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Service Delivery Innovation Profile

Multidisciplinary Team, Real-Time Information, and Incentives Help Medical Homes Improve Mental Health and Patient Experience, Reduce Utilization and Costs


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Snapshot

Summary

As part of a statewide, public-private initiative authorized by the Vermont legislature known as Blueprint for Health, the diverse Burlington health service area (1 of 13 such areas in the state) supports 18 patient-centered medical home practices via a multidisciplinary team that provides preventive, chronic disease, and mental health care as well as social service support to at-risk patients. Based within the practices and the community, team members provide services and make referrals to each other and to community resources as necessary. The program also provides participating practices with real-time electronic information to support the provision of appropriate care and pays them meaningful financial incentives based on their performance. The program has enhanced the appropriateness of care, improved mental health outcomes and the patient experience, and reduced inpatient and emergency department use and growth in health care spending. (For more information about Blueprint for Health, go to the related profile at http://innovations.ahrq.gov/content.aspx?id=3640).

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of inpatient and emergency department use among program participants, comparisons of inpatient and emergency department use and overall spending growth in two participating practices to a matched control group of similar patients in nonparticipating practices, pre- and post-implementation trends in depression and anxiety scores among patients referred to the program for behavioral health services, post-implementation comparisons of patient satisfaction with their care experience between participating and nonparticipating patients, and findings from focus groups conducted with providers in participating practices after program implementation.
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Developing Organizations

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

Use By Other Organizations

St. Johnsbury became the first Vermont health service area to launch Blueprint for Health on July 1, 2008; following the Burlington launch, a third health service area (Barre Hospital) launched it in January 2010.

Date First Implemented

2008
The Burlington health service area began pilot testing the program on October 1, 2008.begin ppxml

Patient Population

The program covers all patients of participating practices, regardless of payer.end 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. While 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
  • Unrealized potential of State-sponsored support: State governments are often well positioned to develop multifaceted programs to support community practices in providing these services, including working with other stakeholders to fund incentives and other support, such as community-based providers who serve multiple practices. Yet relatively few states provide such support.1

What They Did

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Description of the Innovative Activity

As part of Blueprint for Health, the Burlington health service area supports 18 patient-centered medical home practices via an insurer-funded multidisciplinary team that provides preventive, chronic disease, and mental health care as well as social service support to at-risk patients. Based within the practices and the community, team members provide services and make referrals to each other and to community resources as necessary. The program also provides participating practices with real-time electronic information to support the provision of appropriate care and pays them meaningful financial incentives based on performance. A brief overview of each major program element follows:
  • Identifying and referring at-risk patients: Physicians in participating practices generally identify at-risk patients who could benefit from the program during regular office visits. Fletcher Allen–employed providers send a referral via Fletcher Allen Health Care's electronic health record (EHR), and community-based providers send a fax to the program's main office (see below for more details about this office). Patients are assigned to an appropriate team member based on their needs and other information included in the referral. For example, a patient referred for assistance with healthy eating will be assigned to a health coach or registered dietitian (if the patient has an associated medical condition).
  • Insurer-funded multidisciplinary team spread across service locations: Partially funded by insurers, a multidisciplinary community health team helps referred patients overcome the many social, economic, and behavioral barriers to managing their health, including chronic disease(s). Led by a nurse, the 22-person team includes nurses, social workers, registered dietitians, and health coaches. Team members work full- or part-time at one or more practice- and community-based sites, allowing patients to meet with them at a convenient location, as outlined below.
    • Physician practices: Team members work out of 18 patient-centered medical home practices, interacting closely with physicians and other office staff and clinicians to identify and serve at-risk patients. Team members may work at a practice on a full- or part-time basis, depending on its size and patient population. Most meetings between patients and team members take place at these practice sites.
    • Main office: Known as the Community Health Improvement Office, this site is located in the community about a mile from the main hospital. It has several consultation and meeting rooms in which team members work with patients.
    • Hospital: The program also has a small office at the medical center where team members meet with patients.
    • Home: Some patients (e.g., those who are disabled or frail and elderly) receive periodic home visits from social workers as necessary.
  • Flexible service provision based on needs: The assigned team member meets with the patient to perform an intake evaluation that includes a standard medical assessment along with questions related to mental health and substance use (e.g., anxiety, depression, alcohol intake). As appropriate, the team member provides services to meet the patient's medical, psychological, and social needs, and/or refers the patient to other team members or community resources as necessary. Team members help patients set realistic, achievable goals using motivational interviewing. The typical patient has roughly four visits with team members before "graduating" (see below for more details), although the number of visits will vary based on needs. Key services offered by the team and other providers include the following:
    • Chronic disease education and management: Nurses provide chronic disease education and management related to type two diabetes, high cholesterol, hypertension, obesity, and medication management.
    • Nutrition counseling and education: Registered dietitians provide nutrition counseling and education related to pregnancy, lactation, childhood nutrition (for infants, young children, and adolescents), disease prevention, and healthy weight loss, as well as lifestyle counseling related to various chronic conditions.
    • Assessment and short-term management of mental health: Social workers provide support connecting clients to community resources as needed, as well as psychosocial and brief mental health assessments.
    • Health coaching: Using motivational interviewing and other techniques, health coaches offer guidance related to basic nutrition and lifestyles that promote good health, such as appropriate portion size, adequate levels of physical activity, and strategies for reducing blood pressure and cholesterol.
  • Referral to community resources: The team maintains relationships with multiple community health agencies and partners, with patients being referred as needed. Key partners are outlined below:
    • Mental health providers: Team members refer patients with complex psychosocial needs to the Howard Center (Fletcher Allen's community mental health agency) or to community-based behavioral and mental health providers.
    • Community resources: Team members refer patients to a variety of community resources, such as Community Health Improvement's own Health Assistance Program (HAP) to help people get insurance coverage and prescription drugs, the Vermont Chronic Care initiative (a Medicaid program that provides intense interventions to frequent users of health care services), the Agency on Aging, the Visiting Nurse Association, local home health agencies, and other local social service agencies.
    • Self-management programs: Patients can be referred to a fall prevention program, a peer-led mental health support group, and/or to self-management programs, such as Healthier Living workshops on general health, diabetes, and chronic pain.
    • Fitness programs: The program contracts with the local Y (formally known as the YMCA) to provide fitness evaluations and training, and offers free passes to patients who want to use YMCA facilities.
  • "Graduation" and followup: Patients graduate from the program when they have met or are well along the way to meeting the goals they and the team have identified. Within the first 6 months after graduating, patients receive a followup call from their designated team member, who evaluates the individual's progress and reassesses levels of anxiety, depression, and alcohol use. If necessary, patients can be invited to return to the program. The team member will also contact a patient's physician if he or she discovers through conversation or from information in the EHR that the patient's health indicators are trending in the wrong direction (e.g., a diabetes patient with increasing levels of blood glucose).
  • Provider support and incentives: The program supports the patient-centered medical home practices in several other ways and provides financial incentives to encourage strong performance, as outlined below:
    • Regular meetings between team and physicians: The team meets with providers at participating practices each month to discuss general program issues and relevant issues related to patients currently in the program and those being considered for it. As needed between meetings, team members discuss issues related to existing participants with practice staff.
    • Health IT-facilitated patient monitoring: The team uses a database to facilitate ongoing monitoring of patients, and team members copy providers on any patient notes they add to the record. 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. The community health team uses the registry to evaluate trends in population health and identify gaps in care.
    • Significant, all-payer financial incentives: Blueprint for Health provides participating practices with significant payer-funded monthly payments for improving performance on standards incorporated within the National Committee for Quality Assurance Patient-Centered Medical Home™(NCQA-PCMH™) program. Participating practices receive an enhanced per-person per-month (PPPM) payment based on performance, with reimbursement rates raised or lowered based on incremental changes in 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 practice-based incentive payments based roughly on the number of members seen by participating practices. The Vermont Medicaid program also pays the incentives for its beneficiaries, while the state (through the Department of Vermont Health Access) pays them for Medicare patients, making the program an all-payer initiative.

Context of the Innovation

One of 13 such areas in Vermont, the Burlington health service area covers urban and rural communities that are home to about 150,000 people, nearly a quarter of the state's population. Designated a Federal refugee resettlement center, the service area has an ethnically and socioeconomically diverse population that includes many low-income, multigenerational families experiencing chronic health conditions. A 362-bed medical center affiliated with the University of Vermont, Fletcher Allen Health Care serves as the community hospital for most Burlington service area residents and as a regional referral center to approximately one million people throughout Vermont and northern New York. Fletcher Allen owns 10 of the 35 primary care clinics and most specialty clinics in the area.

The impetus for this program came from Fletcher Allen's Director of Community Health Improvement (Ms. Penrose Jackson), who became interested in Blueprint for Health after hearing about its pilot programs in diabetes care. (See the related profile at http://innovations.ahrq.gov/content.aspx?id=3640 for more information on Blueprint for Health.) Believing that, as Vermont's only academic medical center, Fletcher Allen should engage in the initiative, Jackson encouraged hospital leaders to apply for a planning grant from the State Department of Health.

Did It Work?

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Results

The program has enhanced the appropriateness of care, improved mental health outcomes and the patient experience, and reduced inpatient and emergency department (ED) use and growth in health care spending.3,4

  • More appropriate care and services: In a Blueprint for Health study that includes the Burlington health service area (and others), participating practices reported that the program had a positive impact on the management and provision of care. Cited benefits included 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 indicated that patients with chronic conditions previously seen only once a year are now seen up to four times a year. Physicians reported being better able to respond to the full range of 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.3,4
  • Better mental health: An analysis of patients referred to the program for behavioral health services from Fletcher Allen Health Care found that three-quarters of those with moderate to severe depression scores and 70 percent of those with moderate to severe anxiety scores at baseline experienced significant improvements (to levels suggesting mild or clinically insignificant depression or anxiety) after 6 months in the program.
  • Better patient care experience: Surveys of patients at Fletcher Allen Health Care found that a higher proportion of participants rated 11 measures of their care experience as a "5" (the top rating on a 5-point Likert scale) than did nonparticipants. These measures covered various aspects of care, including provider support, achievement of goals, access to counseling, and medication management.
  • Less inpatient and ED utilization: The program has reduced inpatient and ED utilization, as outlined below:
    • Burlington site analysis: A review of 1,090 participating patients found that inpatient admissions fell by 13 percent and ED visits by 37.4 percent between October 2006 (before implementation in 2008) and April 2012.
    • Blueprint for Health Analysis: A 4-year analysis that includes Burlington and other Blueprint for Health service areas found that the annual rate of inpatient admissions fell by 6 percent (from 43.4 to 40.8 visits per 1,000 members) in 2 participating practices, compared to only a 1-percent decline in 2 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.3,4
  • Slower growth in spending: The 4-year analysis cited above found that 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 versus 50 percent), outpatient spending (32 versus 39 percent), ED spending (50 versus 56 percent), and total expenditures for patients with at least 1 chronic condition (21 versus 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.3,4 Program leaders are currently working with a medical economist to evaluate more formally the program's impact of utilization and costs.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of inpatient and emergency department use among program participants, comparisons of inpatient and emergency department use and overall spending growth in two participating practices to a matched control group of similar patients in nonparticipating practices, pre- and post-implementation trends in depression and anxiety scores among patients referred to the program for behavioral health services, post-implementation comparisons of patient satisfaction with their care experience between participating and nonparticipating patients, and findings from focus groups conducted with providers in participating practices after program implementation.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Planning initiative: After receiving the aforementioned planning grant, Fletcher Allen executives worked for roughly a year to develop an implementation plan for Blueprint for Health in the Burlington service area. Topics evaluated during this phase included determining health IT and interconnectivity requirements, activating and engaging the community, promoting better patient self-management, and improving the systems at participating practices.
  • Securing implementation grant: Fletcher Allen executives applied for and received a 1-year implementation grant from the state, became a Blueprint for Health pilot site, and began designing the multidisciplinary community health team to serve multiple practices.
  • Introducing program to physicians: Program developers visited each practice to describe the Blueprint for Health program and community health team.
  • Becoming NCQA-certified medical homes: Burlington area practices began working toward NCQA medical home certification; as of July 2012, 18 primary care, pediatric, and family medicine clinics have received this designation.
  • Pilot testing at two practices: Fletcher Allen leaders chose two practices to test the community health team concept: a primary care/internal medicine practice owned by the hospital with approximately 12 full-time–equivalent physicians and mid-level providers, and a community-based practice run by a sole practitioner. Gradually over time, the program expanded to serve additional sites.
  • Staffing program: Program developers asked the pilot sites for feedback on the appropriate staffing mix for the community health team and identified and hired qualified staff to serve on it. Over time, the program has continued to grow organically in response to increases in patient volume, changing physician and patient needs, team referral patterns, and the need to balance team member expertise at each site.
  • Making program permanent: In 2010, the Vermont legislature passed Act 128, which called for the 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 Burlington pilot program would continue as a permanent program.

Resources Used and Skills Needed

  • Staffing: The 22-person team includes a registered nurse (RN) who serves as team manager, 3 other RNs (one of whom serves as nurse supervisor), 4 social workers (also including a supervisor), 4 registered dietitians (also including a supervisor), 4 health coaches, a case coordinator, a pediatric care coordinator, an administrative supervisor, and 3 administrative assistants.
  • Costs: Program costs total roughly $1.7 million per year, consisting mostly of staff salaries and benefits.
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Funding Sources

Department of Vermont Health Access; Fletcher Allen Health Care
Funding sources include the Department of Vermont Health Access, Fletcher Allen Health Care, Medicaid, Medicare, and the three largest commercial insurers in the state. 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 (including Vermont Medicaid and Medicare through a demonstration project grant) fund the community health team, and insurers and the State Medicaid program pay the financial incentives to participating practices based on formulas that take into account the number of enrollees seen by the practices. Fletcher Allen Health Care provides financial support for the program through the provision of labor and overhead, IT support, legal review services, and other assistance.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

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Getting Started with This Innovation

  • Identify and engage leaders at community and site level: Although State legislation is not a prerequisite to this type of program, strong leadership must exist at the community level to ensure program adoption and at the practice level to provide the vision and secure the commitment and resources needed to undertake this type of transformation in care delivery.
  • Introduce team concept early: Begin discussions with physicians early in the development process to give them time to acclimate to the idea of referring patients to a community health team.
  • Consider need to introduce program to practices separately: Medical practices in the Burlington service area tend to be fiercely independent, with clinicians often being reluctant to share information and opinions with colleagues. Consequently, program leaders introduced the community health team concept during individual site visits to the practices. This approach served to enhance clinician comfort with the idea of sharing feedback with and requesting services from team members.
  • Be flexible in addressing physician concerns: During upfront discussions about the program, physicians may offer feedback unrelated to the community health team (e.g., about problems with hospital-based services). Program developers should remain open to such feedback and try to address any issues raised. This approach helps to build strong, trust-based relationships with the physicians.
  • Hire experienced individuals familiar to program developers: The initial team should consist of experienced individuals who are familiar to program developers, either through their work at a local health system or in the community. Team members should have a track record of supporting collaborative, community-based care; understand the mission of the program; and be positive, flexible, and creative.
  • Educate physicians about appropriate referrals: Initially, physicians may refer only those patients with long-standing, complex medical and social needs. Over time, team members can discuss with physicians other patients who may benefit from the program and can provide specific examples of patients who are and are not appropriate. For example, physicians should be encouraged to refer patients who seem ready to make lifestyle changes.

Sustaining This Innovation

  • Be flexible with staffing: It may take up to 5 years to figure out how many and what type of staff can best serve a particular population. Consequently, program developers should remain open to changing staffing levels and mix until the program reaches a steady state.
  • Ensure proper reimbursement: Adequate reimbursement for medical home activities is critical to sustaining this type of initiative. For example, 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.
  • Evaluate program economics: Over time, program leaders will better understand the economics of the program. In states without a legislative mandate, a formal evaluation of the program's impact on cost and quality can help to determine the wisdom of sustaining it over time.
  • Be patient: Initially, physicians may be skeptical about the value of the community health team. Over time, however, the team's work with patients should lead to better quality and lower costs, something that physicians will recognize. In fact, experience suggests that many physicians come to depend on the support they receive from community health team.

Use By Other Organizations

St. Johnsbury became the first Vermont health service area to launch Blueprint for Health on July 1, 2008; following the Burlington launch, a third health service area (Barre Hospital) launched it in January 2010.

More Information

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Contact the Innovator

Penrose Jackson
Director, Community Health Improvement
Fletcher Allen Health Care 324SA1
128 Lakeside Avenue, Suite 106
Burlington, VT 05401
(802) 847-2278
E-mail: penrose.jackson@vtmednet.org

Innovator Disclosures

Ms. Jackson reported having no financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

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

Onpoint Health Data. Vermont Blueprint Evaluation: A Four-Year Overview Based on Two-Year Cohorts with Matched Controls, January 2012. Available at: http://dvha.vermont.gov/advisory-boards
/t0064-vermont-blueprint-evaluation-a-four-year-overview-based-on-two-year-cohorts-with-matched-controls-pp-presentation.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Bielaszka-DuVernay C. Vermont’s Blueprint for medical homes, community health teams, and better health at lower cost. Health Aff (Millwood). March 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.

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):10-7. [PubMed]
2 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001.
3 Bielaszka-DuVernay C. Vermont’s Blueprint for medical homes, community health teams, and better health at lower cost. Health Aff (Millwood). March 2011;30(3):383-6. [PubMed]
4 Onpoint Health Data. Blueprint Evaluation: A Four-Year Overview Based on Two-Year Cohorts with Matched Controls, January 2012. Available at: http://dvha.vermont.gov/advisory-boards
/t0064-vermont-blueprint-evaluation-a-four-year-overview-based-on-two-year-cohorts-with-matched-controls-pp-presentation.pdf
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Original publication: December 05, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 18, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.