Transforming Care Delivery

Problem: 

The current health care system is a confusing tangle of individual providers who typically don’t connect the dots for patients who need coordinated, connected care. Delivery system transformation integrates care across settings and providers, “defrags” the current system and creates a connected, more efficient medical neighborhood[S1] .

This isn’t just about changing business models: It’s about improving health.  A growing body of research[S2]  shows that much of an individual’s health--and the health of a population--relates to non-medical factors.

Our Solutions: 

Each Rocky Mountain Health Plans (RMHP) project supports a larger strategy to further evolve the delivery system and pay providers based on quality and outcomes. By connecting information technology with direct, hands-on practice transformation support, RMHP is moving provider practices forward, enhancing their ability to measure their own performance and to take action on what they learn from measurements.

Colorado’s Medicaid Accountable Care Collaborative (ACC) is a central part of Medicaid reform, and Rocky Mountain Health Plans serves as the Regional Care Collaborative Organization (RCCO) for Region 1 of Colorado.

RMHP provides extensive training and education, as well as technical assistance, to build providers’ competence to serve as medical homes. Community Care Teams (CCTs) across the Western Slope provide direct care coordination support to primary care providers. These teams may include social workers, behavioral health specialists, registered nurses and others. Across communities, the CCTs develop close relationships with primary care medical practices. 

This program supports delivery system transformation at the local and regional levels. It changes the incentives and health care delivery processes from rewarding a high volume of services to holding providers accountable for healthier patients​. In RCCO Region one, ACC members receive support in navigating the system for their medical, behavioral health and non-medical needs, like help with housing, food instability and other social needs. This support has increased overall quality of care while lowering costs to the system.

The practice transformation team at Rocky Mountain Health Plans (RMHP) has been selected to provide practice facilitation to practices on the Western Slope of Colorado for the five year Comprehensive Primary Care Plus (CPC+) initiative.  RMHP is part of a larger CPC+ Regional Practice Network that is led by the Lewin Group in direct partnership with TMF Health Quality Institute and HealthTeamWorks. There are 32 CPC+ practices, ranging from small rural practices to 15 + physician practices. The RMHP practice transformation team will work with practices to provide guidance that will help practices achieve the five Comprehensive Primary Care Functions: Function 1: Access & Continuity Function 2: Care Management Function 3: Comprehensiveness & Coordination Function 4: Patient & Caregiver Engagement Function 5: Planned Care & Population Health. This will provide practices with the framework for delivering better care, smarter spending, and healthier people.

The Rocky Mountain Health Plans Practice Transformation Team offers a suite of services that support practices as they develop the competencies to show value through delivery of advanced primary care.

For more than 16 years, the Practice Transformation Team at Rocky Mountain Health Plans (RMHP) has fostered relationships with clinicians, helping them provide patient-centered, coordinated, team-based care to the residents of Western Colorado. The RMHP team provides a suite of evidence-based tools and the talent, including Quality Improvement Advisors, Clinical Informaticists and Integrated Behavioral Health Advisors.

The result: Practices that are advancing toward the Quadruple Aim:

  1. Improve the health of the population
  2. Enhance the patient experience of care (including quality, access, and reliability)
  3. Control the per capital cost of care
  4. Improve provider/clinician job satisfaction 

As practices more toward the Quadruple Aim, they are better prepared for value-based reimbursement.

RMHP’s approach to practice transformation succeeds because it’s based on practice and community needs while maintaining close alignment with state and federal transformation programs.

Participating primary care practices advance through curricula based on engaged leadership, data-driven improvement, empanelment, team-based care, patient-team partnership, population management, continuity of care, prompt access to care, compre­hensiveness and care coordination, and integration.

RMHP’s step-wise approach to transformation gives physicians and their teams the opportunity to fundamentally redesign their practices and prepare for value-based payments while achieving the Quadruple Aim.