ExecutiveSummary&AnalysisbyLevelofCare. CalendarYear2018:January-December2018-SubmittedMarch1,2019

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1 UTILIZATIONMANAGEMENT FORADULTMEMBERS ExecutiveSummary&AnalysisbyLevelofCare CalendarYear2018:January-December2018-SubmittedMarch1,2019

2 Submittedby: LoriSzczygiel,ChiefExecutiveOfficer RobertPlant,PhD,SVPofAnalytics&Innovation AnnPhelan,SVPofRecovery&ClinicalOperations SandrinePirard,MD,PhD,MPH,ChiefMedicalDirector Preparedby: ElizabethMcOsker,MPH,DataAnalyst ErikaSharilo,AVPofClinicalServices CarrieBourdon,VPofPerformanceImprovement&Provider Partnerships LynneRinger,AVPofUtilizationManagement Foranyinquiries,comments,orquestionsrelatedtotheuseofTableau,ortheinteractive featureswithinthisreport,pleasecontactelizabethmcoskerat ABeaconHealthOptions-CTDashboard ThisreportwascreatedbyBeaconHealthOptionsonbehalfoftheCTBehavioralHealthPartnership.Howevertheopinions, conclusions,andrecommendationscontainedhereinaresolelythoseofbeaconhealthoptions,andmaynotrepresentthoseofdss, DMHAS,andDCF.

3 UTILIZATIONREPORTFORADULTMEMBERS CalendarYear2018:January-December2018 GeneralOverview Onatleastasemiannualbasis,thereportsmutualyagreeduponinExhibitEoftheCTBHPcontractaresubmittedto thestateforreview.theshifttosemiannualreportswasdesignedtominimizenoisecreatedbyquarter-to-quarter fluctuationsthatdonotreflectatruetrendinthedata.themarchdeliverableservesastheannualreportandcovers fourconsecutiveyearsofutilizationdata.theseptemberdeliverablecovers10consecutivequarterswithafocused analysisonthetwomostrecentquarters,butmayincludethepastfourifthereisinformationnecessarytoreview thathadnotbeenanalyzedpreviously. Thisreportfocusesontheutilizationmanagementportionofthesereports,evidencedinthe4Aseries,whichreviews utilizationstatisticssuchasadmissionsper1,000members(admits/1,000),daysper1,000members(days/1,000), andaveragelengthofstay(alos). Withinthisinteractivereport,alutilizationdataisavailableviadrop-downfilters,butthenarrativehighlightsthe areasofinterestrelatedtocertainutilizationtrends.insomecases,demographicbreakoutsareavailabletoenhance theunderstandingofutilization.additionaly,thenarrativeidentifiestheunderlyingfactors,whichdrivethetrends andassociatedprogrammaticresponsestakenbybeaconhealthoptionstoimpact/mitigateorsupportthetrend. Beaconalsopresentsrecommendationstoaddressremainingchalengesandreportsprogressrelatedtothese plannedrecommendations.theareasoffocusforthisdeliverablearelistedonthefolowingpage. Methodology Thedatacontainedinthisreportarebasedonauthorizationadmissionsandarerefreshedforeachsubsequentsetof updatesduringtheyear.duetochangesineligibility,theresultsforeachquarteroryearmaychangefrom the previouslyreportedvalues.thereportsandanalysesforallevelsofcareareaffectedbythischange.pleasenote thatutilizationmetricsmaychangewiththerefreshofthedata.therefore,thereadershouldbecautiouswhen interpretingthelatestquarterofdata.thecontractorwilmonitorthepost-refreshchangesclosely.ifwarranted, methodologywilberevisited. Themethodologyformembershiptotalsremainsunchanged.FortheTotalMembershipcounts,eachmemberisonly countedonceperquarter,evenifhe/shechangeseligibilitygroupsorexperiencesgapsineligibility.forinstance,ifa memberchangesbenefitgroupswithinthequarter,thatmemberisincludedinthetotalsforeachbenefitgroup,but onlyonceforthetotalmembership.thismethodologyisreferredtointhegraphsas UniqueMembership".Forthe benefitgroups,membersarecountedineachgroupinwhichtheywereeligibleduringthetimeperiod(quarteror year).thismeansthattheindividualbenefitgroupmembershipcountscannotbeaddedtoobtainanoveraltotal, sincememberscanshiftbetweenbenefitgroups. Themethodologyforcalculatingagehaschanged,resultinginaslightshiftinadultandyouthmembershiptotals. Previoustothisreport,countsforadultsandyouthwerebasedonifamembermetthatagecriteriaduringthetime period.thismeantthatyouthwhowereboth17and18yearsoldinaquarterwerecountedinboththeadultand youthtotals.inordertoalow forthedril-downofdemographicandageinformation,itwasrequiredthatmembers becountedinonlyonegroupduringatimeperiod.agegroupisnow basedontheagethatamemberwasforthe majorityofthetimeperiod(quarteroryear).otherdemographicssuchasgenderandrace/ethnicityarebasedonthe mostrecentlyupdatedeligibility.thesedemographicswilupdateasneededaswewanttoreportonthemost accurategenderorrace/ethnicitythatamemberidentifieswith. Additionaly,whileunchangedfrom previousreportingperiods,itisworthnotingthattheper1,000measures comparetheutilizationratesofthepopulationtothepopulation s membermonths.thismeansthatwhenviewing theadmits/1,000ofhuskydmemberstherateisbasedonthenumberofadmissionswithinthehuskydpopulation, nottheentireadultpopulation.thishelpstoanalyzewhichpopulationsarepotentialymorechronic,acute,orin need. Reports Used:

4 EXECUTIVESUMMARYFORADULTMEMBERS CalendarYear2018:January-December2018 TotalMembership Sincethechangeineligibilitycriteriaimplementedin2015,ConnecticutMedicaidmembershipincludingdualshasremainedstablewith ayearlychangeofnomorethan1.5%.almembers,includingdualyeligiblemembers,decreasedslightlyfrom 2017(from 975,577to 975,346).However,almemberswithoutdualshadanalmost1% increasefrom 2017to2018,whichwasoffsetbya6% decreasein adultmemberswithdualswhichmayhavebeenimpactedbydatareporting/processingissues.[1] Adultmembers,includingduals,continuetocomprise63% ofthetotalmedicaidmembership.in2018,therewere617,684adult members,includingdualyeligiblemembers.thisrepresentsa0.2% decreasefrom 2017,whichwasagaindrivenbythereductionin adultdualmembership.statewide,thepopulationdecreased0.4%[2]in2018,andtheunemploymentratefeleverymonth,reaching just4.0% indecember,thelowestunemploymentratesince2001.[3]inotherstates,medicaidmembershiphasdecreaseddueto populationreductionandaneconomicboom thatincreasedthenumberofpeoplereceivingemployer-sponsoredinsurance.[4]however, similarreductionsinctmedicaidmembershiphavenottranspired.onepossibleexplanationforwhyconnecticutdidnotseeagreater reductioninmedicaidmembershipisthatin2017,theuninsuredratewentupforthefirsttimesincetheimplementationofthe AffordableCareAct.[5]Itisthereforepossiblethatin2018theuninsuredratebegantodecreaseagain,whichmayhaveoffsetother potentialreductionsinmembership. PleaseseetheaccompanyingTableaudashboardstoview graphicalrepresentationsofthedatapresentedhere,aswelastousefilters tosegmentthedataindifferentways. MembershipDemographics TheoveraldemographicmakeupoftheCTMedicaidpopulationhasshiftedslightlyinthepastfouryears.Membershipbygenderhas remainedconsistent,asfemaleadultswithoutdualmembershipcontinuetoconstituteapproximately56% ofthepopulation,while malescomprise44%.agegroupdemographicshaveshiftedslightlyinthepastfouryearstowardanolderpopulation.25-34year-olds arestilthelargestgroup,at26.8% oftheadultnon-dualpopulationin2018,while the18-24and45-54year-oldagegroupsbothdecreasedbyabout1% since2015. Meanwhile,the55-64year-oldand65+agegroupshaveeachincreasedoverthe pastfouryears.whilenotdramatic,theseshiftsdoindicateaslightlyolder Medicaidpopulation,whichcanimpactutilization,lengthsofstay,andoveral Medicaidspending. Racialandethnicdemographicshavechangedmoreappreciablysince2016.AsnotedintheCY 2017andQ1/Q22018deliverables,changestotheImpaCTsystem usedtomanagemember eligibilityhaveledtoasignificantincreaseinmembersidentifyingas"unknown"race/ethnicity. In2018,thegroupidentifiedasUnknowncontinuedtorise,upafurther10% from 2017.In2018, morethanonequarteroftheadultmedicaidpopulation(27.2%)iscategorizedasunknown race/ethnicity.beacon'sinvestigationshaverevealedthatthisisatrueunknown,asmembers arenotrequiredtochoosearace/ethnicitywhenapplyingformedicaid.thereareconcernsthat havingsuchalargeunknownwilhindereffortsattrackingutilizationandoutcomestoidentify andreducehealthdisparities,aswecannotknow iftheunknownsareevenlydistributedamong racialandethnicgroupsorifcertaingroupsaremorelikelytooptoutofresponding.beacon understandsthatourstatepartnersshareourconcernsandarediscussingpotentialsolutions. [1]DualyeligibleadultmembershipinitialydroppedsteeplyinQ1'18,asmanymemberslostdualeligibilityatendof2017.Dualmembershipfelagain inq2,increasedinq3butfelagaininq4.beaconconsultedwithdssandlearnedfrom CHNviaDSSthatDeloittewasnotconsistentlysendingoverthe mostrecentthirdpartyliabilityinformationonmembers.thisissuewasresolvedinseptember2018butwhiletheweeklyfilehasincreasedinmembers, itisnotbacktooriginalsnumbersseeninmid [2]USCensusBureau(2018)."QuickFacts:Connecticut."Retrievedfrom census.gov/quickfacts/ct [3]ConnecticutDepartmentofLabor(2019)."LaborMarketInformation:StateofConnecticutvs.UnitedStatesUnemploymentRate."Retrievedfrom ctdol.state.ct.us/lmi/unempratectus.asp [4]Firth,Shannon(2018)."MedicaidEnrolmentDipsby1.1Milion."MedPageToday24Oct.2018.Retrievedfrom medpagetoday.com/publichealthpolicy/medicaid/75895 [5]Andrews,Elen(2018)."Connecticut'suninsuredrateup,reversingfour-yeartrend."CTHealthPolicy12Sept.2018.Retrievedfrom cthealthpolicy.org/index.php/2018/09/12/connecticuts-uninsured-rate-up-reversing-four-year-trend/ 1

5 In2018,Whitememberscontinuetobethelargestracial/ethnicgroup (34.4%)despiteafurther3% declinefrom 2017.TheUnknowngroupis thesecondlargestracial/ethnicgroupagainfor2018.thehispanicand Blackgroupsremainedstable,at19.2% and14.7% ofthemedicaid populationwithoutduals,respectively.membersidentifyingasasian (2.8%)andOtherRaces(1.7%)continuetoremainsteadyandrepresent asmalportionofthenon-dualmedicaidpopulation. BenefitMembership HUSKYDcontinuestobethelargestbenefitgroupforadultMedicaid members,increasingby3.8% overthepastyearto310,996members (or53.2% ofaladultmedicaidmemberswithoutdualeligibility).over thesametimeperiod,huskyamembershipdecreased12.3% andnow accountsfor38.2% ofadultmembers(223,365members),downfrom 42.3% in2017.huskyc(abd/single)increased3.8% to41,932 membersin2018(7.2% ofaladultnon-dualmembers),whileother non-dualbenefitgroupsremainedstable.thesetrendshaveimportant implicationsforutilization,ashuskydandhuskyc(abd/single)tend tobethehighestutilizinggroups. StartingonJanuary1,2018,theincomeeligibilitylevelforHUSKYA changedfrom 155% to138% offederalpovertylevel(fpl)andletters alertedimpactedmembersthattheywouldloseeligibility.onjuly1st, eligibilityreturnedtoitspreviouslevelof155% FPL;however,itis Figure1:AdultMedicaidPopulationbyRace/Ethnicity, likelythatmanywhowereformerlyenroledinhuskyadidnotknow theywereagaineligible,didnotre-enrol,orwaitedtore-enrolso thattheyhavenotyetbeenaddedbacktomembershiprols.therewasanincreaseinhuskyamembershipinq3'18,afterthe eligibilityrequirementsreturnedtotheirformerlevels,butmembershipdroppedagaininq4'18.byq4'18,therewerenearly7,000 fewerhuskyamembersthaninq4'17.itwilbeimportanttoseeifthehuskyapopulationbeginstoreturntopre-eligibilitychange levelsin2019,orifthereareotherfactorscontributingtothedecreaseinhuskyamembership.onepossibleotherfactorcouldbethe low unemploymentrate,asadultswhoqualifiedforhuskyamayhavebeenabletofindemploymentwithhealthbenefits. HUSKYDisthelargestsinglebenefitgroupoveralandformostdemographicgroups.Approximately68% ofadultmaleswithoutduals and54.3% ofwhiteadultshadhuskydin2018.huskydwasthelargestbenefitgroupforeveryagegroupexcept35-44(whichhad themostinhuskya),and65+(whichhadthemostinhuskyc[abd/single]).despiteoveraldeclinesinhuskyamembership,husky Astilcovers49.7% offemales,57.8% of35-44year-olds,andisthetopbenefitgroupforfemales25-34and35-44,suggestingthat HUSKYAcontinuestoprovidenecessarymedicalcoverageformothersandtheirchildren. Inconcordancewiththe6% declineindualmembership,aldualbenefitgroupshadadecreaseinmembershipin2018.huskyc (ABD/Dual)continuestobethelargestdualbenefitgroup,accountingfor69% ofaladultdualmembers.theadultdualpopulation continuestobeolder(58.7% were65+),female(61.3%),andwhite(59.1%).demographictrendsremainedstablein2018,showing thataldemographicgroupsdecreasedindualmembershipfairlyconsistentlyin2018. InpatientPsychiatricHospitalUtilization Annualdischargevolumefrom inpatientpsychiatrichospitals(inandout-of-state, butexcludingstatefacilities)hasremainedunchangedoverthepastfouryears, with10,548dischargesin2018foralmemberswithoutduals.discharges remainedstablebyagegroup,with25-34yearoldscontinuingtohavethemost discharges(3,169in2018;30% oftotal).malesalsocontinuetohaveslightlymore dischargesthanfemales(54.3% formalesvs.45.7% forfemales),andwhiteadults continuetohavethemostdischargesofalracialandethnicgroups(40.3% of discharges).malesandwhitesaredisproportionatelyoverrepresentedininpatient stays,asmalesrepresent44% oftheadultmedicaidnon-dualpopulationbuthave 53% ofinpatientdischarges,while34% oftheadultmedicaidnon-dualpopulation arewhiteandhave40% ofinpatientdischarges. HUSKYDmembershavethehighestpercentageofdischarges(69.8%)ofadultnon-dualmembers,folowedbyHUSKYA(15.7%)and HUSKYC(ABD/Single)(14.1%).Annualtrendsshow thesamepatternasthequarterlytrendsbeaconpreviouslyreported.huskyd inpatientdischargesincreased16% from 2017(includingaten-quarterhighof71.6% ofalinpatientdischargesinq4'18),whilethe overalhuskydpopulationincreasedbyabout4%.similarly,huskyainpatientdischargesdecreased35% from 2017to2018,while theoveralhuskyapopulationdecreasedby12% overthesametimeperiod. 2

6 Asnotedintheprevioussemi-annualdeliverable,therefore, membershipchangesalonecannotaccountfortheincreasein HUSKYDanddecreaseinHUSKYAinpatientutilization. Previously,Beaconhypothesizedthatachangeinseverity, accountedforbyanincreaseinthepercentofhuskydmembers withaprimaryschizophreniadiagnosis,couldexplainthisshift inutilization.from 2017to2018,thepercentageofHUSKYD inpatientstaysforschizophreniaincreasedfrom 22.8% to25%, whilethepercentageofhuskyainpatientstaysfor schizophreniadecreasedfrom 19% to13.5%.[6]also,thehusky Dpopulationhasarateofhomelessness(7.1%)thatisnearly 50% morethanthatofthetotaladultmedicaidpopulation (4.9%).Thismetrichighlightsthesocialissuesthatmay compoundhealthissuesandcauseincreasingutilizationamong thehuskydmembership. Figure2:PercentofInpatientStaysforSchizophreniaDiagnosisbyBenefit Group, Theaveragelengthofstay(ALOS)increasedby0.6daysfrom 8.9daysin2017to9.5 daysin2018.thealoshasincreasedapproximately0.5dayseachyearsince2015. Thisoveralincreasemaybedrivenbymanyfactors,includingsystem changeand pressuresthatreducepost-dischargeoptions.additionaly,thereappearstobean increaseintheacuityoftheinpatientpopulationasevidencedbyanincreaseinthe percentofdischargesaccountedforbymemberswithaprimarydiagnosisof schizophrenia/psychoticdisorder.from 2016to2018,inpatientdischargeswitha primarydiagnosisofschizophrenia/psychoticdisorderincreasedfrom 25.9% to 27.2%.[6]In2018,memberswithaprimarydiagnosisofschizophrenia/psychotic disorderhadanalosmorethanthree(3)dayshigherthanthestatewideaverage.the ALOSformemberswithaprimarydiagnosisofschizophrenia/psychoticdisorder(12.8 days)islongerthanformajordepression(7.8days)orbipolardisorder(8.9days) diagnoses.thisriseinschizophreniadischargescertainlyhadanimpactonrisingalos. Byagegroup,ALOSremainedfairlystablefrom 2017to2018,witholdergroupshavingthelongestlengthsofstay(65+at13.2days and55-65at11.1days),likelyduetoage-relatedmedicalcomorbiditiesandoveraldurationofpsychiatricdiagnoses,amongother factors.theotheragegroupsrangedfrom 8.8daysforthe35-44year-oldagegroupto9.7daysforthe18-24year-oldagegroup.ALOS increasedbyabouthalfadayforbothmalesandfemalesin2018,withmaleshavinganalosof9.6daysandfemales9.4days. TheALOSincreasedsteadilybyonehalftoafuldayforalracialandethnicgroupsexceptAsianadults,whohadaslightdecrease from 13daysto12.7days.TheALOSfortheAsianadultpopulationremainsthehighestALOSofanyracialorethnicgroup.As mentionedinthepriorsemi-annualdeliverable,asianmembershavelow behavioralhealthinpatientutilization(only105discharges in2018),whichmaymeanthattheyhavehadfewerpriorservicesbeforeaninpatientstayandthereforeneedalongerlengthofstay tostabilize.alotherracialandethnicgroupshavealosclusteredbetween8.4days(otherraces)and9.8days(blackmembers). Theaveragelengthofstayislargelystableamongmostbenefitgroups,exceptforHUSKYC(LTC/Single),whichincreasedby5days from 14.1daysin2017to19daysin2018.HUSKYC(ABD/Single)hasthesecondlongestALOSof11.5daysfor2018.Asnotedin previousdeliverables,thisisconsistentwiththecompositionofthehuskycpopulationsbasedoneligibilitycriteria,ashuskyc tendstobeanolderpopulationwithmorechronicconditions.huskydmembershadanalosof9.5daysfor2018,whichisthe averageforalgroups.huskya(7.7days)andhuskyb(5.8days)hadthelowestalosofalbenefitgroupsin2018. In-statePARhospitals,whichexcludestheHospitalforSpecialCare,Prospect RockvileHospital seatingdisorderunit,natchaughospital,andsharon Hospital,accountedfor10,232dischargesin2018.Morethanathird(35.6%)of thesedischargescamefrom thethreelargestfacilities:yalenew HavenHospital (1,354discharges),HartfordHospital(1,239discharges),andSt.Vincent's MedicalCenter(1,051discharges). [6]Note:thisdatacomesfrom theadultinpatientdatadashboard.thedatafeedingthisdashboardisupdatedweekly,anddataupdatesmayimpact priorweeks'numbersaswel,soanynumbersreportedfrom theadultinpatientdatadashboardinthisdeliverablemaydifferslightlyfrom thenumbers currentlyshownonthedashboard. 3

7 ProspectManchesteraddedageriatricunitandProspectWaterburyshiftedformeradolescentbedstoadults,sobothhospitals increasedtheircapacityandtheirtotaldischargesin2018.johnsonandmemorialhospitalandthehospitalofcentralconnecticut eachhadapproximately100fewerdischargesin2018thanin2017.johnsonandmemorial'sdecreaseindischargevolumecanbe attributedtoareductioninstaffingandtemporaryroom closures.thehospitalofcentralconnecticuthadanearlythree-dayincrease inalos,whichmayexplainthereductionindischarges. TheALOSforin-statePARhospitalsin2018was9.4days,an increaseofmorethanhalfadayfrom 2017.Thetwolargest hospitalsbytotaldischarges,yalenew HavenandHartford Hospital,hadanALOSthree(3)andtwo(2)daysabovethestate average,respectively.hartfordhospitalhasmadesomechanges clinicalyandatthesystem level,whichmaybringdowntheiralos inthefuture.yale'slongeralosmaybedrivenbythegreater proportionofutilizationbypatientswithschizophrenia(39.2% at Yalevs.27.2% statewide).[7]withhartfordhospitalandyalenew HavenHospitalremoved,thestatewideALOSdropsto8.6days. MostprovidershadanincreaseinALOSin2018.TheHospitalof CentralConnecticuthadthehighestALOSat14.3days,upnearly3 daysfrom 2017.TheHospitalofCentralConnecticutalsohasone ofthelowestreadmissionrates(1.6% vs.thestateaverageof 4.3%). ThebiggestreductionsinALOSoccurredatDanburyHospital (downalmost2daysto8.8days)andprospectwaterburyhospital (down1dayto10.9days).danbury'sreferralstostatebedshave reducedthisyear,andsincewaitingforstatebedstendstoincur longerwaittimes,theirdecreaseinalosisexpected.waterbury Hospitalimplementedseveralstrategiestoreducelengthofstay, includingimprovedcolaborationwithkeycommunityproviders. PerthedatasharedwithprovidersaspartoftheProviderAnalysis andreporting(par)program,the7-dayreadmissionrates increasedslightlyinq1andq2 18to5.4% anddroppedtoaten Figure3:InpatientDischargesbyPARHospital, quarterlow of4.3% inq3andq4'18.[7]the30-dayreadmissionrateforq1andq2 18increasedto16.1%,butreducedto15.2% duringq3andq4 17.Althree(3)providerswithnotablylongALOSin2018(HartfordHospital,YaleNew HavenHospital,andthe HospitalofCentralCT)hadlowerthanaverage7-and30-dayreadmissionrates. SincetheALOSforinpatientutilizationhasincreasedeachofthepastfouryears,logicwouldexpectacorrespondingdecreasein discharges,sincefewerpeoplewouldbemovingthroughthesystem inayear.however,dischargeshaveremainedflatoverthepast fouryears.asnotedintheprevioussemi-annualdeliverable,increasesinthehuskydpopulation(whotendtohavealongeralos)and decreasesinthehuskyapopulation(whotendtohaveshorteralos),mayexplainsomeoftheutilizationtrends.additionaly, Beacon'sdatashowsonlytheMedicaidutilization.Usualy,notaloftheinpatientbedsatahospitalareusedforMedicaidpatients. Therefore,ifinpatientutilizationbypeoplewithprivateinsurancehasdecreased,hospitalsmayhaveshiftedmoreoftheprivatebeds overtomedicaidtoaccommodatetheneed.moreover,ongoingsystem changessuchas;timelyaccesstostate,intermediateand residentialbeds;homelessness;probatehearings;maybeslowlygrowingthealosovertime. Recommendation1:ContinueAdultInpatientPARProgram RegionalNetworkManagerscontinuedtoconductProviderAnalysisandReporting(PAR)meetingswiththeadultinpatientpsychiatric hospitalsduringcy2018.clinicalandmedicalaffairsstaff from BeaconareabletoparticipateinPARdiscussionsasneeded.These conversationsprovideanimportantforum tounderstandthevariedclinicalphilosophies,communityresources,treatmentapproaches, andculturalinfluencesateachhospitalandwithineachcommunity.understandingaprovider sperformancewithinthiscontext furthersourabilitytoshapeproviderpracticeviatheparprogram. [7]Note:thisdatacomesfrom theadultinpatientdatadashboard.thedatafeedingthisdashboardisupdatedweekly,anddataupdatesmayimpact priorweeks'numbersaswel,soanynumbersreportedfrom theadultinpatientdatadashboardinthisdeliverablemaydifferslightlyfrom thenumbers currentlyshownonthedashboard. 4

8 AsinpreviousPARcycles,thereremainsnotablevariationinALOSandreadmissionratesacrossthenetwork.PARdiscussionsin2018 continuedtofocusonbarriersandbestpracticesforattainingand/ormaintainingefficientlengthofstayandlow readmissionrates. Factorsinfluencingthesemetricswereidentifiedbythehospitalsasfolows:staffingshortagesacrossdisciplines;breakdownin adherencetoprotocols;timelyaccesstostate,intermediateandresidentialbeds;homelessness;probatehearings;electro-convulsive therapy(ect);andmemberswithschizophrenia/psychoticdisordersandgeriatricpopulation.thewaitforstatebedshasincreasedby morethan5daysinthepastyear,from 61.7daysin2017to67daysin2018,whiletheacuteALOSonlyincreased.4days(8.4daysto 8.8days)inthesametimeperiod.AsnotedinRecommendation3below,BeaconwilstarttrackingwaittimesforResidentialRehab startinginq1'19. Tofurtherimproveefficienciesacrosshospitalsystems,PARmeetingsand statewideworkgroupswereconvenedtopromotenew andexistinginitiativesand bestpractices.theoctober2018adultinpatientworkgroupmeetingprovided opportunityformeaningfuldialoguewithatargetedfocusonexpandingaccessto MedicationAssistedTreatment(MAT)formemberswithanOpioidUseDisorder (OUD)whileonaninpatientpsychiatricunitaswelaspromotingODprevention includingprescriptionofnarcan.hospital-specificoud/auddatashowedevidence ofmissedopportunitiesforscreeningforthesediagnoses,highlightingtheneed foruniversalscreeningandsubsequentevidence-basedtreatment. Lastly,thereremainsexpressedinterestbyhospitalsinthesocialdeterminantsofhealth(SDOH),withparticularfocusonindividuals needsrelatedtohousing,transportationandfoodinsecurity.thesefactorstendtobedriversofemergencyandinpatientservicesand canexacerbatehospitallosandreadmissionrates.hence,providersareinterestedinconsideringcolaborationswithbeaconthatmay supportmembersandprovidersinaddressingsdohasasystemsapproachtoimprovingqualityofcare. Recommendation2:ModifyInpatientBypassProgram BeaconcontinuestoofferanAdultInpatientBypassProgram andwecontinuetomeasurebypass statusbasedonalos( 8.2),7-dayreadmissionrates( 6%)anddischargeform completionrate (90% form completionwithin2businessdays).inq3&q4 18Beaconmadesignificantprogress towardsanipfparcase-mixpredictivemodel.throughmultiplestakeholderinputs,beacon utilizedanumberofdifferentepisode-leveldemographic,socialdeterminant,utilization, expenditure,diagnosis,andseverityvariableswithcalendaryeardischargedates to predicttotallengthofstay.twofinalseparatepredictivemodelsweredevelopedforchildren(<18 yearsofage)andadults(18+yearsofage).thepredictivemodeluseddatafrom theparreports, authorizations,andclaimstoprovideacomprehensivedataset.inoperationalizingthevariablesof interest(i.e.,predictors),new methodologieswerecreatedinordertofulycapturepossible predictorsoflengthofstay.beacontrained,validated,andtestedthepredictivemodelsforboth youthandadults.severaldifferentpredictivemodelswereexploredandassessedforpossible inclusion,however,abackwardeliminationmultiplelinearregressionwasselectedasthefinal predictivemodelwithstrongfitstatistics. Figure4:SignificantPredictorVariablesforAdultIPFPARCase-MixPredictive Model Thisrefinementofthecurrentbypassstructurethrough case-mixadjustmentwasintroducedtoasubsetofthe providersduringtheadultinpatientworkgroup.thebasic premiseofthecasemixinitiativeistocreateamore equitablelosevaluativeprocessbycapturingtheclinical complexityofmemberstreatedwithininpatientfacilities andgeneratinganexpectedlosaccordinglyforthese individuals.thesenewlyproposedbypassmetricswil expandfrom threetosixandinclude:losdifference,los improvement/maintenance,7-dayreadmit,bhedvisitwith 7-dayspostIPFdischarge,dischargeform andbedtracking completionrates. ResultsofthepredictivemodelwerepresentedtotheState PartnersduringtheNovember29,2018CoreExecutive Meeting.AdditionalStatePartnerandProviderWorkgroup meetingswilbeheldinq1andq2of2019toreview how thepredictivemodelappliestoq1toq32018ipfpar dischargesattheproviderlevel.furthermore,theimpact ofthenew bypassmetricsandpointsystem wilbereviewedwithstakeholdersinupcomingworkgroupmeetings. 5

9 Recommendation3:TrackingofAdultOverstayReasons Withtheincreaseinthelengthofstay,Beaconhasbegunincreasedtrackingofthereasonsforadultmembersremaininginthehospital beyondtheacuteportionoftheirstay.startinginq12019,clinicalcaremanagersarenow abletotrackifmembersareremainingin careawaitingbedsforvariouslocationsand/orservices-skilednursingfacility,statebeds,adultgrouphomes,residential rehabilitation,andreceivingservicesfrom thedepartmentofdevelopmentalservices.thiswilalow BeaconandourStatePartnersto betterunderstandwheredelaysareoccurringwithinthesystem inordertostrategizewaystoaddressthebarriersandimpactlos. Recommendation4:IdentifyUM StrategiestoAddressIncreaseinALOS Theteam recognizesandisconcernedwiththeincreaseintheaveragelengthofstay.whileaportionoftheincreaseisduetothe awaitingofstatebedsandotherlocationsand/orservices,webelievethatthereisaportionwherewecanbeimpactfulandwil proposerecommendationstoaddress.wewilpresenttheadditionalrecommendationswithin60to90days. InpatientDetoxification HospitalUtilization InpatientDetoxificationintheHospital(IPDH)continuestobeutilizedmainlybyWhitemales,45-54yearsold,andintheHUSKYD benefitgroup.asexpectedduetothegreatermedicalrisksinvolvedwithalcoholdetoxification,hospitaldetoxificationdischarges weremostlyforalcoholuse(95.2%).dischargesremainedstablein2018at3,613dischargesfor2,138uniquemembers suggesting manyrepeatutilizers.[8]duetodetoxificationprotocols,theannualalosremainedsteadywithonlyaslightincreaseto5.5days. Whiletherearecertainlysituationswheremembersenterdetoxificationwithsignificantmedicalissuesandlongerlengthsofstay,the leavingagainstmedicaladvice(ama)rate(8.1%)likelyoffsetsthoseoutliers,keepingthealosstable. Adultsaged45-54yearsoldaredisproportionalyoverrepresentedintheInpatientDetoxification Hospitalserviceclass,asthey represent17% ofthetotaladultmedicaidpopulationand34.1% oftheipdhpopulation.adultsinthe55-64year-oldagegrouparealso overrepresentedwith13.8% oftheadultmedicaidpopulationand24.3% ofipdhdischarges.alosvariesthemostbyagegroupwith the45-54year-olds(5.8days)andthe55-64year-olds(5.9days)havingslightlylongerhospital-baseddetoxificationstaysonaverage. Dischargesforbothmalesandfemalesincreasedslightlyin2018,thoughmalesstilcomprise71.9% oftheipdhdischarges.malesare notablydisproportionalyoverrepresented,at44.2% ofthetotaladultmedicaidpopulationandnearly72% ofipdhdischarges. Dischargesremainedstableacrossracialandethnicgroups.Whitemembersstilhavethemostdischarges(54.7%),andarealso disproportionalyoverrepresentedastheymakeuponly34.4% ofthetotaladultmedicaidpopulation.in2018,83.7% ofdischarges from IPDHwereHUSKYDmembers,anincreaseofmorethan8% from 2017.HUSKYDisoverrepresentedwith53.2% ofthetotaladult Medicaidpopulationandnearly84% oftheipdhdischarges. ThetopthreeprovidersforIPDHin2018wereYaleNew HavenHospital(786discharges),St.FrancisHospital(466discharges),and BridgeportHospital(261discharges).In2018,hospitalsrangedfrom analosof3.9days(st.francishospital)to9.9days(middlesex Hospital).OnlyMiddlesexHospitalhadanALOSofmorethanonedaygreaterthanthestatewideaverageof5.5days.Middlesex Hospitalhadnine(9)memberswithstaysof10ormoredays,andtheseoutliersincreasedMiddlesexHospital'sALOSbymorethan4 daysfrom 2017to2018.Asstatedintheprevioussemi-annualdeliverable,mosthospitalsprovidinginpatientdetoxificationdonot completethedischargeform,somembersmayhavebeendischargedpriortothelastdatebeaconhasonfile,whichwouldreducethe averagelengthofstay. From thedatasharedintheprovideranalysisandreporting(par)program,thetotal7-dayreadmissionratesforalin-stateipdh providers(excludingstatefacilities)was8.9% for2018.[8]thereadmissionrateincreasedafulpercentagepointfrom 8.4% inq1and Q2'18to9.4% inq3andq4'18.the30-dayreadmissionrateroseto29.2% statewidefor2018afteratenquarterhighof30.5% inq3 andq4'18. Recommendation5:ContinueHospital-basedDetoxificationPARProgram withhigh-volume facilities PARmeetingswereheldinthesecondhalfoftheyearwiththetwohighestvolumeproviders,St. FrancisandYale.ThefocusofthePARmeetingswasonincreasingutilizationofMedication AssistedTreatment(MAT)forbothAlcoholUseDisorder(AUD)andOpioidUseDisorder(OUD).In recentmonths,yaleandtrinityhealthhavebothinvestedinnew AddictionMedicineexpertise andresources,withthegoalofexpandingaccesstomatacrossthehospital.keytothispractice changeisforgingnew providerrelationshipswithinandbeyondestablishedcatchmentand geographicalboundariestoensureaccesstomatforalindividualsacrossthecontinuum ofcare. Assuch,BeaconhascolaboratedwiththeMedicalDirectorsoftheAddictionMedicineServicesto establishreferralpathwaysfrom thehospitaltooutpatientmat.thisworkwilcontinuein2019. [8]Note:thisdatacomesfrom theadultinpatientdatadashboard.thedatafeedingthisdashboardisupdatedweekly,anddataupdatesmayimpact priorweeks'numbersaswel,soanynumbersreportedfrom theadultinpatientdatadashboardinthisdeliverablemaydifferslightlyfrom thenumbers currentlyshownonthedashboard. 6

10 InpatientDetoxification FreestandingUtilization InpatientDetoxificationatFreestandingCenters(IPDF)continuestobeutilizedmainlybyWhitemalesintheHUSKYDbenefitgroup. IPDFservesayoungerpopulationthanIPDH.In2018,dischargesweremainlyforalcohol(47.7%)oropioid(41.7%)withdrawal. Dischargesremainedstablein2018at11,247.TherearelimitedbedsforIPDFandmostfacilitiesusualyoperateatfulcapacity,soit isnotsurprisingthatdischargeshaveremainedsteadydespitetheongoingopioidepidemic.thealosalsoremainedstableat4.3days in2018.thealoswas4.0daysforopioidwithdrawal(witha20.2% AMArate)and4.5daysforalcoholwithdrawal(witha14.2% AMA rate).[9]anincreaseininductiontomedicationassistedtreatment(mat)couldresultinchangesinthealosforopioidwithdrawal, butwearenotyetsurewhatthosechangesmaybe. Dischargesremainedfairlystableacrossagegroups,withsmalincreasesfor35-44year-oldsand55-64year-olds.Membersinthe 25-34year-oldagegrouphadthemostdischarges(36.3%)in2018,whichisadisproportionaloverrepresentationwhencomparedwith their26.8% shareofthetotaladultmedicaidpopulation.thealosremainedstableacrossagegroups,withtheexceptionofthe65+ agegroup,whichincreasedhalfadayto5.5days,likelyduetomoremedicalcomplicationsrequiringmoretimetostabilize. Bygender,menhadmoredischarges(70.8%)thanfemales,whichisagainadisproportionaloverrepresentationofmales.TheALOS was4.3daysforbothmalesandfemales.dischargesremainedstableacrossracialandethnicgroups,withwhitemembershavingthe mostdischarges(51.6%) again,adisproportionaloverrepresentationcomparedwithwhitemembers'proportionofthetotal population(34.4%).huskydcontinuestoaccountforthevastmajority(85.4%)ofdischargesfrom IPDF,withHUSKYA(10.8%)and HUSKYC(ABD/Single)(3.7%)havingmuchlowervolumes.Asineachofthepastfouryears,ALOSwasnearlyidenticalacrossbenefit groupsat4.2to4.3days. Likein2017,thesevenin-stateinpatientfreestandingdetoxprovidersaccountedfor11,222 dischargesin2018.thelargestproviderovereachofthepastfouryearswasintercommunity, whichhad2,666discharges(23.8%)in2018.recoverynetworkofprogramshadthesecondhighest numberofdischarges(1,838,or16.4% ofthetotal)in2018.becausetreatmentisprotocoldriven, thereislittlevarianceamongprovidersforalos.in2018,alosrangedfrom 3.7daysatboth CornelScott-HilHealthandIntercommunityto4.9daysatbothStoningtonBehavioralHealthand MidwesternCTCouncilonAlcoholism. From thedatasharedintheprovideranalysisandreporting(par)program,the 7-dayreadmissionratesforalin-statefreestandingdetoxificationproviders increasedeachyearfrom 2015to2018.[9]Thestatewide7-dayreadmissionrate was5.4% in2018,includingahighof5.8% inq3andq4'18.the30-day free-standingdetoxreadmissionrateincreasedeachyearfrom 2015to2017and remainednearlyflatatastatewiderateof18.9% in2018.themajorityof discharges(76.0% of7-dayreadmissionsand61.7% of30-dayreadmissions)are readmittingtoadifferentprovider. Figure5:7-DayReadmissionRatesforIn-State FreestandingDetoxProviders, Recommendation6:ContinueProviderWorkgroupMeetingsandPARProgram During2018,Beaconcontinuedtomeetwiththefreestandingdetoxification facilitiestoengageindiscussionsabouttheparmeasuresusedininpatient MedicalDetoxdashboardswhichincludeALOS,readmissions,AMArates,discharge form completion,andconnecttocarerates.whilethealosrangeisrelatively smal,the7-dayreadmissionrateandamaratevaryacrossthenetwork.in additiontoreviewingtheaforementionedmetrics,rnmsalsogatheredinformation onemergingbestpractices,relationshipswithcommunityproviders,andbarriers impactingreadmissionsandconnectiontocarepostdetox. DuringPARmeetings,RegionalNetworkManagerswereabletoleveragedatatohighlighttheneedforadifferent,evidenced-based treatmentphilosophytomanageindividualswithopioidusedisorder(oud).inductionontoamedicationassistedtreatment(mat) optionwhileindetox,suchasmethadoneorbuprenorphine,isbestpracticewhentreatingopioidaddiction.havingthedatatosupport thisconversationandtoshow thehighamaratesofmemberswithaprimarydiagnosisofoudwhencomparedtothosewithaprimary diagnosisofalcoholusedisorderhasstrengthenedproviderinterestinshiftingtreatmentphilosophiesandeventakingactionto operationalizeanew approach. [9]Note:thisdatacomesfrom theadultinpatientdatadashboard.thedatafeedingthisdashboardisupdatedweekly,anddataupdatesmayimpact priorweeks'numbersaswel,soanynumbersreportedfrom theadultinpatientdatadashboardinthisdeliverablemaydifferslightlyfrom thenumbers currentlyshownonthedashboard. 7

11 Whilethereisvariabilityamongstthesevenfree-standingsinreadinesstooperationalizetreatmentandcontinuum change,al receivedthesamemessagethatwaswelsupportedbyindividualdataandalwereopentonextstepsinaddressingtheraised concerns.atarecentproviderworkgroupmeeting,providerswereencouragedtosharebestpractices,successes,andareasof improvementwithoneanotherinanefforttopromotematacrossthenetwork.therehasbeennotableinterestfrom providersto continuethisforum andtopartnerinwaystoimprovepractices. InanefforttoprovideadeeperdiveintoMAT-relateddata,fournew datameasures wereintroducedtothefree-standingprovidersatthenovemberworkgroup: ConnectiontoMATpostdischargefrom WithdrawalManagement,2)Connectionto MATbyMedicationType,3)MATInductionRatesand4)MultipleWithdrawal ManagementEpisodeswithinpast365daysatthesameprovider.Federalregulations under42-cfrcreatesbarrierstosharingdataonreadmissionstoother,vs.thesame, providerwherethebulkofthereadmissionsoccur.beaconandthestateshould continuetoseeksolutionsthatwouldalow forthesharingofrelevantclinicalyuseful dataeitherthroughcolectingreleasesforinformationsharingatintake,and/or continuingtoseekmodificationstocurrentregulations. Lastly,tofurthersupportstandardizationofcomprehensiveMATeducationandinductionwhileinthewithdrawalmanagementLOC, Beacon,DSS,andDMHAShavepartneredwithtwocentralylocatedproviders,InterCommunityandRushford,tolaunchtheChanging PathwayspilotinQ4 18.ThegoaloftheChangingPathwaysPilotisto changepathways torecoveryforthememberswithoudfrom ataper-to-zeroprotocoltoinductionononeofthreeevidence-basedmatoptions,i.e.buprenorphine,methadoneornaltrexone,witha seamlesstransitionfrom inpatientwithdrawalmanagement/detoxtooutpatientmat. Whileintheshort-term,effortswilbefocusedonthesetwopilotproviders,thelong-term goalistodisseminateabestpractices/ lessonslearnedtoolkittotheremainingwithdrawalmanagementproviderscoupledwiththedevelopmentandmonitoringofvarious MATmetricstobeabletotrackprogress.ThiswilbethefocusofBeacon'snextstatewideworkgroup.Thisinitiativewilbereviewed indetailwithinourperformancetargetsummary. Recommendation7:IncreaseFocusonReadmissionsandChangingPathways InNovember2018,IPDFauthorizationrequestsweremovedtoaregistrationprocesswherebyprovidersreceivefive(5)units/dayupon submissionoftheinitialrequest.initialrequestsformemberswhoarereadmittingwithin30daysofdischargefrom anipdfpendfor clinicalreview,whichalowsforincreasedconversationswithprovidersabouteffortstoengagemembersindiscussionsaboutthemat optionsandtryingadifferentpathwaythistime. HomeHealthUtilization Admissions(authorizationinitiations)forMedicationAdministrationdecreasedslightlyin2018,withonlyHUSKYDmembershavingan increase.huskydnow hasthehighestvolumeofmedicationadministrationadmissions(842),folowedbyhuskyc(abd/single) (603)andHUSKYC(ABD/Dual)(554).FortheHUSKYC(ABD/Single)andHUSKYC(ABD/Dual)groups,55-64year-oldshadthemost admissions(189and155,respectively).forhuskyd,25-34year-oldshadthemostadmissions(250),andforhuskya,18-24year-olds hadthemostadmissions(67).asmentionedinthepriordeliverable,therehasbeenashiftinthepopulationreceivingthemedication Administrationservice,sinceitusedtobemostly55-64year-oldHUSKYC(altypes)members.Throughout2018,theshiftcontinued andnow HUSKYDhasthemostadmissions,andmostofHUSKYD'sutilizersareyoung(18-34yearsold). DespiteaslightuptickinQ4'17,thetwicedaily(BIDrate)forMedicationAdministrationhascontinuedtoremainsignificantlylower thaninprioryears(around20% in2014).oncedaily(qd)administrationhasincreasedslightlyoverthesametimeframe.notably, evenwhilefewermembershavemedicationadministrationservicesmultipletimesperday,theedrate(29.5% inq1'18and28.2% in Q2'18)andIPrate(9.5% inq1'18and8.2% inq2'18)havecontinuedtodecreaseovertime. StartofCare/ResumptionofCareauthorizationscontinuetoreplaceSkiledNursing authorizations.theuseofaskilednursingvisitisnow limitedtoaonceweeklypre-pourof medications,inhomewoundcareformembersreceivingbehavioralhealthservices,oraful nursingassessmentintheeventofachangeincondition.utilizationofskilednursinghas declinedtojust115admissionsformembersincludingdualsin2018.utilizationforstartof Care/ResumptionofCareincreasedforeverybenefitgroupfrom 2017.SinceSkiledNursingand StartofCare/ResumptionofCareareauthorizedinconjunctionwithMedicationAdministration, thetrendsbybenefitandagegrouparethesameasformedicationadministration. 8

12 Figure6:SkiledNursingAuthorizations, Figure7:Start/ResumptionofCareAuthorizations, HomeHealthPrompting,HomeHealthAide,MedBoxandMedTechrequestsfornew authorizationshavebeenexceptionalylow with fewerthan40admissionsapiecein2018.medboxandmedtechservicesareoftenutilizedthroughthemedicalasoand/orthewaiver programs. Recommendation8:ContinueHomeHealthBypassProgram BeaconcontinuedtheBypassandBypassPlusProgram forhomehealthagenciesin2018.thebypassprogram providesadministrative reliefforhomehealthagencieswhilepromotingpracticechangethatwilbenefitmembersandimprovetheefficiencyofhomehealth services.theagenciesonbypassareauthorizedforlongerperiodsoftime,thusdecreasingthenumberofconcurrentreviewsrequired foranepisodeofcare.thebypassprogram eligibilitycriteriacontinuestobeachievementofabidmedicationadministrationtarget rateandemergencydepartmentvisitrate. BeaconheldastatewideHomeHealthprovidermeetinginNovember2018andpresentedthemostrecentclaimsdata(Q2 18),which includedperformanceonthebypassmetrics.nine(9)ofthe19bypass-eligiblehomehealthprovidersweremeetingthetargetstobe includedinthebypassplusprogram,six(6)providerswereincludedinthebypassprogram,one(1)providerwasatriskduetomissing themetricsforthefirstquarterandthree(3)providerswerenotincludedinthebypassduetomissingthemetrics.alproviders excludedfrom thebypassprogram oratriskofbeingremovedfrom thebypassprogram wereencouragedtoworkcloselywithbeacon staff aroundbestpracticesidentifiedbyotherproviders.inadditiontothebypassprogram,othertopicswerecovered,suchasways tosafelymanageopioids/controledsubstancesinthehomeandthe485prescribersignoff.apresentationonthezerosuicide Frameworkwasalsocompleted,whichresultedinincreasedinterestinhavingmorein-depthpresentationsoneachofthecomponents oftheframework. Beaconcontinuestoreview opportunitiestoenhancethebypassprogram parameterstofurtherincentivizeagenciestodecrease memberrelianceonhomecareservices.onechangebeingconsideredwouldbetoincentivizeproviderswhoaremeetingaspecificqd rateinadditiontothealreadyidentifiedbidandedrate.afinalproposalwilbepresentedfolowingthenextrunoftheclaimsdatain February2019. LowerLevelofCareUtilization Outpatientadmissionsforadultshavecontinuedtoincreaseyearoveryear,risingto 118,679admitsin2018(21admits/1,000).Outpatientadmissionscontinuetorepresent thevastmajority(80%)ofaladmissionstolowerlevelsofcare. Figure8:AdultOutpatientAdmissions, Mostotherserviceclassesdecreasedslightlywhileadmits/1,000 decreasedorremainedflat,suggestingtruedecreasesin utilization,notjustareductioninpopulationsize.intensive Outpatient(IOP)wasthesecondmostutilizedLowerLevelofCare, with19,947admissionsin2018,folowedbymethadone Maintenancewith5,328admissionsandPartialHospitalization (PHP)with4,840admissions.MethadoneMaintenanceadmissions decreasedfrom 5,875in2017to5,328in2018.Beaconhas hypothesizedthatmoreprovidersarerecommendingalternative MAT,suchasbuprenorphine,tomethadone,butwedonotyethave thedatatotestthatassumption.iopadmissionsincreaseddueto sixteen(16)new IOPprogramsopeningstatewidein

13 EnhancedCareClinics(ECCs) Thetotalnon-ECCregistrationvolume(inclusiveofbothadultsandyouth)continuesto steadilyincreaseovertime,whilethetotaleccvolumehasslightlydeclined.in2018, non-eccregistrationsconstituted88.6% ofaloutpatientregistrations.eccvolume decreasedbymorethan1,500registrationsto18,668registrationsin2018.adultecc volumedecreasedby8.3% to9,742registrationsin2018. In2018,the95% accessstandardwasmetforalthreeaccesstypesforeccs(routine,urgentandemergent).foradultsin2018, routinestandardsweremet99.3% ofthetime,urgentweremet98.1% ofthetime,andemergentweremet100% ofthetime.across aloutpatientevaluations,eccscontinuetohavehigherratesofmeetingthe95% accessstandardthannon-eccclinicsasexpected basedonthelevelofattentiongiventotheaccessstandardsbytheeccsbutthenon-eccclinicscontinuetodemonstrateastrong performancewithoutaddedincentives. Recommendation9:AssessECCinitiative Overthepastyear,thereweremanymeetingsheldtodiscussanECCRedesignthataddressestheoperationalizationofECCprogram metrics,incorporationofvaluebasedpaymentmethodologies,andopportunitiestobroadentheinitiative.thesediscussionsremain ongoing.duringtheseptemberoperationssubcommittee,anopeninvitationforfeedbackoneccredesignwasgiventoproviders. WhilethesubsequentOperationsSubcommitteemeetingshavenotgeneratedanyadditionalfeedback,theCTBHPECCteam remains opentoproviderinput. 10