1. Patient Centered Medical Home: Overview of the Primary Care Footprint in Rhode Island Nurse Care Manager Best Practice Sharing Day Debra Hurwitz, MBA, BSN, RN CTC Co-Director May 5, 2015 1

2. 2 The Rhode Island Care Transformation Collaborative(CTC- RI) Vision: Rhode Islanders enjoy excellent health and quality of life. They are engaged in an affordable, integrated healthcare system that promotes active participation, wellness, and delivers high quality comprehensive health care. Mission: To lead the transformation of primary care in Rhode Island in the context of an integrated health care system; and to improve the quality of care, the patient experience of care, the affordability of care and health of the population we serve

3. 3 The key to building PCMH is measured progress toward the Triple Aim

4. 4 CTC-RI helps plans and practices build sustainable Patient-Centered Medical Homes Data-driven practice transformation NCQA Level 3 Nurse Case Manager on the team Common Contract All-payers involved PMPM paid on attributable lives PMPM based on performance

5. 5 Improving Primary Care Architecture Increasing Primary Care Spend: 10.7% of commercial insurers’ medical spend devoted to primary care Increased focus on payment for value Electronic health record, interoperability, Current Care ACA: patient benefit to seeking care in patient centered medical homes

6. 6 Improving Primary Care Architecture Community Health Teams Two pilots : South County and Pawtucket Identification of high risk patients Shared resources among CTC practices Behavioral Health and Community Resource Specialists Integrated Behavioral Health 12 CTC practices Practice team meets with integrated behavioral health practice facilitator to implement integrated behavioral health model Webinars for all practices

7. 7 Increased Access to PCMH

8. 8 Improvements in Primary Care Architecture NCM Practice team focused on knowing patients who are most vulnerable and creating high risk patient registry NCM focused on patients who are “high risk” and “at risk” Reporting on patient engagement and collaboration with health plan resources

9. 9 Anticipated Outcomes Improved quality of care Improved patient experience Reduced cost as measured by reduced ER/IP utilization Improved staff satisfaction Practice readiness for shared savings

10. 10 Questions?