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Vermont Blueprint for Health Integrated Pilot Programs
PCPCC Call
Lisa Dulsky Watkins, MDVermont Department of Health
January 20, 2009
Vision
Vermont will have a statewide system of care that improves the
lives
of individuals with and at risk for chronic conditions
Improved Outcomes-Healthier People
ProductiveInteractions
Self-Management
Support
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Health System
Health Care Organization
Community Resources and
PoliciesPublic HealthPolicies, Systems,
Environment
Supportive Environment
Informed,Activated
Patient
Prepared,Proactive
Practice Team
Adapted from the chronic care model which is used by permission of “Effective Clinical Practice.”
What is the Blueprint?
Who are the players?• State Government
– Executive and Legislative branches– Department of Health
• Over 100 volunteers serving on committees and workgroups• Insurers – publicly and privately funded• University of Vermont College of Medicine• Vermont Information Technology Leaders• Local and national QI organizations
– Vermont Program for Quality in Health Care – Institute for Healthcare Improvement – Agency for Healthcare Research and Quality– AcademyHealth/Commonwealth Fund
• Providers – MD, DO, NP, PA, nursing and office staff• Patients and families
Bennington
Burlington
St. Johnsbury
Barre
Springfield
Windsor2005—Initial two pilot Hospital Service Areas (Diabetes Focus)
Healthier Living Workshops
Community Physical Activity Grants
April 2007
2004—Planning
2003—Launch of the Blueprint
2006—Four new Hospital Service Areas (Diabetes Focus)
Blueprint DevelopmentBlueprint Development
2006—Statutory Endorsement
2007— Medical Home Integrated Pilots in Statute
2009 - Integrated Medical Home Pilots(all chronic conditions + prevention)
Health Care Reform Legislation2006
Health Care Affordability Acts (Acts 190, 191) Common Sense Initiatives (Appropriations Bill) Sorry Works! (Act 142) Safe Staffing and Quality Patient Care (Act 153)
2007 Corrections and Clarifications to the Health Care Affordability Acts of 2006 (Act
70) An Act relating to Ensuring Success in Health Care Reform (Act 71)
2008 An Act Relating to Health Care Reform (Act 203) An Act Relating to Managed Care Organizations and the Blueprint for Health
(S.283)
Blueprint Integrated Pilot Summary
1. Financial reform- Payment based on NCQA PCMH standards- Shared costs for Community Care Teams- Medicaid & commercial payers- BP subsidizing Medicare
2. Multidisciplinary care support teams (CCT Teams)- Local care support & population management- Prevention specialists
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
Primary Care PCMH-Docs-NPs-PAs-MAs-Staff
Community Care Team (CCT)e.g. NP, RN, MSW, Dietician,Behavior Specialist, Community Health Worker, VDH Public Health Specialist
CCT SupportPanel ManagementCoachingPatient / family contactAssessmentReinforce treatment planEducationRemindersSelf management
Social / Economic SupportLiaison to other programsEnrollment assistance
Prevention & Self ManagementReferral to community programsCoordinate community programs
Vermont Health Information Platform (VITL)
Referral & care support Education & Improvement
PCMHPayment reformComprehensive guideline based careHealth maintenance & preventionChronic conditionsPanel managementCoachingRemindersGoal settingHealth IT – planned visitsHealth IT – population managementHealth IT – eRxPaper based or EMR practices
Referrals,Communication& QI Planning
Blueprint Integrated Pilot Model
Primary Care PCMH-Docs-NPs-Staff
Community Care Team (CCT)e.g. NP, RN, MSW, Dietician,Behavior Specialist, Community Health Worker, VDH Public Health Specialist
Referrals &Communication
Vermont Health Information Platform (VITL)
Hospital-Educators-Transitional care-Ambulatory center (wellness programs)
Referral & care support Education & Quality Improvement
Policies and SystemsLocal, state, and federal policies and laws, economic and cultural influences, media
CommunityPhysical, social and cultural
environment
OrganizationsSchools, worksites, faith-based
organizations, etcRelationships
Family, peers, social networks, associations Individual
Knowledge, attitudes, beliefs
Adapted from: McElroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Education Quarterly 15:351-377, 1988.
Model for Health & Prevention
Prevention
Healthcare
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
Pilot Site # Provider # Patients
Community Practice
St. Johnsbury
Caledonia Internal Medicine 3 2,011
Concord Health Center 2 2,183
Corner Medical 6 14,500
Danville Health Center 2 3,088
St. Johnsbury Family Health Center 2 2,822
Total St Johnsbury 15 24,604
Burlington
Fletcher Allen AffiliatedAesculapius Medical Center 9 15,774
Private Practice – Non Affiliated 1 1,800
Total Burlington 10 17,574
Bennington
Planning stages
Total (first 2 sites only) 25 42,178
Pilot # 1
Pilot # 2
Pilot # 3
Standards
NCQA PCMH PointsAverage PPPM
Payment
0 0.00
5 0.00
10 0.00
15 0.00
20 0.00
25 1.20
30 1.28
35 1.36
40 1.44
45 1.52
50 1.60
55 1.68
60 1.76
65 1.84
70 1.92
75 2.00
80 2.07
85 2.15
90 2.23
95 2.31
100 2.39
Provider Payment Table($PPPM for each provider)
Requires 5 of 10 must pass elements
Requires 10 of 10 must pass elements
Practice Evaluation & Quality Improvement
QI (current) Clinical Microsystems Training VHR DocSite
Evaluation (current) Chart Review ACIC (readiness) Focus Groups
Evaluation (integrated pilot) Review against NCQA standards Onsite Review Analysis of DocSite data Report based on NCQA scoring
Payment
Evaluation (Integrated pilot) Use reports Guide Microsystems Training Guide QA / QI planning Focused on NCQA PCMH Stds
Ongoing QA / QI
Practice Evaluation & Payment Model
Evaluator’sReport
NCQAReview
Start PaymentRetroactive to index date$ PPPM calculation -initial NCQA score -active patient panelActive patient panel (attribution) -visit <12 months to practice PCP -eligibility checkPaid quarterly or Monthly (payer defined)
30days
30days
Evaluator’sReport
NCQAReview
6 months
Adjust PaymentRetroactive to 6 month interval date$ PPPM calculation -refreshed NCQA score -refreshed active patient panelActive patient panel (attribution) -visit <12 months to practice PCP -eligibility checkPaid quarterly or Monthly (payer defined)
07 / 08 10 / 08 07 / 09 10 / 09 07 / 2010
Pilot # 1
Pilot # 2
Pilot # 3
01 / 09 01 / 2010
Category Data Source Evaluation Outline
PCMH healthcare process quality NCQA PCMH ScoreVCHIP practice reviewNCQA recognition
Integrated Pilot practices Change from baseline
Clinical process measures DocSite data baseVCHIP Chart Review
Integrated Pilot practices Practices delivering routine care Change from baseline & comparison
Health status measures DocSite data baseVCHIP Chart Review
Integrated Pilot practices Practices delivering routine care Change from baseline & comparison
Episodic vs. Preventive healthcare – claims based measures
VHCURES – multipayer database Pilot practices vs non-pilot practices Change from baseline & comparison
Healthcare Costs – claims based measures VHCURES – multipayer databaseFinancial Impact Model
Pilot practices vs non-pilot practices Impact on healthcare costs in Vermont Change from baseline & comparison
Population Health Indicators •VDH Health Surveillance databases • Community risk profiles• State level assessments
Blueprint Pilot Timeline & Evaluation
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
VDH Health Surveillance
Analyst
ContractedAnalysisServices
Blueprint Integrated PilotsEvidence Based Quality Improvement
Population Management
Quality Improvement
Individual Patient Care & Support
Services
Data Processing & Storage
EMRs used forIndividual Patient
Care
DocSite used forIndividual Patient
Care
DocSite used forIndividual Patient
Care
DocSite Database
EMR Databases
DocSiteReporting
Tool
Program Evaluation & Sustainability
Program Evaluation & Sustainability
VCHIPChart Review & NCQA Scoring
VCHIPChart Review & NCQA Scoring
Medical Claims from Commercial
Insurers & Medicaid
Medical Claims from Commercial
Insurers & Medicaid
Public Health Surveys & Data
Collection
Public Health Surveys & Data
Collection
DataSource
Data transmission & transformation
VITL / GE
DataAnalysis
Data Reports & Uses
EMRReporting Tool or
Analyst
Public HealthRegistries & Databases
Public HealthRegistries & Databases
VDH Health Surveillance
Analytic Database
VDH Health Surveillance
Analytic Database
BISCHAMultipayerDatabase
BISCHAMultipayerDatabase
VCHIPDatabases
VCHIPDatabases
VCHIPAnalysis & Report
Generation
VCHIPAnalysis & Report
Generation
BISCHAReports
BISCHAReports
HealthcarePatterns &
Resource Utilization
HealthcarePatterns &
Resource Utilization
Healthcare Expenditures & Financial Impact
Healthcare Expenditures & Financial Impact
VDH Health Surveillance
Analyst
VDH Health Surveillance
Analyst
HealthStatus
Measures
ClinicalProcess
Measures
Population Indicators &Risk Factors
Population Indicators &Risk Factors
ContractedAnalysisServices
ContractedAnalysisServices
Community Prevention Planning
Community Prevention Planning
Healthcare Quality Measures & Standards
Healthcare Quality Measures & Standards
Provider Payment for
Quality
Provider Payment for
Quality
Blueprint Integrated PilotsEvidence Based Quality Improvement
Program Evaluation & Sustainability
ContractedAnalysisServices
Quality Improvement
Data Processing & Storage
EMRs used forIndividual Patient
Care
EMRs used forIndividual Patient
Care
DocSite used forIndividual Patient
Care
DocSite used forIndividual Patient
Care
DocSite DatabaseDocSite Database
EMR Databases
EMR Databases
DocSiteReporting
Tool
DocSiteReporting
Tool
Population Management
Population Management
VCHIPChart Review & NCQA Scoring
VCHIPChart Review & NCQA Scoring
Medical Claims from Commercial
Insurers & Medicaid
Public Health Surveys & Data
Collection
Public Health Surveys & Data
Collection
DataSource
Data transmission & transformation
VITL / GE
Data transmission & transformation
VITL / GE
DataAnalysis
Data Reports & Uses
EMRReporting Tool or
Analyst
EMRReporting Tool or
Analyst
Public HealthRegistries & Databases
Public HealthRegistries & Databases
VDH Health Surveillance
Analytic Database
VDH Health Surveillance
Analytic Database
BISCHAMultipayerDatabase
VCHIPDatabases
VCHIPDatabases
VCHIPAnalysis & Report
Generation
VCHIPAnalysis & Report
Generation
BISCHAReports
HealthcarePatterns &
Resource Utilization
Healthcare Expenditures & Financial Impact
VDH Health Surveillance
Analyst
VDH Health Surveillance
Analyst
HealthStatus
Measures
HealthStatus
Measures
ClinicalProcess
Measures
ClinicalProcess
Measures
Population Indicators &Risk Factors
Population Indicators &Risk Factors
Community Prevention Planning
Community Prevention Planning
Individual Patient Care & Support
Services
Individual Patient Care & Support
Services
Healthcare Quality Measures & Standards
Healthcare Quality Measures & Standards
Provider Payment for
Quality
Provider Payment for
Quality
Blueprint Integrated PilotsEvidence Based Quality Improvement
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
Blueprint Integrated PilotsPlan for statewide expansion
BP Integrated PilotExperience
ContinuousQuality
ImprovementUse experience from
Integrated Pilot program to refine &
target BP Community grants. Build capacity & readiness for more complete healthcare
reform. BP Community Experience
ContinuousQuality
Improvement
Transform from BP Community to
Integrated Pilot Community, and/or,
expand existing Integrated Pilot to
include more Blueprint practices in a community
Shift BP Grant to new community or expand across a community
Build a model for effective and sustainable healthcare reform
Multi payer financial reform (from volume to quality)
Healthcare environment (PCMH, CCTs, PH specialists, Health IT)
Healthcare focus (from sick care to wellness / prevention)
Healthcare culture (evidence based QI)
Blueprint Integrated PilotsBuilding a Scalable Model
Contact Information
Lisa Dulsky Watkins, MDAssistant Director
Vermont Blueprint for HealthVermont Department of Health
Burlington, [email protected]
(802) 652-2095