Health HOME QUALITY PERFORMANCE MANAGEMENT PROGRAM

1. Health HOME QUALITY PERFORMANCE MANAGEMENT PROGRAM Recommendations of the Quality and Outcomes Subcommittee of the HH/MCO Workgroup Health Home MCO Enacted Budget Item Summit June 2018

2. Goals and Principles • Identify and/or develop a set of metrics to be evaluated in a standardized way which, in conjunction with service delivery standards, will allow stakeholders to make well-informed decisions regarding future value-based payment arrangements • Support a model of care that ensures members receive high quality, personalized services at the appropriate time, intensity, and for the right duration • Ensure that the recommended measures: • Reflect areas, to the extent possible, that can be influenced by care management, and where that influence can be quantified • Are sensitive to the unique attributes of the Health Home population, which differ significantly from the general population • Do not encourage “teaching to the test” or “gaming the system” to minimize the risk of unintended consequences • Promote meaningful collaboration between Health Homes, MCOs, CMAs, and providers • Demonstrate the impact of Health Home Care Management

3. Measure Evaluation Framework

4. Recommended Measures • Outpatient Engagement • Inpatient Detoxification Readmissions • Inpatient Utilization • Follow-up After Hospitalization for Mental Illness (7 and 30 days) • Medication Adherence • Antipsychotics • Antidepressants • Mood Stabilizers

5. Measure Selection Rationale

6. Outpatient Engagement • One of the known variables impacting health outcomes for the Health Home population is insufficient or inexistent connectivity to outpatient health care services. It is well-established that outpatient engagement has a direct impact on preventing avoidable adverse health events. • This measure is being recommended to focus Health Home care managers on connecting members to appropriate outpatient services immediately upon enrollment. The workgroup recognizes the importance of primary care providers, but decided to include any outpatient care to • (1) offset any potential provider-type coding issues (e.g., member using nephrologist as PCP) and • (2) allow care managers the ability to connect members to the most immediate areas of need and member readiness (e.g., mental health, substance abuse) prior to PCP engagement.

7. Inpatient Detoxification Readmissions • Health home care management should impact the rate of outpatient treatment for enrolled members following inpatient detoxification. It is known that continuity of care post-detox results in longer periods of abstinence, lower criminal justice involvement, and decreased readmissions to detox. Therefore, this measure will drive care managers to actively engage members upon discharge and participate in the coordination of care amongst the member and outpatient SUD providers.

8. Inpatient Utilization • Health Home care management should lower the risk of unplanned hospitalizations for enrolled members. • This measure includes hospitalizations for both medical and behavioral health reasons as focus should not be placed on one over the other. Both medical and behavioral health hospitalizations are indicative of poor health, high cost, and low quality of life. • The goal is to incentivize health home care managers to better coordinate care and connect members to appropriate outpatient services prior to an inpatient admission becoming necessary. • The outpatient care should not only be reactive to worsening chronic conditions, but also focus on appropriate preventive care and screenings.

9. Follow-up After Hospitalization for Mental Illness (7 and 30 days) • While this is a process measure, sufficient evidence exists to demonstrate its importance in preventing readmissions. • It is also reasonably within the control of care managers to participate in facilitating follow-up care (with certain external limitations). • Despite the measure’s focus exclusively on the mental health population, the prevalence of mental health hospitalizations and the potential impact of care management on follow-up necessitates its inclusion in the workgroup’s recommendations.

10. Medication Adherence • The workgroup acknowledges the limitations of these measures of medication adherence. Specifically, the recommended measures are representative of prescriptions filled rather than prescriptions taken. However, it is the belief of this workgroup that: • These are acceptable proxy measures given the inability to directly observe medication therapy, and • These measures will drive conversations between Health Home care managers and members about medication adherence.

11. Social Determinants of Health • Most existing quality measures do not account for confounding variables such as socioeconomic/sociodemographic factors, underlying mental health conditions, and significant medical comorbidities • In order to avoid the unintended consequences of “cherry picking” lower risk members (and therefore demonstrating “better” outcomes), the workgroup recommends developing a risk adjustment methodology that addresses: • Housing status • HIV status • Criminal justice involvement • Health Literacy • Functionality

12. Data Collection, Analysis, and Performance Monitoring • The workgroup proposes that the NYS Department of Health be the entity responsible for calculating performance, for the reasons that: • MCOs will need time to develop mechanisms for building measures that are not part of any currently existing measure set • Plan-level resources to develop the measures should be dedicated after a period in which measure efficacy is assessed • Many members move between managed care plans within measurement periods • A substantial number of members remain in fee-for-service Medicaid • Measurement should be stratified by length of enrollment in the health home in order to account for the churn of members (enrollment of new high risk members and discharge of stabilized members) and to better understand the “dose-response” relationship of the health home care management intervention • Baseline performance data should be calculated and shared for each selected measure • Performance data should be shared with the Health Homes and the MCOs at regular intervals • Performance data should include member-level detail and data in order to support the development of tailored, collaborative quality improvement projects • The possibility of expanding PSYCKES to include all enrolled Health Home members, along with the addition of quality flags for the selected measures, should be considered

13. Future Tasks of the Subcommittee • Develop reliable, valid, and objective standards across Health Homes for collecting data on social and functional factors • Identify key care management interventions and activities that impact the outcomes of interest • Develop methods to measure cost, quality of life, and step-down/graduation • Pending additional clarification, develop a mechanism for the application of incentives and/or penalties • Monitor and assess the selected measures to determine the need for revision, abandonment, or addition of metrics • Identify a method to account for changes in Health Home and/or MCO enrollment to appropriately attribute members in performance calculations • Develop methods for accurately assessing the effectiveness of Health Home care management against an appropriate control group