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TI 2.0 Kick-Off Meeting

Session 2: Health Information Exchange (HIE) & Closed Loop Referral System (CLRS)

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Introductions

  • Jane Otenyo, Project Manager, Targeted Investments Program, AHCCCS
  • Susan Podshadley, Program Director, Whole Person Care Initiative, AHCCCS
  • Kristina Belinte, SDOH Senior Advisor, Contexture
  • Hector Araujo, Community Engagement Manager, Unite Us
  • Jayme Pina, Director, Development and Engagement, Contexture
  • Margaret Hackler, VBP/DAP Manager, AHCCCS

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AHCCCS Whole Person Care Initiative

Susan Podshadley

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AHCCCS & Whole Person Care

  • AHCCCS’ Whole Person Care Initiative is our next step toward integrated care
    • Focused on ways to improve the Health-Related Social Needs of members
  • Health-Related Social needs include:
    • Housing & Basic Amenities
    • Food
    • Transportation
    • Income, Employment & Job Security
    • Education & Childhood Development
    • Justice/Legal Support
    • Interpersonal & Environmental Safety
    • Social Isolation, Social Support, & Non-discrimination
    • Access to Outdoor Spaces & Parks

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Why is AHCCCS Addressing Health-Related Social Needs?

Sources:

Institute for Clinical Systems Improvement (2014) Going Beyond Clinical Walls: Solving Complex Problems. https://www.icsi.org/wp-content/uploads/2019/08/1.SolvingComplexProblems_BeyondClinicalWalls.pdf

World Health Organization. (2024). Social Determinants of Health. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1

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How is AHCCCS addressing Health-Related Social Needs?

  • Housing Programs, Properties, Wraparound Services & Data Sharing Projects
  • Employment & Vocational Rehab Services
  • Justice Initiatives & Pre-release Support
  • Data Sharing Projects to Help Members with Food Insecurity
  • Revised Transportation Policy & Guidance to Health Plans
  • Community Reinvestment Program
  • New Policy & Services to Support Members Experiencing Social Isolation
  • Partnership with the AZ State Parks Department for Programs on Using the Outdoors to Support Physical & Mental Health
  • Working with Targeted Investments & Differential Adjusted Payments
  • Implemented the Statewide Closed-Loop Referral System, CommunityCares

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Path to a Statewide Closed-Loop Referral System

  • AHCCCS contracted with Contexture to implement and manage a statewide system for providers to screen members for HRSN & refer them to services
  • After a few hurdles the platform went live in November 2022
  • Top five referral categories have been for:
  • Food Assistance
  • Housing & Shelter
  • Utility Assistance
  • Clothing, Diapers/Infant Supplies, & Household Goods
  • Transportation
  • Major impact on physical and mental health

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Benefits of the System

For Members

  • Connections to services to improve HRSN, improve health outcomes
  • Reduced hardships and increased equity

For Providers

  • Easy screening & referral platform that can be integrated into current clinic flow
  • Helps with complex cases & underlying HRSN
  • Decreased ED visits, crisis services, inpatient stays, & improved outcomes
  • Reporting for epidemiology analysis
  • Financial incentives

For Community-Based Organizations

  • Easy way to receive referrals
  • Utilization reporting to help with grant applications & monitoring
  • Financial incentives

For AHCCCS

  • Better understanding of member needs, regional shortages, & utilization reporting
  • Data to support funding requests to improve care for members

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Closed-Loop Referral System CommunityCares

Kristina Belinte & Hector Araujo

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TI 2.0 CLRS Milestones in Years 2-3

Jane Otenyo

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TI 2.0 CLRS Milestone Requirements

Year 2 (10/1/2023 - 9/30/2024) - Year 3 (10/1/2024 - 9/30/2025)

Connect to and demonstrate effective use of the statewide closed loop referral system (CommunityCares) to connect members to community resources. Implementation shall include:

  1. Completing a CommunityCares scope of work.
  2. Ensuring practice team members can access and generate reports in Community Cares.
  3. Effectively documenting relevant data from CommunityCares into the practice EHR.
  4. Making referrals and demonstrating effective follow-up on referrals through CommunityCares.

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TI 2.0 Incentive Payment for Participation

Year 2

(October 1, 2023 – September 30, 2024)

By September 30, 2024 be ready to Submit Year 2 application in the AHCCCS Online TI 2.0 Application Portal

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  • Create policies and procedures (Upload to TI portal as PDF document):
    • generating reports from CommunityCares
    • documenting health related social need (HRSN) screening results in CommunityCares
    • documenting referral data from CommunityCares into the EHR
    • keeping your organization's information up to date in CommunityCares

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  • Identify at least 1 team member responsible for generating reports using CommunityCares data

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  • Attest that all TI participating clinics have team members (as needed) with accounts to log into CommunityCares

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  • Upload Scope of Work with CommunityCares

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TI 2.0 Incentive Payment for Participation

Year 3

(October 1, 2024 – September 30, 2025)

Part 1: By March 31, 2025 all TI participating clinics must have screened and documented results for at least 85% of the population between October 1, 2024 - March 31, 2025 using a HRSN screening tool (e.g. PRAPARE).

  • Conduct an assessment on
    • Full practice population OR Practice record review of a random sample of at least 20 members that were screened for HRSN
      • Numerator: # of patients who received HSRN Screenings during visit/Denominator: Total # of patients visit

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TI 2.0 Incentive Payment for Participation

Year 3

(October 1, 2024 – September 30, 2025)

Part 1: By March 31, 2025 all TI participating clinics must have screened and documented results for at least 85% of the population between October 1, 2024 - March 31, 2025 using a HRSN screening tool (e.g. PRAPARE).

  • Conduct an assessment on
    • Full practice population OR Practice record review of a random sample of at least 20 members that were screened for HRSN
      • Numerator: # of patients who received HSRN Screenings during visit/Denominator: Total # of patients visit

Part 2: Between April 1, 2025 - September 30, 2025 make referrals with CommunityCares

  • Conduct an assessment to show at least 85% of the population were referred in CommunityCares April 1, 2025 and September 30, 2025
    • Full Practice Population OR Practice Record Review of a random sample of at least 20 members that requested assistance with an identified health related social need (HRSN)
      • Numerator: # of completed referrals from individuals who requested referrals/Denominator: Total # of individuals who requested a referral

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TI 2.0 Incentive Payment for Participation

Year 3

(October 1, 2024 – September 30, 2025)

Part 1: By March 31, 2025 all TI participating clinics must have screened and documented results for at least 85% of the population between October 1, 2024 - March 31, 2025 using a HRSN screening tool (e.g. PRAPARE).

  • Conduct an assessment on
    • Full practice population OR Practice record review of a random sample of at least 20 members that were screened for HRSN
      • Numerator: # of patients who received HSRN Screenings during visit/Denominator: Total # of patients visit

Part 2: Between April 1, 2025 - September 30, 2025 make referrals with CommunityCares

  • Conduct an assessment to show at least 85% of the population were referred in CommunityCares April 1, 2025 and September 30, 2025
    • Full Practice Population OR Practice Record Review of a random sample of at least 20 members that requested assistance with an identified health related social need (HRSN)
      • Numerator: # of completed referrals from individuals who requested referrals/Denominator: Total # of individuals who requested a referral

Part 3: By September 30, 2025

  • Submit Year 3 application in the AHCCCS Online TI 2.0 Application Portal
  • Attest that all TI participating clinics:
    • conducted assessments that show 85% pass rate for HRSN screening and CommunityCares referrals
    • added information about practice operations in CommunityCares
    • generated at least one report during Year 3

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CLRS Milestone Timeline

10/1/23 - 9/30/2024

  • Create policies for operationalizing CommunityCares at your clinic(s)
  • Identify at least 1 team member responsible for generating reports
  • Create CommunityCares accounts for team members
  • Establish Scope of Work with CommunityCares

Fall 2024

Submit Year 2 Application &

Attestation

10/1/2024 - 3/31/2025

  • Screen for HRSN
  • Document results in EHR system
  • Denominator: Pull random sample of patient population seen (at least 20)
  • Numerator: number of patients in denominator that had HRSN screening
  • Pass if 85% or more

4/1/2025 - 9/30/2025

  • Confirm if patient wants a referral
  • Make referrals in CommunityCares
  • Document referral in EHR system
  • Denominator: Pull random sample of patient population that wanted a referral (at least 20)
  • Numerator: Number of patients in denominator that had referral in CommunityCares
  • Pass if 85% or more
  • Add clinic information in CommunityCares
  • Generate at least one report

Fall 2025

Submit Year 3 Application & Attestation

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Year 2 Timeline

Year 3 Timeline

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HIE - Contexture

Jayme Pina

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TI 2.0 Eligibility Requirements - HIE

Jane Otenyo

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Year 1 HIE Eligibility Criteria

Year 1 (October 1, 2023 – September 30, 2024)

Year 2 (October 1, 2023 – September 30, 2024)

Year 3 (October 1, 2024 – September 30, 2025)

  • All TI 2.0 organizations completed either a Scope of Work with Contexture OR HIE Commitment Letter during the application process

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  • All TI 2.0 Participants committed to the following:
  • Electronic Health Record (EHR) System Requirement: No later than 9/30/2025, all participating clinics under the participating Tax ID will implement an EHR system capable of sending and receiving data from Contexture.
  • Health Information Exchange (HIE) Requirement: By 9/30/2025, or within one year of Contextures new platform availability (whichever is later), all participating clinics under the participating Tax ID will achieve bi-directional data sharing with the new HIE platform.

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  • Submit Year 2 and Year 3 application in the AHCCCS Online TI 2.0 Application Portal
    • Attest that your organization is meeting or is on track to meet the EHR System requirement and the HIE requirement by 9/30/2025

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AHCCCS Differential Adjusted Payments (DAP)

Margaret Hackler

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Differential Adjusted Payment (DAP) Background

  • Since 2016 DAP has been used to incentivize providers that have committed to supporting actions that improve patients’ care experience, improve members’ health, and reduce cost of care.
  • DAPs are intended to be short-term payments to incentivize specific behaviors on the part of the providers.
  • DAPs are positive adjustments to the AHCCCS Fee Schedule and the health plans are required to pass through DAP increases to their contracted rates.
  • AHCCCS uses DAPs to promote policy goals for participation in information-sharing systems such as the SDOH CLRS and the HIE.
  • AHCCCS currently has DAPs available for various provider types such as inpatient and outpatient hospitals, physicians, outpatient clinics, HCBS providers, etc.
  • DAPs are time-limited and expire at the end of the contract year.

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CYE 2025 HIE and SDOH DAP

  • Health Information Exchange (HIE) Participation
    • Providers that meet specified milestones and performance criteria are eligible for a DAP.
    • In order to qualify, by April 1, 2024 the Provider must complete a HIE Participation Agreement and submit a Statement of Work (SOW).

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  • Social Determinants of Health Closed Loop Referral System
    • Providers that meet specific milestones are eligible to earn a DAP.
    • In order to qualify, by April 1, 2024 the provider must complete a CommunityCares Agreement and submit a Statement of Work (SOW).

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  • To Participate in the HIE DAP or SDOH DAP, please send an inquiry to DAP@Contexture.org.

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Helpful Information

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RESOURCES

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Whole Person Care & Closed-Loop Referral System Resources

AHCCCS Whole Person Care Initiative

www.azahcccs.gov/wpci

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Overview of CommunityCares

www.azahcccs.gov/communitycares

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Contexture’s Website on CommunityCares

www.contexture.org/communitycares

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TI 2.0 Program Resources

AHCCCS TI Website:

https://www.azahcccs.gov/PlansProviders/TargetedInvestments/

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ASU TIPQIC Website:

https://tipqic.org/about.html

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Questions?

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Thank You.