Connecting to HIE and The 1115 Waiver: What Providers Need to Know

1. Connecting to HIE and The 1115 Waiver: What Providers Need to Know Tara Larson Training for Sandhills Providers October 18, 2018 Asheboro November 1, 2018 Hamlet Cansler Collaborative Resources, Inc.

2. Training Agenda • Provide a review of the HIE and the legislative requirements • Provide a status update of the HIE Behavioral Health/IDD Implementation Workgroup • Identify the relationship between HIE and the 1115 Medicaid Waiver Standard Plans and Tailored Plans • Identify steps for agency planning and change management steps for successful HIE and data analytics implementation • Identify how and why HIE and data analytics are necessary for value based purchasing • Identify lessons learned by behavioral health /IDD providers who have successfully connected to HIE or who are in VBP arrangements Cansler Collaborative Resources, Inc.

3. Have You Asked? • Where is our agency going to be for the Standard Plan/Tailored Plan with Medicaid transformation? • Are we operating pay check to pay check in this current environment? • Where are we hurting? Why do we need to change the Status Quo? • Do we know the Vision of the PLE, CPs, PHPs for the network and health regions? • Have you conducted a self assessment on readiness in the new environment? • Are we paying attention to the right metrics? • Are our processes mapped and well understood?

4. Have you Asked? • Do we even know agency wide what “data collection” systems are being used and have we included them as part of day to day operations? • Do we use the data to help to identify the risk to the agency? • Are the staff equipped with the knowledge of the tools and the techniques of improvement and data management? • Is it after the fact or early in the process that trends and signals arise within the process? • Do we know what the trends are showing and why?

5. So what is the Vision for capacity to exchange data? For IT systems to talk to each other? To do whole person care, all in an environment that has questions and uncertainty? How do all the dots fit together?

6. What are the common denominators to the factors related to sustainability of the Provider of Value? DATA and Systematic Analysis Being able to achieve market share Providing services that will produce desired outcomes Meet the needs of the purchaser

7. The Answer…..Data • Having the means to collect data…meaningful data • What is data? • Having the means to share data, in a meaningful way that is not reams and reams of information like pages of clinical records that may or may not be used • Health Information Exchange – HIE

8. HIE is not…. • An Electronic Health Record • The information shared is only as good as the information received. Dirty data in will be dirty data going out • HIE is not a single system • It’s a pipe that can accept from various feeds IF • There is interoperability • Having data on the back in that is sequel based will work • It will not be the only data collection feeds/platform

9. What is NC HealthConnex? • The North Carolina General Assembly created the North Carolina Health Information Exchange Authority (NC HIEA) in 2015 to facilitate the creation of a modernized HIE to better serve North Carolina’s health care providers and their patients. (NCGS 90-414.7). • Housed within the Department of Information Technology’s Government Data Analytics Center (GDAC). • Technology partners are SAS Institute and Orion Health. • Advisory Board made up of various health care representatives will provide input.

10. Goals of NC HealthConnex Tolinkall providers across the state via a modernized HIE To put patient care at the center of all decisions to help improve health care quality and outcomes To support Medicaid Reform in the transition from fee for service to whole patient care

11. Types of HIEs in North Carolina State-wide HIEs – run by state governments or may be the state’s designated entity (i.e. the North Carolina Health Information Exchange Authority/ NC HealthConnex is the state-designated HIE) Private/Proprietary HIEs – often concentrate on a single community or network (i.e. Mission Health Connect, CareConnect – HIEs developed by Mission Health and Carolinas HealthCare respectively) Regional/Community HIEs – often not for profit (i.e. Coastal Connect in eastern North Carolina is a good example of this type of HIE)

12. Query – “Do you know my patient?” How Does the Technology Work? • HIE responds with a list of patients. • Registry Stored Query - “What do you know about my patient?” • HIE responds with a list of documents. This list includes a Patient Summary CCD and any documentsthat the HIE is aware of. • Retrieve Document Set • “May I have it?” Hospitals Chronic Care EHR Requesting EHR Standalone Direct Secure Messaging HL7 ClinicalPortal DSM Pharmacy Clinical Data Repository Integration Platform CCDA EHR EMPI Public Health HL7 CCD/A Orion Document Repository EHR LME/MCOs CPs and PLEs Providers and Practices

13. HIE Status - Updates to the Law • Hospitals as defined by G.S. 131E-176(3), physicians licensed to practice under Article 1 of Chapter 90 of the General Statutes, physician assistants as defined in 21 NCAC 32S .0201, and nurse practitioners as defined in 21 NCAC 36 .0801 who provide Medicaid services and who have an electronic health record system shall connect by June 1, 2018. • All other providers of Medicaid and state-funded services shall connect by June 1, 2019. • Prepaid Health Plans (PHPs), as defined in S.L. 2015-245, will be required to connect to the HIE per their contracts with the NC Division of Health Benefits (DHB). Clarifies that PHPs are required to submit encounter and claims data by the commencement of the contract with NC DHB. • Clarifies that Local Management Entities/Managed Care Organizations (LMEs/MCOs) are required to submit encounter and claims data by June 1, 2020. • If the medicaid transformation timelines change for LME/MCOs then the HIE responsibilities also will change

14. HIE Status – Updates to the Law • Allows NC DIT to establish an extension process in consultation with NC DHHS to grant limited extensions of time for providers to establish connectivity to the HIE network if such providers can “demonstrate ongoing good faith effort to take necessary steps to establish such connectivity.” More information on this process will be available in a future update. • This is currently in development. Lack of funding is not one of the discussed criteria or too small to participate • Clarifies that 42 C.F.R. Part 2 programs (i.e., federally assisted substance use disorder treatment facilities) are exempt from sending data pertaining to substance use disorder treatment services, pursuant to federal law. Providers who participate in these programs will still be required to send clinical data that is not subject to these restrictions.

15. HIE Status – Updates to the Law • Repeals the emergency opt out provision (G.S. 90-414.10(e)). When a patient opts out of the HIE, his/her data is sent to the HIE, but it is blocked from being shared with any of the HIE’s authorized users (those accessing the HIE for treatment, payment, or other HIPAA-covered purposes). The former law allowed for a treating provider to access the record of a patient who had opted out in the case of a medical emergency. The NC HIEA requested the repeal of this provision because the current HIE technology only allows for a privacy officer at the NC HIEA or SAS to open a patient record that had been blocked due to an opt out request. For example, an ER physician would not be aware that a patient record exists in the HIE for a patient who has opted out. The NC HIEA expects the impact of this change to be minor, as the current opt-out rate is >0.1% of patients with records in the HIE.

16. HIE Status – Updates to the Law • Requires a joint study to be conducted by NC DHHS, NC DIT, and the State Health Plan to better understand which data elements providers other than hospitals, doctors, and mid-level practitioners collect electronically, and whether those data elements have clinical meaning for HIE users. This is a priority for the NC HIEA and our partner agencies to provide clarity to these provider types impacted by the mandate. There are several legislative reports that are/will be submitted • There are several ways that this information is being gathered • Various workgroups – there is a group of behavioral health/IDD providers, LME/MCO reps and association reps

17. Connecting the Dots for Behavioral Health/IDD Providers • Most providers started taking steps earlier for connectivity when the law required the 2018 implementation date • However, there are many who still are not aware of what HIE is and their obligations to submit data • Granted, there have been delays and “more to workout” for the behavioral health/IDD field - thus the work group and also several providers who are willing to “pilot.” It’s important that smaller providers, not just the large statewide or regional providers • Many of the small(er) providers don’t have internal IT support and just understanding the lingo can be challenging

18. What does Connect Mean? • To meet the state’s mandate, a Medicaid provider is “connected” when its clinical and demographic information pertaining to services paid for by Medicaid and other State-funded health care funds are being sent to the NC HealthConnex at least twice daily – either through a direct connection to NC HealthConnex or via a hub (i.e. a larger system with which it participates, another HIE with which it participates, or EHR vendor).  Participation agreements signed with the designated entity would need to list all affiliate connections. • In order to be connected as defined above, what does that mean for you the provider about your internal capabilities and use of the information that is being generated?

19. The Initial Steps • Technology in Place: The NC HIEA Participation Agreement requests EHRs that are minimally capable of sending HL7 messages, version 2 and higher. The first step is to have the ability to send HL7 messages (version 2.0 and higher) to enable the technical connection and data submission to NC HealthConnex. EHR products that are ONC certified for Meaningful Use for the for Centers for Medicare & Medicaid Services (CMS) Incentive Programs are preferred.     • There are two ways to access NC HealthConnex: via the Clinical Portal or via EHR integration. • Clinical Portal Access: The NC HIEA teams works with each facility to establish secure access to our clinical portal to view available information. We’ll provide portal training to designated users and prepare staff to educate patients about participation. • EHR Integration: The NC HIEA team is working with several EHR vendors to build technical solutions that will allow the data from NC HealthConnex to be integrated within a participant’s EHR system to avoid interruptions in workflow.

20. The Initial Steps • Participation Agreement: Each new facility is required to sign a Participation Agreement governing its connection to NC HealthConnex. At this time and for the foreseeable future, there are no fees to connect. • The NC HIEA Full Participation Agreement, now aligned with federal standards – the Data Use and Reciprocal Support Agreement or DURSA--will allow providers full use of the NC HealthConnex current and future value-added features as well as provide for the State’s requirement for the submission of clinical and demographic data. • The Submission Only Participation Agreement, will enable a provider to submit the clinical and demographic data required by law in a one-way technical connection in order to be in compliance. However, this agreement will prohibit all other data exchange services including HIE query/data exchange and clinical registries. • Identify three points of contact within your agency that will collaborate with the NC HIEA and SAS

21. How does this all fit with Medicaid Transformation? • Data collection and data exchange is an underlying foundation to successful managed care – regardless who manages the plan(s) • Data exchange is necessary across provider types and networks that promote integrated care • Care Management and Advanced Medical Homes • Resource mapping for social determinants, access standards, pay for performance

22. Payers Shared Goals and Better Outcomes Providers Showing Value Knowing people are getting better but can’t prove it, no data Available data doesn’t tell the real story Can’t afford the requirements Paying for Value Have lots of data and don’t know if people are getting better Available data doesn’t tell the story Can’t afford the cost

23. Common Themes • Improve the experience of care, improve the health of populations and reduce per capita costs of health • Decrease fragmentation, improve coordination of care and provide care which is appropriate and meets the needs (not just what is available) • Transition to care delivery and payment arrangements that align quality and cost incentives

24. We Know That Health is…

25. North Carolina’s Quality Strategy North Carolina’s Quality Strategy is built around the desire to build an innovative, whole-person, well-coordinated system of care, which addresses both medical and non-medical drivers of health and promotes health equity. This vision is distilled into three central Aims:

26. Aim 1: Better Care Delivery. Make health care more person-centered, coordinated and accessible. • Goal 1: Ensure appropriate access to care • Objective 1.1: Ensure timely access to care • Objective 1.2: Maintain Medicaid provider engagement • Goal 2: Drive patient-centered, whole person care • Objective 2.1: Promote patient engagement in care • Objective 2.2: Link patients to appropriate care management and care coordination services • Objective 2.3: Address behavioral and physical health comorbidities

27. Aim 2: Healthier People, Healthier Communities. Improve the health of North Carolinians through prevention, better treatment of chronic conditions, and better behavioral health care, working collaboratively with community partners. • Goal 3: Promote wellness and prevention • Objective 3.1: Promote child health, development, and wellness • Objective 3.2: Promote women’s health • Objective 3.3: Maximize long term services and supports (LTSS) populations’ quality of life • Goal 4: Improve chronic condition management • Objective 4.1: Improve behavioral health care • Objective 4.2: Improve diabetes management • Objective 4.3: Improve asthma management • Objective 4.4: Improve hypertension management

28. Goal 5: Work with communities to improve population health • Objective 5.1: Address unmet resource needs • Objective 5.2: Address the Opioid Crisis • Objective 5.3: Address tobacco use • Objective 5.4: Reduce health disparities • Objective 5.5: Address obesity

29. Aim 3: Smarter Spending Pay for value rather than volume, incentivize innovation and ensure appropriate care. • Goal 6: Pay for value • Objective 6.1: Ensure high-value, appropriate care

30. So what is Data and Systematic Review • Some may say it is being a data driven organization • What does “that” mean? • Not a question that data is changing healthcare • You’ve heard about P4P • Talk about quality providers but who and what does that mean? • Incentive payments • Some, but not all providers, can tell how many people served, what they get paid but other than that…not all providers know the rest of their story or what their role may be in the new chapter of healthcare.

31. Data Sources Today and Their Use • Most data sources in today’s market are claims based • Limited behavioral health sites are pulling information from EHRs or other case management systems • In order for true whole person care to happen, data sharing and integration must be more “real time” • Being used for • Population Management • Financial and Forecasting • Benchmarks and Outcomes • Provider Management and Performance ratings

33. What Does the 1115 Waiver and Standard Plan RFP Say? • PHPs are required and incentivized to develop and lead innovative strategies to increase the use of VBP arrangements over time arrangements that appropriately incentivize providers and are required to submit their VBP strategies to DHHS and report on their use of VBP contracting arrangements each year. • DHHS has defined VBP – for the first two years of PHP operations as payment arrangements that meet the criteria of the Health Care Payment (HCP) Learning and Action Network (LAN) Advanced Payment Model (APM) Categories 2 through 4. (NC Quality Strategy) • By end of contract year 2, PHP expenditures with either increase by 20% or represent 50% of total medical expenditures

34. Alternative Payment Model Framework

35. Models of Value Based Contracting • Increasing Risk • Increasing Accountability • Health Care Payment Learning and Action Network (HCP-LAN) Advanced Payment Model Framework.

36. Required PHP Quality Metrics: Standard Plan • Section VII, Attachment E. Required PHP Quality Metrics, Page 37-54 • https://files.nc.gov/ncdhhs/30-19029-DHB-2.pdf • There are measures that are priority measures and those that also have withholds: Financial penalties. • Can you help the PHP/SP meet the measures? • In addition to the measures, there are additional reporting requirements. • Examples

37. Quality Measures State will track 64 quality measures drawn from: • A select set of CMS Adult and Child Core measures, • All HEDIS measures required for accreditation • A select set of additional measures aligned to the Aims, Goals, and Objectives of the Quality Strategy 33 measures align with the state quality strategy, will be tied to the Advance Medical Home performance incentive program and will be publicly reported Outcomes of six measures will be tied to quality withholds for the PHP https://files.nc.gov/ncdhhs/documents/DRAFT_QualityStrategy_20180320.pdf

38. Sources of Data feeding HIE and Agency Decisions • Medicaid Medical Claims Data • Medicaid Medication Claims Data • MH/SA/DD Claims Data • Medicaid/State Eligibility Data • Including Coordination of Benefits • Medicaid Provider Data • MCO/NCTracks/NPPES/..... • NPIs for Facility, Site and Clinicians • Admission Discharge Transition (ADT) • ED Admission / Discharge • Hospital Admission / Discharge • Format - HL-7 V2 Messages • Consolidated Clinical Document Architecture (CCDA) • Clinical Summary of Care • Care Transition • Format – XML • WHAT’S MISSING ??????

39. NCQA Standards Specific to BH Integration - Examples • Standard 2 – Team based care • Documenting about addressing behavioral health needs • Training and assigning care team members to support self-management, self-efficacy and behavior change • Standard 3 – Population Health Management • Tobacco use • Comprehensive health assessments • Screening for depression using standardized tools • Implementing evidence based guidelines

40. NCQA Standards Specific to BH Integration - Examples • Standard 4 – Care Management Support • Behavioral health • Social determinants of health • High use/high cost services • Standard 5 – Care Coordination and Transitions • Maintaining agreements with behavioral health providers • Describing the approach for integrated health providers within the practice sites

41. Possible Sources or Types of Data to be Shared • Health Risk Assessment • SIS • Other Assessments • PHQ-2 and 9 • ASAM • ACES • LOCUS and CALLOCUS • SBIRT • ETC. • Immunizations • Plan of Care/Treatment Plans • Personal Information and Information Source • Allergies • Medications • Problem Lists • Procedures • Diagnostic Results (labs) • Encounters or events • Vital Signs • SDoH

42. Examples of Measures Tied to Payments • Increase in Primary Care Visits • Comprehensive Depression Suite • Utilization of the PHQ-9 • PHQ -9 follow up at 6 and 12 month intervals • Appropriate follow up with interventions or responses such as same day appointment, • follow up care • Adolescent depression MH/SU screening • Above in isolation or with optimal care for physical condition such as diabetes, hypertension, cardiovascular, etc.

43. Examples of Measures • Intervention or Supports resulted in an improvement in quality of life: • Employment - % who maintained/obtained employment or higher education status • Participation in community activities • Meaningful day activities • Integrated Housing - % with maintenance of stable or improved housing status • Reduction of criminal justice involvement • Reduction of Churn • Decrease in inpatient readmission • Decrease in ED visits

44. Examples of Measures • Initiation and engagement of alcohol and other drug dependence treatment • Adherence to medications (personal payments/incentives) • Combines physical/behavioral health inpatient rates • Services and engagement for individuals transitioning from incarceration

45. Talking Measures/Outcomes • Getting there is not a flip of a switch • Honest analysis • Capacity • Literacy • Use and tracking

46. Develop a Healthcare Analytics Strategy • The strategy must be effective which means • The right approach to gathering and organizing data • Getting the right data to the right people to drive improvements • Experienced Analytics expertise CAN be bought BUT be cautious about marketing • Using a healthcare enterprise data that combines clinical and financial data is a good method for aggregating and optimizing data for analysis. • The infrastructure must allow for the delivery of the linked clinical and financial data to clinicians on the frontlines of care. • One approach is to create frontline teams of clinicians, analysts and QI personnel who analyze the data to identify quality problems and determine the right protocol for addressing the problem

47. Identify Areas for Clinical Quality and Cost Improvement • Identify the areas of greatest variation within the measures focused on • By service, specialty, staff/provider and other applicable groupings • Use the data to identify opportunities for waste reduction such as determining which areas can benefit from increased standardization and evidence based protocols • By the productivity of staff • Identifying time for completion of workflows or even the need to develop workflows and swim lanes • Geo mapping for service designation and office locations

48. PHM must have these elements to be successful Population Health Management = PHM Health is where we live, work Learn and play

49. Changing Financial Environment • Complex Discussion of Alternative Managed Care Models (MCO/ACO/RCO/Shared Saving/Shared Risk/Sub-Capitation)and PAY FOR PERFORMANCE • Increased Competition for Market Share in Provider Networks • Economies of Scale (Mergers/Acquisitions) • Providers Viewed a Key to LME-MCO Risk Management

50. Moving to the Next Financial Level • Most people think direct and indirect cost – overhead and administration • Do you know your: • Total cost per patient • Cost per complex patient – what is complex • Cost per visit or episode of care • Change in net assets to expense ratio • Working capital to monthly expense ratio • Long term debt to equity ratio • Cost of workflows in place