Maine PCMH Pilot and MaineCare Health Homes Update Maine Quality Forum Advisory Council Lisa Tuttle June 2013

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

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

4 FQHC: federally qualified health center H-O: hospital-owned

Maine PCMH Pilot Expansion 5

Maine’s Medical Home Movement ~ 540 Maine Primary Care Practice Sites 25 Maine PCMH Pilot Practices 50 Pilot Phase 2 Practices 14 FQHCs CMS APC Demo 100+ NCQA PCMH Recognized Practices 80 MaineCare HH-only Practices Payers: Medicare Medicaid (HH) Commercial plans (Anthem, Aetna, HPHC) Self-funded employers Payer: Medicare Payer: Medicaid 6

Alignment of Pilot with MaineCare Health Homes Initiative Affordable Care Act (ACA) Sect 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 + Community Care Team (CCT) Provided opportunity to leverage multi-payer PCMH model, practice transformation support infrastructure 7 7

CMS Health Homes – ACA Section 2703 Implementation January, 2013 CMS will provide 90/10 match for Health Home services to eligible members for eight quarters Health Homes may serve individuals with: Two or more chronic conditions One chronic condition and who are at risk for another Serious mental illness – Adults with serious mental illness (SMI) – Children with severe emotional disturbance (SED) Cannot exclude Dual eligible beneficiaries

– Mental health – Substance abuse – Asthma – Diabetes – Heart disease – Overweight (BMI > 25) & Obesity CMS Health Homes – ACA Section 2703 Chronic conditions (per CMS): – Chronic Obstructive Pulmonary Disease (COPD) – Hypertension – Hyperlipidemia – Tobacco use – Developmental Disabilities & Autism Spectrum – Acquired brain injury – Cardiac & circulatory congenital abnormalities – Seizure disorder Maine-specific :

Required Health Home services include: – Comprehensive care management – Care coordination and health promotion – Comprehensive transitional care – Individual and family support – Referral to community and social support services – Use of health information technology (HIT) – Prevention and treatment of mental illness and substance abuse disorders – Coordination of and access to preventive services, chronic disease management, and long-term care supports CMS Health Homes – ACA Section 2703

Maine Health Homes Stage A: Health Home = Medical Home primary care practice + CCT Payment weighted toward medical home Eligible Members: Two or more chronic conditions One chronic condition and at risk for another

Maine Health Homes Stage B: Health Homes = CCT with behavioral health expertise + primary care practice Payment weighted toward CCT Eligible Members: Adults with Serious Mental Illness Children with Serious Emotional Disturbance

All Health Home practices (including hospital-based) will receive a per member per month (PMPM) payment for eligible Health Home members. The PMPM rate will be $12, compared to $3.50 for PCCM. Practices will only be paid on Health Home-eligible members. Practices will still receive a PCCM payment of $3.50 PMPM for members who are enrolled in PCCM but are not eligible for Health Homes. Health Homes Payment & Practice Eligibility

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) Lisa Letourneau 14

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

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 16

PCMH-HH-CCT: Efforts to Align Reporting MAPCP uses RTI Portal for Utilization reports Health Homes Portal and Utilization reports through USM Muskie School – in progress! MHMC produced Cost and Utilization Reports – currently rolling out Commercial – Medicare and MaineCare in early 2014 CCT and PCMH/HH alignment on self- assessment of progress for quarterly reports

Primary Care Practice Reports – Cost & Utilization Maine Health Management Coalition (MHMC ) workshops/webinars: – Objective · The purpose of the reports The data they are generated from, and Ideas on how they can improve care. – Location: EMMC, Bangor - Tuesday, June 11 MaineHealth, Portland - Tuesday, June 18 MaineGeneral, Augusta - Monday, June 24

Maine PCMH Pilot/HH “Core Expectations” for all Practices 1.Demonstrated physician leadership for improvement 2.Team-based approach 3.Population risk-stratification and management 4.Practice-integrated care management 5.Same-day access to care 6.Behavioral-physical health integration 7.Inclusion of patients & families 8.Connection to community / local HMP 9.Commitment to reducing avoidable spending & waste 10.Integration of health IT 19

HH Reporting Requirements MaineCare will report on the majority of CMS-required and state-specific quality measures through analysis of claims data. Beginning in January 2014, CMS will require reporting of three quality measures that cannot be assessed through claims analysis: – Adult BMI assessment – Care transitions record transmitted to PCP (within 24hrs) – Depression screening & follow up MaineCare is working with HealthInfoNet to directly upload these measures directly from the EMR..

From outset: – Measure BMI in all adult patients at least every two years, and at BMI percent-for age at least annually in all children. Addt’l Service Requirements: Assessment & Screening By year 2: – Annual depression and substance abuse screening (PHQ9 and AUDIT, DAST) for all adults with chronic illness, and substance abuse screening (CRAFFT) for adolescents. – Annual ASQ or PEDS developmental screening for all children age one to three, and the MCHAT 1 for at least one screening between ages months with a follow-up MCHAT 2 if a child does not pass the screening test.

PCMH Pilot: How are we doing? 2013 Must Pass elements – Core Expectations QC Database and Dashboarding efforts to prioritize technical assistance QC Open ‘office hours,’ monthly webinars, early focus on action plans to provide support Clinical Quality Measures – still confounded by Electronic Health Record capabilities

PCMH: Lessons Learned NCQA PCMH ≠ PCMH Move to PCMH requires transformation (not incremental change) of entire practice, culture, and personal transformation (esp. physicians!) Medical home is not something that can be “installed” Change starts with effective leadership – organizational, clinician, and administrative Supportive culture & leadership trumps all Include patients & families early & often 23

Contact Info / Questions  Lisa Tuttle, MPH  Maine Quality Counts (See “Programs”  PCMH 24