Slide 1: One Care Care Model Focus Initiative (CMFI)
One Care Implementation Council
December 2022 Status Update Meeting – CMFI

December 13, 2022

Note: The MassHealth logo is in the upper right corner of this slide. The logo includes an image of the state of Massachusetts, with the word MassHealth in front of the state map, from west to east.
Slide 2: Contents
•	Introduction
•	Key Performance Indicators (KPIs)
•	LTSS Denial Escalations Process
•	IC Recruitment and Procurement 
•	Member Communications
•	Additional CMFI Workstreams
o	Contract Amendments
o	Care Coordinator Shared Learning
o	LTS-C Convening 
•	Closing
Slide 3: CMFI Workstreams
There are now 7 workstreams in progress to advance the work from CFMI.

Note: the following topics are grouped below Workstreams and are shown in boxes.

Workstreams
•	Key Performance Indicators
•	IC Recruitment and Procurement 
•	Contract Amendments
•	LTSS Denial Process and Oversight Enhancements
•	Member Communications
•	Care Coordinator Shared Learning 
•	LTS-C Role

Slide 4: Key Performance Indicators (KPIs)
CMFI discussions determined the criticality of improving One Care and health plan performance reporting using KPIs. MassHealth has used currently available data to develope initial, baselining KPI reports for One Care.

Objectives
•	Develop and produce a slate of Key Performance Indicators that provide insight into the overall health of the One Care Care Model, to be refreshed on a quarterly basis

Scope
•	Focus on data accessible today – either gathered already, or obtained with relative ease
•	Focus KPIs on supporting CMFI domains
•	Include breakdowns by rating category and plan where sensible and feasible

CMFI Deliverable
•	KPI report showing data from July-September 2022
Slide 5: Key Performance Indicators (KPIs)

The initial KPI report will be refined over the remainder of CY22 and refreshed in CY23.

Key Accomplishments
•	Confirmed method of capturing and presenting KPIs
o	Worked with Member Experience and Engagement unit and My Ombudsman to develop template for member complaints and escalations data
o	Surveyed One Care plans for data not captured elsewhere
•	Conducted initial quality control, went back to plans as needed to clarify or update certain data points
•	Modified as needed to mask PII/PHI 
•	Identified areas of improvement for future reporting
o	Example: Plans use slightly different bucket areas for authorizations/denials and appeals & grievances data – opportunity for MassHealth to develop aligned categorization

Upcoming Activities
•	MassHealth validation
o	Final clean-up and quality assurance
o	Determine any low-lift improvement efforts to enhance data quality for next refresh
•	Plan preview
o	Plans will have the opportunity to review their own data for accuracy, and to flag any methodological or contextual concerns 
•	Implementation Council subset: data group preview
o	MassHealth will be asking the One Care Implementation Council to identify a subset of members to engage in a data preview

Slide 6: Key Performance Indicators

•	Enrollment
o	Continuing and New Enrollment
o	Overall Enrollment by Plan and Rating Category
o	One Care Members, Passive Enrollment vs. Self-Selection

•	Disenrollment
o	One Care Total Disenrollments, Voluntary vs. Involuntary
o	Quarterly Disenrollment by Plan, Disenrollment Type, and Reason
o	Quarterly Disenrollment Summary by Plan, Disenrollment Type, and Reason
o	% of Average Members that Voluntarily Disenrolled by Rating Category and Month

•	Assessment Completion
o	90 Day Comprehensive Assessment Rate

•	Individual Care Plans
o	Ratio of Enrollees with an ICP

•	Member Experience
o	Summary of Complaints and Inquiries by Month, Plan
o	Complaints and Inquiries Detail by Call Reason/Subject Matter

•	Appeals and Grievances
o	Grievances Per 1,000 Members by Category and Month
o	Appeals by Category and Month
o	Appeals by Decision and Month

•	Care Coordinator Staffing
o	Care Coordinator FTEs, Filled and Vacant, by Month and Plan
o	Care Coordinator to Enrollee Ratio, by Month and Plan

•	Service Authorizations and Denials
o	One Care Authorizations and Denials by Decision and Month
o	Authorizations and Denials by Plan and Month
o	Denials Per 1,000 Members by Category and Plan
Slide 7: IC Discussion of KPIs
No content on this slide.
Slide 8: LTSS Service Denial Process Enhancement and Oversight

CMFI determined LTSS request evaluation must be refined to ensure person-centeredness in considering services critical to, or supportive of, independent living, while also recognizing the need to make sure resources are appropriately deployed.

Objectives
•	Require communication between Care Coordination and Evaluation functions of the health plan
•	Require evidence that Care Plan is updated, member is informed, and independent living goals are considered

Scope
•	Develop a reconciliation process codifying steps for health plans to follow when considering service request denials and communicating reasoning to Care Coordinators/Enrollees
•	Analyze process changes and resources required to ensure service denial reconciliation can be effectively supported
•	Identify steps required to strengthen contract language
•	Increase transparency in evaluation processes for LTSS and flexible services

CMFI Deliverable
•	An implementation workplan to codify reconciliation process, put it into practice, and incorporate it into future versions of the One Care contract
Slide 9: LTSS Service Denial Workstream – Key Features
All aspects of the LTSS Denial Proposal flow from the concepts below. Discussions and negotiations about how these concepts are achieved will be the basis for ongoing work with health plans on implementation of the LTSS Denial Proposal.

KEY CONCEPTS FOR LTSS DENIAL WORKSTREAM

•	Person-centered care is the foundation of One Care and requires that services to support independent living be considered/evaluated in relation to the Enrollee’s ICP.
•	LTSS decisions must support Enrollees in functioning independently and successfully in the home and community. This includes the ability of the member to live in the least restrictive setting preferred by the member. 
•	Care Coordinators (both health plan-employed and contracted) play a central role as conduits for communicating Enrollee needs and preferences within health plans and must be aware and engaged in LTSS service authorization considerations and decisions. Care Coordinators can bring the Enrollee, LTSS-Cs, providers, and other care team member perspectives into the authorization process as needed to help ensure UM and prior authorization processes fully consider the ICP.
•	Rationales (bases) for decisions must be transparent and evidence based.
•	UM and PA functions are essential for proper management of resources. These units can offer valuable information to Care Coordinators (and by extension, to Enrollees, providers and Care Teams) about how decisions are made and how to best present requests for services and the rationales (bases) for UM/PA decisions.
•	Enrollees and entities assisting the Enrollee in addressing UM and PA decisions must be able to see and use the updated care plan, the request documentation, and  decision documentation to understand the health plan action and challenge it, if it is their decision to do so.
•	Both Care Coordinators and UM/PA staff should have access to information about how services are used and contribute to independence and quality of life for consumers by those with direct experience providing services to them.
•	LTSS denials that are based on considerations other than the service merits of the request (administrative denials) must be minimized using all practical methods available.
Slide 10: LTSS Service Denials
The LTSS Service Denials Proposal will update existing LTSS denial processes to increase transparency and oversight, fully engage Care Coordinators, ensure Care Plan consultation, and increase confidence in the appropriateness of service decisions.

Key Accomplishments
•	Aligned with health plans on supportive contract amendment language
•	Developed LTSS Denial Summary Form to facilitate review of escalated LTSS denials and support LTSS denial audits
o	Designed process around LTSS Denial Summary Form to ensure request for submission, submission, and data storage are streamlined
o	Process requires submission of Care Plan for review
o	Process requires engagement of Care Coordinator and interaction with UM/PA functions

Upcoming Activities
•	Pilot LTSS Denial Summary Form for LTSS denial escalations via MassHealth (including My Ombudsman referrals)
o	Pilot launch target December 13, 2022
•	Refine LTSS denial audit proposal and review with health plans; plan implementation of LTSS denials audit process
•	Collect feedback on use of Summary Form Process
o	Explore data collection utilities (e.g., administrative denials, type of services, patterns)
o	Make workflow and form adjustments as needed
•	Determine next steps in how to leverage new process tools for improving transparency and access to services

Slide 11: Discussion of LTSS Denials Escalation Process
No content on this slide
Slide 12: Implementation Council Recruitment and Procurement

CMFI determined that promotion of health equity in One Care is largely contingent on diversity within the Implementation Council; MassHealth will promote Implementation Council diversity by stimulating recruitment and refining the procurement process to make it easier for interested persons to apply.
Objectives
•	Improve diversity of Implementation Council through effective, widespread recruiting
•	Collaborate with Legal to formulate “recurring” procurement structure and encourage diverse responses 

Scope
•	Identify and prioritize mechanisms to be applied toward Implementation Council recruitment
•	Refresh Implementation Council website to more effectively communicate IC mission, role, and importance to individuals eligible to serve on the Implementation Council 
•	Create new materials to promote the Implementation Council
•	Identify methods to simplify the application process
•	Propose a way forward to optimize procurement to increase Implementation Council diversity

CMFI Deliverable
•	A tactical work plan with steps to ensure robust IC recruitment and roadmap for CY23 procurement

Slide 13: Implementation Council Recruitment and Procurement
MassHealth will prioritize recruitment to generate authentic Implementation Council interest prior to re-procurement in CY23.

Key Accomplishments
•	Drafted Implementation Council mission statement
•	Drafted and reviewed Recruitment Flyer with Implementation Council; refined flyer with MassHealth Publications Team
•	Drafted supporting ‘one-pager’ Recruitment Flyer and aligned Implementation Council webpage with one-pager for consistency
•	Collect individual and executive bios of the members already with the Implementation Council for addition to website
•	Discussed ways to make the application process more member-friendly with MassHealth Legal

Upcoming Activities
•	Submit Recruitment Flyer to MassHealth for final review
•	Establish Implementation Council social media presence
•	Determine revisions required to streamline procurement process; develop tactical plan to refine procurement process
•	Perform procurement in early CY23
Slide 14: Implementation Council Recruitment
MassHealth will promote Implementation Council recruitment through multiple mechanisms, but the Implementation Council webpage will remain the primary source of information about the procurement.

Note: the following information is shown as a graphic with each item in an oval. The IC Webpage item is in the center with the other items surrounding it, with lines connecting each item to the IC Webpage item in the center.

IC Webpage
Home page for IC recruitment, with information about the IC, current members, and how to get involved

Recruitment Flyer
Educational pamphlet providing information about eligibility and describing the impact one can have on One Care by joining the IC

One Pager
Hand-out with detailed information about the IC; mirrors the IC webpage in organization and content

Social Media
An IC presence providing information through media heavily utilized by Millennial and Gen Z One Care    members

Additional Webpages
More in-depth information around the IC and links to other One Care webpages
Slide 15: Discussion of IC Recruitment and Procurement
No content on this slide
Slide 16: Member Communications
Addressing CMFI-identified challenges in Member Communications will require improving understandability and usability of Enrollee-facing materials and One Care program descriptions for potential Enrollees.

Objectives
•	Improve navigability and practicality of Enrollee-facing materials; ensure content is up to date, not duplicative, and easily understandable
•	Increase emphasis on Enrollee empowerment in communications

Scope
•	Clarify roles and terminology used in One Care (specifically programs, services, and role titles/responsibilities)
•	Develop frequently asked questions (FAQ) for Enrollees to address One Care assessments and care plan development; service coordination; care team roles, responsibilities, and points of contact (e.g., Member Support Call Center); appeals and grievances
•	Simplify and rationalize One Care website to allow Enrollees and potential members to locate information and identify how key services are made available in One Care
•	Review new or revised Enrollee-facing materials with MassHealth Integrated Care Team (ICT) and Implementation Council

CMFI Deliverable
•	A tactical work plan with steps to ensure potential and current One Care Enrollees have a practical, easily accessible series of materials and references to understand what the program is, how it works, and what to expect from it
Slide 17: Member Communications
The Member Communications work group will focus on standardizing language and graphics while increasing communications accessibility.

Key Accomplishments
•	Determined work group members, roles, and bandwidth; held work group kickoff on 11/9
•	Identified language to be standardized between MassHealth and plans
•	Consolidated repositories of non-digital communications to streamline prioritization
•	Prioritized revisions to webpages and non-digital communications based on complexity and impact

Upcoming Activities
•	Engage supplementary team members from MassHealth Publications Unit, MassHealth Communications Team, and My Ombudsman to provide specific expertise on member communications
•	Begin redesign, development, and implementation of priority webpages and non-digital communications
•	Develop VLOG to be added to One Care website
Slide 18: Discussion of Communications Workstream
No content on this slide
Slide 19: Contract Amendments
CMFI led to certain proposed amendments to One Care contracts to clarify and strengthen Care Model execution, reinforce person-centered concepts, and further solidify member protections.

Objectives
•	Align around new contract language
•	Develop One Care contract amendments to improve capacity to reinforce the Care Model

Scope
•	Consolidate RFR and CMFI draft amendment language
•	Review amendment language with MassHealth Legal and leadership
•	Submit amendment language to CMS
•	Engage with CMS for review/discussion/approval
•	Receive health plan final review/discussion/approval

CMFI Deliverable
•	Packaged contract amendments for internal review with MassHealth and submission to CMS

Slide 20: CMFI Proposed Three-way Contract Language

•	CMFI Core Team recommended changes to the Three-way Contract (“Contract”) between One Care plans, MassHealth, and the Centers for Medicare & Medicaid Services (CMS) to support and clarify expectations around person-centered care and care coordination.
•	In some cases, CMFI recommendations complement and enhance previously contemplated Contract updates, including from the 2019 RFR for One Care Plans, and subsequent recommendations from Implementation Council members.
•	Based on these recommendations, MassHealth expects to propose updates to the Contract in the following sections:
o	Section 1 – Definitions of terms 
•	Flexible Benefits
•	Person-centered Care and Planning
o	Section 2.5.4 Care Coordination
o	Section 2.5.5 Long-Term Services and Supports 
o	Section 2.6.3 Individualized Care Plan
•	MassHealth aims to submit CMFI-related amendment language to CMS by the end of calendar year 2022; the next Contract amendment would likely be effective in mid-2023.
Slide 21: Definition of Terms – CMFI Recommendations
•	Defining Flexible Benefits and Person-Centered Care and Planning provides MassHealth, CMS, One Care plans, and One Care Plan Enrollees with a baseline understanding of the following:
o	How MassHealth and CMS define Flexible Benefits beyond the scope of covered services that are outlined in Appendix B, Exhibit 1, Exhibit 2, and Exhibit 3 of the Three-way Contract, 
o	Provides a framework for plans to utilize capitation dollars to cover Flexible Benefits, and 
o	Brings Flexible Benefits into scope when doing person-centered care planning to address independent living, recovery, community connections, social determinants of health and health equity.
Slide 22: Proposed In-Person Visit Requirement for the Care Coordinator
Proposed amendment language establishes circumstances under which Care Coordinators are responsible for conducting home visits/in-person interactions with Enrollees.

•	Identifies key criteria for One Care plans when determining when Enrollees should have an in-person visit.
•	Provides additional guidance for One Care plans when Enrollees who identify that in-person visits are not their preferred method of interacting with their Care Coordinator.
Slide 23: Long-Term Services and Supports (LTSS)
•	Creates additional processes in Utilization Management workflows when reviewing LTSS Service Authorization requests:
o	One Care Plans must evaluate LTSS services Enrollee received during the continuity of care period and identify whether reducing the amount, duration, or scope of a service would diminish the Enrollee’s ability to live independently in the community
o	One Care Plans may not deny or modify a service authorization request for LTSS services until it has been confirmed that an active ICP is in place
o	Require Plans to implement processes for internally escalating LTSS denials prior their issuance and to address escalations of these denials by providing an LTSS Denial Form
Slide 24: Care Coordinator Shared Learning
CMFI determined that addressing challenges in the Care Coordinator role will require promoting effective, accountable, person-centered relationships between Care Coordinators and Enrollees; encouraging ICT  representation within the health plan; and ensuring Care Coordinators effectively “navigate” on Enrollees’ behalf.

Objectives
•	Establish principles guiding Care Coordinators in executing their roles; connect principles with expected outcomes to drive a goal-oriented approach to the Care Coordinator role
•	Develop options to drive person-centeredness in executing the Care Coordinator role

Scope
•	Align on and develop principles to which Care Coordinators can refer to successfully execute their roles
•	Brainstorm potential materials, programs, and/or exercises to standardize elements of Care Coordinator training across health plans
•	Explore and document best practices for Care Coordinator in relating to Enrollees, engaging with Care Teams, and navigating to advance Enrollee goals within the health plan

CMFI Deliverable
•	An agreed-upon set of principles and principle-driven outcomes to guide Care Coordinators in person-centered care, ICT leadership, and Enrollee empowerment
Slide 25: Care Coordinator Shared Learning
The Care Coordinator Shared Learning initiative will provide an opportunity to standardize and enhance  understanding in how Care Coordinators approach their role through a series of training modules, each woven together with themes from CMFI.

Key Accomplishments
•	Aligned on training topics and methods with Care Coordinator Shared Learning work group leads
o	Shared Learning initiative is planned to be broken into seven modules, each with training objectives aligned to topics identified during CMFI
•	Established Care Coordinator Shared Learning Taskforce, a multidisciplinary team comprised of health plan representatives, IC members, and UMass CWM training leads
o	Taskforce will provide input and feedback on training, but will not perform a governance/ oversight role
•	Initiated collaboration with UMass CWM to develop Module 1 and finalize design of Module 2

Upcoming Activities
•	Hold second Taskforce meeting to collate input/ recommendations on curriculum content for Module 2
•	Finalize development of Module 1 by the end of CY22; develop Module 2 in early CY23
•	Align on module training objectives for CY23; begin design of Module 3

Slide 26: Shared Learning Taskforce Overview
Purpose
The Taskforce’s purpose is to provide insight, guidance and recommendations on all aspects of the Initiative.

Goals
The goal for the Taskforce is to ensure Shared Learning modules acknowledge One Care-specific nuances of the Care Coordinator role, accurately portray real-world situations, and optimize training delivery.

Expected Outcomes
Standardized training for all One Care health plans’ Care Coordinators to support their role in providing person-centered care to One Care Enrollees.

Ensure the Shared Learning Initiative reflects the overall mission, vision and recommendations of CMFI.

Taskforce Participant	Affiliation
Henri McGill	MassHealth Integrated Care Team
Jean Carlevale	MassHealth Integrated Care Team
Lisa Fleming	Commonwealth Care Alliance
Kelli Barrieau	Commonwealth Care Alliance
Mariuca Tuxbury	Commonwealth Care Alliance
Lisa Fulchino	Tufts Health Unify
Sarah Gauss	Tufts Health Unify
Jess Colangelo 	Cityblock Health

Taskforce Participant	Affiliation
Tony Dodek	UnitedHealthcare
Cori Leech 	UnitedHealthcare
Keyla Williams	UnitedHealthcare
Lisa McGlinchy 	UMass Commonwealth Medicine
Abby Velazco	UMass Commonwealth Medicine
Jeffrey Keilson	Implementation Council
TBD	Implementation Council (consumer)
Slide 27: Taskforce Milestones

Task	Target Date	
Shared Learning Taskforce		
Module 1 Review		
Assess and provide input on objectives for proposed training modalities	November 18, 2022	
Assess and provide input on competency assessments and Needs Assessment Survey 	December 2022	
Review and provide input training content and baseline process flows reinforcing the goals of Module 1	December 2022	
Module 2 Review		
Assess and provide input on objectives (including Needs Assessment Survey) and training modalities	Winter 2023	
Assess and provide input on competency assessments	Winter 2023	
Review and provide input on training content and baseline process flows reinforcing the goals of Module 2	Winter 2023	
Alignment		
Attend December Taskforce meeting	December 13, 2022	

Slide 28: Proposed Topics of Learning Modules
Note:  The following information is shown in boxes on this slide. The first two are in blue, and the remaining are in green.

•	Best Practices in Person-Centered Engagement 
•	Best Practices as Enrollee Internal Advocate

•	Comprehensive Assessment and Care Plan Process
•	External Agency Coordinator 
•	Facilitating Care Teams 
•	Clinical Training 
•	Navigating Internally and Externally
•	Provider Network and Community-based Support 
•	Member Services and Benefits
Slide 29: LTS-Coordinator (LTS-C) Convening
CMFI identified inconsistency across One Care in understanding the LTS-C role. MassHealth will leverage UMass CWM to improve communication around role descriptions, training, and expectations of LTS-Cs.

Objectives
•	Implement a shared understanding of the LTS-C role in One Care to more consistently meet the needs of One Care members as well as care teams

Scope
•	Align on understanding of LTS-C role across Enrollees, care teams, One Care health plans, ASAPs, and ILCs
•	Provide stakeholders an opportunity to strengthen the LTS-C role for Enrollees and care teams; develop near-term, actionable recommendations for doing so
•	Plan finalized kit for state-wide implementation of revised education around LTS-C role

CMFI Deliverable
•	Establish, with UMass CWM, a statement of work with secured funding and alignment on next steps on LTS-C role, position in the ICT, training consistency, expectations, and contracting​
Slide 30: Work Group Kickoff
The kickoff covered the following topics:
•	The importance of the Independent Living Philosophy 
•	The LTS-C’s statutory role as a conflict-free member of the care team, with expertise in independent living and recovery principles
•	The work group’s charge, next steps, and a timeline for the work 
•	Work group members shared their perspectives on the LTS-C role. Here is what was shared:
o	Implementation Council member: The LTS-C was envisioned as an independent person on the care team who understands the independent living philosophy who can be there to speak to the member’s needs and support the member to engage in the care team so that the care plan and mix of services align with the person’s wellness and independent living goals. 
o	ILC representative: The role is about helping people to have positive health outcomes, to live independently in the community. 
o	ASAP representative : The role’s challenges include health plans being required to buy and building the LTS-C role, implementing One Care’s policies that give flexibility in what can be authorized, and LTS-Cs’ difficulty accessing the centralized record.  
o	One Care Plan: We have tried to standardize our approach and have a clear model to ensure that members are receiving the same level of care, no matter where in the state they live. 
o	MassHealth representative : MassHealth fully supports the LTS-C role and wants to see more utilization of by the One Care plans. There are opportunities through this forum to come together to design a standard understanding of the role.
Slide 31: Timeline and Approach
Discovery: October – March
What: Establish an evidence-based foundation supporting the way the LTS-C role is currently understood, explained, and functions across Enrollees, care teams/One Care Plans, ASAPs, and ILCs.

How: UMass Chan will collect trainings, policies and procedures, and any other materials CBOs and the health plans have on the LTS-C role. UMass Chan will conduct interviews to obtain perspectives and clarify questions on information received from work group members. 

Work Group Convenings & Recommendations: 
March – June

What: Consider options for strengthening the LTS-C role for Enrollees and care teams, concluding with near-term and actionable implementation recommendations.

How: UMass Chan will share Discovery findings at a work group meeting in March. Work group members will then meet regularly to work on their recommendations based off findings from Discovery. 
Slide 32: CMFI Workstream Liaison List
The following liaisons are the points of contact for the ongoing CMFI efforts.

Workstream	Point of Contact1	Point of Contact Email	
Key Performance Indicators (KPIs)	Elise Emerson	elise.emerson@state.ma.us	
LTSS Denials Escalation Process	Robin Callahan
Henri McGill	robin.callahan2@mass.gov
henri.m.mcgill@mass.gov	
Implementation Council Recruitment and Procurement	Daniel Cohen
Robin Callahan
Hilary Deignan
Henri McGill	daniel.cohen@mass.gov
robin.callahan2@mass.gov
hilary.deignan@umassmed.edu
henri.m.mcgill@mass.gov	
Member Communications	Daniel Cohen	daniel.cohen@mass.gov	
Contract Amendments	Corri Altman Moore
Henri McGill	corrinne.altmanmoore@mass.gov
henri.m.mcgill@mass.gov	
Care Coordinator Shared Learning	Henri McGill
Jean Carlevale	henri.m.mcgill@mass.gov
jean.carlevale@state.ma.us	

1 Points of contact are current as of: 11/18/2022
Slide 33: Deloitte.
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