Healthier Washington Medicaid Transformation
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Level of physical and behavioral health
integration at practice/clinic site
Metric description: Practice/clinic site measure reflecting responses to MeHAF Site Self Assessment
(SSA) Survey.
Reporting period and deadline: Semi-annual, DY 3 through DY 5
Reporting Period Reporting Deadline
January – June 2019 07/31/2019
July – December 2019 01/31/2020
January – June 2020 07/31/2020
July – December 2020 01/31/2021
January – June 2021 07/31/2021
July – December 2021 01/31/2022
DSRIP Program Summary
Project affiliation:
Project 2A Project 3A □
Metric respondent criteria: All practice/clinic sites identified by the ACH as a partnering provider
engaged in Project 2A transformation strategies.
Question and response format:
• The Maine Health Access Foundation (MeHAF) developed the Site Self Assessment (SSA)
Survey to assess levels of primary and behavioral care integration.
• The SSA Survey focuses on two domains: 1) integrated services and patient and family
services, and 2) practice/organization.
• Each domain has characteristics to rate on a scale of 1 to 10 depending on the level of
integration or patient-centered care achieved.
• Practice/clinic sites may use the MeHAF facilitation guide to assist in completing the SSA.
1
1
https://waportal.org/resources/mehaf-facilitation-guide
Metric Information
DSRIP Metric Details
Healthier Washington Medicaid Transformation
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Question
Response format
Practices participating in Project 2A should complete the
MeHAF SSA Survey (dated September 29, 2014) found as
an attachment (ATTACHMENT).
Respondents should complete both sections (‘Integrated
Services and Patient and Family-Centeredness’ and
‘Practice /Organization’
Respondents should record responses for each of the 21
questions, using whole numbers ranging from 1 to 10.
Using the 1-10 scale, respondents
indicate one numeric rating for each
of the 21 characteristics.
The numeric rating for each of the 21
characteristics are submitted to the
ACH.
Potential Follow-up Questions
Follow-up questions are included for some metrics. The Independent Assessor (IA) and/or the
Independent External Evaluator (IEE) may use these questions in follow-up conversations with partnering
provider sites (practice/clinic, community-based organization) and ACHs. ACHs may elect to use them for
their own follow-up activities with partnering provider sites.
Version Control
July 2018 Release: Full P4R metric specifications released.
November 2018: MeHAF SSA Survey (ATTACHMENT) replaced with version with typo correction, removal
of identifying information that is not applicable to MTP, and PDF with higher resolution for readability.
March 2019: Includes link to new resource (‘MeHAF facilitation guide’) under DSRIP Metric Details.
Adapted from the PCRS – Developed by the Robert Wood Johnson Foundation
Diabetes Initiative, www.diabetesintiative.org; Also adapted from the ACIC survey developed by
the MacColl
Institute for Healthcare Innovation, Group Health Cooperative.
1"
The purpose of this assessment is to show your cur
rent status along several dimensions of integrated care and to stimulate
conversations among your integrated care team members about where you would like to be along the continuum of integrated care.
Please focus on your site’s current extent of integration for patient and family-centered primary care, behavioral and mental health care.
Future repeated administrations of the SSA form will help to show changes your site is making over time. Organizations working with
more than one site should ask each site to complete the SSA.
Please respond in terms of your site’s current status on each dimension. Please rate your patient care teams on the extent to which
they currently do each activity for the patients/clients in the integrated site. The patient care team includes staff members who work
together to manage integrated care for patients. This often, but not always, involves health care providers, behavioral health specialists,
specialty care providers, case managers or health educators and front office staff.
Using the 1-10 scale in each row, circle (or mark in a color or bold, if completing electronically) one numeric rating for each of the 21
characteristics. If you are unsure or do not know, please give your best guess, and indicate to the side any comments or feedback you
would like to give regarding that item. NOTE: There are no right or wrong answers. If some of this wording does not seem appropriate
for your project, please suggest alternative wording that would be more applicable, on the form itself or in a separate email.
This form was adapted from similar formats used to assess primary care for chronic diseases.
NO
Identifying Information:
Name of your site:
Name of person completing the SSA form:
Did you discuss these
ratings with other members of your team?
YES
ATTACHMENT: Project 2A Pay for reporting metric
September 29, 2014
MeHAF – Site Self Assessment
2"
I. Integrated Services and Patient and Family-Centeredness (Circle one NUMBER for each characteristic)
Characteristic
Levels
1. Level of integration: primary
care and mental/behavioral
health care
. . . none;
consumers
go to
separate
sites for
services
1
. . . are coordinated; separate sites
and systems, with some
communication among different types
of providers; active referral linkages
exist
2 3 4
. . are co-located; both are available at
the same site; separate systems,
regular communication among
different types of providers; some
coordination of appointments and
services
5 6 7
. . . are integrated, with one reception
area; appointments jointly scheduled;
shared site and systems, including
electronic health record and shared
treatment plans. Warm hand-offs
occur regularly; regular team
meetings.
8 9 10
2. Screening and assessment
for emotional/behavioral health
needs (e.g., stress, depression,
anxiety, substance abuse)
2. (ALTERNATE: If you are a
behavioral or mental health site,
screening and assessment for
medical care needs)
. . . are not
done (in this
site)
1
. . .are occasionally done;
screening/assessment protocols are
not standardized or are nonexistent
2 3 4
. . .are integrated into care on a pilot
basis; assessment results are
documented prior to treatment
5 6 7
. . . tools are integrated into practice
pathways to routinely assess
MH/BH/PC needs of all patients;
standardized screening/ assessment
protocols are used and documented.
8 9 10
3. Treatment plan(s) for primary
care and behavioral/mental
health care
. . . do not
exist
1
. . . exist, but are separate and
uncoordinated among providers;
occasional sharing of information
occurs
2 3 4
. . .Providers have separate plans, but
work in consultation; needs for
specialty care are served separately
5 6 7
. . . are integrated and accessible to
all providers and care managers;
patients with high behavioral health
needs have specialty services that are
coordinated with primary care
8 9 10
4. Patient care that is based on
(or informed by) best practice
evidence for BH/MH
and
primary care
. . . does not
exist in a
systematic
way
1
. . . depends on each provider’s own
use of the evidence; some shared
evidence-based approaches occur in
individual cases
2 3 4
. . .evidence-based guidelines
available, but not systematically
integrated into care delivery; use of
evidence-based treatment depends
on preferences of individual providers
5 6 7
. . . follow evidence-based guidelines
for treatment and practices; is
supported through provider education
and reminders; is applied
appropriately and consistently
8 9 10
September 29, 2014
MeHAF – Site Self Assessment
3"
5. Patient/family involvement in
care plan
. . . does not
occur
1
. . . is passive; clinician or educator
directs care with occasional
patient/family input
2 3 4
. . . is sometimes included in decisions
about integrated care; decisions about
treatment are done collaboratively
with some patients/families and their
provider(s)
5 6 7
. . . is an integral part of the system of
care; collaboration occurs among
patient/family and team members and
takes into account family, work or
community barriers and resources
8 9 10
6. Communication with patients
about integrated care
. . . does not
occur
1
. . . occurs sporadically, or only by use
of printed material; no tailoring to
patient’s needs, culture, language, or
learning style
2 3 4
. . . occurs as a part of patient visits;
team members communicate with
patients about integrated care;
encourage patients to become active
participants in care and decision
making; tailoring to patient/family
cultures and learning styles is
frequent
5 6 7
. . .is a systematic part of site’s
integration plans; is an integral part of
interactions with all patients; team
members trained in how to
communicate with patients about
integrated care
8 9 10
7. Follow-up of assessments,
tests, treatment, referrals and
other services
. . . is done at
the initiative
of the
patient/family
members
1
. . . is done sporadically or only at the
initiative of individual providers; no
system for monitoring extent of follow-
up
2 3 4
. . . is monitored by the practice team
as a normal part of care delivery;
interpretation of assessments and lab
tests usually done in response to
patient inquiries; minimal outreach to
patients who miss appointments
5 6 7
. . . is done by a systematic process
that includes monitoring patient
utilization; includes interpretation of
assessments/lab tests for all patients;
is customized to patients’ needs,
using varied methods; is proactive in
outreach to patients who miss
appointments
8 9 10
8. Social support (for patients to
implement recommended
treatment)
. . . is not
addressed
1
. . . is discussed in general terms, not
based on an assessment of patient’s
individual needs or resources
2 3 4
. . . is encouraged through
collaborative exploration of resources
available (e.g., significant others,
education groups, support groups) to
meet individual needs
5 6 7
. . . is part of standard practice, to
assess needs, link patients with
services and follow up on social
support plans using household,
community or other resources
8 9 10
9. Linking to Community
Resources
. . . does not
occur
1
. . . is limited to a list or pamphlet of
contact information for relevant
resources
2 3 4
. . . occurs through a referral system;
staff member discusses patient
needs, barriers, and appropriate
resources before making referral
5 6 7
. . . is based on an in-place system for
coordinated referrals, referral follow-
up and communication among sites,
community resource organizations,
and patients
8 9 10
September 29, 2014
MeHAF – Site Self Assessment
4"
MeHAF Plus Items
10. Patient care that is based
on (or informed by) best
practice evidence for
prescribing of psychotropic
medications
… does not
exist in a
systematic
way
1
. . . depends on each provider’s own
use of the evidence; some shared
evidence-based approaches occur in
individual cases
2 3 4
. . .evidence-based guidelines
available, but not systematically
integrated into care delivery; use of
evidence-based treatment depends
on preferences of individual providers
5 6 7
. . . follow evidence-based guidelines
for treatment and practices; is
supported through provider education
and reminders; is applied
appropriately and consistently;
support provided by consulting
psychiatrist or comparable expert
8 9 10
11. Tracking of vulnerable
patient groups that require
additional monitoring and
intervention
… does not
occur
1
… is passive; clinician may track
individual patients based on
circumstances
2 3 4
… patient lists exist and individual
clinicians/care managers have varying
approaches to outreach with no
guiding protocols or systematic
tracking
5 6 7
… patient lists (registries) with
specified criteria and outreach
protocols are monitored on a regular
basis and outreach is performed
consistently with information flowing
back to the care team
8 9 10
12. Accessibility and efficiency
of behavioral health
practitioners
… behavioral
health
practitioner(s)
are not
readily
available
1
… is minimal; access may occur at
times but is not defined by protocol or
formal agreement; unclear how much
population penetration behavioral
health has into primary care
population
2 3 4
… is partially present; behavioral
health practitioners may be available
for warm handoffs for some of the
open clinic hours and may average
less than 6 patients per clinic day per
clinician (or comparable number
based on clinic volume)
5 6 7
… is fully present; behavioral health
practitioners are available for warm
handoffs at all open clinic hours and
average over 6 patients per clinic day
per clinician (or comparable number
based on clinic volume)
8 9 10
September 29, 2014
MeHAF – Site Self Assessment
5"
II. Practice/Organization (Circle one NUMBER for each characteristic)
Characteristic
Levels
1. Organizational leadership for
integrated care
. . . does not
exist or
shows little
interest
1
. . . is supportive in a general way, but
views this initiative as a “special
project” rather than a change in usual
care
2 3 4
. . . is provided by senior
administrators, as one of a number of
ongoing quality improvement
initiatives; few internal resources
supplied (such as staff time for team
meetings)
5 6 7
. . . strongly supports care integration
as a part of the site’s expected
change in delivery strategy; provides
support and/or resources for team
time, staff education, information
systems, etc.; integration project
leaders viewed as organizational role
models
8 9 10
2. Patient care team for
implementing integrated care
. . . does not
exist
1
. . . exists but has little cohesiveness
among team members; not central to
care delivery
2 3 4
. . . is well defined, each member has
defined roles/responsibilities; good
communication and cohesiveness
among members; members are cross-
trained, have complementary skills
5 6 7
. . . is a concept embraced, supported
and rewarded by the senior
leadership; “teamness” is part of the
system culture; case conferences and
team meetings are regularly
scheduled
8 9 10
3. Providers’ engagement with
integrated care (“buy-in”)
. . . is minimal
1
. . . engaged some of the time, but
some providers not enthusiastic about
integrated care
2 3 4
. . . is moderately consistent, but with
some concerns; some providers not
fully implementing intended
integration components
5 6 7
. . . all or nearly all providers are
enthusiastically implementing all
components of your site’s integrated
care
8 9 10
4. Continuity of care between
primary care and
behavioral/mental health
. . . does not
exist
1
. . . is not always assured; patients
with multiple needs are responsible for
their own coordination and follow- up
2 3 4
. . is achieved for some patients
through the use of a care manager or
other strategy for coordinating needed
care; perhaps for a pilot group of
patients only
5 6 7
. . . systems are in place to support
continuity of care, to assure all
patients are screened, assessed for
treatment as needed, treatment
scheduled, and follow-up maintained
8 9 10
September 29, 2014
MeHAF – Site Self Assessment
6"
5. Coordination of referrals and
specialists
. . . does not
exist
1
. . . is sporadic, lacking systematic
follow-up, review or incorporation
into the patient’s plan of care; little
specialist contact with primary care
team
2 3 4
. . . occurs through teamwork &
care management to recommend
referrals appropriately; report on
referrals sent to primary site;
coordination with specialists in
adjusting patients’ care plans;
specialists contribute to planning
for integrated care
5 6 7
. . . is accomplished by having
systems in place to refer, track
incomplete referrals and follow-up
with patient and/or specialist to
integrate referral into care plan;
includes specialists’ involvement in
primary care team training and
quality improvement
8 9 10
6. Data systems/patient records
. . . are
based on
paper
records
only;
separate
records
used by
each
provider
1
. . . are shared among providers on
an ad hoc basis; multiple records
exist for each patient; no aggregate
data used to identify trends or gaps
2 3 4
. . . use a data system (paper or EMR)
shared among the patient care team,
who all have access to the shared
medical record, treatment plan and
lab/test results; team uses aggregated
data to identify trends and launches
QI projects to achieve measurable
goals
5 6 7
. . . has a full EMR accessible to all
providers; team uses a registry or
EMR to routinely track key indicators
of patient outcomes and integration
outcomes; indicators reported
regularly to management; team uses
data to support a continuous QI
process
8 9 10
7. Patient/family input to
integration management
. . . does
not occur
1
. . . occurs on an ad hoc basis; not
promoted systematically; patients
must take initiative to make
suggestions
2 3 4
. . . is solicited through advisory
groups, membership on the team,
focus groups, surveys, suggestion
boxes, etc. for both current services
and delivery improvements under
consideration; patients/families are
made aware of mechanism for input
and encouraged to participate
5 6 7
. . . is considered an essential part of
management’s decision-making
process; systems are in place to
ensure consumer input regarding
practice policies and service delivery;
evidence shows that management
acts on the information
8 9 10
8. Physician, team and staff
education and training for
integrated care
. . . does
not occur
1
. . . occurs on a limited basis
without routine follow-up or
monitoring; methods mostly didactic
2 3 4
. . . is provided for some (e.g. pilot)
team members using established and
standardized materials, protocols or
curricula; includes behavioral change
methods such as modeling and
practice for role changes; training
monitored for staff participation
5 6 7
. . . is supported and incentivized by
the site for all providers; continuing
education about integration and
evidence-based practice is routinely
provided to maintain knowledge and
skills; job descriptions reflect skills
and orientation to care integration
8 9 10
September 29, 2014
MeHAF – Site Self Assessment
7"
9. Funding sources/resources
. . . a
single
grant or
funding
source; no
shared
resource
streams
1
. . . separate PC/MH/BH funding
streams, but all contribute to costs
of integrated care; few resources
from participating
organizations/agencies
2 3 4
. . . separate funding streams, but
some sharing of on-site expenses,
e.g., for some staffing or
infrastructure; available billing codes
used for new services; agencies
contribute some resources to support
change to integration, such as in-kind
staff or expenses of provider training
5 6 7
. . . fully integrated funding, with
resources shared across providers;
maximization of billing for all types of
treatment; resources and staffing
used flexibly
8 9 10