El Rio Community Health CenterKathy Byrne & Mary Spoerl

“Begin with the End in Mind”Steven Covey – The 7 Habits of Highly Effective People

Achieving Patient-Centered Medical Home Recognition

Presentation Objectives

Overview of PCMH / NCQA Survey

El Rio’s Experience Current Status

Timelines

Implementation Process Key Steps and Lessons Learned

PCMH Initiatives

Barriers / Challenges

Costs / Benefits

Data Driven

A Medical Home

Patient Engagement and Self Management

Provider Leadership

Care Coordination Continuity

TeamsCare Teams & Change TeamsAccess

Patient-Centered Medical Home Characteristics1. Personal Physician

2. Physician directed medical practice

3. Whole Person Orientationa. Individual Care Plan

i. Acuteii. Preventiveiii. Chronic Illnessiv. End of Life

b. Self-Management Support

4. Care is Coordinateda. Specialists trackingb. Linkage to community servicesc. Care transitions

5. Quality and Safetya. Patient registriesb. E-Prescribingc. Electronic Health Recordd. Test Trackinge. Performance Reporting

6. Enhanced Access to Carea. Patient Portal

7. Payment structure that recognizes services and value

Team-Based Care:NP/PARN/LPNMedical AssistantsOffice StaffCare CoordinatorsNutritionists/EducatorsPharmacistsBehavioral HealthCase ManagersCommunity ResourcesOthersPatientFamily/Support System

PCMH 2011 Content and Scoring

Must Pass Elements – Designated elements that a practice must pass at a score of ≥ 50% to achieve NCQA recognition.

Critical Factor – A factor identified as central to the concept being assessed within particular elements and is required for practices to receive more than minimal or, for some factors, any points. Critical factors are identified in the scoring section of the element.

Meaningful Use Requirements – The CMS implementation of the American Recovery and Reinvestment Act (ARRA) of 2009 (Recovery Act) provides incentive payments to eligible professionals for adopting and demonstrating meaningful use of certified EHR technology. Criteria for meaningful use are electronically capturing health information for care coordination and reporting clinical quality measures and public health information.Stage 1 has 25 requirements, including 15 Core Requirements that must all be met and 10 Menu Requirements, 5 of which must be met.

A Simple Comparison

Must Pass Elements require a ≥ 50% Performance

TimelinesReceived Submitted ResultsAdministration/Board – November 2009Project Started --------- January 2010

2008 SurveyOrganizational/Group Application Nov 23, 2010 Dec 1, 2010El Pueblo Peds/Fam Medicine Feb 7, 2011 April 1, 2011Pascua Peds/Fam Medicine Feb 8, 2011 April 1, 2011Northwest Peds/Fam Med/Int Med March 8, 2011 April 1, 2011Southeast Peds/Fam Medicine March 9, 2011 April 1, 2011Congress Fam Med/Int Medicine March 17, 2011 June 6, 2011Southwest Peds/Int Medicine April 12, 2011 June 6, 2011Congress Pediatrics June 3, 2011 July 13, 2011

2011 SurveyProject Started-----------November 2011Special Immunology PendingBroadway PendingCMS Grant Pending

Begin the Process – Key Steps1. Project Leader2. Education / Awareness / Messaging3. Steering / Advisory Committee4. Baseline Assessment / Timelines

Begin the Process – Key Steps1. Project Leader2. Education / Awareness / Messaging3. Steering / Advisory Committee4. Baseline Assessment / Timelines

PCMH/MU Work Approach ExamplePCMH

Element 5C:Coordinates with facilities and

care transitions

MUGoal C:

Improve Care Coordination

Measures – Provides electronic care summary to another care facility (for at least 50% of transitions of care and referrals)

WorkplanAssessing EMR capabilities Producing reports Process Redesign & Workflow Writing policies and procedures System Configuration & Upgrades Producing Screen Shots & Documentation Addressing Overlaps between PCMH & MU

Begin the Process – Key Steps1. Project Leader2. Education / Awareness / Messaging3. Steering / Advisory Committee4. Baseline Assessment / Timelines5. Information Technology / Meaningful Use

Assessment and Timelines6. Chart Reviews / Continuous Data

Improvement

Chart Review 48 Charts – 12 for each significant condition

3C – Care Management: (must pass)1. Conducts pre-visit preparations2. Collaborates with patient/family to develop individual care plan, including treatment goals reviewed and

updated at each relevant visit3. Gives the patient/family a written plan of care4. Assesses and addresses barriers when the patient has not met treatment goals5. Gives the patient/family a clinical summary at each relevant visit6. Identifies patients/families who might benefit from additional care management support7. Follows up with patients/families who have not kept important appointments

3D – Medication Management1. Reviews and reconciles medications with patients/families (critical factor)2. Provides information about new prescriptions to patients/families3. Assesses patient/family understanding of medications for patients with data of assessment4. Assesses patient responses to medications and barriers to adherence for patients with date of assessment5. Documents over-the-counter medications, herbal therapies and supplements for patients/families with the

date of updates

4A – Support Self-Care Process: (must pass)1. Provides educational resources or refers patient/families to educational resources to assist in self-

management2. Uses an EHR to identify patient-specific education resources and provide them to patients, if appropriate3. Develops and documents self-management plans and goals in collaboration with patients/families (critical

factor)4. Documents self-management abilities for patients/families5. Provides self-management tools to record self-care results for patients/families6. Counsels patients’ families to adopt health behaviors

Must Pass – must earn a score of 50% or higherCritical Factors – scores for an element will not exceed 0% if the identified critical factors are not met

Initiatives Related to PCMHPre-PCMH Start-up:

• EMR• Patient-Driven Scheduling• Patient Satisfaction Surveys• Cultural Competency Committee• Job Functions/Job Descriptions

Post PCMH Start-up:• i2i/proactive outreach for preventive services• Proactive Referral Tracking• Patient Portal• RN Care Coordinators• Hospital Discharge Program• Nursing Committee – Patient Education/Counseling Protocols

and Staff CDI• Performance Improvement Teams

What are the Challenges/Barriers to Implementation? Information Technology Quality Improvement Care Management / Outreach

(utilizing non-physician staff) Wellness / Outreach Culture Changes Costs/Benefits Physician Incentives Practice Reimbursement

References & Researchhttp://www.jointcommission.org/primary_care_medical_home_

prepublication_standards/

Contact

Kathy Byrne, Executive Director(520) 670-3706

kathyb@elrio.org

Mary Spoerl, Director of Innovation(520) 670-3766

maryas@elrio.org