The Patient Centered Medical Home:

Using Patient Registries and Automated Patient Outreach to Qualify for NCQA Level 3

Medical Home

Joseph Mambu MD CMD CHENovember 2009

The Joint Principles of the Patient Centered Medical Home (PC-MH)

AAFP, AAP, ACP, AOA: March, 2007

Personal physician Physician directed medical practice Whole person orientation Enhanced access to care Care is coordinated and/or integrated Quality of care / culture of patient safety Payment reform

Core Care Components &

Infrastructure Components

Patient Centeredness… Delivers effective treatment by a trustworthy physician &

medical staff. Offers access to timely reliable healthcare information and

advice. Considers patients’ cultural traditions, their personal

preferences, values and their family situations. Involves the patient in all decision making and respects the

patients’ preferences and right to decline treatment. Makes the patient & loved ones an integral part of the

healthcare team collaborating with the team in making clinical decisions.

Puts responsibility for important aspects of self-care and monitoring in patients’ hands — along with the necessary tools and support . 

Ensures that transitions between providers, departments and health care settings are respectful, coordinated, and efficient.

When care is patient centered, then unneeded and unwanted services can be reduced.

The Current Model of Care:Connection by Billing

Insurer

The Future Model of Care: Patient Centered Integrated Delivery System

Sub-specialty “Medical Home Neighbors” Referrals and Procedures

Insurer

Patient Centered Hospital

Patient Centered Medical Home

Data Center

PCPCC–THE BUYERS OF HEALTHCARE

Linkage of PCMH to Reimbursement:One Model

Monthly Management Fee per patientBased upon NCQA level of recognition

Enhanced Fee Schedule for Visits/ProceduresE&M Coding

Quality, and Patient ExperienceBased upon performance reporting and patient satisfaction reporting

Profit-sharing

Which Payment System Is Best?

Depends on the Disease/Condition

OveruseUnderuse

Underpayment

Inefficiency

CostPer

Episode

Episode Payment

Comprehensive Care Pmt.(or Year-Long Episodes)

Fee for Service

Comprehensive Care Pmt.+

Episode Payment

Examples:COPD,

Congestive Heart Failure

Examples:Heart Disease,

Back Pain

Examples:Immunizations,Simple Injuries

Examples:Hip Fractures,

Labor & Delivery

Frequency of Episodes

•Since 1999, the state has invested in many MH components through disease management payments to practices with Medicaid pts.

• Emphasis on physician led team approach, disease tracking & care managers within practices.

•Significant improvements in cost, utilization, and quality measures. Two major evaluations estimate it CNCC saved the state between $230 and $260 million in 2004.

Community Care of North Carolina

300

325

350

375

400

425

450

CY 2006 CY 2007

Medical Home Non-Medical Home

Geisinger Medical Home Sites and Hospital Admissions

Source: Geisinger Health System, 2008.

Hospital admissions per 1,000 Medicare patients

Geisinger Medical Home Pilot Sites Reduce Medical Cost

Source: G. Steele, “Geisinger Quality—Striving for Perfection,” Presentation to The Commonwealth Fund Bipartisan Congressional Health Policy Conference, Jan. 10, 2009.

550

560

570

580

590

600

610

620

630

CY 2006 CY 2007

Non-medical home

Medical home

Allowed per member per month

Cost Savings of DM Management

National Committee for Quality Assurance (NCQA) Currently, the most used

“stamp” of approval Practices can apply for

and achieve “recognition” (not certification . . )

Three levels possible Long application Fees involved Can re-apply/get level

changed

PPC-PCMH: What it is

Provides valid, reliable and “auditable” means for incentivizing investment in quality infrastructure and processes

Encourages practices to adopt proven systems for improving care

Complements evaluation of clinical effectiveness, patient experiences, and efficiency

PPC-PCMH: What it’s NOT

The definition of a PCMH The joint principles (and others as well) “define”

the PCMH A tool to “certify” practices as medical homes

It, along with attestation only qualifies a practice as having met the basic standards that COULD be a PCMH

Permanent in content and scoring Was designed to evolve over time

Physician Practice Connections/PCMH

January, 2008

PPC-PCMH Content and ScoringStandard 1: Access and CommunicationA. Has written standards for patient access and patient

communication**B. Uses data to show it meets its standards for patient

access and communication**

Pts

45

9

Standard 2: Patient Tracking and Registry Functions A. Uses data system for basic patient information (mostly

non-clinical data) B. Has clinical data system with clinical data in searchable

data fields C. Uses the clinical data system D. Uses paper or electronic-based charting tools to

organize clinical information**E. Uses data to identify important diagnoses and

conditions in practice**F. Generates lists of patients and reminds patients and

clinicians of services needed (population management)

Pts

2

33

64

3

21

Standard 3: Care ManagementA. Adopts and implements evidence-based guidelines

for three conditions **B. Generates reminders about preventive services for

clinicians C. Uses non-physician staff to manage patient care D. Conducts care management, including care plans,

assessing progress, addressing barriers E. Coordinates care//follow-up for patients who receive care

in inpatient and outpatient facilities

Pts

3

4

35

5

20

Standard 4: Patient Self-Management Support A. Assesses language preference and other communication

barriersB. Actively supports patient self-management**

Pts

24

6

Standard 5: Electronic Prescribing A. Uses electronic system to write prescriptions B. Has electronic prescription writer with safety checksC. Has electronic prescription writer with cost checks

Pts33

2

8

Standard 6: Test Tracking A. Tracks tests and identifies abnormal results

systematically** B. Uses electronic systems to order and retrieve tests

and flag duplicate tests

Pts7

6

13

Standard 7: Referral Tracking A. Tracks referrals using paper-based or electronic

system**

PT4

4

Standard 8: Performance Reporting and Improvement A. Measures clinical and/or service performance by

physician or across the practice** B. Survey of patients’ care experience C. Reports performance across the practice or by

physician **D. Sets goals and takes action to improve performance E. Produces reports using standardized measures F. Transmits reports with standardized measures

electronically to external entities

Pts

3

33

3

21

15

Standard 9: Advanced Electronic Communications A. Availability of Interactive Website B. Electronic Patient Identification C. Electronic Care Management Support

Pts121

4**Must Pass Elements

Phytel Patient Outreach

Patient-Centered Medical Home (PPC-PCMH™) Qualification

PPC2: Patient Tracking and Registry Function Element F - Use of System for Population Management

PPC3: Care Management Element A – Guidelines for Important Conditions

PPC3: Care Management Element B - Preventive Service Clinician Reminders

"Phytel’s registry and care management activities helped our practice achieve level 3 recognition - the highest of the NCQA’s medical home qualification”

Joseph Mambu, M.D.President, Family Medicine, Geriatrics and Wellness

INITIAL LESSONS LEARNED

1. Personal Transformation of Physicians Required

2. Transformation to a PCMH is developmental requiring “Core Competencies” and “Adaptive Reserves”

3. Regarding technologies, There is no “Plug and Play”

4. “Change Fatigue” - a Serious Obstacle even within Capable and Highly Motivated Practices

PRACTICE RECOMMENDATIONS

Establish Realistic Expectations for Time and Effort a. Change in the doctor-patient relationship to a more personalized partnership b. Shift from authoritative leadership style to one that

facilitates and empowers c. Shift from physician-centered care to team-based care

Learn to be a Learning Organizationa. Systems Thinkingb. Personal Masteryc. Mental Modelsd. Shared Visione. Team Learning

Redesigned Work Flow1. Communication - enhanced electronically, daily huddles, monthly staff & weekly committee meetings2. Cross training - with licensed employees working at the tops of their licenses3. New Roles - administrator, clinical care coordinator/health coach, DM/prevention coordinator, EMR customizer, QI physician4. Pre-visit and post-visit care PRN5. Scheduled Patient visits with RN health coach6. Group visits7. Patient portal 8. Universal email access

IMPROVING THE CARE OF CHRONIC DISEASE

DISEASE MANAGEMENT

What Phytel Does Phytel Mines Data This data will help your practice begin to meet

the challenge of achieving the HEDIS, IOM, AQA, NCQA standards.

Phytel interacts with your practice management and electronic health record.

Phytel can identify patients due for recommended care based on evidenced based protocols.

Patients are contacted via automated outreach.

What Phytel Does Phytel has scripted messages to contact

patients via telephone. The system is secure and HIPPA compliant. Phytel can track patient response and monitor

compliance. Phytel will generate reports to document quality

and P4P data as well. Phytel will generate reports to document

increased bookings and financial and clinical results.

Primary Care Protocol Set*Appointment Reminders/Missed Appointment F/U

Prevention/Screening:

Annual Preventive Medicine Visits

Breast Cancer

Cervical Cancer

Immunizations:

Influenza

Pneumonia

HPV

Mammography

Osteoporosis

Prostate Cancer

Welcome to Medicare Visits

Disease Management:

Congestive Heart Failure:

F/U Visit Frequency

ACE/ARB/Beta Blocker Therapy †

Coronary Artery Disease:

F/U Visit Frequency

Anti-platelet Therapy †

________________________________________

*Provided all data-points currently coded.

† PQRI CPT II Coding Required

‡ Non-PMS data point(s) required.

Diabetes:

F/U Visit Frequency

Hemoglobin A1c Frequency †

Hemoglobin A1c Level Control ‡

Hyperlipidemia:

F/U Visit Frequency

LDL-C Frequency †

LDL-C Level Control ‡

Hypertension:

F/U Visit Frequency

Systolic/Diastolic Frequency †

Systolic/Diastolic Level Control ‡

Asthma:

F/U Visit Frequency

Appropriate Pharmacologic Therapy †

Thyroid Disease

F/U Visit Frequency

COPD

F/U Visit Frequency

Practice Development Campaigns:

Back to School Physical Examinations

Travel Examinations

Childhood Immunizations

New Providers/Services

PATIENT REGISTRIES

MEASURING PATIENT-CENTEREDNESS

SUMMARY POINTS PCMH - revolutionary redesign of primary

healthcare delivery, repositioning the doctor-patient relationship at the epicenter of that system

PCMH transformation requires superior leadership, expert change management, enough time (years) and substantial financial support in order to realize its full potential. Payment reform must “co-evolve”.

Adequately funded and fully deployed, the PCMH

can become the key component that could then catalyze regional then national networking to form the framework for a revitalized healthcare system