Maine PCMH Pilot and MaineCare Health Homes Update

Maine Quality Forum Advisory

CouncilLisa TuttleJune 2013

Maine PCMH Pilot Leadership

Maine Quality Counts

Dirigo HealthAgency’s (DHA’s)

Maine QualityForum

Maine Health Management

Coalition

MaineCare (Medicaid) 2

Maine PCMH Pilot - MAPCP Timeline

ME PCMH Pilot - Original

ME PCMH Pilot - Extended

Jan 1, 2010

Dec 31, 2014

Jan 1, 2012

Pilot Expansion,

HHs

2011 2012 2013 Dec 31, 2014

MAPCP Demo – 3yr

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FQHC: federally qualifiedhealth center

H-O: hospital-owned

Maine PCMH Pilot Expansion

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Maine’s Medical Home Movement

~ 540 Maine Primary Care Practice Sites

25 Maine PCMH Pilot Practices

50 Pilot Phase 2

Practices

14 FQHCs CMS APC

Demo

100+ NCQA PCMH Recognized Practices

80 MaineCare HH-only Practices

Payers: • Medicare• Medicaid (HH)•Commercial plans (Anthem, Aetna, HPHC)•Self-funded employers

Payer: Medicare

Payer: Medicaid

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Alignment of Pilot with MaineCare Health Homes Initiative

• Affordable Care Act (ACA) Sect 2703 - 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 + Community Care Team (CCT)

• Provided opportunity to leverage multi-payer PCMH model, practice transformation support infrastructure

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CMS Health Homes – ACA Section 2703• Implementation January, 2013• CMS will provide 90/10 match for Health Home services

to eligible members for eight quarters • Health Homes may serve individuals with:

• Two or more chronic conditions• One chronic condition and who are at risk for another• Serious mental illness

– Adults with serious mental illness (SMI)– Children with severe emotional disturbance (SED)

• Cannot exclude Dual eligible beneficiaries

– Mental health– Substance abuse– Asthma– Diabetes– Heart disease– Overweight (BMI > 25) &

Obesity

CMS Health Homes – ACA Section 2703

Chronic conditions (per CMS): – Chronic Obstructive

Pulmonary Disease (COPD)– Hypertension– Hyperlipidemia– Tobacco use– Developmental Disabilities &

Autism Spectrum– Acquired brain injury– Cardiac & circulatory

congenital abnormalities– Seizure disorder

Maine-specific:

Required Health Home services include:– Comprehensive care management– Care coordination and health promotion– Comprehensive transitional care– Individual and family support– Referral to community and social support services– Use of health information technology (HIT)– Prevention and treatment of mental illness and substance

abuse disorders– Coordination of and access to preventive services, chronic

disease management, and long-term care supports

CMS Health Homes – ACA Section 2703

Maine Health Homes Stage A:•Health Home = Medical Home primary care practice + CCT •Payment weighted toward medical home•Eligible Members:

• Two or more chronic conditions• One chronic condition and at risk for another

Maine Health Homes Stage B:•Health Homes = CCT with behavioral health expertise + primary care practice•Payment weighted toward CCT•Eligible Members:

• Adults with Serious Mental Illness• Children with Serious Emotional Disturbance

• All Health Home practices (including hospital-based) will receive a per member per month (PMPM) payment for eligible Health Home members.

• The PMPM rate will be $12, compared to $3.50 for PCCM. Practices will only be paid on Health Home-eligible members.

• Practices will still receive a PCCM payment of $3.50 PMPM for members who are enrolled in PCCM but are not eligible for Health Homes.

Health Homes Payment & Practice Eligibility

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)

Lisa Letourneau 14

High-need Individual

Maine PCMH Pilot Community Care Teams

Transportation

Workplace

Environment

Food Systems

Shopping

Income

HeatFaith

Community

Literacy

Coaching

Physical Therapy

Hospital Services

Specialists

Outpatient Services

Med Mgt

HousingCare Mgt

Behav. Health & Sub

Abuse

Family

Schools

Lisa Letourneau

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

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PCMH-HH-CCT: Efforts to Align Reporting

• MAPCP uses RTI Portal for Utilization reports• Health Homes Portal and Utilization reports through USM Muskie School

– in progress!• MHMC produced Cost and Utilization Reports – currently rolling out

Commercial – Medicare and MaineCare in early 2014• CCT and PCMH/HH alignment on self-assessment of progress for

quarterly reports

Primary Care Practice Reports – Cost & Utilization

• Maine Health Management Coalition (MHMC ) workshops/webinars:– Objective

• · The purpose of the reports• The data they are generated from, and• Ideas on how they can improve care.

– Location: • EMMC, Bangor - Tuesday, June 11• MaineHealth, Portland - Tuesday, June 18• MaineGeneral, Augusta - Monday, June 24

Maine PCMH Pilot/HH “Core Expectations” for all Practices

1. Demonstrated physician leadership for improvement2. Team-based approach3. Population risk-stratification and management4. Practice-integrated care management5. Same-day access to care6. Behavioral-physical health integration7. Inclusion of patients & families8. Connection to community / local HMP9. Commitment to reducing avoidable spending & waste10. Integration of health IT

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HH Reporting Requirements• MaineCare will report on the majority of CMS-required and state-specific quality measures through

analysis of claims data.• Beginning in January 2014, CMS will require reporting of three quality measures that cannot be

assessed through claims analysis:– Adult BMI assessment– Care transitions record transmitted to PCP (within 24hrs)– Depression screening & follow up

MaineCare is working with HealthInfoNet to directly upload these measures directly from the EMR..

• From outset: – Measure BMI in all adult patients at least every two

years, and at BMI percent-for age at least annually in all children.

Addt’l Service Requirements: Assessment & Screening

•By year 2: – Annual depression and substance abuse screening (PHQ9 and

AUDIT, DAST) for all adults with chronic illness, and substance abuse screening (CRAFFT) for adolescents. – Annual ASQ or PEDS developmental screening for all children age

one to three, and the MCHAT 1 for at least one screening between ages 16-30 months with a follow-up MCHAT 2 if a child does not pass the screening test.

PCMH Pilot: How are we doing?

• 2013 Must Pass elements – Core Expectations• QC Database and Dashboarding efforts to

prioritize technical assistance • QC Open ‘office hours,’ monthly webinars,

early focus on action plans to provide support• Clinical Quality Measures – still confounded by

Electronic Health Record capabilities

PCMH: Lessons Learned• NCQA PCMH ≠ PCMH• Move to PCMH requires transformation (not

incremental change) of entire practice, culture, and personal transformation (esp. physicians!)

• Medical home is not something that can be “installed”• Change starts with effective leadership – organizational,

clinician, and administrative• Supportive culture & leadership trumps all• Include patients & families early & often

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Contact Info / QuestionsLisa Tuttle, MPH

• ltuttle@mainequalitycounts.org

Maine Quality Counts• www.mainequalitycounts.org (See “Programs” PCMH

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