SECTION 1. Chapter 111 of the General Laws is hereby amended by inserting after section 78A the following section:

Section 78B. (a) The Commissioner of the Department of Public Health, the Commissioner of the Department of Mental Health, the Director of Medicaid, the Executive Director of the Group Insurance Commission, the Executive Director of the Health Policy Commission, and the Executive Director of the Center for Health Information and Analysis, in consultation with representatives of hospitals, long term care facilities, outpatient facilities, primary and emergency care providers, community health centers, community mental health centers, consumer representatives, patients with chronic conditions and any other representatives deemed necessary, shall, subject to appropriation, develop a plan: (1) to reduce the incidence of chronic disease, including, but not limited to, chronic cardiovascular disease, cancer, stroke, chronic lung disease, chronic obstructive pulmonary disease, diabetes, arthritis, chronic metabolic disease, and mental illness; (2) to improve chronic care coordination in the Commonwealth; and (3) for each type of health care facility and coordinated care organization as defined by the Massachusetts General Laws including Integrated Care Organizations, Accountable Care Organizations, and Patient-Centered Medical Homes to reduce the incidence and effects of chronic disease.

(b) On or before January 15, at least 1 year after completion of the plan required in subsection (a) the commissioners and directors shall submit a bi-annual report to the governor, the chairs of the joint committee on public health, the chairs of the joint committee on mental health and substance abuse, and the chairs of the joint committee on health care financing concerning chronic disease and the implementation of said plan. The commissioners and directors shall also make the report available on the departments’ web sites not later than 30 days after submitting the report. The report shall include, but need not be limited to: (1) a description of the chronic diseases that are most likely to cause a person's death or disability, the approximate number of persons affected by each chronic disease and an assessment of the financial effect of each disease on the Commonwealth and on hospitals and other health care facilities; (2) a description and assessment of programs and actions that have been implemented by the departments or hospitals and other health care facilities to improve chronic care coordination and prevent disease; (3) the source and amount of funding received by the departments to treat persons with multiple chronic conditions and to treat or reduce the most prevalent chronic diseases in the state; (4) a description of chronic care coordination between the departments and hospitals and other health care facilities and among health care facilities to prevent and treat chronic disease; (5) detailed recommendations concerning actions to be taken by Integrated Care Organizations, Accountable Care Organizations, Patient-Centered Medical Homes, hospitals and other health care facilities, and by the Commonwealth in licensing and promoting community-based models for health care delivery, to reduce the effects of the most prevalent chronic diseases, including recommendations concerning: (i) ways to reduce hospital readmission rates, (ii) transitional care plans, (iii) drug therapy monitoring, (iv) collaborative drug therapy management, (v) comprehensive medication management as defined in Section 3503(c) of the Affordable Care Act (ACA) (SEC. 935 of 42 U.S.C. 299b–35(c)) to help patients with multiple chronic conditions achieve clinical and patient goals of therapy and improve clinical outcomes, (vi) adoption of quality standards that are evidence-based measures endorsed through a multi stakeholder process such as the National Quality Forum and (vii) patient self-management training; (6) identification of anticipated results from a hospital or other health care facility's implementation of the recommendations described in clause (5) of this subsection; (7) identification of goals for coordinating care and reducing the incidence of persons having multiple chronic conditions; and (8) an estimate of costs and other resources necessary to implement the recommendations described in clause (5) of this subsection.