How To Achieve aPatient Centered Medical Home (PCMH)

Robbye Penrod CPC RMC RMAOffice Manager, MedPeds Medical Clinic, PA

Using

Nusrat Khan M.D. MBA FAAPMedical Director, MedPeds Medical Clinic, PA

MedPeds Medical Clinic, PAInternal Medicine and PediatricsNCQA PCMH Level III Certified Facility

(by 2011 Standards ) 1st 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

PCMH and Primary CareConcept 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.

What is PCMH?

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

Why bother with PCMH?POINT• Primary care reimbursement has not kept pace with the care burden• For now there is no incentive payments for PCMHCOUNTER 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

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

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

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

Electronic Access Through

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

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 non-

compliance with follow-up

Standard 3

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

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

What We DidCreating a healthcare delivery team in the office

• Diabetes Team Leader• Preventative Care Team Leader

• Patient Care Coordinator• Individual Care Plan

Standard 4

Provide Self-Care Support and Community Resources

• Support Self-Care Process• Provide Referrals to Community

Resources

Provide Self-Care SupportUse EHR to identify patient-specific education resources

and provide them to more than 10% of patients

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

Standard 5

Track and Coordinate Care• Test Tracking and Follow-up• Referral Tracking and Follow-up• Coordinate with Facilities/Care

Transitions

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

Referral Tracking and Follow-upDemonstrate electronic exchange of key clinical

information between clinicians

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

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

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 SurveysMeaningful Use-2CG-CAHPSMOC

Meaningful Use Data

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).815-825.• Schwenk,T. “The Patient Centered Medical Home. One size Does Not Fit All”. JAMA.Feb.2014.311

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

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

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 itbut cross train all employees

‘shared decision making’---listen to patients and employees regularly. Regular team meetings.

• Questions & Discussion…….

Care Management Codes99495 - 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

99496 - 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