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M INN E S OT A A C CO UN T AB L E H E A LT H M O D E L – S I M M IN N ES O TA SIM ACH Resources / Literature Review Below is a summary of current literature and references on Community Care Team (CCT) and Accountable Communities for Health (ACH) arrangements. Information was prepared by Atsushi Sorita, Preventive Medicine Fellow at Mayo Clinic, one of three CCT pilots. Contents Minnesota Community Care Teams ........................................................................................................... 1 Community Care of North Carolina (CCNC) ................................................................................................ 2 Vermont Community Care Teams, Blueprint for Health ....................................................................... 3 Maryland................................................................................................................................................... 3 Agency for Healthcare Research and Quality (AHRQ) ........................................................................... 5 Centers for Medicare and Medicaid Services (CMS) ........................................................................ 7 Commonwealth Fund Resources ......................................................................................................... 9 Association of State and Territorial Health Officials (ASTHO) ............................................................ 10 US Preventive Services Task Force (USPSTF) ................................................................................. 12 Statewide Health Improvement Program/Community Transformation Grant (SHIP/CTG) 12 Theoretical framework for PC-PH collaboration ........................................................................... 12 Minnesota Community Care Teams Since 2011, three Community Care Teams (Essentia Ely, Mayo Clinic Rochester, and HCMC Brooklyn Park) along with Hennepin Health have been working on building successful models for integrated services between health care, public health, behavioral health, social services, and other community partners. The Community Care Teams (CCT) have developed new community partnerships that focus on prioritized community health needs and service integration to address gaps in care through referral, transitions management, and implementation of new practice guidelines. Lessons learned through the development of and the on-going support of CCT was used as the basis for the development of Accountable Communities of Health. Vanderboom, C. E., Holland, D. E., Lohse, C. M., Targonski, P. V., & Madigan, E. A. (2013). Enhancing Patient-Centered Care: Pilot Study Results of a Community Care Team Intervention. West J Nurs Res. doi: 10.1177/0193945913490841 Enhancing patient-centered care: pilot study... [West J Nurs Res. 2014] PubMed - NCBI Information: www.mn.gov/sim Contact: [email protected] Page 2 of 13 Community Care of North Carolina (CCNC) https://www.communitycarenc.org/ “Community Care of North Carolina: Improving Care Through Community Health Networks”, Annals of Family Medicine, 2008 http://www.annfammed.org/content/6/4/361.long - The program is an innovative effort organized and operated by practicing community physicians - CCNC was a grassroots response by practicing physicians, community health care leaders, and state policy makers - In partnership with hospitals, health departments, and departments of social services, these community networks have improved quality and reduced cost over the past 25 years. - The CCNC program has created community health networks organized and operated by community physicians, hospitals, health departments, and departments of social services. - Each network employs a full-time program director, a part-time medical director, and a team of case managers - Each network has a steering committee and medical management committee - A statewide infrastructure, which helps to coordinate and support the 14 individual networks provides direct financial assistance in proportion to the number of patients in the network - Key functions; Linking Patients to a Medical Home, Engaging Practices in Quality Improvement Efforts, Case Managing High-Risk Patients, Planning Interventions and Measuring Success, Providing Statewide Structure With Regional Control o Each CCNC patient is linked to a medical home o Community partners, such as local hospitals, health departments, and county health departments and county departments of social services, are integral members of each network, so that the CCNC medical practices are linked more strongly to the community o By joining a network, the practices gain access to a team of case managers who work with all patients in a given network. A single practice may share a case manager with several other small practices. The ratio of case managers to patients is generally high (about 1:4,000). The group of patients in need of case management is identified primarily through claims data o Case management has been most successful when case managers and clinicians regularly share treatment plans - THE CREATION OF CCNC: KEY FACTORS o Started Small o Strong Physician Leadership From Outset o Strong Office of Rural Health o Best Practices From Pilot Programs o Created During Crisis Page 3 of 13 Vermont Community Care Teams, Blueprint for Health http://hcr.vermont.gov/blueprint http://www.commonwealthfund.org/Newsletters/States-in-Action/2009/July/June-July2009/Snapshots/Vermont-Community-Care-Teams-and-Health-IT.aspx - 2013 Annual Report http://hcr.vermont.gov/sites/hcr/files/Blueprint/Blueprint%20for%20Health%202012%2 0Annual%20Report%20%2002_14_13_FINAL.pdf - “Vermont’s Blueprint For Medical Homes, Community Health Teams, And Better Health At Lower Cost”, Health Affairs, 2011 http://content.healthaffairs.org/content/30/3/383.full - Launched in 2003 and codified into law in 2006 - All citizens in the state will be able to participate - Community health teams work with primary care providers to assess patients’ needs, coordinate community-based support services, and provide multidisciplinary care for a general population. A web-based central health registry will capture all patient data. - Community health teams create a crucial link between primary care and community-based prevention of chronic disease - Each community health team is staffed by five fulltime-equivalent employees and serves a population of approximately 20,000. The composition of any particular community health team is determined locally, with input from area practices and hospitals, but teams typically include nurse coordinators, behavioral health counselors, and social workers. - They offer individual care coordination, health and wellness coaching, and behavioral health counseling, and they connect patients to social and economic support services. In addition, they perform community outreach to support public health initiatives. - The behavioral health counselor also works in primary care practices. The fact that the counselors work in a familiar setting lessens the reluctance some patients have to seek mental health treatment. - Primary care practices taking part in the pilots continue to receive fee-for-service payments from insurers and Medicaid. In addition, they receive a per person per month payment based on their National Committee for Quality Assurance score against patient-centered medical home standards. - The community health team’s cost is shared among Vermont’s three major commercial insurers as well as Medicaid. Maryland - Community-Integrated Medical Home model http://hsia.dhmh.maryland.gov/Documents/CIMH%20Project%20Narrative.pdf http://hsia.dhmh.maryland.gov/SiteAssets/SitePages/payer-provider/SIM%205-913%20Slides.pdf o The four pillars of this vision are (1) primary care, (2) community health, (3) strategic use of data, and (4) workforce development Page 4 of 13 Page 5 of 13 - Community Health Partnership in Baltimore http://patientadherence.com/wp-content/uploads/2012/09/A-Qualitative-Evaluation-of-aCitywide-Community-Health-Partnership-Program.pdf o The CHP utilizes a community health liaison (CHL) and a community health action team (CHAT) consisting of community health leaders who are hands-on activists and health care workers who coordinate activities and provide guidance for the CHP Agency for Healthcare Research and Quality (AHRQ) http://www.innovations.ahrq.gov/linkingClinicalPractices.aspx http://www.ahrq.gov/professionals/prevention-chronic-care/improve/community/ - At the 2010 Summit, stakeholders identified strategies to support local efforts to develop PCPH/community linkages for prevention, and recommended the development of metrics to support related research http://www.innovations.ahrq.gov/LinkagesReportTOC.aspx o The linkages fell into several categories: (1) referral process, (2) provision of training and resources to improve medical provider practices, (3) clinical partner referral to health resources, (4) clinical partner volunteering at community programs, and (5) other. o Individual case analyses and cross-case analyses were conducted. Cross-case analyses yielded further understanding of how linkages are developed and implemented and how they contribute to delivery of clinical preventive services in the community. In particular, the case studies revealed organizational, community, provider, and intervention characteristics that serve as facilitators to the linkages. o A wide variety of clinical and community partners can be engaged in these linkages; key facilitators of developing linkages have to do with finding a compatible organizational partner. Page 6 of 13 - The Clinical-Community Relationships Measures (CCRM) project, a collaborative effort to explore how to define, measure, and evaluate programs that support the delivery of clinical preventive services through clinical-community relationships. - CCRM Atlas http://www.innovations.ahrq.gov/content.aspx?id=3879 http://www.ahrq.gov/professionals/prevention-chronic-care/resources/clinicalcommunity-relationships-measures-atlas/index.html o The CCRM Atlas focuses on a subset of care coordination between clinics and community-based resources that are not typically considered health care organizations. o Structure, Process, and Outcome domain categories o Elements (clinic/clinician, patient, community resource) and Relationships (between elements) measurement domains o Based on socioecological model and expanded chronic care model - Clinical–Community Relationships Evaluation Roadmap http://www.innovations.ahrq.gov/content.aspx?id=3973 http://www.ahrq.gov/professionals/prevention-chronic-care/resources/clinicalcommunity-relationships-eval-roadmap/index.html# - Care Coordination Atlas http://www.ahrq.gov/legacy/qual/careatlas/careatlas.pdf Page 7 of 13 Centers for Medicare and Medicaid Services (CMS) - Innovation Center http://innovation.cms.gov/initiatives/index.html - Health Care Innovation Awards o Funding up to $1 billion in awards to organizations that are implementing the most compelling new ideas to deliver better health, improved care and lower costs to people enrolled in Medicare, Medicaid and Children's Health Insurance Program (CHIP) o As of November 2013, grantees of the 2nd round are being selected o Award project profiles http://innovation.cms.gov/Files/x/HCIA-Project-Profiles.pdf Page 8 of 13 - Medicare Coordinated Care Demonstration (Ended in 2007) http://innovation.cms.gov/initiatives/Medicare-Coordinated-Care/ o Evaluation summary http://innovation.cms.gov/Files/x/Evaluation-of-Medicare-Coordinated-Care.pdf o Tested whether care coordination programs can be applied in Medicare fee-forservice settings o Few evidence that the demonstration resulted in improving patient outcomes - Community-based Care Transitions Program http://innovation.cms.gov/initiatives/CCTP/ o Tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries o Community-based organizations (CBOs) will use care transition services to effectively manage Medicare patients' transitions o The CBOs will be paid an all-inclusive rate per eligible discharge based on the cost of care transition services provided at the patient level and of implementing systemic changes at the hospital level - Multi-Payer Advanced Primary Care Practice Demonstration http://innovation.cms.gov/initiatives/Multi-Payer-Advanced-Primary-Care-Practice/ o Participating States; Maine, Vermont, New York, Rhode Island, Pennsylvania, North Carolina, Michigan, and Minnesota. o The demonstration program will pay a monthly care management fee for beneficiaries receiving primary care from advanced primary care (APC) practices. o The care management fee is intended to cover care coordination, improved access, patient education and other services to support chronically ill patients. o Each participating State will have mechanisms to offer APC practices community support and linkages to State health promotion and disease prevention initiatives. - Comprehensive Primary Care Initiative http://innovation.cms.gov/initiatives/comprehensive-primary-care-initiative/ o A multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care o Primary care practices that choose to participate in this initiative will be given resources to better coordinate primary care for their Medicare patients o Practices were selected based on their use of health IT, ability to demonstrate recognition of advanced primary care delivery by accreditation bodies, service to patients covered by participating payers, participation in practice transformation and improvement activities, and diversity of geography, practice size and ownership structure. Page 9 of 13 - FQHC Advanced Primary Care Practice Demonstration http://innovation.cms.gov/initiatives/fqhcs/ o Show how the patient-centered medical home model can improve quality of care, promote better health, and lower costs - Independence at Home Demonstration http://innovation.cms.gov/initiatives/independence-at-home/ o Work with medical practices to test the effectiveness of delivering comprehensive primary care services at home o Selected primary care practices will provide home-based primary care to targeted chronically ill beneficiaries for a three-year period Commonwealth Fund Resources - Integration of Mental and Medical Health Care, Missouri http://www.commonwealthfund.org/Innovations/State-Profiles/2011/Jan/Missouri.aspx o Primary Care Nurse Liaisons and Community Mental Health Case Managers o Building Bridges Between Medicaid and Mental Health Departments - Assessing and Addressing Legal Barriers to the Clinical Integration of Community Health Centers and Other Community Providers http://www.commonwealthfund.org/Publications/Fund-Reports/2011/Jul/ClinicalIntegration.aspx - Care Management for Medicaid Enrollees Through Community Health Teams http://www.commonwealthfund.org/Publications/Fund-Reports/2013/May/CareManagement.aspx o The report focuses on eight states—Alabama, Maine, Minnesota, Montana, New York, North Carolina, Oklahoma, and Vermont—that provide funding in support of multidisciplinary community health teams that are shared among multiple practices. o Core characteristics of the eight programs multidisciplinary care teams that coordinate services, promote self-management, and help manage medications sustained, continuous relationships between patients and team staff that are established and cultivated through regular face-to-face contact mechanisms to routinely send and receive information about patients between practices and care teams whole-person care of patients identified as high-risk, high-need, or high-cost Page 10 of 13 a focus on transitions in care, especially between hospital and home team members who routinely connect patients with relevant community-based resources enhanced reimbursement for primary care practices that collaborate with teams o A hallmark of the community health team is the early and ongoing engagement of primary care providers throughout program development and implementation o Expectations for community health teams team functions and composition; target population identification; patient care; linkages with hospitals; electronic data tracking; practice education, including helping primary care practices meet medical home standards and quality improvement standards o Data on the effectiveness of community health teams are very limited; with the exception of Community Care of North Carolina. State programs have been in operation for less than four years and generally are in the early stages of implementation Association of State and Territorial Health Officials (ASTHO) - - Primary Care and Public Health Integration http://www.astho.org/Programs/Access/Primary-Care-and-Public-Health-Integration/ http://www.astho.org/PCPHCollaborative/Strategic-Map-Info/ http://www.astho.org/pcph-strategic-map/identify-what-works/ http://www.astho.org/pcph-strategic-map/create-compelling-cases/ Provides comprehensive resource lists and success stories Page 11 of 13 National Governors Association - Strategies for States to Encourage and Fund Community Care Teams http://www.nga.org/cms/home/nga-center-for-best-practices/center-publications/pagehealth-publications/col2-content/main-content-list/strategies-for-states-to-encoura.html Page 12 of 13 - Strategies that states can use to put such sustainable financing in place, either directly or indirectly, include the following: o Include the formation of community care teams in the specifications and funding of medical or health homes to take advantage of the enhanced federal Medicaid financing of health homes o Adopt payment policies to reimburse for community care services, such as community health workers, that offer incentives for the provision of such services under the states’ Medicaid and CHIP programs o Include the provision of community care team services as a specification for directing contracting arrangements with provider delivery systems, such as ACOs. Provide for advanced payment to these systems to develop care teams o Include the provision of community care team services in Managed Care Organization (MCO) contract specifications for certain Medicaid populations o Encourage the funding of community care team programs by private foundations, charitable organizations and counties through grant making US Preventive Services Task Force (USPSTF) - Integrating Evidence-Based Clinical and Community Strategies to Improve Health http://www.uspreventiveservicestaskforce.org/uspstf07/methods/tfmethods.htm Statewide Health Improvement Program/Community Transformation Grant (SHIP/CTG) - - The Community Health Educator Referral Liaison Program, CDC http://www.innovations.ahrq.gov/content.aspx?id=2244 SHIP Implementation Guides, Health Care (Clinical-Community Linkage) in the Strategy Implementation Guide section http://www.health.state.mn.us/healthreform/ship/Implementation.html Healthy Northland (CTG Grantee), Clinical Care http://www.healthynorthland.org/pages/default.aspx?id=130 Theoretical framework for PC-PH collaboration 1. Guide for medicine and public health collaboration http://books.google.com/books/about/Pocket_guide_to_cases_of_Medicine_public.html?id=B T9rAAAAMAAJ Described six types of collaboration (Synergy I-VI) 2. The Community Oriented Primary Care (COPC) Model Community Health Worker Model and Family Health Strategy in Brazil http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3681592/ Page 13 of 13 - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3477957/#!po=34.6154 http://www.radcliffehealth.com/ljpc/article/integrating-primary-care-and-public-healthlearning-brazilian-way Lay community health workers covering all households and communicate with primary care providers and public health systems - Community Care Network Demonstration Project http://mcr.sagepub.com/content/60/4_suppl/5S.long http://www.rwjf.org/reports/grr/029519.htm - Community Oriented Primary Care http://www.gru.edu/mcg/fmfacdev/fd_copc.php - Safety Net Medical Home Initiative http://www.safetynetmedicalhome.org/about-initiative - Infrastructure for Maintaining Primary Care Transformation (IMPaCT) http://www.ahrq.gov/research/findings/factsheets/primary/impactaw/index.html - Primary and Behavioral Health Care Integration Program (PBHCI) http://www.integration.samhsa.gov/about-us/pbhci - Clinical-Community Linkages to Prevent Diabetes (CC-Link) study http://www.ncbi.nlm.nih.gov/pubmed/20484325 Community-based partnership (full paper not accessible) http://www.ncbi.nlm.nih.gov/pubmed/22608875 Cambridge Health Alliance http://content.healthaffairs.org/content/30/3/435.full - Home visits by a nurse for asthma children - Funded by the Institute for Community Health http://icommunityhealth.org/ San Diego Prevention Research Center http://www.ncbi.nlm.nih.gov/pubmed/23355255 Partnership with universities, FQHCs, and community advisory board - Target Spanish population