1. Missouri Primary Care Health Home Initiative

2. 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

3. What is a Health/Medical Home?
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
Health/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 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.
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 1/1/12
Community Mental Health Center Health Home for individuals with serious and persistent mental illness: CMS approval Effective date
Multi-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 illness
Two qualifying chronic conditions
One qualifying chronic condition and at risk for a second qualifying chronic condition
State Defined Conditions
Qualifying 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 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)

7. 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
Provider requirements were outlined in the application document
NCQA 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 Smith
Missouri 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 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.
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
CyberAccess
Direct 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 warehouse
Hospital and ER utilization from claims
Notification of Hospital Admit from MHN concurrent authorization system
Care Coordination via CyberAccess
Medication Adherence reports
The 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 promotion
Comprehensive transitional care including follow-up from inpatient and other settings
Patient and family support
Referral to community and support services
Section 2703 of the ACA outlined the health home services
Definitions 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 scheduling
conducting referrals and follow-up monitoring
participating in hospital discharge processes
communicating with other providers and clients/family members.

15. 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.

16. 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.

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

19. Health Home Team Members
Health Home Director
Nurse Care Manager
Behavioral Health Consultant
Care Coordinator
Health 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 Director
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

21. Health Home Director Continued
Designs and develops prevention and wellness initiatives Referral tracking
Training and technical assistance
Data management and reporting
Non-PMPM paid staff training time

22. Nurse Care Manager 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

23. Nurse Care Manager Continued
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

24. Behavioral Health Consultant
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

25. Behavioral Health Consultant Continued
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

26. 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

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 enrollees
Chart audits for compliance
Reminding enrollees regarding keeping appointments, filling prescriptions, etc.
Requesting and sending Medical Records for care coordination

28. 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.
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 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
Additional 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 MHD
Questions can be addressed to MHD via at:

30. Cost-Savings Incentive Payment
Cost-saving sharing incentives ONLY IF
Entire initiative saves money
Site/organization saves money
Individual performance determines participation in incentives
When 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 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
Performance 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 asthma
Primary Care practices in the 84 county MFH Region

33. Learning Collaborative
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)

34. Learning Collaborative (Continued)
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

35. 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

36. 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
Developed 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 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

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 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
Application 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 Resources
MO HealthNet Division, Primary Care Health Home Information
Missouri Health Home State Plan Amendment Information
National Committee for Quality Assurance:
Commonwealth Fund: Safety Net Medical Home Initiative
Improving 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