Health Care Home Fervor!
Two foundational pieces of legislation
2007- First “medical home” legislationProvider Directed Care Coordination for
patients with complex illness in the Medicaid
FFS population (now Primary Care
Coordination) PCC
2008- Health Care reform legislations
requires “health care homes” for all
Medicaid/ SCHIP/ state employees/ privately
insured in Minnesota, Health Care Homes,
HCH
Primary Care Coordination: PCC
Health Care Homes: HCH
Both programs promote care coordination
and focus on achievement of outcomes.
PCC: focuses on most chronically ill fee for
service Medicaid patients
HCH: focuses on all patients who have or
are at risk of chronic or complex conditions,
can benefit from the services of a HCH and
are interested in participation
Both have new payment options for per
person care coordination
Legislative Requirements for HCH
Care Coordination Payment
[62U.03]
- Health plans include HCHs in their provider
networks by January 1, 2010 and make care
coordination payments by July 1, 2010
- Payment conditions and terms shall be
developed “in a manner that is consistent
with” the system under 256B.0753
Legislative Requirements for HCH
Care Coordination Payment
[62U.03]
- Health plans include HCHs in their provider
networks by January 1, 2010 and make care
coordination payments by July 1, 2010
- Payment conditions and terms shall be
developed “in a manner that is consistent
with” the system under 256B.0753
Opportunity and Goals for HCH
payment methodology
- Create alignment across the
marketplace through transparent public
development of the payment
methodology
- Lay the groundwork for improved risk
stratification
- Minimize duplication of administrative
processes
2008 HCH Legislation… the standards
developed by the commissioners
must meet the following criteria:
use of primary care
focus on high-quality, efficient, and effective health care
services
encourage patient-centered care
provide consistent, ongoing contact with a personal clinician or
team of clinical professionals
ensure appropriate comprehensive care plans for their patients
with complex or chronic conditions
measure quality, resource use, cost of care, and patient
experience;
use of scientifically based health care, patient decision-making
aids
use of health information technology and systematic follow-up,
including the use of patient registries
What is a medical home? In
Minnesota its a Health Care Home
Health care home means a clinic or a personal clinician that
is certified. A certified health care home:
A. facilitates consistent and ongoing communication among the
health care home and the patient and family and provides the
patient with continuous access to the patient’s health care home;
B. uses an electronic, searchable patient registry that enables the
health care home to manage health care services, provide
appropriate follow-up and identify gaps in patient care;
C. includes care coordination that focuses on patient and familycentered care;
D. includes a care plan for selected patients with a chronic or
complex condition and involves the patient, and if appropriate,
the patient’s family, in the care planning process; and
E. reflects continuous improvement in the quality of the patient’s
experience, the patient’s health outcomes and
the cost-effectiveness of services.
What We Know About Access to Care in a
Patient & Family-Centered Medical (Health
Care) Home:
Patient and family-centered care is increased
Family worry and burden are reduced
Care coordination and chronic condition
management lead to:
Reduction in emergency room use
Reduction in hospitalizations
Reduction in redundancy
Efficiency and effectiveness are increased
Center for Medical Home Improvement
HCH Development process
Emphasis of public – private collaboration
Collaboratively organized in state government between the
Departments of Health and Human Services with emphasis on
public-private collaboration with broad stakeholder input.
A combination of grant contracts and state organized
processes
Integration with all of the other parts of the Health Care Reform
legislation
Learning from and building on local and national experiences
with HCH models
Flexibility within the parameters of the legislation creating
opportunity to test different models
Meaningful measures that focus on “triple aim” outcomes
Transformation with refinement of model over time
HCH Activities
Foundational
• Outcomes recommendations, ICSI contract
• Capacity Assessment (clinics and consumers), Primary Care
Consortium contract
• Consumer and Family Council
• Learning Collaborative Development, Wilder contract
Community Engagement Process
• Workgroups with broad representation developed standards and
criteria
• Community survey, 285 respondents.
• Recommendations to the Commissioners
• Rule development and feedback process
• Certification process development
Payment Methodology Development
A Great Health Care Home …
Is satisfying
for
patients,
families,
providers
and clinic
staff!
Carolyn Allshouse, Sr. Planner, MDH
Draft Rules Structure:
Parts
0010
0020
0030
0040
0050
0060
0070
Applicability and Purpose
Definitions
Certification and Recertification
Procedures
Standards
Variances
Appeals
Revocation, Reinstatement and
Surrender
0010: Applicability and Purpose
Certification is voluntary
Eligible providers deliver services that meets
the standards and criteria established by the
commissioners of health and human
services.
Certified HCH’s are eligible for per-person
care coordination payments under the care
coordination payment system.
0020: Definitions for the rules
Words are defined that may not have
common meanings.
State and national resources were used as
the basis of the definitions.
Definitions may not have the same meaning
in the rule as commonly defined by the
reader.
Refer back to the definitions when reading
the rules.
0030: CERTIFICATION AND
RECERTIFICATION PROCEDURES
Who may apply:
An eligible provider that provides the full range of
primary care services and takes responsibility for
the patient’s care may apply for certification as a
health care home.
Personal clinicians are certified as a health care home
providers. A clinic may not be certified unless all
of the clinic’s personal clinicians meet the
requirements for participation in the health care
home.
Health care homes provide: personal clinician
directed, team delivered care
Certification Application:
Who can apply?
Certification Phases
Recertification required annually
At Certification: Applicant meets designated
certification requirements.
At the end of year one: Certified HCH applies for
recertification and meets all the health care home
requirements (initial and end of year one).
At the end of year two & future years: Certified HCH
meets all recertification requirements or applies for a
variance for superior outcomes.
Certification requirements are either met or not met,
there are no scoring tiers.
Variances
Requesting a variance
A variance may be granted to the HCH for
good cause or when failure to grant a
variance would result in hardship.
Experimental variance where a HCH offers
an innovative replacement to meet the
standard.
Applicant completes the form to request a
variance and submits it at certification, at
certification denial or appeal, or at recertification.
Health Care Homes
0040: Standards Categories:
Access / Communication
Patient Tracking and Registry Functions
Care Coordination
Care Plans
Performance Reporting & Quality
Improvement
Certification Assessment Tool
Rules Language
Rule language with
standards and
criteria.
Certification Verification
Data Sources / Documentation
Document systems, processes,
processes, Document data sources such as
models, workflows,
workflows,
reports, records, process
practices, policies and
measures, data showing
procedures and elements of
evidence of action, materials,
those that demonstrate the
educational resources, surveys,
applicant meets the
interviews, demonstrations, or
certification requirements
requirements.
audits that provide
documentation and evidence to
meet certification standards.
Access and Communication
Standards At Certification
The HCH must be available to patients who
have or
are at risk of developing or have complex or
chronic conditions
can benefit from the services of a health
care home
are interested in participation
There is a system in place to recruit patients to
the HCH and to tell them about the services
of the health care home. Participation is
voluntary.
Certification Assessment Tool:
Example: Access and Communication Standard
Rule: The applicant for certification must actively recruit patients into
the health care home... make its health care home available to patients
who (a) have or are at risk of developing complex or chronic conditions,
(b) can benefit from the services of a health care home and (c) are
interested in participation;
Verification
Develop a procedure on how the clinic will consistently identify
patients at risk of developing complex or chronic conditions.
Establish a verbal and written communication process to tell
patients what a health care home is and establish a
documentation method for this communication.
Documentation
Submit a procedure and an example of the written
document for communication.
Observes the process and reviews the clinical
documentation review at site visit
Access and Communication
Standards At Certification
The patient knows how to access their health care
home 24/7
The person responding to the patient has access to
the patient’s health care home information
Access is addressed by protocol to avoid
unnecessary ED visits or hospitalizations
There is a process to collect cultural, racial and
primary language and it is used in providing care
The team knows the patient/ family preferred method
of communication
Certification Assessment Tool:
Example: Access and Communication Standard
Rule
…document that the applicant is using participants’ preferred
mode of communication, if that mode of communication is
available within the health care home’s technological
capability;
Verification
Develop a procedure for collecting patients’ preferred
communication mode for all patients and denote the patient’s
preference in a consistent location.
Documentation
Submit access policy and procedures
Observe process at site visit
Clinical documentation review at site visit
Access and Communication
Standards At Certification
There is a process in place to inform
participants that they may choose specialty
care resources without regard to whether a
specialist is a member of the same provider
group or network as the health care home.
Participants are responsible for determining
whether specialty care resources are covered
by their insurance.
Access and Communication Standards
At Recertification, end of year one
The HCH demonstrates that it encourages
participants to take an active role in
managing their health care.
The HCH has improved participant
involvement and communication by
addressing one of the following:
participants’ readiness for change
literacy level
or other impediment to learning
Patient Tracking and Registry Functions
Standards
At certification:
Registry is searchable and electronic
There is sufficient data to identify gaps in
care for patients with chronic or complex
conditions that are identified by the clinic
At recertification, end of year one:
Registry is “worked” by the HCH team to
identify gaps in care and processes are in
place to prevent gaps such as appointment
reminders or pre-visit planning
Certification Assessment Tool:
Example: Patient Tracking and Registry Standard
Rule: …. uses a searchable, electronic registry to record
participant information and track participant care…The registry
must contain sufficient data elements to be capable of producing a
report that reflects the gaps in care for specific subgroups of
patients with a chronic or complex condition.
Verification:
The clinic defines the population of patients and data elements
required for their registry.
Clinic develops a process on how the registry is used and a
method which patients are identified and contacted.
Documentation:
Submit an example of clinic process and blinded example of
the registry report.
At interview, clinic staff shows how the registry report is used
At the clinic leadership interview, leaders describe
how the registry is used to support their
quality goals.
Care Coordination
At Certification:
Describes the role and requirements for the
care coordinator.
Describes the role of the team and the
personal clinician.
Establishes the processes in place to track
referrals, tests, give timely results, and do
post D/C planning
Care Coordination
At Recertification at end of year one:
Patient and family centered care principles
are in place, such as shared decision
making.
Community connections are demonstrated
with key community resources.
Team members are working at the top of
their license.
There is planning for transitions.
Certification Assessment Tool:
Example: Care Coordination Standard
Rule
Uses health care home teams to provide and coordinate
participant care, including communication and collaboration with
specialty providers…..
Verification
Documentation showing that a PCP and care coordinator are
identified for each patient in the health care home.
Documentation
Provide a copy of the document from the clinical record that lists
the care coordinator, and PCP.
An organizational chart with the health care home team
members.
Clinic team members review at site visit the HCH
practice for communication with specialty providers.
Care Plans
At Certification:
The HCH implements a policy that guides the team
on which patients with chronic or complex
conditions needs a care plan and identifies the
assessment and care planning process.
Participants are considered a partner in care
planning.
Evidence-based guidelines are used whenever
available.
The care plan includes the participant’s goals and
the action plan as identified by the participant and
the HCH team members.
Care Plans
At Recertification, end of year one:
The care coordinator and the participant
determine whether the participant has any
external care plans.
Together they create a comprehensive care
plan with other members of the community
team.
Such as, social services, mental health,
home health, aging services, school services
and many others.
Certification Assessment Tool:
Example: Care Plans Standard
Rule: The applicant must establish and implement policies and
procedures to guide the health care home in assessing whether a
care plan will benefit participants with complex or chronic
conditions. In creating a care plan with a participant, the health
care home must do the following: include an assessment of
health risks and chronic conditions …
Verification
Policy and procedure which outlines the assessment process and
sets criteria on which patients should have a care plan and how
decisions are guided.
Documentation
Submits policy and procedure. Review care plans at site visit.
Interview clinicians and care coordinator about process for
development of care plan.
Interview a patient who has participated in
development of their care plan.
Performance Reporting & Quality
Improvement (QI)
At Certification:
QI processes are core to the health care
home team.
There is measurement that includes
analysis and tracking of at least one quality
indicator.
There is meaningful involvement on the QI
team by participants.
The health care home participates in a
learning collaborative with other HCHs.
Performance Reporting & Quality
Improvement (QI)
At Recertification:
HCH submits data to the statewide
measurement reporting system.
The HCH selects a quality indicator for
improvement in each of the quality
outcomes areas; health, patient experience
or cost / value.
Certification Assessment Tool:
Example: Performance Reporting and Quality
Improvement Standard
Rule: show that the applicant has completed measurement,
analysis and tracking changes in at least one quality indicator
selected by the applicant based upon the opportunity for
improvement
Verification:
Establishes HCH quality team membership and schedule for
quality team meetings.
Team completes measurement, analysis and tracking of at
least one quality indicator selected for improvement
Documentation
At quality team interview describes how team identified quality
goals, presents plan / data and discusses progress and how
patient input was included in plan.
Submits copy of team meeting minutes and schedule.
Health Care Homes Certification
Measurement
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At Certification
Certification Verification:
Process to verify clinic meets
HCH certification standards
Outcomes Measurement:
Measurement of improvement or
decline in quality health, pt.
experience or cost/value
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Verification
End of Year One
HCH Certification Time Line
End of Year Two & future years
Moving from certification verification
to outcomes measurement.
At the end of year two, the commissioner will
determine whether the HCH has met the
requirements for recertification and
demonstrated sufficient progress in
improving the quality of its services.
The commissioner will use benchmarks
announced annually to determine whether
an applicant has demonstrated sufficient
progress for outcomes for the clinic.
How are outcomes measurement
decisions made?
The benchmarks will be based on one or more of the following
factors:
A. an improvement over time as reflected by a comparison of
data submitted by the health care home over time.
B. a comparison of data measuring quality submitted by other
health care homes;
C. standards established by state or federal law;
D. best practices recommended by a scientifically-based
outcomes development organization;
E. measures established by a national accrediting body
or professional association.
Next Steps: HCH Outcomes
Measurement Workgroup
Workgroup charge:
Shape outcomes measurement strategies based
on the HCH rules and outcomes work of ICSI
* Measurement over time
* Variance for superior outcomes
Identify how outcomes measurement
decisions should be made.
Make recommendations on how HCH
outcomes measurement could work within the
broader state wide reporting structure.
Next steps: Timeline for HCH
Payment Methodology Development
- Summer / Fall 2009
- HCH Steering Committee co-chair ICSI &
DHS/MDH
- Critical investigation of non-medical complexity
and risk stratification
- Stakeholder workgroups on payment
components, clinic processes, payment,
consumer design, currently posted for members
on health reform web site
- Fall / December 2009
- Public conversation on proposed methodology
- Large stakeholder meetings
Next Steps: Primary Care
Coordination (PCC) Program as a
Starting Point
- 2007 legislation created a medical
home program for very complex feefor-service public program enrollees
- Federal approval in early 2009,
providers can register with DHS and
begin enrolling patients this summer
- Registration / payment opportunities
begin summer 2009.
Next Steps: Health Care Homes
Publish Rules for public formal comment early July,
for one month; finalize rules in August.
Certification workshops posted on health reform
web site starting in July.
Begin accepting letters of intent for certification mid
July. Begin certification site visits August.
Complete capacity assessment survey work in July,
identify dollars for RFP’s for supporting
implementation of health care homes by fall.
Continue workgroup activities for outcomes and
payment methodology through fall / winter.
Health Care Homes learning
collaborative kick off meetings late
October. Watch for dates!
Further Information:
Health Care Homes in Minnesota
Health Care Homes rules / information at MDH Health
Reform Web site.
http://www.health.state.mn.us/healthreform/index.ht
ml
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Thank you for your interest in Health Care Homes!
Health Care Homes
Marie Maes-Voreis RN, BSN, MA
Health Care Homes, Program Manger
Minnesota Department of Health
Minnesota Department of Human Services
[email protected]
phone: 651-201-3626
Or
[email protected]
Health Care Home Fervor!