Volume_1
Welcome (Vol.1)
Quality Measurement and Feedback - Changes in Chart Reviews Give Fast Turnaround of Data to Practices
Welcome to the Community Care Communications blog. The purpose of this blog is to facilitate communications throughout the state about the program, the 646 waiver, network activities and other news. Community Care staff members welcome suggestions and comments.
Quality Measurement and Feedback - Changes in Chart Reviews Give Fast Turnaround of Data to Practices
Community Care networks and practices are getting practice results and data from chart reviews in a matter of days, not months. A new system of multi-disease chart reviews has sped up getting the results back to practices. Community Care has been guided by performance measures since its start in 1998, and in changes currently being implemented by Community Care staff, instead of focusing on specific illness initiatives, reviews are more holistic. Community Care partners with the N.C. AHEC Program to ensure impartial outside reviews. A consistent panel of health care professionals (pharmacists, nurses, and others) receives extensive training on the chart review process, which now includes automated data entry using a Multi-Disease web-based audit tool. Reviewers will conduct thorough chart reviews in each network, on a random selection of charts in more than 1,200 practices. The new process will result in broader analysis and will speed the return of data to community-based practices.
The new system, which has completed 50 percent of its audits as of July and will be fully complete by the end of 2009, is a 'huge leap' for the practices, said Jennifer Cockerham, Chronic Care Coordinator with Community Care. Between February and November 2009, AHEC will conduct about 26,000 chart reviews, compiling the data into network-level reports to be distributed in December 2009 or January 2010. For more details on the chart reviews, please see http://www.communitycarenc.com and click under the Quality Improvement pull-down menu to the Introduction bar to find more on Quality Measurement and Feedback initiatives.
Interconception Care Update
An analysis of the proposed Interconception Care Waiver showed anticipated costs about 25 times higher than the potential savings. In the state's current budget shortfall, and likely in any budget year, this differential has precluded the Division of Medical Assistance from moving forward on a waiver as originally designed. A number of different proposals during a recent conference call were suggested and are currently being investigated. Some of these proposals include expansion of the Nurse Family Partnership Program, conducting a smaller pilot project with modifications to the original Interconception Care Waiver within several networks, and examination of similar initiatives in other states.
In addition, a separate suggestion is to engage in a quality improvement program similar in scope to other Community Care quality improvement initiatives, such as asthma and diabetes. There are already a number of quality initiatives in the State around obstetrics care and the question is how to enhance these programs. In addition to existing quality initiatives, there are many groups working in North Carolina that align with Community Care, such as the Perinatal Quality Collaborative of N.C. or the Family Medicine Maternal Child Health Committee. Finally, there are regional perinatal quality improvement initiatives, including IMPLICIT. (Please see theJournal of the American Board of Family Med 2009; 22 380-386; 'Improving Maternal Care with a Continuous Quality Improvement Strategy: A Report from the Interventions to Minimize Preterm and Low Birth Weight Infants through Continuous Improvement Techniques (IMPLICIT) Network', http://www.jabfm.org/cgi/content/abstract/22/4/380.
A high risk OB work group has been initiated in partnership with the Division of Public Health. Opportunities to identify the highest risk Medicaid pregnant women will be explored as well as potential interventions that will increase birth weights, decrease NICU admissions and increase intervals between pregnancies.
Community Care/Division of Aging Pilots
N.C. DHHS Secretary Lanier Cansler, with encouragement from AARP, has held a series of meetings with Community Care and Division of Aging staff to discuss how the Division of Aging and its community partners can join with Community Care in improving the management and coordination of care for aged, blind and disabled enrollees with medical, mental, social, or functional needs. The goal of the project would be to develop pilot programs that will create replicable approaches of community collaboration. Possible pilot counties include:
• Buncombe / Madison
• Cumberland
• Lincoln
• New Hanover
• Orange / Chatham
State Employees Health Plan
At the request of the State Employees Health Plan (SEHP), Allen Dobson, MD, Warren Newton, MD, Chris Collins, and Tork Wade met in early June with Derek Prentice, Consulting Medical Director, and Anne Rogers, Director of Integrated Health Management to discuss potential opportunities for working together. After a productive first meeting, the next step will be a follow-up in late July to brief SEHP staff on the current status of Community Care clinical improvement and analytical efforts.
Kate B. Reynolds Prevention Grant - Stroke Prevention and Childhood Obesity
The Kate B. Reynolds Foundation has provided funding to Community Care, through the NCFAHP (North Carolina Foundation for Advanced Health Programs, Inc.) to develop and implement a two-pronged prevention initiative. One prong of the initiative is targeting stroke prevention and the other is targeting childhood obesity. Three Community Care networks (Carolina Collaborative Community Care, Northwest Community Care and Sandhills Community Care Network) are participating in a stroke prevention initiative. There are four networks participating in the childhood obesity initiative (Access II Care of Western N.C., Carolina Community Health Partnership, Partnership for Health Management and Community Care of Wake and Johnston Counties).
In the stroke prevention initiative the networks are targeting Medicaid enrolled patients with hypertension and defining two subgroups to receive more intensive interventions - patients who have a primary care provider within one of the 18 'target practices' and patients whose pharmacy claims history indicates that they are not taking their blood pressure medication regularly. The 18 large target practices receive provider education, chart audits and performance feedback. Each network has developed a plan for physician and practice education based on local resources and practice preferences. A quick-reference physician guide to evidence-based clinical guidelines pertinent to stroke prevention / cardiovascular risk reduction had been developed and disseminated (also available on the Community Care web site). Between 800 and 1,200 high-risk patients will be invited to participate in a telephonic program for patient education and tailored self-management support, using a model developed by Dr. Hayden Bosworth and colleagues from Duke University and the Durham VA Medical Center. Objectives are to demonstrate a 10 percent improvement over baseline clinical performance metrics (such as blood pressure control, cardiovascular risk factor assessment, cholesterol management, and appropriate use of aspirin) in target practices; and increased awareness of treatment goals and adherence to blood pressure medications among high-risk patients. Early accomplishments include the following: high rates of provider and practice participation in educational programs and performance review, improved clinical flow processes, and successful recruitment and retention of patients into the self-management program.
The childhood obesity initiative is targeting Medicaid enrolled patients between the ages 2 and 18 in 113 practices. Providers and primary care practices are aiming to increase BMI (body mass index) screening and improve self-efficacy in assessing patients for overweight and obesity. In partnership with the N.C. Division of Public Health, provider toolkits based on evidence-based guidelines were developed and distributed. In addition, family education messages about healthy eating and physical activity were included in the pilot. Accomplishments to date include training practices in the use of obesity screening tools (practice re-design workshops); assisting practices in designing and implementing co-location models with nutritionists; establishing links to community resources for patient and family education; and increasing the use of BMI screening and completing an initial needs assessment.
The pilot networks will be able to develop a model that can be replicated in other networks and communities and will help Community Care in the development and implementation of meaningful preventive measures.
Staffing End of Life Care Initiative
Dr. Jonathan Fischer has joined the Community Care team on a part-time basis. Much of his 'other' time is spent working as a primary care physician at Piedmont Health, a federally-qualified health center. Dr. Fischer will lead an 'end of life care' initiative for Community Care, and he can be reached at fischerj@piedmonthealth.org. Anyone interested in participating in a work group on end of life or having their network participate as a pilot site, should email him or Denise Levis, at Denise.Levis@dhhs.nc.gov.
646 Demonstration (Vol.1)
Update on 646 Waiver - CMS Labels it 'Approved'
Negotiations are still underway between N.C. Community Care Networks, Inc., and the federal Centers for Medicare and Medicaid Services (CMS) on the 646 waiver. NCCCN and federal representatives are finalizing demonstration protocols and other details.
Working toward a Fall 2009 start date, the pace of activity with CMS has intensified, including weekly calls to clarify or resolve the remaining demonstration issues. Although most of the big issues have been resolved, the remaining ones, which are technical in nature, have the potential for adding significant complexity to the demonstration. One of the thorniest issues is the identification of demonstration physicians. While it is now clear that only primary care physicians can be participating physicians, one complication has resulted from the different ways CMS and Community Care look at participating providers. Unlike Community Care, which is built around the practice, CMS is looking at the individual physician. This is making the crosswalk more complicated and will make capturing comparative data more difficult. A second, related challenge, is defining the type of agreement NCCCN needs to have in place with participating physicians and/or practices.
While CMS has made every effort to fit the demonstration within the Community Care system and structure, design variations can bring significant complications. Community Care staff members expect to receive a substantially completed Demonstration Protocol from CMS by mid-August.
Medicaid (Vol.1)
New Medical Director
Dr. Craigan L. Gray began his new job as director of DMA in late April. Dr. Gray was formerly vice president of medical affairs and chief medical officer at the Bon Secours Our Lady of Bellefonte Hospital in Ashland, Kentucky. He is board certified in obstetrics-gynecology, has a law degree and master's in business administration, and also has practiced in Asheville.
Health Choice Transition
The transition is underway for Health Choice/Kid's Care to become part of Medicaid, which will take over the fiscal and administrative duties for the program, no longer using BCBS. A new vendor will be selected to process claims, and the transition should be complete by 2011.
Reductions in the State Budget will Result in Cuts in Medicaid
For detailed updates on the State budget reductions go to www.dhhs.state.nc.us/dma/provider/budgetinitiatives.htm. The site has details on electronic billing, screening requirements, program reductions and other service limitations resulting from budget cuts at the state level.
Informatics Center (Vol.1)
NCCCN's Informatics Center: Recent Developments, New Staff on Board
As of July 1, the Informatics Center (IC) has successfully migrated the Case Management Information System (CMIS) into the IC's hosting site. The CMIS had been developed and managed by 5Rivers Systems Inc. for the past seven years. This migration is part of a comprehensive effort to bring multiple data systems into the IC so Community Care can serve the information and data needs of the networks in a more integrated way. CMIS will be maintained, supported, and enhanced by the IC.
Also, the migration of all major elements of the decision support system in DMA (called the DRIVE system) is scheduled for completion by the end of July. In addition the IC has established front end portals for accessing data from disease specific chart reviews, chronic care reports, and pharmacy home. The Informatics Center is working to establish a protocol for importing certain laboratory results from Lab Corp. and is in the process of accepting Medicare data in preparation for the 646 waiver.
New Staff for Informatics Center
Effective August 1, Annette DuBard, MD, will become Director of Informatics, Quality, and Evaluation replacing Gustavo Fernandez, who has served as Interim Director of the Informatics Center. Dr. DuBard obtained her medical degree from John Hopkins and has completed residences in family medicine and preventive medicine and has an MPH in Health Policy and Administration from UNC-Chapel Hill. Dr. DuBard has been a Clinical Consultant with Community Care for the past three years and has worked with DMA and the Cecil G. Sheps Center for Health Services Research.
The IC also has hired a new Project Manager. Anne Shotton has worked as the Account Director for Ingenix Inc. for the past twelve years, which deals with the DRIVE system in DMA. She is knowledgeable in the management of large and complex data bases. The IC also recently hired a new Developer Manager, Rick Mauney, to replace Charles Little and to oversee the developing of the Reports Center. Charles Dewar was promoted to Analytics Manager beginning July 1. Charles will handle data requests and supervise the analytics team.
Improving Health and Healthcare in North Carolina by Leveraging Federal IT Stimulus Funds
The N.C. Health Information Technology Task Force has released a draft report on plans to use funds from the federal health IT stimulus plan, available at http://www.ncrecovery.gov/library/pdf/HIT_Task_Force_Report_6-24-09.pdf. Allen Dobson, MD, Laura Gerald, MD, and Sam Spicer, MD (a member of Community Care's HIT committee) are members of the task forcce, and Clyde Brooks, MD (chair of the HIT committee) is a Subject Matter Expert for the Task Force. The Task Force recommends Community Care as a starting point for implementation of the N.C. Health Information Exchange with the understanding that lessons learned will be used to expand the program to all providers, patients, and payers.
Pharmacy (Vol.1)
Prior Authorizations
The state budget crisis is having a ripple effect on Pharmacy. On July 20, the N.C. Division of Medical Assistance will begin the first three of a series of prior authorization policies under the Outpatient Pharmacy Program. The change comes as a result of the State's effort to save approximately $160 million in drug costs. Twelve to fifteen new Prior Authorizations are expected to occur over the next few months. The goal of Community Care staff is to make any coverage policies that come to pass as patient- and provider-friendly as possible. As with prior efforts, Community Care staff will be engaging in a large-scale educational effort with pharmacies, practices, and enrollees.
Transitioning patients to drugs not subject to Prior Authorization can be expedited with the use of the MD Easy Forms. The MD Easy Forms are pre-populated, patient-specific forms that will identify patients affected by the Prior Authorization. Once a physician completes, signs, and faxes it to the pharmacy, it legally becomes the patient's prescription. From past experience, the forms have reduced the physician's time spent requesting prior authorizations and patient gaps in therapy. To obtain MD Easy Forms, please contact your Network Pharmacist.
E-Prescribing Project Launched
About 85 percent of the pharmacies statewide are now activated for fully integrated e-prescribing, and activity has greatly increased since the launch in July 2008 of Community Care's e-Prescribing Project, according to Surescripts data. About 36 percent of Community Care practices have at least one active prescriber in the project as of the end of February and roughly 15 percent of all non-controlled substance prescriptions are sent electronically, up from 6 percent three months prior to the beginning of the project.
More on Generics
In another pharmacy initiative, Community Care is encouraging the broader use of generics and will continue to promote increased utilization of generic prescriptions in the next two years. Under the Generics Initiative with Community Care, more patients are choosing generics. In the first quarter of 2007, 59 percent of prescriptions were generics, and in the first quarter of 2009, that rate had increased to 69 percent. To meet the state's pharmacy budget goals, roughly 80 percent of prescription fills will need to be for generics.
North Carolina Lauded for E-Prescribing
The State of North Carolina was awarded a 2008 Safe-Rx Award by Surescripts, which operates the country's largest electronic prescribing network. The award, which is presented to the top 10 e-prescribing states in the nation, was presented on June 22 at the National Press Club. North Carolina is now sixth in the nation for e-scripts. The award recognized the e-prescribing partnership between the Department of Health and Human Services, Community Care, and Blue Cross/Blue Shield in North Carolina's success.
News/Updates (Vol.1)
State Budget and Legislative Update - Special Community Care Provision
A substitute Community Care Special Provision (10.36) has been introduced into the budget conference process. No action has yet been taken on Special Provisions. In addition, the proposed Conference Budget now contains a Community Care savings target of just under $70 million state dollars, which translates into a savings target of more than $200 million in total dollars when the federal matching funds are removed. The Budget has not yet been adopted. For the full section of the Special Provision, please email a request to ccnc.program@ncmail.net.
Health Choice
The proposed Conference Budget does eliminate $900,000 in State funds ($3 million in total funds) to the Community Care networks to manage Health Choice beneficiaries. There is also Special Provision language that could eliminate Health Choice care management payments to Community Care physicians. This cut does not, at this point, show up in the Money Report. No final action has yet been taken.
House Committee Health Reform Proposes Medical Home Pilot
The Committee on Ways and Means of the U.S. House of Representatives has proposed sweeping health care reform legislation that includes a five-year pilot on medical homes. Title III of the unnamed draft legislation aims at 'Promoting Primary Care, Mental Health Services, and Coordinated Care.' Section 1302 would enact a Medical home pilot program 'to assess the feasibility of reimbursing for qualified patient-centered medical homes.' There will be two models in the program: 1) the 'independent patient-centered medical home,' that will target high-need Medicare beneficiaries with multiple chronic conditions, and 2) the 'community-based medical home' that targets Medicare beneficiaries with chronic illness who could be served by state-based or nonprofit entities providing care management. The second model is built on the Community Care approach and emerged from the testimony of Allen Dobson, MD, and others. Dr. Dobson's testimony can be found at about minute 50:00 of the two-hour testimony: http://help.senate.gov/Hearings/2009_01_22/2009_01_22.html.
The complete text of the draft legislation can be found at http://waysandmeans.house.gov/media/pdf/111/hrdraft1xml.pdf (Section 1302 of Title III begins on p. 384), and fuller descriptions and fact sheets are on the web site for the Ways and Means Committee, on their health care reform page, http://waysandmeans.house.gov/MoreInfo.asp?section=52.
Mercer Completes Analysis
Mercer Government Human Services Consulting completed its analysis of cost savings generated under Community Care for the Aged, Blind and Disabled enrollees during the State Fiscal Year 2008. The two key financial findings are:
• Changes in care management for SFY 2008 versus SFY 2007 appear to have increased SFY 2008 costs under the Community Care/ACCESS program by a relatively modest $6 million.
• All care management initiatives to date, including the changes referenced above, appear to have reduced SFY 2008 costs under the Community Care/ACCESS program by $400 million.
The Executive Summary, along with past Mercer reports, can be found at www.communitycarenc.com under the Program Impact section of the web site.
State Health Access Program through HRSA
At the request of the Governor's office, Community Care joined with the Division of Medical Assistance, the Office of Rural Health and Community Care, and the Institute of Medicine in preparing a grant proposal under the State Health Access Program (SHAP). The SHAP is a HRSA program designed to support implementing health insurance coverage for the low-income uninsured. Depending on the scope of the project, $2 million to $10 million a year for five years may be available.
North Carolina's proposal will use the grant funds to develop a low-cost, limited benefit plan built on Community Care by emphasizing preventive, primary care and chronic disease management. The limited benefit coverage will initially be offered in two to three Community Care networks to working parents with incomes below 125 percent of the federal poverty level. By Year 4, a 1115 federal waiver will be submitted that would make the limited benefit plan an option under Medicaid. The projected award date is September 15, and about $75 million is available nationally under the grant initiative.
Family Physician Shortage in N&O
The Raleigh News and Observer had a cover story on the shortage of family physicians in North Carolina, both in rural and urban communities, and featured a reference to Community Care. See the full story at http:www.newsobserver.com/150/story/1595525.html.
Community Care Issue of N.C. Medical Journal
In response to the high level of national attention to health reform, the North Carolina Medical Journal's May/June edition focuses entirely on Community Care. The issue describes how the medical home was implemented, examines how it works, and discusses its strengths and weaknesses as a model for national reform. 'I applaud the Journal for focusing an entire issue on Community Care because of it's great importance to the state and potential usefulness for national health care reform. This issue is a great resource for individuals interested in learning more about the program and for states considering implementing a similar model,' said Allen Dobson, MD, chair of N.C. Community Care Networks, Inc. The full issue can be viewed at http://www.ncmedicaljournal.com/May-Jun-09/toc0509.shtml. To receive email alerts for upcoming North Carolina Medical Journal issues, contact Cristine Nielsen at 919-401-6599, ext. 25 or cnielsen@nciom.org.
Organizing for Higher Performance - the Commonwealth Fund Profiles Community Care
In the company of the nation's top health programs, Community Care is profiled in The Commonwealth Fund's July 2 summary of 15 case studies of nationally recognized health care programs, including Group Health Cooperative, Kaiser Permanente, and the Geisinger Health System. Community Care is the only model listed under 'government-facilitated networks of independent providers.' The full summary is at http://www.commonwealthfund.org/Content/Publications/Case-Studies/2009/Jul/Organizing-for-Higher-Performance-Case-Studies-of-Organized-Delivery-Systems.aspx and the profile of Community Care, published on June 22, is at http://www.commonwealthfund.org/Content/Publications/Case-Studies/2009/Jun/Community-Care-of-North-Carolina-Building--Community-Systems-of-Care-Through-State-and-Local-Partner.aspx.
Kaiser Family Foundation Brief on Community Care as National Health Reform Model
The Kaiser Family Foundation has released a brief outlining Community Care as an example of how Medicaid can be used as a platform for national health reform that covers all Americans. The full brief can be read at http://kff.org/medicaid/kcmu051209pkg.cfm and it is part of the Kaiser Family Foundation's series published on May 12. The brief summarizes the development and structure of the networks and outlines how Community Care's enhanced medical home model allows for cost containment and higher quality services and outcomes.
Clinton Medical Clinic Featured in AFP Journal
Co-location efforts through the ICARE program bringing a psychologist to the Clinton Medical Clinic will be featured in an upcoming issue of the N.C. Family Physicians. The article outlines how co-location of behavioral health and PCPs benefits patitents and clinicians. For a copy of the article, please email a request to ccnc.program@ncmail.net.
'New' Staff at Community Care
In addition to the new team at the Informatics Center, Community Care is pleased to announce some staff changes in Raleigh. Chris Collins has been permanently named Deputy Director at the Office of Rural Health and Community Care and Assistant Director of Managed Care for the Division of Medical Assistance. Jennifer Cockerham, who has worked with Community Care for the past eight years as the Senior Clinical Consultant, accepted the position of Chronic Care Coordinator effective July 1, 2009. Jennifer will be responsible for overseeing various aspects of the chronic care program.
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