We encourage our community to share and discuss more details, ideas, issues and emerging products and results on State Refor(u)m. Especially as SIM Design and Pre-Testing states complete their State Health Care Innovation Plans there is interest in how population health strategies will be integrated. Do you know of state activity or analyses that we should add to this chart? Eager to update a fact we’ve included? Your contributions are central to our community’s ongoing, real-time learning, so tell us in a comment below, or email the author with your suggestion.
|Population Health Objectives in the Model||Arkansas’ primary strategy for population health is through its medical homeand health home initiatives. Arkansas plans to expand access to medical homes within 3-5 years. These medical homes will proactively examine the patient’s health with a focus on preventive services and chronic disease management. Arkansas will also change the payment mechanism to underwrite the costs of primary care practice transformation and reward providers for effective population health management.||Maine’s model will deliver care through patient-centered, primary-care based, multi-payer Accountable Care Organizations that are responsible for improving population health, patient experience of care, and controlling healthcare costs. These ACOs will also integrate primary care and behavioral health, align healthcare and public health systems to support improving chronic disease outcomes and address health disparities, and improve health measures and equity. These ACOs will also build on the model of MaineCare (state Medicaid program) Accountable Communities (SIM plan 7-8).||Massachusetts will integrate public and population health into its multi-payer model. The state defines primary care providers broadly to include not just primary care practices and hospital-based providers, but also community health/mental health centers that provide primary care services. These provider organizations may be embedded in larger organizations, ranging from integrated delivery systems to independent practice associations toACOs. Additionally, the Department of Public Health serves with the four other departments as an Implementing and Strategic Partner (see pg. 7).||Minnesota’s Health Care Delivery System (HCDS) demonstration aligns withACO models from other public and private payers creating financial incentives for delivery system innovation to bring better integration and coordination of care across the spectrum of services. Participating organizations are given incentives to partner with community organizations to create 15 Accountable Communities for Health that integrate medical care with behavioral health, mental health, public health, long-term care, social services, and other providers and share accountability for population health.||Oregon’s primary focus is the reduction of chronic diseases and the risk factors that contribute to them.Oregon is using SIM to accelerate population health goals in 3 areas:1. Advancing the spread of the Coordinated Care Model – with emphasis on prevention and proactive population health management;2. Providing targeted support for a handful of local “flood the zone” collaborations aimed at creating changes in practice around leading causes of death and disease.3. Enabling increased population health performance measurement.||Vermont’s SIM model seeks to reach the three overarching priority areas for health improvement as identified in Vermont’s 2012-2015 State Health Improvement Plan including:1. Reduction in the prevalence of chronic disease through improving physical activity, nutrition and decreasing the rates of tobacco use2. Reduction in the prevalence of Vermonters with or at risk of substance abuse and/or mental illness3. Improvement of childhood immunizationVermont also believes that the primary models it will pursue through SIM–Shared Savings ACOs, Bundled Payments, and Pay for Performance,–will help build provider capacity to better manage population health.|
|Strategies in the Model to Address Social, Economic, and Behavioral Determinants of Health and Health Equity||Arkansas is designing interventions to specifically address and support challenges faced by its communities such as poor rankings in smoking, early prenatal care, preventable hospitalizations, as well as reducing the disease burden presented by rising rates of obesity and Type 2 diabetes (SIM plan 13).||Accountable Communities are required to serve a minimum number of MaineCare (Medicaid) members and must include MaineCare enrolled providers. Maine notes that in order to change and prevent disparities a multi-level approach such as the one envisioned by its model is required to eliminate health disparities and reach health equity.||The reduction of health disparities is a goal of the Prevention and Wellness Trust Fund (see below). Additionally, the Massachusetts SIM operational plan (see pgs. 65-66) notes that there is substantial evidence that a strong primary care base delivered through PCMH – as the state is doing – will reduce disparities in care and narrow racial disparities in health outcomes.||The fifteen Accountable Communities for Health will form with a priority on communities in areas with a lower level of ACO penetration, greater disparities, and greater health care needs.The payment structure and incentives for ACOs will encourage them to adopt strategies such as coordinated and integrated health care and multi-payerHealth Care Homes, Community Health Teams, and Service Coordination Teams, which will provide the infrastructure to address social and behavioral determinants of health.||Oregon is poised to implement the Congregate Housing with Services model. This approach targets a low-income population living in subsidized housing apartments or other highly concentrated, naturally occurring communities with a greatly coordinated and efficient model of support. This strategy will target social determinants of health, include prevention and wellness programs, and seek to prevent unneeded emergency and acute health care.Oregon’s model also builds on, and provides operational support to, its existing Regional Health Equity Coalitions. These coalitions seek to reduce disparities and address social determinants of health. SIM support will also be used to expand health care interpreters and other efforts to enhance communication and education across all populations, and to reduce barriers to services.||The Vermont Department for Health (VDH) is actively developing strategies that can be used by all programs in the model to reduce health disparities. The Department is taking the lead, but is collaborating with other agencies and partners to achieve health equity.|
|Strategies in the Model to Address Mental Health and Substance Abuse Disorders||Arkansas will use the health home model for those with developmental disabilities, long-term services and supports, and behavioral health issues. Arkansas’ health home functions match the CMS definition and aim to ensure provider accountability for the full client experience including health outcomes, and will coordinate all health care and support services needed by a client over time.||Maine’s model expands the use of patient-centered medical homes, and develops Health Homes for people with chronic conditions and significant behavioral health needs. The model also builds on Community Care Teams, which are already being used in some medical home pilots in the state.||Mental health is integrated into the model by including mental health providers among those whose services qualify as primary care, and are subsequently integrated into its patient-centered medical home initiative and integrated delivery system models.||In phase two of its model the services for which ACOs participating in Medicaid HCDS and Hennepin Health (safety-net ACO) are held accountable will be expanded by the Minnesota Department of Health Services (DHS) to include intensive mental health, long-term care, and home and community-based services.||Oregon is using SIM to provide TA to CCOs in order integrate mental health and addiction services. Oregon has also identified measures related to mental health and substance abuse that CCOs will be required to report.||Community Health Teams are the heart of Vermont’s Blueprint Model. Under the model these teams may be expanded to include the identification of, and coordination of care for, high-risk individuals with multiple chronic conditions and people living with mental health and substance abuse disorders.|
|Engaging and Integrating Community Health and Prevention into Delivery System and Payment Reform Models||Referrals to community and social supports are a critical function of Health Homes in the CMS definition. Health Homes will work in collaboration with medical homes to coordinate across all types of care for individuals, and to support them on care transitions, adherence to a care plan, and access to community and social supports (SIM plan 17).||Maine will employ several strategies to activate consumers and communities including: increased use of shared decision making tools, learning collaboratives to disseminate patient engagement tools, and increased public awareness of shared decision making and health care self management. The model also builds off of existing strategies including consumer supports such as Better Health Better ME and Get Better Maine and existing patient supports including: peer navigators, peer supports, and community health workers.||The model builds off of Chapter 224, passed in 2012. This law created thePrevention and Wellness Trust Fund, and provides the fund with $57 million over 4 years. This fund is administered by the Department of Public Health and supports community-based partnerships including municipalities, healthcare systems, business, regional planning organizations, and schools to work together to provide interventions that: reduce rates of the most prevalent and preventable health conditions, increase healthy behaviors, increase the adoption of workplace-based wellness or health management programs, and address health disparities.SIM funds will support the development of an electronic open-source referral system to nine community health centers (CHCs) with a minimum of four different community resources. Additionally, 30 CHCs have committed to transforming into PCMH.||Accountable Communities are explicitly set up to be guided by local needs assessments, with wide flexibility in determining which community organizations to partner with and which services to prioritize, as well as how to integrate various health care streams and determine financial allocations. Minnesota’s SIM plan will also link with Health Care Homes and Community Care Teams already underway in Minnesota. Minnesota has also created aCommunity Advisory Task Force, focused on engaging communities and patients.||Oregon’s model integrates Non-Traditional Health Care Workers (NTHWs), which include Community Health Workers, Peer Wellness Specialists, Patient Navigators, Doulas and Health Care Interpreters.A core requirement for CCOs is that they collaborate with local hospitals, public health agencies, social services organizations, and others to conductcommunity health needs assessments, and develop a community health improvement plan based on the needs and resources identified.||Practices participating in the Vermont Blueprint for Health are complemented by and collaborate with Community Health Teams (mentioned above). These teams connect patients with existing and developing social and community supports and increase the effectiveness and span of primary care in managing population health. These teams will be expanded under the SIM model.|
|Population Health Metrics Used in Model||Arkansas will monitor progress indicators and intermediate outcomes including: decreased disease progression (e.g. diabetes, congestive heart failure), greater control of hypertension, reduced re-hospitalization rates and ambulatory sensitive hospitalizations (e.g. pneumonia, asthma), and fewer late-stage cancer diagnoses. (SIM plan 13). Specific goals include: reducing premature deliveries (before 39 weeks) to less than 10% statewide, achieving 50% adherence rate of comprehensive diabetes metrics, and measuring and improving documentation of blood pressure control in PCMHs. (SIM plan 15).||MaineCare will be submitting an Integrated Care Model state plan amendmentfor its Accountable Communities initiative. This will include a quality framework with goals and objectives, specific quality measures, and how quality measurement will be used to improve care. MaineCare’s Health Homes State Plan Amendment will also include an alignment with CMS Adult and Children’s Core Measure sets. To measure patient experience of care Maine will conduct a statewide CG-CAHPS survey.||Massachusetts will use the performance measures developed for Primary Care Payment Reform (PCPR). Massachusetts selected measures that are externally validated and already in use, such as measures compiled by HEDIS, AHRQ, CMS, and private payers in the state. These metrics focus on: adult prevention and screening, health and care coordination (adult and pediatric), adult chronic conditions, access (adult and pediatric), and behavioral health (adult and pediatric).||Possible metrics for Minnesota Accountable Communities for Health include: reduction in chronic condition exacerbations, chronic disease management, patient satisfaction with quality and care coordination, patient engagement in health care and health, health disparities, preventive care utilization, access to care, community services and partnerships, behavioral and mental health services resources, and others.||Oregon’s model calls for the OHA and its CCOs to collect several measures related to population health in various areas including health disparities, member/patient experience of care, tobacco use, obesity rate, health and functional status, and several others.Each CCO is expected by contract and accountability metrics to prioritize working with members who have high health needs, chronic conditions, mental illness or chemical dependency and involves those members in accessing managing appropriate preventive, health, remedial and supportive care and services.||Vermont’s SHIP cites its state health assessment (Healthy Vermonters 2020) to describe priority indicators. These include:• Increase the percentage of adults who meet physical activity guidelines from 59 to 65%.• Reduce coronary health disease deaths from 112 to 99 per 100,000 people• Increase the percentage of adults who receive recommended colorectal cancer screening from 71% to 80%.• Reduce hospitalizations for asthma in children under 5 years of age from 18.8 to 14 per 100,000 people.
• Increase the percentage of children 19-35 months who receive recommended vaccines from 41% to 80%.
• Reduce the percentage of 12-17 year olds who binge drink from
Vermont’s SIM will also accelerate the development of a Learning Health System infrastructure designed to meet the needs of providers engaged in delivery system reform and the state’s need for ongoing evaluation of the impact of reforms in a number of areas including population health.