6/7/2012 Analytic Framework Target Population Integrated Health - - PDF document

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Integrated Health Service Models for Rural Communities

NOSORH June 7, 2012

Analytic Framework

Impact

Target Population Clinical Services Integrating Services Structure Linkages Financing

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Rural Model Analytic Framework - 1

• Target Community/Population

– Who is the model designed to serve?

• Coordinated Clinical Services

– Which clinical services are brought together in the model?

• Integrating Services

– Which additional services/activities support the clinical service integration?

• Organizational Structure

– How is the model organized?

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Rural Model Analytic Framework - 2

• Finance/Payment Considerations

– How will implementation and operation of the model be supported?

• Linkages

– How will the services in the model be linked to external service systems?

• Anticipated Impact/Outcome

– What are the anticipated outcomes of the new model?

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Health Reform Impacts

• Health Service

– Improve health service effectiveness. – Improve health service quality.

• Health Status

– Improve patient health. – Improve population health.

• Health Utilization

– Improve health service access. – Reduce inappropriate health care use. – Reduce unnecessary health care expenditures.

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Models Examined

• Frontier Health System Model (MT, WY, AK,ND)

– A CAH-based integrated service model.

• Hidalgo Plan Model (NM)

– A primary care/public health centered integrated service model.

• Coordinated Care Organization Model (OR)

– A more general purpose integrated service model.

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Frontier Health System Model (FHS)

• Background/Overview

– The Frontier Health System model is an outgrowth of the Frontier Community Health Integration Demonstration Program. – The Demonstration program was authorized by the Medicare Improvements to Patients and Providers Act (MIPPA), and expanded by the Patient Protection and Affordable Care Act (PPACA) – The Model is the basis of a Medicare demonstration program that would create a new Medicare classification and conditions of participation for networks of health services in certain eligible communities in four states (MT, AK, ND, WY). – Each network would be centered around a Critical Access Hospital and include additional health services. – A separate Medicare reimbursement mechanism would be established for the integrated services of the participating network.

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FHS: Clinical Services

• Clinical care services aggregated into the new Frontier Health

System include:

– Hospital-based services (new CAH 35 bed limit)

• Hospital inpatient
• Hospital swing beds
• Hospital outpatient
• hospital ER (at a Level IV Trauma center certification)

– Ambulance services – Expanded rural health clinic services – Home health services – Extended care

• Visiting nurse services that may provide

– physical, occupational or speech therapy in the frontier patient’s home

• Home hospice services

– Prevention services

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FHS: Integrating Services

• Integrating Services included in the FHS model:

– Clinical Care Coordination: Patient-centered medical home for the coordination and delivery of services to Medicare patients:

• Preventive services
• Primary care,
• Extended care (including Visiting Nurse Services (VNS) with

therapies),

• Long term care
• Specialty care.

– Transition Management: Management of patient transition between care providers. – Chronic Care Management: Monitoring and treatment of patients with chronic conditions, including services to the homebound. – Practice Quality Improvement: Pay for Outcome (P4O).

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FHS: Financing and Reimbursement

• Financial Support for FHS operations will come from several

sources: – Medicare cost-based reimbursement for integrated

• services. This will be a new mechanism.

– Payment incentives for quality improvement – Shared savings with CMS for cost/utilization reduction – Financing is anticipated to be largely budget-neutral.

• Most included services are currently cost-based.
• Some additional services will pay for themselves

through savings.

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FHS: Anticipated Outcomes/Impact

• Key target outcome is reduction of Medicare payment

per patient – Achieved through reduction of preventable events - unnecessary admissions and readmissions to inpatient, ER and long term care settings. – Additional savings from quality improvement. – Also achieved by improved clinical preventive services. – All savings to be shared with FHS to help offset non- cost based services – similar to ACO model.

• Additional outcome - improved access to key services,

including long term care and home health.

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FHS: Target Population and Replicability

• Target population

– Medicare patients in eligible communities of 4 states. – Isolated communities as small as 1,000 population. – Could be translated to other communities with CAHS, both frontier and non-frontier.

• CMS would need to modify current rules to permit

implementation: – Increase in CAH bed limit from 25 to 35 – Include coverage of preventive and care management services for reimbursement. – Modify several other conditions, including distance limits.

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Hidalgo Plan Model (HP)

• Overview/Background

– Developmental approach from a frontier community with no hospital and a single provider of primary care and public health services. – Seeks to implement an expanded coordination of

• utpatient care for local residents with a public health –

health improvement effort. – Also implements coordinated outreach and service to high risk and chronic care patients. – Seeks multi-payer participation in model reimbursement, emphasizing Medicaid and public health funding sources.

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HP: Service Components - 1

• Clinical Services

– Primary Care

• Medical
• Oral Health
• Behavioral Health

– Preventive Care

• Integrating Services

– Clinical care coordination – Chronic care management – High risk patient engagement/health improvement – Social support services

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HP: Service Components - 2

– Health Education

• Community education
• Patient education – including self-care

– Patient Communication – Service Improvement

• Quality
• Effectiveness
• Health Outcome

– Integrated Informatics

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The Preferred Flow of Health Systems and Costs

Tertiary Care Secondary and Subspecialty Care Integrated Primary Care

Community Engagement / Accountability Social Determinants

Horizontal – Actual / Virtual Team Support

V E R T I C A L

C O O R D I N A T I O N

Tertiary Sub- Specialty PC

Current Model

Center for Health Innovation

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Cost/Complexity % Population

Management w/ Team Interventions Interventions Based on Spectrum of Health Services – Broad Focus Diagnosis & Treatment Prevention

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HP: Service Intervention Alignment

Virtual

• Population / Community Level Prevention

– Mass Media Outreach – Public Information Campaigns – Community Infrastructure – Economic Development

• Patient Population Communication

– Health Information / Reminders – Organizational Promotion – Social Media

• Categorical Patient Support

– Condition Specific Information – Tele-Communications / Texting – Email, Text Messages, Social Media

• Patient Level Communication

– Auto-Reminders / Scheduling – Patient Portals – Internal and External Referral Systems

Face to Face

• Community Prevention Engagement

– Health Fairs – Promotion / Early ID – Access - Eligibility – Nutrition Support

• Viva NM, Grocery Store Tours / Label

Reading

– Exercise Classes / Support

• Diagnosis and Treatment

– Social / Behavioral Assessments – Clinical Preventive Services – One On One Support – Prescription Assist – Self-Management and Referral Follow-up – Non-Visit Contacts

• Care Management

– Care Coordination – Decision Support / Home Visits – Social Support

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New Types of Health Professionals

Clinical Support Staff

• Community Health Workers (Global)

– Outreach – Community Health – Prevention Campaigns

• Community Health Navigators

(Horizontal) – Patient Support / Eligibility – Education – Social Determinants

• Care Coordinators (Vertical)
• (MA) Patient Communication

Specialists – Clinical Preventive Services – Scheduling / Reminders

Administrative Support Staff

• Researchers and Evaluators

– EMR Utilization to Support Patient Care Priorities and Program Development – Geographic Analyses – Move from Process Problems to Outcomes Improvements

• Virtual Patient Systems

Communicators – Community / Patient Population Levels – EMR Infrastructure Support

• UNM HEROs

– Resource Linking

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HP: Anticipated Outcomes/Impacts

• Improved health status:

– General population – High risk sub-population – Chronically ill.

• Improved care coordination:

– General patient population – Patients with chronic disease

• Improved clinical practice
• Reduction of unnecessary service utilization
• Reduction of service cost for target community

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HP: Funding Sources

• Financing Sources:

– Medicaid /Medicaid MCOs – Private insurors – Public Health

• Chronic Disease Management Programs
• Prevention Programs
• Payment Approaches:

– Global payment per patient for outpatient, prevention and care management services. – Supplemental grant support for key services, informatics and service improvement.

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HP: Target Population and Replicability

• Target population

– Medicaid/privately insured patients in rural/frontier community. – High risk population in rural/frontier community. – Chronically ill population in rural /frontier community. – Sole provider communities as small as 3,000 population.

• Could be transferred from community sole provider

community model to a community health network.

• Could be transferred to rural/frontier communities with

hospital.

• Could work with Medicare patient population.

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Coordinated Care Organization Model

• Overview/Background

– As part of Oregon’s health care reform activities, a new service model, called the Coordinated Care Organization (CCO) has been developed. – The model is designed to integrate services for Medicaid/Oregon Health Plan patients – including medical, behavioral health and oral health services. – The care coordination model will seek to improve health, reduce cost and improve health service quality and effectiveness. – The model is designed for both rural and urban communities.

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CCO: Service Components

• Clinical Services

– Physical Health Care – Behavioral Health – Oral Health – Preventive Services

• Supplemental Services

– Care Management – using Patient-Centered Primary Care Home approach – Chronic Disease Management – Health Education – Service Improvement – Informatics

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CCO: Organizational Structure

• CCO must be a Health Service Network:

– Governed by:

• Major components of health care delivery system
• Entities undertaking financial risk
• Community at large

– Advised by Community Advisory Council with consumer majority. – Contracting with:

• Public Health Programs
• Mental Health Authority

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CCO: Funding Sources

• Financing Sources:

– Medicaid /Oregon Health Plan – Medicare (for dual eligibles)

• Payment Approaches:

– Global payment per enrolled patient for all but selected services (long term care…) – Alternative payment mechanisms for participating providers: to be proposed by applicant . – Incentive Payments for participating providers stressing improved health outcomes, prevention, early intervention, service efficiency, cost containment, and care coordination.

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CCO: Anticipated Outcomes/Impacts

• Improved health status:

– General population – High risk sub-population – Chronically ill.

• Improved health service access
• Improved care coordination:

– General patient population – Patients with chronic disease

• Improved clinical practice
• Reduction of unnecessary service utilization
• Reduction of service cost for target community

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CCO: Target Population and Replicability

• Target population

– Medicaid/Oregon Health Plan patients, including dual diagnosis, chronically ill and high risk patients. – Medicaid patients to be included under PPACA.

• Replicability

– ACO model without major limits. – Could be replicated in many different communities – rural, frontier or

• urban. Likely would require hospital participation in CCO.

– Would require formation of new organizational entities. – Would require State Medicaid Plan waivers and State Medicaid program rule changes. – Would require new State licensure categories.

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Next Steps: Defining a Rural Integrated Service Model

• Target Communities/Populations

– Which communities/subpopulations should be targeted?

• Outcomes/Impact

– What are the target outcomes anticipated?

• Clinical Services

– Which clinical services should be coordinated? – Which services would be recommended for small, medium, large frontier/rural communities?

• Integrating Services

– Which supplemental integrating services should be included? – Which services would be recommended for small, medium, large frontier/rural communities?

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Next Steps (con’t)

• Linkages

– How should the local model link with other needed services – both local and regional?

• Organizational Structure

– What organizational structure should be established for the model?

• Financial Support

– What payment structure/financial support should be pursued for the model?

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