October 21, 2103 1

Community Health Teams

The Vermont Experience

Lisa Dulsky Watkins, MDAssociate Director

Vermont Blueprint for Healthlisa.watkins@state.vt.us

Department of Vermont Health Access

October 21, 2103 22

Principles of Team-Based Care

Shared Goals

Clear Roles

Mutual Trust

Effective Communication

Measureable Processes and Outcomes

Mitchell et al, Core Principles & values of effective team-based health care, 2012 (Discussion

Paper, Institute of Medicine, Washington, DC. www.iom.edu222

Department of Vermont Health Access

October 21, 2103 3

Team-Based Care

“Team-based health care is the provision of healthservices to individuals, families, and/or their

communities by at least two health providers who work collaboratively with patients and their caregivers

– to the extent preferred by each patient – to accomplish shared goals

within and across settings to achieve coordinated, high-quality care.”

Naylor et al, Inter-professional team-based primary care for chronically ill adults: State of the Science, 2010

Department of Vermont Health Access

October 21, 2103 4

Department of Vermont Health Access

Vermont’s Executive Branch and Legislature Consistent Support for Health Reform

2003 Blueprint launched as Governor’s initiative

2005 Implementation of Wagner’s Chronic Care Model

2005 Medicaid Global Commitment (Section 1115) Waiver

2006 Blueprint codified as part of sweeping reform legislation (Act 191)

2007 Blueprint leadership and pilots established (Act 71)

2008 Community Health Team structure and insurer mandate (Act 204)

2010 Statewide Blueprint Expansion outlined (Act 128)

2011 Planning for “Single Payer” (Act 48)

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Insurers

•Community Health Teams•Funded by all insurers•Intent is to minimize barriers

•$35,000/2000 active pts./yr.•Scaled based on population

•Medicaid•Commercial Insurers•Medicare

•SASH Teams•Funded by Medicare (CMMI Demonstration Project)

•$70,000/100 participants/yr.•Scaled based on # panels

•Addictions Teams•Funded by Medicaid Health Home (potential 90/10 federal match)

•2 FTEs/100 suboxone pts.•Scaled based on # pts. in prescribing practices

Blueprint Payment Reforms

Payments to Practices1) FFS2) PBPM Enhanced Payments

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Health IT Framework

Evaluation Framework

Primary Care

Practice

Hospitals

Public Health Programs & Services

Core Community Health TeamNurse Coordinators

Social WorkersNutrition Specialists

Community Health WorkersPublic Health Specialists

Extended Community Health TeamMedicaid Care Coordinators

Medicare Teams based in Housing HubsAddiction Teams

Specialty Care & Disease Management

Programs

A foundation of medical homes and community health teams that can support coordinated care and linkages with a broad range of services

Multi-insurer payment reform that supports this foundation of medical homes and community health teams

A health information infrastructure that includes EMRs, hospital data sources, a health information exchange network, and a centralized registry

An evaluation infrastructure that uses routinely collected data to support services, guide quality improvement, and determine program impact

Mental Health & Substance Abuse

Programs

Social, Economic, & Community Services

Self Management Workshops

Primary Care

Practice

Primary Care

Practice

Primary Care

Practice

Multi-Insurer Payment Reform Framework

HVVo Visiting

Nurse/Home Health Agency

Health Service Area Architecture

TIMELINEPatient Centered Medical Homes and

Community Health Team Staffing in Vermont

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7October 21, 2103

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VermontHealth

InformationExchange

(VITL)

Central Clinical Registry and

Integrated Health Record

(Covisint DocSite)

Core data elements

Core data elements Core data elements

Hosted EMR

EMR

CommunityHealth Team

Independent Primary Care

Practices

Primary Care Practices

No EMR

Organization-owned

Primary Care Practices

Core data elements

Tobacco Cessation

Counselors

Senior Support Services

Vermont Health Information Technology Infrastructure

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CHT Identification of High-Risk Patients

• Practice panel management, outreach and referrals

• Referrals from other health care and community service organizations • Risk stratification and utilization data from Medicare

• Risk stratification and utilization data from Medicaid • Data from commercial insurers

10

CHT Example

Providers refer via the EHR (PRISM). CHT provides in person 1:1 support, in groups or by phone, 3-6 visits, commonly 4

interactions. CHT helps patients set realistic goals and timelines utilizing motivational

interviewing, action planning and short term goal setting CHT focuses on achievable realistic outcomes with our patients, addressing barriers

that may interfere with success. Short term case management, most often provided by our medical social worker. CHT patients can re-engage with the team as necessary after graduation

Services include: Health coaching around nutrition,

exercise and stress management Basic Diabetes Education Medication Management Behavioral/Mental Health Connection to community and

financial resources

October 21, 2103 111111

0%

20%

40%

60%

How Satisfied Are you with the Services You Can Offer To Your Patients by Referral ?

% Satisfied & Very Satisfied -Pilot Site 50% 17% 33% 17% 29%

% Satisfied & Very Satisfied - Other FAHC

Primary Care Practices

38% 19% 13% 6% 19%

Nutrition

Counseling

Exercise

Counseling

Stimulating

Behavior Change

Patient

Education Overall

CHT Example

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0%

20%

40%

60%

80%

100%

How Satisfied Are you with the Services You Can Offer To Your Patients Within Your Office Team ?

% Satisfied & Very Satisfied - Pilot Site 100% 67% 50% 50% 67%

% Satisfied & Very Satisfied - Other FAHC

Primary Care Practices

6% 6% 6% 6% 6%

Nutrition

Counseling

Exercise

Counseling

Stimulating

Behavior Change

Patient Education

MaterialsOverall

CHT Example

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CHT Example

Clinical Outcomes

Patients were tracked by the multidisciplinary CHT using a common database and assessed 6 months after “graduation” (data collected between March 2009 and August 2012)

• 59% of patients referred to the CHT for diabetes-related issues had sustained improvement in BMI (n =44) and 67% of patients had sustained improvement in HbA1c (n=87)

• 49% (n=118) of patients referred to the CHT for exercise and nutrition issues had a sustained improvement in their BMI and 31.5% (n=117) had a sustained improvement in their LDL (average decrease of 24mg/dL)

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CHT Challenges

• Documentation• Consistency• Double data entry• Reporting to funders (“ROI”)

• Communication• Patient/consumer engagement• General public awareness