Maine PCMH Pilot & Community Care Teams (CCTs)

1. Maine PCMH Pilot & Community Care Teams (CCTs) Lisa M. Letourneau MD, MPH October 2013

2. Maine PCMH Pilot Leadership Dirigo HealthAgency’s (DHA’s)Maine QualityForum Maine Health Management Coalition Maine Quality Counts MaineCare (Medicaid) 2

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

4. Implications of CMS MAPCP Demo 4 Projected to achieve budget-neutrality (i.e. to reach $10 pmpm savings) via reductions in avoidable ED use, hospitalizations Stronger focus on reducing waste & avoidable costs Introduced CCTs as targeted strategy to support high-needs patients & reduce avoidable costs Access to Medicare data to identify high patients Opportunity to add 50 additional practices to join “Phase 2” of Pilot (Jan 2013)

5. Maine PCMH Pilot - MAPCP Timeline Jan 1, 2010 2011 2012 2013 Dec 31, 2014 ME PCMH Pilot - Original Jan 1, 2012 MAPCP Demo – 3yr CCTs ME PCMH Pilot - Extended Dec 31, 2014 Pilot Expansion, Medicaid HHs

6. 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 Lisa Letourneau

7. Maine PCMH Pilot Community Care Teams Schools Transportation Environment • Community Care Team Housing Outpatient Services Workplace Care Mgt Family Food Systems High-need Individual PCMH Practice Med Mgt Specialists • Community Resources Shopping Coaching Hospital Services Behav. Health & Sub Abuse Income Physical Therapy Heat Literacy 7 Faith Community

8. CCT Selection • Used structured application, selection process • CCTs committed to PCMH Core Expectations • Had to get agreement from PCMH/HH practices • Had to meet minimum practice population size ~15,000 8

9. ME PCMH Pilot CCTs • AMHC • Androscoggin Home Health • Coastal Care Team (Blue Hill FP, Community Health Center/MDI, Seaport FP) • CHANS (MidCoast area) • Community Health Partners (Newport FP, Dexter FP) • DFD Russell (FQHC) • Eastern Maine Homecare • Kennebec Valley (MaineGeneral Health) • Maine Medical Center PHO • Penobscot Community Health Care (FQHC) 9

10. Maine PCMH Pilot Community Care Teams, Phase 1 and Phase 2 Practice Sites

11. Alignment of Pilot with MaineCare Health Homes Initiative • Affordable Care Act (ACA) Sect 2703 - opportunity to develop Medicaid “Health Homes” initiative • MaineCare elected to align HH initiative with current multi-payer Pilot – part of VBP initiative • Defined MaineCare “Health Home”(HH): HH = PCMH practice + CCT • Provided opportunity to leverage multi-payer PCMH model, practice transformation support infrastructure 11

12. MaineCare Health Homes • Community Care Team Stage A: Help Individuals with Chronic Conditions Care Mgt PCMH Practice Health Homes Beneficiary Med Mgt Coaching Behav. Health & Sub Abuse 12

13. Maine’s Medical Home Movement ~ 540 Maine Primary Care Practices Payer: Medicaid ~150 eligible MaineCare HH-Practices 120+ NCQA PCMH Recognized Practices • Payers: • Medicare • Medicaid (HH) • Commercial plans (Anthem, Aetna, HPHC) • Self-funded employers 50 Pilot Phase 2 Practices 14 FQHCs CMS APC Demo 25 Maine PCMH Pilot Practices Payer: Medicare 13

14. CCT Populations Served CCTs review data from available sources (Medicare RTI reports, MaineCare Utilization reports, other payers, HIN) to identify • Hospital Admissions • 3 or more admissions in past 6 months • 5 or more admissions in past 12 months • Emergency Department Utilization • 3 or more E.D. visits in past 6 months • 5 or more E.D. visits in past 12 months • Payer identification of high-risk or high-cost patients 14

15. CCT Staffing Minimum expectations: • Medical Director (part-time) • CCT Manager • Nurse Care Manager • LCSW / Care Coordinators • Access to BH, SA expertise 15

16. 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 16

17. CCT Payments • Practice population-based capitated payments • Medicare: $2.95 pmpm • Commercial payers: $0.30 pmpm • Per-person capitated payments • Medicaid / Health Homes: $129.50 pmpm 17

18. CCT Goals & Performance Measurement • Improve care, reduce costs for most high-cost, high- needs individuals of PCMH/HH practices • Reduce hospitalizations, readmissions • Reduce ED visits • Performance tracked through quarterly reporting • Number CCT contacts • Number ED visits, hospitalizations pre/post CCT 18

19. CCT Reporting 19

20. 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 20

21. Maine CCTs: Successes • Have developed functional CCT infrastructure • CCT structure, support highly welcomed by practices, patients • Most PCMH/HH practices report high levels of satisfaction with CCT services • Have demonstrated numerous examples of high-needs individuals positively impacted by CCTs 21

22. Maine CCTs: Challenges & Lessons Learned • Need to focus on most high-cost individuals, particularly those with frequent hospitalizations, who are open to intervention • Be cautious of focusing on high-needs individuals who are highly resistant to changing behaviors • Value of trauma-informed approach 22

23. Maine CCTs: Challenges & Lessons Learned • Building CCT structure & relationships takes time (up to 2-6 mos) • Data critical to identifying potential patients; current data sources are siloed, time-lagged • Successful interventions depend on strong relationships, with individuals & with practices 23

24. PCMH: Hub of Wider Delivery & Payment Reform Models (ACOs!) ACO

25. Primary Care & CCT Payment in ACOs: So What Will Change? • Despite PCMH, ACO pilots, FFS remains most predominant payment model for providers • Relying on FFS payments continues to emphasize volume & threatens meaningful practice change • Little meaningful change yet to concept of “productivity” *Payment Reform for Primary Care within ACOs, A. Goroll & S. Schoenbaum, JAMA, Aug 2012

27. Contact Info / Questions • Maine Quality Counts • www.mainequalitycounts.org • Maine PCMH Pilot • www.mainequalitycounts.org (See “Programs”  PCMH) • Lisa Letourneau MD, MPH • LLetourneau@mainequalitycounts.org, 207.415.4043 • Hpeterson@mainequalitycounts.org, 207.266.7211