Spotlight on Vermont

July 2015

This brief highlights the major strategies, lessons learned, and outcomes from Vermont’s experience during the first 5 years of the quality demonstration funded by the Centers for Medicare & Medicaid Services (CMS) through the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA). For this demonstration, CMS awarded 10 grants that supported efforts in 18 States to identify effective, replicable strategies for enhancing the quality of health care for children. With funding from CMS, the Agency for Healthcare Research and Quality is leading the evaluation of the program.

Vermont increased the pediatric focus of its advanced primary care model

Before the demonstration, Vermont engaged family practices, but not pediatric practices, in the Blueprint for Health initiative, the State’s advanced primary care practice model.¹ Practices participating in the initiative receive a variety of supports, including (1) assistance with patient-centered medical home (PCMH) recognition, (2) access to community health teams that help coordinate medical and social services, and (3) quality feedback reports. Medicaid and the State’s three commercial payers support practices’ involvement in the Blueprint with enhanced payments based on the practices’ PCMH recognition scores. Vermont used CHIPRA quality demonstration funds to accelerate the participation of pediatric practices in the initiative and enhance the technical assistance offered on pediatric topics. Vermont—

• Hired a practice facilitator with expertise in pediatrics. During the first few years of the demonstration, Vermont employed a practice facilitator specifically to engage and support pediatric practices in their quality improvement (QI) efforts. The practice facilitator helped 28 pediatric practices—representing approximately 82 percent of all pediatric practices in the State—implement new processes to improve access to and quality of care. Rather than replace the pediatric-focused practice facilitator when she left her position toward the end of the demonstration, Vermont decided that pediatric practices would receive assistance from facilitators already supporting family practices. The State reported that integration of the pediatric practices into the broader Blueprint for Health initiative increased project sustainability. However, some practices noted that the family practice facilitators lacked sufficient clinical expertise in pediatrics.
• Helped practices obtain PCMH recognition. Over the course of the demonstration, all but one of the 28 participating practices received PCMH recognition from the National Committee for Quality Assurance (NCQA). To gain that recognition, practices implemented new strategies such as using data to monitor practice performance, involving families in care plan development, and working with social workers and care coordinators to integrate medical and social services. Several practices indicated that the PCMH recognition process was burdensome and diverted resources from other QI efforts. Almost all practices, however, plan to update their PCMH recognition—which is required for continued participation in the Blueprint—to maintain access to community health teams and enhanced payments.
• Hosted a learning collaborative on pediatric care coordination. Community health teams working with pediatric practices and care coordinators within the practices told the State that they wanted additional training in pediatric topics such as family engagement strategies. In response, Vermont hosted a learning collaborative for 11 practices that involved three in- person meetings, monthly conference calls, and site visits. Practices reported that they learned new care coordination strategies, though several are concerned about reimbursement from payers for those activities.

Vermont helped practices use a State electronic data registry

Vermont developed an electronic registry that stores health information that is either uploaded directly from providers’ electronic health records (EHRs) or entered manually. Using demonstration funds to improve the functionality of the electronic registry for child-serving providers, Vermont—

• Incorporated pediatric visit planners into the registry for preventive services, asthma, attention deficit hyperactivity disorder, and obesity. Visit planners are electronic forms that guide a provider through a given visit, comparing a patient’s health indicators with current guidelines and suggesting preventive services or assessments to be delivered during the visit. Demonstration staff worked with State agencies, practices, and health plans to identify child-focused quality measures for inclusion in the registry and started exploring the feasibility of programming the registry to calculate and report those measures.
• Helped practices use electronic data to improve care. The electronic registry was most useful for practices without EHRs. Such practices entered chart data into the system manually and used visit planners and quality reports to improve care. Most practices with EHRs indicated that their systems were not only incompatible with the State’s registry (thus making automatic uploads infeasible) but that entering information into the registry was also duplicative of information that resided in their EHRs. Moreover, by the end of the demonstration, many practices had used their own resources to implement EHRs that enabled them to analyze patient information without using the State’s electronic registry. Practice facilitators helped these practices incorporate visit planners into and pull reports directly from their EHRs to guide care delivery.

Vermont supported the development and expansion of improvement partnerships

State improvement partnerships engage a broad group of stakeholders, such as pediatric providers, hospitals, health plans, and academic medical centers, to identify strategies for improving the quality of pediatric care. The National Improvement Partnership Network (NIPN), operated by the University of Vermont, helps States develop or expand their partnerships.² Vermont provided NIPN with CHIPRA quality demonstration funds to continue its work. With this support, NIPN—

• Provided technical assistance to improvement partnerships in more than 20 States. NIPN staff conducted site visits to States and hosted monthly and annual training sessions for improvement partnerships. NIPN provided States with expert advice on QI strategies (for example, hosting virtual learning sessions) and QI topics (for example, oral health, asthma, and developmental screening). States’ demand for NIPN’s technical assistance grew over the demonstration period, and by the end of the demonstration, States’ needs exceeded NIPN’s capacity.

Key demonstration takeaways

• Expansion of the Blueprint for Health initiative to pediatrics was already on Vermont’s agenda, but the availability of CHIPRA demonstration funds accelerated the timeline for implementation and allowed Vermont to provide additional technical support to pediatric practices.
• Practices relied on support from practice facilitators and community health teams with pediatric expertise to gain PCMH recognition and deliver more coordinated, comprehensive care.
• Use of the electronic registry was limited because many providers experienced difficulty in connecting their EHRs to the system, were concerned that the system required duplicative data entry, or both.
• NIPN provided valuable support to improvement partnerships in more than 20 States, but, without identifying additional funds, NIPN’s technical assistance to other States following the demonstration will be greatly reduced or eliminated.

Endnotes

1. For more information on the Blueprint, visit http://blueprintforhealth.vermont.gov/.
2. For more information on NPIN, visit http://www.uvm.edu/medicine/nipn/.

Learn More

Vermont’s CHIPRA quality demonstration experiences are described in more detail on the national evaluation Web site available at http://www.ahrq.gov/policymakers/chipra/demoeval/demostates/vt.html.

The following products highlight Vermont’s experiences—

• Evaluation Highlight No. 2: How are States and evaluators measuring medical homeness in the CHIPRA Quality Demonstration Grant Program?
• Evaluation Highlight No. 4: How the CHIPRA quality demonstration elevated children on State health policy agendas.
• Evaluation Highlight No. 6: How are CHIPRA quality demonstration States working together to improve the quality of health care for children?
• Implementation Guide No. 1: Engaging Stakeholders to Improve the Quality of Children’s Health Care.
• Reports from States: Vermont developed a paper that describes the work of the National Improvement Partnership Network.