bree collaborative meeting · in crafting the total joint bundle rpf effort, several key objectives...

Bree Collaborative Meeting

March 20th, 2019 | Puget Sound Regional Council

Housekeeping

Web Access: listed throughout room

Slide 2

Agenda

Chair Report January 23rd Meeting MinutesAction Item: Approve minutes

Implementation Update: Premera Blue CrossNew Workgroup: Shared Decision Making

Action Item: Adopt Charter and RosterWorkgroup Update: Palliative Care

Action Item: Adopt Charter and Roster

BREAKAccountable Communities of Health and HealthierhereWorkgroup Update: Risk of Violence to Others

Action Item: Adopt Charter and RosterWorkgroup Update: Maternity Bundle Workgroup Update: Opioid Prescribing Next Steps and Close Slide 3

January 23rd Meeting Minutes

Slide 4

Confidential and proprietary – restricted. Solely for authorized persons having a need to know. © 2018 Premera

Premera’s Total Joint Replacement Implementation

Overview

March 20, 2019

Laura Butcher, MPHDirector, Provider StrategyPremera Blue Cross

Confidential and proprietary – restricted. Solely for authorized persons having a need to know.

2

Summary for today’s discussion

Background:

▪ In October of 2018 Premera released an RFP to the providers in Washington for a total joint replacement bundle

▪ This was the first payer initiative RFP to purchase healthcare services directly from providers

▪ The requirements were informed by The Health Care Authority’s 2015 RFP with a heavy emphasis on the Bree Collaborative evidence based guidelines

Today’s discussion will:

▪ provide an overview of why Premera chose to engage with the provider community through an RFP and,

▪ give an update on where we are at in our early stage implementation effort


3

Premera is purchasing healthcare differently

▪ The shift from volume- to value-based reimbursement continues to gain traction through the US health care industry

▪ Driven nationally by CMS and locally by Washington State’s largest healthcare purchaser, the Health Care Authority, this movement is challenging health plans to change their traditional, payer-focused role in the ecosystem

▪ Premera is responding to that challenge by re-imagining our provider relationships to address the issues of high cost, inconsistent value, and poor experience that neither Premera nor providers can address independently


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Total joint replacement bundle objectives

In crafting the total joint bundle RPF effort, several key objectives were identified to ensure the initiative had a true north and a clear way to evaluate success

▪ Achieve Premera’s purpose to make healthcare work better

▪ Maximize value for our customers

▪ Increase likelihood of good outcomes for our members

▪ Address the 4-customer problems

▪ Spread adoption of the Bree Collaborative guidelines


Driving value from provider to employer to member

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• Joint accountability for healthcare performance, focused on outcomes

• Better population health and fewer care gaps thanks to data integration and resource sharing

• Empowered decision making at the point of care

• Enhanced customer experience and more efficient operations

People pay too much (consumers and other payers)

Too often people don’t get the care or other support they need

Too often, people get more care than they need

Generally, the experience is poor

WHAT BUNDLEDPROGRAMS CAN DELIVER

Solving the Four Customer Problems


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Bundle design focused on clinical quality and outcomes

Hips and Knee replacements are a high-volume service with wide variance in quality, outcomes, experience, and cost

Leveraging best practices from the Bree Collaborative guidelines will yield demonstrated improvement in outcomes and high levels of patient/member satisfaction

▪ Premera is the program administrator for the HCA total joint replacement and total knee replacement and spine surgery bundles

▪ Demonstrated improved clinical outcomes and high patient satisfaction with the experience (NEJM Case Study: October 2018)

▪ Premera provides enhanced care coordination and travel benefits


Engaging differently with providers

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▪ Providers agree to follow the Bree Collaborative evidence based guidelines and to report on required clinical, outcomes, and performance measure

▪ Agree to collaborate closely on implementation and member experience with dedicated teams from Premera and the providers

▪ The scoring methodology provided greater weight for providers’ ability to meet the Bree guidelines.

▪ The total score was based on the combined quality and cost proposals

First payer initiated RFP – allows Premera to collaborate deeply with engaged providers


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The response from the provider community

In 2015 the HCA noted that few providers at that time were able to demonstrate an ability to meet all requirements

▪ Providers responded overwhelmingly to our initial RFP and submissions were robust and thoughtful

▪ Responses demonstrated improvement in the provider communities adoption of the Bree Collaborative guidelines

▪ Providers showed they are interested in engaging more collaboratively with payers


From TJR RFP to Center of Excellence implementation

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▪ Time Line: RFP released in October of 2018, responses were received in December, and the apparently successful bidder was notified in late February 2019

▪ Dedicated teams are being assembled for the implementation efforts required for the 1/1/2020 go live

▪ Premera and the apparently successful bidder will engage closely throughout the agreement period to ensure the goals of the bundle center of excellence are realized

▪ This solution will include benefit design to support members receiving these services at the selected center of excellence

▪ Premera welcomes the opportunity to return and update this body on progress and outcomes

Confidential and proprietary – restricted. Solely for authorized persons having a need to know.10

New Workgroup: Shared Decision Making

Emily Transue, MD, MHAAssociate Medical Director,Washington State Health Care Authority

March 20th, 2019 | Bree Collaborative Meeting

Workgroup Members

Chair: Emily Transue, MD, MHA, Associate Medical Director, Washington State Health Care Authority

David Buchholz, MD, Medical Director, Premera

Sharon Gilmore, RN, Risk Consultant, Coverys

Leah Hole-Marshall, JD, General Counsel and Chief Strategist, Washington Health Benefit Exchange

Steve Jacobson MD, MHA, CPC, Associate Medical Director, Care Coordination, The Everett Clinic, a DaVita Medical Group

Dan Kent, MD, Medical Director, United Health Care

Andrew Kartunen, Program Director, Growth and Strategy, Virginia Mason Medical System

Dan Lessler, MD, Physician Executive for Community Engagement and Leadership, Comagine Health

Jessica Martinson, MA, Director of Clinical Education and Professional Development, Washington State Medical Association

Karen Merrikin, JD, Consultant, Washington State Health Care Authority

Randy Moseley, MD, Medical Director, Quality, Confluence Health

Michael Myint, MD, Medical Director, Population Health, Swedish Hospital

Martine Pierre Louis, MPH, Director, Interpreter Services, Harborview Medical Center

Karen Posner, PhD, Research Professor, Laura Cheney Professor in Anesthesia Patient Safety, Department of Anesthesiology & Pain Medicine, University of Washington

Angie Sparks, MD, Family Physician and Medical Director, Clinical Knowledge Development, Kaiser Permanente of Washington

Anita Sulaiman, Patient Advocate Slide 2

Literature Review for Shared Decision Making

Title Brief Description Topic Year Published Author(s) Associated

Fee/Subscription

MetaAnalysis?

Shared Decision

Making in the

Medical

Encounter: Are

We All Talking

about the Same

Thing?

This article aims to explore 1) whether after all the

research done on shared decision making (SDM) in the

medical encounter, a clear definition (or definitions) of

SDM exists; 2) whether authors provide a definition of

SDM when they use the term; 3) and whether authors are

consistent, throughout a given paper, with respect to the

research described and the definition they propose or cite.

Defining what

SDM is

2007

(Medical Decision Making)

Nora Moumjid, Amiram

Gafni, Alain Bremond, Marie-

Odile Carrere

Subscription or other

payment options Yes

(76 reports)

Implementation of Shared Decision Making into Practice

Group Health’s

Participation

In A Shared

Decision-Making

Demonstration

Yielded Lessons,

Such As Role Of

Culture Change

(PDF available)

In 2007 Washington State became the first state to enact

legislation encouraging the use of shared decision making

and decision aids to address deficiencies in the informed-

consent process. Group Health volunteered to fulfill a

legislated mandate to study the costs and benefits of

integrating these shared decision-making processes into

clinical practice across a range of conditions for which

multiple treatment options are available. The Group

Health Demonstration Project, conducted during 2009–11,

yielded five key lessons for successful implementation,

including the synergy between efforts to reduce practice

variation and increase shared decision making; the need

to support modifications in practice with changes in

physician training and culture; and the value of identifying

best implementation methods through constant

evaluation and iterative improvement. These lessons can

guide other health care institutions moving toward

informed patient choice as the standard of care for

medical decision making.

Implementing

SDM into practice

2013

(Health Affairs)

Ben Moulton, Jamie King Open access No

Slide 3

Washington State Health Care Authority

“Shared decision making is a process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences.

Patient decision aids are tools that can help people engage in shared health decisions with their health care provider. Research shows that use of patient decision aids leads to increased knowledge, more accurate risk perception, and fewer patients remaining passive or undecided about their care. For example, a patient decision aid could help a pregnant woman who previously had a cesarean section to determine if she is a good candidate for a vaginal birth after cesarean.”

Source: www.hca.wa.gov/about-hca/healthier-washington/shared-decision-making

Slide 4

http://www.hca.wa.gov/about-hca/healthier-washington/shared-decision-making

Patient Decision Aid Certification

“Washington State law recognizes that certification plays a significant role in assuring the quality of decision aids used by consumers, providers and payers.

With support from the Gordon and Betty Moore Foundation, we worked with state and national stakeholders to develop a process to certify high quality patient decision aids for use by providers and their patients in Washington State. Washington State’s leadership in creating the decision aid certification process provides a model that other states can adopt.

HCA began accepting patient decision aids for certification in April 2016.”

Source: www.hca.wa.gov/about-hca/healthier-washington/patient-decision-aids-pdas

Slide 5

https://www.hca.wa.gov/about-hca/healthier-washington/patient-decision-aids-pdas

Thought Leader GroupMet 2017-2018

Defining shared decision making Narrow: protocol for specified set of “preference sensitive conditions,”

including tools) VS

Broad: approach to patient care in which decisions are made by the patient with help and support from their provider; this process involves an informed, activated patient and a provider who helps the patient to interpret medical information and apply it in concordance with their values

Beyond informed consent, education, or motivational interviewing

Discussed barriers Increased time. Can address with published evidence.

Fear of revenue loss (rate of procedures)

Discussed facilitators Defining pain points: for providers and others, what important problems can

this work solve?

Defining “What’s in it for me” (for all stakeholders)/business case

Using purchasing power (HCA, Medicare)

Discussed roles for various stakeholders, need to align with other efforts Slide 6

Prioritizing Topics

Is SDM the best approach? (More than one clinically appropriate treatment option, with significantly different clinical and/or personal implications for patients.)

Are quality PDAs available (OPTIONAL or under development?)

Is the condition highly prevalent, and/or is there high use/high variation IN WA?

Would an SDM intervention advance health equity?

Is this a current or future state health care priority area? E.g. Bree

Would the SDM intervention have significant financial or other value to providers?

Would the SDM intervention have significant financial or other value to payers and/or purchasers?

Are there clinical and policy champions throughout the affected health care entity?

At the agency/policy level?

Are we likely to get “engagement rather than mere compliance” among affected staff?

Are there lower “barriers to entry” to affected providers?

Is there real potential for the SDM intervention to spread beyond the affected clinical area or staff?

Are there certified PDAs available for the affected condition? (If no, could this be done in a timely manner?)

Slide 7

Results of Topic Poll

Slide 8

* End-of-Life Care/Advance care planning 6*Attention deficit hyperactivity disorder 5*Prostate-Specific Antigen (PSA) Testing 3*Depression 3Breast Cancer Screening 3Contraceptive options 2*Opioid Use Disorder 2*Lumbar Fusion Surgery 2*Back Pain (including surgery) 2*Abnormal Uterine Bleeding (including hysterectomy) 2

Runners up (1 vote)

*Hip and Knee Osteoarthritis (including total joint replacement)

*Alzheimer's Disease and Other Dementias

*Cesarean Section (e.g., trial of labor after cesarean)

Hyperlipidemia (including statin choice)

Arrhythmia (including implantable defibrillator)

*Coronary Artery Disease (including coronary artery bypass surgery)

*Early Stage Prostate Cancer

Colorectal Cancer Screening

Prenatal Genetic Testing

Circumcision Slide 9

Other Options (0 votes)

Low Dose CT-Lung Screening

Cervical Spine Fusion Surgery

*Uterine Fibroids (including hysterectomy)

Stroke Prevention (including carotid artery procedure)

Atrial Fibrillation (including taking an anticoagulant)

*Weight control (including bariatric surgery)

*Hysterectomy

Gallstones

Enlarged Prostate

*Early Stage Breast Cancer

Osteoarthritis of the Shoulder (including shoulder replacement surgery)

ER Admission for chest pain

Panic Attacks including Anxiety Slide 10

Problem Statement

Involving patients as equal partners in health care decisions that have multiple clinically appropriate options by fully discussing risks and benefits is often not a routine part of care.

The Washington State Health Care Authority defines shared decision making as “a process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences.”

Shared decision making for preference-sensitive conditions has been shown to improve patient satisfaction with care, health outcomes, and appropriateness of care.

However, use of shared decision making remains limited within clinical practice. Sources: Washington State Health Care Authority. Shared Decision Making. 2018. Accessed: November 2018. Available: www.hca.wa.gov/about-hca/healthier-washington/shared-decision-

making.

Arterburn D, Wellman R, Westbrook E, Rutter C, Ross T, McCulloch D, et al. Introducing decision aids at Group Health was linked to sharply lower hip and knee surgery rates and costs. Health Aff (Millwood). 2012 Sep;31(9):2094-104.

Stacey D, Légaré F, Col NF, Bennett CL, Barry MJ, Eden KB, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014 Jan 28;(1):CD001431.

Slide 11

http://www.hca.wa.gov/about-hca/healthier-washington/shared-decision-making

Aim

To recommend policies and clinical pathways for widespread adoption of shared decision making across the country.

Slide 12

Purpose

To propose evidence-based, actionable, practical recommendations to the full Bree Collaborative on:

A Washington state-specific shared decision making toolkit.

Building on the work of the 2018 thought leader group.

Leveraging and adapting the National Quality Forum shared decision making playbook and previous Bree Collaborative recommendations.

Addressing barriers and recommending enablers for shared decision making adoption and sustainable use.

Providing guidance and support for cross-sector implementation activities.

Identifying other areas of focus, funding opportunities, or modifying areas, as needed.

Slide 13

Recommendation

Adopt Charter and Roster

Slide 14

Workgroup Update: Palliative Care

John Robinson, MD, SMChief Medical Officer, First Choice Health


Workgroup Members

Slide 2

Chair: John Robinson, MD, SM, Chief Medical Officer, First Choice Health Lydia Bartholomew, MD, Senior Medical Director, Pacific Northwest, Aetna George Birchfield, MD, Inpatient Hospice, EvergreenHealth Raleigh Bowden, MD, Director, Okanogan Palliative Care Team Mary Catlin, MPH, Senior Director, Honoring Choices, Washington State Hospital Association Randy Curtis, MD, MPH, Director, Cambia Palliative Care Center of Excellence, University of Washington Medicine Leslie Emerick, Legislative Consultant, Home Care Association of Washington Ross Hayes, MD, Palliative Care Program, Bioethics, Rehabilitation, Pediatrician, Seattle Childrens Greg Malone, MA, MDiv, BCC, Palliative Care Services Manager, Swedish Medical Group Kerry Schaefer, MS, Strategic Planner for Employee Health, King County Bruce Smith, MD, Medical Director of Providence Hospice of Seattle, Providence Health and Services Richard Stuart, DSW, Psychologist, Swedish Medical Center - Edmonds Campus Stephen Thielke, MD, Geriatric Psychiatry, University of Washington Cynthia Tomik, LICSW, Manager, Palliative Care, Evergreen Health Gregg Vandekieft, MD, MA, Medical Director for Palliative Care, Providence St. Peter Hospital Hope Wechkin, MD, Medical Director, Hospice and Palliative Care, EvergreenHealth

Definitions

“Palliative care focuses on expert assessment and management of [symptoms including] pain…assessment and support of caregiver needs, and coordination of care. Palliative care attends to the physical, functional, psychological, practical, and spiritual consequences of a serious illness. It is a person- and family-centered approach to care, providing people living with serious illness relief from the symptoms and stress of an illness.”

National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care, 4th edition. Richmond, VA: National Coalition for Hospice and Palliative Care; 2018. www.nationalcoalitionhpc.org/ncp.

Slide 3

http://www.nationalcoalitionhpc.org/ncp

Data from National Palliative Care Registry

Slide 4Source: National Palliative Care Registry. Washington State. Accessed: February 2019. Available: https://registry.capc.org/wp-content/uploads/2017/08/WA_Pacific_StateReport.pdf

https://registry.capc.org/wp-content/uploads/2017/08/WA_Pacific_StateReport.pdf

National Coalition for Hospice and Palliative CareClinical Practice Guidelines for Quality Palliative Care 4th edition

1. Structure and Processes of Care: The composition of an interdisciplinary team is outlined, including the professional qualifications, education, training, and support needed to deliver optimal patient- and family-centered care. Domain 1 also defines the elements of the palliative care assessment and care plan, as well as systems and processes specific to palliative care.

2. Physical Aspects of Care: The palliative care assessment, care planning, and treatment of physical symptoms are described, emphasizing patient- and family-directed holistic care.

3. Psychological and Psychiatric Aspects: The domain focuses on the processes for systematically assessing and addressing the psychological and psychiatric aspects of care in the context of serious illness.

Slide 5

Continued

4. Social Aspects of Care: Domain 4 outlines the palliative care approach to assessing and addressing patient and family social support needs.

5. Spiritual, Religious, and Existential Aspects of Care: The spiritual, religious, and existential aspects of care are described, including the importance of screening for unmet needs.

6. Cultural Aspects of Care: The domain outlines the ways in which culture influences both palliative care delivery and the experience of that care by the patient and family, from the time of diagnosis through death and bereavement.

7. Care of the Patient Nearing the End of Life: This domain focuses on the symptoms and situations that are common in the final days and weeks of life.

8. Ethical and Legal Aspects of Care: Content includes advance care planning, surrogate decision-making, regulatory and legal considerations, and related palliative care issues, focusing on ethical imperatives and processes to support patient autonomy.

Slide 6

Problem Statement

People with serious illness often have a range of needs that may not be met by life-prolonging or curative care.

The structures, processes, and the definition of palliative care are lacking.

Poor or lack of reimbursement for palliative care services alongside life-prolonging and/or curative care contributes to a lack of access.

Palliative care has been associated with reduction in symptom burden, higher satisfaction with care, higher referrals to hospice, and fewer number of days in a hospital.

For patients with cancer, early delivery of palliative care has been associated with increased quality of life.

Gomes B, Calanzani N, Curiale V, McCrone P, Higginson I. Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Sao Paulo Med J. 2016 Jan-Feb;134(1):93-4.

Hall S, Kolliakou A, Petkova H, Froggatt K, Higginson IJ. Interventions for improving palliative care for older people living in nursing care homes. Cochrane Database Syst Rev. 2011 Mar 16;(3):CD007132.

Haun MW, Estel S, Rücker G, Friederich HC, Villalobos M, Thomas M, et al. Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev. 2017 Jun 12;6:CD011129.

Slide 7

Aim(Text is red is new)

To develop best practice recommendations for palliative care regarding:

Assessment of patients with serious illness for primary and/or specialty palliative care need,

Care delivery frameworks, and

Payment models to support delivery of care.

Slide 8

Purpose

To propose evidence-based recommendations to the full Bree Collaborative on:

Defining care delivery pathways for interdisciplinary team-based palliative care including pain management, assessing patient and caregiver needs, and care coordination.

Standard evaluation of patients with serious illness for primary or specialty palliative care need.

Educational standards for primary care staff about palliative care.

Integrating palliative care alongside life-prolonging and/or curative care.

Payment models to support delivery of palliative care alongside life-prolonging and/or curative care.

Addressing racial and income disparities as well as other health disparities within palliative care.

Process and patient outcome metrics.

Addressing barriers to integrating recommendations into current care systems.

Identifying other areas of focus or modifying areas, as needed.

Slide 9

Recommendation


Slide 10

Accountable Communities of Health

Emily Transue, MD, MHA, Associate Medical DirectorMarch 20th, 2019

3

Medicaid Transformation

Developments and milestones for 2019Semi-annual report #3 (covers Jan – June 2019) due July 31, 2019. Includes:• Updated Implementation Plan• ACH Quality Improvement Strategy • Site-level Roster of Partnering Providers• Financial reporting extracts from the Financial Executor Portal

Independent Assessor to conduct mid-point assessment in Q3-Q4 2019. • Scope and approach still in design• The goal is to gain insight on progress across projects, while minimizing provider or

ACH reporting burden• Pending assessment scope, follow-up could include adjustments or course correction

ACH and MCO VBP incentive payments under DSRIP begin in 2019• These are separate from project incentives earned by ACHs over the course of MTP.• Incentives encourage alignment between ACHs and MCOs• The 2018 (DY2) P4R portion for the ACHs will be processed in Q2 2019• The MCO VBP payments will be processed in Q3 2019

Sustainability Planning• There is shared interest and energy this year to start sustainability

mapping in earnest.

• First steps include: identifying necessary levers, evaluation needs, and other dependencies to sustain projects and practice transformation.

• This requires statewide coordination between MCOs, ACHs, state agencies (including the Medicaid Program) and other partners.

• This effort will inform investment decisions that ACHs are still contemplating, as ACHs want to maximize resources and providers are looking for some assurance on viability going forward.

Questions?More Information:https://www.hca.wa.gov/about-hca/healthier-washington/medicaid-transformation-

resources

Emily Transue, MD, MHA, Associate Medical [email protected]

6

https://www.hca.wa.gov/about-hca/healthier-washington/medicaid-transformation-resources

mailto:[email protected]

HealthierHere

Susan McLaughlin, PhDExecutive Director, HealthierHere

Workgroup Update: Risk of Violence to Others

Kim Moore, MDAssociate Chief Medical Director, CHI Franciscan


Workgroup Members

Slide 2

Chair: Kim Moore, MD, Associate Chief Medical Director, CHI Franciscan G. Andrew Benjamin, JD, PhD, ABPP, Clinical Psychologist, Affiliate Professor of Law, University of Washington Kate Comtois, PhD, MPH, Professor, Department of Psychiatry and Behavioral Sciences, Harborview Medical Center Jaclyn Greenberg, JD, LLM, Policy Director, Legal Affairs, Washington State Hospital Association Laura Groshong, LICSW, Clinical Social Work, Private Practice Ian Harrel, MSW, Chief Operating Officer, Behavioral Health Resources Neetha Mony, State Suicide Prevention Plan Program Manager, Injury & Violence Prevention, Prevention and Community Health, Washington State Department of Health Kelli Nomura, MBA, Behavioral Health Administrator, King County Mary Ellen O'Keefe, ARNP, MN, MBA, Clinical Nurse Specialist - Adult Psychiatric/Mental Health Nursing; President Elect, Association of Advanced Psychiatric Nurse Practitioners Jennifer Piel, MD, JD, Psychiatrist, Department of Psychiatry, University of Washington Julie Rickard, PhD, Program Director, American Behavioral Health Systems – Parkside Samantha Slaughter, PsyD, Member, WA State Psychological Association Jeffery Sung, MD, Member, Washington State Psychiatric Association Amira Whitehill, MFT, Member, Washington Association for Marriage and Family Therapists Certified counselor

Presentation from Jennifer Piel, MD, JD,Psychiatrist, Department of Psychiatry, University of Washington

Slide 3


Slide 4


Slide 5


Slide 6

Problem Statement(text is red is new)

Since the 2016 Washington State Supreme Court decision Volk v. DeMeerleer, patients may be reluctant to engage with health care providers about their violence risk. Health care providers may also be uncertain about how to meet their legal obligations.

Slide 7

Aim

To recommend clinical best practices for patients with risk of violence.

Slide 8

Purpose

To propose evidence-based recommendations to the full Bree Collaborative on: Assessing an individual’s risk for violence Identifying risk factors for violence Reconciling the individual’s right to confidentiality, least restrictive

environment, and the provider’s duty to protect Actions to take when there is a concern about an individual’s risk for

violence including treatment Actions to take when there is a concern about an individual’s risk for

violenceDischarging patients based on treatment setting Record-keeping to decrease variation in practice patterns in these areas Augmenting the Bree Collaborative Suicide Care recommendations Identifying other areas of focus, or modifying areas, as needed

Slide 9

Volk v. DeMeerleer187 Wn.2d 241, 386 P.3d 254

2016 Washington State Supreme Court decision “Alters the scope of the ‘duty to warn or protect’ in at least three critical ways: 1. It brings into question the groups of health care professionals who

are subject to the duty to warn or protect in the voluntary inpatient and outpatient setting. 2. The duty now clearly applies in the voluntary inpatient and

outpatient setting. 3. Most importantly, outside of the context of an involuntary

commitment proceeding, the scope of persons to warn or protect now includes those that are ‘foreseeable’ victims, not reasonably identifiable victims subject to an actual threat.” Source: www.phyins.com/uploads/file/Volk%20recs-FINAL.PDF

Slide 10

http://www.phyins.com/uploads/file/Volk%20recs-FINAL.PDF

Legislative Ask

“Identify best practices for mental health services regarding patient mental health treatment and patient management. The workgroup shall identify best practices on:

patient confidentiality, discharging patients, treating patients with homicide ideation and suicide ideation, record-keeping to decrease variation in practice patterns in these areas, and other areas as defined by the workgroup.

The workgroup shall be comprised of: clinical and administrative experts including psychologists, psychiatrists, advanced practice psychiatric nurses, social workers, marriage and family therapists, certified counselors, and mental health counselors.”

Slide 11

Recommendation


Slide 12

Workgroup Update: Maternity Bundled Payment Model

Carl Olden, MDFamily Physician, Pacific Crest Family Medicine


Workgroup Members

Slide 2

Chair: Carl Olden, MD, Family Physician, Pacific Crest Family Medicine Anaya Balter, RN, CNM, MSN, MBA, Clinical Director for Women's Health, Washington State Health Care Authority David Buchholz, MD, Medical Director, Collaborative Health Care Solutions, Premera Andrew Castrodale, MD, Family Physician, Coulee Medical Center Francie Chalmers, MD, Pediatrician, Member , Washington Chapter of the American Academy of Pediatrics Angela Chien, MD, Obstetrics and Gynecology, EvergreenHealth Neva Gerke, LM, President, Midwives Association of Washington Molly Firth, MPH, Patient Advocate Lisa Humes-Schulz, MPA/Lisa Pepperdine, MD, Director of Strategic Initiatives/ Director of Clinical Services, Planned Parenthood of the Great Northwest and Hawaiian Islands Rita Hsu, MD, FACOG, Obstetrics and Gynecology, Confluence Health Caroline Kline, MD, Obstetrics and Gynecology, Overlake Medical Center Dale Reisner, MD, Obstetrics and Gynecology, Swedish Medical Center Janine Reisinger, MPH, Director, Maternal-Infant Health Initiatives, Washington State Hospital Association Mark Schemmel, MD, Obstetrics and Gynecology, Spokane Obstetrics and Gynecology, Providence Health and Services Vivienne Souter, MD, Research Director, Obstetrics Clinical Outcomes Assessment Program

Source: http://hcp-lan.org/workproducts/cep-whitepaper-final.pdf

http://hcp-lan.org/workproducts/cep-whitepaper-final.pdf

Learning from Other ExamplesSource: http://hcp-lan.org/workproducts/cep-whitepaper-final.pdf

Tennessee Health Care Improvement Innovation Initiative

40 weeks prior to delivery through 60 days after delivery or discharge

Mother only Arkansas Health Care Payment

Improvement Initiative Roughly 40 weeks before delivery through 60

days postpartum Mother only

Community Health Choice (TX) Mother: 270 days prior to delivery through

60 days post discharge Mother and newborn

Providence Health & Services (OR) Positive pregnancy confirmation until 6

weeks after delivery Mother and newborn

Geisinger Health System Prenatal: Identification of pregnancy in the

first or second trimester Mother only Slide 4

Pacific Business Group on Health (CA) Hospital labor and delivery only Mother only

American Association of Birth Centers (PA) Enrollment in freestanding birth center through

and including 6-week postpartum care visit Mother and newborn care through first 28 days of

life Baby+ Company (NC, TN, CO)

Initial OB visit at birth center through 6 weeks postpartum

Mother and newborn The Minnesota Birth Center's BirthBundleTM

270 days prior to delivery and 56 days postpartum Mother and newborn

Ohio Episode-Based Payment Model 280 days prior to delivery until 60 days post

delivery Mother only


Ohio and Tennessee

Slide 5

Steps for Ohio and Tennessee

Slide 6

Patient Population

Defining who fits within low-risk pathwayDeveloping additional layers (additional $$)

Depression, Substance Use Disorder, BMI, HIV, high-risk-baby?

Slide 7

Standard Pathway

+ Depression

+ Opioid Use Disorder

Prenatal Birth Postpartum

Example from HPC-LAN

When does bundle start? (e.g., conception, 270 days before delivery) 270/280 days

When does bundle end? (neonatal care, 30-days post delivery) 6 weeks

Slide 8Source: http://hcp-lan.org/workproducts/cep-whitepaper-final.pdf


Themes

Need to avoid unintended consequences Overly incentivizing vaginal delivery to detriment of baby Loosing access to services

Wanting to make big bold changes (e.g., bundle for 12 months post-delivery) Will propose a pragmatic bundle that works with today’s system but also

some reach goals

Want all hospitals to be able to respond to emergenciesModel applicable to urban and rural areasConnecting patients with best-suited type of provider (midwife, fam

practice, OB) Flexibility for innovative types of services (e.g., group visits,

telehealth)Slide 9

WorkgroupUpdate:OpioidPrescribing

GaryFranklin,MD,MPHMedicalDirector,WashingtonStateDepartmentofLaborandIndustries

March20th,2019|BreeCollaborativeMeeting

WorkgroupMembers�  Co-Chair:GaryFranklin,MD,MPH,MedicalDirector,WashingtonStateDepartmentofLaborandIndustries

�  Co-Chair:CharissaFotinos,MD,DeputyMedicalOfficer,HealthCareAuthority�  Co-Chair:AndrewSaxon,MD,Director,CenterofExcellenceinSubstanceAbuseTreatmentandEducation(CESATE),VAPugetSoundHealthCareSystem

�  JaneC.BallantyneMD,FRCA,Professor(retired)ofAnesthesiologyandPainMedicine,Director,UniversityofWashingtonPainFellowship

�  ChrisBaumgartner,DirectorPrescriptionMonitoringProgram,WashingtonStateDepartmentofHealth

� DavidBuchholz,MD,MedicalDirectorofProviderEngagement,PremeraBlueCross�  PamelaJ.DaviesMS,ARNP,ACHPN,BC,TeachingAssociate,UniversityofWashingtonMedicalCenter

� DeborahFulton-Kehoe,PhD,MPH,SeniorResearchScientist,UniversityofWashington�  FrancesGough,MD,ChiefMedicalOfficer,Molina� DanKent,MD,ChiefMedicalOfficer,UnitedHealthcare�  KathyLofy,MD,ChiefScienceOfficer,WashingtonStateDepartmentofHealth�  JaymieMai,PharmD,PharmacyManager,WashingtonStateDepartmentofLaborandIndustries

�  JosephO.Merrill,MD,MPH,ActingAssistantProfessor,InternalMedicine�  AttendingPhysician,AdultMedicineClinic,Harborview� MarkMurphy,MD,AddictionMedicine,MulticareHealth�  YusufRashid,PharmD,VicePresident,CommunityHealthPlanofWashington�  ShirleyReitz,PharmD,Pharmacist,OmedaRx,CambiaHealth� GregRudolf,MD,PainServices,Swedish� MarkStephens,Principal,CareSyncConsulting,LLC� MarkSullivan� DavidTauben,MD,ChiefofPainMedicine,UniversityofWashingtonMedicalCenter� GregoryTermanMD,PhD,Professor,DepartmentofAnesthesiologyandPainMedicineandtheGraduatePrograminNeurobiologyandBehavior-Co-ChairPeri-opWorkgroup

�  JohnVassall,MD,FACP,PhysicianExecutive,QualisHealth� MichaelVonKorff,ScD,SeniorInvestigator,GroupHealthResearchInstitute

Slide2

TaperingOffLong-TermOpioidTherapy

� DatafromLaborandIndustriesandHealthCareAuthority�  JaymieMai,PharmD,PharmacyManager,WashingtonStateDepartmentofLaborandIndustries

� CharissaFotinos,MD,DeputyChiefMedicalOfficer,WashingtonStateHealthCareAuthority

� LiteratureonAssessmentTools� MichaelVonKorff,ScD,SeniorInvestigator,KaiserPermanenteWashingtonResearchInstitute

� LiteratureonTapering� MichaelSullivan,MD,PhD,Professor,Psychiatry;AdjunctProfessor,AnesthesiologyandPainMedicine,UniversityofWashingtonMedicine

Slide3

www.oregonpainguidance.orgDevelopedbyMarkStephens

TaperingFlowchart

Source:MarkStephens,ChangeManagementConsulting.www.oregonpainguidance.org

ComplexPersistentOpioidDependence

• Complex:Dependenceiscomplicatedbydesiretocontinuetakingopioidforthetreatmentofpain.Withdrawaliscomplicatedbyanhedoniaandhyperalgesiawhich,unlikeclassic‘physical’symptoms,maynotreversewithindays.• Persistent:Taperingispoorlytolerated.Tapering,therefore,mayfail,orishighlyprotracted(takesmonthsoryears).• WhatdistinguishesCPODfromOUD:• Nocraving• Nocompulsiveuse• Noharmfulusethatisnotmedicallydirected(patienttakesopioidexactlyasprescribed)• SocialdisruptionisattributedtopainandnottoOUD

Credit:Dr.JaneBallantyne Source:MarkStephens,ChangeManagementConsulting.www.oregonpainguidance.org

BRAVOProtocol–Dr.Lembke,Stanford


OregonHealthAuthorityOpioidTaperTaskForce

• OHAseekingexpertsandcommunitymemberswillingtoserveonOregonOpioidTaperGuidelinesTaskForce• Approximatelyfive-monthprocesstoidentifytaperingbestpractices• Meetingswillbepublic• Guidelineswillprovideframeworkforcliniciansandpatientsandserveasstartingpointfordialogue


August9thConference

• FundingfromDBHR• Vancouver,WA• Currentlyplanningagenda

Next Meeting:

Wednesday, May 15th, 201912:30 – 4:30

Puget Sound Regional Council5th Floor Board Room1011 Western Avenue, Seattle WA

bree collaborative meeting · in crafting the total joint bundle rpf effort, several key objectives...

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