Implementing a Patient-Centered Primary Care Home Pilot within a

Community Health Center

Safina Koreishi MD MPHNeighborhood Health Center

OCHIN learning ForumNovember 15 and 16, 2012

What will we talk about today?• What is going on in health care?• Why move towards patient-centered primary care

home transformation? • NHC’s journey towards becoming a patient-

centered primary care home• The role of EMR in patient-centered primary care?

The Platform is burning…

• Costs are unsustainable• Access is increasingly difficult• Quality measures are not meeting goals….

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Insurance Company

Specialists

Hospitals

Community organizations

A confusing healthcare system ??

A buffet of health care ?

The Platform is Burning AND…

• Patient satisfaction is low• Staff satisfaction is low• High provider burnout• Access is increasingly an issue

o Supply and demand issue

Where is Transformational Change?

A Call for Change: IHI Triple Aim

Healthcare Transformation at all levels

• National policy level: Accountable Care Act• State policy level: Coordinated Care Organizations• Local level: CCO implementation (public health,

community partnerships, PCPCH)• On the ground: Primary care Patient-centered

primary care home

Healthcare Transformation- State Level

• In 2011 the Oregon Legislature and Governor John Kitzhaber created Coordinated Care Organizations (CCOs) through House Bill 3650

• Aimed at achieving the Triple Aim:o Improving healtho Increasing the availability of quality careo lowering costs by transforming the delivery of health care.

• Essential elements of CCO transformation are:o Integration and coordination of benefits and serviceso Local accountability for health and resource allocationo Standards for safe and effective careo A global Medicaid budget tied to a sustainable rate of growth

Healthcare Transformation: CCO

• 16 CCOs, community-based and offer primary and mental health care (sometimes dental) for Oregon Health Plan clients

• CCOs focus on prevention and helping people manage chronic conditions

• Helps reduce unnecessary emergency room visits • Gives people support to be healthy

Healthcare Transformation: CCO

• CCOs have flexibility within budgets to support new models of care that are patient-centered and team-focused, and reduce health disparities

• Can better coordinate services and focus on quality outcomes, prevention, chronic illness management and person-centered care

• The PCPCH model is a critical component of CCOs that coordinates all the care for OHP members

• Goal: Meeting the Triple Aim of better health, better care and lower costs for the population they serve

Oregon Patient Centered Primary Care Home Program

• Developed as a charge from the Oregon Health Fund Board

• Central part of health system transformation• 6 Attributes and 23 Standards developed in

Oregon with communities and experts across the state

• First clinics could be certified as of 10/1/2011• 270 clinics are certified as of 9/13/2012!

Oregon PCPCH Program

Attribute Patient Perspective

Access to Care Be there when we need you

Accountability Take responsibility for making sure we receive the best possible health care

Comprehensive Whole Person Care

Provide or help us get the health care, information, and services we need

Continuity Be our partner over time in caring for us

Coordination and Integration

Help us navigate the health care system to get the care we need in a safe and timely way

Person and Family Centered Care

Recognize that we are the most important part of the care team – and that we are ultimately responsible for our overall health and wellness

Why become a primary care home?

 ACO

CCO

ACA

PCMH

PCPCHNCQA

UDSHRSA

Meaningful Use

Why become a primary care home?

 

CCO PCPCH

What is a Primary Care Home Really?

• Not just a program• Not just a stamp of recognition• It is a core component of healthcare reform• A fundamental shift in the operating principles of

an organization• Core building blocks and drivers of what

constitutes a primary care home

Patient and Population Centered Primary Care

• Learned from the Primary Care Renewal Collaborative

• Wanted to spread the best practices they discovered

• Medical Home tools and techniques combined with process improvement skills

Drivers of PC3

Patient and Population Centered Primary Care

Leadership

Data for Action

Well OrganizedWork

Clinic Support Systems

Care Management

• Setting a vision• Roles and Functions of Leadership• Planning a Kick Off

• Empanelment• Setting a “True North”• Measuring the Process• Visual Systems• Tasks of medical homes• Flow mapping• Standard work of teams• Supply and Demand Management• Open Access• Telephone Processes

• Risk Stratification• Standards of Care• Coaching and Follow Up

On the ground: primary care home transformation

ALL THE WORK

What we did… and what we learned Our first year

• Leadership• Empanelment• Data• Team-based care• Process improvement (team based and systems

based)

Leadership• Fundamental shift in operating principles of the

organization• Informs all decisions of the organization• Not just a project or program• Managing change effectively

o Dealing with competing prioritieso Working to change an organization while still “putting out fires”

• Communicating change effectively

Kick-off• Presentation about primary care

home concepts in 12/2011to ALL staffo Empanelmento Datao Improvemento Changing culture

Empanelment

• First step was to “empanel” our patientso All patients are assigned a PCPo Script for schedulerso Process for continual evaluation

• PCP/team “ownership” of the panel• Can then start looking at panel-level data

Data• Discussed data as a concept with staff• Without data, unable to measure improvement• We want the data measures to be meaningful• This is a cultural change and a shift in how we

approach medical care• Rolled out dashboard to first “introduce” data

without clinical indicators• Tried to get consensus on transparency

Dashboard

Data and EMR Obstacle

• Data proved to be an obstacleo Report writingo Understanding data systems (business objects and

solutions)o Understanding where to input information in order to

ensure reports are correcto Understanding how to develop work flows to ensure data

is correcto Wanted to ensure data was meaningful and could be

trusted before rolling it out to staffo Unable to link data to action immediately

Team Based Care• Team-based care helps

re-distribute work • Implemented team

meetings• Team level process

improvemento PDSA cycles and standard

work development

Calling a team a “team” versus functioning as a true team

• Cultivating respect and trust amongst team members

• Forming, storming, norming, performing• Team norms• Team meeting guidelines

o Not a griping session or a venue for blame

• Changing rolls• Process improvement

Process Improvement• Team meetings

o Standard work to improve daily work• Provider coverage process• Back office coverage process• Triage Process• MA phone call expectation

• Improvement as part of job description and expectation of daily work

Clinic Systems Improvement

• Using Lean methods of improvement to decrease waste and increase efficiency in systemo Referralso Registration o Phoneso Refills

What we heard from staff

• Confusion over what being a primary care home really means

• “Waiting” for something to happen• Confusion over rolls in primary care home• Did not understand that we were already moving

towards primary care home

A primary care home pilot:

Integrating concepts in a

meaningful way

• One clinic, one team• Integrating concepts of primary care home

o Clinical guidelines/evidence based medicineo Pre-visit planning (scrubbing)o Huddlingo Proactive outreacho Team buildingo Using data for actiono Process improvement

Patient-Centered Primary Care Home Pilot

• Women’s Health focuso Cervical Cancer Screeningo Breast Cancer Screeningo Address other preventive services, but pap and mammography used as

an example for pre-visit planning and outreach

Patient-Centered Primary Care Home Pilot

• Conversation/discussion with pilot team• Shared vision• Understanding what patient centered medical

home means• Understanding hopes, fears, questions, concerns• Discussing new and old tasks, and restructuring

team to redistribute work• Adding new staff/roles• Team building• Involving the patient voice

Patient-Centered Primary Care Home Pilot: New Tasks

• Panel data evaluation• Scrubbing• Huddling• Proactive outreach to close gaps in care• Systems improvement and standard work to

improve clinical outcomes• “New” epic tool: health maintenance

EMR Integral in PCPCH Implementation

• Data is not reflecting actual work • Needed to understand how data reports are being

run, and from where data is being pulled • Data reports are only as accurate as the data

inputted into EMR• New tasks need new work flows• New work flows must correlate with EMR• Staff need to be trained on correct work flows so

that we are able to pull the correct data

New Work Flows: Health Maintenance

• Presently not being used by NHC• Work flows in the community for scrubbing are

presently not using health maintenance • Health Maintenance module in OCHIN can act as

an important scrubbing tool and reminder for team what services are needed

• Satisfying HM, satisfies solutions and can lead to more accurate clinical reports

What is Health Maintenance?

• Preventive Care Tracking Tool• Alerts for Immunizations, screening, and

management of chronic disease• Composed of Topic and Plans• Modifiers• OCHIN currently uses USPSTF guidelines to build

topics/plans

A Look at Health Maintenance

HM Continued

Resulting Health Maintenance

• Some Health Maintenance Plans will automatically be satisfied upon certain procedures completed others have to be manually satisfied

• Paps are automatically satisfied in the system upon the order and result of a Pap lab

• Mammograms must be manually satisfied (override) in HM

• Procedures done externally can historically be ordered and resulted, or manually “doned” to satisfy the HM alert

Manual Override

• The patient has reported receiving a service elsewhere

• The HM topic does not include completing procedures.

Historical Order

• Patient reported receiving lab/procedure• You have received the results• Order the lab as you would any order• The order Class must say historical lab

• Access the enter/edit results activity to result the historical lab

• Once resulted the HM will be satisfied (assuming it is a result procedure in the topic)

Solutions: Panel Data and HM

• Satisfying solutions from HM requires:o Ordering and performing the service (pap

smear)o Historically ordering and resulting the service

(pap smear)o “doneing” pap smear/mammogram manually

in HM

Solutions: Panel Data• Pap smears• No metrics for mammograms

o Use the number “overdue” on roster as numeratoro Number of women 50-74 on panel as denominator

• Used as an impetus for improvement

Solutions Data: Rosters• Patient level information regarding who is due for

a service• Allows for closing gaps of care

Scrubbing (pre-visit preparation) work flow

Goal: identify and document any needed services that are due at the time of appointment. Ensures visit is well organized

Proactive outreach workflow

Current Restrictions with HM

• Additional plans and topics to make it more comprehensive

• Addition of more modifiers to include or exclude patient populations

• Will be most useful if all preventive services have completing procedures (automatically satisfying HM)

Population Centered Primary Care Married to EMR

• Panel data is integral to primary care home transformation and clinical improvement

• EMR is a powerful tool to be used for documentation, and data

• Need correct clinical workflows to get accurate, meaningful data

Primary Care Home Transformation through a Pilot• Helps to integrate core principles of PCPCH• Helps with staff understanding and acceptance• Helps to move organization forward faster

o Jumping into the pool versus sliding in slowly

• This is hard work BUT…• Always remembering our driving force…

Health System Transformation

Patient and Famil

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Medical

Home Team

Specialty

Hospital

Personal Support System

Social Agency Suppor

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Family

Community

Work

School

Social Servic

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Special Thanks• Ela Rasmussen- NHC Quality Coordinator• Brittany Bozarth- Interim site specialist