Disability Legislation

Colorado Cross-Disability Coalition (CCDC) helps guide policy efforts to efficiently and effectively address the needs of people with all types of disabilities. Through our trained volunteer advocates, we provide guidance to State Departments, and a substantial number of our members serve on Boards and Commissions. Our members testify at hearings, attend meetings and advocate for policies and practices that benefit the disability community. Our members also monitor and address unintended consequences and assure that various programs work as intended. For more information contact CCDC Executive Director Julie Reiskin at jreiskin@ccdconline.org or by calling 303-839-1775.

Colorado Department of

Health Care Policy and Financing

HCPF's logop

 

REQUEST FOR INFORMATION

RFI UHAA 2015000017

Accountable Care Collaborative Request for Information

 

THIS IS A REQUEST FOR INFORMATION (RFI) ONLY

THIS IS NOT A FORMAL BID SOLICITATION.

 

NO AWARD WILL RESULT FROM THIS RFI.

 

 


Table of Contents

SECTION 1.0        OVERVIEW...

3

1.1.      PURPOSE OF THIS REQUEST FOR INFORMATION (RFI)

3

1.2.      DEPARTMENT BACKGROUND..

3

1.3.      PROGRAM BACKGROUND..

3

1.4.      VISION FOR THE NEXT RCCO RFP..

4

SECTION 2.0        ADMINISTRATIVE INFORMATION..

5

2.1.      RFI TERMS AND CONDITIONS.

5

2.2.      POINT OF CONTACT..

6

2.3.      NOTICES AND COMMUNICATIONS.

6

2.4.      TIMELINE..

6

SECTION 3.0        RESPONSES.

7

3.1.      INQUIRIES.

7

3.2.      PROTECTED HEALTH INFORMATION..

7

3.3.      RESPONSE FORMAT..

7

 RESPONSE WORKSHEET`                                                                                                  8-32

APPENDIX:  DEFINITIONS AND ACRONYMS                                                             33-35

 

 

 

 

 

SECTION 1.0                       

OVERVIEW

1.1.           

PURPOSE OF THIS REQUEST FOR INFORMATION (RFI)

1.1.1.                 

The Colorado Department of Health Care Policy and Financing (Department) is issuing this Request for Information (RFI) to solicit input on the next phase of the Accountable Care Collaborative (ACC).

1.1.2.                 

Information provided to the Department in response to this Request for Information will inform the Department’s Request for Proposals (RFP) for the Regional Care Collaborative Organizations (RCCO) and the future design of the ACC Program.

1.1.3.                 

Anyone interested in responding is welcome to submit a reply (persons or entities responding to this RFI are called “respondents” throughout this document).  The Department encourages everyone with ideas about the ACC to respond.

1.2.           

DEPARTMENT BACKGROUND

1.2.1.                 

The Department serves as the Medicaid Single State Agency, as defined by Code of Federal Regulations (CFR) Title 45 Section 205.100 (45 CFR §205.100).  The Department develops and implements policy and financing for Medicaid and the Children's Health Insurance Program, called Child Health Plan Plus (CHP+) in Colorado, as well as a variety of other publicly funded health care programs for Colorado's low-income families, children, pregnant women, the elderly, and people with disabilities.  For more information about the Department, visit www.Colorado.gov/HCPF.

1.3.           

PROGRAM BACKGROUND

1.3.1.                 

The Accountable Care Collaborative (ACC) Program started in May 2011 with around 500 clients.  Since that time, the ACC has grown in many ways.  Today, the program covers over 700,000 people.  The current phase of the ACC is focused on developing a strong network of contracted providers that can serve as medical homes for Medicaid clients.  At the start of the program, enrollment was comprised largely of adults, and the pay-for-performance measures were designed for an adult population. 

1.3.2.                 

Over the course of the last three years, the ACC has expanded its focus from the medical home to the whole neighborhood of providers, such as specialists.  Program enrollment expanded, increasing the number of children to mirror the overall Colorado Medicaid population. To continue developing the ACC, the Department updated pay-for-performance measures to include children and changed the payment model to support improved medical homes.

1.3.3.                 

The ACC strives to provide the Colorado Medicaid program with a client and family-centered, whole-person approach that improves health outcomes and ensures savings.  The program design includes a focus on clinically-effective and cost-effective utilization of services.  The ACC works to identify the needs of clients and to use local resources to meet those needs.

1.3.4.                 

The ACC was designed as a platform to transform the Colorado Medicaid program.  The upcoming request for proposals (RFP) will build upon the successes of the current program by further developing the ACC to serve more people through greater efficiency and other incremental improvements.  In addition to these updates to the program, this RFP will also seek to make bolder, more-comprehensive changes to the ACC through deeper integration, new payment reforms, and the promotion of whole-person/whole-family health. 

1.3.5.                 

These improvements will also be strengthened by significant investments in technology, as with the forthcoming Business Intelligence and Data Management (BIDM) system.  These new platforms will allow for enhanced program monitoring and evaluation, and will give all parts of the ACC Program better data to improve care and decision-making.

1.3.6.                 

As one of the major parts of the ACC, the RCCOs leverage local infrastructure, relationships, and community resources.  The RCCOs' main responsibilities in the first RFP were:

1.3.6.1.                       

Provider network development: developing a formal contracted network of primary care providers and an informal network of specialists and ancillary providers;

1.3.6.2.                       

Care coordination: the RCCOs must ensure that every client has access to an appropriate level of medical management and care coordination; 

1.3.6.3.                       

Provider support: supporting providers in delivering efficient, high-quality care by offering clinical tools, client materials, administrative support, practice redesign, etc.; and

1.3.6.4.                       

Accountability and reporting: the RCCOs are responsible for reporting to the Department on the region's progress, and meeting programmatic and Departmental goals.

1.3.7.                 

The RCCOs are responsible for assisting clients with every aspect of their care.  This means that they have to assist clients with their physical health and their behavioral health.  The state pays providers directly for physical health services.  In Colorado, Medicaid behavioral health services are managed by five Behavioral Health Organizations (BHOs) statewide.  RCCOs frequently work with the BHOs to coordinate care.  Almost all Medicaid clients are enrolled in a BHO when they receive Medicaid. The BHOs get a set amount of money to manage the care for Medicaid clients, and the BHOs reimburse their network of providers for delivering services to those clients.  The five regions that the BHOs manage do not match the regions managed by the RCCOs.

1.3.8.                 

Today, there are seven RCCOs, each working in a specific part of Colorado.  Each RCCO has adopted a different approach that works in its region.  The RCCOs and their leadership play a vital role in the ACC and offer customized and local health care experience to the program. The ACC leverages personal, human connections to build on the strengths of local and regional partners.

1.3.9.                 

Just as the first RCCO RFP initiated the ACC Program in Colorado, this second RFP will launch the next iteration of the ACC.  What the program looks like in the future depends upon the RFP, and the content of the RFP depends upon the insight and guidance you offer through opportunities such as this Request for Information.

1.3.10.             

For more information on the ACC Program, click here

1.4.           

VISION FOR THE NEXT RCCO RFP

1.4.1.                 

The next phase of the ACC Program will build on the strengths and the lessons learned during the first iteration.   There are three main goals of the next RFP.  The Department welcomes input on these goals and how to achieve them.

1.4.1.1.                       

1. Transforming our system from a medical model to a health model. 

1.4.1.1.1.                             

A person's health is impacted by his or her social situation (for example housing, income, transportation, nutrition, presence of supportive family and friends) as well as medical care.  The next phase of the ACC Program aims to promote health by developing systems that support healthy lives, rather than just medical care.

1.4.1.2.                       

2. Moving toward person-centered, integrated, and coordinated supports and services.

1.4.1.2.1.                             

Person-centered care means that the individual/family/caregiver is an equal participant with the provider in defining health goals and developing treatment plans.  These both must address the whole person and be achievable within the context of the person's life.  To accomplish this, RCCOs must also be able to coordinate more-closely with non-medical services and other state agencies.  In order to do this, RCCOs must understand the community and culture where the person lives. 

1.4.1.2.2.                             

Part of a whole-person or person-centered approach is addressing both a person's physical and behavioral health needs in a way that is coordinated and cohesive, often referred to as integration. Taking steps towards integration or better coordination of physical and behavioral health care for Medicaid clients is a primary goal of the next RFP. Behavioral health care refers to all services to treat health conditions that primarily present as alterations in thinking, mood or behavior and changes in emotional (mood), psychological (thinking), or social well-being (behavior) and conditions related to addictions. To create the infrastructure for this integration, the Department seeks input on whether or how the Behavioral Health Organization (BHO) or RCCO maps or functions should be adjusted so that they are aligned.

1.4.1.2.3.                             

This next RFP will aim to continue to build on local strengths of each community.  This RFP aims to be sensitive to the diverse needs of clients with Medicaid coverage and will develop specific expectations around meeting the unique needs of subpopulations such as children, adults, the elderly, persons with disabilities, clients involved in the criminal justice system, and all others.

1.4.1.2.4.                             

Incorporating clients' perspectives is an ongoing process. The next RFP aims to strengthen opportunities for clients and advocates to provide input and play an important role in program design and ongoing improvement.

1.4.1.3.                       

3. Leveraging efficiencies to provide better quality care at lower costs to more people.

1.4.1.3.1.                             

The next RFP aims to capture efficiencies and save money through enhanced technology and by supporting a diverse and changing health care workforce.

1.4.1.3.2.                             

The RFP endeavors to align the financial drivers for all elements of the Medicaid delivery system.  Through the RFP process, the Department will explore different ways to pay for care, bend the cost curve, and be as cost-effective as possible.

SECTION 2.0                       

ADMINISTRATIVE INFORMATION

2.1.           

RFI TERMS AND CONDITIONS

2.1.1.                 

This RFI is issued solely for information and planning purposes and does not constitute a solicitation.  Information about costs and pricing is submitted voluntarily and is non-binding on the respondent.  Responses to this RFI will not be considered legal offers nor will they result in an award of any type of contract.

2.1.2.                 

The Department is not responsible for any costs incurred by any respondents for the development and provision of a response to this RFI. 

2.1.3.                 

The Department is subject to strict accountability and reporting requirements as a recipient of funds from public sources.  Responses to this RFI are subject to disclosure by the Department as required by the Colorado Open Records Act (CORA).  The Department plans to make responses to this RFI available for review online. 

2.1.4.                 

The Department reserves the right to copy any information provided by respondents for the purposes of facilitating the Department’s review of / use of the information.  

2.1.5.                 

The Department reserves the right to use information or ideas that are provided by respondents.  By submitting information in response to this RFI, the entity or individual represents that such copying or use of information will not violate any copyrights, licenses, or other agreements with respect to information submitted.

2.1.5.1.                       

The responses received from this RFI may be used for the development of a future solicitation.  Should a solicitation be issued, further details on the solicitation process will be provided.

2.2.           

POINT OF CONTACT

2.2.1.                 

The Department’s point of contact for this RFI is:

2.2.1.1.                       

Kevin Dunlevy-Wilson (note:  other Department staff may address e-mails or phone calls)

2.2.1.2.                       

Department of Health Care Policy and Financing

2.2.1.3.                       

Accountable Care Collaborative Strategy Unit

2.2.1.4.                       

1570 Grant Street

2.2.1.5.                       

Denver, CO   80203-1818

2.2.1.6.                       

Phone: 303-866-5351

2.2.1.7.                       

RCCORFP@state.co.us

2.3.           

NOTICES AND COMMUNICATIONS

2.3.1.                 

Communication with respondents will be via various methods including, but not limited to, e-mail, phone, mail, the Department's ACC RFP Web site at:
https://www.colorado.gov/pacific/hcpf/regional-care-collaborative-organizations-rccos-request-proposals-rfp
and notices on the CORE Web site at:
https://codpa-vss.hostams.com/webapp/PRDVSS1X1/AltSelfService;jsessionid=00007DX5IavpsnQoNcRwuPiYmie:189n1q4b1.  Respondents can view information posted on CORE by clicking on the “Public Access” button.  It is the respondent’s responsibility to periodically check the Colorado CORE Web site or the ACC RFP Web site for notices, changes, additional documents or amendments that pertain to this RFI.

2.4.           

TIMELINE

2.4.1.                 

The timeline for this RFI is as follows:

ACTIVITY

DATE

RFI RELEASE DATE

OCTOBER 21, 2014

INQUIRIES REGARDING THE RFI ACCEPTED UNTIL

OCTOBER 31, 2014

11:00 AM MOUNTAIN TIME

DEPARTMENT RESPONSES TO RFI INQUIRIES (ESTIMATED)

NOVEMBER 10, 2014

RFI RESPONSE SUBMISSION DUE DATE

NOVEMBER 24, 2014

3:00 PM MOUNTAIN TIME

SECTION 3.0                       

RESPONSES

3.1.           

INQUIRIES

3.1.1.                 

For inquiries about this RFI, you may send an email to: RCCORFP@state.co.us.  If preferred, you may also contact the ACC RFP team by phone at: 303-866-5351.  Include the RFI number and title listed in the e-mail subject line.

3.1.1.1.                       

The Department will track the questions that it receives and aggregate the questions into an “Inquiries and Answers” document.

3.1.2.                 

Inquiries received by the Department by the Inquiry Deadline will be responded to by the Department via a posting of the “Inquiries and Answers” document on the CORE Web site and the ACC RFP Web site.  Inquiries received after the Inquiry Deadline may not be included in the Department’s response.

3.2.           

PROTECTED HEALTH INFORMATION

3.2.1.                 

Do not include Protected Health Information (PHI) in your response.

3.2.2.                 

If the Department discloses the responses online or via a CORA request, unless the responder explicitly requested otherwise, responses by all Medicaid clients will be identified only by first initial and county of residence.  Example: John Doe would be listed as:  "'J.' Weld County."  Requests for pseudonyms will generally be granted if requested.  

3.3.           

RESPONSE FORMAT

3.3.1.                 

The RFI is broken into the following sections:

3.3.1.1.                       

Basic information about you, the respondent. 

3.3.1.2.                       

General Questions

3.3.1.3.                       

Behavioral Health Integration

3.3.1.4.                       

Care Coordination

3.3.1.5.                       

Program Structure

3.3.1.6.                       

Stakeholder Engagement

3.3.1.7.                       

Network Adequacy and Creating a Comprehensive System of Care

3.3.1.8.                       

Practice Support

3.3.1.9.                       

Payment Structure and Quality Monitoring

3.3.1.10.                   

Health Information Technology

3.3.2.                 

The Department is requesting respondents to send any comments or answers, no matter how minor, to the Department.  Respondents are encouraged to address the questions listed in the Response Worksheet, but you do not have to reply to all of the questions in a section.

3.3.3.                 

Please note that early responses are appreciated. Respondents do not need to wait until SUBMISSION DATE (see Section 2.4) to submit comments.  The Department appreciates receiving any and all comments from respondents. 

3.3.4.                 

Reponses should be emailed to RCCORFP@state.co.us. Your answers may be submitted as an attachment or an email.  If they cannot be emailed, they may also be sent, in hard copy, to: Colorado Department of Health Care Policy and Financing, Attention: ACC Team, 1570 Grant St., Denver, CO 80203.  Following receipt of your response, you should receive a confirmation email within three (3) business days.



 

RESPONSE WORKSHEET

Basic Questions for All Respondents to this Request for Information:

 

Please provide your name and location:

 

Name:             Julie Reiskin

Location:         Denver, CO

If you are a member of (or affiliated with) an association, business, or other similar entity, please provide the name and location of that organization:

 

Name of organization:            Colorado Cross-Disability Coalition

Location:                                 Denver, CO

Please check if you are answering on behalf of this entity

 

 

Please choose the best description for you, your organization, or the person on the behalf of whom this response is being submitted – Check all that apply:

Client

Client's family member

Client advocate

Medical provider / PCMP / other provider

              i.     

Type or specialty: Click here to enter text.

            ii.     

Area of practice: Click here to enter text.

Provider advocate (e.g. medical society)

Potential bidder for RCCO contract

Behavioral Health Organization

Data or HIT entity

Foundation

Educational or research institution

Another public or private program

Legislator or elected official

Other (please describe): Click here to enter text.

 

Are you currently involved in the ACC program?

Yes

No

I don't know

 

If you answered "yes" above, how long?

Less than one year

1-2 years

2-3 years

3-4 years

Since before the program was implemented.

How have you been involved in the ACC program and what interaction have you had with RCCOs:

Worked with two RCCO on disability issues and with one on client engagement.  Worked with HCPF on similar issues.  Involved in Duals Demonstration.

 

Please briefly describe your involvement with Medicaid, either in Colorado or another state:

CCDC has been deeply involved with Medicaid and HCPF since the department was formed.  We are on numerous advisory and stakeholder committees, and have had a member on the MSB since its’ inception.  We are a key group that brings the client voice to HCPF.  We have developed programs such as CDASS and have been very active in all areas of community based LTSS and have been involved with Olmstead and transition.   We have been active in benefit collaborative work.  We were active in the managed care contract, which was the predecessor to the ACC/RCCO program.    We also provide individual advocacy for clients and applicants on both eligibility and service related issues.  We represent people with appeals and complaints as needed.   We work with most of the provider groups both in an advocacy role and when appropriate as a collaborator on projects.     A significant part of the work of our organization is directly involved with Medicaid.

 

If you are a client, provider, or potential bidder, what is the likelihood that you will seek to participate in the program?

Very likely

Likely

Reserved (waiting to see the RFP)

Unlikely without significant changes

Will not seek to participate

N/A

 

The program is here and we support this program as a way to coordinate and manage care without using a capitation model, which does not work well for the population we represent.   We think the program is showing promising results, even though the data for disability groups is less promising, we are eager to see it move forward.

 

 

 

 

 

 

 

 

 

 

General Questions

1)     

What is working best in the Accountable Care Collaborative (ACC) right now?

There are two RCCO organizations that are actively working with the disability community and seeking our involvement and input.   Rocky is doing some innovative care coordination and starting a payment reform pilot project.  We are pleased that the Duals demo will include Independent Living Philosophy. 

2)     

What is not working well in the ACC Program?

Physician attribution and poor mailing list addresses are making it very hard for the RCCOs to do appropriate early outreach.  They are getting bad information from HCPF.  The opt out rate at least for duals is concerning.   The data on disability shows that there needs to be more attention paid to disability and that is not surprising given only one RCCO is really paying close attention to this population in a meaningful way and figuring out why there are not the same gains in terms of reduction of ER, imaging, etc. for this population. 

 

3)     

What is working best in the Behavioral Health Organization (BHO) system right now?

Very little is working well in this system except that there are a few good providers and the people lucky enough to be in those clinics are getting quality services.  These clinics are those that stay small enough to do a good job.   Denver Health does a good job for the people in their clinic who are able to manage to show up at appointments and follow their rules.  CHARG is fantastic. 

 

4)     

What is not working well in the BHO system?

Access to care remains a VERY serious problem.   People are reporting a 3-6 month wait and access to medications and psychiatrists is the biggest problem.  People who move or who come out of jail are forced to decompensate because they cannot get services and many cannot get into a primary care doctor either. 

The data for whatever reason is not capturing this serious access problem.  Clients that come to the attention of the system may get an appointment but most clients just wait and for some reason it is not showing that they are waiting as long as they are.   We do not see a lot of good innovative treatment in the public mental health system.  We do not see strong client engagement, meaningful recovery markers, etc.   There seems to be little to no mental health advocacy that is client focused. 

The system remains very punitive and harsh, despite great language in the HCPF contract and great promises by the BHOs clients continue to get kicked out of treatment for not showing up, unless they commit crimes and get into some special program.   If the client is just disorganized and unable to manage their lives to be where they are supposed to be are being left out in the cold. 

5)     

What is working well with RCCO and BHO collaboration right now?

We have not seen evidence of anything working well, this does not mean that nothing is working, only that we have not seen it.  There may be some ability in Colorado Access to make referrals more easily but we have not seen that result in quicker access to actual care.   In Colorado Access there is ability of case managers to come together because they work for the same company.

6)     

What is not working well with RCCO and BHO collaboration right now?

The silo mentality is still alive and well so not much is happening.  The lack of access to mental health care and continuation of the mental health center monopoly for Medicaid clients creates a huge access issue.  Our information is that most preventable emergency room care is due to behavioral health emergencies, but the RCCO’s are not allowed to interfere and do anything about the problem.  They are required to collaborate with the BHOs and are not in a place politically (and in one case structurally) to report to HCPF areas where the BHO is not fulfilling their contractual obligations.  For this to work it is imperative that HCPF do some independent enforcement OR put the RCCO in a position of authority over the BHO (preferably the former). 

 



 

 

Behavioral Health Integration

7)     

What should be the next steps in behavioral health integration in Colorado?

[1]

Until the behavioral health system can handle the client needs nothing more can or should be done.  We should not assume that primary care doctors cannot and should not do any behavioral health prescribing.  The model that has been in place has not worked.  We need to admit that and move on.  We have a few areas that have produced results (Denver Health, CHARG, etc) and we should figure out why they work and replicate.   It is disturbing that the crisis contract was not given to a company that has innovation experience in other states but that was not a HCPF decision.    Access to even basic psychiatric care is a crisis in Colorado in the public system.

Co-location is OK for some clients in some situations.   There are varying needs amongst the large Medicaid population and the system should not assume that all clients have the same needs.   Some clients need ONLY a psychiatrist and medication management and do not need therapy.  Others may need ONLY therapy and no medications.   Still others need case management and psychosocial supports. 

It is important to NOT assume that all people with mental illness have substance abuse problems and to make sure that the two populations are not dumped together as there may be victimization against those with serious mental illness by substance abusers.  Moreover, the clinical needs are different.  People with both drug and alcohol abuse and mental illness have a different set of needs and need to be treated for both problems.  

Of course, the complete lack of behavioral health for people with developmental disabilities still continues to be a problem.

 

 


8)     

Barriers to the integration of behavioral health and physical health services.  Using the table below, please explain which issues are barriers, and how they can be addressed:

 

Barrier?

 

Factor:

Yes

No

If yes, please provide details of the barrier and how to address it:

Community Mental Health Center financing structure

[2]

This is a problem but not a barrier, they are getting paid for every man, woman and child on Medicaid and expected to provide specific services but have no consequences for failure to do so

Community Behavioral Health Services Rule

Not sure if the rule is really the problem, but the lack of consequences for failure to meet access standards is a problem. 

Covered diagnoses list

We need to add autism on because people with autism use the same medications and need behavioral health interventions.   The BHOs also Must be forced to stop denying services to people with TBI and I/DD

Different behavioral / physical health reimbursement

I do not know enough about the details to know if reimbursement is a problem, but there seems to be enough money in the system.

Institutions for Mental Diseases exclusion

Please do not eliminate this, we need to make sure there are strong incentives against putting people in state institutions.  If someone needs a hospitalization to address a medical problem they should be on a psych ward but in a regular hospital with medical backup –like Denver Health or Porter—not in a stand alone psychiatric facility especially a state run institution.

OBH rules, reporting, or financing (regulatory differences between agencies)

We need one enforceable standard and increased enforcement of access standards and increased quality oversight

PCMP financing structure

Not sure how this affects behavioral health care, however there is a problem with not enough primary care doctors and clients with mental health or other disabilities are at risk for not having any PCP

Per-member per-month amount

If this amount is not adequate the BHO should not sign a contract. 

Physical space constraints

Unsure but with the huge increase in Medicaid clients this might be a problem

Privacy Laws (HIPAA, 42 CFR)

This is a problem everywhere and in mental health it becomes worse –this seems to come up more when people want to avoid involvement of families and advocates.    HIPAA rules do cause problems with law enforcement and mental health but it is probably a good civil rights protection to have the restrictions.

Professional / cultural divisions

Lack of disability cultural competency is an issue for sure—there is lack of cultural competency in other arenas as well.   This includes lack of respect for Native people in SW CO, lack of cultural competency in rural resort communities, etc.

RCCO or BHO contracts

The contracts themselves are pretty good, the enforcement is the problem.

Staff capacity

This is a HUGE issue in the behavioral healthcare arena.  It is also a problem with primary care.  Everyone knew that the Medicaid roles would be exploding after ACA so there should have been more preparation.  Now that the ACA has been in place, contractors that have not addressed the problem should be replaced.   If there is really no way to have adequate staff then something else needs to happen, such as using other doctors to prescribe.  Telling people with genuine mental illnesses to wait months, or even weeks, to get medication is unacceptable.

State/Federal rules or reporting requirements

As a client advocacy organization we are not aware of requirements that are a problem.

Technical resources / data sharing

We know the RCCO organizations are not getting accurate information for new clients which makes outreach hard.

Training

There is a lack of training on disability accessibility, disability cultural competence, ADA compliance and how to provide appropriate services and effective communication to the population we represent.   There is a lack of clinical expertise on how to work with people with I/DD and the few that are able to do this seem to be excluded from provider networks. 

Others

Please type your response here.

The Medicaid roles have exploded due to the implementation of ACA.  This is great, however we need to make sure those with the greatest need are not cast aside to serve those with lesser needs.   The access issues have become extreme especially with behavioral health care. There is no one enforcing the contracts and the data is not showing the problems, but everywhere people report the same thing.  

Some of the people that have a great need for integrated care are those not served by the BHO system such as people with TBI, autism, Alzheimer’s, etc.   Since the BHO system is unlikely to serve them well (given the track record with other disabilities) funds paid on behalf of these populations should be diverted to a system willing and able to provide the care.  In some instances this could be the RCCO. 

 

While co-location is OK that will only work if clients have access to both the psychiatrist and the physician.    Just having two provider types at the same location is not going to cause integration.  Integration will only occur if there is a go to person, such as a social worker or medical care manager that can really know the client and carry info between both provider types.  It is important that these care coordinators NOT be treated like doctors.   Doctors go to medical school for a reason and having nurses and others prescribe drugs, at least to people with complex conditions has had devastating results.

 

For many clients a shared electronic portal where the client could write information or even a system where a client could self-report symptoms and health issues that both the medical and behavioral providers could also access could be a great tool and would mitigate the need for co-location and even can work if the PCP and mental health professional are in different places.  Some clients have good doctors and get mental health elsewhere and these systems work for the most part and should not be disrupted.  

 

Clients that have both mental and physical disabilities need personalized care and do not do well in large clinics where there is a lot of confusion and many rules to follow.   They need ONE go to person that can connect them to the right person, in a compassionate, humane, ethical manner.


 

9)     

What characteristics are necessary for the State to recognize a clinic as providing integrated, whole-person/whole-family physical and behavioral health care?

a)     

Every client is assigned to ONE person with clinical skills who will have access to medical and psychiatric expertise as needed.  The client will have a direct phone number and email and can communicate with the go to person as needed.  The case load will be such that same day response will be the norm for issues that require it.

b)     

All clients on psychiatric medication have complete annual physicals and quarterly blood work.  

c)     

All clients on psychiatric medication are OFFERED (but not required) support for weight management.  This needs to be done in a non-judgmental, kind manner, and cannot be about lecturing or shaming clients. 

d)     

Clients who are opposed to taking psychiatric medication can still get other behavioral health care services such as therapy. 

e)     

Physicians are trained in mental health and are graded by clients with mental illness about compassion and listening ability.  There are measures to assure that physicians take seriously medical complaints of people with mental illness and do not assume that complaints are psychosomatic in origin. 

f)      

There is emotional support for caregivers even if they are not on Medicaid.    Medicaid services that ease the life of a caregiver are considered medically necessary and not an item of convenience (within reason of course) and all providers are trained on long term caregiver stress.

g)     

It becomes standard practice to prescribe supports so that there is no longer an expectation that parents continue to bathe, dress, and toilet a child, or provide 24 hour line of sight supervision, or deal with sleep deprivation without support once doing these tasks is no longer age appropriate.  For example after toddlerhood a parent should not have to deal with nighttime interruptions, once a child is 10 or older parents should not be involved with bathing and dressing unless they are a compensated attendant (and never should the parent be the only attendant).    It is the doctor that needs to be having these conversations with the family at an early age.

h)     

Prevention and health promotion are for everyone.     This means that ALL clients are screened for things like pain management, sleep regularity, nutrition, etc.

i)       

Doctors are encouraging clients to have a meaningful day and act as active advocates and promote/prescribe whatever supports are necessary to make that happen.   This means the doctor or someone at the office needs to know about LTSS and other resources.  For example that might be a referral to CDASS or IHSS, encouraging someone to volunteer, refer to DVR, assure that the client has a wheelchair that is appropriate for outdoor use,  etc.   There is support to help clients pursue. 

j)       

Doctors and staff understand and can articulate the Independent Living Philosophy and Olmstead.

10) 

Please share any other general advice or suggestions you may have about behavioral health integration.

Until HCPF holds the BHOs accountable for access standards, there will not be successful integration of behavioral health.  The RCCOs are in an awkward position in that they are supposed to coordinate but if they have to work as partners with the BHOs they cannot really report to HCPF or actively advocate.     People have been saying there are access problems for years, and there continues to be data problems.  This should tell HCPF that either the data collection is a problem or they are not collecting the right data or something else is wrong.  Otherwise this would not continue to be a problem.   Simply the behavioral health emergency room visits should be enough to prove there is a problem. 

HCPF should hire clients to be secret shoppers to test access and other aspects of the system.  This might require HCPF to give clients dummy ID numbers. 

Clients do not know what to expect so they do not complain when they do not get adequate access.  If they decompensate due to lack of medication by the time they can get help they are often in such bad shape that they cannot complain.   Perhaps having the RCCO give clients’ information on what they should expect in terms of access to behavioral health could help.   That may be a conflict of interest for some, but at least it should be tried.    Contracting with other organizations such as Independent Living Centers or organizations like Family Voices could get the word out about access standards and also help clients understand what they should expect regarding quality would also help.   Even providing information on these issues to application assistance sites might help. 

 

 

 


 

 

Care Coordination

11) 

Care coordination is an important part of the ACC Program.

a.     

What is the best definition of care coordination?    The below definition is about long-term care coordination but is relevant for all care coordination, specific tasks are outlined in footnote #2.

Long Term Care Coordination is a consumer-directed, team approach to the integration of care, services and support for optimizing health and social outcomes.

Those outcomes include:

• Care coordination(1) must allow people to maintain control to the greatest extent possible.

• Care coordination and activities of care coordination2 must recognize people may require different levels of support based upon individual strengths and/or desires.

• Care coordination must allow people to change care coordinators upon request.

• Care coordination provides tools and supports for people to take increased levels of personal responsibility.

• Care coordination encompasses person centered care(3), self-determination (4) and consumer direction(5)

. 1 Care coordination is the facilitation on behalf of the person to obtain or retain medical and non-medical services to meet their goals and needs.

2 Activities include finding providers, scheduling appointments, helping problem solve to mitigate any barriers such as transportation, copays, assisting with applications, redeterminations, prior authorizations, appeals processes and all ancillary care. It provides referrals to resources to assist the person in meeting their other life needs and goals, including offering referrals to advocacy organizations and peer-to-peer support

3 Person Centered care focuses on the preferences, strengths, capacities, needs and desired outcomes or goals expressed by the person. Any planning process, regardless of the person’s choice of service delivery must be an interactive process that supports and enhances the individual’s stated preferences. Any discussion related to an individual or event supporting an individual must focus on the Person-Centered approach and should utilize the values of Self-Determination.

4 Freedom to decide how one wants to live his or her life; Authority over a targeted amount of dollars; Supports to organize resources in ways that are life enhancing and meaningful to the person; Responsibility for the wise use of public dollars; Recognition of the contribution individuals across Disability and aging can make to their communities and Confirmation of the important roles that individuals must play in the newly designed system”

5 People with disabilities assess their own needs and make choices about what services would best meet those needs. It makes a statement that consumers can and should have options:

- to choose the personnel or provider entities that deliver their services,

- manage the how, when, and where of delivery of services, and- monitor the quality of services.

Choice is guaranteed including the choice of how much to direct or not direct services.

THE ABOVE DEFINITION HAS BEEN AGREED UPON AND VETTED BY MANY ORGANIZATIONS AND INDIVIDUALS WITHIN THE DISABILITY COMMUNITY.  Please see www.INDIVISIBLE-CO.org

b.     

How should RCCOs prioritize who receives care coordination first?

First, it should be based on anyone that asks for care coordination.  CCDC has been disappointed in a couple of situations where a client self-identified the need and was denied meaningful or any care coordination.   Even if the client is difficult and time consuming, the RCCO should absolutely be required to provide this.    Literature and HCPF/RCCO web sites should provide specific email and contact information for people to make this request.

Second, should be based on data.  They currently are doing this with high ER utilizers and this is OK but they should also be prioritizing in other areas including:    All of these are situations where the client should be OFFERED care coordination but not required.  It should be stated clearly what care coordination is, what the offer is and that there is no consequence to saying no.  Clients should be allowed to meet with someone to discuss and there should be something written given to the clients to explain what it is an expectations.

-People with no known address

-People with no PCP especially if they have specialty needs

-People who have been taken off HCBS for any reason

-Anyone that has been in a rehab center if not on HCBS

-People with multiple medical testing or more than 10 medications should be offered it

c.      

How should RCCOs identify clients and families who need care coordination?

-They should do outreach and allow as many clients as possible to self identify.  This includes web sites with clear info on what it is and how to access.

-They should have an easy process for other agencies, including advocacy and provider organizations to refer for care coordination.  This should be an online process and should allow for the submission of a release if the provider or advocacy organization wants to be kept in the loop (and the client wants this also).     The process should explain clearly what to expect (e.g. if you make a referral the client will receive an email or call within X days and should be able to have an in person meeting at an office in X town within X days.  It should tell us how to access Medicaid transportation for the first appointment.   There should be a place for our clients to ask questions before agreeing to care coordination.

-Using claims data to do outreach and offer care coordination.

d.     

How should RCCOs track care coordination when the care coordination takes place at a delegated Medical provider?

There should be a very easy to use standard tracking program,  if a medical provider office is not willing to use that form then they should ask for reporting in whatever way the provider will do it and try to incorporate into their system.

Tracking should include both outcomes and outputs and should not assume quantity will be the same for all clients.  Tracking should help inform decisions like appropriate caseload size for a care coordinator.  It should also have a way to incorporate client feedback.

 

12) 

What services should be coordinated and are there services that should not be a part of care coordination?

Finding providers, scheduling appointments, helping problem solve to mitigate any barriers such as transportation, copays, assisting with applications, redeterminations, prior authorizations, appeals processes and all ancillary care. It provides referrals to resources to assist the person in meeting their other life needs and goals, including offering referrals to advocacy organizations and peer-to-peer support

It should include advocacy to get into LTSS and perhaps advocacy if client has a problem with the LTSS care manager but should not include that at this time since that is a different system (at some point we can address this but not right now). 

It SHOULD include helping people with problems that affect health such as housing advocacy –e.g. advocating that a local housing authority do appropriate pest control.   They should also be doing things like writing reasonable accommodation letters for housing issues.  

It SHOULD help people get services and supports to have a meaningful day (e.g. move to CDASS so they can get an attendant mid-day) but should NOT be involved in any way with employment or even volunteer work or education.  These are areas where ones’ health care has no business.  

It SHOULD help people get resources for healthier living (access to gyms or rec centers, getting transportation to said places, etc.) but should NOT engage beyond that or engage with family issues or psychosocial issues unless there is a health connection. 

It SHOULD do whatever is appropriate to help a child stay in school, especially if the child has school avoidance behaviors.

13) 

What pieces of information are most important to have about someone in order to know what care coordination he or she needs?

-What are current services and are they working well (IF SO LEAVE IT ALONE)

-Does person have unmet health goals? If so what?

-Does person have things that they do during the day that are meaningful?    If not that will lead to bad health. 

Do they have other stresses that are too much (caregiving on top of a job, etc)

-Do they eat enough and have choices of what they eat (or do they have to eat government cheese and lots of 99 cent fast food)?

-Do they sleep well?

-Do they have a primary care physician and if so are they comfortable with the person?

-Do they have dental care?

-Do they have untreated or unmanaged pain? 

14) 

Many clients and their families have access to a number of different care coordinators.  These coordinators often work in different systems. 

a.     

What care coordination is going on today?

-LTSS—all waiver clients have a care manager

-Mental health-some BHO clients have a care manager

-Clients in some housing programs have a care manager

-Some clients have care managers from other places like Independent Living Centers, AAAs, Arc’s (ILC and ARC do not do case management but often end up doing the same things because no one else is doing it and their client needs it). 

-EPSDT (rare but some people have it)

-People on probation

b.     

What care coordination takes place outside of the RCCO or ACC, and what makes that coordination different?

See above, each is different.  For example HCBS coordinates ONLY LTSS.  In the DD system it is different and more involved but in the EBD system it is more gatekeeping (which is OK) and setting up services, does not really deal with health.  

Mental health case management when it happens is the closest to what the RCCO should be doing.

Housing/homeless programs often help people deal with benefits, sometimes they are transitional and go away after a specific amount of time.  

c.      

How can the ACC avoid duplicating or disrupting current care coordination relationships?

Ask each client who else they work with and if they already have a case manager bow out unless the client wants them to be involved.   Make sure that there is NO interference with LTSS but should be strong referral to LTSS.  RCCO CM should be able to advocate for client with the LTSS CM (example, the client is getting sick because the house is not clean enough and client needs more homemaking hours, client needs to be getting out of the house and needs non-medical transportation)

d.     

What are the gaps in care coordination across the continuum of care?

-People with complex or high needs but who do not abuse the ER and do not abuse drugs or alcohol are completely left out and are not getting their needs met.   Also people who are may not have high needs but who have needs and are unable to access care without help need care coordination. 

-People who need help with cross-systems issues—for example they need medical letters for housing purposes, or need help moving due to a medical problem, or need transportation to get to a probation appointment need coordination.  

-People with disabilities that want to engage in healthier habits and lifestyle have no one to help them navigate and find resources to help make it happen.

-People with communication barriers including but not limited to people with speech impairments, traumatic brain injury, mental illness, learning disability and people with cognitive impairment who do not have guardians.

15) 

RCCOs' roles in addressing clients' and their families' non-medical needs.  Please complete the table below, keeping in mind adults, children, and families:

Non-medical need:

Should the RCCO have a role?

Should the RCCOs coordinate with community supports and services?

Should the RCCOS have an additional role beyond coordinating with these supports? If so, what should that role be?

 

Yes

No

Yes

 

Abuse, neglect, and trauma

 

Unless client wants counseling or there are medical issues as a result.  They should understand and practice trauma informed care.  They should understand that some in the disability community experienced abuse by medical professionals.

Affordability (assistance with prescriptions or co-pays)

 

Medicaid co-payments are minimal, however they should still try to help if someone is unable to follow medical advice due to these payments. 

Daycare / childcare

 

This is a challenge for all low income parents.  CDHS runs a program which is not terribly client friendly. 

Economic stability & employment

 

Economic stability is a need for everyone and while poor health and poverty are correlated, the RCCO cannot be all things to all people.  The one exception is that they should encourage people to work and make sure providers are supporting what people need to work in terms of DME, pain management, etc.

Education

 

They may want to coordinate with school based health clinics in some situations.  However education is something all kids need and is very important, but again, this is a health program and cannot be all things to all people.  Providers should make sure they are prescribing and advocating for what kids and young adults need to be successful like DME, assistive technology, etc.   Kids with IEPs should not be forced to spend half their school day getting therapy and losing important educational time.

Environment

 

Not sure exactly what this is about but if it is about things like bed bug mitigation or asbestos they should be involved as advocates and perhaps even helping clients access financial resources.

Food access / nutrition

 

People cannot be healthy without food, they should give people information and refer to community resources.  Some clients may need advocacy. RCCO case managers should help clients get as many medical deductions as possible to increase food stamps.

Health literacy

 

This is absolutely a perfect fit for RCCOs.

Housing

 

Housing and health are connected but it is important that housing and services are NOT connected.  I checked yes ONLY because there is a need for case managers to help with advocacy, reasonable accommodation letters, etc.    RCCO should not provide it directly but should refer and be involved with advocacy as often clients need a medical professional especially if they deal with housing authorities. 

Language or translation services

 

This is a requirement under CMS for LEP

Literacy

 

Literacy is important for all, it is not a health issue in general.  RCCOs should refer to community resources.

Transportation

 

RCCO should not provide it directly but should refer and help people use Medicaid transportation and should also refer and fill out paperwork for paratransit or mobility training as needed.  The case managers should understand local transportation options so they can encourage and support clients.

Other

 

Please type your response here.  Feel free to list as many non-medical factors as you want, and please explain how the RCCO should be involved.

 

16) 

Requirements about who should be doing care coordinationCare coordination is often a team effort with several people with different skills working together to serve Clients and families.  Please use the table below to describe who should be a part of coordinating care and what roles those different people should play:

Type:

Coordinate care?

In what capacity should these individuals coordinate care in the ACC Program?

 

Yes

No

 

Advanced Practice (Registered) Nurses

For medical care only but not social care

Certified Addiction Councilors

 

Certified Nurse Midwives

For pregnancy and infancy related care only

Community Health Workers

Need more info about what this means –but they should be able to help with community referrals and advocacy

Generalists (BA/BS/MA/MS)

Would need more info as to qualifications, having a degree alone is not enough

Health Coaches

 

Licensed Clinical Social Workers

Ideal for care coordination if properly trained

Licensed Marriage and Family Therapist

 

Licensed Mental Health Counselors

 

Licensed Professional Counselor

 

Masters of Public Health

 

Medical Doctors / Doctors of Osteopathic Medicine

Only for some medical coordination –for example coordination of a complex medical procedure only but not social or supportive follow up

Nurse Practitioners

Should focus on medical aspects

Patient Navigators

If properly trained should be able to do all aspects of care coordination and do it well

Peer Advocates

If properly trained should be able to do all aspects of care coordination and do it well

Promotoras

If properly trained should be able to do all aspects of care coordination and do it well

Psychiatrists

 

Psychologists

 

Registered Nurses

Only for health related aspects

Social Workers

Only if licensed

Wraparound facilitators

 

Other

Please type your response here.

Contracts with Independent Living Centers or other advocacy organizations like Family Voices could be used to do specialized care coordination. 

Some LTSS care management organizations especially some of the ones that have worked with CHCBS might be good care coordinators.

 

17) 

Care coordination requirements for specific populations. Please use the table below to describe if any of the following populations require unique care coordination requirements, or if general requirements are sufficient:

Population

Specific

General

If specific, please describe

Newborns and infants

 

Children

 

Children who are healthy, but in socially-complex environments

Depends on situations but if parents want it or if DHS is involved

Children involved in the foster care system

Absolutely legal knowledge is imperative for issues like medical records

Children with a chronic illness

If no one else is doing it-should have family systems training

Children with a serious emotional disturbance

If no one else is doing it-should have family systems training

Children with medical complexity

Should be medical management if no one else is doing it—should have family systems training

Children or youth with a behavioral health diagnosis or substance use disorder

 

Transition-age adolescents

 

Parents and families

 

Pregnant women

 

Adults

 

Adults who are healthy, but in socially-complex situations

Only if client wants it

Adults with a chronic illness

 

Adults with a behavioral health diagnosis or substance use disorder

Depends on needs

Clients involved in the criminal justice system

Yes definitely

Clients with a disability

Depends on needs

Clients in a nursing facility

Oversight to make sure medical care is OK and for MFP

Elderly clients

Depends on needs

Frail elderly clients

Yes but already should have through LTSS

Clients in palliative care

They would have this through palliative care already

Other populations, please comment:

 

 

18) 

How do you envision the RCCOs working with child-serving agencies in the state to deliver care for medically or socially complex children or for children involved in the foster care system?

Would defer to Family Voices and Parent to Parent and EMPOWER on this question.

 

19) 

How should care coordination be evaluated?  How should its outcomes be measured?

What is client goal?  Did CC help client meet goal?

Are more adults with disabilities working or volunteering without interruption due to preventable medical problems (pressure sores or contractures)  or failed systems (broken wheelchair) or inability to get care when they need it (mental health)?

Reduced hospitalizations

Are more adults taking action to improve health (going to dentist, losing weight, increasing activity, etc.) after receiving care coordination support?

 

20) 

Today, RCCOs receive $8-$9 per member per month (PMPM) to cover care coordination and other expenses, like developing and supporting a network of providers. 

a.     

What is the PMPM cost for providing care coordination services? 

We are not a provider so cannot answer.

b.     

Is it advisable to have the PMPM vary by specific population? If so, what would be the recommended PMPM cost by population?

Yes it would be advisable as some populations require people who are culturally and otherwise competent to work with them (e.g,. Deaf) but we are not provider so cannot answer cost.

We will say that people with complex needs need a LOW client to case manager ratio.

 

21) 

Should there be care coordinator to client ratio requirements in the next RFP?  How should this vary by client acuity or population?

YES and should vary by population and level of service expected

a.     

Care coordinator to client ratios.  If you answered “yes” to the previous question: with roughly 45% adults, 55% children, and with 6% of covered clients having disabilities, please estimate how many clients one care coordinator can serve.  Please use the table below for your response:

Clients

 

Fewer than 25

26-50

51-100

101-200

201-500

501-1,000

1,001-1,500

1,501-2,000

2,001-3,000

3,001-4,000

4,001-5,000

More than 5,000

THIS IS VERY HARD TO ANSWER BECAUSE ONE DOES NOT KNOW WHAT THE NEEDS ARE--

 

22) 

How should care coordination outcomes be evaluated by the Department?  Which metrics are most important?

Reduction of preventable ER and hospital visits

For adults with disabilities days lost from usual activity and increase in having a usual activity,  getting to a baseline will take some time. 

Weight loss of people with obesity

Other health measures such as reduced smoking, drinking, etc.

 

23) 

Please share any other general advice or suggestions you have about care coordination in the ACC.

 


Care coordination is the key of how this whole thing will work.  For those whose needs are the greatest (may not be most expensive in system) a low client ratio is important.  Care coordination should not have rigid limits and should be about doing whatever it takes to get the job done.  For some clients that will be wildly non traditional.  For example some clients may need to have a relationship with a care coordinator before they will feel comfortable listening.  It might be something like having the client call the care coordinator and get together each time the client wants to use the ER—that might mean Sundays or late at night.  Lasting behavior change comes from a close relationship and ability to make small changes, get positive reinforcement, then more changes.  A few clients might need this forever. 

 

Program Structure

24) 

If you could require all RCCOs to implement certain functions in the same way across the state (or across all regions), what functions would you consider most important?  (The Department has heard examples such as: care coordination requirements, data reporting to the RCCOs, data reporting from the RCCOs, provider contracting, and payment methodologies).

-Data should be the same so we can measure apples to apples

-Care coordination should have some of the same elements but RCCO should be allowed to experiment also

-Required client engagement that is meaningful –each one should do what works in their community but each should be able to point to specific activities and give client names and advocacy organizations for references

25) 

What should be required of a bidder to ensure that, as a RCCO, it could form community relationships and understand community strengths and needs?

-References from several community organizations including advocacy and client run organizations

-Proof that they have worked cooperatively on joint projects with community organizations including advocacy organizations and organizations other than medical providers.

-Demonstration on how they have reached out to the community to determine client needs

-Proof that they have supported community activities including local non-profits.  Did they participate in local fairs, Veteran Stand Down, etc.

 

 

26) 

The Department has received suggestions that, in the next RFP, PCMPs should be allowed to choose the RCCO to which that practice's clients are enrolled.  Please comment on this proposal.

-Not sure how this would work since clients are assigned based on where they live.  Would this mean that there would be more than one RCCO per area?   While CCDC always supports choice, we are not sure there is enough data to demonstrate a need to have more than one at this time.

27) 

Should the RCCO region maps change?  Why or why not?  If so, how? We have no reason to think they should be changed at this time.

 

28) 

Should the BHO region maps change?  Why or why not?  If so, how?

 

Yes they should match the RCCO regions so if needed the RCCO can take over this function if the BHOs cannot be fixed.

 

29) 

Based on the current scope of work for RCCOs, how many months of transition would new vendors require?  What needs to happen during the transition period?  What are the expenses involved in this transition?

We are not providers and could not comment with much knowledge, but if there were new vendors client communication would be imperative so it would be important that communications are not held up in clearance at HCPF.

30) 

What legislation, policy, rules, or changes in procedure are needed to make the ACC more effective?

No legislation is needed, not sure rule changes are needed other than in definitions,  Enforcement of existing rules and implementation of what is already promised is most important.  

-Defining care coordination and then enforcing provision of it for complex clients

-Enforce access standards on BHOs

-Fix the problems with addresses and attribution and fix CBMS problems that kick people off Medicaid inappropriately. 

-Need more primary care doctors to work with Medicaid clients especially those with disabilities and particularly those with pain management needs.

31) 

What are the limitations of the current benefit structure and what – if any – changes are needed?

The Medicaid benefit structure in CO is pretty good.  Coverage of glasses and hearing aids for adults would be terrific.  

32) 

Should there be multiple RCCOs per region?  This would involve two or more entities operating in the same region and competing for clients and providers.  If so, why? If so, how many and where?  What issues would this address? 

This might be a good thing for the future but for right now we should get the program off the ground more—we have not had complaints from clients wanting a different RCCO.  We have had a couple complaints about the care coordination being inadequate or non existing and that might be solved with ability to move to another RCCO.    However requirements about care coordination and forcing them to work with disabled and complex clients and allowing all clients to choose and change the specific care coordinator should suffice with less administrative hassle.

 

 

 

33) 

If you or your practice provide services to clients referred through a BHO, but you are not a Medicaid provider, would you be willing to become a Medicaid provider? If so, what has prevented you from becoming a provider in the past? If not, why not?

NA

34) 

What role should RCCOs play in attributing clients to their respective PCMPs?

They should help find a PCP practice at request of the client.  This means there have to be enough doctors to take the clients.  They would need to make sure the PCP could meet the client needs.

35) 

What types of collaboration should exist between the ACC Program and the Colorado Department of Public Health and Environment?

CDPHE should meet with care coordinators to ascertain what are REAL threats to health and safety.   They should also ask questions about what hospitals may need additional oversight particularly in terms of inappropriate discharges.

36) 

What types of collaboration should exist between the ACC Program and the Colorado Department of Human Services?

CDHS should meet with RCCO care coordinators to hear about how programs are or are not working such as their child care program, need for additional medical exemptions for the food stamp program

37) 

What types of collaboration should exist between the ACC Program and the insurance marketplace / Connect for Health Colorado?

Unsure

38) 

What types of collaboration should exist between the ACC Program and the Colorado Department of Regulatory Agencies or the Division of Insurance?

Unsure

 


 

 

Stakeholder Engagement

39) 

What should be required of the RCCOs in terms of stakeholder engagement with clients, clients' families, and client advocates?

Meaningful client engagement, this means a real process, not a pro forma advisory group that never meets or that only hears presentations.  Each RCCO should have a written plan about client engagement and that should involve some external group in a meaningful way.   This should include a communication plan.

Ongoing education about client populations provided by client run organizations for cultural competency.

Hiring clients or advocacy organizations to help do satisfaction surveys.

Engaging clients and advocacy organizations for what should be on websites, testing and working on client facing communications, etc.  

40) 

What specific requirements should RCCOs have for stakeholder engagement with providers, community organizations, social service providers, and others in their region?

Not sure about providers but they should make sure to include advocacy organizations.

41) 

Many of the successes of the ACC Program can be attributed to the involvement of local communities.  How can enhanced community engagement be created in the ACC?

If there is adequate and appropriate client and provider and community organization engagement that will happen organically.

42) 

How should the Department structure stakeholder engagement for the ACC as a whole?

 

Require each RCCO to have written plan as above, HCPF should have a statewide oversight group that has staff to make sure it well run.  There should be contracts for advocacy groups to assure client participation and to get information to clients and from clients to the department.   


 

 

Network Adequacy and Creating a Comprehensive System of Care

43) 

Does the current network of PCMPs, specialists, behavioral health providers, hospitals, pharmacies, dental, home health, and non-medical providers adequately serve the ACC population?

NO

a.     

If no, what are the gaps? 

Primary care for people with complex needs and pain management is biggest medical gaps

Lack of choice of DME and NO complex rehab in some parts of state

PDN for kids and adults

Specialists access varies regionally

b.     

Please address gaps for the population as a whole, and for specific subpopulations such as children/families and individuals with disabilities.

We are only able to speak for people with disabilities of all ages

44) 

ACC Clients and the RCCOs interact with many parts of the Medicaid program, as well as with service entities and other types of providers or facilities. 

a.     

What role should hospitals play in the next iteration of the ACC Program?

Hospitals are important.  In Montrose there was a lot of praise for the local hospital –what are they doing and how can it be replicated?   All hospitals should remain open to Medicaid clients.

b.     

What role should pharmacies play in the next iteration of the ACC Program?

Currently almost all pharmacies serve the Medicaid population and this should continue

c.      

What role should specialists play in the next iteration of the ACC Program?

 

d.     

What role should home health play in the next iteration of the ACC Program?

Home health is becoming less relevant in LTSS as most LTSS is now done through IHSS or CDASS but it is still important for two reasons:  If IHSS requires most services to be unskilled people will stay in home health because it will be financially impossible to use iHSS.   Also if parents cannot be paid paid under personal care via CDASS parent C.N.A.s will have to stay in home health.  Finally, home health is important for acute care to help people leave hospitals earlier.

e.     

What role should hospice care play in the next iteration of the ACC Program?  Hospice is an essential wonderful service that should be available to all people if they are in a terminal situation.   Hospice should be available without requiring people to forgo all curative treatment.

 

f.       

What role should Single Entry Points (SEPs) and Community Centered Boards (CCBs) play in the next iteration of the ACC Program?

There should be some coordination but we need to be careful to avoid duplication.  Also LTSS is NON medical and while there is some overlap most people want to keep some separation between every day life and medical care.

g.     

 What role should counties play in the next iteration of the ACC Program?

NONE—we should get eligibility to eligibility sites and the SEPs

 

 

h.     

 What role should local public health agencies play in the next iteration of the ACC Program?

They are very important for EPSDT and in rural communities but we do not have specific information other than that they should be involved.

i.       

 What role should community organizations and non-profits play in the next iteration of the ACC Program?  Are there potential partnerships with these organizations which have been overlooked in the past?

A couple RCCO’s do not appear to have any contracts with disability rights organizations to help them with client engagement and cultural competency.    RCCO’s should contract with client run organizations to help them in this regard.  The ones that do so should be commended and rewarded.  They should also be involved with other organizations such as Homeless outreach groups, Veteran advocacy groups, etc.

45) 

How can RCCOs help to support clients and families in making and keeping appointments?

Common sense, implement effective communication protocols and use reasonable modification of policy, practice and procedure.  Reminder calls/emails, help with transportation advocacy if needed.

46) 

Community Health Workers are lay members of a community who provide coordination or help people to navigate the health care system in that community.  Should the Department require Community Health Workers or Patient Navigators as part of the next RFP?

No, it should not be required but there should be funds for those who want to use it. Ideally the RCCO should make the system work so that clients do not need yet ONE MORE person in our lives to help us navigate the system.  Just make the system understandable and customer friendly.   However we are so far from that in some systems that something like this might be needed but should happen in conjunction with systems change.

47) 

Community Health Worker reimbursement.  Please use the table below to detail how Community Health Workers should be reimbursed:

Reimbursement process

(Please check all that apply)

Independently bill

On staff (salary) at Primary Care Medical Provider Clinic

On staff (salary) at RCCO

Per Member Per Month Payment

 

48) 

Oral health is an important part of overall health for both children and adults.  Oral health benefits in Colorado are currently structured through an administrative services organization.  What should be the RCCO's role in coordinating dental care and ensuring an adequate network of providers?

None other than encouraging clients to use the service.

49) 

Cultural competence among providers is important to ensure a Client-centered, effective system that supports the health and well-being of clients and families.

a.     

What does cultural competence mean to you?

                          [1] Culturally Competent: The ability to interact effectively with people of different cultures, including different disability cultures, and socioeconomic backgrounds.

b.     

What RCCO requirements would ensure cultural competency? 

That all staff including administrators have training by people from the affected populations  (not by others talking about us) and that they have implemented the recommendations from those trainings.  For disability that means policies in place to assure effective communication as required by ADA and process for requesting and receiving reasonable modification to policy, practice and procedure.  It also means adherence to the IL philosophy.

c.      

What skills must providers and staff have in order to provide culturally and linguistically-responsive care to all Clients/families including those with low health literacy?

Effective Communication

d.     

Low heath literacy, different cultural health beliefs, and language barriers make communicating about health complicated.  What RCCO requirements would help address these and reduce inequality in health outcomes?

Need to have staff who are members of various cultural groups, for low incidence groups they should hire consultants to help.

50) 

Should the next RFP allow for preferred networks for specialty, facility, or ancillary care?

NO—need to keep this FFS and any willing provider.

51) 

Nationally, rates of emergency room utilization are on the rise.  This presents challenges in terms of cost and coordination of care.  What should the ACC do to address this trend?

Some of this needs to be HCPF and maybe the legislature to get more primary care doctors.  HCPF also needs to enforce the access standards in the BHO contracts.  The RCCO can find out why clients are using the ER and report to HCPF so there can be joint solutions.  

52) 

Please feel welcome to share other general advice, suggestions, and information you may have about network adequacy, PCMPs, specialists, pharmacies, or hospitals.

Most ER visits are for uncontrolled pain, dental emergencies, and behavioral health emergencies. Dental emergencies should be reduced now that there is a benefit for Medicaid clients.

 


 

Practice Support

53) 

Support for practices.  Please use the table below to describe the types of support RCCOs should offer to practices and other providers.  Please check boxes to indicate if specific tools should be provided, and if the state, rather than the RCCOs, should offer a platform of support:

Type of support

 

Should a specific tool be required?

Should the state provide?

 

 

Yes

No

 

Administrative support

 

Network provider education

 

Assistance with practice redesign

 

Assistance with efficiency-enhancing activities

 

Provide web-based resources and directories

 

Provide practice-specific data reports

 

Provide clinical care guidelines and best practices.

 

Provide clinical screening tools

 

Provide health and functioning questionnaires

 

Provide chronic care templates

 

Provide registries

 

Offer client reminders

 

Offer client self-management tools

 

Offer educational materials about specific conditions

 

Supply behavioral health surveys

 

Supply other self-screening tools

 

Administer behavioral health surveys

 

Administer other self-screening tools

 

Prepare client action plans

 

Provide training on providing culturally-competent care

 

Provide training to supporting staff

 

Provide training on motivational interviewing

 

Provide tools and software for phone call and appointment tracking

 

Provide tools and resources for tracking labs, referrals, etc.

 

Provide referral and transitions of care checklists

 

Provide visit agendas or templates

 

Provide standing pharmacy order templates

 

Provide comprehensive directory of community resources

 

Provide directory of other resources

 

Provide materials regarding Nurse Advice Line

 

Ensure all tools and resources are centrally located on RCCO-specific website

 

 

Others

 

Resources for ADA compliance

 

 

             

 

54) 

If you checked any of the boxes in the column entitled "should a specific tool be required" from the table above, please provide details about the specific process, tool, or product that should be required.

Only checked it because in those areas it would be confusing to have different tools or lists

55) 

What RCCO requirements or services should be required to support practices in practice transformation or to assist practices in becoming more efficient and robust medical homes? 

Not sure anything should be required, there is too much variation and if things are required practices will not want to join.

56) 

What is the most effective way to recognize and reimburse PCMPs based on their capacity to serve as a client's medical home?

Not sure but increased dollars for complex or difficult clients are needed.

57) 

Should the Department require that PCMPs utilize disease registries to manage the health of their population?

NO

58) 

Please share any other advice or suggestions about provider support in the ACC.

 

PLEASE do not mandate anything for providers regarding reporting or how they have to practice;  we have enough shortage as it is and cannot afford to lose more Medicaid providers.


 

 

Payment Structure and Quality Monitoring

59) 

Does the current payment structure support the goals of the ACC?  How can financial incentives be further aligned to support these goals?

Unsure –perhaps financial incentives for specific outcomes but this has to be done VERY carefully.  Incentives should be given for providers to treat people who no one else will treat such as chronic pain patients.

60) 

If PCMPs could voluntarily elect to receive capitation payments rather than fee-for-service, would your practice be interested in participating?  Under what parameters? What services should be included in a primary care capitation?

NA but CCDC does NOT support capitation as that always is bad news for our population.

61) 

Do providers have the infrastructure to be successful in an environment where payments are tied to value?  If not, what are the barriers to developing that infrastructure?

Not sure

62) 

The Department is evaluating various financial and administrative arrangements that may involve licensure by the Division of Insurance (DOI).  Licensure may require financial reserves or the fulfillment of other regulatory requirements.  For potential RCCO bidders: is your organization licensed by the DOI with an LSLPN, HMO, or other license?  Would the requirement to obtain a Limited Service Licensed Provider Network (LSLPN) license or a Health Maintenance Organization (HMO) license preclude your organization from bidding? 

NA but CCDC opposes ANY movement towards capitation or HMO model.

63) 

What role – if any – should the RCCOs play in the distribution of payments to providers? 

They should be allowed to distribute bonuses only if they have no conflict of interest.

64) 

Please feel welcome to add any further thoughts or suggestions pertaining to payment reform within the ACC.

We should not make any changes until we see results of the payment reform demonstration.

65) 

What types of measures should be tied to payment in order to ensure the program improves the quality of care, satisfaction of clients and providers, and health outcomes?

Client satisfaction

No dumping of clients

Willingness to take clients that are labeled as difficult or unpopular or clients that need a lot of support.

 


 

66) 

Measuring Client experience.  Please complete the table below to indicate how the Department should measure Client/patient experience:

Tool:

Should it be used?

Comments:

 

Yes

No

 

Consumer Assessment of Healthcare Providers and Systems (CAHPS)

This is fairly useless and does not measure much that is important or that means good care.

SF-12 Health Survey

Do not know what this is

Other types of client interviews / surveys

We should find something meaningful

Patient Activation Measure

Yes patient activation is tied to health

Focus groups

Yes good way to get info

Other

Please type your response here.

 

 

67) 

Knowing that, at this time, the Department only has claims data, how should population health be measured?

Specific measures such as ER and inpatient claims (why and were they preventable), dental claims (are people going for preventative), physician claims (preventative)

Look at specific codes

68) 

How should quality and performance data be reported to the RCCOs, PCMPs, and the public?

Via HCPF web site, RCCO WEB SITES, news releases, social media,

69) 

Measures for payment.  Please use the table below to describe how many measures should be tied to payment at one time.  These could function similarly to Key Performance Indicators, but they do not necessarily have to do so.  Please assume that the Department will try to align measures with other programs to the extent possible.

Measures

 

1-7

8-10

11-20

21-30

31-40

41-50

51+

None

 

 

70) 

What percent of RCCO payments should be tied to measures or performance?

Percentage

 

10-20%

21-30%

31-40%

41-50%

51-60%

61-70%

71-80%

81-90%

91%+

 

71) 

Should all RCCOs, across each region of the state, be paid on the same Key Performance Indicators (KPIs)?  Should providers and RCCOs be paid on the same KPIs? 

Yes

72) 

Should RCCOs be reimbursed based on their performance compared to national standards or based on improvement?

National Standards

73) 

Should the Department only tie payment to measures where data can be provided on a monthly or regular basis (as opposed to annually or bi-annually)?  This will mean that, for a period of time, we may be constrained to only tying payment to claims-based measures.

No

74) 

Incentive payment frequency.  Please use the table below to answer how frequently the Department should make incentive payments:

Monthly

Quarterly

Annually

Other

If you checked the "Other" box, please describe payment frequency below: maybe twice a year but no more

 

 

 

75) 

For potential offerors and other similar organizations: please describe the fixed costs of operating a RCCO.

NA

76) 

For practices and community providers, what are you currently measuring to assess the quality of your care delivery? Are you being reimbursed on any of these measures?

 

NA


 

Health Information Technology (HIT)

77) 

Types of communication.  For clients with Medicaid coverage, please use the table below to rank each by whether or not you would use it to communicate with your provider or RCCO:

Type of Communication

No, I wouldn't use

Yes, I would use

Phone call / phone number

Text message

Web portal

Email

Telemedicine / Video chat

Face-to-face meeting

Smartphone app

Other:

All are important and should be options

78) 

HIT investments by organizations.  For all organizations, including potential bidders, networks, practices, and others: the table below asks about what HIT your organization has invested in and what it plans to invest in over the next two years.  Please complete the table below:

Tool

Own / Operate

Plan to Operate in next 2 years

Population analytics / reporting

Digital care management tool

Care transitions alerts

Electronic Health Records (EHRs)

Health risk assessment software

Practice assessment tools

Practice management tools (scheduling, billing)

Client web portal for communicating care plan, services, benefit enrollment

Patient education/wellness tools

Provider/case manager directory

Shared decision-making tools

Telemedicine software

Other:

 

Other:

 

79) 

Importance of technology by type.  The Department is working to determine what technology is in place, what technology is needed, and what technology should be standardized.  For RCCOs, providers, and other organizations, use the table below to answer what HIT infrastructure outside of the SDAC your organization would use to perform population health management activities.  Tools are scored from 1-5, where 1 are those items least-likely to be used, and 5 are items most-likely to be used:

Tool

1
Least

2

3

4

5
Most

Population analytics / reporting / dashboard

Care management tool

Care transitions alerts

Electronic Health Records (EHRs)

Practice assessment tools

Health risk assessment software

Practice management tools (scheduling, billing)

Client web portal for communicating care plan, services, benefit enrollment

Patient education wellness tools

Provider/case manager directory

Shared decision-making tools

Telemedicine

Other:

 

 

80) 

 What are the primary barriers to RCCOs and providers increasing their use Health Information Technology to improve the performance of Primary Care Practices?

NA

81) 

How can Health Information Technology support Behavioral Health Integration?

NA

82) 

In the next iteration of the ACC, should there be a shared resource for data and analytics?  Please describe the basic criteria for what a shared data and analytics platform needs to contain in order for it to be useful.

If this can be connected to the all Payer Claim Database and if there is external funding, do not divert scarce Medicaid dollars for this.

83) 

Should there be a shared care management tool?  Please describe the basic criteria for what a care management tool would need to contain in order for it to be useful.

Without seeing a specific tool hard to say, if so there MUST be extensive client engagement before adopting to make sure the tool is useful and not too intrusive.

84) 

Should there be a shared population health management tool?  Please describe the basic criteria for what a population health management tool would need to contain in order for it to be useful.

Would need more info

85) 

Please describe the functionality that a common Medicaid provider directory would need to contain in order for it to be useful.

Search by county, if they are taking new patients, what services they provide, if they take Medicare also,  if they are accessible, and address (if they are on public transit line would be great but anyone can figure that out with specific address).   Hours would be good also

86) 

How can the RCCOs support providers' access to actionable and timely clinical data? 

Unsure

87) 

What are the HIT solutions that would benefit clients, providers, and RCCOs?  Please comment on the parameters these tools or platforms would need to possess and the ways in which they could be used.

Web based portal where client can see and comment on all medical records, make requests for prescriptions, or other things that need to be signed would be great

Any ability to self schedule appointments would be awesome for clients

 

88) 

What technical assistance or resources related to HIT infrastructure should the RCCOs supply?  This assistance or these resources could be for providers, social service organization, clients/families, or for others.

Unsure

89) 

What role should health information exchange platforms like CORHIO or QHN play in the next iteration of the ACC?

Unsure

90) 

Please share any information, advice, and suggestions you have about health information technology in the ACC Program.

 

 


 

 

Appendix: Definitions and Acronyms

 

The following words have been defined for the purpose of this RFI.

 

42 CFR is a federal regulation outlining when information about someone's Substance Use Disorder (SUD) treatment may be disclosed with or without his or her consent. 

 

Accountable Care Collaborative (ACC) Program is Colorado Medicaid's program designed to affordably optimize Client health, functioning, self-sufficiency, and well-being. The primary goals of the ACC Program are to improve Medicaid Client health outcomes and to control costs.

 

Attribution is the process of connecting Clients to primary care medical providers in the ACC Program.

 

Behavioral Health Organizations (BHOs) are the five regional entities responsible for arranging mental health and substance use disorder services for Colorado Medicaid Clients.  Almost all Medicaid clients are enrolled in a BHO when they receive Medicaid.  The BHOs get a set amount of money to manage the care for Medicaid clients.  The BHOs reimburse their network of providers for delivering services to those clients.

 

Behavioral Health Integration is the process of delivering behavioral and physical health care together.  When a Client is a partner in integrated care, he or she (along with his or her family or other support structure) has access to broader, more comprehensive care.

 

Care Coordinator is someone responsible for the coordination of a person's medical and non-medical care.  In the ACC, care coordinators may either work for RCCOs or at primary care clinics.

 

Client is a person who is enrolled in the Colorado Medicaid program.

 

Clinical Quality Measures are used to assess the performance of individual clinicians, RCCOs, providers, or programs.  Measures are often backed by evidence to support their association with improved health outcomes. 

 

Colorado Regional Health Information Organization (CORHIO) is a non-profit organization in Colorado that serves the health care industry with health information technology functionality.  It is a Health Information Exchange (HIE) which helps to securely transmit all kinds of health care data between providers, hospitals, pharmacies, and other entities. 

 

Community Behavioral Health Services Rule is the name of the state's regulation which governs community mental health services.  It defines the populations which are, and are not, eligible to receive services, the service types which are covered, and the structure through which payments are made.  It is found in the Colorado Code of Regulations, 8.212. 

 

Community Centered Boards (CCBs) are Colorado's 20 private, non-profit organizations that serve as single entry points into the long-term service and support system for persons with developmental disabilities.  Community Centered Boards may also provide services.

 

Community Health Workers (CHW) are non-traditional, lay health workers who provide coordination or education, assist people in managing their health, or help people to navigate the health care system in their community.

 

Community Mental Health Center (CMHC) is an entity that provides behavioral health services for Medicaid clients.  In Colorado, In Colorado, CMHCs are generally paid by the Behavioral Health Organizations, essentially on a per-capita basis, rather than reimbursement for each service rendered.

 

Covered diagnoses list is a list of roughly 350 behavioral health diagnoses.  Any client may be assessed by a BHO provider, regardless of diagnosis, but in order to have ongoing services paid by the BHOs, clients must have a covered diagnosis.

 

Department of Health Care Policy and Financing (the Department) is the state agency that administers the Medicaid and Child Health Plan Plus programs as well as a variety of other programs for Colorado’s low-income families, the elderly, and people with disabilities. Our mission is to improve health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources. This means that we work to make our clients healthier while getting the most for every dollar that is spent.

 

Fee-For-Service (FFS) is a way of paying for services where providers are reimbursed a set amount for each service they provide such as an office visit, test, procedure, or other health care service.

 

Health Insurance Portability and Accountability Act (HIPAA) is a federal law designed to provide privacy and security standards to protect patients' medical records and other health information.  These standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed.

 

Health Information Exchange (HIE) is an electronic system capable of sharing secure health care records and information between different providers or other entities in the health care system.

 

Health Information Technology (HIT) is any computerized system for health care data or records.

 

Health literacy is a term used to describe how comfortable and capable a person is obtaining, understanding, and using health care information to make decisions about his or her health.

 

Institutions for Mental Diseases (IMD) exclusion is a federal regulation that prohibits Federal Medicaid payments for clients aged 21-64, receiving care in institutions with more than 16 beds, when more than half of the people being served have a serious mental illness or substance use disorder.

 

Key Performance Indicators (KPIs) are utilization and quality measures which are tied to payment in the ACC Program.  KPIs are used to incentivize RCCOs and providers.   

 

Medical Home is the focal point of care for a client.  Medical Homes provide coordinated and comprehensive primary care services.  Throughout the RFI, the term "Medical Home" is used in a general sense.  It does not refer to a specific model or licensure requirement.  However, there are some common qualities that Medical Homes should have.  These include: improved Client access to care that is coordinated, integrated, whole-person/family-oriented, culturally competent, and outcomes-focused.

 

Member is any Medicaid Client who is enrolled in the ACC Program.

 

Office of Behavioral Health (OBH) is a state office which is part of the Department of Human Services.  OBH is tasked with monitoring, evaluation, and oversight of Colorado's public behavioral health system. 

 

Payment Reform is the term used to describe the process of moving away from paying for volume and towards paying for value in the health care system.

 

Per-Member Per-Month (PMPM) is a per-person payment method that makes a fixed payment per enrollee each month, regardless of actual number or nature of services provided.

 

Practice Support is the process of supporting a provider in the transition towards becoming a more effective Medical Home. 

 

Primary Care Medical Provider (PCMP) is a primary care provider contracted with the ACC Program.  These providers may be FQHCs, RHCs, clinics, or other practices that provide the majority of a Member's comprehensive primary, preventive, and sick care.  PCMPs are reimbursed fee-for-service, but they also receive a per-member per-month payment and can receive KPI incentive payments.

 

Quality Health Network (QHN) is a Colorado-based nonprofit operating in the field of health information technology.  QHN operates a health information exchange platform which serves people living in Western Colorado. 

 

Regional Care Collaborative Organizations (RCCOs) are the regionally-based entities responsible for ensuring care coordination, achieving improved health outcomes and improved well-being for their clients, and ensuring cost savings for the ACC Program.  RCCOs leverage local infrastructure, relationships, and community resources to ensure clients receive the right care, at the right time, in the right setting.  RCCOs are paid by the State on the basis of a per-member per-month payment which covers all of their responsibilities.

 

Single Entry Points (SEPs) are usually county agencies which provide case management, referrals, and care planning to Clients receiving Long Term Services and Supports.

 

Statewide Data and Analytics Contractor (SDAC) is the entity with which the Department contracts to provide data aggregation, analysis, and distribution in support of the ACC Program.

 

 




[1]

Many terms and definitions can be found in the Appendix at the end of this document.

[2]

More information about these rules, payment types, and entities can be found in the Appendix at the end of the document.

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