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HIV Patient Centered Medical Homes Construction:

A Multi-Site Experience

Erin Gael Friedman Sonali Kulkarni, MD, MPH

Amy Sitapati, MDWayne Steward, PhD, MPH

http://www.publichealth.lacounty.gov/index.htm

DisclosuresThis continuing education activity is managed and accredited by

Professional Education Service Group. The information presented in this activity represents the opinion of the author(s) or faculty. Neither PESG, nor any accrediting organization endorses any commercial product displayed or mentioned in conjunction with this activity.

Commercial Support was not received for this activity.

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DisclosuresErin Gael Friedman

Has no financial interest or relationships to disclose

Sonali Kulkarni, MD, MPHHas no financial interest or relationships to disclose

Amy Sitapati, MDHas no financial interest or relationships to disclose

Wayne Steward, PhD, MPHHas no financial interest or relationships to disclose

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Learning ObjectivesAt the conclusion of this activity, the participant will be able to:1. Identify the major elements of a patient-centered medical

home (PCMH).2. Characterize how implementation of a PCMH in HIV primary

care settings is similar to or different from implementation in other care environments.

3. Develop a set of questions to help determine if a PCMH model would work well in his or her own clinic.

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Overview1. Introduction to the Patient-Centered Medical Homes

Demonstration Project Research Initiative2. Introduction to the PCMH Model3. Implementing the PCMH in HIV Care Settings

HIV ACCESS, Alameda County, CADepartment of Public Health, Los Angeles County, CAANCHOR, Owen Clinic, UC San Diego Health System

4. Summary5. Questions & Answers

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Introduction to the Patient-Centered Medical Homes

Demonstration Project Research Initiative

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• Supported by the California HIV/AIDS Research Program (CHRP)

• CHRP funds research projects that inform HIV prevention and treatment efforts in the state

• National Advisory Board for the PCMH Initiative includes HRSA/HAB representation

• Funded demonstration sites are all Ryan White Program grantees

Patient-Centered Medical Homes (PCMH) Demonstration Project Research Initiative

• Conduct research that demonstrates the effectiveness of

Patient-Centered Medical Homes (PCMH) for persons with HIV /AIDS in California.

Purpose of the Initiative

• Up to $400,000 per year for three years in direct costs

• Single Institution or Consortium• Research populations represent those most

highly impacted by HIV, particularly those with a history of health disparities and/or over the age of 50.

• Required representative set of critical services provided directly and through referral.

• Electronic health record system.

CHRP RFA: Funding & Eligibility

CHRP RFA: Use of Funds

PCMH Model DevelopmentElectronic Health Record Systems

• Improve electronic exchange of information with other providers

• Improve/expand electronic health record systemDissemination Direct Patient Care and/or Prevention Services

Not Eligible for Funding

GranteesFive PCMH Demonstration Projects

San Francisco Department of Public HealthLA County Division of HIV and STD ProgramsTri-City Health Center (Alameda County in San

Francisco Bay Area)St. Mary Medical Center, Long BeachUC San Diego Health System, Owen Clinic

Cross-Site Evaluation CenterUCSF Center for AIDS Prevention Studies

Introduction to the PCMH ModelWayne T. Steward, PhD, MPH

Principal InvestigatorCross-Site Evaluation Center

Center for AIDS Prevention StudiesUniversity of California, San Francisco

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National Committee for Quality Assurance (NCQA)

“The PCMH 2011 program’s six standards align with the core components of primary care.”

Access and ContinuityIdentify and Manage Patient PopulationsPlan and Manage CareProvide Self-Care Support and Community

ResourcesTrack and Coordinate CareMeasure and Improve Performance

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Future of Family Medicine

PCMH has the following characteristics:Personal medical homePatient-centeredTeam approachElimination of barriers to accessAdvanced information systemsRedesigned offices

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Future of Family Medicine

PCMH has the following characteristics (continued):Whole-person orientationCare provided within a community contextEmphasis on quality and safetyEnhance practice financeCommitment to provide family medicine’s basket of services

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Synthesis

Key elements of a PCMH:Structure of Provider TeamsStructure and Practices of CareStructure and Design of Information SystemsEngagement of PatientsPerformance Monitoring and Improvement

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Structure of Provider Teams

Clinical care is designed so that:Patients have a primary care providerProvider is a part of a team that is collectively responsible for

the person’s careCare is coordinated across the health care system and

patient’s communityProviders have a patient-centered focus

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Structure and Practice of Care

Overall care environment facilitates access. This can be accomplished by:

Co-location of servicesAssistance with health system navigationCoordination and tracking of referralsOpen-scheduling and expanded hoursEnhanced patient-provider communication (e.g., secure

emails)

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Structure and Design of Information Systems

Providers exchange patient health information via electronic health records to:

Augment quality of care through referral trackingMake use of databases containing evidence-based guidelinesBetter track needed tests or carePromote better patient-provider dialog by facilitating

electronic communications

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Engagement of Patients

Goal is promote more active patient engagement (more active role) in care. Facilitated through:

Patient portals allowing access to electronic health recordsEducational tools and programsPatient-provider collaboration in development of treatment

plansEncouraging use of available community resources

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Performance Monitoring and Improvement

Strive for higher quality servicesConsistent review of services provided, both at provider and clinic

levelConducting patient surveys to understand satisfaction or

concerns with services deliveredDistributing performance findings within and outside of the

PCMH

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PCMH Causal PathwayChanges in PCMH elements

(care practices, information systems, and performance monitoring tools

and practices)

Patient engagement

in care

Patient and Provider

Satisfaction

HIV-related health

outcomes

Changes in care (improved coordination

and quality of care)

Implementing the PCMH in HIV Care Settings

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HIV ACCESS PCMH Demonstration Project

Alameda CountyErin Gael Friedman

Project Director

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Panel Management DefinitionsPopulation-based, data-driven approach to care

improvement, esp. chronic diseaseTeam-basedRequires registry functionRequires protected timeAllows for shared responsibility, improved

coordination of care and “task shifting”

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Project Work Plan

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Patient Centered Medical HomeImplementation Continuum

Pre-contemplation (Inconvenient hours, no outreach to missing patients, difficult to reach clinic on phone)

Visualized as PCMH (Philosophic commitment to PCMH and talk about concepts, no action yet)

Organized as PCMH(Patient navigators, panel management, staff huddles, using registry)

Standardized as PCMH (Staff training and job descriptions include new duties, reimbursement is tied to pt satisfaction)

Recognized as PCMH (By NCQA, etc.)

Realized as PCMH (Org culture and operations have fully integrated PCMH)

Doctor and Staff Centered model

PCMH Fully Integrated

Project GoalsImprove health outcomes

Improve continuity of care

Reduce transmission of HIV

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What We DidLeveraged Countywide alignment of

incentives

Capacity building

Recruited executive leaders as project champions

Used Steering Committee members as on-site educators and movement builders 29

Pilot Snapshot

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Panel management pilot in early stages at Alameda County Medical Center

Preliminary Clinical Outcomes

6 months post-implementation

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Denta

l Ref

erra

l

Viral S

uppr

ession

Qua

ntife

ron

or P

PD Pap

0%

40%

80%

120%

Pre-PilotPost-Pilot

Tools We Used: Telling a Story

Innovative use of video

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Tools We Used: Movement BuildingSteering Committee

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Tools We Used: Clinic SupportCoaching

Webinars

Home Improvement Bulletin

Workflow analysis & clinic observation

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What We Learned: Challenges

FQHCs can be a chaotic environment in which to conduct research

Organizational changes at all levelsStaff turnover made it difficult to build

momentumRepetition of message and project objectives

was key

No way to reimburse for panel management activities

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What We Learned: SolutionsIncentives and priorities must be aligned

Create opportunities for synergistic resource sharing

Leaders must be engaged

System changes take timeMethodical documentation of change is keyJob descriptions must reflect enhanced job

dutiesKeep the focus on the patients

Patients appreciated extra attention during pilot panel management clinics

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On the Horizon…Embedding PCMH transformation processes

into clinic workflowsMaking PCMH part of “Organizational DNA”

Orientation for staff at participating clinicsPanel Management 101PCMH Concepts

Further engagement of leadersCreating systems of accountability

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Los Angeles County Patient-Centered HIV Medical Home

Sonali Kulkarni, MD, MPHHIV Medical Director/Principal

InvestigatorDivision of HIV and STD Programs

Los Angeles County Department of Public Health

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http://www.publichealth.lacounty.gov/index.htm

Rationale for PCMH in LACFragmented HIV service delivery

Large service area – over 4,000 square milesMedical and support service providers at different locations and/or agencies

with limited coordination of care across sitesDuplication of services with medical and non-medical case managementPatient information not being shared or used to create care plan that

address both medical and psychosocial problems

Suboptimal health outcomes for HIV patientsRetention in care and viral suppression

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Ryan White “in Care” Treatment Cascade, 2009

RW System of Care

RW Medical Care

On ART

Retained in HIV Care

Undetectable VL

- 5,000 10,000 15,000 20,000

18,345

12,752

90%

74%

65%

Number of Individuals

40Ryan White Casewatch Data, January – December 2009 (CY2009)

Among RW clients in medical care and on ART, 72% have an undetectable VL.

LAC-PCMH Model

A Medical Care Coordination (MCC) service model to improve health outcomes and care-seeking behaviors for people living with HIV/AIDS

A population health management system (i2i Tracks) that interfaces with the electronic health record (EHR) to enhance HIV panel management and care delivery

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PCMH Components

Provider Teams

Practice of Care

Engagement of Patients

Information Systems

Performance Monitoring and Improvement

LAC-PCMH: Provider Teams

MCC team consists of an RN, a Master-level Social Worker, and paraprofessional Case WorkerCo-located at HIV clinicWork with all clinic providers to identify and address issues that may be impeding patients’ health

Attend patient appointments as needed Follow-up visits or calls between appointmentsMultidisciplinary case conferencing on regular basis

Physicians, nurses, psychiatrists, MCC team, navigators

Brief interventions and referrals

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LAC-PCMH: Structure and Practice of care

MCC team works with patients and their providers to:Identify and address medical and psychosocial factors that may affect

patient’s health through assessment and development of individualized care plans

Address preventive health needs (TB screening) or management of comorbidities (out of control diabetes)

Referrals to needed psychosocial services

Deliver evidence based interventions ART adherence intervention Risk reduction intervention (DEBI)

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LAC-PCMH: Engagement of Patients

The services delivered by the MCC team are intended to increase patient self-care capacities through:

Tracking and monitoring patient acuity levels through formal assessment

Motivational Interviewing and Strengths Based approach to develop individualized patient-centered care plans

Brief, structured interventions to support behavior change around health and well-being

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LAC-PCMH: Information Systemsi2i Tracks is a population health management software program that

integrates EMR, laboratory, pharmacy, and other patient data systems

Allows providers to track patient outcomes for their panel

Creates reminders for overdue procedures or referrals to improve quality of care

Facilitates care coordination and group based panel management

Created HIV-specific tracking modulePatients with no visit in >6 monthsPatients whose last viral load was >200

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LAC-PCMH: Monitor and Improve Performance

Health registry to readily generate standard or tailored performance reports for providers

Programmed 20 HIV performance measures

Providers can assess their performance in comparison to other providers in their practiceEasy identification of areas for improvement and patients to follow up with

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Measure Number Percentage

Syphillis – Completed in past 12 months

150 75.0%

Syphilis – Not Completed in past 12 months

50 25.0%

LAC-PCMH: Lessons Learned

SuccessesCoordination with RW Planning Body critical

MCC teams allocated to all 30 RW funded HIV clinics

CHRP grant has allowed investment of time to develop thorough MCC assessment tools, acuity trees, protocols, and training materials

ChallengesTime line for making dramatic changes to the LAC RW

landscape of services prolongedHiring staff, IT infrastructure to implement disease registry system

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A Novel Centered Home Optimizing Retention Amy Sitapati, MD Anchor PI & Owen Clinic Director

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UCSD Owen ClinicANCHOR

Funded by California HIV/AIDS Research Program (CHRP) to serve as a pilot center for application of Patient Centered Medical Home in HIV

Site based focus to improve Retention

The OWEN CLINICUniversity of California, San Diego20 years of experience 3,000 HIV/AIDS patientsHigh proportion of Medi-Cal/ Medicare/ RW funding

Who are we?

CaliforniaHIV/AIDS:112,602

ALAMEDA

ALPINEAMADOR

BUTTE

CALAVERAS

COLUSA

CONTRACOSTA

DEL NORTE

EL DORADO

FRESNO

GLENN

HUMBOLDT

IMPERIAL

INYO

KERN

KINGS

LAKE

LASSEN

LOS ANGELES

MADERA

MARIN

MARIPOSA

MENDOCINO

MERCED

MODOC

MONO

MONTEREY

NAPA

NEVADA

ORANGE

PLACER

PLUMAS

RIVERSIDE

SACRAMENTO

SANBENITO

SAN BERNARDINO

SAN DIEGO

SANJOAQUIN

SAN LUIS OBISPO

SANMATEO

SANTA BARBARA

SANTA CLARA

SANTACRUZ

SHASTA

SIERRA

SISKIYOU

SOLANOSONOMA

STANISLAUS

SUTTER

TEHAMA

TRINITY

TULARE

TUOLUMNE

VENTURA

YOLO

YUBA

San DiegoHIV/AIDScases:11,275HIV/AIDSDischarges:1,211

UC San DiegoHealth System

Owen clinic3,073 (27.2%)

InpatientHIV discharges1,211 (39.6%)

CY 2011 OSHPD Patient Discharge Data

Where are we?

Definition of terms

Epic Ambulatory Care UCSD is running version 2010 of Epic EMR

MyChart Patient Portal Secure website for UCSD patients to view EMR

Population Management Clinical workflow to manage groups of patients that

need similar health screenings

Group Visit (Shared Medical Appointment) A 90 minute office visit with one doctor and 10 patients who are treated sequentially with group observation and discussion

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Snapshot

Website for HIV literacy and resourcesComputer Training Lab for PatientsSpanish Web Portal for Electronic Medical RecordEHR enhancements

RegistriesPopulation managementProvider Report CardsProvider Efficiency Metrics

Shared Medical Visits

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Source: National Committee for Quality Assurance http://www.ncqa.org

Spanish MyChart Web Site/Computer Lab

EMR Registry Build

EMR Health Maintenance

Provider Report CardsEMR Performance

Metrics

Shared Medical Visits

PCMH elements addressed

http://www.ncqa.org/

http://www.ncqa.org/

Snapshot

Website for HIV literacy and resources Computer Training Lab for PatientsSpanish Web Portal for Electronic Medical RecordEHR enhancements


Shared medical visits

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Patient Centered Web site

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Snapshot




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MyUCSDChart in Spanish

Human Translation of Clinical MessagesCompliance and Risk Considerations

Current Laws and Regulations (Important consideration)

Federal HIPAA – Business Associate Agreement (BAA)

State California SB 853: HC providers must provide language services

Proposed Legislation SAFE-ID Act (Safeguarding Americans from Exporting

Identification Data Act): proposed act prohibiting exportation of PI off-shore

Institution Polices and ProceduresInsurance requirements for third party

providers of medical translation servicesOffshoring of medical translation services

Snapshot




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Clinical Performance• Patient satisfaction• Compliance/Billing• Meaningful Use

Provider Performance• EMR use• Provider Report Card

(Standards of Care)

Patient • Demographics• Acuity

Epic System Performance• Response time• Decision

Support• Click counts• Cognitive load

Clinical Metric Model

Individual Provider Quality Indicator Report Cards16 HIVQUAL IndicatorsEach indicator chart contains

Provider score Clinic score HIVQUAL CY 2009 mean

scoreThe indicator sidebar

contains Indicator definitions Provider’s total patient count Provider’s compliant patient

count

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Provider report cards based on HIVQual measures … circulated by email

Snapshot




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Key lessons learnedCore challenges to PCMH uptake

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On-site: Dissemination of knowledge across diverse silosLimited resourcesComplexity of PCMH construct

Local/Regional:Limited time contactLimited baseline knowledgeState:Relevancy across different sitesDiverse PCMH portfolio and active workNational:

Interest in standardizationSheer number of different care provider

settings,Resources, electronic health platform, isolated HIV Populations within larger health

communities

Summary

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Comprehensive Model

The PCMH represents a holistic change to clinic organization and approach to care

The model has underlying common objectives, but is ultimately tailored to each clinical environment

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Diverse Stakeholders

WITHIN a site (e.g., patients, providers, IT department, larger institutions)

ACROSS sites (e.g., providers, IT departments, legal affairs offices, planning groups)

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Multiple Steps to Implementation

1. Create necessary infrastructure (e.g., IT systems, protocols)

2. Begin using new systems and new protocols

3. Monitor performance

All three steps are necessary to achieve true PCMH status 69

Why the PCMH Model is Appropriate for HIV Care

HIV disease is complex. Treatment may involve expertise from multiple healthcare fields.

Vulnerable populations affected by HIV benefit from complementary support services.

As people with HIV age, often experience co-morbid conditions. Treatments must be coordinated.

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How the PCMH Model is Unique When Applied to HIV Care

HIV disease has its own routine/preventive care standards.HIV care, particularly in Ryan White funded settings, has a strong

emphasis on support services.Linkages between primary care and support services may

have different complications than linkages between medical specialties.

HIV notable for its impact on diverse populations that have varying levels of health literacy.

Not all patients can engage (participate actively) in the same way.

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Questions & Answers

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Contact Information

Erin Friedman: [email protected]

Sonali Kulkarni: [email protected]

Amy Sitapati: [email protected]

Wayne Steward: [email protected]

Obtaining CME/CE Credit

If you would like to receive continuing education credit for this activity, please visit:

http://www.pesgce.com/RyanWhite2012

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http://www.pesgce.com/RyanWhite2012

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