The Integrated Care Resource Center, an initiative of the Centers for Medicare & Medicaid Services Medicare-Medicaid Coordination Office, provides technical assistance for states coordinated by Mathematica Policy Research and the Center for Health Care Strategies.

Working with Medicare Medicare & Medicaid Nursing Facility Benefits:

The Basics and Options for Improved Coordination and Quality

May 3, 2018

2:00-3:00 pm Eastern Time

Agenda

• Welcome and Introductions

• The Basics: Medicare Skilled Nursing Facilities (SNFs), Medicaid Nursing Facilities (NFs), and Resident Characteristics

• Fee-for-Service (FFS) and Managed Care Payment Basics, and Options to Address Coordination and Quality Issues

• Questions and Answers

• Concluding Remarks

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Presenters

• Danielle Chelminsky, ICRC

• Erin Weir Lakhmani, ICRC

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Medicare and Medicaid Spending on Dually Eligible Beneficiaries

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Dually Eligible Beneficiaries as a Share of Medicare and Medicaid Enrollment and Spending, CY 2013

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Note: Enrollment counts include number of beneficiaries ever-enrolled in CY 2013. Spending and enrollment totals include full and partial benefit dually eligible beneficiaries. Spending excludes program administration. Medicaid spending excludes payments by state Medicaid programs for Medicare premiums.SOURCE: MedPAC–MACPAC. “Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid.” Exhibit 4. January 2018.

FFS Spending on Full Benefit Dually EligibleBeneficiaries by Type of Service, 2013

Note: Medicare spending percentages include only Part A and Part B services and do not sum to 100 because spending is shown only for selected services. Medicare Part D spending is not included. Medicaid managed care capitation includes payments to limited-benefit managed care plans for behavioral health, transportation, and/or dental services.SOURCE: MedPAC–MACPAC. “Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid.” Exhibits 3, 14, and 15. January 2018.

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Medicaid and Medicare Share of Total Payments to Nursing Facilities, 2016

7Note: Total payments include both nursing facilities and continuing care retirement communities. SOURCE: National Health Expenditures Projections, 2017-2026. Table 13. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html

Nursing Facility Benefits under Both Programs

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Medicare and Medicaid Coverage of Nursing Facility Care

Medicare Coverage: Skilled Nursing Facilities (SNFs)• Short-term skilled nursing care and rehabilitation services• Up to 100 days of SNF care per spell of illness• Ordered by a physician• Requires a 3-day hospital stay to qualify• Includes skilled nursing, rehabilitation, medical social services,

drugs/biologicals, durable medical equipment, and bed and board

Medicaid Coverage: Nursing Facilities (NFs) • Long-term custodial care • Safety net for persons who cannot afford the cost of NF care • Mandatory service for ages 21+/optional for under age 21• Includes room and board, skilled nursing care and related services,

rehabilitation, and health-related care• Optional state coverage of therapies, such as physical therapy,

occupational therapy, and speech pathology and audiology services

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Medicare and Medicaid Nursing Facility Eligibility in FFS

Medicare SNFs Medicaid NFs

Program Eligibility

• Eligible for Medicare Part A because of age (65+) or disability

• Financial eligibility(income and assets)

• Categorical or medically needy eligibility

• Variation across groups and states

BenefitEligibility

• Must be preceded by a 3+ dayhospital stay

• Require skilled nursing or skilled rehab daily (e.g., physical therapy following stroke, wound treatment following surgery)

• Level of care criteria:• Functional limitations

in (ADLs/IADLs)• Cognitive capacity• Need for supervision

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Beneficiary Responsibility for Nursing Facility Costs

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Medicare Cost-Sharing for SNF

Medicaid Beneficiary Responsibility for NF

• Days 1-20: $0• Days 21-100: $167.50 per day

(2018)

• All income (minus personal needsallowance) applied to the cost of care

• Special rules apply to community spouses

Who Pays These Costs for Dually Eligible Beneficiaries?

• Medicaid pays Medicare cost-sharing for most dually eligible beneficiaries

• Other payers might include retiree insurance, Medigap, or out-of-pocket

• Beneficiaries’ income may come from a variety of sources such as Social Security, Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), and pensions

Characteristics of Nursing Facilities and Residents

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Medicare & Medicaid Certified Nursing Facility Statistics, 2014/2016

• 14,409 nursing facilities (or 92%) participated in both Medicare and Medicaid (2014)

• About 13% had 50 or fewer beds, and 50% had 100+ beds*

• Combination of SNF and NF beds

• Profit Status

• For profit: 70% of nursing facilities and 72% of beds

• Non-profit: 24%

• Government: 6%

• Of All Medicare-Certified Facilities (2016)

• 96% - Free-standing facilities

• Provide both SNF and NF services

• Only a limited number of SNF patients on a given day, but higher per diem reimbursement than NF patients. Higher turnover of SNF patients; NF patients stay longer.

• 4% - Hospital-based facilities

• Dedicated SNF beds

• Swing beds in some rural hospitals

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* Describes all nursing facilities, not just dually Medicare and Medicaid certified. SOURCE: CMS Nursing Home Compendium, 2015. Figures 1.2, 1.3 and 1.4. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/nursinghomedatacompendium_508-2015.pdf.Medicare Payment Advisory Commission (MedPAC) and Medicaid and CHIP Payment and Access Commission (MACPAC). Report to Congress. “Medicare Payment Policy.” Table 8-1. March 2018:http://www.medpac.gov/docs/default-source/reports/mar18_medpac_entirereport_sec.pdf?sfvrsn=0.

Characteristics of All Residents in Medicare- and/or Medicaid-Certified Nursing Facilities, 2014

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Note: Data describe all residents, regardless of payer or program participation.SOURCE: CMS Nursing Home Compendium 2015. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/nursinghomedatacompendium_508-2015.pdf

Demographics• 42% ≥ age 85, 16% < age 65• 66% are women• 78% are white

Impairments• 20% - no limitation in ADLs• 63% - 4-5 ADLs

Cognitive impairment• 37% severe• 25% moderate• 39% mild

Common Scenarios for Entry into Medicare SNF and Medicaid NF

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Doorways into Medicare SNF Stay Doorways into Medicaid NF Stay

• Experience an acute episode that results in an ED visit, followed by a hospital stay of ≥ 3 days.

• Experience ≥ 3 day hospital stay, transferred to community or other post-acute setting, transferred to SNF within 30 days.

• Prior to NF stay, individual may be receiving home- and community-based services at home or in assisted living. Becomes increasingly frail and in need of higher level of care. Admitted to NF.

• Transferred from Medicare SNF stay to extended stay as private pay. Deplete income and assets on care until qualify for Medicaid.

• Already dually enrolled and residing in NF. NF sends resident to hospital. Return for skilled care as Medicare SNF. Then back to NF.

Medicare and Medicaid SNF/NF Payment Basics in FFS

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Medicare SNF Prospective Payment System

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SOURCES: Medicare Payment Advisory Commission (MedPAC). “Report to the Congress: Medicare Payment Policy.” Chapter 8: Skilled Nursing Facility Services. March 2018: http://www.medpac.gov/docs/default-source/reports/mar18_medpac_entirereport_sec.pdf?sfvrsn=0; MedPAC. “Skilled Nursing Facility Services Payment System.” Payment Basics, October 2017: http://medpac.gov/docs/default-source/payment-basics/medpac_payment_basics_17_snf_finalb4a411adfa9c665e80adff00009edf9c.pdf?sfvrsn=0; Medicare Learning Network SNF PPS Fact Sheet, November 2016: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/snfprospaymtfctsht.pdf

Medicare SNF Payments: Recent Trends• CMS Proposed Changes to SNF PPS for 2018/2019*

• Base payments more on needs of medically complex patients and less on therapies provided (starts 10/1/19)

• Incentive payments (+/-) for reducing all-cause 30-day hospital readmissions (starts 10/1/18)

• High and sustained Medicare SNF margins (difference between Medicare payments and provider costs)• Average margin over 10% for 17 years in a row (11.4% in 2016)• ¼ of freestanding SNFs had margins of 20.2% or higher in 2016

• Costs and margins varied widely among facilities• Ownership (for-profit facilities larger margins than nonprofit)• Size (larger facilities have higher average margins than smaller)• % of intensive therapy days vs. % of medically complex patients

• Medicare Advantage pays considerably less than FFS• Medicare FFS payments received in 2017 by three large nursing home

companies averaged 21% higher than Medicare Advantage rates

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*Centers for Medicare & Medicaid Services, “Medicare proposes fiscal year 2019 payment & policy changes for skilled nursing facilities.” (April 27, 2018). Available at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-04-27-4.html

SOURCES: Medicare Payment Advisory Commission (MedPAC). “Report to the Congress: Medicare Payment Policy.” Chapter 8: Skilled Nursing Facility Services. March 2018: http://www.medpac.gov/docs/default-source/reports/mar18_medpac_entirereport_sec.pdf?sfvrsn=0; Centers for Medicare & Medicaid Services, “Medicare proposes fiscal year 2019 payment & policy changes for skilled nursing facilities.” (April 27, 2018). Available at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-04-27-4.html

FFS Medicaid Traditional NF Payment Approach

• States establish reimbursement methodologies and rates within broad federal guidelines

• §1902(a)(30)(A) of the Social Security Act requires that Medicaid nursing facility payments be“consistent with efficiency, economy, and quality of care and…sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area”

• Under FFS, NFs are paid directly by states

• Retrospective (interim rates + cost settlement) or prospective (rate determined prior to services, final reimbursement when services billed)

• Cost-based or price-based methodology (or a combination of both)• Adjustments based on acuity (case-mix), peer group (groups of facilities of same size and in the

same geographic area), or for high need patients

• Supplemental payments, incentive payments

• Facility-specific, statewide, peer group

• Rate setting methodology varies significantly among states

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SOURCES: §1902(a)(30)(A) of the Social Security Act: https://www.ssa.gov/OP_Home/ssact/title19/1902.htm; Medicaid and CHIP Payment and Access Commission (MACPAC). “Medicaid Nursing Facility Payment Policy.” April 2016. Issue Brief. Available here: https://www.macpac.gov/wp-content/uploads/2016/04/Medicaid-Nursing-Facility-Payment-Policy.pdf; Navigant. “Nursing Facility Payment Method Options.” August 9, 2016. Available here: https://11042-presscdn-0-63-pagely.netdna-ssl.com/wp-content/uploads/indres/080916flahcanhpps.pdf

Some Illustrative Features of Medicaid NF Payment Policies, 2014

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SOURCE: MACPAC. “State Medicaid Payment Policies for Nursing Facility Services.” October 2014: https://www.macpac.gov/publication/nursing-facilty-payment-policies/

Notes: Cost-based payments are based primarily on reported past facility costs, while price-based payments are based on estimates of future costs. Facility-specific rates are based on a composite estimate of the costs of all residents of a facility, while resident-specific rates vary with individual residents. Bed-hold days are days for which Medicaid pays NFs all or part of the regular per diem rate to keep a bed open for a resident’s return. In this table, states include the District of Columbia.

Basic Payment Policy Basis of Rates Duration of Bed Holds

During HospitalizationsAcuity-Based Payment

System

Quality/Pay-for-Performance

Incentives

Type # of States

Type # of States

Type # of States

Type # of States

Type # of States

Cost-Based 30 Facility Specific

43 <10 days 12 RUGs-Based

33 Yes 23

Price-Based 12 Resident Specific

7 10 – 19 days 20 State specific

7 No/NoneFound

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Both 9 Statewide 1 20 – 30 days 1 No/None Found

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Not To Exceed Hospitalization Days

1

No/None Found

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Medicaid NF Payments: Recent Trends

• In 2017, 36 states and the District of Columbia increased Medicaid payment rates for nursing facilities • More than in 2016

• 14 states froze rates; 1 state reduced rates

• Medicaid revenue per day reached its highest point in 5 years

• 28 states and the District of Columbia said that they would increase rates in 2018• 20 states planned to freeze; 2 states planned to reduce

• 1 state was undecided at the time of request

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SOURCE: Medicare Payment Advisory Commission (MedPAC). “Report to the Congress: Medicare Payment Policy.” Chapter 8: Skilled Nursing Facility Services. March 2018, pp. 231-232: http://www.medpac.gov/docs/default-source/reports/mar18_medpac_entirereport_sec.pdf?sfvrsn=0

Challenges with FFS Reimbursement System for SNF/NF Benefits

• Incentives to hospitalize residents• Medicare SNF rates are generally substantially higher than

Medicaid NF rates. To get higher SNF rate, residents must be hospitalized for 3 days.• May lead to unnecessary hospitalizations to renew Medicare spell of illness and

bring in higher reimbursement

• State bed-hold policies for NFs• Pays NFs for empty beds while residents are hospitalized• But helps ensure residents can return to their former residence following

hospitalization

• Insufficient clinical staff in NFs to treat complex residents on site, especially on weekends• Can result in avoidable hospitalizations

• Insufficient linkages between SNF/NF care and acute care (physicians, hospitals, prescription drugs)• Challenges remain for states to effectively use data on Medicare FFS utilization

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Managed Care Payment Options for SNFs and NFs

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Health Plan Reimbursement Options for Nursing Facilities

• Under Medicaid and Medicare managed care arrangements, states and/or CMS typically pay health plans a per-member, per-month (capitated) rate for all covered services

• Although many plans mimic FFS payment structure when negotiating rates with SNFs and NFs, they have flexibility to design other payment approaches and pay amounts that differ from FFS

• When one managed care organization is responsible for Medicare and Medicaid benefits, it reduces financial incentive to ‘cost-shift’ via unnecessary hospitalizations

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Health Plan Reimbursement Options for Nursing Facilities (cont’d.)

Health plans can:• Waive SNF three-day hospital stay requirement• Limit payment to NFs for “bed-hold days”• Use savings from decreased avoidable hospitalizations and

SNF days to fund additional on-site clinical staff at NFs • Pay NFs more for high-need residents and less for lower-need

residents• Can include extra short-term payment for services

needed to avoid unnecessary hospitalizations• Can reduce payment “cliffs” when residents shift

between Medicare and Medicaid benefits• Encourage use of HCBS in lieu of institutional care,

particularly for lower-need residents• Make performance-based incentive payments to NFs

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State and Health Plan Options to Address SNF and NF Coordination

and Quality Issues

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Motivation for States and Managed Care Plans to Change the Status Quo• Improved quality of care in NFs can:

• Lead to improved health outcomes and quality of life for individuals

• Contain spending for states and health plans

• Mechanisms:• Reduce triggers for avoidable hospitalizations (including

the health and financial risks associated with such stays)

• Support care management for SNF/NF residents

• Increase individuals’ quality of life in SNF/NFs

• Reduce avoidable costs associated with SNF/NF care

State Opportunities Under Integrated Care ProgramsStates in which one managed care entity is at risk for hospitalizations, SNF/NF stays, and other Medicare and Medicaid benefits for dually eligible enrollees – as in the CMS Financial Alignment Initiative or in states with Fully Integrated D-SNPs (FIDE SNPs) – can work with these health plans to:

• Reduce avoidable hospitalizations and emergency room use for SNF/NF residents

• Operate SNF and NF benefits more seamlessly• Improve care transitions between SNFs/NFs, hospitals, and the

community• Increase use of home-and community-based services as

alternatives to SNF/NF services• Improve monitoring and utilization of Part D prescription drugs,

especially in NFs

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State and Health Plan Tools to Improve Quality of Care in NFs• Provide on-site clinical staff in nursing facilities• Use state contracted and/or health plan staff and

networks to support transitions into the community• Designate high-performing facilities as “centers of

excellence”• Share quality measures with facilities, even if they are

not linked to payment• Promote evidence-based models of care that raise the

bar on quality• e.g., greater use of care coordination tools like INTERACT

• Increase use of electronic e-prescribing or certification• Can reduce medication errors, drug and allergy interactions

and therapeutic duplication

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Value-Based Payment (VBP)• States and managed care plans increasingly link financial rewards to

demonstrated value• MACPAC identified 23 states using VBP programs to incentivize quality in

nursing homes in 2014

• ICRC interviewed 6 states and 5 managed care plans in early 2017 –TA Tool: http://www.integratedcareresourcecenter.com/PDFs/ICRC_VBP_in_Nursing_Facilities_November_2017.pdf

• States can either:• Design their own VBP approach, or • Encourage managed care plans to do so

• Most state or plan VBP approaches use a defined set of measures and benchmarks that reward quality with specified payment• Some allow managed care plans or providers to identify a strategy that fits

their needs and earn payment relative to the proposed design

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VBP Framework and Measuring Quality

• All VBP approaches have three key components:• Quality or performance measures• Benchmarks or targets• Incentives

• Performance measures used in state VBP initiatives: • Clinical care quality (e.g., vaccination rates, use of antipsychotics, use of

restraints, pressure ulcers, falls, and urinary tract infections)• Resident and family experience (from surveys on quality of life)• Staffing (e.g., staff time devoted to care, staff retention rate)• Utilization (e.g., avoidable inpatient admissions, readmissions within 30 days)• Administrative compliance (e.g., submitting accurate data or payment)

• Source data can include: • Claims, encounters, state surveys, or other administrative data (e.g.,

compliance reports)• CMS’ CASPER/OSCAR, Minimum Data Set (MDS), or Nursing Home Compare

Star Ratings• State NF quality report cards

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Lessons for States Designing VBP for NFs

• Payment: • Over time, continue to increase the size of payments available• Consider adjustments to the structure of NF reimbursement

• Quality measures: • Align measures in VBP programs with those reported in Nursing Home

Compare Star Ratings or used in the Medicare SNF VBP program• Standardize data collection methods or instruments across facilities• Approach the quality measures that inform VBP as a work in progress

and adjust over time as needed

• Administration: • Carefully select stakeholders to be involved in designing the program• Provide technical assistance to participating facilities• Evaluate program outcomes

CMS Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents – Phase 1

• Enhanced Care and Coordination Provider (ECCP) organizations in seven states (AL, IN, MO, NE, NV, NY, and PA), 144 participating facilities

• Results from Phase 1 final evaluation:• Decline in all-cause hospitalizations (all 7 states, statistical significance in 6)• Decline in Medicare expenditures (6 states, statistical significance in 4)

• Strategies of most successful models (IN, MO, and PA): • Strong role of Initiative-funded nurses

• Consistent, hands-on clinical care led to changes in facility culture, support for reducing avoidable hospitalizations, and buy-in from facility staff

• Importance of strong building relationships between nurses and staff, and between nurses and primary care providers

• Initiative components that participating facilities were most likely to continue• INTERACT tools, medication review focused on reducing antipsychotic medications,

quality improvement efforts to reduce avoidable admissions, and use of advance care planning/advance directives

• Potential challenges to implementation• Staff turnover, consistent buy-in among physicians, pressure from family for hospitalizations,

difficulty with new technology, facility leadership support, time of initiative implementation

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SOURCE: “Evaluation of the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents: Final Report.” September 2017. Available here: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/NFPAHFinalReport092017.pdf

CMS Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents – Phase 2

• 7 states (AL, CO*, IN, MO, NV*, NY, and PA)* HealthInsight Nevada Admissions and Transitions Optimization Program is working with facilities in Colorado and Nevada

• Testing new payment model • Payments to facilities and practitioners to provide higher

level of care on site at nursing facilities• Payments for nursing facility services; practitioner diagnosis,

certification, and treatment; and practitioner care coordination/caregiver engagement

• Targeting residents with six qualifying conditions• Pneumonia, congestive heart failure, COPD/asthma, skin

infection, fluid or electrolyte disorder/dehydration, urinary tract infection

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SOURCE: “Evaluation of the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents –Payment Reform: First Annual Report: February 2018. Available here: https://downloads.cms.gov/files/cmmi/rahnfr-phasetwo-firstannrpt.pdf

How States and Health Plans Can Use Results From the CMS Initiative

• CMS Initiative is conducted in FFS settings• Aimed at changing NF behavior

• States and health plans, as payers for NF services, can:• Use VBP approaches to tie payment to NF performance

and quality• Provide incentives for:

• Use of nurse practitioners, INTERACT tools, advance care planning/advance directives

• Reductions in use of antipsychotics, avoidable hospitalizations

• If states take the lead in FFS, health plans can build on that and innovate

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Examples of Resources Commonly Used by CMS Nursing Facility Initiative Participants

Resource Description Link

INTERACT (Interventions to Reduce Acute Care Transfers) Tools

INTERACT is a quality improvement program focused on management of acute change in resident condition. Includes tools for quality improvement, communication, decision support, and advance care planning

http://www.pathway-interact.com/interact-tools/interact-tools-library/interact-version-4-0-tools-for-nursing-homes/

National GuidelineClearinghouse

Agency for Healthcare Research and Quality clearinghouse containing summaries of evidence-based clinical practice guidelines

https://www.guideline.gov/

How States Can Expand Access to Palliative Care

Health Affairs blog post (January 2017) explaining the value of palliative care and strategies states can use to advance palliative care

https://www.healthaffairs.org/do/10.1377/hblog20170130.058531/full/

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Examples of Resources Commonly Used by CMS Nursing Facility Initiative Participants

Resource Description Link

American GeriatricsSociety Beers Criteria 2015

Lists of potentiallyinappropriate medications for older adults

https://geriatricscareonline.org/ProductAbstract/american-geriatrics-society-updated-beers-criteria-for-potentially-inappropriate-medication-use-in-older-adults/CL001

CMS Webinar –Behavioral Health and Antipsychotics

CMS Webinar about improving behavioral health treatment and reducing antipsychotic use in nursing facilities

https://www.youtube.com/watch?v=U1_rpO0bwbM&list=UUhHTRPxz8awulGaTMh3SAkA&index=3&feature=plcp

CDC MedicationSafety Program

Website with information and resources regarding medications and adverse drug events

https://www.cdc.gov/medicationsafety/

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Examples of Resources Commonly Used by CMS Nursing Facility Initiative Participants

Resource Description Link

TeamSTEPPS for Long-Term Care

Agency for Healthcare Research and Quality curriculum to improve patient safety, teamwork, and communication skills among healthcare professionals

https://www.ahrq.gov/teamstepps/longtermcare/index.html

ReadinessAssessment and Developing Project Aims

Health Resources and Services Administration (HRSA) resource on readiness assessments in quality improvement programs

https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/readinessassessment.pdf

“Oral Health in Ageing Societies” (WHO)

World Health Organization report on integration of oral health and general health

http://www.who.int/oral_health/events/Ageing_societies/en/

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Examples of Resources Commonly Used by CMS Nursing Facility Initiative Participants

Resource Description Link

Data Collection Tracking Tools

National Nursing Home Quality Improvement Campaign tools to assist nursing facilities with tracking a variety of organizational and clinical metrics for data-driven quality improvement projects

https://www.nhqualitycampaign.org/trackingTools.aspx

“What is Telehealth”

Telehealth Resource guide with practice guidelines, toolkits and other resources

https://www.healthit.gov/sites/default/files/telehealthguide_final_0.pdf

Performance Improvement Plan Launch Checklist

CMS checklist to ensure importance steps have been executed before launching a performance improvement project

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/PIPLaunchChecklistdebedits.pdf

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About ICRC

• Established by CMS to advance integrated care models for dually eligible beneficiaries

• ICRC provides technical assistance (TA) to states, coordinated by Mathematica Policy Research and the Center for Health Care Strategies

• Visit http://www.integratedcareresourcecenter.com to submit a TA request and/or download resources, including briefs and practical tools to help address implementation, design, and policy challenges

• Send other ICRC questions to: integratedcareresourcecenter@chcs.org