Population Health Components of State Innovation Model (SIM) Plans: Round 2 Model Testing States

The Round Two State Innovation Model (SIM) Test Awards granted by HHS to eleven states (Colorado, Connecticut, Delaware, Idaho, Iowa, Michigan, New York, Rhode Island, Ohio, Tennessee, and Washington) support state efforts to build multi-payer models of health system transformation. As noted in a previous analysis, population health improvement is an important component of the SIM awards. The SIM Funding Opportunity Announcement (FOA) required states to describe how their models would improve population health in a number of areas, including prevention, health equity and the social determinants of health, rates of obesity and diabetes, and healthy behaviors, including reduced tobacco use. The FOA also required states to incorporate new delivery system models into their population health improvement plans.

This chart contains population health strategies, as defined by the states, that the states plan to implement through their SIM Round Two Model Test initiatives. The information in the chart is derived from the states’ proposals and other documents that you will find linked in the text below. Information on the population health components of the Round One SIM Model Test Awards can be found in our previous SIM population health chart. Please note that because the information in these charts was abstracted from early documents, we anticipate that this information may change as the states implement their models.

We encourage our community to share and discuss more details, ideas, issues and emerging products and results on State Refor(u)m. Do you know of state activity or analyses that we should add to this chart? Eager to update a fact we’ve included? Your contributions are central to our community’s ongoing, real-time learning, so tell us in a comment below, or email aclary@nashp.org with your suggestions.

Population Health Objectives in the Model Strategies in the Model to Address Social, Economic, and Behavioral Determinants of Health and Health Equity Engaging and Integrating Community Health and Prevention into Delivery System and Payment Reform Models Population Health Metrics Used in Model Strategies in the Model to Integrate Primary Care and Mental Health and Substance Abuse Disorder Services
Colorado Colorado seeks to improve population health by establishing a close partnership between public health, behavioral health, and primary care, and prioritizing ten population health focus areas including obesity, substance use, and mental health (SIM p.1). Colorado state agencies are collaborating to address the social determinants of health using a “life stages” approach to targeting resources. The plan will include data collection on disparities in tobacco use, diabetes, and obesity (SIM p. 2, 11, 62). Colorado will examine the possibility of long-term reimbursement models for population-based prevention and wellness services (SIM p. 25).Population Health Transformation Collaboratives made up of community health leaders will work with the state’s new Health Extension Service on local community health initiatives (SIM p. 4-5, 10). Targeted local public health agencies will receive funding for community prevention activities and to link practices, community resources, and public health (SIM p. 2). Colorado will collect data on the progress in 12 core population health target areas:hypertension, obesity, tobacco use, prevention, asthma, diabetes, ischemic vascular disease, safety, depression, anxiety, substance use, safety, and child development (SIM p. 7-8). The program’s shared risk and savings payment model will incentivize integrated physical and behavioral health services (SIM p. 2, 12-13, 23). A child mental health coordinator will develop prevention and early intervention programs for mental health challenges in children (SIM p. 5-7).
Connecticut Connecticut plans to strengthen primary care and integrate community and clinical care. It also aims to improve prevention and screening, including mental health and substance abuse screening, and chronic illness management (SIM p. 1; 22-23). Connecticut will convene a multi-sector Population Health Council tasked with setting priorities for health improvement areas, focusing on the barriers most likely to contribute to health disparities. The Health Enhancement Communities initiative focuses resources on the areas of the state with greatest disparities and will include payment incentives to address social determinants of health (SIM p. 2-3). The Equity and Access Council watches for under-service that may result from shared savings incentives. Connecticut plans to develop sustainable Prevention Service Centers (PSCs) that will offer community-based preventive services. Reimbursement for Community Health Workers (CHWs) may also be part of the plan (SIM p. 2-3; 8). The state will also augment its use of Value-Based Insurance Design (VBID) and shared savings programs to incentivize prevention, health improvement, and management of chronic diseases (SIM p. 8, 12). Connecticut will report measures for statewide population health targets including tobacco use, obesity, and diabetes (SIM p. 25). The plan also includes quality targets on preventive screenings, asthma, and premature death from cardio-vascular disease. The state will monitor equity gaps on core measures and select areas for improvement (SIM p. 26-28). The model will complement the state’s existing Behavioral Health Home initiative, which coordinates physical and mental healthcare for Medicaid recipients with serious and persistent mental illness (SIM p. 29).
Delaware Delaware aims to integrate population health with value-based payment models. It seeks to attribute every patient to a primary care provider (PCP) who is incentivized to address population health issues (SIM p. 1-8). Delaware emphasizes cross-agency collaboration as part of its strategy to address social determinants of health. Also, as part of its Healthy Neighborhoods strategy, the Delaware Division of Public Health (DPH) will support staff health equity training (SIM p. 5-6). Delaware’s Healthy Neighborhoods strategy seeks to enlist schools, employers, and community organizations in changing health behaviors. The plan will support a multi-stakeholder community coalition focused on identifying and addressing health needs (SIM p. 1-6). The proposed population health metrics include measures related to smoking; nutrition; physical activity; prevalence of hypertension, obesity, and diabetes; cancer deaths per 100,000; heart disease deaths; 30-day post-PCI mortality rate; and infant mortality (SIMp. 37). Delaware’s model will focus on providing team-based, integrated physical and behavioral health care for high-risk patients, including by providing incentives for EHR use to behavioral health providers. It will complement the existing PROMISE program that coordinates care for beneficiaries with mental illness.
Idaho Idaho will develop a plan to improve population health by integrating population health with primary care and the healthcare delivery system through the use of Patient-Centered Medical Homes (PCMHs) covering 80% of the population (SIM p. 2-4). Idaho is also planning a virtual PCMH telehealth initiative to serve remote communities. The state’s seven public health districts will also form Regional Collaboratives to integrate public and physical health locally to improve access to care. Idaho will collect data on the social determinants of health as part of a statewide health assessment. PCMH providers will be allowed to practice at the top of their license to ameliorate workforce shortages. Telehealth initiatives and models for using CHWs and community health emergency medical services personnel in health promotion will also be explored (SIM p. 5-6). Idaho will use the following population health performance measures to monitor the success of the Model Test: depression, tobacco use, asthma ED visits, hospitalizations, hospital readmissions, avoidable ED use without hospitalization, elective deliveries, low birth weight, adherence to antipsychotic meds for people with schizophrenia, weight counseling for children and adolescents, diabetes, childhood immunizations, adult BMI, and rate of prescribed opioid use for non-cancer pain. Idaho will also collect data on costs and patient experience of care (SIM p. 22-23). PCHMs will coordinate care with Medical Neighborhoods of ancillary providers, including behavioral health providers. The state’s multi-payer common performance measures include screening for depression, adherence to antipsychotics for people with schizophrenia, and rates of prescribed opioid use for non-cancer pain.
Iowa Iowa will build upon its existing ACO model to improve performance in six population health priority areas, including tobacco use, obesity, prevention and health literacy (SIMp. 1-3). The state’s plan also seeks to use ACOs to integrate public health providers with acute care delivery systems. Iowa will provide support and technical assistance to encourage ACOs to develop workforce models, including telehealth, that address provider shortages and reduce the disparities between rural and urban areas (SIM p. 1). New Community Care Teams will connect ACOs with social services and local public health resources to address social determinants of health. Value-based payments will also incentivize ACOs to address the social determinants of health (SIM p. 12-15). Iowa’s model seeks to expand care delivery into the community setting, and will track communities’ progress on population health initiatives. Community Care Teams will integrate public health and local ACOs to improve outcomes, and will facilitate connections with non-ACO providers (SIM p. 12-13). Iowa will measure progress in six population health target areas: reducing tobacco use, obesity, hospital-associated infections, and early elective deliveries; and improving patient engagement and health literacy, including diabetes self-management (SIM p. 3-5). Iowa will continue to incorporate behavioral health providers into its ACO structures, including the use of integrated health homes for individuals with mental illness (SIM p. 7-11).
Michigan Michigan plans to improve wellness and reduce health risks on a population level through the use of Community Health Innovation Regions. PCMHs and integrated care networks called Accountable Systems of Care are also key elements (Blueprint p. 4-6). Michigan is considering payment models that incentivize efforts to address social & environmental determinants of health. They are also planning greater use of and support for Community Health Workers to help reduce disparities (Blueprint p. 10-11, 37-41, 131-135). Michigan’s Community Health Innovation Regions will work with local public health and cross-sector partners to engage patients and community members in wellness and health promotion activities. Michigan will also explore sustainable financing models for population-level prevention and wellness efforts. Michigan will also seek to allow providers to practice at the top of their license and training to increase access to primary care (Blueprint p. 4-5, 10, 132, 157). Michigan’s plan includes monitoring access to primary care, clinical quality, patient experience of care, utilization, and other measures from the Michigan Health and Wellness dashboard, including measures related to birth outcomes and teen birth rates, obesity, alcohol consumption, nutrition, physical activity rate, tobacco use, dental health, mental health, STDs (Blueprint p. 72-75; p. 146-151). Michigan plans to integrate behavioral health providers into person-centered health care teams. (Blueprint p. 126-127).
New York New York’s plan has five primary population health goals:1. Prevent Chronic Disease2. Promote Healthy and Safe Environments

3. Promote Healthy Women, Infants and Children

4. Promote Mental Health and Prevent Substance Abuse; and

5. Prevent HIV, STDs, Vaccine-Preventable Diseases and Healthcare Associated Infections (SIM p. 1).

New York’s plan will support population health, preventive services, and integrated behavioral primary care through its advanced primary care medical home model, and through the use of SIM-funded public health consultants and practice transformation teams (SIM p. 1-2). New York aims to pay for 80% of advanced primary care under a value-based payment model. Further, the project’s Public Health Consultants will also connect the community with public health and clinical resources (SIM p. 2-3). The state will also work to ensure that providers are practicing at the top of their license to improve access to care. The project, including the advanced primary care model, will be evaluated according to an evolving statewide set of industry-standard quality and efficiency metrics, which includes progress toward prevention and public health goals (SIM p. 20-21). New York will focus on integrating primary and behavioral health care, and will convene a workgroup to analyze gaps in behavioral health services and make recommendations. Initiatives supported by the new Public Health Consultants may include tobacco cessation for people with mental illness and other efforts to address mental illness and substance abuse disorders (SIM p. 2, 4,7).
Ohio Ohio plans to target the prevention or reduction of obesity, chronic disease, tobacco use and exposure, and infant mortality; and plans to expand patient-centered primary care (SIM p. 5). Ohio is testing ways to share data to improve population health, such as building on its current ability to use vital statistics data to indicate when a mother or infant may be at risk of poor health outcomes (SIM p. 6). Ohio’s episode-based payment model and statewide use of PCMHs are intended to incent providers to work with community-based and public health resources to address social determinants of health (SIM p. 12). Ohio’s SIM outcome metrics will include population health measures such as flu immunization and tobacco use, as well as care coordination and chronic conditions measures. Measures will be aligned across quality initiatives (SIM p. 24-28). Ohio merged the formerly separate departments overseeing mental health and substance use disorders. The state is focused on integrated, person-centered care and care coordination for Medicaid beneficiaries with mental illness and other populations (SIM p. 5).
Rhode Island With the help of community leaders, Rhode Island will develop a population-based plan that responds to the results of community health assessments, and continues efforts to reduce tobacco use and obesity and improve diabetes care management (SIM p. 4; SHIPp. 80-87). Rhode Island will work with the community to develop community-driven goals for the healthcare system, and use Community Health Teams to help community organizations coordinate with primary care practices to support healthy lifestyles and address the social and environmental determinants of health and health disparities (SHIP p. 69, 75; SIM p. 4-5). Rhode Island will rely on input from community-based leadership to guide the transformation of Rhode Island’s care delivery system, which will emphasize primary care and patient-centered medical homes, with Community Health Teams focusing on rising-risk and high-risk populations (SIM p. 4-5, 8; SHIP p. 63, 100). Increasing prevention activities, statewide quality measurement and patient engagement tools are included in Rhode Island’s plan (SHIP p. 73-74), as are reducing over-utilization of unnecessary services, increasing screening and prevention, reducing health disparities, and renewing focus on the social determinants of health, among other aims (SHIP p. 94, 110). Rhode Island will build on current efforts to integrate behavioral health and primary care through the use of health homes and co-location (SHIP p. 90; SIM p. 8).
Tennessee Tennessee seeks to improve population health in five priority areas: obesity, diabetes, tobacco, child health, and perinatal health (SIM p. 2, 13). PCMH providers will be incentivized to address social determinants of health through activities such as addressing environmental asthma triggers, tobacco cessation, and connecting patients to social services (SIM p. 4). Tennessee’s project will also facilitate the sharing of real-time hospital Admitting/ Discharge /Transfer (ADT) data with primary care providers and care coordinators to analyze gaps in care and prioritize resources for the most at-risk patients. Tennessee plans a population-based, multi-payer patient-centered medical home initiative that will incentivize prevention and primary care. PCMHs will be evaluated on outcomes such as preventing avoidable ED visits and hospitalizations, controlling diabetes and high blood pressure, and screening for depression (SIM p. 22). At minimum, Tennessee will measure the program’s impact on rates of child immunization, self-reported health status, tobacco use, obesity, and the proportion of diabetics with 2 or more A1C tests in the past year (SIM p. 25-26). Tennessee will integrate its SIM funding and Health Homes initiative to provide integrated, value-based “behavioral and primary care services for people with Severe and Persistent Mental Illness (SPMI)” (SIM p. 7).
Washington Washington plans to reduce tobacco use, obesity and diabetes, and increase the portion of the population who receive clinical and community services that reduce preventable conditions (SIM p. 5-6). Washington will implement regional Accountable Communities of Health (ACH) to integrate the delivery of social services and healthcare services. ACHs will work across sectors, aligning housing, education, local government and the private sector to advance population health and address the social determinants of health (SIM p. 2, 6). Washington also plans to increase the number of communities with environments that promote physical and behavioral health and health equity (SIM p. 5). Washington plans to engage “individuals, families, and communities” in a system that “supports social and health needs,” as well as improve the health of 90% of Washington residents and their communities by 2019 through prevention and early mitigation of disease (SIM p. 5, 26). Washington will develop a statewide set of core measures that includes tobacco use, obesity and diabetes (SIM p. 6). It will also incorporate the “Results Washington”performance targets, including children’s vaccination rates, reducing preterm birth and cesarean section rates, increasing the number of residents with a personal healthcare provider, and increasing rates of services for post-discharge mental health consumers (SIM p. 27). By 2020, Washington will require integrated physical and behavioral healthcare purchasing (SIM p. 10-11).
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Chart produced by Amy Clary