Patient Centered Medical Home: How the latest standards address health equity

Transcription

1 Patient Centered Medical Home: How the latest standards address health equity Marianella Napolitano, RN, MBA Neighborhood Family Practice Linda Stokes, PhD The MetroHealth System

2 Disclosure Presenters reported no financial interest relevant to this presentation

3 Objectives

4 Principles of Patient Centered Medical Home Personal physician Physician directed medical practice Whole person orientation Care is coordinated and/or integrated Quality and safety Enhanced access to care Payment recognizes added value

5 Key Competency Areas Patient- Centered Medical Homes Definition and Concepts Patient Self- Management Quality Standards Patient Centered Medical Homes Change Management Security and Privacy Team Based Care

6 NCQA Recognition Requirements for 2014 Standards Similar topics to prior versions Greater percentages needed to meet requirements Additional emphasis: Integration of Behavioral Healthcare Focus care management for high-need populations QI projects and report across longer timeframes

7 The Joint Commission Certification Requirements Topics similar to NCQA patient access, care coordination, offering culturally/linguistically appropriate services, self management and data collection and reporting. Additional emphasis on: Patient Rights Care Coordination & Care management for populations QI projects and reporting

8 NCQA Level 3 PCMH Recognition Requirements Compared to 2011 Joint Commission Standards and EPs Source: The Joint Commission (

9 Population Health Management The health outcomes of a group of individuals, the distribution of those outcomes within the group and analysis to determine how to effect improvement of those outcomes. Population Based Analysis Tools for practitioners Additional tools Framing Questions Example Projects

10 Population-based Analysis Quality Improvement Identify topic/intervention Track results Case Management Identify Population Track Interventions Group Interventions Multiple participants and oversight Stratification of population

11 Patient Risk Distribution

12 Tools for Population Health Mgmt EMR Clinical Data Data Source for other tools Reporting Identify Population Track Interventions Registries by Condition by Other Factors

13 Applications and Databases EMR Production Financial Applications Reporting Tools Reporting Database ODBC Connection Tools: Access SAS Claims or Other Data Sources

14 Framing Questions Where to start? Topic to study Define population Define what population will be compared to How to ask? Selection criteria Detail on who to select Detail on time period to select Detail on what data to include Detail on where/locations to select Detail on how list of patients or summary only

15 Red Carpet Care Recruitment of high risk patients - DM, HTN, HF, multiple ED visits and IP, high cost Hotspotter approach using dedicated APNs Makes use of Registries, ED alerts/care plans Evaluated based on utilization and cost savings pre and post intervention period

16 Medicaid Waiver Care Plus Enrollment up to 30,000 patients Benefits included pharmacy, dental, and transportation not previously covered in charity care programs Care Coordinators imbedded in practice Collaboration with 2 FQHC practices Created closed network for care Utilization measures Cost measures Health outcomes

17 Hypertension Project Complete refresher on procedure to check blood pressure with staff. Interventions: follow up with nurse and provider Compare rates of BP taken pre and post project

18 Cervical Cancer Screening Project at NFP Use EMR report to identify patients due for PAP Patients are contacted to schedule appointment Screening completed at appointment and information updated in EMR

19 Conclusion Data makes everything better!

20 Thank You Questions?