Appendix D – ACO Initiatives to Address All-Payer ACO Model Quality Measures Measure Current ACO Activities Underway Planned ACO Activities Underway Goal #1: Increase Access to Primary Care Percentage of adults with primary care provider Ensuring that all VMNG beneficiaries attributed to the program through specialists have a primary care provider identified. For beneficiaries with a PCP outside the VMNG network, we are working with local communities on workflows to ensure there is a point of contact to facilitate connection to primary care Finalize community workflows and document expectations for quality measurement and care coordination through VMNG communities Plan for similar experiences as we expand to more contracts with specialist attribution in 2018 Planning for primary care payment reform (i.e. AIPBP) that could enhance recruitment of primary care providers with more favorable/reliable reimbursement Medicare ACO composite of 5 questions on Getting Timely Care, Appointments and Information Disseminate 2016 quality results (ACO and once they become available in late Summer 2017 Plan and conduct at OCV Grand Rounds in June 2017 on the Medicare Wellness Visit, specifically new models such as use of RN Identify positive outliers and cull for best practices; disseminate to OCV network Ongoing quality improvement (QI) work in HSAs and with specific practices to improve access and timeliness of care Percentage of Medicaid adolescents with well-care visits Identified as a 2017 OCV clinical priority area under the category of preventive care Assessing best practices in communities through partnership between OCV and BP in local HSAs Actively partnering with VCHIP CHAMP team on a QI project to improve this pediatric measure; 22 OCV pediatric-serving practices actively participating in the monthly QI project including education/training and monthly measurement Regular discussion and report out at OCV Pediatrics Subcommittee on lessons learned from VCHIP’s national technical assistance work in this domain Preparing to run data reports for 22 practices in VCHIP CHAMP QI project (July 2017); developing a dissemination and wrap up plan with VCHIP Scheduled meeting with VDH MCH leadership and staff to discuss new innovations to improve on this measure (i.e. What are we learning nationally? strategies? Practice-based strategies?) Consider the impact of future primary care payment reform on improving well-child visit rates
Researching tools and resources for patients to build out a patient resource library on in Care Navigator Statewide prevalence of chronic disease: Diabetes Provider referrals to CHT self-management workshops and related resources Quality measurement data on BMI screening and follow-up Support the design of a RiseVT expansion plan to additional communities Explore future education and QI initiatives on as part of our overall population health management strategy Medicare ACO chronic disease composite: Diabetes HbA1c poor control; controlling high blood pressure; and all-cause unplanned admissions for patients with multiple chronic conditions See above See above Percentage of VT residents receiving appropriate asthma medication management Providers are building protocols into their EMRs Dissemination of best practices and evidence-based protocols for asthma medication management Multi-Payer ACO tobacco use assessment and cessation intervention Provider referrals to CHTs for counseling and support around tobacco cessation Partner with VDH to support 3-4-50 campaign in local communities with emphasis on Vermont Quits resources and tools Explore focused QI activities through OCV’s newly forming Primary Care Subcommittee