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Supporting Practices

Supporting practices to help advance patient-centered care.

Alabama
Alabama has launched three pilot patient care networks (the geographic regions were selected with stakeholder input) to support primary medical providers (PMPs), with services including:
  • 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. One of the state’s strategies to support and sustain provider change is through information technology. With a Medicaid Transformation Grant in 2007, Alabama Medicaid is working with PMPs to help them use the QTool, the Agency’s electronic health record and clinical support tool. Additionally, PMPs have access to in-home monitoring program data that allows patients to record certain vital signs and/or test results at home and transmit the data to a central repository. Patient 1st PMPs receive a quarterly physician report card, known as the Profiler, which contains summary information on a PMP's panel for 12-month period. The Profiler contains information on how a particular PMP compares with his or her peers on certain key quality and cost measures. Alabama has begun work to create a system to reimburse and integrate community pharmacists/pharmacies for their cognitive and professional services.
Alaska No known activity at this time.
Arizona No known activity at this time.
Arkansas No known activity at this time.
California No known activity at this time.
Colorado
Medical Homes for Children Program:
  • 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.MedicalHomeColorado.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.
HealthTeamWorks Multi-payer Pilot:
  • Technical assistance provided through on-site quality improvement (QI) coaching, learning community webinars, and learning collaborative.
  • Practices submit monthly narrative progress reports and QI measures which span prevention, wellness, and chronic disease.
  • Practices must have registry functionality for population management and care coordinator.
Connecticut
Connecticut Medicaid and the Community Health Network of Connecticut, the HUSKY Health administrative services organization, are providing the following practice supports:
  • 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.
Delaware No known activity at this time.
District of Columbia No known activity at this time.
Florida No known activity at this time.
Georgia No known activity at this time.
Hawaii No known activity at this time.
Practices participating in the Safety Net Medical Home Initiative, a partnership between The Commonwealth Fund, Qualis Health, and The MacColl Institute for Healthcare Innovation at the Group Health Research Institute, receive practice transformation technical assistance to facilitate practice transformation to improve enhanced access, care coordination and patient experience. The Safety Net Medical Home Initiative is also funding a Medical Home Facilitator in each participating practice.
Primary care providers participating in Illinois Health Connect receive several types of non-financial support, including:
  • 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.
Indiana No known activity at this time.
The Iowa Healthcare Collaborative, a non-profit organization dedicated to educating and equipping health care providers across Iowa, leads a Medical Home Learning Community. The leader of the Iowa Healthcare Collaborative is also chair of the Iowa Medical Home System Advisory Council (MHSAC).
 
The IowaCare 1115(a) waiver states that, “The State must collaborate with the State’s HIE [health information exchange] designated entity to ensure that primary network providers are a high priority for connecting to the State’s HIE.”
Kansas No known activity at this time.
Kentucky No known activity at this time.
The Louisiana Health Care Quality Forum (LHCQF) developed a patient-centered medical home (PCMH) toolkit as a resource for providers.  As a Regional Extension Center, LHCQF is currently providing health information technology technical assistance.
 
Bayou Health care coordination networks are required to develop a PCMH Implementation Plan, which includes a description of the technical assistance that the networks will provide to primary care physicians to support practice transformation and national recognition/accreditation. Technical assistance activities will vary across networks. The networks are required to participate in Patient-Centered Primary Care Collaborative activities.
The Maine Patient-Centered Medical Home (PCMH) Pilot is offering a variety of supports to participating practice. These supports include:
  • 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 pilot will reopen the Community Care Team application process for Phase 2 of the pilot this summer. 
According to the practice participation agreement, the Maryland Health Care Commission (MHCC) is responsible for establishing a learning collaborative with the support of the Community Health Resources Commission (CHRC). The objectives of the learning collaborative are to support practices in obtaining medical home recognition and effectively using a care manager. Practice staff are required to participate in the learning collaborative. A timeline of learning collaborative activities— which include webinars, in-person large group meetings, site visits, and regional meetings—is available here.
 
The CHRC is also providing the MHCC with resources to hire “practice transformation coaches.” Coach responsibilities include:
  • 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.
Patient-Centered Medical Home Initiative (PCMHI) practices are receiving a variety of supports, including:
  • 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
The Michigan Primary Care Transformation (MiPCT) Project will support physicians and practice transformation by providing educational opportunities, a Care Management Resource Center, and the Michigan Data Collaborative. The focus of support is on care management, self-management, care coordination and linking to community services. Educational opportunities include learning collaboratives, lean workshops, practice-based coaching, webinars, and seminars. The Michigan Data Collaborative will create a multi-payer claims database and generate metric feedback reports.
 
MiPCT will also provide clinical models, resources and support aimed at avoiding emergency room and inpatient use for ambulatory sensitive conditions, reducing fragmentation of care among providers and involving the patient in decision-making.

Health care homes in Minnesota are receiving a variety of supports:

  • 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.
Mississippi No known activity at this time.
All MOHealthNet providers have access to a web-based HIPAA-compliant electronic medical record program for their Medicaid patients,  known as CyberAccess.
 
ACA Section 2703 Health Home State Plan Amendment – Community Mental Health Centers: Missouri state agencies and health care foundations will join providers in spending over $1.5 million to cover training and technical assistance during practice transformation.
 
Participating community mental health centers will participate in a number of statewide learning activities, including learning collaboratives, monthly practice team calls to reinforce learning sessions, practice coaching, and monthly practice reporting (data and narrative) and feedback.
 
Learning activities will focus on teaching practices to coordinate patient- and family-centered, quality-driven, cost-effective, culturally and linguistically appropriate care (including the use of health technology).
Montana
In response to the provider medical home survey results, Montana plans to create educational materials and coordinate a series of webinars on medical home transformation for interested providers.
 
The Montana Patient-Centered Medical Home Advisory Council has identified key attributes for a practice technology support platform that will be rolled out in conjunction with the state’s medical home initiative. Further information is available here.
The Nebraska Department of Health and Human Services (DHHS) has provided each practice with:
  • 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
  • regular performance reports throughout participation in the pilot
In addition, the state conducted an orientation and will provide two day-long learning collaboratives. Physicians, nurses, and key office staff attend and the practice receives honoraria and travel reimbursement.
Nevada No known activity at this time.
New Hampshire No known activity at this time.
No known activity at this time.
The state has met with the Department of Health to identify and target case mangers to work with the Managed Care Organizations and provider networks to identify and manage care for high-cost, high-risk children/patients.
Adirondack Medical Home Demonstration: Each participating Adirondack Medical Home Demonstration practices received a readiness assessment to develop individualized work plans to guide practice transformation. Practices are receiving grant-supported consulting assistance from EastPoint Health to achieve practice transformation.
 
Practices also receive additional support from one of three sub-regional Pods (community-based organizations providing shared care coordination services to participating practices including patient education and care management). The Adirondack Health Institute is serving as an umbrella organization for the three Pods.
 
A $7 million HEAL NY Phase 10 grant (HEAL NY 10) enabled all participating providers to implement an electronic health record.
 
It also should be noted that Chapter 59 of the Laws of 2011 authorizes the commissioner of health to provide technical assistance to regional multi-payer program participants (providers, payers and consumers), which may impact the Adirondack initiative as well as future initiatives as well.
 
Statewide Patient-centered Medical Home Program: There is limited practice support from a quality organization contracted by the state.
 

HEAL NY 10 grants were also made available to support health IT infrastructure development for non-Adirondack medical homes.

Local community networks provide support to physicians. Networks consist of:

  • 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 Dakota No known activity at this time.
Ohio Substitute House Bill 198 (128th General Assembly) requires participating practices to receive comprehensive training on medical home operations, including leadership training, scheduling changes, staff support and care management.
The SFY2010 Performance and Quality Report states that the Oklahoma Health Care Authority (OHCA) Quality Assurance and Improvement Department conducted 557 visits to educate providers on the medical home requirements from July 1, 2009 – June 30, 2010. 
 
Oklahoma is currently piloting non-profit, administrative Health Access Networks (HANs) to support care coordination and quality improvement.
 
Oklahoma provides four profiles to selected providers biannually that give information about their patients' utilization and health care needs. Also, SoonerExcel, a pay-for-performance program, provides practice feedback on targets for Child Health Exams (Early Periodic Screening, Diagnosis, and Treatment [EPSDT]) and Breast and Cervical Cancer screenings.
Chapter 595 of the 2009 Oregon Laws required OHPR to establish a learning collaborative for state agencies, payers, providers, and third party administrators to: 
  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
The Chronic Care Initiative (CCI) rollouts have provided for learning collaboratives, including revenue to cover time lost when providers and practice staff were out-of-office. The CCI has also provided web-based patient registries and practice coaching. Under Phase II, the Department of Health is leading the learning collaboratives, holding monthly group calls for all practices, and overseeing practice coaching. Practices are asked to regularly submit clinical data to the practice coach for quality improvement purposes. Priorities for further practice transformation have also been identified.
Chronic Care Sustainability Initiative (CSI-RI) practices receive support through practice coaching and learning collaboratives. They are also receiving health IT support through the Beacon Community program (see above) as well as ongoing data feedback. Additionally, practices have received support for hiring nurse care managers or contracting for remote nurse care manager support.
South Carolina
Under the Medical Homes Network Program, the South Carolina Department of Health and Human Services contracts with Care Coordination Service Organizations to provide care coordination, disease management and data management support.
South Dakota No known activity at this time.
Tennessee No known activity at this time.
Texas No known activity at this time.
Practices participating in the Children’s Healthcare Improvement Collaboration (CHIC) will receive support through in-person learning sessions (one or two annually), site visits (three to six times per year, with a practice coach and/or peer mentor), and conference calls (six to ten annually).
Practice support has included:
Virginia No known activity at this time.
Washington State Patient Centered Medical Home (PCMH) Multipayer Reimbursement Pilot has not provided for participating practices to receive supports other than enhanced payment.
 
The PCMH Collaborative has provided a range of supports to participating practices, including practice coaching, in-person learning sessions, and a series of webinars. Many webinar archives are available online, as are materials from the in-person learning sessions.
 
The Washington State Department of Health (DOH) and the Washington State medical Home Leadership Network also maintain a website devoted to helping providers and others better serve children and youth with special health needs through the medical home model.
Practices participating in the Medical Home Performance Incentive Pilot received a technical assistance package valued at $25,000 per practice, including:
  • 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.
Wisconsin No known activity at this time.
Wyoming No known activity at this time.