1. Qsource

2. QIN-QIOs Across the Country 2

3. Qsource- Who we are and What we do 3 We are Contracted by the Centers for Medicare & Medicaid Services (CMS) Change agents focused on three aims: Better care Smarter Spending Healthier People Partner with patients, providers, and practitioners across five states to conduct quality improvement activities that put patients first and equip providers to do the same.

4. Qsource- Who we are and What we do 4 Committed to: promoting effective prevention and treatment of chronic disease by promoting safe care that is patient and family- centered, reliable and accessible making care safer and reducing harm caused in the delivery of care promoting effective communication and coordination of care making care more affordable Skilled in: creating opportunities for providers to learn from each other, applying advanced improvement and analytical methods, structuring processes for sustaining positive change

5. atom Alliance Partners 5 Multi-state alliance for powerful change composed of three nonprofit, healthcare QI consulting companies

6. In Primary Care Advancing Behavioral Health

7. Why is Advancing Behavioral Health Important? 7 Physicians screen fewer than half of their patients for alcohol use disorders Roughly two-thirds of those with a behavioral health disorder do not get behavioral health treatment Depression is identified in fewer than half of primary care patients Depression and alcohol use disorder are common behavioral health conditions in adults, yet they are often under-identified in primary care settings.

8. Why is Advancing Behavioral Health Important? 8 Approximately 6.7 percent of American adults−about 14.8 million people−live with major depression. About 9.2 million adults have co-occurring mental health and addiction disorders. Additionally, challenges in effective care coordination for these and other behavioral health conditions contribute to high hospital readmission rates and problems with treatment adherence.

9. Behavioral Health and Primary Care

10. 68% of adults with BH conditions have medical and 29% of adults with medical conditions have BH

11. How We Will Advance Behavioral Health ? 11 By Partnering with Primary Care Practices And Inpatient Psychiatric Facilities.

12. Goals of this initiative Provide technical assistance and education interventions to: Increase physician/provider rates of BH screening for depression and alcohol abuse Increase outpatient follow-up for psychiatric discharges Reduce 30-day readmission rate Primary Care Practices: 10,000 practices with screen a majority of their Medicare population for depression and alcohol abuse. A total of 1.5 million beneficiaries will be screened by 2019. Inpatient Psychiatric Facilities: Reduce Psychiatric readmission rate Increase follow up rate for behavioral health practitioners following discharge. 12

13. What are your challenges? 13 The atom Alliance recognizes that there are challenges that practices face in the effort to integrate behavioral health in the primary care setting: limited BH referral resources lack of BH training competing priorities

14. atom Alliance can be part of the Solution! 14 With the atom Alliance you have access to: Industry best practices Healthcare and Integration expertise Cherokee Health Systems (CHS) and Medical Decision Logic, Inc.© (mdlogix) Overall value to our partners

15. atom Alliance can be part of the Solution! 15 Return on Investment (ROI) Financial Access to experts, education, and resources paid for by CMS ROI average screening reimbursement rates are $16 per patient, multiplied by the number of patients seen per practices Qualitative- Improved patient care Protection for clinicians –Not knowing a patient has behavioral health or substance use risks can increase risk for the clinician, such as prescribing medications that may be contraindicated Access to data from atom Alliance

16. atom Alliance can be part of the Solution! 16 Partner with Primary Care Providers to implement and/or improve the use of depression and alcohol screeners in the primary care setting Provide technical and clinical assistance in the integration of behavioral screeners into the current HIT capabilities and practice workflows Provide verified depression and alcohol screeners (e.g. PHQ9, AUDIT C) in the practice’s chosen format (i.e. integrated into EHR, included in patient packet, etc.) Assess the practice’s Behavioral Health neighborhood to identify referral sources and build a robust BH referral network Provide ongoing educational and learning opportunities for practice staff including CEU’s Provide telephonic “office hours” for providers to call with questions

17. atom Alliance can be part of the Solution! 17 Building the Behavioral Health Neighborhood Care Coordination Communities: Implement evidence-based interventions to reduce hospital admissions and readmissions Track changes and progress using real-time and claims-based Redesign workflow, to improve care coordination between facilities Assemble, lead or contribute to care coordination communities

18. atom Alliance can be part of the Solution! 18 atom Alliance helps communities by: Supporting and promoting community meetings and care coordination activities Hosting on-site and virtual learning events Assisting facilities and communities in selecting measures for quality reporting Preparing data feedback reports and providing technical assistance Sharing the collective tools and resources of the five state atom Alliance

19. atom Alliance work with RHA’s and FQHC’s 19 As of February 2016 FQHCs and RHCs are able to take part in this Behavioral Health initiative ! Because CMS does not have access to claims data for this initiative, the practice will be responsible for collecting and reporting the data. Alternative data must be submitted monthly to Qsource/ atom Alliance state advisors. The data needed to be reported is. The number of Medicare beneficiaries seen during the month The number of Medicare beneficiaries seen and completed the depression screening The number of Medicare beneficiaries seen and completed the alcohol screening

20. The Process 20

21. Overall Technical Approach 21

22. Other Qsource/atom Alliance Initiatives 22 Reducing Healthcare-Acquired Conditions We are uniting nursing homes in a powerful collaborative to share tools, knowledge and experiences for improving resident safety and clinical processes and reducing preventable healthcare conditions. Coordination of Care We are bringing together statewide communities to create powerful collaborations of change that promote the seamless coordination of care for older adults. Value-Based Payment, Quality Reporting & Physician Feedback We help healthcare providers assess clinical quality of care, care coordination, patient safety, and much more to meet CMS quality reporting and value-based payment requirements. Improving Immunization Rates Historically, immunization rates among adults have been low. atom Alliance aims to change that by working with practitioners, providers, and beneficiaries. Improving Cardiac Health & Reducing Disparities We assist home health agencies, physician offices, clinics and others spread the use of evidence-based practices to promote the “Cardiac ABCS” and support the Million Hearts initiative. Reducing Disparities in Diabetes Care Diabetes Self management Education (DSME) is a proven intervention for empowering persons with diabetes to acquire the knowledge and skills necessary to improve the quality of their lives. Prevention Coordination through Meaningful Use We collaborate with Regional Extension Centers (RECs) to showcase proven interventions that result in primary care providers successfully meeting the requirements of the Medicare Electronic Health Record (EHR) Incentive Program. Reducing Healthcare-Associated Infections Using evidence-based strategies to prevent healthcare- associated infections (HAIs) can increase the quality of patient care, save lives and decrease healthcare costs.

23. Reduce Disparities in Diabetic Care 23 Medicare Diabetes Prevalence & Expenditures 60% of Medicare beneficiaries have multiple chronic conditions* 14% of Medicare beneficiaries have 6 or more chronic conditions. Top 5 are: Hypertension, High Cholesterol, Ischemic Heart Disease, Arthritis and Diabetes* Dual Eligible beneficiaries (those with both Medicare and Medicaid coverage) are 1.4 times more likely to have diabetes* 26.9% of Medicare beneficiaries age 65+ (10.9 million Americans) have diabetes and account for about 32% of Medicare spending** Everyone With Diabetes Counts (EDC) Initiative Refer patients with diabetes and prediabetes to the free Medicare diabetes education classes Volunteer to become an education site Contact us to learn more about free QIN-QIO assistance in becoming a certified diabetes education site for Medicare billing and training appropriate staff to facilitate the DEEP DSME classes

24. Improving Immunization Rates 24 Promote Effective Prevention and Treatment of Chronic Disease Improving Medicare beneficiary immunization rates through improved tracking, documentation and reporting of Pneumococcal Vaccination Influenza Vaccination Herpes Zoster Vaccination Reducing immunization healthcare disparities Atom Alliance will be working with Eligible Professionals (EPs) Eligible Hospitals (EHs) Critical Access Hospitals (CAHs) Home Health Agencies (HHAs)

25. Important Facts 25 Influenza and pneumonia combined were the 8 th leading cause of death in the United States for 2012 One out of three people age 60 years and older will get shingles and one out of six of those people 60 years and older having the shingles will have severe pain that can last for months or even years

26. Technical Assistance 26 Provide health literacy and educational tools for beneficiaries Offer LAN meetings where peer-to-peer learning of best practices and success stories can be shared Assist with processes and procedures that will increase quality across all Qsource/atom Alliance initiatives.

27. Resources Helpful Links atomalliance.org/initiatives/behavioral-health/ mdlogix.com/ cherokeehealth.com/ integration.samhsa.gov/clinical-practice/screening-tools cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/ MPS_QuickReferenceChart_1.pdf cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/ MPS-QuickReferenceChart-1TextOnly.pdf 27

28. Your state advisors contact information 28 Kibibi Wood-Montgomery, CSW Email: kmontgomery@qsource.org or kmontgomery@qsource.org kibibiwood-montgomery@area- G.hcqis.org Telephone: 502-381-5792 Mark Bush, RN Email: mbush@qsource.orgmbush@qsource.org or mark.bush@area-G.hcqis.org mark.bush@area-G.hcqis.org Telephone: 502-649-5369

29. Questions 29