Session #A3b
Friday, October 11, 2013
Health Homes: A Holistic Approach
to Service Delivery
David A. Johnson, MSW, ACSW
Collaborative Family Healthcare Association 15th Annual Conference
October 10-12, 2013
Broomfield, Colorado U.S.A.
1
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
Outline
Overview
Current
Health Home
Activities
Health
Home
Models
Health
Home
Development
6
What is a home
7
Health Homes? Home Health? Patient Centered
Medical Home?
8
“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”?
9
Real Story
10
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
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.
11
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
12
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
13
What does a Health Home
Address?
A health home
addresses
physical and
mental health
issues and
conditions…
coordinating
with community
supports and
services
14
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
15
Outline
Overview
Current
Health Home
Activities
Health
Home
Models
Health
Home
Development
16
Patient-Centered Medical Homes
and 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
17
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.
Eligible Populations
 At least two chronic conditions, including
– Asthma
– Obesity
– Diabetes
– Mental condition
– Heart disease
– Substance abuse disorder
 One chronic condition and be at risk for another
 One serious and persistent mental health condition
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
18
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
Source: Integrated Care Resource Center
20
States Health Homes Status
21
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)
Sources: http://www.samhsa.gov/healthreform/healthhomes/; http://downloads.cms.gov/cmsgov/archiveddownloads/SMDL/downloads/SMD10024.pdf
22
Outline
Overview
Current
Health Home
Activities
Health
Home
Models
Health
Home
Development
23
Key Components of the AGP Health Homes Model
Consumer
Considerations
Provider
Considerations
State/MCO
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
• Health Home provider
identification and
credentialing –
• Team-Based Care
• Multi-discipline teams
• HIT/Service
Records/Continuity of
Care Document
• HH Capabilities
Development
• Single vs. multicarrier
operating models
• Service area
requirements and rollout
• Financial Model
• HIT and HIE
requirements
• Quality Assurance
• Success metrics and
reporting
• Independent evaluation
24
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?”
25
Sample of Health Home Models by State
State
Target
Population
Health 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
Voluntary
Estimate 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
26
NY Health Home Model
Lead
HH
MCO
Primary Care
Medicaid
Agency
BH Services
Hospital
CM Agency
Case
Manager
Community
27
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
Source: Implementing Medicaid Health Homes in New York: Early Experience (February 2013).
Medicaid Institute, At United Hospital Fund available online: www.uhfnuc.org.
28
KS Health Home Model
CBO
MCO
Medicaid
Agency
Health Home
Care
Manager
Primary Care
Community and Support
Services
Specialty Services
Hospital and Facility Services
29
Kansas Health Home Planning Process
• Established a central work group
• Established seven sub-workgroup
–
–
–
–
–
–
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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
30
Outline
Overview
Current
Health Home
Activities
Health
Home
Models
Health
Home
Development
31
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 indicators
32
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
33
Disruptive Innovations
Evolving 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
Individual
Physical, cognitive, attitudes, beliefs, values
Health
Promotion
Healthy
Function
Disease/
Condition
Management
Acute Illness
Treatment
Reduced
Performance
Barriers —
psychosocial
Chronic
Condition
Health Home
Manage
Pain
Palliative Care
HCBS
Housing, Employment
Service Mix
Screening—blood pressure; cholesterol, blood
sugar, depression, anxiety, alcohol, drugs, dental,
vision, hearing
Life Style Management—smoking, alcohol, sleep,
diet, exercise, stress management
Disease Prevention—immunizations
Outpatient—triage, tests and
procedures, pharmacy,
inpatient—surgery,
ED; behavioral health conditions;
co-occurring conditions
Diagnosis and treatment of long-term
conditions, labs, procedures
self-care/condition management; pain
management; advanced directives
35
Establishing a Comprehensive Care Coordination
Model | Focus on the Service Delivery System
MCO ensures
continuity of care
& quality,
manages inpatient
utilization,
administers
claims and other
administrative
functions
End-to-End Care Coordination
Community
ED, Inpatient,
Residential,
LTSS
Specialists,
Ancillary
Services, RX,
Dental, Vision
Health
Home—
Outpatient
Physical and
Behavioral
Health
Health Home
establishes a
consistent and
holistic health
service
coordinating
across service
delivery system
36
Program Activities:
Roles and Responsibilities
Health Home
MCO
Outreach 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 services
Ancillary services
Facilitate Transitions in Care
Utilization management
Monitor members over time--registries to track
QA/QI Reporting
37
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
38
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-A
David.Johnson@amerigroup.com