Medical Home at the University of Iowa Hospitals and Clinics

Medical Home at the University of Iowa Hospitals and Clinics Prepared for Iowa Healthcare Collaborative Medical Home Learning Community Presented by Stacey T. Cyphert, Ph.D. Assistant Vice President for Health Policy & Deb Steinbaker, RN, MA, MBA, NE-BC Assistant Director, Primary Care Clinic North September 7, 2011 Presentation Overview IowaCare Background and Context (Cyphert) UIHC s Medical Home (Steinbaker) IowaCare History IowaCare Act (House File 841) passed in 2005 IowaCare is a Section 1115 demonstration waiver that has been renewed through December 31, 2013 Provides a limited benefit package, limited provider network Replaced the loss of $65 million in federal funding from intergovernmental transfers Goals of IowaCare are to: Expand access to health h care coverage for low-income, uninsured adults who are not eligible for Medicaid Provide financial stability for safety net hospitals who have high amounts of uncompensated care Experiment with health care innovations 1

IowaCare Members IowaCare covers single adults and childless couples ages 19-64, up to 200% FPL, who do not qualify for Medicaid or other insurance More than 80% of IowaCare members have incomes below 100%FLP Average monthly income for an IowaCare members is $850 Members are required to pay a monthly sliding scale premium if above 150% FPL (up to $85 per month at 200% FPL) 95% of IowaCare members do not pay any premium Family 200% of FPL Size 1 $21,780 2 $29,420 3 $37,060 4 $44,700 5 $52,340 6 $59,980 IowaCare Has Proven to be a Popular Program IowaCare has grown from 5,700 enrollees its first month to over 50,000 today. IowaCare Enrollment Varies By County (At end of July 2011 Total Enrollment was 50,297) Lyon Osceola Dickinson Emmet Winnebago Worth Kossuth Mitchell Howard Winneshiek Allamakee 30 32 121 85 111 79 77 125 174 146 Sioux O Brien Clay Palo Alto Hancock Cerro Gordo 108 Floyd Chickasaw 99 70 158 66 92 754 234 122 Fayette Clayton Plymouth Cherokee Buena Vista Pocahontas Humboldt Wright Franklin Butler Bremer 418 187 84 73 106 51 72 127 124 152 168 Woodbury Ida Sac Calhoun Webster Hamilton Hardin Grundy Black Hawk Buchanan Delaware Dubuque 740 41 56 75 474 136 199 105 2,590 355 213 1,187 Jackson Monona Crawford Carroll Greene Boone Story Marshall Tama Benton Linn Jones 281 86 93 104 108 256 562 604 335 388 3,738 243 Clinton 1,087 Harrison Shelby Audubon Guthrie Dallas Polk Jasper Poweshiek Iowa Johnson Cedar 278 Scott 66 54 41 87 339 14,612 582 258 293 2,673 2,919 Muscatine Pottawattamie Cass Adair Madison Warren Marion Mahaska Keokuk Washington 1,272 273 113 55 103 319 405 506 234 518 Louisa 249 Mills Montgomery Adams Union Clarke Lucas Monroe Wapello Jefferson Henry Des Moines 23 103 20 129 147 127 105 1,037 784 530 966 Fremont Page Taylor Ringgold Decatur Wayne Appanoose Davis Van Buren 11 78 33 57 128 86 202 75 Lee 178 NOTE: IowaCare enrollment grew by 27.8% in FY 11. 928 2

IowaCare Services IowaCare services include: Inpatient and outpatient hospital services Physician and advanced registered nurse practitioner services, including annual preventive physicals Limited dental services Smoking cessation Extremely limited prescription drug coverage Except for emergency, obstetric, and some routine preventive medical examinations, services must be received from a network provider for IowaCare to pay for them. Examples of medically necessary services for which there is not currently any IowaCare coverage include: Mental health care Skilled nursing home care Home health care Durable medical equipment Outpatient pharmaceuticals IowaCare Provider Network From SFY 2006 2010, the provider network only included: University of Iowa Hospitals and Clinics (UIHC) - Iowa City Broadlawns Medical Center - Des Moines Two FQHCs were added to the provider network in October 2010. People s Community Health Center Waterloo Siouxland Community Health Center Sioux City In July 2011 three more FQHCs were added: Community Health Center of Fort Dodge Crescent Community Health Center Dubuque Primary Health Care Marshalltown Additional FQHCs are expected to be added over time. Members receive care based on their county of residence and needs: Members receive primary care from their medical home (or the UIHC if not assigned to a medical home) Secondary and higher levels of service are provided at the UIHC (Polk County residents only may receive secondary services at Broadlawns) IowaCare Providers Are Expected to be a Medical Home As a condition of participation in the IowaCare program, network providers must also qualify as medical homes, pursuant to Iowa Code Chapter 135, division XXII. Per 135.157(4) Medical home means a team approach to providing health care that originates in a primary care setting; fosters a partnership among the patient, the personal provider, and other health care professionals, and where appropriate, the patient s family; utilizes the partnership to access all medical and nonmedical health-related services needed by the patient and the patient s family to achieve maximum health potential; maintains a centralized, comprehensive record of all health-related services to promote continuity of care; and has all of the characteristics specified in section 135.158. Network providers are to execute a contract with the Department of Human Services to be an IowaCare medical home and receive enhanced medical home reimbursements. The contract is to include performance measurements and specify expectations and standards for a medical home. 3

IowaCare Medical Home Requirements At a minimum, the Medical Home will: Have National Committee for Quality Assurance (NCQA) Level 1 certification or equivalent certification within 18 months of the start of the contract. Medical homes that achieve a higher level of accreditation from NCQA or equivalent shall be designated as such for purposes of payment. Deliver Provider-Directed Care Coordination Services aimed at managing all aspects of a member s care, ensuring quality of care and safety. Care Coordination is a comprehensive process whereby all necessary medical and complimentary services needed by the IowaCare member are provided at the site or are arranged for by the Medical Home provider. This includes but is not limited to coordination of transportation, services, care from other providers, or assistance with receiving benefits that may be provided by other agencies of state government. Develop a Continuity of Care Document (CCD) for each member that details important aspects of member s medical needs. This document will be updated and maintained by the medical home and will be updated as a means of communication between the referring provider and the consulting provider. Submit a CCD and personal treatment plan prior to each referral. IowaCare Medical Home Requirements (cont.) IME specified minimum standards also include: Provide access to care and information Accessibility 24-hours a day with a health care provider on call On-site triage during regular office hours, same-day services will be provided or arranged if determined appropriate Designate a Care Management/Care Coordination staff person Implement a Disease Management Program Diabetes Disease Management is required during the first year. Subsequent studies will be added based on disease burden. Implement a Wellness/Disease Prevention Program with quarterly reporting on quantities and activities. Demonstrate evidence of acquisition, installation and adoption of an electronic health record (EHR) system Develop a reminder service to inform members of appropriate preventative services. Develop an effective system of facilitating referrals and sharing of clinical information between the medical home and the specialty provider. IowaCare Performance-Based Payment Performance Payment. A performance-based PMPM payment will be paid at the end of the SFY to the Medical Home contingent on meeting Medical Home performance measures and available state funding. The Medical Home shall submit their annual performance report by August 1st or the first business day thereafter. The performance payment shall be paid by October 31 or the first business day thereafter and is in addition to any other IowaCare reimbursement. This payment is based on monthly enrollment figures, not by year end enrollment figures. 4

IowaCare Performance-Based Payment Schedule Level of Recognition/Year Initial 18 months of operation No Medical Home recognition Medical Home recognition at level other than highest Medical Home Payment PMPM Performance Based Reimbursement $3.00 $1.00 $4.00 $1.00 $1.00 $2.00 $2.50 $1.50 $4.00 Possible Total Reimbursement PMPM Medical Home recognition at highest level $3.50 $1.50 $5.00 IowaCare Performance-Based Criteria Performance criteria that must be met to obtain the performance incentive payment are as follows: As reported by each Medical Home, at least 65 percent of members enrolled in the pilot, over the age of 50, should have their colon cancer screening status reviewed on an annual basis. Colon checks could be performed by any method with appropriate follow up based on US Preventive Services Task Force (USPSTF) guidelines, including: Fecal occult blood test Flexible sigmoidoscopy Double contrast barium enema Colonoscopy As reported by each Medical Home, at least 75 percent of members enrolled in the pilot should have their body mass index (BMI) measured or calculated and recorded in their medical record, and reported to the Department on an annual basis. BMIs should be reported in aggregate to be aware of the status of the population. IowaCare Performance-Based Criteria (continued) Performance criteria that must be met to obtain the performance incentive payment are as follows: Educational and informational printed material provided to the enrolled members should be culturally and linguistically appropriate to the medical home patient population. Each medical home is to report a list of available languages for printed material, samples of a patient medication list, two examples of patient home-bound instructions, and two examples of patient reminder notices. Additional information should be provided on the current process in place to improve this form of communication to patients. All members referred to UIHC for secondary and/or tertiary care should be tracked via a referral tracking system (either manually [paper based] or electronically maintained). Each Medical Home is to report on their process for ensuring the referral tracking system and to report any known or suspected failures of tracking. As reported by the Medical Home, an active medication list must be maintained for at least 80% of all members enrolled by having at least one entry (or an indication that the patient is not currently prescribed any medication) recorded. 5

IowaCare Performance-Based Criteria (continued) Performance criteria that must be met to obtain the performance incentive payment are as follows: All members enrolled in the Medical Home Pilot are entered into the registry according to their chronic condition(s). Only a Diabetes Registry is required during year one. Each center is to report on their process for ensuring entry into the registry and to report any known or expected failures. As reported by the Medical Home, at least 75 percent of all members enrolled in pilot will have their tobacco use status documented. Each Medical Home is to report what percent of members enrolled in the program have annual immunizations or there is documentation that immunizations were offered, education provided to member, and member refused. As reported by each Medical Home, at least 70 percent of all eligible women enrolled should have an age appropriate cervical screen or documentation of need for exam. As reported by each Medical Home, at least 80 percent of all enrolled members with a diagnosis of diabetes have had at least one A1C annually. IowaCare Medical Home Coverage Began October 1, 2010 Other than primary care in medical home counties, secondary and higher levels of care are provided at the UI Hospitals and Clinics (although Broadlawns can provide some limited secondary care for residents of Polk County only). Lyon Osceola Dickinson Emmet Winnebago Worth Kossuth Mitchell Howard Winneshiek Allamakee Sioux O Brien Clay Palo Alto Hancock Cerro Gordo Floyd Chickasaw Non-UIHC Medical Home Fayette Clayton Plymouth Cherokee Buena Vista Pocahontas Humboldt Wright Franklin Butler Bremer UIHC Medical Home Webster Black Buchanan Delaware Dubuque Woodbury Ida Sac Calhoun Hamilton Hardin Grundy Hawk Jackson Monona Crawford Carroll Greene Boone Story Marshall Tama Benton Linn Jones Not in a medical home* Clinton Harrison Shelby Audubon Guthrie Dallas Polk Jasper Poweshiek Iowa Johnson Cedar Scott Pottawattamie Cass Adair Madison Warren Marion Mahaska Keokuk Washington Muscatine Louisa Mills Montgomery Adams Union Clarke Lucas Monroe Wapello Jefferson Henry Des Moines Fremont Page Taylor Ringgold Decatur Wayne Appanoose Davis Van Buren Lee *People not assigned to a medical home are served by the UIHC. Continual Growth in IowaCare Program A Challenge in Operating a Medical Home 22.4% increase in own medical home beneficiaries UIHC s medical home counties have seen an increase in IowaCare enrollment of 1,809 beneficiaries (from 8,077 to 9,866) between October 1, 2010 and July 31, 2011. 22.1% increase in beneficiaries unassigned to medical homes Counties not assigned to medical homes for which the UIHC is responsible for primary and greater care have seen an increase in IowaCare enrollment of 3,407 beneficiaries i i (from 15,447 to 18,854) 8 between October 1, 2010 and July 31, 2011. 6

Deb Steinbaker, RN, MA, MBA, NE-BC Assistant Director Primary Care Clinic North Corporate Goals Short Term NCQA-PCMH Certification at a Level 3 for IowaCare Enrollees Long Term NCQA-PCMH Certification for all other payers including Pediatric population Achieving the Standards 7

Building Partnerships With Patients Building Partnerships with Medical Homes The UIHC is also the source for secondary, tertiary and quaternary care for IowaCare beneficiaries so there are many opportunities for interactions. Per Iowa Administrative Code 441-92.8(6)(c), IowaCare beneficiaries must receive a referral from their medical home provider to access the UIHC for any services not available from the medical home. 249J7(7) of the Code of Iowa authorizes the use of clinical transfer and referral protocols to be used by providers. Electronic communication tools have been put in place -- Care Link is in use with FQHC medical homes and have seamless electronic information sharing with Broadlawns. Team Structure Providers (MDs and Extenders) Case Manager RNs MAs Additional Support Staff Pharmacist support pp Social Services support 8

IowaCare web page created at UIHC for patients, medical homes and staff www.uihealthcare.org/iowacare Share Key Performance Indicators Internally Teams Administration Tools necessary for success EPIC Reports Phone Contacts Individual and group health coaching EPIC reminder letters My Chart Automated Telephone Reminders Future Cell phone text message reminders? Face Book contacts? 9

Care Coordination Navigating the healthcare maze for the patient QUESTIONS? 10