CSI/RI Extension contracts

W I T N E S S E T H:  WHEREAS, the Plan and the Provider desire to enter into an agreement for the funding toward the Rhode Island Chronic Care Sustainability Initiative (“CSI-RI”) on the terms and conditions set forth herein; and   WHEREAS, CSI, a Multi-Payer Demonstration of the Patient- Centered Medical Home (“PCMH”), a model of primary care that will improve the care of chronic disease and lead to better overall health outcomes for Rhode Islanders.   NOW, THEREFORE, in consideration of the mutual covenants, promises and undertakings hereinafter set forth and for other good and sufficient consideration, the receipt of which is hereby acknowledged, the parties hereto agree as follows:

Participating Practices  University Medicine Foundation, Inc. –Governor St.  285 Governor Street, Suites 200 and 300  Providence, RI  Coastal Medical, Inc. - Smithfield  41 Sanderson Road  Smithfield, RI  Family Health & Sports Medicine  725 Reservoir Avenue  Cranston, RI  Hillside Family and Community Medicine  727 East Avenue  Pawtucket, RI  Thundermist Health Center - Woonsocket  450 Clinton Street  Woonsocket, RI 02895

Compensation  Contract Year 1: $5.50 PMPM  Contract Year 2: scaled rate based upon performance in Contract Year 1: $5.00 PMPM if 0-1 Target is met $5.50 PMPM if Target #1 is met along with one other Target (Target #2 or Target #3) $6.00 PMPM if 3 Targets are met  Attribution methodology

Nurse Care manager – lynchpin for success “It is the expectation that the Provider will have a dedicated NCM retained to sufficiently support these types of functions listed in Attachment A”

Nurse Care manager – lynchpin for success  Attachment A: Nurse Care Manager Role and Responsibilities   Complete initial patient assessment, including a comprehensive medical, psychosocial, and functional assessment of the patient, including in the home setting if needed.  Provide detailed education about patient’s specific chronic illness, including the pathology, signs and symptoms, complications, and medications used in treatment.  Assure that screening tests are up to date.  Utilize a multi-disciplinary team approach to address opportunities to plan and coordinate care.  Establish care management plans, Interventions, treatment goals – including self-management goals, and contact schedules.  Help to arrange contact with ancillary personnel.  Promote compliance with chronic care plan.  Coordinate care and communicate with multiple providers, both within and external to the practice  Review test results and tracks outcomes.  Review patient compliance issues.  Work one-on-one with patients.  Arrange group visits.  Leverage EMR / chronic disease registry reporting to prioritize patient follow-up.  Identify and utilize cultural and community resources.  Develop reporting (to be defined) on service volume, distribution of patients by plan, and types of services provided.  Ensure open communication, regarding patient status, with physicians and office staff.  Provide training to non-RN Quality Assistant and other practice staff as needed.  Act as liaison to hospital, long-term care, specialists and home health representatives.  Attend required training and collaboration sessions [i.e., learning sessions, outcomes congress, care management collaboration meetings, and practice team meetings] as scheduled.  Train staff on motivational interviewing  Interact and coordinate with hospital and other provider staff, when applicable in caring for the patients within the Patient Centered Medical Home.

Performance targets  Target #1: Utilization Metric  Target #2: Quality and member satisfaction metric  Target #3: Process Improvement metric

Target #1: Utilization Metric:  CSI Providers will achieve a five percent (5%) relative reduction in hospital admissions per thousand as compared to similar, non –PCMH providers  CSI Providers will achieve ten percent (10%) relative reduction in ED visits per thousand as compared to similar, non –PCMH provider  {(or) 1% above target on one and 75% of other target }

Target #2: Quality and member satisfaction metric  Provider will achieve the target on three out of the six CSI clinical quality measures  Provider will conduct member satisfaction survey that demonstrates achievement of greater than 80% average “satisfied” or “very satisfied” rate (at end of year one)

Target #3: Process Improvement:  Provider’s After Hours Protocol  Participation in hospital – outpatient transitions best practices  Compacts with high volume specialists  NCM activity reporting

Training and reporting  Participation in training program  Chosen by steering group  “Participation” determined by steering group  The Provider shall endeavor to engage its patients in the CSI-RI program  Provider and plan* agree to participate in evaluation  Plan reporting requirements…

Plan reporting requirements  Hospital Emergency Department (ED) visits / Quarterly  Percentage of Eligible Subscribers with greater than two (2) ED visits within ninety (90) days - Quarterly  Hospital admissions / 1000 – Quarterly  Subscriber Panels – Quarterly  Subscriber Inpatient and ED Utilization – Weekly  Other reports as agreed to by the Plan

Plan reporting requirements (2)  Beginning Quarter 5, Plan will contribute to the RI “All Payer” data base  Beginning Quarter 6, Plan will provide Provider, if applicable, quarterly high dollar imaging activity. Plan will include the number of tests ordered by category  Beginning Quarter 5, Plan will report to Provider three (3) additional measures selected through statewide “harmonization”

Term and termination  “prompt and equitable settlement of all disputes or grievances “  “Negotiate directly and in good faith”  If resolution not possible “refer to CSI RI Steering Committee for review and comment”

Ways CSI-RI Could Fail (1)  No practices are willing to become pilot sites under tenets of the project  Plans and practices do not come to agreement on contract amendments  Champions at pilot sites are unable to convince colleagues/administration at their organizations the value of participation

Ways CSI-RI Could Fail (2)  Physicians at pilot sites are unsuccessful at transforming practices into PC-MHs  Patients do not take advantage of additional services offered by the PC-MH  Patient and physician utilization of PC-MH features does not result in improvements in outcomes

Ways CSI-RI Could Fail (3)  PC-MH supported improvements in clinical outcomes are modest, and insufficient to motivate change by others  Other practices  Other payers/same payers in other venues  Purchasers  PC-MH supported improvements in clinical outcomes are significant, but too costly