Patient Centered Medical Home; The Army Medical Department Experience
-
date post
21-Oct-2014 -
Category
Education
-
view
8.922 -
download
5
description
Transcript of Patient Centered Medical Home; The Army Medical Department Experience
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Patient Centered Medical Home
The Army Medical Department Experience
29 April 2011
Gary A. Wheeler, MD, COLWestern Regional Medical Command CMIO
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
“The views expressed are those of the author and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.”
Slide 2 of
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
• Board Certified, Internist• Fellow, American College of Physicians• Education: BS, UC Berkeley; MD, USUHS• Residency: Walter Reed Army Medical Center• Member, Army Medical Department PCMH WG• Internal Medicine Consultant, OTSG• Past jobs:
– Department Chief, Madigan Army Medical Center– Deputy Commander for Clinical Services (CMO), Weed ACH– Chief, Clinical Informatics, MAMC– Chief, Internal Medicine Service, MAMC– Staff Internist, Walter Reed; Moncrief ACH, Ft Jackson, SC
Who Am I?
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
•Terminal Learning Objectives– Define Patient Centered Medical Home– Understand PCMH History– Identify principles of patient centered care– Review the current evidence for patient-centered
care– Review the 2008 and 2011 NCQA standards– Review PCMH implementation in the Army Medical
Department– Introduce the Comprehensive Care Plan
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
PATIENT CENTERED MEDICAL HOME
Definition
• Medical home, also known as Patient-Centered Medical Home (PCMH), is defined as "an approach to providing comprehensive care that facilitates partnerships between individual patients and their personal providers and when appropriate, the patient’s family”
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
History
• American Academy of Pediatrics introduced the term in 1967
• Model in caring for children with special needs
• Single source of patients’ medical information (medical record)
• Grew to include a partnership approach with families to provide primary health care
• Accessible• Family-centered• Coordinated• Comprehensive• Continuous• Compassionate• Culturally effective
• Within a decade it was AAP policy
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
History• Joint Statement of PCMH Principles – March 2007
• Four groups• American Academy of Family Physicians (AAFP)• American Academy of Pediatrics (AAP)• American College of Physicians (ACP)• American Osteopathic Association (AOA)
• Represent 333,000 physicians
• Provide the vast majority of primary care services to children, adolescents, and adult patients in the United States.
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
History - 2007 Joint Statement Principles
• Personal physician
• Physician directed medical practice
• Whole person orientation
• Care is coordinated and/or integrated across all elements of the complex health care system
• Quality and Safety
• Enhanced Access to Care
• Payment appropriately recognizes the added value
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Personal Physician
• Primary care physician
• Could be a specialist or subspecialist for patients requiring
ongoing care for certain conditions• Severe asthma
• Complex diabetes
• Complicated cardiovascular disease
• Rheumatologic disorders
• Malignancies
• HIV
• Primary care physicians are defined as physicians who are
trained to provide first-contact, continuous, and comprehensive care
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Primary Care Manager Directed Medical Practice
• PCM is team leader
• The personal physician•Leads a team of individuals at the practice level•Team collectively take responsibility for the ongoing care of patients
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Whole Person Orientation
• Respectful, patient centered
• Not disease centered
• Not provider centered
• Family and cultural sensitive
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Whole Person Orientation
• Personal physician•Provides for all the patient’s health care needs
or
•Takes responsibility for appropriately arranging care with other qualified professionals
Includes care for all stages of life•acute care
•chronic care
•preventive services
•end of life care
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Care is Coordinated and/or Integrated across all levels of care
•Subspecialty care•Hospitals•Home health agencies•Nursing homes•Patient’s community
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Care is Coordinated and/or Integrated across all levels of care
• Care is facilitated by• registries• information technology• health information exchange• other means
to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Care is Coordinated and Integrated across all levels of care
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Quality and Safety
• Evidenced-based, safe medical care
• Outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family
• Evidence-based medicine and clinical decision-support tools guide decision making
• Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Quality and Safety
• Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met
• Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication
• Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.
• Patients and families participate in quality improvement activities at the practice level.
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Enhanced Access
• Meet access standards from the patient perspective
• Enhanced Access to care is available through systems such as open scheduling, expanded hours and new options for communication
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Comparison of PPC-PCMH and PCMH 2011 PPC-PCMH (9 standards/30 elements)
1.Access and Communication– Processes – Results
2.Patient Tracking and Registry Function
3.Care Management– Continuity Between Settings
4.Self-Management Support
5.Electronic Prescribing
6.Test Tracking
7.Referral Tracking
8.Performance Reporting and Improvement– Measures of Performance– Patient Experience
9.Advance Electronic Communication
PCMH 2011 (6 standards/25 elements)
1. Access and Continuity – Access - Practice Organization– Continuity - Electronic Access– Medical Home Responsibilities
2. Identify/Manage Patient Populations
3. Plan / Manage Care– Care Management – Medication Management
4. Self-Management Support
5. Track and Coordinate Care– Test/Referral Tracking– Facilities– Community Resources / Referrals
6.Performance Measurement and Quality Improvement– Measures of Performance– Patient Experience– Quality Improvement
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
NCQA 2011 standards
Slide 20
PCMH 2011 Goals
Increase patient-centeredness
Align the requirements with processes that improve quality and eliminate waste
Increase the emphasis on patient feedback
Enhance the use of clinical performance measure results
Integrate behaviors affecting health, mental health and substance abuse
Enhance coordination of care
6 Standards• Enhance Access and Continuity
• Identify and Manage Patient Populations
• Plan and Manage Care
• Provide Self-Care Support and Community Resources
• Track and Coordinate Care
• Measure and Improve Performance
NCQA has refreshed their recognition standards effective February 1, 2011
Achieving NCQA standards will require the AMEDD to optimize all existing IT technologies by aligning them with defined PCMH care delivery processes.
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
PCMH 2011 Alignment with Measures of Meaningful Use• E-prescribing – medication list, allergies
• Patient tracking/registry – demographics, diagnoses, vital signs, smoking, population management, insurance
• Care management – reminders for follow-up care, decision support, RX reconciliation
• Electronic capability – e-health info. to patient, visit summary, e-access to health information, provider information exchange
• Performance reporting/improvement
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
OutcomesGeisinger Health System
• Implemented a Patient Centered Medical Home redesign in 11 of its primary care practices beginning in 2007.
• Focus on Medicare beneficiaries, primary care-based care coordination with team models featuring nurse care coordinators, EHR decision-support, and performance incentives.
• Two year follow-up results: • Better quality: Statistically significant improvements in quality of preventive (74.0% improvement), coronary artery disease (22.0%) and diabetes care (34.5%) for PCMH pilot practice sites. • Reduction in costs: statistically significant 14% reduction in total hospital admissions relative to controls, and a trend towards a 9% reduction in total medical costs at 24 months.
• $3.7 million net savings from the implementation of its PCMH model, for a return on investment of greater than 2 to 1
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
R. A. Paulus, K. Davis, and G. D. Steele, Continuous Innovation in Health Care: Implications of the Geisinger Experience, Health Affairs, Sept./Oct. 2008 27(5):1235?45
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Outcomes
Group Health
• Quality•Pilot clinic had an absolute increase of 4% more of its patients achieving target levels on HEDIS quality measures•Patients also reported significantly greater improvement on measures of patient experiences, such as care coordination and patient activation.
• Better work environment•Less staff burnout, with only 10% of pilot clinic staff reporting high emotional exhaustion at 12 months compared to 30% of staff at control clinics, despite being similar at baseline; •Major improvement in recruitment and retention of primary care physicians.
• 29% reduction in ER visits 11% reduction in admissions.
• Investment in primary care of $16 per patient per year was associated with a savings of $17 per patient per year
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
25
The Quadruple Aim
Readiness
Improving quality and health outcomes for a defined population. Advocating and incentivizing healthy behaviors.
Patient and family centered care that is seamless and integrated. Providing patients the care they need , exactly when and where they need it.
Managing the cost of providing care for the population. Eliminate waste and reduce unwarranted variation; reward outcomes, not outputs.
Enabling a medically ready force, a ready medical force, and resiliency of all MHS personnel.
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
26
Creating Alignment: Military Health System Quadruple Aim
• Readiness– Pre-, During, and Post-deployment– Family Health – Behavioral Health – Professional Competency/Currency
• Population Health– Healthy service members, families, and retirees– Quality health care outcomes
• A Positive Patient Experience– Patient and Family centered Care, Access, Satisfaction
• Cost– Responsibly Managed– Focused on value
Quadruple Aim as an Enduring Construct for Care
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Army Medical Home:Experience to Date
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
• 35 Hospitals (Parent Sites)• 114 Child Sites•PCMH early adopters
– 11 MTFs with 66 PCMH Teams – No NCQA recognized sites yet
PCMH in Army Inventory
10 of 11
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
OPORD 11-20 published Feb 2011
9 of 11
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Army PCMH Model
• PCMH ratios. – 2 exam rooms per PCM– 3.1 support staff
• direct staff who work for a single PCM• shared staff who work among several PCMs in the PCMH Team
– < two exam rooms per PCM, the enrollment cap will be reduced accordingly
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Army Medical Home Initiative
Community Based Medical Homes (CBMH)
Military Treatment Facility based Medical Homes
Army Medical Home
• OPORD 11-20 published Feb 2011• NCQA 2008 Self Assessments Feb-Mar 2011
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Army Medical Home Implementation TimelinePhase 1: Build the Team and Patient Centered Experience of Care
Duration: 6-12 months
• Team STEPPS• Staff Roles and
Responsibilities• Building the Patient
Partnership• Service and
Communication Standards
• Patient Centered Workflow
• The Huddle
Phase 2: Effectively Manage Demand
Duration: 6-12 months
• Empanelment• Patient Welcome
Process• Access Management• E-visits• Care Coordination• Population Health
Phase 3: Implement Advanced Medical Home Practices
Duration: 6-12 months
• Comprehensive Care Plan
• Advanced Access• Team Care • Patient Activation:
Coaching Wellness and Patient Self Management
Caveat: Implementation progress depends on Payment Reform, Workforce Transformation, Performance Measure Alignment, Facility Optimization, and Marketing/STRATCOM Effectiveness
STAFFING ADJUSTMENTS
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Phase 1: Build the Team and Patient Centered
Experience of CareDuration: 6-12 Months
Phase 2: Manage Demand
Duration: 6-12 Months
Phase 3: Implement Advanced
Medical Home PracticesDuration: 6-12 Months
Team STEPPSStaff Roles and ResponsibilitiesBuilding the Patient Partnership
Service and Communication StandardsPatient Centered Workflow
The HuddleEmpanelment
Access ManagementE-visits
Care CoordinationPopulation HealthComprehensive Care Plan
Advanced AccessTeam Care
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Army Medical Home Transformation Plan
Three phases:
1. MEDCOM trains Regional transformation teams in San Antonio (Apr 26-28 2011)
2. Regional teams assess MTF readiness and develop MTF-specific transformation plans. (May-Jun 2011)
3. Regions oversee and support MTF transformation plans. (Begin NLT Sep 11)
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Phase 1 Concept of Operation • 1. Command guidance
– Training topics: TSG on PCMH and standardization, Critical Performance Measures, PBAM, Funding, Work Force Transformation
• 2. Franchise Model of Operations (based on CBMH model)– Integrates Team STEPPS and Customer Service training already slated
for Army-wide roll-out.
• 3. Transformation support– Informatics, Logistics, Facilities, Marketing and Strategic
Communications
• 4. Expanding the Team and Scope of Practice– Integrated Behavioral Health, Post-deployment Health, Pharmacy,
Health Promotion and Wellness, Subspecialty Care, Pain Management
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Key Points• Community-based and MTF-based PCMH are integrated
– Key leaders for vision, strategy, and implementation plan support both versions of Army Medical Home
– CBMH initiative is “clean slate, start from scratch” version– MTF MH initiative is “transformative” version
• EHR Workflow reengineering is critical piece for both initiatives• Secure Messaging will begin deployment this year
– CBMH’s are first priority– Team-based workflow and processes must be in place first
• Ongoing Tri-Service integration efforts – will be essential component of our success
– Common experience of care– Resourcing– Metrics– Payment reform
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
COMMUNITY BASED MEDICAL HOMES
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
The Army is Investing inHealthcare Capacity
Improve the readiness of our Army & our Army Family
Improve access to and continuity of care
Facilitate Patient-Centered Medical Home
Reduce emergency room episodes
Improve patient and provider satisfaction
Implement Best Practices & standardize services
Increase space available in MTFs for expanded active duty and specialty services
Improve physical and psychological health promotion and prevention
17 Clinics in 11 Markets -- Beginning in Fall of 2010
FT Bragg, NC – 3 clinicsFT Campbell, KY – 2 clinicsFT Hood, TX – 3 clinicsFT Jackson, SC – 1 clinicFT L. Wood, MO – 1 clinicFT Lewis, WA – 2 clinicsFT Sam Houston, TX – 1 clinicFT Shafter, HI – 1 clinic
FT Sill, OK – 1 clinicFT Stewart, GA – 1 clinicFt Benning – 1 clinic
Army Community Based Medical Homes
8 of 11
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
The Screaming Eagle Medical Home Experience
• 29 Nov- Staff assembled for training, TSG ribbon cutting• 29 Dec- Open for patient care• 12,585 Square feet of leased space on Clarksville Gateway
Hospital campus• Pharmacy, Moderate Complexity Lab, Tx Room, Vax onsite• Radiology from Blanchfield or Gateway• 5/6 PCMs,1 float and Psych NP on-hand
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Typical Appointment
• Greeted by Patient Care Coordinator• LPN takes to room, presents orientation packet, acquires vital signs,
med reconciliation, allergies, PMH, SHx, acquires HPI, conducts ROS, identifies age appropriate preventive medical and wellness requirements, and documents all.
• Conveys pertinent data to Provider• Provider engages patient, expounds on history, conducts PE while nurse
documents findings• Assessment and Plan formulated, orders input. Care plan completed• Physician exits; nurse educates patient as needed• Warm handoff to lab, pharmacy, Care Coordinator as needed
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
MILITARY TREATMENT FACILITY ARMY MEDICAL HOMES
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Q9 Q10 Q11 Q12 Q13 Q14 Q21
.00
.10
.20
.30
.40
.50
.60
.70
.80
.90
1.00
Q9 – OVERALL PHONE SERVICE
Q10 – CONSIDERATE SCHEDULE
Q11 – TIME BETWEEN SCHEDULE & VISIT
Q12 – WAIT TIME
Q13 – STAFF COURTESY / HELPFULLNESS
Q14 – COORDINATION OF VISIT
Q21 – OVERALL VISIT SATISFACTION
OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
0
10
20
30
40
50
60
70
80
90
34 36 38 40 39 41 41 41 41 39 39 41
6671 69
7774 76
7277 75
7268
74
OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
50
60
70
80
90
100
77 78 7982 81 82 82 82 82 81 81 8283
86 8588 88 88 88
90 90 90
84
90
60%
90%85.5%
PRIMARY CARE MANAGER (PCM) CONTINUITY PRIMARY CARE MANAGER TEAM CONTINUITY
HEDISARMY PROVIDER LEVEL SATISFACTION SURVEY (APLSS) 52 WEEK AVG.
DUNHAM CLINIC % TARGET %MEDCOM %
85%
% Mam-mogram
% Asthma on LTC Meds
% Diabetes w A1C
% Diabetes w A1C<9
% Diabetes w LDL <100
% Cervical Cancer Screen
% Colorectal Cancer Screen
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%DUNHAM % MEDCOM % 50th Percentile 90th Percentile
FY 2010 ATC Metrics: Dunham Clinic
Q11 – TIME BETWEEN SCHEDULE & VISIT
Q12 – WAIT TIME
Internal Medicine ClinicMadigan Healthcare System
• Approximately 15,000 patients• 22 internists / nurse practitioners• IM residency continuity clinic• Annual well-come visits Nov 2009
• Pre-visit HEDIS review, lab / rad• 30 minute LPN screen pre-visit• De novo or copy forward PMHx, PSHx, SocHx, FamHx, Allergies, Med Rec
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Overa
ll Sat
isfac
tion
Staff
Courte
sy/H
elpf
ulne
ss
Overa
ll Pho
ne S
ervic
e80%
82%
84%
86%
88%
90%
92%
94%
PCMH = Customer Service
Internal Medicine Clinic PatientsMEDCOM Benchmark
Source: APLSS
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
FY2008
FY2009
FY2010
MEDCO
M T
arge
t02468
1012141618
PCMH = Trying Harder
Internal Medicine Clinic RVU's per FTE per DayLinear (Internal Medicine Clinic RVU's per FTE per Day)MEDCOM Target
Sources: a) RVU’s per FTE per Day – Decision Support Centerb) MEDCOM Target 16.04 RVU’s/FTE/Day – Decision Support Center
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
FY2007
FY2008
FY2009
FY2010
Nation
al Ave
rage
0
0.2
0.4
0.6
0.8
1
1.2
1.4
PCMH = Working Smarter
Internal Medicine Clinic RVU's per EncounterLinear (Internal Medicine Clinic RVU's per Encounter)National Average for Internal Medicine
Sources: a) RVU’s per encounter – Decision Support Centerb) Workload RVU’s per E/M Code – Decision Support Centerc) National Average – ACP Practice Management Center
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
2007 2008 2009 2010 HEDIS 90th
0%
10%
20%
30%
40%
50%
60%
70%
80%
PCMH = Quality Care
Internal Medicine Clinic Colorectal Cancer ScreeningLinear (Internal Medicine Clinic Colorectal Cancer Screening)HEDIS 90th Percentile
Source: June 2010 PIFA Report
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Source: June 2010 PIFA Report
Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Oct-10 Nov-10 Dec-10 Jan-1150%
55%
60%
65%
70%
75%
71.6% 71.9%71.0%
71.7% 72.1% 72.3%72.9%
72.0% 71.9%72.4% 72.7% 72.9%
68.4%
69.6%
55.8%
59.4%
COLORECTAL CA SCREEN
IMC with Colorectal Screening 90th Percentile Colo-Rectal 50th Percentile Colo-Rectal
% W
ITH
Data Source: MHSPHP Action List
Notes: 2010 benchmarks in effect starting with Apr10 data. No Data from MHS portal for Jul10-Sep10.
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Source: June 2010 PIFA Report
Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Oct-10 Nov-10 Dec-10 Jan-1160%
65%
70%
75%
80%
85%
73.9% 73.8%74.3% 74.6%
75.8% 76.0% 76.3% 76.7%75.7% 75.4% 75.3% 75.6%
78.2%78.7%
68.5%
70.0%
BREAST CA SCREENING
IMC with Mammo 90th Percentile MAMMO 50th Percentile Mammo
% W
ITH
Data Source: MHSPHP Action List
Notes: 2010 benchmarks in effect starting with Apr10 data. No Data from MHS portal for Jul10-Sep10.
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Source: June 2010 PIFA Report
Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Oct-10 Nov-10 Dec-10 Jan-1165%
70%
75%
80%
85%
77.3% 77.7% 77.6%78.2%
79.6% 79.9% 79.9% 80.2% 80.4% 80.6% 80.7% 80.5%
87.8%86.7%
82.0%81.4%
CERVICAL CA SCREENING
IMC with Pap 90th Percentile Cervical Exam 50th Percentile Cervical Exam
% W
ITH
Data Source: MHSPHP Action List
Notes: 2010 benchmarks in effect starting with Apr10 data. No Data from MHS portal for Jul10-Sep10.
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Source: June 2010 PIFA Report
Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Oct-10 Nov-10 Dec-10 Jan-1175%
80%
85%
90%
95%
90.8% 91.1% 91.1% 91.1% 91.2%92.2% 92.2% 92.2%
93.2%92.7% 92.4% 92.7%
82.0%
PNEUMOCOCCAL IMMUNIZATION
IMC with Pneumococcal Pneumococcal Target
% W
ITH
Data Source: current enrollment file for patients 65+ with most current data.
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Source: June 2010 PIFA Report
Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Oct-10 Nov-10 Dec-10 Jan-1135%
40%
45%
50%
55%
60%
65%
57.8%59.1%
58.3% 58.2% 58.6% 58.2% 57.9% 57.9%
59.6%60.6%
58.8%58.1%
52.3%
53.9%
43.9%
45.3%
DIABETIC LDL<100
IMC DM with LDL<100 90th Percentile DM LDL<100 50th Percentile DM LDL<100
% W
ITH
Data Source: MHSPHP Action List
Notes: 2010 benchmarks in effect starting with Apr10 data. No Data from MHS portal for Jul10-Sep10.
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Source: June 2010 PIFA Report
Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Oct-10 Nov-10 Dec-10 Jan-1165%
70%
75%
80%
85%
90%
79.4%80.4% 80.1%
79.5% 79.9% 79.8%80.5% 80.8%
81.9%
82.2%
81.0%
79.6%
81.0%81.3%
71.1%
72.2%
DIABETIC HbA1c <=9
IMC DM with HbA1c<=9.0 90th Percentile DM HbA1c<=9 50th Percentile DM HbA1c<=9
% W
ITH
Data Source: MHSPHP Action List
Notes: 2010 benchmarks in effect starting with Apr10 data. No Data from MHS portal for Jul10-Sep10.
Data Source: MHSPHP Action List
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Army Medical Home:Comprehensive Care Plan
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Un(der)managed
Care
Specialty Care
Emergency Care
Inpatient Care
Primary Care
CPGsRGsConsultsRegistries
DischargeSummaries
Essentris ED note
Patient Care Landscape - Current
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
PATIENT CENTERED MEDICAL HOME
History - 2007 Joint Statement Principles
• Personal physician
• Physician directed medical practice
• Whole person orientation
• Care is coordinated and/or integrated across all elements of the complex health care system
• Quality and Safety
• Enhanced Access to Care
• Payment appropriately recognizes the added value
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Communication of care
One of the best benefits of implementation of the Patient Centered Medical Home is the establishment of standard work. Everyone has an expected role and a way to document. Before the PCMH, reviewing the medical record was like dumpster diving for data
•Group Health Provider
PATIENT CENTERED MEDICAL HOME
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
How Do We Integrate Care?
60
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Integrating Care Delivery Pathways:The Comprehensive Care Plan Concept
Slide 61
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Primary Caregiver Serves as a Portal Between Specialist and the CCP
Slide 62
PCMH
CCP
Outcomes (Quadruple Aim)
• Experience of Care
• Population Health
• Readiness
• Per Capita Cost
Patient
Value Added CCP Lifecycle Activities
The Patient Centered Medical Home (PCMH) Primary Care Team manages the CCP lifecycle with co-management roles defined for the Accountable Care Organization (ACO) and the patient.
ACO
Specialist
Specialist
Specialist
All CCP activities are recognized allowing better attribution of value to MHS strategic outcome measures.
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Comprehensive Care Plan (CCP) Overview
The Comprehensive Care Plan will be based on a database of organized and searchableinformation and will serve as the primary portal for each patient touch point.
Electronic Representation
Comprehensive Care Plan (CCP)
• Individualized: Contains only the information relevant to that patient
• Automated: Makes proactive requests for care activities
• Integrated: Organizes information logically from all data sources
Unhealthy behaviors/High disease burden
High utilization of resourcesLower PCMH empanelment
capability
Patient Today
Healthy behaviors/Lower disease burden
Less utilization of resourcesHigher PCMH empanelment
capability
Patient Ideal
Comprehensive, Coordinated Care
Delivery
Patient
7 of 11
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Documentation Allows Provider Recognition
One of the key value propositions from the implementation of PCMH is increased patient-provider interaction and review. Increased documentation allows provider recognition.
MultipleInteractions
Face to Face VisitGroup Visits
RN VisitCase Management
Telephone
EmailWeb Visit
VTCResult ReviewSpecialty Input
Documentation Result
• Increased awareness of providers implementing the principles of PCMH within their respective
teams.• Recognition in correlation with the
value proposition of a PCMH
CCP Documentation
PCM Team
Specialist Specialist
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Transforming into a PCMH:Capabilities Provided by the CCP
Slide 65
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
All CCP Elements copy forward from AIM to AIM within the Triservice Workflow AIM Group
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Standard CCP
• 7 Condition Blocks (each ties to a CPG)1. Metabolic Syndrome (DM, HTN, HLD, Obesity)
2. Asthma/COPD
3. Low Back Pain
4. CV Disease
5. Depression/PTSD/SPMI
6. Pain Management
7. Substance Abuse
68
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
CCP – 7 Core Items1. Diagnosis
2. Goal of Therapy: (Generally pre-populated – example “A1C <7, BP <130/80, LDL<100, BMI <25)
3. Actionable data: (Generally pre-populated with name of data – example A1C: 8.2 on 12/16/10)
4. Co-managing Team/Consultants: (“Which cooks are in the kitchen?” - nurse/tech will ask pt the 1st time this is documented, any additions can be added by ordering provider)
5. Barriers to achieving goal: Provider-driven entry (requires judgment)
6. Timeframe for f/u: Provider-driven entry
7. Patient’s goal for next appt: Provider-driven entry, negotiated between provider and pt at today’s visit (example: cut smoking rate in ½, exercise additional 1 hr/week, lose 2 lbs, take meds as prescribed)
Ideally, provider only has to enter these 3 fields. Additional data can be added at provider discretion and copied forward. The above 7 items are the minimum standard for CCP.
69
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
New Patient To Your Clinic
• 36 year Old female• How do you learn of this patient?
• How should you learn of this patient?• In a PCMH Clinic what should you do when you learn of your
new patient?
70
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Initial Intake
• Pro-active data gathering
71
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Chart ReviewConducted Prior to Visit By Nurse
Records review• Seasonal allergies• Hyperlipidemia• BMI 30• Generalized anxiety• Family Planning OCP’s• Smoker
72
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Now What?
Provider Concerns• Smoking / OCP use• Quit smoking• Lipid management• Weight loss to BMI 25
73
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Intake Nurse Visit
Patient Concerns• Husband deployed• Two children under age 8 (one with ADD)• Full-time job• Worries all the time
74
Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]
Put It All Together(shared decision making)
Individualized Comprehensive Care Plan (CCP)• Pt satisfied with SAR tx if she can stop sneezing and itchy eye
and not feel tired from any medication (has a job and kids)• Pt has been thinking about quitting smoking but too much
stress right now (contemplative stage with barriers)• Willing to stop her OCP to reduce stroke risk since husband is
deployed anyway• Willing to see someone about her anxiety but doesn’t want to
start any medication that will “knock her out or get her addicted”• Wants help with her “hyper child” causing her a lot of stress and
she gets very frustrated with him.• She has tried to lose weight many times and will be stressful
right now to lose all the weight needed to get to BMI of 25 but willing to work with team to achieve 10% weight loss to reduce risk of medical complications 75