News & Notes

New HUD Olmstead guidance: The 1999 Supreme Court’s Olmstead decision affirmed that the unjustified segregation of individuals with disabilities is a form of discrimination prohibited by the Americans With Disabilities Act (ADA). The U.S. Department of Housing and Urban Development (HUD) has issued new guidance on how the Olmstead ruling applies to HUD’s programs and activities. The guidance is intended to better educate state and local housing agencies, housing developers, and housing providers on their obligations under the ADA’s “integration mandate.” The guidance makes clear that entities that receive financial assistance from HUD must provide housing for people with disabilities in the most integrated setting appropriate to their needs. According to the guidance, integrated settings are “those that provide individuals with disabilities opportunities to live, work, and receive services in the greater community, like individuals without disabilities.” Examples include scattered-site apartments providing supportive housing, rental subsidies that enable individuals to obtain housing on the open market, and apartments scattered throughout housing developments. “By contrast,” the guidance states, “segregated settings are occupied exclusively or primarily by individuals with disabilities.” The 11-page guidance document is available on the HUD Web site at portal.hud.gov/hudportal/documents/huddoc?id=OlmsteadGuidnc060413.pdf.

PCPCC “cross-walk” of transformation proposals: Although U.S. health care spending exceeds $2.5 trillion annually and per capita spending is among the world’s highest, the nation ranks low in terms of access, quality, and outcomes. Policy makers seeking to improve the system focus on changing its design, which prioritizes volume of visits and procedures over value-based elements such as care coordination and expanded access. A “cross-walk” document from the Patient-Centered Primary Care Collaborative (PCPCC) reviews five major public policy proposals and their implications for patient-centered primary care. The proposals, from the Partnership for Sustainable Health Care, the Brookings Institution, the Center for American Progress, the Bipartisan Policy Center, and the Commonwealth Fund, make recommendations to support the alignment of major public policy priorities and private-sector innovations, including payment reform incentives, new delivery models, and patient and consumer engagement. The PCPCC’s comparative analysis indicates consensus across the health care marketplace and political spectrum that patient-centered, coordinated, team-based primary care is critical to system transformation. The PCPCC, which was founded in 2006, focuses on creating an effective and efficient system based on a strong foundation of primary care and the patient-centered medical home. The Primary Care Consensus: A Comparison of Health System Transformation Proposals is available on the PCPCC Web site at www.pcpcc.net/resource/primary-care-consensus-comparison-health-system-transformation-proposals.

CIHS sustainability strategies for integrated care: In recent years many primary care and behavioral health care settings have made important strides toward integrating care—some by using state or federal funds to implement integration projects. Sustainability—making integrated care stick—is now on the minds of many administrators and providers. In a recent eSolutions Newsletter, the Center for Integrated Health Solutions (CIHS) offers tips and strategies for sustainability, which should not be confused with financing, according to CIHS. Although financing is critical, it is only one component of a solid sustainability plan for “bidirectional integrated care,” which includes both administrative and clinical components. A key aspect of any sustainability plan is use of electronic health records, which will allow integrated care organizations to generate and share a coordination-of-care document that includes both primary health and behavioral health information for each patient. Creating clinical workflows that support integration and training staff in techniques such as motivational interviewing should also be part of the plan. CIHS also addresses billing and financing, health homes, and quality improvement. A sustainability checklist designed to help organizations prioritize and begin the process of developing a sustainability plan can be downloaded. CIHS is funded jointly by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration and operated by the National Council for Community Behavioral Health. The sustainability resources are available at www.integration.samhsa.gov/about-us/esolutions-newsletter/esolutions-make-it-last-how-to-sustain-integrated-care.

“Depression care bundle” focus of AHRQ policy innovation profile: Many patients with depression seek care in primary care settings, which often lack the resources and reimbursement support to identify and treat them. Integrating mental health assessment and treatment in primary care settings is a solution, but most primary care clinics do not offer integrated care. The Agency for Healthcare Research and Quality (AHRQ) recently profiled a Minnesota program known as DIAMOND (Depression Improvement Across Minnesota Offering a New Direction), in which six nonprofit health plans pay certified practices a flat monthly rate for providing a bundled set of depression care services to each patient who meets eligibility criteria. Participating practices implement the DIAMOND care model and receive monthly performance reports based on data they submit on process and outcome measures for depression care. The initiative has generated high rates of remission and treatment response among participating patients, along with high levels of provider satisfaction. The program was developed by the Institute for Clinical Systems Improvement in collaboration with the Minnesota Department of Human Services, the six health plans, multiple medical groups, employers, and patients. More details on the program are available on AHRQ’s Innovations Exchange Web site at www.innovations.ahrq.gov/content.aspx?id=3838.

Five states offer lessons in measuring care coordination: As states and providers undertake new strategies to integrate care, early lessons are accumulating. A new report from the National Academy for State Health Policy (NASHP) summarizes results from five states that participated in the three-year ABCD III initiative (Assuring Better Child Health and Development), which sought to improve care coordination between primary care providers (PCPs) and providers of community services to Medicaid-eligible children up to three years of age who were identified via screening as having potential developmental delays. The care coordination strategies were piloted and evaluated in Arkansas, Illinois, Minnesota, Oklahoma, and Oregon. ABCD III focused specifically on improving referral and follow-up communication between PCPs and Part C Early Intervention providers. The states explored ways to pay for care coordination (for example, via medical homes), facilitate systematic communication (for example, via standardized forms, data sharing agreements, and privacy policies), and support and sustain coordination across systems (for example, via structured quality improvement projects and electronic data systems that automate measurement). The 26-page report, which is available on the NASHP Web site at nashp.org/sites/default/files/measuring.improving.care_.coordination.pdf, describes the evaluation methods, summarizes results, and highlights lessons learned from the states’ experiences evaluating care coordination.

Kaiser brief on transitioning beneficiaries with complex care needs to Medicaid managed care: Between June 2011 and May 2012, Medi-Cal, the California Medicaid program, transitioned about 240,000 seniors and persons with disabilities from fee-for-service to mandatory Medicaid managed care as part of its “Bridge to Reform” Medicaid waiver. (Persons who were dually eligible for Medi-Cal and Medicare were excluded.) Goals of the transition were to increase plan and provider accountability and oversight, improve beneficiary access to care, and make costs more predictable. An issue brief from the Kaiser Commission on Medicaid and the Uninsured examines how health service providers, plan administrators, and community-based organizations in three California counties experienced the transition. The brief describes challenges faced in four areas and strategies used to address them: sharing beneficiary data and information, expanding the provider network to include both primary care and specialty providers with expertise in complex care, coordinating the logistics of care for persons with complex needs, and ensuring resources to support the transition (some providers reported delivering unreimbursed care, and plans reported that Medi-Cal capitation rates did not cover actual costs). Findings presented may inform similar transitions of high-need beneficiaries in other states as well as coverage expansions in 2014 under the Affordable Care Act. The 15-page issue brief is available on the Kaiser Commission Web site at kff.org/medicaid/issue-brief/transitioning-beneficiaries-with-complex-care-needs-to-medicaid-managed-care-insights-from-california.

Interactive U.S. maps track activities related to medical homes: In the past five years, state Medicaid and Children’s Health Insurance programs (CHIP) have made significant efforts to implement patient medical homes—an enhanced model of primary care that provides whole-person, accessible, comprehensive, ongoing, and coordinated patient-centered care. The National Academy for State Health Policy has created a set of interactive maps that let users explore state activities in five areas: creation of medical homes, including payments to medical homes (only eight states have not undertaken any activities); multipayer initiatives, Affordable Care Act Section 2703 health homes; alignment of medical home payments with qualification standards; and shared practice supports. Users can also click away from the map to obtain detailed information about the status of Medicaid and CHIP medical homes in each state (nashp.org/med-home-map).

Applying behavioral economics to improve health care quality: Some economists are turning to psychology to explain why the health care system does not function optimally. Behavioral economics seeks to answer such questions about human behavior as the following: Why do people fail to exercise in spite of its well-known benefits? Why do people skip medications that could prevent serious illness? Why do physicians stick to their usual practices in the face of ample evidence of better approaches? Why have pay-for-performance programs not always succeeded? A central theory of behavioral economists is that patients and physicians are “predictably irrational” in their decision making. The lead article in the June/July issue of Quality Matters, the Commonwealth Fund newsletter, explores how researchers are using such concepts as “loss aversion,” “present bias,” and “decision fatigue” and combining them with telemedicine tools that monitor and deliver targeted feedback to patients (called “automated hovering”) to improve the quality of care by engaging patients and providers. The issue also features an interview with Douglas Hough, Ph.D., a faculty member at Johns Hopkins Bloomberg School of Public Health and author of the recently published book Irrationality in Health Care: What Behavioral Economics Reveals About What We Do and Why. Quality Matters is available on the Commonwealth Fund’s Web site at www.commonwealthfund.org/Publications/Newsletters.aspx.

AHRQ seeks clinician input on shared decision-making tools: AHRQ’s Effective Health Care Program invites clinicians to participate in an online survey about their needs and preferences for tools to educate patients about treatment options. The results will inform the development of new tools and a workshop. Survey participation will help ensure that AHRQ provides resources that bring the most value to patients, caregivers, and health care professionals. Access the survey at www.surveymonkey.com/s/AHRQ-EHC.