Last fall, the Ohio Department of Medicaid http://medicaid.ohio.gov and the Ohio Department of Health www.odh.ohio.gov contracted with the Health Policy Institute of Ohio www.hpio.net to engage stakeholders to provide guidance on how to improve population health planning.
The objective was to align population health priority areas and strategies with the design and implementation of Ohio’s Patient-Centered Medical Home (PCMH) model www.odh.ohio.gov/pcmh. The PCMH model has traditionally been focused on improving care coordination and disease management for those who already have chronic conditions such type 2 diabetes or heart disease.
Within the Ohio PCMH model, the vision for a fully transformed PCMH, practice can also play an important role in helping healthy patients stay well and also intervene with patients at risk for chronic conditions.
Ohio’s vision for PCMH is to assess care plans to identify and document a full set of needs for patients that incorporates community-based partners to reflect socioeconomic and ethnic differences into treatment plans.
Ohio’s model for a fully transformed PCMH is expected to:
- Actively connect members to broader social services and community-based prevention programs
- Ensure ongoing bi-directional communication with social services and community-based prevention programs
- Collaborate meaningfully with partners based on achievement of health outcomes
- Actively engage in advocacy and collaborations to improve basic living conditions and opportunities for health behaviors
Local health departments and nonprofit hospitals need to include representatives from PCMH practices in community health priorities and in the planning process. It is also important to include aggregated PCMH data in community health assessments identified in patient satisfaction surveys, clinical utilization data, or outcome data.
The State Executive Branch recommends exploring single-instrument grant awards to local health departments to allow for flexibility in addressing needs across sectors or silos. Another recommendation is to develop payment models that would encourage and incentivize Medicaid managed care plans and providers to work with local health departments, social service agencies, and other community-based organizations.