Hitting a Home Run: The Patient Centered Medical Home and Home Care

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1 Hitting a Home Run: The Patient Centered Medical Home and Home Care This paper has been prepared by the Home Care Alliance of Massachusetts to support home health agencies seeking to align with community health centers and physician practices in Massachusetts to support the transition to a medical home model. It incorporates research on medical homes, current home health practice, as well as work done in 2009 by the Massachusetts Patient Centered Medical Home Coordinating Committee. Momentum is building in Massachusetts and elsewhere around the country to reconfigure primary care physician practices towards a medical home model targeted at reducing care fragmentation and better managing costly chronic diseases. Massachusetts is one of several states that has received a grant from the Commonwealth Fund to implement the Patient Centered Medical Home (PCMH). In 2010, this grant is expected to support PCMH implementation in at least a dozen selected community health centers. Additionally, the state FY 2010 budget included funding for a PCMH pilot in selected primary care practices. The long term goal is a very broad statewide transformation of primary care practice into a PCMH model that encompasses all payors and patient types with demonstrated effectiveness, both in terms of improved clinical outcomes and cost savings.

2 The movement toward a medical home depends on the state developing a set of core competencies and transformation strategies that will define and move current primary care practices towards a PCMH. These competencies and trainings are drawing on work done in other states, as well as the National Committee on Quality Assurance s (NCQA) Standards and Guidelines for PCMH. However, Massachusetts expects to develop our own framework for implementation that works for Massachusetts. Essential components will include patient centeredness, smooth transitions across care settings, integrated care teams, patient self management coaching of patients with chronic diseases, case coordination and care management. Although many medical home models don t specifically emphasize or articulate a strategy to make the home an actual site of care, 1 many of the strategies Massachusetts is looking to (e.g., managing patients one-on-one, reducing costly and unnecessary office visits, engaged families and empowered patients) can all be linked to the home care model. Therefore, there is great potential for practice transformation to a PCMH to be accomplished for physician groups by building on or reconfiguring existing home care relationships to meet the state s expected practice parameters. This paper uses some of the tenets of a PCMH to present an overview of the skills and qualifications that home health care agencies could bring to a possible PCMH partnership. PCMHs will need Chronic Care Management and Patient Self Management Programs For a PCMH to be successful, the management of chronic disease must ultimately occur in the patient s home, not necessarily in the practice office. Despite restrictive rules and coverage limitations in caring for Medicare beneficiaries with chronic illnesses, many home health agencies have participated in CMS Home Health Quality Improvement (HHQI) pilots and projects to redesign their routine care plan services to incorporate and in some cases become certified in evidence-based chronic care management models (e.g the Wagner and Coleman models) and patient self management (Stanford Model). Several agencies now have Certified Diabetic Educators (CDEs) on their staffs Close to half of the state s home health agencies have remote vital sign monitoring capacities, and more than half use electronic medical records, both of which could be central part of a medical home s data driven chronic care strategy. Additionally, all certified home health agencies have experiencing in assessing patients and their homes for basic human needs such as food, hygiene, and safety and in connecting patients with community supports. PCMHs will need all of these skills. PCMHs Will Need To Provide 24/7 Care Practice infrastructure redesign is among the biggest challenges of conversion to a PCMH, especially for small practices. A recent evaluation of practice readiness in Massachusetts 2 found that the least common capability among practices was being regularly open to provide care on weekends (24%). On the contrary, home health agencies have significant experience in operating in a 24/7 environment as required by the Medicare Conditions of Participation. In this role, home care agencies routinely coordinate care among multiple physicians, assist patients with medication adjustments, and provide follow-up care and counsel after hours. 1 Landers, Steve; The Other Medical Home, Journal of the American Medical Association, January, Freidberg, Mark W, et al; Readiness for the Patient-Centered Medical Home: Structural Capabilities of Massachusetts Primary Care Practices Journal of General Internal Medicine, December 3,

3 An essential PCMH performance measurement may well be their success in keeping patients out of hospitals and emergency rooms on evenings and weekends. Since many practices may find 24/7 operation to be too onerous, models may be considered that share resources of home heath on-call nurses and specialists to perform this essential function. PCMHs will Need to Integrate Care Management into their Practices The Geisinger and Mayo Clinic sites are often cited as models of integrated, patient centered care. Less recognized, but equally successful, has been pioneering work of Baptist Health in Little Rock, AK, which has been on the forefront of work using a home-based chronic care model. Based on work by Dr. Edward Wagner, the Baptist Home Health Network s Home-Based Chronic Care Model demonstrates how a practice can make home care the center of care management and cost efficiency. The model incorporates Wagner s work on patient-centeredness and shared responsibility; but it also incorporates telehealth technology to keep clinical information flowing and current. Importantly, the model capitalizes on existing relationships that local home care agencies have with physicians, hospitals, insurance case managers and most importantly - patients with chronic disease. It has proven successful. Baptist Health s Home Based Chronic Care Model 3 has cut that system s rehospitalizations almost in half and won Modern Health Care s 2008 Spirit Award. With innovative leadership, local home care agencies could easily retool their staff and operations to help the state and certain practices avoid the costly construct of a new care management system and thus help to achieve a much quicker return on investment in a PCMH. Strong Physician Home Health Agency Relationships Exist as a PCMH Building Block A survey conducted in Fall 2008 by the Massachusetts Medical Society survey showed that a vast majority of physicians believe home health care services provide multiple advantages in improving health care quality and reducing care delivery costs. 89 percent of responding physicians indicated an opinion that home health services can reduce inpatient hospital admissions, 63 percent said that they reduce emergency room visits, and 41 percent indicated that they can produce overall costs savings. When the survey looked at responses by specialty, the connection between primary care and home care in this state was clear: 64% of primary care physicians indicated using home health for chronic disease management; and 82% of primary care physicians indicating using home care for hospice and palliative care. Physician respondents were clear that relationships with home health care agencies (see graph below) are important to efforts to achieve better patient compliance with a care plan (78%) and to stress reduction on the part of patient s families (72.9%) The value in these relations may only grow with the trend in home care agencies to develop specialists in such areas of high incidence disease states, such as certified diabetes educators, wound, ostomy and cardiac nurses, and palliative care specialists. 3 The Center for Excellence in Chronic Care Management, HealthcarePromise A Blueprint to Deliver the Promise of Healthcare Reform, Center for 2020 Solutions, Little Rock, Arkansas 3

4 In your opinion, what are the main advantages to using home health care services in your practice? % Better compliance with care plan Stress reduction patients' caregivers Better coordination of care Reduction in ED vis its Faster recovery post-acute care Cost savings 4 Not fam iliar with these policies Source: Mass Medial Society Survey of Physicians and Home Care, August, 2009 Conclusion Studies are just beginning to appear that provide solid evidence as to whether and how the PCMH can deliver on the promise of reducing costs by improving care quality and coordination. At least one previously published study of disease management provides both a cautionary and supportive tale as to the home health/physician partnership as a possible success factor in a PCMH. Mathematica s recent Report to Congress on the Evaluation of the Medicare Coordinated Care Demonstration indicated that none of the 15 demonstration sites lowered overall costs and illustrated the difficulties of reducing the need for expensive medical care among beneficiaries with chronic illnesses. The findings did identify some characteristics across the most potentially effective programs. Among their conclusions were that: in-person contacts, whether in the patient s home or at a physician s office or clinic, help establish the trust and rapport needed for the patient to be responsive to the care coordinator s advice. Program staff have also noted that seeing the patient and his or her living environment (including aspects that the patient might not tell staff about on the telephone) greatly enhances their ability to understand the patient s situation and tailor the intervention to it. 4 4 Mathematica Policy Research, Inc Report to Congress on the Evaluation of the Medicare Coordinated Care Demonstration, January 3,

5 Recommendations As the state prepares to move forward with seeking practices to volunteer to reconfigure towards a PCMH, home health agencies can: 1. Become familiar with the model and support and seek partnerships with physician practices considering the potential value on converting to a PCMH 2. Work with health centers and practices to alert them to agency resources and specialty skills that PCMHs may need (e.g., on staff certified diabetes educators, patient self management coaches, medication reconciliation expertise, falls prevention programs, telehealth) 3. Consider the construct of the financial relationship between and agency and a PCMH to provide necessary services that practices may be required to either embed or contract for, such as case management, care coordination 4. Explore and operationalize web-based physician communication practices through electronic health records, physician portals etc 5. Be prepared to demonstrate use of evidence based practice guidelines and outcomes August,

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