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

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A Close Look at Care Coordination within
Patient-Centered Medical Homes West Virginias
Experience

• Web Seminar
• May 9, 2013
• Follow this event on Twitter Hashtag AHRQIX

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What is the Health CareInnovations Exchange?

• Publicly accessible, searchable database of
  health policy and service delivery innovations
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• Learning and networking opportunities
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• Sign up at http//www.innovations.ahrq.gov under
  Stay Connected

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Innovations Exchange Web Event Series

• Archived Event Materials
• Available within two weeks under Events
  Podcasts at http//www.innovations.ahrq.gov
• Next Events
• Thursday, June 5, 2013 1-2 pm ET
• Building Health Information Exchanges to Support
  Accountable Care Organizations and Medical Homes
  Delawares Experience

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Todays Event Moderator

• James Becker, MD

Medicaid Medical Director, West Virginia Bureau
for Medical Services
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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

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What Are Our Health Challenges?

• Chronic diseases
• Mental health, substance abuse
• Aging population
• Poverty, unemployment
• Low educational achievement
• Lifestyle issues
• Health literacy issues

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Whats Working?

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

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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

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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, Alzheimers, congestive
  heart failure, chronic obstructive pulmonary
  disease
• SPAs broadly define care coordination, care
  managers and care coordinators

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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

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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
• Weve found no single credential or skill set
  that best identifies a care coordinator

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Care Coordination Models

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

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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..

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• Everyone likes care coordination, but were not
  sure how we should pay for it!

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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

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Respondent

• William Golden, MD

Medical Director, Arkansas Medicaid Enterprise
at Arkansas Department of Human Services
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Rural Challenges

• Workforce variation team, alternatives, access
• Practice infrastructure capitalization
• Socioeconomics, health literacy
• Perverse incentives

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Evolving Environment

• Workforce
• Practice ownership, management
• Health Information Technology

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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

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Quality Standards and Shared Savings
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Upside Only Gain-Sharing
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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

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Payment Initiative
Care Coordination Within Health Home
Service Episode
300 M Adult Developmental Disability
Expenditures
35 M Halo expenditures for adults1 (e.g.,
medical, behavioral)

• Ensure care provision is efficient and based on
  client needs
• Align resources provided with level of need
• Expand plan customization options for clients
• Minimize resources / time not focused on
  delivering client care

Initial phase 7,020 clients1

• Increased care coordination
• Integrate care across medical, behavioral,
  health
• Reduce unnecessary medical and behavioral health
  spending
• Promote wellness activities

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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 2010
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New Activities

• Provider report cards data supported change
• Health Information Technology (HIT) expansion
• Vendor options for care coordination

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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

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Unknowns Value, Pricing of New Services

• Avoid new economic silos
• Telemedicine
• Care coordination for whom, how intensive

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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

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Todays Event Moderator

• David Meyers, MD

Director of the Center for Primary Care,
Prevention, and Clinical Partnerships, AHRQ
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AHRQ Resources
PCMH.AHRQ.GOV
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PCMH Basics

• Defining the PCMH
• 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

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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

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Measuring Care Coordination

• AHRQ Care Coordination Measurement Atlas
• http//www.ahrq.gov/qual/careatlas/
• Review and Recommendations on the Best Tools for
  Accountability and Assessing Care Coordination
• http//www.ahrq.gov/research/findings/final-report
  s/pcpaccountability/index.html
• Caveat Patient and Family Surveys

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PCMH CAHPS

• Consumer Assessment of Healthcare Providers and
  Systems (CAHPS) program https//www.cahps.ahrq.gov
  /Surveys-Guidance/CG/PCMH.aspx
• 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

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Questions?

• Click me to get QA box to appear

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The Innovations Exchange

• Visit our Web site
• http//www.innovations.ahrq.gov/
• Follow us on Twitter
• _at_AHRQIX
• Send us email
• info_at_innovations.ahrq.gov

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