Maine PCMH Pilot & Community Care Teams (CCTs) Lisa M. Letourneau MD, MPH October 2013

Maine PCMH Pilot Leadership Dirigo Health Agency’s (DHA’s) Maine Quality Forum Maine Health Management Coalition Maine Quality Counts MaineCare (Medicaid) 2

Maine PCMH Pilot Practice “Core Expectations” Demonstrated physician leadership Team-based approach Population risk-stratification and management Practice-integrated care management Same-day access Behavioral-physical health integration Inclusion of patients & families Connection to community / local HMP Commitment to waste reduction Patient-centered HIT

Implications of CMS MAPCP Demo Projected to achieve budget-neutrality (i.e. to reach $10 pmpm savings) via reductions in avoidable ED use, hospitalizations Stronger focus on reducing waste & avoidable costs Introduced CCTs as targeted strategy to support high-needs patients & reduce avoidable costs Access to Medicare data to identify high patients Opportunity to add 50 additional practices to join “Phase 2” of Pilot (Jan 2013) 4

Maine PCMH Pilot - MAPCP Timeline Jan 1, 2010 2011 2012 2013 Dec 31, 2014 ME PCMH Pilot - Original Jan 1, 2012 MAPCP Demo – 3yr CCTs ME PCMH Pilot - Extended Pilot Expansion, Medicaid HHs Dec 31, 2014

Community Care Teams Multi-disciplinary, community-based, practice- integrated care teams Build on successful models (NC, VT, NJ) Support patients & practices in Pilot sites, help most high-needs patients overcome barriers – esp. social needs - to care, improve outcomes Key element of cost-reduction strategy, targeting high-needs, high-cost patients to reduce avoidable costs (ED use, admits) 6 Lisa Letourneau

Maine PCMH Pilot Community Care Teams Behav. Health & Sub Abuse Schools Environment Transportation Community Care Team Housing Outpatient Services Workplace Care Mgt Family Food Systems High-need Individual PCMH Practice Med Mgt Specialists Community Resources Shopping Coaching Hospital Services Behav. Health & Sub Abuse Income Physical Therapy Heat Literacy 7 Faith Community

CCT Selection Used structured application, selection process CCTs committed to PCMH Core Expectations Had to get agreement from PCMH/HH practices Had to meet minimum practice population size ~15,000 8

ME PCMH Pilot CCTs AMHC Androscoggin Home Health Coastal Care Team (Blue Hill FP, Community Health Center/MDI, Seaport FP) CHANS (MidCoast area) Community Health Partners (Newport FP, Dexter FP) DFD Russell (FQHC) Eastern Maine Homecare Kennebec Valley (MaineGeneral Health) Maine Medical Center PHO Penobscot Community Health Care (FQHC) 9

Maine PCMH Pilot Community Care Teams, Phase 1 and Phase 2 Practice Sites

Alignment of Pilot with MaineCare Health Homes Initiative Affordable Care Act (ACA) Sect 2703 - opportunity to develop Medicaid “Health Homes” initiative MaineCare elected to align HH initiative with current multi-payer Pilot – part of VBP initiative Defined MaineCare “Health Home”(HH): HH = PCMH practice + CCT Provided opportunity to leverage multi-payer PCMH model, practice transformation support infrastructure 11

MaineCare Health Homes Health Homes Beneficiary Community Care Team Stage A: Help Individuals with Chronic Conditions Care Mgt PCMH Practice Health Homes Beneficiary Med Mgt Coaching Behav. Health & Sub Abuse 12

Maine’s Medical Home Movement ~ 540 Maine Primary Care Practices Payer: Medicaid ~150 eligible MaineCare HH-Practices 120+ NCQA PCMH Recognized Practices Payers: Medicare Medicaid (HH) Commercial plans (Anthem, Aetna, HPHC) Self-funded employers 50 Pilot Phase 2 Practices 25 Maine PCMH Pilot Practices 14 FQHCs CMS APC Demo Payer: Medicare 13

CCT Populations Served CCTs review data from available sources (Medicare RTI reports, MaineCare Utilization reports, other payers, HIN) to identify Hospital Admissions 3 or more admissions in past 6 months 5 or more admissions in past 12 months Emergency Department Utilization 3 or more E.D. visits in past 6 months 5 or more E.D. visits in past 12 months Payer identification of high-risk or high-cost patients 14

CCT Staffing Minimum expectations: Medical Director (part-time) CCT Manager Nurse Care Manager LCSW / Care Coordinators Access to BH, SA expertise 15

Financing CCTs: Maine Approach Linked CCT model, payment to multi-payer PCMH model Leveraged public, private payers agreement to provide pmpm payment Participation in CMS MAPCP demo brought in Medicare as payer Alignment of ACA Health Homes with multi-payer Pilot provided opportunity to leverage federal 90:10 match for CCT services 16

CCT Payments Practice population-based capitated payments Medicare: $2.95 pmpm Commercial payers: $0.30 pmpm Per-person capitated payments Medicaid / Health Homes: $129.50 pmpm 17

CCT Goals & Performance Measurement Improve care, reduce costs for most high-cost, high- needs individuals of PCMH/HH practices Reduce hospitalizations, readmissions Reduce ED visits Performance tracked through quarterly reporting Number CCT contacts Number ED visits, hospitalizations pre/post CCT 18

CCT Reporting 19

Unique Features of Maine Approach Defining “Health Home” as PCMH + CCT Adding CCT services to specifically support high-needs, high-cost members (recognizing these mbrs can often outstrip capacity of most primary care practices – even PCMHs!) Recognizes differences between “routine”/chronic disease care management & CCT multi-disciplinary team approach for most high-needs mbrs 20

Maine CCTs: Successes Have developed functional CCT infrastructure CCT structure, support highly welcomed by practices, patients Most PCMH/HH practices report high levels of satisfaction with CCT services Have demonstrated numerous examples of high-needs individuals positively impacted by CCTs 21

Maine CCTs: Challenges & Lessons Learned Need to focus on most high-cost individuals, particularly those with frequent hospitalizations, who are open to intervention Be cautious of focusing on high-needs individuals who are highly resistant to changing behaviors Value of trauma-informed approach 22

Maine CCTs: Challenges & Lessons Learned Building CCT structure & relationships takes time (up to 2-6 mos) Data critical to identifying potential patients; current data sources are siloed, time-lagged Successful interventions depend on strong relationships, with individuals & with practices 23

PCMH: Hub of Wider Delivery & Payment Reform Models (ACOs!)

Primary Care & CCT Payment in ACOs: So What Will Change? Despite PCMH, ACO pilots, FFS remains most predominant payment model for providers Relying on FFS payments continues to emphasize volume & threatens meaningful practice change Little meaningful change yet to concept of “productivity” *Payment Reform for Primary Care within ACOs, A. Goroll & S. Schoenbaum, JAMA, Aug 2012

Contact Info / Questions Maine Quality Counts www.mainequalitycounts.org Maine PCMH Pilot (See “Programs”  PCMH) Lisa Letourneau MD, MPH LLetourneau@mainequalitycounts.org, 207.415.4043 Hpeterson@mainequalitycounts.org, 207.266.7211