Introduction to the Patient-Centered Medical Home - Saipan … Medical … · PPT file · Web...

Introduction to the Patient-Centered Medical

HomeVincent Castro, Executive Director

Katherine Elstun, MD, Medical Director

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.

Kagman Community Health Center

Source: www.ahrq.gov

Defining the Medical HomeThe medical home is an approach to primary care

Committed to Quality and Safety

Maximizes use of health IT, decision support and other

tools

AccessibleCare is delivered with short waiting times, 24/7 access

and extended in-person hours

CoordinatedCare is organized across

the ‘medical neighborhood’

ComprehensiveWhole-person care provided by a team

Person-Centered

Supports patients and families in managing

decisions and care plans

Source: UCSF Center for Excellence in Primary Care.

http://cepc.ucsf.edu/

http://cepc.ucsf.edu/

Public Health

Employers

Schools

Faith-Based Organizations

Community Centers

HomeHealth

Hospital

Pharmacy

Diagnostics

Specialty & Subspecialty

Skilled Nursing Facility

MentalHealth

Patient-Centered Medical Home

Community Organizations

Health IT

Health IT

$

$

PCMH at of “Medical Neighborhood”

Health Care Delivery Organizations

Utilize care teams•Care coordinators•Health coaches•Peer support•Care managers•Community

supports and social workers•Pharmacists•Patients, families &

Caregivers

• Consider experience of care from the patient’s perspective – and include 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

Include patients, families & caregivers as part of care

team

KCHC Patient Engagement Contract

Dear Patient, Welcome and thank you for choosing KCHC. We are committed to providing you with the best medical care based on your health needs. Our hope is that we can form a partnership to keep your whole self as healthy as possible, no matter what your current state of health. Your commitment to our patient-centered medical home practice will provide you with an expanded type of care. We will work with both you and other health care providers as a team to take care of you. You will also have better access to us through phone and group visits. As your primary care team, we will: • Learn about you, your family, life situation, and health goals and preferences. We will remember these and your health

history every time you seek care and suggest treatments that make sense for you. • Take care of any short-term illness, long-term chronic disease, and your all-around well-being. • Keep you up-to-date on all your vaccines and preventive screenings. • Connect you with other members of your care team (specialists, health coaches, etc.) and coordinate your care with

them as your health needs change. • Be available to you after hours for your urgent needs. • Notify you of test results in a timely manner. • Communicate clearly with you so you understand your condition(s) and all your options. • Listen to your questions and feelings. We will respond promptly to you – and your calls – in a way you understand. • Help you make the best decisions for your care. • Give you information about classes, support groups, or other services that can help you learn more about your

condition and stay healthy.

We trust you, as our patient, to: • Know that you are a full partner with us in your care. • Come to each visit with any updates on medications, dietary supplements, or remedies you’re using, and questions you may

have. • Let us know when you see other health care providers so we can help coordinate the best care for you. • Keep scheduled appointments or call to reschedule or cancel as early as possible. • Understand your health condition: ask questions about your care and tell us when you don’t understand something. • Learn about your condition(s) and what you can do to stay as healthy as possible. • Follow the plan that we have agreed is best for your health. • Take medications as prescribed. • Call if you do not receive your test results within two weeks. • Contact us after hours only if your issue cannot wait until the next work day. • If possible, contact us before going to the emergency room so someone who knows your medical history can care for you. • Agree that all health care providers in my care team will receive all information related to your health care. • Pay your share of any fees. • Give us feedback to help us improve our care for you. • I look forward to working with you as your primary care provider in your patient-centered medical home. Provider Signature Printed Provider Name Date__________________________ __________________________________ __________________ Patient Signature Printed Patient Name Date__________________________ __________________________________ __________________

KCHC Patient Engagement Contract

Kagman Community Health Center - PCMH

Benefits of the PCMH• Cost Savings• Fewer ER visits/Hospitalizations• Improved Health• Improved patient and staff

satisfaction

Program Outcomes Date Published

Report Type

Anthem BC ACO $4.7 Million (in 6 months) June 2014 Industry ReportBCBS Michigan PCMH Program

$26.37 PMPM (2009-2010)$155 million (2008-2011)

July 2013 Peer-Reviewed

Oregon Coordinated Care Organizations (Medicaid)

18-19% reduction in ER visit spending Nov 2013, June 2014

Industry Report

Vermont Blueprint for Health (Multi-Payer)

Reduced expenditures in 2012 by:• $386 PMPY commercial (ages 1-17)• $586 PMPY commercial (ages 18-64)• $200 PMPY Medicaid (ages 1-17)• $447 PMPY Medicaid (ages 18-64)

Jan 2014 Industry Report

CareFirst BCBS PCMH Program (DC, MD, VA)

$267 million avoided costs (2011-2013) July 2014 Industry Report

Monarch Healthcare CMS Pioneer ACO (CA)

5.4% reduction in medical costs in 2012 (Medicare)


Horizon BCBS of New Jersey PCMH Program

$4.5 million savings (ER visits and hospitalizations)4% lower total cost of care (all patients)4% lower cost of care (diabetes patients)

July 2014 Industry Report

Independence BC PCMH Program (PA)

Total cost savings for high risk groups: 7.9% and 11.2% (2010, 2009)

March 2014 Peer-Reviewed

Reported Outcomes: Cost Savings

Reported Outcomes: Fewer ER/Hospital Visits

Source: Primary Care Innovations and PCMH Map by Outcomes. PCPCC. Accessed September 2014. http://www.pcpcc.org/initiatives/evidence


Report Type

Aetna PCMH - New York

35% fewer hospital admissions (WESTMED Medical Group, year 1)

June 2014 Industry Report

CareFirst BCBS PCMH Program (DC, MD, VA)

6.4% fewer hospital admissions8.1% fewer readmissions (all-cause)11.1% fewer hospital days


BCBS Michigan PCMH Program

27.5% lower hospital stays11.8% lower PC-sensitive ER visits (adults)9.9% lower ER visits (adults)14.9% lower ER visits (pediatrics)


Missouri Health Homes (Medicaid)

6-8% decrease in ER use10-13% decrease in hospitalizations

Nov 2013 Industry Report

New York Health Homes (Medicaid)

23% decrease in hospital admissions and ER visits

March 2014

Industry Report

Rhode Island Chronic Care Sustainability Initiative (Multi-Payer)

11.6% fewer ambulatory-sensitive ER visits (2013)Fewer inpatient hospitalizations among more experienced participants (2014)

Nov 2013,May 2014

Peer-Reviewed,Industry Report

Reported Outcomes: Improved Health



Report Type

Anthem BC ACO (CA) Increase in meeting quality measures:• 7.5% LDL (diabetes)• 3.8% in cholesterol management for heart

disease patients


CareFirst PCMH Program (DC, MD, VA)

• 3.7% higher quality scores for panels receiving incentives• 9.3% higher quality scores for PCMH panels

(2011-2012)


Horizon BCBS NJ PCMH Program

• 14% higher rate in improved diabetes control• 12% higher rate in cholesterol management


South Central Pennsylvania Alliance

Improved blood pressure control from 67% in 2010 to 79% in 2013 (East Berlin Family Medicine practice)


Fresno PCMH Initiative (CA-AFP)

50% increase in diabetes patients with controlled blood sugar after 1-yr pilot

Feb 2014 Industry Report

Primary Care Information Project (NY Medicaid)

Outperformed non-PCMH practices on BP control in hypertension/ diabetes patients, and smoking cessation intervention measures

June 2014 Peer-Reviewed

Reported Outcomes: Improved Patient/Clinician Satisfaction


Program Outcomes DatePublished

Report Type

Fresno PCMH Initiative (CA-AFP)

Overall improvement in patient satisfaction

Feb 2014 Industry Report

MGM Resorts Direct Care Health Plan

88% satisfaction rating among members (2013)


Rhode Island Chronic Care Sustainability Initiative (Multi-Payer)

Practices increased their positive patient experience ratings for:• access to care• communication with care team• office staff responsiveness• shared decision-making• self-management support

May 2014 Industry Report

VA Patient-Aligned Care Team (National)

• Lower staff burnout in PCMH practices (2.29 vs. 2.80, p=.02)• Higher patient satisfaction scores in

PCMH practices (9.33 vs. 7.53, p<.001)

June 2014 Peer-Reviewed

Thank You

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.


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