Rural Health Advisory Committee
Tuesday, March 26, 2013
9:00 a.m. - 11:00 a.m.
RHAC Members Present: John Baerg, Tom Boe, Tom Crowley, Ray Christensen, Ellen Delatorre, Daron Gersch, Margaret Kalina, Jackie Osterhaus, Millicent Simenson, Nancy Stratman, Tom Vanderwal
ORHPC Staff: Rachel Gunsalus, Tim Held, Mark Schoenbaum, Kristen Tharaldson, Will Wilson
Guests: Virginia Barzan (Minnesota Academy of Family Physicians), Marie Maes-Voreis (MDH Health Care Homes)
Health Care Homes Update
Marie Maes-Voreis (MDH Health Care Homes program). Ms. Maes-Voreis is a nurse with 25 years of experience working in primary care. She was a lead nurse for family medicine clinics at Hennepin County Medical Center and served on the medical home team at Park Nicollet.
The health care home (HCH) framework is based on the Institute of Medicine’s Triple Aim which includes three goals: healthier communities, better health care and lower costs. HCHs are part of Minnesota’s health reform efforts and connect to statewide quality reporting systems and future State Innovation Model (SIM) grant activities.
HCHs work with public health systems to serve local communities. They are not a service that only benefits people living with chronic or complex conditions. One provider said that after becoming a health care home, his workload was reduced and more information was available at clinical decision points because team perspectives are used in the new system.
Currently there are 226 certified health care homes in Minnesota. This represents 31 percent of primary care clinics. The certification process is voluntary and includes benchmarking. HCH standards include:
- Access - 24/7 to medical record.
- Care Coordination - happens on a continuum of services.
- Registry tools – patient tracking.
- Continuous improvement - care transitions.
There have been challenges related to the payment methodology. However, bigger companies have started to pay for HCHs, including Walmart and Blue Cross Blue Shield. There is a lot of interest in trying to resolve payment issues in general. The Medicare Multi-payer Advanced Primary Care Practice (MAPCP) demonstration project has been around for 18 months, and will be continue for three years. This allows for reimbursement for care coordination services for fee-for-service Medicare beneficiaries. Some clinics are submitting a lot of claims related to Medicare, and some are submitting none.
An evaluation consultant has been hired to determine next steps for improving HCH care coordination payment mechanisms. MDH has looked at payment models in other states including attribution models, care coordination grants and flat rates per patient. Minnesota will need approval from CMS for any changes in the current payment methodology. There will also be development of expanded payments for behavioral health homes (BHHs). The ultimate goal is to make sure payment for care coordination reaches primary care providers.
MDH has hired regional HCH nurses to support implementation and program development. HCH nursing staff are willing to work with clinics to determine concerns and barriers. Also, learning collaborative trainings will take place May 1-2, 2013. Topics will include: care coordination, care planning, complex Medicare patients, diabetes prevention for pre-diabetics, smoking cessation, and cross walking HCH programs with meaningful use of EHRs.
Health Care Homes Q & A
Ray Christensen: How will medical students learn this system and be utilized in HCHs?
Marie Maes-Voreis: There is interest in the metro area to include medical students and residents into the HCH model. HCMC has included a curriculum for training medical students into this system. There is still work to do to include medical students.
Ray Christensen: Is there anything in the HCH program to compensate for education?
Marie Maes-Voreis: Currently there is no specific payment for education. We’re going to have to think about this as health care homes evolve. We’ve provided mini grants for clinics for implementation, so some clinics may have put those dollars towards education.
Ray Christensen: I believe medical students need to be involved, as well as physician assistants and nurse practitioners. I like the inter-professional components that could come out of this. We need to make sure that rural providers are being compensated for education.
Daron Gersch: Is the health care home model available for all types of patients? The payment model is different for chronic disease patients and patients from the rest of the clinic.
Marie Maes-Voreis: The HCH program does look at the complexities of the patients. We’re looking at care coordination for people who need additional resources. Patients in Level 1 may be very busy at first, and then over time, the clinic receives care coordination payments to help maintain that patient. The more complex patients require more care coordination. This is the reason the payment methodology started there.
Daron Gersch: I come at it from a different angle. Rural Minnesota has limited resources. We would have an easier model if there was a set amount per patient, and that would take away the burden of trying to tier and activities involved with that. Is it true this type of payment would not be allowed?
Marie Maes-Voreis: Yes, you’re right, the law would not allow that type of payment at this time. We have to go back to the original principles. Do complex patient’s require additional care coordination? The tiering is a common part of medical home models, and these models use medical tiering to sort out patients from a population-based perspective to see who needs more resources and who needs less. The whole team needs to know the very complex patients, and know they have additional resources for tracking these patients.
Daron Gersch: When tiering is tied into the payment, it adds an extra burden for rural providers.
Marie Maes-Voreis: Providers were involved in the planning. Some clinics have been able to implement this in a very efficient way. It requires you to move some processes from the clinical side to the financial side. There will be additional opportunities to have input on this.
Tom Crowley: Our hospital has a pre-diabetics program, smoking cessation program, and we were excited about HCH components. We made contact with the state that we’d like to be a health care home provider, but we cannot because we do not employ physicians. Our physicians are part of Mayo, and other staff is hospital-employed. How does that work for a hospital that provides programs to complex patients? Also, 40 percent of our patients come from Wisconsin. How do we integrate them into HCHs as well?
Marie Maes-Voreis: These are really good questions. We’ve certified various clinics, including border clinics, HIV clinics, and a mental health community clinic. Let’s connect to discuss the situation.
Tom Vanderwal: Has EMS been involved in development of HCHs? Have you included the community paramedic community? How will the payment methodology blend in with that?
Marie Maes-Voreis: One clinic works directly with community paramedics to do lab draws, follow up safety checks, look at elements on the care plans, and get patients back into clinic. We think that’s a good intersection, and it will evolve over the time.
Mark Schoenbaum: The State Innovation Model (SIM) grant emphasis is on Medicaid ACOs that are already in place, and then it will move onto broader concepts of community-oriented accountable care.
Marie Maes-Voreis: We have three community health team pilots to expand roles. Community health workers are working in the primary care clinic, and are extensions into the community. This might be a good topic for the rural health conference.
Daron Gersch: I’ve heard from health care home providers that some patients are being charged co-pays for health coordination fees, and they’ve dropped out because of that.
Marie Maes-Voreis: We have heard that concern with patients that have employer-based insurance with high deductible plans. Unfortunately, this area is located under the federal tax code and it is hard to get around that. Some clinics have been able to work around that, but it remains an issue. Some clinics have a policy to write it off. It is a decision made at the clinic level. We do not want patients to have care coordination copays. It is a huge barrier. However, this situation is extremely rare. Very few clinics are allowing it to happen. They’re working with their payers and with their contract agreements or have an internal policy.
It is clear from this discussion that HCHs work differently in rural areas. What does the Rural Health Advisory Committee want to do on rural aspects of health reform implementation? The options are (1) stop here, or (2) keep it on watch status or (3) explore it further in an issue brief.
Tom Crowley: We should continue the dialogue, and see how we can better serve patients. Maybe a sub-committee of rural providers could bring their issues.
Jackie Osterhaus: Our system hasn’t jumped in yet, so what do you see are the major issues for implementation of HCHs in rural?
Daron Gersch: The biggest barriers are the amount of work needed to become a health care home. You need to invest a certain amount of money upfront, and the payment methodology is a problem. The current payment methodology is such that you do not get paid back nearly enough for what you are putting in, and that is very important for rural. Our administrators think it’s a good idea, but if it means we have to remove different parts of our programs, it’s a hard sell at this point. If we get better payment systems, it would be easier to sell if it would pay for itself down the road after initial startup costs.
Behavioral Health Update
Rachel Gunsalus (RHAC intern). In 2011, Minnesota had a total of 1110 psychiatric patient beds, with 500 in non-metro areas. The number of beds in rural areas increased from 169 in 2007 to 291 in 2011. However, the number of psychiatric patients is increasing as well as the number of psychiatric patient transports.
Community Behavioral Health Hospitals. Community Behavioral Health Hospitals (CBHHs) were implemented in 2007. At the start, there were 10 CBHHs with 16 beds each. The length of stay in CBHHs tends to be shorter (19 days) when compared to state hospitals (45 days). They provided 24-hour nursing care, including illness management and recovery. Over time, staff shortages became a problem and CBHHs were not working to full capacity.
In 2013, only seven CBHHs remain open. There were 1,488 people served in 2011 and 95 percent were from non-metro areas. Additional staff such as social workers, occupational therapists and dieticians have broadened the range of available services. Workforce shortages (RNs and psychiatrists) continue to be problematic. Patients CBHHs are unable to care for include those with complex health issues and violent patients.
One major barrier to better use of CBHHs is that medical clearance is needed. No medical care or primary care is provided on site. This challenge was not a problem initially; however, there have been substantial increases in patients with serious mental illness, complex medical conditions and violent behavior. It is difficult for non-metro areas to provide specialized services for these populations. In the metro area, only one location serves this gap for the mentally ill with violence problems.
Mental health bed tracking system. The mental health bed tracking system is an online bed locator for inpatient services. It was developed after a mental health workgroup tried to find solutions for mental health patients who enter hospitals through the emergency room. Early development began in 2007 and now it is used statewide. Mental health beds can be location by age or zip code. Services located by using the system are inpatient beds and adult community-based services.
The mental health bed tracking system runs on voluntary provider participation with email reminders to update the mental health bed count in an online system. EMS providers also access the bed tracking system remotely. Those who have limited access to the system include psychiatric patients, the general public and law enforcement.
Successes of the mental health bed tracking system include:
(1) Keeping hospitals accountable.
(2) Contract with the state of Vermont to develop a similar system.
Limitations of the mental health bed tracking system include:
(1) voluntary participation.
(2) No process for evaluation.
(3) Lacks children’s bed information.
(4) Lacks non-acute bed information.
Crisis Response Teams. There are 41 active members of crisis response teams (CRTs) in Minnesota. Medical Assistance pays for face-to-face crisis response, but there is not payment for follow-ups, staff on-call or non-public program patients. An evaluation showed CRTs lower the burden of mental health calls for law enforcement and admissions to emergency rooms. A 2007 Governor’s Mental Health Initiative provided $6 million for initial program development. Governor Dayton has currently proposed $2 million to establish four additional CRTs to serve 16 additional counties and two tribal communities.
Some CRTs are mobile and some are used in residential settings. The number of mobile interactions (episodes) is increasing and the number of referrals after interventions is also increasing. CRTs are effective because they locate appropriate levels of care for assessment and treatment of psychiatric cases.
CRTs also work with police and other first responders. They may provide training for law enforcement to change how communities respond to mental health crises. Communities can define which field responses are most appropriate given local resources. Community education is also needed to educate EMS, hospitals and clinics about the approaches used by CRTs.
Behavioral Health Q & A
RHAC members identified responses to behavioral health emergencies as an issue the committee is interested in hearing about. Rachel shared a lot of information. Where do we go from here? Does this satisfy your interest, or should we take further steps?
Tom Crowley: An issue we face is the county not being able to staff community health services, which restricts access to crisis units and services being readily available. It is still a struggle to find beds, do crisis intervention and place difficult individuals. Where are adequate resources to fund these programs? How do we use this to educate our county commissioners to get budgeting decisions to fund these issue?
John Baerg: The biggest problem in the county is that the sheriff’s department/jail was the mental health resource of choice, and we know that’s inappropriate.
Jackie Osterhaus: It seems crisis intervention teams are working as local emergency resources. We need to get that information out to those who do not have crisis intervention teams and could benefit from forming one.
Tom Vanderwal: Let us vision ahead a little bit. Using community paramedics, or blending utilization of community paramedics with behavioral health care coordinators - have they talked about that with health care homes? Its sounds like mental health is set aside as another health care home model (i.e. behavioral health homes).
Mark Schoenbaum: Some HCHs do a better job of including mental health than others. One of the precursors to the HCH model is the DIAMOND Project. It is used to managed depression care in adults.
Regarding the Governor’s proposal to fund additional crisis response team, some committees in the past have chosen to weigh in with their support or opposition to policies and proposals that are under consideration. If RHAC was so inclined, there is certainly a precedent and a role for you to do that. Would you like to weigh in on the budget proposal?
A motion was made to write a letter of support (Daron Gersch). Second (Ray Christensen). Motion passes.
Mark: We’ll draft something and work with John to get it ready to get a signature and be forwarded.
- ORHPC staff will be involved in a strategic planning retreat, and will report back to you. Your work informs how we plan our priorities as an office.
- Rural health conference in June is coming together. We cover RHAC expenses to attend the conference.
- Dr. Gersch participated in a panel on health reform with Commissioner Jessen from Department of Human Services. It addressed a lack of access to psychiatric care, low imbursement for nursing homes, staffing issues in nursing homes and other issues. A fair amount of the panel discussion was rural-oriented.
- SIM grant: We’ll report on this grant more at the next meeting. We will send you a link to the summaries of that project if you want to know more in the meantime.
Meeting is adjourned at 2:00 p.m. The next RHAC meeting will be May 21st from 10-2pm in St. Paul at the American Lung Association.