Supporting practices to help advance patient-centered care.
|Alabama||Patient Care Networks of Alabama (PCNA), and ACA Section 2703 Health Homes: Alabama has launched four patient care networks run by Patient Care Networks of Alabama (PCNA) in select counties to support primary medical providers (PMPs), with services including:
The networks are each developing initiatives around topics that have already been identified (high cost/high co-morbidity patients, asthma, diabetes, etc.) and topics that will be defined through mutual agreement.
|Alaska||According to the Alaska Patient-Centered Medical Home Initiative (AK-PCMH-I) Request for Proposals (RFP), technical assistance for the project is provided by the Alaska Primary Care Association’s Training and Technical Assistance Department. Pilot practices have access to a number of practice supports, including an initial readiness assessment, group learning sessions, peer learning opportunities, practice coaching sessions, teleconferences and webinars, and networking opportunities. A comprehensive technical assistance schedule is included in the RFP.|
|Arizona||No known activity at this time.|
|Arkansas||No known activity at this time.|
|California||No known activity at this time.|
|Colorado||Medical Homes for Children Program:
Accountable Care Collaborative (ACC) Program: Under the Accountable Care Collaborative, Regional Care Collaborative Organizations (RCCOs) and the Statewide Data and Analytics Contractor (SDAC) provide support for participating Primary Medical Care Providers (PCMPs). RCCOs provide:
Comprehensive Primary Care Initiative (CPCi): Colorado practices participating in the Comprehensive Primary Care Initiative receive practice coaching services from HealthTeamWorks or Rocky Mountain Health Plan depending on their location.
HealthTeamWorks Multi-payer Pilot: Participating practices received technical assistance provided through on-site quality improvement (QI) coaching, learning community webinars, and a learning collaborative.
|Connecticut||Connecticut Medicaid and the Community Health Network of Connecticut, the HUSKY Health administrative services organization, are providing the following practice supports:
|Delaware||No known activity at this time.|
|District of Columbia||No known activity at this time.|
|Florida||No known activity at this time.|
|Georgia||No known activity at this time.|
|Hawaii||No known activity at this time.|
|Idaho||Idaho Medical Home Collaborative (IMHC): The IMHC is supporting pilot practices through learning collaboratives and practice coaching. Program staff will lead learning collaborative activities; provide technical assistance to facilitate practice transformation using Safety Net Medical Home Initiative materials; and support practices in preparing for NCQA PCMH recognition.Learn more on IMHC’s Expectations, Roles, and Responsibilities page.|
|Illinois||Primary care providers participating in Illinois Health Connect receive several types of non-financial support, including:
|Indiana||No known activity at this time.|
|Iowa||IowaCare: The Iowa Healthcare Collaborative, a non-profit organization dedicated to educating and equipping health care providers across Iowa, leads a Medical Home Learning Community. The leader of the Iowa Healthcare Collaborative is also chair of the Iowa Medical Home System Advisory Council (MHSAC).The IowaCare 1115(a) waiver states, “The State must collaborate with the State’s HIE [health information exchange] designated entity to ensure that primary network providers are a high priority for connecting to the State’s HIE.”ACA Section 2703 Health Homes: Iowa is in the process of implementing a statewide health information exchange which health home practices will be required to join.|
|Kansas||Health Homes: The Kansas Department of Health & Environment contracted with Wichita State University to convene a learning collaborative to support program implementation. Learning activities have included a mix of in-person and remote activities designed to facilitate peer-to-peer learning and promote continuous quality improvement. A January 2014 report on the collaborative report is available here.|
|Kentucky||No known activity at this time.|
|Louisiana||The Louisiana Health Care Quality Forum (LHCQF) developed a patient-centered medical home (PCMH) toolkit as a resource for providers. As a Regional Extension Center, LHCQF is currently providing health information technology technical assistance.Bayou Health care coordination networks are required to develop a PCMH Implementation Plan, which includes a description of the technical assistance that the networks will provide to primary care physicians to support practice transformation and national recognition/accreditation. Technical assistance activities will vary across networks. The networks are required to participate in Patient-Centered Primary Care Collaborative activities.|
|Maine||Maine PCMH Pilot: The Maine Patient-Centered Medical Home (PCMH) Pilot is offering a variety of supports to participating practices. These supports include:
Maine launched eight community care teams (CCTs) in early 2012 to support medical home practices. “The primary goal of the CCT is to provide support for the most complex, high risk, high need, and/or high-cost patients served by ME PCMH Pilot.” According to Maine Quality Counts, “CCTs will coordinate and connect patients to additional healthcare and community resources in order to support their health improvement goals, achieve better health outcomes and reduce avoidable costs.” The state launched two new CCTs in January 2013 to support the pilot’s 50-practice expansion. The new teams were selected through an RFP process.
ACA Section 2703 Health Homes: Like Maine PCMH Pilot practices, health homes are also supported by Maine’s community care teams, who provide intensive care coordination and other wrap-around services to the top 5-percent of high-cost, high-risk beneficiaries.
|Maryland||According to the practice participation agreement, the Maryland Health Care Commission (MHCC) is responsible for establishing a learning collaborative with the support of the Community Health Resources Commission (CHRC). The objectives of the learning collaborative are to support practices in obtaining medical home recognition and effectively using a care manager. Practice staff are required to participate in the learning collaborative. A timeline of learning collaborative activities— which include webinars, in-person large group meetings, site visits, and regional meetings—is available here.The CHRC is also providing the MHCC with resources to hire “practice transformation coaches.” Coach responsibilities include:
Practices will be expected to use an MHCC-provided registry unless they have an acceptable EMR.
Maryland participated in the North Carolina Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Learning Community, where it was one of four states to receive technical assistance and guidance from North Carolina on how to develop a primary care support and quality improvement system. Through participation in this project Maryland provided support to primary care practices. Mary supported all of the practices participating in the Maryland Multi-Payer Patient-Centered Medical Home Program(MMPP) in implementing an Electronic Health Record (EHR). Additionally, 65% of the practices now participate in the State-Designated Health Information Exchange. The Maryland Learning Collaborative (MLC) used an expert consultant to train Practice Transformation Coaches who provide logistical and educational support to primary care practices in transforming into PCMH. Additionally, the MLC secured a care manager responsible for implementing the changes necessary for practices to become PCMHs in each of the pilot practices.
|Massachusetts||Chapter 224 of the Acts of 2012 requires the newly formed Health Policy Commission to establish a patient-centered medical home training program; participation in the training program may be necessary for certification.Massachusetts Patient-Centered Medical Home Initiative: Patient-Centered Medical Home Initiative (PCMHI) practices received a variety of supports, including:
Primary Care Payment Reform Initiative (PCPRI): Massachusetts Executive Office of Health and Human Services (EOHHS) is providing participating practices with a variety of supports through learning collaboratives and other means:
|Michigan||The Michigan Primary Care Transformation (MiPCT) Project will support physicians and practice transformation by providing educational opportunities, a Care Management Resource Center, and the Michigan Data Collaborative. The focus of support is on care management, self-management, care coordination and linking to community services. Educational opportunities include learning collaboratives, lean workshops, practice-based coaching, webinars, and seminars. The Michigan Data Collaborative will create a multi-payer claims database and generate metric feedback reports.MiPCT will also provide clinical models, resources and support aimed at avoiding emergency room and inpatient use for ambulatory sensitive conditions, reducing fragmentation of care among providers and involving the patient in decision-making.In June 2012, the Michigan Public Health Institute, in partnership with the state’s Department of Community Health, won a $14 million Health Care Innovation Award to support primary care in two counties.The project will train and deploy about 90 community health community workers and will also develop community hubs that will link patients to needed services. Michigan discussed their plans to build community hubs on a NASHP webcast in April 2012; the presentation is available here.|
|Minnesota||Health care homes in Minnesota are receiving a variety of supports:
Payers are providing data feedback to support health care homes in measuring progress and identifying areas for improvement.
|Mississippi||No known activity at this time.|
|Missouri||All MOHealthNet providers have access to a web-based HIPAA-compliant electronic medical record program for their Medicaid patients, known as CyberAccess.ACA Section 2703 Health Homes – Community Mental Health Centers and Primary Care Health Homes: Missouri state agencies and health care foundations will join providers in spending over $1.5 million to cover training and technical assistance during practice transformation.Participating community mental health centers and primary care health homes will participate in a number of statewide learning activities, including learning collaboratives, monthly practice team calls to reinforce learning sessions, practice coaching, and monthly practice reporting (data and narrative) and feedback.Learning activities will focus on teaching practices to coordinate patient- and family-centered, quality-driven, cost-effective, culturally and linguistically appropriate care (including the use of health technology).|
|Montana||The Montana Commissioner of Securities and Insurance maintains a list of practice transformation resources for interested primary care providers, including a series of five webinars hosted by the Commissioner’s Office. The webinar content was informed in part by the results of a 2011 provider survey.|
|Nebraska||Nebraska Medicaid Patient-Centered Medical Home Pilot: The Nebraska Department of Health and Human Services (DHHS) provided each practice with:
In addition, the state conducted an orientation and provided two day-long learning collaboratives for physicians, nurses, and key office staff.
|Nevada||No known activity at this time.|
|New Hampshire||No known activity at this time.|
|New Jersey||No known activity at this time.|
|New Mexico||The state has met with the Department of Health to identify and target case mangers to work with the Managed Care Organizations and provider networks to identify and manage care for high-cost, high-risk children/patients.|
|New York||Adirondack Medical Home Demonstration: Each participating Adirondack Medical Home Demonstration practices received a readiness assessment to develop individualized work plans to guide practice transformation. Practices are receiving grant-supported consulting assistance from EastPoint Health to achieve practice transformation.Practices also receive additional support from one of three sub-regional Pods (community-based organizations providing shared care coordination services to participating practices including patient education and care management). The Adirondack Health Institute is serving as an umbrella organization for the three Pods.A $7 million HEAL NY Phase 10 grant (HEAL NY 10) enabled all participating providers to implement an electronic health record.
It also should be noted that Chapter 59 of the Laws of 2011 authorizes the commissioner of health to provide technical assistance to regional multi-payer program participants (providers, payers and consumers), which may impact the Adirondack initiative as well as future initiatives as well.Statewide Patient-Centered Medical Home Program: There is limited practice support from a quality organization contracted by the state.HEAL NY 10 grants were also made available to support health IT infrastructure development for non-Adirondack medical homes.
ACA Section 2703 Health Homes: A Health Homes Learning Collaborative, intended to identify and discuss best practices and lessons learned, launched in September 2012. Findings will inform ongoing implementation and state policymaking.
|North Carolina||Community Care of North Carolina (CCNC), ACA Section 2703 Health Homes, and Medicare Advanced Primary Care Practice (MAPCP) Demonstration: Local community networks provide support to physicians participating in all three programs. Networks consist of:
In addition to providing education programs and informational services, Area Health Education Centers (AHECs) are also helping practices achieve electronic health record (EHR) meaningful use as Regional Extension Centers.
The CCNC Patient-centered Medical Home (PCMH) team hosted eight webinars to help practices achieve 2008 NCQA PCMH Recognition and has completed a 2008 NCQA PCMH Recognition Workbook. A 2011 NCQA PCMH Recognition webinar series and workbook is in development.
North Carolina also received an Infrastructure for Maintaining Primary Care Transformation (IMPaCT) award from the Agency for Healthcare Research and Quality (AHRQ) in September 2011. North Carolina’s IMPaCT project featured a Regional Leadership Collaborative and a Care Transitions Learning Collaborative to accelerate local-level process improvements and quality improvement in clinical performance measures. The Regional Leadership Collaborative focused on developing leadership and quality improvement skills among regional teams. The Care Transitions Learning Collaborative concentrated on integrating care transitions into primary care practices’ roles as part of the PCMH.
|North Dakota||No known activity at this time.|
|Ohio||PCMH Education Pilot Project: Substitute House Bill 198 (128th General Assembly) requires participating practices to receive comprehensive training on medical home operations, including leadership training, scheduling changes, staff support and care management.ACA Section 2703 State Plan Amendment – Community Behavioral Health Centers (CBHCs): The Ohio Department of Mental Health and Ohio Office of Medical Assistance launched a Health Home Learning Community in February 2013. The state reports that it plans to “include a series of accelerated and intensive in-person and virtual learning sessions on a variety of topics including integration of physical and behavioral health needs, transitions in care, and assertive outreach and engagement with input from community mental health centers and key partners. The series will focus on high-quality care, improving care coordination and enhancing the consumer experience.” For more information on technical assistance for health home practices, visit the Ohio Medicaid Health Homes webpage.|
|Oklahoma||SoonerCare Choice: The SFY2010 Performance and Quality Reportstates that the Oklahoma Health Care Authority (OHCA) Quality Assurance and Improvement Department conducted 557 visits to educate providers on the medical home requirements from July 1, 2009 – June 30, 2010.Oklahoma provides four profiles to selected providers biannually that give information about their patients’ utilization and health care needs. Also, SoonerExcel, a pay-for-performance program, provides practice feedback on targets for Child Health Exams (Early Periodic Screening, Diagnosis, and Treatment [EPSDT]) and Breast and Cervical Cancer screenings.Oklahoma is currently piloting three non-profit, administrative Health Access Networks (HANs) to support care coordination and quality improvement. According to Oklahoma Health Care Authority’s 2012 Annual Report, the state’s three HANs served 382 practices and over 78,000 SoonerCare Choice members as of June 2012.Practices participating in the SoonerCare Health Management Programreceive 4-6 weeks of practice facilitation services to support work with high-risk SoonerCare Choice members with chronic conditions. In addition, practices are invited to participate in regional collaboratives.|
|Oregon||Oregon Patient-Centered Primary Care Home (PCPCH) Program:Chapter 595 of the 2009 Oregon Laws required OHPR to establish a learning collaborative for state agencies, payers, providers, and third party administrators to:
|Pennsylvania||The Chronic Care Initiative (CCI) rollouts have provided for learning collaboratives, including funding to cover lost time and revenue when providers and practice staff were out-of-office. CCI has also provided web-based patient registries and practice coaching. Under Phase II, the Department of Health is leading the learning collaboratives, holding monthly group calls for all practices, and overseeing practice transformation consulting. Practices are asked to regularly submit clinical data for quality improvement purposes. Priorities for further practice transformation have also been identified.|
|Rhode Island||Chronic Care Sustainability Initiative (CSI-RI): CSI-RI practices receive support through practice coaching (currently via TransforMED) and learning collaboratives. They have also receiving health IT support through the Beacon Community program since July 2010, as well as ongoing data feedback. The state plans to continue key data analysis and practice functions provided by the Beacon Community when Beacon funding ends in spring 2013. Additionally, practices have received support for hiring nurse care managers or contracting for remote nurse care manager support.|
|South Carolina||Under the Medical Homes Network Program, the South Carolina Department of Health and Human Services contracts with Care Coordination Service Organizations to provide care coordination, disease management and data management support.|
|South Dakota||No known activity at this time.|
|Tennessee||The Bureau of TennCare and the Tennessee Department of Children’s Special Services have partnered with the Tennessee Chapter of the American Academy of Pediatrics (TNAAP) and Tennessee Voices for Children to develop educational and training materials to support medical home implementation, particularly to serve children and youth with special health care needs. As part of this work, TNAAP has developed a website with resources and toolkits for practices; TNAAP has also held a series of online and in-person learning events.|
|Texas||No known activity at this time.|
|Utah||Practices participating in the Children’s Healthcare Improvement Collaboration (CHIC) will receive support through in-person learning sessions (one or two annually), site visits (three to six times per year, with a practice coach and/or peer mentor), and conference calls (six to ten annually).|
|Vermont||Practice support has included:
|Virginia||No known activity at this time.|
|Washington||Washington State’s mutli-payer Patient Centered Medical Home (PCMH) Pilot did not provide for participating practices to receive supports other than enhanced payment.The PCMH Collaborative has provided a range of supports to participating practices, including practice coaching, in-person learning sessions, and a series of webinars.The Washington State Department of Health (DOH) and the Washington State Medical Home Leadership Network also maintain a website devoted to helping providers and others better serve children and youth with special health needs through the medical home model.|
|West Virginia||Practices that participated in the Medical Home Performance Incentive Pilot received a technical assistance package valued at $25,000 per practice, including:
|Wisconsin||No known activity at this time.|
|Wyoming||The Wyoming Department of Health provided $250,000 in funding to increase the number of practices receiving support from TransforMED through a Health Care Innovation Award led by the Wyoming Institute for Population Health.|