1
Introduction to Health Care
Homes Webinar Series
Session 1:
The Business Case for Health Care Homes
and Overview of Legislation and Standards
2
Agenda
• Welcome
• Overview of Webinar Series
• The Business Case for Health Care Homes
• Health Care Homes Certification Standards / HCH Rule
• Q&A
• Wrap Up
3
Introduction to Health Care Homes
Webinar Series Objectives
• At the end of this series, participants will be able to:
• Understand MN standards and criteria for health care home
certification
• Gain a high-level overview of how to work with patients and
improve quality in a health care home
• Assess clinic operations, and complete gap analysis that identifies
areas of focus needed to prepare for certification
• Set a plan for closing the identified gaps, and smoothly
transitioning toward achieving certification
• Understand the culture change process needed for health care
home implementation
4
Introduction to Health Care Homes
Webinar Series Schedule
5
Session 1 Objectives
• At the end of this learning activity, participants will
be able to:
• Understand why becoming a health care home
is a good business decision
• Understand the health care home certification
standards and health care home rule
6
The Business Case for Health Care
Homes
Sanne Magnan, MD, PhD
President and CEO
Institute for Clinical Systems Improvement
7
Top Ten Business Reasons for Becoming
a Health Care Home
10. Business of health care is in trouble--we need a new
chassis.
9. Team based care that meets the Triple Aim is the
future of health care.
8. This is primary care’s time to really shine- focus on
relationships.
7. Takes primary care to a new version – provides
access 24/7; thinks populations, care coordination,
care plans, linkages to community resources, etc.
8
Top Ten Business Reasons for Becoming
a Health Care Home (cont.)
6.
5.
4.
3.
2.
1.
It’s the right thing to do.
“Skate to where the puck is going to be.”
There’s money in it.
Be part of an exciting time-move to the future with
redefining care.
Learn and work with great people.
Patients, families and communities will thank you for it puts patients, families and communities in the center.
9
Health Care Homes
Marie Maes-Voreis, RN, MA
Director Health Care Homes
10
Health Reform in Minnesota
Minnesota’s Three
Reform Goals
• Healthier communities
• Better health care
• Lower costs
Institute for Healthcare Improvement’s
Triple Aim
11
What is a health care home?
• Also known nationally as the patient-centered medical
home (PCMH) or federally as advanced primary care
(APC) or a ‘health home.’
• A health care home is an approach to primary care in
which primary care providers, families, and patients work
in partnership to improve health outcomes and quality of
life for individuals with chronic or complex health
conditions.
• Reimbursement for care coordination – something that is
not paid for now.
12
Health Care Home
Health Care Home is not:
Health Care Home is:
• A nursing home or home health
• Population clinical care
care
• A restrictive network
• A service that only benefits
people living with chronic or
complex conditions
redesign
• Transformed services to meet a
new set of patient-and familycentered standards to achieve
triple aim
• Community partnerships that
build healthy communities
• Foundation to new payment
models such as ACOs
13
Primary Care Population-Based Care
Delivery Redesign, What is different?
14
HCH Certification Updates
• # Certified Clinics: 260
Total
• 36% of Primary Care
Clinics in Minnesota (6 in
border states)
• Certified Clinicians: 2700
• Approximately 2.8 million
patients receiving care in a
certified HCH.
• Applicants are from all
over the state.
• Variety of practice types
such as solo, rural, urban,
independent, community,
FQHC and large
organizations.
• All types of primary care
providers are certified,
family medicine, pediatrics,
internal medicine,
med/peds and geriatrics.
15
Minnesota’s Certified Health Care Homes
16
What Makes Minnesota’s HCH Approach
Unique?
• Statewide approach, public/private partnership
• Standards for certification all types of clinics can achieve
• Support from a statewide learning collaborative
• Development of a payment methodology
• Integration of community partnerships to the HCH
• Outcomes measurement with accountability
• HIT EMR & interoperability adoption plan
• Statewide HCH Evaluation supported by legislation.
• Focus on patient- and family-centered care concepts
17
Together, patients and families, providers,
payers, agencies, and other team
members designed new standards for
health care homes
18
Health Care Home Standards
• Access: facilitates consistent communication among the HCH
•
•
•
•
and the patient and family, and provides the patient with
continuous access to the patient’s HCH
Registry: uses an electronic, searchable registry that enables
the HCH to identify gaps in patient care and manage health
care services
Care Coordination: coordination of services that focuses on
patient and family-centered care
Care Plan: for selected patients with a chronic or complex
condition, that involves the patient and the patient’s family in
care planning
Continuous Improvement: in the quality of the patient’s
experience, health outcomes, cost-effectiveness of services
19
Rules Structure: 4764:0010-0070
20
Health Care Homes Certification
• HCH foundational legislation passed in 2008.
• The health care home rule was adopted and published on
January 11, 2010.
• Certification as HCH is Voluntary
• Clinics complete the application process online.
• There is flexibility for innovation built into the application
process.
21
Who Can Apply for HCH Certification?
• An eligible provider is a physician, nurse practitioner, or
physician assistant that works as part of a team that takes
responsibility for the patient’s care and provides the full
range of primary care services including:
• First point of contact acute care
• Preventive care
• Chronic care
• Providers are certified.
• A clinic is certified when all the clinic’s providers meet the
requirements for certification.
22
Clinics in border states to Minnesota can
apply for certification.
• Local trade area clinician.
“Local trade area clinician”
means a physician, physician
assistant, or advanced
practice registered nurse who
provides primary care
services outside of
Minnesota in the local trade
area of a state health care
program recipient and
maintains compliance with
the licensing and certification
requirements of the state
where the clinician is located.
23
HCH Population Based
HCH is Your Entire Clinic
24
The Patient and Family Centered
Health Care Home
25
Access and Communication Standards:
0040 Subp. 1A
• How does a patient know about a health care home?
• The HCH must be available to patients who:
• Are at risk of developing or have complex or chronic conditions.
• Are interested in participation.
• There is a system in place to tell patients about the
services of the HCH.
• Participation is voluntary and patients agree to participate.
26
Access and Communication Standards:
0040 Subp. 1B, C, D
• The patient knows how to access their health care home
•
•
•
•
continuously (24/7, 365)
The person responding to the patient has access to the
patient’s health care home information, the triage system,
on-call provider or clinic staff.
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
27
Access and Communication Standards:
0400 Subp. 1E
• 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.
28
Access and Communication Standards:
Data Privacy, 0040 Subp. 1F
• The HCH applicant must have a system in place to
establish adequate information and privacy security
measures to comply with applicable privacy and
confidentiality laws, including the requirements of the
Health Insurance Portability and Accountability Act, Code
of Federal Regulations, title 45, parts 160.101 to 164.534,
and the Minnesota Government Data Practices Act,
Minnesota Statutes, chapter 13.
29
Patient Tracking and Registry Functions
Standards: 0040 Subp. 3A, 3B, 4
• At certification: Has a registry.
• Registry is searchable and electronic
• Systematic reviews of participant population
• There is sufficient data to identify gaps in care for patients with
chronic or complex conditions.
• 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
30
Care Coordination, definitions:
• Subp. 3: Care coordination. “Care coordination” means a
team approach that engages the participant, the personal
clinician or local trade area clinician, and other members
of the health care home team to enhance the participant’s
well being by organizing timely access to resources and
necessary care that results in continuity of care and builds
trust.
• Subp. 5: Care coordinator. “Care coordinator” means a
person who has primary responsibility to organize and
coordinate care with the participant in a health care home.
31
Care Coordination Standards:
0040 Subp. 5A
• Implements a system of care coordination that promotes
•
•
•
•
patient/family centered care:
There is collaboration within the HCH that includes the
patient / family, care coordinator and clinician.
HCH team and patient / family sets goals and identifies
resources to achieve goals.
The HCH ensures consistency & continuity of care.
The HCH and patient / family determines together when
and how often the patient has contact with the care team
or community resources for care.
32
Care Coordination Standards:
0040 Subp. 5B
• A personal clinician and care coordinator are identified as
a primary contact for the patient and develops a
relationship with the patient / family.
• The care coordinator develops a relationship with the
personal clinician and has direct communication where
routine face to face discussions take place with the
personal clinician.
• The care coordinator has dedicated time to perform care
coordination responsibilities.
33
The Care Coordinator: A New Role in the
Primary Care Clinic
• A personal clinician and care coordinator are identified as
•
•
•
•
a primary contact for the patient.
The care coordinator develops a relationship with the
patient / family and members of the health care team.
Tracks appointments, test results, referrals, medication
refills, and uses evidence based guidelines
Coordinates admissions, post discharge and transitions
planning and care planning with the patient / family and
other members of the health care team.
The care coordinator has dedicated time to perform care
coordination responsibilities.
34
Capacity Assessment Survey: Care Plan
and Care Coordination
35
Definition: Care Plan
• Subp. 6. Care plan. “Care plan” means an
individualized written document, including an electronic
document to guide a participant’s care.
• Subp. 12. Comprehensive care plan. “Comprehensive
care plan” means the care plan for a participant plus all
available and relevant portions of any external care plans
created for that participant.
36
Care Plan Standards:
0040 Subp. 7A, 1, 2
• The HCH establish and implements policies and
procedures to guide the HCH in assessing whether a care
plan will benefit patients with complex or chronic
conditions:
• Patient and families are actively engaged and there is
active planning with patients and families in development
of the care plan to ensure joint understanding of the care
plan.
• Based on the patients care needs appropriate members
of the care team are engaged.
37
Care Plan Standards:
0040 Subp. 7A, 3, 4
• Incorporate pertinent elements of the assessment that a
qualified member of the health care team has performed
about the patients health risks and chronic condition.
• The care coordinator lists diagnosis on the care plan that
a clinician or RN team member has identified.
• The care plan is reviewed with and amended jointly at
intervals appropriate to the patients care.
38
Care Plan Standards:
0040 Subp. 7A 4,5,6
• The care plan includes the participant’s goals and an
action plan identified by the patient / family and the HCH
team.
• A copy of the care plan is provided to patients / families.
• Evidence-based guidelines are used whenever available.
39
Care Plan: At Certification
0040 Subp. 7B
• Care plan includes goals and an action plan for:
• Preventive care, including reasons for deviating from
•
•
•
•
standard protocols.
Care of chronic illness
Plans for early contact with the HCH when there is a
exacerbation of a known condition.
End-of-life care and advanced directives
Goals are updated as warranted by the patients condition.
40
We have focused on improved outcomes
for the health of our families, patient
experience, and cost and value.
41
Performance Reporting & Quality
Improvement (QI) Standards:
0040 Subp. 9
• QI processes are core to the HCH. There is measurement
that includes analysis and tracking of at least one quality
indicator
• The QI team reflects the structure of the organization and
includes at minimum a HCH team clinician, care
coordinator, manager and two or more participants at the
clinic level.
• Procedures are established by the QI team to share their
work and elicit feedback from HCH team members
regarding QI activities.
42
Capacity Assessment Survey: Do you feel
like a partner in your care?
43
HCH Team Quality Improvement Standards:
0040 Subp. 9
• At certification: There is measurement that includes
analysis and tracking of at least one quality indicator (i.e.,
PDSA cycles).
• At recertification end of year one: The QI team has
selected at least one quality indicator, measured analyzed
and tracked those indicators for improvement in patient
health, patient experience and cost effectiveness.
• At the end of year two, the commissioner determines
whether the HCH has met the requirements for
recertification
44
Outcomes Measurement Requirements:
0040 Subp. 9
• HCHs must submit data to the statewide measurement
reporting system
• Outcomes measures are based on the clinic’s total
certified population
• The commissioner announces annually:
• HCH outcome measures
• Benchmarks to determine whether a HCH has demonstrated
sufficient progress
• These are determined through a community workgroup
process.
45
Learning Collaborative Participation:
0040 Subp. 9
• The HCH team participation in the learning collaborative
reflects the structure of the organization and includes at
minimum a HCH team clinician, care coordinator,
manager and two or more participants at the clinic level.
• Procedures are established by the HCH team to share
information learned through the collaborative with other
staff and participants in the HCH.
46
Certification Assessment: Getting Started
• Establish quality committee or HCH implementation
team to guide the process. Include patients in this
process.
• Identify leadership and clinician champions.
• Use the Certification Assessment Tool to complete
your gap analysis, identify outstanding work with
your team.
• Keep track of your progress (QI work such as PDSA
cycles).
• Work closely with IT to establish IT tools to support
workflows.
47
Certification Assessment: Getting Started
(cont.)
• Do regular review with the team and remind the
HCH planning team members of
accountabilities for timelines
• Collect documents along the way to support
your certification application.
• Complete your chart audit, confirm
documentation.
• Regularly work on culture change with team
members.
• Include patients and families!
48
Certification Steps
• Optional pre-application activities
• STEP 1: Letter of intent & Application
Demographics forms
• STEP 2: Certification Assessment
• STEP 3: Site visit
• STEP 4: MDH Review and Notification
• STEP 5: Recertification
• Optional: Variance requests, Appeal Process
49
Online Certification Application System
• Go to Certification
Webpage:
http://www.health.state
.mn.us/healthreform/ho
mes/certification/index.
html
50
Certification Assessment
• There is flexibility for innovation built into the application
•
•
•
•
process
HCH Standards are a road map to implementation, clinics
determine how!
Certification assessment confirms clinic is ready for site
visit.
Site visit shows how work is done
MDH is not looking for a lot of new policies, show how you
do your work.
51
Documentation at Certification
• Standards are designated as pass at initial certification or
•
•
•
•
•
recertification.
Documentation sources are flexible except three criteria
requires a policy per the HCH rules
There are ten documents to submit.
You may put “see attachment” if all the information is in
the document.
For the remaining rule parts, add a brief 5-10 sentence
paragraph describing your work.
Less and succinct is better. This is the baseline
information.
52
Legislative Requirements for HCH Care
Coordination Payment
• [256B.073]
• DHS and MDH develop a system of per-person care
coordination payments to certified HCHs by January 1, 2010
• Fees vary by thresholds of patient complexity
• Agencies consider feasibility of including non-medical
complexity information
• Implemented for all public program enrollees by July 1, 2010
• Payment Methodology Resources:
http://www.health.state.mn.us/healthreform/homes/payme
nt/index.html
53
Multi-Payer Investment in HCH’s
Primary Care Transformation
SOURCE: Adapted from MDH Health Economics Program,
Medicare enrollment data and SEGIP enrollment data
54
HCH Payment Implementation
• Understand HCH population and payers for complex
•
•
•
•
patients who will receive more intensive care
coordination.
Begin to work with payers to negotiate payment rates.
Work with billing partners to establish processes. Identify
team members who will do tiering, billing processes and
procedures to process claims.
See payment training documents / webinar on MDH
website.
Submit Medicare provider numbers at certification to
participate in MAPCP demonstration. Attend webinar.
55
MAPCP Demonstration: CMS Goals
• CMS joined state-led, Multi-Payer PCMH initiatives in
•
•
•
•
progress by adding Medicare FFS enrollees. 2011 – 2014.
Evaluate the impact of advanced primary care on quality,
utilization, and expenditures
Ensure budget neutrality. Participating in MAPCP
independent evaluation.
Implementation of the MAPCP Resources Tool Kit for
Coordination of Care and Transition Management.
DHS Medicare / Medicaid claims feedback reports.
56
Capacity Building / Practice Facilitation
• Regional HCH Nurses, Implementation support
• Technical Assistance
• Grants: Learning Community Grants & others
• Learning Collaborative
• MAPCP Demonstration Workgroups
• Purchaser / BHCAG Tool Kit
• Building partnerships with Communities
57
Learning Collaborative Activities
• Orientation for New HCH’s
• Skills based training quality, patient centered care, care
coordination / care planning.
• Statewide Learning Days Fall / Spring
• Assessment: focused on skill building and sharing implementation
strategies
• Regular webinars / regional training
• Learning Communities, focused, intensive, topic based,
collaborative activities
58
Additional Information & Materials
http://www.health.state.mn.us/healthreform/homes/index.htm
l
• Find Certified Health Care Homes
• Certification Requirements and Process
• Education & Resources (Resource Guides / Tools Kits)
• Events (Conference Calls & Webinars)
• Payment Methodology
• Medicare Payment
• Outcomes Measurement
• Learning Collaborative
59
HCH Evaluation:
• Minnesota Statute §256B.0752 directs the commissioners
to complete a comprehensive evaluation report of the
HCH model three and five years after implementation.
• The first HCH evaluation legislative report is due to the
legislature December 15, 2013
• Second HCH evaluation legislative report is due to the
legislature December 15, 2015.
60
TRANSFORMING PRIMARY CARE
CLINICS INTO HEALTH CARE
HOMES IN MINNESOTA:
WHAT HAVE WE LEARNED?
THE TRANSFORMN STUDY
Leif I. Solberg, MD
Patricia Fontaine, MD MS
Thomas Flottemesch, PhD
Juliana Tillema, MPA
HealthPartners Institute for Education & Research
Funded by Grant 1R18HS019161 from AHRQ
61
TransforMN Conclusions
• Most HCH clinics have greatly increased their practice
systems from 2008 to 2011
(variation & room to improve)
• On average, HCH clinics have higher quality scores for
diabetes and CV disease
(overlap & variation in both groups)
• Clinics with more practice systems have higher quality
scores
Transforming Primary Care Clinics into Health Care Homes in Minnesota:
What Have We Learned? The TransforMN Study: 2013 HealthPartners Research
Foundation
62
TransforMN Relation Between System
Change and Outcome Change
Every 10% increase in systems score is associated with:
• 1% increase in optimal diabetes care score
• 2.4% increase in optimal CV disease care score
Transforming Primary Care Clinics into Health Care Homes in Minnesota:
What Have We Learned? The TransforMN Study: 2013 HealthPartners Research
Foundation
63
TransforMN Key Findings
• Patients with diabetes at higher functioning HCH have
fewer ED encounters and hospital admissions
• Rapid change of HCH systems is associated with fewer
ED encounters and hospital admissions
• High functioning HCH appear to have more complex
patients
Transforming Primary Care Clinics into Health Care Homes in Minnesota:
What Have We Learned? The TransforMN Study: 2013 HealthPartners Research
Foundation
64
TransforMN: Would you do it again?
Was it worth the effort for your clinic to become a medical home?
Transforming Primary Care Clinics into Health Care Homes in Minnesota:
What Have We Learned? The TransforMN Study: 2013 HealthPartners
Research Foundation
65
TransforMN: Would you do it again?
Responses
• Firm Yes (18/31)
• “Absolutely, absolutely. I’d do it again in a heartbeat. It has been
the career-changing thing in my life.”
• “It’s worth the effort because patients are happier, getting better
care.”
• “Absolutely. We thought it would increase the rate of improvement
here…definitely found that true”
• Yes/no (11/31)
• “I think so. It’s definitely the right work for the patient. I don’t know
that we’re seeing the reimbursement for the hard work we’re
doing.”
• “In the early stages it’s a lot of work, but it feels good to me right
now.
Transforming Primary Care Clinics into Health Care Homes in Minnesota:
What Have We Learned? The TransforMN Study: 2013 HealthPartners Research
Foundation
66
Health Care Home As Foundation to
ACO’s or Total Cost of Care Payment
Methods
67
Health Care Homes Contact Information
[email protected]
http://www.health.state.mn.us/healthreform/homes/index.ht
ml
654-201-5421