Applying Science to Transform LivesTREATMENT RESEARCH INSTITUTE

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Mady Chalk, Ph.D

Treatment Research Institute

CADPAAC Conference

May, 2011

Coordinated Care and Health Homes

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Health Homes Defined

• Health home models are intended to encourage a population-based, proactive and planned approach to care, including chronic care, that is coordinated across providers.

• Health homes models are intended to provide a single point of coordination for all health care, including specialty care, hospitals, and post-acute care.

• Health homes provide patient self-management support.

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Health Homes Defined

• Health homes are centrally managed, generally by a primary care physician or non-physician administrator.

• Health homes receive supplemental payments to support operations expected of a medical home.

• Health home models rely on use of data systems to enhance safety and reliability.

• The rationale is to reduce fragmentation in ways that lower costs and lead to better outcomes.

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Medical Societies’ Joint Principles

• In 2007, four Medical Societies approved Joint Principles of the Patient-centered Medical Home

• The joint principles originate from two distinct conceptual frameworks, the primary care model and the chronic care model, each of which was developed for different purposes.

• The primary care model focuses on all patients in a practice and emphasizes whole-person care over time, rather than single disease-oriented care.

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Medical Societies’ Joint Principles

• The chronic care model focuses on “system changes intended to guide quality improvement and disease management activities” for chronic illness.

• The chronic care model assumes that before implementation of a medical or health home every chronically ill person has a primary care team that organizes and coordinates their care.

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“To deliver patient-centered primary care, practitioners have to restructure their practices so that they are more accessible, promote prevention and wellness more effectively, proactively support patients with chronic illness rather than treat the symptoms of those illnesses, and, proactively support patients in self-management and decision-making.”

Statement of Joint Principles

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Summary of Joint Principles

• Ongoing Relationship with Personal Physician• Team Approach at the practice level with

collective responsibility for ongoing care• Whole Person Approach including responsibility

for providing, arranging for, and staying informed about all care

• Coordination and Integration of Care facilitated by information technology

• Quality and Safety are hallmarks - advocacy, evidence-base, continuous quality improvement

• Expanded Access To Care

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Patients Need to Know

• Patients need to know which practice serves as their health home so they know who to count on to coordinate and manage their overall care.

• In addition, patients need to be aware of what the health home will provide if they are to work closely with the health home and change the way they use care.

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Behavioral Health in the Health Home

• While physicians have input into which patients they serve, in many cases, they may not be aware of other physicians, non-physician clinicians, and treatment programs their patients see, especially in the areas of behavioral health.

• We know that about two-thirds of primary care visits have a psychosocial component (Robinson and Reiter,

2007) and about 25% of general healthcare patients report that they have a co-morbid substance use condition (NSDUH, 2005).

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Behavioral Health in the Health Home

• Patients who receive integrated services during treatment have been shown to have almost twice the odds of abstinence; receipt of primary care by patients with substance use disorders (2-10 visits) during and following treatment is predictive of remission at 5 years (Mertens, Risher et al., 2008).

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Incentives for Behavioral Health

To improve the possibility for inclusion of behavioral health in the health homes, behavioral health incentives can be used:

•Monthly stipends to help programs with developing initial administrative functions •Monthly care coordination payments•Short-term monthly stipends to provide IT assistance for the program

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Planning Ahead

• States and Counties with existing or planned health home initiatives need to compare what they are intending to do to the Definition of Health Home.

• There is no single model of a health home.• States and Counties need to inventory programs

and decide which ones can be aligned with health home services.

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Questions to Ask

Focus for States and Counties:•Patient Population: What Medicaid beneficiaries are eligible for services and how many patients will receive services?

•Geographic Area: Where are services provided, e.g., in specific regions? Statewide?•Delivery Model: In what delivery system are services provided (e.g., through health plans, in fee-for-service, etc.)

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Questions to Ask

Focus for States and Counties:•Provider Network: Who is delivering the services and how many providers are there?•Provider Eligibility and Standards: Who is eligible to provide services? What standards must they meet?•Quality Measures Reporting: What performance measures will be used to assess quality improvement, utilization, costs, etc.? What performance information is being shared with service providers?

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Questions to Ask

Services: What are the specific services provided to patients?

1. Comprehensive care management

2. Care coordination and health promotion

3. Transition care and support (from inpatient, nursing home, residential care, etc.)

4. Individual and family support

5. Referrals to community and social support services

6. Use of HIT to link services

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Questions to Ask

Focus for States and Counties:

•Information Exchange: How will clinical information be exchanged with patients and providers outside of the health home? What explicit agreements between the patient and health home need to be reached to assist with exchange of information?

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Questions to Ask

Focus for States and Counties:

•Funding: How will services be funded? What do you know now about what will be the average cost per beneficiary?•Oversight: How will the state and/or county oversee the program?

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Challenges

• Capital and courage to start• Reliance on Electronic Health Records (EHRs)

for most health home models and for most treatment programs will require new investments in hardware and software as well as time to learn how to use and maintain EHRs.

• Team-based care may require cultural changes in the way that care has traditionally been delivered.

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Challenges

• Educating patients on their roles within the health home and teaching them new skills and pathways to become informed and active in their health care will likely be necessary.

• Patients putting all of their information eggs in one health home basket; patients fearing that health home will serve as a gatekeeper they don’t want.

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Challenges

• As challenging as the medical home-patient exchange of information is, the medical home-specialist exchange may be more so.

• Need for supports to primary care clinics and practices to provide and manage medications for treatment of substance use and co-morbid mental disorders.

• Funding for supports to primary care clinics.

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For more information

Contact

Mady Chalk, Ph.D.

Treatment Research Institute

mchalk@tresearch.org