The Need
The HCBS system is complex with a number of technology systems and an enormous data infrastructure. To adequately prepare for the future, these systems need continual maintenance and updates. The tools and technologies the Department uses not only impact our administrative functions, but each is integral to our providers’ ability to perform their contractual obligations and to provide care to our members.
In addition, technological advancement is necessary to support our members and their families who rely on our systems to access services, seek resources, and gauge provider quality. For these reasons, the Department proposes a package of investments to elevate our current suite of tools and technology and to develop new and emerging systems that will prepare us for the future.
Initiative 6.01. - Home Health/PDN Acuity Tool
Home Health
The Department will design and develop an adult Long Term Home Health (LTHH) acuity tool and two Private Duty Nursing (PDN) tools for adult and pediatric members to better determine the appropriate medically necessary level of care and associated nursing hours for members. These tools will streamline the benefit delivery and ultimately provide long-term savings to the State by providing an additional basis with which to determine appropriate service needs for members.
The Department received funding to implement a LTHH acuity tool in FY 2019-20 through R-9, “Long Term Home Health/Private Duty Nursing Acuity Tool.” The Department used this funding to conduct an environmental scan in FY 2020-21 of other state approaches but was unable to identify an appropriate tool, concluding that the Department must build one from the ground up. There was not adequate funding to build and implement a tool with the funding from that request.
The Department will create, pilot, and validate an LTHH as well as pediatric and adult PDN acuity tools tailored to Colorado home health policies. The Department will conduct both a policy and systems crosswalk of the proposed variables required for the LTHH acuity tool with the long-term services and supports (LTSS) assessment tool that determines nursing facility and/or hospital level of care for members seeking LTSS services. This will help determine opportunities for alignment of the tools to ensure that as members’ needs change, they do not have barriers to accessing other State Plan or waiver benefits, nor is there duplication of services. A crosswalk has already been completed for PDN tools.
Once the acuity tools are developed, the Department will integrate the developed tools as a module within the Care and Case Management System. The utilization management vendor will either access the CCM tool directly or through a workflow that will allow them to perform the necessary medical necessity prior authorization determinations for PDN and LTHH benefits.
Initiative 6.06. - HCBS Provider Digital Transformation
Note: As of November 2021, this project has incorporated project 6.04 HCBS Provider Electronic Health Record System Upgrades under the scope of its efforts.
The purpose of this project is to provide funding to home and community-based providers to digitally transform their care delivery. Funding will include investments in upgrading or implementing electronic health record systems to be able to better coordinate care, access real-time information through health information exchanges, and the purchase of tools necessary for the delivery of virtual services. This project will leverage lessons and processes from the Department’s Electronic Health Record incentive program and the Office of eHealth Innovation’s telemedicine projects, with a focus on inclusive and equitable approaches and solutions. These funds will be provided through a competitive grant program that is aligned with other developing efforts, such as HB 21-1289, “Funding for Broadband Deployment.”
Initiative 6.08. - Care & Case Management System Investments
The Department will fund investments in system changes, software, and hardware to support the new care and case management system. These initiatives will support data sharing in ways that support person-centered, timely provision of care, improving the member experience. The Department is reviewing investments in system changes, software, and hardware to support the new care and case management system. These initiatives will support data sharing in ways that support person-centered, timely provision of care, improving the member experience.
Device Costs
The Department will provide one-time funding for CMAs to purchase laptops or other mobile devices compatible with the new case management IT solution, the Care and Case Management (CCM) system. These devices will be used to support agencies in utilizing the new CCM system to perform case management functions during their regular business operations. Case managers will have the IT technology necessary to leverage the capabilities of the new CCM tool, including accessing the log notes offline, perform assessments in the home, or upload assessments with the latest technology. Members will be able to be assessed quickly in their homes and provide signatures in real time.
System Costs
Funding will also be used to implement policy change requirements and enhancements that were not captured with the implementation of the CCM system. For example, the CCM system does not include remote signature capability of support plans by all stakeholders; this has been identified as an opportunity for future enhancements. Another potential enhancement is to allow providers to upload incident reports directly to the member record for the case manager to review and identify whether a critical incident occurred. This is highly encouraged by CMS to ensure incidents are tracked, mitigated, and trended prior to becoming a critical incident. Further, the Department will create bidirectional data feeds between providers and the CCM, building on existing statewide data sharing strategies in development or in place regarding EHRs.
The Department intends to create a regional advisory board to support improvements to provider IT sophistication and interoperability, to include the development of data dictionaries of key elements needed by providers.
Initiative 6.09. - Updates to Salesforce Database
As part of this technology project, the Department will implement a system where complaints, issues, grievances, clinical documentation, and quality care complaints are compiled and centralized. This will include updates to the Salesforce system to allow for clinical review and time tracking for staff as well as tracking for creative solutions and complex solution calls to allow for tracking of diagnosis, services, and length of time it takes to locate a solution for the case.
Initiative 6.12. - Systems Infrastructure for Social Determinants of Health
The Department, in partnership with the Office of eHealth Innovation, will expand the infrastructure for a Social Health Information Exchange (SHIE) which provides case management agencies, RAEs, care coordinators, and health care providers with real-time connections to resources like food, energy assistance, wellness programs, and more. This will be part of a broader social health information exchange ecosystem being developed by the Office of eHealth Innovation. In addition, the Department will distribute funding in the form of state-only community grants to help connect small non-clinical agencies that specialize in and serve the HCBS population to the health information exchange and access the functionality. The Department will build upon lessons learned from the recent build of the prescriber tool that connects providers to information that helps inform real-time decisions needed to best help members.
Initiative 6.03. - Member Facing Provider Finder Tool Improvement
The Department administers a “Find A Doctor” provider search tool on the Department’s website that identifies health care providers based on certain search criteria selected by the user. The Department is currently working to add additional functionality to the tool, including the ability to search by practitioner location, practitioner associations, and provider specialties.
Under this project, the Department will add the critical criteria of “Cultural Competency” to the search tool. Cultural competence in health care is broadly defined as the ability of providers and organizations to understand and integrate these factors into the delivery and structure of the health care system. The goal of culturally competent health care services is to provide the highest quality of care to every patient, regardless of race, ethnicity, cultural background, English proficiency, or literacy. Through this project, the Department will add cultural competence search criteria to the tool. This could include criteria such as: woman or minority owned/operated, cultural and ethnic subgroups, etc.
Initiative 6.05. - Member Tech Literacy
Like HCBS providers, many HCBS-enrolled members could benefit from greater access to electronic systems. Under this project, the Department will develop a program for members that would provide digital literacy training, with the hope of improving access to benefits virtually and more broadly.
Initiative 6.11. - Centers of Excellence in Pain Management
Many HCBS members deal with chronic pain and are unsure how to navigate the system to providers that are best equipped to help them manage their pain and thrive. The Department will pilot a program in which a contractor team consisting of a nurse practitioner and a licensed clinical social worker will assess the needs of chronic pain patients for mental health or substance use disorder treatment. The team will coordinate appropriate referrals to mental health, SUD, or Centers of Excellence for Chronic Pain providers primarily via telemedicine using best practices for appropriate pain management. This team will also coordinate with RAEs to offer training and support to further expand the program and meet the needs of all members seeking treatment for chronic pain.
Initiative 6.13. - Connect CMAs to ADT Data
(previously named Connect Case Management Agencies to CORHIO)
The Department will connect CMAs to the Colorado Regional Health Information Exchange Organization (CORHIO) to obtain hospital admission data in real-time. While Admission, Discharge, and Transfer (ADT) data from hospitals is transmitted from the BIDM to the CCM system, there is a significant lag, which prevents it from being actionable. This project will purchase a license for one user at each CMA to access ADT information via CORHIO.
Case managers will benefit from knowing when members have been hospitalized, alerting them to possible changes in functional needs and services and supports, as well as possible critical incidents. Case managers will be able to better coordinate care and participate in discharge planning with access to this information.
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Initiative 6.15. - Interface with Trails
The Department will implement system changes to connect Trails, the State’s child welfare system, with the MMIS to allow counties to improve quality and reduce duplicate cases. This will improve the eligibility determination process for LTSS utilizers. The interface will allow county staff to determine if a child who is going to be entered in Trails already has an open case in another system. This may be accomplished by building a warehouse, an interface, or allowing Trails and the MMIS to communicate in real-time.
Initiative 6.02. - Specialty Search in Provider Specialty Tool
HCBS providers struggle to identify which specialty they qualify for and which one to select when using the MMIS online enrollment module. As a result, providers either spend a lot of time researching provider specialties on the Department’s website or select specialties in the MMIS for which they are not qualified or do not wish to enroll.
The Department will develop an optional “specialty finder” tool that will, through a series of questions, help providers identify which specialty or specialties they would like to enroll in, as well as the HCBS population they would like to serve. The tool will also provide guidance on other enrollment requirements that may be necessary to enroll and point to non-HCBS provider types they may be eligible for. Once an algorithm is developed, it will be integrated into the Department’s website. This tool will allow providers to quickly understand which specialties they are eligible for, understand the steps necessary to enroll, and cut down on questions to MMIS staff and staff across the Department and the Department of Public Health and Environment.
Initiative 6.07. - Innovative Tech Integration
Technology changes rapidly, including in the healthcare field. The Department will explore innovative technology that will improve diagnoses, services access, health outcomes, and program delivery for medical, behavioral, and HCBS services provided to HCBS members. The Department will research potential innovative models for diagnoses, access, outcomes, and delivery, as well as evaluate whether those technologies would work in Colorado practices. Recommendations, including implementation steps, for pursuing these forms of technology will be developed.
Initiative 6.10. - Member Data Sharing
Through the CMS Interoperability Rule, which is a part of the 21st Century Cures Act, the Department received funding from its FY 2021-22 R-9 “Patient Access and Interoperability Rule Compliance” decision item to develop an agreed upon, consensus-based approach regarding compliance with the Interoperability Rule. Compliance is based on the creation of an open framework that will allow data to be stored, shared, and pulled into consumer-chosen, consumer-facing applications, vetted through a federally mandated review process.
The Department will use funding to integrate key data points from the CCM tool into a data set that meets federal technical requirements. This data could include member assessments, case management log notes, and critical incidents. The data will be available for members to access through consumer-facing applications or other Electronic Health Record (EHR) applications, leveraging recommendations from the Testing and Experience and Functional Tools (TEFT) Grant, in consultation with the Governor’s Office of eHealth Innovation. The implemented solution would be a way for members to access data collected by and maintained in the CCM tool, as well as information about qualified providers as maintained in the BIDM, and could include functionality like secure, in-app texting/reminders that could occur between Health First Colorado members and their care team or teams. The Department will design a Long-Term Services and Supports-focused application or other point of access. Any solution will include functionality that is compliant with the Americans with Disabilities (ADA) Act.
Members will be able to access their CCM-related data through the application of their choice, using a device of their choosing. Members will have a seamless experience with their CCM-related health data, irrespective of payer or provider or originating IT source, and be able to access that information using technology of their choosing. This solution builds on existing work done statewide to provide access to health care data.
Initiative 6.14. - Data Sharing with the State Unit on Aging
The Department suspects that many LTSS older adult members are receiving services through their local community, including the Area Agencies on Aging. These individuals may not be accessing the care that they need and are eligible for through Medicaid. Understanding who these individuals are and what services they are relying on from community-based organizations will help the Department to better target services. Additionally, if the Department can improve access to Medicaid services for these individuals, it would free up resources for older adults who are not eligible for Medicaid LTSS.
In this project, the Department will work with the Office of Aging and Adult Services within the Department of Human Services to conduct a system mapping of program and IT systems to determine a mechanism to share data and information across offices. The goal will be to implement a technology solution to access the Area Agencies on Aging data to identify and better track Medicaid LTSS members who are receiving services. Current efforts are underway through Colorado’s Health IT Roadmap led by the Office of eHealth Innovation to accelerate the sharing of information and establish infrastructure, governance, and policy that enable the broader health IT ecosystem and State agencies to support care delivery and quality measurement.
Initiative 6.16. - Eligibility Systems Improvements
The Department will improve eligibility systems to hasten application processing, improve determination accuracy, and provide real-time provider eligibility status insights. To do this, the Department will streamline eligibility processing for HCBS members. This will include system enhancements, policy requirements, modifications, and training to address barriers to long-term care eligibility. Part of the project will be to create a bidirectional interface between CBMS and the CCM.
These changes will further automate the exchange of information between case managers and county technicians and eliminate the need to maintain a third system acting as a go-between for the entities, increasing operational efficiency and improving the member experience.