1. The Michigan Primary Care Transformation (MiPCT) Project MiPCT Update PGIP March 11, 2016

2. Agenda 2016 Summits MiPCT/Medicaid Care Management Coordination Meeting MiPCT Clinical Subcommittee Update SIM/MiPCT Update Questions/Discussion 2

3. MiPCT 2016 Summits – Save the Date! October 13, 2016 – Thompsonville Summit (North) - TENTATIVE October 18, 2016 – Grand Rapids Summit (West) - CONFIRMED October 26, 2016 – Ann Arbor Summit (Southeast) - CONFIRMED 3

4. Joint Medicaid Health Plan/MiPCT Meeting The new five year Medicaid Managed Care Plan Contract includes a requirement for health plans to establish standardized work processes (including a single point of contact) between health plan care management staff and MiPCT care managers to promote coordination of services and to avoid duplication of services. WHAT: Joint meeting of POs and Plans to discuss building synergies for optimal care of patients WHEN: April 14 from 9am to 1pm at Lansing Community College WHO: PO Leadership; MiPCT Care Manager leaders who have experience with coordination of care with health plans Calendar notices sent to PO Leaders on March 3 with registration link – reply early as seating is limited

5. MiPCT Clinical Subcommittee Update 5

6. Areas to Update SDOH/ IBH toolkit 211 update CMMI Accountable Health Communities

7. Steps to creating the Toolkit Addition of SDOH and BHI for the 2015-2016 extension Creation of Tiger team to create framework Development of “toolkit of toolkits” related to additional focus areas Roll out and feedback

8. Tiger Team membership Marie Beisel Mary Ellen Benzik Debra Collins Larry Cowsill Jerry Frankel Jean Malouin Diane Marriott Linda Pappas Linda Scarpetta Kara Schrader Kevin Taylor James Forshee Jane Turner Sue Vos Lauren Yaroch Sue Crenshaw Amanda First Ginger Gamble Scott Johnson Ewa Matuszewski Meghan Sheridan Dana Watt Lori Zeman

9. The Task of the Tiger Team

10. Creating the Model Began two separate groups which merged as treating the behavioral health issues often intertwined with the social determinants of health Defined key steps at the PO and Practice level necessary to achieve SDOH and IBH Stressed the importance of building this on a strong advanced PCMH framework Framework addresses planning and operationalizing the change at the practice level

11. Planning Framework – key steps at the PO and practice level Behavior Health integration Addressing the SDOH Financial analysis and business plan Assessment of current state of integration Assessment of resources at the practice, PO and community Current state assessment of community partnerships and joint planning of intervention Current state assessment for readiness for change BUILDING INTEGRATION ON A FRAMEWORK OF ADVANCED MEDICAL HOME CAPABILITY PRESENT IN MiPCT PHYSICIAN ORGANIZATIONS AND PRACTICES Tools for each step linked into the grid

12. Implementatio n Framework Rust color represents steps that are steps for population health management of SDOH / IBH Blue are the patient level steps for addressing and impacting SDOH / IBH Tools are organized on the websites for each box

13. MiPCT website tool kit http://mipct.org/ ▫Resources ▫Social determinants of health and behavioral health – A Practical Guide http://mipct.org/social-determinants-of-health- a-practical-guide/http://mipct.org/social-determinants-of-health- a-practical-guide/

14. Identifying Social Needs http://www.211counts.org/home/index Create real time custom dashboards by location and needs (% of calls by category ) Each region can be broke down to zip code, county or congressional districts Each category with further breakdown – as seen in utilities category Working with 211 Tom Page and his team on identifying opportunities to improve Application for smart phones which is more user friendly Ability to track which needs are not met Use of PO surveys to identify regions of best practices, and potential improvement

15. CMMI Accountable Health Communities 5 year cooperative agreement to examine various levels of partnerships related to addressing social determinants and the impact on cost and quality The AHC Model aims to identify and address beneficiaries’ health-related social needs in the following core areas: ▫Housing instability and quality, ▫Food insecurity, ▫Utility needs, ▫Interpersonal violence, and ▫Transportation needs beyond medical transportation. Three tracks ▫Making patients aware of community resources ▫Facilitated referrals – navigation for high risk beneficiary ▫Multistakeholder engagement to address the social determinants Applications due March 31 st Requires engagement of state Medicaid or regional Medicaid provider related to data submission

16. Patient Centered Medical Homes State Innovation Model Putting people first, with the goal of helping all Michiganders lead healthier and more productive lives, no matter their stage in life.

17. Michigan’s Blueprint for Health Innovation Putting people first, with the goal of helping all Michiganders lead healthier and more productive lives, no matter their stage in life. 17 I Coordinated Care Delivery Models: Patient Centered Medical Homes and Accountable Systems of Care II Value-Based Payment Models III Community Health Innovation Regions IV Health Information Technology and Enhanced Interoperability

18. Our Foundation and Objectives Patient Centered Medical Homes are the foundation for coordinated care delivery strategies PCMH efforts are intentionally building upon the Michigan Primary Care Transformation Project (MiPCT) including sustentative involvement of MiPCT participating providers and payers and leveraging the project’s existing infrastructure PCMH-specific objectives include: – Increasing the percentage of active primary care providers practicing in PCMH accredited settings – Increasing the percentage of Michigan residents receiving primary care services in a PCMH accredited setting – Increasing the percentage of active primary care providers participating in Category 3A or higher Alternative Payment Methodologies – Continuing measurable improvements in quality of care, health outcomes and patient satisfaction measures – Making a positive impact on total cost of care, including better equipping PCMHs to understand and manage their patients’ healthcare costs Putting people first, with the goal of helping all Michiganders lead healthier and more productive lives, no matter their stage in life. 18

19. Focus for PCMHs Developing care plans to ensure a comprehensive approach in coordinating and meeting health needs Supporting timely, effective transitions of care Providing referral decision support, scheduling and follow-up Interfacing with other providers to promote an integrated treatment approach Engaging supportive services through community-clinical linkages Leading patient relationships to support patient education on health and self-care Utilizing patient registry functionality to support population health improvement Putting people first, with the goal of helping all Michiganders lead healthier and more productive lives, no matter their stage in life. 19

20. Key Components of the PCMH Initiative Goal of reaching statewide scale in 2019 Inclusive PCMH accreditation approach Maintaining (and growing) multi-payer participation Broadened patient population attributed to PCMHs Performance-oriented payment model structure Total cost of care management Continued investment in PCMH support and training Streamlined performance metrics, including adoption of core set Greater degree of data access and HIT enablement Sustainable financing for the payment model and infrastructure Putting people first, with the goal of helping all Michiganders lead healthier and more productive lives, no matter their stage in life. 20

21. Coming Next SIM test location announcement SIM update webinar(s) Operational Plan public comment process Regional and statewide stakeholder engagement opportunities Advisory committees and implementation workgroups development – Including MiPCT governance and advisory transitions Fall 2016 PCMH participation application and agreement process January 1, 2017 launch date for new PCMH payment model Putting people first, with the goal of helping all Michiganders lead healthier and more productive lives, no matter their stage in life. 21

22. Patient Centered Medical Homes State Innovation Model Putting people first, with the goal of helping all Michiganders lead healthier and more productive lives, no matter their stage in life.

23. 23 Putting people first, with the goal of helping all Michiganders lead healthier and more productive lives, no matter their stage in life. For Reference: Alternative Payment Methodology Framework

24. 24 Putting people first, with the goal of helping all Michiganders lead healthier and more productive lives, no matter their stage in life. For Reference: Core Set Measures

25. Questions/Discussion