Transcript The Rhode Island Chronic Care Sustainability Initiative

The Rhode Island Chronic Care
Sustainability Initiative (CSI-RI)
Presentation for PCMH-Kids Stakeholders
November 20, 2013
Debra Hurwitz, MBA, BSN, RN
CSI Co-Director
1
The Rhode Island Chronic Care
Sustainability Initiative (CSI-RI)
Vision :
• Rhode Islanders enjoy excellent health and quality of life.
They are engaged in an affordable, integrated healthcare
system that promotes active participation, wellness, and
delivers high quality comprehensive health care.
Mission:
• To lead the transformation of primary care in Rhode Island in
the context of an integrated health care system. CSI-RI brings
together critical payers, providers, purchasers, consumers,
educators and other leaders to develop, implement, evaluate,
refine and spread models to deliver, pay for, and sustain high
quality comprehensive primary care.
2
What is CSI-RI?
• Working with all major health care stakeholders to
transform primary care in Rhode Island.
• Promotes the PCMH, a model of primary care that is
patient-centered, coordinated, accessible and teambased. The model focuses on prevention, wellness
and appropriate treatment.
• This will lead to improved care, lower costs and better
health outcomes for Rhode Islanders.
3
Where is CSI?
• 48 practices (297 providers)
–
–
–
–
5 Pilots (2008)
8 Expansion 1 (2010)
3 Expansion 2 (2012)
32 Expansion 3 (2013)
• 14 Community Health Centers
4
CSI-RI Collaboration Partners
Payers
• Medicaid
• All commercial plans
• Medicare
Purchasers
• Self-insured employers
Providers
• Primary care providers (private practices, community health centers,
hospitals and clinics)
State
• Office of the Health Insurance Commissioner, Executive Office of Health
and Human Services, Department of Human Services, Department of
Health
Technical Experts
• Department of Health; QIO
5
CSI-RI helps plans and practices build
sustainable Patient-Centered Medical Homes
• Data-driven practice
transformation
• NCQA Level 3
• Nurse Case Manager on
the team
• Common Contract
• All-payers involved
• PMPM paid on
attributable lives
• PMPM based on
performance
Used with permission of Ed Paul MD,
Yuma Regional Medical Center
6
Key Elements of CSI-RI
PCMH
• Common Developmental Contract
•
•
•
•
•
•
•
Supplemental payments to practices
Nurse Care Manager at the practice site
Practice coaching for team-based care
Participation in learning collaborative
NCQA recognition Level 3
HIE capacity
Common measures of performance for improved management
of chronic conditions (i.e., diabetes, heart disease, depression,
tobacco cessation)
• Data and reporting on quality measures
• Performance incentives based on PMPM
7
Transformative Change Built
into the Common Contract
CSI Steering Committee
Executive Committee
Patient Advisory
Group
Marketing/
Communication
Working Committees
Data and
Evaluation
PTST
Practice
Reporting
Payment
Reform/
Contract
Service
Expansion and
Integration
9
Care Management Activities
Nurse Care Manager
lynchpin for success
• Located within practices, regardless of payer
• Activities
• Identification of high risk patients
• Patient assessment
• Care coordination (transitions of care; specialist referrals; homeand community-based services and supports)
• Patient/family education
• Engage patients in shared decision-making
• Team communication
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What about the patient?
• “Being in a patient-centered medical home has changed my life. I’m not
just living with a chronic condition – diabetes – I’m actively engaged in the
dialogue focused on my care. Together, my care team and I try to find the
best preventive and treatment solutions that work for me.”
Connie Susa, of Warwick, a patient at Hillside Family and Community medicine, in the April 6,
2013 issue of the Providence Journal
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CSI-RI is growing
• 20 practice expansion 10/01/13
• Goal to add 20 practices per
year
• Future:
– Learn and refine model with
RIQI
– Employer engagement
(benefit design)
– Employee engagement
(PCP designation)
12
Harmonized Measures of
Change in Multiple Domains
Transparency in Adjudication
of the Common Contract
Take Home Points #2
• Measures and targets all parts of the triple aim
– Triangulation allows a better overall picture of
progress
– Example: Patient experience and utilization driving
access change
• Contract on measures you have used
– Develop and test new measures in the field
– Set targets so that 2/3 of practices benefit
• Measure and pay on the same populations
whenever possible
Does it work?
Evidence of transformation
Proactive Population
Management &
Tracking
Improved
Professional
Satisfaction
Overall
Transformation
• “The single most successful piece has been the
ability to record, track and respond to outcomes
data. On a population-level, knowledge is power.”
• “The professional satisfaction now compared to
[before the pilot] is through the roof.”
• It’s hard to believe how far we’ve come. Just the fact
that so much has changed is one of the most important
things about the whole project… The project has given
us both time to think outside of the box and has helped
us develop a meaningful way to get out of the box and
transform our practice to something new.”
From M. Rosenthal, Presentation to CSI-RI Steering Committee, 7/13/2012
16
All CSI Site Variation in HTN BP Control
Variation in HTN BP Control
STDEV/AVG
1
0.8
0.6
0.4
0.16729966
0.2
0
Q4 2011
Q4 2011
Variation in HTN BP Control
0.08096773
0.072702508
Q3 2012
Q1 2013
Q3 2012
Variation in HTN BP Control
Q1 2013
Variation in HTN BP Control
1
1
1
0.8
0.8
0.8
0.6
0.6
0.6
0.4
0.4
0.4
0.2
0.2
0.2
0
0
Thirteen CSI Sites
0
Thirteen CSI Sites
Thirteen CSI Sites
All Cause Admissions
Number of Admissions in Rolling Year per 1000 Member-Months
12
11
10
9
8
7
6
0
2
4
6
8
10
12
CSI Pilot Group
CSI South County Group
CSI Comparison Group
Linear (CSI Pilot Group)
Linear (CSI South County Group)
Linear (CSI Comparison Group)
y = -0.0461x + 8.5864
R² = 0.1306
y = -0.1665x + 9.3014
R² = 0.7495
14
y = -0.0378x + 10.192
R² = 0.5971
Take Home Points #3
• Practice change precedes performance change
– Need analytic capacity to watch for both
• All-payer involvement and common set of targets
allows practices to focus efforts
– Harmonizing targets between primary care, sub-specialty
care and hospitals would build on that focus
• State can help overcome sticking points in
negotiation
– Attribution
– Harmonization of measures
– Aggregation
Many questions remain
• Can you support PCMH on a FFS model?
– Maybe, probably not easily
• What sort of financial model best supports a
PMCH model?
– Mix of FFS, PMPM, PFP and SS/bundle/capitation
– Various notions of how much of each
• No more than 70% FFS per Bailit
• Can you built SS into a PCMH model?
– Likely need to aggregate
Payment ideas currently
under discussion
• Graduation: What comes after PY2?
• Community Health Teams to Support Small
Practices (VT-like)
• Include child health services
• Bundle Payment for Primary Care Services (MAlike)
• Incentive for improvement in community health
indicators (OR-like)
Build a structure to continue the conversation!
Concluding thoughts
• PCMH Kids should be built on success of
unique RI initiatives
– Affordability standard: Primary Care Spend is a
tremendously powerful driver of change. Expand
it to 17% and include integration with the Medical
Neighborhood.
– Collaborative all-payer approach: CSI has set an
amazing table; bring in more stakeholders
(families, sub-specialists, hospitals) and give them
permission to continue the work.