Session #A3b Friday, October 11, 2013
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Transcript of Session #A3b Friday, October 11, 2013
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Session #A3bFriday, October 11, 2013
Health Homes: A Holistic Approach to Service Delivery
David A. Johnson, MSW, ACSW
Collaborative Family Healthcare Association 15th Annual ConferenceOctober 10-12, 2013 Broomfield, Colorado U.S.A.
Faculty Disclosure
I currently have the following relevant financial relationships (in any amount) during the past 12 months:
Employed by Amerigroup/WellPoint, companies providing programs and services for persons enrolled in Medicaid and/or Medicare
Objectives
Define health homes in comparison and contrast to patient centered medical homes
Describe rational for health homes as a disruptive innovation in health service delivery system
Identify health home models and discuss their advantages and disadvantages considering such factors as clinical and financial implications, patient and provider pretences and orientation to service delivery
Learning Assessment
Audience Question & Answer
Learning Assessment
Audience Question & Answer
Current Health Home Activities
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Outline
Health HomeDevelopment
OverviewHealth HomeModels
What is a home
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Health Homes? Home Health? Patient Centered Medical Home?
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“If We Build It They Will Come”• Who is the person requesting health
services?• What is being requested? What is it that
this person wants when seeking health services?
• What is his or her prior experience?• What is the person’s understanding of
health services? • Where is the person seeking health
services supposed to go?• How does the person know what it is he
or she is supposed to do to address health conditions?
• Is the health services delivery system “familiar, safe, secure, comfortable, and in harmony with the person’s surroundings”?
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Real Story
Chronic Medical Conditions
• Among individuals enrolled in Medicare and Medicaid 62 percent live with two or more chronic medical conditions; 22 percent experience five or more chronic medical conditions (2009 Medicare data)
• In a population of 1 million, Miller (2012) estimates that of 13 chronic conditions with co-occurring behavioral health conditions the health care cost differential is $665 million more between individuals with and without co-morbidity1
• CMS estimates 45 percent of dual-eligible hospitalizations could have been avoided in 2005 if care had been better coordinated2 11
1. Miller, B. (2012) SHAPE, Sustaining Integrated Care. 2. Cassidy, A, et al. (2012) Care for Dual Eligibles. Efforts are afoot to improve care and lower costs for roughly 9 million people enrolled in both Medicare and Medicaid. Health Policy Brief, Health
Affairs, Robert Wood Johnson Foundation.
What Is the Problem?• Individuals with chronic conditions that are poorly
managed and controlled resulted in having premature mortality and higher costs for more intensive treatment
• Factors– Self-care is poor
» Lack resources» Lack knowledge» Lack motivation
– Health delivery system is fragmented» Lack communication between health service providers» Lack focus on the long-term health needs of individuals; structure of the delivery
system oriented to defining a problem and a solution—acute episodic care model» Lack a consumer-focused structure (office hours, engagement and education of
individual) » Lack a financial model to promote collaboration and a long-term view of individual’s
health
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Point of View• Health homes are focused on individuals with multiple co-
occurring chronic conditions or a severe mental illness• A health home represents collaborative and integrated
health services addressing physical and behavioral health issues/conditions inclusive of community resources and supports, as well as long-term services and supports
• Service delivery model may include a primary physician clinic, a Community Mental Health Center, a Community Health Clinic (FQHC/FQHC look-a-like) or other community-based health services delivery organizations
• Preferred Model: An Managed Care Organization (MCO) provides end-to-end care coordination in collaborating with a health home lead organization that represents a point-of-service with co-located physical, behavioral health services, as well as a co-located care manager
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A health home addresses physical and mental health issues and conditions…
coordinating with community supports and services
What does a Health Home Address?
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Premise for Health Homes• Mind and body are connected• Team care is better care• Engagement and self care• Coordination, collaboration, continuity enhance health
services• Mobilizing and coordinating primary medical services,
specialists, behavioral health, and long-term services and supports increases efficiencies and improves patient outcomes
• Outcomes– Increases health status and quality of life– Reduces premature mortality– Enhances service quality– Reduces Hospital Inpatient admits/length of stays– Reduces Emergency Department utilization– Reduces redundancy in tests and procedures– Reduces costs
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Current Health Home Activities
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Outline
Health HomeModels
Health HomeDevelopment
Overview
Patient-Centered Medical Homesand Health Homes• PCMH seeks to strengthen the physician-patient
relationship by replacing episodic care based on illnesses and an individual’s complaints with coordinated care for all life stages (acute, chronic, preventive and end-of-life) and establish a long-term therapeutic relationship
• The physician-led health team is responsible for coordinating all of the individual’s health service needs and arranges for appropriate services with other qualified physicians and support services
• Joint principles of PCMH– Personal physician– Physician directed medical practice– Whole person orientation– Care that is coordinated and/or integrated– Quality and safety – Enhanced access to care – Payment structure
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What Is a Health Home?
Definition: An integrated, person-centered, and physical and behavioral service delivery system aimed at populations with complex, chronic conditions – fueled by exchange of health information, evidence-based practices and care coordination. Intended to improve outcomes by reducing fragmented care and promoting patient-centered care.
Health Home Services Required Comprehensive care management Care coordination and health promotion Comprehensive transitional care Individual and family support (includes Auth Rep) Referral to community and social support services HIT to link services, as feasible and appropriate
Eligible Populations At least two chronic conditions, including
– Asthma– Diabetes– Heart disease
One chronic condition and be at risk for another One serious and persistent mental health condition
– Obesity– Mental condition – Substance abuse disorder
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Key Differences From Patient-Centered Medical Homes• Statutorily defined with enhanced FMAP to eligible
populations, conditions and services• Multiprovider care team focus—does not have to be physician
lead• Chronic condition focus with integration of medical and
behavioral health• Integration of community resources, family/social supports• New potential primary care roles for Health Home (e.g. BH
specialists or community-based providers)• New payment methodologies (e.g. patient management fee,
shared savings, P4P, e-consult payments)• Extensive health information sharing
States in CMS Approval Process• States with approval (12)
– Alabama, Idaho, Iowa, Maine, Missouri, North Carolina, New York, Ohio, Oregon, Rhode Island, Washington, Wisconsin
• States with planning requests approved by CMS (8)– Arkansas, Arizona, California, District of Columbia, Mississippi, New Jersey,
Nevada, New Mexico• States that have submitted draft state plan amendments to
CMS (7)– Alabama, Illinois, Maine, Massachusetts, Oklahoma, Vermont, Wisconsin
• States working on a draft of SPA (2)– Indiana, West Virginia
• States in conceptualization phase (10)– Colorado, Delaware, Georgia, Hawaii, Kansas, Michigan, Minnesota, North
Dakota, New Hampshire, Texas
20Source: Integrated Care Resource Center
States Health Homes Status
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Health Homes Federal Guidance• Established by the PPACA Section 2703• States selection of this option must apply by filing a State
Plan Amendment (SPA)• Requires consultation with SAMHSA • CMS is collaborating with SAMHSA, HRSA and AHRQ to
ensure evidence-based approach and consistency in implementing
• CMS issued draft Health Home Core Quality Measures (Jan. 15, 2013)
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Sources: http://www.samhsa.gov/healthreform/healthhomes/; http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD10024.pdf
Current Health Home Activities
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Outline
Health HomeModels
Health HomeDevelopment
Overview
Key Components of the AGP Health Homes ModelConsumer Considerations
• Member identification and placement
• Voluntary vs. mandatory participation
• Complex Care Coordination
• Physical and behavioral health integration
• Case and disease management
• Continuity of care• Quality metrics
Provider Considerations
• Health Home provider identification and credentialing –
• Team-Based Care • Multi-discipline teams• HIT/Service
Records/Continuity of Care Document
• HH Capabilities Development
State/MCO Considerations
• Single vs. multicarrier operating models
• Service area requirements and roll-out
• Financial Model• HIT and HIE
requirements• Quality Assurance• Success metrics and
reporting• Independent evaluation
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Models for Health Homes (as defined in PPACA, Section 2703)• A designated provider, physician, clinical/group practice,
etc.• A team of health professionals with links to a designated
provider—free-standing, virtual, hospital-based, community mental health centers, etc.
• A health team: medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral health providers
• These delivery models are reflected in two orientations:– Care Management/Case Management (2)– Co-located, integrating physical and behavioral health services (1 & 3)
Considering these models what is the potential meaning to individuals who would “come home?”
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Sample of Health Home Models by StateState Target
PopulationHealth Home Providers
Enrollment Payment
Alabama (4/9/13)
Two Chronic conditions; or one and at risk of a second (multiple conditions listed)
Team of Health Care Professionals: Primary Medicaid Providers, including FQHCs & Rural Health Clinics
VoluntaryEstimate up to 220,000
PMPM &FFS
Idaho(1/1/13)
SMI, SED, Diabetes and asthma
Community based providers that meet set standards
Voluntary—self-refer or automatically enrolled with opt out
PMPM
Iowa(7/1/12)
Two Chronic conditions; or one and at risk of a second
Primary Care , CMHCs, FQHCs
Opt-in when presenting at provider’s clinic
PMPM, & Quality Payment
Maine(1/1/13)
Variety of chronic conditions
Community Care Teams partner with primary care health homes practices
Auto assigned by State (opt-out)
PMPM
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NY Health Home ModelLead HH
Case Manager
CM Agency
Primary Care
BH Services
Hospital
Community
Medicaid Agency
MCO
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New York Implementation Challenges in Health Homes Implementation, End of Year 1• Six areas are identified as posing significant challenges in
establishing health homes– Becoming operational– Enrolling eligible beneficiaries– Determining payment rates– Building relationships and defining roles– Developing health information exchanges– Measuring quality
• Challenge finding and enrolling eligible beneficiaries (84,000 identified, 41,000 enrolled); contracting MCOs and Health Homes has taken longer than expected and delayed enrollment efforts– As of January 2013 about 17,000 individuals are receiving health home services
or are in in the outreach and engagement phase– Approximately 13,000 of these individuals converted from legacy case
management programs
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Source: Implementing Medicaid Health Homes in New York: Early Experience (February 2013). Medicaid Institute, At United Hospital Fund available online: www.uhfnuc.org.
KS Health Home Model
Medicaid Agency
MCO CBO
Care Manager
Specialty Services Hospital and Facility Services
Community and Support Services
Health Home
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Primary Care
Kansas Health Home Planning Process
• Established a central work group • Established seven sub-workgroup
– Quality Measures– Service Definitions– Stakeholder Engagement– Target Populations– Web Page Development– Provider Qualifications– Payment
• Focus group reviews workgroup products
• Statewide forum representing a diversity of groups, CMHC, FQHC, ID/DD, hospitals, private foundations, Department of Health
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Current Health Home Activities
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Outline
Health HomeModels
Health HomeDevelopment
Overview
Goals in Establishing Health Homes• Build capacity among health services providers in
establishing a team-based model of services• Establish health information technology for documentation
and information sharing– Patient registries with alerts to follow- up with patients– Referral tracking systems to monitor specialty services utilization – Notification systems to identify an individual’s admission or discharge from an
emergency department, inpatient or residential/rehabilitation setting– Monitor prescriptions for counter-indicated prescriptions and refills of needed
medications– Mobile technologies for self-monitoring with provider notification systems– Direct provider communications (continuity of care documents)
• A system for constructing personal health plan promoting self care
• Establish clinical processes to facilitate collaboration between the MCO and health home care managers
• Monitoring and tracking of quality indicators32
Goals in Establishing Health Homes, cont’d.• Capacity to track quality indicators and program outcomes• CMS has established eight recommended core measures:
– Adult body mass index– Ambulatory Care –Sensitive Condition Admissions– Care Transitions– Follow-up after hospitalization for mental illness– Plan—all cause readmission– Screening for depression and follow-up plan– Initiation and engagement of alcohol and other drug dependence treatment– Controlling high blood pressure
• PPACA provides for independent program evaluation to include a reduction in hospital admissions and emergency department utilization
• Establish program evaluation and define outcomes• Establish payment models to sustain core health home
services
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Disruptive InnovationsEvolving the Health Service Delivery Model
Move From Move To
Admit/discharge Engagement/follow-up
Acute—in the moment focus Long-term
Specific presenting condition Holistic—mind and body
Compliance Adherence
Physician decision-making Shared decision-making
Passive patient Active/engaged individual
Episodic documentation Registries, alerts and reminders
File audits, episodic events Outcomes—clinical, financial and consumer
Disease coping Disease management and health behaviors
Individual provider Service team
Volume financial model (FFS) Value financial model (shared risk)34
Establishing a Comprehensive Care Management Model | Focus on the Individual
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Healthy Function
Reduced Performance
ChronicCondition
Acute Illness Treatment
Disease/Condition Management
Health Promotion
Health Home
Service Mix
Screening—blood pressure; cholesterol, blood sugar, depression, anxiety, alcohol, drugs, dental, vision, hearingLife Style Management—smoking, alcohol, sleep, diet, exercise, stress managementDisease Prevention—immunizations
Barriers —psychosocial
Palliative Care
Outpatient—triage, tests and procedures, pharmacy, inpatient—surgery,ED; behavioral health conditions;co-occurring conditions
Diagnosis and treatment of long-term conditions, labs, proceduresself-care/condition management; pain management; advanced directives
Individual Physical, cognitive, attitudes, beliefs, values
HCBSHousing, Employment
Manage Pain
Community
ED, Inpatient, Residential, LTSS
Specialists, Ancillary Services, RX, Dental,
Vision
Health Home—Outpatient Physical and Behavioral
Health
End-
to-E
nd C
are
Coo
rdin
ationMCO ensures
continuity of care & quality,
manages inpatient utilization,
administers claims and other
administrative functions
Health Home establishes a
consistent and holistic health
service coordinating
across service delivery system
Establishing a Comprehensive Care Coordination Model | Focus on the Service Delivery System
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Program Activities: Roles and Responsibilities
Health Home MCOOutreach and engagement Identify members from data files for HH
Biopsychosocial assessment, establish personal health plan inclusive of safety, advanced directive
Benchmarks, expected outcomes
Outpatient Physical and Behavioral Health Services—assessment and health plan
Provide sample clinical guidelines-pathways to manage members with chronic conditions
Wellness Visits and Health Promotion Monitor health screenings completed
Chronic Condition Management: acute episodes of care, education and self-management (chronic care)
Monitor care for chronic conditions, duplication of test and procedures, ER/inpatient admissions
Case management; refer to community/social supports Comprehensive care management—c communicate with HH on social supports
Individual and Family Support Respite Services, value added benefits
Care Coordination between PH & BH; primary care & specialists
Vendor servicesAncillary services
Facilitate Transitions in Care Utilization management
Monitor members over time--registries to track QA/QI Reporting
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Point of View ReDux• Establish health homes for individuals
experiencing co-occurring chronic conditions or a severe mental illness that incorporate physical and behavioral health providers co-located, collaborating, and providing integrated services
• Care managers are co-located to facilitate collaboration and coordination with specialists, facilities, and community resources
• Services are coordinated between primary service providers and specialty service providers, long-term services and supports, as well as ensuring transitions in services between hospital and other community-based facilities
• Collaboration and coordination ensures continuity in services over time
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Point of View ReDux, cont’d.
• A health home may be established in a physician clinic, community mental health center, FQHC, Rural Health Services, or other CBOs that establish a mechanism to offer physical and mental health services
• The role of the MCO is to interface with health homes to ensure continuity and coordination of the health services delivery system