the medical home the role of and opportunities for dietitians opportunities for collaboration between the patient centered medical home and community public health.

1
Department of Vermont Health Access
Vermont Blueprint for Health Foundation of
Medical Homes and Community Health Teams
Lisa Dulsky Watkins, MD Associate Director,
Vermont Blueprint for Health lisa.watkins_at_state.vt
.us
VDA 2012 Annual Meeting April 27, 2012

1
2
Department of Vermont Health Access
Agenda

• What is a Patient-Centered Medical Home (Advanced
  
• Primary Care Practice)?
• The Vermont Blueprint for Health
• Roles and opportunities for dietitians
• Current and potential collaboration with
• community-based Public Health

2
3
Department of Vermont Health Access
Agenda

• What is a Patient-Centered Medical Home (Advanced
  
• Primary Care Practice)?
• The Vermont Blueprint for Health
• Roles and opportunities for dietitians
• Current and potential collaboration with
• community-based Public Health

3
4
Patient Centered Medical Home (PCMH) Definition
The Patient Centered Medical Home is a health
care setting that facilitates partnerships
between individual patients, and their personal
physicians, and when appropriate, the patients
family. Care is facilitated by registries,
information technology, health information
exchange and other means to assure that patients
get the indicated care when and where they need
and want it in a culturally and linguistically
appropriate manner.
5
Department of Vermont Health Access
Patient Centered Medical Home Definition
(continued)
1. Patient-centered The primary care medical
home provides primary health care that is
relationship-based with an orientation toward the
whole person. Partnering with patients and their
families requires understanding and respecting
each patients unique needs, culture, values, and
preferences. The medical home practice actively
supports patients in learning to manage and
organize their own care at the level the patient
chooses. Recognizing that patients and families
are core members of the care team, medical home
practices ensure that they are fully informed
partners in establishing care plans. 2.
Comprehensive care The primary care medical home
is accountable for meeting the large majority of
each patients physical and mental health care
needs, including prevention and wellness, acute
care, and chronic care. Providing comprehensive
care requires a team of care providers. This team
might include physicians, advanced practice
nurses, physician assistants, nurses,
pharmacists, nutritionists, social workers,
educators, and care coordinators. Although some
medical home practices may bring together large
and diverse teams of care providers to meet the
needs of their patients, many others, including
smaller practices, will build virtual teams
linking themselves and their patients to
providers and services in their communities.

5
6
Department of Vermont Health Access
Patient Centered Medical Home Definition
(continued)
3. Coordinated care The primary care medical
home coordinates care across all elements of the
broader health care system, including specialty
care, hospitals, home health care, and community
services and supports. Such coordination is
particularly critical during transitions between
sites of care, such as when patients are being
discharged from the hospital. Medical home
practices also excel at building clear and open
communication among patients and families, the
medical home, and members of the broader care
team. 4. Superb access to care The primary
care medical home delivers accessible services
with shorter waiting times for urgent needs,
enhanced in-person hours, around-the-clock
telephone or electronic access to a member of the
care team, and alternative methods of
communication such as email and telephone care.
The medical home practice is responsive to
patients preferences regarding access.

6
7
Department of Vermont Health Access
Patient Centered Medical Home Definition
(continued)
5. A systems-based approach to quality and
safety The primary care medical home
demonstrates a commitment to quality and quality
improvement by ongoing engagement in activities
such as using evidence-based medicine and
clinical decision-support tools to guide shared
decision making with patients and families,
engaging in performance measurement and
improvement, measuring and responding to patient
experiences and patient satisfaction, and
practicing population health management. Sharing
robust quality and safety data and improvement
activities publicly is also an important marker
of a system-level commitment to quality.

7
8
(No Transcript)
9
Department of Vermont Health Access
2011 Must-Pass Standards and Elements Summary
NCQA PCMH 2011 six standards Six must-pass elements
Enhance Access and Continuity Access During Office Hours
Identify Manage Patient Populations Use Data for Population Management
Plan Manage Care Care Management
Provide Self-Care Community Support Support Self Care Process
Track Coordinate Care Track Referrals Follow-up
Measure Improve Performance Implement Continuous QI
9
10
Department of Vermont Health Access
Agenda

• What is a Patient-Centered Medical Home (Advanced
  
• Primary Care Practice)?
• The Vermont Blueprint for Health
• Roles and opportunities for dietitians
• Current and potential collaboration with
• community-based Public Health

10
11
Department of Vermont Health Access

• Vermonts Administration and Legislature have
  consistently supported Healthcare Reform
• 2003 Blueprint launched as a Governors
  Initiative
• 2005 Implementation of Chronic Care Model
• 2006 Blueprint codification as part of sweeping
  reform legislation
• (Catamount Health Act 191)
• 2007 Blueprint leadership and Integrated PCMH
  Pilots
• (Act 71)
• 2008 Community Health Team structure and
  insurer mandate
• (Act 204)
• 2009 Accountable Care Organization Exploration
• 2010 Statewide Blueprint Expansion (Act 128)
• Planning for Single Payer and Health
  Insurance Exchange
• (Act 48)

11
12
Department of Vermont Health Access
Blueprint Implementation (March 2012)
82 Primary Care Practices 365 Primary Care
Providers 346,028 Patients 69 Community Health
Team members

12
13
Department of Vermont Health Access

• A foundation of medical homes and community
  health teams that can support coordinated care
  and linkages with a broad range of services
• Multi-Insurer Payment Reform that supports this
  foundation of medical homes and community health
  teams
• A health information infrastructure that includes
  EMRs, hospital data sources, a health information
  exchange network, and a centralized registry
• An evaluation infrastructure that uses routinely
  collected data to support services, guide quality
  improvement, and determine program impact

Hospitals
Advanced Primary Care
Specialty Care Disease Management Programs
Community Health Team Nurse Coordinator Social
Workers Nutrition Specialists Community Health
Workers Mental Health Specialists Health
Educators Extended Community Health
Team Medicaid Care Coordinators SASH Teams
(Seniors)
Advanced Primary Care
Social, Economic, Community Services
Advanced Primary Care
Mental Health Substance Abuse Programs
Advanced Primary Care
Healthier Living Workshops
Public Health Programs Services
Health IT Framework
Evaluation Framework
Multi-Insurer Payment Reform Framework
11/20/2013
13
13
14
Department of Vermont Health Access
Vermont Healthier Living Workshop Topics
Techniques to deal with problems such as
frustration, fatigue, pain and
isolation Breathing techniques and guided
imagery to reduce stress Exercise for
improving and maintaining strength, flexibility,
and endurance Taking medications and
lessening their side effects Communicating
with family, friends, and health
professionals Healthy eating
Evaluating health treatments
14
15
HLW Patient Activation Measures
Participants fill out a baseline questionnaire
during their first class and follow-up
questionnaires at six and twelve months after the
program ends measuring how well respondents are
able to manage their conditions before and after
their attendance. At 12 month follow-up, many
participants show increased confidence in living
with and managing their chronic conditions.
15
16
Current Blueprint Multi-insurer Payment Reforms

• Medicaid
• Commercial Insurers
• Medicare

Insurers

• Patient Centered Medical Home
• Payment to practices
• Consistent across insurers
• Promotes quality

• Fee for Service
• Unchanged
• Allows competition
• Promotes volume

• Community Health Teams
• Shared costs as core resource
• Consistent across insurers
• Minimizes barriers

• Based on NCQA PPC-PCMH Score
• 1.20 - 2.49 PPPM
• Based on active case load

• 5 FTE / 20,000 people
• 350,000 per 5 FTE
• Scaled based on population

17
Department of Vermont Health Access
Hospitals
Patients are not billed for any CHT
services. This has eliminated the financial
barriers that have kept people from receiving
needed education, counseling and follow up.
Advanced Primary Care
Specialty Care Disease Management Programs
Community Health Team Nurse Coordinator Social
Workers Nutrition Specialists Community Health
Workers Mental Health Specialists Health
Educators Extended Community Health
Team Medicaid Care Coordinators SASH Teams
(Seniors)
Advanced Primary Care
Social, Economic, Community Services
Advanced Primary Care
Mental Health Substance Abuse Programs
Advanced Primary Care
Healthier Living Workshops
Public Health Programs Services
Health IT Framework
Evaluation Framework
Multi-Insurer Payment Reform Framework
11/20/2013
17
17
18
Department of Vermont Health Access
Agenda

• What is a Patient-Centered Medical Home (Advanced
  
• Primary Care Practice)?
• The Vermont Blueprint for Health
• Roles and opportunities for dietitians
• Current and potential collaboration with
• community-based Public Health

18
19
Department of Vermont Health Access
Opportunities for Dieticians
The Chittenden County CHT has 2 fulltime RDs and
is hiring a 3rd. They travel to and serve 12
primary care practices, including pediatrics. As
Health Coaches do basic nutrition education, the
RDs tend to see more complex patients. Modes of
contact include 11 60 minute visits every 4-6
weeks, phone or email interim support, and group
classes (Healthy Changes). RDs refer patients
to the YMCA for free assessment, 2 personal
training sessions and 30 day membership for
exercise instruction.
A menu of options

19
20
Department of Vermont Health Access
Opportunities for Dieticians
The Bennington Community Health Team hired a
fulltime RD in November 2011. She spends 4 hours
twice a month in each of 8 practices (and they
all want her more). Frequent topics include
diabetes and readiness assessment for Bariatric
surgery. They have noted that there are far fewer
no-shows when patients are seen in their
primary care practice rather than at a separate
outpatient nutritional counseling service.
Greater access, fewer barriers

20
21
Department of Vermont Health Access
Opportunities for Dieticians
The Community Health Centers of the Rutland
Region has a fulltime RD, who spends much of her
time with patients dealing with obesity and
diabetes. The CHT will be hiring an RD in June
2012 who will be working with the patients at
the Rutland Regional Medical Center-owned
practices 1 day per week. Diabetic education
staff from CHCRR and RRMC meet quarterly. They
are exploring group meetings related to chronic
diseases, cooking and shopping sessions and are
polling PCMH patients on their needs and
preferences.

Listening to the public
21
22
Department of Vermont Health Access
Opportunities for collaboration
with community-based Public Health
Middlebury CHT has access to 4 certified or
registered dieticians (the most awesome
people!). 2 are dedicated to pediatric
patients, but all work with the local VDH
District Office Public Health nutritionist
toward the shared goal of increasing WIC
enrollment in Addison County, which has
precipitously declined in recent
years. Collaborating with a local dentist,
pediatric practices and the Parent Child Center
on pediatric dental hygiene as part of the
spectrum of need related to eating habits,
multi-generational obesity, poverty and health
literacy.
Creative alignment of purpose

22
23
Department of Vermont Health Access
Opportunities for collaboration
with community-based Public Health
St. Johnsbury Fit Healthy Coalition Working
with the Towns of St. Johnsbury (Three Rivers
Recreation Path) and Burke (traffic signs) on
providing safe transportation routes for bikers
and pedestrians. Working with local farmers and
the local food alliance to provide better access
to local Foods. Local produce delivered to
worksites Sponsoring a local food lecture and
film series Working with local schools on using
local produce in their cafeterias Improving
access to fruits and vegetables by assessing
access to fruits and vegetables in convenience
stores and recognizing stores for making positive
changes. Working with local businesses to
implement worksite wellness programs to improve
the health of their employees and their bottom
line. Working with the St. Johnsbury Recreation
Department, Area Agency on Aging, and others to
provide low cost programs and services to get
people of all ages moving more. Purchasing
improved signage for recreation areas and
community gardens to increase awareness.

23
24
Department of Vermont Health Access
Opportunities for collaboration
with community-based Public Health
In the Upper Valley, the town of Bradford has an
established community garden and
Farm-to-School Program which will become part
of the planned Parent Education program,
partnering with nutritionists, community
educators and CHT staff.
Pairing education and health

24