PCMH and Care Management: Where do we start?

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1 PCMH and Care Management: Where do we start? Patricia Bohs, RN, BSN Quality Assurance Manager Kelly McCloughan QA Data Manager Wayne Memorial Community Health Centers Honesdale, PA

2 Wayne Memorial Community Health Centers FQHC 11 sites, 30 providers 60,000 total pt visits Medicare=25% Medicaid=28% Private=63% Uninsured=10%

3 SOURCE: %20Scoring%20Summary.pdf

4 Primary Care and managing care transitions PCMH Standard 5: Tracking and Coordinating Care

5 Standard Intentions Track and follow-up on lab and imaging results Track and follow-up on referrals Coordinates care received at hospitals and other facilities

6 Parallels Meaningful Use Incorporates clinical lab results into the medical record Electronically exchanges clinical information with other clinicians and facilities Provides electronic summary of care record for referrals and care transitions

7 PCMH 5: Track and Coordinate Care PCMH 5A: Test Tracking and Follow-up *PCMH 5B: Referral Tracking and Follow-up = must pass = most missed 2011 standards. *Things may be happening, but not well documented PCMH 5C: Coordinate with Facilities and Care Transitions Historically this is where the care breakdown occurs: ex: comgmt PCP and specialists these patients can fall out of the loop. EX: endocrinologist and PCP.

8 PCMH 5C: Coordinate with Facilities and Care Transitions NCQA says that the practice must systematically demonstrate: 1.) Process to identify patients with hospital admissions and ED visits 2.) Process to share clinical information with hospital/ed Need to have arrangements with hospital to see who is admitted 3.) Process to obtain patient discharge summaries

9 PCMH 5C: Coordinate with Facilities and Care Transitions, cont d. 4.) Process to contact patients for follow-up care after discharge 5.) Process to exchange patient information with hospital 6.) Collaboration with patient/family to develop written care plan for transitions from pediatric to adult care. (NA for adults) 7.) Electronic exchange of key clinical information with facilities 8.) Provides electronic summary of care for more than 50% of transitions of care

10 PCMH 5C Coordinate with Facilities and Manage Care Transitions Practice Demonstrates 1. Process to identify patients with hospital admissions and ED visits 2. Processes to: share clinical information with hospital/ed; obtain patient d/c summaries; contact patients for f/u care after d/c; process to exchange patient information with hospial Documentation 1. Documented process to identify patients and log or report 2-5.Documented process and examples of providing clinical information, obtaining d/c summaries, follow up and exchange information.

11 PCMH 5C Coordinate with Facilities and Manage Care Transitions Practice Systematically Demonstrates: 6. Pediatric to adult written care plan (n/a for adults) 7. Capability for electronic exchange of clinical information with facilities 8. Provides electronic summary of care for more than 50% of transitions of care Documentation 6. Example of a written transition care plan 7. Screen shot 8. Report numerator, denominator and percent 3-12 months of transitions.

12 Scoring: 6 points 5-8 factors = 100% 4 factors = 75% 2-3 factors = 50% 1 factor = 25% N/A counts as Yes

13 What is WMCHC doing? Wayne Memorial Hospital Readmission Project A Multidisciplinary, multi-interventional approach to reducing readmissions in the rural setting Goal: plan and implement care interventions to decrease the readmission rate at WMH

14 Clinical Research Study Led by Dr. Louis O Boyle and an integrated team at WMH which includes members of the physician staff, utilization review, nursing, local home care agencies, social services, pharmacy and others. Study: analyze readmission data and established baseline for 4 targeted diagnosis that will receive penalties including CHF, Pneumonia, AMI, and COPD. GOAL = READMISSION REDUCTION

15 Research 2009 New England Journal: estimated an annual cost of 17.4 billion dollars for unplanned hospital readmissions The Affordable Care Act: includes measures to begin penalizing hospitals with higher than expected readmission rates starting in FY Future transitioning from fee-for-service to pay-for performance models which we will all expect to include financial penalties for excess readmissions as part of their plans.

16 RURAL BARRIERS Unique Barriers: lack of access to PCP Inadequate transportation and infrastructure Lack of availability of home care services Health literacy

17 What has WMH done? 1.) established discharge coordinator positions 4/part-time positions created from nursing pool Risk assessment, bedside teaching and completion of the PASS transition record is done while inpatient as well as follow-up phone calls after discharge A GUIDE for: medication education/reconciliation 911 when to call PC Appointment scheduling Important contact information

18 What has WMH done? 3.) Home visit in 1 st hours WMH has agreed to offer for a single home health visit for every patient identified WMH Home Health primarily providing this service but the team has also partnered with WC Aging Office to provide home coaching Home visits specifically target compliance with medications, home safety evaluation and medication confirmation.

19 NEXT STEP: WMCHC September 2012 WMCHC partnered with WMH Readmissions team to assist in this project PCMH Requirement = Care Management PCMH RECAP..

20 PCMH CARE MANAGEMENT Care is coordinated across medical subspecialties, hospitals, home health agencies, and nursing homes. Care is coordinated with the patient, the patient s family, and public and private community based services. Care is facilitated by registries, information technology, health information exchange. Care is culturally and linguistically appropriate

21 WMCHC Care Management What have we done?? WMCHC has partnered with the WMH Readmission team and RN s have collaborated to parallel efforts from both hospital and practice fronts.

22 WMCHC Care Management Initiatives 1.) Established a clear line of communication between the readmission team and CHC offices including providing the WMH team with all our office brochures and contact numbers so they can link providers/offices with patients in need of a medical home. 2.) Established a daily automatic discharge list of WMCHC patients so that we can provide the following follow-up from CHC end: medication reconciliation, ensure f/u phone call within 48 hours of d/c and follow-up appt. is scheduled with our providers within 5 days f/u CHC phone call to patient notifications to both front desk and provider of any "red flags" or high acuity follow up. Collaboration with home health, area agency on aging, OT/PT,

23 WMCHC Care Management Initiatives 3.) Established some barriers including difficulty making f/u appts. for CHC offices from the hospital, medication adherence, transportation availability, knowledge of affiliated providers. 4.) Established Care Management follow up at our Women's Health Care clinic where our Healthy Beginnings Plus Care Coordinators are following up with all OBGYN inpatient admissions. 5.) Finalizing providing the same education materials in our offices the 4 "hot" diagnosis (CHF, Pneumonia, COPD, and AMI) is uniform across the continuum.

24 WMCHC Care Mgmt. Initiatives, cont d. 6.) Partnered with surrounding hospitals to get discharge summaries automatically sent within 48 hours. 7.) Partnered with WMH Information Services to get automated notification of inpatient and ED admissions of our system patients so care management can start in the hospital. 8.) Partnered with Keystone ACO for enhancement of care management services.

25

26 Understanding Accountable Care Organizations Formally organized entity (physicians, hospitals, other relevant health services professionals) that have elected to join together who are responsible through contracts with payers for providing a broad set of health care services to their Medicare patients.

27 Understanding Accountable Care Organizations cont d. Entity is accountable for organizing and aligning health care services to deliver seamless, coordinated care Impetus = to change the way providers are paid. No longer for each service, rewards providers that are able to manage chronic disease and meet certain quality measures including REDUCING HOSPITAL ADMISSIONS AND ED VISITS. **If the quality of care improves and costs are constrained, the systems can share in the savings.

28 ACO Objectives ACO s aim to provide financial incentives for broad cost containment and quality performance across multiple sites of care. ACO s encourage providers to think of themselves as a group with a common patient population, care delivery goals, and performance metrics, rather than as discrete entities

29 ACO Objectives, cont d. Utilize specific care models to drive down cost Chronic Care model Focus on high cost disease states Diabetes Cardiac disease COPD/Asthma Obesity 80/20 rule 20% of patients consume 80% of health care cost

30 7.) Keystone ACO Partners Andrew Gibbons Director of Operations Evangelical Medical Services Organization Dr. Jon Sternburg Highland Physicians, Ltd. Fred Jackson Executive Director Wayne Memorial Community Health Center

31 Similarity of quality measures Federal grant requirements Patient Centered Medical Home (PCMH) Meaningful Use Electronic record incentives Pay-for-Performance WMHC IPIP Residency Collaborative

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36 Examples of WMCHC efforts Care management template

37 Examples of WMCHC efforts Hospital electronic admission/discharge lists

38 Examples of WMCHC efforts Discharge summary and lab interface

39 COORDINATED CARE = ESSENTIAL BLOCK FOR PCMH and ACO participation P4P C MeAningful Use H C D O S

40 = everyone wins PCMH BUILDING BLOCKS 1. Community Health Centers 2. Personal Physician 3. Provider Directed Teams 4. Enhanced Access 5. Whole Person Care 6. Coordinated Care 7. Payment Reform 8. Quality and Safety

41 References %208%20Change%20Concepts,%20Appllications,%20Tools%20and%20Resources.pdf *** *** Organizations.aspx Keystone ACO. Wayne Memorial Hospital Readmission Project

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