Center for Medicare and Medicaid Innovation Health Care Innovation Challenge 1115 Waiver Opportunities Overview Letter of Intent due December 19 Electronic Application due January 27 Period: March 30, 2012 through March 29, 2015 Purpose

Delivering the 3 part aim – better health, better health care and lower cost through improved quality

Test alternative models for care delivery and payment

Facilitate learning and diffusing of best practices

Promote the development of a workforce capable of supporting care transformation

Successful models will:

Rapidly develop or deploy requisite workforce to support the proposed model

Show capability to improve care within the first six months of the award

Create a sustainable pathway to net Medicare/Medicaid savings within 2-3 years

Improve coordination, efficiency, and quality Many populations including the frail elderly often face obstacles when accessing health services or working towards a healthier life style. Traditional visit based, in-office services often do not effectively meet their needs, contributing to poor health outcomes and an increasing trend in cost of care for these patients. Current innovative programs in urban and regional areas could be expanded to broader populations across the country. Improvement networks work cooperatively on strategies. One factor limiting diffusion of ideas has been the shortage of an appropriately trained workforce. Staff needs to be trained in prevention, care coordination, care process re-engineering, dissemination of best practices, team based care, continuous quality improvement, and the use of data to support a transformed system. Training and educational experiences will be needed to help develop this knowledge and these skills. Such systems also require new knowledge transfer and information technology infrastructure. Electronic health records are central to this effort and are being

supported through several national initiatives. Learning health systems can deliver better outcomes. The Health Care Innovation Challenge will fund applicants who propose the most compelling new service delivery and payment models that will drive system transformation and deliver better outcomes. Not intended to be prescriptive, but an open invitation to:

Engage a broad set of innovation partners to identify and test new care delivery and payment models that originate in the field and that produce better care, better health, and reduced cost through improvement for identified populations

Identify new models of workforce development and deployment and related training and education that support new models either directly or through new infrastructure activities.

Support innovators who can rapidly deploy care improvement models within six months through new ventures or expansion, in conjunction with public and private sector partners.

Proposals

Should focus on high risk groups, such as persons with multiple chronic conditions and frail elderly.

Describe the services to be delivered and how payment would be constructed around the delivery model. How payment approach tested related to benefit designs that CMS can consider for broader application.

Introduce tests of scalability for models known to achieve three part aim outcomes.

New payment approaches should focus on models that do not simply expand fee for service payments

Current payment policies do not support workforce needs. Many coordination models utilize less expensive but potentially highly effective individuals who are trained to interact with patients in a focused way to address preventive health and chronic conditions.

Use of personal and home care aides to help the elderly age at home

Expanding use of paramedics to extend available primary care resources in rural communities

Use of community based nurse teams working with primary care practices to provide intensive care management for complex patients

Infrastructure support could test broad implementation of registries, data intermediaries for quality reporting and information sharing to support coordination of care, community based care coordinating systems, innovation or improvement networks or community collaborative. Partners can include: clinicians, health systems, private and public payers, community colleges/vocations schools, community and faith based organizations, local

governments. Applicants should have a track record of success in identifying and caring for these populations. And should be able to quickly expand or actualize a well developed model Preference will be given to those proposals that create capacity and demonstrate workforce impact and potential for replication and scale. Speed to implementation: Proposed models should already be operational in related contexts or sufficiently developed to be rapidly deployed. Proposals will be expected to complete the infrastructure and capacity related activities within six months of the award. Preference will be given to projects that implement care improvements in less than six months. Training programs are eligible but should be intensive, brief programs connected to the model being tested. Sustainability

Define and test a clear pathway to sustainability.

Funding will support initial start up and support over a limited time period.

Descriptions of expected positive impact on the three part aim must be included along with a proposed sustained business model. Sustain activity beyond the three years of the program, describing the anticipated source of ongoing support. Changes in federal funding and innovative payment approaches may be proposed as the mechanism for sustainability, identifying both the source of payment and anticipated pricing of the service. Demonstrate the ability of the program to inform future payment approaches for CMS consideration and recommendations for the scaling and diffusion of the proposed model.

Sustainability can include: public/private partnerships; multi-payer approaches; new direct payment models for innovative care delivery or service; shared savings opportunities with CMS or other payers; and or proposed agreements with ACOs or advanced primary care models. Evaluation and Monitoring

Clearly include quantifiable means for evaluating the impact of the program on the three part aim

Each applicant must monitor, evaluate, and report on progress and impact

CMS contractors will also conduct an independent evaluation Each applicant will provide quality indicators with a continuous improvement method of measurement to be used to evaluate impact. The following domains should be included: patient satisfaction and or patient experience; utilization, clinical quality, patient access. Measures should be collected and analyzed on an ongoing basis, and enabled where possible with health IT such as certified electronic health records, registries data, and electronic reporting mechanisms.

CMS will make more information on standard measures available at www.innovations.cms.gov Each applicant will be measured on their ability to achieve better health and demonstrate improvements in how their strategies will contribute to improving the health of the targeted population. Impact on lower costs – each model is expected to generate savings for the total cost of care for the beneficiary population its program affects. Must complete budget form SF 424A and a financial plan demonstrating the ability to achieve savings over the three year term of the award and on an annualized basis after project is completed. Also need detailed back up financial models explaining the logic driving their forecast cost of care savings (that is increased care coordination expenses of x will drive reductions in ER visits representing Y). Successful applicants will demonstrate the ability to achieve satisfactory improvement in cost of care along the following dimensions –

Program level net savings over the duration of each award and

Projected medical cost trend reduction that results from building the sustainable new model continuing after the cooperative agreement period is complete

Operational Performance Awardees will be measured on their ability to execute their proposed operational work plan. The components of the work plan include but are not limited to:

Meeting proposed milestones and deliverables

Producing timely and accurate reports with clear progress on quality and cost performance as described above

Acquiring, training, and deploying workforce

Building and/or enhancing required infrastructure Awardees will be expected to report actual performance compared to forecast on cost and quality measures and operational performance, and CMS will regularly monitor the results. CMS will also collect a standard minimum set of performance indicators through its monitoring and evaluation contractors. Learning and Diffusion Awardees will be required to participate in CMS sponsored learning sessions about how care delivery orgs can achieve performance improvements quickly and effectively. CMS will look for convergence among awardees and create learning networks to share practices. Restrictions on awards Award dollars cannot be used for specific components that are not integrated into the entire service delivery and payment model proposed. Proposals cannot replicate models

being currently tested in other initiatives. CMS may work with awardees to align and group proposed models with some shared characteristics. Range of awards $1 -30 million Awards will be made through cooperative agreements. Review and selection Recommendations of the review panel based on -

Geographic diversity of awardees

Range of service delivery and payment models proposed

Reviews for programmatic and grants management compliance

Reasonableness of estimated cost and anticipated results CMS intends to fund projects in communities with a wide variety of geographic and socio-economic characteristics, including underserved urban and rural areas.

Health Care Innovation Challenge - Project Overview 11/29/2011 12/5/2011

Identify small committed workgroup including roles and responsibilities 11/29/2011 12/5/2011

Review project requirements along with risks and benefits 11/29/2011 12/5/2011

Review all materials issued to date 11/29/2011 12/5/2011

Develop a list of questions and issues to address with CMS 11/29/2011 12/5/2011

Develop Conceptual Model 11/29/2011 1/13/2012

Identify opportunities for shared services and operations based on CMS project guideline 12/5/2011 12/9/2011

Identify proposed participants and evaluate current state of development for 11/29/2011 12/9/2011

Care transitions 11/29/2011 12/9/2011

Clinical coverage models 11/29/2011 12/9/2011

Staff training and expertise 11/29/2011 12/9/2011

Electronic medical record systems 11/29/2011 12/9/2011

Evidence based care development for a set of clinical conditions to identify and implement EBC rapidly 11/29/2011 12/9/2011

Supporting shared service efficiencies 11/29/2011 12/9/2011

Identify proposed participants current relationships and outcomes 12/9/2011 12/21/2011

Identify relationship for improved care coordination and long term care provision 12/9/2011 12/21/2011

Document and develop a logic model that shows potential efficiencies and supporting rationale 12/9/2011 12/21/2011

Identify individual provider best practices and opportunities for sharing/implementing regionally 12/9/2011 12/21/2011

Develop proposed structure for statewide steering committee to guide regional networks 12/9/2011 12/21/2011

Determine an organizational structure that provides oversight to potential regional network entities 12/9/2011 12/21/2011

Determine regional network entity organization and legal issues/ramifications 12/9/2011 12/21/2011

Identify communication plan for the network 12/9/2011 12/21/2011

Develop shared services plan 12/9/2011 12/21/2011

Establish the model for statewide and regional network management 12/28/2011 1/13/2012

Finalize model based on agreed services, efficiencies, and proposed outcomes 12/28/2011 1/13/2012

Finalize list of member participants 12/28/2011 1/13/2012

Determine resource needs for proposed model 1/13/2012 1/20/2012

Review system challenges and current Michigan projects to address barriers 1/13/2012 1/20/2012

Complete project application and narrative 1/13/2012 1/20/2012

Bundled payment model development 11/29/2011 12/16/2011

Identify small committed workgroup including roles and responsibilities 11/29/2011 12/16/2011

Review project requirements along with risks and benefits 11/29/2011 12/16/2011

Review CMS demonstration projects - issues and outcomes 11/29/2011 12/16/2011

Review all materials issued to date 11/29/2011 12/16/2011

Develop a list of questions and issues to address with CMS 11/29/2011 12/16/2011

General Lit review on rehospitalizations and fragmented care 11/29/2011 12/16/2011

Send a letter to included providers in LOI 12/19/2011 12/21/2011

Identify current provider relationships especially with hospitals and physicians for proposed conditions 1/3/2012 1/19/2012

Review available outcome data for the particpating providers and determine opportunities 1/3/2012 1/27/2012

Review cost and pricing issues for individual participating providers 1/3/2012 1/27/2012

Identify regional ability to incur risk and demonstrate risk taking ability to CMS 1/27/2012 2/9/2012

Determine opportunities to work with State entities - Medicaid, etc and develop communications plan 12/1/2011 2/9/2012

Develop specific project activities designed to foster efficiencies and outcomes 12/1/2011 2/9/2012

Continuously re-engineering/rapid cycle improvement processes 12/1/2011 2/9/2012

Creation of a learning network 12/1/2011 2/9/2012

Develop care coordination model that includes resources and plans for access to clinical oversight 12/1/2011 2/9/2012

Develop parameters for bundled payment project 12/1/2011 2/22/2012

Review 18 sample episode definitions and data analysis 12/1/2011 12/21/2011

Review CMS data provided 12/14/2011 1/18/2012

Review model for regional networks and identify need for additional data 12/14/2011 1/3/2012

Determine the episode of care based on previous analysis 1/18/2012 2/8/2012

Consider dual eligible models with lengthened PA periods and Medicaid involvement 1/18/2012 2/8/2012

Determine conditions most likely to provide savings opportunities and outcome improvement 1/18/2012 2/14/2012

Determine what evidence based models apply to selected conditions and how they can be implemented 1/3/2012 2/22/2012

Determine how many beneficiaries can effectively be reached and potential Medicare/ provider savings 1/3/2012 2/22/2012

Determine pricing plans 1/18/2012 2/7/2012

Determine opportunities based on CMS data and any additional data used 1/18/2012 2/1/2012

Determine entities to be included 1/18/2012 2/7/2012

Develop a communications/engagement plan for potential providers and consumers 1/18/2012 2/7/2012

Determine quality assurance monitoring plan 1/3/2012 2/15/2012

Determine CMS minimum reporting expectations 12/1/2011 1/3/2012

Develop learning network structure 12/1/2011 1/3/2012

Rapid cycle improvements based on evidence based practices 12/1/2011 1/3/2012

Develop overall QI plan 1/2/2012 1/31/2012

Develop the application 2/22/2012 3/1/2012

Confirm and document the final proposed model 2/1/2012 3/1/2012

Develop the workplan 2/1/2012 3/1/2012

Complete application 2/1/2012 3/1/2012