Patient Centered Medical Home_Waldren

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    Patient Centered

    Medical Home

    New Model of Care

    Steven E. Waldren, M.D.

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    Agenda

    History of Patient Centered MedicalHome (PCMH)

    Current models

    Current evidence

    Challenges in US

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    PCMH History

    Concept started in 1960s bypediatricians (American Academy ofPediatrics) for special needs children

    Future of Family Medicine Project

    1999 - http://www.futurefamilymed.org

    Multiple Names

    New Model

    TransforMED Model Medical Home Model

    Patient Centered Medical Home

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    http://www.futurefamilymed.org/http://www.futurefamilymed.org/http://www.futurefamilymed.org/

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    Adoption by Industry

    Patient Centered Primary CareCollaborative (www.pcpcc.net)

    Over 700 organizations promotingPCMH

    Purchasers

    Employers

    Health Plans

    Physicians Patients

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    http://www.pcpcc.net/http://www.pcpcc.net/

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    PCMH Concept Joint Principles

    AAFP, AAP, ACP, and AOA http://www.pcpcc.net/content/joint-principles-patient-centered-

    medical-home

    Personal physician

    Physician directed medical practice Whole person orientation

    Care is coordinated and integrated

    Quality and safety are hallmarks

    Practice advocates for patient

    Evidence Based Medicine

    Health IT

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    http://www.pcpcc.net/content/joint-principles-patient-centered-medical-homehttp://www.pcpcc.net/content/joint-principles-patient-centered-medical-homehttp://www.pcpcc.net/content/joint-principles-patient-centered-medical-homehttp://www.pcpcc.net/content/joint-principles-patient-centered-medical-home

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    PCMH Model: AAFP View

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    http://www.aafp.org/pcmh

    http://www.transformed.com

    http://www.transformed.com/http://www.transformed.com/http://www.aafp.org/pcmhhttp://www.aafp.org/pcmh

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    Access to Care & Information

    Health care for all Same-day appointments

    After-hours access coverage

    Accessible patient information Online patient services

    Electronic visits

    Group visits

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    Practice-Based Services

    Comprehensive care for both acuteand chronic conditions

    Prevention screening & services

    Surgical procedures

    Ancillary therapeutic and supportservices

    Ancillary diagnostic services

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    Care Management

    Population management Wellness promotion

    Disease prevention

    Chronic disease management Patient engagement and education

    Leverages automated technologies

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    Care Coordination

    Community-based resources Collaborative relationships

    Emergency room

    Hospital care

    Behavioral health

    Maternity care

    Specialist care

    Pharmacy Case management

    Care transition

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    Quality and Safety

    Evidence based best practices Medication management

    Patient satisfaction feedback

    Clinical outcomes analysis Quality improvement

    Risk management

    Regulatory compliance

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    Practice Management

    Disciplined financial management Cost-benefit decision making

    Revenue enhancement

    Optimized coding and billing Personnel management

    Facilities management

    Optimized office design/redesign Change management

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    Health Information Technology

    Electronic medical record Electronic orders and reporting

    Electronic prescribing

    Evidenced based decision support Population management registry

    Practice Web site

    Patient portal

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    Source: Health Affairs April 2010

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    Many On-going PCMH Pilots

    http://www.pcpcc.net/pcpcc-pilot-projects

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    Summary of Evidence

    http://www.pcpcc.net/content/pcmh-outcome-evidence-quality

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    http://www.pcpcc.net/content/pcmh-outcome-evidence-qualityhttp://www.pcpcc.net/content/pcmh-outcome-evidence-quality

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    Evidence

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    Challenges

    No single PCMH Requires transformation of the

    practice

    Current Health IT is not designed tosupport PCMH

    Variability and diversity of practices

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    Summary

    Achieving the PCMH will not beeasy, but can be done

    Evidence predicts increased qualityand lower costs

    Work is needed to identify thehighest value components of thePCMH

    Current policy changes andindustry support is improving abilityto achieve PCMH model

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