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 6.04. - HCBS Provider Electronic Health Record System Upgrades

Note: This project has been incorporated into the scope of project 6.06 HCBS Provider Digital Transformation project efforts. All future reporting will be conducted under that project effort.

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 - Completed

Project Achievements and/or Activities:

Like HCBS providers, many HCBS-enrolled members could benefit from greater use of electronic systems. Every day we are all expected to adopt new technologies that improve our lives and help us to access the things we need, including our healthcare. This includes accessing doctor's portals, utilizing email and text messaging reminder systems for appointments, or receiving services through expanding telehealth and telemedicine options.  

Under this project, HCPF contracted with the Center for Inclusive Design and Engineering (CIDE) to understand the technology literacy landscape for members served through Long Term Services and Supports (LTSS) and identify best practices for effective instruction in achieving desired outcomes including increased digital literacy and use among LTSS members. The outcome of this work is the development of a Digital Literacy Pilot, which included 29 members and 18 coaches, aimed at improving the digital literacy skills of Colorado Medicaid recipients so they may better access online health information and services. During this project, the team is proud to have accomplished the following:  

• Conducted stakeholder engagement through a community survey, small group feedback sessions, and subject matter experts to inform the development of the digital literacy curriculum for people with disabilities. Report  
• Conducted a scholarly literature review of the technology literacy landscape for people with disabilities.  
• Developed a comprehensive Digital Literacy Coach Facilitation Guidebook.
• Developed two interactive digital literacy curriculums accessible via learning modules, one for coaches and another for learners.
• Conducted a pilot with 29 volunteer learners (HCBS recipients) and 18 coaches (service providers, family members, and friends) to evaluate the effectiveness of the curricula and learning modules.  
• Evaluated the learning experience and shared results in a final report.
• Published the full curriculum and modules online for anyone in the general public to access through Moodle.

Summary / Project Outcome:

This project developed a learning experience to aid members in developing digital literacy skills including how to access health information online utilizing a coach and learner structure. The learning plans include lessons on foundational skills, online healthcare, cybersecurity, and digital equity. The pilot participants shared their satisfaction with the learning experience in the evaluation process.

Moving forward, the developed content and learning management system will be available publicly for anyone to access, free of charge. Additionally, the team from the University of Colorado - Center for Inclusive Design & Engineering (CDIE), in partnership with the Colorado Office of Employment First (COEF), plans to continue to look for future funding opportunities to expand the curriculum.

External Facing Reports/Websites:  

• Learning opportunity in Moodle  
• Scholarly literature review
• Stakeholder Engagement Report
• Digital Literacy Coach Facilitation Guidebook
• Final Report 

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 - Completed 

(previously named Connect Case Management Agencies to CORHIO)

Key Project Achievements and/or Activities:

The following details the key achievements and activities resulting from the Connect Case Management Agencies (CMAs) to Admission, Discharge, Transfer (ADT) pilot project:

• HCPF was able to regularly deliver and distribute readable and user-friendly daily ADT data to each of the CMA participants.  
• Policy and process recommendations were submitted as Case and Care Management (CCM) system change requests to add event notifications and a work queue for ADT data.  
• The CMA pilot participants were able to learn how to use ADT data for identifying and following up on Critical Incidents Reports.
• The participants were able to identify potential areas of collaboration with their Regional Accountable Entities (RAEs) as a result of this project.  
• HCPF was able to successfully gather and implement stakeholder feedback through monthly meetings and surveys.  
• Connect Case Management Agencies (CMAs) to Admission, Discharge, and Transfer (ADT) Data Pilot Summary of Findings and Recommendations report was completed by the HCPF.

Summary / Project Outcome:

The 6.13 Case Management Agencies (CMAs) to Admission, Discharge, Transfer (ADT) Data pilot project began in January 2023 and concluded in December 2023.  The pilot consisted of seven participating CMAs who received daily ADT hospital data files via a secure site from HCPF. The CMAs used the ADT data to identify members associated with their agency who had visited the hospital, alerting them to possible changes in functional needs and services and supports, as well as possible critical incidents. All of which made CMAs more effective at case management while enhancing member experience. The HCPF staff utilized feedback received from monthly participant meetings and monthly participant survey responses to determine the results and outcomes from the pilot project. Multiple positive outcomes were identified as a result. The feedback from participants resulted in the submission of a system change request to generate ADT notifications and a work queue in the Case and Care Management (CCM) system. As a result of having access to the ADT data, participants reported improved outreach and increased communication between case managers and their members thus enhancing member experience. Participants also stated feeling empowered to conduct more effective and comprehensive follow up with their members and identified increased opportunities for the coordination of discharge planning, in turn leading to a more seamless continuity of care.  It was determined that both members and case managers benefited from connecting CMAs to ADT hospital data. Case managers were able to better coordinate care and participate in discharge planning with access to this vital information.  Overall, this improved health outcomes and the quality of care for members.

Project Metrics:  

Seven grants were issued to Case Management Agencies (CMAs) with a focus on diversity. 85.7% of grantees were designated with a diversity classification and were identified as small businesses. Pilot participants completed 12 monthly surveys which included an average of 10 questions across three different categories: Quality of Admission, Discharge, Transfer (ADT) data, Critical Incident Reporting, and Regional Accountable Entity (RAE) and CMA Coordination. The respondents were also asked to upload examples of ADT follow-up activities. Pilot participants engaged in 12 monthly meetings with HCPF staff to discuss and review outcomes related to the quality of ADT data, progress of Critical Incident Reporting, and communication with the RAEs. HCPF project leads spent 30+ hours gathering, documenting, and organizing stakeholder feedback for the ADT project. HCPF distributed 290 days of ADT data to pilot participants between January 26, 2023 and December 31, 2023, despite a brief interruption due to a nationwide data outage during the months of June and July 2023. An analysis demonstrated that the distribution of the ADT data impacted an average of 704 members per month.

External Facing Reports/Websites:  

Connect Case Management Agencies (CMAs) to Admission, Discharge, and Transfer (ADT) Data Pilot Summary of Findings and Recommendations Report 

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 - Completed

Key Project Activities and/or Achievements:

• Identified related service types  
• Web page to help guide prospective providers  
• Provider notification memo 

A web page has been deployed to help prospective HCBS providers select the right specialty in advance of enrolling with Gainwell or starting the licensure process with the Colorado Department for Public Health & Environment. This will save prospective providers time, reduce the amount of applications returned, and increase the number of available HCBS providers.

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 - Completed 

Key Project Achievements and/or Activities: 

HCPF worked with a vendor to determine future data-sharing capabilities with the Office of Aging and Adult Services (SUA) within the Department of Human Services (DHS), as well as address gaps, opportunities, and barriers to data-sharing in Colorado and reporting on best practices used in other states. The vendor designed a system map of program and IT systems to determine a mechanism to share data and other information across offices. The goal was to implement a technology solution to access the Area Agencies on Aging (AAAs) data to identify and better track Medicaid (Long Term Services and Supports) LTSS members who are receiving services post-ARPA. 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. 

Summary / Project Outcome:

Through meeting with representatives from Colorado Case Management Agencies (CMAs), Area Agencies on Aging (AAAs), Aging and Disability Resource Centers (ADRCs), and Health Care Policy and Financing (HCPF), the vendor was able to identify key barriers to cross-agency data sharing that ultimately result in members missing out on certain benefits or supports. The vendor also completed thorough analyses on data sharing allowances related to Medicaid-centric agencies as supported by statutes and regulations, and on opportunities to improve data-sharing through Department initiatives. To point to a feasible path toward data-sharing improvements, the vendor completed a study on data-sharing best practices in other states, and the various systems used by CMAs, AAAs, and ADRCs, and also highlighted allowances in HIPAA regulations.

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.