CMS Innovation Grant
Topic Workgroup Meeting Notes
CMS Innovation Grant – Topic Workgroup Meeting Notes
Attendees
Anthony Chen
Laurie Jinkins
Paul Schneider
Joe Contris
Julie Lindberg
Greg Tanbara
Cheri Dolezal
Rick McCornack
Shawn West
David Flentge
Kevin Murray
Heidi Winston
Kirsten Frandsen
Jane Sisk
Welcome and Introductions
Today’s group will build on ideas from last week’s Vision workgroup and come up with three priority focus areas that
they will bring to the large group meeting on Apr. 7.
Recap of Large Group Discussion on Grant Topic Ideas
Greg Tanbara listed the four grant criteria for the group:
1. Must implement the service delivery model
2. Must submit a fully developed new Medicare, Medicaid, or CHIP payment model by end of the project period
(three years)
3. Models should aim to improve care within 6 months
4. Should create sustainable pathways to net savings within 3 years
The group discussed the four criteria. Doctors would implement the service model and seek funding in the form of a
grant. The implementation would be county wide, but could end up that it is by site. The group discussed short and long
term goals.
Kirsten Frandsen listed five pillars from the Feb. 24 collective vision presentation. They are HIE/HIT, Learning Culture, BH
Integration, Quality Measures and CHW’s. She also shared the “whats” that are needed in addition to the five pillars for
the grant application.
Kirsten referenced a list of grant ideas from the Feb. 24 meeting and shared an info graphic from the Community Health
Assessment meetings. The five key findings: mental health, substance abuse, access to quality health services, health
disparities and protecting and improving the environment link with the pillars listed in the collective vision. Kirsten
shared these key findings were the result of brainstorming and recommendations. Much of the focus is on chronic
disease.
The group discussed guiding principles, including short and long term goals and the need to build on existing resources
and assets. They discussed diversion of inappropriate or unnecessary ED visits and readmission to the ED. They
discussed the need to open up urgent cares and for all systems and primary care providers to work together to ensure
there is after hour access. The group discussed mental health, creating a list of identifiers and care coordinators that can
do outreach on mental health.
03/27/2014
Page 1 of 6
CMS Innovation Grant
Topic Workgroup Meeting Notes
Group members shared areas they are working on, challenges and ideas:







Medical Health Homes and integration
OptumHealth partners with Franciscan and MultiCare
Partners talked about payment models and integrated charts
Registry adaptations and using each other’s EHR
Mental health records and health records being separate
Telemedicine
Triple P – Positive Parenting Program
Details from flip chart notes:
What are we currently working on- what are promising topic areas?
1. Community Health Care
 We can reduce ER (re)admissions by coordinating better
2. Franciscan
 Opened after-hours urgent care facility to re-direct patients from emergency rooms
3. MultiCare
 MultiCare is considering the same, but current barriers are that it is resource intensive.
 MultiCare has a system to coordinate care of frequent flyers/super users
4. OptumHealth
 Have Health Homes for care coordination
 Increases coordination of high risk patients and improves quality
 Have begun to have some conversations on BH/Primary Care integration
 Has auto-alert system to notify them of patients who utilize various services(?)
 Has “outcome” rich data- particularly- outcomes related to hospitalization
 Partnership with Franciscan- co-location of services (in 20 clinics and St Joe ER)
 Partnership with MultiCare- roving health van (med and psych services)
5. Coordinated Care
 Has PRC program to address and coordinate services for frequent flyers in ER
 Purpose is to make sure that they are connected to resources and services- and improve
coordination- e.g. patients use one pharmacy to get all prescriptions
 Patients are identified for care coordination based on risk.
 Have incentives
 Payment model?
6. Molina
 Frequent flyers = super users
 Used targeted outreach methods
 Value based contracting
 Consistent care program (Spokane)
 High risk patients- more frequent doc visits (reduce ER)
 Have care plans for members who misuse/abuse ER
 Educate patients on using the ER wisely
 Health Homes- want to expand participation
03/27/2014
Page 2 of 6
CMS Innovation Grant
Topic Workgroup Meeting Notes
7.
8.
9.
10.
11.
12.
 Working on a PC funded grant- Transitions
 Conduct pro-active planning using workflow processes, integration
 Use CHW’s for members who are not eligible for health home support/model
TPCHD
 Have asthma outreach workers who conduct home visits
 Asthma action plans are developed in conjunction with provider
 Referrals come from MultiCare/Mary Bridge
 UW has data
Franciscans
 Currently have 6 medical homes- soon to be 12
 Looking to hire 4 MSW’s to start integration of BH/Primary Care
 Have tele-care abilities. Looking into tele-psychiatry
MultiCare/OptumHealth Partnership
 Have some data
 Have a roving “behavioral /primary care health” van. MultiCare has the van and medical staff.
OptumHealth provides psych services.
 Van has electronic capabilities and is hooked up to EPIC so can utilize record system “real time”.
Coordinated Health Care
 Partner with Greater Lakes Mental Health Care
 Do not have but would like shared electronic health records (e.g. can we share the same patient
identifier #?)
 Who are our mental health/chemical dependency providers (there are 37 in Pierce County?)
 Phone counseling?
 Co-locate behavioral clinics at Madigan
TPCHD
 Has Triple P parenting program
 Concept- educate and train staff at all levels of an org or system to provide consistent messaging at
a variety of levels- i.e. message saturation. Whole system approach to one priority area.
 Important that we use a learning culture to develop these systems
 For application, better to have on the ground experience and success to show the funders, as
opposed to starting something new and projecting cost savings.
OptumHealth
 Has data to show $1.8M cost savings from interventions (which ones?)
 Take this data and merge with UW cost savings data and interventions for the application
 These savings will be re-invested in the work in Pierce County
Dr. Chen explained Triple P to the groups and that it is one of the models the Health Department uses. Cheri Dolezal
shared background on the model OptumHealth is using that is creating reductions in costs and creating savings. Cheri
will send Dr. Chen information on how OptumHealth is doing this. Dr. Chen commented on the importance of being able
to justify the work. The group talked about the different population each organization works with and the challenges in
applying these models. The systems that are developed need to reach out to those not yet identified as in need.
03/27/2014
Page 3 of 6
CMS Innovation Grant
Topic Workgroup Meeting Notes
Population Health Data and Community Health Assessment
Health Department Assessment Manager Cindan Gizzi, gave a high level overview the CHA. The Health Department is
one of four partners in this collaborative effort. The other partners are Franciscan Health System, MultiCare Health
System and University of Washington-Tacoma. Cindan shared background on each of the key finding, quotes and data.
Develop and Prioritize Three Topics for the Innovation Grant Proposal
The workgroup discussed a number of topics, issues and ideas to address the issues.
1. CHA Key findings – Predominance of perceived mental health gap, State Health care Innovation plan with a
better focus on chronic issues and physical health.
2. Adopter of accountable communities of health
3. Better integration of health care. A lot of partners are in the infancy and need support. Short term what are we
facing from an insurer view, long term - integrated benefits. We break down silos.
4. Access and coordinating care for patients with a coordinator and outreach persons. To be affective in integrating
health care we need to pay attention to what keeps people from getting there. It is not always medical. It can be
lower education, transportation and accessing the care.
5. Ways to address access issues: Project Access, lower the no show rate. People get there when we address these
issues. It relates to outcome.
6. Talked about what healthcare coordinators can and cannot control. Enlist help from outside in the community
with expertise in these areas.
7. Thinking differently about the payment model (CMS).
8. Community health workers with a focus on behavioral health
9. Health information technology, Heath Information Exchange (HIT/HIE) integration and records exchange –
collaboration on existing HIE technology to impact outcomes.
10. Tools that will get us to where we want to be in the outcome of mental health and behavioral health. Show how
we will use these tools. Data to prove the model works and demonstrate this.
11. Develop standard care plan in a way that it influences point of care (POC) and access to care
12. Issues with system communicating with one another: EPIC, EDI and others – we need a workgroup on the
integration of these systems
Details from flip chart notes:
Grant Topic Areas
1. Molina
 Seems like we should focus on behavioral health- confirmed by Community Health Assessment and
other assessment and discussion
 We’ve said that we want to position ourselves to be early adopters of state plan and triple aim goals
 Lots of us doing BH/PC integration – we’re all starting- let’s pull it all together
 With the Medicaid populations- Behavioral health integration- will see benefit in Jan 2016 (account risk
management entities)
 If health data (HIE) is shared, we can coordinate systems and approaches- for instance through a
standard care plan.
 How do we use and train people to use the technology to influence what is happening at the point of
care?
03/27/2014
Page 4 of 6
CMS Innovation Grant
Topic Workgroup Meeting Notes
2.
3.
4.
5.
6.
 Let’s look at IMPACT- it’s a well tested model and it’s in our backyard.
MultiCare
 BH/PC integration important
 Insurance is not the only barrier to accessing care
 Need to address access issues. We need to look at barriers outside of the health realm- issues such as
childcare and transportation.
 Each health system has different way to implement the principles we’re discussing. Whatever system(s)
are developed, we need to include current “non-health care users”. Because they will be new users in
the future.
Project Access
 Need to address barriers in order to get the health outcomes we need
 Data is available to show that addressing barriers can improve access and increased utilization of
services
TPCHD
 Need to get other folks in the community involved- outside of the health care system. E.g. pharmacies.
Community Transformation Partnership
 Community Health Workers – critical to implementing new service delivery models and reducing costs
 HIE and HIT both important- need shared electronic medical records. Systems are set up and ready to
go.
TPCHD
 Look at integration as an instrument-for instance, can reduce ER admissions and improve diabetic
outcomes
 Pillars- foundations. Community Health Workers- service delivery model- utilize technology such as
IPads to increase communication and access to care. Can address multiple chronic diseases.
 Looking at outcomes for the grant. Don’t need to see health outcomes at month 6 (such as decreases in
number of individuals with diabetes), but rather process outcomes (such as decreases in A1C, number of
people who don’t miss doc appointments, number of hospital days, number of admissions).
 Each partner org can provide their project outcomes and data. Let’s pull them all together to develop a
collective model.
 Other process measures might include patient and provider satisfaction.
 We will stipulate in our grant what we will measure and then promise to deliver.
 We can create the types and ways that we want to communicate across systems- e.g. thru One Health
Port
 Can take years to develop the coordination of these types of systems. Let’s build on what currently
exists through the CTG work (HIE, HIT, Quality Measures, etc), Health Homes, etc.
 Let’s pull all the pieces together and put it into one (county model). County model can be expanded to
be a state or national model.
 For clinical outcomes- pick #1 killer.
 UW has data that if you treat depression, you can show cost savings.
03/27/2014
Page 5 of 6
CMS Innovation Grant
Topic Workgroup Meeting Notes
7. Jane Sisk (Consultant)
 Triple P program sounds interesting and good outcomes (decrease in child abuse and improved ACE’s
scores)
 Appealing to invest in children but more of a long term approach given returns may be seen beyond our
grant timeline- except some child diseases such as diabetes, oral health, obesity which can be achieved
short term.
8. OptumHealth
 Progress notes, etc can be connected to one system through HIE. Let’s provide examples in our work to
help illustrate.
 Edi (?)- have 19 orgs working on it- same system
9. Northwest Physician’s Network
 We need to think about sustainability
 To fund our ongoing efforts, consider a “pay it forward” strategy (similar to social impact bonds). Pool
funds for coordination needs. Need to show payer that the return is good. For instance, any payer
covering Pierce County populations can pay a disparity tax used to support current work. Savings from
improved coordination and health outcomes will go back to the payers. For instance, put in 3-4% and
get back 8%.
 Talk with Dorothy Teeter (HCA) and Dan Lessler (WA CMS) regarding these ideas.
The group discussed the challenge of showing clinical focus/outcomes in six months. They talked about showing
improvement where they have a lot of experience and information; take what they are already doing and expand on the
data. We show the Payor that the return is there. We target diabetes and depression.
Next Steps
Laurie Jinkins will schedule a follow up group meeting.
03/27/2014
Page 6 of 6