2 Agenda What is a Primary Care Health/Medical Home? Overview of Section 2703 of the Affordable Care ActOverview of Missouri Primary Care Health Home InitiativeHealth Home ServicesHealth Home Team MembersEnrolling PatientsShared Savings and Performance Goals/MeasuresLearning CollaborativePatient Centered Medical Home Recognition
3 What is a Health/Medical Home? Health/Medical Homes Provide:comprehensive and coordinated care in the context of individual, cultural, and community needsMedical, behavioral, and related social service needs and supports are coordinated and provided by provider and/or arrangedemphasize education, activation, and empowerment through interpersonal interactions and system-level protocolsat the center of the health/medical home are the patient and their relationship with their primary care teamHealth/Medical Homes have their roots in Community Oriented Primary Care, Services for Children with Special Healthcare Needs, and the Care Model
4 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 quartersMissouri 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.Enhanced Federal Match requires 10% State Match to receive 90% Federal Match ($1 of state money leverages $9 of federal money)Missouri will have three types of health homes:Primary Care Health Home for individuals with chronic disease: CMS Approval Effective Date 1/1/12Community Mental Health Center Health Home for individuals with serious and persistent mental illness: CMS approval Effective dateMulti-payer Health Home for the entire population of Anthem covered lives in the 84 county MFH Region
5 Section 2703 of the ACA: Qualifying Conditions Qualifying Patient Conditions:Serious and persistent mental illnessTwo qualifying chronic conditionsOne qualifying chronic condition and at risk for a second qualifying chronic conditionState Defined ConditionsQualifying patient conditions and criteria were outlined in Section 2703 of the ACA.States had the option to propose additional conditions:Missouri received approval for developmental disabilities to be an additional qualifying condition.
6 Missouri Selected Qualifying Conditions Combination of TwoDiabetes (CMS approved to stand alone as one chronic disease and risk for second)Heart Disease, including hypertension, dyslipidemia, and CHFAsthmaBMI above 25 (overweight and obesity)Tobacco UseDevelopmental DisabilitiesSerious and Persistent Mental Illness (Community Mental Health State Plan Amendment)
7 Participating Sites Provider Requirements Medicaid/Uninsured Threshold Using EMR for six monthsPlans to apply for National Committee for Quality Assurance (NCQA) Patient Centered Medical Home Recognition within 18 monthsOrganizations Selected to Participate18 FQHCs operating 67 clinic sites6 Hospitals operating 22 clinic sitesOne Independent Rural Health ClinicProvider requirements were outlined in the application documentNCQA Patient Centered Medical Home Recognition within 18 months of State go-live date of January 1, 2012
8 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 SmithMissouri Hospital Association (MHA)Missouri School Board Association (MSBA)The planning process for Missouri’s Health Home model has included stakeholders and has been a collaborative effort between the agencies and organizations listed
9 Goals of the Primary Care Health Home Initiative Reduce inpatient hospitalization, readmissions and inappropriate Emergency Room visitsImprove coordination and transitions of careImplement 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; andSupport 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.These goals are the overarching goals of the Missouri Primary Care Health Home State Plan Amendment
10 Use of Health Information Technology to Link Services CyberAccessDirect Inform (Patient portal)MO HealthNet (“MHN”) maintains a web-based electronic health record (EHR) accessible to enrolled Medicaid providers, including primary care practices, CMHCs, pharmacies and schools.A module of the CyberAccess allows enrollees to look up their own healthcare utilization and receive the same content in laypersons’ terms. The information facilitates self-management and monitoring necessary for an enrollee to attain the highest levels of health and functioning.
11 Data Management and Analytics Clinical Information via MPCA data warehouseHospital and ER utilization from claimsNotification of Hospital Admit from MHN concurrent authorization systemCare Coordination via CyberAccessMedication Adherence reportsThe Data Management, Analytics, and reporting will be covered in more detail on a series of webinars that will be hosted by MHN.
12 Health Home Services Comprehensive care management Care coordination Health promotionComprehensive transitional care including follow-up from inpatient and other settingsPatient and family supportReferral to community and support servicesSection 2703 of the ACA outlined the health home servicesDefinitions for each Health Home Service is provided in the next set of slides in the presentation
13 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.
14 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 schedulingconducting referrals and follow-up monitoringparticipating in hospital discharge processescommunicating with other providers and clients/family members.
15 Health Home Services: Health Promotion Consists of providing health education specific to an individual’s:chronic conditionsdevelopment of self-management plans with the individualeducation regarding the age appropriate immunizations and screeningsproviding 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.
16 Health Home Services: Comprehensive Transitional Care Comprehensive transitional care including follow-up from inpatient and other settingsMember 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 communityShift the use of reactive care and treatment to proactive health promotion and self management.
17 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 communityFor individuals with Developmental Disabilities the health team will refer to and coordinate with the approved Developmental Disabilities case management entityExamples of Resources and Supports: including transportation to medically necessary services. A primary focus will be increasing health literacy, ability to self manage their care and facilitate participation in the ongoing revision of their care/treatment plan.
18 Health Home Services: Referral to Community and Support Services Assistance to patients including but not limited to:obtaining and maintaining eligibility for healthcaredisability benefitsHousingpersonal need and legal servicesFor individuals with developmental disabilities the health team will refer to and coordinate with the approved DD case management entity for this service.
19 Health Home Team Members Health Home DirectorNurse Care ManagerBehavioral Health ConsultantCare CoordinatorHealth Home Team Member roles were outlined in the State Plan Amendment approved by CMS. Detailed information regarding the roles for each health home team member will be outlined in the next group of slides.
20 Health Home DirectorProvides leadership to the implementation and coordination of Healthcare Home activitiesChampions practice transformation based on Healthcare Home principlesDevelops and maintains working relationships with primary and specialty care providers including inpatient facilitiesMonitors Healthcare Home performance and leads improvement efforts
21 Health Home Director Continued Designs and develops prevention and wellness initiatives Referral trackingTraining and technical assistanceData management and reportingNon-PMPM paid staff training time
22 Nurse Care Manager Develop wellness & prevention initiatives Facilitate health education groupsParticipate in the initial treatment plan development for all of their Primary care health home enrolleesAssist in developing treatment plan health care goals for individuals with co-occurring chronic diseasesConsult with Community Support Staff about identified health conditionsAssist in contacting medical providers & hospitals for admission/discharge
23 Nurse Care Manager Continued Provide training on medical diseases, treatments & medicationsTrack required assessments and screeningsAssist in implementing MHD health technology programs & initiatives (i.e., CyberAccess, metabolic screening)Monitor HIT tools & reports for treatmentMedication alerts & hospital admissions/dischargesMonitor & report performance measures & outcomes
24 Behavioral Health Consultant Integration with Primary CareSupport 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
25 Behavioral Health Consultant Continued InterventionsIdentification of the problem behavior, discuss impact, decide what to changeSpecific and goal directed interventionsUse monitoring formsUse behavioral health “prescription”Multiple interventions simultaneously
26 Behavioral Health Consultant Continued screening/evaluation of individuals for mental health and substance abuse disordersbrief interventions for individuals with behavioral health problemsbehavioral supports to assist individuals in improving health status and managing chronic illnessesThe 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
27 Care Coordinator 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 enrolleesChart audits for complianceReminding enrollees regarding keeping appointments, filling prescriptions, etc.Requesting and sending Medical Records for care coordination
28 Payment MethodProviders that meet the Health Home requirements will receive a Per-Member-Per-Month (PMPM) payment of $58.47 for performing Health Home services and activitiesProviders will be required to pay a small PMPM ($3.47) to cover administrative costs associated with data management, training, technical and administrative supportThe 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.Breakdown of the PMPM is outlined in the Primary Care State Plan Amendment
29 Auto Enrollment Process Participant must meet the following criteria:MO HealthNet eligibleNot be locked into hospiceMeet spend-downPay any premiums dueHave 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 useHave at least $2600 in spendIf seen by more than one eligible health home provider the patient is attributed to the health home provider seen the most during the analysis periodAdditional detail regarding the auto enrollment process used can be found on MO HealthNet Division’s Health Home website:The procedure for adding, discharging, or transferring patients to the health home will be shared on conference calls and webinars hosted by MHD as well as correspondence from MHDQuestions can be addressed to MHD via at:
30 Cost-Savings Incentive Payment Cost-saving sharing incentives ONLY IFEntire initiative saves moneySite/organization saves moneyIndividual performance determines participation in incentivesWhen the state plan amendment is amended in the future, the state will propose that practice sites could be paid for up to 50% of the value of the reduction in total health care per-member-per-month costs for the practice site’s attributed MHN patients, relative to prior year experience. Savings will be distributed on a sliding scale based on performance relative to a set of site-specific preventive and chronic care measures generated and reported by the practice and subject to DSS audit.
31 Performance Goals and Measures Improve primary health careImprove behavioral health careImprove patient empowerment and activationImprove coordination of careImprove preventive careImprove diabetes careImprove asthma careImprove cardiovascular carePerformance goals and measures are outlined in the Primary Care State Plan Amendment
32 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 asthmaPrimary Care practices in the 84 county MFH Region
33 Learning Collaborative Funded by:Missouri Foundation for HealthGreater Kansas City Health Care FoundationMissouri Hospital AssociationCSI Solutions is the contractorServes 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)
34 Learning Collaborative (Continued) Four Cohorts (Locations)St. Louis CentralMid-MissouriKansas CitySt. Louis SouthComponents of Learning SessionsPrework CallsFace to Face Learning SessionsVirtual Learning SessionsIntersession Periods with Monthly Team Conference Calls
35 Payers are Driving PCMH Recognition and Performance Centers for Medicare and MedicaidHealth Resources and Services Administration: Bureau of Primary Health Care (HRSA-BPHC)Insurers-Private and PublicFoundationsPayers want value: better outcomes with cost savings
36 Joint Principles of the Patient-Centered Medical Home Developed and Adopted March 2007Personal PhysicianPhysician Directed Medical PracticeWhole Person OrientationCare is Coordinated and/or IntegratedQuality and SafetyEnhanced AccessPayment ReformDeveloped and Adopted by:American Academy of Family Physicians (AAFP)American Academy of Pediatrics (AAP)American College of Physicians (ACP)American Osteopathic Association (AOA)
37 Benefits of PCMH Process Provides an excellent review of the organization’s :Quality Improvement ProgramsCare Coordination- Both internal and externalCommunity Linkages and access to specialty carePolicies and proceduresCorporate complianceData extraction/reportingMeaningful Use of EMR
38 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 homesRecognition requires completing an application and providing adequate documentation to show evidence that specific processes and policies are in placeRecognition is offered at three levels:Level 1 – basicLevel 2 – intermediateLevel 3 – advancedApplication for NCQA PCMH Recognition is required within 18 months of the go-live of the State Plan Amendment (Application must be submitted by June 2013)
39 This is a high level overview of the content and scoring for the 2011 NCQA PCMH Recognition Standards. The full set of standards and explanation is approximately 40 pages and contains a great deal of detail.
40 NCQA PCMH Recognition Scoring requires a site accomplish the given number of points and Must Pass Elements in order to achieve a given level of recognition
41 Tools and ResourcesMO HealthNet Division, Primary Care Health Home InformationMissouri Health Home State Plan Amendment InformationNational Committee for Quality Assurance:Commonwealth Fund: Safety Net Medical Home InitiativeImproving Chronic Illness Care:The Joint Commission:Patient-Centered Primary Care Collaborative:American College of Physicians:Tools and resources to find additional information on Missouri State Plan Amendments, Patient Centered Medical Home Recognition, and Practice Transformation