Blueprint for Health: Foundations of the Blueprint (2 of 3)

Uploaded by ahrqinnovations on 25.09.2012

NARRATION The Blueprint for Health calls for the creation
of Patient Centered Medical Homes supported by Community Health Teams working in conjunction
with public health services to improve the health of both individuals and populations.
CRAIG JONES So what a Patient Centered Medical Home really
is, is high quality primary care, high quality preventive care. Great access for its patients--do
they really have the ability to get in and get the health care they need when they need
it? Is the care they get really well coordinated? Do they communicate well with the families
and the patients that come to them? Do they follow up closely? Do they track things carefully
in electronic systems? Do they manage a population by pulling reports and looking at all the
people who are missing tests or need assessments or who haven’t been in?
NARRATION The Blueprint changes the incentive structure
for healthcare providers. All of the payers, including insurance companies, Medicare, and
Medicaid pay into a system to provide incentives for practitioners and to fund the community
health teams that support those providers. Rather than being rewarded for volume, Patient
Centered Medical Homes are reimbursed based on how well they are evaluated according to
national standards.
CRAIG JONES Every practice in the Blueprint in Vermont
is scored against these standards by a team from the University of Vermont. That then
makes then eligible for the payment reforms that help support that high quality care.
NARRATION The Patient Centered Medical Homes are supported
by Community Health Teams.
PENROSE JACKSON So the Community Health Team has nurses, social
workers, registered dieticians, health coaches, and other supports. We looked at our resources
in terms both of our community resources and also what the clinics had and needed. And
then we said, “What does our community have and need?” And then started to develop it
based on that.
NARRATION Sometimes, team members are embedded in primary
care practices.
CHELSEA My name is Chelsea. I’m the chronic care
HILLARY Nice to meet you.
LAUREL RUGGLES We have care coordinators and the behavioral
health specialists. Most of them are nurses as well, and their role is different from
the typical office nurse. The care coordinators have the time to sit and talk with a patient
and find out what else is going on in their lives.
HILLARY I really don’t want to go on the medicine,
so if you really feel like this would help, I feel very confident.
NARRATION In addition to having Community Health Team
members embedded in Patient Centered Medical Homes, team members may also be available
in the community. These community health workers assist patients with health education and
non-medical social supports that may affect their ability to receive healthcare.
STEVE Yeah, I may lose the health insurance I have
with my job. They cut me back.
CONNIE Yeah, that’s what I understood.
STEVE So I’m back to part time now, and my wife’s
really worried. She’s disabled and it may really affect her not to have the insurance.
CONNIE Okay. You know what we could do? We could
apply for Social Security Disability if you wanted.
PAM SMART We’ve found that by working together, partnering,
and wrapping people with services, we’re preventing crisis. We really do get a chance
to look at what’s going on with folks because they can’t concentrate on their illness
until the rest of their life is stable.
PAM FARNHAM We really look at it as a partnership with
the providers, the doctors and nurses in the medical home. We meet regularly with them.
We communicate via the electronic health record. They send us referrals on their patients that
they think could benefit from help with any number of issues.
NARRATION Many communities also take advantage of Community
Health Team extenders to support more targeted subpopulations. The Support and Services at
Home, or SASH program, helps older adults to live and age safely in their own homes.
GARY Welcome home, Audrey!
AUDREY Thank you!
GARY How are you doing?
AUDREY With the SASH program, I think they filled
a need. I had a fractured ankle, which arthritis has set into now. And I have Parkinson’s.
There’s a lot of stuff available here. I didn’t have the courage to go there and
see until I got into this program.
NARRATION The Blueprint for Health also supports Healthier
Living Workshops: a series of classes that empower participants to better cope with their
symptoms through peer support and skill-building exercises.
BARBARA Gardening is completely foreign to me. But
I decided that I would do one hour every other day as a realistic goal, two or three times
a week. And I haven’t quite gotten it together to do it every other day.
PAM SMART And that’s part of the self-management skills,
that sometimes life gets in the way, doesn’t it. We might have the best plan….
NARRATION The Blueprint’s support for local innovation
is clearly evident in the Functional Community Health Team.
PAM SMART We have a community really rich in resources,
not a lot of money, not a lot of funding, but a lot of people who really care.
NARRATION This broad group includes local community
health and human services programs including non-profit organizations and public health
KAREN STEWART I’m Karen Stewart. I’m the acting district
director for the St. Johnsbury Vermont Department of Health office.
NARRATION By coordinating with this larger group, the
core community health team can leverage enormous resources to help provide expanded services
for their patients.
ROSE SHEEHAN And so, one of our interests is to provide
some kind of a program for high school students who are already engaged in drug and alcohol
NARRATION They can also work with this larger group
to support the development of new services in their community.
NAME So as we looked St. Johnsbury thinking, you
know, “what do we have around here--just for teens--that they can feel safe and talk
about their issues and try to work through some of those?” And we couldn’t think
of anything that we specifically had, so we thought, “Well, why don’t we see if we
can start something?”
NARRATION The Blueprint connects Patient Centered Medical
Homes and multi-disciplinary Community Health Teams with public health resources and health
IT infrastructure.
BETH TANZMAN The role of public health in the Blueprint
for Health has been a really important one, and it brings that broader point of view about
how we think about the health of the whole population and well beyond the scope of just
primary care.
PENROSE JACKSON This is the kind of work that is really starting
to get clinicians and public health officials talking across the board and talking together
about how their work can be beneficial each to the other. I’m now hearing clinicians
talk about the social determinants of health and I never would have heard that ten years
ago. And I’m hearing people in the public health arenas talk about the value of the
clinical care and how public health needs to support it.
NARRATION The Blueprint model encourages health care
providers to use electronic medical records.
The Department of Vermont Health Access is building the IT infrastructure needed to collect
health information from the electronic medical records of health care providers into a Health
Information Exchange. This exchange can then interface with a Central Clinical Registry,
which can provide data back to health care providers, community health teams, and public
health policy makers. This data can enable visit planning, better care coordination,
and more accurate reporting.
BETH TANZMAN The importance of the central clinical registry
and the health information infrastructure that we’re talking about with the Blueprint
can’t be overstated in terms of improving care and also helping us understand where
are the next things we need to focus on as a system.
CRAIG JONES The real idea here to help achieve the Institute
of Medicine’s vision for a learning health system is that people--just by going to work
every day, electronic medical records capture information; a multi-payer claims databases
capturing information about the quality of healthcare and healthcare expenditures. They’re
able to capture very important information and we needed to bring that information together
into systems where it could turn into knowledge
LAURAL RUGGLES I can give you an example. The care coordinators
located in the medical homes all have access to their patients who were seen in this hospital,
so they get those lists automatically every morning and then they can see who of their
patients were in the hospital and they can follow up. And that’s just seamless, it
just happens.
CRAIG JONES And that knowledge then is available back
to the practices, back to the communities, so they can continuously see how they’re
doing and set goals and try to improve against that information. That’s a learning health
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