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  • Improve maternity care (decrease electives, increase VBACs, p. 15-18)
  • Health Homes for Complex Patients
  • Integrate palliative care into primary care

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  • Colorado Medicaid has established 7 Regional Coordinated Care Organizations (RCCOs) which receive out-come based payments, along with the participating primary care providers within the RCCOs.
  • Primary care providers use “Medical Neighborhood” approach to partner with selected specialists and to leverage telehealth opportunities.
  • Incremental approach to care coordination/shared savings and risk/ global budgets. (p. 79-88)

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  • Advanced Medical Homes for Primary Care, with financial incentives for pay-for-performance.
  • Incremental shift from fee-for-service to value-based payment (rewards for quality and care experience), then moving to shared savings.
  • Must align payers to adopt similar rewards and common scorecard.

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  • Elements of clinical reform: patient registries, risk stratification, clinical guidelines, care coordination, multi-dimensional teams, patient engagement, performance review.

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  • Expand Patient Centered Medical Homes (PCMHs).
  • Care coordination for high-risk: Medicaid Health Homes.
  • Community Care Networks reimbursed by all payers and focusing on those at risk of a chronic disease or already with complex chronic disease, 3 pilots for super-utilizers: Behavioral Health, Community Paramedicine, and Department of Public Safety. Emergency Medical Technicians (EMTs) may be extenders for Federally Qualified Health Centers (FQHCs) (EMTs in rural areas provide post-acute care with statewide Electronic Medical Record (EMR) and single contract for service delivery).
  • Also, a focus on recidivating inmates with chronic diseases in partnership with the Department of Public Safety.

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  • This is a very medically-oriented (not community-oriented), private (nongovernmental) model. Focus of most of the Plan is to move to Patient Centered Medical Homes (PCMHs) across the State, led by a new non-profit, the Idaho Healthcare Coalition and Regional Collaboratives. (It was decided that local public health would not be the chosen structure for the Regional Collaboratives. Regional Collaboratives would be newly developed extensions of the Idaho Healthcare Coalition in order to be faster and more consistent.) (p.23)
  • Places all coordination responsibilities, including those with entities in the “medical neighborhood”, with the Patient Centered Medical Home (PCMH), as well as on-going population health management. (Pg. 32).

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  • Key goal #1 of the Plan is to develop integrated delivery systems of providers serving identified patient populations and linked by shared governance, performance management, Health Information Technology systems, shared savings payments, and practice-level care coordinators. Begins with Medicaid, to advance to Medicare, large employers including the state, and commercial plans. Plan expects to eventually develop standardized pay-for-performance targets across all payers – Medicaid, Medicare, commercial.

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  • Using a request for proposal (RFP) process the state will detail the deliverables of the Accountable Care Organizations (ACOs) but will not dictate what type of entity can be an Accountable Care Organization. This is to better manage the high-cost, high need population and cut down on unnecessary emergency room usage and hospital admissions and days, care coordination, and appropriate use of services. To ensure, that this is not the only population, specific measures will also be added for children. (pg. 135) Will also continue to explore metrics for holding Accountable Care Organizations to performance standards related to social determinants of health. See page 146 for a detailed diagram of cost reduction and population health improvement goals.

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  • Community Integrated Medical Homes (CIMHs) will be certified by the state, using the multiple eligibility and performance criteria already in use across different payers.
  • Goal is for 80% of the population to receive care from a CIMH by the end of the SIM grant.
  • Initial focus is on getting Medicare and dually-eligible people into CIMHs to support the 5-year Medicare cost savings goal of the Maryland' hospital waiver. Also, Medicare enrollees are more likely to be superutlizers and are the least managed of all groups.
  • Medicare will HAVE to participate in monitoring, bonuses, etc of the CIMH, if the Maryland plan is funded.

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  • "Patient Centered Medical Homes (PCMHs) are the core of the blueprint: expanding existing PCMH project by promoting interprofessional teams, increasing the number of providers and payers participating, and maintaining the support of existing payers. (pgs. 78-82)"
  • Creates "Accountable Systems of Care" to promote integration, provider communication, and share in investments in data and Health Information Technology (HIT). (pgs. 83-93)

New Hampshire:
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  • Pg. 29 for flow diagram. Will also expand Life Plan Coordination to those that may not meet criteria, such as those that are 21 and seniors. Families/Individuals will also have a long term services and supports (LTSS) budget in order to expand access to services, increase choice, and assist in managing costs of the system. In addition, because many in the target group receive supports from many programs and payers, efforts of the care coordination and medical home will be to assure the correct payer and decreased duplication of services. (pgs. 52-54)

New York:
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  • Advanced Primary Care (APC) – new care model defined as an augmented patient centered medical home (PCMH) that provides patients with timely, well-organized and integrated care, and enhanced access to teams of providers. (pg. 5) Built on 3 progressively advanced levels of integrated care: 1. Pre-APC, includes most primary care practices; 2. Standard APC, practice which meets and exceeds NCQA’s current standards for PCMH recognition; and, 3. Enhanced APC, practices in which behavioral health care is integrated into the primary care setting & practice participates in initiatives focused on improving broader community health.
  • Focus on primary prevention at the clinical and community level, and implementing effective linkages between primary care and community-based organizations.
  • Patient centered care measured by chronic disease management (diabetes and cardiovascular care) with specific focus on higher-risk populations and a spotlight on secondary & tertiary prevention. (pg. 27)
  • Make care more accessible through extended hours, same day appointments, and use of technology (telehealth, video, online/phone based consultations).

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  • Improve the use of clinical data to assess and monitor population health, and create greater capacity to reach into more neighborhoods and improve health outcomes in whole populations.
  • Mention integration of clinical services and population health.
  • Patient Centered Medical Home (PCMH) Model - Integration of primary care, public health, and community health.
  • Episode-based payment model – encourages providers to coordinate patient care throughout the duration of an episode rather than on specific visits or procedures; increases coordination of care among multiple providers
  • Five episodes identified include: perinatal, asthma acute exacerbation, Chronic Obstructive Pulmonary Disease (COPD) exacerbation, joint replacement, and percutaneous coronary intervention. Ohio’s plan is to design, with payer and provider input, 20 episodes over the next three years.

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  • Chronic Care Initiative – this was launched in 2009.
  • Create a Healthcare Transformation Support Center (Transformation Support Center) – provide training courses, offer on-site technical assistance and link practices with community resources. Allows for dissemination of best practices throughout the state and provide instruction on how to engage in practice transformation. (pg. 40 and pgs. 43-44)
  • Special focus on patient engagement (pg. 51)
  • Regional Hubs as part of this initiative (pg. 56)
  • Expand telemedicine – provide additional specialty consultation services in outpatient (telepsychiatry) & inpatient settings throughout state.
  • Provide office-based care coordination and care management services throughout Pennsylvania through Accountable Provider Organizations (APOs) and Patient-Centered Medical Homes (PCMHs). (pg. 14)
  • Targeting the top 5% of Medicaid’s high risk consumers, community-based Care Management Teams (CM Teams) will provide services to two key populations:
    1. Medicaid consumers with complex medical needs who receive care from practices that are too small to maintain their own care management resources;
    2. Medicaid consumers not affiliated with an APO who have very complex psycho-social-physical needs that exceed the capability of primary care practice-based care management.

Rhode Island:
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  • Integrate primary care with community groups, hospitals & specialists.
  • Full, statewide availability of Patient Centered Medical Homes – including pediatrics; involve specialists and hospitals also.
  • Expand use of Community Health Teams (CHTs) – using Vermont's Blueprint for Health as model – use CHTs for care coordination and management outside of clinical setting. Also, focus on needs of high-risk and rising-risk populations. Using specialized CHTs to focus on specific needs of persons with behavioral health needs. (pg. 63)
  • Use Community Health Teams as Patient Centered Medical Home (PCMH) enabler
  • Have nurse as care manager and clinical coordinator, as well as "stable" of care professionals.
  • Intermediary services for high emergency department (ED) utilizers – Rhode Island Medicaid has implemented “Communities of Care” which identifies high end ED utilizers, offers a progressive array of case management services and tracks utilization. (pg. 65)
  • Use of care transitions to reduce hospital readmissions. (pg. 68)

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  • Care coordination included in Patient Centered Medical Home (PCMH) model
  • (Pg. 27) PCMH Care delivery model: The care delivery model is the centerpiece of the PCMH strategy. In Tennessee, the care delivery model will have several significant features:
    • Tailored care plans based on patient need: PCMH providers will be encouraged to develop individualized care plans for high-risk patients. Plans will focus on coordination of care and the improvement of a patient’s health status over time. Risk-stratification of patients will ensure that all high-needs patients are proactively engaged in care, while encouraging appropriate stewardship of resources. TennCare payers already risk-stratify their Medicaid membership for TennCare’s Population Health programs using proprietary algorithms and share that information with payers.
    • Team-based care with care coordination: A PCMH provides care through a multi-disciplinary team, with the PCP at the center. Teams will collaborate to develop care plans, improve diagnosis and treatment, and deliver appropriate patient coaching. Many PCMHs will have dedicated care coordination staff.
    • Evidence-informed pathways: Care will reflect known standards for the most appropriate care for superior outcomes and cost-effectiveness. Care will also be patient-centered, guided by the patient’s specific needs and preferences.
    • Improved access: Enhancements in access may include 24/7 phone support, evening and weekend hours, or same-day appointments for high-needs patients. Specific access improvements will be left to the discretion of individual providers and payers.

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  • Clinical Care Transformation Programs – Medical Home Training Program, Medical Home Recognition Program, Chronic Disease Care Recognition Program (Model 2) (pg.145-153)
  • Sustaining Practice Transformation in Medicaid Managed Care (Model 3, Innovation 2) (pg. 171)
  • Multi‐Payer Engagement and Alignment (Model 5, Innovation 1 & 2): Building Capacity for Multi‐payer Collaboration, Multi‐payer Alignment on Diabetes Care Transformation and Prevention (pg. 174-178)
  • Build Capacity for Continuous, Ongoing Improvement and Innovation throughout the Health Care and Public Health Systems in Texas - foster collaboration in spreading and sustaining best practices in service delivery and payment, and closing the gap between the demand for and capacity of primary care (pg. 9, pg. 187)
  • Patient‐Centered Medical Home Programs and Specialty Practices - six clinics in Texas becoming NCQA-recognized patient-centered specialty practices. Accountable Care Organizations (ACO) are gaining popularity in Texas due in large part to the availability of federal funding (pg. 76-79)

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  • Aim 2 focuses on helping patients designate their own life sustaining treatments. Subaims under Aim 2 look to make sure that physician ordered life sustaining treatments (POLSTs) and patient advanced directives are electronically available to ensure that patient wishes regarding end-of-life care are honored. Additionally, providers will be taught how to have crucial conversations with patients regarding end of live care and how to assist patients in the development and institutionalization of POLSTs and advanced directives.
  • Utah’s plan addresses end of life preferences in three ways. These ways include: 1) the use of information technology as an infrastructure to improving access to the end of life directives, 2) training physicians on crucial conversations, and 3) conducting community outreach and educational activities. The goal of such interventions is to create a cultural shift towards the expression of end of life preferences, documentation of such preferences, and access to those preferences at the right time. If conducted with dignity and respect, an overall decrease in end of life institutional spending should decrease with subsequent increases in home based comfort care.
  • Utah aims to model the successful teamwork approach to healthcare delivery.

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  • One of three key strategies in the overall plan, improving chronic illness care through better integration of care and social supports, particularly for individuals with physical and behavioral co-morbidities. (pg. 56)
  • Spreading adoption of the Chronic Care Model.
  • Supporting the integration of physical and behavioral health care at the delivery level through expanded data accessibility and resources, practice transformation support, increased workforce capabilities, and reduction of administrative and funding silos on a phased basis.
  • Restructuring Medicaid procurement into regional service areas to support integrated physical and behavioral health care and linkages to community resources.
  • The State will create a Transformation Support Regional Extension Service that operates at the state and community levels. This entity will ensure providers receive the necessary support in Washington’s rapidly changing health care environment. (pg. 3) See pg. 34 for more details.