Advancing the Patient Centered Health Home in California s Community Health Centers

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1 Advancing the Patient Centered Health Home in California s Community Health Centers Concept Paper, April 2011 Concept Description California s community clinics and health centers are pursuing a common goal of improving the health of their communities through the adoption of the patient centered health home as a model of care for lowincome and underserved populations in the State. Together, health centers, the California Primary Care Association (CPCA), and the Regional Associations of California (RAC), along with partners in the field, are designing a multi-tiered approach to develop the resources and supports required to transform health centers across the State. Health centers are leading this movement, redesigning practices and care teams to provide coordinated, leading edge healthcare. Regional associations are supporting these efforts with training and technical assistance customized to the needs of the region. At a statewide level, CPCA, the PCHH Committee, SQIC, and RAC are working to develop and spread standardized definitions, data strategies, and a unified policy agenda to move health centers forward in a coordinated manner. The Statewide Quality Improvement Collaborative (SQIC) will serve as the coordinating body for this work, ensuring that improved data collection, analysis and sharing is a driving force for change. An essential factor in the PCHH design is empowering patients and engaging them in their care and health promotion. Based on input from health centers and collective thinking on what is needed to move the field forward, a collaborative effort among these partners will provide the statewide vision and leadership, resources, and training required to redesign the patient experience within California s health centers. As stated in the working definition and principles adopted by the CPCA Board of Directors, a Patient Centered Health Home is an approach that uses a whole person orientation to provide comprehensive health care by facilitating an active partnership between patients, their family, and their primary care provider team to provide high quality, timely care in a coordinated and consistent way. This approach provides patients with what they need and when they need it, in a manner that patients and providers work as partners in managing their care that is coordinated with the right people talking to each other. The basic tenet of the Patient Centered Health Home (PCHH) is to reduce episodic sick care and move toward management of the patient and community to maintain their collective health. I. Program Goal Improve population health and patient care while controlling health care costs by transforming California community health centers into Patient Centered Health Homes by Program Objectives: 1. Assess California CCHCs for readiness to adopt PCHH models 2. Identify existing PCHH models and develop new models adapted for California CCHCs Page 1

2 3. Identify and leverage existing tools and resources to support the transformation of CCHCs to PCHH models 4. Provide regional training and technical assistance to build the capacity of CCHC leadership, providers and staff 5. Convene CCHCs for sharing of best practices and peer learning 6. Collect standardized clinical, operational and other relevant data (e.g. patient experience) for use at the statewide, regional, and local health center level 7. Explore options for payment reforms and controlling health care costs through PCHH innovations 8. Certify/recognize health centers as PCHHs according to national standards 9. Evaluate implementation of PCHH models across the State II. Project Background The Patient Protection and Affordable Care Act (ACA), when fully implemented, will provide health coverage to approximately 4.4 million uninsured Californians. Health centers have been held up as a model for the future and will play an essential role in caring for the newly insured. Therefore, California s health centers are faced with the challenge of rapidly building the infrastructure, capacity, and highly trained workforce required to step up as providers of choice. Included within the ACA were provisions to improve the quality of care for patients living with chronic conditions. Incentives will be given to providers operating as part of a Patient Centered Health Home. National health care reform provides the roadmap and the timeline for this journey of change. This movement to redesign patient care at the health center builds upon and ties together current statewide and national efforts to improve the quality of care, including: Adoption and meaningful use of electronic health records (EHR); Reducing health disparities and addressing social determinants of health; Movement from episodic care to prevention and population health; Building culturally and linguistically responsive health systems; and Development of local integrated healthcare delivery systems. This work has been underway for many years across the State and the lessons, expertise, and systems gained form the foundation upon which the PCHH models will be built. Since 2007, health centers, regional associations, and CPCA have been engaged in a collaborative project, Accelerating Quality Improvement through Collaboration (AQIC), to improve diabetes care. Through AQIC, project partners have built continuous quality improvement programs within health centers, improved data collection and validation processes, and developed the infrastructure and expertise to report data on standardized clinical and operational measures. This work will prove invaluable in meeting national standards (e.g. meaningful use, PCHH certification) and ultimately in transforming care for patients with chronic conditions within the PCHH. Page 2

3 III. Activities/Approaches The transformation of care at health centers will at its core be focused on the individual needs of the patient and encourage patient ownership of their health and self-management of their care, thereby improving the patient experience and outcomes. Through both the Super Region structure and the regional associations, assessment, training and technical assistance will be mobilized to support and coach health centers through the transformation process, based on the needs of health centers in the region. The four Super Region work groups will identify champions of innovation within health centers and regional associations who will be trained in PCHH transformation best practices. The Super Regions will host learning sessions to allow health centers to share progress to date and develop new concepts and methodologies. These collaborative activities will be closely aligned with the in-depth training and technical assistance provided to health centers as well as the local relationship building and health systems development facilitated by individual regional associations. Demonstration projects will be cultivated within each of the Super Regions and will serve as tangible models to surrounding health center partners. The activities conducted at the statewide and regional level will be informed by needs assessments and input from health centers, with the ultimate goal of assisting health centers in redesigning practice and providing leading edge health care. The resources and training provided to health centers will be designed to meet emerging national standards including meaningful use of electronic health records and certification/recognition as a PCHH. Activities to be conducted broadly across California will be coordinated at a statewide level by SQIC in collaboration with CPCA, the PCHH Committee, and RAC, in partnership with health centers. These activities will help to provide common definitions and direction for PCHH adoption, develop standardized training and technical assistance resources, and lead policy efforts to support sustainability of the PCHH model within health centers. To help health centers achieve recognition as a PCHH, CPCA will develop and lead a PCHH certification/ recognition process based on national standards, such as the NCQA PCMH Standards. Patient Level Activities Coordinated in partnership with families and PCHH care team 1. Engagement in health care services 2. Self-management of chronic disease and health promotion Health Center Level Activities Coordinated by health centers in partnership with patients 1. Implementation of electronic health records and efforts towards achieving meaningful use 2. Developing care coordination and patient-centered processes 3. Work with patients to develop data-driven health improvement plans 4. Redesigning care teams 5. Preparing and applying for certification/recognition as a PCHH Page 3

4 6. Quality improvement to measure cost effectiveness of the PCHH models and assess the impacts of PCHH model on patient experience and service delivery 7. Transparency in data sharing with other health centers and consortia Regional Level Activities Coordinated by Super Regions and regional associations in partnership with health centers 1. Assessment of health center readiness for transformation to the PCHH, including readiness assessments for PCHH recognition based on existing tools (NCQA, Joint Commission, AAFP) 2. Cultivate commitment by stakeholders in the region to pursuing the PCHH concept to improve population health, improved patient care, and decreased costs 3. The development of regional training plans based on the clinic-readiness results 4. Training, technical assistance and coaching to health centers utilizing the PCHH Resource Center/Toolkit (using a train the trainer model and drawing upon health center champions ) 5. Build capacity to share clinical and financial data across local health system partners 6. Develop local partnerships to build a true system of care in the region 7. Demonstration projects (at least 1 within each Super Region) and coordination of site visits or Peer-to-Peer technical assistance for health centers in various stages of change 8. Employ statewide data strategy to support health centers in the collection, validation, analysis, and use of data to improve outcomes 9. Report on health outcomes to local community stakeholders Statewide Level Activities Coordinated through strategic partnerships between CPCA, PCHH Committee, CPCA Data Accuracy and Reporting Group, SQIC, and RAC 1. Standardized definition of terms, model components, and measures 2. Development of California Community Clinic PCHH Resource Center/Toolkit (module-based and web-based platform) and training curriculum 3. Identification and documentation/sharing of demonstration projects, pilots, and best practices 4. Branding and marketing of PCHH to clinic leadership, providers, staff and clients 5. Policy agenda regulatory changes, payment reform, including promoting the alignment of health plan incentive programs, and PCHH national recognition/standards 6. Statewide PCHH conference to share best practices and lessons from demonstration projects 7. Defining and implementing a statewide data strategy, including methods for data collection, reporting, validation, and use including the collaborative development, collection and reporting of PCHH measures (cost effectiveness, clinical, operational) in a statewide dashboard 8. Certification/recognition of health centers as PCHHs based on national standards 9. Work with other state associations and Medi-Cal plans on payment reform 10. Statewide coordination of PCHH Transformation evaluation plan Training and Resource Development Health centers, regional associations and CPCA spent a day and a half together exploring PCHH concepts and how they could transform health centers. With the assistance of a facilitator, the group utilized the Page 4

5 Deep Dive Method to collaboratively identify the training, technical assistance, and support that would be required to assist health centers in California move towards adoption of the PCHH model. The concept of a one-stop, web-based resource site for California health centers emerged as a needed tool. An online PCHH Resource Center/Toolkit could provide background research and reference articles, provide sample forms, policies, and assessment tools for use in planning for and implementing change at the health center level and provide a guide for preparing for certification/recognition as a PCHH. There is a wealth of resources on the PCHH available across the nation. Existing resources will be leveraged whenever possible, reducing the need for reinventing new tools or resources. Training curricula would be developed to support use of the resource materials. Training and technical assistance would be coordinated regionally and provided by regional associations through face-to-face trainings, webinars, and on-site as needed. Examples of topics include: Change management and leadership buy-in Patient engagement and self-management Data collection and management Motivational interviewing Referral and strategic partnership development Patient navigation Care team formation Staff mentoring / coaching Health indicator adoption (e.g. Healthy People 2020 Goals) Patient experience measurement and alignment with national efforts (e.g. CAHPS surveys) IV. Audience/Stakeholders Audience for the project: The audience includes community health centers, regional associations, and other organizations that support health centers, policymakers and funders at the local, state and federal level, and ultimately health center patients who would benefit from more effective care. Additional Project Stakeholders: Across all levels of activities, strategic partnerships and formal relationships will be established with service partners across communities, such as: Public hospitals County public health departments and programs (WIC, SNAP, immunization programs) Women s health services Behavioral health services Oral health services Workforce development partners (community colleges, provider training programs) Specialty care networks Cal econnect, CalHIPSO Page 5

6 VII. Desired Outcomes Improved patient experience with health center services and improved health outcomes. Increased health center capacity to meet community needs. Enhanced ability of health centers to apply for PCHH certification/recognition. Increased selection of health centers as providers of choice and leading edge healthcare. Clear roles between CPCA, SQIC, RAC, and health centers Formalized relationships between health centers and community partners Identification and use of standardized indicators, including Healthy People 2020 objectives Recruitment of highly trained workforce in the PCHH, a recognized employer of choice VIII. Evaluation/Measurement Evaluation of the proposed activities will include multiple strategies, such as: Patient experience surveys Focus groups with health center staff and patients Training impact assessments Dissemination tracking for materials and resources Public reporting of meaningful use data Page 6