Maine PCMH Pilot & Community Care Teams: A Targeted Strategy to Improve Care & Control Costs for High-Needs Patients Lisa M. Letourneau MD, MPH MeHAF Legislative Breakfast March 2013

The Medical Home: A Start for Change! Providers transform practice, create value with viable & sustainable payment for desired services = Practice Transformation Employers & payers pay for desired services because primary care demonstrates value & saves money = Payment Reform ANDAND 2

Maine PCMH Pilot Leadership Maine Quality Counts DHA’s Maine Quality Forum Maine Health Management Coalition MaineCare (Medicaid) 3

Maine PCMH Pilot Expansion 4

Maine PCMH Pilot Practice “Core Expectations” 1.Demonstrated physician leadership 2.Team-based approach 3.Population risk-stratification and management 4.Practice-integrated care management 5.Same-day access 6.Behavioral-physical health integration 7.Inclusion of patients & families 8.Connection to community / local HMP 9.Commitment to waste reduction 10.Patient-centered HIT 5

Community Care Teams Multi-disciplinary, community-based, practice- integrated care teams Build on successful models (NC, VT, NJ) Support patients & practices in Pilot sites, help most high-needs patients overcome barriers – esp. social needs - to care, improve outcomes Key element of cost-reduction strategy, targeting high-needs, high-cost patients to reduce avoidable costs (ED use, admits) 6

PCMH Practice High-need Individual Maine PCMH Pilot Community Care Teams Transportation Workplace Environment Food Systems Shopping Income Heat Faith Community Literacy Coaching Physical Therapy Hospital Services Specialists Outpatient Services Med Mgt Housing Care Mgt Behav. Health & Sub Abuse Family Schools

Maine Medicaid (MaineCare) Health Homes Initiative Stage A: Health Home = PCMH primary care practice + CCT Payment weighted toward medical home Eligible Members: Two or more chronic conditions One chronic condition and at risk for another Stage B: Health Home = CCT with behavioral health expertise + PCMH primary care practice Payment weighted toward CCT Eligible Members: Adults with Serious Mental Illness Children with Serious Emotional Disturbance 8

PCMH Practice Health Homes Beneficiary Coaching Med Mgt Care Mgt Behav. Health & Sub Abuse MaineCare Health Homes Proposal Stage A: Help Individuals with Chronic Conditions 9

Health Homes Beneficiary PCMH Practice Coaching Med Mgt Care Mgt Behav Health & Sub Abuse MaineCare Health Homes Proposal Stage B: Help Individuals with Severe Mental Illness and/or Children with Serious Emotional Disturbance 10

Unique Features of Maine Approach Defining “Health Home” as PCMH + CCT Adding CCT services to specifically support high-needs, high-cost members (recognizing these mbrs can often outstrip capacity of most primary care practices – even PCMHs!) Recognizes differences between “routine”/chronic disease care management & CCT multi-disciplinary team approach for most high-needs mbrs 11

Financing CCTs: Maine Approach Linked CCT model, payment to multi-payer PCMH model Leveraged public, private payers agreement to provide pmpm payment Participation in CMS MAPCP demo brought in Medicare as payer Alignment of ACA Health Homes with multi- payer Pilot provided opportunity to leverage federal 90:10 match for CCT services 12

Maine’s Medical Home Movement ~ 540 Maine Primary Care Practice Sites 25 Maine PCMH Pilot Practices 50 Pilot Phase 2 Practices 14 FQHCs CMS APC Demo 100+ NCQA PCMH Recognized Practices 70 MaineCare HH-only Practices Payers: Medicare Medicaid (HH) Commercial plans (Anthem, Aetna, HPHC) Self-funded employers Payer: Medicare Payer: Medicaid

14 : Who We Are Independent, multi-stakeholder alliance in Maine working to transform health and healthcare by leading, collaborating, and aligning improvement efforts Only organization working to improve quality of care for all Maine people Members include consumers, doctors, nurses, hospitals, health systems, payers, employers, government, policy makers, and others working to improve health and healthcare

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Contact Info / Questions  Lisa Letourneau MD, MPH  Maine Quality Counts  Maine PCMH Pilot (See “Programs”  PCMH) 16