1. CCO OREGON ROUND TABLE HEALTH METRICS AND OUTCOMES AMIT SHAH, MD

2. WHY MEASURE?

3. WHAT WE ALL WANT Access to Care Be there when I need you. Accountability Take responsibility for making sure I receive the best possible health care. Comprehensive Whole Person Care Provide or help me get the health care services I need Continuity Be my partner over time in caring for my health. Coordination And Integration Help me navigate the health care system to get the care I need in a safe and timely way. Person and Family Centered Care Recognize that I am the most important member of my care team – and that I am ultimately responsible for my overall health and wellness. Patient/ Provider View Payer/ Purchaser View

4. WHY MEASURE? -Health care transformation will require significant amount of infrastructural and clinical system redesign -We know what we should be doing but why are we not achieving? -We know what we should be doing but often do not know how we are doing? -Allocation of funds to move transformation based on performance -Subjective improvement not always =objective improvement

5. OHA INCENTIVE METRIC -P4P program part of CMS waiver granted to Oregon for transformation -Outcomes based (important to move towards outcomes with understanding of what is need to build the process) -OHA delegated committee to determine which metrics used and approved by CMS -17 of 33 metrics are incentivized (must reach certain threshold in order to obtain full quality bonus and participate in bonus pool of money) -monies used to fund transformation at clinic system level

6. LIST OF MEASURES 1.Alcohol or substance (SBIRT) 2.Follow-up after hospitalization for mental illness 3.Screening for clinical depression and follow-up plan 4.Prenatal timeliness of care 5.Elective delivery before 39 weeks 6.Ambulatory Care: Outpatient and ED utilization 7.CRC 8.Patient-Centered Primary Care Home Enrollment 9.Developmental screening in the first 36 months of life 10.Adolescent Well Child Visits 11.HgA1C control 12.CAHPS 13.EHR adoption 14.Mental and physical health assessment within 60 days for children in DHS custody