Transcript The Rhode Island Chronic Care Sustainability Initiative

Community Health Team Pilot
Program within CSI-RI
September 13, 2013
Debra Hurwitz, MBA, BSN, RN
CSI Co-Director
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Agenda
• Background of CHTs and summary of other
states’ models
• Existing Resources in RI
• Committee Membership
• Committee Charter/Plan
• Deliverables and Time Frame
• Next Steps
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CSI-RI Strategic Plan
• Plan: As part of the 2013 Strategic Plan, CSI
will develop and pilot the implementation of 2
CHT.
• Purpose: To help support small practice in
becoming PCMHs.
• Budget: $75,000 per site to launch pilot by
April 1,
– Contingent on approval of the plan by Budget
Committee
– Additional budget ask for next year
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What is a Community Health
Team?
Definition:
• Community Health Teams (CHT) work with primary care
practices in a given region or network to improve care for
patients with chronic conditions.
• The CHT often provides direct care:
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Care management
Behavioral health care,
Assists with transitions of care
Links patients to community resources.
• Based in a pre-existing health care entity (such as a hospital,
primary care organization or an FQHC) or a newly-formed
non-profit and provide services to a number of associated
primary care practices.
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Vermont CHT Model
Overview
• Each Hospital Service Area (HSA) has a project
manager who oversees two HSA-wide workgroups:
the Health Information Technology Workgroup and
the Integrated Health Services Workgroup (IHS).
• IHS oversees CHT implementation: reorganization of
existing services, creating new services, CHT
composition and administrative entity
• CHT employed by administrative entity (CMS eligiblehospital or health center)
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Vermont CHT
Services
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Vermont CHT Measures
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Vermont CHT Funding
• Direct predefined payment from participating payers:
commercial, Medicare and Medicaid
• Funding required by 2007 legislation
• There is an agreed upon shared cost structure paid to
administrative entity
• Rates: $350,000 per year for salaries and benefits for
each community health team
• CHT use is not based on insurance status and does not
require co-pays or prior authorization
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Oregon CHT Overview
• Coordinated Care Organizations (CCOs) are regional provider
networks made up of a variety of health care providers who
work together to deliver coordinated acute and preventive
care to the State’s Medicaid beneficiaries.
• Preexisting health care entities apply to serve as a regional
CCO.
• Each CCO (currently 15 in operation) develops a transformation
plan specific to the needs of the community it serves.
• These plans demonstrate how the organization will work to
improve health outcomes, increase member satisfaction and
reduce overall costs.
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Oregon CHT Services
Each CCO must have:
•Pcp/nurses
•Mental health providers
•Community members
•Consumer advisory council
(representative sits on the
CCO board
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Oregon CHT Measures
•
17 CCO incentive measures
Access to Care: Getting Care Quickly (CAHPS)
Patient-Centered Primary Care Home Enrollment
Adolescent well-care visits (NCQA)
Prenatal and postpartum care: timeliness of prenatal
care (NQF 1517)
Alcohol and drug misuse: screening, brief intervention
and referral for treatment (SBIRT)
Satisfaction with Care: Health Plan Information and
Customer Service (CAHPS)
Ambulatory care: outpatient and emergency department
utilization
EHR adoption
Colorectal cancer screening (HEDIS)
Elective Delivery
Developmental screening in the first 36 months of life
(NQF-1448)
Screening for clinical depression and follow-up plan
Follow-up after hospitalization for mental illness (NQF
0576)
Controlling high blood pressure
Follow-up care for children prescribed ADHD medications
(NQF 0108)
Diabetes: HbA1c poor control
Mental and Physical Health Assessments within 60 days
for Children in DHS Custody
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Oregon CHT Funding
• CCOs operate on an accountable global
budget from the state
• Participants in CCOs have one single health
plan which integrates physical, dental and
mental health care
• SIM grant of $45 million
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Environmental Scan:
Funding
• Most states fund CHTs under the authorization
of
– 1915 (b) Medicaid Managed Care Waivers
– 1115 research and demonstration waivers
– PPACA 2703 health homes state plan amendments
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Environmental Scan:
Funding
• Vermont-CHT receives direct pre-defined
payment from participating payers
• Alabama, Maine, Montana, North Carolina,
South Carolina, Oklahoma-CHT receives direct
PMPM from participating payers
• New York- Primary care practices receive
direct PMPM from payers and “pass-on”
portion to their associated CHT
• Minnesota- CHT funded through state grant
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References
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The Association of State and Territorial Health Officials. Community health teams issue report (Job Code 16015). Retrieved
from website: http://www.astho.org/Programs/Access/Primary-Care/_Materials/Community-Health-Teams-Issue-Report/
Buxbaum, Jason. (2012, April). Community-based support teams: The national landscape. Building medical home
neighborhoods through community-based teams: lessons from three states with emerging programs. Retrieved from
http://www.nashp.org/webinar/building-medical-home-neighborhoods-through-community-based-teams
Craig Jones, M.D. (Chair), (9/21/12). Webcast: Vermont blueprint for health: working together for better care.
Department of Vermont Health Access, (2010). Vermont blueprint for health implementation manual. Retrieved from
website: http://hcr.vermont.gov/blueprint
Department of Vermont Health Access, (2012). Vermont blueprint for health 2011 annual report. Retrieved from website:
http://hcr.vermont.gov/blueprint
U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2012). Policy innovation
profile: Statewide program supports medical homes through multidisciplinary teams, easy access to information, and
incentives, leading to lower costs and better care. Retrieved from website:
http://www.innovations.ahrq.gov/content.aspx?id=3640
Lisa Watkins, MD, Associate Director, Vermont Blueprint for Health, L. W. Maine Quality Counts PCMH Pilot, (2011).
Community health teams and the medical home. Retrieved from website: http://www.mainequalitycounts.org/hosp-toolsand-resources/doc_view/212-community-health-teams-a-new-tool-for-improving-care-and-outcomes.html
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