Sunset over a Colorado meadow and Mount Wilson in Telluride, Colorado

SIM Overview and Resource Page

The State of Colorado received funding from the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), Center for Medicare and Medicaid Innovation (CMMI) under the State Innovation Model (SIM) initiative to implement and test its State Health Care Innovation Plan over a four-year period, beginning in February 2015 through July 2019. Colorado’s plan, entitled “The Colorado Framework,” was poised to create a system of clinic-based and public health supports to spur innovation.

The Practice Innovation Program was instrumental in helping actualize this plan, working in concert with the SIM office to achieve the goal of improving the health of Coloradans by increasing access to integrated physical and behavioral healthcare services in coordinated systems and encouraging SIM practices to test value-based payment structures.

How SIM Influenced How Care is Delivered in Colorado

Integrating Behavioral Health

Over the course of the SIM initiative, 319 primary care practices and four bi-directional health homes participated, contributing to SIM’s aim to influence the healthcare of 80% of Colorado residents through its efforts.

Readiness for Cross-Sector Partnerships 

These resources were developed as part of the SIM initiative and it is our hope that you can use them for your reference and adapt as needed to fit your needs and that of the practices you support.

This is just sample of the resources and tools used and created for the SIM initiative. If you have any questions please submit a support request to the Practice Innovation Program. 

Foundational Resources

*If you are interested in the current Behavioral Health Training Certificate (IBHT), recognized by the Office of Behavioral Health, please see information under e-Learning modules.

Summary

The State of Colorado will receive up to $65 million over a four year period from the Center for Medicare and Medicaid Innovation (CMMI) to implement and test its State Healthcare Innovation Plan. Colorado’s plan, entitled “The Colorado Framework,” creates a system of clinic-based and public health supports to spur innovation that will improve the health of Coloradans.

The Colorado Framework builds on work already underway in the state, especially the Comprehensive Primary Care Initiative (CPCI). The SIM initiative adopts many high value primary care activities of CPCI like team-based care, care management, and data driven improvement. The Colorado Framework adds several key components. The most prominent include an emphasis on integrated behavioral health services, the inclusion of pediatric practices, and a broader definition of primary care practices to include behavioral health centers. More information about the SIM award can be found at http://www.coloradosim.org/.

This Implementation Guide was developed as a resource for primary care practices and community mental health centers participating in SIM, along with their supporting Practice Transformation Organizations (PTO’s), Practice Facilitators (PF’s), Clinical Health Information Technology Advisors (CHITA’s), and Regional Health Connectors (RHC’s). This guide provides a description of the SIM Cohort 1 Milestones and recommendations on how to meet the objectives described in the milestones. A toolkit of additional materials and resources to help participants educate themselves as they undertake the work of SIM accompanies this Implementation Guide with links referenced throughout.

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Link to Interactive Implementation Guide

The SIM Framework and Milestones are intended to be benchmarks that guide and measure where participating practice sites are in their transformation journeys. They are derived from the Bodenheimer Building Blocks and the Comprehensive Primary Care (CPC) initiative milestones and activities and reflect the priorities of payers that support SIM practices. The milestones have been developed by the SIM office, Multi-Payer Collaborative, and the University to emphasize and support SIM’s focus on advancing behavioral health integration within primary care settings.

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The objective of the BHI modules is to provide comprehensive and practical information about behavioral health integration that can be applied towards healthcare practices. The modules are designed to be interesting, engaging and to enhance the learners' ability to understand and maximize BHI into healthcare practices. There are a variety of modules, some created specifically for SIM and we encourage you to check out the ones that fit your interest.

Link to e-Learning Modules 

Directions
Once you click on the link to the e-Learning modules, please follow these instructions for registration:

  • Click on the Register link
  • A registration pop-up box will appear. Please enter your email address and set up your password. For registration code, please enter: SIM
  • You will then be redirected to “My Account” page where you can access the SIM e-Learning modules

***For the Integrated Behavioral Health Training Certificate

The Integrated Behavioral Health Training (IBHT) certificate provides behavioral health professionals, academic programs, and stakeholders with an eLearning opportunity to explore the 8 core competencies for integration into primary care. Completion of the certificate program is recognized by the Office of Behavioral Health. Additionally, IBHT learners will have access to the other State Innovation Model (SIM) e-Learning modules. To register for the IBHT Certificate:

  • Website: http://cuelearning.org
  • Click on the Register link
  • A registration pop-up box will appear. Please enter your email address and set up your password. For registration code, please enter: IBHT
  • You will then be redirected to “My Account” page where you can access the IBHT e-Learning modules

The SIM Office will be posting the below reports on their website.

  • SIM Final Report - Coming fall 2019
  • ROI Report - Coming fall 2019
  • Final Evaluation Report (Outcome / Process)

Measures & Reporting

In April 2013 the SAMHSA-HRSA Center for Integrated Health Solutions released A Standard Framework for Levels of Integrated Healthcare authored by Bern Heath, Pam Wise Romero and Kathy Reynolds. This issue brief expanded, updated and re-conceptualized the initial work of Doherty, McDaniel, and Baird (1996) to produce a national standard with six levels of collaboration/integration that run from Minimal Collaboration to Full Collaboration in a Transformed/ Merged Integrated Practice. In presenting this framework, the authors developed three tables. The first table provides Core Descriptions of each level, the second table introduces the Key Differentiators for each level (categorized as Clinical Delivery, Patient Experience, Practice/Organization and Business Model), and the third table discusses the Advantages and Weaknesses of each level. Despite the degree of detail provided in these tables, the subjective placement of practices on the continuum of the six levels has been inconsistent between practices and has fallen short of establishing an objective and reliable categorization of practices by level.

Description of the Instrument

The authors of the IPAT have devised this tool to place practices on the level of collaboration/integration defined by the issue brief. The IPAT uses a decision tree model rather than a metric model. This more accurately mirrors the issue brief tables, avoids the challenge of weighting responses to questions and ending up with other than placement in a discrete level (e.g., a 3.75 colocation). The decision tree model uses a series of yes/no questions that cascade to a level determination.

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The below link contains a copy of the Comprehensive Primary Care Practice Monitor – Mental Health Version that is a part of the practice assessments.

Please consider how fully each item has been implemented or functions in the portion of your Mental Health Center that provides integrated primary care services (referred to here as the “practice”). Fill in the circle that best reflects the completeness of implementation in your practice. If you rate something as a 4, it means it is now routine across the entire practice. A rating of 1, 2, or 3 means that the statement is only done sometimes, or only in part, or not by everyone in the practice.

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The below link contains a copy of the Medical Home Practice Monitor that is part of the practice assessments.

Comprehensive Primary Care Practice Monitor

“Building Blocks” Version – 12-8-15

Please consider how fully each item has been implemented or functions in your practice. Fill in the circle that best reflects the completeness of implementation in your practice. If you rate something as a 4, it means it is now routine across the entire practice. A rating of 1, 2, or 3 means that the statement is only done sometimes, or only in part, or not by everyone in the practice.

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The below link contains a copy of the Clinician and Staff Experience Survey that practice members are expected to complete as part of their assessments.

For each of the following questions, please indicate your level of agreement or disagreement with each statement as it applies to you and your colleagues in your work in your practice. Your responses are confidential, and the results of the survey will be reported back to the practice only in a summary form that will not identify you or your responses (or not at all if it would be easy to identify you). For each item below, 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree.

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This Milestone Attestation Checklist has been developed to guide practices and Practice Facilitators in attesting to practice progress with the milestones for both “Good Standing” status and qualification for SIM achievement-based payments.

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SIM milestones are organized by building blocks (1-10), activities (A-D) and steps (1-3). SIM does not require that practices achieve all the milestones activities and steps by a certain time. Practices will work through the milestones at their own pace, choosing which milestones to focus on based on their local priorities and resources.

At baseline and every 6 months practices will complete the SIM Milestone Activity Inventory to document the current status of milestone implementation and track progress over time Answers will translate to a report indicating red (have not started), yellow (in progress), green (process established) ratings for each milestone to help practices identify strengths and focus future priorities. In items where answers are binomial, for example just yes or no as optional answers, there may only be categories of red and green. Some items included in the inventory will not receive a red, yellow, green score, but provide context for using the inventory to support practice transformation and the SIM milestones.

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The HIT Assessment is intended to assist Clinical Health Information Technology Advisors (CHITAs) and practice sites in the identification of health information technology (HIT) barriers or opportunities, and prioritization of quality improvement work to be completed in SIM. In completing the assessment the following is accomplished:

  • Evaluation of practice site data elements captured and clinical quality measure (CQM) reporting capabilities (focusing on the data elements, CQM reports, and HIT tools that align with SIM goals of integration of advanced primary care activities, behavioral health services, and payment reform).
  • Understanding for the CHITA of the practice site dynamics around using data to improve patient care.
  • Enhancement of practice site knowledge and confidence in data driven improvement, use, and submission.
  • Identification of practice site barriers with HIT (specifically related to alternative payment models).

The HIT Assessment additionally addresses health information exchanges (HIEs), utilization of telehealth services, and broadband connectivity and access. The assessment in broken out into the four sections:
1) Data Elements
2) Clinical Quality Measures
3) EHR System & HIE Features
4) Telehealth Utilization & HIT Needs/Barriers

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Field Notes should be completed by Practice Facilitators (PF) and Clinical Health Information Technology Advisors (CHITA) on a monthly basis. Any substantive contact with a practice site regarding practice transformation work should be documented in the monthly field note. The SIM Monthly Field Note (FN) is divided into four sections: 1) General Information & Monthly Encounters 2) Milestone Activity Statuses 3) Clinical Quality Measures & Health Information Technology Resources (CHITA Only Section) 4) Additional Field Note Documentation.

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The Colorado State Innovation Model (SIM) Clinical Quality Measures Guidebook offers SIM participants the information needed for taking the first steps toward integrative healthcare and practice transformation. To be successful in understanding and implementing the Colorado SIM measures, this guidebook offers the measure specifications approved for Colorado SIM practice sites, flowcharts establishing each measure’s numerator and denominator, as well as additional clinical resourcing and supplemental information for embedding new measures into a practice workflow.

We encourage use of this document by both SIM practices and Practice Transformation Organizations (PTOs). The intent is to use the information available to plan accordingly for each practice’s data quality needs, as identified in their Data Quality Assessment and Practice Improvement Plans. The Clinical Health Information Technology Advisors (CHITAs) and Practice Facilitators can each benefit from the information provided, in order to support practices to meet their defined SIM SMART goals. CHITAs will likely use the specification and flowcharts to support new measure build or existing measure optimization, in order to generate accurate reports per SIM data submission requirements. Practice Facilitators can make use of additional resourcing to assist practices and care teams in realizing new measures within their practice workflow. Through this tandem approach, the SIM CQM Guidebook is of use across PTOs to support SIM practices with successful implementation.

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Business Support

Introduction
This beginning chapter will provide an introduction to forming relationships and working on contracts with your commercial payers. We will cover the basics of what payer contracting is, an overview of the local Colorado insurance market, and touch on how and why your data is such an important piece in this process.

Key Takeaways
I. Understand commercial payer contracting basics
II. Learn more about the local Colorado insurance market
III. Understand the role data plays in contracting

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Introduction
In this chapter we will review the three most common reimbursement models utilized by payers (Fee for Service, Per Member Per Month, and Value Based) and also analyze the risk that is associated with your contracts. This chapter will cover the nuances of each reimbursement model along with the best ways to use your practice information to effectively analyze risk and negotiate your commercial contracts.

Key Takeaways
I. Know the various reimbursement models and the specific elements
II. Understand the data elements that are important to each model
III. Understand the risk in your contracts and how to capture it

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Introduction
This section will cover some Managed Care Contracting Strategies, which will help you structure your thoughts and bring your information to the payers. It is imperative to put a plan together before you approach the Health Plans in order to have an effective conversation.

Key Takeaways
I. Understand how to strategize for successful contract negotiations
II. Know your data sources and how to compile the information
III. Understand how to use your data to prepare yourself for negotiations

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Introduction
This chapter will teach you how to build lasting relationships with your payers by presenting your information in a way that will help effectively negotiate your contracts.
This includes impactful communication techniques and knowing who to contact with
questions or concerns.

Key Takeaways
I. Know the proper channels of communication for contract negotiations
II. Understand how/why it is important to build lasting payer relationships
III. Understand how to use your data to tell your story

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Objectives:

  • Define the current major payment models in the United
    States
  • Understand the strengths and limitations of different
    payment models for primary care and integrated
    behavioral health
  • Describe the evidence for different payment models

View Slides

LF Feb 21 2019 from UC Denver | Family Medicine on Vimeo.

Some of the Topics Discussed

Benefits of Coding
Medical Coding
What is Current Procedural Terminology (CPT)?
Category I, II and III Codes
Composite Measures Category II Codes
CPT Advisory Committee
What is RBRVU, RCU, IDC, HCPS?
E/M Codes
Medical Coding Compliance

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Objectives

  • Define value proposition
  • Who is my customer?
  • How to develop a practice value proposition
  • Examples of value propositions
  • Share your story
    View Slides

LF Mar 21 2019 from UC Denver | Family Medicine on Vimeo.

Objectives of this presentation:

  • Understand the opportunities for FFS billing in CO including 6 Medicaid BH visits annually
  • List the key therapy codes suited for short term care in the primary care setting
  • Recognize the key components of documentation compliance
  • Comprehend the value opportunities in demonstrating outcomes based on effective care

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*These resources were created as part of the SIM initiative that ran from February 2015 – July 2019. The information on this page and the associated documents have not been updated since the conclusion of the initiative.

SIM Highlights

  • Over 85% of practices in all three SIM Cohorts indicated that participating in the SIM Initiative had assisted the practice site in its work to improve integration of behavioral and physical health.
  • Over the course of the initiative, 14 Collaborative Learning Sessions (CLS) were held across the state with over 3000 clinicians, practice staff, behavioral health providers, and other stakeholders in attendance.
  • Approximately 38,000 individual surveys, comprised of SIM assessments, Practice Rosters, clinical quality measure, and field note submissions were administered through SPLIT across SIM cohorts.

Cohort 2 & 3

  • Over 50% (53.51%) of practice sites participating in SIM indicated the practice changed its budgeting or business practices in preparation for alternative payment models as a result of the SIM initiative.
  • Approximately 33% of practice sites participating in SIM had an increase in the percentage of practice site revenue from sources other than fee-for-service because of participation in SIM.

SIM Partners

The work SIM accomplished would have never been possible without the organizations below. Check out their websites for additional resources.