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Session #A3bFriday, October 11, 2013

Health Homes: A Holistic Approach to Service Delivery

David A. Johnson, MSW, ACSW

Collaborative Family Healthcare Association 15th Annual ConferenceOctober 10-12, 2013 Broomfield, Colorado U.S.A.

Faculty Disclosure

I currently have the following relevant financial relationships (in any amount) during the past 12 months:

Employed by Amerigroup/WellPoint, companies providing programs and services for persons enrolled in Medicaid and/or Medicare

Objectives

Define health homes in comparison and contrast to patient centered medical homes

Describe rational for health homes as a disruptive innovation in health service delivery system

Identify health home models and discuss their advantages and disadvantages considering such factors as clinical and financial implications, patient and provider pretences and orientation to service delivery

Learning Assessment

Audience Question & Answer

Learning Assessment

Audience Question & Answer

Current Health Home Activities

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Outline

Health HomeDevelopment

OverviewHealth HomeModels

What is a home

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Health Homes? Home Health? Patient Centered Medical Home?

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“If We Build It They Will Come”• Who is the person requesting health

services?• What is being requested? What is it that

this person wants when seeking health services?

• What is his or her prior experience?• What is the person’s understanding of

health services? • Where is the person seeking health

services supposed to go?• How does the person know what it is he

or she is supposed to do to address health conditions?

• Is the health services delivery system “familiar, safe, secure, comfortable, and in harmony with the person’s surroundings”?

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Real Story

Chronic Medical Conditions

• Among individuals enrolled in Medicare and Medicaid 62 percent live with two or more chronic medical conditions; 22 percent experience five or more chronic medical conditions (2009 Medicare data)

• In a population of 1 million, Miller (2012) estimates that of 13 chronic conditions with co-occurring behavioral health conditions the health care cost differential is $665 million more between individuals with and without co-morbidity1

• CMS estimates 45 percent of dual-eligible hospitalizations could have been avoided in 2005 if care had been better coordinated2 11

1. Miller, B. (2012) SHAPE, Sustaining Integrated Care. 2. Cassidy, A, et al. (2012) Care for Dual Eligibles. Efforts are afoot to improve care and lower costs for roughly 9 million people enrolled in both Medicare and Medicaid. Health Policy Brief, Health

Affairs, Robert Wood Johnson Foundation.

What Is the Problem?• Individuals with chronic conditions that are poorly

managed and controlled resulted in having premature mortality and higher costs for more intensive treatment

• Factors– Self-care is poor

» Lack resources» Lack knowledge» Lack motivation

– Health delivery system is fragmented» Lack communication between health service providers» Lack focus on the long-term health needs of individuals; structure of the delivery

system oriented to defining a problem and a solution—acute episodic care model» Lack a consumer-focused structure (office hours, engagement and education of

individual) » Lack a financial model to promote collaboration and a long-term view of individual’s

health

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Point of View• Health homes are focused on individuals with multiple co-

occurring chronic conditions or a severe mental illness• A health home represents collaborative and integrated

health services addressing physical and behavioral health issues/conditions inclusive of community resources and supports, as well as long-term services and supports

• Service delivery model may include a primary physician clinic, a Community Mental Health Center, a Community Health Clinic (FQHC/FQHC look-a-like) or other community-based health services delivery organizations

• Preferred Model: An Managed Care Organization (MCO) provides end-to-end care coordination in collaborating with a health home lead organization that represents a point-of-service with co-located physical, behavioral health services, as well as a co-located care manager

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A health home addresses physical and mental health issues and conditions…

coordinating with community supports and services

What does a Health Home Address?

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Premise for Health Homes• Mind and body are connected• Team care is better care• Engagement and self care• Coordination, collaboration, continuity enhance health

services• Mobilizing and coordinating primary medical services,

specialists, behavioral health, and long-term services and supports increases efficiencies and improves patient outcomes

• Outcomes– Increases health status and quality of life– Reduces premature mortality– Enhances service quality– Reduces Hospital Inpatient admits/length of stays– Reduces Emergency Department utilization– Reduces redundancy in tests and procedures– Reduces costs

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Current Health Home Activities

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Outline

Health HomeModels

Health HomeDevelopment

Overview

Patient-Centered Medical Homesand Health Homes• PCMH seeks to strengthen the physician-patient

relationship by replacing episodic care based on illnesses and an individual’s complaints with coordinated care for all life stages (acute, chronic, preventive and end-of-life) and establish a long-term therapeutic relationship

• The physician-led health team is responsible for coordinating all of the individual’s health service needs and arranges for appropriate services with other qualified physicians and support services

• Joint principles of PCMH– Personal physician– Physician directed medical practice– Whole person orientation– Care that is coordinated and/or integrated– Quality and safety – Enhanced access to care – Payment structure

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What Is a Health Home?

Definition: An integrated, person-centered, and physical and behavioral service delivery system aimed at populations with complex, chronic conditions – fueled by exchange of health information, evidence-based practices and care coordination. Intended to improve outcomes by reducing fragmented care and promoting patient-centered care.

Health Home Services Required Comprehensive care management Care coordination and health promotion Comprehensive transitional care Individual and family support (includes Auth Rep) Referral to community and social support services HIT to link services, as feasible and appropriate

Eligible Populations At least two chronic conditions, including

– Asthma– Diabetes– Heart disease

One chronic condition and be at risk for another One serious and persistent mental health condition

– Obesity– Mental condition – Substance abuse disorder

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Key Differences From Patient-Centered Medical Homes• Statutorily defined with enhanced FMAP to eligible

populations, conditions and services• Multiprovider care team focus—does not have to be physician

lead• Chronic condition focus with integration of medical and

behavioral health• Integration of community resources, family/social supports• New potential primary care roles for Health Home (e.g. BH

specialists or community-based providers)• New payment methodologies (e.g. patient management fee,

shared savings, P4P, e-consult payments)• Extensive health information sharing

States in CMS Approval Process• States with approval (12)

– Alabama, Idaho, Iowa, Maine, Missouri, North Carolina, New York, Ohio, Oregon, Rhode Island, Washington, Wisconsin

• States with planning requests approved by CMS (8)– Arkansas, Arizona, California, District of Columbia, Mississippi, New Jersey,

Nevada, New Mexico• States that have submitted draft state plan amendments to

CMS (7)– Alabama, Illinois, Maine, Massachusetts, Oklahoma, Vermont, Wisconsin

• States working on a draft of SPA (2)– Indiana, West Virginia

• States in conceptualization phase (10)– Colorado, Delaware, Georgia, Hawaii, Kansas, Michigan, Minnesota, North

Dakota, New Hampshire, Texas

20Source: Integrated Care Resource Center

States Health Homes Status

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Health Homes Federal Guidance• Established by the PPACA Section 2703• States selection of this option must apply by filing a State

Plan Amendment (SPA)• Requires consultation with SAMHSA • CMS is collaborating with SAMHSA, HRSA and AHRQ to

ensure evidence-based approach and consistency in implementing

• CMS issued draft Health Home Core Quality Measures (Jan. 15, 2013)

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Sources: http://www.samhsa.gov/healthreform/healthhomes/; http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD10024.pdf

Current Health Home Activities

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Outline

Health HomeModels

Health HomeDevelopment

Overview

Key Components of the AGP Health Homes ModelConsumer Considerations

• Member identification and placement

• Voluntary vs. mandatory participation

• Complex Care Coordination

• Physical and behavioral health integration

• Case and disease management

• Continuity of care• Quality metrics

Provider Considerations

• Health Home provider identification and credentialing –

• Team-Based Care • Multi-discipline teams• HIT/Service

Records/Continuity of Care Document

• HH Capabilities Development

State/MCO Considerations

• Single vs. multicarrier operating models

• Service area requirements and roll-out

• Financial Model• HIT and HIE

requirements• Quality Assurance• Success metrics and

reporting• Independent evaluation

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Models for Health Homes (as defined in PPACA, Section 2703)• A designated provider, physician, clinical/group practice,

etc.• A team of health professionals with links to a designated

provider—free-standing, virtual, hospital-based, community mental health centers, etc.

• A health team: medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral health providers

• These delivery models are reflected in two orientations:– Care Management/Case Management (2)– Co-located, integrating physical and behavioral health services (1 & 3)

Considering these models what is the potential meaning to individuals who would “come home?”

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Sample of Health Home Models by StateState Target

PopulationHealth Home Providers

Enrollment Payment

Alabama (4/9/13)

Two Chronic conditions; or one and at risk of a second (multiple conditions listed)

Team of Health Care Professionals: Primary Medicaid Providers, including FQHCs & Rural Health Clinics

VoluntaryEstimate up to 220,000

PMPM &FFS

Idaho(1/1/13)

SMI, SED, Diabetes and asthma

Community based providers that meet set standards

Voluntary—self-refer or automatically enrolled with opt out

PMPM

Iowa(7/1/12)

Two Chronic conditions; or one and at risk of a second

Primary Care , CMHCs, FQHCs

Opt-in when presenting at provider’s clinic

PMPM, & Quality Payment

Maine(1/1/13)

Variety of chronic conditions

Community Care Teams partner with primary care health homes practices

Auto assigned by State (opt-out)

PMPM

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NY Health Home ModelLead HH

Case Manager

CM Agency

Primary Care

BH Services

Hospital

Community

Medicaid Agency

MCO

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New York Implementation Challenges in Health Homes Implementation, End of Year 1• Six areas are identified as posing significant challenges in

establishing health homes– Becoming operational– Enrolling eligible beneficiaries– Determining payment rates– Building relationships and defining roles– Developing health information exchanges– Measuring quality

• Challenge finding and enrolling eligible beneficiaries (84,000 identified, 41,000 enrolled); contracting MCOs and Health Homes has taken longer than expected and delayed enrollment efforts– As of January 2013 about 17,000 individuals are receiving health home services

or are in in the outreach and engagement phase– Approximately 13,000 of these individuals converted from legacy case

management programs

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Source: Implementing Medicaid Health Homes in New York: Early Experience (February 2013). Medicaid Institute, At United Hospital Fund available online: www.uhfnuc.org.

KS Health Home Model

Medicaid Agency

MCO CBO

Care Manager

Specialty Services Hospital and Facility Services

Community and Support Services

Health Home

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Primary Care

Kansas Health Home Planning Process

• Established a central work group • Established seven sub-workgroup

– Quality Measures– Service Definitions– Stakeholder Engagement– Target Populations– Web Page Development– Provider Qualifications– Payment

• Focus group reviews workgroup products

• Statewide forum representing a diversity of groups, CMHC, FQHC, ID/DD, hospitals, private foundations, Department of Health

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Current Health Home Activities

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Outline

Health HomeModels

Health HomeDevelopment

Overview

Goals in Establishing Health Homes• Build capacity among health services providers in

establishing a team-based model of services• Establish health information technology for documentation

and information sharing– Patient registries with alerts to follow- up with patients– Referral tracking systems to monitor specialty services utilization – Notification systems to identify an individual’s admission or discharge from an

emergency department, inpatient or residential/rehabilitation setting– Monitor prescriptions for counter-indicated prescriptions and refills of needed

medications– Mobile technologies for self-monitoring with provider notification systems– Direct provider communications (continuity of care documents)

• A system for constructing personal health plan promoting self care

• Establish clinical processes to facilitate collaboration between the MCO and health home care managers

• Monitoring and tracking of quality indicators32

Goals in Establishing Health Homes, cont’d.• Capacity to track quality indicators and program outcomes• CMS has established eight recommended core measures:

– Adult body mass index– Ambulatory Care –Sensitive Condition Admissions– Care Transitions– Follow-up after hospitalization for mental illness– Plan—all cause readmission– Screening for depression and follow-up plan– Initiation and engagement of alcohol and other drug dependence treatment– Controlling high blood pressure

• PPACA provides for independent program evaluation to include a reduction in hospital admissions and emergency department utilization

• Establish program evaluation and define outcomes• Establish payment models to sustain core health home

services

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Disruptive InnovationsEvolving the Health Service Delivery Model

Move From Move To

Admit/discharge Engagement/follow-up

Acute—in the moment focus Long-term

Specific presenting condition Holistic—mind and body

Compliance Adherence

Physician decision-making Shared decision-making

Passive patient Active/engaged individual

Episodic documentation Registries, alerts and reminders

File audits, episodic events Outcomes—clinical, financial and consumer

Disease coping Disease management and health behaviors

Individual provider Service team

Volume financial model (FFS) Value financial model (shared risk)34

Establishing a Comprehensive Care Management Model | Focus on the Individual

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Healthy Function

Reduced Performance

ChronicCondition

Acute Illness Treatment

Disease/Condition Management

Health Promotion

Health Home

Service Mix

Screening—blood pressure; cholesterol, blood sugar, depression, anxiety, alcohol, drugs, dental, vision, hearingLife Style Management—smoking, alcohol, sleep, diet, exercise, stress managementDisease Prevention—immunizations

Barriers —psychosocial

Palliative Care

Outpatient—triage, tests and procedures, pharmacy, inpatient—surgery,ED; behavioral health conditions;co-occurring conditions

Diagnosis and treatment of long-term conditions, labs, proceduresself-care/condition management; pain management; advanced directives

Individual Physical, cognitive, attitudes, beliefs, values

HCBSHousing, Employment

Manage Pain

Community

ED, Inpatient, Residential, LTSS

Specialists, Ancillary Services, RX, Dental,

Vision

Health Home—Outpatient Physical and Behavioral

Health

End-

to-E

nd C

are

Coo

rdin

ationMCO ensures

continuity of care & quality,

manages inpatient utilization,

administers claims and other

administrative functions

Health Home establishes a

consistent and holistic health

service coordinating

across service delivery system

Establishing a Comprehensive Care Coordination Model | Focus on the Service Delivery System

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Program Activities: Roles and Responsibilities

Health Home MCOOutreach and engagement Identify members from data files for HH

Biopsychosocial assessment, establish personal health plan inclusive of safety, advanced directive

Benchmarks, expected outcomes

Outpatient Physical and Behavioral Health Services—assessment and health plan

Provide sample clinical guidelines-pathways to manage members with chronic conditions

Wellness Visits and Health Promotion Monitor health screenings completed

Chronic Condition Management: acute episodes of care, education and self-management (chronic care)

Monitor care for chronic conditions, duplication of test and procedures, ER/inpatient admissions

Case management; refer to community/social supports Comprehensive care management—c communicate with HH on social supports

Individual and Family Support Respite Services, value added benefits

Care Coordination between PH & BH; primary care & specialists

Vendor servicesAncillary services

Facilitate Transitions in Care Utilization management

Monitor members over time--registries to track QA/QI Reporting

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Point of View ReDux• Establish health homes for individuals

experiencing co-occurring chronic conditions or a severe mental illness that incorporate physical and behavioral health providers co-located, collaborating, and providing integrated services

• Care managers are co-located to facilitate collaboration and coordination with specialists, facilities, and community resources

• Services are coordinated between primary service providers and specialty service providers, long-term services and supports, as well as ensuring transitions in services between hospital and other community-based facilities

• Collaboration and coordination ensures continuity in services over time

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Point of View ReDux, cont’d.

• A health home may be established in a physician clinic, community mental health center, FQHC, Rural Health Services, or other CBOs that establish a mechanism to offer physical and mental health services

• The role of the MCO is to interface with health homes to ensure continuity and coordination of the health services delivery system

Q-and-ADavid.Johnson@amerigroup.com