Supporting Practices

• Quality improvement;
• Pharmacy assistance;
• Care management for high-risk and high-needs patients; and
• General medical home maturation.

The networks are each developing initiatives around topics that have already been identified (high cost/high co-morbidity patients, asthma, diabetes, etc.) and topics that will be defined through mutual agreement.

• Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Outreach and Case Management & Colorado Children’s Healthcare Access Program (CCHAP) staff will support providers by providing links to community services as well as assistance with medical home certification, quality improvement, and practice coaching.
• Provider Hotline supported by Family Voices Colorado, CCHAP, and the Department of Health Care Policy and Financing (HCPF).
• Providers have access to Colorado Immunization Registry.
• Develop comprehensive website for providers at www.ColoradoMedicalHome.org.
• Specific training for parents. 

Accountable Care Collaborative (ACC) Program: Under the Accountable Care Collaborative, Regional Care Collaborative Organizations (RCCOs) and the Statewide Data and Analytics Contractor (SDAC) provide support for participating Primary Medical Care Providers (PCMPs). RCCOs provide:

• Technical assistance provided through on-site quality improvement (QI) coaching, learning community webinars, and learning collaborative;
• Administrative support includes RCCOs providing PCMPs with information and education on Colorado Medicaid and providing assistance with prior authorization requests and payment issues;
• Practice support includes RCCOs assisting PCMPs to establish and implement patient-centered medical homes, including supporting practice redesign;
• Resources such as a provider website that includes general and specific information about the program and RCCO support services; and
• Access to client health, claim, and utilization data provided from the SDAC and assist in the acquisition and analysis of SDAC reports.

Comprehensive Primary Care Initiative (CPCi): Colorado practices participating in the Comprehensive Primary Care Initiative receive practice coaching services from HealthTeamWorks or Rocky Mountain Health Plan depending on their location.
 
HealthTeamWorks Multi-payer Pilot: Participating practices received technical assistance provided through on-site quality improvement (QI) coaching, learning community webinars, and a learning collaborative.

• Referral assistance and appointment scheduling;
• Provider recruitment;
• Health education;
• Utilization management including prior authorization (including a web portal to request authorizations);
• Case management including intensive care management;
• Quality management; and
• Health data analytics and reporting

In addition, Connecticut Medicaid is also providing financial incentives to “Glide Path” practices seeking NCQA medical home recognition to help with start-up transformation costs.

• Semi-annual profiles that show aggregated screening rates and how a particular health care provider compares with his/her peers. Early Periodic Screening, Diagnosis, and Treatment (EPSDT) screening rates have dramatically increased, as have the use of other evidence-based services. These profiles are aligned with the Illinois Health Connect pay-for-performance criteria.
• Illinois Health Connect primary care providers have access to a database listing specialists who are willing to see Illinois Health Connect patients.
• Every week, Illinois Health Connect staff make 350 visits to provider offices to offer coaching or technical assistance on topics such as requirements for program participation, coding and billing, and enrollment.
• Illinois’s Enhancing Developmentally Oriented Primary Care (EDOPC) program is a joint initiative of the Illinois Department of Healthcare and Family Services (Medicaid), a health system, and two primary care provider associations (the state chapters of the American Academy of Pediatrics and the American Academy of Family Physicians). EDOPC offers online and in-office training on topics including developmental screening, perinatal depression, and autism. (Office trainings are eligible for continuing medical education credit.) Trainings include discussion of cultural and linguistic competency.
• Illinois Health Connect is exploring possibilities for creating a primary care extension program to support primary care providers in transforming into medical homes.

• In-person learning collaborative meetings three days a year
• Practice coaching through the Maine Practice Improvement Network (MPIN)
• Technical assistance on behavioral health integration, engaging consumers, connecting to community-based supports, and health information technology
• Feedback through practice performance reports (see here for a sample report). The reports include information on effective care (preventative care, cardiovascular care, diabetes care, musculoskeletal conditions, respiratory conditions, and medication management), supply sensitive costs, and preference sensitive costs.

Maine launched eight community care teams (CCTs) in early 2012 to support medical home practices. “The primary goal of the CCT is to provide support for the most complex, high risk, high need, and/or high-cost patients served by ME PCMH Pilot.” According to Maine Quality Counts, “CCTs will coordinate and connect patients to additional healthcare and community resources in order to support their health improvement goals, achieve better health outcomes and reduce avoidable costs.” The state launched two new CCTs in January 2013 to support the pilot’s 50-practice expansion. The new teams were selected through an RFP process.
 
ACA Section 2703 Health Homes: Like Maine PCMH Pilot practices, health homes are also supported by Maine’s community care teams, who provide intensive care coordination and other wrap-around services to the top 5-percent of high-cost, high-risk beneficiaries.

• Providing registry support for practices without electronic medical records (EMRs);
• Developing practice-specific medical home implementation plans and timetables; and
• Providing support for achieving National Committee for Quality Assurance (NCQA) medical home standards.

Practices will be expected to use an MHCC-provided registry unless they have an acceptable EMR.
 
Maryland participated in the North Carolina Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Learning Community, where it was one of four states to receive technical assistance and guidance from North Carolina on how to develop a primary care support and quality improvement system. Through participation in this project Maryland provided support to primary care practices. Mary supported all of the practices participating in the Maryland Multi-Payer Patient-Centered Medical Home Program(MMPP) in implementing an Electronic Health Record (EHR). Additionally, 65% of the practices now participate in the State-Designated Health Information Exchange. The Maryland Learning Collaborative (MLC) used an expert consultant to train Practice Transformation Coaches who provide logistical and educational support to primary care practices in transforming into PCMH. Additionally, the MLC secured a care manager responsible for implementing the changes necessary for practices to become PCMHs in each of the pilot practices.

• Access to a patient registry, if the practice lacks an electronic medical record (EMR) with registry functionality
• Use of an online portal to see practice performance on key metrics over time and compared to other practices
• Nine days of in-person learning collaborative meetings over February 2011 and January 2013
• Monthly hour-long webinars or conference calls
• The assistance of medical home facilitators

Primary Care Payment Reform Initiative (PCPRI): Massachusetts Executive Office of Health and Human Services (EOHHS) is providing participating practices with a variety of supports through learning collaboratives and other means:

• Claims-based data to guide care coordination and care management efforts, including a list of attributed enrollees and claims history, claims-based risk scores for all attributed enrollees, and per-member per-month utilization metrics for different types of services.
• Targeted technical assistance on topics such as quality improvement and data analysis.

• In select areas of the state, community care teams (CCTs) have been funded to support health care homes in, “coordinating seamlessly with a broad range of health and community service providers,” to better serve patients and families. Further information is available in the CCT request for proposals.
• Practice coaching is available through several state-funded health care homes regional nurse consultants.
• The Institute for Clinical Systems Improvement (ICSI) has been selected to lead a statewide health care home learning collaborative.
• Minnesota maintains a resource guide of materials that may help practices in undertaking transformation.

Payers are providing data feedback to support health care homes in measuring progress and identifying areas for improvement.

• Technical assistance for transforming into a medical home through a contract with TransforMED;
• Funding for a care coordinator staff position;
• Funding for a patient registry;
• Access to claims data; and
• Regular performance reports throughout participation in the pilot;

In addition, the state conducted an orientation and provided two day-long learning collaboratives for physicians, nurses, and key office staff.

• Part to full time paid Medical Director – oversight of quality efforts, meets with practices, holds medical management meetings and serves on State Clinical Directors Committee.
• Clinical Coordinator – oversees the overall network operations.
• Local care managers (CM). Small practices share/large practices may have their own assigned CM to support practice’s high risk and high cost population and population management activities.
• Pharmacists to assist with medication management, poly-pharmacy and poly-prescribing.
• Networks provide population management support to the practices, including customized reports. They work with practices in the implementation of all Community Care of North Carolina (CCNC) initiatives including:
• Practice re-design (network staff and/or Improving Performance in Practice [IPIP]/Area Health Education Center staff).
• Develop relationships with community agencies/organizations including links to mental health, public health, hospitals, etc.
• Transitional support processes – participate in discharge planning, medication reconciliation.
• Customize practice and patient tools and educational materials.
• Sponsor learning sessions for network and practice staff.
• Facilitate group medical visits for chronic conditions.
• Targeted outreach to patients that will benefit from care management interventions in concert with medical home.

In addition to providing education programs and informational services, Area Health Education Centers (AHECs) are also helping practices achieve electronic health record (EHR) meaningful use as Regional Extension Centers.
 
The CCNC Patient-centered Medical Home (PCMH) team hosted eight webinars to help practices achieve 2008 NCQA PCMH Recognition and has completed a 2008 NCQA PCMH Recognition Workbook. A 2011 NCQA PCMH Recognition webinar series and workbook is in development.
 
North Carolina also received an Infrastructure for Maintaining Primary Care Transformation (IMPaCT) award from the Agency for Healthcare Research and Quality (AHRQ) in September 2011. North Carolina’s IMPaCT project featured a Regional Leadership Collaborative and a Care Transitions Learning Collaborative to accelerate local-level process improvements and quality improvement in clinical performance measures. The Regional Leadership Collaborative focused on developing leadership and quality improvement skills among regional teams. The Care Transitions Learning Collaborative concentrated on integrating care transitions into primary care practices’ roles as part of the PCMH.

1. Share information about quality improvement;
2. Share best practices that increase access to culturally competent and linguistically appropriate care;
3. Share best practices that increase the adoption and use of the latest techniques in effective and cost-effective patient centered care;
4. Coordinate efforts to develop and test methods to align financial incentives to support patient centered primary care homes;
5. Share best practices for maximizing the utilization of patient centered primary care homes by individuals enrolled in medical assistance programs, including culturally specific and targeted outreach and direct assistance with applications to adults and children of racial, ethnic and language minority communities and other underserved populations;
6. Coordinate efforts to conduct research on patient centered primary care homes and evaluate strategies to implement the patient centered primary care home to improve health status and quality and reduce overall health care costs; and
7. Share best practices for maximizing integration to ensure that patients have access to comprehensive primary care, including preventative and disease management services.

• A quality improvement collaborative sponsored by the Vermont Program for Quality in Health Care;
• Funding for expanded electronic medical record (EMR) use, including population management, data sharing, and a web-based clinical tracking system with e-prescribing;
• The University of Vermont’s Vermont Child Health Improvement Program (UVM VCHIP) works with practices to apply for and achieve NCQA PCMH recognition
• Practice coaching;
• A care integration coordinator at each practice; and
• Multidisciplinary community care teams including Vermont Department of Health (VDH) Public Health Prevention Specialists.

• A practice assessment;
• Access to learning events (including face-to-face sessions, webinars, and monthly conference calls);
• Training and practice coaching to meet NCQA standards; and
• Preparation for measures reporting.