Blueprint Integrated Pilot Programs Community Activation & Prevention Academy Health Coordinating State Health Reform November 20 – 21, 2008 Craig Jones MD Craig.jones@state.vt.us
Improve Quality Health Care Reform Goals Contain Costs 60+ Initiatives Increase Access
Vermont Blueprint Context Vermont Blueprint Context • Relatively good distribution of Primary Care Providers (PCPs) statewide – 800 PCPs in 300 practices in 13 Hospital Service Areas • Three major health plan carriers + Medicaid + Medicare • Most PCPs participate in all plans • History of working together
Funding Programs Products Blueprint Communities (Act 191, 2006) � Clinical Transformation VPQ Coordinated Training Clinical Microsystems � Provider Incentives � Improved Care Delivery (Diabetes) Participation & Training � Community Activation � IT enhanced care (Diabetes) Blueprint / State � Improved self mgmt (HLW attendees) Local Programs � Self Management • Global Commitment � Local exercise / prevention programs Sustainable Transformation • Catamount Fund � VHR - Descriptive statistics (Diabetes) Healthier Living Workshops � Health Information Technology � VCHIP – Chart review • Federal Funds VPQ Hosted Registry (VHR) • HIT Fund � Evaluation VPQ Registry Reports VCHIP Chart Review � VITL Health Information Exchange Network � Advanced Medical Home � Improved Care Delivery (General) Blueprint Integrated Pilots � Local care support & DM services Payer Support (Act 71 2007, Act 204 2008) � Sustainable Financial Reform • Medicaid � Financial Reform � Improved Self Mgmt (Multi-faceted) • BCBS � IT enhanced care Enhanced provider payment • Cigna Shared costs for CCT -Chronic disease • MVP � Local Care Support -Health maintenance CCT as shared resource -eRx � Prevention � Prevention & Wellness Programs Public Health Specialist on CCT -Community team Grant Support ? Local Prevention Team -Evidence based � Health Information Technology -Linked with care delivery VITL EMR Pilot Project VPQ Hosted Web Based CIS with eRx � VITL Health Information Exchange Network � Evidence based healthcare process � Routine QA / QI � Evaluation of health impact Evaluation Infrastructure � Evaluation of financial impact � Multi payer claims data base � Predictive modeling (claims / clinical) � Clinical / demographic data base � Epidemiologic / outcomes research � VCHIP NCQA PCMH scoring � CCT Utilization Patterns � VCHIP chart review
BP Pilot – Healthcare transformation. 1. Financial reform - Payment based on NCQA PCMH standards - Shared costs for Community Care Teams - Medicaid & commercial payers - BP subsidizing Medicare 2. Multidisciplinary care support teams (CCT Teams) - Local care support & population management - Prevention specialists 3. Health Information Technology - Web based clinical tracking system (DocSite) - Visit planners & population reports - Electronic prescribing - Health information exchange network 4. Community Activation & Prevention - Prevention specialist as part of CCT - Community profiles & risk assessments - Evidence based interventions 5. Evaluation - NCQA PCMH score (process quality) - Clinical process measures - Health status measures - Multi payer claims data base
Model for Health & Prevention PCMH Primary Care PCMH � Payment reform - Docs � Comprehensive guideline based care - NPs � Health maintenance & prevention - PAs � Chronic conditions - Staff � Panel management CCT Support � Coaching � Panel Management � Reminders � Coaching � Goal setting � Patient / family contact � Health IT – planned visits � Assessment Referrals, � Health IT – population management � Reinforce treatment plan Communication � Health IT – eRx � Education & QI Planning � Paper based or EMR practices � Reminders � Self management Social / Economic Support � Liaison to other programs Community Care Team (CCT) � Enrollment assistance e.g. NP, RN, MSW, Dietician, Behavior Specialist, Community Prevention & Self Management Health Worker, VDH Public � Referral to community programs Health Specialist � Coordinate community programs Vermont Health Information Platform (VITL) Referral & care support Education & Improvement Public Health & Prevention
Community Assessment & Planning Timeline October 2008 PHASE 2a - Community PHASE 2b - Community Profile Assessment • Community description • Quantitative Context - state level • Community inventory 10 year trend analysis of risk PHASE 3 - Community PHASE 4 - Implementation Phase 5 – • Quantitative Context - factors associated with morbidity Planning Evaluation • Timeline depends on scope Descriptive health statistics & healthcare costs • Planning with key leaders and resources of planned • Focus groups on the rates of risk factors • Planning with stakeholders intervention • Formal key leader interviews in each community • Iterative interactive process • Continue until no new themes (5 year aggregate data) • Consensus building • Test themes in new interviews • Test findings in community forums 3 - 5 4 - 6 2 - 4 months months months PHASE I - Develop capacity • Facilitate systems approach • Train Prevention Specialist • Prevention Model and Framework • Data collection techniques • Environment and policy change
Community Assessment Phase 2A - Community Profile Targeting and Planning Phase 2b - Community Assessment Quantitative Assessment Health Statistics •State level multi-variant analysis of health risk and •Demographic risk factors for chronic disease demographic data to determine associates with •Outcomes data: health systems use, morbidity and mortality outcome data •Health risks data: nutrition, physical activity, tobacco use, substance abuse, depression/mental health, and access to Plan Targeted Assessment health care, pharmacotherapy and self-management services •Review community description, inventory, and health statistics Qualitative Assessment •Identify emerging issues •Focus groups •Distinguish target audience(s) •Formal key leader interviews •Develop assessment question •Continue interviews until no new themes •Prioritize assessment questions •Analyze data Community Description & Inventory •Prepare local assessment plan •Test themes in new interviews •Meet with key leaders & stakeholders •Finalize ideas / findings in community forums •Description of the community •Inventory of community resources •Key issues •Health issues December 2008 – July 2009 August 2008 – December 2008 Collaborative • Key stakeholders • Community members • District public health prevention specialists • Blueprint hospitals • VDH health surveillance team • VDH HPDP team • Blueprint team
Phase 2b Community Assessment Process Quantitative Analysis and Reporting Qualitative Data Collection and Reporting Quantitative Assessment •Multi-variant trend analysis of health risk and • Identify gatekeepers demographic data associated with disease prevalence, • Develop interview protocol morbidity, and healthcare costs. • Create focus group guide •Comparison of state level data to local data • Data collection •Identification of health disparities at the community • Data analysis level based on associations •Provides context for qualitative data collection and planning. • Revise and repeat until no new themes emerge • Prepare written report
Blueprint for Health: Planned Analyses Vermont Department of Health Surveillance Group November 7, 2008 � Initial Health Statistics report will be used for planning the targeted assessment. � The Health Statistics report will include the rates of demographic indicators, health risks, and outcomes in 5 year aggregate periods for each District as compared to state � The Quantitative Analysis will be used to help inform the Qualitative Community Assessment & Planning processes. � The Quantitative Analysis will include a multivariate state level evaluation of demographic indicators and health risks most closely associated with Hospitalizations and Costs (trend analysis over 10 year period)
Model for Health & Prevention Referrals & Hospital Primary Care PCMH Communication Healthcare -Educators - Docs -Transitional care - NPs -Ambulatory center - Staff (wellness programs) Community Care Team (CCT) e.g. NP, RN, MSW, Dietician, Behavior Specialist, Community Health Worker, Prevention VDH Public Health Specialist Policies and Systems Local, state, and federal policies and laws, economic and cultural influences, media Community Physical, social and cultural environment Organizations Schools, worksites, faith-based organizations, etc Relationships Family, peers, social networks, associations I ndividual Knowledge, attitudes, beliefs Adapted from: McElroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Education Quarterly 15:351-377, 1988. Vermont Health Information Platform (VITL) Referral & care support Education & Quality Improvement
H s o r H e s e a p d l i t t i h v a I o T l s r P h t l a s e r e H r u s c n I i l b u P Every dollar of health care spending is a dollar of income to someone Three “Inconvenient Truths” about Health Care. Fuchs NEJM 2008 359;17:1749 Contracted Benefits Pharmaceutical Managers Services Companies
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