Community Health Team Pilot Program within CSI-RI September 13, 2013 Debra Hurwitz, MBA, BSN, RN CSI Co-Director 1

Agenda Background of CHTs and summary of other states’ models Existing Resources in RI Committee Membership Committee Charter/Plan Deliverables and Time Frame Next Steps 2

CSI-RI Strategic Plan Plan: As part of the 2013 Strategic Plan, CSI will develop and pilot the implementation of 2 CHT. Purpose: To help support small practice in becoming PCMHs. Budget: $75,000 per site to launch pilot by April 1, – Contingent on approval of the plan by Budget Committee – Additional budget ask for next year 3

What is a Community Health Team? Definition: Community Health Teams (CHT) work with primary care practices in a given region or network to improve care for patients with chronic conditions. The CHT often provides direct care: – Care management – Behavioral health care, – Assists with transitions of care – Links patients to community resources. Based in a pre-existing health care entity (such as a hospital, primary care organization or an FQHC) or a newly-formed non-profit and provide services to a number of associated primary care practices. 4

Vermont CHT Model Overview Each Hospital Service Area (HSA) has a project manager who oversees two HSA-wide workgroups: the Health Information Technology Workgroup and the Integrated Health Services Workgroup (IHS). IHS oversees CHT implementation: reorganization of existing services, creating new services, CHT composition and administrative entity CHT employed by administrative entity (CMS eligible- hospital or health center) 5

Vermont CHT Services 6

Vermont CHT Measures 7

Vermont CHT Funding Direct predefined payment from participating payers: commercial, Medicare and Medicaid Funding required by 2007 legislation There is an agreed upon shared cost structure paid to administrative entity Rates: $350,000 per year for salaries and benefits for each community health team CHT use is not based on insurance status and does not require co-pays or prior authorization 8

Oregon CHT Overview Coordinated Care Organizations (CCOs) are regional provider networks made up of a variety of health care providers who work together to deliver coordinated acute and preventive care to the State’s Medicaid beneficiaries. Preexisting health care entities apply to serve as a regional CCO. Each CCO (currently 15 in operation) develops a transformation plan specific to the needs of the community it serves. These plans demonstrate how the organization will work to improve health outcomes, increase member satisfaction and reduce overall costs. 9

Oregon CHT Services 10 Each CCO must have: Pcp/nurses Mental health providers Community members Consumer advisory council (representative sits on the CCO board

Oregon CHT Measures 17 CCO incentive measures 11 Access to Care: Getting Care Quickly (CAHPS)Patient-Centered Primary Care Home Enrollment Adolescent well-care visits (NCQA)Prenatal and postpartum care: timeliness of prenatal care (NQF 1517) Alcohol and drug misuse: screening, brief intervention and referral for treatment (SBIRT) Satisfaction with Care: Health Plan Information and Customer Service (CAHPS) Ambulatory care: outpatient and emergency department utilization EHR adoption Colorectal cancer screening (HEDIS)Elective Delivery Developmental screening in the first 36 months of life (NQF-1448) Screening for clinical depression and follow-up plan Follow-up after hospitalization for mental illness (NQF 0576) Controlling high blood pressure Follow-up care for children prescribed ADHD medications (NQF 0108) Diabetes: HbA1c poor control Mental and Physical Health Assessments within 60 days for Children in DHS Custody

Oregon CHT Funding CCOs operate on an accountable global budget from the state Participants in CCOs have one single health plan which integrates physical, dental and mental health care SIM grant of $45 million 12

Environmental Scan: Funding Most states fund CHTs under the authorization of – 1915 (b) Medicaid Managed Care Waivers – 1115 research and demonstration waivers – PPACA 2703 health homes state plan amendments 13

Environmental Scan: Funding Vermont-CHT receives direct pre-defined payment from participating payers Alabama, Maine, Montana, North Carolina, South Carolina, Oklahoma-CHT receives direct PMPM from participating payers New York- Primary care practices receive direct PMPM from payers and “pass-on” portion to their associated CHT Minnesota- CHT funded through state grant 14

References The Association of State and Territorial Health Officials. Community health teams issue report (Job Code 16015). Retrieved from website: Buxbaum, Jason. (2012, April). Community-based support teams: The national landscape. Building medical home neighborhoods through community-based teams: lessons from three states with emerging programs. Retrieved from Craig Jones, M.D. (Chair), (9/21/12). Webcast: Vermont blueprint for health: working together for better care. Department of Vermont Health Access, (2010). Vermont blueprint for health implementation manual. Retrieved from website: Department of Vermont Health Access, (2012). Vermont blueprint for health 2011 annual report. Retrieved from website: U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2012). Policy innovation profile: Statewide program supports medical homes through multidisciplinary teams, easy access to information, and incentives, leading to lower costs and better care. Retrieved from website: Lisa Watkins, MD, Associate Director, Vermont Blueprint for Health, L. W. Maine Quality Counts PCMH Pilot, (2011). Community health teams and the medical home. Retrieved from website: and-resources/doc_view/212-community-health-teams-a-new-tool-for-improving-care-and-outcomes.htmlhttp:// and-resources/doc_view/212-community-health-teams-a-new-tool-for-improving-care-and-outcomes.html 15