Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions: Annual Report - Year Two

Brenda C. Spillman, Elizabeth Richardson, Anna Spencer and Eva Allen

TABLE OF CONTENTS

ACRONYMS

EXECUTIVE SUMMARY

I. INTRODUCTION

Overview of the Section 2703 Health Homes Model

Evaluation Aims and Content of Baseline Report

II. EVALUATION TIMELINE, STRUCTURE, AND METHODS

Research Questions

Qualitative Data and Activities

Quantitative Data and Activities

III. PROFILE OF STATE HEALTH HOME INITIATIVES

North Carolina

Oregon

Rhode Island

Missouri

New York

Alabama

Iowa

Ohio

Wisconsin

Idaho

Maine

IV. IMPLEMENTATION THEMES AND ISSUES

Implementation Context

Health Home Models

Communication

Provider Issues and Challenges

Health Information Technology

The Enhanced Match

V. OVERVIEW OF EVALUATION DESIGN AND CHALLENGES

Challenges to Quantitative Evaluation

Potential Approaches to Address Challenges

VI. THIRD YEAR ACTIVITIES

VII. CONCLUSION

NOTES

APPENDICES

APPENDIX A: Health Homes Site Visit Protocol

APPENDIX B: Memoranda on Pre-Existing State Initiatives and Summary of State Plan Amendments for Section 2703 Medicaid Health Homes
(NOTE: Each state's paper is also available as a separate PDF document. The links are listed at the end of this paper, as well as at the HTML state link below.)

Alabama

Idaho

Iowa

Maine

Missouri

New York

North Carolina

Ohio

Oregon

Rhode Island

Wisconsin

 

LIST OF FIGURES

FIGURE 1: Health Home Models

FIGURE 1: Idaho Healthy Connections Regions

FIGURE 1: Map of MO HealthNet Managed Care Regions

FIGURE 1: Organizational Structure of CCNC

LIST OF TABLES

TABLE 1: Evaluation Cohort States, Programs and Timeline

TABLE 2: Research Questions for the Long-Term Evaluation

TABLE 3: Key Features of Programs

TABLE 1: Target Population and Designated Providers--Alabama

TABLE 2: Health Home Service Definitions--Alabama

TABLE 3: Health Home Goals and Quality Measures--Alabama

TABLE 4: Evaluation Methodology--Alabama

APPENDIX: Pre-Existing Initiatives in Alabama

TABLE 1: Target Population and Designated Providers--Idaho

TABLE 2: Health Home Service Definitions--Idaho

TABLE 3: Assumed Division of Care Management Responsibilities--Idaho

TABLE 4: Goal-Based Quality Measures--Idaho

TABLE 5: Evaluation Methodology--Idaho

APPENDIX: Pre-Existing Initiatives in Idaho

TABLE 1: Target Population and Designated Providers--Iowa

TABLE 2: Health Home Provider Standards--Iowa

TABLE 3: Health Home Service Definitions--Iowa

TABLE 4: Health Home Payment Tiers--Iowa

TABLE 5: Health Home Quality Incentive Payment Formula--Iowa

TABLE 6: Goal-Based Quality Measures--Iowa

TABLE 7: Evaluation Methodology--Iowa

APPENDIX: Pre-Existing Initiatives in Iowa

TABLE 1: Target Population and Designated Providers--Maine

TABLE 2: Health Home Service Definitions--Maine

TABLE 3: Standards for MaineCare PCCM and Maine PCMH Pilot Practices

TABLE 4: Health Home Goals and Quality Measures--Maine

TABLE 5: Evaluation Methodology--Maine

APPENDIX: Pre-Existing Initiatives in Maine

TABLE 1: Target Population and Designated Providers--Missouri

TABLE 2: Health Home Staff Roles--Missouri

TABLE 3: Health Home Service Definitions--Missouri

TABLE 4: Provider Qualifications by Provider Category--Missouri

TABLE 5: Health Home Goals and Quality Measures--Missouri

TABLE 6: Evaluation Methodology--Missouri

APPENDIX: Pre-Existing Initiatives in Missouri

TABLE 1: Target Population and Designated Providers--New York

TABLE 2: New York's Health Home Analytical Products

TABLE 3: Health Home Service Definitions--New York

TABLE 4: Health Information Technology (HIT) Standards--New York

TABLE 5: Health Home Goals and Quality Measures--New York

TABLE 6: Evaluation Methodology--New York

APPENDIX: Pre-Existing Initiatives in New York

TABLE 1: Target Population and Designated Providers--North Carolina

TABLE 2: Health Home Service Definitions--North Carolina

TABLE 3: PMPM Rates for Health Home Services as of March 2011--North Carolina

TABLE 4: Health Home Goals and Quality Measures--North Carolina

TABLE 5: Evaluation Methodology--North Carolina

APPENDIX: Pre-Existing Initiatives in North Carolina

TABLE 1: Target Population and Designated Providers--Ohio

TABLE 2: Health Home Service Definitions--Ohio

TABLE 3: Goal-Based Quality Measures--Ohio

TABLE 4: Evaluation Methodology--Ohio

TABLE 1: Target Population and Designated Providers--Oregon

TABLE 2: Health Home Service Definitions--Oregon

TABLE 3: Health Home Goals and Quality Measures--Oregon

TABLE 4: Evaluation Methodology--Oregon

APPENDIX A: Pre-Existing Initiatives in Oregon

APPENDIX B: Initial Implementation Measures for PCPCHs--Oregon

TABLE 1: Target Population and Designated Providers--Rhode Island

TABLE 2: Provider Qualifications--Rhode Island

TABLE 3: Health Home Goals and Quality Measures--Rhode Island

TABLE 4: Evaluation Methodology--Rhode Island

TABLE 5: Health Home Service Definitions--Rhode Island

APPENDIX: Pre-Existing Initiatives in Rhode Island

TABLE 1: Target Population and Designated Providers--Wisconsin

TABLE 2: Health Home Service Definitions--Wisconsin

TABLE 3: Health Home Goals and Quality Measures--Wisconsin

TABLE 4: Evaluation Methodology--Wisconsin

 

ACRONYMS

The following acronyms are mentioned in this report and/or appendices.

ABD	Aged, Blind or Disabled
ACA	Affordable Care Act
ACO	Accountable Care Organization
ADD	Attention Deficit Disorder
ADHD	Attention Deficit Hyperactivity Disorder
ADMH	Alabama Department of Mental Health
ADPH	Alabama Department of Public Health
AIDS	Acquired Immune Deficiency Syndrome
AMI	Acute Myocardial Infarction
AOD	Alcohol or Other Drug
APCP	Advanced Primary Care Practice
ARCW	AIDS Resource Center of Wisconsin
ASC	Ambulatory Sensitive Condition
ASO	AIDS Service Organization
BCBS	BlueCross Blue Shield
BCBSNC	BCBS of North Carolina
BHCCH	Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals
BIPP	Balancing Incentive Payment Program
BMI	Body Mass Index
BPCI	Bundled Payments for Care Improvement Initiative
BPMS	Behavioral Pharmacy Management System
CAD	Coronary Artery Disease
CAHPS	Consumer Assessment of Healthcare Providers and Systems
CBHC	Community Behavioral Health Center
CBO	Community-Based Organization
CC4C	Care Coordination for Children
CCC	Connect Care Choice
CCD	Continuity of Care Document
CCIP	Chronic Care Improvement Program
CCNC	Community Care of North Carolina
CCO	Coordinated Care Organization
CCT	Community Care Team
CCTP	Community-based Care Transitions Program
CD4	Cluster of Differentiation Four
CDPHP	Capital District Physicians' Health Plan
CEDARR	Comprehensive Evaluation, Diagnosis, Assessment, Referral, Re-evaluation
CG	CAPHS Clinician and Group survey
CHCS	New York Center for Health Care Strategies
CHF	Congestive Heart Failure
CHIP	Children's Health Insurance Program
CHIPRA	Children's Health Insurance Program Rauthorization Act
CIDP	New York Chronic Illness Demonstration Project
CIMOR	Customer Information Management, Outcomes and Reporting
CMHC	Community Mental Health Center
CMHO	Community Mental Health Organization
CMIS	North Carolina Care Management Information System
CMMI	CMS Center for Medicare and Medicaid Innovation
CMS	HHS Centers for Medicare and Medicaid Services
COBRA	Consolidated Omnibus Budget Reconciliation Act
COPD	Chronic Obstructive Pulmonary Disease
CPCI	Comprehensive Primary Care Initiative
CPR	Community Psychiatric Rehabilitation
CPRC	Community Psychiatric Rehabilitation Program
CPST	Community Psychiatric Support and Treatment
CRG	Clinical Risk Group
CSHCN	Children with Special Health Care Needs
CSI	Chronic Care Sustainability Initiative
CVD	Cardiovascular Disease
CY	Calendar Year
DHA	Dirigo Health Agency
DHS	Iowa Department of Health Services Rhode Island Department of Human Services Wisconsin Department of Health Services
DM 3700	Disease Management 3700 Project
DMAP	OHA Division of Medical Assistance Programs
DMH	Missouri Department of Mental Health
DOH	New York Department of Health
DTap/DT	Diphtheria, Tetanus and Pertussis Vaccine
DUA	Data Use Agreement
EHR	Electronic Health Record
eMedNY	New York's Medicaid claims processing system
EMR	Electronic Medical Record
EOHHS	Rhode Island Executive Office of Health and Human Services
EPSDT	Early and Periodic Screening, Diagnosis, and Treatment
FFS	Fee-For-Service
FPL	Federal Poverty Level
FQHC	Federally Qualified Health Center
FSD	Missouri Family Support Division
FTE	Full-Time Equivalent
GERD	Gastro Esophageal Reflux Disease
HbA1c	Glycated Haemoglobin
HCS	New York Health Commerce System
HEAL NY	Health Care Efficiency and Affordability Law for New Yorkers
HEDIS	Healthcare Effectiveness Data and Information Set
HH	Health Home
HHS	U.S. Department of Health and Human Services
HIE	Health Information Exchange
HIN	Health Information Network
HIT	Health Information Technology
HITECH	Health Information Technology for Economic and Clinical Health Act
HIV	Human Immunodeficiency Virus
IBHP	Idaho Behavioral Health Plan
IDHW	Idaho Department of Health and Welfare
IHDE	Idaho Health Data Exchange
IMD	Institutions of Mental Disease
IME	Iowa Medicaid Enterprise
IMHC	Idaho Medical Home Collaborative
IPV	Polio Vaccine
LDL-C	Low-Density Liproprotein Cholesterol
LLC	Limited Liability Company
LME	Local Management Entity
LTSS	Long-Term Services and Supports
MAPCP	Multi-payer Advanced Primary Care Practice demonstration
MATS	New York Managed Addiction Treatment Services
MCO	Managed Care Organization
MCP	Managed Care Plan
MFH	Missouri Foundation for Health
MHAS	Ohio Department of Mental Health and Addiction Services
MHCA	Mental Health Consumer Advocates of Rhode Island
MIP	Maximum Incentive Payment
MMC	Maine Medical Center
MMCP	Medicare-Medicaid Coordinated Plan
MMIS	Medicaid Management Information System
MMR	Measles, Mumps and Rubella Vaccine
MOU	Memorandum of Understanding
MPCA	Missouri Primary Care Association
MRT	Medicaid Redesign Team
NAMI	National Alliance on Mental Illness
NC-CCN	North Carolina Community Care Network
NCQA	National Committee for Quality Assurance
NES	Not Elsewhere Classified
NOMs	National Outcome Measures
NOS	Not Otherwise Specified
NQF	National Quality Forum
NYCCP	New York Care Coordination Program
OASAS	New York Office of Alcoholism and Substance Abuse Services
OASIS	Outcome and Assessment Information Set
OB/GYN	Obstetrics/Gynaecology
OHA	Oregon Health Authority
OHITT	New York Office of Health Information Technology Transformation
OHP	Oregon Health Plan
OMH	New York Office of Mental Health
P4P	Pay-For-Performance
PCCM	Primary Care Case Management
PCDCA	Primary Care Development Corporation Assessment
PCM	Pregnancy Care Management
PCMH	Patient-Centered Medical Home
PCMHA	Patient-Centered Medical Home Assessment
PCNA	Patient Care Networks of Alabama
PCP	Primary Care Provider
PCPCH	Patient-Centered Primary Care Home
PDC	Proportion of Days Covered
PDSA	Plan-Do-Study-Act
PHO	Physician Hospital Organization
PMP	Primary Medical Provider
PMPM	Per Member Per Month
PPC	Physician Practice Connections
PPR	New York Potentially Preventable Readmission project
Q-Tool	Alabama's web-based health information exchange
Q4U	Alabama's care management system
QMAF	Quality Measurement and Feedback
Qx	Alabama's data hub
RCC	Regional Coordinating Center
RCO	Regional Care Organization
RFP	Request for Proposal
RHC	Rural Health Clinic
RHIO	Regional Health Information Organization
RHP	Rhody Health Partners
RI-BHOLD	Rhode Island Behavioral Health Online Dataset
RICCMHO	Rhode Island Council of Community Mental Health Organizations
SAMHSA	HHS Substance Abuse and Mental Health Services Administration
SED	Serious Emotional Disturbance
SEP	Single-Entry Point
SHIN-NY	Statewide Health Information Network for New York
SHIP	State Health Care Innovation Plan
SIM	State Innovation Model
SMD	State Medicaid Director
SMI	Serious Mental Illness
SNF	Skilled Nursing Facility
SNMHI	Safety Net Medical Home Initiative
SPA	State Plan Amendment
SPMI	Serious and Persistent Mental Illness
SUD	Substance Use Disorder
T-CHIC	Tri-State Child Health Improvement Consortium
TA	Technical Assistance
TCM	Targeted Case Management
VZV	Varicella-Zoster Virus

 

EXECUTIVE SUMMARY

This report presents findings from the first two years of the long-term evaluation of Medicaid health homes, a new integrated care model authorized in Social Security Act Section 1945, created in Section 2703 of the Affordable Care Act. The model is designed to target high-need, high-cost beneficiaries with chronic conditions or serious mental illness (SMI). The Urban Institute is conducting the long-term evaluation of this program for the U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary of Planning and Evaluation. This evaluation will assess:

• The care models and processes states are using.

• The extent to which health homes result in increased monitoring and care coordination.

• Whether these models result in better care quality; reduced hospital, skilled nursing facility, and emergency department use; and lower costs.

Findings from the evaluation will inform a 2017 Report to Congress.

The Medicaid health home model elevates the importance placed on integrating physical health care with behavioral/mental health care and on linking enrollees to social services and other community supports. States with health home State Plan Amendments (SPAs) approved by the HHS Centers for Medicare and Medicaid Services (CMS) receive eight quarters of 90% federal match for six defined services: comprehensive care management, care coordination and health promotion, comprehensive transitional care, individual and family support services, linkage and referral to community and social support services, and use of health information technology (HIT). States have flexibility with respect to chronic conditions selected, geographic coverage, providers designated, and the payment system for health home services. The minimum eligibility criteria for beneficiaries include a diagnosis of two chronic conditions, one chronic condition and being at risk of a second, or one SMI.

Evaluation Structure, Timeline, and Methods

The long-term evaluation began October 1, 2011, and will continue for five years. This report examines the 13 SPAs in 11 states included in the evaluation. These include two SPAs from both Rhode Island and Missouri, and one SPA each from North Carolina, Oregon, New York, Alabama, Iowa, Ohio, Wisconsin, Idaho, and Maine. For each included SPA, the evaluation team developed background materials on program design and implementation context and conducting site visits. These will provide a qualitative foundation for tracking and interpreting program progress over the eight-quarter intervention period during which the enhanced federal match is available. Follow-up telephone interviews are being conducted roughly annually after the initial in-person site visits. Quantitative analysis of key outcomes will occur largely in the final two years of the evaluation and will examine utilization and costs for health home participants and comparison groups of beneficiaries.

Profile of State Health Home Initiatives

The health home programs included in the evaluation reflect the substantial flexibility states have in designing their programs, with variation occurring in the designated provider types, the chronic conditions targeted, and how health home services are defined and reimbursed. Most of the 13 SPAs focus on persons with two chronic conditions or one condition and risk for a second chronic condition. States have the ability to define their own qualifying physical and mental/behavioral conditions. Four states included SMI as an independent eligibility criterion. Wisconsin is unique in defining the eligible population as persons with HIV/AIDS served by specialized providers, while Ohio's SPA, and one SPA each in Rhode Island and Missouri focus entirely on persons with serious and persistent mental illness, SMI, serious emotional conditions, or substance abuse who are served by mental health centers. Conversely, North Carolina, Iowa and Missouri's second SPA base eligibility solely on multiple chronic physical conditions. Rhode Island's second program is the only SPA that focuses specifically on younger beneficiaries with special health care needs receiving care from specialized providers known as "Comprehensive Evaluation, Diagnosis, Assessment, Referral, Re-evaluation" (CEDARR) Family Centers. Regardless of whether mental/behavioral conditions are the criterion for eligibility, all health home programs must integrate physical and mental/behavioral health care for all participants.

With one exception, all 11 states are relying on per member per month (PMPM) payment for health home services. The exception to PMPM payments is Rhode Island's CEDARR Family Center-based health homes, which are paid through a mix of fixed service fees and established rates per quarter hour of effort. Several states base their PMPM on staffing needs assumptions (Missouri, Idaho, and Maine). Rhode Island uses a similar methodology based on personnel costs and staffing ratios for its community mental health organizations under the second SPA. The PMPM in Ohio is calculated based on the state's Uniform Cost Report Requirements (licensure ad reporting requirements for community mental health centers), which considers staffing costs, indirect costs related to health home service provision and projected caseloads. New York uses regional and case-mix adjusted PMPM payments for health home enrollees and pays providers 80% of the PMPM during the period when they are attempting to enroll eligible beneficiaries. PMPM payments in Oregon are set at three levels based on the extent to which providers meet established criteria for patient-centered primary care homes.

Implementation and Emerging Issues

Our observations during the first two years of the evaluation have yielded a number of insights regarding key program features and early implementation lessons that we will continue to track over the intervention period.

Health Home Models: Broadly speaking, states have designed health homes program that fall into one of three general types: specialty provider-based (Missouri [one SPA], Ohio, Rhode Island [two SPAs], and Wisconsin); medical home-based models (Idaho, Iowa, Missouri [one SPA], and Oregon); or care management networks (Alabama, Maine, New York, and North Carolina). The specialty provider model centers on entities that traditionally serve special populations but integrate specialized care with primary care. The medical home extension model is based on the patient-centered medical home, but extends to include specialty and other providers beyond the traditional primary care practice. The care management networks are networks or coalitions of physical and mental/behavioral health care providers, care coordination entities, social services agencies, and other community organizations overseen by a lead organization or administrative entity.

Flexibility: Health home programs differ in the degree of flexibility afforded to participating providers, particularly in terms of enrollee composition and payment processes. More prescriptive models may entail greater up-front provider investments to meet staffing requirements. In these more prescriptive systems under-enrollment or enrollment discontinuities are problematic for providers if they do not generate sufficient revenue to cover these costs.

Care Integration: Integration of physical health, mental health, and nonclinical support services is crucial to the success of health homes, but is a challenge even in states with more experience with integration. Mental/behavioral health and primary care providers in most states report that paying attention to both physical and mental health issues represents a significant culture change in the approach to patient care.

Children: Incorporating children into the health home model presents some challenges. By and large, the health home model is viewed as more applicable to adults and their providers because of its focus on beneficiaries with chronic conditions less common among children, although the model is being applied broadly to children in some states (Rhode Island and Alabama).

Communication: Modes and patterns of communication are still being developed within and across sites of care, and particularly between health home providers, hospitals, and managed care organizations. The extent to which new patterns of communication and new protocols are needed depends in part on how much of a change from the existing care system the health home program represents. In all programs the lack of widespread and interoperable HIT systems and regulatory restrictions on sharing patient information created barriers to communication at all levels.

Provider Issues and Challenges: Depending on the program, providers are either taking on new roles or becoming a part of a more integrated system. Common issues include possible mismatch between who incurs costs and who benefits from return on investments, the inadequacy of data systems to meet provider needs, and the pace and effects of practice transformation.

HIT Infrastructure and Issues: Providers in all states noted the inadequacy of current electronic health records (EHRs) in supporting care integration, the documentation of nonclinical services, or cross-site communication. The lack of funding to support EHR adoption by mental/behavioral health providers was seen as a significant barrier.

Role of Complementary Programs: All states in this evaluation are building on structures and programs that already exist, are attempting to align their health home programs with other reforms. Participating states have been able to draw on resources and technical assistance made available at both the state and federal level in the last several years to support practice transformation, care coordination, and mental health integration more generally.

The Enhanced Match: In many states, the availability of the enhanced federal Medicaid match rate was cited as an important part of the motivation for implementing health homes. However, several states were already engaged in delivery system transformation and indicated that they would have pursued this model of care regardless of the match.

Overview of Evaluation Design and Challenges

Our research design uses a mixed-methods approach employing both qualitative and quantitative data collection and analysis. We have identified several challenges to the quantitative aspects of the evaluation and potential strategies for addressing them.

• The primary challenge is that the two-year implementation window is a short time over which to realize measurable improvements, as all the participating states noted.

• Implementation of health homes is statewide in nearly all cases and occurring alongside a range of other reforms, making it difficult if not impossible to isolate a health home effect and to identify "uncontaminated" comparison groups.

• The variety in state approaches to health home design and enrollment practices may present opportunities to identify state-specific or program-specific design adaptations to support analyses of changes in utilization and cost, although not necessarily their attribution to health homes.

Coming Year Activities

In the evaluation's third year, we will continue to monitor progress in all the states in our evaluation group. We also will be receiving administrative data from CMS that will allow us to begin developing profiles of the health home-eligible populations in each state. We will continue to work with states to identify suitable comparison groups, obtain identifiers for health home enrollees, and obtain information on quality monitoring measures the states are collecting from health home providers. These activities will support quantitative activities expected to begin in the fourth year of the evaluation and be completed in year 5.

Conclusion

For the most part, states included in this evaluation have used the Medicaid health homes option to augment existing programs, to accelerate implementation of existing policies, as one part of larger system reform efforts, or some combination of these strategies. Even so, implementation appears to be a slow process, at least with respect to the eight-quarter intervention period. Particular issues revealed through the site visits are those relating to the need to improve communication across provider types and settings, as well as the special challenges associated with integrating care. We will continue to observe how progress toward full implementation and system reform differs across these maturing programs, and will document these and other implementation issues that emerge. These findings may inform other states considering health homes about challenges encountered and best practices to address them.

 

I. INTRODUCTION

This report presents findings from the first two years of the long-term evaluation of Medicaid health homes, a new integrated care model authorized by Social Security Act Section 1945, created in Section 2703 of the Affordable Care Act (ACA).¹ The model is designed to target high-need, high-cost beneficiaries with chronic conditions or serious mental illness (SMI). We introduce the initial group of 11 states implementing the health homes option between its inception in October 2011 and January 2013, describe the programs they have designed and the programmatic and health system context in which they are being implemented, and discuss key themes and issues for implementation.

The long-term evaluation, one of two called for in Section 2703, is being conducted by the Urban Institute for the Department of Health and Human Services (HHS), Office of the Assistant Secretary of Planning and Evaluation. Ultimately, the evaluation will inform a 2017 Report to Congress about the effectiveness of the health home option in reducing hospital admissions, emergency department visits, admissions to skilled nursing facilities (SNFs), and costs. The second evaluation is a survey of states and interim evaluation conducted by a HHS Centers for Medicare and Medicaid Services (CMS) contractor to inform a 2014 Report to Congress.

Overview of the Section 2703 Health Homes Model

The Section 2703 health homes model is closely related to the "patient-centered medical home" (PCMH) model for integrating and coordinating health care, but is distinctive in three primary respects: (1) the focus on persons with specific chronic physical or behavioral conditions; (2) the variety of providers who may deliver health home services; and (3) the elevated importance placed on integration of physical health care with mental/behavioral health care, and on linking enrollees to nonclinical community social and long-term services and supports (LTSS), as well as supports for the enrollee and family. The vision is that the model will ensure coordination and continuity of care across care settings by providing a "cost-effective, longitudinal 'home' to facilitate access to an inter-disciplinary array of medical care, behavioral health care, and community-based social services and supports for both children and adults with chronic conditions."²

States can implement health homes by submitting and obtaining CMS approval for a Medicaid State Plan Amendment (SPA) to add health home services as an optional benefit. States with approved health home SPAs receive eight quarters of 90% federal match for specific health home services identified in Section 2703. These include: comprehensive care management; care coordination and health promotion; comprehensive transitional care, including appropriate follow-up; individual and family support services, linkage and referral to community and social support services, if relevant; and use of health information technology (HIT), as feasible and appropriate. Consistent with the aim of integrating physical and mental/behavioral health care and supportive services, Section 2703 requires states to consult with the HHS Substance Abuse and Mental Health Services Administration (SAMHSA) in developing their proposals, regardless of whether the eligible population is defined primarily by chronic physical conditions or primarily by mental/behavioral health conditions.

The law allows states latitude in designing their health home programs. States may designate a wide range of providers or groups of providers other than primary care practices as health homes (e.g., community mental health centers [CMHCs], home health agencies), so long as these providers have the required systems and infrastructure in place to provide health home services and meet the qualification standards. Payment methodologies for health homes may include tiered payments for enrollees according to the number or severity of their conditions and for providers based on their capabilities, and states may design methodologies other than capitated per member per month (PMPM) payments, subject to CMS approval.

States also have flexibility in choosing the eligible population. The minimum eligibility criteria are having two chronic conditions, one chronic condition and being at risk of a second, or one serious and persistent mental health condition. Section 2703 specifies a list of eligible chronic conditions (a mental health condition, a substance use disorder, asthma, diabetes, heart disease, or being overweight, to name a few). States may select particular conditions, all of the conditions, or, with CMS approval, other conditions, such as HIV/AIDS. States also may choose to focus on persons with a larger number of conditions or greater severity than the minimum criteria. All SPAs must include a requirement that hospitals serving Medicaid beneficiaries have procedures for referring eligible emergency department patients to health homes, consistent with the aim of reducing avoidable use of hospital services.

Section 2703 allows states to focus on particular geographic areas and to provide services to health home participants that are different in scope, duration, or quantity than those offered to other Medicaid beneficiaries without obtaining a waiver of statewideness or comparability. States are required to offer health home enrollment to all persons meeting the state's eligibility standards who are categorically needy, including children, those who are dually eligible for Medicare and Medicaid, and those receiving services under a Section 1915(c) home and community-based services waiver, and may not use age as an eligibility criterion. States also may choose to include the medically needy and participants in Section 1115 Demonstrations.

Evaluation Aims and Content of Baseline Report

The primary aims of the long-term evaluation are to assess: (1) what models, providers, and processes states are choosing for health homes; (2) the extent to which state health home designs result in increased monitoring and coordination across clinical and nonclinical domains of care; and (3) whether the models result in better quality of care and outcomes, reduced use of hospital, SNF, and emergency departments, and lower costs.

This report focuses primarily on the design, motivations and goals, monitoring measures to be collected, and other basic parameters for each CMS-approved SPA in the 11 states selected for evaluation. Section II discusses the basic evaluation structure, methods, and activities over the first two years of the evaluation. Section III summarizes the health home program(s) in each of the states. Section IV discusses themes and issues for implementation. Section V summarizes the initial evaluation design, challenges for the design presented by the programs states are implementing and the context for their implementation, as well as ways in which our evaluation design may need to be adapted. Section VI briefly concludes and discusses third-year activities.

 

II. EVALUATION TIMELINE, STRUCTURE, AND METHODS

The long-term evaluation began October 1, 2011 and is scheduled to continue for five subsequent years. The first three years focus on qualitative and quantitative data collection, and the final two years will focus on finalizing the quantitative data analysis plan, conducting quantitative analyses, and preparation of findings for the Secretary's 2017 Report to Congress.

The evaluation is examining the 13 programs in 11 states that had effective dates no later than January 1, 2013, and had been approved by April 30, 2013 (Table 1). The cutoff dates were chosen to increase the likelihood of having claims data to assess outcomes in at least one year of the intervention period, in recognition of substantial lags in the availability of Medicaid data. For each SPA, the intervention period is defined as the eight quarters of enhanced federal match for health home services, beginning with the SPA effective date selected by the submitting state. For quantitative analyses of effects of each program on service use and costs, we also have defined a baseline period for comparison as the eight quarters immediately preceding the program effective date.

Initial evaluation activities for each state included developing background materials summarizing the design and the implementation context of each health home program and conducting site visits. These activities provide a qualitative data foundation for tracking and interpreting program progress and adjustments during the intervention period. Follow-up telephone interviews are being conducted roughly annually after in-person site visits. Quantitative analysis of the key outcomes largely will be confined to the final two years of the evaluation, both because of lags in the availability of Medicare and Medicaid data and to allow time for full implementation of the programs.

Research Questions

We have developed research questions in the domains of structure, process, and outcomes to be addressed by the evaluation and to guide our activities (see Table 2). Questions in the top panel of Table 2 address state choices of target populations and providers, the design of programs, the rationale for the design, and fundamental elements of structure and process. These questions underpin data collection and follow-up for each state. Questions in the lower panel of Table 2 relate to outcomes and relative performance of different providers and models for different target populations, which will be monitored and assessed over the intervention period.

Qualitative Data and Activities

Qualitative data activities in the first two years of the evaluation included the production of detailed memoranda profiling each approved program and the context in which it was being implemented, site visits, and follow-up phone interviews. We developed generic interview protocols based on the research questions (provided in Appendix A) and adapted them as needed to reflect each program.

State Profiles

We developed health home profiles through a systematic process of data collection for each state, drawing on existing reports, background information from state websites and other publicly available sources, and review of each SPA.

The SPAs provide data on the target population; the types of organizations and health care practices that may be health home providers and the qualifications they must meet to participate; state-specific definitions of the six health home services in each program; methodology for monitoring hospital utilization and cost savings from improved chronic care coordination and management; how HIT will be used to improve service delivery and care coordination across care settings; information to be collected from health home providers to monitor hospital admissions, emergency department visits, and SNF admissions, and the frequency of reporting this information.

In the SPAs, states also identify measures for quality monitoring corresponding to each of the required health home services or to specific program goals (e.g., improve health outcomes for persons with chronic conditions, improve diabetes care). For either service-based or goal-based approaches, states are asked to identify measures in the three domains of clinical outcomes, experience of care, and quality of care. CMS ultimately has provided specifications for a "core" set of common measures across all health homes programs.

Based on the information collected, we produced a memorandum for each state included in the evaluation. The memoranda summarize the key structural dimensions of the program, as well as the larger policy and health system context within each state that may have implications for implementation and evaluation. (These memoranda are provided in Appendix B.)

Site Visits and Follow-Up Phone Interviews

We arranged conference calls with contacts in each state to introduce the evaluation team, explain the purpose and aims of the evaluation, answer any questions, and discuss the scope and logistics for site visits, including the types of informants to be interviewed. At a minimum, informants included the state Medicaid Director, the health home program director, a HIT officer, the official leading the state's evaluation of the initiative, selected participating providers, and patient and provider advocacy groups. During the first year of the evaluation, we completed site visits in the four states which had programs approved prior to April 30, 2012 (Oregon, Rhode Island, Missouri, and New York). In the second year, we conducted site visits in the remaining seven states with programs approved before April 30, 2013 (North Carolina, Alabama, Iowa, Ohio, Wisconsin, Idaho, and Maine). Following each site visit, we developed high-level observations on major findings and identified key issues to be tracked over the course of the evaluation.

In the second year, we also conducted the first round of follow-up phone calls with key informants in the initial four states. These calls, which will continue annually with all evaluation states, are designed to collect additional data on program implementation, enrollment, and any program changes or mid-course corrections made over time.

Quantitative Data and Activities

Activities related to quantitative data collection and analysis in the first two years of the evaluation included: (1) developing a provisional analysis plan (see Section V); (2) refining the plan as needed, based on what we learned about the design of programs; (3) identifying and requesting the CMS administrative data required to address the primary evaluation questions relating to utilization and costs; (4) developing and executing data use agreements (DUAs) with individual states and beginning to obtain health home participant identifiers, enrollment and disenrollment dates, and algorithms used to select participants and for claims-based quality measures; and (5) beginning to develop analysis files for the baseline period. During the site visits, we identified contacts whowere involved in state evaluations and data systems and would be willing to work further with us on data issues, including the identification of potential comparison groups for analyses of health homes effects.

Data for the central quantitative analyses specified in Section 2703 (effects on hospital, emergency department, and SNF use, and on costs) are being obtained on an ongoing basis through a DUA with CMS. The evaluation design calls for examining utilization and costs for health home participants and a comparison group in the eight-quarter baseline period prior to the each program's effective date and the eight quarters of the intervention period. Because states are determining eligibility and participation on a rolling basis and may make adjustments depending on the number of eligibles successfully enrolled, our data request includes beneficiary, claims, and managed care encounter data for all Medicaid enrollees in each state for the full 16 quarters of the baseline and intervention periods, as well as Medicare beneficiary and claims information for dually eligible enrollees.

 

III. PROFILE OF STATE HEALTH HOME INITIATIVES

In this section, we provide an overview of the 13 health home programs selected for the evaluation, including two each in Rhode Island and Missouri. The programs reflect the substantial flexibility states have in designing their programs, with variation in the designated provider types, the chronic conditions targeted, and how health home services are defined and reimbursed. Most of the 13 programs are available to beneficiaries statewide. The three exceptions are Alabama, Ohio, and Wisconsin, which provide services in targeted geographic areas. Most of the 11 states focus on persons with two chronic conditions, one chronic condition and at-risk for a second, or one serious and persistent mental health condition, but several are defining the eligible population based on only chronic physical conditions, (North Carolina, Iowa, Wisconsin, and Maine), or focusing exclusively on those with SMI (Ohio). Missouri developed separate programs for those with chronic physical conditions and those with SMI. Key design features of each program are shown in Table 3, ordered by SPA effective date. Detailed information is provided in the state memoranda in Appendix B.

North Carolina

North Carolina's health home program is built within its existing statewide care management program, Community Care of North Carolina (CCNC). CCNC is the larger of two primary care case management (PCCM) programs that serve the majority of the state's Medicaid beneficiaries. The second PCCM program--known as Carolina Access --provides a lower intensity of care management than CCNC. The CCNC care management infrastructure is made up of 14 regional networks of providers--including physicians, hospitals, local health departments, and departments of social services. This infrastructure is overseen by a public-private entity called North Carolina Community Care Network, which operates under contract with the state. To be eligible for health home enrollment, beneficiaries must have at least two chronic conditions that fall within one of ten diagnostic categories, or one of eight specific chronic conditions that place the beneficiary at-risk for developing a second chronic condition. Mental illness and developmental disabilities are excluded as qualifying conditions. Beneficiaries with one chronic condition who develop a second pregnancy-related chronic condition also are eligible for health home services. Of the more than 1.2 million Medicaid and North Carolina Health Choice (the state Children's Health Insurance Program [CHIP]) beneficiaries enrolled with a CCNC network, approximately 560,000 were enrolled in the health homes program in July 2013.

Health home services are not distinct from services already provided to CCNC enrollees. Identification and enrollment as a health home beneficiary is an administrative process handled at the state level. The enhanced federal matching rate--which went into effect in October 2011 and ended September 2013--was used to offset state costs. No health home-related changes were made to the CCNC program or provider payments. For most Medicaid beneficiaries, enrollment with one of the state's PCCM programs is mandatory. New CCNC enrollees must select a primary care provider (PCP) enrolled with that program, and those who require additional care management receive those services through the CCNC network. Each regional network employs care managers who work at either the network or practice level. Care managers perform a number of functions, including home visits, medication reconciliation, care planning and referral coordination, as well as providing technical support for practice transformation. Networks also employ a pharmacist who directs medication management and e-prescribing, and a psychiatrist who directs behavioral health integration efforts. In addition, networks employ quality improvement staff to work with enrolled practices and may obtain their own grant funding for discrete initiatives. CCNC also frequently serves as the coordinating body for pilot initiatives and demonstrations that may later be rolled out statewide, for example, the pregnancy care management (PCM) program. The PCM program promotes healthy mothers and babies by providing care management for high-risk women during pregnancy and for two months after delivery. Risk criteria for receiving pregnancy-related care management services include but are not limited to the history of pre-term birth, chronic conditions that may complicate pregnancy, substance abuse, and missing more than two prenatal appointments.

Providers receive no additional payments for health home enrollees. The payment method for health home enrollees is the same as that paid for other CCNC enrollees. In addition to the base Medicaid fee-for-service (FFS) schedule, CCNC medical homes receive a tiered PMPM payment for each enrolled beneficiary ($5 for Aged, Blind or Disabled [ABD] beneficiaries; $2.50 for all others). CCNC networks also receive a tiered PMPM ($12.85 for the ABD population, $5.22 for those who qualify through pregnancy, and $4.33 for all others). A portion of this PMPM is retained by the CCNC central office to support its activities.

CCNC has a well-developed health information exchange (HIE) infrastructure known as the Informatics Center. The Informatics Center uses data from many sources to perform a range of functions and includes several different platforms that CCNC networks and providers can use to manage the health of enrolled Medicaid patients. Current Informatics Center data includes Medicaid claims data, patient record data, laboratory data, and hospital data, which network employees and providers can access through web-based portals. The Informatics Center also produces quarterly reports that are used to identify individuals in need of additional screening and care management services. CCNC conducts regular chart audits using an electronic audit tool, the results of which are made available to both practices and networks.

Oregon

Oregon's health home program was added as a new component within the state's Patient-Centered Primary Care Home (PCPCH) initiative, which was established in 2009. The PCPCH program is a key component of health system transformation in the state, along with the implementation of coordinated care organizations (CCOs), which began during the first year of health homes implementation. These community-based integrated care organizations have a mission similar to that of health homes but without the focus on particular conditions. Health home services were delivered through qualified PCPCHs, which also serve other Medicaid enrollees, government employees, and state education personnel. To qualify for health home services, beneficiaries had to have two or more chronic conditions, one chronic condition and be at risk of developing another, or SMI. The state specified 11 chronic illnesses and nine mental health conditions in the list of qualifying conditions, and based its definition of "at-risk" on guidelines from the U.S. Preventive Services Task Force, the Health Resources and Services Administration Women's Preventive Services, and Bright Futures. Under these criteria, about 118,000 individuals were eligible for health home services, roughly 14% of the Medicaid population. The enhanced federal match rate went into effect in October 2011 and ended in September 2013, after which providers no longer enrolled beneficiaries into the program or received enhanced reimbursement for health home services. During the eight quarters of the health homes program, more than 93,000 individuals were enrolled.

To be recognized as a PCPCH, a provider must demonstrate the ability to meet certain measures and standards. The state assigns providers to one of three tiers based on the number and type of standards met, with Tier 3 reflecting the most advanced level of functioning as a PCPCH. Over the period of the enhanced match, any recognized PCPCH was eligible to apply to provide health home services by submitting an addendum to its PCPCH agreement with the state. Once approved, PCPCHs were eligible to receive a supplemental health home payment (described below) for each qualified patient for whom specific service and documentation requirements were met. These requirements include: (1) providing at least one state-defined core service each quarter; (2) performing panel management at least once per quarter, using data for all patients or for sub-groups of patients for such functions as care management or quality assurance; (3) performing patient engagement and education, and obtaining patient agreement to participate in the health home program; and (4) developing a person-centered health plan. A PCPCH was not required to provide all health home services on site, but no provider could qualify as a PCPCH if they did not offer primary care services on site. Thus, CMHCs were eligible to be health homes only if they also offer primary care on site. All of the health home services were available to any patients enrolled with a PCPCH, but only services for patients identified as health home-eligible were reimbursed at a higher rate.

Providers identified beneficiaries they believed to be eligible for health home services and submitted them to the state for approval, either through the patient's managed care organization (MCO) or directly, for patients not enrolled with an MCO (about 80% of the state's Medicaid population is enrolled in managed care). Once approved and assigned, the enrollee was informed of their assignment and could then opt-out or select a different provider. Providers were required to update and resubmit health home enrollee lists each quarter, which served as attestation of meeting the quarterly health home service requirements and triggered payment. The state guidelines for achieving PCPCH recognition specified the information that a practice must be able to show in support of its attestation, which was subject to audit.

Payment for health home services provided to health home enrollees was a PMPM amount that varied by the provider's qualification level: Tier 1--$10 PMPM; Tier 2--$15 PMPM; and Tier 3--$24 PMPM. For FFS patients, payments went directly to providers; for MCO-enrolled members, payments were administered by the MCO. Any portion of the payment retained by the MCO was required to be used to carry out health home-related functions and was subject to approval by the state.

Health home providers were encouraged to develop or use their current HIT capacity to perform a range of functions, including electronic health record (EHR) use and data gathering and reporting. Oregon also links certain PCPCH measures to HIT capacity. For example, implementation of an EHR is not required, but providers who have an EHR can earn additional points towards their qualification as a Tier 3 PCPCH. The state also maintains a provider portal and patient panel management system. Use of this system is required as part of the provider's service provision, but it also allows the provider to review data on their patient panel and identify any gaps in care.

Rhode Island

Rhode Island's two health home programs target populations served by existing specialized providers. The first population is persons with SMI served by community mental health organizations (CMHOs), which are overseen by the Department of Behavioral Health, Developmental Disabilities and Hospitals. The second is children and youth with SMI and/or other disabling or chronic physical or developmental conditions served by "Comprehensive Evaluation, Diagnosis, Assessment, Referral, Re-evaluation" (CEDARR) Family Centers, which are overseen by the state Department of Human Services. CEDARR centers provide care exclusively to children and youth with special health care needs, including needs assessment, referral to resources, integration of services provided through different state systems, and a limited number of direct services. An estimated 7,800 enrollees are eligible for health home services statewide, about 5,300 of them through CMHOs. Of this latter population, about 60% are dually eligible. The enhanced federal matching rate went into effect for both state programs in October 2011, and ended in September 2013. During the eight quarters of the enhanced match period, over 9,500 individuals were enrolled in both programs.

CEDARRs and the CMHOs submit lists of potentially eligible clients to Department of Human Services for enrollment into the health home program. To be eligible to receive health home services through a CMHO, an enrollee must have SMI and meet additional criteria related to their level of impairment. (These criteria are the same as those used to determine eligibility for the state's existing Community Support Services Program, which targets persons with SMI who can be managed outside of institutional settings.) Eligible beneficiaries are auto-assigned to receive health home services based on qualifying conditions and an existing relationship with a CMHO, but may opt-out or change provider. Hospitals also may refer potentially eligible beneficiaries. Beneficiaries may be referred to CEDARR Centers through a number of channels, including PCPs and self-referral. Children and youth receiving care through a CEDARR are eligible for health home services if they have a mental health condition, two chronic conditions, or one chronic condition and the risk of developing another. About 95% of current CEDARR clients meet these diagnostic criteria.

The state has two Medicaid managed care providers, which cover 60% of CEDARR participants and 35% of eligible CMHO participants (through capitated plans known as RIte Care and Rhody Health Partners, respectively). The remaining adult Medicaid population is enrolled in a FFS-based PCCM program called Connect Care Choice. In order to avoid duplication of services, the state-developed operational protocols outlining which care management activities will be conducted by MCOs and which will be conducted by CEDARRs and CMHOs.

The required health home care team for CEDARR includes two members, a licensed clinician and a family service coordinator, who share responsibility for the core health home services but collaborate with other health professionals and CEDARR staff, including the enrollee's PCP. The required team for a CMHO health homes includes at least seven members with behavioral, clinical, or social support expertise.

CMHOs are paid through a PMPM rate reflecting personnel costs and staffing ratios based on estimates of client need. The estimated staff needs for a team serving 200 clients is 11.25 full-time equivalent, or approximately nine staff hours per client per month. CMHOs are required to submit highly detailed encounter data to document services provided. CEDARR centers continue to be paid on a FFS basis. Three existing CEDARR activities--family intake and needs assessment, family care plan development following initial needs assessment, and annual family care plan review--are paid at fixed rates ranging from $347 to $397 per enrollee. Two additional services--health needs coordination and therapeutic consultation--are reimbursed at established hourly rates paid per quarter hour of effort and tiered according to the type of professional providing them.

The HIT infrastructure underpinning these two initiatives is built on the existing systems used by CEDARR Family Centers and the two state Medicaid MCOs. Neither group of providers is required to have an EHR, but CMHOs that have an EHR or registry may be required to participate in a pilot study to measure their effect on both care and patient outcomes. CEDARR centers use their existing electronic case management system as well as the KIDSNET Child Health Information System, which provides access to a range of public health and social services information. CEDARR health homes also offer to enroll all clients into CurrentCare, Rhode Island's electronic HIE.

Missouri

Missouri's health home program builds on the state's relatively long history of behavioral and physical health care integration. The selected populations--beneficiaries with SMI and those with chronic physical conditions--have been the focus of several previous initiatives aimed at integrating physical and behavioral health and coordinating care for patients with multiple chronic conditions. CMHCs are the designated providers for the behavioral health population, while primary care centers--specifically, federally qualified health centers (FQHCs), rural health clinics (RHCs), and hospital-operated primary care clinics--are the designated providers for persons with chronic physical conditions. The qualifying chronic physical conditions are the same in the two SPAs. The primary distinction between the two SPAs is that substance use and mental illness are not qualifying conditions to receive health home services through a primary care center; beneficiaries with these conditions are assigned to a CMHC health home. The Missouri Department of Social Services estimates that about 43,000 Medicaid beneficiaries are eligible statewide, and about 34% of these are dual eligibles. As of March 2014, roughly 35,000 beneficiaries were enrolled in both health home programs. The enhanced federal match period was in effect from January 2012 to December 2013.

Missouri uses a claims-based algorithm to identify eligible persons and auto-assigns them to the relevant type of provider, based on their conditions. Enrollees in both health home-types may opt-out of the program or change providers. Hospitals also may refer unassigned patients to a health home. Though both FFS and managed care enrollees are eligible for health home enrollment, Missouri's managed care program is offered in only certain geographic regions and serves primarily children, youth, and pregnant women. In addition, some CMHCs serve only adult populations. Consequently, managed care enrollees represent a relatively small percentage of health home enrollment (about 10% overall).

The care teams are explicitly defined in both SPAs and similarly structured. Both teams include a director, nurse care manager, and administrative support staff. The CMHC team, however, includes a primary care physician consultant, while the primary care team includes a behavioral health consultant and a care coordinator, as well as additional clinical staff (such a physician or nurse practitioner). The staffing ratio for each of these roles is also defined in the SPA.

Health home services are paid on a PMPM basis, and payment levels are based on staffing needs assumptions. The PMPM payment for services at CMHCs is $78.74, and the PMPM payment for services delivered at primary care centers is $58.87. The state originally planned to re-evaluate the PMPM determination annually, but did not adjust payments over the initial two years of the program.

The HIT infrastructure underpinning the initiative is based primarily on the Medicaid HIT infrastructure. Missouri HealthNet maintains a web-based EHR called CyberAccess, which is accessible to all enrolled Medicaid providers, including CMHCs. This system also includes a web-portal called Direct Inform, which allows enrollees to look up information on their care utilization, calculate their cardiac and diabetic risk levels, and develop a personal health plan. The CMHCs also use a tool called ProAct™, which provides medication and care management reports. The ProAct™ tool also produces an Integrated Health Profile that pulls together information from these reports, as well as data on hospital and emergency department use, and other service utilization. ProAct™ is used by health homes to upload metabolic screening data on individuals receiving psychotropic medications, as required since 2010 by the Department of Mental Health.

In addition, Missouri HealthNet maintains an authorization-of-stay tool that requires hospitals to notify Missouri HealthNet within 24 hours of a new Medicaid-financed admission of any Medicaid enrollee, as well as to provide information about diagnosis, condition, and treatment, which triggers a notification email to the health home provider. The system does not yet include Medicare-financed admissions of dually eligible enrollees or emergency department visits that do not result in admission.

New York

New York phased-in its health home program under three separate SPAs, all of which are included in this evaluation. The first SPA covered ten counties with an effective date of January 1, 2012. The second SPA expanded health homes to 12 additional counties, effective April 1, 2012, and the third expanded them to the remaining 39 counties, effective July 1, 2012. The enhanced federal match ended for the first ten counties in December 2013, and will end for the remaining groups of counties in March 2014 and June 2014, respectively. The state is focusing on individuals who have HIV/AIDS and are at risk of developing another chronic condition, those with two or more chronic conditions (including substance abuse or a mental health conditions), and those with SMI. Approximately 158,000 Medicaid beneficiaries statewide are enrolled and about 20% of enrollees are dually eligible for Medicaid and Medicare. The state also plans to implement a second and third wave of health home expansion, with the second wave expanding eligibility to the long-term care population, and the third targeting enrollees with developmental disabilities.

Health home providers are designated through an application process in which a lead health home organization must demonstrate how it will meet health home requirements through its network of partners and affiliated providers. Approved health home providers include hospital networks with affiliated physical health, behavioral health, and community support providers, existing condition-specific Targeted Case Management (TCM) programs, and community-based organizations.

New York State Department of Health identifies and assigns beneficiaries to a health home using a series of algorithms that identify an individual's level of risk and connectivity to the health system. Eligible beneficiaries with a higher level of clinical risk and a lower level of connectivity have higher assignment priority. For FFS enrollees, the state provides candidate "tracking lists" directly to health homes. For managed care enrollees, the state transmits the list to the relevant managed care plan (MCP), which is then responsible for assigning candidates to the health home organization that can best serve their needs. Approximately 65% of eligible health home beneficiaries are enrolled in managed care; the rest are in Medicaid FFS.

Providers receive PMPM payments at two levels: outreach and engagement, and active care management. The active care management group consists of participants who have enrolled in a health home. Beneficiaries in the outreach and engagement group have been assigned to a provider but have not yet agreed to enroll. Services for this group are reimbursed at 80% of the active care management rate for up to three months after a beneficiary is assigned to cover the cost of outreach and engagement. If the beneficiary is not enrolled within that timeframe, a three-month hiatus is required before the outreach and engagement payment can resume. Payment for FFS enrollees goes directly to the health home, while payment for managed care enrollees goes through the plans; MCOs may retain up to 3% of the payment for administrative services. Rates are adjusted by region and case-mix.

Standards for HIT use by health homes are phased-in gradually. Providers must meet a set of initial standards in order to qualify and have 18 months to meet final standards. Final standards require that health homes have interoperable HIT systems and policies that allow for the development and maintenance of the care plan, that they use a certified EHR that complies with the official Statewide Policy Guidance on HIT, that they participate in Regional Health Information Organizations (RHIOs) for the purposes of sharing data, and that they employ clinical decision-making tools where feasible.

Alabama

Alabama offers health home services to beneficiaries who have two chronic conditions, one chronic condition and at-risk for developing another, or SMI. The qualifying chronic conditions include a mental illness, substance use disorder, asthma, diabetes, cardiovascular disease, chronic obstructive pulmonary disease (COPD), cancer, HIV/AIDS, and sickle cell anemia. Persons who have received a transplant within the last five years are also eligible for inclusion. Any beneficiary with one of these targeted conditions is considered to be at-risk for developing another chronic condition.

Services are provided through designated teams of health care providers that include PCPs, behavioral health providers, state-employed case managers, and providers who are part of the Patient Care Networks of Alabama (PCNA). PCNAs, established in 2011, operate as independent, nonprofit entities that contract with the state and participating Medicaid providers to offer wraparound care management services for eligible beneficiaries enrolled in the state's PCCM program, Patient 1st. Primary responsibility for care management rests with the participant's designated PCP. However, depending on diagnosis, participants may instead receive care management through a state-licensed CMHC, a substance abuse provider, or an Alabama Department of Public Health (ADPH) care manager. Any participant who is unstable but deemed ineligible for care management through a behavioral health or ADPH provider may be referred to the PCNA for care management. Though case management services are available statewide through the Patient 1st program, the PCNA program--and by extension the health homes program--operates in four targeted geographic regions, comprising 21 of the state's 67 counties. Currently, little over 70,000 Medicaid beneficiaries receive health home services through a PCNA.

Enrollment in Patient 1st is mandatory for all Medicaid beneficiaries, with the exception of certain groups of children, members of federally recognized Indian tribes, and individuals who are dually eligible for Medicaid and Medicare. The state identifies health home-eligible individuals through a monthly review of claims data, with an 18-month lookback period. For those with organ transplants, the lookback period is five years. Other providers may also refer patients for enrollment. Once identified, patients are contacted by mail and permitted to choose a primary medical provider (PMP), after which they are enrolled with the PCNA contracted to that practice.

Patient 1st providers receive $8.50 PMPM for health home beneficiaries, and PCNAs receive $9.50 PMPM. Rural health centers and FQHCs that participate as PMPs do not qualify for the case management fee because these services are covered under their prospective payment system reimbursement.

Neither Patient 1st PMPs nor PCNAs currently are required to have an EHR or use an electronic Continuity of Care Document to exchange information. However, PCNAs are expected to use and document in a web-based care management tool known as the Realtime Medical Electronic Data Exchange, which provides claims-based data on utilization. Alabama is in the process of implementing a statewide HIE platform known as One Health Record, which will connect providers with state agencies and eventually serve as the primary platform for patient data exchange. A consumer portal is already operational through One Health Record, as is a platform for direct secure messaging between providers who are connected to it.

Iowa

Iowa offers health home services to categorically and medically needy beneficiaries with either two or more chronic conditions, or one chronic condition and at risk of developing another. Qualifying chronic conditions include a mental health condition, a substance use disorder, asthma, diabetes, heart disease, body mass index (BMI) over 25 (or BMI for age over the 85th percentile for children), and hypertension. The definition of at-risk is based on guidelines from the U.S. Preventive Services Task Force, and includes a diagnosed condition with established chronic co-morbidities, a documented family history of a heritable condition included among the state's qualifying conditions, or environmental exposures known to contribute to those conditions. As of January 2014, 4,396 of the approximately 100,000 health home-eligible beneficiaries were enrolled.

To qualify as a health home, providers must meet state-developed standards, must complete and submit the TranferMED PCMH self-assessment at the time of their enrollment, and are expected to achieve National Committee for Quality Assurance (NCQA) recognition (level unspecified), or another national recognition, within the first year of operation as a health home. Health home practices may include, but are not limited to primary care practices, CMHCs, FQHCs, and RHCs. Designated practices may have multiple sites, provided that these sites are identified as members of a single organization with shared policies and practices, and are supported by a common information technology infrastructure.

Health home enrollment is initiated by providers, who are encouraged to identify and enroll eligible beneficiaries from their existing patient panel. The state may also identify beneficiaries from claims data and notify a health home, but this is intended only to assist providers in identifying and prioritizing patients for enrollment. The provider is still responsible for assessing and enrolling those patients. The assessment, which is based on a state-developed Patient Tier Assignment Tool, is used to assign patients to one of four tiers, with higher tiers corresponding to higher levels of clinical risk.

Payment for health home services is made through a PMPM amount that varies according to a participant's tier (Tier 1--$12.80; Tier 2--$25.60; Tier 3--$51.21; Tier 4--$76.81). Iowa has also incorporated a pay-for-performance component into their health home program, with incentive payments based on achievement of selected quality and performance benchmarks. These 16 measures are separated into five categories: preventive measures; diabetes/asthma measures; hypertension/systemic antimicrobial measures; mental health measures; and total cost of care. Payments were scheduled to begin in the second year of Iowa's health home program (which started July 2013), but due to ongoing HIT implementation challenges, it remains unclear whether the incentive payment program will be operational within the two-year timeframe of the enhanced match.

Health home providers are required to implement an EHR that includes referral tracking capabilities, and have in place a plan for complying with federal meaningful use requirements. Providers also must employ a population management tool, such as a patient registry, and are encouraged to use email, text messaging, patient web-portals, and other technology where possible to enhance patient access and self-management. Providers are also expected to connect to and participate in the statewide Health Information Network (HIN), which was implemented in 2012.

Ohio

Ohio's health home program is a joint effort between Ohio Medicaid and the Ohio Department of Mental Health and Addiction Services and focuses on adults and children with serious and persistent mental illness (SPMI), SMI, or serious emotional disturbance (SED) served by Community Behavioral Health Centers (CBHCs). Medically needy beneficiaries are excluded from the health homes option. In January 2014, more than 10,000 beneficiaries were enrolled in the health home program.

CBHCs that meet state requirements for integration of physical and behavioral health and other standards relating to their certification, care structures and processes, and relationships with other providers and MCPs are eligible to apply for health homes designation. The health home care team must include a team leader, an embedded primary care clinician, a care manager, and a qualified health home specialist; each health home determines the staffing needed to meet service requirements. Each health home must participate in technical assistance provided by the state, including the Health Homes Learning Community--a learning collaborative established to support health home implementation--and other activities.

Beneficiaries with the specified health home conditions and receiving services at one of the participating CBHCs are engaged and enrolled in the health home program, with a choice to opt-out or enroll with another health home provider. Hospitals, specialty providers, MCOs, or other providers may refer Medicaid beneficiaries to health homes. MCOs are required to establish a partnership with the CBHC health home in their service area and develop procedures for exchanging health information and sharing care management responsibilities. In addition, MCOs are expected to perform ongoing identification, including enrollment assistance, of members who may benefit from health home services and must track which members are receiving these services. MCOs must also participate in transitional care activities with the health home and integrate results from the health homes quality measures into their quality improvement programs.

Payment levels for health home services are based on the state's Uniform Cost Report Requirements, which consider staffing costs, the indirect costs related to health home service provision, and the estimated health home caseload. The monthly case rates cover all health home service components and range from about $270 to just over $400 per month. Providers must submit claims to receive payments. Only one claim may be submitted per beneficiary per month.

HIT requirements will be phased-in over two years. Within one year of health home designation, the CBHC must adopt an EHR. Within two years, it must demonstrate that the EHR is used to support all health home services. Furthermore, the CBHC must participate in Ohio's statewide HIE when available. CBHCs will receive quarterly utilization profiles on each health home beneficiary and will be required to use the data in developing appropriate care and coordination plans.

Wisconsin

Wisconsin's health homes program targets individuals with a single chronic condition--HIV/AIDS--who have at least one other diagnosed chronic condition or are at risk of developing another. The at-risk criteria adopted by the state includes individuals who, in addition to being diagnosed with HIV/AIDS, meet clinical benchmarks related to low CD4 cell counts, low BMI, and certain cardiovascular and metabolic risk indicators. The designated provider of health home services are AIDS service organizations (ASOs), which are specialized HIV/AIDS service providers identified under Wisconsin statute. The state has two designated ASOs, the AIDS Network and the AIDS Resource Center of Wisconsin (ARCW). Each organization is responsible for a particular service area; the AIDS Network covers 13 counties in the southern part of the state and operates three clinic sites, and ARCW covers the remaining 59 counties and operates nine sites. Both entities offer a range of medical and social services, including case management, dental care, mental health screening and referral, and prevention services.

Health home eligibility is limited to categorically and medically needy individuals in four noncontiguous counties in the state, three of which are served by ARCW. Though ARCW provides limited services in the fourth county, primary responsibility for coordinating care in that area lies with the AIDS Network, which was not initially qualified as a health home. As a result, initial eligibility for health home enrollment is limited to those who are able to enroll with ARCW in the three designated counties where ACRW has primary responsibility for care coordination. ARCW clinic sites in Brown, Kenosha, and Milwaukee counties offer medical, behavioral health, and social services, as well as preventive services such as sexually transmitted infection screening and needle exchange. Dental clinics are also available on-site in two counties, and the Milwaukee site offers clinical pharmacy services through its on-site pharmacy. Clients requiring services not provided directly at given clinic locations are referred to other providers within the community.

Eligible beneficiaries are auto-enrolled into the health home program. ARCW is required to contact beneficiaries to inform them of the benefits of enrollment and offer them the opportunity to opt-out. By agreeing to participate in the initial assessment and care planning process, the beneficiary consents to enrollment. Beneficiaries who are enrolled in managed care cannot also be enrolled in a health home because of concerns about duplication of services. As of March 2014, ARCW had 188 health home enrollees.

Wisconsin is using two payment methodologies: a PMPM case rate paid to the ASO for providing at least one health home service per month, and a flat fee that covers the initial assessment and development of a care plan for each new enrollee. This latter service can be billed once a year if the care needs of the health home member require another comprehensive assessment and care plan review. Current rates are $102.95 for the PMPM, and $359.37 for initial assessment and care plan development.

ASO health homes must have an EHR that is accessible to all care team members and contains health homes enrollee treatment plans. The treatment plan must be updated regularly to reflect services provided. The state requires that providers adopt EHRs that have the capacity to interface with specialty and inpatient care providers, but there is no defined timeline for adoption. It is not made explicit whether this interface will take place through the state's HIE (Wisconsin State Health Information Exchange) or another mechanism. The state HIE is still under development.

Idaho

Idaho offers health home services to categorically needy beneficiaries who have a SMI or SED, have asthma and diabetes, or have either asthma or diabetes and are at-risk one of developing another chronic condition. The identified risk factors include BMI greater than 25, dyslipidemia, tobacco use, hypertension, or diseases of the respiratory system. Medicaid beneficiaries can self-refer or be referred by a provider to a health home. Participating providers are responsible for identifying potentially eligible beneficiaries among their patients. Those confirmed eligible by the state are auto-enrolled, with the right to opt-out.

Idaho's health homes initiative builds on the state's Medicaid PCCM program, Healthy Connections. All Idaho Medicaid beneficiaries are enrolled in some form of managed care, with majority being enrolled in Healthy Connections. Enrollees with disabilities, special health care needs, or who are dually eligible for Medicaid and Medicare are eligible for additional benefits under the Enhanced Plan or the Medicare-Medicaid Coordinated Plan. There are an estimated 30,000 health home-eligible Medicaid beneficiaries in the state, and roughly 9,100 are currently enrolled in the program.

Any Healthy Connections provider who meets state qualifications may serve as a health home, including solo or group practices, RHCs, CMHCs, and home health agencies. The health home provider identifies and leads the care coordination team, which may include other providers as necessary to meet a particular beneficiary's needs. The SPA defines a clear role for a care coordinator in providing care management but does not require a dedicated care coordinator to be part of the health home team, which provides some flexibility for smaller providers. The integration of behavioral health is required and may be achieved through tele-health, co-location of behavioral health professionals within the clinic, or referral to a behavioral health professional. Health home providers must achieve at least Level 1 PCMH NCQA certification by the end of their second year of operation as a health home, as well as meet the 11 health home qualifications required by the state. Health homes are required to conduct two other assessments: the PCMH Assessment, intended to identify strengths and weaknesses in the clinic, and the Primary Care Development Corporation Assessment with is used to map the clinic's progress towards NCQA recognition.

Payment for health home services is made on a PMPM basis. In building the rate, the state assumed that the health homes care team would take on defined roles within the health home, and calculated a rate based on the average salaries and presumed division of labor for each member of the care team. An extra $1.00 was added to the PMPM to cover the costs of NCQA recognition process. The $15.50 PMPM is paid to Healthy Connections providers that offer at least 46 hours of clinic access per week to enrollees. Monthly contact with the enrollee is not required in order to receive the PMPM.

Initial HIT standards for participating providers at the time of enrollment include structured information system that will allow providers to use a disease management program for chronically ill enrollees. An EHR is not required, but is encouraged. The final standards require that providers use HIT to: (1) systematically follow-up on tests, services, and referrals; (2) practice population management and identify care gaps; and (3) access and use the Idaho Health Data Exchange, the state HIE. Providers must submit a plan to achieve the final HIT requirement to the state within 24 months of program initiation (or by December 31, 2014) in order to be approved as a Health Home provider, as well as have an electronic disease registry in line with NCQA standards.

Maine

Maine's health home program is being implemented statewide as part of an expansion of the state's pre-existing PCMH pilot. Maine's health home program incorporates care management by regional Community Care Teams (CCTs), which assist practices in managing the needs of high-cost, high-risk patients. As of September 2013, there were approximately 160 designated health homes and ten CCTs. Health home services are offered to categorically and medically needy beneficiaries with two or more chronic conditions, or one chronic condition and the risk of developing another. Qualifying conditions are a mental health condition, substance use disorder, diabetes, heart disease, BMI over 25, tobacco use, COPD, hypertension, hyperlipidemia, developmental disabilities or autism spectrum disorders, cardiac and circulatory congenital abnormalities, acquired brain injury, asthma, and seizure disorders. Beneficiaries with SPMI or SED are currently not eligible to enroll, but the state plans to expand health homes to this population under a separate SPA.

Health home providers are primary care practices that meet the state's established qualifications. They are required to contract with a CCT to provide wraparound clinical care management services for high-risk, high-cost patients within a designated geographic region. Health home practices and CCTs share accountability for reducing avoidable health care costs, with a specific focus on reducing inpatient and emergency department utilization, providing timely post-discharge follow-up, and improving patient outcomes. CCTs are required to establish regular communication and coordination procedures with the health home practices they serve. Each CCT must be led by a CCT manager or director and must include a medical director, responsible for clinical quality improvement efforts, and a clinical leader who directs care management activities. CCT staff typically includes a mix of nurses, social workers, and other health care professionals. Each CCT must establish a process for identifying a patient's needs and linking them to a lead coordinator whose expertise matches those needs. Both primary care practices and CCTs are required to participate in the PCMH Pilot Learning Collaborative, to have the capacity to share patient data and collect and report quality measures, and to commit to meeting the standards of Maine's multi-payer PCMH Pilot. Practices also must have achieved Level 1 NCQA recognition for PCMH by December 31, 2013.

Eligible beneficiaries are identified through both claims data and provider identification. Eligible beneficiaries who are either enrolled with or who regularly visit a health home practice are notified by the practice of their eligibility and may elect not to participate in the program. Patients are auto-enrolled if they have not opted out within 28 days. The state notifies eligible beneficiaries not enrolled with a health home practice of the benefits of participating and provides a list of health homes in their area. Health home-eligible beneficiaries receiving TCM services may choose to continue in TCM or switch to care management through a health home. Health home enrollees with basic needs receive care management and coordination services through the health home practice, while patients with more complex needs are referred by the health home to a CCT for enhanced care management services. Patients identified as high utilizers (i.e., those with frequent hospital admissions and emergency department visits, and others who are considered priority patients), are eligible for referral to the CCT. Health home practices are encouraged to identify others who would benefit from CCT services, including enrollees who have three or more conditions, are failing to meet treatment goals, are using multiple drugs for their chronic condition(s), or have social service needs that interfere with care. The state estimates that roughly 5% of a practice's patient panel will require CCT services. As of January 2014, almost 43,000 patients were enrolled in the health home program, which is about 30% of the estimated eligible population.

Both health home practices and CCTs receive a separate PMPM payment for the provision of care management services. The PMPM rate paid to the practice is $12, and is based on estimates of the staffing costs associated with providing health home services not otherwise reimbursable under MaineCare. The CCT payment is described as an "add-on" payment to support care management services for the high-need individuals referred to them, and is set at $129.50. The state will provide add-on payments for no more than 5% of the total number of health home enrollees associated with a given primary care practice.

Maine requires all health homes to have a fully implemented EHR. Many of the providers are already participating in the MaineCare HIT incentive program and the state's tele-health laws provide incentives for the use of remote monitoring and other technologies. The HIT infrastructure varies across communities. Some CCTs and practices share an EHR, or have negotiated agreements that allow CCTs to use the practice's EHR. In other cases, the two use the state's HIE, HealthInfoNet (HIN). This exchange connects to more than 80% of Maine hospitals and almost half of primary care practices. HIN includes an enrollee portal, as well as a notification system to alert care managers when an assigned enrollee has visited the emergency department or been admitted to a hospital.

 

IV. IMPLEMENTATION THEMES AND ISSUES

In this section we report on what we learned during our site visits, including the implementation context, key features across the state programs, and early implementation issues and challenges. Some features reflect the health care landscape prior to implementation and may not be generalizable. Others reflect state choices that may provide lessons for other states and for CMS as it considers health home policies. We will continue to track these issues over the evaluation period, as well as identify new issues as they arise.

Implementation Context

As previously noted, states were granted substantial flexibility in designing their health home programs, resulting in a high degree of diversity among the 13 programs in our evaluation. These baseline differences both reflect and are amplified by the specific context in which the health homes programs have been established. Decisions regarding key health home features depend on a number of factors, including the state's broader policy goals, the existing health system infrastructure, and the other reform initiatives underway in the state. In certain cases, such as in North Carolina and Rhode Island, the state targeted providers who already offered health home-like services, and made little or no substantive changes to their care coordination efforts. In these states, the enhanced match replaced ongoing state expenditures for the eight quarters in which it was available. In other states, health homes are part of a broader transformation of the health care system. Oregon, Idaho, and Maine, for example, incorporated their health home programs into their statewide--and in the case of Idaho and Maine, multi-payer--medical home initiatives. In these states, the enhanced match facilitated ongoing delivery system transformation efforts. Thus, the degree to which health homes represent a new care delivery model varies. All 11 states are building on structures and programs already in place, attempting to align the health home initiative with other reform efforts already underway, or both.

To support health home implementation, some states have taken steps to identify additional resources and coordinate across multiple programs and governmental offices. Their ability to do so depends on the extent to which administrative structures and funding streams are in place. For example, as part of a broader health system transformation process Ohio consolidated its Department of Mental Health and Department of Alcohol and Drug Addiction Services to reduce administrative complexity for its behavioral health programs, including health homes. Similarly, Rhode Island's Section 1115 Global Waiver--in place since 2009--has facilitated the state's attempts to streamline administrative processes and align funding streams between the Medicaid office and the mental health department.

States also have linked health homes with broader HIT transformation processes. In both Alabama and Iowa, providers are expected to connect with and use the statewide HIE, though the timeline for this connection is as yet unspecified. New York and Idaho have made funding and technical assistance available to providers to assist them in either adopting or using HIT. New York provides grants to support EHR adoption through the state's Health Care Efficiency and Affordability Law for New Yorkers Capital Grant Program, while Idaho provides ongoing technical support in using registry data to drive quality improvement.

In addition to these HIT supports, states are leveraging resources and technical assistance made available in the last several years to support practice transformation, care coordination, and mental health integration more generally. Some funding has come directly from the state, as in the case of New York's statewide medical home program and Rhode Island's Chronic Care Sustainability Initiative. Other initiatives have been the fruit of partnerships between the state and private organizations. Missouri partnered closely with its provider associations and the Missouri Foundation for Health to implement a series of reforms to its mental health system, including a pilot care integration program involving collaborations between FQHCs and CMHCs. Some health home providers have also been the recipients of SAMHSA co-location grants and thus have prior experience developing their internal care structures and processes.

The various contextual factors have significant implications for a given state's success in implementing a health homes program and, critically, sustaining it once the enhanced federal match period is over. Many of the state officials and providers we spoke to notedthat two years is a short timeframe over which to demonstrate significant impacts on the main outcomes of interest. States and health home providers likely will need to identify additional resources to support the practice transformation and HIT adoption that underpin the health homes programs.

Health Home Models

Though health home models vary widely in their specifics, they can be grouped into one of three general categories: specialty provider models, medical home models, and care management network models (See Figure 1).

CMHCs are the most common specialty provider, designated as the primary health home provider for SPAs, in Rhode Island, Missouri, and Ohio. The second Rhode Island SPA designates CEDARR Centers, which exclusively serve children with special needs, as the primary health home provider, and Wisconsin has designated ASOs. These designations reflect the relatively narrow patient populations targeted under each SPA. Patients with SMI or AIDS, for example, are a relatively small subset of the Medicaid population, but often have care needs that go beyond the services typically provided and managed through PCPs. As a result, they may receive the majority of their services through specialty providers. Tapping providers who already manage the specialized services may be more appropriate in order to minimize any disruption in established patient-provider relationships.

Oregon, Missouri (through its second SPA), Iowa, and Idaho have adopted a medical home model, most often with primary care practices, FQHCs, or RHCs as the central health home provider. Oregon and Idaho have built their health home programs into their existing medical home initiatives, while Iowa's program was seen as an initial step toward establishing a broader medical home infrastructure. Missouri's primary care health home model places greater emphasis on the integration of behavioral health services into the primary care setting than the other three programs, but like Iowa and Idaho, Missouri requires that providers achieve Level 1 NCQA recognition. Missouri also differs in restricting primary care health home designation to FQHCs, RHCs, and hospital-owned primary care practices, whereas the other three states will designate any provider that meets the established criteria. In all four states, however, state officials view the health home program as a lab for implementing a medical home model that could be applied to any patient requiring enhanced services, rather than as a model only for patient populations defined by the presence of specific conditions. Some of the providers we spoke with echoed this sentiment, and saw no real distinction between health home services and the kind of services that an advanced medical home should be providing.

North Carolina, New York, Alabama and Maine have adopted a model that relies on a care network which collectively provides comprehensive care management. North Carolina's health home program focuses on a subset of beneficiaries served by its longstanding CCNC care management model. Aside from meeting health home reporting requirements, no health home-related changes were made to any aspect of the program. Alabama and Maine drew explicitly on the CCNC example in developing their health home models, although both programs differ from North Carolina and each other in certain respects. Alabama and Maine both utilize regional care coordination teams, and refer high-needs patients out to these teams (the PCNA or the CCTs in Maine). Unlike the CCNC central office, however, neither of these entities provides administrative oversight or payment directly to the regional providers. New York's model is unique, relying on a lead entity that assembles an array of provider partners that collectively are able to provide all health home services. The lead entity oversees administrative responsibilities and distribution of payment. In all four cases, however, the health home is a team of health care professionals and social service partners collaborating across care settings. This approach provides a mechanism through which providers can access coordination and care management services that may not otherwise be available to them, as well as technical assistance or practice transformation resources.

Program Structures and Processes

Health home programs differ in the degree of flexibility afforded to participating providers, particularly in terms of health home team composition and payment processes. Rhode Island, Missouri, Iowa, and Ohio are the most prescriptive; the composition of the health home team is explicitly defined in the SPA, as are staff roles within each health home. North Carolina, New York, Alabama, Wisconsin and Maine are less prescriptive about the composition of the health home team, although each sets certain minimum requirements. Alabama, for example, requires that PCNAs meet baseline staffing criterion, but allows PCNAs to hire additional staff as necessary. The state also does not specify the staffing mix for a given patients' care team. Oregon and Idaho are the least prescriptive, and do not specify staffing requirements, health home team composition, or team member roles.

A prescriptive model with respect to program structure may entail greater up-front investments in order to meet staffing or administrative requirements, so that under-enrollment or enrollment discontinuities may be problematic for providers. Providers in Missouri initially were facing this problem, with lower enrollment than initially expected. Payment levels had been calculated based on a prescribed staffing ratio, with some providers adding new staff in anticipation of the projected increase in enrollment. The delays in enrolling new patients meant that they were unable to generate the expected amount of health home revenue to cover these costs. Providers in New York and Maine also reported difficulties with under-enrollment. To mitigate issues related to up-front costs, some states elected to phase in requirements over a period of time to allow providers to develop new capacity. Oregon set its PCPCH standards deliberately low in order to encourage practices to become PCPCH and participate as health homes, with the intent of gradually raising those standards over time. Iowa and Idaho require providers to achieve NCQA recognition, but allows them one and two years, respectively, to achieve it.

Regardless of timeline, the payment model is a significant factor in successful implementation of health home structures and processes. With the exception of Rhode Island CEDARRS, health home services in all states are reimbursed through a PMPM rate. (Wisconsin's health home provider also receives a flat fee to cover initial assessment and care plan development, which may be billed annually.) The structure and the level of these PMPM payments differ across programs, and, as a result, have different effects on providers. In Rhode Island, CMHCs are required to submit detailed encounter data supporting service provision in order to receive PMPM payments, and must provide at least one hour of service, recorded in five minute increments, to each enrollee every month. In contrast, in Idaho, the PMPM is paid for each patient attributed to that practice--providers are not required to attest that those patients have received a service in that month. Thus, the difference in administrative burden associated with these two payment mechanisms is substantial. In New York, lead health home agencies can keep no more than 3% of the PMPM for administrative costs (and MCOs can retain an additional 3%). Under-enrollment thus posed a challenge for lead agencies, as the administrative costs of establishing and maintaining multi-provider networks can be significant. The state mitigated this problem somewhat through its tiered payment approach, which allowed providers to receive a reduced PMPM payment during the process of outreach and enrollment.

Eligibility and Enrollment

The range of qualifying conditions targeted for health home eligibility varies significantly, resulting in substantial differences in the size of each state's eligible health home population. In New York, for example, roughly 700,000 Medicaid beneficiaries, 14% of all Medicaid enrollees, are eligible for health home services, while Rhode Island's health home population (under both SPAs) is just under 8,000, 4% of Medicaid enrollees. Regardless of the range of qualifying conditions, providers in several states noted that determining eligibility based on specific conditions inevitably excludes some high-cost, high-need beneficiaries who might benefit from health home services. Furthermore, demand for services may outstrip supply, even in states with relatively small eligible populations. Both Iowa and Idaho's health home programs are statewide, but provider shortages--especially in rural and frontier areas--are an ongoing challenge. Locating providers that would accept new Medicaid patients also has been a challenge for PCNAs in Alabama.

The process for identifying and enrolling potential eligibles also can present challenges. States may opt for a centralized approach, as in Missouri and New York; a dispersed approach, as in Oregon, Rhode Island, Ohio, and Idaho; or some mixture of both. In centralized identification, the state uses enrollment and claims data to identify persons potentially eligible for health home services by the presence of eligible conditions and sometimes other factors, such as level of expenditure (Missouri), or connectivity to the primary care system (New York). In dispersed enrollment, health home providers identify clients who meet the conditions criteria and whom they believe could benefit from health home services. Centralized identification of the eligible population has the benefit of yielding a potentially more complete list of eligible beneficiaries. But Medicaid enrollees, especially those with mental health and/or substance abuse issues, are a difficult population to track. Individual health homes have found it challenging to locate and enroll people identified centrally, because contact information or qualifying conditions may have changed, and enrollees may be wary of such contact. Dispersed identification decreases search costs and time but risks missing eligible individuals who are not well-known to the health home staff, including those with low provider connectivity. Provider-based identification also has the potential to allow cherry-picking of enrollees, although we heard no concerns in that area on our site visits.

Most programs appear to be either planning or already implementing a mixed enrollment system, although there is variation in how responsibility for patient identification is shared between the state and providers. New York, for example, initially adopted an entirely centralized approach, but low enrollment and requests from providers to enroll patients they had identified led the state to implement a community referral process in late 2012. Referrals may now come from the criminal justice system, state-operated psychiatric centers, hospitals, MCPs, designated health homes, case management programs, and other providers. The state continues to develop lists of eligible patients based on a series of algorithms designed to target people with high needs and "low ambulatory connectivity," who are not already being seen regularly by providers in the community. Lists of eligible patients are sent to the health homes or the MCOs for outreach and enrollment. In Iowa, the state relies primarily on providers to identify health home-eligible patients, but has begun to generate a list of health home-eligible patients to supplement providers' health homes patient panels.

The general expectation appears to be that enrollees will continue to receive health home services unless they become ineligible for Medicaid coverage. (The exceptions are children in the CEDARR health homes program, which eventually age out or may need enhanced care coordination services for only a short time.) All of the health home programs allow for disenrollment, or provide beneficiaries the opportunity to opt-out of the program. However, neither state officials nor providers reported high rates of disenrollment due to patient opt-out. Both state officials and providers expressed concerns, however, about enrollment discontinuities stemming from loss of Medicaid eligibility, particularly among medically needy beneficiaries and others who must "spend-down" income to eligible levels. Such disruptions present challenges for continuity of care and connections to needed services in the community. Health home services may continue, as was reported in Rhode Island, but enrollees may lose access to primary care and medications during coverage hiatuses, unless providers are willing to continue to provide services temporarily without payment. Besides reducing continuity of care, some informants suggested eligibility loss works counter to another fundamental goal of health homes by encouraging use of emergency departments during coverage gaps.

Integration of Care

Integration of mental health, physical health, and nonclinical supports is a key component of the health home concept. States have approached integration in different ways, and there is substantial variation between providers within each state in terms of how the concept of integration is operationalized. Key parameters of differences are staffing size and mix, the systems and processes in place to identify and address patient needs, the mechanism through which patient information is shared, and the degree to which services are co-located versus referred to outside providers. The integration process depends on where each provider started, the needs of the patient population, and the resources available in the community. We heard of large contrasts across providers operating in the same health home program in more than one state. For example, in one state, a large urban organization offering co-located physical and mental health services, substance abuse counseling and treatment, and housing services was implementing an EHR that would allow staff from across the organization to document services accessed in patient care plans. In contrast, a health home practice managed by a solo provider in a comparatively rural area largely provided referrals to external mental health and community support services and was unable to share information electronically with outside entities involved in patients' care.

Issues for integrating mental health care into a primary care-based health home are not symmetric to those for integrating physical health care into a mental health provider-based health home. Primary care and mental health providers have distinct organizational structures and processes, reflecting differences in both clinical culture and in the way that these providers are regulated and reimbursed for their services. Regardless of the direction of care integration, however, implementation requires a culture change in the approach to patient care, appropriate training for all care team members, and systems that support open communication and exchange of information. These issues were raised by many of the providers we spoke with and are explored in greater detail below.

Mental health advocates reported that mental health historically has been underfunded and applauded the health home initiative for bringing greater attention and funding to mental health care. They also felt that PCPs have a new incentive to look for mental health issues among their patients because mental health diagnoses can qualify an enrollee for health home services. However, many PCPs we interviewed varied in their ability to address those mental health needs once they were identified. Some providers expressed frustration over the lack of training to manage patients with serious mental health problems, as well as the limited number of external resources available for referrals in their respective communities.

Many participating primary care practices also report struggling to effectively integrate community and other social supports into the practice, although they recognize the importance of such integration and are generally supportive. This type of integration was less of a challenge among CMHCs, which traditionally have paid more attention to nonclinical supports, such as housing and employment, and were more likely to employ social workers and other support staff with knowledge of community resources. One frequently cited advantage of the care management model employed by North Carolina, New York, Alabama and Maine was that it provided an external mechanism for connecting patients to the services they needed, rather than requiring that a PCP invest in additional staff to perform those tasks. The health homes focus on whole-person care also has enhanced attention to nonclinical aspects of care. CMHCs traditionally have paid more attention to nonclinical supports, such as housing, school, and employment, than have primary care practices.

Applicability to Children

Many states are struggling with how to incorporate children into the health home model. In general, the health home model is seen as being more appropriate for adults because of its focus on chronic conditions that are relatively rare among children. The pediatric care model also differs from the adult model in several important respects, including the type and level of support required, the approach to decision-making, and the level of family involvement. The health home model's ability to address the needs of children will depend in part on state decisions regarding the qualifying conditions, designated health home providers, and the quality measures used to measure performance. The CEDARR model in Rhode Island is de facto child-focused and specifically tailored to serve a subset of children with special needs. For most of the other participating states, children make up a small share of the health home-eligible population. The relatively small size of the pediatric health home population may be a barrier to participation for pediatric practices, as health home enrollees would represent a very small share of patients over which to spread the fixed cost of practice transformation.

Nevertheless, providers across these programs felt that the health home model could be adapted to the pediatric population, if the eligibility standards were structured to allow more children to qualify. Some providers also noted that addressing the health needs of children today may be able to reduce the number of adults requiring health home services in the future.

Communication

Communication within the care team and across providers is a fundamental component in achieving the health home model's aims of care integration, management, and coordination. The extent to which new patterns of communication and new protocols are needed depends in part on how much of a change from the existing care system the health home program represents. The change in basic functions and responsibilities is small for Rhode Island's CEDARRs and Wisconsin's ASO, and negligible or nonexistent for North Carolina's CCNC. For other programs having to build new communications processes, the changes are significant and, in some cases, represent a source of ongoing challenges. Barriers to communication include lack of widespread and interoperable information technology systems, different rules covering different types of information sharing (particularly substance abuse, mental health, and HIV/AIDS, which are all prevalent in the target populations), and the competing priorities of the participating entities. Communication is very much a work in progress in most all programs.

Intra-Organization Communication

Communication within care teams, as well as across teams within a health home, supports the integration of mental and physical health and community supports. Common forms of intra-team communication include the patient "huddle," a mini-team meeting of relevant team members before a patient's appointment to discuss his or her health problems and treatment needs, or regular team meetings at varying or fixed intervals. Informants at some sites reported that such intra-organization processes are productive, while other informants said they have been difficult to integrate into the workflow. Some participating health homes did not have the buy-in of all providers within the practice and, as such, coordinating a huddle or regular meeting to discuss health home patients was difficult. Other reported challenges to team communication include EHRs or other patient records that must be modified to support the full range of team input, particularly nonclinical information.

Though intra-organization communication is an important component in team-based care regardless of the health home model, it is particularly critical in the wraparound care model, where members of the health home team must collaborate with partnering organizations. Among the states that have adopted this model (North Carolina, New York, Alabama, and Maine) a key issue routinely cited by both state officials and providers was the need to establish systematic communication processes that involved both in-person meetings and shared access to patient clinical data. These processes vary substantially in practice. For example, CCNC may "embed" a care manager into a practice that has a large Medicaid population, which facilitates regular and frequent communication. In other practices, care managers interact with providers much less often, and in some cases in an ad hoc fashion, which was deemed to be a limiting factor in care coordination. In Maine, care teams meet monthly with partnering practices and, in some cases, have direct access to their EHRs. These communication processes were seen as essential in building trust between the practices that provide most of the care and the external care team staff.

Primary Care and MCOs

Where the health home is not the PCP, as in the specialty provider models adopted in Rhode Island, Missouri and Ohio issues can arise when communication beyond the team or health home is necessary. Education may be required to help the PCPs understand the importance of communicating with the health home and coordinating well with them. Many nonhealth home physicians do not have a clear understanding of what health homes are and what their role in them should be. Thus, training about health homes may need to extend beyond the health home itself, and communication processes may need further development. For many of the health homes we visited, an internal EHR facilitates communication within the health home team, but external communications still require email or fax. The communication issues are different not only among states but also among different health homes within the states, reflecting different existing patterns of care and communication and variable capacity for change.

In states with Medicaid managed care programs, the responsibilities for communication between health homes and MCOs differ. In New York, MCOs are required to assist with identification of eligible beneficiaries, and health homes must report service provision through the MCO, which then reports to the state. In Rhode Island and Ohio, MCOs are to provide care profiles to the health home for their health home enrollees; and in Oregon, they are contractually obligated to encourage practice transformation. In North Carolina and Idaho, behavioral health services are reimbursed on a FFS basis, and health homes are expected to communicate regularly with MCOs responsible for managing the behavioral health needs of their patients.

In each state, the systems and processes that underpin the relationship between MCOs and health homes are still being systematized and fine-tuned. In North Carolina, Ohio and Idaho, for example, health home providers had no prior formal relationships with MCOs and have needed to develop them. Their success in establishing these relationships varies. MCOs share the health home goal of better care coordination and decreased hospital and emergency department use, which may facilitate the relationship-building process. The structures and reporting requirements of the health home program may not overlap with those of existing MCOs, however, which may create administrative burden for both entities. The competitiveness of the MCO market may have an impact on the level of administrative burden. In New York, the number of MCOs operating in the market varies by region; some health homes must establish relationships with relatively few MCOs, while others must interact with several, each of which may establish separate processes for accessing or reporting patient information.

Hospitals

Transitional care to better manage patients after hospitalization is a critical health home service that can support reductions in avoidable readmissions, but getting timely information from hospitals is seen as a challenge in nearly all states, particularly with regards to emergency department visits. North Carolina and Alabama health home providers reported relatively few problems getting timely information from hospitals, which they attributed to the formal and informal relationships established between hospitals and the regional care management networks in each state. In North Carolina, 56 of the state's 150 hospitals provide twice-daily updates to CCNC on admissions, discharges, and transfers of CCNC-enrolled patients. In Alabama, PCNAs must include a hospital representative on their Board of Directors. In both states, care managers employed by the regional network are either embedded in hospitals or visit them regularly to collect information on admissions or emergency department visits.

In some states, hospitals are directly affiliated with the health home. In New York, health homes include hospitals among their partnering organizations, which facilitates the notification process for patients who are admitted to a partner hospital or visit its emergency department. In Maine, CCTs may be based at a hospital and have access to that hospital's EHR. Hospitals may also own health home practices in some cases, such as the hospital-run clinics in Missouri's primary care health home program. In Oregon, each PCPCH is required to have written agreements with its usual hospital providers on how communications would happen. However, while these formal affiliations and agreements allow for better communication about the services provided within specific hospitals, patients may visit multiple hospitals within a geographic area. In such cases, notification remains challenging.

Many states are attempting to leverage their HIE infrastructure to exchange hospital data, but those systems are still developing. Missouri has an authorization-of-stay tool that requires hospitals to alert the Medicaid agency when any enrollee is admitted for a Medicaid-financed stay. The admission alert triggers an email from the Medicaid agency to the health home. Such alerts are not triggered by emergency department use, however, unless it is associated with a hospital admission. Informants reported that this system also misses even some inpatient hospital use--most glaringly, admissions of dual eligibles, for which Medicare is the first payer. Health home providers in several states (for example, Missouri, Iowa and Ohio) reported that in some cases they learn about an admission weeks or months later, and sometimes only when reported by the health home enrollee. In Rhode Island, MCOs are able to serve as intermediaries between hospitals and health homes.

Some informants reported hospital communication problems specific to the mental health component of the initiative. Mental health providers may have more problems getting access to hospital floors because they often are not credentialed at the hospital. This makes it difficult to provide transitional care and coordination for hospitalized enrollees. In Rhode Island, the CMHOs have had hospital liaisons in the past, and this concept has been reintroduced under health homes.

Medication reconciliation post-discharge is seen as a particular challenge for health homes. Although usually thought of as a hospital quality measure, health home providers recognize the importance of medication reconciliation for care management and good outcomes. Medication reconciliation is a central transitional care goal of the care management networks in North Carolina, Alabama, and Maine. Establishing good post-discharge communication with hospitals is key to meeting this important quality goal.

Most states see hospital communication as an area that needs work. Until real-time/same-day communication is established and is the norm for both inpatient stays and emergency department visits, successful communication will continue to depend on personal relationships with staff in the medical and psychiatric wards and the emergency department, with disruptions associated with personnel turnover.

Provider Issues and Challenges

Depending on the program, providers are either taking on new roles or becoming a part of a more integrated system. Common themes we heard related to who would incur costs and who would benefit from the return on investments, the inadequacy of data systems to meet provider needs, and the pace and effects of practice transformation.

The Role of MCOs

The management of care for high-need, high-cost enrollees could logically be thought of as the responsibility of MCOs. The development of a new entity for care management, paid according to a separate structure, can be seen as usurping the role of the MCO. Health home guidelines require that there not be duplication of payment for services, which requires careful specification of the different roles that health homes and MCOs take in care coordination. The states are approaching this issue in different ways. In New York, MCOs may keep no more than 3% of the health home PMPM unless they provide specific health home services. In Oregon, an MCO had to demonstrate to the state what services it was providing to justify the amount retained. At the time of our visit, only one MCO had been approved to retain a portion of the payment.

The degree to which health homes must interact with MCOs also varies. In Missouri, managed care is limited to children, youth, and pregnant women living in defined geographic areas; few health home enrollees are included. In Wisconsin, health home patients must disenroll from managed care if they choose to enroll in the health home. In Idaho, patients with SPMI who are stable will be managed primarily by health homes, while those in crisis or needing additional support for the mental illness will be managed by the state's behavioral health MCO. North Carolina uses the Four Quadrant Clinical Integration model to determine which entity will take the lead in managing patient care. Although mental illness is explicitly excluded from the list of qualifying health home conditions in North Carolina, health home enrollees who also have high behavioral health needs will be jointly managed by the regional MCO and the health home team.

The different roles and responses of MCOs to health homes reflect to some degree the history and structure of the MCO sector in each state. Even within states, different MCOs have reacted differently. Some have welcomed the clarification of roles of providers and plan, as in the case of the protocols for care coordination developed in Rhode Island. Some are taking advantage of the opportunity to participate in health homes even if, as was the case in Oregon, it means a dilution of their role because health homes are part of a larger system transformation. In other states, such as in North Carolina and Idaho, capitated managed care is a relatively new development. At the time of our visit, the details of how and to what extent MCOs would collaborate with health home providers were still taking shape.

Revenues and Costs

In some states, health home providers expressed concern that although savings will be generated by actions taken by providers those savings will accrue to the Medicaid program. Similarly, there were concerns that hospitals will find some way to recoup any revenue lost from reduced emergency department use or hospitalizations. Some health homes see the practice making the investment in transformation--not all of which is reimbursed by the health home payments--and the return on that investment going elsewhere.

Section 2703 allows states to pay providers for services that previously were not reimbursable under Medicaid, but the effects of participation on provider revenues differs widely across the programs, from mildly negative to strongly positive. In Missouri, providers saw the health home reimbursement as very attractive, as did providers in Ohio and Wisconsin. In New York, most providers will see increased revenues under health homes, with the exception of TCM service providers. Under the state's first SPA, TCM providers would see a gradual reduction in the reimbursement. TCM providers told us that the effect would be mitigated to some extent as their case-mix was also likely to change, and they will have greater flexibility in how the services are provided. However, this change proved difficult to implement, and in November 2013 the state submitted another SPA asking to extend the legacy rate until January 2015. Some informants noted that the lack of funding for infrastructure development was a challenge for lead health home agencies, especially given that many partnering organizations lacked an EHR.

For a provider with only a few healthhome-eligible patients, the cost of setting up and maintaining a billing process just for those patients may be a barrier to participation, especially if there are substantial documentation requirements and the expected additional revenue is low. Even comparatively simple requirements can prove challenging. Providers in Oregon and Iowa saw an increase in their revenues associated with the health home payment, but also reported that the administrative burden associated with the billing process was substantial, and noted difficulties in adapting their systems to identify and track services automatically.

Data Issues

Complete, timely, and accurate data is important both for health homes services--case management, care coordination, and care transitions--and for program evaluation. Yet, data from other payers, particularly Medicare for the dually eligible, is difficult for health home providers to obtain, leaving a gap in their knowledge of enrollee utilization and needs. The challenge associated with this issue depends on the share of dually eligible beneficiaries in the health home population. In Missouri and New York, for example, dual eligibles represent 34% and 20% of the overall health home-eligible population, respectively. In Rhode Island, 60% of enrollees in CMHO health homes are dual eligibles, and the lack of data on Medicare-financed admissions was noted in both initial and follow-up interviews as a significant problem.

Data on specific services of particular importance to the health home population also need special attention. The rules governing sharing of patient information on substance abuse, mental health, and HIV status require additional patient agreements, and some states have struggled with implementing the necessary consent processes, at least in the initial stages of the health home program. In initial follow-up interviews, Rhode Island reported development of a patient consent process to allow authorized providers to share and access personal health information, including substance abuse treatment, through its HIE, but the process has not yet been approved or implemented. Another issue identified in site visits relates to provider understanding of disclosure regulations. We heard from several providers and state officials that these rules are poorly understood, leading some providers to withhold information unnecessarily.

Providers also have varying levels of experience using patient data to drive quality improvement efforts and perform population management. Many health home providers felt that integrating these processes into a busy clinic, especially when the provider may be receiving a large volume of utilization data or reports from multiple sources, was particularly challenging. In Ohio, for example, CMHCs received six months of historical data from the state as well as from MCOs. To assist providers in incorporating data use into their care routines, states have offered various levels of technical assistance to support meaningful use. In Alabama, the state provided training to PCNA staff through monthly meetings, while the Idaho Medicaid department provided direct practice coaching, and Ohio sponsored on-line learning collaboratives. Providers in all of these states found this assistance to be extremely helpful.

Practice Transformation

For most providers, practice transformation requires the investment of time, staff and money. Infrastructure costs include developing the HIT systems necessary to support many of the health home services, and training staff in new processes and routines, which may result in temporary productivity losses. For the most part, providers must make these investments well in advance of receiving any additional payment from the initiative. Lack of start-up financing may have been a bar to recruiting practices to be health homes in some cases.

The acuity of this problem varies across the states. For North Carolina's CCNCs, Rhode Island's CEDARRs and Wisconsin's ASO, the problem is minimal. In Oregon, New York, Iowa, and Idaho, where requirements are phased-in, practices may be able to spread out the practice transformation costs. In Oregon, early adopters were predominantly qualified at the highest current level, suggesting that health home participation was most attractive to practices that were already well down the practice transformation road.

In addition to the data analysis training noted above, states have also provided other technical assistance to support practice transformation. Some programs are more general education about the health home concept, while others have a specific focus, such as training for wellness coaches or peer counselors. In some cases, the state has funded training or provided direct technical assistance. In other cases mental health or primary care associations have provided some training for the members through planned peer learning activities or responses to questions from practices.

Oregon, for example, implemented a PCPCH Institute Learning Collaborative as a central resource for PCPCHs, and made additional training available in conjunction with the audits it conducts during monitoring site visits. Missouri, New York, and Iowa also have organized learning collaboratives to help practices understand health homes principles and provide support for practice transformation. These learning collaboratives have been supported by state agencies, provider organizations, and state foundations.

In North Carolina, New York, Alabama, and, Maine, the external care management team is also a source of technical assistance for affiliated PCPs. In North Carolina, for example, CCNC networks employ quality improvement specialists to assist practices in population health management and improvement on quality measures of interest.

Even if training is provided for the health homes free of charge, practices still must invest staff time and sometimes travel costs to participate. Thus, practices must weigh the value of the training against the cost of participation and practice transformation. The health home certification process alone may be expensive, particularly in those states that require health homes to acquire certification from a national organization such as the NCQA. Providers expressed a preference for training focused less on vision and more on best practices. In-person practice coaching was viewed very positively by practices that received it, as were the opportunities for peer-to-peer sharing.

Almost all health homes are struggling to fully implement the initiative, and several noted the need for a ramp-up period of six or even 12 months. Some informants indicated that greater certainty about the permanence of the model would allow practices to commit to the health home model more fully. Most states expect that some practices will not be able to transform fully over the two-year span of enhanced match. How well practices succeed at transformation depends in part on where they started from, their existing strengths and weaknesses, and leadership at the practice level. As many informants noted, two years is a very short period in which to put in place all of the needed health home components and achieve the necessary culture change.

Health Information Technology

HIT is a critical component of the health home option, and underpins the provision of all six health home services. However, HIT implementation remains an ongoing challenge for both states and providers, regardless of the HIT requirements that states have mandated. EHRs are not yet the norm in many settings, nor are HIEs reliably in place to facilitate communication. Several of the challenges highlighted in the preceding sections--specifically, those related to: (1) communication between providers and across care settings; and (2) data collection and use--are amplified by inadequate HIT systems. In recognition of these and other HIT-related challenges, several states have phased-in their HIT requirements for health home providers, and some have offered technical assistance through learning collaboratives and practice coaching.

Some HIT issues are specific to moving care outside the clinic walls. Often the services provided in the community are not easily documented on current EHRs and may be less adaptable to coding. More generally, EHRs may need to be modified to incorporate health home services, especially nonclinical community support services. Data security is also a concern. Many of the state officials and providers we spoke with noted the regulatory challenges related to sharing health information across care settings. Some argued that the multiple layers of state and federal privacy laws--particularly those related to substance abuse--were a significant barrier to care integration. This was attributed in large part to uncertainty among providers about what information can be shared, and under what circumstances.

Other information technology issues are specific to the effort to integrate mental and physical health care. Behavioral health providers may have higher costs for acquiring information technology infrastructure since they are not eligible for Medicaid or Medicare EHR incentive payments. Even if they were, the structure of a behavioral health visit differs from that of a physical health visit and so the content of an EHR is different, hampering sharing. Many behavioral health providers feel that available EHRs are less well-suited to their practices than to primary care practices. Lack of integration in the past has meant that often parallel systems have developed. For example, in Missouri, behavioral health providers have access to one data system for pharmacy management and another for routine reporting and outcomes, while PCPs have access to a different system through the local primary care association. The state is in the process of adapting behavioral health outcomes reporting system for primary care health home use.

Practices must also have the necessary infrastructure to communicate within and across sites of care, and staff must be trained in how to use it effectively. A central information technology infrastructure is needed to facilitate communication across sites of care. Central infrastructure can also push data to practices to improve individual care management, as well as patient panel management. Communication through a central site may come with costs, such as connectivity costs associated with a RHIO, which may be hard for some providers to afford or to justify. Though all 11 states have implemented some form of HIE, there is significant variability in terms of the robustness of the data that can be accessed. Even in states with access to relatively well-developed HIT and data infrastructure, such as that developed by North Carolina's CCNC program, practices may struggle to incorporate its use into daily workflow, especially if they are required to use a different system to access information. This problem may be a particular issue in practices with a relatively small Medicaid population.

When a practice transforms, the new models for providing care can be expected to spread to all patients in the practice. As the health home enrollees are a high needs population, some of the care management strategies and procedures may be less applicable to a broader clinic population. Still, many providers say that when they are caring for their patients they do not typically consider what reimbursement might be attached to that person, so changes in how they operate will likely spread to other patients with needs that are similar to health home enrollees. In some cases, such as in Oregon, Idaho, and Maine, this was an explicit policy goal. Health home payments were intended to drive practice-wide changes that would apply to all patients, not just health home enrollees. However, the level and structure of the payments may not cover the costs of those changes, and the spill-over effects of health home implementation may be limited by the size of the Medicaid patient panel. This was a point of concern in Maine. Of the 159 health home practices in the state, roughly 75 were involved in a multi-payer pilot, while the remaining 84 received enhanced payments from Medicaid alone. Some of the key stakeholders we interviewed were concerned that these payments would be insufficient to cover the costs of transformation in those practices.

Some components of the initiatives are not dependent on a complete change of culture at the practice or the system level to have a broader effect. Specifically, improved information technology infrastructure will benefit the whole practice, as will greater electronic connectivity among sites of care.

The Enhanced Match

The enhanced match for health home services is meant to encourage states to take up the optional health home benefit. Most states said that the availability of the enhanced match was an important part of their motivation for implementing health homes, but not necessarily a deciding factor. In North Carolina the match simply offset state costs, with no changes in the ongoing CCNC program. In contrast, in both Alabama and Maine, state officials characterized it as an essential source of implementation support, while in Rhode Island the match allowed Medicaid to continue to fund the CEDARR centers and to extend an integrated model into CMHOs, something the state would have been unable to do in the current budget environment. Similarly, in Missouri, the match allowed progress on integration to continue under budget stringency, and the expectation is that the achieved savings will justify continuation of the program. In Oregon, the match allowed the state to add financial incentives for practices to its plan for primary care delivery system transformation, which was said to have been an important enticement to practice participation in the larger initiative. In New York and Idaho, the match was characterized as an important driver of their reform program. Some states we spoke with said that the enhanced match did not offset additional spending on newly eligible Medicaid beneficiaries and noted that the nominal 90% match was less substantial than face value, given the level of Federal Medical Assistance Percentages, which ranged from 50% to 73% in fiscal year 2013. Several states, however, indicated that irrespective of the match they would have embarked on delivery system transformation because "it is the right thing to do."

Though the enhanced match was generally viewed as a positive inducement, all state officials and providers we spoke to felt that eight quarters was an insufficient timeframe to achieve and demonstrate meaningful delivery system transformation.

 

V. OVERVIEW OF EVALUATION DESIGN AND CHALLENGES

Our evaluation design uses a mixed-methods approach employing both qualitative and quantitative data collection and analysis. In this approach, qualitative data collected through program review, site visits, and follow-ups as described above, provide context and rich profiles of programs, insights into the motivations behind state choices, common patterns across programs and states, implementation progress over the intervention period, and provider and participant perspectives. These data also generate information that can be used in quantitative analyses to identify key factors in achieving favorable outcomes.

A key design element of the quantitative component is the use of comparison groups of beneficiaries in analyzing trends and relative gains in the target outcomes for health home enrollees versus comparisons in both the baseline and intervention periods. Analysis of experience in the baseline period serves two purposes. First, it will establish utilization patterns and cost prior to implementation. Second, it will improve our ability to isolate effects associated with health home participation by allowing us to control for common Medicaid program and other factors that may affect both a comparison group and health homes participants before and during the intervention. A pre/post-only design without a comparison is likely to make it more difficult to discern any marginal improvements for health home enrollees over the relatively short intervention period and prevents attribution of changes to the health home model.

Challenges to Quantitative Evaluation

A number of potential challenges for quantitative analysis of the effects of health homes on the key outcomes of hospital, emergency department, and SNF utilization and costs have become clear as we have learned about the specific design of programs, some of which we anticipated in our provisional design. These challenges will make it more difficult to detect changes associated with the health homes model.

An overarching issue is the eight-quarter duration of the intervention period. Under the best of circumstances, two years is a short time over which to realize improvements. Implementation necessarily moves at a slow pace, owing to the transformations in structures, processes, and care culture necessary for the health home model.

A second fundamental issue is that the majority of states are either building marginally on a system that has some components already in place, using health homes as a part of a broader system reform, or both. All of the states are participating or planning to participate in other initiatives. These include the Integrated Care for Dual Eligibles Demonstration and the Financial Alignment Initiative, both of which aim to support care coordination and integration for duals by allowing states to integrate Medicare and Medicaid financing; the Multi-payer Advanced Primary Care Practice Demonstration; the Children's Health Insurance Program Reauthorization Act (CHIPRA) ten-state CHIP Evaluation; the CHIPRA Quality Demonstration; and the State Innovation Model Test demonstration. Participation in other initiatives implies that practice transformation occurring outside of Section 2703 may contribute to the success of the model but also will make it more difficult to isolate effects attributable to it. At the same time, state participation in other initiatives makes it much more difficult to find "uncontaminated" comparison groups that could help isolate health home effects.

All states except Alabama, Ohio, and Wisconsin have implemented their programs statewide, which eliminates the possibility of using Medicaid enrollees in nonparticipating geographic areas for comparison. In theory, statewide implementation implies that the only "similar" beneficiaries with respect to their condition profile receiving care outside of health homes would be those who refused enrollment or could not be found, which also could mean they would be difficult to find through eligibility algorithms applied to claims data. An additional issue elucidated through our qualitative activities was the potential for biases from differential enrollment practices--centralized selection of an eligible population versus provider referrals. Relative to a consistently applied central eligibility determination process, provider referrals are subject to inter-provider variability and to use of patient-specific factors in referral decisions that we will not be able to observe.

Potential Approaches to Address Challenges

Given the variety in state approaches to health homes, it may be possible to identify state-specific or program-specific design adaptations. We are continuing to work with states toward this end.

Alabama, Ohio, and Wisconsin all have geographically limited programs, so that it may be possible to draw comparison beneficiaries from other geographic areas.

In Rhode Island, enrollment is primarily through provider identification. The number of Medicaid beneficiaries meeting criteria for services through CEDARR Centers is substantially larger than enrollment, so that it may be possible to identify comparison beneficiaries who are not enrolled. The same may be true for CHMO health homes, since initial enrollment was of beneficiaries already receiving services through CMHOs.

In Missouri, the initial selection of health home enrollees was based on a combination of conditions and expenditure patterns over a consistent calendar year, and, to date, provider identification of eligible enrollees contemplated for the future is not in effect. This may allow identification of a similar population based on a different reference period not captured in the initial state identification. The state indicated that only 16% of enrollees fall into the high-expenditures category for more than one year, so that selection using a different year may be able to generate a comparable but nonoverlapping comparison group.

In New York, enrollment prioritizes eligibility based on condition severity and low connectivity to PCPs, although low connectivity has presented enrollment challenges. In this case, it may be possible to develop a comparison group of those with low connectivity who could not be located but could be tracked in claims data. New York's phased geographic rollout also may provide opportunities for identifying comparison groups by geographic area, phase, and time in program.

In Oregon, Iowa, Ohio, and Idaho, enrollment is through provider recommendation, so that it may be possible to identify similar beneficiaries using nonparticipating providers as comparisons. Maine's enrollment also involves provider recommendation for those already involved with health home providers, but is further complicated by a parallel enrollment process in which the state uses claims analysis to identify eligible persons not served by health home practices and provides them with information about nearby health home providers.

 

VI. THIRD YEAR ACTIVITIES

In the upcoming year, we will continue to monitor the states selected for the evaluation and conduct follow-up phone interviews with key informants. In addition to working with states on issues relating to comparison groups and identifiers for health home enrollees, we also hope to begin obtaining information from states on quality monitoring measures they are collecting from health home providers. We also hope to receive administrative data through our DUA with CMS that will allow us to begin developing baseline comparative profiles of the health home-eligible populations in each evaluation state.

 

VII. CONCLUSION

All states included in the long-term evaluation cohort have in common that they have used the Medicaid health homes option to augment existing programs, to accelerate movement down an established pathway toward transforming the state's health care delivery system, or both. The models adopted by these states fall generally into three classes: those relying on specialty providers, those based on the medical home model, and those using comprehensive networks assembled by a lead agency or overseen by an administrative entity. Even that categorization is not hard and fast and may not be enduring, however, in a climate of system reform. For example, during the first year of its health homes implementation, Oregon began implementing a reorganization based on CCOs, community-based integrated care organizations that have a mission similar to that of health homes but without the focus on particular conditions. By the time its health home program ended, the Oregon health system structure was more similar to the network approach taken in North Carolina, New York, Alabama, and Maine.

Our findings over the last year indicate that the issues identified during site visits in the initial four states also are challenges in the final seven states in the evaluation cohort, and that although progress has been made, work remains to be done. Implementation appears to be a slow process that is likely to take longer than the eight-quarter period of enhanced match both for states in the evaluation cohort, as well as for other states choosing to add a health home benefit.

Central issues are those relating to the need to build or improve internal and external communications and systems needed to support the aims of health homes. This was especially true in some states for communications between hospitals and health home providers. This avenue of communication is critical to improving transitional care and to the key health homes aim of reducing inappropriate or unnecessary use of hospital-based care and avoidable readmissions. Integrating behavioral and physical health is an area in which systems integration faces special challenges that differ depending on the direction of integration. Our qualitative analyses so far suggest that both functional aspects of system transformation, such as improving or adapting the HIT infrastructure, and human aspects, such as adapting to new processes and routines and culture change, continue to be a work in progress in all the states studied.

As we continue our evaluation activities over the next year, all of the evaluation cohort will have completed their initial eight quarters. This will allow us to follow-up on the issues identified in this report and find out whether they persist in maturing programs, as well as begin exploring issues the states may face relating to program sustainability. Documentation of the timeline for full implementation, how it may vary across health home models, and the ways states in the evaluation cohort have addressed implementation challenges may provide important lessons for other states initiating their own health home programs.

FIGURE 1. Health Home Models
Model Type	State	Description
Specialty Provider	Rhode Island (2 SPAs), Missouri (1 SPA), Ohio, Wisconsin	Centered on entities traditionally serving special populations, but integrating specialized care with primary health care.
Medical Home and Extensions	Oregon, Missouri (1 SPA), Iowa, Idaho	Based on the PCMH, but extended to include specialty and other providers beyond the traditional primary care practice.
Care Management Network	North Carolina, New York, Alabama, Maine	Networks or coalitions of physical and behavioral health care providers, care coordination entities, social services agencies, and other community organizations, overseen by a lead organization or administrative entity.

 

TABLE 1. Evaluation Cohort States, Programs, and Timeline
State/ Program	Target Population	Designated Providers	Geographic Coverage	Effective Date	Evaluation   Period End Date	Approval Date
North Carolina	1 chronic conditions, or 1 chronic condition and at risk of another	CCNC, Medicaid-enrolled PCPs	Statewide	10/1/2011	9/30/2013	5/24/2012
Oregon	2 chronic conditions, 1 chronic condition and at risk of another, SMI	PCPCHs	Statewide	10/1/2011	9/30/2013	3/13/2012
Rhode Island (CEDARR-HHs)	Children with 2 chronic conditions, 1 chronic condition and at risk of another, SMI	CEDARR Family Centers	Statewide	10/11/2011	9/30/2013	11/23/2011
Rhode Island (CMHO-HHs)	SMI	CMHOs	Statewide	10/1/2011	9/30/2013	11/23/2011
Missouri (CMHC-HHs)	SMI, mental health condition or substance use disorder and 1 other chronic condition, or a mental health condition or a substance use disorder and tobacco use	CMHCs	Statewide	1/1/2012	12/31/2013	10/20/2011
Missouri (PCP-HHs)	2 chronic conditions, 1 chronic condition and at risk of another	Primary care practices: FQHCs, RHCs, hospital-operated primary care clinics	Statewide	1/1/2012	12/31/2013	12/23/2011
New York	2 chronic conditions, 1 chronic condition and at risk of another, SMI	Any Medicaid-enrolled provider that meets HH standards	Statewide*	1/1/2012	12/31/2013	2/3/2012
				4/1/2012	3/31/2014	12/5/2012
				7/1/2012	6/30/2014	12/6/2012
Alabama	2 chronic conditions, 1 chronic condition and at risk of another, SMI	PCNA, Medicaid-enrolled PCPs	4 regions comprising   21 counties	7/1/2012	6/30/2014	4/9/2013
Iowa	2 chronic conditions, 1 chronic condition and at risk of another	Any Medicaid-enrolled provider that meets HH standards	Statewide	7/1/2012	6/30/2014	6/8/2012
Ohio	SPMI, SMI, SED	CBHCs	5 counties	10/1/2012	9/30/2014	9/17/2012
Wisconsin	HIV/AIDS and 1 other chronic condition or at risk of another	ASOs	4 counties	10/1/2012	9/30/2014	1/29/2013
Idaho	2 chronic conditions, 1 chronic condition and at risk of another, SMI, SED	Any Medicaid-enrolled PCP that meets HH standards	Statewide	1/1/2013	12/31/2014	11/21/2012
Maine	2 chronic conditions, 1 chronic condition and at risk of another	CCTs, Medicaid-enrolled PCPs	Statewide	1/1/2013	12/31/2014	1/17/2013
* New York's HH program was made statewide under 3 separate SPAs.

 

TABLE 2. Research Questions for the Long-Term Evaluation
Base Year and Follow-Ups: Implementation
How important was the enhanced match for the decision to initiate health homes? For the type of health home undertaken? What changes, if any, do states anticipate after the enhanced match ends? Which conditions are states targeting, and are they developing specialized models? What was the rationale for the conditions/models selected? What structures and processes have been put in place... to introduce or improve care coordination/chronic disease management, including transition coordination? to encourage/support enrollee participation, beneficiary-centeredness, and self-management of conditions? What measures are states collecting to assess care improvements? What experience of care measures are states collecting from providers, beneficiaries, and families? Are states using specialty providers as health home providers? If so, what was the impetus for the state? Are other less specialized types of providers also being used? What factors did states use in deciding which types of organizations to include as health homes? Which states are using medical homes as the foundation for health homes? Are they using medical homes not based in a primary care practice? What payment structures are states using? How are participating providers integrating behavioral health, primary care, and supportive services? What structures have put in place to create these links? What processes reinforce linkages for providers and beneficiaries? What is the relationship between health homes and state mental health and long-term services and supports systems?
Assessments Over the Intervention Period
Have care coordination, chronic disease management, patient experience, and clinical outcomes improved for individuals? Have patient compliance and adherence improved? Do improvements differ for different participant groups defined by conditions? From whose perspective are these outcomes defined and measured (i.e., do providers and beneficiary advocates define and assess them similarly)? Are beneficiaries and/or caregivers able to participate more effectively in decision-making concerning care? Is care more beneficiary-centered? Are beneficiaries better able to self-manage their conditions? Have health homes improved access to community-based supports? Has the focus on better integrating care for selected populations resulted in cost savings? Have the targeted potentially avoidable types of utilization been reduced? Have reductions resulted in reduced total costs or growth in total costs for these services? What is the net result for total costs of treating the targeted population? Which types of organizations are better suited to becoming health homes? Does "better suited" differ for different target populations? How do challenges and costs of practice reform and infrastructure differ across different types of organizations (e.g., primary care practices, other providers such as CMHCs and home health agencies, large integrated care organizations, specialty providers, health teams)? Are there identifiable organizational types that are associated with better quality and cost outcomes? How could pre-existing medical home models be modified to address individuals with multiple chronic conditions and/or SMI? Which structures and processes, if any, are missing from existing medical home models? How well do various payment structures work in bringing about practice transformation?

 

TABLE 3. Key Features of Programs
State/ Program	Estimated Eligible Population1	Eligibility Groups Included2	Health Home Eligibility Criteria	Qualifying Conditions3	Enrollment Processes	Payment System	Payment Level
North Carolina	400,000	Categorically and medically needy	2 chronic conditions, 1 chronic condition and at risk of another	Blindness Congenital anomalies Alimentary system disease Mental/cognitive conditions, except mental illness or developmental disabilities Musculoskeletal conditions CVD Pulmonary disease Endocrine/metabolic disease Infectious disease Neurological disorders	State identification and assignment	PMPM care management fee, paid to network and PCP	PMPM fee based on beneficiary classification: Networks--$12.85 for ABD; $5.22 for pregnant patients; $4.33 for all others. PCPs--$5.00 for ABD; $2.50 for all others.
Oregon	118,000	Categorically needy	2 chronic conditions, 1 chronic condition and at risk of another, SMI	Asthma Overweight Cancer Chronic kidney disease Chronic respiratory disease Diabetes Heart disease Hepatitis C HIV/AIDS Substance abuse disorder Mental health condition	Provider identification; state verification	PMPM care management fee	PMPM fee based on provider qualification level: Tier 1--$10 PMPM Tier 2--$15 PMPM Tier 3--$24 PMPM
Rhode Island (CEDARR-HHs)	2,500	Categorically and medically needy	2 chronic conditions, 1 chronic condition and at risk of another, SMI	Mental health condition Asthma Developmental disability Diabetes Down syndrome Mental retardation Seizure disorder	Provider identification; state verification	FFS	Fixed rates of $347, $366, or $397, depending on the service. Additional payments of either $9.50 or $16.63 made per quarter hour for 2 other services
Rhode Island (CMHO-HHs)	5,300	Categorically and medically needy	SMI and evidence of need for supports to remain in the community3	Mental health condition, with a history of intensive psychiatric treatment, no or limited employment, and poor social functioning	Provider identification; state verification	PMPM care management fee	Based on 9 staff hours per client per month
Missouri (CMHC-HHs)	43,000 (across both categories of HH)	Categorically needy	SMI, mental health condition or substance use disorder and 1 other chronic condition, or a mental health condition or a substance abuse disorder and tobacco use	Substance use disorder Mental health condition Asthma CVD Developmental disability BMI over 25 Diabetes Tobacco use	State identification and assignment	PMPM care management fee	$78.74
Missouri (PCP-HHs)			2 conditions, 1 and at risk of another.	Asthma CVD Developmental disability BMI over 25 Diabetes Tobacco use	State identification and assignment	PMPM care management fee	$58.87
New York	700,000 (Phases I-III)	Categorically and medically needy	2 chronic conditions, HIV/AIDS, or a serious mental condition	Substance use disorder Respiratory disease CVD Metabolic disease BMI over 25 HIV/AIDS Other chronic conditions	State identification and assignment	PMPM care management fee	Paid at 2 levels depending on enrollee status, and adjusted for case-mix and geography
Alabama	75,000	Categorically needy	2 chronic conditions, 1 chronic condition and at risk of another, SMI	Mental illness Substance use disorder Asthma Diabetes Transplant recipients (within last 5 years) CVD COPD Cancer HIV/AIDS	State identification and assignment	PMPM care management fee, paid to network (PCNA) and PCP	PCNA--$9.50 PCP--$8.50
Iowa	100,000	Categorically and medically needy	2 chronic conditions, 1 chronic condition and at risk of another	Mental health condition Substance use disorder Asthma Diabetes Heart disease BMI over 25 Hypertension BMI over 85th percentile for pediatrics	Provider identification; state verification	PMPM care management fee, plus lump-sum performance-based incentive	PMPM fee varies by patient acuity tiers: Tier 1--$12.80 Tier 2--$25.60 Tier 3--$51.21 Tier 4--$76.81 Incentive pay based on achievement against 16 measures
Ohio	14,600	Categorically needy	SPMI, SMI, or SED	Beneficiaries who meet the state definition for SPMI, SMI, or SED	Provider identification; state verification	PMPM care management fee	Site-specific and based on costs; ranges from $270-$400 PMPM
Wisconsin	520	Categorically and medically needy	HIV/AIDS and 1 other chronic condition or at risk of another	HIV/AIDS	Provider identification; state verification	PMPM care management fee, plus annual flat fee	PMPM--$102.95 Fee--$359.00
Idaho	30,000	Categorically needy	2 chronic conditions, 1 chronic condition and at risk of another, SMI, SED	Mental health condition Asthma Diabetes	Provider identification; state verification	PMPM care management fee	$15.50
Maine	125,000	Categorically and medically needy	2 chronic conditions, 1 chronic condition and at risk of another	Mental health condition Substance use disorder Asthma Diabetes Heart disease BMI over 25 Tobacco use COPD Hypertension Hyperlipidemia Developmental disabilities or autism Seizure disorder Congenital cardiovascular abnormalities Other conditions as identified by providers	State and provider identification	PMPM care management fee, paid to CCT and PCP	CCT--$129.50 PCP--$12.00
Data obtained through personal communications with state Medicaid officials. Oregon, Missouri, Alabama, Ohio, and Idaho do not have medically needy programs. See Appendix B for detailed criteria and conditions.

 

NOTES

1. Public LAW 111-148--MAR. 23, 2010, Title II, Subtitle I--Improving the Quality of Medicaid for Patients and Providers, Section 2703. State option to provide health homes for enrollees with chronic conditions. http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf . Social Security Act, Sec. 1945. [42 U.S.C. 1396w-4] State Option to Provide Coordinated Care Through a Health Home for Individuals with Chronic Conditions http://www.ssa.gov/OP_Home/ssact/title19/1945.htm.

2. Mann, Cindy. 2010. "Health Homes for Enrollees with Chronic Conditions." CMS: State Medicaid Director Letter #10-024, ACA #12

 

APPENDIX A. HEALTH HOMES SITE VISIT PROTOCOL

I. Introduction
(all interviewees)

Overview of the purpose of the long-term evaluation:

• Did it "work" (i.e., did it have the intended effect on health outcomes, costs, and health care utilization)?
• If so, what made it work (structure and processes)?
• Is it replicable and scalable?
• What can we learn for other states, other populations?

What we know about the state's initiative already (verify matrix of components)?

What we need to know going forward (i.e., the purpose of the site visit and of the ongoing evaluation activities). Explain option years, ongoing activities.

• To give context for the findings on outcomes down the road.
• To establish baseline structure and processes.
• To be able to identify mid-course corrections and their effect on eventual outcomes.

Overview of interview questions.

Any questions for us?

II. Design of the Program
(Medicaid director, health home program director, legislators, associated state agency directors, provider health home director, patient advocates)

Motivation

What was the motivation behind the development of the state's health home initiative?

• Probe: Role of: the availability of the enhanced federal match, other cost/budget issues, specific stakeholders (providers, advocates, beneficiaries, other), the legislature.

Who were/are the initiative's champions? Who were/are its major detractors?

Specific Design Choices

Why this population?

Why this geographic coverage?

Why these providers?

Context

How does the initiative fit into historical/current context (i.e., does it build on or replicate existing initiatives)?

• If so, have any changes been made to the existing programs/models to meet health home criteria?

  • Probe: Were there any specific structures and processes missing from existing models and needed to meet health home requirements? Beyond health home requirements, were there any other structures or processes added, and, if so, what and why?

• If not, why not?

The Model (plus: director of nursing, care coordination manager)

What are the specific goals of the initiative?

What do you think are the most important features of this model to help meet these goals?

• Probe: Providers, payment method, integration supports, continuity of pre-existing initiatives, community supports, HIT, other.

How are these features supported (financial, technical assistance, capital investment)?

What is the working relationship between health homes and the state mental health and long-term services and supports systems?

Details of initiative's structure and processes to support the following:

• Community supports, care coordination/chronic disease management, transition coordination, condition self-management, patient-centeredness, integration of mental health/behavioral health and physical health services.

III. Enrollment
(health home program director, health home evaluation team, associated state agency directors, patient advocates)

How many of each eligibility group are there in the state? What share of these do you expect to enroll?

How are enrollees notified of eligibility? What outreach activities have been used? Which have been most successful?

How are beneficiaries enrolled (e.g., on-line, auto-enrollment, by providers, at time of eligibility determination, other)? Do beneficiaries have a choice of whether to participate in any health home? If there is auto-enrollment, are these beneficiaries able to opt out of health homes entirely?

What has been beneficiary response to date? Relative to your goals/ expectations is total enrollment low, high, on target? If low, what might be the cause? What steps will you take to increase it? If high, is provider capacity sufficient? If it is insufficient, are you considering expansion? If so, why and how? If not, why not?

What is your experience with continuity of enrollment? What's the drop-out rate? If high, any ideas why? What are the chief causes of discontinuity of enrollment?

• Probe: Medicaid eligibility change, beneficiary dissatisfaction, provider drop-outs, deaths, other.

What policies are in place to minimize cherry-picking of enrollees? Any evidence to date on the extent of this problem, if any?

IVa. Providers
(health home program director, health home evaluation team, associated state agency directors, patient advocates)

Provider Participation

How do providers qualify as health homes?

How does actual provider participation match expected participation? What share of eligible providers are participating?

If low, what might be the cause? Are you considering steps to increase it? If so, what?

• Probe: Qualifications, payment, beneficiaries.

Practice Transformation

What processes are in place to facilitate providers' adoption of health home services and practices?

• Probe: Technical assistance, peer-to-peer efforts such as learning collaboratives, other.

Has provider participation in practice transformation activities and their level of enthusiasm (or resistance) met your expectations?

What has been the progress to date? How is progress measured? What have been the hardest areas to change?

What is your expectation on whether all or most practices will get there (i.e., become functioning health homes)? How long do you think it will take? Have you thought about how you will address failure to achieve progress?

IVb. Providers
(provider health home director, director of nursing, care coordination manager, patient advocates)

Participation (plus control practices)

What factors influenced your decision (not) to participate as a health home?

• Probe: How important was the enhanced federal match in your decision to participate? Your current patient panel? Beneficiary advocates?

What changes did you make to qualify as a health home? What support did you get for this effort? What types of support have been most useful? What additional support do you need, if any?

Practice Transformation

What processes are in place to facilitate providers' adoption of health home services and practices? Which of these do you find most useful? What other help, if any, do you think would be useful?

• Probe: Financial support, technical assistance, peer-to-peer/learning collaboratives, other.

What has been your experience to date as a health home? What have been the areas that you have found most challenging? Most rewarding?

• Probe: Staff's ability to meet the new demands; beneficiary response, cooperation of providers outside the health home such as hospitals.

What has been your experience to date with the reporting requirements associated with being a health home? Have the data collection and reporting efforts been of use to your practice in meeting the health home objectives? Do you use the data you collect to assist you in your practice?

Beneficiary Experience

How well do you think that beneficiaries are adapting to the new structure and processes of the health home? What areas do you think they find most difficult? Most beneficial?

How are you assessing beneficiary experience? What has this assessment shown to date? Based on your assessment, have you made or would you recommend any changes in structure or processes?

Payment

Do you feel that the payment system (method and levels) is supportive of the health home services that you are providing? What role did providers play in establishing the method and/or levels for services?

V. Payment System
(Medicaid director, health home program director, rate setting team leader)

Why was the specific payment methodology chosen? What other payment systems were considered?

• Probe: Provider input, advocate/beneficiary input, legislature input, consultant recommendation, example from other states/private insurers

What is your assessment to date of effectiveness of payment method at supporting health home services and practice transformation? What do providers say about the method or level, either generally or with respect to specific services? Based on this assessment, are you considering changing either the payment method or level?

VI. Health Information Technology
(Medicaid director, health home program director, data coordinator, Medicaid information technology coordinator, legislators, associated state agency directors, provider health home director)

What is the role of HIT in supporting the initiative? (open-ended)

• Probe: Contribution of HIT to the state's ability to monitor the progress of the initiative? To facilitating care coordination? To integration of mental health and physical health services? To reducing emergency department use and re-hospitalizations? To other health home goals? Which of these would not be possible without HIT?

Was new investment required (on state side, on provider side)? How was it paid for? Was there any associated technical assistance required?

VII. Reporting/Data
(Medicaid director, health home program director, data coordinator, Medicaid information technology coordinator, health home evaluation director, associated state agency directors, provider health home director, advocates)

How were the reporting requirements/data elements/periodicity chosen?

• Probe: Role of national standards, CMS requirements, other.

Are reporting requirements entirely new or do they build on existing systems? Do they represent a big change or just tweaks?

What has been your experience with provider reporting of the required data elements? What assistance have you offered providers?

• Probe: Provider capability, cooperation, adherence.

What is your experience to date of data timeliness, accuracy, and completeness? Are there any notable problem areas? If so, which areas and how are you addressing them?

What data is collected from beneficiaries and their families/caregivers? Have you encountered any problems in collecting this data?

Will the state be willing/able to share with us directly or through CMS the provider-level data providers must report to the state? The data collected from beneficiaries/families? If so, how long is the lag between service delivery and data availability? What format are these data in?

VIII. Evaluation Design
(Medicaid director, health home program director, health home evaluation director, data coordinator, associated state agency directors, provider health home director, advocates)

Verify our understanding of the evaluation design.

What are the comparison groups and how were they chosen?

• Probe: Are there similar beneficiaries (eligible by chronic condition profile) not currently being served by CMHO or CEDARR, respectively, who will not be auto-enrolled and might be able to serve as a comparison group?

Across what time period(s) will the comparisons be made? If your evaluation calls for comparisons with a pre-initiative period, what period has been designated and where will the data for the pre-period be found?

What methods do you intend to use in comparing beneficiaries and the comparison group(s)?

IX. Wrap-Up
(all interviewees)

Any key things we did not ask about?

Who else should we be talking to?

Periodic follow-up over the next year (and the option years): who should be our point of contact?

We will write-up the notes from this interview. Would you like to have the opportunity to review them?

Thank yous.

 

APPENDIX B. MEMORANDA ON PRE-EXISTING STATE INITIATIVES AND SUMMARY OF STATE PLAN AMENDMENTS FOR SECTION 2703 MEDICAID HEALTH HOMES

(NOTE: Each state's paper is also available as a separate PDF document. The links are listed at the end of this paper, as well as at the HTML state link below.)

APPENDIX B STATE PAPERS

Alabama

Idaho

Iowa

Maine

Missouri

New York

North Carolina

Ohio

Oregon

Rhode Island

Wisconsin

 

Alabama's Health Home Program at a Glance
Health Home Eligibility Criteria	2 chronic conditions, 1 chronic condition and at risk of another, serious mental illness
Qualifying Conditions	Mental illness Substance use disorder Asthma Diabetes Transplant recipients (within last 5 years) CVD COPD Cancer HIV/AIDS Sickle cell anemia
Enrollment*	70,206
Designated Providers	Patient Care Networks of Alabama (PCNAs), Medicaid-enrolled primary medical providers (PMPs)
Administrative/ Service Framework	The state offers health home services through a designated team of health care providers that include primary care providers, behavioral health providers, state-employed case managers, and the PCNAs. PCNAs operate as independent, nonprofit entities that contract with the state and participating Medicaid providers to offer wraparound care management services for eligible beneficiaries enrolled in the state's PCCM, Patient 1st. The PCNA program--and by extension the health homes program--operates in four targeted geographic regions, comprising 21 of the state's 67 counties.
Required Care Team Members	Not specifically mandated, though all providers must meet state requirements related to licensure. PCNAs are also required to meet certain staffing requirements. Depending on patient needs, the team may include a PMP, mental health provider, substance abuse provider, care manager/coordinator, pharmacist, transitional care nurse, dietician, and community health worker.
Payment System	Per member per month (PMPM) care management fee
Payment Level	PCNA: $9.50 PMP: $8.50
Health Information Technology (HIT) Requirements	PCNAs and PMPs are currently not required to have an electronic health record (EHR) or use an electronic Continuity of Care Document to exchange information. Alabama is in the process of implementing a statewide health information exchange platform known as One Health Record™. Providers who receive HITECH EHR incentive payments will be required to connect to One Health Record™ when operational. In the meantime, providers use existing web-based tools.
* January 2014 data provided to the Centers for Medicare and Medicaid Services' Health Home Information Resource Center.

Introduction

Alabama's Section 2703 Health Homes State Plan Amendment (SPA) was approved by the Centers for Medicare and Medicaid Services (CMS) on April 8, 2013 with a retroactive effective date of July 1, 2012. To be eligible for services, beneficiaries must have a serious mental illness (SMI), two chronic conditions, or have one chronic condition and be at risk of another chronic condition. The qualifying chronic conditions include a mental illness, substance use disorder, asthma, diabetes, heart disease, cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD), cancer, HIV with an 18 month lookback of Medicaid claims data for identification of medications, and sickle cell anemia. People who have received a transplant within the last five years are also eligible for inclusion. Alabama considers any beneficiary with one of these targeted conditions to be at-risk for developing another chronic condition.

The state offers health home services through a designated team of health care providers that include primary care providers (PCPs), behavioral health providers, state-employed case managers, and providers known as Patient Care Networks of Alabama (PCNA). PCNAs were established in 2011 and operate as independent, nonprofit entities that contract with the state and participating Medicaid providers to offer wraparound care management services for eligible beneficiaries enrolled in the state's primary care case management (PCCM) program, Patient 1st. Enrollment in Patient 1st is mandatory for all Medicaid beneficiaries, with the exception of certain groups of children (described further in the next section), members of federally recognized Indian tribes, and those who are dually eligible for Medicaid and Medicare. Though case management services are available statewide through the Patient 1st program, the PCNA program--and by extension the health homes program--operates in four targeted geographic regions, comprising 21 of the state's 67 counties.¹

Implementation Context

Alabama is implementing a range of health care payment and delivery reforms, many of which have implications for both the health homes program and the national evaluation. These reforms include medical home transformation activities, health information technology (HIT) initiatives, and changes to the state's managed care program, among others.

Care Delivery Reforms

Alabama operates a PCCM program known as Patient 1st, which was established in 1997 under a Section 1915(b) waiver. In September 2013, the Patient 1st program was incorporated into the State Plan.² All Medicaid enrollees must participate, with the exception of dually eligible individuals, members of federally recognized tribes, and children who are in foster care, who receive case management services through specialized providers, or who are eligible for Supplemental Security Income.² Roughly 650,000 of the state's 930,000 beneficiaries are currently enrolled in the program.³ Participating providers (known as Primary Medicaid Providers [PMPs]) receive a risk-adjusted case management fee for all enrolled patients, and in turn are expected to directly provide primary care and serve as gatekeepers to specialty care. PMPs may also refer patients for case management services, which are provided through contracts with the Alabama Departments of Public Health (ADPH) and the Alabama Department of Mental Health (ADMH). ADPH and ADMH case managers provide traditional case management services, including risk assessment, care plan development, patient education, and transportation assistance.

The PCNA program (described in greater detail below) was established in 2011 on a pilot basis, with the goal of providing enhanced care management services for high-risk, high-need beneficiaries. The first three PCNAs were established in the northern, eastern, and western regions of the state; a fourth PCNA was established in the southern region in 2012, as part of the program's transition from pilot to health home status. In March 2013, the state legislature passed SB 340, which called for the Medicaid agency to establish provider-based, risk-bearing managed care entities known as Regional Care Organizations (RCOs).⁴ It is anticipated that RCOs will build on the PCNA model, expanding over time to cover the majority of Medicaid beneficiaries. Eventually, RCOs will manage and be at-risk for the full continuum of primary, behavioral, and long-term care services provided within their respective regions. The details of the RCO program are still under development, and implementation is dependent on federal approval of the state's pending Section 1115 waiver application.⁵ Provider networks are expected to be in place by April 2015, and will begin receiving capitation payments by October 2016.⁶ While RCOs are under development, the state will continue, and possibly expand, the existing PCNA program.

The primary goal of the Patient 1st program (and by extension the PCNA program) is to provide a medical home for Medicaid enrollees. Other medical home initiatives underway in the state include the CMS Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration, which includes seven practices in Alabama.⁷ This demonstration began in 2011, and will run for three years. Participating practices receive a monthly care management payment, as well as technical assistance to support their application for Level 3 medical home recognition from the National Committee for Quality Assurance (NCQA).⁸

Two Alabama Area Agencies on Aging are also participating in the Community-based Care Transitions Program, which is aimed at reducing readmission for Medicare beneficiaries with chronic conditions. Under this program, grantees receive a two-year award from CMS, which may be extended annually until the end of the five-year demonstration project. Top of Alabama Regional Council of Governments in Alabama will partner with four hospitals to implement a Care Transitions Intervention program for Medicare patients in three counties--two of which are also served by PCNA organizations.⁹ This program provides coaching, medication reconciliation, chronic disease management, and referrals for patients following discharge from a participating hospital. The Southern Alabama Regional Council on Aging will partner with eight regional hospitals in seven rural counties designated as Health Professional Shortage Areas. However, these counties are not currently served by a PCNA.¹⁰

Payment Reforms

Alabama is one of 12 states participating in the Medicaid Emergency Psychiatric Demonstration, which was created under Section 2707 of the Affordable Care Act. Under current Medicaid payment rules, private psychiatric hospitals may not be reimbursed for providing emergency inpatient psychiatric care without a prior admission to an acute care hospital. This exclusion, known as the "Institution for Mental Diseases (IMD) exclusion," is cited as a contributing factor to high emergency department utilization, as well as higher costs. The demonstration will test whether eliminating this exclusion will lead to better health outcomes, reduced burden on hospital emergency departments, and lower costs for Medicaid beneficiaries experiencing a mental health crisis.¹¹ In Alabama, the demonstration includes four free-standing psychiatric hospitals which together cover more than 30 counties. All four hospitals have assigned nurses to conduct follow-up with Medicaid beneficiaries at three, 21, and 90 days after discharge.¹²

Payment reform demonstrations are also underway at the provider level. The Bundled Payments for Care Improvement (BPCI) Initiative is testing four bundled payment models, two of which include Alabama providers. Model 2 and Model 3--which involve the University of Alabama and Amedisys Home Health, respectively, are retrospective bundled payments that reconcile actual expenditures for an entire episode of care against a target price for the same episode. Participants may select up to 48 clinical condition episodes to be paid for under this bundled model. Model 2 payments will cover both hospital and post-acute care for 30, 60, or 90 days after discharge, while Model 3 will cover episodes in the post-acute period only, beginning no more than 30 days after discharge, and ending either 30, 60, or 90 days after initiation of the episode of care.¹³ Providers will phase in their assumption of financial risk over several months; by October 2014, providers will be at full risk for their selected episodes of care.

Health Information Technology Infrastructure

Alabama is implementing a statewide health information exchange (HIE) known as One Health Alabama (described further below), which builds on the infrastructure developed through the state's Together for Quality Initiative. Together for Quality was funded through a two-year Medicaid Transformation Grant from CMS, and sought to create HIT infrastructure that linked existing data sources and would allow providers to better manage care for their patients.¹⁴ As part of this initiative, the state-developed a web-based HIE known as Q-Tool, which supported both clinical decision-making tools and e-prescribing functions. Q-Tool was first piloted in 11 counties before being made available more broadly.¹⁵ The state also partnered with BlueCross BlueShield (BCBS), the largest private insurance carrier in the state. As part of this partnership, BCBS made its medical and pharmacy claims available through Q-Tool, allowing enrolled providers to access health information on any patient who had transitioned from BCBS to Medicaid coverage. To encourage participation, Patient 1st providers who used Q-Tool received an extra dollar in per patient case management fees. By January 2010, roughly 300 providers were enrolled in Q-Tool.¹⁶ Q-Tool was discontinued at the end of the grant period in September 2010, as the state began work on One Health.

The Together for Quality initiative also included implementation of a care management program for patients with asthma and diabetes, and a data hub for information exchange among Medicaid and other state agencies.¹⁴ The HIT infrastructure underpinning this care management program--Realtime Medical Electronic Data Exchange (RMEDE)--is operated by the University of South Alabama's Center for Strategic Health Innovations, and it allows enrolled providers to track key health indicators for their diabetic and asthmatic patients.¹⁵ This system also supports an in-home monitoring program for patients with congestive heart failure, hypertension, and diabetes.¹⁷ Enrolled patients use a telephonic system to enter their own health data, which are then sent to RMEDE. If a patient's metrics are outside of established parameters, the system generates an alert for follow-up by the PMP or an ADPH Nurse Care Manager. RMEDE also generates monthly reports that can be used for targeted intervention and quality improvement activities.

Implications for the Alabama Section 2703 Medicaid Health Homes Evaluation

Alabama has implemented its health home program in selected geographic areas, which may improve the ability to identify a comparison group for analysis of key outcomes. However, the health homes program is built directly within an existing care management infrastructure, and it is unclear what changes--if any--have been made to these underlying care structures and processes as part of the implementation of health homes. Several aspects of the program--particularly the HIT infrastructure supports and data collection systems--are still under development. It also is not yet clear how health homes will participate in the state's efforts to establish RCOs, or align with other reform efforts underway. PCNAs and Patient 1st providers will have differing levels of capacity for care management, coordination, and integration. Analyses will need to take into account baseline characteristics and major changes over time, enrollee and provider time in the program, and, to the extent possible, identify enrollees in other care management programs prior to enrollment.

Population Criteria and Provider Infrastructure

Alabama offers health home services to categorically needy beneficiaries with SMI, two chronic conditions, or one chronic condition and the risk of developing another. The qualifying chronic conditions include a mental illness, substance use disorder, asthma, diabetes, heart disease, CVD, COPD, cancer, HIV/AIDS, and sickle cell anemia. Any beneficiary with one of these conditions is considered to be at-risk for developing another chronic condition. Beneficiaries who have received a transplant within the last five years are also eligible for inclusion (see Table 1).

Health home services are delivered by a team of providers working across care settings. Primary responsibility for care management rests with a patient's designated Patient 1st Primary Medicaid Provider (PMP), who works in partnership with a regional PCNA--described in greater detail below--to coordinate the full range of a patient's medical, behavioral, social, and long-term care needs. Depending on their diagnosis, patients may instead receive care management through a state-licensed Community Mental Health Center (CMHC), a substance abuse provider, or an ADPH care manager. PMPs or PCNAs can refer patients for screening to determine their eligibility for care management services with those providers. If they are deemed ineligible, they are referred back to the PMP. Any patient who is unstable but deemed ineligible for care management through a behavioral health or ADPH provider may be referred to the PCNA for care management.

Patient Care Networks of Alabama (PCNAs)

PCNAs were established in 2011 as an enhancement of the state's existing PCCM program, Patient 1st. Modeled after the Community Care of North Carolina program, PCNAs are regional networks that build on local care capacity to support Patient 1st PMPs in managing and coordinating care for their highest-need patients. Four networks are operational, and provide services in 21 of the state's 67 counties. As stated in the original Request for Proposal (RFP), the goals of the program are to develop and implement holistic, patient-centered care plans; promote the patient-centered medical home model; improve care quality and health outcomes; reduce emergency department and inpatient utilization; and improve utilization of HIT.¹⁸ PCNAs are expected to provide care coordination, direct care management, transitional care, medication management, and population health management for health home enrollees.

PCNAs operate as 501(c)(3) nonprofit entities, and must establish contracts with the state and with the PMPs enrolled in their network. In addition to these contractual relationships, PCNAs are expected to develop working relationships with CMHC and substance abuse providers, and the local Departments of Public Health and Human Resources. The relationships between these various entities and organizations are reinforced through the PCNA board of directors, at least half of whom must be made up of Patient 1stprimary care physicians. Boards must also include at least one representative from an FQHC, a hospital, the health department, a CMHC, a state-licensed substance abuse provider, and a community pharmacist.¹⁹ PCNA staff composition varies, but each entity must designate an Executive Director; a Medical Director; a Network/Clinical Pharmacist; and a Chronic Care Clinical Champion, who works directly with high-risk patients and supports existing case managers in the network. Additional staff members include care managers, transitional care nurses, behavioral health nurses, dieticians, and community health workers. Since 2012, PCNAs have been required to include the local CMHC in their management meetings, and must have an identified member of their staff with behavioral health expertise to work with the local CMHC.

The state outlined four primary roles for these networks in supporting health home patients:¹⁹

1. Coordinate the work of providers across settings to ensure effective, nonduplicative, higher quality care.

2. Provide direct care management for Medicaid patients who are unstable.

3. Facilitate care integration between primary care and CMHC or substance abuse providers.

4. Review health home enrollee data on a monthly basis, in collaboration with PMPs.

PCNAs are also expected to sponsor regional meetings for providers enrolled in the network, as well as learning collaborative opportunities. The state intends to supplement these activities through providing statewide learning opportunities and technical assistance.

Identification and Enrollment

Alabama identifies eligible individuals through a monthly review of claims data, with a lookback of the previous 18-month period. For those with organ transplants, the lookback period is five years. Hospitals and PMPs may also identify and refer patients for enrollment. Once identified, those patients are contacted by mail and permitted to choose a PMP, after which they will be enrolled with the PCNA contracted to that practice. The patient may choose to opt-out of receiving health home services, or may switch provider at any time. However, enrollment with a PMP is still mandatory for nonhealth home services covered under the state's PCCM program. As previously noted, individuals who qualify for health home services based on either a mental health or substance use disorder will receive care management primarily through a CMHC or substance abuse provider, rather than their PMP. PCNAs may serve all health home patients with chronic conditions, regardless of diagnosis.

Service Definitions and Provider Standards

The service definitions provided in the SPA are adapted in Table 2 below. Comprehensive care management is the primary responsibility of the PMP, who must develop relationships with local CMHCs and substance abuse providers to ensure effective care management for patients with mental health or substance abuse diagnoses. Coordination is led by the PCNA, which serves as a liaison between the patient, PMP, other care management providers, and state agencies. Coordination activities may also be led by CMHC, substance abuse, or ADPH case managers, depending on patient need, but these latter providers are reimbursed through a different methodology (see Payment section). Health promotion, care transition, individual and family support services, and referral to community and social support services may be provided by any member of the health home team.

In addition to meeting the 11 core standards identified by CMS, all health home team member must meet state and federal licensure requirements, and have the ability to provide health home services as stipulated in the SPA (See Table 2).

Use of Health Information Technology

Alabama is in the process of implementing a statewide HIE platform known as One Health Record™, which will connect providers with state agencies and eventually serve as the primary platform for patient data exchange. A consumer portal is already operational through One Health Record™, as is a platform for direct secure messaging between providers who are connected to it. Eventually, the state envisions that the network will allow providers to view paid claims data, access emergency department utilization data, implement e-prescribing, and review clinical data. Providers who receive Health Information Technology for Economic and Clinical Health (HITECH) Act EHR Incentive Payments will be required to connect to One Health Record™. However, neither Patient 1st PMPs nor PCNAs currently are required to have an electronic health record (EHR) or use an electronic Continuity of Care Document to exchange information. Once connected to One Health Record™, both PMPs and PCNAs will use its standardized format for data exchange.

In the interim, the state is encouraging continued use of existing web-based tools like RMEDE, which the state expects to integrate with One Health Record™. The state has recently developed a new data repository to link to One Health Record™, which has replaced the data warehouse maintained by the University of South Alabama. PMPs and PCNAs will use this repository to access clinical and administrative data and report quality measures.

Payment Structure

Payment to PMPs and PCNAs for the provision of health home services will be made on a per member per month (PMPM) case rate basis. PMPs receive $8.50 PMPM, while PCNAs receive $9.50 PMPM.² (Rural health centers and FQHCs that participate as PMPs do not qualify for the case management fee. 17 ) These payments will be made in addition to standard fee-for-service reimbursement, and are paid for patients meeting three criteria: (1) they are enrolled with a PMP who is participating in a PCNA; (2) they are identified by either the state, the PMP, or the PCNA as having one of the qualifying conditions; and (3) they have received a minimum level of care management services, which includes monitoring for treatment gaps in care. PCNAs are expected to review patient data on a monthly basis to identify such gaps, and follow-up with the PMP or the patient to determine that any identified issues are being addressed. Care management services provided by CMHCs, substance abuse providers, and ADPH care managers are not reimbursed through a PMPM. These providers receive a standard fee reimbursement.

Quality Improvement Goals and Measures

The state has identified seven goals for the health homes program, and has set corresponding targets for performance improvement. These goals are listed in Table 3 below, along with the corresponding measures that will be used to evaluate progress against the identified benchmark goals. Most of the selected measures will be generated through claims; other data sources include Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data, data from ADMH, and eventually One Health Record™ chart audit. The state is also developing a standardized web-based assessment to collect depression screening data.

Evaluation Measures and Methods

The evaluation measures and methods described in the SPA are adapted in Table 4 below (sentences that were identical across cells were deleted). The state plans to assess the impact of health home services at the practice, network, and state level, based on the selected quality measures. No consistent evaluation design is specified for key health home outcome measures. For hospital admissions, the intent is to measure, for persons age 18 or older as of December 31 of the measurement year, the acute admission rate for each qualifying condition in the geographic areas covered by health homes and in the remainder of the state, the number of all-cause readmissions after an acute admission, and the predicted probability of an acute readmission. For skilled nursing facility (SNF) use, total admissions for health home enrollees in Patient 1st will be compared with total SNF admissions among health home enrollees outside of Patient 1st. Cost savings will be assessed by comparing actual PMPM amounts for the included geographic regions with projected PMPM. The projection methodology is not described.

TABLE 1. Target Population and Designated Providers--Alabama
SPA Approval (Effective Date)	April 09, 2013 (July 1, 2012)
Designated Provider(s)	Patient 1st PMPs, CMHCs, ADPH, and substance abuse providers partnering with a PCNA
Health Home Team Composition	Not specifically mandated, though all providers must meet state requirements related to licensure. PCNAs are also required to meet certain staffing requirements. Depending on patient needs, the team may include: PCP Mental health provider Substance abuse provider Care manager/coordinator Pharmacist Transitional care nurse Dietician Community health worker
Target Population	Medicaid beneficiaries with SMI, 2 chronic conditions, or 1 chronic condition and the risk of developing another
Qualifying Chronic Conditions	Mental illness Substance use disorder Asthma Diabetes Heart disease Transplant recipients (within the last 5 years) CVD COPD Cancer HIV/AIDS Sickle cell anemia

 

TABLE 2. Health Home Service Definitions--Alabama
Care Coordination	Defined as an enrollee-centered, assessment-based inter-disciplinary approach to integrating health care and social support services in which an individual's needs and preferences are assessed, a comprehensive care plan developed, and services managed, monitored and reassessed as needed by an identified care coordinator following evidence-based standards of care to the degree possible. In addition to the core elements of care coordination/care management, the care coordinator provides disease management education, medication reconciliation, facilitation of sub-specialty referrals, transitional care interventions, works to ensure appropriate level of care is being provided and unnecessary emergency department visits are avoided, as well as providing education to patients about the importance of a medical home. Activities within scope of this service are performed by PCNAs, CMHCs, substance abuse providers, or ADPH care managers, in accordance with patient needs. They include: Staffing to support the PMP in care management. Patient care team must be accessible to individuals 24/7. Screening for clinical depression. Development of a comprehensive assessment of an individual's health and psychosocial needs and preferences, including health literacy status and deficits. Planning with the individual, family or caregiver, providers, the payer, and the community to maximize health care responses, quality, and cost-effective outcomes. Development of a comprehensive health plan that is person-centered for each individual and coordinates and integrates all of the individual's clinical and nonclinical health care related needs and services. Development of the comprehensive health plan is collaborative with the enrollee and family or caregiver and using a team approach. The comprehensive health plans must have the capacity to accommodate individuals with multiple diseases and co-morbidities. The comprehensive health plan identifies the individual, caregiver, PCNA, specialists and other ancillary providers involved in the participant's care. Coordination and access to preventive and health promotion services, including prevention of mental illness and substance use disorders. Coordination and access to mental health, substance abuse, and LTSS. Establishment of a continuous quality improvement program, and collection and reporting on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level. Management, monitoring and reassessment of an individual as needed by an identified care coordinator following evidence-based standards of care and enrollee-centered, assessment-based inter-disciplinary approach to integrating health care and social support services. Traditional case management services through public health, including assistance with understanding program requirements, helping with transportation needs, and assessment of the home environment and factors that may impede patient compliance with medical care protocols; also includes mental health, substance abuse and child health issues such as understanding the need for preventive care. Disease management education, medication reconciliation, facilitation of sub-specialty referrals and transitional care interventions. Facilitated communication and coordination between members of the health care team in order to minimize fragmentation in the services. Empowerment of the individual to problem-solve by exploring care options to achieve desired outcomes. Encouragement of the appropriate use of health care services to improve quality of care and maintain cost-effectiveness. Assistance in transitioning of care to the next appropriate level. Promotion of individual self-advocacy and self-determination. Advocating for both the individual and the Medicaid Program to facilitate positive outcomes for the individual, the health care team, and the Medicaid Program.
Comprehensive Care Management	Activities within the scope of this service are performed by the PMP and include: Identifying high-risk individuals (in addition to the efforts by the state directly to identify high-risk enrollees). Conducting outreach to, planning and communicating with other primary and specialty care providers regarding a patient's care. Developing a comprehensive health plan informed by the patient, which integrates care across various systems (mental health/substance abuse/primary care). Clarifying and communicating the patient's preference to all involved providers while assuring timely delivery of services.
Health Promotion	Activities within the scope of service are performed by all team members, and include: Patient education to the individual, family or caregiver, and members of the care team about treatment options, community resources, insurance benefits, psychosocial concerns, care management, etc. Also, patient education about the importance of a medical home. Adhering to EPSDT requirements. Providing health education specific to an individual's chronic conditions. Providing education regarding the importance of immunizations and screenings, child physical and emotional development. Providing health-promoting lifestyle interventions, such as substance use prevention, smoking prevention and cessation, nutritional counseling, obesity reduction and prevention and increasing physical activity. Development of a treatment relationship with the individual and the inter-disciplinary team of providers. Promoting evidence-based wellness and prevention by linking health home enrollees with resources based on individual needs and preferences.
Comprehensive Transitional Care	Activities within the scope of service are performed by all team members. PMPs are expected to assist the enrollee in the safe transitioning of care to the next most appropriate level, including movement from inpatient to a nursing facility or home setting. PCNAs assist the enrollee in the safe transitioning of care to the next most appropriate level.
Individual and Family Support Services	Activities within the scope of service are performed by all team members. PMPs are expected to provide patient and family support as appropriate. PMPs must educate and empower the enrollee and the family or caregiver about treatment options, community resources, insurance benefits, psychosocial concerns, care management, etc., so that timely and informed decisions can be made. Other care management providers (PCNAs, CMHCs, substance abuse providers, and ADPH) are expected to provide patient and family support as appropriate. PMPs and PCNAs to advocate for both the state and the enrollee to facilitate positive outcomes for the enrollee and where a conflict arises to prioritize the needs of the enrollee.
Referral to Community and Social Supports	Activities within scope of service are performed by all team members. Where relevant and as appropriate, PMPs and PCNAs are specifically required to establish an ongoing process with community providers and other community agencies to coordinate the planning and provision of care management and other support services for enrollees needing those services. However, all care management managers may engage in this activity for their specific population. Services include LTSS such as housing, home delivered meals, services for individuals with disabilities and adult day care. For individuals with public health needs, the ADPH will take the lead to assure community and social support services relevant to public health and obtained through the public health infrastructure are available to health home services enrollees. Since much of the public health infrastructure in Alabama is through the state, the ADPH will coordinate these efforts as a participant in the team.

 

TABLE 3. Health Home Goals and Quality Measures--Alabama
Goal-Based Measures
Improve Health Outcomes for Adults with Diabetes	Benchmark goals: Increase care compliance for diabetic patients receiving health home services by 2% in year 1 and another 2% by year 2. Clinical outcome measures: Percent of patients with a diagnosis of diabetes mellitus who had an HbA1c test performed during the past year. Percentage of patients 18-75 years of age with a diagnosis of diabetes mellitus (type 1 and type 2) who had a low-density liproprotein cholesterol (LDL-C) test in the past year.
Improved Health Through Reduction in Adult Body Mass Index (BMI)	Benchmark goals: Increase identification of adult BMI level by 2% over baseline year (2012). Clinical outcome measures: Adult BMI assessment.
Reduction in Hospital Readmission and Ambulatory Care-Sensitive Condition Admissions	Benchmark goals: Reduce ambulatory care-sensitive condition admissions rate by 2.5% in year 1 and another 2.5% by year 2. Reduce the 30 day readmission rate by 2.5% in both year 1 and year 2. Clinical outcome measures: Ambulatory care-sensitive condition admission. Quality of care measures: Plan all-cause readmission.
Improve Care Coordination for People with Asthma	Benchmark goals: Increase influenza immunization rate in children with an asthma diagnosis by 1% in year 1 and year 2. Decrease emergency department visit rate for asthmatic enrollees by 5% in year 1 and another 2.5% by year 2. Clinical outcome measures: Influenza immunization rate in children with an asthma diagnosis. Quality of care measures: Percent of patients with an emergency department/urgent care office visit for asthma in the past 6 months.
Improve Care Coordination Through Transmission of Transition Records	Benchmark goals: Increase the timely transmission of transition record (inpatient discharges to home/self-care or any other site of care) by 5% in year 1 and another 2.5% by year 2. Quality of care measures: Percent of patients for whom a care transition record was transmitted to the follow-up care provider within 24 hours of discharge.
Improve Pediatric Preventive Care	Benchmark goals: Increase the percentage of children receiving well-child checks by 2% from the baseline for year 1 and year 2. Clinical outcome measures: Percentage of children age 12-21 who had at least 1 comprehensive well-care visit with a PMP. Experience of care measures: CAHPS 1.0 survey response regarding access to dental care for children. Quality of care measures: Percentage of children (under age 21) who had at least 1 dental visit during the measure year.
Improve Treatment for Depression	Benchmark goals: Benchmark goal to be determined based on information collected from the baseline. Quality of care measures: Percentage of patients age 18 and older screened for clinical depression using a standardized tool, with follow-up documented.
Service-Based Measures
Comprehensive Care Management	Quality of care measures: Percentage of discharges for members age 6 and older who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 7 days of discharge.
Care Coordination	Clinical outcome measures: Percentage of adolescents and adult members with a new episode of alcohol or other drug (AOD) dependence who received initiation and engagement of AOD treatment.
Comprehensive Transitional Care	Quality of care measures: Transition record with state-specified elements received by discharged patients (inpatient discharges to home or any other care site).

 

TABLE 4. Evaluation Methodology--Alabama
Hospital Admission Rates	Assess hospital admission rates, by service (medical, surgical, maternity, mental health and chemical dependency), for acute care hospitals (nonpsychiatric hospitals) in the participating health home geographic sites and remainder of state for the chronic conditions identified as eligible for health home services using Medicaid Claims (annual). MMIS claims data will be analyzed using current and new data warehouse and distributed via email or disc distribution. Eligible population will be those 18 years of age and older, as of December 31 of the measurement year. The focus of the collection is the number of acute inpatient stays during the measurement year that were followed by an acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. The state will utilize the quality process and outcome measures described in the SPA to assess quality improvements and clinical outcomes. For registry-based, claims-based and audit-based measures, assessment will occur both at the individual practice level, the PCNA level, at the aggregate level for each geographic area, and for all participating health homes. For claims-based measures, the state will track change over time to assess whether statistically significant improvement has been achieved. One year after One Health Record™ is operational, the state will move to national measures where national measures exist.
Chronic Disease Management	The state will assess the provision of chronic disease management by the PMPs and Networks for individuals with the chronic conditions specified within the SPA based on the selected quality measures. The state has determined that it will start with national standardized methodologies, including the use of National Quality Forum and/or CHIPRA measure specifications until further clarification is provided, for pre/post-comparisons. The Alabama Medicaid care management system has data on referrals sent, which tracks referrals to social services and community and social support. One Health Record™ consumer portal is already operational and provides information to consumers on Alabama state programs. One Health Record™ will provide the infrastructure for PMPs and PCNAs to also connect with state agencies, including Medicaid, ADPH, and ADMH and other health home providers who choose to connect to One Health Record™ through a state "gateway" that will be available in 2012. PMPs and PCNAs will be encouraged to utilize current HIT systems and connect to One Health Record™ when it becomes available to communicate with patients, family and caregivers in a culturally appropriate manner. The state has also already put into place quality measure reporting requirements for health homes that apply to both the PMPs and the PCNAs, including the collection and reporting of data on patient outcomes and the collection of data on patient experience of care. The state is planning a CAHPS survey for CY 2013. Barriers to implementation identified by the state include the remaining uncertainty of the final set of measures, as adult measures are anticipated the first quarter of CY 2012. The state will not be able to address all of the core set of measures on the effective date of the SPA, but has a plan to address barriers to implementation, including but not limited to health information capacity statewide. The state is developing a timeline by which to phase in the implementation, to be completed within one year. The state has identified proxy measures that will be reported to CMS in the interim. Alabama will establish business and technical operational structures to comply with the evaluation reporting requirements, including: nature, extent, and use of the health home model of service delivery, assessment of program implementation processes and lessons, assessment of quality improvements and clinical outcomes and estimates of cost savings. MMIS claims data can be shared across the systems. It will be analyzed using the current and future state enterprise wide data repository/warehouse system along with other systems as they become available through One Health Record™ and Medicaid eligibility system enhancements. Chart review replacement will be considered once One Health Record™ is operational for a year to give all providers the opportunity to fully utilize their EHR systems. The Alabama care management system is used for data analysis and will continue to be used until and if it is replaced by a future state enterprise wide data repository/ warehouse that includes analytical capabilities. The PMPs and PCNAs will be encouraged to utilize current HIT systems and connect to One Health Record™ when it becomes available to link to, promote, manage and follow health promotion activities such as the use of public health and patient registries.
Coordination of Care for Individuals with Chronic Conditions	The state will also assess the provision of care coordination services for individuals with the chronic conditions specified within this SPA based on the measurements presented earlier in the State Plan. The state has already put into place quality measure reporting requirements for health homes that apply to both the PMPs and the PCNAs, including the collection and reporting of data on patient outcomes and the collection of data on patient experience of care. The state is planning a CAHPS survey for CY 2013. MMIS claims data can be shared across the systems. It will be analyzed using the current and future state enterprise wide data repository/warehouse system along with other systems as they become available through One Health Record™ and Medicaid eligibility system enhancements. Chart review replacement will be considered once One Health Record™ is operational for a year to give all providers the opportunity to fully utilize their EHR systems. The Alabama care management system is used for data analysis and will continue to be used until and if it is replaced by a future state enterprise wide data repository/warehouse that includes analytical capabilities. The PMPs and PCNAs will be encouraged to utilize current HIT systems and connect to One Health Record™ when it becomes available to link to, promote, manage and follow health promotion activities such as the use of public health and patient registries. The state will not be able to address all of the core set of measures on the effective date of the SPA, but has a plan to address barriers to implementation, including but not limited to health information capacity statewide. The state is developing a timeline by which to phase in the implementation, to be completed within one year. The state has identified proxy measures that will be reported to CMS in the interim. Alabama will setup business and technical operational structures to comply with the evaluation reporting requirements including: nature, extent and use of the health home model of service delivery, assessment of program implementation processes and lessons learned, assessment of quality improvements and clinical outcomes, and estimates of cost savings.
Assessment of Program Implementation	The state will monitor implementation through the evaluation process addressed in the State Plan. The Medicaid Agency is also working directly with the ADPH, ADMH, etc. and meeting regularly to goals established in the State Plan and performance indicators provided elsewhere in the SPA. The state will monitor health home providers to ensure that health home services are being provided that meet the state's health home provider standards and CMS' health home core functional requirements. Oversight activities will include, but not be limited to contract management, clinical and claims data review and analysis, and other activities defined by the state for Medicaid program integrity and ongoing management.
Processes and Lessons Learned	The state will monitor implementation through the evaluation process addressed in the State Plan. The Medicaid Agency is also working directly with the Alabama Department of Human Resources, ADMH, ADPH and meeting regularly to goals established in the State Plan and performance indicators provided elsewhere in the SPA. Federal requirements are provided in contracts between the state and the PCNAs, and the state and the PMPs.
Assessment of Quality Improvements and Clinical Outcomes	The state will utilize the quality process and outcome measures described in the prior section to assess quality improvements and clinical outcomes. For registry-based, claims-based and audit-based measures, assessment will occur both at the individual practice level, the network level, at the aggregate level for each geographic area, and all participating health homes. For claims-based measures, the state will track change over time to assess whether statistically significant improvement has been achieved. One year after One Health Record™ is operational, the state will move to national measures where national measures exist. The state has already put into place quality measure reporting requirement s for health homes that apply to both the PMPs and the PCNAs, including the collection and reporting of data on patient outcomes and the collection of data on patient experience of care. The state is planning the CAHPS survey for CY 2013.
Estimates of Cost Savings	The state will determine total cost for all patients in the region, divided by the total number of eligible beneficiaries reported monthly, stratified by age (1, 1-5, 6-18, >19), and also report median PMPM for providers in region, as no national measurement is available to match. PMPM amounts for the geographic regions will be compared with projected PMPM to determine cost savings. Through the use of the proposed CHIPRA measures, the adult Medicaid measures and the Meaningful Use measures, the state seeks to align with some of the information, including cost savings, which will be collected for the report to Congress.

 

APPENDIX: Pre-Existing Initiatives in Alabama
	Patient 1st/ PCNA2, 17, 18, 19	RCOs5, 6	FQHC Advanced Primary Care Demonstration7, 8	Community-Based Care Transition9, 10	Medicaid Emergency Psychiatric Demonstration11, 12	BPCI Initiative--Models 2 and 313	Together for Quality14, 15
Timeline	1997: Patient 1stwas established 2011: PCNA was established in 3 regions 2012: Fourth PCNA was established; counties added to existing networks	October 2013: RCO regions established October 2014: RCO boards approved by Medicaid April 2015: Provider networks in place October 2015: RCO solvency requirements met October 2016: RCOs accept capitation payments	The demonstration began in September 2011, and will run through August 2014	The demonstration will run from 2011-2015. Grants were awarded on a rolling basis until September 2012 Awardees receive grants for 2 years, which may be extended annually thereafter	The demonstration began in March 2012, and will run until 2015	Phase 1 (preparation period) began January 2013, and will end in fall 2014 Phase 2 (risk-bearing phase) will begin either October 2013 or January 2014 Providers will be fully at-risk for target episodes by October 2014	Grant period ran from June 2008-September 2010
Geographic Area	Patient 1st is statewide; PCNA covers 21 counties in 4 regions	Statewide	Statewide	3 counties in northern Alabama, and 7 counties in southern Alabama	Statewide	Counties served by the six participating facilities	Piloted in 11 counties
Sponsors	Alabama Medicaid	Alabama Medicaid	CMS, Health Resources and Services Administration, National Association of Community Health Centers	CMMI	CMMI	CMMI	CMS, Alabama Medicaid, BCBS
Scope	Patient 1st: all Medicaid enrollees, certain groups excepted PCNA: all Patient 1stMedicaid enrollees in their network who meet health home eligibility	All Medicaid providers All Medicaid beneficiaries, excluding duals and people receiving care under existing waivers	7 practices in Alabama	12 hospitals serving Medicare beneficiaries with multiple chronic conditions	4 free-standing psychiatric hospitals Medicaid recipients between age 21-64 who are experiencing a psychiatric emergency	1 hospital 5 home health facilities Medicare beneficiaries receiving a targeted episode of care	Medicaid providers in the pilot counties and their enrolled Patient 1stpatients
Goals	Provide Medicaid recipients with a medical home Achieve long-term cost, quality, access, and utilization objectives through improved care management	Establish networks to manage the continuum of health services under a single capitated rate Reduce fragmentation and enhance care access Improve quality and contain cost	Evaluate the effect of the advanced primary care practice model on care quality, health outcomes, and the cost of care provided to Medicare beneficiaries served by FQHCs	Establish or enhance partnerships between hospitals and CBOs Implement transitional care models to improve quality of care and reduce readmission	To assess whether eliminating the IMD payment exclusion improves access to and quality of psychiatric care To determine whether this change in reimbursement policy is cost-effective	Test new methods of paying for acute and post-acute care Promote care coordination Reward quality and contain costs	Create a web-based HIE with clinical support and e-prescribing tool for providers (Q-Tool) Implement a care management system for Patient 1stMedicaid recipients with asthma and diabetes (Q4U) Establish a data hub for sharing information across state agencies (Qx)
Payment Approach	Patient 1st: $8.00 PMPM for health home, $0.50 PMPM for all other enrollees PCNA: $9.50 PMPM	Global capitation payment	$6 PMPM care management fee, paid in addition to the "all inclusive per visit payment" that FQHCs receive for providing Medicare services	CBOs are paid an all-inclusive rate per discharge of an eligible Medicare beneficiary, only once within a 180-day timeframe for a given beneficiary	Standard Medicaid hospital payment	Retrospective bundled payment made for select episodes of care Model 2 covers acute and post-acute care; Model 3 covers post-acute care	Providers were paid an additional $1 PMPM for using Q-Tool
Technical Assistance (TA)	Patient 1stproviders receive support from their PCNA where available, and PCNAs receive monthly TA and training from the state	No information found	TA will support practices in medical home transformation and achieving NCQA recognition	CBOs are encouraged to contact their Medicaid Quality Improvement Organization for support; the Lewin Group will provide TA for all awardees	No information found	CMMI will host TA calls with participating providers, and has made resources available on-line	No information found
HIT Use	Patient 1st: Providers are required to connect to One Health to receive HITECH support PCNA: Use of RMEDE and One Health Record™	RCOs and providers are expected to rely on existing tools like RMEDE, and will eventually rely on One Health Record™for HIE	Practices are not required to have an EHR, but are encouraged to adopt tools such as registries and schedulers	No information found	No information found	No information found	Q-Tool was implemented, and RMEDE was used to support Q4U care management activities
Evaluation Methods	See Evaluation section	No information found	CMS will conduct bi-annual NCQA recognition readiness assessments, and an independent evaluator will assess impact on access, quality and cost outcomes.	CMS will contract with an independent evaluator to assess program performance. Outcomes of interest include 30, 90, and 180-day readmission, mortality, and emergency department visits	CMS will contract with an independent evaluator to assess: Impact on average inpatient stays, emergency department visits, and costs Discharge planning by participating hospitals Percentage of Medicaid enrollees admitted as a result of the demonstration compared to those admitted through other means	No information found	The state contracted with the School of Public Health at the University of Alabama at Birmingham to conduct the evaluation, which was published in 2010

Endnotes

1. Headley, N., and C. Miller. Health Home Information Resource Center. "Patient Care Networks of Alabama." Available from: http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Downloads/HH-IRC-Exploring-HH-5-13.pdf.

2. Alabama Medicaid State Plan Amendment (AL-13-005). "Transitions the Alabama Patient 1st Primary Care Case Management Program from a 1915(b) Waiver Authority to the State Plan Authority." September 2013. Available from: http://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/AL/AL-13-005-Att.pdf.

3. Personal communication with Alabama Medicaid staff.

4. Medicaid Agency. "Delivery of Medical Services to Medicaid Eligible Persons through Regional Care Organizations." SB 340. 2013 Regular Session. Assigned Act No. 2013-261. Available from: http://medicaid.alabama.gov/documents/2.0_Newsroom/2.7_Topics_Issues/2.7.3_RCOs/2.7.3_Act_2013_261_(SB%20340)_RCOs.pdf.

5. Alabama Medicaid Agency. "Alabama 1115 Waiver Concept Paper." Submitted May 15, 2013. Available from: http://medicaid.alabama.gov/documents/2.0_Newsroom/2.7_Topics_Issues/2.7.3_RCOs/2.7.3_1115_Submission_CMS_5-17-13.pdf.

6. Alabama Medicaid website. "RCO Timeline." Published June 17, 2013. Available from: http://medicaid.alabama.gov/documents/2.0_Newsroom/2.7_Topics_Issues/2.7.3_RCOs/2.7.3_RCO_Timeline_6-17-13.pdf.

7. Center for Medicare and Medicaid Innovation website. "FQHC Advanced Primary Care Practice Demonstration." Available from: http://innovation.cms.gov/initiatives/FQHCs/#collapse-tableDetails.

8. Center for Medicare and Medicaid Innovation website. "Federally Qualified Health Center Demonstration Fact Sheet." Available from: http://innovation.cms.gov/initiatives/FQHCs/FQHC-Fact-Sheet.html.

9. CMS press release. "CMS Continues Efforts to Improve Quality of Care for People with Medicare: Top of Alabama Regional Council of Governments in Huntsville Named in Initiative to Improve Transitions from the Hospital to Home or Other Care Settings." March 7, 2013. Available from: http://tarcog.us/wp-content/uploads/2013/03/TARCOG_CCTP_March2013.pdf.

10. Center for Medicaid and Medicaid Innovation website. "CCTP Site Summaries: Alabama." Available from: http://innovation.cms.gov/initiatives/CCTP/CCTP-Site-Summaries.html.

11. Center for Medicaid and Medicaid Innovation website. "Medicaid Emergency Psychiatric Demonstration." Available from: http://innovation.cms.gov/initiatives/medicaid-emergency-psychiatric-demo/.

12. Alabama Medicaid Agency. "Alabama Medicaid Emergency Psychiatric Demonstration Operational Manual." July 1, 2012. Available from: http://medicaid.alabama.gov/documents/4.0_Programs/4.4_Medical_Services/....

13. CMS Fact Sheet. "Bundled Payments for Care Improvement Initiative." September 30, 2013. Available from: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-01-31.html.

14. Hostetter, M. "Case Study: Alabama's Together for Quality Program--Putting Health IT to Work for Medicaid Beneficiaries." Commonwealth Fund. Quality Matters Newsletter. July/August 2009. Available from: http://www.commonwealthfund.org/Newsletters/Quality-Matters/2009/July-August-2009/Case-Study.aspx.

15. Bronstein, J., J. Klapow, N. Menachemi, and S. Engler. "Final Report: Evaluation of the Alabama Medicaid Together For Quality Program, June 2008-September 2010." School of Public Health, University of Alabama at Birmingham. Available from: http://medicaid.alabama.gov/documents/4.0_Programs/4.7_Health_Information_Technology/4.7.1_Together_for_Quality/4.7.1_TFQ_Pilot_Program_UAB_Final_Report_rev.pdf.

16. Together for Quality Stakeholders Council. "January 2010 Progress Report." Available from: http://www.medicaid.state.al.us/documents/Transformation-TFQ-Documents/TFQ_Stakeholders_Council_1_13_10_Progress_Report.pdf.

17. Alabama Medicaid Agency. "Medicaid Provider Manual, Chapter 39: Patient 1st." October 2013. Available from: http://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.7_Provider_Manuals_2013/6.7.7.4_October_2013/Oct13_39.pdf.

18. Alabama Medicaid Agency. "Request for Proposals: Patient Care Networks of Alabama." RFP #2010-PCNA-01. December 1, 2010. Available from: http://www.medicaid.alabama.gov/documents/2.0_Newsroom/2.4_Procurement/2.4_RFP_Patient_Care_Networks_12-1-10.pdf.

19. Alabama Medicaid Agency. "Request for Proposals: Patient Care Networks of Alabama." RFP #2012-PCNA-03. April 9, 2012. Available from: http://medicaid.alabama.gov/documents/2.0_Newsroom/2.4_Procurement/2.4_RFP_Patient_Care_Networks_North_AL_4-8-12.pdf.

 

 

Idaho's Health Home Program at a Glance
Health Home Eligibility Criteria	2 chronic conditions, or 1 chronic condition and at risk of another, serious mental illness, serious emotional disturbance
Qualifying Conditions	Mental health condition Asthma Diabetes
Enrollment*	9,179
Designated Providers	Any Medicaid-enrolled primary care provider that meets health home standards.
Administrative/ Service Framework	The health home program uses the state's existing Medicaid primary care case management program, Healthy Connections. Any Healthy Connections provider who meets state qualifications can serve as a health home. To avoid duplication of services, Medicaid beneficiaries receiving targeted case management will shift the delivery of this care to their health home practice.
Required Care Team Members	The designated provider can include primary care physicians, mental health care providers, nurse practitioners, or physician assistants. The designated provider will operate in coordination with other health care professionals as deemed necessary.
Payment System	Per member per month care management fee.
Payment Level	$15.50
Health Information Technology (HIT) Requirements	The initial HIT standards require that providers have a structured information system in place that allows usage of a disease management database. An electronic medical record is not required, but providers are encouraged to have them and to use HIT tools as feasible. The final standards require that providers use HIT to systematically follow-up on patients' care, conduct population management, and access the Idaho Health Data Exchange. Providers must submit a plan to achieve the final HIT requirement to the state within 24 months of program initiation in order to be approved as a health home provider, as well as have an electronic disease registry in line with National Committee for Quality Assurance standards. Providers are also expected to report on the selected quality measures using HIT.
* January 2014 data provided to the Centers for Medicare and Medicaid Services' Health Home Information Resource Center.

Introduction

Idaho's Section 2703 Health Home State Plan Amendment (SPA) was approved by the Centers for Medicare and Medicaid Services (CMS) on November 21, 2012, with an effective date of January 1, 2013. To be eligible for health home services, Medicaid beneficiaries must have a serious and persistent mental illness or serious emotional disturbance (SED); have diabetes and asthma; or have either diabetes or asthma and be at-risk for another chronic condition (see Table 1).

The health home initiative builds off of Idaho's Medicaid primary care case management (PCCM) program, Healthy Connections. Any Healthy Connections provider who meets state qualifications can serve as a health home, including solo or group practices, rural health clinics, community health centers, community mental health centers (CMHCs), and home health agencies. To avoid duplication of services, members currently receiving targeted case management will shift the delivery of this care to their health home practice.

Idaho Medicaid

In state fiscal year 2012, there were approximately 228,897 beneficiaries enrolled in Idaho Medicaid, all of whom are enrolled in some form of managed care.¹ Most of these are enrolled in Healthy Connections, the state's PCCM program, which is administered on a regional basis (see Figure 1). The state's three benefit plans are structured differently depending on the eligibility category. Most beneficiaries are enrolled in the Medicaid Basic Plan, which covers health, prevention, and wellness benefits for low-income children and adults with eligible dependent children. Enrollees with disabilities, special health needs, or who are dually eligible for Medicaid and Medicare are eligible for certain enhanced benefits under the Enhanced Plan or the Medicare-Medicaid Coordinated Plan (MMCP).

Implementation Context

Idaho has introduced a range of initiatives aimed at reforming the way health care is organized, financed, and delivered, many of which have implications for the health home-eligible population.

Managed Care

In February 2011, the Idaho Legislature enacted a law (HB 260) that directed the Division of Medicaid to develop and put in place risk-based managed care tools, with a special focus on enrolling high-cost populations. Medicaid has several managed care programs in place, including PCCM, dental benefits, and transportation. More recently, Medicaid began implementing additional managed care initiatives related to behavioral health benefits, care coordination for the dually eligible, and patient-centered medical care.

CMS-approved a Section 1915(b) Waiver that authorizes the state to establish a Prepaid Ambulatory Health Plan for beneficiaries with serious mental health conditions. The state has contracted with Optum for the administration of behavioral health services, known as the Idaho Behavioral Health Plan (IBHP).² Under this risk-based contract, Optum manages a range of behavioral health services, including outpatient community-based mental health services, substance use disorder services, and case management. Inpatient and institutional services are not included, but the contract includes financial incentives for Optum to keep patients out of the hospital.³ The contract term is for three years, with a possibility of two extensions of two years. IBHP began operations on September 1, 2013.²

Idaho had planned to participate in the CMS Financial Alignment Initiative, one of several initiatives designed to integrate and coordinate care for all dually eligible Medicare-Medicaid enrollees. The state proposed a capitation model, entailing a three-way contract between the state, CMS, and managed health care plans to provide integrated, comprehensive coverage to over 17,000 dually eligible beneficiaries.⁴ The state's design calls for these services to be fully capitated, and the contracts will require health plans to ensure that all necessary Medicaid and Medicare services (including primary and acute care, pharmacy, behavioral health, and long-term services and supports) are provided, coordinated and managed. For individuals who qualify for the health home benefit, health plans will contract directly with the health home designated providers, which will provide the care management and coordination. Enrollment in these managed care plans was scheduled to begin in March 2014. As only one health plan applied to participate in the Demonstration to Integrate Care for Dual Eligibles, Idaho decided not to participate in the Demonstration and instead expanded the covered benefits in its MMCP. MMCP is a voluntary program that permits dually eligible beneficiaries to enroll in a single managed care organization (MCO) that receives capitated payments to deliver both Medicaid and Medicare services to the individual. Currently, there are more than 650 participants enrolled in the one participating Medicare Advantage plan.⁵

State Medical Home Initiatives

State Health Care Innovation Plan (SHIP): Idaho is testing several medical home initiatives, with the aim of connecting every Idahoan to a primary care provider (PCP) and implementing payment reform methodologies. Idaho is one of 16 states to receive a State Innovation Model (SIM) Design award from the CMS's Center for Medicare and Medicaid Innovation to develop a SHIP. The planning process run from June 2013 to December 2013, and the funding--up to $3 million in total--supported the ongoing development of a blueprint to fully implement patient-centered medical care and "[move] the state towards an accountable, integrated and sustainable health care delivery and payment system."⁶ A range of stakeholders, including private payers, provider and health professional associations, the Governor's Office and state legislature, the Idaho Department of Insurance, the Idaho Health Data Exchange (IHDE) and the North Idaho Health Network provided input for the SHIP. The proposed plan addressed key system transformation needs, such as the resources required to improve communication and coordination across care settings; statewide implementation of the patient-centered medical home (PCMH) model; and methods for linking the local health care system through partnerships with hospitals, PCPs, and county health and social service agencies. The state plans to develop a Model Testing grant proposal, seeking $45 million to implement the SHIP over a five-year period.⁷

Safety Net Medical Home Initiative (SNMHI): An early step in the movement toward health system transformation was the state's participation in the SNMHI, a demonstration project jointly sponsored by the Commonwealth Fund, Qualis Health, and the MacColl Institute for Healthcare Innovation at the Group Health Research Institute. The project worked with safety net primary care clinics to help them transform into high-performing PCMHs.⁸ Idaho was one of five Regional Coordinating Centers (RCCs) chosen to participate in the project, which called for partnerships between safety net providers and community stakeholders to work together to improve the integration and coordination of primary care in safety net settings. Each RCC partnered with 12-15 safety net clinics in their state to provide practice coaching, peer-to-peer learning, and other forms of technical assistance on practice transformation, care coordination, quality improvement strategies, health information technology (HIT) use, and evaluating patient experience. The Idaho RCC also worked to create state health policy changes--including enhanced reimbursement for PCMH services--to support practice transformation and ensure that the PCMH model is sustainable and able to spread throughout the state. To this end, the RCC and the Idaho Primary Care Association worked with the Governor to establish the Idaho Medical Home Collaborative (IMHC).⁹

Idaho Medical Home Collaborative (IMHC): Created in 2010 by executive order 2010-10,¹⁰ the IMHC is a collaboration of Idaho Medicaid, primary care physicians, private health insurers, and health care organizations created to make recommendations to the governor on the development, promotion, and statewide implementation of a PCMH model of care. Idaho Medicaid, BlueCross of Idaho, Pacific Source, and Regence BlueShield of Idaho are working with 21 pilot practices (family, pediatric and multi-specialty) to provide additional payment to deliver care coordination. These payments vary by payer, and range from $15.50 to $42.00 per member per month (PMPM).

In order to participate, practices must implement the 11 critical elements of a PCMH identified by IMHC, as well as meet a set of minimum standards. These common minimum standards are identical to those outlined in the state's health home SPA. Participating pilot practices must attain 2011 National Committee for Quality Assurance (NCQA) PCMH Level 1 recognition by the end of the two-year pilot; use an electronic registry with reporting functionality; attend learning collaborative and training events; and meet data reporting requirements. In addition, practices must qualify for enhanced reimbursement from two or more payers to participate in the pilot, which requires practices to also meet any additional standards set by the insurers with whom they contract.

Federally Qualified Health Center (FQHC) Advanced Primary Care Practice (APCP) Demonstration: In October 2011, CMS announced that 500 FQHCs had been selected for the FQHC APCP demonstration project, including four sites in Idaho. The three-year demonstration is evaluating the impact of the PCMH on improving care and lowering costs for fee-for-service (FFS) Medicare beneficiaries--including the dually eligible--who receive care at FQHCs. Participating FQHCs receive a monthly care management fee of $6.00 for each eligible beneficiary attributed to their practice, in addition to usual payment for Medicare-covered services. The management fee is intended to help defray the cost of transformation into "a person-centered, coordinated, seamless primary care practice."¹¹ Participating FQHCs are expected to achieve Level 3 NCQA recognition by the end of the demonstration, help patients manage chronic conditions, as well as actively coordinate care for patients, with technical assistance from CMS and the Health Resources Services Administration.

Children's HealthCare Improvement Collaboration: In February 2010, Idaho received a five-year Children's Health Insurance Program Reauthorization Act (CHIPRA) quality demonstration grant, which it is implementing in partnership with the State of Utah. The demonstration has three main goals: support three practices in becoming medical homes, with a special focus on caring for children with special health care needs; develop a quality improvement network among child-serving providers, which will identify and pursue quality improvement goals such as care integration; and facilitate automatic measures reporting and electronic health information exchange (HIE).¹²

Implications for the Idaho Section 2703 Medicaid Health Homes Evaluation

Health homes build on the state's prior experience with PCMH-type initiatives, but are just one component of much broader systems-level changes that are underway throughout Idaho. Fundamental questions to be addressed in the evaluation include the role of the enhanced federal match in development of health homes, the extent to which the health home option represents a new kind of service rather than an expansion to additional populations or continuation of medical home and advanced primary care initiatives, and how health homes are being integrated into broader systemic reforms such as the shift into risk-based managed care and the activities undertaken through the SIM planning grant.

The integration of health homes with other related initiatives represents a challenge for isolating health home effects. Eligible providers include any willing Medicaid provider who can meet the state standards; levels of experience with--and infrastructure to support--integrated service delivery and coordination may vary substantially across providers. Understanding the structures and processes that are in place at baseline will be important in order to characterize the changes made as a consequence of becoming health homes. Participant and provider time in health homes and pre-existing initiatives also will be important factors in assessing implementation progress and for the effort to discern health home effects on outcomes.

Population Criteria and Provider Infrastructure

Idaho offers health home services to categorically needy beneficiaries who have a serious mental illness (SMI) or SED, have asthma and diabetes, or have either asthma or diabetes, and are at risk of developing another chronic condition. The identified risk factors include Body Mass Index (BMI) greater than 25, dyslipidemia, tobacco use, hypertension, or diseases of the respiratory system (see Table 1).

Any Healthy Connections provider who agrees to meet the requirements of becoming a health home is eligible to participate. The provider may be a physician, a clinical practice or clinical group practice, rural clinic, community health center, CMHC, home health agency, or any other entity or provider (including pediatricians, gynecologists, and obstetricians), but must be a Healthy Connections provider. The composition of the care team is not specified, but the health home provider will identify and lead the care coordination team, which may include other providers as necessary to meet the particular beneficiary's needs. Other provider types include, but are not limited to registered nurse, medical assistant, dietician, or behavioral health provider. The integration of behavioral health is a required element of the health home, and may be achieved through tele-health, co-location of behavioral health professionals within the clinic, or referral to a behavioral health professional.

Enrollment

Health home beneficiaries can self-refer or be referred by another provider to a health home. Health homes are responsible for generating a list of potentially eligible beneficiaries from their patient roster, which they must submit to the state for verification.¹³ Eligible beneficiaries will be auto-enrolled, with the right to opt-out. Following this initial enrollment process, eligible beneficiaries must be identified on an ongoing basis by the provider, who completes and submits an enrollment form on their behalf.

Service Definitions and Provider Standards

The state's health home service definitions are reproduced in Table 2 below. The health home provider is responsible for identifying and leading the care coordination team, but no individual team member is identified as the care coordinator. The SPA allows but does not appear to require a dedicated care coordinator to be part of the health home team, though the service definitions in Table 2 describe a clear role for a care coordinator in care management, coordination, and transitions. This provides some flexibility for smaller providers who may not be able to support a dedicated care coordinator on staff.

Aside from being enrolled in Healthy Connections, providers must achieve at least Level 1 NCQA certification by their second year of operation as a health home, and meet the 11 health home requirements detailed in the State Medicaid Director's Letter #10-024, "Health Homes for Enrollees with Chronic Conditions." To enroll, the designated provider must submit a Health Home Readiness Assessment and a signed agreement stipulating that all necessary systems are in place to provide health home services and report all required data.

Health homes are required to conduct two other assessments, the Patient-Centered Medical Home Assessment (PCMHA) and the Primary Care Development Corporation Assessment (PCDCA). The PCMHA, intended to identify strengths and weaknesses in the clinic, must be done within one month of enrollment and repeated every six months thereafter. The PCDCA must be completed within six months of enrollment, and is used to map the clinic's progress towards NCQA recognition. This assessment is conducted quarterly thereafter, until recognition is achieved.

Providers are required to report quality measures specified in the SPA (see the Quality Measures section) directly to the state Medicaid program through a web-based reporting platform, and must in addition submit a quarterly narrative progress report to the state, outlining their progress on goals, their challenges, and any technical assistance needs they have. They are also expected to conduct a baseline patient satisfaction survey, which will be repeated semi-annually. Providers may select their own, but are encouraged to use the Consumer Assessment of Healthcare Providers and Systems survey.

Use of Health Information Technology

Idaho has established initial and final HIT standards for participating providers. At the time of enrollment, providers must have a structured information system in place that will allow providers to populate a disease management database and to track and manage patients with chronic diseases. An EMR is not required, but providers are encouraged to have them, and to use HIT as feasible to create and manage care plans, monitor patient outcomes, follow-up on testing and referrals, and communicate with other providers.

The final standards require that providers use HIT in three broad processes: (1) systematic follow-up on tests, services, and referrals, which are incorporated into the patient's care plan; (2) population management and identification of care gaps; and (3) access and use of the IHDE, which is the state HIE. Providers must submit a plan to achieve the final HIT requirement to the state within 24 months of program initiation (December 31, 2014) in order to be approved as a health home provider, as well as have an electronic disease registry in line with NCQA standards. Providers are also expected to report on the selected quality measures using HIT.

Payment Structure

Payment for health home services is made on a PMPM rate, in addition to the existing FFS payments to participating providers. To build this rate, the state assumed that the health homes care team--consisting of a PCP, nurse, medical assistant, behavioral health professional, and clerical staff--would take on defined roles within the health home (see Table 3). In practice, these roles may be distributed as the provider deems necessary, but the state sees them as essential components in care management.

The payment rate was derived from the average salaries for each member of this assumed care team, and based on and estimate about the division of labor among them, along with the additional time that the care team will spend on care management. It was assumed that the PCP and clerical staff would spend 5% time; the registered nurse and medical assistant would each spend 35%, and the behavioral health professional would spend 20%. An extra $1.00 was added to the PMPM to cover the costs of NCQA recognition. The $15.50 PMPM is paid to the provider as long as the provider remains part of Healthy Connections and offers expanded clinic hours to patients (46 hours of clinic access per week is required). No monthly contact with the patient is required in order to receive the PMPM.

Quality Improvement Goals and Measures

Participating providers are required to establish a formal quality assessment and improvement strategy, drawn from models like Six Sigma, Lean, Plan-Do-Study-Act (PDSA) cycles and the Model for Improvement.¹⁴ Data reporting is done on a quarterly basis through the web-based Idaho Patient-Centered Medical Home Registry. The state has selected nine clinical quality measures (two measures each for diabetes, hypertension, and depression, and three for asthma), six preventive care measures, and two practice transformation measures. These measures are all from the National Quality Forum (NQF) and correspond to the six goals listed in the SPA, with the exception of the practice transformation measures. However, as the practice transformation measures are listed on the state website, they are included in Table 4.¹⁵ Providers must report on two clinical quality measures, two preventive quality measures, and the two practice transformation measures.

Evaluation Measures and Methods

The evaluation measures and methodology described in the SPA are reproduced in Table 5. In addition to the data collected through regular provider self-assessments and the web-based registry, the state will use annual claims data and a purely pre/post health enrollment analysis of health homes enrollees to assess quality outcomes and qualitative interviews to evaluate the implementation process. The state intends to use a pre/post comparison to evaluate hospital admissions, emergency department visits, and costs. The state will also contract with an outside entity to evaluate the IMHC and develop an evaluation framework that will allow the Collaborative to assess the progress of primary care medical homes involved in the IMHC on an ongoing basis.

FIGURE 1. Idaho Healthy Connections Regions
ALT TEXT for FIGURE 1, State Map of Idaho, broken down by region/county:    Region 1 counties: Boundary, Bonner, Kootenai, Benewah, Shoshone    Region 2 counties: Latah, Nez Perce, Clearwater, Lewis, Idaho    Region 3 counties: Adams, Washington, Payette, Gem, Canyon, Owyhee    Region 4 counties: Valley, Boise, Ada, Elmore    Region 5 counties: Camas, Blaine, Gooding, Lincoln, Jerome, Minidoka, Twin Falls, Cassia    Region 6 counties: Bingham, Power, Bannock, Caribou, Oneida, Franklin, Bear Lake.

 

TABLE 1. Target Population and Designated Providers--Idaho
SPA Approval (Effective Date)	November 21, 2012 (January 1, 2013)
Designated Provider(s)	Any Medicaid-enrolled entity or provider that: (a) has the systems and infrastructure in place to provide health home services; and (b) is a Healthy Connection provider.
Health Home Team Composition	The designated provider can include primary care physicians, mental health care providers, nurse practitioners, or physician assistants. The designated provider will operate in coordination with other health care professionals as deemed necessary, including (but not limited to) a nurse care coordinator, registered nurse, nutritionist, social worker, behavior health professional, or other traditional or nontraditional health care workers.
Target Population	Beneficiaries must have a SMI, 2 chronic conditions, or 1 chronic condition and the risk of developing another. Identified risk factors include BMI greater than 25, dyslipidemia, tobacco use, hypertension, or diseases of the respiratory system.
Qualifying Chronic Conditions	Mental health condition Asthma Diabetes

 

TABLE 2. Health Home Service Definitions--Idaho
Care Coordination	Patients will choose and be assigned to a designated provider to increase continuity, and to ensure individual responsibility for care coordination functions. A person-centered plan will be developed based on the needs and desires of the patient with at least the following elements: options for accessing care, information on care planning and care coordination, names of other primary care team members when applicable, and information on ways the patient participates in this care coordination, including home and community-based services. Care coordination functions can include but are not limited to: tracking of ordered tests and result notification, tracking referrals ordered by its clinicians, including referral status and whether consultation results have been communicated to patients and clinicians, demonstrating a process for consistently obtaining patient discharge summaries from the hospital and emergency departments, following up to obtain a specialist's reports, and direct collaboration or co-management of patients with mental health or substance abuse diagnoses. Under the direction of the designated provider, the care coordinator will help facilitate the patient's care needs. The coordinator should have knowledge and experience in the health care setting.
Comprehensive Care Management	A care plan will be developed based on the information obtained from a health risk assessment performed by the designated provider. The assessment will identify the enrollee's physical, behavioral and social service needs. Idaho anticipates family members and other support involved in the patient's care to be identified, included in the plan, and executed as requested by the patient. The care plan must also include outreach and activities that will support engaging the patient in their own care and promote continuity of care. The care plan will include periodic reassessment of the individual's needs, goals, and clearly identify the patient's progress towards meeting their goals. Changes in the care plan will be made based on changes in patient needs. The designated provider's comprehensive assessment and care plan may include, but are not limited to family/social/cultural characteristics, medical history, advanced care planning, communication needs, and a depression screening for adults and children. Designated providers will identify patients/families that might benefit from additional care management support. The care coordinator in each practice will work closely with the designated provider to develop reminders for needed tests (e.g., HbA1c), track medical services provided out of the primary care clinic office, and streamline communication and coordination of the comprehensive care needs of each patient. Comprehensive care management functions can include, but are not limited to: conducting pre-visit preparations, collaborating with the patient/family to develop an individual care plan (including treatment goals that are reviewed and updated at each relevant visit), providing the patient/family with a written care plan, assessing and addressing barriers when the patient has not met treatment goals, and giving the patient/family a clinical summary at each relevant visit. The care coordinator in each health home will track all referrals to ensure coordination of care between service providers. Designated providers will be responsible for obtaining and reviewing follow-up reports from medical and mental health specialists regarding services provided outside the health home.
Health Promotion	A designated provider will be required to actively seek to engage patients in their care by phone, letter, HIT and community outreach. Each of these outreach and engagement functions will include all aspects of comprehensive care management, care coordination, and referrals to community and social support services. All of the activities are built around the notion of relationships to care that address all of the clinical and nonclinical care needs of an individual including health promotion. The designated provider will support continuity of care and health promotion through the development of a treatment relationship with the individual and the health care professionals. The designated provider will promote evidence-based wellness and prevention by linking health home enrollees with resources for tobacco cessation, diabetes, asthma, hypertension, self- help recovery resources, and other services based on individual needs and preferences.
Comprehensive Transitional Care	Comprehensive transitional care will be provided to prevent enrollee's avoidable readmission after discharge from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing or treatment facility) and to ensure proper and timely follow-up care. To accomplish this, Idaho Medicaid requires the designated provider to develop and utilize a process with hospitals and residential/rehabilitation facilities in their region to provide the health home care coordinator prompt notification of an enrollee's admission and/or discharge to/from an emergency department, inpatient, or residential/rehabilitation setting. The designated provider will be required to develop and have a systematic follow-up protocol in place to assure timely access to follow-up care post-discharge that includes at a minimum receipt of a summary care record from the discharging entity, medication reconciliation, and a plan for timely scheduled appointments at recommended outpatient providers. The health home care coordinator will be an active participant in all phases of care transition.
Individual and Family Support Services	Peer supports, support groups, and self-care programs will be utilized by the designated provider to increase patients' and caregivers knowledge of the individual's disease(s), promote the enrollee's engagement and self-management capabilities, and help the enrollee improve adherence to and family support their prescribed treatment. The designated provider will ensure that communication and information shared with the patient/patient's family is understandable.
Referral to Community and Social Supports	The designated provider will identify available community-based resources and actively manage appropriate referrals, access to care, engagement with other community and social supports, coordinate services and follow-up post engagement with services. Designated providers will develop policies, procedures and accountabilities to support effective collaboration with community-based resources that clearly define the roles and responsibilities of the patients. They will also assist the participant in locating individual and family supports, including referral to community, social support, and recovery services.

 

TABLE 3. Assumed Division of Care Management Responsibilities--Idaho
Primary Care Provider	Consults with team psychiatrist and/or mental health professionals Consults with specialists as needed Assists coordination with external medical providers
Registered Nurse	Promotes health and education through facilitation Facilitates health education groups Participates in the initial treatment plan development for their health home enrollees Assists in developing treatment plan health care goals for individuals with chronic diseases   Consults with Community Support Staff about identified health conditions Assists in contacting medical providers and hospitals for admission/discharge Provides training on medical diseases, treatments and medications Tracks required assessments and screenings Monitors HIT tools and reports for treatment
Medical Assistant	Tracks referrals Provides training and technical assistance Conducts data management and reporting Manages scheduling for health home team and enrollees Conducts chart audits for compliance Reminds enrollees regarding keeping appointments, filling prescriptions, etc. Requests and sends medical records for care coordination
Behavioral Health Provider	Screens/evaluates individuals for mental health Conducts brief interventions for individuals with behavioral health problems Discusses impact of interventions and decides what to change Educates patients on mental health issues or concerns
Clerical Staff	Assists team with coordination of care Assists in booking appointments for enrollees Reminds enrollees regarding keeping appointments

 

TABLE 4. Goal-Based Quality Measures--Idaho
Improve Care for Diabetes Among Adults	Clinical outcome measures: NQF #59: HbA1c poor control (>9.0) Quality of care measures : NQF #57: Annual HbA1c testing
Improve Care for Patients with Heart Disease	Clinical outcome measures : NQF #18: Controlled high blood pressure Quality of care measures : NQF #13: Blood pressure measurement
Improve Outcomes for People with Depression	Quality of care measures : NQF #105: Antidepressant medication management NQF #418: Screening for clinic/practice depression
Improve Care for Asthma Among Adults and Children	Quality of care measures : NQF #1: Asthma assessment NQF #47: Asthma pharmacologic therapy NQF #25: Management for people with asthma
Increase Preventive Care for Adults	Quality of care measures : NQF #28a: Tobacco use assessment NQF #28b: Tobacco cessation intervention NQF #421: Adult weight screening and follow-up
Increase Preventive Care for Children	Quality of care measures : NQF #24: Weight assessment counseling for children and adolescents ages 3-17 NQF #1516: Percentage of members 3-6 years of age who received 1 or more well-child visits with a PCP during the measurement year NQF #1507: Annual risky behavior assessment or counseling from age 12-18
Practice Transformation Measures (not listed in the SPA)
Third next available appointment Health home participant visits that occur with the selected provider

 

TABLE 5. Evaluation Methodology--Idaho
Hospital Admission Rates	Idaho will compare admission rates pre/post health home in addition to patient's admission rates outside of a health home. Idaho will also stratify admission rates for each diagnosis (e.g., mental health condition, asthma, diabetes, and hypertension).
Chronic Disease Management	Idaho will use clinical quality data to compare pre/post health home to evaluate improvement in quality of clinical care. Idaho will also use standardized assessment tools and qualitative interviews with health home administrative staff and providers to evaluate the status of implementation related to chronic disease management processes.
Coordination of Care for Individuals with Chronic Conditions	Idaho will use standardized assessment tools and qualitative interviews with health home administrative staff and providers to evaluate the status of implementation related to care coordination processes and HIT tools.
Assessment of Program Implementation	Idaho will use standardized assessment tools and qualitative interviews with health home administrative staff and providers to monitor the progress and status of program implementation related to the six components of the health home as described in Section 2703 of the ACA.
Processes and Lessons Learned	Learning Collaboratives will be developed with designated providers to identify implementation challenges as well as potential solutions. Idaho will monitor, comment, and make recommendations on implementation strategies that are working as well as those that are not based on the PDSA model. The group will use the health home patient eligibility criteria, as well as the provider qualification criteria (as articulated by the NCQA and as adapted by Idaho Medicaid), as guides in assessing program processes and outcome success. Idaho will use information gathered through assessments of program implementation as well as ongoing quality monitoring using administrative data to review program successes and areas for improvement.
Assessment of Quality Improvements and Clinical Outcomes	Idaho has identified a list of quality and outcome measures that will be derived from Medicaid claims and chart review. The quality measures are indicators of chronic disease management including processes and outcomes. Ongoing assessments of these quality measures will be conducted to monitor improvement in processes and outcomes.
Estimates of Cost Savings	The state will annually perform an assessment of cost savings using a pre/post-period comparison.

 

APPENDIX: Pre-Existing Initiatives in Idaho
	Medicaid Behavioral Health Managed Care2, 3	Demonstration to Integrate Care for the Dual Eligible4	SNMHI	IMHC	Children's HealthCare Improvement Collaboration12, 16
Timeline	3-year contract awarded to Optum in 2013; possible extension to 2020	Effective January 2014, with phased enrollment from March-July 2014	May 2008-May 2013	Created by Executive Order in October 2010. PMPM to participating practices initiated January 1, 2013	2010-2015
Geographic Area	Statewide	Statewide	Statewide	Statewide	Statewide
Sponsors	Idaho Department of Health and Welfare (IDHW)	CMS, IDHW	Idaho Primary Care Association, The Commonwealth Fund, Qualis Health, and the MacColl Center for Health Care Innovation at the Group Health Research Institute	Idaho Medicaid, BlueCross of Idaho, Regence BlueShield of Idaho, and PacificSource	CMS, IDHW, and Utah Department of Health
Scope	Optum will administer outpatient mental health, substance abuse, and case management services for all beneficiaries with a mental health diagnosis	17,735 dual eligible beneficiaries in Idaho	No data	21 Participating organizations contracted with a minimum of 2 payers, serving patients with chronic disease(s)	3 child-serving practices participating in a demonstration 8 practices participating in a Quality Improvement learning collaborative
Goals	Reduce hospitalization and duplication of services Improve health outcomes for people with behavioral health needs	Ensure beneficiaries have full, streamlined access to needed services Improve quality and continuity of care for duals Eliminate regulatory conflicts and cost-shifting between Medicaid and Medicare	Develop and demonstrate a replicable and sustainable model for medical home implementation in primary care safety net clinics Through technical assistance, peer-to-peer learning, and practice transformation coaching, assist primary care safety net sites become high-performing PCMHs	Improve health outcomes for chronic disease Improve patient, clinician, staff satisfaction Improve clinic flow/efficiency Provide comprehensive and coordinated approach to patient care Enhance provider recruitment and retention Prepare for health reform	Improve the child HIT infrastructure in the state Support provider transformation into medical homes Develop a statewide network of providers engaged in quality improvement activities
Payment Approach	Risk-based capitation payment, with a 10% withhold based on hospital utilization targets, and a shared savings component	Risk-based capitation payment, with a percentage withhold based on quality outcomes and savings shared between Medicare and Medicaid	No information found	PMPM for care coordination. Rate ranges from $15.50 to $42.00	No information found
Technical Assistance (TA)	No information found	No information found	Technical assistance in the form of: Creation of Statewide Collaborative Learning Model Practice Transformation Coaching Peer-to-Peer learning	Technical assistance in the form of collaborative learning, face-to-face practice coaching, and regular webinars	Practices will participate in learning collaboratives that will assist them in quality improvement activities
HIT Use	No information found	Contracted MCOs will use technology to track and coordinate care, avoid duplication, and catch medication errors	Implementation of a Quality Improvement Strategy by participating pilot practices	Implementation of a patient registry NCQA Level 1 certification by end of 2 year pilot period, including EMR implementation	Idaho is: Testing software to extract and report quality measures from EMRs Contributing to an on-line portal that provides resources on CSHCN Connecting the IHDE to Utah's HIE
Evaluation Methods	No information found	No information found	No information found	Will contract with an evaluator to assess the impact and effectiveness of the Collaborative	The National CHIPRA Quality Demonstration Evaluation will collect quantitative and qualitative data to evaluate the impact of all demonstration projects, including Idaho

Endnotes

1. Idaho Department of Health and Welfare. "Facts Figures and Trends." Available from: http://healthandwelfare.idaho.gov/Portals/0/AboutUs/Publications/FFT2012-2013LR.pdf.

2. Idaho Department of Health and Welfare. "Idaho Behavioral Health Plan (IBHP) Contract Awarded." Available from: http://www.healthandwelfare.idaho.gov/Medical/Medicaid/MedicaidBehavioralHealthManagedCare/tabid/1861/Default.aspx. Accessed July 3, 2013.

3. Personal communication with Idaho Department of Health and Welfare staff. June 24, 2013.

4. Idaho Department of Health and Welfare. "Idaho Division of Medicaid Demonstration Proposal to Integrate Care for Dual Eligibles." May 2012. Available from: http://www.healthandwelfare.idaho.gov/Portals/0/Medical/Managed%20Care/Proposal%20Submission%20to%20CMS.pdf. Accessed June 29, 2013.

5. Idaho Department of Health and Welfare. "Integrating Care for Dual Eligibles: Medicare-Medicaid Coordinated Plan (MMCP) Update." February 26, 2014. Available from: http://healthandwelfare.idaho.gov/Medical/Medicaid/LongTermCareManagedCare/tabid/1910/Default.aspx.

6. Center for Medicare and Medicaid Innovation. "State Innovation Models Initiative: Model Design Awards." Available from: http://innovation.cms.gov/initiatives/state-innovations-model-design/. Accessed June 29, 2013.

7. Idaho Department of Health and Welfare. "State Healthcare Innovation Plan (SHIP)." Available from: http://healthandwelfare.idaho.gov/Medical/StateHealthcareInnovationPlan/tabid/2282/Default.aspx/.

8. Safety Net Medical Home Initiative. Available from: http://www.safetynetmedicalhome.org/. Accessed June 29, 2013.

9. Idaho Medical Home Collaborative. Available from: http://imhc.idaho.gov/default.aspx. Accessed June 29, 2013.

10. The of the Governor. "Executive Order No. 2010-10: Establishing an Idaho Medical Home Collaborative to Implement a Patient-Centered Medical Home Model of Care (Collaborative)." Executive Department of the State of Idaho. September 2010. Available from: http://imhc.idaho.gov/Docs/Executive_Order_2010_10.pdf. Accessed July 1, 2013.

11. Center for Medicare and Medicaid Innovation. "Federally Qualified Health Center Demonstration Fact Sheet." Available from: http://innovation.cms.gov/initiatives/FQHCs/FQHC-Fact-Sheet.html. Accessed July 1, 2013.

12. Agency for Healthcare Research and Quality. "State at a Glance: Idaho." National Evaluation of the CHIPRA Quality Demonstration Grant Program. Available from: http://www.ahrq.gov/policymakers/chipra/demoeval/demostates/id.html#objectives. Accessed July 1, 2013.

13. See http://www.healthandwelfare.idaho.gov/Portals/0/Medical/MedicaidCHIP/ParticipantEnrollement.pdf.

14. Idaho Department of Health and Welfare. "Quality Improvement." Health Home Program information. Available from: http://www.healthandwelfare.idaho.gov/Portals/0/Medical/MedicaidCHIP/QualityImprovement.pdf. Accessed July 1, 2013.

15. Idaho Department of Health and Welfare. "Data Reporting." Health Home Program information. Available from: http://www.healthandwelfare.idaho.gov/Portals/0/Medical/MedicaidCHIP/DataReporting.pdf.

16. Idaho Department of Health and Welfare. "Children's Healthcare Improvement Collaboration." Available from: http://www.healthandwelfare.idaho.gov/Medical/Medicaid/ChildrensHealthcareImprovementCollaboration/tabid/1894/Default.aspx. Accessed July 3, 2013.

 

 

Iowa's Health Home Program at a Glance
Health Home Eligibility Criteria	2 chronic conditions, 1 chronic condition and at risk of another
Qualifying Conditions	Mental health condition Substance use disorder Asthma Diabetes Heart disease Body mass index (BMI) over 25 Hypertension BMI over 85th percentile for pediatrics
Enrollment*	4,396
Designated Providers	Any Medicaid-enrolled provider that meets health home standards
Administrative/ Service Framework	The state offers health home services statewide. Providers include primary care practices, community mental health centers, federally qualified health centers, and rural health centers.
Required Care Team Members	Designated practitioner Dedicated care coordinator Health coach Clinic support staff
Payment System	Per member per month (PMPM) care management fee, plus lump-sum performance-based incentive
Payment Level	PMPM fee varies by patient acuity tiers:    Tier 1--$12.80    Tier 2--$25.60    Tier 3--$51.21    Tier 4--$76.81 Incentive pay based on achievement against 16 measures.
Health Information Technology (HIT) Requirements	Health home providers are required to implement an electronic health record, demonstrate compliance with federal meaningful use requirements, and employ a population management tool. Providers are also encouraged to use technology where possible to enhance patient access and self-management. Additionally, providers are also expected to connect to and participate in the statewide Health Information Network.
* January 2014 data provided to the Centers for Medicare and Medicaid Services' (CMS') Health Home Information Resource Center.

Introduction

Iowa's Section 2703 Health Home State Plan Amendment (SPA) was approved on June 7, 2012, with an effective date of July 1, 2012. Iowa Medicaid Enterprise (IME), which manages the Medicaid program within the state's Department of Human Services, is responsible for implementation of the state's Medicaid health homes. The state is targeting beneficiaries with two or more chronic conditions, or individuals with one chronic condition and at risk of developing another (see Table 1). Qualifying conditions include mental health conditions and substance abuse disorders, asthma, diabetes, heart disease, high body mass index (BMI), and hypertension. Iowa is using the U.S. Preventive Services Task Force guidelines to inform its definition of "at-risk," which includes genetic predisposition, a diagnosis with established co-morbidities that include one of the qualifying conditions, and environmental exposures known to cause those conditions.

The state offers health home services statewide. As of January 2014, more than 4,300 Medicaid beneficiaries were enrolled in the health home program. Providers include primary care practices, community mental health centers (CMHCs), federally qualified health centers (FQHCs), and rural health centers (RHCs). To be considered a health home, providers must attest to meeting state standards and, in cases where a practice includes multiple sites, share policies, procedures, and electronic systems across locations. The state is also developing a second SPA focusing on adults and children with serious and persistent mental illness.

Implementation Context

Iowa Medicaid includes both a categorically and medically needy program, and covers nearly half a million people, 93,000 of whom are estimated to be health home-eligible.¹ The state operates both fee-for-service and managed care programs. Since 2012, Meridian Health Plan has served as the state's only health maintenance organization, and enrolled approximately 41,000 beneficiaries in 23 counties.² Meridian covers only physical health services, as the state carves out behavioral health services. These are managed under a contract with Magellan Health Services.

The state is pursuing a number of simultaneous reforms to its physical, behavioral, and long-term care systems, several of which are relevant to the health home population. Three initiatives in particular have directly informed the development of health homes: the IowaCare Medical Home Project, the Magellan Integrated Health Homes pilot, and the Statewide Mental Health System Redesign.³

The IowaCare Medical Home Project began in 2005 under a Section 1115 waiver.⁴ The goals of the demonstration are to expand access to health care coverage, improve care quality through the medical home model, and provide financial stability for safety net hospitals with high levels of uncompensated care.⁵ IowaCare enrollees are assigned to a participating medical home, and receive inpatient and outpatient hospital services, physician and nurse practitioner services, some prescription drug and dental services, preventive medical exams, and smoking cessation services.⁶

The demonstration targets two populations:

• Single adults and childless couples between the ages 9-64, who are living at or below 200% of the Federal Poverty Level (FPL) and who are either uninsured or whose insurance does not cover their medical condition.

• Pregnant women with income at or below 300% FPL whose medical expenses--or those of their family--reduce their available income to 200% of the FPL.

The initial phase of the demonstration included two FQHC networks located in Iowa City and Des Moines. By 2010, 39,000 individuals had been enrolled. IME amended its waiver in 2010 to expand IowaCare services into a broader network of FQHCs throughout the state, bringing the total number of participating networks to eight. As of June 2012, IowaCare was providing health care services to over 60,000 Iowans.⁷ IME will phase out IowaCare when the Affordable Care Act's Medicaid expansion goes into effect in 2014.

Another building block in the state's health home program was a pilot project run by Magellan Behavioral Care of Iowa, the state's behavioral health managed care provider. As part of its contract with the state, Magellan allocates a portion of its annual capitation payment to fund innovative pilots through its Community Reinvestment Fund.^{8, 9} From June 2011 through December 2012, Magellan piloted an early form of health homes which targeted individuals with major depression, bipolar disorder, and schizophrenia who were receiving care from one of five participating behavioral health providers. Each of these behavioral health providers partnered with a local FQHC to provide or coordinate primary care services. The care team included a care coordinator, peer support specialist, and a primary care nurse case manager. Nurse case managers were embedded at each site to provide consults to behavioral health staff as well as direct primary care services.

In addition to implementing these two projects, Iowa is in the process of restructuring the funding and management of its mental health and disability services system. The ultimate goals of the system redesign are to expand statewide access to behavioral health services and address the funding imbalances that often underpin access problems. The state legislature passed a bill in 2012 (Senate File 2315) requiring the current county-based system to be reorganized into a regional system by 2014, and created a list of core services to be offered in every region. These core services include treatment, crisis response, community and social support services, and service coordination through case management and health homes. The state also defined baseline requirements related to the administrative, financing, and service structures that each region must establish. The details of these regional structures and processes are still under development, but each region's service management plan must include provisions to ensure individuals with co-occurring conditions can access the services they need.¹⁰

The state is aligning this redesign with a federal Balancing Incentive Payment Program (BIPP) demonstration, which targets the long-term services and supports (LTSS) system.¹¹ This grant provides an increased federal match of 2% for noninstitutional community-based services. The enhanced match will support: (1) the establishment a single-entry point (SEP) system of referral to LTSS; (2) the development of a standardized assessment tool to determine both eligibility for services, as well as individual service needs; and (3) case management services to coordinate community-based services. As part of the mental health system redesign, regional systems will establish agreements with local entities that will act as SEP agencies. In addition to providing information, assessments and referrals, these agencies will also provide follow-up to referred services, including health homes.¹¹

Health homes will play a role in Iowa's State Innovations Model Design grant, awarded in February 2013 by the Center for Medicare and Medicaid Innovation (CMMI). The grant provided support for the development of a State Health Care Innovation Plan, which involves developing integrated care delivery models and strategies for payment realignment.¹² Under the current proposal, Iowa will develop a plan to implement an accountable care organization (ACO) structure similar to that developed by Wellmark BlueCross BlueShield of Iowa, and will expand this model to include LTSS and behavioral health services. Eventually, the state plans to serve all Medicaid and Children's Health Insurance Program (CHIP) beneficiaries through these ACO structures. Health homes will be among the various participating providers.¹³ The details of how health home payments and quality measures will align with those developed for the new ACO structures are still under discussion.

Implications for the Iowa Section 2703 Medicaid Health Homes Evaluation

Health homes build on the state's prior experience with medical or health home-type initiatives, but are just one component of much broader systems-level changes underway. Fundamental questions to be addressed in the evaluation are the role of the enhanced federal match for health home services, the extent to which the health home demonstration represents a new kind of service rather than an expansion or continuation of existing services, and how health homes are being integrated into broader systemic reforms such as the mental health system redesign and the state innovations grant planning. The integration of health homes with several related initiatives in the broader system reform presents a challenge for isolating health home effects.

Eligible providers range from primary care clinics to RHCs and FQHCs, to CMHCs and may have differing levels of experience with--and infrastructure to support--integrated service delivery and coordination. Providers that participated in the IowaCare demonstration or the behavioral health pilot may be farther along than other providers enrolling in health homes. It will be important to understand the structures and processes that are in place at baseline and to characterize the changes made as a consequence of becoming health homes. Some of the structures and processes that will underpin health homes, such as a statewide health information network (HIN), are not yet in place, and the state may make adjustments to aspects of the program based on feedback from providers and periodic internal review. It also will be necessary to take into account both the participants' and providers' time in program in assessing implementation progress and outcomes.

Population Criteria and Provider Infrastructure

Iowa offers health home services to categorically and medically needy beneficiaries with either two or more chronic conditions, or one chronic condition and the risk of developing another. Qualifying chronic conditions include a mental health condition, a substance use disorder, asthma, diabetes, heart disease, BMI over 25 (or BMI over 85th percentile for children), and hypertension (see Table 1). The definition of at-risk is based on guidelines from the U.S. Preventive Services Task Force, and includes a diagnosed condition with established chronic co-morbidities, a documented family history of a heritable condition included among the state's qualifying conditions, or environmental exposures known to contribute to those conditions.

Health home practices may include, but are not limited to: primary care practices, CMHCs, FQHCs, and RHCs. Designated practices may have multiple sites, provided that these sites are identified as members of a single organization with shared policies and practices and are supported by a common information technology infrastructure. In the original SPA, the state required that health home-eligible beneficiaries receiving targeted case management (TCM), case management, or community-based waiver services be disenrolled and shifted into a health home practice. However, in July 2013 the state amended the SPA to require that health home providers collaborate at least quarterly with the case managers assigned to their health home patients.

Enrollment

The health home enrollment process is initiated by providers, who are encouraged to identify and enroll eligible beneficiaries from their existing patient panel. The state may also identify beneficiaries from claims and notify a health home of their eligibility, but this is intended only to assist providers in identifying and prioritizing patients for enrollment. The provider is still responsible for assessing and enrolling those patients. The state adopted this enrollment strategy in order to allow providers to implement the health homes program at their own pace, but may pursue an auto-enrollment strategy at a later date.

Service Definitions and Provider Standards

Iowa has laid out seven key provider standards to which Designated Providers must adhere in order to operate as a health home practice. These include:

1. Recognition/certification.
2. Personal provider for each patient.
3. Continuity of care document (CCD).
4. Whole-person orientation.
5. Coordinated and integrated care.
6. Emphasis on quality and safety.
7. Enhanced access.

The state definitions for each of these seven attributes are presented in Table 2. To qualify as a health home, providers must attest to meeting these standards by signing an agreement with the state. Providers must complete and submit the TranferMED Patient-Centered Medical Home (PCMH) self-assessment at the time of their enrollment, and are expected to achieve the National Committee for Quality Assurance (NCQA) recognition (level unspecified), or another national recognition, within the first year of operation as a health home. Exceptions to these requirements are allowed in cases where a provider has submitted an application and the ruling is still pending. However, if a provider has not achieved the required recognition/certification within two years of operation, the state may terminate that health home's status. The health homes agreement also stipulates that the state may revoke health home status for any reason with 30 days' notice.

Health home service definitions are reproduced in Table 3. Primary responsibility for each service is assigned to a particular provider. With the support of a care coordinator and a health coach, the designated practitioner is charged with care management and shares responsibility for health promotion and transitional care needs of health homes beneficiaries. Care coordination and referral to community and social support services are led by the care coordinator, while the health coach is the lead provider for individual and family support services.

Use of Health Information Technology

Health home providers are required to implement an electronic health record (EHR), that includes referral tracking capabilities, and have in place a plan for complying with federal meaningful use requirements. Providers also must employ a population management tool, such as a patient registry, and are encouraged to use email, text messaging, patient web-portals, and other technology where possible to enhance patient access and self-management.

Providers are also expected to connect to and participate in the statewide HIN, which was implemented in 2012. The state is working to make the HIN available to health home providers as part of a joint effort between the health home team and the state health information technology (HIT) team. The HIT team is responsible for monitoring the rate of adoption and meaningful use of EHRs within the Medicaid program, and for monitoring and reporting on the progress of HIN creation.

Payment Structure

Base Payment

Payment for health homes services is made on a per member per month (PMPM) basis, and is comprised of four tiers, with each tier reflecting increasing levels of patient risk (see Table 4).

The rate is based on estimates of provider time required for care coordination, and on the assumption that this work would be distributed among care team members paid at different rates. The number of patient conditions serves as a proxy for the time required to coordinate patient care, and is expressed in minutes per month in Table 4.

All qualifying beneficiaries are automatically considered to be Tier 1. At the time of their enrollment, the health home uses the state's Patient Tier Assignment Tool to assess each patient's chronic conditions and determine if they qualify for a higher tier. The health home then requests member enrollment through the Iowa Medicaid Portal Access application, after which they may begin submitting monthly claims for Patient Management Payments.

Payment is contingent on several criteria outlined in the SPA. Patients must meet health home eligibility requirements, must have full Medicaid benefits at the time of payment, and must be fully enrolled with the designated provider. The health home must be in good standing with IME and, at a minimum, provide a health home service as defined by the SPA or conduct care management monitoring to identify any treatment gaps that may be addressed through a health home service. The provider also must document these activities in the patient's EHR.

Pay-for-Performance (P4P)

In addition to the above PMPM fee schedule, Iowa has incorporated a P4P component into their health home program. Incentive payments are based on achievement of selected quality and performance benchmarks that health homes will report annually to the state. These 16 measures are separated into five categories: preventive measures, diabetes/asthma measures, hypertension/systemic antimicrobial measures, mental health measures, and total cost of care.

Each category of measure is weighted based on importance and attainability, which is expressed as a percentage of the total incentive payment. Within these categories, the health home must meet the minimum established benchmark for each measure, otherwise the category is valued at zero (see Table 5). The maximum incentive payment (MIP) that a health home can attain is 20% of the total annual PMPM payments made to that health home. Payment will be distributed on a lump-sum basis within three months of the end of the performance year.

Payments were scheduled to begin in the second year of Iowa's health home program (starting July 2013), but due to ongoing HIT implementation challenges, it is unclear whether the incentive payment program will be operational within the two-year timeframe of the health homes program.

Quality Improvement Goals and Measures

Iowa has identified two key goals for the health homes program:

1. Change patient behavior to increase the use of preventative services, and increase awareness of appropriate chronic condition management.

2. Transform provider practices by the adoption of the PCMH model to improve the population health of members.

The selected quality measures are listed in Table 6. They are based on both National Quality Forum (NQF) and Children's Health Insurance Plan Reauthorization Act (CHIPRA) measures, although the exact specification for some these measures are not detailed in the SPA. Some measures overlap with those selected for quality incentive payment benchmarks, and as with the P4P program, all measures will be generated from claims data collected through the state health information exchange.

Evaluation Measures and Methods

The evaluation measures and methodology described in the SPA are reproduced in Table 7, with the exception of avoidable hospital readmission and cost savings, which are discussed in greater detail below. Most of the data collected for evaluation purposes will come from Medicaid claims. As part of the assessment, the state will also solicit provider and patient input on implementation, quality improvement, clinical outcomes, and lessons learned. Clinical data will also be collected as part of the state's evaluation of chronic disease management and care coordination efforts. The SPA does not specify how this clinical data will be collected.

Iowa tracks avoidable hospital readmissions through a system that records events rather than individual beneficiaries; after the first admission, readmission events are calculated for periods of seven, 14, and 30 days afterward.

The University of Iowa Public Policy Center will determine overall cost savings through two analyses. One analysis will compare the PMPM costs for health home enrollees in the year prior to their enrollment in the program to those for the first six, 12, and 18 months after joining. Costs will be tracked and compared every six months. Researchers also plan to match each enrollee who has been in the health home for one year with one who has been enrolled in Medicaid, but not a health home. They will control for age, gender, and condition in the match, and adjust the regression using propensity scoring to reduce bias.

The state will also compare hospital admissions and emergency department visits for these two groups, using Healthcare Effectiveness Data and Information Set (HEDIS) specifications. Skilled nursing facility admissions will be assessed individually to determine the reason for admission and the associated costs.

TABLE 1. Target Population and Designated Providers--Iowa
SPA Approval (Effective Date)	June 7, 2012 (July 1, 2012)
Designated Provider(s)	Medicaid-enrolled practices adhering to the Health Home Provider Standards including, but not limited to:   Physician clinic CMHCs FQHCs RHCs
Health Home Team Composition	Required: Designated practitioner Dedicated care coordinator Health coach Clinic support staff
Target Population	Beneficiaries must have 2 chronic conditions or 1 chronic condition with the risk of developing another
Qualifying Chronic Conditions	Mental health condition Substance use disorder Asthma Diabetes Heart disease BMI over 25 Hypertension BMI over 85th percentile for pediatric population

 

TABLE 2. Health Home Provider Standards--Iowa
Recognition/ Certification	Comply with all federal and state laws in regard to recognition and certification. Comply with the standards laid out by the Iowa Department of Public Health, when they are finalized (these will likely include NCQA recognition or another national accreditation). In the interim, providers must: Complete the TransforMED self-assessment and submit this to the state at the time of program enrollment. Achieve NCQA or other national accreditation within the first year of operation.
Personal Provider for Each Patient	Ensure that every patient has an ongoing relationship with a personal provider, physician, nurse practitioner, or physician assistant who serves as the first point of contact and provides continuous, comprehensive care.
Continuity of Care Document (CCD)	The provider will keep an updated CCD for all eligible patients, detailing important aspects medical needs, treatment plan, and medication list.
Whole Person Orientation	Provide or arrange for care through other qualified professionals for acute care, chronic care, preventive services, long-term care, and end-of-life care.
Coordinated and Integrated Care	Assign a care coordinator to each patient to assist with medication adherence, appointments, referral scheduling and follow-ups, understanding health insurance coverage, reminders, transition of care, wellness education, health support and/or lifestyle modification, and behavior changes. Communicate with patients and families/caregivers about care decisions in a culturally appropriate manner. Arrange, track, and evaluate evidence-based preventive services. Either directly provide or coordinate mental/behavioral health, oral health, long-term care, chronic disease management, recovery services and social health services, patient self-management support, transitional care. Assess the social, education, housing, transportation, and vocational needs that may inhibit patient self-management. Maintain systems and protocols for tracking referrals.
Emphasis on Quality and Safety	Demonstrate use of clinical decision support within the practice workflow. Demonstrate use of a patient registry, as well as the ability to evaluate results, implement interventions, and improve outcomes. Implement an EHR and establish a plan to comply with federal meaningful use requirements. Participate in the statewide HIN. Implement or support an evidence-based diabetes disease management program that includes diabetes clinical outcomes. Implement subsequent disease management programs required by the state following the first year of enrollment. Implement a formal screening tool to assess mental health, substance abuse and physical health care needs. Report annually on outcomes and process measures.
Enhanced Access	Provide for 24/7 access to the care team that includes, but is not limited to, a phone triage system with appropriate scheduling during and after regular business hours. Monitor access outcomes such as the average third next available appointment and same-day scheduling availability. Use of email, text messaging, patient web-portals and other technology as available to the practice to communicate with patients.

 

TABLE 3. Health Home Service Definitions--Iowa
Care Coordination	Assisting members with medication adherence, appointments, referral scheduling, understanding health insurance coverage, reminders, transition of care, wellness education, health support and/or lifestyle modification, and behavior changes. Coordinate, direct, and ensure results are communicated back to the health home.
Comprehensive Care Management	The responsibility of the Designated Practitioner role within the health home and must include at a minimum: Providing for all the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals. Developing and maintaining a CCD for all patients. Implementing a formal screening tool to assess behavioral health treatment needs along with physical health care needs.
Health Promotion	Coordinating or providing behavior modification interventions aimed at supporting health management, improving disease outcomes, disease prevention, safety and an overall healthy lifestyle. Use of Clinical Decision Support within the practice workflow. Implementation of a formal Diabetes Disease Management Program. Health Promotion services are the responsibility of the Health Coach and Designated Practitioner.
Comprehensive Transitional Care	Includes the services required for ongoing care coordination. For all patient transitions, a health home shall ensure the following: Receipt of updated information through a CCD. Receipt of information needed to update the patients care plan that includes short-term transitional care coordination needs and long-term care coordination needs resulting from the transition. The Designated Provider shall establish personal contact with the patient regarding all needed follow-up after the transition. Comprehensive transitional care services are the responsibility of the Dedicated Care Coordinator and designated practitioner.
Individual and Family Support Services	Communication with patient, family, and caregivers in a culturally appropriate manner for the purposes of assessment of care decisions, including the identification of authorized representatives. This is the responsibility of the Health Coach.
Referral to Community and Social Supports	Includes coordinating or providing recovery services and social health services available in the community, such as understanding eligibility for various health care programs, disability benefits, and identifying housing programs. This is the responsibility of the Dedicated Care Coordinator.

 

TABLE 4. Health Home Payment Tiers--Iowa
Tier	Minutes Per Month	Patient Acuity	Rate
1	15	1-3 chronic conditions	$12.80
2	30	4-6 chronic conditions	$25.60
3	60	7-9 chronic conditions	$51.21
4	90	10+ chronic conditions	$76.81

 

TABLE 5. Health Home Quality Incentive Payment Formula--Iowa
Category	Measures (reported to the state HIN)	Percent of the MIP
1. Preventive (best 2 out of 3 measures are counted)	Immunization screening for children by age 2 Influenza vaccination, ages 6 months+ Documentation of BMI and appropriate follow-up when needed	35%
2. Disease Option 1 (health home picks most applicable condition for their population)	Diabetes management: Annual dilated eye exam Annual microalbumin Annual foot exam HbA1c levels 8 LDL levels 100 Asthma management: Asthma-related emergency department visits Use of appropriate medications for people with asthma Percentage of asthma patients age 5-40 who have been seen	30%
3. Disease option 2 (health home picks most applicable measure for their population)	Hypertension: Proportion of patients with blood pressure 140/90 Antibiotic use: Otitis Media--Avoidance of inappropriate use of systemic antimicrobials	20%
4. Mental Health (health home picks most applicable measure for their population)	Percentage of patients age 6+ hospitalized for a mental health condition who had an outpatient visit, intensive outpatient encounter, or partial hospitalization with mental health practitioner within 7 days of discharge Clinical depression screening	15%
5. Total Cost of Care (reporting only)	Total cost of care per member per year	0%

 

TABLE 6. Goal-Based Quality Measures--Iowa
Change Patient Behavior to Increase the Use of Preventative Services, and Increase Awareness of Appropriate Chronic Condition Management	Increase use of preventive services: NQF #38: Childhood immunization status Comprehensive diabetes care: NQF #55: Annual dilated eye exam NQF #62: Annual micro albumin NQF #56: Annual foot exam NQF #575: Proportion with HbA1c 8.0 NQF #64: Proportion with LDL 100
Transform Provider Practices by the Adoption of the PCMH Model to Improve the Population Health of Members	CHIPRA #10: Well-child visits in the first 15 months of life CHIPRA #21: Follow-up care for children prescribed ADD medication CHIPRA #13: Annual dental visit NQF #31: Breast cancer screening NQF #32: Cervical cancer screening NQF #41: Percent of patients aged 6 months and older who received an influenza immunization

 

TABLE 7. Evaluation Methodology--Iowa
Hospital Admission Rates	Medicaid claims data will be assimilated to determine hospital admission rates in categories established through NCQA HEDIS specifications. Rates and costs will be compared for the pre/post-program period for enrollees in a health home and those who are not enrolled.
Chronic Disease Management	Clinical data received from providers on health home enrollees.
Coordination of Care for Individuals with Chronic Conditions	Clinical data received from providers on health home enrollees.
Assessment of Program Implementation	This will consist of a review of program administrative costs, reported patient outcomes, and overall program cost savings and patient surveys. A formative evaluation that details the process of implementation and the challenges experienced and adaptations that were made will be undertaken.
Processes and Lessons Learned	An evaluation that includes provider and patient input on the health home program will inform the state on ways to improve the process. As more successful health homes are identified via clinical data and claims data, implementation guidelines and suggestions will be documented and trained to further promote success statewide.
Assessment of Quality Improvements and Clinical Outcomes	An evaluation that includes provider and patient input on the program. An evaluation of the clinical data shared by providers will allow the state to adjust the clinical outcome measures to ensure the optimal results and continued improvement.
Estimates of Cost Savings	Population: There are two populations of interest--those who enter Medicaid and the health home at the same time and those who have been in Medicaid for a period of time and then enter the health home. Cost savings will be estimated for both groups. Methodology: Regression analyses will be utilized to determine the expected PMPM for enrollees in the health home assuming the health home were not in place. Limitations: There may be a propensity for enrollees who have the most to gain from the health home to enroll earlier than those with less to gain. Additionally, dual eligibles may be difficult to include.

 

APPENDIX: Pre-Existing Initiatives in Iowa
	IowaCare3	Magellan Behavioral Health Homes8	Statewide Mental Health System Redesign10	BIPP1111	State Innovations Model Design13, 14
Timeline	Launched in 2005; expected to be eliminated December 31, 2013 in transition to Health Care Exchanges	Pilot began July 1, 2011; funded through December 2012	Began July 1, 2012; full regional implementation effective December 31, 2013	Projected to run from 2012 through 2016	March 2013-September 2013
Geographic Area	Phase one: 2 FQHC networks in Iowa City and Des Moines; later expanded to broader network throughout state	Statewide	Statewide	Statewide	Statewide
Sponsors	CMS, Iowa Department of Health Services (DHS)	IME, Magellan Behavioral Care of Iowa	DHS	IME; Mental Health and Disability Services Division of DHS	CMMI
Scope	60,000+ patients 8 participating FQHC networks	740 enrolled adults 4 behavioral health providers partnering with FQHCs and 1 hospital	All Iowans receiving state behavioral health services	All Iowans receiving state LTSS	Medicare, Medicaid, CHIP beneficiaries Wellmark BlueCross BlueShield (Iowa's largest commercial payer)
Goals	Expand access to health care coverage Improve care quality Provide financial stability for safety net hospitals	Coordinate primary care services for individuals with depression, bipolar disorder, and schizophrenia	Reorganize the county-based system into a regional system by 2014 Expand statewide access to behavioral health services Address statewide variation in funding for behavioral health services	Shift LTSS for the disabled towards community-based care Establish a SEP system of referral Develop a standardized assessment tool to determine service eligibility and needs Provide case management for community-based services	Develop integrated care delivery models and strategies for payment realignment Develop an ACO implementation plan Ensure all Medicaid and CHIP beneficiaries can receive care through ACOs
Payment Approach	PMPM payment between $2 and $5 for services rendered consistent with U.S. Office of Management and Budget circular A-87 Program receives federal matching funds at Medicaid program rate	No information found	No information found	No information found	ACOs may elect to share 50%, 60%, or 70% of savings or losses relative to a set PMPM cost savings target ACO may earn additional shared savings payment if their actual PMPM approaches the Consumer Price Index target
Technical Assistance (TA)	No information found	No information found	No information found	CMS has contracted with Acumen, LLC and the Mission Analytics Group to provide technical assistance to participating states14	State will work with technical assistance offered by CMS Wellmark BlueCross BlueShield of Iowa will also provide technical assistance State will also seek an additional technical assistance vendor
HIT Use	Providers must have an EHR or have a plan for adopting 1 within the extension period Medical homes must have a disease registry in operation that it uses to manage at least 1 chronic disease	No information found	State is requiring that qualified TCM providers use electronic systems of record keeping	State is developing a SEP website under the BIPP State also plans to implement electronic collection of functional assessment data State has implemented electronic case management files for LTSS recipients	State plans to support data-sharing and analysis by ACOs through the Iowa HIN
Evaluation Methods	State must conduct annual performance review on selected evaluation measures	No information found	Annual report required from each region	No information found	No information found

Endnotes

1. Iowa Department of Human Services. "Financial Alignment Demonstration Proposal for Medicare-Medicaid Members." May 2012. Available from: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/IAProposal.pdf.

2. Iowa Department of Human Services. "Iowa Medicaid Managed Care Fact Sheet." January 27, 2014. Available from: http://www.dhs.state.ia.us/uploads/IowaMedicaid_ManagedCare_FactSheet.pdf.

3. Vermeer, J. "Iowa's Health Home for Medicaid Members with Chronic Conditions." Webinar presentation: Exploring Medicaid Health Homes: Leveraging State Pilot Experience in Health Home Programs. Integrated Care Resource Center, August 2, 2012. Available from: http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Downloads/HH-Slides-Aug-2012.pdf.

4. Medicaid.gov website. "IowaCare Section 1115 Demonstration Waiver Terms and Conditions." Available from: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waiv....

5. Vermeer, J. "Partnering with FQHCs and Applying the Medical Home Model to Improve Access to and Quality of Care for IowaCare Members." Powerpoint Slides.

6. Iowa Medicaid Enterprise website. "IowaCare for Members." Available from: http://www.ime.state.ia.us/IowaCare/.

7. Iowa Office of the Auditor. "A Review of the Iowacare Program Administered by the Iowa Medicaid Enterprise Within the Department of Human Services: July 1, 2009 Through June 30, 2012." February 15, 2013. Available from: http://auditor.iowa.gov/specials/1260-4010-B0P1.pdf.

8. Vermeer, J., and M. Bussell. "Iowa's Health Home for Medicaid Members with Chronic Conditions." Webinar presentation: Exploring Medicaid Health Homes: Leveraging State Pilot Experience in Health Home Programs. Integrated Care Resource Center, August 2, 2012. Available from: http://www.integratedcareresourcecenter.com/hhexploringmedicaid.aspx. Also see: http://ir.magellanhealth.com/releasedetail.cfm?ReleaseID=594039.

9. National Governor's Association. "Case Study: Iowa Pilots Integrated Health Homes for People with Serious Mental Illness." State Health Policy Options website, October 2012. Available from: http://statepolicyoptions.nga.org/sites/default/files/private/casestudy/pdf/Iowa....

10. Iowa Medicaid Enterprise. "Overview of Mental Health and Disability Services System Redesign Legislation." July 24, 2012. Available from: http://www.dhs.state.ia.us/docs/MHDSRedesignLegislationOverviewJuly242012_080312.pdf.

11. Iowa Department of Human Services. "State of Iowa Balancing Incentives Payment Project." April 2012. Available from: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long....

12. Center for Medicare and Medicaid Innovation website. "State Innovation Models Initiative: Model Design Awards." Available from: http://innovation.cms.gov/initiatives/State-Innovations-Model-Design/index.html.

13. Iowa Department of Human Services. "Unifying Iowa's Health Care Delivery System Project Narrative. State Innovation Models Cooperative Agreement." Available from:http://www.dhs.state.ia.us/uploads/Iowas%20SIM%20Project%20Narrative%20Project%20Plan.pdf.

14. Technical Assistance Center for the Balancing Incentive Program website. Available from: http://www.balancingincentiveprogram.org/.

 

 

Maine's Health Home Program at a Glance
Health Home Eligibility Criteria	2 chronic conditions, 1 chronic condition and at risk of another
Qualifying Conditions	Mental health condition Substance use disorder Asthma Diabetes Heart disease Body mass index over 25 Tobacco use Chronic obstructive pulmonary disease Hypertension Hyperlipidemia Developmental disabilities or autism Seizure disorder Congenital cardiovascular abnormalities Other conditions as identified by providers
Enrollment*	42,958
Designated Providers	Community Care Teams (CCTs), Medicaid-enrolled primary care providers (PCPs)
Administrative/ Service Framework	The health homes program is implemented statewide, as part of an expansion of the state's pre-existing Patient-Centered Medical Home (PCMH) Pilot. The program also incorporates wraparound care management by regional CCTs, which contract with multiple practices to assist them in managing the needs of high-cost, high-risk patients.
Required Care Team Members	CCT manager, director or coordinator Medical director (at least 4 hours/month) Clinical care management leader An established partnership with a health home practice
Payment System	Per member per month (PMPM) care management fee
Payment Level	CCT: $129.50 PCP: $12.00
Health Information Technology (HIT) Requirements	All health homes are required to have a fully implemented electronic health record, though the level of HIT use varies among communities. The state's health information exchange, HealthInfoNet, connects to more than 80% of Maine hospitals and more than half of primary care practices.
* January 2014 data provided to the Centers for Medicare and Medicaid Services' Health Home Information Resource Center.

Introduction

Maine's Section 2703 Health Homes State Plan Amendment (SPA) was approved by the Centers for Medicare and Medicaid Services (CMS) on January 22, 2013 with a retroactive effective date of January 1, 2013. The state offers health home services to beneficiaries with two chronic conditions, or one chronic condition and who are at risk of another chronic condition. Qualifying conditions are a mental health condition (excluding serious persistent mental illness [SPMI] and serious emotional disturbance [SED]), substance use disorder, asthma, diabetes, heart disease, body mass index (BMI) over 25, tobacco use, chronic obstructive pulmonary disease (COPD), hypertension, hyperlipidemia, developmental disabilities or autism spectrum disorders, acquired brain injury, seizure disorders, and cardiac and circulatory congenital abnormalities. Any beneficiary with one of these conditions, except asthma, acquired brain injury, or seizure disorders, is automatically considered to be at-risk for developing another chronic condition. Beneficiaries with asthma, acquired brain injury, or seizure disorders also may enroll if a health home provider determines and documents in the electronic health record (EHR) that the beneficiary is at risk of another chronic condition. The health homes program is implemented statewide, as part of an expansion of the state's pre-existing Patient-Centered Medical Home (PCMH) Pilot.

Maine's health home program also incorporates wraparound care management by regional Community Care Teams (CCTs), which assist practices in managing the needs of high-cost, high-risk patients. CCTs contract with multiple practices to identify and provide care management services for this segment of population. As of January 2014, there were over 150 PCMH and health home practices, as well as ten CCTs.¹ The state has submitted a request to expand health homes to beneficiaries with SPMI or SED in a subsequent SPA, which is currently being reviewed by the CMS.

Implementation Context

Maine's health home Initiative is an extension of its multi-payer PCMH Pilot, which began in 2009. Both programs build on the state's existing primary care case management program (PCCM), in which over 400 MaineCare primary care physicians participate.² The PCMH/health homes initiative is an integral part of the state's Value-Based Purchasing Strategy, which aims to strengthen primary care, improve care transitions, and implement a shared savings model of Accountable Care Organization across the state.³ The state is pursuing these three goals through multiple state and federal initiatives, many of which have implications for both the implementation and evaluation of the health homes program.

Patient-Centered Medical Home Implementation

In 2007-2008, the Maine legislature created the bipartisan Commission to Study Primary Care Medical Practice. The Commission recommended the development of a PCMH pilot,⁴ and in 2009 the legislature appropriated $500,000 for that purpose. The Maine PCMH Pilot is a five-year multi-payer initiative aimed at transforming primary practice and payment in the state, and is jointly led by the Maine Quality Forum (part of the state's Dirigo Health Agency [DHA]⁵), Quality Counts (a nonprofit regional health improvement collaborative of health care delivery organizations, payers, employers, providers, associations and individuals⁶), and the Maine Health Management Coalition (an employer-led coalition). Fifty practices applied for participation; 22 adult practices and four pediatric practices were selected.

Enhanced per member per month (PMPM) payments to practices began in January 2010. Two years later, Medicare joined the pilot as part of the broader CMS Multipayer Advanced Primary Care Practice (MAPCP) demonstration.⁷ Participating payers are MaineCare, Medicare, and private insurers, Aetna, Anthem BlueCross BlueShield, and Harvard Pilgrim Health Care. Private insurers are paying approximately $3 PMPM to cover care management services, while Medicare is paying $7 PMPM.⁸ (MaineCare's payment structure is described in the Payment Structure section below.)

In early 2012, the pilot program added a wraparound care management service component to the model, known as Community Care Teams (CCTs). Eight regional CCTs were formed to support participating providers in managing their highest-risk, highest-cost patients (e.g., the top 5% of high utilizing/high-cost patients). Two additional CCTs were formed in January 2013 when 50 practices were added to the multi-payer pilot and the state SPA went into effect. In addition to receiving enhanced payments from the participating payers, the practices and CCTs in the PCMH pilot receive a variety of transformation supports, including a learning collaborative, practice coaching, and consultation with key experts.⁴

As part of its statewide implementation of the SPA, MaineCare also designated 84 additional health home practices in January 2013.⁹ These practices do not participate in the multi-payer pilot, and thus only receive enhanced payment from MaineCare. Due to funding constraints, these practices did not receive technical assistance from the state's primary quality improvement contractor, Quality Counts, until July 2013 through implementation of the State Innovation Model (SIM) grant, described below. Six of these practices, however, began receiving technical assistance--as well as enhanced payments from Medicare--in September 2011 through their participation in the Federally Qualified Health Center (FQHC) MAPCP Demonstration. This demonstration is separate from MAPCP, but like MAPCP is intended to support the implementation of the advanced primary care practice model and test its effects on selected outcomes.¹⁰ Fourteen FQHCs in Maine were selected to participate in the demonstration, which will end in August 2014.

Maine is also participating in the five-year CHIPRA Quality Demonstration Grant, which aims to identify promising practices for improving child health care quality.¹¹ Maine's project, known as Improving Health Outcomes for Children, is pursuing three interrelated efforts: (1) to include child health measures in the state's existing quality measurement and performance payment system; (2) to collect and report these measures, as well as other health data, electronically; and (3) to support the four pediatric practices participating in the PCMH pilot, which will track and report selected pediatric measures through their EHRs.

Improving Care Transitions

In 2010, MaineCare partnered with Maine General (a large hospital system) to pilot a targeted care management program for 35 beneficiaries with high rates of emergency department use. Over one year, the pilot achieved a 33% reduction in emergency department visits.¹² Over the course of 2011, MaineCare expanded the pilot, known as the Emergency Department Collaborative Care Management Project, to all 36 hospitals in the state.¹¹ The Collaborative involves partnerships between participating hospitals, primary care practices, behavioral health providers, state agencies, and other care managers. The goal of the care management process is to connect high service utilizers to a primary care provider (PCP) and a community-based care manager. Where community-based care management resources are not available, MaineCare care managers work directly with the identified members. To date, the program has targeted approximately 1,692 MaineCare beneficiaries, generating an estimated $8.6 million in savings.¹³

One of the state's Area Agencies on Aging is also a recipient of a CMS Center for Medicare and Medicaid Innovation Community-based Care Transitions Program (CCTP) grant.¹⁴ These grants provide funding to test care transition models for high-risk Medicare beneficiaries. The goals of the CCTP are to improve transitions from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk Medicare beneficiaries, and to document measurable savings to the Medicare program. In Maine, the CCTP grant builds on previous care transition improvement efforts undertaken by the Maine Medical Center's (MMC's) Physician Hospital Organization (PHO). From a small pilot involving one MMC hospital, the project has expanded to include four hospitals owned by MaineHealth, another hospital system. The Southern Maine Agency on Aging began partnering with the MMC PHO to provide social work and community resource development in 2010, and the project currently targets 5,700 Medicare beneficiaries with multiple chronic conditions. Efforts are also underway to expand the model to additional MaineHealth hospitals.

Accountable Care Organizations and Payment Reform

In February 2013, Maine received a $33 million SIM grant from CMS, which will be used to implement the SIM.¹⁵ In addition to supporting the state's ongoing efforts to leverage and align the various initiatives already underway in the state, it will also support the formation of multi-payer Accountable Care Organizations (ACOs). MaineCare has also established a Medicaid shared saving ACO initiative, known as Maine's Accountable Communities Medicaid AC0.¹⁶ Accountable Communities are driven by three overarching strategies: (1) Transformation of Care: Accountable Communities must align with and build on the ten core expectations of Maine's PCMH/heath home initiative; (2) Community-Led Innovation: ACOs must meet baseline provider qualifications and reporting requirements, but will be granted some measure of flexibility to structure services in a way that reflects the local context; and (3) Shared Savings: the state will phase in risk-sharing payment structures, and may test a range of different models beyond shared savings, including shared savings with no downside risk, shared savings with some level of risk, partial capitation and global capitation.¹⁷

SIM grant funding will also support a range of additional project components, including the data analytic structure needed for multi-payer claims analysis, public reporting, and secure information sharing; quality improvement support and other forms of technical assistance; and development of new workforce models to support the transformed system. Health homes are considered to be a fundamental component in the transformation of primary care across the state, but they are not required to participate in Accountable Communities at this time.

Implications for the Maine Section 2703 Medicaid Health Homes Evaluation

Like many states, Maine is participating in a broad range of reform initiatives, many of which are designed to overlap or align closely with each other. Analyses of health home effects will need to take into account that 75 health home practices have been receiving both technical assistance and enhanced payment from multiple sources in the PCMH pilot, while about 80 others are receiving only MaineCare payments and, at least at the outset, less technical assistance. To date, six entities have applied to be ACOs, and almost all primary care sites within the ACOs are also health homes.

Both CCTs and health home practices will have very differing levels of experience--as well as capabilities--in providing care management and coordination services, and will be starting from different places in terms of the staffing, technical assistance, and health information technology (HIT) infrastructure available to them. Many of the structures and processes that underpin the identification, management, and transition of the highest-need patients between CCT and practice are still being refined. These, as well as other program details, will continue to evolve. It will be necessary to understand baseline characteristics and any significant changes made over the course of the evaluation period. It will also be necessary to control for participant and provider time in the program, as well as enrollee participation in other care management prior to health home enrollment when assessing program outcomes.

Population Criteria and Provider Infrastructure

Maine offers health home services to categorically and medically needy beneficiaries with two or more chronic conditions, or one chronic condition and the risk of developing another. Qualifying conditions are a mental health condition, substance use disorder, asthma, diabetes, heart disease, BMI over 25, tobacco use, COPD, hypertension, hyperlipidemia, developmental disabilities or autism spectrum disorders, acquired brain injury, seizure disorders, and cardiac and circulatory congenital abnormalities. Any beneficiary with one of these conditions--except asthma, acquired brain injury, or seizure disorders--is automatically considered to be at-risk for developing another chronic condition. Beneficiaries with asthma, acquired brain injury, or seizure disorders also may enroll if a health home provider determines and documents in the EHR that the beneficiary is at risk of another chronic condition (see Table 1). Beneficiaries with serious and persistent mental illness or serious emotional disturbance are excluded from this phase of health home implementation, as the state plans to target this population under a separate SPA (referred to as Behavioral "Stage B" health homes), which is currently being reviewed by CMS.

Health home providers are primary care practices that meet the state's established medical home criteria (see next section). They are required to contract with a state CCT that provides wraparound clinical care management services for high-risk, high-cost patients within a geographic region in order to deliver services as a health home team. The state estimates that roughly 5% of a practice's patient panel will need this higher level of care management at any one time. Entities that provide CCT services currently include hospitals, health systems, home health agencies, FQHCs, rural health centers (RHCs), primary care practices or groups of primary care practices, behavioral health organization, social service agencies, and/or other community-based entities.

CCT staff are multidisciplinary, and are typically led by a CCT manager and designated care management and clinical/medical directors. Most CCTs include a mix of nurses and social workers including behavioral health social workers, and may also include a care coordinator, nutritionist, case manager, pharmacist, chronic care assistant, community health worker, care navigator, health coach, and/or other staff approved by the state. Each CCT must establish a process for identifying a patient's needs and linking them to a lead coordinator whose expertise matches those needs. This process is flexible, as patient needs may shift and require the designation of a different lead coordinator.

Health home practices and CCTs share accountability for reducing avoidable health care costs, with a specific focus on reducing inpatient and emergency department utilization, providing timely post-discharge follow-up, and improving patient outcomes. As part of their care management process, CCTs are required to establish communication and coordination procedures with the health home practices they serve, and must meet with the practice team at least monthly in order to identify and coordinate care for high-needs beneficiaries. CCTs and health home practices are also required to submit quarterly reports on their activities.

Enrollment and Patient Risk Stratification

Eligible beneficiaries are identified through both claims data analysis and provider identification. Once a practice obtains health home status, eligible beneficiaries who are either enrolled with or who regularly visit that practice receive written notification that their current practice is becoming a health home. They also receive information about the initiative and are notified of their ability to opt-out. Beneficiaries who do not opt-out within 28 days will automatically be enrolled on either the 1st or the 15th of the month, and will also maintain the right to opt-out any time after the 28 day period. Eligible beneficiaries who are not already enrolled with a practice receive written notification from the state outlining the benefits of participating in the MaineCare health home initiative, as well as a list of health homes in their area from which they can choose. These members are encouraged to respond within 28 days of receiving the letter, but may enroll at a later date if they choose. Finally, health home-eligible members currently receiving targeted case management (TCM) services receive written notification of their choice to either continue receiving TCM or to receive care management through a health home.¹⁸

Once enrolled, members with baseline needs receive care management services from the health home practice, including assessment, monitoring, and follow-up on clinical and social service needs; medication review; and coordination with other providers. Health homes patients with more complex needs are referred to the CCT for enhanced care management services, such as comprehensive needs assessments, case management, behavioral health intervention, substance abuse services, and medication review and reconciliation. Following the resolution or stabilization of that member's needs, the health home practice resumes responsibility for care management.

Patients who meet any of the following criteria are considered priority patients and thus eligible for referral to the CCT:

1. Hospital admissions:

   • Three or more admissions in the past six months, or
   • Five or more admissions in the past 12 months.

2. Emergency department utilization:

   • Three or more emergency department visits in the past six months, or
   • Five or more emergency department visits in the past 12 months.

3. Payer identification of high-risk or high-cost utilizers.

4. Provider identification of high utilizers.

Health home are encouraged to identify and target patients who would benefit from CCT services, particularly those with three or more conditions, who are failing to meet treatment goals, who are using multiple drugs for their chronic condition, and patients with social service needs that interfere with care. CCTs may add criteria to the risk stratification plan as deemed appropriate for their health home partner practices, patient population, and the health home's ability to obtain reliable patient data.

Service Definitions and Provider Standards

Service definitions as provided in the SPA are adapted in Table 2. In order to qualify as a health home, practices must be enrolled as MaineCare PCCM providers (see Table 3 for a list of PCCM standards), achieve PCMH recognition by the National Committee for Quality Assurance (NCQA) within the timeframe given by the state, and have an EHR. The SPA does not list staffing requirements for practices.

Each CCT must be led by a CCT manager or director, and must include a medical director and a clinical leader. The medical director (who must be provide at least four hours per month) is responsible for clinical quality improvement efforts, while the clinical leader directs care management activities across the entire CCT.

Both practices and CCTs are required to: (1) enroll in the MaineCare program; (2) participate in the PCMH Pilot Learning Collaborative; (3) have the capacity to share patient data, collect and report quality measures, and ensure notification of admission or discharge as well as timely follow-up; and (4) commit to meeting the ten Core Expectations of Maine's multi-payer PCMH Pilot (see Table 2).

Use of Health Information Technology

Maine requires all health homes to have a "fully implemented" EHR, but the SPA does not specify what full implementation entails. Many of the providers are participating in the MaineCare HIT incentive program and, as a result, practices have the capacity and experience to use technology in a meaningful way. Maine also has tele-health laws that provide some incentives for the use of remote monitoring and other technologies that improve care at reduced costs. The HIT infrastructure underpinning the exchange of enrollee information varies across communities. In some cases, the CCT and practice share an EHR, or have negotiated agreements that allow CCTs to document--or at least access--the practice's EHR. In other cases, the two must rely on direct secure messaging through the state's health information exchange, HealthInfoNet (HIN). This exchange connects to more than 80% of Maine hospitals, and as of January 2013 an additional 15% of the state's hospitals have either contracted or verbally committed to joining. Almost half of primary care practices are also connected, with an additional 30% under contract. HIN will eventually include an enrollee portal, which the state anticipated to be operational by fall 2013. HIN has also developed a notification system to alert care managers when an assigned enrollee has visited the emergency department or been admitted. The state is currently working to make this system available to health home providers.

Payment Structure

Both health home practices and CCTs receive a separate per member per month (PMPM) payment for the provision of care management services. The PMPM rate paid to the practice is $12 per health home enrollee and is based on estimates of the staffing costs associated with providing health home services not otherwise reimbursable under MaineCare. At a minimum, the practice must monitor a health home enrollee for treatment gaps or provide some form of outreach and engagement each month to receive the payment. Case management payments for all other patients not enrolled in health homes remain at the current $3.50 PMPM under the state's PCCM program.

The Community Care Team payment is described as an "add-on" payment to support care management services for the high-need individuals referred to them, and is set at $129.50. The state provides those add-on payments for no more than 5% of the total number of health home enrollees associated with a given health home practice. At a minimum, the CCT must conduct engagement and outreach with the identified enrollees, or must provide a core health home service in order to receive payment.

Quality Improvement Goals and Measures

The state has selected 23 goal-based quality measures, all of which will come from claims data, and most of which align with the reporting requirements of other initiatives or organizations (e.g., the Improving Health Outcomes for Children initiative and the Healthcare Effectiveness Data and Information Set [HEDIS]). These are listed in Table 4.

Evaluation Measures and Methods

The evaluation measures and methodology described in the SPA are reproduced in Table 5. As the health home initiative is aligned with the PCMH pilot and the MAPCP demonstration, the evaluation of the program will build on a study already being conducted by the Muskie School of Public Service School at the University of Southern Maine. This PCMH Pilot evaluation will include three years of data from the pilot (2010-2013, with 2008 as baseline), and will examine cost-efficiency and quality outcomes for PCMH Pilot practices compared with two groups of comparison practices: other NCQA-recognized practices, and practices that do not have NCQA recognition. These practices will be matched using propensity scoring.

The health home evaluation will have a pre/post design with a matched comparison group, using 2012 as a baseline. Patients will be tracked over the two years of the enhanced match. The comparison group will be matched by health home disease criteria, other chronic conditions, age, gender, and geography, then assigned to a nonhealth home practice based on a historical claims. The study may control for other practice and member characteristics that may be obtained through administrative data. A final evaluation plan will be developed and coordinated with any national health homes evaluation.

The evaluation will also collect qualitative data at the practice level data, including data from quarterly health home reports, other key project documents, and interviews. The state may also assess consumer experience through interviews, focus groups, and surveys.

TABLE 1. Target Population and Designated Providers--Maine
SPA Approval (Effective Date)	January 22, 2013 (January 01, 2013)
Designated Provider(s)	Primary care practices working in partnership with Community Care Teams (CCTs)
Health Home Team Composition	A CCT must have: CCT manager, director or coordinator Medical director (at least 4 hours/month) Clinical care management leader Established partnership with a health home practice
Target Population	MaineCare beneficiaries with 2 chronic conditions, or 1 chronic condition and the risk of developing another.
Qualifying Chronic Conditions	Mental illness (excluding SPMI and SED) Substance use disorder Asthma Diabetes Heart disease BMI over 25 Tobacco use COPD Hypertension Hyperlipidemia Developmental disabilities or autism spectrum disorders Seizure disorder Cardiac and circulatory congenital abnormalities

 

TABLE 2. Health Home Service Definitions--Maine
Care Coordination	The health home will: (1) coordinate and provide access to high-quality health care services informed by evidence-based clinical practice guidelines; (2) coordinate and provide access to preventive and health promotion services, including prevention of mental illness and substance use disorders; (3) coordinate and provide access to mental health substance abuse services; (4) develop a care plan for each individual that coordinates and integrates all of his or her clinical and nonclinical health care related needs and services as appropriate. Health Home Practice Care for all Health Home Members: The health home practice team provides all enrollees with a comprehensive set of high-quality health care services informed by evidence-based guidelines, and coordinates care across providers to assure that enrollees receive timely, safe, and high-quality care. These services include: (1) delivery of health promotion and preventive health services, including prevention of mental illness and substance abuse disorders; (2) delivery and coordination of acute and chronic care services, and integration of physical and mental health care; and (3) coordination with care provided by other specialty providers, including mental health and substance abuse services. For Health Home Members During Period(s) of Very High Needs: The CCT provides "wraparound" care management support to address the complex needs of CCT enrollees and/or to help CCT enrollees overcome barriers to care, while coordinating care with the health home practice. The health home practice will be accountable for engaging and retaining health home enrollees in care; coordinating and arranging for the provision of services; supporting adherence to treatment recommendations; and monitoring and evaluating the enrollee's needs. When the health home practice identifies enrollees with very high needs, they will refer the enrollee to their partnering CCT. The health home practice will be required to develop policies, procedures and accountabilities with their CCT to support and define roles and responsibilities for effective collaboration. For enrollees receiving home-based long-term services and supports the health home team will communicate with and conduct outreach to providers of these services, and will work actively to incorporate these services into the enrollee's care plan. These policies and procedures will direct referrals, follow-up consultations, and regularly scheduled case review meetings with all members of the inter-disciplinary care team. The health home practice and the CCT will have the option of using technology conferencing tools including audio, video and/or web deployed solutions when security protocols and precautions are in place to protect enrollee health information. The health home practice, in collaboration with the CCT will develop and use a system to track and share enrollee information and care needs across providers, monitor enrollee outcomes, and initiate changes in care as necessary to address enrollee need.
Comprehensive Care Management	Health Home Practice Care for all Health Home Members: The health home practice provides care management services for individuals who have one or more chronic conditions and are at a risk for experiencing adverse outcomes. These services include: prospective identification of enrollees; conducting clinical assessments; monitoring and follow-up of clinical and social service needs; conducting medication review and reconciliation; communicating and coordinating care with other providers. For Health Home Members During Period(s) of Very High Needs: Health home enrollees with high/complex needs will be referred to the CCT. Services provided by the CCT include medical assessments and community/social service needs assessments; nurse care management, case/panel management; behavioral health; substance abuse services; psychiatric prescribing consultation; and medication review and reconciliation. Following the resolution or stabilization of the members' high/complex needs, CCT "hands back" the enrollee to the health home practice for basic care management support. The PCP will develop a care plan that, in consultation with the enrollee, identifies the enrollee's health goals, and will identify all services necessary to meet the enrollee's care management goals, including prevention, wellness, medical treatment by specialists and behavioral health providers, transition of care form provider to provider, and social and community-based services. The care plan will be recorded in the enrollee's EHR. The CCT will contribute to the care plan by communicating its interactions and recommendation to the health home practice care providers. The CCT communicates regularly with the health home practice team to stay informed about the beneficiaries care. The health home practice and CCT, where appropriate, will work together to ensure that the enrollee (and/or guardian) plays a central and active part in the development and execution of the care plan, and that there is agreement with the plans' goals, interventions, and timeframes. Family members and other support involved in the enrollee's care should be identified and included in the plan, as requested by the patient. The care plan will be shared with the enrollee at each visit, generated as a summary from the EHR.
Health Promotion	Health promotion will begin with enrollee engagement and outreach by the health home team. The health home practice will promote enrollee education and chronic illness self-management for eligible enrollees with practice-based screening for tobacco and alcohol use, as primary causes of chronic illness, and proceeding to the CCT for the highest-need members for follow-up education with the enrollee and family, and enrollee/family referrals to community-based prevention programs and resources. Maine's plan for outreach and engagement will require health home practices to confirm eligible enrollees' involvement with the practice; actively seek to engage enrollees in care by phone, letter, HIT and/or community outreach. CCTs outreach and engagement activities will seek to engage the highest 5% of HH-eligible enrollees who have been referred to CCT and/or have been identified as high needs enrollees based on their emergency department use and hospital admissions. Outreach and engagement functions will include aspects of comprehensive care management, care coordination, and linkages to care that address all of an enrollee's clinical and nonclinical care needs, including health promotion. The health home practice will support continuity of care through coordination with the inter-disciplinary CCT, and will promote evidence-based care for tobacco cessation, diabetes, asthma, hypertension, COPD, hyperlipidemia, developmental and intellectual disorders, acquired brain injury, seizure disorders, and cardiac and circulatory congenital abnormalities, self-help recovery resources, and other services based on individual needs and preferences.
Comprehensive Transitional Care	Comprehensive transitional care will be provided to prevent avoidable readmission after discharge from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing or treatment facility), and to ensure proper and timely follow-up care. To accomplish this, the Team of Health Care Professionals will be expected to establish processes with the major acute care hospital(s), SNFs, long-term care and other residential facilities in their community to: provide prompt notification of an enrollee's admission and/or discharge to/from an emergency department, or an inpatient or residential/rehabilitation setting; assure timely access to post-discharge follow-up care that includes, at a minimum, receipt of a summary care record from the discharging entity, medication reconciliation, and a plan for timely scheduled appointments at recommended outpatient providers. For Health Home Members with Baseline Needs: The health home practice team supports the coordination of care for all enrollees transitioning between care settings, including the following: (1) Acute Inpatient Hospital, Skilled Nursing, and Long-Term Care Facilities: The health home practice team establishes processes with the major acute care hospital(s), SNFs, and long-term care facilities in their community to ensure that the practice is notified in a timely manner when enrollees from the practice are discharged. The Practice Team conducts follow-up call to discharged enrollees and ensures that medication reconciliation and timely post-discharge follow-up are completed. (2) Pediatric enrollees: The health home practice team facilitates transition to an adult system of care, and supports communication with and referral to appropriate providers. For Health Home Members During Period(s) of Very High Needs: The CCT will establish processes with the major acute care hospital(s), SNF/long-term care and residential facilities in their community to ensure that they are notified in a timely manner when CCT enrollees are discharged. The CCT conducts follow-up calls to discharged enrollees and ensures that medication reconciliation and timely post-discharge follow-up are completed, and may conduct a home visit if indicated. The CCT will also ensure that a timely follow-up visit with the health home practice is scheduled, and will help to address barriers such as transportation needs to ensure that the visit occurs. The CCT component of the health home team will be a leader in all phases of care transition for members receiving intensive care management services from the CCT, including discharge planning and follow-up to assure that enrollees receive follow-up care and services, and re-engagement of enrollees who have become lost to care.
Individual and Family Support Services	The health home will provide: (1) self-management support to enrollees, such as health coaching; and (2) chronic disease management education and skill building. It will also ensure that a member receives timely follow-up care following a discharge or other care transition. The health home will use peer supports, support groups, and self-care programs to increase enrollee and caregiver knowledge about the enrollee's chronic illness(es), promote the enrollee's engagement and self-management capabilities, and help the enrollee improve adherence to their prescribed treatment. The health home will also discuss and provide information on advance directives for end-of-Iife decisions. The health home will ensure that all communication with the enrollee and their caregivers meets health literacy standards and is culturally appropriate, and the plan of care will reflect and incorporate member and/or family preferences, education and support for self-management, self-recovery and other resources as appropriate.
Referral to Community and Social Supports	For Health Home Members with Baseline Needs: The health home practice team provides referrals to community and social support services as relevant to enrollee needs, including actively connecting enrollees to community organizations that offer supports for self-management and healthy living, and routine social service needs. For Health Home Members During Period(s) of Very High Needs: The CCT provides referrals to community, social support and recovery services to high-needs enrollees while they are in a high-needs period, including but not limited to actively connecting enrollees to community and social service support organizations that offer supports for self-management and healthy living, as well as social service needs such as transportation assistance, housing, literacy, economic and other assistance to meet basic needs. The plan of care will include community-based and other social support services, and appropriate and ancillary health care services that address and respond to the enrollee's needs and preferences, and contribute to achieving the enrollee's goals.

 

TABLE 3. Standards for MaineCare PCCM and Maine PCMH Pilot Practices
Maine Primary Care Management Standards	Provide or arrange for 24/7 coverage Be a Prevention, Health Promotion, and Optional Treatment Services Provider for enrollees age 20 and younger Provide enrollee education on the MaineCare PCCM program, and submit all material developed to support that education for approval by the state Maintain a member on his/her panel until and unless another PCP is selected Review and correct member utilization reports provided by the state Develop and manage a care plan for MaineCare beneficiaries with chronic conditions
Maine PCMH Pilot Core Expectations	Demonstrated leadership Team-based approach to care Population risk stratification and management Practice-integrated care management Enhanced access to care Behavioral-physical health integration Inclusion of enrollees and families in implementation of PCMH model Connection to the community Commitment to reducing unnecessary health care spending, reducing waste and improving cost-effective use of health care services Integration of HIT

 

TABLE 4. Health Home Goals and Quality Measures--Maine
Reduce Inefficient Health Care Spending	Clinical outcome measures: Ambulatory care-sensitive admission Plan all-cause readmission Emergency department utilization Nonemergent emergency department visits Use of imaging studies for low back pain Percent of members with fragmented primary care
Improve Chronic Disease Management	Quality of care measures: Diabetic care adult (18-75 years of age) HbA1c testing Diabetic care pediatric/adolescent (5-17 years of age) HbA1c test Diabetic eye care exams (18-75 years of age) Diabetic LDL measured within previous 12 months Diabetic nephropathy screening Use of spirometry testing in the assessment and diagnosis of COPD Cholesterol management for patients with cardiovascular conditions Follow-up after hospitalization for mental illness HEDIS claims Initiation and engagement of alcohol and other drug dependence treatment
Improve Preventive Care for Children	Quality of care measures: Well-child visits in first 15 months of life Well-child visits between 15 months and 3 years of age Well-child visits ages 3-6 and 7-11 Adolescent well-care visit (12-20) Developmental screenings in the first 3 years of life
Ensure Evidence-Based Prescribing	Quality of care measures: Use of appropriate medications for people with asthma/pediatric measures medication therapy   Non evidence-based antipsychotic prescribing Use of high-risk medications in the elderly

 

TABLE 5. Evaluation Methodology--Maine
Hospital Admission Rates	Maine's Medicaid claims data will be used to compute hospital admission rates for individuals in the health homes. To the extent possible, Medicaid cross-over claims will be used for calculation of rates for members who are dually eligible. To the extent cross-over claims are not complete or inadequate for measure construction, Maine will work with CMS to obtain the necessary data use agreements to obtain Medicare data. Maine is already getting Medicare data from CMS for the Medicare Advanced Primary Care Demonstration but would need a separate agreement and data for the evaluation of the health homes.
Chronic Disease Management	The state will use a combination of claims, administrative and qualitative data to monitor chronic disease management processes and outcomes. The state will examine the frequency and characteristics of patients who are referred to CCTs and variations in referral patterns across practices. Information will be gathered from existing initiatives (e.g., Maine Quality Counts Learning Collaboratives, the PCMH evaluation and PCMH Working Group steering committee meetings), and supplemented by additional key informant interviews, as necessary, to identify other process or structural elements of chronic disease management that the health homes use to assess needs, coordinate services, triage referrals to CCTs, and communicate with other specialty or community-based providers. For members who are referred to the CCTs, the state will analyze the Health Monitoring Outcome Reports submitted by each team and examine trends over time. These reports include individual-level data on blood pressure monitoring and control (all CCT patients), tobacco use and counseling services (all CCT patient), diabetes monitoring and control (CCT patients with diabetes), and depression screening (CCT patients with diabetes or CVD). This information may be supplemented with chart reviews or audits of some of the health home practices.
Coordination of Care for Individuals with Chronic Conditions	Claims data will be used to examine 2 claims-based care coordination measures identified above: (1) fragmentation of care; and (2) follow-up care after mental health hospitalization for people in health homes and in a comparison group. Structural measures of care coordination will be examined using a monitoring tool that examines the extent to which the core expectations of the health home practices are being met and progress in meeting those goals. Other qualitative data and case record reviews will be used to illustrate and assess the processes and protocols used by the health homes and the CCTs to coordinate care for people with chronic conditions. This may include case record reviews of the practices and CCTs to assess other components of care coordination, including items such as date of comprehensive assessment and care plan development, contacts during and after a hospitalization, and frequency and intensity of care management for high-risk patients. Each quarter the CCTs will identify at least 1 patient story that illustrates the work of the CCT and provide the story of this individual. These reports will be used to inform the implementation of the CCTs and will inform lessons learned. The state will regularly communicate and work with the health homes and CCTs to identify the challenges and strategies used to implement the care coordination and care management processes within and across organizations.
Assessment of Program Implementation	Qualified practices and CCTs will be required to submit quarterly reports on their progress in meeting the PCMH core expectations. These expectations are outlined in the Memorandum of Understanding (MOU) with the practices and CCTs. Practices and CCTs will report on the degree of progress in each of these areas (e.g., no progress, early progress, moderate progress, and fully implemented). The criteria for making progress in each of these areas are defined in the reporting tool.
Processes and Lessons Learned	Maine Department of Health and Human Services will work with Maine Quality Counts to assess and monitor lessons learned through reports and discussions with the PCMH Working Group, the PCMH Pilot Learning Collaborative for the PCMHs. Maine will also work with the health home practices that are not part of the multi-payer PCMH Pilot to monitor and obtain feedback on the lessons learned by these practices. Quarterly reports on the structures of care and processes of care (as outlined in the CCT MOU) and the bi-annual Health Monitoring and Outcome Reports (also outlined in the CCT MOU) will inform the discussions of the Working Group and the PCMH Learning Collaborative.
Assessment of Quality Improvements and Clinical Outcomes	The quality and clinical outcome measures will be calculated at the patient-level. Where appropriate, models will be risk-adjusted and change over time will be examined for health home and comparison patients for the pre/post-period.
Estimates of Cost Savings	Medicaid and Medicare data will be used to compute cost savings in the pre/post-period. Maine will calculate baseline Medicaid and Medicare cost per person in the base year 2012, and 3 years of Implementation. The cost savings estimates will be risk-adjusted. The final method for computing cost savings will be determined as part of a final evaluation plan and will be conducted with the national evaluation plan.

 

APPENDIX: Pre-Existing Initiatives in Maine
	Maine PCMH Pilot2, 5, 6	FQHC MAPCP Demonstration7, 19, 20	CHIPRA Quality Demonstration (IHOC)8	CCTP11, 21	Emergency Department Collaborative Care Management Program10	State Innovation Model Testing Grant13
Timeline	January 2010--26 practices selected for the initial pilot (1 later dissolved) January 2012--Medicare joins as a payer (MAPCP) Early 2012--8 CCTs formed January 2013--Pilot expanded to include 50 practices and 2 CCTs	The demonstration began in September 2011, and will run through August 2014	The demonstration began in February 2010, and will run through January 2015	The demonstration will run from 2011-2015 Grants were awarded on a rolling basis until September 2012 Awardees receive grants for 2 years, which may be extended annually thereafter	September 2010--MaineGeneral Hospital initiated a care management program for the 35 highest emergency department utilizers Summer 2011--Program was expanded statewide	The grant period runs from 2013-2016
Geographic Area	Statewide	Statewide	Statewide	5 counties in southern Maine	Statewide	Statewide
Sponsors	MaineCare, CMS, Anthem BlueCross BlueShield, Aetna, Harvard Pilgrim Health Care, Maine Health Management Coalition, Quality Counts	CMS, HRSA, National Association of Community Health Centers	CMS, MaineCare	CMMI	State hospitals, MaineCare	CMS, MaineCare, Maine Health Management Coalition
Scope	75 practices, covering roughly 25% of the state population	14 FQHCs and their attributed Medicare FFS patients	4 pediatric practices involved in the PCMH pilot	5 hospitals serving 5,700 Medicare beneficiaries with multiple chronic conditions	36 hospitals Primary care, care management, and behavioral health providers 1,600 patients	The grant will support implementation of the Maine Innovation Model, which targets the state's entire health system
Goals	Enhance primary care across the state Improve health outcomes Reduce overall health care costs	Evaluate the effect of the advanced primary care practice model on care quality, health outcomes, and the cost of care provided to Medicare beneficiaries served by FQHCs	Collect and report child health quality measures through electronic clinical records, and integrate them into the state reporting system Implement an electronic health assessment for children in the foster care system Support TA to the 4 pediatric practices in the PCMH pilot	Establish or enhance partnerships between hospitals and community-based organizations (CBOs) Implement transitional care models to improve quality of care and reduce readmissions	Reduce avoidable emergency department use Improve care management and health outcomes for high-needs individuals Contain costs	Implement payment reform across public and private payers Transform the primary care system through the PCMH model Build the data infrastructure to support performance measurement, quality improvement, and public reporting of quality and cost data
Payment Approach	Medicare pays $7 PMPM to the practices and $3 PMPM to CCTs Private insurers pay approximately $3 PMPM to practices and $0.30 PMPM to CCTs MaineCare pays $12 PMPM to practices and $129.50 PMPM to CCTs for HH patients only	$6 PMPM care management fee, paid in addition to the "all-inclusive per visit payment" that FQHCs receive for providing Medicare services	PMPM care management fee Approximately $3 PMPM from MaineCare and private payers	CBOs are paid an all-inclusive rate per discharge of an eligible Medicare beneficiary CBOs will be paid only once within a 180-day timeframe for a given beneficiary	No information found	The state will test a range of payment models: Shared savings Shared savings plus risk-sharing Partial capitation models Global capitation
Technical Assistance (TA)	Maine Quality Counts and CMS are offering TA through a variety of mechanisms	TA will support practices in medical home transformation and achieving NCQA recognition	CHIPRA funds are being used to support pediatric-specific TA to the 4 practices	CBOs are encouraged to contact their Medicaid Quality Improvement Organization for technical support, and have contracted with the Lewin Group to provide TA for all awardees	No information found	Grant funding will support a range of TA to providers
HIT Use	Practices and CCTs are expected to achieve 10 core expectations, among which is HIT integration	Practices are not required to have an EHR, but are encouraged to adopt tools such as registries and schedulers	Practices are testing methods for collecting and reporting data electronically	No information found	No information found	Grant funding will support HIT infrastructure development and enhancement at multiple levels, from statewide data collection and reporting to provider-level EHR implementation and use
Evaluation Methods	The Muskie School at the University of Southern Maine will evaluate both the implementation process and impact on selected outcomes, using a pre/post comparison group design	CMS will conduct bi-annual NCQA recognition readiness assessments, and an independent evaluator will assess impact on access, quality and cost outcomes	Agency for Healthcare Research and Quality and CMS have contracted with an independent evaluator to assess the impact of CHIPRA demonstration activities on child health outcomes across the 18 states participating in the demonstration	CMS will contract with an independent evaluator to assess program performance. Outcomes of interest include 30-day, 90-day, and 180-day readmission, mortality, and emergency department visits	Initial evaluation of the pilot at Maine General found a 33% reduction in emergency department visits. Cost savings are projected to reach 9.75 million by the end of 2013	The state will contract with a third party evaluator to develop and implement an evaluation plan

Endnotes

1. "Maine PCMH and Health Home Participating Practices." Available from: http://www.mainequalitycounts.org/page/2-708/pcmh-participating-practices. "Maine Patient Centered Medical Home Pilot--Community Care Teams." Available from: http://www.mainequalitycounts.org/page/896-654/community-care-teams.

2. "MaineCare: Health Homes Initiative and Behavioral Health Integration." Annual Medicaid Innovations Forum presentation. February 5, 2013. Available from: http://www.apshealthcare.com/healthhome/medicaidinnov-mainehealthhomes.pdf.

3. MaineCare Services. "Request for Information: Stage B Health Homes for Adults with Serious Mental Illness and Children with Serious Emotional Disturbance." April 25, 2013. Available from: http://www.maine.gov/dhhs/oms/vbp/health-homes/stageb.html.

4. National Academy for State Health Policy website. "Maine PCMH Pilot." Available from: http://nashp.org/med-home-states/Maine.

5. The Maine Legislature created the DHA in 2003 as "an independent executive agency to arrange for the provision of comprehensive, affordable health care coverage to eligible small employers, including the self-employed, their employees and dependents, and individuals on a voluntary basis." HA also is responsible for "monitoring and improving the quality of health care in this State." Available from: http://www.mainelegislature.org/legis/statutes/24-A/title24-Asec6902.html.

6. National Governors Association. "Maine Quality Counts Partners with State to Improve Quality." Available from: http://statepolicyoptions.nga.org/sites/default/files/private/casestudy/pdf/Main....

7. Centers for Medicare and Medicaid Services. "Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration Fact Sheet." April 5, 2012. Available from: http://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/Downloads/mapcpdemo_Factsheet.pdf.

8. Centers for Medicare and Medicaid Services. "Targeting Medicaid Super-Utilizers to Decrease Costs and Improve Quality." Center for Medicaid and CHIP Services Informational Bulletin. July 24, 2013. Available from: http://www.medicaid.gov/federal-policy-guidance/downloads/CIB-07-24-2013.pdf.

9. Maine Quality Counts. "Maine PCMH Pilot 'Phase 2' Practices Selected." Available from: http://www.mainequalitycounts.org/page/2-869/maine-pcmh-pilot-phase-2-practices.

10. Medicare Federally Qualified Health Center Advanced Primary Care Practice Demonstration website. "Demonstration Overview." Available from: http://www.fqhcmedicalhome.com/demooverview.aspx.

11. Agency for Healthcare Research and Quality website. "National Evaluation of the CHIPRA Quality Demonstration Grant Program. State at a Glance: Maine." Available from: http://www.ahrq.gov/policymakers/chipra/demoeval/demostates/me.html.

12. MaineCare Services presentation. "Value-Based Purchasing Strategy: Quality Counts Brown Bag Forum." November 22, 2011. Available from: https://www.maine.gov/dhhs/oms/pdfs_doc/vbp/qual_counts_112211_present.pdf.

13. MaineCare Services presentation. "Value-based Purchasing Strategy and CMMI State Innovation Model Grant." February 28, 2013. Available from: http://www.maine.gov/tools/whatsnew/attach.php?id=510096&an=1.

14. CMS Center for Medicare and Medicaid Innovation. "CCTP Site Summary: The Southern Maine Agency on Aging/Aging and Disability Resource Center." Available from: http://innovation.cms.gov/Files/x/Community-based-Care-Transitions-Program-Selectee-Southern-Maine.pdf.

15. Maine Health Management Coalition. "Maine Is One of Six States to Receive Major Healthcare Innovation Award: $33 Million Federal Grant Will Help Transform Healthcare in Maine." Available from: http://www.mehmc.org/news-events/mhmc-in-the-news/sim-grant/.

16. MaineCare Services. "Maine Accountable Communities Concept Paper." August 10, 2012. Available from: http://www.maine.gov/dhhs/oms/pdfs_doc/vbp/Maine%20Accountable%20Communities%20concept%20paper%208%2014%2012.pdf.

17. MaineCare State Innovation Model Grant Application. "Testing the Maine Innovation Model: Proposal Narrative." September 2012. Available at: http://www.maine.gov/dhhs/oms/pdfs_doc/vbp/4-%20PROPOSAL%20NARRATIVE%20_Sept%2024_.pdf.

18. Groups eligible for TCM include children with behavioral, developmental disabilities, and/or chronic medical conditions, adults with development disabilities, substance abuse disorders, and/or HIV, and persons who are homeless. "MaineCare Benefits Manual," Chapter II, Section 13. Available from: http://www.maine.gov/sos/cec/rules/10/ch101.htm.

19. Medicare FQHC APCP Demonstration website. "Fact Sheet: Care Management Fee Payments to Participating FQHCs." Available from: http://www.fqhcmedicalhome.com/docs/04_Care%20Management%20Fee%20Payments.pdf.

20. Medicare FQHC APCP Demonstration website. "Fact Sheet: Considerations For Interested Practices." Available from: http://www.fqhcmedicalhome.com/docs/01_Considerations%20for%20Interested%20Practices.pdf.

21. Community-based Care Transitions Program website. "Community-Based Care Transitions Program Fact Sheet." Available from: http://innovation.cms.gov/Files/fact-sheet/CCTP-Fact-Sheet.pdf.

 

 

Missouri's Health Home Program at a Glance
	State Plan Amendment 1	State Plan Amendment 2
Health Home Eligibility Criteria	Serious Mental Illness (SMI), SMI or substance use disorder (SUD) and 1 other chronic condition, SMI or a SUD and tobacco use	2 chronic conditions, 1 chronic condition and at risk of another
Qualifying Conditions	Mental health condition SUD Asthma Cardiovascular disease (CVD) Developmental disability Body mass index (BMI) over 25 Diabetes Tobacco use	Asthma CVD Developmental disability BMI over 25 Diabetes Tobacco use
Enrollment*	19,631	15,382
Designated Providers	Community Mental Health Centers (CMHCs)	Primary care providers: Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), hospital-operated PCPs
Administrative/ Service Framework	Health home services are delivered through 21 full-service CMHCs and 9 affiliated sites throughout all geographic regions of the state	Health home services are delivered at 18 FQHCs operating 67 clinic sites; 6 public hospitals operating 22 clinic sites; and 1 Independent RHC
Required Care Team Members	Health home director Nurse care manager Administrative support staff/care coordinator Primary care physician consultant	Health home director Primary care physician or nurse practitioner Nurse care manager Administrative support staff/care coordinator Licensed nurse or medical assistant Behavioral health consultant
Payment System	Per member per month care management fee
Payment Level	$78.74	$58.87
Health Information Technology (HIT) Requirements	The state requires all health home providers to implement and use electronic health record in addition to using provider-specific HIT systems.
* January 2014 data provided to the Centers for Medicare and Medicaid Services' Health Home Information Resource Center.

Introduction

Missouri has two approved Medicaid Health Home State Plan Amendments (SPAs), the first targeting beneficiaries with serious mental illness (SMI) or behavioral health conditions, and the second targeting beneficiaries with multiple chronic physical conditions. The former was approved on October 20, 2011, while the latter was approved on December 23, 2001; both SPAs went into effect on January 1, 2012. Community mental health centers (CMHCs) are the designated providers for the behavioral health population, while primary care centers--specifically, federally qualified health centers (FQHCs), rural health clinics (RHCs), and hospital-operated primary care providers (PCPs)--are the designated providers for the population with multiple chronic physical conditions. (Throughout this memorandum, we denote the initiative targeting persons with behavioral health conditions as the CMHC-HH, and the second targeting beneficiaries with multiple chronic conditions as the PCP-HH.)

Missouri's CMHC catchment system divides the state into 25 geographic areas, each of which is served by at least one, but in some case more than one, CMHC. In total, there are 21 full-service CMHCs--which serve all age ranges and provide psychiatric services, counseling, case management, crisis intervention, and housing support, among other services--and nine affiliate sites--which focus primarily on case management and housing support, and are not required to serve beneficiaries of all ages.¹ As of January 2012, the state had selected 18 FQHCs operating 67 clinic sites, six public hospitals operating 22 clinic sites, and one independent RHC to participate.² The health home program will be statewide, and the Missouri Department of Social Services estimates that about 43,254 Medicaid beneficiaries are eligible. As of January 2014, 35,013 individuals were enrolled; 19,631 in CMHC-HHs, and 15,382 in PCP-HHs.³

Implementation Context

The Missouri Medicaid program (known since 2007 as MO HealthNet) operates both a managed care and a fee-for-service (FFS) program. Participation in Medicaid managed care is largely a function of geography, though certain eligibility groups are also required to enroll, under the state's Section 1915(b) waiver.⁴ Those who are dually eligible for Medicaid and Medicare, those meeting disability standards for Supplemental Security Income, and those receiving adoption subsidy benefits can choose to receive FFS benefits, enroll in managed care, or disenroll at any time under the waiver.⁵ The state contracts with five managed care organizations (MCOs)--Molina Healthcare, HealthCare USA, Harmony Health Plan, Missouri Care Health Plan, and Blue Advantage Plus of Kansas City--who jointly manage care in the Central, Eastern, and Western regions. These regions are roughly located along the I-70 corridor, which runs East to West and includes the state's major urban areas. Counties to the North and South of this corridor are more rural and sparsely populated; these operate on a FFS basis. (See state map.)

The Missouri health home initiative takes place within a broader context of state-sponsored care coordination and integration initiatives, many of which predate the passage of the Affordable Care Act. Though Missouri began implementing targeted care coordination and integration programs for its SMI population in 2003,⁶ the major push for reform began in 2005. In that year, the state convened the Missouri Medicaid Reform Commission to develop recommendations for restructuring the entire Medicaid program. Among its many recommendations, the final report endorsed the concept of the medical home for Medicaid recipients, citing the need for better continuity and coordination of care. It also developed several recommendations relating to the integration of behavioral and physical health services.⁷ These recommendations for the mental health system were developed in consultation with the Missouri Department of Mental Health (DMH),⁸ which subsequently would act as the lead agency on the state's mental health reform efforts. In collaboration with MO HealthNet, the Missouri Coalition of Community Mental Health Centers, and the Missouri Primary Care Association (MPCA), DMH led a series of programs--collectively referred to as DMH Net--which were intended to improve the quality of care for persons with SMI, as well as support the clinical integration of primary and behavioral health care. These initiatives would eventually form the basis of the health home initiative.⁹

In 2006, the state received a Transformation Grant from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to support its reform efforts.¹⁰ The subsequent Comprehensive Plan for Mental Health, which was published in early 2008, underscored the state's commitment to care integration and specifically cited the efforts of DMH Net as part of the reform plan.¹¹ In 2007, DMH secured state funding for a pilot care integration program involving collaborations between FQHCs and CMHCs. In this pilot, FQHCs were required to open primary care clinics on site at the partnering CMHCs, while CMHCs provided behavioral health consultants to the FQHC's primary health care teams. Of 13 applicants, seven pilot sites were selected. Each received $100,000 for the first six months of 2008, then $200,000 per year for the next three fiscal years. The six sites that were not selected were awarded one-time planning grants of $30,000, to allow them to lay the groundwork for subsequent funding cycles.⁸ Technical assistance for these pilot sites was funded by the Missouri Foundation for Health (MFH), which is a grant-making organization focused on supporting health improvement programs for underserved and uninsured populations. The 13 collaborative sites vary in structure; one CMHC also has FQHC status, while another fully merged with an FQHC. Other CMHCs contract with FQHCs to provide services to patients.¹²

More broadly, DMH implemented a range of reforms to both the structures and processes in place within the mental health system. The Community Psychiatric Rehabilitation (CPR) program established a team approach to care, and focused attention on meeting a broad array of needs (housing, work, recreation, etc.) to support patients with SMI.¹³ A range of health information technology (HIT) tools were developed to support that care (e.g., the Behavioral Pharmacy Management System [BPMS], Medication Adherence Report, and CyberAccess, which are discussed in further detail below). In 2007, the Missouri Coalition of CMHCs began training case managers to improve care coordination and develop treatment plans that include physical health interventions.¹² Nurse liaisons were also added to CMHC teams to educate behavioral health staff on physical health issues and review patient charts.⁹ CMHCs also introduced a number of prevention and wellness services, such as screening for metabolic and cardiovascular conditions, smoking cessation counseling, and nutrition education. More recently, DMH and MO HealthNet collaborated on a two-year disease management project targeted at the 3,700 highest-cost, nondual Medicaid enrollees with SMI and chronic medical conditions. Under this initiative, DMH agreed to contact identified clients, enroll them in the CPR program, and manage their care. The project, known as DM 3700, began in November 2010.¹⁴

In addition to these reforms to the mental health system, Missouri also introduced a major primary care case management program, which ran from 2007 to 2010. The Chronic Care Improvement Program (CCIP) was aimed at improving quality of care for MO HealthNet clients with chronic conditions, decreasing their complications, reducing the cost of their care, and connecting them with a "health care home." The program was managed by APS Healthcare, a disease and care management company, and covered all active FFS Medicaid enrollees (roughly 10% of whom are CMHC clients¹⁵) with a diagnosis of asthma, diabetes, chronic obstructive pulmonary disorder (COPD), gastro esophageal reflux disease (GERD), cardiovascular disease (CVD), and sickle cell anemia.³ Under this program, APS conducted outreach and education, telephone support for beneficiaries with questions about medical concerns, and a web-based plan of care that was accessible to any provider with an Internet connection and a password.¹⁶ Providers were paid an incentive to conduct and initial health risk assessment, as well as to develop and use these care plans on a regular basis.⁶ As of 2010, CCIP provided additional care management and coordination services to approximately 180,000 patients.¹⁵ Due to budgetary constraints, the program was discontinued in August 2010.

On the private sector side, in 2011 the MFH announced a Request for Applications for a multi-payer patient-centered medical home (PCMH) collaborative project.¹⁷ Though this medical home project is distinct from the health homes initiative, the framework for it was developed to resemble Missouri's health home SPA, and the two initiatives will share in learning collaboratives. The project was funded for two years and included Anthem BlueCross. Unlike the health homes initiative, it was not statewide but covered the 84 counties served by the MFH.

Beneficiaries who are enrolled in both Medicare and Medicaid are a significant sub-population of health home enrollees (12,230 of the current health home beneficiaries are dually enrolled, roughly 29% of the overall population). The state is currently finalizing a proposal to Centers for Medicare and Medicaid Services (CMS) for a demonstration project that targets the dual eligible population through its health home initiative. Under the current draft, the state proposes to share with CMS the Medicare savings that health homes generate, which the state will in turn share with providers through a pay-for-performance program.³ As a part of the demonstration, the state is seeking CMS funding to support three additional staff positions: two analysts to work with Medicare data, and a coordinator who will facilitate integration of the two health home programs.

Implications for the Missouri Section 2703 Medicaid Health Homes Evaluation

These various pre-existing initiatives have several key implications for both the implementation and evaluation of the health homes demonstration. The state has worked with CMHCs for several years to provide care coordination and disease management services to Medicaid enrollees with multiple chronic conditions and SMI. Thus, CMHC providers and state officials have a substantial base of experience in organizing and providing health home-type services. It will be critical to establish how the enhanced federal match will be used by the state, and to what extent the health home demonstration represents a new kind of service rather than an expansion of an existing initiative. In the latter case, the evaluation may find few changes in structure, process, or outcomes. However, the demonstration may serve as a proof of concept for the health home model, as well as provide valuable insight into the issues and challenges surrounding its implementation.

Given that health home-type services have been provided by some providers for a number of years, while others will be relatively new to the program, it will be necessary to clearly identify and describe the structures and processes that are in place at baseline, and to characterize the changes that providers make to these structures and processes as a consequence of becoming health homes. It will also be necessary to adjust the analysis for both the participants' and providers' time in program. Some of these structures and processes are not yet in place, and the state will likely make adjustments to certain aspects of the program based on feedback from providers and periodic internal review. For example, the delineation between the care coordination activities provided through health homes and that provided by MCOs is not yet fully detailed, and the payment system may be altered following the 18-month review planned in the SPA. The relationship between the hospitals and health homes--a critical piece of the picture given that admissions, readmissions, and emergency department use are three of the major outcomes being tracked--is still being formalized in many cases. Though much of Missouri's HIT infrastructure was already in place, the state is still making changes necessary to implement and support health home activities. In addition to the information gathered during the site visit, the Urban Institute team will conduct follow-up calls at regular intervals to discuss the progress of these and other implementation activities.

Population Criteria and Provider Infrastructure

Table 1 summarizes the population criteria for both SPA programs and the designated providers and requirements regarding the minimum composition of the health home teams. As noted above, the CMHC-HH SPA targets beneficiaries with behavioral health conditions, including both mental illness and substance use, while the PCP-HH SPA targets those with chronic physical conditions. The qualifying chronic physical conditions are the same in the two SPAs: diabetes, asthma, CVD, obesity (defined as having a body mass index [BMI] over 25), developmental disability, and tobacco use. The primary distinction is that substance use and mental illness are not qualifying conditions to receive health home services through a primary care center; such beneficiaries would have their health home services managed by a CMHC.

The two types of providers on which Missouri is building its health home infrastructure have varying experience with health home-type services, and have care teams that reflect the different needs of their respective populations. As Table 2 shows, both teams include a Director, Nurse Care Manager, and administrative support staff. The CMHC-HH team adds a primary care physician consultant, while the PCP-HH team adds a behavioral health consultant and a care coordinator, as well as additional clinical staff (i.e., a physician or nurse practitioner, as well as a licensed nurse or medical assistant). Both SPAs indicate that additional team members may be included, depending on beneficiary needs. These members can include the treating physician (if the participant is enrolled in a CMHC-HH), a dietician/nutritionist, and school personnel, among others.

Table 2 is adapted primarily from the current draft of the state's dual eligible proposal to CMS, which outlines the specific roles and responsibilities of each key care team member. Certain CMHC staff roles will continue unchanged (or largely unchanged), though these individuals will play a role in patient care. Behavioral health clinicians and the Community Psychiatric Rehabilitation Center (CPRC) teams will remain unchanged, while Community Support Specialists will receive enhanced training to enable them to serve as health coaches who promote lifestyle changes and preventive care, and support participants both in managing their health conditions and accessing primary care.

Service Definitions and Provider Standards

Definitions of health home services are identical for the two SPAs, though the providers who have primary responsibility for managing those services differ slightly. (Table 3 provides the full-service definitions.) Nurse Care Managers play a key role in all of the defined services across both provider categories, with support from the other team members.

The qualifications for health home status are also similar between the two SPAs. All health home providers must meet initial and ongoing qualifications in addition to those qualifications that are already required for designation as a CMHCs, FQHCs, RHCs, or hospital-operated primary care clinic. The full list of health home qualifications is provided in Table 4. In order to meet these qualifications, both types of health home will transform their practices over a two-year period by participating in ongoing training sessions or learning collaboratives.¹⁸ These learning collaboratives are funded jointly by MFH, the Greater Kansas City Health Care Foundation, and the Missouri Hospital Association.

Training began in August 2011 and continued throughout 2012. These training modules focused on three components: understanding and implementing the health home initiative as mandated under state law; transforming practice in order to improve care quality and efficiency, as well as meet health home accreditation standards; and understanding the Healthcare Home model, incorporating "whole-person" strategies into service delivery, understanding and assisting in managing chronic diseases, and working with children and adolescents on their basic health literacy.²

Use of Health Information Technology

Missouri's health home initiative is supported primarily through the existing Medicaid HIT infrastructure, though the state is building on this infrastructure in several ways that relate to broader statewide initiatives as well as health homes, specifically, the state's electronic health record (EHR) incentive program, meaningful use compliance, and the development of the health information exchange. MO HealthNet maintains a web-based EHR called CyberAccess, which is accessible to all enrolled Medicaid providers, including CMHCs. This system also includes a web-portal called Direct Inform, which allows enrollees to look up information on their care utilization, calculate their cardiac and diabetic risk levels, and develop a personal health plan. This feature is intended to facilitate patient self-management and monitoring. In addition, MO HealthNet maintains an initial and concurrent authorization-of-stay tool that requires hospitals to notify MO HealthNet within 24 hours of a new admission of any Medicaid enrollee, as well as to provide information about diagnosis, condition, and treatment.

The state is currently working with its HIT vendor to extend its data transfer capabilities between hospitals and outpatient providers, which would allow health home providers to use hospitalization episodes to identify eligible beneficiaries, facilitate the necessary outreach and transfer of care between inpatient and outpatient, and coordinate with the hospital on the discharge process. The state will also encourage health home providers to monitor Medicaid eligibility using the Family Support Division (FSD) eligibility website (FSD determines client eligibility for the MO HealthNet program and database), and will refine the process for notifying health home providers of impending eligibility lapses. The state requires all health home providers to implement an EHR if they do not already have one, which they will also use for extracting and reporting data.

In addition to these umbrella activities, CMHC-HHs and PCP-HHs will each have provider-specific HIT resources on which to draw. CMHC-HHs will continue to make use of two systems: the Customer Information Management, Outcomes and Reporting (CIMOR) for routine reporting, and ProAct for Care Management Reports. Under the health home initiative, the capacity of the CIMOR system will be expanded to enable assignment of enrollees to a CMHC-HH based on enrollee choice and admission for services, and the system will be cross-referenced with the above-mentioned inpatient pre-authorization system to enable concurrent reporting of inpatient authorizations to the appropriate CMHC-HH. The ProAct Care Management Reports include the BPMS, Medication Adherence Report and the Disease Management Report. The BPMS report is used for tracking and reporting on prescribing patterns. The Medication Adherence report alerts to medication adherence concerns. The Disease Management Report provides information on treatment gaps based on diagnosis and evidence-based practice. PCP-HHs will have access to the Missouri Quality Improvement Network, which is maintained by the MPCA and will serve as a patient registry as well as a platform for gathering quality measures. The data will be refreshed daily, and will be used to generate reports to support meaningful use requirements, quality improvement, and best practice identification.

Payment Structure

Both types of health homes will be paid a per member per month (PMPM) capitation rate. The PMPM rate for each enrollee in CMHD-HHs will be $78.74, and the rate for PCP-HHs will be $58.87.

These rates are built up from the assumed staffing ratios for each type of health home personnel. (These are listed above, in the description of the various types of staff that will be involved in the health homes.) In addition to staffing ratios, the input to the PMPM rates included the annual salary (and benefits and overhead) of each type of staffer, which Missouri determined from 2011 surveys of organizations likely to become health homes. For example, if the surveys showed that salary, benefits, and overhead for a given type of staff person came to $60,000 annually, and the assumed staffing ratio was one full-time equivalent (FTE) per 400 patients, then the costs of this type of staff within the total PMPM would be $60,000 divided by 400 divided by 12 months, or $12.50 PMPM.

For both types of health homes, the assumed staffing ratios total to 1-1¼ staff hours (for all types of staff combined) per patient per month. Activities covered by current Medicaid funding streams are not being counted in the planned staffing. PMPM rates reflect only marginal health home-specific staffing requirements.

Missouri plans to adjust the PMPM annually, based on the consumer price index. In addition, the PMPM determination method will be reviewed 18 months after the first PMPM payments "to determine if the PMPM is economically efficient and consistent with quality of care." Consideration will be given at that point to a "tiered rate"--that is, to different PMPM amounts for patients with different characteristics and perhaps to health homes with different characteristics.

Quality Improvement Goals and Measures

Missouri has defined eight overarching quality improvement goals for its health homes, each with defined clinical outcome and quality of care measures, summarized in Table 5. The measures are generally similar, with the few differences noted in the table. The only experience of care measure identified is patient satisfaction, which will be obtained from patient surveys, for the goal of empowerment and self-management. Most measures will come from claims, disease registry, medical records, and the web-based health record (CyberAccess).

Evaluation Measures and Methods

The evaluation measures and methodology, as described in the SPAs and reproduced in Table 6, are the essentially the same for CMHC-HHs and PCP-MHs, with the exception of estimated cost savings, discussed below. Four of the evaluation areas--chronic disease management; coordination of care; assessment of program implementation, and processes and lessons learned; and assessment of quality improvements and clinical outcomes--pertain to performance and progress toward health homes goals and rely on a combination of processes, including examination of reports on the goals and quality measures listed in Table 3, audits of practices, and ongoing assessment and oversight of implementation by a Health Homes Work Group and the Steering Committee of the Missouri Medical Home Collaborative. The clinical outcome and quality measures listed in Table 5 also will be used to assess improvements over time at the health home practice level and for health home practices as a group, with comparisons to regional and national benchmarks where feasible, although it is noted that such benchmarks will not be available specifically for persons with chronic conditions.

The final two measures specify comparison groups in one or both SPAs, but will need clarification in our discussions with the state. For both CMHC-HHs and PCP-HHs, hospital admission rates will be assessed for beneficiaries with the clinical conditions targeted during the learning collaborative year, and for similar beneficiaries, using combined FFS claims and encounter data for participating health home sites and a control group of nonparticipating sites, not otherwise specified. For CMHC-HHs the comparison beneficiaries will have SMI, two or more chronic conditions, or one chronic condition and at-risk for developing a second. Selection criteria are the same for PCP-HHs, except that SMI is omitted. Because the description of the timing of the assessments for the two groups and the nature of the comparison sites is not clear, we will need to explore the design of this assessment further with the state. Finally, for estimates of cost savings, both SPAs provide details of the computation of savings, but only the CMHC-HH SPA specifies an analysis design, a pre/post analysis of both health home providers and a group of comparison practices selected to be as similar as possible to participating practices. Comparison practices will be identified by practice type (e.g., FQHC), geographic region, and number of Medicaid beneficiaries with SMI or two or more chronic conditions. The definition of the pre/post periods is not given and will need to be explored with the state. We will also have to clarify with the state whether a similar pre/post design is intended for the PCP-HH but was inadvertently omitted.

FIGURE 1. Map of MO HealthNet Managed Care Regions
SOURCE: http://dss.mo.gov/mhk/hregions.htm.
ALT TEXT for FIGURE 1, State Map of Missouri, broken down by county:    Central counties: Linn, Macon, Shelby, Marion, Chariton, Randolph, Monroe, Ralls, Audrain, Saline, Howard, Boone, Pettis, Benton, Cooper, Morgan, Candem, Laclede, Moniteau, Callaway, Montgomery, Cole, Osage, Gasconade, Miller, Maries, Pulaski, Phelps;    Eastern counties: Piatte, Clay, Ray, Jackson, Lafayette, Cass, Johnson, Bates, Henry, St. Clair, Vernon, Cedar, Polk;    FFS counties: Atchison, Holt, Nodaway, Andrew, Buchanan, Worth, Gentry, Dekalb, Clinton, Harrison, Daviess, Caldwell, Mercer, Grundy, Livingston, Carroll, Putnam, Sullivan, Schuyler, Adair, Scotland, Knox, Clark, Lewis, Crawford, Hickory, Dallas, Barton, Jasper, Newton, McDonald, Dade, Lawrence, Barry, Greene, Christian, Stone, Taney, Webster, Wright, Douglas, Ozark, Texas, Howell, Dent, Shannon, Oregon, Iron, Reynolds, Carter, Ripley, Wayne, Butler, Bolliger, Cape Girardeau, Stoddard, Scott, Mississippi, New Madrid, Dunklin, Pemiscot;    Western counties: Pike, Lincoln, Warren, St. Charles, St. Louis, St. Louis City, Franklin, Jeferson, Washington, St. Francois, St. Genevieve, Perry, Madison.

 

TABLE 1. Target Population and Designated Providers--Missouri
	SPA 1	SPA 2
SPA Approval (Effective Date)	October 20, 2011 (January 1, 2012)	December 23, 2011 (January 1, 2012)
Designated Provider(s)	CMHCs	PCPs (FQHCs, RHCs, hospital-operated clinics)
Health Home Team Composition	Required: Health home director Nurse care manager Administrative support staff/care coordinator   Primary care physician consultant Optional: Treating physician or psychiatrist Mental health case manager Nutritionist/dietician Pharmacist Peer recovery specialist School personnel Others as appropriate	Required: Health home director Primary care physician or nurse practitioner Nurse care manager Administrative support staff/care coordinator Licensed nurse or medical assistant Behavioral health consultant Optional: Nutritionist Diabetes educator School personnel Others as appropriate
Target Population	Beneficiaries must have: A serious mental health condition (SMI) SMI or a SUD and another chronic condition SMI or a SUD and tobacco use	Beneficiaries must have: 2 chronic conditions 1 chronic condition and the risk of developing another
Qualifying Chronic Conditions	Asthma CVD Developmental disability BMI over 25 SUD (CMHC only) SMI (CMHC only) Diabetes* Tobacco use*
* Qualifies a person for being at risk of having a second chronic condition.

 

TABLE 2. Health Home Staff Roles--Missouri
Team Member	Key Roles	Staff Ratio
Health Home Director	Provides leadership to the implementation and coordination of health home activities Champions practice transformation based on health home principles Develops and maintains relationships with primary and specialty care providers Monitors performance and leads improvement efforts Designs and develops prevention and wellness activities	PCPs: 1 FTE/2500 enrollees CMHCs: 1 FTE/500 enrollees
Nurse Care Manager	Develops wellness and prevention initiatives Facilitates health education groups Develops the initial treatment plan and health care goals Consults with community support staff about patient conditions Liaises with hospital providers on admission/discharge Provides training on medical issues Tracks required assessments and screenings Assists in implementing core HIT programs and initiatives Monitors HIT tools and reports for treatment Monitors medication alerts and hospital admissions/discharges Monitors and reports performance measures and outcomes	1 FTE/250 enrollees
Behavioral Health Consultant (PCPs only)	Screening/evaluation of individuals for mental health and SUD Brief interventions for individuals with behavioral health problems Behavioral supports to assist individuals in improving health status and managing chronic illnesses Meets regularly with the primary care team to plan care and discuss cases, and exchanges appropriate information with team members Supports integration with primary care Conducts treatment interventions and patient education Provides formal feedback to PCP on behavioral health care issues	1 FTE/750 enrollees
Primary Care Physician Consultant (CMHCs only)	Participates in treatment planning Consults with team psychiatrist Consults regarding specific participant health issues Assists coordination with external medical providers	1 FTE/500 enrollees
Care Coordinator/ Administrative Staff	Referral tracking Training and technical assistance Data management and reporting Scheduling Chart audits Reminding enrollees regarding appointments, filling prescriptions, etc. Requesting and sending medical records for care coordination	PCPs: 1 FTE/750 enrollees CMHCs: 1 FTE/500 enrollees

 

TABLE 3. Health Home Service Definitions--Missouri
Care Coordination	Care coordination is the implementation of the individualized treatment plan (with active client involvement) through appropriate linkages, referrals, coordination and follow-up to needed services and supports, including referral and linkages to long-term services and supports (LTSS). Specific activities include, but are not limited to: appointment scheduling, conducting referrals and follow-up monitoring, participating in hospital-discharge processes and communicating with other providers and clients/family members.
Comprehensive Care Management	Identification of high-risk individuals and use of client information to determine level of participation in care management services Assessment of preliminary service needs Treatment plan development, which will include client goals, preferences and optimal clinical outcomes Assignment of health team roles and responsibilities Development of treatment guidelines that establish clinical pathways for health teams to follow across risk levels or health conditions Monitoring of individual and population health status and service use to determine adherence to treatment guidelines Development and dissemination of progress reports on outcomes for client satisfaction, health status, service delivery and costs
Health Promotion	Health promotion minimally consists of: Providing health education specific to an individual's chronic conditions Development of self-management plans with the individual Education regarding the importance of immunizations and screenings Child physical and emotional development Providing support for improving social networks and providing health-promoting lifestyle interventions (e.g., substance use prevention, smoking prevention and cessation, nutritional counseling, obesity reduction and prevention, and increasing physical activity) Assisting clients in participating in treatment plan implementation, and empowering to understand and self-manage chronic conditions
Comprehensive Transitional Care	Care coordination services are designed to streamline plans of care, reduce hospital admissions, ease the transition to LTSS, and interrupt patterns of frequent hospital emergency department use A health team member collaborates with physicians, nurses, social workers, discharge planners, pharmacists, and others to implement the treatment plan, focusing on increasing clients' ability to manage care and live safely in the community, and shift the use of reactive care and treatment to proactive health promotion and self-management
Individual and Family Support Services	These services include, but are not limited to advocating for individuals and families, and assisting with obtaining and adhering to prescribed treatments. In addition, health team members are responsible for identifying resources for individuals to support them in attaining their highest level of health and functioning in their families and in the community, including transportation to medically necessary services. A primary focus will be increasing health literacy and patient ability to self-manage. For individuals with developmental disabilities the health team will refer to and coordinate with the approved developmental disabilities case management entity for services related to habilitation.

 

TABLE 4. Provider Qualifications by Provider Category--Missouri
Qualifications Required for Both Providers	Have a substantial percentage of its patients enrolled in Medicaid (at least 25%) Have strong, engaged, committed leadership (demonstrated through the application process and agreement to participate in learning activities; and that agency leadership have presented the "Paving the Way for Health Care Homes" PowerPoint introduction to Missouri's health home Initiative to staff) Meet state requirements for patient empanelment (i.e., each patient receiving CMHC-HH services must be assigned to a physician) Provide assurance of enhanced (24/7) patient access to the health team, including the development of telephone or email consultations Use MO HealthNet's EHR to conduct care coordination and prescription monitoring for Medicaid participants Utilize an interoperable patient registry to input annual metabolic screening results, track and measure care of individuals, automate care reminders, and produce exception reports for care planning Agree to convene internal health home team meetings to plan and implement goals and objectives of health home practice transformation Agree to participate in CMS and state-required evaluation activities Agree to develop required reports describing health home activities, efforts and progress in implementing health home services Maintain compliance with all required terms and conditions or face termination as a provider of health home services Propose a health home delivery model that the state determines to have a reasonable likelihood of being cost-effective Within 3 months of health home service implementation, have developed a contract or memorandum of understanding with regional hospital(s) or system(s) to ensure a formalized structure for transitional care planning, to include communication of inpatient admissions of health home participants and identification of health home-eligible individuals seeking emergency department services Develop quality improvement plans to address gaps and opportunities for improvement identified during and after the application process Demonstrate continuing development of health home functionality at 6 months and 12 months through an assessment process to be applied by the state Demonstrate significant improvement on clinical indicators specified by and reported to the state
Provider Qualifications Particular to CMHC-HHs	Routinely use a BPMS to determine problematic prescribing patterns Conduct wellness interventions as indicated based on clients' level of risk Complete status reports to document clients' housing, legal, employment status education, custody, etc. Provide a health home that demonstrates overall cost effectiveness Meet National Committee for Quality Assurance (NCQA) Level 1 PCMH requirements OR submit an application for NCQA recognition by month 18 from start of supplemental payments OR meet equivalent recognition standards approved by the state as they are developed
Provider Qualifications Particular to PCP-HHs	Have a formal process for patient input into services provided, quality assurance, access, etc. Have completed electronic medical record (EMR) implementation and been using the EMR as its primary medical record system Attain NCQA 2011 PCMH Level 1 Plus recognition, defined as meeting Level 1 standards, plus the following NCQA 2011 PCMH standards at the specified levels of performance: 3B at 100% and 3C at 75%. Minor deficiencies may be addressed through submission and approval of provider plans of correction Meet equivalent recognition standards approved by the state as developed

 

TABLE 5. Health Home Goals and Quality Measures--Missouri
Improve Primary Health Care	Clinical outcome measures: Ambulatory care-sensitive admissions per 100,000 population under 75 years of age Preventive/ambulatory caresensitive emergency room visits (algorithm, not formally a measure) Hospital readmissions within 30 days Quality of care measures: Percent of hospitaldischarged members with whom the care manager made telephonic or facetoface contact within 3 days of discharge and performed medication reconciliation with input from PCP Adherence to prescribed medication for mental condition (CMHC only)
Improve Behavioral Health Care/Reduce Substance Abuse	Clinical outcome measures: Reduced proportion of adults (18 and older) reporting use of illicit drugs (past year for CMHC, past 30 days for PCP) Reduced proportion of adults reporting excessive drinking of alcohol (past year for CMHC, past 30 days for PCP) Quality of care measures (PCP only): Percent patients 18+ years old receiving depression screening Percent children screened for mental health issues Percent members 18+ years old screened for substance abuse
Improve Patient Empowerment and Self-Management	Clinical outcome measures:: Patient use of personal EHR (CyberAccess or its successor, or (PCP only) practice EMR patient portal) Experience of care measures: Satisfaction with services (CMHC: Mental Health Statistics Improvement Program survey; PCP: CAHPS CG 1.0 Adult and Child Primary Care Surveys)
Improve Coordination of Care	Clinical outcome measures:: Use of CyberAccess PMPM (or its successor) for nonMCO enrollees Quality of care measures: Percent of hospitaldischarged members with whom the care manager made telephonic or facetoface contact within 3 days of discharge and performed medication reconciliation with input from primary care physician
Improve Preventive Care	Clinical outcome measures:: Percent of patients with documented BMI between 18.5-24.9 Percent of patients aged 18 and older with a calculated BMI in the past 6 months or during the current visit documented in the medical record AND if the most recent BMI is outside parameters, a followup plan is documented (PCP) Percent of patients age 2-17 who had documented evidence of BMI percentile, counseling for nutrition and physical activity (PCP) Quality of care measures: Percent members receiving metabolic screening in past 12 months (CMHC) Percent of children 2 years of age who had 4 DTaP/DT, 3 IPV, a MMR, 3 Haemophilus influenza type B, 3 hepatitis B, a chicken pox vaccine (VZV) and 4 pneumococcal conjugate vaccines by their second birthday (PCP)
Improve Diabetes Care	Clinical outcome measures:: Percent of patients with diabetes (type 1 or 2) who had HbA1c 8.0% (Adults age 18-75 only for CMHC) Percent of patients 18-75 years old with diabetes (type 1 or 2) who had blood pressure and LDL below certain levels (PCP) Quality of care measures: Adherence to diabetes medication (PCP) Percent of members receiving metabolic screening in past 12 months (CMHC)
Improve Asthma Care	Clinical outcome measures:: Percent of patients age 550 who were identified as having persistent asthma and were appropriately prescribed medication during the measurement period. Quality of care measures: Adherence to prescription medication
Improve Cardiovascular Care	Clinical outcome measures:: Percent of patients age 18 and older with a diagnosis of hypertension with a blood pressure adequately controlled after 2 office visits Percent of patients age 18 and older diagnosed with coronary artery disease (CAD) with lipid level adequately controlled (LDL100) Quality of care measures: Adherence to CVD and antihypertensive medications Use of statins by persons with a history of CAD (CMHC)

 

TABLE 6. Evaluation Methodology--Missouri
Hospital Admission Rates	The state will consolidate data from its FFS MMIS-based claims system and from MCO-generated encounter data for the participating health home sites to assess hospital admission rates, for the participating health home sites and for a control group of nonparticipating sites. The analysis will consider: (a) the experience of beneficiaries with the clinical conditions of focus during the learning collaborative year (expected to grow from year 1 to year 2); and (b) all beneficiaries with SMI, 2 or more chronic conditions, or 1 chronic condition and at-risk for a second, drawn from a list of chronic conditions defined by the state.
Chronic Disease Management	The state will audit each practice. Audits will assess: (a) documented self-management support goal setting with all beneficiaries identified by the practice site as high-risk; (b) Practice team clinical telephonic or face-to-face beneficiary follow-up within 2 days after hospitalization discharge; (c) documentation that there is a care manager in place; and (d) that the care manager is operating consistently with the requirements set forth for the practices by the state.
Coordination of Care for Individuals with Chronic Conditions	The state will measure: (a) care manager contact during hospitalization; (b) practice team clinical telephonic or face-to-face beneficiary follow-up within 2 days after hospitalization discharge; (c) active care management of high-risk patients; and (d) behavioral activation of high-risk patients. The measurement methodologies for these 4 measures are described in the preceding section.
Assessment of Program Implementation	The state will monitor implementation in 2 ways. First, a Health Homes Work Group comprised of Department of Social Services and DMH personnel and provider representatives will meet regularly to track implementation against: (a) a work plan; and (b) against performance indicators to assess implementation status. The meetings will initially occur on a biweekly basis, and then will transition to monthly meetings 6 months into implementation. Second, the 2 departments will join private payers and provider representatives on the Steering Committee of the Missouri Medical Home Collaborative to review monthly practice data submissions and analysis by the MFH, as well as the status of practice transformation activities in conjunction with a MFH-funded learning collaborative and possible practice coaching to be provided to at least some of the participating practices.
Processes and Lessons Learned	The aforementioned work group, as well as the Steering Committee of the Missouri Medical Home Collaborative will approach the health home transformation process for the participating practices as an ongoing quality improvement exercise. Using a combination of evaluation data, information from the learning collaborative Quality Improvement Advisor who will be reviewing regularly submitted practice narrative and data reports, feedback from any practice coaches, and feedback provided to the Health Homes Work Group and the Collaborative Steering Committee by practice representatives, the state will assess what elements of its practice transformation strategy are working--and which are not. Critical attention will be paid to: (a) critical success factors, some of which have already been identified in the literature; and (b) barriers to practice transformation.
Assessment of Quality Improvements and Clinical Outcomes	The state will utilize the quality process and outcome measures described in the prior section to assess quality improvements and clinical outcomes. For registry-based, claims-based and audit-based measures, assessment will occur both at the individual practice level, and at the aggregate level for all participating health homes. For registry and claims-based measures, the state will track change over time to assess whether statistically significant improvement has been achieved. For registry-based measures for which national Medicaid benchmark data is available for Medicaid managed care plans, comparisons will be made to regional and national benchmarks.
Estimates of Cost Savings	CMHC only: The state will annually perform an assessment of cost savings using a pre/post-period comparison with a control group of Medicaid primary care practices serving clinically similar populations but not participating as health homes. Control group practices will be similar to participating practices to the extent that it is feasible to do so. They will be identified by practice type (e.g., FQHC), geographic region, and number of Medicaid beneficiaries with SMI or 2 or more chronic conditions. Savings calculations will be risk-adjusted, truncated claims of high-cost outliers annually exceeding 3 standard deviations of the mean, and will net out the value of supplemental payments made to the participating sites during the 8-quarter period. PCP: Methods for calculating cost savings for inpatient hospital, emergency department, and skilled nursing facility use, and how those inputs will be used to calculate savings net of health home PMPM are illustrated, but no parallel structure is given for a pre/post comparison of costs for participating health home practices with those for similar nonparticipating practices, as was provided in the CMHC SPA.

 

APPENDIX: Pre-Existing Initiatives in Missouri
	CCIP	Missouri PCMH Initiative	Missouri Primary/ Behavioral Health Care Integration Initiative	DM 3700
Timeline	CCIP began enrolling participants in November 200619 Patient management in CCIP began January 200719 Program ended in August 201020	Applications for participating in the Missouri Medical Home Collaborative were released by MFH in the summer of 201117 The initiative is currently funded for 2 years Practices were notified of selection in fall 2011	DMH received funding for a pilot integration grant in 2007 7 sites were selected in November 2007 Funding began in 2008, and lasted for 3 years	DMH Net implemented DM 3700 in November 2010 The project is slated to end in 2012
Geographic Area	CCIP began exclusively serving the I-70 corridor, but was expanded to include Northeast, Southeast, and Southwest regions in Missouri21	84 counties served by MFH	7 pilot sites throughout the state	Statewide
Sponsors	DMH Net	MFH, Anthem BlueCross, United	DMH Net	DMH Net
Scope	As of 2010, approximately 180,000 were enrolled Conditions targeted include asthma, diabetes, CAD, congestive heart failure, COPD, GERD, and sickle cell anemia21	Includes both licensed physicians and other licensed health care professionals At least 66% of selected practices must be MO HealthNet providers17	FQHCs and CMHCs partnered on: Location of an FQHC primary care clinic at CMHC site Integration of a behavioral health provider from the CMHC into the FQHC care team Adoption of appropriate best and promising practices Full documentation of care in an on-site record Incorporation of appropriate care management technologies	Criteria for inclusion in the project include: $30,000 or greater in combined Medicaid pharmacy and medical costs between June 2009 and May 2010 A diagnosis of Schizophrenia, Schizoaffective Disorder, Bipolar Disorder, or Major Depression-Recurrent Not currently a DMH client
Goals	Provide MO HealthNet beneficiaries more coordinated, better quality care Help beneficiaries make better health-related choices and more effectively manage their own health needs19	To improve primary care services to enhance quality of care and patient experience17 To reach underserved and high-risk populations in Missouri To spur innovation in achieving better health outcomes and lower clinical costs To develop and promote a sustainable, effective health home model	To improve clinical care To improve collaboration between the behavioral and physical health systems To improve access to primary care and behavioral health services and supports	To provide care coordination and disease management to identified beneficiaries To reduce the cost to the state of providing care and treatment and improve outcomes for enrolled clients
Payment Approach	FFS, with incentive payments Physicians received a $50 payment for completing an initial assessment for CCIP participants, and $25 each month a physician logs onto a CCIP patient's web-based care plan16	Practices receive PMPM payments for their Medical Home activities Practices are also eligible for Shared Savings payments of up to 40% of the savings from reductions in costs related to inpatient acute care and emergency department visits. These savings will be calculated relative to historic costs, with risk and outlier adjustments and all costs related to accident and injury excluded. An additional PMPM payment is available if practices hire or contract out work for a clinical care manager Practices who applied and were accepted to the MO HealthNet Health Home initiative will receive supplemental payments through both programs if selected by MFH22	Sites received grant payments of $100,000 for the first 6 months of 2008, then $200,000 per year for the next 3 fiscal years	FFS, plus an incentive payment of $24 PMPM paid at the end of the year if providers meet cost reduction goals23
Technical Assistance (TA)	The 2007 legislation also created the MO HealthNet Oversight committee to oversee implementation of all aspects of the legislation, including those related to health care homes	Practices participating in the MFH medical home program will participate in the same learning collaboratives as those in the MO HealthNet health home program2	Technical support for the 7 integration pilot sites was funded through a grant from the MFH	No information found
HIT Use	Providers have access to MO HealthNet infrastructure, including CyberAccess, the BPMS, Disease Management Report, and Medication Adherence Reports	Participating providers are required to maintain a patient registry, either as part of the practice's EMR or as a free-standing web-based registry22	Providers have access to MO HealthNet infrastructure, including CyberAccess, the BPMS, Disease Management Report, and Medication Adherence Reports	Providers have access to MO HealthNet infrastructure, including CyberAccess, the BPMS, Disease Management Report, and Medication Adherence Reports
Evaluation Methods	The 18-member Advisory Committee contracted with Mercer to conduct an analysis of program outcomes Key evaluation measures include cost analyses, clinical outcomes comparisons across groups, and examinations of medical and cost outcomes19	Practices must obtain NCQA PCMH recognition at "Level 1 Plus" by the 18th month following receipt of the first Medical Home payment CSI Solutions will perform the formal evaluation, which may include surveys and interviews	Evaluation components included:24 Analysis of both behavioral and physical health performance measures (e.g.; diabetes and hypertension control, behavioral health screening performed) Staff surveys and interviews Consumer surveys Financial impact analysis	The state will collect data on:23 Emergency room visits, admissions, readmissions Episodes of outpatient care Aggregate medication possession ratios by drug class HEDIS indicators (unspecified) Total health care utilization for: inpatient, outpatient, pharmacy, CPRC; by behavioral vs. physical

Endnotes

1. Missouri Department of Mental Health. "Response to CMS Regarding Missouri Medicaid CMHC Health Home SPA Draft." Available from: http://dmh.mo.gov/docs/medicaldirector/MissouriresponsetoCMS3-10-11feedb....

2. Missouri Department of Mental Health. "Missouri Primary Care Health Home Initiative." Available from: http://dmh.mo.gov/about/chiefclinicalofficer/PCHHPavingtheWayPresentatio....

3. "Health Home Enrollee/Provider Estimates." Available from: http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-A....

4. Missouri Department of Health and Human Services website. "MO HealthNet Managed Care Overview." Available from: http://dss.mo.gov/mhd/mc/pages/overview.htm.

5. Missouri Department of Health and Human Services website. "About the MO HealthNet Division." Available from: http://dss.mo.gov/mhd/general/pages/about.htm#waiv.

6. Missouri Department Department of Mental Health website. "Missouri's Approach to Integrated Care for Medicaid/Medicare Dual Eligible Individuals." Available from: http://dmh.mo.gov/docs/medicaldirector/WebsiteDualEligibleInfo.doc.

7. "Missouri Medicaid Reform Commission Final Report." Available from: http://www.senate.mo.gov/medicaidreform/MedicaidReformCommFinal-122205.pdf.

8. Schuffman, D. et al. "Mending Missouri's Safety Net: Transforming Systems of Care by Integrating Primary and Behavioral Health Care." Psychiatric Services, May 2009, 60(5): 585-588. Available from: http://ps.psychiatryonline.org/data/Journals/PSS/3878/09ps585.pdf.

9. The Commonwealth Fund. "Missouri: Pioneering Integrated Mental and Medical Health Care in Community Mental Health Centers." States in Action Newsletter, January 20, 2011. Available from: http://www.commonwealthfund.org/Innovations/State-Profiles/2011/Jan/Miss....

10. SAMHSA press release. "SAMHSA Awards $21.9 Million for Mental Health Transformation State Incentive Grants." September 27, 2006. Available from: http://www.samhsa.gov/news/newsreleases/060927_mh.aspx.

11. "State of Missouri Comprehensive Plan for Mental Health, January 2008-January 2013." Available from: http://dmh.mo.gov/docs/transformation/FINALVERSIONJULY12008.pdf.

12. Kyles, W. et al. "Show Me the Integration." National Councils Magazine, 2010, Issue 3. Available from: http://www.cmthealthcare.com/IndustryArticles/2010_Issue_3_National_Coun....

13. Missouri Department of Mental Health website. "Paving the Way for Healthcare Homes." Presentation. Available from: http://dmh.mo.gov/docs/medicaldirector/PavingtheWayforHealthcareHomeFina....

14. Missouri Department of Mental Health website. "Disease Management 3700." Available from: http://dmh.mo.gov/mentalillness/provider/DM3700.htm.

15. Takach, M. et al. "A Tale of Two Systems: A Look at State Efforts to Integrate Primary Care and Behavioral Health In Safety Net Settings." National Academy for State Health Policy, May 2010. Available from: http://www.nashp.org/sites/default/files/private/TwoSystems_0.pdf.

16. Center for Health Care Strategies. "Using Pay for Performance to Support HIT Efforts in Missouri." April 2008. Available from: http://www.chcs.org/publications3960/publications_show.htm?doc_id=680583.

17. Missouri Foundation for Health. "Application for Participation in the Missouri Medical Home Collaborative." July 29, 2011. Available from: http://www.mffh.org/mm/files/PCMHCollaborativeRFA_final.doc.

18. Integrated Care Resource Center. "Initial Models for Health Home Program Development." Webinar presentation, November 29, 2011. Available from: http://www.chcs.org/usr_doc/ICRC_HH_SlidesFull2.pdf.

19. "MO HealthNet Oversight Committee meeting minutes." August 4, 2009. Available from: http://www.dss.mo.gov/mhd/oversight/pdf/handout2009aug04.pdf.

20. APS Healthcare. "A Health Coach Disease Management Model: Evaluating the Impact on Treatment Compliance in Community-Based Settings." Presentation at the 138th American Public Health Association Meeting, November 10, 2010. Available from: http://www.apshealthcare.com/site/files/cm/file/posters&presentations/mo_healthcoach.pdf.

21. MO HealthNet Division. "CCIP ASO Outcome Overview." Presentation slides. Available from: http://www.dss.mo.gov/mhd/cs/advisory/dur/pdf/090121slides.pdf.

22. Missouri Foundation for Health. "Missouri Medical Home Collaborative Provider Application Process Questions and Responses." August 18, 2011. Available from:http://www.mffh.org/content/565/pcmh-faq.aspx.

23. Missouri Department of Mental Health. "Disease Management 3700 Project Implementation." Official Memorandum, October 6, 2010. Available from: http://dmh.mo.gov/docs/mentalillness/diseasemgmt.pdf.

24. "Missouri Behavioral Health and Primary Care Integration Initiative: What is it About?" Presentation. Available from: http://www.alphca.com/uploadedFiles/aphca/Resource_Center/Resource_Libra....

 

 

New York's Health Home Program at a Glance
Health Home Eligibility Criteria	2 chronic conditions, HIV/AIDS, or a serious mental illness
Qualifying Conditions	Substance use disorder Respiratory disease Cardiovascular disease Metabolic disease Body mass index over 25 HIV/AIDS Other chronic conditions
Enrollment*	158,460
Designated Providers	Any Medicaid-enrolled provider that meets health home standards
Administrative/ Service Framework	The initiative was rolled out in 3 geographically-based phases and ultimately covered Medicaid enrollees with chronic physical or behavioral conditions statewide. Health home providers include hospital networks with affiliated physical health, behavioral health, and community support providers, existing condition-specific Targeted Case Management programs, and community-based organizations.
Required Care Team Members	Multidisciplinary team led by a dedicated case manager
Payment System	Per member per month care management fee
Payment Level	Paid at 2 levels depending on enrollee status, and adjusted for case-mix and geography
Health Information Technology (HIT) Requirements	HIT standards are phased-in over time; providers must meet the initial standards on becoming a health home and the final, more comprehensive standards must be met within 18 months. The state has provided funding and learning opportunities to support health home providers in HIT development.
* January 2014 data provided to the Centers for Medicare and Medicaid Services' Health Home Information Resource Center.

Introduction

New York's Medicaid Health Home State Plan Amendment (SPA) was approved by the Centers for Medicare and Medicaid Services (CMS) on February 2, 2012, with a retroactive effective date of January 1, 2012.¹ The state envisioned this program as the first step in a health home initiative that was rolled out in three geographically-based phases and ultimately covered Medicaid enrollees with chronic physical or behavioral conditions statewide. The first approved SPA represents Phase I and covers ten counties. Separate SPAs have been submitted and approved for Phase II, which covers an additional 12 counties, and Phase III, which expands health homes to the remaining 39 counties. The retroactive effective dates for the latter phases are April 1, 2012, and July 1, 2012, respectively.

The three-phase initiative cover enrollees in two groups: those who have a serious mental illness (SMI), who have HIV/AIDS and are at risk of developing another chronic condition, or those with two or more chronic conditions (including substance abuse). The state also plans to extend statewide coverage two additional population groups in later SPAs: enrollees with developmental disabilities and enrollees in need of long-term care services. The state organized Medicaid enrollees who qualify for health homes into these four groups (Chronic Condition, Intellectual Developmental Disabilities, Long-Term Care, and Behavioral Health) hierarchically so that they are mutually exclusive, and estimates that about 975,000 of its approximately five million Medicaid members fall into one of the four population groups. The population with chronic physical or behavioral conditions covered by Phases I, II, and III represents by far the largest share, with the combined eligible population estimated at 700,000.

The state identifies health home providers through an application process in which a health home lead organization demonstrates how it will meet the health home requirements through its partners and affiliated providers. Health home lead organizations have already been designated for all three Phases. Approved health home providers include hospital networks with affiliated physical health, behavioral health, and community support providers, existing condition-specific Targeted Case Management (TCM) programs, and community-based organizations.

The second health home wave will expand coverage to the long-term care population. The design of this wave is currently under discussion, but it is expected that the program will be based on the existing managed long-term care program and a network of nursing home and noninstitutional providers. The third wave will target enrollees with developmental disabilities. Care for this population is currently managed by a TCM program, which is expected to convert to a health home in conjunction with implementation of the state's Section 1115 Medicaid Waiver program, People First, currently under development.

Implementation Context

In January 2011, Governor Andrew Cuomo convened a Medicaid Redesign Team (MRT) to assess the Medicaid program overall and develop recommendations for reform, with a focus on quality of care and cost containment and a vision of care management for all. The state's Medicaid program currently has both fee-for-service (FFS) and managed care components. About 70% of all beneficiaries are currently enrolled in managed care, although the share in managed care varies across different eligibility groups. The state has asserted that care for most enrollees is being managed well within a primary care setting but that population groups with increasingly costly and complex medical, behavioral, and long-term health care needs could benefit from additional care management. One of the MRT's 78 approved recommendations was to initiate a statewide health home program. A second key recommendation was to extend managed care to all program enrollees.

A wide range of programs similar to health homes has informed the development and implementation of the state's initiative. Some are geographically-based initiatives; others are statewide and target enrollees with specific conditions. Many programs are limited to Medicaid enrollees, but a substantial number include other payers as well.

The TCM programs have given the state a decade of experience in comprehensive case management and community support services for particular populations. Three existing case management initiatives will eventually be incorporated into health homes. The Office of Mental Health (OMH) has a TCM program that supports people with behavioral or mental health issues. The AIDS/COBRA program provides case management for people who are HIV-positive, and an Office of Alcoholism and Substance Abuse Services (OASAS), Managed Addiction Treatment Services (MATS) program serves enrollees with substance abuse problems.

Some programs, such as the New York Care Coordination Program (NYCCP) and the Chronic Illness Demonstration Projects (CIDPs), are particularly relevant for health home implementation, as they both focus on care coordination for patients with mental/behavioral health conditions. The NYCCP is a regional consortium of mental health providers and state and county governments, which over the past decade has developed and implemented a program aimed at coordinating physical and behavioral health care for Medicaid patients.² The CIDP initiative began in 2009, when the state-funded six provider groups to provide FFS comprehensive care management for enrollees with both physical and mental health conditions, as well as to address their social service needs. The state has identified the CIDPs as a direct precursor to the health home initiative.³ One significant lesson from CIDP was that outreach and enrollment costs were much higher than expected. The state found that the complexity and severity of enrollee's needs often made it difficult to interest this population in joining a CIDP when they were struggling with other life issues.⁴ This experience led to enhanced consideration and provisions for community outreach in the development of health homes, as well as for strong community supports, especially those related to housing and services following hospital discharge. The state's demonstrations and past initiatives have also highlighted the importance of the existing health information technology (HIT) infrastructure and the changes necessary to implement and support health home activities.

The state also is engaged in two patient-centered medical home (PCMH) initiatives authorized in the state's 2009 legislative session. The Adirondack Medical Home Demonstration is a five-year regional multi-payer initiative to improve care, expand access, and contain costs in the rural upstate region.⁵ Participating payers include Medicare, Medicaid, and the state's civil service system along with several private payers.⁶ The pilot was initiated in 2010 and focuses on preventive care and coordination of care for people with chronic conditions. Reimbursement includes a FFS component, a care coordination fee, and performance-based payment for improved patient outcomes. Providers must achieve National Committee for Quality Assurance (NCQA) Physician Practice Connections-Patient-Centered Medical Home (PPC-PCMH) Level 2 or Level 3 status within one year of the beginning of the pilot, and they must report on quality improvements for access of care, coordination and disease management, and hospitalization rates/readmission rates.⁷

The second PCMH initiative, also begun in 2010, is a statewide program for individuals enrolled in Medicaid, Family Health Plus (the state's public health insurance program for adults), or Child Health Plus (the state's Children's Health Insurance Program [CHIP]).⁸ Eligible providers include office-based practices, federally qualified health centers (FQHCs), and mental health diagnostic and treatment centers, and may serve both FFS and managed care beneficiaries. As in the Adirondack pilot program, the state adopted NCQA standards for practice certification. The MRT recommended that the PCMH program be expanded to new payers and a broader patient population. The 2011 legislative session authorized the Department of Health (DOH) to establish additional multi-payer medical home initiatives throughout the state. In response, Medicaid submitted a SPA to CMS in June 2011 to test new payment models for qualifying medical home practices, including risk-adjusted global payments and pay-for-performance (P4P).⁸

In August 2011, DOH announced a three-year initiative to improve the quality and coordination of primary care services provided to Medicaid patients by teaching hospitals under a grant from CMS.⁹ This initiative has two components: (1) the Hospital-Medical Home project, which provides financial incentives for the transformation of hospital teaching programs; and (2) the Potentially Preventable Readmissions (PPR) project, which provides competitive grants to hospitals to develop strategies to reduce the rate of preventable medical or behavioral health-based readmissions.⁹ The agreement includes increased financial support for mental health clinics through grants to diagnostic and treatment centers for services provided to uninsured individuals throughout the state. These programs are authorized to operate through December 31, 2014, and are supported under a Section 1115 waiver called the Partnership Plan.⁹

The Capital District Physicians' Health Plan (CDPHP) Enhanced Primary Care Program pilot is a medical home initiative in the Albany region that is considered a "virtual all-payer" system. It began in 2008 and now encompasses 24 practices, 50,000 members, and nearly 160 network physicians.¹⁰ The CDPHP uses a capitation payment model with a bonus incentive based on quality and efficiency.¹⁰ Participating practices receive payments under a risk-adjusted capitation model based on expected levels of care utilization and costs associated with a patient's individual risk profile.¹¹ The plan keeps "shadow" FFS billing in place. Further, it promised to help doctors if their costs were higher than predicted by the model and to give them the difference if the practice billed less than the model predicted.¹¹ Data on clinical quality (based on 18 Healthcare Effectiveness Data and Information Set [HEDIS] measures), cost and efficiency (utilization-based hospital and emergency department rates, population-based metrics, and episode-based medical costs), and patient/provider experience (from surveys) are collected for evaluation.¹⁰

The Hudson Valley P4P Medical Home Initiative was created under a 2008 grant from DOH to Taconic Health Information Network and Community. It targets adults with chronic conditions in the Mid-Hudson Valley region. The five-year initiative brings IBM, a dominant employer in the region, together with six commercial health plans, who are underwriting the pilot with DOH. This project bases quality and care coordination benchmarks and incentives on the NCQA Level 2 PPC-PCMH standards. The program also seeks to facilitate adoption and use of electronic health records (EHRs) in office practices in the Hudson Valley.¹²

In addition to these state-level initiatives, New York is involved in several CMS projects. It is one of eight states selected to participate in the Medicare Advanced Primary Care Practice demonstration program, and it is also participating in the CMS duals demonstration program.⁷ In addition, the Capitol District-Hudson Valley Region of New York has been selected to participate in the CMS's Comprehensive Primary Care Initiative, a multi-payer initiative promoting collaboration between public and private health care payers to strengthen primary care. Medicare will work with these payers and offer bonus payments to primary care doctors who better coordinate care for their Medicare patients.⁷

DOH staff has developed a comprehensive Medicaid reform action plan based on the work of the MRT.¹³ In particular, the action plan recommends the development of a comprehensive Section 1115 Medicaid waiver to ensure that the state has flexibility to enact all of the reforms proposed by the MRT. This new waiver is designed to allow the state to reinvest in its health care infrastructure in preparation for national health care reform and to work to contain the overall health care cost growth rate.¹³ The state expects to use the Section 1115 savings to assist health homes in attaining long-term sustainability, including help with costs, HIT investment, and recruitment and training of care managers.¹⁴

The state has also undertaken a numbered series of state-funded initiatives under the Health Care Efficiency and Affordability Law for New Yorkers, known as HEAL NY, to improve its information technology capacity, several of which are relevant for health homes. In particular, HEAL 10 provides financial support to PCMH projects throughout New York to help providers improve care coordination and enhance the continuum of care through HIT linked through the Statewide Health Information Network for New York (SHIN-NY).¹⁵ HEAL 17 builds on this funding for PCMH projects, and HEAL 22 authorizes state funding to support EHR implementation specifically for behavioral health providers.^{16 , 17}

Implications for the New York Section 2703 Medicaid Health Homes Evaluation

These various initiatives have several key implications for both the implementation and evaluation of the health homes program. The state has worked with a range of providers over many years to improve care coordination and disease management services to Medicaid enrollees with chronic conditions and SMI, targeted variously to particular conditions, specific geographic areas, and particular providers. Thus, both providers and state officials have a substantial base of experience in organizing and providing health home-type services. It will be critical to establish how the enhanced federal match will be used by the state and to what extent the health home initiatives represent a new kind of service rather than an expansion of an existing initiative. The variety of models that are being developed means that the evaluation will need to pay close attention to changes in structure and process across the individual health homes and any differences in outcomes.

Given that some providers have offered services that are similar to health home services for a number of years while other providers will be relatively new to the program, it will be necessary to clearly identify and describe the structures and processes that are in place at baseline, and to characterize the changes that providers make to these structures and processes as a consequence of becoming health homes. The state and the participating health homes will likely make adjustments to the program based on feedback from providers and periodic internal review, so it will also be necessary to conduct regular follow-ups with key stakeholders over the course of the evaluation.

Population Criteria and Provider Infrastructure¹⁸

New York's health home program both builds on existing provider relationships and encourages development of new provider partnerships. Eligible health home providers include any type of provider that is enrolled in the Medicaid program and meets the state's designated health home requirements. Health homes are empowered to determine the most appropriate composition of the health home team for the members it will serve, the state only requires that the team be "multidisciplinary" and led by a dedicated care manager. Health homes can use teams consisting of medical, mental health and substance abuse treatment providers, social workers, nurses, and other care providers. All members of the team are responsible for reporting to the care manager and for ensuring that care is patient-centered, culturally competent, and linguistically appropriate. Table 1 summarizes the population criteria, the designated providers, and the health home team composition requirements.

Enrollee Identification and Assignment¹⁹

The identification of eligible health home enrollees is based on a set of algorithms and is the same for FFS and managed care enrollees, although the process for assigning eligible enrollees to specific health homes differs. DOH identifies the enrollees eligible for health home services using a proprietary clinical risk group (CRG) software and an "intelligent" assignment algorithm that predicts for negative events using claims and encounters. The state uses an Ambulatory Connectivity Measure to help determine enrollees' health home assignment priority, with priority given to assigning enrollees with high costs and low ambulatory care connections. The state is also exploring ways to include information on housing and other social services needs and use. Assignment to a particular health home is made using a "loyalty" algorithm to match beneficiaries with providers based on their existing relationships with providers. Managed care plans (MCPs) may use the same assignment algorithm to assign their members to an appropriate health home if they so choose, but may also use additional information.

Health home beneficiaries are categorized into mutually exclusive CRGs using claims data and, when available, additional data. These CRGs can be used to predict the amount and type of health care services that individuals should have used in the past and can be expected to use in the future. CRG-based attribution modeling is being used for group selection, and CRG-based acuity modeling is being used to establish different health home payment tiers. The state then assigns enrollees to a specific health home-based on their level of clinical risk and their current level of connectivity to an outpatient provider. Eligible beneficiaries with a higher level of clinical risk and a lower level of connectivity have higher assignment priority. Health homes may also accept members that are referred to them from providers or other sources such as local health districts; these are known as community referrals.

Table 2 shows how each of the State Health Home Analytical Products is used in enrollee identification and assignment.

For FFS enrollees, the state provides candidate "tracking lists" to health homes electronically via the Health Commerce System (HCS). Lead health homes send out welcome letters to these candidates and assign them to individual providers for outreach and engagement, with participant data to be reported to the lead health home. For managed care enrollees, the state provides candidate "tracking lists" to the MCPs for their members via the HCS, based on the same intelligent assignment algorithm, loyalty model, and risk scores as used for FFS members. MCPs are responsible for assigning candidates to the lead health home that can best serve their needs. The lead health homes receive these member assignments and again assign candidates to individual providers for outreach and engagement. Established case management providers (OMH TCM, MATS, HIV COBRA TCM, and CIDPs) that choose to convert to health homes will determine the most appropriate assignment for each of their members. DOH is designing portals to allow real-time access to beneficiary-level data.

Service Definitions and Provider Standards

There are six core health home services (identified in Table 3) that must be provided by designated health home providers. Health homes must provide at least one of the first five core services (use of HIT is excluded for first 18 months as a billable service) per month to receive payment. Service "touches" include face-to-face meetings, mailings, telephone calls, consultation meeting with family, and referrals. Providers must provide written documentation that clearly demonstrates how the core service requirements are being met for each patient.

Health home provider qualification standards were developed to ensure that health homes adhere to the federal health home model and state Medicaid standards. Representatives from the DOH Offices of Health Insurance Programs, Office of Health Information Technology Transformation (OHITT), the AIDS Institute, OASAS, and OMH participated in the development of these standards. Designated health homes must be enrolled (or be eligible to be enrolled) in the Medicaid program and they must agree to comply with all of the health home requirements. Providers can either directly provide or subcontract for health home services but remain responsible for all the health home program requirements.

Health homes are required to have dedicated care managers to lead care management and coordination, and the care managers must be involved in all aspects of transitional care management. The health home provider standards do not require that any other roles be specifically assigned to particular care team members.

As described in the SPA, health home providers must meet six general qualifications:

1. They must be enrolled (or be eligible for enrollment) in the state Medicaid program and agree to comply with all Medicaid program requirements.

2. They can either provide services directly, or subcontract for their provision, but they remain responsible for all health home program requirements, including services performed by the subcontractor.

3. Care coordination and integration of heath care services will be provided by an inter-disciplinary team of providers, under the direction of a care manager who is accountable for ensuring access to services and community supports as defined in the enrollee care plan.

4. Hospitals that are part of the health home network must have procedures in place for referring eligible individuals who seeks treatment in a hospital emergency department to a designated health home provider.

5. They must demonstrate their ability to perform the eleven core functions as defined in the CMS State Medicaid Director's Letter of November 2010.

6. They must meet standards for delivery of six core health home services (see Table 3), and they must provide written documentation that clearly demonstrates how the requirements are being met.

In order to guide health home providers as they implement the new program, DOH has held a series of teleconferences and webinars; several health homes were also awarded a contract from the Department of Labor and DOH to provide workforce retraining for current TCM providers as they transition into their new roles as health home providers.²⁰ This training will include both web-based and face-to-face training and will be based on curriculum developed by the NYCCP. DOH will also convene a Learning Collaborative for health home providers, which will allow providers to share best practices around health home design and implementation.

Use of Health Information Technology

DOH developed standards for HIT use by health homes that will be phased-in over time. Providers must meet the initial standards on becoming a health home; final, more comprehensive standards must be met within 18 months. Under the initial standards, qualified health homes must have a systematic process to follow referrals and services provided, and must have a health record system to ensure that protected health information and an individual's plan of care is accessible to the health home team. Final standards require that health homes have interoperable HIT systems and policies that allow for the development and maintenance of the care plan, that they use a certified EHR that complies with the official Statewide Policy Guidance on HIT, that they participate in the RHIOs for the purposes of sharing data, and that they employ clinical decision-making tools where feasible. (See Table 4 for a full list of the initial and final requirements.)

Health home providers will be encouraged to use wireless technology as available to improve coordination and management of care and patient adherence to provider recommendations. In order to support providers in their efforts to meet final HIT requirements, New York has made additional funding and learning opportunities available to them through the HEAL program and upcoming Learning Collaborative. OHITT is also working to identify additional opportunities for health homes to enhance their HIT capacity.¹

Payment Structure

Payment is made on a per member per month (PMPM) basis at two levels: Outreach and Engagement, and Active Care Management. Members in the outreach and engagement group are those who have been assigned to the provider but have not yet engaged in active care management. The active care management group consists of actual health home participants.

Health homes are reimbursed directly by the state for FFS members and through the MCPs for managed care members. MCPs may keep up to 3% of payments for administrative services. TCMs, MATs, and CIDPs bill the state directly for a limited period of time. All monthly payments will be made through eMedNY (the New York State Medicaid program claims processing system).

Health home providers' payment rates vary based on region and case-mix. Rates are calculated and paid at a member-specific level directly by eMedNY. The state intends to adjust the rates by member functional status once such data is available. Outreach and engagement for Medicaid FFS and managed care members will be paid at 80% of the active care management rate. Once a patient is fully engaged in the program and receiving active care management services, the provider receives full active care management group PMPM rate.

Rate Information and Determination

The health home care management rates were calculated based on caseload variation, case management cost, and patient-specific acuity. Caseload variation data was developed based on experience in the TCM programs, CIDPs, and other states' demonstrations related to chronic illness management. Case management cost analysis is based on financial data reported to DOH from existing programs. Patient-specific risk factors were developed using CRG software. DOH is currently developing an additional adjustment for functional status.

Converting TCMs and CIDPs will bill eMedNY directly for their existing caseload at their historical rates. These rates will be phased out over two years for TCMs and over one year for CIDPs, at which time only health homes and MCPs will be reimbursed through eMedNY for health home services.

Quality Improvement Goals and Measures

The state has identified five quality improvement goals:

• Reducing utilization associated with avoidable inpatient stays;
• Reducing utilization associated with avoidable emergency department visits;
• Improving outcomes for persons with mental illness and/or substance use disorders;
• Improving disease-related care for chronic conditions; and
• Improving preventative care.

Table 5 lists each goal with its corresponding measures. Most of the measures are based on HEDIS specifications; two are measures proposed in the Affordable Care Act,²¹ and two are specific to New York. Data for these measures are to be drawn entirely from administrative and pharmacy claims.

Evaluation Measures and Methods

Care management metrics are divided into process metrics and outcome (quality) metrics. The state's goal was to have a uniform platform and a standard set of process metrics in place by fall 2012. Outcome metrics are taken from Medicaid records--enrollment, claims, encounter, and pharmacy data--as well as other state databases that record provisions of substance abuse treatment services. The selected outcome metrics are described in full in Table 6.

The state will work with CMS to develop a patient experience survey that draws from both the Consumer Assessment of Healthcare Providers and Systems survey, and behavioral health-specific items from the Mental Health Statistics Improvement Program. New York will work with academic partners to supplement these databases with additional data.

The state proposes a variety of approaches to measuring the impact of health homes on selected quality and cost outcomes (hospital admission rates, chronic disease management, assessment of quality improvements and clinical outcomes, and estimates of cost savings). It will analyze historical utilization and cost data, employ statistical matching, and explore the possibility of using propensity score methods by region to identify comparison groups of people with similar demographic, geographic, and medical characteristics as health home enrollees. It expects that the phased nature of enrollment will allow identification of variations in outcome measures between enrollees and the eligible but not yet enrolled beneficiaries. Finally, it may look at the differences in outcomes across the designated health homes, adjusting for differences in client characteristics. The state will be working with local academic partners in completing these analyses.

TABLE 1. Target Population and Designated Providers--New York
SPA Approval (Effective Date)	February 3, 2012 (January 1, 2012)
Designated Provider(s)	Any Medicaid-enrolled provider that meets health home standards; includes MCPs, primary care providers (PCPs), home health agencies, and substance abuse treatment facilities
Health Home Team Composition	Required: Multidisciplinary team; led by a dedicated case manager Optional: Nutritionist/dietician, pharmacist, outreach workers (peer specialist, housing representatives, etc.)
Target Population	Beneficiaries must have: 2 chronic conditions HIV/AIDS A serious mental condition
Qualifying Chronic Conditions	Mental health condition: Bipolar disorder Conduct, impulse control, and other disruptive behavior disorders Dementing disease Depressive and other psychoses Eating disorder Major personality disorders Psychiatric disease (except schizophrenia) Schizophrenia Substance use disorder: Alcohol liver disease Chronic alcohol abuse Cocaine abuse Drug abuse--cannabis/NOS/NEC Substance abuse Opioid abuse Other significant drug abuse Respiratory disease: Asthma Chronic obstructive pulmonary disease Cardiovascular disease: Advanced coronary artery disease Cerebrovascular disease Congestive heart failure Hypertension Peripheral vascular disease Metabolic disease: Chronic renal failure Diabetes BMI over 25 HIV/AIDS Other chronic conditions diagnosed in the population

 

TABLE 2. New York's Health Home Analytical Products
Methodology	Purpose
CRG-Based Attributions	For cohort selection
CRG-Based Acuity	For payment tiers
"Intelligent" Assignment Algorithm	For assignment priority
Ambulatory Connectivity Measure	For assignment priority
Provider Loyalty Model (connectivity to existing providers)	For matching to appropriate health home and to guide outreach activity

 

TABLE 3. Health Home Service Definitions--New York
Care Coordination	The care manager ensures the coordination of services, adherence to treatment recommendations, and generally oversees the needs of the health home member. The health home provider will promote prevention and wellness by providing resources for prevention and any other services members need.
Comprehensive Care Management	An individualized patient-centered care plan based on a comprehensive health risk assessment. Care management must be comprehensive, meeting physical health, mental health, chemical dependency, and social service needs.
Comprehensive Transitional Care	Health home providers must emphasize the prevention of avoidable readmissions and must ensure proper and timely transitions from 1 setting to another and follow-up care post-discharge.
Individual and Family Support Services	Individualized care plans must be shared and clear for the patient, family members, or other caregivers to understand. Patient and family preferences must be given appropriate consideration.
Referral to Community and Social Supports	Health home providers are responsible for identifying and actively managing appropriate referrals, and coordinating with other community and social supports.
Use of HIT to Link Services, as Feasible and Appropriate	Health homes are encouraged to use regional health information organizations (RHIOs) to access patient data and to maximize the use of HIT in the services they provide and in care coordination. Health home provider applicants have 18 months from program implementation to submit a plan for achieving compliance with the final health home HIT requirements.

 

TABLE 4. Health Information Technology (HIT) Standards--New York
Initial Standards	Health home provider has structured information systems, policies, procedures and practices to create, document, execute, and update a plan of care for every patient. Health home provider has a systematic process to follow-up on tests, treatments, services, and referrals which is incorporated into the patient's plan of care. Health home provider has a health record system which allows the patient's health information and plan of care to be accessible to the inter-disciplinary team of providers and which allows for population management and identification of gaps in care including preventive services. Health home provider makes use of available HIT and accesses data through the RHIO/qualified entity to conduct these processes, as feasible.
Final Standards	Health home provider has structured interoperable HIT systems, policies, procedures and practices to support the creation, documentation, execution, and ongoing management of a plan of care for every patient. Health home provider uses an EHR system that qualifies under the Meaningful Use provisions of the HITECH Act, which allows the patient's health information and plan of care to be accessible to the inter-disciplinary team of providers. If the provider does not currently have such a system, they will provide a plan for when and how they will implement it. Health home provider will be required to comply with the current and future version of the Statewide Policy Guidance which includes common information policies, standards and technical approaches governing health information exchange (HIE). Health home provider commits to joining regional health information networks or qualified HIT entities for data exchange and includes a commitment to share information with all providers participating in a care plan. RHIOs/qualified entities provides policy and technical services required for HIE through SHIN-NY.

 

TABLE 5. Health Home Goals and Quality Measures--New York
Reduce Utilization Associated with Avoidable (preventable) Inpatient Stays	Clinical outcome measures: Inpatient utilization--The rate of utilization of acute inpatient care per 1,000 member months. Data will be reported by age for categories: Medicine, Surgery, Maternity and Total Inpatient.
Reduce Utilization Associated with Avoidable (preventable) Emergency Room Visits	Clinical outcome measures: Ambulatory care (emergency department visits)--The rate of emergency department visits per 1,000 member months. Data will reported by age categories.
Improve Outcomes for Persons with mental Illness and/or Substance Use Disorders	Clinical outcome measures: Mental health utilization--The number and percentage of members receiving the following mental health services during the measurement year for: (1) any service; (2) inpatient; (3) intensive outpatient or partial hospitalization; and (4) outpatient or emergency department. Follow-up after hospitalization for mental illness--Percentage of discharges for treatment of selected mental illness disorders who had an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health provider within 7 days and within 30 days of discharge. In addition, "retention" in services, defined as at least 5 qualifying visits with mental health providers within 90 days of discharge. Follow-up after hospitalization for alcohol and chemical dependency detoxification--The percentage of discharges for specified alcohol and chemical dependency conditions that are followed up with visits with chemical treatment and other qualified providers within 7 days and within 30 days and who have ongoing visits within 90 days of the discharges. Quality of care measures: Antidepressant medication management--Percentage of members who had a new diagnosis of depression and treated with an antidepressant medication who remained on the antidepressant for acute phase and recovery phase of treatment. Follow-up care for children prescribed ADHD medication--Percentage of children newly prescribed ADHD medication that had appropriate follow-up in the initial 30 days and in the continuation and maintenance phase. Adherence to antipsychotics for individuals with schizophrenia--Percentage of patients with a schizophrenia diagnosis who received an antipsychotic medication that had a proportion of days covered (PDC) for antipsychotic medication >0.8 during the measurement period. Adherence to mood stabilizers for individuals with bipolar I disorder--Percentage of patients with bipolar I disorder who received a mood stabilizer medication that had a PDC for mood stabilizer medication >0.8 during the measurement period.
Improve Disease-Related Care for Chronic Conditions	Quality of care measures: Use of appropriate medications for people with asthma--Percentage of members who are identified with persistent asthma and who were appropriately prescribed preferred asthma medication. Medication management for people with asthma--The percentage of members who were identified as having persistent asthma and were dispensed appropriate medications in amounts to cover: (1) at least 50% of their treatment period; and (2) at least 75% of their treatment period. Comprehensive diabetes care (HbA1c test and LDL-C test)--Percentage of members with diabetes who had at least 1 HbA1c test and at least 1 LDL-C test. Persistence of beta-blocker treatment after heart attack--Percentage of members who were hospitalized and discharged alive with a diagnosis of acute myocardial infarction (AMI) and who received persistent beta-blocker treatment for 6 months after discharge. Cholesterol testing for patients with cardiovascular conditions--Percentage of members who were discharged alive for AMI, coronary artery bypass graft or percutaneous coronary intervention or who have a diagnosis of ischemic vascular disease and who had a least one LDL-C screening. Comprehensive care for people living with HIV/AIDS--Percentage of members living with HIV/AIDS who received: (a) 2 outpatient visits with primary care with 1 visit in the first 6 months and 1 visit in the second 6 months; (b) viral load monitoring; and (c) syphilis screening for all who 18 and older.
Improve Preventive Care	Quality of care measures: Chlamydia screening in women--Percentage of women who were identified as sexually active and who had at least 1 test for Chlamydia. Colorectal cancer screening--Percentage of members 50+ who had appropriate screening for colorectal cancer.

 

TABLE 6. Evaluation Methodology--New York
Hospital Admission Rates	New York has been monitoring avoidable hospital readmissions (PPRs) for Medicaid populations since 2009 using 3M software. This software has an algorithm for determining whether a readmission is plausibly connected to an initial admission. New York will calculate PPRs within 30 days of an initial inpatient discharge; calculating the rate across all conditions and also within condition (i.e., mental health condition, substance use disorder, asthma, diabetes, heart disease, HIV/AIDS, and hypertension). As indicated, historical avoidable readmission rates for statistically matched comparison group will be calculated. The state will also compare avoidable readmission rates across health home providers.
Chronic Disease Management	Data on chronic disease management will be collected in 2 ways. First, New York will examine how the health homes implement disease management across key chronic illness management functional components of state health home qualification criteria. With the aid of state and academic partners, New York will work with stakeholders to assess the key functional components to include: (1) inclusion of preventive and health promotion services; (2) coordination of care between primary care, specialty providers and community supports; (3) emphasis on collaborative patient decision-making and teaching of disease self-management; (4) structuring of care to ensure ongoing monitoring and follow-up care; (5) facilitation of evidence-based practice; and (6) use of clinical information systems to facilitate tracking of care as well as integration between providers. The state will modify standardized assessment tools as well as use qualitative interviews with health home administrative staff and providers to determine the implementation of these functional components. Additionally, the patient Experience of Care measure will provide information on self-management support from the health home. Second, New York will conduct cohort analyses as part of the evaluation focusing on groups at-risk to incur high costs.
Coordination of Care for Individuals with Chronic Conditions	New York will use claims, encounter, and pharmacy data to collect information on coordination of care. As indicated in the quality measures section of this SPA, the state will use claims, encounter, and pharmacy data to collect information on post-inpatient discharge continuation of care (e.g., persistent beta-blocker treatment after hospitalization for AMI) or transition to another level of care (e.g., outpatient care following hospitalization for a behavioral health condition). This coordination of care measures will be compared to historical controls, to statistically matched comparison groups, and across health home providers. In addition, New York State is considering the feasibility of more closely examining provider behavior through medical chart reviews, case record audits, team composition analysis, and key informant interviews. As part of this process, the state will carefully monitor the use of HIT as a primary modality to support coordination of care.
Assessment of Program Implementation	As indicated above, Learning Collaboratives will be constituted with a group of providers of health homes to identify implementation challenges as well as potential solutions. Other data related to implementation including responses to the health home experiences of care survey and, if feasible, provider audits and surveys, and stakeholder interviews will be collected. All implementation data will be shared with the Health Home Advisory Group (comprised of state, provider, community, and academic members) and a compilation of lessons learned.
Processes and Lessons Learned	Learning Collaboratives will be constituted with a group of early adopter providers of health homes to identify implementation challenges as well as potential solutions. New York will use the Health Home Advisory Group to monitor, comment, and make recommendations on implementation strategies that are working as well as those that are not. The group will use the health home functional components as well as the provider qualification criteria as guides in assessing program processes and outcome success. The Advisory Group will use information gathered through assessments of program implementation as well as from ongoing quality monitoring using administrative data to review program successes and failures.
Assessment of Quality Improvements and Clinical Outcomes	New York has identified an extensive list of quality and outcome measures that will be derived from administrative claims and encounter data. The quality measures are indicators of chronic illness management while the clinical outcome measures are indicators of poor disease management leading to high-cost treatment episodes. Ongoing assessments of these quality measures will be conducted at the levels of health home providers, region, and statewide. The endpoint evaluation will be designed as a quasi-experimental longitudinal study where endpoint outcomes will be patient-level indicators of poorly managed care of chronic conditions; indicators of stable engagement in guideline concordant care; and high-cost utilization of services. There are a number of clear indicators of poorly managed care across disorders: emergency department visits, hospital readmissions, poor transition from inpatient to outpatient care, etc. In addition, the state will attempt to define, where possible, more refined measures that are disease-specific (e.g., repeated detox in substance abuse.
Estimates of Cost Savings	New York will work with state and academic partners to devise a sophisticated econometric analysis of the overall health home initiative as well as of each vendor. First, the state will monitor costs savings through by tracking high-cost forms of utilization (e.g., preventable hospitalizations, emergency department use, and detoxification). Utilization of high-cost events will be compared with historical rates as well as with statistically matched comparison groups as indicated above. Additionally, New York will compare total costs of care for health home enrollees--including all services costs, health home costs and managed capitation--to statistically matched comparisons. The econometric analyses will begin with descriptive statistics and increase in complexity to the minimal level necessary to address the question of cost savings. Analyses will focus on PMPM expenditures of enrollees compared to controls as described in this section's preamble. For regression analyses that examine changes in cost relative to controls, New York employs longitudinal nested designs that account for serial correlation within person and within provider and region. Regression analyses will account for prior year costs by type of utilization (e.g., emergency department, inpatient, mental health), clinical complexity (e.g., PPR risk score), regional utilization characteristics, and demographic factors. Parameter estimates for health home participants will indicate differences in PMPM relative to controls while controlling for historical utilization patterns, regional practice variation, and individual demographic characteristics.

 

APPENDIX: Pre-Existing Initiatives in New York
	NYCCP	CIDP22, 23	Adirondack Medical Home Demonstration24, 25	Statewide PCMH Program7, 26
Timeline	Founded by 6 counties in West and Central New York in 2000 Formed partnership with Beacon Health Strategies (MCO) in 2009 Awarded contract as Behavioral Health Organization for Western Region in 2011	Program authorized in 2007 legislation Demonstration project began January 2009 Contract ended March 29, 2012, and program participants were converted into health home members	New York legislature authorized the Adirondack Medical Home Demonstration in 2009 Demonstration began January 2010 Participating practices applied for NCQA certification in February 2011 Began participating in the Advanced Primary Care Practice demonstration in 2011 Demonstration will end in 2015	New York legislature established a statewide PCMH program for Medicaid, CHIP, and Family Health Plus enrollees in 2009 Program was expanded to include other payers in 2011 State submitted a SPA to CMS to test new payment models for medical home practices in 2011
Geographic Area	7 state counties concentrated in west and central New York	5 state counties and 4 boroughs of New York City	5-county region in Northeast New York	Statewide
Sponsors	State OMH, county government	New York DOH, Center for Health Care Strategies (CHCS), New York Health Foundation	DOH and 7 private payers	DOH
Scope	Targeted at all levels of the mental health system	6 provider organizations covering the areas listed above	Nearly all PCPs in the region; 5 hospitals, 123 physicians in group and solo practice	Eligible providers include PCPs, nurse practitioners, FQHCs, diagnostic and treatment centers
Goals	Build culture of person-centered care and individual empowerment Coordination of services delivered by multiple providers A rehabilitation and recovery model of services Implementation of evidence-based best practices, with outcome-based performance measurement Improved information systems	Establish inter-disciplinary models of care designed to improve health care quality Ensure appropriate use of services Improve clinical outcomes Reduce the cost of care for Medicaid beneficiaries with medically complex conditions	Strengthen regional ability to attract and retain PCPs Improve quality, access, and outcomes Contain costs Create a new clinically integrated model that can be replicated in other parts of the state	Incent the development of PCMHs through enhanced payment to providers who obtain NCQA recognition Improve health outcomes through better coordination and integration of patient care
Payment Approach	1 initiative involved P4P in 2 counties; providers rewarded for achieving undefined performance targets	PMPM care management fee, with a risk corridor and shared savings available in second and third year to entities that met performance targets	FFS, plus a $7 PMPM care management fee	Enhanced payment for certain evaluation, management, and preventive services, plus a PMPM incentive payment from MCPs for participating enrollees. Rates for both enhanced FFS and the PMPM are tiered by NCQA recognition. Fees range from $5.50-$21.25, and PMPM rates range from $2-$6. Enhanced payment for Level 1 certification will end in December 2012
Technical Assistance (TA)	Beacon has provided technical assistance to providers on care management, and various pilot projects have involved training for providers on care integration and person-centered care	Participating providers took part in learning collaboratives led by DOH and CHCS	Technical assistance was provided to participating providers in implementing HIT, practice transformation, as well as in establishing the cost basis and rates to be paid to participating practices	A quality improvement contractor is providing some support to practices in meeting NCQA requirements
HIT Use	No information found	Contractors were expected to use or develop HIT capacity to support care management functions	Practices had to adopt electronic medical records and information exchange capacity, including connection to the RHIO, specialists and hospitals, and 2 data warehouses. 2 grants supported this; 1 from HEAL 10 and 1 from the state medical society	No information found
Evaluation Methods	Many of the projects have been formally evaluated, with the results published on the program website: http://www.carecoordination.or/results.shtm	The program is being evaluated by MDRC, and final reports are expected in 201327	Evaluation will be conducted by the demonstration's governance council	The state health commissioner is required to report on the program's impact on quality, cost, and other outcomes by December 2012

Endnotes

1. Unless otherwise noted, information contained in the first two pages of this memorandum are drawn from one of two sources: (1) New York State Medicaid Update. "Introducing Health Homes: Improving Care for Medicaid Recipients with Chronic Conditions." Volume 28, Number 4, April 2012. Available from: http://www.health.ny.gov/health_care/medicaid/program/update/2012/2012-04_pharmsped_edition.htm. (2) National Academy for State Health Policy webinar. "Implementing Section 2703 Health Homes: Lessons from Leading States." June 2012. Available from: http://www.nashp.org/webinar/implementing-section-2703-health-homes-lessons-leading-states.

2. New York Care Coordination Program website. Available from: http://www.carecoordination.org/about_the_wnyccp.shtm.

3. National Academy for State Health Policy webinar. "Implementing Section 2703 Health Homes: Lessons from Leading States." June 2012. Available from: http://www.nashp.org/webinar/implementing-section-2703-health-homes-lessons-leading-states.

4. New York Department of Health website. "Medicaid Health Home Question and Answer." Available from: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/questions_and_answers.htm#cidp.

5. Adirondack Region Medical Home Pilot website. Available from: http://www.adkmedicalhome.org/.

6. Private insurers include BlueShield of Northeastern New York, Capital District Physicians' Health Plan, Empire BlueCross, Excellus, Fidelis Care, MVP Healthcare, and United Healthcare.

7. National Academy for State Health Policy website. Available from: http://www.nashp.org/med-home-states/new-york.

8. New York State Department of Health website. "New York State Proposal to Redesign Medicaid." Available from: http://www.health.ny.gov/health_care/medicaid/redesign/docs/descriptions_of_recommendations.pdf.

9. New York State Department of Health website. "New York State Awarded More Than 300 Million from Federal Government to Expand Medicaid Demonstration Programs." 2011 Press Release. Available from: http://www.health.ny.gov/press/releases/2011/2011-08-05_medicaid_demonstration_programs.htm.

10. Patient Centered Primary Care Collaborative. "CDPHP Patient-Centered Medical Home Pilot." Available from: http://www.pcpcc.net/content/cdphp-patient-centered-medical-home-pilot.

11. Feder, JL. "A Health Plan Spurs Transformation Of Primary Care Practices Into Better-Paid Medical Home Pilot." Health Affairs, 2011, 30(3): 397-399.

12. Patient Centered Primary Care Collaborative website. "Hudson Valley P4P Medical Home Project." Available from: http://www.pcpcc.net/content/hudson-valley-p4p-medical-home-project.

13. New York State Department of Health. "Medicaid Redesign Team: Progress Update." Webinar presentation, January 2012. Available from: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/meetings_webinars.htm.

14. Hiscock and Barclay LLP. "Legal Alert." Available from: http://www.hblaw.com/alerts/Medicaid-Redesign-Waiver-07-02-2012.

15. New York Department of Health website. "Improving Care Coordination and Management through a Patient Centered Medical Home Model Supported by an Interoperable Health Information Infrastructure." Available from: http://www.health.ny.gov/technology/efficiency_and_affordability_law/phase_10.htm.

16. New York Department of Health. "Expanding Care Coordination Through the Use of Interoperable Health Information Technology- HEAL NY Phase 17." Press release. Available from: http://www.health.ny.gov/technology/efficiency_and_affordability_law/heal_ny_17.htm.

17. New York eHealth Collaborative website. Available from: http://nyehealth.org/heal22/.

18. Unless otherwise noted, information provided on the design of the Health Home program is drawn from the text of the New York Health Home SPA. Available from: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/chronic_conditons_spa_11-56_phase.pdf.

19. This section draws from a state-sponsored webinar conducted on June 6, 2012. PowerPoint slides. Available from: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/meetings_webinars.htm.

20. New York State Care Management Training Initiative website. Available from: http://healthhometraining.com/.

21. Section 2701 outlines quality directives for Medicaid.

22. New York Department of Health. "Health Department Launches New Projects to Improve the Care of Chronically Ill Medicaid Patients." Press release, 2009. Available from: http://www.health.ny.gov/press/releases/2009/2009-01-05_medicaid.htm.

23. New York Department of Health. "Request for Proposals for Chronic Illness Demonstration Projects." RFP No. 0801031003, 2008. Available from: http://www.health.ny.gov/funding/rfp/inactive/0801031003/0801031003.pdf.

24. Burke, G., and S. Cavanaugh. "The Adirondack Medical Home Demonstration: A Case Study." United Hospital Fund, 2011. Available from: http://www.uhfnyc.org/assets/888.

25. Adirondack Region Medical Home Pilot website. Available from: http://www.adkmedicalhome.org/home/.

26. New York Department of Health. "Announcing New York Medicaid's Statewide Patient-Centered Medical Home Incentive Program." Medicaid Update, December 2009, 25(16). Available from: http://www.health.ny.gov/health_care/medicaid/program/update/2009/2009-12spec.htm.

27. MDRC website. Available from: http://www.mdrc.org/project_20_92.html.

 

 

North Carolina's Health Home Program at a Glance
Health Home Eligibility Criteria	2 chronic conditions, 1 chronic condition and at risk of another
Qualifying Conditions	Blindness Congenital anomalies Alimentary system disease Mental/cognitive conditions, except mental illness or developmental disabilities Musculoskeletal conditions Cardiovascular disease Pulmonary disease Endocrine/metabolic disease Infectious disease Neurological disorders
Enrollment*	559,839
Designated Providers	Community Care of North Carolina (CCNC), Medicaid-enrolled primary care providers (PCPs)
Administrative/ Service Framework	Health home services are coordinated through a pre-existing care management program, CCNC.
Required Care Team Members	The team centers on PCPs, with wraparound clinical services provided and coordinated through the CCNC program. The program includes 3 primary elements: (1) regional, nonprofit networks of health and social service providers that collaborate to pursue common quality, cost, and access goals; (2) a care management infrastructure that assists providers in coordinating care; and (3) a statewide coordinating agency that liaises with the state, networks, and providers to establish and meet common goals.
Payment System	Per member per month (PMPM) care management fee, paid to network and PCPs
Payment Level	PMPM fee based on beneficiary classification: Networks: $12.85 for ABD; $5.22 for pregnant patients; $4.33 for all others PCPs: $5.00 for ABD; $2.50 for all others
Health Information Technology (HIT) Requirements	No HIT requirements. CCNC has a well-developed health information exchange infrastructure. Care teams access and record patient data through a web-based portal known as the Care Management Information System. A Provider Portal allows participating PCPs to access key patient health data. The CCNC website also includes a community health information portal that aggregates health and demographic data from public databases and which networks can use to identify community health trends and target interventions to improve public health and patient access.
* January 2014 data provided to the Centers for Medicare and Medicaid Services' Health Home Information Resource Center.

Introduction

North Carolina's Section 2703 Health Home State Plan Amendment (SPA) was approved by the Centers for Medicare and Medicaid Services (CMS) on May 24, 2012, with a retroactive effective date of October 1, 2011. The state offers health home services through its existing statewide medical home program, Community Care of North Carolina (CCNC). To be eligible for services, enrollees must have at least two chronic conditions that fall within one of ten diagnostic categories, or one of eight specific chronic conditions that the state has determined place the beneficiary at-risk for developing a second chronic condition (see Table 1). Patients with one chronic condition who develop a second, pregnancy-related chronic condition are also eligible for health home services.

CCNC (sometimes referred to as Carolina Access II) is the largest of two primary care case management (PCCM) programs that serve the majority of North Carolina's Medicaid beneficiaries. The second PCCM program, Carolina Access I, predates CCNC by several years. Both programs were established under a Section 1915(b) managed care waiver, and both require enrollees to identify a primary care practice that is responsible for managing their care. Medical providers are paid fee-for-service (FFS), and practices receive a per member per month (PMPM) management fee for both categories of enrollee. Enrollment in one of these two PCCM (CA I and CA II) programs is mandatory for most Medicaid beneficiaries. Optional enrollment groups include those dually eligible for Medicare and Medicaid, children receiving Supplemental Security Income or foster care/adoption assistance, members of federally recognized Indian tribes, individuals with end stage renal disease and pregnant women. Those ineligible for enrollment include individuals in nursing homes, those on a deductible, or those receiving limited Medicaid coverage. Beneficiaries may apply for an exemption from PCCM for medical reasons (e.g., in cases where the enrollee is terminally ill, receiving radiation or chemotherapy, or is too cognitively impaired to understand or participate in care management).

Both CCNC and Carolina Access I operate statewide; at present, approximately 300,000 are enrolled in Carolina Access I, while more than 1.2 million Medicaid and Children's Health Insurance Program (CHIP) beneficiaries are enrolled in CCNC. The primary distinction between the two programs is in the degree of care management available to enrollees. Medical home providers for Carolina Access I enrollees must offer 24/7 access to care and comply with some other minimal requirements, and receive a very modest fee (reportedly about $1 PMPM) in return. CCNC enrollees, in contrast, have access to care management services that are coordinated by one of 14 regional networks of providers and overseen by a nonprofit organization called North Carolina Community Care Network (NC-CCN), which operates under contract to the state. These services are described in greater detail in the next section, but include care transition support, medications management, and quality of care monitoring, among others. In addition, CCNC also plays a role in several state-supported pilots and demonstration projects.

Implementation Context

North Carolina's health home program has been implemented within a much broader context of care coordination and integration activities, many of which are directly relevant to the provision of health home services. Through its partnership with CCNC, the state is participating in several federally sponsored demonstration pilots and projects, and has spearheaded a range of initiatives targeting sub-populations with special needs. This section provides a brief overview of these initiatives, with special focus on those that are similar to the health home program or have implications for the long-term evaluation.

In 2010, North Carolina received a five-year 646 demonstration waiver from CMS which allowed CCNC to manage care for dual eligibles in 26 counties. The demonstration enrolled more than 40,000 beneficiaries receiving care at over 200 practices. As part of this initiative, CCNC screened enrollees for risk and identifies those in need of enhanced care management services, tracked performance and set quality improvement goals, and tested different care models. These care models included home visits, care management, and palliative care.¹ In May 2011, the state submitted an application for a CMS State Demonstration Grant to Integrate Care for Dually Eligible Individuals (duals grant).² In December 2012, the 646 demonstration was discontinued in anticipation of the duals demonstration. However, the state subsequently decided not to pursue the duals grant application.³

In November 2010, North Carolina was also selected to take part in the Medicare Multi-payer Advanced Primary Care Practice (MAPCP) demonstration. As part of this demonstration, CCNC has partnered with Medicare, BlueCross BlueShield of North Carolina (BCBSNC), and the State Health Plan for Teachers and State Employees in seven rural counties, with the goal of aligning incentives for quality improvement and cost containment. Participating practices are required to apply for primary care medical home recognition from the National Committee for Quality Assurance (NCQA), as well as perform a range of care management and coordination services for enrollees.⁴

CCNC also has launched initiatives targeting children and pregnant women, two of which involve federal partners. In 2009 the state received a Children's Health Insurance Program Reauthorization Act (CHIPRA) Quality Demonstration Grant to incorporate and report on child-focused quality measures, enhance its medical home model for children with special health care needs, and evaluate the impact of a pediatric electronic health record (EHR).⁵ In June 2012, CCNC received a three-year grant from the Center for Medicare and Medicaid Innovation (CMMI) to implement a program known as the Child Health Accountable Care Collaborative. Under this program, the state will incorporate approximately 50,000 children with complex health needs into its medical home model, embed pediatric care managers in hospitals and specialty clinics, and provide patient navigation assistance to families of children with these complex needs.⁶ At the state level, CCNC is partnering with other state agencies on the Care Coordination for Children (CC4C) initiative, which is an at-risk population management program serving children from birth to age five who meet certain risk criteria (e.g., children with special health care needs, those exposed to severe stress, and children transitioning out of neonatal intensive care).⁷ On the maternal health side, CCNC recently launched the Pregnancy Medical Home program, which links obstetric practices to the CCNC regional networks and provides specialized care management services to women during their pregnancy. Since the program began in March 2012, more than 300 practices have signed up to become pregnancy medical homes.⁸

Other state-level initiatives include disease-specific care management programs for asthma, diabetes, congestive heart failure (CHF), and chronic obstructive pulmonary disease; as well as a Behavioral Health Integration initiative that involves a range of targeted projects. The initiative was launched in February 2010 in order to support the integration of mental health and substance abuse treatment into primary care practices enrolled in CCNC. Current projects include a chronic pain management project (Project Lazarus), a project promoting the integration of substance abuse screening and treatment interventions into primary care, and several projects related to prescribing practice and drug safety.⁹ CCNC also works with newly implemented Local Management Entities-Managed Care Organizations (LME-MCOs) to better coordinate the care of enrollees with both medical and behavioral health conditions. LME-MCOs were established under a Section 1915(b)/(c) waiver, and receive a capitated payment for managing care related to mental illness, substance abuse, and developmental disabilities.¹⁰

Underpinning these initiatives is a well-developed information technology infrastructure (described in greater detail below), which supports both health information exchange (HIE) and the various tools used by participating providers and care managers. CCNC is the first Qualified Organization participating in the state HIE.¹¹ The earliest adopters of the state platform are those practices involved in the North Carolina Program to Advance Technology for Health, which is a collaboration with the BCBSNC and AllScripts, that provides practices with assistance in EHR adoption and use. CCNC will also collaborate with the HIE to develop platforms that support medical home practices. The first of these will focus on expanding CCNC's medication management program Pharmacy Home. In addition to these statewide information technology initiatives, one CCNC regional network is also a Beacon Community grant recipient. Southern Piedmont Community Care Network received funding to add care managers, pharmacists and mental health counselors to its staff, expand a patient education program into a range of clinics, and test a range of care management technologies.¹²

Implications for the North Carolina Section 2703 Medicaid Health Homes Evaluation

CCNC is a well-established program that has been providing health home-like services for several years, and is involved in other major initiatives to integrate care, including multi-payer initiatives. It does not appear that any significant changes have been made to the networks' underlying structures and processes as a result of the state's adoption of the health home option. Because of this, and because CCNC acts as the coordinating entity for so many different pilots and programs, many of which target or include beneficiaries who are health home-eligible, it may be difficult--perhaps impossible--to distinguish a "health home effect" from the effects of other ongoing CCNC initiatives. Its statewide coverage and dominant role in serving Medicaid beneficiaries further complicate the ability to identify similar beneficiaries not exposed to health home services or other initiatives for comparison.

Population Criteria and Provider Infrastructure

North Carolina offers health home services to all categorically needy and medically needy Medicaid beneficiaries with two chronic conditions, or one chronic condition and the risk of developing another. (See Table 1 for a full list of the population criteria, designated providers, and the health home team composition requirements.) The state has identified eight specific conditions that qualify a beneficiary as being at risk of developing a second condition, and has further specified that beneficiaries with one qualifying condition will become eligible for health homes if they become pregnant and develop a related chronic condition such as gestational diabetes or gestational hypertension. Mental illness and developmental disability are specifically excluded from the list of conditions, since managing the care of beneficiaries with those conditions is the primarily the responsibility of the newly established LME-MCOs. Health home services will be coordinated through a pre-existing care management program, CCNC, and will be provided through the state's network of designated Primary Care Medical Homes, described in greater detail below.

Community Care of North Carolina

CCNC was officially launched as a statewide PCCM program in 2001, having evolved from a pilot care coordination program established in the 1980s.¹³ Though the program was initially state-run, since 2007 most of the program development and management responsibilities have been transferred to a nonprofit, public-private partnership. This partnership acts as the umbrella organization for 14 regional networks, each of which comprises physicians, hospitals, local health departments, and departments of social services (see Figure 1). Each regional network is responsible for managing the care of enrollees within its constituent counties, including linking enrollees to a medical home, providing care management services, managing care transitions, referring patients to social and long-term care supports, and implementing a range of quality improvement initiatives.¹⁴ Statewide, more than 1.2 million Medicaid and NC Health Choice (the state CHIP program) beneficiaries--including roughly 100,000 dual eligible--are currently enrolled in CCNC.

Once enrolled, each beneficiary is linked to one of more than 1,500 participating primary care medical homes. In addition to providing acute, chronic, and preventive care, these medical homes are also responsible for comprehensive care management and referral to specialty care, long-term care support, and social and community services. Medical homes are supported in this endeavor through their involvement in a regional network, which provides a range of different resources and support to practices, depending on their needs and the existing care infrastructure.

Each regional network employs a staff of care managers who work to augment the care management services provided by the medical home team. Care managers may work at either the network or practice level, and they serve a number of roles, including home visits, medication reconciliation, care planning and referral coordination, and practice redesign. Networks also employ a pharmacist, who directs medication management and e-prescribing initiatives, and a psychiatrist, who directs behavioral health integration efforts and provides support to practices in managing patients with behavioral health needs.¹⁵ Networks also employ dedicated quality improvement staff to work directly with enrolled practices, and may also obtain their own grant funding for discrete initiatives (as in the case of the aforementioned Southern Piedmont, which is a Beacon Community grant recipient).¹⁶

The central CCNC agency provides a range of support to practices as well. For example, though formal certification as a medical home is not required for practices not participating in the MAPCP demonstration, CCNC does provide resources and tools to practices wishing to obtain NCQA certification. CCNC frequently serves as the coordinating body for pilot initiatives and demonstrations that may later be rolled out statewide. The Pregnancy Care Management (PCM) program is one example of this. Beneficiaries who become eligible for health home services during pregnancy will be served through this program, which includes local care management in collaboration with obstetrics providers. The program also provides supplemental, specialized care management related to obstetric care needs.

CCNC and Carolina Access I enrollees typically select their medical home when they apply for Medicaid (a process which is handled by county Department of Social Service offices), choosing from a list of providers who are participating in each program. It does not appear that this procedure is any different for the health home-eligible. From the beneficiary's perspective, participation in the health home initiative is "invisible" (i.e., beneficiaries are not notified of their eligibility or treated differently from any other CCNC enrollee). For the purposes of correctly allocating the enhanced funding available for services provided to the health home population, however, the state identifies health home beneficiaries primarily through Medicaid claims data, though beneficiaries may also be identified and enrolled through direct referral, chart review, or screenings and assessment.

Service Definitions and Provider Standards

Health home services do not differ substantively from those of the broader CCNC program. The division of roles is flexible, and CCNC care managers may play an active part in all six defined services. Their role is most explicitly defined in comprehensive care management and transitional care (see Table 2). The estimated average caseload per care manager ranges 5,000-7,000 for the Aid to Families with Dependent Children, and 1,500-3,000 for the Aged, Blind, and Disabled (ABD) population. The state bases this caseload on the assumption that only 5%-10% of a given population will need care management services at any one time and that services will vary in terms of intensity, ranging from home visits to telephonic intervention.

Regional CCNC networks also have a mandated role to play in service provision, most notably in facilitating relationships between hospitals and primary care, ensuring timely notification of admission and sharing of patient records post-discharge. In hospitals with high rates of admission among the Medicaid ABD population, transitional care nurses (56 statewide) are embedded full-time to manage the care transition process. In other cases, CCNC care managers visit patients in the hospital and then conduct follow-up home visits that include medication reconciliation. Network-employed pharmacists also review medication lists post-discharge and alert the primary care provider (PCP) of any discrepancies or other findings.

Network psychiatrists assist in the implementation of the state's behavioral health integration model, which aims to improve care coordination through screening and treatment of mental health conditions in the primary care setting and enhancement of the referral processes for patients with more complex needs. Regional networks also play a role in helping practices conduct health promotion activities and connect patients to long-term support services, both by including local social service agencies within the network and by producing resource manuals for providers.

In addition to meeting the basic requirements of any Medicaid provider, practices that wish to participate in a CCNC network must agree to collaborate with that network on a range of care management activities. Specifically, these include:

• Developing and utilizing care management systems and tools for Medicaid enrollees, including identification of a "practice champion," participation in network meetings, the development of a transitional care process, and sharing necessary clinical information with the network.

• Complying with policies and procedures developed by network leadership to improve quality and reduce cost.

• Cooperating with the network's patient risk assessment process for identifying and tracking patients who need disease and care management, and participating in inter-disciplinary teams to help manage their care.

• Coordinating with the CCNC care managers and participating in the implementation of care management plans.

• Collaborating with the Network to:

  • develop strategies to address special needs of the Medicaid population;
  • develop referral processes and communication with other providers;
  • promote patient self-management;
  • meet utilization and budget targets;
  • evaluate and implement appropriate changes in service utilization; and
  • develop and refine CCNC measures, utilization reports, management reports, quality improvement goals, and care management initiatives.

Use of Health Information Technology

CCNC has a well-developed HIE infrastructure--referred to as the Informatics Center--sponsored by both the state and CMS. The Informatics Center uses data from many sources to perform a range of functions and includes several different platforms that CCNC networks and providers can use to manage the health of enrolled Medicaid patients. Current Informatics Center data includes Medicaid claims data, patient record data, laboratory data, hospital data, and Medicare and pharmacy claims for those dual eligibles who are participating in certain demonstrations. For 56 of the state's 123 hospitals, admissions and emergency department visit data are automatically sent to the Informatics Center through real-time feeds.

Care managers (as well as other network-employed providers such as pharmacists and social workers) access these real-time feeds and other data through a web-based portal known as the Care Management Information System (CMIS). CMIS acts as a centralized care management tool, allowing care managers to access and manually update key patient health and PCP information (including inpatient admissions and emergency department visits for patients who visit one of the 67 hospitals that do not have automated real-time feeds), develop and implement care plans, identify care gaps through chart audits, and access health promotion and patient self-management tool kits. All care management information is recorded in CMIS and can be used to report on a range of queries related to a patient's care, as well as to monitor and evaluate the performance of care managers.

CCNC also maintains a Provider Portal, which incorporates elements of CMIS and allows authorized providers to access a range of Medicaid patient data. This includes visit history, pharmacy claims, lab and imaging records, care team contact information, and encounter information that occurred outside the local health system. Providers are also able to access population management reports and quality metrics for their patient population. In addition to data from CMIS, the Provider Portal incorporates data from Pharmacy Home, a separate database that provides patient profiles and medication histories, and Informatics Center Report Site, which allows networks to conduct population needs assessments, identify high-need patients, monitor utilization, and track performance indicators. The CCNC website also includes a community health information portal that aggregates health and demographic data from public databases and which networks can use to identify community health trends and target interventions to improve public health and patient access.

This health information technology (HIT) infrastructure plays an important role in CCNC's ongoing quality improvement monitoring and evaluation process. For example, the Informatics Center produces quarterly reports on over 70 data elements related to the ABD population, which are used to identify individuals in need of additional screening. CCNC also conducts regular chart audits using an electronic audit tool that randomly selects patients based on diagnosis and pre-populates an audit report that can be reviewed by outside auditors. The results of these audits are then made available to practices and networks through the Informatics Center Report Site.

Payment Structure

North Carolina made no changes to its CCNC payment system as part of its implementation of the health homes option. Instead, the enhanced federal match is used to offset state funding of services provided to health home beneficiaries enrolled in CCNC. In addition to the base Medicaid FFS schedule, CCNC medical homes receive a tiered PMPM payment for each enrolled beneficiary. CCNC networks also receive a tiered PMPM for the provision of services to all health home enrollees, a portion of which is retained by the central CCNC office to support its activities.

The PMPM is higher for the ABD population, and networks can also receive add-on payments for services related to the PCM program (see Table 3). The rates are based on estimated costs at the practice and network level, which are regularly re-evaluated and include staffing, facilities, and infrastructure.

Of this PMPM, the central office retains $3.75 and $0.65 for each ABD and non-ABD enrollee, respectively.¹⁷ Payment of the health home PMPM is triggered for a given patient when all four criteria below have been met:

• The patient is identified as meeting health home eligibility criteria on both the Medicaid Management Information System and the CCNC care management system.

• The patient is enrolled as a health home member.

• The patient has received care management monitoring or another health home service.

• The health home has recorded the service on a monthly activity report, which will track and record whether CCNC or another provider performed the service, the provider number, the beneficiary number, and the date of service.

Quality Improvement Goals and Measures

North Carolina has selected 38 quality improvement measures shown in Table 4. Fourteen are goal-based, and 24 are service-based. Twelve measures target children, and the rest are adult measures. The majority of these measures are scores from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, which will be administered for both adults and children. The rest will be derived primarily through claims, though the state will also survey CCNC providers and conduct chart review for certain measures. Some of the measures identified in the SPA (such as those related to admissions, readmissions, and blood pressure control) are made available to practices and care managers through CCNC's information technology system.

Evaluation Measures and Methods

North Carolina has a developed a substantial data collection and reporting infrastructure for its CCNC program, which is used to monitor networks and providers throughout the year as well as set targets for achievement. In addition, some of this data is made available to networks at the patient, practice and network level through the Provider Portal. Measures tracked include avoidable hospital readmissions, admissions for asthma and heart failure, and emergency department visit rates, among others. These measures are generally collected monthly and reported quarterly and are stratified by health home and nonhealth home patients as part of the state's ongoing monitoring and evaluation strategy. Table 5 reproduces this strategy as detailed in the SPA. The state's measures are based on the ABD population not dually eligible for Medicare and Medicaid, with notations that for claims-based measures, "dually eligible Medicare claims [will be] included to extent CMS develops capacity to share them as currently proposed" and that targets for the dual eligibles will be established based on experience.

The state plans to use claims analysis to measure overall cost savings and acute care cost savings--excluding behavioral health costs and residential services--by date of service, and will report them separately for health home enrollees. Costs, to be reported on an annualized basis, include PMPM payments, acute care costs, and emergency department costs. The SPA is not clear on any plan to identify a comparison group of similar beneficiaries not enrolled in health homes.

FIGURE 1. Organizational Structure of CCNC

 

TABLE 1. Target Population and Designated Providers--North Carolina
SPA Approval (Effective Date)	May 24, 2012 (October 1, 2011)
Designated Provider(s)	Primary care medical homes participating in the CCNC program
Health Home Team Composition	The team centers on PCPs, with wraparound clinical services provided and coordinated through the CCNC program. The program includes 3 primary elements: (1) regional, nonprofit networks of health and social service providers that collaborate to pursue common quality, cost, and access goals; (2) a care management infrastructure that assists providers in coordinating care; and (3) a statewide coordinating agency that liaises with the state, networks, and providers to establish and meet common goals.
Target Population	Beneficiaries must have: 2 chronic conditions 1 chronic condition and the risk of developing another
Qualifying Chronic Conditions	Blindness Congenital anomalies Chronic alimentary system disease Chronic mental and cognitive conditions, excepting mental illness or developmental disability Chronic musculoskeletal conditions Chronic cardiovascular disease Hypertension* Anemia/chronic blood disorder* Chronic pulmonary disease Asthma* Pulmonary disease/chronic bronchitis* Chronic endocrine and metabolic disease Diabetes* BMI over 25* Chronic infectious disease Perinatal infections* Chronic neurological disorders Chronic pain*
* Indicates conditions for which the state will presume the patient is at-risk for a second chronic condition.

 

TABLE 2. Health Home Service Definitions--North Carolina
Care Coordination	The implementation of the individualized care plan through appropriate linkages, referrals, coordination and follow-up to needed services and supports. Specific activities include, but are not limited to: appointment scheduling, conducting referrals and follow-up monitoring, participating in hospital-discharge processes and communicating with other providers and clients/family members. Care Managers or PCP team members are responsible for conducting care coordination activities across providers and settings, and CCNC care manager coordination interventions are identified and documented in the CMIS.
Comprehensive Care Management	Involves active participation from PCPs, care managers, and patient and family/caregivers and includes: Patient identification and comprehensive assessment. Developing an individualized care plan. Care coordination: The care manager ensures the patient's care plan is implemented, communicating and coordinating across providers and delivery settings. Care manager interventions are identified and documented. Reassessment and monitoring: The health care team monitors the patient's progress and adjusts care plans, as needed. Outcomes and evaluation: The health care team uses quality metrics, assessment and survey results, and utilization of services to monitor and evaluate the impact of interventions.
Health Promotion	PCPs, their care teams, and/or CCNC care managers help patients participate in the implementation of their care plan and place a strong emphasis on skills development for management and monitoring chronic health conditions. Services include health education and coaching specific to an individual's chronic conditions, development of self-management plans with the individual, education regarding the importance of immunizations and screenings, and promoting lifestyle interventions such as nutrition counseling and smoking cessation.
Comprehensive Transitional Care	Every CCNC hospital admission is assessed for transitional care need, in some cases using real-time data from multiple sources. Transitional care is initiated for patients with chronic conditions at high-risk of readmission and for conditions in which the admission is for an ambulatory care sensitive condition. Networks also ensure timely transmission of patient information to the relevant providers upon discharge. The primary role of the care manager in the transitional care process is to: Facilitate inter-disciplinary collaboration among providers during transitions. Encourage the PCPs, patients, and family/caregivers to play a central and active role in the formation and execution of the care plan. Promote self-management skills and direct communication among the patient and/or caregiver, the PCP, and other care providers. Achieve medication reconciliation by consulting with the network pharmacist, hospital, PCP, specialists, and the patient and his/her caregiver.
Individual and Family Support Services	Provided by care teams or CCNC care managers, these services include, but are not limited to, advocating for individuals and families and assisting with obtaining and adhering to medications and other prescribed treatments. In addition, health team members are responsible for identifying resources to support individuals in attaining their highest level of health and functioning in their families and in the community, including transportation to medically necessary services and access to long-term care and support services.
Referral to Community and Social Supports	CCNC works to increase access to appropriate community and social support services, and to utilize and organize community resources. Locally-based care managers share their knowledge of local resources with network providers by providing resource manuals containing relevant contact information for an array of community and social support services.

 

TABLE 3. PMPM Rates for Health Home Services as of March 2011--North Carolina
	CCNC-Enrolled Medical Homes	CCNC Central Offices and Regional Network
ABD	$ 5.00	$ 12.85
Non-ABD	$ 2.50	$ 4.33
PCM	---	$ 5.22

 

TABLE 4. Health Home Goals and Quality Measures--North Carolina
Goal-Based Measures
Reduce Avoidable Emergency Department Utilization	Clinical outcome measures: Emergency department visit rate for nondual ABD and non-ABD per 1,000 member months Experience of care measures--adult: CAHPS Core Question 4: In the last 6 months, when you needed care right away, how often did you get care as soon as you thought you needed it? CAHPS Core Question 6: In the last 6 months, not counting the times you/your child needed care right away, how often did you get an appointment for health care at a doctor's office or clinic as soon as you thought you needed it? CAHPS Core Question 21: In the last 6 months, how often was it easy to get the care, tests, or treatment you thought you needed through your health plan? Experience of care measures--child: CAHPS Core Question 4: In the last 6 months, when your child needed care right away, how often did your child get care as soon as you thought you needed it? CAHPS Core Question 6: In the last 6 months, not counting the times your child needed care right away, how often did your child get an appointment for health care at a doctor's office or clinic as soon as you thought your child needed it? CAHPS Core Question 24: In the last 6 months, how often was it easy to get the care, tests, or treatment you thought your child needed through your health plan?
Reduce Avoidable Hospitalizations	Clinical outcome measures: Inpatient admissions for enrolled nondual ABD members per 1,000 member months Asthma hospitalization for enrolled nondual ABD members per 1,000 member months Heart failure admissions for enrolled nondual ABD members per 1,000 member months
Increase Integration of Primary Care and Behavioral Health Care	Experience of care measures--adult: CAHPS Supplemental Question CC6: In the last 6 months, were any decisions made about your health care? CAHPS Supplemental Question CC7: In the last 6 months, how often were you involved as much as you wanted in these decisions about your health care? Experience of care measures--child: CAHPS Core Question CC1: In the last 6 months, how often did you have your questions answered by your child's doctors or other health providers? Quality of care measures: Percent of practices with co-located behavioral health providers
Service-Based Measures
Comprehensive Care Management	Quality of care measures: Percent of patients meeting CCNC priority criteria who received a Comprehensive Health Assessment or an Intervention
Care Coordination	Experience of care measures--adult: CAHPS Supplemental Question OHP5: How satisfied are you with the help you received to coordinate your care in the last 6 months? CAHPS Supplemental Question MH2: In the past 6 months, did you need any treatment or counseling for a personal or family problem? CAHPS Supplemental Question MH3: In the past 6 months, how often was it easy to get the treatment or counseling you needed? Experience of care measures--child: CAHPS Core Question CC17: In the last 6 months, did your child get care from more than 1 kind of health care provider or use more than 1 kind of health care service? CAHPS Core Question CC18: In the last 6 months, did anyone help coordinate your child's care among different providers or services? CAHPS Core Question CC14: In the last 6 months, did you get or try to get counseling for your child for an emotional or behavioral problem? CAHPS Core Question CC15: In the last 6 months, how often was it easy to get this treatment or counseling for your child?
Comprehensive Transitional Care	Clinical outcome measures: Percent of avoidable admission in the enrolled nondual ABD population, stratified by mental health and nonmental health population Heart Failure 30-day readmissions Experience of care measures--adult: CAHPS Supplemental Question CC18: In the last 6 months, have you been a patient in a hospital overnight or longer? CAHPS Supplemental Question OHP3: In the last 6 months, did anyone from your health plan, doctor's office, or clinic help coordinate your care among other doctors or health providers? Experience of care measures--child: CAHPS Supplemental Question OHP3: In the last 6 months, did anyone from your child's health plan, doctor's office, or clinic help coordinate your care among other doctors or health providers? Quality of care measures: Percent of patients with Medication Reconciliation or Medication Review documented in CMIS with 30 days post-discharge
Health Promotion	Clinical outcome measures--adult: Mammography rates among women 40-69 Pap smear rates among women 21-64 Colorectal cancer screening rate among men and women 50-75 Clinical outcome measures--child: Well-child visits in the first 15 months of life Well-child visits among children aged 3-6 Adolescent well-care visits Experience of care measures--adult: CAHPS Supplemental Question H1: In the last 6 months, how often did you and a doctor or other health provider talk about specific things you could do to prevent illness? Experience of care measures--child: CAHPS Supplemental Question H1: In the last 6 months, how often did you and your child's doctor or other health provider talk about specific things you could do to prevent illness in your child? Quality of care measures: Percent of hypertensive patients whose most recent blood pressure is less than 130/80 Percent of diabetic patients whose most recent blood pressure is less than 130/80

 

TABLE 5. Evaluation Methodology--North Carolina
Avoidable Hospital Readmissions	Potentially preventable readmissions within 30 days as a percent of potentially preventable hospital admissions, any diagnosis, excluding mental health. Data will be reported quarterly from baseline year 2010. The target is a 4% reduction from baseline rate by end of year 1 (state fiscal year 2011); maintained from baseline rate by end of year 2 and year 3. These targets are currently for ABD nonduals. Duals targets will be set after additional experience and spread statewide. Hospital admissions within 30 days of prior discharge date with CHF as the primary or secondary diagnosis, as a percentage of CHF hospital discharges. Reported quarterly on a rolling 12 month basis.
Hospital Admissions	In addition to measures specific to health homes enrollees, Community Care uses information in its Informatics Center to evaluate health home performance related to hospital admission rates for the Community Care program that will be made available to the program evaluation. The Informatics Center contains Medicaid health care claims data and also real-time hospital data from 56 large North Carolina hospitals. Network targets are set annually and performance toward the targets is reviewed throughout the year to identify if improvement plans need to be developed. In addition to measures cited above and in Table 4, the state will also track mental health readmissions within 30 days.
Emergency Department Visits	In addition to the emergency department measures already cited, the state will also measure the asthma emergency department visit rate per 1,000 member months.
Skilled Nursing Facility (SNF) Admissions	SNF Admission rate per 1,000 member months.
Chronic Disease Management	Community Care captures Chronic Disease Management process of care measures across all recipients receiving care management, and also captures disease-specific outcomes for disease management initiatives. Standardized processes for care managers who provide care management services to these patients are monitored routinely by supervisors, using reports from CMIS. Specific quality measures that are monitored include chart review and claims-based measures included in the CCNC Quality Measurement and Feedback (QMAF) program (see Assessment of Quality Improvements and Clinical Outcomes section below for further details) and other measures identified by NC-CCN and Network that impact cost and quality. In addition, Community Care has several disease management initiatives in place in every network, and CCNC has the capacity to capture and measure outcomes by diagnosis for disease-specific measures as needed. Current disease management initiatives include asthma, diabetes, ischemic vascular disease, and CHF. Evaluation of these initiatives is conducted on a routine basis through monitoring clinical, utilization, and cost measures for targeted patients at the practice, Network, and program-wide level.
Care Coordination	Community Care captures care manager performance in Care Coordination using the Care Management Standardization Plan developed by CCNC. The Care Management Standardization Plan provides definitions and specificity in care management priorities, care management actions steps, medication management steps, components of the transitional care model, and care management intensity levels. A standardized care management plan will facilitate evaluation of performance in coordination of care. Community Care monitors and evaluates the performance and activities of all care managers through CMIS. Networks and the central office have the ability to create parameterized queries at the patient, practice, network or care manager level. For example, Community Care can generate a report on all heavy-intensity patients at a practice or those who are served by a specific care manager. These reports enable both care managers and supervisors to examine activities and interventions on a macro level and compare progress and outcomes of interventions.
Assessment of Program Implementation	The Community Care program has been implemented statewide, across all regional networks. The state has the capacity to assess and monitor ongoing performance of the Community Care program across networks through NC-CCN. CCNC develops a comprehensive statewide assessment of progress and results of implementing the quantitative, analytical, utilization, quality, cost containment, and access goals and deliverables established each year. Similar evaluation of program implementation is a required activity of networks, whose role it is to work with practices to continuously improve the care they provide.
Processes and Lessons Learned	There are continuous opportunities within Community Care to evaluate processes and lessons learned, supported by Community Care's extensive reporting infrastructure and its regional network organization. The state Medicaid Agency, practices and networks receive monthly, quarterly, and annual feedback on process, cost, utilization, and quality metrics that will be useful for evaluation purposes.
Assessment of Quality Improvements and Clinical Outcomes	Since its beginning in 1998, CCNC has used performance measurement and feedback to help meet its goals of improving the quality of care for Medicaid recipients while controlling costs. Quality measurement is intended to stimulate or facilitate quality improvement efforts in CCNC practices and local networks, and to evaluate the performance of the program as a whole. CCNC's QMAF program was substantially expanded in 2009, in response to the needs of an expanded ABD enrolled population with multiple chronic conditions, and in response to requests from providers and practices to seek alignment in quality measures across multiple payer or stakeholder entities. A work group with representation from all 14 CCNC networks was convened in 2007, and met over the course of a year for in-depth review of candidate measures. Goals were to identify a broad set of quality measures with: Clinical importance (based on disease prevalence and impact, and potential for improvement). Scientific soundness (strength of evidence underlying the clinical practice recommendation. Evidence that the measure itself improves care; and the reliability, validity, and comprehensibility of the measure). Implementation feasibility, and synergy with other state and national quality measures or quality improvement programs. Measures are not intended to capture every aspect of good clinical care. Reports on QMAF measures are available through the Informatics Center Provider Portal for CCNC staff and providers. Where possible, reports include relevant benchmarks, both internal (network and program-wide) and external (HEDIS mean and 90th percentile, NCQA and North Carolina Healthcare Quality Alliance targets). Approximately 50 quality measures are currently tracked in the QMAF system.
Cost Savings	The state will capture both overall cost savings and acute care cost savings measures that exclude behavioral health costs. These will be reported for health homes enrollees as separate from other Community Care enrollees. Costs will be captured using date of service, and cost trends will be reported on an annualized basis. Cost measures will include: Total PMPM costs (subtracting behavioral health costs and residential services). Acute care costs. Emergency department costs.

 

APPENDIX: Pre-Existing Initiatives in North Carolina
	Medicare 646 Demonstration1, 19	Dual Eligible Beneficiary--Integrated Delivery Model	MAPCP Demonstration20, 21	CHIPRA Quality Demonstration5, 22	Child Health Accountable Care Collaborative6, 23	CC4C6, 24	Pregnancy Medical Home8, 25	Behavioral Health Initiative9
Timeline	Original timeline was January 2010-May 2014; program has since ended	Application approval pending; proposed start date was January 2013	October 2011-September 2014	February 2010-February 2015	July 2012-June 2015	Emerged in 2011 as the replacement for a child-focused targeted case management program	Launched in April 2011	Launched in February 2010
Geographic Area	26 counties	Statewide	7 rural counties	Statewide, with certain activities taking place in 8 networks	Statewide	Statewide	Statewide	Statewide
Sponsors	CCNC and CMS	CCNC, CMS, and the North Carolina Department of Health and Human Services	CMS, CCNC, North Carolina State Health Plan, BCBSNC	CCNC and CMS	CMMI	CCNC, North Carolina Medicaid, and the North Carolina Department of Public Health	CCNC, North Carolina Medicaid, and North Carolina Department of Public Health	CCNC
Scope	200+ practices 900+ providers 8 regional networks	All 14 networks 176,000+ full-benefit dual eligibles	95,000 patients 154 practices 490+ providers	24-27 practices participating in Learning Collaboratives, statewide reporting of measures and testing of pediatric EHR models	All 14 networks 5 academic medical centers 7 tertiary care hospitals Enrolled children with complex medical conditions	All 14 networks Local Health Departments Enrolled children from birth to age 5 who meet certain risk factors	350 pregnancy medical homes (private practice, federally qualified health centers, hospital-based clinics) 1,500 providers, including obstetrics, midwives, physician assistants, and nurse practitioners	All 14 networks LME-MCOs Behavioral health agencies
Goals	Improve quality of care and patient outcomes for dually eligible and Medicare-only beneficiaries	Improve quality of care and patient outcomes for dually eligible beneficiaries Reduce system fragmentation and costs	Improve quality, reduce spending, and decrease costs through use of HIT-supported care management and coordination	Report all 24 CHIPRA quality measures to both CMS and CCNC Strengthen the pediatric medical home model Develop and test a pediatric EHR model	Improve access and continuity of care Reduce emergency department visits, hospitalizations, and pharmacy costs for children with complex medical conditions	Improve health outcomes and reduce costs for enrolled children	Improve care for pregnant women Improve health outcomes Reduce maternal care costs	Integrate behavioral health into primary care and share best practices Collaborate with LME-MCOs and behavioral health providers Improve prescription monitoring
Payment Approach	Medicare savings shared with NC-CCN; contingent on meeting performance benchmarks and capped at a percentage of overall savings.	Tiered PMPM for care management Provider capacity development incentive payment Retrospective performance payment to providers	Tiered PMPM for Medicaid and Medicaid enrollees Enhanced FFS for evaluation and management codes billed to BCBSNC	No information found	No information found	No information found	Participating Pregnancy Medical Homes receive an add-on payment for care management, and financial incentives for performing screenings and evaluations	No information found
Technical Assistance (TA)	No information found	No information found	CCNC and BCBSNC offer practices support in obtaining NCQA recognition	Quality improvement specialists work with all networks on Quality improvement activities; will work intensely with Learning Collaborative practices	No information found	No information found	Practices receive Quality improvement support from CCNC	CCNC-employed psychiatrists provide consultations and guidance to providers
HIT Use	Medicare data for enrollees was integrated into the Informatics Center	Medicare data will be integrated into the Informatics Center	BCBSNC and Medicare data integrated into Informatics Center	It is expected that: Measures will be integrated into CCNC's system Pediatric EHRs will interface with CCNC and the state HIE	Pediatric care managers will have access to Informatics Center data through CMIS	CC4C care managers will have access to Informatics Center data through CMIS	Informatics Center was augmented to include obstetric-related data such as pre-term birth rates, caesarian rates, etc.	HIE varies; some networks share data with their regional LME-MCO and behavioral health agencies, others do not
Evaluation Methods	Comparison group composed of beneficiaries receiving a qualifying service from a PCPs in 78 counties in 5 other states	The state has selected a range of quality measures that it will track on an ongoing basis to evaluate performance	CMS has contracted with a vendor to evaluate the effects on Medicare patients	CMS has contracted with a vendor to evaluate a range of outcomes for the national CHIPRA demonstration	No information found	Evaluation measures focus on reducing emergency department and hospital utilization, and increasing primary care and prevention access	CCNC will track practice-level performance related to birth weight and caesarian rate goals.	CCNC is tracking a range of measures focusing on reducing inpatient and emergency department utilization, and improving care coordination and transitions

Endnotes

1. Wade, T. et al. "An Update on Community Care of North Carolina's Medicare Demonstrations." NCMJ, 2011, 72(3):225-228. Available from: http://www.ncmedicaljournal.com/wp-content/uploads/2011/05/72314-web.pdf.

2. "North Carolina State Demonstration to Integrate Care for Dual Eligible Individuals." Available from: http://www.communitycarenc.com/media/files/final-dual-proposal-pdf.pdf.

3. Personal communication with state officials.

4. CCNC website. "Multi-payer Advanced Primary Care Practice Project (MAPCP)." Available from: https://www.communitycarenc.org/emerging-initiatives/multi-payer-demonstration/.

5. CCNC website. "CCNC Pediatrics (Including CHIPRA Quality Demonstration)." Available from: https://www.communitycarenc.org/population-management/ccnc-pediatrics-in....

6. CCNC website. "Child Health Accountable Care Collaborative: Improving Care for the State's Most Vulnerable Children." Available from: https://www.communitycarenc.org/emerging-initiatives/child-health-accountable-care-collaborative/.

7. CCNC website. "Care Coordination for Children." Available from: https://www.communitycarenc.org/emerging-initiatives/care-coordination-children-cc4c/.

8. CCNC website. "Pregnancy Medical Home: Better Care, Better Birth Outcomes." Available from: https://www.communitycarenc.org/emerging-initiatives/pregnancy-home/.

9. CCNC website. "Behavioral Health Integration: Meeting Both Behavioral and Physical Needs." Available from: https://www.communitycarenc.org/population-management/behavioral-health-page/.

10. North Carolina Department of Health and Human Services. "How is North Carolina Implementing the 1915(b)/(c) Medicaid Waiver?" Available from: http://www.ncdhhs.gov/mhddsas/communicationbulletins/commbulletin123/mco....

11. CCNC website. "North Carolina Health Information Exchange: Onramp to the Information Superhighway." Available from: https://www.communitycarenc.org/informatics-center/nc-hie/.

12. Further information available from: http://www.healthit.gov/sites/default/files/private/pdf/beacon-communities/southern-piedmont-beacon-summary.pdf.

13. CCNC website. "A History of CCNC: The Evolution of Community Care of North Carolina." Available from: https://www.communitycarenc.org/about-us/history-ccnc-rev/.

14. Kaiser Commission on Medicaid and the Uninsured. "Community Care of North Carolina: Putting Health Reform Ideas into Practice." May 2009. Available from: http://www.kff.org/medicaid/upload/7899.pdf.

15. "CCNC Toolkit, Module 4: Building Community Networks." Available from: http://commonwealth.communitycarenc.org/toolkit/4/default.aspx#2.

16. Available from: https://www.communitycarenc.org/emerging-initiatives/multi-payer-demonstration/.

17. Steiner, B.D. et al. "Community Care of North Carolina: Improving Care Through Community Health Networks." Annals of Family Medicine, July 2008, 6(4): 361-367.

18. NASHP website. Available from: http://www.nashp.org/med-home-states/north-carolina.

19. McKethan, A. "Reforming Provider Payments: A Critical Step for Better Health Care and Lower Costs." National Governor's Association presentation, January 8, 2010. Available from: http://www.nga.org/files/live/sites/NGA/files/pdf/1001PAYMENTREFORMMCKETHAN.PDF.

20. CCNC. "North Carolina Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration: Questions and Answers for Participating Practices and Providers." Available from: https://www.communitycarenc.org/media/related-downloads/multi-payer-faq.pdf.

21. Community Care of Lower Cape Fear. "North Carolina Multi-Payer Advanced Primary Care Demonstration." PPT presentation. Available from: http://www.nashp.org/sites/default/files/private/Barrington_IMPaCT_Final.pdf.

22. North Carolina Medical Journal. "CHIPRA Quality Demonstration Grant Fact Sheet." Available from: http://www.ncmedicaljournal.com/wp-content/uploads/2011/09/ECOP_CHIPRA-Summary_2011-12-16.pdf.

23. North Carolina Institute of Medicine. "Examining the Impact of the Patient Protection and Affordable Care Act in North Carolina, Appendix E: New Models of Care in North Carolina." 2013. Available from: http://www.nciom.org/publications/?examining-the-impact-of-the-patient-p....

24. Lowe, C. "CC4C Overview." PPT presentation. Available from: http://www.nciom.org/wp-content/uploads/2011/11/ECOP_Lowe_6-15-2012.pptx_.pdf.

25. CCNC. "Pregnancy Medical Home Update." October 2012. Available from: https://www.communitycarenc.org/media/files/pregnancy-medical-home-overview.pdf.

 

 

Ohio's Health Home Program at a Glance
Health Home Eligibility Criteria	Serious and Persistent Mental Illness (SPMI), Serious Mental Illness (SMI), or Serious Emotional Disturbance (SED)
Qualifying Conditions	Beneficiaries who meet the state definition for SPMI, SMI, or SED
Enrollment*	10,312
Designated Providers	Community Behavioral Health Centers (CBHCs)
Administrative/ Service Framework	The health homes program is a joint effort between Ohio Medicaid and the Ohio Department of Mental Health and Addiction Services (MHAS). MHAS oversees the state's behavioral health system; funding for behavioral health services is channeled from the state to the county, where local mental health and addiction boards are responsible for managing behavioral health services through contracting with provider agencies, including CBHCs, for the provision of behavioral health services.
Required Care Team Members	Health home team leader Embedded primary care clinician Care manager Qualified health home specialist
Payment System	Per member per month (PMPM) care management fee
Payment Level	Site-specific and based on costs, ranging from $270-$400 PMPM
Health Information Technology (HIT) Requirements	HIT requirements are phased-in over 2 years. The only initial requirement is that health homes be able to receive utilization data electronically. Within 1 year of being designated a health home provider, the CBHC must adopt an electronic health record (EHR). Within 2 years, it must demonstrate that the EHR is used to support all health home services. Furthermore, the CBHC must participate in Ohio's statewide Health Information Exchange when it becomes available in their region.
* January 2014 data provided to the Centers for Medicare and Medicaid Services' Health Home Information Resource Center.

Introduction

Ohio's Section 2703 Health Home State Plan Amendment (SPA) was approved by the Centers for Medicare and Medicaid Services (CMS) on September 17, 2012, with an effective date of October 1, 2012. The state offers health home services to beneficiaries with serious and persistent mental illness (SPMI), and to children with serious emotional disturbance (SED) who receive care through qualifying Community Behavioral Health Centers (CBHCs). The approved SPA targets five counties (Butler, Adams, Scioto, Lawrence, and Lucas), though the state intends to expand health home services statewide in a subsequent phase. This expansion was scheduled to begin October 1, 2013,¹ drawing upon lessons learned during the initial phase of implementation, but was later delayed due to concerns form the mental health community about the proposed rules regarding enrollment criteria and reimbursement.²

The health homes program is a joint effort between Ohio Medicaid and the Ohio Department of Mental Health and Addiction Services (MHAS), the latter of which was created on July 1, 2013 through a merger between the Department of Mental Health and the Department of Alcohol and Drug Addiction Services. MHAS oversees the state's behavioral health system, which is organized into three tiers. Funding for behavioral health services is channeled from the state to the county, where local mental health and addiction boards are responsible for planning, developing, managing, and evaluating behavioral health services within their respective jurisdictions. These boards contract with provider agencies, including CBHCs, for the provision of behavioral health services.³ As of April 2013, there were six certified health homes operating in 20 clinic sites in the five designated counties.⁴

Implementation Context

In January 2011, Governor John Kasich created the Office of Health Transformation (OHT)⁵ to oversee reforms to the administration, financing, and delivery of health care services for Medicaid beneficiaries.⁶ Medicaid health homes have been implemented alongside a number of broader health care system reforms, including managed care expansion and performance improvement plans and the creation of a State Health Care Innovation Plan (through the State Innovation Model Design Grant award) for increasing access to patient-centered medical care and reforming the payment system for public and private health insurers.

Managed Care

Ohio Medicaid provides coverage to categorically needy families and children, the aged, blind, or disabled, and individuals who qualify for certain limited benefits. These include Medicare beneficiaries who receive only Medicare premium assistance, working age persons with disabilities who "buy-in" to Medicaid, and those who receive services under the State Family Planning Waiver. The program covers roughly 2.2 million Ohioans, 1.6 million of whom are enrolled in managed care.⁷ Individuals receiving long-term care, who are dually eligible for Medicaid and Medicare, and who qualify as medically needy are excluded from managed care. In January 2012, the state announced its plans to restructure its managed care program, and to renegotiate its contracts with managed care plans (MCPs) operating in the state. As part of this restructuring, the state reduced the number of service regions from eight to three and combined coverage for the categorically needy populations in each region. Under the terms of the new managed care contracts, plans are now required to develop quality improvement incentives for the providers they contract with, and meet certain performance standards in order to receive the full capitation payment from the state.⁸ Behavioral health services are carved out and reimbursed on a fee-for-service basis. As of July 1, 2013, five plans have contracted with Ohio Medicaid to provide services.⁹

The state is also pursuing managed care reforms for beneficiaries who are dually eligible for Medicaid and Medicare. In December 2012, the state entered into a Memorandum of Understanding (MOU) with CMS, as part of a three-year demonstration that will test a new managed care model for the state's 182,000 dually eligible beneficiaries. Under this MOU, the state and CMS will contract with Integrated Care Delivery System plans to coordinate and oversee the provision of all services for this population, including physical, behavioral, and long-term services and supports (LTSS).¹⁰ In May 2014, the program will be implemented in seven regions covering 29 counties, and will enroll an estimated 115,000 people.

In June 2013, the state was awarded a Balancing Incentive Payment Program grant to restructure its LTSS system, with the ultimate goal of shifting care for this population into home and community settings. The state designated the 12 Area Agencies on Aging as the lead agencies in the statewide Aging and Disability Resource Network, which will oversee a No Wrong Door/Single-Entry Point system for screening, referral, and support navigation functions for people who need long-term care. The timeline for implementation has not been finalized, but it is anticipated that full implementation will be completed by September 2015.¹¹

Care Delivery Reform Initiatives

Ohio has taken a number of steps to expand the medical home model. In June 2010, the state legislature passed Ohio House Bill 198, which created the Patient-Centered Medical Home (PCMH) Education Advisory Group and the PCMH Education Pilot.¹² The pilot is focused on advancing medical and nursing curricula to include the PCMH principles of care delivery. It involves 50 practice sites, all of which are affiliated with a medical or nursing school. Some of the stated goals of the program are to facilitate the adoption of the medical home model, develop the primary care physicians' workforce within Ohio, improve health care quality and reduce costs, and create learning sites where clinicians in training can experience working in the PCMH model. The Education Advisory Group provides assistance and advice on implementation of the pilot, and direct technical assistance to pilot sites is provided by the American Academy of Family Physicians.

Ohio Medicaid is also participating in several federal demonstrations and projects, including the Comprehensive Primary Care Initiative (CPCI), the Community-based Care Transitions Program, and the State Innovation Model Planning grant. The CPCI is a multi-payer initiative involving Medicare, Medicaid, and private insurers. Participating primary care practices receive technical assistance and resources to improve patient quality of care, implement care management for high-need patients, and coordinate care with other providers.¹³ The Care Transitions Program is testing models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries. Grantees received a two-year award from CMS, which may be extended annually until the end of the five-year demonstration project. Seven entities in Ohio received grants, two of which will cover health home counties: The Southwest Ohio Community Care Transitions Collaborative¹⁴ and the Southern Ohio Care Transitions Project.¹⁵ Both grants involve partnerships between Area Agencies on Aging, county mental health boards, hospitals, primary care providers (PCPs), and other community-based organizations. The funding will support implementation of a Care Transitions Intervention program for patients diagnosed with heart failure, heart attack, pneumonia, or multiple chronic conditions. The program provides coaching, medication reconciliation, chronic disease management, and referrals for patients following discharge from a participating hospital.

In February 2013, the state also received a six-month State Innovation Model Planning grant from CMS, which builds on the state's other ongoing initiatives, including health homes.¹⁶ The goal for this planning period will be to develop a framework for making medical homes available to the majority of Ohio residents and implementing episode-based payment systems across Medicaid, Medicare, and the commercially insured.¹⁷

Implications for the Ohio Section 2703 Medicaid Health Homes Evaluation

Several of the initiatives described in the preceding section have implications for both the implementation and evaluation of the state's health homes program, particularly those related to managed care and care transitions. It is not yet clear how health homes will be integrated or aligned with these initiatives. Many of these details are still being developed and may change over the course of the evaluation. Given the range of initiatives underway, it may be difficult to identify a "health home effect" on the identified outcomes. However, because health homes are being offered initially in only five counties, it may be possible to identify an appropriate comparison group for all or part of the evaluation period.

The state is using this initial phase of health home implementation to test different models of care. Participating CBHCs have differing levels of experience with providing integrated care and infrastructure in place to support health home implementation. For example, two health homes are co-located with PCPs, while the rest must coordinate entirely with off-site providers. Important early evaluation activities will be documenting the baseline structures and processes in place and identifying changes made as a result of health home implementation. Because of the anticipated expansion, analyses also will need to control for participant and provider time in the program.

Population Criteria and Provider Infrastructure

Ohio offers health homes services to categorically eligible beneficiaries who meet the state definition of SPMI, which includes persons with SPMI, serious mental illness (SMI), or SED.¹⁸ Medically needy beneficiaries are excluded from the health homes option. Qualified CBHCs operating in one of the five designated counties are eligible to apply to be health homes. The care team and their respective role are explicitly defined in the SPA, and will at a minimum include:

• A Health Home Team Leader, who provides administrative and clinical leadership, as well as oversight of health home services.

• An Embedded Primary Care Clinician, who assists with provision of health home services, provides consultation to other team members, and provides direct care.

• A Care Manager, who provides and coordinates all care management services.

• A Qualified Health Home Specialist, who assists the Care Manager with all health home services.

Each health home will determine and assemble the appropriate number of full-time equivalents required to meet service requirements and must participate in technical assistance provided by the state. This assistance includes the Health Homes Learning Community, a learning collaborative established to support health home implementation, and other activities, which may be supplemented by health home team calls.

Enrollment

Medicaid beneficiaries receiving services at a qualifying CBHC are engaged and enrolled in the health home by that CBHC. Beneficiaries have the ability to opt-out or enroll with another health home provider. Hospitals, specialty providers, MCPs, or other providers may refer Medicaid beneficiaries to participating health homes, which are responsible for determining whether those clients meet the criteria. The state also notifies eligible beneficiaries through mail and through public education campaigns conducted in partnership with advocacy groups such as NAMI-Ohio and the Ohio Empowerment Coalition.

Service Definitions and Provider Standards

Service definitions are reproduced in Table 2. The role that each care team member plays in the provision of these services is explicitly described in the SPA, with the Team Leader, Embedded Primary Care Clinician, and Care Manager each playing a part. Qualified Health Home Specialists support the Care Manager in care coordination, health promotion, individual and family support services, and referral to community and social support services. Ohio has also established broad standards that CBHCs must meet before qualifying as health homes, relating primarily to their certification, care structures, processes, and relationships with other providers and MCPs.

In order to qualify as a health home, CBHCs must:

• Be certified by the Ohio Department of Mental Health as eligible to provide Medicaid-covered community mental health services.

• Provide all health home services as necessary and appropriate for beneficiaries.

• Meet state requirements related to integration of physical and behavioral health, including achievement of accreditation from a state-approved certification body such as the Joint Commission or National Committee for Quality Assurance.

• Establish a partnership and a referral/coordination process with specialty providers, inpatient facilities, and MCPs in the service area.

• Support the delivery of person-centered care as defined by the state.

• Have the capacity to receive electronic data from a variety of sources to facilitate service provision.

• Maintain a comprehensive and continuous quality improvement program capable of collecting and reporting data on utilization and health outcomes, and be able to report this data to the state or its designee.

• Participate in the Medicaid Health Homes Learning Community.

• Be a current eligible provider in the Ohio Medicaid Program, and have the capacity to serve health home-eligible Medicaid individuals in the designated service area.

The SPA also includes clear expectations for MCPs. MCPs are required to establish a partnership with the CBHC health home in their service area and develop written policies and procedures that address the way these organizations exchange information and share care management responsibilities. MCPs must also develop a transition plan for each member receiving health home services. Additionally, MCPs are expected to perform ongoing identification of the plan's members who may benefit from health home services and assist them with selecting and enrolling in a health home, if they so choose. MCPs must track which members are receiving health home services, and are required to integrate all information transmitted by the health home or the state regarding a member into the MCP's system. MCPs must also participate in transitional care activities with the health home and integrate results from the health homes quality measures into their quality improvement program. Finally, MCPs, like health homes, must participate in the Medicaid Health Homes Learning Community. The state monitors MCPs to ensure that they are actively supporting the CBHC health homes.

Use of Health Information Technology

Ohio decided to phase-in requirements related to the use of health information technology over two years. The only initial requirement is that health homes be able to receive utilization data electronically from a variety of sources, including clinical patient summaries and notifications regarding a patient's admission to or discharge from an inpatient facility. Within one year of being designated a health home provider, the CBHC must adopt an electronic health record (EHR). Within two years, it must demonstrate that the EHR is used to support all health home services. Furthermore, the CBHC must participate in Ohio's statewide Health Information Exchange when it becomes available in their region.

CBHCs receive quarterly utilization profiles on each health home beneficiary, which underpins the provision of all health home services. Providers are required to develop internal processes to act on and disseminate patient utilization data, and use this patient data to update care plans and establish necessary relationships with other providers to ensure care coordination. Providers must also be able to take patient summary information and format it in a useful way for the client.

Payment Structure

Payment levels for health home services are site-specific, and are based on the state's Uniform Cost Report Requirements, which considers staffing costs, the indirect costs related to health homes service provision, and the estimated health homes caseload. These case rates vary in practice from about $270 to just over $400 per month.

Providers must submit claims to receive payments, and may do so only if a health home service is rendered during the billing month for a given individual. Only one claim may be submitted per individual per month. The monthly case rate covers all health home service components, and is made in addition to the community behavioral health treatment services reimbursed under existing Medicaid payment mechanisms.

This rate determination methodology is in effect only for the providers targeted in the initial SPA. For health homes approved in the next phase of implementation, the state is developing a different rate which has yet to be determined.¹⁹

Quality Improvement Goals and Measures

Ohio has identified eight goals for its health homes program. In addition to reporting the core health home measures selected by CMS, the state will also report on 26 performance measures, which are detailed in Table 3 below. Measures will be generated from claims data, as well as data from vital statistics and patient experience surveys.

Evaluation Measures and Methods

The evaluation measures and methodology described in the SPA are reproduced in Table 4 below. Ohio will use annual HEDIS data to evaluate inpatient admission, readmission, emergency department visits, and skilled nursing facility admissions. The 26 performance measures will be used to evaluate clinical outcomes and for quality improvement. Assessment of processes and lessons learned will be conducted through the Medicaid Health Homes learning collaboratives, which will elicit and analyze feedback on implementation successes and challenges and review evaluation data and reports. To estimate cost savings, Ohio intends to use a pre/post design with a comparison group. Savings will be evaluated by comparing per member per month (PMPM) costs for a baseline period and the evaluation period for health home enrollees with those for similar beneficiaries with SPMI who are not enrolled in health homes, with further adjustment for individual and geographic characteristics.

TABLE 1. Target Population and Designated Providers--Ohio
SPA Approval (Effective Date)	September 17, 2012 (October 1, 2010)
Designated Provider(s)	CBHCs
Health Home Team Composition	Health home team leader Embedded primary care clinician Care manager Qualified health home specialist
Target Population	Beneficiaries who meet the state definitions for SPMI, SMI, or SED

 

TABLE 2. Health Home Service Definitions--Ohio
Care Coordination	Care coordination is the implementation of the single, integrated care plan. With a person-centered focus, the CBHC will facilitate and direct the coordination, communication, and collaboration which is necessary for the individual to demonstrate progress on the goals/actions of the care plan and achieve optimal health outcomes. This will include, but not be limited to, the following: providing assistance to the consumer in obtaining health care; performing medication management and reconciliation; tracking tests and referrals with the necessary follow-up; sharing the crisis plan, assisting with and coordinating prevention, management and stabilization of crises and ensuring post-crisis follow-up care is arranged and received; participating in discharge planning; and making referrals to community, social and recovery supports. The CBHC-HH will be required to assist the individual with making appointments and validating that the services were received.
Comprehensive Care Management	Comprehensive care management begins with the identification of eligible individuals. The health home will be responsible for identifying individuals with SPMI who are currently affiliated with the health home site. SPMI individuals without a CBHC affiliation or a routine source of health care may be identified through referral from another provider or an administrative data review and connected to a CBHC-HH to begin the comprehensive care management process. The next step is for the CBHC to engage the eligible individual and his/her family by explaining the benefits of participation and receiving health home services, and the right to opt-out of HH services. The health home will complete a comprehensive assessment of the individual's physical health, behavioral health, long-term care and social needs. The assessment must account for the cultural and linguistic needs of the individual and use relevant comprehensive data from a variety of sources, including the individual/family, caregivers, medical records, team of health professional, etc. At a minimum, the CBHC-HH will reassess the individual at least once every 90 days. Based on the health assessment, the CBHC health home will assemble a team of health professionals, and establish and negotiate roles and responsibilities for each member of the team, including the accountable point of contact. The health home will develop and continuously update a single care plan that will include prioritized goals and actions with anticipated timeframes for completion and will reflect the individual's preferences. Prior to implementation of the care plan, a communication plan must be developed to ensure that routine information exchange, collaboration, and communication occurs between the team members, providers, and the individual/family. The CBHC-HH will frequently and routinely monitor the care plan to determine adherence to treatment guidelines and medication regimes, barriers to care, or any clinical and nonclinical issues that may impact the individual's health status or progress in achieving the goals and outcomes outlined in the care plan. As part of the monitoring, the CBHC and team of health professionals are expected to adhere to the communication plan when providing updates and progress reports on the individual.
Health Promotion	Health promotion services are intended to equip the individual/family with relevant knowledge and skills which will: increase his/her understanding of diseases/conditions identified in the assessment, promote self-management, and improve quality of life and daily functioning. This may be accomplished through the following examples: education about wellness and healthy lifestyle choices; provision of or referrals to evidence-based wellness programs; and connections to peer supports. A focus of health promotion will be to support and engage the individual and the family in the development, implementation and monitoring of the care plan. By empowering the individual and promoting self-advocacy, there will be an increased ability to be proactive in the self-management of existing conditions, increase the utilization of preventative services, and accessing care in appropriate settings.
Comprehensive Transitional Care	Comprehensive transitional care services are designed to ensure continuity of care and prevent unnecessary inpatient readmissions, emergency department visits and/or other adverse outcomes, such as homelessness. The CBHC-HH will develop arrangements with inpatient facilities, emergency departments and residential facilities for prompt notification of an individual's admission and/or discharge to/from a hospital emergency department, inpatient unit or residential facility. The CBHC-HH will coordinate and collaborate with inpatient facilities, hospital emergency departments, residential facilities and community partners to ensure that a comprehensive discharge plan and/or transition plan, and timely and appropriate follow-up is completed for an individual who is transitioning to/from different levels and settings of care. The CBHC-HH will conduct and/or facilitate effective clinical hand offs that include timely access to follow-up post-discharge care in the appropriate setting, timely receipt and transmission of a transition/discharge plan from the discharging entity, and medication reconciliation.
Individual and Family Support Services	The CBHC-HH will offer and/or arrange for on-site and off-site community and social support services through effective collaborations with social service agencies and community partners. The CBHC-HH will identify and provide referrals to community, social, or recovery support services such as maintaining eligibility for benefits, obtaining legal assistance, and housing. The CBHC-HH will assist the consumer in making appointments, validate the service was received, and complete any follow-up as necessary.

 

TABLE 3. Goal-Based Quality Measures--Ohio
Improve Cardiovascular Care	Clinical outcome measures: Cholesterol management for patients with cardiovascular conditions Controlling high blood pressure
Improve Care Coordination	Experience of care measures: SAMHSA National Outcome Measures (NOMs): general satisfaction with care, access to care, quality and appropriateness of care, participation in treatment, cultural competence Quality of care measures: Timely transmission of transition record Reconciled medication list received by health home
Improve Diabetes Care	Clinical outcome measures: Comprehensive diabetes care: HbA1c level Comprehensive diabetes care: LDL-C screening
Improve Care for Persons with Asthma	Clinical outcome measures: Use of appropriate medications for people with asthma
Improve Health Outcomes for Persons with Mental Illness	Clinical outcome measures: Proportion of days covered of medication Experience of care measures: NOMs as listed above Quality of care measures: Follow-up after hospitalization for mental illness Annual assessment of BMI, glycemic control, and lipids for people with Schizophrenia who were prescribed antipsychotics Screening for clinical depression and follow-up plan Annual assessment of BMI, glycemic control, and lipids for people with Bipolar Disorder who were prescribed mood stabilizers
Improve Preventative Care	Clinical outcome measures: Percent of live births weighing less than 2,500 grams Quality of care measures: Prenatal and post-partum care Adult BMI assessment Weight assessment and counseling for nutrition and physical activity for children/adolescents Adolescent well-care visits Adults' access to preventive/ambulatory health services Appropriate treatment for children with upper respiratory infections Annual dental visit, age 2-21 Annual dental visit, age 22 and older
Reduce Substance Abuse	Quality of care measures: Initiation and engagement of alcohol and other drug dependence treatment Smoking and tobacco use cessation
Improve Appropriate Utilization/Site of Care	Clinical outcome measures: Ambulatory care-sensitive condition hospitalization rate Inpatient and emergency department utilization rate All-cause readmission

 

TABLE 4. Evaluation Methodology--Ohio
Hospital Admission Rates	The state will use claims data and HEDIS methods to calculate admission rates for general hospital/acute care, inpatient alcohol and other drug services, and inpatient mental health services discharges. It will also use this data to calculate the number of inpatient stays that were followed by an acute readmission for any diagnosis within 30 days.
Chronic Disease Management	The state will use claims data to calculate performance measures to monitor the management of the following chronic diseases and conditions: heart disease, hypertension, obesity, diabetes, asthma, schizophrenia, bipolar disorder, and alcohol and other dependence.
Coordination of Care for Individuals with Chronic Conditions	The state will use claims data to determine whether health homes received a reconciled medication list at the time of discharge and to monitor whether transition records were transmitted to health homes within 24 hours of a discharge.
Assessment of Program Implementation	The state has selected 26 performance measures that will be used to evaluate clinical outcomes and for the purposes of quality improvement.
Processes and Lessons Learned	The state will develop Medicaid Health Home Learning Communities as an ongoing quality improvement effort. The Learning Communities will elicit feedback to understand any operational barriers of implementing health home services, review evaluation data and reports, and review relevant program feedback to determine which elements of the health home service delivery are working and which are not.
Assessment of Quality Improvements and Clinical Outcomes	The state has selected 26 performance measures that will be used to evaluate clinical outcomes and for the purposes of quality improvement.
Estimates of Cost Savings	Changes in PMPM costs will be evaluated over time for the 2 distinct SPMI populations--those enrolled in health homes and those not enrolled in health homes. The latter group will serve as the control. The PMPM costs for both groups will be calculated for each year of implementation and compared to costs in an unspecified baseline period. Actual costs (those generated for the health home population) will be compared to expected costs (those generated for the control group) to determine program savings associated with the health homes initiative. Findings will be adjusted for populations and geographic characteristics. Dual eligible enrollees will be evaluated separately.

Endnotes

1. Ohio Department of Mental Health and Addiction Services. "Medicaid Health Home Highlights Newsletter." April 2, 2013. Available from: http://mha.ohio.gov/Portals/0/assets/Planning/Medicaid/health-home-web-page/april22013-inaugural-edition.pdf. Accessed July 11, 2013.

2. Memorandum from Ohio MHAS Director Tracy Plouck and ODM Director John McCarthy. August 14, 2013. Available from: http://mha.ohio.gov/Portals/0/assets/Planning/Medicaid/Health%20Home%20update%20081413.pdf. Accessed April 21, 2014.

3. Behavioral Health Generations website. "Ohio Behavioral Healthcare System." Available from: http://www.bhg.org/system.htm. Accessed July 14, 2013.

4. Ohio Department of Mental Health and Addiction Services. "Certified Ohio Medicaid Health Home Service Providers for Individuals with Serious and Persistent Mental Illness as of April 2013." Available from: http://mha.test.ohio.gov/Portals/0/assets/Planning/Medicaid/health-home-web-page/certified_ohio_medicaid_health_home_service_providers_contact_information.pdf.

5. Executive Office of the Ohio Governor. "Executive Order 2011-02K: Creating the Governor's Office of Health Transformation." January 13, 2011. Available from: http://governor.ohio.gov/portals/0/pdf/EO_2011-02K.pdf.

6. Ohio Governor's Office of Health Transformation website. Available from: http://healthtransformation.ohio.gov/.

7. Health Policy Institute of Ohio. "Ohio Medicaid Basics 2013." HPIO issue brief, March 2013. Available from: http://a5e8c023c8899218225edfa4b02e4d9734e01a28.gripelements.com/pdf/publications/medicaidbasics2013_final.pdf.

8. Ohio Office of Health Transformation. "Modernize Medicaid: Reform Health Plan Payments." OHT fact sheet, January 31, 2013. Available from: http://www.healthtransformation.ohio.gov/LinkClick.aspx?fileticket=RXVVPlaDmWE%3d&tabid=121.

9. Ohio Office of Health Transformation. "Medicaid Managed Care Program: Managed Care Regions, effective July 1, 2013." Available from: http://www.healthtransformation.ohio.gov/LinkClick.aspx?fileticket=m3rG4siLa5A%3d&tabid=121.

10. Centers for Medicare and Medicaid Services. "Fact Sheet: CMS and Ohio Partner to Coordinate Care for Medicare-Medicaid Enrollees." December 12, 2012. Available from: http://www.healthtransformation.ohio.gov/LinkClick.aspx?fileticket=Lp-_El9KcSE%3d&tabid=105; http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Ohio.html.

11. Ohio Office of Medical Assistance. "Balancing Incentive Program Application." Submitted March 15, 2013. Available from: http://healthtransformation.ohio.gov/LinkClick.aspx?fileticket=JXGJjK8db4E%3d&tabid=125.

12. Ohio Department of Health website. "PCMH Education Pilot Project: Ohio House Bill 198." Available from: http://www.odh.ohio.gov/landing/medicalhomes/Education%20Pilot%20Project.aspx.

13. Centers for Medicare and Medicaid Services. "Fact Sheet: Comprehensive Primary Care Initiative." August 22, 2012. Available from: http://innovation.cms.gov/Files/fact-sheet/CPCI-Fact-Sheet.pdf.

14. Greater Cincinnati Health Council website. "Southwest Ohio Community Care Transitions Collaborative." Available from: http://www.gchc.org/southwest-ohio-community-care-transitions-collaborative/.

15. Center for Medicare and Medication Innovation website. "Southern Ohio Care Transitions Project." Fact sheet. Available from: http://innovation.cms.gov/Files/x/CCTP-SouthernOH.pdf.

16. Centers for Medicare and Medicaid Services, "State Innovation Models Initiative: General Information." Available from: http://innovation.cms.gov/initiatives/state-innovations/.

17. Ibid.

18. State definitions are detailed in 5122-29-33 health home service for persons with serious and persistent mental illness. Available from: http://codes.ohio.gov/oac/5122-29-33.

19. Ohio Department of Mental Health and Addiction Services Memorandum. August 14, 2013. Available from: http://mha.ohio.gov/Portals/0/assets/Planning/Medicaid/Health%20Home%20update%20081413.pdf.

 

 

Oregon's Health Home Program at a Glance
Health Home Eligibility Criteria	2 chronic conditions, 1 chronic condition and at risk of another, Serious Mental Illness
Qualifying Conditions	Chronic Health Conditions Asthma Overweight Cancer Chronic kidney disease Chronic respiratory disease   Diabetes Heart disease Hepatitis C HIV/AIDS Substance use disorder	Serious Mental Health Conditions Alzheimer's Anorexia nervosa Attention deficit disorder Autism Bipolar disorder Dementia Depression Post-traumatic stress disorder   Schizophrenia
Enrollment*	93,253
Designated Providers	Patient-Centered Primary Care Homes (PCPCHs)
Administrative/ Service Framework	Health home services are delivered through Medicaid-enrolled providers who meet the state's PCPCH standards.
Required Care Team Members	It is required that the health home team is inter-disciplinary and inter-professional. Team of health care professionals may include nonphysician health care professionals, such as a nurse care coordinator, nutritionist, social worker, behavior health professional, or other traditional or nontraditional health care workers.
Payment System	Per member per month (PMPM) care management fee
Payment Level	PMPM fee based on provider qualification level:    Tier 1--$10 PMPM    Tier 2--$15 PMPM    Tier 3--$24 PMPM
Health Information Technology (HIT) Requirements	Health home providers are encouraged to develop or use their current HIT systems and certain provider measures are linked to HIT capacity. For example, although an electronic medical record (EMR) is not required, those who have an EMR are able to earn additional points towards their qualification as a Tier 3 PCPCH. Another of the measures for Tier 3 qualification is the ability of a PCPCH to share clinical information electronically in real-time with other providers and care entities.
* January 2014 data provided to the Centers for Medicare and Medicaid Services' Health Home Information Resource Center.

Introduction

Oregon's Medicaid State Plan Amendment (SPA) instituting a Section 2703 Health Home benefit was approved by the Centers for Medicare and Medicaid Services (CMS) on March 13, 2012, with a retroactive effective date of October 1, 2011.¹ Oregon's health home program builds on the state's Patient-Centered Primary Care Home (PCPCH) program, established in 2009.² To be eligible for health home services, enrollees must have a serious mental health condition, two or more chronic conditions, or one chronic condition and be at risk of developing another. The state specified 11 chronic illnesses and nine serious mental health conditions in the list of health home qualifying conditions. It based its definition of "at-risk" on guidelines from the U.S. Preventive Services Task Force, the Health Resources and Services Administration Women's Preventive Services, and Bright Futures. (See Table 1 for a full list of qualifying conditions.)

The health homes program represents just one component of a larger state effort to transform how medical care is delivered in Oregon. Health home services, which are aligned with the state's PCPCH Standards, are to be delivered through qualified PCPCHs and are available to a PCPCHs entire patient population. However, the state will provide a supplemental per member per month (PMPM) payment only for those patients identified by the provider as meeting the health home eligibility criteria. The state is also working toward providing supplemental payments to PCPCHs for other populations including all Medicaid enrollees, government employees, and state education personnel. The state's goal is to make PCPCH services available to 75% of all Oregonians by 2015.³ Any recognized PCPCH can apply to become a health home through submission of an addendum to its PCPCH agreement with the state, as described below.

PCPCHs (inclusive of their health home services) are also a central component of Oregon's health system transformation efforts, particularly through their role in Coordinated Care Organizations (CCOs, described in more detail below). The CCO program was proposed by the Legislature June 2011, and the first CCOs began operations in August 2012. A CCO is a community-based network of health care providers who have agreed to collaborate in the provision of services for people with Medicaid and/or Medicare coverage. CCOs receive a fixed global payment for mental and physical health care services and, in return, are accountable for the health outcomes of the population they serve.⁴ These CCO payments are separate from the health home payments, which go to the PCPCHs. The state also plans to integrate oral health care services in the future. The state's hope is that these integrated health care organizations will provide more efficient delivery of and better access to care, strengthen primary care networks while integrating services, and better align incentives to generate substantial savings. CCOs are required to include recognized PCPCHs in their networks of care to the extent possible and to support their member practices in achieving PCPCH recognition.⁴ The emphasis on coordinated care, integration of physical and mental health care services, and community linkages is consistent with health home goals but, under the state's PCPCH program, they are applied to a broader population.

Oregon's health home benefit is managed through the Oregon Health Authority (OHA), which was established in 2009 and is charged with purchasing health insurance for approximately 850,000 Medicaid enrollees, government employees, and state education personnel (representing about one in four people in Oregon).⁴ Oregon has approximately 645,000 people enrolled in its Medicaid program (known as the Oregon Health Plan [OHP]), which it has operated under a Medicaid Section 1115 waiver (described below) since 1993.^{4, 5} The state managed care program covers approximately 80% of OHP beneficiaries. Prior to August 2012 and the formation of CCOs, acute and ambulatory physical health care services were provided by managed care organizations (MCOs), while mental health, chemical dependency, and dental services were carved out and paid for on a capitated basis.⁴ Oregon does not have large, national health plans participating in its Medicaid program; most of the MCOs and CCOs are local, community-based nonprofits that serve only publicly insured enrollees; many are physician-owned and run. In some sparsely populated areas, the state contracts directly with providers for primary care case management.

Implementation Context

Oregon has several initiatives underway that have goals that are similar to those of the health home benefit or involve the same type of provider. Some of the initiatives have been developed by the state, while others are part of national demonstration projects. These initiatives are seen as complementary and as part of a broad evolution towards a more integrated system of care in the state. These programs are described in greater detail in Appendix A.

In 2009, the state legislature passed two bills (HB 2009 and HB 2116) that included provisions to provide health insurance coverage for all children and bring more low-income adults into Medicaid. The HB 2009 legislation also created the OHA and the Oregon Health Policy Board and established the PCPCH Program within the Office for Oregon Health Policy and Research.⁶

As the state began to implement the PCPCH program, many stakeholders felt that the 2008 National Committee for Quality Assurance (NCQA) medical home standards for care coordination did not include a strong enough emphasis on health outcomes and accountability, and so encouraged the state to develop its own. In response, the state convened the Patient-Centered Primary Care Home Standards Advisory Committee and charged it with developing the framework of core attributes, standards, and measures that would be used to define a PCPCH.⁷ These standards were released in 2010. (See Appendix B for a list of PCPCH attributes and standards.)

During the 2011 legislative session, the state authorized the creation of the Oregon Integrated and Coordinated Health Care Delivery System, which aimed to move the Medicaid managed care system towards an integrated care management model, and passed legislation to establish CCOs.⁴ As noted above, CCOs are community-based networks that are to contract with the state to provide integrated, comprehensive health care, mental health care, and eventually dental care for a defined patient population. CCOs focus on patients with chronic conditions, as well as on people with addiction problems and mental illnesses who have traditionally received care through the OHA's Addictions and Mental Health Division.⁸ CCOs have flexibility within their budgets to provide services alongside traditional OHP medical benefits with the goal of meeting the "Triple Aim" of better health, better care, and lower costs for the population they serve, but they are required to include PCPCHs within their networks to the extent possible.⁶ By making CCOs responsible for the full array of services and paying a fixed global payment, the state hopes these coordinated networks will improve quality outcomes and be more cost-efficient. The state staggered the rollout of CCOs; the first wave of eight CCOs was launched August 1, 2012. In 2013, there were 16 CCOs operating in all regions of the state, serving more than 600,000 Oregonians enrolled in Medicaid.^{9, 10}

Oregon was also one of 15 states that received a grant from CMS to develop a pilot program to better "coordinate care across primary, acute, behavioral health and long-term services and supports (LTSS) for dual eligible individuals."² Under the State Demonstrations to Integrate Care for Dual Eligible Individuals program, CMS has provided funding and technical assistance to the selected states to develop enhanced patient-centered methods to coordinate the entire continuum of care for dual eligible individuals and to identify delivery system and payment models that can be replicated in other states. The state eventually decided not to move forward with the financial alignment of the duals demonstration.

As part of the state's efforts to align payment methods to support its primary care home model, Oregon is participating in the CMS Comprehensive Primary Care Initiative, which began in fall 2012. In this multi-payer initiative, Medicare collaborates with public and private insurers in the selected regions with the goal of strengthening primary care. Participating practices receive a PMPM care management fee and be given technical assistance to help them better coordinate and manage care. After two years, providers will also have the opportunity to participate in a shared savings model.¹¹ In Oregon, six health insurance plans and 70 practices were selected to participate.¹²

Oregon is also participating in the Tri-State Child Health Improvement Consortium (T-CHIC), a Children's Health Insurance Program Reauthorization Act (CHIPRA) Quality Demonstration Project funded by CMS. T-CHIC is an alliance among the Medicaid/Children's Health Insurance Programs of Alaska, Oregon, and West Virginia, led by Oregon, with the goal of improving children's health care quality. In February 2010, the consortium was awarded approximately $11.5 million over a five-year period ($2.2 million was awarded in the first year). The overarching goal of the CHIPRA quality demonstration is to establish and evaluate a national quality system for children's health care.¹³ In Oregon, this demonstration is linked to two additional pediatric medical home practice improvement projects through the Oregon Pediatric Improvement Partnership, which aims to improve children's care through a range of collaborative and educational activities.¹⁴

Many practices in Oregon have been or are in the process of being recognized as a Patient-Centered Medical Homes (PCMHs) by the NCQA.⁶ While the PCMH model shares many common concepts with Oregon's PCPCH, there are a few areas in which the two models are not fully aligned. PCMH practices attempting to gain recognition as PCPCHs must contractually attest to being NCQA-certified but must also submit additional information, centered on the contractual attestation of screening strategies for mental health and substance abuse conditions, hospice and palliative care, and quality measurement and patient tracking.⁶

Implications for the Oregon Section 2703 Medicaid Health Homes Evaluation

These various initiatives have several implications for both implementation and evaluation of the health home program. The state has envisioned health homes as an integral part of its effort to transform the primary care delivery system across the state for all payors. Other initiatives are key to this overall transformation as well, particularly the development of CCOs and the contractually required encouragement of PCPCHs by the CCOs. The providers of health home services are not designated as "health homes" but rather health home enrollees are identified within the PCPCHs by their receipt of health home services once they meet the qualifying criteria. The state intends for the changes that providers make to care for health home beneficiaries to permeate the PCPCH practice for all patients, but the enhanced payments for health home services apply only to identified eligibles. The state's plan is to institute a care coordination payment for other beneficiaries in the future but at a much lower level.

In many practices that have become PCPCHs and are thus eligible to serve health home beneficiaries, practice transformation began before the implementation of the health homes initiative, and providers are charged with identifying health home services recipients. Thus, it will be difficult--and may be impossible--to disentangle a health home effect from the effect of ongoing transformation.

Population Criteria and Provider Infrastructure

Oregon offers health home services to categorically needy beneficiaries (there is no medically needy program in Oregon) who have two or more chronic conditions, one chronic condition and are at risk of contracting another, and those with a serious mental illness.¹ (Oregon uses the term "ACA-qualified" for beneficiaries meeting the condition criteria for health home eligibility.) Both fee-for-service (FFS) and managed care enrollees are eligible for these services. Table 1 below provides a full list of the population criteria, the designated providers, and the health home team composition requirements.

Health homes are based on the state's PCPCH model, described in further detail below; thus, PCPCH standards are health home standards and the two designations will be used interchangeably with respect to providers. Payment for health home services, however, is limited to the health home-eligible population and this distinction will be maintained. Any designated PCPCH is eligible for a health home payment if specific service and documentation requirements are met for each patient. These requirements include: (1) providing at least one core service each quarter (described in Table 2); (2) performing panel management at least once per quarter, using data for all clients or for sub-groups of clients for such functions as care management or quality assurance; (3) performing patient engagement and education and obtaining patient agreement; and (4) developing a person-centered health plan.

PCPCH/health homes include, but are not limited to, physical and behavioral health care providers, solo practitioners, family and group practices, community mental health centers, drug and alcohol treatment facilities, rural health clinics, federally qualified health centers, and school-based health centers.¹ A PCPCH/health home is not required to provide all of the health home services on-site, but it is responsible for coordinating and/or offering those services through partnerships within their community.

All PCPCH-recognized providers wishing to participate in Medicaid and provide health home services must submit an addendum to their Medicaid provider enrollment agreement to the OHA's Division of Medical Assistance Programs (DMAP).⁶ This is true for providers serving both FFS and MCO/CCO-enrolled members. PCPCH providers serving MCO/CCO-enrolled members will also have a contract with the MCO/CCO, and the payment arrangement will be negotiated between the MCO/CCO and the provider.¹⁵

Member Identification and Assignment

Health home-eligible beneficiaries are identified through a referral process managed by DMAP. The process begins with providers, who draw up a list of the patients they believe are eligible from among their FFS and MCO/CCO clients. They then submit the list of FFS patients directly to DMAP and the list of MCO/CCO-enrolled patients to the appropriate MCO/CCO, which will in turn submit the list to DMAP.⁶ DMAP then screens these patients for eligibility and sends a report to each recognized provider or health care entity identifying which of their patients were successfully assigned to their health home. This list must be updated and submitted quarterly. DMAP worked with CMS to determine how best to coordinate sending a letter to the qualified health home patients notifying them that their provider is now their primary care health home. Enrollees are informed that they may opt-out of health home coverage or may select a different provider.

Service Definitions and Provider Standards

There are six core health home services, at least one of which must be provided once per quarter for each patient on a provider's list. (See Table 2 for the service definitions found in the SPA.) These services do not require an office visit and can be performed by any member of the health care team. Health home services do not require or replace treatment or medical services, and they cannot include services for which a provider is already billing. The provider attests to providing one of these six core services through submitting the quarterly list of health home-eligible enrollees, and must document the services provided in each patient's medical record.⁶

Core Attributes and Corresponding Standards for Patient-Centered Primary Care Homes

Oregon based their provider qualifications on the six attributes of the state's pre-existing PCPCH model, which are cross-walked in the SPA with the core health home functions outlined by CMS in the State Medicaid Director's letter of November 2010.¹⁶ These six core PCPCH attributes (Access to Care, Accountability, Comprehensive Whole-Person Care, Continuity, Coordination and Integration, Person-Centered and Family-Centered Care) each have corresponding standards and measures, divided into "Must-Pass Measures" and "Tiers 1-3". These are described in greater detail below.

PCPCH Measures and Tiers

To practice and be recognized as a PCPCH, a provider must demonstrate the ability to meet the guideline PCPCH measures that correspond to each standard. PCPCH measures are divided into ten "Must-Pass" measures and a range of other measures that place the PCPCH practice in one of three Tiers.⁶ Must-Pass and Tier 1 measures focus on the basic foundational structures and processes of a PCPCH. Foundational elements should be achievable by most practices, and are not considered to require significant financial expenses. Tier 2 measures reflect intermediate PCPCH functions, demonstrating performance, structural, and process improvements. Tier 3 reflects advanced PCPCH functions, in which the provider demonstrates mature performance improvement capacity, and is accountable for quality. (See Appendix B for a full list of attributes, standards, and measures.)

Except for the ten Must-Pass measures, each measure is assigned a point value corresponding to a tier. Tier 1 measures are worth 5 points, Tier 2 measures are worth 10 points, and Tier 3 measures are worth 15 points. For a practice to be recognized as a PCPCH, it must meet all of the 10 Must-Pass measures. Practices must score 30 to 60 points to qualify as Tier 1, 65 to 125 for Tier 2, and 130 or more for Tier 3.⁶

Practices demonstrate their current level of practice by contractually attesting to meeting certain of the standards and by submitting data on others. Contractual attestation is contained in the agreement negotiated between a practice and any payer the practice contracts with and is also submitted to the state through a web-based process described in further detail below. (Contractual attestation measures are marked with a "C" in Appendix B.) No other documentation on these measures is required at the time of application, but practices are subject to random audit by the OHA, and all contractual attestation measures must be reported annually for a practice to maintain its PCPCH status.

Six of the PCPCH measures require quantitative data submission (marked with a "D" in Appendix B).⁶ These measures will be used by the state to track PCPCH progress and will also be reported to the PCPCHs to help them identify trends in care and identify areas for quality improvement. Recognized PCPCH providers must also submit patient experience of care survey data. Tier 2 and Tier 3 providers are required to use the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey tools for this purpose.⁶

The OHA has developed a web-based provider portal system where practices can submit all required data to the state (see Health Information Technology section below for more details). Based on the point system, the OHA will score PCPCHs by combining the contractual attestation information with the quantitative data received. Practices and various plans, insurance carriers, and/or other entities will then be notified of their score.

Use of Health Information Technology

Health home providers are encouraged to develop or use their current health information technology (HIT) capacity to perform a range of functions, including:

• Gather and report data and group it by subset.

• Create and maintain electronic health records (EHRs).

• Share clinical information with clients and other providers.

• Link to, manage, and track health promotion activities and referrals to community-based or social services.

• Communicate with other providers, family members, and local supports.

Oregon links certain of its provider measures to HIT capacity. For example, although implementation of an electronic medical record (EMR) is not required, those who have an EMR are able to earn additional points towards their qualification as a Tier 3 PCPCH. The state has indicated that they will encourage providers to implement an EMR that contains at a minimum a problem list, medication list, allergies, basic demographic information, preferred language, Body Mass Index (BMI)/BMI percentile chart, and immunization record. Another of the measures for Tier 3 qualification is the ability of a PCPCH to share clinical information electronically in real-time with other providers and care entities.

As noted above, OHA also maintains a provider portal and patient panel management system. This system is run by a contractor, Quality Corporation. Use of this system is required as part of the provider's demonstration of "comprehensive care management," but it also allows the provider to review data on services they have provided to their patient panel, and identify any gaps.

Payment Structure

Payment for health home services is made on a PMPM basis that varies by the provider's qualification level: Tier 1--$10 PMPM; Tier 2--$15 PMPM; and Tier 3--$24 PMPM.¹ For FFS patients, DMAP makes payments directly to PCPCH/health home providers; for MCO/CCO-Enrolled members, DMAP makes payments to the MCO/CCO, which then make payments to the health home. Any portion of the payment that is retained by the MCO/CCO must be used to carry out health home-related functions and is subject to approval and oversight by the OHA.¹⁷ Providers are eligible for the PMPM payment if the service and documentation requirements are met for each patient. Submission of the quarterly patient list serves as attestation of meeting the quarterly health home service requirements.

The health home must engage in panel management activities at least once quarterly. One team member from each health home provider practice must log on to the OHA's provider portal, which can be used as a panel management tool and for tracking quality measures. A health home has six months to engage and obtain consent from each eligible patient assigned to their care.¹⁷ Education about PCPCH/health home services and benefits can be done in-person, by phone, or by mailing a letter or brochure. (OHA provides patient brochures to all PCPCH/health home providers.) Engagement and member agreement to participate must be active but does not require a patient visit; if a patient declines to participate or the health home is unable to get agreement after 6 months of attempts, the provider should notify DMAP and omit that patient from future patient list submissions.¹⁷

Quality Improvement Goals and Measures

The state has identified five quality improvement goals, each with defined clinical outcome and quality of care measures:

• Reducing the rate of potentially avoidable hospital readmissions.

• Decreasing potentially avoidable hospitalizations and increase the ratio of ambulatory care to emergency department visits.

• Improving transitions of care between primary care providers (PCPs) and inpatient facilities.

• Improving care transitions for people with mental health conditions.

• Improving documentations, tracking, and reporting of health risks and use of preventive services.

The state has also identified two service-based measures, both tied to comprehensive care management. Table 3 below lists each goal with its corresponding measures. Data for these measures will be drawn mostly from administrative data, CAHPS survey data, claims data, and EMRs.

Evaluation Measures and Methods

The state will rely primarily on administrative data, the Medicaid Management Information System (MMIS), provider-reported measures, and patient survey results in their evaluation of the health home program. A Learning Collaborative composed of providers and patients will also provide information on program implementation, processes, and lessons learned. For most health home measures, beneficiaries who have been enrolled for at least one year will be compared with beneficiaries not enrolled in a health home. It is not clear how comparison groups will be identified. Table 4 below excerpts the information provided in the SPA.

TABLE 1. Target Population and Designated Providers--Oregon
SPA Approval (Effective Date)	March 13, 2012 (October 1, 2011)
Designated Provider(s)	Any Medicaid-enrolled provider that meets the state's PCPCH health home standards; includes FFS providers, managed care plans, PCPs, home health agencies, certified nurse practitioners, clinical group practices, rural community health centers, community mental health facilities, and substance abuse treatment facilities.
Health Home Team Composition	Required: The team is inter-disciplinary and inter-professional. Optional: Team of health care professionals includes nonphysician health care professionals, such as a nurse care coordinator, nutritionist, social worker, behavior health professional, or other traditional or nontraditional health care workers. These professionals can operate as free-standing, virtual, or based at any of the clinics/facilities expressed above.
Target Population	Beneficiaries must have: 2 chronic conditions 1 chronic condition and the risk of developing another A serious mental condition
Qualifying Chronic Conditions	Chronic Health conditions: Asthma BMI over 25 (for adults 20 years or older) BMI 85th percentile or higher (for patients under age 20) Cancer Chronic kidney disease Chronic respiratory disease Diabetes Heart disease Hepatitis C HIV/AIDS Substance abuse disorder Serious Mental Health conditions: Alzheimer's Anorexia nervosa Attention deficit disorder Autism Bipolar disorder Dementia Depression Post-traumatic stress disorder Schizophrenia

 

TABLE 2. Health Home Service Definitions--Oregon
Care Coordination	Patients will choose and be assigned to a care team, which will develop a care plan based on the needs and desires of the patient with at least the following elements: options for accessing care, information on care planning and care coordination, names of other primary care team members when applicable and information on ways the patient participates in this care coordination. Care coordination functions can include but are not limited to: tracking of ordered tests and result notification, tracking referrals ordered by its clinicians, including referral status and whether consultation results have been communicated to patients and clinicians, and direct collaboration or co-management of patients with specialty mental health, substance abuse, and providers of services and supports to people with developmental disabilities and people receiving LTSS. Co-location of behavioral health and primary care is strongly encouraged.
Comprehensive Care Management	Providers will be able to identify patients with high-risk environmental or medical factors, including patients with special health care needs, who will benefit from additional care planning. Care management activities include but are not limited to defining and following self-management goals, developing goals for preventive and chronic illness care, developing action plans for exacerbations of chronic illnesses, and end-of-life care planning when appropriate.
Health Promotion	The provider will develop a treatment relationship with the individual, other primary care team members and community providers. The health home provider will promote wellness and prevention by linking the enrollee with resources for smoking cessation, diabetes, asthma, self-help resources and other services based on individual needs and preferences. Health promotion activities will be utilized to promote patient/family education and self-management of the chronic conditions.
Comprehensive Transitional Care	The provider will have either a written agreement and/or procedures in place with its usual hospital providers, local practitioners, health facilities and community-based services to ensure notification and coordinated, safe transitions, as well as improving the percentage of patients seen or contacted within 1 week of facility discharges.
Individual and Family Support Services	The provider will have processes for patient and family education, health promotion and prevention, self-management supports, and obtaining available nonhealth care community resources, services and supports. The care plan will reflect the client and family/caregiver preferences for education, recovery and self-management. Peer supports, support groups and self-care programs will be utilized to increase the client and caregivers knowledge about the client's individual disease.
Referral to Community and Social Supports	The provider will demonstrate processes and capacity for referral to community and social support services, such as patient and family education, health promotion and prevention, and self-management support efforts, including available community resources. Care coordination functions will include the use of the care plan to manage such referrals and monitor follow-up as necessary.

 

TABLE 3. Health Home Goals and Quality Measures--Oregon
Goal-Based Measures
Reduce the Rate of Potentially Avoidable Hospital Readmissions	Clinical outcome measures: Pneumonia--Hospital 30-day, all-cause, risk standardized readmission rate following pneumonia hospitalization.
Decrease Potentially Avoidable Hospitalizations and Increase the Ratio of Ambulatory Care to Emergency Room Visits	Experience of care measures: Percentage of adult health plan members who reported how often their doctor and other health provider talked about specific strategies for self-managed illness prevention. Quality of care measures: Number of outpatient visits, emergency department visits, ambulatory surgeries/procedures, and observation room stays.
Improve Transitions of Care Between PCPs and Inpatient Facilities	Experience of care measures: Percentage of adult health plan members who reported how often their personal doctor seemed informed and up-to-date about care they got from other doctors or other health provider. Quality of care measures: Percentage of patients, regardless of age, discharged from an emergency department setting to ambulatory care or home health care, or their caregiver(s), who received a transition record at the of emergency department discharge.
Improve Transitions for People with Mental Health Conditions	Quality of care measures: Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental disorders and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 30 days of discharge.
Improve Documentation, Tracking, and Reporting of Health Risks and Use of Preventative Services	Quality of care measures: Percentage of members 18-74 years of age who had an outpatient visit and who had their BMI documented during the measurement year or the year prior.
Service-Based Measures
Comprehensive Care Management	Clinical outcome measures: Percentage of patients, regardless of age, discharged from an emergency department setting to ambulatory care or home health care, or their caregiver(s), who received a transition record at the time of emergency department discharge. Quality of care measures: Percentage of members who had an outpatient visit and who had their BMI documented during the measurement year or the year prior.

 

TABLE 4. Evaluation Methodology--Oregon
Hospital Admission Rates	Using MMIS, Risk-adjusted Prevention Quality Indicators will be compared to non-PCPCH/health home members. Assessments will be stratified by risk, tier, and length of enrollment. Propensity scores and difference scores will be used to assess the rates, lengths of stay, and billed charges. Hospital admission evaluation will also be adjusted by the type of hospital (critical access, geographic location, etc.). Data collection will be taken up at baseline, year 2, and 3.
Emergency Room Visits	Using annual MMIS data, the state will compare emergency department use that did not result in an admission for noninjury and illness diagnosis for clients who have been enrolled in a health home for at least 1 year versus clients not in a health home.
Skilled Nursing Facility (SNF) Admissions	Using annual MMIS data, the state proposes to compare skilled nursing admissions for clients in a PCPCH/health home for at least 1 year versus clients not in a PCPCH/health home.
Chronic Disease Management	Through administrative data, MMIS and submitted quality measures required for PCPCH recognition, a series of national chronic disease-specific measures will be monitored and compared between patients in versus not in a PCPCH/health home.
Coordination of Care for Individuals with Chronic Conditions	Centered on patient experience of care, administered through CAHPS surveys by the state annually.
Assessment of Program Implementation	Oregon will use Learning Collaborative models throughout the implementation of PCPCH/health homes. A select group of practices and a select group of patients identified as being the highest risk will meet to discuss challenges and opportunities.
Processes and Lessons Learned	Cites the Learning Collaborative models process--these collaborative meetings will be public and results become a public record so that dissemination of results is easy to access and is transparent.
Assessment of Quality Improvements and Clinical Outcomes	Data sources will include administrative data, MMIS, additional quality measures submitted by PCPCH/health home providers and contracted MCOs/CCOs.
Estimates of Cost Savings	The state will use administrative data, MMIS, and will compare members enrolled versus not enrolled in PCPCH/health home providers for their primary care. Analysis will focus on looking at care utilization, cost, and cost savings related to inpatient admissions, emergency department visits, diagnostic use, specialty care, pharmacy claims, and emergent and nonemergent transportation.

 

APPENDIX A: Pre-Existing Initiatives in Oregon
	CCOs	Comprehensive Primary Care Initiative19	T-CHIC	Demonstration to Integrate Care for Dual Eligibles20
Timeline	State authorized the creation of CCOs in July 201121 First wave of CCOs began enrolling beneficiaries in September 2012	Practices began delivering enhanced services in fall 2012 Demonstration will run for 4 years	Oregon was awarded $11.3 million in February 2010 Planning was conducted from March-November 2010 Implementation stage will run from November 2010-March 2015	Oregon submitted its proposal to CMS in May 2012 Pending approval, full implementation is scheduled to begin in January 2014
Geographic Area	Statewide	Statewide	Statewide	Statewide
Sponsors	OHA	CMS/CMMI	CMS	CMS
Scope	Eventually will include all Medicaid beneficiaries Plans also underway to extend the coordinated care model to state employees Standards for the Qualified Health Plans in the state Health Insurance Marketplace will include elements of the coordinated care model	70 primary care practices 517 providers 49,000 Medicare beneficiaries 6 payers, including Medicaid and Medicare	8 pilot sites in Oregon, 3 in Alaska, 10 in West Virginia22	All full-benefit Medicare-Medicaid enrollees, excluding individuals in the Program of All-Inclusive Care for the Elderly (forecasted at 68,000 individuals)
Goals	Provide and coordinate physical, behavioral, and dental care services Reduce health care costs Improve care quality through the alignment of financial incentives and integration of care	Participating practices will:11 Provide care management for high-need patients Ensure 24/7 accessibility to care Pprovide timely and appropriate preventive care Encourage patient and caregiver self-management Coordinate care across the care spectrum	Develop, implement, and evaluate pediatric quality measures Establish pilot EHR projects and health information exchanges Pilot different models of care delivery for pediatric patients	Coordinate and integrate physical, behavioral, and oral health care for dual eligibles within CCO networks Ensure that CCOs coordinate with the long-term care system and share accountability for outcomes
Payment Approach	Global payment	Risk-adjusted PMPM care management fee; Medicare beneficiary payment average of $20 for years 1-2, then $15 for years 3-4 Shared savings available to practices in years 3-4	Incentives for Learning Collaborative participation vary by state	Capitation payment to CCOs for mental, physical, and dental care. The state is also considering various quality incentive payment models
Technical Assistance (TA)	With input from CMS, the state will provide technical assistance to CCOs in the development and implementation of a mandated Quality Assurance and Performance Improvement Plan23 Oregon Transformation Center will provide technical assistance and tools to support system transformation	CMMI will provide resources to participating practices to assist them in practice evolution	Oregon is convening a series of Learning Collaboratives focused on practice improvement and implementing core quality measures	No information found
HIT Use	CCOs are required to develop HIT infrastructure that links providers across the continuum of care	CMMI required that all practices have an EHR or electronic registry, and preference was given to those who had obtained stage 1 meaningful use24	HIT system integration and quality measure reporting through EHRs are major goals of the demonstration	In addition to general requirements placed on CCOs, the state proposes to implement technology solutions that will permit patient data-sharing between the relevant state agencies, CCOs, and long-term care providers
Evaluation Methods	The state will use independent entities to conduct routine audits of performance against quality metrics, and establish an annual review process for evaluating the appropriateness of those metrics25	CMMI will hire an independent contractor to evaluate the impact of the initiative on health, care experience, and costs	CMS has hired an independent contractor to evaluate the entire CHIPRA demonstration, which includes Oregon Oregon will also conduct its own evaluation	The state proposes both ongoing evaluation of CCO and long-term care metrics, as well as a post-implementation evaluation to assess how shared accountability is working, best practices, and lessons learned

 

APPENDIX B: Initial Implementation Measures for PCPCHs--Oregon18
	Standard	Must-Pass	Tier 1 5 Points Each	Tier 2 10 Points Each	Tier 3 15 Points Each
Core Attribute #1: Access to Care	In-Person Access	N/A	PCPCH surveys a sample of its population on satisfaction with in-person access to care and reports results (C)	PCPCH surveys a sample of its population using 1 of the CAHPS survey tools and reports results on the access to care domain (C)	PCPCH surveys a sample of its population using 1 of the CAHPS survey tools, reports results on access to care and meets a patient satisfaction benchmark in access to care (C)
	After Hours Access	N/A	PCPCH offers access to in-person care at least 4 hours/week outside traditional business hours (C)	N/A	N/A
	Telephone and Electronic Access	PCPCH provides continuous access to clinical advice by telephone (C)	N/A	N/A	N/A
Core Attribute #2: Accountability	Performance and Clinical Quality Improvement	PCPCH tracks 1 quality metric from core or menu set of PCPCH Quality Measures (C)	N/A	PCPCH tracks and reports to the OHA 2 measures from core set and 1 measure from the menu set of PCPCH Quality Measures (D)	PCPCH tracks, reports to the OHA and meets benchmarks on 2 measures from core set and 1 measure from the menu set of PCPCH Quality Measures (D)
Core Attribute #3: Comprehensive Whole Person Care	Preventive Services	N/A	PCPCH offers or coordinates 90% of recommended preventive services (C)	N/A	N/A
	Medical Services	PCPCH reports that it routinely offers: Acute care for minor illnesses and injuries; Ongoing chronic disease management; Office based procedures and diagnostic tests; Patient education and self management (C)	N/A	N/A	N/A
	Mental Health, Substance Abuse, and Developmental Services	PCPCH documents its screening strategy for mental health, substance use, or developmental conditions and documents onsite and local referral resources (C)	N/A	PCPCH documents direct collaboration or comanagement of patients with specialty mental health, substance abuse, or developmental providers (C)	PCPCH documents actual or virtual colocation (with the use of telemedicine or telepsychiatry) with specialty mental health, substance abuse, or developmental providers (C)
	Comprehensive Health Assessment and Intervention	N/A	PCPCH documents comprehensive health assessment and intervention for at least 3 health risk or developmental promotion behaviors (C)	N/A	N/A
Core Attribute #4: Continuity	Personal Clinician Assigned	PCPCH reports the percentage of active patients assigned a personal clinician and/or team (D)	N/A	N/A	PCPCH meets a benchmark in the percentage of active patients assigned to a personal clinician and/or team (D)
	Personal Clinician Continuity	PCPCH reports the percent of patient visits with assigned clinician/team (D)	N/A	N/A	PCPCH meets a benchmark in the percent of patient visits with assigned provider (D)
	Organization of Clinical Information	PCPCH maintains a health record for each patient that contains at least the following elements: problem list, medication list, allergies, basic demographic information, preferred language, BMI/BMI percentile/growth chart as appropriate, and immunization record (C)	N/A	N/A	N/A
	Clinical Information Exchange	N/A	N/A	N/A	PCPCH shares clinical information electronically in real-time with other providers and care entities (health information exchange) (C)
	Specialized Care Setting	PCPCH has a written agreement with its usual hospital providers or directly provides routine hospital care (C)	N/A	N/A	N/A
Core Attribute #5: Coordination and Integration	Population Data Management	N/A	PCPCH demonstrates the ability to identify, aggregate, and display uptodate patient data (C) PCPCH demonstrates the ability to identify, track and proactively manage the care needs of a subpopulation of its patients (C)	N/A	N/A
	Electronic Health Record	N/A	N/A	N/A	PCPCH has an EHR and demonstrates meaningful use (C)
	Care Coordination	N/A	PCPCH assigns responsibility for care coordination, tells each patient or family the name of the team member responsible for coordinating his or her care (C)	PCPCH describes and demonstrates its process for identifying and coordinating the care of patients with complex care needs (C)	N/A
	Test and Result Tracking	N/A	PCPCH demonstrates tracking of tests ordered by its clinicians and ensures timely and confidential notification to patients, families, and ordering clinicians (C)	N/A	N/A
	Referral and Specialty Care Coordination	N/A	PCPCH tracks referral orders, including referral status and whether consultation results have been communicated to patients and/or caregivers and clinicians (C) PCPCH either manages hospital or SNF care for its patients or demonstrates active involvement and coordination of care in these specialized care settings (C)	N/A	PCPCH tracks referrals and coordinates care where appropriate for community settings outside the PCPCH (C)
	Comprehensive Care Planning	N/A	PCPCH demonstrates the ability to identify high-risk patients, who will benefit from additional care planning. PCPCH demonstrates it can provide these patients and families with a written care plan (C)	N/A	N/A
	End-of-Life Planning	PCPCH demonstrates a process to offer or coordinate hospice and palliative care and counseling for patients and families who may benefit from these services (C)	N/A	N/A	N/A
Core Attribute #6: Person and Family-Centered Care	Language/Cultural Interpretation	PCPCH documents the offer and/or use of providers or telephonic trained interpreters to communicate with patients and families in their language of choice (C)	N/A	N/A	N/A
	Education and Self-Management Support	N/A	PCPCH documents patient and family education, health promotion and prevention, and self-management support efforts, including available community resources (C)	N/A	N/A
	Experience of Care	N/A	PCPCH surveys a sample of its patients and families at least Annually on their experience of care. The recommended patient experience of care survey is 1 of the CAHPS survey tools (C)	PCPCH surveys a sample of its population using 1 of the CAHPS survey tools (C)	PCPCH surveys a sample of its population using 1 of the CAHPS survey tools and meets benchmarks on the majority of the domains (C)
NOTES: (C) refers to contractual attestation measures. (D) refers to measures that require quantitative data submission

Endnotes

1. Approved Oregon State Amendment Plan (SPA) Transmittal Number 11-011. Available from: http://www.chcs.org/usr_doc/OR11-011_Approval_Package_(3_13_12).pdf.

2. National Academy for State Health Policy (NASHP) website. "State of Oregon." Available from: http://www.nashp.org/med-home-states/oregon.

3. Oregon Health Authority website. "About the Patient-Centered Primary Care Home Program." Available from: http://cms.oregon.gov/oha/OHPR/pages/healthreform/pcpch/about_us.aspx.

4. Coughlin, T., and S. Corlette. "ACA Implementation in Oregon--Monitoring and Tracking: Oregon Site Visit Report." Urban Institute and the Robert Wood Johnson Foundation, March 2012.

5. Medicaid website. "State of Oregon." Available from: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/Oregon.html.

6. Office for Oregon Health Policy Research, Patient-Centered Primary Care Home Program. "Oregon Patient-Centered Primary Care Home Model: Implementation Reference Guide." October 2011. Available from: http://www.oregon.gov/oha/OHPR/HEALTHREFORM/PCPCH/docs/implementation-gu....

7. NASHP webinar. "Patient Centered Primary Care Homes: An Overview of Oregon's Implementation of the ACA Section 2703 Health Home Provisions." June 14, 2012. Available from: http://www.nashp.org/webinar/implementing-section-2703-health-homes-lessons-leading-states.

8. Oregon Health Authority website. "Addictions and Mental Health Services." Available from: http://staging.apps.oregon.gov/OHA/amh/pages/system-change/index.aspx.

9. Oregon Health Policy Board. "Coordinated Care Organizations." Available from: http://www.oregon.gov/oha/ohpb/pages/health-reform/ccos.aspx.

10. Oregon Health Authority. "Health System Transformation Quarterly Report, February 2014: Executive Summary." February 2014. Available from: http://www.oregon.gov/oha/Metrics/Documents/Exec%20summary_Final.pdf.

11. Center for Medicaid and Medicaid Innovation. "Comprehensive Primary Care Initiative Fact Sheet." August 2012. Available from: http://innovation.cms.gov/Files/fact-sheet/Comprehensive-Primary-Care-Initiative-Fact-Sheet.pdf.

12. Center for Medicaid and Medicaid Innovation website. "Comprehensive Primary Care Initiative." Available from: http://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/index.html.

13. "Overview of the Centers for Medicare and Medicaid Services' Quality Demonstration Grant Program: The Tri-state Children's Health Improvement Consortium Grant Award." Available from: http://www.oregon.gov/OHA/OHPR/GRANT/docs/CHIPRA.pdf.

14. Oregon Pediatric Improvement Partnership website. Available from: http://www.oregon-pip.org/index.html.

15. Oregon Health Authority. "Patient-centered Primary Care Home Program: Supplemental Payment Options for Recognized Clinics." June 2012. Available from: http://cms.oregon.gov/OHA/OHPR/HEALTHREFORM/PCPCH/docs/dmap-enrollment-p....

16. Centers for Medicare and Medicaid Services. "Health Homes for Enrollees with Chronic Conditions." State Medicaid Director Letter #10-024, November 16, 2010. Available from: http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD10024.pdf.

17. Oregon Health Authority webcast. "Patient Centered Primary Care Home Initiative: Understanding the Medicaid PCPCH Payment Requirements." Presentation slides, May 14-15, 2012. Available from: http://www.oregon.gov/oha/OHPR/HEALTHREFORM/PCPCH/docs/pcph-payment-ince....

18. Office for Oregon Health Policy and Research. Table adapted from "Oregon Patient-Centered Primary Care Home Model: Implementation Reference Guide October 2011." Available from: http://cms.oregon.gov/OHA/OHPR/HEALTHREFORM/PCPCH/docs/PCPCH_Implementat....

19. Center for Medicare and Medicaid Innovation website. "Comprehensive Primary Care Initiative: Oregon." Available from: http://www.innovations.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/Oregon.html.

20. Oregon Health Authority. "State Proposal to CMS: Medicare/Medicaid Alignment Demonstration to Integrate Care for Dual Eligibles." May 2012. Available from: https://cco.health.oregon.gov/DraftDocuments/Documents/Duals%20Demonstration%20Proposal%20-%20Final%20Public%20Comment%20Draft%203-2-12.pdf.

21. Oregon Health Authority. "Timeline for Coordinated Care Organizations." Current as of October 9, 2012. Available from: http://www.oregon.gov/oha/OHPB/docs/cco-timeline.pdf.

22. Oregon Health Authority. "CHIPRA Quality Demonstration Semi-Annual Progress Report." February 2012.

23. Oregon Health Authority. "Application for Amendment and Renewal of the Oregon Health Plan 1115 Demonstration Project." March 2012. Available from: https://cco.health.oregon.gov/DraftDocuments/Documents/narrative.pdf.

24. Center for Medicaid and Medicaid Innovation. "Comprehensive Primary Care Initiative: Primary Care Practice Solicitation." Available from: http://www.innovations.cms.gov/Files/x/CPC_PracticeSolicitation.pdf.

25. Oregon Health Policy Board. "Coordinated Care Organizations: Implementation Proposal." January 24, 2012. Available from: http://www.oregon.gov/oha/legactivity/2012/cco-implementation-proposal.pdf.

 

 

Rhode Island's Health Home Program at a Glance
	State Plan Amendment 1	State Plan Amendment 2
Health Home Eligibility Criteria	Serious Mental Illness (SMI) and evidence of need for supports to remain in the community	2 chronic conditions, 1 chronic condition and at risk of another, SMI
Qualifying Conditions	Mental health condition, with a history of intensive psychiatric treatment, no or limited employment, and poor social functioning	Mental health condition Asthma Developmental disability Diabetes Down syndrome Mental retardation Seizure disorder
Enrollment*	6,772	2,855
Designated Providers	Community Mental Health Organizations (CMHO)	CEDARR Family Centers
Administrative/ Service Framework	Health home services are provided by 7 CMHOs and 2 specialty providers of mental health services	Health home services are provided by CEDARR Family Centers, operating at 4 sites and primarily serving children
Required Care Team Members	Master's team coordinator Psychiatrist Registered nurse Master's level clinician Community psychiatric support and treatment (CPST) specialist CPST specialist/hospital liaison Peer specialist	Licensed clinician Family service coordinator
Payment System	Per member per month (PMPM) care management fee	Fee-for-service
Payment Level	Based on 9 staff hours PMPM	Fixed rates of $347, $366, or $397, depending on the service. Additional payments of either $9.50 or $16.63 made per quarter hour for 2 other services
Health Information Technology (HIT) Requirements	No HIT requirements. The state plans to phase-in HIT support to its health home providers and, in the interim, relies on the existing infrastructure
* January 2014 data provided to the Centers for Medicare and Medicaid Services' Health Home Information Resource Center.

Introduction

Rhode Island has two approved State Plan Amendments (SPAs); one for persons with serious and persistent mental illness (SPMI), and one for persons with SPMI and/or other disabling or chronic physical or developmental conditions (this latter group is de facto limited to children and youth by virtue of the providers designated in the SPA). Both SPAs were approved on November 23, 2011, and have a retroactive effective date of October 1, 2011. Health home services under the first SPA will be provided by seven community mental health organizations (CMHOs)--which provide behavioral health services to persons with SPMI, and predominantly serve Medicaid, Medicare, the dually eligible, and the uninsured--and two specialty providers of mental health services, Fellowship Health Resources, Inc., and Riverwood Mental Health Services.¹ The Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) oversees CMHOs and the specialty providers. Children and youth receive services through specialized providers known as CEDARR Family Centers (CEDARR stands for Comprehensive Evaluation, Diagnosis, Assessment, Referral, Re-evaluation). To be eligible for care at CEDARR centers, an individual must be eligible for Medical Assistance, under age 21, a Rhode Island resident, live at home, and have a disabling or chronic condition that is cognitive, physical, developmental and/or psychiatric.² The Rhode Island Department of Human Services (DHS) oversees the four CEDARR centers.

Implementation Context

Rhode Island's two SPAs were developed in the context of several ongoing initiatives aimed at reforming the health system so as to increase care management, develop the medical home model, and integrate care for those who are dually eligible for Medicare and Medicaid, with particular focus on high-cost, high-need populations. The state has characterized the health homes model as an opportunity to improve an existing system of care, develop new payment methodologies to accommodate activities such as community-based care coordination, and provide a consistent system of care for children with special health care needs as they transition to adulthood.³ An important aspect of Rhode Island's reform is the five-year Global Consumer Choice Compact Waiver approved by the Centers for Medicare and Medicaid Services (CMS) in early 2009, under which Rhode Island operates its entire Medicaid program. Among other things, the waiver has allowed the state to mandate enrollment in either capitated or fee-for-service (FFS) managed care. The state also is participating in the Multipayer Advanced Primary Care Practice (MAPCP) Demonstration, through which CMS provides a monthly care management fee for Medicare enrollees in advanced primary care practices.⁴ In addition, the state has received a Money Follows the Person grant to support efforts to help institutional residents return to health and supportive care in community settings and is working with CMS to implement models for integrating Medicare and Medicaid services and financing for persons dually eligible for the two programs in capitated or FFS managed care.⁵ As part of the integration plan, the state is considering creating a Community Health Care Team to focus on long-term services and supports (LTSS) for FFS participants and incorporating managed LTSS into the service package for managed care participants.

CEDARR Family Centers were selected as health home providers based on their experience managing care for children and youth with special health care needs. The centers, established in 2000, currently coordinate care for roughly 2,700 children and youth at any given time. These centers are responsible for assessment of need, referral to resources, and the integration of services provided through different systems (education, Medicaid FFS, Medicaid managed care, child welfare), oversight of Medicaid FFS specialized home and community-based services, and reassessment and adjustment of treatment plans on an annual basis. CEDARR centers also provide direct services, such as home-based therapeutic services, personal assistance services and supports, KIDS CONNECT therapeutic day care, and respite services. About 95% of CEDARR clients meet health home diagnostic criteria.³

CMHOs, which were established in 1964 and served about 20,000 persons in 2010, also have experience with care integration. Two of the seven CMHOs designated as health home providers received the Substance Abuse and Mental Health Services Administration primary care/behavioral health integration grants in September 2010.⁶ Health homes will build on this existing infrastructure, which includes community hospital contracts with CMHOs to conduct emergency psychiatric assessments in emergency departments, and long-term relationships between some CMHOs and local federally qualified health centers and primary care practices (e.g., co-location and formal integrated care agreements). CMHO services also include 24-hour crisis intervention and stabilization, medication prescription and management, bio-psychosocial assessment, psychotherapy, counseling, psychiatric evaluation, community psychiatric supportive treatment specific to substance abuse and supported employment, rehabilitative residence, substance abuse treatment, supported housing/residential services, and two levels of intensive community-based treatment.⁷ Basic mental health and substance abuse services are provided through managed care organizations (MCOs) for those enrolled; more extensive services for enrollees with SPMI are available on a FFS basis.⁸

Rhode Island has multiple programs intended to better coordinate and manage care for high-risk populations, including those with disabilities. Under its Section 1115 Global Consumer Choice Compact Waiver, the state has not only continued its efforts to increase access to community-based supports and services and reduce institutional care--a process which was begun in 2006 under a Real Choice Systems Transformation Grant--but has also expanded the scope of its health system reform.⁹ As of fall 2009, Rhode Island adults age 21 and older who qualify for Medical Assistance must enroll in either Connect Care Choice (CCC), a FFS-based primary care case management (PCCM) program, or a capitated Medicaid MCO through Rhody Health Partners (RHP), both of which were initiated in 2007.¹⁰ Children with special health care needs living outside of institutional settings (which include the target population for the CEDARR-based health home program) must enroll in a RIte Care managed care plan (MCP).¹¹ UnitedHealthcare of New England and Neighborhood Health Plan of Rhode Island are the two participating plans for both RIte Care and RHP. In late 2008, the state launched a pilot program known as the Chronic Care Sustainability Initiative (CSI) which is a PCCM program focused on patients who suffer from diabetes, depression, and/or coronary artery disease (CAD). In 2011, the program was accepted for participation in the three-year CMS MAPCP Demonstration.¹² These programs are described in greater detail in the table found in the Appendix.

Implications for the Rhode Island Section 2703 Medicaid Health Homes Evaluation

The initiatives described above demonstrate that the state has made significant efforts toward expanding care coordination and management in its health system, integrating health services with community support services, and in planning additional expansions and models. The health homes initiative provides a vehicle for further system development for two particularly high-need subsets of the Medicaid population. Under the state's Section 1115 Global Waiver both children with special health care needs and adults with disabilities have been required to enroll in managed care for their physical health care--RIte Care MCPs in the case of children and CCC or RHP in the case of adults. Although both CEDARR Family Centers and the SPMI providers have experience with various aspects of health home structures, there appear to be significant differences in the level of development between the CEDARR and SPMI providers, and among the designated SPMI providers themselves. The two SPAs differ significantly in terms of service definition, level of training required, payment structure, and evaluation measures. The range of additional demonstrations and plans for care integration the state is undertaking may have implications for the availability of comparison groups for the evaluation, particularly for adults in the CMHO health homes. However, state materials relating to these integration efforts suggest that there are adults with SPMI outside of CMHOs who may be appropriate as comparisons. On the other hand, the progress of these additional care integration efforts may affect the validity of comparisons over time and will need to be monitored over the evaluation period.

Health home-type services have been provided by CEDARR centers for a number of years. Therefore, it will be particularly important to clearly identify and describe the structures and processes that are in place at baseline, and to characterize the changes that providers make to these structures and processes as a consequence of becoming health homes. It will also be necessary to adjust the analysis for both the participants' and providers' time in program.

The picture is more complex for CMHOs and the two specialty providers because some sites appear to have more experience with care integration and coordination than others. All, however, will require more substantial reorganization and training than the CEDARR centers to meet health home requirements. As in the CEDARR center evaluation, it will be necessary to clearly delineate the existing structure and processes, but it will also be important to document variations between mental health provider sites and how the state is addressing the variations. The baseline site visits will be a critical tool for filling in gaps in our understanding of both provider groups.

Population Criteria and Provider Infrastructure

Table 1 summarizes the population criteria, the designated providers, and requirements regarding the minimum composition of the health home team for both health home initiatives. In the rest of the discussion, we denote the initiative targeting persons with SPMI as the CMHO-HH, and the second targeting special needs children and youth as the CEDARR-HH. The CMHO-HH SPA lists additional eligibility criteria aside from diagnostic category that limit those eligible to enroll to a highly impaired subset who have mental or emotional disorders that seriously impair daily functioning, but for whom long-term 24-hour care may be averted.¹³ The CEDARR-HH population is also fairly narrowly focused by virtue of the eligibility criteria for receiving CEDARR services. Children and youth are eligible for health home services if they have a mental health condition, two chronic conditions, or one chronic condition and the risk of developing another. The conditions are a mental health condition, asthma, diabetes, Down syndrome, a developmental disability, mental retardation, or a seizure disorder.

CMHOs and CEDARR Family Centers have varying experience with health home-type services and have care teams that reflect both the extent to which they are already providing health home-like services and the different needs of their respective beneficiary populations. The required health home team for CEDARR-HH includes only two members, a licensed clinician and a family service coordinator, who will share responsibility for the core health home services. The required team for CMHO-HH includes at least seven members with behavioral, clinical, or social support expertise. However, the CEDARR-HH SPA states that the centers employ both licensed health professionals and staff trained to provide health home-type services, and that the two-person team is expected to collaborate regularly with the child's primary care provider (PCP).

Service Definitions and Provider Standards

Rhode Island has established both overarching and provider-specific definitions for the six health home services. (A full list of these services is provided in Table 5.) Overall, the differences between the provider-specific definitions between the CMHO-HH and the CEDARR-HH reflect the different characteristics and needs of their respective patient populations. Thus, for example, care coordination, transitional care, and referral to support services at CEDARR-HHs would potentially involve school-based services, whereas CMHO-HH services generally would not. Similarly, CMHO-HHs will focus more than CEDARR-HHs on ensuring adequate housing, social integration and functioning, substance abuse treatment, and vocational training. The assignment of service provision within the teams is flexible; although each service is assigned to a provider who will have primary responsibility, many services for both CEDARR-HH enrollees and CMHO-HH enrollees may be performed by various members or combination of members of the health home team.

The information provided in the SPAs suggests that practice transformation requirements for the two provider groups will be somewhat different. CEDARR Family Centers already meet established state certification standards, which will serve as the basis for health home qualification and will be changed as necessary to meet any additional health home requirements.¹⁴ Additional requirements for health home status have been added as an Appendix to the CEDARR Family Center Recognition Standards and include the requirement that health homes agree to perform the 11 health home functions identified by CMS in the November 16, 2010, State Medicaid Director (SMD) Letter on Section 2703.¹⁵ CEDARR-HHs must also agree to establish a protocol to gather, store, and transmit to the state all required reporting data as part of their quality improvement plan. Additional reporting requirements are listed in Table 2.

The requirements for CMHO-HHs are more extensive. (See Table 2 for a detailed list.) In addition to meeting state licensure requirements for being behavioral health centers, CMHOs must submit a proposal demonstrating how they will structure team composition and member roles to meet health home goals, a requirement that is not included for CEDARR teams. CMHOs must also sign a certificate of agreement that outlines their roles and responsibilities as health homes and that includes requirements related to care organization, transitional care arrangements with hospitals, progress reports, and state evaluations. CMHOs must also agree to participate in statewide learning activities, which will focus on training providers to perform the 11 health home functions identified by CMS in the November 2010 SMD letter. Community support specialists are specifically required to undergo a 17-week training designed to improve their clinical and case management skills.

Use of Health Information Technology

Rhode Island plans to phase-in health information technology (HIT) support to its health home providers and, in the interim, will rely on the existing infrastructure used by CEDARR Family Centers and the state Medicaid MCOs, which cover 60% of CEDARR-HH participants and 35% of eligible CMHO-HH participants. The state is working with the MCOs to develop utilization profiles covering the last 12 months, including the number of emergency department and urgent care visits, date and diagnosis of most recent emergency department visit, PCP and number of visits, prescription drug information, and behavioral health utilization. To the extent possible, the state will develop similar profiles from the Medicaid data warehouse and other applicable sources for the remaining FFS individuals. For CMHO-HH participants who are dually eligible for Medicare and Medicaid, the state will work closely with the CMS Center for Medicare and Medicaid Innovation to obtain Medicare utilization and cost data. The state will query CMHO providers about the use of HIT in the delivery of care coordination services and may establish pilot tests of a subset of providers (e.g., those with electronic health records [EHRs] and patient registries) to measure changes in health outcomes, experience of care, and quality of care among clients. The Rhode Island Behavioral Health Online Dataset (RI-BHOLD) also is cited as the source for some clinical outcome data, but is not otherwise described in the SPA.

CEDARR-HHs use an existing electronic case management system, which can support linkages of information from medical and human service providers and school programs, and the Rhode Island KIDSNET Child Health Information System, which provides access to information such as blood lead levels, immunizations, newborn developmental assessment, hearing assessment, the Special Supplemental Nutrition Program for Women, Infants, and Children participation, and early intervention participation. CEDARR-HHs also will offer to enroll all clients into "CurrentCare," Rhode Island's electronic health information exchange.

Payment Structure

The two types of health homes will have very different payment structures. CMHO-HHs are paid on a monthly case rate basis, with the rate reflecting personnel costs and staffing ratios based on estimates of client need. The estimated staff needs, for a team serving 200 clients, is 11.25 full-time equivalent, or approximately nine staff hours per member per month (PMPM). CMHO-HHs are required to submit detailed encounter data to the state. After six months, and annually thereafter, the state will consider whether to adjust the case rate or consider alternate payment methodologies, based on analysis of program costs versus services received by recipients.

CEDARR-HHs are paid on a FFS basis. Three existing CEDARR activities, with established rates, are defined to be the "comprehensive care management" component of a health home. These are initial family intake and needs assessment, family care plan development following initial needs assessment, and annual family care plan review. Fixed rates for each of these three services are in the $350-$400 range. All the other health home services are mapped to two established CEDARR services: health needs coordination and therapeutic consultation. The skill mix associated with each health home service is specified in the SPA. Care coordination, comprehensive transitional care, individual and family support services, and referral to community and social support services are considered to be health needs coordination. Health promotion is considered to be therapeutic consultation. Payment rates per quarter hour for each type of professional are established hourly rates, and billing is by quarter-hour units of time actually spent on each service. There is no stated plan for revision of the payment system for CEDARR-HHs.

Quality Improvement Goals and Measures

There are five quality improvement goals for CEDARR-HHs and six for CMHO-HHs, summarized in Table 3 below, along with the quality measures that will be used. There is little overlap in either the goals or the measures used, in part because of the very different participant populations for the two types of providers. Both SPAs list "improved care coordination" as the first goal, but the measures diverge, with CEDARR-HH measures focusing on physician consultations, use of Rhode Island KIDSNET, and communication with MCO PCPs, while those for CMHO-HHs focus on chart documentation of physical and behavioral health needs and post-hospitalization follow-up visits. Other goals are similar in concept, but have very different measures. For example, goals for CEDARR centers include "decrease occurrence of secondary conditions," "decrease ED use and preventable admissions," and "improve quality of transitions from inpatient/residential care to community," while CMHO goals include "increase use of preventive services," "reduce preventable ED use," and "improve transitions to CMHO care." There are only a few overlaps in measures (e.g., documentation of BMI and depression screening). Both patient groups will be surveyed on their satisfaction with service access and quality.

Data sources also vary, though both evaluations will use claims and encounter data as well as chart/record review and client surveys. The CEDARR data sources also will include KIDSNET, and CMHO data sources will include the Rhode Island Outcomes Evaluation Instrument, and RI-BHOLD.

Evaluation Measures and Methods

The evaluation measures and methodology described in the CMHO-HH and CEDARR-HH SPAs are reproduced in Table 4 and are different in both content and evaluation methodology for the two provider groups.

The CEDARR-HH evaluation strategy is limited to an entirely pre/post design for all data collected from practices and for cost savings estimates. Based on the detailed information provided for the cost savings estimation, the intent is to consider the "pre" period to be the single quarter preceding the effective date of October 1, 2011 (the first quarter of the state's fiscal year 2012), and the "post" period to be the eight subsequent quarters over which the enhanced federal match for health home services is in effect. No comparison group of beneficiaries or practices is specified. Hospital admission rates and length of stay, and the number of emergency department visits and skilled nursing facility admissions will be computed bi-annually.

The CMHO-HH strategy for evaluating chronic disease management, coordination of care, assessment of program implementation, and processes and lessons learned, and assessment of quality improvements and clinical outcomes, does not specify either a pre/post design or a comparison group, apparently relying on change over time after implementation. For hospital admission rates (to be measured per 1,000 member months), both a pre/post analysis of rates for CMHO-HH participants and a comparison with rates for clinically similar individuals not receiving CMHO-HH services are envisioned. It is not made clear whether the intent is to examine rates pre/post for both participants and comparison group, which is the preferred approach. For savings estimations, the state proposes to estimate baseline total costs for Medicare and Medicaid beneficiaries who would have been eligible for CMHO health home services at any time during the fourth quarter of state fiscal year 2011 (April 2011-June 2011), presuming they can obtain appropriate Medicare claims data for dual eligible clients. Cost savings will be estimated annually by comparing those baseline estimates with costs for the same beneficiaries one year and two years later. Assessments also will include performance measures, which we interpret as the clinical outcome measures shown in Table 3, and targeted areas of cost in addition to total costs.

TABLE 1. Target Population and Designated Providers--Rhode Island
	SPA 1	SPA 2
SPA Approval (Effective Date)	November 23, 2011 (October 1, 2011)	November 23, 2011 (October 1, 2011)
Designated Provider(s)	CMHOs; 2 specialty mental health providers	CEDARR Family Centers
Health Home Team Composition	Required: Master's team coordinator Psychiatrist Registered nurse Master's level clinician Community psychiatric support and treatment (CPST) specialist CPST specialist/hospital liaison Peer specialist Optional: PCP Pharmacist Substance abuse specialist Vocational specialist Community integration specialist	Required: Licensed clinician Family service coordinator Optional: Other medical providers as necessary
Target Population and Qualifying Chronic Conditions	Beneficiaries must have SMI, be Medicaid eligible and: Have either undergone psychiatric treatment more intensive than outpatient care more than once, experienced a single episode of continuous, supportive residential care other than hospitalization for at least 2 months, or have impaired role functioning. Meet at least 2 of the following criteria, on a continuing or intermittent basis for at least 2 years: If employed, is employed in a sheltered setting, or has markedly limited skills or a poor work history. Requires public financial assistance for out-of-hospital maintenance and may be unable to procure such assistance without help. Shows inability to establish or maintain a personal social support system. Requires help in basic living skills. Exhibits inappropriate social behavior which results in demand for intervention by the mental health and/or judicial system	Beneficiaries must have: 2 chronic conditions 1 chronic condition and the risk of developing another SPMI Qualifying chronic conditions include: Mental health condition Asthma Diabetes Developmental disability Down syndrome Mental retardation Seizure disorder

 

TABLE 2. Provider Qualifications--Rhode Island
CEDARR Qualifications
Agree to perform the 11 health home functions identified by CMS in the November 10 SMD Letter. Establish a protocol to gather, store and transmit to the state all required reporting data. Perform yearly outreach to the child's PCP and Medicaid MCP (if applicable). Perform yearly Body Mass Index (BMI) Screening for all children 6 years of age or older. If this is not clinically indicated, reason must be documented. Perform documented yearly depression screening for all children 12 years of age or older. If this is not clinically indicated, reason must be documented. Conduct a yearly review of immunizations, screenings and other clinical information contained in the KIDSNET Child Health Information System.
CMHO Qualifications
Each CMHO health home provider must sign a certification agreement that outlines CMHO's roles and responsibilities, which will minimally require: Have psychiatrists/nurse specialists assigned to the health home team, and available 24/7 for all services that address whole-person needs;. Conduct wellness interventions as indicated based on individuals' level of risk. Agree to participate in any statewide learning sessions that may be implemented for health home providers. Within 3 months of health home service implementation, have developed a contract or memorandum of understanding with regional hospitals or system(s) to ensure a formalized structure for transitional care planning, as well as maintain a collaboration to identify individuals seeking emergency department services that might benefit from connection with a CMHO health home provider. Agree to convene internal health home team meetings with all relevant providers to plan and implement practice transformation. Agree to participate in CMS and state-required evaluation activities. Agree to develop required reports describing CMHO health home activities, efforts and progress in implementing health home services. Maintain compliance with all of the terms and conditions as a CMHO health home provider or face termination as a provider of those services. Each CMHO health home must develop and submit to BHDDH for approval its approach for conducting health home services. Proposals must include: An overview of the provider's health home approach (e.g., discussion of a care management model, etc.). A description of the health team, including team member roles and functions. Local hospitals with which the CMHO health home will establish transitional care agreements. A description of the health home's processes for integrating physical and behavioral health care, including coordinating care with PCP. A list of primary care practices with which the CMHO will develop referral agreements. An overview of how each of the 6 health home service components will be carried out by the CMHO health home, and, if applicable: A description of the provider's use of EHRs or patient registries; A description of the providers use of HIT to support care management (e.g., care management software); A list and description of quality measures currently collected and tracked by the CMHO, and, if applicable; An overview of embedded or collected primary care services delivered at the CMHO health home provider. Community support professionals will also undergo a 17-week Community Support Professional Certification Training Program funded by BHDDH and administered by the Rhode Island Council of Community Mental Health Organizations (RICCMHO).

 

TABLE 3. Health Home Goals and Quality Measures--Rhode Island
Shared Goal: Improve Care Coordination
CEDARR	Clinical outcome measures: Percent of physician consultation claims to the number of care plans developed and renewed Number of hits on the KIDSNET Child Health Information System per 1,000 enrollees Percent of MCO enrollees with outreach to MCO documented in the CEDARR record Experience of care measures: Satisfaction with services, accessibility of services, availability of services Percent of initial assessment appointment dates offered within 30 days of request Percent of care plans completed within 30 days of completion of the initial assessment Percent of care plans reviews completed prior to expiration of current care plan Quality of care measures: Percent of clients who have adequate or higher level of knowledge of condition Percent of clients who indicate having a high level of stress caused by condition(s)
CMHO	Clinical outcome measures: Percent of patients whose chart includes documentation of physical and behavioral health needs Percent of hospital-discharged patients with a follow-up visit within 14 days of hospital discharge Experience of care measures: Percent of patients with a regular source of health care Percent of patients who had a physical exam in the past 12 months Quality of care measures: Percent of hospital-discharged patients contacted by the health home team by phone or in person within 2 days of discharge
CEDARR Goals
Improve Health Outcomes of Children and Youth with Special Health Care Needs	Clinical outcome measures: Percent of clients who indicate having adequate or higher level of knowledge of condition Number of referrals to community-based resources per member per year Experience of care measures: Satisfaction with services, accessibility of services, availability of services Percent of community-based service treatment plans reviewed within 30 days of submission to the health home Quality of care measures: Percent of clients who indicate having a high level of stress caused by condition(s) Parent/guardian self-rating of child's ability to take part in age appropriate community and social activities
Decrease the Occurrence of Secondary Conditions	Clinical outcome measures: Yearly BMI is calculated for all clients 6 years of age and older with documented intervention if 85th percentile Yearly screening for depression for all clients 12 years of age or above Experience of care measures: Satisfaction with services, accessibility of services, availability of services Quality of care measures: Reduction of clients with a BMI >85th percentile Clients who screened positive for depression who received further treatment or evaluation
Decrease Emergency Department and Inpatient Treatment for Ambulatory Sensitive Conditions (ASCs)	Clinical outcome measures: Percent of patients with 1 or more emergency department visits for any conditions appearing in a state-defined list of diagnoses that can be treated in a nonemergency department setting Percent of patients with 1 or more admissions for any conditions appearing in a state list of diagnoses that can be avoided through preventive care Experience of care measures: Satisfaction with care, accessibility of care Quality of care measures: Medical follow-up within 7 days of ASC admission Medical follow-up within 7 days of ASC emergency department visit
Improve the Quality of Transitions from Inpatient/Residential Care to Community	Clinical outcome measures: Percent of discharges for admissions >7 days in length with active participation of health home staff Percent of discharges for admissions >7 days in length who are contacted by health home staff within 7 days of discharge Percent of clients re-admitted or utilizing emergency department within 30 days of discharge with same diagnosis as admission Experience of care measures: Satisfaction with care, accessibility of care Quality of care measures: Percent of clients with nonpsychiatric admissions within 30 days of hospital discharge Percent of clients with a psychiatric admission within 30 days of psychiatric hospital discharge
CMHO Goals
Reduce Preventable Emergency Department Visits	Clinical outcome measures: Percent of patients with 1 or more emergency department visits for any conditions named in the New York University emergency department methodology Percent of patients with 1 or more emergency department visits for a mental health condition Experience of care measures: Satisfaction with care, accessibility of care Quality of care measures: Percent of hospital-discharged patients contacted by the health home team by phone or in person within 2 days of discharge
Reduce Hospital Readmissions	Clinical outcome measures: Hospitalization rate for conditions where appropriate ambulatory care prevents or reduces the need for admission, per 100,000 under age 75 Number of acute inpatient stays followed by all-cause readmission within 30 days and the predicted probability of an acute readmission Experience of care measures: Satisfaction with care, accessibility of care Quality of care measures: Percent of hospital-discharged patients with a follow-up visit to a CMHO or medical provider within 14 days of hospital discharge Percent of hospital-discharged patients contacted by health home team member by phone or in person within 2 days of discharge
Increase Use of Preventive Services	Clinical outcome measures: Percent of patients who report that they smoke Percent of patients who report using illicit substances or abusing alcohol Percent of members 18-74 years of age who had an outpatient visit and who had their BMI documented Age and gender appropriate use of pap test, mammogram, and colonoscopy, using HEDIS specifications Experience of care measures: Percent of patients who are satisfied with their access to outpatient services and with the quality of those services Quality of care measures: Percent of patients aged 18 years and older screened for clinical depression using a standardized tool AND follow-up documented Percent of members with a new episode of alcohol or other drug (AOD) dependence who received initiation or engagement of AOD treatment Percent of patients having 1 or more well-visits/physical examination visits in 12 month period Percent of smokers counseled and referred for smoking cessation Percent of drug/alcohol abusers counseled and referred to drug/alcohol treatment
Improve Management of Chronic Conditions	Clinical outcome measures: Percent of patients with diabetes (type 1 or type 2) who had HbA1c 8.0% Percent of patients identified as having persistent asthma and were appropriately prescribed controller medication Percent of patients with a diagnosis of hypertension who have been seen for at least 2 office visits, with blood pressure controlled at 140/90 Percent of patients diagnosed with CAD with lipid level adequately controlled (LDL 100) Quality of care measures: Percent of patients who are adherent to prescription medications for asthma and/or chronic obstructive lung disease Percent of patients who are adherent to medication--cardiovascular disease and anti-hypertensive medication Percent of patients using a statin medication who have a history of CAD
Improve Transitions to CMHO Services	Clinical outcome measures: Percent of discharges for members 6 years of age and older who were hospitalized for selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 7 days of discharge Experience of care measures: Percent of patients satisfied with their access to outpatient services and with the quality of those services Quality of care measures: Percent of hospital-discharged patients contacted by health home team member by phone or in person within 2 days of discharge Percent of patients discharged from inpatient facility for whom a transition record was transmitted to health home for follow-up care within 24 hours

 

TABLE 4. Evaluation Methodology--Rhode Island
	CEDARR-HH	CMHO-HH
Hospital Admission Rates	Comparison of claims and encounter data pre/post-implementation of health homes.	The state will consolidate data from its Medicaid data warehouse which contains both FSS claims and managed care encounter data, to assess general and psychiatric hospital readmission rates of CMHO health home service users. The state will calculate readmissions per 1,000 member months among CMHO users. The state will track pre/post-hospital readmission rates among health home participants. Rates will also be compared with clinically similar individuals not receiving CMHO health home services.
Chronic Disease Management	Comparison of claims and encounter data pre/post-implementation of health homes.	For new individuals of CMHO health home services, the state will track hospital referrals and/or hospital liaison encounters as well as track face-to-face follow-up by a health team member within 2 days after hospitalization discharge. The state will also monitor the number of referrals/post-discharge follow-up contacts that resulted in the development of a care plan.
Coordination of Care for Individuals with Chronic Conditions	Comparison of claims and encounter data pre/post-implementation of health homes.	The state will monitor updates to RI-BHOLD to track changes in psychiatric diagnoses, determine individuals' difficulty with Axis N diagnoses (e.g., housing problems, problems with access to health care services) and track individuals' self-reported co-occurring physical health conditions.
Assessment of Program Implementation	Comparison of claims and encounter data pre/post-implementation of health homes.	The state will monitor implementation through processes developed for regularly occurring meetings of DHS, BHDDH, RICCMHO, MCOs and PCCMs.
Processes and Lessons Learned	CEDARR-HH survey to be developed.	The state and RICCMHO will develop tools to elicit feedback from CMHOs to understand any operational barriers of implementing CMHO health home services.
Assessment of Quality Improvements and Clinical Outcomes	Comparison of quarterly and annual data pre/post-implementation of health homes. The state will utilize quality process and outcome measures described in the prior section to assess quality improvements and clinical outcomes.
Estimates of Cost Savings	The state will analyze Medicaid and Medicare claims cost and utilization data in order to conduct the cost savings methodology. The state will determine baseline costs of Medicaid and Medicare beneficiaries who would have been eligible for CMHO health home services at any time during the fourth quarter of state fiscal year 2011 (April 2011-June 30, 2011). In order to calculate costs savings and the impact of health home services, the state will perform an annual assessment of baseline costs compared with total Medicaid and Medicare costs of those same CMHO health users 1 year and 2 years following the SPA effective date. The assessment will also include the performance measures enumerated in the Quality Measures section. In addition to looking at overall cost, BHDDH will work with EOHHS to determine specific targeted areas of cost most likely to be impacted by health home implementation for a more detailed analysis. In order to perform both of these operations, the state will require timely and affordable access to Medicare data.

 

TABLE 5. Health Home Service Definitions--Rhode Island
Comprehensive Care Management
Overarching State Definition	Comprehensive care management services are conducted with an individual and involve the identification, development, and implementation care plan that addresses the needs of the whole-person. Family/peer supports can also be included in the process. The service involves the development of a care plan based on the completion of an assessment. A particular emphasis is the use of the multidisciplinary team including medical personnel who may or may not be directly employed by the provider of the health home. The recipient of comprehensive care management is an individual with complex physical and behavioral health needs.
CEDARR Definition	Comprehensive care management is provided by CEDARR health homes by working with the child and family to: assess current circumstances and presenting issues, identify continuing needs, and identify resources and/or services to assist the child and family to address their needs through the provision of an Initial Family Intake and Needs Determination; develop a Family Care (or Treatment) Plan which will include child specific goals, treatment interventions and meaningful functional outcomes; and regular review and revision of the Family Care Plan to determine efficacy of interventions and emerging needs. Integral to this service is ongoing communication and collaboration between the CEDARR health homes team and the clients PCP/medical home MCO, behavioral health and institutional/long-term care providers. This service will be performed by the licensed clinician with the support of the family service coordinator.
CMHO Definition	Comprehensive care management services are conducted with beneficiaries, their families and supporters to develop and implement a whole-person oriented treatment plan and monitor the individual's success in engaging in treatment and supports. Comprehensive care management services are carried out through use of a bio-psychosocial assessment of each individual's physical and psychological status and social functioning. The assessment determines an individual's various needs and expectations, and may be conducted by a psychiatrist, registered nurse or a licensed and/or master's prepared mental health professional. Based on the bio-psychological assessment, a goal-oriented, person-centered care plan is developed, implemented and monitored by a multidisciplinary team in conjunction with the individual served. Comprehensive care management services may be provided by any member of the CMHO health home team; however, Master's Level Health Home Team Coordinators will be the primary practitioners providing comprehensive care management services.
Care Coordination
Overarching State Definition	Care coordination is the implementation of the treatment plan developed to guide comprehensive care management in a manner that is flexible and meets the need of the individual receiving services. The goal is to ensure that all services are coordinated across provider settings, which may include medical, social and, when age appropriate, vocational educational services. Services must be coordinated and information must be centralized and readily available to all team members. Changes in any aspect of an individual's health must be noted, shared with the team, and used to change the care plan as necessary. All relevant Information is to be obtained and reviewed by the team.
CEDARR Definition	Care coordination is designed to be delivered in a flexible manner best suited to the family's preferences and to support goals that have been identified. This includes: Follow-up with family, providers, and others involved in the child's care to ensure the efficient provision of services. Provide information to families about specific disorders, treatment and provider options, systems of support, services, assistance and legal rights available, and resources beyond the scope of services covered by Medicaid, such as those which may be available from other parents, family members, community-based organizations, school-based services, etc. Service delivery oversight and coordination to ensure that services are being delivered in a satisfactory manner. Assistance in locating and arranging specialty evaluations as needed, in coordination with the child's PCP. This also includes follow-up and ongoing consultation with the evaluator as needed. This service will be performed by the licensed clinician or the family service coordinator depending on the exact nature of the activity.
CMHO Definition	Care coordination is the implementation of the individualized treatment plan (with active involvement of the individual served) for attainment of the individuals' goals and improvement of chronic conditions. Care managers are responsible for conducting care coordination activities across providers and settings. Care coordination involves case management necessary for individuals to access medical, social, vocational, educational, as well as other individualized supportive services, including, but not limited to: Assessing support and service needed to ensure the continuing availability of required services. Assistance in accessing necessary health care; and follow-up care and planning for any recommendations. Assessment of housing status and providing assistance in accessing and maintaining safe and affordable housing. Conducting outreach to family members and significant others in order to maintain individuals connection to services, and expand social network. Assisting in locating and effectively utilizing all necessary community services in the medical, social, legal and behavioral health care areas and ensuring that all services are coordinated. Coordinating with other providers to monitor individuals' health status, medical conditions, medications and side effects. Care coordination services may be provided by any member of the CMHO health home team; however, CPST Specialists will be the primary practitioners providing care coordination services.
Health Promotion
Overarching State Definition	Health promotion services encourage and support healthy ideas and concepts to motivate individuals to adopt healthy behaviors. The services also enable individuals to self-manage their health.
CEDARR Definition	Health Promotion assists children and families in implementing the Family Care Plan and in developing the skills and confidence to independently identify, seek out and access resources that will assist in managing and mitigating the child's condition(s), preventing the development of secondary or other chronic conditions, addressing family and child engagement, promoting optimal physical and behavioral health, and addressing and encouraging activities related to health and wellness. This service will include the provision of health education, information, and resources with an emphasis on resources easily available in the families' community and peer group(s). This service will be performed by the licensed clinician.
CMHO Definition	Health promotion services encourage and support healthy ideas and concepts to motivate individuals to adopt healthy behaviors. The services also enable individuals to self-manage their health. Health promotion services may be provided by any member of the CMHO health home team. Health promotion activities place a strong emphasis on self-direction and skills development for monitoring and management of chronic health conditions. Health promotion assists individuals to take a self-directed approach to health through the provision of health education. Specific health promotion services may include, but are not limited to, providing or coordinating assistance with: Promoting individuals' health and ensuring that all personal health goals are included in person-centered care plans. Promotion of substance abuse prevention, smoking prevention and cessation, nutritional counseling, obesity reduction, and increased physical activity. Providing health education to individuals and family members about chronic conditions. Providing prevention education to individuals and family members about health screening and immunizations. Providing self-management support and development of self-management plans and/or relapse prevention plans so that individuals can attain personal health goals. Promoting self-direction and skill development in the area of independent administering of medication. Health promotion services may be provided by any member of the CMHO health home team; however, psychiatrists and nurses will be the primary practitioners providing health promotion services.
Comprehensive Transitional Care
Overarching State Definition	Comprehensive transitional care services focus on the movement of individuals from any medical/psychiatric inpatient or other out-of-home setting into a community setting, and between different service delivery models. Members of the health team work closely with the individual to transition the individual smoothly back into the community and share information with the discharging organization in order to prevent any gaps in treatment that could result in a readmission.
CEDARR Definition	Transitional care will be provided by the CEDARR health homes team to both existing clients who have been hospitalized or placed in other noncommunity settings as well as newly identified clients who are entering the community. The CEDARR health homes team will collaborate with all parties involved including the facility, PCP, health plan (if enrolled) and community providers to ensure a smooth discharge into the community and prevent subsequent readmission(s). Transitional care is not limited to Institutional transitions but applies to all transitions that will occur throughout the development of the child and includes transition from early intervention into school-based services and pediatric services to adult services. This service will be performed by the licensed clinician with the support of the family service coordinator.
CMHO Definition	Comprehensive transitional care services focus on the transition of individuals from any medical, psychiatric, long-term care or other out-of-home setting into a community setting. Designated members of the health home team work closely with the individual to transition the individual smoothly back into the community and share information with the discharging organization in order to prevent any gaps in treatment that could result in a readmission. To facilitate timely and effective transitions from inpatient and long-term settings to the community, all health home providers will maintain collaborative relationships with hospital emergency departments, psychiatric units of local hospitals, long-term care and other applicable settings. In addition, all health home providers will utilize hospital liaisons to assist in the discharge planning of individuals, existing CMHO clients and new referrals, from inpatient settings to CMHOs. Care coordination may also occur when transitioning an individual from a jail/prison setting into the community. Hospital liaisons, community support professionals and other designated members of the team may provide transitional care services. The team member collaborates with physicians, nurses, social workers, discharge planners and pharmacists within the hospital setting to ensure that a treatment plan has been developed and works with family members and community providers to ensure that the treatment plan is communicated, adhered to and modified as appropriate. Comprehensive transitional care services may be provided by any member of the CMHO health home team; however, hospital liaisons will be the primary practitioners providing comprehensive transitional care services.
Individual and Family Support Services
Overarching State Definition	Individual and family support services assist individuals to accessing services that will reduce barriers to treatment and improve health outcomes. Family involvement may vary based on the age, ability, and needs of each individual. Support services may include advocacy, information, navigation of the treatment system, and the development of self-management skills.
CEDARR Definition	The CEDARR health homes team is responsible for providing assistance to the family in accessing and coordinating services. These services include the full range of services that impact on children with special health care needs and include, but are not limited to, health, behavioral health, education, substance abuse, juvenile justice and social and family support services. The CEDARR health homes team will actively integrate the full range of services into a comprehensive program of care. At the family's request, the CEDARR team can play the principal role as organizer, information source, guide, advocate, and facilitator for the family by helping the family to assess strengths and needs, identify treatment goals and services, and navigate agency and system boundaries. This service will be performed by the licensed clinician or the family service coordinator depending on the exact nature of the activity.
CMHO Definition	Individual and family support services are provided by community support professionals and other members of the health team to reduce barriers to individuals' care coordination, increase skills and engagement and improve health outcomes. Individual and family support services may include, but are not limited to: Providing assistance in accessing needed self-help and peer support services. Advocacy for individuals and families. Assisting individuals to identify and develop social support networks. Assistance with medication and treatment management and adherence. Identifying resources that will help individuals and their families reduce barriers to their highest level of health and success. Connection to peer advocacy groups, wellness centers, the National Alliance on Mental Illness (NAMI) and family psycho-educational programs. Individual and family support services may be provided by any member of the CMHO health home team; however, CPST Specialists will be the primary practitioners providing individual and family support services.
Referral to Community and Social Support Services
Overarching State Definition	Referrals to community and socials support services ensure that individuals have access to a myriad of formal and informal resources. Ideally, these resources are easily accessed by the individual in the service system and assists individuals in addressing medical, behavioral, educational, social and community Issues.
CEDARR Definition	Referral to Community and Social Support Services will be provided by members of the CEDARR health homes team and will include information about formal and informal resources beyond the scope of services covered by Medicaid, such as those which may be available from other parents, family members, community-based organizations, service providers, grants, social programs, funding options, school-based services, faith-based organizations, etc. Whenever possible, families will be informed of opportunities and supports that are closest to home, that are the least restrictive and that promote integration in the home and community. Members of the CEDARR Health Homes Team will emphasize the use of informal, natural community supports as a primary strategy to assist children and families. This service will be performed by the licensed clinician or the family service coordinator depending on the exact nature of the activity.
CMHO Definition	Referral to community and social support services provide individuals with referrals to a wide array of support services that will help individuals overcome access or service barriers, increase self-management skills and improve overall health. Referral to community and social support involves facilitating access to support and assistance for individuals to address medical, behavioral, educational, and social and community issues that may impact overall health. The types of community and social support services to which individuals will be referred may include, but are not limited to: PCPs and specialists. Wellness programs, including smoking cessation, fitness, weight loss programs, yoga. Specialized support groups (i.e., cancer, diabetes support groups). Substance treatment links in addition to treatment supporting recovery with links to support groups, recovery coaches, 12-step. Housing. Social integration (NAMI support groups, Mental Health Consumer Advocates of Rhode Island (MHCA) OASIS, Alive Program (this program and MHCA are Advocacy and Social Centers) and/or Recovery Center. Assistance with the identification and attainment of other benefits. Supplemental Nutrition Assistance Program. Connection with the Office of Rehabilitation Service as well as internal CMHO team to assist person in developing work/education goals and then identifying programs/jobs. Assisting person in their social integration and social skill building. Faith-based organizations. Access to employment and educational program or training. CPST Specialists will be the primary practitioners providing referrals to community and social support.

 

APPENDIX: Pre-Existing Initiatives in Rhode Island
	CCC/RHP		CSI
Timeline	The programs were implemented in September 2007; now include all Medicaid beneficiaries.		Pilot began in October 2008, and the initiative is currently operating as part of the 3-year CMS MAPCP Demonstration program.
Geographic Area	Statewide		Statewide
Sponsors	State		Center for Health Care Strategies provided a grant to the Rhode Island Office of the Health Insurance Commissioner for the pilot; the program is now part of the Medicare MAPCP demonstration.
Scope	Both the CCC and RHP programs serve Rhode Island adults age 21 and older who qualify for Medicaid and are not covered by Medicare or private insurance.16 CCC participants enroll in a PCP, which provides case management services, and have access to all specialists who accept Medicaid FFS payments.16 RHP participants enroll in a capitated managed care health plan, which provides all care, except for a few services (e.g., dental care) that continue to be covered on a FFS basis.17		The medical home multi-payer pilot program in Rhode Island covered 76% of the states' residents who have health insurance at implementation. The acceptance of the program into the CMS MAPCP Demonstration added Medicare as a payer and increased eligibility to 98% of insured residents. The pilot aims to cover Rhode Island residents who suffer from diabetes, depression, and/or CAD.18 Originally began with 5 primary care practices, but in April 2010 an additional 8 sites were included in the pilot. By October 2010 there were 13 sites, 55 providers, 46,000 lives, and 28 Family Medicine residents were participating in the pilot.19
Goals	The CCC program is intended to improve access to primary care, provide links to social services, enable more coordinated care, and facilitate improvement in self-managed care.16 RHP has the goal of improving access to care, the quality of care, and health outcomes while containing costs.20		To align the quality improvement and financial incentives to provide better and more efficient primary care for people who suffer from chronic illnesses. To prioritize the "whole-person" approach to medicine by more effectively coordinating care and integrating community supports with the beneficiary's personal physician team.18 Enhance payment to PCPs so they are able to achieve recognition as medical homes and provide high-quality chronic illness care.18
Payment Approach	CCC: Participating practices receive monthly care coordination fees, which are adjusted to account for time spent caring for patients with complex health care needs. Practices that care for moderate to high-risk CCC members and employ a nurse care manager receive an additional $35-$40 PMPM.12	RHP: Medicaid contracts with private plans to provide managed health care. Participating plans are UnitedHealthcare of New England and Neighborhood Health Plan of Rhode Island.17	The payment structure is effectively enhanced FFS, with capitated payment (PMPM) and support for services in kind.18 Medicaid MCOs, PCCM, and FFS programs pay $3 PMPM, and health plans supply funding for nurse care managers who work at each practice. Participating practices receive a PMPM care coordination fee, and receive subsidies for hiring on-site nurse care manager.12 Purchasers include Care New England and Lifespan, 2 of the largest private sector employers, Rhode Island Medicaid, state employees--health benefits program, Rhode Island Business Group on Health.18
Technical Assistance (TA)	No information found		Training is provided by the Rhode Island Department of Health and Rhode Island Quality Improvement organization, which also has technical experts whom practices may contact for assistance.21 Assistance includes on-site practice assistance, statewide learning sessions, mentoring, monthly best practice sharing meetings, nurse care manager training, and sponsorship at national conferences.21
HIT Use	No information found		Some medical homes are receiving HIT support through the Beacon Community program, as well as ongoing data feedback. It is unclear how many of the pilot sites are receiving this support, however.
Evaluation Methods	Externally funded third-party evaluations will track several key clinical measures focusing on cost, return on investment, quality improvements, and patient/provider satisfaction. An evaluation of Rhode Island's Global Consumer Choice Compact Waiver included CCC and RHP.9 Analyses included a comparison of expenditures for FFS and CCC/RHP programs and changes in medical care service utilization. The report concludes that managed care programs were cost-effective and improved access to physician services.		Practices report clinical quality data each quarter, which are shared with other demonstration practices, health insurance providers involved in the pilot, convening organizations, practice transformation consultants, and a stakeholder coalition.19 The practices provide clinical quality data related to treatment for diabetes, CAD, and depression, while health plans are reporting inpatient hospitalization and emergency department use to practices.19 Claims data will be utilized to assess clinical quality, patient experience, provider experience, cost and quality measures.21 Data on provider experience and satisfaction will be collected from interviews and surveys of providers, and patient satisfaction will be measured through a patient experience survey upon the pilot's completion.19 Evaluators from the Harvard School of Public Health will collect qualitative data to assess the process of practice transformation, the changes in patient outcomes, and the patient experiences of care.12

Endnotes

1. Rhode Island Council of Community Mental Health Organizations. "Building a Recovery-Oriented, Integrated System of Care for Persons with Serious Mental Illness: Rhode Island's Proposal for Medicaid Health Homes." Presentation to IACP, February 2012. Available from: http://nationalblockgrantconference.com/presentations/2011/Elizabeth%20Earls.pdf. Accessed April 4, 2012.

2. Rhode Island Department of Health and Human Services website. "CEDARR Family Centers." Available from: http://www.dhs.ri.gov/ChildrenwithSpecialNeeds/CEDARRFamilyCenters/tabid/795/Default.aspx.

3. Rhode Island Health Home Initiative. "Presentation to the RI Global Waiver Task Force by Paul Choquette, RI Executive Office of Health and Human Services (EOHHS)." December 19, 2011. Available from: http://www.eohhs.ri.gov/documents/documents11/Health_Homes_Initiative_presentation.pdf. Accessed December 4, 2012.

4. CMS Innovations Center. "Advanced Primary Care Initiative." Presentation. Available from: http://www.innovations.cms.gov/Files/slides/Comprehensive-Primary-Care-Initiative-Open-Door-Forum-Slides.pdf. Accessed December 4, 2012.

5. Rhode Island Executive Office of Health and Human Services. "CMS Proposal to Integrate Care for Medicare and Medicaid Beneficiaries." Available from: http://www.eohhs.ri.gov/documents/documents12/CMS_Demonstration_Proposal_042612.pdf. Accessed December 4, 2012.

6. Substance Abuse and Mental Health Services Administration. "HHS Awards $26.2 million to Expand Primary Care to Individuals with Behavioral Health Disorders." News release, September 24, 2010. Available from: http://www.samhsa.gov/newsroom/advisories/1009245435.aspx. Accessed December 4, 2012.

7. Rhode Island Executive Office of Health and Human Services. "Final Operational Protocols for Collaboration Between Health Plans and Health Homes." Available from: http://www.chcs.org/usr_doc/Health_Home-MCO_protocols_FINAL_090111.pdf. Accessed December 4, 2012.

8. Substance Abuse and Mental Health Services Administration. "State Profiles of Mental Health and Substance Abuse Services in Medicaid: Rhode Island." Data as of July 2003. Available from: http://store.samhsa.gov/shin/content//NMH05-0202/NMH05-0202-RI.pdf. Accessed December 4, 2012.

9. Lewin Group. "An Independent Evaluation of Rhode Island's Global Waiver." December 6, 2011. Available from: http://www.ohhs.ri.gov/documents/documents11/Lewin_report_12_6_11.pdf. Accessed December 4, 2012.

10. Rhode Island Department of Human Services website. Available from: http://www.dhs.ri.gov/AdultswithDisabilities/HealthMedicalServices/MedicalAssistanceFeeForService/tabid/350/Default.aspx.

11. Rhode Island Department of Human Services website. Available from: http://www.dhs.ri.gov/Portals/0/Uploads/Documents/Public/Children%20w%20Spec%20Needs/CSHCN_enroll_hp_FAQ.pdf.

12. National Association for State Health Policy website. Available from: http://www.nashp.org/med-home-states/rhode-island.

13. According to information on the Rhode Island BHDDH website, these criteria plus the additional requirements shown in Table 1 are the eligibility criteria for receiving community support services, defined as case management services and supportive assistance to individuals in order to attain the goals of their behavioral health treatment plan, as well as access to medical, social, educational and other services essential to meeting basic human needs. Available from: http://www.bhddh.ri.gov/MH/eligibility.php,http://www.bhddh.ri.gov/MH/description.php.

14. The certification standards are available from: http://www.dhs.ri.gov/Portals/0/Uploads/Documents/Public/Children%20w%20Spec%20Needs/CEDARR_cert_stds.pdf.

15. Centers for Medicare and Medicaid Services. "Health Homes for Enrollees with Chronic Conditions." State Medicaid Director Letter #10-024. Available from: http://www.cms.gov/smdl/downloads/SMD10024.pdf.

16. Rhode Island Department of Human Services. "Connect Care Choice Fact Sheet." Available from: http://www.dhs.ri.gov/Portals/0/Uploads/Documents/Public/ConnectCareChoice/ccc_fact_sheet.pdf.

17. Rhode Island Department of Human Services. "Rhody Health Partners Fact Sheet." Available from: http://www.dhs.ri.gov/Portals/0/Uploads/Documents/Public/Rhody%20Health%20Partners/rhp_fact_sheet.pdf.

18. Office of the Health Insurance Commissioner. "CSI Rhode Island: The Chronic Care Sustainability Initiative." Available from: http://www.ohic.ri.gov/documents/Committees/CSI%201st%20annual%20forum/1_Genesis%20of%20the%20RI%20Chronic%20Care%20Sustainability%20Initiative.pdf.

19. Patient-Centered Primary Care Collaborative website. Available from: http://www.pcpcc.net/pilot/rhode-island-chronic-care-sustainability-initiative. Accessed December 4, 2012.

20. See http://www.eohhs.ri.gov/documents/documents11/2011_performance_goal_program_10_27_11_final.pdf.

21. Patient-Centered Primary Care Collaborative. "Patient-Centered Medical Home: Building Evidence and Momentum." 2008. Available from: http://www.pcpcc.net/content/pcpcc_pilot_report.pdf.

 

 

Wisconsin's Health Home Program at a Glance
Health Home Eligibility Criteria	HIV/AIDS and 1 other chronic condition or at risk of another chronic condition
Qualifying Conditions	HIV/AIDS
Enrollment*	188
Designated Providers	AIDS Service Organizations (ASOs)
Administrative/ Service Framework	ASOs, which are specialized HIV/AIDS service providers identified under Wisconsin statute, are the sole health home provider. Health home eligibility is limited to the categorically and medically needy in 4 noncontiguous counties in the state
Required Care Team Members	Primary care physician Nurse Case manager Mental health or substance abuse professional Dentist Pharmacist Other members as deemed necessary or desirable
Payment System	Per member per month (PMPM) care management fee, plus annual flat fee
Payment Level	PMPM: $102.95; Fee: $359.00
Health Information Technology (HIT) Requirements	ASO health homes must have an electronic health record (EHR) that is accessible to all care team members, and contains a given patient's treatment plan. Additionally, the state requires the EHRs have the capacity to interface with specialty and inpatient care providers through the state's health information exchange or another mechanism
* January 2014 data provided to the Centers for Medicare and Medicaid Services' Health Home Information Resource Center.

Introduction

Wisconsin's Section 2703 Health Home State Plan Amendment (SPA) was approved on January 29, 2013, with a retroactive effective date of October 1, 2012. It targets individuals with a single chronic condition--HIV--who have at least one other diagnosed chronic condition or are at risk of developing another. AIDS Service Organizations (ASOs), which are specialized HIV/AIDS service providers identified under Wisconsin statute, are the sole health home provider. In the approved SPA, health home eligibility is limited to the categorically and medically needy in four noncontiguous counties in the state, three of which are served by one ASO: the AIDS Resource Center of Wisconsin (ARCW). Though ARCW provides limited services in the fourth county, primary responsibility for coordinating care in that area lies with a second ASO, the AIDS Network, which is not qualified as a health home. As a result, eligibility for health home enrollment is in practice currently limited to those who are able to enroll with ARCW.

Implementation Context

As of May 2013, there were more than 1.1 million Medicaid beneficiaries in Wisconsin, roughly 730,000 of whom are enrolled in some form of risk-based managed care.¹ In addition to covering low-income residents who are elderly, blind, and disabled (as defined by Supplemental Security Income guidelines), Wisconsin offers coverage to all children, to childless and caretaker adults living at or below 200% of the federal poverty level (FPL), and pregnant women living at 300% of FPL. These various populations are subject to differing benefit and premium structures, depending on eligibility category and income levels.² Under the current governor's proposal for Medicaid reform, however, eligibility for Medicaid will be reduced to 100% of FPL, and current beneficiaries who have incomes above this level will be required to purchase coverage through the new state health insurance marketplace.³ This change has been delayed until April 2014.

HIV/AIDS in Wisconsin

Wisconsin statute requires that all providers in the state, as well as blood and plasma centers, correctional facility clinics, military entrance processing centers, and laboratories submit confidential, name-associated reports of confirmed cases of HIV/AIDS to the Wisconsin Department of Health Services (DHS). As of December 2011, an estimated 8,300 Wisconsin residents were living with HIV/AIDS. More than half of these cases resided in Milwaukee County, and another 12% lived in Dane County (two of the four counties targeted by the state in its health homes SPA).⁴

ASOs are major providers of HIV prevention and treatment services in the state. Under Wisconsin statute, they are defined as "nonprofit corporations or public agencies that provide, or arrange for the provision of, comprehensive services to prevent HIV infection and comprehensive health and social services for persons who have HIV infection."⁵ Wisconsin has two designated ASOs, the AIDS Network and ARCW. Each organization is responsible for a service area; the AIDS Network covers 13 counties in the southern part of the state and operates three sites, while ARCW covers the remaining 59 counties and operates nine sites.⁶ Both entities were established in the 1980s and offer a range of medical and social services to their clients, including case management, dental care, mental health screening and referral, and prevention services.

The DHS manages Wisconsin's HIV/AIDS program, which coordinates and oversees HIV/AIDS prevention, screening, and treatment efforts. The program collaborates with a range of public and private sector agencies and organizations, including local health departments, community-based organizations, academia, and advocacy groups to develop and implement the statewide response to the disease. This response encompasses several initiatives, including regular provider trainings, targeted outreach to groups most affected by the disease, and grant-funded projects such as Linkage to Care, which is a four-year Health Resources and Services Administration Special Project of National Significance grant that seeks to develop innovative ways to improve access to and retention in treatment. As a major insurer of the HIV-positive population in Wisconsin, the state Medicaid program works closely with the HIV/AIDS program on these efforts.

Funding for these activities come from federal, state, and private sector sources. In FY 2011, Wisconsin received more than $20 million in federal grants to support HIV/AIDS prevention and treatment, $13 million of which came from Ryan White Program funding alone.⁷ The state also provides a substantial amount of support, with the Medicaid program spending approximately $30 million annually to cover services for HIV-positive beneficiaries. In addition, the state provides direct support to ASOs through the Michael Johnson Life Care Services and Early Intervention Program. This program, established by the legislature in 1993,⁸ provides more than $3.5 million annually to support case management and care coordination services offered by ARCW and the AIDS Network. These funds support 40 case managers statewide.⁹

For the last several years, the state has been encouraging the implementation of a medical home model for its HIV/AIDS providers.⁴ State legislation¹⁰ passed in May 2010 allows entities which receive support from the Michael Johnson program and meet certain additional criteria to bill Medicaid for care coordination services. Qualifying criteria are identical to those listed in the Section 2703 Health Homes SPA. ACRW was instrumental in identifying Section 2703 health homes as an opportunity for enhanced funding for care coordination services and in developing the legislation that made the SPA possible. In 2011, the organization received medical home accreditation from the National Committee for Quality Assurance (NCQA), and is currently the sole HIV/AIDS medical home operating in the state.

Implications for the Wisconsin Section 2703 Medicaid Health Homes Evaluation

Wisconsin presents an unusual case for the long-term evaluation, both in terms of the target population and the designated provider. No other state in the health homes evaluation has targeted a single chronic condition or a single provider, which raises questions about comparability to other health home programs. In addition, ARCW has been offering some form of case management and care coordination services for almost 20 years, which will make it difficult to identify a "health home effect." It may be possible to identify a comparison group of HIV-positive beneficiaries served by ARCW or other nonhealth home providers operating outside of the targeted counties. To delineate any health homes effect, it will be critical to establish the baseline structures and processes at ACRW health home sites, and what changes--if any--were made as a result of becoming a health home. It also will be important to consider beneficiaries' time with ARCW before and after health home designation in assessing effects.

Population Criteria and Provider Infrastructure

Wisconsin offers health home services to beneficiaries with HIV who have at least one other chronic condition, or who are at-risk for developing another chronic condition. The at-risk criteria adopted by the state include individuals who, in addition to being diagnosed with HIV/AIDS, meet clinical benchmarks related to CD4 cell counts (a measure of immune system strength), low body weight as measured by conventional Body Mass Index (BMI) criteria, and certain cardiovascular and metabolic risk indicators (see Table 1). Chronic conditions are defined as any condition that has lasted six months, is likely to last at least another six months, or which is likely to recur. Under the approved SPA, health home services may be offered in four counties: Brown, Kenosha, Milwaukee, and Dane, which together contain the state's four largest cities.

The providers designated in the SPA are the two ASOs operating in the state, the AIDS Network and ARCW. These specialized providers offer comprehensive care services to people living with HIV. As previously noted, however, the AIDS Network has not qualified as a health home. Therefore, ARCW--which has primary care coordination responsibility in the remaining three counties and has qualified as a health home--is the de facto sole provider of health home services under the SPA as approved. ACRW offers only housing and limited preventive services in Dane County, so only beneficiaries in the remaining three counties currently have access to a health home.

AIDS Resource Center of Wisconsin

ARCW was established in Milwaukee in 1985, and has since expanded to nine cities statewide. ARCW clinic sites in Brown, Kenosha, and Milwaukee counties offer medical, behavioral health, and social services, as well as preventive services such as sexually transmitted infection screening and needle exchange. Dental clinics are also available on-site in Brown and Milwaukee counties, and the Milwaukee site offers clinical pharmacy services through its on-site pharmacy. Services not provided directly at a given clinic location are referred to other providers in the community. Given ARCW's high level of service co-location, patient referrals are low--1.2 referrals per patient per year on average¹¹--and are typically for specialty medical and behavioral health services such as OB/GYN or crisis stabilization services. The care team designated in the SPA must include a primary care physician, nurse, case manager, mental health or substance abuse professional, dentist, and pharmacist. Optional care team members may include outreach workers, peer specialists, dieticians, or other community care representatives. Each care team must have an identified care coordinator, as well as a leader who is responsible for ensuring communication and coordination both among team members and with the health home patient. The team leader and care coordinator can be the same individual.

Health home members who do not have a mental health diagnosis are routinely screened for depression and substance abuse, and the state will provide technical assistance to support additional efforts to integrate primary and behavioral health care, including training on Screening, Brief Intervention, and Referral to Treatment protocols, designed to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs.

Enrollment

Eligible beneficiaries are auto-enrolled into the health home program, after which time ARCW is responsible for contacting the beneficiary to inform them of the benefits of enrollment and offer them the opportunity to disenroll. By agreeing to participate in the initial assessment and care planning process, the beneficiary consents to enrollment. Those who are enrolled in managed care may not be simultaneously enrolled in a health home because of concerns about duplication of services. As of June 2013, ARCW had 521 potentially eligible clients; of these, 142 were enrolled in the health home program, while 209 were in managed care. As of January 2014, there were 188 health home enrollees. Contacts with the remaining eligible clients are ongoing.¹¹

Service Definitions and Provider Standards

Full-service definitions are reproduced in Table 2. Aside from care coordination--which is the responsibility of the team lead--services are not explicitly assigned to a particular provider within the care team.

The SPA lists three broad standards for qualifying ASOs:

1. That it be located in a setting that integrates medical, behavioral, pharmacy, and dental care.

2. That it agree to meet the 11 health home functions outlined in State Medicaid Director's Letter #10-024, "Health Homes for Enrollees with Chronic Conditions."¹²

3. That it be accredited as a medical home by a nationally recognized certification program, or that it meet a range of standards which align closely with those established by NCQA for its medical home accreditation process.

Requirements also include having written standards for patient access and communication, using electronic charting tools to organize clinical information, and establishing systematic processes for tracking test results, referrals, and performance against quality measures.

Use of Health Information Technology

ASO health homes must have an electronic health record (EHR) that is accessible to all care team members, and contains a given patient's treatment plan. This treatment plan must be updated regularly by the team lead/care coordinator to reflect patient education interventions, transitional care needs, referrals and follow-up, and any support services provided. The state requires that providers adopt EHRs that have the capacity to interface with specialty and inpatient care providers, but it is unclear from the SPA whether there is a defined timeline for adoption or whether this interface will take place through the state's health information exchange (HIE) or another mechanism. The state HIE is still under development, but current plans call for a decentralized, or federated exchange model, whereby patient information can be retrieved and assembled from the EHR of participating providers.¹³

The provider standards outlined in the SPA also stipulate that ASOs use data to demonstrate that they meet requirements related to patient access and communication, identify diagnoses and conditions among their patient panel, and measure and report on provider performance.

Payment Structure

Wisconsin is using two payment methodologies: a per person per month (PMPM) case rate paid to the ASO for providing at least one health home service per month, and a flat fee that covers the initial assessment and development of a care plan for each new enrollee. This latter service can be billed once a year if the care needs of the health home member require another comprehensive assessment and care plan review. Current rates are $102.95 for the PMPM, and $359.37 for initial assessment and care plan development.¹⁴

Quality Improvement Goals and Measures

The SPA lists two goals: (1) reduce the risk of complicating opportunistic infections and improve health outcomes; and (2) ensure integration of oral and medical health care for HIV patients. Table 3 lists the corresponding measures used to measure progress against these goals.

Evaluation Measures and Methods

The evaluation measures and methodology described in the SPA are reproduced in Table 4. Most of the data used for evaluation purposes will come from claims and will be reported quarterly. Providers also will submit semi-annual reports on a variety of indicators not detailed in the SPA, and health home members will also be surveyed, both formally and informally. The frequency or methodology employed for these surveys is not reported in the SPA. Though the state will review and monitor the program, it does not plan to conduct a formal evaluation.

TABLE 1. Target Population and Designated Providers--Wisconsin
SPA Approval (Effective Date)	January 29, 2013 (October 1, 2012)
Designated Provider(s)	ASOs operating in Brown, Kenosha, Milwaukee, and Dane counties. ARCW is the sole provider in those counties.
Health Home Team Composition	Primary care physician Nurse Case manager Mental health or substance abuse professional Dentist Pharmacist Other members as deemed necessary or desirable
Target Population	Beneficiaries diagnosed with HIV who have a chronic condition or are at risk of developing another. "At-risk" individuals are defined as meeting 1 of the following criteria:   CD4 cell count of less than 200 cells/μL or CD4 cells accounting for fewer than 14% of all lymphocytes BMI lower than 18.5 Fasting plasma blood sugar of 100-125 mg/dL or HbA1c 5.7-6.4% Systolic pressure between 120-139 mm/Hg; diastolic pressure between 80-89 mm/Hg Cholesterol greater than 200 mg/dL HDL levels 40 mg/dL for men and 50mg/dL for women LDL levels >130 mg/dL
Qualifying Chronic Conditions	In addition to HIV, any condition which is present for at least 6 months and expected either to reoccur or last at least another 6 months

 

TABLE 2. Health Home Service Definitions--Wisconsin
Care Coordination	Ongoing management of the patient's medical, behavioral, pharmacological, dental, and community care needs by a designated team lead. The team lead will ensure that the patient has a current, written, person-centered, multidisciplinary care and treatment plan that addresses all aspects of the patient's care (including preventive care needs, all medical sub-specialties, institutional care, home and community care).
Comprehensive Care Management	The use of evidence-based guidelines to provide systematic, responsive and coordinated management of all aspects of primary and specialty care (physical and behavioral needs) for individuals with HIV, including the early identification of individuals who meet the criteria for health home enrollment.
Health Promotion	All activities aimed at prevention, assisting the patient in better understanding their disease, and learning how to direct the care and treatment they receive. This includes enhanced patient education and active promotion of self-management and self-care.
Comprehensive Transitional Care	Includes establishment of an automatic referral arrangement between institutional care providers and the health home provider to ensure that there is immediate communication and/or referrals of HIV patients who are admitted or are seen in the emergency department. Automatic referrals include the establishment of policies and procedures to ensure that there is systematic and timely sharing of information related to the patient's institutional or emergency department care. Transitional care will include timely face-to-face or telephone contacts with the patient (or the patient's authorized representative) following emergency department visit or institutional discharge, a review of the discharge summary with the patient, and support in receiving the recommended care, including scheduling follow-up appointments and filling prescriptions.
Individual and Family Support Services	Includes activities related to advocating on the member's behalf and mobilizing services and support for the member. It will include contacts with anyone identified as instrumental to the member's day-to-day support and care, including peer-to-peer information sharing and support. Information must be communicated in a manner that is simple, clear, straightforward and culturally appropriate.
Referral to Community and Social Supports	Includes activities related to providing assistance to members to ensure they have access to social support services identified in the care plan. To the extent feasible, the health home provider will establish meaningful working relationships with community-based organizations that provide services to individuals with HIV infection.

 

TABLE 3. Health Home Goals and Quality Measures--Wisconsin
Reduce the Risk of Complicating Opportunistic Infections and Improve Health Outcomes	Clinical outcome measures: Percentage of health home patients with a CD4 count 350 cells per microliter who initiate antiretroviral therapy Percentage of health patients with an undetectable viral load within 6 months of anti-retroviral therapy initiation
Ensure Integration of Oral and Medical Health Care for HIV Patients	Quality of care measures: Percentage of HIV+ oral health patients aged 1+ years who had a dental and medical health history (initial or updated) at least once in the measurement year

 

TABLE 4. Evaluation Methodology--Wisconsin
Hospital Admission Rates	The state will use claims data for fee-for-service claims paid on behalf of members enrolled in the health home. The state will compare admission rates for the health home participants to the rates of members with HIV who are not participating. Additionally, the state will use pre-implementation (baseline) data to compare to post-implementation rates.
Chronic Disease Management	The state will use claims data (e.g., office visits, lab testing, pharmacy, emergency department visits) to monitor chronic disease management. In addition, providers will be required to submit semi-annual reports responding to a series of identified indicators (for example, the number of face-to-face visits between the member and the care coordinator and the number of patients who received self-management counseling and support).
Coordination of Care for Individuals with Chronic Conditions	The state will use claims data to determine the amount of care coordination provided. The state will monitor data reports and survey results from health home providers to further determine the level and frequency of coordination activities.
Assessment of Program Implementation	The state Medicaid and Public Health (HIV) Divisions will collaborate on the assessment of program implementation. Assessment activities are to be determined but could include joint health home visits and reviews of reports and data.
Processes and Lessons Learned	The state Medicaid and Public Health (HIV) Divisions will collaborate on the review of the processes established by the health homes. The state will work in partnership with health home providers to identify aspects of the health home implementation that work and those that need modification. A significant portion of this activity will rely on the outcome of member surveys (both formal and informal).
Assessment of Quality Improvements and Clinical Outcomes	The state Medicaid and Public Health (HIV) Divisions will use the clinical outcome measures described above to assess quality improvements and gains/setbacks in clinical outcomes within the health homes.
Estimates of Cost Savings	On an annual basis, the state will analyze the cost of providing care to beneficiaries within and outside of the health home. Analyses of the level of utilization for routine care versus emergency care (inpatient hospital, emergency department and ambulance transportation) are contemplated, but details were not specified in the SPA.

Endnotes

1. Wisconsin ForwardHealth Portal website. "Monthly Enrollment by MCO." Available from:https://www.forwardhealth.wi.gov/WIPortal/Tab/42/icscontent/Member/caseloads/enrollment/enrollment.htm.spage. Accessed June 7, 2013.

2. Wisconsin Department of Health Services website. "BadgerCare Plus: Common Questions." Available from: http://www.dhs.wisconsin.gov/badgercareplus/faq.htm. Accessed June 10, 2013.

3. Wisconsin Department of Health Services website. "Joint Committee on Finance Testimony of Secretary-Elect Kitty Rhoades Department of Health Services March 20, 2013." Available from: http://www.dhs.wisconsin.gov/aboutdhs/initiatives/budget/KR32013.pdf. Accessed June 8, 2013.

4. Wisconsin HIV/AIDS Community Planning Network. "Wisconsin HIV/AIDS Strategy: 2012-2015." September 2012. Available from: http://wihiv.wisc.edu/communityplanning/libraryDownload.asp?docid=753.

5. "Wisconsin Statute 252.12(1)(b)." Available from: http://docs.legis.wisconsin.gov/statutes/statutes/252/12/1/b.

6. A map of their respective sites are available from: http://www.aidsnetwork.org/assets/Uploads/map.pdf and http://www.arcw.org/locations/.

7. Kaiser Family Foundation website. "State Health Facts: Total Federal HIV/AIDS Grant Funding, FY2011." Available from: http://kff.org/hivaids/state-indicator/total-federal-grant-funding/. Accessed June 10, 2013.

8. "Wisconsin Statute 252.12(2)(a)8." Available from: http://docs.legis.wisconsin.gov/statutes/statutes/252/12/2/a/1.

9. Wisconsin Department of Health Services website. "Life Care Services and Early Intervention." Available from: http://www.dhs.wisconsin.gov/aids-hiv/resources/overviews/AIDS_life_care.htm.

10. "2009 Wisconsin Act 221." May 2010. Available from: http://docs.legis.wisconsin.gov/2009/related/acts/221.pdf.

11. Personal communication with ARCW staff members. June 4, 2013.

12. Centers for Medicare and Medicaid Services. "Health Homes for Enrollees with Chronic Conditions." State Medicaid Director Letter #10-024, November 16, 2010. Available from: http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD10024.pdf.

13. Wisconsin Statewide Health Information Network website. "FAQ on WISHIN and HIE." Available from: http://www.wishin.org/ResourceCenter/FAQLibrary/FAQonWISHINHIE.aspx. Accessed June 10, 2013.

14. Personal communication with Wisconsin DHS staff. June 3, 2013.

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Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions

This report was prepared under contracts #HHSP23320100025WI and #HHSP23337001T between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Urban Institute. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/office_specific/daltcp.cfm or contact the ASPE Project Officer, Emily Jones, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: Emily.Jones@hhs.gov.

Reports Available

Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions: Final Annual Report - Base Year (December 2012)

Executive Summary   http://aspe.hhs.gov/daltcp/reports/2012/HHOptiones.shtml

Full HTML Version   http://aspe.hhs.gov/daltcp/reports/2012/HHOption.shtml

Full PDF Version   http://aspe.hhs.gov/daltcp/reports/2012/HHOption.pdf

Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions: Annual Report - Year Two (June 2014)

Executive Summary   http://aspe.hhs.gov/daltcp/reports/2014/HHOption2es.cfm

Full HTML Version   http://aspe.hhs.gov/daltcp/reports/2014/HHOption2.cfm

Full PDF Version   http://aspe.hhs.gov/daltcp/reports/2014/HHOption2.pdf

U.S. Department of Health and Human Services
Office of Disability, Aging and Long-Term Care Policy
Room 424E, H.H. Humphrey Building
200 Independence Avenue, S.W.
Washington, D.C. 20201
FAX:  202-401-7733
Email:  webmaster.DALTCP@hhs.gov