America s Voice for Community Health Care

America s Voice for Community Health Care The NACHC Mission To promote the provision of high quality, comprehensive and affordable health care that is coordinated, culturally and linguistically competent, and community directed for all medically underserved people. 1

2011 Tennessee Primary Care Association Clinical Conference Leading the journey to 2015 Health Reform: Quality and Health Centers are Front and Center David M. Stevens, MD National Association of Community Health Centers April 14, 2011 Franklin, TN Budget Update Original $2.2 Billion Appropriation $600 Million Cut Trust Fund of $1 Billion Take $600 Million From Trust Fund Restore $2.2 Billion Additional $250 Million to continue care from ARRA/IDS Take $400 Million from Trust Fund, leaving $150 Million Take out FTCA and apply 0.2% across the board cut About $100 Million 2

Today s Discussion. Background/Context Quality & Health Reform Health Center challenges & strategies The American Health Care Crisis Costs: U.S. health care costs per person are 250% higher than the median for 29 other developed nations* Annual cost of measurable medical errors that harm patients was $17.1 billion in 2008**** Access and Safety: 50.7 million Americans (16.7%) are uninsured*** 56 million Americans have NO regular source of care Safety: Adverse events in one-third of hospital admissions** Adults receive about half of recommended care; children less than half^ * Health Spending In OECD Countries In 2004: An Update, Health Affairs 26/5, Sept.-Oct. 2007 ** New England Journal of Medicine, 354(11), March 2006 (report on RAND Corp study, funded by Robert Wood Johnson Foundation) ***Census Bureau, 2009 ****Health Affairs, April 2011, Vol.30 No.4 ^McGlynn, EA. www.rand.org/pubs/research_briefs 3

2010 National Healthcare Quality and Disparities Reports (www.ahrq.gov) Quality is improving: 2.3% per year Access and disparities are not improving Urgent attention necessary to improve quality and reduce disparities: Cancer screening and management of diabetes States in the central part of the country Residents of inner-city and rural areas Disparities in preventive services & access to care Progress is uneven in 8 national priority areas. All 8 show disparities related to race, ethnicity, and socioeconomic status Two are improving: palliative & end-of-life care; and patient & family engagement Three are lagging: population health, safety, and access Three require more data to asses: care coordination, overuse, and health system infrastructure National Strategy for Quality Improvement in Health Care March, 2011 Better Care Affordable Care Health People/Healthy Communities Priorities Safety Engaged individuals & families Effective communication & coordination of care Most effective prevention and treatment practices for leading causes of mortality, e.g. cardiovascular disease Community partnerships to promote wide use of best practices for healthy living More affordable quality care by developing and spreading new care delivery models 4

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% of Medicare beneficiaries admitted for 31 select conditions, re-admitted 30 days after leaving hospital 11 Today s Discussion. Background/Context Quality & Health Reform Health Center challenges & strategies 6

Evolution of Payment Reform From Incremental Reporting Bonuses to More Comprehensive and Integrated Population-Level Reforms (E. Fisher,NQF, Growing Demand for Accountability Webinar, 10/1/2009) Supporting Better Performance Paying for Better Performance Pay for reporting. Payment for reporting on specific measures of care. Data primarily claims-based. Payment for coordination. Case management fee based on practice capabilities to support preventive and. chronic disease care (e.g., medical home, interoperable HIT capacity). Pay for performance. Provider fees tied to one or more objective measures of performance (e.g., guidelinebased payment, nonpayment for preventable complications). Episode-based payments. Case payment for a particular procedure or condition(s) based on quality and cost. Paying for Higher Value Shared savings with quality improvement. Providers share in savings due to better care coordination and disease management. Partial or full capitation with quality improvement. Systems of care assume responsibility for patients across providers and settings over time. Accreditation & PCMH: not about the certificate on the wall it s about accountability for quality and cost outcomes! FQHC Incentives and Performance Characteristics (Shin, Stevens et al in preparation, do not duplicate) 7

Accountable Care Organizations (Adapted from E. Fisher, NQF, Growing Demand for Accountability Webinar, 10/1/2009) ACOs are multi-stakeholder public/private collaborations in which providers assume responsibility for overall patient care across clinicians and settings; ACO configurations can vary, reflecting the diversity of local healthcare markets and preferences of participants; Integrated delivery systems, Physician-Hospital Organizations, Independent Practice Associations (IPA), physician group practices, regional collaboratives Several characteristics are essential for all ACOs: Can provide or manage a continuum of care as a real or virtually integrated delivery system Are of sufficient size to support comprehensive performance measurement & improvement Are capable of prospectively planning budgets and resource needs & sharing among the ACO participants Will the PCMH Address Quality, and Cost? Quality of care, patient experiences, care coordination, and access are demonstrably better. Investments to strengthen primary care result within a relatively short time in reductions in emergency ED visits and inpatient hospitalizations that produce savings in total costs. These savings at a minimum offset the new investments in primary care in a cost-neutral manner, and in many cases appear to produce a reduction in total costs per patient. The Outcomes of Implementing Patient-Centered Medical Home Interventions: A Review of the Evidence on Quality, Access and Costs from Recent Prospective Evaluation Studies, August 2009 Source URL: http://www.pcpcc.net/content/pcmh-outcome-evidence Kevin Grumbach, MD, Thomas Bodenheimer, MD MPH & Paul Grundy, MD 8

PCMH 2011 Key Components: NCQA Recognition Program Access Evening/weekend hours, agreement with facility for after-hours care Coordination of care Information to/from specialists/facilities/patient, update care plan Team-based care Defined roles and responsibilities, training, communication Role of medical home Discuss roles/expectations for medical home and for patients Care management Pre-, post-visit planning, care planning during visit, patient self-care Medication management Include mental health/substance abuse/behaviors affecting health Community resources/referrals Identify/address population needs/risks Quality improvement Performance measurement Patient experience Patient Experience Optional Modules Separate distinction for reporting patient experiences data (scoring in future) Requires use of PCMH version of CAHPS Clinician and Group survey (in field testing now) Standard methods for data collection and sampling Performance Measures Under development Requirements to be published in 2011 9

PCMH 2011 Alignment with Measures of Meaningful Use E-prescribing medication list, allergies Patient tracking/registry demographics, diagnoses, vital signs, smoking, population management, insurance Care management reminders for follow-up care, decision support, RX reconciliation Electronic capability e-health info. to patient, visit summary, e-access to health information, provider information exchange Performance reporting/improvement PCMH Accreditation/Recognition Programs and FQHC National & State Initiatives CMS Advanced Primary Care Demonstration for FQHCs will utilize the NCQA standards and tools HRSA resources support existing recognition/accreditation medical home programs QUALIS/Commonwealth Fund Demonstration Accreditation Association for Ambulatory Health Care Joint Commission ( available July, 2011) National Association for Quality Assurance (NCQA) URAC (Utilization Review Accreditation Commission) 10

Commonwealth Fund/Qualis Safety Net Medical Home Initiative (SNMHI): Supporting 65 Clinics in Five State Become PCMH Regional Coordinating Centers 1. Massachusetts League for Community Health Centers and Executive Office of Health and Human Services (MA) 2. Oregon Primary Care Association and CareOregon 3. Colorado Community Health Network Five Regional Coordinating Centers (orange) were selected from 42 applicants (blue) to participate www.qhmedicalhome.org 4. Idaho Primary Care Association 5. Pittsburgh Regional Health 21 Initiative What Are Key Design Features of a PCMH: Commonwealth Fund Safety Net Medical Home Initiative Engaged Leadership Quality Improvement Strategy Empanelment (provider/team accountability for specific population of patients) Enhanced access Continuous, team based healing relationships with patients Patient centered interactions (e.g. self-management support) Organized evidenced base care Care coordination 11

Health Reform: Health Center Payer Mix in 2015 Current (2009) Patients by Payer Source (National Averages) Post-Reform (2015) Patients By Payer Source (Averages) Private 16% Uninsured 39% Medicaid 34% Exchange 7% Uninsured 26% Private 12% Medicaid 42% Other Public 1% CHIP 2% Medicare 8% Other Public 1% Medicare 8% CHIP 4% NOTE: Medicare patients will grow significantly over the next 10 years CMS Health Center Demonstration: Objectives To evaluate the impact of the advanced primary care practice (APCP) model, commonly known as the patientcentered medical home (PCMH), on improving health, improving care, and reducing healthcare costs among Medicare beneficiaries served by FQHCs To assess the impact that additional support (e.g., quarterly care management fees, technical assistance) has on FQHCs transforming their practice and becoming formally recognized by the NCQA as a level 3 PCMH 24 12

CMS Health Center Demonstration: Goals Achieve better health, better care, and lower costs for beneficiaries receiving care from FQHCs 90% of participating FQHCs achieve level 3 NCQA recognition by the end of the demonstration 25 Thirty-Seven States Advancing Medical Homes in Medicaid and/or CHIP Programs 3 Federal Demos: 1. CMS Medicare MH 2. CMS Advanced Primary Care Pilot w/ state Medicaid 3. Medicare FQHC MH pilot program = Identified to have a medical home initiative 26 Source: National Academy for State Health Policy State Scan, May 2010. http://www.nashp.org/med-home-map 13

Health Reform Timeline of Some Key Events 2012 Medicare Primary Care Medical Home and Accountable Care Organization (ACO), Medicare FQHC Medical Home demos begin; state Medicaid demonstration for medical homes for beneficiaries with chronic diseases 2013 2014 Medicare physician value-based care begins, Medicaid PCMD rates adjusted to 100% of Medicare. Medicaid expansion to cover all non-elderly 133% FPL now required Individual & employer mandates begin, State Health Insurance Exchanges open with subsidies offered to individuals. Today s Discussion. Background/Context Quality & Health Reform Health Center challenges & strategies 14

Health Center Quality Journey 1990 s: Clinical Measures & TOTS: --Structure & Process outcomes --Life Cycle Clinical measurement; system approach & state based knowledge network begins --National partners: JCAHO, CDC 1980 s: BCRR Table V --Quality: accountability, quality control --Outputs versus results --No national quality partners; --no state quality infrastructure 2010+ Health 998-2000 s Quality as a System: Centers as System --Care, Improvement & Learning models of Care --Performance Measurement & Improvement for --Patient Centered Health center practices --Knowledge Network -- Formal External Validation --National Partners: Major Expansion Health Home --Health System Integration --Expansion to additional populations --Community Health National Survey of FQHCs Survey administered by Harris Interactive from March-May 2009 1,007 FQHCs were mailed the survey and 795 responded, yielding a 79 percent response rate Questionnaire completed by executive directors or clinical directors at FQHCs Data weighted to reflect universe of primary care community health centers Report Released May 2010 (www.commonwealthfund.org) With support from Kaiser Community Benefit, NACHC and GWU Geiger Gibson Program providing additional analysis 15

Quality of Care Quality Improvement The Commonwealth Fund 2009 Survey of Federally Funded Qualified Health Centers TN Nation Base: All Respondents Does your center have enough of the following to support Quality Improvement (QI) activities? 19 795 1. Clinical outcomes (e.g., percent of diabetic patients with good glycemic control) % At the Provider Level % At the Group Practice Level 46% 85% 61% 78% 2. Surveys of patient satisfaction and experiences with care % At the Provider Level % At the Group Practice Level 30% 90% 43% 84% 3. Physician/Provider productivity % At the Provider Level % At the Group Practice Level 74% 67% 83% 63% The Commonwealth Fund 2009 Survey of Federally Funded Qualified Health Centers Base: All Respondents Quality of Care Care Coordination & Management Does your center have enough of the following to support Quality Improvement (QI) activities? 1. Dedicated staff to lead QI activities % Do Not Have % Yes, But Need More % Yes, And Have Enough 2. Information systems to provide timely data and feedback to staff on QI activities % Do Not Have % Yes, But Need More % Yes, And Have Enough 3. Financial support for QI activities % Do Not Have % Yes, But Need More % Yes, And Have Enough 4. Opportunities for staff training in QI % Do Not Have % Yes, But Need More % Yes, And Have Enough 5. Opportunities for staff recognition for QI activities % Do Not Have % Yes, But Need More % Yes, And Have Enough TN Nation 19 795 22% 56% 22% 21% 63% 16% 46% 54% 21% 74% 5% 30% 65% 18% 63% 17% 14% 66% 19% 31% 58% 10% 21% 67% 11% 32% 57% 10% 16

IT Elements of Quality & Care Coordination The Commonwealth Fund 2009 Survey of Federally Funded Qualified Health Centers Underlined questions are meaningful use measures BASE: All Respondents With patient medical records system you currently have, how easy would it be for this staff in your largest site to generate the following information about the majority of your patients? List of patients by health risk % Easy % Cannot Generate List of patients by lab result (e.g., HbA1>9.0) % Easy % Cannot Generate List of patients who are due or overdue for test or preventative care % Easy % Cannot Generate List of patients taking a specific medication (e.g., patients on ACE inhibitors) % Easy % Cannot Generate List of panel of patients by provider % Easy % Cannot Generate Tennessee National 19 795 20% 40% 45% 25% 15% 32% 19% 55% 63% 10% 27% 28% 45% 16% 25% 22% 27% 31% 58% 10% IT Elements of Quality & Care Coordination The Commonwealth Fund 2009 Survey of Federally Funded Qualified Health Centers Underlined questions are meaningful use measures BASE: All Respondents How often, if ever, are the following tasks performed at your largest site. Patients are sent reminder notices when it is time for regular preventative or follow-up care % Usually % Never Provider receives an alert/prompt at point of care for appropriate care services needed by patients (e.g., pap smear or immunizations due) % Usually % Never Provider receives an alert or prompt to provide patients with test results % Usually % Never Laboratory test ordered are tracked until results reach clinicians % Usually % Never Tennessee National 19 795 16% 7% 14% 22% 25% 29% 60% 5% 18% 16% 23% 24% 33% 30% 54% 11% 17

Quality of Care Care Coordination & Management The Commonwealth Fund 2009 Survey of Federally Funded Qualified Health Centers Underlined questions are meaningful use measures Base: All Respondents When patients are referred to specialist or subspecialist outside your largest site, how often does each of the following occur? 1. The referring provider receives a report back from the specialist/subspecialist about care given to the patient % Usually/Often % Sometimes % Rarely/Never 2. The report from the specialist/subspecialist is received by the center within 30 days % Usually/Often % Sometimes % Rarely/Never 3. Your center tracks specialist/subspecialist referrals until the consultation report returns to the referring provider % Usually/Often % Sometimes % Rarely/Never Tennessee National 19 795 61% 39% -- 55% 46% -- 68% 27% 6% 73% 19% 6% 64% 23% 11% 70% 15% 13% Quality of Care Care Coordination & Management The Commonwealth Fund 2009 Survey of Federally Funded Qualified Health Centers Underlined questions are meaningful use measures Base: All Respondents Thinking about the hospital to which patients at your largest site are most commonly admitted; if admitted how often does the following happen? 1. Hospital notifies your center that a patient has been admitted % Usually/Often % Sometimes % Rarely/Never 2. Emergency department notifies your center that your patient has had an Emergency Room visit % Usually/Often % Sometimes % Rarely/Never 3. Your center receives a discharge summary or report from the hospital to which your patients are usually admitted % Usually/Often % Sometimes % Rarely/Never Tennessee National 19 795 42% 26% 31% 42% 16% 42% 59% 5% 36% 48% 18% 33% 39% 18% 42% 56% 20% 22% 18

Quality of Care Care Coordination & Management The Commonwealth Fund 2009 Survey of Federally Funded Qualified Health Centers Underlined questions are meaningful use measures BASE: Center Receives Discharge Reports How long does it usually take for a hospital discharge summary or report to arrive? % Less than 48 hours % 2-4 days % 5-14 days % 15-30 days % More than 30 days BASE: All Respondents Please estimate the proportion of patients at your largest site that has limited English proficiency. 0-10% 11-24% 25 50% Greater than 50% Tennessee National 16 726 11% 27% 51% 6% 5% 14% 23% 31 % 16 % 9% 19 795 65% 42% 24% 15% 11% 22% -- 19% Quality of Care Quality Improvement The Commonwealth Fund 2009 Survey of Federally Funded Qualified Health Centers Base: All Respondents Which, if any, of the following performance data are collected and reported at your center? 1. Setting goals based on measurement results % Yes Tennessee National 18 795 95% 97% 2. Taking action to improve performance of individual physicians % Yes 94% 87% 3. Taking action to improve performance of the practices in your center % Yes 100% 99% 4. Taking action to improve performance of the center as a whole % Yes 100% 99% 19

Quality of Care Care Coordination & Management The Commonwealth Fund 2009 Survey of Federally Funded Qualified Health Centers TN Nation Base: All Respondents How often do you think your patients experience the following at your largest site 19 795 1. Patient scheduled with personal clinician vs. another clinician % Usually 2. Patients are able to receive same or next-day appt. when they request one % Usually 3. Patients can get telephone advice on clinical issues during office hours % Usually 4. Patients can get telephone advice on weekends or after regular office hours % Usually 5. Patients can e-mail providers about clinical issues %Usually 81% 36% 48% 43% -- 64% 42% 42% 48% 3% Today s Discussion. Background Patient Centered Medical Home Are we ready?-- survey results Discussion: Frame Work For Action 20

On to Action: NACHC s Health Reform Strategies Population Health Reducing disparities Growth Patient Centered Medical Home Advocacy Transformation Engagement Patient and community Based upon IHI Triple Aim Value Improve quality; reduce cost NACHC Learning Communities AIM: PCMH Institute - a one year applied learning forum for a cohort of state/regional primary care association and network leaders to design and build capacity and infrastructure for health center transformation to patient centered medical homes. HIV in Primary Care Learning Community - to expand the capacity to deliver HIV services within primary care systems developing as patient centered homes at up to thirty non-ryan White funded health centers. 21

2011 PCMH Institute Curriculum Building the Foundation Strategic plans at PCA and health center levels based upon practice assessments Leadership Improvement Strategy Stakeholder partnerships & opportunities Identify and characterize health center patient population/meaningful Use capacities Empanelment Designing the PCMH system Team Based Care & Continuity Patient Centered Care Work flow redesign Revenue maximization Staff vitality Data for Decision Making: Meaningful Use & HIT PCA State-based quality improvement infrastructure: needs, roles & models Integrating with external systems Partnerships Care management Care coordination Manage the health and costs of the health center population Integrating/coordinating PCA state QI infrastructure with local, state & national efforts NACHC PCMH Learning Community Learning Labs Freestanding 2 day workshops offered to PCA/HCCN and health center staff throughout the y Examples: Care Coordination Care Management Revenue maximization PCA State Based Infrastructure: Design and Implementation 22

Thank You! Any Questions? 23