blueprint integrated pilot programs building community systems of health

Blueprint Integrated Pilot ProgramsBuilding community systems of health

Craig Jones MDDirector, Vermont Blueprint for Health

[email protected]

State Coverage InitiativesVermont Site VisitAcademy Health

Robert Wood Johnson Foundation

Funding

Blueprint / State•Global Commitment•Catamount Fund•Federal Funds•HIT Fund

Grant Support ?

Multi Insurer Reform•Medicaid•BCBS•Cigna•MVP

Clinical TransformationVPQ Coordinated TrainingClinical Microsystems

Provider IncentivesParticipation & Training

Community ActivationLocal Programs

Self ManagementHealthier Living Workshops

Health Information TechnologyVPQ Hosted Registry (VHR)

EvaluationVPQ Registry ReportsVCHIP Chart Review

VITL Health Information Exchange Network

Financial Reform Enhanced provider payment Shared costs for CCT

Local Care Support CCT as shared resource

Prevention Public Health Specialist on CCT Local Prevention Team

Health Information Technology VITL EMR Pilot Project VPQ Hosted Web Based CIS with eRx

VITL Health Information Exchange Network

Multi payer claims data base Clinical / demographic data base VCHIP NCQA PCMH scoring VCHIP chart review

Blueprint Communities(Act 191, 2006)

Programs Products

Blueprint Integrated Pilots(Act 71 2007, Act 204 2008)

Evaluation Infrastructure

Improved Care Delivery (Diabetes) IT enhanced care (Diabetes) Improved self mgmt (HLW attendees) Local exercise / prevention programs VHR - Descriptive statistics (Diabetes) VCHIP – Chart review

Su

stai

nab

le T

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sfo

rmat

ion

Advanced Medical Home Improved Care Delivery (General) Local care support & DM services Sustainable Financial Reform Improved Self Mgmt (Multi-faceted) IT enhanced care

-Chronic disease -Health maintenance -eRx

Prevention & Wellness Programs -Community team -Evidence based -Linked with care delivery

Evidence based healthcare process Routine QA / QI Evaluation of health impact Evaluation of financial impact Predictive modeling (claims / clinical) Epidemiologic / outcomes research CCT Utilization Patterns

Health IT Framework

Global Information Framework

Evaluation Framework

Operations

Blueprint Integrated PilotsCoordinated Health System

PCMH

PCMH

PCMH

PCMHHospitals

Public Health Prevention

Community Care TeamNurse Coordinator

Social WorkersDieticians

Community Health WorkersOVHA Care Coordinators

Public Health Prevention Specialist

Mental Health & Substance

Use Disorders

Blueprint Integrated Pilot Summary

1. Financial reform (2 major components - includes MCAID & commercial insurers)- Payment to practices based on NCQA PCMH score- Shared costs for Community Care Teams

2. Multidisciplinary care support teams (CCT Teams)- Local care support & population management

3. Health Information Technology- Web based clinical tracking system (DocSite)- Visit planners & population reports

- Electronic prescribing- Updated EMRs to match program goals and clinical measures in DocSite - Health information exchange network

4. Community Activation & Prevention - Prevention specialist as part of CCT - Community profiles & risk assessments

- Evidence based interventions

5. Evaluation- NCQA PCMH score (process quality)- Clinical process measures- Health status measures- Multi payer claims data base- Population Indicators

$0.00

$0.50

$1.00

$1.50

$2.00

$2.50

$3.00

0 10 20 30 40 50 60 70 80 90 100

NCQA PCMH Score

$ P

PP

M p

er

pro

vid

er

PPPM Payment

NCQA Scoring & Provider Payment

5 of 10 MP 10 of 10 MP

St. Johnsbury Family HCChronic Care Coor .5 FTEBeh. Health Spec. .5 FTE

Concord Health Ctr.Chronic Care Cood .5 FTEBeh. Health Spec. .5 FTE

Danville Health CenterChronic Care Coor .5 FTEBeh. Health Spec .5 FTE

Corner MedicalChronic Care Coor 1 FTEBeh. Health Spec 1 FTE

OtherOVHA Care ManagersHospital Care ManagersHospital-based CC EducatorsCommunity-based Advocates

Community ConnectionsCommunity Health WorkersCC Comm. Health Worker

VDH District OfficePublic Health Specialist

Calodenia Int. MedicineChronic Care Cood .5 FTEBeh. Health Spec. .5 FTE

St. Johnsbury Community Care TeamCare Integration Coordinator

1 FTE

St Johnsbury Community Care TeamStaffing

Behavioral Health

Specialist

Chronic Care Coordinator

Community Connections

VT Department of Health

Community Care Managers

(OVHA, AAA, Umbrella, etc.)

Physicians

Nurse Practitioners

Physician Assistants

COMMUNITY CARE TEAM

PRIMARY CARE OFFICE

St Johnsbury Community Care TeamReferral and Communication Flow Chart

Chittenden CountyCommunity Care Team

Nurse Lead Manager1 FTE

Medical Asst.2 FTEs

Aesculapius

Admin. supp..25 FTE

Admin. Supp..5 FTE

Dr. Moore

Behavioral Specialist.25 FTE

Med. Social Worker1 FTE

ExercisePhysiologist.25 FTE PD

Cert. DiabeticEducator1 FTE

Dietitian/Nutritionist.25 FTE PD

HealthEducator1 FTE

Admin. Supp1 FTE

VDHPublic Health

Specialist

Chittenden County Community Care TeamStaffing

Central – Public Health Prevention Team•State level assessments•State level strategic planning•Data review & interpretation•Design campaigns / programs•Technical assistance / support

Regional – Public Health Prevention Teams•Local assessments•Local intervention planning•Organizing & coordination•Multidisciplinary Services

Surveillance

HPDP

ADAP

Blueprint

MCH

Preparedness

Rural Health

Business Office

•Program content•Best practices•Domain expertise•Data analysis•Reporting

Transportation

Education

Labor

Medicaid

Corrections

Mental Health

Children & Families

DAIL

•Input•Review•Domain expertise•Coordination•Planning

Departments VDH Programs

State & Local Coalitions

Community Groups

Community Stakeholders

Community Health Teams

VDH Prevention Teams

An Integrated Model for HealthFunctional Map – Public Health Operations

Community Care Team # 1




PHASE 4 - Implementation

Timeline depends on scope and resources of planned intervention

PHASE 3 - Community Planning

Planning with key leadersPlanning with stakeholdersIterative interactive processConsensus building

PHASE 2b - Community Assessment

Quantitative Context - state level 10 year trend analysis of risk factors associated with morbidity & healthcare costs

Focus groupsFormal key leader interviewsContinue until no new themesTest themes in new interviewsTest findings in community forums

Phase 5 – Evaluation

2 - 4 months

4 - 6 months

3 - 5 months

PHASE 2a - Community Profile

Community description Community inventoryQuantitative Context - Descriptive health statistics

on the rates of risk factors in each community (5 year aggregate data)

PHASE I - Develop capacity

Facilitate systems approachTrain Prevention Specialist

Prevention Model and FrameworkData collection techniquesEnvironment and policy change

Community Assessment & Planning TimelineOctober 2008

Health IT Framework

Global Information Framework

Evaluation Framework

Operations

PCMH

PCMH

PCMH

PCMHHospitals






Behavioral Health & Substance

Abuse Services

Prevention Programs

Policies and SystemsLocal, state, and federal policies and laws, economic and cultural influences, media

CommunityPhysical, social and cultural environment

OrganizationsSchools, worksites, faith-based organizations, etc

RelationshipsFamily, peers, social networks, associations

IndividualKnowledge, attitudes, beliefs

Blueprint Integrated PilotsCoordinated Health System – Integrating Existing

Programs

Blueprint Integrated PilotsCoordinated Health System

Healthcare Information Framework

Health System Information Framework

Evaluation & Framework

Operations & Uses Framework

•EMRs•DocSite•Practice Management Systems•Hospital Information Systems

•EMRs•DocSite•Practice Management Systems•Hospital Information Systems•Multi-payer claims database•Public Health Databases•Chart reviews•NCQA Scoring

•NCQA Scores•Clinical Process Measures•Health Status Measures•Healthcare Resource Utilization•Healthcare Expenditures•Financial Impact ROI•Population Health Indicators

•Individual Patient Care•Population Management•Quality Improvement•Program Evaluation•Program Sustainability•Community Activation / Prevention•Health Policy

PCMH

PCMH

PCMH

PCMHHospitals






Behavioral Health & Substance

Abuse Services

Blueprint Integrated PilotsWhy measure?

Group 1Good Disease

Control

Group 2Intermediate

Disease Control

Group 3Poor

Disease Control

Average = 7.46 Average = 7.36

HealthcarePatterns &

Resource Utilization

Healthcare Expenditures & Financial Impact

HealthStatus

Measures

ClinicalProcess

Measures

Population Indicators &Risk Factors

Healthcare Quality Measures & Standards

Population Management

Quality Improvement

Program Evaluation & Sustainability

Community Prevention Planning

Individual Patient Care & Support

Services

Provider Payment for

Quality

Data Processing & Storage

EMRs used forIndividual Patient

Care

DocSite used forIndividual Patient

Care

DocSite Database

EMR Databases

DocSiteReporting

Tool

VCHIPChart Review & NCQA Scoring

Medical Claims from Commercial

Insurers & Medicaid

Public Health Surveys & Data

Collection

DataSource

Data transmission & transformation

VITL / GE

DataAnalysis

Data Reports & Uses

EMRReporting Tool or

Analyst

Public HealthRegistries & Databases

VDH Health Surveillance

Analytic Database

BISCHAMultipayerDatabase

VCHIPDatabases

VCHIPAnalysis & Report

Generation

BISCHAReports


Analyst

ContractedAnalysisServices

Blueprint Integrated PilotsEvidence Based Quality Improvement


Quality Improvement


Services



Care


Care


Care

DocSite Database

EMR Databases

DocSiteReporting

Tool






Insurers & Medicaid


Insurers & Medicaid


Collection


Collection

DataSource


VITL / GE

DataAnalysis

Data Reports & Uses


Analyst




Analytic Database


Analytic Database



VCHIPDatabases

VCHIPDatabases


Generation


Generation

BISCHAReports

BISCHAReports








Analyst


Analyst

HealthStatus

Measures

ClinicalProcess

Measures










Quality


Quality




Care


Care


Care

DocSite Database

EMR Databases

EMR Databases

DocSiteReporting

Tool


Quality Improvement






Insurers & Medicaid


Insurers & Medicaid


Collection


Collection

DataSource


VITL / GE


VITL / GE

DataAnalysis

Data Reports & Uses


Analyst


Analyst




Analytic Database


Analytic Database



VCHIPDatabases

VCHIPDatabases


Generation


Generation

BISCHAReports

BISCHAReports








Analyst


Analyst

HealthStatus

Measures

ClinicalProcess

Measures








Services




Quality


Quality





Care


Care


Care


Care

DocSite DatabaseDocSite Database

EMR Databases

EMR Databases

DocSiteReporting

Tool

DocSiteReporting

Tool







Insurers & Medicaid


Insurers & Medicaid


Collection


Collection

DataSource


VITL / GE


VITL / GE

DataAnalysis

Data Reports & Uses


Analyst


Analyst




Analytic Database


Analytic Database



VCHIPDatabases


Generation

BISCHAReports

BISCHAReports








Analyst


Analyst

HealthStatus

Measures

HealthStatus

Measures

ClinicalProcess

Measures

ClinicalProcess

Measures








Services


Services


Quality

Quality Improvement



Quality Improvement



Care


Care


Care


Care


EMR Databases

EMR Databases

DocSiteReporting

Tool

DocSiteReporting

Tool





Insurers & Medicaid


Insurers & Medicaid


Collection


Collection

DataSource


VITL / GE


VITL / GE

DataAnalysis

Data Reports & Uses


Analyst


Analyst




Analytic Database


Analytic Database



VCHIPDatabases


Generation

BISCHAReports

BISCHAReports








Analyst


Analyst

HealthStatus

Measures

ClinicalProcess

Measures








Services


Services




Quality


Quality




Quality Improvement



Care


Care


Care


Care


EMR Databases

EMR Databases

DocSiteReporting

Tool

DocSiteReporting

Tool






Insurers & Medicaid


Collection


Collection

DataSource


VITL / GE


VITL / GE

DataAnalysis

Data Reports & Uses


Analyst


Analyst




Analytic Database


Analytic Database


VCHIPDatabases

VCHIPDatabases


Generation


Generation

BISCHAReports





Analyst


Analyst

HealthStatus

Measures

HealthStatus

Measures

ClinicalProcess

Measures

ClinicalProcess

Measures






Services


Services




Quality


Quality



Quality Improvement



Care


Care


Care


Care


EMR Databases

EMR Databases

DocSiteReporting

Tool

DocSiteReporting

Tool








Insurers & Medicaid


Insurers & Medicaid


Collection

DataSource


VITL / GE


VITL / GE

DataAnalysis

Data Reports & Uses


Analyst


Analyst



Analytic Database



VCHIPDatabases

VCHIPDatabases


Generation


Generation

BISCHAReports

BISCHAReports








Analyst

HealthStatus

Measures

HealthStatus

Measures

ClinicalProcess

Measures

ClinicalProcess

Measures





Services


Services




Quality


Quality


Blueprint Integrated PilotsFinancial Impact

2009 2010 2011 2012 2013Percentage of Vermont population participating 6.7% 9.8% 13.0% 20.0% 40.0%

Participating population 42,179 61,880 82,332 127,045 254,852

# Community Care Teams 2 3 4 6 13

Build a model for effective and sustainable reform

Multi Insurer Financial Reform (PCP payment, CCTs)

Financial Incentives (balance volume & quality)

Environment (PCMH, CCTs, PH specialists, Health IT)

Focus (quality, wellness, prevention)

Evaluation (multidimensional, routine)

Culture (self management, engaging yet objective)

Blueprint Integrated PilotsBuilding a Scalable Model

blueprint integrated pilot programs building community systems of health

Documents

community care teams

care deliveryevidence

cctlocal care support

clinical measures

ncqa pcmh score shared

vermont blueprint

program goals

major components