Meeting Minutes

Meeting #3

September 9, 2015 12:30pm-3:30pm
Location: New York State Department of Health 90 Church Street, New York, NY 10007

Overview

This was the third meeting in a series of meetings for the Social Determinants of Health (SDH) and Community Based Organizations (CBO) Subcommittee (SC). The purpose of the meeting was to review and discuss the work completed by the workgroups that were formed during the previous meetings. Between Meetings 2 and 3, the four workgroups convened twice to develop draft recommendations for review with the larger subcommittee. The workgroups were: Guidelines for Providers and the State (Guidelines); Identifying Effective Interventions; Capturing Savings across Public Spending (Capturing Savings); and Housing Determinants. Toward the end of the meeting, a brief brainstorming discussion took place regarding CBOs and their role in VBP. This helped to focus the topics and questions that will be addressed during the upcoming meetings. The members of the SC were also free to discuss any questions related to the agenda items and raise questions or concerns.

The specific Agenda for this meeting included the following:

  • Review of Workgroup Draft Recommendations
    1. Guidelines and Standards for Providers and the State
    2. Identifying Effective Interventions
    3. Capturing Savings across Public Spending
    4. Housing Determinants
  • Discussion on Next Steps

Key Discussion Points

1) Review of Workgroup Draft Recommendations - Guidelines and Standards for Providers and the State (Reference "SDH and CBO Subcommittee Meeting 3" deck, slides 4-11)

The VBP Roadmap questions in scope for the Guidelines workgroup were reviewed and a recap was provided on the definition of a guideline versus a standard. All recommendations made by this workgroup were presented to the SC and categorized by those which apply to (i) provider/provider networks, (ii) provider/provider networks and MCOs, (iii) MCOs, and, (iv) the State. It was agreed that a "provider" is defined as a licensed Medicaid provider and a "provider network" is a combination of providers. Each recommendation was classified as either a guideline or a standard, with a few remaining undefined for the larger SC to debate, as consensus could not be made within the workgroup.

Recommendations for Providers/Provider Networks

  • Implement interventions on a minimum of one SDH
    The workgroup was unable to agree if this should be a guideline or a standard. The SC came to a consensus that this should be a guideline for Level 1 VBP providers and a standard for Level 2 and 3 VBP providers.
  • Maintain a robust catalogue of resources in order to connect individuals to community resources that are expected to address SDH
    The workgroup proposed this as a guideline, and it was accepted as is for all providers/provider networks, irrespective of level of VBP arrangement.
  • Employ a workforce that reflects and is culturally sensitive to the community served
    The workgroup proposed this as a guideline, and it was accepted as is for all providers/provider networks, irrespective of level of VBP arrangement.

Recommendations for Providers/Provider Networks and MCOs

  • Utilize an assessment tool, measure and report on social determinants that affect their individual patients, which include elements of each of the SDH domains identified (economic stability; education; health and healthcare; social, community, and family; neighborhood and environment)
    The workgroup proposed this as a standard, but the SC came to a consensus that it should be a guideline for Level 1 VBP providers and a standard for Level 2 and 3 VBP providers and MCOs. As there are many providers who have invested both time and money in, and who are already using, tools to assess and report on the SDs that impact patient´s health and well-being, the recommendation does not require a standardized assessment tool. However, the tool should have a set of common core measures that could easily be analyzed across all of the providers/provider networks.
  • Invest in ameliorating an SDH at the community level
    The workgroup was unable to agree if this should be a guideline or a standard. The SC came to a consensus that this should be a guideline for Level 1 VBP providers and a standard for Level 2 and 3 VBP providers and MCOs.
  • Track discrete outcomes of the interventions and use a continuous quality improvement (CQI) model for enhancing interventions
    The workgroup proposed this as a standard, but the SC came to a consensus that this should be a guideline for Level 1 VBP providers and a standard for Level 2 and 3 VBP providers and MCOs.
  • Incorporate feedback on the services received
    The workgroup proposed this as a guideline, but the SC came to a consensus that this should be a guideline only for Level 1 VBP providers and a standard for Level 2 and 3 VBP providers and MCOs.

Recommendations for MCOs

  • Incentivize and reward providers for taking on patients´ SDH
    The workgroup proposed this as a standard, and this was accepted as is, with the addition that it should also be a standard for the State. For the State, this may take the form of pilot program support to providers taking on Level 1 and 2 VBP arrangements and the VBP Innovator Program for providers in Level 3 VBP arrangements. Specifics around technical assistance and criteria and policies for the VBP innovator program is under the purview of the Technical Design II subcommittee.

Recommendations for the State

  • Set up a system that aims to track what interventions are successful and how they are measured
    The workgroup proposed this as a standard, and this was accepted as is.
  • Incorporate SDH into QARR quality measures
    The workgroup proposed this as a standard, and this was accepted as is.

A document including the final recommendations, which will reflect the decisions made above, will be prepared and provided to the SC for signoff.

2) Review of Workgroup Draft Recommendations - Identifying Effective Interventions (Reference "SDH and CBO Subcommittee Meeting 3" deck, slides 12-18)

The VBP Roadmap questions in scope for the Identifying Effective Interventions workgroup were reviewed. The SDH Intervention Menu and corresponding narrative developed by the workgroup were also explained. The menu is split into the aforementioned key domains of SDH. Under each domain, several SDs are identified and relevant interventions for each are detailed. This tool can be used as a reference for providers/provider networks who plan to invest in and implement an intervention. It was emphasized that the menu is a list of suggested evidence-based and promising interventions, and should not be perceived as an exhaustive list of choices from which a Provider/Provider network must select. The narrative, which elaborates on the menu and includes recommendations that align with those made by the Guidelines group, was also discussed. The menu will be revisited and possibly reformatted, as new contributions continue to be made by workgroup members. Overall, the SC agreed that the key points and the menu brought forth by the workgroup are effective tools that augment the recommendations made by the Guidelines workgroup. Once all work has been completed, the menu will be distributed to the SC for final signoff.

The final recommendations of the SC will be organized into a recommendation report and submitted to the VBP workgroup for review and approval.

3) Review of Workgroup Draft Recommendations - Capturing Savings Across Public Spending (Reference "SDH and CBO Subcommittee Meeting 3" deck, slides 19-24)

The Roadmap questions pertaining to the Capturing Savings workgroup were reviewed during this portion of the meeting. It was noted that the corresponding narrative which includes and explains the workgroup´s three recommended mechanisms (Innovative Contracting, Co-Investing, and Social Impact Bonds) is not an exhaustive list. The SC members were encouraged to brainstorm and communicate any additional relevant methods and examples for capturing savings to the workgroup. While further recommendations are yet to be made, some SC members suggested that the wording of the narrative should be revised and provided new language. Overall, the SC approved of the recommendations and agreed that they should be viewed as advisory guidance on possible mechanisms for consideration. Once finalized, the recommendations will be presented to the SC for signoff.

4) Review of Workgroup Draft Recommendations - Housing Determinants (Reference "SDH and CBO Subcommittee Meeting 3" deck, slides 25-30)

The Roadmap questions related to housing and the Housing Determinants workgroup´s four recommendations were reviewed with the SC. The workgroup will reconvene again to discuss the SC´s feedback on the draft recommendations and produce updated recommendations for signoff. A summary of key points on the housing recommendations is provided below:

Housing Recommendations

  • Require Medicaid providers to collect standardized housing stability data
    A discussion ensued around collecting housing data - whether it can/should be collected during the Medicaid enrollment process (on the application) or if providers should be responsible for collecting this data. One idea was that if housing data collection becomes part of the enrollment process, and the data is collected electronically and provided to the plans, then the plans could come up with a strategy to share housing data with providers. It was also noted that some facilities are already collecting housing data through the HARP assessment tool and some health homes are beginning to do so as well. While this data collected is only for a small subset of the Medicaid population, perhaps this information could be leveraged and the collection expanded. While the SC could not come to a finite conclusion, the members agreed that there needs to be a way to systematically collect this data and that providers need to receive training on how to deal with a Medicaid members´ housing needs/challenges in a sensitive manner. An important question that arose was, "how can the (housing) information be connected to electronic medical records (EMRs)?" Altogether, further discussion on this topic is needed and the current DSRIP CIO Steering Committee was identified as a potential avenue for in-depth dialogue.
  • Leverage MRT Housing Workgroup money to advance a VBP-focused action plan
    There is an existing housing workgroup that makes recommendations to the Medicaid Reform Team (MRT) every year on how to use shared savings that have been allocated for housing. A quarter of a billion dollars was set aside last year to be used for housing over next two years. It is recommended that the MRT Housing Workgroup align its work and investments with VBP. The members of the SC did not comment on this recommendation.
  • Submit a NYS waiver application to CMS that tracks the June 26, 2015 CMCS Information Bulletin titled, Coverage of housing-related activities for individuals with disabilities
    The workgroup would like to have a waiver submitted to CMS to track the guidance on the statements made in the bulletin in regards to CMS paying for programs related to housing. This is a good way to ensure that the State can leverage as much housing money as it is entitled from the federal government. The workgroup suggested that the money could be used to fund housing-related case management, tenant education and coaching, housing transition services, and crisis/respite services, amongst other programs. It would also be beneficial to the State, VBP systems, and community housing facilities if CMS could pay for a portion of what is already being provided. The New York State Department of Health is doing an exhaustive review of this waiver to see if the State needs to apply for this funding or if it can be done under the existing plan. The SC agreed that this should be a recommendation put forth to the VBP workgroup.
  • Submit a New York State waiver application that challenges the restrictions on rent in the context of VBP
    The workgroup recommended submitting a waiver application to convince CMS to view housing interventions as healthcare for people with chronic conditions. The members of the SC did not comment on this recommendation.
Materials that were distributed prior to the meeting:
# Document Description
1 SDH and CBO Meeting 3 PowerPoint A PDF presentation of the slide deck created for Meeting #3, which covers work completed by the four workgroups and next steps for the upcoming meetings.
2 Guidelines Recommendations and Descriptions A narrative detailing the Guidelines and Standards for Providers and the State workgroup´s draft recommendations.
3 Social Determinants and Sample Interventions A narrative detailing the Identifying Effective Interventions workgroup´s draft recommendations.
4 SDH Intervention Menu Draft 9 9 15 An excel document that lists possible interventions for specific social determinants.
5 Capturing Savings Across Public Spending A narrative detailing the Capturing Savings Across Public Spending workgroup´s draft recommendations.
6 Housing Action Plan A narrative detailing the Housing Determinants workgroup´s draft recommendations.

Next Steps (Reference "SDH and CBO Subcommittee Meeting 3" deck, slide 31)

The focus for the upcoming SC meetings will be on CBOs. A brief discussion ensued around the approach the SC should take, emphasizing that we need to not only identify the CBOs, but determine what it is they need to do to participate in VBP and how the State can assist. Several suggestions around infrastructure, contracting and shared services, mergers, and compliance were entertained and will be explored/discussed in more detail during the upcoming meetings.

Key Decisions

The SC discussed recommendations that the workgroups brought to the table and came to the following conclusions. The formal recommendations will be distributed to the SC for final review and signoff in an upcoming meeting.

Proposed Guidelines and Standards on SDH

# Draft Recommendation VBP Level 1 Providers VBP Level 2 or 3 Providers MCOs The State
1. Implement interventions on a minimum of one SDH Guideline Standard - -
2. Maintain a robust catalogue of resources in order to connect individuals to community resources that are expected to address SDH Guideline Guideline - -
3. Employ a workforce that reflects and is culturally sensitive to the community served Guideline Guideline - -
4. Invest in ameliorating an SDH at the community level Guideline Standard Standard -
5. Incentivize and reward providers for taking on patient and community-level SDH. - - Standard Standard
6. Utilize an assessment tool; measure and report on SD that affect their patients, which includes elements of each of the SDH domains identified. Guideline Standard Standard -
7. Track discrete outcomes of the interventions and use a CQI model for enhancing the interventions Guideline Standard Standard -
8. Incorporate patient feedback on services received Guideline Standard Standard -
9. Set up a system that aims to track what interventions are successful and how they are measured - - - Standard
10. Incorporate SDH into QARR measures - - - Standard

Recommended Mechanisms for Capturing Savings Across Public Spending

The subcommittee recommended the following mechanisms for capturing savings across public spending. These mechanisms should not be viewed as an exhaustive list, but as a guideline for the State´s consideration.

  • Innovative contracting
  • Co-investing
  • Social impact bonds

Recommendations for Housing

The Housing Determinants workgroup will reconvene to further develop the recommendations pertaining to housing determinants.

Action Items

  1. Please email Josh McCabe (joshuamccabe@kpmg.com) if you attended the meeting on the phone or did not sign the attendance sheet.
  2. Please email Josh McCabe (joshuamccabe@kpmg.com) with any ideas on areas or questions to focus on regarding the upcoming meetings on CBOs.

Conclusion

The upcoming meeting will shift focus to CBOs, and will aim to answer the Roadmap questions regarding their role in VBP.