A Close Look at Care Coordination within Patient-Centered Medical Homes: West Virginia s Experience

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1 A Close Look at Care Coordination within Patient-Centered Medical Homes: West Virginia s Experience Web Seminar May 9, 2013 Follow this event on Twitter Hashtag: #AHRQIX

2 Using the Webcast Console and Submitting Questions To submit a question, type question here and hit submit. Click the Q&A widget to get the Q&A box to appear 2

3 Accessing Presentations Download slides from console Click on the Download Slides widget for a PDF version 3

4 What is the Health Care Innovations Exchange? Publicly accessible, searchable database of health policy and service delivery innovations Searchable QualityTools Successes and attempts Innovators stories and lessons learned Expert commentaries Learning and networking opportunities New content posted to the Web site every two weeks Sign up at under Stay Connected 4

5 Innovations Exchange Web Event Series Archived Event Materials Available within two weeks under Events & Podcasts at Next Events Thursday, June 5, pm ET Building Health Information Exchanges to Support Accountable Care Organizations and Medical Homes: Delaware s Experience 5

6 Today s Event Moderator James Becker, MD Medicaid Medical Director, West Virginia Bureau for Medical Services 6

7 How Rural Are We? We are a state of 1.8 million individuals Yet, our two largest cities approach 50 K in number Many parts of the State are geographically isolated and medically underserved Medicaid currently serves 410,000 individuals Over 200,000 individuals are uninsured Many patients cross borders to receive care 7

8 What Are Our Health Challenges? Chronic diseases Mental health, substance abuse Aging population Poverty, unemployment Low educational achievement Lifestyle issues Health literacy issues 8

9 What s Working? Prevention programs and wellness, especially for selected conditions Federally Qualified Health Centers and the rural health network meet much of the region s need and are widely accepted in their communities Comprehensive behavioral health system University outreach networks with satellite services, technology and grant support 9

10 What Is Our Direction? In 2009 we adopted the Triple Aim and began building Patient-Centered Medical Homes (PCMH) around the state with grant support The legislature endorsed PCMH and a state plan for health improvement Since then, each private health carrier has adopted some elements No central payment methodology is established 10

11 Currently. West Virginia has a series of state plan amendments (SPAs) in development related to Health Homes (ACA 2703) The first will involve bipolar individuals with/or at risk of hepatitis Future SPAs expected for diabetes, obesity, asthma, mental illness, Alzheimer s, congestive heart failure, chronic obstructive pulmonary disease SPAs broadly define care coordination, care managers and care coordinators 11

12 In Our Experience Care coordination is a highly individual skill Flexibility and creativity Sense of mission Experience-based Best delivered face-to-face Shared coordinators and telephonic care Best in the setting of team care 12

13 In Our Experience Requires leadership and resources Is effective when there is data to guide decisions Electronic health records and care coordination Information technology for population management We ve found no single credential or skill set that best identifies a care coordinator

14 Care Coordination Models The Health Home Patient-Centered Medical Home Targeted Case Management Managed Care Organizations Community Health Workers Other community services 14

15 Payment for Care Coordination Under the state plan amendments, Medicaid will use a fee-for-service plus per member per month model A private carrier is promoting a move to an Accountable Care Organization with pay for performance (P4P) and pay for value features Another insurer is adopting a comprehensive payment model with a P4P shared savings A network in the state operates under grant-based payment So you see.. 15

16 Everyone likes care coordination, but we re not sure how we should pay for it! 16

17 A Bit of Strategy Adopt consistent or similar payment models Capture similar measures in similar ways Allow flexibility within practices as long as they are moving toward accepted standards Recognize the unique features of practices and communities 17

18 Respondent William Golden, MD Medical Director, Arkansas Medicaid Enterprise at Arkansas Department of Human Services 18

19 Rural Challenges Workforce variation; team, alternatives, access Practice infrastructure; capitalization Socioeconomics, health literacy Perverse incentives 19

20 Evolving Environment Workforce Practice ownership, management Health Information Technology 20

21 Arkansas Payment Reform Harmonize economic incentives: multi-payer, promote local innovation, care coordination Episodes of care Gain sharing for total cost of care, quality metrics Reward more effective providers; break cycle of payment regardless of practice variation Medical home: New per member per month for transformation/care coordination; gain sharing for total cost of care, quality metrics 21

22 Quality Standards and Shared Savings 22

23 Upside Only Gain-Sharing 23

24 Concepts: Medical Home versus Health Home Medical Home: The Clinical Game Plan Care coordination/coaching for high priority patients; medically frail, complex psychosocial, literacy concerns Health Home: Community Coordination for Select Populations Developmental disability Significant mood disorder 24

25 Payment Initiative Initial phase: 7,020 clients 1 Service Episode $300 M Adult Developmental Disability Expenditures 1 Ensure care provision is efficient and based on client needs Align resources provided with level of need Expand plan customization options for clients 2 Minimize resources / time not focused on delivering client care Care Coordination Within Health Home $35 M Halo expenditures for adults 1 (e.g., medical, behavioral) 3 Increased care coordination Integrate care across medical, behavioral, health Reduce unnecessary medical and behavioral health spending Promote wellness activities 1 Includes clients ages 18+ with development disabilities not currently enrolled in public school, excludes 22 clients receiving therapy only 2 Includes all medical and behavioral spending (in-patient, out-patient and pharmacy) SOURCE: Medicaid claims data for claims incurred in SFY

26 New Activities Provider report cards; data supported change Health Information Technology (HIT) expansion Vendor options for care coordination 26

27 Issues Engaging all practices; not just early adopters Engaging patients Pooling practice data; statistical, actuarial necessity Diverse installed electronic medical record base; limitations of data extraction Accountability for use of per member per month 27

28 Unknowns: Value, Pricing of New Services Avoid new economic silos Telemedicine Care coordination; for whom, how intensive 28

29 Brighter Future Providers and payer agree that change is needed Pain of change becoming less than pain of status quo Opportunity window to create smarter, more effective health care 29

30 Today s Event Moderator David Meyers, MD Director of the Center for Primary Care, Prevention, and Clinical Partnerships, AHRQ 30

31 AHRQ Resources PCMH.AHRQ.GOV 31

32 Defining the PCMH PCMH Basics Evidence and evaluation Tools and resources: care coordination, quality and safety, patient-centeredness, and more Implementation: A How-To Guide on Developing and Running a Practice Facilitation Program, new case studies 32

33 White Papers and Briefs on Care Coordination The Roles of Patient-Centered Medical Homes And Accountable Care Organizations in Coordinating Patient Care Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms Coordinating Care for Adults with Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions 33

34 Measuring Care Coordination AHRQ Care Coordination Measurement Atlas Review and Recommendations on the Best Tools for Accountability and Assessing Care Coordination Caveat: Patient and Family Surveys 34

35 PCMH CAHPS Consumer Assessment of Healthcare Providers and Systems (CAHPS) program Released in late October 2011 Built on existing, well-validated clinician and group survey Covers topics such as provider-patient communication, coordination of care, and shared decision making Available in English and Spanish; adult and child versions 35

36 Questions? Click me to get Q&A box to appear 36

37 The Innovations Exchange Visit our Web site: Follow us on Send us 37

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