PCMH. NCQA definition. Appropriate Access 2/9/2015. Patient-Centered Medical Home A Greeley Experience

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1 PCMH Patient-Centered Medical Home A Greeley Experience NCQA definition O Access and Continuity O Manage Patient Population O Plan and Manage Care O Provide Self Care Support O Track and Coordinate Care O Measure and Improve Performance Appropriate Access O Open Access O PCP Continuity 1

2 Care Team O Previsit O Top of License Care O Medication Reconciliation O Standing orders O Care Transition Planned Care O Evidence-based practice O Referral Coordination O Registry O Performance Improvement Making a Difference Most choose healthcare because they want to make a difference in people s lives It is a trusted profession Physicians work hard, arduous hours learning and practicing their profession 2

3 What Happened? 17% of GNP is spent on health care, projected to be 100% by the end of the century Compared to other first world countries, US had more cost (twice the per capita spending or the next most expensive system Less quality in terms of population health compared with other countries. You get what you pay for O Paul Grundy, the mastermind of the Patient Centered Medical Home summed it up: O : The rewards system in health care (in the US) is so convoluted that people become opportunities to make money. Somewhere in that we lose the humanity. The system begins to chew them up. Under the wrappings O Veterinarians contact pet owners about missing immunizations-why not patients? Patient-Centered? O Most expensive health care among first world countries O Below average in quality in terms of a number of quality outcome measures 3

4 The Cost Conundrum O Atule Gewande, surgeon and health care writer O Compares cost and quality in two Texas cities with similar demographics: El Paso and McAllen, Texas O Cost of care doesn t correlate with quality More good news O 17% of Gross National Product is spent on Healthcare O Projected to be 100% by 2100 at present growth rates O Flat economy-raises(expendable income) that once spurred the economy are going to increasing health care premiums O $1000 of a family s annual health care premium goes toward uncompensated health care. What about other health systems? O Aren t we better? O Don t Canadians cross the border to get care? O Don t we have innovative treatments/procedures? O Don t other doctors come here to train because it is superior training? 4

5 It isn t necessarily so O Compared with other first world countries, O U.S. had more cost (nearly twice the next closest) O Population health is poorer compared with most other systems. Where has all the money gone? 90% of health care dollars are spent healthcare Healthcare is only 10% of Health SOMETHING S GOTTA GIVE! O Our healthcare is unsustainable! O No new dollars to fund it O Fighting over remaining dollars (Primary Care vs. Specialists, Large independent provider groups vs. hospitals) in a Win/Lose battle won t do it O There is waste in the system that could fund a change in the way healthcare is delivered- Win-Win 5

6 New Goals: the triple aim O Don Berwick, Harvard trained and educated, former head of Centers for Medicare/Medicaid came up with three goals for our health system: O 1. Better Care O 2. Less Cost O 3. Better patient experience Back at the Ranch O Provider dissatisfaction O Onslaught of baby boomers into the Geritol Generation O Aging Primary Care Providers O Reimbursement decline Turf Battles O I for one, have had enough, and frankly, I don t see much of a future for primary care I think the powers that be want a massive physician shortage so they can argue for the replacement of..docs with PAs and NPs 6

7 Work Force O I left a position with a rural hospital because of burnout. I know our practice needed to make changes and I was for it for the most part but I won t kill myself for a healthcare system that doesn t care pounding doctors into the ground doesn t increase your revenue or your quality of care. Alternative Care Models O I discovered the Direct Primary Care practice models and after networking with other docs that have been joyfully and passionately doing this for years, happiness in medicine became an attainable goal. Politics O Who knows what new obstacles will await us? Is the ACA unraveling? What will that mean? 7

8 Changing Patient Demographics O Medicaid Expansion-20% of Colorado s patients insured by Medicaid O Mandate for Health Insurance coverage O High deductible insurance And you think docs are unhappy? Patient s View of Health Care 8

9 Something s Gotta Give PCMH O Paul Grundy-IBM worldwide medical director O IBM faced with rising costs of medical care considered providing their own Kaiser styled medical system. O Dr. Grundy advised that if the system was that broken, that maybe IBM should consider the BHAG of changing healthcare in US 9

10 Birth of a home O Major trade organizations of pediatricians, internists, family medicines, osteopathic profession and developed the 7 Principals of PCMH: O 1. Safety and quality O 2.Coordinated and integrated care O 3. Whole person orientation O 4. Everyone deserves a personal physician O 5. Enhanced Access O 6.Physician directed practice (in the context of a team) O 7. Payment of added Value-payment reform ' What is a medical home? O A concept to bring back accountability to a broken system. O Personal health care where you know your caregiver and trust that they are there for you in sickness and for health. 10

11 s O Culture change from physician centric to team building-care coordination O Behavioral Health O Patient participation-shared decision making, motivational interviewing O Medical neighborhood where enhanced communication flows both ways Quadruple Aim? O Addresses the 4 th leg of the triple aim - physician satisfaction and frustration O Emperors Medical Robe-EMR (it s hard to put lipstick on that pig-nuff said) O Documentation, patient satisfaction scores, etc., etc. Back to Basics O It s not the patient s problem O Why did I go into medicine? O Innovate-What would happen if the judicial system demanded the judge document court proceedings? O Why would doctors be expected to balance all the balls of documentation, patient engagement, empathy, etc.? 11

12 Hope O CPCI-Comprehensive Primary Care Initiative O Purpose: O 1. Access and continuity of care O 2. Planned care for chronic conditions and preventive care O 3. Risk Stratified care management O 4. Patient and caregiver management O 5. Coordination of care across the medical neighborhood CMMC Innovation O Unique collaboration between public and private care payers. O 501 practices across 7 regions across the US based on payer interest and geographic diversity 12

13 Criteria to be chosen O Meaningful users of EHRs O PMCH recognition and experience in quality improvement initiatives O Data feedback on cost, service use, quality of care patient, provider, and staff experience. O Data feedback on cost, service use, quality of care patient, provider, and staff experience. O IF it works, it rolls out to all other practices as the standard model of reimbursement! Costs O PCMH isn t free O Costs must be born by all payers-no segregated care based on Health Plan O Paid for by reducing unnecessary ER visits and hospitalization/re-hospitalization and other thoughtful evidence- based practices (Choosing Wisely) 13

14 Price Tag to Maintain PCMH O $70K to $115K per provider per year O $35 per visit on a fee for service reimbursement O $4-7 on a PMPM reimbursement Personnel Costs O Triage Nurse O Behavioral Health O Referral specialist O Clinical Pharmacist O Billing Manager O IT IT costs O Registry O Meaningful Use O Upgrades and simplification of documentation 14

15 Implementation O Culture change O Training of staff and physicians O Coaching Quality Improvement O PDSA cycles O One more thing, Doc O One more meeting over noon hour O One more quality measure to do and document O One more behavior change PCMH in Greeley, CO O In spite of a growing plethora of PCMH recognition, NCQA, JCAH, others, there are similarities O If you have seen one PCMH, you have seen one PCMH O Quality measurement O Care coordination O Expanded hours 15

16 Similarities O Quality measurement O Care coordination O Expanded hours/open access O Patient participation and feedback O Closing the loop of labs and referrals O Measurement of Patient Satisfaction Scores O Accountability for a Population Health O Patient interaction with practice O Continuous Improvement process What s the difference O Duck analogy-calm on the surface but peddling like mad beneath the surface! O Initial experience- O Making an appointment-patient portal, open scheduling O Pre-work: Gathering information, identifying preventive care deficiencies/opportunities O Triage to assess appropriate care for urgencies 16

17 O Care coordinator has contacted transitions of care patient from the hospital/er/nh and set up follow up care with provider O Care coordinator coordinates Home Health care, durable medical equipment, needs of the patient O Letters have been sent reminding patients of chronic care, preventive care appointments O Visit-Staff get training to create customer friendly atmosphere O MA greets patient, takes vitals, updates immunizations, preventive care appointments, records chief complaint, communicates special information by to provider O MA documents meds O Provider reviews chart, data before entering room O Scribe enters room with doc and is introduced as member of the team who allows provider to fully engage with patient. O Doc reviews history with patient, discusses refusals 17

18 O Scribe documents exam, diagnosis, orders labs, x-rays, referrals, O Scribe uses pre-written materials for patient plan O Scribe writes meds O Provider reviews plan and prints O MA hands plan to pt. and reviews O Between patients, physician replies to messages, makes arrangements for workins, communicates with front desk, coders, etc. O Documentation is completed between patients O Providers get regular feedback on patient satisfaction scores, quality metrics Providers are provided with option of coaching to improve scores O Problems are addressed and dealt with on a regular basis 18

19 What s Next? O Goal-cut down on out of office practice creep O Increase access with evening and weekend office hours. O Use of a team of providers-np, PA, BH, PharmD O Familiar Physician model, Peter Anderson, MD O Improve EMR system! O Spread the model O Financial Sustainability O Bring back the joy of practice! O Thank you! 19