WHERE ARE THEY NOW? SURVEY REPORT 2016 and 2017 Medicare Reimbursement Learning Collaborative Participants

The National Council on Aging 251 18th Street South, Suite 500 Arlington, VA 22202

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TABLE OF CONTENTS LIST OF TABLES ...................................................................................................................................... ii

1. BACKGROUND AND INTRODUCTION ............................................................................................. 1

2. PURPOSE .......................................................................................................................................... 2

3. METHOD .......................................................................................................................................... 2

4. LIMITATIONS ................................................................................................................................... 2

5. FINDINGS ......................................................................................................................................... 2

Accreditation Status. ................................................................................................................ 3

Medicare Part B Service Being Implemented. ......................................................................... 4

Helpfulness of the Learning Collaborative Experience. ........................................................... 5

Medicare Provider Status. ........................................................................................................ 6

Reimbursement. ....................................................................................................................... 7

Factors that Facilitated Success. .............................................................................................. 8

Challenges. ................................................................................................................................ 8

What Participants Were Most Proud Of. ................................................................................. 9

Lessons Learned. ..................................................................................................................... 10

How NCOA Can Continue to Support Participants. ............................................................... 10

Additional Comments. ............................................................................................................ 11

6. CONCLUSIONS AND RECOMMENDATIONS .................................................................................. 11

7. APPENDIX: SURVEY QUESTIONNAIRE .......................................................................................... 14

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LIST OF TABLES

Table 1. Learning Collaborative Participants by Year and Focus Area..………………………………………. 3 Table 2. Accreditation Status by Organization…………………………………………………………………………… 4 Table 3. Participants Implementing Medicare Part B Services by Year and Service Type……………. 5 Table 4. Medicare Provider Status of Organizations That Have Become a Medicare Provider, Have a Contractual Agreement with a Medicare Provider, or Are Working Toward One, the Other, or Both…………………………………………………………………………………................. 6

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1. BACKGROUND AND INTRODUCTION The National Council on Aging’s (NCOA) Center for Healthy Aging (CHA), funded by the Administration for Community Living, Administration on Aging, serves as the National Resource Center to help community-based organizations implement, bring to scale, and sustain evidence-based chronic disease self-management education (CDSME), self-management support, and falls prevention programs. In recognition of the need for more intense support and technical assistance to help grantees and the broad network of community partners develop sustainable evidence-based program networks, NCOA launched two ten-month learning collaboratives focused on Medicare reimbursement in January 2016. Since then, NCOA has implemented two more Medicare Reimbursement Learning Collaborative initiatives, one in 2017 (May 2017 through April 2018) and one in 2018 (May 2018 through April 2019). The two learning collaboratives launched in 2016 focused on achieving Medicare reimbursement for a specific Medicare Part B benefit, the first on Diabetes Self-Management Training (DSMT) and the second on Health and Behavior Assessment and Intervention (HBAI), a psychosocial service. Participants who were in the DSMT learning collaborative also received technical assistance and resources to work toward achieving national accreditation for diabetes self-management education and support (DSMES) services, which is a requirement to receive Medicare reimbursement for the DSMT benefit. Due to feedback from the 2016 participants, subsequent learning collaboratives were structured to focus on Medicare reimbursement overall, covering both DSMT and HBAI, rather than only one benefit. Additionally, the time frame was expanded from 10 months to a full year. Further, each year, the process and content were refined to improve participants’ experience. In 2017, legislation was passed to introduce a new Medicare Part B benefit, Chronic Care Management (CCM). Therefore, this benefit was also included in the learning collaborative curriculums for 2017 and 2018. Participants learned about all three benefits (DSMT, HBAI, and CCM) but selected one benefit as their primary focus for implementation throughout the learning collaborative period. This approach helped participants concentrate their efforts on one benefit, while learning valuable information about other benefits that they might decide to implement in the future. In fact, a number of participants are incrementally working toward offering and obtaining reimbursement for multiple Medicare Part B benefits to help sustain their evidence-based programs. The overarching goal or aim for all of the learning collaborative initiatives was that participating organizations “achieve or make significant progress toward achieving Medicare reimbursement for CDSME programs and accreditation for diabetes self-management programs (for those who selected diabetes as their focus)” by the end of the learning period. Progress was measured by specific stages of organizational change around five programmatic elements: accreditation (participants focused on DSMT only), program implementation, clinical supervision, billing, and documentation and tracking. Participant profiles and charters that define the purpose, time frame, aims, and expectations for each learning collaborative can be found on NCOA’s CHA website at the following link: https://www.ncoa.org/center-for-healthy-aging/cdsme-resource-center/sharing-best-practices/community-integrated-health-care/learning-collaboratives/.

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2. PURPOSE The purpose of this report is to present the findings of the Where Are They Now? Survey administered to the 2016 and 2017 learning collaborative participants to determine their progress and challenges in working toward Medicare reimbursement and national accreditation for DSMES services (for those focused on DSMT). While a formal evaluation was conducted and a final report developed for each separate learning collaborative, the purpose of the Where Are They Now? Survey was to learn what happened over time, i.e., two years later for 2016 participants and one year later for 2017 participants. The report will be disseminated to learning collaborative participants, as well as the broad network of local, state, and national partners, and used to inform NCOA’s future integrated health care work.

3. METHOD NCOA distributed the Where Are They Now? Survey, a 19-item online questionnaire, from March 6 through April 11, 2019 to the 23 primary organizations that participated in one or more of the Medicare Reimbursement Learning Collaborative initiatives launched in 2016 and 2017 (see Appendix for survey questionnaire). One representative (the lead, co-lead, or successor/designee for the learning collaborative initiative) from each organization was asked to respond to the survey, even if an organization was involved in two learning collaboratives (i.e., both HBAI and DSMT in 2016). Respondents were asked to coordinate their answers with team members and partners to ensure complete and accurate information. The survey included questions about the following topics: area of focus (DSMT, HBAI, or CCM), accreditation, implementation, Medicare provider status, and reimbursement. Participants were also asked to identify key factors that facilitated their success, major challenges, and lessons learned. Further, they were asked what continued support they would like from NCOA. The response rate was 100%, with all 23 organizations completing the survey, which consisted of a combination of Likert-scale, open-ended, and close-ended questions.

4. LIMITATIONS There were several limitations to the survey. First, the learning collaborative lead, co-lead, or a designee/successor was asked to complete the survey for each organization that participated. In several instances, the respondent was a designee/successor who may not have been involved in the learning collaborative initiative and consequently may have not had a thorough understanding of the issues to respond to the questions accurately and completely. Second, survey respondents were asked to coordinate with their team members and partners. However, the extent to which they did or did not coordinate with others before submitting their responses is not known. A third limitation has to do with the online survey method itself. While the process was efficient and led to some important findings, responses lacked detail and depth that could have been elicited through an interview method.

5. FINDINGS Fourteen of the 23 respondents participated in one or both of the 2016 learning collaboratives; 6 participated in DSMT, 5 in HBAI, and 3 in both. Nine respondents participated in the 2017 learning

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collaborative; 3 focused on DSMT, 3 on HBAI, and 3 on CCM. Table 1 below shows a list of organizations that participated in the learning collaborative by year and focus area. Table 1. Learning Collaborative Participants by Year and Focus Area

Year Participant State Focus Area

DSMT HBAI CCM

2016

AgeOptions IL x

Centralina Area Agency on Aging NC x

Florida Health Networks FL x x

Connecticut Department of Health CT x

Maryland Living Well Center of Excellence/MAC Inc. MD x x

Michigan State University MI x x

Mississippi State Department of Health MS x

North Central Texas Council of Governments TX x

Oregon Wellness Network OR x

Philadelphia Corporation for Aging PA x

South Dakota University State Extension SD x

Southeastern Colorado AHEC CO x

Valley Program for Aging Services VA x

Wisconsin Institute for Healthy Aging WI x

2017

Area Agency on Aging Region One AZ x

Jewish Family Service of Metropolitan Detroit MI x

Lake County Tribal Health Consortium, Inc. CA x

Nebraska Department of Health NE x

The Oasis Institute MO x

Piedmont Triad Regional Council Area Agency on Aging NC x

Senior Connection Center, Inc. FL x

Southwestern Connecticut Area Agency on Aging, Inc. CT x

Spectrum Generation/Healthy Living for ME ME x

Accreditation Status. Of the 12 organizations focused on DSMT, 7 were successful in achieving national accreditation, 4 during the learning collaborative period and 3 after the learning collaborative ended. Of the 5 remaining organizations, one (Florida Health Networks) just submitted its application for accreditation to the national accrediting organization and anticipates becoming accredited soon. Three organizations are still working on accreditation, and one (Michigan State

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University Extension) decided not to pursue accreditation after the learning collaborative ended but is working to achieve reimbursement for the Medicare Part B Diabetes Prevention Program (DPP) benefit in partnership with Solera Health. Table 2 below shows the accreditation status for each of the 12 organizations that selected DSMT as their focus area. Additionally, one organization (AgeOptions) that did not focus on DSMT during the learning collaborative reported working toward reaccreditation. Table 2. Accreditation Status by Organization

Accreditation Status Organization

Achieved national accreditation • Centralina Area Agency on Aging

• Connecticut Department of Health

• Lake County Tribal Health Consortium

• Maryland Living Well Center for Excellence/MAC Inc.

• North Central Texas Council of Governments

• Philadelphia Corporation for Aging

• Piedmont Triad Regional Council Area Agency on Aging

Submitted application for accreditation • Florida Health Networks

Still working on accreditation • Oregon Wellness Network

• Senior Connection

• Wisconsin Institute for Healthy Aging

Decided not to pursue accreditation (Working toward reimbursement of the Diabetes Prevention Program benefit)

• Michigan State University Extension

Medicare Part B Service Being Implemented. Approximately half of respondents (11) said that they are currently implementing at least one Medicare Part B service. While the survey included questions about the primary Medicare benefits covered in the learning collaborative curriculum (i.e., DSMT, HBAI, and CCM), there were no questions about related benefits. For example, data was not gathered on the Medicare medical nutrition therapy (MNT) benefit because MNT is a core component of the DSMT program model and is typically offered in conjunction with DSMT. Furthermore, no questions were asked about another related Medicare benefit, the Diabetes Prevention Program (DPP). The curriculum provided an overview of DPP as an optional service that could be offered together with DSMT. While the survey was not intended to study these related benefits, one participant (Piedmont Triad Regional Council Area Agency on Aging) reported offering MNT in conjunction with DSMT, and one participant (Michigan State University Extension) reported implementing DPP. Table 3 below shows a list of organizations that are actively implementing Medicare Part B services by year and type of service. Likewise, nearly half (11) of respondents said that they are continuing to work toward implementation. Several are working toward implementation of two services simultaneously. A total of 7 organizations are working toward implementation of DSMT, 4 toward HBAI, and 3 toward CCM. One organization is not implementing a service or working toward implementation. Organizations not yet implementing services are at various stages in the process. Several respondents described delays due to challenges, including staff turnover and difficulty securing partnerships with health care entities. Two organizations have conducted pilot programs. Florida

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Health Networks, which serves as a network “hub,” partnered with four community-based organizations to offer DSMT and assisted all four in completing DSMT pilots. Florida has submitted its application for accreditation to the national accrediting organization and plans to start full-scale implementation once the accreditation certificate is received. Florida is also working on starting pilots for CCM, and Valley Program for Aging Services mentioned a CCM pilot that is underway. Two organizations (North Central Texas Council of Governments and Connecticut Department of Health) have identified community-based organizations to serve as their billing partners, and both are working collaboratively with their partners to develop a step-by-step billing process. Table 3. Participants Implementing Medicare Part B Services by Year and Service Type

Year Medicare Service Type

DSMT HBAI CCM Other

2016 Participants

Centralina Area Agency on Aging x MNT

Connecticut Department of Health x

Maryland Living Well Center of Excellence/MAC Inc. x

Mississippi Department of Health x

North Central Texas Council of Governments x

2017 Participants

Area Agency on Aging Region One x

Lake County Tribal Health Consortium x

Michigan State University Extension DPP

The Oasis Institute x

Piedmont Triad Regional Council Area Agency on Aging x

Southwestern Connecticut Area Agency on Aging x x

Helpfulness of the Learning Collaborative Experience. In response to the question “How helpful was the learning collaborative in being able to implement or work toward implementation of Medicare Part B services?” there was a strong consensus among participants across both years that the experience was helpful. Eleven or half of respondents to this question (n=22) said it was “very helpful,” 10 said it was “somewhat helpful,” and 1 said it was “slightly helpful.” Comments provided in response to the helpfulness of the learning collaborative experience were extremely positive. Two respondents from the 2016 cohort said they wanted to see examples of other organizations that had been able to break even or make a profit before they felt comfortable investing the time and resources to implement the services. Below are a sampling of typical comments about the helpfulness of the learning collaborative: “Thank you for the valuable resources.”

• “Excellent discussion on costing out a project and validating the importance of the CBO philosophy and capacity.”

• “With so many intricacies and potential pathways, being in the learning collaborative was incredibly helpful in developing our implementation plan . . . the examples provided and advice we received from the NCOA team and the mentors were valuable to ensure that we were developing our program appropriately.”

• “Wonderful learning experience, giving all the information needed to implement a successful program!”

• “It was helpful because it provided the information to know about the process but

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. . . there are different challenges by state and organizations.” • “If we could build success in these learning collaboratives into our grant proposals or find

additional funding to pay for staff time to invest in the learning collaborative efforts, we would be able to do more on this. . . . Funding, plus one on one consulting, plus accountability, plus more sharing of how each of us are making it work . . . would be super-helpful.”

• “Materials were awesome. Would have built our confidence if there had been an example of an agency that had both become accredited and was actually turning a profit.”

Medicare Provider Status. Learning collaborative participants were offered two different options or models for how they could achieve Medicare reimbursement. They could become a Medicare provider themselves or partner with an existing Medicare provider through a contractual arrangement. Of the 23 participants across both years, 9 opted to become Medicare providers. Six of the 9 have been successful in achieving Medicare provider status, and 3 are still working toward or plan to work toward becoming a provider within the year. Three of the 6 organizations that have become Medicare providers indicated they have also established a contractual agreement with a Medicare provider, demonstrating a combined approach to Medicare reimbursement. Five participants are working toward developing a contract or plan to work toward developing a contract with a provider as their sole approach, and one participant is working on developing a contract with a provider, while simultaneously working toward becoming a Medicare provider. Table 4 below shows a list of the 14 participants who have been successful in becoming a Medicare provider or developing a contractual agreement with a Medicare provider, as well as those who are working toward one or both of these reimbursement models. Table 4. Medicare Provider Status of Organizations That Have Become a Medicare Provider, Have a Contractual Agreement with a Medicare Provider, or Are Working Toward One, the Other, or Both

Learning Collaborative Participant

Medicare Provider

Working Toward Becoming a Medicare Provider

Contractual Agreement with a Provider

Working Toward or Plan to Work Toward Developing a Contractual Agreement with a Provider

AgeOptions x Area Agency on Aging, Region One

x x

Centralina Area Agency on Aging

x x

Connecticut Department of Health

x x

Florida Health Networks x Jewish Family Service of Metropolitan Detroit

x x

Lake County Tribal Health Consortium

x x

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Learning Collaborative Participant

Medicare Provider

Working Toward Becoming a Medicare Provider

Contractual Agreement with a Provider

Working Toward or Plan to Work Toward Developing a Contractual Agreement with a Provider

Maryland Living Well Center of Excellence/MAC Inc.

x x

Michigan State University Extension

x

Oregon Wellness Network x Piedmont Triad Regional Council Area Agency on Aging

x

Senior Connection Center x Spectrum Generation/ Healthy Living for ME

x

North Central Texas Council of Governments

x

Participants were given the opportunity to describe their Medicare provider status. Their comments are summarized below:

• Florida Health Networks has a contractual agreement with a Managed Service Organization to handle billing and is in the process of securing a contractual agreement with a Medicare Advantage plan to serve as a referral system to enroll participants in CDSME classes.

• AgeOptions is exploring the option for an AADE version of DSMT with JenCare Medical Centers.

• Maryland Living Well Center of Excellence/MAC Inc. is working on developing contracts with Medicare providers to offer CCM.

• Area Agency on Aging, Region One has existing contracts with Medicare Advantage Plans and plans to leverage these relationships to enroll as a provider of HBAI services.

• Spectrum Generation/Healthy Living for ME has developed contracts to provide CCM. While the services are not yet being billed to Medicare, a contract is being developed with a Medicare provider who has agreed to provide reimbursement for CCM services.

• Southwestern Connecticut Area Agency on Aging has a contract for reimbursement outside of Medicare.

• Piedmont Triad Regional Council Area Agency on Aging serves as its own Medicare provider for DSMT/MNT and plans to expand the services to another county.

Reimbursement. Participants were asked to describe their current reimbursement status for Medicare Part B services either by billing Medicare directly or through a contractual agreement. Four participants have filed claims for reimbursement (Centralina Area Agency on Aging, Connecticut Department of Health, Mississippi State Department of Health, and Piedmont Triad Regional Council Area Agency on Aging), all for the DSMT benefit. Two of the 4 organizations have

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received reimbursement for the claims (Mississippi State Department of Health and Piedmont Triad Regional Council Area Agency on Aging). Nearly three quarters of participants (17) are still working toward reimbursement, while 2 participants indicated they are no longer working toward reimbursement. Three participants indicated the source of reimbursement. Two (Centralina and Piedmont) are being reimbursed by Original Medicare. Piedmont has also received reimbursement from two Medicare Advantage plans and is in the process of becoming approved as a network provider for two additional Medicare Advantage plans. One organization (Mississippi) has received reimbursement from Medicaid. The learning collaborative was designed to help participants make decisions for reimbursement that would best serve their organization. As noted by Piedmont, “Our organization was trying to decide if we should contract with a company to file claims or complete the filing on our own. Through guidance from the learning collaborative, we decided to enter our claims through the Medicare Administrative Contractor’s software and work with a clearinghouse for claim submission and tracking. This decision led to a low-cost and effective way to attain reimbursement.” Factors that Facilitated Success. Participants identified having written policies and processes for activities associated with delivering services as the lead factor in facilitating their success. Throughout the learning collaborative, there was an emphasis on the importance of written processes, including a homework assignment that involved developing written documentation and billing processes. Other key factors that participants attributed to facilitating their success included the following:

• support and commitment of the organization’s leadership;

• a dedicated program coordinator;

• reliable partners, e.g., Mississippi State Department of Health pointed out that the Diabetes Coalition of Mississippi laid the groundwork for obtaining Medicaid coverage;

• technical assistance, resources, and support from NCOA; and

• funding to support the efforts until the Medicare services are sustainable. Challenges. When asked what challenges affected their ability to achieve reimbursement, a large majority of participants who responded to this question (15 of 20) said they had difficulty developing partnerships with health care providers or health plans. Several participants indicated this challenge was related to health care entities not recognizing the value of the services they were offering, not considering the services a priority, or reluctance to take on the responsibilities associated with serving as a billing partner. Another challenge identified by a majority of respondents (11) was difficulty securing clinical supervision, which is a requirement for delivering Medicare Part B services. Participants were given three options as to how they could provide supervision. They could hire a clinician, contract with a clinician, or partner with another organization to secure the services of a clinician. Issues related to this challenge that surfaced were financial limitations and difficulty locating a clinician or a partner that would provide clinical services for oversight and supervision of the services. Additionally, half of respondents (10) identified other competing priorities within their organization as a major challenge. One participant noted,” We are working on many projects within our organization,” and it is challenging to ensure “we have good systems in place to manage this

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project.” A related organizational challenge encountered by 8 participants was human resource management, i.e., change in leadership, staff turnover, or insufficient staff to carry out the project. Other challenges included the following:

• partners who “backed out” or were not able to fulfill their commitment, • inadequate funding to continue the effort,

• issues related to controlling costs and determining a financially sustainable business model,

• putting the necessary processes in place to bill Medicare, and • insufficient referral sources or difficulty recruiting Medicare patients to fill classes.

What Participants Were Most Proud Of. When asked what they were most proud of accomplishing during or since the learning collaborative period, participants cited increased understanding about the Medicare benefits and the reimbursement process, as well as specific accomplishments toward making the stages of organizational change necessary to achieve reimbursement. A number of participants said they were most proud of accomplishments related to achieving reimbursement for DSMT. Four participants said they were most proud of becoming accredited (Philadelphia Corporation for Aging, Centralina Area Agency on Aging, North Central Texas Council of Governments, Lake County Tribal Health Consortium) or completing and submitting the application for accreditation (Florida Health Networks). Two participants were proud of their unique implementation approaches: Mississippi State Department of Health offered DSMT through public health clinics, while Florida Health Networks completed DSMT pilots with four different partners and is developing partnerships with health plans. Piedmont was proud of moving through all of the stages of organizational change to successfully achieve Medicare reimbursement. Similar to the accreditation process to offer DSMT, one participant (Oregon Wellness Network) was proud of becoming a Medicare Diabetes Prevention Program (DPP) Supplier, which entails going through a rigorous process to become recognized by the Centers for Disease Control and Prevention (CDC). While not a major focus of the learning collaborative, the benefits of offering DPP as an optional service, alongside DSMT, were discussed; and much of the learning content for the other benefits also applies to DPP. Other participants highlighted accomplishments related to billing and reimbursement. Sometimes even a seemingly small step forward was considered a major accomplishment because it involved a policy-level decision. As one participant (Senior Connection Center) noted, “My board of directors and I made the decision to pursue becoming a Medicare provider. This was a huge accomplishment, just making this decision.” Other accomplishments related to billing and reimbursement included the following:

• building internal capacity for reimbursement (Maryland Living Well Center for Excellence/ MAC Inc.),

• partnering with a federally qualified health center on a fee-for-service basis to offer diabetes self-management education (Southwestern Connecticut Agency on Aging),

• making strides in partnering with a Medicare Advantage plan to pay for its programs (Area Agency on Aging and Oasis), and

• developing a “fully launched network with a sustainability plan,” with some contracts in place (Spectrum Generation/Healthy Living for ME).

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Two participants said they were most proud of improving the way their CDSME programs were delivered. Jewish Family Service of Metropolitan Detroit trained staff in motivational interviewing and certified them as health coaches to offer chronic care management services and CDSME classes for the agency’s clients. South Dakota State University Extension was able to embed CDSME programs in the health care culture as a result of “developing much stronger partnerships with health care.” The above accomplishments demonstrate that participants gained knowledge and skills during the learning collaborative that could be adapted to their unique circumstances and would ultimately have far-reaching effects. Lessons Learned. When asked about their greatest lesson learned as a result of participating in the learning collaborative, respondents across both years concurred that they came to understand the complexity of Medicare reimbursement and the importance of having a full commitment from their organization and partners to make the initiative a priority. They gained an awareness of the importance of dedicating sufficient human and financial resources to the effort, rather than relying on one person to “go it alone.” Likewise, participants learned that they needed to enlist buy-in and support from all levels of their organizations: the executive director, board members, managers, and staff, including financial/billing personnel. There was a realization that with dedicated time, resources, and effort, they could work through the barriers and ultimately achieve success. Additionally, participants gained an understanding of the need to develop strategies to overcome common barriers to implementing Medicare Part B Services, including how to address concerns or objections from potential health care partners that didn’t understand the value of the services or were hesitant to enter into a contract. One participant (Piedmont Triad Regional Council on Aging) explained, “Every plan, beneficiary, community partner, and situation are a little bit different and provide a new lesson learned. Patience and trial and error are important components of implementing and receiving reimbursement from Medicare. There is always more to learn and improve.” Several other participants said they learned that they needed a reliable referral network. One participant (Mississippi State Department of Health) elaborated, “Just because it's reimbursable doesn't mean the patients will come.” Another (AgeOptions) explained, “We…need…a population health approach with a major insurer or health care provider” with specific criteria for referrals, rather than relying on individual doctors to refer patients to the services. How NCOA Can Continue to Support Participants. When asked how NCOA could continue to support their efforts, participants across both years strongly concurred that they want and need ongoing support. They described a variety of types of support that they would like to receive, including webinars, training, and resources, as well as continued access to the online community platform. Participants also expressed a need for continued technical assistance to respond to their individual questions and to help them navigate through the complex process of achieving reimbursement and developing sustainable business models for their services. Specifically, they indicated that they need more “hands on” technical assistance with the following:

• the nuances of developing partnerships with different types of health care organizations, including identifying appropriate partners, initiating contact, and negotiating agreements and contracts to provide Medicare Part B services;

• overcoming partnership challenges; • building referral networks;

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• working through the details of billing and reimbursement; • developing and refining appropriate implementation models, including conducting pilots

with health care partners; and • selecting and negotiating with third party contractors to purchase a secure integrated

technology platform for documentation, tracking, and billing.

Because Medicare regulations are constantly evolving, participants indicated that they want NCOA to provide updates to keep them abreast of changes. Additionally, they requested opportunities to learn from one another and share best practice examples and success stories, including the perspective of health care partners. Finally, a couple participants said they would like to see NCOA serve as a broker to facilitate linkages between a group of community-based organizations and a third party integrated technology platform vendor. The intent behind this suggestion is to lower the cost of services by creating volume, thereby achieving an economy of scale. Additional Comments. Participants were given an opportunity to provide additional comments to clarify the current status of their implementation efforts. They reiterated that while the work is difficult and they have encountered a number of challenges, they remain firmly committed to the process and are optimistic about the future. They acknowledged the benefits of the learning collaborative and expressed gratitude to NCOA for the support. Several participants also shared plans for their next steps. A sampling of responses are highlighted below:

• “I very much appreciate the time I spent in the collaborative learning and working on this process. We haven't given up yet . . . we have some new agencies we are working with that might be able to make this a go, and that is exciting!”

• “We have heard positive feedback from our first program, and we are looking to continue offering these services and expanding into a neighboring county. Support from NCOA has provided a wonderful resource to aid in our success.”

• “We continue to work towards obtaining accreditation and testing pilots for Medicare reimbursement.”

• “We are working on being enrolled to bill for the services.” • “We plan to be accredited and become a Medicare provider this year. . . .We also plan to

. . . partner with a clinic as our biller until we can become a stand-alone provider.” • “Your work is making our work possible in the medical field. Thank you.”

6. CONCLUSIONS AND RECOMMENDATIONS The survey findings indicate that the process of achieving Medicare reimbursement is a complex,

yet worthwhile endeavor for community-based organizations to undertake to help sustain CDSME

programs. This work requires a significant commitment of time, effort, and resources from a lead

organization, as well as willing partners to assist with specific roles and responsibilities. The learning

collaboratives offered by NCOA were quite helpful to participants in understanding the specific

Medicare benefits and gaining the knowledge and skills to embark on the path toward accreditation

(for DSMT) and reimbursement.

As a result of the learning collaborative experience, participants have been able to shift their

organizational focus from relying solely on Older Americans Act and grant funding to sustain their

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CDSME programs to serving as providers of health care services. This transition itself was a

significant accomplishment that enabled organizations to take incremental steps and complete

specific stages of organizational change toward reimbursement for their services.

Participants across both years have made varying degrees of progress toward their goals and

remain firmly committed to the process, even though they have encountered a number of

challenges since the learning collaboratives ended. Nearly all participants are actively implementing

one or more Medicare Part B services. The majority are still working toward reimbursement. A few

have actually filed claims or received reimbursement. A large majority of the organizations focused

on DSMT have become accredited, and others are continuing to work toward accreditation. A little

more than a quarter of organizations have become Medicare providers and/or developed a

contractual agreement with a Medicare provider, while a number of others have taken important

steps toward becoming a provider or developing a contract with a provider to secure

reimbursement for their services.

The survey data provide ample evidence that participants value and have benefited from the

learning collaborative experience. On the whole, they have made significant organizational changes

toward the goal of reimbursement. However, the overall trajectory toward reimbursement, and

ultimately integrated, sustainable CDSME program networks, requires a long-term vision and

commitment from community-based organizations and from NCOA to support their efforts. The

survey findings point to a need for ongoing support and technical assistance to help participants

overcome implementation challenges and maintain forward momentum. The recommendations

below are offered to support the 2016 and 2017 learning collaborative participants:

• Recommendation 1 – Continue to provide access to the online community. Learning

collaborative participants would benefit from accessing archived resources, interacting

with their peers, and receiving online technical assistance from NCOA via the existing

Salesforce platform. The following specific activities are suggested: a) post questions,

reminders, topic discussions/reviews, and updates on a regularly scheduled basis (e.g.,

weekly or bi-weekly) to engage participants and encourage them to share their

approaches, challenges, successes, and resources; and b) highlight existing resources that

can help participants overcome implementation challenges.

• Recommendation 2 – Expand the list of resources to increase participants’ knowledge

and understanding of the various Medicare Part B benefits and reimbursement process.

New resources that would be helpful include implementation models, billing and

reimbursement guidance, other Medicare benefits (e.g., DPP or psychiatric collaborative

care model) that can be offered in conjunction with those currently being implemented,

and success stories to highlight participants’ accomplishments.

• Recommendation 3 – Offer webinars on a variety of topics to enhance participants’

understanding of Medicare Part B benefits and the reimbursement process. Webinars

that feature participants’ successes would provide an opportunity for peer-to-peer

learning and interaction. Additionally, brief refresher webinars or interactive training

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modules on specific topics, with time allotted for meaningful discussion, would be useful

to reinforce concepts and further learning.

• Recommendation 4 – Form several small work groups based on Medicare type to guide

participants through the remainder of the stages of change. Formal work groups would

provide structure, accountability, and real-time support to help participants overcome

their challenges and continue moving toward their goals.

• Recommendation 5 – Offer one-on-one technical assistance via email and brief phone

call sessions as needed to respond to specific concerns or questions posed by

participants.

• Recommendation 6 – Determine whether NCOA could serve in a broker role to facilitate

agreements between groups of community-based organizations and one or more

integrated technology platform vendors.

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7. APPENDIX: SURVEY QUESTIONNAIRE: Please see below.

NCOA is administering this survey to 2016 and to 2017 Medicare Reimbursement LearningCollaborative participants to gather information about your current status related to providing andreceiving Medicare reimbursement for DSMT, HBAI, and/or CCM services. We are interested inlearning about your progress, challenges, and plans to develop viable business models forMedicare Part B services, as well as your recommendations for future technical assistance andresources to support your efforts.

Your responses will be used to inform our integrated health care work and to develop a report ofthe findings, which will be disseminated by NCOA to the Administration for CommunityLiving/Administration on Aging (ACL/AoA and the vast network of partners through NCOA’s Centerfor Healthy Aging website.

We ask that only one person (the lead, co-lead, or successor/designee) respond to the survey foreach CBO, even if your organization served as the primary participant in two learningcollaboratives (e.g., HBAI and DSMT in 2016). Please coordinate your responses between your leadand co-lead, as well as with your team/partners as needed to ensure accurate and completeinformation.

Please submit your responses by March 19, 2019. The survey should take about 20 minutes of yourtime. If you have any questions about the survey, please contact Cora Plass atcora.plass@ncoa.org.

Thank you.

1. Name of your organization:

2. What was your role with the learning collaborative?

Lead

Co-Lead

Lead and Co-Lead (2016 only if invloved in both DSMT and HBAI)

Successor or Designee (if Lead and Co-Lead are no longer available)

3. In what year did you participate?

2016

2017

4. What benefit was your primary focus during the learning collaborative? (If your focus changed during thelearning collaborative, please select only your final focus.)

DSMT

HBAI

DSMT and HBAI (2016 only)

CCM (2017 only)

Comments:

5. Please indicate your or your partner entity’s accreditation status for diabetes self-managementeducation and support services (DSMES): (Select all that apply)

We attained accreditation before the learning collaborativeended

We have attained accreditation since the learningcollaborative ended

We are still working on attaining accreditation

We have decided not to pursue accreditation

We have let our accreditation lapse

Please briefly describe your implementation status:

6. Which Medicare Part B service(s) are you currently implementing (whether or not you are beingreimbursed): (Select all that apply)

DSMT

HBAI

CCM

Other (please specify below)

None yet, but we are working toward implementation. Whichbenefit? (please specify below)

None and we are NOT working toward implementation

Comments:

7. How helpful was your learning collaborative experience in being able to implement or work towardimplementation of this Medicare Part B service, even if it wasn’t your primary focus?

Very helpful

Somewhat helpful

Slightly helpful

Not at all helpful

I did not participate in the learning collaborative

Comments:

8. Are you currently enrolled as a Medicare Part B provider?

Yes

No

Not yet, but we are in the process of becoming a provider

Comments:

9. Do you currently have a contractual agreement with a Medicare Part B provider to offer DSMT, HBAI, orCCM?

Yes

No

Not yet, but we are in the process of developing a contractual agreement with a Medicare provider

Please briefly describe your reimbursement status:

10. Which of the following best describes your current reimbursement status for Medicare Part B services(DSMT, HBAI, and/or CCM), either directly or through a contractual arrangement?

We are receiving reimbursement

We have filed claims but not yet received payment

We are still working toward reimbursement

We are NOT receiving reimbursement or working toward it

Comments:

11. For which Medicare Part B service(s) have you filed claims or are you receiving reimbursement?(Select all that apply)

DSMT

HBAI

CCM

Other (please specify in Comments below)

Comments:

12. How are your services being reimbursed? (Select all that apply)

Medicare (original)

Medicare Advantage

Medicaid (State plan or Medicaid Managed Care)

Commercial Health Plan

Other (please specify in the Comments below):

Comments:

13. How helpful was your learning collaborative experience in being able to file claims and attainreimbursement for the service(s) you provide, whether or not it was your primary focus?

Very helpful

Somewhat helpful

Slightly helpful

Not at all helpful

I did not participate in the learning collaborative

Please briefly describe your most significant facilitating factor(s).

14. Which of the following factors have facilitated your success? (Select all that apply).

Support and commitment of our organization’s leadership

A dedicated program coordinator

Reliable partners

A unique niche that we can fill in the marketplace to deliver thisservice in our area

Funding that can support us until the services are sustainable

Steady referral sources

Written policies and processes for activities associated withoffering the services

Effective communication between the front and back offices

Technical assistance, support, and resources from NCOA

Other (please specify below):

Please briefly describe your most significant challenge(s).

15. Which of the following challenges have affected your ability to receive reimbursement? (Select all thatapply)

Difficulty securing the necessary clinical supervision

Too much competition in the marketplace

Other competing priorities within our organization

Change in leadership within our organization

Loss of staff, staff turnover, or inadequate human resources

Inadequate funding to continue our efforts

Difficulty developing partnerships with health care providersor health plans

One or more key partner(s) did not follow through with theircommitments or decided not to work with us

Insufficient referral sources

Other (please specify below):

16. We want to understand more about your current status with implementing and receiving reimbursementfor Medicare Part B services. Please briefly describe what you are most proud of since the learningcollaborative ended:

17. Please briefly describe your greatest lesson learned as a result of your experience working towardimplementation and reimbursement of Medicare Part B services:

18. How can NCOA best support your continued efforts with Medicare Part B services and/or withcommunity-integrated health care more broadly?

19. Please provide any final remarks or further information to help us understand your current status withMedicare Part B services: