Maine PCMH Pilot & Community Care Teams (CCTs)
description
Transcript of Maine PCMH Pilot & Community Care Teams (CCTs)
Maine PCMH Pilot & Community Care Teams (CCTs)
Lisa M. Letourneau MD, MPH
October 2013
Maine PCMH Pilot Leadership
Maine Quality Counts
Dirigo HealthAgency’s (DHA’s)
Maine QualityForum
Maine Health Management
Coalition
MaineCare (Medicaid) 2
Maine PCMH Pilot Practice “Core Expectations”
1. Demonstrated physician leadership2. Team-based approach3. Population risk-stratification and management4. Practice-integrated care management5. Same-day access6. Behavioral-physical health integration7. Inclusion of patients & families8. Connection to community / local HMP9. Commitment to waste reduction10. Patient-centered HIT
3
Implications of CMS MAPCP Demo• 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)
4
4
Maine PCMH Pilot - MAPCP Timeline
ME PCMH Pilot - Original
ME PCMH Pilot - Extended
Jan 1, 2010
Dec 31, 2014
Jan 1, 2012
Pilot Expansion,
Medicaid HHs
2011 2012 2013 Dec 31, 2014
MAPCP Demo – 3yr
5
CCTs
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)
Lisa Letourneau 6
High-need Individual
Maine PCMH Pilot Community Care Teams
Transportation
Workplace
Environment
Food Systems
Shopping
Income
HeatFaith
Community
Literacy
Coaching
Physical Therapy
Hospital Services
Specialists
Outpatient Services
Med Mgt
HousingCare Mgt
Behav. Health & Sub
Abuse
Family
Schools
7
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
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
Maine PCMH Pilot Community Care Teams, Phase 1 and Phase 2 Practice Sites
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
Health Homes Beneficiary
Coaching
Med Mgt
Care Mgt
Behav. Health & Sub Abuse
MaineCare Health HomesStage A: Help Individuals with Chronic Conditions
12
Maine’s Medical Home Movement
~ 540 Maine Primary Care Practices
25 Maine PCMH Pilot Practices
50 Pilot Phase 2
Practices
120+ NCQA PCMH Recognized Practices
~150 eligible MaineCare HH-Practices
Payers: • Medicare• Medicaid (HH)•Commercial plans (Anthem, Aetna, HPHC)•Self-funded employers
Payer: Medicaid
Payer: Medicare
14 FQHCs CMS APC
Demo
13
CCT Populations ServedCCTs review data from available sources (Medicare RTI reports, MaineCare Utilization reports, other payers, HIN) to identify •Hospital Admissions
o 3 or more admissions in past 6 monthso 5 or more admissions in past 12 months
•Emergency Department Utilizationo 3 or more E.D. visits in past 6 monthso 5 or more E.D. visits in past 12 months
•Payer identification of high-risk or high-cost patients
14
CCT Staffing
Minimum expectations:•Medical Director (part-time)•CCT Manager•Nurse Care Manager•LCSW / Care Coordinators•Access to BH, SA expertise
15
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
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
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
CCT Reporting
19
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
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
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
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
PCMH: Hub of Wider Delivery & Payment Reform Models (ACOs!)
Payers
Pharmacies
Home Care
HealthMane
PartershipsSpecialists
NursingHomes
Home Health
Hospitals/Hospitalists/
CareManagers
Employers
Primary Care Providers
PatientCenteredMedical Home
24
ACO
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
26
Contact Info / QuestionsMaine Quality Counts
• www.mainequalitycounts.org Maine PCMH Pilot
• www.mainequalitycounts.org(See “Programs” PCMH)
Lisa Letourneau MD, MPH• [email protected], 207.415.4043• [email protected], 207.266.7211
27