Minnesota Department of Health (MDH)
Health Care Homes (HCH)
Initial Certification
Reviewed: 4/20/17
1
Learning Objectives
1. Describe the HCH legislative rule subpart
criteria required for initial certification.
2. Identify strategies to implement the HCH
model into the clinic culture.
3. Discuss process improvement in the clinic
practice.
2
Health Reform in Minnesota
Minnesota’s Three Reform Goals
• Improve the health of the population
• Improve patient experience
• Improve the affordability of health care
Institute of Medicine’s Triple Aim
3
MN Health Reform
4
MN Health Reform Results
(expanded from previous slide)
1) HCH clinic certifications
2) Accountable Communities for Health
3) Integrated Health Partnerships
5
The HCH Model
• The Health Care Homes Program (HCH) is one of the
centerpieces of Minnesota's health reform initiative.
Through redesign of care delivery and meaningful
engagement of patients, HCH Clinics are transforming
care and lives - for millions of Minnesotans.
• The name "Health Care Homes" acknowledges a shift
from a purely medical model of health care to a model
which links primary care with wellness, prevention,
self-management and community services.
6
Goals of the HCH Model
• Continue to build strong primary care foundation
ensuring all Minnesotans have the opportunity to
receive team-based, coordinated, patientcentered care.
• Increase care coordination and collaboration
between primary care and community resources
to facilitate the broader goals of improving
population health and health equity.
• Improve the quality and the individual experience
of care, while lowering health costs.
7
HCH Certification Updates
Certified HCH Clinics
• 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.
8
The Patient- and Family-Centered Health Care Home
9
Consumer Perspective:
Better Health Made Easy
10
HCH Certification
• Certification as HCH is Voluntary
• There is no fee to apply for MDH HCH certification.
• MDH is the organization that will facilitate the
certification process.
• All application forms are submitted electronically
through the MDH HCH online portal.
11
Certification Questions
• The clinic defines the timeline to submit the application; clinics apply
when they meet the standards and criteria and are ready for a
successful certification process. HCH Planners are available for support.
• As HCH model is implemented in new clinic sites (referred to as
“spread”) the new clinicians are certified.
• When a previously certified clinician leaves a clinic and goes to work at
a non-certified clinic, the new clinic and clinician/s apply for their
certification. The previous clinic employer identifies an “end” date for
that clinician in the HCH online portal.
12
Progression Over Time
• Certification requirements are met at initial certification with
subparts supporting progression overtime.
• The clinic/s complete an annual ‘check-in’ with their
designated nurse planner ensuring progression, and to follow
up on recommendations or variances from the previous
certification.
• HCH clinics are recertified every three years in a “Team
Meeting” format; recertification ensures the progression in
the HCH model implementation over time.
• The certifying HCH clinic/s meets all requirements or applies
for a variance. A variance may be granted for good cause or
when failure to grant a variance would result in hardship.
13
Certification Steps for the Applicant
Step 1: Eligibility
Step 6: Assessment
Step 2: Guides & Tools
Step 7: Site Visit
Step 3: Request Access
Step 8: MDH Notification
Step 4: Letter of Intent
Optional Step:
Variance and Appeals
Step 5: Application
14
Step 1: Eligibility
• 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.
• Application may be submitted by: clinician, department, clinic,
or organization.
15
Step 2: Guides & Tools
Preparation and guidance
16
MDH HCH website Portal link
http://www.health.state.mn.us/healthreform/homes/index.html
17
Step 3: Request Access
(Initial Request only)
• Go to
https://apps.health.state.mn.us/hchcertification/login.seam
• Click on “Request Access to Letter of Intent”
18
Step 3: Request Access
(Initial Information needed)
• The applicant for certification is the organization.
The applicant name should be the broad legal
organization name.
• The clinic’s primary contact will receive
communication from MDH HCH.
• The desired username should be at least 6
characters long, all in CAPS.
• MDH HCH will contact you once the request has
been processed.
19
Log-in to the MDH HCH Portal
https://apps.health.state.mn.us/hchcertification/login.seam
20
Step 4: Letter of Intent
I.
Applicant Intent
II. Applicant Demographic Information
Organization/clinic name, address, applicant clinician(s) information
III. HCH Information
Yes/ No questions regarding health care home policies and procedures
IV. Additional Information
V. Contact Information
21
Step 5: Application
I. Applicant Demographic Info
Organization/ clinic name, address,
applicant clinician(s) information
II. Additional Clinician Info
Providers and services available to clinic,
hours working on HCH
III. Clinic’s Patient Profile
Age, race, gender, payer mix, language,
patient characteristics
IV. Representations and Signature of
Authorized Person
22
Step 6: Certification Assessment
• The certification assessment is used to determine
if the applicant meets the documentation
requirements for HCH certification and is ready
for a site visit.
• Applicants submit their HCH Assessment online
three weeks prior to their certification site visit at
a minimum.
• Site evaluators will review the clinics submitted
assessment prior to the site visit.
23
Certification Assessment
• There is flexibility for innovation built into the
application process
• HCH Standards are a road map to implementation; the
applicant identifies strategies, workflows and
processes to meet the standards.
24
Certification Assessment Tool
Documentation and Data Sources
At initial certification the clinic meets the ODD numbered subparts (1,3,5,7,9). There are
ten documents to submit. Progression is ensured through the addition of the EVEN
numbered subparts (2,4,6,8,10) at the anniversary ‘check-in’ with the clinic.
Documentation examples include:
• written policies, protocols and procedures
• workflows
• guidelines
• forms, flow sheets
• EMR and registry screen shots
• patient education materials, prepared resources, pamphlets
• meeting minutes with dates and member roles
• de-identified patient medical records
• PDSA cycles
25
Working with the Assessment
*The online submission of required subparts reflects the printable Assessment tool.
26
Submission of individual Subparts
• The hyperlinks to “Rule Intent” and “Rule Language” correlate with
the Certification Assessment Tool.
• The clinic may note “see attachment” if all the information is
summarized in the document.
• The clinic’s brief narrative describes the work for the subparts where a
document is not attached.
• Statements should be concise and succinct, initial certification
provides baseline information.
27
Eligibility Requirements
.0030 1A - Clinic organizational Structure
*required document (*consider the position of the patient)
.0030 1B - Board Certification/Licensure: HCH
Structure
*required document (*this is met in the contents of the LOI)
28
Access and Communication
Standard
• .0040 1A 1,2- Services to all patients with chronic & complex conditions
interested in participation
*required document
• .0040 1B 1,2 a,b,c,d & 3 a,b - Access to participant information.
*required document
• .0040 1C - Collect and apply cultural and language information
• .0040 1D - The patient’s preferred method of communication
• .0040 1E - Inform patients of access to specialty resources
• .0040 1F - Ensure compliance with privacy and security
29
Access and Communication Standard
.0040 1A 1,2
The applicant establishes a process to systematically screen
patients to identify patients who would benefit from care
coordination services based on the patient’s medical and
non-medical complexity.
•
•
•
•
A population screening
Defines patient risk level
Trigger to identify as a patient receiving CC services
policy/protocol outlines the intent, “who does what”
and “how”.
30
Access and Communication Standard
.0040 1B 1,2 a,b,c,d & 3 a,b
Aa system to support continuous access during and after regular clinic hours for
patient to communicate with the HCH team and the team knows the patient’s
preferred communication method.
1) Patients are informed that they have continuous access
2) the designated clinic staff has continuous access to medical record information:
(a) contact information, PCP name and contact information, patient identified as
receiving CC services.
(b) racial or ethnic background, primary language and preferred means of
communication
(c) Consents and restrictions for releasing medical information
(d) the participant's diagnoses, allergies, medications related to chronic and
complex conditions, and whether a care plan has been created for the participant
3) appointment scheduling is appropriate based on:
(a) acuity
(b) access to avoid unnecessary ER visit or hospitalization
31
Access and Communication Standard
.0040 1C
Language, ethnic and racial background
supports the provision of relevant care, that is
of value to the patient and supports a
culturally appropriate care plan.
• Process to document the information
• Staff is trained
• Plan to access interpreters as appropriate
32
Access and Communication Standard
.0040 1D
The clinic asks the patient and their family
about their preferred method of
communication.
This information is accessible to the HCH
clinic team.
33
Access and Communication Standard
.0040 1E
The participant may choose a specialty care
resource without regard to whether a
specialist is a member of the same provider
group or network as the participant's health
care home, and that the participant is then
responsible for determining whether specialty
care resources are covered by the participant's
insurance.
34
Access and Communication Standard
.0040 1F
The applicant has privacy and security
measures to comply with 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
35
Registry Standard
• 3A - Searchable registry for systematic population review
*required document
The applicant uses a registry and process to guide the
management of health care services, provide appropriate
follow-up and identify any gaps
in care for clinic populations.
• 3B 1,2 - Electronic registry data elements necessary to track
care. (name, age, gender, contact information, and
identification number)
36
Care Coordination Standard
• 5A 1,2,3 - Requirements for care coordination team
• 5B - Use of health care team, designation of personal clinician, & patient
is informed
*required document
• 5C - Routine face-to-face discussion between personal clinician & care
coordinator
• 5D - Dedicated time for care coordinator
*required document
• 5E 1,2,3,4,5,6 - Care Coordination processes & documentation
37
Care Coordination Standard
5A 1,2,3
HCH team relationships are central to the HCH. The PCP,
CC and participant relationships support effective
information sharing, goal setting, care coordination, care
planning and follow-up support.
• The participant and the care team set goals and identify resources
to achieve goals.
• The PCP and CC ensure continuity of care.
• The participant and care team identify method of contact with the
care team and community services.
38
Care Coordination Standard
5B
Health care team, designation of PCP, and patient is informed
*required document
To assure continuity of care, each patient has a designated primary
care provider. Patients receiving care coordination services also have
a designated care coordinator. The health care home teams provide
and coordinate the patient’s care, including communication and
collaboration with specialists.
• Process for selecting PCP
• PCP and CC (if receiving CC services) are identified in the EMR
39
Care Coordination Standard
5C
Routine face-to-face discussion between personal clinician
and care coordinator
Direct communication in which routine, face-to-face
discussions take place between the PCP and
the care coordinator.
Definition: Subp. 15. Direct communication. "Direct
communication" means an exchange of information
through the use of telephone, electronic mail, video
conferencing, or face-to-face contact without the use of an
intermediary. For purposes of this definition, an interpreter
is not an intermediary.
40
Care Coordination Standard
5D
Dedicated time for care coordinator
*required document
Designated protected time is essential to performing care
coordination functions and making improvements in
population outcome measurements.
• Job description
• Job responsibilities
• Job training
41
Care Coordination Standard
5E
Care coordination processes reflect a plan for
communication between the team and the
patient to assure continuity of care and services.
1.
2.
3.
4.
5.
6.
Referrals
Tests ordered or due
Admissions to hospital or skilled nursing facilities
Discharge planning
Medication reconciliation and pharmacy communication
Links to external care plans
42
Care Plan Standard
• 7A 1,2,3,4,5,6 - Care plan policies & procedures
*required document
• 7B 1,2,3,4 & C - Care plan goals & action plans
43
Care Plan Standard
7A 1,2,3,4,5,6
Care Planning Policy/Procedure document
*required document
1) actively engage and verify joint understanding of the care plan
2) engage all appropriate members of the health care team
3) incorporate pertinent elements of the assessment about the patient’s health risks and
chronic conditions
4) review, evaluate, and, if appropriate, amend the care plan, jointly with the participant, at
specified intervals appropriate to manage health and measure progress toward goals
5) provide a copy of the care plan to the participant upon completion of
creating or amending the plan
6) Use and document the use of evidence-based guidelines for medical services and
procedures.
44
Care Plan Standard
7B 1,2,3,4 & C
Care plan goals & action plans
• Patient specific, medical emergency plan, chronic disease
exacerbation plan, PCP, CC, Specialty providers’ plan,
medications, problem list, past medical history, community
services/programs, preventive care, end of life planning
emergency contacts, cultural considerations, patient
identified, patient centered SMART goals.
• De-Identified Care Plans uploaded or available at the site
visit for review by the MDH HCH Team- will review for the
required elements, and SMART Goals.
45
Quality Improvement (QI) Standard
9A 1,2,3,4 - Establishes HCH quality team that reflects clinic structure
*required document
9B - Quality team has a mechanism for communication & feedback
*required document
9C - Quality team demonstrates ability to do quality measurement
9D 1,2,3,4 - Participation in the learning collaborative
9E - Team has mechanism for communication & feedback for info.
from Learning Collaborative
46
Quality Improvement Standard
9A 1,2,3,4
HCH quality team that reflects clinic structure
*required document
A patient- and family-centered health care home relies on
participants and health care team members to provide input to the
clinic’s quality activities.
•
•
•
•
•
•
•
Patient Partners
Medical Director/Physician Champion
Performance Improvement Director /Co-Physician Champion
Director of Nursing
Reception Supervisor
Community Services/ Assistant Medical Home Coordinator
Care Coordinator
47
Quality Improvement Standard
9B
Quality team has a mechanism
for communication & feedback
*required document
The applicant follows procedures to share their work and
elicit feedback from HCH team members staff
regarding quality improvement.
• Process
• How are staff informed of QI
• How are patients informed of QI
48
Quality Improvement Standard
9C
Quality team demonstrates ability to measure, analyze,
and track changes in at least one quality indicator
selected by the applicant based upon the opportunity
for improvement.
•
•
•
•
•
•
•
Patient advisory involvement?
What is the objective?
What are the methods
How will you measure
What was the outcome?
Next Steps?
A PDSA process
49
Quality Improvement Standard
9D 1,2,3,4
Participation in the learning collaborative.
The MDH HCH Learning Collaborative provides a
supportive learning environment for the clinic.
Participation through representatives that reflect
the structure of the clinic is encouraged:
(1) one or more clinicians who deliver services in the HCH
(2) one or more care coordinators
(3) one or more participants from administration/mgmt
(4) two or more participant representatives
*Documentation of staff attending, dates, sessions.
50
Quality Improvement Standard
9E
Team has mechanism for communication & feedback
for information from Learning Collaborative
The applicant has a process for sharing information
and
eliciting feedback as a result of participation in the
MDH HCH Learning Collaborative.
*This process could be addressed in 9B
51
Variances and Recommendations
52
Variance Criteria
4764.0050 Subpart 1
At certification or recertification, the applicant may
request a variance or the renewal of a variance from a
requirement in parts 4764.0010 to 4764.0040.
53
Variance Types
• Minor variance may be granted to the HCH for good
cause or when failure to grant a variance would
result in hardship. It is identified that a minor
element of the rule is not implemented.
• Experimental variance may be granted where a HCH
offers an innovative replacement to meet the
standard.
• Hardship Variance: A significant hardship that
prevents implementation.
54
Variance Process
• Applicant submits a variance for an identified
subpart within the HCH online portal.
• The Nurse Planner is available to support the
applicant with this process.
55
Variance submission
A variance may be submitted:
• During the application process
• After the site visit
• During remedial planning
• After an appeal
56
Variance Duration
Subpart 2. Conditions and duration.
The commissioner may impose conditions on the
granting of a variance according to Minnesota Statutes,
section 14.055. The commissioner may limit the
duration of a variance and may renew a variance.
• Variances are normally in place for one year or until
resolved.
• Clinics may submit a request to extend a variance at
recertification.
57
Recommendations
Recommendations are observations made by
the site visit evaluators reflecting opportunity
for improvement.
Recommendations are:
• Not prescriptive
• Addressed by the clinic as appropriate
• Reviewed at the following recertification to
describe how they were addressed.
58
Site Visit
59
Step 7: Site Visit
• Completed at initial certification.
• Assesses the implementation of the HCH certification
standards in the care delivery model.
• Completed by trained reviewers from clinical staff,
consumers and Minnesota State employees.
• Completed at the three year recertification cycle in a
two hour team meeting format.
60
Application Process
An automated MDH email notifies the applicant that the
recertification completion date is 90 days away.
During this time period:
• Required letter of intent, application and self assessment
have been submitted.
• Required documents have been submitted and reviewed.
• Site visit has been completed.
61
Step 8: MDH Notification
MDH will notify the applicant of certification status.
• The report summarizes how the clinic is meeting
each of the standards.
• Applicants meeting all of the standards achieve
certification.
• Celebrate!
• Payer notification to be completed by the
applicant.
62
Optional Step: Variance and Appeals
Options for unmet standards:
• Submit a request for a variance.
• Request support or technical assistance from MDH.
• Develop and submit a corrective action plan which is
reviewed by MDH.
• File an appeal. The applicant has 30 days from the
date of receiving the denial notice to appeal the
decision.
63
Care Coordination:
Billing and Reimbursement
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. [62U.03]
•
Covers SGIP, small group self-insured
64
Care Coordination Payment Guiding Principles
• HCHs provide population management.
Every patient is part of the clinic’s HCH.
• HCHs determine which patients will benefit from:
•
•
care coordination and are eligible for reimbursement
routine panel management (preventive care,
appointment follow-up).
• Clinics implement key processes for successful care
coordination billing.
65
Population Management Goal
Clinics implement processes to identify patients
from the entire clinic population who would
benefit from care coordination services.
• New patients
• Current patients with health changes
• Established patients with chronic conditions.
• Patients who are identified and decline care
coordination services.
66
Population Management
What does your population look like?
67
Implement HCH Tier Tool
68
Complexity Tier Level
Needed for Payment
• Patient’s Tier Level (based on the count of
“major” condition groups)
•
•
•
•
•
Tier 0 (none)
Tier 1 (1-3)
Tier 2 (4-6)
Tier 3 (7-9)
Tier 4 (10 or more)
• Presence of either of the two “supplemental”
complexity factors
69
Workflow Development:
Tiering & Billing
• Determine who does what and when.
• Complete the Care Coordination Tier Assignment tool.
• The care team establishes a work flow for communication
of the tier score.
• Key: Establish billing and accounting department
workflows and communication processes.
• Establish payer contracting (see slide #73).
• Develop automated workflows within EMR. May begin
with a manual process.
• Tier level is supported by documentation.
70
Coding Structure for Billing
71
Key Billing Process Steps
72
Key Denial Process Steps
73
Multi- Payer Communication
•
•
•
•
Prior to Certification, identify payer networks supporting
care coordination reimbursement.
Work with payers to establish payment rates and method of
claim submission and payment
• Tiering Methodology (Medicaid; private and
commercial plans)
• PMPM Contract Arrangements
• CMS – Medicare Care Coordination (chronic care
management codes – see slide #75-76)
Identify payers where there may be a patient co-pay and
determine a process.
Address how to manage billing for uninsured.
74
New Medicare -CMS Chronic Care Management
(CCM) Codes, January 2015
As of January 1, 2015, practices began
submitting billing under the new CCM codes.
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/index.html
75
CMS Chronic Care Management Codes
• Replaces Medicare: MAPCP, CPI and other PCMH demos.
• Practices need to meet standards similar to the HCH standards to
submit claims. (see CMS requirements).
• Patient agreement to services is required.
• Service requirement of at least 20 minutes of clinical staff time
directed by a physician or qualified health care professional per
calendar month.
• Patient has two or more chronic conditions expected to last at
least 12 months.
• Electronic health records requirement; specific requirement for
an electronic care plan.
• A comprehensive care plan is established, implemented, revised
and monitored.
• PCMH certification is not required.
76
Create Your Clinic’s Roadmap
• Population Management
in Health Care Homes
• Care Coordination
Tiering Processes
• Billing Workflows
• Multi-payer Input
77
Certification details: Your questions
• New clinics or clinicians added over time within the
certified organization follow the same recertification cycle.
• The certification site visit date serves as the recertification
three year cycle date.
• Email questions to [email protected]
78
Recertification Timeline
page2
Goal: Maintain relationship, provide ongoing technical assistance, and
facilitate advancement of implementation standards.
79
Evaluation
Health Care Homes, Five Year Program Evaluation:
Key findings from the University of Minnesota Evaluation
80
Health Care Homes
A Business Case
81
Thank you!
Visit the MDH HCH website:
http://www.health.state.mn.us/healthreform/homes/index.html
MDH HCH main phone number: 651–201–5421
82
HCH Nurse Planners’ Contact Information
• Bonnie LaPlante, MDH HCH Program Director
• 651–201–3744
• [email protected]
• Tina Peters – Metro Area
• 507–951–5780
• [email protected]
• Kathleen Conboy – Metro Area
•
•
651–201–3753
[email protected]
• Joan Kindt – Southern Region
• 507–272–4486
• [email protected]
• Danette Holznagel – Northern Region
• 218–206–3239
• [email protected]
83