Health Care Home: Personalized Care for Better Health

2. MN Health Reform In 2008 MN legislature passed health reform legislation that takes a comprehensive approach. • Public health investment • Market transparency • Care redesign and payment reform • Consumer engagement

3. Framework for Minnesota’s Vision: IHI’s Triple Aim • Improve population health • Improve the patient/consumer experience • Improve the affordability of health care

4. What is a health care home? • Also known nationally as the patient centered medical home or federally as APC, advanced primary care or a “health home”. • A health care home is an approach to primary care in which primary care providers, families and patients work in partnership to improve health outcomes and quality of life for individuals with chronic or complex health conditions. • Reimbursement for care coordination – something that is not paid for now

5. Health Care Home Better health made easy A clinic or provider that is certified as a health care home offers personalized care with your team of providers and specialists to meet your health care needs and improve your health.

6. Primary Care Delivery Redesign, What is different?

7. What We Know About Care in a Patient & Family-Centered (Health Care) Home: Center for Medical Home Improvement • Patient and family-centered care is increased • Family worry and burden are reduced • Care coordination and chronic condition management lead to: • Reduction in emergency room use • Reduction in hospitalizations • Reduction in redundancy • Efficiency and effectiveness are increased

8. Health Care Home Certification • The health care home rule was adopted and published on January 11, 2010. • HCH certification is voluntary for clinics / clinicians. • Providers who provide the full scope of primary care services can apply, including geriatricians. • There is flexibility for innovation built into certification. • Clinics are recertified annually. Over time based on improvements in outcomes measures.

9. Health Care Home Standards • Access: facilitates consistent communication among the HCH and the patient and family, and provides the patient with continuous access to the patient’s HCH • Registry: uses an electronic, searchable registry that enables the HCH to identify gaps in patient care and manage health care services • Care coordination: coordination of services that focuses on patient and family-centered care • Care plan: for selected patients with a chronic or complex condition, that involves the patient and the patient’s family in care planning • Continuous improvement: in the quality of the patient’s experience, health outcomes, cost-effectiveness of services

10. MN Health Care Home Rule, Consumer Focus • Continuous after hours access to your clinic, includes access to medical record care • Focus on shared-decision making and patient choice. • Care coordination that focuses on patient and family centered care, such as development of your care plan with patient and families. • Development of patient centered goals and emergency after hours plan with patients and families • Collection and use of cultural, race and ethnicity data.

11. MN Health Care Home Rule, Consumer Focus • Use of registry for consistent patient and family communication. Patient quote “makes you feel like they care about you all the time”. • Families and consumers participate on HCH clinic advisory committees or QI committees • Quality improvement verification patient satisfaction/ experience survey • Patient Experience measurement required element for recertification.

12. MN Health Care Home Rule, Community Partnerships • Patients team is defined by the patient’s needs. • Care planning is done with extended community partners. Goal, one comprehensive care plan. • HCH’s required to establish partnerships with community referral resources.

13. HCH Certification Updates # Certified: Clinics: 134 # Certified Providers: 1,651 Patients receiving health care in a certified clinic: 1,797,230. May 16, 2011 Applicants are from all over the State Variety of practice types such as solo, rural, urban, independent, community, FQHC and large organizations. All types of primary care providers are certified, family medicine, peds, internal med, med/peds and geriatrics.

14. Certified Clinicians / Clinics • Allina Medical Clinics • Bluestone Physician Service • CentraCare Health System • Children’s Clinics • Christopher J. Wenner, MD • Fairview Clinics • HealthPartners • Lakewood Health Clinics • Mankato Clinic, Pediatrics • Mayo Health System-Austin Medical Center, FM • Mayo Health System - Owatonna Pediatrics • Mayo Clinic -Employee Community Health Clinics • North Metro Pediatrics • NorthPoint Health & Wellness • Park Nicollet, St. Louis Park, Minneapolis, Eagan & Plymouth Clinics • SMDC Pediatric Clinic • United Hospital District Clinics • University of Minnesota Physicians Clinics

15. To Find a Certified Health Care Home

16. How do we know which clinic is a HCH?

17. Referrals • All certified clinics are required to have a process for new HCH patients. • Call clinics through their routine methods, provider referral, call center, social services, etc. • Notify them that you have a person who would benefit from a health care home.

18. Health Care Homes Contacts: health.healthcarehomes@state.mn.us http://www.health.state.mn.us/healthreform/homes/index.html 651-201-5421 Marie Maes-Voreis, RN MA HCH Program Director marie.maes-voreis@state.mn.us