a step by step approach to building a patient-centered medical home
DESCRIPTION
What Does That Mean for One Patient? Ms. Jones, a 55 year old diabetic, is a patient of Dr. Smith’s practice In 2010, Ms. Jones: Showed poor understanding of her diabetes and link between diet and blood sugar readings Rarely checked her blood sugar at home Did not consistently take her medications for diabetes or high blood pressure Hgb A1-C >10; BP 170/110; Wt. 165 Went to ER 5 times with complaints of headache and blurred vision; an infected foot ulcer; pain and tingling in her feet In 2011, Ms. Jones: Met 1:1 with the Diabetes Educator and attended group diabetes classes with her husband Learned how to check and record her blood sugar results daily The Care Manager helped her obtain low cost medications from a pharmaceutical company Hgb A1-C down to 8.3; BP 140/80; Wt. 143 Went to ER once for chest pain and shortness of breath Case Manager coordinated her referral to cardiologist Dr. Smith’s practice in 2010 Dr. Smith’s practice in 2011 as a PCMHTRANSCRIPT
A Step by Step Approach to Building a Patient-Centered Medical Home
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What Does That Mean for One Patient?
• Ms. Jones, a 55 year old diabetic, is a patient of Dr. Smith’s practice
In 2010, Ms. Jones:• Showed poor understanding of her
diabetes and link between diet and blood sugar readings
• Rarely checked her blood sugar at home
• Did not consistently take her medications for diabetes or high blood pressure
• Hgb A1-C >10; BP 170/110; Wt. 165• Went to ER 5 times with complaints of
headache and blurred vision; an infected foot ulcer; pain and tingling in her feet
In 2011, Ms. Jones:• Met 1:1 with the Diabetes Educator
and attended group diabetes classes with her husband
• Learned how to check and record her blood sugar results daily
• The Care Manager helped her obtain low cost medications from a pharmaceutical company
• Hgb A1-C down to 8.3; BP 140/80; Wt. 143
• Went to ER once for chest pain and shortness of breath
• Case Manager coordinated her referral to cardiologist
Dr. Smith’s practice in 2010 Dr. Smith’s practice in 2011 as a PCMH
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Key Points from the Patient - Centered Primary Care Collaborative February 2016 Annual Update Report
• PCMH studies continue to demonstrate impressive improvements across a broad range of categories including: cost of medical care, utilization of services, population health, prevention, access to care, and patient satisfaction.
• Advanced primary care is foundational to delivery system transformation. The PCMH model continues to play an important role in strengthening the larger health care system, particularly Accountable Care Organizations and other integrated healthcare delivery systems.
• Payment reform is necessary to sustain delivery system changes. Multiple payment innovation models are currently being tested, such as pay-for-performance; per member per month (PMPM) payments, often adjusted for PCMH Recognition level, in addition to FFS billing; and/or shared savings arrangements.
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PCMH Success: Examples of PCMH results
Initiative Health Cost & Utilization Outcomes Health Outcomes Years of Data Review
Patient Satisfaction
PA Chronic Care Initiative • All- cause hospitalization reduced 1.7%
• All - cause ED visits reduced 4.7%• Specialty visits reduced 17.3%
• Higher performance 4 Diabetes measures including HbA1c testing and eye exams; and breast cancer screening
10/2007-9/2012
North Carolina: Community Care of North Carolina (Medicaid)
• Decreased spending almost all categories
• Reductions in readmissions, inpatient admissions for diabetes, ED visits for asthma
• Approx. 10.7% decline in prescription drug use
2003 - 2012
Colorado Multi-Payer PCMH Pilot
• 9.3 % fewer ED visits• Reduction in ED costs of $3.50
PMPM• 10.3% reduction in ACSC
inpatient admissions
• Increased cervical cancer screening rates
2009-2012
Source: The Patient-Centered Medical Home’s Impact on Cost and Quality: Annual Review of Evidence 2014-2015; February 2016
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What Is a Patient-Centered Medical Home?
• Defined as “a team-based model of care led by a personal physician who provides continuous, coordinated care throughout a patient’s lifetime, to maximize health outcomes.” (American College of Physicians)
• The PCMH provides or arranges for all of the patient’s healthcare needs,
including: • Preventive care• Treatment of acute and chronic illnesses• Assistance with end-of-life/palliative care
• Key building blocks: teamwork, leadership, communication, willingness
to change
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Core Components of a Patient - Centered Medical Home
Transformation of care delivery to become a model of primary care, delivering care that is:
These core components track closely with NCQA’s PCMH Recognition Standards.
Source: Agency for Healthcare Research and Quality- An agency within the Department of Health & Human Services committed to improving care safety and quality
Patient centered Comprehensive Coordinated Accessible
Continuously focused on improvement through systems-based approach to quality and safety
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Key Attributes of a PCMHPhysician
Leadership/Engagement
Team-based approach to care
delivery
Use of Evidence-based Medicine
and Clinical Decision Support
Tools
Identify and Measure key
Quality Indicators
Use of Health Information Technology
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Characteristics of a PCMH
Ensure continuity of
care
Identify and manage high risk patients
Develop and document
patient self-management
care plans
Involve patients and caregivers in
shared decision making
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• Ensure that you will get a return on your investment• Assess the state of your system, when applicable• Assess the state of your practices• Determine any gaps in care & service delivery in relation
to the PCMH Standards• Calculate the cost of PCMH implementation• Calculate the potential benefits, including opportunity for
higher reimbursement based on PCMH Recognition
Implementing a PCMH Model of Care: Factors to Consider
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Creating a Profile of Your PatientsFocus Priorities Estimated percentage of
Patient Panel
Complex care patients Intensive, multi-disciplinary care coordination in a community-based model
5%
High risk chronic care Need for aggressive, ongoing monitoring of symptoms, focus on compliance
15%
Lower risk chronic care patients Longitudinal monitoring of symptoms with focus on managing risk factors
25%
Healthy / chronic disease risk Longitudinal monitoring and management of risk factors
20%
Healthy / primary prevention Focus on prevention 20%
0-5 children / compromised or at risk
Aggressive, early, multi-disciplinary intervention emphasizing parent engagement
5%
0-5 healthy children / primary prevention Protocol driven primary prevention 10%
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Building an Interconnected, Patient-Centric Care System
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Becoming a PCMH
Evaluate current work
processes
GAP ANALYSI
S
Improvement plan &
implementation
NCQA Accreditation
Getting paid for value
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Process for NCQA Recognition
Obtain approval to apply for
multi-site PCMH
Internal reviewDocumentation for Standards &
ElementsComplete online toolUpload appropriate documentation
Submit application
Follow required NCQA
registration
Purchase survey tools
Recognition decision within 60 days of site Survey Tool submission.
Participate in NCQA PCMH Learning Initiatives
Self-assessment
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NCQA Recognition Program The National Committee for Quality Assurance (NCQA)’s Patient-Centered Medical Home Recognition Program provides a roadmap to physician practices working to improve care delivery and the experience of care for both patients and clinicians.
• The six Standards align with the core components of primary care• Three possible Recognition Levels: Level I-III
• Based on total points scored on the Recognition application
Six PCMH Recognition Standards
Patient -Centered
Access
Team-Based Care
Population Health
Management
Care Management
& Support
Care Coordination
& Care Transitions
Performance Measurement
& Quality Improvement
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NCQA Must-Pass Elements Six Must - Pass Elements considered essential to a successful PCMH and required to achieve recognition at any level:
1A: Patient-Centered
Appointment Access
2D: The Practice Team
3D: Use Data for Population Management
4B: Care Planning & Self-Care Support
5B: Referral Tracking and
Follow-up
6D: Implement Continuous
Quality Improvement
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Enhance Access and Continuity
*Must earn a score of 50% or higher to pass this element
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Provide Team-Based Care Continuity
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The Practice Team
*Must earn a score of 50% or higher to pass this element
1919
Plan and Manage Care
2020
Use Data for Population Management
*Must earn a score of 50% or higher to pass this element
2121
Provide Self-Care Support and Community Resources
2222
Provide Self-Care Support and Community Resources
*Must earn a score of 50% or higher to pass this element
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Track and Coordinate Care
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Track and Coordinate Care
*Must earn a score of 50% or higher to pass this element
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Measure and Improve Performance
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Measure and Improve Performance
*Must earn a score of 50% or higher to pass this element
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Appendix 1 – Scoring Sheet
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Getting Started: Evaluate Current Work Processes
FundamentalsRevenue Cycle
Ability to manage
documentation, billing, and collections
Efficient patient flow
Is it patient -centric?
Information Technology
Do you have a robust platform
that all staff members can
use effectively?
Data ReportingAre you sending information to
your providers on a regular basis?
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Next level of requirements
Governance- Do you engage your physicians
in decision-making?
Provider compensation
- Can your compensation
structure accommodate
quality metrics?
Human Resources
- Do you have the right mix of staff members and are they in
the right positions?
Cost of Service- How much does it cost the practice
to offer a given service?
Evaluate Current Work Processes
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Gap analysis• Revenue cycle• Efficient patient flow• IT platform• Data reporting• Governance• Provider compensation• Human Resources• Cost of Service
• Evaluate current care and service delivery
• Pay particular attention to the NCQA Must - Pass Elements
• Determine priorities and identify “low-hanging fruit” to begin transforming care delivery
Evaluate Current Work Processes
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Implementing the PCMH Model of Care
Implementation Plan
• Develop & implement standardized treatment orders/evidenced-based clinical guidelines
• Utilize Disease Registries for population health management
• Track and coordinate care across healthcare continuum
• Exchange clinical information electronically with referral providers-build a strong “Medical Neighborhood”
• Integrate comprehensive medication management program
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NCQA Patient-Centered Medical Home (PCMH 2014) Recognition Program - Standard Survey PricingNumber of Clinicians in
the PracticeInitial Fee for Practice to Obtain a
Survey Tool LicenseApplication Fees for NCQA
Review and RecognitionTotal License and Application
Fees
1 $80 $550 $630
2 $80 $1100 $1180
3 $80 $1650 $1730
4 $80 $2200 $2280
5 $80 $2750 $2830
6 $80 $3300 $3380
7 $80 $3850 $3930
8 $80 $4400 $4480
9 $80 $4950 $5030
10 $80 $5500 $5580
11 $80 $6050 $6130
12 $80 $6600 $6680
13 $80 $6600 + $55 for each clinician
$6800 + $55 for each clinician
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PCMH Implementation: Potential Challenges & Obstacles • Potential increased physician practice costs upfront: additional staff,
expanded office hours, acquisition/implementation of Health Information Technology
• Limited or no reimbursement by payors for PCMH infrastructure and care management/care coordination functions
• Inconsistent availability/use of Health Information Technology• Must have functional EHR to achieve NCQA Level 3 Recognition• Lack of Electronic Health Record system interoperability between
hospitals and physician practices• Physician collaboration and communication• Patient buy-in and participation in self-care management• Engagement and collaboration with community-based organizations
Questions
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Resources• Patient Centered Primary Care Collaborative: http://www.pcpcc.net/
• National Committee for Quality Assurance : www.ncqa.org
• American Academy of Family Physicians: http://www.aafp.org/online/en/home/membership/initiatives/pcmh.html
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Thank You
Contact for more information:
Louise BrydePrincipal, Stroudwater Associates
404.790.8251 [email protected]
770.206.9160
Mike FleischmanPrincipal, Stroudwater Associates