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Reshaping Healthcare Delivery in Vermont

June 7, 2011
by Jennifer Prestigiacomo
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Using the patient-centered medical home model to enact clinical and payment reform

In May 2006, Vermont's state legislature passed the Health Care Affordability Act, which refocused the state’s Blueprint for Health program on prevention and management of chronic conditions through helping primary care providers operate their practices as patient-centered medical homes. Over time the initiative switched from being focused solely on chronic care to tackling full delivery system reform. The Blueprint initiative was rolled out in several pilot sites, and in 2008 Blueprint started its first pilot communities: St.

In May 2006, Vermont's state legislature passed the Health Care Affordability Act, which refocused the state’s Blueprint for Health program on prevention and management of chronic conditions through helping primary care providers operate their practices as patient-centered medical homes. Over time the initiative switched from being focused solely on chronic care to tackling full delivery system reform. The Blueprint initiative was rolled out in several pilot sites, and in 2008 Blueprint started its first pilot communities: St. Johnsbury (July 2008), Burlington (October 2008), with later expansion to Central Vermont (January 2010) and the Bennington area (November 2010).

All these sites include a mix of hospital-affiliated practices, independent practices, and federally qualified health centers. In addition to employing a Web system (from the Detroit-based Covisint DocSite, built on Microsoft .NET technology) that combines a portal, health exchange, analytics, data warehouse, and electronic health record for patient data collection and interpretation, the infrastructure employs community care teams to aid in patient management. These teams work across practices, offering decision support, integrated care plans, and performance reporting and health information exchange interoperability.

In the following years, Vermont passed legislation requiring insurers to participate in payment reforms. In November 2010, Vermont was chosen by the Centers for Medicare & Medicaid Services (CMS) as one of eight states to participate in the three-year Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Project. Statewide expansion has been quickly accelerating in the first half of this year. HCI Associate Editor Jennifer Prestigiacomo spoke with Craig Jones, director, Vermont Blueprint for Health about the challenges surrounding this statewide healthcare delivery reform. Here are excerpts from that conversation.

How are these community care teams created?

In each health service area in the state, the leaders from the practices and other non medical services, like social services and economic services, organize in an integrated health services workgroup. In the planning stages they look at what are the support services we have in the community and what we need. They determine to some degree the mix of nurse coordinators, social workers, and licensed counselors they need. That begins the set-up of the community health team. Then the practices get scored from a University of Vermont-based team against national NCQA [National Committee for Quality Assurance] medical home standards. Once that scoring is complete and they have that initial health team planning completed, then the payment reforms start, and they’re able to hire the community health team members and begin actual operations. In addition to that integrated health services workgroup, we have an information technology workgroup, [which include] leads from all the practices. They get together with the entity [Vermont Information Technology Leaders (VITL)] that is planning our statewide health information exchange and Covisint DocSite, and they plan their connections and interfaces to their practice management systems and EMRs and begin to develop their IT infrastructure.

How do you work across both paper and electronic practices?

What we’re trying to do is build an architecture that can support any of the different circumstances that we’ll bump into. If you have and electronic medical record, we have a core guideline-based data dictionary that is what the Covisint DocSite registry is built from. VITL and the Covisint DocSite team, work with the practices. They map their EMRs against the core guideline-based data dictionary, develop the interface to extract the elements, and even make recommendations for opportunities to improve the EMR for enhanced use of guideline-based tracking elements.

If the practice doesn’t have an EMR, they always have practice management systems for scheduling and business. What we do there is build an extraction from their practice management system so their patient base is loaded into the registry. In that case, the registry becomes the electronic tracking system for the practice and can produce individualized visit planners based on the diagnosis, the age, and the gender, so the providers in that practice will just use those visit planners from the registry and that becomes their tracking system.

When the EMR is being used, the feeds to the registry build a reporting system for that practice so they can pull outreach reports, panel management reports, comparative effectiveness and quality performance reports. If the practice is paper-based, it can use it for individual patient care and also use it for the reporting functionality. By building this architecture where we feed everything through the health information exchange, we get a master person identifier, then the information feeds into the registry. It’s Web-based, so we can support practices that are paper-based and those with EMRs.

How are protocols for evidence-based care going to be shared with other sites?

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