health care home certification · the burning platform • mdh data suggests hch has decreased tcoc...
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Health Care Home Certification
Fairview Physician AssociatesIndependent Primary Care Clinics
Where did this come from?
• 2008 Minnesota health reform law
• Improved outcomes due to better
coordinated care for complex and chronic
conditions
• Identified need for care coordination
reimbursement
• Platform to achieve “Triple Aim”
What is a Health Care Home
(HCH)?
An approach to primary care in which
primary care providers, staff, families and
patients work in partnership to improve
health outcomes and quality of life for
individuals with chronic or complex health
conditions.
5 Major Standards of The HCH
• Access/Communication
• Patient tracking and registry functions
• Care Coordination
• Care Plans
• Performance reporting and quality
improvement
The Burning Platform• MDH data suggests HCH has decreased
TCOC by 6%
• Some payers are starting to require HCHCertification
• Fee for service model is shifting to shared savings/bundled payment
• Patient Choice – Patient’s are starting to look for this certification when selecting a clinic
• Quality- FMG as well as other HCH’s, have seen improved quality outcomes
• Heart of ACO
• Promotes Team Based Model- Distributes care responsibilities to appropriate scope of practice
Care redesign and payment reform!
Today’s Care Health Care Home
Patients are recipients of services by providers and clinics Patients and families are partners in the planning and
provision of care
Patients are those who make appointments to see us Patients agree to participate in HCH and understand how to
contact their HCH
Care is determined by today’s problem and available time Proactive care planning is done with patient/family to
anticipate needs
Care varies by memory or skill of the provider Care is standardized with evidence-based guidelines, protocols
and planned visits
Patients are responsible to coordinate their own care A team, including the care coordinator, coordinates care with
patient/family
I know I deliver quality care because I’m well trained We measure our quality and outcomes and make ongoing
changes to improve, and we include patients/families in our
quality work
It’s up to the patient to tell us what happened to them We use a registry to track visits and tests and we do follow-up
after ED and hospital visits.
Clinical operations center on meeting provider needs A multidisciplinary team works at the top of their scope to
provide patient/family-centered care.
Comparing Today’s Care and HCH
Process• Clinics apply for HCH certification
• MDH site visit
• Annual recertification
• Flexibility for all kinds of providers and
clinics to be HCH as long as they provide full
range of primary care services
– First point of contact for acute care
– Preventative care
– Chronic care
Access and Communication
Standards• System in place to tell patients about HCH
services
• Patient knows how to access HCH
continuously
• Person responding to patient call has access
to patient’s HCH info, triage system, on-call
provider or clinic staff
Access and Communication
Standards• Access addressed by protocol
– To avoid unnecessary ED visits or
hospitalizations
• There is a process to collect cultural, racial
and primary language information and it is
used in providing care
• The team knows the patient’s/family’s
preferred communication method
Access and Communication
Standards• Process in place to inform HCH participants they
may choose specialists without regard to being in
same provider group or network
• HCH encourages patients to play active role in
managing their own health care
• HCH improves participant involvement by
addressing readiness for change, literacy level,
other impediments to learning
• HCH complies with all privacy and confidentiality
laws
Registry and Patient Tracking
Standards• Must have a registry that is electronic and searchable
– Sufficient data available to manage patients with
chronic or complex conditions
– Customized for various conditions
• Systematic reviews of participant population to
identify care gaps
• Processes in place to prevent care gaps
– Appointment reminders and pre-visit planning
Care Coordination Standards
• Team approach that engages participant,
provider, other members of health care team
• Organizes timely access to resources and care
• Provides continuity of care
• Care coordinator has primary responsibility
to organize care for participants of HCH
Care Coordination Standards
• Promotes patient/family-centered care
• Fully engage patients/family members in care
planning and shared decision making
– Process is documented
• HCH identifies community resources
• Team members practice at top of scope
• HCH plans for transitions among clinicians
and at life stages
Care Coordinators• Track appointments, test results, referrals,
medication refills
– Use evidence-based guidelines
– Medication reconciliation and refills
– Test results reported timely
• Coordinate admissions, post discharge and
transition planning
• Develop resources and links participants to them as
needed
• Document in chart and maintains care plan
What is a care plan?
• Individualized written document that
identifies patient needs, goals and actions
• Comprehensive plan includes relevant
portions of external care plans
• Patient and family have input into plan of
care
Care Plan Standards
• Incorporate assessment of patient health risks
and chronic conditions
• List diagnoses identified by provider and RN
team members
• Reviewed with patient and jointly amended at
intervals appropriate to patient’s care
• Includes goals and action plans identified by
HCH team and patient/family
Care Plan Standards• A copy is provided to the patient/family
initially and with each change
• Evidence-based guidelines are used
• Includes goals and actions for
– Preventative care
– Care for chronic illnesses
– Special needs
– Plans for early contact with HCH for
exacerbation of condition
– End of life care and advance directives
Identifying HCH Potential
Patients
The “Usual Mix”
Tier 050%
Tier 112%
Tier 217%
Tier 312%
Tier 49%
HCH Participants
50% Tier 0
No chronic conditions or less
complex conditions.
Routine panel—management and
preventative care.
50% Tiers 1-4
Chronic conditions or more
severe, complex conditions.
Need more intense care and
coordination.
Who’s included?• Included (about 40% of Minnesotans)
– Medicaid and state-funded public programs
– State employees
– Fully-insured private insurance (small employer
groups and individual policies)
• Not included (about 60% of Minnesotans)
– Medicare
– Self-insured private insurance (large employers)
– Uninsured
How are we paid for the care?
• Paid by the patient, not by the visit
• Fees vary by thresholds of patient complexity
– Complexity represents time and work needed to
coordinate care
– Higher fees for more complex patients
• Complexity includes both medical and
psychosocial factors. 15% rate increase for
serious mental conditions and primary
language other than English.
Definitions
• Chronic conditions have lasted at least six
months, can reasonably be expected to
continue for at least six months, or are likely
to recur
• Severe conditions are major and potentially
unstable conditions that, without optimal
care, are likely to worsen and lead to altered
physiologic state, impairment, or death.
Definitions• Requires a care team means a care team is
required for this condition to attain or maintain
stability and optimal health status for the patient.
This includes preventive care or coordination to
prevent progression of disease, deterioration, or
gaps in care.
• Care team is a group of health professionals who
plan and deliver care in collaboration with a
participant. Includes a provider, a care
coordinator and may include others based on
patient need.
Complexity Info Needed for
Payment• Patient’s tier level (based on count of major
condition groups)
– Tier 0 (none)
– Tier 1 (1-3)
– Tier 2 (4-6)
– Tier 3 (7-9)
– Tier 4 (10 or more)
• Presence of either of the two supplemental
complexity factors
Reimbursement Rates
• Based on a mix for each hour of
care of 20% physician time, 50%
care coordination time, 30%
office/clerical
• Rate for one hour of care
coordination in HCH=$40.54
• Per member per month (PMPM)
rates based on minutes of care
coordination per month
• Additional 15% for each of the
supplemental factors
Tier Minutes of
work PMPM
PMPM
Rate
0 N/A N/A
1 15 10.14
2 30 20.27
3 60 40.54
4 90 60.81
Add 15% for each supplemental factor
Tier Assignment Tool
Assigning Patients to Tiers
1. Determine if any condition in the group is
chronic
– If yes, mark box
– If no, stop and mark score as 0
2. Determine if any condition in the group is
severe
– If yes, mark box
– If no, stop and mark score as 0
Assigning Patients to Tiers
3. Determine if any condition in the group
requires a care team
– If yes, mark box
– If no, stop and mark score as 0
4. Total the scores for each group. The sum
count determines the tier.
5. Mark any supplemental factors (but don’t
add to the sum count)
Example 1: Sarah
Supplemental Factors• Need to communicate about health care in
non-English primary language
– Includes hearing impaired needing sign language
interpreter
– Consider if language barrier is significant enough
to prevent discussion with care team for
coordination of severe, chronic conditions
– Designation is in addition to billing for
interpreter services and reimburses for extra
work of care coordination
Supplemental Factors
• Has a serious and persistent mental illness diagnosis
– Applies to patient or caregiver
– Has active diagnosis of schizophrenia, bipolar disorder,
major depression, borderline personality disorder
– Implies some level of functional impairment observed
– Designation is in addition to mental health diagnosis
checked in condition group and reimburses for added
intensity of care coordination
Conclusion• HCH is a way to improve clinical outcomes
and decrease costs
– Patient involvement is key
• This model recognizes the importance of care
coordination and is willing to pay for it
• Care coordination needs determined by tier
• Care coordinators are essential to make
this work
• THANK YOU for all you do!