Patient-Centered Medical Home Pilot Site Meeting

October 26, 2010 – Community Health Institute

8:00 am –10:00 am

Attendees:Shawn Lyon (Lifelong Care), Deb Donovan (DerryMedicalCenter), Dan Waszkowski (DerryMedicalCenter), Marcie Doyle (Lamprey Health Care), Laura Davie (Institute of Health Policy & Practice), Paddy DiPadova (Community Health Institute), Heather Staples (Citizens Health Initiative/UNH),Scott Bodette (Cigna Health Care), Doug Draper (Concord Hospital), Nikki Watson (Lamprey Health Care), Ed Shanshala (AmmonosucCommunityHealthCenter), Mike Dowd (IBM/Dr. Grundy)

Phoned in:Signe Peterson Flieger (BrandeisUniversity), Peggy Rosen (Mid-StateHealthCenter), Rick Wilson (West Side), Bob Cawley (MVP Healthcare), Joyce Gallimore (MVP Healthcare)

Overview ~ Paddy

This meeting will be an informal discussion around where people are and where they want to go. This is also an opportunity to find out what ways Paddy or Heather can help sites with or what technical assistance needs they might have to help round out this year and make it an even more positive and successful pilot as a result of trying to hone in on lessons pilot sites may have learned and things sites might have identified that they need help with.

ServiceLinkResourceCenter (SRCs)/Care Coordination ~ Laura Davie(PowerPoint handout)

Laura began by explaining that she works for the Institute of Health Policy & Practice (IHPP) and also for the Citizens Health Initiative. Under the IHPP, a good portion of Laura’s work centers around working with ServiceLinkResourceCenters in our state under the Aging and DisabilityResource Center (ADRC) federal project. Her purpose today was to 1) figure out if medical homes are aware of these centers and what they can provide to medical homes in terms of the resources they have, and 2) specifically, talk about a new project through the ADRC through the Administration on Aging budget project called patient-centered caretransitions, which is care coordination that all medical homes are currently doing and there are some components in those care coordination projects that are care transitions. Laura’s interest is to gauge today about how involved medical homes want to be in that project and make sure we’re not duplicating efforts. Laura is interested in what those care coordination models look like now. What is occurring in their medical homes that the communities can leverage and vice versa? Is there opportunity to share and coordinate?

Laura explained what the ServiceLinks are as some were unfamiliar with this resource. Laura explained that SRCsare a single point of entry for the long-term care system across the nation and in each of the states. One of these centers can be found in each of the counties and a lot of the counties have satellite offices. Each ServiceLink does a number of different things in terms of the programs they provide everywhere from Medicare eligibility to Part D counseling and they also have caregiver support projects, a whole long-term care counseling/options counseling. ServiceLinks are also a known entity for education information on Part D. They have a lot of volunteers during the month of November/December (when open enrollment of Part D is happening) where people can come in and receive help in figuring out their options. They can’t make decisions for people but give them ideas on next steps and support those looking for information. Heather asked what people are eligible to use the ResourceCenters? Laura said anybody as insurance does not matter. Volunteers will look at your eligibility for both public and private programs and anyone walking through the door will be served. Heather asked if there was telephonic support. Laura said there is an 800 number you can call as well. The 800# is directed to one of the sites in Concord and then it’s a soft transfer – so if someone calls from Barrington…it gets picked up in Concord and transferred to the Strafford Office with the caller still on the line. If the call is from out-of-state, it comes into that main number and the caller is asked where the loved one is and upon the response to that question,theoffice to assist is determined and caller is transferred.

Laura is willing to set up the medical home pilot sites with their local ServiceLinks and have them come in. She mentioned that SRCs do have some uniqueness to them depending on the areas they serve. This relationship can start by having Laura come into the medical home pilot site and doing all the services and possibly bringing someone with her to do that or another option is Laura setting up some one-on-one time, either would be a great next step.

Heather said it appears like the federal government is going to continue to putmore and more money into these resource centers, particularly with a focus on care transition and managment. Laura confirmed this. In July under the “Affordable Care Act” NH applied for four ADRC grants and we are only one in four states in the country who applied for all four funding opportunties. NH is seen as a leader of implementation of the ADRC projects. Two of those grants came to the University of NH directly and one is an options counseling grant which is standardizing the delivery of the options counseling and the last one is around the care transition project. Laura said they applied for the patient-centered care, evidenced-based care transitions project and were awarded the grant and are working on three communities with three hospitals currently. One of those hospitals is CheshireMedicalCenter, which is also a Medical Home and Laura is working very closely with their medical home because their care coordinators already make the hospital visits and doing some elements of care transition. A participant asked who the other sites were that Laura was working with. Laura said they were also working up in CarrollCounty at MemorialHospital and working in BelknapCounty with LakesRegion GeneralHospital. Laura said they did receive funding for two years on specific evidenced-based care transition models and from what Laura hears and understands, there is going to be a lot more opportunities around this idea of care transitions with care coordination and care transitions by themselves. So there will be more funding opportunities coming down the pike. She said it would be interesting right now to identify the hospitals since meeting participants are already working with them. She thinks there is a great opportunity to work with the medical home and the primary care practice sites. Laura mentioned that the thing we need to think about and line up with is the AOA releases of funding of evidenced-based programs that they want you to work with. So there were four specifically included in the RFP; the two care transition ones, the Colman Care Transition Intervention Model and another which Laura could not recall the name of. Laura said there could be some real funding to pay someone to do the care coordination and care transitions elements and working with the community ServiceLinks in a more robust way. Two communities are currently using the Colman Care Transition Intervention model; in Cheshire and MemorialHospitals. The LakesRegion GeneralHospital has been utilizing the BOOST model for awhile and while that wasn’t in the RFP, we did submit that that was the care transitions model we were working with and we were told that that was acceptable to use. BOOST stands for “better outcomes for older adults” or something along those lines, Laura said.

Someone asked if Laura’s website had a lot of information on this on it. In the handout Laura referenced that the last slide has their website and all information discussed today can be found there. There is also information on the website that shows all the evidence-based models and other community-based models that are occurring in NH.

A participant asked how Laura got her funding if you had someone going out to your home to do a visit. How does that person get reimbursed for expenses? Laura said through this project—through the model it would be reimbursed through the grant funds. The participant then countered as to what happens when that runs out? Laura said that is what we are looking at. How do we prove that this is saving money and is good quality and that is why they want the evidenced-based programs. These programs have already proven to be cost-effective in terms of rehospitalization and improved quality of life. So, if we can

continue to build that evidence in our own systems (and what Laura thinks they would like to do with their ServiceLinks) is enhance that community connection and the resources. We could find where some

of these models have limitations and build in the ServiceLinks as the resource. Right now, the core function of the ServiceLinkis funded through general funds. So in 2003 when ServiceLink began there were grant funds and over time transitioned after we were able to show that this was effective and that this was the way to deliver services into the communities and they now have the general funds to do that. So now the programs that Laura gets from the AOAare just enhancing our programs, showing their viability and then making the case that the state should continue to fund these. Laura referenced Slide 8 & 9. Laura’s main objective here is how to move forward to let each of the medical homes know about ServiceLinks and the wealth of resources that are available and to make those referrals through primary care physicians. Also, is there interest in how we look at care coordination or care transitions over the next six months such that we can align ourselves with future funding opportunities to look at the primary care model.

Deb (DerryMedicalCenter) responded that she feels Laura needs to reach out to the individual actual practices themselves. Deb said they have clinical meetings once a month with all clinical staff (PAs, MDs, etc.). That type of forum would be great for Laura to get the information about ServiceLink out.

Another participant asked if Laura had thought about harnessing the student body in graduate Nursing to use some of the analysis/or look at different models because sustainablitity is at risk given the way it is funded now. For their final aversion, it might be worth engaging some nursing students to look at things like this because they are a big part of the Medical Home and to get them now while they are in school and still forming their opinion of the health care system would be advantageous.

Another participant stated that there is a significant business side to this. So if you can poll MBA students to get them engaged in thinking about this not in terms of “expense” but more as an “investment” this would be a huge win as the norm is to think of healthcare as a “cost”. It would be nice to get some co-mingling. This participant attended the NH Medical Society Scientific Meeting and in the capacity of a non-provider. One thing he witnessed was the amount of relational damage that we’ve inherited with people with “C” in front of their title and he happened to be one of them-- CPO. With insurance companies and providers the damage is just incredible. The history has been one of adversarial relationships and for us to do this, we have to move beyond that.

Finding Our Bearings: Where are we? What gains have been made?

Paddy mentioned that although this may look like strategic planning every site is at different levels in the process. We’re really not doing a strategic plan on how to move one organization ahead but rather planning and prioritizing maybe some technical assistance to help move each organization futher ahead then they currently are. It will still be done in a traditional way in determining where each organization is currently, looking at where we want to be, figuring out what the gaps are and hopefully, between Heather, Paddy and the other resources we can pull in, helping you get to where you want to be. Paddy has met many via the phone and she explained that her background is Practice Management and working with clinics in some other states as well in working towards being more patient-centered. The hope it to assist sites with technical assistance or do more one-on-one as Laura had mentioned as well. First, we need to identify those areas. We need to identify where you are as opposed to where you thought you would be and where you’d like to be. Discussion began with some things sites felt they had achieved compared to where they were a year or two ago.

A participant shared that he works at a Nurse Practioner Independent Practice up in New London and he just came back from Washington, DC, where he did a presentation for the PCPCC and it was a shocking experience of sorts because just before he went up to give the presentation –someone walked up to him from NCQA to let him know that they finally had a vote and decided that they are going to come up with a name for his practice. They’ve been in limbo all along as a Nurse Practitioner Clinic. They were not allowed to be officially recognized. So his organization had a raffle to come up with their own name, but they’re going to wait this week now for the official recognition. They are the first Level III Nurse Practitioner Clinic in the country. He acknowledged this group for helping to make that happen. He also noted that it was an amazing thing to see that this group has moved to the national stage and he’s not talking about us (this group) but the state itself and that folks are coming up from all around asking about what’s going on here. This participant’s practice is switching to the same system (Care Partners McKesson) New LondonHospital has in January, but their biggest challenge right now is that they can’t get the data right now. When he tries to do a filter, setting it up, he can’t filter based on dates. So he has all this information and it’s pretty much like doing a Chart Review at this point and going back to get all the information that he wants.Every first Tuesday at 4pm the Payment Task Force has a conference call that this participant urges others around the table to join. With payment reform where are we going to do a bunch of incentives with the medical home? There is so much talk about how we’re putting money back into the physician’s pocket essentially which is sort of a negative conversation of “oh, we are going to pay the providers more”. There is another piece to that when you have a Medical Home or ACO. What happens with improved services--especially in the North Country and the rural areas? We don’t have enough psychiatrists or mental health providers, substance abuse providers, etc. Is there some way that some of this money that is coming back is going to help improve some of those services?

Another participant mentioned that pediatric psychiatryfor them to get access to counseling for a non-verbal child who needs counseling services is very difficult. It does segue into to what degree do we engage patients within their EMR to leverage some of the electronic to provide a tele albeit not perfect presences to a Service Psychiatric Counseling aside from putting someone in a car with someone they don’t know with gas in their tank that they can’t afford to drive to Concord with and are scared and lost and have them go to a provider they’ve never met and go to a building that they’ll get lost in once again? What’s a fair evaluation of patient provider interaction buffeted against the patient wasn’t going to go because they can’t afford to get there. The geographic dispersion of the need is just too great.

Another participantstated that web-based utilization has been another challenge. This participant expects that there would be a greater collaboration in this group relative to –such as there are three areas of concern: Diabetes, CHS and CAD, we would divide and conquer in the sense of who has the expertise. We could poll this educational aspect together, the web-based education and coming up with competency-based education as we don’t have any of that right now built into it. How do we know somebody’s achieved something we say we want them to achieve and that piece this participant feels is way under-ripe. It has to go forward. We can’t say that we’ve improved outcomes until we’ve improved what’s related to those outcomes because that’s what is going to be lasting. That’s what trickles down on the family.

Paddy grouped what was said into categories and what has been discussed, two fall into the category of self-care while the other addresses “access”. Paddy asked the group if there were any issues internally that they were experiencing? At the next meeting Paddy mentioned that they would do some team building. She doesn’t want to do that if the group doesn’t think it’s necessary.