2. C LINICAL T ECHNICAL B USINESS Overview of the Patient Protection and Affordable Care Act (ACA) ACA Impact on SBHCs Emerging Health Care Delivery Models Accountable Care Organizations (ACO) Patient-Centered Medical Home (PCMH) Opportunities for SBHCs to become involved in the Healthcare Reform movement Strategies to assist SBHCs in quality improvement efforts Continuous Improvement is a Quality Movement

3. C LINICAL T ECHNICAL B USINESS On March 23, 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act (ACA), into law The ACA includes provisions to expand coverage, control health care costs, and improve the health care delivery system Continuous Improvement is a Quality Movement

4. C LINICAL T ECHNICAL B USINESS Create state-based American Health Benefit Exchanges through which individuals can purchase coverage Premium and cost sharing credits available to individuals/families with income between 133-400% of the federal poverty level (the poverty level is $18,310 for a family of three in 2009) Create separate Exchanges through which small businesses can purchase coverage Require employers to pay penalties for employees who receive tax credits for health insurance through an Exchange, with exceptions for small employers Impose new regulations on health plans in the Exchanges and in the individual and small group markets Expand Medicaid to 133% of the federal poverty level Continuous Improvement is a Quality Movement

5. C LINICAL T ECHNICAL B USINESS Individual Mandate Requirement to have coverage Employer Requirements Requirement to offer coverage Other Requirements Expansion of Public Programs Treatment of Medicaid Treatment of CHIP Continuous Improvement is a Quality Movement

6. C LINICAL T ECHNICAL B USINESS Premium and Cost-Sharing Subsidies to Individuals Eligibility Premium credits Cost-sharing subsidies Verification Subsidies and abortion coverage Continuous Improvement is a Quality Movement

7. C LINICAL T ECHNICAL B USINESS Premium Subsidies to Employers Small business tax credits Reinsurance program Tax Changes Related to Health Insurance or Financing Health Reform Tax changes related to health insurance Tax changes related to financing health reform Benefit Design Essential benefits package Abortion coverage Continuous Improvement is a Quality Movement

8. C LINICAL T ECHNICAL B USINESS Health Insurance Exchanges Creation and structure of health insurance exchanges Eligibility to purchase in the exchanges Public plan option Consumer Operated and Oriented Plan (CO-OP) Benefit tiers Insurance market and rating rules Qualifications of participating health plans Requirements of the exchanges Basic health plan Abortion coverage Effective dates Continuous Improvement is a Quality Movement

9. C LINICAL T ECHNICAL B USINESS Changes to Private insurance Temporary high-risk pool Medical loss ratio and premium rate reviews Administrative simplification Dependent coverage Insurance market rules Consumer protections Health care choice compacts and national plans Health insurance administration Continuous Improvement is a Quality Movement

10. C LINICAL T ECHNICAL B USINESS State Role Regulator mandates Cost Containment Administrative simplification MedicareMedicaid Prescription drugs Waste, fraud, and abuse Continuous Improvement is a Quality Movement

11. C LINICAL T ECHNICAL B USINESS Improving Quality/Health System Performance Comparative effectiveness research Medical malpractice Medicare Dual eligible Medicaid Primary care National quality strategy Financial disclosure Disparities Continuous Improvement is a Quality Movement

12. C LINICAL T ECHNICAL B USINESS Prevention/Wellness National strategy Coverage of preventive services Wellness programs Nutritional information Long-Term Care CLASS Act Medicaid Skilled nursing facility requirements Continuous Improvement is a Quality Movement

13. C LINICAL T ECHNICAL B USINESS Other Investments MedicareWorkforce Community health centers & school-based health centers Trauma care Public health and disaster preparedness Requirements for non-profit hospitals American Indians Financing Coverage and financing Continuous Improvement is a Quality Movement

14. C LINICAL T ECHNICAL B USINESS The ACA requires HHS to establish new programs to support School-Based Health Centers (Title IV, Section 4101(a)) Authorizes the Health Resources and Services Administration (HRSA) to administer the School-Based Health Centers Capital (SBHCC) Program Continuous Improvement is a Quality Movement

15. C LINICAL T ECHNICAL B USINESS Grants are intended to address capital funding that is needed to improve delivery and support expansion of services at SBHCs Applicants must demonstrate how their proposal will lead to improvements in access to health services for children at a SBHC Continuous Improvement is a Quality Movement

16. C LINICAL T ECHNICAL B USINESS A cap of $500,000 has been established as the maximum amount of Federal funding that can be requested in a SBHCC application An eligible applicant may submit one application proposing a maximum of 10 projects This may include any combination of site-specific, stand- alone facility projects, and one project to purchase moveable equipment, for example HRSA received approximately $100 million to fund grants to an estimated 200 SBHCC grants in FY 2011 For more information visit: http://www.hrsa.gov/grants/apply/assistance/sbhcc/ Continuous Improvement is a Quality Movement

17. C LINICAL T ECHNICAL B USINESS HRSA issued a Funding Opportunity Announcement (FOA) in October 2010 In June 2011, HRSA awarded 278 grants under the SBHCC Program FOA totaling $95M $934,435 was awarded to 4 Maryland SBHCs May 9, 2012, HHS announced $75M available through the SBHCC program for the renovation and construction of SBHCs Continuous Improvement is a Quality Movement

18. C LINICAL T ECHNICAL B USINESS Accountable Care Organizations (ACOs) Patient-Centered Medical Homes (PCMHs) Continuous Improvement is a Quality Movement

19. C LINICAL T ECHNICAL B USINESS A group of providers that come together for the purpose of rendering coordinated, high quality care Providers includes hospitals, primary care, specialists, and other health care providers Establish patient population management and innovative care delivery model Model based on shared accountability and funded through shared savings arrangements Continuous Improvement is a Quality Movement

20. C LINICAL T ECHNICAL B USINESS ACO mentioned in all draft reform bills Included in Section 3022 of the ACA, entitled Shared Savings Programs Authorized CMS to create an ACO program by no later than January 1, 2012 Continuous Improvement is a Quality Movement

21. C LINICAL T ECHNICAL B USINESS CMS has launched a couple of programs to incentivize providers to link together and exchange data in order to lower costs and share savings Medicare Shared Savings Program A program that helps a Medicare fee-for-service program providers become an ACO Advance Payment Initiative A supplementary incentive program for selected participants in the Shared Savings Program Pioneer ACO Model A program designed for early adopters of coordinated care (no longer accepting applications) For more information visit: http://innovations.cms.gov/initiatives/ACO/index.html Continuous Improvement is a Quality Movement

22. C LINICAL T ECHNICAL B USINESS National Committee for Quality Assurance (NCQA) Program launched in November 2011 Six organizations had applied for ACO accreditation in January 2012 Continuous Improvement is a Quality Movement

23. C LINICAL T ECHNICAL B USINESS ACO Structure and Operations Access to Needed Providers Patient-Centered Primary Care Care Management Care Coordination and Transitions Patient Rights and Responsibilities Performance Reporting and Quality Measures Continuous Improvement is a Quality Movement

24. C LINICAL T ECHNICAL B USINESS 1967: The American Academy of Pediatricians (AAP) introduced the term “medical home” and it was AAP policy within a decade 1978: The World Health Organization (WHO) outlined some of the basic tenets of the medical home and the importance of primary care 1990’s: Medical Home concept embraced by Institute of Medicine (IOM) 2002: Study by Family Medicine resulting in The Future of Family Medicine: A Collaborative Project of the Family Medicine Community 2004: American Academy of Family Physicians (AAFP) PCMH Demonstration 2006: Patient-Centered Primary Care Collaborative (PCPCC) was established 2008: First release of NCQA Recognition standards Continuous Improvement is a Quality Movement

25. C LINICAL T ECHNICAL B USINESS Whole person orientation Safety and quality Care coordination and integration Personal Provider Enhanced Access Continuity of Care Capacity and Accountability For more information visit: http://www.pcpcc.net/ Continuous Improvement is a Quality Movement

26. C LINICAL T ECHNICAL B USINESS Well-organized and on-time visits Enhanced access with a self-selected provider for continuity (same day appointments, 24/7 clinical support, alternatives to the 1:1 visit) Proactive care management (evidence based clinical care, panel management, reminder systems, registries) Care coordination across settings (assistance with referrals, tracking for tests and referrals, care during transitions) Continuous Improvement is a Quality Movement

27. C LINICAL T ECHNICAL B USINESS Patient engagement, and participation in care decisions (provider-patient relationship, patient-centered, and consumer driven) Connections to community resources to extend support for self-care management Health outcomes focused and plan for continuous improvement Data driven use of health IT as a tool to support the advancement of primary care Continuous Improvement is a Quality Movement

28. C LINICAL T ECHNICAL B USINESS Well-trained workforce organized as a multi- disciplinary care teams Mutual accountability among the team and between team and patients System designed to support care management and coordination through enhanced access, continuity, and information availability Cross boundary cooperation and partnership among all provider types Technology infrastructure for information management and exchange Payment reform to support the work Continuous Improvement is a Quality Movement

29. C LINICAL T ECHNICAL B USINESS On April 13, 2010, Governor O’Malley signed House Bill 929: Patient Centered Medical Home Program into law Statute authorizes the Maryland Health Care Commission (MHCC) to establish a multi-payer PCMH program MHCC is also permitted to authorize a single carrier PCMH program Effective from July 1, 2011 through December 31, 2015 Continuous Improvement is a Quality Movement

30. C LINICAL T ECHNICAL B USINESS Large payersLarge payers PMPMPMPM 3 year Pilot3 year Pilot 53 practices53 practices Quality MeasuresQuality Measures NCQA Recognition requiredNCQA Recognition required Maryland’s Multi- Payer PCMH Program (MMPP) Single PayerSingle Payer Multiple IncentivesMultiple Incentives Live ProgramLive Program Over 3K PCPsOver 3K PCPs Pt Care Account/Quality MeasuresPt Care Account/Quality Measures NCQA Recognition Not RequiredNCQA Recognition Not Required CareFirst Primary Care Medical Home Continuous Improvement is a Quality Movement

31. C LINICAL T ECHNICAL B USINESS National Committee for Quality Assurance (NCQA) The Joint Commission (TJC) URAC (formerly the Utilization Review Accreditation Commission) Accreditation Association for Ambulatory Health Care (AAAHC) Continuous Improvement is a Quality Movement

32. C LINICAL T ECHNICAL B USINESS Program DetailsNCQATJCURAC Program Name Patient-Centered Medical Home (PCMH) Primary Care Medical Home (PCMH) Patient Centered Health Care Home (PCHCH) Award LabelRecognitionCertificationCertificate of Achievement Accreditation RequiredNoYesNo Level of AssessmentPractice SiteOrganizationPractice Site Levels of AchievementYes, Levels 1, 2, 3Pass/FailPass (65%)/Fail Submit documentationYesNoYes On-site survey requiredNoYes On-site survey administered by: N/ATJC Surveyor Independent Certified URAC PCHCH Auditor # of Categories6 (Standards)5 (Op. Characteristics)7 (Modules) # of Standards28 (Elements)12 (Focus Areas)28 (Standards) # of Requirements152 (Factors)47 (Requirements)162 (Elements) Must pass standards6 (Elements)All7 (Standards) Length of award3 years 2 years Scoring Level 1: 35-59; Level 2: 60-84; Level 3: 85-100 Including the 6 Must-Pass Elements with at least 50% for each and identified Critical Factors In addition to achieving accreditation, the practice must meet the additional requirements consisting of five operational characteristics and 12 focus areas. Overall score of 65%. The 7 mandatory standards that must be at least partially implemented + additional selected essential standards Cost Application fee of $500 per clinician, plus $80 for the survey tool PCMH certification included w/accreditation. Accreditation fees includes a fee for the initial survey and an annual fee. Fees based upon annual visits. Range for initial survey: $3,445 for 120,000 Range for annual fee: $1,950 for 120,000 Cost range for additional sites: $1,190 for 1-2 to $5,905 for 9-10. Fees are per clinician: 1-3 = $720 (additional standards are $1,155 each); 4-7 = $1,440 (additional standards $1,875 each); 8-20 = $2,400 (additional standards $2,835). The PCHCH Toolkit is available for $59. Onsite survey costs ~$1,500/day plus travel & lodging. Continuous Improvement is a Quality Movement

33. C LINICAL T ECHNICAL B USINESS Continuous Improvement is a Quality Movement Points Standard and ElementNo. FactorsCritical FactorsMeaningful UseMust Pass (50% score) 201 Enhance Access and Continuity343 4A Access During Office Hours4Factor 1X 4B After-Hours Access5Factor 3 2C Electronic Access 6-1 C, 2 M, 3 C 2D Continuity3- 2E Medical Home Responsibilities4- 2F Culturally and Linguistically Appropriate Services (CLAS)4- 4G The Practice Team8Factor 2 162 Identify and Manage Patient Populations340 3A Patient Information 12-1, 2, 3, 4, & 5 C 4B Clinical Data9-1-9 C 4C Comprehensive Health Assessment9- 5D Use Data for Population Management4-1 & 2 MX 173 Plan and Manage Care243 4A Implement Evidence-Based Guidelines3Factor 31 C 3B Identify High-Risk Patients2- 4C Care Management7-X 3D Medication Management6Factor 11 M 3E Use Electronic Prescribing6Factor 21-3 C and 6 M 94 Provide Self-Care Support and Community Resources101 6A Support Self-Care Process6Factor 32 MX 3B Provide Referrals to Community Resources4- 185 Track and Coordinate Care252 6A Test Tracking and Follow-Up10Factors 1 and 29 M 6B Referral Tracking and Follow-Up7-6 C and 7 MX 6C Coordinate with Facilities/Care Transitions8-8 M 206 Measure and Improve Performance220 4A Measure Performance4- 4B Measure Patient/Family Experience4- 4C Implement Continuous Quality Improvement4-X 3D Demonstrate Continuous Quality Improvement4- 3E Report Performance 3- 2F Report Data Externally4-1 C; 3 & 4 M 0G Use Certified EHR Technology2-1 & 2 C 100 Points 28 Elements152 Factors9 Critical Factors15 Core 10 Menu6 MP = 29 pts

34. C LINICAL T ECHNICAL B USINESS Stay current on healthcare activities Take advantage of funding opportunities Tap into community resources Collaborate and coordinate among SBHCs Adopt and utilize health IT Continuous Improvement is a Quality Movement

35. C LINICAL T ECHNICAL B USINESS Identify a quality improvement champion Establish a healthcare transformation team Engage a subject matter expert to facilitate transformation Conduct comprehensive clinical, technical, and business assessments Identify and engage Stakeholders Continuous Improvement is a Quality Movement

36. C LINICAL T ECHNICAL B USINESS Develop/evaluate programs and initiatives Progressive program promotion/awareness Coordinate efforts Cost-sharing Adopt technology Participate in community and political events Continuous Improvement is a Quality Movement

37. C LINICAL T ECHNICAL B USINESS Assess Plan Prepare Leverage Resources Execute Study & Scrutinize Continuous Improvement is a Quality Movement

38. C INDY F RIEND, RN, BSN, MSN, MBA/HCA M ANAGING D IRECTOR 443.413.6901 C INDY F RIEND @T RIVANTAGE S OLUTIONS. COM WWW.T RIVANTAGE S OLUTIONS. COM