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Massachusetts Health Policy Commission
April 2018
It’s telehealth month at the HPC! In this newsletter edition we are pleased to share some lessons from our investment awardees and PCMH PRIME practices on promising practices for adopting telehealth to increase access to behavioral health. We are also excited to introduce the first installment in a new series of policy briefs focused on the state of capabilities of HPC-certified ACOs and are busy gearing up for our Spring event “Partnering to Address the Social Determinants of Health: What Works?”

Please let us know if there are any other care delivery transformation topics or work in the Commonwealth that you’d like to see the HPC showcase in this newsletter. We love to hear from you! Email us at HPC-Caredeliverytransformation@massmail.state.ma.us .
Team HPC
PCMH PRIME Knowledge Sharing Session: Telehealth for Behavioral Health Integration in Primary Care
On April 12, representatives from Codman Square Health Center, Yogman Pediatric Associates, and the Pediatric Physician’s Organization at Children’s (PPOC) participated in a PCMH PRIME Knowledge Sharing Session on using telehealth technologies and complementary care models to facilitate behavioral health integration within their primary care practices. Over 20 representatives from provider organizations were in attendance. A recording of this event can be viewed here on the HPC's YouTube channel.  

  • Daniel Hogan, MPH, LICSW described Codman Square Health Center’s efforts to build provider capacity in medication assisted treatment for substance use disorder (SUD) through participation in Project ECHO trainings. Project ECHO (Extension for Community Healthcare Outcomes) includes both provider-to-provider case consultations and didactic sessions. 
  • Dr. Michael Yogman and Susan Betjemann, MSW, LICSW described Yogman Pediatric Associates’ recent initiation of virtual therapy visits to ease travel burden. 
  • Dr. Jonas Bromberg, PsyD described PPOC's collaboration with Boston Children’s Hospital Department of Psychiatry to provide remote video consultations for patients at distant primary care sites with limited access to behavioral health services.
The moderator, Dr. Jean Glossa of Health Management Associates, noted, “ We’re not going to solve the shortage of psychiatrists by just making more psychiatrists; we need to use them more innovatively.” Members of the panel discussed key factors to successful telemedicine for behavioral health, or teleBH, use in primary care, including:
  • Business model: Panelists stated that developing a clinical model, communicating with all relevant payers, and defining work flows should occur before proceeding to contract with a teleBH vendor. Practices should develop clinical models that reflect the unique needs and preferences of practice demographics.

  • Education: Panelists who participated in Project ECHO stated that encouraging the entire clinical care team to participate in telehealth sessions supports the culture shift that is often necessary for a practice to embrace telehealth.

  • Sustainability plan: Panelists stressed the importance of leveraging physician champions within their organizations and collecting and disseminating data that demonstrates return on investment for telehealth.

The HPC would like to thank Daniel Hogan, Dr. Michael Yogman, Susan Betjemann, and Dr. Jonas Bromberg for presenting on their efforts to introduce telehealth to their primary care practices, and Dr. Jean Glossa for her expert facilitation of the event. For more resources shared at this event, check out the Resources and Publications section below.
Telemedicine Awardee: Pediatric Physician’s Organization at Children’s

HPC Telemedicine Pilot Initiative awardee, the Pediatric Physician’s Organization at Children’s (PPOC), is a network of independent pediatric primary care practices with locations across the Commonwealth. PPOC’s initiative focuses on providing psychiatric evaluations to children and adolescents in their primary care office using telemedicine technology. Through PPOC’s partnership with Boston Children’s Hospital Department of Psychiatry (DoP), the initiative provides pediatric patients access to much-needed psychiatric care locally, regardless of where their primary care physician (PCP) is located. With a primary goal of providing evaluations within 15 days of referral, PPOC is working to expand access to crucial behavioral health care to young residents of the Commonwealth regardless of geography.

PPOC spent a significant amount of time and energy during their six-month preparation period focused on building the administrative processes necessary for running the program. At the start of the implementation period, the PPOC team had established intake processes as well as billing processes so that it was ready to serve patients starting day 1. While no amount of preparation can guarantee 100% success, PPOC has benefited from thoughtfully engaging in their preparation period before delivering services, and has been able to focus more energy on expansion during the implementation period.
At the outset of PPOC’s initiative, three practice sites were participating. However, now in the fourth quarter of their work, PPOC has expanded to five sites. PPOC attributes some of the success of the expansion efforts to a focus on provider education and engagement. PPOC worked with the clinicians at each partnering practice site to fully explain what the appropriate target population was for referrals to the initiative, increasing the visibility of the program and spreading awareness of the services being offered to more providers.

Patient, family, and provider satisfaction ratings for the PPOC initiative have been very high. The program not only helps to provide the psychiatric evaluations that can lead to improved behavioral health outcomes for patients, but also offers treatment visits for patients to continue work with the psychiatrist beyond their initial evaluation appointment.

As PPOC continues to spread the model to additional affiliated practice sites, a next step is to secure additional tele-psychiatry resources to accommodate the growing number of patients that they are serving. Each new site brought into the program represents another Massachusetts community receiving much-needed access to behavioral health care for its children.
Telemedicine Awardee: Riverside Community Care
Riverside Community Care offers emergency care, urgent and outpatient services, in-home and residential care, psychiatric day programming, early intervention, employment support and domestic violence services throughout eastern and central Massachusetts and is an HPC Telemedicine Pilot Initiative awardee. Through its HPC award, Riverside delivers high quality behavioral health care via telemedicine to older, homebound adults who have unmet behavioral health needs. Riverside shared the following patient story highlighting how providing behavioral health care to those in need can lead to broader improvements in clients’ lives.

The client is an older woman who suffers from severe rheumatoid arthritis (RA), cardiac myopathy caused by RA, insomnia from pain, depression, and other comorbidities. Additionally, she experiences chronic pain day and night, coupled with extreme fatigue. She has had multiple joint replacement and related surgeries. She had a successful career until her RA, especially in her hands, made it impossible for her to work.

After speaking with the Riverside program team, the client was willing to try cognitive behavioral therapy and mindfulness meditation with a Riverside clinician using the teleBH model. However, her chronic intense pain and sleep deprivation undercut the benefits of these approaches to managing her depression. Additionally, her anti-depressant dosing was at a typical starting dose, and not enough to be therapeutic.

The client agreed that her pain was undertreated but was shy about having a frank conversation with her PCP about better pain management. With her permission, the tele-consulting Riverside clinician connected with the client’s PCP and discussed her situation. The client and her PCP then met and agreed to an increase in her pain medication dosage and changed the timing of it to help her sleep. The PCP also increased her anti-depressant dosing to an appropriate therapeutic dose.

The client reported that, for the first time in over a year, she was able to sleep well and get through the day with less pain. She feels the anti-depressant is also now helping. With better sleep and less pain, she was able to try meditation and consider participating in some social activities. Ultimately, complex clinical situations like this client’s serve to illustrate how interwoven behavioral health and medical conditions are, and how telemedicine can serve as a valuable vehicle to deliver needed behavioral health care services to home-bound clients.
Enhancing Transitions through a Collaborative Approach: Health Care Innovation Investment Awardees
Two of the HPC's Targeted Cost Challenge Investments (TCCI) awardees, Brookline Community Mental Health Center and Lynn Community Health Center, presented at a recent New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO) webinar titled Enhancing Transitions Through a Collaborative Approach . Both teams shared strategies and early learnings from their programs designed to serve patients with complex social, behavioral, and medical needs. The presenting teams cited a few key lessons learned, including:

  • Deploy community health workers (CHWs) to conduct home visits. It is important to gain an understanding of a patient’s environment, support network, and day-to-day activities in order to comprehensively address a patient’s needs.
  • Tip: Presenters plan for more frequent contact (one face-to-face meeting a week) with new patients in order to achieve some “early wins” and build trust, then adjust over time.

  • Develop a care plan and prioritize services based on patient-driven goals.
  • Presenters stated that it is critical for the goals to be identified by the patient. For example, while a clinical goal for a patient with diabetes may be to reduce HbA1c levels, he or she may first want to focus on securing stable employment or improving stress management and coping skills. As Ms. Emily Johnson, LSW, Director of Community Outreach at Lynn Community Health Center summarized: “Meeting patients where they are means that the patient determines the goals. The patient is the captain of the ship, and we [the care team] are the crew.”

  • Communicate the care plan to other providers and partners who are also serving the patient in order to coordinate efforts and avoid duplication of services.
  • Brookline Community Mental Health Center has co-located teams across provider settings, most recently working with ACOs, to achieve optimal care coordination and increased savings.

The HPC would like to thank the teams from Brookline Community Mental Health Center and Lynn Community Health Center for their time and effort in presenting on their initiatives. Presentation slides and a transcript of the webinar  are available on the QIN-QIO website.
Transforming Care: ACO Brief #1: Introduction to Accountable Care Organizations in Massachusetts
The HPC is developing a series of written reports and other resources detailing the state of HPC-certified ACOs and their capabilities. The first brief in the series, published this month, provides background information on ACOs in Massachusetts and the HPC ACO Certification program ,   and highlights a few key facts about the certified ACOs, including:

  • Approximately 1.9 million commercial or Medicare patients in Massachusetts are served by HPC-certified ACOs.

  • The 17 HPC-certified ACOs hold a total of 66 commercial risk contracts, 17 MassHealth risk contracts, and 11 Medicare risk contracts.

  • Over 80% of HPC-certified ACOs have at least one hospital as an ACO participant.
Visit the HPC’s Transforming Care website to read the full brief.
Proposed Regulation for Public Comment on Risk-bearing Provider Organization (RBPO) and Accountable Care Organization (ACO) Internal Appeals and External Review
On April 25, 2018, the HPC approved release of a proposed regulation on RBPO and ACO internal appeals and external review. The proposed regulation builds on Interim Guidance, released in April 2016, directing RBPOs and HPC-certified ACOs to implement an internal appeals process and also provides for an external review process, to be administered by the Office of Patient Protection (OPP), for patients of provider organizations under risk contracts. The proposed regulation implements important statutory protections for consumers who may face challenges accessing appropriate care and referrals of patients of provider organizations managing risk.  Patients eligible for this process are limited to commercial risk patients of the RBPO/ACO. The regulation does not apply to MassHealth and Medicare patients who have other legal protections.
A public hearing on the proposed regulation will be held on May 25, 2018 at 9:30AM at the HPC Offices. All testimony and comments must be received by 5:00 PM on Friday, May 25, 2018. You can view the proposed regulation and notice of public comment here. For more information, you can watch a video of the HPC’s April Board meeting on our YouTube Channel or view the slide presentation here.
American College of Healthcare Executives
Westborough, MA
May 4, 2018
7:30am – 12:00pm ET

Massachusetts Coalition for Serious Illness Care
Boston, MA
May 15, 2018
10:30am—2:30pm ET

Health Policy Commission
Boston, MA (UMass Club, One Beacon St)
May 17, 2018
8-11am ET

New England Quality Innovation Network-Quality Improvement Organization
May 22, 2018
2:00-3:00pm ET (webinar)

Massachusetts Health Data Consortium
May 23, 2018
9:00am-11:00am ET (webinar)

Massachusetts Health & Hospital Association
Burlington, MA
June 22, 2018
9:00am – 2:30pm ET
Provide assistance, education and information to organizations and individuals who are actively providing or interested in providing health care at a distance.
Provides support on legal and regulatory telehealth topics such as: physician and nurse licensure; credentialing and privileging; Medicare and Medicaid reimbursement; and private insurance payment policies.

The Commonwealth Fund and KPMG
Yogman et al.

Blue Cross Blue Shield of MA Foundation
Blue Cross Blue Shield of MA Foundation
Blue Cross Blue Shield of MA Foundation
Institute for Healthcare Improvement

The Commonwealth Fund
Bureau of Substance Abuse Services
Massachusetts Department of Public Health
Massachusetts Association of Community Health Workers
Health Policy Commission
50 Milk Street, 8th Floor
Boston, MA 02109