Strategies for Integrating and Coordinating Care for Behavioral Health Populations: Case Studies of Four States. E. Covered Populations and Services


Enrollment process. There is no formal enrollment process for patients; rather, PCPs enroll into Blueprint. All types of PCPs are eligible to enroll, but they must meet NCQA standards to be recognized as a PCMH and receive quality incentive payments. Vermont recognizes multiple provider specialties as PCPs, including internal medicine, general medicine, family medicine, pediatrics, and naturopathic medicine. Vermont also recognizes nurse practitioners and physician assistants as PCPs.

As of December 2012, 102 PCPs had achieved NCQA recognition and another 24 PCPs were preparing for recognition, together representing about two-thirds of Vermont's PCPs. Over 420,000 patients were associated with the recognized practices, or approximately two-thirds of the state's population. Also in December 2012, 89 full-time equivalent core CHT members were working with the practices (DVHA 2013b). With NCQA's recent release of standards for specialty practices, Blueprint is developing plans to expand payment and practice reforms to specialty mental health and addiction treatment facilities through the Hub and Spoke model and other efforts. While PCPs are not resisting Blueprint enrollment, a state staff member we spoke with for this study noted that small practices in particular may be less inclined to enroll due to difficulty meeting NCQA's PCMH standards.

Patients served. All Vermont residents are eligible for care management from CHTs and for self-management workshops--at no cost to them or their provider. (Patients may incur a copay established by their insurance contract for a medical appointment, but they do not incur copays for assistance provided by CHT members.) However, CHTs tend to target certain types of patients, such as those with diabetes, mental illness, or co-occurring conditions. According to a state staff member, a typical patient referred to the CHT might have both diabetes and depression and need additional support to get the diabetes under control. Another patient might have a mental health or substance abuse issue and could benefit from more treatment, follow-up, or care coordination than a practitioner can provide during a typical appointment. In addition to identifying patients via referrals from practitioners, CHTs also target certain patients based on panel management or population management, a process whereby CHTs examine clinical data to identify and target specific subgroups (for example, women over age 50) that could benefit from outreach and intervention, then implement an intervention protocol established by the practice, and later follow up with patients to influence adherence. Other services under the Blueprint framework that support specific populations include Support and Services at Home (SASH), which helps Medicare patients live at home, and Hub and Spoke, a health home model designed to curb opioid addiction.

Patient services. For patients, Blueprint's most fundamental reforms have been the transition of PCPs to NCQA-certified PCMHs and the establishment of CHTs. Each is described below.

  • Patient-centered medical homes. NCQA's standards for PCMHs, listed in Table VI.2, establish the services that patients seen by PCMHs should receive. PCMHs offer improved access for patients, more communication and follow-up, consistent care based on national guidelines for prevention and control of chronic diseases, improved coordination of care and linkages with other services (medical, behavioral health, and social and economic), and resources to enable patients to better manage their own care (NCQA 2011). Vermont has shaped the PCMH services available to patients through the Blueprint framework of CHTs, self-management workshops, and data systems that make population management and continuous quality-improvement possible (data systems are described below).

  • Community health teams. CHTs perform a range of functions: they coordinate service linkages for vulnerable participants across medical and non-medical service settings, help treat mild depression and anxiety, support patient self-care through one-on-one interactions and workshops, track care and conduct more intensive and individualized follow-up than what a practice can typically provide to increase the likelihood that patients adhere to treatments or referrals, and conduct population management and engage the general population in preventive health care. CHT members come from nursing, social work, nutrition, psychology, pharmacy, administrative support, and other backgrounds. Core CHT members tend to work within a practice (or split their time across multiple practices) and meet regularly with functional team members who represent local service providers to form a continuum of care (DVHA 2013b). A Blueprint staff member added that team members might also meet to figure out how to serve a particular patient without duplicating their efforts.

TABLE VI.2. NCQA's 2011 Standards and Related Elements for Patient-Centered Medical Home Recognition
Standard 1: Enhance Access and Continuity
  • Access during office hours
  • After-hours access
  • Electronic access
  • Continuity
  • Medical home responsibilities
  • Culturally and linguistically appropriate services
  • Practice team
Standard 4: Provide Self-Care Support and Community Resources
  • Support for self-care process
  • Provision of referrals to community resources
Standard 2: Identify and Manage Patient Populations
  • Patient information
  • Clinical data
  • Comprehensive health assessment
  • Use of data for population management
Standard 5: Track and Coordinate Care
  • Test tracking and follow-up
  • Referral tracking and follow-up
  • Coordination with facilities/care transitions
Standard 3: Plan and Manage Care
  • Use of evidence-based guidelines
  • Identification of high-risk patients
  • Care management
  • Medication management
  • Use of electronic prescribing
Standard 6: Measure and Improve Performance
  • Performance measurement
  • Patient/family experience measurement
  • Continuous quality-improvement
  • Demonstration of continuous quality-improvement
  • Reporting on performance
  • Reporting of data externally
SOURCE: Adapted from DVHA 2013b and NCQA 2011.
NOTE: NCQA scores PCPs for demonstrating elements. Elements in bold are considered "must-pass elements" that practices must meet for NCQA recognition.

Benefit of PCMHs and CHTs for patients with mental illness. Some aspects of Blueprint's service reforms were designed specifically to improve care for patients with mental illness. Through PCMHs and CHTs, Blueprint aims to increase the capacity of PCPs to treat common mental health illnesses and addictions and coordinate care with specialists. Blueprint practices implement standardized screening and treatment protocols for conditions such as depression, anxiety, ADHD, and substance abuse; monitor the impact of care; and consult with specialized psychiatric or other mental health professionals.

Self-management workshops also have the potential to be an important resource for individuals with mental illness. As of February 2012, six workshops had been conducted on topics such as self-management of chronic disease, diabetes, chronic pain, tobacco cessation, and mental illness. The chronic disease workshop and the variations for diabetes and chronic pain are based on the Stanford Chronic Disease Self-Management Program, created by Dr. Kate Lorig, and are led by trained and certified peers. The mental illness workshop uses the WRAP curriculum, which offers information and teaches skills to individuals with depression and anxiety. WRAP aims to shift the focus in mental health care from symptom control to prevention and recovery. Participants create recovery plans and identify activities and resources to help them maintain their well-being. All of the self-management workshops encourage patients to set goals, create self-care plans, and solve personal obstacles. WRAP workshops meet four hours a week for six weeks (DVHA 2013b).

According to a state staff member, Blueprint added WRAP to its menu of self-management workshops in 2012 after one CHT went seeking a mental health treatment program for patients experiencing coverage and access barriers with specialty providers (including long wait lists). Vermont's Department of Mental Health first introduced WRAP in 1997, and the curriculum has since expanded to other states with support from SAMHSA, although with inconsistent funding over the years. Under the Department of Mental Health, WRAP had been implemented in community mental health centers. By including WRAP as a self-management workshop, Blueprint shifts outreach for WRAP to a primary care setting, enables use of Medicaid funding, and expands the number of workshops available statewide.

Other Blueprint and state initiatives targeted toward specific patient groups. Blueprint encompasses two other initiatives of note that support specific patient groups, the Hub and Spoke program and SASH, and it intersects with a third state initiative that does so, VCCI. These are described below. Targeted services are likely to expand in the future as the state considers a Medicaid SPA to extend the health home concept to other sectors, including the long-term care system and specialty mental health clinics.

  • Hub and Spoke. This is the state's first major effort to extend the health home concept and Blueprint payment reforms to mental health and addictions centers. The focus is on treating opioid addiction, a rising public health and fiscal concern in Vermont. "Hubs" are regional specialty mental health and addiction treatment centers, which provide intensive treatment to patients, and consultation to and coordination with practices (the "spokes"). Vermont plans to have all practices in which physicians prescribe buprenorphine become spokes. Patients are stabilized in hubs and then referred to spokes, which provide less intensive treatment and which can refer patients back to hubs for episodic care as necessary (such as for a relapse), thus facilitating a continuum of treatment. This model also helps the state integrate into the broader mental health and physical health care settings two medication treatment approaches (methadone and buprenorphine) that had been separated due to different funding streams and regulations. Implementation efforts began in 2013 (DVHA 2013b).

  • Support and Services at Home. SASH is a Blueprint initiative funded through Medicare. SASH teams help Medicare beneficiaries living in subsidized housing or elsewhere in the community age safely at home by coordinating health care and long-term care. SASH also seeks to reduce Medicare expenditures. Services focus on care coordination, education and coaching to support self-care, and transition support after a stay in a hospital or rehabilitation facility. Team members, who may work for local housing organizations, help participants develop an individualized healthy aging plan and meet their aging goals. SASH teams also identify goals that are common across participants to create a community-level healthy aging plan. Team members include a coordinator and wellness nurse, as well as representatives from local home health agencies, area agencies on aging, mental health providers, and other professionals. SASH began as a pilot in 2009; as of January 2013, there were 26 teams across most regions of the state (Cathedral Square Corporation 2013; DVHA 2013b).

  • Vermont Chronic Care Initiative. Although VCCI is a distinct state initiative separate from Blueprint, its goals overlap with Blueprint's goals of improved chronic care management and Medicaid cost reduction. VCCI staff also collaborate with core CHT members as functional team members. VCCI targets Medicaid patients whose costs are in the top 5 percent, or whose utilization patterns (for example, hospitalizations) indicate risk of high costs. VCCI staff, typically nurses or case workers, provide case management and care coordination, coaching and health education to promote self-care, and education to improve patients' communication with their health care providers (DVHA 2013b, 2013d). Staff are collocated in practices or medical facilities.

Supports for providers. In addition to increasing the capacity of practices through CHTs, the Blueprint framework provides various supports to practices. These supports, listed below, can help practices meet PCMH standards, and more generally help the state achieve its goal of creating a more coordinated and patient-centered system of care (DVHA 2013b):

  • Evaluation Quality Improvement Program (EQuIP) practice facilitators help practices achieve NCQA recognition. Generally, EQuIP facilitators help practices institute quality-improvement mechanisms. They can teach practices to use the HIT infrastructure and improve their management of chronic conditions, immunizations, preventive services and screenings, and access to care (such as same-day appointments and avoidance of EDs). Support from facilitators can continue after NCQA recognition. Facilitators come from social work, nursing, patient advocacy, and other disciplines. In 2012, 13 practice facilitators helped around 90 practices achieve NCQA-PCMH recognition.

  • Learning collaboratives bring together staff (physicians, nurses, office managers) from multiple practices to improve care. In 2012, learning collaboratives focused on medication-assisted treatment for opiate addiction and on asthma treatment. Generally, the practices agree to collect common data on quality measures, identify and test practice improvements, and share information about practice changes.

  • Training in shared decision-making (SDM) is available for PCP staff, EQuIP facilitators, and CHT members. SDM workshops focus on empowering patients to have more informed and productive conversations with providers. The workshops are provided through a partnership with Health Dialog and the Foundation for Informed Medical Decisions, which together developed the SDM tools. State legislation required the Blueprint state team to test SDM as a pilot program and to use a nationally certified intervention model.

  • HIT infrastructure, including the central clinical registry, offers work flow tools and reports to aide in population management and planning. Blueprint also assists practices in using the HIT infrastructure via Blueprint Sprint teams (see Section G).

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