Colorado’s major cities are well known leaders in high-tech healthcare. But beyond the bustling streets of Denver, Colorado Springs and Aurora, lay vast expanses of land and isolated towns that can be hundreds of miles from the nearest specialist care. Of the state’s 64 counties, only seven contain cities with populations above 100,000. The challenge of providing equal access to quality healthcare services across the rest of the primarily rural state is beyond understatement.
As a state, Colorado also has an unusually deep need for behavioral health services. Faced with one of the highest suicide rates in the country, much of the state’s rural regions lack access to quality mental health services, if any are available at all. Mental health clinics aren’t usually connected to primary care physician offices, and mental health specialists tend to have minimal interaction with hospitals until an inpatient encounter, which often occurs long after the best opportunity for productive wellness intervention.
Thanks to a $65 million grant from the Center for Medicare and Medicaid Innovation (CMMI), Colorado is solving two huge problems at once—and is one of the few states in the country to integrate physical and behavioral healthcare in primary care settings and expand access, through teleconsults and other technologies.
Healthcare Informatics spoke with two of the project’s leaders, Healthcare IT Program Manager Ako Quammie and Barbara Martin, R.N., to learn more about the project’s four-year mission and the implementation lessons learned so far.
The four-year Colorado State Innovation Model (SIM) project began with a single idea: harness technology to connect primary care practices with mental health services at every patient encounter. In Colorado, solving the remote factor would mean using telehealth technology to bridge the service gaps, ultimately bringing needed quality services to any location.
Within its greater scope, the Colorado SIM project focuses on four sub-goals:
1. Payment reform
3. Population health
4. Health information technology
From its initial grant application, the project became a mission for both technology innovation and state reform, says Martin, who is the SIM director. “The SIM was a call to action for our state to drive delivery systems and payment reform. It enabled us to come to table and say, ‘this is our vision of healthcare delivery,’” she says. “In Colorado we had tremendous leadership groups across the state and multi-stakeholder engagements that recognized that we couldn’t improve health outcomes and reduce cost of care without also thinking about the behavioral health aspect in our populations.”
Colorado’s roots in integrating primary care and behavioral health date back to 2007, far earlier than most states, Martin adds. “We want to make sure we're getting our patients activated with their physical health and their behavior health at the point when they come in for primary care, instead of waiting for them to come to a specialty mental health center.”
Charting the Course
It’s no surprise that the most popular aspect of the project has been the IT innovation, Quammie notes. But providing the connectivity and data intelligence needed to level access to healthcare services is easier said than done. Many of the physician practice groups in the state have an electronic health record (EHR) system, but didn’t always know how to utilize it to its full functionality or do high-level analytics needed for doing deep-level population health.
“For us, it's not just about interfaces. It's about working on a scale that doctors understand and see value from,” he explains. “So, let’s say you have an electronic health record, you have your staff, and then you have data that's created from that EHR. How do you manage all that? What tools and processes can be employed to ensure that the data you're putting in is accurate?”
To help SIM practice turn data into actionable information, SIM funds a dedicated advisory squad of IT professionals who go to the physician group practice sites and help staff learn more about what the data systems and network could do to advance their practices. The help team, called the Clinical Health Information Technology Advisors (CHITAs), help practices where the rubber meets the road: streamlining revenue and improving documentation for reporting. CHITA members also work one-on-one with practices to show them how to assess the reports generated by their EHRs and how to harvest that data for greater initiatives, like discovering hidden reimbursement gaps or improving high-risk patient outcomes. “When it comes to physician buy-in, it’s primarily about trust,” Quammie says. “The CHITA team is there to say, ‘well, here are some examples of patients who didn’t meet the outcome grade,’ and we can show them why, and grow together through that data learning curve.”
Getting IT Done
As the project begins its third year, the team has learned plenty about implementing such a large project without losing focus on its missions.
“Health information technology has been one of the most challenging parts so far because there are a lot of data silos and a lot of restrictions and data sharing,” Martin says. “We’ve also been working hard to determine our roles in technology implementation. There’s so much technology—it seems there's a new app every week—so there are amazing ways of connecting with patients that we didn't have five or 10 years ago. We want the providers to decide what can help them reach their patients.”
Eagerness has abounded among primary care physicians and mental health specialists. Not surprisingly, one of the big factors in getting physician practices and mental health specialists on board is proving outcomes value—and for Colorado, that began with showing the data on the Medicaid and high-risk populations and the opportunities for payment reform, especially through robust population health interventions. As of May 2018, the Transforming Clinical Practice Initiative, one of the sub-projects born out of Colorado’s SIM, has gained nearly 2,000 clinician participants.
But the wisest choices for IT investment aren’t always the most obvious ones, Quammie explains. “It's one of those chicken-eggs scenarios. Do you invest in the technology upfront and then hopefully be able to contract better rates later? Or do you wait for the carrier contracts to tell you what they want you to do? It's been one of those back-and-forth scenarios, because the technology isn't cheap. So you have to prove the future value, which often depends on how well those contracts were negotiated, and whether they included telehealth or not.”
Partnering for Success
As anyone involved in healthcare transformation knows, all the health IT initiatives in the world won’t matter unless the payers are on board. So, as part of the process, the SIM project has partnered with most of the state’s major payers, including UnitedHealthcare, Anthem, Rocky Mountain Health Plans, Cigna, Kaiser and Colorado Medicaid.
The project team also is partnering for greater broadband connectivity in remote areas, something that remains an issue within parts of the state, Quammie notes.
Yet, the sheer availability of technology isn’t always the whole story, Martin observes. “We’ve had an explosion of telehealth opportunities for patients, but not a lot of structure around those opportunities,” she says. “The technology exists for patients to get an email from their health plan for telehealth options. They can also get telehealth services from their provider and potentially also be able to access it just like they would in person. But, without coordinating that with the patient's medical home or with their primary care doctor, we have concerns that we aren’t really providing coordinated care. And, we also still need to figure out how to monitor that and how cost-effective it is.”
As more physician practices join the endeavor, the SIM project will see greater results in chronic care management, Martin predicts. “Physician practices should be thinking of telehealth as a modality that can help with some of their chronic care patients that live far away but only need to see a clinician once a year, while, say, managing their diabetes via telehealth every quarter.”
The Structure for Moving Forward
Colorado’s SIM project has laid the IT groundwork for allowing its clinicians to focus to engaging patients in wellness instead of waiting until they’re sick. That new data communication platform is helping to change the state’s health equation from passive care to proactive care. All that data is being used to populate a statewide database from all payers of procedures and care services, called the Civic Center for Improvement Value and Healthcare, which increases transparency on the costs associated with certain procedures and allows health consumers to make more informed choices, the main goal of the Triple Aim concept. “We're one of the few states that actually has an all-payer claims database,” Martin adds. “So if you are a commercial plan in Colorado, you must send your claims data to the state’s centralized database. One of the things it publishes on an annual basis is the specific costs for a certain high-dollar surgeries like knee surgeries.”
The Colorado SIM project stands as a hallmark of what can be done when IT and quality care efforts meet at the physician practice level and meet patients where they first arrive in the healthcare continuum. As the state’s population health endeavors reach toward connectivity between primary care and behavioral health specialists, patients will see the lowering of barriers to care and a lifelong engagement in their physical health as well as their mental health.
Pamela Tabar is a healthcare writer based in Medina, Ohio.