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Blueprint Integrated Pilot Programs Building community systems of health

Blueprint Integrated Pilot Programs Building community systems of health. State Coverage Initiatives Vermont Site Visit Academy Health Robert Wood Johnson Foundation. Craig Jones MD Director, Vermont Blueprint for Health craig.jones@vdh.state.vt.us. Funding. Programs. Products.

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Blueprint Integrated Pilot Programs Building community systems of health

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  1. Blueprint Integrated Pilot Programs Building community systems of health State Coverage Initiatives Vermont Site Visit Academy Health Robert Wood Johnson Foundation Craig Jones MD Director, Vermont Blueprint for Health craig.jones@vdh.state.vt.us

  2. Funding Programs Products Blueprint Communities (Act 191, 2006) • Clinical Transformation VPQ Coordinated Training Clinical Microsystems • Provider Incentives Participation & Training • Community Activation Local Programs • Self Management Healthier Living Workshops • Health Information Technology VPQ Hosted Registry (VHR) • Evaluation VPQ Registry Reports VCHIP Chart Review • VITL Health Information Exchange Network • Improved Care Delivery (Diabetes) • IT enhanced care (Diabetes) • Improved self mgmt (HLW attendees) • Local exercise / prevention programs • VHR - Descriptive statistics (Diabetes) • VCHIP – Chart review • Blueprint / State • Global Commitment • Catamount Fund • Federal Funds • HIT Fund • Advanced Medical Home • Improved Care Delivery (General) • Local care support & DM services • Sustainable Financial Reform • Improved Self Mgmt (Multi-faceted) • IT enhanced care -Chronic disease -Health maintenance -eRx • Prevention & Wellness Programs -Community team -Evidence based -Linked with care delivery Sustainable Transformation Blueprint Integrated Pilots (Act 71 2007, Act 204 2008) • Multi Insurer Reform • Medicaid • BCBS • Cigna • MVP • Financial Reform Enhanced provider payment Shared costs for CCT • Local Care Support CCT as shared resource • Prevention Public Health Specialist on CCT Local Prevention Team • Health Information Technology VITL EMR Pilot Project VPQ Hosted Web Based CIS with eRx • VITL Health Information Exchange Network Grant Support ? • Evidence based healthcare process • Routine QA / QI • Evaluation of health impact • Evaluation of financial impact • Predictive modeling (claims / clinical) • Epidemiologic / outcomes research • CCT Utilization Patterns Evaluation Infrastructure • Multi payer claims data base • Clinical / demographic data base • VCHIP NCQA PCMH scoring • VCHIP chart review

  3. Blueprint Integrated Pilots Coordinated Health System Hospitals PCMH PCMH Community Care Team Nurse Coordinator Social Workers Dieticians Community Health Workers OVHA Care Coordinators Public Health Prevention Specialist Mental Health & Substance Use Disorders PCMH PCMH Public Health Prevention Health IT Framework Global Information Framework Evaluation Framework Operations

  4. Blueprint Integrated Pilot Summary 1. Financial reform (2 major components - includes MCAID & commercial insurers) - Payment to practices based on NCQA PCMH score - Shared costs for Community Care Teams 2. Multidisciplinary care support teams (CCT Teams) - Local care support & population management 3. Health Information Technology - Web based clinical tracking system (DocSite) - Visit planners & population reports - Electronic prescribing - Updated EMRs to match program goals and clinical measures in DocSite - Health information exchange network 4. Community Activation & Prevention - Prevention specialist as part of CCT - Community profiles & risk assessments - Evidence based interventions 5. Evaluation - NCQA PCMH score (process quality) - Clinical process measures - Health status measures - Multi payer claims data base - Population Indicators

  5. NCQA Scoring & Provider Payment 5 of 10 MP 10 of 10 MP

  6. St Johnsbury Community Care Team Staffing St. Johnsbury Family HC Chronic Care Coor .5 FTE Beh. Health Spec. .5 FTE VDH District Office Public Health Specialist Calodenia Int. Medicine Chronic Care Cood .5 FTE Beh. Health Spec. .5 FTE St. Johnsbury Community Care Team Care Integration Coordinator 1 FTE Concord Health Ctr. Chronic Care Cood .5 FTE Beh. Health Spec. .5 FTE Community Connections Community Health Workers CC Comm. Health Worker Danville Health Center Chronic Care Coor .5 FTE Beh. Health Spec .5 FTE Other OVHA Care Managers Hospital Care Managers Hospital-based CC Educators Community-based Advocates Corner Medical Chronic Care Coor 1 FTE Beh. Health Spec 1 FTE

  7. Community Connections COMMUNITY CARE TEAM Behavioral Health Specialist Physicians Nurse Practitioners Physician Assistants VT Department of Health Chronic Care Coordinator Community Care Managers (OVHA, AAA, Umbrella, etc.) PRIMARY CARE OFFICE St Johnsbury Community Care Team Referral and Communication Flow Chart

  8. Chittenden County Community Care Team Staffing Exercise Physiologist .25 FTE PD Cert. Diabetic Educator 1 FTE Med. Social Worker 1 FTE Behavioral Specialist .25 FTE Dietitian/ Nutritionist .25 FTE PD Chittenden County Community Care Team Nurse Lead Manager 1 FTE HealthEducator 1 FTE VDH Public Health Specialist Admin. Supp 1 FTE Dr. Moore Aesculapius Admin. supp. .25 FTE Admin. Supp. .5 FTE Medical Asst. 2 FTEs

  9. An Integrated Model for Health Functional Map – Public Health Operations Departments VDH Programs Transportation Surveillance Education HPDP VDH Prevention Teams Labor ADAP • Input • Review • Domain expertise • Coordination • Planning • Program content • Best practices • Domain expertise • Data analysis • Reporting • Central – Public Health Prevention Team • State level assessments • State level strategic planning • Data review & interpretation • Design campaigns / programs • Technical assistance / support Medicaid Blueprint Corrections MCH Mental Health Preparedness Children & Families Rural Health DAIL Business Office • Regional – Public Health Prevention Teams • Local assessments • Local intervention planning • Organizing & coordination • Multidisciplinary Services State & Local Coalitions Community Care Team # 1 Community Care Team # 2 Community Groups Community Care Team # 3 Community Stakeholders Community Care Team # 4 Community Health Teams

  10. Community Assessment & Planning Timeline October 2008 • PHASE 2a - Community Profile • Community description • Community inventory • Quantitative Context - Descriptive health statistics on the rates of risk factors in each community (5 year aggregate data) • PHASE 2b - Community Assessment • Quantitative Context - state level 10 year trend analysis of risk factors associated with morbidity & healthcare costs • Focus groups • Formal key leader interviews • Continue until no new themes • Test themes in new interviews • Test findings in community forums • PHASE 3 - Community Planning • Planning with key leaders • Planning with stakeholders • Iterative interactive process • Consensus building • PHASE 4 - Implementation • Timeline depends on scope and resources of planned intervention Phase 5 – Evaluation 3 - 5 months 4 - 6 months 2 - 4 months • PHASE I - Develop capacity • Facilitate systems approach • Train Prevention Specialist • Prevention Model and Framework • Data collection techniques • Environment and policy change

  11. Blueprint Integrated Pilots Coordinated Health System – Integrating Existing Programs Hospitals PCMH PCMH Community Care Team Nurse Coordinator Social Workers Dieticians Community Health Workers OVHA Care Coordinators Public Health Prevention Specialist Behavioral Health & Substance Abuse Services PCMH PCMH Public Health Prevention Health IT Framework Global Information Framework Evaluation Framework Operations

  12. Blueprint Integrated Pilots Coordinated Health System • EMRs • DocSite • Practice Management Systems • Hospital Information Systems Hospitals PCMH PCMH • EMRs • DocSite • Practice Management Systems • Hospital Information Systems • Multi-payer claims database • Public Health Databases • Chart reviews • NCQA Scoring Community Care Team Nurse Coordinator Social Workers Dieticians Community Health Workers OVHA Care Coordinators Public Health Prevention Specialist Behavioral Health & Substance Abuse Services PCMH PCMH • NCQA Scores • Clinical Process Measures • Health Status Measures • Healthcare Resource Utilization • Healthcare Expenditures • Financial Impact ROI • Population Health Indicators Public Health Prevention Healthcare Information Framework Health System Information Framework • Individual Patient Care • Population Management • Quality Improvement • Program Evaluation • Program Sustainability • Community Activation / Prevention • Health Policy Evaluation & Framework Operations & Uses Framework

  13. Blueprint Integrated Pilots Why measure? Average = 7.46 Average = 7.36 Group 1 Good Disease Control Group 2 Intermediate Disease Control Group 3 Poor Disease Control

  14. Blueprint Integrated Pilots Evidence Based Quality Improvement Data Source Data Processing & Storage Data Analysis Data Reports & Uses EMRs used for Individual Patient Care EMR Databases Data transmission & transformation VITL / GE EMR Reporting Tool or Analyst Clinical Process Measures Individual Patient Care & Support Services DocSite used for Individual Patient Care DocSite Database DocSite Reporting Tool Health Status Measures Population Management Contracted Analysis Services Healthcare Quality Measures & Standards Quality Improvement Medical Claims from Commercial Insurers & Medicaid BISCHA Multipayer Database BISCHA Reports Healthcare Patterns & Resource Utilization Provider Payment for Quality VCHIP Chart Review & NCQA Scoring VCHIP Analysis & Report Generation Healthcare Expenditures & Financial Impact Program Evaluation & Sustainability VCHIP Databases Public Health Surveys & Data Collection Public Health Registries & Databases VDH Health Surveillance Analytic Database VDH Health Surveillance Analyst Population Indicators & Risk Factors Community Prevention Planning

  15. Blueprint Integrated Pilots Evidence Based Quality Improvement Data Source Data Processing & Storage Data Analysis Data Reports & Uses EMRs used for Individual Patient Care EMR Databases Data transmission & transformation VITL / GE EMR Reporting Tool or Analyst Clinical Process Measures Individual Patient Care & Support Services DocSite used for Individual Patient Care DocSite Database DocSite Reporting Tool Health Status Measures Population Management Contracted Analysis Services Healthcare Quality Measures & Standards Quality Improvement Medical Claims from Commercial Insurers & Medicaid BISCHA Multipayer Database BISCHA Reports Healthcare Patterns & Resource Utilization Provider Payment for Quality VCHIP Chart Review & NCQA Scoring VCHIP Analysis & Report Generation Healthcare Expenditures & Financial Impact Program Evaluation & Sustainability VCHIP Databases Public Health Surveys & Data Collection Public Health Registries & Databases VDH Health Surveillance Analytic Database VDH Health Surveillance Analyst Population Indicators & Risk Factors Community Prevention Planning

  16. Blueprint Integrated Pilots Evidence Based Quality Improvement Data Source Data Processing & Storage Data Analysis Data Reports & Uses EMRs used for Individual Patient Care EMR Databases Data transmission & transformation VITL / GE EMR Reporting Tool or Analyst Clinical Process Measures Individual Patient Care & Support Services DocSite used for Individual Patient Care DocSite Database DocSite Reporting Tool Health Status Measures Population Management Contracted Analysis Services Healthcare Quality Measures & Standards Quality Improvement Medical Claims from Commercial Insurers & Medicaid BISCHA Multipayer Database BISCHA Reports Healthcare Patterns & Resource Utilization Provider Payment for Quality VCHIP Chart Review & NCQA Scoring VCHIP Analysis & Report Generation Healthcare Expenditures & Financial Impact Program Evaluation & Sustainability VCHIP Databases Public Health Surveys & Data Collection Public Health Registries & Databases VDH Health Surveillance Analytic Database VDH Health Surveillance Analyst Population Indicators & Risk Factors Community Prevention Planning

  17. Blueprint Integrated Pilots Evidence Based Quality Improvement Data Source Data Processing & Storage Data Analysis Data Reports & Uses EMRs used for Individual Patient Care EMR Databases Data transmission & transformation VITL / GE EMR Reporting Tool or Analyst Clinical Process Measures Individual Patient Care & Support Services DocSite used for Individual Patient Care DocSite Database DocSite Reporting Tool Health Status Measures Population Management Contracted Analysis Services Healthcare Quality Measures & Standards Quality Improvement Medical Claims from Commercial Insurers & Medicaid BISCHA Multipayer Database BISCHA Reports Healthcare Patterns & Resource Utilization Provider Payment for Quality VCHIP Chart Review & NCQA Scoring VCHIP Analysis & Report Generation Healthcare Expenditures & Financial Impact Program Evaluation & Sustainability VCHIP Databases Public Health Surveys & Data Collection Public Health Registries & Databases VDH Health Surveillance Analytic Database VDH Health Surveillance Analyst Population Indicators & Risk Factors Community Prevention Planning

  18. Blueprint Integrated Pilots Evidence Based Quality Improvement Data Source Data Processing & Storage Data Analysis Data Reports & Uses EMRs used for Individual Patient Care EMR Databases Data transmission & transformation VITL / GE EMR Reporting Tool or Analyst Clinical Process Measures Individual Patient Care & Support Services DocSite used for Individual Patient Care DocSite Database DocSite Reporting Tool Health Status Measures Population Management Contracted Analysis Services Healthcare Quality Measures & Standards Quality Improvement Medical Claims from Commercial Insurers & Medicaid BISCHA Multipayer Database BISCHA Reports Healthcare Patterns & Resource Utilization Provider Payment for Quality VCHIP Chart Review & NCQA Scoring VCHIP Analysis & Report Generation Healthcare Expenditures & Financial Impact Program Evaluation & Sustainability VCHIP Databases Public Health Surveys & Data Collection Public Health Registries & Databases VDH Health Surveillance Analytic Database VDH Health Surveillance Analyst Population Indicators & Risk Factors Community Prevention Planning

  19. Blueprint Integrated Pilots Evidence Based Quality Improvement Data Source Data Processing & Storage Data Analysis Data Reports & Uses EMRs used for Individual Patient Care EMR Databases Data transmission & transformation VITL / GE EMR Reporting Tool or Analyst Clinical Process Measures Individual Patient Care & Support Services DocSite used for Individual Patient Care DocSite Database DocSite Reporting Tool Health Status Measures Population Management Contracted Analysis Services Healthcare Quality Measures & Standards Quality Improvement Medical Claims from Commercial Insurers & Medicaid BISCHA Multipayer Database BISCHA Reports Healthcare Patterns & Resource Utilization Provider Payment for Quality VCHIP Chart Review & NCQA Scoring VCHIP Analysis & Report Generation Healthcare Expenditures & Financial Impact Program Evaluation & Sustainability VCHIP Databases Public Health Surveys & Data Collection Public Health Registries & Databases VDH Health Surveillance Analytic Database VDH Health Surveillance Analyst Population Indicators & Risk Factors Community Prevention Planning

  20. Blueprint Integrated Pilots Evidence Based Quality Improvement Data Source Data Processing & Storage Data Analysis Data Reports & Uses EMRs used for Individual Patient Care EMR Databases Data transmission & transformation VITL / GE EMR Reporting Tool or Analyst Clinical Process Measures Individual Patient Care & Support Services DocSite used for Individual Patient Care DocSite Database DocSite Reporting Tool Health Status Measures Population Management Contracted Analysis Services Healthcare Quality Measures & Standards Quality Improvement Medical Claims from Commercial Insurers & Medicaid BISCHA Multipayer Database BISCHA Reports Healthcare Patterns & Resource Utilization Provider Payment for Quality VCHIP Chart Review & NCQA Scoring VCHIP Analysis & Report Generation Healthcare Expenditures & Financial Impact Program Evaluation & Sustainability VCHIP Databases Public Health Surveys & Data Collection Public Health Registries & Databases VDH Health Surveillance Analytic Database VDH Health Surveillance Analyst Population Indicators & Risk Factors Community Prevention Planning

  21. Blueprint Integrated Pilots Financial Impact

  22. Blueprint Integrated Pilots Building a Scalable Model • Build a model for effective and sustainable reform • Multi Insurer Financial Reform (PCP payment, CCTs) • Financial Incentives (balance volume & quality) • Environment (PCMH, CCTs, PH specialists, Health IT) • Focus (quality, wellness, prevention) • Evaluation (multidimensional, routine) • Culture (self management, engaging yet objective)

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