Problem Addressed

• Inadequate health IT: The United States lags behind other nations in the adoption of health IT,¹ particularly in physician offices. The leaders of many practices, especially smaller ones, often believe they cannot afford such technology. Although the Federal government and some State governments have begun offering financial incentives, adoption remains low.
• Little community-based support: Ensuring the provision of effective preventive and chronic care services often requires the assistance of multidisciplinary support staff such as social workers, behavioral health specialists, home health care services, and other community-based support typically not available within a physician practice.
• Few financial incentives: The current fee-for-service (FFS) payment system creates a strong incentive for physicians to maximize the volume of patients seen, often leaving inadequate time to address all preventive and chronic care needs during the short time allotted for a visit. The Institute of Medicine has identified payment reform as a critical strategy for improving the quality of the nation's health care system.²
• Unrealized potential of state-sponsored support: State governments are often well-positioned to develop multifaceted programs to support community practices in providing such services, including mandated insurer funding of incentives and other types of support and the mobilization of community-based providers to serve multiple practices. Yet relatively few states currently provide such support.

Description of the Innovative Activity

• Authorizing legislation: In 2007, the Vermont legislature passed an act creating the Blueprint for Health program, which was charged with leading a transformation to a true systems-based approach to care and prevention. (See the Context section for more details on what led to passage of this act.)
• Insurer-funded community health teams: Participating practices, which include private offices, hospital-affiliated practices, and Federally Qualified Health Centers, have access to insurer-funded, multidisciplinary, community-based health teams that help patients overcome the many social, economic, and behavioral barriers to ongoing management of their health, including chronic disease(s). Stakeholders within participating communities determine the appropriate composition of the team based on local needs, which vary considerably. Private insurers, the State Medicaid program, and Medicare fund the addition of roughly five full-time equivalent (FTE) staff who work with practice-based personnel and others in the community. Each team typically includes a care coordinator (usually a nurse), chronic care coordinator, and behavioral health specialist, and may also include a social worker, health educator, dietitian/nutritionist, exercise physiologist, and others. Although team members are typically hired by a local organization (e.g., a hospital) through funding provided by insurers, they visit practices in the area and move within the community to interact with patients, clinicians, community-based organizations, and each other as needed. Examples of how the teams assist the practices include the following:
  • Identifying and assessing at-risk patients: Using health IT made available to the practices (see below), team members help practices identify at-risk patients and conduct structured assessments to uncover barriers (e.g., mental health issues, social service needs) to appropriate care and management of their condition(s).
  • Facilitating access to needed services: The teams provide needed services or work with existing resources within the practice and community to get patients the assistance they need.
  • Developing daily management and followup plans: The team works with patients to develop a daily plan for self-managing their condition(s), and follows up with patients on a regular basis to track progress and assist with any problems.
• Preventive health specialist: Each health team also includes a public health prevention specialist based in the local Vermont Department of Health district office. Using community risk profiles from existing data sources, the specialist works closely with other team members to assess risk factors and conditions that contribute to public health problems (e.g., smoking, obesity, alcoholism, substance abuse, chronic disease), build consensus among stakeholders on interventions to address these risk factors, and implement and evaluate these interventions. Before this program, Vermont public health officials (like their counterparts in most states) seldom worked closely with local delivery systems.
• Easy, real-time access to needed information: Participating practices have ready access to a Web-based clinical tracking system (known as DocSite) and registry that supports the provision of age- and gender-appropriate, guideline-based care for preventive, health maintenance, and chronic disease care. Practices with an electronic medical record (EMR) or access to a hospital-based data warehouse obtain this support through these existing systems, while those without such tools access this system through a standard computer. The system, which is updated annually to incorporate the latest evidence, produces "visit planners" that outline needed services for individual patients before their visit, along with population-based reports that help practices identify and address opportunities for improvement. For example, these reports tell practices what percentage of patients are receiving appropriate preventive care, screenings, and chronic care, along with performance data on various clinical outcomes for certain subgroups of patients. Similar functions, along with additional data from a multipayer database, allow for ongoing evaluation and improvement of the overall program. A patient portal is currently under development.
• Significant, all-payer financial incentives: Through the Blueprint for Health, all insurers provide participating practices with bonuses for improving performance based on a set of standards incorporated within the National Committee for Quality Assurance Patient-Centered Medical Home™ (NCQA-PCMH™) program. Participating practices receive an enhanced per-person per-month (PPPM) payment based on how they perform on the NCQA's scoring system. The rate increases or decreases based on incremental changes in the scores. For example, under the current system, a practice that scores 50 overall would receive an additional $1.60 PPPM, which translates into $23,040 in additional payments each year to a physician with an active caseload of 1,200 patients. A score of 75 would yield $2.00 PPPM, equivalent to $28,800 for this physician each year. State law requires private insurers to fund these incentive payments based roughly on the number of their members seen by participating practices (although precise payment mechanisms vary by insurer). The Vermont Medicaid program also pays incentives, and Medicare joined the Blueprint as part of the Multi-payer Advanced Primary Care Practice Demonstration, making the program an all-payer initiative. Practices typically use the funds not only to boost physician income (thus creating incentives to spend time with the community health team and engage in patient assessment and planning), but also to bolster practice infrastructure, including health IT.
• Coordination with and expansion of other state health initiatives: As part of its model for developing PCMHs and community health teams, Blueprint for Health is working with or expanding a number of existing state initiatives to facilitate continuity of care, including (but not limited to) the following:
  • Vermont Chronic Care Initiative (VCCI): Under this initiative, Medicaid care coordinators act as case managers for high-risk patients with certain chronic conditions. Care coordinators are now considered by Blueprint for Health to be “community health team extenders,” holding joint care conferences with the teams to ensure that specific treatment goals are met. Patients move in and out of the VCCI program as needed, but are followed by the PCMH and the community health team on an ongoing basis.
  • Support and Services at Home (SASH): This program provides services (such as self-management education and support for patients returning home after an inpatient admission) to high-risk Medicare beneficiaries so that they can age safely at home. SASH staff are embedded in subsidized housing sites and other housing organizations for the elderly. As with the VCCI case managers, SASH staff are considered “community health team extenders.” Blueprint for Health has received Medicare funding to roll out the SASH teams statewide.
  • Healthier Living Workshops: Blueprint for Health is expanding the number and type of “Healthier Living Workshops,” the Vermont version of the Stanford Chronic Disease Self Management Program. These community-based self-management education workshops have been held across the state since 2004.

References/Related Articles

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Innovator Disclosures

Results

• Lower utilization and expenditure growth: A comparison over a 4-year period (2007 to 2010) between patients at two pilot sites and a matched control group of similar patients at nonparticipating practices found that participants had greater reductions and/or smaller increases in health care utilization and expenditures.³ The results outlined below reflect cumulative changes during this 4-year period, which includes a baseline year (2007), a startup year (2008), and 2 years of operation (2009, 2010):
  • Greater decline in admissions and emergency department (ED) visits: The annual rate of inpatient admissions decreased by 6 percent (from 43.4 to 40.8 visits per 1,000 members) in participating practices, compared with a 1-percent decline among nonparticipants. The annual rate of ED visits decreased slightly (from 161.8 to 160.7 per 1,000 members) at participating practices, while the rate for nonparticipants increased by 10 percent.
  • Lower growth in spending: Total annual expenditures per capita increased by 22 percent for participants, slightly below the 25-percent increase for nonparticipants. This pattern held true for inpatient expenditures (41 vs. 50 percent), outpatient spending (32 vs. 39 percent), ED spending (50 vs. 56 percent), and total expenditures for patients with at least one chronic condition (21 vs. 29 percent). Once statewide expansion of the program has been completed, Vermont officials estimate that it will reduce the year-to-year growth rate in health care expenditures by 37.4 percent.
• Anecdotal reports of improved provision of care: Participating practices report that the program has had a positive impact on the management and provision of care, including increasing the number of at-risk patients identified and assessed, improving teamwork across the community, and enhancing access to needed support services for patients. For example, focus groups with participating practices indicate that patients with chronic conditions previously seen only once a year are now seen up to four times a year. Physicians report being better able to respond to the full range of their patients’ clinical and nonclinical needs thanks to the support of the community health team. In particular, they highlighted the program’s positive impact on access to mental health services, as patients in need of such services can now receive them onsite from a behavioral health specialist.⁴

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

Key steps included the following:

• Designing clinical model and payment system: Program leaders worked with insurers and clinicians over a 6- to 9-month period to develop and gain consensus on key elements of the program, including the community care teams and financial incentives. Through meetings and negotiations, agreements were reached to use the NCQA-PCMH™ standards as the basis for the new payment system.
• Passing legislation endorsing program and requiring insurer participation: The state passed legislation endorsing Blueprint for Health as the foundation for the prevention and management of chronic diseases in the state (Act 191, 2006) and expanding the scope of the program (Act 71, 2007). To guarantee insurer participation, the legislature passed a bill (Act 204, 2008) requiring insurers operating in Vermont to participate in the financial incentive system and to fund the community health teams. Although most insurers had already agreed to take these steps, the regulation ensured that all would participate. The insurers generally appreciated the law, as it eliminated any potential reluctance within their organizations.
• Pilot testing: As noted earlier, the St. Johnsbury Hospital service area began pilot testing the program on July 1, 2008. A second pilot (Burlington Hospital service area) began on October 1 of that year, and a third (Barre Hospital service area) launched in January 2010. These three pilot test sites served roughly 60,000 individuals, or about 10 percent of Vermont’s population.
• Developing health IT architecture: With assistance from several vendors and the Vermont Information Technology Leaders (the designated health information exchange for the state of Vermont), program staff worked with technology teams at each participating site to build the data registry and create an interface to it through existing systems used by the sites, such as an EMR. This process involved many discussions designed to convince site representatives of the value of the new architecture and the sharing of real-world examples of how the system would operate. As noted earlier, work continues on this architecture, including a patient portal.
• Expanding program statewide: The legislature passed a bill (Act 128, 2010) calling for expansion of the program to all willing providers in Vermont by October 2013; the same legislation required expansion to at least two PCMH practices in each service area by July 2011. As of December 31, 2011, the program includes 79 primary care medical homes that collectively have 431 primary care clinicians who serve over 350,000 Vermonters (just over 58 percent of all residents) in 14 communities. Current expansion efforts are focused on updating EMRs to match program data elements, build needed health IT interfaces, and create the nucleus of the community care teams in each area. In 2010, the program created a team of facilitators to help practices meet NCQA standards for becoming medical homes. (After achieving PCMH status, practices become eligible for payment incentives.) These facilitators also help already established medical homes to develop working relationships with community health teams, adopt other Blueprint for Health activities, and promote ongoing quality improvement. Program staff continue to collaborate with representatives of the Vermont Information Technology Leaders, the University of Vermont, the Vermont Program for Quality in Healthcare, and several other organizations as part of this expansion effort.
• Planned expansion into addiction and mental health: Blueprint for Health leaders plan to incorporate a more structured approach to caring for those with addiction and mental health disorders into its framework of PCMHs, community health teams, and support services.
• Planned measurement of cultural impact: To quantify the cultural impact of the program, Blueprint for Health leaders are developing various methods to assess team-based care (including how it has evolved across communities), provider interactions and perceptions, and patient experiences.

Resources Used and Skills Needed

• Staffing: Each community health team has approximately five FTEs and handles roughly 20,000 patients. As of December 2011, the teams collectively employed 53 FTEs. In addition, each of the 13 practice facilitators works with 10 to 15 practices. The program also includes a director, assistant director, community/self-management director, project administrator, statistician/analyst, grants administrator, public health specialists (4.5 FTEs), health IT staff, and communication specialists.
• Costs: Each community health team requires roughly $350,000 per year to cover salaries and benefits. The fiscal year 2012 budget for the Blueprint for Health program totals approximately $4.4 million.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Identify and engage leaders at community and site level: Although State legislation is not a prerequisite to this type of program, strong leadership at the State, regional, and/or community level must exist to drive discussions and negotiate consensus, particularly if multiple insurers are expected to agree on payment reform, and/or if an information exchange is to be built at a regional or state level. Strong leadership also must exist at the practice level to provide the vision and secure the commitment and resources needed to undertake this type of transformation in care delivery.
• Think beyond practice to community: The program will be more effective if it extends beyond the individual physician practice. The aforementioned precursor program on diabetes care demonstrated the limits of what an individual practice can do on its own to improve care. True success requires support from community-based resources, including social workers, mental health specialists, and other support services.
• Think comprehensively: Focusing on only one aspect of the problem will be less effective than taking a more comprehensive approach. For example, a program to help practices build better IT systems will not be successful if clinicians do not have the time or incentive to use them. Paying practices additional money will not improve care without a commitment to providing required support services. Consequently, effective programs should encompass financial, clinical, and public health issues.

Sustaining This Innovation

• Build on existing infrastructure: To the extent possible, the program should integrate within existing organizations, workflows, and processes. For example, Blueprint for Health leaders decided to build interfaces to allow participating practices to use their existing health IT systems to access needed information. They also decided to have existing organizations (e.g., hospitals) hire members of the community health teams, rather than creating new entities within each community to do so.
• Maintain local ownership: Although Blueprint for Health created and gained consensus among stakeholders on the overall model, individual communities maintain ownership over design and implementation at the local level. For example, local teams designed the composition and directed the activities of the community health teams based on the unique characteristics of the community. A top-down, one-size-fits all approach would not only have alienated local stakeholders, but also would have proven inefficient and ineffective given the significant differences in resources available across participating communities and practice sites. Insurance company leaders, who funded the care teams, initially felt uncomfortable letting local teams decide how to spend "their money," but quickly recognized and came to appreciate the benefits of this approach as local communities developed robust, effective teams.
• Cultivate culture change: Team-based, patient-centered care requires clinicians and staff at participating practices to interact and coordinate care in a dramatically different way than they have in the past. These cultural changes tend to evolve naturally over time after some initial hesitation. Only after a culture of team-based care has developed, however, will the program become truly sustainable. As noted, Blueprint for Health has launched an effort to evaluate and quantify the social, culture, and anthropological changes that have occurred.

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