A P U B L I C A T I O N O F T H E

KATE B. REYNOLDSC H A R I T A B L E T R U S T FAL L /W IN T ER 20 10 I VOLUME 4 I NUMBER 1

cat•a•lyst /kat-'l-est/ n 1: an agent that speed

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significant change 2: an agent that enabl

es a reaction

to proceed at a faster rate or under different conditions

than otherwise possible 3: a person who acts as a

stimulus in bringing about or hastening a result.

128 Reynolda Village I Winston-Salem, NC 27106-5123336.397.5500 Phone I 336.723.7765 Fax800.485.9080 Toll-Free I www.kbr.org

CATALYST

John Frank, Director of the Health CareDivision, retired from the Trust,effective December 31, 2009.

In recognition of his contributionsto improving community healthcare for state residents, particularlythose living in low-income areas,John has received awards honoringhis successful career from the North

Carolina Division of Public Health and the North CarolinaAcademy of Family Physicians.

In presenting the Ronald H. Levine Legacy Award, [former]State Health Director, Dr. Leah Devlin, recognized John andthe Health Care Division of the Trust for “major grantand funding programs related to public health andcommunity health.”

During this year's Jim Bernstein Leadership Fund Dinnerin October, John received the Jim Bernstein CommunityHealth Career Achievement Award in recognition of hisleadership in funding innovative health care programsand his particular commitment to improving health carein low-income communities.

“John's leadership in the Health Care Division has beenexceptional and has made a difference in improvinghealth care for North Carolinians of all ages,” saidKaren McNeil-Miller, Trust President. “We wish him well ashe begins a well-deserved retirement.”

Frank’s Career inImproving Health Carefor North Carolinians

AWARDS HONOR

WHERE’S THAT

WHEN YOU NEED IT?Crystal Ball

Remember Professor Marvel from The Wizard of Oz?He told Dorothy’s “future” by looking at clues he sawin a photo from the past and by carefully assessing herpresent situation. All of us – health care professionals,funders, legislators, and the general public – are grapplingwith the many questions surrounding health care reform atthe national and state levels. We seem to be searching ourown respective crystal balls, looking for a glimpse into thefuture to unveil optimal solutions for improving the qualityof health care for all North Carolinians… especially those wholive in low-income communities.

But glimpses of the future are rare these days, so I propose that welook for clues from the past and cues in the present to find our answers.When we do that at KBR, we see that we must forge ahead, using ourcollective best judgment, our most out-of-the-box ideas, and all theresources we can muster to find viable answers to this generation’shealth care dilemmas.

This issue of Catalyst takes a look at the concept of a medical home –a service delivery option designed to make health care more accessible… morepatient-centered… more equitable… and more cost efficient.Those of us atthe Trust believe in its potential as an important solution and aresupportive of efforts built on the medical home model.

In fact, we have been supporting efforts that encompass at least some ofthe characteristics ascribed to such a model for more than 25 years. TheTrust awarded a 1983 grant of $49,504 and a 1986 grant of $63,566to fund pilot efforts to develop medical homes for Medicaid recipients.Since then, we have invested more than $2.8 million in the evolution ofCommunity Care of North Carolina (CCNC), which has become a modelfor programs across the country (see Page 4).

Developing the technology… streamlining processes… assembling teams of providers…retraining staff… integrating mental health… and a myriad of other challengesare waiting to be addressed. It will take time, resources, innovation,collaboration, and lots of energy. We are committed to being a partof its continuing evolution. No, we can’t boast a glimpse of the future,but we see potential, and that’s all the invitation to action we need.

‘Til next time,

Karen McNeil-Miller

2 Catalyst

The term was first used in the 1960s by the American Academy of Pediatrics to refer to

a central location for archiving a child's medical record. Since that time, the concept has

broadened significantly. Over the past decade, the American Academy of Family Physicians,

the American College of Physicians, and the American Osteopathic Society have joined the

American Academy of Pediatrics in developing their own medical home models. In 2007,

they collaborated to issue the Joint Principles of the Patient-Centered Medical Home.

The principles include the following points:

• “Each patient has an ongoing relationship with a personal physician trainedto provide first contact and guide continuous and comprehensive care.”

• “The personal physician leads a team of individuals at the practice levelwho collectively take responsibility for the ongoing care of patients.”

• “The personal physician is responsible for providing for all the patient'shealth care needs or taking responsibility for appropriately arranging carewith other qualified professionals.”

• “Care is coordinated and/or integrated, for example, across specialists,hospitals, home health agencies, and nursing homes.”

• Quality and safety are assured by a care-planning process, evidence-basedmedicine, clinical decision-support tools, performance measurement, activeparticipation of patients in decision-making, information technology, a voluntaryrecognition process, quality improvement activities, and other measures.

FOCUS O

NMEDICAL HOMES

According to Vision to Reality, a publication issued bythe Patient-Centered Primary Care Collaborative, criticsof themedical homeconcept doubt that the approach can“adequately address the fragmentation and qualityproblems” of health care delivery. In response, theCollaborative points to the system's potential forimprovement through organizing care, enhancingoffice practice systems, building patient relationships,and changing reimbursement levels.

Making the patient-centered medical home concept a reality in

North Carolina – or nationwide – promises to be a formidable task.

There are questions to be answered and issues to be resolved.REALITYMaking Medical Homes A

1 Somecritics liken patient-centeredmedical homes to the “gatekeeper”managed care models. Advocates,however, refute the similarities,saying the gatekeeper modelrewarded physicians for lesscare while the medical homemodel rewards quality,patient-centered care.

2 The American College of EmergencyPhysicians, the American OptometricAssociation, and the AmericanPsychological Association questionthe effect of themedical homemodel onspecial sectorsof the health care system.Advocates of the concept reiterate thataccess to amultidisciplinary team is integralto the medical home model.

3

As the issue of health care reform remains front and center,one promising idea that is receiving lots of attention on both

the state and national levels is the concept of a MEDICAL HOME.

In North Carolina

• Enhanced access to care through "open scheduling, expanded hours and new optionsfor communication.”

• Payment must “appropriately recognize the added value provided to patients whohave a patient-centered medical home.” Payment should reflect the value of “workthat falls outside of the face-to-face visit,” should support adoption and use ofhealth information technology for quality improvement, and should “recognize casemix differences in the patient population being treated within the practice.”

Sources: NC Medical Journal, May/June 2009;Joint Principles of the Patient-Centered MedicalHome, March 2007; Closing the divide: howmedical homes promote equity in health care,Results from The Commonwealth Fund, 2006Health Care Quality Survey; American MedicalNews, December 2008; Family PracticeManagement, January/February 2009;Journal of the American Medical Association,May 20, 2009; "Medicare to fund MedicalHome Model," Wall Street Journal, September16, 2009.

The list of questions and concerns is long. But thenegatives can be partially offset by a growing bodyof evidence that shows having a medical homeleads to easier access, better preventive care, fewerhospitalizations, reduced errors, and fewer disparities.

The Trust will support efforts to meet the many challengesto continuing to develop the medical home concept inNorth Carolina.

The availability of flexible, efficient health informationtechnology is critical to raising the quality and reducingthe cost of health care. Refining current systems willrequire time, money, staff training, and changes tooffice procedure. CCNC networks are workingwith AHEC (Area Health Education Centers) to trainquality improvement consultants to help practicestake advantage of the electronic capabilities thatare available.

4

— Rueben N. Rivers, MDCumberland Internal Medicine, Fayetteville“ ”

“CCNC’s track record for improving quality along with both patient

and provider satisfaction has been proven to me. I will continue

to participate and I encourage others to do so as well.

Although the Joint Principles cannot be regarded as an industry-wide definition of Patient-CenteredMedical Home, they reflect the common indicators that appear in definitions/descriptions across theboard: patient-centered care, better access, more preventive screenings, improved quality of care,and fewer racial and ethnic disparities.

Since being published in 2007, the Joint Principles have received support from the AmericanMedical Association. In addition, medical home guidelines and standards have been proposed byprofessional organizations such as the National Committee for Quality Assurance, and the NewEngland Journal of Medicine has published recommendations for the success of medical homes.

In 2008, then-Presidential candidate Barack Obama expressed support for medical homes in hiswritten response to a survey from the American Academy of Family Physicians: “I support theconcept of a patient-centered medical home.” He continued that as president he would “encourageand provide appropriate payment for providers who implement the medical home model.”

Currently, more than ten states have introduced legislation to promote medical homes, andall versions of the health care reform bills under consideration by the U.S. Congress includeprovisions that would encourage widespread use of medical homes programs.

FALL/WINTER 2010 4

Quality, Affordable Health CareCCNC Puts N.C. Ahead in the Quest for

EXPERTfrom the

North Carolina's Community Care of North Carolina (CCNC) is receiving nationwide attention as a viablemodel of a patient-centered medical home delivery system that provides quality care at an affordable price.

CCNC is a statewide partnership between primary care physicians and the North Carolina Medicaidprogram. When the partnership started in the early 1990s, it was called Carolina Access and wasdesigned as a way of encouraging Medicaid patients to reduce their use of hospital emergency rooms totreat routine illnesses. Under the plan, Medicaid agreed to increase reimbursement and provide monthlyincentive payments to primary care practices that would offer on-call services to Medicaid patients.

As the partnership model was implemented, early results showed that both emergency room use andhospitalizations decreased among participants. Because the model was particularly effective for children,95% of the state's pediatric practices joined the partnership, agreeing to expand office hours and offeron-call triage services.

Enhancements to the program, introduced as Carolina Access II and III, encouraged flexibility andinnovation so that communities across the state could adjust the details of the partnership to meetspecific needs and to build on their existing resources. The Trust awarded grants totaling more than one milliondollars in support of the development and expansion of these programs. In 2000, the state mandated that theprogram should be expanded statewide and should be called Community Care of North Carolina.

Today, CCNC is a system of 14 provider networks covering 94 of the state's 100 counties. The systemincludes more than 1,380 medical practices working with local health departments, hospitals, andsocial services agencies to manage the care of more than 970,000 Medicaid and North CarolinaHealth Choice (NCHC) participants. By putting in place the community networks and supporting themwith State-provided resources, information, and technical support, CCNC has built an infrastructurethat is key to expanding and improving health care delivery to other populations as well.

Through quality improvement initiatives, all CCNC community networks are engaged in setting localobjectives, measuring performance, sharing best practices, and ensuring coordination of care. TheAsthma and Diabetes Disease Management initiatives began in the year 2000; over the decade, otherinitiatives have been established: Congestive Heart Failure Disease Management, Emergency Room Utilization,Pharmacy Management, Case Management for High Risk/High Cost Patients, Chronic Care and Mental Health.

Although long-term results of each initiative and of the total program are still in the making,short-term indicators reflect fewer hospital admissions and emergency room visits among asthmapatients, improved blood pressure and lipid levels among diabetes patients, and greater access topreventive care among all participants.

Since 2000, the Trust has awarded grants totaling $1.7 million in support of CCNC services:• $511,900 to fund two prevention programs – one focused on stroke preventionand a second targeting prevention of childhood obesity.

• $653,000 toward the development of Integrated, Collaborative, Accessible,Respectful, and Evidence-Based Care Initiative (ICARE) to improve mentalhealth, developmental disabilities, and substance abuse services provided toMedicaid recipients.

• $249,968 toward the expansion of physician practice improvement programsto include a new program to improve integration of prevention practices.

• $300,000 toward operating funds to assist in program development andexpansion into additional counties.

In cost savings, too, CCNC indicators are significant. The Sheps Center Report estimatedthat between 2000 and 2002, the Asthma Disease Management Initiative saved $3.5million from lower hospital and emergency department costs and the Diabetes DiseaseManagement Initiative saved $2.1 million. Substantial savings from the PharmacyManagement Initiative are also being tracked. Governor Mike Easley's administrationestimated that CCNC saved state taxpayers more than $231 million during fiscal years2005 and 2006. A recent study from Mercer Human Resource Consulting Group foundthat in fiscal year 2007 the program saved the State of North Carolina approximately$147 million when compared to projected expenses without any concerted efforts tocontrol costs.

In recognition of its impact, CCNC received the 2007 Annie E. Casey InnovationsAward in Children and Family System Reform given by the Ash Institute forDemocratic Governance and Innovation at Harvard University's John F. KennedySchool of Government.

— Pam SilbermanPresident and CEO

North Carolina Institute of Medicine

Q.What characteristics must a medicalpractice demonstrate in order to qualify asa Patient-Centered Medical Home?

A. The idea of a Patient-Centered MedicalHome is still evolving, so there is no single,definitive answer. But I believe the real-lifemedical home must include some exampleof these characteristics:

• A health care practice that coordinates carefor their patients across multiple providers.

• Easy access to care.

• A multidisciplinary team of medical providers.

• Dedication to continuous quality improvement.

• Health technology systems designed toadd efficiency to the practice, streamlinepatient records, and provide qualityimprovement prompts.

to improve the quality of life

and quality of health for the

financially needy of North Carolina.

— MISSION OF THE TRUST

Through the Health Care Division, the Kate B. Reynolds Charitable Trust responds to healthcare and wellness needs and invests in solutions that improve the quality of health forfinancially needy residents of North Carolina.

The Trust envisions tremendous potential in the Patient-Centered Medical Home (PCMH)concept of service delivery. PCMH directly supports multiple priorities of the Health Care Divisionof the Trust:

•SUPPORTING PREVENTION: Disease and Illness Prevention•DIABETES – Efforts to identify and support those most at risk of developingdiabetes through strategies reflecting the best practices in the field.

•MENTAL HEALTH AND SUBSTANCE ABUSE – Efforts to identify and support thosemost at risk of impairment and addiction reflecting the best practices in the field.

• PROVIDING TREATMENT: Access to Primary Medical Care•PROVIDING A MEDICAL HOME – Efforts to identify and secure a medical home for all.

•INCREASING HEALTH CARE COVERAGE – Efforts to increase the number of low-incomeNorth Carolinians who have coverage.

• PROVIDING TREATMENT: Mental Health Services•DEVELOPING OR STRENGTHENING A CONTINUUM OF CARE – Effortsthat respond both to systemic gaps and to gaps in individual care.

•INTEGRATED CARE – Efforts that bring mental and primary healthcare providers together in concurrent assessment and treatment.

• PROVIDING TREATMENT: Diabetes Care and Management•ACCESS TO QUALITY MEDICAL CARE – Efforts to provide a physician-coordinated teamthat consists of a comprehensive initial patient evaluation and a continuum of care.

•PATIENT SELF-MANAGEMENT – Efforts to provide individualized self-management planning.

Did YouKNOW?

Although U.S. per capita health care spending far exceeds that of other countries,care in the U.S. is less equitable, less effective, less efficient, and less safe.

Among Americans 65 and older, almost two-thirds have multiple chronic conditions.

Between 1999-2000 and 2007-2008, North Carolina's uninsured rate increased by 19.2%(almost double the national rate of 9.9%).

The three largest groups of uninsured North Carolinians are the following:

Adults with income below 200% of federal poverty guidelines (724,000)

Employees (and their dependents) of businesses with fewer than 25 employees (432,000)

Children from families with income below 200% of federal poverty guidelines(179,000 - 93% are eligible for, but not enrolled in, Medicaid orNC Health Choice)

Since 1999, health insurance premiums have increased 131% nationwide –compared with inflation (28%) or wage growth (38%).

Sources: Mirror, Mirror on the Wall: An International Update on the ComparativePerformance of American Health Care, The Commonwealth Fund publication No.1027; Chronic Conditions: Making the Case for Ongoing Care, Partnership forSolutions, Johns Hopkins University, 2002; Health Reform presentation, NCIOM,September 2009.

STRA

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HEALTH CARE DIVISIONMarch 2010 GRANT CYCLE

Two special Requests for Applications havebeen issued in existing priority areas. Deadline forproposals is March 15. For additional information

or to schedule an advance consultation, pleasesee www.kbr.org or contact the Trust Program

Associate at 866-551-0690.

POOR AND NEEDY DIVISIONResponsive grantmakingwill resume in July 2010.

Deadline for proposals is July 15.

TRUST SEEKS NEW FELLOWSThe Trust is seeking two emerging leaders in

the philanthropy and nonprofit sector to join us

for a two-year fellowship beginning June 2010.

Go to www.kbr.org for completegrantmaking schedules and current updates.

inthisISSUEinthisISSUE

•FocusonMedicalHomes

•CCNC-AViableModel

•RememberingPamWyatt

GRANTMAKING128ReynoldaVillageIWinston-Salem,NC27106-5123

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PAIDWinston-Salem,NC

27102PermitNo.178

CATALYSTWe at the Trust lost our friend and co-worker, PamWyatt, on November 20 aftera hard-fought struggle with cancer. Pam joined the Trust staff as Director of thePoor and Needy Division in November 2008.

Although she had only been at the Trust for a short while, she left her mark as acreative and dedicated community leader. She had established relationships with theleaders of many Forsyth County organizations and was active in building collaborativeefforts to support low-income families during this challenging economic period.

We will miss her professionalism and her friendship, and we are most grateful forthe opportunity to work with her over the past year.

in uncertain economic times

RememberingPam Wyatt

The Trust is pleased to announce that Allen Smart assumed leadershipof the Health Care Division effective January 1, 2010, following JohnFrank’s retirement. Since joining the Trust in 2006, Allen has been asenior program officer in the Health Care Division with responsibilityfor eastern North Carolina programming focused on health careaccess, diabetes, mental health, racial disparities, and communityengagement. He has led the Trust’s capacity-building efforts and hasrepresented the Trust in statewide funding collaboratives, includingthe Nurse Family Partnership, a national program of preventive careintervention for low-income women and their children.

“Allen is the total package,” said Karen McNeil-Miller, President of the Trust. “I am delightedthat he has accepted this opportunity and challenge.”

LeadershipRoll