Professional Documents
Culture Documents
Chronic Disease
Prevention and Management
Health Care Safety-Net Toolkit for Legislators
Chronic Disease Prevention and Management
Introduction
Chronic diseases are among the most prevalent and costly health
conditions in the United States. Nearly half of Americans suffer
from at least one chronic condition, and the number is growing.
Chronic diseases—such as cancer, diabetes, hypertension, stroke,
heart disease, respiratory diseases, arthritis, obesity, and oral dis-
eases—can lead to hospitalization, long-term disability, reduced
quality of life and, often, death.1 In fact, such persistent condi-
tions are the nation’s leading causes of death and disability.
According to the Centers for Disease Control and number had grown to 133 million, and by 2020,
Prevention, more than two-thirds of deaths in the experts project that 157 million will be affected.3
United States are the result of chronic diseases.
Heart disease, cancer, respiratory diseases and These diseases affect more than one in two adults
stroke are the leading killers of Americans; the and more than one in four children in the United
top two alone account for nearly half of all deaths States. More than 25 percent live with multiple
annually. Diabetes is on the rise among Americans, chronic conditions.4 The incidence of multiple,
and follows close behind as the seventh leading concurrent diseases is also on the rise.5 People with
cause of death.2 multiple chronic conditions have more complicat-
ed health needs than their peers—adding another
The prevalence of chronic disease has increased layer of complexity and cost to their health care.
steadily among people of all ages in recent years. Due to the nation’s rapidly aging population and
At the turn of the century, 125 million Americans a nationwide increase in risk factors for chronic
had at least one chronic condition; by 2005, that disease—such as obesity—this trend shows no sign
of abating.6
• Chronic diseases and conditions are the leading cause of death and disability in the United States,
causing seven in 10 deaths nationwide.8 Approximately one quarter of Americans live with a dis-
ability caused by a chronic illness.
• Many chronic diseases are among the most preventable of all U.S. health problems.
• Seventy-five percent of health care spending in the United States goes to treat chronic conditions.
This figure is even higher for Medicaid, where 80 cents of every $1 is spent on chronic conditions.9
• Heart disease and cancer account for 47 percent of all U.S. deaths.
• Chronic disease affects the majority of Americans: 51 percent of adults have at least one chronic
condition, and 26 percent live with multiple chronic diseases.
• The number of people with chronic conditions is increasing rapidly; by 2020, an estimated 47
percent of the nation’s population will have a chronic condition.10
• Significant racial, ethnic and geographic disparities exist in the prevalence of chronic disease.
• Numerous policy options are available to states that are interested in preventing and managing
chronic disease to improve health and reduce costs.
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Chronic Disease Prevention and Management
4
Health Care Safety-Net Toolkit for Legislators
centers through general fund appropriations tion between providers and patients to improve
or tobacco settlement funds. access to care; and educate patients about how best
• Support measures that increase the number of to manage their conditions. This delivery system
people with health coverage, such as strength- not only offers an opportunity for states to reduce
ening employer-sponsored insurance, support- costs and improve care for the chronically ill, but
ing health insurance exchange outreach and also reflects states’ movement toward support of
enrollment, supporting Medicaid and CHIP team-based health care.
coverage and more.
• Support health care workforce initiatives.
Legislators may want to consider the follow-
ing policy options to support the medical home
Loan repayment programs and other incen-
model.
tives address clinical workforce shortages by
supporting primary care providers who prac-
tice in underserved areas.
• Adopt policies and programs to advance medi-
cal homes. As of April 2013, 43 states were
• Review facility licensure laws. Exempt certain planning or implementing the medical home
providers, such as rural health centers, from model for certain Medicaid or CHIP benefi-
specific laws or regulations to make it easier ciaries. Many focus on people with chronic
for them to operate in underserved areas. conditions and other high-cost beneficiaries.18
• Review health professional licensing and scope • Support payment reform. Provide reimburse-
of practice laws. Create policies that allow ment for supplemental primary care services,
primary care providers to practice to the full such as care coordination, patient education
extent of their training. and disease self-management.
• Encourage Medicaid reimbursement for oral, • Review health professional licensing and scope
behavioral and other health services. of practice laws. Develop policies that allow
• Support other, evidence-based policies that providers to practice to the full extent of their
aim to lower the cost and improve the quality training to help facilitate team-based care.
of health care. • Provide financial incentives for providers to
switch to more team-based care. Develop
Support establishment of medical policies that encourage training health care
and health homes professionals on team-based care.
Designed to meet patient needs, the patient- • Establish health homes to coordinate care for
centered medical home—or health home model Medicaid beneficiaries. Under Section 2703 of
of care—aims to improve access to and coordina- the Affordable Care Act, states can obtain 90
tion of patient care. The model consists of a team percent federal matching funds for two years
of health care providers—such as physicians, for developing health homes that integrate
nurses, nutritionists, pharmacists, community and coordinate all primary, acute, behavioral
health workers and social workers—who focus on health and long-term services and supports for
a person’s overall health and provide coordinated, Medicaid beneficiaries who have two or more
comprehensive care for those whose needs are chronic conditions; have one chronic condi-
complex, such as people with chronic conditions. tion and are at risk for a second; or have one
Medical homes coordinate care across health, be- serious and persistent mental health condi-
havioral, community and long-term services; offer tion.19
extended office hours and enhanced communica-
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Chronic Disease Prevention and Management
Support policies that improve coordination • Modify existing statutes to ensure that health
of care between health settings, such as information can be exchanged electronically
health information technology (HIT) im- while maintaining patient privacy.
provements • Develop incentives for HIT adoption. Offer
People with chronic conditions, and especially tax credits, link medical school loan repay-
those with multiple chronic conditions, receive ment to HIT competency, or link facility
care from numerous providers in various settings licensure to HIT implementation and mean-
and regularly juggle multiple prescription drugs, ingful use.
making care coordination key.20 Coordinating care
between providers and across settings potentially
• Provide funding for HIT efforts. Include HIT
initiatives in general appropriations; create a
can improve patient health, use resources more
dedicated funding stream from dues, bonds,
efficiently and reduce costs. Evidence suggests
insurer assessments or user fees; or provide
that use of health information technology—such
targeted funding through grants and loans to
as electronic health records—can help manage
groups such as community health centers.
chronic diseases more effectively. Electronic health
records facilitate communication and improve • Support statewide development of HIT infra-
patient safety by reducing duplicative tests, proce- structure.
dures and costly medical errors.21 HIT use among • Encourage adoption of electronic health
providers has increased since enactment of the records (EHR).23
Affordable Care Act and the Health Information • Support reforms that reward providers for care
Technology for Economic and Clinical Health coordination and smooth transitions between
(HITECH) Act. However, only a little more than health care settings.
half of U.S. primary care physicians currently use
electronic health records.22 States can influence Support policies that ensure an adequate
care coordination and HIT use through their role health care workforce
as purchasers, planners, regulators and providers Studies suggest that one of the most effective ways
and through supporting infrastructure, innova- to address chronic disease is through team-based
tion and workforce development. To improve care care.24 However, the primary care providers neces-
coordination across settings, legislators may want sary for these teams are in short supply in some
to consider the following policy options. geographic areas. The strain on the primary care
workforce will only increase as millions of Ameri-
• Leverage state purchasing power through cans, newly insured under the Affordable Care
Medicaid and/or the state employee health Act, seek medical care in primary care settings in
plan to drive adoption of health information 2014.25 More available providers will be needed
technology. to ensure that new enrollees have adequate access
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Health Care Safety-Net Toolkit for Legislators
• Provide financial incentives to recruit and • Implement smoke-free policies for all public
retain primary care providers. Offer tuition places, including workplaces, restaurants and
assistance, loan repayment programs, scholar- bars. At least twenty six states currently have
ships and other incentives to recruit providers smoke-free laws that cover all these locations.26
to practice in underserved areas. • Support and enforce programs that reduce
• Review health professional licensing, regula- youth access to tobacco and/or increase the
tion and scope of practice laws. Develop age limit for purchasing tobacco products.
policies that allow providers to practice to the • Offer financial incentives—such as tax credits,
full extent of their training in a wide range of sales tax exemptions and support for public-
settings. private partnerships—to improve access to
• Establish reimbursement policies that com- healthy, fresh, low-fat and whole-grain food.
pensate for chronic disease prevention and At least six states and the District of Columbia
case management. Consider use of enhanced have enacted such policies.27
Medicaid payments for providers that act as • Encourage or require schools, prisons and
medical homes; provide monthly payments for state-licensed child care facilities to serve
care coordination and case management; or healthy foods and snacks.
reimburse providers for care coordination for
Medicaid beneficiaries.
• Specify physical education requirements in
schools, school wellness policies, and physical
• Consider system-wide changes, such as shift- activity during recess.
ing the emphasis of the health care delivery
system to primary and preventive care.
• Promote community designs that facilitate
physical activity, such as sidewalks and bicycle
lanes.
Promote health and wellness programs at
schools, worksites, health care and
• Develop state employee and citizen wellness
programs statewide.
community-based settings
Healthy behaviors—such as eating a nutritious
Support programs that focus on eliminating
diet, being physically active and not smoking—
racial and ethnic health disparities
can prevent, mitigate and even eliminate some
Significant disparities exist in the prevalence of
chronic health problems. States across the nation
chronic diseases. In reality, Americans’ health often
are implementing wellness policies, programs and
varies by their population group or ZIP code.
incentives to help people become and stay health-
Even when researchers control for income and
ier. Initiatives address a wide range of preventable
health insurance coverage, they find that racial
risks for chronic conditions such as cancer, heart
minorities generally live with more diseases, die
disease and type 2 diabetes. These include well-
sooner than whites and suffer more with many
ness programs that encourage tobacco-free living,
chronic diseases. Nearly half of African Americans
healthy eating and availability of nutritious food
are obese, compared to 40 percent of Hispan-
and promote active lifestyles and development of
ics and 34 percent of whites.28 African-American
healthy, safe environments for physical activity.
children are twice as likely to have asthma as white
Legislators may wish to consider the following
children, are twice as likely to be hospitalized or
strategies that some states have adopted to pro-
visit an emergency department for the condition,
mote community health and wellness.
and four times more likely to die from it.29 In ad-
7
Chronic Disease Prevention and Management
dition, African-American and non-Hispanic white • Include community health workers as part of
American men are more likely die from heart team-based health care to better serve diverse
disease than any other group.30 Economic, social communities and improve the health of un-
and environmental conditions—such as poverty, derserved communities.
education level, lack of access to health care, and
physical environment—contribute to these dispar- Support efforts to effectively educate the
ities. For example, poverty limits access to health public about health and prevention of
insurance, health care and resources to manage chronic disease
health. The communities in which people live af- Research shows that, when patients are actively in-
fect whether they have access to fresh, healthy food volved in managing their own health and engaged
and safe areas where they can be physically active. in health care decisions, their health is more likely
Policymakers who are interested in reducing the to improve.31 Educating people about their chron-
economic and human costs of such disparities may ic conditions, teaching self-management skills and
wish to consider options that increase access to involving patients in the medical decision-making
high-quality, culturally competent chronic disease process thus can help improve health outcomes
management among groups that are dispropor- and reduce costs for those with chronic diseases.32
tionately affected; some of these are listed below. Community health centers and medical homes
incorporate chronic disease self-management
• Expand access to health care services through skills in the services they provide. Community
low-cost health insurance, Medicaid, support health workers (CHWs)—also known as outreach
for medical homes, community health centers workers or promotores de salud—offer services
and other delivery system reforms. similar to medical homes, but on a smaller scale.
• Develop health system integration and pay- CHWs help educate residents in the communities
ment reform based on data-driven measures they serve, providing linguistically and culturally
that account for race, ethnicity, language and competent assistance, helping people understand
income. risky behaviors and motivating them to man-
• Develop a statewide strategic plan to reduce age those risks.33 Some policy options to support
health disparities among minority popula- public education and disease self-management are
tions. listed below.
• Support integration of CHWs at the state barriers to health care in Vermont, serving patients
level. State health departments can collaborate regardless of their insurance status, without copay-
with other stakeholders to develop a compre- ments, prior authorization or eligibility restric-
hensive approach to developing policies for tions.35
CHWs.
Blueprint has received continual support from
State Program Examples state lawmakers. In both 2010 and 2011, the state
A few states are incorporating many of the policy legislature called for full implementation of the de-
options mentioned in this report into comprehen- livery system in every willing primary care practice
sive systems to prevent and manage chronic condi- by 2013. As an incentive for participation, Blue-
tions, improve care and reduce costs. print provides enhanced per-member per-month
payments to providers that achieve medical home
status. Participating providers also receive the sup-
Vermont Blueprint for Health
port and assistance of community health teams.
Vermont Blueprint for Heath aims to improve
In addition, Blueprint offers guidance, support
health and control costs by delivering comprehen-
and advice to medical practices that are making
sive, well-coordinated care statewide. Launched
the transition to the medical home model. As of
in 2003 by then-Governor James Douglas, the
December 2012, 106 primary care practices were
public-private partnership offers an innovative
engaging in patient-centered medical home activi-
delivery system based on a foundation of patient-
ties and were serving more than 420,000 people.
centered medical homes and community health
Vermont also allows its health care workforce to
teams (CHTs). The Blueprint focuses on four
function at its highest capacity. Nearly one-third
broad areas: transitioning providers to the patient-
of primary care providers who work in recognized
centered medical home model, improving individ-
medical homes are mid-level providers, such as
ual self-management of chronic conditions, devel-
nurse practitioners, advanced practice registered
oping health information systems and improving
nurses and physician assistants. Blueprint has fur-
availability of community health care. Three years
ther expanded the available workforce by formally
after its inception, Blueprint was codified by the
recognizing naturopathic physicians as primary
General Assembly as part of Act 191.
care providers, making them eligible to receive
benefits—such as payment reform and access to
Community health teams—multidisciplinary,
community health teams for their patients—when
locally based teams— provide a link between
recognized as a medical home. Blueprint also is de-
primary care and community-based services, con-
veloping a statewide health information exchange
necting patients to medical, social and economic
and helping providers achieve meaningful use of
support. CHTs offer individual care coordina-
electronic health records.36
tion, behavioral health counseling, and health and
wellness coaching, and also teach self-management
According to a recent qualitative analysis of Ver-
skills. Teams consist of a variety of professionals
mont Blueprint for Health, patients with chronic
and effectively expand the capacity of primary care
conditions are seeing providers more frequently.
practices by providing patients direct support and
Providers have responded favorably to the patient
individualized follow-up. Services are available
support community health teams provide, which
to all primary care practices that are recognized
allows them to address both clinical and nonclini-
or certified as patient-centered medical homes
cal patient needs. An analysis of one pilot program
participating in Blueprint. The model minimizes
9
Chronic Disease Prevention and Management
found the model also significantly decreased hospi- As of May 2011, 14 community care networks
tal admissions, emergency department visits and consisting of more than 5,000 providers covered
related costs. 100 counties in the state and provided services to
more than 1.2 million patients (including both
Community Care of North Carolina Medicaid enrollees and some low-income, un-
In 1998, North Carolina began implementing an insured residents). Results appear positive. One
enhanced medical home model of care for Medic- recent study estimated that Community Care of
aid beneficiaries, aimed at improving quality and North Carolina saved the state nearly $1 billion
cost-effectiveness of care.37 Community Care of between 2007 and 2011.38 Another determined
North Carolina (CCNC) is a public-private part- that individual health care use patterns of CCNC
nership that focuses on four elements: develop- enrollees are consistent with other high-perform-
ing networks of physicians and local community ing medical homes. Compared to non-CCNC
health organizations that provide coordinated care participants, CCNC enrollee inpatient hospital
to high-cost Medicaid beneficiaries with chronic and emergency department use were consistently
conditions; using population management tools lower and primary care visits were higher.39
to support primary care providers; providing case
management and clinical support to medical home Missouri Community Mental Health
providers that manage patients with complex Center (CMHC) Healthcare Homes
medical, social and behavioral conditions; and Missouri has established an innovative initia-
collecting data and feedback on patient health and tive that provides care coordination and disease
opportunities for improvement. management for Medicaid beneficiaries with both
severe mental illness and chronic conditions.
Each network of providers and community ser- Developed in partnership by the Missouri Depart-
vices is responsible for linking beneficiaries with ment of Mental Health, MO HealthNet (the state
a medical home, providing disease management Medicaid agency), and the Missouri Coalition of
and care coordination, and implementing quality Community Mental Health Centers, the program
improvement initiatives–for which they receive uses community mental health centers (CMHCs)
an enhanced per-member per-month fee. Case as a medical home for people with severe mental
managers, such as social workers, nurses or other health conditions.40 Because Medicaid beneficiaries
clinicians, are an integral part of the team. They with severe mental illness are two to three times
work with physicians to coordinate care, provide more likely to have a chronic medical condition,
disease management education, and collect and it is fitting to provide services that focus on the
report data as part of continuous quality improve- “whole person” at a location where those with
ment efforts. Community Care of North Caro- mental illness already receive care.41
lina emphasizes evaluation; data monitoring and
reporting facilitate ongoing quality improvement The CMHC-based health home model relies on
for providers, regional networks and the program the existing mental health system and provides ad-
overall. Data on performance are collected, com- ditional training to providers on chronic diseases
pared to regional and national benchmarks, and and use of data and analytic tools. For Medicaid
shared with participating practices. beneficiaries who do not have a regular primary
care provider, community mental health centers
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Health Care Safety-Net Toolkit for Legislators
become the site of central care coordination. the health-home model of team-based primary
Case managers coordinate care, providing services care, improve care coordination and offer incen-
typical of both behavioral and medical health tives to maintain health and wellness. The law also
case management. CMHCs screen for common includes various workforce training and develop-
chronic conditions; promote physical activity; and ment provisions and initiatives to recruit and
provide smoking cessation counseling, instruction retain primary care providers in medically under-
on obesity and weight reduction for diabetes, and served communities.44 In addition, the federal gov-
other services.42 Key to this innovative program is ernment funds federally qualified health centers,
the partnership between the state Medicaid agency an integral provider of chronic disease prevention
and the Department of Mental Health. and management services for those who lack other
access to care.45
In 2012, Missouri established CMHC Healthcare
Homes, using health home funding under the Af- The U.S. Department of Health and Human Ser-
fordable Care Act to expand the existing CMHC vices’ Health Resources and Services Administra-
model. Initially, more than 15,000 high-cost Med- tion also recently announced new funding to help
icaid beneficiaries with a serious mental illness, eight states in the Delta region—parts of Alabama,
mental health condition, substance abuse disorder, Arkansas, Illinois, Kentucky, Louisiana, Missis-
or one of the above and a chronic condition were sippi, Missouri and Tennessee—address specific
enrolled. Still in its initial phases, this initiative chronic conditions that disproportionately affect
has been used by the state to expand the number that area of the country.46
of primary care nurse managers and primary care
physician consultants at community mental health Conclusion
centers. Data are not yet available on how this As some of the most common, costly and prevent-
model will affect hospitalization rates and emer- able health problems, chronic diseases and condi-
gency department visits.43 tions place a significant burden on society. Not
only do they affect the lives of millions of Ameri-
Federal Action cans, they result in lost productivity, missed school
Through the Affordable Care Act and other initia- and work days, and high health care costs. Many
tives, the federal government is working to prevent states are developing policies, programs and initia-
and manage chronic conditions. The ACA con- tives to redesign health care delivery and payment
tains significant funding opportunities for states to systems to improve health, reduce costs, and better
help reduce the burden of chronic disease. Provi- prevent and manage chronic disease.
sions aim to improve access to care, move toward
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Chronic Disease Prevention and Management
HealthIT.gov
www.healthit.gov/
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Health Care Safety-Net Toolkit for Legislators
13
Chronic Disease Prevention and Management
21. Shaline Rao, C. Brammer, A McKethan, and 31. Jessica Greene and Judith Hibbard, “Why
M.B. Buntin, “Health information technology: trans- Does Patient Activation Matter? An Examination of
forming chronic disease management and care transi- the Relationships Between Patient Activation and
tions,” Primary Care 39 no. 2 (2012), www.ncbi.nlm. Health-Related Outcomes,” Journal of General Internal
nih.gov/pubmed/22608869. Medicine 27, no. 5 (2011).
22. HHS News Release, “Doctors and hospitals’ 32. Thomas Bodenheimer, Kate Loriq, Halsted
use of health IT more than doubles since 2012” (Wash- Holman, and Kevin Grumback, “Patient Self-Manage-
ington, D.C.: U.S. DHHS, May 2013), www.cms.gov/ ment of Chronic Disease in Primary Care,” JAMA 288,
EHRIncentivePrograms and www.healthit.gov. no. 19 (2002): 2469-75.
23. Ibid. 33. Brandeis University, Cancer Prevention and
24. Thomas Bodenheimer, Ellen Chen, and Heath- Treatment Demonstration for Ethnic and Racial Minori-
er D. Bennett, “Confronting the Growing Burden of ties, report prepared for U.S. Department of Health and
Chronic Disease: Can the U.S. Health Care Workforce Human Services, Centers for Medicare and Medicaid
Do the Job?” Health Affairs 28, no. 1, (2009). Services, 2003, www.cms.gov/Medicare/Demon-
25. By 2020, the Health Resources and Services stration-Projects/DemoProjectsEvalRpts/downloads/
Administration anticipates there will be more than 1.2 CPTD_Brandeis_Report.pdf.
million job openings for nurses, 305,000 for physicians 34. J. Nell Brownstein, Talley Andrews, Hilary
and surgeons, and hundreds of thousands more for Wall, and Qaiser Mukhtar, Addressing Chronic Dis-
other primary care providers. ease through Community Health Workers: A Policy and
26. National Conference of State Legislatures, Systems-Level Approach (Atlanta, Ga.: National Center
“State Stats: Smoke-Free Laws Lift Clouds,” State Leg- for Chronic Disease Prevention and Health Promotion,
islatures (National Conference of State Legislatures) 37, CDC, n.d.).
no. 1 (January 2011): 5. 35. Christina Bielaszka-DuVernay, “Vermont’s
27. Amy Winterfeld, “The New Healthy,” State Blueprint for Medical Homes, Community Health
Legislatures (National Conference of State Legislatures) Teams, and Better Health at Lower Cost,” Health Af-
38, no. 1 (January 2012): 28. fairs 30, no. 3 (2011): 383-386.
28. Katherine Flegal, Margaret Carroll, Brian Kit, 36. Department of Vermont Health Access, Ver-
and Cynthia Ogden, “Prevalence of Obesity and Trends mont Blueprint for Health: 2012 Annual Report (Wil-
in the Distribution of Body Mass Index Among U.S. liston, Vt.: Department of Vermont Health Access,
Adults, 1999-2010,” JAMA 307, no. 5 (2012). 2013).
29. President’s Task Force on Environmental 37. Community Care of North Carolina website,
Health Risks and Safety Risks to Children, Coordinated www.communitycarenc.org/about-us/.
Federal Action Plan to Reduce Racial and Ethnic Asthma 38. Robert Cosway, Chris Girod, and Barbara Ab-
Disparities (Washington, D.C.: U.S. EPA, 2012), www. bott, Analysis of Community Care of North Carolina Cost
epa.gov/childrenstaskforce. Savings, report prepared for the North Carolina Divi-
30. National Center for Health Statistics, Health, sion of Medical Assistance, (San Diego, Calif.: Milli-
United States, 2012: With Special Feature on Emergency man Inc., Dec. 15, 2011), www.communitycarenc.org/
Care, Table 26 (Hyattsville, Md.: NCHS, 2013), www. media/related-downloads/milliman-cost-savings-study.
cdc.gov/nchs/data/hus/hus12.pdf#026. pdf.
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Health Care Safety-Net Toolkit for Legislators
39. Treo Solutions, Performance Analysis: Healthcare City, Mo.: MOHealthNet and Department of Health,
Utilization of CCNC-Enrolled Population 2007-2010, 2012), http://dmh.mo.gov/docs/medicaldirector/
prepared for Community Care of North Carolina CMHC-SixMonthReview.pdf.
(Raleigh, N.C.: CCNC, June 2012), www.communi- 44. Melinda Abrams, Rachel Nuzum, Stephanie
tycarenc.org/media/related-downloads/treo-solutions- Mika and, Georgette Lawlor, Realizing Health Reform’s
report-on-utilization.pdf. Potential: How the Affordable Care Act Will Strengthen
40. “Missouri: Pioneering Integrated Mental and Primary Care and Benefit Patients, Providers and Payers
Medical Health Care in Community Mental Health (New York, N.Y.: The Commonwealth Fund, 2011),
Centers,” States in Action Newsletter (The Common- www.commonwealthfund.org/~/media/Files/Publica-
wealth Fund), December 2010/January 2011, www. tions/Issue%20Brief/2011/Jan/1466_Abrams_how_
commonwealthfund.org/Innovations/State-Pro- ACA_will_strengthen_primary_care_reform_brief_
files/2011/Jan/Missouri.aspx v3.pdf.
41. Joseph Parks, Tim Swinfard, and Paul Stuve, 45. HHS.gov/Health Care, The Affordable Care
“Mental Health Community Case Management and its Act, Section by Section (Washington, D.C.: U.S. Depart-
Effects on Healthcare Expenditures,” Psychiatric Annals ment of Health and Human Services, 2012), www.hhs.
40, no. 8 (2010): 415-419. gov/healthcare/rights/law/index.html.
42. “Missouri: Pioneering Integrated Mental and 46. HRSA News Release, “$5.6 Million to Fight
Medical Health Care.” Chronic Health Diseases in Delta Region” (Wash-
43. MOHealthNet and Missouri Department of ington, D.C.: U.S. Department of Health and Hu-
Mental Health, Missouri Community Mental Health man Services, 2013), www.hrsa.gov/about/news/
Center Healthcare Homes: Six-Month Review (Jefferson pressreleases/130118deltahealth.html.
15
This brief was written by Megan Comlossy.
The author also thanks the following NCSL staff who reviewed the
primer and made recommendations: Laura Tobler, Martha King,
Melissa Hansen, Jacob Walden and Chris Edmonds. In addition,
thanks go to Leann Stelzer for editing.