Blueprint Integrated Pilot Programs Building an Advanced Model of Primary Care

Blueprint Integrated Pilot Programs Building an Advanced Model of Primary

Office of Reform Office of Vermont Health Access Vermont Health Reform 312 Hurricane Lane, Suite 201 Williston, VT 05495 Blueprint Team Vermont Department of Health 108 Cherry Street Suite 301 PO Box 70 Burlington, VT 05402 Susan W. Besio, Ph.D. Director Office of Vermont Health Access Vermont Health Reform 802-879-5901 susan.besio@ahs.state.vt.us Craig Jones, MD Blueprint Executive Director (802) 879-5988 phone (802) 859-3007 fax craig.jones@vdh.state.vt.us 802-879-5901 craig.jones@vdh.state.vt.us Hunt Blair Deputy Director Reform (802) 879-5901 Hunt.Blair@ahs.state.vt.us Diane Hawkins Executive Staff Assistant (802) 879-5988 diane.hawkins@vdh.state.vt.us Lisa Dulsky Watkins, MD Blueprint Assistant Director (802) 652-2095 phone (802) 859-3007 fax lwatkin@vdh.state.vt.us Jenney Samuelson, MS Blueprint Community & Self Management Director (802) 863-7204 phone (802) 859-3007 fax jsamuel@vdh.state.vt.us James Morgan, MSW Blueprint Project Administrator (802) 865-7795 phone (802) 859-3007 fax jmorgan@vdh.state.vt.us Terri Price Blueprint Administrative Support Healthier Living Workshop Statewide Coordinator (802) 652-2096 phone (802) 859-3007 fax tprice@vdh.state.vt.us Diane Hawkins Executive Staff Assistant Office of Health Reform 312 Hurricane Lane Williston, VT 05495 (802) 879-5988 diane.hawkins@vdh.state.vt.us

Coordinated Health System Hospitals PCMH PCMH Mental Health & Substance Use Disorders Community Health Team Nurse Coordinator Social Workers Dieticians Community Health Workers OVHA Coordinators Prevention Specialist PCMH PCMH Prevention Health IT Framework Global Information Framework Evaluation Framework Operations

Blueprint Integrated Pilot Summary 1. Financial reform (2 major components - includes MCAID & commercial insurers) - Payment to practices based on NCQA PCMH score - Shared costs for Community Teams 2. Multidisciplinary care support teams (CCT Teams) - Local care support & population management 3. Health Information Technology - Web based clinical tracking system (DocSite) - Visit planners & population reports - Electronic prescribing - Updated s to match program goals and clinical measures in DocSite - Health information exchange network 4. Community Activation & Prevention - Prevention specialist as part of CCT - Community profiles & risk assessments - Evidence based interventions 5. Evaluation - NCQA PCMH score (process quality) - Clinical process measures - Health status measures - Multi payer claims data base - Indicators

Evidence Based Improvement Source Processing & Storage Reports & Uses s used for bases transmission & transformation VITL / GE Reporting Tool or Clinical Process & Support DocSite used for DocSite base DocSite Reporting Tool Health Status Management Contracted & Standards Improvement Medical Claims from Commercial Insurers & Medicaid Multipayer base Reports Patterns & Resource Utilization Provider Payment for Chart Review & NCQA Scoring bases & Report Generation Expenditures & Financial Impact Program Evaluation & Sustainability Surveys & Collection Registries & bases Analytic base Indicators & Risk Factors Community Prevention Planning

Financial Impact IMPACT OF MEDICAL HOME SAVINGS ACROSS TOTAL POPULATION INCREMENTAL COST PER YEAR $420,000,000 $400,000,000 $380,000,000 $360,000,000 $340,000,000 $320,000,000 $300,000,000 1 2 3 4 5 INCREMENTAL EXPENDITURES WITHOUT MEDICAL HOMES INCREMENTAL EXPENDITURES WITH MEDICAL HOMES YEARS 2009 2010 2011 2012 2013 Percentage of Vermont population participating 6.7% 9.8% 13.0% 20.0% 40.0% Participating population 42,179 61,880 82,332 127,045 254,852 # Community Teams 2 3 4 6 13

Evidence Based Improvement Source Processing & Storage Reports & Uses s used for bases transmission & transformation VITL / GE Reporting Tool or Clinical Process & Support DocSite used for DocSite base DocSite Reporting Tool Health Status Management UVM CCTS Health Informatics Platform & Standards Improvement Medical Claims from Commercial Insurers & Medicaid Multipayer base Reports Patterns & Resource Utilization Provider Payment for Chart Review & NCQA Scoring bases & Report Generation Expenditures & Financial Impact Program Evaluation & Sustainability Surveys & Collection Registries & bases Analytic base Indicators & Risk Factors Community Prevention Planning

HIPPA Compliant Environment DocSite Clinical Multipayor Claims PHI PHI Central Repository Storage Normalization De-identification Re-identification Analytics (Routine) Analytics (Exploratory) Workbench Reporting De- Identified High Performance Computing Center Processing Query for experiments Sources Transmission UVM CCTS Health Informatics Platform

Routine Comparative Effectiveness Reporting State # 1 claims data Encrypted or assigned identifier HIPPA Compliant Environment State # 2 claims data State # 3 claims data State # 4 claims data State # 5 claims data Encrypted or assigned identifier Encrypted or assigned identifier Encrypted or assigned identifier Encrypted or assigned identifier Central Repository Storage Normalization De-identification Re-identification Analytics (Routine) Analytics (Exploratory) Workbench Reporting De- Identified High Performance Computing Center Processing Query for experiments Sources Transmission UVM CCTS Health Informatics Platform

Building a Scalable Model Build a multidimensional evaluation framework Support patient care & population management Support ongoing quality improvement Evaluate trends in clinical outcomes Evaluate trends of financial impact Support sustainability & expansion