Strategies for Integrating and Coordinating Care for Behavioral Health Populations: Case Studies of Four States. Appendix A. State Profile Tables


TABLE A.1. Louisiana Program Characteristics
Program Name Louisiana Behavioral Health Partnership (LBHP)
Program Overview The program is intended to improve the quality of behavioral health care and increase access to a broad array of evidence-based home and community-based services. The program combines funding from multiple state agencies into a single managed care contract with Magellan Health Services that provides mental health and substance abuse services for both Medicaid-eligible and non-Medicaid-eligible populations.
Program Type Full statewide capitation for adult behavioral health services. Specialized services for children/youth.
Participating State Agencies OBH within the DHH, Medicaid, DCFS, DOE, and OJJ.
State Context There have been many changes in the organization of behavioral health services in Louisiana during the past several years. The Office of Mental Health and the Office for Addictive Disorders were merged into the OBH to encourage the integration of mental health and substance abuse services throughout 10 health care districts referred to as LGEs. OBH has initiated the consolidation of state-operated addictive disorders clinics and mental health clinics and has 36 community mental health centers and 19 outreach locations across the state.
Dates of Operation March 1, 2012-present (Dates refer to period during which Magellan contract was effective; LBHP has a longer history).
Funding and Costs
Funding/Financing Funding is pooled from several state agencies into the contract with Magellan to manage all behavioral health services for eligible adults and children. Magellan is at-risk for the adult services described above. Magellan also manages services for children/youth on a non-risk basis. By combining funding, the participating state agencies sought to create a larger pool of available Medicaid matching dollars and free SGFs to serve the non-Medicaid population.
Medicaid Funding Mechanism (waiver, state plan amendment) 1915(b) waiver for prepaid inpatient health plan with mandatory enrollment and selective services contracting, 1915(c) Home and Community-Based Waiver, and 1915(i) SPA for Adult Mental Health Rehabilitation services for adults with SMI.
Other Funding Sources Federal: Substance Abuse Prevention and Treatment Block Grant.
State: General funds.
Program Costs Projected 1915(b) costs for the first year of the program were $56.39 PMPM.
Populations Served
Eligible Adult Populations Medicaid adults (including dual eligibles); Medicaid adults eligible for 1915(i) services (those who meet the federal definition for SMI); medically needy, non-Medicaid-eligible adults.
Excluded Adult Populations Medicare-only, adults in Intermediate Care Facilities for Individuals with Mental Retardation, adults in Program of All-Inclusive Care for the Elderly, and some other smaller groups. Medically needy individuals in spend-down are ineligible for inpatient or outpatient behavioral health services.
Number Enrolled/ Served As of March 2011, those eligible for 1915(b) services included 168,550 non-disabled adults and 133,050 disabled adults.
Referral and Enrollment Process There is no separate enrollment process for Magellan. Non-Medicaid adults receive a unique identifier when their eligibility for services is established.
Covered Services For adults, the Magellan contract provides inpatient psychiatric services, outpatient mental health services, rehabilitative substance abuse services, case-conferencing services, crisis intervention, psychosocial rehabilitation, and other CPST.
Covered Provider Types (behavioral health, primary care, others) Licensed and unlicensed mental health and substance abuse providers.
How/Where Services are Accessed Magellan maintains a toll-free, 24-hour number to allow individuals to talk with a care manager who can connect them with providers. Consumers can access services at any network provider.
Services Not Covered/ Coordination with Services Not Covered Physical health services are provided through several separate MCOs. Magellan and physical health plans do not currently share data, but there is an effort underway to pursue data sharing to improve care coordination. Case managers from Magellan and physical health plans can interact to share information about patients, but there are no formal mechanisms specifically to encourage this. There are also plans to allow physical health providers to download information about patients from Magellan's information system.

Magellan and OBH anticipate that Magellan will take over the management of a supportive housing program in 2013.

Quality Monitoring and Incentives
Quality Assurance Processes (for example, what is monitored and how) Under the oversight of OBH, a committee was formed to monitor the quality of care. This committee is composed of state agency representatives and state and regional advisory councils, which include consumers, representatives of Magellan, and state leaders. LBHP has a comprehensive quality strategy to monitor the utilization and outcomes of services. There are several performance indicators relevant to adults; these include measures of ED utilization, inpatient admissions, lengths of stay, follow-up care, readmissions, consumer-reported functioning, drug utilization review, and several others. In addition, an EQRO monitors the Magellan contract.
Measurement or Evaluation of Quality Outcomes OBH and Magellan have gathered performance data, but these data have not been released or publically reported.
Mechanisms to Discourage Harmful Practices or Encourage Evidence-Based Care Magellan has performance measures to monitor the number of individuals whose care makes use of evidence-based and promising practices. It also monitors the extent to which those practices have been implemented with fidelity. A clinical advisory committee recommends evidence-based practice guidelines that are reviewed annually, and Magellan is seeking to increase the availability of ACT in rural areas.
Information Systems
Provider Requirements Providers can use Magellan's Clinical Advisor electronic behavioral health record but it is not required.
Challenges and Successes
Selected Challenges Rapid system transformation placed pressure on providers and state agencies.

Some providers had difficulty transitioning to the use of EHRs; orienting providers to Medicaid billing and coding procedures has been challenging.

Data sharing between plans and state agencies has been challenging. Physical health plans and Magellan are not currently sharing information about consumers, and they do not have any formal collaborative relationships.

Selected Successes The network of providers was rapidly expanded, in part by allowing unlicensed providers to bill if they practice as part of a credentialed agency.

Consumers are provided with centralized statewide case management support 24 hours a day, 7 days a week.

The program created a culture of change and strengthened collaboration between state agencies by establishing shared goals.

TABLE A.2. North Carolina Program Characteristics
Program Name Community Care of North Carolina (CCNC)
Program Overview Community Care of North Carolina is a statewide population management and care coordination infrastructure founded on a primary care medical home model. CCNC incorporates leadership by local clinicians, a strong emphasis on care coordination, disease and care management, medication management, and quality-improvement to improve the cost-effectiveness and quality of care for Medicaid enrollees with chronic illness. CCNC's central office, 14 regional networks, and locally based care managers work together with CCNC-affiliated primary care physician practices (primary care medical homes) to coordinate services and to connect patients with a broad range of separately funded human services such as housing assistance, heating assistance, educational assistance, vocational rehabilitation, and food programs. CCNC's behavioral health program aims to facilitate integration of primary care and behavioral health care by supporting PCPs in becoming the medical home for enrollees with mild to moderate behavioral health issues typically served in the primary care system as well as those with SMI typically served in the specialty behavioral health system. In addition, CCNC works with the state's LMEs (local government entities that govern the delivery of mental health services) to connect individuals with SMI with specialty behavioral health services.
Program Type Enhanced Primary Care Case Management.
Participating State Agencies and Organizations North Carolina DMA; North Carolina Office of Rural Health, Research, and Development; North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse; North Carolina Department of Public Health; and the North Carolina Foundation for Advanced Health Programs, Inc.
State Context CCNC began 30 years ago as a small medical homes program in 1 rural county but has continued to evolve to encourage physician participation in Medicaid and thus improve access to care and reduce reliance on EDs. It was eventually expanded to a statewide PCCM program (Carolina Access). In 1998-2001, the current CCNC program was officially piloted in 7 rural counties. The program added several new elements to Carolina Access: (1) regional physician networks; (2) population management tools; (3) case management and clinical support; and (4) data and feedback. A directive from the North Carolina Department of Health Services calling for the state to improve Medicaid access to care, cost-effectiveness, and quality prompted the pilot. The CCNC model worked well in NC because it was adaptable to both urban and rural contexts and experienced high rates of participation by PCPs. CCNC was expanded statewide in 2001. CCNC's behavioral health program was added in 2010, in part as an effort to improve quality of care and reduce health care expenditures for individuals with behavioral health needs, particularly those with physical health comorbidities.
Dates of Operation Single-county medical homes program (Wilson County Health Plan) operated 1983-1988; Carolina Access (PCCM program) operated 1989-1998; CCNC piloted 1998-2001; CCNC expanded statewide in 2001; CCNC's Behavioral Health Program implemented in 2010.
Funding and Costs
Funding/Financing DMA funds CCNC through a $12.85 PMPM fee for ABD Medicaid enrollees. A portion of this fee supports CCNC's behavioral health program. A lower PMPM fee (of $0.24-$9.01) is paid for non-ABD enrollees.

DMA pays each CCNC physician practice (primary care medical home) $5 PMPM for ABD enrollees and $2.50 PMPM for non-ABD enrollees to fund participation in CCNC's disease management, care coordination, and quality-improvement work.

Medicaid Funding Mechanism (waiver, state plan amendment) Initially, 1915(b) waiver; currently, SPA.
Other Funding Sources DMA is currently the only source of PMPM funding. However, CCNC is currently piloting expansions to other payers (including Medicare and private insurers) in several counties. CCNC also receives grant funding for specialized initiatives from state agencies and other sources.
Program Costs CCNC's 2 largest (but most critical) costs have been related to training and the development of its data and information systems.
Populations Served
Eligible Adult Populations Nearly all North Carolina Medicaid beneficiaries are eligible to enroll, including full dual eligibles who are not required to enroll with a primary care medical home but have the option to do so.
Excluded Populations Partial dual eligibles; nursing home residents.
Number Enrolled/ Served As of March 2013, 1.3 million Medicaid beneficiaries (over 75% of the state's Medicaid enrollees) were enrolled in CCNC. As of 2010, nearly one-third of the enrolled non-dual ABD population (21,070 of 72,297) had a serious and persistent mental illness.
Referral and Enrollment Process All North Carolina Medicaid beneficiaries must choose a Medicaid PCP. Patients who do not choose a PCP are automatically assigned to a CCNC-affiliated provider, but can also "opt out" and choose a non-CCNC-affiliated provider at that time. Not all enrolled in CCNC are actively managed. CCNC targets patients in greatest need for case management based on analysis of diagnoses, health care utilization and expenditures, and provider referrals.
Covered Services Direct services to patients include care management and coordination between physical health, behavioral health, and social services and close management of transitions between care settings.
Covered Provider Types (behavioral health, primary care, others) Any licensed Medicaid PCP can become a CCNC-affiliated PCP. However, providers must agree to take part in CCNC's care coordination and disease management initiatives, refer patients to CCNC for case management as needed, and offer after-hours care (24 hours a day, 7 days a week).
How Services are Integrated/Coordinated CCNC has 600-800 care managers statewide (a combination of registered nurses and social workers). Each works with identified "priority patients" to make sure they are getting the health care, medications, and other resources they need. Some care managers are embedded full-time in hospitals and medical practices and health departments. Care managers conduct home visits, provide patient education, support lifestyle changes, schedule follow-up medical appointments, arrange transportation services, assess medication adherence, and assist with care transitions and hospital discharge planning.
Quality Monitoring and Incentives
Quality Assurance Processes Quality-improvement is an integral part of CCNC's work; thus the majority of CCNC's quality measurement and monitoring is self-initiated. Local clinicians actively delivering care to the Medicaid population play a significant role in developing quality-improvement goals and processes, an arrangement that enhances physician buy-in and collaboration. CCNC produces electronic quarterly reports at the practice level that compare quality measures for each practice over time and with other practices. These reports also list the practice's patients for whom quality measure were not met so that the practice can put systems in place to better serve these patients. To evaluate cost savings, DMA contracts with an actuarial firm to evaluate whether CCNC is achieving projected cost savings targets.
Quality Measures CCNC collects 28 quality measures at the program, network, and practice level. Most are related to chronic diseases, including diabetes, asthma, heart failure, and hypertension, and preventive measures such as cancer screening for adults. Two are specific to behavioral health, but not to adults: baseline glucose and baseline lipids in children prior to initiation of antipsychotics, then upon follow-up. CCNC also measures rates of preventable ED use and hospitalizations. The current set of quality measures was developed by a work group of representatives from all 14 CCNC networks and local clinicians who met over the course of a year for in-depth review of candidate measures. Quality measures are reviewed on an annual basis, and final measures are approved by vote of the CCNC clinical directors.
Mechanisms to Discourage Harmful Practices or Encourage Evidence-Based Care CCNC's provider portal calculates patient medication adherence and helps prevent medication errors. It also generates clinical care alerts that indicate, for example, whether patients with chronic illness have received the tests recommended by clinical care guidelines. CCNC regularly holds lunchtime educational seminars at primary care practices on topics such as screening for substance abuse. CCNC is also working with the state to implement an incentive-based payment system for PCPs, where those who are providing evidence-based care will receive higher payments.
Information Systems
Information Systems CCNC's work relies heavily on data and information systems at the program, network, and provider levels. At the program level, CCNC uses Medicaid claims data, real-time hospital data, and other clinical information from provider EHRs, along with proprietary risk-adjustment software, to identify at-risk individuals. Priority patients are typically outliers for cost of care based on diagnoses or those with preventable hospitalizations or multiple ED visits. Priority patients are communicated to the local network care managers and are targeted for case management. Network care managers use CCNC's Care Management Information System to access patient information, document the patient care plan and progress toward goals, and access screening tools. This system is available to CCNC's care managers as well as to those at local health departments. At the provider level, CCNC has built a provider portal, a web-based secure site that displays patient service and medication use across care settings. This tool is accessible to all providers and care managers (including LME care managers) and enables them to deliver more targeted and appropriate care. Networks and physician practices can also use the provider portal to generate demographic, cost, utilization, and quality monitoring reports on the population of patients they are responsible for, in order to better target quality-improvement activities. CCNC has invested substantial resources into researching and addressing the varied state and federal legal requirements related to patient privacy, and into establishing the required contracts, training, supports, and safeguards needed to ensure that users have access only to permissible information.
Provider Requirements Providers are highly encouraged to use EHRs and to make use of the provider portal that CCNC has built, but are not required to do so. Providers cannot input data into this system, but they can use it to see what services and medications their patients have been using.
Challenges and Successes
Selected Challenges Mental health and physical health services are delivered under separate systems in North Carolina, which makes integration more challenging. For patients with SMI, CCNC must work closely with the LMEs to make sure patients are receiving proper treatment for behavioral health needs and physical comorbidities. In addition, North Carolina is currently implementing a managed care carve-out for all behavioral health services. Eleven separate full-risk MCOs will be implemented by 2013, each with different policies and procedures. This has made it even more difficult for CCNC to closely coordinate with the LMEs to ensure that individuals with SMI receive proper treatment for all health needs. To address these challenges, CCNC is taking various approaches, including piloting an integrated care management model with 1 LME-MCO that it hopes to expand to other LME-MCOs in the future.
Selected Successes Evaluations of the program suggest that it has resulted in both improved care and significant cost savings.

Many of CCNC's scores on HEDIS quality measures are in the top 10% in the U.S. (which includes commercial plans).

The program has successfully built upon the existing health care infrastructure in North Carolina rather than completely revamping the way care is financed and delivered.

CCNC has achieved widespread engagement of PCPs; approximately 90% of primary care services to Medicaid beneficiaries are delivered by CCNC-affiliated providers (primary care medical homes).

TABLE A.3. Tennessee Program Characteristics
Program Name TennCare
Program Structure To reach its goal of implementing a fully integrated delivery system that works with providers to ensure that TennCare members receive all their medical and behavioral services in a coordinated and cost-effective manner, Tennessee stopped providing behavioral health services through separate BHOs and instead required its existing MCOs to provide these services. Continuing its quest to improve care coordination for the whole person, Tennessee most recently integrated long-term care services into its MCO contracts through the CHOICES program. The 3 MCOs in the state are at-risk for all services and are monitored by the state.
Managed Care Arrangement Behavioral health services are fully integrated into MCOs. There are 3 MCOs serving the state: United (the West, Middle, and East regions of the state); BlueCare-Volunteer State Health Plan (the West and East regions); and Amerigroup (the Middle region).
Participating State Agencies Bureau of TennCare within the Tennessee Department of Finance and Administration; TDMHSAS.
State Context Tennessee has enrolled all of its Medicaid members into managed care since 1994. Using a medical home model, all enrollees are matched with a PCP to provide patient-centered care. In 2007, Tennessee began integrating behavioral health services into its MCO contracts in an effort to ensure that enrollees in need of behavioral health care received services in a coordinated manner through the MCOs. Integration was completed in 2009. In 2010, Tennessee launched the CHOICES program, which expanded MCO responsibilities into long-term care services.
Dates of Operation 2007-present (behavioral health services fully integrated by 2009).
Funding and Costs
Funding/Financing TennCare is the state Medicaid program and therefore funded by the state and Federal Government. For every dollar spent on medical services for TennCare enrollees, 66 cents currently comes from the Federal Government and 34 cents comes from the state.
Medicaid Funding Mechanism (waiver, state plan amendment) A Section 1115 waiver from CMS is the funding mechanism; CHOICES was implemented through an amendment to this waiver.
Other Funding Sources None.
Program Costs PMPM costs in FY 2013 for MCO acute care averaged $275.59 for TennCare members. For the disabled population specifically, the cost was $896.57 PMPM; for the general Medicaid population (TANF and related groups) it was $199.88 PMPM.
Populations Served
Eligible Adult Populations Any adult enrolled in Medicaid (TennCare) is eligible. Adults eligible for TennCare include participants in the state's Family First (TANF) program; pregnant women, single parents or caretakers of a minor child, SSI eligibles and related groups, and individuals in institutional placements and receiving home-based services as alternatives to institutional care.
Number Currently Enrolled/Served as of April 2013 1.2 million Tennesseans are enrolled in TennCare, and of those, 120,000 have SMI. In 1 MCO (Volunteer State Health Plan), 85,000 of its 432,000 members are considered to have SMI. As of July 2013, 31,974 were enrolled in CHOICES (15,000 of those were considered SMI).
Referral and Enrollment Process All TennCare members who require behavioral health services are automatically enrolled either through the Medicaid enrollment process or when receiving services. TennCare members do not need a referral to access behavioral health services.
Covered Services Behavioral health, addiction and substance abuse services, primary care, long-term care, home and community-based services, housing and employment support services.
Covered Provider Types (behavioral health, primary care, others) Licensed behavioral health and PCPs.
How/Where Services are Accessed Every TennCare member is matched with a primary care physician. MCOs rely on providers' assessments of whether members need case management. Members can also access community mental health centers or behavioral health providers directly. If they receive treatment in an inpatient setting, MCOs have access to claims data and will follow up with services.
Services Not Covered/ Coordination with Services Not Covered Methadone clinic services are not covered.
Quality Monitoring and Incentives
Quality Assurance Processes (for example, what is monitored and how) All MCOs are required to be NCQA-certified. They are also measured on standardized, evidence-based performance measures through HEDIS; the scores are compared to national averages and published annually. The HEDIS measures include behavioral health measures such as antidepressant and ADHD medication compliance and follow-up after hospitalization for mental illness.

In addition to reporting HEDIS measures, the MCOs are required to conduct annual CAHPS surveys and PIPs. The state also imposed access standards on the MCOs regarding the number and types of providers who must participate.

An EQRO also provides independent reviews of the MCOs.

Measurement or Evaluation of Quality Outcomes HEDIS and CAHPS reports are available; EQRO reports include behavioral health measures; the state must submit interim and final evaluation reports to CMS as part of its demonstration requirements.
Mechanisms to Discourage Harmful Practices or Encourage Evidence-Based Care The state offers pay-for-performance quality incentive payments to MCOs if they demonstrate significant improvement from the baseline for specified measures (including behavioral health) or meet a specific goal.

MCOs also have incentive programs for providers such as pay-for-performance programs that are customized to the provider. Providers' raises are tied to specific performance metrics. For behavioral health providers, measures that monitor outcomes are included in their contracts with the MCOs. If the providers do not meet the metrics, they are paid less. Providers who have negative or unsafe outcomes are terminated.

Information Systems
State Information Systems Eligibility, administrative, and claims systems (these systems were already in place at the MCOs before the integration so new information systems were not needed).
Provider Requirements Not required, but the many providers use EHRs.
Challenges and Successes
Selected Challenges Some behavioral health providers were initially concerned that the MCOs would not understand behavioral health cases, but that issue has been alleviated over time.

The state had to work closely with the community mental health centers to educate them on issues such as billing for services, submitting claims in a timely manner, getting prior-authorization, etc. The centers were used to delivering services under the old system, which relied heavily on lump-sum grants.

Selected Successes Providers have welcomed the integration. They were already used to Medicaid managed care for general health services. Incentives were aligned because the state, providers, and MCOs did not want to see unnecessary hospitalizations or emergency room utilizations, and neither did enrollees.

A fully integrated health care delivery system has emerged that provides comprehensive care for the whole person.

Costs for both behavioral and physical health services have been significantly reduced. Specifically, MCOs have seen a reduction in inpatient utilization.

TABLE A.4. Vermont Program Characteristics
Program Name Vermont Blueprint for Health
Program Overview Blueprint for Health is a statewide, multipayer PCMH initiative to improve health care, improve population health, and reduce health care costs. Blueprint provides support and funding for locally developed multidisciplinary CHTs to support PCMHs and patients, patient self-management workshops, quality payments to providers based on quality of care, and HIT. Vermont's largest commercial insurers, along with Medicare and Medicaid, contribute funding for CHTs and quality incentive payments for providers.

Other Blueprint services target specific populations. Through the SASH program, local housing agencies partner with health and human services providers to help Medicare beneficiaries live safely at home. Through the VCCI, registered nurses and social workers offer high-cost Medicaid beneficiaries case management, health education, and linkages to social services. SASH and VCCI staff are integrated into CHTs as CHT extenders. In addition, a Medicaid Health Home model integrates behavioral and physical health services to reduce opioid addiction.

Program Type PCMH model.
Participating State Agencies Blueprint is operated by the DVHA (the state Medicaid agency), within the Agency of Human Services. DVHA contributes funding as the Medicaid payer.a Blueprint's executive committee includes the commissioners of DVHA, Department of Health, Department of Mental Health, and Department of Information and Innovation, as well as other government officials, and the state's major health insurers and other non-governmental stakeholders. Blueprint is implemented at the community level. Local agencies include PCPs/PCMHs, community mental health clinics, social service agencies, housing agencies, area agencies on aging, and other local service providers.
State Context Blueprint is a key component of the state's health care reform agenda. After a pilot, the state passed legislation requiring Vermont insurers to pay for CHTs and quality incentive payments on behalf of participating providers. Legislation also requires the Blueprint team to enroll all willing PCPs by October 2013. The small size of the state (population is approximately 630,000) limits the number of insurers, which helps to make this approach achievable.
Dates of Operation First codified in 2006 as part of Vermont's health reform legislation (Vermont Act 191), piloting began in 2007; statewide expansion in 2010; Medicare began participating in 2011. Moving toward including specialty providers as medical homes in 2013.
Funding and Costs
Medicaid Funding Mechanism (waiver, state plan amendment) A Section 1115(a) waiver authorizes use of Medicaid funding for Blueprint services. CMS's Multipayer Advanced Primary Care Practice Demonstration authorizes use of Medicare funds. Vermont has a pending SPA to exercise the Medicaid Health Home option under the ACA.
Other Funding Sources All private insurers, Medicaid, and Medicare contribute funding for provider quality incentive payments and core CHT members. Self-management workshops are funded through state appropriations and Medicaid, plus some tobacco settlement money for the smoking cessation workshop. Other funding sources are used for targeted components. Blueprint uses Medicare funds for its SASH program, and the state uses Medicaid funds for VCCI. Blueprint uses funding from Medicaid and the Division of Alcohol and Drug Abuse Programs (which funds methadone) to support health homes to treat opioid addiction. Other state and federal funds support the technology infrastructure.
Program Costs Costs for Blueprint's core payment reforms are as follows: Vermont's 5 insurers each contribute quality incentive payments at the same PMPM rate, based on the number of patients enrolled in their plans who were seen by participating PCMHs in the last 24 months. Incentive payments range from $1.40 to $2.50 PMPM, depending on the PCMH's NCQA score. Additionally, all insurers share the costs for core CHT members. CHT members cost $70,000 (~1.0 full-time equivalent) per 4,000 patients. Four of the insurers each contribute approximately 22% of the total core CHT costs, and the fifth insurer, which is smaller, contributes about 11%.
Populations Served
Eligible Populations All patients are eligible for core services. CHTs typically work with patients who have more complex and chronic health care needs, such as those with mental illness. Targeted programs, such as SASH and Hub and Spoke (for opioid addiction), support specific populations.
Excluded Populations No populations are excluded.
Number Enrolled/ Served Blueprint was serving 421,739 patients through 106 practices and 89 full-time equivalent CHTs as of December 2012, representing approximately two-thirds of Vermont's population and PCPs.
Referral and Enrollment Process There is no formal enrollment for patients; rather, practices must enroll. CHTs identify patients based on referrals or by examining clinical data to target specific subgroups.
Covered Services Services include individual case management and care coordination with other social and economic supports in the community, such as housing, food security, and transportation; treatment of common mental health illness and addictions in a primary care setting; coordinated treatment for opioid addiction through the Hub and Spoke medical home model; outreach to conduct preventive screenings; and self-management and behavior modification through a series of workshops, including the General Healthy Living Workshop and WRAP, an information and skills workshop for people with depression and anxiety. Statewide, Blueprint offers approximately 50-70 workshops. Additionally, Blueprint provides support to providers to incentivize and enable practices to serve as certified PCMHs.
Covered Provider Types (behavioral health, primary care, others) All forms of PCPs are eligible, and payments extend to patients seen by registered nurses and physician assistants. PCPs must meet NCQA standards to be recognized as a PCMH and receive quality incentive payments. With NCQA's recent release of standards for specialty practices, Blueprint is expanding payments and services to specialty mental health and addiction treatment facilities.
How/Where Services are Accessed Services for patients are mainly accessed through CHTs. Each community forms a work group of local medical and non-medical stakeholders to create a CHT. Core members, who are funded by insurers, work alongside functional CHT members, who represent other medical or non-medical support programs; together they act as 1 CHT. CHT members come from nursing, social work, nutrition, psychology, pharmacy, administrative support, and other backgrounds. Core and functional CHT members can be embedded in PCMHs or work in local community health and human service programs or non-profits.
Services Not Covered/ Coordination with Services Not Covered CHTs coordinate care with local service providers.
Quality Monitoring and Incentives
Quality Assurance Processes (for example, what is monitored and how) Practices must be able to measure and improve performance to achieve PCMH recognition and receive quality payments. Linking payments on a sliding scale to NCQA scores incentivizes high performance. Blueprint supports to providers create capacity for continuous improvement. Annual reports on Blueprint implementation explore whether Blueprint is associated with a change in health care expenditures and health care utilization patterns, in particular, a shift from acute episodic care (for example, ED visits) to more effective and preventive care (for example, cancer screening). Preliminary evaluation results in the 2012 annual report examined 5-year trends for Blueprint and comparison participants along quality measures (below). A more rigorous and comprehensive analysis of CHTs and SASH is underway as part of CMS's Multipayer Advanced Primary Care Practice Demonstration. SASH is also being studied by the U.S. Department of Housing and Urban Development.
Measurement or Evaluation of Quality Outcomes Quality measures include health care expenditures, health care utilization, quality of health services, health outcomes, and patient experience of care. Data derive from an all-payer claims database, the central clinical registry, NCQA's PCMH patient experience survey, and the NCQA-PCMH scoring database.
Mechanisms to Discourage Harmful Practices or Encourage Evidence-Based Care PCPs must deliver care consistent with NCQA standards for a PCMH to receive quality payments. NCQA-PCMH standards are designed to ensure improved access for patients, improved communication and follow up, more consistent care based on national guidelines for prevention and control of chronic diseases, improved coordination of care and linkages with other services (medical and non-medical), patient level self-management, and enhanced use of HIT and decision-support systems. Blueprint practice facilitators support practices to achieve NCQA-PCMH recognition and encourage continuous quality-improvement.
Information Systems
Information Systems Blueprint uses a central clinical registry (developed and supported by Covisint DocSite) to house and generate reports on client demographic and clinical information. It is web-based and allows providers to create individualized patient reports and reports of subgroups to conduct panel management; it also offers workflow tools. Data feed into the registry from practices' and hospitals' EHRs either via Vermont's Health Information Exchange or directly from practices. Blueprint created and routinely updates a data dictionary and condition measure set for the registry, which standardizes input. There were 363 licensed registry users at the end of 2012.
Provider Requirements Providers are highly encouraged, but not required, to use the central clinic registry and EHRs. The only required reporting is for practices to report the CHT staff paid for by the commercial and public insurers so the state can make incentive payments.
Challenges and Successes
Selected Challenges In practice, lack of standards for data nomenclature, unstructured text entries, and the packaging and transmission of data by end users have created challenges. Issues around data quality and timeliness and consent to view data have challenged implementation of Blueprint.
Selected Successes Blueprint's core CHT members have increased the ability of primary care to interface with the broader health and human services and housing infrastructure in their communities. The network of CHTs and local partners can be used as a vehicle to implement other state or locally based initiatives.

The Blueprint framework is both comprehensive and flexible, enabling a transformation of service delivery that is adaptable to local needs and resources.

All insurers participate.

  1. DVHA is designated as the state's Medicaid MCO. There are no behavioral health carve-outs under the MCO arrangement, although long-term care services are separately managed.

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