Blueprint Integrated Pilot Programs Building community systems of health Craig Jones MD Director, Vermont Blueprint for Health

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Presentation transcript:

Blueprint Integrated Pilot Programs Building community systems of health Craig Jones MD Director, Vermont Blueprint for Health State Coverage Initiatives Vermont Site Visit Academy Health Robert Wood Johnson Foundation

Funding Blueprint / State Global Commitment Catamount Fund Federal Funds HIT Fund Grant Support ? Multi Insurer Reform Medicaid BCBS Cigna MVP  Clinical Transformation VPQ Coordinated Training Clinical Microsystems  Provider Incentives Participation & Training  Community Activation Local Programs  Self Management Healthier Living Workshops  Health Information Technology VPQ Hosted Registry (VHR)  Evaluation VPQ Registry Reports VCHIP Chart Review  VITL Health Information Exchange Network  Financial Reform Enhanced provider payment Shared costs for CCT  Local Care Support CCT as shared resource  Prevention Public Health Specialist on CCT Local Prevention Team  Health Information Technology VITL EMR Pilot Project VPQ Hosted Web Based CIS with eRx  VITL Health Information Exchange Network  Multi payer claims data base  Clinical / demographic data base  VCHIP NCQA PCMH scoring  VCHIP chart review Blueprint Communities (Act 191, 2006) ProgramsProducts Blueprint Integrated Pilots (Act , Act ) Evaluation Infrastructure  Improved Care Delivery (Diabetes)  IT enhanced care (Diabetes)  Improved self mgmt (HLW attendees)  Local exercise / prevention programs  VHR - Descriptive statistics (Diabetes)  VCHIP – Chart review Sustainable Transformation  Advanced Medical Home  Improved Care Delivery (General)  Local care support & DM services  Sustainable Financial Reform  Improved Self Mgmt (Multi-faceted)  IT enhanced care -Chronic disease -Health maintenance -eRx  Prevention & Wellness Programs -Community team -Evidence based -Linked with care delivery  Evidence based healthcare process  Routine QA / QI  Evaluation of health impact  Evaluation of financial impact  Predictive modeling (claims / clinical)  Epidemiologic / outcomes research  CCT Utilization Patterns

Health IT Framework Global Information Framework Evaluation Framework Operations Blueprint Integrated Pilots Coordinated Health System PCMH Hospitals Public Health Prevention Community Care Team Nurse Coordinator Social Workers Dieticians Community Health Workers OVHA Care Coordinators Public Health Prevention Specialist Mental Health & Substance Use Disorders

Blueprint Integrated Pilot Summary 1. Financial reform (2 major components - includes MCAID & commercial insurers) - Payment to practices based on NCQA PCMH score - Shared costs for Community Care Teams 2. Multidisciplinary care support teams (CCT Teams) - Local care support & population management 3. Health Information Technology - Web based clinical tracking system (DocSite) - Visit planners & population reports - Electronic prescribing - Updated EMRs to match program goals and clinical measures in DocSite - Health information exchange network 4. Community Activation & Prevention - Prevention specialist as part of CCT - Community profiles & risk assessments - Evidence based interventions 5. Evaluation - NCQA PCMH score (process quality) - Clinical process measures - Health status measures - Multi payer claims data base - Population Indicators

NCQA Scoring & Provider Payment 5 of 10 MP10 of 10 MP

St. Johnsbury Family HC Chronic Care Coor.5 FTE Beh. Health Spec..5 FTE Concord Health Ctr. Chronic Care Cood.5 FTE Beh. Health Spec..5 FTE Danville Health Center Chronic Care Coor.5 FTE Beh. Health Spec.5 FTE Corner Medical Chronic Care Coor 1 FTE Beh. Health Spec 1 FTE Other OVHA Care Managers Hospital Care Managers Hospital-based CC Educators Community-based Advocates Community Connections Community Health Workers CC Comm. Health Worker VDH District Office Public Health Specialist Calodenia Int. Medicine Chronic Care Cood.5 FTE Beh. Health Spec..5 FTE St. Johnsbury Community Care Team Care Integration Coordinator 1 FTE St Johnsbury Community Care Team Staffing

Behavioral Health Specialist Chronic Care Coordinator Community Connections VT Department of Health Community Care Managers (OVHA, AAA, Umbrella, etc.) Physicians Nurse Practitioners Physician Assistants COMMUNITY CARE TEAM PRIMARY CARE OFFICE St Johnsbury Community Care Team Referral and Communication Flow Chart

Chittenden County Community Care Team Nurse Lead Manager 1 FTE Medical Asst. 2 FTEs Aesculapius Admin. supp..25 FTE Admin. Supp..5 FTE Dr. Moore Behavioral Specialist.25 FTE Med. Social Worker 1 FTE Exercise Physiologist.25 FTE PD Cert. Diabetic Educator 1 FTE Dietitian/ Nutritionist.25 FTE PD Health Educator 1 FTE Admin. Supp 1 FTE VDH Public Health Specialist Chittenden County Community Care Team Staffing

Central – Public Health Prevention Team State level assessments State level strategic planning Data review & interpretation Design campaigns / programs Technical assistance / support Regional – Public Health Prevention Teams Local assessments Local intervention planning Organizing & coordination Multidisciplinary Services Surveillance HPDP ADAP Blueprint MCH Preparedness Rural Health Business Office Program content Best practices Domain expertise Data analysis Reporting Transportation Education Labor Medicaid Corrections Mental Health Children & Families DAIL Input Review Domain expertise Coordination Planning DepartmentsVDH Programs State & Local Coalitions Community Groups Community Stakeholders Community Health Teams VDH Prevention Teams An Integrated Model for Health Functional Map – Public Health Operations Community Care Team # 1 Community Care Team # 2 Community Care Team # 3 Community Care Team # 4

PHASE 4 - Implementation  Timeline depends on scope and resources of planned intervention PHASE 3 - Community Planning  Planning with key leaders  Planning with stakeholders  Iterative interactive process  Consensus building PHASE 2b - Community Assessment  Quantitative Context - state level 10 year trend analysis of risk factors associated with morbidity & healthcare costs  Focus groups  Formal key leader interviews  Continue until no new themes  Test themes in new interviews  Test findings in community forums Phase 5 – Evaluation months months months PHASE 2a - Community Profile  Community description  Community inventory  Quantitative Context - Descriptive health statistics on the rates of risk factors in each community (5 year aggregate data) PHASE I - Develop capacity  Facilitate systems approach  Train Prevention Specialist  Prevention Model and Framework  Data collection techniques  Environment and policy change Community Assessment & Planning Timeline October 2008

Health IT Framework Global Information Framework Evaluation Framework Operations PCMH Hospitals Public Health Prevention Community Care Team Nurse Coordinator Social Workers Dieticians Community Health Workers OVHA Care Coordinators Public Health Prevention Specialist Behavioral Health & Substance Abuse Services Prevention Programs Policies and Systems Local, state, and federal policies and laws, economic and cultural influences, media Community Physical, social and cultural environment Organizations Schools, worksites, faith- based organizations, etc Relationships Family, peers, social networks, associations Individual Knowledge, attitudes, beliefs Blueprint Integrated Pilots Coordinated Health System – Integrating Existing Programs

Blueprint Integrated Pilots Coordinated Health System Healthcare Information Framework Health System Information Framework Evaluation & Framework Operations & Uses Framework EMRs DocSite Practice Management Systems Hospital Information Systems EMRs DocSite Practice Management Systems Hospital Information Systems Multi-payer claims database Public Health Databases Chart reviews NCQA Scoring NCQA Scores Clinical Process Measures Health Status Measures Healthcare Resource Utilization Healthcare Expenditures Financial Impact ROI Population Health Indicators Individual Patient Care Population Management Quality Improvement Program Evaluation Program Sustainability Community Activation / Prevention Health Policy PCMH Hospitals Public Health Prevention Community Care Team Nurse Coordinator Social Workers Dieticians Community Health Workers OVHA Care Coordinators Public Health Prevention Specialist Behavioral Health & Substance Abuse Services

Blueprint Integrated Pilots Why measure? Group 1 Good Disease Control Group 2 Intermediate Disease Control Group 3 Poor Disease Control Average = 7.46Average = 7.36

Healthcare Patterns & Resource Utilization Healthcare Expenditures & Financial Impact Health Status Measures Clinical Process Measures Population Indicators & Risk Factors Healthcare Quality Measures & Standards Population Management Quality Improvement Program Evaluation & Sustainability Community Prevention Planning Individual Patient Care & Support Services Provider Payment for Quality Data Processing & Storage EMRs used for Individual Patient Care DocSite used for Individual Patient Care DocSite Database EMR Databases DocSite Reporting Tool VCHIP Chart Review & NCQA Scoring Medical Claims from Commercial Insurers & Medicaid Public Health Surveys & Data Collection Data Source Data transmission & transformation VITL / GE Data Analysis Data Reports & Uses EMR Reporting Tool or Analyst Public Health Registries & Databases VDH Health Surveillance Analytic Database BISCHA Multipayer Database VCHIP Databases VCHIP Analysis & Report Generation BISCHA Reports VDH Health Surveillance Analyst Contracted Analysis Services Blueprint Integrated Pilots Evidence Based Quality Improvement

Population Management Quality Improvement Individual Patient Care & Support Services Data Processing & Storage EMRs used for Individual Patient Care DocSite used for Individual Patient Care DocSite used for Individual Patient Care DocSite Database EMR Databases DocSite Reporting Tool Program Evaluation & Sustainability VCHIP Chart Review & NCQA Scoring VCHIP Chart Review & NCQA Scoring Medical Claims from Commercial Insurers & Medicaid Public Health Surveys & Data Collection Data Source Data transmission & transformation VITL / GE Data Analysis Data Reports & Uses EMR Reporting Tool or Analyst Public Health Registries & Databases Public Health Registries & Databases VDH Health Surveillance Analytic Database BISCHA Multipayer Database BISCHA Multipayer Database VCHIP Databases VCHIP Databases VCHIP Analysis & Report Generation VCHIP Analysis & Report Generation BISCHA Reports BISCHA Reports Healthcare Patterns & Resource Utilization Healthcare Patterns & Resource Utilization Healthcare Expenditures & Financial Impact VDH Health Surveillance Analyst Health Status Measures Clinical Process Measures Population Indicators & Risk Factors Population Indicators & Risk Factors Contracted Analysis Services Contracted Analysis Services Community Prevention Planning Healthcare Quality Measures & Standards Provider Payment for Quality Blueprint Integrated Pilots Evidence Based Quality Improvement

Data Processing & Storage EMRs used for Individual Patient Care EMRs used for Individual Patient Care DocSite used for Individual Patient Care DocSite Database EMR Databases DocSite Reporting Tool Population Management Quality Improvement Program Evaluation & Sustainability VCHIP Chart Review & NCQA Scoring VCHIP Chart Review & NCQA Scoring Medical Claims from Commercial Insurers & Medicaid Public Health Surveys & Data Collection Data Source Data transmission & transformation VITL / GE Data transmission & transformation VITL / GE Data Analysis Data Reports & Uses EMR Reporting Tool or Analyst EMR Reporting Tool or Analyst Public Health Registries & Databases Public Health Registries & Databases VDH Health Surveillance Analytic Database BISCHA Multipayer Database BISCHA Multipayer Database VCHIP Databases VCHIP Databases VCHIP Analysis & Report Generation VCHIP Analysis & Report Generation BISCHA Reports BISCHA Reports Healthcare Patterns & Resource Utilization Healthcare Patterns & Resource Utilization Healthcare Expenditures & Financial Impact VDH Health Surveillance Analyst Health Status Measures Clinical Process Measures Population Indicators & Risk Factors Population Indicators & Risk Factors Contracted Analysis Services Contracted Analysis Services Community Prevention Planning Individual Patient Care & Support Services Healthcare Quality Measures & Standards Provider Payment for Quality Blueprint Integrated Pilots Evidence Based Quality Improvement

Healthcare Quality Measures & Standards Data Processing & Storage EMRs used for Individual Patient Care EMRs used for Individual Patient Care DocSite used for Individual Patient Care DocSite used for Individual Patient Care DocSite Database EMR Databases DocSite Reporting Tool DocSite Reporting Tool Population Management Program Evaluation & Sustainability VCHIP Chart Review & NCQA Scoring Medical Claims from Commercial Insurers & Medicaid Public Health Surveys & Data Collection Data Source Data transmission & transformation VITL / GE Data transmission & transformation VITL / GE Data Analysis Data Reports & Uses EMR Reporting Tool or Analyst EMR Reporting Tool or Analyst Public Health Registries & Databases Public Health Registries & Databases VDH Health Surveillance Analytic Database BISCHA Multipayer Database BISCHA Multipayer Database VCHIP Databases VCHIP Analysis & Report Generation BISCHA Reports BISCHA Reports Healthcare Patterns & Resource Utilization Healthcare Patterns & Resource Utilization Healthcare Expenditures & Financial Impact VDH Health Surveillance Analyst Health Status Measures Health Status Measures Clinical Process Measures Clinical Process Measures Population Indicators & Risk Factors Population Indicators & Risk Factors Contracted Analysis Services Contracted Analysis Services Community Prevention Planning Individual Patient Care & Support Services Provider Payment for Quality Quality Improvement Blueprint Integrated Pilots Evidence Based Quality Improvement

Population Management Quality Improvement Data Processing & Storage EMRs used for Individual Patient Care EMRs used for Individual Patient Care DocSite used for Individual Patient Care DocSite used for Individual Patient Care DocSite Database EMR Databases DocSite Reporting Tool DocSite Reporting Tool Program Evaluation & Sustainability VCHIP Chart Review & NCQA Scoring Medical Claims from Commercial Insurers & Medicaid Public Health Surveys & Data Collection Data Source Data transmission & transformation VITL / GE Data transmission & transformation VITL / GE Data Analysis Data Reports & Uses EMR Reporting Tool or Analyst EMR Reporting Tool or Analyst Public Health Registries & Databases Public Health Registries & Databases VDH Health Surveillance Analytic Database BISCHA Multipayer Database BISCHA Multipayer Database VCHIP Databases VCHIP Analysis & Report Generation BISCHA Reports BISCHA Reports Healthcare Patterns & Resource Utilization Healthcare Patterns & Resource Utilization Healthcare Expenditures & Financial Impact VDH Health Surveillance Analyst Health Status Measures Clinical Process Measures Population Indicators & Risk Factors Population Indicators & Risk Factors Contracted Analysis Services Contracted Analysis Services Community Prevention Planning Individual Patient Care & Support Services Healthcare Quality Measures & Standards Provider Payment for Quality Blueprint Integrated Pilots Evidence Based Quality Improvement

Program Evaluation & Sustainability Contracted Analysis Services Quality Improvement Data Processing & Storage EMRs used for Individual Patient Care EMRs used for Individual Patient Care DocSite used for Individual Patient Care DocSite used for Individual Patient Care DocSite Database EMR Databases DocSite Reporting Tool DocSite Reporting Tool Population Management VCHIP Chart Review & NCQA Scoring VCHIP Chart Review & NCQA Scoring Medical Claims from Commercial Insurers & Medicaid Public Health Surveys & Data Collection Data Source Data transmission & transformation VITL / GE Data transmission & transformation VITL / GE Data Analysis Data Reports & Uses EMR Reporting Tool or Analyst EMR Reporting Tool or Analyst Public Health Registries & Databases Public Health Registries & Databases VDH Health Surveillance Analytic Database BISCHA Multipayer Database VCHIP Databases VCHIP Databases VCHIP Analysis & Report Generation VCHIP Analysis & Report Generation BISCHA Reports Healthcare Patterns & Resource Utilization Healthcare Expenditures & Financial Impact VDH Health Surveillance Analyst Health Status Measures Health Status Measures Clinical Process Measures Clinical Process Measures Population Indicators & Risk Factors Population Indicators & Risk Factors Community Prevention Planning Individual Patient Care & Support Services Healthcare Quality Measures & Standards Provider Payment for Quality Blueprint Integrated Pilots Evidence Based Quality Improvement

Community Prevention Planning Quality Improvement Data Processing & Storage EMRs used for Individual Patient Care EMRs used for Individual Patient Care DocSite used for Individual Patient Care DocSite used for Individual Patient Care DocSite Database EMR Databases DocSite Reporting Tool DocSite Reporting Tool Population Management Program Evaluation & Sustainability VCHIP Chart Review & NCQA Scoring VCHIP Chart Review & NCQA Scoring Medical Claims from Commercial Insurers & Medicaid Public Health Surveys & Data Collection Data Source Data transmission & transformation VITL / GE Data transmission & transformation VITL / GE Data Analysis Data Reports & Uses EMR Reporting Tool or Analyst EMR Reporting Tool or Analyst Public Health Registries & Databases VDH Health Surveillance Analytic Database BISCHA Multipayer Database BISCHA Multipayer Database VCHIP Databases VCHIP Databases VCHIP Analysis & Report Generation VCHIP Analysis & Report Generation BISCHA Reports BISCHA Reports Healthcare Patterns & Resource Utilization Healthcare Patterns & Resource Utilization Healthcare Expenditures & Financial Impact VDH Health Surveillance Analyst Health Status Measures Health Status Measures Clinical Process Measures Clinical Process Measures Population Indicators & Risk Factors Contracted Analysis Services Contracted Analysis Services Individual Patient Care & Support Services Healthcare Quality Measures & Standards Provider Payment for Quality Blueprint Integrated Pilots Evidence Based Quality Improvement

Blueprint Integrated Pilots Financial Impact Percentage of Vermont population participating6.7%9.8%13.0%20.0%40.0% Participating population42,17961,88082,332127,045254,852 # Community Care Teams234613

Build a model for effective and sustainable reform  Multi Insurer Financial Reform (PCP payment, CCTs)  Financial Incentives (balance volume & quality)  Environment (PCMH, CCTs, PH specialists, Health IT)  Focus (quality, wellness, prevention)  Evaluation (multidimensional, routine)  Culture (self management, engaging yet objective) Blueprint Integrated Pilots Building a Scalable Model