A Close Look at Care Coordination within Patient-Centered Medical Homes: West Virginia’s Experience Web Seminar May 9, 2013 Follow this event on Twitter Hashtag: #AHRQIX

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Today’s Event Moderator James Becker, MD Medicaid Medical Director, West Virginia Bureau for Medical Services 6

How Rural Are We? We are a state of 1.8 million individuals We are a state of 1.8 million individuals Yet, our two largest cities approach 50 K in number Yet, our two largest cities approach 50 K in number Many parts of the State are geographically isolated and medically underserved Many parts of the State are geographically isolated and medically underserved Medicaid currently serves 410,000 individuals Medicaid currently serves 410,000 individuals Over 200,000 individuals are uninsured Over 200,000 individuals are uninsured Many patients cross borders to receive care Many patients cross borders to receive care 7

What Are Our Health Challenges? Chronic diseases Chronic diseases Mental health, substance abuse Mental health, substance abuse Aging population Aging population Poverty, unemployment Poverty, unemployment Low educational achievement Low educational achievement Lifestyle issues Lifestyle issues Health literacy issues Health literacy issues 8

What’s Working? Prevention programs and wellness, especially for selected conditions Prevention programs and wellness, especially for selected conditions Federally Qualified Health Centers and the rural health network meet much of the region’s need and are widely accepted in their communities Federally Qualified Health Centers and the rural health network meet much of the region’s need and are widely accepted in their communities Comprehensive behavioral health system Comprehensive behavioral health system University outreach networks with satellite services, technology and grant support University outreach networks with satellite services, technology and grant support 9

What Is Our Direction? In 2009 we adopted the “Triple Aim” and began building Patient-Centered Medical Homes (PCMH) around the state with grant support In 2009 we adopted the “Triple Aim” and began building Patient-Centered Medical Homes (PCMH) around the state with grant support The legislature endorsed PCMH and a state plan for health improvement The legislature endorsed PCMH and a state plan for health improvement Since then, each private health carrier has adopted some elements Since then, each private health carrier has adopted some elements No central payment methodology is established No central payment methodology is established 10

Currently…. West Virginia has a series of state plan amendments (SPAs) in development related to Health Homes (ACA 2703) West Virginia has a series of state plan amendments (SPAs) in development related to Health Homes (ACA 2703) The first will involve bipolar individuals with/or at risk of hepatitis The first will involve bipolar individuals with/or at risk of hepatitis Future SPAs expected for diabetes, obesity, asthma, mental illness, Alzheimer’s, congestive heart failure, chronic obstructive pulmonary disease Future SPAs expected for diabetes, obesity, asthma, mental illness, Alzheimer’s, congestive heart failure, chronic obstructive pulmonary disease SPAs broadly define care coordination, care managers and care coordinators SPAs broadly define care coordination, care managers and care coordinators 11

In Our Experience… Care coordination is a highly individual skill Care coordination is a highly individual skill – Flexibility and creativity – Sense of “mission” – Experience-based Best delivered “face-to-face” Best delivered “face-to-face” – Shared coordinators and telephonic care Best in the setting of team care Best in the setting of team care 12

In Our Experience… Requires leadership and resources Requires leadership and resources Is effective when there is data to guide decisions Is effective when there is data to guide decisions – Electronic health records and care coordination – Information technology for population management We’ve found no single credential or skill set that best identifies a care coordinator We’ve found no single credential or skill set that best identifies a care coordinator

Care Coordination Models The ‘Health Home’ The ‘Health Home’ Patient-Centered Medical Home Patient-Centered Medical Home Targeted Case Management Targeted Case Management Managed Care Organizations Managed Care Organizations Community Health Workers Community Health Workers Other community services… Other community services… 14

Payment for Care Coordination Under the state plan amendments, Medicaid will use a fee-for-service plus per member per month model Under the state plan amendments, Medicaid will use a fee-for-service plus per member per month model A private carrier is promoting a move to an Accountable Care Organization with pay for performance (P4P) and pay for value features A private carrier is promoting a move to an Accountable Care Organization with pay for performance (P4P) and pay for value features Another insurer is adopting a comprehensive payment model with a P4P shared savings Another insurer is adopting a comprehensive payment model with a P4P shared savings A network in the state operates under grant-based payment A network in the state operates under grant-based payment So you see….. So you see….. 15

Everyone likes care coordination, but we’re not sure how we should pay for it! 16

A Bit of Strategy… Adopt consistent or similar payment models Adopt consistent or similar payment models Capture similar measures in similar ways Capture similar measures in similar ways Allow flexibility within practices as long as they are moving toward accepted standards Allow flexibility within practices as long as they are moving toward accepted standards Recognize the unique features of practices and communities Recognize the unique features of practices and communities 17

Respondent William Golden, MD Medical Director, Arkansas Medicaid Enterprise at Arkansas Department of Human Services 18

Rural Challenges Workforce variation; team, alternatives, access Workforce variation; team, alternatives, access Practice infrastructure; capitalization Practice infrastructure; capitalization Socioeconomics, health literacy Socioeconomics, health literacy Perverse incentives Perverse incentives 19

Evolving Environment Workforce Workforce Practice ownership, management Practice ownership, management Health Information Technology Health Information Technology 20

Arkansas Payment Reform Harmonize economic incentives: multi-payer, promote local innovation, care coordination Harmonize economic incentives: multi-payer, promote local innovation, care coordination Episodes of care Episodes of care – Gain sharing for total cost of care, quality metrics – Reward more effective providers; break cycle of payment regardless of practice variation Medical home: New per member per month for transformation/care coordination; gain sharing for total cost of care, quality metrics Medical home: New per member per month for transformation/care coordination; gain sharing for total cost of care, quality metrics 21

Quality Standards and Shared Savings 22

Upside Only Gain-Sharing 23

Concepts: Medical Home versus Health Home Medical Home: The Clinical Game Plan Care coordination/coaching for high priority patients; medically frail, complex psychosocial, literacy concerns Care coordination/coaching for high priority patients; medically frail, complex psychosocial, literacy concerns Health Home: Community Coordination for Select Populations Developmental disability Developmental disability Significant mood disorder Significant mood disorder 24

Payment Initiative ▪ Ensure care provision is efficient and based on client needs – Align resources provided with level of need – Expand plan customization options for clients ▪ Minimize resources / time not focused on delivering client care ▪ Increased care coordination – Integrate care across medical, behavioral, health – Reduce unnecessary medical and behavioral health spending – Promote wellness activities Initial phase: 7,020 clients 1 Service Episode Care Coordination Within Health Home $300 M Adult Developmental Disability Expenditures $35 M Halo expenditures for adults 1 (e.g., medical, behavioral) Includes clients ages 18+ with development disabilities not currently enrolled in public school, excludes 22 clients receiving therapy only 2 Includes all medical and behavioral spending (in-patient, out-patient and pharmacy) SOURCE: Medicaid claims data for claims incurred in SFY

New Activities Provider report cards; data supported change Provider report cards; data supported change Health Information Technology (HIT) expansion Health Information Technology (HIT) expansion Vendor options for care coordination Vendor options for care coordination 26

Issues Engaging all practices; not just early adopters Engaging all practices; not just early adopters Engaging patients Engaging patients Pooling practice data; statistical, actuarial necessity Pooling practice data; statistical, actuarial necessity Diverse installed electronic medical record base; limitations of data extraction Diverse installed electronic medical record base; limitations of data extraction Accountability for use of per member per month Accountability for use of per member per month 27

Unknowns: Value, Pricing of New Services Avoid new economic silos Avoid new economic silos Telemedicine Telemedicine Care coordination; for whom, how intensive Care coordination; for whom, how intensive 28

Brighter Future Providers and payer agree that change is needed Providers and payer agree that change is needed Pain of change becoming less than pain of status quo Pain of change becoming less than pain of status quo Opportunity window to create smarter, more effective health care Opportunity window to create smarter, more effective health care 29

Today’s Event Moderator David Meyers, MD Director of the Center for Primary Care, Prevention, and Clinical Partnerships, AHRQ 30

AHRQ Resources PCMH.AHRQ.GOV 31

PCMH Basics Defining the PCMH Defining the PCMH Evidence and evaluation Evidence and evaluation Tools and resources: care coordination, quality and safety, patient-centeredness, and more Tools and resources: care coordination, quality and safety, patient-centeredness, and more Implementation: A How-To Guide on Developing and Running a Practice Facilitation Program, new case studies Implementation: A How-To Guide on Developing and Running a Practice Facilitation Program, new case studies 32

White Papers and Briefs on Care Coordination The Roles of Patient-Centered Medical Homes And Accountable Care Organizations in Coordinating Patient Care The Roles of Patient-Centered Medical Homes And Accountable Care Organizations in Coordinating Patient Care Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms Coordinating Care for Adults with Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions Coordinating Care for Adults with Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions 33

Measuring Care Coordination AHRQ Care Coordination Measurement Atlas AHRQ Care Coordination Measurement Atlas Review and Recommendations on the Best Tools for Accountability and Assessing Care Coordination Review and Recommendations on the Best Tools for Accountability and Assessing Care Coordination reports/pcpaccountability/index.html reports/pcpaccountability/index.html Caveat: Patient and Family Surveys Caveat: Patient and Family Surveys 34

PCMH CAHPS Consumer Assessment of Healthcare Providers and Systems (CAHPS) program Released in late October 2011 Released in late October 2011 Built on existing, well-validated clinician and group survey Built on existing, well-validated clinician and group survey Covers topics such as provider-patient communication, coordination of care, and shared decision making Covers topics such as provider-patient communication, coordination of care, and shared decision making Available in English and Spanish; adult and child versions Available in English and Spanish; adult and child versions 35

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