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OHA Transformation and Quality Strategy (TQS) CCO: Willamette Valley Community Health

Willamette Valley Community Health

Transformation and Quality Strategy March 16, 2018

Table of Contents

Table of Contents Page

Number CCO Governance and Program Structure for Quality and Transformation 2

Review and approval of TQS 8

TQS Projects and Components 1. Access to timely, expanded mental health services 9 2. Member Engagement and Health Equity 11 3. Parent Education Classes 14 4. Grievances and Appeals System and Quality Improvement Strategies 16 5. Delegated Entity Compliance Package 19 6. HIT Workgroup 21 7. Small Practice Wrap Around Team 24 8. Expanded Emergency Department High Utilizers Project 26 9. Developmental Screenings Project 29 10. Primary Care Home Utilization and Access 31 11. APM and VBPM Models 33

QAPI Minutes 3-7-2017 36 TraQ Minutes 9-13-2017 38 TraQ Minutes 11-2-2017 42 WVCH Member Rights and Responsibilities Policy 46 WVCH Committee Organizational Chart 52 TraQ Committee Charter 53

of 35 Last updated: 3/16/2018

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Section 1: Transformation and Quality Program Information A. CCO Governance and Program Structure for Quality and Transformation:

i. Describe your CCO’s quality program structure, including your grievance and appeal system and utilization review:

Willamette Valley Community Health (WVCH) is a Coordinated Care Organization (CCO) governed by a Board of Directors. The Board consists of CCO risk group owners and community partners, thus, Board members are invested in the success of the CCO and in implementing effective quality and transformation activities. The WVCH Board reset mid-2017 to re-organize the CCO’s organizational and committee structure. WVCH minimized the number of committees in operation and combined the Quality Assurance and Performance Improvement (QAPI) committee with the Clinical Advisory Panel (CAP) into one large committee: the Transformation and Quality Committee (TraQ). The goal of re-organizing the Board-level committee structure was to improve communication and integration between committees and the Board, and align efforts across the CCO. WVCH’s revised governance and committee structure is attached to the end of this report. In 2017, WVCH leadership also created a business plan to provide detailed strategic framework for the operations of the CCO. This business plan functions as WVCH’s strategic plan, including requirements of the CCO contract, CMS, OARs and CFRs. WVCH Board of Directors and executive leadership conduct a strategic planning retreat annually to guide the direction of the CCO for the coming year and evaluate the previous year’s successes and areas of improvement. Operationalizing the strategic direction of the Board while ensuring contractual requirements are met is tasked by WVCH directors, committees and executives.

WVCH’s Transformation and Quality Committee (TraQ) is chartered by, and directly reports to, Willamette Valley Community Health (WVCH)’s Board of Directors and WVCH executives to assist the Board by serving as an oversight and advisory committee to monitor and improve overall CCO systems, quality of services and care delivered to WVCH members. This includes areas such as:

• Quality assurance • Performance improvement • Health care transformation • Utilization review and medical management • Clinical integration

TraQ Committee meets bi-monthly and consists of clinical providers, clinic administrators, medical and dental directors, dental staff, behavioral health administrators, Marion-Polk Early Learning Hub, Marion and Polk Counties public health and behavioral health staff, hospitals, quality improvement staff, behaviorists, pediatricians, community engagement staff, CCO executives, delegated entities, pharmacists, subject matter experts, etc. TraQ uses a workgroup structure to monitor, analyze, and devise strategies for specific tasks or subject matters. The workgroups report back to TraQ for information, larger discussion and/or a vote to recommend action by WVCH. WVCH’s Chief Medical Officer, Chief Operating Officer, Director of Quality and Transformation, Director of Regulatory Compliance, Director of Business Intelligence, Community Engagement Manager, and other CCO staff attend TraQ, thus integrating direct communication to/from executives and the Board. Workgroups include: internal quality improvement/TQS workgroup, opioid reduction workgroup, quality incentive metrics workgroup, emergency department high utilizers community collaboration, and a chronic disease payment system task force. Additionally, collaboration across committees (TraQ, Community Advisory Council, Dental Care Organization meeting, etc.) and task-focused efforts are compiled internally with CCO staff and leadership and brought back to committees to utilize committee time most efficiently.


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Grievances and Appeals Program WVCH Grievance and Appeals (GA) Program has a 1.0 FTE supervisor and numerous support staff to implement, monitor, assess, direct, train, and process all grievances, hearings, appeals, and notices of action/denials. Having one supervisor as the point person for this program improves consistency in assessing, analyzing, and implementing a quality GA Program. WVCH compliance and quality staff regularly monitor and participate in the GA Program, implementing strategies to mitigate complaints and trends as they arise. TraQ Committee also monitors and assesses trends from grievance and appeals data as they arise—stratified by race and ethnicity—and identify areas for quality improvement as a result of these trends. WVCH Compliance Committee also monitors and assesses the GA Program, to ensure oversight and accountability in addressing identified issues related to quality and the GA Program. Additionally, all quality of care grievances are reviewed by medical management clinical staff. Thus, WVCH provides daily oversight of the GA Program and monitors program efficiency, timeliness, quality, and trends closely. To ensure broad CCO awareness, compliance and high quality of program operation, the GA Program conducts annual training for all CCO staff. This annual training also ensures all staff can and shall document and send any and all expressions of dissatisfaction to the grievance system, and encourage members and partners to do the same. Reporting of complaints to the GA Program is a measurement of success as WVCH utilizes GA data to improve communication and quality of care for all members. Utilization Management and Review Program Utilization Management and Review (UM) is performed to ensure an effective and efficient medical delivery system. It is designed to evaluate the cost, accessibility and quality of medical services. The goal of utilization management is to assure appropriate utilization, which includes evaluation of both potential overutilization and underutilization. To effectively achieve program goals and objectives, the UM Program is comprised of licensed healthcare professionals, including nurses, physicians and clinical pharmacists. These healthcare professionals review, assess and assist CCO members and providers in the healthcare rendered to those members. Additionally, non-licensed associates support the business operations of various utilization management focused departments. A collaborative environment exists for comprehensive UM and numerous CCO departments and staff are included: Medical Management, Quality Management, Compliance, Grievance and Appeals, Provider Services, Customer Service, Claims, Finance, Information Systems, Legal Counsel and Human Resources to ensure that department objectives are attained. The Chief Medical Officer (CMO), Medical Director and Associate Medical Directors are physicians who are board-certified in his or her designated area of practice and whose principle accountability is to provide guidance in the development and administration of WVCH’s UM and Quality and Transformation Program. The CMO/Medical Director/Associate Medical Directors review and make recommendations regarding policies and procedures. The CMO/Medical Director/Associate Medical/Clinical Director also provide medical determinations for cases that do not appear to meet the CCO’s guidelines and criteria to assure that the member receives the most appropriate health care in the most cost-effective setting. WVCH delegates a large portion of UM activities to WVP Health Authority but retains oversight and accountability in addressing identified issues related to quality and utilization. WVCH’s UM Program is conducted and monitored through the CCO’s Medical Management program, Compliance Department, TraQ Committee, Chief Medical Officer, Medical Director, Medical Management Director, Intensive Case Management Manager, Director of Quality, Appeals and Grievances Supervisor, Chief Compliance Officer, Chief Financial Officer, Director of Business Intelligence, Pharmacy Director, and other medical management, quality, and compliance staff. Some duties include: • The Medical Management Director is a registered nurse. The director’s accountability objective is to

manage the UM Department to provide ongoing, effective and efficient assessment of all aspects of patient care to help ensure the coordination delivery of high quality, safe, cost-effective medical care to all WVCH members.


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• The Medical Management Referral and Prior Authorization Manager is a registered nurse whose accountability objective is to serve as the departmental resource for outpatient prior authorizations, preadmission, and home health care, and to conduct departmental quality improvement monitoring. This position also coordinates provider appeal determinations and acts as an interdepartmental liaison to ensure prompt resolution of UM issues and questions.

• The Intensive Case Management Manager is a registered nurse whose accountability objective is to serve as a clinical resource and to provide supervision for staff and the day-to-day operations of the case management functions. In addition, to serve as the departmental resource for concurrent and retrospective review for inpatient admissions, discharges, transitions of care, and to conduct departmental quality improvement monitoring.

• The Director of Pharmacy Services is a doctor of pharmacy whose accountability objectives are to promote the clinically appropriate use of pharmaceuticals and to assure the optimal performance of the Pharmacy Benefit Management (PBM) services vendor utilized by WVCH. He/she also provides systematic and relevant feedback to participating physicians regarding individual prescribing patterns. Review of drug utilization reports, Risk Alert letters and formulary compliance reporting and production of articles for the monthly newsletters are additional responsibilities. He/she is responsible for coordinating and monitoring all aspects of the pharmacy program for WVCH members. Responsibilities include oversight of the daily pharmacy program operations, contracted Pharmacy Benefits Manager (PBM), utilization management of prescription drugs, oversight of any groups delegated to provide a pharmacy program and providing clinical support to the care management team and other departments.

• The Pharmacy Coordinators are certified pharmacy technicians whose accountability objective is to provide administrative, clerical support for the pharmacy department. This position acts as a referral source of potential cases for case management.

Additionally, WVCH hired a Director of Internal Audit in the WVCH Compliance Department to ensure CCO oversight and accountability for providing high quality of care on a broad scale for CCO entities and activities. This position is responsible for auditing delegated entities, contractors, programs, and deliverables to ensure compliance and integrity.

ii. Describe your CCO’s organizational structure for developing and managing its quality and

transformation activities (please include a description of the connection between the CCO board and CAC structure):

Willamette Valley Community Health (WVCH) is a Coordinated Care Organization (CCO), governed by a Board of Directors, serving Medicaid members and OHP recipients in Marion and Polk Counties. WVCH employs a patient-centered, whole-person approach to integrated healthcare services to address physical, behavioral, and dental health needs, all the while being a partner in the community to align efforts and collectively improve social determinants of health. Activities and initiatives undertaken by WVCH are directed by the WVCH Board and WVCH leadership and are designed to advance the organization’s mission to improve health status and outcomes for Marion and Polk residents in a system that is cost-effective, integrated, and equitable. WVCH Board of Directors retains final authority, responsibility, and oversight, however, WVCH Board and WVCH leadership direct activities and initiatives recommended for implementation by the WVCH Transformation and Quality (TraQ) Committee, Community Advisory Council (CAC), Compliance Committee (for quality assurance and compliance activities), and WVCH executives and staff. The WVCH Compliance Officer is also delegated to monitor and fulfill quality assurance and compliance needs which integrate with all contractual requirements and Transformation and Quality Strategy (TQS) focus areas. TraQ Committee is tasked with making clinical and quality recommendations to the Board, WVCH leadership, and the CAC when applicable for transformation and quality activities. TraQ is


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chartered by, and directly reports to, Willamette Valley Community Health (WVCH)’s Board of Directors and WVCH executives to assist the Board by serving as an oversight and advisory committee. TraQ Committee’s mission is to oversee, analyze, and develop CCO transformation and quality strategies to advise the WVCH Board of Directors on improving quality of services and care, member and provider experience, health outcomes for members in the WVCH community, and aiming to reduce costs (Quadruple Aim).

TraQ utilizes a workgroup structure to tackle task-focused areas. One TraQ workgroup that meets is the Quality Improvement/TQS Workgroup, which monitors the development, implementation, and compliance with CCO requirements for quality and transformation. WVCH employs a Director of Quality and Transformation to oversee, develop and manage transformation and quality activities, initiatives, and program requirements. In 2017, WVCH hired a Community Engagement Program Manager to function as the CAC coordinator and to oversee and manage CAC’s responsibilities, including the Community Health Needs Assessment and Community Health Improvement Plan. CAC and TraQ both report committee activities and barriers to WVCH Board through education and recommendations. Additionally, CAC and TraQ activities and barriers are addressed through developing and implementing quality improvement strategies which are integrated between committees and programs, and integrated into the development of the Transformation and Quality Strategy.

Both TraQ and CAC are chartered by and report to the WVCH Board of Directors and WVCH executives. CAC and TraQ have standing time on each committee’s agendas to integrate communication and align efforts throughout primary strategic objectives of WVCH. WVCH’s Chief Executive Officer is a member of CAC and ensures CAC has a direct link to CCO leadership. This cross-staff integration allows for updates about CAC’s work and activities, as well as allows for TraQ feedback to be integrated into the work of CAC, and vice versa. The CAC created issue briefs and recommendation documents to share with both the TraQ Committee and the WVCH Board related to CHIP areas, health disparities, and the member experience. These were created with input from the CAC, community partners, and WVCH members with direct experience with each CHIP area. This structure has improved communication and drastically reduced fragmentation between different committees across the CCO. The result is an integrated transformation and quality strategy developed with the direction of TraQ, CAC, Medical Management, Compliance, Quality, Business Intelligence, delegated entities, partners, and WVCH leadership.

WVCH has a robust annual Transformation Project Program (WVCH’s community benefit program) to fund clinics and community agencies to implement projects focused on clinical integration and community engagement. In 2017, WVCH Board of Directors acknowledged much of the money granted was to clinics, so the Board voted to almost-double its investment in the community, reserving $2 million of its net income to implement community-based projects which improve areas of the CHIP. The Transformation Project Program was completely revised in 2017. Transformation Projects proposed for clinical integration were reviewed by TraQ and Transformation Projects for community investment were reviewed by CAC.

Additionally, CAC and the CAC coordinator have played a pivotal role in health equity efforts and holding the CCO accountable for delivering services in a culturally and linguistically appropriate manor. The group is the driving force behind the development of cultural competency training and has proven adept at applying a health equity lens to CCO issues. The WVCH CAC coordinator will continue to enhance the role of the CAC and ensure the group stays abreast of all CHIP and applicable transformation and quality areas.


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iii. Describe how your CCO uses its community health improvement plan as part of its strategic planning process for transformation and quality: The WVCH Community Advisory Council (CAC) is tasked by WVCH Board of Directors to oversee implementation and participate in the development of the Community Health Improvement Plan and Community Health Needs Assessment (CHA). In 2017, WVCH conducted months of CAC meeting time to in-depth discuss all areas of the CHIP and gain valuable information on the member experience, identify barriers and recommend strategies for improvement. The CAC developed a CHIP Strategy Recommendations document which compiled the qualitative data provided by the CAC, community partners and WVCH members. These CHIP strategy recommendations were presented to WVCH Board of Directors, WVCH TraQ committee, WVCH executives and partners. Many of these CAC-devised CHIP strategies are integrated into WVCH Performance Improvement Projects (PIPs), this Transformation and Quality Strategy (TQS), and the WVCH Business Plan. Integrating CAC feedback and recommendations allows WVCH to address these issues from many angles and creates buy-in and partnership from leadership, clinics and community partners. One example was for the CHIP strategy to reduce tobacco use: CAC, TraQ, dental care organizations, local public health and behavioral health all assessed and made recommendations for improving tobacco cessation and identified technical assistance needs for implementation. WVCH integrated feedback and needs of all of these groups and created a collective and feasible technical assistance proposal. This tobacco technical assistance proposal incorporated CAC tobacco strategies, clinical strategies and needs, and was approved for recommendation by TraQ to WVCH. This proposal was approved and will be implemented as part of WVCH’s 2018 business plan, Transformation and Quality workplan, and CCO strategic direction. WVCH has numerous representatives involved with the community-wide regional CHA currently being developed. There is a regional effort underway for a collective CHA. This group includes Marion County, Polk County, WVCH, Salem Health, Legacy Silverton Hospital, community partners and organizations. WVCH’s CAC coordinator is a member of the regional CHA Steering Committee to provide the member voice. WVCH TraQ coordinator is also a member of the regional CHA Steering Committee. CAC will continue to be involved in WVCH’s new CHA and CHIP as with the hiring of the CAC coordinator, the CAC better understand their responsibility to provide oversight in developing and implementing the WVCH CHIP. Data obtained from the CHA will be used to develop the CHIP, and will be assessed and integrated by the Transformation and Quality Program for integration into CCO transformation and quality strategies. The CHA and CHIP are invaluable for understanding the diverse population and needs of WVCH members, addressed by both the CHIP and transformation and quality activities to achieve the Quadruple Aim.

iv. Describe how your CCO is working with community partners (for example, health systems, clinics, community-based organizations, local public health, local mental health, local government, Tribes, early learning hubs) to advance the TQS: WVCH integrates community partners at all levels of the CCO’s structure. Community partners serve on WVCH Board of Directors, TraQ Committee, CAC, System of Care Executive Council, Finance Committee, and Compliance Committee. WVCH is governed and owned primarily by health systems and clinics, and delegates care and services to a wide breadth of clinics and community partners to best serve the diverse needs of our diverse members. Approximately one-half of WVCH’s membership is under the age of 18 years old. WVCH partners regularly with a variety of community organizations, including: Marion County, Polk County, health systems and clinics, Mid-Valley Community Action Agency, Marion-Polk Early Learning Hub, addictions and mental health treatment providers, Marion County Psychiatric Crisis Center and Youth and


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Family Crisis Center, housing authorities and housing providers, community service agencies focused on improving social health outcomes, Council of Governments, homeless initiatives, dental care organizations, tribes, transportation providers, FQHCs, NW Seniors and Disabilities, Project Able (peer delivered services), faith community, Boys and Girls Club, Family Building Blocks, DHS, Juvenile Justice, law enforcement, other CCOs, etc. WVCH Director of Quality is a member of the Marion County Commission on Families and Children and is a partner of the Polk County Public Health Advisory Board. Many of these community organizations receive partnership and/or funding through sponsorships or projects to advance efforts throughout the community. Some recent community projects WVCH partners with, include:

• Partnered with Community Action Agency to implement a co-location model for the homeless to improve social determinants of health

• Falls City Direct Connect- partnered with Polk County to provide regular transportation to the rural and underserved community of Falls City, hiring a driver who serves as a certified resource navigator

• Fostering Hope Initiative- partnered with Catholic Community Services to implement the FHI approach to neighborhood-based supports, similar to a medical home model, but for social services and supports in high-disparity neighborhoods identified by DHS

• LEAD THIS Change- partnered with Marion County law enforcement to divert the top 100 utilizers of the jail and emergency department to services and supports

• Partnered with a variety of agencies and the System of Care Executive Council for a Youth and Families Crisis Center and peer-delivered services

• High Utilizers of the Emergency Department- WVCH convened a vast array of community partners to coordinate care. This community collaborative aims to align efforts across the community for the shared population and integrate comprehensive referrals to services to better health outcomes

• WVCH is a co-applicant of the Marion and Polk Public Health Modernization grant to advance health equity and reduce prevalence rates of sexually transmitted infections across our region

WVCH partners closely with the Marion-Polk Early Learning Hub, both organizations are members of the other’s Boards, and have implemented several projects together to focus efforts to improve health outcomes for children. One project which highlights a close partnership with the Early Learning Hub is the Immunization Book Project. WVCH and the Hub began a project in January 2018 to improve childhood immunization rates and promote early learning by mailing a children’s book (most are in English and Spanish) to every WVCH child ages 0-2 years old at regular intervals aligning with the CDC immunization schedule. This project was designed to educate parents with a CDC “Ages and Stages” handout and to motivate parents to make a timely appointment with their child’s primary care doctor for their recommended well-child check and subsequent immunizations. Over 21,000 books were purchased in 2017 for the implementation of this project. WVCH's Transformation Project Program reserves community investment funds to support and partner with community organizations to improve community health outcomes and social determinants of health. Partners include health departments, mental health programs, hospitals, the Early Learning Hub, social service organizations, clinics, dental care organizations, and often involve multiple partners. The clinical project applications are reviewed by TraQ, and the community project applications are reviewed by CAC and all applications are vetted to determine alignment with CCO efforts before they are sent to the Board for final approval.


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B. Review and Approval of TQS i. Describe your CCO’s TQS process, including review, development and adaptation, and schedule:

WVCH’s Transformation and Quality Program and Director lead the development and review of the Transformation and Quality Strategy (TQS), integrating feedback, initiatives, priorities, strategic direction and recommendations from TraQ, the CAC, WVCH executives, WVCH Compliance Department, and community partners. WVCH Board of Directors has oversight of all transformation and quality activities. TraQ plays a large role in the review, development and adaptation of the TQS. The TQS is aligned with, and a large focus of, the WVCH annual business plan. WVCH Board holds a strategic planning retreat in October of each year to evaluate the current year and develop strategic intent for the coming year. WVCH begins discussion and meeting with TraQ and partners in November and December of each year to begin developing and adapting the TQS for the following year. WVCH aligns the TQS with its Transformation Project Program which determines projects to implement for both clinical integration and community investment by each December. The TQS is reviewed and monitored by WVCH leaders regularly and by the TraQ QI/TQS workgroup. Individual projects and programs highlighted in each of the TQS components will be monitored and implemented by its subject matter expert and project lead, reporting directly to WVCH at least twice per year. Additionally, WVCH Board of Directors and WVCH Chief Executives review the annual TQS and monitor for compliance and performance. WVCH Board of Directors, TraQ and CAC have received several presentations in 2017 and 2018 about the integration of the Transformation Program and Quality Program (QAPI) by OHA and the new Transformation and Quality Strategy deliverable for CCOs. TraQ and its members were an integral part of this process. TraQ is comprised of clinical providers, administrators, medical and dental directors, dental staff, behavioral health administrators, Marion-Polk Early Learning Hub, Marion and Polk Counties public health and behavioral health staff, hospitals, quality improvement staff, behaviorists, pediatricians, community engagement staff, CCO executives, delegated entities, pharmacists, subject matter experts, etc., and thus, TraQ has a wealth of knowledge and expertise to offer for a comprehensive TQS. Clinics and community partners were engaged in the process of contributing their activities and projects in the areas of the TQS for integration into TQS strategies. Additionally, TraQ utilizes a workgroup structure to address and monitor task-focused areas. One TraQ workgroup that meets is the Quality Improvement/TQS Workgroup, which monitors the development, implementation, and compliance with CCO requirements for quality and transformation. WVCH employs a Director of Quality and Transformation to oversee, develop and manage transformation and quality activities, initiatives, and program requirements. TraQ and CAC activities and barriers are addressed through developing and implementing quality improvement strategies which are integrated between committees and programs, and integrated into the development and adaptation of the Transformation and Quality Strategy.


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Section 2: Transformation and Quality Program Details

The following section will address all thirteen components of the Transformation and Quality Strategy for Willamette Valley Community Health.

1. Access to timely, expanded mental health servicesA. TQS Component

Primary Component: Access Secondary Component: CLAS standards and provider network

Additional Components: Health Equity: Cultural Competency

Subcomponents: Access: Timely access Additional Subcomponent(s):

Access: Availability of Services

B. NARRATIVE OF THE PROJECT OR PROGRAMThe CCO and Mid Valley Behavior Care Network (MVBCN) have been proactive in increasing timely access to providers and expanding existing services for members. This project is focused on increasing access to WVCH members wishing to receive mental health services with at least a 95% rate of getting an appointment for services within 14 days. The MVBCN actively recruit culturally and linguistically diverse staff, and provide a wide array of training for behavioral health providers and staff. Additionally, a Provider Spanish Assessment Audit is conducted quarterly to verify all WVCH Spanish speaking members are provided a gateway to services in Spanish from the initial call. The audit also determines if a provider has not developed an informative pathway to services for members of the initial call.

C. QUALITY ASSESSMENTEvaluation Analysis: Several challenges members face seeking mental health services for access to care include

but not limited to 1) lack of providers, 2) lack of off-hour access, and 3) trained provider capacity. To set a timely standard for access to care, Mid-Valley Behavior Care Network (MVBCN), WVCH’s behavioral health delegate, implemented a project to improve timely access to all members seeking outpatient mental health services. Timely is defined as receiving an offer for an appointment within 14 days of the initial call.

Performance for measuring timely behavioral health appointments will be monitored using an “Access to Mental Health Report” which is completed by the behavioral health access coordinator on a quarterly basis. The quality improvement coordinator analyzes and reviews the report with executives and leadership to ensure compliance with OARs and standards of practice. The goal is to meet OAR access metric of 95%. The Access to Mental Health Report includes data on timeliness with scheduling within 14 days.

Input from MVBCN Board of Directors and MVBCN access coordinators were catalysts for increasing and expanding services for mental health in WVCH’s region. MVBCN hosted two community summits in March 2017 to gain insight, input, and recommendations from community partners on behavioral health, mental health, and addictions service needs for Marion and Polk Counties. As a result, MVBCN Board voted in the fall of 2017 to expand existing services, add new in-panel providers, expanding services to Latino members, and expanding outpatient service capacity.

To support expanded services in culturally and linguistically appropriate ways, MVBCN: • Increased reimbursement rates by 37% to attract and retain prescribers


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• Hosted a job fair in October 2017 for to attract clinicians, prescribers, and mentalhealth administrative staff

• Actively recruit bilingual and bicultural mental health providers• Conduct a quarterly Provider Spanish Assessment Audit• Host cultural competency trainings for behavioral health providers, including:

LGBTQ cultural competency training, Trauma 101, commercial sexual exploitation ofchildren, male trauma, etc.

D. PERFORMANCE IMPROVEMENTActivity: In August 2017, contracts were approved to expand existing services and add new in-panel providers to serve hundreds of new members, including children, youth, adults and families. Expanded services include: in-home, various types of therapy, case management and co-occurring. Providers are extending all of these expanded services to Latino members to ensure equitable access to services with culturally appropriate care. Additionally, the BCN Board approved expanding outpatient services by an additional ~1000 members, including expansion for all age categories. Access flyers were created and distributed in English and Spanish for providers or members interested in accessing mental health or addictions treatment. Additionally, MVBCN updated their webpage to identify in-network providers and services provided.

WVCH and MVBCN partnered with Marion County and other organizations to develop and implement a new Child and Family Crisis Center in 2017. A new Transition-Aged Youth drop-in center, TAY Peer Services, and expanded Family Peer Services were approved by MVBCN in August 2017 for implementation.

The access coordinator is working directly with WVCH members to find a provider for the following circumstances 1) providers do not have capacity, 2) specialty services are requested, including culturally and linguistically appropriate care, and 3) out of panel provider is needed.

Task 1) Initial call- Member contact provider to schedule a mental health assessment appointment Task 2) Provider is unable to schedule an appointment, contacts Access Coordinator at the MVBCN Task 3) Access Coordinator works referral by contacting other providers to schedule appointment within 14 days of initial call Task 4) Access Coordinator gathers data for access report Task 5) Access report is monitored, analyzed and reviewed monthly by executives and leadership

☐ Short-Term Activity or☒ Long-Term Activity

How activity will be monitored for improvement

Baseline or current state

Target or future state

Time (MM/YYYY)

Benchmark or future state

Time (MM/YYYY)

Access Report data for members receiving an appointment within 14 days

93.6% (2017 Q1) 95% Quarterly 94% 12/2018

# cultural competency trainings offered

4 12 12/2019 8 12/2018


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2. Member Engagement and Health EquityE. TQS ComponentPrimary Component: Health equity and data Secondary Component: Access Additional Components: CLAS and Provider Network

Subcomponents: Health Equity: Cultural competence

Additional Subcomponent(s):

Access: Cultural Considerations; Access: Quality and Appropriateness of Care to all Members

F. NARRATIVE OF THE PROJECT OR PROGRAMWVCH began creating strategies for enhancing member outreach and engagement and advancing health equity in Marion and Polk Counties.

• WVCH is working with a firm specialized in communication and tools to reach our membership, stakeholdersand partners. WVCH seeks to include the member voice to ensure high quality and appropriateness of care isprovided to all members. To gain knowledge about the member experience and obtain valuable feedback,focus groups were performed with seven (7) groups of WVCH members to better understand communicationneeds related to the CCO and healthcare services needed, access issues and barriers to services, culturalappropriateness, and other healthcare desires. Focus groups were conducted in conjunction with Mid-ValleyBehavioral Care Network (MVBCN), WVCH’s behavioral health delegate. Focus groups included both Englishand Spanish groups of WVCH members.

• WVCH identified an underserved population in the WVCH service area and partnered with a communitymember who is an advocate for this community. WVCH met with a Cambodian leader and convened aluncheon for the Cambodian community to discuss healthcare and address needs and concerns of Cambodianfamilies. WVCH continues to work with underserved populations and when possible, with traditional healthworkers, to make a connection and better understand needs, quality and appropriateness of care, andexperiences of our diverse population.

• To engage a broader range of members in diverse communities, WVCH is expanding its Community AdvisoryCouncil to host Regional Advisory Councils in more rural areas of the community which have higher rates ofSpanish-speaking members and members with higher health disparities

• WVCH is a partner with Marion and Polk Counties for a regional Public Health Modernization Grant from OHA.This project entails conducting a regional health equity assessment and convening a regional health equitycoalition to advance heath equity throughout our region.

G. QUALITY ASSESSMENTEvaluation Analysis: The focus groups covered a variety of topics, resulting in a written report. The groups were

asked about physical health, behavioral health, and oral health in each focus group. There were seven (7) groups in total, with one Spanish Speaking group. The Spanish speaking group was made up of all women, and may have been missing the Spanish speaking male perspective. Themes emerged including a desire for knowledge of and access to peer services, and a desire to have texting as an option for communication from the CCO.

As a result of this Cambodian outreach, WVCH learned that many people who speak Khmer do not read or write in that language, meaning that translating written materials does not mean the members can understand them. WVCH also learned that the translation service used translates Khmer in a linguistically inappropriate way, “like the Bible.” Trust is vital to engagement in this community and ensuring equitable access to services is achieved. In addition, WVCH learned that a single, trusted community champion who can read and speak English fluently, is often assisting other community members by making


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appointments for them, opening and interpreting their mail for them, and assisting with other social determinants of health like communicating with children’s schools or helping a community member understand legal fees or bills they receive. This population leader is sought out for assistance understanding and interacting with the medical and social service community on a regular basis.

As a result of this outreach, WVCH began exploring funding models for integrating a more robust Traditional Health Worker model to build trust in diverse populations and improve access and health outcomes, and ensure services and materials are truly culturally and linguistically appropriate for WVCH members.

H. PERFORMANCE IMPROVEMENTActivity:

• Identify and work with leaders in diverse and underrepresentedpopulations to provide outreach and build trust among members toimprove access and coordination of care.

• Explore health equity strategies to improve quality and appropriateness ofcare furnished to underrepresented populations, implement culturally andlinguistically appropriate services and materials, and apply culturalconsiderations to access (and barriers to access)

• WVCH is building momentum and capacity for increasing the utilization ofTraditional Health Workers throughout the WVCH network to connecteffectively with diverse populations. WVCH worked with OHA’s Office ofEquity and Inclusion to educate WVCH TraQ on the efficacy andimportance of THW in the system. A THW and peer support presentationwas given in attempts to gain provider support for moving forward withpotential funding mechanisms to integrate traditional health workers intothe existing CCO model

• WVCH identified health disparities among its Pacific Islander Populationand is working to identify a community champion for future communityengagement and outreach activities

• Share results of the focus groups with WVCH’s public relations firm toinform the communication strategy and web site creation to meet thediverse needs of members.

• WVCH is in the process of re-vamping the website to increase accessibilityand engagement.

• WVCH hired a Community Engagement Program Manager to facilitateenhanced member outreach and engagement, as well as improve therelationship with the CAC.

• WVCH established a regional CAC (RAC) meeting held in Polk County in aneffort to gain more of the rural WVCH member’s voice and experience

• Share results of the focus groups with Marion and Polk County PublicHealth Departments for inclusion with the region-wide, cross-organizational Community Health Needs Assessment

• Themes from focus groups will be addressed in CHIP strategies andCommunication Plan

• Using feedback from diverse populations, Spanish-speaking and ruralmembers, ensure all media and materials are culturally and linguisticallyappropriate, aligning CLAS standards with the member voice and theCommunity Health Needs Assessment



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• Partner with Marion and Polk Counties Public Health Departments toconduct a regional health equity scan and convene a regional health equitycoalition




Time (MM/YYYY)


Time (MM/YYYY)

Share results of focus group summaries

Written report only, not yet sent to PR firm

Input integrated feedback into communication efforts, website, materials, etc.

6/2018 Explore feasibility of adding texting as an option for CCO members

1/2019

Re-vamp WVCH website and increase access to services and resources online

Currently in planning stages, vendor has been selected

Launch preliminary website

6/2018 Launch new website and have access to available service providers, member materials, education, provider tools, increase social media presence, etc.

1/2019

Increase access to peer support resources in PCP clinics (Aligns with 2018 CHIP strategy)

Rack cards are in process of being created for distribution

Materials distributed to all PCP clinics

6/2018 Increase in utilization of peer services as evidenced by Marion Polk Peer Coalition Survey data

6/2019

Convene Regional Advisory (RAC) Groups

One RAC was held in Polk County

Convene two RACs

7/2018 Convene three RACs

1/2019

Conduct member outreach and engagement activities to diverse, underrepresented populations

1 2 7/2018 4 7/2019

Community Health Worker hours for Pacific Islander Population (identified with data to be underserved and have higher health disparities)

None CHW training completed

12/2018 5 hours/week 1/2019


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3. Parent Education ClassesI. TQS Component

Primary Component: CLAS standards and provider network Secondary Component: Access

Additional Components: Social Determinants of Health and Health Equity

Subcomponents: Access: Cultural considerations

Additional Subcomponent(s): Add text here.

J. NARRATIVE OF THE PROJECT OR PROGRAMThe purpose of this project is to increase the availability of multiple high quality parent education across the community through a partnership with the Marion-Polk Early Learning Hub (MPELH). This project will link medical providers with parenting education providers to allow culturally and linguistically appropriate health messages to be reinforced at parenting classes. Classes are offered in clinics and throughout the WVCH region, in both urban and rural locations. Classes and materials are culturally and linguistically appropriate, are offered in English and Spanish and are designed to engage a wide range of WVCH members. Classes are open to people of all income levels. MPELH is targeting efforts to clinics that primarily serve children and those who serve a high percentage of Oregon Health Plan members. K. QUALITY ASSESSMENTEvaluation Analysis: A parent’s understanding of how to support their child’s social, emotional, and

physical development impact the health and well-being of the child. Parenting education can also reduce trauma in youth and aid with better health outcomes as adults. There has been a growing interest in cross-sector partnership to improve social determinants of health and health outcomes for children and families; medical providers and early learning providers have begun to attend each other’s meetings and find ways to integrate and align efforts to best serve the patient and their family. This project is one cross-sector partnership aimed to increase access to culturally and linguistically appropriate parenting education classes, targeting low income families, to improve social determinants of health and improve overall health outcomes for children ages 0-10 and their families.

MPELH conducts three observations over the course of the series at beginning, mid-way, and close to the end. This allows for coaching and/or specific technical assistance if needed to families and clinicians. It also provides assurance that child-parenting activities are working well. Each participant in an Oregon Parenting Education Collaborative (OPEC) funded class completes a parent skill ladder survey, which allows the parent to report the gains they and their children have made while in the class. We utilize this parent skill ladder survey to measure the impact of the training.

L. PERFORMANCE IMPROVEMENTActivity: Classes began January 2018 and will continue throughout the year. x Short-Term Activity or

☐ Long-Term ActivityHow activity will be monitored for improvement



Time (MM/YYYY)


Time (MM/YYYY)


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Number of Parent Skills Ladder Surveys showing an increase in positive behavior changes

0 15 7/2018 40 1/2019

Total number of class series offered (8-10 weeks each)

0 3 7/2018 8 1/2019

Total number of classes offered in Spanish

0 1 7/2018 3 1/2019

Number of participants successfully completing a course

0 30 7/2018 80 1/2019


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4. Grievances and Appeals System and Quality Improvement StrategiesTQS component

Primary Component: Grievance and appeal system Secondary Component: Health equity and data

Additional Components: Special Health Care Needs, Access

Subcomponents: Health Equity: Cultural competence


Access: availability of services and quality and appropriateness of care

M. NARRATIVE OF THE PROJECT OR PROGRAM

WVCH Grievance and Appeals (GA) Program has a 1.0 FTE supervisor and numerous support staff to implement, monitor, assess, direct, train, and process all grievances, hearings, appeals, and notices of action/denials. Having one supervisor as the point person for this program improves consistency in assessing, analyzing, and implementing a quality Grievance and Appeals Program. WVCH Transformation and Quality Committee monitor and assess trends from grievance and appeals data—stratified by race and ethnicity—and identify areas for quality improvement as a result of these trends. WVCH Compliance Committee also monitors and assesses the Grievance and Appeals System, from individual claims to quarterly reports and annual summaries. WVCH provides daily oversight of the Grievance and Appeals System and monitors program efficiency, quality, and trends closely.

As a result of grievance and appeals trends, WVCH implemented a variety of quality and performance improvements. Some include:

• WVCH began stratifying grievances by race and ethnicity late in 2016 making 2017 the first full year of healthequity trend monitoring

• In an effort to promote health equity, WVCH began sending letters to members in the language requested.Initially, WVCH aimed to send each and every letter back in the language in which it was initially received,however, due to limited processing time in the Grievance and Appeals System (especially for appeals), it wasunnecessary and not practical to have every document translated without member/provider request. WVCHcontinues to translate letters as requested by members. WVCH’s GA supervisor is keeping track of the numberof appeals to determine feasibility in the future.

• WVCH created and subsequently updated a Grievance Desk Reference for its behavioral health delegate, Mid-Valley Behavioral Care Network (MVBCN), to include the appeals and grievance process as part of their internaldocument. This Desk Reference is aimed to improve the grievance and appeals system for behavioral healthgrievances and ensure timely responses and compliant follow up occurs. This update has been distributed to allMVBCN.

• The Grievance and Appeals Program conducts annual training for all CCO staff to ensure awareness,compliance, and high quality of program operation. This annual training also ensures any staff can and shalldocument and send any and all complaints of service to the grievance system.

• WVCH monitored and observed an increasing trend in member billing grievances. Internal processes werecreated to assist the member in ensuring they are not incorrectly placed with financial responsibility. Trainingwas conducted to the customer service representatives on the internal processes and necessary informationneeded in order to fully resolve these concerns. The GA department worked with the CCO’s provider relationsprogram and claims administrator (PhTech) to create a member billing workflow. This workflow was createdand implemented in May 2017.


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• The CCO identified a trend of out-of-area providers balance billing WVCH members. WVCH GA staff contactedthe identified providers and encouraged them to enroll with the State in order to obtain direct reimbursementfrom the Oregon Health Authority. WVCH revised the grievance process—and in addition to phone contactwith provider offices—WVCH created letters to send to those providers to ensure effective communication,educate office staff on applicable OARs and CFRs related to billing, and make certain that billing issues arecorrectly resolved for the members.

• WVCH behavioral health delegate reviews and monitors all behavioral health grievances and shares findingswith their clinical quality committee to identify trends and need for improvement.

N. QUALITY ASSESSMENT

Evaluation Analysis: 2017 Grievance and Appeals System data highlights: • WVCH averaged 94,386 enrolled members• 2,035 grievances filed• 1,123 (55.2%) of grievances resolved within 5 working days• 30,219 Notice of Action letters (NOA) sent to members• 1,904 (6.3%) NOAs resulted in an appeal or hearing request• 400 (21%) appeals overturned by WVCH• Top categories for complaints/grievances:

o Transportation- 39%o Issues with Provider- 12.5%o Client Billing Issues- 12%

In 2017, WVCH Grievance and Appeals System processed over 2,000 grievances, equating to approximately 170 grievances per month. Only 6.3% of NOA denials resulted in an appeal or hearing request. WVCH Grievances and Appeals Program reviews data and trends daily and implements a variety of improvement activities to resolve issues as they arise. Completed complaints for 2017 were reviewed and 58.8% were Caucasian and 41.4% were Non-Caucasian. Historically, transportation has been WVCH’s top category for member grievances. Due to this, the CCO implemented a wealth of strategies to improve the member experience, especially for those with special health care needs, by working with the Non-Emergent Medical Transportation (NEMT) brokerage. Continuously high rates of dissatisfaction and low quality of care resulted in WVCH issuing an RFP for a new NEMT vendor. The RFP process took place over much of 2017 and a new NEMT vendor began providing services to WVCH members March 1, 2018.

As WVCH moves toward a revamping of the website and increases social media presence, it will become much easier for expressions of dissatisfaction to be recorded and require CCO logging/resolution. Although a measurable reduction in overall grievances would be ideal, the information given is valuable to quality improvement of the CCO and is dependent upon external factors outside of the CCO’s control. Approximately 30% of total grievances are NEMT (+/- 600 grievances per year) and that remains fairly consistent year over year, however the new NEMT contract is experiencing normal implementation challenges– 50% of which are members unhappy with change to their habits or routine, and due to OAR NEMT regulations being enforced. OHP has added additional membership to WVCH from the FamilyCare transition and Oregon has included the Cover All Kid contract in OHP. With a new NEMT contract, additional members—including those who may not be experienced with healthcare access to providers and the CCO—does realistically translate into an


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increase in complaints versus any potential for reduction. At this time WVCH will continue to monitor total number of grievances, however, it is expected grievances will rise.

O. PERFORMANCE IMPROVEMENT

Activity: • As mentioned above, WVCH recently contracted with a new NEMT

brokerage to improve member experience, increase access to services,improve quality and appropriateness of care, and reduce the number oftransportation-related grievances

• The CCO’s Grievance and Appeals Program has observed an increasingtrend in pharmacy appeals due to the many formulary changes and criteriaimplemented over the duration of 2017. A pharmacist reviews appealsprior to the Medical Director/Chief Medical Officer to ensure all thenecessary information is received and to provide review consistencyWVCH will continue to integrate the pharmacist into the grievance systemwith hopes of reducing the number of pharmacy-related hearings andimproving overall CCO quality and efficiency

• The CCO will continue to implement strategies to improve the timelinessof grievance response and quality of care for all WVCH members throughthe Grievances and Appeals System. WVCH will create workflows,trainings, and other needed initiatives to continually improve the systemand respond to trends in grievance and appeals data

• The CCO will continue to monitor race and ethnicity demographics amonggrievances and if negative trends are observed, respond with a healthequity-focused plan of action to minimize cultural and linguistic disparities.Additionally, WVCH is tracking the number of appeals which could benefitfrom additional translation services to determine proactive and defaulttranslation documents

☐ Short-Term Activity or

☒ Long-Term Activity




Time (MM/YYYY)


Time (MM/YYYY)

Percentage of grievances resolved within 5 working days

55.2% 56% 01/2019 58% 01/2020


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5. Delegated Entity Compliance PackageP. TQS ComponentsPrimary Component: Fraud, waste and abuse Secondary Component: Access Additional Components: Complaints and Grievances

Subcomponents: Access: Second opinions


Access: Quality and Appropriateness of Care furnished to all members

Q. NARRATIVE OF THE PROJECT OR PROGRAMThe need for increased communication among providers and defined CCO expectations were met by creation and distribution of WVCH’ Delegated Entity Compliance Package. This package is a compilation of 70 current CCO policies and procedures. The Delegated Entity Compliance Package includes a current Fraud, Waste, and Abuse (FWA) Policy and Procedure, which was revised twice in 2017 and again in February 2018 to ensure compliance with State and federal regulations, and to align with the 2018 OHA-CCO contract. Also included in the Delegated Entity Compliance Package is WVCH’s Second Opinion Requests for Healthcare Services Policy and Procedure. This policy educates staff, providers, and delegated entities of a member’s right to a second opinion from an in-network provider, at no cost to the member. If an in-network provider is unavailable, assistance in obtaining a second opinion outside of the WVCH provider network is coordinated. WVCH communicates member rights and responsibilities, including the right to a second opinion, via the WVCH Member Handbook. WVCH monitors the Appeals and Grievances System for complaints and denials for accessing and scheduling second opinions. Requests for second opinions are monitored by the Appeals and Grievance System and WVCH Medical Management. WVCH offers training to providers on compliance policies and standards; much of which is defined and referenced in the 70 policies and procedures included in the Delegated Entity Compliance Package.

CCO staff, CCO Compliance Officer, and subcontractors receive a variety of training and education throughout the year to remain current and informed in all areas of compliance and FWA. National conferences where staff earn continuing education units (CEU) is important to having well educated staff capable of recognizing current fraudulent ploys/tactics while looking through data to discover reportable circumstances that may be potential fraud. Each compliance staff attends at least two conference per year that devote significant curriculum to the detection, prevention and reporting of fraud. Other training from nationally recognized associations is presented in webinars and through DVD recorded trainings. The OIG publishes YouTube presentations on fraud for staff and others viewing. In the past members of the WVCH Compliance Committee, who are also members of the Board of Directors, have attended national conferences for Compliance/FWA. In 2018, the Co-Chair of the Compliance Committee and the Chief Compliance Officer are scheduled to attend HCCA’s Compliance Institute in Las Vegas in mid-April. The Director of Regulatory Compliance attended a Managed Care conference in Arizona in February 2018. The Director of Finance, Provider Networks and Contracts attended a Resource Initiative and Society of Education Summit in Tennessee for auditing and data analysis. The Director of Internal Auditing is attending an American Academy of Professional Coders Conference covering topics like billing, coding and compliance advances in healthcare.

R. QUALITY ASSESSMENTEvaluation Analysis: WVCH’s Compliance Department utilizes Navex Global’s EthicsPoint Incident

Management software to track and monitor fraud, waste, and abuse (FWA) allegations and cases. In 2017, WVCH had one potential case of member fraud, which was promptly reported to the Medicaid Fraud Control Unit as well as the Program Integrity Unit at OHA. There were zero provider or CCO cases of FWA in 2017. In May 2018, WVCH will be participating in a FWA audit by CMS.

WVCH hired a Director of Internal Auditing to enhance program integrity and ensure compliance throughout the system. During an audit of the interpretive languages contractor, over $17,000 were recouped from errors/fraud in billing practices.


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Delegated entity staff, CCO audit staff and/or OHP members report perceived/potential fraud, waste, and abuse instances. While numerous reports/allegations of fraud are received each year, most are attributable to events like billing error, poor record keeping, ignorance and lack of understanding on the part of the reporter of what constitutes fraud. Reporting of perceived/potential FWA activities is the measurement of success even when the report is deemed to be something other than fraud. Audit and monitoring activities occur daily at both the CCO level and at delegated entities. WVCH, in conjunction with one delegated entity, resulted in the three FWA referrals so far in 2018.

S. PERFORMANCE IMPROVEMENTActivity: • In an effort to better educate staff and delegated entities, WVCH requested a

presentation by Paulette Golden, Program Integrity Audit Manager from OHA tothe Transformation and Quality Committee (TraQ). TraQ is composed of WVCHleaders, staff, providers, clinic administrators, behavioral health and dentalhealth providers, and partners

• WVCH will continue to educate through communication and policy updates tothe WVCH Delegated Entity Compliance Package and send out at least annually

• WVCH will continue to attend and train staff, contractors, and the ChiefCompliance Officer on FWA and other compliance topics

• Develop an annual report for monitoring and assessing trends for second opinionrequests and integrate the report with utilization review, cross-walking data withAppeals and Grievances

• WVCH is participating in an audit by CMS in May 2018 on our FWA program• WVCH identified a need for hiring 1.0 FTE compliance staff for Fraud, Waste, and

Abuse to monitor service and pharmacy utilization, member identity, programintegrity, etc. WVCH Chief Compliance Officer began advocating for theadditional staff from WVCH Board with a goal of hiring this position by 1/2019

☐ Short-Term Activity orx Long-Term Activity




Time (MM/YYYY)


Time (MM/YYYY)

Send out Delegated Entity Compliance Package annually as updated with new policies

Created and sent to delegated entities in 2017

Update and send Compliance Package annually

12/2019 Update and send Compliance Package annually

12/2018

CCO staff, CCO, and contractors attend training/education/conferences for compliance topics which include FWA

Currently staff attend a minimum of two trainings per year

Offer additional training for providers and TraQ on FWA and other compliance issues

12/2019 Ensure CCO staff, Chief CO and at least one contractor attend a FWA training

12/2018

Monitor and analyze second opinion requests comprehensively with Utilization Review and Appeals and Grievances

Annual review needed

Monitor reports annually for trends, denials, QI activities and compliance

12/2018 Create a data request for reviewing all second opinion requests

6/2018


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6. WVCH Data & Technology WorkgroupA. TQS Components

Primary Component: Health information technology Secondary Component: Health equity and data Additional Components: HIT: Patient engagement

Subcomponents: HIT: Health information exchange

Additional Subcomponent(s): HIT: Analytics

T. NARRATIVE OF THE PROJECT OR PROGRAMWVCH Data & Technology Workgroup: A workgroup composed of the CCO partner organization representatives and WVCH Board members and leadership, was convened to assess and outline specific data and technology needs according to contractual and operational needs and requirements for health information exchange, analytics, and patient engagement. Needs were outlined and detailed with specific contract requirements and data needs use cases presented. The workgroup developed a recommendation for improvement which is based in this fundamental developmental goal: To build a single integrated data asset for population, partners and community that includes claims and clinical insights, meets contractual requirements and allows us to regularly monitor performance in all of our quality metrics, as well as creates a community health record for our members inclusive of regionally integrated EMR and claims data.

Three of the vendor solutions which best fit these needs were invited for a live demonstration of product. Vendors were reviewed and assessed using a health IT functionality assessment framework and scoring guide that was developed by an independent and reputable health IT vendor assessment organization. One vendor outperformed both vendors in every category in the assessment and was ranked as the best fit for our CCO by 8 of our 12 reviewers. U. QUALITY ASSESSMENTEvaluation Analysis: The CCO contract requires that in addition to meeting the minimum standards for HIT we

also need to be able demonstrate the development of our own goals for transformation and improvement in these areas. These efforts are foundational to this development. In regards to information exchange the contract requires that we then develop and implement a plan for improvement in analytics for measuring health equity, disparities, and health outcomes for our network. WVCH does not currently have a health information exchange except for Premanage which have done a lot of work around but does not qualify as an HIE. WVCH utilizes CIM which is a claims management system, not an HIE and does not measure outcomes. WVCH currently lacks ability to aggregate and monitor clinical quality incentive metric performance among partners and clinics on a regular, ongoing basis. Currently WVCH receives one annual report at the end of the year which is submitted to the state. Over the course of 2017, WVCH attempted to receive clinic performance data quarterly which not all clinics participated. Mining data is arduous and time consuming for partners and within each organization, there are varying levels of ability to accurately pull reports.

Problem Statement: WVCH lacks sufficient data & technology infrastructure to support population, partner & community objectives.

Disparate and siloed data sources create obstructive administrative burden and stifle efficient operations, identification of insights, subsequent action, and innovation. The efforts of this workgroup resulted in a comprehensive summary of root cause of the problem, identification of specific and key gaps which currently exist within current data & technology landscape, and how addressing these gaps builds capacity for adherence to current and future CCO contract needs and member engagement in monitoring their healthcare.


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V. PERFORMANCE IMPROVEMENTActivity: A workgroup was convened to assess and outline specific data and technology needs according to contractual and operational requirements for health information exchange, analytics, and patient engagement. Needs were outlined and detailed with specific contract requirements and data needs use cases presented. A solution statement was developed. Solution Statement: Build a single integrated data asset for population, partners & community that includes claims and clinical insights--to facilitate pioneering and excellence in value based care. Functional Objectives of Solution:

• Develop singular patient record which includes clinical, claims and socialinsights and can be used in the clinical setting as well as provide supportfor WVCH executive operations.

• Offer aggregated quality incentive metrics reporting and analysis(including EMR based metrics) that is readily available to all of our partnersfor insight into performance, drivers, variation, and opportunities.

• Offer executive level reporting and analysis that is readily available to all ofour partners for insight into contract performance, drivers of thisperformance, variation among partners/clinics in performance, andopportunities for action.

• Develop business intelligence to directly drive and support communityimprovement projects--Provide aggregated data to support CHIP projectsincluding BMI, depression, prenatal care and tobacco use.

• Aggregate accurate demographics data to understand and meaningfullyrespond to social determinants of health.

• Develop a payer agnostic solution which can be utilized by partners fortheir entire clinic populations.

• Align with, incorporate and build on state HIT development efforts.

Possible vendor solutions were invited for a live demonstration of their product. Vendors were reviewed and assessed using a health IT functionality assessment framework and scoring guide that was developed by a professional, independent and reputable health IT vendor-assessment organization (KLAS). (Please see attachments for workgroup: Functionality Assessment & Vendor Feedback Summary).

Functionality for one of these vendors outperformed both other vendors in every category in the assessment and was ranked as the best fit for our CCO by 8 of our 11 reviewers. The workgroup recommends our CCO move forward with a regional implementation of this platform for the use by CCO and its partners.





Time (MM/YYYY)


Time (MM/YYYY)

Continue efforts with the workgroup to advance approval for contract negotiation and secondary project

Claims Data only- lacks information about provider performance, effectiveness of

Please see Functional Objectives of Solution above.

12/2019 Engagement in contract negotiation and complete at least 3 data source

12/2018


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planning process for implementing an HIE

treatment, and health outcomes.

connections (claims data feed and at least 2 EMR feeds) and go-live within platform.


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7. Small Practice Wrap Around Team ProjectW. TQS Components

Primary Component:

Integration of care (physical, behavioral and oral health) Secondary Component:

Patient-centered primary care home

Additional Components: Access

Subcomponents: Access: Availability of services


Access: quality and appropriateness of care

X. NARRATIVE OF THE PROJECT OR PROGRAMThe WVCH Board of Directors attend an annual retreat for strategic planning of the coming year. In 2017, WVCH Board unanimously voted to make the advancement of the medical home model, Patient-Centered Primary Care Homes, (PCPCH), the strategic intent of the CCO for 2018. WVCH has created a project which begun implementation in 2018. The Small Practice Wrap-Around Support Team advances the Quadruple Aim objectives by expanding access to clinical services in an efficient and effective manner. WVCH members receiving care at small practices throughout the community will have access to a comprehensive array of services that were previously unavailable or difficult to access, increasing access centralized resources that are typically only available to patients receiving care at large clinics. This project supports the core attributes of the Medical Home Model and ensures that clinics provide the right care, in the right place, at the right time. Many small practices lack the resources to balance the requirements outlined in Patient Centered Primary Care Home (PCPCH) certification and the Medicare Access and CHIP Reauthorization Act (MACRA) with providing care to patients. These and other emerging programs necessitate substantial upfront investments.

The Small Practice Wrap-Around Support Team was designed to ensure that all WVCH members have access to a robust care team regardless of which primary care clinic they are assigned. This new approach will significantly expand the number of WVCH members who have access to critical services such as medication reconciliation, nutritional counseling, behavioral health services, and community service navigation. These resources are critical components of a robust medical home and invaluable tools for providers looking to deliver patient-centered care. This project assists healthcare providers in working collectively to deliver comprehensive care despite resource limitations through resource-sharing and location-sharing of imbedded specialists to expand access to comprehensive care teams and increase PCPCH Tier statuses for participating clinics. Additional clinical staff will be hired to implement the Small Practice Wrap-Around Support Team project, including behaviorist, pharmacist, dietician, and clinical quality improvement coordinator to assist participating clinics with achieving higher PCPCH certification.

Y. QUALITY ASSESSMENTEvaluation Analysis: WVCH has provided funding for 17 behaviorists to serve CCO members in primary care

clinics across the network. The CCO has worked diligently to promote physical-behavioral health integration and has a number of primary clinics who have also funded embedded behaviorists independently.

The clinics participating in the WVCH Small Practice Support Grant collectively serve 15% of all members assigned to the CCO and would be the largest single clinic in the network if combined, however their individual size has limited their ability to secure resources comparable to those found at large clinics. This project addresses that disparity by calling for the formation of a Small Practice Wrap-Around Support Team comprised of the following positions:

• Behavioral Health Worker• Clinical Quality Improvement Coordinator• Nutritionist• Clinical Pharmacist


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Members receiving care at practices participating in the project have above-average utilization in a number of areas including, emergency department use, hospital admissions and pharmaceutical consumption. These figures reinforce the notion that members assigned to small practices would greatly benefit from having access to comprehensive wrap-around services.

Z. PERFORMANCE IMPROVEMENTActivity: All baseline rates and improvement targets are based upon participating primary care clinics (not the entire WVCH network)

☐ Short-Term Activity or Long-Term Activity

How activity will be monitored for improvement for clinics participating in Project



Time (MM/YYYY)


Time (MM/YYYY)

ED Visits Per 1,000 550.64 440.13 12/31/2019 500 12/2018 Inpatient Admissions Per 1,000

108.75 87.00 12/31/2019 99 12/2018

Hospital 30 day Readmission Rate

8.55% 5.48% 12/31/2019 7% 12/2018

Depression Screening and Follow-Up

18% 36% 12/31/2019 23% 12/2018

Childhood Immunization Status

46.74% 70.11% 12/31/2019 55% 12/2018

Diabetes HbA1c Poor Control

25.37% 19.02% 12/31/2019 23% 12/2018

Controlling High Blood Pressure

66.66% 76.65% 12/31/2019 70% 12/2018

# of PCPCH Tier status upgrades for participating clinics

0 2 12/31/2019 1 1/2019


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8. Expanded ED High Utilizers ProjectExpanded Emergency Department High Utilizers Project

Primary Component: Severe and persistent mental illness Secondary Component: Special health care needs

Additional Components: UTILIZATION REVIEW; Access; Integration of Care; Social Determinants of Health

Subcomponents:

Access: Quality and appropriateness of care furnished to all members


AA. NARRATIVE OF THE PROJECT OR PROGRAM WVCH’s Intensive Case Management (ICM) program provides extensive case and care management for WVCH members with special health care needs and thus, high utilizers of the costly Emergency Department (ED). WVCH identified a small subgroup of the population is responsible for a disproportionately large share of hospital ED visits. WVCH implemented a wide array of strategies to reduce the rate of ED visits, specifically for high utilizers of ED services and those with severe and persistent mental illness. WVCH also aims reduce the number of days in the hospital for patients with a history of high emergency department utilization. Most high ED utilizers have at least one psychiatric diagnosis and one or more chronic illnesses, plus a variety of social and health conditions which place them at risk of developing functional disabilities. High ED utilizers commonly experience significant barriers to accessing routine health care, including homelessness, substance abuse, severe chronic illnesses, physical disability, dental disease, early life trauma, and mental health problems. Due to mental health issues and chemical dependency, many high ED utilizers have difficulty navigating the health care system and keeping scheduled health care provider appointments. Thus, these patients tend to continue to visit the ED frequently over time and many continue to generate high costs year after year. One analysis showed that nearly 60% of Medicaid beneficiaries who were among the most expensive 10% in one year remained among the top 10% in two subsequent years. Other factors that might increase the risk of excessive ED utilization include no recognized source of primary care, multiple chronic diseases, inadequate housing, no transportation options, poor health self-rating, minimal social support, irregular employment, residence proximate to an ED, and absent trust in the health care system.

WVCH is expanding its current efforts with the WVCH Intensive Case Management program, which oversees the Emergency Department Intervention Team (EDIT). The EDIT team monitors and follows up with members utilizing the emergency department by providing intensive case management. Three additional full time care managers have been housed at Salem Health and have begun actively engaging 300 patients referred to them from the Salem Health emergency department, not only providing downstream care, but also providing outreach to the top 1000 high utilizers of the ED for prevention. Intensive Care Managers bridge and connect patients to community-based services and transition care to long-term services as needed. They have access to a broad range of community support options, including primary care, peer support, mental health and addictions counselling, dental care, and other social services as needed. Care managers offer outreach, home visits, medication assistance, transportation, crisis interventions, supportive therapy, practical needs assistance and care coordination. Once this project is fully implemented, Care Managers will maintain a caseload of approximately 100 active patients and broadly serve the 1000 high utilizers, all of which are WVCH clients. This project integrates with the WVCH Quality Incentive Metrics. Providers were not achieving ED utilization targets for the Quality Incentive Metrics: the target is 45.7 ED Visits/1000 members and WVCH was seeing 49.8 visits/1000 members. This equates to 4094 ED visits above target in 2016.

Mid Valley Behavior Care Network, WVCH’s behavioral health delegate, is providing additional follow up for members receiving outpatient mental health services who utilize and discharge from the ED. These targeted efforts provide quality and appropriate care for those being treated or at risk for severe and persistent mental illness (SPMI). Once a member is discharged from ED services, providers receive daily alerts from the PreManage system. Members are contacted by a provider to schedule a follow-up appointment with a therapist, case manager, and psychiatric services. Providers track follow-up contact and efforts with a BCN code in conjunction with PreManage data, 75% is the monthly


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targeted goal. This data will be gathered monthly by the Quality Improvement Coordinator and reviewed with Quality & Network Director to determine if changes in the network are necessary for providers working with SPMI and other mental health diagnoses.

Additionally, WVCH launched a project with Marion County Sheriff’s Office to launch a Law Enforcement Assisted Diversion as Transformational Health Intervention System Change (LEAD THIS Change) to focus efforts on the top 100 utilizers of the ED and jail in two of Salem’s high-risk areas, targeted based on police contact reports and arrests and ED utilization data. WVCH convened a community-wide collaborative to bring partners throughout the community together to coordinate care and align efforts for high ED utilizers and those entering into the ED with SPMI and other mental health diagnoses. This community collaborative gathered health care partners, WVCH’s Transformation and Quality Committee, CCO leadership, intensive case managers, behavioral health providers, addictions providers, both Marion and Polk County staff, housing providers, law enforcement, social support providers, Community Action Agency, etc.

BB. QUALITY ASSESSMENT Evaluation Analysis: Evidence shows that ED intensive care management programs add value and align with the

Triple Aim to reduce costs, improve health, and improve quality of care: 1) Reduce Costs:

a. Save costs through fewer emergency department (ED) visits and lowerhospitalization and readmission rates for complex patients

2) Improve health:a. Help patients engage more fully in their care and adhere to care plansb. Help patients address social, economic, mental health, addictions, and

chronic conditions that lead to poor health outcomes3) Improve quality of care:

a. Improve health and care utilization, reflected in performance measures andstandards promoted by Willamette Valley Community Incentive MeasureBenchmarks, and Healthcare Effectiveness Data and Information Set(HEDIS), Hospital Consumer Assessment of Healthcare Providers andSystems (HCAPS) and other quality measures

b. Improve retention in care through outreach to reduce no-shows andassistance with insurance enrollment and retention

A review of 2016 ED discharge data shows that 1000 WVCH patients had four or more ED visits. While these patients represent approximately 1% of WVCH members, they account for nearly 24% of all emergency room visits. Twenty-six clinics provide primary care for the top 1000 high ED utilizers. Providers will have daily communication using PreManage regarding members who have been admitted and discharged from the ED. They will have the ability to coordinate care with the hospital, PCP and other organizations that may be a part of member care team.

CC. PERFORMANCE IMPROVEMENTActivity: • Three additional ED Intensive Case Managers were hired to begin outreach

and continue case management serving the top 1000 highest utilizers of theED, referring to PCPs, warm hand-offs to mental health and/or addictions,dental health, and addressing basic needs including but not limited to: rentassistance, medication assistance, utilities, food, housing, job placement,transportation and childcare

• Convene quarterly High ED Utilizers Community Collaborative to facilitatecommunity-wide alignment of services and coordination of care



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• Marion County Sheriff’s Office begun the LEAD THIS Change, aligned with theExpanded ED Intensive Case Management Project, to target highest utilizers inour community

• Conduct post-ED care and follow up to ensure members receiving outpatientmental health services and those with severe and persistent mental illnessreceive follow up care




Time (MM/YYYY)


Time (MM/YYYY)

WVCH ED visits per 1000

49.8 45.7 1/2019 47 07/2018

Number of home visits 0 100 1/2019 50 07/2018 # Care plans approved by PCP

0 100 1/2019 50 07/2018

# Care plans with mental health integration

0 100 1/2019 50 07/2018

# referrals to mental health services, addiction/dependence tx

0 100 1/2019 50 07/2018

# referrals to housing and entitlement programs

0 100 1/2019 50 07/2018


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9. Developmental Screenings ProjectDD. TQS Components

Primary Component: Social determinants of health Secondary Component:

Integration of care (physical, behavioral and oral health)

Additional Components: Add text here.

Subcomponents: Choose an item. Additional Subcomponent(s): Add text here.

EE. NARRATIVE OF THE PROJECT OR PROGRAM Health outcomes are often the result of the interaction between individuals and their social and physical environment. According to the World Health Organization, social determinants of health are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. The purpose of this project is to increase the quality and usefulness of developmental screenings conducted in Marion and Polk County, as well as increase collaboration and information-sharing between early learning providers, early intervention specialists and medical providers. Research shows that children who enter Kindergarten ready to learn are more likely to succeed academically and graduate from high school, thus impacting their social determinants of health. Research also shows the importance of early intervention: the earlier a child receives intervention and support for any developmental concerns, the more time there is to prepare them for Kindergarten. By ensuring children receive a developmental screening and connecting them to any needed early intervention services, we can improve health and social outcomes for children in our community. WVCH is partnering with the Marion-Polk Early Learning Hub (MPELH) to expand on connections made in recent years between early learning providers, early intervention, medical clinics and behavioral health. ASQ Online will be purchased for early learning providers to use, to increase the quality of screenings conducted, and allow data to be collected about how many children indicate a developmental concern. Two staff will be supported to implement this project, one at the Marion and Polk Early Learning Hub and one at Willamette Education Service District. FF. QUALITY ASSESSMENT Evaluation Analysis: This project expands on previous efforts in Marion and Polk counties to create a pathway to

bring ASQ-3 developmental screen information from early learning providers to WVCH medical providers. Early learning providers have been uploading the ASQ-3 developmental screen scores into the CIM tool to share with WVCH medical providers. This partnership has included Child Care Resource and Referral who has provided multiple trainings to childcare providers about how to use and score the Ages and Stages Questionnaire (ASQ). These efforts also included a partnership with Oregon Pediatric Improvement Partnership (OPIP) who completed a project with Willamette Education Service District (WESD) and Childhood Health Associates of Salem (CHAOS) to map out what happens from the time a child receives a developmental screening to the time they are referred for services in an effort to discover where children get lost in the screening-to-referral process. This information helped inform how to improve referral, information sharing, and follow up by both the medical clinic, behavioral health, and early intervention. This project aims to improve integration between the medical community and early learning by intervening early and getting children connected to needed services and supports to improve health and social outcomes.

GG. PERFORMANCE IMPROVEMENT Activity: Build on adjacent and corresponding efforts to improve communication, feedback loops, and quality of developmental screenings between WESD and medical clinics.

1. Collect data from early learning providers about children's developmentalneeds in our community. By using the ASQ online, data will be able to be

x Short-Term Activity or ☐ Long-Term Activity


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pulled about children who are enrolled in early learning programs. 2. Increase the quality of developmental screenings. The ASQ Online has an

ASQ calculator that accurately calculate the child's age or adjusted age. Thedatabase then provides the correct ASQ to use, virtually eliminating thepossibility of error.

3. Increase the number of appropriate referrals from medical providers toearly intervention.

4. Increase the number of clinics that are implementing the tools initiallycreated by OPIP. At least two more clinics will implement these processesduring 2018.

5. Increase communication and referrals between early intervention andmedical clinics. Medical clinics and WESD will share data about referralsmade and received.


Baseline or current state July 2017 – Dec 2017


Time (MM/YYYY)


Time (MM/YYYY)

Number of physician/clinic referrals to WESD that resulted in services received

159 200 07/2018 300 1/2019

Number of total physician/clinic referrals from medical providers to early intervention

428 550 07/2018 700 1/2019

Number of clinics that implement tools and materials created by OPIP

2 2 07/2018 4 1/2019


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10. Primary Care Home Utilization and AccessHH.TQS Components Primary Component: Utilization review Secondary Component: Health equity and data Additional Components: Access

Subcomponents:



Access: Cultural Considerations; Health Equity: Data

II. NARRATIVE OF THE PROJECT OR PROGRAMThe Reproductive Health Equity Act is going into effect in April. In preparation for this, WVCH partnered with Marion and Polk County Public Health Departments to educate, provide outreach, and re-route members to their primary care home for reproductive health services and to improve the quality and appropriateness of care for all members through an integrated, patient-centered approach to care. Many people go to public health departments for reproductive health services because they do not know to go to their PCP’s or due to cultural preference. Members will receive more patient centered care and wrap-around services from their PCPs, and their PCPs will be able to identify other services that they may need. Local Public Health Departments (PHD) will no longer be required to provide reproductive health services. Marion and Polk PHD state they will not stop providing reproductive health services but are working with WVCH and providers to increase utilization of members’ primary care homes for immunization and reproductive health services, thus, increasing access and availability of services for true safety-net patients. WVCH is also deploying initiatives to increase utilization and access of reproductive health services, including early prenatal care and sexually transmitted infection (STI) services, with a special focus on youth and the housing-insecure population.

JJ. QUALITY ASSESSMENT Evaluation Analysis: WVCH analyzed and assessed claims data for utilization and access of reproductive health

services paid to Marion and Polk County health departments for services. WVCH analyzed utilization and access data and de-aggregated by member clinic assignment to assess prevalence of members’ primary care home clinics who obtain reproductive health care at PHD instead of their PCPCH. Additionally, WVCH stratified utilization data by geography/zip codes, age, and race/ethnicity to assess utilization using a health equity lens and identifying access barriers.

Marion and Polk County PHD began surveying patients coming in for reproductive health services to determine needs, insurance status, cultural trends, reasons why choosing PHD for services and not a PCP, etc. Key informant interviews are being conducted by county staff for WVCH clinics identified to have a high numbers of assigned members receiving services at local PHD to build relationships directly with clinics and gain valuable information from clinics and providers about these members and utilization of services. Results of both patient surveys and clinic key informant interviews will be integrated into strategies to re-direct appropriate PHD users to their primary care clinics to improve quality and appropriateness of comprehensive, culturally appropriate healthcare and disease prevention for members.

KK. PERFORMANCE IMPROVEMENT Activity:

• Conduct member and key informant surveys and integrate qualitative datafrom members and clinic staff to devise outreach and education activitiesto engage members in seeking care at their PCPCH

• Work with clinics to implement “one key question” for reproductive healthscreening and referral to services, offering materials in various languages

Short-Term Activity or X Long-Term Activity


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• Deploy a street-outreach team for increasing access to reproductive healthcare services and link homeless and disparate youth and teens to theirprimary care homes, or assisting them in establishing a primary care home

• Promote referrals to Oregon Mother’s CareHow activity will be monitored for improvement



Time (MM/YYYY)


Time (MM/YYYY)

# Completed member surveys

0 40 1/2019 25 7/2018

# Key informant interviews with clinics

0 8 7/2018 n/a n/a

# WVCH members receiving reproductive health services at Marion County

413 (as of 12/31/17)

Decrease utilization by 40%

12/2019 Decrease utilization by 15%

12/31/2018

# WVCH members receiving reproductive health services at Polk County

421 (as of 12/31/17)

Decrease utilization by 30%

12/2019 Decrease utilization by 10%

12/31/2018

Implement street-outreach team to reach underserved populations

Convened partners to develop outreach team, awaiting funding for implementation

Contact made with 50 youth/teens and refer for reproductive health and STI services

1/2019 Begin street outreach

6/2018


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11. APM and VBPM ModelsLL. TQS Components

Primary Component: Value-based payment models Secondary Component:

Patient-centered primary care home

Additional Components: Access

Subcomponents:



MM. NARRATIVE OF THE PROJECT OR PROGRAMWVCH invests in value-based payment models that align payment with health outcomes to achieve better care, controlled costs, and better health for members. WVCH receives council from our OHA Innovator Agent for devising innovative and feasible alternative payment methodologies (APM) and value-based payment models in addition to those currently implemented. Our Innovator Agent has presented to the Board and WVCH leadership on existing transformational APMs employed by CCOs and others throughout the state. Our Innovator Agent meets regularly with leadership, including the CEO, WVCH Community Advisory Council, WVCH Board of Directors, and WVCH’s Transformation and Quality Committee. WVCH participated in OHA’s APM survey that led to a report distributed by OHA to all CCOs. WVCH has participated in various sessions for APMs at events such as OHA’s Innovation Cafes, CCO Oregon conferences and HealthInsight quality conferences. Additionally, WVCH Chief Operating Officer participated in technical assistance calls from the Transformation Center around APMs.

WVCH implements a value-based payment model which incentivizes providers to achieve quality incentive metric (QIM) benchmarks and support the advancement of clinic’s PCPCH Tier status. Payment is dispersed the following year and is based on the previous year’s performance in health outcomes using claims data, clinical performance, and CAHPS surveys. WVCH holds a bi-monthly Metrics Workgroup meeting to assist providers with CCO guidance and peer-to-peer discussion to support clinics achieving these metrics. WVCH engages providers in the designing and refining of the CCO’s Quality Pool Payment Methodology to incentivize providers to standardize and improve quality and appropriateness of care for all members and advance proliferation of PCPCH Tier certification. WVCH provider network receive performance incentive payments using the Quality Incentive Metrics performance and health outcomes annually.

WVCH is interested in developing and implementing two additional APMs beyond the quality performance payments to further align payment with the quadruple aim. WVCH created a Behavioral Health Task Force to advance behavioral health integration within primary care homes (PCPCH models) and is exploring APMs such as a per member per month (PMPM) model to clinics with embedded behaviorists. This model would be a tiered payment model depending on the ratio of behaviorists and would align with PCPCH’s behaviorist-to-primary care physician FTE ratio standards.

In 2017 WVCH initiated a transition to acuity adjusted capitation rates using the Chronic Disease Payment (CDPS) model. This acuity adjustment is applied to WVCH Primary Care Risk Groups. This transition began in response to an identified strategic need for continued progress toward more equitable base rate distribution. Acuity adjustments incentivize providers to serve members with higher service needs, in turn opening access. Members with chronic conditions consistently require a higher level of care, e.g. specialty, hospitalizations, RX, diagnostics, more often seen in the office. Some risk groups inherently attract higher/lower acuity members based on provider types in the risk group and having an open panel. The equity in distribution serves a critical function in maintaining access for our sickest members while also maintaining a sustainable network and funding model that accounts for variation among our primary care risk groups. When WVCH began using this method of acuity adjustments in the 2017 contract year it included +/- 3% guardrails to give Primary Risk Group (PCG’s) a glide path to full acuity adjustments. WVCH is currently working to finalize a timeline for transition to full acuity adjustment without guardrails.


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WVCH has been working with our OHA Innovator Agent to assist with developing these alternative payment methodologies, as well as others (such as “Pathways” for care management).

NN. QUALITY ASSESSMENT Evaluation Analysis: 99% of WVCH members are assigned to a primary care clinic that receives payments from

the WVCH Quality Pool payment distribution process.

The CCO has solicited feedback from primary care providers to help ensure its QIM performance payment methodologies support the implementation of high quality care. These activities help set the foundation for the future expansion of APM across the WVCH provider network.

OO. PERFORMANCE IMPROVEMENT Activity: • WVCH revises CCO Quality Pool Payment Methodology on an annual basis to

ensure the process maximizes provider performance and participation• WVCH created a Board-directed CDPS Task Force to assess the current CDPS

system and evaluate the removal of guard rails, implementing an alternative,value based payment methodology for treating those chronically ill

• WVCH receives council from our OHA Innovator Agent for devising innovativeand feasible APMs and value-based payment models in addition to thosecurrently implemented

• Continue to explore implementing a behavioral health APM for clinics withimbedded behaviorists

☐ Short-Term Activity orX Long-Term Activity




Time (MM/YYYY)


Time (MM/YYYY)

WVCH QIM Performance- percentage of metrics met (2016 performance)

78% of metrics met

Continue to monitor and develop strategies to meet CCO targets

5/2018 Maintain >75% performance through continuous quality improvement in these areas.

5/2019

Develop a plan for implementation of acuity rates using a chronic disease payment system (CDPS)

Task Force convened

WVCH Board approval of 2019 CDPS

12/2018 Implement 2019 CDPS

2/2019


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willamette valley community health - oregon...mar 16, 2018 · to ensure compliance and integrity....

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