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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?

There is a broad array of metrics and guidelines being used. We take a series of national guidelines, and take the evidence-based core data elements and recommendations out of them. That’s what we use to establish the registry data dictionary. In effect, you’re using this guideline-based data dictionary to help promote guideline-based care in practices across the state, either by improving the EMR data collection against it or by the visit planners for paper-based practices or by reporting it [based] on guideline-based data elements.

If you think of the complete architecture here—what’s being done with practices, information exchange, the registry—you have the ability to support individual patient care, either through the EMR or the registry. You have the ability to support reporting for everybody, outreach, panel management, quality reporting, and also one key aspect with the community health teams—if you’re a team of people supporting a collection of practices, where’s the one place where you can go to see all the information of the individuals from all the sites they may receive care at? The registry also provides a central integrated health record for care coordination and population management.

Can you tell me about what the results of this initiative have been?

We have quite a bit of early results coming out of our pilot communities, which drove the state legislator and the state governor to expand the program statewide. In the first community, the St. Johnsbury area, they’ve seen a reduction in hospital inpatient admissions and emergency department visits for the general population of patients. The same has been seen in Burlington, and we’ll see the early results from central Vermont this year. In addition, Medicaid has seen in its own data in the first two pilot communities the same trends, reductions in both the hospitalizations and emergency room visits.

On the clinical side, we’ve seen a real improvement in self management support, working with patients to track self management goals, referring to self management programs, support from the community health teams in terms of achieving good coordination of care. We’ve seen a real strong upsurge and focus on self management.

What is the sustainability plan for Blueprint?

Way back when it was a chronic care initiative it was funded by the state. It came through legislation in 2007 that called for comprehensive delivery system reform, called Act 71. And the following year they passed legislation requiring insurers to participate in payment reforms, and so that’s why in 2008 we were able to gear up the first pilot communities. And from 2008 till now, with these pilots it has switched from a chronic care initiative to being an agent of change for full delivery system reform. We’re building a foundation across the state with the advanced primary care practices and community health teams, to ensure payment reform, which is the key to sustainability. The support for medical homes and community health teams is through the insurance payment reform. All our insurers in Vermont, commercial, Medicare—and Medicaid is about to join us—have undertaken payment reforms to support the medical homes and the community health teams. That’s the first time that has ever been done. Those are sustainable payment reforms, and achievable based on good clinical and financial outcomes.

What challenges have you and your organization faced?

There are challenges at different levels. [Number one is] at the practice level when you’re engaging primary care providers to change operations and improve the way health services are delivered and coordinated. Number two, when you’re instituting community health teams, you have to get all the independent practices and providers, clinical and non medical services, to work together to plan and implement this. Number three would be engaging the insurers in these payment reforms. This is a whole new way of paying for healthcare; we’re not just paying for volume any more. Getting the insurers on board was really mixed. The ones in Vermont were very interested, but the national insurers were not; so that is why the guiding legislation was required. The IT build-out has challenges itself. Being able to work within each practice, map the EMR set up against guideline-based data elements, engage the vendors to build the interfaces, and make modifications is a tremendous challenge.

The key was to making something financially sustainable so they could get the strong buy-in of providers, clinicians, hospitals. Probably the most important aspect to overcoming challenges, is there’s such strong state-level leadership in both the legislature and the governor in guiding the health delivery system reform.

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