Community Health Teams The Vermont Experience

1. Department of Vermont Health Access Community Health TeamsThe Vermont Experience Lisa Dulsky Watkins, MD Associate Director Vermont Blueprint for Health lisa.watkins@state.vt.us October 21, 2103

2. Department of Vermont Health Access Principles of Team-Based Care • Shared Goals • Clear Roles • Mutual Trust • Effective Communication • Measureable Processes and Outcomes • Mitchell et al, Core Principles & values of effective team-based health care, 2012 (Discussion Paper, Institute of Medicine, Washington, DC. www.iom.edu October 21, 2103 2 2 2 2

3. Department of Vermont Health Access Team-Based Care “Team-based health care is the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers – to the extent preferred by each patient – to accomplish shared goals within and across settings to achieve coordinated, high-quality care.” Naylor et al, Inter-professional team-based primary care for chronically ill adults: State of the Science, 2010 October 21, 2103

4. Department of Vermont Health Access • Vermont’s Executive Branch and Legislature • Consistent Support for Health Reform • 2003Blueprint launched as Governor’s initiative • 2005Implementation of Wagner’s Chronic Care Model • 2005 Medicaid Global Commitment (Section 1115) Waiver • 2006Blueprint codified as part of sweeping reform legislation (Act 191) • 2007 Blueprint leadership and pilots established (Act 71) • 2008 Community Health Team structure and insurer mandate (Act 204) • 2010 Statewide Blueprint Expansion outlined (Act 128) • Planning for “Single Payer” (Act 48) October 21, 2103

5. Blueprint Payment Reforms • Medicaid • Commercial Insurers • Medicare Payments to Practices 1) FFS 2) PBPM Enhanced Payments Insurers • Community Health Teams • Funded by all insurers • Intent is to minimize • barriers • SASH Teams • Funded by Medicare • (CMMI Demonstration • Project) • Addictions Teams • Funded by Medicaid • Health Home (potential • 90/10 federal match) • $35,000/2000 active pts./yr. • Scaled based on population • $70,000/100 participants/yr. • Scaled based on # panels • 2 FTEs/100 suboxone pts. • Scaled based on # pts. in • prescribing practices October 21, 2103

6. Health Service Area Architecture • 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 Visiting Nurse/Home Health Agency HVVo Hospitals Primary Care Practice Specialty Care & Disease Management Programs Core Community Health Team Nurse Coordinators Social Workers Nutrition Specialists Community Health Workers Public Health Specialists Extended Community Health Team Medicaid Care Coordinators Medicare Teams based in Housing Hubs Addiction Teams Primary Care Practice Social, Economic, & Community Services Primary Care Practice Mental Health & Substance Abuse Programs Primary Care Practice Self Management Workshops Public Health Programs & Services Multi-Insurer Payment Reform Framework Health IT Framework Evaluation Framework October 21, 2103

7. TIMELINEPatient Centered Medical Homes and Community Health Team Staffing in Vermont # of Patients # of CHT FTEs and Practices October 21, 2103

8. Vermont Health Information Technology Infrastructure Organization- owned Primary Care Practices Senior Support Services Hosted EMR Tobacco Cessation Counselors Core data elements Independent Primary Care Practices Vermont Health Information Exchange (VITL) Central Clinical Registry and Integrated Health Record (Covisint DocSite) Core data elements Core data elements EMR Core data elements Primary Care Practices No EMR Community Health Team October 21, 2103

9. CHT Identification of High-Risk Patients • Practice panel management, outreach and referrals • Referrals from other health care and community service • organizations • Risk stratification and utilization data from Medicare • Risk stratification and utilization data from Medicaid • Data from commercial insurers October 21, 2103 9 9

10. CHT Example • Providers refer via the EHR (PRISM). • CHT provides in person 1:1 support, in groups or by phone, 3-6 visits, commonly 4 interactions. • CHT helps patients set realistic goals and timelines utilizing motivational interviewing, action planning and short term goal setting • CHT focuses on achievable realistic outcomes with our patients, addressing barriers that may interfere with success. • Short term case management, most often provided by our medical social worker. • CHT patients can re-engage with the team as necessary after graduation Services include: • Health coaching around nutrition, exercise and stress management • Basic Diabetes Education • Medication Management • Behavioral/Mental Health • Connection to community and financial resources 10

11. CHT Example October 21, 2103 11 11

12. CHT Example October 21, 2103 12 12

13. CHT Example • Clinical Outcomes • Patients were tracked by the multidisciplinary CHT using a common database andassessed 6 months after “graduation” (data collected between March 2009 and August 2012) • 59% of patients referred to the CHT for diabetes-related issues had sustained improvement in BMI (n =44) and 67% of patients had sustained improvement in HbA1c (n=87) • 49% (n=118) of patients referred to the CHT for exercise and nutrition issues had a sustained improvement in their BMI and 31.5% (n=117) had a sustained improvement in their LDL (average decrease of 24mg/dL) October 21, 2103 13 13

14. CHT Challenges • Documentation • Consistency • Double data entry • Reporting to funders (“ROI”) • Communication • Patient/consumer engagement • General public awareness October 21, 2103 14 14