Ohio Health Quality Improvement Plan

Ohio Health QualityImprovement PlanAn Action Plan based on the Recommendations of theOhio Health Quality Improvement Summit

Co n t e n t s368121416222526272830IntroductionOhio Health Quality Improvement PlanPatient-Centered Medical HomesHealth Information TechnologyPayment ReformInformed and Activated Patients and IndividualsMeasuring SuccessNext StepsAppendix I — Statewide EffortsAppendix II — Responses to QuestionsAppendix III — Survey ResultsAppendix IV — Comments from Statewide Organizations

Introduc tionIn November 2008, more than 180 health care providers, business leaders, government officials and health advocatesinterested in pursuing health system reform participated in the Ohio Health Quality Improvement Summit. During thisthree-day event, those attending developed twelve strategies for creating a high-quality, cost-effective, high-performinghealth system in Ohio by 2013. The report summarizing their work can be downloaded at http://ohqis.pbwiki.com/Report.Participants at the Summit also proposed corresponding tactics for each of the twelve strategies in order to optimize thehealth of Ohioans across a continuum from prevention through end- of- life care (see Figure 1 for list of strategies andvote totals from the Summit).Since the Summit, a number of participants have used the summit strategies and subsequent activities to develop the OhioHealth Quality Improvement Plan. In April 2009, the plan was presented in a draft form to Summit participants and otherstakeholders for review and comment. The plan contained within this report reflects the input received through a meetingattended by more than 150 individuals and a comprehensive and widely distributed survey.Summit Strategies(with votes received)Adopt Chronic Care ModelPromote health, wellness through lifestyle optionsPatient-centered primary, secondary care348318487Increase percentage receiving preventive servicesReduce error rate, improve transitions communicationDecrease non-value-added administrative, transaction costsPatient-centered decision making for end-of-life careEvidence-based medicine and managementSystem-wide culture of safetyReduce health care-associated infections230192188187184171171Fig. 1Reduce adverse drug eventsInjury prevention791433

In t r o d u c t io nBackgroundIn June 2007, Ohio was selected to participate in the Robert Wood Johnson Foundation’s State Coverage Initiative (SCI).Through this effort, policymakers in participating states were provided with policy and technical assistance to help themexpand health care coverage at the state level. As part of SCI, the Governor appointed a 45-member bipartisan team,which worked closely with a broad-based coalition of stakeholders, to develop strategies to expand coverage to moreOhioans and make coverage more affordable. After a year-long process of uncovering the facts, analyzing the coveragesystem, and modeling proposed reforms, the SCI team reached consensus on a set of recommendations. The July 2008final SCI report to the Governor included recommendations in six categories, one of which focused on the link betweenhealth care coverage and health system improvement. Widespread agreement existed among participants that in order toexpand quality, affordable health care to all Ohioans, Ohio needed to make significant changes in health care delivery.As a result of the SCI work, Ohio was one of nine states chosen to participate in the Commonwealth Fund/AcademyHealth State Quality Improvement Institute (SQII). The SQII was an intensive, competitively selected effort tohelp states create and implement concrete action plans for improving health system performance across targeted qualityindicators. This effort was kicked off in June 2008 with a meeting of participating states in Chicago. After participatingin this meeting, Ohio’s team concluded that, rather than addressing a limited number of targeted indicators, an opportunityexisted to pull together a diverse group of stakeholders to coalesce around a portfolio of health system improvementstrategies.To accomplish this, the team designed the Ohio Health Quality Improvement Summit to: (1) build a set of wide-rangingstrategies that offer opportunities for short- and long-term return on investment, (2) commit to action with a larger groupof partners, and (3) maximize the value of local initiatives already underway throughout the state.The Work at the SummitPrior to the Summit, four small planning groups met and, using a firm base of research, developed draft strategies andtactics as a platform from which participants in the Summit would build. The four areas of focus were:• Improving chronic care management;• Improving patient safety and reducing errors;• Promoting health and preventing disease and injury; and• Improving efficiency and decreasing costBackground reading material and preliminary recommendations were provided to participants prior to the Summit.At the Summit, participants heard from national and state experts, and then divided into work groups around the fourfocus areas. With the assistance of a facilitator, groups were instructed to identify a maximum of four strategies andrelated tactics with the greatest potential for improving the quality of the health care system. In addition, facilitatorsinstructed each group to address four cross cutting issues that affect each of the focus areas: health disparities, healthinformation technology (HIT), workforce development and payment reform.The result of the focus group conversations was a set of 12 recommended strategies to improve the quality of Ohio’shealth system. After a presentation from each of the focus groups, participants convened and ranked the strategies. Thefocus groups then reconvened to develop tactics and next steps for the top one or two strategies in their focus area, asprioritized in Figure 1 on the previous page. These tactics were presented by each group to all participants on the final dayof the Summit.Reporting on the SummitAs the Summit reached its conclusion, participants expressed excitement for reform and shared a commitment toensuring the recommendations were taken seriously and acted upon. To that end, the SQII team immediately convened an4

In t r o d u c t io nimplementation team consisting of leadership from various organizations and associations across health care stakeholdergroups who participated in the event.In addition, the SQII team prioritized creating a report both for Summit participants and those interested in health reformwho could not attend. Summit attendees and other interested stakeholders were asked to review a draft report and providefeedback throughout December 2008 and early January 2009. One hundred and nine (109) individuals, many of whomdid not attend the Summit, commented on the report.Vision for a Healthy OhioPrior to drafting the action plan, the implementation team recognized that while the Strickland Administration’s Visionfor a Healthy Ohio covered many elements of the desired future state of health and health care in Ohio, the vision shouldbe revised to maintain the spirit of the Summit — a collaborative work product across the public and private sectors.Through an open refinement process, the implementation team, with additional input from members of the Governor’scabinet, created the following Vision and Principles for a Healthy Ohio:VisionAll Ohioans achieve and maintain optimal health and wellness through access to high quality health care, healthy foodand activities that stimulate physical, mental and emotional well-being.All Ohioans have the information needed to make cost effective, clinically appropriate and culturally relevant decisionsrelated to prevention of illness and injury and treatment or care.PrinciplesIn order to achieve the Vision for a Healthy Ohio, healthcare must be:• Affordable;• Preventive;• Effective;• Coordinated and continuous;• Focused on the whole person: body and mind;• Patient-centered with a team approach; and• Provided at the right time, in the right amount, and atthe right location.Ohio’s health care system must:• Be economically sustainable;• Be efficient;• Be safe;• Address health disparities;• Improve population-based health; and• Be culturally competent.The revised vision was subsequently agreed to by the full implementation team.5

Oh io He a l t h Qu a l it y Im p r o v e m e n t Pl a nDeveloping the Ohio Health Quality Improvement PlanBetween January and May 2009, the core SQII team developed a road map for implementing the strategies developed atthe Summit. Initially, their efforts centered on prioritizing strategies; however, there was an immediate recognition thatcreating a truly transformational health system for Ohioans would require work on two fronts. First, transformationalchange would require creating an affordable and sustainable health care financing and delivery system. Second,strategies would need to be implemented to move from a sick-care system to one focused on wellness and health. Theimplementation team also identified critical concepts that are essential for the success of any of the 12 strategies identifiedat the Summit.Collaborative TransformationalStrategiesThe team decided to refocus its attention from the12 strategies to 4 core collaborative transformationalstrategies (CTS):• Patient-centered medical home• Health information technology• Payment reform; and• Informed and Activated Patients and Individuals.The team used the following criteria for selecting thefour collaborative transformational strategies (CTS):• Each of these strategies is considered animportant contributor to and factor for thesuccess of the twelve strategies developed at theSummit.• None of the four transformational strategies hasa clear institutional home to provide directionand leadership (as opposed to strategies suchas patient safety and health promotion, bothof which have identified institutional homesPatienttoensure continued ongoing work on thoseCenteredMedicalactivities).Home• The four strategies all have the potential toenhance access to care, including the abilityOHQISto make coverage both more affordable andFig. 2available.• The four strategies are interrelated andcomplementary, building off of each other toward a greater whole.MetricsProcess level Metrics (work progress) System Level Metrics (health outcomes)Vision for Healthy OhioAll Ohioans achieve and maintain optimal health and wellness through access tohigh quality health care, healthy food and activities that stimulate physical, mentaland emotional well-being.All Ohioans have information needed to make cost effective, clinically appropriateand culturally relevant decisions related to prevention of illness and injury and treatmentor care.Affordable andSustainable Financingand Delivery SystemPaymentReformHealthInformationTechnologyActivatedand EngagedOhioansCore Collaborative Transformational StrategiesImplementation TeamCore Planning TeamFocus on Health andWellnessHealthyOhioPatientSafetyInstituteUnified LongTerm CareOhioBusinessRoundtablehealthinitiativesWork in Other Areas (examples of state-wide work, not exhaustive)Figure 2 is a graphical representation of the relationship between the “building block” initiatives and how that work couldlead to achieving the Vision for Healthy Ohio.Summit Strategies and Collaborative Transformational StrategiesTo confirm that these four collaborative strategies would support the success of the 12 Summit strategies, the core teamcreated a crosswalk between these two groups of strategies (see figure 3 below). In addition, the table acknowledges thatimportant key work is taking place in other state-level initiatives, including but not limited to: Healthy Ohio within the6

Oh io He a l t h Qu a l it y Im p r o v e m e n t Pl a nOhio Department of Health; the Ohio Patient Safety Institute – a collaborative founded by the Ohio Hospital Association,the Ohio State Medication Association, and the Ohio Osteopathic Association; the Unified Long Term Care Budget, led bythe Ohio Department of Aging; and work being sponsored by the Ohio Business Roundtable. A brief description of someof these initiatives can be found in Appendix I (page 26).Health Disparities and Workforce CapacityThe team also recognized health disparities and workforce capacity must be addressed in order to transform thestate’s health system and achieve the vision for all Ohioans. As evident during the Summit, these issues cross all fourcollaborative transformational strategies. To address the reduction of health disparities, an ad hoc, public-private workgroup was created specifically to focus on the issue in the months after the Summit. Recommended tactics developed bythe work group have been considered and incorporated in each Collaborative Transformational Strategy and will continueto be developed as part of the Health Care Coverage and Quality Council’s (HCCQC) work to identify priorities andfacilitate implementation of the Plan. 1Work groups, consisting of participants from the summit, were formed around each of the Collaborative TransformationalStrategies. In the course of their work, the CTS workgroups developed a set of proposed short, mid, and long-term processmilestones/metrics for their tactics.Descriptions of each strategy, benefits and outcomes, related tactics, proposed milestones and metrics, and decision pointsfollow.Fig. 3Core CollaborativeTransformationalStrategiesWork in other areas(Examples of state-wide work,not meant to be exhaustive)Summit Strategies(listed in order of votes received)Patient Centered MedicalHomesPayment ReformActivated/InformedPatientsHealth InformationTechnologyHealthy OhioPatient Safety InstituteUnified Long Term CareChronic Care Model Culture of wellness Patient-centeredprimary careClinical preventive screenings Reduce errorsduring hand-offs Decrease non-value-addedadmin costs Patient-centeredend-of-life decisions Evidence-basedmedicine System-wide cultureof safetyReduce health care-associatedinfectionsReduce adversedrug events Injury prevention Ohio BusinessRoundtable healthinitiatives1 The Ohio Health Care Coverage and Quality Council was created in February, 2009, by an Executive Order of Gov. Ted Strickland. Thereis more information about the Council in the Next Steps section of this report.7

Pa t ie n t Centered Me d ic a l Ho m e sPromote the use of the Patient-Centered Medical Home (PCMH) approach to supportthe delivery of comprehensive primary care for children, youth and adults.Through collaboration at both the state and regional levels, develop the informational, technological and reimbursementinfrastructure needed to implement and support widespread dissemination of the PCMH approach throughout Ohio.Defining the PCMH*The following definition should be used to advance the PCMH approach in Ohio. The PCMH in Ohio should provide thefollowing to its patients:• A continuous relationship with a physician or other credentialed clinician;• A multidisciplinary team that is collectively responsible for providing for a patient’s longitudinal health needs andmaking appropriate referrals to other providers;• Coordination and integration with other providers, as well as public health and other community services, supportedby health information technology;• The patient as a partner in decision-making about health care;• An expanded focus on quality and safety;• Enhanced access through extended hours, open scheduling, and/or e-mail or phone visits; and• Culturally competent care.This definition is consistent with the Joint Principles describing the characteristics of a PCMH developed by the AmericanAcademy of Pediatrics, American Academy of Family Physicians, American College of Physicians and AmericanOsteopathic Association; the PCMH minimum capabilities identified by the Medicare Payment Advisory Committee(MedPAC); and the PPC®-PCMHTM standards established by the NCQA.* The term PCMH is being used because of its widespread visibility, including in federal law, even though other termsmay be more encompassing/descriptive.Benefits and Outcomes• The Medical Home initiative at Geisinger Health Systems in Pennsylvania cut hospital admissions by 20 percent andcosts by 7 percent. 2• The North Carolina Chronic Disease Management collaborative produced cost savings of $957,493 for a sample of2,745 patients through the use of chronic disease registries. 3• The report, Financing the New Model of Family Medicine (2004), estimated that if every American had a medicalhome, health care costs would likely decrease by 5.6 percent, resulting in national savings of $67 billion per year, withan improvement in the quality of the health care provided. 4• Research conducted by RAND and the University of California at Berkeley found that care provided according toPCMH principles produced the following results: patients with diabetes had significant reductions in cardiovascularrisk; CHF patients had 35% fewer hospital days; and asthma and diabetes patients were more likely to receiveappropriate therapy. 5• The Commonwealth Fund found that a Medical Home can reduce or even eliminate racial and ethnic disparities inaccess and quality for insured persons. 62 Fox M., “Medical Home” plan cut hospital admission: study,” Reuters, September 10, 2008.3 North Carolina Department of Health and Human Services, North Carolina Chronic Disease Management Collaborative, June 2006.4 Spann S. J. et al, “Report on Financing the New Model of Family Medicine, ” Annals of Family Medicine, Vol. 2, Supplement 3, November/December 2004.5 A Robert Wood Johnson-funded evaluation of the effectiveness of the Chronic Care Model and the IHI Breakthrough Series Collaborative in improvingclinical outcomes and patient satisfaction with care, accessed January 15, 2009 at http://www.rand.org/health/projects/icice/index.html.6 Beal A. C., Doty M. M., Hernandez S. E., Shea K. K., and Davis K., Closing the Divide: How Medical Homes Promote Equity in Health Care: Results FromThe Commonwealth Fund 2006 Health Care Quality Survey, The Commonwealth Fund, June 2007 .8

Pa t ie n t Centered Me d ic a l Ho m e sTacticsPCMH Task ForceCreate a PCMH Task Force under the newly created Health Care Coverage and Quality Council (HCCQC). The TaskForce should include consumers, policymakers, educators, practitioners, payers and providers, and have co-chairs fromthe public and private sectors. The PCMH Task Force should play statewide leadership roles in the following areas:Education• Promote the PCMH approach as an effective tool for improving health care access, quality and efficiency througheducation of Ohio policymakers and the general public.• Convene institutions and associations in Ohio, at both the state and local levels, to establish learning and sharingopportunities on the PCMH approach (i.e. learning collaborative) and provide technical assistance to primary carepractices (e.g., Improving Performance in Practice, TransforMED, Institute for Health care Improvement) interestedin implementing the PCMH approach and using Health Information Technology (HIT) to transform their clinical andbusiness practices.• In coordination with the Patient and Public Involvement Task Force develop culturally competent messages, materialsand curriculums that can be used to teach patients/caregivers how to use the PCMH and self-manage chronicconditions. For some populations consideration should be given to programs that educate the patient within thePCMH.Communication and Coordination• Serve as a technical resource to keep track of federal PCMH developments and best practices in other states andcommunities, and share that information with Ohio-based PCMH advocates and program initiators.• Serve as the conduit to the federal government and national associations on PCMH issues and initiatives.• Promote coordination and linkages with other non-primary-care, health-related systems and long-term care systems tomeet the needs of individuals as they move across care settings (e.g., hospitals, home care, long-term care facilities,hospices), including:◦◦ Behavioral health systems to meet the needs of individuals with severe mental illness and/or addiction◦◦ Public health and community aging resources, and long-term services and supports (e.g., education, immunizationprograms, chronic disease management programs) to activate and support patients◦◦ Pharmacy, including making e-prescribing and Medication Therapy Management available to support the needs ofpatients, especially those with chronic conditionsFacilitation• Operationalize the PCMH definition, including, if necessary, adopting specific criteria (e.g., NCQA) for each elementof the definition for credentialing, certification and reimbursement purposes.• Promote and support local/regional PCMH initiatives and collaborations. Especially those that focus on reducinghospital readmissions through coordination between hospitals and PCMHs and invest savings into expanding accessto care.• Track PCMH initiatives and outcomes across the state.• Encourage access to the PCMH approach to people regardless of racial, ethnic, geographical and economicdifferences, through implementation in community health centers, through mobile units or other means to reachpeople in medically underserved areas and at-risk populations.• Support regional and multi-payer collaboratives to address perceived barriers, such as anti-trust issues.Evaluation• Identify and use standardized financial and clinical metrics vetted by creditable organizations to measure return oninvestment (e.g., cost avoidance and savings) of the PCMH approach (including patient safety and preventable errorrates); quality of care provided through the PCMH; and ability of the PCMH to reduce health disparities, expandaccess to care, and improve outcomes among at-risk populations.• Promote, facilitate and support the use of medical registries (e.g., American Osteopathic Association’s ClinicalAssessment Program) and Electronic Medical Records (EMR) to provide practitioners information aboutdemographics (e.g., race, ethnicity), outcomes and utilization of appropriate care processes in their patientpopulations.9

Pa t ie n t Centered Me d ic a l Ho m e sPCMH Payment ModelsThe PCMH Task Force should develop and promote public policies that create economic incentives and financingstrategies that support and encourage implementation of the PCMH approach. Incentives and strategies should focus onensuring that all Ohioans have access to appropriate and high-quality primary care. Consideration should be given to:• Researching, including identifying pros/cons and implications for Ohio, the different PCMH payment reformoptions. While there is no clear consensus or evidence to support a single, best financing mechanism, there is generalagreement on a number of key attributes, including the following:◦◦ Payment reform is a critical component of any effort to re-design primary care and promote the PCMH approach;◦◦ Funding mechanisms must be transparent to providers, payers, and consumers;◦◦ Funding mechanisms must provide reimbursement for services and activities not currently covered undertraditional fee-for-service (FFS) payments. These include coordination of care, improved access, and caremanagement;◦◦ Funding mechanisms must reward providers for improving health outcomes, improving quality of care, anddecreasing cost through better preventative and disease management services;◦◦ Payers must recognize that there are transitional and start-up costs associated with moving to the PCMHapproach, including investments in health information technologies;◦◦ Develop incentives to ensure providers in medically underserved areas adopt the PCMH approach and havesufficient resources to do so; and,◦◦ Regardless of the payment mechanism, resources and shared savings will need to be redirected to optimize thelevel of primary care service.• Determining how publicly funded health care programs and benefits (e.g., Medicaid, FQHCs, state and countyemployees’ health benefits, worker’s compensation) can be used to encourage/stimulate the development of thePCMH approach in Ohio.• Identifying funding (e.g., AHRQ) and developing finance strategies that promote the creation of regional10collaboratives.Primary Care WorkforceIn collaboration with state agencies, provider/practitioner organizations, educational institutions and consumer groupsthe HCCQC should coordinate efforts to expand and enhance the primary care workforce in order to support theimplementation of the PCMH approach. Consideration should be given to:• Defining the clinical and support professionals needed for primary care and PCMH;• Fortifying the pipeline to primary care careers, and fostering opportunities for students to participate in primary careeducational and training experiences, while also increasing exposure to primary care for health professional students;• Ensuring that there is an adequate supply of programs and teachers to train the future primary care workforce;• Creating opportunities and incentives for health professionals entering primary care careers, including placement andtraining opportunities in underserved areas, and training as members of interdisciplinary teams;• Revising the current provider payment system to reflect the essential role and value of primary care in the health caredelivery system, attract more primary care professionals, improve access to primary care and encourage coordinated,team-based care;• Reviewing state scope of practice laws to improve collaborative practices and improve location options for all primarycare professionals;• Designing interdisciplinary training programs (e.g., health care education, CME/CE) that target the needs of thePCMH approach and support care of special needs populations (e.g., older adults, behavioral health, chronicconditions, long term disabilities) receiving care through the PCMH;• Increasing the awareness of providers/practitioners as to how culture affects who seeks treatment and where they seektreatment as well as the understanding of cultural bias; and• Developing and enhancing curricular integration of informatics in health care with emphasis on population-basedcare, quality and safety, and evidence-based practice.

Pa t ie n t Centered Me d ic a l Ho m e sProposed Milestones/MetricsTactic 1: Create a PCMH Task Force under the newly created Health Care Coverage and Quality Council.• 6 Months – By September 1, 2009 identify members of the PCMH Task Force and convene the first meeting of theTask Force.• 1 Year – By March 1, 2010 submit a detailed plan to the HCCQC that establishes the infrastructure needed to supportthe implementation of the PCMH in Ohio, including identifying standardized financial and clinical metrics (withbenchmarks) to measure: return on investment, quality of care, and ability of the PCMH to reduce health disparitiesand expand access to care.• 1 Year – By December 2010 develop a set of cultural competency standards for PCMH’s.• 2 to 3 Years◦◦ At least five regions of the State of Ohio have established PCMH programs.◦◦ At least 5% of primary care practices are implementing the PCMH approach.◦◦ A 15% increase in the numbers of PCMH’s in census tracts with high health disparities.Tactic 2: The PCMH Task Force, in collaboration with the Payment Reform Task Force of the Coverage and QualityCouncil, will develop and promote public policies that create economic incentives and financing strategies to support andencourage implementation of the PCMH approach.6 Months – By September 1, 2009 Payment Reform/PCMH Work Group established.• 1 Year – By March 1, 2010 the Work Group recommends payment reform strategies and policies, to be included indetailed plan noted above, that support and encourage implementation of the PCMH.• 2 to 3 Years◦◦ At least one state-funded health care program supports the implementation of the PCMH approach in Ohio.◦◦ At least one multi-payer collaborative is formed to support the implementation of the PCMH approach in Ohio.Tactic 3: In collaboration with state agencies, provider organizations, educational institutions and consumer groups createplans and incentives, building on existing initiatives in Ohio and across the country, to expand and enhance the primarycare workforce to support the implementation of the PCMH approach.• 6 Month – By July 1, establish a work group to create a plan that supports the findings of the “Physician Supply andDemand Consultation to the Ohio Board of Regents,” and other research, identifies incentives, recommends changesto public policy and establishes metrics and benchmarks.• 1 Year – Begin to implement the recommendation in the plan.• 2 to 3 Years:◦◦ Begin to see an increase in the percentage of Ohio medical and nursing school graduates entering Primary Care(General Internal Medicine, General Pediatrics, FP/GP) residencies and/or practices.◦◦ Increase in the number of CME/CEU courses that focus on care coordination and the PCMH approach.◦◦ Increase the numbers of culturally diverse medical staff working in PCMH’s by 15% by December 2010.Decision Points1.2.3.4.Which elements/models of payment reform would be most beneficial to implementing the PCMH approach in Ohioand constraining spending in the non-primary care sector?How should Ohio balance efforts in advancing the PCMH approach in Medicaid and in multi-stakeholder modelsincluding both commercial and public payers?How should state government incentivize and support the regional PCMH and access plan collaboratives that arecurrently bubbling up around the state through local initiatives?Should Ohio’s initial implementation of the PCMH approach be focused on improving outcomes for individuals withmultiple chronic conditions or all populations?11

He a l t h In f o r m a t io n Te c h n o l o g yDevelop a technology infrastructure that supports the adoption of electronic medical records andsupports the medical home concept through a robust health information exchange.A non-profit organization will be designated to achieve these goals by:• Creating a statewide health information network• Developing a center of excellence to provide health care information technology integration and education servicesdirectly to health care providers• Improving electronic medical record (EMR) adoption• Coordinating and leveraging the outstanding higher education system and research and development activities withinthe state of OhioBenefits and Outcomes• Lower health care costs. A study released by the Ohio Business Roundtable in December 2008 estimates that $6billion can be saved by improving information sharing between patients and clinicians.• Improved health care outcomes through better care management. One example is a reduction in adverse druginteractions by providing health care providers access to current and recent prescriptions for their patients.• Improved population health by aggregating statewide health data in a timely, accurate and electronic method.TacticsThe PartnershipThe State of Ohio will designate a non-profit entity to create and manage the statewide health information network.This non-profit will also act as Ohio’s center of excellence for health information technology. The non-profit will workcollaboratively with the Ohio Health Care Coverage and Quality Council.Action Steps• Create or designate non-profit• Create or modify articles of incorporations and governance structure• Implement ethics, management and financial controlsThe Ohio Health Information NetworkThe health information network will be the primary tool to share data from the individual EMR tools used by Ohio healthcare providers. The network will allow authorized providers to see an individual’s care history regardless of the settingof care. This will facilitate better care coordination across the care continuum (including at handoffs and transitions) aswell as a reduction in redundant tests. The network will facilitate improved population health by providing researchersand policy makers access to a broad set of health data. The network will provide enhanced patient security by providingaccess to patient authorization, roll-based requester privileges, and automatic data access tracking. The network willpromote patient participation by allowing integration of a number of personal health record tools.The network exchange will be managed in a federated model. This model will support a variety of users accessing thenetwork in the most effective manner based on their role.As the name implies, data partners are those network members whose primary role revolves around the management ofdata. There are two types of data partners. One type is a member of the network who has patient data available for accessby other network members. Examples of this type of data partner include health care providers, labs, or state government.The other type of data partner would be a member who is authorized to access or extract large quantities of data, typicallyfor population health purposes. Examples of this type of data partner include state government, research organization orthe federal government.Providers are network members who are accessing data for the primary purpose of patient care. In this role, providershave view-only access to the data available. Providers may also be data partners, but have different access andpermissions based on the role in which they are accessing the data.12

He a l t h In f o r m a t io n Te c h n o l o g yPatients can only access their own data. This access could be enhanced by using a personal health record such asMicrosoft HealthVault, Google Health, etc. Patients can also access the audit and query database to see who has accessedtheir data.Action Steps• Apply for federal stimulus funds• Develop network requirements• Create and issue a request for proposals (RFP)• Award RFPThe Ohio Center of Excellence for Health Information TechnologyThe center of excellence will provide a variety of services to help health care providers maximize the benefits ofelectronic medical records and health information exchanges. One of the center’s initial objectives will be to provideEMR integration services to health care providers. These integration services will help providers modify their work flowto take advantage of the EMR tools. Integration services will also help providers integrate their EMR systems with theirpractice management tools. The center of excellence will also provide toolkits and publish best practices to help providersmaximize the benefits of implementing EMRs. Ohio envisions these objectives to be accomplished through strongrelationships with Ohio’s system of higher education and other qualified experts.Action Steps• Develop specific services• Apply for federal stimulus funds• Develop criteria for integration service providers• Create a integration service provider certification process• Develop best practices toolkit• Develop health care provider communication strategyImproving Electronic Medical Record AdoptionThe value of the statewide health exchange depends critically on the number of providers using EMRs. Special attentionneeds to be paid to improve adoption by small providers and nonprofit clinics. This segment of the market may not havethe financial or resource capability to adequately implement or manage an EMR solution. The partnership may provide anEMR tool as a service to this market segment. Alternatively, the partnership may facilitate a purchasing collaborative toallow a large number of small providers access to better pricing for one or more EMR solutions.Action Steps• Survey provider community to determine interest in collaborative versus service approach• Develop detailed plan based on service decision• Release and award RFPProposed Milestones/Metrics• Partnership designated – June 1, 2009• EMR service strategy finalized – August 1, 2009• Loan program strategy finalized – August 1, 2009• HIE RFP awarded – January 1, 2010• Center of excellence service provider certification program completed – August 1, 2009• Establish realistic adoption targets for EMR and health information exchange usage – January 1, 2010Decision Points1.2.3.Should the state designate a newly formed non-profit or designate an existing non-profit to manage health ITinitiatives?Should the non-profit provide an EMR as a service or facilitate a purchasing collaborative?What services need to be provided through the center of excellence?13

Pa y m e n t Re f o r mThe purpose of payment reform is to transform public and private payment systems inorder to improve the value of health care spending.Improve the quality and efficiency of patient care and reduce health care costs by adopting and implementing payment modelsto support medical homes, health promotion, patient safety and more efficient business processes and delivery of care for allOhioans.Benefits• Patient health, safety and care will improve, particularly in prevention and management of chronic conditions.• More primary care practices will adopt the patient centered medical home model leading to improved patient health,culturally competent care and improved outcomes.• Health care will be better coordinated, decreasing the need for hospitalizations for conditions that should be appropriatelymanaged in ambulatory settings.• More providers will adopt electronic medical records and e-prescribing, decreasing the likelihood of unnecessary care andavoidable adverse events.• Cost effective care, such as the use of generic drugs, will be incentivized.• Expenditures for redundant tests, inappropriate care, and avoidable adverse events will decrease.• Administrative costs will be reduced through efficiencies created by electronic billing and electronic eligibility verification.TacticsTactic 1: Identify and recommend payment models to support patient centered medical homes (PCMH) and develop paymentmethodologies (e.g. fee for service with incentives/disincentives, reimbursement bundling based on episodes of care, outcomesbased reimbursement, capitation, etc.).• The Coverage and Quality Council should appoint a stakeholder group of payers, professional organizations and agenciesto evaluate and agree upon payment reform models to support PCMHs and to create metrics for quality and transparentoutcomes. The stakeholder group should:◦◦ Work with the PCMH group to define critical elements in the PCMH that should be reimbursed;◦◦ Work with the PCMH group to develop strategies to build workforce capacity such as providing partial loan forgivenessto new physicians and nurse practitioners who choose to become primary care providers in underserved areas and withunderserved populations;◦◦ Identify and evaluate available PCMH payment models;◦◦ Confer with national PCMH payment reform experts as to available models;◦◦ Decide what to measure on payment reform for PCMH on quality, cost savings and reduction of disparities;◦◦ Develop metrics and outcomes measures for the effectiveness of payment models;◦◦ Develop payment models for all Ohio payers to encourage statewide adoption of PCMHs;◦◦ Determine how to document savings, how to “capture savings,” and how to share savings in PCMHs; and◦◦ Collect and analyze data on cost and quality in other parts of the health delivery system and develop recommendationsneeded for improvements, including metrics related to identifying outcomes affecting disparate populations.Tactic 2: Design financial incentives to promote e-prescribing, e-health records, e-billing and electronic eligibility verification.• The Coverage and Quality Council should appoint a stakeholder group focused on payment reform to support e-healthrecords, e-billing and electronic eligibility verification. The stakeholder group should:◦◦ Work with the HIT group to develop strategies for financial and technical assistance to encourage use of e-healthrecords, e-billing and electronic eligibility verification;◦◦ Work with the HIT group to ensure that HIT initiatives include education and incentives for providers to collect data tosupport population health initiatives that address health disparities and chronic disease;◦◦ Identify private funding sources to help small providers and providers in underserved areas obtain technology;◦◦ Recommend changes to Medicaid regulations to encourage e-billing;◦◦ Develop and recommend private payer incentives for e-health records, e-billing and electronic eligibility verification;◦◦ Identify or develop grant and/or loan opportunities to help small providers and providers in underserved areas acquirethe hardware to enable the e-health records, e-transmission of claims and electronic eligibility verification;14

Pa y m e n t Re f o r m◦◦◦◦◦◦Work with HIT group to develop the software/back office operations needed by small providers and providers inunderserved areas to integrate e-health records, e-billing and electronic eligibility verification efficiently;Develop training programs and a communications plan to support e-health records, e- billing and electronic eligibilityverification; andEstablish metrics to evaluate effectiveness and value of initiatives.Tactic 3: Develop payment policies and reform models that discourage the overuse, underuse and misuse of health care services,products and procedures when evaluated against standards and protocols of evidence based care.• Use available information and criteria to identify likely procedures, practices, pharmaceuticals and technology that providelittle or no value, or have the potential to cause harm.• Collect and analyze Ohio medical claims data from a broad and diverse data set to determine the incidence and prevalenceof such utilization overall and for at risk populations.• Establish metrics to improve patient safety.Tactic 4: Target payment policies to discourage avoidable adverse events.• Develop principles regarding avoidable adverse events using existing criteria from public and private payers.• Identify procedures, services, complications and outcomes that should be subject to an avoidable adverse events policy.• Implement avoidable adverse events payment policies to reduce and eliminate occurrences.• Establish metrics to evaluate effectiveness and value of avoidable adverse events policies.Tactic 5: Develop programs for preferred therapeutic drug substitution.• Identify best practices from national, sister states and private sector efforts.• Develop principles to guide adoption of drug utilization review methodologies to identify and monitor prescribing practices.• Address possible adverse reactions that some minority populations may have to certain drug interventions.• Review existing program policies to inventory current activities and compliance and identify cost effective opportunities.• Develop and implement programs of academic detailing and medication therapy management.• Create educational programs for new and existing practitioners and communications strategy for consumers.• Establish metrics to evaluate the effectiveness and value of preferred therapeutic drug substitution initiative.Proposed Milestones/MetricsWithin 6 months:• Payment reform stakeholder group’s membership appointed by the Council.Within one year:• Existing medical claims data utilization reviewed to determine areas of overuse, underused, misuse• Principles regarding avoidable adverse events established• Medicaid and private payer incentives identified• Financial incentives for e-prescribing, e-billing, e-health records and electronic eligibility verification identifiedWithin two years:• Establish payment policies that discourage underuse, misuse and overuse of services, products and procedures• Establish payment models to support PCMHs• Implement payment models to support PCMHsDecision Points1. What are the principles, values and criteria we should use to evaluate and choose payment reform models?2. What principles, values and criteria should be used to determine overuse, underuse, and misuse of medical services andprocedures?3. Are some payment reform models going to be implemented through regulation and, if so, which ones?4. If payment reform models are voluntary, how will we convince and work with payers to adopt the models we haverecommended?5. How will public and private payment reforms be aligned and coordinated?15

In f o r m e d a n d ActivatedPa t ie n t s a n d In d iv id u a l sInform and activate patients and individuals to promote deeper involvement inimproving their health and in making health care decisions.The concept of patients being more actively involved in their health and health care is a dramatic change from the currentstate where most Americans place responsibility for their health and illnesses in the hands of their doctors. Despite clearbenefits of being involved in our own health and health care, our behavior has not kept pace with advances in medicine,technology and health care services. Obtaining the benefit of these advances to prevent, manage and cure disease dependsincreasingly on one’s own energy, knowledge and skills, regardless of whether one is well or sick. 7An informed, engaged and activated patient is one with a clear understanding of his or her own health condition(s), theskills to self manage, and the ability to share responsibility with the provider for the plan of care. Nearly 90 percentof the care a person needs to manage a chronic disease must come directly from the patient. Evidence is growing thatself-management interventions, such as self-monitoring and decision making, lead not only to improvements in healthoutcomes and health status, but also to increased patient satisfaction and reductions in hospital and emergency room costs.It is important to note the difficult challenges this entails. The shift to activation and shared responsibility cannot be donealone; it requires the help of the health care provider and the support of family, friends and the community. It is not justabout giving patients and individuals better resources to make decisions. Much of the health care system is now drivenby extensive marketing to patients and individuals that increase health care costs by encouraging unhealthy habits and theconsumption of high cost health care products and services. Counteracting these messages effectively is not going to beeasy or inexpensive.For this collaborative transformational strategy, activation is defined as “actions that individuals must take to preventdisease and obtain the greatest benefit from knowledge of both disease prevention and the health care services andcoverage options available to them through the health care system.”The Informed and Activated Patients Team identified two broad aims of engaging and activating patients and/orindividuals: managing health care and managing health. (1) Managing health care involves those actions related eitherto the role of patient in the medical encounter or to that of consumer-purchaser of health care services. These two verydifferent roles are expected to work in seamless coordination as patients/consumers navigate the course of seekingcare and making treatment decisions. (2) Managing health involves those actions shown to prevent disease and thoseassociated with the successful self-management of chronic disease. The objective is to encourage, empower and assistpatients and/or individuals to develop the aptitude to acquire and utilize competencies for:• Healthy lifestyle choices• Health care coverage decisions• Health care treatment decisions• End-of-life decisions• Cultural transformation to informed and activated patients who are valued partners in all aspects of the envisionedpatient-centered health care system.The following principles characterize an optimal culture of informed and activated patients and individuals:• Partnerships (or shared decision making) between patients and providers/practice teams must be underscored.Collaboration and dialogue are essential to the success of the patient-provider partnership and patient-centeredmedicine. Health care and services based on shared decision making increases the likelihood of safe and quality careand positive health outcomes.• A commitment to shared responsibility between patients/individuals and their social environment or the materialconditions of one’s life that impact the well being of individuals and populations. This social environment includes the7 Gruman, J. (2008) A New Definition of Patient Engagement: What is Engagement and Why is it Important. Center for the Advancement of Health.Washington, D.C. 2008.16

In f o r m e d a n d ActivatedPa t ie n t s a n d In d iv id u a l spractices and policies of: employers, schools, health care providers, legislators, policy makers, insurers, neighborhoodassociations, and public health officials.• Equity supports a culture of informed and activated patients. It is essential for all actors belonging to the socialenvironment (described above) to understand and address problems of social equity to ensure access to services for allvulnerable groups, including: the poor, disabled, non-English speaking, and racial-ethnic minorities.• Accurate and reliable information must be made available to patients/individuals and providers/teams. Providers andpractice teams must use evidence-based standards, establish common clinical guidelines and evaluation measures.Accurate and reliable information makes it possible for patients to make informed choices and attain optimal health.Additionally, HIT should be leveraged to attain reliable data for practitioners and patients and allow the monitoring ofprogress.• Health Literacy must be a priority in order to appropriately engage patients and individuals at various phases intheir life span and those who are differentially involved in their health care. In addition to learning about one’s (or afamily member’s) medical condition, individuals can be encouraged to develop self-care and community-care skills(to incentivize less engaged individuals/patients: training the trainers to do outreach in their communities). Patientswill have access to health resources, personal health records, HIT training, tools and incentives through a workingpartnership with providers, practice teams, public health officials and other health care outreach efforts.• Accountability and Transparency to patients, the public and one another is an essential component of an integratedand collaborative health system. Partnership and dialogue can educate patients on what type of care to expect fromtheir providers and empower them to hold their providers accountable. Additionally, unbiased data that providesinformation about pricing and safety of procedures, devices, and medications, must be a priority.BenefitsPatient activation has the potential to reduce harm; reduce disparities; reduce disease burden; and reduce waste. 8Findings from two separate studies indicate that both patient activation and health literacy contribute to health outcomes. 9While only moderately correlated, both make independent contributions to health behaviors, health choices, and healthoutcomes. Health literacy contributes more to choices and the use of information; activation contributes more tohealth behaviors. Another study indicated that activation may help to compensate for lower literacy skill, increasingcomprehension among those with lower literacy. 10There is empirical evidence that giving patients information and involving them in decisions about their health care canresult in beneficial psychological and physical outcomes, including enhanced patient satisfaction, 11 adherence to treatmentplans, 12 and greater confidence in health care recommendations. 13Empirical evidence also suggests that as patients traverse the four stages of activation – (1) the patient does not yet believethat he or she has an active and important role in their health; (2) the patient lacks the confidence and knowledge to takeaction; (3) the patient begins to take action; and (4) the patient maintains behaviors over time – they display behaviorsindicative of becoming fully competent managers of their health. 148 National Partnership. National Priorities and Goals: Patient and Family Engagement. November 2008.9 Hibbard, J.H., Greene, J., & Tusler, M. (2006). An Assessment of Beneficiary Knowledge of Medicare Coverage Options and the Prescription Drug Benefit(Pub I.D. 2006-12). Washington, DC: AARP Public Policy Institute.10 Hibbard, J.H., Peters, E.M., Dixon, A., & Tusler, M. (2007). Consumer competencies and the use of comparative quality information: It isn’t just aboutliteracy. Medical Care Research and Review, 64(4), 379-394.11 Roter, D. L. (‘83). Physician/patient communication: Transmission of information & patient effects. MD State Medical Journal, 32, 260–265.12 Janis, I. (1982). Effective interventions in decision counseling: Implications of the findings from 23 field experiments. In I. Janis (Ed.), Counseling onpersonal decisions: Theory and research on short-term helping relationships. New Haven, CT: Yale University Press.13 Brody, D. S. (1980). The patient’s role in clinical decision making. Annals of Internal Medicine, 93, 718–722.14 Hibbard JH, Mahoney E, Stockard J, Tusler M. (2005). Development and Testing of a Short Form of the Patient Activation Measure (PAM). Health ServicesResearch. Vol. 40 No. 6 p.1918-1930.17

In f o r m e d a n d ActivatedPa t ie n t s a n d In d iv id u a l sTacticsPatient and Public Involvement Task ForceThe Health Care Coverage and Quality Council “HCCQC” should appoint a Patient and Public Involvement “PPI” TaskForce. The PPI would be charged with identifying methods of activating individuals and patients to take a proactive rolein making health and health care decisionsAction Steps• Task Force should include experts in patient outreach, engagement, and self-management support. In addition, theseexperts teamed with broad stakeholder representation would draw attention to the importance of patient activation andenhance the credibility of the Task Force across disciplines and beyond the medical sector.• Adopt a common measure to assess patient activation and seek adoption by health providers and delivery systems.• Adopt a method to hold providers and delivery systems accountable for supporting and increasing patient activation.Healthy Lifestyle ChoicesAddressing health status improvement is an opportunity and a challenge. It requires a concerted, multi-pronged approachthat combines a synergistic combination of marketing and public policy. Yet behavioral and environmental changespresent the greatest opportunities to save lives and reduce costs. All stakeholders share responsibility for change.• Leverage implementation of Healthy Ohio’s goals and objectives related to Supporting Individuals and Families asdelineated in the Ohio Obesity Prevention Plan, which aggressively targets the primary causes of obesity in Ohio.• Make information and tools related to health promotion and disease prevention widely available.Action Steps◦◦ Integrate a mix of effective communications, community- and school-based approaches, and workplace wellnessprograms to educate and motivate individuals to engage in healthy behaviors.◦◦ Create and distribute materials to persuade individuals of the need to continue the lifelong continuum ofunderstanding health information.• Support financing proposals that give state and local public health agencies adequate and sustainable funding. Publicpolicies should facilitate and provide incentives for healthy living, with a dedicated revenue stream to support publichealth activities at the federal, state, and local level. This funding could support community-based programs to fosterhealthy behaviors, such as nutrition, exercise, and smoking cessation counseling.Action Step◦◦ Collaborate with ODH, OPHA and the Administration to develop a business case for increased funding for stateand local public health.Health Care Coverage Decisions• Develop a model for an Ohio health insurance exchange “connector” through which consumers can easily comparehealth plans and prices to enable them to select the health care plan that best fits their health care and budget.Action Step◦◦ Identify best practices used in developing tools which help individuals:▪▪ Compare coverage options, match to their own values, needs and preferences and select affordable, qualitycoverage (if private insurance through self or employer is applicable)▪▪ Gather and submit relevant eligibility documentation if applying for or seeking to maintain public insurance(e.g., Medicaid, Medicare, SCHIP), compare coverage options if applicable, match to their own values, needsand preferences, and select affordable, quality coverage.▪▪ Use all available comparative performance information (including cost data) to identify prospective providersand facilities.18

In f o r m e d a n d ActivatedPa t ie n t s a n d In d iv id u a l s▪▪Ascertain benefit coverage restrictions or incentives such as mental health benefits limitations, precertificationrequirements, access restrictions to specialists or adjunct health providers, variables in co-paysfor specific types of care or providers before seeking treatment.• Promote broad public access to and use of webCHAT Choosing Healthplans All Together, an abbreviated internetversion of the research and educational tool used by the Ohio Department of Insurance to determine what uninsuredOhioans think a “basic” health plan must offer. 15Health Care Treatment DecisionsTo be effective, information and decision supports related to health care treatment should be offered in understandableformats and take into account the range of health literacy levels and decision-making skills found in society.• Commission the development and testing of skill-building tools, which support health care treatment decision-making,patient activation, patient/provider care teams and self-management.Action Steps◦◦ Identify and facilitate access to culturally and linguistically appropriate tools and practices that have beendemonstrated to support patient engagement and self management.◦◦ Identify and facilitate use of proven, culturally and linguistically appropriate strategies and tools to enablepatients to understand all treatment options and to make decisions consistent with their values and preferences.◦◦ Develop and test culturally and linguistically appropriate tools, strategies or practices if they are not already inexistence.• Develop and implement a “shared decision-making” pilot in one or more of the state controlled medical plans (e.g.,Medicaid, state employee health plan), or in conjunction with early medical home initiatives with an initial focus ona few common expensive conditions where there are multiple treatment options. Key strategies supportive of patientself-management include identifying and disseminating evidence-based self management practices; recognizing thecentrality of self-management to good patient care and incorporating it into health care culture; developing programsand tools applicable to diverse populations; providing incentives for integrating the appropriate self managementsupports into the delivery of health care; and making better use of all members of the health care team.Action Steps◦◦ Identify and prioritize the high prevalence/high cost conditions to target.◦◦ Identify evidence-based self-management practices, disease-specific education programs and patient aids.◦◦ Establish a clearinghouse of patient education, self-management and decision-making tools.◦◦ Identify disease- and/or condition-specific tools that are evidence-based, age, culturally, and linguisticallyappropriate.◦◦ Make tools readily available to patients through marketing campaigns, Web sites, distribution through PCMHsand community organizations.◦◦ Propose incentives for integrating the appropriate use of self management supports into the delivery of healthcare.16• Develop and implement a pilot “academic pharmaceutical detailing” program in one or more of the state controlledmedical plans (e.g., Medicaid, state employee health plan), to provide independent information and support to15 CHAT TM is a computer simulation game, which was developed by physician ethicists at the National Institutes of Health and the University of Michigan.CHAT simulates the challenges in making decisions about health plan benefits packages when there are more choices than resources.16 Academic detailing is “university-based educational outreach.” The process involves face-to-face education of prescribers by trainedhealth care professionals, typically pharmacists, physicians, or nurses. The goal of academic detailing is to change prescribing of targeteddrugs to be consistent with medical evidence, support patient safety, and to be cost-effective medication choices. A key component ofuniversity-based academic detailing programs is that they (academic detailers, management, staff, program developers, etc.) do not haveany financial links to the pharmaceutical industry. For more information on academic detailing visit:http://www.prescriptionproject.org/tools/fact_sheets/files/0007.pdfSee also A Template For Establishing And Administering Prescriber Support And Education: A collaborative, service-based approach forachieving maximum impact. A report by Prescription Policy Choice’s Academic Detailing Planning Initiative. July 2008.19

In f o r m e d a n d ActivatedPa t ie n t s a n d In d iv id u a l sprescribers to counteract the effect of aggressive marketing of branded drugs by the pharmaceutical industry. StateBest Practices with accompanying Toolkits are available through Prescription Policy Choices —http://www.policychoices.org.• Promote the implementation of health literacy initiatives and tools such as those available through the Health LiteracyStudies Web Site: www.hsph.harvard.edu/healthliteracy and the Health Literacy Tool Kit developed by the Council ofState Governments. 17End-Of-Life Decisions• Develop and implement a social marketing campaign promoting the execution of advance directives so that patients’desires are respected and costs are not unnecessarily incurred.• Support initiatives crafted to improve the delivery of effective communication from health care professionals aboutpatient’s options for treatment; realistic information about patient’s prognosis; timely, clear, and honest answers topatient’s questions; advance directives; and a commitment not to abandon patients regardless of their choices over thecourse of their illness.Action Steps◦◦ Promote development of necessary communication skills by health care professionals, which will elicit values andadvance directives.◦◦ Promote uniform messages by health care professionals concerning end-of-life decision-making and theircommitment to not abandon the patient regardless of choices over the course of the illness.◦◦ Promote health care professionals’ communication about treatment options; realistic prognosis; and advancedirectives with patients with life-limiting illnesses.Cultural TransformationEngaging patients in treatment and self-care requires a transformational change in culture from the paternalism which stillcharacterizes most transactions between patients and providers, to a ‘partnership’ approach in which patients are supportedto engage in shared decision-making.Action Steps◦◦ Identify proven and promising methods to activate individuals and patients to take a proactive role in improvingtheir health and in assuring they receive evidence-based quality care from the health system.◦◦ Promote advances at the local, regional and national levels, which contribute to the formation of a supportiveinfrastructure for culturally competent patient-centered care.◦◦ Work with the PCMH Task Force to ensure practice transformation strategies related to medical homes incorporatebest practices in patient activation.Proposed Milestones/MetricsWithin 6 months:• HCCQC will establish and appoint individuals to a Patient & Public Involvement “PPI” Task Force.Within one year:• A baseline measure for the Self-Efficacy for Managing Chronic Disease 6-Item Scale will be determined.• Promotion of webCHAT has taken place in at least one-third of all counties.• Advanced directives executed increased over prior 12-month period.• A framework for an Ohio Health Insurance Connector is circulated for public comment.17 http://www.csg.org/pubs/Documents/ToolKit03HealthLiteracy.pdf20

In f o r m e d a n d ActivatedPa t ie n t s a n d In d iv id u a l sWithin two years:• Generic prescription drugs increase as a percentage of prescription drugs dispensed over the prior 12-month period.• The percentage of Ohioans receiving recommended care for chronic conditions will improve over the baseline.Within five years:• Healthy Ohio will achieve the goals and objectives related to Supporting Individuals and Families as delineated in theOhio Obesity Prevention Plan.18• Ohio will improve its’ ranking among states in per capita State Funding for Public Health.• Within 12 months of its release, at least one Ohio health care system will evaluate the feasibility of implementing theJoint Commission Standards that Support the Provision of Culturally & Linguistically Appropriate Services. 19Decision Points1.2.3.How do we ensure that patient activation/involvement is embedded in the health care delivery system? How dowe ensure that there is continuous improvement in this aspect of patient-centered care? How do we ensure patientactivation/involvement delivers real measurable benefits?How should the Health Care Coverage and Quality Council incentivize delivery systems, in particular patient centeredmedical homes, to engage in patient activation/involvement efforts?How can we provide a balance between involvement from individual patients and involvement from representatives ofpatient groups?18 State Funding for Public Health FY 2007-2008. Trust for America’s Health, http://healthyamericans.org/states/?stateid=OH Last accessed April 20, 2009.19 Joint Commission Standards that Support the Provision of Culturally and Linguistically Appropriate Services (May 2007, pdf)http://www.jointcommission.org/NR/rdonlyres/1401C2EF-62F0-4715-B28A-7CE7F0F20E2D/0/hlc_jc_stds.pdf Last Accessed 4-9-09.21

Me a s u r in g Su c c e s sIn addition to the strategy-specific milestones and measures proposed above, the core team recommends system-leveloutcome measures to help focus attention on the goal of creating a high-quality, cost-effective, high-performing healthsystem in Ohio by 2013. As the strategy-specific measures focus on assuring progress is taking place to implement theidentified tactics, system-level measures will help assess if the strategies and tactics together are producing the desiredtransformation of Ohio’s health care system.In developing the system measures, the team recommends using a balanced scorecard approach, with measures in fivedifferent areas to determine success. The proposed areas are: quality; access; wellness; health spending; and satisfaction(provider and individual). In addition, any metrics identified would be designed to ensure geographic, racial and otherdisparities are being addressed.All of the proposed measures are draft and under development. They require input from participants in the health caresystem to assure that they best assess the tactics selected, progress made, and outcomes desired.Proposed Collaborative Transformational Strategy MeasuresAs discussed within each collaborative strategy description, the CTS workgroups developed a set of proposed short, mid,and long term process milestones/metrics for their tactics. The milestones/metrics typically result in achievement of adesired process end, such as greater adoption of health information technology or a higher percentage of people having apatient-centered medical home. The proposed milestones/metrics and a potential time line are summarized in Figure 4.Fig. 4Proposed Milestones/MetricsPartnership designatedEMR service strategy finalizedLoan program strategy finalizedCenter for excellence service provider certification program completedHIE RFP awardedEstablish realistic adoption targets for EMR and HIE usageProposed OHQIS Process Metric Implementation TimelineCreate a PCMH task force under the HCCQCDevelop PCMH implementation planDevelop plan/ create incentives to expand/enhance primary care workforce to support PCMHImplement primary care workforce plan and incentivesPayment reform stakeholder group(s) appointedExisting medical claims data utilization reviewed to find overuse, underuse, misusePayment policies that discourage underuse, misuse and overuse identifiedPrinciples regarding avoidable adverse events establishedMedicaid and private payer incentives identifiedFinancial incentives for e-prescribing, e-billing, e-health records and electronic eligibility verification identifiedEstablish payment models to support PCMH implementationImplement PCMH plan and payment modelsPatient- and public-involved task force establishedA health insurance exchange model is developedHealth information delivery methods are developed and testedA “shared decision-making” pilot is developed and implementedA pilot “academic detailing” program is developed and implementedOne or more pilot self-management programs developed, implemented in conjunction with early PCMH initiativesA social marketing campaign promoting the execution of advance directives developed, testedQ2 2009 Q3 2009 Q4 2009 Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011Health Information TechnologyActivated Patient= milestone achievedPatient Centered Medical Home (PCMH)Payment Reform22

Me a s u r in g Su c c e s sProposed System LevelMeasuresThe four collaborative strategies aswell as other state-level efforts areaimed at creating the building blocksand infrastructure necessary to fostera transformed health system for allOhioans. Such a transformation requiresboth an enhanced emphasis on wellnessand health rather than the treatment ofillness, and the adoption of an affordableand sustainable health care financing anddelivery system.Fig. 5Potential system level outcome dashboardThe core team decided that the goals ofsuch a transformation would be reflectedin positive outcomes in five areas:improved and optimal health for allOhioans; available and affordable accessto quality care; more efficient delivery of health care services; sustainable health financing and economic performance;and demonstrated satisfaction among both consumers and providers of health care.These five areas identify the reality that a successfully transformed health system must produce clear, positive results inmultiple dimensions at the same time. Having measures in all five of these areas ensures that one set of outcome goalsdoes not come at the expense of desired goals in other areas. Figure 5 is an example of what a potential system-leveloutcome dashboard might look like.Potential measures for each of these five areas are listed below. The final determination of system-level measures willrequire additional discussion and shared commitment, as well as the identification of data sources, baseline measures,and attainable yet aggressive performance targets and time frames. As part of this discussion, each measure must includethe capacity to examine outcomes (and thereby the impact on health disparities) by race/ethnicity, geographic area withinOhio, gender, and income level.Improved and optimal health for all Ohioans (examples of measures)• Prevalence rates for the five leading chronic health conditions• Prevalence rate for intentional and unintentional injury• Immunization rates• Low birth weight and infant mortality ratesAvailable and affordable access to care (examples of measures)• Identification of a usual source of care (not the emergency department)• Uninsured rateEfficient delivery of health care services (examples of measures)• Rate of hospitalization for people with ambulatory sensitive conditions• Rate for 30-day readmission to hospitals• Mortality rate amenable to health care• Patient safety measure23

Me a s u r in g Su c c e s sSustainable health financing and economic performance (examples of measures)• Average health spending rate• Cost of lost productivity due to poor healthSatisfaction of both Ohioans and their providers of care (measures to be developed)• Create patient satisfaction measure• Create provider satisfaction measureResources Needed for MeasurementThe proposed measure system will require resources to support staff and data collection, but there are some data setsalready in existence that may be used as proxies and/or as long-term data sources. For example:• Medicare and Medicaid data - for initial health spending and health system delivery measures• CDC’s Behavioral Risk Factor Surveillance System or Ohio Family Health Survey – for data on wellness, access tocare and possibly patient satisfaction.Measures from Other State Level EffortsThe core team also recommends obtaining and tracking proposed measures from other major state-level efforts in Ohiosuch as the Office of Healthy Ohio, the Ohio Patient Safety Institute, Unified Long Term Care Budget Planning and thehealth- related work of the Ohio Business Roundtable. For further information, see Figure 3, page 7 and Appendix 1, page26.24

Ne x t StepsOhio Health Care Coverage and Quality CouncilConcurrent with this Plan’s development, in February 2009, Governor Ted Strickland issued an Executive Order creatingthe Ohio Health Care Coverage and Quality Council. The 30-member Council is charged with advising the Governorand General Assembly on improvements to health programs and policies; monitoring and evaluating implementation ofstrategies for increasing access and improving quality of the health care system in Ohio, and cataloging existing healthcare data reporting efforts, among other responsibilities. The recommendations contained in the Ohio Health QualityImprovement Plan will be presented to the Council at its first meeting (tentatively to occur in June 2009), with theexpectation that the Council and its members will act to facilitate the implementation of these recommendations, continueto incorporate tactics addressing the issues of disparities and workforce capacity, and propose other initiatives to transformand create a high-performance health care system in Ohio.Phase II of the State Quality Improvement Institute (SQII)Ohio has been invited by the Commonwealth Fund and AcademyHealth to participate in Phase II of the State QualityImprovement Initiative, which will begin in May 2009 and continue for 18-months. During this time, Ohio will haveadditional access to extensive technical assistance from nationally-recognized experts in health system transformation.The timing of SQII Phase II is ideal for Ohio in light of the creation of the Ohio Health Quality Improvement Plan and theOhio Health Coverage and Quality Council.25

Appendix I— Statewide EffortsBelow is a list of examples (not meant to be exhaustive) of prominent statewide efforts to improve health quality in Ohio.Healthy OhioHealthy Ohio, a Governor’s initiative located at the OhioDepartment of Health, provides and supports programsand activities promoting health and prevention of chronicdisease and injury. The program’s goals are to assure ahealthy, productive workforce, equip students for learning,and create a better quality of life while also contributingto the more efficient and cost-effective use of medicalservices.Program initiatives include the prevention and reductionof obesity, chronic disease prevention (including theBreast and Cervical Cancer Program and others addressingdiabetes, heart disease and stroke, and comprehensivecancer), injury prevention (including the child passengersafety program), and sexual assault and domestic violenceprevention. In addition, Healthy Ohio encompasses thecomprehensive Tobacco Use Prevention and CessationProgram. Healthy Ohio also works with sister agenciesto enhance, develop, and coordinate health promotionand disease prevention programs, especially for targetpopulations such as seniors, those with low-incomes, orthose with mental health and/or substance abuse issues.The Office of Healthy Ohio includes a dedicatedHealth Equity Coordinator charged with improving theDepartment’s and state’s identification and improvement ofhealth disparities, whether associated with race, ethnicity,gender, geography, or income.Ohio Patient Safety InstituteThe Ohio Patient Safety Institute (OPSI) is an organizationdedicated to improving patient safety in Ohio. The Instituteis a subsidiary of the Ohio Health Council, which wasfounded by the Ohio Hospital Association, the OhioState Medical Association, and the Ohio OsteopathicAssociation. Through this collaboration and common effort,OPSI has the ability to work with more than 180 hospitalsand 9,000 physicians in Ohio to improve patient safety forall Ohioans.Representative work undertaken by OPSI includesinitiatives in medication safety, surgery and anesthesiasafety, standardized hospital wristbands for patients,fall prevention, and reducing methicillin-resistantStaphylococcus aureus (MRSA) transmission and infection.In 2009, the Agency for Health care Research and Quality(AHRQ) designated OPSI as a Patient Safety Organization.OPSI is the first organization in Ohio to receive the federaldesignation and one of 46 in the U.S. to date.Ohio Business Roundtable HealthInitiativesIn addition to its overall health care reform advocacy, theOhio Business Roundtable has three initiatives underway inwhich it has a direct leadership role:1. An employer-led actions initiative aimed at catalyzingadoption of employer best practices to improve health,reduce cost, and increase access across 18 priorityreform areas identified in the BRT’s recent diagnosticreport, Improving Ohio’s Health System.2. A child obesity initiative that, in addition to developing3.long-term population health improvement strategies,focuses on improving nutrition, physical activity, andphysical fitness reporting standards in schoolsSolutions for Patient Safety, a partnership between theCardinal Health Foundation, OHA, OCHA, severalparticipating hospitals, and other organizations thataims to reduce preventable health care associatedinfections and avoidable medication errors.The BRT’s health care report may be accessed by visitingwww.BRTHealthReport.com.Unified Long-term Care BudgetThe Unified Long-term Care Budget is a flexible fundingprocess that provides long-term care services and supportsbased on consumer choice and need; helps to contain stateand federal Medicaid costs; and includes both nursingfacilities and home- and community-based settings.The Unified Long-term care Budget would eventuallyserve all consumers with chronic or recurring needs forservices, regardless of age or disability. Several of therecommendations made by the Unified Long-term CareBudget Workgroup support enhanced care management andeasing the transition from acute care to long-term care.26

Appendix II — Response to QuestionsAt the Ohio Health Quality Improvement Summit Part II,held April 27, 2009, questions were asked related to specificrecommendations as well as several general topics orcross-cutting issues. In response to these questions, modificationsor clarifications have been made where appropriateto the plan. Below we have noted some of the mostfrequently raised comments that we received at the Summitand through the subsequent survey replies.Reduction of Health DisparitiesThe reduction of health disparities remains a critical issue.The November 2008 OHQIS identified health disparities asa cross-cutting topic to be addressed by each strategic focusarea. Recognizing the crucial role reducing health disparitieswill play in an overall transformation of Ohio’s healthcare system, an ad hoc, public-private work group wascreated shortly after the Summit to specifically focus onthe issue. Given the size and scope of the topic, recommendationswere not completed in time to be reviewed at theSummit Part II (April 27, 2009). However, recommendedtactics developed by the work group have been consideredand incorporated in each Collaborative TransformationalStrategy. In addition, these and other tactics to address andreduce disparities will continue to be developed as part ofthe Health Care Coverage and Quality Council’s (HCCQC)work to identify priorities and facilitate implementation ofthe Plan. The Council’s diverse membership will assureongoing consideration of the issue and will work with theOffice of Healthy Ohio and the Ohio Department of Health,in particular the state’s dedicated Health Equity Coordinator,to coordinate efforts.Health Promotion/Prevention of Diseaseand InjurySeveral comments were received related to the apparentabsence of strategies and tactics related to the promotion ofhealth and prevention of disease and injury, a topic that hadbeen a Strategic Focus Area at the November Summit.incorporate, and align related activities, since there is broadrecognition that addressing this area will contribute notonly to improving health, but also the reduction of unnecessarymedical expenditures. In addition, CTS strategiessuch as payment reform, the medical home, and informedindividuals each incorporate components of health promotionand disease prevention.Patient SafetyWe also received comments reinforcing Summit participants’desire to address patient safety concerns across thecare continuum. This, too, had been a Strategic FocusArea at the November Summit. In honing initial prioritiesfor the draft plan, team members noted that there aremany existing groups across the state already workingextensively to improve patient safety. For example, theOhio Patient Safety Institute – a collaborative effort of theOhio Hospital Association, Ohio State Medical Association,and Ohio Osteopathic Association – has many activeinitiatives with proven track records for improving patientsafety and reducing errors. There are also several statewideand regional safety-focused hospital collaborativescurrently underway across the state led by groups like theOhio Hospital Association, the Ohio Business Roundtable,Cardinal Health Foundation, the Ohio Children’s HospitalAssociation, regional health and hospital associations, andother groups. In addition, many Ohio health care institutionshave ongoing initiatives focused on improving patientsafety that have been nationally recognized for their success.In many cases, these initiatives align directly with therecommendations developed by the Patient Safety StrategicFocus Area work team and Summit participants. Nonetheless,in developing the Collaborative TransformationalStrategies and draft work plan, the work team and Summitparticipants’ recommendations were considered, andseveral of these recommendations were embedded in thetactics for each of the four CTS strategies.As noted in the Plan’s discussion of the CollaborativeTransformational Strategies, one of the criteria used toidentify the focus areas was whether the strategy had anexisting institutional home providing direction and leadership.In the case of health promotion and disease/injuryprevention, such a home exists in the Office of HealthyOhio, located at the Ohio Department of Health. The HC-CQC will continue to work with Healthy Ohio to consider,27

Appendix III — Su r v e y ResultsThe Ohio Health Quality Improvement Plan was presentedto a reconvening of many of those who attended theNovember 2008 Summit, along with others interested in therecommendations. Following the April 27, 2009 meeting,a follow-up survey was sent out to obtain feedback onthe plan. One hundred twenty five (125) individualsresponded from April 30, 2009 – May 11, 2009. Surveyrespondents were asked to respond to questions based onthe Ohio Quality Improvement Draft Plan and were giventhe opportunity to offer general comments. Revisions tothe plan may be made based on the results of and generalcomments from the survey. Following are the resultsobtained through the follow-up survey.OverallRespondents represented a broad group of stakeholdersin both the private and public sectors. The majority ofindividuals responding did not attend the Ohio HealthQuality Improvement Summit in November 2008 (70.9%didn’t attend) or the April 27th follow-up meeting (67.5%didn’t attend). Additional feedback was obtained at theApril 27th meeting as well as through a follow-up survey.All four collaborative transformational strategies alignedwith current work at the respondents’ organizations:Informed and Activated Patients and Individuals had thehighest level of correlation (79.2%) with the existingwork of organizations, followed by Health InformationTechnology (66.4%), Patient Centered Medical Homes(66.4%) and Payment Reform (54.4%).When asked to rank the importance of the collaborativetransformational strategies in helping to achieve the visionfor a Healthy Ohio, 34.7% ranked Informed and Activatedpatients and individuals as the most important strategyand 32.8% ranked Payment reform as the most importantstrategy. Patient Centered Medical Homes was ranked by32.2% as the second most important strategy and HealthInformation Technology was ranked last in the importanceof helping to achieve the vision for a Healthy Ohio.Survey results show that many believe there are substantialbarriers to implementing the strategies. Respondentsindicated that the most challenging barriers to overcomein implementing strategies are funding (68% rated as mostchallenging), access to health insurance (43.8% rated asmost challenging) and culture change (42.5% rated asmost challenging). The following barriers were ranked asmoderately challenging: care coordination across settings(37.8%); physician buy-in (36.2%); access to clinics(34.4%); access to technology (32.3%); and workforcecapacity (30.6%). Lack of information, purchaser buy-in,transportation, access to web services and health disparitiesalso were rated as moderate challenges.Individuals and organizations responding to the surveywere asked in which area/areas their organizations wouldbe able to help achieve the vision for a Healthy Ohio:71.9% said they could help by adopting health informationtechnology (22.8% said it was not applicable to theirorganization); 54.7% believe they could help implementpayment reform strategies that support PCMH (35.8% saidit was not applicable to their organization); 65.2% wouldbe able to help implement patient centered medical homes(25% said it was not applicable to their organization); and82.3% could help engage patients in managing their ownhealth care.Patient-Centered Medical HomesWhen asked to rate the importance of each componentof the definition for Patient Centered Medical Homes(PCMH), as defined in the Ohio Health QualityImprovement Plan, the majority of respondents rated thefollowing components as very important: a continuousrelationship with a physician or other credentialed clinician(63.4%); a multidisciplinary team that is collectivelyresponsible for providing for a patient’s longitudinal healthneeds and making appropriate referrals to other providers(62.1%); coordination and integration with other providers,as well as public health and other community services,supported by health information technology (61.5%); andenhanced access through extended hours, open scheduling,and/or e-mail or phone visits (48.4%). An expanded focuson quality and safety was rated moderately important by41.5% of respondents and very important by 39.8% ofrespondents.Expanding traditional fee for service payments to coveractivities such as coordination of care and care management(48.4% rated as very important, 39.8% rated as moderatelyimportant), and rewarding providers for improving healthoutcomes (44.7% rated very important, 31.7% rated asmoderately important) were rated as key components ofpayment reform to implement the patient centered medicalhome. The majority of respondents rated paying providersfor start-up costs associated with moving to the PCMHapproach as moderately important (37.4%), while somebelieve that this element is very important (33.3%).Survey responses indicate that 56.5 % believe that Ohioshould focus its initial implementation of the PCMH28

Appendix III — Su r v e y Resultsapproach on populations with multiple chronic conditions,32.3% believe that initial implementation should focuson children, 28.2% believe that all populations shouldbe focused on in the implementation, 27.4% believe thefocus should be on children with special health care needs,18.5% believe focus should be on populations with a singlechronic condition, and 10.5% offer an alternative response(rural access, uninsured, low income, Medicaid, andpatients with disabilities).Health Information TechnologyThe majority of respondents (71.2%) said they wouldtrust a non-profit with broad board participation to run astate wide health exchange. Approximately forty eightpercent (48.4%) prefer that the non-profit facilitate an EMRpurchasing collaborative and 36.9% prefer the non-profit toprovide an EMR as a service. Over forty-one percent(41.9 %) said they would pay a nominal fee toelectronically access patient data to which they do notcurrently have electronic access, 24.2% indicated theywould not pay a nominal fee and 33.9% didn’t feel they hadsufficient information to answer the question.Payment ReformRespondents overwhelmingly responded that the followingpayment reform strategies should be the same forgovernment programs and private health plans: expandingtraditional fee for service payments to cover activitiessuch as coordination of care and care management(86.7%); rewarding providers for improving healthoutcomes (87.5%); and paying providers for start up costsassociated with moving to the PCMH approach (72.9%).Approximately fifty nine percent (58.9%) believe thatpayment reform strategies should be implemented throughmandatory requirements, while 38.4% believe paymentreform strategies should be implemented through voluntarycompliance. When asked which payment reform strategyshould be implemented first, 40.2% agreed that strategiesto support medical homes should be implemented first;followed by strategies to support health informationtechnology (41.5%); and lastly, strategies to eliminateduplication, waste and errors in the delivery of care(38.7%).Informed and Activated Patients andIndividualsWhen asked to rank the order of importance of areas inwhich individuals often need help to effectively managetheir health and health care, 46.6% ranked assistance withmaking healthy lifestyle choices as the most important area.Assistance with making health care treatment decisions wasranked as the second most important area (41.3%) followedby assistance with making health care coverage decisions.Respondents ranked assistance with making end-of-lifedecisions as the least important area in helping patients toeffectively manage their health and health care.The following populations that often need support toeffectively manage their health and health care wereranked based on their potential for immediate impact(listed in order of most immediate to longest time forimpact): individuals with chronic illness (most immediate),uninsured individuals, individuals with public healthcare coverage, all Ohioans under 65 years of age, andindividuals with employer-sponsored health coverage(longest time for impact).When surveyed, the majority of respondents indicatedthat web-based information, community activities, andmarketing campaigns are neutral to moderately ineffectivein helping individuals to become more engaged intheir health and health care. Respondents indicated thatencouragement or information from providers as well asfinancial incentives are the most effective ways of engagingindividuals in their health and health care. The majorityof respondents indicated that providers are moderatelyto very effective in informing and educating individualsabout their care. Respondents indicated that individuals aremoderately effective in educating themselves about theircare. Schools, communities, employers and health plans/insurers are moderately to neutrally effective in educatingindividuals about their care.29

Appendix IV — Co m m e n t s f r o mStatewide Or g a n iz a t io n sAARP1.2.30Which strategies or tactics would yourorganization be able to help implement?AARP would be able to assist the Council implementthe Health Quality Improvement Plan. We areparticularly positioned to help the Council assessthe impact that strategies and tactics within eachCollaborative Transformational Strategies (CTSs)might have among the 50 – 64 population.Which strategies or tactics are already prioritiesfor your organization?• Making information and tools related to healthpromotion and disease prevention widely available.• Supporting “academic pharmaceutical detailing”programs.◦◦ Promoting broad public access to and use ofwebCHAT Choosing Healthplans All Together.Promoting coordination and linkages with othernon-primary-care, health-related systems and longtermcare systems to meet the needs of individualsas they move across care settings.• Coordinating efforts to expand and enhance the primarycare workforce in order to support the implementationof the PCMH approach.3.4.What do you believe should be the top priority forthe Council?The top priority should be the integration of the fourCTSs.What are your specific comments to any or all ofthe decision points?PCMHHow should state government incentivize and supportthe regional PCMH and access plan collaboratives thatare currently bubbling up around the state through localinitiatives?To offer real value to patients, state government shouldserve as the entity that establishes the criteria clinicalpractices must achieve to earn the designation of“medical home.” For example, state government’ssupport could include setting the attributes of “asystem,” which each collaborative would be expectedto demonstrate such as being able to track patients,tests, and referrals, offer care management and patientself-management support, and perform registryfunctions.Should Ohio’s initial implementation of the PCMHapproach be focused on improving outcomes forindividuals with multiple chronic conditions or allpopulations?The initial focus should be on concurrently improvingoutcomes for individuals with chronic conditions andpreventive care for all populations.Payment ReformWhat are the principles, values and criteria we should useto evaluate and choose payment reform models?Payment reform models should be based on the extentto which they meet the following patient-centered andsocietal goals:• Promote and reward high quality, patient-centeredcare that is cost-effective and reduces disparities• Ensure patients receive the “right care, at the righttime, from the right provider,” incorporating thevalues and preferences of patients• Foster improvement and innovation• Effectively slow the growth of the costs of healthcareReforms to health care payment systems should reflectthe following six core payment principles:1. Payment reforms should promote health byrewarding the delivery of quality, cost-effectiveand affordable care that is patient-centered andreduces disparities.2. Health care payments should encourage andreward patient-centered care that coordinatesservices across the spectrum of health careproviders and care setting while tailoring healthcare services to the individual patients’ needs,values and preferences.3. Payment policies should encourage alignmentbetween public and private health care sectors topromote improvement, innovation and meetingnational health priorities, and to minimize theimpact of payment decisions in one sector on theother.4. Decisions about payment should be made throughindependent processes that are guided by whatserves the patient and helps society as a whole, andpayment decisions must balance the perspectivesof consumers, purchasers, payers and physiciansand other health care providers.

Appendix IV — Co m m e n t s f r o mStatewide Or g a n iz a t io n s5.6.Payment policies should foster ways to reduceexpenditures on administrative processes (e.g.,claims payment and adjudication).Reforms to payment should balance the need forurgency against the need to have realistic goalsand timelines that take into account the need tochange complex systems and geographic and othervariations.Academy of Medicine of Cleveland &Northern OhioThe Academy of Medicine of Cleveland & NorthernOhio (AMCNO) the premier regional medical associationin Northern Ohio representing over 5,000 physicians ispleased to be involved in the development of the OhioHealth Quality Improvement Plan. We believe that ourorganization could help implement any number of thestrategies and tactics, however, if we were to pick onethat is a priority for our organization it would be theimplementation of an appropriate health informationtechnology (HIT) infrastructure which is of utmostimportance to both physicians and our patients in the future.In order to achieve the HIT goal interoperability issues andcost factors for physicians must first be addressed.With regard to the strategies and tactics outlined in theplan, clearly an HIT infrastructure will be necessary inorder to track patients and their records through a patientcentered medical home model, as well as to evaluatechronic diseases, patient compliance issues and follow-upcare.Physicians are faced with inefficient health systemspending that does not add any value to patient care, suchas excessive costs associated with dealing with the myriadof insurance companies. Real payment reform cannotbe achieved without the use of HIT to provide for theelectronic transfer of information between physicians andpayors on a real time basis. However, this will requirechanges not only on the part of physicians but uniformchanges by the insurance industry as well.The AMCNO is involved in many projects in our regiondealing with health information technology, developing apatient centered medical home model, and working withphysicians and our patients on chronic disease issues. Inaddition, payment reform and changes in the insuranceindustry have always been top of the mind for physiciansand their practice and we believe that there are changesthat could be made within the insurance industry that couldstreamline how physicians practice and save money in thelong run.Patients must be an integral part of the discussion as wellsince declining health status also contributes to medicalcosts. In addition to focusing on the HIT issue the councilshould strive to engage the consumers of health care in thisdebate to assure that there is a cultural transformation andpatients begin to take a proactive role in improving theirhealth status.The physician leadership of the AMCNO would be pleasedto participate in discussions on any of the strategies andtactics as this discussion continues in the future.American Heart AssociationOn behalf of the American Heart Association, I ampleased to offer comments on the Ohio Health QualityImprovement Plan. Access to quality health care is anintegral component of our goal to reduce death, disabilityand risk from cardiovascular disease and stroke by 25% by2010. As we begin to look beyond 2010, access and qualityto care will become an even greater focus.As a research driven organization, we are committed tonot only fund needed research projects, but also to thetranslation of research into practice. This is the only wayto impact health quality, cost and disease prevention. TheAmerican Heart Association/American Stroke Associationrecognizes many collaboration points in the plan and looksforward to partnering and furthering the collaboration wehave already begun with other organizations.Patient-Centered Medical HomesThe system of care and active patient involvement iscritical. We are developing resources and utilizing HITand payment reform to increase the collaboration betweencomponents of the system of care. Additional links areprovided.Health Information TechnologyThe American Heart Association jointly published a HealthIT roadmap in 2006 for cardiovascular disease and stroke.Those efforts continue through our development of newproducts and through partnerships. (Links can be foundbelow.) The organization is able to bring this knowledgeand success from other states to impact efforts in this area.31

Appendix IV — Co m m e n t s f r o mStatewide Or g a n iz a t io n sOur efforts are also focused on the system approach toimprove care – particularly focusing on care from diseaseprevention, to early activation of the health care system,to early advanced care, to follow up care and secondaryprevention. It is critical all participants are informedthroughout the process and Health IT is a key component.Payment ReformAs we look towards impacting our goals through hospital/provider collaboration, it is critical to look at paymentreform. For instance, we are already working ontelemedicine to increase access to quality care for strokepatients. As hospitals share resources, payment reform isneeded for full implementation.Informed and Activated Patients and IndividualsAgain, to improve outcomes, strong systems are needed.This includes informed and activated patients. Theorganization is launching Heart 360 and has partneredwith others to increase patient education. Again, links areprovided. We are pleased to bring this knowledge andexpertise to the Ohio Health Quality implementation.Through our work, we have found there is no one solution.Instead, we believe a coordinated approach variousdisciplines is most impactful. While the organization willcontinue to focus on research and research translation, welook forward to utilizing our knowledge and resources toassist with the Ohio Health Improvement Plan. We arefortunate to have one of our national volunteers based inOhio, Dr. Pina.American Cancer SocietyIt was my privilege to represent the American CancerSociety, Ohio Division at the November OHQI Summit.Thanks to all who took the information discussed andpresented at the Summit to create a draft plan. Here are mycomments:1. We would be able to help with section on Informedand Activated Patients and Individuals - tactics wouldinclude serving on the Patient and Public InvolvementTask Force. Also - the tactic addressing Health CareCoverage Decisions is of interest to us. The AmericanCancer Society has produced an evidence-baseddefinition of meaningful insurance that focuses on the“Four As”: Adequacy, Availability, Affordability, andAdministrative Simplicity. This is already a priority forour organization.322.Access to health care should be a top priority for thecouncil.I look forward to further discussion of this importantdocument and work. Thank you.Council of Smaller EnterprisesFor more than 35 years, the Council of Smaller Enterprises(COSE) has been a resource for small businesses and anationally recognized advocate and innovator for providingaccess to quality, affordable health insurance for NortheastOhio’s small business community. COSE insures morethan 13,000 small businesses with more than 71,000employees accessing coverage for over 178,000 lives.Because of the importance of access to health care for smallbusiness as a pillar of enabling entrepreneurship and anenabler for the ongoing growth and success of independentsmall businesses in our community, the needs of smallbusinesses must be recognized in our discussions abouthealth care reform in Ohio.COSE commends the work of the Ohio Health QualityImprovement Team. We believe that the plan’s fourCollaborative Transformational Strategies (CTS) providean effective framework for the future efforts of the OhioHeath Care Coverage and Quality Council (the Council).COSE encourages the Council to adopt both the conceptsand the framework advanced by this report.We believe that there are two fundamental building blockson which any approach to health care reform must be built:(1) development of an effective marketplace through HealthInformation Technology and Payment Reform (HIT) and(2) a fundamental alteration of the mindset of today’s healthcare stakeholders (Patient Centered Medical Homes andInformed and Activated Patients and Individuals).COSE believes that the top priority for the Council shouldbe to pursue HIT advances for Ohio. As a foundationstrategy, HIT will support and enable every other healthcare reform effort Recent efforts in Ohio like the HospitalMeasures Advisory Council (on which COSE served)require the type of systems support that OHQI’s HITstrategy envisions. It is important that the state’s HIT effortleverage the work that has already been done on RHIO’sand patient electronic records in our state.COSE also believes strongly in creating “Informed and

Appendix IV — Co m m e n t s f r o mStatewide Or g a n iz a t io n sActivated Patients.” COSE’s work over the last few yearswith implementing Health Risk Assessments, employersponsored wellness programs and wellness mini-grantsto reward progress is encouraging. While wellness isbeginning to see acceptance within larger companies, moreneeds to be done to increase the participation in theseefforts within the small business community.In addition, COSE’s experience of offering over twentyplan designs for health insurance has shown that a diversityof choice provides for the best fit for a small businesses’needs. We are supportive of the ideas that seek to providean opportunity for educated decision-making by consumersand small businesses among competing alternatives. Assuch, we believe that a well constructed “exchange” or“clearinghouse,” to effectively interact with the state’ssmall businesses and individuals, could be an importantasset in our efforts.Finally, approaches to subsidize and enable access tobasic benefits for the poorest Ohioans are important. Overtime, however, our longer-term health care reform effortscan only succeed if we change the consumer mindset byhelping the consumer make the connections among value,cost and responsibility in their day-to-day health andwellness activity.COSE is optimistic that the Council can attack the workahead with an open, collaborative conversation of keyhealth care reform stakeholders that have a shared focus onimproving access for Ohioans and the health status of ourstate. We look forward to participating in that work andin advancing these ideas in any way that we can with ourconstituents.Employers HealthEmployers Health believes that the OHQI Draft Plan is agood start to transforming the health care delivery systemin Ohio. It is intuitive that the successful implementationof any of the Collaborative Transformational Strategies willhave a profound impact on the quality and cost of healthcare delivery.As the Governor’s Health Care Coverage and QualityCouncil begins its evaluation of the Plan, Employers Healthencourages it to augment the Plan with a comprehensivedata collection and analysis effort designed to pin-pointthe causes of the underperformance of Ohio’s health caredelivery system. The OHQI Draft Plan was created withoutthe benefit of such data or analysis. Thus, the attainmentand analysis of such data will be critical to developing areform plan with the highest possible level of efficiency.Employers Health lends its full support to the efforts of theOhio Health Quality Improvement Implementation Teamand the Governor’s Health Care Coverage and QualityCouncil. If the Council desires assistance of any kind,please convey my availability and willingness to help.Employers Health Coalition of Ohio, Inc.I appreciate the opportunity to participate in theOhio Health Quality Improvement project with theImplementation Team. The following paragraphs containthe activities of the Employers Health coalition in eachof the Collaborative Transformational Strategies andcomments regarding the Ohio Health Quality ImprovementDraft Plan.The mission of the Employers Health Coalition of Ohio,Inc. is to help its member organizations improve thequality, accessibility and cost of health care for their healthbenefit plan enrollees and the communities in which theyreside. As such, Employers Health engages in activities ineach of the Collaborative Transformational Strategies.Below is an abbreviated list of the projects and servicesEmployers Health is involved with and the affectedCollaborative Transformational Strategy:Patient Centered Medical Home• Employer Education• Data Warehouse and AnalysisHealth Information Technology• Electronic PrescribingPayment Reform• Bridges to Excellence• Evalue8• Employer Education• Data Warehouse and Data AnalysisInformed and Activated Patients and Individuals• Consumer Guide to Hospital Quality (www.ohiohospitalquality.com)• Leapfrog33

Appendix IV — Co m m e n t s f r o mStatewide Or g a n iz a t io n s• Patient and physician education on GI health andappropriate use of antibiotic medications• Diabetes handbookOhio Academy of Family PhysiciansOhio Academy of Family Physicians (OAFP) will beworking over the next three months to develop its 2010-2013 strategic plan that includes these strategies and tactics,which are already priorities for the Academy. OAFP wouldbe able to assist in implementation of all these strategiesthrough work on any task forces or committees to helpeducate and communicate with Ohio’s family physicians.The top priority for the Council should be to educateprimary care physicians on what the patient-centeredmedical home (PCMH) is; how physicians can transformtheir practices into PCMH; and provide information onthe Ohio health information network to assist physiciansin the electronic health record (EHR) conversion. Thisshould take place while payment reform is addressedcorresponding with the PCMH.The four collaborative transformation strategies can beintegrated by focusing on the primary care system:• Primary care physicians will become PCMH witheducation on how to transform their practices andwill also move forward with the EHR conversionbecause it is part of the PCMH and will be willing tomove forward once a health information exchange isestablished• Payment reform will be accomplished with the34integration of PCMH. It is imperative that paymentreform play a paramount role in practice transformationtoward PCMH integration. Without this critical piece ofthe PCMH principles, primary care education and othercollaborative efforts will fail to reach desired outcomes.There will be informed and activated patients and•individuals through effective use of PCMH.Ohio Association of Advanced PracticeNursesThe Ohio Health Quality Improvement Plan offers acohesive and all encompassing proposal to reform Ohio’shealth system. Advanced Practice Nurses currently provideprimary care services to tens of thousands of Ohio’scitizens. We are experienced in the provision of wellnessand chronic care medical services and prepared to take partas leaders and members of the Patient Centered MedicalHome initiatives in Ohio.Patient Centered Medical HomeImplementation of the patient centered medical home ismost crucial to real health care reform. The realization ofthis model of care delivery requires the integration of all ofthe other transformational strategies including IT, PaymentReform, and the Activated Patient. Changes in access andaffordability can be greatly accelerated through the PCMHmodel. The Ohio Association of Advanced Practice Nurses,(OAAPN), can assist in providing outreach, education andassistance to APNs in pursuing the PCMH model in theirown health care practices.Payment ReformPayment reform will be elusive, contentious and mostdifficult to pursue since all interested stakeholders arestriving to proceed as they always have in their own selfinterest. Ohio’s managed care organizations, public andprivate insurers, hospitals, and physician trade associationshave demonstrated their power and influence with Ohio’slegislators in eliminating all budget bill provisions thatcould have promoted cooperation. Is payment reformlikely in such a politically hot environment? Possibly, butit won’t be easy. APNs can be found in independent APNpractices, physician provider and hospital based practices,long term care practices, retail and employer based clinics,and in other settings. Their investment in the status quo isless than most other providers since they are currently paidless for providing similar services with very high quality.The question that must be asked is “Why insurers wouldwant to continue to pay more when they could pay less andget a high quality service?”Council PrioritiesThe top priority for the council should be to proceed withthe implementation of the PCMH for the underserved,underinsured and the poor in Ohio. Insurance coveragewithout access is not coverage however and all barriers thatprevent health providers from practicing to the fullest scopeof practice should be removed.OAAPN can assist with the implementation of the PCMHin member practices, assist with needed education of Ohio’sAPNs regarding PCMH and encourage APNs to enter theprimary care workforce.OAAPN is also committed to serving on health care policycommittees whose purpose is to pursue positive change inthe delivery of health care services to Ohio’s citizens.

Appendix IV — Co m m e n t s f r o mStatewide Or g a n iz a t io n sOhio Association of Area Agencies onAgingThank you for the opportunity to comment on the OhioHealth Quality Improvement Plan as it relates to thestrategy entitled Patient-Centered Medical Home. TheOhio Association of Area Agencies on Aging (OAAAA)supports this strategy as a central focus area in home andcommunity-based case management and waiver services.For over thirty years, Ohio’s Area Agencies on Aginghave been a leader in the long term care industry by beingcommitted to meeting the chronic care needs of a growingaging population. Area Agency on Aging 10B (AAA 10B)has been in the forefront of advancements in improvingconsumer care and we highlight their excellent work as anillustration of coordinating care across various segments ofthe health care system.AAA 10B has utilized an approach and integrates caredelivery with the initial assessment which transitionsto case management with continuous, comprehensive,coordinated care, as a partnership between consumers andtheir health care team. The medical home will emphasizescoordinated and/or integrated care across all elements ofthe complex health care system; enhance access to makeit easier for members to contact their personal health careteam; improve quality and safety by promoting prevention,proactively managing chronic illness, engaging members intheir care, and using our electronic systems for support.AAA 10B has partnered with 7 regional hospitals andlocate Long Term Care Nurse Consultants on eachcampus. This initiative began in 2000 to effectuate theshift in focus toward a more comprehensive, holisticcare and incorporates the characteristics associated withboth lower costs and better outcomes. In the last 2 years,AAA 10B has provided long term care consultant visitsto 5000 individuals per year with plan development forcommunity arrangements to meet their chronic care needs,with enrollment in a program or receipt of other communityservices. This coordinated care is across all elements ofthe member’s community, including the physician, hospitalteam, nursing home, home health agencies, and othercomponents of a complex health care system—includinghealth information exchange to assure the indicated care isattained when and where it is needed.AAA 10B enhances clinical staff skill set in order tomitigate the impact of risk factors for members at highrisk of nursing facility placement. AAA 10B has workedclosely in partnership with SummaCare MedicareAdvantage Plans and are actively pursing other health plansfor the integration of health plans with our communitybasedbenefits in order to promote community-based care isintegrated and coordinated, in addition to quality and safetyas hallmarks. AAA 10B’s partnership improves enhancedaccess to dual members by system advances and newcommunication options between partners.Additionally, AAA 10B conducts a weekly caremanagement interdisciplinary team (CMIT) meetingwhich includes a physician with geriatrics specialty,staff care managers, staff Clinical Nurse SpecialistSupervisor, and representatives from the communitythat may include hospice, direct care providers, adultprotective services, local housing coordinators, and visitingpharmacists. CMIT aligns efforts for integrated caredelivery and mitigates the community resources with thehealth system for productive interactions which improvemember’s functional and clinical outcomes. The member’sprimary care physician collaboration occurs throughcommunication from the team meeting discussion andwritten updates. Member outcomes that occur from theresult of the CMIT care conference may be arrangementsto referrals to physician specialists, revision of AAA 10Bcare plan services, housing relocation assistance, outpatientutilization, chronic disease management training, andaccessing medical care appropriately and timely with theinvolvement of the case manager.Finally, AAA 10B continues to add clinical staff to bolsterour proficiency in managing chronically impaired olderadults. Building on our addition of our PASSPORTClinical Nurse Specialist AAA 10B began the initiativeof adding Registered Nurse High Risk Care Managers tohelp our most vulnerable members better manage prevalentmedical risk factors to minimize the risk of permanentnursing facility placement.Ohio Association of Health PlansThe Ohio Association of Health Plans (OAHP) appreciatesthe opportunity to participate with other stakeholders,through HQII, to discuss strategies for creating a highquality,cost-effective, high performing health system inOhio. I commend all those that participated in the processand the time many dedicated to capture their input anddevelop the final document. I believe this has been a35

Appendix IV — Co m m e n t s f r o mStatewide Or g a n iz a t io n svaluable learning experience as we each continue to striveto understand the challenges being faced by all stakeholdersin the health care system.OAHP hopes we are afforded an opportunity to continueour involvement with the newly formed Health careCost and Quality Council and the development of theimplementation details for the four core strategies. Wewould like to ensure there is a focus on achievable resultsand a process that captures work being done at the nationallevel in many of these areas. In fact, leaders from ourindustry are initiating efforts on consumer engagement,electronic technology, payment strategies and medicalhome pilots across the country. We look forward to briningour expertise on these issues.For the health insurance industry, we are particularlyinterested in the efforts concerning payment reform,engaging the consumer and the development of patientcentered medical homes. In looking for a top priority, Ithink the council will be confronted with a chicken andegg scenario. Do you fix the problems with the currenthealth care system and follow-up with payment reforms toreward the changes or do you reform the payment structurein hopes of achieving the changes needed to transform thehealth care system? I think this will be a major focus andpotential struggle for the Council.In reviewing the CORE strategies there are opportunitiesfor integration. For example, I believe payment reformcan have an impact on the patient centered medical homedevelopment which also references development ofpayment reforms. In all of these areas, it will be importantto avoid duplication of efforts.Finally I have comments on the draft report and area forfuture consideration. In the area of activated patientsand individuals, there appears to be lacking a tactic toprovide information to consumers on costs or outcomes ofmedical providers and facilities or to educate consumerson their rights and responsibilities as a patient and userof the health care system. I believe this would round outthe area of activated patients and individuals. In the areaof payment reform, it will be important for this groupto look at payments within the entire system and findways to address the subsidy that is being imposed in thecommercial insurance market by medical providers tocover the inadequate payments from government programs.36Additionally, I would caution against implementationof payment reforms by regulations. Any paymentmodels recommended by the council should be basedupon proven results from pilots or other efforts alreadyunderway in Ohio or other states. There should also beagreement that payment reform involves realigning thecurrent dollars available for medical services based uponoutcomes and “what we want to achieve” from the system.Acknowledgment of this will be needed to achieve successin any payment reform discussion.Ohio Business RoundtableThe Ohio Business Roundtable is thankful for theopportunity we were given to participate in Ohio’s HealthQuality Improvement initiative, and we commend the workof the core and implementation teams for their work indeveloping the Ohio Health Quality Improvement Plan.We share a sense of ownership with the plan’s other cocreators,and we believe the plan takes a comprehensiveand holistic approach to reforming our health care systemwhile also identifying four key and appropriate initialpriorities for focusing Ohio’s health reform efforts.Our attention – and, we hope, the attention of the plan’sother co-creators – now shifts from diagnosing andprioritizing health care reform priorities to the much harderwork of implementing solutions. The creation of the OhioHealth Care and Coverage Council is a good start forcoordinating implementation-focused reform efforts, andwe strongly urge lawmakers to invest the modest resourcesneeded to fund the Council and its staff that were requestedin the Governor’s proposed budget so that this muchneededwork can move forward.To maximize its potential for success, we urge the Councilto maintain a disciplined focus on the initial prioritiesidentified in the draft plan. These priorities align well withthose identified in our recently released Improving Ohio’sHealth System diagnostic report (see, for example, thepopulation health, chronic disease management, consumervalue consciousness, provider value consciousness,and technology-enabled clinical information sharingopportunities discussed on pages 9, 40-47, 53-58, 76-79,and 90-92 of the report) . There have been and will bemany temptations to take on everything when tacklinghealth care reform. Maintaining focus on the plan’spriorities will help combat these temptations – and, infact, the Council should consider even further focusing

Appendix IV — Co m m e n t s f r o mStatewide Or g a n iz a t io n sinitial efforts on tactics within two of the strategies thatwe believe offer the most immediate opportunities fortransforming our system. Those two strategies are (1)payment reform, including moving away from fee-forservicereimbursement and towards a more comprehensive,risk-adjusted payment system that incentivizes health careproviders to reduce the highly fragmented nature of ourcurrent delivery system (through, for example, accountablecare organizations or other vertically integrated modelsthat include medical homes to coordinate care, especiallyamong patients with multiple chronic conditions), and (2)catalyzing more rapid adoption of electronic health recordsas part of integrated health information systems.The Ohio Business Roundtable stands ready to commitits time, talent, and resources to ensure the success ofthe Council and the plan – and we hope our partnersin developing the plan will continue to invest theirfull energies toward the common vision and principlesidentified in the plan for transforming Ohio’s health system.Ohio Chamber of CommercePatient Centered Medical HomesA Patient Centered Medical Homes (PCMH) model issomething that Ohio should strive to adopt. Encouragingpatients to develop a continuous relationship with a healthcare provider can enhance patient care and help ensurequality of care and reduce cost in the system. Employersshould be considered an integral part of the PCMH Taskforce in order to encourage the widespread use of PCMHsin our current employer based health care system. Toensure that the adoption of PCMH does not simply layeradditional cost on the system, the state should be mindfulthat a PCMH does not necessarily need to be a physician,other health care providers may be a more appropriatehome for coordination of care and other functions ofa PCMH. Also, adoption of a PCMH model does notnecessarily equate to more physicians; in fact a wellrespected research group The Dartmouth Institute forHealth Policy and Clinical Practice just commented on thisvery issue. At this early stage, it seems appropriate that thestate could first implement this approach with the Medicaidpopulation, which amounts to about 13 percent of Ohioansand focus the PCMH approach on those with chronicconditions first.Health Information TechnologyHealth Information Technology (HIT) is going to benecessary if Ohio is going to move forward in reformingour health care system. There have been many advances inthe area of HIT in the past few years. A number of payershave adopted or are in the process of adopting IT systemsthat can process claims quicker and more efficiently, allowpatients access to claims on-line and use electronic tools tohelp educate patients about disease prevention and chroniccare management. While at the same time, providers arebeginning to utilize other technological advances suchas e-prescribing and personal health records to advancecontinuity and quality of care. Large providers especially,have taken a leading role in the adoption of technology topromote optimal care. But smaller, individual provideroffices are lagging behind in the adoption of suchtechnology that will be necessary to implement several ofthe strategies laid out in this proposal including PCMHs.Further, the state should take care not to duplicate effortstaking place by the private sector. A number of productsare available on the market and while the state should spareno effort to encourage the use of HIT, it should not becompeting with private sector products.Payment ReformArguably the most discussed of the four reform strategies,payment reform, though necessary, is not the silver bulletfor fixing our health care system, but rather a means toachieve the necessary reforms. Through payment reforms,the state can achieve quicker adoption of PCMHs and HIT,but payment reform alone will not address the staggeringincreases in the cost of health care. Payments should focuson “episodes of care” rather than payments for individualservices. In addition, it seems appropriate for the state towork in conjunction with health care providers to developbest practices that include standards of care for commonepisodes or procedures, similar to the Geisinger HealthSystem’s ProvenCare program in Pennsylvania.Informed and Activated Patients and IndividualsInformed and active individuals are a critical piece ofthe health care reform puzzle, without such individuals itwould be virtually impossible to reform our health caresystem. In moving to ensure that all individuals becomeinformed and activated, the state must ensure that there isfocus on transparency in all aspects of the care continuum,including incentives for compliance and penalties for noncompliance.37

Appendix IV — Co m m e n t s f r o mStatewide Or g a n iz a t io n sOhio Council for Home CareOhio Council is a statewide non-profit association thatrepresents 416 home health care and hospice providers. Wehave been advocating for clients, agencies and employeessince 1965.My responses to the strategies and tactics are in order of thedraft’s organization.Patient-Centered Medical HomesTask Force Tactics• Education – We can assist with all tactics listed undereducation as they include elements of the home caredelivery system.• Communication and Coordination – Home careplans to be involved since named as non-primary careprovider. We would also assist in the development ofchronic disease management programs.A tactic that appears to be missing is the utilization of“assessment” in care coordination. This is a function thathome health care has adopted as part of care management.The Leadership Council of Aging Organization (LCAO)developed principles one of which is the “AssessmentDriven Principle.” Care coordination must be based onan assessment, including, as appropriate, the individual’sphysical, mental, psychosocial, and cognitive functioning,spirituality, medication use, use of adaptive equipment, andfamily caregiver capacity to provide care.• Facilitation – The one action item that is a priorityfor home care is focusing on reducing hospitalreadmissions. Research studies conclude that utilizingcertain tactics by home care can effectively reducereadmissions within the first 30 days of discharge.In addition there are opportunities to also reduceunplanned emergency department visits when homecare is involved.• Evaluation – Home care currently uses clinical metricsin their delivery of care in addition home care isrequired to utilize the outcomes assessment informationset (OASIS) on patients. These strengths would benefitthe structure of the evaluation tactic.• PCMH Payment Models – A tactic that appears tobe missing is utilizing risk-adjustment which allowsfor the consideration of the complexity of individualconditions and the care coordination services. Therealso needs to be recognition for the amount of timenecessary to communicate with the individual andfamily or decision maker.• PCMH Decision Points – Question 4. Is a resoundingYES from us as we believe that the greatest impact andtransformation is with not just improving outcomesfor those with multiple chronic conditions, butmanagement of their conditions.Payment Reform• Tactic 1: please include recognition of tradeassociation so that we may be included.• Tactic 4: home cares knowledge of “avoidable adverseevents” comes as a result of OASIS data and outcomebased quality improvement (OBQI). Home care canassist with all tactics under Tactic 4.Informed and Activated Patients and Individuals• Health Care Treatment Decisions – the first set ofaction steps related to support health care treatmentdecision-making is a requirement of home care undertheir conditions of participation required by Centers forMedicare and Medicaid (CMS).• End-of-Life Decisions – Since this is what hospiceprovides, we can assist with all tactics listed.Side Note: The US Senate just introduced theComprehensive End-of-Life Care Legislation by Sen.Rockefeller, S. 1150. The four sponsors are all Democraticmembers of the Senate Finance.Missing from this section is the consumer protections piece.Either in this section or under care coordination thereshould be legal safeguards such as appeal rights, expeditedappeal, quality review and informed consent. I was unableto find anything regarding consumer protection under anysection of the draft plan.Ohio Education AssociationThank you for the opportunity to provide feedback relativeto the OHQI Plan. I would like to answer the first 3 of yourquestions directly, then add several recommendations to theproposed Plan.38

Appendix IV — Co m m e n t s f r o mStatewide Or g a n iz a t io n si.ii.I work with a number of organizations that could assistin the implementation of the plan; those include thepublic schools directly, and the School EmployeesHealth Care Board, School Employees RetirementSystem of Ohio (SERS), the State Teachers RetirementSystem (STRS) and the State Employment RelationsBoard (SERB) indirectly.The organization that I work for, the Ohio EducationAssociation, has been working for over a decadeto develop operational standards for health planadministration and evaluation to make up for the lackof such regulation in the school market. Our challengeis getting health plans and school organizations(schools and their health plan purchasing consortia) todevelop employee health risk management plans thatcan support healthy lifestyle choices and provide stressreduction opportunities.iii. The top priority should be to develop supply- anddemand-oriented solution sets in order to counterthe existing health system incentives that providepatients and providers with confusing and sometimesinappropriate behavioral signals for medical serviceoveruse, underuse and misuse.Having worked on the planning committee in preventionfor the HQII effort, I was gratified to find the importancethat ‘informed and activated patients and individuals’ hasfound in the proposed Plan. I would like to offer severalobservations and recommendations to improve that sectionof the Plan; I did not feel qualified to answer your questions(iv) and (v), nor to comment on the other sections in thePlan.The Gruman paper that is referenced on page 18 of the Planlays out the issues involved in patient engagement quitewell. However, the Plan re-names the concept ‘activation’,and does not take advantage of the comprehensive‘Engagement Behavior Framework’ as a potential metric.I would urge you to revert to the original wording in orderto facilitate clarity among researchers and practitioners,and would recommend that you expand your metrics tocreate engagement behavior baselines in a number ofpilot populations. Once completed, the results from thesesmaller populations could be folded into the ‘businesscase’ communications to drive the point home. In a similarmanner, other researchers are using small-scale studies toidentify the benefits of behavioral interventions on healthplan prices and individual health; see, for example, DeeEdington’s latest publication available from the Universityof Michigan Health Management Research Center (HMRC)(http://www.hmrc.umich.edu/).Again, thank you for the opportunity to provide feedback. Iremain more than willing to assist in the effort.Ohio Hospital AssociationOhio Hospital Association (OHA) appreciates theopportunity to be part of the Implementation Team of theState Quality Improvement Initiative, and supports thevision and principles articulated in the Ohio Health QualityImprovement Plan. OHA represents 178 hospitals andhealth systems throughout Ohio. Governed by a 21-memberBoard of Trustees, the association helps its members meetthe health care needs of their communities.The collaborative transformational strategies that comprisethe core of the Ohio Health Quality Improvement Planintersect with OHA’s sphere of interest at varying levels.In general, we support each strategy, within the context ofthe association’s own goals and principles for health carereform. In addition to supporting the objectives of thestate implementation plan, OHA also has several qualityinitiatives:• The Ohio Patient Safety Institute (OPSI), anorganization founded by OHA, the Ohio State MedicalAssociation and the Ohio Osteopathic Associationin 2000 to improve patient safety in Ohio. OPSIfocuses on strengthening and promoting policiesand principles to improve patient safety, identifyingstrategies to enhance patient safety in Ohio health-careorganizations, identifying barriers to implementationof strategies for improving patient safety anddeveloping strategies that overcome these barriers,promoting identification and dissemination of reliablepatient safety information to the public and providercommunities, and improving patient safety for allOhioans.• The OHA Quality Institute, created in 2008, withthe goal of driving transformational change in areas ofquality and safety in Ohio hospitals and to affiliatedproviders. The Institute includes OHA qualityimprovement collaboratives in Dayton (established in1999), Cincinnati (‘05), Columbus (‘08), as well as a39

Appendix IV — Co m m e n t s f r o mStatewide Or g a n iz a t io n s40statewide children’s hospital collaborative (‘07). In2009, an initiative, “Solutions for Patient Safety” waslaunched with the support of Cardinal Health, the OhioBusiness Round Table, 17 Central Ohio hospitals andeight children’s hospitals. This project will addressmedication errors and hospital-acquired infections.OHA also partners with The Joint Commission to helphospitals attain a level of continuous survey readinessfor accreditation surveys, and leads other state andlocal quality and patient safety initiatives.• The OHA Data Services Department has beenworking to develop web-based data submission andprocessing applications for hospital data, includinga comprehensive statewide information technologyexchange that allows data sharing among providers.The goal is to adopt data standards for healthinformation by the end of 2009, and to disperse thetechnology through existing collaborative purchasingmodels.OHA’s principles for health care reform directly touch thedecision point evaluating and choosing payment reformmodels. The system should be organized to meet the needsof the community and the individual patient, with a goalof customer value. The system should provide incentivesfor managing controllable costs, and should include:reliance on a balance of fair market forces and appropriategovernment regulations, a seamless delivery system to meetthe needs of the patient, a comprehensive system focusedon prevention and wellness, flexibility to meet the changingneeds of the purchaser/consumer, care in the most costeffective setting, a fair and balanced tort resolution process,and personal accountability. For more information on theOhio Hospital Association’s vision, goals, and principlesfor health care reform, refer to http://www.ohanet.org/reform/default.htm.Thank you for the opportunity to be part of this process andto comment on the final report.Ohio Nurses AssociationAll health care should be center on the individual not uponthe profession providing the care. In this day and age weneed to stop protecting turf and start trying to provide theright care, at the right time that is affordable. Access tocare for all should be the driver for the future of health carewith the health care providers being adequately reimbursedfor provided service. Prevention should be started youngand practiced by all through the ages so that less health careservices are required and the quality of life is enhanced.Ohio Osteopathic AssociationThe Ohio Osteopathic Association is pleased to endorse thefour collaborative transformation strategies contained in theOhio Health Quality Improvement Plan. Health promotionand disease prevention, health information technologyand payment reform using the Medical Home and Payfor Performance models are high priorities of the OOA.We are uniquely qualified to assist the state in these areasbecause:• According to The Physician Supply and DemandConsultation to the Ohio Board of Regents, publishedFebruary 27, 2007: “88% of direct patient carephysicians in Ohio are allopathic physicians (MD) and12% are osteopathic physicians (DOs). Osteopathicgraduates of Ohio medical schools [the Ohio UniversityCollege of Osteopathic Medicine] are more likely to bein direct patient care, primary care (36.7% vs. 43.6%),are more likely to practice in a rural area (10.8% vs16.0%), and more likely to be in a Primary Care HealthProfession Shortage Area (7.1% vs. 9.9%)”• The American Osteopathic Association (AOA) wasone of the four physician organizations that developedJoint Principles of the Patient-Centered MedicalHome (March 2007). In addition, the AOA serveson the Executive Committee of the Patient CenteredPrimary Care Collaborative, a coalition of more than500 employers, consumer groups, patient qualityorganizations, health plans, labor unions, hospitals,physicians and others who have joined together todevelop and advance the patient centered medicalhome.• The AOA’s Clinical Assessment Program (CAP),developed under the leadership of George Thomas,DO, Cleveland, and Richard J. Snow, DO, Columbus,measures current clinical practices in the physician’soffice and compares the physician’s outcomes measuresto their peers using national evidence-based clinicalpractice standards. Measure sets include CoronaryArtery Disease, Diabetes Mellitus, and Women’s HealthScreenings. CAP is among 32 medical registriesqualified to submit quality data to the Centers forMedicare and Medicaid Services (CMS) on behalf of

Appendix IV — Co m m e n t s f r o mStatewide Or g a n iz a t io n sthe 2008 CMS Physician Quality Reporting Initiative(PQRI).• The Ohio University College of Osteopathic Medicine(OU-COM) is a leader in information technology.OhiONE and COREnet have been two of the mostinnovative components of the college’s medicaleducation consortium, known as the Centers forOsteopathic Research and Education (CORE). Utilizingthese technology-based systems, the College and itstraining hospitals throughout Ohio provide high qualityeducational programs, conduct meetings, and supportresearch across the entire CORE consortium. Thesetechnologies allow our member hospitals to integratepostgraduate training programs and share presentationsby nationally known lecturers. In recent years, OhiONEand COREnet have been so successful that they havegrown into one of the largest interactive systems in theUnited States.• From 1993 to 1999, OU-COM was designated by theU.S. Department of Health and Human Services asone of only 25 Centers of Excellence in the UnitedStates (and the only one in Ohio) to insure the trainingof a population of physicians who are skilled inmulticultural medicine. Part of the college’s longtermmission is to recruit, educate, train and retaineconomically disadvantaged and minority students insupport of a culturally competent physician work force.• The Osteopathic Heritage Foundations, Columbus,have approved over $100 million in grants designedto improve the health and quality of life of vulnerablepopulations and advance osteopathic medicine inCentral and Southeast Ohio since 1999. Communityfunding priorities include: obesity, homelessness andoral health care.Ohio State Medical AssociationI. Which strategies or tactics would your organizationbe able to help implement?The Ohio State Medical Association (OSMA) is able andwilling to participate in all four priorities. However, theOSMA will have very limited ability and resources to affectinformed and activated patients. The OSMA has limiteddirect access to educating patients. We could however,work with our physician members on messaging to theirpatients.II. Which strategies or tactics are already priorities foryour organization?Patient centered medical home (PCMH) and HealthInformation Technology (HIT) both are a priority for theOSMA. Payment reform is a priority for the OSMA at thestate level, and to the extent that a state medical associationcan affect payment reform as a national issue. Informedand activated patients are not currently a priority of theOSMA.III. What do you believe should be the top priority forthe Council?The four priorities are so complex and interdependent thatone cannot be effective without the others and the groupwould not be as effective if any one part is missing. Thepriorities create a new “system” that can be viewed ashaving two main components, service and payment. Theservice starts with the PCMH which is dependent on HITand informed and activated patients in order to be effective.The payment structure must be different than today’spayment environment in order to support the new system.This raises a challenging question that the health caresystem must address, do we invest in building a systemdesigned to work more effectively and save money in thelong-run, or do we reward through enhanced paymentsa system that has proven to be more effective and savesmoney? In other words, it’s not a question of who’s goingto pay for it, it’s a question of when. The top priority ofthe Council should be to create an implementation strategyinvolving all four interconnected priorities and to addressthe timing of payment reform.IV. What are the opportunities of integration betweenand among the four collaborative transformationalstrategies?As stated above there are not only opportunities forintegration, but it is critical that all four strategies arehighly integrated and happen simultaneously.V. What are your specific comments to any or all of thedecision points?The PCMH system will not function the same way in everycommunity. Each community has different infrastructureand resources and that community must work within theirgiven environment in order to set up a PCMH system thatdelivers the desired outcomes. While systems my looksomewhat different they should all have similar principlesand desired outcomes set for by this Council. The Council41

Appendix IV — Co m m e n t s f r o mStatewide Or g a n iz a t io n smust defines its specific goals for supporting the fourinitiatives. It should not build a PCMH model and see whathappens, but rather identify specific desired outcomes andbuild a system to achieve those outcomes.The issues of supporting an adequate medical workforceand meeting the challenges of ethnic and racial disparitiesin both the workforce and patient populations are importantissues that must be included as we move forward throughthe decision time frames.Service Employees International UnionSEIU fully supports the Core Transformational Strategiesof achieving Payment Reform, establishing primary careand the Patient Centered Medical Home as the anchor forimproved outcomes, increased efficiencies and affordableaccess, Creating Informed and Activated Individuals andPatients, and transforming Health Information Technologyas outlined in the Ohio Health Quality Improvement Plan.Integration of other initiatives, especially the UnifiedLong Term Care Budget Workgroup recommendationsinto the Health Care Coverage and Quality Council isessential to achievement of the Vision for a Healthy Ohio.Payment reform initiatives must exist across the continuum,including primary care, acute, and long term care systems.Likewise, without a long term care system in place thatwill be responsive to the needs and desires of the activatedand informed patient, the benefits outlined in that strategicfocus area are minimized, if not reversed. Additionally, thegoals outlined in the Activated/Informed consumers focusarea can only be effective if there is an equally focused anddeliberate effort to change the culture of providers and howthey relate to consumers.When looking at a Patient Centered Medical Home thattakes care of all health care needs of an individual, Homeand Community Based services and supports can not be leftout of the equation. This is especially true when lookingat Ohioans with chronic care needs. Homecare workersare often the only providers who have daily interactionwith the individual with chronic care needs as they are inthe home on a daily basis over the long term. Homecareworkers could be trained to provide the kind of chroniccare management/monitoring that we envision in a PatientCentered Medical Home.As SEIU represents health care workers across care42settings in Ohio, the issue of workforce capacity is apriority for our organization. This is especially true in thearea of the Ohio’s homecare direct support workforce.The stabilization, professionalization and growth of thisgroup of workers will be essential into the future as ourpopulation ages, and an ever larger share of the state budgetis directed toward providing long term care for Ohioans.We look forward to working with the Council to addressthe issues of this workforce.Through our membership of 35,000 individuals we havethe ability to reach many consumers to encourage andmarket the methods laid out towards creating activated andinformed consumers.As the HCCQC begins to move forward on therecommendations outlined in the plan, a coordinatedadvocacy and lobbying strategy should be developed toaddress barriers that exist to implementation at a federallevel. As a national organization SEIU is heavily involvedin national health reform discussions and has the capacityadvocate strongly and effectively for reforms that musthappen in order to move these initiatives forward on astate level. As an organization with an additional presenceon local and regional levels, we have the desire andability to share best practices developed in other regions,and to advocate for states’ abilities to continue to act aslaboratories to health reform strategies.UHCAN Ohio and Ohio Consumers forHealth CoverageI write on behalf of UHCAN Ohio (a statewide consumerhealth advocacy organization) and Ohio Consumers forHealth Coverage, a coalition uniting diverse consumerinterests in health care reform. On behalf of Ohio’s healthcare consumers, we are extremely supportive of the visionand strategies embodied in the plan, as we seek highquality, affordable health care for all Ohioans.We are committed to collaborating with all stakeholders onpursuing strategies and tactics beneficial to consumers.We will help to build support, through public education andadvocacy, for public policies that:• expand patient-centered medical homes, especially toOhioans with or at risk for developing chronic healthconditions• adopt payment methods that make significantinvestment in patient-centered medical homes and

Appendix IV — Co m m e n t s f r o mStatewide Or g a n iz a t io n shealth outcomes and that reward providers for meeting performance benchmarks• increase public reporting on quality, utilization, spending, and other transparency data to measure, analyze, andimprove quality and cost-effectiveness, and• enable consumers and providers to choose the most effective, safe, and appropriate treatments and medications.We believe that improving both quality and cost-effectiveness of health care is critical to achieving a healthy Ohio,but that expanding coverage to all Ohioans should not wait until delivery system reform is achieved. Rather, coverageexpansion and quality improvement must happen at the same time.Consumers – the customers and beneficiaries of health care – are too often excluded, confused, or ill-served by today’scomplex, fragmented health care system. Unless organized consumers are actively involved both in their own healthcare and in improving the health care system, efforts to improve health care may fail. We are committed to ensuring thata coordinated consumer voice informs the development, implementation and evaluation of all strategies described inthe plan, and we will work with others to organize effective consumer participation in key aspects of the work. We willalso work to make sure that consumers have adequate resources to become partners both in their own health care and inimproving the health care system for all.We also want to make sure that quality health care in Ohio is affordable to all consumers and will lend our expertise indeveloping affordability standards that prevent consumers from going without needed care or suffering financial hardship.We are committed to ensuring that health care delivery reform reduces racial and ethnic disparities in health care and thathealth care is culturally appropriate to all residents of Ohio. We also seek to prevent implementation of strategies andtactics that are punitive to, or impose hardships on consumers.43

Im p l e m e n t a t io n Te a mDr. Alvin JacksonOhio Department of HealthAmy Rohling McGeeOffice of Governor Ted StricklandBill HayesHealth Policy Institute of OhioBrent MulgrewOhio State Medical AssociationCathy LevineUHCAN OhioCarrie HaughawoutOhio Chamber of CommerceChristine KozobarichSEIU 1199Col OwensLegal Aid Society of Greater CincinnatiCristal ThomasExecutive Medicaid Management AdministrationDavid UldricksEmployers Health Purchasing Corporation of OhioErnie BoydOhio Pharmacists AssociationGingy Harshey MeadeOhio Nurses AssociationJerry FreidmanOhio State Medical CenterJim CastleOhio Hospital AssociationJane TaylorAARP OhioJon WillsOhio Osteopathic AssociationKelly McGivernOhio Association of Health PlansKen FrisofMetroHealthMary Jo HudsonOhio Department of InsuranceChristine WilliamsOhio Association of Advanced Practice NursesNick LashutkaOhio Children's Hospital AssociationTy PineNational Federation of Independent BusinessRichard StoffOhio Business RoundtableSteve MillardCouncil of Smaller Enterprises44

CORE PLANNING TEAMAmy Rohling McGeeOffice of Governor Ted StricklandBerna BellOhio Hospital AssociationBill HayesHealth Policy Institute of OhioCathy LevineUHCAN OhioChristina WilliamsOhio Business RoundtableCristal ThomasExecutive Medicaid Management AdministrationCynthia BurnellOhio Department of InsuranceDeborah Clement SaxeOhio Department of Job and Family ServicesDoug AndersonOhio Department of InsuranceJanet GoldbergHealth Policy Institute of OhioJon WillsOhio Osteopathic AssociationKara MillerOhio Department of Job and Family ServicesKen FrisofMetroHealthKristina RedgraveOffice of Governor Ted StricklandMarc MoleaOhio Department of AgingNicholas WiselogelHealth Policy Institute of OhioRex PlouckOhio Department of InsuranceRob EdmundOhio Business RoundtableRon BridgesAARP OhioSteve MillardCouncil of Smaller Enterpriseshttp://ohqis.pbwiki.com45 23