Community Health Teams The Vermont Experience Lisa Dulsky Watkins, MD Associate Director Vermont Blueprint for Health Department of Vermont Health Access 1October 21, 2103

22 Principles of Team-Based Care  Shared Goals  Clear Roles  Mutual Trust  Effective Communication  Measureable Processes and Outcomes Mitchell et al, Core Principles & values of effective team-based health care, 2012 (Discussion Paper, Institute of Medicine, Washington, DC Department of Vermont Health Access October 21, 2103

3 Team-Based Care “Team-based health care is the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers – to the extent preferred by each patient – to accomplish shared goals within and across settings to achieve coordinated, high-quality care.” Naylor et al, Inter-professional team-based primary care for chronically ill adults: State of the Science, 2010 Department of Vermont Health Access October 21, 2103

4 Department of Vermont Health Access Vermont’s Executive Branch and Legislature Consistent Support for Health Reform 2003 Blueprint launched as Governor’s initiative 2005 Implementation of Wagner’s Chronic Care Model 2005 Medicaid Global Commitment (Section 1115) Waiver 2006 Blueprint codified as part of sweeping reform legislation (Act 191) 2007 Blueprint leadership and pilots established (Act 71) 2008 Community Health Team structure and insurer mandate (Act 204) 2010 Statewide Blueprint Expansion outlined (Act 128) 2011 Planning for “Single Payer” (Act 48) October 21, 2103

5 Insurers Community Health Teams Funded by all insurers Intent is to minimize barriers $35,000/2000 active pts./yr. Scaled based on population Medicaid Commercial Insurers Medicare SASH Teams Funded by Medicare (CMMI Demonstration Project) $70,000/100 participants/yr. Scaled based on # panels Addictions Teams Funded by Medicaid Health Home (potential 90/10 federal match) 2 FTEs/100 suboxone pts. Scaled based on # pts. in prescribing practices Blueprint Payment Reforms Payments to Practices 1) FFS 2) PBPM Enhanced Payments October 21, 2103

Health IT Framework Evaluation Framework Primary Care Practice Hospitals Public Health Programs & Services Core Community Health Team Nurse Coordinators Social Workers Nutrition Specialists Community Health Workers Public Health Specialists Extended Community Health Team Medicaid Care Coordinators Medicare Teams based in Housing Hubs Addiction Teams Specialty Care & Disease Management Programs  A foundation of medical homes and community health teams that can support coordinated care and linkages with a broad range of services  Multi-insurer payment reform that supports this foundation of medical homes and community health teams  A health information infrastructure that includes EMRs, hospital data sources, a health information exchange network, and a centralized registry  An evaluation infrastructure that uses routinely collected data to support services, guide quality improvement, and determine program impact Mental Health & Substance Abuse Programs Social, Economic, & Community Services Self Management Workshops Primary Care Practice Primary Care Practice Primary Care Practice Multi-Insurer Payment Reform Framework 6 HVVo Visiting Nurse/Home Health Agency Health Service Area Architecture October 21, 2103

TIMELINE Patient Centered Medical Homes and Community Health Team Staffing in Vermont # of CHT FTEs and Practices # of Patients 7 October 21, 2103

8 Vermont Health Information Exchange (VITL) Central Clinical Registry and Integrated Health Record (Covisint DocSite) Core data elements Hosted EMR EMR Community Health Team Independent Primary Care Practices Primary Care Practices No EMR Organization- owned Primary Care Practices Core data elements Tobacco Cessation Counselors Senior Support Services Vermont Health Information Technology Infrastructure October 21, 2103

99 CHT Identification of High-Risk Patients Practice panel management, outreach and referrals Referrals from other health care and community service organizations Risk stratification and utilization data from Medicare Risk stratification and utilization data from Medicaid Data from commercial insurers 9October 21, 2103

10 CHT Example  Providers refer via the EHR (PRISM).  CHT provides in person 1:1 support, in groups or by phone, 3-6 visits, commonly 4 interactions.  CHT helps patients set realistic goals and timelines utilizing motivational interviewing, action planning and short term goal setting  CHT focuses on achievable realistic outcomes with our patients, addressing barriers that may interfere with success.  Short term case management, most often provided by our medical social worker.  CHT patients can re-engage with the team as necessary after graduation Services include:  Health coaching around nutrition, exercise and stress management  Basic Diabetes Education  Medication Management  Behavioral/Mental Health  Connection to community and financial resources

11 October 21, 2103 CHT Example

12 October 21, 2103 CHT Example

13 October 21, 2103 CHT Example Clinical Outcomes Patients were tracked by the multidisciplinary CHT using a common database and assessed 6 months after “graduation” (data collected between March 2009 and August 2012) 59% of patients referred to the CHT for diabetes-related issues had sustained improvement in BMI (n =44) and 67% of patients had sustained improvement in HbA1c (n=87) 49% (n=118) of patients referred to the CHT for exercise and nutrition issues had a sustained improvement in their BMI and 31.5% (n=117) had a sustained improvement in their LDL (average decrease of 24mg/dL)

14 CHT Challenges Documentation Consistency Double data entry Reporting to funders (“ROI”) Communication Patient/consumer engagement General public awareness 14October 21, 2103