West Virginia Medical Home Initiative Through the Health Improvement Institute AAFP Southeast Family Medicine Forum Briefing and Overview August, 2008

Medicaid Transformation Grants Centers for Medicare & Medicaid Services (CMS) initiative under DRA providing grants to states for innovative improvement of Medicaid program WV DHHR received 5 awards Each award is focused on a different aspect of Medicaid Redesign Each grant has 24 month timeline

Advanced Medical Home Medicaid Transformation Grants Five CMS grants awards: Personal ResponsibilityPersonal Responsibility Health System ImprovementHealth System Improvement Applied TechnologyApplied Technology Stronger Medicaid ProgramStronger Medicaid Program Enhanced Medication ManagementEnhanced Medication Management

Health System Improvement Grant focused on: Improving primary care delivery system Creating patient-centered medical homes Launching Health Improvement Institute to help facilitate enhancement of primary care system of care Activities in this area are coordinated by project management team

Delays & Waits for access 1-12 weeks3:1 Staffing Ratio THE PREVALENT SYSTEM OF CARE DELIVERY 20-55% Compliance with Evidence Based Guidelines Less than 18% use IT for patient care 40% waste & inefficiency 45% Internet traffic is patients seeking self management info Practice working in a vacuum Reimbursement Piecemeal Fee for Service

The Potential-The Pioneers Time with doctor has gone from 8.2 minutes to 12.5 minutes Total visit time has gone from 90 minutes to 42 minute average HbA1c for their population of focus came down from 11 to 8 Encounters and revenue for behavioral health services skyrocketed (in Medicaid cost based reimbursed and Medicare is 60% of the cap for behavioral counseling services) There are several key clinical indicators where they have reversed the health disparities and outcomes for minority populations are better Third available appointment has gone from 140 to 0 days Went from breakeven/deficit spending to 7% positive margin Total average aggregate costs of care for people with Diabetes 30-70% less than all other providers Grew from 16,000 patients to 40,000 CareSouth Carolina Source: Ann Lewis, CEO CareSouth Carolina

PLANNED CARE IN THE NEW ENVIRONMENT M.D. N..P. N.P. R.N. R.N. M.A. DIETICIAN EXTERNAL TEAM Guidelines In exam room With PDAs EMR eliminate All paper Registry used For Master Scheduling Community Resources Part of care team Open Access No shows decrease to 2-5% Group Visits Used 25% 17% visits by Reimbursement Aligned to support Planned care Care Team Work Spread 8:1 Ratio Continuous Flow minimize On-site time

Diabetes Outcome Measures October 2005 – September 2006 All MCI diabetes patients n = 8631

CMS Profit = $8.00 / test Yields $100,000 / yr.

Transformational change: In the Health Care Delivery System IndicatorCareSouth All Family Practice Physicians (Median) Avg. total annual payment per patient $1, 340 $1,778 Avg. annual drug payment per patient* $502$576 Avg. office visit payment per patient* $441$168 Avg. inpatient hospitalization payment* $172$634 Average emergency room payment* $15$22 For Medicaid patients with Diabetes receiving these services Source: South Carolina Office of Budget and Control 2004

West Virginia Health Improvement Institute Stakeholder Advisory Group Meet Quarterly Virtual Engagement On- Going Provider Education Self Management Adoption of HIT Measurement/ Reimbursement/ Reporting Innovation Community 150+ Practices Pilots Pilots Measures& Pilots Steering Committee

Medical Home Learning Community WV Health Improvement Institute Results Recruitment Cohort Demonstrations Practice Teams Team-based learning around a care team Learn elements of Medical Home Test practice changes Share ideas, successes and failures with each other Monitor and report common measures of performance Evolve the practice into a patient-centered medical home Provider Training and Support Workgroup Coaching and technical assistance Measures for monthly reporting Topic-specific webcasts Monthly team calls Virtual short-cycle learning sessions Self-Management Workgroup Coaching and technical assistance Topic-specific webcasts Measurement and Reimbursement Workgroup Measures for monthly reporting Adoption of Electronic Health Records Workgroup Coaching and technical assistance Self-Management Demonstration Payer Pay for Performance Demonstration Electronic Health Records Demonstration Performance measures Clinical outcomes measures New reimbursement models Economic indicators reflected in Medicaid claims and health status of overall Medicaid populations Increased successful adoption of EHRs New care models to spread to providers across the state Medical Home penetration

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Roger Chaufournier