1. The Rhode Island Chronic Care Sustainability Initiative (CSI-RI) Presentation for PCMH-Kids Stakeholders November 20, 2013 Debra Hurwitz, MBA, BSN, RN CSI Co-Director 1

2. The Rhode Island Chronic Care Sustainability Initiative (CSI-RI) Vision : Rhode Islanders enjoy excellent health and quality of life. They are engaged in an affordable, integrated healthcare system that promotes active participation, wellness, and delivers high quality comprehensive health care. Mission: To lead the transformation of primary care in Rhode Island in the context of an integrated health care system. CSI-RI brings together critical payers, providers, purchasers, consumers, educators and other leaders to develop, implement, evaluate, refine and spread models to deliver, pay for, and sustain high quality comprehensive primary care. 2

3. What is CSI-RI? Working with all major health care stakeholders to transform primary care in Rhode Island. Promotes the PCMH, a model of primary care that is patient-centered, coordinated, accessible and team- based. The model focuses on prevention, wellness and appropriate treatment. This will lead to improved care, lower costs and better health outcomes for Rhode Islanders. 3

4. Where is CSI? 48 practices (297 providers) – 5 Pilots (2008) – 8 Expansion 1 (2010) – 3 Expansion 2 (2012) – 32 Expansion 3 (2013) 14 Community Health Centers 4

5. CSI-RI Collaboration Partners Payers Medicaid All commercial plans Medicare Purchasers Self-insured employers Providers Primary care providers (private practices, community health centers, hospitals and clinics) State Office of the Health Insurance Commissioner, Executive Office of Health and Human Services, Department of Human Services, Department of Health Technical Experts Department of Health; QIO 5

6. CSI-RI helps plans and practices build sustainable Patient-Centered Medical Homes Data-driven practice transformation NCQA Level 3 Nurse Case Manager on the team Common Contract All-payers involved PMPM paid on attributable lives PMPM based on performance Used with permission of Ed Paul MD, Yuma Regional Medical Center 6 6

7. Key Elements of CSI-RI PCMH Common Developmental Contract Supplemental payments to practices Nurse Care Manager at the practice site Practice coaching for team-based care Participation in learning collaborative NCQA recognition Level 3 HIE capacity Common measures of performance for improved management of chronic conditions (i.e., diabetes, heart disease, depression, tobacco cessation) Data and reporting on quality measures Performance incentives based on PMPM 7

8. Transformative Change Built into the Common Contract

9. 9 CSI Steering Committee Executive Committee Patient Advisory Group Working Committees Data and Evaluation Practice Reporting PTST Payment Reform/ Contract Payment Reform/ Contract Service Expansion and Integration Marketing/ Communication

10. Care Management Activities Nurse Care Manager lynchpin for success Located within practices, regardless of payer Activities Identification of high risk patients Patient assessment Care coordination (transitions of care; specialist referrals; home- and community-based services and supports) Patient/family education Engage patients in shared decision-making Team communication 10

11. What about the patient? “Being in a patient-centered medical home has changed my life. I’m not just living with a chronic condition – diabetes – I’m actively engaged in the dialogue focused on my care. Together, my care team and I try to find the best preventive and treatment solutions that work for me.” Connie Susa, of Warwick, a patient at Hillside Family and Community medicine, in the April 6, 2013 issue of the Providence Journal 11

12. CSI-RI is growing 20 practice expansion 10/01/13 Goal to add 20 practices per year Future: – Learn and refine model with RIQI – Employer engagement (benefit design) – Employee engagement (PCP designation) 12

13. Harmonized Measures of Change in Multiple Domains

14. Transparency in Adjudication of the Common Contract

15. Take Home Points #2 Measures and targets all parts of the triple aim – Triangulation allows a better overall picture of progress – Example: Patient experience and utilization driving access change Contract on measures you have used – Develop and test new measures in the field – Set targets so that 2/3 of practices benefit Measure and pay on the same populations whenever possible

16. Does it work? Evidence of transformation 16 Proactive Population Management & Tracking “The single most successful piece has been the ability to record, track and respond to outcomes data. On a population-level, knowledge is power.” Improved Professional Satisfaction “The professional satisfaction now compared to [before the pilot] is through the roof.” Overall Transformation It’s hard to believe how far we’ve come. Just the fact that so much has changed is one of the most important things about the whole project… The project has given us both time to think outside of the box and has helped us develop a meaningful way to get out of the box and transform our practice to something new.” From M. Rosenthal, Presentation to CSI-RI Steering Committee, 7/13/2012

17. All CSI Site Variation in HTN BP Control

18. Number of Admissions in Rolling Year per 1000 Member-Months

19. Take Home Points #3 Practice change precedes performance change – Need analytic capacity to watch for both All-payer involvement and common set of targets allows practices to focus efforts – Harmonizing targets between primary care, sub-specialty care and hospitals would build on that focus State can help overcome sticking points in negotiation – Attribution – Harmonization of measures – Aggregation

20. Many questions remain Can you support PCMH on a FFS model? – Maybe, probably not easily What sort of financial model best supports a PMCH model? – Mix of FFS, PMPM, PFP and SS/bundle/capitation – Various notions of how much of each No more than 70% FFS per Bailit Can you built SS into a PCMH model? – Likely need to aggregate

21. Payment ideas currently under discussion Graduation: What comes after PY2? Community Health Teams to Support Small Practices (VT-like) Include child health services Bundle Payment for Primary Care Services (MA- like) Incentive for improvement in community health indicators (OR-like) Build a structure to continue the conversation!

22. Concluding thoughts PCMH Kids should be built on success of unique RI initiatives – Affordability standard: Primary Care Spend is a tremendously powerful driver of change. Expand it to 17% and include integration with the Medical Neighborhood. – Collaborative all-payer approach: CSI has set an amazing table; bring in more stakeholders (families, sub-specialists, hospitals) and give them permission to continue the work.