Department of
Vermont Health Access
Community Health Teams
The Vermont Experience
Lisa Dulsky Watkins, MD
Associate Director
Vermont Blueprint for Health
lisa.watkins@state.vt.us
October 21, 2103
1
Department of Vermont
Health Access
Principles of Team-Based Care
Shared Goals
Clear Roles
Mutual Trust
Effective Communication
Measureable Processes and Outcomes
Mitchell et al, Core Principles & values of effective team-based health care, 2012
(Discussion Paper, Institute of Medicine, Washington, DC. www.iom.edu
October 21, 2103
2
Department of Vermont
Health Access
Team-Based Care
“Team-based health care is the provision of health
services to individuals, families, and/or their
communities by at least two health providers who
work collaboratively with patients and their caregivers
– to the extent preferred by each patient – to
accomplish shared goals
within and across settings to achieve coordinated,
high-quality care.”
Naylor et al, Inter-professional team-based primary care for chronically ill adults: State of the
Science, 2010
October 21, 2103
3
Department of Vermont
Health Access
Vermont’s Executive Branch and Legislature
Consistent Support for Health Reform
2003 Blueprint launched as Governor’s initiative
2005 Implementation of Wagner’s Chronic Care Model
2005 Medicaid Global Commitment (Section 1115) Waiver
2006 Blueprint codified as part of sweeping reform legislation (Act 191)
2007 Blueprint leadership and pilots established (Act 71)
2008 Community Health Team structure and insurer mandate (Act 204)
2010 Statewide Blueprint Expansion outlined (Act 128)
2011 Planning for “Single Payer” (Act 48)
October 21, 2103
4
Blueprint Payment Reforms
Payments to
Practices
1) FFS
2) PBPM Enhanced
Payments
•Community Health Teams
•Funded by all insurers
•Intent is to minimize
barriers
•$35,000/2000 active pts./yr.
•Scaled based on population
Insurers
•SASH Teams
•Funded by Medicare
(CMMI Demonstration
Project)
•$70,000/100 participants/yr.
•Scaled based on # panels
October 21, 2103
•Medicaid
•Commercial Insurers
•Medicare
•Addictions Teams
•Funded by Medicaid
Health Home (potential
90/10 federal match)
•2 FTEs/100 suboxone pts.
•Scaled based on # pts. in
prescribing practices
5
Health Service Area Architecture
 A foundation of medical homes
Visiting
Nurse/Home
HVVo
Health Agency
Hospitals
Primary
Specialty Care &
Care
Disease Management
Practice
Programs
Core Community Health Team
Nurse Coordinators
Primary
Social Workers
Care
Social, Economic, &
Nutrition Specialists
Practice
Community Services
Community Health Workers
Public Health Specialists
Primary
Mental Health &
Care
Extended Community Health Team
Substance Abuse
Practice
Medicaid Care Coordinators
Programs
Medicare Teams based in Housing Hubs
Addiction Teams
Primary
Care
Practice
Self Management
Workshops
Public Health
Programs & Services
and community health teams that
can support coordinated care and
linkages with a broad range of
services
 Multi-insurer payment reform that
supports this 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
Multi-Insurer Payment Reform Framework
Health IT Framework
Evaluation Framework
October 21, 2103
uses routinely collected data to
support services, guide quality
improvement, and determine
program impact
6
TIMELINE
Patient Centered Medical Homes and
Community Health Team Staffing in Vermont
483,147 500,000
458,437
442,175
423,015
CHT FTEs
Recognized Practices
Patients
395,725
80
79
60
58
43
40
29
400,000
300,000
62.0
200,000
49.5
36.6
23.9
21.0
100,000
11
20
13
3
20
13
Q
Q
2
20
13
1
20
12
Q
Q
4
20
12
3
20
12
Q
Q
2
20
12
11
Q
1
20
11
Q
4
20
11
Q
3
20
2
Q
1
20
20
10
11
0
Q
Q
4
20
10
3
20
10
11
Q
Q
2
20
10
1
Q
4
11
7
20
09
7
Q
2
Q
7
20
09
7
20
09
1
20
08
7
Q
Q
4
20
08
3
118.5
18
3
5
0
11.1 11.1 11.1 11.1
Q
8.8
5.8
20
09
20
16.6 16.6 15.4
19.3
114.6
356,341
120
105.9
342,067
104
113
100
107
93
89.9
279,828
85.9
84
79.6
246,983
100
Q
# of CHT FTEs and Practices
120
# of Patients
140
October 21, 2103
7
Vermont Health Information
Technology Infrastructure
Organizationowned
Primary Care
Practices
Senior
Support
Services
Hosted EMR
Core data elements
Tobacco
Cessation
Counselors
Independent
Primary Care
Practices
EMR
Primary Care
Practices
Core data elements
Vermont
Health
Information
Exchange
(VITL)
Core data elements
Core data elements
No EMR
October 21, 2103
Central Clinical
Registry and
Integrated Health
Record
(Covisint DocSite)
Community
Health Team
8
CHT Identification of High-Risk Patients
• Practice panel management, outreach and referrals
• Referrals from other health care and community service
organizations
• Risk stratification and utilization data from Medicare
• Risk stratification and utilization data from Medicaid
• Data from commercial insurers
October 21, 2103
9
CHT Example
Providers refer via the EHR (PRISM).
CHT provides in person 1:1 support, in groups or by phone, 3-6 visits, commonly 4
interactions.
CHT helps patients set realistic goals and timelines utilizing motivational
interviewing, action planning and short term goal setting
CHT focuses on achievable realistic outcomes with our patients, addressing barriers
that may interfere with success.
 Short term case management, most often provided by our medical social worker.
 CHT patients can re-engage with the team as necessary after graduation
Services include:
 Health coaching around nutrition, exercise
and stress management
 Basic Diabetes Education
 Medication Management
 Behavioral/Mental Health
 Connection to community and financial
resources
10
CHT Example
How Satisfied Are you with the Services You Can Offer To Your
Patients by Referral ?
60%
40%
20%
0%
Nutrition
Exercise
Stimulating
Patient
Counseling
Counseling
Behavior Change
Education
% Satisfied & Very Satisfied -Pilot Site
50%
17%
33%
17%
29%
% Satisfied & Very Satisfied - Other FAHC
38%
19%
13%
6%
19%
Overall
Primary Care Practices
October 21, 2103
11
CHT Example
How Satisfied Are you with the Services You Can Offer To Your
Patients Within Your Office Team ?
100%
80%
60%
40%
20%
0%
% Satisfied & Very Satisfied - P ilot Site
% Satisfied & Very Satisfied - Other FAHC
Nutrition
Exercise
Stimulating
P atient Education
Counseling
Counseling
Behavior Change
Materials
100%
67%
50%
50%
67%
6%
6%
6%
6%
6%
Overall
P rimary Care P ractices
October 21, 2103
12
CHT Example
Clinical Outcomes
Patients were tracked by the multidisciplinary CHT using a
common database and assessed 6 months after
“graduation” (data collected between March 2009 and
August 2012)
• 59% of patients referred to the CHT for diabetes-related
issues had sustained improvement in BMI (n =44) and
67% of patients had sustained improvement in HbA1c
(n=87)
• 49% (n=118) of patients referred to the CHT for exercise
and nutrition issues had a sustained improvement in their
BMI and 31.5% (n=117) had a sustained improvement in
their LDL (average decrease of 24mg/dL)
October 21, 2103
13
CHT Challenges
• Documentation
• Consistency
• Double data entry
• Reporting to funders (“ROI”)
• Communication
• Patient/consumer engagement
• General public awareness
October 21, 2103
14