Primary Care Medical Home Model

State: FL Type: Model Practice Year: 2010

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This practice addresses the public health issue of disparity in affordable healthcare coverage and quality of care for uninsured, low-income adults in Pinellas County. This population has a high prevalence of unmanaged chronic diseases and the average annual health care cost for people with chronic conditions is five times higher than for people without. In Pinellas, 19.7% of adults 18-64 are uninsured (BRFSS, 2008) and approximately 45% of uninsured adults in Florida live below the federal poverty level (Kaiser Family Foundation, 2007–2008). When compared to the United States and Florida, Pinellas County often ranks worse in leading health indicators for obesity, cardiovascular disease, and diabetes with significant racial and economic health disparities. These and other chronic conditions are among the key contributors to the rising cost of healthcare and a major source of illness, hospitalization and long-term disability.

The principal goal is to ensure access to the continuum of healthcare for 3,000 uninsured, low-income residents of Pinellas County, ages 18-64, living at up to 100% of the Federal Poverty Level. Overall, this practice intends to move healthcare from a sick care model to a disease management model promoting the integrated delivery of preventive care and disease management at the medical home. The first objective is 1) to establish a medical home for all within the target population. More than 40% of the uninsured (9% insured) report postponing or forgoing needed healthcare because they do not have a regular place to receive care. Approximately 20% of the uninsured (3% insured) report their usual source of care as an emergency room (Kaiser Commission on Medicaid and the Uninsured, 2003). The medical home has been shown to be a critical means for improving quality of care and containing healthcare costs. Having a medical home has also been associated with better health and reductions in disparities in health among individuals and populations.

Other objectives include 2) improving the health of the target population and 3) decreasing the cost of healthcare for the target population. Nearly half of all uninsured adults 18-64 suffer from at least one chronic condition and according to Centers for Disease Control and Prevention (CDC) reports, unmanaged chronic conditions account for 75% of the nation’s healthcare spending. Uninsured adults are more likely to have unmanaged chronic disease due to substantially higher unmet healthcare needs. Disease management of chronic conditions at the medical home reduces complications and demand for specialty care and acute services, reducing the overall cost of care for the target population.

The first objective was to establish three medical home sites and enroll 3,000 clients for 8,400 medical encounters. In year one, PinCHD had 5,733 clients enrolled in a medical home and provided 16,569 encounters. Medical home locations have grown from three to eight to provide access county-wide. The second objective was to improve the health of the target population. In year one, quarterly quality assurance audits were conducted using HEDIS measures and there were improvements in the health status of the target population as indicated by A1C levels, blood pressure readings, LDL levels, asthma therapy and tobacco cessation. The third objective was to decrease the cost of health care for the target population. In year one, decreased costs were realized from outreach, disease management, prescription assistance and volunteer specialists. Area hospitals made over 4,000 referrals to the outreach team who provided more than 1,500 eligibility and nursing assessments. There were improvements in controlled A1C, blood pressure and LDL levels which together provide an annual savings of $1,112 per client. MedNet navigators saw clients for an estimated $12.00 return on every $1.00 investment. The volunteer specialty network recruited 15 volunteer specialists who provided 953 encounters.

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Pinellas County Health Department
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Primary Care Medical Home Model
This practice addresses the public health issue of disparity in affordable healthcare coverage and quality of care for uninsured, low-income adults in Pinellas County. This population has a high prevalence of unmanaged chronic diseases and the average annual health care cost for people with chronic conditions is five times higher than for people without. In Pinellas, 19.7% of adults 18-64 are uninsured (BRFSS, 2008) and approximately 45% of uninsured adults in Florida live below the federal poverty level (Kaiser Family Foundation, 2007–2008). When compared to the United States and Florida, Pinellas County often ranks worse in leading health indicators for obesity, cardiovascular disease, and diabetes with significant racial and economic health disparities. These and other chronic conditions are among the key contributors to the rising cost of healthcare and a major source of illness, hospitalization and long-term disability. The principal goal is to ensure access to the continuum of healthcare for 3,000 uninsured, low-income residents of Pinellas County, ages 18-64, living at up to 100% of the Federal Poverty Level. Overall, this practice intends to move healthcare from a sick care model to a disease management model promoting the integrated delivery of preventive care and disease management at the medical home. The first objective is 1) to establish a medical home for all within the target population. More than 40% of the uninsured (9% insured) report postponing or forgoing needed healthcare because they do not have a regular place to receive care. Approximately 20% of the uninsured (3% insured) report their usual source of care as an emergency room (Kaiser Commission on Medicaid and the Uninsured, 2003). The medical home has been shown to be a critical means for improving quality of care and containing healthcare costs. Having a medical home has also been associated with better health and reductions in disparities in health among individuals and populations. Other objectives include 2) improving the health of the target population and 3) decreasing the cost of healthcare for the target population. Nearly half of all uninsured adults 18-64 suffer from at least one chronic condition and according to Centers for Disease Control and Prevention (CDC) reports, unmanaged chronic conditions account for 75% of the nation’s healthcare spending. Uninsured adults are more likely to have unmanaged chronic disease due to substantially higher unmet healthcare needs. Disease management of chronic conditions at the medical home reduces complications and demand for specialty care and acute services, reducing the overall cost of care for the target population. The first objective was to establish three medical home sites and enroll 3,000 clients for 8,400 medical encounters. In year one, PinCHD had 5,733 clients enrolled in a medical home and provided 16,569 encounters. Medical home locations have grown from three to eight to provide access county-wide. The second objective was to improve the health of the target population. In year one, quarterly quality assurance audits were conducted using HEDIS measures and there were improvements in the health status of the target population as indicated by A1C levels, blood pressure readings, LDL levels, asthma therapy and tobacco cessation. The third objective was to decrease the cost of health care for the target population. In year one, decreased costs were realized from outreach, disease management, prescription assistance and volunteer specialists. Area hospitals made over 4,000 referrals to the outreach team who provided more than 1,500 eligibility and nursing assessments. There were improvements in controlled A1C, blood pressure and LDL levels which together provide an annual savings of $1,112 per client. MedNet navigators saw clients for an estimated $12.00 return on every $1.00 investment. The volunteer specialty network recruited 15 volunteer specialists who provided 953 encounters.
Ensuring access to the continuum of healthcare for uninsured, low-income adults through the medical home model addresses the public health issue of disparity in affordable healthcare coverage and quality of care for low-income adults in Pinellas County, the high prevalence of unmanaged chronic diseases among this population and the high cost of caring for people with unmanaged chronic disease. In Florida, 26% of adults are uninsured and approximately 45% of uninsured adults live below the federal poverty level (Kaiser Family Foundation, 2007–2008). In Pinellas County, 19.7% of adults 18-64 are uninsured with the rate among Blacks almost three times higher than Whites (W: 9.5%; B: 27.8%) (BRFSS, 2008). In 2008, the unemployment rate for Pinellas was 6.3 %, up from 3.9% the year prior. The county has a poverty rate of 6.9%, per capita income of $29,139 and almost 30% of households with an annual income less than $25,000 (American Community Survey, 2008). When compared to the United States and Florida, Pinellas County often ranks worse in leading health indicators for obesity, cardiovascular disease, and diabetes with significant racial and economic health disparities. These and other chronic conditions are among the key contributors to the rising cost of healthcare and a major source of illness, hospitalization and long-term disability. Nearly half of all uninsured adults 18-64 suffer from at least one chronic condition and according to Centers for Disease Control and Prevention reports, unmanaged chronic conditions account for 75% of the nation’s healthcare spending. The average annual health care cost for people with chronic conditions is five times higher than for people without. Pinellas County reported an increase in overweight/obesity from 58.9% in 2002 to 63.2% in 2007. In the same year, 26.5% of adults reported meeting vigorous physical activity recommendations, 36.8% met moderate physical activity recommendations and 21.2% reported no leisure time physical activity. The rate of hypertension was 28.1% and almost half of Black respondents had hypertension (W: 27.7%; B: 46.5%). The rate of high cholesterol was 30.2% in Pinellas and persons with income less than $25,000 reported a diagnosis of high cholesterol over 1.5 times more frequently (45.4%). In 2007, 8.7% of adults had a diagnosis of diabetes leading to more than 26,000 hospitalizations among diabetics. Asthma was reported in 8.8% of adults with almost 8,000 asthma related hospitalizations. In 2007, 12.7% of Pinellas residents reported a diagnosis of Cardiovascular Disease, compared to a rate of 9.3% in Florida. Cardiovascular disease was reported almost twice as often in persons with an annual income under $25,000 (23.2%). Further, cardiovascular disease is the leading cause of death in Pinellas and accounts for approximately 25,000 hospitalizations per year. (Florida CHARTS, 2008). The Pinellas County Health Department proposed to provide primary care services for Pinellas County Health Plan (PCHP) clients through the medical home model in response to a Pinellas County Health and Human Services request for medical homes. HHS funds the PCHP to cover uninsured, low-income residents of Pinellas County 18-64 living at up to 100% of the FPL in order to address disparities in affordable healthcare coverage and quality of care for this population. First, PinCHD ensured that this public health issue aligns with its strategic priorities. Because it addresses disparities in healthcare coverage, this issue aligns with PinCHD’s access to care strategic priority, which states: The Pinellas County Health Department seeks to assure access to and affordability of healthcare to the diverse communities within Pinellas County through increasing health options, strengthening healthcare resources, and providing customers access to healthcare information. To determine the prevalence of uninsured, low-income adults living in Pinellas County, PinCHD used the Florida CHARTS database. S
Agency Community RolesPinCHD defines our core services to include: identification of the uninsured, eligibility determination, provision of primary care, wellness and prevention services; participation in county network for pharmacy, laboratory, radiology and other ancillary services; conducting behavioral health screening, working with HHS staff to coordinate case/disease management services; provision of healthy behavior promotion and education and nutrition services including tobacco cessation, chronic disease prevention, weight loss and other healthy lifestyle programs; provision of utilization management; participation in the specialty healthcare network; and referrals to inpatient, rehabilitation, nursing home and assisted living facility services. A primary care visit to a PinCHD medical home includes eligibility determination, an admitting process, triage, and examination and evaluation. The evaluation includes a history and physical assessment, diagnosis, medical treatment plan and a client wellness and treatment plan to include recommendations, services and referrals such as prescriptions for ancillary services and specialist evaluations, prescriptions, diagnostic evaluations, counseling such as exercise, nutrition, and tobacco cessation or lifestyle modifications. PinCHD staff enters all patient information including demographics, services, prescriptions, referrals, results and care plans in HMS. PinCHD provides four medical homes locations and also contracts with four private primary care providers in the community to provide medical homes in order to increase access across the county. Additionally, PinCHD St. Petersburg was established as the medical home for a Saturday LIP clinic and PinCHD Pinellas Park was established as the medical home for a Thursday evening LIP clinic to provide primary care services on a sliding fee scale basis for uninsured adults in Pinellas County not eligible for the PCHP. These clinics are held at established medical home sites at times the clinics are not providing primary care to PCHP clients in order to maximize existing resources. PinCHD is responsible for hiring and assigning staff necessary to provide care through the primary care medical home model. PinCHD physicians rotate call in order to provide medical home clients access to an examiner 24 hours per day, seven days a week. PinCHD also recruits and coordinates health care volunteers using DOH volunteer statute and sovereign immunity under Florida Statutes 766 and 110 respectively in order to increase access to the most cost–effective specialty care for PCHP clients. In addition to the medical home team, PinCHD provides a LIP grant coordinator, admitting staff to perform PCHP eligibility at all PinCHD health center locations, support staff for volunteer specialists providing specialty care in the medical homes and clerks to staff an uninsured helpline. Key stakeholders in this model include Pinellas County Health and Human Services, The Health and Human Services Coordinating Council (HHSCC) for Pinellas County, Suncoast Health Council and DOH. HHS and the DOH are the main funders of the model, HHS through the Pinellas County Health Plan (PCHP) and DOH through a LIP grant. HHSCC is a county-wide agency utilizing dedicated property tax revenue to better the lives of children and families. The Pinellas County Health Department Director is an appointee on the HHSCC Health and Behavioral Health Leadership Network (HBHLN) along with representatives from community clinics, hospitals, behavioral health providers, government and other healthcare agencies. The HBHLN works to develop a common understanding of how care is delivered in Pinellas County, identifies system level best practices that could expand access to healthcare for county residents, and establishes short, intermediate and long term policy, funding and system strategies for increasing access to healthcare in the County.  Costs and ExpendituresPinellas County Health Department (PinCHD) secured funding from Pinellas County Health and Human Services (HHS) for start-up costs to establish medical homes, to provide primary care, wellness, prevention, nutrition, and education services, recruit volunteer physicians and conduct quality assurance. PinCHD also secured a Florida Department of Health (DOH) Low Income Pool (LIP) grant to provide disease management, targeted community outreach and primary care clinics for uninsured adults not meeting HHS criteria. PinCHD initially established medical home locations at Willa Carson Health Resource Center, PinCHD Pinellas Park and PinCHD St. Petersburg. Based on community need, PinCHD expanded access to medical homes through contracts with four primary care providers in the community and later added PinCHD Tarpon Springs as an eighth medical home. Additionally, PinCHD St. Petersburg and PinCHD Pinellas Park were established as medical homes for Saturday and Thursday evening LIP clinic clients respectively. With funding and medical homes in place, PinCHD defined core services and hired and assigned staff. Primary care teams include: physicians/mid-level providers, nurses, medical assistants, nutritionists, disease managers, case managers, and clerks. PinCHD physicians rotate call in order to provide medical home clients access to an examiner 24 hours per day, seven days a week. A volunteer specialty network was developed to provide specialty care services in conjunction with HHS contracted specialists. A Utilization Management department was implemented to review all referrals to the contracted specialists. PinCHD also funds a LIP grant coordinator, admitting staff to perform eligibility at all PinCHD health center locations, support staff for volunteer specialists providing specialty care in the medical homes and clerks to staff an uninsured helpline. MedNet navigators, provided in-kind from the Suncoast Health Council, are located county-wide to assist clients in obtaining prescribed medications. Disease management, case management and quality assurance were put into practice to improve the health of the target population and in turn, decrease the cost of care. Disease management has been implemented for diabetes, hypertension and obesity, cardiovascular disease, COPD and asthma at all medical homes. Case managers have been assigned to all medical homes to coordinate medical, preventive and social/economic services for clients. Auditing tools for quality assurance were developed along with key indicators including HEDIS measures in the following areas: asthma, hypertension, diabetes, breast and cervical cancer, tobacco, communicable disease, mental health and colorectal cancer. PinCHD’s largest funding source is Pinellas County Health and Human Services. PinCHD received approximately $1.8 million in funding from HHS in the first year of the contract to establish medical homes, provide primary care, wellness, prevention, nutrition, and education services, recruit volunteer physicians and conduct quality assurance for the HHS Pinellas County Health Plan (PCHP) clients. HHS also provides all medical homes with case management staff and disease managers for COPD, asthma, hypertension and obesity. HHS contracts with specialists to provide specialty care and facilitate inpatient hospitalization, pharmacy, behavioral health, and other ancillary services. An additional funding source is a Department of Health Low Income Pool (LIP) grant. This $646,729 grant provides funding for diabetes disease management, targeted community outreach and two sliding fee scale based primary care clinics for uninsured adults not eligible for the PCHP. Disease managers are currently funded through the LIP grant for diabetes and cardiovascular disease. The outreach team consists of a nurse and eligibility specialists who provide field nursing and eligibility assessments to promote enrollment in a medical home and ER diversion.  ImplementationPinCHD first secured funding from HHS to provide primary care services for PCHP clients. PinCHD also secured funding through a Florida DOH LIP grant to provide disease management, targeted community outreach and sliding fee scale primary care clinics for uninsured adults not eligible for the PCHP. PinCHD first established medical home locations at Willa Carson Health Resource Center in Clearwater, PinCHD Pinellas Park and PinCHD St. Petersburg. Medical Home sites were chosen based upon the highest concentration of uninsured residents identified by zip codes using Geographic Information Systems. Hours of operation were set with plans to adjust based on client needs. PinCHD St. Petersburg was established as the medical home for a Saturday LIP clinic for the uninsured and PinCHD Pinellas Park was established as the medical home for a Thursday evening LIP clinic for the uninsured. PinCHD later expanded locations in order to increase access to medical homes for PCHP clients. A medical home was established at PinCHD Tarpon Springs and PinCHD initiated contracts with four existing primary care providers in the community to serve PCHP clients for a total of eight medical homes. PinCHD defined core services to include: identification of the uninsured, eligibility determination, provision of primary care, wellness, prevention, behavioral health screening, healthy behavior promotion, education and nutrition services; participation in HHS network for pharmacy, laboratory, radiology and other ancillary services, coordination of case/disease management services with HHS; provision of utilization management; participation in the specialty health care network; referrals to inpatient, rehabilitation, nursing home and assisted living facility services. PinCHD hired and assigned staff necessary to provide care through the primary care medical home model. Primary care teams were assigned to include: physicians/mid-level providers, nurses, medical assistants, RD/nutritionists, disease managers, case managers and clerks. PinCHD also hired a utilization management team, a volunteer coordinator, a quality assurance coordinator, an outreach team, and clerks to staff an uninsured helpline. PinCHD physicians are scheduled to rotate call in order to provide medical home clients access to an examiner 24 hours per day, seven days a week. In order to decrease the cost of care for the target population, a volunteer specialty network was developed to provide specialty care services in conjunction with HHS contracted specialists. Currently, PinCHD has volunteer physician specialists in the following specialties: Podiatry, Ophthalmology, Dermatology, Cardiology, General Surgery, Gynecology, Urology, Gastroenterology, Nephrology, Acupuncture, Physical Therapy Rehabilitation and Osteopathic Manipulative Treatment. Further, PinCHD implemented a Utilization Management department that must approve all referrals to the contracted specialists. Laboratory and pharmacy vendor contracts and formularies were developed and are utilized to ensure the lowest possible costs for services and to ensure a consistent standard of care for medical management among the medical homes. MedNet compassionate drug programs are in place and MedNet navigators are located countywide to assist clients in obtaining prescribed medications at no cost. Data from the Suncoast Health Council compassionate drug program shows a $12.00 return on each $1.00 investment for utilizing a MedNet navigator to obtain medications for clients. Disease management, case management and quality assurance are the main components that were put into practice in the primary care medical home model to improve the health of the target population and in turn, decrease the cost of care. Currently, disease management is provided for diabetes, hypertension and obesity, cardiovascular disease, COPD and asthma at all medical homes. Disease managers are responsible for increasing clients’ knowledge.
Ensure access to the continuum of health care for 3,000 uninsured, low-income residents of Pinellas County, ages 18-64, living at up to 100% of the Federal Poverty Level through a disease management model promoting preventive care and disease management coordinated at the medical home.Establish a medical home for all 3,000 clients in the target population. • Three medical home sites established by October 1, 2008 • Two primary care teams in place to cover three locations by Oct. 1, 2008 • 3,000 clients enrolled in a medical home within one year • 8,400 encounters provided in the first year• Enrollment was captured in HMS, collected in a report by Information Technology • Disenrollment was captured in HMS, collected in a report by Information Technology • Medical encounters were captured in HMS, collected in a report by Information Technology • Enrollment- monthly report collected by close of following month • Disenrollment- monthly report collected by close of following month • Encounters- monthly report collected by close of following month Reports on enrollment, disenrollment and encounters were received by the primary care teams, PinCHD and HHS Medical Directors and leadership teams of both agencies. Reports indicated that demand for services was greater than anticipated and medical homes and primary care teams were expanded to accommodate client need. • 5,733 eligible clients were enrolled in a medical home (short-term) • 16,569 medical encounters were provided (short-term) • eight medical home locations established (long-term)Improve the health of the target population as measured by key indicators. • Quality assurance process developed by end of first quarter • Indicators defined by end of first quarter • Goals for each indicator set by end of second quarter • Quarterly audits completed quarterly in the first year • Disease Management for three chronic diseases in place within one year • Disease management referrals, plans of care and care coordination were captured in HMS, collected in a report by Information Technology •The follow HEDIS measures were collected in a chart audit conducted by the quality assurance coordinator: o Hypertension- Measurement of adults whose blood pressure is controlled: most recent reading < 140/90 o Asthma- clients with persistent asthma who were prescribed medication therapy for long-term control of asthma. o Diabetes- HbA1C, LDL, BP, eye exam o Breast and Cervical Cancer- screening complete o Mental Health- screening tool and appropriate referral completed o Colorectal Cancer- screening complete • The following HEDIS measures were captured in HMS, collected in a report by the quality assurance coordinator. o Communicable Disease- flu vaccine in most recent flu season o Tobacco- smoking cessation counseling in past year • Disease management referrals- quarterly report collected by close of month following end of quarter • Disease management plan of care- monthly report collected by close of following month • Disease Management care coordination- monthly report collected by close of following month • All HEDIS Measures- quarterly chart audit collected by close of month ending following quarter • Disease management reports were received by the disease managers and supervisors, primary care teams, PinCHD and HHS Medical Directors and leadership teams of both agencies. The disease managers learned that there were more clients with chronic diseases than anticipated and that client conditions were more complex with co-morbidities common. Disease management model was adjusted with condition specific disease managers to better meet client needs. • HEDIS reports were received by primary care teams, PinCHD and HHS Medical Directors and leadership teams. • Quality assurance process based on HEDIS measures in place and being conducted quarterly (long term)
There is sufficient commitment to providing primary care for the uninsured, low-income population from key stakeholders. This commitment is evidenced and ensured by the following factors: • Operating under the Florida Department of Health, PinCHD has served as the lead safety net healthcare provider for uninsured and medically underserved populations in Pinellas County for more than 70 years. Provision of primary care for the target population aligns with the agency’s mission to promote, protect and improve the health of all people in Pinellas County and works toward its strategic priority of access to care. • PinCHD's 680 staff provided 2,036,514 units of health services to 192,349 clients in FY08/09, including over 17,000 primary care services annually to the target population. • There has been a longstanding need for the provision of primary care for the target population recognized by all stakeholders. • PinCHD has demonstrated a strong capability to work with stakeholders large and small, including state, local and federal governments, wherever the needs of the underserved population can best be met. • Collaborative relationships have been built between PinCHD, HHS and area hospitals since the implementation of the model. PinCHD will continue to build relationships with the private sector, including safety net hospitals and providers to realize further cost savings. • Over time, PinCHD, and in turn HHS and area hospitals, will be to care for the target population with less money as their chronic diseases become managed. We will be able to show this cost savings with data collected and reported on an ongoing basis. This potential for long term cost savings justifies continuation of the practice and ensures stakeholders are committed to continuing to fund it. PinCHD plans to sustain the primary care medical home model over time by leverage existing resources in the following ways: • PinCHD will continue to track positive outcomes and document successes to promote continued funding and replication of best practices. Positive outcomes tracking will encourage current funders, including HHS and DOH to continue to provide funding. • Locally, the county government is Pinellas’ largest funder of health and human services for uninsured and at risk populations. They are likely to replicate and fund successful interventions that shift health services to primary, secondary and tertiary prevention resulting in a more cost effective system for the uninsured. • At the state level, proven results may result in new allocations of funds for the target population or an increase to current funds such as an increased LIP grant award. • PinCHD will continue to expand the volunteer specialty network to provide more cost-effective delivery of specialty care for PCHP clients including decreased cost to HHS to provide specialty care. This will free up existing funds to provide primary care services. Similarly, PinCHD will continue to provide utilization management services to ensure resources are being used appropriately and use of volunteer specialty network is maximized. • PinCHD will work to secure funding from other sources including hospitals should HHS funding not be available or fully available in the future. • PinCHD will work to expand the use of MedNet service and track referrals to include savings provided through MedNet. This will maximize existing HHS funds available for PCHP clients.
 
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