1. Vermont Blueprint for Health Integrated Pilot Programs PCPCC Call Lisa Dulsky Watkins, MD Vermont Department of Health January 20, 2009

2. Vision Vermont will have a statewide system of care that improves the lives of individuals with and at risk for chronic conditions

3. Improved Outcomes-Healthier People Productive Interactions Self- Management Support Delivery System Design Decision Support Clinical Information Systems Health System Health Care Organization Community Resources and Policies Public Health Policies, Systems, Environment Supportive Environment Informed, Activated Patient Prepared, Proactive Practice Team Adapted from the chronic care model which is used by permission of “Effective Clinical Practice.” What is the Blueprint?

4. Who are the players? State Government – Executive and Legislative branches – Department of Health Over 100 volunteers serving on committees and workgroups Insurers – publicly and privately funded University of Vermont College of Medicine Vermont Information Technology Leaders Local and national QI organizations – Vermont Program for Quality in Health Care – Institute for Healthcare Improvement – Agency for Healthcare Research and Quality – AcademyHealth/Commonwealth Fund Providers – MD, DO, NP, PA, nursing and office staff Patients and families

5. Bennington Burlington St. Johnsbury Barre Springfield Windsor 2005—Initial two pilot Hospital Service Areas (Diabetes Focus) Healthier Living Workshops Community Physical Activity Grants April 2007 2004—Planning 2003—Launch of the Blueprint 2006—Four new Hospital Service Areas (Diabetes Focus) Blueprint Development 2006—Statutory Endorsement 2007— Medical Home Integrated Pilots in Statute 2009 - Integrated Medical Home Pilots ( all chronic conditions + prevention)

6. Health Care Reform Legislation 2006  Health Care Affordability Acts (Acts 190, 191)  Common Sense Initiatives (Appropriations Bill)  Sorry Works! (Act 142)  Safe Staffing and Quality Patient Care (Act 153) 2007  Corrections and Clarifications to the Health Care Affordability Acts of 2006 (Act 70)  An Act relating to Ensuring Success in Health Care Reform (Act 71) 2008  An Act Relating to Health Care Reform (Act 203)  An Act Relating to Managed Care Organizations and the Blueprint for Health (S.283)

7. Blueprint Integrated Pilot Summary 1. Financial reform - Payment based on NCQA PCMH standards - Shared costs for Community Care Teams - Medicaid & commercial payers - BP subsidizing Medicare 2. Multidisciplinary care support teams (CCT Teams) - Local care support & population management - Prevention specialists 3. Health Information Technology - Web based clinical tracking system (DocSite) - Visit planners & population reports - Electronic prescribing - Updated EMRs to match program goals and clinical measures in DocSite - Health information exchange network 4. Community Activation & Prevention - Prevention specialist as part of CCT - Community profiles & risk assessments - Evidence based interventions 5. Evaluation - NCQA PCMH score (process quality) - Clinical process measures - Health status measures - Multi payer claims data base

8. Primary Care PCMH -Docs -NPs -PAs -MAs -Staff Community Care Team (CCT) e.g. NP, RN, MSW, Dietician, Behavior Specialist, Community Health Worker, VDH Public Health Specialist CCT Support  Panel Management  Coaching  Patient / family contact  Assessment  Reinforce treatment plan  Education  Reminders  Self management Social / Economic Support  Liaison to other programs  Enrollment assistance Prevention & Self Management  Referral to community programs  Coordinate community programs Vermont Health Information Platform (VITL) Referral & care supportEducation & Improvement PCMH  Payment reform  Comprehensive guideline based care  Health maintenance & prevention  Chronic conditions  Panel management  Coaching  Reminders  Goal setting  Health IT – planned visits  Health IT – population management  Health IT – eRx  Paper based or EMR practices Referrals, Communication & QI Planning Blueprint Integrated Pilot Model

9. Primary Care PCMH -Docs -NPs -Staff Community Care Team (CCT) e.g. NP, RN, MSW, Dietician, Behavior Specialist, Community Health Worker, VDH Public Health Specialist Referrals & Communication Vermont Health Information Platform (VITL) Hospital -Educators -Transitional care -Ambulatory center (wellness programs) Referral & care supportEducation & Quality Improvement Policies and Systems Local, state, and federal policies and laws, economic and cultural influences, media Community Physical, social and cultural environment Organizations Schools, worksites, faith-based organizations, etc Relationships Family, peers, social networks, associations Individual Knowledge, attitudes, beliefs Adapted from: McElroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Education Quarterly 15:351-377, 1988. Model for Health & Prevention Prevention Healthcare

10. PHASE 4 - Implementation  Timeline depends on scope and resources of planned intervention PHASE 3 - Community Planning  Planning with key leaders  Planning with stakeholders  Iterative interactive process  Consensus building PHASE 2b - Community Assessment  Quantitative Context - state level 10 year trend analysis of risk factors associated with morbidity & healthcare costs  Focus groups  Formal key leader interviews  Continue until no new themes  Test themes in new interviews  Test findings in community forums Phase 5 – Evaluation 2 - 4 months 4 - 6 months 3 - 5 months PHASE 2a - Community Profile  Community description  Community inventory  Quantitative Context - Descriptive health statistics on the rates of risk factors in each community (5 year aggregate data) PHASE I - Develop capacity  Facilitate systems approach  Train Prevention Specialist  Prevention Model and Framework  Data collection techniques  Environment and policy change Community Assessment & Planning Timeline October 2008

11. Pilot Site# Provider# Patients CommunityPractice St. Johnsbury Caledonia Internal Medicine32,011 Concord Health Center22,183 Corner Medical614,500 Danville Health Center23,088 St. Johnsbury Family Health Center22,822 Total St Johnsbury1524,604 Burlington Fletcher Allen Affiliated Aesculapius Medical Center915,774 Private Practice – Non Affiliated11,800 Total Burlington1017,574 Bennington Planning stages Total (first 2 sites only)2542,178 Pilot # 1 Pilot # 2 Pilot # 3

12. Standards

13. NCQA PCMH Points Average PPPM Payment 00.00 5 100.00 150.00 200.00 251.20 301.28 351.36 401.44 451.52 501.60 551.68 601.76 651.84 701.92 752.00 802.07 852.15 902.23 952.31 1002.39 Provider Payment Table ($PPPM for each provider) Requires 5 of 10 must pass elements Requires 10 of 10 must pass elements

14. Practice Evaluation & Quality Improvement QI (current)  Clinical Microsystems Training  VHR  DocSite Evaluation (current)  Chart Review  ACIC (readiness)  Focus Groups Evaluation (integrated pilot)  Review against NCQA standards  Onsite Review  Analysis of DocSite data  Report based on NCQA scoring Payment Evaluation (Integrated pilot)  Use reports  Guide Microsystems Training  Guide QA / QI planning  Focused on NCQA PCMH Stds Ongoing QA / QI

15. Practice Evaluation & Payment Model Evaluator’s Report NCQA Review Start Payment  Retroactive to index date  $ PPPM calculation -initial NCQA score -active patient panel  Active patient panel (attribution) -visit <12 months to practice PCP -eligibility check  Paid quarterly or Monthly (payer defined) 30 days 30 days Evaluator’s Report NCQA Review 6 months Adjust Payment  Retroactive to 6 month interval date  $ PPPM calculation -refreshed NCQA score -refreshed active patient panel  Active patient panel (attribution) -visit <12 months to practice PCP -eligibility check  Paid quarterly or Monthly (payer defined)

16. 07 / 0810 / 0807 / 0910 / 0907 / 2010 Pilot # 1 Pilot # 2 Pilot # 3 01 / 0901 / 2010 CategoryData SourceEvaluation Outline PCMH healthcare process quality  NCQA PCMH Score  VCHIP practice review  NCQA recognition  Integrated Pilot practices  Change from baseline Clinical process measures  DocSite data base  VCHIP Chart Review  Integrated Pilot practices  Practices delivering routine care  Change from baseline & comparison Health status measures  DocSite data base  VCHIP Chart Review  Integrated Pilot practices  Practices delivering routine care  Change from baseline & comparison Episodic vs. Preventive healthcare – claims based measures  VHCURES – multipayer database  Pilot practices vs non-pilot practices  Change from baseline & comparison Healthcare Costs – claims based measures  VHCURES – multipayer database  Financial Impact Model  Pilot practices vs non-pilot practices  Impact on healthcare costs in Vermont  Change from baseline & comparison Population Health IndicatorsVDH Health Surveillance databasesCommunity risk profiles State level assessments Blueprint Pilot Timeline & Evaluation

17. Healthcare Patterns & Resource Utilization Healthcare Expenditures & Financial Impact Health Status Measures Clinical Process Measures Population Indicators & Risk Factors Healthcare Quality Measures & Standards Population Management Quality Improvement Program Evaluation & Sustainability Community Prevention Planning Individual Patient Care & Support Services Provider Payment for Quality Data Processing & Storage EMRs used for Individual Patient Care DocSite used for Individual Patient Care DocSite Database EMR Databases DocSite Reporting Tool VCHIP Chart Review & NCQA Scoring Medical Claims from Commercial Insurers & Medicaid Public Health Surveys & Data Collection Data Source Data transmission & transformation VITL / GE Data Analysis Data Reports & Uses EMR Reporting Tool or Analyst Public Health Registries & Databases VDH Health Surveillance Analytic Database BISCHA Multipayer Database VCHIP Databases VCHIP Analysis & Report Generation BISCHA Reports VDH Health Surveillance Analyst Contracted Analysis Services Blueprint Integrated Pilots Evidence Based Quality Improvement

18. Population Management Quality Improvement Individual Patient Care & Support Services Data Processing & Storage EMRs used for Individual Patient Care DocSite used for Individual Patient Care DocSite used for Individual Patient Care DocSite Database EMR Databases DocSite Reporting Tool Program Evaluation & Sustainability VCHIP Chart Review & NCQA Scoring VCHIP Chart Review & NCQA Scoring Medical Claims from Commercial Insurers & Medicaid Public Health Surveys & Data Collection Data Source Data transmission & transformation VITL / GE Data Analysis Data Reports & Uses EMR Reporting Tool or Analyst Public Health Registries & Databases Public Health Registries & Databases VDH Health Surveillance Analytic Database BISCHA Multipayer Database BISCHA Multipayer Database VCHIP Databases VCHIP Databases VCHIP Analysis & Report Generation VCHIP Analysis & Report Generation BISCHA Reports BISCHA Reports Healthcare Patterns & Resource Utilization Healthcare Patterns & Resource Utilization Healthcare Expenditures & Financial Impact VDH Health Surveillance Analyst Health Status Measures Clinical Process Measures Population Indicators & Risk Factors Population Indicators & Risk Factors Contracted Analysis Services Contracted Analysis Services Community Prevention Planning Healthcare Quality Measures & Standards Provider Payment for Quality Blueprint Integrated Pilots Evidence Based Quality Improvement

19. Program Evaluation & Sustainability Contracted Analysis Services Quality Improvement Data Processing & Storage EMRs used for Individual Patient Care EMRs used for Individual Patient Care DocSite used for Individual Patient Care DocSite used for Individual Patient Care DocSite Database EMR Databases DocSite Reporting Tool DocSite Reporting Tool Population Management VCHIP Chart Review & NCQA Scoring VCHIP Chart Review & NCQA Scoring Medical Claims from Commercial Insurers & Medicaid Public Health Surveys & Data Collection Data Source Data transmission & transformation VITL / GE Data transmission & transformation VITL / GE Data Analysis Data Reports & Uses EMR Reporting Tool or Analyst EMR Reporting Tool or Analyst Public Health Registries & Databases Public Health Registries & Databases VDH Health Surveillance Analytic Database BISCHA Multipayer Database VCHIP Databases VCHIP Databases VCHIP Analysis & Report Generation VCHIP Analysis & Report Generation BISCHA Reports Healthcare Patterns & Resource Utilization Healthcare Expenditures & Financial Impact VDH Health Surveillance Analyst Health Status Measures Health Status Measures Clinical Process Measures Clinical Process Measures Population Indicators & Risk Factors Population Indicators & Risk Factors Community Prevention Planning Individual Patient Care & Support Services Healthcare Quality Measures & Standards Provider Payment for Quality Blueprint Integrated Pilots Evidence Based Quality Improvement

20. Blueprint Integrated Pilots Financial Impact 20092010201120122013 Percentage of Vermont population participating6.7%9.8%13.0%20.0%40.0% Participating population42,17961,88082,332127,045254,852 # Community Care Teams234613

21. Blueprint Integrated Pilots Plan for statewide expansion BP Integrated Pilot Experience Continuous Quality Improvement Use experience from Integrated Pilot program to refine & target BP Community grants. Build capacity & readiness for more complete healthcare reform. BP Community Experience Continuous Quality Improvement Transform from BP Community to Integrated Pilot Community, and/or, expand existing Integrated Pilot to include more Blueprint practices in a community Shift BP Grant to new community or expand across a community

22. Build a model for effective and sustainable healthcare reform  Multi payer financial reform (from volume to quality)  Healthcare environment (PCMH, CCTs, PH specialists, Health IT)  Healthcare focus (from sick care to wellness / prevention)  Healthcare culture (evidence based QI) Blueprint Integrated Pilots Building a Scalable Model

23. Contact Information Lisa Dulsky Watkins, MD Assistant Director Vermont Blueprint for Health Vermont Department of Health Burlington, VT lwatkin@vdh.state.vt.us (802) 652-2095