How To Achieve a Patient Centered Medical Home (PCMH) Using

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1 How To Achieve a Patient Centered Medical Home (PCMH) Using Nusrat Khan M.D. MBA FAAP Medical Director, MedPeds Medical Clinic, PA Robbye Penrod CPC RMC RMA Office Manager, MedPeds Medical Clinic, PA

2 MedPeds Medical Clinic, PA Internal Medicine and Pediatrics NCQA PCMH Level III Certified Facility (by 2011 Standards ) 1 st Clinic in Texas to Achieve this Status under NCQA 2011 credentialing guidelines NCQA Recognition in Diabetes Care Management (DRP) NCQA Recognition in Heart/Stroke Care Management (HSRP) Bridges to Excellence Recognition in Medical Home Clinic Bridges to Excellence Recognition in Diabetes Care Bridges to Excellence Recognition in Preventative Cardiac Care Bridges to Excellence Recognition in Coronary Artery Disease Bridges to Excellence Recognition in Office Systems Management

3 PCMH and Primary Care Concept supported by the: American Academy of Family Physicians American College of Physicians American Academy of Pediatrics American Osteopathic Association American Association of Nurse Practitioners American Association of Physician Assistants -Principles for the Patient Centered Medical Home; this defines critical principles within the PCMH model.

4 What is PCMH?

5 PCMH-The Concept Enhanced Patient Access - during and after office hours Team-Based Care approach from the clinic team Improved delivery & tracking of preventive services Clinical excellence in chronic disease management Improved care at Transition of Care points: Reduced utilization of ER and hospitals Shared Decision Making: better quality and experience of care Long-term Patient & Provider Relationships High performing, cost effective, integrated care delivery system

6 Why bother with PCMH? POINT Primary care reimbursement has not kept pace with the care burden For now there is no incentive payments for PCMH COUNTER POINT Market forces & regulations within the system are forcing changes in healthcare: the practice of medicine is transforming Consumers of healthcare are demanding better access to care, and third party payers are transitioning to pay for performance There is a tsunami of change that is going to move us away from a fee for service industry PCMH concepts are born out a need for such health care reform

7 Standard 1 Enhance Access and Continuity Access during office hours Access after hours Electronic access Continuity Medical Home responsibilities Culturally and linguistically appropriate Practice Team Approach

8 Access During Office Hours Provide Same-day appointments Provide timely clinical advice by telephone during office hours Provide clinical advice by secure electronic messages during office hours Documenting clinical advice in medical record

9 What We did Improved Access to Care Offered timely care during & after hours --innovative scheduling Adopted patient portals (Updox and A Charts) Electronic messaging Educated our patients to Call Us First --so that we could direct their care

10 Electronic Access Through

11 Standard 2 Identify and Manage Patient Populations Patient Information- demographics Clinical Data- problem list, allergies, vital signs Comprehensive Health Assessment -PMHx, SocHx, Advance Care Planning, Developmental screenings, Depression screening

12 What We did Use Amazing Charts to create reminders in the system for age appropriate screenings Chronic Disease specific services:- example in DM, CKD Use Amazing Charts to identify chronic disease patients = high utilizers of care Use Amazing Charts to identify noncompliance with follow-up

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14 Standard 3 Plan and Manage Care Implement Evidence Based guidelines Identify High Risk Patients Care Management Medication Management Use Electronic Prescribing

15 Care Management Conducts pre-visit preparations Collaborates with patient to develop individual care plan and gives patient written plan of care Assesses barriers when the patient has not met treatment goals Identifies patients who might benefit from additional care/management support

16 What We Did Creating a healthcare delivery team in the office Diabetes Team Leader Preventative Care Team Leader Patient Care Coordinator Individual Care Plan

17 Standard 4 Provide Self-Care Support and Community Resources Support Self-Care Process Provide Referrals to Community Resources

18 Provide Self-Care Support Use EHR to identify patient-specific education resources and provide them to more than 10% of patients

19 What We did Enhanced our website to include patient education accessible 24/7 Began a monthly newsletter to inform patients about current healthcare issues and ongoing series such as Diabetes Today Began in-house Diabetes Education Classes Made a registry of community based resources

20 Standard 5 Track and Coordinate Care Test Tracking and Follow-up Referral Tracking and Follow-up Coordinate with Facilities/Care Transitions

21 What We Did Care co-ordination with specialists Continuity of care at Transition of Care points:-hospital d/c, rehab d/c, etc. Clinical Care Coordinator continues to play a role

22 Referral Tracking and Follow-up Demonstrate electronic exchange of key clinical information between clinicians

23 Standard 6 Measure and Improve Performance Measure Performance Measure Patient Experience Implement Continuous Quality Improvements Demonstrate Continuous Quality Improvements Report Performance Report Data Externally Use of Certified EHR Technology

24 Demonstrate Continuous Improvement Track Results Over Time Assessing the effect of its action Achieving improved performance on one measure Achieving improved performance on a second measure

25 What We did Surveyed our patients to obtain their perceptions of care and customer service Assessed and addressed areas for improvement Re-Surveyed our patients The Importance of Surveys Meaningful Use-2 CG-CAHPS MOC

26 Meaningful Use Data

27 PCMH: one size does not fit all Its not for every practice. and may not be needed for every patient in the practice Large healthcare delivery systems seem to be adopting it first. Smaller practices may have challenges in such transformation. Strategy:- Chronic disease = high risk patients = >High utilizers of care. Particular focus on the complex patients Pay 4 Performance Friedberg M. et al. Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care.JAMA.2014;311(8) Schwenk,T. The Patient Centered Medical Home. One size Does Not Fit All. JAMA.Feb

28 Consider PCMH Concepts use on High Utilizers of Care Use Amazing Charts Queries to: cull data on subset populations identify high risk groups Identify patients that need further intervention in care Identify lack of follow-up Resolve poly-pharmacy and medication interaction issues at point of care

29 Proposal for Your Practice Establish a Clinical Care Coordinator in office Intervene at Transition of Care points Enhance communication with your specialists Survey your patient perceptions of care

30 Creating a Healthcare Delivery Team in Your Office Keep employees who share in the vision and mission of the organization Evolve away from top-down leadership trends into a shared leadership philosophy Assign specific task oriented roles to specific team members.. identify the strength of each employee and utilize it but cross train all employees shared decision making ---listen to patients and employees regularly. Regular team meetings.

31 Questions & Discussion.

32 Care Management Codes Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit, within 14 calendar days of discharge Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of high complexity during the service period Face-to-face visit, within 7 calendar days of discharge