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Vermont Blueprint for Health Craig Jones, M.D. Blueprint Executive Director Burlington, VT [email protected] 7/16/2015 Vermont Blueprint Context Dedicated leadership Guiding Legislation History of working together Improve quality & control of costs Focus on prevention & wellness 13 Hospitals & Service Areas 3 major commercial insurers, Medicaid, Medicare Hospitals A foundation of medical homes and Advanced Primary Care Specialty Care & Disease Management Programs Community Health Team Nurse Coordinator Social Workers Nutrition Specialists Community Health Workers MCAID Care Coordinators Public Health Specialist Social, Economic, & Community Services Mental Health & Substance Abuse Programs Advanced Primary Care Advanced Primary Care Healthier Living Workshops Public Health Programs & Services Health IT Framework Evaluation Framework 7/16/2015 Advanced Primary Care community health teams that can support coordinated care and linkages with a broad range of services Multi Insurer Payment Reform that supports a 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 Multi-insurer Payment Reforms Insurers •Fee for Service •Unchanged •Allows competition •Promotes volume + •Patient Centered Medical Home •Payment to practices •Consistent across insurers •Promotes quality + •Based on NCQA PPC-PCMH Score •$1.20 - $2.49 PPPM •Based on active case load •Medicaid •Commercial Insurers •Medicare? •Community Health Teams •Shared costs as core resource •Consistent across insurers •Minimizes barriers •5 FTE / 20,000 people •$ 350,000 per 5 FTE •Scaled based on population Data Sources Categories of Measures Reporting Central Registry Clinical Processes Health Status Web based Flexible & dynamic Multi-Payer Claims Database Resource Utilization Expenditures Standard Reports Web based Flexible & dynamic Chart Reviews Clinical Processes Health Status Standard Reports NCQA Scoring Clinical Processes PCMH Standards Standard Reports Public Health Registries Population level Risk Factors Guide planning Track change Standard Reports IMPACT OF INTEGRATED HEALTH SYSTEMPOTENTIAL COST AVOIDANCE ACROSS TOTAL POPULATION ANNUAL CHANGE IN HEALTHCARE EXPENDITURES $450,000,000 $400,000,000 INCREMENTAL EXPENDITURES WITHOUT INTEGRATED HEALTH SYSTEM 28.7% $350,000,000 INCREMENTAL EXPENDITURES WITH INTEGRATED HEALTH SYSTEM $300,000,000 $250,000,000 $200,000,000 1 2 3 4 5 508,17 80% 25 637,130 100% 32 YEARS Target Population % of VT Population # CHTs 42,179 6.7% 2 126,286 316,662 20% 50% 6 16 Building a Learning Health System State • Policy & leadership Web based reporting platforms • Strategic planning Multi-disciplinary study teams • Coordination Comparative effectiveness & evaluation • IT Infrastructure • Central Registry • Multi-payer database University of Vermont • NCQA scoring • Chart review • Analytics • Reporting • Informatics platform • Multi-disciplinary expertise Coaching & Facilitation Team (Blueprint & University of Vermont) Practices Community Health Teams Hospitals Other Services & Providers