grantee webinar april 2012.ppt€¦ · 4/13/2012 12 department of vermont health access community...

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Vermont’s Success in Developing a Sustainable Infrastructure for CDSMP

Agenda

Learn about Vermont’s unique model and strong state partnerships that include the departments of disabilities/aging, health, and health access.• Jenney Samuelson, Assistant Director, Blueprint for Health, Department

of Vermont Health Access

Q&A – All

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Department of Vermont Health Access

Vermont’s Efforts to Develop a Sustainable Infrastructure for Self-management

Within Health Care Reform

Jenney Samuelson, MS MCHESAssistant Director

Vermont Blueprint for HealthDepartment of Vermont Health Access

[email protected]


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What is the Blueprint ?


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• The Blueprint program is an agent of change

• Guiding a transition from ‘Here’ to ‘There’

• ‘Here’ = high cost fragmented care

• ‘There’ = a foundation of high quality health services

o Improves healthcare and health services for individualso Improves the health of the populationo Improves control of healthcare costs

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Building A Foundation For The Future

• Advanced Primary Care Practices (PCMHs)

• Community Health Teams

• Community Based Self-management Programs

• Multi-insurer payment reforms

• Health Information Infrastructure

• Evaluation & Reporting Systems

• Learning Health System Activities


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Primary Care Practices

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• Multi-disciplinary quality improvement team(NCQA PCMH recognition)

• Seamless coordination of care(CHT development)

• Information technology (DocSite/VITL interface)

Blueprint Advanced Primary Care Practices


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Community Health Teams

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Community Health Teams• Multi-disciplinary support for PCMHs & their patients

• Work locally in communities and directly with practices

• Functionally integrated into the practice setting

• Team is scaled based on the # patients in the PCMHs they support

• Core resource that is readily available to patients based on need

• The ‘glue’ in a community system of health for the general population

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Health IT Framework

Evaluation Framework

Advanced Primary

Care

Hospitals

Public Health Programs & Services

Community Health TeamNurse Coordinator

Social WorkersNutrition Specialists

Community Health WorkersMedicaid Care Coordinators

Public Health Specialist

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 a 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

Healthier Living Workshops

13

Advanced Primary

Care

Advanced Primary

Care

Advanced Primary

Care


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Advanced PrimaryCare Practice

Community HealthTeams

Specialized & TargetedServices

HigherAcuity &

Complexity

LowerAcuity &

Complexity

Locus of Service & Support

Level of N

eed

Continuum of Health Services

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HigherAcuity &

Complexity

LowerAcuity &

Complexity

Locus of Service & Support

Level of N

eed

• Health Maintenance• Prevention• Access• Communication• Self Management Support• Guideline Based Care• Coordinate Referrals• Coordinate Assessments• Panel Management

• Specialty Care• Advanced Assessments• Advanced Treatments• Advanced Case Management• Social Services• Economic Services• Community Programs• Self Management Support• Public Health Programs

Advanced PrimaryCare Practice

Community HealthTeams

Specialized & TargetedServices

Continuum of Health Services - General

• Support Patients & Families• Support Practices• Coordinate Care• Coordinate Services• Referrals & Transitions• Case Management

o Medicaid Care Coordinatorso Senior Services Coordinators

• Self Management Support• Counseling• Population Management

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Estimated State Totals

82 Practices

365 Primary Care Providers FTEs

346,028 Patients

69 CHT Personnel

Blueprint Expansion, March 2012

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Self-management Programs


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Self-management Programs

• Healthier Living Workshops (Standford University Self-management)– Chronic Disease– Pain – Diabetes

• Tobacco Cessation– QuitNetwork– Quit In-person (groups; CHT)


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Payment Reforms

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MedicaidMedicareBlueCrossMVPCignaSelf Insured

Advanced Primary Care

NCQA StandardsPatient Centered CareAccessCommunicationGuideline Based CareUse of Health IT

Community Support

Community Health TeamsMCAID CCsSASH Teams

Fee for Service (Volume)

$ PPPM - NCQA Score

Specialized Services

HospitalsSpecialty CareMental Health ServicesSubstance Use ServicesFamily ServicesSocial ServicesEconomic ServicesLong Term CareNursing Homes

Payment Reform Delivery System ReformFinancing

Shared Costs

“Phase 1”

“Phase 2”

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Health Information Technology


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MedicalHome

Blueprint Integrated PilotsHealth Information Infrastructure

data warehouse

VITL HIE

Central Clinical Registry (DocSite)

Core data elements

Core data elements

Core dataelements

Core data elements

MedicalHome

Hospital(hosted EMR)

FQHC(hosted EMR)

Web

Acc

ess

Web

Access

CommunityHealth Team

Central Registry•Visit planners•Care coordination•Reporting

MedicalHome

MedicalHome

MedicalHome

MedicalHome EMR

MedicalHome EMR

MedicalHome

No EMR4/13/2012

MedicalHome

Core dataelements ADT


Evaluation and Reporting



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Data Sources & Evaluation

Central Clinical Registry

Multi-payer Claims Database

Chart Reviews

NCQA Scoring

Public Health Registries

Patient Provider Qualitative Assessment

Patient Experience


Learning Health System



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Dynamics & Infrastructure for a Learning Health System

Supportive Core Data

Dictionaries & Measure

Sets

Data Capture, EMR Templates,

Interfaces & HIE, Blueprint Registry,

Chart Review, MPCD, other

Evaluation, Reporting Systems, Analytics,

Simulations

Process Measures, Outcomes Measures, Models, Actionable

Knowledge

Collaborative Learning, Site

Level Facilitation & Coaching

Integrated health services model,

ongoing improvement &

refinement

Gui

ding

Leg

isla

tion

& P

olic

y

Fina

nanc

e&

Pay

men

t Ref

orm

s

Patient CenteredHealth Services

Esta

blis

hed

Gui

delin

e &

Mea

sure

s


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Learning Health System• In practice facilitation and support• Shared learning meetings for:

– facilitators– practices– project managers– CHT leaders– self-management coordinators



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Patients Engaged & Empowered

Payment Reform

Seamless Services

Access to Real Time Data & Information

Generation of Useful

Knowledge

Culture of Change &

Transparency

Continuous Improvement


Community-based Self-management Programs


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Integrated Into a Continuum of Services

• Primary care practices• Community health teams

– (core, extended, functional)• Local organizations and resources

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State-wide Infrastructure for Evidence Based Programs

• Intra-agency collaboration• Support to local implementation teams through the State

– Training and workforce development– Marketing support– Program evaluation– Learning health system

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CDSMP, DSMP, CPSMP

• Administered locally through the local Blueprint infrastructure (primarily hospitals)

• 14 grant funded regional coordinators• Generally co-located with other ‘wellness’ programs or ambulatory

care services such as tobacco cessation, diabetes education, asthma education

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Local Partnerships

Local Implementation Teams• Department of Health Districts• Agencies on Aging• Hospitals

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Training Workforce Development

• New leader training/Cross trainings– CDSMP: 5 trainings; 37 graduates– Diabetes: 2 trainings; 16 graduates– Pain: 1 training; 13 graduates

• Refreshers (every 2 years)– 3 refreshers; 37 participants

• Audits (every 2 years)

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2011 Healthier Living Workshops and Infrastructure

CharacteristicsNumbers

HLW ‐ General 43

HLW ‐ Diabetes 9

HLW ‐ Chronic Pain 8

HLW Leaders ‐ General 99

HLW Leaders ‐ Diabetes 27

HLW Leaders – Chronic Pain 15

HLW Master Trainers 6 (13)*

HLW T‐Trainers 1

HLW Regional Coordinators 14

*Master Trainers ‐ 6 Chronic Disease, 2 Pain, 2 Diabetes, 13 master trainer trained auditors

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Evaluation

• State coordinator manages a central database• Data analyst• Reports to regional coordinators annually• Future – flag participants in the all-payers claims database to get

information on changes in health care utilization

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Learning Health System/SM

• Quarterly regional coordinator calls• Annual in person meetings• Master trainer meetings

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Engaging Primary Care

• Help meet NCQA PCMH Standards• Panel management• Embed program in practice• Rolling admissions and referral process• Email provider on registration and completion• Train practice staff in CDSMP

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Retention

• Structure of grants to incent completers• Reminder calls• No show calls• Soup/meals• Incentives working local organizations

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Funding

• Medicaid 1115 Waiver – Global Commitment


Q&A

www.ncoa.org

grantee webinar april 2012.ppt€¦ · 4/13/2012 12 department of vermont health access community...

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