Skip Navigation
Service Delivery Innovation Profile

Community- and Practice-Based Teams, Real-Time Information, and Financial Incentives Help Medical Homes Improve Care, Reduce Utilization and Costs


Tab for The Profile
Comments
(0)
   

Snapshot

Summary

As part of Blueprint for Health (a statewide, public-private initiative authorized by the Vermont legislature), the largely rural St. Johnsbury health service area supports its six patient-centered medical home practices via a multidisciplinary team that provides preventive, chronic disease, and mental health care as well as social service support. Team members are based within practices and in the community. The program also provides real-time electronic information to support the provision of appropriate care and offers significant financial incentives that reward practices for becoming recognized as a National Committee for Quality Assurance Patient-Centered Medical Home™. The program has improved the provision of appropriate care and services and reduced utilization and growth in health care spending. (For more information about Blueprint for Health, go to the related profile.)

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of comparisons of trends in utilization and spending on various health services over a 4-year period between patients at two pilot sites and a matched control group of patients at nonparticipating practices. Other evidence includes findings from focus groups conducted with providers in participating practices after implementation.
begin doxml

Developing Organizations

Department of Vermont Health Access
The Department of Vermont Health Access operates the program. State law requires insurers to fund the financial incentives and community health teams. Northeastern Vermont Regional Hospital serves as the health service area’s administrative entity for Blueprint for Health.end do

Date First Implemented

2008
The St. Johnsbury, VT, health service area began testing the program on July 1, 2008.begin ppxml

Patient Population

The program covers all patients of participating physician practices, regardless of payer.Vulnerable Populations > Rural populationsend pp

Problem Addressed

Physician practices typically lack the multidisciplinary resources, health information technology (IT), and incentives to provide high-quality preventive and chronic care services on a consistent basis. These challenges are particularly acute in rural areas, which face additional problems such as provider shortages and sicker and aging populations. Although state governments are often well-positioned to encourage and support community practices, relatively few do so.
  • Lack of resources: Ensuring the provision of effective preventive and chronic care services often requires the assistance of social workers, behavioral health specialists, home health services, and other community-based support typically not available within a physician practice.
  • Inadequate health IT: The United States lags behind other nations in the adoption of health IT,1 particularly in physician offices. The leaders of many practices, especially smaller ones, often believe they cannot afford such technology. Although the Federal government and some State governments have begun offering financial incentives, adoption remains low.
  • Few financial incentives: The current fee-for-service (FFS) payment system creates a strong incentive for physicians to maximize the volume of patients seen, often leaving inadequate time to address preventive and chronic care needs during the short time allotted for a visit. The Institute of Medicine has identified payment reform as a critical strategy for improving the quality of the nation's health care system.2
  • Additional challenges in rural settings: The aforementioned problems become particularly acute in rural settings, which face additional challenges related to health and heath delivery. For example, workforce shortages are widespread, with nearly 82 percent of rural counties classified as medically underserved areas. In addition, approximately 15 percent of rural residents are 65 or older, compared with about 12 percent in the nation as a whole. Rural residents are also more likely than their urban counterparts to have chronic diseases such as arthritis, asthma, heart disease, diabetes, obesity, hypertension, and mental disorders.3
  • Unrealized potential of state-sponsored support: State governments are often well-positioned to develop multifaceted programs to support community practices in providing such services, including working with other stakeholders to fund incentives and other support, such as community-based providers who can serve multiple practices. Yet relatively few states provide such support.1

What They Did

Back to Top

Description of the Innovative Activity

As part of Blueprint for Health, the largely rural St. Johnsbury health service area supports its six patient-centered medical home practices via a multidisciplinary team that provides preventive, chronic disease, and mental health care as well as social service support. Team members are based within practices and in the community. The program also provides real-time electronic information to support the provision of appropriate care and offers significant financial incentives that reward practices for becoming recognized as a National Committee for Quality Assurance Patient-Centered Medical Home™(NCQA-PCMH™). A brief overview of each major element of the St. Johnsbury program follows:
  • Multidisciplinary community health team: A multidisciplinary community health team (funded partially by insurers) identifies at-risk patients and helps them overcome the many social, economic, and behavioral barriers to managing their health, including chronic disease(s). Team members provide needed services or refer patients to existing resources within the practice and/or community.
    • Practice-based team: Overseen by a team coordinator, full- and part-time care coordinators and behavioral health specialists within the practices work with patients to develop a plan for self-managing their condition(s) and follow up with patients on a regular basis to track progress and assist with any problems, as outlined below:
      • Care coordinators: Four care coordinators (three of whom are nurses) work onsite at six primary care practices. They collaborate with physicians and other clinicians to coordinate care for patients who have or are at risk for chronic conditions. Care coordinators perform the following activities: counsel patients on self-management goals; provide care management for complex patients; educate patients about appropriate care settings; track and follow up with patients about overdue appointments and diagnostic tests; follow up with patients after discharge from the hospital or emergency department (ED); perform medication reconciliation; follow up with patients and pharmacies to ensure adherence to medication regimens; and track referrals to specialists and for diagnostic testing and health education.
      • Behavioral health specialists: Three behavioral health specialists work onsite at the practices to identify patient needs, evaluate medication therapy, provide short-term counseling services (three to eight sessions), and refer patients to community-based mental health clinicians for longer therapy when necessary.
    • Community-based team: This team includes community health workers and a care coordinator based in a senior housing community. Their roles are outlined below:
      • Community health workers: Through Community Connections (an established program of hospital-employed workers located in a community office), three community health workers help clients and their families navigate social services by identifying their needs (e.g., determining if clients need help securing insurance coverage or finding a primary care physician), connecting them to needed services (e.g., food, transportation, utilities), and assisting in scheduling appointments. One worker with a background in health coaching supports clients with chronic conditions; in addition to arranging social services, she reinforces physician treatment plans and supports patients' self-management goals, identifies opportunities for increased physical activity, coaches patients on stress reduction techniques, promotes medication adherence, makes home visits, and/or accompanies patients to appointments as necessary.
      • Care coordinator in senior housing community: A care coordinator works onsite at a senior housing community, assisting residents with negotiating health and social services that help them to live and age safely in the community. The coordinator provides inperson health and social needs assessments, motivational coaching, and daily visits to high-risk residents.
    • Identification and referrals across teams: Any team member can identify at-risk patients and make appropriate referrals to other team members for needed medical and social services. For example, during a medical visit, a care coordinator may refer a patient with social service needs to a community health worker. Alternatively, community health workers may refer a client with health issues to one of the local practice-based teams. Any team member can refer to community services, such as home health organizations, tobacco cessation classes, Healthier Living Workshops (a Blueprint for Health–funded program based on the Stanford Chronic Disease Self-Management Program), the Growing Stronger Program (an Area Agency on Aging–sponsored weight training program for individuals over age 40), fall prevention programs, the state Medicaid program, Legal Aid, domestic violence organizations, and others.
  • Real-time electronic health information: All six practices use (different) electronic medical record (EMR) systems to track patient care. They also have access to a hospital information system (linked with each practice’s EMR) that allows staff to view up-to-date information on patients receiving inpatient and diagnostic care at the hospital. Practices also have access to a Blueprint for Health Web-based clinical tracking system and registry (known as DocSite) that supports the provision of age- and gender-appropriate, guideline-based care for preventive, health maintenance, and chronic disease care.
  • Significant, all-payer financial incentives: Blueprint for Health provides the six medical homes with significant payer-funded bonuses for improving performance on standards incorporated within the NCQA-PCMH™ program. Participating practices receive an enhanced per-person per-month (PPPM) payment based on their performance, with reimbursement rates raised or lowered based on incremental changes in the scores. For example, a practice that scores 50 overall would receive an additional $1.60 PPPM, which translates into $23,040 a year for a physician with an active caseload of 1,200 patients. A score of 75 would yield $2.00 PPPM, equivalent to $28,800 for this physician each year. State law requires private insurers to fund these incentive payments based roughly on the number of members seen by participating practices. The Vermont Medicaid program also pays the incentives for its beneficiaries. For the Blueprint pilot (2008 to 2010) the state paid for Medicare patients. Now that Vermont is also a Medicare Advanced Primary Care Practice pilot, Medicare pays the enhanced payment.

Context of the Innovation

The St. Johnsbury health service area is one of 13 health service areas in Vermont. This largely rural area includes approximately 30,000 residents, roughly 40 percent of whom are covered by Medicare and 20 percent by Medicaid. Like elsewhere in the state, many health service area residents have one or more chronic diseases, including diabetes (7 percent of residents), asthma (13 percent), and hypertension (26 percent). The health service area is served by the 25-bed Northeastern Vermont Regional Hospital (a critical access hospital that handles roughly 1,400 admissions and 16,000 ED visits annually) and six NCQA-PCMHs™ (five adult practices and one pediatric practice).

Beginning in 2001, the St. Johnsbury health service area began participating in several statewide collaboratives, including one focused on the chronic care model and another on clinical microsystems for diabetes care. Primary care practices began making system changes to better coordinate care as part of these initiatives. Due to these and other activities, the St. Johnsbury health service area was chosen by the Vermont Department of Health as one of two sites to pilot the Blueprint for Health initiative, a statewide, public private initiative authorized by the Vermont legislature. For more information about Blueprint for Health, see the related profile. In addition to participating in Blueprint for Health, the St. Johnsbury health service area participates in several other initiatives that support the provision of care in medical homes, including a pilot program with the University of Vermont in which hospital pharmacists work onsite at one of the medical homes, and a 30-month Centers for Disease Control and Prevention project evaluating the impact of community health teams on clinical outcomes.

Did It Work?

Back to Top

Results

The program has improved the provision of appropriate care and services4 and reduced utilization and growth in health care spending.5
  • More appropriate care and services: Participating practices report that the program has had a positive impact on the management and provision of care, increasing the number of at-risk patients identified and assessed, improving teamwork across the community, and enhancing access to needed support services. For example, focus groups with participating practices indicate that patients with chronic conditions previously seen only once a year are now seen up to four times a year. Physicians report being better able to respond to the full range of their patients’ clinical and nonclinical needs thanks to the support of the community health team. In particular, they highlighted the program’s positive impact on access to mental health services, as patients can now receive services onsite from a behavioral health specialist.4
  • Lower utilization and expenditure growth: A comparison over a 4-year period (2007 to 2010) between patients at two pilot sites and a matched control group of similar patients at nonparticipating practices found that participants had greater reductions and/or smaller increases in health care utilization and expenditures,4 as outlined below:
    • Greater decline in admissions and ED visits: The annual rate of inpatient admissions decreased by 6 percent (from 43.4 to 40.8 visits per 1,000 members) in participating practices, compared with only a 1-percent decline in nonparticipating practices. The annual rate of ED visits fell slightly (from 161.8 to 160.7 per 1,000 members) at participating practices, while the rate at nonparticipating practices increased by 10 percent.
    • Lower growth in spending: Total annual expenditures per capita increased by 22 percent in participating practices, slightly below the 25-percent increase in nonparticipants. This pattern held true for inpatient expenditures (41 vs. 50 percent), outpatient spending (32 vs. 39 percent), ED spending (50 vs. 56 percent), and total expenditures for patients with at least one chronic condition (21 vs. 29 percent). Once statewide expansion of the program has been completed, Vermont public health officials estimate that it will reduce the predicted increase in total health spending by 37.4 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of comparisons of trends in utilization and spending on various health services over a 4-year period between patients at two pilot sites and a matched control group of patients at nonparticipating practices. Other evidence includes findings from focus groups conducted with providers in participating practices after implementation.

How They Did It

Back to Top

Planning and Development Process

Key steps included the following:
  • Becoming medical homes: All six primary care practices in the St. Johnsbury health service area completed the NCQA process to become designated as certified patient-centered medical homes.
  • Hiring new staff: The health service area hired two additional community health workers for the Community Connections program and four new staff (care coordinators and behavioral health specialists) to work onsite at the medical homes.
  • Adjusting hospital information system: IT staff modified the hospital information system to allow community-based providers to add information about patients using the departmental order entry component of the system.
  • Developing care coordinator job description: Physicians in the different medical homes created a job description for the care coordinator position based on what would be most helpful to the practices and their patients.
  • Informally introducing program: Given that the health service area was already involved in care coordination and other process improvement activities, introduction of the Blueprint for Health program was somewhat informal, with the initiative positioned as a continuation of existing activities.
  • Making program permanent: In 2010, the Vermont legislature passed Act 128, which called for expansion of Blueprint for Health to all willing providers in Vermont by October 2013. The same legislation required expansion to at least two patient-centered medical home practices in each service area by July 2011, and mandated that any insurer doing business in Vermont provide enhanced reimbursement to the medical homes. In effect, this legislation confirmed that the St. Johnsbury initiative would continue as a permanent program.

Resources Used and Skills Needed

  • Staffing: Staffing includes 12 full-time equivalent staff, including a chronic care team coordinator with oversight responsibilities, 4 care coordinators, 3 behavioral health specialists, 3 community health workers (one of whom focuses on patients with chronic conditions), and a senior housing care coordinator.
  • Costs: Program costs total roughly $700,000 per year, consisting mostly of staff salaries and benefits. Expenses associated with office supplies, training, travel, and patient education run approximately $7,500 a year.
begin fsxml

Funding Sources

Department of Vermont Health Access
The Department of Vermont Health Access funds Blueprint for Health, including the financial incentives for Medicare patients at participating practices and the creation of health IT interfaces between participating practices and the registry. As noted, insurers and the State Medicaid program pay financial incentives to participating practices based on formulas that take into account the number of their enrollees seen by the practices. Northeastern Vermont Regional Hospital and Blueprint for Health (through insurer contributions) each fund about half the cost of St. Johnsbury’s program.end fs

Tools and Other Resources

More information about the Department of Vermont Health Access is available at: http://dvha.vermont.gov/.

More information about Blueprint for Health, including additional details about the major elements of the program described earlier, is available at: http://hcr.vermont.gov/blueprint.

The aforementioned NCQA-PCMH™ program standards cover the following six areas: enhance access and continuity, identify and manage patient populations, plan and manage care, provide self-care support and community resources, track and coordinate care, and measure and improve performance. Multiple measures exist within each area, and more information can be found at: http://www.ncqa.org/tabid/631/Default.aspx.

Adoption Considerations

Back to Top

Getting Started with This Innovation

  • Identify and engage leaders at community and site level: Although State legislation is not a prerequisite to implementing this type of program, strong leadership at the community level must exist to ensure that the program is adopted. Strong leadership also must exist at the practice level to provide the vision and secure the commitment and resources needed to undertake this type of transformation in care delivery.
  • Think beyond practice to community: Program success will be enhanced if the scope extends beyond the individual physician practice, as there are limits to what a practice can do on its own to improve care. Support is also needed from community-based resources, including social workers, mental health specialists, and other support services.
  • Think comprehensively: Focusing on only one aspect of the problem will be less effective than taking a more comprehensive approach. For example, a program to help practices build better IT systems will not be successful if clinicians do not have the time or incentive to use them. Paying practices additional money will not improve care without a concomitant commitment to providing required support services. Effective programs should encompass financial, clinical, and public health issues.
  • Leverage experience with process improvement: Training and/or experience in process improvement, clinical microsystems, and other quality improvement methods can be important in supporting the development of medical homes and a team-based approach to care.
  • Build on existing resources: Build on the community- and practice-based staff and IT systems already in place.

Sustaining This Innovation

  • Maintain local ownership: Although the statewide Blueprint for Health program gained consensus on the overall model, local St. Johnsbury stakeholders maintained ownership over design and implementation at the local level. For example, St. Johnsbury stakeholders decided on the appropriate composition and activities of the community health teams based on unique characteristics of the community. A top-down, one-size-fits all approach would not only have alienated local stakeholders, but also would have proven inefficient and ineffective given the specific work processes and resources that already existed in the community.
  • Ensure proper reimbursement: Adequate reimbursement for medical home activities is critical to sustaining this type of initiative. Practices should be reimbursed for the time it takes to coordinate care. Blueprint for Health has succeeded in large part because all payers are legally required to reimburse providers for care coordination.
  • Emphasize quality and efficiency: Physicians and other providers will continue to support the program if they recognize its value in improving care for patients and enhancing their own efficiency. In particular, physicians often come to depend on the support they receive from the professionals to whom they refer patients. To help providers recognize the program's value, regularly share data that documents the program's impact on quality, costs, and efficiency.

Spreading This Innovation

A second Vermont health service area (Burlington Hospital’s service area) launched the program on October 1, 2008 and a third (Barre Hospital’s service area) launched it in January 2010 as part of the initial pilot project. Blueprint for Health now serves more than half the state’s residents in 13 health service areas.

More Information

Back to Top

Contact the Innovator

Laural Ruggles, MBA
VP Marketing and Community Health Improvement
Northeastern Vermont Regional Hospital
PO Box 905
St. Johnsbury, VT 05819
(802) 748-7590
E-mail: l.ruggles@nvrh.org

Innovator Disclosures

Ms. Ruggles reported having no financial interests or business/professional affiliations relevant to the work described in this profile other than the funders listed in the Funding Sources section.

References/Related Articles

State of Vermont. Department of Vermont Health Access. Vermont Blueprint for Health 2011 Annual Report. January 2012.

Onpoint Health Data. Blueprint Evaluation: A Four-Year Overview Based on Two-Year Cohorts with Matched Controls. January 2012.

Bielaszka-DuVernay C. Vermont’s Blueprint for medical homes, community health teams, and better health at lower cost. Health Aff (Millwood). 2011;30(3):383-386. [PubMed]

Vermont's Health Care Reform. Vermont Blueprint for Health. Powerful Tools. 2010 Annual Report. January 2011. Available at: http://hcr.vermont.gov/sites/hcr/files/final_annual_report_01_26_11.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)

Footnotes

1 Balfour DC 3rd, Evans S, Januska J, et al. Health information technology—results from a roundtable discussion. J Manag Care Pharm. 2009;15(1 Suppl A):S10-S17. [PubMed]
2 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
3 Bailey JM. The Top 10 Rural Issues for Health Care Reform. Center for Rural Affairs. March 2009. Available at http://files.cfra.org/pdf/Ten-Rural-Issues-for-Health-Care-Reform.pdf.
4 Bielaszka-DuVernay C. Vermont’s Blueprint for medical homes, community health teams, and better health at lower cost. Health Aff (Millwood). 2011;30(3):383-386. [PubMed]
5 Onpoint Health Data. Blueprint Evaluation: A Four-Year Overview Based on Two-Year Cohorts with Matched Controls. January 2012.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: February 17, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 28, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.