Health Care Home Certification

Fairview Physician AssociatesIndependent Primary Care Clinics

Where did this come from?

• 2008 Minnesota health reform law

• Improved outcomes due to better

coordinated care for complex and chronic

conditions

• Identified need for care coordination

reimbursement

• Platform to achieve “Triple Aim”

What is a Health Care Home

(HCH)?

An approach to primary care in which

primary care providers, staff, families and

patients work in partnership to improve

health outcomes and quality of life for

individuals with chronic or complex health

conditions.

5 Major Standards of The HCH

• Access/Communication

• Patient tracking and registry functions

• Care Coordination

• Care Plans

• Performance reporting and quality

improvement

The Burning Platform• MDH data suggests HCH has decreased

TCOC by 6%

• Some payers are starting to require HCHCertification

• Fee for service model is shifting to shared savings/bundled payment

• Patient Choice – Patient’s are starting to look for this certification when selecting a clinic

• Quality- FMG as well as other HCH’s, have seen improved quality outcomes

• Heart of ACO

• Promotes Team Based Model- Distributes care responsibilities to appropriate scope of practice

Care redesign and payment reform!

Today’s Care Health Care Home

Patients are recipients of services by providers and clinics Patients and families are partners in the planning and

provision of care

Patients are those who make appointments to see us Patients agree to participate in HCH and understand how to

contact their HCH

Care is determined by today’s problem and available time Proactive care planning is done with patient/family to

anticipate needs

Care varies by memory or skill of the provider Care is standardized with evidence-based guidelines, protocols

and planned visits

Patients are responsible to coordinate their own care A team, including the care coordinator, coordinates care with

patient/family

I know I deliver quality care because I’m well trained We measure our quality and outcomes and make ongoing

changes to improve, and we include patients/families in our

quality work

It’s up to the patient to tell us what happened to them We use a registry to track visits and tests and we do follow-up

after ED and hospital visits.

Clinical operations center on meeting provider needs A multidisciplinary team works at the top of their scope to

provide patient/family-centered care.

Comparing Today’s Care and HCH

Process• Clinics apply for HCH certification

• MDH site visit

• Annual recertification

• Flexibility for all kinds of providers and

clinics to be HCH as long as they provide full

range of primary care services

– First point of contact for acute care

– Preventative care

– Chronic care

Access and Communication

Standards• System in place to tell patients about HCH

services

• Patient knows how to access HCH

continuously

• Person responding to patient call has access

to patient’s HCH info, triage system, on-call

provider or clinic staff

Access and Communication

Standards• Access addressed by protocol

– To avoid unnecessary ED visits or

hospitalizations

• There is a process to collect cultural, racial

and primary language information and it is

used in providing care

• The team knows the patient’s/family’s

preferred communication method

Access and Communication

Standards• Process in place to inform HCH participants they

may choose specialists without regard to being in

same provider group or network

• HCH encourages patients to play active role in

managing their own health care

• HCH improves participant involvement by

addressing readiness for change, literacy level,

other impediments to learning

• HCH complies with all privacy and confidentiality

laws

Registry and Patient Tracking

Standards• Must have a registry that is electronic and searchable

– Sufficient data available to manage patients with

chronic or complex conditions

– Customized for various conditions

• Systematic reviews of participant population to

identify care gaps

• Processes in place to prevent care gaps

– Appointment reminders and pre-visit planning

Care Coordination Standards

• Team approach that engages participant,

provider, other members of health care team

• Organizes timely access to resources and care

• Provides continuity of care

• Care coordinator has primary responsibility

to organize care for participants of HCH

Care Coordination Standards

• Promotes patient/family-centered care

• Fully engage patients/family members in care

planning and shared decision making

– Process is documented

• HCH identifies community resources

• Team members practice at top of scope

• HCH plans for transitions among clinicians

and at life stages

Care Coordinators• Track appointments, test results, referrals,

medication refills

– Use evidence-based guidelines

– Medication reconciliation and refills

– Test results reported timely

• Coordinate admissions, post discharge and

transition planning

• Develop resources and links participants to them as

needed

• Document in chart and maintains care plan

What is a care plan?

• Individualized written document that

identifies patient needs, goals and actions

• Comprehensive plan includes relevant

portions of external care plans

• Patient and family have input into plan of

care

Care Plan Standards

• Incorporate assessment of patient health risks

and chronic conditions

• List diagnoses identified by provider and RN

team members

• Reviewed with patient and jointly amended at

intervals appropriate to patient’s care

• Includes goals and action plans identified by

HCH team and patient/family

Care Plan Standards• A copy is provided to the patient/family

initially and with each change

• Evidence-based guidelines are used

• Includes goals and actions for

– Preventative care

– Care for chronic illnesses

– Special needs

– Plans for early contact with HCH for

exacerbation of condition

– End of life care and advance directives

Identifying HCH Potential

Patients

The “Usual Mix”

Tier 050%

Tier 112%

Tier 217%

Tier 312%

Tier 49%

HCH Participants

50% Tier 0

No chronic conditions or less

complex conditions.

Routine panel—management and

preventative care.

50% Tiers 1-4

Chronic conditions or more

severe, complex conditions.

Need more intense care and

coordination.

Who’s included?• Included (about 40% of Minnesotans)

– Medicaid and state-funded public programs

– State employees

– Fully-insured private insurance (small employer

groups and individual policies)

• Not included (about 60% of Minnesotans)

– Medicare

– Self-insured private insurance (large employers)

– Uninsured

How are we paid for the care?

• Paid by the patient, not by the visit

• Fees vary by thresholds of patient complexity

– Complexity represents time and work needed to

coordinate care

– Higher fees for more complex patients

• Complexity includes both medical and

psychosocial factors. 15% rate increase for

serious mental conditions and primary

language other than English.

Definitions

• Chronic conditions have lasted at least six

months, can reasonably be expected to

continue for at least six months, or are likely

to recur

• Severe conditions are major and potentially

unstable conditions that, without optimal

care, are likely to worsen and lead to altered

physiologic state, impairment, or death.

Definitions• Requires a care team means a care team is

required for this condition to attain or maintain

stability and optimal health status for the patient.

This includes preventive care or coordination to

prevent progression of disease, deterioration, or

gaps in care.

• Care team is a group of health professionals who

plan and deliver care in collaboration with a

participant. Includes a provider, a care

coordinator and may include others based on

patient need.

Complexity Info Needed for

Payment• Patient’s tier level (based on 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

Reimbursement Rates

• Based on a mix for each hour of

care of 20% physician time, 50%

care coordination time, 30%

office/clerical

• Rate for one hour of care

coordination in HCH=$40.54

• Per member per month (PMPM)

rates based on minutes of care

coordination per month

• Additional 15% for each of the

supplemental factors

Tier Minutes of

work PMPM

PMPM

Rate

0 N/A N/A

1 15 10.14

2 30 20.27

3 60 40.54

4 90 60.81

Add 15% for each supplemental factor

Tier Assignment Tool

Assigning Patients to Tiers

1. Determine if any condition in the group is

chronic

– If yes, mark box

– If no, stop and mark score as 0

2. Determine if any condition in the group is

severe

– If yes, mark box

– If no, stop and mark score as 0

Assigning Patients to Tiers

3. Determine if any condition in the group

requires a care team

– If yes, mark box

– If no, stop and mark score as 0

4. Total the scores for each group. The sum

count determines the tier.

5. Mark any supplemental factors (but don’t

add to the sum count)

Example 1: Sarah

Supplemental Factors• Need to communicate about health care in

non-English primary language

– Includes hearing impaired needing sign language

interpreter

– Consider if language barrier is significant enough

to prevent discussion with care team for

coordination of severe, chronic conditions

– Designation is in addition to billing for

interpreter services and reimburses for extra

work of care coordination

Supplemental Factors

• Has a serious and persistent mental illness diagnosis

– Applies to patient or caregiver

– Has active diagnosis of schizophrenia, bipolar disorder,

major depression, borderline personality disorder

– Implies some level of functional impairment observed

– Designation is in addition to mental health diagnosis

checked in condition group and reimburses for added

intensity of care coordination

Conclusion• HCH is a way to improve clinical outcomes

and decrease costs

– Patient involvement is key

• This model recognizes the importance of care

coordination and is willing to pay for it

• Care coordination needs determined by tier

• Care coordinators are essential to make

this work

• THANK YOU for all you do!