Prescription for Pennsylvania

1. Prescription for Pennsylvania Governor’s Chronic Care Initiative: Transforming Care in Pennsylvania July 2010

2. Public-Private Partnership Improving chronic care is win-win for both cost reduction and improved quality. For 2007, PA hospitals charged $4 billion for avoidable hospitalizations for those with chronic conditions. This does not include avoidable ER visits. We know that patients are receiving only about 56% of the evidence-based primary care they need and it is even less for those with multiple chronic conditions. We needed to change both how care is delivered at the primary care level and how it is paid for, and to do so we needed to partner with the private sector to get it done. 2

3. The Governor’s Chronic Care Initiative The Pennsylvania Chronic Care Management, Reimbursement and Cost Reduction Commission was established by Governor Rendell’s Executive Order in May 2007 The purpose of the Commission is to design the informational, technological and reimbursement infrastructure needed to implement and support widespread dissemination of the Chronic Care Model throughout Pennsylvania The Commission presented its Strategic Plan to the Governor and the Speaker of the House on February 13, 2008 The Plan provides a business case and framework for implementing the Chronic Care Model across the Commonwealth 3

4. The Chronic Care Model Community Health System Health Care Organization Resources and Policies ClinicalInfoSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

5. Self Management Support Emphasize the patient's central role in managing their illness. Assess patient self-management knowledge, behaviors, confidence, and barriers. Provide effective behavior change interventions and ongoing support with peers or professionals. Assure collaborative care-planning and problem solving by the team. 5

6. Delivery System Design Define roles and delegate tasks amongst team members. Use planned interactions to support evidence-based care (planned follow-up care) Provide clinical case management services. Assure continuity by the primary care team. Give care that patients understand and that fit their culture. 6

7. Decision Support Embed evidence-based guidelines which describe stepped-care into daily clinical practice. Integrate specialist expertise into primary care. Use proven provider education modalities to support behavior change. Share guidelines and information with patients. Provide stepped care based on the needs of the patient. 7

8. Health Care Organization Include measurable goals for chronic illness in the business plan. Leaders visibly support improvement in chronic illness care. Use effective improvement strategies aimed at comprehensive system change. Promote good chronic illness care through benefit packages. Encourage better chronic illness care through provider incentives. 8

9. Clinical Information Systems Provide reminders for providers and patients. Identify relevant patient subpopulations for proactive care. Facilitateindividual patient care planning. Share information with providers and patients Monitor performance of team and system 9

10. Community Resources and Policies Encourage patients to participate in effective programs Form partnerships with community organizations to support or develop programs Advocate for policies to improve care. 10

11. Our Approach in a Nutshell Selection of teams based on the financial model created for each region. Prework 2-8 weeks prior to the first Learning Session Learning Sessions held every 3-4 months to assess progress and introduce the next phase of concepts Action Period expectations established for each region – these expectations become the foundation for Coaching Support Coaching Support for the practice to include monthly feedback, site visits and open communication to address issues at the practice level as they arise. Monthly Conference Calls per region designed with the teams progress as the guide for topics Use of regional listserv to distribute information to the teams, encourage discussions and networking. 11

12. Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act Plan Study Do From: Associates in Process Improvement

13. Integration of the Patient Centered Medical Home PCMH includes components of the Chronic Care Model but… Puts increased emphasis on HIT Does not extend beyond the practice walls Used as a validation tool to promote and measure transformation within and across regional rollouts Regions now incorporate additional requirements beyond NCQA scoring levels (Level 1 – Plus) Recognition rewarded by plans Extended to nurse-managed centers in SEPA 13

14. NCQA PPC-PCMH Standards **Must Pass Elements

15. Partner Organizations in the Initiative GOHCR Governor’s Chronic Care Commission Improving Performance in Practice (IPIP), PA PA Department of Health Insurance Companies Provider Organizations Quality Improvement Experts including the MacCall Institute Professional Organizations/Societies PA Academy of Family Physicians (PAFP) American Board of Internal Medicine (ABIM) American College of Physicians (ACP) National Committee on Quality Assurance (NCQA) …And Many More …As Well As Some New Ones 15

16. Implementation of the Chronic Care Model in PA Incremental rollout across the state based on regions and payer representation. Rollout framework has flexibility by region as determined by regional steering committee Regional rollout will run for at least three years from the start date. Compensation based on payer mix at the practice or one-time grant from GOHCR At eighteen and thirty-six months a formal evaluation will assess whether the rollouts are achieving desired quality and cost containment goals, and whether to continue. 16

17. 17

18. Southeast PA Start Date – May 13, 2008 32 Practices 206 Providers 210,000 patients (12,500 DM) Current Topics High Risk and Care Management Spread Plans for 12 months of work Sustainability of the System Regional Components Infrastructure Support $20,000 max NCQA Recognition by Month 12 (payments based on Level of recognition and number of FTEs) Care Management (must use a portion of the funds to hire/contract for CM) Unique Situations First Rollout Payers are very engaged CRNP Practices included 8 Pediatric Practices 18

19. SE First Year Outcomes All 32 practices achieved at least Level 1 NCQA certification within 12 months 33% improvement in diabetics who gained control of their blood sugar Number of diabetics getting eye exams increased 71% and foot exams 142% Those who lowered cholesterol below 130 increased by 43% and blood pressure below 140/90 by 25% Diabetes (1452) 11.3% increase in prescription costs 26% reduction in inpatient admissions 18.4% reduction in ER visits 15.9% reduction in overall costs ($46.37 pmpm) Asthma (1227) 17% reduction in inpatient admissions 6.3% reduction in overall costs ($9.60 pmpm) 42% reduction in ER visits “utilization definitely went down” 19

20. SE PA #1 25 adult medicine practices All 25 practices NCQA-recognized patient centered medical homes since June 2009 Started improvement collaborative in May 2008 11,000 diabetes patients Practice-reported data

21. Percentage of Patients with A1C>9 18% improvement 27% improvement over two years 11% improvement Note: Lower is better.

22. Percentage of Patients with BP<140/90 9% improvement 32% improvement over two years 27% improvement

23. Percentage of Patients with LDL<130 11% improvement 50% improvement over two years 35% improvement

24. Percentage of Patients with A1C Test 65% improvement over one year 65% improvement Note: Data not available for 2008.

25. Percentage of Patients withLDL Test 15.5% improvement 67% improvement over two years 45% improvement

26. Percentage of Patients withFoot Exam 6.5% improvement 139% improvement over two years 125% improvement

27. Percentage of Patients withSelf Management Goal 19% improvement 186% improvement over two years 141% improvement

28. Southcentral PA Start Date – February 11, 2009 Next Session – September 29, 2010 25 Practices 78 Providers 137,000 patients (17,500 DM) Current Topics Securing the System of Care, Spread Implementation of Care Management NCQA application Regional Components Infrastructure Support $20,000 max Care Management payment at Month 13 ($1.50pmpm) NCQA Recognition (Level 1 Plus) by Month 18 ($1.50pmpm) Optional – NCQA Recognition at Level 3 will generate additional $1.00pmpm starting at Month 25 Unique Situations Large geographic region with multiple systems Some compensated and uncompensated practices 2 Pediatric Practices 28

29. Southwest PA Start Date – May 21, 2009 23 Practices 86 Providers 155,000 patients (13,500 DM) Current Topics High Risk and Care Management NCQA application Regional Components Infrastructure Support $20,000 max Care Management payment at Month 13 ($1.50pmpm) NCQA Recognition (Level 1 Plus) by Month 18 ($1.50pmpm) Optional – NCQA Recognition at Level 3 will generate additional $1.00pmpm starting at Month 25 Unique Situations Duplicate of SCPA rollout Lots of other initiatives going on in the region Coaching support provided by faculty 29

30. * UPMC Senior Care: % DM Pts >=75 A1C >9 Lower is better on this measure.

31. Northeast PA Start Date – October 28, 2009 Next Session – June 15, 2010 31 Practices 139 Providers 235,000 patients Current Topics High Risk and Care Management Spread Plans for 6 months of work Sustainability Regional Components Practice Support $1.50pmpm starting at Month 1 Care Management $1.50pmpm starting at Month 4 Shared Savings paid after 1 year based on movement of identified measures and recognition by NCQA at Level 1 Plus Unique Situations Health Systems involved (Geisinger, PHA, Intermountain, Horizon, etc.) Smaller practice sizes Care Management initiated very early on in the creation of a system of care 31

32. Grant-funded Collaboratives • $12,000 grant program funded by the Governor’s Office of Health Care Reform • No support by regional insurance companies • Each will run for 18 months • NCQA Recognition + by year 1 • Monthly narrative and data reporting 32

33. Grant-funded Collaboratives Southeast #2 Start Date – December 3, 2009 23 Practices 159 Providers 228,000 patients (4,200 DM) Northcentral PA Start Date – November 10, 2009 9 Practices 81 Providers 75,000 patients (1,700 DM) Northwest PA Start Date – September 10, 2009 16 Practices 34 Providers 102,000 patients (3,000 DM) 33

34. Other Collaboratives • South Central – 2 / Lehigh Valley Hospital and Health Network • GOHCR to coordinate and provide technical support • Lehigh Valley to provide funding and support to practices • 20 practices – Lehigh Valley Hospital and Health Network • Practices will report on CCI measures • Pittsburgh Regional Health Initiative • Meeting to work out details 34

35. One Best Practice Change 35 A paradigm shift from “I tell the patients and it is up to them to follow my advice.” to “How can I empower patients to manage their diabetes?” Institutionalization of care management (CRNP and RN) Implemented new asthma visit template Implementing SMS (new staff roles, enhanced educational resources, patient outreach, planned visits) Open access scheduling (homeless clinic) Ophthalmology Clinic Developed Patient as a team member Use of disease registry for tracking patient Expanding the role of our medical assistants to fill out diabetes flow-sheets and perform monofilament exams Replicating immunization follow up for diabetics Patient Panel review with PCP and RN prior to start of office hours Implementation of an EMR Developed diabetic report card

36. Additional Features www.MeetYourHealthHalfway.com Asthma Educator Training & Certification Continuing Education Credits Community Resources – Trainings offered to support Group Visits, Self Management Supports and recognition by NCQA Behavioral Health Integration Statewide Communication Plan recently created that will disseminate information about the initiative Electronic Reporting of narrative and data reports PA Listserv – to share information with all practices in all regions 36

37. Next Steps Formal evaluation of the project Sharing the data Continue rollouts across the state Maintain and enhance spread Work with Regional Steering Committees to sustain the project. CMS Advanced Primary Care Collaborative Application Implement creative ways to engage additional practices Prepare for Gubernatorial Transition 37

38. Lessons Learned Prior Proper Planning Prevents Poor Performance Friend vs. Improvement Coach vs. Purse Stings Touch points with practices Data measure specifications and performance expectations Include performance requirements for money Increase staff support of the project Engage hospitals sooner and more actively Care Manager Support at month 6 (make sure it covers FT person) No prework = No participation/No improvement $$$ may not have as big of an impact as we thought 1st impressions are not always right 38

39. Additional Information www.rxforpa.com Brian Ebersole Governor’s Office of Health Care Reform 439 Forum Building Harrisburg, Pennsylvania 17120 bebersole@state.pa.us 717-346-9712 717-772-9069 (fax) 39