Health Home Initiative

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Nov 17, 2013 (3 years and 11 months ago)

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Missouri Primary Care
Health Home Initiative

Agenda


What is a Primary Care Health/Medical Home?


Overview of Section 2703 of the Affordable Care Act


Overview of Missouri Primary Care Health Home
Initiative


Health Home Services


Health Home Team Members


Enrolling Patients


Shared Savings and Performance Goals/Measures


Learning Collaborative


Patient Centered Medical Home Recognition


Health/Medical Homes Provide:


comprehensive and coordinated care in the context of
individual, cultural, and community needs


Medical, behavioral, and related social service needs
and supports are coordinated and provided by provider
and/or arranged


emphasize education, activation, and empowerment
through interpersonal interactions and system
-
level
protocols


at the center of the health/medical home are the patient
and their relationship with their primary care team

What is a

Health/Medical Home?

Section 2703 of the
Affordable Care Act


Section 2703 of the Affordable Care Act allows
states to amend their Medicaid state plans to
provide
Health Home Services

for enrollees
with qualifying chronic conditions.


States are eligible for an enhanced federal match
for eight quarters


Missouri received approval from the Centers for
Medicare & Medicaid Services (CMS) for two
State Plan Amendments to be able to provide
Health Home Services to Missourians who are
Medicaid eligible participants with chronic
illnesses.

Section 2703 of the ACA:
Qualifying Conditions


Qualifying Patient Conditions:


Serious and persistent mental illness


Two qualifying chronic conditions


One qualifying chronic condition and at risk
for a second qualifying chronic condition


State Defined Conditions


Missouri Selected
Qualifying Conditions


Combination of Two


Diabetes
(CMS approved
to stand alone as
one
chronic disease and risk for second)


Heart
Disease,
including hypertension,
dyslipidemia, and CHF


Asthma


BMI above 25 (overweight and obesity
)


Tobacco Use


Developmental
Disabilities


Serious and Persistent Mental Illness
(Community Mental Health State Plan
Amendment)


Participating Sites


Provider Requirements


Medicaid/Uninsured Threshold


Using EMR for six months


Plans to apply for National Committee for Quality
Assurance (NCQA) Patient Centered Medical
Home Recognition within 18 months


Organizations

Selected

to

Participate


18

FQHCs

operating

67

clinic

sites


6

Hospitals

operating

22

clinic

sites


One

Independent

Rural

Health

Clinic


Partners in Planning


Department of Social Services (DSS)


Department of Mental Health (DMH)


MO Foundation for Health (MFH)


MO Primary Care Association (PCA)


MO Coalition of Community Mental Health
Centers (CMHCs)


Consultants: Michael Bailit & Alicia Smith


Missouri Hospital Association (MHA)


Missouri School Board Association (MSBA)


Goals of the Primary Care Health
Home Initiative



Reduce inpatient hospitalization, readmissions and
inappropriate Emergency Room visits


Improve coordination and transitions of care


Implement and evaluate the Health Home model as a way
to achieve accessible, high quality primary health care and
behavioral health care;


Demonstrate cost
-
effectiveness in order to justify and
support the sustainability and spread of the model; and


Support primary care and behavioral care practice sites by
increasing available resources and improving care
coordination to result in improved quality of clinician work
life and patient outcomes.

Use of Health Information
Technology to Link Services



CyberAccess


Direct Inform (Patient portal)





Data Management and
Analytics


Clinical Information via MPCA data warehouse


Hospital and ER utilization from claims


Notification of Hospital Admit from MHN
concurrent authorization system


Care Coordination via
CyberAccess


Medication Adherence reports


Health Home Services


Comprehensive care management


Care coordination


Health promotion


Comprehensive transitional care including
follow
-
up from inpatient and other settings


Patient and family support


Referral to community and support services


Health Home Services:

Comprehensive Care Management


Identification of high
-
risk individuals and use of client
information in care management services; assessment of
preliminary service needs;


Treatment plan development, which will include patient
goals, preferences and optimal clinical outcomes;


Assignment by the care manager of health team roles and
responsibilities;


Development of treatment guidelines that establish clinical
pathways for health teams to follow across risk levels or
health conditions;


Monitoring of individual and population health status and
service use to determine adherence to or variance from
treatment guidelines and;


Development and dissemination of reports that indicate
progress toward meeting outcomes for client satisfaction,
health status, service delivery and costs.






Health Home Services:

Care Coordination


Implementation of the individualized treatment plan
(with active patient involvement)


Appropriate linkages, referrals, coordination and follow
-
up to needed services and supports
--

e.g.


appointment scheduling


conducting referrals and follow
-
up monitoring


participating in hospital discharge processes


communicating with other providers and
clients/family members.






Health Home Services:

Health Promotion


Consists of providing health education specific to an individual’s:


chronic conditions


development of self
-
management plans with the individual


education regarding the age appropriate immunizations and
screenings


providing support for improving social networks and providing health
promoting lifestyle interventions, including but not limited to,
substance use prevention, smoking prevention and cessation,
nutritional counseling, obesity reduction and prevention and
increasing physical activity.


Health promotion services also assist patients to participate in the
implementation of their treatment plan with a strong emphasis on
person
-
centered empowerment to understand and self
-
manage chronic
health conditions.






Health Home Services:

Comprehensive Transitional Care


Comprehensive transitional care including follow
-
up from
inpatient and other settings


Member of the health home team provides care coordination
services designed to streamline plans of care, reduce
hospital admissions and interrupt patterns of frequent
hospital emergency department use.


The health home team member collaborates with
physicians, nurses, social workers, discharge planners,
pharmacists, and others to continue implementation of the
treatment plan with a specific focus on increasing patients’
and family members’ ability to manage care and live safely
in the community


Shift the use of reactive care and treatment to proactive
health promotion and self management.




Health Home Services:

Patient and
Family Support


Advocating for individuals and families, assisting with
obtaining and adhering to medications and other
prescribed treatments.


Health team members are responsible for identifying
resources for individuals to support them in attaining
their highest level of health and functioning in their
families and in the community


For individuals with Developmental Disabilities the
health team will refer to and coordinate with the
approved Developmental Disabilities case
management entity






Health Home Services:

Referral to Community and
Support Services



Assistance to patients including but not limited to:


obtaining and maintaining eligibility for
healthcare


disability benefits


Housing


personal need and legal services


For individuals with developmental disabilities the
health team will refer to and coordinate with the
approved DD case management entity for this
service.



Health Home Team Members




Health Home
Director


Nurse Care Manager


Behavioral Health Consultant


Care Coordinator



Provides
leadership to the implementation
and coordination of Healthcare Home
activities


Champions practice transformation based on
Healthcare Home principles


Develops and maintains working relationships
with primary and specialty care providers
including inpatient facilities


Monitors Healthcare Home performance and
leads improvement efforts


Health Home Director


Designs
and develops prevention and
wellness initiatives Referral tracking


Training and technical assistance


Data management and reporting


Non
-
PMPM paid staff training time


Health Home
Director
Continued


Develop
wellness & prevention initiatives


Facilitate health education groups


Participate in the initial treatment plan development
for all of their Primary care health home enrollees


Assist in developing treatment plan health care goals
for individuals with co
-
occurring chronic diseases


Consult with Community Support Staff about
identified health conditions


Assist in contacting medical providers & hospitals for
admission/discharge

Nurse Care
Manager


Provide training on medical diseases, treatments &
medications


Track required assessments and screenings


Assist in implementing MHD health technology
programs & initiatives (i.e.,
CyberAccess
, metabolic
screening)


Monitor HIT tools & reports for treatment


Medication alerts & hospital admissions/discharges


Monitor & report performance measures & outcomes


Nurse Care Manager
Continued


Integration
with Primary Care


Support to Primary Care physician/teams in
identifying and behaviorally intervening with
patients who could benefit from behavioral
intervention.


Part of front line interventions with first looking
to manage behavioral health needs within the
primary care practice.


Focus on managing a population of patients
versus specialty care


Behavioral Health Consultant


Interventions


Identification of the problem behavior, discuss
impact, decide what to change


Specific and goal directed interventions


Use monitoring forms


Use behavioral health “prescription”


Multiple interventions simultaneously


Behavioral Health
Consultant

Continued


screening/evaluation
of individuals for mental
health and substance abuse disorders


brief interventions for individuals with behavioral
health problems


behavioral supports to assist individuals in
improving health status and managing chronic
illnesses


The behavioral health consultant both meets
regularly with the primary care team to plan care
and discuss cases, and exchanges appropriate
information with team members in an informal
“curbside “ manner as part of the daily routine of
the clinic


Behavioral Health Consultant

Continued


Referral
tracking


Training and technical assistance


Data management and reporting (can be
separated into second part time function)


Scheduling for Primary care health home
Team and enrollees


Chart audits for compliance


Reminding enrollees regarding keeping
appointments, filling prescriptions, etc.


Requesting and sending Medical Records for
care coordination



Care
Coordinator

Payment Method


Providers that meet the Health Home requirements
will receive a Per
-
Member
-
Per
-
Month (PMPM)
payment of $58.47 for performing Health Home
services and activities


Providers will be required to pay a small PMPM
($3.47) to cover administrative costs associated with
data management, training, technical and
administrative support


The current state plan will be amended in future to
add a request for a second payment method so that
providers may receive
incentive payments

based on
shared savings and relating to performance.

Auto Enrollment Process


Participant must meet the following criteria:


MO
HealthNet

eligible


Not be locked into hospice


Meet spend
-
down


Pay any premiums due


Have paid and
final claims (excluding original claims that were
reversed/voided) with paid dates between 8/15/2010 and 8/14/2011
with an approved primary care diagnosis in one of the first five
positions on a
claim.


Have two or more of the approved chronic conditions or one of the
approved chronic conditions and be at risk for a second chronic
condition by being overweight/obese or tobacco use


Have at least $2600 in spend


If seen by more than one eligible health home provider the patient is
attributed to the health home provider seen the most during the
analysis period


Cost
-
Savings Incentive Payment


Cost
-
saving sharing incentives ONLY IF


Entire initiative saves money


Site/organization saves money


Individual performance determines
participation in incentives



Performance Goals and
Measures


Improve primary health care


Improve behavioral health care


Improve patient empowerment and
activation


Improve coordination of care


Improve preventive care


Improve diabetes care


Improve asthma care


Improve cardiovascular care

Missouri Foundation for Health’s
Missouri Medical Home Collaborative


Multi
-
stakeholder
initiative to provide
support and incentives to Missouri primary
care practices to undergo the transformation
process to become Medical Homes.


Participating payers include MO
HealthNet

and large commercial
insurer
(Currently,
Anthem).


Initial year practices will focus on diabetes,
cardiovascular disease, and asthma


Primary
Care practices in the 84 county
MFH Region



Funded
by:


Missouri
Foundation for
Health


Greater Kansas City Health Care Foundation


Missouri Hospital Association


CSI Solutions is the contractor


Serves as the learning collaborative for the following
initiatives:


MO
HealthNet
, Missouri Primary Care Health Home
Initiative (ACA Section 2703)


CMHC Health Home Initiative (ACA Section 2703)


Missouri Foundation for Health, Missouri Medical
Home Collaborative (Multi
-
payer Initiative)


Learning Collaborative


Four Cohorts (Locations)


St. Louis Central


Mid
-
Missouri


Kansas City


St. Louis South


Components of Learning Sessions


Prework

Calls


Face to Face Learning Sessions


Virtual Learning Sessions


Intersession Periods with Monthly Team
Conference Calls

Learning Collaborative
(Continued)

Payers are Driving PCMH
Recognition and Performance


Centers
for Medicare and Medicaid


Health Resources and Services Administration:
Bureau of Primary Health Care (HRSA
-
BPHC)


Insurers
-
Private and Public


Foundations


Payers want value: better outcomes with
cost savings

Joint Principles of the

Patient
-
Centered Medical Home

Developed and Adopted March 2007


Personal
Physician


Physician Directed Medical Practice


Whole Person Orientation


Care is Coordinated and/or Integrated


Quality and Safety


Enhanced Access


Payment Reform


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Benefits of PCMH Process


Provides an excellent review of the
organization’s :


Quality Improvement Programs


Care Coordination
-

Both internal and external


Community Linkages and access to specialty
care


Policies and procedures


Corporate compliance


Data extraction/reporting


Meaningful Use of EMR

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National Committee for Quality
Assurance (NCQA) and the PCMH


NCQA developed a set of standards and a 3
-
tiered recognition process program) to assess
the extent to which health care organizations
are functioning as medical homes


Recognition requires completing an
application and providing adequate
documentation to show evidence that specific
processes and policies are in place


Recognition is offered at three levels:


Level 1


basic


Level 2


intermediate


Level 3


advanced


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Tools and Resources


MO
HealthNet

Division, Primary Care Health Home Information


http://dss.mo.gov/mhd/cs/health
-
homes
/



Missouri Health Home State Plan Amendment Information


http://dmh.mo.gov/about/chiefclinicalofficer/healthcarehome.htm



National Committee for Quality Assurance:

www.ncqa.org/tabid/631/Default.aspx



Commonwealth
Fund: Safety Net Medical Home Initiative


www.qhmedicalhome.org/safety
-
net/change
-
concepts.cfm



Improving Chronic Illness Care:


www.improvingchroniccare.org/index.php?p=Patient
-
Centered_Medical_Home&s=224



The Joint Commission:

http
://
www.jointcommission.org/accreditation/pchi.aspx



Patient
-
Centered Primary Care Collaborative:

www.pcpcc.net/content/patient
-
centered
-
medical
-
home



American College of Physicians:

www.acponline.org/running_practice/pcmh/


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