community health teams the vermont experience lisa dulsky watkins, md associate director vermont...
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Community Health Teams
The Vermont Experience
Lisa Dulsky Watkins, MDAssociate Director
Vermont Blueprint for [email protected]
Department of Vermont Health Access
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Principles of Team-Based Care
Shared Goals
Clear Roles
Mutual Trust
Effective Communication
Measureable Processes and Outcomes
Mitchell et al, Core Principles & values of effective team-based health care, 2012 (Discussion
Paper, Institute of Medicine, Washington, DC. www.iom.edu222
Department of Vermont Health Access
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Team-Based Care
“Team-based health care is the provision of healthservices to individuals, families, and/or their
communities by at least two health providers who work collaboratively with patients and their caregivers
– to the extent preferred by each patient – to accomplish shared goals
within and across settings to achieve coordinated, high-quality care.”
Naylor et al, Inter-professional team-based primary care for chronically ill adults: State of the Science, 2010
Department of Vermont Health Access
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Department of Vermont Health Access
Vermont’s Executive Branch and Legislature Consistent Support for Health Reform
2003 Blueprint launched as Governor’s initiative
2005 Implementation of Wagner’s Chronic Care Model
2005 Medicaid Global Commitment (Section 1115) Waiver
2006 Blueprint codified as part of sweeping reform legislation (Act 191)
2007 Blueprint leadership and pilots established (Act 71)
2008 Community Health Team structure and insurer mandate (Act 204)
2010 Statewide Blueprint Expansion outlined (Act 128)
2011 Planning for “Single Payer” (Act 48)
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Insurers
•Community Health Teams•Funded by all insurers•Intent is to minimize barriers
•$35,000/2000 active pts./yr.•Scaled based on population
•Medicaid•Commercial Insurers•Medicare
•SASH Teams•Funded by Medicare (CMMI Demonstration Project)
•$70,000/100 participants/yr.•Scaled based on # panels
•Addictions Teams•Funded by Medicaid Health Home (potential 90/10 federal match)
•2 FTEs/100 suboxone pts.•Scaled based on # pts. in prescribing practices
Blueprint Payment Reforms
Payments to Practices1) FFS2) PBPM Enhanced Payments
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Health IT Framework
Evaluation Framework
Primary Care
Practice
Hospitals
Public Health Programs & Services
Core Community Health TeamNurse Coordinators
Social WorkersNutrition Specialists
Community Health WorkersPublic Health Specialists
Extended Community Health TeamMedicaid Care Coordinators
Medicare Teams based in Housing HubsAddiction Teams
Specialty Care & Disease Management
Programs
A foundation of medical homes and community health teams that can support coordinated care and linkages with a broad range of services
Multi-insurer payment reform that supports this foundation of medical homes and community health teams
A health information infrastructure that includes EMRs, hospital data sources, a health information exchange network, and a centralized registry
An evaluation infrastructure that uses routinely collected data to support services, guide quality improvement, and determine program impact
Mental Health & Substance Abuse
Programs
Social, Economic, & Community Services
Self Management Workshops
Primary Care
Practice
Primary Care
Practice
Primary Care
Practice
Multi-Insurer Payment Reform Framework
HVVo Visiting
Nurse/Home Health Agency
Health Service Area Architecture
TIMELINEPatient Centered Medical Homes and
Community Health Team Staffing in Vermont
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VermontHealth
InformationExchange
(VITL)
Central Clinical Registry and
Integrated Health Record
(Covisint DocSite)
Core data elements
Core data elements Core data elements
Hosted EMR
EMR
CommunityHealth Team
Independent Primary Care
Practices
Primary Care Practices
No EMR
Organization-owned
Primary Care Practices
Core data elements
Tobacco Cessation
Counselors
Senior Support Services
Vermont Health Information Technology Infrastructure
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CHT Identification of High-Risk Patients
• Practice panel management, outreach and referrals
• Referrals from other health care and community service organizations • Risk stratification and utilization data from Medicare
• Risk stratification and utilization data from Medicaid • Data from commercial insurers
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CHT Example
Providers refer via the EHR (PRISM). CHT provides in person 1:1 support, in groups or by phone, 3-6 visits, commonly 4
interactions. CHT helps patients set realistic goals and timelines utilizing motivational
interviewing, action planning and short term goal setting CHT focuses on achievable realistic outcomes with our patients, addressing barriers
that may interfere with success. Short term case management, most often provided by our medical social worker. CHT patients can re-engage with the team as necessary after graduation
Services include: Health coaching around nutrition,
exercise and stress management Basic Diabetes Education Medication Management Behavioral/Mental Health Connection to community and
financial resources
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0%
20%
40%
60%
How Satisfied Are you with the Services You Can Offer To Your Patients by Referral ?
% Satisfied & Very Satisfied -Pilot Site 50% 17% 33% 17% 29%
% Satisfied & Very Satisfied - Other FAHC
Primary Care Practices
38% 19% 13% 6% 19%
Nutrition
Counseling
Exercise
Counseling
Stimulating
Behavior Change
Patient
Education Overall
CHT Example
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0%
20%
40%
60%
80%
100%
How Satisfied Are you with the Services You Can Offer To Your Patients Within Your Office Team ?
% Satisfied & Very Satisfied - Pilot Site 100% 67% 50% 50% 67%
% Satisfied & Very Satisfied - Other FAHC
Primary Care Practices
6% 6% 6% 6% 6%
Nutrition
Counseling
Exercise
Counseling
Stimulating
Behavior Change
Patient Education
MaterialsOverall
CHT Example
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CHT Example
Clinical Outcomes
Patients were tracked by the multidisciplinary CHT using a common database and assessed 6 months after “graduation” (data collected between March 2009 and August 2012)
• 59% of patients referred to the CHT for diabetes-related issues had sustained improvement in BMI (n =44) and 67% of patients had sustained improvement in HbA1c (n=87)
• 49% (n=118) of patients referred to the CHT for exercise and nutrition issues had a sustained improvement in their BMI and 31.5% (n=117) had a sustained improvement in their LDL (average decrease of 24mg/dL)
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CHT Challenges
• Documentation• Consistency• Double data entry• Reporting to funders (“ROI”)
• Communication• Patient/consumer engagement• General public awareness