Missouri Primary Care Health Home Initiative

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

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 Servicesfor 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.

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

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

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)

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.

10. Use of Health Information Technology to Link Services • CyberAccess • Direct Inform (Patient portal)

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

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

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

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

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 ConsultantContinued • 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 ConsultantContinued • 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.

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

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

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

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 HealthNetand 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

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

41. Tools and Resources • MO HealthNet Division, Primary Care Health Home Information http://dss.mo.gov/mhd/cs/health-homes/ • Missouri Health Home State Plan Amendment Information http://dmh.mo.gov/about/chiefclinicalofficer/healthcarehome.htm • National Committee for Quality Assurance: www.ncqa.org/tabid/631/Default.aspx • Commonwealth Fund: Safety Net Medical Home Initiative www.qhmedicalhome.org/safety-net/change-concepts.cfm • Improving Chronic Illness Care: www.improvingchroniccare.org/index.php?p=Patient-Centered_Medical_Home&s=224 • The Joint Commission: http://www.jointcommission.org/accreditation/pchi.aspx • Patient-Centered Primary Care Collaborative: www.pcpcc.net/content/patient-centered-medical-home • American College of Physicians: www.acponline.org/running_practice/pcmh/