Health Care Homes Community Meeting - December 12, 2008
Question and Answer Panel
- Dr. Sanne Magnan, Commissioner of Health
- Carol Backstrom, Assistant to the Commissioner
- Carolyn Allshouse, Cordinator, Minnesota Learning Collaborative
- Marie Maes-Voreis, Program Manager, Health Care Homes
Audience Question No. 1
Will community-based providers like block nurse programs have access to care coordination payments?
Sanne Magnan:
I think that’s as we set out looking at what are the outcomes we are trying to accomplish, and what are the criteria for who can be a health care home, that’s all part of this process, so I can’t answer that right now, but again, it’s looking at the outcomes. Somebody asked the other day, can a specialist be qualified for a health care home? Again we are going to have to go back to the outcomes, what are we trying to accomplish, what are we trying to put forward. But we expect that there will be some different models. We expect it’s not just going to be the tried and true, so we would invite things like that to think outside the box and think about how could people be health care homes that we haven’t traditionally thought of?
In fact, someone was having a big discussion about, well, are health care homes individual doctors, or are they clinic systems, a group of providers? You know, who can be a health care home? And this physician I think wisely said, “You know in some sense we ought to be thinking about how health care homes could be a community?” That it’s really a community. So you know block nurse programs is getting closer to that concept as a community, so I would say keep those ideas and those thoughts coming, and look and be involved in how this evolves.
Marie Maes-Voreis:
And just a note related to that, in our workgroups, we really wanted to make sure we included those people in our work and our thinking, so we have invited local public health representation and also the home care association to participate in our work.
Audience Question No. 2
Is the medical home index published for interested parties, and where might that be found?
Carolyn Allshouse:
The medical home index is a tool that was developed by the Center for Medical Home Improvement. And they have a Web site. They are a national medical known group. You can google them. I don’t have the Web site memorized offhand, but we also do have the tool on the Department of Health, Minnesota Children with Special Health Needs section Web site. So it can be accessed in a couple of different ways, and it can be downloaded and it can be used and there is a pediatric medical home index and an adult version of the medical home index for adult providers.
Audience Question No. 3
How do psycho-social services such as those for behavioral health fit into a health care home?
Carolyn Allshouse:
I can tell you from the work that we’ve been doing, behavioral health has been a very important part of how the practices and the providers have implemented medical home. And in fact, I think working with all of the specialty providers has been very important in how they coordinate together and communicate together has been essential, so I think to answer the question, yes they are very important.
Marie Maes-Voreis:
And just a note in our planning process, we also have invited the behavioral health people from the Minnesota Psychological Association and another group to join us so that we have their perspective at the table.
Audience Question No. 4
Will this model integrate or replace current care coordination performed by health plans or counties?
Sanne Magnan:
I think this is part of the evolution. I happened to have worked at Blue Cross at one time where we had disease management coordination that was being done, and there was recognition by health plans that that needed to be gotten closer to the patient and their providers. So I think yes, things are evolving, but again, I think we have to keep looking at the outcomes, and what we are trying to accomplish. I think there will always be a role for case management – that is different than care coordination. There are lots of different roles and responsibilities, different things that need to be done within the health care system. But we are working to involve health plans in these discussions and thinking about how we move forward, but again, we’ve got to get back to, that’s why that outcome piece is so important. About so what are the outcomes? And if the current care coordination does better than what medical home is going to do, people are looking at what are the outcomes? How can we get the best quality for the dollars we are spending? So we need new models that are going to get us to the next place that we need to be.
Some of the other work that isn’t talked about here today, but as Jeff, or Marie or Carol mentioned, we are integrating with other health care reform legislation. There is a whole part in that legislation about visibility, transparency, of quality and cost measures. And that work is going on as we speak also. Minnesota Community Measurement, with a consortium of other groups, won that RFP to be working on collecting, what are the measures that we know? What are the things that we know that we can measure about patient experience? What can we measure about health? What can we measure about affordability, getting back to the triple aim? So those measures are being developed as we are thinking about outcomes, as we are thinking about design.
So again, I think that will help us in saying, “What do we need?” Do we need current care coordination? Is that doing a good job? …Groups that are working with that? Medical home groups? Block nurse programs?
…Other ways of being able to deliver the care and looking at how can we get the best value, and how can we know it.
Audience Question No. 5
We have tools to measure specific diseases like diabetes, but how do we change the model to support the conditions we are not able to measure, and their impact on the community?
Carolyn Allshouse:
One of the things that’s true for the population of children with special health care needs is that usually they don’t have specific diagnoses that can be measured and that there’s specific outcomes for.
And I think the success that we’ve seen in the pediatric population translates very well to the idea that there are diagnoses for whom there are specific outcomes that aren’t yet available or be able to be measured.
Sanne Magnan:
I think the other thing is this is part of the learning. Some places where there aren’t measures yet, and if we as a community say we want to develop some. Think about that clinic I just shared with those three measures. I don’t think any of those are out there in the public domain yet, but they are going to develop those measures of what they can do. There are measures, other ones, that we just, I went to a shared decision-making collaborative, and one of the measures I’d never heard of before was a measure of decisional conflict. And it was a measure saying that shared decision-making, you know some of Jack Wennberg's work, that could actually help to decrease patient’s decisional conflict. And I had never even heard of that measure. So I don’t know if it’s ready for prime time or not, so there are measures that we need to create that we don’t even have now, and particularly ones from a patient’s perspective. But I think the other thing I would caution us with is having to have the perfect measure. Sometimes you have to just start.
And I’ll give you an example of depression. In our community, well first we struggled with whether we have a guideline for depression. We finally got over that, and then we said, OK let’s measure patient refills of anti-depressants. And so we started with that measure, and then what we found was that clinics were focusing on …OK, are we documenting that the refills are being done, and we are not documenting whether the patient's actually getting better, or whether they are actually taking them. So it’s like, OK the measure was directionally correct, it was focusing on depression, but it was really focusing on a process that wasn’t related to necessarily the outcome.
So then we moved as a community to measuring PHQ-9s, and started working with clinics with a patient health questionnaire that actually is a true measure of outcome around depression, and so ICSI did some of this work, others have done some of this work, so we actually took this evolution of something where there was nothing, and worked carefully on improving it, and I am sure there is an improvement that needs to be made now, that I am not even aware of. So, yes there are going to be things that we don’t have measures for right now. There are some of the things that we are going to need to hear from you and from patients and communities of what do we need to be measuring that’s most important to you, and then how do we develop these new measures, and test them, and make them valid and figure out how they meet our needs.
Audience Question No. 6
In a health care home the payment coordination payments may not start right away.
How can we address the need for infrastructure, investment by clinics, or primary-care collaboratives?
Marie Maes-Voreis:
We have a number of grant opportunities coming up. Right now the Department of Human Services and …I am sorry Dr. Schiff isn’t here ... they are just going through a process around some RFPs around the PCC standards. Later on in the process, we will be looking at some care collaboration grants. We just wrote one of those, and Sarah, do you want to add anything to that, around the care collaboration grants?
OK, so anyway, those will be coming out sometime later in the year, around looking at, OK, what are the pieces that we need to put in place in helping systems to take a look at those. So we are just on the cusp of putting that together, and sometime in January that will be posted out on our Web site.
Audience Question No. 7
Under health care homes, will health plans be able to provide their own care coordination and not pay the provider or clinic directly ...in a high-risk pregnancy, for example?
Sanne Magnan:
This is kind of a part of the evolution, you know the health plans get to decide that. That’s not for us to decide. I think it's going to determine what population. That’s about case management in that particular setting. And that may be a role for case management versus for care coordination within a clinic system, so again we are trying to make a better system in what goes forward. I think it’s going to determine, as I said in my brief opening remarks, what patients? What's the initial patients that will qualify? And it’s to focus first on the most complex, complicated patients. And we need to decide what’s that group of patients, that the care coordination payments will be for. But again, this whole redesign of care is really about redesigning care for everyone. And there will be some patients that are eligible for the care coordination payments …and then as that evolves and we show that we can produce better outcomes at a better cost, I think it will expand more, but we are going to have to start somewhere, so, I don’t know that that group will be the first group that might get included, or if it will be another group. Certainly the children with special health care needs and some of the patients with complex medical conditions at DHS is going to be the first place that they are putting their focus.
Audience Question No. 8
Can you say more about the makeup of the work groups, and if we are not part of the work group, how can we weigh in?
Marie Maes-Voreis:
We divided the work groups at this point into the five areas. We have representation from agencies, consumer representation, other providers in the state, such as the Minnesota Dental Association, the Minnesota Hospital Association, the Minnesota Medical Association, Minnesota Visiting Nurse Association, those professional other provider organizations. The payers, the Minnesota Council of Health Plans, the Minnesota Department of Human Services, and a number of other payer groups, and then a broad number of representatives of primary care providers. The Minnesota Academy of Family Physicians, Pediatrics, the Osteopathic Medical Society, and then a number of community clinic representatives, such as the Neighborhood Health Care Network, and a number of representatives from the Indian Health Board as well. As far as those agency groups, we have agencies that are representative through government and also through communities such as the Minnesota Community Measurement and the Minnesota Chamber of Commerce. …So a very broad group of people.
As far as the second part of your question, we really welcome your feedback and we are planning to put our work up onto the Web site so that you can review our progress and send us feedback. As well as you can contact any of the other of us on this contact sheet. If you have specific ideas or suggestions around other ways to give feedback or participation, we really welcome hearing that.
Audience Question No. 9
There are a number of questions that focus on primary care.
Sanne Magnan:
And I would just refer to the legislation that talks about that the standards for health care homes are to, quote, “…emphasize, enhance and encourage the use of primary care.” So it doesn’t say that it’s exclusively primary care, but it does say that it’s to emphasize, enhance and encourage the use of primary care. Why is that? It’s because research shows that places you have primary care, it’s associated with higher quality and lower cost. It’s part of the triple aim. …And that patients who experience good primary care are very satisfied. So how it all fits out, and again whether others can be, and how primary care can be defined and what it can look like can really vary, but the legislation does say that health care homes are to emphasize, enhance and encourage the use of primary care.
Audience Question No. 10
A timely question is what is the effect of the state's budget deficit and our ability to carry out work on health care home?
Sanne Magnan:
(Laughter) Someone in the audience who would like to take that? You know, we are continuing to proceed. The authors of this bill, Senator Berglin and Representative Huntley, I was just at a reforming states group meeting with them, and they are very pleased with where we are headed. They have given no indication that we are supposed to slow down. And in fact you can argue that what we are doing is actually going to help the budget situation.
I mean if we can get better value, better quality, more appropriate care for people that’s more affordable and a better patient experience, we are going to help the state budget; and we are going to help the state economy; by businesses being able to afford health care, and businesses who want to stay in our state because we have a healthy work force.
So we are proceeding full steam ahead, but I will acknowledge it will be a challenging legislative session. And so I would encourage all of you who care about the components of the health care reform bill that were passed, everything from the Statewide Health Improvement Program, to the health care homes, to all the pieces …that you would let your voice be heard, about what you think, and what you value, and where you think we should invest. But it is going to be a very challenging budget season coming up.
Audience Question No. 11
Is there an opportunity for more clinics and/or teams to join the medical home learning collaborative, and if so, how?
Carolyn Allshouse:
We are, at this point …We don’t know the method that will be ongoing for adult learning and the collaborative learning models. So the current learning collaborative is going to continue through the end of June, and then we will have a new process in place but we don’t know what that will be yet. And so we do want providers to participate in what will evolve into the next collaborative learning process, and again, we will make that known as that is developed.
Audience Question No. 12
Can anyone on the panel say more about patient choice and how that fits into the concept of health care home?
Carolyn Allshouse:
Well it’s essential. I think this is really key to the concept of a primary care relationship. And what Commissioner Magnan already said is in the legislation really is designed I think to support the fact that the primary care relationship with the patient and with the family is key to quality health outcomes, and that really is the foundation for the work that’s been done nationally around medical home, and what is going to be happening with health care home in Minnesota.
Sanne Magnan:
I just had the legislation in front of me. I was trying to look. At one point the legislation had that certain patients were going to be required to be in a health care home. And because one of the values that Minnesotans hold dear in their health care system, when you talk about what they want, is they want choice, as Carolyn said. So the legislation doesn’t require patients to be in a health care home. Choice is very important for patients. Choice of providers, choice of plans, you know, choice of what they want to do.
And I think we need to honor that, even when sometimes that choice doesn’t follow what we as providers want them to do. And, as long as they understand and are fully informed, I think we need to honor those choices. …So I think the system is being designed with, as Carolyn said, choice being an essential component.
Audience Question No. 13
This is a question about the concept of a virtual health care home versus an actual physical place. This is a question…virtual health care home versus a physical place.
Carolyn Allshouse:
The concepts behind medical home and health care home is that it is not intended necessarily to be a specific location. It is a philosophy of providing care in partnership with families and patients.
So, the ultimate goal would be that a provider chooses to enhance the way that they provide primary care in partnership with the patients and families that they service, so that when a patient goes to would, in partnership with the patients and families that they serve so that when a patient or family member goes to a primary care physician they are getting that high-quality care. I’m not sure if that’s addressing the question.
Sanne Magnan:
I think what the person may be getting to and what I as Commissioner of Health, and I am sure Commissioner Ludeman would love to see is some different models and to get way from the tyranny of the visit. And that’s the whole purpose behind care coordination payments to get away from; oh the only way providers get paid and business-wise is to have a visit.
How many of you in the audience have Facebook. OK! Some people in the audience. You look at the next generation coming up and how they stay connected, and how they get information, and how they put things together. We can really begin to think about how do we build health and health care in a totally different way. …Totally different social connections, dynamics, getting information. I mean go out and look at some of these patient-centered Web site things. I think one of them is “Patients Like Me?” Is that the one?
Yeah, “Patients Like Me.” There are patients who are forming their own clinics in some sense, on line to address their needs. It’s patients like me …some of these very rare conditions …So they have patients across the entire world who are getting help, and information, and advice, and health care in some sense through this process. So I think the concept of, again coming back to those, what are we trying to accomplish? If we can show we can put that together, I think there’s huge potential for that, and particularly for the generations coming up.
So we should not be locked into the traditional models that we have now, of who does it, and where they do it, of how we want to get to this triple aim of improved patient experience, improved health and improved affordability.
Audience Question No. 14
I've been through the presentations, and the concept seems theoretical and undefined. Could someone on the panel give an example of one family that could be helped by health care home?
Carolyn Allshouse:
I think I can give you some examples that I hope will be helpful. In the pediatric medical home model, there’s a young man who was born with very significant medical conditions, that required a great deal of medical support. And his family was seeing a wonderful pediatrician who was very supportive and provided great care, but deferred everything to specialty care, because he was uncomfortable with the ability of his own practice to be able to really coordinate and make decisions about that particular child.
The family ended up switching to a different primary care provider, who was practicing within a medical home model. And initially that child and family developed a care plan to address all of the specific diagnoses that the child had, and the ability to be able to coordinate with all of the specialty care within that primary care setting. So that that primary care physician was able to communicate with all of the specialists involved with that child’s care, and they were able to really come up together with the family to develop a real plan that was an approach that allowed the family to anticipate what was going to happen as the care needs went along.
I think the concept of having a planned care visit where you spend time really going over each of the diagnoses. What’s the status of the diagnoses? How are the medications working? So taking the time to really look at the whole picture. Is the child up to date with all of the preventive care that’s needed, all of the immunizations, and being able to have that all put together in a plan.
Then the family is able to take that plan when they do go to see the specialist and say, ”Here is the plan that we have developed, and here are all of the things that we are going to be doing over the next maybe six months, or maybe the next year, to make sure that we are addressing all of the issues in this child’s care that’s needed.”
This allows the family to be actively involved; it also allows the specialist to be actively involved; it helps to prevent duplication of services because there’s a very specific plan in place; and there also is known to the family, “What do we do when the child is sick?” “How do we access the appropriate physicians and get the support and care we need in an acute situation, as well as that planned care.”
I am hoping that that helps to paint a clearer picture a little bit better about what happens.
Some of the things that the clinics are doing are pre-visit phone calls for families where before a family is coming in for that planned care visit, they call ahead and say to the family, “What are your goals to accomplish in this visit that you are coming in for next week?” And that gives the provider an opportunity to have an awareness of what the family’s goals are, and be able to address that in that planned care visit, and then hopefully incorporate those goals to that care plan as well. Does that help?
Assistant to the Commissioner Carol Backstrom:
I think that’s a great example. Marie, did you want to say something?
Marie Maes-Voreis:
Yes, I would just add one more thing in that in the health care home the clinic is deliberately developing systems for planning for patients as a team, and the clinic is continuously doing quality improvement, and looking at communication mechanisms with patients and how is that impacting their outcomes? And there is a much more deliberate team effort to support the clinician and to have people doing the right work at the right time, as well as making a more desirable working environment for the team, because they have each other to count on rather than making all of the work feel so burdensome for just one or two members of the team, and really setting a plan, around how to work as a team and how to measure your work. And I think that’s one of the differences that I have observed.
