Download State Innovation Models (SIM) Award: Community Integrated Medical Home

State Innovation Models (SIM) Award:
Community Integrated Medical Home
A Framework for Health Care Reform
Raquel E. Samson, MPH
Deputy Director Health Systems and Infrastructure
Maryland Department of Health & Mental Hygiene
DHMH Health System and Infrastructure
Administration Organizational Structure
DHMH Public Health
Health System and
Infrastructures Administration
Primary Care
Access and
Workforce
Population
Health and
Quality
School
Health
Local Health
Department
Core Funding
3
The Affordable Care Act:
Better Health, Better Care, Lower Costs
Better Health
Prevention Fund and
National Strategy
Better Care
Delivery System Reforms
Community
Transformation Grants
Value-Based Purchasing
Tobacco
Shared Savings
Partnership for Patients
Lower Costs
Rate Review
Medical Loss Ratio
Delivery System Reforms
Obesity
Lydia L. Ogden, PhD, MPP, CDC Director, Office of Health Reform - September 13, 2011
The Logic of Health Reform
Improved
Health
Outcomes
Expanded
Insurance
Coverage
• Conditions are
amenable to
care
• Social
determinants of
health
addressed
High Value
Care
• Medicaid &
CHIP
• Exchanges
• High Quality
• Delivered
Efficiently
Expanded
Access to
Care
• Emphasis on
primary care
• Assumes
supply
sufficient to
meet demand
Effective
Care
• In and out of
clinical
environment
• Patient selfefficacy,
health
literacy,
adherence
Reduced
Health
Spending
• Population
health and
spending are
the sum of
individual
health and
spending
Lydia L. Ogden, PhD, MPP, CDC Director, Office of Health Reform - September 13, 2011
Social Determinants of Health
Integration of public health and the medical delivery system is required if
our goal is to improve health of the individual and population.
Delivering Care in the Appropriate Setting
Higher Cost
Lower Cost
State Innovation Models (SIM)
Grant Solicitation
• Released by Center for Medicare & Medicaid Innovation
(CMMI) at CMS to develop, implement, and test new health
care payment and service delivery models at the state-level
• Maryland received “Model Design” award
– $2.37 million
– 6-month planning grant (April 1 – August 31, 2013)
– Opportunity to apply for “Model Testing” award for up to $60 million
to fund implementation over a 4 year period.
• “State Innovation Plan” that articulates the Community
Integrated Medical Home (CIMH) model in detail and basis
for Model Testing application to CMMI
Community-Integrated Medical Home
(CIMH)
• Integration of a multi-payer medical home model with
community health resources is to improve health care
quality, experience and to lower cost.
• 4 pillars:
1)
2)
3)
4)
Primary care
Community health
Strategic use of new data
Workforce development
• CIMH is a framework with certain programmatic standards
that allows for innovations across payers
Community-Integrated Medical Home
Local Health Improvement Coalition (LHIC)
Engagement Process
• Complement medical care by linking high-need patients
with wrap-around community-based health services
• Capacity of LHICs will be strengthened
• Recommend Community Health Worker role
• Use new data and mapping resources to “hot-spot” high
utilizers and bring them into CIMH
New Data Resources
• Chesapeake Regional Information System for our Patients
(CRISP) State Wide Health Information Exchange
developing mapping tools for “hot-spotting”
• DHMH will expand Virtual Data Unit
• Maryland Health Care Commission to assess and plan expansion
of All-Payer Claims Database (APCD)
Sample Hot-Spotting Map CRISP
Workforce Development and CIMH
Readiness
• Community Health Worker development
– Inventory of training programs and CHW models
– Identify best practices for integration of CHW into medical
practices and broader health care system
– Will present findings at LHIC stakeholder engagement process
• Technical assistance and CIMH readiness
–
–
–
–
Identify various ongoing TA and develop recommendation for streamlining
Convene TA providers and chart path forward
Identify and describe quality improvement efforts in local communities
Assist in scaling up of promising QI models
Population Health Improvement at All
Levels of Health Need
A
Secondary Prevention
and Effective Care
Coordination – Aim for
80% PCP participation in
medical home (currently
at 50%)--including a new
state-certified PCMH--to
cover 80% of
Marylanders. Enhanced
community-based
preventive interventions
in collaboration with
PCMH
super
utilizers
chronically ill
& at risk of
becoming
super utilizer
B
“Hot Spotting” –
Deploying effective
complementary
community-based supports
that “wrap around” the
primary care medical
home; patient assessment
determines range of
services offered
C
chronically ill but
under control
healthy
6 Million Marylanders
Promoting and Maintaining
Health through the Built
Environment, Structured
Choice & Effective Primary
Prevention – Aim for 80%
uptake of USPSTF grade A/B
preventive services. Make the
healthy choice the easy choice
by creating defaults through
effective town planning and
other behavioral economic
14
approaches.
B
“Hot Spots” Designing Community
Intervention Models for Maryland
overlap
– “super-utilizers” (needs further
operational definition)
– chronically ill at higher-risk
super
utilizers
• Assess, understand, and care for the
whole person, addressing all types of
risk to health
– Customize intervention plan based on
assessment and participant needs,
preferences, and values
– Mindset is longitudinal not episodic
chronically ill at
risk of becoming
super utilizer
Greatest ROI Potential
• Best return on investment (ROI)
opportunities appears to be among
chronically ill and
under control
healthy
DRAFT
Roles/Responsibilities for Care Managers &
Community Health Professionals
Community Health Team
PCMH with office-based care manager(s)
Community
Team
Leader +
CHWs
CM
PCMH
Community-Clinical Integration
PCMH without office-based care manager(s)
Community
Team Leader +
CHWs
PCMH
CM
16
Eight-Component Model of Coordinated
School Health
Comprehensive
School
Health
Education
Family &
Community
Involvement
Mental health issues
Asthma
Physical
Education
Diabetes
Violence/bullying
School-site
Health
Promotion for
Staff
School
Health
Services
Teen pregnancy
Academic
achievement
Healthy
School
Environment
Nutrition
Services
Counseling,
Psychological &
Social Services
Source: ASTHO: Making the Connection
www.thesociety.org
Wellness policies
HIV prevention
ETC!
Community-Integrated Medical Home
Example: Pediatric Asthma
HOSPTIAL
UTILIZATION DATA
(CRISP)
Community Health Team
• Environmental assessment
• Individualized asthma
education
• Evidence based intervention
• Support/Implement care plan
• Support social service referrals
• Accompany to appointments
SBHC and/or School Nurse
•
•
•
•
•
Prevention/Asthma education
Ongoing nursing assessments
Develop/Implement care plan
Treatment
Academic follow-up
PCP
•
•
•
•
Assessment/Diagnose
Treatment/Medications
Care Plan
Care coordination
Specialist
• Diagnose/Treatment
• Care Plan/follow-up
• Prescribe medication
Community-Integrated Medical Home
School
Health
Contacts
Karen Matsuoka, PhD
Director, Health Systems and Infrastructure Administration
[email protected]
Raquel Samson, MPH
Deputy Director, Health Systems and Infrastructure Administration
Director, Office of Primary Care Access
[email protected]
Angela Wakhweya, MD, MSc
Director, Office of School Health
[email protected]
Cheryl De Pinto, MD, MPH
Medical Director, Office of School Health
[email protected]