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The Patient-Centered Medical Home: Preparing for the PCMH Transformation

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Mark Janiszewski, SVP Product Management

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Cindy Dunn, RN, FACMPE, has 35-plus years of healthcare experience holding leadership positions in both small and large healthcare organizations, including primary care, multi-specialty and large integrated systems. Her healthcare background encompasses a broad range of services, including medical practice management, operational improvement, technology engagement, organizational development and revenue cycle analysis. Drawing upon diverse operational, clinical, and financial experience, Cindy provides a unique insight into the needs and challenges facing physicians and integrated delivery systems.

She is the Associate Director of Client Services for a specialty healthcare company.

Cindy is an independent consultant for the Medical Group Management Association (MGMA) Health Care Consulting Group and a Fellow in the American College of Medical Practice Executives. She participated as a member of the HIMSS Davies Ambulatory Committee, the eHealth Initiative, faculty for Health IT Certification, and as a Provider Juror and Tester for CCHIT (Certification Commission for Health Information Technology). Her hands-on management style results in interactions that are positive, lively and educational.

About the Speaker

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• Examine history of Patient-Centered Medical Home (PCMH) and the need for change

• Identify seven joint principles of PCMH and describe the model of care

• Review recognition programs

• Discuss proven results and benefits

• Share challenges and tips for success

Objectives

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Which of the following best describes your practice’s PCMH status?

Our practice is currently PCMH-certified

We plan to be PCMH-certified within 6 months

We plan to be PCMH-certified within 6 months to a year

We plan to be PCMH-certified a year or more in the future

Our practice has no current PCMH-certification plans, but is interested

Our practice is not currently interested in PCMH certification

Unsure/don’t know

Poll: Question 1

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• Patients want more from the healthcare system and from their physicians

• Purchasers of insurance (individuals, employers, government) are looking for quality and value

• Runaway healthcare costs must be addressed in ways that preserve and enhance access

to high-quality, effective medical care

Why PCMH?

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• Access to care

• Customer service, technology and outcomes

• New alternatives to pay for care

• More outpatient procedures

• Better coordinated care

• Personalized medicine

• Communication

• Accessibility

• Portable medical records

• New and better drugs

http://www.physicianspractice.com/blog/top-ten-changes-patient-expectations-2013

Patient Expectations 2013

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Priorities for U.S. healthcare reform…

• Quality

– WHO (World Health Organization) identifies the U.S. healthcare system as the “most

individually responsive”

– WHO ranks U.S. healthcare 37th overall (among 191 countries)

• Efficiency

– People with acute and chronic medical conditions receive only about two-thirds of the

healthcare they need

– Between 20% and 30% of tests and procedures provided to patients are neither needed nor

beneficial

*Leatherman and McCarthy, Quality of Health Care in the United States: A Chartbook, 2002. The Commonwealth Fund

*Schuster, McGlynn, and Brook.

Healthcare Reform

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Priorities for U.S. healthcare reform…

• Cost

– The U.S. spends more on healthcare per capita than any other nation

– The U.S. spends more on healthcare as a proportion of GDP (Gross Domestic Product) than any

other nation

• Patient-friendly

– Public confidence in hospitals and personal doctors remains relatively high

– While individuals report generally positive experience with medical care, public confidence and

trust in the system at large is eroding

*Leatherman and McCarthy, Quality of Health Care in the United States: A Chartbook, 2002. The Commonwealth

Healthcare Reform

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Priorities for U.S. healthcare reform…

• Access

– Lack of insurance is a major reason for not obtaining access to needed care

– Even with insurance, barriers to care still exist:

• Lack of an established relationship with a doctor

• Language and cultural barriers

• Social determinants of health

• Transportation issues

• Geography

• High out-of-pockets costs, even for those with insurance (e.g., high deductibles, underinsured,

etc.)

Healthcare Reform

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Priorities for U.S. healthcare reform…

• Automation

– Infrastructure for healthcare delivery has not kept pace with the electronic innovations of

other industries

– Many institutions still rely on systems that are not automated and allow opportunities for

human error, even though technology exists to minimize errors and improve efficiency

Healthcare Reform

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Why is your medical practice interested in pursuing PCMH certification?

Increase practice revenue

Increase practice reimbursements

We felt this was the direction medicine was going

Ability to provide better care

Poll: Question 2

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• Introduced by American Academy of Pediatrics (AAP) in 1967

• Initially referred to a central location for medical records

• The medical home concept was expanded in 2002 to include:

– Accessible

– Continuous

– Comprehensive

– Family-centered

– Coordinated

– Compassionate

– Culturally sensitive care

• In 2007, the AAP, the American Academy of Family Physicians (AAFP), the American Osteopathic

Association (AOA), and the American College of Physicians (ACP) adopted a set of joint principles to

describe a new level of primary care

History of the PCMH Concept

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The Patient-Centered Medical Home - A healthcare setting that facilitates partnerships between individual patients, their personal physicians and, when appropriate, the patient’s family.

PCMH Defined

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• Quality Measures

• Patient Experience

• Practice Organization

• Health Information Technology

PCMH Focus

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• “Build In” quality measures

• Practices live a culture of improvement

– Continually take steps to measure and improve clinical and service quality, including feedback from

patients

– Staff members learn from each other through a systematic and disciplined approach, such as regular

team meetings

– Practice installs reliable systems (e.g., to track lab results, referrals and transitions in care)

• Uses checklists, reminders and evidence-based, point-of-care decision-support tools

Quality Measures

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• Patients want access to comprehensive primary care

– When they need it

– When it’s convenient

– Personalized and coordinated care

– Patient-centered

• PCMH creates the opportunity and support for patients to engage in their own care and in shared

decision-making

• Practice

– Builds in same-day access and 24/7 coverage

– Innovates with new approaches to engage patients, such as group visits and on-line services

Patient Experience

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• Business management systems are in place to assure:

– Disciplined financial management, personnel management and reliable processes to manage clinical care

– A strong financial base in order to be sustainable and invest in itself

– Practice-based care team has effective leadership, communication and task delegation

– A consistent, pro-active, systematic approach to wellness promotion, disease prevention and care

coordination

Practice Organization

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• Technology

– Engine that propels many critical functions

– Facilitates a variety of essential information-driven functions:

• Business and clinical processes (e.g., intra-office electronic messaging, clinical results and test

tracking)

• Connectivity and patient communication (e.g., e-prescribing, patient portals and clinical

messaging with patients)

• Evidence-based medicine support (e.g., point-of-care clinical decision-support and clinical

reminders); population management (e.g., patient registries)

• Fully functioning electronic health record system serves as the practice’s central nervous system

Health Information Technology

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• Patients have an important role

– All of the work does not fall on the practice

– Must educate patients about their rights and responsibilities as part of our/their Medical Home

Keep in Mind

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• Good for patients

– Patients enjoy better health

– Patients share in healthcare decisions

• Good for physicians

– Physicians focus on delivering excellent medical care

• Good for practices

– Team works effectively together

– Resources support the delivery of excellent patient care

• Good for payers and employers

– Ensures quality and efficiency

– Avoids unnecessary costs

Outcomes

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What is currently the biggest barrier to your pursuing PCMH certification?

Price of qualifying/certifying

Time involved in pursuing certification

Need to build more support within the organization

Lack of knowledge about the PCMH process

Need to make necessary technological updates first

Unsure about revenue implications

Not sure if PCMH will be sustainable long-term

Poll: Question 3

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• A personal physician who coordinates all care for patients and leads the team

• Physician-directed medical practice – a coordinated team of professionals who work together to care for

patients

• Whole person orientation – this approach is key to providing comprehensive care

• Coordinated care that incorporates all components of the complex health care system

• Quality and safety – medical practices voluntarily engage in quality improvement activities to ensure

patient safety is always being met

• Enhanced access to care – such as through open-access scheduling and communication mechanisms

• Payment – a system of reimbursement reflective of the true value of coordinated care and innovation

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

Joint Principles of PCMH

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• Personal physician

– Each patient has an ongoing relationship with a personal physician trained to provide first contact,

continuous and comprehensive care

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

Joint Principles of PCMH

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• Physician-directed medical practice

– The personal physician leads a team of individuals at the practice level who collectively take

responsibility for the ongoing care of patients

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

Joint Principles of PCMH

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• Whole person orientation

– The personal physician is responsible for providing for all the patient’s healthcare needs or taking

responsibility for appropriately arranging care with other qualified professionals, including care for all

stages of life: acute care, chronic care, preventive services and end-of-life care

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

Joint Principles of PCMH

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• Care is coordinated and/or integrated

– Across all elements of the complex healthcare system (e.g., subspecialty care, hospitals, home health

agencies, nursing homes) and the patient’s community (e.g., family, public and private community-

based services)

– Care is facilitated by registries, information technology, health information exchange and 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

Joint Principles of PCMH

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Joint Principles of PCMH

• Quality and safety

– Practices advocate for patients, support attainment of optimal, patient-centered outcomes defined by a care planning process driven by compassionate, robust partnership between physicians, patients and patients’ families.

– Evidence-based medicine and clinical decision-support tools guide decision-making

– Physicians accept accountability for continuous quality improvement, voluntary engagement in performance measurement/improvement

– Patients actively participate in decision-making; feedback is sought to ensure patients’ expectations are being met

– Information technology used to support optimal patient care, performance measurement, patient education and enhanced communication

– Practices go through a voluntary recognition process

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Joint Principles of PCMH

• Enhanced access

– Care is available through systems such as open scheduling, expanded hours

– New options for communication between patients, their personal physician and practice staff

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

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Joint Principles of PCMH

• Payment (recognize added value)

– Reflect value of physician and non-physician management work that falls outside of the face-to-face visit

– Pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers and community resources

– Support adoption and use of health information technology for quality improvement

– Support provision of enhanced communication access, such as secure email and telephone consultation

– Recognize the value of physician work associated with remote monitoring of clinical data using technology

– Allow for separate fee-for-service payments for face-to-face visits

– Recognize case mix differences in the patient population being treated within the practice

– Allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting

– Allow for additional payments for achieving measurable and continuous quality improvements

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• Partnerships are developing as more and more stakeholders see value in the Joint Principles

• The Patient-Centered Primary Care Collaborative (PCPCC)* is a coalition of major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, physicians and others to develop and advance PCMH

• The PCPCC has well over 1,000 members

*www.pcpcc.net

Growing Support for PCMH

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Where Will the Money Come From?

• Improved office efficiency

– Many of the suggested changes do not require capital investment

– Electronic health records are quickly becoming standard of care

– Gains in efficiency outweigh the cost

• Enhanced payment for primary care

• Incentive payments for quality

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What model of PCMH are you considering or participating in?

NCQA

AAAHC

Joint Commission

URAC

Do not know/Does not apply

Poll: Question 4

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• No single path meets every practice’s needs

• Which is best for your practice?

– Find out if your state has a defined, state-developed or specific state recognized process

– AAFP Government Relations 2011 State Legislation: Medical Homes Report

– Determine if practice is required by another group to be recognized or accredited (accountable care organization, Health Resources and Services Administration [HRSA], etc.)

– Determine if this recognition is the same as the major health plans or payers for your practice (Medicaid, private insurance, etc.)

Recognition and Accreditation as PCMH

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• Accreditation Association for Ambulatory Health Care (AAAHC) Medical Home On-Site Certification

• The Joint Commission (TJC) Designation for your Primary Care

• National Committee for Quality Assurance (NCQA) Patient Centered Medical Home (PCMH 2011) Recognition

• URAC Patient-Centered Health Care Home Recognition

Recognition and Accreditation as PCMH

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PCMH Value for Providers

Improved Patient Outcomes

• Fewer ER visits (6-19%)

• Fewer hospital admissions (0-29%)

• Lower mortality rates

• Better preventive service delivery

• Better chronic disease care

• Higher patient satisfaction

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PCMH Value for Providers

Improved Efficiency

• Lower total costs of care

• Increase savings

• $71 - $640 per patient

• Shorter patient wait times

• Less staff burnout/turnover

• Higher staff satisfaction

• Increased productivity

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PCMH Value for Providers

State Differential Payment Comments

CO $4.00 to $8.50 Add. PMPM Payments

MD Commercial $3.51 - $6.01 Medicaid $4.08 - $7.00 Medicare $9.62 - $11.54

Add. PMPM payments based upon PCMH level

NC $2.50 - $5.00 to Practice $3.00 - $8.00 to Network

Add. PMPM Payments

OH $2.50 - $6.00 PMPM Add. PMPM Payments

OK $3.03 - $8.69 PMPM Add. PMPM Payments

PA $0.60 - $7.00 PMPM Also eligible for shared savings based on performance

RI $3.00 PMPM Add. $1.16 PMPM available for Nurse Care Management Payment

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PCMH Value for Providers

Group Health Cooperative of Puget Sound

• 29% decrease in ER visits

• 16% decrease in hospital admissions

• Measured reduction in costs of care and increased quality

Geisinger Health System

• 18% decrease in hospital admissions

• 7% decrease in overall healthcare costs

• Measured increase in improvements in diabetes and heart disease care

Intermountain Healthcare Medical Group Care Management Plus

• 39% decrease in ER visits

• 24% decrease in hospital admissions

• Net reduction in costs of $640/patient $1650/high-risk patients

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Practice Considerations

• Establish realistic expectations for time/effort

• Provider buy-in

• Evaluation of roles/resources

• Team-based approach

• Learn to be a learning organization

• Systems thinking

• Shared vision

• Collaboration learning

• Redesign practice workflows/patient process

• Communication

• Cross-training

• New roles

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Practice Considerations

• Establish realistic expectations for time/effort

• Change physician-patient relationship

• Evaluation of practice resources and roles

• Shift from physician-centered care to team-based care

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Practice Considerations

• Learn to be a learning organization

1. Systems thinking

2. Shared vision

3. Team learning

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What additional resources do you need most right now on your practice’s PCMH

journey?

Best practice recommendations

Educational webinars

Fee-for-service consulting

Facilitate PCMH community groups

Poll: Question 5

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Next Steps

• Redesign practice workflows

• Communication- enhance electronically, huddles, monthly meetings

• Cross-training

• New roles

• Administrator

• Clinical care coordinator

• EMR customizer

• QI physician

• Social worker

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Next Steps

• Redesign patient process

• Pre-visit/Post-visit workflows

• Additional visits with health coach

• Patient portal

• Group visits

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• Demonstrates the quality of care provided in medical practice

• Positions medical practice at an advantage for the changing healthcare landscape

• Transforms patient care to help medical practice achieve the three-part aim of Better Care, Healthy People and Communities, and Affordable Care

Why PCMH?

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Questions?

Thank You

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• National Quality Recognition – Accreditation: http://bphc.hrsa.gov/policiesregulations/accreditation.html

– AAAHC, TJC – NCQA recognition: http://bphc.hrsa.gov/policiesregulations/policies/pal201101.html – Comparison chart: http://bphc.hrsa.gov/policiesregulations/policies/qualrecogn.pdf – URAC : https://www.urac.org/pchch/

• PCMH Readiness Assessment Tools

– Primary Care Development Corporation (PCDC): http://www.pcdc.org/resources/patient-centered-medical-home/pcdc-pcmh/ncqa-2011-medical-home.html

– PCMH Assessment (PCMH-A) from the Safety Net Medical Home Initiative: http://www.safetynetmedicalhome.org/practice-transformation/assessment

– Medical Home Implementation Quotient Assessment (MHIQ) from TransforMED: http://www.transformed.com/userLogin.cfm

• PCMH Change Concepts: http://www.safetynetmedicalhome.org/change-concepts • Patient-Centered Primary Care Collaborative (PCPCC): http://www.pcpcc.net/content/pcmh-

outcome-evidence-quality

Resources

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• Agency for Healthcare Research and Quality (AHRQ) PCMH Resource Center: http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483

⁻ Clinical Practice Guidelines: http://www.ahrq.gov/clinic/cpgsix.htm

⁻ US Preventive Services Task Force: http://www.uspreventiveservicestaskforce.org/tools.htm

⁻ Consumer Assessment of Healthcare Providers and Systems (CAHPS patient experience survey): https://www.cahps.ahrq.gov/default.asp

⁻ Innovations Exchange: http://www.innovations.ahrq.gov/

⁻ Patient Health Literacy Toolkit: http://www.ahrq.gov/qual/literacy/

Resources