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Developing Health Network

Patient-Centered Medical Home – a

community health center imperative!

Date: Dec 14, 2012Host: GE Foundation

Presenter: Dr. Timothy Long, Alliance of Chicago & Near North Health Center, Chicago, IL

Forum Introduction

3GE Title or job number

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Developing Health™ Program

GE Foundation grants

Skill-based volunteering

$50MM multi-year commitment launched in 2009 Focus on underserved populations across US

Goal:Improve ACCESS to primary care in targeted underserved communities across the US through direct health center support and system capacity building.

How it works:1. Health centers are invited to partner through formal selection process.

2. GE Foundation grants fund programs to drive ACCESS to primary care.

3. Local GE employees and retirees offer skill-based volunteer support.

Leadership network

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4GE Title or job number

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SALT LAKE CITYSALT LAKE CITY

HOUSTON HOUSTON NEW ORLEANSNEW ORLEANS

ATLANTAATLANTA GREENVILLEGREENVILLE

WILMINGTONWILMINGTON

BALTIMORE/DCBALTIMORE/DC

NEW YORK CITYNEW YORK CITY

FAIRFIELD COUNTYFAIRFIELD COUNTY

SCHENECTADYSCHENECTADY

ERIEERIEMILWAUKEEMILWAUKEE

LOUISVILLELOUISVILLE

CINCINNATI CINCINNATI

CHICAGOCHICAGO

LYNN/BOSTONLYNN/BOSTON

A growing network of health center partners…

94 health centers across 27 cities

More than 200 leaders driving93,000 volunteer hours.

80%+ FQHC’s… all with low-income clients

MIAMIMIAMINON GE CITYNON GE CITY

GE CITYGE CITY

DAYTON/KETTERINGDAYTON/KETTERING

GRAND RAPIDSGRAND RAPIDS

2009

2010

2011

2012

GE launch

DETROITDETROIT

LOS ANGELESLOS ANGELES

PHOENIXPHOENIX

JACKSONJACKSON

NASHVILLENASHVILLE

Developing Health™ US ProgramGoal: Improve ACCESS to primary care in targeted underserved communities across the US

through direct health center support and system capacity building.

DALLASDALLAS

ALBUQUERQUEALBUQUERQUE

CLEVELANDCLEVELAND

Leadership Network for health centersSponsored by GE Foundation

What is it?A forum for Developing Health partner health centers to share ideas, challenges and

best practices, facilitated by GE Foundation.

What is the goal?

Enable discussion across health centers to share ideas and challenges, and accelerate learning and best practice adoption.

Possible topics of interestOperating practicesTechnology innovations

Leadership network

GE Foundation grants

Skill-based volunteering

Supply chain management

Staffing challenges

Patient compliance

Chronic disease treatment

GE’s Developing Health™ Program

Agenda:

• NCQA standards of PCMH

• Health Center examples of reaching certain standards

• Health center staff involvement in the process

• Discussions - Q&A

GE’s Developing Health Network

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• The webinar will last for 90 minutes and will consist of a presentation and Q&A

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Webinar Details

• Dr. Long is the Chief Clinical Officer at the Alliance of Chicago Community Health Services (Alliance) and the Interim Medical Director at Near North Health Service Corporation. In this role he is responsible for promoting and facilitating a cohesive Alliance-wide clinical leadership, advancing a vision of quality healthcare and serving as the chief clinical staff to support clinicians, research activities, and users of the Alliance Electronic Health Record System. Since 1997, Dr. Long has been a practicing Internist at Near North Health Service, an urban community health center in Chicago, specializing in preventive and public health care, chronic disease management, and HIV/AIDS care.

• He completed his medical degree at Rush University in Chicago and then finished his Internal Medicine/ Primary Care Residency at John Stroger/Cook County Hospital, with a focus on HIV/AIDS care.

• Dr. Long promotes improving quality healthcare in our network of community health centers through the consistent use of national standardized protocols to serve as basis for computerized clinical decision support. He is a strong supporter of patient engagement through the use of real time use of the EHRS, advancement of Patient Centered Medical Home and promotion of healthcare for the underserved.

Timothy J. Long, MD

Our Speaker

Patient Centered Medical Home -A Community Health Center

Perspective

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Mission

The Mission of Near North Health Service Corporation (NNHSC) is to provide access to high quality health care and to improve the health and well-being of the diverse populations and communities we serve. We are a culturally sensitive, patient centered community health center that empowers individuals through education and health prevention, regardless of one’s ability to pay.

Vision

To be nationally recognized and locally known as the Patient Centered Medical Home of choice that lives by its values and is trusted and respected by an informed and engaged patient population.

Near North Profile

No. of health centers – 8 2011 Patient Visits – 103,022

No. of WIC locations - 3 2011 Non-Clinical users - 11,308

Organization Size - 219 Operating Budget - $18.6M

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Near North served approximately 11,308 non-clinical users in fiscal year 2011 through its programs, which include:

Healthy Start/Healthy Families Illinois Alcohol and Substance Abuse Case Management/Outreach Postpartum Depression Chicago Family Case Management Teen Clinic Kid Care/Family Care/All Kids/MPE Mental Health Services WIC/Nutrition Education Oral Health Expansion ProgramEIS HIV/AIDS Domestic Violence Crime Intervention Program Family Support Initiative Neighborhood Referral Program Breast Feeding Diabetes Management Program Youth Focused Programs Information Communication Technology

Patient Centered Medical Home –Community Health Center

Perspective

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We would like to know your health center PCMH certification/recognition?

- Level 1

- Level 2

- Level 3

- In the process of NCQA PCMH recognition

- Joint Commission Primary Care Medical Home certification

Polling Question

∗ Communication

∗ Access

∗ Convenience

∗ Coordination

∗ Responsiveness

∗ Source: Medfusion, an AAFP affinity partner, 2008

Patients today are savvy consumers of health care and have higher expectations.

∗ 75% want the ability to interact with their physician online (appointments, prescriptions, test results).

∗ 77% want to ask questions without a visit.

∗ 75% want email access as part of their overall care.

∗ 62% of patients say access to these services would influence their choice of physicians.

∗ Source: Medfusion, an AAFP affinity partner, 2008

Patient Expectations

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A PCMH puts patients at the center of the health care system and provides primary care that is:

“accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and

culturally effective.”

(American Academy of Pediatrics)

So what is a Patient Centered Medical Home?

Brief History Of The PCMH

AAP “Medical Home”Records

AAP Medical Home Provider Policy

AAFP Future of Family Medicine

PCPCC

Joint Principles of PCMH

NCQA-PCMH

PPACA

CMMI

ACOs

Private Payer Initiatives

Direct Primary Care

CPCI

Advanced Primary Care

1960s

2000s

2010s

Future

1990s

∗ The Patient Centered Medical Home is a care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when andwhere they need it, in a manner they can understand.

Again, what is a PCMH?

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∗ A central setting that facilitates partnerships between individual patients, and their personal providers, and when appropriate, the patient’s family.

∗ Care is facilitated by patient registries, health information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it

∗ Care is delivered in a culturally and linguistically appropriate manner.

PCMH Objectives

∗ A personal provider who coordinates all care for patients and leads the team.

∗ Provider-directed care – 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.

“Joint Principles” of the Patient-Centered Medical Home

∗ HRSA and CMS are incentivizing FQHCs to become Patient Centered Medical Homes.

∗ Many commercial payers now have PCMH programs.

∗ 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.

∗ Local and National Collaborative are forming.

*www.pcpcc.net

Growing Support for the Patient-Centered Medical Home

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∗ Community orientated ambulatory primary care

∗ Health promotion and behavior change

∗ Chronic disease management

∗ Maternity care

∗ Well-child care and child development

∗ Preventive health care and wellness

∗ Primary mental health care

∗ Social Needs

∗ Hospital care

Community Health CentersHow we provide care:

Change is here and we are ready!∗ Patients want more from the healthcare system and from their providers.

∗ 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.

∗ There are ways to do both!

The Patient-Centered Medical Home as a Preferred Model of Care

∗ Become a true medical home: a health center of the 21st

century, where care is coordinated, accessible, and keeps patients at the center

∗ “Provider of Choice” for patients

∗ Develop more efficient, effective, patient centered processes

∗ Continue our journey to use technology to leverage quality

∗ Staff Satisfaction and Improved Morale

Rationale for Obtaining PCMH Recognition

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∗ NCQA Recognition by September 2013

∗ At least Level 2, but goal is Level 3.

∗ Continuous process of becoming more efficient

∗ Continuous process of becoming more patient-centered

Goal in Seeking Recognition

It’s time for PCMH!

Timeline & Approach

Spring 2013: Evaluate, Modify, and Run Reports

Laying the Foundation: Team Huddles, Patient Panels

Laying the Foundation: Open Access Scheduling

Patient Engagement: Update Processes at Reg & Intake

Documenting New processes: Policies, Reports, Workflows

Measure and Improve Performance: Engage in CQI & Publish Outcomes

June 2013: Submit Survey

September 2013: Obtain Recognition

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PCMH Recognition is based on meeting specific elements included in six standard categories.

1. Enhance Access and Continuity

Accommodate patients’ needs with access and advice during and after hours, give patients and their families information about their medical home and provide patients with team-based care

NCQA Standards

PCMH Recognition is based on meeting specific elements included in six standard categories.

2. Identify and Manage Patient Populations

Collect and use data for population management

NCQA Standards

PCMH Recognition is based on meeting specific elements included in six standard categories.

3. Plan and Manage Care

Use evidence-based guidelines for preventive, acute and chronic care management, including medication management

NCQA Standards

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PCMH Recognition is based on meeting specific elements included in six standard categories.

4. Provide Self-Care Support and Community Resources:

Assist patients and their families in self-care management with information, tools and resources

NCQA Standards

PCMH Recognition is based on meeting specific elements included in six standard categories.

5. Track and Coordinate Care

Track and coordinate tests, referrals and transitions of care

NCQA Standards

PCMH Recognition is based on meeting specific elements included in six standard categories.

6. Measure and Improve Performance

Use performance and patient experience data for continuous quality improvement

NCQA Standards

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∗ Standard 1A: Access During Office Hours

∗ Standard 2D: Using Data for Population Management

∗ Standard 3C: Care Management

∗ Standard 4A: Self-Care Process

∗ Standard 5B: Referral Tracking and Follow-Up

∗ Standard 6C: Implement Continuous Quality Improvement Process

NCQA Must-Pass Elements

One Patient Entire Patient Population

Paradigm Shift

PatientPartner in Health Care

Lone Provider Team Based Health Care

An Ultimate AuthorityShared Decision Making

Acute, Episodic CarePlanned, Proactive Whole Person Care

Disparities In CareEvidence Based Medicine

• Engaged Leadership• Quality Strategy

Laying the Foundation

• Empanelment• Continuous, team-based healing relationships

Building Relationships

• Patient-Centered Interactions• Organized, evidence-based care

Changing Care Delivery

• Enhancing Access• Care Coordination

Reduce Barriers to Care

Keep It Simple and Manageable

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∗ Leadership Team∗ PCMH Project Team∗ Providers∗ Nurses∗ Medical Assistants∗ Front Office∗ Educators∗ Referral Team∗ Behavioral Health/ Case Management

Roles & Responsibilities

Team Based Care

• Physicians

• APN/PA

• RN/LPN

• Medical Assistant

• Office Staff

• Care Coordinators

• Nutritionists/Educators

• Pharmacist

• Behavioral Health

• Case Manager

• Social Worker

• Community Resources

• Hospitals

What will it mean for me?

New Clinical Operations

• Staff Training and re-training

• New P&P

• New workflows

• Practice at the top of your license

• Population Health Management

• Patient Panels

• Team Huddles

• New communication mechanisms

• Pre-visit preparations

• Educate patients about continuity of care

• Include patients in QI activity

• Patient Portal

• Notification of Normals

Getting recognized by NCQA is a stepping stone to becoming a true medical home

∗ NCQA process is time and labor intensive

∗ Job functions will be modified- for the better!

∗ Willingness of all to make this change

∗ 100 hours of documentation!

What will it take?

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Next Steps

Q&A

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Near North is a community based Federally Qualified Health Center operating eight primary health care facilities and three supplementary WIC sites in medically underserved Chicago areas: Cottage View Health Center’s focus is on the local senior citizen population.

Denny Community Health Center serves the residents of Lawson House and surrounding Near North communities.

Flannery Health Center is located inside the Thomas J. Flannery Apartments and serves the Near North neighborhood with its primary focus on the surrounding senior community.

Komed Holman Health Center serves the south side communities of Kenwood, Oakland and Grand Boulevard.

Reavis School-Based Health Center is located inside of the Reavis Elementary School and serves the students along with members of the Bronzeville, Grand Boulevard, and Kenwood/Oakland communities.

Uptown Community Health Center serves the Uptown, DePaul, Lincoln Park, North Park and Wicker Park communities located on the north and northwest side.

Winfield Moody Health Center serves the Near North, Cabrini-Green, West Town, and Humboldt Park communities.

Louise Landau Health Center serves the Southwest Humboldt Park community.

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Near North’s staff is composed of approximately 219 employees, including physicians, advance practice nurses, physician assistants, clinical support staff, social services staff, public health nutritionists and dieticians, Alliance, contractual and administrative staff.

In fiscal year 2011, Near North had a total of 103,022 center visits.

Komed Holman saw 13,384 users, while Winfield Moody saw 13,467 users, Uptown saw 747 users, Louise Landau saw 3,884 users, Denny saw 684 users, Reavis saw 575 users and Cottage View saw 1,593 users.

Near North operates annually with a budget of approximately $18.6M, which includes a percentage of free care for uninsured users of our programs and services that qualify for the sliding fee scale.