grantee webinar april 2012.ppt€¦ · 4/13/2012 12 department of vermont health access community...
TRANSCRIPT
1A non-profit service and advocacy organization © 2011 National Council on Aging
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2A non-profit service and advocacy organization © 2011 National Council on Aging
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
4/13/2012 3
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
Department of Vermont Health Access
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Department of Vermont Health Access
What is the Blueprint ?
Department of Vermont Health Access
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Department of Vermont Health Access
• 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
4/13/2012 6
Department of Vermont Health Access
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
Department of Vermont Health Access
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Department of Vermont Health Access
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Department of Vermont Health Access
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
Department of Vermont Health Access
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Department of Vermont Health Access
Community Health Teams
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Department of Vermont Health Access
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
Department of Vermont Health Access
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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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Department of Vermont Health Access
Self-management Programs
Department of Vermont Health Access
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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)
Department of Vermont Health Access
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Department of Vermont Health Access
Payment Reforms
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Department of Vermont Health Access
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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Department of Vermont Health Access
Health Information Technology
Department of Vermont Health Access
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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
Department of Vermont Health Access
Evaluation and Reporting
Department of Vermont Health Access
Department of Vermont Health Access
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Department of Vermont Health Access
Data Sources & Evaluation
Central Clinical Registry
Multi-payer Claims Database
Chart Reviews
NCQA Scoring
Public Health Registries
Patient Provider Qualitative Assessment
Patient Experience
Department of Vermont Health Access
Learning Health System
Department of Vermont Health Access
Department of Vermont Health Access
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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
Department of Vermont Health Access
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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
Department of Vermont Health Access
Department of Vermont Health Access
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Department of Vermont Health Access
Patients Engaged & Empowered
Payment Reform
Seamless Services
Access to Real Time Data & Information
Generation of Useful
Knowledge
Culture of Change &
Transparency
Continuous Improvement
Department of Vermont Health Access
Community-based Self-management Programs
Department of Vermont Health Access
4/13/2012 30
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
4/13/2012 40
Funding
• Medicaid 1115 Waiver – Global Commitment
41A non-profit service and advocacy organization © 2011 National Council on Aging
Q&A
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