Delivery of Care

The State Innovation Model winds down to zero

After five years and $20 million, what is the best way to take stock of what SIM accomplished in Rhode Island?

Image courtesy of the R.I. Department of Health

The State Innovation Model Transformation Wheel, illustrating the SIM initiative's theory of change.

By Richard Asinof
Posted 7/29/19
As the five-year, $20 million federal grant for the State Innovation Model winds down, there are questions that remain about the broader efficacy of the effort to drive care transformation in Rhode Island.
What is the status of the efforts now underway, being led by The Rhode Island Foundation, with more than 30 stakeholders, to develop a statewide health care plan? Now that the efforts by Gov. Raimondo to broker an arranged marriage between Care New England, Lifespan, and Brown have ended in failure, are there opportunities for continued partnerships with Partners Healthcare? When will efforts to implement Medicaid accountable entities include plans for long-term care services? What is the average wait time to see a primary care physician in Rhode Island?
One of the intriguing developments as part of the efforts of Leadership RI is to conduct a visit by its classes to health equity zones in Rhode Island. It is the kind of opportunity to showcase the work being done at the community level, providing folks with a show-and-tell approach to discovering more about one of the truly innovative initiatives in Rhode Island to develop community-based solutions to health disparities. Perhaps newspapers and media outlets should consider a similar kind of approach for reporters.

WARWICK – Once a month, on late Thursday afternoons, members of the State Innovation Model [SIM] steering committee have been gathering for a number of years in the second floor conference room of Hewlett Packard offices at 301 Metro Center Boulevard, a stone’s throw away from the steady drone of rush-hour traffic on Route 95.

The meeting on Thursday, July 25, promised to be the second to last meeting, as the $20 million in funds flowing from the Centers for Medicare and Medicaid Innovation will “zero out” in October, according to Marti Rosenberg, the R.I. SIM director. The last meeting is scheduled for Thursday, Oct. 10.

Members attending the SIM steering committee meetings are a veritable who’s who of the major players in Rhode Island’s health care delivery system: executives from all the major commercial health insurers, Blue Cross and Blue Shield of Rhode Island, Neighborhood Health Plan of Rhode Island, Tufts Health Plan, and UnitedHealthcare; the state agencies such as the R.I. Department of Health, the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals, and the R.I. Office of the Health Insurance Commissioner; representatives from the major hospital systems; statewide initiatives such as the Care Transformation Collaborative; community agencies such as Rhode Island Kids Count; and professional associations such as the Rhode Island Business Group on Health.

At the meeting, the new Secretary of the R.I. Executive Office of Health and Human Services, Womazetta Jones, was introduced, one of a number of public introductions since Jones began work last week on July 22.

Attending a meeting of the SIM steering committee is very much a deep descent into wonkville when it comes to the health care delivery system: the discussion often occurs in the very thin air high up on the mountainside of health delivery. The topics on the agenda for the July 25 meeting included:

The results on efforts to drive transformation of the health care system through the development of alternative payment models to transition from fee-for-service, including a capitation model for primary care, with the work being done by Bailit Health and coordinated with the R.I. Office of the Health Insurance Commissioner.

The results of efforts by a workgroup to align quality measures and priorities to reduce administrative burdens for providers and payers, with the work being done by Bailit Health and coordinated with the R.I. Office of the Health Insurance Commissioner, with the recommendations to be considered by OHIC for possible adoption for 2020 value-based contracts.

A presentation by Sandra Powell, director of the Division of Policy, Information and Communications at the R.I. Department of Health, discussing efforts to create a comprehensive statewide inventory, following up on work that was done in 2015. [See link to ConvergenceRI story below, “RI health care landscape redefined.”]

SIM performance metrics
A snapshot of 11 performance metrics through June 30, 2019, was distributed to the members, with impressive results recorded. Among the top results:

Patients attributed to practices participating in PCMH-Kids, with the number of patients at 82,672, exceeding the goal of 30,000 patients by 276 percent.

Behavioral health workforce training and development participation, with the number of providers trained and impacted at 1,112, exceeding the goal of 500 providers by 222 percent.

Advance Directives uploaded and available in CurrentCare, with 402 advance directives uploaded, exceeding the goal of 50 being uploaded by 804 percent.

Providers trained in SBIRT [Screening, Brief Intervention, and Referral to Treatment, an evidence-based practice used to identify, reduce and prevent problematic use and abuse of illicit drugs and alcohol] by training and resource centers, with 783 providers trained, exceeding the goal of 240 providers trained by 326 percent.

As terrific as all those performance metrics appear to be, the broader context measuring their impact is not clear. For instance, if the low reimbursement rates paid by Medicaid in Rhode Island prevent practices such as Coastal Medical from being able to refer patients to behavioral health and mental health providers, additional training for the behavioral health workforce and providers may not address the gap in unmet needs.

Further, if only 6 percent of those patients presenting with mental health and behavioral health problems and substance use disorders are being treated holistically for both in Rhode Island, as the chief medical officer at the R.I. Department of Behavioral Healthcare, Development Disabilities and Hospital found in a recent analysis, the results in meeting training goals as part of care transformation may not address the underlying gaps in providing services.

Measuring the unmet needs
One of the goals of the health inventory is to provide information to the R.I. Department of Health on access and barriers to health care n Rhode Island, building on the work done on a 2015 statewide health inventory.

Among the results presented by Sandra Powell were:

An oral health survey was conducted, with a 75 percent response rate.

A dialysis survey was conducted, with a 100 percent response rate.

A hospice survey, an ambulatory surgery center survey, and an imaging center survey have all been distributed.

In addition, a patient and community survey has been posted on the R.I. Department of Health, in English and Spanish.

Also, there has been the creation of a new pharmacy survey, working with a Department of Health pharmacy workgroup.

Moving forward, Powell said, there was a need to identify additional sustainable resources to ensure that the inventory was conducted on a regular basis.

In a slide entitled, “Qualitative Anecdotes or Case Study,” some of the responses tabulated by Powell were provocative. In responses to the patient and community survey, addressing what “health issues you think state leaders should focus on, the comments included:

Not enough primary care physicians; waiting time for specialists average 2-3 months

Mental health destigmatization

There should be adult-ed community-based cooking classes available

Also, in responses from the dialysis survey, several respondents said the most difficult question was about race and ethnicity, but they didn’t give a reason why.

The role of nurses
Lynn Blanchette, RN and PH.D., Associate Dean at the Rhode Island College School of Nursing, asked Powell if it were possible, in conducting the state health inventory, to apply the data in terms of future nursing jobs and the high demand in applications to attend nursing school.

In an email to ConvergenceRI following the meeting, Blanchette explained that she wanted to see nursing included in the survey and to explore strategies to pay for nurse-driven outcomes.

Specifically, Blanchette wanted to see the health inventory include:

A count of nurses in Rhode Island, because with the current online licensing system, there is not enough space to learn about where nurses are working, and if they are working part-time.

• A better understanding of where nurses are currently employed and where there is specific need. The number of nurses needed in the future is important to higher education to tailor the education and to produce enough nurses to meet the demand.

“This year, a nursing program closed down in Rhode Island,” Blanchette wrote. “Currently, the program at Rhode Island College is not able to accommodate all of the qualified candidates who are submitting enrollment applications.” Gaining insight into the need for RNs with BSNs, she continued, will provide the data needed to increase the number of seats available in RIC’s nursing program.

“Keep in mind,” Blanchette continued, “the BSN-prepared nurse is able to provide primary care, manage chronic illness, provide health promotion and prevention teaching, provide case management and practice management. He or she is likely the nurse who is the best provider [most effective, well prepared and less expensive] in many settings, including the primary care medical home. Registered nurses are critical for home care, skilled nursing facilities, schools and a host of other settings.”

Additional questions
Following the presentation, ConvergenceRI, in an email to Powell, asked a number of follow-up questions. Answers will be provided next week, according to R.I. Department of Health spokesperson, Joseph Wendelken:

Will the work you have been doing with your extensive surveys be provided to the group of public and private stakeholders, now meeting under the direction of The Rhode Island Foundation, to help them in developing a long-term statewide health plan?

Is there a way to look at the data collected and analyzed from a macroeconomic perspective, as an alternative way to measure the health care economy, from the bottom up, rather than the top down?

What were your takeaways from the work completed to date, reflecting perhaps on your comment at the meeting about the potential to be more “forceful” in the recommendations?

One more brief observation
During the discussion at the SIM meeting, when Elizabeth Burke Bryant, the executive director of Rhode Island Kids Count, shared the data presentation “Childhood Overweight and Obesity: New Data for Rhode Island,” the new R.I. EOHHS secretary, Womazetta Jones, made some forceful remarks about the need to address the root causes of food insecurity.

The responses to Jones by members of the SIM steering committee were somewhat sparse, in ConvergenceRI’s opinion.

Jones had to leave the meeting early, and ConvergenceRI sought her out as she was leaving, introducing himself and officially requesting an interview, a request that had been pending with the communications team at R.I. EOHHS since May.

In addition, ConvergenceRI offered to share with Jones information about existing programs that are specifically geared toward addressing food insecurity in Rhode Island: the Food on the Move mobile market, run by the R.I. Public Health Institute, and the Sankofa Initiative, which includes affordable housing connecting to growing spaces, a greenhouse, and a weekly market.

Jones was intrigued, but the communications officer escorting Jones was angry, in part because he was unfamiliar with any of the programs. Stay tuned to learn if and when an interview with Jones will take place.


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