California Federally Qualified Health Center Alternative Payment Model Implementation Guide MARCH 2023 AUTHORS Greg Howe, Senior Fellow Karla Silverman, MS, RN, CNM, Associate Director, Complex Care Delivery Rob Houston, MBA, MPP, Director of Delivery System and Payment Reform, Center for Health Care Strategies About the Author Greg Howe is a senior fellow; Karla Silverman, MS, RN, CNM, is associate director of complex care delivery; and Rob Houston, MBA, MPP, is director of pay- ment reform at the Center for Health Care Strategies (CHCS). CHCS is a policy design and implementation partner devoted to improving outcomes for people enrolled in Medicaid. CHCS works across sectors and disciplines to connect people and ideas to spark insights, build expertise, strengthen leadership, and spread innovations. About the Foundation The California Health Care Foundation (CHCF) is an independent, nonprofit philanthropy that works to improve the health care system so that all Californians have the care they need. We focus espe- cially on making sure the system works for Californians with low incomes and for com- munities who have traditionally faced the greatest barriers to care. We partner with leaders across the health care safety net to ensure they have the data and resources to make care more just and to drive improve- ment in a complex system. Important Note to Readers The California Federally Qualified Health Cen- CHCF informs policymakers and industry ter Alternative Payment Model (FQHC APM) is a proposed initiative of the California Department of leaders, invests in ideas and innovations, Health Care Services (DHCS). At the date of publi- and connects with changemakers to create cation, the program is subject to approval by the a more responsive, patient-centered health Centers for Medicare & Medicaid Services at the US care system. Department of Health and Humans Services. Infor- mation about the program contained in this guide reflects the most recently available details from DHCS and is subject to change. Official program guidelines are forthcoming from DHCS, and this guide will be updated as new information becomes available. Contents 4 Section 1. 41 Section 4. Understanding the Federally Qualified Bringing Your Organization Along Health Center Alternative Payment Communicating Change . . . . . . . . . . . . . . . . . . . 41 Model and How This Guide Can Redesigning Care. . . . . . . . . . . . . . . . . . . . . . . . . 41 Help You What This Change Means for You. . . . . . . . . . . . 44 Why Is California Moving Toward FQHC APM? . . 4 Understanding Loss Is Part of Making Development of This Guide. . . . . . . . . . . . . . . . . . 4 Positive Change. . . . . . . . . . . . . . . . . . . . . . . . . . 46 Road Map to This Guide . . . . . . . . . . . . . . . . . . . . 5 Leading the Change. . . . . . . . . . . . . . . . . . . . . . . 46 California's Transition to FQHC APM. . . . . . . . . . . 7 Defining FQHC APM. . . . . . . . . . . . . . . . . . . . . . . 9 48 Section 5. Data: Your Success Depends on It 12 Section 2. The Importance of Data in FQHC APM. . . . . . . . 48 An Overview of Financial Incentives in What Data Do You Need to Collect?. . . . . . . . . . 48 FQHC APM and What They Mean for Your Health Center How Do You Ensure That Your Data Are Accurate?. . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 FQHC APM: Adopting a New Approach with New Financial Incentives . . . . . . . . . . . . . . . 12 What Changes Do You Need to Make to Your Current Data Infrastructure?. . . . . . . . . . . . . 51 Counting Traditional Encounters Under FQHC APM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 55 Section 6. Alternative Touches. . . . . . . . . . . . . . . . . . . . . . . 13 Partnering for Success Populations Included in FQHC APM. . . . . . . . . . 13 Collaborating with Other Health Centers . . . . . . 55 Financial Success Under FQHC APM. . . . . . . . . . 14 Working with MCPs. . . . . . . . . . . . . . . . . . . . . . . 56 Additional Financial Considerations . . . . . . . . . . 20 Building External Partnerships. . . . . . . . . . . . . . . 58 23 Section 3. 60 Appendices Focusing on Patients, Not Visits Appendix A. Advisory Group Members . . . . . . . 60 Overview of Care Delivery in FQHC APM. . . . . . 23 Appendix B. Overview of Data Elements and Moving to APMs Means Transforming Sharing Requirements Under FQHC APM. . . . . . 61 Traditional Care Delivery . . . . . . . . . . . . . . . . . . . 25 Appendix C. Additional Resources . . . . . . . . . . . 63 Expanding Who, How, and Where You Appendix D. Ideas for Care Models That Deliver Care to Best Meet Patient Needs. . . . . . 26 Can Help Guide Your FQHC APM Work. . . . . . . 66 Expanding Who Can Deliver Care. . . . . . . . . . . . 26 Facilitating Team-Based Care Delivery . . . . . . . . 32 Expanding How Care Is Delivered. . . . . . . . . . . . 32 Expanding Where Care Is Delivered. . . . . . . . . . 34 Managing Care in New Ways. . . . . . . . . . . . . . . . 36 California Health Care Foundation www.chcf.org 3 SECTION 1. Understanding the Federally Qualified Health Center Alternative Payment Model and How This Guide Can Help You with billable providers. Payment is based on volume of visits rather than value, which can discourage IN THIS SECTION innovation and limits the ways in which providers $ WhyIs California Moving Toward FQHC and teams can care for their patients. Value-based APM? payment (VBP) arrangements have the potential $ Development of This Guide to remedy some of these issues in five meaningful $ Road Map to This Guide ways by:1 $ Is This Guide for You? How Can It Help? $ Is FQHC APM Right for Your Health 1.Giving health centers flexibility to provide care Center? in the ways patients need and want $ California's Transition to FQHC APM 2.Allowing health centers to make critical infra- $ Development and Implementation structure improvements Timeline of FQHC APM $ Defining FQHC APM 3.Helping improve patient outcomes $ Who Participates? 4.Helping deliver comprehensive, team-based, $ Core Components patient-centered care 5.Improving accountability by rewarding health centers that improve quality of care Why Is California Moving Toward FQHC APM? Development of This Guide The FQHC APM is designed to move away from the To create this guide, the Center for Health Care traditional fee-for-service (FFS) payment system, Strategies (CHCS), with support from the California which rewards the volume of services provided, to a Health Care Foundation, drew upon its knowl- model that rewards high-quality and cost-effective edge and experience working with FQHCs, VBP care that is coordinated, team-based, convenient to models, delivery systems, and Medicaid programs access, and best meets patient needs. in California and around the country. CHCS con- ducted interviews with health centers and state "The APM has increased our ability to be primary care association leaders who have devel- flexible in order to be responsive to external oped or participated in APMs for FQHCs to gather specific insights on implementation, best prac- challenges like the pandemic and wildfires." tices, lessons, and advice for success. To inform -FQHC CEO, Oregon the topics and general approach to the guide, as well as review drafts, CHCS convened a group of advisors including staff working at California Under the traditional prospective payment system FQHCs in a variety of roles, a California Medi-Cal (PPS), FQHCs are paid for face-to-face encounters California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 4 managed care plan (MCP) leader, a health center $ Licensed and unlicensed clinical staff. Nurses, CEO involved in Oregon's Alternative Payment and social workers, medical assistants, counselors, Advanced Care Payment Model, and representa- pharmacists, care managers, care coordinators tives from the California Primary Care Association $ Operations. Administrative, information tech- and the California Association of Public Hospital nology, and data analytics staff and Health Systems (see Appendix A for advisory group members). Although staff can find useful information in all sec- tions of the guide, certain sections will be more applicable based on their roles and responsibilities Road Map to This Guide within the organization. Table 1 can help steer you to sections of interest to you (see next page). Is This Guide for You? How Can It Help? This guide is for leaders and staff in FQHCs that are Is FQHC APM Right for Your Health Center? considering or have committed to participating in While this guide does not include a tool for decid- the California FQHC APM, a voluntary VBP initia- ing if your FQHC should participate in FQHC APM, tive offered by DHCS. The guide includes practical it outlines factors that can contribute to your success resources for reimagining and redesigning how under FQHC APM that can help inform your deci- your FQHC delivers care so it can be successful in sion. As you explore the opportunities, challenges, the FQHC APM. and required investments of time and resources covered in the guide, you may wish to consider the The guide will help you: following essential capabilities for success in APMs: $ Understand the impact of participating in $ Leadership and staff buy-in. Leadership, FQHC APM for your FQHC's leaders, staff, including boards of directors, understands the and patients implications of FQHC APM for their FQHC $ Identify key focus areas and is able to articulate a vision for the FQHC as well as support providers and staff in the $ Set priorities transition to FQHC APM. Staff may need to be $ Determine staffing needs trained to implement new quality-based pay- ment models and understand how they are $ Build and expand staff competencies being held accountable. Your health center is able to engage patients and seek feedback on The guide is designed for all FQHC staff, including: patients' experience. $ A new financial model. You and your team $ Leadership. Chief executive officers, chief administrative officers, chief operations offi- understand your current patient population cers, chief financial officers, chief information and financial situation and can identify the officers, chief medical officers, chief behav- financial risks and opportunities in FQHC ioral health officers, chief strategy officers APM, develop a new financial model, and set up new payment processes. $ Providers. Physicians, physician assistants, $ Practice transformation to support FQHC nurse practitioners, certified nurse-midwives, therapists APM goals. To improve on quality and cost California Health Care Foundation www.chcf.org 5 Table 1. Descriptions of This Guide's Sections, and Their Targeted Staff SECTION DESCRIPTION TARGETED STAFF 1. U nderstanding FQHC APM Why California is moving toward FQHC APM; All and How This Guide Can development of the guide; road map to the guide; Help You California's transition to FQHC APM; defining FQHC APM. 2. A n Overview of Financial Adopting a new approach with new financial incen- CEO, finance staff Incentives in FQHC APM tives; alternative touches; what populations are and What They Mean for included; what financial success looks like under Your Health Center FQHC APM; additional financial considerations. 3. F ocusing on Patients, Not Transforming traditional care delivery; expand- Providers, clinical and support Visits ing how, where, and by whom care is delivered; staff, administrative and opera- facilitating team-based care; managing care in new tions staff, IT staff ways. 4. B ringing Your Organization Communicating change; redesigning care; Leadership, providers, clinical Along understanding what this change mean for me; and support staff, administrative understanding that loss is part of making positive and operations staff, IT staff change; leading the change. 5. D ata: Your Success Depends The role of data; capturing and sharing data; ensur- IT staff, finance, and operational on It ing your data are accurate; updating EHRs staff to support the work. 6. Partnering for Success Collaborating with other FQHCs; working with Leadership MCPs and delegates; building external partner- ships. Source: Author's descriptions of the sections in the California Federally Qualified Health Centers Alternative Payment Model Implementation Guide, California Health Care Foundation, 2023. metrics, your health center is able to incorpo- Your health center also has the infrastructure rate clinical best practices into the workflow, in place to share data between health plans, if not already implemented. Roles and pro- state agencies, and external providers. Being cesses are defined and clear to providers and able to share and act on data in real time and staff to ensure coordination and team-based across a wider range of providers is critical care. for effective care coordination, and it often requires sophisticated IT capacity and data $ A robust IT infrastructure and data analytics analytic tools, as well as staff trained in these capacity. Your health center has, or is work- areas. ing toward updating, an electronic health record (EHR) that allows providers to capture $ Robust care coordination efforts. Having a and exchange data, support care coordination care manager on-site increases connections inside and outside the practice, and monitor with patients and the providers involved in and generate reports on targeted metrics. their care. Your health center has the resources Staff are trained to populate the EHRs, use to hire and train staff for care management correct coding, and fully use EHR functionality. roles, and manage care transitions and link to Your health center is able to analyze the data external providers (e.g., specialists, hospitals, to determine the impact on quality and cost. and community organizations). California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 6 California's Transition to FQHC APM Development and Implementation Timeline of California's FQHC APM California's FQHC APM is one of four state-led Efforts to design an APM pilot for California's FQHC APMs that converts FQHC Medicaid rates FQHCs began in 2015 concurrent with the passage to a capitated per-member per-month (PMPM) of Assembly Bill 147 and the convening of stake- payment. The three other models are profiled in holder workgroups to develop a model. These Table 2. Table 2. Examples of State-Led APMs STATE PAYMENT MODEL QUALITY METRICS Oregon $ Health centers receive a base encoun- $ FQHCs are accountable for five metrics that Alternative Payment and ter payment from the health plan and an align with the coordinated care organization Advanced Care Model up-front supplemental capitated PMPM incentive measures: wrap payment from the state. $ Colorectal cancer screening $ Health centers submit reconciliation reports $ Depression screening quarterly, with settlements paid annually. $ Diabetes HbA1c >9% $ A portion of the payment is tied to meeting five quality benchmarks. $ Weight assessment and counseling in children and adolescents $ Controlling high blood pressure Washington $ Health centers receive an up-front PMPM $ Five process and outcome measures, which Alternative Payment payment from the health plan and a monthly were selected from the state's common Methodology 4 "enhancement payment" from the state. measure set, are tracked: $ The rate is then prospectively adjusted $ Antidepressant medication management annually by the state to reflect the FQHC's $ Childhood immunization status performance on five quality targets. $ Well-child visits $ FQHCs continue annual reconciliation to ensure PPS equivalency. $ Controlling high blood pressure $ In lieu of a settlement process, adjustments $ Comprehensive diabetes care, including are made prospectively to future rates. HbA1c >9% Colorado $ APM 2 is a hybrid (partial population-based $ Primary care providers report on 10 quality Alternative Payment payment, partial FFS payment) primary care measures from the state's APM Measure Methodology 2 model that includes provisions for FQHC Set: three mandatory measures and seven participation. measures selected by the provider. The $ FQHCs participating in the model will be Colorado Community Health Network paid a fully population-based payment, coordinates measure selection for all with rates based on historical spending and FQHCs. including an adjustment for quality perfor- $ Measures are categorized into the following mance. types: structural measures, administrative $ Payment to FQHCs will be reconciled measures, and electronic clinical quality annually to ensure PPS equivalency. In cases measures.* of underpayment, FQHCs will receive a onetime payment to make up the difference. In cases of overpayment, no action will be taken. Source: Greg Howe, Rob Houston, and Tricia McGinnis, How Health Centers Can Improve Patient Care Through Value-Based Payment Models, California Health Care Foundation, June 2020. * Primary Care Alternative Payment Model Guidebook, Colorado Dept. of Health Care Policy and Financing, November 2021. California Health Care Foundation www.chcf.org 7 efforts led to the development of a concept paper $ California Association of Public Hospitals and that DHCS submitted to the Centers for Medicare Health Systems & Medicaid Services (CMS). DHCS, during discus- $ California Primary Care Association sions with CMS, and in consultation with other California stakeholders, decided not to pursue the $ California Hospital Association pilot because of the complexity of waiving federal $ California Association of Health Plans PPS equivalency requirements. $ Local Health Plans of California Stakeholder planning efforts for the pilot helped $ Several individual Medi-Cal MCPs and FQHCs foster interest among health plans and FQHCs to build capacity for implementing new payment The process resulted in FQHC APM, a significant models, along with the disruption of the COVID- departure from the current PPS rates. 19 pandemic, which led to the creation of a new planning process launched by DHCS in April 2021. DHCS is planning to submit a State Plan Amendment The new planning process included convening a to CMS in late 2023 to seek approval to implement workgroup of state stakeholders and engaging an FQHC APM, with a proposed implementation date actuarial firm to help with model design and rate of January 1, 2024. See Table 3 for a timeline of the setting. FQHC APM was informed by input from a FQHC APM rollout. broad array of other stakeholders, including: Table 3. Timeline for the FQHC APM Rollout 2023 2024 JAN./FEB. MAR. JUNE AUG. OCT. NOV. JAN. Jan. 31: Meeting with Draft APM Aug. 1: Medicare Final APM Go live! $ FQHCs MCPs to discuss PMPMs $ Interim scope Economic Index PMPM released submit appli- recommenda- released change due released cations to tions Mar. 31: (if applicable) DHCS $ FQHCs $ Last date Mercer analyzes selected to withdraw encounter data from APM for applications submitted Source: Federally Qualified Health Center Alternative Payment Model (FQHC APM) Overview (PDF), DHCS, September 30, 2022. California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 8 Guiding Principles of the FQHC APM DHCS, in consultation with the workgroup (see description above), identified the following principles to guide the development and implementation of the FQHC APM. Payment modernization should support: $ Patient-centered care allowing members to receive needed services conveniently $ Alignment of measures in CalAIM (California Advancing and Innovating Medi-Cal), Medi-Cal managed care, and pay-for-performance programs to ensure greatest impact in quality targets $ Data-informed innovation that encourages deeper health information exchange between MCPs and FQHCs $ Integrated whole-person care, including physical, behavioral, and oral health, and long-term services and supports $ Deliveryreform focused on value, outcomes, and investing in early intervention and primary care result- ing in per capita cost decreases to the larger Medi-Cal program $ Flexibility for FQHCs to reduce disparities and to address member needs, including social determinants of health (SDOH) $ Reduced administrative burden, consistent and timely payment, and a strong and resilient safety net in California Source: Federally Qualified Health Center Alternative Payment Model (FQHC APM) Overview (PDF), DHCS, September 30, 2022. Defining FQHC APM for FQHCs to apply and participate if selected, Who Participates? Medi-Cal MCPs will be required to reimburse par- Participation in FQHC APM is voluntary for FQHCs, ticipating FQHCs under the FQHC APM payment per federal regulations, and FQHCs with multiple provisions. sites with different PPS rates can choose which sites Core Components are included as long as all sites with the same PPS rate are included or excluded. FQHCs apply and The components of FQHC APM are described in are selected based on DHCS criteria.2 If a site is detail throughout this guide. Table 4 provides an selected and there are intermittent sites affiliated overview of the core components of the model (see with that site, then those intermittent locations next page). must be included in the APM. While it is optional California Health Care Foundation www.chcf.org 9 Table 4. Overview of FQHC APM* AREA KEY PROVISIONS Voluntary $ FQHCs must apply and be accepted to participate in the APM. $ FQHCs may withdraw from the program both before and after contract start, subject to providing sufficient notice to DHCS. Payment $ The APM provides prospective, predictable payments. $ The APM allows flexible use of resources to enable and drive delivery system transformation. $ The APM PMPM will replace PPS, incorporating several payment streams that were previously separate: $ Health plan capitation or fee-for-service payments to the FQHC $ DHCS wrap-cap payments to the FQHC to cover the difference between health plan payments and PPS (and any reconciliation payments) $ DHCS PPS payments to the FQHC for visits from health plan members not assigned to the FQHC $ Payment to FQHCs must be at least equal to what would have been received under PPS. Services/Payments $ Includes primary care, non-specialty mental health services, specialty care (cardio, ophthal- mology, dermatology) included in the PPS rate and paid by the MCP, podiatry, chiropractic (to the extent it's in MCP contract). $ Excludes dental, specialty mental health, Enhanced Care Management (ECM), and Community Supports. $ APM PMPM distinct from Medi-Cal MCP pay-for-performance programs; intended to comple- ment rather than supplant. Populations $ The APM applies only to Medi-Cal managed care enrollees; FFS program remains unchanged. $ Dually eligible (full and partial) members excluded. Data Reporting $ All encounter data, including alternative care Current Procedural Terminology (CPT) codes, will be submitted to contracted health plans. Quality and Access $ FQHCs must maintain a floor of 70% PPS visits and alternative care services. Expectations $ FQHCs will be required to meet performance targets for two measures from six domains (12 metrics in total) that will be tied to payment. An additional domain, "Patient Experience of Access and Care," will have two metrics for reporting only. $ FQHCs will be subject to a corrective action plan, a 5% penalty, or removal from the program for not meeting quality measures. * Table developed with information provided by Jill Yegian in the presentation to the CHCS FQHC APM Implementation Guide Advisory Group meeting, December 16, 2021, and later revised using Federally Qualified Health Center Alternative Payment Model (FQHC APM): Overview (PDF), DHCS, September 30, 2022. California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 10 Key Definitions $ Alternative touches. Services not currently considered encounters under PPS but that are activities designed to increase patient engagement, improve patient outcomes, and generally allow better coordi- nated and integrated care. $ Assigned patient. A patient assigned to your health center by the MCP under FQHC APM. $ Pay-for-transformation payment (or wedge). The amount of PMPM payment in excess of the number of encounters. Calculate as the historic encounter utilization priced at the current PPS rate minus the cur- rent encounter utilization priced at the current PPS rate. $ PMPM. Per-member per-month payment for each assigned patient in your health center. $ Quality metrics. The set of 12 measures (at least two measures from each of six domains) that your health center will be required to report on to ensure that it is meeting the quality goals for FQHC APM. Performing well on quality metrics allows your health center to keep the pay-for-transformation payment (or wedge). $ Risk stratification. A technique for systematically categorizing patients based on their health status and other factors. It allows practices to manage patients based on their assigned risk level to make better use of limited resources, anticipate needs, and more proactively manage their patient population.* $ Team-based care. Patient care delivered by and coordinated among two or more members of the care team that addresses a patient's physical, behavioral, and social needs. The care team could include pro- viders, and licensed and unlicensed staff. * James Dom Dera, "Risk Stratification: A Two-Step Process for Identifying Your Sickest Patients," Family Practice Management 26, no. 3 (May/ June 2019): 21–26. California Health Care Foundation www.chcf.org 11 SECTION 2. An Overview of Financial Incentives in FQHC APM and What They Mean for Your Health Center staff (nurses, medical assistants, community health workers) best suited to your patients' needs. IN THIS SECTION $ FQHC APM: Adopting a New Approach with While some aspects of the FQHC APM financial New Financial Incentives model are still under development, the overall $ Counting Traditional Encounters Under thrust is clear: The incentives in the model aim to FQHC APM provide patients with the right care at the right $ Alternative Touches time, addressing patient care needs through flex- $ Populations Included in FQHC APM ible approaches and avoiding unnecessary and $ Financial Success Under FQHC APM preventable visits. This section of the guide will $ Overview of Assignment focus on helping you understand the incentives in $ Assignment and the Role of MCPs place under FQHC APM, which will enable your $ PMPM Rates center to make the necessary care management $ Quality Adjustment transformations, build the data infrastructure, and $ The Bottom Line ready your organization for the APM. More infor- $ Additional Financial Considerations mation on what financial success looks like under $ Understanding Your Current Financial FQHC APM is included later on in this section. Situation $ Payer Mix $ Tracking and Managing Utilization Counting Traditional Encounters Under FQHC APM Even though the PMPM payment structure repre- sents a significant departure from the PPS structure, FQHC APM: Adopting a New the PPS framework will still determine PMPM rates Approach with New Financial (more information below on how this will work). Incentives Therefore, your health center will still have to track In FQHC APM, your health center will need to alter and document traditional encounters to ensure that the way it conducts business to maximize its finan- you are meeting program requirements and that cial success. The fundamental change in the FQHC you receive appropriate reimbursement even if the APM program will be the shift away from encoun- number of encounters falls. ter-based billing practices under PPS toward one that manages care and utilization under an estab- While DHCS understands that FQHC APM could lished PMPM budget. If your health center does reduce the number of traditional encounters per not already receive a PMPM from MCPs, this shift patient for each health center due to the new finan- will discourage increasing the number of traditional cial incentives in place, it also wants to make sure encounters your center has per patient, instead that care will not be rationed or withheld. Therefore, incentivizing your health center to provide compre- under the proposed FQHC APM requirements, hensive care using the methods (virtual, home) and your health center must prove that it is providing at California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 12 Table 5. A Comparison of PPS and FQHC APM Payment Models ITEM PPS FQHC APM Profit motivation Volume Value Revenue source Payment for each encounter PMPM payment for each assigned patient How to increase revenue Perform as many billable encounters as Serve as many assigned patients as possible possible, improve efficiency and quality performance Quality component Optional, if agreed to by FQHC and Mandatory, offers financial incentive MCP Can the FQHC make less than PPS No No rate? Potential perverse incentives Performing encounters that deliver no Withholding needed care from value to the patient; having patients patients; receiving funding without schedule multiple in-person or virtual transforming or improving care visits so that more encounters are created Source: Author's comparison of PPS and FQHC APM payment models, California Federally Qualified Health Centers Alternative Payment Model Implementation Guide, California Health Care Foundation, 2023. least 70% of the encounters it was before its entry Alternative Touches into the FQHC APM. To do that, your FQHC will Alternative touches are services not currently con- need to continue to count encounters. In addition sidered encounters under PPS but are activities to encounters, your health center must also docu- designed to increase patient engagement, improve ment "alternative touches" that can count toward patient outcomes, and generally allow better this 70% threshold (more information below on coordinated and integrated care. There are five alternative touches). If the number of traditional proposed domains of alternative touches: commu- encounters plus alternative touches drops below nication, education, case management, community the threshold, the first step will be for DHCS and supports, and care team support. Please note that the FQHC to investigate why (e.g., data reporting these domains and alternative touches are pro- anomalies, staffing issues, etc.) and to settle on a posed but not finalized. Section 3 addresses how performance improvement plan and timeline. If your health center can deliver alternative touches. access thresholds are not achieved after the perfor- mance improvement plan timeline, your FQHC may receive a financial penalty or be asked to leave the Populations Included in FQHC APM FQHC APM.3 FQHC APM is focused on Medi-Cal patients, but it is important to note that your health center will not be reimbursed for all Medi-Cal patients who enter the health center under the FQHC APM framework. A subset of patients would continue to receive services under the traditional PPS reimbursement California Health Care Foundation www.chcf.org 13 model. Medi-Cal patients who would not be cov- traditional encounters, FQHC APM will provide a ered under the FQHC APM include: monthly PMPM payment for your center's assigned patients that provides a consistent and predictable $ Medi-Cal FFS enrollees revenue stream. $ Individualsdually eligible for Medicare and Medi-Cal services "We're now looking to get more Medicaid $ Patients enrolled in a non-contracted MCP lives to cover, not chasing more encounters." who visit the health center. In this circum- -FQHC chief administrative officer (CAO), Colorado stance, the health plan will pay the full PPS rate to the health center. The way to maximize revenues under such a model Ideally, care would be delivered to Medi-Cal is not to maximize encounters with patients, but patients who are not part of the FQHC APM reim- instead to keep patients well so they do not need bursement structure in a manner consistent with to go to your FQHC as often, thus freeing up avail- the patient-centered incentives in FQHC APM. ability to serve more patients and receive additional Even without the financial incentives contained PMPM payments for newly assigned patients. Your in FQHC APM, your health center can choose to health center will also be incentivized to provide optimize revenue for non-FQHC APM patients and high-quality care through a quality measurement serve them in a more patient-centered manner as and accountability structure. It will be important described in this guide. This decision will likely hap- to engage assigned but not yet seen patients who pen on a center-by-center basis and be informed may not have established relationships with your by the number of patients your health center serves health center, particularly to meet quality measures from these populations, the overall financial health that require preventive services. The structure of the of the health center, the administrative systems payment model will allow greater flexibility for your in place to manage different financial incentives center to provide necessary care to those patients across the organization, and other factors. Before you serve, which will be discussed in more detail deciding to participate in FQHC APM, your health later in this guide. center may want to analyze the percentage of existing patients whose care will be covered under Under the currently proposed FQHC APM payment FQHC APM, which can help determine your health model, your FQHC's Medi-Cal revenue will depend center's approach to implementing the model. on three primary factors: 1.Patient assignment. Financial Success Under FQHC APM 2.PMPM rates. The FQHC APM payment model will create a differ- ent set of incentives to provide optimal care to the 3.A quality adjustment. patients you serve. Instead of providing your health The relationship between these factors and rev- center with encounter-based payments, which enue are shown in Figure 1. FQHC APM Revenue incentivizes your FQHC to maximize the number of Formula and explained below (see next page). California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 14 Figure 1. FQHC APM Revenue Formula Number of Quality Total APM assigned PMPM rate adjustment revenue patients Source: Author's visual representation of the FQHC APM revenue formula in the California Federally Qualified Health Centers Alternative Payment Model Implementation Guide, California Health Care Foundation, 2023. Overview of Assignment methodologies for assignment, including how The cornerstone of your FQHC's revenue stream patients are assigned and reassigned to provid- under FQHC APM will be its assignment of patients, ers. It is likely that many MCP members are already which will determine the number of PMPM pay- assigned to your FQHC in some way - such as via ments your health center will receive. Your primary care provider selection, for quality measure- contracted MCPs will assign patients to your health ment purposes, or other means - and there may center and determine the factors and methodol- even have been a small financial impact tied to this ogy under which to assign a patient to your FQHC. assignment such as a quality bonus or care man- Thus, your center will have less control over day-to- agement fee. If your center is already participating day revenues under FQHC APM than it did under in such arrangements, it is likely, and possibly pref- PPS. It is also important to note that under the erable, that assignment under FQHC APM would proposed FQHC APM assignment methodology, be similar to the existing arrangement. If no such your center will not receive a PMPM or separate assignment methodology currently exists with an PPS reimbursement for Medi-Cal managed care MCP, it would be wise to prenegotiate the frame- members enrolled in a contracted MCP who are work of such an arrangement ahead of time before not assigned to your center yet receive care at your signing a new FQHC APM contract. This way, your center. Instead, care for these managed care mem- FQHC can ensure that a potential arrangement with bers will be incorporated into your PMPM rate for the MCP(s) would be more favorable for your health those patients assigned to your health center over center than the existing PPS structure. time.4 Even though your MCP partners will have greater Assignment and the Role of MCPs influence over your center's revenue, your FQHC Because the MCP will have greater influence over does have significant leverage in negotiations with your FQHC's revenue stream under FQHC APM, MCPs regarding assignment methodology. Some building a trusting and equitable relationship with of these leverage points include: the MCP will be crucial for the financial viability of your health center (see Section 6 for more informa- $ Explicit program terms. If your center is partici- tion on building relationships with MCPs). pating in FQHC APM, an MCP that chooses to contract with you must pay you in accordance Since assignment will be so impactful for your with the program's terms. center's revenue under FQHC APM, it is in your $ More guidance will be coming. Even though best interest to speak with the MCPs you work the assignment methodology is not currently with as soon as possible to fully understand their California Health Care Foundation www.chcf.org 15 well-defined in state guidance, DHCS is planning (# of PPS Eligible Visits – Assigned Members to issue standardized contract language and an + Number of PPS Eligible Visits – Unassigned "All Plan Letter" providing guidance to MCPs Members) × (current PPS for the FQHC) __________________________________________ outlining elements of the program (see Section 6 MCP members assigned (member months) for more details on contracting with MCPs). The to the FQHC contract language and guidance may include relevant information for your FQHC when nego- Note that this proposed approach captures visits tiating assignment with MCPs. to the FQHC by both assigned and unassigned $ Your patients may have a say. Many MCPs offer members in the numerator, but the denominator is patients the opportunity to choose a primary care restricted to plan members assigned to the FQHC provider. If they select your center or a provider APM site.6 If your FQHC has multiple PPS rates at your center, that could trigger assignment under the APM, each of those sites would have its under such a methodology. own PMPM rate calculated by this formula. $ Your center is a valuable provider for your While the PMPM rates will be determined by DHCS, MCP's network. While MCPs have quite a bit FQHCs cannot ultimately be paid under PPS rates, of power to control how many patients you so if the total cost generated by encounters turns get paid for, they will likely want to send many out to be above the projection, your center will patients to your center rather than higher-cost or be paid the difference annually. This process will lower-quality primary care providers, emergency likely be similar to current "wrap-cap" processes, departments, or urgent care practices. In addi- as defined by the two-year payment requirement at tion, MCPs will be monitored for maintaining 42 CFR § 447.45 and 45 CFR § 95, Subpart A. access to, and utilization of, primary care under the CalAIM Population Health Management ini- Pay-for-transformation payments - "the tiative.5 The PMPM payment they offer you may wedge" also provide the MCP a desirable and predict- Due to the financial incentive to provide fewer able cost for primary care, care management, encounters, encounters will likely decrease over and sick visits. time, which could lead to lower future PMPM cal- PMPM Rates culations in some cases. To mitigate this possibility, the state has proposed that FQHCs participating in While the assignment methodology is important FQHC APM can keep the amount of PMPM pay- for determining the number of patients for which ment in excess of the number of encounters as a your center will receive payment for serving under "pay-for-transformation" payment, also colloqui- FQHC APM, the PMPM rate that your health cen- ally referred to as "the wedge," provided that the ter receives is the payment amount per assigned FQHC meets quality standards (see below for more patient. The rates for your health center will be cal- information on quality incentives). The proposed culated by DHCS annually. These calculations will calculation for pay-for-transformation payments is: initially be based on historical utilization of assigned and unassigned members, trended forward as (Total payments made through the APM PMPM) – needed based on program changes, and priced (Program Period PPS eligible visits *Program at projected PPS rates. The proposed, though not Period PPS rate) final, formula for the APM PMPM is: California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 16 Figure 2. Pay-for Transformation Payments, a.k.a. "the Wedge" Percentage of Prior Year's 110 100 Encounters 90 "Wedge" 80 70 60 Time PMPM Payment Number of Encounters Source: Author's interpretation of the Federally Qualified Health Center Alternative Payment Model (FQHC APM) Overview (PDF), DHCS, September 30, 2022. A graphic depicting the wedge is shown in Figure experience metrics. Many of these metrics may be 2. Pay-for Transformation Payments, a.k.a. "the in your contracts with MCPs, or you may participate Wedge". in one or more state or federal VBP programs, such as the Medicare Shared Savings Program. While the It is important to note that pay-for-transformation quality metrics in FQHC APM may not be exactly payments, as currently conceived, are not actually the same as the ones that you've already seen, additional dollars that will be paid to your center. they can likely be approached in a similar way and You will continue to be paid using the same PMPM, should not require extensive changes in the way the provided that the FQHC meets quality benchmarks. data are collected and reported. However, if the number of encounters falls as a result of better, more efficient care, the FQHC can "Pilot each component, and pilot everything keep the wedge amount above PPS, which could represent a significant revenue improvement versus at one place. Choose the most challenging PPS. As a result, your FQHC can increase the size of site because you will be able to identify lots the wedge by improving its efficiency while main- of problems this way." taining its quality and access to care.7 In addition, -FQHC CAO, Colorado maximizing the size of the wedge frees up staff time and resources, thus creating virtual capacity that can be used to serve additional patients who, once Proposed quality measures for the program have assigned over time, could bring in greater revenues. been aligned with the existing Managed Care Accountability Set. Under the current, proposed Quality Adjustment "gate and ladder" approach, your health center The FQHC APM also holds health centers account- will be measured on 22 quality measures across six able for quality performance through the FQHC domains, which will be reported to DHCS on behalf APM's quality metrics. Your FQHC is probably of your health center. Three of these measures, as familiar with pay-for-performance quality metrics, well as an additional "Aggregated Quality Factor which reward or penalize your organization based Score" calculated from all reported measures, are on performance on process, outcome, or patient "gate" measures, and your health center will need California Health Care Foundation www.chcf.org 17 to maintain a baseline score on these measures $ Year 3. Greater than or equal to the 50th per- through its participation in the program. If your centile national or state benchmark to retain health center does not maintain these scores, it is 100% of the excess revenues above the PPS subject to a corrective action plan, a 5% penalty, or payments (up to 3% of excess revenues at risk, removal from the program. Your center can choose evenly distributed across all selected metrics). 12 "ladder" measures from the list of 22, which will $ Year 4. Greater than or equal to the 50th per- be tied to payment, though you must select at least centile national or state benchmark to retain 2 measures from each domain, except for mea- 100% of the excess revenues above the PPS sures in the Patient Experience of Access and Care payments (up to 5% of excess revenues at risk, domain, which will only be reported and not tied to evenly distributed across all selected metrics). payment. The proposed, but not finalized, list of 22 eligible measures, with the 3 gate measures indi- $ Year 5 and beyond. Maintaining the minimum cated, are shown in Table 6 (see next page).8 previous performance levels in Year 4 with an ongoing continuous performance-improve- The quality benchmarks FQHCs will need to achieve, ment program based on gap methodology and how they will be tied to payment, will change outlined. The FQHC has the potential to retain by program year. It is important to note that under up to 100% of the excess revenues above the the currently proposed structure, there is no addi- current PPS payments. The FQHC is at risk for tional financial bonus for quality that FQHCs will an increasing 1% per year of excess revenues receive. Rather, performing well on selected quality (not to exceed 10% of excess revenues). The metrics allows your FQHC to keep the wedge of potential risk will be evenly distributed across the PMPM over PPS. If your center performs poorly all selected metrics for that calendar year. on quality metrics, you may need to pay a percent- age of the excess revenues created by the wedge Meeting quality improvement targets will likely back to the state. These penalties would not apply require your health center to create new inter- if there were no wedge created, and your center ventions or initiatives. Fortunately, FQHC APM's will not receive less than what it would have earned flexibility incentivizes your center to use strategies under PPS as a result of quality performance. The such as team huddles and cross-team collaborations current proposed approach, which has not been that can improve quality performance but would finalized, is as follows: take staff away from earning encounter-based rev- enues under PPS. In addition to DHCS's external $ Year 1. Reporting only to establish baseline. quality metrics, health centers can also use internal metrics to target staff's individual performance and $ Year 2. Greater than or equal to the 33rd per- progress toward quality goals, efficiency metrics, or centile national or state-calculated benchmark both, provided that data are collected at an indi- (if national benchmarks not available) to retain vidual staff level. 100% of the excess revenues above the PPS payments (up to 1% of excess revenues at risk, evenly distributed across all selected metrics). California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 18 Table 6. Proposed FQHC APM Quality Measures QUALITY CATEGORY MEASURE NAME Prevention - Adult Cervical Cancer Screening Prevention - Adult Colorectal Cancer Screening Prevention - Adult Breast Cancer Screening Prevention - Adult Chlamydia Screening in Women Access to Care Child and Adolescent Well-Care Visits* Access to Care Well-Child Visits in the First 15 Months. For children who turned 15 months old during the measurement year, Six or More Well-Child Visits Access to Care Well-Child Visits for Age 15 Months–30 Months. For children who turned 30 months old during the measurement year: Two or More Well-Child Visits* Access to Care Adults' Access to Preventive/Ambulatory Health Services* Prevention - Peds Childhood Immunization Status (CIS 10) Prevention - Peds Immunization for Adolescents Prevention - Peds Fluoride Varnish BH Integration Pharmacotherapy for Opioid Use Disorder BH Integration Depression Screening and Follow-Up for Adolescents and Adults BH Integration Depression Remission or Response for Adolescents and Adults Chronic Care Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) Chronic Care Controlling High Blood Pressure Chronic Care Asthma Medication Ratio Maternity Care Prenatal and Postpartum Care (Postpartum Care) Maternity Care Prenatal and Postpartum Care (Timeliness of Prenatal Care) Maternity Care Prenatal Depression Screening and Follow-Up Maternity Care Postpartum Depression Screening and Follow-Up Patient Experience of Access and Care CG-CAHPS (Consumer Assessment of Healthcare Providers and Systems): Getting Needed Care Patient Experience of Access and Care CG-CAHPS: Getting Care Quickly * Gate measures Source: Federally Qualified Health Center Alternative Payment Model (FQHC APM): Overview (PDF), DHCS, September 30, 2022. California Health Care Foundation www.chcf.org 19 The Bottom Line Additional Financial Considerations Achieving financial success under FQHC APM will The shift from PPS payments to PMPM payments likely require your center to serve a greater num- will require significant changes in how you manage ber of patients through less or alternative touches your health center financially. Transitioning success- or both, while maintaining or improving quality. fully to FQHC APM will likely require your FQHC to: Doing so would create a wedge that would allow your center to perform better financially than it $ Understand your current financial situation would under PPS for the same number of encoun- and how it will be affected by FQHC APM ters. However, it is also important to note that your center cannot perform worse financially under the $ Understand your payer mix proposed FQHC APM formula than under the PPS $ More closely track and manage utilization encounter-based model. As Table 7 shows, the only difference in revenues under APM versus PPS is that Understanding Your Current Financial if the number of encounters decreases, the wedge Situation will keep revenues steady. To develop effective financial strategies to suc- ceed under FQHC APM, you must understand Table 7. Effect on Revenue Under FQHC APM and PPS your health center's current financial situation. This Payments and Utilization will likely include digging into some elements that your health center is already familiar with, such as PAYMENT NUMBER OF PPS EFFECT ON METHOD ENCOUNTERS REVENUE your payer mix, as well as some elements that you currently track but may need to track differently to PPS Up Up function well under FQHC APM, such as utilization. PPS Steady Steady Your existing financial records should be examined both at a high level (revenue, expenses, profit and PPS Down Down loss) as well as an operational level (payer mix, FQHC APM Up Up utilization, cost per patient visit, cost per patient) to understand how your center is performing. FQHC APM Steady Steady The more detail you can gain, the more you can FQHC APM Down Steady (Creates understand your current financial structure and per- Wedge) formance, which will position you better to succeed under FQHC APM. Source: Author-created table showing the effects of revenue under FQHC APM and PPS payments and utilization in the California Federally Qualified Health Centers Alternative Payment Model Implementation Guide, California Health Care Foundation, 2023. Even though the PMPM rates under FQHC APM will be calculated for you, you will need to under- In addition to creating the wedge, your FQHC could stand the true costs of providing care under this also maximize revenues by increasing the number more predictable revenue stream. For example, it of assigned patients in future years. This would be might be helpful to calculate the following: easiest to do in conjunction with the wedge, which would create the "virtual capacity" to care for addi- $ Cost of an average patient visit tional patients. $ Average annual cost per patient served $ Cost of specific intervention or service California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 20 $ Cost of alternative touches be unnecessarily burdensome. Conversely, some FQHCs may consider it a low-risk opportunity to $ Percentage of currently served patients that test the PMPM payment model with a small portion will be included in FQHC APM versus PPS or of the population. other payment structures While your health center's payer mix will likely not These values could also be stratified by condi- change significantly as a result of participation in tions, demographics, or other criteria to get a more FQHC APM, the size of your current population detailed look. Once these values are known, they eligible under FQHC APM may influence your cen- can be compared with PPS rates, PMPM rates, or ter's approach to the program. It will also inform other calculations to provide valuable data to help your financial plan, as only a portion of your health your center understand how it is performing in the center's revenue will be coming through the FQHC new APM. Potential information that might be help- APM payment structure. ful to calculate include these: Tracking and Managing Utilization $ Cost of an average patient visit versus PPS rate The most fundamental shift under the FQHC APM $ PMPM rates versus average PPS revenue per payment structure will be how utilization is incentiv- patient per month ized. Under PPS, your health center was financially incentivized to have as many encounters with $ PMPM rate versus (average visits per patient × patients as possible, which includes perverse incen- cost of average patient visit) tives such as providing needed services separately over multiple visits to maximize revenue, which is These data can help identify high-value services not optimal, patient-centered care. Under FQHC or areas where costs could be streamlined due to APM's PMPM structure, the opposite is true. Your greater efficiency, optimized staffing, and other health center will be financially incentivized to see means. patients as little as possible because you will be paid the PMPM whether the patient needs services Payer Mix or not. However, this does not mean that patient Your health center's payer mix is an important con- access will be reduced under FQHC APM, as the sideration for participating successfully in the FQHC quality metrics in place will help assure that patient APM. Due to the nature of most FQHCs' patient care is being delivered efficiently and effectively, populations, Medi-Cal patients who would be and if your assigned patients decide to seek care included in FQHC APM will likely represent a large elsewhere, they may be assigned to other Medi-Cal proportion of many FQHC's assigned patients, thus providers in future years. providing impetus for organization-wide change of patient workflows, care models, staffing, and financial strategy. However, if your FQHC's Medi- "Increase your timeline by a factor of two. It Cal population has many Medi-Cal FFS patients, takes more time than you think to plan and people dually eligible for Medicare and Medi-Cal, implement." or Medicare, commercial, or uninsured patients who will still be under PPS, implementing such -Oregon FQHC leader a dramatic organization-wide change for a rela- tively smaller population under FQHC APM could California Health Care Foundation www.chcf.org 21 While your health center probably tracks utilization purely on utilization at other provider organizations in some way beyond encounters, the way it does (e.g., an inpatient hospital stay). However, because so may need to change to reduce costs rather than many quality metrics reward positive health out- maximize volume, which may also affect care man- comes and decreased utilization at high-cost or agement workflows. For example, internal policies inappropriate care settings, tracking those activities and procedures may currently call for an in-person may be worthwhile as well. See Section 6 for strate- follow-up physician visit to discuss test results to gen- gies for engaging MCPs and external providers to erate another billable encounter, but under FQHC share data and coordinate care for your patients. APM, your health center may consider providing a more cost-effective phone call from a registered For these reasons, if the majority of your FQHC's nurse (RN) to follow up with the patient. Your center patients are assigned to the FQHC under FQHC may also choose to provide preventive care in new APM, your FQHC may want to consider shifting to ways, such as through group visits (which combine a cost-based budgeting strategy since revenue will clinical care, health education, and peer support) or likely be more stable and predictable. Such a strat- home visits. These visits are potentially beneficial, egy would allow your FQHC to optimize efficiency cost-effective, patient-centered services but would in operations and processes, right-size staffing, and not be defined as PPS encounters. Since FQHC allow staff to practice to the top of their licenses. APM is not a total cost of care–based payment Analyzing existing processes with this frame of ref- model that tracks patients' utilization and costs erence may also uncover opportunities to add staff, outside the services provided by the FQHC, your such as community health workers, peer navigators, health center will not have its payments adjusted social workers, and others. California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 22 SECTION 3. Focusing on Patients, Not Visits Overview of Care Delivery in FQHC IN THIS SECTION APM $ Overview of Care Delivery in FQHC APM Your care delivery model under an APM should be tailored to meet the needs of the individuals and $ Moving to APMs Means Transforming Tradi- tional Care Delivery families you care for. However, no organization moving to APMs should be starting from scratch in Set Goals and Measure Your Progress terms of transforming how care is delivered. If you Toward Them are ready to move to the APM, you will have already $ Expanding Who, How, and Where You engaged in a fair amount of practice transformation, Deliver Care to Best Meet Patient Needs whether you are a patient-centered medical home, $ Expanding Who Can Deliver Care or if over time you have made staffing changes and New Types of Visits been engaged in workflow redesign to make care more person-centered and accessible. New(ish) Types of Staff $ Facilitating Team-Based Care Delivery Empanelment Providers means physicians, nurse practitio- Standing Orders ners, certified nurse-midwives, and physician assistants or others, including some behav- EHR Permissions ioral health professionals like therapists and $ Expanding How Care Is Delivered psychiatrists licensed to diagnose and treat and provide medical or behavioral health care Phone Calls, Emails, Texts, and Patient or both. In the traditional FFS/PPS payment Portals model, these providers were the only staff who Group Visits could bill. $ Expanding Where Care Is Delivered Home Visits Telehealth However, you and your team will still want to think about how a change in the way your organization $ Managing Care in New Ways gets paid can help you go further with your care Care Management delivery model. For example, what types of care Trauma-Informed Care and services can now be delivered by staff other than a provider? What current staff could take on new roles? What kinds of training will they need? This is an opportunity to provide more compre- hensive, integrated care for your patients through a team-based approach. Not only will this team- based approach improve access to a wider range of services and care for your patients, it may also ultimately reduce burnout and stress for your staff. California Health Care Foundation www.chcf.org 23 With the implementation of APM, your health cen- metrics. Since payment is no longer directly tied to ter will focus on patients, not visits. Under APM your in-person visits with providers, health care opera- organization will receive a capitated (fixed) rate for tions no longer need to revolve solely around them. each patient assigned to your health center whether Under FQHC APM, some health care patient ser- you see them for a visit or not. You will no longer be vice revenue will still be tied to visits, but not all paid by each visit a patient has with a provider (FFS of it as previously in the FFS model. This gives you PPS payments). In the APM, unlike the old FFS PPS and your team the opportunity to think expansively model, your organization will benefit financially if about what types of care and services will result in your patients have better health outcomes. better outcomes for your patients. It also allows you to have all staff working at the top of their license The APM payment will be on a PMPM basis for for what they were trained to do. each patient, and your organization will receive a payment adjustment for performance on quality Old Model: Volume-Based / Provider Schedule Driven $ FFS delivery model $ Encounter-based billing $ Hamster wheel $ Highly variable income The more The more The more encounters financially patients with stable we see providers we are versus New APM/Value-Based Population Health Approach $ Capitated model provides flexibility to traditional scheduling and supports team-based care model $ Can improve provider and staff satisfaction and retention $ Risk-stratified care model $ Upside/downside risk contract The more we The more we improve the The more tailor our care health and financially to the needs of outcomes of stable our patients our patients we are Source: Adapted from "Value-Based Care Journey 2012–2022" (Mountain Family Health Centers presentation). California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 24 Any population health9 work your organization is Set Goals and Measure Your Progress engaged in will be an important foundation to build Toward Them on. Staff involved in population health manage- When you think about expanding your team-based ment should be key players in the APM redesign. care delivery model as you adapt APM, it is helpful Any team-based care approaches that you currently to first set goals about what you want to accom- use will also be a critical part of your care delivery plish. It is also important to think about how you will model and should grow and expand under FQHC track progress toward your goals: APM. Understanding who your patients are, what illnesses they have, what behavioral health condi- Work with Identify tions they have, and what health-related social leadership to which data needs (HRSNs) they have will be important informa- identify goals you have for your care to track tion to track. You will need data, and you will need redesign improvement to examine and discuss these data with providers and care team staff. Your care model and your staff- ing model, likely to be a team-based approach to care, should be in response to what you see in the Create plan Identify for closing data and should address the specific needs of your data gaps data tracking gaps specific patients. Nurses, social workers, care man- agers, care coordinators, and other staff delivering care alongside providers often improves access to a wider range of care and services for your patients. Following are some ideas about what data you might use to measure the success of your rede- signed care delivery and staffing model: Moving to APMs Means Transforming Traditional Care $ Quality and patient experience Delivery $ Patient access and care Changing how you deliver care to patients when you $ Financial sustainability are used to doing things a certain way can be hard to imagine. Helping everyone else at your health $ SDOH / HRSN center change how they have always done things $ Health equity–related data including race, can feel daunting. For tips on getting everyone on board and addressing people's fear of change, see ethnicity, language, and disability (RELD) Section 4. Also, remember that best practice is that $ Health disparities you and your colleagues do not change everything $ Diversity of staff and congruence of race and all at once. You are not going to do this overnight! Change takes time, and it is important to address ethnicity with patients this transformation methodically, one part at a time, $ Team composition so that no one feels overwhelmed. $ Team functioning and communication "Take your time, take it slow." $ Employee satisfaction including staff percep- tions of well-being and burnout -FQHC CAO, Colorado California Health Care Foundation www.chcf.org 25 If you choose any, or all, of these areas to focus on, Expanding Who, How, and Where work with your leadership and your team to iden- You Deliver Care to Best Meet tify specific goals within each area that you want Patient Needs to address. Make sure to identify how you will Health center staff who have already transitioned measure progress and identify if you already col- to an APM have underscored that an APM is all lect certain types of data that could help you track about moving to and fully embracing a team-based improvement. Try to build on what already exists at approach to care. To create high-functioning, inter- your organization. Also, for information on specific disciplinary care teams, you and your team will metrics that your organization will have to report on want to think about expanding roles of current for FQHC APM, see Section 2. team members, establishing competencies for new roles, recruiting additional staff, and assessing One benefit of implementing APM is that it allows training needs. It would also be valuable to think you to change staffing and care delivery processes about career ladders and opportunities for staff to better meet the needs of families and patients. By such as medical assistants (see page 28) regarding expanding how you deliver care and by whom care Mosaic Medical's approach to MAs), community is delivered, you can address some of the HRSNs of health workers, and any supervising changes or your patients. You also can better integrate behav- approaches that may be needed. ioral health care services and employ staff with lived experience to connect with the patients and fami- lies you serve. These and other care transformation Expanding Who Can Deliver Care changes give you an opportunity to provide higher In states where FQHCs are already being paid quality, comprehensive care that can reduce dispar- under APMs, a core part of FQHC care transforma- ities you may see across your patient population. tion has been the expansion of the types of care being delivered by an interdisciplinary care team. It is possible your organization may already have You will want to clearly identify new roles and enough data to understand where disparities in responsibilities for nonprovider staff who may now outcomes exist for the patients you care for. Using be asked to do things they did not do previously or health equity as a focus and working toward meet- that they provided before only as part of a visit with ing specific health equity metrics by collecting a provider. While you want to try to have everyone RELD data and reducing disparities for specific con- working to the top of their license, you'll also want ditions can also help you and your team think about to make sure you are not asking anyone to conduct what types of care and support your patients might duties that they are not licensed to perform. need more of. That in turn can help you think about new types of care and what staff might deliver it. To think more about this, here is an example that Finally, you will need to be able to produce a broad the Institute for Health Care Improvement uses in range of internal and external reports that capture "Team-Based Care: Optimizing Primary Care for the meaningful patient services provided outside of Patients and Providers"11 to illustrate how work can a traditional visit.10 be shared by different members of a team: Let's consider the example of a diabetic patient. Does a physician need to do their foot exam? No, a nurse can do the initial assessment. Does California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 26 a physician need to be the one to discuss their improved staff satisfaction and reduced turnover at dietary requirements and restrictions? No, in their organization. fact, a dietitian - given the specialization of their training - might be a more effective edu- Here are some additional ideas about staff that cator. By reassigning these responsibilities to you may want to consider adding to your inter- other care team members, the physician can disciplinary care teams to provide higher quality, then spend more time focusing on what matters person-centered care that can meet your popula- most to patients, such as communicating with tion health goals. Key roles include: patients, collaboratively setting goals, or using their expertise for more serious conditions. $ Behavioral health staff: therapists, social work- ers, peer counselors Make sure that what you are asking staff to do is $ Pharmacists/PharmDs congruent with what they are licensed or regulated to do. If you do not have these already, you may $ Nutritionists, educators want to develop competencies for each clinical $ Care managers role in your organization. Staff can then be trained and/or assessed on these competencies. This may $ Care coordinators be something you want in your onboarding pro- $ Community health workers cess with new staff as well. Even staff licensed to provide certain types of care or to perform certain See the upcoming section New(ish) Types of Staff tasks may need additional training or a refresher for more information. if they are going to handle different responsibili- ties than they had previously. Do not run the risk of Finally, if your organization is unionized, you may assuming staff can make this transition just because want to check in with union representatives as appli- you ask them to. cable before these changes start. It is important to ensure that the union supports any transitions for Without support and training you may find staff staff in terms of their roles or tasks. blocking your efforts because they are fearful or not feeling confident about what they are being asked New Types of Visits to do. It is also good to know that different staff Nurse encounters may have different concerns. For example, provid- LVNs and RNs can play a significant and impor- ers may need time before they fully trust that some tant role in team-based primary care, taking over tasks they may have done are now being done by substantial amounts of care and services that may other clinical and support staff. And nurses and have previously been unnecessarily handled by medical assistants, for example, may worry that this providers.12 Having nurses take on tasks and care change means they will be asked to take on even they can handle can free up providers to manage more work than they already do. Take the time to care for patients with more serious or complicated talk to staff about their concerns and to observe medical issues. how changes are impacting workflow and work- load. But remember, staff taking on new tasks and roles may also be a very positive opportunity for them to grow and attain skills. Many clinics report that this increase in responsibilities has frequently California Health Care Foundation www.chcf.org 27 presents an opportunity to create a career ladder RN Visits at Mountain Family Health for MAs, which can help reduce turnover and fur- Center (Colorado) Under APMs ther increase job satisfaction.15 $ Goal: 30% of visits seen by RNs $ 11–12 visits a day Resources: Expanding Medical Assistant $ Call center screens patients to determine Roles if they need to see a provider or can be $ New Roles for Medical Assistants in Inno- seen by a nurse vative Primary Care Practices16 $ Anurse facilitator reviews the nurse panel/ $ An Expanded Role for the Medical Assis- schedule each day tant in Primary Care: Evaluating a Training $ Maintainsseparate RN and medical assis- Pilot17 tant (MA) schedules $ How to Train Medical Assistants for Expanded Roles: AHRQ Webinar18 To get ideas about what expanded roles LVNs and RNs might play in your clinic, the following are examples Medical assistants are unlicensed personnel, and of roles of RNs in exemplary primary care practices:13 in California their scope of practice includes the following:19 $ Complex care management $ Facilitating prescription renewals $ Administering medication only by intrader- mal, subcutaneous, or intramuscular injections $ Patient education (including flu and pneumonia shots) $ Care coordination, including transitions of care $ Administering medication orally, sublingually, support when patients are moving between topically, vaginally, or rectally, or by provid- acute care settings such as hospitals into pri- ing a single dose to a patient for immediate mary care and to home self-administration $ Chronic disease management $ Administering by inhalation if medications are $ Planning and coordinating care with the clini- patient-specific and have been or will be rou- cal team tinely and repetitively administered by patient $ Performing venipuncture or skin puncture Medical assistant encounters (including "finger sticks") for the purpose of Medical assistants (MAs) are key staff in a team- withdrawing blood based primary care model, and using them to their $ Performing skin tests full capabilities can benefit both patients and MAs. Organizations who expand roles for MAs have $ Measuring and describing skin test reaction reported improved patient satisfaction measures, and making a record in the patient's chart and MAs who have played an increased role in $ Performing electrocardiograms the delivery of team-based primary care, although reporting higher workloads, state that they have greater job satisfaction.14 Moving to APMs also California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 28 $ Applying and removing bandages and dressings Resources: Incorporating CHWs in FQHCs $ Taking blood pressure and glucose monitor- $ Including Community Health Workers ing readings (CHWs) in Health Care Settings (PDF)22 $ Performing pregnancy and HIV testing $ Community Health Worker Core Con- sensus Project: CHW Assessment Toolkit (PDF)23 $ Community Health Worker Core Consen- Oregon's Mosaic Medicals' Investment in Medical Assistants sus Project Mosaic Medical developed a systemic, tiered $ Strategies to Improve the Integration of program to provide opportunities and career Community Health Workers into Health growth for MAs after APM was implemented. Care Teams: "A Little Fish in a Big Pond"24 Before doing so, MA advancement was not $ IntegratingCommunity Health Workers standardized and was not well-resourced. into Primary Care to Support Behavioral Mosaic Medical noticed the critical value that Health Service Delivery: A Pilot Study25 MAs have in team-based care and invested in $ IntegratingCommunity Health Workers them by developing MA training, competen- on Clinical Care Teams and in the Com- cies, and opportunities for MAs systemically munity26 (rather than by clinic). They also created an MA supervisor role to support MAs and to manage the program. CHW is a broad term that includes promotores de salud, health advocates, peer health advisors, and health navigators.27 One of the most important Interviews with other organizations that have things that CHWs bring to a care team in addi- implemented the APM at their FQHC stressed tion to their interactions with patients and families the importance of developing a standardized, is their lived experience (behavioral health, jus- tiered program for different levels of MA roles. tice-involved, etc.) and perspective. If you do not Additionally, investments in training, competencies, already use CHWs at your organization, you may and clear articulation of how MAs can advance in want to consider doing so under the APM. You can their roles was viewed as particularly important for hire them into your organization, or you can part- successfully implementing different levels of roles ner with a local CHW organization to provide this for MAs.20 type of support. CHWs can be an excellent way to address patients' health-related social needs, and New(ish) Types of Staff to build and maintain trust with the people you care Community health workers for - critically important if you are trying to reduce health disparities and drive more equitable care. The American Public Health Association defines a community health worker (CHW) as a frontline But bringing on new staff, particularly unlicensed public health worker who is a trusted member of staff, to work with patients and to be part of an a community or someone with a thorough under- interdisciplinary care team can be challenging if you standing of the community being served.21 do not have a clearly thought-out plan beforehand. You will want to have a strong grasp of what needs California Health Care Foundation www.chcf.org 29 to be in place before CHWs join your care teams. the CHWs will do and what their core skills are to Questions regarding the role of CHWs should be them and to care team staff. The Community Health discussed at both the leadership and the care Worker Core Consensus Project identified 10 core delivery level. roles and 11 core skills for CHWs:33 Following are some best practices. Core Roles 1. Cultural mediation among individuals, com- How to help CHWs integrate successfully into munities, and health and social service systems primary care teams 2. Providing culturally appropriate health educa- $ Provide clarity around the role of the CHWs tion and information and other members of the health care team to 3. Care coordination, case management, and avoid confusion and service duplication, avoid system navigation the tendency of providers to "dump" tasks on the CHW,28 and help avoid bias from other 4. P roviding coaching and social support care team members, especially for CHWs with 5. Advocating for individuals and communities lived experience (e.g., behavioral health, jus- tice involvement, etc.). 6. B uilding individual and community capacity $ Ensure opportunities for CHWs to share with 7. Providing direct service the team their unique perspectives and under- 8. Implementing individual and community standing of the community and the value of assessments community linkages. 29 9. Conducting outreach $ AllowCHWs to access and contribute to care team notes in electronic health records.30 10. Participating in evaluation and research $ Engage leadership champions to educate Core Skills staff about the role of the CHW before and throughout CHW program implementation.31 1. Communication $ Set up a standard way to assessment CHWs' 2. Interpersonal and relationship building skills. 3. Service coordination and navigation $ Offer individual caseloads for CHWs instead 4. Capacity building of shared patients/clients to avoid duplicating the work of other care team members. 5. Advocacy $ Provide training and structured supervision for 6. Education and facilitation CHWs and include them in team meetings.32 7. Individual and community assessment Determining Core Roles and Core Skills of 8. Outreach CHWs 9. Professional and conduct Since clarity around the role of CHWs is a best prac- 10. Evaluation and research tice for successful integration and acceptance onto a care team, you will want to clearly identify what 11. Knowledge base California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 30 Your CHW program is more likely to succeed if the If you use pharmacists, you will want to think about perspectives of CHWs, who know their own roles how you can best support their success in your and unique challenges within the target populations FQHC and as members of your care teams. and the community, are considered.34 Periodically, sharing the success of CHWs with CHC leadership and the entire care team gives value and credibility Resources: Incorporating Pharmacists in to the CHW profession. Demonstrating the results FQHCs of their work fosters respect within the care team $ Pharmacist Care in Federally Qualified and supports the sustainability of these positions.35 Health Centers: A Narrative Review40 $ Pharmacistsin Federally Qualified Health Pharmacists and Pharmacy Technichians Centers: Models of Care to Improve Many FQHCs use, or are starting to use, pharma- Chronic Disease41 cists and/or pharmacy technicians (pharm techs) $ Integration of Pharmacy Teams into as key members of the interprofessional primary Primary Care care team. These clinical staff can play an impor- tant role in the care of those with chronic and acute conditions. Some of the results that FQHCs have seen with the use of pharmacists and pharm techs What helps pharmacists integrate successfully included improved medical outcomes, achievement into primary care teams? of clinical metrics, helping clinics reach national $ Clinicians directly referring patients to standards, and increased patient access to care and pharmacists medication.36 Pharmacists and pharm techs may be $ Patientvisits with pharmacists separate from especially useful in providing medication therapy dispensing functions management (MTM), a multifaceted approach of reviewing medications, identifying and remedying $ Availabilityof private rooms for pharmacist medication-related problems, providing disease and patient meetings state management and self-management educa- $ Clinicians' prior experience collaborating with tion, addressing medication adherence issues, and pharmacists on patient care, and pharmacists considering preventive health strategies to opti- with experience providing comprehensive mize medication-related health.37 The use of pharm MTM techs as part of primary care teams has also been noted to reduce total cost of care by reducing acute $ Educatingnonclinicians and other clinic staff care utilization costs.38 on MTM (what it entails, what its benefits are) $ Educating patients and clinicians on the role If you use pharmacists and/or pharm techs, you will of pharmacists to improve understanding and want to think about how you can best support their participation42 success in your FQHC and as members of your care teams. Some tips for thinking about approaching this include securing physician and provider leader- ship commitment to this staffing model, identifying high risk populations for interventions, and work- ing closely with clinic staff to integrate pharmacists and/or pharm techs into clinic workflow.39 California Health Care Foundation www.chcf.org 31 Facilitating Team-Based Care or direct order from the attending provider at the Delivery time of the interaction.46 Many organizations have set up standing orders to help streamline the deliv- Empanelment ery of care. Some examples of how this can work Empanelment is the act of assigning patients to cer- include standing orders for: tain primary care providers (PCPs) and care teams, with sensitivity to patient and family preference. $ Immunizations, flu and COVID vaccines Under APM it also can apply to RNs, LVNs, and MAs, who also may have a group of patients who like to $ Lab testing see them when those patients need their services. $ Routine screenings such as mammograms and Patients can reliably visit or have an appointment fecal immunochemical testing for colorectal with their same provider or staff person any time cancer they need care. Empanelment is the basis for pop- ulation health management, and it prioritizes the $ Pregnancy testing relationship that patients have with clinical staff as a $ HIV testing critical part of high-quality care. The goal of focusing on a population of patients is to ensure that every EHR Permissions established patient receives optimal care, whether Depending on how your EHR permissions were set or not they regularly come in for visits. Accepting up before APM, you may need to update them so responsibility for a finite number of patients, instead that non-provider staff can document in the appro- of the universe of patients seeking care in the prac- priate places in your EHR. See Section 5 for more tice, allows the provider and care team to focus information about EHRs. more directly on the needs of each patient.43 Expanding How Care Is Delivered Resources on Empanelment Phone Calls, Emails, Texts, and Patient $ Empanelment: How to Form Patient Pan- Portals els in Primary Care44 Communicating with patients outside of office visits $ SafetyNet Initiative, Empanelment: might have been discouraged under the old PPS Establishing Patient-Provider Relationships payment model. With the APM there is no reason (PDF)45 to not communicate with patients by phone, email, patient portal, or text (assuming it can be done securely), especially if it may help them with their Standing Orders health issues. Standing orders authorize nurses, pharmacists, and other appropriately trained health care personnel, where allowed by state law, to assess a patient's Telehealth Visits and Phone Calls Can immunization status and to administer vaccinations Help Relieve Stress for Providers according to a protocol approved by a medical One FQHC in Oregon set up blocks of tel- director in a health care setting, a physician, or ephonic visits for each provider so that they another authorized practitioner. Standing orders got a break from seeing patients with complex work by enabling assessment and vaccination of the health needs all day long. patient without the need for clinician examination California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 32 Billing and payment are not connected to in-person Group therapy visits can also be helpful for those visits under APM; improving health for your patients with behavioral health diagnoses, and research is. If it is clinically indicated, patients should be shows that group therapy is just as effective - if not brought into the office. However, if care or advice more so - than individual therapy.54 There are two or a consultation can just as easily be delivered by predominant kinds of group psychotherapy. In a phone, telehealth, or through secure messaging, it heterogeneous group, people with different symp- should be provided that way. Patients who call the toms and diagnoses come together and explore clinic can be offered the option of a telehealth visit their interpersonal relationships via the social micro- or phone call rather than being required to make an cosm of the group; for example, a Black women's appointment for an office visit. group that focuses on single parenting, or a men's group that focuses on substance use. In homoge- Group Visits neous groups, currently the most popular group Group medical visits are a clinic-based intervention therapy format, people come together to explore that aims to improve patient health by combining their shared problem or diagnosis.55 clinical care, health education, and peer support. Research shows that group visits can provide a way Some examples of common conditions that group for patients and providers to interact that can posi- visits can focus on include: tively impact health care inequalities.47 Group visits, in addition to providing medical care, can provide $ Substance use disorder the added benefit of community and support. This $ PTSD peer support may have lasting benefits for people's health and help those managing a chronic condi- $ Grief tion to be able to engage in better self-care. $ Dealing with specific physical illnesses $ Anxiety Resources: Group Visits $ Depression $ GroupMedical Visits as Participatory Care $ Bipolar disorder in Community Health Centers48 $ Integrated Center for Group Medical Visits $ Caregiving $ Comparing Two Approaches to Group $ Eating disorders Medical Visits for Patients with Diabetes49 $ Example of Diabetes Group Visits Curricu- lum from Serve the People Health Center (PDF)50 $ Centering Pregnancy Care51 $ SAMHSA Resources on Group Therapy for Substance Abuse52 $ Guidefor Clinicians Leading Substance Abuse Group Therapy53 California Health Care Foundation www.chcf.org 33 home from the hospital or other acute or long-term Resources: Home-Based Services care facilities. $ ACOs Use Home Visits to Improve Care Management, Identify Needs, and Reduce Primary care provided in the home can increase Hospital Use56 access and reduce risks for certain high-risk popula- $ The Team Approach to Home-Based tions who have complex health or social needs or Primary Care: Restructuring Care to Meet both. In particular, homebound, and functionally Patient, Program, and System Needs57 limited patients, may have significant challenges $ FourTips for Adding House Calls to Your accessing office-based primary care.59 According Practice58 to a Home-Based Primary Care Interventions Systematic Review by AHRQ, home-based primary care can better address the needs, values, and pref- erences of chronically ill, frail, and disabled patients If you have previously done group visits, you know who have difficulty accessing traditional office- that these visits have always required that the based care.60 The potential benefits of home-based provider signs off on every patient so that all the primary care include: patients can be billed for. You will no longer need $ Increased access to care for people who to do this. But when considering implementing group visits at your center, think about what makes have difficulty traveling to outpatient medical the most sense given the types of patients you care offices or for whom going to a medical office for and examine your clinic data if you need help is contraindicated thinking about what kind of group visits or sessions $ Better understanding of patients' environ- might help your patients specifically. ments, needs, and constraints that can improve care and outcomes Expanding Where Care Is Delivered $ Decreased hospitalizations and urgent care Under FQHC APM, you will have more options in use when acute incidents are prevented or how and where care is delivered. For example, cer- addressed in the home tain types of care or services can now be delivered $ Potential for prevention or slowing of func- in the home. This approach can improve patient and tional and cognitive decline family engagement and can significantly improve $ Better support for and reduced burden on outcomes for those patients who may have trouble coming to the office. family caregivers $ Increased satisfaction of patients and Home Visits providers 61 APMs allow you to deliver care outside of the walls of the clinic. You and your team will want to think According to the American Academy of Family about what care and services can be delivered only Physicians, the best candidates for home visits are in the clinic and what might be better delivered in patients with complex or high-risk conditions who the home, or at least provided as an option to be have difficulty getting to the office, including: delivered at home. Home visits can also be use- $ Frail older adults with multiple (often five or ful for providing care management and transition of care support to those who have recently come more) chronic conditions and deficiencies in activities of daily living California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 34 $ Younger homebound patients, usually with the clinic. It may also be a way to manage burnout one principal neuromuscular condition such and improve quality of life for clinical staff, provid- as multiple sclerosis, amyotrophic lateral ing them time to work remotely, which can improve sclerosis, or cervical spine injuries (some on retention rates. ventilators) $ Patients with high-risk diagnoses like con- gestive heart failure and chronic obstructive Resources: Telehealth pulmonary disease $ California Telehealth Resource Center $ APractical Guide to Expanding Home- $ Patientswith high hospital and emergency Based Primary Care with Telehealth65 department (ED) utilization in the past 6 to 12 $ FQHCS and Telehealth66 months $ How FQHCs are Conquering the Digital $ Patientswith hierarchical condition category Divide in Telehealth, Remote Monitoring67 (HCC) scores62 greater than 2.0 $ FQHC Telehealth Consortium Focuses on Addressing Health Disparities in Phase II $ Postacute transitional care management Work68 patients who would benefit from a short course $ Payment Reimbursement Tips: Mental of home-based primary care that reduces Health Telecommunications Services69 complications and readmissions63 $ Telehealthfor the Treatment of Serious Telehealth Mental Illness and Substance Use Disor- Although the California legislature approved parity ders (PDF)70 of phone and video visits with in-person visits64 so these visits were reimbursable as PPS visits, mov- ing to the APM can be an opportunity to move to Telehealth can also be a way to improve access or expand your telehealth program as part of the to behavioral health services for your patients. larger redesign of care delivery at your FQHC. Although the delivery of behavioral health through telehealth is not right for everyone, it can make this The use of telehealth can improve access to care for care accessible for populations who might not be patients and can advance health equity by increas- able to, or who do not feel comfortable, accessing ing access to care for marginalized and underserved care in the office. It can also be a person-centered communities. Telehealth is easier to provide under option for patients who prefer to engage in care APM. You do not have to use the complex cod- through telehealth. Patients should always have the ing needed for providing telehealth under the choice of receiving services in person but ideally FFS model. Also, providers have more freedom to can also choose a hybrid delivery of services (e.g., deliver care that patients need in the most appropri- receiving services in person some of the time and via ate, effective, and accessible form (e.g., video visit, telecommunications technology at other times).71 phone call, or in person) without worrying about Many behavioral health practices have seen that what is and is not covered. Lower expenditures when they offer behavioral health service through for providers and lower costs for patients may also telehealth, no-show rates for patients decrease.72 come with the provision of telehealth, eliminating expenses such as transportation and childcare that Finally, telehealth may also increase your ability to patients might otherwise incur if they had to visit get care to people in rural areas, and it may improve California Health Care Foundation www.chcf.org 35 access for those in urban areas where there may be health and social needs. Sometimes payers or longer waits for appointments. Medicaid managed care organizations are also pro- viding care management to members they consider Some questions to consider in expanding or begin- high risk. It is worth exploring at the organizational ning telehealth visits as part of your move to APMs: level whether this is the case and for which patients and which plans so that services are not being dupli- $ What will be the workforce implications of mov- cated, patients are not confused about which care ing some proportion of visits to telehealth? manager is their primary care manager, and mul- tiple care managers can coordinate with each other. $ What staff will you need more or less of? $ Are there some types of visits or patients that Key components of care management include: you will want to primarily move to telehealth? $ Identifying and engaging high-risk or at-risk You and your team will want to have a clearly patients thought-out strategy for when you will provide in- $ Providing a comprehensive assessment of person, telehealth, and hybrid options for care and their needs for what service and by what staff based on the needs of your patient population and your staffing $ Creating an individual care plan model and care model goals. $ Engaging in patient education $ Monitoring clinical conditions Managing Care in New Ways $ Coordinating needed services74 Care Management Borrowing from the Center for Health Care Strategies, You and your team will also want to think about AHRQ defines care management as a "promising, who will be offered care management and how you team-based, patient-centered approach 'designed group patients according to risk. to assist patients and their support systems in man- aging medical conditions and chronic illness more Identifying patients for care management effectively.'"73 Risk stratification is a technique for systematically categorizing patients based on their health status Providing care management for patients who are and other factors.75 It allows practices to manage high risk, or at risk of becoming high risk - whether patients based on their assigned risk level to due to medical, behavioral, or social needs - can make better use of limited resources, anticipate be another intervention in your value-based care needs, and more proactively manage their patient strategy under the APM. population.76 Care management usually involves intensive, one- The following risk groupings and descriptions of on-one services provided by a nurse or other health each group are from the Value Transformation worker (sometimes a social worker or even unli- Framework Action Guide by the National censed supervised staff) for those with complex Association of Community Health Centers.77 While there are other approaches to risk groupings, this list may help you consider how to think about California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 36 assigning your patients a risk level and where to A care manager works with patients to ensure focus your care management services. that they receive appropriate chronic disease management and preventive services. However please note that DHCS will be establish- $ Rising risk. This tier includes patients who ing a standardized risk stratification, segmentation, often have one or several chronic conditions or and tiering process for all Medi-Cal members via risk factors, and who move in and out of stabil- the PHM Program and PHM Service (see more in ity with their conditions. One analysis showed the DHCS CalAIM: Population Health Management that extending care management to this pop- Policy Guide). ulation reduced the number of patients who moved to the high-risk group by 12%, with a Risk groupings 10% decrease in overall costs.78 With rising- $ Highly complex. This is a small group of risk patients, successful models of care focus patients with the greatest care needs. This on managing risk factors more than disease group, likely less than 5% of the population, states. Common risk factors for this popula- has multiple complex illnesses, often includ- tion include obesity, smoking, blood pressure, ing psychosocial concerns or barriers. Care and cholesterol levels. Identifying these risks models for this population require intensive, enables staff to target the root causes of mul- proactive care management. The goal for this tiple conditions. group is to use lower-cost care management services to achieve better health outcomes $ Low risk. This group includes stable or healthy while preventing high-cost emergency or patients. These patients have minor conditions unnecessary acute care services. It is impor- that can be easily managed. The care model tant to remember that in California, some for this group aims to keep them healthy and patients who fall into this group may also engaged in the health care system, without qualify for ECM. The ECM provider will likely the use of unnecessary services. be the patient's health home but not always. If the FQHC is providing care management and The American Academy of Family Physicians (AAFP) the patient is also receiving care management suggests using a combination of objective data and services elsewhere, coordination between the subjective input to better assess a patient's risk various care managers and coordinators is level. essential. It is also best practice to discuss with the patient how multiple care managers will Here is an example combining objective data and work together to provide care for them. subjective input to arrive at a more accurate risk score for a particular patient: $ High risk. The next tier includes patients with multiple risk factors that, if left unmanaged, A patient with diabetes whose A1C is 9.2 could be would result in them transitioning into the categorized as high risk. However, consider that the highly complex group. It typically describes patient had an A1C of 12 earlier in the year but has about 20% of the patient population. This since begun exercising, lost 30 pounds, and started cohort of patients is appropriately engaged in taking his or her medication as prescribed. This sub- a structured care management program that jective data leads us to assign the patient a lower provides one-on-one support in managing risk level.79 medical, social, and care coordination needs. California Health Care Foundation www.chcf.org 37 The AAFP has also endorsed a two-step process $ Does the patient have complications of for identifying the sickest patients.80 They advise chronic disease or high-risk social determi- approaching risk stratification in the following way: nants of health? $ Isthe patient potentially in danger of dying or Step 1. Sort patients into one of three groups (high, being institutionalized within the next year?81 medium, and low) based on objective data you take from your EHR. Think about risk based on the pres- The AAFP states that "whatever method you use, ence or absence of factors such as: risk stratification should be seen as a dynamic pro- cess. You should reevaluate risk scores regularly and $ Chronic conditions as you become aware of changes in the patient's $ Advanced age status."82 $ Multiple comorbidities Best practices in care management $ Physical limitations The authors of Implementation of Care Management: An Analysis of Recent AHRQ Research reviewed $ Substance disorder and analyzed findings from 12 AHRQ projects and $ Lack of insurance summarized best practices in care management.83 Here are a few things they highlighted that may be $ Low health literacy helpful to keep in mind for your care management $ Frequent hospitalizations program. $ ED visits $ Recent major surgery or brain trauma Resources: Care Management and Risk $ Polypharmacy Stratification $ NAHC Value Transformation Framework $ Difficulty following a treatment plan Action Guide84 $ Two-Step Process for Identifying Your Sick- Step 2. Assign each patient to a risk level based on est Patients85 how your providers and staff answer the following $ AAFP risk stratification algorithm86 questions: $ Care Management: Implications for Medical Practice, Health Policy, and Health $ Isthe patient healthy with no medical prob- Services Research87 lems? If so, are the patient's biometrics in or $ Care Management: An Implementation out of range? Guide for Primary Care Practices88 $ Does the patient have chronic conditions but $ The Medical Home: Care Management89 is doing well? $ Does the patient have chronic conditions that Best practices included: are out of control but without complications? $ Care managers performing the following functions: California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 38 $ Self-management support - goal setting, circumstances that is experienced by an individual care plan development, motivational inter- as physically or emotionally harmful or life threat- viewing, behavior change counseling, health ening and that has lasting adverse effects on the education, self-care skills building individual's functioning and mental, physical, social, emotional, or spiritual well-being."92 $ Strengthening linkages and relationships - ongoing outreach and follow-up services, Examples of trauma include: transmission of clinical information during transitions across the care continuum, linking $ Experiencing or observing physical, sexual, to community resources, building a continu- and emotional abuse ous relationship with patient and caregiver $ Childhood neglect $ Clinical care - medication reconciliation, assessment of adherence to treatment rec- $ Having a family member with a mental health ommendations, treatment intensification, or substance use disorder monitoring for adverse events $ Experiencing or witnessing violence in the $ Administration - participating in qual- community or while serving in the military ity improvement activities and care team $ Poverty, exposure to racism, and systemic meetings discrimination93 $ Care managers having a broad focus on issues not often addressed by primary care provid- Using a trauma-informed care approach at your ers - that is, looking at the patient's overall clinic can help to create an environment where resources and ability to follow through on the patients who may feel distrustful or have had nega- PCP's recommendations. tive experiences with the health care system can feel safe and where patients who may sometimes $ Care managers having their own high-risk feel unseen or unheard can feel welcome, seen, patient panels and meeting with providers regu- and listened to. Trauma-informed care can be a larly to discuss and coordinate the care of these powerful method for reducing health disparities, patients.90 providing more equitable care, and helping higher- risk patients engage in their care. Trauma-Informed Care People who come from marginalized communities What is trauma-informed care? and who have experienced poverty, likely a large Trauma-informed care seeks to: portion of your patients, are more apt to have trauma, and to have more difficulty recovering from $ Realizethe widespread impact of trauma and it.91 Trauma can have a profound negative impact understand paths for recovery on people's mental and physical health, on their ability to form trusting relationships, and on their $ Recognize the signs and symptoms of trauma ability to care for themselves or family members. in patients, families, and staff $ Integrate knowledge about trauma into poli- The Substance Abuse and Mental Health Services cies, procedures, and practices Administration states that "individual trauma results from an event, series of events, or set of $ Actively avoid re-traumatization94 California Health Care Foundation www.chcf.org 39 Resources to Support Trauma-Informed Care $ Trauma-Informed Care Implementation 95 Resource Center $ Key Ingredients for Successful Trauma- Informed Care Implementation96 $ Guideto Trauma-Informed Organizational Development97 Best practices and practical steps for implementing trauma-informed care include: $ Identifying a person or group of people who want to help the organization become trauma-informed $ Announcing to all staff the organization's com- mitment to becoming trauma-informed and initiating a continuous quality improvement or performance improvement plan $ Providing training from consultants/trainers with expertise in trauma-informed systems change98 California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 40 SECTION 4. Bringing Your Organization Along When you implement the APM, you may have the inclination to share only parts of the bigger pic- IN THIS SECTION ture transformation, or you may think that sharing $ Communicating Change information with clinical staff on a "need to know" $ Redesigning Care basis will be sufficient. Experiences from FQHCs in $ Create a Guiding Committee other states who have implemented an APM stress $ Coordinate with Operations, IT, Data, the importance of being transparent with all staff. Quality, and Finance Teams In fact, most FQHC interviewees who have been $ Create a Sense of Urgency through this advised that erring on the side of shar- ing more information, rather than less, is the best $ What This Change Means for You approach. $ Clinical Staff $ Leadership Change management experts advise that when $ Operations and Finance change is happening, you want to share why change $ The Board is happening, you want to do so multiple times, $ Payers and Funders and you want to get the message out through mul- tiple channels and messengers. You also want to $ Unions (as Applicable) make yourself and leadership available to hear and $ Patients answer the questions that people have. $ Understanding Loss Is Part of Making Posi- tive Change As one FQHC staff member in the workgroup $ Leading the Change stated, "If you don't share information about why $ UsingStrategies from Implementation and how a change will take place, staff will simply Science to Help Guide Practice Transfor- make up ideas about what is not shared with them." mation Redesigning Care Create a Guiding Committee As you begin your care redesign process, you will Communicating Change want to pull together a committee or group of Managing and leading the transition to FQHC APM internal advisors who work at your FQHC to pro- requires a strategy and preparation for how you will vide input and guidance around needed changes communicate with staff, colleagues, leadership, and and to receive feedback on how things are going as your board. It requires listening to staff and stake- implementation progresses. holders at all levels of the organization. It means communicating different messages at different You want to get multiple perspectives on the patient phases of the work. It means relying on deputies experience, as well as the experience of delivering and champions to help get the message out and care and the entire workflow in the current setup so ensuring that questions or concerns are coming that improvements can be identified. For example, back to you and your team. you may want to include: California Health Care Foundation www.chcf.org 41 $ Front desk staff authority and power (e.g., providers), feel like they can prepare some ideas and get ready to partici- $ Medical assistants and lab techs pate in brainstorming. Agendas also help busier $ Community health workers, peer counselors, people to understand what will be discussed and HIV counselors why they should attend. Make sure that calendars are blocked if these meetings are taking place $ Referral coordinators when patients are normally seen so that clinical staff $ Care coordinators, care managers, and referral can attend and you have leadership buy-in for the coordinators meetings. Remember to discuss care models that you will base the work on and which metrics you $ Nurses, social workers, and behaviorists will focus on. $ Providers and the medical director Ask the team to think about how they would $ Any other staff who work with patients or has a describe the patients you care for. If how you deliv- window into patient and staff experience ered care could be changed to better meet your patients' needs, what would it look like? You want At this point in the brainstorming process you want to make it clear at this stage that the mandate for to strive to let everyone have a say, to allow every- the group is to think expansively and creatively and one's voice to be heard. This approach also sets truly brainstorm about new ways of delivering care. the tone for the more team-based model you will be moving toward. These meetings need a leader Following are sample questions to spur discussions or a facilitator, but part of their role is to draw out with staff: diverse opinions to get the best ideas on the table about how care can be improved. $ Do our patients need more access to ser- vices like behavioral health or case/care management? Ensuring That Providers Feel Supported and Are On Board with the Care $ What types of care or services could be Changes of the FQHC APM delivered by a registered nurse or a licensed At one FQHC organization, the chief medi- vocational nurse? What types by a medical cal officer (CMO) set up one-hour meetings assistant or licensed practical nurse? with every provider in the organization to talk $ What types of visits must be conducted by a with them about what this change meant for them and to answer their questions. While provider? these interviews were time-intensive, the CMO $ Are there patients who might benefit or prefer reported they were extremely effective. They a home visit or telehealth visit instead of an also allowed the CMO to learn about any in-person visit? concerns the providers had so they could be addressed ahead of time. $ What is the current state of our telehealth vis- its? What would it look like if nurses, social workers, care managers, or peer counselors It is helpful to share agendas before meetings so could deliver care through telehealth if they that staff who struggle to talk in groups, especially are not already? in front of those who traditionally hold the most California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 42 $ What kind of care might be improved through Create a Sense of Urgency group visits? Change management experts and those who have already done this work stress that you want to create $ What kind of data would be helpful (e.g., a sense of urgency. Even if people seem excited to population health, quality improvement, make changes when new concepts are introduced, demographics) to help you understand who they may begin to doubt that now is the right time your patients are and what common issues to make changes. Others may doubt right from the they may have? start that a change will be positive. Coordinate with Operations, IT, Data, Quality, and Finance Teams While redesign discussions are happening, it is Lessons from the Executive Team at important to coordinate with any operations, IT, Virginia Garcia Health and Other FQHCs in Oregon data, quality, or finance teams. Keep them in the At Virginia Garcia Health Center in Oregon, loop and make sure that parallel discussions are the executive team dispersed across clinics happening with them, as well as having them and had ongoing discussions at staff meetings attend some meetings where they can hear the dis- about their short- and long-term goals. cussions the clinical redesign team are having. For any process improvements or care redesign to suc- At another clinic in Oregon, the CMO set aside ceed, you will need to coordinate closely with these an hour in each provider's schedule to meet other teams. with them. While this took time, it was valuable in aligning the providers and the health center as a whole. Lessons from Leadership at Community Care Cooperative in Massachusetts Your first task is to demonstrate why now? What FQHC leaders across the country have used are the benefits of doing this now, and what are different strategies to improve communication the risks of not doing this now? Some reasons you about change. Community Care Cooperative might share include: (C3) is a nonprofit accountable care organiza- tion governed by 18 FQHCs in Massachusetts. $ Providing more flexibility. The APM provides At C3, the CEO, CMO, and chief financial officer (CFO) wrote letters to each other regard- flexibility for FQHCs to offer more comprehen- ing their movement toward APM. Their letters sive care to patients while allowing clinical staff openly addressed what they needed to be suc- to offer enhanced care sustainably. cessful in their own role and what they needed $ Reducing staff burnout. The team-based care from their colleagues. This strategy aimed to model can help reduce burnout and turnover facilitate communication, work through chal- because it spreads accountability across the team lenges, and develop alignment. and allows all staff to take on more responsibility. $ Addressing care gaps. Implementing the APM allows the organization the flexibility to deliver care that can address previously noted gaps (for example, through nurse visits, complex care management, or mental health services). California Health Care Foundation www.chcf.org 43 $ Reducing that "hamster wheel" feeling. "Don't jump. Use phases. Develop an on- Improving and transforming the care delivery ramp. Make the process incremental." and staffing model can reduce the "hamster -FQHC CEO, Oregon wheel" feeling that providers often have see- ing patients in short visits back-to-back all day. However, it may increase certain kinds of work for Interviewees stressed the importance of develop- other clinical staff. ing "strategic pathways toward value" and having leadership understand the importance of grow- $ Working at the "top of license." To get every- ing the organization's data and analytics capacity. one working at the top of their license, your Leadership's commitment to the necessary culture organization will need to invest in and build change required for the APM must take place for adaptive reserves and the capacity of those staff the care delivery improvement and redesign to be who will be taking on tasks or roles they may not successful. have occupied previously. Operations and Finance It is critical that operations and finance staff have What This Change Means for You an understanding and are on board for the APM Clinical Staff implementation. As one interviewee stated, "You Those who have been through this process stress need to get the CEO, CMO, and CFO on the same the importance of talking to staff about their chang- page or nothing is going to work." ing roles and what the impact of that looks like on a day-to-day basis. Best practice is to try to stand Other best practices include making sure to com- in their shoes and listen to their preferences, con- municate clearly to operations and finance staff that cerns, and opinions on an ongoing basis. the organization will have a foot in both the FFS world and the APM world. There will be both capi- Also, it is good to remember that the communica- tated payment for services under FQHC APM, and tion and messaging you develop to gain support FFS for services not included in FQHC APM (e.g., internally for APM can be used to recruit providers Medicaid dental, Medicare, commercial insurance, and other clinical staff to work at your FQHC. There etc.). This is a substantial change! are many clinicians who want to work in an environ- ment where the focus of the day is purely and truly The Board on improving the health outcomes of patients with- Similarly, interviewees stressed the importance of out the stress of meeting productivity metrics and buy-in from the board before embarking on the APM worrying about how many billable visits a day are journey. You, your team, and leadership will want to taking place. know how much the board understands about how your FQHC gets paid. As one interviewee stated, Leadership "Not all FQHC board members have a deep back- Key takeaways from those who have been through ground in finance and accounting. If the board is this process include the importance of buy-in from confused, they will not make good decisions." Most leadership and solid agreement across all levels of board members prefer receiving information at a staff and departments on why the organization was high level and may not need to know all the details moving to the APM and what that meant for care of the payment model, for example. and staffing redesign. California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 44 "Get buy-in from your board. Bringing them efficiency of care for those who are higher risk and higher cost may also help funders understand the in early will help keep things moving." benefits of the transition. -FQHC CEO, Oregon Unions (as Applicable) Training for the board on the APM and how it fits in For leaders of organizations with unionized staff, it with the visions of care may also be helpful. It will will be key to partner with union leadership so both be important for the board to understand that the union and management see the importance and reports they are used to reviewing will start to look value in pursuing APM. This may take some time to different. develop. One helpful model to look at is the Kaiser Labor Management Partnership.99 "Leadership was not brought in at the You will want to have early conversations with the beginning, and that slowed us down." union regarding how the roles of unionized staff -FQHC CEO, Oregon may need to change under APM. It is also impor- tant to review what is not changing. Specifically, you may want to discuss and highlight with the union Here are some points you may want to review with and union staff that under APM, staff will be work- your board before and during the transition to APM: ing to their full scope. If broadening the scope of certain staff is relevant, it is also something to raise $ What is FQHC APM? What will it mean for our with the union in the beginning of this process to health center? gauge interest and to see if it could be of value to $ How does the APM work with VBP models? their membership. $ What are financial indicators (e.g., dashboards) Patients for APM? It is important to have a dedicated time and a strat- $ What services will still be FFS? egy to hear from and communicate directly with patients about how this change will and will not $ What are samples of financial reports (from affect them. Two-way communication about the Oregon health centers in APM)? APM and expected change is important to have $ What are care model changes that will be with your patients if you want patients to continue implemented? to seek care at your clinic. Payers and Funders "With patients it was surprisingly the hardest. Medi-Cal payers in California are compelled to par- Patients were afraid they would be blocked ticipate in APM, so they likely understand the "why" behind this change. Still, many interviewees cau- from care. We made flyers with pictures of tioned to not forget about payers and funders during the care team members connected with the this transition. For funders and donors in particular, primary care doctor and provided ways to workgroup participants shared that emphasizing "enhancements" over "change" is the best way to reach them all." communicate what is taking place. Demonstrating -FQHC staff in OR how the APM will improve the effectiveness and California Health Care Foundation www.chcf.org 45 Some ideas for supporting two-way communication Leading the Change with patients are to: Interviewees with FQHCs in other states with mul- tiple sites that have gone through this transition $ Establish patient advisory groups. had this advice: "Focus on one clinic first, possibly $ Solicit input from patients about what this the one that has the most challenges. Once things change means for them. are running smoothly there, you can test out and spread these processes to another clinic, and then $ Develop clear messaging about what will to all of them." and will not be changing for patients. For example, depending on your plan you might Using Strategies from Implementation tell patients that this change will not affect Science to Help Guide Practice access to the doctors and clinical staff they Transformation are used to seeing. But you also might tell You and your colleagues are likely already familiar them that this change will make it easier to with Plan-Do-Study-Act cycles and the Model for get an appointment or to reach clinical staff by Improvement,102 and this approach may help you phone, receive care at home or by a telehealth evaluate and refine the changes you are imple- appointment, etc. Try to stand in their shoes menting as part of your care model redesign under and think about what their concerns might be. APM. It is important to make sure that you are not Do not just imagine what their fears are, ask implementing changes that have not been thor- them. oughly assessed before you spread and scale them more broadly. Here are tips for how to think about Understanding That Loss Is Part of this process: Making Positive Change When an organization or group of people is asked Take a modular approach to change: to undertake change - even when it is seen as a positive and welcome change - some, if not $ Go one clinic at a time, or even one "team" at all, members involved will feel a sense of loss.100 a time within a clinic. Ignoring this feeling that your employees may $ Test out the proposed changes with one team experience, failing to validate or discuss it, can cre- or clinic first. ate roadblocks for your organization as staff resist going along with change. $ Use the results of tests of change to decide if the test was successful. As leaders at your organization, you may have $ Identify and address challenges before adopt- already had time to work through any feelings of ing further changes. loss or anxiety you have about the coming change, but you must allow space for others to do this as well and recognize these kinds of reactions as nor- Resources: Scaling and Spreading mal parts of the change management process. Changes What is often below that feeling of loss is not a fear $ Spreadingand Scaling up Innovation and of change but a fear of not being successful in a Improvement103 new way.101 $ Scalingand Spreading Innovation in Health Care Delivery104 California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 46 Scale changes more broadly once you are confident that a change is working and that staff are on board with the change: $ What works at one site may also work at another or may need to be evaluated individ- ually at each site and adjusted based on the needs of that location, staff, and patients. $ Continue to use data and metrics to measure how the change is going both at individual sites and across the organization as a whole. California Health Care Foundation www.chcf.org 47 SECTION 5. Data: Your Success Depends on It are essential for quality improvement and for meet- ing required benchmarks. IN THIS SECTION $ The Importance of Data in FQHC APM Sharing data is also critical to demonstrating your $ What Data Do You Need to Collect? accomplishments and highlighting any gaps. Your $ Quality health center needs to have an EHR that allows $ Alternative Touches providers to capture and exchange data, support $ Patient Care and Engagement care coordination inside and outside the practice, and monitor and generate reports on targeted met- $ Risk Stratification rics (that require EHR data). You will want to make $ Utilization and Financial Monitoring sure that staff have access to any new training - $ Patientand Provider Experience and provided by your health center or offered through Satisfaction outside organizations - they may need to input $ Health Equity specific data or notes, use correct coding, and fully $ How Do You Ensure Your Data Are Accurate? utilize EHR functionality. Your health center must $ Defining "Good Data" also have the infrastructure to share data between health plans, state agencies, and external provid- $ Ensuring Accurate and Comprehensive Coding and Data Entry ers. Being able to share and act on data in real time and across a wide range of providers is helpful for $ Correcting Data effective care coordination. Data are also important $ What Changes Do You Need to Make to for future rate setting that impacts your revenue. Your Current Data Infrastructure? $ Creating a Data Governance Plan "Someone cares about the work I do because $ Considering Staffing Needs $ Identifying EHR Changes and Optimization someone is tracking the work I do." -FQHC CMO, Oregon This section highlights key data considerations and how they relate to the various topics described in The Importance of Data in FQHC this guide. For greater detail about how to use data APM in those specific topics (e.g., caring for patients), Data are critical to your success in FQHC APM. please refer to those sections. Patient-level data are important for engaging patients, managing care, tracking care transitions, addressing health-related social needs, stratifying What Data Do You Need to Collect? risk, and providing insights on population health. The following section describes the kinds of data Financial data, including utilization and revenue, you will need to collect and how they will be used will help you determine if your health center is per- in FQHC APM. Appendix B provides an overview forming well financially. Clinical and process data of data elements and data sharing requirements under FQHC APM. California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 48 Quality to community supports when necessary. To track As described in Section 2, your FQHC will be HRSN under FQHC APM, DHCS is directing health required to track a set of quality measures, that will centers to use only the 18 Z codes outlined for In be reported to DHCS by the MCPs, to ensure you Lieu of Services. are meeting the initiative's quality goals. The list of quality metrics can be found in Table 6. Many of Additionally, under a new model of delivering these metrics are likely in your contracts with MCPs, care, you will want to consider ways to enhance or you may participate in one or more state or fed- data sharing and communication between patients eral VBP programs. While the quality metrics in and their providers. Patients will need to be able FQHC APM may not be the same as the ones you to access their own health information (test results, have already seen, they can likely be approached in visit summaries), make requests of providers and a similar way and not require extensive changes in staff (appointment scheduling, prescription refills), the way the data are collected and reported. and be connected to health resources (health edu- cation, community supports). Your health center will Alternative Touches need to have a reliable electronic platform for com- As described in Section 3, alternative touches are puter or smartphone access to that information and services currently not considered encounters under services, and for patient and provider communica- PPS but that are designed to increase patient tion through text, telephone, videoconferencing, engagement, improve patient outcomes, and and remote monitoring. generally allow better coordinated and integrated care. There are five domains of alternative touches: Risk Stratification communication, education, case management, Risk stratification is a technique for systematically community supports, and care team supports. categorizing patients based on their health status Alternative touches will be tracked via CPT codes. and other factors. It allows practices to manage Leveraging EHR templates and smart sets to set-up patients based on their assigned risk level to make or flag these codes in the EHR can help with CPT better use of limited resources, anticipate needs, coding accuracy. and more proactively manage their patient popu- lation.105 See Section 3 for determining patient risk Patient Care and Engagement levels and how to focus care accordingly. Except for capturing alternative encounters, most of the data you currently collect for providing good Utilization and Financial Monitoring patient care and the way you use them will not As described in Section 2, your health center will change in the new FQHC APM. However, because need to continue to track and document encounters you will have greater flexibility to provide a broader to ensure that you are meeting program require- range of services under the new model, one area ments and that MCPs will reimburse you fairly for that may require additional data is health-related your activities. You will also want the ability to track social needs (HRSNs). You may need to imple- and analyze how alternative services are being ment new processes for identifying HRSNs through utilized, to better understand the needs of your assessments and screening tools (see Section 3). patients and how these services impact your health You may also want to consider how you could lever- center financially. You may also want to analyze how age your EHR to support providers in screening for some providers use their time, and some EHRs have and documenting HRSNs, coordinating the deliv- the capability to do this. While you are not required ery of services by your health center, and referring to track patient utilization and costs outside the California Health Care Foundation www.chcf.org 49 services provided by the FQHC (e.g., an inpatient health equity. Beyond identifying race, ethnicity, stay at a hospital), your health center may want to language, and disability data elements which are track those activities, as there may be opportunities a critical first step towards identifying and tracking for your health center to be rewarded for helping health disparities, you will want to think about what improve health outcomes and decrease utilization process and outcome measures you might want to at high-cost or inappropriate care settings. track for subpopulations and specific conditions that impact patients who come to your health cen- Patient and Provider Experience and ter and who live in your community. These data Satisfaction will allow you to conduct a deeper analysis of gaps Two measures of patient experience (Patient and to develop actionable strategies to reduce dis- Experience of Access and Care domain) are parities in care. CMS created the Disability Impact included in the quality metrics and are collected Statement, a tool to address health disparities in through the CAHPS Clinician & Group Survey: practices by identifying health disparities and pri- Getting Needed Care and Getting Care Quickly ority populations, defining goals, establishing a (see Section 2, Table 6). You may want to collect health equity strategy, determining organizational additional data to understand the impact of the needs to implement a strategy, and monitoring and new model on patients and providers. For patients, evaluating progress.106 Having a data strategy that you could design and conduct surveys that capture supports your overall health equity strategy will be patient experience and satisfaction in key areas you critical to tracking and measuring your success. are targeting in the new model. Likewise, you could survey your staff to determine their experience and satisfaction in working in the new model, and ask for Additional resources: suggestions for improvements, as well as insights $ A Typology for Health Equity Measures on what is working and best practices. $ Achieving Health Equity: A Guide for Health Care Organizations Using Data to Measure Health Equity For a deeper understanding of the impact on patients, and to drive more equitable care, you will want to have a strategy for using data to drive California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 50 contribute to patient care planning, population How Do You Ensure Your Data Are health, and stratification. As a result, your staff Accurate? will likely need additional training on coding, and Defining "Good Data" internal processes will need to emphasize the Because of the importance of encounter data, importance of coding. Larger FQHCs may consider DHCS will continue to engage all stakeholders to hiring dedicated staff for coding and documen- improve encounter data by defining clear standards tation, and FQHCs of any size may want to work on data quality with a goal of establishing a single closely with their MCPs to identify best practice source of truth. For all types of data, the American strategies to accurately document patient diagno- Health Information Management Association offers ses and characteristics. External consulting firms the following characteristics of data quality:107 also provide support for accurate coding and bill- ing infrastructure. $ Accuracy. The data should be free of errors. In addition to coding, the importance of capturing $ Accessibility. Proper safeguards have been accurate data in all areas will need to be bolstered. established to ensure data are available when Your health center may also want to explore addi- needed. tional training and to create standardized processes $ Comprehensiveness. The data contain all for writing notes, making assignments for seeing required elements. patients, and updating patient contact information. $ Consistency. The data are accurate and the Correcting Data same across the entire patient encounter. MCPs and FQHCs will need to work together to $ Currency. Data are up-to-date. ensure encounter data and membership data are accurate for quality reporting (see Section 6 on $ Definition. All data elements are clearly defined. working with MCPs). In the absence of explicit $ Granularity. The data are at the appropriate DHCS requirements about correcting data discrep- level of detail. ancies, your health center will need to work with the MCP to develop processes to ensure accurate data. $ Precision. The data are precise and collected in If your health center is in a delegated arrangement their exact form. that includes independent practice associations or $ Relevancy. Data are relevant to the purpose they clinically integrated networks, you will also need to were collected for. consider how these entities interact with your data. $ Timeliness. Documentation is entered promptly, is up-to-date, and is available within specified What Changes Do You Need and required time frames. to Make to Your Current Data Ensuring Accurate and Comprehensive Infrastructure? Coding and Data Entry Creating a Data Governance Plan While your staff likely already know the importance While your health center may already have policies of entering diagnoses and notes into a patient's and a data infrastructure in place, it will be helpful EHR for documentation and to inform their care for leadership to map out a data strategy for FQHC plan and future visits, coding takes on a new impor- APM based on the new financial, patient care, and tance under a FQHC APM. Coding properly will quality reporting requirements (see Appendix B). California Health Care Foundation www.chcf.org 51 Lessons from Community Care Cooperative: Risk Adjustment and Billing Infrastructure Support for FQHCs C3 is a nonprofit accountable care organization (ACO) governed by 18 FQHCs in Massachusetts. To sup- port successful participation in the ACO, C3 offers participating health centers access to experts in ICD-10, HCPCS, and CPT coding for a limited fee and for varying amounts of time. Certified Risk and Professional Coders provide the following services to health centers: $ Post-encounter coding. Using a certified coder to determine the accuracy of codes documented by pro- viders, and providing recommendations for alterations of the specific encounter before claims submission. $ Retrospective record review. Reviewing past medical history, pharmacy, and labs to identify diagnosis trends and opportunities. $ Individual or group provider education. Training from a clinical coding expert to drive improvement efforts in provider documentation. $ Prospective chart review. Reviewing past medical history, pharmacy, and labs to identify coding opportu- nities before a planned visit occurs. This support is one component of C3's larger efforts to support health centers in moving toward VBP. C3 also assigns a cross-functional Health Center Performance Management Team (HCPM) that partners with each health center's leadership team to support, monitor, and promote performance across the various programs and state deliverables. HCPMs have subject matter expertise in the full scope of C3's business operations, including care management, risk adjustment, quality, practice transformation, telehealth, EHR optimization, and population health platform technology optimization. HCPMs meet with health centers monthly to review performance metrics and progress, and meet as needed with quality, risk adjustment, and care management leads to provide assistance, offer guidance, and receive updates on targeted quality improvement initiatives. C3 has found this level of support to be critical to each health center's success in the ACO model. Source: Provider Manual (PDF), Community Care Cooperative, September 2021. $ Establish program priorities. One way is to pri- Typically, the chief information officer (CIO) is oritize critical data elements for the organization. responsible for leading this process and would seek It is important to consider where these critical out input from staff throughout the organization, data elements are used, how they are defined, either individually or by creating a team of opera- and how they are used during the entire data tional and clinical staff that would work together to lifecycle (i.e., data creation, collection, use, and develop a strategy. destruction). The American Health Information Management $ Ensure accountability. It is critical to have clearly Association identified the following best practices defined roles and responsibilities (e.g., sponsors, for data governance in health care organizations.108 data stewards, domain owners, technical leads), While these practices are foundational for any outlining who is responsible for what and when. health center, they are even more important for Having a governance structure in place allows your health center in FQHC APM: the organization to address questions and issues California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 52 hiring additional staff to meet data and infrastruc- as they arise as well as work toward the required ture needs. Table 8 outlines key data responsibilities goals. and competencies required under FQHC APM (see $ Demonstrate value by defining key metrics. next page). Consider measuring the results of your data gov- ernance work by tying key metrics to program Identifying EHR Changes and Optimization goals. For example, key metrics may be tied to Your health center needs to have an EHR that allows data quality (e.g., data accuracy, data complete- providers to capture and exchange data, support ness), risk or cost reduction (e.g., reduction in care coordination inside and outside the practice, rework), or process improvement (e.g., data and monitor and generate reports on targeted issues corrected). There can also be value in metrics. An efficient EHR frees time for providers to tracking data literacy across the organization focus on care delivery. (e.g., knowledge of data management princi- ples; adherence to data management standards, Your health center could consider making the fol- policies, and procedures; published data defini- lowing changes to optimize your existing EHR, tions; attendance at trainings). keeping in mind the type and current capacity of your EHR, your data goals, and your budget to $ Support collaboration. Those in data gov- make changes: ernance roles should have opportunities to collaborate, discuss challenges, and share best $ Configureyour EHR to capture and generate practices throughout the organization. reports on alternative encounters $ Include screening tools for health-related socials Considering Staffing Needs needs and links to internal and external resources As described in the data coding section, staff at all $ Ensure the EHR captures data required for risk levels of the organization will need to understand stratification changes to data collection and use under FQHC $ Linkthe EHR with real-time data from health plans APM. This effort will require training by internal data staff or external experts, reassigning roles and and outside entities to facilitate care transitions and follow-up care responsibilities among staff, and in some cases California Health Care Foundation www.chcf.org 53 Table 8. Data Considerations and Desired Outcomes for Key Staff STAFF CONSIDERATIONS DESIRED OUTCOMES Leadership $ Is there a data governance plan in place? $ Quality data are accurate and timely. CEOs, CAOs, CFOs, CIOs, $ Can the IT infrastructure and EHR meet our $ Assignment is correct. CMOs, Chief behavioral needs? $ Alternative touches are counted accurately. health officers $ Is there adequate staffing for coding, IT $ Risk is stratified and accurately reflects support, and data analysis? clinical and social needs. $ Are staff fully trained to take on new $ Clinical data are actionable, and staff are responsibilities? using them to provide better care. $ Do staff roles need to be adjusted? $ Health center payments reflect the services $ Is data collection and use reflected in the being provided. workflows? $ Internal reports show the financial impact $ Will existing financial reports capture of FQHC APM. financial performance under FQHC APM? $ MCPs are engaged in ensuring good data. $ Do you need to invest in additional analytical or acuity tools? $ Can you review financial metrics in real time? $ What changes will you need to make to collect data? $ Are MCPs sharing data and participating in improvement activities? Providers $ Do clinicians understand new processes for $ Clinical staff are entering encounter data Physicians, physician entering clinical and SDOH data in EHRs? accurately and are incorporating such data assistants, nurse $ How are data being used to improve entry into their workflow. practitioners, certified quality, particularly on APM metrics? $ Clinical staff are engaged in risk nurse-midwives, stratification activities. behavioral health $ Clinical staff are capturing and using SDOH providers data to provide better care and to make appropriate referrals. $ Staff have access to data to inform quality improvement activities. Licensed and unlicensed $ Do staff understand new processes for $ Staff are responsive to clinical and social clinical staff entering and accessing data in EHRs? needs. Nurses, social workers, $ Are the data available so that staff can act $ Data allow staff to coordinate care with medical assistants, on them and provide better care? providers and licensed and unlicensed staff. counselors, pharmacists, care managers, care coordinators Administrative, $ Do coders understand changes, particularly $ Coding is accurate. operations, and IT staff for tracking alternative touches? $ Alternative touches are captured. $ Do IT staff understand new reporting $ Process is in place for participating in, and requirements, processes, and EHR updates making changes to, data governance plan. to support clinical staff? Source: Authors analysis based on key informant interviews and review of DHCS APM Overview, September 2022: FQHC APM September 2022 Overview (PDF). California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 54 SECTION 6. Partnering for Success processes, progress on quality metrics, and finan- cial best practices. IN THIS SECTION $ Collaborating with Other Health Centers Regional and statewide organizations can provide $ Working with MCPs opportunities for problem solving, technical assis- $ Knowing Your Value tance, and collaboration. Your health center may $ Building Relationships with MCPs already be part of a regional network of health $ MCP Responsibilities Under FQHC APM centers. Statewide, the California Primary Care $ Contracting with MCPs for FQHC APM Association and the California Association of Public Hospitals and Health Systems support health cen- $ Building External Partnerships ters in FQHC APM in a number of ways regularly updated on their websites. DHCS will establish a learning and improvement community for health centers participating in FQHC APM. Your success in FQHC APM will be greatly enhanced through collaboration with external partners. Health centers in other states participating in APMs Learning from Other FQHCs: Statewide have affirmed the value of strong relationships with Learning Collaboratives other health centers implementing similar initia- Massachusetts. C3, along with MassLeague, tives, health plans, specialists, hospitals, and state the state's primary care association, convened agencies. This section provides an overview of the Community Health Center Readiness Pro- opportunities and considerations for partnerships. gram, a learning collaborative to help FQHCs be successful in VBP and accountable care. The collaborative covers topics such as change Collaborating with Other Health management, care coordination, transition of Centers care, and quality measures. Collaborating and learning from other FQHCs can Oregon. Oregon's Primary Care Association led be worthwhile, with the caveat that one health cen- various learning collaboratives that covered the ter is one health center. Capacities of health centers shift in the care model that brought in experts differ based on their geographic location (e.g., and provided training. For example, one train- rural vs. urban) and size. Because of these differing ing led by leaders from the MacColl Institute capacities, health centers have varying capabili- focused on the 10 building blocks of high-per- ties to address issues that arise as well as differing forming primary care. abilities to work with external partners, such as negotiating with MCPs. Staff from all areas of your health center (care delivery, finance, operations) would benefit from making connections with staff in similar roles at other health centers. Health cen- ters will benefit from sharing takeaways about new California Health Care Foundation www.chcf.org 55 Working with MCPs $ Identify champions within the health plan Collaborating with the MCPs is critical to your suc- and build a positive relationship with them. cess in just about every area of FQHC APM and Suggestions include medical directors, direc- will include ensuring that patients are assigned tors in quality and access, and directors of accurately, your health center is receiving its full provider relations departments. Forge rela- PMPM, receiving and sharing information about tionships between those in similar roles (e.g., patient care and care transitions, coordinating CEO to CEO, CMO to CMO). care management efforts, providing reports and $ Get to know the history and mission of local receiving feedback on meeting quality goals, and aligning current pay-for-performance efforts with plans. FQHC APM. This section can help you prepare for $ Be able to explicitly articulate your vision for discussions with your MCPs about contracting and changes related to FQHC APM. improving the health of your community. $ Ask plan leaders about their priorities and pain Knowing Your Value As you enter discussions with the MCPs, it will be points. Be ready to clearly articulate yours. helpful for you to understand the value that your $ Begin initial discussions by putting forward health center brings to the MCP by being prepared to answer the following questions: ideas (areas or goals you want to pursue together with the plan) rather than starting $ What is your health center's mission and pur- conversations about specific proposals. pose, and how do they align with FQHC APM? $ Find opportunities to work together outside of $ Whom do you serve and what services do you your contracted relationship. provide? $ Who are your biggest competitors? The report also includes recommendations for mak- ing requests for financial support: $ What makes you better or at least different than your competitors? $ Meet face-to-face with health plan leaders. This can help you understand and align pri- Building Relationships with MCPs orities before creating finalized plans or asks. Beyond reaching an agreement on the initial con- Understanding priorities before fully develop- tractual provisions, your health center will benefit ing an idea can allow a plan to provide helpful from having a good ongoing working relationship input, and it generates buy-in. with MCPs. Based on interviews with people who $ Align with the plan's major areas of focus. had worked for both an MCP and an FQHC, JSI Research and Training Institute published "What Even if your current priorities don't align with I Wish I Had Known About Health Plans When the plan's, consider whether supporting the I Worked at a Health Center . . .": Insights for plan's priority could be beneficial in building Strategically Engaging with Public Medi-Cal Health a relationship. Plans.109 This resource includes the following insights $ Recognize that health plan financial per- about building partnerships with MCPs, which you formance is cyclical. These cycles can be can apply to your work on FQHC APM: tracked by reviewing comments of the CEO California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 56 or publicly available board meeting minutes. elements that may be included in modified contract In up cycles, a plan may have more appetite language are shown in the "Possible Elements of to invest strategically in initiatives that have Contract Modifications" box. Many of the contrac- longer-term returns. In down cycles, quicker tual provisions relate to finance, and Section 2 of return becomes a more important criterion for this report includes recommendations for negotiat- investment. ing aspects of these provisions of the contract with MCPs, particularly around assignment. $ Create a well-thought-out financial business case. Health plan boards will require it. The added value of any ask is not captured solely Possible Elements of Contract in the business case but on how a proposal Modifications contributes to the health plan's mission, goals, $ Contract revision implementation timeline and quality improvement efforts as a whole. $ APM PMPM must be paid to FQHCs for Health plans aim to generate the most over- each assigned member all - not just financial - value for the dollars $ Medi-Calpopulations covered and not they oversee and invest in the community. covered by the APM payment methodol- ogy $ Ask for what you need. Onetime invest- $ Scope of services included in the APM ments (e.g., for more efficient and effective $ Timing of DHCS notification to the plans information systems, management practices, of the capitation rate and the clinic-specific and infrastructure that will improve quality APM PMPMs outcomes) may be easier to gain approval for $ Member assignment than requests for ongoing support. $ FQHC payment requirements MCP Responsibilities Under FQHC APM $ Detailed reporting and data sharing DHCS requires MCPs under FQHC APM to: requirements $ Reconciliation process $ Ensure that FQHCs are paid the full state- $ Proceduresfor collecting and reporting established APM PMPM (equal to projected accurate encounter data PPS) for assigned members $ Aligning the new payment methodology $ Share complete FQHC encounter data with with existing health plan incentive pro- grams for providers DHCS $ Process for resolving disputes between $ Conduct dispute resolution with FQHCs health plans and health centers, includ- ing when the health plan does not have a $ Review and reconcile quality data issues with relationship with the health center FQHCs Contracting with MCPs for FQHC APM If your center is participating in FQHC APM, the MCP will need to modify the contract with you under Other items you will want to consider include these: the FQHC APM terms. DHCS will issue guidance to MCPs via an "All Plan Letter" that will include $ How will you and the MCP work together on suggested practice for MCP efforts to modify improving quality? their contracts with participating FQHCs. Possible California Health Care Foundation www.chcf.org 57 $ What will communication look like between following questions can guide your health center in your health center leaders and the MCP? How exploring partnership opportunities: often will you meet to discuss roadblocks and address problems, and who will be part of $ Where are your patients getting clinical care those meetings? outside of your health center? Which hospi- tals, behavioral health providers, specialists $ With regard to data sharing, who will be the see your patients? main points of contact between your health center and the MCP, and what will be the pro- $ What links do you currently have with these cess for resolving problems? facilities and providers? $ How can the MCP support your health cen- $ How can you work together to manage care ter's care management efforts? What are the transitions and to develop shared care man- expectations around care transitions? agement plans? $ Are there opportunities to share data in real Building External Partnerships time, such as through participation in local health information exchanges or other data Most of the work you will do to prepare for and exchange framework? Can data be linked implement FQHC APM will be within your own directly to your EHR to provide accurate and health center, or in partnership with other sites within timely care? your FQHC. In addition to working with MCPs, you may wish to explore expanding or creating new $ What organizations in your community are partnerships with other external entities to support addressing health-related social needs? How and advance your efforts to care for your patients, can you work together to identify health and meet the quality metrics, and succeed financially. social needs and make referrals? Partnerships can also position your health center $ What facilities provide after-hours care? How to participate in current or future VBP opportunities can you receive data about the care provided outside FQHC APM that could provide additional to your patients in these facilities, and what resources or flexibility. data can you share to allow for better after- hours care? Using the available data and expertise of your health center, and ideally in partnership with the MCPs, the California Federally Qualified Health Center Alternative Payment Model Implementation Guide 58 Working Together for Better Patient Care: Lessons from Rocky Mountain Health Plans and Mountain Family Health Centers Mountain Family Health Centers, an FQHC with four sites in Colorado, and Rocky Mountain Health Plans have been working together since 2014 as contractual partners under various state VBP and APM programs for their Medicaid patients. Through this partnership, they identified the following key lessons: $ It's not who you are, it's what you do. $ Follow "first principles": transparency, responsibility for community, inclusion, performance. $ Regular meetings (at least quarterly) between the plan and health center provided the opportunity for the plan to discuss areas of common concern and address emerging issues. $ Focusing on common goals helped forge a strong partnership. Goals and shared activities include: $ Moving away from an FFS mentality $ Engaging in rigorous, transparent, and objectively measured practice transformation $ Creating a durable program founded on local leadership $ Sharing data for transparent analysis and goal setting $ Sharing the burdens and benefits, equitably and timely $ Working to improve community capacity and health trends $ Health plan support was critical to success. The health plan provided a practice transformation team that served as "boots on the ground" and engaged in practice transformation, quality improvement, and developing data-use competencies. The plan also deployed community care teams, sometimes led by the FQHC. $ Making sure that risk adjustment was working, payments were accurate, and reporting for monitoring finan- cial outcomes took a culture change and a commitment operationally for both partners. $ Both entities leaned into new activities to address health-related social needs, such as promoting social risk factor screening and awareness, developing incentives and supports for screening, and curating a network of human and community service providers. $ The health plan supported efforts to build a broader network of community partners and develop mutually beneficial relationships with them. The plan also rolled out a social information exchange to support alerts, task and record sharing, and consent management to allow health care providers, human services, and community agencies to share information. Sources: Greg Howe, "Health Plan Leaders Find Success Working with FQHCs Through Value-Based Payment Arrangements," Center for Health Care Strategies (CHCS), January 24, 2020; P. Gordon and A. Fernandez, "Advanced Payment Models FQHC & CMHC Engagement" (CHCS meeting, Sacramento, California, May 9, 2019); and Interview with Art Fernandez, Mountain Family Health Centers, April 12, 2022. California Health Care Foundation www.chcf.org 59 APPENDICES Appendix A. Advisory Group Members Erik Cho, Director of Strategy and Business Development, Ventura County Health Care Agency Meredith Evans, Director of Integrative Behavioral Health, Peach Tree Health Chuck Fenzi, MD, CEO/CMO, Santa Barbara Neighborhood Clinics Charles Kitzman, CIO, Shasta Community Health Center David Lown, MD, CMO, California Health Care Safety Net Institute, California Association of Public Hospitals and Health Systems Porshia Mack, MD, Associate CMO, Ambulatory Services, Alameda Health System Andie Martinez Patterson, CEO, Community Health Center Network, and CEO, Alameda Health Consortium Robert Moore, MD, CMO, Partnership HealthPlan of California Jim Schultz, MD, CMO, Neighborhood Healthcare Matthew Sur, Reimbursement Director, San Francisco Health Network Christy Ward, CEO, Share Our Selves California Federally Qualified Health Center Alternative Payment Model Implementation Guide 60 Appendix B. Overview of Data Elements and Sharing Requirements Under FQHC APM PERSON STAFF RESPONSIBLE RESPONSIBLE FOR REPORTING/ HOW/WHEN WITH WHOM EXAMPLE DATA FOR COLLECTING USING IS IT CAPTURED? IS IT SHARED? HOW IS IT USED? WHAT'S CHANGING QUALITY ICD-10 codes $ Clinician $ Clinical staff $ Patient visit $ Health center $ Ensure your health Your health center will need to report on 22 CG-CAHPS $ Medical $ QI staff $ Lab tests staff center is delivering quality measures. 12 of those measures will survey assistant $ MCPs quality care be tied to payment. Many of these metrics are $ Operations staff likely in your contracts with MCPs, or you may $ Lab technician $ DHCS $ Determine quality $ Finance staff adjustment and participate in one or more state or federal VBP ongoing participa- programs. Some metrics in FQHC APM may tion in be new to your health center, but can likely be FQHC APM approached in a similar way and not require extensive changes in the way the data are collected and reported. ALTERNATIVE TOUCHES CPT codes $ Clinician $ Clinical staff $ Patient visit $ Health center $ Deliver comprehen- Alternative touches are services currently (with assigned $ Medical $ Nonprovider care $ Nurse advice line staff sive and coordinated not billable under PPS but that are designed relative value assistant team $ MCPs care to increase patient engagement, improve units) $ CHW visit patient outcomes, and generally allow better $ Dietician $ Finance staff $ DHCS $ Track utilization and $ Pharmacy visit what care is being coordinated and integrated care. They fall under $ Care manager delivered five domains: communication, education, case $ Wellness activity management, community supports, and care $ Health coach Meeting with care $ Set future rates $ team support. $ CHW manager PATIENT CARE AND ENGAGEMENT 18 ICD-10-CM $ Clinician $ Clinical staff $ Patient visit $ Health center $ Address HRSNs using You will now have greater flexibility to provide Z codes $ Care manager $ Nonprovider care $ Nurse advice line staff health center services a broader range of services to address health- designated team $ MCPs or referring to related social needs, which may require for In Lieu of $ Medical $ CHW visit community services additional data. You may need to implement Services by assistant $ Finance staff $ Meeting with care new processes for identifying HRSNs through DHCS $ CHW manager assessments and screening tools, documenting HRSNs, coordinating the delivery of services by your health center, and referring to community supports when necessary. UTILIZATION AND FINANCIAL MONITORING Encounter $ Clinician $ Finance staff $ Patient visit/ $ Health center $ Ensure you are All encounter data from your health center will data: PPS $ Medical encounter staff meeting program go through the MCP to DHCS. Encounter data billable visits assistant $ MCPs requirements from your health center are critical for quality vs. patients $ Ensure MCPs will reporting, rate setting, care management, engaged $ DHCS and all aspects of the FQHC APM. You may reimburse you fairly ICD-10 codes want to analyze how some providers use and $ Understand how bill their time. To take advantage of future HCPS codes providing new opportunities for your health center to be CPT codes services impacts rewarded for impacting positive health outcomes your health center and decreased utilization at high-cost or financially inappropriate care settings, you may want to track patient utilization and costs outside the services provided by the FQHC (e.g., an inpatient stay at a hospital). California Health Care Foundation www.chcf.org 61 Appendix B. Overview of Data Elements and Sharing Requirements Under FQHC APM (continued) PERSON STAFF RESPONSIBLE RESPONSIBLE FOR REPORTING/ HOW/WHEN WITH WHOM EXAMPLE DATA FOR COLLECTING USING IS IT CAPTURED? IS IT SHARED? HOW IS IT USED? WHAT'S CHANGING RATE SETTING Historic health $ Finance staff $ Finance staff $ Patient visit/ $ MCPs $ Set rates DHCS will use historic utilization data to set rates plan payments encounter $ DHCS for FQHC APM. to FQHCs; Historic PPS Wrap payments to FQHCs RISK STRATIFICATION ICD-10-CM, $ Clinician $ Care manager $ New patient visit $ Health center $ Systematically catego- Your health center may develop and implement including Z $ Care manager $ Operations staff $ Visit with new staff rize patients based on a risk stratification process to better target the codes chronic condition their health status and care you deliver. This process would take into $ Clinician other factors account a patient's health-related social needs, CPT codes diagnosis $ Finance staff $ Help to make behavioral health, and chronic health conditions. $ Transition of care $ Clinical leadership better use of $ Chart review limited resources, anticipate needs, and more proactively manage your patient population PATIENT AND PROVIDER EXPERIENCE AND SATISFACTION CG-CAHPS $ Patient (self- $ QI staff $ Surveys: mail or in $ Health center $ Understand the Three measures of patient experience are Your own reported) $ Clinicians person after visit staff impact of the new included in the quality metrics requirements: surveys $ Providers $ MCPs model on patients provider rating, timeliness of receipt of $ Clinical leaders and providers requested appointment, and if the patient would $ Operations staff $ DHCS recommend this provider. You may want to collect additional data by conducting surveys of both patients and providers. HEALTH EQUITY Race, Ethnicity, $ Clinician $ Clinical staff $ New patient visit, $ Health center $ Measure and track For a deeper understanding of the impact on Language, and $ Medical assis- $ Nonprovider care intake staff disparities patients, and to drive more equitable care, Disability tant team $ Patient visit $ MCPs $ Conduct a deeper you will want to identify and ensure that you (RELD) data analysis of gaps in are collecting RELD data elements. With these $ Finance staff $ Surveys $ DHCS data, your health center may want to conduct an care analysis of disparities, identify gaps in care, and $ Develop actionable create a strategy for reducing health disparities. strategies to reduce disparities in care California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 62 Appendix C. Additional Resources Expanding Medical Assistant Roles $ New Roles for Medical Assistants in Innovative Primary Care Practices $ An Expanded Role for the Medical Assistant in Primary Care: Evaluating a Training Pilot $ How to Train Medical Assistants for Expanded Roles: AHRQ Webinar Incorporating CHWs in FQHCs $ Including Community Health Workers (CHWs) in Health Care Settings (PDF) $ The Community Health Worker Core Consensus Project: CHW Assessment Toolkit $ Community Health Worker Core Consensus Project $ Strategies to Improve the Integration of Community Health Workers into Health Care Teams: "A Little Fish in a Big Pond" $ Integrating Community Health Workers into Primary Care to Support Behavioral Health Service Delivery: A Pilot Study Incorporating Pharmacists in FQHCs $ Pharmacist Care in Federally Qualified Health Centers: A Narrative Review $ Pharmacists in Federally Qualified Health Centers: Models of Care to Improve Chronic Disease Empanelment $ Empanelment: How to Form Patient Panels in Primary Care $ Safety-Net Initiative, Empanelment: Establishing Patient-Provider Relationships Group Visits $ Group Medical Visits in Community Health Centers $ Integrated Center for Group Medical Visits $ Comparing Two Approaches to Group Medical Visits for Patients with Diabetes $ Example of Diabetes Group Visit Curriculum from Serve the People Health Center in CA $ Centering Pregnancy Care $ SAMHSA Resources on Group Therapy for Substance Abuse $ Guide for Clinicians Leading Substance Abuse Group Therapy Home-Based Services $ ACOs Use Home Visits to Improve Care Management, Identify Needs, And Reduce Hospital Use California Health Care Foundation www.chcf.org 63 $ The Team Approach to Home-Based Primary Care: Restructuring Care to Meet Patient, Program, and System Needs $ Four Tips for Adding House Calls to Your Practice Telehealth $ California Telehealth Resource Center $ A Practical Guide to Expanding Home-Based Primary Care with Telehealth $ FQHCS and Telehealth $ How FQHCs are Conquering the Digital Divide in Telehealth, Remote Monitoring $ FQHC Telehealth Consortium Focuses on Addressing Health Disparities in Phase II Work $ Payment Reimbursement Tips: Mental Health Telecommunications Services $ Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders Care Management and Risk Stratification $ NAHC Value Transformation Framework Action Guide $ Two-Step Process for Identifying Your Sickest Patients $ AAFP risk stratification algorithm $ Care Management: Implications for Medical Practice, Health Policy, and Health Services Research $ Care Management: An Implementation Guide for Primary Care Practices $ The Medical Home: Care Management Supporting Trauma-Informed Care $ Trauma-Informed Care Implementation Resource Center $ Key Ingredients for Successful Trauma-Informed Care Implementation $ Guide to Trauma-Informed Organizational Development Scaling and Spreading Changes $ Spreading and Scaling up Innovation and Improvement $ Scaling and Spreading Innovation in Health Care Delivery Patient-Centered Medical Home $ PCMH certification $ AHRQ on the PCMH $ AHRQ's Tools for Implementing the PCMH California Federally Qualified Health Center Alternative Payment Model Implementation Guide 64 Building Blocks of Primary Care $ The 10 Building Blocks of High-Performing Primary Care $ The Ten Building Blocks of High Performing Primary Care: A Framework for Achieving the Patient Centered Medical Home Health Equity $ Creating a Disparities Impact Statement $ A Typology for Health Equity Measures $ Achieving Health Equity: A Guide for Health Care Organizations Data $ Health Care Data Governance Managed Care $ Engaging with Medi-Cal MCPs California Health Care Foundation www.chcf.org 65 Appendix D. Ideas for Care Models That Can Help Guide Your FQHC APM Work The suggested models below have been used by various FQHCs that have made the transition to APMs. They are listed here as options to help provide a template or road map to guide FQHCs' work in transition- ing to APMs. Patient-Centered Medical Home The patient-centered medical home110 is an approach to delivering high-quality, cost-effective primary care. Using a patient-centered, culturally appropriate, and team-based approach, the PCMH model coordinates patient care across the health system. The model has been associated with effective chronic disease man- agement, increased patient and provider satisfaction, cost savings, improved quality of care, and increased preventive care.111 The Building Blocks of Primary Care Through their studies of "exemplary primary care practices" and their work helping other practices become more person-centered, Dr. Thomas Bodenheimer and his colleagues formulated the "essential elements of primary care," also known as the 10 building blocks of high-performing primary care.112 They noted that high- performing primary care practices vary in size, resources, staffing, and populations served, yet they exhibit surprising similarity in how they provide high-quality, accessible, and patient-centered health care. Those similarities were identified as the building blocks of high-performing primary care.113 These building blocks have four foundational elements: $ Engaged leadership $ Data-driven improvement $ Empanelment $ Team-based care In turn, these four foundational elements assist the implementation of the other six building blocks: $ Patient-team partnerships $ Population management $ Continuity of care $ Prompt access to care $ Comprehensiveness and care coordination $ Template of the future California Federally Qualified Health Center Alternative Payment Model Implementation Guide 66 Endnotes 1. Greg Howe, Rob Houston, and Tricia McGinnis, How Health 16. Chapman and Blash. Centers Can Improve Patient Care Through Value-Based 17. Marlaine Figeroa Gray et al., "An Expanded Role for the Payment Models (PDF), California Health Care Foundation, Medical Assistant in Primary Care: Evaluating a Training June 2020. Pilot," Permanente Journal 25, no. 4 (Dec. 1, 2021): 1–9. 2. Federally Qualified Health Center Application (PDF), 18. Kurt Elward, "How to Train Medical Assistants for Expanded California Dept. of Health Care Services (DHCS), October Roles: Webinar," AHRQ, last reviewed November 2018. 2022; and FQHC Application/Participation Criteria - Process and Procedures (PDF), DHCS. 19. Medical Assistants in California: Legal Scope of Practice (PDF), UCSF, September 2013. 3. Federally Qualified Health Center Alternative Payment Model (FQHC APM) Overview (PDF), DHCS, September 30, 20. Megan Hasse (Mosaic Medical), interview with Greg Howe 2022. and Karla Silverman, Center for Health Care Strategies, February , CHCS, February 7, 2022. 4. FQHC APM Overview, DHCS. Under this payment approach, if a health plan member visits an FQHC site to which the 21. "Community Health Workers," Amer. Public Health Assn., member is not assigned, that FQHC does not receive a 2022. separate PPS payment; those funds have been incorporated 22. Including Community Health Workers (CHWs) in Health Care into the FQHC's APM PMPM with that plan. The exception is Settings: A Checklist for Public Health Practitioners (PDF), visits to FQHCs not contracted with the health plan; in that Centers for Disease Control and Prevention (CDC), June case, the plan pays the non-contracted FQHC participating 2019. in the APM the PPS rate. Health plans will need access to the PPS rates for non-contracted FQHC sites participating 23. Caitlin G. Allen et al., Community Health Worker Assessment in the APM so that the plans can pay the correct PPS rate if/ Toolkit: A Framework for Assessing Skills Proficiency and when those FQHCs see a health plan member. Fostering Professional Development (PDF), Community Health Worker Core Consensus Project (C3 Project), 2018. 5. "CalAIM Population Health Management Initiative," DHCS, last modified December 19, 2022. 24. Caitlin G. Allen et al., "Strategies to Improve the Integration of Community Health Workers Into Health Care Teams: 'A 6. FQHC APM Overview, DHCS. Little Fish in a Big Pond,'" Preventing Chronic Disease 12 7. DHCS. (Sept. 17, 2015): E154. 8. DHCS. 25. Ashley Wennerstrom et al., "Integrating Community Health Workers into Primary Care to Support Behavioral Health 9. David Kindig and Greg Stoddart, "What Is Population Service Delivery: A Pilot Study," Journal of Ambulatory Care Health?," Amer. Journal of Public Health 93, no. 3 (Mar. Mgmt. 38, no. 3 (July/Sept. 2015): 263–72. 2003): 380–83. Defined as "the health outcomes of a group of individuals, including the distribution of such outcomes 26. "Integrating Community Health Workers on Clinical Care within the group." Teams and in the Community," CDC. 10. Kindig and Stoddart, "What Is Population Health?" 27. M. Sprague et al., "'Part of Getting to Where We Are Is Because We Have Been Open to Change': Integrating 11. Cindy Hupke, "Team-Based Care: Optimizing Primary Community Health Workers on Care Teams at Ten Ryan Care for Patients and Providers," Institute for Healthcare White HIV/AIDS Program Recipient Sites," BMC Public Improvement, May 16, 2014. Health 21 (May 2021): 922. 12. Margaret Flinter et al., "Registered Nurses in Primary Care: 28. Sprague et al., "Open to Change." Emerging New Roles and Contributions to Team-Based Care in High-Performing Practices," Journal of Ambulatory Care 29. Cristina Leal and Esly Reyes, Integrating CHWs into Care Management 40, no. 4 (Oct./Dec. 2017): 287–96. Teams (PDF), MHP Salud. 13. Flinter et al., "Registered Nurses in Primary Care." 30. Sprague et al., "Open to Change." 14. Susan A. Chapman and Lisel K. Blash, "New Roles for 31. Sprague et al. Medical Assistants in Innovative Primary Care Practices," 32. Sprague et al. Health Services Research 52, no. 51 (Feb. 2017): 383–406; and Bethany Sheridan et al., "Team-Based Primary Care: The 33. "C3 Project Findings: Roles and Competencies," C3 Project, Medical Assistant Perspective," Health Care Management 2022. Review 43, no. 2 (Apr./June 2018): 115–25. 34. "Community Health Workers (CHW) Inclusion Checklist," 15. Chapman and Blash, "New Roles." CDC, last reviewed June 19, 2019. California Health Care Foundation www.chcf.org 67 35. MHP Salud is a national nonprofit for community health 56. Taressa K. Frase et al., "'Eyes in the Home': ACOs Use worker programs. Home Visits to Improve Care Management, Identify Needs, and Reduce Hospital Use," Health Affairs 38, no. 6 (June 36. Jennifer L. Rodis et al., "Pharmacist Care in Federally 2019): 1021–27. Qualified Health Centers: A Narrative Review," Journal of the Amer. College of Clinical Pharmacy 5, no. 12 (Dec. 2022): 57. Jennifer M. Reckrey et al., "The Team Approach to Home- 1207–1306. Based Primary Care: Restructuring Care to Meet Individual, Program, and System Needs," Journal of the Amer. 37. Jennifer L. Rodis et al., "Pharmacists in Federally Qualified Geriatrics Society 63, no. 2 (Feb. 2015): 358–64. Health Centers: Models of Care to Improve Chronic Disease," Preventing Chronic Disease 16 (Nov. 21, 2019): 58. "Four Tips for Adding House Calls to Your Practice," Quick E153. Tips (blog), Amer. Academy of Family Physicians (AAFP), May 24, 2021. 38. Innovator Highlight: Integration of Pharmacy Teams into Primary Care Teams, Center for Care Innovations, November 59. "An Overview of Home-Based Primary Care: Learning from 8, 2017. the Field," Commonwealth Fund, June 7, 2017. 39. Innovator Highlight, 2017. 60. "Home-Based Primary Care Interventions Systematic Review," AHRQ, Nov. 19, 2014. 40. Rodis et al., "Pharmacist Care." 61. "Home-Based Primary Care," AHRQ. 41. Rodis et al., "Pharmacists in FQHCs." 62. "Hierarchical Condition Category Coding," AAFP, 2022. 42. Rodis et al., "Pharmacists." 63. "Four Tips," Quick Tips. 43. Bonni Brownlee and Nicole Van Borkulo, Empanelment: Establishing Patient-Provider Relationships (PDF), Safety Net 64. "California Telehealth Policy Coalition: Telehealth Policy in Medical Home Initiative, May 2013. California," Center for Connected Health Policy. 44. Bonni Brownlee and Nicole Van Borkulo, Empanelment: 65. Jill Slaboda et al., A Practical Guide to Expanding Home- How to Form Patient Panels in Primary Care, Agency for Based Primary Care with Telehealth, The Playbook, Center Healthcare Research and Quality (AHRQ), May 2013. for Health Care Strategies (CHCS), December 2019. 45. Brownlee and Van Borkulo, Empanelment: Establishing 66. "Federally Qualified Health Centers (FQHC) Center," Relationships. Centers for Medicare & Medicaid Services (CMS), last updated November 7, 2022. 46. Using Standing Orders for Administering Vaccines: What You Should Know (PDF), immunize.org, January 2022. 67. Anuja Vaidya, "How FQHCs Are Combating the Digital Divide in Telehealth, Remote Monitoring," 47. Ariana Thompson-Lastad, "Group Medical Visits as mHealthIntelligence, June 10, 2022. Participatory Care in Community Health Centers," Qualitative Health Research 27, no. 7 (June 2018): 1065–76. 68. Rajiv Leventhal, "FQHC Telehealth Consortium Focuses on Addressing Health Disparities in Phase II Work," Healthcare 48. Thompson-Lastad, "Group Medical Visits." Innovation, April 22, 2021. 49. Bethany M. Kwan and Jeanette Waxmonsky, "Comparing 69. Payment Reimbursement Tips: Mental Health Two Approaches to Group Medical Visits for Patients with Telecommunication Services (PDF), Natl. Assn. of Diabetes," Patient-Centered Outcomes Research Institute, Community Health Centers (NACHC), June 2022. last updated November 30, 2022. 70. Telehealth for the Treatment of Serious Mental Illness and 50. Sarah Torres and Eileen Cueva, Diabetes Group Medical Substance Use Disorders, SAMHSA, 2021. Visits Curriculum (PDF), Serve the People Community Health Center. 71. Payment Reimbursement Tips, NACHC. 51. "CenteringPregnancy," Centering Healthcare Institute. 72. David Raths, "Extending APM Models Critical to Care Transformation, Clinical Leaders Say," Healthcare Innovation, 52. Brief Interventions and Brief Therapies for Substance Abuse, April 12, 2021; and Improving Behavioral Health Access & TIP 34, Substance Abuse and Mental Health Services Integration Using Telehealth & Teleconsultation: A Health Administration (SAMHSA), September 2012. Care System for the 21st Century (PDF), Natl. Academy for 53. Quick Guide for Clinicians - Substance Abuse Treatment: State Health Policy, November 2015. Group Therapy, TIP 41, SAMHSA, September 2015. 73. Timothy W. Farrell et al., "Care Management: Implications 54. Rebecca A. Clay, "A Group Therapy Approach Is Helping for Medical Practice, Health Policy, and Health Services Practitioners Tackle the Nation's Mental Health Crisis," Research," AHRQ, last reviewed August 2018. Monitor on Psychology 53, no. 8 (Nov. 1, 2022): 65. 74. Value Transformation Framework: Action Guide - Care 55. Clay, "Group Therapy Approach." Management (PDF), NACHC, July 2019. California Federally Qualified Health Center Alternative Payment Model Implementation Guide www.chcf.org 68 75. Value Transformation Framework, NACHC. 97. Guide to Trauma-Informed Organizational Development (PDF), Thrive Initiative, Natl. Health Care for the Homeless 76. James Dom Dera, "Risk Stratification: A Two-Step Process Council, 2010. for Identifying Your Sickest Patients," Family Practice Mgmt. 26, no. 3 (May/June 2019): 21–26. 98. Guide, Thrive Initiative. 77. Value Transformation Framework, NACHC. 99. Labor Management Partnership, Kaiser Permanente and Partnership. 78. "Playbook for Population Health: Building the High- Performance Care Management Network" (paywall), 100. "The 7 Emotional Phases Employees Go Through During Advisory Board Company, 2013. Change," LaMarsh Global, June 22, 2021. 79. "Playbook for Population Health," Advisory Board Company. 101. Jessica Beans, "Change Management: The Art of Understanding Loss," Emergent Performance Solutions, 80. Dera, "Risk Stratification." April 19, 2019. 81. Dera. 102. "How to Improve," Institute for Healthcare Improvement. 82. Dera. 103. Trisha Greenhalgh and Chrysanthi Papoutsi, "Spreading and 83. Andrada Tomoaia-Cotisel et al., "Implementation of Care Scaling Up Innovation and Improvement," BMJ 365 (May Management: An Analysis of Recent AHRQ Research," 10, 2019): 12068. Medical Care Research and Review 75, no. 1 (Feb. 2018): 104. Shivan J. Mehta, "Scaling and Spreading Innovation in 46–65. Health Care Delivery," Joint Commission Journal on Quality 84. Value Transformation Framework: Action Guide - and Patient Safety 44, no. 10 (Oct. 2018): 564–65. Community Health Management (PDF), NACHC, July 2019. 105. Dera, "Risk Stratification." 85. Dera, "Risk Stratification." 106. Disparities Impact Statement (PDF), CMS, last revised March 86. James Dom Dera, Risk Stratification Algorithm (PDF), AAFP, 2021. 2019. 107. Healthcare Data Governance (PDF), Amer. Health 87. Farrell et al., "Care Management." Information Mgmt. Assn. (AHIMA), January 2022. 88. Jodi Summers Holtrop et al., Care Management: An 108. Healthcare Data Governance, AHIMA. Implementation Guide for Primary Care Practices, AHRQ, 109. Sofia Rojasova and Rachel Tobey, "What I Wish I Had Known September 2017. About Health Plans When I Worked at a Health Center . . .": 89. "Key Functions of a Medical Home: Care Management," Insights for Strategically Engaging with Public Medi-Cal AAFP. Health Plans (PDF), JSI, July 2018. 90. Tomoaia-Cotisel et al., "Implementation." 110. "Patient-Centered Medical Home (PCMH)," NCQA. 91. Kathryn Collins et al., Understanding the Impact of Trauma 111. "Patient-Centered Medical Home (PCMH) Model," CDC, and Urban Poverty on Family Systems: Risks, Resilience, and 2021. Interventions, Natl. Child Traumatic Stress Network, 2010; 112. Thomas Bodenheimer et al., "The 10 Building Blocks of and Rachel A. Fusco et al., "Trauma, Sleep, and Mental High-Performing Primary Care," Annals of Family Medicine Health Problems in Low-Income Young Adults," Intl. Journal 12, no. 2 (Mar. 2014): 166–71. of Environmental Research and Public Health 18, no. 3 (Jan. 28, 2021): 1145. 113. Bodenheimer et al., "10 Building Blocks." 92. "Trauma and Violence," SAMHSA, last updated September 27, 2022. 93. Christopher Menschner and Alexandra Maul, Key Ingredients for Successful Trauma-Informed Care Implementation, CHCS, April 2016. 94. "What Is Trauma-Informed Care?," Trauma-Informed Care Implementation Resource Center. 95. "Trauma-Informed Care Implementation Resource Center," CHCS. 96. Menschner and Maul, Key Ingredients. California Health Care Foundation www.chcf.org 69