1. Maine PCMH Pilot & Community Care Teams (CCTs)
Lisa M. Letourneau MD, MPH
October 2013

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

3. Maine PCMH Pilot Practice “Core Expectations”
Demonstrated physician leadership
Team-based approach
Population risk-stratification and management
Practice-integrated care management
Same-day access
Behavioral-physical health integration
Inclusion of patients & families
Connection to community / local HMP
Commitment to waste reduction
Patient-centered HIT

4. Implications of CMS MAPCP Demo
Projected to achieve budget-neutrality (i.e. to reach $10 pmpm savings) via reductions in avoidable ED use, hospitalizations
Stronger focus on reducing waste & avoidable costs
Introduced CCTs as targeted strategy to support high-needs patients & reduce avoidable costs
Access to Medicare data to identify high patients
Opportunity to add 50 additional practices to join “Phase 2” of Pilot (Jan 2013) 4

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

6. 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) 6
Lisa Letourneau

7. Maine PCMH Pilot Community Care Teams Behav. Health & Sub Abuse
Schools
Environment
Transportation
Community Care Team
Housing
Outpatient Services
Workplace
Care Mgt
Family
Food Systems
High-need Individual
PCMH Practice
Med Mgt
Specialists
Community Resources
Shopping
Coaching
Hospital Services
Behav. Health & Sub Abuse
Income
Physical Therapy
Heat
Literacy 7
Faith Community

8. CCT Selection Used structured application, selection process
CCTs committed to PCMH Core Expectations
Had to get agreement from PCMH/HH practices
Had to meet minimum practice population size ~15,000 8

9. ME PCMH Pilot CCTs AMHC Androscoggin Home Health
Coastal Care Team (Blue Hill FP, Community Health Center/MDI, Seaport FP)
CHANS (MidCoast area)
Community Health Partners (Newport FP, Dexter FP)
DFD Russell (FQHC)
Eastern Maine Homecare
Kennebec Valley (MaineGeneral Health)
Maine Medical Center PHO
Penobscot Community Health Care (FQHC) 9

10. Maine PCMH Pilot Community Care Teams, Phase 1 and Phase 2 Practice Sites

11. 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 + CCT
Provided opportunity to leverage multi-payer PCMH model, practice transformation support infrastructure 11

12. MaineCare Health Homes Health Homes Beneficiary
Community Care Team
Stage A: Help Individuals with Chronic Conditions
Care Mgt
PCMH Practice
Health Homes Beneficiary
Med Mgt
Coaching
Behav. Health
& Sub Abuse 12

13. Maine’s Medical Home Movement
~ 540 Maine Primary Care Practices
Payer:
Medicaid
~150 eligible MaineCare HH-Practices
120+ NCQA PCMH Recognized Practices
Payers:
Medicare
Medicaid (HH)
Commercial plans (Anthem, Aetna, HPHC)
Self-funded employers
50 Pilot Phase 2 Practices
25 Maine PCMH Pilot Practices
14 FQHCs CMS APC Demo
Payer:
Medicare 13

14. CCT Populations Served
CCTs review data from available sources (Medicare RTI reports, MaineCare Utilization reports, other payers, HIN) to identify
Hospital Admissions
3 or more admissions in past 6 months
5 or more admissions in past 12 months
Emergency Department Utilization
3 or more E.D. visits in past 6 months
5 or more E.D. visits in past 12 months
Payer identification of high-risk or high-cost patients 14

15. CCT Staffing Minimum expectations: Medical Director (part-time)
CCT Manager
Nurse Care Manager
LCSW / Care Coordinators
Access to BH, SA expertise 15

16. Financing CCTs: Maine Approach
Linked CCT model, payment to multi-payer PCMH model
Leveraged public, private payers agreement to provide pmpm payment
Participation in CMS MAPCP demo brought in Medicare as payer
Alignment of ACA Health Homes with multi-payer Pilot provided opportunity to leverage federal 90:10 match for CCT services 16

17. CCT Payments Practice population-based capitated payments
Medicare: $2.95 pmpm
Commercial payers: $0.30 pmpm
Per-person capitated payments
Medicaid / Health Homes: $ pmpm 17

18. CCT Goals & Performance Measurement
Improve care, reduce costs for most high-cost, high- needs individuals of PCMH/HH practices
Reduce hospitalizations, readmissions
Reduce ED visits
Performance tracked through quarterly reporting
Number CCT contacts
Number ED visits, hospitalizations pre/post CCT 18

19. CCT Reporting 19

20. 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 20

21. Maine CCTs: Successes Have developed functional CCT infrastructure
CCT structure, support highly welcomed by practices, patients
Most PCMH/HH practices report high levels of satisfaction with CCT services
Have demonstrated numerous examples of high-needs individuals positively impacted by CCTs 21

22. Maine CCTs: Challenges & Lessons Learned
Need to focus on most high-cost individuals, particularly those with frequent hospitalizations, who are open to intervention
Be cautious of focusing on high-needs individuals who are highly resistant to changing behaviors
Value of trauma-informed approach 22

23. Maine CCTs: Challenges & Lessons Learned
Building CCT structure & relationships takes time (up to 2-6 mos)
Data critical to identifying potential patients; current data sources are siloed, time-lagged
Successful interventions depend on strong relationships, with individuals & with practices 23

24. PCMH: Hub of Wider Delivery & Payment Reform Models (ACOs!)

25. Primary Care & CCT Payment in ACOs: So What Will Change?
Despite PCMH, ACO pilots, FFS remains most predominant payment model for providers
Relying on FFS payments continues to emphasize volume & threatens meaningful practice change
Little meaningful change yet to concept of “productivity”
*Payment Reform for Primary Care within ACOs, A. Goroll & S. Schoenbaum, JAMA, Aug 2012

27. Contact Info / Questions
Maine Quality Counts
Maine PCMH Pilot
(See “Programs”  PCMH)
Lisa Letourneau MD, MPH