State Innovation Model Evaluation Results The Lewin Group First Annual Evaluation Report Results December 8, 2015

Welcome and IntroductionsData Sources & AnalysisFindings: MaineCare Stage A Health HomesFindings: MaineCare Stage B Behavioral Health HomesFindings: Data InfrastructureFindings: Workforce DevelopmentConclusion & Next Steps Agenda

Introduction Maine engaged Lewin in July 2014 to support the Maine self- evaluation of its State Innovation Model (SIM). The December 2015 annual report displays data collected by Lewin for activities occurring 2013 – Sept – Full report is available on Maine SIM website Lewin employed a mixed methods evaluation approach to assess implementation, cost effectiveness, and impact of SIM initiatives: – Qualitative data collection – surveys and interviews – Quantitative data – claims and related datasets

Data Sources & Analysis Exhibit 1. Data Sources for Maine SIM Evaluation Data Source for FindingsMethod to Obtain Data Accountability measures and targets SIM partners quarterly reports Cost effectiveness and impact, including core metrics MaineCare claims data ConsumersSurveys of 1,500 MaineCare enrollees ProvidersInterviews with 84 Health Home providers StakeholdersInterviews with 18 key stakeholders

Findings: MaineCare Stage A Health Homes Quality Findings MaineCare Stage A Health Homes differed significantly from the similarly matched control group on three core metrics. The trends from pre (CY 2012) to post (CY 2013) evaluation period are: Exhibit 2. Summary of Significantly Different Core Metrics Performance Core MetricStage AControlDesired Outcome Non-Emergent ED Use-14.0%-2.6%Decrease Fragmentation of Care Index0.0%+6.8%Decrease Access to Primary Care for Children Ages %+0.5%Increase

Findings: MaineCare Stage A Health Homes Consumer Interview Findings (1) Perceptions of provider communications are positive. See the next slide for further details on this score. Consumers scored how well providers actually engage patients as partners in their health care lower, as illustrated in Exhibit 3. Exhibit 3. Low Scoring Items Under Patient Engagement (1) See the full Lewin report for details of the methodology used to determine these scores. Item DescriptionIntervention Score Control Score Encouraging patients to ask questions73%67% Seeking ideas from parents regarding their child’s health 45%61% Providing support to patients to take care of their own or their child’s health 52%58%

Findings: MaineCare Stage A Health Homes Consumer Interview Findings: Summary of Composite Measures

Findings: MaineCare Stage A Health Homes Service Utilization and Expenditure Findings Pre-intervention period: CY 2012; Post-period: CY 2013 Reduced expenditures per member per month (PMPM) in relation to the control group, including total, medical, and behavioral health costs. Exhibit 4. MaineCare Stage A Health Homes – PMPM Cost Avoidance by Category Service Category PMPM Cost Avoidance Percent of Total PMPM Total$ % Inpatient Med/Surgical$406.5% Outpatient Clinic Expenditures (2) $111.8% Professional Behavioral Health Services (3) $111.8% [2] Hospital-based outpatient clinics that provide services, such as urgent care, preventive medicine, dialysis, cardiology. [3] Diagnostic evaluation, psychotherapy, drug services, and prescription management in an office setting. *Average PMPM in the stage A Health Home group was $615 in the post period *Average PMPM in the stage A Health Home control group was $690 in the post period

Findings: MaineCare Stage A Health Homes Service Utilization and Expenditure Findings (continued) Cost avoidance generated by lower inpatient medical/surgical costs: 17.9% reduction in overall PMPM is notable, pointing to positive impact of interventions designed to strengthen primary care. Higher inpatient medical/surgical expenditures in the control group were attributed to: Injury-related admissions (8.2%) Septicemia (7.8%) Complications of medical care (3.4%). Exhibit 5. Changes in Utilization Associated with Decrease in Cost CategoryInterventionControl Inpatient medical/surgical services-1.8%+ 69.3% Facility outpatient clinic costs+ 22.6%+ 52.2% Non-emergent ED visits- 14.0%- 2.6%

Findings: MaineCare Stage B Behavioral Health Homes Quality Findings Pre-intervention period: April 2013 – March 2014 Post-intervention period: April 2014 – March 2015 Preliminary findings suggest a notable cost avoidance in the MaineCare Stage B Behavioral Health Homes intervention group. Further analysis is needed to fully understand the changes that are occurring in the data. MaineCare Stage B Behavioral Health Homes differed significantly from the similarly matched control group on one core metric. Exhibit 6. Summary of Significantly Different Core Metric Performance Core MetricStage BControlDesired Outcome Fragmentation of Care Index-0.9%-8.3%Decrease

Findings: MaineCare Stage B Behavioral Health Homes Consumer Interview Findings Consumers in the intervention and control groups report being verysatisfied with the care they are receiving(4): Consumers in the intervention and control groups report being very satisfied with the care they are receiving (4): Exhibit 7. Summary of High Domain Scores (4) See the full Lewin report for details of the methodology used to determine these scores. DomainsInterventionControl Perceptions of access to care91%96% Cultural sensitivity100% General satisfaction89%95% Participation in treatment planning95% Quality and appropriateness of care95%94% Scores were lower for functioning and outcomes for both groups, including improvements in their behavioral health condition (Intervention: 84%/Control: 86%).

Findings: MaineCare Stage B Behavioral Health Homes Consumer Interview Findings: Summary of Domain Scores

Findings: Data Infrastructure 28 of 54 (52%) behavioral health providers say HealthInfoNet’s support for adoption of EHR technologies is key to coordinating with other providers and gaining access to information needed to deliver effective care Some participating providers have experienced barriers with developing bidirectional connections with the HIE. The practice reports under SIM are generally seen as valuable, but utility is diminished because data is not current. 27 of 69 (39%) of providers interviewed reported that multiple portals and other related tasks (e.g., attestation related to Health Home members) are burdensome and create confusion.

Findings: Workforce Development Key provider and stakeholder findings: A majority of providers and stakeholders indicate that LearningCollaboratives have delivered opportunities for best practicesdevelopment and peer learning for participants. A majority of providers and stakeholders indicate that Learning Collaboratives have delivered opportunities for best practices development and peer learning for participants. Providers would benefit from inclusion of more advancedtopics and sessions with a stronger focus on learning frompeers. Providers would benefit from inclusion of more advanced topics and sessions with a stronger focus on learning from peers. 5 participating providers view Community Health Worker (CHW) pilots favorably. Providers are working with the CHWs to establish: Greater cultural sensitivity Continuity with community-based resources in their practices

Findings: Workforce Development There are many concurrent efforts underway in Maine to improve care coordination, including the Community Care Teams (CCTs) 29 of 50 (58%) of providers that commented on CCTs, were favorable about the overall ability of CCTs to positively impact patient care and/or integrate with MaineCare Health Homes. Respondents stated that there is a wide variation in how CCTs operate: Some pointed to CCTs’ responsiveness and flexibility (e.g. some CCT’s make home visits, while some do not). However, some suggested that more standardization would be beneficial.

Conclusion & Next Steps Key Highlights MaineCare Stage A Health Home models showing robust claims-based cost reductions relative to controls Stage A Health Homes are making significant progress in reducing non- emergent ED use and fragmentation of care. Consumer engagement findings suggest providers are sharing information with patients; but more opportunities exist to engage patients in their health care decision making. Findings related to the impact of centralizing data, workforce development, and development of new payment models are inconclusive and could be targeted for future evaluation efforts. Rapid Cycle Improvement Discussions – used to dig deeper into key findings from the evaluation to improve upon SIM in the 3 rd year of grant.