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Accountable Care Organizations

What is an ACO?

Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers who organized voluntarily to be jointly responsible for managing the quality and cost of a targeted Medicare patient population. ACOs are focused on the provision of coordinated, high quality care to their Medicare patients—especially those who are chronically ill, elderly, and disabled—who are in not enrolled in a Medicare Advantage program. Patients may opt to enroll in an ACO (voluntary) and also have the ability to opt out at any time, for any reason. ACOs are part of the Affordable Care Act legislation under the framework of the Medicare Shared Savings Programs.

Consumers might be attracted to participating with an ACO for several reasons. They may be recruited by their primary care provider who is affiliated with the ACO (ACO providers are required to notify their patients of their ACO status). Consumers may decline ACO enrollment. They may be referred by the hospital staff where they receive frequent services. Consumers are usually free to see doctors of their choice outside the network without paying more. Consumers seeking a more person-centered approach to health care delivery may find that the holistic approach to care offered by the ACO is an attractive alternative to the lack of coordinated care in a fee-for-service model.

The goal of coordinated care is to ensure that patients, receive the “right care at the right time and in the right place.” This frequently means providing treatment in community settings when possible, instead of institutions, like hospitals or skilled nursing facilities. ACOs are on a mission to avoid unnecessary duplication of services and to reduce or prevent medical errors. While ACO providers are often paid fee-for-service rates, they are being paid based on a pre-determined budget for total cost of health care, which leads to an incentive for cost effective and evidence-based care. This includes all covered Medicare Part A & B services, such as: physician services, hospital admissions, diagnostic testing, outpatient procedures, and medical equipment. ACOs are structured to create an incentive to be more efficient by offering bonuses when providers keep costs down. They must carefully manage consumers with chronic conditions, focusing on prevention, to impact utilization of services and reduce overall costs of care. Additionally, providers and hospitals that participate in an ACO must meet specific quality benchmarks, focusing on prevention and carefully managing patients with chronic diseases. The primary emphasis for care management practices in ACOs is patient-centered care, keeping consumers healthy and out of the hospital.

If an ACO is unable to reduce the cost of care, there are no savings to share. This could adversely affect their operating budget, such as costs of investments made to improve care, e.g., adding staff/resources. An ACO also may have to pay a penalty if it doesn’t meet quality and cost savings benchmarks. (Learn more about the Shared Savings and Losses and Assignment Methodology.)

ACOs that are successful in delivering both high-quality care and reducing health care costs can share in the savings accrued by the Medicare program. By meeting the tenets of their ACO agreements with the Centers for Medicare and Medicaid Services (CMS)—and reducing health care costs through reductions in costly institutional care through more preventative engagement with consumers—ACOs can reap significant savings and maximize their Medicare incentives. While ACOs must be organized according to rules established by CMS, several ACO program models can be used.

Use the following links to learn more about the three most prominent models:

Accountable Health Care Communities Model

In addition to ACOs, CMS introduced the Accountable Health Communities Model.  Though there are just over 30 of these unique organizations nationwide, they address an emerging aspect of integrated care—social determinants of health (SDOH). SDOH include unmet social needs such as food insecurity and inadequate or unstable housing, which potentially:

  • Increase the risk of developing chronic conditions;
  • Reduce consumers’ ability to manage these conditions; and
  • Lead to avoidable health care utilization and an increase in health care costs.

This model emphasizes engagement of both clinical and SDOH services as part of the person-centered planning care management model.  By identifying and addressing the SDOH needs of targeted consumers, this innovative approach can reduce health care utilization and positively impact health care costs.

This model will promote clinical-community collaboration through:

  • Screening of community-based consumers to identify key unmet SDOH needs;
  • Provision of referrals and navigation support for community-based consumers to increase awareness of and access to community services; and
  • Encouragement of alignment between clinical and community-based organizations to ensure that community services are available and responsive to the needs of targeted community-based consumers.

It is important to note that while the ACO construct is based on CMS rules and regulations, CMS allows flexibility so that each community ACO may differ in structure, payment models, and other characteristics. The Medicare provisions for ACO certification provides for adequate flexibility in the design of the ACO structure—allowing them to create programs and services that meet the unique needs of their communities and consumers. Some of these ACO models offer incentives for efficient high quality care and are not penalized for exceeding their budget or care. If an ACO can come in under budget while still meeting quality metrics, they may receive a bonus payment from Medicare.

Shared savings ACO quality measures are segregated into four key domains and include over 30 metrics.  These domains serve as the basis for assessing, benchmarking, rewarding, and improving ACO quality performance.  Each of the 4 domains are equally weighted and account for 25 percent of an ACO’s quality score.

The four domains include:

  1. Patient/caregiver experience
  2. Care coordination/patient safety
  3. Preventative health
  4. At-risk populations

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Why Partner with an ACO?

Older adults are the predominant population of Medicare beneficiaries. They are also among the nation’s most vulnerable and costly populations affected by chronic disease.  As such, many ACOs are seeking opportunities to provide prevention and wellness services to improve the management of their patients’ chronic conditions. Studies have shown that personal behavior impacts health outcomes by 30-40%. Therefore, it is important to offer evidence-based Chronic Disease Self-Management Education (CDSME) programs that increase patient awareness and build skills that address healthy diets, smoking, physical activity, substance use, and more.

CDSME programs are evidence-based. They have been shown to engage and motivate patients so that they are more involved in their care, increase their self-efficacy for symptom and health care management, and improve a number of measures related to health status, health care and costs. CDSME programs are well suited to help improve the status of high risk patients because they are: peer-led, provide a supportive environment to facilitate change, and empower patients to take charge of their health.

ACOs are designed to foster patient involvement, patient education, and self-management support. They play an important role in encouraging patients to keep appointments, attend health education activities, and self-manage their medical conditions.  Moreover, as noted earlier, ACOs must meet quality of care metrics in order to qualify for bonuses.  For example, patients with diabetes mellitus, have specific prevention measures that must be completed annually.  Self-management programs can help to motivate patients to complete these screenings in a timely manner which, in turn, enhances the quality scores for the ACOs.  In addition, ACO patients are surveyed annually. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is administered by independent organizations approved by CMS.  There are a myriad of CAHPS survey versions which are specific to the kind of organization being evaluated. ACO consumers complete the Clinical & Group version of CAHPS. CAHPS surveys measure a broad swath of consumer satisfaction topics.

Those measures most likely to be impacted by CDSME programs include:

  • Provider support for managing chronic conditions;
  • Provider-consumer communication;
  • Health Promotion and education;
  • Health status and functioning; and
  • Help taking prescribed medications.

Considering all of these factors, ACOs are good candidates for offering or making referrals to evidence-based workshops.  However, before referrals can be made, the ACO and the community-based organizations need to establish a contract and a business associate agreement in order to share patient data. The ACO will issue their own contract and business associate agreement for the community-based organization to review and execute.

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Identifying and Engaging the ACO

How do you identify local ACOs in your community? If you don’t have established relationships and are part of a community-based organization (CBO) collaborative effort, such as a statewide network hub, you might choose to approach your state hospital or ACO associations or conduct a search on the CMS or National Association of ACOs websites to identify ACOs within your state. Some states may also have websites that provide information on local ACOs. If you are single service provider, such as an area agency on aging (AAA), you may choose to partner with the ACO in your designated service area. However, be aware of the need to expand your collaboration with other CBOs since the ACO may want more geographic coverage to be provided beyond your state unit on aging (SUA) designated region.

Take steps to gather information on the organizations’ priorities and to learn the roles and responsibilities of key staff. It is also a good idea to include representatives from the ACO on your local advisory boards as a way to develop key relationships with those who can become potential champions for evidence-based programs.

To select an ACO that is the best fit for partnering, consider the following (this information may be located on their website or ask your ACO contact for written material):

  • Which ACOs have a vision and mission that are similar to yours?
  • Which ACOs have the capacity to reach the greatest number of people in your target population?
  • Which ACOs are best positioned to expand the program to a high-priority underserved area?
  • Which ACOs seem to be the easiest to start a long-term partnership with?
  • Which ACOs are looking for external support for prevention and wellness interventions for their population?
  • Does the ACO’s network include community-based organizations? Is this an opportunity to become one of the ACO’s community-based partners?
  • Which ACOs are willing to invest in strategies that improve population health outcomes that focus on behavior change?
  • With which ACOs have some of your current clients been engaged? What feedback do you have about their experience?

Research the Potential Partnership

Before contacting the ACO, it is important to conduct research not only on the ACO, but also on your own capacity to serve their target population. The first key step in the research process should include identifying what your organization has to offer the ACO to improve their patients’ health. It is also important to demonstrate an understanding of the regulatory, contractual, and industry culture and nomenclature used by ACOs. Approaching the ACO with knowledge of their regulatory reporting requirements and quality initiatives and metrics can establish an immediate common ground, common language, and a way to demonstrate your value.  Identify your capacity to impact priority ACO outcomes. For example, be prepared to address factors such as:

  • Which group or segment of the ACO’s population is most challenging?
  • Is there a group or segment of the patient population that is a particular priority?
  • Could your efforts help the ACO improve the health outcomes of this population?
  • Specifically, how can you demonstrate this impact?

You should be ready to demonstrate the key value proposition of evidence-based programs tied to their quality and performance indicators.  Moreover, you must demonstrate the ease of access ACO patients will have to evidence-based programs. If you are offering local workshops, important infrastructure questions to ask yourself about your organizational operations include:

  • Do you offer programs at a variety of times during the week and on weekends?
  • How quickly can you schedule a workshop?
  • Do you have a system in place to manage referrals, share progress, coordinate billing and payment, track individual patient activity, etc.?
  • Do you have programs in place that will complement evidence-based programs, such as transportation or meals?
  • Do you know the costs associated with offering the workshops, how the costs will be covered, what you plan to ask the ACO to pay for, and what payment mechanisms are in place, or need to be in place, to sustain the program?
  • Have you developed a strong value proposition that reinforces the evidence-based program’s capacity to impact patient activation and compliance, improve quality outcomes, and meet financial benchmarks?
  • Does the ACO have a registry of high-risk patients they want to target and if so, do they need your assistance to make these connections and enhance access to programs?

Make the Initial Contact

If you have a current relationship with an ACO leader or physician in a leadership position, or the name of a direct contact, that would be good place to start. Building upon relationships you already have with ACO staff gives you a foot in the door and an opportunity to further engage center leaders in adopting evidence-based programs.

If you are cold calling or utilizing an introductory letter to secure a meeting, ask to speak with the person recommended by your partners during the fact-finding stage. If you don’t have recommended contacts, ask to speak with the person responsible for the following roles:

  • Network Management Administrator
  • Executive Director
  • Financial Officer
  • Quality Director
  • Medical Director
  • Clinical Site Directors

Be prepared to match the representatives from your organization to the ACO representative with whom you are meeting. For example, if you are meeting with the ACO Executive Director, have your Executive Director present; if you are meeting with clinical leadership, your senior clinical staff should be present.  In addition, map your cover letter or initial call content to the person’s area of specialty, e.g., clinical, financial, administrative, etc.

When connecting with the ACO leadership, your approach should highlight your organization’s capacity to address and contribute to key areas of interest for the ACO.  Consider asking not only to join their delivery network, but also to join their advisory board.  Your expertise in the aging and disabilities services network can prove valuable to the ACO’s execution of their mission and service strategies.

Make the Value Proposition

It is important to establish the rationale for an ACO to understand how partnering with you to embed CDSME and other evidence-based programs into their organization benefits them BEFORE YOUR FIRST CONTACT. In addition, it is critical to understand their burning issues, risks and high priorities. You can search the CMS Medicare website to identify past performance of the ACO to help zero in on their points of pain in order to fine tune your value proposition premises.  If you are collecting information from current clients regarding their ACO experience, be prepared to share this important feedback as well.  Draw from the Stanford research and other NCOA information to demonstrate the effectiveness of CDSME and other evidence-based programs in meeting the Affordable Care Act’s (ACA) Triple Aim of better health, better care, lower costs, as well as ACO quality and performance measures.  Analyze the outcomes and satisfaction data that you are currently collecting on your evidence-based programs to document:

  • How your evidence-based programs engage and positively influence local health outcomes for individuals similar to the ACO’s targeted population, and
  • How your participant satisfaction scores can help meet the ACO consumer survey satisfaction targets.

The annual ACO patient satisfaction surveys assess a number of parameters for which CDSME programs have been shown to improve patient responses including:

  • Improved communication with health care providers, including between visit communication
  • Patient’s rating of provider
  • Health promotion and education
  • Shared decision making
  • Medication adherence

Ultimately, be prepared to discuss how evidence-based programs can be part of an overall strategy to improve the services offered to high-risk older adults in the target market (this term is defined differently by various ACOs), while increasing health care utilization at the center. Your value proposition should highlight these following benefits of the partnership:

  • CDSME is proven effective in improving self-management skills which influence clinical outcomes of patients.
  • CDSME has been effective in increasing patient activation which leads to better health management and lower health cost. (See the National Study of the Chronic Disease Self-Management Program: A Brief Overview) 
  • Patients who participate in CDSME and achieve better health outcomes can positively impact ACO quality and performance measures.
  • CDSME helps with patient advocacy by encouraging patients to work together with their providers to set measurable, achievable goals that result in improved health.
  • Participation in CDSME can increase health care cost-savings by preventing emergency department visits, hospitalizations, in patient stays, and premature morbidity.
  • CDSME programs are appropriate to address any ongoing health condition such as diabetes mellitus, osteoarthritis, congestive heart failure, chronic obstructive pulmonary disorder, and others.
  • Collaboration with community-based organizations supports ACO outreach efforts for hard to reach consumers-via their ‘boots on the ground’ personal engagement strategies.
  • CDSME outcomes can support ACO achievement of the Triple Aim goals for health care.

Find Common Ground and Determine Expectations

Sustainable partnerships lead to sustainable evidence-based programs. One of the foundations of sustainable partnerships is the ability to establish common ground, set expectations and identify mutually beneficial outcomes. In early meetings with your ACO partners, use your value proposition to guide discussions about potential outcomes and expectations for the partnership. Also in these early meetings, begin to identify the potential champions in the ACO who can assist you in developing and strengthening the partnership.  Aligning the focus between your two entities will also support development of standardized program evaluation processes.  Utilize the newly released NCOA CDSME video, Improving Quality of Life and Health Care Outcomes Through CDSME Programs, to support your presentation.

Develop a Plan of Action

When engaging a new partner, take time to develop a specific plan of action to define the terms of the partnership. Doing so will ensure that you and your partners are on the same page and will help move the collaboration forward. Partnerships that start out with formally defined expectations are more likely to be sustainable. Ask the ACO to help you convene a planning group or help identify internal champions that should be involved with the planning process. Leave appropriate background materials to support the ACO personnel you meet with to conduct follow-up discussions with their staff, providers, and other stakeholders.

Focus on Sustainability from the Very Beginning

CDSME programs achieve the broadest impact when they are offered on a long-term, ongoing basis. Therefore, it is important to discuss sustainability from the very beginning to plan for long-term funding, staffing, and embedding of the program. Additionally, it is critical to note that sometimes it takes more than a year to realize the significant impact evidence-based programs have on health care outcomes.  It is important to ensure that the CDSME programs are ongoing and embedded into the foundation of the ACOs service coordination practices. If you are not able to maintain routine delivery of CDSME programs, your partnership engagement may dissolve.

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Formalizing the Partnership

Formalizing partnerships with ACOs may seem daunting; however, there are some simple actions you can take. Being honest, cultivating a spirit of sharing and effective communication, and emphasizing mutually beneficial outcomes that meet the needs of your organization and those of the ACO will be instrumental in formalizing the partnership with the ACO. Doing so will strengthen your relationship and ensure that the relationship has value for both partners.

Use Business Practices to Formalize and Strengthen Your Partnership

Use common business practices to manage the partnership and ensure that the partnership retains its value in the eyes of the ACO. Specifically, develop written documents to outline expectations and avoid miscommunications. Develop a formal agreement that covers what you are going to do together and who is responsible for what by when.

Many types of agreements are available that outline the roles and responsibilities of partners, the budget, monies to be paid for services, and the timeline for work to be accomplished. Common examples include Memorandums of Agreement (MOAs), Memorandums of Understanding (MOUs), or contracts.

Regardless of which agreement you choose, it should set a framework for clear communication between the parties involved. You can use workflow process diagrams to outline communication pathways and roles for each stakeholder in every stage of evidence-based program delivery, including participant screenings, referral, enrollment, and follow-up.

Establish the Terms for Risk Sharing and Value-Based Contracting

Risk sharing means determining the costs of offering evidence-based programs for the partner organization, and outlining how those costs will be shared. Many providers such as ACOs know this concept as a “value-based contracting.” Value-based contracting is a model of health care contracting where the provider is eligible to receive a financial reward or face a potential penalty based on the value that the provider delivers to the payer (e.g., Medicare, other insurer). Value is defined as reduced overall cost of care and improved clinical indicators. When the provider is able to improve clinical indicators and reduce costs, they bring more value to the payer.

If and when cost savings are achieved, then the joint risk is rewarded. Not only do you need to define costs, but you also need to explain how you will jointly determine success and how you each will be rewarded. For example, the reward may be a pre-determined percentage of shared savings, an increased budget for the next workshop series, an additional workshop series planned, or the sponsorship of a leader training.

Identify, Designate and Cultivate a Champion(s)

Identify ACO staff members to champion the program and be your “go-to people.” Champions are on the front lines and can provide needed access to providers, patients, and partners necessary to grow your evidence-based program efforts. ACO program coordinators, outreach workers, and care coordinators can make good champions. Cultivate relationships with your champions by being positive and understanding that their time is very valuable.

Establish Processes for Marketing and Recruitment

Assist the ACO in embedding the program by developing a process for promoting it. Schedule regular meetings with ACO staff to brainstorm goals, marketing, recruitment, referral, partnerships, and the logistics of the program delivery. Identify opportunities to share program brochures and materials, and ensure there are plenty on hand. Find ways to avoid duplication in new materials development. For example, editing an existing brochure template, rather than developing a new one, can expedite decision-making by the practice.

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Nurturing the Partnership

Engaging ACOs involves building strong, trusting relationships with staff at every level of the practice. This includes front office and administrative staff, as well as medical providers and executive leadership. Stay in touch on a regular basis to strengthen the relationship and to continue to explore opportunities to fully embed evidence-based programs into their care delivery system. Avoid leaving behind literature and program materials without first interacting with the health center staff.

Cultivate Ongoing Interaction

Recognize that a partnership cannot be established in a single interaction. Expect and plan for multiple meetings, presentations to different teams, and even possible delays, given the organization’s priorities and workflow.

Model Key Self-Management Concepts and Skills

Just like CDSME leaders do in workshops, you should prepare an agenda for your meetings and presentations. Take a copy of the CDSME participant book and the video to show the resources that ACO patients will receive. Include brief demonstrations of a skill taught in the CDSME curriculum. For example, you might brainstorm with the meeting participants to identify which patients would be a great fit for CDSME. As you discuss action planning for patients, you can reference your partnership action plan. Then, at the end of the discussion, you might set an action plan to be accomplished by the next meeting.

Be Patient and Remain Nonjudgmental

It’s not just the ACO’s leadership that need to buy into evidence-based programs – other staff should be introduced to the program and its benefits and included in meetings. Successful adoption of CDSME will require support from staff who do outreach, care coordination, and work the front desk. Fostering and reinforcing their participation is critical to your success.

Remember that each ACO may be at a different stage of readiness to partner with you, so don’t judge or be surprised if you face initial resistance to the partnership. You may not be meeting with the right staff members, or you may be talking with them at the wrong time. Change takes time. Begin building partnerships by taking small steps, and realize that the organization will need to take small steps too. Stay positive, relevant, and ready to restate your value proposition in a different way. You also will need to be responsive to the challenges and the barriers that might be real for the ACO and work collaboratively toward creative solutions.

Celebrate Successes

Build on and celebrate all of your successes along the way – after the first meeting, the first referral, the first workshop, and the first testimonial from a patient who benefited from the program. Highlighting and celebrating your successes will reinforce the value of your collaboration and keep the ACO engaged.

Provide Tools and Examples

ACOs will need tools to assist them in screening, referring, enrolling, and following up with consumers who participate in workshops. Have sample referral workflows and forms on hand.

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Sustaining the Partnership

It’s important to continually review and discuss the value, risks, and rewards of your partnership and how it will help both the ACO and your organization meet your respective priorities.

Revisit and Reinforce Commitment to Demonstrable Value

Continue to revisit your value proposition throughout the life of your partnership to ensure that your collaboration is addressing the needs of the practice and their patients. Call attention to how your efforts in delivering CDSME will reinforce the ACO’s efforts in providing coordinated care.  Regularly highlight reaching benchmarks and other accomplishments.  Be prepared to amend your strategies to align with evolving priorities/needs of the ACO.

Obtain Support for Ongoing Delivery and Expansion of the Program

Keeping the CDSME program funded and expanding it to new service areas not only strengthens trust and value within the partnership, but ultimately ensures the continuity of the program to reach the greatest number of patients.

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Federally Qualified Health Centers

What is an FQHC?

Federally Qualified Health Centers (FQHCs), known interchangeably as Community Health Centers (CHCs), are community-based organizations that provide comprehensive primary care and preventive care, including health, oral, and mental health/substance abuse services. They provide necessary care to medically underserved and vulnerable populations, including the uninsured and those living in poverty.

FQHCs receive a special designation from the Bureau of Primary Health Care and the Centers for Medicare and Medicaid Services that allows them to get reimbursed for care provided to medically underserved populations (MUPs) or in medically underserved areas (MUAs), such as rural areas and inner cities. FQHCs are primarily funded by the Health Resources and Services Administration (HRSA) under Section 330 of the Public Health Service (PHS).

Regulatory changes to Medicare and Medicaid policies, authorized by the Affordable Care Act, have highlighted the soaring health care expenditures to treat the growing population of older adults. There has been a particular focus on how the U.S. health care system can begin to address the complex needs of dual-eligible Medicare beneficiaries. This population is more likely to have two or more chronic conditions than younger age groups, and it has the highest per capita spent. FQHCs are in a prime position to address the needs of underserved and dual-eligible older adults, and they must establish strategic partnerships to be able to fully serve this population.

Find an FQHC

You can locate FQHCs in your state by visiting HRSA’s Find a Health Center website. Primary Care Associations (PCAs) receive funding from HRSA’s Bureau of Primary Health Care to provide training and technical assistance to FQHCs across the country to assure quality performance. Each state has a Primary Care Association that supports the health centers in their service area. They are a good source for connecting with FQHCs throughout your state.

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Why Partner with FQHCs?

Federally Qualified Health Centers (FQHCs), known interchangeably as Community Health Centers (CHCs), are considered “safety net providers,” responsible for getting care to the nation’s most vulnerable populations. Since older adults are among the nation’s vulnerable populations affected by chronic disease, many FQHCs are seeking opportunities to increase the number of older adults they serve and provide them with critical self-management services. Doing so helps FQHCs meet the Health Services and Resources Administration’s (HRSA’s) requirements to increase the volume of services provided to high-risk older adults, enabling them to sustain their 330 grant funding.

Chronic Disease Self-Management Education (CDSME) programs have been shown to activate patients so that they are more involved in their care, increase their self-efficacy, and improve a number of measures related to health status, health care, and costs. Because CDSME programs are peer led, provide a supportive environment to facilitate change, and empower patients to take charge of their health, they are well suited for helping to improve the health status of vulnerable populations. They can be particularly useful in helping FQHCs improve the health of older adults who are disproportionately affected by chronic diseases.

FQHCs are designed to be inclusive of patient involvement, patient education, and self-management support. As the safety net provider for underserved populations, FQHCs often have special relationships with their patients to address barriers to care, including lack of transportation or problems in navigating health systems to access needed services. FQHCs play an important role in encouraging patients to keep appointments, attend health education activities, and self-manage their medical conditions. These dynamics can make FQHCs good candidates for offering or making referrals to CDSME workshops.

FQHCs receive reimbursement incentives by becoming Patient-Centered Medical Homes (PCMHs). When they become recognized or accredited as a PCMH, they must have an effective Medicare/Medicaid billing infrastructure to provide sustainable services. Therefore, FQHCs are primed to serve as a unique billing partner with CDSME program providers who want to establish a reimbursement strategy to sustain CDSME programs.

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What’s in it for FQHCs?

Federally Qualified Health Centers (FQHCs), known interchangeably as Community Health Centers (CHCs), are required, as part of their HRSA 330 grant funding, to increase the number of consumers they serve each year, including high-risk older adults. If a health center experiences a decrease in its service population, it can lose some or all of its grant funding. To prevent this, health centers must submit utilization data to HRSA each year, including the number of consumers served, the average number of times they received services, and their age distribution. Health centers that increase the volume of services provided to high-risk older adults are looked upon favorably in HRSA’s decisions to sustain or increase their 330 grant funding.

FQHCs also must increase the volume of insured consumers served by their center. High-risk older adults often have Medicare and Medicaid benefits that will allow for full compensation for health services rendered, including CDSME. Older adults who have two or more chronic conditions can be eligible for CDSME programs and have their participation reimbursed. As such, they are a potentially profitable target population that supports the recruitment and health care requirements of HRSA and contributes to the overall financial viability of the health center.

The Patient Protection and Affordable Care Act of 2010 encourages state Medicaid programs to develop medical homes and implement provider incentive payment programs for care to patients with chronic diseases. As a result, many FQHCs are becoming Patient-Centered Medical Homes (PCMHs), a primary care, team-based approach to meeting a patient’s health care needs. FQHCs are focusing on a PCMH approach with care that is:

  • Patient-centered
  • Comprehensive
  • Coordinated
  • Accessible
  • Committed to quality and safety

To achieve these goals, FQHCs are looking for ways to:

  • Increase the volume of patients seen in the PCMH that receive care coordination
  • Provide quality care at lower costs to patients, resulting in improved management of chronic conditions
  • Improve patient activation in chronic disease self-management behaviors

FQHCs receive PCMH accreditation from organizations such as the National Committee for Quality Assurance (NCQA). They also can receive bonus payments from the Centers for Medicare and Medicaid Services and the Health Resources Services Administration for improving the quality and coordination of patient care leading to the management of chronic conditions. NCQA accreditation includes achieving the 6 PCMH standards:

  • PCMH 1 Access and Continuity
  • PCMH 2 Identify and Manage Patient Populations
  • PCMH 3 Plan and Manage Care
  • PCMH 4 Provide Self-Care Support and Community Resources
  • PCMH 5 Track and Coordinate Care
  • PCMH 6 Measure and Improve Performance

Chronic Disease Self-Management Education (CDSME) is proven effective in achieving several patient outcomes consistent with NCQA PCMH accreditation standards and Affordable Care Act legislation. Key outcomes of CDSME that align with NCQA PCMH accreditation standards include patient activation and improved management of chronic disease symptoms.

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Identifying and Engaging the FQHC

Before you get started, it’s important to identify potential FQHC partners. There are many ways to decide which FQHC to approach. If you are part of a collaborative effort, such as a statewide network, you might choose to approach your state primary care association to identify FQHCs within your state that are interested in expanding their services to older adults. However, if you are single service provider, such as an Area Agency on Aging (AAA) or a senior center, you might choose to partner with an FQHC in your designated service area. If you have a current relationship with an FQHC or the name of a direct contact, that would be good place to start.
To select the FQHC that is the best fit for partnering, consider the following:

  • Which FQHCs have a vision and mission that are similar to yours?
  • Which FQHCs have the capacity to reach the greatest number of people in your target population?
  • Which FQHCs are best positioned to expand the program to a high-priority underserved area?
  • Which FQHCs seem to be the easiest to start a long-term partnership with?

Research the Potential Partnership

Before contacting the FQHC, it is important to conduct research not only on the health center but also on your own capacity to serve this population. The first key step in the research process should include identifying what your organization has to offer the health center. If you are offering access to local workshops, do you offer them at a variety of times? If you are offering to take FQHC patient referrals, do you have a system in place to handle those referrals? Do you have programs in place that will complement CDSME, such as transportation or meals that you can also offer to the health center? How quickly can you have a workshop scheduled? Also, it is important to assess the costs associated with offering the workshops, how the costs will be covered, what you plan to ask the FQHC to pay, and what payment mechanisms are in place or need to be in place to sustain the program.

Next, determine if you have existing contacts at the health clinic. Building upon relationships you already have with health center staff gives you a foot in the door and an opportunity to further engage center leaders in adopting CDSME. As you get to know the center personnel, think about who might serve as a program champion.

It is also important to learn the regulations and terminology. Approaching the FQHC with knowledge of the Patient-Centered Medical Home regulations and requirements establishes immediate common ground, common language, and a way to demonstrate your value to the health center.

Make the Initial Contact

Making the initial contact with the health center may feel challenging. Preparing in advance of the contact builds confidence and demonstrates to the FQHC that you have an understanding of their needs and interests. If making the initial contact by phone, ask to speak with the person recommended by your partners during the fact-finding stage. If you don’t have recommended contacts, ask to speak with the person leading the PCMH transformation work, the Director of Clinical Operations, the Practice Manager, or the Quality Improvement Manager. The goal of your first call should be to establish your first in-person meeting with the FQHC. The initial meeting provides an opportunity to listen to the health center’s needs and to reflect on what assistance you can provide. It is critically important that you highlight your capacity to access high-risk older adults, a population the FQHC is aiming to serve. Use an agenda to help guide your early conversations with the FQHC. Once you have established common ground regarding what the health center needs and what you can offer, your next step is to develop a value proposition to promote the benefits of CDSME for the FQHC.

Make the Value Proposition

It is important to establish common ground and help the FQHC understand how partnering with you to embed CDSME programs into their organization benefits them. Be sure to discuss how CDSME will help the FQHC meet the 6 NCQA standards for PCMH accreditation. Most important, discuss how CDSME can be part of an overall strategy to improve the services offered to high-risk older adults in the target market, while increasing utilization at the center. Your value proposition should highlight the following benefits of the partnership:

  • CDSME is proven effective in improving the self-management skills and clinical outcomes of patients;
  • Better outcomes achieved through CDSME can help meet PCMH recognition standards;
  • CDSME helps with patient advocacy by encouraging patients to work together with their providers to set measurable, achievable goals that result in improved health; and
  • Participation in CDSME can increase healthcare cost-savings by preventing hospitalizations and premature morbidity.

Find Common Ground and Determine Expectations

Sustainable partnerships lead to sustainable CDSME programs. One of the foundations of sustainable partnerships is the ability to establish common ground, set expectations, and identify mutually beneficial outcomes. In early meetings with your FQHC partners, use your value proposition to guide discussions about potential outcomes and expectations for the partnership. Also in these early meetings, begin to identify the potential champions who can assist you in developing and strengthening the partnership.

Develop a Plan of Action

When engaging a new partner, time should be taken to develop a specific plan of action to define the terms of the partnership. Doing so will ensure that you and your partners are on the same page and will help move collaboration forward. Partners who have specific roles and responsibilities are more likely to stay engaged. Ask the FQHC to help you convene a planning group or to help identify internal champions that should be involved with the planning process. Always end your meetings by asking how and when you can follow up. Leave appropriate background materials to support the FQHC personnel you meet with in carrying on discussions with their staff, providers, and other stakeholders.

Focus on Sustainability from the Very Beginning

CDSME programs achieve the broadest impact when they are offered on a long-term, ongoing basis. Therefore, it is important to discuss sustainability from the very beginning to plan for long-term funding, staffing, and embedding of the program. It is important to ensure the CDSME programs are ongoing and embedded into the health center’s care services. If you are not able to maintain routine delivery of CDSME programs, the trust that is necessary to maintain the partnership with the FQHC can be compromised.

Your Homework: Put Toolkit Tips into Practice

Check the health center’s website and talk to your health center contacts to gather information on the health center’s status as a PCMH and to learn staff names and titles. Key people within a health center to consider including in the initial contact are the Clinical Director of Operations, the Practice Manager, and the Quality Improvement Manager.

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Formalizing the Partnership

Formalizing partnerships with Federally Qualified Health Centers (FQHCs) may seem daunting; however, there are some simple actions you can take.

Cultivate a Spirit of Sharing, Effective Communication, and Mutually Beneficial Outcomes

Being honest, cultivating a spirit of sharing and effective communication, and emphasizing mutually beneficial outcomes that meet the needs of your organization and those of the FQHC will be instrumental in formalizing the partnership with the FQHC. Doing so will strengthen your relationship with the FQHC and ensure that the partnership has value for both partners.

Use Business Practices to Formalize and Strengthen Your Partnership

Use common business practices to manage the partnership and ensure that the partnership retains its value in the eyes of the FQHC. Specifically, develop written documents to outline expectations and avoid miscommunications. Develop a formal agreement that covers what you are going to do together and who is responsible for what by when.

There are many types of agreements that outline the roles and responsibilities of partners, the budget, monies to be paid for services, and the timeline for work to be accomplished. Common examples include memorandums of agreement (MOAs), memorandums of understanding (MOUs),  or contracts.

Regardless of which agreement you choose, it should set a framework for clear communication between the parties involved. You can use workflow process diagrams to outline communication pathways and roles for each stakeholder in every stage of CDSME delivery, including participant screenings, referral, enrollment, and follow-up.

Establish the Terms for Risk Sharing and Value-Based Contracting

Risk sharing means determining the costs of offering CDSME for the partner organization, and outlining how those costs will be shared. Many providers such as FQHCs know this concept as a “Value-Based Contracting.” Value-based contracting is a model of health care contracting where the provider (FQHC) is eligible to receive a financial reward or face a potential penalty based on the value that the provider delivers to the payer (e.g., Medicare, other insurer). Value is defined as reduced overall cost of care and improved clinical indicators. When the provider is able to improve clinical indicators and reduce costs, they bring more value to the payer.

If and when cost savings are achieved, then the joint risk is rewarded. Not only do you need to define costs, but you also need to explain how you will jointly determine success and how you each will be rewarded. For example, the reward may be a pre-determined percentage of shared savings, an increased budget for the next workshop series, an additional workshop series planned, or the sponsorship of a leader training.

Designate a Champion(s)

Identify FQHC staff members to champion the program and be your “go-to people.” Champions are on the front lines and can provide needed access to providers, patients, and partners necessary to grow your CDSME efforts. FQHC program coordinators, outreach workers, and care coordinators can make good champions. Cultivate relationships with your champions by being positive and understanding that their time is very precious.

Establish Processes for Marketing and Recruitment

Assist the health center in embedding the program by developing a process for promoting it. Schedule regular meetings with FQHC staff to brainstorm goals, marketing, recruitment, referral, partnerships, and the logistics of the program delivery. Identify opportunities to share program brochures and materials, and ensure there are plenty on hand. Find ways to avoid duplication in new materials development. For example, editing an existing brochure template, rather than developing a new one, can expedite decision-making by the practice.

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Nurturing the Partnership

Build Trusting Relationships at Every Level

Engaging Federally Qualified Health Centers (FQHCs) involves building strong, trusting relationships with staff at every level of the practice. This includes front office and administrative staff, as well as medical providers and executive leadership. Stay in touch on a regular basis to strengthen the relationship and to continue to explore opportunities to fully embed CDSME programs into their care delivery system. Avoid leaving behind literature and program materials without first interacting with the health center staff.

Cultivate Ongoing Interaction

Recognize that a partnership cannot be established in one interaction. Expect and plan for multiple meetings, presentations to different teams at the health center, and even possible delays, given the center’s priorities and workflow.

Keep the FQHC’s Priorities in Mind

An FQHC’s two most important priorities are their patients and meeting quality care standards. Be prepared to wait if a meeting starts late, and understand if the leadership or staff have limited time to talk with you. It helps to be flexible with scheduling, as FQHCs are often very busy. Make the most of their time by helping the FQHC see how your partnership provides value in helping them carry out their priorities. Consistently make it easy to contact you, get materials from you, and refer patients to you. This availability will underscore your commitment to sustainability.

Model Key Self-Management Concepts and Skills

Just like CDSME leaders do in workshops, you should prepare an agenda for your meetings and presentations. Take a copy of the CDSME participant book and the video to show the resources that FQHC patients will receive. Include brief demonstrations of a skill taught in the CDSME curriculum. For example, you might brainstorm with the practice to identify which patients would be a great fit for CDSME. As you discuss action planning for patients, you can reference your partnership action plan. Then, at the end of the discussion, you might set an action plan to accomplish by the next meeting.

Be Patient and Remain Nonjudgmental

It’s not just the center’s leadership or health care providers that need to buy into CDSME – other staff should be introduced to the program and its benefits and included in meetings. Successful adoption of CDSME will require support from staff who do outreach, care coordination, and work the front desk. Fostering and reinforcing their participation is critical to your success.

Remember that each practice may be at a different stage of readiness to partner with you, so don’t judge or be surprised if you face initial resistance to the partnership. You may not be meeting with the right staff members, or you may be talking with them at the wrong time. Change takes time, so be patient. Begin building partnerships by taking small steps, and realize that the health center will need to take small steps too. It is important to stay positive, relevant, and ready to restate your value proposition in a different way. You also will need to be responsive to the challenges and the barriers that might be real for the FQHC and work collaboratively toward creative solutions.

Celebrate Successes

Build on and celebrate all of your successes along the way – after the first meeting, the first referral, the first workshop, and the first testimonial from a patient who benefited from the program. Highlighting and celebrating your successes will reinforce the value of your collaboration and keep the FQHC engaged.

Provide Tools and Examples

FQHCs will need tools to assist them in screening, referring, enrolling, and following up with participants who participate in workshops. Have sample referral protocols, workflows, and other forms needed for referrals on hand.

Your Homework: Put Toolkit Tips into Practice

The goal for your initial meeting with the FQHC should be to determine their readiness to partner to offer CDSME. Once you determine that an FQHC is ready, it is important to set the tone for the partnership by identifying mutual benefits and establishing expectations, roles, and next steps. Bring sample work plans and a suggested workflow for your collaboration. It is easier to discuss and change a sample work plan than to create one from scratch. Also, be prepared to address typical program costs and how those costs might be shared.

Once the FQHC decides to partner, consider announcing collaborative activities by presenting at the center’s all-staff meeting. Explain how the partnership helps the FQHC achieve its goals by reaching out to underserved older adults with chronic conditions and by supporting patients in self-management. The meeting can serve as the official launch of the CDSME program and highlight the process for enrolling patients.

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Sustaining the Partnership

It’s important to continually review and discuss the value, risks, and rewards of your partnership and how it will help both the Federally Qualified Health Center (FQHC) and your organization meet your respective priorities.

Revisit and Reinforce Commitment to Demonstrable Value

Continue to revisit your value proposition throughout the life of your partnership to ensure that your collaboration is addressing the needs of the practice and their patients. Call attention to how your efforts in delivering CDSME will reinforce the center’s efforts in operating as a high-performing Patient-Centered Medical Home (PCMH) and providing coordinated care.

Obtain Support for Ongoing Delivery and Expansion of the Program

Keeping the CDSME program funded and expanding it to new service areas not only strengthens trust and value within the partnership, but ultimately ensures the continuity of the program to reach the greatest number of patients. Learn about innovative models in your state that offer opportunities to embed CDSME into FQHC practices.

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Consortium for Older Adult Wellness

The Consortium for Older Adult Wellness (COAW) is a Colorado non-profit organization and national leader in engaging and inspiring adults, communities, and health systems in realizing their prevention, wellness, and self-management potential. COAW offers training, consultation, and community-based program implementation. It focuses on connecting clinical and community-based interventions in service to the individual. For additional information, e-mail info@coaw.org.

Lynnzy McIntosh, Executive Director of COAW and Maripat Gallas, Director of Implementation share their experience on partnering with Federally Qualified Health Centers (FQHCs).

woman with physician

We’d been working with senior centers, recreation centers, and community centers. But we weren’t reaching the people that we thought could really benefit from CDSME.

Lynnzy McIntosh

What was the impetus for COAW to partner with FQHCs?

Working with FQHCs was a way to reach people that we weren’t reaching through our traditional methods. We’d been working with senior centers, recreation centers, and community centers. But we weren’t reaching the people that we thought could really benefit from Chronic Disease Self-Management Education (CDSME) … people who are underserved, aren’t insured, and not necessarily used to going to recreation centers, people who aren’t necessarily older adults. There are a lot of people that we weren’t reaching.

How was COAW successful in getting started: identifying and engaging the FQHC?

The Metro Community Provider Network, Health TeamWorks, and Colorado Community Health Network collaborate with our FQHCs and have given us expertise and support. No doubt, partnering with statewide organizations to give us introductions to a clinic and helping support community health centers in getting these programs established has been key for us. Initially it was essential to have one of these partners to introduce COAW to the local clinics ­– someone that they were already working with, already trusted. These [type of] organizations help you get your foot in the door, are a support to you, and give you that credibility.

When we go into those meetings, I can’t emphasize enough how important it is to get a ‘temperature’ or feel for the personality of the clinic. Champions could be a variety of people in a number of different positions – it’s not necessarily the clinical manager.

Maripat Gallas

We will approach at any level that the clinic allows us to! It’s usually a practice manager that’s the key player, (someone) you may have a one-on-one with. They hear about the program, what the value and the benefits would be, and then they open it to the rest of the staff. When we go into those meetings, I can’t emphasize enough how important it is to get a “temperature” or feel for the personality of the clinic. Champions could be a variety of people in a number of different positions – it’s not necessarily the clinical manager. You’ll want to align with that person who is going to keep momentum going, really getting this program sustained and embedded. Our conversation from the very beginning is, “How can we get this embedded for you?”

How was COAW successful in nurturing the partnership?

One of the things we realized, and still continue to realize, is that you need to demonstrate your value before you say to someone, “… and here’s what it’s going to cost you.”  We found that we had organizations that were willing to pay to train, share costs to implement workshops, and were interested in data if we could give them reports on how they compared to the state as a whole. We started building those systems so we could give our partners the information they needed that they found value in. We started seeing the value in giving information back to the clinics on who we contacted on their behalf and why they were enrolling or weren’t enrolling.

When we first started, our pre-designed script was that we would talk to the clinics about how great the chronic disease curriculum was, and the workshops that are available, and here’s how it can benefit patients.  The CDSME program is not hard to sell — that can be almost secondary because the staff understands patient self-management. But, we weren’t giving the clinic and the practice what they needed to refer people to the program. Clinic staff want to know, “What kind of work do we have to do?”  We switched the script to say, “Here’s what’s in it for the clinic and the practice and here’s what’s in it for the patient.”

We try to give a little information about the program itself and then get into the referral process. We explain how COAW can streamline this. We work a lot on that referral process. That’s why in the beginning, we would prefer to handle the logistics of the program for the clinic to really embed the referral process. The really successful practices we have now have solid referral processes. They don’t all look the same, because they need to tailor it to their systems and practices. Once the referral process is solid, then we can layer on the logistics of implementing workshops.

We have several types of cost-sharing arrangements. Some FQHCs have embedded the program and pay for the implementation themselves. Others do everything, except we provide class materials.

Lynnzy McIntosh

How was COAW successful in formalizing the partnership?

You need to get a sense of the dynamics of that practice, who is really the decision maker, who is going to make the decision that this is going to go ahead or not. If they’re very business oriented, financially oriented, they might ask, “What is this going to cost us?” or “How much time is this going to take?” If it’s a small family practice in a small rural town, it could be very much the “TLC” component; they want to do good things for their people. These are their neighbors, it’s their community. If you start answering their needs and their questions as quickly as possible, you’ll start to get buy-in.

We have a staff person assigned to all 20 of the community health centers across the state. One of the reasons we have a specific staff person assigned to the community health centers is because she’s bilingual. It’s crucial, in Colorado, to have bilingual staff when speaking with community health centers. About 50% of community health center patients are Spanish-speaking. She goes to the community health network meetings and presents at statewide conferences. This helps us to understand what is happening in the clinics and gives us visibility. Her job is to always keep in touch with them. It helps her remind community health centers of general requirements like maintenance of leader training, managing fidelity, recruitment, retention, and completer rates. Depending on the clinic and ability to reach staff, they’ll meet anywhere from biannually to quarterly. We download all of the data, we look at graphs, see who they are reaching, problem-solve as needed. We discuss any new curricula they would like to add. For example, chronic pain is starting to come on the horizon. It is an ongoing relationship.

With some of the FQHCs, we had the Administration for Community Living (ACL) funding to support the basics in terms of getting to know the practice, nurturing the partnership, and establishing the referral and enrollment systems. We would cover the costs for the first workshop as a way to demonstrate the value of CDSME.  We would establish the value and cost of the program from the beginning, so moving forward we could have conversations about how we could cost share, help embed the program, etc. Initially, we ask the FQHC’s to give space for the workshops on site and to focus on referring patients. Once we have a system established and a workshop in progress, we discuss the clinic picking up a portion of the costs. This might be the stipend for one of the two leaders or books. At this point we frequently have the conversation about training their staff to help co-lead the program. We charge for training, so we may offer an FQHC a scholarship to train their staff in exchange for the commitment to co-lead a set number of workshops (usually two).

We have several types of cost-sharing arrangements. Some FQHCs have embedded the program and pay for the implementation themselves. Others do everything, except we provide class materials. Some are funding their workshops and sending additional leaders to train with us as they have staff changes, new locations, or expand their offerings. For some, based on funding source, we will split costs. Most of the FQHCs are covering costs through their education budgets. Some have told us they are using the method of counting patient contacts through on-site workshops. Their budgets are set, in part, by reporting this type of statistic which then gives them the funds to offer the programs. Even if the FQHC has trained their own staff and is covering all their costs themselves, we still provide ongoing technical assistance, licensing, data collection and reporting, tracking leader certification, fidelity observations, and marketing assistance.

From our perspective, taking a longer-term view of the investment and partnership is most important. It’s a cost-sharing and risk-sharing proposition from the start.

Lynnzy McIntosh

How was COAW successful in sustaining the partnership?

We establish annual Memorandums of Understanding (MOUs) with all of our partners. This includes basic information on implementing the program, as well as an addendum that is customized to each partner. The addendum specifies what the clinic is responsible for and what COAW is responsible for. We talk from the beginning about the cost of implementing the program. Usually, we cover the cost of the first class and getting things set up. One of the lessons learned is not to have clinics train leaders and try to implement the program on their own from the beginning. We see short-term gains because they implement workshops, but they don’t have the experience to manage everything else. From our perspective, taking a longer-term view of the investment and partnership is most important. It’s a cost-sharing and risk-sharing proposition from the start. We will invest by supporting this class for you. You will invest by referring patients to the class.

Some clinics manage everything themselves. Clinics always have access to our technical support, our centralized referral system and database, data reports and the Stanford license. We have program staff here at COAW who the FQHC can call, sort of like a hotline. The other part is all of the data access we have, including comparing their data to national or statewide statistics.  We do all of the fidelity monitoring. Our database has triggers to indicate when fidelity assessments are due. We make sure all of their leaders get annual fidelity assessments in English or Spanish. We also have templates of all of our posters, brochures, tear-off flyers, tri-folds flyers, etc. Partners can plug in the dates and times of their workshops, or we can do it and send them copies. All of that is available to them on our website. They can also access all of those forms and all of those tools on our website.

The FQHCs may have an interest in a wide age range. We’re partnering with one of our AAAs here in Boulder, CO. They capture referrals that are over 60, and we capture the rest.

Maripat Gallas

Any other tips for success?

If Area Agencies on Aging (AAAs) really wants to work more with a community health center, it’s important for them to get knowledge of what the FQHC population looks like. The FQHCs may have an interest in a wide age range. We’re partnering with one of our AAAs here in Boulder, CO. They capture referrals that are over 60, and we capture the rest. AAAs need to consider how they want to approach the issues of a wide age range.

An award-producing partnership: PCMH of the Year

One of the organizations that our staff has an ongoing quarterly meeting with has moved from training with COAW to fully embedding CDSME in their clinic. They recently won the “PCMH of the Year” award. They invited us to their celebration and acknowledged our staff person in front of the practices and said that embedding CDSME for their patients was the reason they won the award. That’s a success story in and of itself!

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Hospitals

Impact of Payment Reform

Multiple health reform legislative changes are impacting hospitals. Specifically, the payment model for hospitals is shifting from a fee-for-service model to a payment based on outcomes. These changes impact all hospitals that receive reimbursement from the Medicare program. Hospitals that have a non-profit and for-profit status are both equally impacted by the payment reform changes. The two pieces of legislation that have the greatest impact on hospital reimbursement models includes the Affordable Care Act (ACA) and the Medicare Access and CHIP Reauthorization Act (MACRA). Both legislative bills require health systems, hospitals, and physicians to begin moving towards a reimbursement model that pays for outcomes and requires provider participation in alternative payment models (APMs).

Generally, an alternative payment model is a form of payment reform in which the provider receives payment or a financial penalty based on the overall outcome of the care that is provided to a beneficiary or group of beneficiaries. These new alternative payment models extend risk to providers for the outcome of the services they render.

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High-Risk Populations

The shift toward payment for outcomes, contrasted with traditional fee-for-service payment models, has brought renewed emphasis on the impact of social determinants of health on high-risk populations. When poor outcomes are potentially attributed to social determinants of health, it is incumbent upon providers to identify resources to address these non-medical factors that impact health. If providers do not effectively address the social determinants of health, their resulting reimbursement may be reduced or they may face a financial penalty.

Dual eligible beneficiaries are an example of a population that is disproportionately impacted by social determinants of health and has a greater utilization of healthcare resources. A dual eligible beneficiary is an individual that is eligible for both Medicare and Medicaid. To qualify for both programs, an individual must meet the state Medicaid definition for poverty and meet the Medicare age (65+) or disability eligibility requirements.

All Medicare beneficiaries are included in alternative payment model programs, including dual eligibles. Hospitals are increasingly looking for strategies to address the health and welfare of their most vulnerable patient populations, which usually includes dual eligible beneficiaries.

Additional ACA requirements that are directly impacting hospital reimbursement and business operations include each of the value-based payment programs. CMS defines value-based programs as those that reward health care providers with incentive payments for the quality of care they give to Medicare beneficiaries. The value-based programs impacting hospitals include the following:

  • Hospital Value-Based Purchasing (HVBP) Program: The Hospital VBP Program rewards acute care hospitals with incentive payments for the quality of care they provide to individuals with Medicare. This program adjusts payments to hospitals under the Inpatient Prospective Payment System (IPPS) based on quality of care.
  • Hospital Readmission Reduction (HRR) Program: A hospital will incur penalties if its overall percentage of readmissions is greater than the national average. The penalty can be up to 3% of the total Medicare reimbursement. The penalty is assessed prior to the start of each calendar year and impacts the hospital’s global reimbursement for the remainder of that year.
  • Hospital Acquired Conditions (HAC) Program: The HAC Program rewards or penalizes hospitals based on the percentage of Medicare beneficiaries that experience a hospital acquired condition, such as a pressure ulcer or infection.

Each of these programs can potentially exact a financial penalty to hospital reimbursement when a hospital has poor outcomes related to readmissions, hospital acquired conditions, and/or patient satisfaction ratings.

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Non-Profit Hospitals

Both for-profit and non-profit hospitals are equally impacted by mandatory health reform measures. However, additional requirements are levied upon non-profit hospitals. The ACA mandates that for a hospital to maintain its 501(c)(3) non-profit status, it must comply with new reporting and excise taxes. Each 501(c)(3) hospital organization is required to meet four general requirements on a facility-by-facility basis:

  1. Establish written financial assistance and emergency medical care policies.
  2. Limit amounts charged for emergency or other medically necessary care to individuals eligible for assistance under the hospital’s financial assistance policy.
  3. Make reasonable efforts to determine whether an individual is eligible for assistance under the hospital’s financial assistance policy before engaging in extraordinary collection actions against the individual.
  4. Conduct a CHNA and adopt an implementation strategy at least once every three years. (These CHNA requirements are effective for tax years beginning after March 23, 2012).

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Community Health Needs Assessment

The Community Health Needs Assessment, one of the four requirements that a non-profit hospital to must meet, is included in Section 501(r) of the IRS code. An organization that seeks to do business with a hospital can use the information that is reported in the Community Health Needs Assessment to develop a strategy and business model to support these critical requirements. For example, a Community Health Needs Assessment, that outlines diabetes as a primary health issue impacting the community, may lead to additional financial support to address diabetes preventive health efforts for the target population. The hospital expenditures can be counted toward the community benefit resource allocation that supports the maintenance of the hospital non-profit status. The Community Health Needs Assessment is often made available to the public, along with the Community Benefit Report, via the hospital website.

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Conducting a Market Analysis

Generally, hospitals and physicians are more open to different models of care when they are directly impacted by risk-based payment contracts. Providers that take on more risks are more likely to be willing to engage in alternative approaches to care. It is critical to assess the status of payment reform activity in your market. You should begin with an assessment of CMS alternative payment models that are active in your market. The Centers for Medicare and Medicaid Services (CMS) provides public reports, which list all healthcare providers that are participating in one or more Medicare alternative payment models. This listing is posted on the CMS website, and the participating providers can be found under the following program titles:

Each of these payment models requires the participating providers to begin taking financial risks, based on their performance. The hospital and physician participants should improve quality and reduce the total cost of care for the Medicare beneficiaries they serve. The greater the participation in these risk models, the more likely that the hospitals will want to adopt new approaches to care delivery. In addition, these providers will want to increase efforts to improve patient activation, increase patient self-management activity, and achieve improved health outcomes. These broad objectives will require providers to integrate with community-based organizations to achieve targeted outcomes.

In addition to assessing alternative payment model participation, your market analysis should also include a review of the non-profit hospital Community Health Needs Assessment and Community Benefit Report, as well as the hospital readmission penalties and ratings. These items will provide your organization with an assessment of the current health needs and priorities for the hospital. In addition, the hospital’s participation in risk-based payment model programs provides insight into the hospital’s potential desire to develop new models of care.

Lastly, you should assess the prevalence of Medicare beneficiaries that are at-risk for social determinants of health. This population is generally comprised of large numbers of dual eligible beneficiaries with greater utilization of healthcare resources and worse health outcomes. The American Hospital Association and MedPAC have both noted that hospitals that serve a greater percentage of dual eligible beneficiaries have worse health outcomes, more readmissions, and greater utilization of healthcare resources for the population they serve. Therefore, these hospitals are disproportionately impacted by penalties related to health outcomes.

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Choosing a Hospital Partner

Once you have decided to pursue a partnership with a hospital, the first step is to select or decide on the hospital to partner with. The question then becomes how you decide what hospital to partner with. You might begin by considering which hospital(s) are looking for and how post-acute programming can benefit them.

It is important to understand a hospital’s openness to entering into a partnership and its willingness to engage in multiple conversations to explore related issues and opportunities that can be mutually beneficial. Below are some questions to ask in helping to determine a hospital’s “readiness” to partner.

  1. Is the hospital involved with Care Transitions?: This program is focused on providing resources to help community-based organizations and hospitals begin addressing hospital readmission rates. Hospitals that participate in this initiative have to have a higher than average readmissions and a committed desire to address the problem by partnering with community-based organizations.
  2. What is are the readmission rates?: CMS publishes data each year on hospital readmission rates. This is required as part of the Affordable Care Act. The data shows the comparative readmission rates for all hospitals (except Maryland hospitals) and the associated penalties that were applied to hospital reimbursement rates, due to the readmissions.
  3. What are the major goals for the next fiscal year, and how can your community-based program fit within these goals?: Non-profit hospitals must complete a Community Health Needs Assessment and a Community Benefit Report. If the hospital maintains non-profit status, you can access the health needs and goals for the facility, based on these reports. Per the American Hospital Association (AHA), 18% of U.S. hospitals are private, for-profit hospitals; 23% are owned by state and local governments; and 59% hold non-profit status.
  4. Does it have a unified all-payer system?: An all-payer reimbursement system occurs when a state applies for a special waiver to the Centers for Medicare and Medicaid Services to regulate payment to hospitals and providers in the state across all payers/insurers, including Medicare and Medicaid. Currently, there are only two states that have all-payer waivers, Maryland and Vermont. If a state is considering adopting an all-payer waiver, it must first get approval from CMS. This approval process must include the State Division of Medicaid preparing a State Plan Amendment (SPA) and obtain stakeholder input on the impact of the proposed waiver on beneficiaries in the State.
  5. Is there a population health department?: To prepare for the multiple payment reform initiatives in the market, many hospitals are bringing on new staff members to prepare and track performance in the programs. Many hospitals have created a division related to population health to spearhead their work in alternative payment models and payment reform initiatives. This unit is often linked with the quality improvement division of a hospital. If you are not sure whether or not your hospital partner has a population health department, you should inquire with the leadership overseeing quality, performance, and payment to determine the appropriate contact.
  6. What is the hospital’s position on community involvement?: Most major hospitals are non-profit, and all non-profit hospitals are required to show a benefit to the communities they serve. This information can be found by researching the Community Health Needs Assessment and Community Benefit Report if the hospital holds non-profit status.
  7. Is the hospital offering similar or related programs?: Hospital-based health promotion programs are generally limited to participants that seek care at the hospital. However, most of the health reform payment models require a hospital to address the health of the entire population served in the market. Therefore, many hospitals can have a greater impact on the health of the community by partnering with community-based organizations to extend health promotion activities into community settings.

Information regarding the first five questions provides insight into the basic organization of the hospital and how such a partnership might be achievable, e.g., operating under a unified all-payer system may ease issues regarding finances. Information about questions 6 and 7 provide insight into the hospital’s experience in delivering a health promotion program and working with a community organization.

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Engaging the Hospital

The initial steps in preparing to contact the hospital and then actually making the contact are often delicate and lengthy processes. It is important to be informed about how the hospital is organized (e.g. what departments exist and what services are already being offered), who the top person, and who other key players are. This information is necessary to identify decision makers who can help you move forward. Generally, hospitals have Population Health departments, and this is a good place to start in terms of making your contact. Other good points of contact may be the Quality Assurance department or the Community Outreach section.

You might also develop contacts by networking—becoming involved with hospital activities, such as health coalition meetings, seminars, work groups, etc. It should be your goal to help key decision makers in the hospital understand the benefits of the program. It is also important to help them see that the program is not in competition with the interests or needs of the hospital but rather is or can be a complementary or value added to improve care and health outcomes for patients and to help the hospital meet achieve its goals (e.g., reducing health care costs and readmissions).

Once you are satisfied that you have adequate background information, a reasonable profile of the potential partner, and a point of contact, you are ready to make your initial contact. An introductory email, followed by a phone call to introduce yourself is a good way to start. Keep your conversation short, explaining briefly why you want to meet and how your program can benefit the hospital. The main goal of the initial contact is to schedule an in-person meeting.

Preparing for Your First Meeting

Once you’ve made your initial contact, you should begin preparing for your first meeting with the hospital and begin working to provide the value proposition on why your program will help improve patient outcomes and achieve the hospital’s goals. At this point you need to be ready to (1) advocate for your program in a positive way, and (2) provide information about the program, its known benefits, and how these benefits are achieved. It is extremely important to show how the program fits into or advances the current needs and interests of the hospital, as well as how it could help to meet future needs.

Your assessment of these factors of hospital reform and community needs should be followed by a review of your current capacity to deliver programs and services to the at-risk population. You should determine if there is a correlation between your program and services and the defined community health needs. Next, you should document your current capacity to serve the population and address these defined community health needs. Lastly, you should highlight which aspects of your programs and services will lead to improve health outcomes that relate to hospital required performance measures. Taking these steps will assure that you are well prepared for your first meeting.

Developing Your Value Proposition

 A value proposition is generally considered as the amount of benefit that the program or service provides to the custom. This is closely related to the Return on Investment (ROI). Both value proposition and ROI must be determined based on your ability to help the customer (hospital/provider) achieve their overall objectives of reducing overall cost of care and improving health outcomes as compared to the cost of your services. You should have a well-defined value proposition completed prior to meeting with a potential hospital partner. During your presentation, you should highlight the value proposition which justifies why the hospital should partner with your organization to achieve the shared improvements to health outcomes for the defined population.

Remember that every hospital is different and has its own needs, so be prepared to meet the hospital at whatever level it is operating and go from there. Be realistic about what you can and cannot accomplish in a given amount of time and accept that it may take longer than you think to achieve the desired goal of developing an active and committed partnership. In some instances it may take as long as a year or more to realize that goal. Much depends upon the hospital and its needs, as well as the goal(s) you hope to achieve.

Examples of a Value Proposition

  1. We are Anywhere AAA. We provide a range of services with a niche for addressing the social determinants of health for high-risk dual eligible beneficiaries. For the past 50 years, we have been the leading providing of home and community based services that enable significant cost savings to the Medicare and Medicaid program by reducing institutional care and supporting high-risk older adults and persons with disabilities to remain in community settings as long as possible.
  2. We are Anywhere AAA. We provide a Nationally Accredited, evidence-based diabetes education program targeting older adults and persons with disabilities. Our program is unique in that we provide our diabetes education program in community settings with a focus on high-risk community dwelling older adults that have limited mobility and transportation challenges. Our program has an 80% completion rate and is fully sustainable through Medicare reimbursement.

Planning and Conducting the Initial Meeting

Prior to the Meeting

  • Schedule your meeting at a time and location that is convenient for your partner.
  • Ensure that your meeting invitation list includes key decision makers.
  • Establish a list of defined objectives that you want to achieve during your meeting.
  • Be prepared to state your value position clearly and succinctly and prepare for questions that might be raised about your program.
  • Develop an agenda that is realistic and allows you to achieve your defined objectives. A sample agenda should include the following key points:
    • Introduction of your agency
    • Description of your intervention
    • Overview of the target population
    • Value proposition and return on investment
    • Costs

During the Meeting

  • Be on time, but also be understanding and flexible in case the meeting is delayed.
  • Greet everyone and create a welcoming environment. Find common ground and begin to build relationships. That is one of the most important tasks during this first meeting.
  • After introductions, allow the hospital representatives to time to talk about their needs, goals, and priorities. Then, make your value proposition clearly and succinctly to show how your program can help achieve those goals. Be prepared to answer questions and handle objections.
  • Review the meeting purpose, and use the agenda to provide focus to the meeting, while also keeping the tone friendly and conversational.
  • Before ending the meeting, summarize what was discussed and decided, talk about your next steps, and schedule your next meeting.
  • Close the meeting on time, and thank everyone for coming. Be sure to get names and contact information before leaving.

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Developing the Partnership

In developing the partnership, it is important to maintain regular contact to avoid loss of interest and keep forward momentum. Communication via phone, email, and in person will help to establish the relationship. Be prepared to answer questions, work through challenges, and continue to educate hospital personnel about the benefits of your program. Take time to plan each meeting, stick to your allotted time, and close each meeting with a brief summary of what you agreed to and what your next steps are.

Also, seek out ways to include discussion of the program as part of casual conversation or unexpected “teachable moments” with individuals you interact with in the hospital setting. Take advantage of any established collegial relationships or personal contacts with hospital staff to talk about the program and what it can accomplish. Base what you do or say on how the program can benefit the hospital, how it aligns with and can help achieve the hospital’s goals, and how it can reduce costs.

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Formalizing the Partnership

Formalizing the partnership will require the execution of an agreement. You should consult an attorney for legal advice on how to negotiate the terms of a legal agreement with a partnering hospital. In addition, you will need to execute a business associate agreement. The business associate agreement is an agreement between a business associate (in this instance, the community-based organization) and a HIPAA-compliant entity. The agreement is required to ensure that all parties work to protect personal health information of the individuals that are served.

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Strengthening and Sustaining the Partnership

Strengthening and sustaining the relationship will require ongoing revalidation of the value your services and programs that you provide to the partnering hospital. You must also be prepared to document the outcomes of your interventions and have objective quality measures that are tracked, reported, and shared with the hospital. It will be important to continue to meet on a regular basis to discuss progress and address any implementation challenges that might arise, as well as to review the status of the following items:

  • Referral numbers
  • Source of referrals
  • Quality metrics
  • Per beneficiary and population health outcomes

 Over time, there may also be a need or desire to modify or expand the agreement. Once hospital decision makers see how your program benefits the hospital and the population it serves, they may be interested in expanding the agreement to include other programs or services that you offer.

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MAC, Inc. Living Well Center of Excellence

The MAC, Inc. Living Well Center of Excellence (LWCE) is an Area Agency on Aging in Maryland. MAC is dedicated to the principle that older persons are entitled to lives of dignity, security, physical, mental, and social well-being; and to full participation in society. Leigh Ann Eagle, Director of the Living Well Center of Excellence, shares their experience partnering with hospitals to implement the Living Well with Hypertension module.

In Maryland, chronic diseases, including heart disease, stroke, and diabetes, are the leading causes of death and account for 75% of health care costs.

Leigh Ann Eagle

Focus of the Initiative

To utilize the Living Well with Hypertension module and a pre-post blood pressure screen to:

  1. Identify individuals with poorly controlled or uncontrolled hypertension;
  2. Establish a protocol for appropriate referrals to manage blood pressure; and
  3. Document the impact of CDSME programs in increasing participants’ self-management skills.

Need and Problem

In Maryland, chronic diseases, including heart disease, stroke, and diabetes, are the leading causes of death and account for 75% of health care costs. The State of Maryland’s prevalence of hypertension is 31.3%, compared to 38.2% in Wicomico County, 41.9% in Worcester County, and 45.4% in Somerset County (2014 Professional Research Consultants Community Health Needs Assessment report).

The Maryland Department of Health and Mental Hygiene (DHMH) identified the need for a hypertension intervention, given the prevalence of the disease. A small DHMH grant through the state’s Million Hearts initiative provided initial funding for the hypertension module and the opportunity to document changes in blood pressure. The LWCE worked with the New York Quality Improvement and Technical Assistance Center (NYQTAC) at the University of Albany to train CDSME Master Trainers as leaders for a single session/session 0 hypertension module, known as Living Healthy with Hypertension in New York.

Intervention

The initial pilot was conducted beginning January 1, 2014 through June 30, 2014 with 235 participants; the program is ongoing with over 500 people participating to date. Past participants include older adults (79%), individuals with disabilities (40%), adults with hypertension (43%), adults with multiple chronic conditions at risk of hypertension (85%), and African Americans (50%).

Initially the module was offered on the lower eastern shore of Maryland. Since then, the program has expanded from four to fourteen Maryland counties and Baltimore City.

MAC, in collaboration with Peninsula Regional Medical Center (PRMC), the Maryland DHMH, and NYQTAC, took the following steps to achieve success with the hypertension model:

  • Purchased a state license and trained five CDSME Master Trainers as Master Trainers for the Living Well with Hypertension Module via online training.
  • Held eight hypertension leader trainings in three parts of the state including the Eastern Shore and Western and Central sections of Maryland.
  • Developed a protocol for blood pressure screening and referral based on participant’s screening numbers.
  • Established data-sharing agreements with the hospital and health department to share participant health conditions, blood pressure readings, and other measures.
  • Expanded the participant consent form to allow data sharing with the hospital and providers.
  • Expanded the Maryland statewide database to:
    • Tracking hypertension module documents
    • Log pre-post blood pressure measurements
    • Implement a referral process and track participant engagement in order to provide feedback to the health care provider.
  • Implemented initial workshops, collected hypertension prevalence and change in blood pressure, and reported disaggregated data to DHMH.
  • Maryland Department on Aging offered incentives to senior centers to provide the Living Well with Hypertension module or a healthy eating module in 2016.
  • Continue to include Living Well with Hypertension training in CDSMP/DSMP leader trainings.

Initial Pilot Outcomes

62% of participants had improved blood pressure measurements from week one to week seven of the CDSMP workshop.

Leigh Ann Eagle
  • Training and participation
    • During the six-month period, 37 leaders were trained in the Living Well with Hypertension module and 10 new leaders were trained in DSMP, including 5 community health workers;
    • 225 individuals on the Eastern Shore participated in the Session 0 and blood pressure screening held at 20 sites; and
    • Participants were referred back to MAC for resources via the process developed by the Million Hearts initiative.
  • Results of the initial blood pressure screening  (n= 196)
    • 34% of individuals screened had hypertension
    • 21% of participants had poorly controlled hypertension and were advised to check in with their health care provider
    • 10% of participants had uncontrolled hypertension and were referred directly to a provider or community health worker for guidance
  • Number of individuals that completed a blood pressure screening that participated in a CDSMP or DSMP Workshop (n=79)
    • 58 workshop participants had hypertension
    • 40 workshop participants had diabetes
  • Difference between blood pressure screenings completed during week one and week seven of CDSMP or DSMP (n=40)
    • 24 (62%) participants had improved blood pressure measurements from week one to week seven.
    • 11 (28%) participant’s blood pressure measurements remained the same. Seven (18%) of these participants had blood pressure measurements in the healthy zone during both screenings.
    • 5 (13%) participants had higher blood pressure measurements in week seven, compared to week one.

Major Accomplishments and Impact

Blood pressure screenings identified individuals with poorly controlled and uncontrolled hypertension, so they could receive the appropriate referral to participate in a CDSMP or DSMP workshop or to consult with a provider or community health worker. Twelve individuals identified with uncontrolled hypertension or other unmanaged chronic conditions were referred to community health workers for longer-term interventions.

Specifically, the following accomplishments were identified:

  • The blood pressure screenings served as an incentive to learn more about CDSMP and DSMP and increased recruitment for both types of workshops.
  • The use of Session 0 provided a clear description of the types of activities conducted in CDSMP and allowed individuals to make an informed decision about participating.
  • Screening participants for hypertension validated that MAC was conducting outreach to people with chronic health conditions.
  • The collection of blood pressure measurements provided a clinical measure to document participants’ conditions from the beginning to the end of CDSMP and DSMP workshops, demonstrating the positive impact of these evidence-based programs.

Implications

Showing the impact of CDSME workshops on a specific clinical measure has been invaluable in elevating the awareness of participants’ risk and in establishing MAC as an important member of the health care team.

Leigh Ann Eagle
  • The collaboration between hospital, home care agency, and MAC’s community health workers has resulted in a critical cross-referral of individuals who need additional clinical oversight or need home and community-based resources, such as home delivered meals, and transportation.
  • Documenting the importance of home and community-based services and the impact of evidence-based self-management programs in reducing risk of complications and hospitalization underscores the importance of both clinical and non-clinical services in maintaining and improving the health of individuals with hypertension and/or diabetes.

Challenges or Barriers to Success

It took time to develop the referral processes and to educate providers about the value of  evidence-based CDSME programs.

Next Steps

MAC continues to use the Living Well with Hypertension Module to increase and retain participants, identify hypertension risk, document clinical measures, and link individuals to the appropriate resources to manage their health.

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Patient Centered Medical Homes

What is the PCMH Model?

The Patient Centered Medical Home (PCMH) is a care delivery model that incorporates comprehensive, coordinated, whole-person care, offered by a team of providers in partnership with patients and their families as core team members. Numerous health care providers, including private practices, Federally Qualified Health Centers (FQHCs), and large multi-site health care systems, are transforming their practices to become PCMHs.

According to the Agency for Healthcare Research and Quality, the Patient Centered Medical Home (PCMH) is a primary care delivery model that is designed to improve health outcomes. The patient is at the center of this team-based care approach delivered by multiple health professionals (doctors, nurses, social workers, physician assistants, pharmacists, nutritionists, and others) working together with the patient, family members, and other health care entities across the entire continuum of care – specialty care, hospital, home health, and community-based services.

The health care team and the patient establish shared goals and work together to support self-management and self-care to achieve those goals. Family members and caregivers are also involved in the management of the patient’s care and play a vital role in providing social and emotional support. Evidence-based chronic disease self-management education (CDSME) programs can support PCMHs to improve the self-management practices of their patients, to provide a more positive health care experience for them and their family members, and to improve health outcomes.

Five Primary Functions of a PCMH

  1. Patient-Centered:Partnerships among practitioners, patients, and their families ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.
  2. Comprehensive Care:A team of care providers is wholly accountable for a patient’s physical and mental health care needs, including prevention and wellness, acute, and chronic care.
  3. Coordinated Care: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, and community services and supports.
  4. Accessible:Patients are able to access services with shorter waiting times, “after hours” care, 24/7 electronic or telephone access and responsive communication through health information technology innovations.
  5. Quality and Safety:Clinicians and staff provide safe, high-quality patient care through clinical decision-support tools, evidence-based medicine, shared decision-making, performance measurement and improvement, and population health management. Publicly sharing quality data and improvement activities contributes to a systems-level commitment to enhance quality.

 Recognition and Accreditation Programs

Generally, in order to become a PCMH, medical practices must apply for recognition from an accrediting organization. There are a number of local, state, and national recognition and accreditation programs. Some practices are required to complete a recognition program, but for others, becoming a recognized PCMH, is voluntary.

The National Committee for Quality Assurance (NCQA) is the most widely adopted national organization. Other national organizations include the Accreditation Association for Ambulatory Care (AAHC), URAC, and The Joint Commission (TJC). In order to achieve NCQA recognition as a PCMH, there are six standards that relate to the five PCMH attributes above that every practice must meet. You can locate NCQA-recognized PCMH practices in your state by using NCQA’s recognition directory.

Once a practice becomes recognized as a PCMH, it is eligible to receive reimbursement incentives under the Centers for Medicare & Medicaid (CMS) Comprehensive Primary Care (CPC) Initiative and the Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration. Some commercial health insurance plans also provide financial incentives to practices that achieve PCMH recognition. In order to receive reimbursement incentives, PCMHs must increase quality, reduce costs, and improve patient outcomes.

Providing an increased level of support specifically to high risk patients, such as older adults and dual eligibles, can lead to improved outcomes with potential cost savings, which in turn can result in qualifying for reimbursement incentives.

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What are the Benefits of Partnering?

There are several reasons that PCMHs can benefit from partnering with community-based organizations (CBOs) that offer CDSME programs.

Meet National Recognition and Accreditation Requirements

The requirements for national recognition and accreditation include standards for self-care, as well as referrals to community organizations. For example, the National Committee on Quality Assurance (NCQA) has Six Standards of Care that must be met. Of these standards, PCHM 2, 3, 4, and 5 have specific language related to self-care, preventive services, chronic care services, community referrals, and care coordination that align with CDSME programming. Offering CDSME will help the PCHM “check off” that they meet the “must pass” requirements for these standards.

  • PCHM Standard 2: Team-Based Care
    • Element B, Medical Home Responsibilities, requires the care team to provide access to self-management support. Offering evidence-based CDSME programs onsite is an ideal way to increase access to self-management support.
    • Element D, The Practice Team, involves training and assigning members of the care team to support patients/families/caregivers in self-management, self-efficacy, and behavior change.
  •  PCMH Standard 3: Population Health
    • Element D requires that the PCMH proactively identifies and notifies patients or their families/caregivers of their needed care, including preventive services and chronic care services. CDSME programming can be included as a preventive and chronic care service that can help individuals with a chronic health condition, especially individuals who are newly diagnosed, as well as those who have difficulty following their medical plan of care.
    • Element E, Implement Evidence-Based Decision Support, specifies that the care team implement clinical decision support following evidence-based guidelines for a chronic medical condition. This could include referring a patient to an evidence-based CDSME program.
  • Standard 4: Care Management and Support
    • Element A, Identify Patients for Care Management, necessitates a systematic process and criteria for identifying patients who can benefit from care management. In setting these criteria, the PCMH might consider factors, such as poorly controlled conditions, multiple chronic conditions, social determinants of health, and patients who are high risk/high cost. CDSME programs can help improve the care and outcomes of these patients once they are identified.
    • Element B, Self-Planning and Self- Care sets the expectation that the care team, patient and family/caregiver collaborate to develop and keep up-to-date an individual care plan that must include a self-management plan.
    • Element E, Support Self-Care and Decision Making, requires PCMH practices to provide educational materials and resources to patients and to provide self-management tools. This includes offering or referring patients to self-management group classes and support, maintaining a list of key resources in the community, and assessing the usefulness of identified community resources. The CDSME program can be offered to meet the requirements of this element.
  •  Standard 5: Care Coordination and Care Transitions
    • This standard involves tracking and coordinating of referrals and coordination of care across health settings, including from hospital to the community. Since CDSME is an important intervention to help patients manage and improve their health, there should be a process in place to identify points along the care continuum, such as after a hospitalization, for referring patients to CDSME programs. There should also be a way to track those referrals and to document the outcomes – which patients who were referred actually attended a workshop.

Improve Health Care Outcomes and Reduce Costs, Especially for High-Risk and Underserved Populations

The PCMH’s focus on patient-centered, coordinated, and team-based care makes it a good model to improve health outcomes for high-risk and underserved populations. The Affordable Care Act (ACA) has enacted provisions that require high-risk older adults and dual-eligible Medicare beneficiaries to receive care that includes self-management education and a whole-person approach, such as that provided by the PCMH model, to address their complex needs.

The ACA legislation provides a prime opportunity for CBOs to introduce CDSME programming to PCMHs and demonstrate its value to improve health outcomes for this population. The expertise and experience that CBOs bring with regard to reaching frail and vulnerable older adults and adults with disabilities and enrolling them in evidence-based CDSME programming, can be a valuable service to PCMHs in terms of improving outcomes for disparate populations.

Qualify to Receive Reimbursement Incentives

PCMHs can qualify to participate in financial incentive payment models through the receive Centers for Medicare & Medicaid Services (CMS) Innovation Center alternative payment programs. There are a number of performance objectives that must be met in order to help PCMHs recoup incentives:

  • Delivery of care coordination
  • Preventing unnecessary hospital admissions
  • Reducing readmissions
  • Limiting emergency room visits
  • Preventing unnecessary chronic disease complications

Chronic Disease Self-Management Education (CDSME) programs can help PCMHs to qualify for incentives, thereby increasing their bottom line. They have been demonstrated to improve self-efficacy, increase patient activation (e.g., communication with health care providers, healthy lifestyle behaviors, medication adherence), improve self-reported health, and lower health care utilization (emergency room visits and hospitalizations).

A Mutually Beneficial Partnership

Partnering with a PCMH is also beneficial to the CBO that offers CDSME programs. The PCMH offers a reliable and ongoing source of referrals that can help fill workshops and serve more people. By serving more people, the CBO can help achieve the goal of improving the health and quality of life of a greater number of older adults and adults with disabilities in its respective geographic area. Further, if the organization partners with other CBOs to form a network of providers for CDSME, there is potential for wider geographic distribution of CDSME programs within the state or region.

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Centralized and Coordinated Processes

The Network Hub Model

Centralized, coordinated processes refer to logistical practices for recruitment, referral, enrollment, marketing, quality assurance and evaluation that are carried out under the direction of a central organization and coordinated among a network of partners. The model for providing services in this way is known as the Network Hub. It provides a unified and consistent approach to program delivery across a geographic area, either regional or statewide. The central organization is the center of activity that connects a network of partners, including health care systems and local community organizations who offer evidence-based programs, all working together toward a common goal.

Health plans and large health care provider systems are interested in partnering with organizations that have the infrastructure to respond quickly to a large number of referrals, enroll participants in workshops, offer quality workshops on an ongoing basis, and provide timely data on outcomes. The Network Hub model offers a framework for meeting these needs.

Key Benefits of the Network Hub

  • Provides a uniform, consistent way for potential participants to learn about and access programs and receive services
  • Increases program efficiency by reducing duplication of efforts
  • Appeals to health care entities, as there is one organization, rather than several, with which to interface and communicate
  • Can act on behalf of its partners to negotiate and sign contracts with the health care sector
  • Provides a framework to increase program reach and can respond to the volume demands of health plans or health care systems by aligning the efforts of many organizations

Health plans and large health care provider systems are interested in partnering with organizations that have the infrastructure to quickly respond to a large number of referrals, enroll participants in workshops, offer quality workshops on an ongoing basis, and provide timely data on outcomes. The Network Hub model provides a framework to meet these needs.

Five Key Steps to Build the Network Hub

  1. Develop a Leadership Structure
    To succeed, Network Hubs should have an effective leadership structure to provide direction, develop and coordinate logistical processes, and mobilize resources across the network of partners. A strong leadership structure includes adequate staffing, information sharing among the network of partners, and inclusion of both community-based and health care partners in discussions and decision making. At a minimum, your leadership structure should include a director and a program manager. The director is responsible for engaging partners in establishing a vision, mission, and goals for the Network Hub and mobilizing action across the network. Another important role is that of the program manager, who is responsible for overseeing activities related to the direct implementation of the program across the network of partners. Initially, one individual might serve as both the director and the program manager. As resources grow and the network expands, the positions can be separated. Community-based organizations that form the network, as well as health care partners, should be involved in leadership opportunities and have a voice in decision making.
  2. Define Roles and Responsibilities of Partners
    Defining the roles and responsibilities of partners will focus the work of your Network Hub, help avoid disagreements, keep stakeholders engaged, and increase productivity. As you consider assigning roles and responsibilities, be sure to include your partners in the decision making process. Listen to their input about ways that they think they can make a contribution, and identify the strengths that they can bring to the network.
  3. Make Decisions about Program Delivery, Quality Assurance, and Evaluation Processes
    Once roles and responsibilities are defined, involve your partners in discussing and coming to an agreement about program delivery and evaluation processes, including communications, referral, marketing, and quality assurance and performance measures or outcomes. Decisions need to be made about which organizations will serve as host organizations, provide sites for program implementation, contribute Leaders, make referrals, help market the program, offer in-kind support, contribute funding, or assist in other ways to support the network.It is important to develop formalized, written implementation and fidelity processes or manuals to guide your efforts and to define the structure, channels, and flow of communication. Involving your partners in the development of these guidelines from the beginning will keep them engaged and can lead to better processes and outcomes.
  4. Maintain an Infrastructure to Respond to Volume Demands
    Health care organizations are interested in serving their broad base of consumers and want to be assured that you have the mechanisms in place to offer CDSME workshops on a regular basis throughout a defined geographic area. You must have an adequate infrastructure in place to support ongoing delivery of CDSME workshops. This includes a sufficient pool of active Master Trainers and Leaders and reliable host and implementation sites to offer CDSME workshops on a regular schedule across the targeted geographic area.Your infrastructure should include a system for tracking Master Trainers or Leaders; ongoing communications; professional development, support, other Master Trainer/Leader retention strategies; and appropriate program licensing. You may want to consider offering online CDSME programs to offer consumers a choice in program mode and to fill gaps in areas where in-person workshops are not available. You will be expected to demonstrate that you have processes in place to handle a large volume of referrals and to collect, monitor, and manage participant and program data in a timely manner.
  5. Develop a Sustainability Plan
    It is important to think about sustainability of your Network Hub, because you want to be recognized as a trusted and reliable partner to offer the program on an ongoing basis to meet the needs of your health care partners. Business and sustainability plans are a blueprint to help you scale and sustain your programs beyond grant funding. Your sustainability plan should include diversification of funding streams, including payment or reimbursement for your services from health care organizations.

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Marketing and Recruitment

When working with health care partners, it is important to have an effective marketing, recruitment, and enrollment process to meet their volume demands. Collaborating with your health care partners to develop centralized, coordinated marketing, recruitment, and enrollment processes is the key to your success.

Don’t assume that referrals will come automatically just because you have a contract with a health care organization. Health care organizations know their members and the best channels to reach them. Talk with them early in the planning process to identify the appropriate messaging and marketing and referral strategies for reaching their consumers.

There are many ways to reach your health care partners’ consumers. The best strategies will depend on the type of health partner that you are working with and its usual and customary practices for handling marketing, recruitment, and referrals.

Marketing Strategies

  • Patient Registries and Outreach Letters: A large health plan or an Accountable Care Organization (ACO) might agree to provide a registry of their members who have chronic diseases. In Massachusetts, the Healthy Living Center of Excellence (HLCE), a Network Hub, uses this approach in working with a Dual Eligibles Health Plan. If you decide to use this approach, you will need to work with the health plan to determine the process for contacting and engaging individuals on the list to enroll them in workshops. The HLCE sends an outreach letter jointly from the health plan and the Network Hub to introduce the program and then follows up with a direct phone call using motivational interviewing to enroll individuals in scheduled workshops.
  • Robocalls: Some health plans provide mass, automated outreach calls to their members to notify them of programs and services. A computerized auto-dialer leaves a pre-recorded outreach message soliciting program participation. Partners in Care Foundation uses this approach in working with a large health plan.
  • Targeted Outreach: You and your health care partner might decide to identify specific criteria for targeting individuals who would benefit from the program and then focus your efforts on engaging and enrolling them. For example, you might agree on targeting individuals who are newly diagnosed, those who are high utilizers of heath care services, Dual Eligibles, or those with multiple chronic conditions. When this approach is used, the health care partner might agree to send an outreach letter to potential participants to recommend the program and introduce them to you.
  • Referrals or Provider-Led Outreach: Health care professionals, such as doctors, physician assistants, nurse practitioners, nurses, social workers, patient assistants, community health workers, and other members of the health care team play a role in educating patients about the benefits of CDSME programs, referring them to workshops, and helping them enroll. When this approach is used, it is important to work with the health care practice to develop processes for embedding the program into routine organizational operations. Marketing and referral materials should be visible in the practice, and there should be a protocol for introducing the program to patients and referring them to workshops. Regardless of the specific processes that are developed, it is important to report back to your health care partner who was enrolled, who attended, and who completed the program.

Formalizing Your Marketing Approach

As you develop a formal agreement or contract with your health care partner, it is important to include your marketing plan and decisions about who will do what in the written document. There should be language that makes it clear that marketing and recruitment are a joint effort. Further, the costs for outreach and marketing should be included in the negotiated contract rate. A health plan or other health care partners might decide to pay one rate for all members who receive outreach, regardless of whether or not they attend a workshop, and different rates for those who attend at least one session or those who complete (attend four of the six sessions) the workshop.

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Referrals

A centralized and coordinated process should also be in place to receive and respond to referrals made by your health care partners. Below are a few steps for developing and strengthening your referral system.

Determine the Type of Referral to Be Made

There are many ways referrals can be made. The referral system that works best for your efforts will depend on the nature of your relationship with your health care partner. Some common types of referral processes for working with health care partners are described below.

  • Referrals made by a doctor, other health care professional, or a case manager– A provider emails, faxes, calls, uses the website, or some other method to transmit a referral to the Network Hub.
  • Referrals made by a provider using an internal registry– A health care professional or health plan provides a list of patients to the Network Hub. This often involves sending a co-branded outreach letter to the patient from the Network Hub and health care partner.
  • Self-Referrals A patient refers themselves to a workshop by contacting the Network Hub via a toll-free phone number, a website portal, or in some cases via their local community-based organization that is a partner with the Network Hub. There should be a variety of ways that individuals can learn about and easily access CDSME programs in their state.

Develop a Referral Workflow

A referral work flow can help clarify roles and responsibilities in the outreach and enrollment process. You should outline who is responsible for key activities, including scheduling workshops, contacting and enrolling patients, collecting and entering data, tracking and reporting on patient participation and completion, following up on patients who don’t attend or those who drop out.

Technology-Based Referral Systems

Technology-based referral systems can increase efficiencies in communication among CDSME providers, the Network Hub, health plans, health care providers, and other key partners. Technology can be useful in tracking and monitoring referrals, identifying at risk patients, flagging or reminding health care professionals to make referrals, and enhancing communication between health care entities, CDSME providers, and the Network Hub. When sitting down with your health care partners to map out referral processes, discuss how technology can be integrated into your approach.

Use a Bi-Directional Referral System with Mechanisms for Tracking and Feedback

It is important to build into your referral system, mechanisms for providing feedback to your health care partners.

Provide Feedback to Health Care Partners on These Program Elements

  • Outreach efforts
  • Reasons for refusals
  • Attendance
  • Program completers and completion rate
  • Satisfaction surveys
  • Any outcomes that you agree to capture

Develop HIPPA Compliance Procedures

Plan how you will protect the privacy of patient data to satisfy your health care partners’ needs for HIPAA compliance. You should initiate a Business Associates Agreement that will be signed by all providers and partners. You will need to ensure that partners, staff, and volunteers are trained in privacy compliance and HIPAA.

Helpful Resources

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Quality Assurance and Evaluation

Most health care organizations will be interested in your ability to implement CDSME programs across a wide geographic area consistently. You will need an effective quality assurance (QA) and evaluation process to: (1) make certain that the program is delivered with fidelity; (2) maintain consistency in referral and program delivery processes; (3) monitor progress and make necessary adjustments to ensure the program is being implemented as intended; and 4) measure the effectiveness of the program.

It is vital that quality assurance and evaluation activities be planned and conducted in collaboration with your health care partners. Sharing responsibilities between you and your health care partners is important. You should build QA and evaluation agreements into the contract, outlining how responsibilities will be shared and who is responsible for what. Costs for carrying out QA and evaluation need to be taken into consideration and can be included in the unit rate cost for each participant.

As part of these efforts, different types of program and individual-level data can be collected. Metrics may include workshop attendance, participant demographic information, participant activation, participant satisfaction, self-reported outcomes, and/or clinical indicators, such as Hemoglobin A1C levels.

During Early Conversations with Health Care Partners

  • Discuss QA and evaluation as a necessary element of successful collaboration for program delivery
  • Emphasize that QA is an ongoing process, which is more likely to be successful when the health care partner plays a role
  • Review the QA measures that are in place and explain their importance in monitoring and achieving the desired program results
  • Outline the QA and evaluation process in written agreements, including agreed-upon outcome measures that will be tracked and monitored
  • Discuss how QA and evaluation will be a regular part of program review in ongoing partner meetings

Considerations for Your QA Plan as Your Partner with Health Care Organizations

  • Determine together what data you will collect, how you will collect it, and how you will manage it on an ongoing basis
  • Develop a listserv and other ways to share information across the state
  • Develop coordinated data collection and data entry procedures that include monitoring the data for fidelity
  • Develop fidelity monitoring processes and provide training for staff, volunteers, and partners so that everyone understands what is expected
  • Share fidelity tips in newsletters and other communications
  • Provide regular trainings, conferences, and refresher trainings around evidence‐based programs

No matter what data is collected and reported on, it is important to develop a clearly defined process and metrics that are mutually agreeable to the Network Hub, community-based partners, and health care partners.  Once decisions are made, all partners should continue to be involved in discussions and actively engaged in assessing progress and program outcomes.

Helpful Resources

 

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Healthy Living Center of Excellence

The Healthy Living Center of Excellence (HLCE) in Massachusetts is a unique collaboration between community-based organizations, aging service providers, health care systems, governmental agencies, and healthcare payors; all with the shared goal of transforming the traditional health care delivery system. Led by a medical care provider (Hebrew SeniorLife), a community-based organization (Elder Services of the Merrimack Valley), and an Advisory Committee representing diverse community stakeholders, HLCE represents an integrated delivery system which leverages the expertise and resources of the community to achieve better care, better health and lower costs.

Jennifer Raymond, Director of the Healthy Living Center of Excellence, shares their experience in building a hub.

We all agreed that one central hub that contracted between health care systems and community programs across geographic areas would be the best way to assure ease of service, as well as fidelity and quality consistency for the various programs offered.

Jennifer Raymond

How did you get started as a Network Hub? What was the impetus?

The beginning of the HLCE as a Network Hub was the result of several factors coming together that created a “perfect storm.”

A loose statewide coalition of community-based organizations (CBOs) already existed that was implementing evidence based programs (EBPs) in widespread areas of the state. We learned from our health care partners that having a centralized “hub,” whereby providers could access programs across coverage areas, was essential. We initiated conversations with our state unit on aging, department of public health, and community partners with the idea of working together to create a ”statewide provider network” with one central hub to connect health care providers with programs in local communities.

We all agreed that one central hub that contracted between health care systems and community programs across geographic areas would be the best way to assure ease of service, as well as fidelity and quality consistency for the various programs offered. We also addressed the importance and role of the Network Hub in meeting the needs of CBOs and the individuals they serve. After numerous conversations with our many partners and administration of a survey that helped gather interest in and ideas for the hub concept, we decided to form a statewide network with regional coordinators, who could respond to local needs. And that was how we became a Network Hub.

What is nature of your leadership structure? How important was it in the success of the HLCE as Network Hub?

The leadership structure of the HLCE is both broad and deep to carry out its role of serving as an interface between health care providers and CBOs throughout the state. The significance of an effective and efficient leadership structure cannot be overstated—it is integral to the success of the HLCE. The HLCE has a central infrastructure headed by a Director and a part-time Medical Director, and supported by an Assistant Director, Program Manager and two coordinators. Each has his or her own set of responsibilities in maintaining the efficient functioning of the system.

To assure that statewide demands are met, there are seven Regional Coordinators who hold regular coalition meetings with local partners/CBOs and, in that way, extend into all parts of the state. The regional coordinator model has changed over time based on experience, regional needs, and a desire by local partners to be in more direct and closer contact with the HLCE. Last, but not least, the Assistant Executive Director of Elder Services of Merrimack Valley provides important leadership and direction for the HLCE.

Identifying partners who were committed to the concept of a Network Hub was the bread and butter to successfully launch and maintain the HLCE. Building on our earlier work, we were fortunate to have some community partners who were invested from the outset.

Jennifer Raymond

What contributed to the success of the initial launching of the Network Hub?

There were two major assets that were and remain critical to the success of the Network Hub: adequate funding and committed partnerships.

  • Funding: We knew that adequate funding was an important component of success. Initially, we had conversations with, and submitted applications to, a number of foundations and agencies for support of the operation of the HLCE as a Network Hub. We were fortunate in receiving grants from the Administration for Community Living (ACL) through the Massachusetts Executive Office of Elder Affairs and the Department of Public Health, the Tufts Health Plan Foundation, and the John A. Harford Foundation. Elder Services of the Merrimack Valley also continued to provide support in the form of funding, space and other in-kind resources. Recently, we have secured contracts with other groups within the state, out of-state-groups, and national organizations to provide training and technical assistance. These include the Massachusetts Department of Public Health, the National Council on Aging (NCOA), and the National Association on Area Agencies on Aging (n4a).
  • Partnerships: Identifying partners who were committed to the concept of a Network Hub was the bread and butter to successfully launch and maintain the HLCE. Building on our earlier work, we were fortunate to have some community partners who were invested from the outset. We worked diligently to identify and bring on board additional partners, and now work with more than 90 community partners, including senior centers, County Councils on Aging, faith-based organizations, multicultural organizations, YMCAs, Area Agencies on Aging, and housing/assisted living groups. We also established partnerships with health care providers. Currently, we are partnering with a variety of different health plans, Accountable Care Organizations (ACOs), private practice groups, primary care groups, and others. None of the foregoing was accomplished overnight and like anything that is of value, partnership development has required commitment, nurturing, and ongoing attention.

What were your keys to success in building your partnerships?

We realized from the outset that we needed to demonstrate the value of what we were offering before we could say to them—“here’s what it’s going to cost you.” We had regular meetings and in-depth discussions with interested health care partners and deliberated over plans to make the system work. These meetings focused on the benefits of programs to improve health and reduce costs, as well as on their value to increase patient activation and satisfaction. We also discussed the pros and cons of a three-entity configuration—health care providers, CBOs, and the HLCE as the Network Hub or interface between them.

We knew that having partners who were fully committed to the concept of a Network Hub and who shared some responsibility for supporting major functions of the hub were necessities. There were regular statewide coalition meetings which allowed for ongoing discussions and interaction among the parties involved.

Over time, many health care organizations were willing to commit to sharing the costs of marketing, recruiting, referrals, data management, etc. In return we provided them with information about outcomes of CBO programs and assured them that we would monitor the consistency and quality of program content and delivery. There was also considerable interest in monitoring the pattern of participants’ involvement in CBO programs—who was enrolling, who wasn’t, and why some enrolled and others did not.

We realized from the outset that we needed to demonstrate the value of what we were offering before we could say to them—’here’s what it’s going to cost you.’

Jennifer Raymond

We identified the seven Regional Coordinators by distributing a request for proposal (RFP) to determine which agencies could demonstrate capacity and commitment to the system. Most agencies indicated a willingness to pay for training of lay leaders and master trainers, share costs to implement workshops, and offer in-kind contributions. We provided weekly newsletters, fidelity webinars every two months, and an annual continuing education conference. To strengthen local involvement and address needs specific to each region, the Regional Coordinators met every two months.

What contributed to your success in achieving a viable and efficient means for receiving referrals, enrollment in programs and monitoring quality assurance?

Overall, the most important factor in the success of our referral, enrollment, and quality assurance (QA) processes was to take a “partnership approach” to contracting. Instead of seeing the health care partner as the “payer” and the HLCE and its community partners as “vendors,” we approached the referral process as a partnership. Each has a specific role to play in making the system work.

Our Five-Step Referral and Enrollment Process

  1. The health care partners make referrals either by telephone, fax, or through the HLCE website.
  2. As a general rule, the HLCE and the health care partner then send a joint outreach letter that highlights the partnership to patients who are identified as needing the service.
  3. The letter is followed up by direct phone calls from the HLCE to individual patients/clients.
  4. Using Motivational Interviewing, we talk to potential participants about the benefits of the programs and encourage them to enroll. Motivational interviewing is also used to identify and problem solve barriers to their participation and problem solve those barriers so that they are more likely to enroll.
  5. Individuals who agree to participate are then enrolled in local programs. Some who do not wish to participate initially may agree to receive another call in a month or two in case their circumstances have changed, while others may choose not to be contacted again.

Use of a Registry to Identify Potential Participants

We have found that the most effective strategy in working with health care partners to identify potential workshop participants is to ask them to provide an internal registry of patients organized by geographic area. HLCE works with the health care partner to define the criteria for this registry.

The criteria may vary over time, based on a number of factors, including the membership or patient caseload mix, the specific “pain points” (the point at which an organization is open to making a change to solve a problem) for the health care entity, and the outcomes that are desired. In some cases, the health care partner might want to target a specific chronic disease, such as diabetes, or might decide to be use a broader set of criteria, such as members with multiple chronic diseases.

Creation of a registry allows the HLCE to reach out directly to individuals who may be interested in participating in various community programs. All Health Insurance Portability and Accountability Act (HIPAA) and privacy documents must be in order. To assure confidentiality, we develop a Business Associates Agreement which was signed by all providers and all partners. All partners are also trained in HIPAA and privacy compliance.

In some cases, the health care partner might want to target a specific chronic disease, such as diabetes, or might decide to be use a broader set of criteria, such as members with multiple chronic diseases.

Jennifer Raymond

Our Centralized Two-Way Feedback System

We use a two-way feedback system, which involves sharing of information between HLCE and the health care partners. We document and report the following data to the health care partners using secure Excel spreadsheets:

  • Demographic information
  • Attendance information
  • Completion rates
  • Self-reported outcomes
  • Participant activation (via survey)
  • Participant satisfaction (via survey)
  • Refusals and reasons for refusals
  • Outreach efforts

All of the information is centralized at the HLCE. Having all data in one central location allows us to observe trends, including where completion rates are high, where they are low, and which plans are referring clients. In this way we can monitor programs throughout the state and take action, if necessary, to provide help to our partners as needed.

Housing the data in a single location also makes it easy for providers to get information they need. Concerns or questions about any aspect of these data are addressed regularly through e-mails, telephone calls, and/or meetings. This “shared quality improvement” approach works well when the referral process with health care providers is viewed as a “partnership.”

How were you successful in getting health care partners to agree to assume an active role in quality assurance? How does the process work?

We began with a discussion of what quality assurance (QA) is and why it is important. We emphasized QA as an important factor in delivering the program consistently as it was designed to achieve positive results.

Another point of discussion focused on understanding that QA is an ongoing process that is essential to the continued success of programs. We pointed out that QA and evaluation are integral to the contract and are more successful if the health care partner plays an active role. We also talked about the tools that can be used in monitoring QA. Our health care partners have been open to this approach and welcome an opportunity to be invested and involved in the program.

  • QA is More Successful When Viewed as a Partnership Responsibility: When QA is viewed as a partnership responsibility, both the HLCE and health care partner come together to work toward improvement. Partnership QA includes regular meetings to review when referral volume from the health care partner is low or when the transition of members from referral to participation is low. In these situations, the health care partner and HLCE identify negative trends and implement Rapid Change Cycles to address them. For example, when the percentage of members referred who agree to attend a workshop is low, HLCE and the health care partner will meet to discuss how the registry was generated, how it might be altered, and whether better workshop locations can be found that will be acceptable to members.
  • Tools That HLCE Uses to Monitor Fidelity of the Program 
    • Direct observation of new leaders
    • Random quality checks on delivery of content
    • Webinars every two months on a variety of topics related to program implementation for leaders, trainers, and program coordinators
    • Sharing of fidelity concerns and tips via newsletters
    • Quarterly fidelity webinars and an annual conference for leaders, trainers, and program coordinators
    • Reviewing workshop attendance for completion rates

Sharing of concerns, as well as successes, with partners provides a strong basis for assessing and maintaining or taking action to improve the quality of programs being offered. To assure that health care partners are fully informed, we hold regular meetings with them to review the information provided through fidelity monitoring tools and activities.

What about the future? What plans do you have for sustainability of programs?

HLCE plans to continue to strengthen and expand our health care partnerships. We are working to establish reimbursement models with payers and health care providers and also to develop other funding streams. For the Chronic Disease Self-Management Education (CDSME) suite of programs, as well as falls prevention, behavioral health, and other evidence-based programs in Massachusetts, next steps include building on existing contracts by sharing successes with non-contracting health plans and partners. We plan to increase our capacity to bill Medicare for diabetes self-management, diabetes prevention, and behavioral health programs. Also, we have begun to look to payers beyond the health care systems, including employers.

HLCE is taking meaningful steps to create a self-sustaining model of program dissemination for evidence-based CDSME and falls prevention programs and plans to achieve full sustainability within two years. Toward that aim, we are using bridge funding from federal and foundation sources and plan to initiate a combination of contracts with third party payers, including Health Maintenance Organizations (HMOs) and Accountable Care Organizations (ACOs). We are also developing partnerships or agreements for training and consultation, contracts for Title IIID services, philanthropic support, and a variety of other funding sources. By diversifying funding streams, we feel confident in our ability to achieve our sustainability goal.

It is important not to “overpromise” but to start with what you know you can do so that you are able to fulfill the promises that you make.

Jennifer Raymond

What one tip or piece of advice would you give to another organization working to develop a Network Hub?

While it is critical to make sure that you are “ready” before you move forward with partnering with health care organizations, you don’t need to wait until everything is “perfect.” Examine the network that you currently have in place and determine your capacity – what you can do.

It is important not to “overpromise” but to start with what you know you can do so that you are able to fulfill the promises that you make. This might mean starting with small geographic areas and a single health care partner, whose members are located within that area. It might mean starting with one program and growing your capacity. As the saying goes, “Jump off the cliff and build your wings on the way down.” If you don’t, someone else will, and that organization might not have the same commitment to the community that you do.

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Payment Models

What Models are Available?

The Affordable Care Act (ACA) has made many provisions to improve the way health care is delivered. As you work to integrate your CDSME programs with the health care sector, you will need to learn about the different types of payment and service delivery models that are available to you and find out which ones are operating in your state.

Fee-for-Service (FFS)

In the Fee-for-Service traditional health care payment model, each covered service is paid for separately, and payment is made after the service is provided and billed to the health plan. There is an incentive to provide more services because payment is based on quantity or volume, rather than quality or value. Examples are the Diabetes Self-Management Training (DSMT) and the Health and Behavior Assessment and Intervention (HBAI) benefits under the Medicare FFS payment system.

Value-Based Payment Models

Unlike the traditional FFS payment model, the Value-Based Payment (VBP) model promotes quality and value of services, over quantity or volume.

  • Bundled Payment: This payment model reimburses health care providers based on expected costs for an episode of care, such as a hospital stay. As part of the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) Innovation Center was developed to test new payment and service delivery models to achieve better care, better health, and lower costs. The Bundled Payments for Care Improvement (BPCI) Initiative is testing four different bundled payment models during two phases of implementation. You can use the site map to find out if there is an innovation program in your state.
  • Pay for Performance: This model offers rewards to providers who meet or exceed their performance on specific quality metrics that fall into the four categories: process (performance of health care activities), outcome (effects of care on patient), patient experience (satisfaction with care) and structure (facilities, personnel, equipment used in treatment). An example is the Patient-Centered Medical Home, in which the primary care medical home is responsible for providing patient-centered, coordinated care, including wellness, acute, and chronic care.

Shared Savings Program

Established by the Affordable Care Act, the Medicare Shared Savings Program promotes coordination and cooperation among physicians and other health care providers to improve the quality of care to patients, especially those with chronic diseases, and reduce unnecessary costs. Health care providers can participate in a Shared Savings Program by creating or participating in an Accountable Care Organization (ACO). Through this coordinated approach, the ACO is expected to reduce duplication of service and make good decisions about what care is needed when. If the ACO is successful in improving care while lowering costs, it will share in the savings that it achieves. While this model was created for Medicare, currently, there are also a number of Medicaid MCOs. An ACO is a legal entity identified by a Taxpayer Identification Number and authorized under applicable State, Federal, or Tribal law.

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Partners In Care Foundation

Implementing CDSMP through a Contract Payment Model with a Health Plan: Partners in Care Foundation’s Three Modality Approach

The mission of Partners in Care Foundation (Partners) is to design and implement new models of evidence-based care that address the social determinants of health. Partners “raises the quality and effectiveness of community-based healthcare and social services, while also simplifying the delivery of those services, to create a continuum of care that can better help everyone.”

The health plan’s goal was to use health care (clinical) dollars to offer their members more and better disease management services to improve health outcomes. They wanted to outsource everything—all aspects of program delivery.

Dianne Davis

In the following in-depth interview, Dianne Davis, MPH, Senior Director of Health Self-Management Services and Karol Matson, RD, CDE, Director of Diabetes and Health Self-Management Services at Partners share their experience implementing a payment model to bring the Stanford Chronic Disease Self-Management Program (CDSMP) in three modalities—community-based, online, and mailed toolkit—to members of a health plan. The content includes step-by-step “how-tos” for the following key topics:

  • Initiating a partnership with the health plan
  • Key partners and their roles
  • Developing the partnership
  • Negotiating and signing the contract
  • Maintaining and strengthening the partnership
  • Centralized, coordinated logistical processes for program delivery
  • Data management, reporting, and HIPAA compliance
  • Billing and payment processes
  • Quality assurance
  • Advice to others

Initiating a partnership with the health plan

How did the partnership get started? 

We were very pleased that a commercial and Medicare Advantage Health Plan—one of the largest and most innovative in California—approached us about a possible partnership. We seized this opportunity and began to discuss a potential partnership.

  • Internal champion. The health plan’s Program Manager for Disease Management and Medical Director were the champions who spearheaded the effort. Prior to approaching us, they researched what programs were available to improve their disease management services. The Program Manager for Disease Management sought input from Dr. Kate Lorig, Director of the Stanford Patient Education Research Center and program developer for CDSMP. She also spoke with several leading CDSMP service providers, including the California Department of Aging. During these conversations, she learned about the work that we are doing and realized what we could offer. Once the research was completed, the health plan made a decision to offer CDSMP to their members, and that became the basis for pursuing an agreement with Partners.
  • Health plan’s goal. Their goal was to use health care (clinical) dollars to offer their members more and better disease management services to improve health outcomes. They wanted to outsource everything—all aspects of program delivery. This included offering the CDSMP workshops, as well as all associated outreach, engagement, and enrollment activities. They also “wanted their members to be more in contact with social service providers in their community.” We were pleased to hear that they recognized how important it is for older adults to stay involved with their communities because doing so is a significant contributor to well-being and quality of life.

How did the three-modality approach come about?

The health plan wanted to offer both the online and the community-based (in-person) versions of CDSMP, and when the self-study toolkit was developed—about half-way through the planning process—it was included as well. The online programs and the toolkit were important since we serve many rural areas in California that may not have access to in-person programming. All three approaches needed to be offered to meet the health plan’s requirements for member-centered access. The overall intent was to get members involved in their communities, and many members were older adults.

The offer sounded good! We were excited about a new funding source, yet careful to think through the huge commitment that this would take. After discussing it, we knew that we wanted to move forward.

The online programs and the toolkit were important since we serve many rural areas in California that may not have access to in-person programming. All three approaches needed to be offered to meet the health plan’s requirements for member-centered access.

Dianne Davis

As you cultivated a relationship with the health plan, what was your value proposition?

Our primary focus was to understand what the health plan was looking for and to demonstrate how we could meet their needs. We worked with a number of providers and realized the potential for expanding those partnerships to form a statewide network with statewide access to evidence-based disease management programs for members of the health plan. That was a priority for the plan.

For some time, we have served as the Technical Assistance Center for the California CDSME initiative. We had a contract with the state department of aging through the Administration for Community Living (ACL) CDSME grant to work with many other community-based organizations throughout the state to offer these programs. This experience was important in demonstrating our capacity and the added value that we could bring to the health plan’s members.

What were some of the things you needed to consider as you entered into this partnership?

  • Expert representation. We knew that we had to carefully consider what entering into this partnership meant. It was evident to us that we shouldn’t go into a managed care plan contract lightly. We needed expert representation, including people experienced in working with managed care plans. Fortunately, Partners had recently hired staff with many years of this type of experience who could assist with the contract analysis and discussions. We also had good legal counsel available to review and guide contract development, as well as to help with the final negotiations.
  • Openness and flexibility. Our openness to the fact that we had a lot to learn and our flexibility in responding to the health plan’s needs were also important. For example, we had no idea just how long and how much effort it would take to build a functional and responsive network and a Contact Center, but we were willing to take on the challenge. We realized that it would require effort to help our partners who offer CDSME programs understand what was involved in becoming part of the network. We saw this as a compelling opportunity to learn and to serve—an opportunity to be involved with innovative and significant groundbreaking work important to the health of older adults. We were willing and committed to do the hard work that it would take.

Key partners and their roles

Who are your partners, and what are their roles?

Network of providers. Currently, we are organized to serve as a statewide delivery system for evidence-based health promotion programs through a network of 14 contracted providers. We are able to offer CDMSP to rural areas through the online program and the mailed toolkit.

Our network was formed to help guide and assist the work that we do with the health plan. We set out to create an interactive working environment with information flowing both ways. We help members understand the benefits of being part of the network and provide them with a set of expectations and guidelines that assure consistency and quality of services. We schedule regular calls and meetings and offer opportunities for sharing and problem solving. In turn, the member organizations share their updates and best practices with us, as well as with one another. They also inform us of any needs or concerns that they have related to implementing CDSMP or being part of the network. We emphasize the importance of all organizations sharing openly so that we can learn and grow as a network.

Because we have been the Technical Assistance Center for many of these community-based organizations for some time, we have developed trust and work well together. Now, we have a more formal arrangement. These partnerships give us wider coverage so that we can respond to referrals from the health plan.

Karol Matson
  • Community-based delivery organizations – Our network consists of community-based organizations, health system partners, and public health departments that offer CDSME and other health promotion programs in their geographic areas. In addition to scheduling and holding the community workshops, they also help with recruitment to their local programs. Because we have been the Technical Assistance Center for many of these organizations for some time, we have developed trust and work well together. Now, we have a more formal arrangement. These partnerships give us wider coverage so that we can respond to referrals from the health plan.
  • Canary Health – Our online partner, Canary Health, is the only organization licensed to offer the Stanford suite of online programs. From the outset, Canary Health was invested in the project and looked upon their involvement as an opportunity to grow. They are responsible for all aspects of the online program once the member agrees to participate. This includes completing online enrollment through an email, which is sent to the participant. They schedule and deliver the online workshops, as well as manage and maintain the data, which is shared with Partners. We have worked closely together to increase recruitment and enrollment for the online programs.

All organizations in the network operate under subcontracts with Partners; these subcontracts mirror our agreement with the health plan. Partners serves as the “Central Office” or the “Network Hub” for the following: contracts, referral processing and enrollment, billing and payment to the network partners, quality assurance, and data management/reporting.

Developing the partnership

Once the partnership with the health plan was initiated, how did you nurture and develop your relationship?

  • Weekly meetings. We approached this initially by holding weekly meetings with the health plan to discuss the many facets of developing a partnership. The meetings evolved to thirty minutes after about six months but were longer at first. It was important to build trust and come to an agreement about what was expected and how it would be accomplished. We discussed all kinds of operational issues, including work flow for every aspect of operations, quality assurance, logistical processes, and more. Quality metrics and reporting were also important to the health plan, so we had to think about how we could capture the required data elements and provide timely reports.
  • Commitment. Other factors which played a role in the evolution of the partnership included the favorable recommendation from the California Department of Aging and the commitment of our CEO and Board of Directors. They were willing to take the risk to develop a formalized network of partners. It was one thing to see the value of such a partnership but another thing to say, “We’ll make this happen—we’ll figure it out and do it.”
  • Time. As much as ten hours per week were spent talking with our network providers about the partnership with the health plan and how it would work. The time demand was intense. We had to work through a variety of issues, including how to recruit participants for workshops.

Negotiating and signing the contract

Our CEO and senior team members, each with many years of experience and unique talents, worked closely together. By doing so, we could decide when to say yes, when we should hold our ground to say no, and when to suggest changes in the contract language.

Dianne Davis

What factors were involved in negotiating the contract?

  • Understanding what the health plan needed. First of all, we agreed to offer all three modalities: the community-based, online, and toolkit versions of CDSMP. Then, we worked out all the details related to how that would be operationalized and what data would be tracked and reported.
  • Leveraging internal expertise. Having staff with managed care contracting experience was helpful, as was our team approach. Our CEO and senior team members, each with many years of experience and unique talents, worked closely together. By doing so, we could decide when to say yes, when we should hold our ground to say no, and when to suggest changes in the contract language. Legal counsel couldn’t be at every meeting because it would have been extremely expensive, but they carefully reviewed all the documents and helped with the final negotiations.
  • Knowing your costs. The most important thing is to know your recurring costs and cover them. The demands in this type of partnership are significant. It takes as much as two full days to put together the required monthly “dashboard” reports because they are very detailed; and delivering them on time is essential to the relationship. This is more analytical data than most community-based organizations are used to collecting and reporting. Be sure you give yourself enough margin to cover these expenses. We are now working to automate this process, which will require additional resources.
  • Leveraging statewide infrastructure. We had a series of grants that helped us build a statewide infrastructure. That infrastructure was helpful when it came time to develop the formal network. We had to make a commitment to cover the necessary legal fees and other expenses necessary to go into this type of business. That was a business risk that senior management accepted. Also, our contract is not just for CDSMP; it includes care transitions and care management, so all of that had to be taken into consideration. We made the investment because we knew that we were committed for the long run.
  • Transparency in pricing. In negotiating with the health plan, we had transparency in our costs and pricing. We had conducted a cost analysis for each of the three program modalities and were clear about what it would cost us to do the work. We explained how we came up with our pricing and what was included. For example, we explained the outreach, marketing, and quality assurance costs that are associated with offering the program. While we wanted to cover the costs of the program, we knew that it wouldn’t be 100% at the beginning because of the startup costs associated with implementing the required Information Technology, hiring staff with experience in metrics and data analysis, forming a network, and developing the partnership with the health plan. We considered these startup costs (sunk costs) as part of developing a new enterprise and separated them from our recurring costs.
  • Payment structure and rate. Once we discussed the costs of doing business, we were in a position to negotiate payment for the services. We came to an agreement on a rate that incorporates the costs associated with offering the three services: outreach (contacts made with the health plan members); enrollment (signing up for one of the three program modalities); and engagement (attendance at a community-based or online workshop or receipt of the toolkit). The in-person and online programs are priced very similarly; the toolkit is much less expensive.
  • HIPAA and data transfer. Official Information Technology (IT) vetting had to take place before the contract could be signed. We had to demonstrate to the health plan that HIPAA regulations would be strictly adhered to. High level audits were required for all of our systems and vendors. We also had to acquire a secure file transfer portal (SFTP) site that would allow the transfer of data between the two major parties. The entire process of setting up the IT component of our partnership was costly both in terms of time and money, but in the end, it was well worth the effort.
  • Value of a network. The process of negotiating the contract and coming to an agreement on the terms was very involved, but in the end, it was well worth the effort. The value of a network is that only one agency needs to make these upfront investments of time and resources, but all member agencies benefit from the contract.

How long did the process take from initiating the conversations to signing the contract?

It was about nine months from the time we first spoke until the contract was signed. The planning and the contract development went hand in hand. We were also developing our Contact Center while we were involved in the contract negotiations.

Maintaining and strengthening the partnership

Once the contract was signed, how did you go about maintaining and strengthening the relationship?

We have very open and consistent communications, with weekly check-in meetings that typically last 30 minutes. Issues that can’t be resolved at the operational level, move up the ladder to senior management. We hired a Project Manager who acts as the primary contact person for interacting with the health plan. Topics during the meetings include:

  • Contract requirements
  • Operational processes
  • Data dashboard issues
  • Quality improvement
  • Client claims
  • Customer service

We also hold quarterly Joint Operating Committee meetings. These meetings are held to discuss program metrics, successes, challenges, and pilot programs, as well as to share program stories with the operations group and senior management.

Additionally, senior management from both organizations meets quarterly to discuss higher level issues. Recently, the health plan expressed interest in including pricing for A Matter of Balance falls prevention program. That program will be included in our discussions for 2017.

 Maintaining our program delivery partners. In addition to meeting with the health plan regularly, we communicate on an ongoing basis with our network of statewide providers to ensure that the program is running smoothly. Our senior management team and Canary Health meet monthly, and our delivery partner network operations group meets quarterly to work through concerns and discuss strategies that can improve program delivery.

Centralized, coordinated logistical processes for program delivery

How does the health plan identify members who will be notified of the workshops?

We use a technique called geo-mapping, which is a function of our Salesforce software. Here’s how it works: When we know we are having a workshop in a particular area, we put the address in our Salesforce database, and it finds names of adult health plan members with a chronic disease who live in that area. Because members live in counties throughout the state of California; it is essential to organize the names in a manner to support comprehensive and targeted outreach. Large member data files (2,000-6,000 members) are received with each data drop. Those names are collected in an excel file (called a “campaign”), and the file is sent to the IVR vendor to make robocalls, the starting point of the outreach. We often have several workshops in the same area at different locations. There is a different campaign for each area that we serve and for each workshop that is held in that area.

Are the workshops also marketed more broadly to the community?

Yes, in addition to referrals from the health plan, our network providers market the program and recruit people with chronic diseases from their communities to fill the workshops.

Motivational interviewing techniques are used to assist and encourage individuals to sign up for the program. The interview is based on a script designed for this specific purpose. The script, which lasts approximately 15-20 minutes, depending on the individual member, was vetted by the health plan and Medicare.

Karol Matson

Please describe your step-by-step referral and enrollment process.

The health plan developed criteria that determines who will be referred to the program. We’ve received over 70,000 referrals in the past year. There are six steps involved from the point of referral to enrollment in one of the three program modalities:

  1. Data feed from the health plan. Initially the plan forwards a spreadsheet to us with names of persons to be contacted. We upload all the names in our Salesforce database, so that our Contact Center can track whether or not the member gets enrolled, attends a workshop, or receives the toolkit.
  2. Introductory letter. A plan-approved introductory letter is sent to everyone who is referred by the health plan. The letter is sent on the Plan’s letterhead informing members that they will be getting a call about new free programs that are available to them. From there, the information is sent to the IVR (interactive voice response) vendor to initiate calls to the members—these are the robocalls.
  3. IVR and robocalls. Automatic or robocalls are made by the IVR vendor to each individual on the referral list. When a robocall is made, the individual is directed to press “1” to reach the Contact Center to learn more about the free programs that are available to them. If, on that first call, the member does not press “1” to connect with the Contact Center, a second robocall is made. If the person still doesn’t respond, a third and final robocall is made in an attempt to get a response. When a robocall goes to an answering machine, those names are given to the Contact Center to follow up with a hand-dialed call. Our software tracks and provides a report on the result of each robocall attempt.
  4. Call Center. If the member presses “1” on the robocall, he or she is immediately connected to the Contact Center, which is our communications center for the program. Each caller is greeted by a trained Contact Center employee who identifies as being a representative of the health plan. Then, individuals are engaged in conversation, and the Center staff member provides detailed information about each CDSMP modality. Contact Center employees ask individuals what they would like to do that they may not currently be able to do because of their chronic condition, what behaviors they want to change, and how they’d like to go about making the change. Motivational interviewing techniques are used to assist and encourage individuals to sign up for the program. The interview is based on a script designed for this specific purpose. The script, which lasts approximately 15-20 minutes, depending on the individual member, was vetted by the health plan and Medicare. This is the only discussion that occurs; if a member declines to be enrolled in one of the three modalities, there is no further follow up. Once the call to the Contact Center ends, some of the information is automatically recorded by the system, while other information is entered into the Salesforce database by staff for tracking and reporting purposes.
  5. Referral to community providers or Canary Health. When someone enrolls in a workshop, a referral is made to the local community provider (for the in-person version) or to Canary Health (for the online version). Only the person’s name and contact information—no other personal information—is shared. A toolkit is mailed to those who choose that modality.
  6. Reminder calls and emails. After someone enrolls in a workshop, phone call reminders are sent for the in-person version, and email reminders are sent for the online version.

I’m interested in hearing more about the Contact Center. How did you get started, and how is the Center staffed?

  • Planning. Initially, we spent a great deal of time researching contact centers and deciding what software to use. Ultimately, we implemented a cloud-based CRM (Customer Relationship Management) software system and hired a consultant to customize it for our specific needs. We also sought guidance from community mentors who had experience in this area and worked with a staff member who had an MBA to assist with budgeting and planning for the Contact Center. In addition to decisions about technology, we had to consider what human resources would be necessary to operate the Center and whether we would staff it ourselves or outsource the work.
  • Staff. We decided to run the Center ourselves, rather than outsourcing the work. We hired several new employees with varying degrees of experience and technical expertise to operate it: (1) a Director who oversees the overall operation of the Center; (2) several Agents, trained in motivational interviewing, who answer calls and enroll individuals in workshops, and (3) a Director of Quality and Metrics who analyzes and manages the data.
  • Training. We acquired a Motivational Interviewing Consultant to develop a script and a training module on how to conduct motivational interviewing for Contact Center Agents to use when making calls to enroll health plan members in the program. We also trained the Agents as CDSMP leaders to provide them with an in-depth understanding of the program so that they can better respond to questions and concerns that potential participants might raise.
  • Helping others who might be interested. Because it is highly technical and costly to set up and manage a Contact Center, we are willing to work with other community-based organizations that might be interested in this approach to contract use of our Center for their work. We want to help others so that they can gain the same benefits that the Center offers us, while preventing them from having to replicate the complex and costly set-up and management process.

We are willing to work with other community-based organizations that might be interested in this approach to contract use of our Center for their work. We want to help others so that they can gain the same benefits that the Center offers us.

Dianne Davis

Data management, reporting, and HIPAA compliance

You mentioned that you use the Salesforce platform to manage data. Can you tell me more about that?

Salesforce is a cloud-based CRM system. All participants referred from the health plan are entered into the Salesforce database—over 70,000 referrals this past year. Currently all data is sent to us through a secure (SFTP) site. The data is uploaded into and tracked through Salesforce. The status of enrollment of members is recorded through interactions between Salesforce, our automated dialer, and the IVR software.

Salesforce upgrades. We are in the process of making upgrades to our Salesforce database. For example, we are building fields so that data can be automatically uploaded for reporting purposes. The monthly dashboard reports that we provide for the health plan will be created by the system, rather than by gathering data from three independent data sets, which is our current process.

When the upgrades are completed, all data will be automatically uploaded into Salesforce; all data will reside in a single location, and we won’t have to use multiple data sources any longer. This will help resolve problems with errors that can occur when data is entered multiple times in various databases, leading to a much more efficient process. It takes time and some hands-on experience before you realize what is needed to increase efficiencies. For us, it has taken a twenty month pilot period, which ended December 31, 2016; we are glad to be at this stage now.

Is Salesforce also used to track data for the online program?

Canary Health maintains their own database for the online workshops and reports that data to us via our SFTP in a spreadsheet format. Then, we upload the data into Salesforce, and that information is included on the dashboard reports that are provided to the health plan. Once we make the database upgrades, we will be able to upload the data directly from Canary Health.

What about sharing data with the Contact Center? How does that work?

The Contact Center staff view limited fields from the Salesforce database. They see only the names, phone numbers, and contact information of the participants—they see no data that is of a confidential nature. The information is received in an excel file (CSV format) through the secure (SFTP) site. We are very careful about protecting confidentiality and maintaining HIPAA requirements.

What metrics do you capture and report to the health plan?

We track 30 quality metrics related to outreach, enrollment, and engagement. We do not track or report outcome data at this time. Tracking so many metrics has been difficult, time intensive, and costly. It requires the expertise of a Director of Quality and Metrics. However, as we make upgrades to the Salesforce database, the process will be significantly simplified. Metrics are reviewed regularly as part of the preparation for monthly and quarterly reports that we provide to the health plan. Just a few of the metrics we report on include:

  • How many people press “1” to connect to the Contact Center, for each robocall
  • How many members enroll in each of the three program modalities
  • How many members actually attend an in-person or on-line workshop, or receive the toolkit
  • The number of sessions attended and how many members complete a workshop

Also, the health plan intends to produce a retrospective study to look at what, if any, changes occur in member utilization after participating in a CDSMP workshop or receiving the toolkit. They are able to run this type of analysis because they have claims data for their members. Once the study is completed, the results may provide some insight into the cost-effectiveness of the program.

It takes time and some hands-on experience before you realize what is needed to increase efficiencies. For us, it has taken a twenty month pilot period, which ended December 31, 2016; we are glad to be at this stage now.

Karol Matson

How do you handle issues of confidentially and HIPAA?

Meeting HIPAA guidelines and the health plan’s security requirements to protect data is both complex and time consuming. We use a cloud-based secure server and network which are HIPAA compliant. The SFTP server, which meets specific security requirements to protect the information, had to be vetted by the health plan, along with all of our information technology systems. Every vendor that offers components of our services and uses IT as a portion of their work (e.g., the company that makes robocalls or fulfills the mailings) had to undergo audits and vetting. Before any member data can be transferred, the software and the vendor must be approved by the health plan’s IT department.

We hired a Chief Information Officer (CIO) to handle the IT security issues, along with other important duties related to IT. We want to prevent a HIPAA breach for ethical reasons. A breach can negatively impact our business and cost millions of dollars in fines. We require all employees, as well as any volunteers and network partners/subcontractors who come in contact with personal information, to undergo HIPAA training, using an approved HIPAA training module.

Billing and payment processes

What are your billing and payment processes?

Partners serves as the Central Office to handle billing for the Partners at Home (PAH) provider network. We have subcontracts with network providers that offer the community-based version of CDSMP and with Canary Health (for the online program). We mirrored our contract with the health plan in these subcontracts. The provider submits an invoice to Partners with the names of individuals that were referred to them, along with the workshop attendance forms. The information provided on the invoice is checked against data in Salesforce; once the data is verified, we invoice the health plan for all the services provided. When payment is received, we compensate the PAH network providers for the services they offered.

Quality assurance

What about quality assurance? 

The quality of programs and services provided by the network is integral to our success and future expansion. We view quality assurance as a shared responsibility between Partners and the PAH network members. We have several approaches:

  • In our subcontracts with providers, we outline requirements that are designed to ensure quality of the services that are provided, e.g., use of sign-in sheets to monitor attendance and emphasis on maintaining fidelity of the program. One of our immediate goals is to strengthen the requirements in the subcontracts to reinforce the importance of program fidelity and quality assurance.
  • We organize webinars on fidelity and other topics to help improve the quality of programs and invite network members to share best practices.
  • We also hold conference calls with the network providers so that they can assist one another with questions or concerns about fidelity. During calls, we provide technical assistance to help providers understand any changes that might be needed to assure quality.
  • At quarterly intervals, senior management from the health plan listens to calls at the Contact Center to monitor the motivational interviewing process and assess the quality. Partners’ staff monitors calls and provides feedback to Contact Center staff continually.

We have had many calls from around the country about our partnership with the health plan and the operation of our Contact Center; it is our hope that our pioneering work in this area will be helpful to those embarking upon similar partnerships to sustain their programs.

Dianne Davis

Advice to others

What advice would you share to help others who might be interested in developing a similar payment model using the three-modality approach?

Based on our experience, we offer these recommendations:

  1. Conduct a thorough organizational capacity assessment.
  2. Do the background research on each of the dimensions of the system to be established.
  3. Carry out a financial cost analysis to determine the costs associated with offering the program and a break even analysis to determine what volume of referrals is needed to cover the costs.
  4. Decide which components of the system you will operate and which ones you want to outsource. Weigh the costs associated with both options.
  5. Consider how consultants can help with program development and operations.
  6. Identify and allocate some funding to cover planning and start-up operations. Partners made an investment of staff time and leadership resources, and the health plan priced the first year to help recover much of the startup costs. Luckily, we also had enough volume, which provided the revenue to defray costs associated with getting started.
  7. When negotiating a payment rate, allow some margin for unexpected expenses. Be sure to include costs associated with doing business with the health plan, such as providing detailed data reports.
  8. Reach out where you can; for example, we talked with others in the community who had contact centers and asked for their advice.
  9. Make a commitment to stay in it for the long run; building the infrastructure needed for this type of partnership doesn’t happen overnight.
  10. Value the learning opportunities that you are experiencing—in the end, they will lead you to the best product possible.

Those are some excellent pieces of advice. As we bring the interview to a close, is there anything else that you’d like to add?

In some ways creating a working partnership is like opening any new business; you have to make an investment up front to make it work. Some organizations aren’t prepared to incur the “opportunity costs” associated with this type of effort. Our hope is that we can help others understand what is involved and provide some of the services they need. We have had many calls from around the country about our partnership with the health plan and the operation of our Contact Center; it is our hope that our pioneering work in this area will be helpful to those embarking upon similar partnerships to sustain their programs. We invite others to call on us if they would like to learn more about this approach or if they are interested in contracting with our Contact Center to provide outreach and engagement services in their region. We want to extend a helping hand.

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Medicare Payment Opportunities

Understanding Medicare

Medicare is a federal health insurance program for older adults aged 65 plus and younger adults with qualifying permanent disabilities. It is administered by the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. As chronic disease self-management education programs have received increased recognition for improving health care outcomes, Medicare has moved toward polices that support preventive services, including self-management education.

Original Medicare

“Traditional” or “Original” Medicare, refers to Parts A and B. Medicare Part A does not have a premium and covers inpatient hospital care, limited time in a skilled nursing facility, home health services, and hospice care.
Medicare Part B covers services deemed medically necessary, including services or supplies needed to diagnose or treat medical conditions. It also covers some preventive services, such as flu vaccines, and diabetes screenings. While Medicare Part B requires a premium, deductibles, and in some cases copayments, Medicare savings programs are available to assist low-income older adults with subsidies to help pay these costs.

Medicare Advantage Plans

Medicare Part C refers to Medicare Advantage (MA) Plans, which are operated by private insurance companies that contract with Medicare to provide Part A and Part B benefits. Each MA Plan differs, but all have at least the same coverage as Original Medicare, and most offer prescription drug services. Some MA Plans offer additional services that are not covered under Original Medicare. Part C Plans designate levels of reimbursement to providers and hospitals, as well as out-of-pocket costs to enrollees.

Medicare Part B and Chronic Disease Self-Management Education

When the Affordable Care Act was enacted, Medicare increased coverage for prevention and wellness services under Part B. In the first year of enrollment, beneficiaries receive a comprehensive “Welcome to Medicare” check-up, and annual “wellness” assessments thereafter, at no charge.

In addition to these benefits, Medicare provides specific benefits that can be used to cover Chronic Disease Self-Management Education (CDSME) program. These benefits, including the health behavior and assessment intervention, diabetes self-management training, and medical nutrition therapy, are briefly described below.

  • Diabetes Self-Management Training (DSMT): Section 4104 of the Balanced Budget Act of 1997 allows Medicare to reimburse providers as a Part B benefit for Diabetes Self-Management Training (DSMT) when it is an accredited program delivered by an RN, RD, or pharmacist who meets regular continuing education hour requirements and when it is ordered by the patient’s health care provider. The DSMT benefit covers up to 10 hours of training, which may include healthy eating, glucose monitoring, medication management, and self-care practices. Generally, the training can include one hour of individual training and up to nine hours of group training.
  • Medical Nutrition Therapy (MNT)MNT refers to a therapeutic approach to treating medical conditions through a customized diet prepare and monitored by a registered dietician. Under Part B, CMS can also reimburse providers for delivering three hours of Medical Nutrition Therapy (MNT) for enrollees with diabetes or renal disease, and additional hours when deemed necessary by their physician.
  • Health Behavior and Assessment Intervention (HBAI): In 2002, several billing codes were added to cover the Health and Behavior Assessment and Intervention (HBAI) services as a Medicare Part B benefit. As a required benefit under Original Medicare, all Medicare Advantage plans must also cover HBAI services. A few states also fund HBAI under Medicaid, HBAI services are intended to modify the behavioral, social, or psychosocial barriers to self-management of one or more chronic diseases. Chronic Disease Self-Management Education (CDSME) programs can qualify for reimbursement as HBAI services when they are offered to help overcome barriers that individuals encounter in effectively managing their chronic conditions and following their medical plan of care. In the next section, you will learn much more about how to get reimbursed for CDSME programs under these benefits.

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Diabetes Self-Management Training

The Medicare Part B Diabetes Self-Management Training (DSMT) benefit helps eligible beneficiaries learn to manage their diabetes. The training can include tips for healthy eating, blood sugar monitoring, physical activity, medication management, and risk reduction.

Area Agencies on Aging or other community-based organizations can play an integral role in expanding the use of Medicare’s DSMT benefit among underserved older adults with a diagnosis of diabetes. The Stanford Diabetes Self-Management Program can be used as the core curriculum with other components added to meet the national accreditation standards. View the resources below to learn more about how you can tap into this important Medicare benefit.

Toolkits and Guides

  • ACL DSMT Toolkit: The Administration for Community Living (ACL) developed this toolkit to help Area Agencies on Aging, community planners, and healthcare professionals operate cost-effective, accredited DSMT programs that can meet the Centers for Medicare & Medicaid Services (CMS) requirements for Medicare reimbursement.
  • Delmarva DSMT Toolkit: This toolkit for Quality Improvement Organizations (QIOs), Federally Qualified Health Centers (FQHCs), healthcare professionals and other key stakeholders explains implementation and reimbursement for accredited DSMT programs that meet CMS requirements for Medicare reimbursement. The Delmarva Foundation for Medical Care, of the Disparities National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), prepared it.
  • IHS DSMT Toolkit: This toolkit guides Indian Health Service (IHS) staff obtain Medicare reimbursement for Diabetes Self-Management Training (DSMT) services. It outlines seven steps that range from becoming a Medicare-recognized diabetes education program to marketing DSMT services, and shows how to put these steps into practice.

Frequently Asked Questions

  • DSMT Frequently Asked Questions: See answers to some of the most commonly-asked questions about using Stanford’s DSMP as the core curriculum of an expanded DSMT program to meet the national accreditation standards and to receive Medicare reimbursement.

Webinars

Tip Sheets

  • DSMT Tip Sheet: Learn to develop and operate DSMT programs that meet CMS guidelines for Medicare reimbursement.

Sample Processes and Agreements

Planning and Administrative Resources

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Medical Nutrition Therapy

Medical Nutrition Therapy (MNT) Services are used to deliver nutritional assessment, one-on-one counseling, and group counseling services, provided by a registered dietitian or qualified nutrition professional, to eligible Medicare beneficiaries. MNT is a Part B benefit of Original Medicare. As a covered Part B service, MNT is also a covered Medicare Advantage (Part C) benefit because all Medicare Advantage plans are mandated to cover all Medicare Part A and Part B services. MNT can be offered in combination with DSMT to help an individuals with diabetes better manage their conditions. Use the resources below to lean how you can use MNT as a combined benefit with DSMT.

Tip Sheets

Planning and Administrative Resources

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Health and Behavior Assessment and Intervention

Health and Behavior Assessment and Intervention (HBAI) services, a Medicare Part B benefit, are provided to address the psychological, behavioral, emotional, cognitive, and social factors important to the treatment and management of physical health problems. The Chronic Disease Self-Management education (CDSME) program can be used as a HBAI service to help people with chronic diseases better manage their conditions, make positive lifestyle changes, and actively participate in their medical plan of care. Below, you will find resources to guide you in offering and getting reimbursed for CDSME programs as HBAI services.

Helpful Tools and Resources

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Centralina’s DSMT Success Story

The purpose of this resource is to share Centralina’s success in achieving national accreditation for their diabetes self-management education (DSME) program and recognition by the Centers for Medicare & Medicaid Services (CMS) as an approved provider of the Diabetes Self-Management Training (DSMT) benefit. It will describe their approach, learnings, challenges, and helpful tips so that others who wish to pursue accreditation and Medicare reimbursement can learn from their experience.

The information was gathered through an in-depth interview with Annette Demeny, DTR, Aging Program Specialist, Health Promotion, Centralina Area Agency on Aging on June 30, 2017. Annette serves as the Program Coordinator for Centralina’s DSME/T Program and is a strong program champion, whose diligence throughout the planning and implementation process contributed to Centralina’s success. We would like to extend our gratitude to Annette for taking the time to provide this valuable information.

Background and Overview of Centralina’s DSME/T Program

Centralina covers nine counties located in the southwest region of North Carolina, including Charlotte and surrounding areas. In 2008, Centralina introduced evidence-based health promotion programming and today offers seven different evidence-based programs, including the Diabetes Self-Management Program (DSMP), originally developed by Stanford. Their target population consists of older adults with Type II diabetes, specifically those who are low income and reside in community settings.

In 2015, Centralina began working toward AADE accreditation for their DSME, using the Stanford model. They were one of only a handful of AAAs to take on this challenging task. In January 2016, they were selected to participate in NCOA’s DSMT Learning Collaborative to support state and community-based organizations in achieving integrated, sustainable evidence-based program networks. The specific aim of participants was to achieve or make significant progress toward achieving national accreditation for DSMP and Medicare reimbursement for DSMT services.

Through their dedication, hard work, and commitment, Centralina was successful in accomplishing the learning collaborative aims. They became a Medicare Part B provider on April 5, 2016, and received national accreditation from AADE on May 10, 2016. Since then, they have billed Medicare for their first workshop in Gaston County and are awaiting reimbursement. They are now in the process of expanding their program to Mecklenburg County and plan to purchase a comprehensive software system that will seamlessly interface the billing and clinical components of DSMT services.

Key Partners and Their Roles

Who are your key partners?

The University of North Carolina at Asheville (UNCA) is our state network hub. Their role is to collect, manage and analyze the data; create reports; coordinate trainings and continuing education; assure quality of the programs in collaboration with the AAAs; and work with the network of partners to develop a sustainable infrastructure. UNCA designated Centralina AAA to serve as the state training hub. In that role, we offer the majority of trainings for evidence-based programs in the state.

Other Key Partners and Their Roles

  • Senior Centers within our AAA region host the workshops, while Centralina provides the coordination, clinical supervision, and oversight for DSMT.
  • North Carolina Cooperative Extension schedules and markets the workshops for us.
  • A Registered Dietitian (RD) is available through a contractual arrangement to provide the initial assessment and care plan for DSMT, supervision for the group sessions, and one-on-one Medical Nutrition Therapy (MNT) for nutritional assessment and counseling.
  • North Carolina Division of Aging and Adult Services (NCDAAS) and AAAs throughout North Carolina collaborate to share best practices and marketing ideas, as well as to assist one another in working toward accreditation.

Accreditation

We saw a unique opportunity for combining one-on-one DSMT and MNT with the group education sessions that are offered through DSMP to provide a person-centered approach that could really make a difference in people’s lives.

Annette Demeny

What factors led to your decision to work toward national accreditation and Medicare reimbursement?

With the support of Centralina Council of Government’s Executive Director and Board, we made the decision to work toward accreditation because we wanted to address the significant and growing problem of diabetes in our region. We decided to seek accreditation through AADE, since it is the leading association for diabetes educators. We saw a unique opportunity for combining one-on-one DSMT and MNT (Medical Nutrition Therapy) with the group education sessions that are offered through DSMP to provide a person-centered approach that could really make a difference in people’s lives.

Federal and state funding are flat at best. Our Executive Director at Centralina AAA, along with the Centralina Council of Governments Executive Director and Board, recognized the importance of generating a steady stream of funding to sustain our DSME program. That is why we decided to move forward with accreditation and Medicare reimbursement.

When and how did you start the process of working toward accreditation?

We began in 2015 by contracting with an independent consultant to help us. The accreditation application and the steps to become a Medicare provider and bill for the services are complex and time consuming; we weren’t able to commit the time that was needed ourselves. There were resources available through AADE and NCOA; but because the process was so new, we needed someone who could be available on-site to guide us through it.

We knew the consultant because she had previously worked at one of our partner AAAs. She was knowledgeable about DSMT, and we felt that the partnership would be a good fit—that she could offer us what we needed. She handled all the details of the Medicare application and educated us about each step of the process.

Helpful Tools and Resources

The billing information that was provided through the learning collaborative was extremely helpful, especially the break-even analysis. It was great, but it was a lot to absorb. . . . The individual technical assistance calls helped us understand how to apply the learnings . . .

Annette Demeny

Were there tools and resources that you accessed to help you in achieving national accreditation and developing your business model for Medicare reimbursement?

Yes. We used both the AADE Toolkit and the ACL Toolkit, watched a number of webinars, and used other online resources that were wonderful—we couldn’t have done it without this information. The resources and support from NCOA’s DSMT Learning Collaborative were also helpful, primarily with billing in our case, because we already well along the way with preparing our application for accreditation when the learning collaborative started. We benefited greatly from the on-on-one technical assistance that was offered to respond to our questions and help with the Medicare billing process.

We weren’t accustomed to handling billing, and it was much more complicated than we had anticipated. Because I had to carry out my regular duties, I could devote only about 5% of my time to work on the documentation and billing processes that were necessary to bill Medicare, so it took some time to get everything in place.

The billing information that was provided through the learning collaborative was extremely helpful, especially the break-even analysis. But it was a lot to absorb. We had the opportunity to listen to the archived recordings and review the information through an online community, which reinforced the messages. Then, the individual technical assistance calls helped us understand how to apply the learnings to our particular circumstances.

In retrospect, we wish we had started developing the billing process at the same time we were working on the application for accreditation. That would have saved us a lot of time in the long run.

Supervision

In working toward accreditation and ultimately Medicare reimbursement for your DSME program, you had to secure a qualified clinician. How did you go about identifying and securing a clinician?

We secured the RD through a relationship with our local North Carolina Cooperative Extension agent, who is a certified DSMP leader and a Master Trainer. The RD works part-time on a contractual basis. We were fortunate that she already had a National Provider Identifier (NPI) with Medicare and was accustomed to providing the DSMT and MNT services.

Billing and Reimbursement

We thought that we would have a better chance of developing a viable program to cover our costs and sustain DSMT by becoming our own Medicare provider.

Annette Demeny

For Medicare reimbursement, there has to be a recognized Medicare provider. Some organizations decide to partner with an established Medicare provider, but you chose to become a Medicare provider yourself and also to handle the billing in-house. What led you to this decision?

We thought that we would have a better chance of developing a viable program to cover our costs and sustain DSMT by becoming our own Medicare provider. For the same reason, we decided to do our own billing. We want to continue to handle the billing in-house if we can find the correct software with a fully integrated clinical and billing system. That will allow us to track participants, file and check on the status of claims, and also see who has used their full DSMT benefit. Later, if we find that this approach is not financially feasible, we’ll revisit the decision.

What steps did you have to take to become a Medicare provider?

Receiving the Board’s approval from our Council of Governments was the initial step of becoming a Medicare provider. Next, we needed to ensure that our organization was HIPAA complaint since we would be a direct provider. That process began during the planning stages of the Medicare application and took about a year to complete. As a final step, Centralina hired an independent contractor to assist in completing the application to become a Medicare provider.

Once you became a Medicare provider, what other steps were necessary to bill for DSMT?

We had to figure out the billing process—how to file the claims, what codes to use, etc.—and determine what clinical documentation was necessary to support the billing. We submitted a paper claim for the first workshop and are awaiting reimbursement.

We have just finished our second workshop, and are getting ready to submit those bills. We are training a staff member who will be responsible for handling billing for this and all future workshops. Having a dedicated person to carry out the billing function is a priority as the program grows.

Documentation and Tracking

What is your documentation and tracking process? 

At this point, we use secure google documents since we have held only two workshops. We keep track of our workshops through Excel spreadsheets and also send data to UNCA for their reports and entry into the national CDSME database. We are in great need of a software system and are interviewing companies that can offer an integrated clinical and billing system. We are close to making that decision.

How do you share information with participants’ physicians?  What information is shared?

We provide a letter template and a self-addressed envelope to participants so that that they can let their doctor know that they participated in the workshop. The letter can be customized, and participants can choose whether or not to send or give it to their physician. It is up to them, but most want to share how the program benefited them.

How do you ensure HIPAA compliance to protect the confidentiality of participants?

We take this very seriously and have office staff who have the responsibility to ensure that we are HIPAA compliant. In addition to monthly HIPAA training with staff, we use encrypted email and faxes when communicating with the registered dietitian (RD) and other healthcare staff. We also use encrypted email when communicating with DSMP leaders about participants.

Referral and Enrollment

We are planning to develop partnerships with physician practices and clinics to get a steady stream of referrals. Doing so will save time and effort; it will make our program more efficient and help us reach more people.

Annette Demeny

For Medicare reimbursement, there has to be a referral from a physician, nurse practitioner (NP), or physician assistant (PA). Are there specific partners that you are working with to receive these referrals, and how did you go about developing these relationships?

We’ve only offered the program for a year, so we haven’t developed partnerships to receive referrals yet. For the two DSMT workshops that we have successfully completed, participants were known to us, as they were actively participating in other educational programs. North Carolina Cooperative Extension helped with recruitment. Once individuals were enrolled, we reached out to their physicians and asked them to fax referrals to us. This worked well in the small county where the workshop was offered, but it is actually a backwards process.

As you go forward, is there anything that you plan to do differently?

As we expand our program, we want to get the referrals upfront. We are planning to develop partnerships with physician practices and clinics to get a steady stream of referrals. Doing so will save time and effort; it will make our program more efficient and help us reach more people.

When you are approaching new partners, what is your message or your value proposition to get their buy-in?

When we meet with physicians, we talk about the benefits of DSMT—bringing A1cs down; increasing patient activation, self-efficacy, and self-care behaviors; and the added benefit of MNT. DSMT helps patients; it helps physicians too because it makes their job easier and improves their patient outcomes. It can help prevent penalties which might otherwise result from poor clinical measures and outcomes.

Challenges

As you think back, what major challenges did you face and how did you overcome them?

The billing was a challenge. The AAA’s don’t fit the mold of a typical Medicare provider, and billing was new for us. Another major challenge was getting approval of the “Intake Form” for the AADE accreditation application. We had focused on nutrition and hadn’t adequately addressed the other factors that can impact diabetes management, such as smoking, level of physical activity, and psychosocial factors. When we finally received approval, it was for six months. At the end of that period, we had to resubmit, showing that the form had been used by the RD. The lesson we learned was that the initial assessment needs to be broader than just nutrition.

Tips and Advice for Others

Are there any tips or advice that you would offer others who are working toward accreditation and Medicare reimbursement?

  • Talk with other community-based organizations that have successfully gone through this process. They can be tremendously helpful.
  • Learn as much as possible. Utilize resources from NCOA and other reliable sources. Download webinars, and commit time to digest the information.
  • Become a member of AADE to access their resources and information and to stay abreast of the requirements, which are continually changing.
  • Find seed monies and other funding to support your program until you are able to cover your costs, and recognize that this will take some time. You have to be committed to make it work; it doesn’t happen overnight.
  • Designate someone in your organization to be responsible for keeping up to date on the requirements for accreditation and also someone to become the expert on Medicare billing. You have to get the right people in place, and they need to continue to educate themselves—the learning doesn’t stop.
  • Don’t wait until you have completed your accreditation application to dive into your budget and billing process. Learn about reimbursement and billing upfront, at the same time you are preparing your accreditation application.
  • Ask to see participants’ Medicare cards as part of the enrollment process. Individuals’ names must be submitted exactly as they appear on the card. We didn’t know that we needed to do this for our first workshop, so we had to go back and request the information later. Ensuring that the information is accurate up front is important because there is a time frame to submit the billing and to resubmit it if there is an error.
  • Develop policies and procedures, and provide proper training to ensure HIPAA compliance.

Immediate and Long-Term Plans

The most important task in sustaining the program is to retain our volunteer leaders. To have certified leaders for DSMT, we must make sure that we have the best leaders and the best training for them. You can’t have a great program if you don’t have great leaders.

Annette Demeny

What are your next steps and your long-term plans to grow and sustain your program?

We plan to expand into Mecklenburg, our largest county, in the fall (2017). We have identified a clinician there and are in the process of developing a contract for her to provide DSMT and MNT. We also want to reach out to new partners in Mecklenburg County to sponsor the program by purchasing and stickering books and other materials to market the programs to their audiences. This has been a successful practice in Gaston. It is important to be aware of any conflict of interests when approaching healthcare organizations about sponsorship.

Once we establish the program in Mecklenburg, we want to take it to Union County next. There are more people with diabetes in Union County than any of the other nine counties in our region. Gradually, we plan to continue to expand to other counties; and long term, we would like to offer DSMT throughout the region.

The most important task in sustaining the program is to retain our volunteer leaders. To have certified leaders for DSMT, we must make sure that we have the best leaders and the best training for them. You can’t have a good program if you don’t have good leaders. We have a strong group of approximately 140 leaders in our region, and they are in the program for the right reasons. When we became accredited, we celebrated with our leaders. We let them know that we value their work and recognize them for making a difference in the community. That means a lot to them. We are so grateful for our wonderful leaders!

Closing Thoughts

There are other programs that exist, but there’s nothing like. . . the strong Stanford model with the additional clinical supervision and other elements to meet the national standards of accreditation. . . I hope that more AAAs . . . will come on board to work toward accreditation so that the program can be recognized and we can reach more people. . .

Annette Demeny

In closing our interview today, is there anything else that you’d like to add?

I want to reiterate that the success of this program stems from having the full commitment of your organization, as well as the funding to support it until you can cover your costs. The process can take up to two years, so there has to be a commitment. We know that this is something we want in all nine of our counties.

I would advise others, “Educate yourself before you get started. Do your research and learn all you can about the accreditation process and billing. Utilize the resources that are available, and spend the time that must be invested to make it see it through—to make it work.”

There are other programs that exist, but there’s nothing like the DSMT services that we offer—the strong Stanford model with the additional clinical supervision and other elements to meet the national standards of accreditation. This is a solid evidence-based program. I hope that more AAAs and other community-based organizations will come on board to work toward accreditation so that the program can be recognized and we can reach more people to help them manage their diabetes and improve their health outcomes. I think it’s vital.

This project was supported, in part by grant number 90CS0058-01-00, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.

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Virginia's HBAI Initiative

The purpose of this resource is to describe Virginia’s Health and Behavior Assessment and Intervention (HBAI) Initiative so that other state and community-based organizations (CBOs) interested in pursuing Medicare reimbursement for their chronic disease self-management education (CDSME) programs via the HBAI benefit can learn from their experience.

We would like to thank April Holmes, M.S.Ed., Prevention Program Coordinator, Department for Aging and Rehabilitative Services (DARS); Joyce Nussbaum, B.A., Health and Wellness Coordinator, CDSME, Valley Program for Aging Services (VPAS); and Carol Bell, M.P.H., RN, Manager Health Services, “Live Well, Virginia,” Jefferson Area Board for Aging (JABA), for their willingness to pioneer HBAI services and share the rich details of their experience.

The three organizations began the HBAI Initiative in January 2016 and are continuing their efforts to make HBAI services a viable and sustainable means of supporting CDSME programming. The information below is based on an interview held in June 2017.

Background

Virginia was one of nine states selected to participate in NCOA’s 2016 HBAI Learning Collaborative (January 2016-November 2016) funded by the Administration for Community Living. The purpose of the learning collaborative was to support CBOs in achieving integrated, sustainable evidence-based program networks. The specific aim of participants was to obtain Medicare reimbursement for their evidence-based CDSME programs via the HBAI benefit.

Infrastructure for CDSME Programs in Virginia

Role of DARS and Virginia’s Area Agencies on Aging (AAAs)

April: As the State Unit on Aging, DARs has been working for a number of years with AAAs on programs funded by the Older Americans Act and various grant initiatives. We serve as the “network hub” for CDSME programs in Virginia. AAAs operate the program in their designated regions and are responsible for all that entails: recruiting leaders, organizing workshops, marketing, building partnerships to deliver and sustain the program, etc.

We hold monthly calls with AAAs to provide updates and exchange information and best practices. We visit each of the programs once within a two-year period for this grant cycle (August 1, 2016-July 31, 2018) to conduct fidelity monitoring and provide technical assistance and support.

We also promote programs at the state level through our website, which contains sample materials and templates that AAAs can customize. Recently, we created a promotional video, which is featured on Facebook and our CDSME web page. At the local level, organizations market their own workshops because they know best how to engage participants.

Our Commissioner refers to our role as “the convener” because we bring together our statewide CDSME partners to share information and ideas. We plan to share learnings from the HBAI Initiative during our statewide conference calls.

Role of VPAS and JABA

Joyce: VPAS served as the lead on the learning collaborative to determine our approach and the processes that we needed to put in place to offer and obtain Medicare reimbursement for HBAI services. VPAS provides leader training and quality assurance for JABA. Because JABA had a Nurse Practitioner (NP), their role was to provide clinical supervision and to implement the program at the local level. They also served as the Medicare provider and handled the billing because they already had that capacity.

Target Population and Pilot Location for the HBAI Initiative

Carol: We focused on individuals 65 and older (those receiving Medicare) with at least one chronic condition. We offered the pilot workshop at our Mary Williams Senior Community Center in Charlottesville during regularly scheduled center hours. This is an established location where staff members are familiar with clients’ needs and concerns. This location is supported by a nurse and a community center supervisor who could encourage involvement of members and ensure a higher level of participation.

How Virginia’s HBAI Initiative Got Started

What interested you in offering HBAI services, and how did you get started?

Joyce:  April became aware of NCOA’s learning collaborative opportunity and passed it along to those of us who are coordinators. I love to learn and wanted to take advantage of this opportunity, so I decided to submit an application. I never thought we would be chosen. Thank you for that! It was a great opportunity and learning experience.

April: DARS isn’t a provider, so we were looking for a AAA that could actually implement HBAI as a pilot project. We thought VPAS would be a good candidate—they have taken initiative before and are interested in innovation. When you ask Joyce if she wants to try something, she’s very likely to say “yes.”

Partnerships

Our goal was to find a place where we could make this work. We didn’t know if we’d get a return on our investment, but we made a commitment to do this. We already had a good relationship with JABA and built on that. . . . We would focus on making that our first success.

Joyce Nussbaum

What made VPAS decide to form a partnership with JABA?

Joyce: When we first started, we approached a health care provider in Lexington as a partner because we had a leader who worked there, and they could provide the billing and oversight. We had conversations about partnering and drew up an agreement with them. But due to some personnel changes and other priorities, they ultimately decided that it wasn’t a good time to implement HBAI.

Our goal was to find a place where we could make this work. We didn’t know if we’d get a return on our investment, but we made a commitment to do this. We already had a good relationship with JABA and built on that. In conversations with Carol, I learned that JABA had an NP on staff. We decided that it made sense to work with them—to have them provide the supervision, conduct the workshop at one of their sites, and handle the billing. We would focus on making that our first success.

Carol: Our NP had time in her schedule to include HBAI. Also, JABA could assist with the billing because we have our own internal billing process for other insurances but not Medicare. The billing agency that we contract with agreed that they could add Medicare without any additional cost to us. We thought this would be good opportunity to earn additional funding for our CDSME program. We had a lot of internal conversations about how this would work and determined that the finance office could handle the billing. We also decided that we would pilot the workshop at one of JABA’s senior community centers.

Have you developed partnerships with any health care organizations to help you expand HBAI services?

Joyce: Not at this time, but JABA coordinated a meeting to discuss a possible collaboration with the University of Virginia to work with one of their health care partners. We hope that they will be ready to work with us in the fall. They are value-based experts; they could offer a lot to our program in terms of referrals and potentially take on a billing role.

Communication Flow

What is your process for communication among all three organizations and with other AAAs to share information about HBAI?

April: Monthly statewide conference calls are our primary means of communication. For the HBAI Initiative, we also stay in contact through individual phone calls and emails. Joyce and Carol have worked very closely together on the planning and implementation process. Once they receive reimbursement, they will share what they learned, as well as develop guidelines and tips to support others who are interested in offering HBAI.

Carol: There are pitfalls that I’d like to outline for others to help them. It is an arduous process, and you have to be patient. The process can be challenging if your organization plans to become a Medicare provider.

Joyce: We plan to start sharing our process and lessons learned with others within the next month or two. We just have to figure out the billing because we don’t want others to have to worry about that. We want to be able to say, “If you are already offering CDSME, here’s an opportunity to get reimbursed, and here’s how you do it.”

Clinical Supervision

You’ve mentioned that you decided to use an NP as the clinician because JABA had one on staff. Please tell us a little more about the NP’s role and your process for clinical supervision of HBAI services.

Joyce: The NP made the referrals and met with the participants to conduct the initial assessment and care plan that is required for HBAI. She also held individual sessions with participants during the course of the Chronic Disease Self-Management Program (CDSMP) workshop to reinforce their goals and was responsible for supervision of the group sessions provided by the lay leaders. She was required to be in the building and accessible when the group sessions were held but didn’t have to be in the room where the workshop was held. She had information about what was covered during each group session so that she could reinforce the content.

Carol: In some ways, her role was similar to what she was accustomed to, but there were differences, as well. She had to become familiar with medical billing codes. She also had to document in a specific way so that the services provided could be verified in case of an audit. She was dealing with twelve people all at once within a short period of time. Because not everyone came to every session, she had to be flexible as to when she provided individual sessions. There was definitely a learning curve in terms of what was required. Now that we’ve been through the first workshop, we want to document the process so that it will be easier next time.

Benefits of HBAI’s Clinical Supervision for CDSME Participants

(HBAI) gives participants an immediate opportunity to ask their specific questions and get answers during the course of the workshop, rather than have to wait until they have an appointment with their physician. That is a key benefit.

Joyce Nussbaum

From a practice standpoint, have you seen any benefits of offering CDSME HBAI services versus providing the Stanford model without the additional clinical infrastructure that HBAI requires?

Joyce: As CDSME leaders, when asked a question, we are trained to say to participants, “I’m not qualified to answer your question. This is something to ask your health care provider on your next visit.” One huge advantage of having supervision of the NP or other clinician, which is a requirement for HBAI services, is that now we can say, “That’s a great question to ask the NP when she meets with you.” It gives participants an immediate opportunity to ask their specific questions and get answers during the course of the workshop, rather than have to wait until they have an appointment with their physician. That is a key benefit.

Carol: Knowing that they can talk with a clinician in between the group sessions can be an incentive for individuals to attend the workshop. It gives them a chance to ask personal questions and talk about what’s on their mind. I think that HBAI can be helpful in communities where there is poor attendance or high attrition rates within the CDSME programs because it provides ready access to a clinician.

Given your experience thus far in providing clinical supervision, is there anything that you plan to do differently going forward?

Carol: Next time, we will we will conduct the initial health and behavior assessments in a group, whereas this time, the NP held individual meetings. We are learning how to be more efficient and make the best use of the NP’s time.

Billing and Reimbursement

It is important to understand which codes to use and also that there is flexibility regarding when the clinician meets individually with the participants throughout the course of the workshop. Each organization needs to develop a model that works for them. . .

Carol Bell

What steps were necessary to obtain Medicare reimbursement?

Carol: We didn’t realize how much time and effort it would take to become a Medicare provider and establish the billing process for HBAI. First JABA had to obtain a Medicare Provider Transaction Access Number (PTAN), which is administered when an organization enrolls in Medicare. We already had a National Provider Identifier (NPI), a unique identifier for covered health services because we bill other payers. The NP had her own Medicare NPI number but had to request that Medicare assign her NPI to our Medicare number.

All of this had to be submitted through the Provider Enrollment, Chain and Ownership System (PECOS) internet-based system. I worked with one of the agents at the Palmetto Health Medicare Administrative Contractor (MAC) to assure that everything was in order.

How long did this take?

We submitted our initial application to the Centers for Medicare & Medicaid Services (CMS) in December 2016, and it was March 2017 before we were approved.

Does JABA do its own billing or outsource it?

Carol: We have a contract with a billing agency that handles all of our billing for insurances. They work closely with our staff to make the process easier. We input the data, and they take care of it from there. They bill on our behalf and follow up if there are any issues with claims being denied.

What is your billing process?

Carol: First of all, we ask individuals to show us their Medicare cards when they enroll in the program.  We haven’t had a problem with this since we are already providing services, and they know us. Then, the NP has to document the appropriate diagnosis and billing codes, using her clinical judgment about the service that was provided. She also provides clinical documentation to support the billing. The billing information then goes to our finance department where the data is electronically transmitted to the billing agency that processes and submits the claim to Medicare.  Our staff and the billing agency work very closely together.

When did you submit your first claim, and how long did it take you to receive payment?

Carol: We haven’t submitted our claim yet because we have had to clarify the process for documenting and billing groups, and we want to submit all the claims for the first workshop at the same time. We are checking all of our documentation and hope to submit claims for the first workshop in August (2017).

Will you submit the claims electronically or by paper?

Carol: First, Palmetto GBA, our Medicare Administrative Contractor (MAC) had to give approval to our billing agency to accept our claims. The claims will be submitted electronically by our billing agency. The electronic system allows you to make changes and adjustments if something is not submitted correctly. This process is familiar to our billing department.

Would you please share a few tips related to billing and reimbursement that might be helpful to others?

Joyce: I think understanding that there are different codes depending on what type of clinician you use—the codes and rates for the NP are different than those for the social worker or psychologist. It is important to understand which codes to use and also that there is flexibility regarding when the clinician meets individually with the participants throughout the course of the workshop. Each organization needs to develop a model that works for them once they decide on their clinician and understand the codes that are applicable.

Documentation and Tracking

We use the National CDSME Database and are transitioning to use the No Wrong Door System. We hope that an increasing number of medical practices will use No Wrong Door. . . . and ultimately, we would like the system to be used to track all of our CDSME data.

April Holmes

What is your documentation and tracking process? 

Carol: For documentation, we use a paper medical record. The NP documents every encounter for both individual and group sessions. Our records are filed in locked cabinet in compliance with HIPAA regulations. The billing agency keeps track of the claims that are filed, which ones are paid, and which ones have issues.

Do you use a database or spreadsheet to track workshop data, and how do you communicate with a patient’s physician?

April: We use the National CDSME Database and are transitioning to use the No Wrong Door System. Both forms of technology make it possible to track participant attendance and demographic information. We hope that an increasing number of medical practices and health systems will participate in No Wrong Door. We are in the final phase of negotiating a contract with Virginia Premier, one of the state Medicaid Managed Care plans for Long Term Services and Supports to provide CDSME for its members. The No Wrong Door System will be used to receive referrals and track data for this effort; and ultimately, we would like the system to be used to track all of our CDSME data.

Is No Wrong Door HIPAA compliant?

April: Yes

Referrals and Marketing

I get the attention of health care providers, when I ask them “What would it be like if your patients actually followed through on the things they have agreed to do when they leave your office?” This has been a good discussion starter because it is a big issue for them.

Joyce Nussbaum

Referral Process

How did you get referrals for your first workshop, and what are your plans going forward?

Carol: The registered nurse and the Community Center Supervisor, who work at the senior community center on a regular basis, encouraged clients to participate in the program. After an initial assessment, the NP was able to make appropriate referrals to the program.

For Medicare reimbursement, there has to be a referral from a physician, NP, or physician assistant (PA). Besides JABA, are there other partners that you are working with or planning to engage to make these referrals?

Joyce:  Not yet, but we will be looking for additional locations where there is a supervising clinician on site. Then, that site then can make referrals to the program.

Many CBOs find that getting enough referrals to fill their workshops is challenging. Yet, a steady referral stream is important for long-term sustainability of HBAI. How are you working to generate enough volume of referrals to cover the costs of your program? 

Joyce: We have plenty of leaders with the infrastructure and capacity to hold as many workshops as providers want. We just need to partner with the right health care organizations, and we are in the planning stages to develop those relationships. We want to embed CDSME and HBAI services into the practices. We know that it will take time for to build volume and cover our costs, so we are taking it one step at a time.

As you develop those relationships, are there factors that are important to consider in selecting and working with a health care provider?

Carol: It is important to have an ambassador—someone who knows the potential participants and can be influential in getting them together. At the community center, it was easier to get them involved because they come every week at the same time and have established relationships over a long period of time.

Joyce: Clinics have identified people who are frequent utilizers or those who need chronic care management. Patients have a care manager assigned to them, and the care manager can potentially be helpful in the process. We will need to have conversations with health care providers and determine what works.

Marketing

When you approach new partners, what is your message or your value proposition to get their buy-in for HBAI services?

April: We tell them, “CDSME programs can reduce health care costs and improve health outcomes for your beneficiaries by keeping them out of hospital and helping them manage their conditions more effectively.” For HBAI, you could make the argument that you are helping health care organizations with their bottom line by meeting practice standards and reducing the risk of having fines imposed. In a nutshell, there are savings and potential financial gains, as well as improved health outcomes for their patients. Our State Medicaid Agency notified Managed Care Organizations that CDSME can be offered as an enhanced benefit under Medicaid Managed Care. This backing has led to the development of our relationship with Virginia Premier, a Medicaid Managed Care Plan.

Joyce: I get the attention of health care providers, when I ask them “What would it be like if your patients actually followed through on the things they have agreed to do when they leave your office?” This has been a good discussion starter because it is a big issue for them. Then, you can make the point that CDSME HBAI services are designed to activate patients and improve self-care behaviors.

Helpful Resources and Facilitating Factors

The biggest factor that contributed to our progress was our determination. We never gave up; we just kept listening for the next answer. I think when you are piloting something that hasn’t been proven or done before, you can’t stop when there are barriers. You have to . . .  keep going forward.

Joyce Nussbaum

Were there specific tools or resources that you accessed to help develop your business model for HBAI? 

Joyce: Since VPAS was part of the HBAI Learning Collaborative, we had access to all those resources and a lot of technical assistance along the way, including one-on-one and group calls. The break-even analysis tool, a spreadsheet that allowed us to plug in our numbers to see what it would take to cover our costs, was really helpful. NCOA also has an online Toolkit with many valuable resources on community-integrated health care.

Were there facilitating factors that contributed to your progress?

Joyce: The biggest factor that contributed to our progress was our determination. We never gave up; we just keep listening for the next answer. I think when you are piloting something that hasn’t been proven or done before, you can’t stop when there are barriers. You have to keep asking yourself, “What is the way around this?” and keep going forward. My perspective on this has been that we are already providing the workshops, and now we just need to overlay HBAI services. We have to figure out the process and make it happen first; then we can focus on how many workshops we need to cover our costs.

Also, having a good, reliable partner has been important. JABA has been a great partner, and we wouldn’t be where we are now without them.

Challenges

As you think back on your path to reimbursement, what major challenges did you face and how did you overcome them?

Joyce: Our biggest challenge was that we didn’t have another AAA that had done this, so we were charting unfamiliar territory. There was a lot of information to digest, and we had to clarify the process a number of times. It would have been easier if there had been another AAA that had already done this to reach out to. Hopefully, once we submit our claim and receive reimbursement, we’ll be able to offer that to others.

Carol: At JABA, we didn’t realize how much time and effort it would take to become a Medicare provider and establish the billing process for HBAI. Offering and billing for HBAI services would have been easier if we had already been a Medicare provider. But we’ve learned a lot and are proud of what we have accomplished.

Tips

Are there any tips that you can offer to help others who decide to offer HBAI services?

April: After being involved with CDSME for seven years, I’ve learned that there are two essential ingredients for successful programs: organizational leadership at both the state and local levels and a willingness to take risks to try something new (within fidelity guidelines, of course). In Virginia we’ve been very fortunate to have an abundance of both. The roles at each level are vital. While the local program serves the critical role of implementing every aspect of program delivery and maintenance, the state can serve as a valuable resource to provide direction, support, and coordination of local efforts.

Joyce: When developing partnerships, I would encourage engaging more than one potential partner initially, so that if that organization’s priorities change, you still have options. Then, look for a champion in the organization that can help you get buy-in and develop a workable process.

Also, I would suggest that you establish the billing process before you offer the first billable workshop so that both the clinician and the organization know what is expected of them and what needs to be documented for reimbursement. We held our workshop before we had the billing and documentation process worked out; and in retrospect, we wish we had done that differently.

Carol: From JABA’s perspective, I would echo Joyce’s comment about establishing your billing process before you offer the first billable workshop. Also, be sure the clinician is familiar with the billing codes and provides the appropriate document to support the billing. The codes differ based on the type of clinician that is providing the service.

Next Steps and Vision

It takes a collaborative vision with everyone working as a team to make a difference. Our vision is to go as far as we can so that we can truly have consumer-centered and integrated health care.

April Holmes

What are your next steps to grow and sustain HBAI services? 

April: Our modest goal for HBAI in our grant proposal is that HBAI will be established in three AAAs by end of the grant period (July 31, 2018). It’s there in one and close in another (VPAS and JABA). I think we will meet the goal. We don’t really know how extensive we can make this or how many AAAs will be willing to take this on, but we hope to go much broader throughout the state with HBAI as an option for AAAs to help sustain their CDSME programs.

Thank you for taking the time to share your experience. In closing, is there anything else that you’d like to add?

April: First of all, I’d like to thank Joyce and Carol for being bold adventurers. We had a sustainability summit in 2015 to explore how we would go forward with or without grant funding. One option was for AAAs to team up and share resources through regional collaboratives. VPAS, JABA, and another AAA (Shenandoah) took the initiative to form the first regional collaborative.

It takes a collaborative vision with everyone working as a team to make a difference. Our vision is to go as far as we can so that we can truly have consumer-centered and integrated health care.

This project was supported, in part by grant number 90CS0058-01-00, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.

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State Medicaid Waiver Programs- 1915(c)

What is State Medicaid?

This guide serves as a resource to help state and community-based organizations offering chronic disease self-management education (CDSME) programs build partnerships with their State Medicaid Agency to improve the quality of care of low-income older adults and adults with disabilities served by Medicaid in their respective states.

Medicaid is a health insurance program that is jointly financed by the federal and state government and managed by the Centers for Medicare & Medicaid Services. The program helps cover the cost of health care and long-term services and supports (LTSS) for individuals with low-income and limited resources. People who receive Supplemental Security Income (SSI) because they are aged, blind, or disabled with a low income automatically qualify for Medicaid. While there are certain mandatory services that Medicaid covers, each state may choose additional coverage options. Therefore, services vary by state.

The Role of State Medicaid Agencies

Every state and the District of Columbia has a government division or agency that oversees the Medicaid program. State Medicaid Agencies set eligibility standards, determine the scope of services, establish payment rates, and manage the implementation of Medicaid.

State Medicaid Agencies are looking for ways to improve the quality of care, achieve better health outcomes for the individuals they serve, and control costs. Toward this end, a variety of innovative approaches are being implemented, including removing barriers to care and offering evidence-based programs. According to the Centers for Disease Control and Prevention (CDC), chronic diseases — such as arthritis, cancer, diabetes, heart disease, stroke, and obesity — account for 86% of health care costs in the U.S. Evidence-based chronic disease self-management education (CDSME) programs have been demonstrated to improve health and lower costs associated with chronic diseases. When made widely available to people who are covered by Medicaid, these programs can help State Medicaid Agencies achieve their cost containment and quality assurance goals, while also providing a much-needed and valuable service to individuals. CDSME programs have been shown to enhance the health care experience of individuals and help them learn how to manage their health so that they can live longer, healthier lives in their own homes and communities.

State Medicaid Agencies have the option to make changes to the operational approach or payment methodology, changes the Medicaid program (adding or deleting programs), or transition to a managed care model by submitting a State Plan Amendment (SPA) to the Centers for Medicare & Medicaid Services (CMS). State agencies can choose to deliver care to consumers through different delivery models, including traditional fee-for-service payment models using contracted Medicaid providers, managed care models, or integrated care models. Some states have elected to utilize the managed care model, which means that they deliver Medicaid services through contracts with managed care organizations (MCOs). Under a managed care model, the state contracts with two or more MCOs that are paid on a per-member-per-month (PMPM) basis to manage the delivery of health care services to the members that they serve.

When a state intends to issue an SPA to CMS, the state must obtain input from stakeholders. State and community-based organizations providing CDSME programs have an opportunity to provide input by encouraging their State Medicaid Agency to cover CDSME as a benefit.

Joint Federal and State Funding

As a jointly funded program, both the federal government and states contribute financially to Medicaid. States must provide match funding for Medicaid costs covered by the federal government. The state match is calculated using the Federal Medical Assistance Percentage (FMAP) formula, which is updated every three years. The FMAP is the percentage of Medicaid expenses that are covered by the federal government. The remaining percentage of the costs must be paid for by the state. The current average state FMAP is 57% and ranges between 50% and 75%. Using the average FMAP as an example, the state would be required to cover 57% of the total cost of Medicaid for covered beneficiaries. The rest of the costs would be covered by the federal government.

States must include Medicaid costs in their state budget and be adequately prepared for increased Medicaid expenditures, including acute care and long-term services and supports (LTSS). State Medicaid Agencies have the authority to set payment rates for Medicaid services. However, these payment rates must be in compliance with federal guidelines enforced by the Centers for Medicare & Medicaid Services (CMS). When a state contracts with managed care organizations (MCOs) to manage a Medicaid population, the contracted rates are negotiated between the organizations providing the health care services (acute and LTSS) and the MCO. The State Medicaid Agency does not regulate the provider contract rates for MCOs.

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What is Medicaid Managed Care?

According to a Kaiser 2015 report, 39 states have implemented managed care models to deliver Medicaid services. Through Medicaid Managed Care, the State Medicaid Agency establishes contracts with managed care organizations (MCOs) that are responsible for the overall costs and quality of care for a specific group of Medicaid beneficiaries. Under a Medicaid Managed Care model, the MCO operates as a health insurance plan and contracts with a diverse provider network to provide direct services. The provider submits claims to the MCO for the services that are rendered to the designated population.

In order to establish a managed care program, the State Medicaid Agency has to obtain approval from the Centers for Medicare & Medicaid Services (CMS) through the State Plan Amendment (SPA) process. Then, the state issues a request for proposals (RFP) for private health insurance companies to assume the financial risk for managing the Medicaid benefits for a defined segment of the Medicaid population. Most states begin with contracting with an MCO to deliver direct health care services. Long-term services and supports (LTSS) are a separate level of coverage and usually require a separate contract between the State Medicaid Agency and the MCO.

The health insurance company (vendor) that is chosen through the RFP process will receive a contract for managing the Medicaid benefits for a specific population. The health plan is then responsible for managing all of the health care costs for the population using a capitated per member per month payment (PMPM) from Medicaid. Cost overages are the responsibility of the vendor. The vendor has an opportunity to increase their profit in the contract by reducing the overall cost of care for the population. The state benefits by having a consistent expenditure for the Medicaid program and extends the risk of the program to the vendor. 

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What does "Dual Eligible" mean?

“Dual Eligibles” are individuals who qualify for both Medicare and Medicaid benefits. The dual eligible population includes low-income older adults and younger people with disabilities. Medicare is the primary payer for the acute care needs of a Dual Eligible, and Medicaid is the supplemental policy for that individual’s acute care costs. Medicare provides only limited coverage of long-term services and supports (LTSS). In contrast, Medicaid covers many LTSS, including home and community-based services and inpatient long-term care. Services vary by state because states have flexibility to design their own programs as long as they comply with the federal guidelines.

The older adult population is and will continue to be a key growth sector for Medicaid Dual Eligibles, and states will need the expertise of organizations that serve this population to improve health outcomes, provide better health care, and lower costs. Therefore, it is important that state and community-based organizations offering CDSME programs and other health-related services work with their State Medicaid Agency to provide input into the state Medicaid plan. The Medicaid state amendment process provides an opportunity for stakeholder input that can influence the state’s covered services.

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What are the Benefits of Partnering?

Medicaid serves 4.6 million low-income older adults and 3.7 million people with disabilities. [1] Many older adults and people with disabilities have chronic health conditions that can place a burden on the acute care and long-term services and supports (LTSS) systems.

Self-management practices can mitigate the progression of chronic illnesses and thereby reduce the burden on the health care system. Evidence-based CDSME programs show great promise in supporting Medicaid’s efforts to reduce acute care and LTSS expenditures, while improving quality of care and health outcomes. Developing partnerships between community-based organizations (CBOs) that are delivering CDSME programs and Medicaid state agencies can be mutually beneficial. The Medicaid state agency benefits by working with a service provider that is experienced in engaging a population that heavily utilizes Medicaid and can readily deliver CDSME programs. The organization delivering CDSME programs benefits from receiving a reliable source of referrals and an established payment mechanism for their CDSME programming.

Health Reform Positions State Medicaid Agencies to Adopt CDSME 

Under the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) developed the value-based payment program, which reimburses Medicare health care providers for achieving improvements in health outcomes and reducing costs, rather than for the number of services provided to Medicare beneficiaries. States that wish to shift to a Medicaid Managed Care model have the unique opportunity to align Medicaid payment incentives with Medicare value-based payment models for the population of Dual Eligibles (individuals who are eligible for both Medicare and Medicaid).

Evidence-based CDSME programs have been shown to activate patients so that they are more involved in their health, have increased self-efficacy, practice healthy lifestyle behaviors more often, and report feeling better. The programs have been demonstrated to improve a number of quality measures related to health status, health care, and costs. [2] Because CDSME programs are peer-led, provide a supportive environment to facilitate change, and empower participants to take charge of their health, they are well suited for helping to improve the health status of older adults and people with disabilities. These programs can be useful in helping Medicaid improve the health of Dual Eligibles, who are disproportionately affected by chronic diseases.

Helpful Links to Learn More

[1] Medicaid.gov. Seniors & Medicare and Medicaid Enrollees. https://www.medicaid.gov/medicaid-chip-program-information/by-topics/eligibility/seniors-and-medicare-and-medicaid-enrollees.html. Accessed August 4, 2016

[2] Ory, M.G., Ahn, S., Jiang L., Smith, M.L., Ritter, P., Whitelaw, N., & Lorig, K. (2013). Successes of a National Study of the Chronic Disease Self-Management Program: Meeting the Triple Aim of Health Care Reform. Medical Care, 51(11), 992-998.

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Connect with your Medicaid Agency

It is important to locate your State Medicaid Agency, learn about its delivery model, and express interest in participating in their Medicaid change processes. The National Association of Medicaid Directors maintains a map that includes links to each state’s Medicaid agency. You can use the map to visit your State Medicaid Agency’s website and view public notices about proposed changes to the Medicaid program so that you can respond when opportunities arise for community input.

Some Medicaid agencies have established a listserv email group to notify stakeholders about proposed changes or updates to the Medicaid program. Sign up for these listservs. The listserv enrollment process requires the registration of a valid email account.

Identify the Appropriate Contact

Medicaid state agency staff are knowledgeable about initiatives that provide opportunities for community input on proposed changes to Medicaid and might have ideas about how CDSME programs can be integrated into new initiatives or existing efforts and included as a covered service. This can apply to any initiative, whether it’s a Medicaid Health Home initiative, a State Innovation Model (SIM) demonstration, or long-term services and supports (LTSS) Waiver program.

To cultivate a personal relationship with someone at your State Medicaid Agency, start by working with your organization’s internal Medicaid liaison to make the appropriate contact. If you do not have an organizational representative that maintains contact with Medicaid, contact your State Health Department or Area Agency on Aging. Most of the time, they already have a contact with Medicaid that they work with frequently.

Generally, the division within Medicaid that will pay for CDSME programming is the Acute Care Division. You should ask to speak with someone from that division. Other avenues to explore include connections with the person who manages the Medicaid Managed Care or LTSS Waiver program. Because the State Medicaid Agency operates under many rules and regulations, it can take time to develop the relationship and see progress. Also, consider leveraging existing relationships to help support your efforts.

Do Your Research

Making the initial contact with Medicaid may feel challenging, so it’s important to prepare in advance of your initial contact. Do your research before the initial call or meeting with your Medicaid contact to show that you have an understanding of regulatory requirements, agency priorities, and the needs of Medicaid beneficiaries.

  • Acquaint yourself with the regulatory requirements and frequently used terminology of the Medicaid state agency. This will help you establish common ground and language, while helping you demonstrate the value of your service to Medicaid.
  • Develop a clear understanding of how Medicaid is currently being administered in your state. If your state has implemented Medicaid Managed Care, it would be helpful to do a little more research.
    • Gather information about which health plans have contracts with the State Medicaid Agency to serve as managed care organization (MCO) vendors and what benefits are covered by the MCOs.
    • Learn how the contracted health plans are performing in the provision of quality care as measured by the Centers for Medicare & Medicaid Services (CMS) performance measurement data sets. This is important because many Medicaid MCO plans have to align quality outcomes with Medicare quality outcomes to receive payment incentives.
  • Find out about the challenges that the Medicaid state agency is facing, so that you can make the case for the benefits of adopting CDSME.
  • Know the percentage of Medicaid beneficiaries or dual eligibles in your state with chronic illnesses, the extent to which they have access to CDSME programs, and how much Medicaid is spending on health care costs, including acute care, readmissions, and LTSS for this population.

Find out What Medicaid Policies are Currently in Place to Support CDSME

The first place to start with establishing Medicaid payment for CDSME is to identify what policies are already in place that would support these programs. For example, if your state already covers CDSME as an approved Medicaid benefit, then you will need to apply to become a Medicaid provider and obtain a Medicaid provider number. In a standard fee-for-service reimbursement model, you will have to establish a billing system to receive payment. Whether or not CDSME is covered, you should ask the Medicaid state agency to put you in contact with the Medicaid MCO health plans that can benefit from offering CDSME to their patient population. Having the introduction come from the State Medicaid Agency can increase your chances of success in building partnerships with MCOs to make CDSME programs available to their members and ultimately paying you for delivering the service. In some cases, the Medicaid state agency will put in place requirements that Medicaid MCO Health plans cover CDSME for the population they serve.

State Medicaid Agencies develop and enforce Medicaid policies to monitor regulations about what is covered under Medicaid across the state. Therefore, if your state does not offer CDSME as a covered benefit, you should be responding to opportunities to make recommendations for Medicaid changes that include CDSME as a covered benefit. It is important to ensure that your responses include data that demonstrate the benefits of CDSME and show how offering CDSME statewide can improve the health of the state’s population health and lower health care expenditures. There have been many research studies of CDSME programs that can help you present your business case.

Learn about Medicaid Stakeholder Groups

Medicaid is required by the Centers for Medicare & Medicaid Services (CMS) to obtain community input from key stakeholders on proposed changes to Medicaid. State Area Agencies on Aging are often among the group of key stakeholders. Participating in these groups is an opportunity for you to spread the word about the importance of offering CDSME as a Medicaid covered benefit and networking with others who can advance the cause. To learn more about Medicaid stakeholder groups, check your State Medicaid Agency’s website or contact your State Health Department and Area Agency on Aging to inquire about opportunities to become involved.

Develop a State-Focused Value Proposition

 Whether you will be interacting with your State Medicaid Agency by providing community input, participating in stakeholder groups, or having conversations with internal Medicaid representatives, it is important to make a strong case for providing CDSME as a benefit. Since Medicaid serves the entire state, your State Medicaid Agency will want to know how you can provide services throughout your state. You will need to develop a solid statewide infrastructure, possibly developing partnerships and forming a network of service providers to meet the need. It might also involve offering online CDSME programs, which provide consumer choice and can help fill any gaps that might exist in regional service coverage. Contact Canary Health if you are interested in exploring the addition of online CDSME programs to your statewide offerings.

Crafting a value proposition can help you get your message across. It is important to make the case in your value proposition that CDSME can improve health outcomes while lowering costs across the entire state. Be sure to highlight the benefits of CDSME programs in your value proposition.

  • CDSME is proven effective in improving the self-management skills of patients, which leads to improved clinical outcomes (e.g., better self-reported health and quality of life, improved symptom management, increased activity level, reduced depression, improved medication adherence). [1]
  • Better clinical outcomes achieved through CDSME can help Medicaid improve the state’s population health and lower health care expenditures statewide by reducing health care utilization, such as hospitalizations and emergency room visits.
  • CDSME improves patients’ communication with their health care providers and equips them with the skills to work with their providers in setting and obtaining achievable goals that result in improved health.

Include a cost-benefit statement in your value proposition with data to highlight the value of CDSME to the state and the potential return on investment (ROI) by offering the program as a Medicaid covered service. The ROI creates a “win-win situation” for your organization, Medicaid, and most of all, the patient.

Sustainable partnerships lead to sustainable CDSME programs. One of the foundations of sustainable partnerships is the ability to establish common ground, set expectations, and identify mutually beneficial goals. In early meetings with your State Medicaid Agency, use your value proposition to guide discussions about setting expectations and goals for the partnership. Also in these early meetings, begin to identify potential champions who can assist you in developing and strengthening the partnership.

Helpful Links to Learn More

[1] National Council on Aging. Chronic Disease Self-Management Program: Summary of National and State Translational Research Findings. https://www.ncoa.org/wp-content/uploads/Health-Outcomes-Evaluation-Revised-6.24.16-1.pdf. Accessed August 4, 2016

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Medicaid Coverage of CDSME

Engaging in discussions with Medicaid can help you to: 1) align your program delivery and billing strategy with Medicaid services that cover CDSME programs; 2) open the door to partnerships with the Medicaid Managed Care Organizations (MCOs) to help them see the benefits of offering CDSME to their members; and 3) explore opportunities for including CDSME programs in future Medicaid initiatives. Below are some specific opportunities for covering the cost of CDSME that you can discuss with your State Medicaid Agency.

Medicaid Health Home Benefit

Medicaid Health Homes is a new benefit that was established by the Affordable Care Act. States that wish to implement Medicaid Health Homes must submit a State Plan Amendment (SPA) to the Centers for Medicare & Medicaid Services (CMS) for approval. Under the Medicaid Health Home benefit, states can establish Health Homes to coordinate care for Medicaid beneficiaries with chronic conditions. The Health Home provides “whole-person” care by coordinating primary, acute, behavioral health, and long-term services and supports. Health Home Services include: 1) comprehensive care management; 2) care coordination; 3) health promotion, comprehensive transitional care/follow-up, patient and family support; and 4) referral to community and social support services.

Evidence-based CDSME programs, which help individuals take control of their health, foster communication between patients and their health care providers, and promote clinical and community linkages, align well into the Health Home model. Health Home providers can include physicians, clinical/group practices, community health centers, home health agencies, and other providers. If your state offers the Health Home benefit, ask your State Medicaid Agency how to get connected with the Health Home providers. When making the case to embed CDSME to Health Home providers, emphasize the value of the program in reinforcing a whole-person approach to care, as well as its proven ability to achieve positive health outcomes.

Home and Community-Based Services (HCBS) Waivers

States can offer a variety of standard medical and non-medical services in home and community-based settings under the HCBS Waivers. Within the broad federal guidelines, HCBS services vary by state. The services are designed to meet the needs of individuals who prefer to receive services in a home or community setting, rather than in an institutional setting. Services may include case management, home health aide services, personal care, adult day health services, respite care, nutrition assessments, home delivered meals, and “other” types of services that may assist in diverting and/or transitioning individuals from institutional settings into their homes and community.”

Many beneficiaries that are eligible for HCBS Waiver services have two or more chronic diseases. These same beneficiaries may be good candidates for a CDSME program. A few states – Connecticut, Michigan, and Washington — have been successful in making CDSME a covered service. If CDSME programs are not a covered in your state, it is worthwhile to have a conversation about adding this service as a HCBS waiver benefit.

Medicaid Incentives for the Prevention of Chronic Diseases

Through the Affordable Care Act, some states receive grants to provide incentives to Medicaid beneficiaries who demonstrate changes in health risks and outcomes, such as adopting healthy lifestyle behaviors. The program used must address at least one of the following prevention goals: tobacco cessation, weight reduction, lowering cholesterol, lowering blood pressure, preventing diabetes, and improving management of diabetes. CDSME programs can help achieve all of these goals.

Visit the Centers for Medicare & Medicaid Services (CMS) website to learn whether your state is participating in this model. Work with your State Medicaid Agency to connect with stakeholder groups implementing the prevention of chronic diseases model and share the importance of including CDSME as a core service delivery component.

State Innovation Models Initiative (SIM)

This Affordable Care Act initiative provides some states financial and technical support for developing and testing statewide, multi-payer health care payment and service delivery models through SIMs. The goal of the initiative is to increase quality of care and decrease costs for Medicaid, Medicare, and Children’s Health Insurance Program (CHIP) beneficiaries. If your state participates in a SIM demonstration, you have an opportunity to promote CDSME as a program that can improve quality of care and health outcomes, while saving costs. Many states have stakeholder groups that participate in the development of the SIM model. If your state has a SIM, work with your State Medicaid

Agency to get connected with their stakeholder groups. Visit the Centers for Medicare & Medicaid Services (CMS) website to learn whether your state has received a SIM award.

Medicaid Managed Care

Since Medicaid Managed Care Organizations (MCOs) are responsible for managing utilization and costs and demonstrating positive health outcomes and quality of care for beneficiaries, they stand to benefit from offering CDSME programs to their members. Below are some steps that you should take before you contract with an MCO to help prepare you for developing a partnership. By doing your homework first, you will be prepared to develop and present a persuasive value proposition to the MCO.

  • Conduct research about MCOs in your state, specifically the one that you want to approach regarding coverage of CDSME. Review the mandated coverage requirements, geographic region covered, current enrollment, and any quality and cost data that is available for the specific MCO.
  • Conduct an external assessment to determine competition in the marketplace, as well as an internal assessment of the cost of offering CDSME programs, so that you will be prepared to negotiate a contract with an MCO.
  • Determine in advance how you will meet the volume demands that may come as a result of a partnership with an MCO.
  • Describe what processes you have in place for tracking and reporting information to the MCO.
  • Be prepared to explain how you will ensure fidelity and quality of the programming and to discuss factors such as patient satisfaction, performance measures, and outcomes.

As you work with the MCO, you will want to assure that the partnership is mutually beneficial with a return on investment for both your organization and the MCO.

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Working with Your State Medicaid Waiver

Several states have partnered with their State Medicaid Agency to cover CDSME programs under the Medicaid Home and Community-Based Services (HCBS) Waiver developed to help individuals receive long term services and supports in their own homes or communities, rather than in an institutional setting. To learn more about these efforts, interviews were conducted with states that have attained or are actively pursuing coverage of chronic disease self-management education (CDSME) programs under a Medicaid waiver. This section provides highlights from those interviews.

Rationale

Providing CDSME coverage under the State Medicaid HCBS Waiver can be mutually beneficial to the state, the community-based organization offering CDSME programs, and Medicaid recipients.

  • Benefits to the State: CDSME is a valuable program that can improve population health, prevent or delay institutionalization, and lower health care costs in the state.
  • Benefits to Community-Based Organizations Offering CDSME Programs: The community-based organization (CBO) offering CDSME programs can increase their program reach to a vulnerable population and secure a funding stream to help sustain their efforts long term. Furthermore, once they prove the value of CDSME, they have an opportunity to discuss the potential of reimbursement for CDSME programming under other parts of the State Medicaid plan, such as Medicaid Managed Care or the Medicaid Medical Home.
  • Benefits to Medicaid HCBS Waiver Members: Individuals who participate in a CDSME workshop learn how to manage their health, are more likely to become an active partner with their provider in maintaining their health, and have been shown to have positive health outcomes and increased quality of life.

State Successes

A few states have been successful in incorporating CDSME as a covered benefit in their Medicaid Waiver, while other are building the case for coverage.

  • Colorado is completing a claims study of Medicaid members who have participated in a CDSMP workshop to document pre and post program health costs. Any results that show cost savings will be used to try to persuade the State Medicaid Agency in Colorado to implement a pilot program and ultimately to add CDSMP as a state plan benefit.
  • Connecticut provides reimbursement for CDSME programs through their Eldercare Waiver. The state’s third party payer approves providers that can offer CDSME programs and receive reimbursement under the state contract. The third party payer maintains an up-to-date listing of the leaders and the workshop locations. A per session reimbursement rate has been established.
  • The Maine legislature approved Medicaid Waiver funding to cover evidence-based programs, including CDSME, under the MaineCare Section 19: Home and Community Benefits for the Elderly and for Adults with Disabilities Waiver. Pending CMS review, implementation is expected by the end of 2016. Once the changes to this waiver are approved, Maine plans to explore the potential of adding CDSME programs to other waivers.
  • Michigan offers reimbursement for CDSME through the Michigan Choice Home and Community Based Medicaid Waiver. The state established billing codes for CDSME programs, as well as a general code for other evidence-based programs that may be recommended for Medicaid members.
  • Utah created a Utah Medicaid Policy Issue Brief and is holding discussions with the State Medicaid Office in an effort to establish codes for self-management education. Once the codes are in place, organizations that offer CDSME programs will be able to apply to become a Medicaid provider and bill for their services.
  • Vermont’s Blueprint for Health was enacted in 2006, funded by a Centers for Medicare and Medicaid (CMS) Section 1115 Global Commitment for Health Waiver. Grants are made to community entities which have regional coordinators to implement self-management interventions in hospital and community locations for both Medicaid and non-Medicaid individuals. Vermont’s success in implementing their Blueprint for Health is described in this webinar.
  • Washington included CDSME in two 1915 C Waivers:
    • The Community Options Program Entry System (COPES) Waiver, designed to provide in-home and community-based services to help individuals who require nursing home level of care remain in a community setting, and
    • The New Freedom Waiver, a self-directed waiver, which provides participants with a monthly budget to purchase an array of services.

Challenges

 The process of obtaining Medicaid reimbursement can be lengthy, requiring negotiations with the State Medicaid Agency, the legislature, and other partners, as well as approval by CMS.

  • Physical and cognitive limitations of individuals who are served by the State Medicaid Wavier can result in a small pool of members who are able to participate in a community-based workshop.
  • Under a capitated reimbursement system, Medicaid providers (organizations that provide and bill for Medicaid services) receive a finite amount of funding for each slot approved in their service area. Because some Medicaid members require a great deal of care, providers may hold a certain amount of funding in a risk pool to fund individuals who are considered “higher need.” Consequently, they may be less likely to consider offering preventive and health promotion programs, such as self-management education.
  • Quantifying usage can be a challenge in self-directed programs or capitated systems in which the State Medicaid Agency purchases training and support, but the types of training and support are not specified. It is recommended that specific codes be established for CDSME so that use of the program can be monitored and appropriate steps taken to ensure that individuals who can benefit are being offered the service.
  • Staff turnover and large caseloads are barriers to making referrals to CDSME programs. New care managers might not make referrals because they are not sufficiently trained to understand the benefits of CDSME. Further, they might miss opportunities to make referrals due to large caseloads, which limit the time that they can spend with any one patient.
  • In some states, care managers are not employees of the Medicaid provider. Instead, their services are provided through a contractual agreement, which can limit the degree of control the Medicaid provider has to enforce its policies and procedures.

Lessons Learned and Recommendations for Future Efforts

  • Develop relationships with the State Medicaid Agency, Medicaid MCOs, Medicaid Waiver providers, and consumer organizations to determine which evidence-based programs will best meet the needs of the Medicaid population in your state.
  • Secure buy-in for the programs at the local and regional levels, in addition to the state level.
  • Use the CDSMP Cost Calculator or develop a worksheet to help determine an accurate cost of the program before approaching your State Medicaid Agency.
  • When negotiating the reimbursement rate, build in the costs for wraparound services, such as transportation and respite care, so that members have the support they need to attend the workshops.
  • Meet with State Medicaid Agency, Medicaid MCOs, Medicaid providers, and other stakeholders to ensure they have a clear understanding of CDSME and can explain the program and its benefits to Medicaid members, their family members, and caregivers. Be sure to include care managers in conversations, as they are responsible for assessment, referrals, and care planning.
  • Work collaboratively to establish written policies and processes to guide the referral and enrollment process. Be sure to develop referral criteria for CDSME programs.
  • Establish effective, ongoing communication channels through regular meetings and conference calls to develop, review, and improve processes.
  • Work with your State Medicaid Agency and Medicaid MCOs to develop an orientation and ongoing training process for ensuring that care managers and other key staff are knowledgeable about CDSME programs and their value.
  • Discuss strategies for marketing the programs early in the process and develop shared responsibilities. As part of your marketing strategy, include information about CDSME in newsletters or other communications that are sent to Medicaid members.
  • Develop a user-friendly packet of information about the CDSME programs and their benefits that can be shared with key personnel and distributed to Medicaid members, their family members, and caregivers.
  • Consider including CDSME as a standard component of the standard assessment tool that is used to identify and plan for the needs of Medicaid members. By doing so, care managers will be expected to identify and make needed referrals as a routine part of the assessment process.
  • Explore offering the online Better Choices, Better Health® Programs as an option for members who might not be able to attend a community-based workshop due to physical limitations, lack of transportation, or unavailability of a nearby workshop.

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