O c t o b e r 2 8 , 2 0 1 9

One Louisiana Clinic’s PCMH Journey

Kate Hill, RNThe Compliance TeamVP Clinical Services

Brandon Dees, RN, NLI FellowDi t f R l H lthDirector of Rural Health Services Hardtner Medical

Today’s Objectives

•Understand the PCMH programs and The Compliance •Understand the PCMH programs and The Compliance Team’s model

Sh th b i f Th C li T ’ PCMH • Share the basics of The Compliance Team’s PCMH Program

• Learn from one program’s PCMH Journey

Nationally Recognized PCMH Accreditor

From CMS in the MIPS Validation Criteria

Our Philosophy

• Standards written in Simple Language which Leads to Better Understanding and Higher Compliance

• An On-Going Commitment to Rural America and Small to Medium Primary Care PracticesCare Practices

• Simplification leads to clarity, and clarity allows the provider to focus on p y, y pwhat matters most to patients…..Safety, Honesty & Caring.

• This brings us to the creation of

“PCMH Simplified”

What is a Patient Centered Medical Home?

Clearly it’s a journey, not a destination!

Elements of the PCMH Model

Comprehensive Care

Patient Centered

Coordinated Care

Accessible Services

Quality and Safety

PCMH – Why is it important?

Reduce Emergency Department utilization

Reduce Hospital Re-Admissions

Reduce Hospital admissions for chronic disease

Increase preventative screening

**PCMH models provide evidence of consistent reductions in high-cost care that is often avoidable.

Why Become a Patient Centered Medical Home

• Puts patients first

• Make primary care more accessible

• Improves staff satisfaction

• Improves patient satisfaction

• Improves patient outcomes

• Mitigates health disparities

• Increase revenue

B th id f h i i it• Become the provider of choice in your community

• Consistent reductions of high cost care

Why Become a Patient Centered Medical Home

• It is different than a traditional PCP, being more patient and provider-friendly

• Increased access to care responds to the real-life needs of patients in the community.

• Patients are impowered and utilize fewer staff resources when they use customized self-management plans to achieve goals or manage their diseases

• High-risk patients benefit, as pro-active coordination and follow-up communication by the Care Team saves them (and their caregivers) both time and money

• Staff members report greater happiness when focusing on “what matters most” to the ti tpatient

• Care Coordinators feel pride in collaborating with healthcare providers and community resources

• Providers report satisfaction by keeping their most vulnerable patients out of the hospital

• Care Team members function at their highest level, “to the top of their license or certificate”

• PCMH Accreditation results in higher reimbursement from some payers

Why Become a Patient Centered Medical Home

• PCMH as a Value-Based Strategy

• Medicare has moved to change how it structures payment from a gquantity to a quality approach. It will provide incentives for better processes and outcomes.

• Medicaid programs have made enhanced payments to providers Medicaid programs have made enhanced payments to providers who achieved certain distinctions or process measures.

Why Become a Patient Centered Medical Home

• Every $1.00 increase in Primary care spending equals $13.00 in savings.

• This study provides another piece of evidence supporting the hypothesis that PCMH can lead ot lower cost of care.

• Nevertheless this study shows a consistent pattern suggesting a Nevertheless, this study shows a consistent pattern, suggesting a robust cost saving across all the cost categories. Study shows the PCMH impact on each of the three main components of the total cost: acute inpatient, outpatient, and professional costs.cost: acute inpatient, outpatient, and professional costs.

(Geisinger Study)

Barriers to Becoming a Patient Centered Medical Home

• Resistance to change

• Inadequate financial resources

• Low workforce

• Low adaptive reserve

• Your EHR

• Staff buy in

• Motivation

Rethinking PCMH

• Anything taking you away from patient care is heading in the wrong direction!

• Our Team’s PCMH Accreditation Program focuses on getting back to patient care and looks at day to day operations patient care and looks at day to day operations.

• Its a Winning Approach for both Clinics and Patients.g pp

Good news

• Most practices are already doing much of this informally but not getting credit for it.

• Becoming a PCMH formalizes the process and identifies performance gapsgaps.

Studies show that PCMH:

• Make primary care more accessible, comprehensive and coordinated.

• Provides better support and communication

• Creates stronger relationships with your providers

• Improves patient outcomes

• Lowers overall healthcare costs

Working with a TCT Call Advisor

Our call advisors:

- Walk the practice through the standards line by line in one hour sessions.

- Provide checklists to keep the practice on track.

Trained FacilitatorsWe train facilitators:

To assist ith enrollment• To assist with enrollment

• To be accountability coaches for the practice

• To keep the practice on track

• To guide the practice toward needed resources in the State or other organizations

• To explain how the PCMH model benefits the practice

To encourage the staff throughout the process• To encourage the staff throughout the process

The facilitator is invited to every advisor call so all are on the same page and can be t th d f present on the day of survey.

To date we have trained 23 PCMH Facilitators

The Louisiana Project• State Office of Rural Health Grant and a Small Hospital

• Improvement Program (SHIP) Grant• Improvement Program (SHIP) Grant

• TCT trained 18 Facilitators

• Clinics will have financial support toward their Accreditationpp

• Facilitators will Participate in the Process

• Partnered with The Compliance Team for a Simplified PCMHCollaboration with 

LRHALDHLPCAAHECSBHC

NOSORH

The organization provides advanced access to its patients

• Same day appointments for urgent illness• Evidence of expanded weekday, evening or weekend Evidence of expanded weekday, evening or weekend

appointments• Call coverage or arrangements for after hours emergencies

24/7• A specific plan to handle all types of patient communication

The First Steps in the Journey

• You will feel overwhelmed

• You will wonder how you will ever get buy in from your staff, providers, and administratorsadministrators.

• You will wonder how you will ever meet many of the PCMH Standards much less all of them at the same time.

• The answers to all of these are:• PCMH is a JOURNEY• Form a core team• Form a core team

Our Core Team

From Left to Right: Myself; Brandi Hebron, RN, BSN Assistant PCMH Director; Brittany Edwards, LPN, Referral / Prior Authorization Supervisor & Clinic HIM; Karen Estbrook, RN, Director of Quality Hardtner Medical System; Alishia Varner, LPN, , , Q y y ; , ,PCMH Care Coordinator; Shonna Bell, Patient Access Supervisor; Daphanie Veillion, LPN PCMH Care Coordinator; & Whitney Thompson, Patient Access Supervisor

Our Team

Developing a workflowAttends huddle meetings 

Addresses Health Maintenance as needed  

List of visit cancellations 

List same day appointments  Conduct Huddle Meeting with each team once weekly

Notify PCMH care Coordinator of any High risk\Multiple Ed visits or CCM patient added to schedule  

List of urgent care visits requested in past 24 hours  

Add any test, referrals, and follow up appointments on PCMH Post Visit Medical Summary and give copy 

weekly 

Prepare list of high risk patient and CCM patient that are scheduled for the week  

Follow up with high risk/Multiple ED & admissions, and CCM patient that have been seen within last 72 hours. 

of Summary to the patient  

Conduct Huddle meetings 

Discuss high risk/ Multiple ED/ Admissions and CCM during huddle  

 

The organization meets the needs of patients when they are closed.

• After-hours triage service• Phone access to an on-call provider Phone access to an on call provider • Monitored email inquiry with timely response

A comprehensive written process that provides patients the ability to communicate their healthcare needs after hours

Team Based Approach for Patient-Centered Coordinated Care

• A team can be one Provider, a nurse, and an MA or many other combinations as long as it’s led by a provider

• Patients are assigned to a primary provider

• Written work-flow for all team members

• New patients are educated on the PMCH model and what it e pa e s a e educa ed o e C ode a d a means to them (brochures etc.)

Huddles

One of the most important parts of PCMH!This is when all the hard work completed behind the scenes pays off, because the

providers, are given information that can help them to start their treatment plan. This is also the time from them to give input items they may need to have processes started.

What makes Huddles so Valuable Chart Scrubbing

10/17/2019 13 30 Patient Name 10/7/1951 1234 4 MONTH F/U INFLUENZA VACCINATION 10/1/2018

Visit Date Patient DOB MR# Reason for Visit Health Maintenance Item Next Due

13:30

10/17/2019 15:00

Patient Name 1/13/1951 1234 1 mth f/u back pain

DM with Attention to Nephropathy 4/11/2020

INFLUENZA VACCINATION 10/1/2018

10/17/2019 15:30

Patient Name 9/4/1954 1234 1 mth f/u htn, dizziness, dm

DM with Attention to Nephropathy 9/20/2020

HgbA1C 3/20/2020Influenza Vaccination 65 &

Older 9/19/2020

Additional Chart Notifications to help prompt Nurses and Providers about certain problemscertain problems.

Team Based Approach: The Care Coordinator

The Care Coordinator role is the hub of the Patient Centered Medical Home Medical Home. • Develops a relationship of trust with patients as the “go to

person” for questions and advicep q• Provides direct access to the care team • Organizes and manages the many facets of the medical g g y

community and specialty care• Coordinate with hospital discharge planners

• Connect patients with needed community resources

• Manage medication adherence with the pharmacist

• Assist patients to establish health goals

The Care Coordinator connects….

Patients to Resources in the community.

The Organization ensures Patient Health Records are Complete

B d th l l t PCMH ddBeyond the usual elements, PCMH adds:BMICare plansPatient health goalsBehavioral Screening when symptomatic for depression (PHQ 2 or 9)( )Cognitive health Screening for pts over 65, BIMS (Brief interview of mental status)After-Visit summaryAfter Visit summary

The Organization ensures Patient Health Records are Complete

P t ti H lth Preventative Health Measures:

MammogramsPap SmearsColonoscopyImmunizationsPSAFecal Occult BloodTobacco CessationTobacco Cessation

Key Features

Structured recording of patient health informationMaintaining a comprehensive electronic care planManaging transitions of care and other care management servicesCoordinating and sharing patient healthcare information timely and outsidethe practice

Continuous relationship with a designated member of the care teamPatient support for chronic disease to achieve health goals/ d h l h f24/7 patient access to care and health information

Receipt of preventative carePatient and caregiver engagement

Chronic Care Management

The Chronic Care Model (CCM) is an organizational approach to caring for people with chronic disease in a primary care setting. The system is population-based and

t ti l ti id b d i t ti creates practical, supportive, evidence-based interactions between an informed, activated patient and a prepared, proactive practice team.

After Visit Summary

• Vital signs• Medications• Labs• Labs• Instructions• Follow up

The organization takes steps to reduce unnecessary utilization of services.

Focus:Focus:Hospital readmissionsEmergency Department usage

• Performs after visit calls the following day to provide patient support. h C C di t it i it h it l • The Care Coordinator monitors ED visits, hospital

admissions to identify high risk patients• Train staff to carefully track outside appointment for

records and consult notes• Train patients about ED use

The Organization utilizes a Patient Centered Health Improvement Plan™ (PCHIP)

Addresses individualized health goals, short and long term

Assesses the environmental factors that can affect the patient’s health and compliance

Documenting Family Support in the care plan as a vital resource

•Address the current and future needs of the whole patient•Address the current and future needs of the whole patient

•Address the communication needs of the patient

•Address the patient’s mobility needs, abilities to perform activities of daily living, safety of the home, etc.

•Address healthcare requirements which cannot be met by the organizationg

The Organization utilizes a Patient Centered Health Improvement Plan™ (PCHIP)

“What matters most” to the Patient

Patient would like to….. But is unable to do this due to…•Walk a flight of stairs•Play on the floor with grandchildren•Play on the floor with grandchildren•Drive a car

The organization provides patient education and self management tools to patients and family/caregivers.

• Written material• Audio visual resources• Referrals to individual counseling or groups• Referrals to individual counseling or groups• Medication management tools• Goal oriented action plans

W b b d i t ti h lth • Web based interactive health programs

Patient education and self management tools.

Self Assessment Tools

 

It is important that you weigh yourself first thing in the morning, after voiding.

 

 

     

 

   

 

 

 

 

 

 

 

 

   

 

 

   

 

 

 

 

The organization has a written process for follow-up.

The Importance of Follow‐Up calls

The organization has a written process for follow-up.

• Missed patient appointments• Medication refills requested by Patient• New high-risk medications • New in-home treatments • Abnormal Lab or diagnostic results• Referrals and consultations• Preventative care or screening remindersPreventative care or screening reminders• Care coordination activities• Frequent emergency department use• Hospital discharges• Hospital discharges

The organization collects data for patient satisfaction and dissatisfaction.

TCT offers a Patient Satisfaction portal to our clients.

We aggregate the data so they can compare own performance quarter to quarter to themselves and to other practices.

How do you know you are providing better Care

Patient Satisfaction Surveys from TCT

97.97% 98.04%95.20% 96.97% 98.38% 96.83% 96.77% 97.06%

98.91%95.31%

97.14%95%

100%

95%

100%

YTD Patient Survey Result

88.69% 89.74% 90.48% 89.94% 88.73% 89.38% 91.10%88.98%

84.68% 85%

90%

95%

85%

90%

95%

65 81%70%

75%

80%

70%

75%

80%

65.81%63.98%

55%

60%

65%

55%

60%

65%

50%

55%

50%

55%

Q 1 % Q 2 % Q 3 % Q 4 % Q 5 % Q 6 % Q 7 % Q 8 % Q 9 % Q 10 % Overall Score

N i l S Cli i O llNational Score Clinic Overall

How do you know you are providing better Carey y p g

Unnecessary Emergency Utilization is Reduced

177

0-1.28%

-2%

0%

170

175

180

-3.90%

6%

-4%

160

165

170

156154 -8%

-6%

150

155

148

12%

-10%

140

145

-11.86%

-14%

-12%

130

135

01/01/19 to 07/30/2019 July Aug Sep

# of visits % Change from Previous Month# of visits % Change from Previous Month

Positive outcomes within months!

Stronger team!g• This is due to daily huddles. During our huddles we share

daily work and short term goals. Our huddles help everyone to y g p yknow the goals and work toward them.

• Chart scrubbing has improved the nurse/tech to provider g p pcommunication as well as to the patient. We scrub charts for short and long term goals.

• Our team is a part of our culture of change. We share knowledge daily listen to concerns and work together through h h llthe challenges.

Positive outcomes within 4 months!

• And the best one: We had a patient who was referred to a pulmonologist,

who ordered a PET scan and advised the patient “everything was p y gfine with their lungs”. Upon our referral staff following up and getting the provider’s notes and PET scan results back in our

i k f ll i i b i blsystem. During a 3 week follow up visit now being able to review the PET Scan saw that the patient had a mass in his tonsils and soft palate She was then able to refer the patient totonsils and soft palate. She was then able to refer the patient to an Oncologist, who diagnosed the patient with stage 2 tonsil cancer with mtastasis to the soft palate. The patient is now p preceiving treatment and is doing well.

Kate Hill, RN

215-654-9110

Brandon Dees, RN, NLI Fellow318-495-3131 Ext. 126215 654 9110

khill@thecomplianceteam.org bdees@hardtnermedical.com