Meeting Minutes

Meeting #5

November 17, 2015 12:30pm-3:30pm
New York State Department of Health 90 Church Street, New York, NY 10007

Overview

This was the fifth meeting for the Social Determinants of Health (SDH) and Community Based Organizations (CBO) Subcommittee (SC). The purpose of this meeting was to first review and finalize the established recommendations for SDH, and secondly, to continue an in-depth discussion on CBO integration in the Value Based Payment (VBP) system. A presentation on the New York State Prevention Agenda was provided to inform the SC of this ongoing initiative and allow the members to consider aligning its recommendations with the Prevention Agenda. Additionally, the VBP Workgroup´s comments on the SDH recommendations were shared with the members. The members were free to discuss any questions related to the agenda items and raise questions or concerns.

The specific Agenda for this meeting included the following:

  • SDH Recommendations for the VBP Workgroup
    • Revisions to Existing Recommendations and New Recommendations
  • CBOs in VBP
    • Prevention Agenda & Cultural Competence
    • Formation of New CBO Entities
    • Draft CBO Recommendations

Key Discussion Points

1. Prevention Agenda (Reference "SDH and CBO Subcommittee Meeting 5" PDF, slides 14-30)

There was a change to the agenda and the meeting began with a presentation on the New York State Prevention Agenda. The purpose of the presentation was to provide the SC members with an overview of the Prevention Agenda, which assesses local health status and needs; identifies local health priorities; and plans, implements and evaluates strategies for community action to improve the community´s health. VBP in Medicaid can work synergistically with the Prevention Agenda if the SC´s recommendations align with the Prevention Agenda´s goals and charge. The presentation concluded with recommendations for connecting the Prevention Agenda to VBP. The SC agreed that the Prevention Agenda should be linked to VBP and will consider this when formulating and editing the existing draft recommendations.

2. VBP Workgroup Comments

The co-chairs received feedback from the VBP Workgroup on the draft SDH recommendations and shared the comments and revisions with the SC. In the table below, the VBP Workgroup´s comments are listed with the response.

VBP Workgroup Comments SC´s Responses
In reference to all recommendations - Change all recommendations presented as standards to guidelines. The recommendations presented as standards will remain as standards, as the Subcommittee had previously discussed this in length and had come to a consensus.
In reference to Recommendation #1 (Implement interventions on a minimum of one SDH) - We recommend that the goal of at least one SDH be revisited and revised upward. Further we recommend that PPSs and MCOs demonstrate that they have engaged with the CBOs which have spent decades addressing the precise SDH which drive-up health care costs. The recommendation will not be changed to increase the minimum number of SDH on which to implement an intervention, as this was already considered. Instead of increasing the minimum number, an additional recommendation was created that speaks to the quality of the intervention.
However, the SC will discuss including a timeline for this recommendation, as it may not be realistic for VBP Level 2 and 3 providers/provider networks to complete this standard immediately upon signing of the contracts.
In reference to Recommendation #3 (Invest in ameliorating SDH at the community level) - If the State is going to require that providers in Level 2&3 arrangement invest savings in these interventions, there must be consistency in reporting requirements among payers and clarity on how contractors would be held accountable for compliance. The recommendation does not require providers to invest savings in interventions and developing a reporting process is not in scope for the SC.
In reference to the narrative preceding the housing recommendations (reference "NYS VBP SDH CBO Draft Recommendations" PDF, page 3) - "As a result, some providers may seek to avoid serving homeless members" implies that homeless individuals are the only Medicaid beneficiaries that are affected by their housing status. Individuals with mental health and behavioral health needs are also affected by housing status. The sentence should be reworded to reflect this reality. The narrative will be edited to more broadly reference housing instability.
In reference to Recommendation #15 (The State should submit a waiver application to CMS that tracks the June 26, 2015 CMCS Information Bulletin)
- The recommendation should also include an exploration of possible strategies to allow MLTC plans to offer certain housing supports that are provided in Section 1915(c) waiver programs, such as assistance with moving into the community and home modifications.		 Recommendation #15 will not be changed, as the VBP workgroup´s request can be better integrated into Recommendation #17. Recommendation #17 (The State should submit a waiver application that challenges the restrictions on rent in the context of VBP) will be amended to include home modifications.
In reference to Recommendation #15 (The State should submit a waiver application to CMS that tracks the June 26, 2015 CMCS Information Bulletin)
- We strongly endorse the recommendation that NYS seek a waiver which will allow Medicaid to cover some eligible housing costs. We so however feel this policy position could be strengthened by specifically attaching waiver or other housing dollars to expansion of the current (limited) Steps To End Homelessness Program (STEHP) which is being administered through NYS OTDA.		 The recommendation will not be changed. If a member is housed through STEHP, their housing and housing-related services would be covered under the existing recommendation.
In reference to Recommendation #16 (Leverage Medicaid Reform Team (MRT) housing workgroup money to advance a VBP-focused action plan) - The State is already using the limited MRT housing funds to leverage multiple areas and align with city and state initiatives and priorities. A very small portion of these funds is devoted to the growing need for affordable housing and services for the elderly, many of whom are at risk for reliance on high-cost Medicaid services. Any further diminution of these funds will undermine efforts to address the housing needs of these individuals. This recommendation will not be changed. The SC will submit this recommendation to the MRT housing workgroup to suggest aligning its work with VBP. The SC does not want to make specific recommendations instructing the MRT housing workgroup how to use the funds.
3. SDH Recommendations for the VBP Workgroup (Reference "SDH and CBO Subcommittee Meeting 5" PDF, slides 5-12)
  1. Revisions to Existing Recommendations and New Recommendations
    The SC reviewed both the revised and new recommendations, which include Recommendations 1, 2, 3,7,13 and 14. The SC´s comments for each are outlined below. For more detailed information on the revised and/or new recommendations, please refer to the NYS VBP SDH CBO Draft Recommendations document that was distributed to all SC members prior to the meeting. The recommendation numbers below match the order in which they are listed in the draft recommendations document.

Revised Recommendation 1: Implement Interventions on a Minimum of One SDH

Revision: The information on how to determine the SD to be addressed was removed from the recommendation description and has been developed into a new and separate recommendation (New Recommendation #2 below).

  • The SC agreed with this revision, and also discussed if language should be added to suggest that the providers/provider networks should work with CBOs to implement the intervention. The SC further discussed creating a new recommendation (or embedding the following suggestion in an existing recommendation): the State should create a task force to research the measurements being used by different provider networks to evaluate what SDH should be addressed. The goal of the task force would be to eventually create standard measures for determining what SDH impact members most.
  • No decision on this was made during the meeting, but a workgroup of SC members will convene to further discuss this topic. The outcome of the meeting will be brought to the next SC meeting on December 16, 2015.

New Recommendation 2: Member and Community Goals

The SD(s) chosen to be addressed by providers/provider networks should be based on the results of an assessment of individual members, their health goals and the impact of SDs on their health outcomes, as well as an assessment of community needs and resources.
VBP Level 1 Providers: Guideline
VBP Level 2&3 Providers/Provider Networks: Standard

The recommendation was created partly from the language that was removed from Recommendation #1 (above) and also because the SC wanted to include the members´ and community´s goals in the selection process for the SD(s) to address.

  • Members of the SC are going to convene to discuss this recommendation further, as they agreed that the word "assessment" (when talking about member and community goals) may be confusing. The outcome of this smaller SC workgroup will be brought to the next SC meeting on December 16, 2015.

Revised Recommendation 3: Invest in Ameliorating an SDH at the Community Level

Revision: Language added to encourage VBP contractors to use the flexibility of the recommendation to determine the best approach for improving an SDH, which may be to collaborate with CBOs.

  • The SC agreed with this revision and made no further comments.

New Recommendation 7: Form a Task Force of Experts Focused on Children and Adolescents in VBP

Form a taskforce of experts specifically focused on children and adolescents in the context of VBP. This process should be initiated by the State in an inclusive manner.
The State: Advisory Guidance

  • The SC agreed with the new recommendation and made no further comments.

New Recommendation 13: Coordinate with Continuum of Care (COC) entities, where they exist, when considering investments to expand housing resources

Providers/provider networks and MCOs should coordinate with Continuum of Care (COC) entities, where they exist, when considering investments to expand housing resources. This could ensure that resources are aligned with documented community needs and priorities, and coordinated with other resources and the many stakeholders seeking to serve this at-risk population.
VBP Level 1 Providers: Guideline
VBP Level 2&3 Providers/Provider Networks: Guideline MCOs: Guideline

  • The SC agreed with the new recommendation and made no further comments.

New Recommendation 14: Update the NY/NY Agreements to give priority to homeless persons who meet HARP eligibility criteria without regard for specific diagnoses or other criteria

New York City, the State, and other involved localities should update the NY/NY Agreements to give priority to homeless persons who meet HARP eligibility criteria without regard for specific diagnoses or other criteria. For units that do not include HUD capital or operating dollars, the definition of "homeless" should be modified to include persons who are presently in institutional or confined settings so they are considered for housing before discharge.
The State, New York City, and other involved localities: Advisory Guidance

  • The SC agreed with the new recommendation. The members further discussed that the State should own a state-wide data system to advise payors, providers, and plans how to process and record acuity levels of members that include information on the SDH that affect them. One consideration was to create a State task force to determine how this can be done. The issues and potential barriers mentioned are the cost and the lack of accurate data. Currently, there is no standardized way to collect SDH data other than the new ICD-10 Z codes. The SC agreed to form a smaller workgroup of SC members to revisit this topic and determine if a new recommendation should be created. The outcome of the workgroup meeting will be provided to the SC during the next meeting on December 16, 2015.
4. CBOs in VBP (Reference "SDH and CBO Subcommittee Meeting 5" PDF, slides 31-40)
  1. Cultural Competence
    The Roadmap mentions cultural competence, but does not provide a working definition. The SC discussed what it means to be culturally competent and several members offered definitions used by their organizations. Many members of the SC felt that it is necessary for VBP contractors to have a standard definition cultural competence, but was unable to decide if the SC should create the definition, or if they should create a recommendation for the State to take on this responsibility. Along with a definition, the recommendation may include how cultural competence of an organization or provider/provider network can be assessed. Ultimately, it was decided that a smaller group of SC members will convene by phone in the upcoming weeks to discuss cultural competence and determine if a related recommendation is necessary. The outcome of this Cultural Competence Workgroup meeting will be brought to the SC meeting on December 16, 2015.
  2. Formation of New CBO Entities
    During the last SC meeting there was discussion around the possibility of CBOs coming together to form legal entities to support their VBP efforts. Additional research was needed to determine if this would be advisable for CBOs, specifically the formation of an Individual Practice Association (IPA). As a follow up from last meeting, the feedback received from several sources was presented to the SC. While CBOs may be able to form an IPA or other entity, there are concerns and barriers to consider including anti-trust issues, risk of significant financial loss, and difficulty with entering into a stop-loss insurance plan. After discussing the risks associated with CBOs forming IPAs and/or other entities, the SC agreed that a recommendation related to this would not be created. However, as the information above is not legal guidance, all interested entities should consult an attorney.
  3. Draft CBO Recommendations
    The SC reviewed the new CBO draft recommendations and made comments as outlined below. For more detailed information on the new draft recommendations, please refer to the NYS VBP CBO Draft Recommendations document that was distributed to all SC members prior to the meeting. The recommendation numbers below match the order in which they are listed in the draft recommendations document. Please note that Recommendations 2 and 4 are not listed below, as the SC members accepted those drafted recommendations without further comment. The SC agreed that all draft recommendations should be reworded where possible to include how the providers/provider networks and MCOs will benefit as a result of meeting the recommendation(s).

New Recommendation 1: Develop Educational Materials

The State or a third party should develop educational materials on VBP that focuses on both CBO´s part in the system and guidance on the value proposition CBOs should expect to provide when contracting with providers/provider networks.

  • The SC agreed with the new recommendation, but decided that education and technical assistance on how to effectively work with CBOs for non-CBO VBP contracting entities should also be included. Providers/provider networks and MCOs need to be made aware of and educated on the services and value that CBOs offer.

New Recommendation 3: Electronically Link Member SDH Information to Appropriate CBO

The State should create a workgroup to determine the possibility of, or options for, developing a user- friendly system for providers to link members´ SDH(s) to the appropriate CBO(s). The providers/provider networks will be responsible for implementing the system within their networks.

  • The SC agreed that the word "electronically" should be removed from the recommendation, and a phrase to indicate that the system linking the providers/provider networks and CBOs should enhance bidirectional communication. The CBOs´ knowledge should be leveraged to assist providers on data collection to ensure the providers are collecting the correct and relevant information.

New Recommendation 5: Assist with PAM Tool Use and Data Collection

Providers should assist CBOs with implementation and data collection of the Patient Activation Measure (PAM) tool.

  • The SC rejected this recommendation and will not submit it to the VBP Workgroup.

New Recommendation 6: Integrate CBO Case Managers

The State should require integration of CBO Case Managers in the acute care setting.

  • A member of the SC volunteered to provide more supporting information for this recommendation. Upon receipt of the additional material, the recommendation will be revised and communicated to the SC.

New Recommendation 7: Contract with CBOs in a Meaningful Way

Every VBP contracting entity (e.g. providers, provider networks) will contract and engage with a minimum of one CBO in a way that the CBO considers meaningful.

  • The SC agreed to add "sharing data, especially in risk-based agreements" to the recommendation as an example of "meaningful".

New Recommendation 8: CBO Representation on the Board of Every VBP Contracting Entity

The State should require that a CBO representative be on the board of every VBP contracting entity to ensure community needs are properly considered.

  • The SC rejected this recommendation and will not submit it to the VBP Workgroup. The members agreed that it is too prescriptive and does not apply to everyone, as not every VBP contracting entity will have a new board.
Materials that were distributed prior to the meeting:
# Document Description
1 SDH and CBO Meeting 5 A PDF presentation of the PowerPoint slide deck created for Meeting #5, which includes the draft SDH recommendations, information on the NYS Prevention Agenda, topics and draft recommendations related to CBOs in VBP.
2 NYS VBP SDH CBO Draft Recommendations A narrative detailing the draft recommendations for addressing SDH.
3 NYS VBP Draft CBO Recommendations A narrative detailing the draft recommendations for integrating CBOs in the context of VBP.
4 Housing Status An article titled "Housing Status, Medical Care, and Health Outcomes Among People Living with HIV/AIDs: A Systematic Review" that was distributed for informational purposes.

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

  • An email was sent out on 11/23/15 to all SC members asking for volunteers to participate in the smaller workgroups to revise and/or formulate additional SDH & CBO recommendations. The email outlines the workgroup tasks and informs of dates and times of the workgroup meetings. Please make every effort to attend the meetings if you volunteered to participate.

Key Decisions

  1. SDH Recommendations for the VBP Workgroup
    • Revised Recommendation 1: Implement interventions on a minimum of one SDH: The SC agreed to remove the guidance on the SD selection process and create a separate recommendation (new recommendation 2). A workgroup of SC members will convene to further discuss the topic and possibly produce another recommendation for CBO involvement in the intervention implementation and a task force to assess the SDH measurement. The outcome of the workgroup meeting will be brought to the next SC meeting on December 16, 2015.
    • New Recommendation 2: Member and Community Goals: Members of the SC are going to convene to discuss this recommendation further, as consensus was that the word "assessment" (when talking about member and community goals) may be confusing. The outcome of this smaller SC workgroup will be brought to the next SC meeting on December 16, 2015.
    • New Recommendation 7: Form a Task Force of Experts Focused on Children and Adolescents in VBP: The SC agreed with the new recommendation and made no further comments.
    • New Recommendation 13: Coordinate with Continuum of Care (COC) entities, where they exist, when considering investments to expand housing resources: The SC agreed with the new recommendation and made no further comments.
    • New Recommendation 14: Update the NY/NY Agreements to give priority to homeless persons who meet HARP eligibility criteria without regard for specific diagnoses or other criteria: The SC agreed to this new recommendation, but will form a smaller workgroup of SC members to determine if a new recommendation should be created for a State task force to determine how to process and record acuity levels of members that includes information on the SDH that affect them. The outcome of the workgroup meeting will be provided to the SC during the next meeting on December 16, 2015.
  2. 2. CBOs in VBP
    • Cultural Competence: A smaller group of SC members will convene by phone in the upcoming weeks to discuss cultural competence and determine if a related recommendation is necessary. The outcome of this Cultural Competence Workgroup meeting will be brought to the SC meeting on December 16, 2015.
    • New Recommendation 1: Develop Educational Materials: The SC agreed with the new recommendation, but decided that education and technical assistance on how to effectively work with CBOs for non-CBO VBP contracting entities should also be included.
    • New Recommendation 2: Develop a CBO "Stress Test": The SC agreed with the new recommendation and made no further comments.
    • New Recommendation 3: Electronically Link Member SDH Information to Appropriate CBO: The SC agreed that the word "electronically" should be removed from the recommendation, and a phrase to indicate that the linking (and communication between provider and CBO) should be bi-directional needs to be included. The CBOs´ knowledge should be leveraged to assist providers on data collection to ensure the providers are collecting the correct and relevant information.
    • New Recommendation 4: Create a "Design and Consultation Team": The SC agreed with the new recommendation and made no further comments.
    • New Recommendation 5: Assist with PAM Tool Use and Data Collection: The SC rejected this recommendation and will not submit it to the VBP Workgroup.
    • New Recommendation 6: Integrate CBO Case Managers: A member of the SC volunteered to provide more supporting information for this recommendation. Upon receipt of the additional material, the recommendation will be revised and communicated to the SC for review.
    • New Recommendation 7: Contract with CBOs in a Meaningful Way: The SC agreed to add "sharing data, especially in risk-based agreements" to the recommendation as an example of "meaningful".
    • New Recommendation 8: CBO Representation on the Board of Every VBP Contracting Entity: The SC rejected this recommendation and will not submit it to the VBP Workgroup.

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 respond to the email sent by Josh McCabe on 11/23/2015 detailing the workgroups if you are interested in participating in reworking and/or creating recommendations as mentioned in the summary above.

Conclusion

The upcoming meeting on 12/16/2015 will include discussion on the final SDH & CBO recommendations to be submitted to the VBP Workgroup.