HCPF Memo Template Accessible - Colorado.gov

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October 2016

Primary Care Alternative Payment Criteria As part of the Department of Health Care Policy & Financing’s (Department) efforts to shift providers from volume to value, the Department is developing a structure to make differential fee-for-service payments to give providers greater flexibility, reward performance while maintaining transparency and accountability, and create alignment across the delivery system. Under the proposed model, providers can earn higher reimbursement (when designated as meeting specific criteria) as they implement and achieve more Advanced criteria. Movement along this framework not only encourages higher organizational performance but also helps the Accountable Care Collaborative (ACC) achieve its respective programmatic goals. In developing the proposed framework, the Department cross-referenced with Departmental initiatives, such as the Comprehensive Primary Care Initiative (CPCi), Comprehensive Primary Care Plus (CPC+), Enhanced Primary Care Medical Provider (EPCMP) incentive program, Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and State Innovation Model (SIM), as well as with National Committee for Quality Assurance (NCQA) standards for PatientCentered Medical Homes (PCMHs). Please note this is a proposed framework intended for discussion. Also note that additional work is being done to align with CPC+ Track 2 – the framework described does not apply to that methodology. Primary Care Alternative Payment Framework Care Delivery Domain

Access to and Continuity of Care

Care Management

Team Based Care

Payment Category

Basic 1. 24 hour phone access 2. Primary care focus 3. Extended hours 4. Same day appts 1. Preventive health screening 2. Medication management 3. Release of previous records

1. Care team roles 2. Care team structure 3. Standing orders

Enhanced 1. Provider Empanelment (75%) 2. Accept new patients 3. 24 hour EHR access 1. Population stratification: methods 2. Population stratification: care protocols 3. Registries 4. Shared care plan: patient 5. E-prescribing 1. Care team empanelment (75%) 2. Patient engagement trainings

Advanced 1. Asynchronous communication 2. Provider Empanelment (95%) 1. Selfmanagement goals

1. Care team empanelment (95%) 2. QI trainings 3. Shared care plans: provider

Outcomes/ Areas of Impact 1. Well child care 2. Depression screening 3. ER utilization 4. Other preventive screenings 1. Appropriate asthma medications 2. HbA1c testing 3. Well child care 4. Depression screening 5. SUD screening 1. HbA1c testing 2. Well child care 3. Depression screening 4. SUD screening 5. ED Visits for ambulatory care-

Our mission is to improve health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources. www.colorado.gov/hcpf

November 2016 3. Population health management trainings 4. Care team huddling Health Neighborhood Care Coordination

1. Care compact: medical providers

1. Referral tracking 2. eConsult

1. Hospital F/U 2. ER F/U 3. Care compact: community partners

1. BH preventive health screening 2. BH referrals

1. BH registry 2. BH share care plan: patient 3. BH shared decision making tool 4. Care compact: behavioral health providers 5. BH agency strategic measures 6. BH referral tracking 1. Shared decision making tools 2. Patient satisfaction survey 1. Agency strategic measures 2. Agency QI plan

1. BH co-location 2. BH providers

Behavioral Health Integration

Patient Engagement and Experience

1. Process for soliciting patient feedback

1. Performs practice improvement activities Quality Improvement

sensitive conditions 6. CAHPS survey 7. ECHO survey 8. National Core Indicators survey

3. Patient advisory group

1. Agency QI projects 2. Family and patient engagement in QI projects 3. QI project progress and communication

2 | Primary Care Alternative Payment Framework and Criteria Draft for Discussion

1. ED Visits for ambulatory caresensitive conditions 2. Total cost of care 1. Well child care 2. Depression screening 3. SUD screening

1. CAHPS survey 2. ECHO survey 3. National Core Indicators Survey

November 2016

Primary Care Alternative Payment Criteria Care Delivery Domain

Measure

Access and Continuity

24 hour phone access

Definition Practices will provide patients with 24 hour, 7 day a week access to a provider or clinician. Practices will focus their care models on wellness and prevention and will provide their patients access to primary care providers from the following specialties: Family Medicine, Internal Medicine, Pediatrics, and OB/Gyn. Practices will provide patients with access to care and their provider/care teams outside of the standard working hours. At least one alternatively scheduled day a week. Practices will assign 75% patients to a provider who will serve as their primary point of care.

Payment Category

Outcomes/ Areas of Impact

Other Department Initiatives

NCQA Standard

Basic

Well Child Care; Depression Screening

CPC, CPC+, SIM

1B2

Basic

Well Child Care; Depression Screening

ACC 1.0

Basic

Well Child Care; Depression Screening

CPC+, ACC 1.0

1A2

Enhanced

Well Child Care; Depression Screening

CPC, CPC+, SIM

2A2

Basic

Well Child Care; Depression Screening

Access and Continuity

Primary care focus

Access and Continuity

Extended hours

Access and Continuity

Provider empanelment (75%)

Access and Continuity

Same day appointments

Practices will ensure timely access to care through integration and use of same day appointments.

Access and Continuity

24 hour EHR access

Practices will provide patients with 24 hour, 7 day a week access to a provider or clinician who has real-time access to their medical records.

Enhanced

Well Child Care; Depression Screening

CPC, CPC+, SIM

1B3

Access and Continuity

Provider empanelment (95%)

Practices will assign 95% patients to a provider who will serve as their primary point of care.

Advanced

Well Child Care; Depression Screening

CPC, CPC+, SIM

2A2

3 | Primary Care Alternative Payment Framework and Criteria

1A1

November 2016

Care Delivery Domain

Measure

Access and Continuity

Accept new patients

Access and Continuity

Asynchronous communication

Definition Practices will take on new Medicaid patients as their care team capacity permits. Practices will implement at least one form of asynchronous communication (patient portal, email, text messaging, etc.) and will set appropriate and timely follow-up standards.

Payment Category

Outcomes/ Areas of Impact

Other Department Initiatives

Enhanced

Well Child Care; Depression Screening

ACC 1.0

Advanced

Well Child Care; Depression Screening

CPC, SIM

Care Management

Preventive health screening

Practices will regular screen patients for preventive health issues.

Basic

Care Management

Medication management

Practices will proactively manage and review each patient's respective medications.

Basic

Care Management

Release of previous records

Practices will develop protocols and processes whereby they can request, receive, and send patient records from previous providers.

Basic

Care Management

Population stratification: methods

Practices will employ data-driven methods and tools (including BDIM) to risk stratify all empaneled patients.

Enhanced

4 | Primary Care Alternative Payment Framework and Criteria Draft for Discussion

Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening

NCQA Standard

1A3, 1B3, 1C5

ACC 1.0

CPC, CPC+, SIM

4C

5C

CPC, CPC+, SIM, ACC 1.0

3D; 4A1

November 2016

Care Delivery Domain

Measure

Payment Category

Practices will develop and implement care protocols for the specific risk pools within their population.

Enhanced

Registries

Practices will develop and implement patient registries to manage the care and outcomes of at least three specific patient populations.

Enhanced

Shared care plan: patient

Practices will develop and monitor care plans with each patient that address relevant needs and that are shared across each patient's care team members.

Enhanced

Care Management

E-prescribing

Practices will develop and implement technologies and partnerships that allow for electronic transmission of patients' prescriptions.

Enhanced

Care Management

Selfmanagement goals

Practices will develop and monitor selfmanagement goals with their respective patients.

Advanced

Care team roles

Practices will define the specific roles for care teams and integrate patient engagement, population health management, and quality improvement responsibilities in each role. These

Basic

Care Management

Care Management

Care Management

Team Based Care

Population stratification: care protocols

Definition

5 | Primary Care Alternative Payment Framework and Criteria Draft for Discussion

Outcomes/ Areas of Impact Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening

Other Department Initiatives

NCQA Standard

CPC, CPC+, SIM, ACC 1.0

4A

SIM, ACC 1.0

4A

CPC, CPC+, SIM, ACC 1.0

4B5

CPC

4D

SIM

4B

SIM

2D

November 2016

Care Delivery Domain

Measure

Definition

Other Department Initiatives

NCQA Standard

SIM

2D

Enhanced

Well Child Care; Depression Screening; SUD Screening; HbA1c testing; ED Visits for Ambulatory Care Sensitive Conditions

SIM

2D

Basic

Well Child Care; Depression Screening; SUD Screening; HbA1c testing

SIM

2D

Enhanced

Well Child Care; Depression Screening

CPC, CPC+, SIM

2A2

Payment Category

Outcomes/ Areas of Impact

roles will ensure that all members are working to the top of their licenses.

Team Based Care

Team Based Care

Care team structure

Care team huddling

Team Based Care

Standing orders

Team Based Care

Care team empanelment (75%)

Practices will define the composition of their agency's care teams. Care team members can include but are not limited to a provider, medical assistant, care coordinator, nurse, social worker, or behavioral health consultant. Practices will create spaces for care teams to meet and perform pre-visit planning. Meetings will include the care team members and any relevant staff, will discuss anticipated needs for the day or patient, and will occur on a consistent basis. Practices will develop and implement written protocols approved by an authorized practitioner that allow qualified clinicians to assess and administer certain clinical services, including vaccines, laboratory tests, and screenings. Practices will assign 75% patients to an interdisciplinary care team who will serve as their primary point of care. Care team members must include but are not limited to: medical provider, care coordinator, and behavioral health provider.

Basic

6 | Primary Care Alternative Payment Framework and Criteria Draft for Discussion

November 2016

Care Delivery Domain

Team Based Care

Measure

Patient engagement trainings

Team Based Care

Population health management trainings

Team Based Care

Care team empanelment (95%)

Team Based Care

QI trainings

Team Based Care

Shared care plans: provider

Definition Practices will employ a common patient engagement curriculum across their agencies and provide consistent trainings for all staff in said curriculum. Curriculums must include topics on shared care plan development, motivational interviewing, patient feedback surveys, etc. Practices will employ a common population health curriculum across their agencies and provide consistent trainings for all staff in said curriculum. Curriculums must include topics on tools (registries, dashboards, etc), delivery systems (integrated care teams, care coordination, etc), and systems integration (community partnerships, integrated care models with external providers, etc). Practices will assign 95% patients to an interdisciplinary care team who will serve as their primary point of care. Care team members must include but are not limited to: medical provider, care coordinator, and behavioral health provider. Practices will employ a common performance improvement methodology across their agencies and provide consistent opportunities to train all staff in said methodology. Methodologies can be based on PDSAs, Lean/Six Sigma, Microsystems, etc. Practices will enact compacts with relevant partner practices, including

Payment Category

Outcomes/ Areas of Impact

Other Department Initiatives

NCQA Standard

Enhanced

CAHPS Survey; ECHO Survey; National Core Indicators Survey

SIM

2D

Enhanced

Well Child Care; Depression Screening; SUD Screening; HbA1c testing; ED Visits for Ambulatory Care Sensitive Conditions

SIM

2D

Advanced

Well Child Care; Depression Screening

CPC, CPC+, SIM

2A2

SIM

2D

SIM

2A4; 4B2/3

Advanced

Advanced

7 | Primary Care Alternative Payment Framework and Criteria Draft for Discussion

Appropriate Asthma medications; HbA1c

November 2016

Care Delivery Domain

Measure

Definition

Payment Category

one behavioral health practice, to grant access to their respective EHRs and their patients' respective medical records and care plans. Health Neighborhood Care Coordination

Care compact: medical providers

Health Neighborhood Care Coordination

Referral tracking

Health Neighborhood Care Coordination

Hospital F/U

Health Neighborhood Care Coordination

ER F/U

Health Neighborhood Care Coordination

Care compact: community partners

Behavioral Health Integration

BH preventive health screening

Practices will enact care compacts with 1-3 relevant partner providers to track and coordinate care.

Basic

Practices will monitor the status of patient referrals between the practice and its respective partners.

Enhanced

Practices will follow up with 75% of hospitalized patients within 72 hours of discharge.

Advanced

Practices will follow up with 75% of emergency room patients within one week of discharge.

Advanced

Practices will enact care compacts with 1-3 relevant community partners to refer and coordinate care.

Advanced

Practices will regular screen patients for behavioral health issues using a nationally recognized screening tool.

Basic

8 | Primary Care Alternative Payment Framework and Criteria Draft for Discussion

Outcomes/ Areas of Impact testing; Well Child Care; Depression Screening; SUD Screening ED Visits for Ambulatory Care Sensitive Conditions; Total Cost of Care ED Visits for Ambulatory Care Sensitive Conditions; Total Cost of Care ED Visits for Ambulatory Care Sensitive Conditions; Total Cost of Care ED Visits for Ambulatory Care Sensitive Conditions; Total Cost of Care ED Visits for Ambulatory Care Sensitive Conditions; Total Cost of Care Well Child Care; Depression Screening; SUD Screening

Other Department Initiatives

NCQA Standard

CPC, CPC+, SIM

4C; 5B

SIM, ACC 1.0

5B2

CPC, CPC+, SIM

5C

CPC, CPC+, SIM

5C

ACC 1.0?

4E

SIM

3C

November 2016

Care Delivery Domain

Measure

Definition Practices will provide access to behavioral health services through referrals to partner providers or internal services. Practices will develop and implement patient registries to manage the care and outcomes of patients with behavioral health needs. Practices will develop and monitor care plans with each patient that address behavioral health needs and that are shared across each patient's care team members.

Behavioral Health Integration

BH referrals

Behavioral Health Integration

BH registry

Behavioral Health Integration

BH shared care plan: patient

Behavioral Health Integration

BH shared decision making tool

Practices will employ shared decision making tools for patients with behavioral health needs.

Behavioral Health Integration

Care compact: behavioral health providers

Practices will enact care compacts with relevant behavioral health providers to track and coordinate care.

Behavioral Health Integration

BH agency strategic measures

Practices will identify and monitor at least one clinical quality measure relevant to behavioral health.

Behavioral Health Integration

BH referral tracking

Practices will monitor the status of patient referrals between the practice and its respective behavioral health partners.

Behavioral Health Integration

BH co-location

Practices will provide on-site behavioral health services through a contracted or in-house provider.

Other Department Initiatives

NCQA Standard

SIM

5B/C

SIM

4A

Enhanced

Well Child Care; Depression Screening; SUD Screening

SIM

4B5

Enhanced

Well Child Care; Depression Screening; SUD Screening

SIM

4E

Enhanced

Well Child Care; Depression Screening; SUD Screening

SIM

4C; 5B

Enhanced

Well Child Care; Depression Screening; SUD Screening

Enhanced

Well Child Care; Depression Screening; SUD Screening

SIM

5B

Advanced

Well Child Care; Depression Screening; SUD Screening

SIM

2

Payment Category

Basic

Enhanced

9 | Primary Care Alternative Payment Framework and Criteria Draft for Discussion

Outcomes/ Areas of Impact Well Child Care; Depression Screening; SUD Screening Well Child Care; Depression Screening; SUD Screening

6A

November 2016

Care Delivery Domain

Payment Category

Outcomes/ Areas of Impact

Other Department Initiatives

NCQA Standard

Advanced

Well Child Care; Depression Screening; SUD Screening

SIM?

2

Basic

CAHPS Survey; ECHO Survey; National Core Indicators Survey

CPC, SIM

Enhanced

CAHPS Survey; ECHO Survey; National Core Indicators Survey

CPC, SIM

6C

Enhanced

CAHPS Survey; ECHO Survey; National Core Indicators Survey

CPC, CPC+, SIM

4E

Practices will convene a patient and family advisory council and publish relevant minutes on a quarterly basis.

Advanced

CAHPS Survey; ECHO Survey; National Core Indicators Survey

CPC, CPC+, SIM

6C4

Performs practice improvement activities

Practices will identify a change area and work on specific activities that will advance progress in that area.

Basic

Agency QI plan

Practices will develop and implement an agency quality improvement plan that is reviewed annually and linked to the strategic and operational direction of the practice.

Enhanced

Measure

Definition

Behavioral Health Integration

BH providers

Practices will employ behavioral health providers as part of their service portfolio.

Patient Engagement and Experience

Solicit patient input

Practices will gather feedback from their patients using a post-visit question or brief set of questions.

Patient Engagement and Experience

Patient satisfaction survey

Patient Engagement and Experience

Shared decision making tools

Practices will employ shared decision making tools for at least two primary care conditions.

Patient Engagement and Experience

Patient advisory group

Quality Improvement

Quality Improvement

Practices will enact and publish results from a patient satisfaction survey on a bi-annual basis.

10 | Primary Care Alternative Payment Framework and Criteria Draft for Discussion

6

ACC 1.0

6

November 2016

Care Delivery Domain

Measure

Quality Improvement

Agency strategic measures

Quality Improvement

Agency QI projects

Quality Improvement

Family and patient engagement in QI projects

Quality Improvement

QI project progress and communication

Definition Practices will identify and monitor at least three clinical quality measures relevant to their specific patient populations or the RAE's strategic initiatives and goals or the State's designated key performance indicators. Practices will implement 1-3 performance improvement projects, using relevant performance improvement tactics and clinical and operational data, to improve their respective clinical quality measures. Practices will solicit and include feedback from patients and families regarding the development and implementation of QI projects. Practices will publicly publish their progress and outcomes from their respective quality improvement initiatives.

Other Department Initiatives

NCQA Standard

Enhanced

CPC, CPC+

6A

Advanced

CPC, CPC+, SIM

6D

Advanced

CPC, CPC+, SIM

6C

Advanced

CPC, CPC+, SIM

6E/F

Payment Category

11 | Primary Care Alternative Payment Framework and Criteria Draft for Discussion

Outcomes/ Areas of Impact

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HCPF Memo Template Accessible - Colorado.gov

October 2016 Primary Care Alternative Payment Criteria As part of the Department of Health Care Policy & Financing’s (Department) efforts to shift pr...

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