Upload
lamanh
View
213
Download
0
Embed Size (px)
Citation preview
PCPCC 2015. All rights reserved.
Patient-Centered Medical Home 101: General Overview
Publicly Available Slide Deck Last Updated: January 2015
Suggested Citation: PCPCC Map Tools. (2015). Patient-Centered Medical Home 101: General Overview. Patient-Centered Primary Care Collaborative. Accessed at https://www.pcpcc.org/resource/map-tools-pcmh-slide-presentations.
PCPCC 2015. All rights reserved.
Purpose of Slide Deck
• We invite users to adapt these slides for your own
presentations. Please see the notes sections for more
detailed information.
• This slide deck – PCMH 101 - is focused on explaining what is
the patient-centered medical home (PCMH) along with how
and why it’s effective. For slides on the outcomes of PCMH,
please access the second slide deck – PCMH 201: A Snapshot
of the Evidence.
• For the most current publicly reported outcomes data, please
go to PCPCC’s “Outcomes View” of the Primary Care
Innovations and PCMH Map:
http://www.pcpcc.org/initiatives/evidence
2
PCPCC 2015. All rights reserved.
Outline
Introduction & General Overview to the Patient-Centered Medical Home (PCMH)
– What it is
– Why it works
– How it works
3
PCPCC 2015. All rights reserved. Source: www.ahrq.gov
Defining the Medical Home The medical home is an approach to primary care that is:
Committed to
Quality and Safety
Maximizes use of health IT,
decision support and other tools
Accessible
Care is delivered with short
waiting times, 24/7 access and
extended in-person hours
Coordinated
Care is organized across
the ‘medical
neighborhood’
Comprehensive
Whole-person care
provided by a team
Person-Centered
Supports patients and
families in managing
decisions and care plans
4
PCPCC 2015. All rights reserved.
Patient-Centered
Comprehensive
Coordinated
Accessible
Committed to quality and
safety
A team of care providers is wholly accountable for patient’s physical and mental health care needs – includes prevention and wellness, acute care, chronic care
Ensures care is organized across all elements of broader health care system, including specialty care, hospitals, home health care, community services & supports, & public health
Delivers consumer-friendly services with shorter wait-times, extended hours, 24/7 electronic or telephone access, and strong communication through health IT innovations
Demonstrates commitment to quality improvement through use of health IT and other tools to ensure patients and families make informed decisions
• Dedicated staff help patients navigate system and create care plans
• Focus on strong, trusting relationships with physicians & care team, open communication about decisions and health status,
compassionate/culturally sensitive care
• Care team focuses on ‘whole person’ and population health
• Primary care could co-locate with behavioral, oral, vision, OB/GYN, pharmacy, etc.
• Special attention paid to chronic disease and complex patients
• Care is documented and communicated effectively across providers and institutions, including patients, primary care, specialists, hospitals, home health, etc.
• Communication and connectedness is enhanced by health information technology
• Implement efficient appointment systems to offer same-day or 24/7 access to care team
• Use of e-communications and telemedicine to provide alternatives for face-to-face visits and allow for after hours care
• EHRs, clinical decision support, medication management to improve treatment & diagnosis.
• Establish quality improvement goals; use data to monitor & report about patient populations and outcomes
Feature Definition Sample Strategies Potential Impacts
Patients are more likely to seek the right care, in the right place, and at the right time
Patients are less likely to seek care from the emergency room or hospital, and delay or leave conditions untreated
Providers are less likely to order duplicate tests, labs, or procedures
Better management of chronic diseases and other illness improves health outcomes
Focus on wellness and prevention reduces incidence / severity of chronic disease and illness
Lower use of ER & avoidable hospital, tests procedures & appropriate use of medicine = $ savings
Why the Medical Home Works: A Framework
Supports patients and families to manage & organize their care and participate as fully informed partners in health system transformation at the practice, community, & policy levels
PCPCC 2015. All rights reserved.
Changing to a new Paradigm
Today Future
Treating Sickness / Episodic Managing Populations
Fragmented Care Collaborative Care
Specialty Driven Primary Care Driven
Isolated Patient Files Integrated Electronic Records
Utilization Management Evidence-Based Medicine
Fee for Service Shared Risk/Reward
Payment for Volume Payment for Value
Adversarial Payer-Provider Relations
Cooperative Payer-Provider Relations
“Everyone For Themselves” Joint Contracting
6
PCPCC 2015. All rights reserved.
Delivery Reform
Payment Reform
Public Engagement
Benefit Redesign
Health System transformation requires…
7
PCPCC 2015. All rights reserved.
Solutions point to strengthened Primary Care
Significant problems
Rising healthcare costs $2.4 trillion (17% of GDP)
Gaps/variations in quality and safety
Poor access to primary care providers
Below-average population health
• PCMHs
• ACOs
• EHR/HIE investment
• Disease-management
pilots
• Alternative care
settings
• Patient engagement
• Care coordination
pilots
• Health insurance
exchanges
• Top-of-license practice
… “Experiments” underway
Across 300+ studies, better primary care
has proven to increase quality and curtail
growth of health care costs
… Primary care-centric projects
have proven results
↑ Aging population & chronic disease
8
PCPCC 2015. All rights reserved. Source: UCSF Center for Excellence in Primary Care.
PCPCC 2015. All rights reserved.
Public Health
Employers
Schools
Faith-Based Organizations
Community Centers
Home Health
Hospital
Pharmacy
Diagnostics
Specialty & Subspecialty
Skilled Nursing Facility
Mental Health
Patient-Centered Medical Home
Community Organizations
Health IT
Health IT
$
$
PCMH at of “Medical Neighborhood”
Health Care Delivery Organizations
10
PCPCC 2015. All rights reserved.
PCMH as hub for “medical neighborhood” and broader community
PCMHs serves as central “hub” for all health and social support services to achieve care coordination
Clinical partners • Specialists • Hospitals • Home health • Long term care • Clinical providers
Non-clinical partners • Community centers • Faith-based organizations • Schools • Employers • Public health agencies • YMCAS • Meals on Wheels
11
PCPCC 2015. All rights reserved.
Public Engagement: Patients, Families & Caregivers, and Consumers must drive demand for the model
Public Engagement
PCPCC 2015. All rights reserved.
PCMH can enhance community partnerships
Benefits for Practices: • Improved access to community
networks
• Increased market share
• Better care transitions
• Reduced disparities
• Increased patient satisfaction
• Access to community health data
• Increased use of preventive services
• Increased use of community services in prevention of rehospitalization
Benefits for Patients: • Increased access to supportive
services
• Better experience of care
• Support addressing healthy behaviors
• Hospitalization and ED visits
• Better health outcomes
Benefits for the Community: • Lower prevalence of disease and
disability • Decreased health costs • Decreased lost productivity • Better coordination between clinical
and public health efforts • Improved outcomes for diverse
populations Source: http://forces4quality.org/provider_community_partnerships
13
PCPCC 2015. All rights reserved.
Patient-centered care associated with better processes of care and better health outcomes
Patients with positive patient experience are:
• More likely to follow physicians’ advice and medication regimens
• More likely to stay with their primary care provider (improved loyalty and retention)
• Less likely to file malpractice complaints
• More likely to report better outcomes post hospital discharge, if their ambulatory care experience was positive
• Often more likely to receive better process of care (e.g., preventive care screening, chronic disease management)
Sources: I. Wilson et al. (2005) Cost-Related Skipping of Medications and Other Treatments Among Medicare Beneficiaries Between 1998 and 2000. Journal of General Internal Medicine; A. M. Fremont et al., (2001) Patient-centered Processes of Care and Long-term Outcomes of Acute Myocardial Infarction. Journal of General Internal Medicine. 14:800–8; K. Browne et al. (2010). Primary Care Analysis & Commentary Measuring Patient Experience As A Strategy For Improving Primary Care. Health Affairs. 29(5).
14
PCPCC 2015. All rights reserved.
Delivery reform: Growing evidence to support that the model works
Delivery Reform
PCPCC 2015. All rights reserved.
PCMH enhances ability to identify and manage high-risk, high-need populations
• Risk stratification and diligent monitoring for all patients
• Track care plans and medication adherence
• Proactive outreach from care team with collaboration among specialists and primary care
• Patient engagement and activation
16
PCPCC 2015. All rights reserved.
• Care coordinators
• Patient navigators
• Health coaches
• Peer support
• Care managers
• Behavioral health/mental health
• Community supports and social workers
• Pharmacists
• Patients, families & Caregivers
PCMH uses diverse empowered care teams
17
PCPCC 2015. All rights reserved.
PCMH facilitates care that is documented and shared electronically
• Shared with patients through electronic records, portals, mobile apps, email – Includes patient-generated data
• Shared across providers and institutions through health information exchanges
• Shared across public and private payers
18
PCPCC 2015. All rights reserved.
PCMH supports improved access to care and better patient experience
• 24/7 access to care team (phone or e-consults with nurses, etc.)
• Alternatives to traditional face-to-face visits, including telemedicine, group visits, e-consults, peer support
• Access to electronic health records and patient portals
19
PCPCC 2015. All rights reserved.
• Consider experience of care from the patient’s
perspective – and includes families & caregivers • Patients with multiple chronic conditions (and/or
their caregivers) often in best position to advise care team on challenges/opportunities to improve care
• Through their stories, patients can energize and encourage team to promote compassionate care
PCMH includes patients, families & caregivers as part of care team
20
PCPCC 2015. All rights reserved.
• Invite patients/caregivers into quality improvement efforts from the very beginning
• Invite patients/caregivers that represent the larger patient population (i.e. ethnicity, culture)
• Invite patients/caregivers with experience managing their own condition
• Provide compensation for patients/caregiver advisors
• Invite more than one patient, family, caregiver
PCMH includes patients, families & caregivers in practice transformation
21
PCPCC 2015. All rights reserved.
Need to Integrate Behavioral Health into Primary Care
22 Source: http://uwaims.org
Consultative Model
• Psychiatrist/psychologist/social worker (behavioral /mental health expert) sees patients in consultation in behavioral health setting
Co-located Model
• Behavioral/mental health expert sees patients in primary care setting
Collaborative (or Embedded) Model • Behavioral/mental health expert provides
caseload consultation about primary care patients; works closely with primary care team
PCPCC 2015. All rights reserved.
Payment Reforms: Necessary to sustain the model (and the progress made)
Payment Reform
PCPCC 2015. All rights reserved.
Primary Care Remains Undervalued U.S. per-capita health spending, 2012
(under 65 with employer-sponsored health insurance)
Hospital inpatient
21%
Hospital outpatient visits/other
28%
Professional procedures
(non-hospital) 30%
Drugs 17%
Primary Care 4%
2012 Health Care Cost and Utilization Report. “ Health Care Cost Institute, Inc. (2013): Table A1 [Internet] Washington, DC: HCCI; 2013 Sept http://www.healthcostinstitute.org/
PCPCC 2015. All rights reserved.
Emerging Payment Reform Trends
Volume-based reimbursement
Value-based reimbursement
Bundled payments
ACOs Global budget
contracts
Fee-For-Service
PCPCC 2015. All rights reserved.
HIT Infrastructure: EHRs and Connectivity
Primary Care Capacity: Patient Centered Medical Home
Operational Care Coordination: Embedded RN Coordinator and Health Plan Care Coordination $
Value/ Outcome Measurement: Reporting of Quality, Utilization and Patient Satisfaction Measures
Value-Based Purchasing: Reimbursement Tied to Performance on Value
Supportive Base for ACOs, PCMH Networks, Bundled Payments, Global Capitation
Trajectory to Value-Based Purchasing It is a journey, not a fixed model of care
26
Source: THINC - Taconic Health Information Network and Community
PCPCC 2015. All rights reserved.
The payment reform imperative
• Increasing % spend on primary care and payment reform is integral to the success of the model
• In fee-for-service (FFS), many PCMH strategies and care processes are rarely/poorly reimbursed (i.e. team based care, care coordination, phone/e-visits)
• Many PCMH practices are paid through FFS component coupled with care management payment (per member per month – PMPM)
• Growing number including: shared savings, bundled payments, partial/full capitation
27
PCPCC 2015. All rights reserved.
Multi-payer payment reforms key to health system transformation
Many states are convening private and public payers and using uniform set of payment & quality metrics to provide needed alignment: • State/local government used as convening entity
(to mitigate antitrust concerns and provide participation of numerous stakeholders)
• Recognizes differences in various markets and encourages local collaboration
• Data from early evaluations trending positive • Funding from Comprehensive Primary Care (CPC)
Initiative & Multi-payer Advanced Primary Care Practice (MAPCP)
28 Source: Dulsky Watkins (2014) Milbank Memorial Fund
PCPCC 2015. All rights reserved.
CMS Innovations Portfolio: Testing New Models to Improve Quality
Accountable Care Organizations (ACOs) Capacity to Spread Innovation
• Medicare Shared Savings Program (Center for Medicare)
Pioneer ACO Model
Advance Payment ACO Model
Comprehensive ERSD Care Initiative
•
•
•
Partnership for Patients
Community-Based Care Transitions
Million Hearts •
•
• Health Care Innovation Awards
State Innovation Models Initiative Primary Care Transformation
•
•
Comprehensive Primary Care Initiative (CPC)
Multi-Payer Advanced Primary Care Practice
(MAPCP) Demonstration
Federally Qualified Health Center (FQHC) Advanced
Primary Care Practice Demonstration
Independence at Home Demonstration
Graduate Nurse Education Demonstration
Initiatives Focused on the Medicaid Population
•
•
Medicaid Emergency Psychiatric Demonstration
Medicaid Incentives for Prevention of Chronic
Diseases
Strong Start Initiative
•
• •
• Medicare-Medicaid Enrollees
•
•
Financial Alignment Initiative
Initiative to Reduce Avoidable Hospitalizations of
Nursing Facility Residents
Bundled Payment for Care Improvement
•
•
Model 1: Retrospective Acute Care
Model 2: Retrospective Acute Care Episode &
Post Acute
Model 3: Retrospective Post Acute Care
Model 4: Prospective Acute Care
•
•
19
PCPCC 2015. All rights reserved.
Need to change “Supply” and “Demand” “Supply side” reforms Reimbursement changes that impact health care delivery: • Increased payment for providers who adopt PCMH model
• Increased use of shared savings , bundled payments, capitated payments
• Alignment across all payers through multi-payer or all-payer initiatives
“Demand side” reforms Reimbursement changes that impact consumers and employers: • Consumers pay less in premiums/copays to use higher-value, PCMH
services
• Limit co-pays for wellness visits/primary care
• Use of tiered pharmacy benefits that encourage the use of cost effective prescriptions (including generics)
• Improve consumer understanding of the PCMH model and primary care to better manage health
30
PCPCC 2015. All rights reserved.
Download Slide Deck 2 - PCMH 201: A Snapshot of the Evidence https://www.pcpcc.org/resource/map-tools-pcmh-slide-presentations
For real-time program and outcome updates, visit PCPCC’s Primary Care Innovations and PCMH Map: http://www.pcpcc.org/initiatives.
31
PCPCC 2015. All rights reserved.
Resources • Agency for Healthcare Research and Quality: www.ahrq.gov • Advancing Integrated Mental Health Solutions Center:
http://aims.uw.edu/ • Centers for Medicare and Medicaid Services Innovation: http://innovation.cms.gov/ • Health Care Cost Institute: http://www.healthcostinstitute.org/ • Milbank Memorial Fund: http://www.milbank.org • Patient-Centered Primary Care Collaborative: http://www.pcpcc.org • Robert Wood Johnson Foundation: Aligning Forces for Quality http://forces4quality.org/provider_community_partnerships • Taconic Health Information Network and Community:
http://www.thincrhio.org/ • UCSF Center for Excellence in Primary Care: http://cepc.ucsf.edu/