SIM Implementation Guide

Introduction

The SIM Cohort 2 Implementation Guide is a resource for participating primary care practices and community mental health centers to succeed in creating an advanced medical home that comprehensively addresses both physical and behavioral health needs. This guide provides a description of the SIM Cohort 2 Milestones and concrete action steps to achieve them.

See documents under “Resources” for details on how SIM will track progress of practices and how practices can maintain “Good Standing” in the SIM program. For further information on how milestone completion will be confirmed, see the SIM Milestone Attestation Checklist.

 

SIM Milestone Operational Algorithm

Practices and Practice Transformation Organizations (PTOs) can use the SIM Milestone Operational Algorithm to visualize how their work on different milestones will align and fit in the overall pathway towards better whole-person care.

Building Blocks

SIM practice transformation milestones are organized within a well-recognized framework, Bodenheimer’s “10 Building Blocks of High-Performing Primary Care,” with some modifications to reflect the SIM program’s focus on behavioral health.

These milestones have been updated from Cohort 1 to further enhance the focus on integrating behavioral health and primary care, create a more structured timeline for progression, and ensure alignment between practice transformation work and the advanced payment models supporting them. The milestones are divided into years 1 and 2; many year 1 milestones involve developing infrastructure to start a new process with a corresponding year 2 milestone to fully implement and scale the process.

Building Block 1: Engaged Leadership That Supports Integration and Change

Goal

Practice establishes agreement(s) with payer organization(s) that cover at least 150 patients across payers, for value-based payment program(s) to support practice transformation under SIM.

Overview:
To successfully drive improvement in quality and patient outcomes, it is critical that leaders respond to challenges and change with innovative ideas, approaches, and the ability to engage and motivate others. This is known as “innovation leadership,” an approach that challenges assumptions, coordinates, integrates and facilitates clinical processes, and builds support to align and link processes throughout the practice.

Implementing integrated behavioral health and primary care services along with the other SIM milestone activities depends on the evolution of payment systems to ensure that advanced primary care activities are sustainable over time. Aligning practice payment with these activities to show improved health outcomes and cost reductions is a key element identified in the Colorado Framework. Building on Colorado’s longstanding Multi-Payer Collaborative, insurers have committed to supporting the goals of SIM, including speeding the expansion of value-based payments, also called alternative payment methods (APMs). Practices, with help from Practice Facilitators, CHITAs and other SIM resources, can take steps to be ready for these new reimbursements.

Year 1 Milestones

BB1.Y1.1 – Practice establishes value-based agreement(s) with payer(s) covering at least 150 patients

Practices who can achieve a majority of revenues through value-based payments experience a tipping point, allowing more rapid and sustainable advances in caring for their patients.

Action Items

  1. Review the materials in the SIM resource hub that describe the types of non-fee-for-service payment methods, also called alternative payment models (APMs).
  2. Identify the APMs that are available to your practice from various payers. List the types of APMs your practice is already paid by health plans and estimate what proportion of the patient population is covered under these arrangements. If you have not yet received communication from the payers in SIM that will be supporting your practice through APMs, contact the SIM Office at gov_simgrant@state.co.us.
  3. Select payer(s)/APM(s) to engage with and focus on for improvement that will cover at least 150 patients. Ideally, select one that rewards activities or outcomes that the practice will be working on as part of SIM, supporting BH integration, and rewards an outcome that interests the practice.
  4. Determine how they will measure the goal or target specified in the APM and how they will monitor and document improvement.
  5. Develop a specific process to accomplish measurement and documentation of improvement on the parameter(s) associated with the APM. For example, if the practice selects a per-member-per-month (PMPM) APM for incorporating a specific activity into the practice, develop a process for incorporating that process and meeting all associated expectations. Build this into QI work (see BB2).
  6. Negotiate and finalize value-based agreement(s) with payer(s).

Practice Attestation Anchor:
Attest to value-based agreement(s) with one or more payers that cover at least 150 patients attributed to the practice site. If not, provide reasons beyond the practice's control why this has not been possible.

Practice Facilitator Attestation Methodology:
Confirm such an agreement or agreements exist.

BB1.Y1.2. Practice has completed an annual budget that includes SIM revenue and planned expenses.

Perhaps the best indicator of future economic success is having and using a budget to plan and evaluate financial performance. Many practice leaders don’t fully realize the value of this management tool and fail to develop a budget, or even if their practice has a financial budget, they fail to take full advantage of the information it provides.

The practice budget serves as an annual financial plan to define the resources available to attain short and long-term goals and compares actual performance to what was forecasted. Components to creating an effective annual budget include:

Step 1: Determine the expectation for compensation for the practice’s physician owners/shareholders/partners.
Step 2: Forecast the volume and types of services you will provide.
Step 3: Estimate the revenue you will receive for the services.
Step 4: Predict the operating expenses for the volume of services.
Step 5: Based on the estimates for practice revenue and operating expenses determine if the physician compensation forecast is reasonable. If not, refine the three components of the budget to achieve a balanced solution.
Step 6: Compare monthly financial statements and productivity reports to the budgeted values to determine why actual performance is different from what was forecast.
Step 7: Revise the budget with updated financial and patient volume information to improve the forecast.

Action Items

  1. Review the budget process by reading, “A Guide to Creating and Using a Budget” in the SIM resource hub.

2. Use a budget template that accounts for compensation expectations, volume estimates, operating expenses, and revenues.

Practice Attestation Anchor:
Attest to the development of a current budget. If the practice has received alternative payments from payers, the budget should include those revenues and planned expenses to meet contract deliverables.

Practice Facilitator Attestation Methodology:
PF confirms that a budget as described exists at whatever level is appropriate for the practice (practice level or system level). Details of the budget do not need to be reviewed.

BB1.Y1.3. Practice develops a quality improvement (QI) team that meets monthly.

Change in practice requires a reflective, action-oriented team to remain focused on established quality improvement goals. Formal clinical and administrative leaders as well as informal leaders from front and back office should meet regularly to inform tests of change and be responsive to practice level data.

Action Items:

  1. Form a QI team with key staff members from each area of the practice.
  2. Provide training on QI methods and tools for all involved staff.
  3. Define responsibilities of each team member and identify a clinical champion. Include who will be responsible for validation, production, review, and communication of metrics. Identify staff member(s) who will lead and be familiar with the Shared Practice Learning and Improvement Tool (SPLIT) which will help facilitate practice performance reporting.
  4. Schedule regular team meetings focusing on QI projects within the practice.
  5. Utilize practice assessment tools to assist the practice in determining their starting point and prioritizing processes for QI work. Assessment tools for SIM include the following:
  6. Practice Application (completed for practice selection)
  7. Medical Home Practice Monitor (completed annually)
  8. IPAT (completed annually)
  9. Clinician and Staff Experience Survey (completed annually)
  10. Milestone Attestation Checklist  (updated every 6 months)
  11. HIT Assessment (updated every 6 months)

The purpose of each of these assessment tools and additional details on their use can be found in Appendix B, SIM Assessments and Reporting Schedule, and can be accessed on the SIM Shared Practice Learning and Improvement Tool (SPLIT).

Practice Attestation Anchor:
Document at least monthly meetings through meeting agendas and/or minutes.

Practice Facilitator Attestation Methodology:
Confirm and document improvement team meetings in monthly field notes. Attest if, in your opinion, the practice has fully accomplished the milestone as described in the anchor statement.

BB1.Y1.4. Practice leadership team presents at meetings and a clinical champion attends SIM Collaborative Learning Sessions.

Often the best solutions come from practices that have tested and implemented innovative ideas. SIM will host bi-annual Collaborative Learning Sessions (CLS) for SIM practices to share their successful ideas and learn from one another. Discussing how different tools and workflows can be incorporated into everyday practice can provide valuable and efficient shortcuts in executing changes. Interaction with other practices helps to provide energy, ideas, and support for change.

Action Items:

  1. Send at least two care team members, typically a provider champion and staff champion, to each SIM CLS.
  2. Encourage other team members that will benefit from the supportive learning environment to attend the CLS.
  3. Actively participate in learning events by suggesting topics you would like addressed or innovative ideas you would like to share on a panel or in a breakout presentation.

Practice Attestation Anchor:
Document through minutes of quality improvement team meetings.

Practice Facilitator Attestation Methodology:
Document in monthly field notes and attest if practice meets the milestone as described in the anchor statement.

BB1.Y1.5. Practice has vision for behavioral health integration and identifies pathway for behavioral health transformation that is signed by leadership.

SIM promotes a broad definition of behavioral health (BH) that encompasses mental health concerns, substance use conditions, health behavior change, life stresses and crises, and stress-related physical symptoms. For children, adolescents, and young adults, BH includes preventive education/counseling, BH and developmental screening and early BH intervention incorporated into the primary care setting.

Behavioral health integration (BHI) refers to “the care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.” BHI can take on many forms: coordinated, co-located, and integrated. SIM does not require all practices to adopt fully integrated models of BHI. Each practice must determine what form is best for them.

SIM also supports community mental health centers implementing a bi-directional health home model. In this model, traditional mental health centers integrate a primary care team within the mental health setting to address the primary care needs of their population. The bi-directional health home initiative seeks to deliver comprehensive, integrated care in the setting most logical and convenient to patients and their families

Action Items:

  1. Complete the practice assessment activities, particularly the Integrated Practice Assessment Tool (IPAT), to understand where your practice currently stands related to the levels of BHI and prioritize next steps in addressing your patients’ BH needs. See Appendix B, SIM Assessments and Reporting Schedule for the list of Assessments and detailed information about each.
  2. Identify the level of BH integration that the practice aspires to achieve according to SAMHSA and AHRQ levels of Collaboration/Integration (Coordinated, Co-Located, or Integrated).
  3. Identify scope of practice/population needs, organizational supports, FTE needs, electronic health record sharing needs, and supervision needs to accomplish level of integration desired.
  4. Create a written, signed vision statement including how your practice will approach BH integration.

Practice Attestation Anchor:
Produce documentation of a vision statement for behavioral health transformation that includes their selected pathway for behavioral health transformation. This can include such things as plans for full integration, improved coordination through collaborative care, use of telehealth, collaboration agreements with behavioral health entities, etc., as appropriate for the practice site.

Practice Facilitator Attestation Methodology:

Confirm that a vision statement exists that includes their planned pathway for behavioral health transformation. This should be documented and shared across the practice and with the PF/CHITA/RHC.

Year 2 Milestones

BB1.Y2.1. Leadership allocates appropriate resources to complete QI work.

Time is a valuable resource in primary care, with time away from patient care often meaning time away from revenue generating opportunities. To succeed in sustainable change and improvement, leadership must recognize and protect time for teams to focus on quality improvement efforts and review data on a regular basis.

Action Items:

  1. Determine the time and space requirements for ongoing QI meetings. Protect time for twice-monthly QI team meetings by blocking patient care responsibilities where necessary.
  2. Consider what time and resources may be required for QI team work outside of regular meetings and budget for anticipated expenses.

Practice Attestation Anchor:
Document ongoing, regular (at least monthly) QI team meetings as in BB1.Y1.3 and show how resources have been allocated to complete QI work.

Practice Facilitator Attestation Methodology:
Confirm ongoing, regular QI team meetings are occurring and document this in monthly field notes. Attest if in PF opinion the practice has allocated sufficient resources for the QI work, including engagement of adequate practice site clinicians and staff in the process.

BB1.Y2.2. Practice designs plan to evaluate effects of value-based payment agreements.

Action Item:

  1. Develop a plan to use value-based payment agreements to improve care, reduce costs, and improve satisfaction. When using additional revenues (i.e., to hire new staff, purchase new equipment, protect time for practice improvement activities), consider how to make these changes sustainable long-term, regardless of payment models available.

Practice Attestation Anchor:
Demonstrate how the practice uses and assesses the impact of value-based payments.

Practice Facilitator Attestation Methodology:
Confirm practice development and implementation of a plan. Attest if the practice site has a plan in place and has evaluated the impact of their value-based payments. Document if barriers have prevented value-based payment agreements from being developed.

Building Block 2: Practice Uses Data to Drive Change

Goal

Practice uses EHR clinical quality measures to provide quarterly panel reports on all SIM measures not extracted through claims data; uses claims data provided through a data aggregation tool to inform QI processes.

Overview:
Data driven improvement is guided by collecting, reporting, and analyzing data to determine priority area(s) in your practice to focus improvement efforts. Using data allows the practice to assess priorities, identify where changes are needed and measure whether the identified changes are improving outcomes. Your practice will use data from your Electronic Health Record (EHR) including demographics, disease registries, utilization indicators, and prescriptions to guide improvement in at least three areas of care measured by the SIM clinical quality measures (CQMs). It is best practice to post care team and practice level data in a centrally located place where all staff and even patients have access to review the data, opening the door for conversation and accountability. See Appendix C for CQM Reporting Summary.

Additional data sources may include:

  1. Payer: cost/utilization reports, gaps in care reports, attribution lists
  2. Health Information Exchange (HIE): utilization; notifications of admissions, discharges, and transfers (ADT); labs; and imaging reports
  3. Patient and family survey/advisory council data
  4. Practice operations: tracking no-shows, cancellations, access, and hospital data on hospitalizations and Emergency Department (ED) utilization

These data will be reviewed during regular quality improvement (QI) team meetings, and will serve as a foundational component in selection of measures that best align to your patient population and transformation priorities. 
 
Appendix C provides a list of the CQMs and summary of the CQM reporting requirements.

Year 1

BB2.Y1.1. Practice successfully submits CQMs quarterly.

SIM CQM reporting requirements are detailed in Appendix C. In general, SIM will use a rolling 12-month reporting period for CQMs. Reporting of numerators and denominators for CQMs at a practice OR provider level will be expected within 1 month from the end of the calendar quarter. Collection and performance reporting of CQMs will be managed within SPLIT.

Action Items:

  1. Review the SIM Clinical Quality Measures (See Appendix C) and reporting requirements.
  2. Choose either the Pediatric or Adult/Family CQM group based on the patient population your practice serves.
  3. Generate numerators and denominators for the CQMs within the chosen CQM group on a quarterly basis. Refer to Appendix C for the timeline of when certain core measures are due.
  4. Submit numerators and denominators within one month of the end of each calendar quarter.

Practice Attestation Anchor:
Selected group of CQMs submitted quarterly to SIM.

Practice Facilitator Attestation Methodology:
This will be monitored through submission of CQMs through the Shared Practice Learning and Improvement Tool (SPLIT).

BB2.Y1.2. Practice reviews data with PF/CHITA quarterly.

Action Items:

  1. Complete the necessary practice agreements with the University of Colorado and complete the PTO matching documents included in SIM Practice Participation Packet to partner with a Practice Facilitator (PF) and Clinical Health Information Technology Advisor (CHITA).
  2. Schedule a kick-off meeting with your PF and CHITA to discuss the SIM initiative requirements and support opportunities within 30 days of match to PTO or project kick-off.
  3. Complete and review the results of your practice assessments with your PF and CHITA, using them to identify gaps and prioritize next steps. CQM run charts are updated daily and can be accessed through your SPLIT login at https://split.practiceinnovationco.org.
  4. Work with your CHITA to identify current reports available from the EHR, Health Information Exchange, or other data sources.
  5. Set regularly scheduled meetings (at minimum quarterly) with your PF and CHITA to review your CQM reports and other related data.
  6. Complete the HIT Assessment with the help of your CHITA at baseline and update it every 6 months.
  7. Create a development plan for CQMs currently not available to your practice, as necessary, prioritizing the core SIM measures and CQMs related to your practice’s QI activities.

Practice Attestation Anchor:
Show evidence that clinical quality measures were reviewed with a PF or CHITA at least every 3 months. This could include documentation in improvement team agendas or meeting minutes.

Practice Facilitator Attestation Methodology:
Document in PF and CHITA monthly field notes and attest if practice meets the milestone as described in the anchor statement.

BB2.Y1.3 Practice begins using model for improvement and has identified opportunities for improvement using CQM data.

The model for improvement, developed by Associates in Process Improvement, is a straightforward and pragmatic tool for accelerating process change. The model consists of 3 fundamental questions and the Plan-Do-Study-Act cycle to test changes. The 3 fundamental questions are:

  1. What are we trying to accomplish? Aims should be time-specific, measurable, and define the target population.
  2. How will we know that a change is an improvement? Measures to examine may be considered in a few areas: outcome measures, how the change impacts patients or other stakeholders; process measures, if the steps towards change are implemented as planned; and balancing measures, if changes are causing problems in other parts of the system.
  3. What change(s) can we make that will result in improvement?

The Plan-Do-Study-Act cycle refers to an approach of planning the change, trying it, examining the results, and acting based on what is learned.

Action Items:

  1. If you or your team are starting from scratch, review the e-Learning Module on Quality Improvement.
  2. Determine which data source(s) will provide the best data to guide improvement. Choose a small number (2-4) of those reports to start with that are readily available, easily updated, align with clinic improvement priorities, can show change in 3-6 months, and measure processes or outcomes important to patient health and experience.
  3. Review data, including CQM data you submitted to SIM, at QI meetings.
  4. Work with your PF/CHITA to select and use a quality improvement tool(s) such as process mapping, brainstorming, and/or fishbone diagrams.
  5. Develop and document a Plan-Do-Study-Act (PDSA) for rapid cycle improvement.

Practice Attestation Anchor:
Document through minutes of quality improvement team meetings.

Practice Facilitator Attestation Methodology:
Document in monthly field notes and attest if practice meets the milestone as described in the anchor statement.

BB2.Y1.4. Practice begins using a data aggregation tool provided by SIM to review cost and utilization data.

SIM will be rolling out tools for practices to review their cost and utilization trends and how they compare to others. Information will be shared with you as soon as these tools are available.

Action Items:

  1. Work with your PF and CHITA to review cost and utilization data in data aggregation tool.
  2. Evaluate changes implemented as part of the Study component of the PDSA to adjust the plan as needed and repeat the PDSA until it is a sustainable process.

Practice Attestation Anchor:
Demonstrate through attestation of use of a tool that provides cost and utilization data, such as Medicaid's Statewide Data Analytics Contractor (SDAC), Stratus, QRUR reports from Medicare, etc.

Practice Facilitator Attestation Methodology:
Attest if practice is learning to review and use a utilization aggregation tool. Document in monthly field notes.

Year 2

BB2.Y2.1. Practice reviews CQM data to inform rapid cycle improvement processes.

Action Items:

  1. Continue Year 1 activities to sustain utilization data review.
  2. Review your practice’s performance on CQMs and compare it to other SIM practices.

Practice Attestation Anchor:
Document the use CQM data in ongoing quality improvement efforts to improve care, such as through improvement team minutes.

Practice Facilitator Attestation Methodology:
Documentation in monthly PF and CHITA field notes. PF can attest if practice meets the milestone by specifically using CQM data in QI efforts.

BB2.Y2.2. Practice develops processes for providing performance feedback to providers, including CQM, cost, and utilization data.

Action  Items:

  1. Review  reporting requirements for any health plan programs in which your practice  participates.
  2. Select which data (including CQM,  cost and utilization data) will be used for performance feedback, and develop  strategy for how this will be presented to providers.
  3. Share QI data with all clinic staff  via clinic-wide meetings or displays in a central area.

Practice  Attestation Anchor:

Document  CQM, cost, and utilization data being tracked and process for sharing with  providers.

Practice  Facilitator Attestation Methodology:

Attest  if there is evidence that performance feedback is provided to providers.

BB2.Y2.3. Practice conducts regular PDSA/QI activities on identified CQMs.

Action  Items:

     

  1. Set a goal for how often you will  complete PDSA cycles on CQMs; revisit this goal in QI team meetings at least  annually.
  2.  

  3. After ensuring that your prior PDSA  is complete and has become a sustainable process, return to action items in  BB2.Y1.3 and select another CQM to focus on next.

Practice  Attestation Anchor:

  Document  use of data for targeted CQMs as part of ongoing, regular QI activities through  improvement team minutes.

Practice  Facilitator Attestation Methodology:

  Document  in monthly PF and CHITA field notes. PF can attest if practice QI efforts  specifically use CQM data.

Building Block 3: Practice Population is Empaneled

Goal

Practice has, and maintains, at least 75% of its patient population empanelment.

Overview:
Empanelment identifies the patients and population for whom the provider and/or care team is responsible and is the foundation for establishing continuity between patient and provider/care team. Effective empanelment requires identification of the “active population” of the practice, meaning those patients who identify and use your practice as a source for primary care. There are many ways to define “active patients” operationally. Generally, the definition of “active patients” includes patients who have sought care within the last 24 to 36 months, allowing inclusion of some patients who have minimal preventive or chronic health care needs.

Empanelment requires ongoing monitoring as patients change primary care providers (PCPs), move, or pass away, as well as when a provider leaves the practice. Empanelment improves patient and care team satisfaction, improves receipt of preventative services, as well reducing hospital admissions and ED visits. For community mental health centers integrating primary care, there may be separate panels for the primary care provider and the psychiatrist. For the purposes of SIM, the patient panel should be aligned with the primary care provider.

CPC+ definition of “active patients”: Active patients refers to patients who received primary care at your practice looking back over a given period. Your practice should define a look back period that is at least 18 months. The specific look back period will depend on your practice’s processes to track patient encounters and your patient population. Typically, practices use a look-back period from 18 to 36 months.

Year 1

BB3.Y1.1. Practice has assessed patient panel and assigned PCPs/care teams to 75% of patient population.

Action Items:

  1. Review empanelment options with key clinicians and staff.
  2. See resource hub for empanelment resources. Determine empanelment methodology and workflow and document agreed upon procedures.
  3. Implement chosen empanelment strategy, assigning all active patients to a provider panel.

Practice Attestation Anchor:
Attest that the practice has empaneled at least 75% of active patients to PCPs and/or care teams, and be prepared to present data supporting this.

Practice Facilitator Attestation Methodology:
Confirm the empanelment process used and attest if the practice has accomplished 75% empanelment.

BB3.Y1.2. Practice reviews payer attribution lists monthly.

Action Items:

  1. Review payer(s) methodologies for distribution of attribution reports and their methodology for reconciling discrepancies.
  2. Review attribution reports and lists of patients and compare against empanelment panels within one week of receipt.
  3. Practice actively follows payer(s) methodologies within one month of receipt of attribution lists to reconcile any discrepancies.
  4. Monitor concordance between internal empaneled patients and payer attribution reports.

Practice Attestation Anchor:
Attest that payer attribution lists are reviewed by someone at the practice or organization on a monthly basis.

Practice Facilitator Attestation Methodology:
PF can attest if practice meets the milestone as described in the anchor statement.

BB3.Y1.3. Practice designs and implements processes for validating PCP/care team assignment with patients.

Action  Items:

  1. Confirm empanelment assignments with  providers and patients.
  2. Develop a plan for empanelment of  new patients.
  3. Monitor extent of empanelment  through EHR or other reports to determine percentage of patients empaneled.

Practice  Attestation Anchor:

Attest  to having a process for assigning patients to primary care providers or care  teams and validating those assignments on an ongoing basis.

Practice  Facilitator Attestation Methodology:

Confirm  practice has implemented a process of assigning patients to PCPs/care teams.  Attest if in PF opinion the practice has fully accomplished the milestone as  described in the anchor statement.

Year 2

BB3.Y2.1. Practice maintains 75% empanelment of patients with provider/care teams

Action Items:

  1. Run reports regularly (i.e., quarterly) to determine empanelment status. Update empaneled patients as necessary to rebalance provider/care team panels and assign un-empaneled patients.

 

Practice Attestation Anchor:
Document process for regularly monitoring and adjusting empanelment and run report to demonstrate that 75% of active patients are empaneled.

Practice Facilitator Attestation Methodology:
Confirm empanelment process. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

BB3.Y2.2. Practice develops policies to support empanelment, including definitions, changing PCPs, assigning new patients, and ensuring continuous coverage.

Action  Items:

  1. Review  and adjust empanelment methodology based on practice needs and experience.  Develop written policies documenting definitions and strategy.
  2. Work  with your Practice Facilitator to decide on a method for measuring continuity  of empaneled patients with their assigned primary care provider and/or care  team.
  3. Consider  the following steps for calculating continuity:
    1. Numerator: Obtain the number of  patients of Provider X that were seen by Provider X in the past month by  reviewing the appointment schedule.
    2. Denominator: Obtain the total number  of patients of Provider X that were seen over the past month.
    3. Divide the numerator by the  denominator (and multiply by 100). This is the percentage of continuity for  Provider X.
  4. Repeat continuity tracking on a  regular basis and review results with QI team.
  5. Adjust scheduling, empanelment,  patient communications, and workflows to improve continuity rates. A suggested  target for continuity rates is 75%; however, some practices with additional  challenges for meeting continuity rates (e.g. residency practice) may need to  set a lower target.
  6. Develop strategies and tools for  informing patients and families about the importance of continuity of care  (e.g. reminders to schedule next appointment with your doctor; protocols for  scheduling appointments with the same provider over time; appointment reminders  with provider names and pictures).

Practice  Attestation Anchor:

Document  policies for these aspects of empanelment (which ideally should be part of the  process developed in year 1).

Practice  Facilitator Attestation Methodology:

Confirms practice site has implemented policies to support  empanelment. Attest if in PF opinion the practice has fully accomplished the  milestone as described in the anchor statement.

Building Block 4: Practice Provides Team-Based Care

Goal

The care team uses shared operations, workflows, protocols to facilitate collaboration and consistently implements specific shared workflows rather than informal processes for at least three measures, including at least one behavioral health measure.

Overview:
Team-based care is a necessity in the primary care setting. Without a team-based approach, clinicians spend valuable time providing care that could be done by well-trained non-clinicians. Estimates suggest that for a panel of 2,500 patients, a clinician would spend 17 to 18 hours per day providing the recommended preventive and chronic care. Teamwork in the primary care practice has been shown to improve clinical quality, patient experience, and provider experience.

Team-based care has also been shown to lead to greater career satisfaction and less burnout of the staff in primary care practices. By working together in a team, physicians report that they have the time they need to listen, think deeply and develop relationships, while other team members are also more involved in direct patient care and, therefore, better able to answer patient questions and coordinate care. As a result of teamwork, all members of the practice team are valued and feel engaged in patient care.

Building practice teams involves expanding roles of staff and care providers, providing training for those expanded roles, developing trust and teamwork, and utilizing protocols and standing orders so staff can act independently. Leadership and a commitment to change the traditional hierarchical model of care to a more team-based culture is crucial to building effective teams.

Year 1

BB4.Y1.1. Practice uses established tool to assess baseline team relationships.

Action Items:

  1. Complete a practice assessment of the distribution of patient care tasks by role to measure how practice teams are functioning.

Practice Attestation Anchor:
Attest that team relationships were assessed and reviewed. Examples of relationship tools could include review of the Medical Home Practice Monitor and the Clinician and Staff Experience Survey, both collected as part of the SIM Assessments.

Practice Facilitator Attestation Methodology:
Confirm review with the practice or practice's quality improvement team of the results of the Medical Home Practice Monitor and the Clinician and Staff Experience Survey, plus any other similar tools the practice site may have used for this purpose.

BB4.Y1.2. Practice has written job descriptions, including clear roles and responsibilities.

Action Items:

  1. Develop clear roles and responsibilities for each team member and put these in writing with a policy and procedure that outlines the process and decisions made.
  2. Develop a plan for when staff turnover occurs to ensure tasks continue to done as planned.

Practice Attestation Anchor:
Produce written job descriptions for at least two roles in the practice (e.g., front desk, MA, RN, etc.) and attest that others are in place.

Practice Facilitator Attestation Methodology:
Confirm review of at least two job descriptions, with practice confirmation that others are in place.

BB4.Y1.3. Practice identifies and implements a team-based care strategy (team huddle, collaborative care planning).

Action Items – Daily Team Huddles:

  1. Create a template agenda for daily huddles that includes the topics that will be discussed each day. Huddles may include time to:
    1. Prospectively plan for patients who can benefit from pre-visit activities (e.g., point of care tests, immunizations, paperwork) and extra time and assistance.
    2. Communicate and prepare for staff, provider, or equipment changes.
  2. Adjust huddle timing, participants, and agenda as needed to best align the team at the start of a clinic session, build team culture, and improve communication for a more engaged workforce.

Action Items – Collaborative Care Planning Sessions:
Collaborative care planning sessions are practice team meetings that help plan for care of an individual patient or panel of patients. Professionals on staff, including but not limited to behavioral health, pharmacy, and care management who share in the care of patients can approach challenges and strategies to better meet the needs of complex patients. This is also a time when multi-disciplinary professionals can communicate directly with one another to address concerns and plan appropriate patient follow up.

  1. Implement a regularly scheduled collaborative care planning session with the practice team to discuss the overall care of selected population of empaneled patients.
  2. Include a varied group of relevant team members such as providers, patients and families, nurses, medical assistants, care coordinators, behavioral health specialists, clinical pharmacists, and psychiatrists.
  3. Adopt consistent strategy and expectations for conducting care planning sessions that will keep the team efficiently moving through the review of multiple patients. Examples may include an agenda or a shared template for preparation and review.

Practice Attestation Anchor:
Attest that at least one of the following team based care strategies are in routine use as outlined below:
- Team Huddle: occur at least once a week, involve more than one role on the team, and have some form of documentation (e.g., written scripts, standing agenda items for huddles, huddle checklists, EHR fields for virtual huddles, written procedures or instructions, etc.)
- Collaborative Care Planning: occur at least quarterly, include two or more team members (physician, BH provider, care manager, nursing, social worker, etc.) and have summary of the plan that includes patient goals within the patients' records.

Practice Facilitator Attestation Methodology:
Confirm practice implementation of team-based care strategies. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

Year 2

BB4.Y2.1. Practice reevaluates team relationship using tool from Year 1.

Action Items:

  1. Complete the practice assessment of the distribution of patient care tasks by role used in Year 1 to re-evaluate how practice teams are functioning.

Practice Attestation Anchor:
Repeat assessment and discussion of team relationships, as described for Year 1.

Practice Facilitator Attestation Methodology:
Confirm review with the practice or practice site's quality improvement team of the results of the Medical Home Practice Monitor and Clinician and Staff Experience Survey, plus any other similar tools the practice may have used for this purpose, including comparing to baseline results.

BB4.Y2.2. Practice develops protocols for shared workflows for three quality measures (with at least one behavioral health measure).

<p>Standing orders are protocol-based workflows that care team members can follow based on common, easily identified patient characteristics such as a symptom, diagnosis, or visit type, without the need for providers to initiate the services each time. Standing orders allow patient care to be shared among members of the care team and all members of the care team to function to their fullest capacity. </p>
<p><u>Action Items:</u></p>
<ol>
<li>Select which clinical quality measures (CQMs) will be targeted for standard protocols. Some standing orders relevant to SIM CQMs to consider include:</li>
<ol>
<li>Well-child and annual visits prompting developmental screening, substance abuse screening, fall risk assessment, and orders for age-appropriate cancer screening. Consider screening for maternal depression at postpartum visits or the 2 week newborn visit. </li>
<li>Disease-based triggering of periodic services, such as A1C testing for patients with diabetes, and filling out a PHQ-9 for patients with depression. </li>
<li>You may also want to consider standing orders for additional targets outside of the SIM CQMs such as appropriate immunization administration at well-child and annual visits; other recommended services for diabetes such as monofilament exams, eye referrals, and urine microalbumin; and symptoms triggering point of care testing for urinary tract infections, pregnancy, influenza, or and strep throat.</li>
</ol>
<li>Develop a written protocol that explains qualifying patient conditions, recommended approach for management of the condition, or developmental needs, staff responsibilities, required documentation, billing procedures, and clinical oversight. Practices may base protocols on national clinical guidelines, adapting them to their own patient population and care team resources. </li>
<li>Increase buy-in by reviewing individual protocols with providers and staff. Empower staff to seek help when a symptom, diagnosis, or situation does not fit within the standard protocol.</li>
<li>Train staff members how to use the standing order protocols. Include time to supervise staff new to the protocol to ensure proper implementation. </li>
<li>Review and update standing orders and protocols on a regular basis and retrain and update providers and staff with the new information.</li>
</ol>
<p><u>Practice Attestation Anchor</u>:<br>
Demonstrate protocols and workflows related to the three chosen quality measures.</p>
<p>&nbsp;</p>
<p><u>Practice Facilitator Attestation Methodology</u>:<br>
Confirm practice implementation of protocols and workflows related to three chosen quality measures. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement. </p>

BB4.Y2.3. Practice reviews roles/responsibilities for team-based care activities to ensure accountability for various tasks assigned.

<p><u>Action Items</u>:</p>
<ol>
<li>Build a culture that supports teamwork that will empower staff to take on new roles, act independently, and communicate effectively. </li>
<ol>
<li>Identify the leader(s) of each practice team. </li>
<li>Establish and provide organizational support for the teams, including protected time for teams to interact and plan their activities. </li>
</ol>
<li>Distribute the workload throughout the team to make optimal use of each member&rsquo;s training and skill set, having members work at the top of their license to the extent possible. Develop training for team members on new skills.</li>
<li>Help patients understand what they can expect from the team-based care model through pamphlets, phone scripts, in-person conversations, and other means of communication.</li>
</ol>
<p><u>Practice Attestation Anchor</u>:<br>
Document roles and responsibilities for the various team-based activities.</p>
<p><u>Practice Facilitator Attestation Methodology</u>:<br>
Confirm implementation of screening. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.</p>

Building Block 5: Practice Has Built Partnership With Patients

Goal

(Combined - Adult and Pediatric): Practice has established use of evidence-based shared decision-making aids or self-management support tools for at least one, preference-sensitive condition, and tracks the use of these tools. Practice establishes a
Patient and Family Advisory Council (PFAC)
to provide input, feedback on practice transformation activities and programs.

Overview:
Advanced primary care practices provide care that is relationship-based with an orientation toward the whole person. Partnering with patients and their families requires understanding and respecting each patient and family’s unique needs, culture, values, and preferences. The advanced primary care practice actively supports patients and families in learning to manage and organize their own care at the level the patient chooses. These practices ensure that patients and families are core members of the care team and fully informed partners in their own care.

One of the ways that patients and families become a full partner in care is through shared decision-making about health care. Shared Decision-Making (SDM) is a process that occurs between the members of a practice and the patients and families. It is demonstrated by collaborative decisions about prevention, treatment, and advanced treatment-planning for the patient and family. It means that the provider is responsible for sharing the latest evidence to inform the care plan, but the plan also takes into account the person/family's culture, values, and opinions. SDM ensures that the person/family are fully informed about treatment and the risks/benefits of treatment and not doing treatment, and supports individualized care decisions.

For patients and families to feel like a full partner, they must have an understanding of how to prevent illness, promote health and well-being, manage healthy lifestyles, and manage chronic illness conditions. Each practice will look at how they can assist patients and families toward gaining independence and self-management of specified high-risk conditions.

To be a true partner, the practice must gain an understanding of the patient's and family's perspective on the care experience. Advanced practices have patients help shape operations by soliciting and acting on feedback from patient surveys, and by engaging patients and families in advisory roles to set and address clinic improvement priorities. Gathering this feedback and establishing ways to communicate information back to the patients and families are goals of Building Block 5.

Year 1

BB5.Y1.1. Practice evaluates patient population to identify one *preference-sensitive condition that is appropriate for decision aids or self-management support tools.

*Preference-sensitive conditions are those which have treatment options that pose tradeoffs that the patient should consider with his/her physician when determining whether to proceed with treatment.

Action Items:

  1. Educate care team members on the concepts of self-management support and available tools.
  2. Choose preference-sensitive conditions that could be improved by providing self-management support resources. Conditions could include physical health or behavioral health concerns that result in high utilization, high cost, and/or lower satisfaction rates or socio-demographic risk factors that contribute to poor utilization of preventative health services.

Examples could include: obesity in children or adults; diabetes in adults; depression care in children, adolescents, and/or adults (e.g., pregnancy-related depression); prematurity or other special health care need in infants; asthma care for children, adolescents, and/or adults; misuse of alcohol or marijuana.

Practice Attestation Anchor:
Indicate the condition(s) chosen for this activity.

Practice Facilitator Attestation Methodology:
Confirm the practice has chosen preference sensitive condition and document this in field notes, along with any changes or additions through the initiative.

BB5.Y1.2. Practice identifies and selects evidence-based decision aids or self-management support tools for identified conditions.

Action  Items:

  1. Once high-risk conditions are  identified, select appropriate self-management tools and make these tools  available to patients. For pediatric populations, self-management tools may  target the parents or primary caregivers in addition to the child, if  developmentally appropriate. Examples include:
    1. Asthma action plans that define  green, yellow, and red indicators of asthma control and what to do for each  level.
    2. Decision aids for cholesterol management such as  Mayo Clinic’s online aid for shared decision-making for cardiovascular  prevention, medication options for depression.

Practice  Attestation Anchor:

Describe  the selected decision aids or self-management tools.

Practice  Facilitator Attestation Methodology:

Confirm  practice implementation of decision aids or self-management tools. Attest if,  in PF opinion, the practice has fully accomplished the milestone as described  in the anchor statement.

BB5.Y1.3. Practice has established a Patient and Family Advisory Council (PFAC) that meets at least quarterly.

Action  Items:

     

  1. Identify one or two practice  champions to co-facilitate the advisory council.
  2.  

  3. Develop a recruitment plan (number  of members, representative of practice population, supports/incentives for  participation, length of service).
  4.  

  5. Recruit participants and secure  commitments for engagement.
  6.  

  7. Set meeting dates/locations in  advance and on a quarterly basis. Adjust times, services, and locations to  maximize participation from target patient advisors. For example, working  adults may need to meet outside of normal business hours, and parents may be  more engaged if they can bring their children and have on-site childcare.  Snacks or meals should be offered depending on the timing of meetings.
  8.  

  9. At the first meeting, determine  governance structure including how agendas will be set, how feedback will be  gathered and shared, and sphere of influence of the advisory council.
  10.  

  11. Periodically review the advisory  council and adjust membership and processes to address patient experience more  effectively. Particularly in the beginning, obtaining feedback from  participants and making the necessary adjustments will increase the success and  longevity of the council.
  12.  

  13. A PFAC has been found to be one of  the most effective ways to obtain patient and family feedback for a practice,  and is recommended as the first choice for patient/family engagement in this  milestone. If a PFAC is not felt to be feasible for the practice at this time,  additional patient and family engagement  strategies to consider include patient satisfactions surveys, adding a patient  representative to the practice quality improvement team, or conducting patient  focus groups to gather patient feedback.

Practice  Attestation Anchor:

  Provide  minutes or other records of quarterly PFAC meetings and documentation of  decisions made based on PFAC input.

Practice  Facilitator Attestation Methodology:

  Confirm  practice implementation of PFAC meetings. Periodically review minutes or other  records of PFAC meetings for discussion in quality improvement team meetings.  Attest if in PF

  opinion  the practice has fully accomplished the milestone as described in the anchor  statement.

Year 2

BB5.Y2.1. Practice identifies patients and families eligible for selected decision aids or self-management support tools.

Action Items:

  1. Establish a method for identifying the denominator of eligible patients to enable evaluation of the proportion of eligible patients that receive the aid or tool.
  2. Determine how patients will be identified or flagged for the aid or tool at the point of care.

 

Practice Attestation Anchor:
Attest that process for targeting patients for decision aids or self-management support has been developed and implemented.

Practice Facilitator Attestation Methodology:
Confirm practice has identified patients eligible for selected decision aids or self-management support tools. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

BB5.Y2.2. Practice implements decision aids or self-management support tools and establishes protocol and workflow for use.

Action Items:

  1. Develop workflow for when and how decision aids or self-management support tools will be used, including which team member will review the aid or tool with the patient.
  2. Train appropriate care team members and providers on when and how to use the tools.

Practice Attestation Anchor:
Attest that workflow for implementation of decision aids or self-management support tools has been developed and implemented, with documentation of use as in BB5.Y2.3.

Practice Facilitator Attestation Methodology:
Confirm practice development of workflow. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

BB5.Y2.3. Practice develops process for tracking and evaluating use of decision aids or self-management support tools.

Action Items:

  1. Create processes and assign responsibility for care team members to track the use and impact of shared decision making tools. These processes should clearly identify outcome and process indicators of change in practice and patient outcomes, specify when and how the data will be collected, analyzed and communicated to the practice.
  2. Use patient input on the tools to make them optimally appropriate for your patient population.
  3. Monitor patient satisfaction with self-management tools and adjust approaches to increase impact of these tools on patient outcomes.

Practice Attestation Anchor:
Describe processes for tracking the use and impact of shared decision making tools and provide data documenting their use.

Practice Facilitator Attestation Methodology:
Confirm practice implementation of process. Attest if in PF opinion the practice site has fully accomplished the milestone as described in the anchor statement.

BB5.Y2.4. Practice uses PFAC to evaluate care experience.

Action Items:

  1. Create a process for review of feedback from PFAC (such as through regularly scheduled QI team meetings) or other patient engagement strategy used. As noted in BB5.Y1.3., additional patient and family engagement strategies include patient satisfactions surveys, adding a patient representative to the practice quality improvement team, or conducting patient focus groups to gather patient feedback.
  2. Share patient feedback with providers in the clinic through all-staff clinic meetings, practice email updates, or other means of communication that will be relayed to all staff.
  3. Identify how to communicate, either by poster or audiovisual display, or by electronic means, what the practice is doing based on patient and family feedback.
    1. If the practice will use a pamphlet or poster, use health literacy tools to engage patients and family and keep the message geared to the population (English, Spanish, lower literacy, etc.).
    2. Practice to identify reporting mechanism that captures successes and features changes as a result of patient and family feedback (e.g., “you told us and we listened” type messages).

Practice Attestation Anchor:
Document PFAC suggestions used to evaluate and improve patient experience of care through PFAC and or improvement team minutes.

Practice Facilitator Attestation Methodology:
Confirm review of PFAC minutes or other records of meetings and identify how practice is working on patient experience of care. Attest if, in PF opinion, the practice has fully accomplished the milestone as described in the anchor statement.

Building Block 6: Practice Risk Stratifies and Actively Manages Patient Population Using Data

Goal

Practice uses population-level data to manage care gaps, develop care management care plans and implement those plans for high-risk patients/families.

Overview:
Population management is a core activity of advanced primary care practices. It requires care teams to take responsibility for a defined group of people (generally their patient panel) and develop interventions to improve health outcomes for the entire group. Efficient practices identify sub-groups of their patients that will benefit from similar interventions, like patients with a particular diagnosis (e.g., asthma or diabetes) or risk factors (e.g., psychosocial, environmental, and familial adversity factors), and then tailor systems of care to those groups that result in measurable health improvements.

The goal of this building block is to help practices successfully identify and develop care plans for patients with increased needs or at higher risk.

Risk stratification is the process of assigning a category of risk for each patient in a practice in order to create subgroups of patients for whom more attention will improve outcomes. Establishing a risk stratification strategy in a practice requires an objective look at the practice’s panel, and evaluating predetermined factors. In general, there are three overarching methods to assign risk to patients:
Care Team Judgment: Providers and other care team members assign a risk category to individuals based on their knowledge of the patient in comparison to other patients in the practice panel.

Algorithms: A risk score is calculated based on a predetermined equation that can combine multiple factors such as demographics, diagnoses, prescription medications, utilization, cost, biometrics, or social determinants. These can be automatically generated or done by hand. Several validated algorithms are available.

Thresholds: Patients are determined to be in a high-risk group once they meet certain conditions. Examples of common threshold categories include high cost utilization, such as patients with 4+ ER visits in a year or anyone with a 30 day readmission in the last 6 months, but thresholds can involve any type of patient factor.

Some practices may choose to combine aspects of one or more method. It will be up to each practice to work with their Practice Facilitator to implement the method or methods that best fit their local needs and resources.

Year 1

BB6.Y1.1(A). Practice identifies, documents a risk stratification methodology. (Recommended, but not required for pediatrics practices.)

Action Items:

  1. Review available risk stratification methods with your QI team and care teams. Keep in mind the time and personnel costs needed to develop each method and how your practice would use the information to improve care processes for high risk patients and their families. Your Practice Facilitator or CHITA can be helpful in identifying resources and information on various choices.
  2. Decide on a risk stratification method.
  3. Assign and empower at least one practice champion to coordinate the development, validation, training, communication, documentation, and monitoring aspects of the risk stratification method.

Once high-risk patients are identified, the next step is to tailor care management interventions to improve outcomes for the highest risk patients and, when appropriate, their families.

Practice Attestation Anchor:
Document a chosen risk stratification methodology that specifically fits the needs and resources of your practice. Note the potential alignment with activities described for BB10.

Practice Facilitator Attestation Methodology:
Confirm practice identification of a risk stratification methodology. Attest if in PF opinion the practice has fully accomplished the milestone as described in the milestone or anchor statement.

BB6.Y1.2. Practice identifies strategy to identify care gaps (e.g., patient registry, data aggregation tool) and prioritize high-risk patients/families.

Registries  (or other means to identify care gaps/target populations) track population  groups targeted for services, referrals and risk stratification. Registries  ensure that planned, recommended activities happen within acceptable time  limits and that patients get the services they need and show improvement for  identified care plan needs. Registries can be condition specific (e.g.  depression) or span a broader subpopulation of the clinic (e.g. wellness  registry).

Action  Items:

  1. Engage the QI team to identify  priority conditions to be tracked.
  2. When making a new registry consider:
    1. The source of the data (e.g., EHR,  claims, other population health registry).
    2. Patient diagnostic criteria (e.g.,  all depression or only depression on medications).
    3. The need for additional medication  management and review (e.g., polypharmacy, frequent hospitalizations with  changes to medications).
    4. The outcomes to be assessed. Those  can be process outcomes (compliance with treatments, appointments), as well as  health outcomes (improved objective measures).
  3. Establish the timeline of the work,  including when the patient cohort will be defined, who will do the data  analysis, and when the outcomes will be assessed.

 

Practice  Attestation Anchor:

Attest  to the development of a strategy and workflow for identification of care gaps  for high risk patients and families, including use of a patient registry, data  aggregation tool, or similar process.

Practice  Facilitator Attestation Methodology:

Confirm  practice implementation of strategy and workflow. Attest if in PF opinion the  practice has fully accomplished the milestone as described in the milestone or  anchor statement.

Year 2

BB6.Y2.1(A). 75% of empaneled patients are risk-stratified. (adult only)

Action Items:

  1. Schedule time to review the process, track the proportion of the clinic’s patients in each category, adjust implementation plans, and link the risk categories to care management strategies in the clinic.

Practice Attestation Anchor:
Provide data indicating that this target has been met.

Practice Facilitator Attestation Methodology:
Review practice data and attest if target is met.

BB6.Y2.2. 75% of high-risk patients/families have a documented care plan.

Individualized  patient treatment plans, also known as “shared care plans” or, simply, “care  plans”, improve efficiency and promote timely, patient-centered care. To be  comprehensive, care plans should incorporate both physical and behavioral  health goals and reflect the goals of providers, patients, and their families.  To support collaborative and continuous care, the documents should be easily  available in the EHR for all practice team members to access. If the practice  is working with an integration partner, this may require the electronic  exchange of information such as through continuity of care documents (CCDs).

Action  Items:

  1. Identify important pieces of  information that should be included in an individualized patient treatment  plan, including physical and behavioral health goals. Create a template with  appropriate headers or instructions for people to follow. Keep in mind care  plans need to allow for a variety of types of patient goals, and components of  the plans may be different for different populations (e.g., adults vs.  children, patients seeing multiple specialists vs. healthy individuals). Include  medication reconciliation in the creation and updating of care plans.
  2. Train all care team members to  create, access, and update care plans.
  3. Set an initial goal for the number  of care plans to be created within a certain amount of time. Consider starting  with a subset of the practice’s empaneled patients to allow care teams to  practice and provide feedback on the process.
  4. Develop a process to update the care  plans regularly to keep all team members up to date.

Practice  Attestation Anchor:

Provide  data indicating the presence of the care plan developed in BB10.Y1.3 for 75% of  high risk patients.

Practice  Facilitator Attestation Methodology:

Review  practice data and attest if target is met.

BB6.Y2.3. Practice implements proactive care gap management and tracks outcomes.

Action  Items:

  1. Based on previously selected  strategy to identify care gaps (e.g., registry), contact patients who are not  achieving pre-specified outcomes.
  2. Engage care team members such as  care managers, front desk staff, and others in patient follow-up as needed.
  3. Build on previous work to assess  outcomes from the registries and adjust clinical workflows and patient outreach  efforts to show improvement in process and patient-centered outcomes.
  4. Once improvements are sustained,  consider focusing on new outcomes and/or new registry populations.

Practice  Attestation Anchor:

Attest  to the implementation of a process for providing care management for high risk  patients and the outcomes of the care management.

Practice  Facilitator Attestation Methodology:

Confirm  practice implementation of an embedded care plan in EHR or another method for  tracking the care plan. Attest if in PF opinion the practice has fully  accomplished the milestone as described in the anchor statement.

BB6.Y2.4. Practice embeds care plan template in EHR.

Action  Items:

  1. Decide where in the EHR the  individualized care plan will be documented.
  2. Consider how individualized care  plans could be shared, with proper permissions, across medical specialties  within the medical neighborhood.

Practice  Attestation Anchor:

Demonstrate  that the care plan is embedded in the EHR, or show another method for tracking  and sharing the care plan if that is not possible.

Practice  Facilitator Attestation Methodology:

Confirm  practice implementation of an embedded care plan in EHR or another method for  tracking the care plan. Attest if in PF opinion the practice has fully  accomplished the milestone as described in the anchor statement.

Building Block 7: Practice Identifies Behavioral Health Resources for Patients/Families, Including Support from SIM Participating Health Plans and Regional Health Connectors (RHCs)

Goal

Practice screens at least 90% of appropriate patients/families for substance use disorder and/or other behavioral health needs, and includes behavioral health and community services as part of care management strategies.

Overview:
Integrated health care means the systematic coordination of physical and behavioral health. The central premise is that physical and behavioral health problems often occur at the same time and often present in primary care clinics before they present in any other formal setting. Employing universal screening processes for behavioral health issues and psychosocial adversity factors in an integrated primary care setting will produce the best results and will afford the most effective approach for all individuals.

For many factors affecting health, elements of community are important. If a patient panel is to show improvement in outcomes such as tobacco cessation, weight control, physical activity, or mental health, community resources affecting those issues will be as important as the clinical factors. Because many of the concepts and skills needed to improve the health of a patient panel are the same as those needed to improve the health of the broader community, effectively measuring health and improving outcomes for a patient panel will translate into a practice’s ability to also influence the health of the broader community.

Year 1

BB7.Y1.1. Practice identifies behavioral health resources for patients/families, including support from SIM participating health plans and Regional Health Connectors (RHCs).

Action Items:

  1. Contact SIM participating plans and identify what behavioral health resources are available through the plan.
  2. Contact Regional Health Connector to assist in identifying community resources and priorities.
  3. Create repository of available behavioral health resources, including local public health agencies.

Practice Attestation Anchor:
Attest to having assessed and identified local behavioral health resources appropriate for the practice's patient population.

Practice Facilitator Attestation Methodology:
Confirm practice effort to identify appropriate local behavioral health resources. Attest if in PF opinion the practice has fully accomplished the milestone.

BB7.Y1.2. Practice identifies a screening tool for reporting on at least two behavioral health screening measures for SIM (depression, maternal depression, developmental disorders, obesity, and substance use disorders, [i.e., unhealthy alcohol use, other drug dependence, and tobacco use]); screens 25% of patients.

Reach is one way to measure the impact of an intervention. It looks at the number and proportion of patients who are eligible for a given intervention that properly receive the intervention.
One example would be a practice that wants to start screening adolescent and adult patients for depression using a combination of an age appropriate PHQ-2 for all patients followed by an age appropriate PHQ-9 if the first screen is positive.

The practice sees 100 qualifying patients on the first day of the intervention, and 70 of the patients finished the appropriate screening questions.
In this scenario, the depression screening intervention “reached” 70 patients or 70% of the potential population with the screening. Further tracking the percentage of patients receiving and then completing treatment can give reach calculations for those treatment steps.

Keeping track of reach across all BH screening and treatments allows practices to see if their efforts to expand BH services are impacting a larger number and percentage of their patient panels. In addition, it is critical to match the anticipated number of patients to be reached through screening activities to the capacity of services that can be provided to patients through the available resources.

Action Items:

  1. Work with the care team and QI team to choose at least two age- and developmentally-appropriate screening tools for behavioral health conditions measured by the SIM CQMs (depression, maternal depression, developmental disorders, unhealthy alcohol use, and tobacco use).
  2. Regularly monitor the use of the tools to track the reach of your screening - the number of patients being screened over the total targeted number of patients. Explore if your EHR is also capable of tracking appropriate follow-up of positive screening tests and patient outcomes over time.
  3.  If <25% of patients receive a behavioral health screening test, consider adjusting current workflows or implementing additional screening tools.

Practice Attestation Anchor:
Show the tool(s) used to screen for depression, maternal depression, developmental disorders, tobacco use, unhealthy alcohol use, and/or other substance use disorder. Produce a measure showing that at least 25% of targeted patients were screened with the tool.

Practice Facilitator Attestation Methodology:
Confirm practice implementation of a screening tool. Attest if in PF opinion the practice site has fully accomplished the milestone as described in the anchor statement.

BB7.Y1.3. Practice has documented process for connecting patients/families with behavioral health resources (from screening), including standing orders and/or protocols and follow-up.

Action Items.

  1. Start by listing the discrete behavioral health screenings (see BB7.Y1.2.), treatments provided in the practice, and behavioral health resources available to patients (see BB7.Y1.1., BB7.Y2.3., BB8.Y1.2.), along with the descriptions of patients who qualify for the interventions.
  2. Develop protocols, documentation standards, monitoring reports, and trainings for how to use and interpret the screening tools, what to do when screenings are positive, and how to manage referrals and follow-up.
        1. Identify how the results will be communicated to the providers and care team.
  3. Consider which screening protocols necessitate BH provider treatment following a particular response pattern. For example, an elevated pregnancy-related depression screener may trigger an automatic consultation with a BH provider.
  4. Design alerts and workflow notifications, as able, to facilitate communicating results to providers. Positive screens may trigger immediate responses depending on the level of severity and whether any safety concerns arise.
  5. Identify/designate the appropriate staff to respond and initiate protocols related to different types of screening outcomes.

 

Practice Attestation Anchor:
Produce documentation of the standing orders or protocols.

Practice Facilitator Attestation Methodology:
Confirm practice site implementation of standing orders or protocols. Attest if in PF opinion the practice has fully accomplished the milestone as described in the milestone or anchor statement.

Year 2

BB7.Y2.1. 50% of patients are screened for behavioral health conditions.

Action Items:

  1. Expand on the use of tools to screen for behavioral health conditions as selected in BB7.Y1.2. If <50% of patients are receiving a behavioral health screening test, consider adjusting current workflows or implementing additional screening tools. As noted in BB7.Y1.2, behavioral health screening measures included in the SIM CQMs are depression, maternal depression, developmental disorders, unhealthy alcohol use, and tobacco use.
  2. Continue to regularly monitor the use of these tools to track the number of patients being screened. If not already done, explore if your EHR is also capable of tracking appropriate follow up of positive screening tests and patient outcomes over time.

Practice Attestation Anchor:
Demonstrate that at least 50% of patients are screened for key behavioral health conditions, chosen as appropriate for the patient population.

Practice Facilitator Attestation Methodology:
Confirm review of practice data to assure that at least 50% of patients are screened for key behavioral conditions.

BB7.Y2.2. Practice performs an assessment of community resources, with Regional Health Connector support when possible, to assist patients with social needs (such as food, housing, transportation).

Action  Items:

  1. Determine  screening questions that you will use to identify specific social needs in your  patients.
  2. Work with your Regional Health  Connector (RHC) to develop a repository of community resources available to  patients with social needs.
  3. Determine who in the practice will  be responsible for maintaining a list of community resources that relate to the  patient population served.
  4. Create protocol to define how to  access community supports.

Practice  Attestation Anchor:

Provide  documentation of the assessment of community resources to assist patients with  social needs. This can include the use of formal external assessments of such  resources.

Practice  Facilitator Attestation Methodology:

Confirm  practice assessment of community resources. RHC may be able to assist. Attest  if in PF opinion the practice has fully accomplished the milestone as described  in the milestone or anchor statement.

BB7.Y2.3. 50% of patients identified with behavioral health need are connected to resources.

Action  Items:

     

  1. Set as your denominator for this  measure the patients that screened positive for targeted behavioral health  conditions using the tools in BB7.Y1.2./BB7.Y2.1.
  2.  

  3. If your practice provides integrated  BH interventions, develop a process for measuring how many qualifying patients  are seen in a month and how many receive the intervention(s).
  4.  

         

    1. Review the reach of the BH  interventions regularly. Adjust workflows or add BH screening or treatments to  improve the reach of BH interventions in the practice. Consider examining  caseload and productivity expectations to ensure that BH clinicians are able to  deliver the services to the population of interest.
    2.    

    3. Consider alternatives to traditional  office visits to provide interventions through other points of access, such as  management via home visits, group visits, phone, email, or patient portal.
    4.  

     

  5. If your practice refers patients who  screen positive to outside BH resources, create a written protocol to track  referrals and referral uptake/completion for offsite BH services. Offsite BH  resources may include psychology, psychiatry, early intervention programs, and  local community health programs.
  6.  

         

    1. See BB8.Y1.2. for additional action  items on assessment of referral pathways to offsite BH resources and BB7.Y1.1.  for other identification of resources.
    2.    

    3. Helpful information to track with  this process includes: the time a referral is made, primary care record  exchange with the behavioral health specialist, documentation of releases of  information for bi-directional communication, when the initial visit occurs,  preliminary treatment plan or plan for services, and when the visit summary is  received by the primary care practice.
    4.    

    5. Include a definition of a  “reasonable time” that makes sense for the practice and patients.
    6.    

    7. Delineate a care team member to be  responsible for tracking this process.
    8.    

    9. If the volume of referrals seems  excessive, consider limiting referral tracking to a logical subset of the  practice’s patients, such as urgent or emergent referrals, referrals of high-risk  patients, or referrals to the most common BH providers/locations.
    10.  

Practice  Attestation Anchor:

  Provide  data indicating that 50% of patients identified with behavioral health needs  are connected to resources; can include resources within or outside the  practice.

Practice  Facilitator Attestation Methodology:

  Review  practice site's data to assure that at least 50% of patients with behavioral  health needs are connected to resources. Attest if in PF opinion the practice  has fully accomplished the milestone as described in the milestone or anchor  statement.

Building Block 8: Practice Provides Prompt Access to Care, Including Behavioral Health Care

Goal

Practice, at a minimum, has established collaborative care management agreements with behavioral health providers in the community and members of the care team can articulate how to use those agreements. Practice has ability to share clinical data based on collaborative care management agreements with behavioral health providers bi-directionally within 7 days.

Overview:
Providing timely access to care is a core attribute of primary care and a key driver of patient satisfaction. A lack of access can cause patients to seek care in emergency rooms or urgent care centers or not receive needed care in a timely manner, leading to increased expenses and poorer health. Access is important day or night, as is provider access to patient information. This level of access promotes continuity of care by enhancing communication and promoting integration between services. Many strategies such as regular monitoring and control of panel size can help lead to improved access.

The definition of access extends beyond “open appointments” to include access to “my provider” when necessary. Access to “my provider” is a core component of continuity, but should be balanced with the patient-centered approach of allowing patients and their families to choose between waiting to see their provider and seeing an available provider sooner. High-performing practices assist patients in deciding which type of access is the priority.

New technologies like electronic patient portals offer advanced options for patients and their families to access health records and interact with their care team. These options can facilitate communicating to patients from the practice, receiving information electronically from patients (e.g., updates on well-being/symptoms, requests for appointments, and medication refills), efficiently sharing changes in practice policies, and providing forms to patients/families to complete prior to or in between appointments.

Care compacts are collaborative agreements that facilitate coordination and create systems to close the loop. They can include a variety of topics, including how quickly a patient should get an appointment, information that needs to be shared prior to the appointment, the time frame for a report from the specialist to reach the primary care provider and vice versa, or an agreement of who is managing the ongoing care of the patient. Beyond specialty medical and behavioral health providers, care compacts are also used to streamline relationships with community groups such as schools, fitness centers, or organizations providing care management and social work services.
Completion of care compacts help primary care practices form a medical neighborhood, and help ensure consistency and reliability for patients through the relationships between primary care, behavioral health, medical specialty care, and community resources.

It is important to emphasize that Community Mental Health Centers (CMHCs) will need the same relationship that is established through care compacts as primary care medical providers. CMHCs will need to develop relationships with medical specialists and their own community groups. If the CMHC is not also a substance use disorder treatment provider, relationships with appropriate organizations will be required. Children and their families will benefit from relationships with pediatric specialists, community resources, and schools.

Year 1

BB8.Y1.1. Practice representative has EHR access available 24 hours, 7 days per week.

Action Items:  

  1. Develop a written protocol for providers to have access to patient health records that includes procedures for record sharing, reporting, documentation, scheduling.
  2. Regularly share information with patients (verbally and in writing) about accessing after-hours services, particularly when they are new to the practice.
  3. Information about accessing after-hours services should be posted at the practice, detailed on websites, and provided in initial patient paperwork.
  4. Regularly review policies and procedures for contacting the practice when the practice is closed, including setting expectations about who will be responding to calls (e.g., a nurse triage line, an on-call provider who is not part of the practice, or the patient’s primary care provider). Be sure to include a process/procedures for responding to behavioral health urgent and emergent situations.
  5. Consider developing processes for secondary triage to on-call response systems, access to clinical information, and next day scheduling systems.

Practice Attestation Anchor:
Attest or provide documentation that after hours call providers have access to the practice's own EHR and patient records.

Practice Facilitator Attestation Methodology:
Confirm that this milestone has been met. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

BB8.Y1.2. Practice performs assessment of referral pathways and available after-hours support for behavioral health, working with RHCs when possible.

Action Items:

        1. Identify policies and procedures on how crisis intervention, urgent care, and emergent care episodes are handled between physical health and behavioral health providers, whether they are in different sites, co-located, or can be accessed with a warm hand-off.
        2. Determine how referrals are made and which patients are referred.
        3. Compile a resource list or spreadsheet of behavioral health providers approved or in-network for the commercial and public plans involved in the SIM initiative. Prioritize behavioral health centers and providers that accept the common payers seen in your practice and those locations open to new patients. Identify behavioral health providers that specialize in working with certain populations (e.g., pediatrics, families, early childhood, substance abuse and dependence) and denote specializations in the resource lists. Information may include hours of operation, procedures for obtaining initial appointments, necessary paperwork, etc. Preliminary lists may be found on company websites and may be added to using experience and word of mouth. For Behavioral Health Providers under Medicaid, a list of Community Mental Health Centers (CMHCs) can be found by contacting the Medicaid office, or by performing searches by county. Regional Health Connectors can assist practices with this information gathering and relationship building.
  1. Review and update this list regularly to ensure accuracy. Assign someone in the practice to keep this resource up to date.
  2. Similarly, Community Mental Health Centers should develop a list for primary care providers approved or in network for the commercial and public plans. Beyond providing lists, behavioral health providers and agencies should provide primary care settings with information sheets and other materials/paperwork that will facilitate and streamline referrals. CMHCs should also create a system to review and update this list regularly. In Medicaid, this may involve partnering with the local regional collaborative care organization or Regional Accountable Entity.

Practice Attestation Anchor:
Attest to development of a pathway for at least one type of referral to behavioral health (preferably one that fits with the reported CQMs and other practice QI efforts), including mechanism for after-hours support.

Practice Facilitator Attestation Methodology:
Confirm practice development of a pathway for at least one type of referral to behavioral health. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

BB8.Y1.3. Practice identifies data sources and technology needed for bi-directional data sharing.

Action Items:

  1. Determine what confidentiality agreements/releases of information will be required for bi-directional data sharing with the behavioral health providers in your referral pathways.
  2. Identify what EHR capabilities are available to send and receive patient data to clinicians outside of the medical home, including how and where outside records can be stored and accessed.

Practice Attestation Anchor:
Describe what is needed to accomplish bidirectional data sharing with behavioral health partners, whether integrated or separate from the practice.

Practice Facilitator Attestation Methodology:
Confirm that the practice has explored data sources and technology for bidirectional data sharing with behavioral health partners.

Year 2

BB8.Y2.1. Practice establishes a collaborative agreement with at least one behavioral health provider.

Action Items:

        1. Review templates for creating a care compact.
        2. Determine a beneficial BH practice with whom to develop a care compact based on the needs of your practice and patient panel. For many practices, including those with an integrated behavioral provider, this could include a Mental Health Center, a psychiatry practice, or another provider of specialty behavioral health care.
        3. Have a medical director or other clinic leader reach out to these BH providers to gauge interest in care compact agreements.
        4. Work collaboratively with partners to create mutually beneficial care compact.
        5. Ensure care team can articulate how to use agreements.

Practice Attestation Anchor:
Document the collaborative agreement.

Practice Facilitator Attestation Methodology:
Confirm the development of at least one collaborative agreement. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

BB8.Y2.2. Practice develops plan for bi-directional data sharing with behavioral health provider.

Action Items:

  1. Develop a process for data sharing for patients known to be under the care of outside behavioral health providers, such as through the use of EHR template letters containing clinic notes that can be automatically faxed or mailed to the behavioral health provider (or primary care provider in the case of CHMCs) after completion of the note.
  2. Plan protocols for how received records will be delivered, to whom they will be delivered, and how they will be reviewed (i.e., expectation of timeliness, if/where outside records can be scanned into the EHR, if it is appropriate to make other documentation or summarize outside information elsewhere in the patient’s chart).

Practice Attestation Anchor:
Attest to having a plan for bidirectional data sharing. Explain barriers if unable to implement plan at this time.

Practice Facilitator Attestation Methodology:
Attest if a plan for bidirectional data sharing has been developed.

Building Block 9: Practice Provides Comprehensive Care Coordination for Primary/Behavioral Healthcare

Goal

Practice has reduced total cost of care while maintaining or improving quality of care for patients, including those with depression and substance abuse disorders, compared with non-SIM practices.

Overview:

The milestone activities in this building block focus on strengthening care coordination at times of care transitions from the hospital or ED to the medical home and monitoring the total cost of care for patients to help determine cost drivers.

Year 1

BB9.Y1.1. Practice Can Identify Total Cost of Care for Patient Panel, and Subset of Patients with Behavioral Health Conditions.

 Action Items:

  1. Using data aggregation tool, identify the total cost of care for your entire patient population.
  2. Identify the total cost of care specific to the subset of patients that have behavioral health conditions.

Practice Attestation Anchor:

Attest to use of cost and utilization tool to identify the cost of care for all patients and for those with at least one specific behavioral health condition. Document use of this data in improvement team minutes.

Practice Facilitator Attestation Methodology:

Confirm practice use of cost and utilization tools. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

BB9.Y1.2. Practice Identifies and Implements Policy and Procedures That Include Timely Follow-up for Emergency Department (ED) and Hospital Admissions.

Action Items:

1.     Determine if and how the practice is receiving hospital admission and discharge notification where patients are accessing care.

2.     Determine who will be responsible for contacting patients after hospitalization or ED visit, such as a care manager, clinic nurse, or patient navigator.

3.     Develop a written policy that describes practice plan for following up with patients post-discharge from the hospital or ED.

4.     Create flexibility in provider schedules to allow for ease of scheduling follow up appointments within 72 hours or one week (as appropriate) after ED visit or hospitalization. This may include blocking a specific number of appointments for this explicit purpose or blocking appointments for urgent needs that can only be scheduled within the preceding 72 hours.

 

Practice Attestation Anchor:

Attest to implementation of policies and procedures for transitions of care for hospitalizations and ED visits.

 

Practice Facilitator Attestation Methodology:

 

Confirm practice implementation of policies and procedures for transitions of care for hospitalization and ED visits. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

Year 2

BB9.Y2.1. Practice Contacts 50% of Patients Within 7 Days of Hospitalization or ED Visit, Including Medication Reconciliation.

Action Items:

  1. Implement policy from BB9.Y1.2. that describes practice plan for following up with patients post-discharge from hospital or ED. Follow-up could include phone call, office visit or other encounter as appropriate.
  2. Track the numerator and denominator of patients hospitalized and seen in the ED to ensure at least 50% of patients are contacted.
  3. Prioritize contacting patients for medication reconciliation and determination of follow up needs for those with chronic conditions or frequent hospital/ED utilization.
  4. Include in the medication reconciliation process ascertainment of patient self-reports of medication adherence, including issues of side effects, forgotten doses, and financial costs. For patients with low adherence, pill counts can be selectively used for critical meds. If appropriate and with patient consent, engage family members and caregivers in medication adherence discussions.

Practice Attestation Anchor:

Provide data demonstrating that at least 50% of patients are contacted within 7 days of hospitalization or ED visit.

Practice Facilitator Attestation Methodology:

Review practice data regarding contact of patients after hospitalization or ED visit. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

BB9.Y2.2. Practice Identifies Cost Drivers for Patients with Behavioral Health Condition(s) and Incorporates in QI Processes.

Action Items:

1.        Examine the cost data from BB9.Y1.1. and evaluate what behavioral health conditions, co-morbidities, medications, demographics, and other patient characteristics are associated with higher costs.

2.        Review this data in QI meetings and use to help guide priority areas to address for patients with behavioral health conditions.

 

Practice Attestation Anchor:

Document QI process for improving cost of care for at least one behavioral health condition through improvement team minutes.

Practice Facilitator Attestation Methodology:

 

Assist practice in QI process to improve cost of care for at least one behavioral health condition. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

BB9.Y2.3. Practice Creates and Reports a Measurement to Assess Impact and Guide Improvement on at Least one of the Following:

a. Notification of ED visit in a timely fashion

b. Medication reconciliation process completed within 72 hours

c. Notification of admission and clinical information exchange at the time of admission

d. Information exchange between primary care and specialty care related to referrals

 

Action Items:

1.        Select an area of focus based on patient population needs and identify a point person to review this data in QI meetings.

2.        Develop a process for assessing the targeted measure and determining improvement.

a.      For notification of ED visit, hospital admissions, and hospital discharges in a timely fashion, also reference BB9.Y1.2. and BB9.Y2.1.      

b.     For medication reconciliation process completed within 72 hours of discharge from hospital or ER, you will need to determine how you will measure a denominator and numerator. There may be EHR functionalities that can be implemented for tracking.

c.      For information exchange between primary care and specialty care related to referrals, you may want to consider developing a specialty care compact with the specialists patients are most commonly referred to. Contact your local HIE who may have information on tools to make this easier. Your CHITA or PF can help connect you to the HIE.

 

Practice Attestation Anchor:

Document the measure and the results of the improvement process through improvement team minutes.

 

 

Practice Facilitator Attestation Methodology:

 

Confirm practice work to measure improvement process. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

Building Block 10: Practice has fully integrated behavioral health care to provide whole-person care

Goal

Patient behavioral health outcomes are systematically measured over time and treatment is adjusted as needed, as measured by outreach, registry and other information readily available for purpose of monitoring and adjustment.

Overview:

This building block advances the skills developed in other building blocks to further grow the practice’s ability to meet the behavioral health needs of their patient population. Tracking and adjusting protocols based on outcomes, in addition to process measures, helps ensure that the care patients are receiving is achieving the goals of the practice. Fully integrating behavioral health allows more patients to have most of their physical and behavioral needs met in their medical home.

Year 1

BB10.Y1.1. Practice Uses Referral Pathway Identified for Behavioral Health Needs (Including Available After-Hours Support and a Representative with EHR Access Available 24 Hours, 7 Days per Week)

Action Items:

  1. For assessment of referral pathways and available after hours support for behavioral health, see BB8.Y1.1. and BB8.Y1.2.
  2. Work with RHCs when possible to access referral sources identified and other community resources.

Practice Attestation Anchor:

Attest to development and implementation of referral pathway.

Practice Facilitator Attestation Methodology:

Confirm practice implementation of a referral pathway for behavioral health needs. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

BB10.Y1.2. Practice Develops a Plan to Systematically Measure and Track Patient Behavioral Health Outcomes.

Action Items:

1.     Select behavioral health outcomes most relevant to your practice population. These may be in addition to the CQMs (for example, rates of smoking cessation), or you may use a CQM that is an outcome rather than process measure:

a.      Depression remission at 12 months (CPC+ CQM which counts for SIM)

b.     Hemoglobin A1c poor control (if targeting an appropriate population with behavioral health conditions, e.g., patients with comorbid depression and diabetes, or patients on antipsychotics)

c.      Controlling high blood pressure (as above, if targeting an appropriate population with behavioral health conditions).

2.     Work with your CHITA to determine how data will be retrieved and accessed through your EHR.

3.     Identify a practice champion to take the lead and be responsible for reviewing the data with your QI team, and plan how often this will occur.

 

Practice Attestation Anchor:

Attest to development of plan to systematically measure and track patient behavioral health outcomes for key conditions targeted by the practice.

 

Practice Facilitator Attestation Methodology:

 

Confirm practice reporting of chosen measures and outcomes and plan for extracting and tracking data. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

BB10.Y1.3. Practice Develops Care Plans that Include Patient Actions to Manage Behavioral Health Conditions.

Action Items:

1.        Select what population you will target for incorporating patient actions to manage behavioral health conditions into care plans. If you are concurrently working on BB6, this may be your high-risk population based on your risk stratification methodology including behavioral health conditions. Otherwise, you may choose to develop care plans for patients that screen positive for behavioral health conditions (BB7).

2.        Educate providers on motivational interviewing and the use of self-management tools (if not already done through BB5).

3.        Develop a protocol and/or a standardized form for care plans that includes either patient goal setting with action steps or identified self-management tools.

 

Practice Attestation Anchor:

Provide examples and evidence of ongoing use of the care plans.

 

Practice Facilitator Attestation Methodology:

 

Confirm practice use of care plans. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

 

Demo Content

Year 2

BB10.Y2.1. Practice Systematically Measures and Tracks Patient Behavioral Health Outcomes.

Action Items:

  1. Implement the plan designed in year 1 (BB10.Y1.2.) by having your designated practice champion pull the appropriate reports at predetermined intervals on your behavioral health outcomes of interest.
  2. Incorporate evaluation of these data into your QI team meetings.
  3. Provide data feedback on these outcomes to providers along with the CQM, cost and utilization data specified in BB2.

 

Practice Attestation Anchor:

Provide data demonstrating systematic tracking of patient behavioral health outcomes for key condition(s) targeted by the practice.

 

Practice Facilitator Attestation Methodology:

Confirm presence of tracking data. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

BB10.Y2.2. Practice Documents and Implements Protocols to Identify and mManage Care for High-Risk Behavioral Health Populations

Action Items:

1.        If not already done in BB6, develop a risk-stratification methodology that incorporates priority behavioral health condition(s). Refer to BB6.Y1.1 (A).

2.        Create a registry or develop an alternative strategy for identifying care gaps. Refer to BB6.Y1.2.

3.        Target patients with identified care gaps with proactive management and outreach. See BB6.Y2.3.

 

Practice Attestation Anchor:

Provide evidence of implementation of care management for conditions chosen as relevant for practice's patient population. Note that this aligns with BB6.Y1.1., BB6.Y1.2., and BB6.Y2.3.

 

 

 

Practice Facilitator Attestation Methodology:

 

Confirm practice implementation of care management for chosen conditions. Attest if in PF opinion the practice has fully accomplished the milestone as described in the anchor statement.

BB10.Y2.3. Practice Identifies and Implements at Least Two Opportunities to Adjust its Protocols to Improve Behavioral Health Status of Patients.

Action Items:

1.        Based on review of CQM, cost, utilization, patient experience, and other behavioral health outcome data in QI meetings, identify two clinic protocols or care processes with room for improvement to better meet goals for your patients with behavioral health needs.

2.        Develop or adjust PDSA cycles (or other QI methodologies used) as necessary to improve these clinic protocols or care processes, including determining at what time interval you will review data to evaluate effectiveness of the change.

 

Practice Attestation Anchor:

Document how protocols have been adjusted to improve behavioral health status through improvement team minutes.

 

Practice Facilitator Attestation Methodology:

 

Confirm practice effort to improve protocols. Attest if in PF opinion the practice has accomplished the milestone in the anchor statement.

BB10.Y2.4. Practice Demonstrates Advanced Access to Behavioral Health Services Including:

Action Items:

1.     Hire a behavioral health clinician, if not already done, to provide behavioral health services integrated into the practice. If available, consider hiring a behavioral health clinician with experience in integrated settings (in CMHCs, hire a primary care clinician if not already done to provide physical health service integrated into the practice).

2.     Develop on-boarding training for the behavioral health clinician as well as training for the primary care clinician to learn how to best work together.

3.     Create standard processes and workflows for how primary care and behavioral health clinicians will interact (e.g., via warm hand-off, co-consultation) and how they will document in the EHR. See BB4.Y1.3. and BB4.Y2.2. for related team-based care strategies.

4.     Implement strategies to promote advanced access to integrated behavioral health services in the practice including:

·       Shared workspace of behavioral health and primary care providers

·       Short behavioral health provider appointment times

·       Blocks of unscheduled time for behavioral health providers to be available for co-consultation and warm hand-offs

 

Practice Attestation Anchor:

Attest to and be prepared to demonstrate full implementation (as described in the SIM Implementation Guide) of either: 1) one or more integrated behavioral clinicians; or 2) another fully developed model for identifying, treating, and monitoring patient behavioral issues that includes a closely coordinated relationship with external behavioral health resources.

 

Practice Facilitator Attestation Methodology:

 

Confirm practice implementation of advanced access to behavioral health services. Attest if, in PF opinion, the practice has fully accomplished the milestone as described in the anchor statement and the Implementation Guide.