Improving the Way Care is Delivered: Examples of Innovative State Efforts

1. Improving the Way Care is Delivered: Examples of Innovative State Efforts Rachel Nuzum, M.P.H. Assistant Vice President, Federal Health Policy The Commonwealth Fund Colorado Commission for the Medically Underserved Annual Meeting October 8, 2010

2. States Have Several Levers to Promote a High Performance Health System • Leadership: Legislation and policy formulation • Purchasers: Using leverage of Medicaid, CHIP, State Employee Health Plans to drive quality • Regulators: Authority over insurance markets & providers • Providers: Unique role to provide care for underserved populations • Technical support and assistance

3. How States Can Promote a High Performance Health System: Strategies to Improve Quality and Efficiency • Promote better organization and integration of care delivery • Provide incentives for improved performance • Use better information to guide and drive improvement • Commit to Continuous Quality Improvement

4. STate Action on Avoidable RehospitalizationsSTAAR Initiative Purpose • Improve quality, patient experience, and reduce avoidable utilization through a multi-stakeholder initiative to reduce rehospitalizations. Methods • Engage state-level leadership and state-wide process improvement . Aims • Improve patient/family satisfaction with care transitions. • Reduce all-cause 30-day rehospitalization rates by 30 percent. Settings • Massachusetts, Michigan, Washington

5. STAAR State Level Strategy Hospital-level Improve the transition out of the hospital for allpatients* Measure and track 30-day readmission rates* Understand the financial implications of reducing rehospitalizations* Community-level Engage organizations across continuum to collaborate on improving care, partner with non-clinical community based services, address lack of IT connectivity, clarify who “owns” coordination, engage patient advocates* Ensure post-acute providers are able to detect and manage clinical changes, develop common communication and education tools* State-level Develop state-level population based rehospitalization data* Convene all payer discussions to explore coordinated action* Link with efforts to expand coverage, engage patients, improve HIT infrastructure, establish medical homes, contain costs, etc.* Establish state strategy, use regulatory levers* * Elements of the STAAR Initiative Available at www.ihi.org/STAAR

6. STAAR State Leadership, Strategy, Policy Elements of the STAAR Initiative Available at www.ihi.org/STAAR

7. Overview of Medical Home Demonstrations, Multi-Payer Activity and Evaluations • 3 Federal Demos: • CMS Medicare Medical Home • CMS Advanced Primary Care Pilot with state Medicaid programs • Medicare FQHC MH pilot program NH MA RI Independent evaluations Multi-Payer pilot discussions/activity Identified pilot activity No identified pilot activity – 6 States Source: Patient Centered Primary Care Collaborative, 2009

8. Summary of Cost and Quality Outcomes from Patient-Centered Medical Home Interventions • Group Health Cooperative • 29 percent reduction in ER visits and 11% reduction in ambulatory sensitive care admissions • $16 per patient per year investment in primary care associated with savings of $17 per patient per year (not statistically significant) • HealthPartners • 39 percent decrease in emergency room visits • 24 percent decrease in hospital admissions • Geisinger Health System • 20 percent reduction in all-cause hospital admissions • 7 percent total medical cost savings ($3.7 million) between intervention and control practices K. Grumbach, T. Bodenheimer, P.Grundy. 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. Available at: http://www.pcpcc.net/files/Grumbach_et-al_Evidence-of-Quality_%20101609_0.pdf; R. Reid, P. Fishman, O. Yu et al., Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care. 2009 Sep 1;15(9):e71-87.

9. Summary of Cost and Quality Outcomes from Patient-Centered Medical Home Interventions, cont’d • Colorado Medicaid and SCHIP • Median annual costs $215 less for children in PCMH practices due to reductions in ER visits and hospitalizations • Median annual costs $1,129 less for children with chronic diseases in a PCMH practice • Intermountain Healthcare • 10% relative reduction in total hospitalizations • Net reduction in total costs $640 per patient per year • $1,650 savings per year among highest risk patients • Guided Care PCMH Model • 24% reduction in total hospital inpatient days, 15% fewer ER visits • 37% decrease in skilled nursing facility days • Annual net Medicare savings of $1,364 per patient

10. Summary of Cost and Quality Outcomes from Medical Home Demonstrations with Low-Income Patients • Cost-savings • Colorado Medicaid/CHIP PCMH program showed median annual costs $215 less for children in PCMH practices due to reductions in ER visits and hospitalizations • Colorado Medicaid/CHIP PCMH program found median annual costs $1,129 less for children with chronic diseases in a PCMH practice • Community Care of North Carolina experienced savings of $535 million (over 8 years) to the Medicaid and SCHIP programs • Reductions ED use and hospitalizations • Community Care of North Carolina found 40% decrease in hospitalizations for asthma and 16% decrease in ER use • Genesee Health Plan (MMC product) found 50 percent decrease in ER visits and 15% decrease in inpatient hospitalizations for patients enrolled in medical home

11. Summary of Cost and Quality Outcomes from Medical Home Demonstrations with Low-Income Patients, cont’d • Clinic Patients in New Orleans • NoLA clinics patients are less likely to forgo care or report inefficiencies than national average of patients • NoLA clinic patients report better access to care than national average • Clinic patients with “excellent patient experience” report better access to care, better preventive care, and more support to manage chronic conditions

12. Commonwealth Fund National Initiative:Transforming Safety Net Clinics Into Patient-Centered Medical Homes Objective: • National demonstration to transform safety net clinics into patient-centered medical homes (PCMH) • To achieve benchmark performance in quality, patient experience and efficiency in safety net primary care practices Supporting 65 clinics in 5 regions: • Colorado, Idaho, Massachusetts, Oregon and Pennsylvania • Initiative led by Jonathan Sugarman, MD, MPH, President and CEO, Qualis Health and Ed Wagner, MD, MacColl Institute for Healthcare Innovation • Clinics started June/July 2009 • Implementation and technical assistance, 2009-2012 Evaluation led by Marshall Chin, MD, MPH, of the University of Chicago Funding: Commitment of $8.7 million over five years (including evaluation) Eight co-funding partners

13. Participants: Regional Organizations from Five States Supporting 65 Clinics • Regional Coordinating • Centers • Massachusetts League for Community Health Centers and Executive Office of Health and Human Services (MA) • Oregon Primary Care Association • Colorado Community Health Network • Idaho Primary Care Association • Pittsburgh Regional Health Initiative Five Regional Coordinating Centers (orange) were selected from 42 applicants (blue) to participate

14. Early Observations from Safety Net Initiative Data collection • Most participating clinics find it difficult to collect and submit data (clinical quality, needs assessments) at the site level and in a timely manner Leadership at the health center level is critical to adopt a culture of continuous innovation Priority “change concepts” — leadership, empanelment, team-based care Level of technical assistance support needed is fairly intense • Anticipate this will diminish over time The most effective “medical home facilitators” are those who 1) work(ed) in FQHCs, and 2) have the health centers’ trust

15. Thank You! Melinda Abrams Vice President, Patient-Centered Coordinated Care Anne-Marie Audet Vice President, Health Care Quality Improvement and Efficiency Georgette Lawlor Program Associate, Patient-Centered Coordinated Care Gabrielle Ritaccio Program Assistant, Health Care Quality Improvement and Efficiency Stephanie Mika Associate Policy Officer