Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. Patient-Centered Medical Home

10/29/2013

In 2009, Maine established 22 PCMH projects state including the EMHS Primary Care Medical Home Demonstration Project. One year later in 2010 CMS issued a demonstration project -- Multi-Payer Advanced Primary Care (MAPCP) -- in which Maine was selected as one of eight states to have Medicare participate as a payer.

The PCMH's are reimbursed by three types of payers: Medicare, MaineCare (state Medicaid Program) and commercial insurers. Medicare pays $7/member/month for PCMH services and $3/member/month for CCT. Maine is projecting to achieve budget-neutrality by decreasing patient inpatient admissions by 6%-7%, decreasing ED visits by 5%, and decreasing specialty consultations and imaging by 5%.

In addition to PCMHs, MaineCare developed health homes that serve individuals with:

  • Two or more chronic conditions.

  • One chronic condition and who are at-risk for another.

  • Serious mental illness (SMI) including:
    • Adults with SMI; and
    • Children with severe emotional disturbance (SED).

The care management infrastructure in the PCMH includes at a minimum a nurse patient care manager embedded in each primary care practice who works with high-risk/high cost patients in the four priority diagnoses established under the Beacon project: diabetes mellitus, chronic heart failure, COPD, and asthma. The primary care managers also target patients who are in risk corridor populations identified under the ACO program as well as high cost patients. If they cannot be effectively managed in the primary care practice, then a referral is made to the CCT to address the patient's need in the community.

Referrals for the PCMH care management come from a variety of sources including:

  • Provider referrals;
  • Hospital discharge referral;
  • Predictive modeling reports from payers;
  • Specialized queries and reports that target patients in the four priority diagnoses and look for clinical measures such as certain lab values; and
  • Registry data.

The patient care managers work directly with individuals to develop a personalized POC. They collaborate with other relevant care coordination teams such as inpatient care managers, cardiology care managers, mental health care managers, home care and home health service, and palliative care to manage risk, costs and transitions. The personalized POC includes individualized services, custom plans based on patient needs, co-management goals and self-management plans. The patient care managers also perform outreach to other services and providers such as community-based services and LTPAC providers. They share information through various tools such as Cerner's PowerChart, e-fax, etc.

PCMH care managers utilize the Centricity EHR system used by all EMHS primary care providers. The patient care managers utilize a number of standardized protocols and have other embedded tools and templates in the EHR. The care managers have developed a care management visit template for documenting in the EHR and have customized the templates based on the patient's condition.

The patient care managers tracking quality and performance improvement indicators for both primary care practices and for care managed patients in the areas of:

  • Clinical outcomes;
  • Preventive measure outcomes;
  • Health care utilization; and
  • Patient reported outcomes.

As noted above, EMHS PCMH may receive reimbursement for community-based care management. Phase II of their medical home program included the development of CCTs. The CCTs manage "super users" (high-risk/high cost patients) with frequent hospitalizations and/or ED visits. Overall health care savings are expected to be realized through reductions in these types of visits.

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