Minnesota Department of Health (MDH) Health Care Homes (HCH) Initial Certification Reviewed: 03/15/18 1
Learning Objectives 1. Describe the HCH legislative rule subpart criteria required for initial certification. 2. Identify strategies to implement the HCH model into the clinic culture. 3. Discuss process improvement in the clinic practice. 2
Health Reform in Minnesota Minnesota s 2008 health reform law seeks to fulfill the promise of the Institute for Healthcare Improvement s Triple Aim Improve the health of the population Improve the patient/consumer experience Improve the affordability of health care Institute of Medicine s Triple Aim 3
Minnesota Health Reform The health reform law resulted in the following MDH initiatives Health Care Homes (HCH) All Payer Claims Database (MN APCD) Statewide Health Improvement Partnership (SHIP) Statewide Quality Reporting and Measurement System (SQRMS) 4
The HCH Program The HCH Program is one of the centerpieces of Minnesota's health reform initiative. Through redesign of care delivery and meaningful engagement of patients, HCH Clinics are transforming care and lives - for millions of Minnesotans. The name "Health Care Homes" acknowledges a shift from a purely medical model of health care to a model which links primary care with wellness, prevention, self-management and community services. 5
Goals of the HCH Program Continue to build strong primary care foundation ensuring all Minnesotans have the opportunity to receive team-based, coordinated, patientcentered care. Increase care coordination and collaboration between primary care and community resources to facilitate the broader goals of improving population health and health equity. Improve the quality, experience, and value of care. 6
HCH Certification Updates Certified HCH Clinics Applicants are from all over the state. Variety of practice types such as solo, rural, urban, independent, community, FQHC and large organizations. All types of primary care providers are certified: family medicine, pediatrics, internal medicine, OB/GYN and geriatrics. 7
The Patient- and Family-Centered Health Care Home 8
Consumer Perspective: Better Health Made Easy 9
HCH Certification Certification as HCH is Voluntary There is no fee to apply for MDH HCH certification. MDH is the organization that will facilitate the certification process. All application forms are submitted electronically through the MDH HCH online portal. 10
Certification Questions The clinic defines the timeline to submit the application; clinics apply when they meet the standards and criteria and are ready for a successful certification process. HCH Planners are available for support. As HCH model is implemented in new clinic sites (referred to as spread ) the new clinicians are certified. When a previously certified clinician leaves a clinic and goes to work at a non-certified clinic, the new clinic and clinician/s apply for their certification. The previous clinic employer identifies an end date for that clinician in the HCH online portal. 11
Progression Over Time Certification requirements are met at initial certification with subparts supporting progression over time. HCH clinics are recertified every three years in a Team Meeting format; recertification ensures the progression in the HCH model implementation over time. Clinics have the option of scheduling a technical assistance/coaching check-in visit or phone call with their designated nurse planner during the period between certification and recertification. The certifying HCH clinic/s meets all requirements or applies for a variance. A variance may be granted for good cause or when failure to grant a variance would result in hardship. 12
Certification Steps for the Applicant Step 1: Eligibility Step 2: Guides & Tools Step 3: Request Access Step 4: Letter of Intent Step 5: Application Step 6: Assessment Step 7: Site Visit Step 8: MDH Notification Optional Step: Variance and Appeals 13
Step 1: Eligibility An eligible provider is a physician, nurse practitioner or physician assistant that works as part of a team that takes responsibility for the patient s care and provides the full range of primary care services including: first point of contact acute care preventive care chronic care Providers are certified. A clinic is certified when all the clinic s providers meet the requirements for certification. Application may be submitted by: clinician, department, clinic, or organization. 14
Step 2: Guides & Tools Preparation and guidance 15
MDH HCH website Portal link https://hchcertification.web.health.state.mn.us/login.seam 16
Step 3: Request Access (Initial Request only) Go to https://hchcertification.web.health.state.mn.us/login.seam Click on Request Access to Letter of Intent 17
Step 3: Request Access (Initial Information needed) The applicant for certification is the organization. The applicant name should be the broad legal organization name. The clinic s primary contact will receive communication from MDH HCH. The desired username should be at least 6 characters long, all in CAPS. MDH HCH will contact you once the request has been processed. 18
Log-in to the MDH HCH Portal https://hchcertification.web.health.state.mn.us/login.seam 19
I. Applicant Intent Step 4: Letter of Intent II. Applicant Demographic Information Organization/clinic name, address, applicant clinician(s) information III. HCH Information Yes/ No questions regarding health care home policies and procedures IV. Additional Information V. Contact Information 20
I. Applicant Demographic Info Organization/ clinic name, address, applicant clinician(s) information II. Additional Clinician Info Providers and services available to clinic, hours working on HCH III. Clinic s Patient Profile Age, race, gender, payer mix, language, patient characteristics IV. Representations and Signature of Authorized Person Step 5: Application 21
Step 6: Certification Assessment The certification assessment is used to determine if the applicant meets the documentation requirements for HCH certification and is ready for a site visit. Applicants submit their HCH Assessment online three weeks prior to their certification site visit at a minimum. Site evaluators will review the clinics submitted assessment prior to the site visit. 22
Certification Assessment There is flexibility for innovation built into the application process HCH Standards are a road map to implementation; the applicant identifies strategies, workflows and processes to meet the standards. 23
Certification Assessment Tool Documentation and Data Sources At initial certification the clinic meets the ODD numbered subparts (1,3,5,7,9). There are ten documents to submit. Progression is ensured through the addition of the EVEN numbered subparts (2,4,6,8,10). Documentation examples include: written policies, protocols and procedures workflows guidelines forms, flow sheets EMR and registry screen shots patient education materials, prepared resources, pamphlets meeting minutes with dates and member roles de-identified patient medical records PDSA cycles 24
Working with the Assessment *The online submission of required subparts reflects the printable Assessment tool. 25
Submission of individual Subparts The hyperlinks to Rule Intent and Rule Language correlate with the Certification Assessment Tool. The clinic may note see attachment if all the information is summarized in the document. The clinic s brief narrative describes the work for the subparts where a document is not attached. Statements should be concise and succinct, initial certification provides baseline information. 26
Eligibility Requirements.0030 1A - Clinic organizational Structure *required document (*consider the position of the patient).0030 1B - Board Certification/Licensure: HCH Structure *required document (*this is met in the contents of the LOI) 27
Access and Communication Standard.0040 1A 1,2 - Services to all patients with chronic & complex conditions interested in participation in care coordination services. *required document.0040 1B 1,2 a,b,c,d & 3 a,b - Access to patient information. *required document.0040 1C - Collect and apply cultural and language information.0040 1D - The patient s preferred method of communication.0040 1E - Inform patients of access to specialty resources.0040 1F - Ensure compliance with privacy and security 28
Access and Communication Standard.0040 1A 1,2 The applicant establishes a process to systematically screen patients to identify patients who would benefit from care coordination services based on the patient s medical and non-medical complexity. A population screening Defines patient risk level Trigger to identify as a patient receiving CC services Policy/protocol outlines the who does what and how of identifying patients for care coordination 29
Access and Communication Standard.0040 1B 1,2 a,b,c,d & 3 a,b A system to support continuous access during and after regular clinic hours for patient to communicate with the HCH team and the team knows the patient s preferred communication method. 1) Patients are informed that they have continuous access 2) the designated clinic staff has continuous access to medical record information: (a) contact information, PCP name and contact information, patient identified as receiving CC services. (b) racial or ethnic background, primary language and preferred means of communication (c) Consents and restrictions for releasing medical information (d) the patient's diagnoses, allergies, medications related to chronic and complex conditions, and whether a care plan has been created for the patient 3) appointment scheduling is appropriate based on: (a) acuity (b) access to avoid unnecessary ER visit or hospitalization 30
Access and Communication Standard.0040 1C Language, ethnic and racial background supports the provision of relevant care, that is of value to the patient and supports a culturally appropriate care plan. Process to document the information Staff is trained Plan to access interpreters as appropriate 31
Access and Communication Standard.0040 1D The clinic asks the patient and their family about their preferred method of communication. This information is accessible to the HCH clinic team. 32
Access and Communication Standard.0040 1E The patient may choose a specialty care resource without regard to whether a specialist is a member of the same provider group or network as the patient's health care home, and that the patient is then responsible for determining whether specialty care resources are covered by the patient's insurance. 33
Access and Communication Standard.0040 1F The applicant has privacy and security measures to comply with the requirements of the Health Insurance Portability and Accountability Act, Code of Federal Regulations, title 45, parts 160.101 to 164.534, and the Minnesota Government Data Practices Act, Minnesota Statutes, chapter 13 34
Registry Standard 3A - Searchable registry for systematic population review *required document The applicant uses a registry and process to guide the management of health care services, provide appropriate follow-up and identify any gaps in care for clinic populations. 3B 1,2 - Electronic registry data elements necessary to track care. (name, age, gender, contact information, and identification number) 35
Care Coordination Standard 5A 1,2,3 - Requirements for care coordination team 5B - Use of health care team, designation of personal clinician, & patient is informed *required document 5C - Routine face-to-face discussion between personal clinician & care coordinator 5D - Dedicated time for care coordinator *required document 5E 1,2,3,4,5,6 - Care Coordination processes & documentation 36
Care Coordination Standard 5A 1,2,3 HCH team relationships are central to the HCH. The PCP, CC and patient relationships support effective information sharing, goal setting, care coordination, care planning and follow-up support. The patient and the care team set goals and identify resources to achieve goals. The PCP and CC ensure continuity of care. The patient and care team identify method of contact with the care team and community services. 37
Care Coordination Standard 5B Health care team, designation of PCP, and patient is informed *required document To assure continuity of care, each patient has a designated primary care provider. Patients receiving care coordination services also have a designated care coordinator. The health care home teams provide and coordinate the patient s care, including communication and collaboration with specialists. Process for selecting PCP PCP and CC (if receiving CC services) are identified in the EMR 38
Care Coordination Standard 5C Routine face-to-face discussion between personal clinician and care coordinator Direct communication in which routine, face-to-face discussions take place between the PCP and the care coordinator. Definition: Subp. 15. Direct communication. "Direct communication" means an exchange of information through the use of telephone, electronic mail, video conferencing, or face-to-face contact without the use of an intermediary. For purposes of this definition, an interpreter is not an intermediary. 39
Care Coordination Standard *required document 5D Dedicated time for care coordinator Designated protected time is essential to performing care coordination functions and making improvements in population outcome measurements. Job description Job responsibilities Job training 40
Care Coordination Standard 5E Care coordination processes reflect a plan for communication between the team and the patient to assure continuity of care and services. 1. Referral tracking and follow up 2. Tests ordered, results tracked and timely notification to patients 3. Admissions to hospital or skilled nursing facilities are tracked 4. Timely discharge planning 5. Medication reconciliation and pharmacy communication 6. Links to external team members and care plans 41
Care Plan Standard 7A 1,2,3,4,5,6 - Care plan policies & procedures *required document 7B 1,2,3,4 & C - Care plan goals & action plans 42
Care Plan Standard 7A 1,2,3,4,5,6 Care Planning Policy/Procedure document *required document 1) actively engage and verify joint understanding of the care plan 2) engage all appropriate members of the health care team 3) incorporate pertinent elements of the assessment about the patient s health risks and chronic conditions 4) review, evaluate, and, if appropriate, amend the care plan, jointly with the patient, at specified intervals appropriate to manage health and measure progress toward goals 5) provide a copy of the care plan to the patient upon completion of creating or amending the plan 6) use and document the use of evidence-based guidelines for medical services and procedures. 43
Care Plan Standard 7B 1,2,3,4 & C Care plan goals & action plans PCP and CC; preventive care; care of chronic conditions; management plan for exacerbations of chronic conditions; end of life planning; patient identified, patient centered goals and resources to achieve those goals. De-Identified Care Plans uploaded or available at the site visit for review by the MDH HCH Team- will review for the required elements, and SMART Goals. 44
Quality Improvement (QI) Standard 9A 1,2,3,4 - Establishes HCH quality team that reflects clinic structure *required document 9B - Quality team has a mechanism for communication & feedback *required document 9C - Quality team demonstrates ability to do quality measurement 9D 1,2,3,4 - Participation in the learning collaborative 9E - Team has mechanism for communication & feedback for info. from Learning Collaborative 45
Quality Improvement Standard 9A 1,2,3,4 HCH quality team that reflects clinic structure *required document A patient- and family-centered health care home relies on patients and health care team members to provide input to the clinic s quality activities. Patient Partners two or more Personal Clinician Clinic administration or management Care Coordinator Submit six months of quality team meeting minutes 46
Quality Improvement Standard 9B Quality team has a mechanism for communication & feedback *required document The applicant follows procedures to share their work and elicit feedback from HCH team members staff regarding quality improvement. Process How are staff informed of QI How are patients informed of QI 47
Quality Improvement Standard 9C Quality team demonstrates ability to measure, analyze, and track changes in at least one quality indicator selected by the applicant based upon the opportunity for improvement. Patient advisory involvement? What is the objective? What are the methods How will you measure What was the outcome? Next Steps? A PDSA process 48
Quality Improvement Standard 9D 1,2,3,4 Participation in the learning collaborative. The MDH HCH Learning Collaborative provides a supportive learning environment for the clinic. Participation through representatives that reflect the structure of the clinic is encouraged: (1) one or more clinicians who deliver services in the HCH (2) one or more care coordinators (3) one or more administration/management participants (4) two or more patient representatives *Documentation of staff attending, dates, sessions. 49
Quality Improvement Standard 9E Team has mechanism for communication & feedback for information from Learning Collaborative *required document The applicant has a process for sharing information and eliciting feedback as a result of participation in the MDH HCH Learning Collaborative. *This process could be addressed in 9B 50
Variances and Recommendations 51
Variance Criteria 4764.0050 Subpart 1 At certification or recertification, the applicant may request a variance or the renewal of a variance from a requirement in parts 4764.0010 to 4764.0040. 52
Variance Types Minor variance may be granted to the HCH for good cause or when failure to grant a variance would result in hardship. It is identified that a minor element of the rule is not implemented. Experimental variance may be granted where a HCH offers an innovative replacement to meet the standard. Hardship Variance: A significant hardship that prevents implementation. 53
Variance Process Applicant submits a variance for an identified subpart within the HCH online portal. The Nurse Planner is available to support the applicant with this process. 54
Variance submission A variance may be submitted: During the application process After the site visit During remedial planning After an appeal 55
Variance Duration Subpart 2. Conditions and duration. The commissioner may impose conditions on the granting of a variance according to Minnesota Statutes, section 14.055. The commissioner may limit the duration of a variance and may renew a variance. Variances are normally in place for one year or until resolved. Clinics may submit a request to extend a variance at recertification. 56
Recommendations Recommendations are observations made by the site visit evaluators reflecting opportunity for improvement. Recommendations are: Not prescriptive Addressed by the clinic as appropriate Reviewed at the following recertification to describe how they were addressed. 57
Site Visit 58
Step 7: Site Visit Completed at initial certification. Assesses the implementation of the HCH certification standards in the care delivery model. Completed by trained reviewers from clinical staff, consumers and Minnesota State employees. Completed at the three year recertification cycle in a two hour team meeting format. 59
Application Process An automated MDH email notifies the applicant that the recertification completion date is 90 days away. During this time period: Required letter of intent, application and self assessment have been submitted. Required documents have been submitted and reviewed. Site visit has been completed. 60
Step 8: MDH Notification MDH will notify the applicant of certification status. The report summarizes how the clinic is meeting each of the standards. Applicants meeting all of the standards achieve certification. Celebrate! Payer notification to be completed by the applicant. 61
Optional Step: Variance and Appeals Options for unmet standards: Submit a request for a variance. Request support or technical assistance from MDH. Develop and submit a corrective action for MDH review. File an appeal. The applicant has 30 days from the date of receiving a certification denial notice to appeal the decision. 62
Care Coordination: Billing and Reimbursement Legislative Requirements for HCH Care Coordination Payment: [256B.073] DHS and MDH developed a system for per-person care coordination payments to certified HCHs Fees vary by thresholds of patient complexity Agencies consider feasibility of including non-medical complexity information Implemented for all public program enrollees by July 1, 2010. [62U.03] Covers SGIP, small group self-insured 63
Care Coordination Payment Guiding Principles HCHs provide population management. Every patient is part of the clinic s HCH. HCHs determine patients who will benefit from: care coordination and are eligible for reimbursement routine panel management (preventive care, appointment follow-up). Clinics implement key processes for successful care coordination billing. 64
Population Management Goal Clinics implement processes to identify patients from the entire clinic population who would benefit from care coordination services. New patients Current patients with health changes Established patients with chronic conditions. Patients who are identified may decline care coordination services. 65
Population Management What does your population look like? 66
Implement HCH Tier Tool 67
Complexity Tier Level Needed for Payment Patient s Tier Level (based on the count of major condition groups) Tier 0 (none) Tier 1 (1-3) Tier 2 (4-6) Tier 3 (7-9) Tier 4 (10 or more) Presence of either of the two supplemental complexity factors 68
Workflow Development: Tiering & Billing Determine who does what and when. Complete the Care Coordination Tier Assignment tool. The care team establishes a work flow for communication of the tier score. Key: Establish billing and accounting department workflows and communication processes. Establish payer contracting (see slide #73). Develop automated workflows within EMR. May begin with a manual process. Tier level is supported by documentation. 69
Coding Structure for Billing 70
Key Billing Process Steps 71
Key Denial Process Steps 72
Multi- Payer Communication Prior to Certification, identify payer networks supporting care coordination reimbursement. Work with payers to establish payment rates and methods, and claim submission Tiering Methodology (Medicaid; private and commercial plans) Per member per month (PMPM) contract arrangements CMS Medicare Care Coordination (chronic care management codes see slide #74-75) Identify payers where there may be a patient co-pay and determine a process. Address how to manage billing for uninsured. 73
New Medicare -CMS Chronic Care Management (CCM) Codes, January 2015 As of January 1, 2015, practices began submitting claims under new CCM codes. http://www.cms.gov/medicare/medicare-fee-for-service- Payment/PhysicianFeeSched/index.html 74
CMS Chronic Care Management Codes Replaces Medicare: MAPCP, CPI and other PCMH demos. Practices need to meet standards similar to the HCH standards to submit claims. (see CMS requirements). Patient agreement to services is required. Service requirement of at least 20 minutes of clinical staff time directed by a physician or qualified health care professional per calendar month. Patient has two or more chronic conditions expected to last at least 12 months. Electronic health records requirement; specific requirement for an electronic care plan. A comprehensive care plan is established, implemented, revised and monitored. PCMH certification is not required. 75
Create Your Clinic s Roadmap Population Management in Health Care Homes Care Coordination Tiering Processes Billing Workflows Multi-payer Input 76
Certification details: Your questions New clinics or clinicians added over time within the certified organization follow the same recertification cycle. The certification site visit date serves as the recertification three year cycle date. Email questions to health.healthcarehomes@state.mn.us 77
Recertification Timeline page2 Goal: Maintain relationship, provide ongoing technical assistance and facilitate forward movement of implementation of standards. Initial Certification Recertification: 3 years from initial certification date (HCH portal will generate a 180 and 90 day notice) Subsequent years: Repeat process of every 3 year recertification The Organization submits letter of intent, application/s, and assessment containing the odd numbered standards 1-9 only. The MDH Nurse Planner will then schedule a Health Care Home site visit evaluating the implementation of the odd numbered standards, 1-9 only. The Organization submits letter of intent, application/s, and assessment containing all standards. The MDH Nurse Planner schedules a team meeting to review all standards in the following manner; Changes with any odd numbered standards 1 9 Review of the even numbered standards Review of standard 11 Review any variances The Organization submits letter of intent, application/s, and assessment containing all standards. The MDH Nurse Planner schedules a team meeting to review all standards. Review any changes in standards Review any variances Analyze benchmarks *MDH Nurse Planner will contact the certified Health Care Home organization and offer optional check-ins during the 3-year certification cycle. 78
Evaluation Health Care Homes, Five Year Program Evaluation: Key findings from the University of Minnesota Evaluation 79
Health Care Homes A Business Case 80
Thank you! Visit the MDH HCH website: http://www.health.state.mn.us/healthreform/homes/index.html MDH HCH main phone number: 651 201 5421 81
HCH Nurse Planners Contact Information Bonnie LaPlante, MDH HCH Program Director 651 201 3744 Bonnie.LaPlante@state.mn.us Tina Peters Metro Area 507 951 5780 Tina.Peters@state.mn.us Kathleen Conboy Metro Area 651 201 3753 Kathleen.Conboy@state.mn.us Joan Kindt Southern Region 507 272 4486 Joan.M.Kindt@state.mn.us Danette Holznagel Northern Region 218 206 3239 Danette.Holznagel@state.mn.us 82