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September 7, 2016 Maine SIM Evaluation Subcommittee September 2016
Today’s Agenda Welcome and Introductions Review & Approve the August 3 rd Meeting Minutes JSI NDPP and CHW Evaluation Update on Steering Committee & MPOC activities Status Update: Provider, Stakeholder, and Consumer Interviews Public Dashboard Updates and Trends Special Studies Update and Next Steps Time for Public Comment Next Steps lewin. com | 1
Today’s Agenda Welcome and Introductions Review & Approve the August 3 rd Meeting Minutes JSI NDPP and CHW Evaluation Update on Steering Committee & MPOC activities Status Update: Provider, Stakeholder, and Consumer Interviews Public Dashboard Updates and Trends Special Studies Update and Next Steps Time for Public Comment Next Steps lewin. com | 2
Meeting Minutes Please see meeting minute handouts for August third • Suggested edits from Committee members? • Additional questions or clarifications? • Motion to approve as written or amended lewin. com | 3
Today’s Agenda Welcome and Introductions Review & Approve the August 3 rd Meeting Minutes JSI NDPP and CHW Evaluation Update on Steering Committee & MPOC activities Status Update: Provider, Stakeholder, and Consumer Interviews Public Dashboard Updates and Trends Special Studies Update and Next Steps Time for Public Comment Next Steps lewin. com | 4
+ Maine SIM Evaluation John Snow Inc. Community Health Worker Initiative National Diabetes Prevention Program September 7, 2016
+ Agenda n National DPP Evaluation n Community Health Worker Initiative Evaluation n n CHW Capacity Building Evaluation CHW Pilot Evaluation
+SIM Population Health Initiatives CHW Evaluation NDPP Evaluation Data to help develop and improve: A strong workforce Sustainable payment models Better access to patient education and wellness Population health
+ Development of the Evaluation Plan n Worked with stakeholders to develop evaluation plan n n Interim findings meeting January 2016 n n 2 planning meetings in Spring/summer 2015 Results sharing in June 2016 Participants included CHWs, consumers, and lifestyle coaches
+ NDPP Evaluation
+ Maine National DPP SIM Evaluation National DPP is a unique component of the ME SIM project National DPP SIM Evaluation aimed to document and understand the project steps, tasks, barriers, solutions, and successes to increase the likelihood of expanding and sustaining National DPP throughout ME TIMELINE Oct 2013 NDPP Project Period Starts May 2015 Input from SIM Stakeholder Group Spring 2013 Jan 2015 ME Awarded SIM Grant JSI awarded to conduct evaluation July 2015 Sept 2016 Database development began Data collection ends June 2015 Evaluation plan finalized Sept 2015 Data collection began
+ Multi-Level Evaluation Question 1: What system, practice, and beneficiary level factors are associated with a sustainable National DPP program? § § Payer/organizational interviews Provider site survey Database Lifestyle Coach Survey Question 2: What was the reach of National DPP? § § Payer/organizational interviews Provider site survey Participant survey Database State Organizational Interpersonal Individual
+ Interviews: The story of National DPP in Maine n Building the workforce n Developing sustainable payment models n n n Working with private and public payers Engaging the employer community Educating community partners, health systems, and the public n Developing referral mechanisms n Re-Think Diabetes. org
+ Organizations offering National DPP 21 • • • • organizations in Maine have initiated the National DPP – many have multiple sites Blue Hill Memorial Hospital (1) Cary Medical Center (1) Central Maine Healthcare (15) Community Health & Counseling Services (1) Eastport Health Care (1) Everyday Nutrition Associates (2) Healthy Acadia (1) Houlton Regional Hospital (1) LL Bean (1) Maine Coast Memorial Hospital (1) Maine General Medical Center (27) Mid Coast Hospital (2) Millinocket Regional Hospital (1) Mount Desert Island Hospital (1) Northern Maine Medical Center (1) • Pen. Bay Medical Centers Diabetes & Nutrition Care Center (2) • St. Joseph’s Diabetes and Nutrition Center (1) • St. Mary’s Regional Medical Center – Center for Diabetes and Endocrinology (1) • Stephen’s Memorial Hospital (1) • Take Control to Prevent Diabetes/A Division of Everyday Nutrition Associates (1) • Waldo County General Hospital (1)
+ Workforce: Lifestyle Coaches 122 Lifestyle coaches in Maine (Goal = 80) What training or experience is needed to be successful? • Organizational skills • Ability to listen, empathize, and be open-minded • Project Management • Facilitation skills • Interest in teaching adults 100% of lifestyle coaches had been a lifestyle coach for five years or less, with the majority (63%) stating less than a year.
+ Employer and Health Plan Engagement and Payment Plan Testing n EMPLOYERS n BIW n LL Bean n Health care orgs such as: Maine General, Maine Health, St Joseph, Penbay Health Care n HEALTH PLANS n State of Maine Employee Health Plan n Maine. Care n Community Health Options n Harvard Pilgrim Health Care n Aetna
+ Barriers and Facilitators Barriers n Patient level n Referrals n Weather/travel n Employers n Orientation to wellness n Infrastructure to support program n Level of awareness/ education on program benefits Facilitators n Patient level n Employer incentives (paid time, participation bonus) n Strong relationship with coach n Referral from provider/health plan n Family engagement with program n Employers n Existing wellness program n Size/# of employees n Self-insured 09/30/2013
+ Question 2: What was the reach of NDPP? n 801 people participated between September 2012 -June 2016 n Education of respondents n 80% had some level of college n 46% had attended 4 or more years n Of the 24 sessions, participants attended an average of 10. Maine DPP programs usually have 22 -24 sessions with some offering as many as 31 sessions. 09/30/2013
+ Participant Satisfaction and health outcomes n Participants lost an average of 6 pounds and engaged in an average of 160 minutes of exercise per week. n Overall, participants were satisfied with the program as measured by their strong agreement with: n n Paid for some other way (52%) n Paid for by health insurance (25%) n Paid for by employer (16%) n Information was important to know (59%) n The majority of participants did not pay for the program Information was easy to understand (71%) Information was useful in daily life (61%) Participants reported they were very likely to recommend the program to the following people: n Friends (83%) n Family (79%) n Co-workers (69%)
+ Recommendations n Encourage peer-to-peer networking and information sharing among lifestyle coaches. n Facilitate opportunities for smaller employers to provide NDPP to employees similar to what has been achieved by larger employers. n Continue exploring multiple funding streams. n Recognize changing payment models. n Further promote benefits of National DPP to self-insured employers. n Ensure the collection and use of data. n Enhance access to the most vulnerable populations. n Systematize the wage for lifestyle coaches.
CHWI Capacity + Building and Pilots Evaluations
Evaluation Activities Implementation n Monitoring & Reporting Tools n Reviewing Quarterly Reports-ongoing n Feedback to grantees to validate data and summarize n Conducted Site Visits and interviews Capacity Building n Joined Monthly TA Calls n Literature Review - focused on cost-effectiveness n Ensure consistent and high-quality data n TA in response to process and findings
+ Evaluation of Capacity Building for Community Health Worker Workforce Development The Maine CHW Initiative Launched in the summer of 2013 in order to: “develop and support an emerging workforce in Maine that allows team members to practice at the height of their license, to address unmet needs in communities with a workforce model that addresses social determinants and community engagement. ”
+ Evaluation Questions Question 1: What progress has been made towards central elements under the Affordable Care Act ? -training -registration and credentialing -process for qualifying CHWs -establishment of reimbursement methodology Question 2: Was effective CHW training guidance developed? Question 3: How have stakeholders managed to advance spread and increase infrastructure to support workforce and sustainable payment mechanisms?
+ What progress has been made towards the central elements under the Affordable Care Act (ACA)? • The CHW Stakeholder Group has developed draft guidance. • A recent 2015 statute to incorporate CHWs within an expanded Maine Registry of Certified Nurse Assistants and Direct Care Service Workers by a target date of 2017. • Advanced recommendations for a process to formally recognize CHWs -continuing • Needed: Clear payer or regulatory requirements to establish credentialing The Community Health Worker (CHW) Core Consensus (C 3) Project advice: proceed with care so as not to “supplant or pre-empt local working knowledge about how CHWs best serve their communities. ”
+ n Was effective CHW and CHW Supervisor training guidance developed? Maine CHW Stakeholder workgroup developed: n CHW Definition n Core Roles and Responsibilities n Core Competencies n Code of Ethics n Draft Standard Qualifications for CHWs n Trainings held for CHWs and their supervisors n In-State capacity to develop standardized training requirements and programs.
+ How have stakeholders managed to advance spread and increase infrastructure to support workforce and sustainable payment mechanisms • CHWI is well-prepared to develop a sustainability recommendation, including a rationale and mechanism for payment/reimbursement for CHW services by the end of the SIM funding period in the fall of 2016. • Important models have been developed, partnerships enhanced, and opportunities explored for mechanisms that can result in payment for CHW services. • Promising models exist to advance the Triple Aim • No single CHW intervention model can meet the needs of all populations and service models.
+ Recommendations n Consider increasing the capacity within the state to offer CHW trainings provided by Maine training entities. n Make supplemental trainings available for CHWs to enhance job readiness and to hone skills over time. n Continue partnerships with the Department of Labor to flesh out how their programs could respectively support CHWs and their employers. n Develop outreach materials (flyer, videos) that explain the role and benefits of CHWs. n Work more extensively to enhance payment/coverage models. n Mobilize providers within the healthcare system and other potential champions. n Continue the Maine CHW Stakeholder group to build on partnerships that advance CHW infrastructure and disseminate effective Maine models.
+ Evaluation of Four CHW Pilots Priority Evaluation Questions: n Question 1: To what extent are model components implemented consistently and with fidelity? n Question 2: What factors are associated with patient engagement and satisfaction in CHW services? n Question 3: What resources are needed (both for local CHW programs and for statewide adoption/promotion of the model) to ensure consistent and effective implementation?
Identified Key Factors in CHW Services © John Snow, Inc.
Question 1: To what extent are model components implemented consistently and with fidelity? n Emphasis on client advocacy n Important to develop local workflows based on evidenced based protocols n Careful consideration of eligibility criteria n Onsite training supplements standard CHW training
+ Question 2: What factors are associated with patient engagement and satisfaction in CHW services? n Brainstorming in teams on how to increase engagement n Connection and communication with provider teams n Flexibility to provide direct assistance and facilitating provider communication n Examples included: n a CHW identified a solution to help reduce a client’s cable bill, so savings could be used to buy new glasses; n CHWs accompanied patients to colonoscopy appointments to provide support and facilitate communication with the provider 09/30/2013
Outcome Measures Vary by site – largely self-selected by each site. Examples: n Linkage to Medical Home/PCP n Referrals n Client Self-Sufficiency n ED Visits n Client Satisfaction n Medications
Sample Reporting Matrix
+ 4 CHW Pilot Sites – Focus Areas + Target Populations n CHW model: clinical care integration and/or communitybased n# of CHWs: 5. 5 total FTEs funded, about 1 -2 per site n. A range of topic areas and client populations: Cancer screening; PCP linkage; referrals; medication review; chronic disease management Hard to reach; not connected to care or high utilizers (ED visits); poorly managed chronic conditions; transportation, language/cultural barriers
+ 4 Pilot Sites – Clients Enrolled & Discharged by end of Quarter 6 report Number of FTE CHWs Total Enrolled* Spectrum/SP Maine. General DFDR Portland All Pilots Combined 1 1. 5 1 2 105 825 562 234 100 per year 45 -70 overall 70 per year 5. 5 1726 80 820 401 162 76% 99% 71% 69% Estimated Target 70 -90 per year Enrollment Total Discharged % of all CHW clients, discharged by Q 6 1463 85%
+ Clients Reached by the Initiative n Sites that focused on preventative screenings clients overall (825 MG, 562 DFDR). enrolled MORE n Sites that focused on chronic disease management enrolled fewer clients (234 PPH, 105 SG/SP).
+ CHW Client Encounters n Sites that enrolled MORE clients had a smaller percentage of intensive clients and face-to-face encounters. n Sites that enrolled fewer clients had a LARGER percentage of intensive clients and face-to-face encounters.
+ Diversity of programs “ Being located within a practice you have a caseload and they [clients] don’t have to find you. In the community it may be harder to link to the physician… A community navigator can help them find transportation resources. Both have great value. Dictated by what that practice or agency want. ” -CHW interviewed 09/30/2013
+ CHW Impact – Select Highlights across the 4 Sites n 87 clients without a PCP were connected to a PCP n 808 clients provided with a medication review n 509 overdue for screening received breast cancer education n n 1084 overdue for screening received colon cancer screening education n n 109 screened 220 screened 98 clients assisted with asthma management Of 86 clients who completed a satisfaction survey, n 94% were satisfied
+ Select Findings from Pilot Sites Referrals successfully connected among SG/SP clients Medication issues identified and reconciled among SG/SP clients
+ Select Findings from Pilot Sites Reduced ED utilization among Portland clients Improved breast cancer screening rates among DFDR patients
+ Select Findings from Pilot Sites Improved colon cancer screening rates among Maine. General patients Arsenault PR, John LS, OʼBrien LM. The Use of the Whole Primary-Care Team, Including Community Health Workers, to Achieve Success in Increasing Colon Cancer Screening Rate. J Healthc Qual. 2016 Mar. Apr; 38(2): 76 -83
+ Recommendations n Continue technical assistance and resources for CHW initiatives until means of sustainability takes root. n Ensure CHWs are included in decision-making throughout interventions. n Centralize availability of protocols that are evidence-based or reflect promising practices. n Enhance trainings with continuing education. n Strengthen pilots serving immigrants and refugee communities. n Support interventions to explore additional models focused on rural communities. n Ensure community-wide outreach in addition to individual client services. n Develop model systems and tools that can support communication. n Identify systems and tools for monitoring and evaluation.
+ Questions & Discussion
Today’s Agenda Welcome and Introductions Review & Approve the August 3 rd Meeting Minutes JSI NDPP and CHW Evaluation Update on Steering Committee & MPOC activities Status Update: Provider, Stakeholder, and Consumer Interviews Public Dashboard Updates and Trends Special Studies Update and Next Steps Time for Public Comment Next Steps lewin. com | 46
Update on Steering Committee & Medicare Proposal Oversight Committee (MPOC) activities • Gloria Aponte-Clarke, Maine SIM Program Director lewin. com | 47
Today’s Agenda Welcome and Introductions Review & Approve the August 3 rd Meeting Minutes JSI NDPP and CHW Evaluation Update on Steering Committee & MPOC activities Status Update: Provider, Stakeholder, and Consumer Interviews Public Dashboard Updates and Trends Special Studies Update and Next Steps Time for Public Comment Next Steps lewin. com | 48
Consumer Survey 2016 (Recap of key concepts) • The 2016 survey adds questions to guide quality improvement – 2015 questions revised to provide more detail on the reasons for responses – Follow–up questions are open-ended, expressed in the consumer’s own words. Responses will be the “voice of the consumer” – New questions address topics suggested by stakeholders- i. e. consumer engagement in their own care and practice feedback, affordability of care impacting care choices • 1500 total targeted completed interviews (500 each from Maine. Care AC, Stage A Health Home and Behavioral Health Home) • Next Steps – Early findings scheduled to be presented at October Evaluation Committee meeting lewin. com | 49
SIM Self-Evaluation: Consumer interview /survey update Interview Totals as of September 6, 2016 AC - Child AC - Adult HH - Child HH - Adult BHH - Child BHH - Adult Total 1738 1541 855 2172 114 925 7345 No Phone Number 175 110 74 181 23 81 644 Invalid Phone Number 501 524 205 531 23 286 2070 Refusals 62 35 28 73 3 45 246 Completes 264 161 136 318 28 216 1123 Total Final Disposition 1032 861 456 1136 78 687 4250 706 680 620 1527 36 238 3095 4022 2694 1604 3375 245 2046 13986 Sample Records Remaining Sample Outreach Attempts lewin. com | 50
Provider Research 2016 (Recap of key concepts) • Tailored questions for ü Behavioral Health Homes ü Maine. Care Stage A Health Homes ü Maine. Care Accountable Communities • Use of online surveys & phone interviews • Includes questions on diabetes management and anti-psychotic medication use • Next Steps – Early findings scheduled to be presented at October Evaluation Committee meeting lewin. com | 51
SIM Self-Evaluation: Provider interview update Maine SIM Provider Interviews Final Totals Provider interviews BHH and HH Invites: Total Complete: AC Invites: AC Complete: 293 107 4 4 lewin. com | 52
2016 Stakeholder Focus Group Update • Focus group discussions related to SIM governance structure, communication, identification of best practices for governance structure for future Maine reform efforts • Focus Group representation – Participants engaged • Group 1 - 8 Representatives from Steering Committee • Group 2 - 7 Representatives from all Sub-committees • Meeting Logistics /Next steps – – Sessions completed late July/ early August Curt Mildner from Market Decisions served as moderator No DHHS representatives present during sessions Initial summary of themes/recommendations will be shared in October lewin. com | 53
Today’s Agenda Welcome and Introductions Review & Approve the August 3 rd Meeting Minutes JSI NDPP and CHW Evaluation Update on Steering Committee & MPOC activities Status Update: Provider, Stakeholder, and Consumer Interviews Public Dashboard Updates and Trends Special Studies Update and Next Steps Time for Public Comment Next Steps lewin. com | 54
Public Dashboard Updates and Trends Direct view of SIM Public Dashboard & discussion of trends. Tanya Disney, Lewin lewin. com | 55
Today’s Agenda Welcome and Introductions Review & Approve the August 3 rd Meeting Minutes JSI NDPP and CHW Evaluation Update on Steering Committee & MPOC activities Status Update: Provider, Stakeholder, and Consumer Interviews Public Dashboard Updates and Trends Special Studies Update and Next Steps Time for Public Comment Next Steps lewin. com | 56
2016 “Special Studies” – Study One • Special Study One seeks to further understand characteristics of patients and health homes that contribute to highest patient outcomes • The following 3 slides provide some early data of patient “clusters” and the related methodology to develop the groupings lewin. com | 57
Category of Service Per Member Per Month Payments PMPM and Claim Count by Category of Service for 2015 Intervention Members Member Months PMPM Outpatient PMPM HCBS PMPM Inpatient PMPM ED PMPM Pharmacy PMPM Accountable Communities only 25, 371 292, 596 $951. 58 $64. 50 $199. 49 $60. 87 $14. 45 $85. 18 Health Home Stage B 2, 140 21, 254 $1, 644. 55 $104. 58 $48. 27 $141. 28 $28. 08 $209. 78 Health Home Stage A and Accountable Community 13, 153 143, 912 $598. 94 $79. 20 $16. 64 $91. 31 $12. 95 $120. 92 Health Home Stage A only 40, 142 429, 147 $519. 19 $59. 70 $26. 80 $72. 12 $12. 33 $122. 99 • Even though the AC only population has a PMPM that is almost half of the PMPM for BHH members, its HCBS PMPM is more than four times the HCBS PMPM for BHH members • Upon further analysis, close to 75% of the HCBS PMPM is made up from the T 2016 procedure code, Habilitation, Residential, Waiver lewin. com | 58
Age Breakdown Age Distribution (in Years) for 2015 Intervention Members Minimum Age Lower Quartile Median Age Upper Quartile Age Maximum Age Mean Age Accountable Communities only 25, 371 0 7 15 36 105 23. 28 Health Home Stage B 2, 140 1 29 45 56 92 41. 70 Health Home Stage A and Accountable Community 13, 153 0 16 33 50 104 34. 40 Health Home Stage A only 40, 142 0 18 36 54 106 37. 62 • The AC only population has younger members, where 50% of its members are 15 or under • The BHH population has older members, where 50% of its members are 45 or older lewin. com | 59
Disease Prevalence Distribution Risk Distribution for 2015 Intervention Accountable Communities only Health Home Stage B Health Home Stage A and Accountable Community Health Home Stage A only • • Average Percent with Number of Percent with 3+ Chronic PTSD Conditions Members Average Risk Mental Health Substance Abuse SPMI Diabetes 25, 371 2. 16 17. 31% 15. 98% 15. 19% 7. 51% 2. 28 20. 34% 11. 76% 2, 140 5. 45 37. 01% 35. 69% 43. 64% 22. 32% 4. 83 62. 15% 38. 36% 13, 153 2. 69 19. 51% 22. 95% 14. 03% 12. 62% 2. 97 31. 38% 8. 69% 40, 142 2. 76 20. 14% 22. 49% 12. 61% 14. 62% 3. 11 34. 44% 6. 01% BHH population has an average ERG retrospective risk score almost double the second highest score of HHA only The average number of chronic conditions is also much higher for BHH The percent of members with three or more chronic conditions is high for all interventions, particularly BHH The percent of members with PTSD is close to 40% for BHH members. This percent is also slightly higher for the AC only population compared to HHA only or HHA and AC. lewin. com | 60
Statistical Clustering Methodology • For each study population, – Rescale input variables • Behavioral Health, Substance Abuse, Mental Health, Severe and Persistent Mental Illness, PTSD, Diabetes, Age, Gender, Medicaid Eligibility Blind/Disabled or Aged, Urban, Physical Health Conditions, Number of Chronic Conditions, PMPM Costs by Category of Service – Run cluster analysis and determine optimal number of clusters using r-square and CCC criterion – Summarize frequency of input variables by cluster lewin. com | 61
2016 “Special Studies” – Study Two “Special Study” Two seeks to: – Surface best practices that are associated with improved physical health and fragmented care outcomes; – Identify best practices associated with behavioral and physical health integration; – Identify best practices of BHHs that impact care and outcomes for patients with diabetes. • Recruitment: • Representatives from 7 “high performing” BHHs as evidenced by diabetes care & screening outcomes • Timeline & Method: Goal to conduct telephone interviews no later than mid-September with initial findings reported in October lewin. com | 62
Today’s Agenda Welcome and Introductions Review & Approve the August 3 rd Meeting Minutes JSI NDPP and CHW Evaluation Update on Steering Committee & MPOC activities Status Update: Provider, Stakeholder, and Consumer Interviews Public Dashboard Updates and Trends Special Studies Update and Next Steps Time for Public Comment Next Steps lewin. com | 63
Next Steps • Next Meeting – October 5, 2016, 2 -4 pm Pine Tree Room 2 Anthony Avenue, Augusta • Future Discussion Topics – – Provider, Stakeholder, & Consumer interview preliminary findings Presentation of additional Special Studies findings Early drafts of Final Evaluation SIM Evaluation Report Future role of the Evaluation Committee lewin. com | 64