Introduction to Health Care Homes Webinar Series Session 1: The Business Case for Health Care Homes and Overview of Legislation and Standards

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Agenda • Welcome • Overview of Webinar Series • The Business Case for Health Care Homes • Health Care Homes Certification Standards / HCH Rule • Q & A • Wrap Up

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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

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Introduction to Health Care Homes Webinar Series Schedule

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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

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The Business Case for Health Care Homes Sanne Magnan, MD, PhD President and CEO Institute for Clinical Systems Improvement

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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.

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Top Ten Business Reasons for Becoming a Health Care Home (cont.)

6. It’s the right thing to do. 5. “Skate to where the puck is going to be.” 4. There’s money in it. 3. Be part of an exciting time-move to the future with

redefining care. 2. Learn and work with great people. 1. Patients, families and communities will thank you for it -

puts patients, families and communities in the center.

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Health Care Homes Marie Maes-Voreis, RN, MA Director Health Care Homes

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Health Reform in Minnesota

Minnesota’s Three Reform Goals • Healthier communities • Better health care • Lower costs

Institute for Healthcare Improvement’s Triple Aim

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.

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Health Care Home

Health Care Home is not:

• A nursing home or home health care

• A restrictive network • A service that only benefits

people living with chronic or complex conditions

Health Care Home is: • Population clinical care

redesign • Transformed services to meet a

new set of patient-and family-centered standards to achieve triple aim

• Community partnerships that build healthy communities

• Foundation to new payment models such as ACOs

Primary Care Population-Based Care Delivery Redesign, What is different?

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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.

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Minnesota’s Certified Health Care Homes

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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

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Together, patients and families, providers, payers, agencies, and other team members designed new standards for health care homes

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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

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Rules Structure: 4764:0010-0070

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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.

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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.

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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.

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HCH Population Based HCH is Your Entire Clinic

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The Patient and Family Centered Health Care Home

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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.

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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

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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.

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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.

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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

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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.

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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.

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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.

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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.

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Capacity Assessment Survey: Care Plan and Care Coordination

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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.

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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.

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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.

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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.

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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.

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We have focused on improved outcomes for the health of our families, patient experience, and cost and value.

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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.

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Capacity Assessment Survey: Do you feel like a partner in your care?

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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

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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.

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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.

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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.

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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!

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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

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Online Certification Application System

• Go to Certification Webpage: http://www.health.state.mn.us/healthreform/homes/certification/index.html

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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.

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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.

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Legislative Requirements for HCH Care Coordination Payment

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• [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/payment/index.html

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Multi-Payer Investment in HCH’s Primary Care Transformation

SOURCE: Adapted from MDH Health Economics Program, Medicare enrollment data and SEGIP enrollment data

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.

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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.

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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

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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

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Additional Information & Materials http://www.health.state.mn.us/healthreform/homes/index.html • 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

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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.

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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

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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

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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

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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

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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

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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

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Health Care Home As Foundation to ACO’s or Total Cost of Care Payment Methods

Health Care Homes Contact Information health.healthcarehomes@state.mn.us

http://www.health.state.mn.us/healthreform/homes/index.html

654-201-5421

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