Complex and Chronic Care Improvement Program Track Implementation Template

2017

Complex and Chronic Care Improvement Program Track Implementation Template

Performance Period One (July 2017- December 2017)

Hospital Name

Submission Date

Green box to be completed by hospital

Red text is provided as examples of hospital-specific responses

Introduction

The Complex and Chronic Care Improvement Program (CCIP) is a track under the Care Redesign Program (CRP)designed to allow a hospital that has signed a CRP Participation Agreement (Hospital) to supportCare Partners in the care management of Medicare beneficiaries that are identified as High Need and Rising Need Patients (defined in section Hospital Responsibility – Patient Identification) with complex and chronic conditions. Hospitals mayalso request to receive comprehensive identifiable Medicare data to be used for the CRP. The CCIP provides Hospitals with an opportunity to share cost savings with Care Partners that improve the care management of High Need and Rising Need Medicare beneficiaries.

The CCIPis designed to:

●Enable Hospitals to provide intervention resources and, if applicable, incentive payments to Care Partnersto provide care for patients with chronic and complex conditions.

●Promote and support collaboration and cooperation betweenHospitals and Care Partners on behalf of Maryland Medicare beneficiaries.

●Promote data-driven, ongoing improvement in care delivery over time.

●Facilitate overall practice transformation towards patient-centered care that produces improved outcomes and meets or exceeds quality measures.

●Leverage common tools and technology including those developed by CRISP, such as the electronic notification system and analytics capabilities.

Required Components of the CCIP

The CCIP consists of activities and processes designed to treat, reduce and improve chronic and complexly ill Medicare patients. In order to participate in the CCIP, the Hospital’s Care Partners must perform CRP Interventions. Hospitals may provide Intervention Resources to Care Partners to help facilitate the Care Partners’ performance of the Allowable CRP Interventions. Hospitals may provide Incentive Payments (if applicable) to Care Partnersbased on their performance of the Allowable CRP Interventions and in accordance with the terms of the Participation Agreement and this Track Implementation Template. Intervention Resources are offered at the outset of the CCIPand may continue throughout the duration of the CCIP.

For instance, the Hospital maydeploy Intervention Resources such as, risk stratification processes, health information technology for use in the creation of care plans and sharing information with providers, reports that provide meaningful and actionable data to Care Partners for use in the care of patients, care management staff, and 24/7 telephone lines staffed by care managers to support the care of the Care Partners’ CCIPMedicare beneficiaries. Care coordination resources will assist Care Partners in managing the care of patients, improving the quality of care, and reducing potentially avoidable admissions and readmissions. The CCIP will work to improve the care of chronically ill and medically complex Medicare beneficiariesby working with the beneficiary, family, and othercare providers to achieve the beneficiary’s stated health goals. The CCIPwill educate Medicare beneficiaries, coordinate care, assist Medicare beneficiariesin managing their conditions, and work to remove barriers to achieving the best possible health result.

Hospital Responsibility - Patient Identification

Hospitals will identify two categories of Medicare beneficiaries in their service area that areeligible for the CCIP: “High Need Patients” and “Rising Need Patients.” Hospitals must include both categories of beneficiariesin their CCIP.

For the risk stratification methodology, the Hospital may use the recommendation below, or propose its own definition to be submitted below in sectionC. CRP Operations Requirements.

Risk Stratification recommendation for the CCIP:

High Need Definition: At least 3 inpatient discharges in past 12 months, plus at least two chronic conditions, one of which is COPD, Diabetes, Heart Failure or Hypertension.

Rising Need Definition: At least 2 inpatient discharges in the past 12 months, plus at least two chronic conditions, one of which is COPD, Diabetes, Heart Failure or Hypertension.

Hospitals are responsible for the operation of their CCIP.

Care Partners – Roles and Responsibility

For Maryland Medicare Beneficiaries, the Hospital will identify Care Partners who may be eligible to participate as the Patient’s Designated Provider (PDP) in the CCIP through patient identification, CRISP data, hospital records, or other methods. Hospitals will invite these providers to participate in the CCIP by sharing information, expectations, and a potential Medicare beneficiary patientlist. Maryland Medicare Beneficiary patientsmust positively affirm that the selected provider is their PDP. The Hospital will provide PDPs with discussion materials to be used with the Medicarebeneficiary.

The Hospital must enter into aCare Partner Arrangementwith each PDP in the CCIP. The PDP must be listed on the Hospital’s certified Care Partner List. The Care Partner Arrangementwill include requirements defined in the Participation Agreement;a description of the CCIP;Care Partner qualifications specific to the CCIP; and the roles and responsibilities of the Hospital, PDP, and Physician Group Practices (PGP), including specific care management requirements. Annual updates will become appendices to the Care Partner Arrangement.

Care Partner Qualifications for the CCIP

The CCIP Care Partners must meet the following Care Partner Qualifications:

• Designated by a Maryland Medicare Beneficiary patient as theirPDP;
• Be licensed as a family practice, general or specialist physician, clinical nurse specialist, or a nurse practitioner;
• Provide services to Maryland Medicare Beneficiaries;
• Have a National Provider Identifier (NPI); and
• Participate in the Medicare Program.

In order to participate in the CCIP the PDP must agree to the following:

• Enter into a Care Partner Arrangement with a Hospital and agree to perform the Allowable CRP Interventions defined in this Track Implementation Template.
• Agree to enroll Maryland Medicare Beneficiaries identified by the Hospital into the CCIP
• PDP will deploy processes to invite Maryland Medicare Beneficiaryparticipation in the CCIP
• Describe the Maryland Medicare Beneficiary’s cost sharing to them (if billing CCM)
• Explain care management services to be provided
• Explain how to revoke participation in the CCIP
• Obtain Maryland Medicare Beneficiary verbal or written agreement for participation in the CCIP
• Secure a written a consent to electronic communication of medical information to medical partners.
• Note that Hospitals will provide PDPs with a template for the discussion and materials to be used with the patient.
• Use Certified Electronic Health Record Technology (CEHRT)and CRISP, Maryland’s Health Information Exchange.
• Agree to upload CCIP participating patient panels into CRISP, including additions and deletions monthly.
• Use a structured record for maintaining patient health information and for providing regular updates to the care plan. The PDP may use itsown software if Hospital compatibility and CEHRT requirements are met.

The PDP Care Partner is responsible for directing the overall care of Maryland Medicare Beneficiaries with chronic and complex conditions, actively working with the Maryland Medicare Beneficiary’s care manager, and participating in or overseeing required CRP Interventions. For the first performance period, the required Allowable CRP Interventions include:

• Completion of a Health Risk Assessment (HRA)
• Completion and maintenance of a care plan
• Medication management and reconciliation
• Ensure that appointments are available for aMaryland MedicareBeneficiary within 7 days after a hospitalization discharge

A PDP Care Partner may participate in multiple Hospitals’ CCIP.

Each year, the Hospital will submit aCCIPTrack Implementation Template which describes the Hospital’s CCIP and defines how it will meet the CCIP requirements. Required CRP Interventions may change each year.

CRP Report

In accordance with the terms of the Participation Agreement, aCRP Report must be submitted by the Hospital to the Health Services Cost Review Commission (HSCRC) and CMS quarterly from its internal systems, CRISP, and a third-party administrator. Hospitals will be provided a template to use for submission of the CRPReport. A Hospital may require the Care Partnerto report on specific metrics which should be detailed in the Care Partner Arrangement.

In addition to the CRP Reporting requirements in the Participation Agreement, Hospitals should include the following information specific to the CCIP in the CRP Reportfor Maryland Medicare Beneficiaries that meet the “High Need Patient” definition or “Rising Need Patient” definition:

Required Metrics / Data Source
Eligible Patients / Number of Eligible High Need Patients as defined by hospital risk stratification method / Hospital
Number of Eligible Rising Need Patients as defined by hospital risk stratification method / Hospital
Enrolled Patients / Number of Enrolled High Need Patients as defined by hospital risk stratification method / Hospital
Number of Enrolled Rising Need Patients as defined by hospital risk stratification method / Hospital
Staffing and Other Resources / The ratio of Care Managers to enrolled patients / Hospital
Number of PDPs participating in the program / Hospital
Estimate of the number of Allowable CRP Interventions performed / Number of High Need patients with a completed Care Plan / Hospital
Number of Rising Need patients with a completed Care Plan / Hospital
Number of enrolled patients with a documented care alert in CRISP / CRISP
Percent of High Need patients in the program with a completed Care Plan / Hospital
Percent of Rising Need patients in the program with a completed Care Plan / Hospital
Number of patients that received medication reconciliation as documented in the Care Plan / Hospital
Number of patients that completed a provider visit within 7 days of acute discharge / CRISP/Administrator
Number of patients with more than one care management phone conversation per month / Hospital
Average number of patients/day that accessed 24/7 patient phone access to a Care Manager / Hospital
Total Number of Care Interventions received by enrolled patients (total number of activities reported in this section) / Hospital
Overall Financial Performance / Utilization Savingsdefined as the Medicare cost savings a Hospital is deemed to have achieved for a CRP Track through the reduction of Potentially Avoidable Utilization or other cost savings, as determined by the State in accordance with the Model Amendment. / Administrator
Total Intervention Resources expended for theCCIP program, by PDP Care Partners or PGP Care Partner / Hospital

Track Implementation Template Instructions

Please complete all required sections of this Template.

In Section A, Hospitals provide general information.

In Section B, Hospitals provide a description of their CRP Committee.

In Section C, Hospitals provide operational details of their CRPOperations Requirements.

In Section D, Hospitals provide details on Tracking CRP Interventions

In Section E, Hospitals provide an anticipated budget for the CCIP.

A. Hospital Information

Date of Implementation Protocol submission: XXXX, XX, 2017

Organization Name and D/B/AName:______

TIN:______

CMS certification #(s) for organization:______

Point of Contact:

Hospital
Name:
Title:
Street Address:
City, State, Zip:
Telephone:
Fax: /
Email:

Name the key personnel and describe the function of the key management personnel for this program.

Key Personnel / Responsibilities
Program Coordinator
Chief Medical Officer/Equivalent
Chief Executive Officer/Designee
Chief Financial Officer/Designee

B.CRP Committee

See the Participation Agreement for a description and requirements of the CRP Committee.

Provide the names of your CRP Committee members and their organization.

Name, Credentials / Job Title and Organization, if applicable
Please designate the appropriate classification of the CRP Committee members.
Participant Hospital Employee / Care Partner Representative / Maryland Medicare Beneficiary
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☐ / ☐ / ☐
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Please answer the following questions about how the CRP Committee will provide oversight, guidance, and management to the CCIP.
1. How often will the CRP Committee meet? (monthly, bi-monthly, quarterly, bi-annually) / Quarterly
2. Does the member composition of your CRP Committee meet the qualifications outlined in the Participation Agreement? / Yes
3. Will the CRP Committee be provided with progress/dashboard reports on CCIPperformance from hospital personnel involved in the CCIP? / Yes
4. If yes, how often will the CRP Committee require these reports? (monthly, bi-monthly, quarterly, bi-annually) / Quarterly
5. How will the CRP Committee assist the Hospital in selecting Allowable CRP Interventions for which to provide Intervention Resources? / The members of the CRP Committee are well versed in the issues facing the Care Partner in the delivery of care. The Committee will be responsible to review appropriate interventions, choosing those that fit with the needs of the institution and monitor the progress of care providers.
6. How will the CRP Committee provide a forum for sharing ideas, identifying problems, and developing solutions between the Hospital and the Hospital’s Care Partners and Downstream Care Partners
7. How will the CRP Committee offer the internal leadership to ensure the integrity of and opportunity for success of the CRP and each CRP Track in which the Hospital is participating?
8. How will the CRP Committee conduct a qualitative analysis by the CRP Committee on the status of the Allowable CRP Interventions and offering suggestions to the Hospital on how implementing the Allowable CRP Interventions could be improved?

1. CRPOperations Requirements

Each section requires a response.

Category / Hospital changes to current care model / Describe the current plan or what is anticipated to be in place by the beginning of the performance period, please limit your response to 200words or less
Infra-structure /

1. Define the information systems to track parameters required for the incentive payments, including quality measures

/ Reports will be generated from Healthy Planet tracking completion of activities and required metrics. Hospital care managers will be responsible for gathering pertinent data if information sits within the PDP EHR.

1. Define the information systems to support care redesign and information sharing

/ Our Health Information Technology team will provide and make available reports via Healthy Planet that assess health care and medication utilization trends. The tools within Healthy Planet will allow our team to identify trends that exceed norms for patients with like demographics and DRGs. Care managers will work with these identified patients and the PDP to develop Care Plans specific to each patient in an effort to better manage utilization and outcomes. Specific factors will be assessed including: multiple primary care providers, use of specialists, extended inpatient stays, co-occurring diagnostic morbidities and medications prescribed and medications filled.

1. Identify care management staff and their respective patient to staff ratios. Will the ratios be evaluated during the program?

/ Care management staff will hire a combination of RNs, Social Workers and Community Health Workers. They will be trained in advance of recruiting patients.
The ratios are the following:
RNs or Social Worker (Care Managers) to patients 1/110
Community Health workers to patients 1/149
Staffing ratios will be examined every quarter to ensure that quality care management is being provided.

1. Describe the supervision and monitoring of the Care Management Staff. How will you ensure that the Care Management Team follows the directives of the PDP?

/ The Care Management Supervisor meets with each staff member weekly to review cases and monitor work. The supervisor has access to reports generated by Epic’s Healthy Planet, our Care Management platform to monitor activities of the care managers and reviews these reports in weekly supervision meetings with the responsible care manager. Care Plans authorized by the PDP will be used to assess if care managers are completing tasks as directed by the PDP.

1. Describe how the Care Management Team will coordinate with PDP existing Care Management Staff.

/ Current hospital PDPs do not employ traditional care management staff due to practice size. Some do have staff responsible for referrals and other activities that a care manager would take on in a larger practice. Hospital care management staff will be responsible for coordinating and communicating with staff who provide care management functions within PDP practices. Management staff assigned regionally across the county and spend time within the communities where patients reside and receive healthcare services. Volume and provider/patient need will dictate frequency at each office.

1. How often will performance assessments be completed for Care Management Staff? (bi-monthly, bi-annually)

/ Annually

1. Develop approaches for sharing clinical and other key information (e.g., Comprehensive Medicare data) with PDPs

/ Monthly performance reports including data related to the PDP’s patient panel will be provided. If the PDP office has the ability to receive reports electronically that is preferred. Relay of data will follow hospital privacy policies, HIPPA and HITECH regulations.
Data /

1. Analyze monthly CMS claims data files

/ The analytics team will develop reports and data for examination by leadership monthly. Reports may include total medical spend per patient, number of service providers, and readmissions etc.

1. Use data to measure completion of the required CRP Interventions

/ Care managers will work with PDP staff to collect this information from the PDP’s EHR bi-annually unless it can be collected via CRISP. We will also make use of the registries available within Healthy Planet to track this information.
In terms of the care management resources we provide to PDPs, we will track those on our CCIP budget that we’ll create, which will include the costs associated of all resources provided.

1. Do you plan to share the comprehensive Medicare data you will receive from CMS with covered entity Care Partners? (check if yes)

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