State Innovation Models
Model Testing Awards
State
Arkansas
Maine
LTC Delivery
Data Collection and Quality
Metrics
Metrics for Risk Populations:
 Patient experience (CAHPS
survey metrics)
 Care coordination (AHRQ
prevention quality indicators)
 Preventive health
Process:
 Aggregate performance
measures will be reported to
providers and used to
determine provider eligibility
for incentive payments
(shared savings and/or PMPM
fees)
Populations: 100% of select complex
population
 Persons with developmental disabilities
(DD),
 Long term services and support (LTSS)
populations
 Behavioral health (BH) populations with
Medicaid Health Homes
Health Home Strategy:
 3 population-based waves over the next
two years.
 End of the project, all providers caring
for these populations will be required to
become certified health homes.
 Clients will have a health home
managed by the client’s primary
provider of services over time, i.e., the
“lead provider”. The health home
assigns accountability to the lead
provider for the full client experience,
including improving health outcomes,
streamlining the care planning process,
and developing and executing an
integrated plan spanning medical care
and DD, LTSS or BH services.
Overall Strategy:
Metrics:

 Align long-term care with the enhanced  Total Cost of Care and Patient
primary care model: assess issues
Experience measures.
related to (1) transitions to and from
 Drill-down services of data to
long-term care facilities; (2) regulatory
individual members for the
issues surrounding eligibility; (3) access
purpose of care management,
to long-term care; (4) HIT needs, and
which will allow use the
(4) workforce needs.
information as a quality and
 50 Health Homes in the next 2 years.
efficiency measure for
specialist.
 Better public health alignment and
Process:
consideration for bringing in LTC
Through Pathways to Excellence,
Workforce Strategy
 Patient management for high-risk work with providers to develop a 
high-utilizing chronically ill patients common set of measures,
 Patient navigation and peer support including working with Behavioral
Health providers to develop a
for at risk populations
1
Data Sources
Utilize all claims
data base
(MHDO) to
provide analysis
of measures, to
provide systemwide analysis of
healthcare
trends, and to
track where the
state is moving
as a whole.
Prometheus to
examine
resources used
State Innovation Models
Model Testing Awards
State
LTC Delivery

Diabetes and pre-diabetes
education
 Outreach to the homebound.
Massachusetts Overall Strategy:
 Payment and delivery system reform,
including behavioral health (BH) and
long term services
 HIT:
o Technical assistance to BH and LTSS
providers to participate in the HIE
o Integrate post-acute and long term
care with primary care.
o Utilize APCD to enable providers to
access claims-based reports for their
entire patient panels, with standard
formats and timeframes.
o Enhance the capability of the
Executive Office of Elder Affairs
(ELD) case management systems,
the Senior Management System
(SIMS), so that it can also process
clinical assessment data.
o Providers will be able to upload data
to the SIMS site, allowing the
patient, caregivers, and case
managers’ access to this data.
2
Data Collection and Quality
Metrics
common set of BH measures, to
be publicly reported.
Data Infrastructure for LTSS:
 ELD case management system
or SIMS upgraded to receive
and distribute information
from clinical assessments,
(data from the MDS, Adult
Foster Care, and Group Adult
Foster Care assessment
information).
 Module: NFs to signal that
they have a section-Q referral.
 Module: enable new
communities (caregivers,
family members, and their
primary care physicians) to
access the SIMS system.
o Phase 1: view-only access
o Phase 2: extended to endto-end information
sharing system
(authorized caregivers and
physicians’ offices could
securely add information
to the consumer’s status
and plan for long-term
community care).
Data Sources
to treat a unique
episode of care

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All Payer Claims
Database
State's data
Warehouse
Multi-payer
patient
experience
measures
(CAHPS) at
practice level
Multi-payer
HEDIS clinical
quality measures
MassHealth
HEDIS clinical
quality measures
Provider and
payer
perspectives on
new models
State Innovation Models
Model Testing Awards
State
LTC Delivery
Data Collection and Quality
Metrics
Minnesota
Overall Strategy:
Metrics:
(Minnesota
 Integrated Delivery Service Delivery:
 subset of DPH’s Statewide
Accountable
Medicaid ACOs to include mental
Quality Reporting and
Health Model)
health, social services, LTSS, community
Measurement System
prevention and public health
(SQRMS)
 Health Home certification
 HIE measures for providers
engaged in ACOs or ACHs, and
 HIT:
compare results with those
o Investments in EHR/HIT adoption,
that are not.
secure information exchange, data
Process:
analytics, practice facilitation,
New care coordination measures
development of risk adjustment
are being developed under the
methodologies, and quality
Health Care Homes program to
improvement.
o New infrastructure supports to: (1) supplement the SQRMS,
including: (1) all-cause hospital
collect, analyze and exchange
readmission, (2) integration of
clinical data securely; (2) address
medical and behavioral health
legal and operational barriers to
care, (3) measures of prevention
accessing and exchanging health
for children and adults, (4) care
care and social services data;
(3)leverage electronic health records for patients with multiple chronic
conditions, and (5) patient
for quality measurement and
experience measure
improvement; (4)effectively use
inter-professional teams in a
coordinated care environment; (5)
participate in quality improvement
initiatives and learning collaborative
to support practice transformation
Data Sources
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Oregon
Overall Strategy:
Reporting and transparency of
 Coordinated Care Organizations (CCOs) performance metrics
will not directly provide long term
services and support
 CCO’s and the LTSS system will
coordinate care and share both
programmatic and financial
accountability: (1) specific contractual
requirements between CCOs and LTSS;
(2) CCOs required to have jointlydeveloped MOUs with the local LTSS; (3)
3
Statewide
Quality
Measurement
and Reporting
System (SQMRS)
Provider peer
grouping and h
Hospital
discharge data
CMS Adult
Quality
Measures
Provider surveys
and/or provider
interviews
Practice site
visits/focus
groups
Beneficiary
surveys/focus
groups
Commercial
ACOs data
CAHPS survey
Administrative
claims data
Population
surveys
Interviews with
state
administrators
State Innovation Models
Model Testing Awards
State
Vermont
LTC Delivery
Data Collection and Quality
Metrics
reporting and transparency of
performance metrics; (4) incentives
and/or penalties linked to performance
metrics
 Mechanisms to achieve system-wide
alignment between CCOs and the LTSS
system: (1) nurse practitioners making
rounds to monitor individuals in nursing
facilities; (2) interdisciplinary care
teams; (3) shared care plans, and (4)
bringing health services to individuals in
their home or community-based care
facility.
Strategy:
Increase both organizational coordination
and financial alignment between Blueprint
advanced primary care practices and
specialty care, including mental health and
substance abuse services, long term services
and supports, and care for Vermonters
living with chronic conditions;
4
Process:
Integrated data platform for
complex data management:
 Multi-payer claims dataset
(VHCURES).
 Statewide HIE (VHIE) with
capacity to produce (1) care
summaries and CCDs, (2) lab
and other diagnostic reports,
(3) demographics related to
admissions, discharges, and
transfers and (4) to query or
pull clinical data from
participating EHRs.
 A "central registry" that
captures a defined set of
clinical data from Vermont
health care practices.
 Trainers who work with
individual provider sites to
develop data input capacity
and quality controls to
produce reliable data sets for
analysis and feedback.
Data Sources

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

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
Hospital
discharge data
set
MDS
Home health
Outcome and
Assessment
Information Set
Social Assistance
Management
System for LTSS
Developmental
Disabilities and
Mental Health
Monthly Service
Report
Alcohol and Drug
Abuse Programs
reporting
systems
Public Health
registries and
reporting
systems (Page
24)
State Innovation Models
Model Pre-Testing Awards
State
LTC Delivery
Colorado
Statewide
Health
Innovations
Fostering
Transformati
ons (SHIFT)
Populations:
Population with co-occurring physical and
behavioral health issues.
Strategies:
 Invest in data, measurement, and
payment infrastructure
 Creation of learning collaborative for
BH and primary care integration (Page
10)
 Provide funding for practices to
finance the cost of and enhance
integration.
 Practice readiness scale
to help practices assess their
organizational capacity for integration
of physical and behavioral health.
Colorado is currently implementing an
LTSS project with funding from MFP. Longterm care providers and case managers
help create smooth transitions when
individuals move from nursing homes and
psychiatric hospitals into the community
(Page 23).
New York
Strategy:
Six models of care were included in the
Innovation Plan. Three specifically related to
LTPAC delivery: (1) Extended Care Transitions
Programs; (2) Community-Based Care
Management for Older Adults; and (3)
Transitioning to Community-Based Care for
Data Collection and Quality
Metrics
Metrics:
 Align with existing measures
for current initiatives in the
state, including ACC and CPC
Initiative measures.
 Agreement on an initial set
of common measures, but
these may need
adjustments to support the
behavioral health focus of
Colorado
Will inform analysis of: (1 the
total cost of care on both a
PMPM and total population
basis, (2) patient satisfaction,
(3) quality outcomes, (4) cost
savings associated with
specific payment and delivery
system interventions, and (5)
total cost savings for both public
and private sector payers. (Page
14)
Process:
The State will: (1) collect and
analyze health care pattern
utilization data for public and
private payers; (2) conduct business
process and systems analyses; (3)
develop quality improvement
5
Data Sources
Survey to assess
readiness (Page 8)
State Innovation Models
Model Pre-Testing Awards
State
Washington
LTC Delivery
Data Collection and Quality
Metrics
Institutionalized People with Developmental
Disabilities (PWDD).
systems, performance standards
and related metrics, and (4) invest
in HIT and HIE improvements.
Strategies:
 Bree Collaborative and Pugent Sound
Health Alliance will coordinate the chronic
conditions component of the model
(Description of Alliance on Page 5).
 Transforming Washington Communities:
effort to reduce chronic disease by
promoting active living, healthy eating,
preventive care, and tobacco cessation
 Health Homes: MCOs and fee-for-service
will employ chronic care management and
evidence-based practices consistent with
the Alliance’s efforts
Metrics:
 Core quality and utilization
metrics: streamlined and
aligned with CMS' Physician
Quality Reporting System
(PQRS), National Quality Forum
, Joint Commission and
Meaningful Use and other
nationally recognized incentive
programs to avoid duplicative
processes and improve
administrative efficiencies
(Page 7 and 14).
Process:
 All payers have agreed to
adopt a core set of
performance measures and are
willing to link those measures
to opportunities for differential
gain sharing (based on
performance) and increase
current peer-to-peer
comparisons to support
improvement.
 Consistent processes for data
collection, monitoring cycles,
and use of a core set of quality
and utilization metrics to
support statewide provider
feedback
 Model uses the BCBSMA AQC
as a template for gain sharing
Alliance will have oversight and
management of data collection and
reporting activities associated with
chronic conditions (Details on Page
27)
6
Data Sources
State Innovation Models
Model Design Awards
State
LTC Delivery
Data Collection and Quality
Metrics
California
Let’s Get
Healthy
California
Strategy:
Preventing and managing chronic disease
and maintaining dignity and independence
at end-of life
Connecticut
Strategy:
 New streamlined ASOs identify those
most in need of care coordination
through predictive modeling and data
analytics.
 Medicaid provides enhanced
reimbursement to enhanced
Behavioral Health (BH) Clinics, which
are certified by DMHAS based on their
capacity to admit individuals who are
not in crisis within specified time
frames and to treat individuals with
co-occurring disorders.
7
Metrics:
 The State employee health
plan and Medicaid PCMH have
common performance measures
to evaluate primary care
providers for achievement of
health and consumer
satisfaction outcomes.
Process:
 APCD is anticipated to be the
primary means through which
data is shared with providers
and consumers
Data Sources
State Innovation Models
Model Design Awards
State
LTC Delivery
Data Collection and Quality
Metrics

Delaware
Individuals key strategies include: 1)
data integration and state of the art
information technology and analytics;
2) Intensive Care Management (ICM)
and care coordination in support of
effective management of co-morbid
chronic disease; 3) expanded access
for MMEs to Person Centered Medical
Home (PCMH) primary care; and 4) a
payment structure that will align
financial incentives (advance
payments related to costs of care
coordination and supplemental
services, as well as performance
payments) to promote value.
 New, multi-disciplinary provider
arrangements called “Health
Neighborhoods” through which
providers will be linked through care
coordination contracts and electronic
means.
Strategy:
 Extend the work of the DCPCMH by
including participation of federally
qualified health centers, mid-level,
long-term care, substance abuse and
behavioral health providers, as well as
innovative approaches such as the
Perioperative Surgical Home Model.
 CMS “Independence at Home”
Demonstration Project to test homebased primary care services to
Medicare beneficiaries with multiple
chronic illnesses and
 Telehealth services are a major
component of CCHS’s chronic disease
management programming along with
specialty programs for addictions and
emergency department and inpatient
high utilizers.
8
Process:
 Integration of data sources
to develop more robust HIT
Infrastructure, including: (1)
claims and clinical data, (2)
locally collected data, (3)
data collected through other
public and private programs,
including public health
records, social service
agencies, long term care
service agencies, community
health centers, mental
health agencies, disease
registries, vital records data,
and (4) data collected via
the Federal Partnership
Exchange.
 State will use data mapping
and integration to expand
point of access care.
Data Sources
State Innovation Models
Model Design Awards
State
LTC Delivery
Hawaii
Strategy:
Patient-centered health care and BH
integration with primary care
Idaho
Community
Care
Network
Model
Strategy:
 Multi-payer medical home
collaborative and integration of PCP/
PCMH within the larger delivery
system.
 Model is focused on providing
preventive, community-based care
with a focus on wellness; however it
will emphasize disease management
strategies for those with special needs
(Page 8).
Illinois
Integrated
Care
Program
(ICP)
Strategy:
 Mandatory program for non-dual
Seniors and Persons with Disabilities
(SPDs) residing in the Chicago suburbs
and collar counties surrounding
Chicago.
 Phases: (1) includes medical services
only and two MCOs participate (2) HFS
expands the ICP to additional
geographic areas by April 2013, and
(3) LTSS will be added in the next
phase of the ICP later this year.
 The Illinois plan will include an
approach to the coordination or
integration of care for those who have
chronic medical and BH conditions
with care management of those at
highest risk for adverse outcomes
including those requiring long term
services and supports (LTSS)
 The State to consolidate HCBS waivers
and incorporate these populations
into new, coordinated delivery and
payment models. (Page 5)
9
Data Collection and Quality
Metrics
Process:
Utilize timely and appropriate
HIT for delivery and payment
system transformation
Begun identifying common
quality measures for PCPs and
launched the Medicaid EHR
Incentive program in 2012 to
help providers adopt certified
EHRs.
Process:
 Targeted technical
Assistance for IT and data
analytics to Care
Coordination Entities (CCEs).
The Illinois Office of Health
Information Technology
(OHIT) is working with the
Illinois HIE Authority in
building the Illinois Health
Information Exchange
(ILHIE)
Data Sources
The Network is
developing systems
for information
exchange across the
continuum.
State Innovation Models
Model Design Awards
State
LTC Delivery
Maryland
No real mention of LTSS
Michigan
Strategy:
 Care Bridge to Behavioral Health and
Long Term Care: (1) organized and
coordinated care delivery system for
Medicaid-Medicare eligible
beneficiaries; (2) Seamless access to
services, including community-based
supports; (3) Lead Supports
Coordinator, and Integrated
Individualized Care and Supports Plan;
(4) Integration of behavioral, medical,
and Long-Term care
 Identifies 3 provider groups that have
developed separate payment streams
for populations based on eligibility
criteria and dominant needs: (1)
behavioral health/intellectual or
developmental disability, 92) long
term care and (3) complex medical.
 Integrated Care Organizations (ICOs)
will manage provider contracts and
payments other than behavioral
health, which remain the purview of
Pre-Paid Inpatient Health Plans
(PIHPs).
 A Lead Supports Coordinator will be
assigned for all eligible beneficiaries,
who may derive from the ICO or a
provider organization. All providers
will utilize a common Integrated
Individualized Care and Supports Plan
maintained in an accessible electronic
health record (EHR) (Page 9).
Strategy:
 Leverage and integrate existing
initiatives into its Design Model,
specifically for populations with
New
Hampshire
Data Collection and Quality
Metrics
Data Sources
APCD, HIE, Public
Health Data
Warehouse
10
Quality Metrics:
Michigan will use NQS metrics
and Foundation Health
Measures of Healthy People
2020.
Process:
 Michigan will build IT
infrastructure; increasing
capacity for standardized
data collection and
reporting; developing staff
capacity to report, analyze,
and use data collected
through the state’s Data
Warehouse.
 MDCH is also developing a
statewide chronic disease
registry. (Pages 11-12).
 The state HIE, MiHIN, offers
a host of shared data
exchange services.
Process:
There is no current mechanism
to look across the delivery
systems and across the payers
to measure the cost
State Innovation Models
Model Design Awards
State
LTC Delivery

Ohio
Pennsylvania
Rhode Island
complex health needs served by
multiple service delivery systems.
Align the LTSS payers around common
goals and outcomes.
Strategy:
Expand the capacity and availability of
qualified medical homes to most Ohioans
across Medicaid/CHIP, Medicare, and
commercially insured patients in a 3-5
year timeframe (Page 12).
Strategy:
Strong emphasis on the need for
innovative models for transitions of care
and care management.
Strategy:
 Implement an "Integrated Care"
payment (Medicare and Medicaid)
and delivery system for dual-eligible
populations (MMEs). P
 rimary, acute, behavioral and long
term care will eventually, if approved,
be brought under a single payment
mechanism through three way
contracts between Managed Care
entities, RI Medicaid, and Medicare (in
the Managed Care option); or will be
integrated by a new “Coordinated
Care Entity” (for RI’s primary care case
management program.)
 Ppilot the deployment of a
“Community Health Team” to provide
ancillary social, transportation,
11
Data Collection and Quality
Metrics
effectiveness of the provided
services or to measure their
performance in improving the
health status and quality of life
for the consumers they serve
(Page 2).
Process:
Create a detailed plan for
providing system infrastructure,
care coordination tools, EMR
adoption requirements and
other capabilities (Page 30)
Process:
Infrastructure to support the
model design: (1) expanded HIT
to facilitate health record data
sharing, (2) advanced
telemedicine services
particularly in rural areas, and
(3) objective measurement of
healthcare workforce data to
make improvements to existing
training.
Process:
Reports through State HIE and
continuing EHR adoption
Data Sources
State Innovation Models
Model Design Awards
State
Tennessee
LTC Delivery
Data Collection and Quality
Metrics
behavioral, peer, nutritional and other
supports.
No mention of Long-term care delivery (at
least in the website description)
Texas
Utah
Texas Institute of Health Care
Quality and Efficiency is to
identify legislative
recommendations for
preventable health conditions
that occur in long-term facilities.
No mention of Long-term care delivery.
12
Data Sources