CMS-10436 Protocol - SASH

MULTI-PAYER ADVANCED PRIMARY CARE PRACTICE DEMONSTRATION
EVALUATION
INTERVIEW PROTOCOL
SASH Coordinators/SASH Wellness Nurses

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Introduction
Thank you for making time to speak with us today. As we mentioned in our email, we are
researchers from RTI, the Urban Institute, and the National Academy of State Health Policy
(NASHP), evaluating the Multi-Payer Advanced Primary Care Practice (MAPCP)
Demonstration.
As previously mentioned in the email we sent you when we set up the interview, we’d like your
candid views about this initiative. Specifically, we’d like to focus on learning about the period
after Medicare joined the state’s initiative and your thoughts on the future. Since we’re asking
about a number of different periods of time, we have created a visual timeline to differentiate
each time period [show the respondent the state’s timeline].
We are also particularly interested in the impact of the initiative on Medicare and Medicaid
beneficiaries generally and special populations (such as those dually eligible for Medicare and
Medicaid) specifically. We understand that some changes are system wide and may not affect
these groups differently, but other changes that payers or practices make may be tailored to these
groups to some degree and have different impacts on these patient populations.
As described in the one-page attachment to our email we sent to you to set up the interview, our
evaluation is being funded by the Centers for Medicare and Medicaid Services (CMS). As a
condition of participation, CMS expects state staff and participants to cooperate with the
evaluation team, but ultimately your decision to participate in this aspect of the study is
voluntary. If you do not wish to participate in this interview or answer specific questions, please
let us know immediately.
We believe there are minimal risks to you from participation, and every effort will be made to
protect your confidentiality. We want to assure you that we will not quote you by name. We will
use some quotes in reports, but quotes will not be attributed to an individual or his/her
organization.
There are no direct benefits to you from participating in this study. But your insights will be used
by federal and state policymakers to better understand the effects of the medical home model on
Medicare and Medicaid beneficiaries as well as the challenges involved in running a medical
home initiative and becoming and maintaining a medical home. The Institutional Review Boards
(IRB’s) at RTI International and the Urban Institute have reviewed this research.
Finally, we would like to record our conversation, to ensure our notes from today are complete.
Are these interview conditions OK with you? Do you have any questions before we begin?

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Background Questions
1. How long have you been with [name of organization]?
2. Please tell me about your role with the SASH program.
[If they have been there long:]
3. How long have you served in this role?
[If they have not been there long:]
4. Were you previously with a similar kind of organization?
5. Please tell me about the staff composition of your SASH team.
a. Please describe the mix of health care professionals and other team members or staff in
your [name of organization].
6. [For SASH Wellness Nurses]: We understand that the primary responsibilities of a wellness
nurse is to provide in-person coaching on proper medication management, monitor vital signs
to look for early warnings of health complications, and provide intensive self-care counseling
and education post-discharge from hospitals and nursing homes. Do you have any other
primary responsibilities?
[For SASH Coordinator]: We understand that the primary responsibilities of a SASH
coordinator includes providing in-person needs assessments, motivational coaching to help
residents meet their personal health aging goals, daily visits with high-risk residents to ensure
medication compliance, and social services coordination. Do you have any other primary
responsibilities?
7. Where do you physically work?
8. What is a typical day like for you?
Progress / State Implementation
9. From your perspective, what are the most significant problems that practices involved in the
Blueprint face in serving Medicare beneficiaries in Vermont?
10. From your perspective, what are the most significant problems that Medicare beneficiaries
face in Vermont?
11. Given the challenges faced by practices and beneficiaries, what are the strengths and
weaknesses of the Blueprint for Health initiative?
a. How well do you think implementation of the Blueprint for Health is going?
b. Do you think the entrance of Medicare has enhanced the initiative?
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c. What new opportunities for improvement do you anticipate in the future, if any?
I would now like to talk more specifically about your activities and coordination with
practices, the CHTs, and Medicare and Medicaid beneficiaries.
[Note to interviewer: try to ask about (1) the time it took to implement any SASH/CHT/practice
changes discussed; and (2) the cost of implementing or sustaining any SASH/CHT/practice
changes discussed]
Coordination with Practices
12. How do SASH staff coordinate patient care with primary care practices?
13. How do you coordinate patient care between the primary care practices you work with and
other providers or facilities, such as hospitals, long term care facilities, medical or surgical
specialists, and behavioral health providers?
14. What kind of services do you provide to practices in your area?
15. Does your SASH team interact with care coordinators in any of the practices in your area? If
so, what is the nature of the interaction?
a. Are there coordination issues?
16. What have been the challenges of working with practices in your area? What is working
well?
Coordination with CHTs
17. Please describe how you coordinate with the CHTs for Medicare beneficiaries that are also
participating in the SASH Program.
a. What kind of information does your SASH team exchange with the CHT team or vice
versa?
b. How do you interact with the CHT team members? What is the nature of the interaction?
Are there coordination issues?
c. Is there joint decision making with the CHT teams on who will be doing what with which
patients?
d. How do you communicate with the CHT team members?
e. What have been challenges of working with the CHT teams?

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Coordination with Medicaid Care Coordinators (CCs)
18. Do you do any coordination with the Medicaid Care Coordinators for Medicaid patients with
complex care needs?
a. What kind of information do you exchange with the Medicaid CCs or vice versa?
b. How do you interact with the Medicaid CCs? What is the nature of the interaction? Are
there coordination issues?
c. Is there joint decision making with the Medicaid CCs on who will be doing what with
these patients?
d. How do you communicate with the Medicaid CCs?
e. What have been the benefits or challenges of working with the Medicaid CCs?
Access to Care and Coordination of Care
Now we’d like to discuss with you how the patients you serve access care and their experiences
with this care.
[Note to interviewer: (1) Try to ask respondents to identify medical home features that
contributed to the observed impacts, or features that could be added to the initiative to improve
outcomes. (2) More specific examples of impacts to care might be discussed during the
interview. For example, timeliness of care is an example of access to care. Other more specific
examples that may be discussed in this section include: discussion of current and potential
changes to a patient’s drug regimen, proactive care (e.g. generating lists of patients who need to
come in for an office visit), and active reminders about tests, treatment, and/or appointments.]
19. How do you identify people who need help or how do they get connected with a SASH
team?
20. Do you, and if so how do you:
a. Assign a staff member within your SASH team to a patient?
b. Follow up with patients after they are discharged from a hospital? ER?
c. Perform medication reconciliation?
d. Coordinate care with specialists?
e. Provide linkages to other services and facilities like long-term care, mental health,
community services, or social services?
f. Work with patients to address challenges they may face accessing care?
g. Work with patients to address challenges they may face caring for themselves?
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h. Other?
21. What are patients’ reactions when you contact them?
22. Are there any special issues or challenges to reaching Medicare beneficiaries? If so, please
describe briefly.
23. What percentage of your patients have language or literacy problems?
a. How do you communicate with patients who have language or literacy problems?
Beneficiary Experience with Care
[Note to interviewer: (1) Try to ask respondents to identify medical home features that
contributed to the observed impacts, or features that could be added to the initiative to improve
outcomes. (2) More specific examples of impacts to care might be discussed during the
interview. For example, shared decision-making is an example of beneficiary experience with
care. Other more specific examples that may be discussed in this section include: provision of
information such as test results to patients in a way that is easy to understand and health literacy.]
24. To what extent do you interact with caregivers and family members of Medicare
beneficiaries? What is the nature of these interactions?
25. What strategies have the [SASH Coordinator/SASH Wellness Nurse]s used to engage
patients more in their care?
26. To what extent are patients, their families, and/or their caregivers actually able to participate
more effectively in decisions concerning their care as a result of the Blueprint for Health
initiative? Can you provide an example or do you have any early data on this?
27. How are you teaching self-management to patients?
a. To what extent are patients actually better able to self-manage their health conditions or
engage in healthy behaviors as a result of the Blueprint for Health initiative? Can you
provide an example or do you have any early data on this?
Quality of Care and Patient Safety
Now we’d like to discuss health care quality and patient safety with you.
28. What role does your SASH team have in monitoring or improving quality of care and patient
safety?
29. Are you involved in the EQuiP activities? If so, how?
30. Do you use clinical data from the DocSite clinical registry for any quality of care or patient
safety improvement activities? If so, for what purpose?
31. Does your CHT receive any other type of performance data on quality and safety?
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Health Information Technology
32. We know that as part of the Vermont Blueprint for Health, practices are required to enter into
agreements with Vermont Information Technology Leaders (VITL) and demonstrate
progress toward being able to communicate with the Vermont statewide health information
exchange (VHIE) and the DocSite clinical registry.
a. Are you also required to use DocSite?
If yes:
b. Are you currently using DocSite?
c. Have there been any challenges to using DocSite?
d. Do you submit clinical data to DocSite? If so, what data?
e. What information or services have you used from DocSite”
i.

The visit planner (individualized visits plans based on age, gender, and diagnosis
that provide guideline based recommendations for annual health maintenance,
prevention, and chronic disease treatment)?

ii.

The integrated health record which contains clinical information for patients
receiving care also from other providers?

iii.

Population level reports? If so, what kinds of reports?

iv.

Comparative performance reports? If so, at what level (providers within a
practice, across independent practices and organizations, or across HSAs within
the state)?

33. What types of other health information technology capabilities do SASH staff use to carry
out their functions? For example, do you use web portals maintained by payers or referral
tracking databases?
a. Can you track services provided to patients? If so, how do you do this?
b. To what extent can you readily exchange health information with the practices you work
with? Other practices/facilities (e.g., specialists, hospitals, long-term care facilities)?
c. What are the major benefits of the health information technology that you use?
d. What are the primary challenges you face, either because of any health information
technology capabilities you are lacking or with the health IT that you have?
34. What additional health IT features would help your SASH team do a better job
assisting/communicating with patients? Practices?

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Performance Monitoring
35. Now I want to talk to you about the beneficiary utilization files that RTI is producing for
practices in the demonstration. The utilization files are Excel files that are posted on the
MAPCP Web Portal that show all of the assigned beneficiaries for the quarter for each
practice, the severity level (HCC risk score), disease status for diabetes and ischemic
vascular disease, some quality measures, and hospital and ER utilization (dates, principal
diagnosis, hospital name). Do you have access to these files? If yes: What aspects or features
of the beneficiary utilization files do you find most useful?
a. Is there information from Medicare claims that could be added to make them more
useful?
b. How are you using these files?
c. Do you receive utilization files from any other entity? If so, who?
36. Now I want to talk to you about the Practice Feedback Reports that RTI is producing for
practices in the demonstration. These are PDF reports summarizing each practice’s
performance on a selection of quality measures that are posted quarterly to the MAPCP Web
Portal. Do you have access to these reports? If yes: What aspects or features of the Practice
Feedback Reports do you find most useful?
a. How are you using these reports?
b. Do you receive feedback reports like these from any other entity? If so, who?
37. Are there other performance monitoring reports that you receive?
Payment and Infrastructure
38. Are the payments you’re receiving through the Blueprint for Health sufficient to support the
needs of your patients and in working with the community and community health teams to
provide services?
Wrap-up
39. Is there anything we have not discussed about the Blueprint for Health or about the Medicare
MAPCP Demonstration that you feel would be important for our Evaluation Team to know?

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