Health Homes for Enrollees With Chronic Conditions Section 2703 Maryland Department Of Health And Mental Hygiene August 18, 2011 - PowerPoint PPT Presentation


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Health Homes for Enrollees With Chronic Conditions Section 2703 Maryland Department Of Health And Mental Hygiene August 18, 2011


* 39% of the U.S. working - age population in 2007 had at least one chronic condition, such as diabetes, up significantly from 35% in 2003 and 34% in 2001. – PowerPoint PPT presentation

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Title: Health Homes for Enrollees With Chronic Conditions Section 2703 Maryland Department Of Health And Mental Hygiene August 18, 2011

Health Homes for Enrollees With Chronic
Conditions Section 2703
Maryland Department Of Health And Mental
Hygiene August 18, 2011
  • Costs of Chronic Conditions
  • Overview of Chronic Health Homes
  • State Plan Amendment Example Missouri

Cost of Chronic Conditions
The Number Of Individuals With Chronic Conditions
Is Increasing.
  • More than 40 of the U.S. Population has one or
    more chronic conditions.
  • 39 of the U.S. working - age population in 2007
    had at least one chronic condition.
  • By 2020, the number of people with multiple
    chronic conditions is expected to increase to 81
    million, up from 57 million in 2000.

Source Brody, Jane E. Tackling care as chronic
ailments pile up, The New York Times, February
21, 2011 Cassil, Alwyn. Innovations in
preventing and managing chronic conditions
Whats working in the real world? Center for
Studying Health System Change, June 2010.

High Share Of Health Care Spending Is On Behalf
Of People With Multiple Chronic Conditions.
  • Sixteen percent of spending is for 50 percent of
    the population that has no chronic conditions.
  • Eighteen percent of spending is for the 22
    percent of the population that has only one
    chronic condition.
  • Seventeen percent of spending is for the 12
    percent of the population that has two chronic
  • Sixteen percent of spending is for the 7 percent
    of the population that has 3 chronic conditions.
  • Twelve percent of spending is for the 4 percent
    of the population that has 4 chronic conditions.
  • Twenty-one percent of spending is for the 5
    percent of the population that has 5 or more
    chronic conditions.

Percentage of Health Care Total Spending by
Number of Chronic Conditions
Source Medical Expenditure Panel Survey 2006
Overview of Chronic Health Homes
Affordable Care Act Provides Support For
Individuals With Chronic Conditions.
  • The Affordable Care Act was passed by Congress
    and signed into law by the President in March
  • Section 2703 of the Act adds section 1945 to the
    Social Security Act to allow states to amend
    their Medicaid state plans to provide Health
    Homes for enrollees with chronic conditions.

Health Homes Provide A Comprehensive System Of
Care For Individuals With Chronic Conditions.
  • Chronic Health Homes is a new Medicaid State Plan
    Option that provides a comprehensive system of
    care coordination for Medicaid individuals with
    chronic conditions.
  • Health Home providers will coordinate all
    primary, acute, behavioral health and long term
    services and supports to treat the
  • The integration of primary care and behavioral
    health services is critical to achievement of
    enhanced outcomes.
  • CMS encourages states to coordinate with existing
    medical home projects.
  • States should compare current programs to the ACA
    health homes definition.

An Individual Must Meet The Eligibility Criteria
Determined By CMS And The State.
  • Medicaid eligible individual having
  • At least 2 chronic conditions,
  • 1 chronic condition and be at risk of developing
    another, or
  • At least 1 serious and persistent mental health

There Are Six Chronic Conditions Listed In The
Federal Statute.
  • The chronic conditions include
  • mental health condition,
  • substance abuse disorder,
  • asthma,
  • diabetes,
  • heart disease, or
  • being overweight (as evidenced by a BMI of gt 25).
  • States may add additional chronic conditions
    with approval from CMS.

CMS Has Given States Flexibility In Implementing
Eligibility Requirements.
  • States may further limit eligibility criteria,
    e.g., based on diagnosis or risk of
  • States must offer services to all enrollees who
    meet the eligibility criteria.
  • States may not exclude individuals dually
    eligible for Medicare.
  • States can limit the geographic area where the
    program is offered to places where the need is
    greatest, or where providers are available.

CMS Has Outlined Specific Services That Are To Be
Offered To Individuals With Chronic Conditions.
  • The following health home services are to be
    provided in a comprehensive, timely, and high
    quality fashion
  • Comprehensive Care Management
  • Care coordination
  • Health promotion
  • Comprehensive transitional care from inpatient to
    other settings
  • Individual and family support
  • Referral to community and social support
    services and
  • The use of health information technology to link
  • States will receive a 90 federal match for
    these specific services.

Specific Provider Types Will Be Able To Provide
Health Home Services.
  • CMS specific provider types include
  • Designated providers, such as physicians,
    clinical practices, rural health clinics,
    community health centers, home health agencies,
    or any other entity/provider
  • A team of health care professionals, including
    physicians, nurse care coordinator, nutritionist,
    social worker, behavioral health professional
    which links to a designated provider or
  • A health team, defined as an interdisciplinary,
    inter-professional team including medical
    specialists, nurses, pharmacists, nutritionists,
    dieticians, social workers, behavioral health
    providers, physicians assistants, etc.
  • Providers are expected to address functions
    including but not limited to
  • Providing quality-driven, cost-effective,
    culturally appropriate, and person-and
    family-centered health home services
  • Coordinating and providing access to high-quality
    health care services informed by evidence-based
  • Coordinating and providing access to mental
    health and substance abuse services and
  • Coordinating and providing access to long-term
    care supports and services.

Federal Support For Implementation
  • The provision offers States additional Federal
    support to enhance the integration and
    coordination of primary, acute, behavioral
    health, and long-term care services and supports
    for Medicaid enrollees with chronic conditions.
  • To aid in planning activities aimed at developing
    and submitting a State Plan Amendment (SPA), the
    legislation originally included funding for state
    grants of up to 500,000, but this was not
    funded. Any planning funds would be matched at a
    States regular FMAP.

States Will Receive A 90 Federal Match For
Services Specified By CMS.
  • A State could receive for the first 8 quarters
    90 FMAP for health home services provided to
    individuals with chronic conditions, and a
    separate 8 quarters of enhanced FMAP for health
    home services provided to another population
    implemented at a later date. 
  • Additional periods of enhanced FMAP would be for
    new individuals served through either a
    geographic expansion of an existing health home
    program, or implementation of a completely
    separate health home program designed for
    individuals with different chronic conditions.

CMS Has Given States Flexibility In Establishing
  • States have significant flexibility in how they
    can reimburse health homes for these services.
  • CMS will allow capitated, fee for service, or
    other models approved by CMS.

CMS Has Outlined Reporting Requirements That
States And Providers Must Follow.
  • Providers
  • Designated providers of health home services are
    required to report quality measures to the State
    as a condition for receiving payment.
  • States
  • States are required to collect utilization,
    expenditure, and quality data for an interim
    survey and an independent evaluation.
  • Congress
  • Survey of States Interim Report to Congress
  • Independent Evaluation Report to Congress 2017

CMS Has Imposed Additional Requirements For
States That Want To Implement Health Homes.
  • States must
  • Consult and coordinate with the Substance Abuse
    and Mental Health Services Administration
  • Collect and report information and
  • Participate in CMS evaluation and assessment by
    an independent organization no later than January
    1, 2017.

CMS Encourages States To Consult With Them During
The Planning Phase.
  • CMS is available to
  • Provide technical assistance to States
    interested in submitting a State plan amendment
  • Engage in rapid learning activities to prepare
    for the release of well-informed regulations and
  • Continue collaborations with Federal partners, to
    ensure an evidence-based approach and consistency
    in implementing and evaluating the provision.

State Plan Amendment Example Missouri
CMS Requires States To Submit A State Plan
Amendment (SPA).
  • CMS has provided states resources to aid in the
    formation of a State Plan Amendment (SPA).
  • SPA must address how the proposed approach will
    assure access to mental health and substance use
    prevention, treatment, and recovery services.
  • SPA must describe how the state will ensure a
    whole-health approach to providing care and how
    the state will address the required functions of
    a health home.

Missouris Healthcare Homes
  • Missouri is the first state to amend its Medicaid
    state plan to implement Healthcare Homes.
  • Missouri will have two types of Healthcare Homes
  • Primary Care Chronic Healthcare Home
  • Federally Qualified Health Centers (FQHC)
  • Rural Health Centers (RHCs)
  • Physician practices
  • Community Mental Health Center Healthcare Home
  • CMHCs and CMHC affiliates
  • Missouri has made significant progress in
    establishing a Community Mental Health Center
    Healthcare Home.

Missouris Healthcare Home Definition
  • Health Homes a place where individuals can come
    throughout their lifetimes to have their
    healthcare needs identified and to receive the
    medical, behavioral and related social services
    and supports they need, coordinated in a way that
    recognizes all of their needs as individualsnot
    just patients.

Missouris Healthcare Homes Target Population
  • Clients eligible for a CMHC Healthcare Home must
    meet one of the following three conditions
    (identified by patient health history)
  • A serious and persistent mental illness,
  • Community Psychiatric Rehabilitation (CPR)
    eligible adults and kids with Serious Emotional
    Disorder (SED)
  • A mental health condition and substance use
    disorder, or
  • A mental health condition and/or substance use
    disorder and one other chronic health condition.
  • Chronic health conditions include
  • Diabetes,
  • Cardiovascular disease,
  • Chronic obstructive pulmonary disease (COPD),
  • asthma, chronic bronchitis, or emphysema
  • Overweight (BMI gt25),
  • Tobacco use,
  • Developmental disability.

Missouris Healthcare Homes Payment Methodology
Part 1 Quarterly start-up, training and infrastructure cost reimbursement Missouri will reimburse Health Homes for start-up costs and lost productivity due to collaboration demands on staff not covered by other streams of payment.
Part 2 Clinical Care Management per-member-per-month (PMPM) payment Missouri will pay for reimbursement of the cost of staff primarily responsible for delivery of services not covered by other reimbursement (Primary Care Nurses, Physician Consultants) whose duties are not otherwise reimbursable by MO HealthNet.
Part 3 Performance Incentive Payment Missouri will pay practices for 50 of the value of the reduction in total health care PMPM cost, including infrastructure PMPM payments described herein, for Health Homes attributed MO HealthNet patients.
Missouris Healthcare Homes Payment Methodology
  • Missouri Chronic Care Management rate is 75
  • Targeted Case Management or waiver service
    providers will be regularly included in the
    overall healthcare team and involved in
    development and performance of the person
    centered plan.
  • Actual costs of the portion of health home
    services performed by Targeted Case Management or
    waiver service providers will not be included in
    the CMHC health home PMPM payment.
  • Maryland Mental Heath Targeted Case Management
    rate is 105 per visit.
  • Maryland MCO medical management rate is 6.31
    PMPM (includes outreach, utilization management,
    disease management, case management, and quality
  • In developing a program, Maryland must determine
    which services are already covered by MCOs and
    TCM and which would be new under Chronic Health
    Homes because services may not be duplicative.

Missouris Healthcare Homes Providers Initial
  • Have a substantial percentage of its patients
    enrolled in Medicaid
  • Have strong, engaged leadership personally
    committed to and capable of leading the practice
    through the transformation process and sustaining
    transformed practice processes as demonstrated by
    through the application process and agreement to
    participate in learning activities.
  • Meet state requirements for patient empanelment
    (i.e., each patient receiving CMHC health home
    services must be assigned to a physician)
  • Meet the states minimum access requirements as
    follows Prior to implementation of health home
    service coverage, provide assurance of enhanced
    patient access to the health team, including the
    development of alternatives to face-to-face
    visits, such as telephone or email, 24 hours per
    day 7 days per week
  • Actively use MO HealthNets comprehensive
    electronic health record (EHR) to conduct care
    coordination and prescription monitoring for
    Medicaid participants
  • Utilize an interoperable patient registry to
    input annual metabolic screening results, track
    and measure care of individuals, automate care
    reminders, and produce exception reports for care

Missouris Healthcare Homes Providers Initial
Qualifications Continued
  1. Routinely use a behavioral pharmacy management
    system to determine problematic prescribing
  2. Conduct wellness interventions as indicated based
    on clients level of risk
  3. Complete status reports to document clients
    housing, legal, employment status education,
    custody etc.
  4. Agree to convene regular, ongoing and documented
    internal Health Home team meetings to plan and
    implement goals and objectives of practice
  5. Agree to participate in CMS and state-required
    evaluation activities
  6. Agree to develop required reports describing CMHC
    Health Home activities, efforts and progress in
    implementing Health Home services
  7. Maintain compliance with all of the terms and
    conditions as a CMHC Health Home provider or face
    termination as a provider of CMHC Health Home
    services and
  8. Present a proposed Health Home delivery model
    that the state determines to have a reasonable
    likelihood of being cost-effective.

Missouris Healthcare Homes Providers Ongoing
  • Within 3 months of Health Home service
    implementation, have developed a contract or MOU
    with regional hospital(s) or system(s) to ensure
    a formalized structure for transitional care
    planning, to include communication of inpatient
    admissions of Health Home participants, as well
    as maintain a mutual awareness and collaboration
    to identify individuals seeking ED services that
    might benefit from connection with a Health Home
    site, and in addition motivate hospital staff to
    notify the CMHC Primary Care Nurse Manager or
    staff of such opportunities. The state will
    assist in obtaining hospital/Health Home MOU if
  • Develop quality improvement plans to address gaps
    and opportunities for improvement identified
    during and after the application process
  • Demonstrate continuing development of fundamental
    medical home functionality at 6 months and 12
    months through an assessment process to be
    applied by the state - Demonstrate significant
    improvement on clinical indicators specified by
    and reported to the state
  • Provide a Health Home that demonstrates overall
    cost effectiveness and
  • Meet NCQA level 1 PCMH requirements as determined
    by a DMH review or submit an application for NCQA
    recognition by month 18 from the date at which
    supplemental payments commence OR meet equivalent
    recognition standards approved by the state as
    such standards are developed.

Missouris Healthcare Homes Healthcare Home Team
  • Primary Care Physician Consultant
  • Provides medical leadership.
  • Healthcare Home Directors 1 FTE/500 enrollees
  • Provide leadership in the implementation and
    coordination of Healthcare Home activities
  • Champions practice transformation based on
    Healthcare Home principles and
  • Develops and maintains working relationships with
    primary and specialty care providers, including
    inpatient facilities.
  • Nurse Care Managers 1 FTE/250 enrollees
  • Develop wellness and prevention initiatives,
    provide trainings, track required assessments,
    administrative support, etc.,
  • Administrative Support 1 FTE/500 enrollees
  • Referral tracking, training, data management,
    reporting, care coordination.

Missouris Healthcare Homes Evaluation
Measure Definition Source Data Source Benchmark Goal Gap Closing Goal
Quality Prescribing Psychiatric Medications- prescriptions flagged as potentially inconsistent with quality practices Missouri Claims gt10 Decrease by 5
All-cause 30-day readmission rate No Claims NCQAs most recently published 50th percentile regional rate for Medicaid managed care Decrease by 10
Preventable admissions per 1000 (i.e., Ambulatory Care-Sensitive Conditions (ACSC) admissions) No Claims NCQAs most recently published 50th percentile regional rate for Medicaid managed care Decrease by 10
ED visits per 1000 No Claims NCQAs most recently published 50th percentile regional rate for Medicaid managed care Decrease by 10
of hospitalized patients who have clinical, telephonic or face-to-face follow-up interaction with the care team within 2 days of discharge during the measurement month Missouri Claims monthly report 80 Increase by 25
Next Steps Deputy Secretary Renata
Additional Information
  • Health homes mailbox for any questions or
    comments -
  • 11/16/10 Health Homes State Medicaid Director
    Letter http//
  • 12/23/10 CMCS Informational Bulletin on Web-Based
    Submission Process for Health Home SPAs