Community Health Team Pilot Program within CSI-RI

September 13, 2013Debra Hurwitz, MBA, BSN, RN

CSI Co-Director

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Agenda

• Background of CHTs and summary of other states’ models

• Existing Resources in RI• Committee Membership• Committee Charter/Plan• Deliverables and Time Frame• Next Steps

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CSI-RI Strategic Plan

• Plan: As part of the 2013 Strategic Plan, CSI will develop and pilot the implementation of 2 CHT.

• Purpose: To help support small practice in becoming PCMHs.

• Budget: $75,000 per site to launch pilot by April 1, – Contingent on approval of the plan by Budget

Committee– Additional budget ask for next year

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What is a Community Health Team?

Definition: • Community Health Teams (CHT) work with primary care practices in

a given region or network to improve care for patients with chronic conditions.

• The CHT often provides direct care: – Care management – Behavioral health care, – Assists with transitions of care– Links patients to community resources.

• Based in a pre-existing health care entity (such as a hospital, primary care organization or an FQHC) or a newly-formed non-profit and provide services to a number of associated primary care practices.

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Vermont CHT Model Overview

• Each Hospital Service Area (HSA) has a project manager who oversees two HSA-wide workgroups: the Health Information Technology Workgroup and the Integrated Health Services Workgroup (IHS).

• IHS oversees CHT implementation: reorganization of existing services, creating new services, CHT composition and administrative entity

• CHT employed by administrative entity (CMS eligible-hospital or health center)

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Vermont CHT Services

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Vermont CHT Measures

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Vermont CHT Funding

• Direct predefined payment from participating payers: commercial, Medicare and Medicaid

• Funding required by 2007 legislation• There is an agreed upon shared cost structure paid to

administrative entity• Rates: $350,000 per year for salaries and benefits for

each community health team• CHT use is not based on insurance status and does not

require co-pays or prior authorization

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Oregon CHT Overview• Coordinated Care Organizations (CCOs) are regional provider

networks made up of a variety of health care providers who work together to deliver coordinated acute and preventive care to the State’s Medicaid beneficiaries.

• Preexisting health care entities apply to serve as a regional CCO.

• Each CCO (currently 15 in operation) develops a transformation plan specific to the needs of the community it serves.

• These plans demonstrate how the organization will work to improve health outcomes, increase member satisfaction and reduce overall costs.

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Oregon CHT Services

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Each CCO must have:•Pcp/nurses•Mental health providers •Community members•Consumer advisory council (representative sits on the CCO board

Oregon CHT Measures• 17 CCO incentive measures

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Access to Care: Getting Care Quickly (CAHPS) Patient-Centered Primary Care Home Enrollment

Adolescent well-care visits (NCQA) Prenatal and postpartum care: timeliness of prenatal care (NQF 1517)

Alcohol and drug misuse: screening, brief intervention and referral for treatment (SBIRT)

Satisfaction with Care: Health Plan Information and Customer Service (CAHPS)

Ambulatory care: outpatient and emergency department utilization

EHR adoption

Colorectal cancer screening (HEDIS) Elective Delivery

Developmental screening in the first 36 months of life (NQF-1448)

Screening for clinical depression and follow-up plan

Follow-up after hospitalization for mental illness (NQF 0576)

Controlling high blood pressure

Follow-up care for children prescribed ADHD medications (NQF 0108)

Diabetes: HbA1c poor control

Mental and Physical Health Assessments within 60 days for Children in DHS Custody

Oregon CHT Funding

• CCOs operate on an accountable global budget from the state

• Participants in CCOs have one single health plan which integrates physical, dental and mental health care

• SIM grant of $45 million

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Environmental Scan: Funding

• Most states fund CHTs under the authorization of – 1915 (b) Medicaid Managed Care Waivers– 1115 research and demonstration waivers– PPACA 2703 health homes state plan

amendments

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Environmental Scan: Funding

• Vermont-CHT receives direct pre-defined payment from participating payers

• Alabama, Maine, Montana, North Carolina, South Carolina, Oklahoma-CHT receives direct PMPM from participating payers

• New York- Primary care practices receive direct PMPM from payers and “pass-on” portion to their associated CHT

• Minnesota- CHT funded through state grant14

References• The Association of State and Territorial Health Officials. Community health teams issue report (Job Code 16015). Retrieved

from website: http://www.astho.org/Programs/Access/Primary-Care/_Materials/Community-Health-Teams-Issue-Report/• Buxbaum, Jason. (2012, April). Community-based support teams: The national landscape. Building medical home

neighborhoods through community-based teams: lessons from three states with emerging programs. Retrieved from http://www.nashp.org/webinar/building-medical-home-neighborhoods-through-community-based-teams

• Craig Jones, M.D. (Chair), (9/21/12). Webcast: Vermont blueprint for health: working together for better care. • Department of Vermont Health Access, (2010). Vermont blueprint for health implementation manual. Retrieved from

website: http://hcr.vermont.gov/blueprint• Department of Vermont Health Access, (2012). Vermont blueprint for health 2011 annual report. Retrieved from website:

http://hcr.vermont.gov/blueprint• U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2012). Policy innovation

profile: Statewide program supports medical homes through multidisciplinary teams, easy access to information, and incentives, leading to lower costs and better care. Retrieved from website: http://www.innovations.ahrq.gov/content.aspx?id=3640

• Lisa Watkins, MD, Associate Director, Vermont Blueprint for Health, L. W. Maine Quality Counts PCMH Pilot, (2011). Community health teams and the medical home. Retrieved from website: http://www.mainequalitycounts.org/hosp-tools-and-resources/doc_view/212-community-health-teams-a-new-tool-for-improving-care-and-outcomes.html

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