The heart and science of medicine. UVMHealth.org/MedCenter Vermont Blueprint for Health John G. King, MD, MPH December 6, 2014

1.Participants will use Vermont's Blueprint for Health as an example of primary care transformation parts of which could be adapted to other setting. 2.Participants will learn a method for supporting primary care to meet NCQA PCMH and health system improvement objectives. 3.Participants will be able to compare care transformation and outcomes in their region/state with the Vermont experience. Learning Objectives

Discuss with your neighbor what you like and don’t like about how family medicine has changed in your area (or state) in the past 5 years. Brain Exercise

What did you learn?

Context - Vermont

Vermont Population: 626,630 One metro area: Chittenden County 150,000 VT US White alone: 93.8% 62.6% Under age 18: 19.6% 23.3% Over 65: 16.4% 14.1% FQHC Hospital-owned Independent Single-site Independent Multi-site Blueprint Practices by type:

Vermont is 13/50 in medical costs per capita The Henry J. Kaiser Family Foundation

2003 initial vision and planning 2006 Vermont Blueprint for Health pilots begin. Revised in 2007, 2008, and , Act 48. Green Mountain Care and state wide funding of PCMH model 2011 Support and Service at Home (SASH) Medicare Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration program, funded by the Center for Medicare and Medicaid Innovation Center (CMMI)2013 State Innovation Model grant from CMS 2013 three ACO’s (Shared Savings Programs) with Medicare, Medicaid and Commercial payers Vermont Health Reform History

Goal Structure Finance Vermont Blueprint for Health

All citizens have access to high quality primary care and preventive health services to establish a foundation for a high value health system in Vermont. Goal

Advanced primary care: NCQA Patient-centered medical homes Multidisciplinary support service: Community health teams (CHT’s) Network of self-management support programs. Multi-insurer payment reforms that fund PCMH transformation and CHTs Multi-faceted evaluation system to determine the impacts of health care reform Learning health system: helps practices and CHT’s plan and implement PCMH and supports continuous improvement and innovation. The Blueprint Model

NCQA PCMH’s

Community Health Team Staff

Coordinator and Wellness Nurse serving panel of 100 Focus on –Transition support after hospital or rehabilitation facility stay –Self-management education and coaching for chronic conditions and health maintenance –Care coordination Function as part of a larger team that includes: CHT, Home Health, Area Agency on Aging, mental health providers. Develop Community Healthy Aging Plans organized around: falls, medication, chronic disease, lifestyle, and cognitive and mental health. Support and Services at Home (SASH)

Care Alliance for Opioid Treatment

Self Management Workshops HLA – Healthier Living Workshop WRAP – Wellness Recovery Action Plan YDPP – YMCA Diabetes prevention

Financing Model

Volume based FFS plus Per Patient Per Month (PPPM) based on primary care practice NCQA-PCMH Recognition Score. –$1.36 PMPM for score of 35 –$2.39 PMPM for score of 100 All insurers share the cost for core CHT members at $70,000/4000 patients ($17.50 per patient) annually Health Information Technology infrastructure – $4.1M Financing Model

644 PCP’s in 123 medical homes 347,489 residents (12/2013) 133 FTE CHT staff state wide 60 FTE SASH staff 30 FTE spoke staff for the Hub and Spoke Opioid Addiction Treatment with 5 regional treatment centers. Distribution of the Blueprint Model

Statewide Distribution of the Blueprint Model

Accountable Care and Shared Savings Programs

Physician level Practice level Regional Statewide Outcomes

Enhanced team-oriented care –Daily care planning huddles –Fall prevention, depression, and substance abuse screening by staff. –Weekly population management huddles –On-site community health team. –On-site psychology, substance abuse counseling and psychiatry consultation. Enhanced health maintenance and chronic disease care reminders and support Self care goal setting tools New Opioid management toolkit and protocols Registries to further support population management in process Personal experience in practice

Sample Tools

Biweekly PCMH meetings. Protocol implementation and standardized training –Well child visits and immunizations –Pill counts and checking the Vermont Prescription Management System –Huddle agenda –Patient safety processes Medical Home Leadership Team (FM, PEDS, PCIM) –Transforming Primary Care Workgroups –Physician Electronic Health Record specialists Multi-practice level outcomes

Milton Family Practice Profile

Practice Profile: Milton

Practice Profile: Milton Age 1-17

Burlington Health Service Area

Linking Claims and Clinical Data

Commercial Expenditures

Medicaid Expenditures

Special Medicaid Services Expenditures

Statewide Outcomes

Inpatient Discharges

Primary Care Visits

Specialty Visits

Emergency Department Visits

Quality Measures stable or improved

SavedInvestedGain/Cost Commercial –Age 1-17 yrs.11.8M 5.9M15.8 –Age yrs.81.5M Medicaid (+SMS) –Age 1-17 yrs.1.0M 2.9M 2.2 –Age yrs. 5.4M Return on investment 2012

Reductions in expenditures per capita Shift toward improved utilization of inpatient hospitalizations, related expenditures and pharmacy A tendency for Medicaid beneficiaries to increase use of Special Medicaid Services as traditional expenses reduce A trend toward higher utilization of preventive services. Summary of Vermont Blueprint Outcomes

Will trends persist in 2013 and beyond. What about Medicare? (Center for Medicare and Medicaid Innovation (CMMI) as part of the Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration program is in progress) Who will Accountable Care Organizations change the equation. How to implement outcomes-based payment reform Questions remain

What’s next

Unified Community Health System Unified Performance Reporting and Data Utility Payment modifications Recommendations 12/2014

Options for Payment Modification – Report to Legislature

What’s happening in your practice? What’s happening in your state? Questions for discussion

Vermont Blueprint for Health Annual Report 2013: ealthAnnualReport2013.pdf ealthAnnualReport2013.pdf National Govenors Association Center for Best Practices: Health Division. The Henry J. Kaiser Family Foundation: State Health Reform Initiatives. health-care-reform-initiative#?program=state-health- care-reform- initiative&_suid= http://kff.org/search/?program=state- health-care-reform-initiative#?program=state-health- care-reform- initiative&_suid= References