How State Medicaid Agencies Can Encourage Team-Based Primary Care

April 19, 2021
Team-based care is an integral component of the Oregon’s Patient Centered Primary Care Home model, which includes community health workers, peer support specialists, patient navigators, and doulas

State governments are recognizing that team-based primary care is one key to success in Medicaid managed care. Oregon is one state leading the way with its Patient Centered Primary Care Home Program.

Neelam Gupta, M.P.H., M.S.W., serves as director of clinical supports, innovation and workforce unity for the Oregon Health Authority (OHA), which oversees the state’s Medicaid program. During a recent webinar put on by the Center for Health Care Strategies, she spoke about why OHA is committed to supporting team-based care and how doing so can promote health equity.

Gupta described the Patient Centered Primary Care Home (PCPCH) program as Oregon’s version of the medical home, which is a model of primary care organization delivery that is patient-centered, comprehensive, team-based, coordinated, accessible and focused on quality and safety. “It provides an evidence-based framework for how primary care practices should provide care for their patients with an emphasis on quality improvement and it's also uniquely Oregonian,” she said.

States like Oregon that rely on managed care are well positioned to use their purchasing power to promote high-quality comprehensive primary care, said Melinda Abrams, M.S., the executive vice president for programs at the Commonwealth Fund, which supports the Center for Health Care Strategies’ work in advancing primary care innovation through Medicaid managed care. “Both the Center for Health Care Strategies and the Commonwealth Fund see that primary care is no longer about the four walls of a practice, and it's not exclusively about the doctor,” she added. “It's quite the opposite. Like the rest of our healthcare system, the primary care sector needs to innovate, needs to be working in multidisciplinary teams, needs to incorporate digital health solutions to enable the sustained relationships between clinicians and patients and their families, and to integrate the physical health, behavioral health and social needs, whether it's in an office, in one's home, or through one’s screen.”

Oregon currently as around 650 practices in the PCPCH program and approximately 75 percent of all Oregonians, regardless of payer source, receive their care at a PCPCH site, Gupta said.

Participation in the PCPCH program is voluntary and recognition is attestation-based. The program conducts on-site visits to a select number of PCPCH sites each year to verify that clinics are meeting the measures they attested to in their applications. The PCPCH recognition criteria is defined by six core attributes, each with specific standards under each attribute, and measures that indicate the extent to which a clinic is meeting that standard.

Gupta stressed that team-based care is an integral component of the PCPCH model. Oregon’s model includes community health workers, peer support specialists, peer workers, patient navigators, and doulas. “We're about to add another category of workers specific to tribes,” she said. “So that's been a critical element that's been identified as part of the primary care payment reform collaborative and other efforts to integrate equity. Our legislature has proposed significant investments in the behavioral health workforce, in increasing the diversity of and also expanding that workforce  to promote integration and achieve team-based care.”

PCPCH practices operate in different care delivery models. One  example is a pediatric practice, which is focused on meeting the needs of the whole child that supports children and families partnering with healthcare providers, other team members, and outside organizations to identify, coordinate and address shared goals.

Another example is a practice with integrated, on-site behavioral health clinicians delivering comprehensive services, which can include warm handoffs, brief assessments and interventions, consultations to primary care clinicians and other care team members, and collaborative treatment planning.

Other practices support patients, families and caregivers with health-related social needs screening, identification, and community resource referrals and follow-up. This is often done by a community health worker, a patient navigator, a care coordinator, or other staff.

Coordinated care organizations

Gupta explained how the PCPCH goes hand in hand with Oregon's model for Medicaid managed care, the coordinated care organizations (CCOs). The CCO model has been implemented in Oregon, and more than 90 percent of Medicaid recipients receive care through 15 CCOs, which are community-based, community-governed organizations that bring together physical, behavioral and dental health providers to coordinating care.

They receive fixed monthly budget payments from the state to coordinate care for patients. They receive financial incentives for improving outcomes and quality and they have flexibility to address their members’ health needs outside of traditional medical services. This model is designed to improve member care and reduce taxpayer costs. This focus helps to reduce unnecessary emergency room visits and gives Oregonians the support they need to be healthy.

CCOS are required to use PCPCHs in their networks for primary care to the greatest extent possible. As a result, approximately 96 percent of all CCO members received their care through a recognized PCPCH practice. Number of members enrolled in a PCPCH practice is a CCO incentive measure, which is one of the set of quality metrics used to show how well CCOs are improving equity and team-based care, reducing healthcare costs and eliminating health disparities

Researchers have found that for every $1 increase in primary care expenditures related to the PCPCH program, there is a $13 savings in other services such as specialty care, emergency department and inpatient care, she said.

An equity lens

Gupta closed by saying the state is embarking on a journey to examine its models through a health equity lens. “Prior to the pandemic, we had contracted with a nationally renowned health equity expert, Ignatius Bau, to review our previous standards through a health equity lens, and recommend some changes, which were then taken to our multi-stakeholder standards advisory committee, and resulted in a new version of the standards that are going to be rolled out starting this summer.”

During the same webinar, Courtney Pladsen, D.N.P., F.N.P., R.N., clinical director of the National Health Care for the Homeless Council (NHCHC), also framed the shift to team-based care as an equity issue. “To improve racial inequities in health outcomes, we must first integrate screening and addressing social determinants of primary care. Team-based care is one way that we can address these health inequities. A one-size-fits-all approach is not going to improve the inequities in our system,” she said.  “We need tailored, individual approaches that really get at equity. If healthcare teams are not aware of barriers to care, treatment plans are rendered ineffective.”

Pladsen gave an example from her own work with a specific homeless man who had been trapped in vicious cycles of incarceration, long-term homelessness and health issues.

He had a chronic illness and was in the emergency department often. He would get discharged from hospitals to go to emergency shelters on the street. And because there is a significant criminalization of homelessness, this person was often cycling in and out of jails, she said. “This is an exceptionally expensive, ineffective system. This person wasn't getting any healthier, was highly traumatized from lots of interactions with police and jail and going back to shelters, so this patient was really stuck in this cycle before engaging with our team.

The patient had a history of chronic leukemia, but because of this cycle of homelessness and incarceration, he struggled to take medications, which caused lots of significant pain for him. He also struggled with bipolar disorder, and due to chronic pain challenges, he struggled with opiate use disorder as well. He had a history of multiple psychiatric hospital admissions. And in his 36 years of life, he's had a total of 12 years of incarceration. “In the past year prior to engagement with our team, he was in the intensive care unit three times and intubated,” Pladsen said. He wasn't getting any better, even though he was cycling through so many systems.

At a federally qualified health center, they used an integrated behavioral health model to help this individual. Through building a trusting relationship, they got him psychiatric care with a psychiatric nurse practitioner on staff. He engaged with their registered nurse, who helped make pillboxes for him once a week.

“I was engaged with him on a weekly basis, and the nurse would as well,” Pladsen said. “We have peer support for people who are in recovery. A case manager helped him apply for housing and connected him to housing resources. A community health worker worked to meet his food needs. A social worker is on staff for individual therapy when and if he needs that, and a medical assistant works to build a trusting relationship."

They have a pharmacist on staff as well. “This is huge team support,” Pladsen said, “but this is what it took to disrupt the cycle. This client was able to secure housing. He’s on a long-term wait list for Section 8 housing. We were able to get him into a single room occupancy. So it's really just the first step in housing. But we're able to get him off the street, which was really important for helping stabilize his health condition.”

She said to help identify needs, they use a tool called PRAPARE (Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences).  It is a national effort to help health centers and other providers collect the data needed to better understand and act on their patients' social determinants of health. PRAPARE is integrated into many electronic health records that are used in safety net settings.

“Until we actually understand what his barriers to care are, we cannot develop an effective treatment plan,” she said. “On an individual level, having our patients screened with this tool is very effective for me to develop treatment plans that are going to meet the client's needs, by knowing what the resources and barriers they have.”