Patient Centered Primary Care Homes An Overview of Oregon’s Implementation of the ACA Section 2703 Health Home Provision

1. Patient Centered Primary Care HomesAn Overview of Oregon’s Implementation of the ACA Section 2703 Health Home Provisions NASHP WebcastJune 14, 2012

2. Presentation Objectives • Identify the building blocks and provide context for Oregon’s Health Home SPA development • Identify other related changes in the Medicaid Program • Highlight key program features • Summarize initial lessons learned

3. Building Blocks for Oregon’s SPA • In 2009, HB 2009 established the Patient-Centered Primary Care Home (PCPCH) program within the Office for Oregon Health Policy and Research • In 2011, The Governor and State Legislature Directed the OHA to update the Medicaid managed care system, developing standards for new Coordinated Care Organizations that will manage an integrated benefit package, have local governance structures and promote expansion of Patient Centered Primary Care Homes • Key Functions of the Patient Centered Primary Care Program: • Develop PCPCH Standards • PCPCH Recognition • Technical assistance development • Communication and provider outreach • Coordination across OHA divisions and health reform initiative • Resources available at www.primarycarehome.oregon.gov

4. Primary Care Home Standards Advisory Committee • 15 members, 6 ex-officio content experts • Multiple stakeholders (patients, providers, plans, employers, health authority, public health) • 7 public meetings Nov 2009 - Jan 2010 • Reviewed past work in Oregon, other state, federal and private efforts across the country • Three principle products • PCPCH Core Attributes and Standards • PCPCH Measures • Guiding Principles for Implementation • Reconvened second group in Fall 2010 with focus on pediatric and adolescent populations

5. Key Program Features: Standards of Care • Patient-Centered Primary Care Home (PCPCH) model • Six Core Attributes • Access • Accountability • Comprehensive Whole Person Care • Continuity • Coordination and Integration • Person- and Family-Centered Care • Each attribute has corresponding standards and measures • Practices recognized as Tier 1, 2, or 3 depending on how advanced the PCPCH is

6. Advanced Primary Care Home Intermediate Primary Care Home Basic Primary Care Home Different Levels of Primary Care “Home-ness” • Proactive patient and population management • Accountable for quality, utilization and cost of care outcomes • Demonstrates performance improvement • Additional structure and process improvements • Foundational structures and processes

7. Primary Care Home Measures • Example: ACCESS TO CARE – Be there when we need you • In-Person Access • Tier 1 – Practice surveys a sample of its population on satisfaction with in-person access to care. • Tier 2 – Practice surveys a sample of its population using one of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey tools and reports on results on the access to care domain. • Tier 3 – Practice surveys a sample of its population using one of the CAHPS survey tools, reports results on the access to care domain, and demonstrates improvement with patient satisfaction in access to care. • Telephone and Electronic Access • After Hours Access

8. Key Program Features: Medicaid Coverage of PCPCH • Target population • PCPCH Program target: All Oregonians • Actively working with other OHA Programs such as Public Employees Benefit Board and Oregon Educators Benefit Board • Medicaid Coverage • Sec. 2703 SPA target: (Approved) • Individuals with a serious mental illness • Individuals with two or more chronic conditions • Individuals with one chronic condition and at-risk of developing another • Modified PCCM SPA (Pending) • Individuals not meeting ACA-qualifying criteria

9. Who is ACA-Qualified? • A patient is ACA-Qualified if they have: • A serious mental health condition (below), or • More than one chronic condition (below), or • One chronic condition and are at risk of developing another (below) • “At risk” is based on the following guidelines: United States Preventive Task Force, HRSA Women’s Preventive Services, and Bright Futures

10. Key Program Features: Provider Enrollment

11. Key Program Features • Beneficiary assignment • FFS Providers submit quarterly patient lists identifying ACA vs. non-ACA qualified individuals • Medicaid Managed Care Plans provide quarterly patient lists of ACA Qualified individuals that are assigned to a PCPCH • Documentation of patient education, engagement, and agreement to participate required within 6 months of assignment • Patient opt-out available

12. Service and Documentation Requirements for ACA-Qualified PMPM Payments • When a PCPCH clinic submits the quarterly patient list, they are attesting to meeting the following requirements for each patient on that list: • Performing patient education, engagement, and obtaining agreement • Developing and documenting a person-centered plan • Providing at least one Core Service for that quarter • Performing panel management at least once that quarter To gain approval from CMS for this specific opportunity, OHA needed to make a few modifications to the original proposal. Through a series of negotiations, the proposal was modified such that recognized PCPCH clinics are eligible for the additional payment if the service and documentation requirements are met for each patient.

13. Key Program Features: Health home services • Comprehensive Care Management • Develop action plans for exacerbations of chronic illnesses and end-of-life care, when appropriate • Develop goals for self management, preventive and chronic illness care • Care Coordination • Emphasis on continuity with the PCPCH provider or team • Develop a person-centered care plan • Track tests and result notification, track referrals ordered by its clinicians, and direct collaboration or co-management with specialty providers • Co-location of behavioral health and primary care is strongly encouraged • Health Promotion • Promote the use of evidence based, culturally sensitive wellness and prevention • Link enrollee with resources for smoking cessation, diabetes, asthma, self-help resources and other services based on individual needs and preferences • Promote patient/family education and self-management of the chronic conditions

14. Key Program Features: Health home services • Comprehensive Transitional Care • Hold written agreements and/or procedures in place with its usual hospital providers, local practitioners, health facilities and community based services to ensure notification and coordinated, safe transitions • Individual and Family Support Services • Provide patient and family education, health promotion and prevention, self management supports, and information and assistance obtaining available non-health care community resources, services and supports • Use peer supports, support groups and self care programs to increase the client and caregivers knowledge about the client’s individual disease • Referral to Community and Social Support Services • Provide referral to community and social support services, such as patient and family education, health promotion and prevention, and self management support efforts, including available community resources, housing, nutrition, etc.

15. Understanding the Core Service Requirement • PMPM payments intended to provide support for activities that are typically non-billable • A Core Service: • Must be provided once per quarter for each patient on a clinic’s list • Does not require an office visit • Can be performed during an office visit • Can be performed any by any member of the health care team • Does not require or replace treatment or medical services • Can not be a service a clinic is already billing for • (think: non-duplication of payment) • MUST be documented in each patients’ medical record

16. Key Program Features • Payment methodology • Automated PMPM payment • Member engagement must be documented in Medical Record • Payment for ACA-Qualified Members available to Managed Care Plans • Medicaid FFS, PCPCH Fee Schedule • ACA-Qualified Members • Tier 1 $10 PMPM • Tier 2 $15 PMPM • Tier 3 $24 PMPM • Non-ACA Qualified Members* • Tier 1 $2 PMPM • Tier 2 $4 PMPM • Tier 3 $6 PMPM *NOT included in Section 2703 SPA

17. Initial Lessons Learned • Don’t be in a rush to begin the first of the eight quarters • Keep in active communication with key stakeholders • Patient identification and attribution is more challenging than you may think • Don’t underestimate provider resistance and the very real operational barriers to additional documentation requirements • Having a clearly defined team to champion the program, identify and address the early implementation issues is critical

18. Questions? www.primarycarehome.oregon.gov www.health.oregon.gov Nicole Merrithew, MPH, PCPCH Program Director nicole.merrithew@state.or.us Ralph Summers, MSW, Senior Policy Advisory Ralph.h.summers@state.or.us E. Dawn Creach, MS, PCPCH Communications & Technical Assistance dawn.creach@state.or.us