Learning Collaboratives: transformation to a Health Home Model in Missouri

CSI Solutions was pleased to partner with multiple stakeholders in Missouri in a statewide initiative to accelerate transformation to a Health Home model of care for the most vulnerable patients. In 2011, Missouri was the first state to gain approval for a Medicaid State Plan Amendments (SPA) authorized under Section 2703 of the Affordable Care Act. Missouri took a unique approach, winning approval for two SPAs, one covering members served by Community Mental Health Centers (CMHC) and another covering Primary Care Practices (PCP). These SPAs provide incremental payment for care coordination, follow-up after hospital discharge, care management and other services for Medicaid recipients with multiple chronic conditions. Over 34,000 Medicaid enrollees were assigned to Health Homes in either a CMHC or PCP and 78 health care organizations were charged with implementing a full range of Health Home services for these individuals.

To accelerate the transformation to a Health Home model, the Missouri Foundation for Health and the Healthcare Foundation of Greater Kansas City contracted with CSI Solutions to conduct a statewide initiative, bringing together behavioral health and primary care teams in a shared 18-month Collaborative. CSI Solutions provided:

• Curriculum development for transformation to a Health Model of care – based on nationally recognized models and adapted to Missouri’s unique needs;
• Logistics and faculty for all Learning Sessions;
• Technical support and coaching between Learning Sessions, including monthly webinars, data and narrative report feedback, and team coaching;
• A secure Knowledge Management portal allowing teams to share resources and data;
• A secure measurement reporting system, allowing teams to enter data, run reports, and compare results for all Collaborative measures;
• Project Management in partnership with multiple Missouri stakeholders.

Results

Behavioral Health
Missouri’s CMHCs participated in the Collaborative and collected data on the 19,000 consumers enrolled in Health Homes. The teams saw significant improvement in core diabetes outcomes for this population.

Primary Care
Primary Care teams collected data for all their patients, not just the subset of patients who were Health Home enrollees. This was done in an effort to promote and assess whole system transformation across the entire population of patients. These teams saw significant improvement at a population level for Hospital Discharge Follow-up, Pediatric BMI Assessment and Counseling, and Adult Tobacco Use Assessment and Referral.

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