Tracking SIM practice transformation efforts 
November 30, 2018
Happy holidays from the SIM team

Emergency department rate for physical health conditions for patients attributed to SIM cohort-1 practices over time. See the full-size graph and more on the SIM data hub.
The Colorado State Innovation Model (SIM) team wishes you and your families, care teams and patients a very happy and healthy holiday season. With just about eight months left in the initiative, the SIM team continues to help thousands of health care providers across the state integrate care and gain skills to succeed with alternative payment models. Ambitious in scope, this federally funded, Governor's office initiative continues to gather and publicize successes from practices and community mental health centers, investments in local public health and more . The team considers you, SIM practice teams, practice transformation organizations and the health plans that support this work to be SIM ambassadors, who will carry the torch well beyond July 2019, when the SIM office closes. The team looks forward to working with Governor-elect Jared Polis and appreciates ongoing support from Governor John Hickenlooper's administration as work continues to expand patient access to integrated care. Read more about SIM successes, which are published on the data hub , SIM blog and through media outlets and  tell us how your work with SIM  has enhanced patient care, care team experiences and your negotiations with health plans to ensure that we capture the full story. 
Provider-payer meeting in January

Mark your calendars for the next Multi-Stakeholder Symposium (MSS), which will be held Jan. 24 (8:00 am to 1:30 pm) at 303 E. 17th Ave. This meeting provides representatives from SIM practices and the health plans that support them in the initiative with an opportunity to talk about challenges as well as successes while building more successful partnerships. The Center for Evidence-Based Policy will be sending practices a survey to rank priorities for future meetings. Please keep an eye out and  read about the last MSS and get a meeting summary .
Communicating the value of practice transformation
To help payers understand the work required for practices to transform care, the SIM team created a "good standing" process for SIM primary care practices in cohorts 2. Practices achieve good standing by successfully completing identified building blocks and achieving key milestones  in the SIM framework, and 95% of cohort 2 SIM practices achieved it by the end of their first year. SIM will send annual good standing reports to practices and payers that support them in the initiative. The first report will be sent by Dec. 31. Read more online .
SIM increases consumer/patient voice on advisory board
Two new members joined the SIM advisory board to represent consumer and patient perspectives during the Nov. 26 meeting. Griselda Peña-Jackson, BSBA, executive director of 2040 Partners for Health, will join the board as a voting member. Peña-Jackson was involved with SIM's consumer outreach this year and brings a wealth of experience with consumer advocacy work and community organizing to the table.
Laura Carroll will join the SIM advisory board in the new role of honorary patient representative. Carroll has been engaged in the Medicare Experience Advisory Council and was recently asked to participate in a National Association of Medicaid Directors conference during "Beneficiaries helping to improve the Medicaid program" session. Carroll explained that participants discussed barriers to widespread integration of physical and behavioral health services and strategies to address those barriers."

Carroll and Pena-Jackson join Carol Pace, who is the second consumer engagement representative on the Governor-appointed board. Click here to read the full story online.
SIM invests in veteran health

Stacy K. Syphers started her work as a SIM-funded veteran health connector (VHC) in eastern Colorado to connect veterans with community resources and develop a community-based plan to prevent suicide. The VHC role is based on regional health connectors, who are partially funded by SIM to facilitate stronger community partnerships. Connecting with veterans was part of the original SIM proposal and the team is pleased to extend this resource. More information will be published in the coming weeks. Please watch  SIM social media channels and the  website for more details and information about the new VHC, who has already started her work.
SIM provider success story

Recognizing the challenges of integrating care, one SIM practice shared the following success story to illustrate: 

In June, I saw a middle-aged male patient for evaluation of a cyst near his eye. Prior to the exam, the practice's medical assistant pointed out that his depression screening (PHQ) scores were high so we discussed depression symptoms and the patient told me that he'd been depressed for years and that his symptoms had worsened recently. He was resistant to counseling but reluctantly agreed to start medication after deeming this appropriate.

The patient came in for a follow-up and was so thankful that the practice screens patients for depression. He thanked me repeatedly during our visit and said he would never have brought this up without being prompted. This patient told me that he has never felt better and regretted waiting this long to get help. He shared that several of his close friends had died by suicide in the past few years and wondered if discussion about depression could have prevented this.

I am the first to admit that I am not perfect about looking at PHQ scores on every patient. I know that many times, patients express their dislike for filling out the PHQ form and give the medical assistants and nurses a hard time about this. As a provider, I will also admit that it can be frustrating when a 15-minute appointment turns into a 30+ minutes when these unexpected issues come up. Today's appointment with this patient helped to validate how important it is to treat the whole patient and how rewarding it can be .
SIM practice creates BHP manual

Delivering integrated care requires a unique skill set as well as processes that support a care team approach that includes behavioral health providers, which is one reasons why Pediatric Associates of Durango, developed a BHP manual to ensure ongoing success. The 46-page manual, which was developed by behavioral health provider Ruth Watkins, PsyD, includes a BHP job description, referral pathways, disclosure statement and informed consent for behavioral health services, screening tools, data collection and more. The resource has helped Pediatric Associates of Durango, a SIM cohort-2 practice, deliver integrated care and ensure a team-based, patient-centered approach to delivering whole-child care, says Pakhi Chaudhuri, MD, practice owner. While the manual is specific to the electronic health record system used by the practice, it could be customized for use in SIM practices, Chaudhuri adds.
Cost and utilization reports uploaded to SPLIT

The most recent Milliman Cost and Utilization Reports for your practice are now available in SPLIT. These reports use data from the Colorado All Payers Claims Database for patients attributed to your practice. General information about the Milliman Cost and Utilization Reports can be found on the archived Webinar hosted by Milliman in August 2017.  
Representatives from Milliman are available to address questions about the Milliman Cost and Utilization Reports. Please direct your questions regarding these reports to Katie Matthews at
SIM practice optimizes staff, prevents ER visits, boosts payment

Testing new ways to optimize team members and expand patient access has paid off for Sustaina Center for Women in Lakewood. A SIM and TCPi practice, Sustaina Center for Women successfully renegotiated one of its payer contracts after explaining how the small practice had retooled its processes to offer "ER visits" at the practice that reduced 302 avoidable emergency room (ER) visits, which saved $257,908 in one year. Click here to read more.
Deadline for small grant invoices

All SIM small grant invoices for cohorts 2 and 3 must be submitted by March 30, 2019, or practices forfeit the funds. Please contact Megan Comer, SIM small grants administrator ( with any questions or concerns. Click here to read articles, listen to podcasts, and learn more about the SIM small grant program. 
Stratus  update

Stratus™ is the claims data aggregation tool that is being offered at no-cost through June 2019 to practices participating in SIM. If you are interested in activating your Stratus™ license, you can do so via this short form. Within a week of submitting your request, you will receive an email confirming license activation from Best Doctors, which will include Stratus™ training resources.
The scheduled November data refresh has been delayed. The SIM team is working to address data quality issues and will update practices and PTOs once the data has been updated in Stratus™.
If you have any questions about Stratus™, please reach out to Elizabeth Mattes with the SIM office,
eCQM solution helps SIM practices succeed with APMs

About 50 practices have applied for the SIM-funded electronic clinical quality measure (eCQM) solution, which helps practices report eCQMs while reducing the administrative burden of doing so. The solution is believed to be the first to leverage blockchain technology for HIPAA-compliant data aggregation and reporting in Colorado. Read more about the eCQM solution and apply today.  
TCPi prepares practices with success with APMs

Creating a budget, retooling processes and engaging in community events were some of the ways that the Transforming Clinical Practices Initiative (TCPi) helped one Colorado practice prepare for alternative payment models (APMs). Listen to the latest episode of Innovation Insights to hear a provider explain how TCPi, a federally funded support network, helped the care team refine workflows and prepare for success with APMs.
Building resilient communities in southwest Colorado

Mary Dengler-Frey, a regional health connector (RHC) at the Southwestern Colorado Area Health Education Center, is tackling opioid addiction and substance abuse, diabetes and suicide. Mary draws on her experience as an architect to build infrastructure that will help providers expand access to care. "Though they seem disparate, there's similarity in the complexity and the coordination of moving parts," she says.  Read a profile of Mary's work and connect with the RHC in your region.
BHPs get SIM-funded training

Integrating behavioral and physical health in primary care settings can be a long, windy road with many challenges yet it leads to better patient care and a more rewarding care team experience, say behavioral health providers (BHPs) who work in integrated care settings. More than 200 of these BHPs attended a SIM-funded training hosted with the Office of Behavioral Health Nov. 1. Providers, who completed the training, received an Integrated Behavioral Health (IBH) Certificate that aligns with the Core Competencies for Behavioral Health Providers Working in Primary Care and IBH Best Practice Guidelines. Click here to read the full article covering the event.
Caring for seniors: Tips, tools, resources

Effective team approaches for this patient population should align with a patient's stage of life as well as his or her unique wants and needs. A new, SIM-funded, e-learning module helps care teams optimize all care team members to ensure that patient care is tailored to fit these unique needs and that it is balanced with individual lifestyle (e.g., physical and mental wellness, safe and healthy nutrition, physical strength and mobility, and access to a social network).  Watch this video for guidance and visit the e-learning platform to participate in 15, free modules funded by SIM (link to flier). Register using the "SIM" code and learn how these modules can help your care team integrate physical and behavioral health.
Protect CO youth: Vape-free November

Data shows that  Colorado youth are vaping nicotine at the highest rate of 37 states surveyed which led Governor John Hickenlooper to proclaim Vape-Free November. "While cigarette smoking among high school students has dropped, vaping nicotine continues to increase," according to the Colorado Department of Public Health and Environment (CDPHE). The 2017 Healthy Kids Colorado Survey shows that while only 7% of high school students smoke cigarettes, 27% said they vape nicotine. The school survey shows 87% of Colorado high school students think cigarette smoking is risky, but only 50% think those risks apply to vaping nicotine.  Get the facts about vaping in this handout   and  read more on the CDPHE website   .
QPP fast facts in 5 minutes

The Quality Payment Program (QPP) began 
Jan. 1 under the Medicare Access and CHIP Reauthorization Act (MACRA) to drive clinician engagement and enhance the quality, cost effectiveness and health of the population. Read the latest installment of fast facts in 5 minutes from the Colorado QPP Coalition to help your practice succeed. The Colorado QPP Coalition, which was formed last year to help practice teams successfully transition to the new program, releases new resources monthly. Visit the web page for updates.
Suggested reading

Dayton, Ohio, had one of the highest overdose death rates in the nation in 2017. The city made many changes, and fatal overdoses are down more than 50 percent from last year.

Nationally, deaths due to drug overdose and suicide increased last year according to data released today by the National Centers for Health Statistics at the Centers for Disease Control and Prevention and analyzed by Trust for America's Health and Well Being Trust.

With the rapid expansion of digital communication tools, there is a growing sense that telehealth can improve access to care and help patients manage their health. The Patient-Centered Outcomes Research Institute ( PCORI) hosted a Facebook Live session for a conversation with a PCORI-funded researcher and stakeholder partner about how telehealth may help improve outcomes for patients living with serious mental illness.
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The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS). The Colorado State Innovation Model (SIM), a four-year initiative, is funded by up to $65 million from CMS. The content provided is solely the responsibility of the authors and does not necessarily represent the official views of HHS or any of its agencies.