Winter Advisory Council Meeting: Celebrating Impact January 31, 2019

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Time Topic Leader

8:00 – 8:30 Networking Coffee & Breakfast Buffet (Working Breakfast)

8:30 – 9:00 Welcome & UpdatesDennis Calcutt, Chair, Region 1 IDN Executive Committee & Ann

Landry, Region 1 Executive Director

9:00 – 11:00

Celebrating Impact: Panel Discussion Project Celebrations: Client, Family and Staff Impact (75 minutes)

Impact of Workforce Funds (15 minutes) Planning for 2020: What’s Next for Project Teams (30 minutes)

Jessica Powell, Region 1 Program Director, Integrated Healthcare & Community Project Teams

11:00 –11:20

The Shift to Performance-Based Funding Mark Belanger, Region 1 Director of Integration

11:20 –11:40

Hub & Spoke Alignment & Integration with IDN 1 Partners and Projects

Sally Kraft, VP, Population Health, Dartmouth-Hitchcock Medical Center & Shawn LaFrance, VP, Population Health, Cheshire Medical

Center

11:40 –11:55

Report Out: Key Takeaways & Lessons Learned Region 1 IDN Partners

11:55 –12:00

Wrap-Up & Next StepsDennis Calcutt, Chair, Region 1 IDN Executive Committee & Ann

Landry, Region 1 Executive Director

Welcome & UpdatesDENNIS CALCUTT & ANN LANDRY

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Project Updates & Panel Discussion

JESSICA POWELL, REGION 1 PROGRAM DIRECTOR, INTEGRATED HEALTHCARE & COMMUNITY PROJECT TEAMS

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IDN Project Team Updates B1: D-H Heater Rd. South/ West Central Behavioral Health Partner Organizations: Community partners servicing specific SDoH domains

Overview:

Continuing bi-weekly project team meetings to work on PDSA of workflows and project protocols

Achievements To Date:

Completion of MDCT meetings since May, 2018

Use of the Shared Care Plan for all of the MDCT Cases

Completion of the Consent Process

Inclusion of Patient Advocate/Representative on the Project Team

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IDN Project Team Updates B1 : Cheshire Medical Center/DHK, Monadnock Family Services

Partner Organizations: Coordinate with the Monadnock System of Care for Children’s Behavioral Health Project, HRSA project for Prescription Drug misuse, Collaboration with the C1/E5 IDN project at MFS

Overview:

Create, test and refine a co-located “reverse integration” Health Home Model that integrates professional disciplines and shared resources, with clients and their families, intended to afford the best possible health outcome.

Achievements to Date: ◦ APRN Hired

◦ Outfitting for Clinical Exam Space -Complete

◦ Current and Future State Mapping

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IDN Project Team Updates B1 : Valley Regional Hospital

Partner Organizations: Counseling Associates, West Central Behavioral Health

Components of Project:

Bi-directional referral system with Counseling Associates

Pilot a DHMC Dept. of Psychiatry-embedded telepsych resource within Valley Primary Care

Establish (2) new FTE positions within Valley Primary Care – MSW, RN

Achievements to Date:

Two monthly meetings: 1st Tuesday for VRH-only staff for internal procedures; 3rd Tuesday for full B1 group to address collaboration-specific components.

Aggressive 8-week training & meeting schedule completed by MSW, including resource manual creation and MSW

VRH and CA workflows created for practices and individual roles.

CCSA (patient questionnaire) in use!

Paper version of Shared Care Plan and formation of MDCT in use!

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IDN Project Team Updates B1 : Newport Health Center

Partner Organizations: West Central Behavioral Health, Counseling Associates, Newport School District-Tiger Treatment Center

Overview:

Integration for Pediatric and Adult Clients at NHC

Achievements to Date: ◦ CHW Hired

◦ Bi-weekly meetings since spring, 2018

◦ CCSA in use!

◦ Current and Future State Mapping

◦ SCP and MDCT underway

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IDN Project Team Updates B1 : Monadnock Community Hospital

Partner Organizations: Community Support agencies for SDoH

Overview: Multi-site integration efforts in Adult, Pediatric Primary Care

Achievements to Date: ◦ Bi-weekly meetings since summer, 2018

◦ Current and Future State Mapping

◦ Review of CCSA

◦ Recruit to Hire for LADC

◦ Review of MDCT, SCP options

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IDN Project Team Updates B1 : DH General Internal Medicine

Partner Organizations: West Central Behavioral Health

Overview: Multi-site integration efforts in Adult, Pediatric Primary Care

Achievements to Date: ◦ Bi-weekly meetings since summer, 2018

◦ Current and Future State Mapping

◦ Review of CCSA

◦ Recruit to Hire for CHW

◦ Review of MDCT, SCP options

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IDN Project Team Updates B1 : Alice Peck Day

Partner Organizations: West Central Behavioral Health

Overview: Multi-site integration efforts in Adult, Pediatric Primary Care

Achievements to Date: ◦ Bi-weekly meetings since fall, 2018

◦ Current and Future State Mapping

◦ Review of CCSA

◦ Recruit to Hire for BHC

◦ Review of MDCT, SCP options

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IDN Project Team Updates C1/E5

Lead Organization: Monadnock Family Services

Community partnerships: Monadnock Collaborative, Cheshire Medical Center

Overview: Person-centered care coordination at staged levels of intensity to patients with a combination of serious physical health issues AND serious mental illness during transitions from clinical settings to the community, as well as an enhanced level of coordination for individuals with the same combined level of need for whom existing services are not currently sufficient.

Implementation Timeline: Clinical program go live in late winter, 2017

Achievements To Date: All resources have been hired and trained. Procedures and protocols established.

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IDN Project Team Updates D3

Lead Organization: Perinatal Addiction Treatment Program- Dartmouth Hitchcock

Community partnerships: Wise, Haven, Parent Child Centers, Children’s Literacy Foundation, The Family Place

Overview: Develop and pilot an evidence-based, gender-specific, trauma informed intensive outpatient treatment program to meet the critical needs of pregnant and parenting women with substance use disorders. In addition to the clinical services (IOP, MAT, & reproductive health), several support services are included such as: peer support, community resource support, on-site family support, life skills (parenting, health relationships and self-care)

Implementation Timeline: Clinical program ready for go-live February 2018. First program attendance April 2018.

Achievements To Date: All resources have been hired and trained. Procedures and protocols established.

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The Shift to Performance-Based Funding

MARK BELANGER, IDN-1 ADMINISTRATIVE TEAM

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1115 Waiver Funding Approach

2019 and 2020 Federal/State funding to Region 1 is 100% performance-based!

In 2019 we can also recoup withheld 2018 funding by completing remaining process milestones

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Source: NH DHHS

Behaviors Encouraged by the MeasuresAs a community of partners we are rewarded financially if we do the following:

1. Provide Positive Patient Experience

2. Screen and follow up for Substance Use, Depression, Intimate Partner Violence, High Blood Pressure, Lipid Disorders, Tobacco Use and Obesity.

3. Follow up quickly on Community Mental Health Center and Substance Use Treatment intakes

4. Manage Chronic Disease within BH Population: High Blood Pressure, Diabetes Care, COPD, Asthma

5. Reduce avoidable hospitalization and readmission. Follow up after ED and Inpatient discharges.

6. Manage medication adherence and metabolic monitoring for patients with Schizophrenia and/or patients using antipsychotics

7. Provide Adolescent well-care visits

8. Send Hospital Discharges

9. Prescribe Opioids Cautiously

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Patient Experience Measures

Desired Behavior: Provide Positive Patient Experience including: presence of medical records at appointment, follow up on tests, coordination with specialists, prescription awareness, and care management among providers and services.

Measure Reporting

EXPERIENCE.01 Experience of Care Survey:• When you visited your personal doctor for a scheduled appointment, how often did he

or she have your medical records or other information about your care?• When your personal doctor ordered a blood test, x-ray, or other test for you, how often

did someone from your personal doctor’s office follow up to give you those results?• How often did your personal doctor seem informed and up-to-date about the care you

got from specialists?• How often did you and your personal doctor talk about all the prescription medicines

you were taking?• How often did you get the help that you needed from your personal doctor’s office to

manage your care among different providers and services?

DHHS Evaluator

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Survey Questions to Medicaid Members:• When you visited your personal doctor for a scheduled appointment,

how often did he or she have your medical records or other information about your care?

• When your personal doctor ordered a blood test, x-ray, or other test for you, how often did someone from your personal doctor’s office follow up to give you those results?

• How often did your personal doctor seem informed and up-to-date about the care you got from specialists?

• How often did you and your personal doctor talk about all the prescription medicines you were taking?

• How often did you get the help that you needed from your personal doctor’s office to manage your care among different providers and services?

Screening and Follow Up Measures

Desired Behavior: Comprehensive Screening and timely follow up on positive screenings for Substance Use, Depression, Intimate Partner Violence, High Blood Pressure, Lipid Disorders, Tobacco Use and Obesity.

Measure Reporting

ASSESS_SCREEN.01 Use of Comprehensive Core Standardized Assessment Process by IDN Primary Care and BH Providers

IDN

ASSESS_SCREEN.02 Appropriate Follow-Up for Positive Screenings for Potential Substance Use Disorder and/or Depression by IDN Primary Care and BH Providers

IDN

ASSESS_SCREEN.03 Selected USPSTF Services for Behavioral Health Population Recommended U.S. Preventive Services Task Force (USPSTF) A&B Services Provided for Behavioral Health Population by IDN Primary Care and BH Providers (Intimate Partner Violence, High Blood Pressure, Lipid Screening, Teen Smoking)

IDN

ASSESS_SCREEN.04 Smoking and Tobacco Cessation Screening and Counseling for Tobacco Users by IDN Primary Care and BH Providers

IDN

Partner reported data

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Source: IDN-1 Quality Data Reporting provided by the Massachusetts eHealth Collaborative

Discussion:• ~6% of Comprehensive

Core Standardized Assessments completed

• 0% documented follow up to positive Substance Use screening

• 48% documented follow up to positive Depression screening

• 20% documented screening and follow up for Tobacco use

• Note: Higher is better for this measure

Timeliness Measures: Community Mental Health Centers and SUD Treatment

Desired Behavior: CMHCs to provide members with first follow up visit within 7 days of intake –and- first psychiatrist/psychopharmacology visit within 30 days.

Alcohol and Drug Dependent members initiate treatment within 14 days of diagnosis –and- engage in two or more additional treatment services within 34 days of the initial treatment visit.

Measure Reporting

CMHC.02 Community Mental Health Center First Follow-up Visit Timeliness DHHS

CMHC.03 Community Mental Health Center First Psychiatrist Visit Timeliness DHHS

CARE.04 Initiation of Alcohol and Other Drug Dependence Treatment DHHS

CARE.05 Engagement of Alcohol and Other Drug Dependence Treatment DHHS

Chronic Disease Management within BH Population Measures

Desired Behavior: Manage Chronic Disease within the Medicaid Behavioral Health Population: High Blood Pressure, Comprehensive Diabetes Care, COPD, Asthma

Measure Reporting

CARE.03_Sub_A PH HEDIS for BH Population: Controlling High Blood Pressure IDN/DHHS

CARE.03_Sub_C PH HEDIS for BH Population: Comprehensive Diabetes Care - HbA1c Control <8.0%

IDN/DHHS

CARE.03_Sub_F PH HEDIS for BH Population: Pharmacotherapy Management of COPD Exacerbation - Systemic Corticosteroid

DHHS

CARE.03_Sub_G PH HEDIS for BH Population: Medication Management for People with Asthma

DHHS

Partner reported data

Avoidable Hospitalizations and Readmissions Measures

Desired Behavior: Reduce avoidable hospitalization and readmissions. Follow up after ED and Inpatient discharge for Mental Health and Substance Use within 7 and 30 days.

Measure Reporting

HOSP_ED.01 Frequent (4+ per year) Emergency Department Use in the Behavioral Health Population

DHHS

HOSP_ED.02 Potentially Avoidable Emergency Department Visits DHHS

HOSP_ED.03 Follow-up After Emergency Department Visit for Mental Illness Within 30 Days DHHS

HOSP_ED.04 Follow-up After Emergency Department Visit for Alcohol and Other Drug Dependence Within 30 Days

DHHS

HOSP_INP.01 Readmission to Any Hospital for Any Cause by Adult Behavioral Health Population Within 30 Days

DHHS

HOSP_INP.03 Follow-up After Hospitalization for Mental Illness Within 7 Days DHHS

HOSP_INP.04 Follow-up After Hospitalization for Mental Illness Within 30 Days DHHS

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Source: NH DHHS, NH DSRIP Baseline Measurement Review, CY 2015 source data.

Discussion:• ~6% or 540 Members

out of 9,000 with 4 or more ED visits in year

• IDN-1 baseline leads the state

• Note: Lower is better for this measure

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Source: NH DHHS, NH DSRIP Baseline Measurement Review, CY 2015 source data.

Discussion:• ED use primarily driven

by working age adults 18-64

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Source: NH DHHS, NH DSRIP Baseline Measurement Review, CY 2015 source data.

Discussion:• ~80 per 1,000 Non-BH

Members using ED for diagnoses generally treated in primary care

• Avoidable ED visit rate is 2.4 times higher among IDN-1 Behavioral Health population, ~190 per 1,000 BH Members

• IDN-1 baseline leads the state

• Note: Lower is better

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Source: NH DHHS, NH DSRIP Baseline Measurement Review, CY 2015 source data.

Discussion:• Statewide age data• Avoidable ED Visits

primarily driven by working age adults 18-64

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Source: NH DHHS, NH DSRIP Baseline Measurement Review, CY 2015 source data.

Discussion:• ~80% of Mental Health

ED Visits with Follow-Up visit within 30 days.

• IDN-1 baseline is the middle of the state

• Note: Higher is better for this measure

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Source: NH DHHS, NH DSRIP Baseline Measurement Review, CY 2015 source data.

Discussion:• ~21% of Substance Use

ED Visits with Follow-Up visit within 30 days.

• IDN-1 baseline is the middle of the state

• Note: Higher is better for this measure

Medication Adherence and Metabolic Monitoring Measures

Desired Behavior: Manage medication adherence and metabolic monitoring for patients with Schizophrenia and/or patients using antipsychotics.

Measure Reporting

CARE.01_Sub_A MH HEDIS: Antidepressant Medication Management - Continuation Phase DHHS

CARE.01_Sub_B MH HEDIS: Adherence to Antipsychotic Medication for Individuals with Schizophrenia

DHHS

CARE.01_Sub_D MH HEDIS: Metabolic Monitoring for Children and Adolescents on Antipsychotics

DHHS

CARE.01_Sub_E MH HEDIS: Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who are Using Antipsychotic medications

DHHS

CARE.01_Sub_F MH HEDIS: Diabetes Monitoring for People with Diabetes and Schizophrenia DHHS

Adolescent Well Care, Medical Record Transition, and Opioid Prescribing Measures

Desired Behavior: Provide Adolescent well-care visits.

Send care summary after hospital discharge.

Prescribe Opioids Cautiously.

Measure Reporting

CARE.02 Adolescent (Age 12-21) Well-Care Visits DHHS

Measure Reporting

HOSP_INP.02 Timely Transmission of Transition Record After Hospital Discharge IDN/DHHS

Measure Reporting

OPIOIDRX.01 Extended Daily Dosage of Opioids Greater Than 120mg Morphine Equivalent Dose

DHHS

Partner reported data

NH DHHS Methodology (conceptual)1115 Waiver Outcomes Improvement Methodology

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StatewideBaseline

Target at85th percentile

IDN-1 Starting Point

AnnualTargets

Source: NH DHHS, Standard Terms and Conditions for NH 1115 Waiver

What’s Next?IDN-1 Administrative Team has requested clarity and detail regarding performance pay from NH DHHS including the targets, current IDN-1 performance, and annual expectations for each measure.

Statewide meeting on performance payment will be held on February 1, 2019 and is expected to clarify:

◦ Incentive payment amounts as a share of potential total payments by year.

◦ How payment proportion for individual measures is derived.

◦ Overview and Q&A regarding schedule and share of potential payment by measure tables (to be provided to IDNs in advance of meeting).

◦ Results of measures for Jan-June 2018 performance period.

Details will continue to be shared through the IDN-1 Data, IT, and Quality Workgroup as available. (Please make sure your organization is represented on that group.)

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Hub & SpokeSALLY KRAFT, MD, VP POPULATION HEALTH DHMC

SHAWN LAFRANCE, VP POPULATION HEALTH, CMC

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AT DA R T M OU T H - H I TC HCOC K L E BA N O N

A D D I C T I ON T R EAT ME N T P R O GR A M

8 5 M EC H A N I C ST R E E T

S U I T E B 3 - 1

L E BA N O N , N H 0 3 7 5 6

6 0 3 - 6 5 0 1 8 60

At Cheshire Medical Center640 Marlboro Street, Keene NH

(Open 8:30-5, Monday-Friday)

Call: 2-1-1 (24/7)

NH Medicaid Delivery System Reform Incentive Program. D-H and Cheshire Medical are Region 1 leads.

NH Doorways program (Hub and Spoke). D-H Lebanon and Cheshire Medical Center are hubs.

What is the Hub and Spoke model?

Centralized and integrated phone system (2-1-1)

Referrals welcome from different sources

Consistent clinical evaluation framework (ASAM)

Continued recovery support for clients

Client-centered community resources and referrals

Person seeks OUD

treatment

Call 2-1-1 (or goes

directly to the Hub)

General Process Flow

After Hours

Patient seen at the Hub

After-Hours Hub Services

Yes

No

Assessment, evaluation,

referral

Assessment, evaluation, referral (acute needs refer patient to ED)

Information from assessment is sent to

local Hub with appropriate security

• Care coordination• Data collection• Naloxone distribution• Flexible spending

account• Case management

• Mental health • Substance use• Primary care• Housing & shelter• Crisis services• MAT• Peer & recovery

supports• MCO’s• Social services• IDN• Employment

• Screening• Clinical Evaluation• GPRA & Data Collection• Naloxone Distribution• Referral to

recommended level of care

• 211• Hub location • Hospitals• Primary care• Self / family

ACCESS POINTS RAPID SERVICES REFERRAL TO SERVICES CONTINUED CARE

HUB & SPOKE FLOW

Doorway (Hub)

Peer Recovery Services

Housing

Primary Care

Mental Health &

Substance Use

Treatment

Social Services

Education

Employment

Debrief: Key Takeaways & Lesson Learned IDN PARTNERS

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