Slide 1: One Care- Care Model Focus Initiative (CMFI)

CMFI for One Care: Implementation Council Meeting
July 12, 2022
Slide 2: Contents
Purpose of CMFI: 3
Core Team Members: 4
CMFI Goals: 6
Process: 7
Solution Prioritization: 10
Key Performance Indicators (KPIs): 11
Next Steps: 12
Appendix: 13
Slide 3: CMFI Purpose
CMFI is a time-limited opportunity to focus on the Care Model that is the foundation of One Care.

Note: the following is shown as three separate items on this slide with a graphic above each one.

Graphic: the earth
MassHealth was at an important inflection point with the One Care program. MassHealth aims to redouble efforts to ensure the One Care model works as intended at present and in the future.

Graphic: a rocket ship
The purpose of the CMFI is to identify and take the action steps that will result in greater alignment, clearer expectations, and increased focus on the Care Model domains.

Graphic: footsteps
CMFI Core Team was formed by bringing together MassHealth, health plans, Implementation Council, MyOmbudsman, CMS, UMass CWM, and procurement for others interested in providing their experience, expertise, and commitment.
Slide 4: CMFI Core Team
Note: the following information is shown in two columns with the last five people grouped under procurement.

MH Integrated Care Team
•	Corri Altman-Moore
•	Henri McGill
Health Plans
•	CCA – Lisa Fleming
•	Tufts – Lisa Fulchino
•	UHC – Dr. Anton Dodek 
Member Engagement and Experience 
•	Roseanne Mitrano
MH OLTSS
•	Dr. Charles Pu
CMS
•	Anna Williams
UMass CWM
•	Hilary Deignan

MH Project Coordinator 
•	Robin Callahan

Implementation Council
•	Dennis Heaphy
•	Jeffrey Keilson
•	Crystal Evans
•	Sara Willig

MyOmbudsman
•	Leslie Diaz

Note:  the people below are from the CMFI Procurement 
Center for Living & Working, Inc.
•	Tania Colon
Boston Center for Independent Living
•	William Henning
Greater Boston Legal Services
•	Nancy Lorenz
•	Dr. Robert Master
Vinfen
•	Kim Shellenberger
Slide 5: CMFI Domains
The CMFI looked at the current-state of One Care’s Care Model across nine domains. 

Note: the following information is shown as three separate groupings with a graphic beside each item.

•	Person-Centered Care
•	Care Team Roles and Composition
•	Assessment Process/Timing
•	Individualized Care Plans (ICTs)
•	Care Coordination (including LTSS and BH)
•	Member Experience and Satisfaction
•	Member Protections
•	Communications To and From Members
•	Health Equity

Care Model Key Performance Indicators (KPIs)
KPIs will be developed to gauge how well the Care Model is performing
Slide 6: CMFI Process
Examination
•	Gather Care Team input about what is working or not in delivering on the Care Model
Goals
•	Promote shared understanding, definitions, and expectations of Care Model concepts
•	Increase trust in the program to serve complex care needs of persons with disabilities effectively through the principles inherent in the Care Model
•	Confirm health plan, provider, and Enrollee roles and responsibilities in the Care Model
•	Identify challenges faced by Enrollees, health plans, and other key partners in implementation of the Care Model and develop strategies for resolution
•	Create action plans for priority activities needed to improve execution on the Care Model
•	Identify key metrics for gauging the effectiveness of the One Care program in executing on Care Model requirements	
Outcome
•	Develop detailed project plan and track action steps
Slide 7: CMFI Process
The CMFI was divided into three phases: Current State Analysis, Prioritization and Planning, and Execution. 

1.	Current State Analysis
•	Evaluate the performance of One Care’s Care Model across the nine identified domains to identify challenges and opportunities
2.	Prioritization and Planning
•	Review findings from Core Team discussions to determine priorities for improving execution of the Care Model
3.	Execution
•	Establish subgroups to address highest priority challenges and develop recommendations, proposals and workplans
Slide 8: CMFI Current-State Analysis
The CMFI used different methods to explore each domain and identify issues.
CMFI Activities To Assess Current-State

Pre-Meetings
Held multiple pre-meetings with One Care subject matter experts
Core Team Meetings
Conducted bi-weekly Core Team meetings to gather input on current-state and existing challenges
Survey Responses
Developed six survey questions and received 13 unique responses to gather CMFI Core Team member perspectives on the current-state of One Care’s Care Model
Document Reviews
Reviewed the One Care contract; Implementation Council Town Hall and other IC meeting documents; CMFI notes; member satisfaction survey data; and other One Care data 
Presentations
Held five presentations to the Core Team including:
•	Person-Centered Care 
•	LTSS Coordinator
•	Member Experience Survey
•	Member Communication 
•	Health Equity 
Slide 9: Challenges Identified
Six challenges consistently arose as areas needing increased focus in the Care Model.
Care Coordinator
Considerations include training, caseloads, and increasing clarity about Care Coordinator roles/ responsibilities.
LTSS Service Denials
Service denials may not be consistent with the person-centered care plan. The reasons for denials are not always clear to Enrollees, and notices language is complex. The relationship between ICPs and health plan evaluation functions needs alignment.
Member Communications
The One Care program is not clearly explained to members, so they can understand what to expect. Members need better information about roles and terminologies, coordination of services, processes, and requests. Potential Enrollees need clearer information to make informed choice.
LTSS Coordinator
Roles and responsibilities of the LTSS-C need to be clarified and better integrated into Care Teams, as LTSS Coordinators significantly contribute an Enrollee’s ability to live independently.
Contracted Provider Participation
Certain contracted providers are not currently reimbursed to participate in planning as part of the Integrated Care Team (ICT). There needs to be better participation of contracted providers in the care planning of Enrollees.
Health Equity
Current disparities in health equity are experienced by One Care Enrollees based on disability and other marginalizing factors. There is a need to take additional steps to increase the health equity lens of the One Care program. 
Slide 10: Solution Prioritization
Following the Current-State Analysis, the CMFI prioritized six topics for additional focus. 

Note: this slide uses color to group things, the items for each group are listed below each statement.

The CMFI will develop specific solution approaches to topics bordered in RED; solutions will be addressed via comprehensive deliverables/work plans/documents – these items have been assessed to be significant areas of concern in the program
Note: items bordered in red are:
•	Care Coordinator
•	LTSS Service Denials
•	Member Communications

The CMFI will develop recommended next steps to address topics bordered in ORANGE; these items need specific interventions and ongoing attention
Note: items bordered in orange are:
•	LTSS-Coordinator
•	Contracted Provider Participation
•	Health Equity

The CMFI will develop performance indicators to evaluate Care Model domains
Note: the item for this point is:
Key Performance Indicators

***Please see the appendix of this deck for more information about the CMFI deliverables, progress to date, and next steps for each of these priority items.***

Slide 11: Key Performance Indicators – Starter Elements
Leveraging Data Elements, We Have Access to Today
Overall Enrollment1
•	Passive vs. Voluntary
Member Experience
•	MyOmbudsman trends
•	Member Experience and Engagement unit trends/Escalations
Overall Disenrollment1
•	Voluntary vs. Involuntary
•	Disenrollment Reason
Appeals and Grievances
•	Favorable vs. Unfavorable determinations
•	Grievance category / reason
Assessment Completion Rates1
•	Comprehensive < 90 days
Care Coordinator Staffing
•	Total Care Coordinator FTEs (plan and contracted)
Individual Care Plans (ICPs)1
•	Ratio of Enrollees with ICP
Service Authorizations and Denials1
•	By service category
•	Random sample audits
1 KPIs that will also be broken out by plan and rating category.
Slide 12: Next Steps
CMFI will sunset as a distinct initiative on July 21, 2022. All recommendations, proposals, workplans, and other deliverable will be handed off to MassHealth, the Implementation Council, and the health plans for future activities and decisions about adoption, implementation, monitoring, and oversight. MassHealth will pursue ongoing project management support for CMFI activities through the end of the year. 
Ongoing Activities
•	Communications Workgroup will continue led by MassHealth Integrated Care unit
•	LTSS-C working group will be convened by UMass CWM
•	Work on contracted provider ICT participation will be led by MH OLTSS CMO
•	Key Indicators Reports will be designed and provided through the Integrated Care unit
•	Integrated Care unit will work with CMS and health plans to make necessary contract amendments
•	Care Coordinator role materials should be integrated into health plan approaches, trainings, and materials
•	New processes related to LTSS service denials will be stood up by MassHealth and integrated with ongoing input by health plans and other stakeholders
•	Provide necessary support to IC for recruitment and procurement activities aimed at increasing diversity 
•	Implementation Council support, involvement, and direction will be critical to all aspects of CMFI work
Slide 13: Appendices
Appendix A: Priority Items Progress to Date 
and Next Steps

Appendix B: KPIs
Slide 14: Appendix A: Subgroup – Care Coordinator
The Care Coordinator subgroup worked to ensure Care Coordinators effectively represent Enrollees and ICPs within health plans and are effective “navigators” on behalf of Enrollees.
Progress to date
•	Project Support Team has drafted principles, responsibilities, and training priorities
•	Core Team has provided comments on principles, responsibilities, and training topics
•	Included proposal for annual home visit requirement for those receiving home-based services and those indicating preference for face-to-face communication
Next Steps
•	Incorporate Core Team feedback into final proposals for Care Coordinator principles, responsibilities, and training priorities
•	Incorporate Care Coordinator role description and expectations in member-facing materials
•	Distribute and use Care Coordinator materials within health plans to promote adoption and consistency across program
•	Determine enhancements to contract language to reinforce and clarify Care Coordinator role
Slide 15: Appendix A: Subgroup – LTSS Service Denials
An LTSS Service Denials Proposal was developed to ensure denials are evaluated through a person-centered lens while recognizing the need to ensure program resources are appropriately deployed.
Progress to date
•	Project Support Team has presented LTSS Service Denial Proposal to Core Team
•	Core Team has provided comments on proposal 
•	Project Support Team has begun work plan tasks for proposal implementation
Next Steps
•	Incorporate comments into final proposal and publish to Core Team
•	Develop work plan to codify and implement proposal
•	Incorporate proposal into contract/ regulations:
o	Establish oversight and audit processes
o	Develop joint UM-Care Coordinator training/processes
o	Submit and review newly-required health plan information
Slide 16: Appendix A: LTSS Service Denial Proposal
The LTSS Service Denial Proposal aims to enforce thorough care plan review and preemptive communication with Care Coordinators prior to health plan denial of LTSS service requests.
Purpose of the LTSS Service Denial Proposal
•	Both Care Team/ICP and UM functions are essential and must work together to ensure true person-centered care is provided while simultaneously assuring efficacy and proper management of resources
Priorities for LTSS Service Denial Proposal
•	Heightened oversight/auditing of denials
•	Joint UM and Care Coordinator/ICT training
o	Joint training and problem-solving
•	Improvements in communication from health plans internally and externally about how concepts like UM, medical necessity, and prior authorization processes incorporate independent living principles and Enrollee preferences

Care Coordinator/Care Plan
•	The Care Coordinator plays a key role in “navigating” health plan, MassHealth, and Medicare complexities; acts as a conduit for Enrollee engagement; and serves as an internal representative for Enrollee needs and preferences within the plan
•	Internal mechanisms must be accessible by plan and contracted Care Coordinators if UM decisions conflict with care plans
Benefits to Enrollees
•	Add continuity of care requirements for LTSS decisions
•	Increase transparency about how decisions are made
•	Increase documentation requirements for health plan decisions in dispute (escalations/appeals)
•	Increase engagement of Enrollee and care team in considerations
Slide 17: Appendix A: Subgroup – Member Communications
The Member Communications subgroup focused on improving understandability and usability of Enrollee-facing materials and One Care program descriptions for potential Enrollees.

Progress to date
•	Project Support Team is developing Member Communications work plan 
•	MassHealth Integrated Care Unit has assumed leadership of Member Communications Workgroup
Next Steps
•	Develop/review/revise workplan with workgroup
•	Continue improving high-priority member notices
•	Standardize One Care role descriptions/ terminology for MassHealth/health plan materials
•	Develop Enrollee FAQ covering care plans, services, care teams, and points of contact
•	Develop potential Enrollee FAQ explaining One Care benefits
•	Update/improve “look and feel” and navigation of MassHealth website and materials
Slide 18: Appendix A: Subgroup – LTSS-Coordinator
Ensuring LTSS Coordinators are used effectively by health plans is critical to optimizing One Care’s support for Enrollees.

Progress to date
•	UMass CWM has submitted a proposed work plan to MassHealth to explore the extent to which LTSS-Cs are included in ICTs; improve LTSS-Cs’ engagement/involvement in developing ICPs; identify parties to improve communications; and standardize training, expectations and role descriptions
•	Reviewed input from health plans, ILC/ASAPs and DPC to identify issues 
Next Steps
•	UMass CWM, as it takes over workgroup leadership, will:
•	Interview and convene key stakeholders from ILCs, ASAPs, health plans, and MassHealth to develop and implement next steps in improving training and ICT integration
•	Address contracting issues or other identified improvement steps
•	Review how LTSS-Cs are offered to Enrollees and included and valued in ICT
Slide 19: Appendix A: Subgroup – Contracted Provider Participation
CMFI recommends establishing a Contracted Provider Workgroup to research options for increasing engagement of contracted providers in One Care (and other provider-related topics).
Progress to date
•	OLTSS CMO, with key contributors, identified challenges of aligning contracted providers with ICTs and presented findings to Core Team with key next steps identified
Next Steps
•	Commission Contracted Provider Workgroup to evaluate reimbursement constraints regarding contracted providers
•	Explore fee-for service mechanisms (e.g., care coordination codes, increasing reimbursable time per visit)
•	Apply QIP and Learning Collaboratives to create options for contracted provider participation (including sub-capitated approaches)
•	Address training to providers on care planning/ ICT participation
Slide 20: Appendix A: Subgroup – Health Equity
One Care must ensure the program actively promotes Health Equity for Enrollees.
Progress to date
•	OLTSS CMO presented EOHHS/MassHealth-wide Health Equity project to CMFI Core Team focusing on disparities in Health Equity related to RELD SOGI1 factors and identified next steps at the EOHHS/MassHealth level
•	Areas of focus were identified specific to the One Care program:
o	More use of community-based resources
o	Ensuring that the One Care program and population is accounted for and derives benefit from EOHHS efforts
o	Increasing diversity in the IC
Next Steps
•	Commit and assign One Care resources to participate in EOHHS/MassHealth planning and execution around Health Equity
•	Fully resource work with the Implementation Council to establish a plan for increasing diversity in the council in its procurement
•	Implement data fields to track Health Equity indicators
•	Leverage QIPS, Learning Collaboratives, and incentive opportunities in One Care to advance Health Equity focus and improvements

1 RELD SOGI is an acronym describing factors that influence health inequity – race, ethnicity, language, disability, sexual orientation, and gender identity.
Slide 21: Appendix B: Key Performance Indicators
Performance indicators developed through CMFI analysis of the Care Model domains will assist with oversight, evaluating One Care’s success in optimizing care delivery, and continuous Care Model improvement.
Progress to date 
•	Created draft list of KPIs to assist with driving care model improvement
•	Core Team reviewed and aligned on proposed KPIs
•	Integrated Care unit introduced broader One Care dashboard project for future development and implementation
•	CMFI established Oct 2022 as date for initial (baseline) KPI publication reflecting data for reporting period July 1, 2022 to Sept 30, 2022; KPIs will be published quarterly thereafter
Next Steps
•	Align on methods of capturing KPIs on a routine basis
•	Collect baseline measurements
•	Draft initial KPI Quarterly Report for presentation in October 2022 (reflecting July, August, and September data)
•	Coordinate between KPI report development and One Care data dashboard project
Slide 22: Deloitte
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