The Rhode Island Chronic Care Sustainability Initiative (CSI-RI)

1. The Rhode Island Chronic Care Sustainability Initiative (CSI-RI) Presentation for RIBGH September 21, 2012 Debra Hurwitz, MBA, BSN, RN David Keller, MD CSI Co-Directors

2. The Rhode Island Chronic Care Sustainability Initiative (CSI-RI) Vision Rhode Islanders enjoy excellent health and quality of life. They are active participants in an affordable, integrated health care system that promotes wellness and delivers high quality, comprehensive primary care. Mission To lead the transformation of primary care in Rhode Island. CSI brings together critical RI payers, providers, purchasers, consumers and other leaders to develop, implement, evaluate, refine and spread models to deliver, pay for and sustain high quality comprehensive primary care.

3. Joint Principles of the PCMHAAP, AAFP, ACP, AOA , March 2007 Personal physician Physician-directed medical practice Whole person orientation Care is coordinated and/or integrated Quality and safety Enhanced access to care Payment to support the PCMH

4. What is CSI-RI? • Working with all major health care stakeholders to transform primary care in Rhode Island. • Promotes the PCMH, a model of primary care that is patient-centered, coordinated, accessible and team-based. The model focuses on prevention, wellness and appropriate treatment. • This will lead to improved care, lower costs and better health outcomes for Rhode Islanders.

5. It Takes a Team…

6. CSI-RI Collaboration Partners Payers • Medicaid • All commercial plans • Medicare Purchasers • Self-insured employers Providers • Primary care providers (private practices, community health centers, hospitals and clinics) State • Office of the Health Insurance Commissioner, Executive Office of Health and Human Services, Department of Human Services, Department of Health Technical Experts • Department of Health; QIO

7. CSI-RI helps plans and practices build sustainable Patient-Centered Medical Homes • Data-driven practice transformation • NCQA Level 3 • Nurse Case Manager on the team • Common Contract • All-payers involved • PMPM paid on attributable lives • PMPM based on performance Used with permission of Ed Paul MD, Yuma Regional Medical Center 7

8. CSI-RI is growing • 5 practice in 2008 • 13 practices in 2010 • 16 practices on Oct 1 • Future: • Learn and refine model with RIQI • More sites in 2013 • Employer engagement (benefit design) • Employee engagement (PCP designation)

9. Key Elements of CSI-RI PCMH • Common Contract additional payment PMPM • Nurse Care Manager at the practice site • Practice coaching for team-based care • Participation in learning collaborative • NCQA recognition Level 3 • HIE capacity • Common measures of performance for improved management of chronic conditions (i.e., diabetes, heart disease, depression, tobacco cessation) • Data and reporting on quality measures • Performance incentives based on PMPM

10. Care Management ActivitiesNurse Care Manager lynchpin for success • Located within practices, regardless of payer • Care Manager college • Activities • Identification of high risk patients • Patient assessment • Care coordination (transitions of care; specialist referrals; home- and community-based services and supports) • Patient/family education • Engage patients in shared decision-making • Team communication

11. CSI-RI and PCMH: What’s the Evidence? Building CSI-RI • Evolving evidence • AHRQ • PCPCC • Early evaluation • Practice transformation • Impact utilization • Ongoing evaluation • Quality • Experience • Cost

12. AHRQ Review “Overall, these findings are encouraging … Our horizon scan identified ongoing studies … that, when published, should more than double the size of the published literature … most are being conducted with the participation of a commercial insurer.” - AHRQ, 2012

13. PCPCC “This report provides significant evidence that Patient-Centered Medical Homes around the country are reducing costs while improving quality of care, access and patient satisfaction for both children and adults.” - PCPCC, 2012

14. PCMH: What works? • Using Health IT to drive patient care • Renaissance Medical Management, PA: Patient engagement reduced hospital admissions and emergency room utilization • Enhanced access • Seven projects in VT, ND, CO, UT, WA, NC, PA: Enhanced communication off hours, reduced preventable hospitalizations and PMPM costs • Use of high-value specialist • Qualitative evaluation of four high-performing practices showed association with reduced costs

15. PCMH: What works? • Population-based care management programs • Care Continuum Alliance: Effective use of registries improved risk factor management • Patient engagement • NC: Patient engagement associated with cost savings of 7 – 15% over four years • Community health teams to manage and coordinate care • VT: CHTs reduce hospital and ER utilization, and enhance utilization of behavioral health resources

16. Evaluating CSI-RI

17. Early Years: 2008-2010 • External evaluation • Commonwealth Fund • Impact on practice • Impact on quality • Impact on utilization • Comparison group

18. NCQA-PPC Improvement Across Submissions Based on PPC-PCMH 2008 Standards Percentages calculated based on formula: points earned / total possible points From M. Rosenthal, Presentation to CSI-RI Steering Committee, 7/13/2012

19. Key Findings • Small changes in outcomes by year 2 • Improved quality • Reduced use of ER for ambulatory sensitive conditions “CSI-RI evaluation suggests that WITH ADEQUATE FINANCIAL AND TECHNICAL SUPPORT small practices can make significant strides in adoption of medical home structures and processes” From M. Rosenthal, Presentation to CSI-RI Steering Committee, 7/13/2012

20. Pilot Successes From M. Rosenthal, Presentation to CSI-RI Steering Committee, 7/13/2012

21. Ongoing Evaluation is driven by the Common Contract • Infrastructure • NCQA Level 3 • Nurse Case Manager on the team • Quality measures • Six in 2011-12 • Seven in 2012-13 • Patient experience • Communication, office staff and access • Utilization • ER use and hospitalization

22. CSI-RI: Building Infrastructure NCQA Level 3 Recognized (2011 Criteria) • Family Health and Sports Medicine (Cranston) • Hillside (Pawtucket) • University Medicine – Governor St. (Providence) • Coastal– Greenville (Smithfield) • Thundermist Health Center (Woonsocket) NCQA Level 3 Recognized (2008 Criteria) • Stuart Demirs, MD (Charlestown) • SCH Family Medicine (East Greenwich) • Memorial Hospital Family Care Center (Pawtucket) • Cesario, Kostrzewa, Maguire, Gonzalez (Wakefield) • Coastal Medical, Inc. (Wakefield) • Kristine Cunniff, MD (Wakefield) • South County Internal Medicine (Wakefield) • Thundermist of South County (Wakefield) • Blackstone Valley CHC, (Pawtucket and Central Falls) • East Bay Community Action Program (Newport) • University Family Medicine, (East Greenwich)*

23. Ongoing Measurement: Are we meeting the Triple Aim?

24. Population Health:Setting Quality Benchmarks • In 2011-12, within our practices: • Patients with diabetes will: • Control their sugar • Control their blood pressure • Control their LDL ( <100) • Patient with coronary artery disease will: • Be treated properly • Patients will be screened and treated for: • Depression • Tobacco use • Patients will report high level of care in • Communication, Office Staff

25. Quality Report Card- 2012 Green = Attained Target Value Yellow = Within 10% of Target Value Red = Not Attained Target Value

26. Measuring Patient Experience

27. Success means growing and moving on… CSI Pilot and Expansion Site Clinical Quality Data

28. Raising the bar… CSI Pilot and Expansion Site Clinical Quality Data

29. And resetting the standards • In 2012-13, within our practices: • Patients with diabetes will: • Control their sugar • Control their blood pressure • Control their LDL ( <100) • Patient with high blood pressure will: • Be controlled • Patients will be screened and treated for: • Obesity • Tobacco use • Patients will report high level of care in • Communication, Office Staff, Access to Care

30. Utilization as a proxy for cost

31. Are we reducing costs? Health plans think so. • Blue Cross Blue Shield of R.I. shows directional reduction (slowing) in inpatient admissions and cost trends at its PCMH sites. • United Healthcare’s internal evaluation is directionally showing a reduction in inpatient admissions and cost trend. National, state and internal business metrics are aligned.

32. What about the patient? “I enrolled in the health plan's medical home option, and selected this practice as our new provider. … We were surprised at the time the staff spent with each of us... We each left the office with a plan, and knew what we needed to do before the next visit. … Change isn't always easy. But I've had to get over my "too busy to take care of myself" mentality. … The patient-centered medical home required some thought, and some work, on my part. But this change has been the best decision of my life, and my family's lives as well.” Diane @ http://3blmedia.com/theCSRfeed/Dont-Let-Name-Fool-You-My-Medical-Home-Experience

33. The future of PCMH “Why would anyone want to buy anything else?” - Paul Grundy, IBM • Expanding the model in Rhode Island • More practices • Benefit designs focused on PCMH • Preparing for the newly insured • Including pediatrics • Building block of new systems of care • ACOs and integration with hospitals • Community Health Teams and public health