M A R Y T A K A C H M P H R N M O N T A N A P C M H S T A K E H O L D E R C O U N C I L

H E L E N A M O N T A N A A P R I L 1 6 2 0 1 3

Strategies to Better Support Team-Based in PCMH Initiatives

2

NASHP

26-year-old non-profit non-partisan organization

Offices in Portland Maine and Washington DC

Academy members

Peer-selected group of state health policy leaders

No duesmdashcommitment to identify needs and guide work

Working together across states branches and agencies to advance accelerate and implement workable policy solutions that address major health issues

2

3

STATE-BASED MEDICAL HOME INITIATIVES

WA

OR

TX

CO

NC

LA

PA

NY

IA

VA

NE

OK

AL

MD

MT

ID

KS

MN

NH

ME

AZ

VT

MO CA

WY

NM

IL

WI

MI

WV

SC

GA

FL

UT NV

ND

SD

AR

IN OH

KY

TN

MS

DE

RI

NJ CT

MA

HI

Medical home activity (45 states and Washington DC)

Making medical home payments (29 states)

Payments based on provider qualification standards (27 states)

AK

As of August 2013

5 PCPCC 2013

EXPANDING MEDICAL HOME CAPACITY

THROUGH MULTI-DISCIPLINARY TEAMS

Key model features

bull Practice teamsmdashoften shared among practices

bull Payments to teams and qualified providers

bull Teams are based in a variety of settings

bull Community developed teams vary from region to region

6

7

WHOSE ON THE TEAM

bull New or Expanded Roles for

bull Nurses

bull Behavioral Health Specialists

bull Community Health Workers

bull Social Workers

bull Peer Specialists

bull Pharmacists

bull Health Coaches

8

SHARED SUPPORT TEAMS

RI

IA

MT

ME

NY

AL

OK

MN

NC

MI

VT

Making Payments to Shared Support Teams

Pursuing similar models through State Innovation Model Grants

MD

ID

IL

PA

9

Michigan

Maine Alabama

SHARED COMMUNITY CARE TEAM SNAPSHOT

Scope Payer(s) Payment Strategy Core Team Composition

Alabama

Patient Care

Networks of

Alabama

4 networks

170000 eligible

patients

Medicaid (Health

Home SPA)

Networks receive $950

PMPM for each Health

Home patient

Must include clinical director or

medical director clinical

pharmacist chronic care clinical

champion (nurse) care managers

(nurse or social worker)

Maine

Community

Care Teams

10 care teams

130000 eligible

patients

Medicaid (Health

Home SPA) Medicare

private plans some

self-insured employers

including state

employees

Teams receive $12950

PMPM for Medicaid Health

Homes $295 Medicaid non

Health Home $295 PMPM

for Medicare $030 PMPM

for privately insured

Must include part-time clinical

leader team composition based

on each entityrsquos care

management strategy

Vermont

Community

Health Teams

14 teams

514000 eligible

patients

Medicaid Medicare

private plans some

self-insured

Teams receive $350000 for

5 FTE team costs divided

proportionately among

payers

Staffing structures are flexible

most include nurse care

managers behavioral health

specialistssocial workers health

coaches panel managers and

tobacco cessation counselors

New York

Adirondack

Region Medical

Home Pilot Pods

3 pods

106000 eligible

patients

Medicaid Medicare

private plans some

self-insured employers

including state

employees

Pods receive $7 PMPM

payment to providers who

contract with pods for

support services Average

payment to pod

approximately $350 PMPM

No specific staffing requirements

structures vary across pods

10

PATIENT CARE NETWORKS OF ALABAMA

bull Four new 501(c)(3) organizations

bull Support Patient 1st Medicaid providers

bull Focus on high risk high acuity patients

bull Providers who partner with networks receive

$160 - $210 PMPM + $1 PMPM from Patient 1st

bull Total PMPM rate for Patient 1st patients in

network areas decreased by 77 vs 06 for

the rest of the state after 1st 6 months bull 3 network areas had a 15 decrease in their ER Use vs non-

network areas that had a 2 during same time (httpmedicaidalabamagovnews_detailaspxID=6608)

11

MAINE COMMUNITY CARE TEAMS

bull Multi-payer support PMPM varies by payer

bull Community care teams based in wide variety

of organizations

bull Support providers meeting ldquoNCQA Plusrdquo

including bull Behavioral health integration

bull Population risk-stratification and management

bull Team-based care

bull Connection to community resources

bull Focus on High Costs utilizers aka ldquoSuper Utilizersrdquo

bull No outcome data available

12

VERMONT BLUEPRINT FOR HEALTH COMMUNITY HEALTH TEAMS

bull Statewide multi-payer support

bull Provider reimbursement tied to NCQA PCMH

recognition and CHTs help practices meet NCQA

PCMH recognition

bull CHTs focus on public health helping patients engage in

preventive services and adopt healthier lifestyles

bull Specialized care coordinators added to teams to care

for elderly patients and substance abusers added

bull 2013 Vermont Annual Report found that people cared

for in PCMH + CHT setting had favorable outcomes vs

comparison groups including reductions in annual

expenditures more than offsetting payer investments in

PCMHs and CHTs

13

ADIRONDACKS REGIONAL PODS

bull Three ldquopodsrdquo in upstate NY supported by a central entity (Adirondack Health Institute)

bull Regional Multi-payer support

bull Workforce shortages was primary reason for development of PCMH initiative

bull Support affiliated practices and smaller independent practices in region

bull PMPM reimbursement passed through by providers

bull From 2006 to 2007 the region lost 24 PCPs Since the pilot began primary care has stabilized and grown total costs of care has been trending downward for commercial payers and Medicaid (httpwwwadkmedicalhomeorgwp-contentuploads201310Dennis-Weaver-Medical-Home-Summit-Presentationpdf)

14

IOWA ldquoCOMMUNITY CARE COORDINATION TEAMSrdquo

bull Pilot launched two regional teams in January 2014

bull Funded by Iowa Legislature through the statersquos Primary Care Association $300000team until June 2014

bull Purpose is to support safety net providers and small practices

bull Teams will support primary care practices in serving high-needs patients

bull Focus on population health and social determinants

bull Team composition based on community needs and resources

14

bull Care management

bull Patient education

bull Pharmacy management

bull Behavioral health

management

bull Link to community resources

15

KEY TAKEAWAYS

bull Team-based care is a key feature of a medical home

bull Meeting medical home criteria including team-based

care is hard work for practicesmdashparticularly small amp

rural practices

bull Shared community-based support teams offer providers

of all types the opportunity to participate in value-based

health care delivery models

bull Community-based teams can extend their reach by

leveraging social public health and other services and

extend their reach

bull Community based teams provide infrastructure for ACOs

15

16

Please visit

bull wwwnashporg

bull www nashporgmed-home-map

bull wwwnashporgstate-accountable-care-activity-map

bull wwwstatereforumorg

Contact

mtakachnashporg

bwirthnashporg

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

For More Information

Searchform-f8cf0search_theSearchform-f8cf0search_the

2

NASHP

26-year-old non-profit non-partisan organization

Offices in Portland Maine and Washington DC

Academy members

Peer-selected group of state health policy leaders

No duesmdashcommitment to identify needs and guide work

Working together across states branches and agencies to advance accelerate and implement workable policy solutions that address major health issues

2

3

STATE-BASED MEDICAL HOME INITIATIVES

WA

OR

TX

CO

NC

LA

PA

NY

IA

VA

NE

OK

AL

MD

MT

ID

KS

MN

NH

ME

AZ

VT

MO CA

WY

NM

IL

WI

MI

WV

SC

GA

FL

UT NV

ND

SD

AR

IN OH

KY

TN

MS

DE

RI

NJ CT

MA

HI

Medical home activity (45 states and Washington DC)

Making medical home payments (29 states)

Payments based on provider qualification standards (27 states)

AK

As of August 2013

5 PCPCC 2013

EXPANDING MEDICAL HOME CAPACITY

THROUGH MULTI-DISCIPLINARY TEAMS

Key model features

bull Practice teamsmdashoften shared among practices

bull Payments to teams and qualified providers

bull Teams are based in a variety of settings

bull Community developed teams vary from region to region

6

7

WHOSE ON THE TEAM

bull New or Expanded Roles for

bull Nurses

bull Behavioral Health Specialists

bull Community Health Workers

bull Social Workers

bull Peer Specialists

bull Pharmacists

bull Health Coaches

8

SHARED SUPPORT TEAMS

RI

IA

MT

ME

NY

AL

OK

MN

NC

MI

VT

Making Payments to Shared Support Teams

Pursuing similar models through State Innovation Model Grants

MD

ID

IL

PA

9

Michigan

Maine Alabama

SHARED COMMUNITY CARE TEAM SNAPSHOT

Scope Payer(s) Payment Strategy Core Team Composition

Alabama

Patient Care

Networks of

Alabama

4 networks

170000 eligible

patients

Medicaid (Health

Home SPA)

Networks receive $950

PMPM for each Health

Home patient

Must include clinical director or

medical director clinical

pharmacist chronic care clinical

champion (nurse) care managers

(nurse or social worker)

Maine

Community

Care Teams

10 care teams

130000 eligible

patients

Medicaid (Health

Home SPA) Medicare

private plans some

self-insured employers

including state

employees

Teams receive $12950

PMPM for Medicaid Health

Homes $295 Medicaid non

Health Home $295 PMPM

for Medicare $030 PMPM

for privately insured

Must include part-time clinical

leader team composition based

on each entityrsquos care

management strategy

Vermont

Community

Health Teams

14 teams

514000 eligible

patients

Medicaid Medicare

private plans some

self-insured

Teams receive $350000 for

5 FTE team costs divided

proportionately among

payers

Staffing structures are flexible

most include nurse care

managers behavioral health

specialistssocial workers health

coaches panel managers and

tobacco cessation counselors

New York

Adirondack

Region Medical

Home Pilot Pods

3 pods

106000 eligible

patients

Medicaid Medicare

private plans some

self-insured employers

including state

employees

Pods receive $7 PMPM

payment to providers who

contract with pods for

support services Average

payment to pod

approximately $350 PMPM

No specific staffing requirements

structures vary across pods

10

PATIENT CARE NETWORKS OF ALABAMA

bull Four new 501(c)(3) organizations

bull Support Patient 1st Medicaid providers

bull Focus on high risk high acuity patients

bull Providers who partner with networks receive

$160 - $210 PMPM + $1 PMPM from Patient 1st

bull Total PMPM rate for Patient 1st patients in

network areas decreased by 77 vs 06 for

the rest of the state after 1st 6 months bull 3 network areas had a 15 decrease in their ER Use vs non-

network areas that had a 2 during same time (httpmedicaidalabamagovnews_detailaspxID=6608)

11

MAINE COMMUNITY CARE TEAMS

bull Multi-payer support PMPM varies by payer

bull Community care teams based in wide variety

of organizations

bull Support providers meeting ldquoNCQA Plusrdquo

including bull Behavioral health integration

bull Population risk-stratification and management

bull Team-based care

bull Connection to community resources

bull Focus on High Costs utilizers aka ldquoSuper Utilizersrdquo

bull No outcome data available

12

VERMONT BLUEPRINT FOR HEALTH COMMUNITY HEALTH TEAMS

bull Statewide multi-payer support

bull Provider reimbursement tied to NCQA PCMH

recognition and CHTs help practices meet NCQA

PCMH recognition

bull CHTs focus on public health helping patients engage in

preventive services and adopt healthier lifestyles

bull Specialized care coordinators added to teams to care

for elderly patients and substance abusers added

bull 2013 Vermont Annual Report found that people cared

for in PCMH + CHT setting had favorable outcomes vs

comparison groups including reductions in annual

expenditures more than offsetting payer investments in

PCMHs and CHTs

13

ADIRONDACKS REGIONAL PODS

bull Three ldquopodsrdquo in upstate NY supported by a central entity (Adirondack Health Institute)

bull Regional Multi-payer support

bull Workforce shortages was primary reason for development of PCMH initiative

bull Support affiliated practices and smaller independent practices in region

bull PMPM reimbursement passed through by providers

bull From 2006 to 2007 the region lost 24 PCPs Since the pilot began primary care has stabilized and grown total costs of care has been trending downward for commercial payers and Medicaid (httpwwwadkmedicalhomeorgwp-contentuploads201310Dennis-Weaver-Medical-Home-Summit-Presentationpdf)

14

IOWA ldquoCOMMUNITY CARE COORDINATION TEAMSrdquo

bull Pilot launched two regional teams in January 2014

bull Funded by Iowa Legislature through the statersquos Primary Care Association $300000team until June 2014

bull Purpose is to support safety net providers and small practices

bull Teams will support primary care practices in serving high-needs patients

bull Focus on population health and social determinants

bull Team composition based on community needs and resources

14

bull Care management

bull Patient education

bull Pharmacy management

bull Behavioral health

management

bull Link to community resources

15

KEY TAKEAWAYS

bull Team-based care is a key feature of a medical home

bull Meeting medical home criteria including team-based

care is hard work for practicesmdashparticularly small amp

rural practices

bull Shared community-based support teams offer providers

of all types the opportunity to participate in value-based

health care delivery models

bull Community-based teams can extend their reach by

leveraging social public health and other services and

extend their reach

bull Community based teams provide infrastructure for ACOs

15

16

Please visit

bull wwwnashporg

bull www nashporgmed-home-map

bull wwwnashporgstate-accountable-care-activity-map

bull wwwstatereforumorg

Contact

mtakachnashporg

bwirthnashporg

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

For More Information

Searchform-f8cf0search_theSearchform-f8cf0search_the

3

STATE-BASED MEDICAL HOME INITIATIVES

WA

OR

TX

CO

NC

LA

PA

NY

IA

VA

NE

OK

AL

MD

MT

ID

KS

MN

NH

ME

AZ

VT

MO CA

WY

NM

IL

WI

MI

WV

SC

GA

FL

UT NV

ND

SD

AR

IN OH

KY

TN

MS

DE

RI

NJ CT

MA

HI

Medical home activity (45 states and Washington DC)

Making medical home payments (29 states)

Payments based on provider qualification standards (27 states)

AK

As of August 2013

5 PCPCC 2013

EXPANDING MEDICAL HOME CAPACITY

THROUGH MULTI-DISCIPLINARY TEAMS

Key model features

bull Practice teamsmdashoften shared among practices

bull Payments to teams and qualified providers

bull Teams are based in a variety of settings

bull Community developed teams vary from region to region

6

7

WHOSE ON THE TEAM

bull New or Expanded Roles for

bull Nurses

bull Behavioral Health Specialists

bull Community Health Workers

bull Social Workers

bull Peer Specialists

bull Pharmacists

bull Health Coaches

8

SHARED SUPPORT TEAMS

RI

IA

MT

ME

NY

AL

OK

MN

NC

MI

VT

Making Payments to Shared Support Teams

Pursuing similar models through State Innovation Model Grants

MD

ID

IL

PA

9

Michigan

Maine Alabama

SHARED COMMUNITY CARE TEAM SNAPSHOT

Scope Payer(s) Payment Strategy Core Team Composition

Alabama

Patient Care

Networks of

Alabama

4 networks

170000 eligible

patients

Medicaid (Health

Home SPA)

Networks receive $950

PMPM for each Health

Home patient

Must include clinical director or

medical director clinical

pharmacist chronic care clinical

champion (nurse) care managers

(nurse or social worker)

Maine

Community

Care Teams

10 care teams

130000 eligible

patients

Medicaid (Health

Home SPA) Medicare

private plans some

self-insured employers

including state

employees

Teams receive $12950

PMPM for Medicaid Health

Homes $295 Medicaid non

Health Home $295 PMPM

for Medicare $030 PMPM

for privately insured

Must include part-time clinical

leader team composition based

on each entityrsquos care

management strategy

Vermont

Community

Health Teams

14 teams

514000 eligible

patients

Medicaid Medicare

private plans some

self-insured

Teams receive $350000 for

5 FTE team costs divided

proportionately among

payers

Staffing structures are flexible

most include nurse care

managers behavioral health

specialistssocial workers health

coaches panel managers and

tobacco cessation counselors

New York

Adirondack

Region Medical

Home Pilot Pods

3 pods

106000 eligible

patients

Medicaid Medicare

private plans some

self-insured employers

including state

employees

Pods receive $7 PMPM

payment to providers who

contract with pods for

support services Average

payment to pod

approximately $350 PMPM

No specific staffing requirements

structures vary across pods

10

PATIENT CARE NETWORKS OF ALABAMA

bull Four new 501(c)(3) organizations

bull Support Patient 1st Medicaid providers

bull Focus on high risk high acuity patients

bull Providers who partner with networks receive

$160 - $210 PMPM + $1 PMPM from Patient 1st

bull Total PMPM rate for Patient 1st patients in

network areas decreased by 77 vs 06 for

the rest of the state after 1st 6 months bull 3 network areas had a 15 decrease in their ER Use vs non-

network areas that had a 2 during same time (httpmedicaidalabamagovnews_detailaspxID=6608)

11

MAINE COMMUNITY CARE TEAMS

bull Multi-payer support PMPM varies by payer

bull Community care teams based in wide variety

of organizations

bull Support providers meeting ldquoNCQA Plusrdquo

including bull Behavioral health integration

bull Population risk-stratification and management

bull Team-based care

bull Connection to community resources

bull Focus on High Costs utilizers aka ldquoSuper Utilizersrdquo

bull No outcome data available

12

VERMONT BLUEPRINT FOR HEALTH COMMUNITY HEALTH TEAMS

bull Statewide multi-payer support

bull Provider reimbursement tied to NCQA PCMH

recognition and CHTs help practices meet NCQA

PCMH recognition

bull CHTs focus on public health helping patients engage in

preventive services and adopt healthier lifestyles

bull Specialized care coordinators added to teams to care

for elderly patients and substance abusers added

bull 2013 Vermont Annual Report found that people cared

for in PCMH + CHT setting had favorable outcomes vs

comparison groups including reductions in annual

expenditures more than offsetting payer investments in

PCMHs and CHTs

13

ADIRONDACKS REGIONAL PODS

bull Three ldquopodsrdquo in upstate NY supported by a central entity (Adirondack Health Institute)

bull Regional Multi-payer support

bull Workforce shortages was primary reason for development of PCMH initiative

bull Support affiliated practices and smaller independent practices in region

bull PMPM reimbursement passed through by providers

bull From 2006 to 2007 the region lost 24 PCPs Since the pilot began primary care has stabilized and grown total costs of care has been trending downward for commercial payers and Medicaid (httpwwwadkmedicalhomeorgwp-contentuploads201310Dennis-Weaver-Medical-Home-Summit-Presentationpdf)

14

IOWA ldquoCOMMUNITY CARE COORDINATION TEAMSrdquo

bull Pilot launched two regional teams in January 2014

bull Funded by Iowa Legislature through the statersquos Primary Care Association $300000team until June 2014

bull Purpose is to support safety net providers and small practices

bull Teams will support primary care practices in serving high-needs patients

bull Focus on population health and social determinants

bull Team composition based on community needs and resources

14

bull Care management

bull Patient education

bull Pharmacy management

bull Behavioral health

management

bull Link to community resources

15

KEY TAKEAWAYS

bull Team-based care is a key feature of a medical home

bull Meeting medical home criteria including team-based

care is hard work for practicesmdashparticularly small amp

rural practices

bull Shared community-based support teams offer providers

of all types the opportunity to participate in value-based

health care delivery models

bull Community-based teams can extend their reach by

leveraging social public health and other services and

extend their reach

bull Community based teams provide infrastructure for ACOs

15

16

Please visit

bull wwwnashporg

bull www nashporgmed-home-map

bull wwwnashporgstate-accountable-care-activity-map

bull wwwstatereforumorg

Contact

mtakachnashporg

bwirthnashporg

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

For More Information

Searchform-f8cf0search_theSearchform-f8cf0search_the

5 PCPCC 2013

EXPANDING MEDICAL HOME CAPACITY

THROUGH MULTI-DISCIPLINARY TEAMS

Key model features

bull Practice teamsmdashoften shared among practices

bull Payments to teams and qualified providers

bull Teams are based in a variety of settings

bull Community developed teams vary from region to region

6

7

WHOSE ON THE TEAM

bull New or Expanded Roles for

bull Nurses

bull Behavioral Health Specialists

bull Community Health Workers

bull Social Workers

bull Peer Specialists

bull Pharmacists

bull Health Coaches

8

SHARED SUPPORT TEAMS

RI

IA

MT

ME

NY

AL

OK

MN

NC

MI

VT

Making Payments to Shared Support Teams

Pursuing similar models through State Innovation Model Grants

MD

ID

IL

PA

9

Michigan

Maine Alabama

SHARED COMMUNITY CARE TEAM SNAPSHOT

Scope Payer(s) Payment Strategy Core Team Composition

Alabama

Patient Care

Networks of

Alabama

4 networks

170000 eligible

patients

Medicaid (Health

Home SPA)

Networks receive $950

PMPM for each Health

Home patient

Must include clinical director or

medical director clinical

pharmacist chronic care clinical

champion (nurse) care managers

(nurse or social worker)

Maine

Community

Care Teams

10 care teams

130000 eligible

patients

Medicaid (Health

Home SPA) Medicare

private plans some

self-insured employers

including state

employees

Teams receive $12950

PMPM for Medicaid Health

Homes $295 Medicaid non

Health Home $295 PMPM

for Medicare $030 PMPM

for privately insured

Must include part-time clinical

leader team composition based

on each entityrsquos care

management strategy

Vermont

Community

Health Teams

14 teams

514000 eligible

patients

Medicaid Medicare

private plans some

self-insured

Teams receive $350000 for

5 FTE team costs divided

proportionately among

payers

Staffing structures are flexible

most include nurse care

managers behavioral health

specialistssocial workers health

coaches panel managers and

tobacco cessation counselors

New York

Adirondack

Region Medical

Home Pilot Pods

3 pods

106000 eligible

patients

Medicaid Medicare

private plans some

self-insured employers

including state

employees

Pods receive $7 PMPM

payment to providers who

contract with pods for

support services Average

payment to pod

approximately $350 PMPM

No specific staffing requirements

structures vary across pods

10

PATIENT CARE NETWORKS OF ALABAMA

bull Four new 501(c)(3) organizations

bull Support Patient 1st Medicaid providers

bull Focus on high risk high acuity patients

bull Providers who partner with networks receive

$160 - $210 PMPM + $1 PMPM from Patient 1st

bull Total PMPM rate for Patient 1st patients in

network areas decreased by 77 vs 06 for

the rest of the state after 1st 6 months bull 3 network areas had a 15 decrease in their ER Use vs non-

network areas that had a 2 during same time (httpmedicaidalabamagovnews_detailaspxID=6608)

11

MAINE COMMUNITY CARE TEAMS

bull Multi-payer support PMPM varies by payer

bull Community care teams based in wide variety

of organizations

bull Support providers meeting ldquoNCQA Plusrdquo

including bull Behavioral health integration

bull Population risk-stratification and management

bull Team-based care

bull Connection to community resources

bull Focus on High Costs utilizers aka ldquoSuper Utilizersrdquo

bull No outcome data available

12

VERMONT BLUEPRINT FOR HEALTH COMMUNITY HEALTH TEAMS

bull Statewide multi-payer support

bull Provider reimbursement tied to NCQA PCMH

recognition and CHTs help practices meet NCQA

PCMH recognition

bull CHTs focus on public health helping patients engage in

preventive services and adopt healthier lifestyles

bull Specialized care coordinators added to teams to care

for elderly patients and substance abusers added

bull 2013 Vermont Annual Report found that people cared

for in PCMH + CHT setting had favorable outcomes vs

comparison groups including reductions in annual

expenditures more than offsetting payer investments in

PCMHs and CHTs

13

ADIRONDACKS REGIONAL PODS

bull Three ldquopodsrdquo in upstate NY supported by a central entity (Adirondack Health Institute)

bull Regional Multi-payer support

bull Workforce shortages was primary reason for development of PCMH initiative

bull Support affiliated practices and smaller independent practices in region

bull PMPM reimbursement passed through by providers

bull From 2006 to 2007 the region lost 24 PCPs Since the pilot began primary care has stabilized and grown total costs of care has been trending downward for commercial payers and Medicaid (httpwwwadkmedicalhomeorgwp-contentuploads201310Dennis-Weaver-Medical-Home-Summit-Presentationpdf)

14

IOWA ldquoCOMMUNITY CARE COORDINATION TEAMSrdquo

bull Pilot launched two regional teams in January 2014

bull Funded by Iowa Legislature through the statersquos Primary Care Association $300000team until June 2014

bull Purpose is to support safety net providers and small practices

bull Teams will support primary care practices in serving high-needs patients

bull Focus on population health and social determinants

bull Team composition based on community needs and resources

14

bull Care management

bull Patient education

bull Pharmacy management

bull Behavioral health

management

bull Link to community resources

15

KEY TAKEAWAYS

bull Team-based care is a key feature of a medical home

bull Meeting medical home criteria including team-based

care is hard work for practicesmdashparticularly small amp

rural practices

bull Shared community-based support teams offer providers

of all types the opportunity to participate in value-based

health care delivery models

bull Community-based teams can extend their reach by

leveraging social public health and other services and

extend their reach

bull Community based teams provide infrastructure for ACOs

15

16

Please visit

bull wwwnashporg

bull www nashporgmed-home-map

bull wwwnashporgstate-accountable-care-activity-map

bull wwwstatereforumorg

Contact

mtakachnashporg

bwirthnashporg

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

For More Information

Searchform-f8cf0search_theSearchform-f8cf0search_the

EXPANDING MEDICAL HOME CAPACITY

THROUGH MULTI-DISCIPLINARY TEAMS

Key model features

bull Practice teamsmdashoften shared among practices

bull Payments to teams and qualified providers

bull Teams are based in a variety of settings

bull Community developed teams vary from region to region

6

7

WHOSE ON THE TEAM

bull New or Expanded Roles for

bull Nurses

bull Behavioral Health Specialists

bull Community Health Workers

bull Social Workers

bull Peer Specialists

bull Pharmacists

bull Health Coaches

8

SHARED SUPPORT TEAMS

RI

IA

MT

ME

NY

AL

OK

MN

NC

MI

VT

Making Payments to Shared Support Teams

Pursuing similar models through State Innovation Model Grants

MD

ID

IL

PA

9

Michigan

Maine Alabama

SHARED COMMUNITY CARE TEAM SNAPSHOT

Scope Payer(s) Payment Strategy Core Team Composition

Alabama

Patient Care

Networks of

Alabama

4 networks

170000 eligible

patients

Medicaid (Health

Home SPA)

Networks receive $950

PMPM for each Health

Home patient

Must include clinical director or

medical director clinical

pharmacist chronic care clinical

champion (nurse) care managers

(nurse or social worker)

Maine

Community

Care Teams

10 care teams

130000 eligible

patients

Medicaid (Health

Home SPA) Medicare

private plans some

self-insured employers

including state

employees

Teams receive $12950

PMPM for Medicaid Health

Homes $295 Medicaid non

Health Home $295 PMPM

for Medicare $030 PMPM

for privately insured

Must include part-time clinical

leader team composition based

on each entityrsquos care

management strategy

Vermont

Community

Health Teams

14 teams

514000 eligible

patients

Medicaid Medicare

private plans some

self-insured

Teams receive $350000 for

5 FTE team costs divided

proportionately among

payers

Staffing structures are flexible

most include nurse care

managers behavioral health

specialistssocial workers health

coaches panel managers and

tobacco cessation counselors

New York

Adirondack

Region Medical

Home Pilot Pods

3 pods

106000 eligible

patients

Medicaid Medicare

private plans some

self-insured employers

including state

employees

Pods receive $7 PMPM

payment to providers who

contract with pods for

support services Average

payment to pod

approximately $350 PMPM

No specific staffing requirements

structures vary across pods

10

PATIENT CARE NETWORKS OF ALABAMA

bull Four new 501(c)(3) organizations

bull Support Patient 1st Medicaid providers

bull Focus on high risk high acuity patients

bull Providers who partner with networks receive

$160 - $210 PMPM + $1 PMPM from Patient 1st

bull Total PMPM rate for Patient 1st patients in

network areas decreased by 77 vs 06 for

the rest of the state after 1st 6 months bull 3 network areas had a 15 decrease in their ER Use vs non-

network areas that had a 2 during same time (httpmedicaidalabamagovnews_detailaspxID=6608)

11

MAINE COMMUNITY CARE TEAMS

bull Multi-payer support PMPM varies by payer

bull Community care teams based in wide variety

of organizations

bull Support providers meeting ldquoNCQA Plusrdquo

including bull Behavioral health integration

bull Population risk-stratification and management

bull Team-based care

bull Connection to community resources

bull Focus on High Costs utilizers aka ldquoSuper Utilizersrdquo

bull No outcome data available

12

VERMONT BLUEPRINT FOR HEALTH COMMUNITY HEALTH TEAMS

bull Statewide multi-payer support

bull Provider reimbursement tied to NCQA PCMH

recognition and CHTs help practices meet NCQA

PCMH recognition

bull CHTs focus on public health helping patients engage in

preventive services and adopt healthier lifestyles

bull Specialized care coordinators added to teams to care

for elderly patients and substance abusers added

bull 2013 Vermont Annual Report found that people cared

for in PCMH + CHT setting had favorable outcomes vs

comparison groups including reductions in annual

expenditures more than offsetting payer investments in

PCMHs and CHTs

13

ADIRONDACKS REGIONAL PODS

bull Three ldquopodsrdquo in upstate NY supported by a central entity (Adirondack Health Institute)

bull Regional Multi-payer support

bull Workforce shortages was primary reason for development of PCMH initiative

bull Support affiliated practices and smaller independent practices in region

bull PMPM reimbursement passed through by providers

bull From 2006 to 2007 the region lost 24 PCPs Since the pilot began primary care has stabilized and grown total costs of care has been trending downward for commercial payers and Medicaid (httpwwwadkmedicalhomeorgwp-contentuploads201310Dennis-Weaver-Medical-Home-Summit-Presentationpdf)

14

IOWA ldquoCOMMUNITY CARE COORDINATION TEAMSrdquo

bull Pilot launched two regional teams in January 2014

bull Funded by Iowa Legislature through the statersquos Primary Care Association $300000team until June 2014

bull Purpose is to support safety net providers and small practices

bull Teams will support primary care practices in serving high-needs patients

bull Focus on population health and social determinants

bull Team composition based on community needs and resources

14

bull Care management

bull Patient education

bull Pharmacy management

bull Behavioral health

management

bull Link to community resources

15

KEY TAKEAWAYS

bull Team-based care is a key feature of a medical home

bull Meeting medical home criteria including team-based

care is hard work for practicesmdashparticularly small amp

rural practices

bull Shared community-based support teams offer providers

of all types the opportunity to participate in value-based

health care delivery models

bull Community-based teams can extend their reach by

leveraging social public health and other services and

extend their reach

bull Community based teams provide infrastructure for ACOs

15

16

Please visit

bull wwwnashporg

bull www nashporgmed-home-map

bull wwwnashporgstate-accountable-care-activity-map

bull wwwstatereforumorg

Contact

mtakachnashporg

bwirthnashporg

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

For More Information

Searchform-f8cf0search_theSearchform-f8cf0search_the

7

WHOSE ON THE TEAM

bull New or Expanded Roles for

bull Nurses

bull Behavioral Health Specialists

bull Community Health Workers

bull Social Workers

bull Peer Specialists

bull Pharmacists

bull Health Coaches

8

SHARED SUPPORT TEAMS

RI

IA

MT

ME

NY

AL

OK

MN

NC

MI

VT

Making Payments to Shared Support Teams

Pursuing similar models through State Innovation Model Grants

MD

ID

IL

PA

9

Michigan

Maine Alabama

SHARED COMMUNITY CARE TEAM SNAPSHOT

Scope Payer(s) Payment Strategy Core Team Composition

Alabama

Patient Care

Networks of

Alabama

4 networks

170000 eligible

patients

Medicaid (Health

Home SPA)

Networks receive $950

PMPM for each Health

Home patient

Must include clinical director or

medical director clinical

pharmacist chronic care clinical

champion (nurse) care managers

(nurse or social worker)

Maine

Community

Care Teams

10 care teams

130000 eligible

patients

Medicaid (Health

Home SPA) Medicare

private plans some

self-insured employers

including state

employees

Teams receive $12950

PMPM for Medicaid Health

Homes $295 Medicaid non

Health Home $295 PMPM

for Medicare $030 PMPM

for privately insured

Must include part-time clinical

leader team composition based

on each entityrsquos care

management strategy

Vermont

Community

Health Teams

14 teams

514000 eligible

patients

Medicaid Medicare

private plans some

self-insured

Teams receive $350000 for

5 FTE team costs divided

proportionately among

payers

Staffing structures are flexible

most include nurse care

managers behavioral health

specialistssocial workers health

coaches panel managers and

tobacco cessation counselors

New York

Adirondack

Region Medical

Home Pilot Pods

3 pods

106000 eligible

patients

Medicaid Medicare

private plans some

self-insured employers

including state

employees

Pods receive $7 PMPM

payment to providers who

contract with pods for

support services Average

payment to pod

approximately $350 PMPM

No specific staffing requirements

structures vary across pods

10

PATIENT CARE NETWORKS OF ALABAMA

bull Four new 501(c)(3) organizations

bull Support Patient 1st Medicaid providers

bull Focus on high risk high acuity patients

bull Providers who partner with networks receive

$160 - $210 PMPM + $1 PMPM from Patient 1st

bull Total PMPM rate for Patient 1st patients in

network areas decreased by 77 vs 06 for

the rest of the state after 1st 6 months bull 3 network areas had a 15 decrease in their ER Use vs non-

network areas that had a 2 during same time (httpmedicaidalabamagovnews_detailaspxID=6608)

11

MAINE COMMUNITY CARE TEAMS

bull Multi-payer support PMPM varies by payer

bull Community care teams based in wide variety

of organizations

bull Support providers meeting ldquoNCQA Plusrdquo

including bull Behavioral health integration

bull Population risk-stratification and management

bull Team-based care

bull Connection to community resources

bull Focus on High Costs utilizers aka ldquoSuper Utilizersrdquo

bull No outcome data available

12

VERMONT BLUEPRINT FOR HEALTH COMMUNITY HEALTH TEAMS

bull Statewide multi-payer support

bull Provider reimbursement tied to NCQA PCMH

recognition and CHTs help practices meet NCQA

PCMH recognition

bull CHTs focus on public health helping patients engage in

preventive services and adopt healthier lifestyles

bull Specialized care coordinators added to teams to care

for elderly patients and substance abusers added

bull 2013 Vermont Annual Report found that people cared

for in PCMH + CHT setting had favorable outcomes vs

comparison groups including reductions in annual

expenditures more than offsetting payer investments in

PCMHs and CHTs

13

ADIRONDACKS REGIONAL PODS

bull Three ldquopodsrdquo in upstate NY supported by a central entity (Adirondack Health Institute)

bull Regional Multi-payer support

bull Workforce shortages was primary reason for development of PCMH initiative

bull Support affiliated practices and smaller independent practices in region

bull PMPM reimbursement passed through by providers

bull From 2006 to 2007 the region lost 24 PCPs Since the pilot began primary care has stabilized and grown total costs of care has been trending downward for commercial payers and Medicaid (httpwwwadkmedicalhomeorgwp-contentuploads201310Dennis-Weaver-Medical-Home-Summit-Presentationpdf)

14

IOWA ldquoCOMMUNITY CARE COORDINATION TEAMSrdquo

bull Pilot launched two regional teams in January 2014

bull Funded by Iowa Legislature through the statersquos Primary Care Association $300000team until June 2014

bull Purpose is to support safety net providers and small practices

bull Teams will support primary care practices in serving high-needs patients

bull Focus on population health and social determinants

bull Team composition based on community needs and resources

14

bull Care management

bull Patient education

bull Pharmacy management

bull Behavioral health

management

bull Link to community resources

15

KEY TAKEAWAYS

bull Team-based care is a key feature of a medical home

bull Meeting medical home criteria including team-based

care is hard work for practicesmdashparticularly small amp

rural practices

bull Shared community-based support teams offer providers

of all types the opportunity to participate in value-based

health care delivery models

bull Community-based teams can extend their reach by

leveraging social public health and other services and

extend their reach

bull Community based teams provide infrastructure for ACOs

15

16

Please visit

bull wwwnashporg

bull www nashporgmed-home-map

bull wwwnashporgstate-accountable-care-activity-map

bull wwwstatereforumorg

Contact

mtakachnashporg

bwirthnashporg

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

For More Information

Searchform-f8cf0search_theSearchform-f8cf0search_the

8

SHARED SUPPORT TEAMS

RI

IA

MT

ME

NY

AL

OK

MN

NC

MI

VT

Making Payments to Shared Support Teams

Pursuing similar models through State Innovation Model Grants

MD

ID

IL

PA

9

Michigan

Maine Alabama

SHARED COMMUNITY CARE TEAM SNAPSHOT

Scope Payer(s) Payment Strategy Core Team Composition

Alabama

Patient Care

Networks of

Alabama

4 networks

170000 eligible

patients

Medicaid (Health

Home SPA)

Networks receive $950

PMPM for each Health

Home patient

Must include clinical director or

medical director clinical

pharmacist chronic care clinical

champion (nurse) care managers

(nurse or social worker)

Maine

Community

Care Teams

10 care teams

130000 eligible

patients

Medicaid (Health

Home SPA) Medicare

private plans some

self-insured employers

including state

employees

Teams receive $12950

PMPM for Medicaid Health

Homes $295 Medicaid non

Health Home $295 PMPM

for Medicare $030 PMPM

for privately insured

Must include part-time clinical

leader team composition based

on each entityrsquos care

management strategy

Vermont

Community

Health Teams

14 teams

514000 eligible

patients

Medicaid Medicare

private plans some

self-insured

Teams receive $350000 for

5 FTE team costs divided

proportionately among

payers

Staffing structures are flexible

most include nurse care

managers behavioral health

specialistssocial workers health

coaches panel managers and

tobacco cessation counselors

New York

Adirondack

Region Medical

Home Pilot Pods

3 pods

106000 eligible

patients

Medicaid Medicare

private plans some

self-insured employers

including state

employees

Pods receive $7 PMPM

payment to providers who

contract with pods for

support services Average

payment to pod

approximately $350 PMPM

No specific staffing requirements

structures vary across pods

10

PATIENT CARE NETWORKS OF ALABAMA

bull Four new 501(c)(3) organizations

bull Support Patient 1st Medicaid providers

bull Focus on high risk high acuity patients

bull Providers who partner with networks receive

$160 - $210 PMPM + $1 PMPM from Patient 1st

bull Total PMPM rate for Patient 1st patients in

network areas decreased by 77 vs 06 for

the rest of the state after 1st 6 months bull 3 network areas had a 15 decrease in their ER Use vs non-

network areas that had a 2 during same time (httpmedicaidalabamagovnews_detailaspxID=6608)

11

MAINE COMMUNITY CARE TEAMS

bull Multi-payer support PMPM varies by payer

bull Community care teams based in wide variety

of organizations

bull Support providers meeting ldquoNCQA Plusrdquo

including bull Behavioral health integration

bull Population risk-stratification and management

bull Team-based care

bull Connection to community resources

bull Focus on High Costs utilizers aka ldquoSuper Utilizersrdquo

bull No outcome data available

12

VERMONT BLUEPRINT FOR HEALTH COMMUNITY HEALTH TEAMS

bull Statewide multi-payer support

bull Provider reimbursement tied to NCQA PCMH

recognition and CHTs help practices meet NCQA

PCMH recognition

bull CHTs focus on public health helping patients engage in

preventive services and adopt healthier lifestyles

bull Specialized care coordinators added to teams to care

for elderly patients and substance abusers added

bull 2013 Vermont Annual Report found that people cared

for in PCMH + CHT setting had favorable outcomes vs

comparison groups including reductions in annual

expenditures more than offsetting payer investments in

PCMHs and CHTs

13

ADIRONDACKS REGIONAL PODS

bull Three ldquopodsrdquo in upstate NY supported by a central entity (Adirondack Health Institute)

bull Regional Multi-payer support

bull Workforce shortages was primary reason for development of PCMH initiative

bull Support affiliated practices and smaller independent practices in region

bull PMPM reimbursement passed through by providers

bull From 2006 to 2007 the region lost 24 PCPs Since the pilot began primary care has stabilized and grown total costs of care has been trending downward for commercial payers and Medicaid (httpwwwadkmedicalhomeorgwp-contentuploads201310Dennis-Weaver-Medical-Home-Summit-Presentationpdf)

14

IOWA ldquoCOMMUNITY CARE COORDINATION TEAMSrdquo

bull Pilot launched two regional teams in January 2014

bull Funded by Iowa Legislature through the statersquos Primary Care Association $300000team until June 2014

bull Purpose is to support safety net providers and small practices

bull Teams will support primary care practices in serving high-needs patients

bull Focus on population health and social determinants

bull Team composition based on community needs and resources

14

bull Care management

bull Patient education

bull Pharmacy management

bull Behavioral health

management

bull Link to community resources

15

KEY TAKEAWAYS

bull Team-based care is a key feature of a medical home

bull Meeting medical home criteria including team-based

care is hard work for practicesmdashparticularly small amp

rural practices

bull Shared community-based support teams offer providers

of all types the opportunity to participate in value-based

health care delivery models

bull Community-based teams can extend their reach by

leveraging social public health and other services and

extend their reach

bull Community based teams provide infrastructure for ACOs

15

16

Please visit

bull wwwnashporg

bull www nashporgmed-home-map

bull wwwnashporgstate-accountable-care-activity-map

bull wwwstatereforumorg

Contact

mtakachnashporg

bwirthnashporg

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

For More Information

Searchform-f8cf0search_theSearchform-f8cf0search_the

9

Michigan

Maine Alabama

SHARED COMMUNITY CARE TEAM SNAPSHOT

Scope Payer(s) Payment Strategy Core Team Composition

Alabama

Patient Care

Networks of

Alabama

4 networks

170000 eligible

patients

Medicaid (Health

Home SPA)

Networks receive $950

PMPM for each Health

Home patient

Must include clinical director or

medical director clinical

pharmacist chronic care clinical

champion (nurse) care managers

(nurse or social worker)

Maine

Community

Care Teams

10 care teams

130000 eligible

patients

Medicaid (Health

Home SPA) Medicare

private plans some

self-insured employers

including state

employees

Teams receive $12950

PMPM for Medicaid Health

Homes $295 Medicaid non

Health Home $295 PMPM

for Medicare $030 PMPM

for privately insured

Must include part-time clinical

leader team composition based

on each entityrsquos care

management strategy

Vermont

Community

Health Teams

14 teams

514000 eligible

patients

Medicaid Medicare

private plans some

self-insured

Teams receive $350000 for

5 FTE team costs divided

proportionately among

payers

Staffing structures are flexible

most include nurse care

managers behavioral health

specialistssocial workers health

coaches panel managers and

tobacco cessation counselors

New York

Adirondack

Region Medical

Home Pilot Pods

3 pods

106000 eligible

patients

Medicaid Medicare

private plans some

self-insured employers

including state

employees

Pods receive $7 PMPM

payment to providers who

contract with pods for

support services Average

payment to pod

approximately $350 PMPM

No specific staffing requirements

structures vary across pods

10

PATIENT CARE NETWORKS OF ALABAMA

bull Four new 501(c)(3) organizations

bull Support Patient 1st Medicaid providers

bull Focus on high risk high acuity patients

bull Providers who partner with networks receive

$160 - $210 PMPM + $1 PMPM from Patient 1st

bull Total PMPM rate for Patient 1st patients in

network areas decreased by 77 vs 06 for

the rest of the state after 1st 6 months bull 3 network areas had a 15 decrease in their ER Use vs non-

network areas that had a 2 during same time (httpmedicaidalabamagovnews_detailaspxID=6608)

11

MAINE COMMUNITY CARE TEAMS

bull Multi-payer support PMPM varies by payer

bull Community care teams based in wide variety

of organizations

bull Support providers meeting ldquoNCQA Plusrdquo

including bull Behavioral health integration

bull Population risk-stratification and management

bull Team-based care

bull Connection to community resources

bull Focus on High Costs utilizers aka ldquoSuper Utilizersrdquo

bull No outcome data available

12

VERMONT BLUEPRINT FOR HEALTH COMMUNITY HEALTH TEAMS

bull Statewide multi-payer support

bull Provider reimbursement tied to NCQA PCMH

recognition and CHTs help practices meet NCQA

PCMH recognition

bull CHTs focus on public health helping patients engage in

preventive services and adopt healthier lifestyles

bull Specialized care coordinators added to teams to care

for elderly patients and substance abusers added

bull 2013 Vermont Annual Report found that people cared

for in PCMH + CHT setting had favorable outcomes vs

comparison groups including reductions in annual

expenditures more than offsetting payer investments in

PCMHs and CHTs

13

ADIRONDACKS REGIONAL PODS

bull Three ldquopodsrdquo in upstate NY supported by a central entity (Adirondack Health Institute)

bull Regional Multi-payer support

bull Workforce shortages was primary reason for development of PCMH initiative

bull Support affiliated practices and smaller independent practices in region

bull PMPM reimbursement passed through by providers

bull From 2006 to 2007 the region lost 24 PCPs Since the pilot began primary care has stabilized and grown total costs of care has been trending downward for commercial payers and Medicaid (httpwwwadkmedicalhomeorgwp-contentuploads201310Dennis-Weaver-Medical-Home-Summit-Presentationpdf)

14

IOWA ldquoCOMMUNITY CARE COORDINATION TEAMSrdquo

bull Pilot launched two regional teams in January 2014

bull Funded by Iowa Legislature through the statersquos Primary Care Association $300000team until June 2014

bull Purpose is to support safety net providers and small practices

bull Teams will support primary care practices in serving high-needs patients

bull Focus on population health and social determinants

bull Team composition based on community needs and resources

14

bull Care management

bull Patient education

bull Pharmacy management

bull Behavioral health

management

bull Link to community resources

15

KEY TAKEAWAYS

bull Team-based care is a key feature of a medical home

bull Meeting medical home criteria including team-based

care is hard work for practicesmdashparticularly small amp

rural practices

bull Shared community-based support teams offer providers

of all types the opportunity to participate in value-based

health care delivery models

bull Community-based teams can extend their reach by

leveraging social public health and other services and

extend their reach

bull Community based teams provide infrastructure for ACOs

15

16

Please visit

bull wwwnashporg

bull www nashporgmed-home-map

bull wwwnashporgstate-accountable-care-activity-map

bull wwwstatereforumorg

Contact

mtakachnashporg

bwirthnashporg

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

For More Information

Searchform-f8cf0search_theSearchform-f8cf0search_the

10

PATIENT CARE NETWORKS OF ALABAMA

bull Four new 501(c)(3) organizations

bull Support Patient 1st Medicaid providers

bull Focus on high risk high acuity patients

bull Providers who partner with networks receive

$160 - $210 PMPM + $1 PMPM from Patient 1st

bull Total PMPM rate for Patient 1st patients in

network areas decreased by 77 vs 06 for

the rest of the state after 1st 6 months bull 3 network areas had a 15 decrease in their ER Use vs non-

network areas that had a 2 during same time (httpmedicaidalabamagovnews_detailaspxID=6608)

11

MAINE COMMUNITY CARE TEAMS

bull Multi-payer support PMPM varies by payer

bull Community care teams based in wide variety

of organizations

bull Support providers meeting ldquoNCQA Plusrdquo

including bull Behavioral health integration

bull Population risk-stratification and management

bull Team-based care

bull Connection to community resources

bull Focus on High Costs utilizers aka ldquoSuper Utilizersrdquo

bull No outcome data available

12

VERMONT BLUEPRINT FOR HEALTH COMMUNITY HEALTH TEAMS

bull Statewide multi-payer support

bull Provider reimbursement tied to NCQA PCMH

recognition and CHTs help practices meet NCQA

PCMH recognition

bull CHTs focus on public health helping patients engage in

preventive services and adopt healthier lifestyles

bull Specialized care coordinators added to teams to care

for elderly patients and substance abusers added

bull 2013 Vermont Annual Report found that people cared

for in PCMH + CHT setting had favorable outcomes vs

comparison groups including reductions in annual

expenditures more than offsetting payer investments in

PCMHs and CHTs

13

ADIRONDACKS REGIONAL PODS

bull Three ldquopodsrdquo in upstate NY supported by a central entity (Adirondack Health Institute)

bull Regional Multi-payer support

bull Workforce shortages was primary reason for development of PCMH initiative

bull Support affiliated practices and smaller independent practices in region

bull PMPM reimbursement passed through by providers

bull From 2006 to 2007 the region lost 24 PCPs Since the pilot began primary care has stabilized and grown total costs of care has been trending downward for commercial payers and Medicaid (httpwwwadkmedicalhomeorgwp-contentuploads201310Dennis-Weaver-Medical-Home-Summit-Presentationpdf)

14

IOWA ldquoCOMMUNITY CARE COORDINATION TEAMSrdquo

bull Pilot launched two regional teams in January 2014

bull Funded by Iowa Legislature through the statersquos Primary Care Association $300000team until June 2014

bull Purpose is to support safety net providers and small practices

bull Teams will support primary care practices in serving high-needs patients

bull Focus on population health and social determinants

bull Team composition based on community needs and resources

14

bull Care management

bull Patient education

bull Pharmacy management

bull Behavioral health

management

bull Link to community resources

15

KEY TAKEAWAYS

bull Team-based care is a key feature of a medical home

bull Meeting medical home criteria including team-based

care is hard work for practicesmdashparticularly small amp

rural practices

bull Shared community-based support teams offer providers

of all types the opportunity to participate in value-based

health care delivery models

bull Community-based teams can extend their reach by

leveraging social public health and other services and

extend their reach

bull Community based teams provide infrastructure for ACOs

15

16

Please visit

bull wwwnashporg

bull www nashporgmed-home-map

bull wwwnashporgstate-accountable-care-activity-map

bull wwwstatereforumorg

Contact

mtakachnashporg

bwirthnashporg

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

For More Information

Searchform-f8cf0search_theSearchform-f8cf0search_the

11

MAINE COMMUNITY CARE TEAMS

bull Multi-payer support PMPM varies by payer

bull Community care teams based in wide variety

of organizations

bull Support providers meeting ldquoNCQA Plusrdquo

including bull Behavioral health integration

bull Population risk-stratification and management

bull Team-based care

bull Connection to community resources

bull Focus on High Costs utilizers aka ldquoSuper Utilizersrdquo

bull No outcome data available

12

VERMONT BLUEPRINT FOR HEALTH COMMUNITY HEALTH TEAMS

bull Statewide multi-payer support

bull Provider reimbursement tied to NCQA PCMH

recognition and CHTs help practices meet NCQA

PCMH recognition

bull CHTs focus on public health helping patients engage in

preventive services and adopt healthier lifestyles

bull Specialized care coordinators added to teams to care

for elderly patients and substance abusers added

bull 2013 Vermont Annual Report found that people cared

for in PCMH + CHT setting had favorable outcomes vs

comparison groups including reductions in annual

expenditures more than offsetting payer investments in

PCMHs and CHTs

13

ADIRONDACKS REGIONAL PODS

bull Three ldquopodsrdquo in upstate NY supported by a central entity (Adirondack Health Institute)

bull Regional Multi-payer support

bull Workforce shortages was primary reason for development of PCMH initiative

bull Support affiliated practices and smaller independent practices in region

bull PMPM reimbursement passed through by providers

bull From 2006 to 2007 the region lost 24 PCPs Since the pilot began primary care has stabilized and grown total costs of care has been trending downward for commercial payers and Medicaid (httpwwwadkmedicalhomeorgwp-contentuploads201310Dennis-Weaver-Medical-Home-Summit-Presentationpdf)

14

IOWA ldquoCOMMUNITY CARE COORDINATION TEAMSrdquo

bull Pilot launched two regional teams in January 2014

bull Funded by Iowa Legislature through the statersquos Primary Care Association $300000team until June 2014

bull Purpose is to support safety net providers and small practices

bull Teams will support primary care practices in serving high-needs patients

bull Focus on population health and social determinants

bull Team composition based on community needs and resources

14

bull Care management

bull Patient education

bull Pharmacy management

bull Behavioral health

management

bull Link to community resources

15

KEY TAKEAWAYS

bull Team-based care is a key feature of a medical home

bull Meeting medical home criteria including team-based

care is hard work for practicesmdashparticularly small amp

rural practices

bull Shared community-based support teams offer providers

of all types the opportunity to participate in value-based

health care delivery models

bull Community-based teams can extend their reach by

leveraging social public health and other services and

extend their reach

bull Community based teams provide infrastructure for ACOs

15

16

Please visit

bull wwwnashporg

bull www nashporgmed-home-map

bull wwwnashporgstate-accountable-care-activity-map

bull wwwstatereforumorg

Contact

mtakachnashporg

bwirthnashporg

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

For More Information

Searchform-f8cf0search_theSearchform-f8cf0search_the

12

VERMONT BLUEPRINT FOR HEALTH COMMUNITY HEALTH TEAMS

bull Statewide multi-payer support

bull Provider reimbursement tied to NCQA PCMH

recognition and CHTs help practices meet NCQA

PCMH recognition

bull CHTs focus on public health helping patients engage in

preventive services and adopt healthier lifestyles

bull Specialized care coordinators added to teams to care

for elderly patients and substance abusers added

bull 2013 Vermont Annual Report found that people cared

for in PCMH + CHT setting had favorable outcomes vs

comparison groups including reductions in annual

expenditures more than offsetting payer investments in

PCMHs and CHTs

13

ADIRONDACKS REGIONAL PODS

bull Three ldquopodsrdquo in upstate NY supported by a central entity (Adirondack Health Institute)

bull Regional Multi-payer support

bull Workforce shortages was primary reason for development of PCMH initiative

bull Support affiliated practices and smaller independent practices in region

bull PMPM reimbursement passed through by providers

bull From 2006 to 2007 the region lost 24 PCPs Since the pilot began primary care has stabilized and grown total costs of care has been trending downward for commercial payers and Medicaid (httpwwwadkmedicalhomeorgwp-contentuploads201310Dennis-Weaver-Medical-Home-Summit-Presentationpdf)

14

IOWA ldquoCOMMUNITY CARE COORDINATION TEAMSrdquo

bull Pilot launched two regional teams in January 2014

bull Funded by Iowa Legislature through the statersquos Primary Care Association $300000team until June 2014

bull Purpose is to support safety net providers and small practices

bull Teams will support primary care practices in serving high-needs patients

bull Focus on population health and social determinants

bull Team composition based on community needs and resources

14

bull Care management

bull Patient education

bull Pharmacy management

bull Behavioral health

management

bull Link to community resources

15

KEY TAKEAWAYS

bull Team-based care is a key feature of a medical home

bull Meeting medical home criteria including team-based

care is hard work for practicesmdashparticularly small amp

rural practices

bull Shared community-based support teams offer providers

of all types the opportunity to participate in value-based

health care delivery models

bull Community-based teams can extend their reach by

leveraging social public health and other services and

extend their reach

bull Community based teams provide infrastructure for ACOs

15

16

Please visit

bull wwwnashporg

bull www nashporgmed-home-map

bull wwwnashporgstate-accountable-care-activity-map

bull wwwstatereforumorg

Contact

mtakachnashporg

bwirthnashporg

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

For More Information

Searchform-f8cf0search_theSearchform-f8cf0search_the

13

ADIRONDACKS REGIONAL PODS

bull Three ldquopodsrdquo in upstate NY supported by a central entity (Adirondack Health Institute)

bull Regional Multi-payer support

bull Workforce shortages was primary reason for development of PCMH initiative

bull Support affiliated practices and smaller independent practices in region

bull PMPM reimbursement passed through by providers

bull From 2006 to 2007 the region lost 24 PCPs Since the pilot began primary care has stabilized and grown total costs of care has been trending downward for commercial payers and Medicaid (httpwwwadkmedicalhomeorgwp-contentuploads201310Dennis-Weaver-Medical-Home-Summit-Presentationpdf)

14

IOWA ldquoCOMMUNITY CARE COORDINATION TEAMSrdquo

bull Pilot launched two regional teams in January 2014

bull Funded by Iowa Legislature through the statersquos Primary Care Association $300000team until June 2014

bull Purpose is to support safety net providers and small practices

bull Teams will support primary care practices in serving high-needs patients

bull Focus on population health and social determinants

bull Team composition based on community needs and resources

14

bull Care management

bull Patient education

bull Pharmacy management

bull Behavioral health

management

bull Link to community resources

15

KEY TAKEAWAYS

bull Team-based care is a key feature of a medical home

bull Meeting medical home criteria including team-based

care is hard work for practicesmdashparticularly small amp

rural practices

bull Shared community-based support teams offer providers

of all types the opportunity to participate in value-based

health care delivery models

bull Community-based teams can extend their reach by

leveraging social public health and other services and

extend their reach

bull Community based teams provide infrastructure for ACOs

15

16

Please visit

bull wwwnashporg

bull www nashporgmed-home-map

bull wwwnashporgstate-accountable-care-activity-map

bull wwwstatereforumorg

Contact

mtakachnashporg

bwirthnashporg

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

For More Information

Searchform-f8cf0search_theSearchform-f8cf0search_the

14

IOWA ldquoCOMMUNITY CARE COORDINATION TEAMSrdquo

bull Pilot launched two regional teams in January 2014

bull Funded by Iowa Legislature through the statersquos Primary Care Association $300000team until June 2014

bull Purpose is to support safety net providers and small practices

bull Teams will support primary care practices in serving high-needs patients

bull Focus on population health and social determinants

bull Team composition based on community needs and resources

14

bull Care management

bull Patient education

bull Pharmacy management

bull Behavioral health

management

bull Link to community resources

15

KEY TAKEAWAYS

bull Team-based care is a key feature of a medical home

bull Meeting medical home criteria including team-based

care is hard work for practicesmdashparticularly small amp

rural practices

bull Shared community-based support teams offer providers

of all types the opportunity to participate in value-based

health care delivery models

bull Community-based teams can extend their reach by

leveraging social public health and other services and

extend their reach

bull Community based teams provide infrastructure for ACOs

15

16

Please visit

bull wwwnashporg

bull www nashporgmed-home-map

bull wwwnashporgstate-accountable-care-activity-map

bull wwwstatereforumorg

Contact

mtakachnashporg

bwirthnashporg

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

For More Information

Searchform-f8cf0search_theSearchform-f8cf0search_the

15

KEY TAKEAWAYS

bull Team-based care is a key feature of a medical home

bull Meeting medical home criteria including team-based

care is hard work for practicesmdashparticularly small amp

rural practices

bull Shared community-based support teams offer providers

of all types the opportunity to participate in value-based

health care delivery models

bull Community-based teams can extend their reach by

leveraging social public health and other services and

extend their reach

bull Community based teams provide infrastructure for ACOs

15

16

Please visit

bull wwwnashporg

bull www nashporgmed-home-map

bull wwwnashporgstate-accountable-care-activity-map

bull wwwstatereforumorg

Contact

mtakachnashporg

bwirthnashporg

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

For More Information

Searchform-f8cf0search_theSearchform-f8cf0search_the

16

Please visit

bull wwwnashporg

bull www nashporgmed-home-map

bull wwwnashporgstate-accountable-care-activity-map

bull wwwstatereforumorg

Contact

mtakachnashporg

bwirthnashporg

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

bullHome | bullAbout NASHP | bullNewsroom | bullE-News signup | bullEmployment | bullContact Us

Search this site

bullChronic amp Long Term Care bullComprehensive Health Reform bullCoverage amp Access bullHealth System Improvement bullSpecific Services amp Populations

bullABCD Resource Center bullMaximizing Enrollment for Kids bullMedicaid and the DRA bullPatient Safety Toolbox bullState Quality Improvement Partnership Toolbox

bullNASHP Projects amp Programs bullNASHP Publications by Category bullNASHP Publications by Date bullNASHP Authors Publications bullNASHP Publications by Related Topics

bullPreconference Sessions bullConference Sessions bullConference Speakers bullSession Speakers

New NASHP Publications bullA State Policymakersrsquo Guide to Federal Health Reform - Part I Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states Through program design regulations policies and practices state decisions and actions already play a profound role in shaping the American health care system Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates Part I of this State Policymakersrsquo Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles Download the file Policymakers Guide Part 1 November 2009 bullState Policymakersrsquo Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHPrsquos state leadership as their most significant priorities for improving their health systems As Academy members discussed their priorities a set of broader themes emerged These larger policy goals are Connect People to Needed Services Promote Coordination and Integration in the Health System Improve Care for Populations with Complex Needs Orient the Health System toward Results Increase Health System Efficiencies This briefing also provides a more detailed list of statesrsquo priorities presented in four major categories of state health policy Coverage and Access Health Systems Improvement Special Services and Populations and Long Term and Chronic Care Download the file Policymakers Priorities November 2009 bullSupporting State Policymakersrsquo Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation Significant federal and private resources to support state-level implementation will be necessary Implementation support must be defined and coordinated quickly Technical assistance must be provided in a manner that corresponds with state needs State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances needs and capacities Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance Download the file Supporting Implementation of Federal Reform November 2009

Will Medicare Join State Multi-Payer Medical Home Initiatives A Conversation with States Regarding Medicarersquos Proposed Advanced Primary Care Demonstration

ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children

bullRWJF Blog Preparing for health reform in the states with Alan Weil

For More Information

Searchform-f8cf0search_theSearchform-f8cf0search_the