such as support from local business and payers, hospital community benefit funding, public funding, and philanthropy, including the United Way. (p. 9)
  • A Population Health Advisory Board will be created to formalize this partnership, and provide guidance to the development and implementation of the Population Health Improvement Plan. (p. 5)
  • Population health improvement is a key objective of Michigan’s Model Test Proposal. Key health targets will be monitored and reported annually on public dashboards. The overarching strategy to address population health is to establish Community Health Innovation Regions, which will be accountable to improve population health Strategies will draw on existing plans, updated based on collaboration with the Centers for Disease Control and Prevention and local experience. The resulting strategies will be included in a Population Health Improvement Plan, and disseminated extensively. (p. 5)

New York

Click Here for Full State Plan
State's SIM website

Summary by Focus Area:

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

Financing Population Health:
  • Beyond SIM funding, sustainability to be derived by: payer contributions as the value of vices is recognized (ex: tobacco cessation), ongoing support through the new Medicaid waiver, and hospital community benefits. (p.3)

Transforming Clinical Care:
  • In 5 years, goal is for 80% of New Yorkers to receive care in an APC; 80% of care is paid for through value-based agreements and consumers will be more engaged with cost and quality information. (p. 11)
  • 3-tiered levels of APC with curriculum and assessment tool and will fund locally-driven practice transformation (~$20,000/yr/practice X 3 years) to achieve goal of ~75% practices achieving APC status from baseline of ~25% (p.6)
  • Will establish policies to increase the primary care workforce, its distribution and scope of practice. It is expected that APCs will move from fee-for-service to graduated levels of value-based payment. NY State will use all available levers (Medicaid and state employee contracts, commercial insurance rate reviews) to promote value-based payment, insurance design and common scorecard and quality reporting. (p.9)

Behavioral Health:
  • Integration of behavioral health (BH) is assumed in fully functioning APC. BH clinical info to be included in the Health Information Exchange (HIE). (p.16)

  • SIM funds will allow for a new Patient Portal and for creation of an All Payer Claims Database. NY supports an award-winning Open Data Initiative. A common set of system indicators will be developed for all payers, providers and regions. A common scorecard is in draft. (p. 20)

  • All workforce efforts focused on supporting primary care physicians, nurse practitioners and physician assistants: their education, distribution, scope of practice at top of license, and retention. (p.7)
  • For physicians the state has embarked on a Medical Residency Training State Matching Grants program to provide matching state funding to sponsors of accredited graduate medical education residency programs in this state to establish, expand, or support medical residency training programs. The program focuses on primary care physician and psychiatrist residencies. (p. 46)

CHNA & Community Benefits
  • Sustainability will be assured through ongoing support of key population health interventions by DSRIP, delivery system transformation, payer support of proven effective services (tobacco cessation) and potential hospital investments in community benefits as required by the Affordable Care Act. (p. 3)

  • NY's concept of overall SIM governance is notable. SIM is linked with the new Medicaid waiver and reports to the Legislature and Governor. Within SIM efforts, there are several workgroups: Population Health, Access to Care, Integrated Care, Pay for Value, Workforce and Health Information Technology/ Measurement/Evaluation. (p. 18)


Click Here for Full State Plan
State's SIM website

Summary by Focus Area:

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

Financing Population Health:
  • As part of SIM Design Process, achieved multi-payer agreement across Medicaid, state employee, and commercial health plans to launch episode-based payments statewide in November 2014. (see abstract).
  • Ohio adopted a goal to enroll 80-90 percent of the total population in value-based payment models that support health care delivery system transformation. (p. 7)

Transforming Clinical Care:
  • As result of SIM Design Process, adapted Southwest Ohio’s Comprehensive Primary Care Initiative (CPCI) for a statewide rollout of Patient-Centered Medical Homes in 2015. (p.10)
  • Ohio Healthcare Delivery System Transformation Plan. (p. 6)
  • Patient Centered Medical Homes model that is flexible to meet the needs of providers and targeted capacity-building support (e.g., EHR implementation, performance measurement education) with increased emphasis on total cost of care accountability (e.g., shared savings) over time. (p. 9-11)
  • Episode-Based Payment Model encourages high quality, patient-centered, cost-effective care by holding a single provider or entity accountable for care across all services in a specific episode; aligns provider incentives and discourages under-utilization. (p. 11)
  • Governor’s Office of Health Transformation working with private payers, health plans, and providers to accelerate the adoption of PCMH and episode-based payment models. (p. 13)

  • PCMH’s are incentivized to work with episode accountable providers to increase quality and manage costs, as well as community-based and public health resources to address social determinants of health. (p. 12)

  • The Governor’s Office of Health Transformation is coordinating the development of a dynamic HIT infrastructure that connects clinical and population health ecosystems and improves overall health system performance. (p. 15)
  • Connect siloed and disparate health registries to enterprise health and human services (HHS) data warehouse. (p. 16)
  • Expand data gateway to connect external systems to state’s enterprise data warehouse. (p. 17)
  • Use case management and assessment tool to connect to enterprise data warehouse to allow case managers access to claims, clinical, and demographic information; enable predictive analytics. (p. 17)
  • Health IT Council will be developed to coordinate broader, statewide HIT/HIE plan.
  • Ohio HIT Plan Activities. (p. 18)

  • Provide targeted capacity-building support for Patient-Centered Medical Home model (e.g., EHR implementation or performance measure education). (p. 10)
  • Comprehensive plan to support advanced primary care and recruitment and retention of minorities into health professions. (p. 14)

CHNA & Community Benefits
  • The state is working to align community health needs assessment and population health planning. Currently, Ohio’s 124 local public health districts and multiple hospital systems are performing Community Health Assessments and Community Health Needs Assessments with varying levels of coordination. During the SIM test, the state will pursue better coordination of these plans, with the goals of identifying clear population health priorities across regions, facilitating stronger relationships among public health districts and health care delivery systems (e.g., PCMH), and explicitly tying hospital community benefit requirements to addressing regional population health priorities. (p. 7)

Rhode Island

State's SIM website
Click Here for Full State Plan

Summary by Focus Area:

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

Financing Population Health
  • The first Population Health Plan vendor will be responsible for the overall development of the plan, working with the Healthy Rhode Island Steering Committee to assess the overall health of the state and identify measurable goals, objectives and interventions. This vendor will also be tasked with monitoring and evaluating our progress in meeting those goals. We have allocated $750,000 for this work.(p. 4)
  • We will hire a second vendor who will be responsible for ensuring our Population Health Plan explicitly recognizes the behavioral health needs of our residents. This vendor will also assist in the implementation of the transformation of our behavioral health system, in concert with our overall healthcare delivery transformation. We have allocated $750,000 for this work. (p. 5)
  • This grant proposal seeks funding in two areas to support the transformation of our health care delivery system. The first is through explicit funding for new models of care or enhancements to existing models that are already alternatives to a volume-based delivery of care. We have allocated $4.6 million towards this effort. We are also proposing to use $6.8 million to support our Health Information Infrastructure. (p. 7)

Transforming Clinical Care
  • Rhode Island’s Population Health Plan and Healthcare Delivery System Plan will be consonant. They will both focus on transforming the health care delivery system to the Value-Based Care Paradigm described in the State Health Innovation Plan. Rhode Island envisions a new system of care that supports lifelong health for the state’s populations. (p. 6)
  • There are six fundamental characteristics to our vision of value-based care (Value-Based Care Paradigm): an orientation to outcomes and population health management, effective provider relationships, person seeking care is active and engaged, alternatives to fee-for-service payment models, and effective use of health information technology.(p. 7)
  • We will use this grant to impact payment and service delivery models by expanding existing models and supporting provider organizations to meet the Value-based Care Paradigm. Existing and new models (PCMH, Health Homes, ACOs, etc.) will need to highlight how they will respond to a person’s behavioral health needs. (p. 8)
  • Our proposal seeks funding for the following projects we believe will directly impact our progress in healthcare transformation: Practice Assistance, Community Health Teams, Patient Centered Medical Home Expansion, Child Psychiatry Access Program, Advanced Illness Care Initiative, and Behavioral Health Transformation. (p. 10)

Behavioral Health
  • We will measure the transformation of the Behavioral Health system with several outcome measures. We will use the measures included in the report, Substance Use and Mental Health in Rhode Island; A State Epidemiological Profile,5 as the basis. (p. 27)
  • We will include measures of Population Health Plan and Behavioral Health Transformation interventions that will impact the health care payment and delivery system. These include Avoidable ED visits; 30 day all cause hospital readmissions; and Readmissions under the Medicare Payment Reduction Program for specific diagnoses. (p. 28)
  • We will hire a second vendor who will be responsible for ensuring our Population Health Plan explicitly recognizes the behavioral health needs of our residents. (p. 5)
  • The development of the Population Health Plan will be supported by several existing initiatives. Among these is a study on the demand, supply and cost of behavioral health treatment that will be completed within the pre-implementation period as well as existing and continuing community health assessments and already available data. (p. 6)
  • Existing and new payment and service delivery models will need to highlight how they will respond to a person’s behavioral health needs. (p. 8)
  • Behavioral Health Transformation Funding Request for $1,250,000. The Transformation Network will be responsible for the implementation of transformation efforts in the behavioral health system. This initiative would support the statewide implementation of Screening, Brief Intervention, and Referral to Treatment (SBIRT) as a way to integrate substance abuse prevention and early treatment across the system. Additional activities will be identified in the planning process. (p. 10)
  • Child Psychiatry Access Program Funding Request: $750,000. These funds will be used to implement a pilot initiative for a children's mental health consultation team designed to help targeted primary care providers meet the needs of children with psychiatric problems. We will explore other funding through other sources such as the Department of Education or the Administration on Children and Families. (p. 10)
  • This proposal seeks to use health information technology in two ways: to improve the State’s ability to collect, analyze, and report data and to impact care delivery at the provider level. (p. 26)
  • This proposal seeks $3,000,000 to modernize state data management, analytics, and information technology. With those funds, we will develop and implement an enterprise wide technical architecture that leverages, aligns, and integrates existing systems such as the Executive Office of Health and Human Services’ (EOHHS) Data Warehouse and Medicaid Management Information System, the State’s new eligibility and enrollment system, the All Payer Claims Database, and public health data sets. (p. 3)
  • We are proposing to use $6.8 million to support our Health Information Infrastructure through the following initiatives: Health Care Quality Measurement, Reporting and Feedback System, Statewide Common Provider Directory, Patient engagement tools, and the All Payer Claims database (APCD). (p. 17-19)
  • The current State HIT Coordinator and a HIT specialist funded with this grant, will assure communication, coordination, and alignment across the various governing bodies. (p. 16)

  • Within this broad-based authority there are numerous opportunities to promulgate regulations in support of the Value-Based Care Paradigm. Examples include utilizing the licensing authority to incentivize the Value-Based Care Paradigm, such as, offering discounts on fees to health professionals who certify as a care team; developing a regulatory “tunnel” to allow ACOs to apply for a single facility license rather than a separate license for each building and practice as current regulation requires; updating Emergency Medical Services (EMS) regulations to support use of EMS for both prevention and coordination of primary care; coordinating professional practice regulations to define team-based practices and develop professional alignment to improve public health outcomes. In addition to regulatory authority, DOH also leverages existing policies and practices to drive healthcare facilities and professionals towards a Value-Based Care Paradigm. (p 12)

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)


Click Here for Full State Plan
State's SIM website

Summary by Focus Area:

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

Financing Population Health:
  • PCMH model will have menu of payment options for providers and payers to agree upon. (p. 6)
  • Principal Accountable Providers (Episodes of Care) – rewarded for high quality and efficient care across the episode, shared savings when patients receive high-quality, efficient care (or in excess costs in care is above average). (p. 9)
  • Value-based purchasing for enhanced respiratory care. (p. 12)

Transforming Clinical Care:
  • Reach over 80% of the state’s population with value-based payment and delivery models. (p. 2)
  • Primary Care Transformation: care coordination, closing the gaps in care; shifting focus toward prevention, health maintenance, and proactive management of chronic conditions (p. 4)
  • Multi-payer Patient Centered Medical Home approach: require 3 managed care organizations to participate in joint PCMH program, will build up to statewide aligned and Medicaid PCMH program. A Technical Advisory Group (TAG) of Tennessee clinical experts to advise on the clinical details of the multi-payer PCMH program. (p. 5-6)
  • Pediatric Patient Centered Medical Homes (p.6-7)
  • Total cost of care accountability with reporting and financial incentives. (p.27)
  • Episodes of care – continuing to build on existing initiative, adding additional episodes every six months with a goal of implementing 75 episodes within five year. (p. 8)

  • Patient Centered Medical Homes: reward providers for addressing social and behavioral determinants of health (asthma, tobacco, social services). (p. 4)
  • Long Term Services and Support Payment and Delivery Reform, including Nursing Facility services and Home and Community Based Services for seniors and adults with physical, intellectual and developmental disabilities. (p. 10-12)

Behavioral Health:
  • Health homes: integrated, value-based behavioral and primary care services for people with Severe and Persistent Mental Illness (SPMI). (p. 7)

  • Tennessee Hospital Association will provide analysis of episode performance to hospitals for internal use and to inform conversations between hospitals and other providers involved in an episode; display through web-based tool. (p. 9)
  • Current All Payers Claims Database (APCD) law to conduct healthcare utilization analysis (p. 15). Generate gaps in care analyses, patient risk scores, and patient prioritization functionality through payers claims data. (p. 17)
  • Build statewide HIE framework starting with real-time and daily batch Admitting/Discharge/Transfer (ADT) data collected from hospitals and EDs and sent to a care coordination interface for PCPs. (p. 16)
  • MCOs collaborate to leverage the state’s Medicaid Management Information System (MMIS) capabilities to create and maintain electronic data interfaces with all hospitals. (p. 16)
  • Development of provider-facing portal that includes single sign-on capability and role-based access for providers to connect all SIM-related provider interfaces. (p. 17)
  • Behavioral health providers participating in the Health Homes program will be eligible for upgrades to their current EHR systems. (p. 18)

  • Development of a comprehensive training program for individuals paid to deliver long term services and support. (p. 12)
  • Tennessee law promotes a mix of professionals in its healthcare workforce, with an emphasis on integrative primary care. (p. 15)
  • Higher than average concentration of nurse practitioners. (p. 15)

CHNA & Community Benefits
  • The DOH will share population health and county level Community Health Assessments data with the universities to inform their approaches to draft regional goals and objectives and gather public input on population health priority topics (obesity, diabetes, tobacco, child health, and perinatal health). (p. 13)
  • Aligning Certificate of Need (CON) Criteria with Payment Reform: Tennessee is required by law to have a state health plan updated annually and approved by the Governor which covers the topics of population health, access to health care, economic efficiency, health care quality, and health care workforce. 7 Pursuant to the State Health Plan, Tennessee regulates the establishment and modification of health care institutions, facilities and services through CON. Certificate of Need applications are reviewed by an independent appointed board based on whether the proposed project is consistent with the State Health Plan, as required by the Tennessee Health Services and Planning Act. Therefore, changes to the State Health Plan as a result of the SIM design grant will align CON criteria with payment and delivery system reform. (p. 15)


Click Here for Full State Plan
State's SIM website

Summary by Focus Area:

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

Financing Population Health:
  • State will be "first mover" to shift 80% of the market from fee-for-service to value-based integrated payment models by 2019. (see chart, p. 13)
  • The 10 prototypes for ACHs were financed with $485,000 in State funds but need SIM funding to fully implement. The proposal is earmarked ~$3.2 mil/year X 4 years for ACHs (see p.4 of Operation Plan). Medicaid payment to be reorganized around the 10 ACH regions. Medicaid contracts will require coordinated care, case finding, patient engagement and community linkages. Reimbursement to Federally Qualified Health Centers and Rural Health Centers will shift from fee-for-service. (p. 21)
  • Puget Sound area public employees' benefit plan to become an accountable delivery model in 2016. (p.12)

Transforming Clinical Care:
  • The State Health Department will lead the Practice Transformation Support Hub to help clinicians move from encounter-to value-based care (p.3). Will work in concert with the ACHs, including links to social and housing support, school-based nursing, and long term care. Requires enhanced patient engagement, measured by adoption of "decision support aids" for maternity, joint replacement and palliative care (see financial analysis p.3)
  • Legislature authorized common measures and quality framework for Medicaid and public employees benefits purchasing. (see p.2 of financial analysis)

Behavioral Health:
  • Substance abuse and mental health integration within Medicaid by 2016 (see p.2 of financial analysis) and full integration by 2020 of Medicaid networks and reimbursement of behavioral health (BH) and physical care. Early adopter counties will get 10% of the resulting savings. (p.11)
  • Certificate of Need requirements suspended in FY 15 for hospitals seeking to shift to psych beds. (p.15)

  • Development of a statewide shared core performance data set of 51 measures, including non-traditional data such as emergency department use, criminal justice involvement, and housing. To be publicly reported at county, plan, hospital, and clinician levels. Above-average uptake of electronic medical records in WA State, but augmenting Health Information Exchange with standards-based interoperability requirements. (p.27-28)
  • Adding incentives to get physical care-linked electronic health records to BH providers. Will link administration, claims and clinical data sets. (p. 17)

CHNA & Community Benefits
  • Washington will invest in a Practice Transformation Support Hub to capitalize on consultant and community expertise in clinical practice transformation. During the Hub Startup phase the Hub will practice needs assessment. (p. 47)
  • Certificate of need. Requirements have been suspended for fiscal year 2015 for hospitals that change the use of their licensed beds to provide psychiatric services to alleviate significant access issues. (p. 25)

  • Project management through the State's Medicaid and Public Employee Board, with a public-private coordinating council. (p. 4) Requested $92.4 M, awarded $64.9 M