Fall QCLC - It takes a Community to Transform Care - CCT's

Patient- and family-centered care is an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families. It redefines the relationships in health care.  Patient- and family-centered practitioners recognize the vital role that families play in ensuring the health and well-being of infants, children, adolescents, and family members of all ages. They acknowledge that emotional, social, and developmental support are integral components of health care. They promote the health and well-being of individuals and families and restore dignity and control to them.

Patient- and family-centered care is an approach to health care that shapes policies, programs, facility design, and staff day-to-day interactions. It leads to better health outcomes and wiser allocation of resources, and greater patient and family satisfaction.  Establishing patient- and family-centered care requires a long-term commitment. It entails transforming the organizational culture. This approach to care is a journey, not a destination—one that requires continual exploration and evaluation of new ways to collaborate with patients and families.

In November 2010, Maine was selected as one of eight states to participate in the Medicare Multi-Payer Advanced Primary Care Practice (MAPCP) demonstration, Medicare’s major medical home initiative.  This means that Medicare will join the private purchasers and Medicaid as a payer in the Maine Patient Centered Medical Home (PCMH) Pilot, beginning January 2012.  The Maine PCMH Pilot began in 2010, with participation by 26 primary care practices and major payers including Anthem BCBS, Aetna, Harvard Pilgrim Health Care and MaineCare.

A key strategy that will be added to the PCMH and MAPCP pilots will be the Community Care Team.  Focused on improving quality and reducing avoidable costs by coordinating care and connecting patients who have complex or chronic conditions to supplemental healthcare and community resources, CCTs have been used successfully around the country with impressive outcomes in improved quality, improved patient and staff satisfaction, and reduced costs.  Various CHT models have been found to be highly successful in other communities. In North Carolina, the program is now saving the State $160 million per year, with concurrent improvements in quality. While costs are falling by 2.5% annually (compared with 7.8% increases nationally), quality scores are in the top 10% in measures for diabetes, asthma, and heart disease. In Camden NJ, the Camden Coalition of Healthcare Providers provided CHT services to 36 individuals who were high utilizers of health care, with savings of $687,000 (a 56% reduction) in overall costs. In San Francisco, case management intervention for 53 patients led to a 40 percent reduction in ED visits, reduced ED costs of 47%, and decrease in homelessness and use of drugs and alcohol – accounting for net savings of $1.44 in hospital costs for each dollar spent on the program. In Vermont, the St. Johnsbury CHT saw a 24% decrease in hospital admissions and 34% decrease in ED visits in the first two years of implementation. (citations available on request)

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.  CCTs and Pilot practices will work together to identify and serve high risk/high need patients in the practice regardless of age, health status or insurance coverage status.  Quality Counts recently issued a Request for Applications to select 6-8 CCT’s that will partner with and provide coordination and linkage services to practices participating in the pilots.  Reviewers representing patients, providers, payers, employers, public health, PCMH practices, and the Community Care Teams program reviewed applications and selected eight organizations to serve as CCT providers for the PCMH practices: Androscoggin Home Care & Hospice, Community Health Center/MDI Hospital, DFD Russell Medical Centers, Eastern Maine HomeCare, MaineGeneral, MaineHealth, Newport Family Practice, and Penobscot Community Health Care. The teams will be organizing this fall, with an estimated start-date for payments to begin in January 2012.

Many feel that, based on the long-term success of programs in other states, this model represents the beginning of a shift in payment systems, and we expect that it will eventually spread outside of the 26 practices that are participating this year. Later in 2012, we hope to expand to an additional 22 practices. As we await the shifting of the tide, many primary care practices could benefit from strategies and functions employed as part of the CCT model.

Some of the most promising of these include:

- Medical assessments and complete community/social service needs assessments;

-Nurse care management (including patient visits prior to hospital discharge, in the primary care practice, group visits or at home);

-Case/panel management (screening, patient identification, scheduling appointments, referrals to care managers and other team members);

-Behavioral health (brief intervention, cognitive behavioral therapy, motivational interviewing, and referral);

-Substance abuse services (screening, brief treatment and referral );

-Psychiatric prescribing consultation for providers (provided by psychiatrist);

-Medication review and reconciliation (may be provided by pharmacists, pharmacy techs, or nurses);

-Pharmacy consultation for providers;

-Oral health services;

-Transitional care;

-Health coaching for nutrition, physical activity, tobacco cessation, diabetes, asthma, other chronic disease;

-Chronic disease self-management education and skill-building, such as linking to Living Well programs;

-Other non-clinical services to actively connect patients to community organizations that offer supports for self-management and healthy living, transportation assistance, housing, literacy, economic and other assistance to meet basic needs.