Transcript Health Care and Patient Centered Medical Homes

Health Care and Patient
Centered Medical Homes
August 21, 2013
Presenters
•
Paul Kleeberg, MD, FAAFP, FHIMSS
CMIO, Stratis Health
REACH Clinical Director
•
Robin Silbernagel
REACH HIT Consultant - ND
North Dakota Health Care Review, Inc.
•
Chastity L. Dolbec, RN, BSN
Clinical Quality Care Director
Coal Country Community Health Centers
•
Dr. Aaron Garman
Medical Director
Coal Country Community Health Centers
Objectives
• Gain a better understanding of Health Care
Homes (HCH) and Patient Centered Medical
Homes (PCMH)
• Identify the benefits of implementing HCH/
PCMH
• Describe how implementation of HCH/PCMH
can assist in achieving Meaningful Use
Health Care Homes
What is a Health Care Home?
• A “health care home,” also called a “medical
home,” is an approach to primary care in which
primary care providers, families, and patients work
in partnership to improve health outcomes and
quality of life for individuals with chronic health
conditions and disabilities.
• The development of health care homes in
Minnesota is part of the ground-breaking health
reform legislation passed in May 2008. The
legislation includes payment to primary care
providers for partnering with patients and families
to provide coordination of care.
What Constitutes a Health Care
Home?
• Providers who meet and demonstrate the
following set of standards and criteria:
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Access and Communication
Tracking care with a registry
Care Coordination
Care Planning
Quality improvement and performance measures
Patient and family centered care
Access and Communication
Standard
• Offer HCH services to patients at risk or who have complex
chronic conditions
• A system to support effective communication among the
members of the HCH team, the participant, and other providers
• Establish adequate information and privacy security measures
• Access to the patient’s medical record information, which
includes:
– Racial or ethnic background, primary language and preferred
means of communication;
– Consents and restrictions for releasing medical information;
– Diagnoses, allergies, medications, and whether a care plan has
been created for the participant
• On-call staff have access to this medical record information
Access and Communication
Standard – Meaningful Use
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Interoperable EHR
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Stage 1 and 2:
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Demographics
Provider’s name and contact info
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Clinical summary and transfer of care /
referral summary
Preferred method of communication
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Vital signs
Problem list
Medication list
Medication reconciliation
Medication allergy list
Smoking status
Advanced directives (Hospital)
Clinical decision support
E-Prescribing
Labs as structured data
Clinical summaries
Stage 2
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Patient reminders
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Referral/Transfer of care summary
Submit to immunization registry
Provide patients with eCopy
Protect electronic health information
Patient list by specific condition
Family health history
Electronic notes
Imaging results
Provide patients with eAccess
Secure eMessages from patients
Report to cancer registries
Report to specialized registries
2014 Quality Measures
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Documentation of current medications
Functional status for complex conditions
Tracking Care with a Registry
• The registry must contain the name, age,
gender, contact information, and identification
number
• Use the registry to
– Review the HCH participant population to manage
services, follow-up, and identify gaps in care.
– Identify gaps in care and implement remedies
such as appointment reminders and pre-visit
planning.
Tracking Care with a Registry
– Meaningful Use
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Stages 1 & 2:
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Demographics
Vital signs
Problem list
Medication list
Medication reconciliation
Medication allergy list
Smoking status
Advanced directives (Hospital)
Computerized Provider Order Entry
(CPOE)
Clinical decision support
Electronic notes
Labs as structured data
Clinical summaries
Referral/Transfer of care summary
Submit to immunization registry
Submit syndromic surveillance data
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Stage 2
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Provide patients with eCopy or
eAccess
Protect electronic health information
Patient list by specific condition
Patient reminders
Family health history
Imaging results
Report to cancer registries
Report to specialized registries
2014 Quality Measures
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64 potential measures to demonstrate
quality of care and identify gaps
Care Coordination
• The health care home team and the participant set goals
and identify resources to achieve the goals
• Coordinate patient care with specialists
• Identify one personal clinician and one care coordinator as
the primary contact for each patient
• Routine, face-to-face discussions between the personal
clinician and the care coordinator.
• Document:
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Referrals for specialty care and the result of the referral
Tests ordered, and results relayed to the participant
Admissions to other facilities
Timely post discharge planning
Communication with participant's pharmacy
Other information such as links to external care plans
Care Coordination – Meaningful
Use
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Stage 1 & 2:
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Demographics
Vital signs
Problem list
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Medication list
Medication reconciliation
Medication allergy list
Smoking status
Family health history
Advanced directives (Hospital)
Computerized Provider Order Entry (CPOE)
Drug - formulary checks
Drug (D-A, D-D) Interactions
Clinical decision support
E-Prescribing
Labs as structured data
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Patient education
Clinical summaries
Referral/Transfer of care summary
Submit to immunization registry.
Provide patients with eCopy
Protect electronic health information
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Patient list by specific condition
Patient reminders
Stage 2:
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CPOE for labs and radiology
Electronic notes
Imaging results
Report to cancer registries
Report to specialized registries
Electronic access to results with tracking
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Care Plan
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And Stage 1 starting in 2014
Stage 2 Transfer of Care and Referral
summary
Secure eMessages from patients
2014 Quality Measures
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Closing the referral Loop
Care Planning
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Engage all members of the health care team
Incorporate patient’s health risks and chronic conditions
Regularly review and amend the care plan with the patient
Provide current copies of the care plan to the patient
Use evidence-based guidelines for medical services and
procedures
• Include goals and an action plan for:
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preventive care
care of chronic illnesses;
exacerbation of a known chronic condition
end-of-life care and health care directives
• Consolidate external care plans into the participant's care plan.
Care Planning – Meaningful
Use
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Stage 1:
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Demographics
Vital signs
Problem list
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Medication list
Medication reconciliation
Medication allergy list
Smoking status
Advanced directives (Hospital)
Computerized Provider Order Entry
(CPOE)
Drug - formulary checks
Drug (D-A, D-D) Interactions
Clinical decision support
E-Prescribing
Labs as structured data
Patient education
Clinical summaries
•
Referral/Transfer of care summary
Provide patients with eCopy or eAccess
Protect electronic health information
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Patient list by specific condition
Quality measures
Stage 2:
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Family history
Electronic notes
Imaging results
Online access to health information
Secure eMessages from patients
Report to cancer registries
Report to specialized registries
Functional Status
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Stage 2 Clinical and Referral / transfer of
care summaries
Care Plan
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Stage 2 Clinical and Referral / transfer of
care summaries
Quality Measures
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64 potential measures to identify gaps
for care planning
Performance Measure, Quality
Improvement and Reporting
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Staffing and Process Items:
– Establish a quality improvement team and procedures that the team uses to
share their work and elicit feedback
– Participate in a health care home learning collaborative and establish procedures
to share information learned through the collaborative
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Reporting Items:
– Demonstrating capability in performance measurement by measuring, analyzing,
and tracking changes in quality indicators
– Participating in the statewide quality reporting system by submitting outcomes for
the quality indicators
– Achieving the state benchmarks for patient health, patient experience, and costeffectiveness
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Meaningful Use Quality Measures
– 2011 – 2013 standards require reporting 6 of 44 possible quality measures
– 2014 standards require reporting 9 of 64 quality measures
Patient and Family Centered
Care
• Encourage patients to take an active role in
managing their health care
• Patients are engaged in care planning and shared
decision-making
• Verify joint understanding of the care plan
• Provide a copy of the care plan to the patient
• Review and amend the care plan with the patient
• Engage patients in planning for transitions among
providers, and between life stages
Patient and Family Centered
Care – Meaningful Use
• Stages 1 & 2:
– Patient education
– Clinical and Referral / transfer of care Summaries
(Care Plan)
– Patient reminders
– Electronic copy of and timely access to health
information
• Stage 2:
– Online access to health information (Patient Portal)
– Secure electronic messaging
– Reports from within EHR to demonstrate patient
engagement
In Closing
• Health Care Homes are an approach to
primary care in which primary care
providers, families and patients work in
partnership to improve health outcomes
and quality of life for individuals with
chronic health conditions and
disabilities.
Patient Centered
Medical Home
Intro to
Patient Centered Medical Home
Robin Silbernagel
REACH HIT Consultant
Regional Extension Assistance Center for HIT (REACH)
REACH
- Achieving
meaningful
REACH - Achieving
meaningful
use of youruse
EHRof your EHR
Objectives
• History of the Medical Home
• Review the Joint Principles of the Patient
Centered Medical Home
• Accreditation/Recognition Organizations
• Medical Home Initiatives in MN and ND
REACH - Achieving meaningful use of your EHR
21
Background of the Medical Home
Concept
• 1967 – AAP introduces the medical home
concept
• 2002 – AAP published a policy statement
expanding the medical home concept
• 2004 – AAFP developed own model called
“medical home”
• 2006 – ACP developed own model called
“advanced medical home”
• 2007 – AAFP, AAP, ACP and AOA release
the Joint Principles
REACH - Achieving meaningful use of your EHR
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Organizations that developed the
Joint Principles
• AAP – American Academy of Pediatrics
• AAFP – American Academy of Family
Physicians
• ACP – American College of Physicians
• AOA – American Osteopathic Association
REACH - Achieving meaningful use of your EHR
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The Joint Principles
• Personal Physician – each patient has an
ongoing relationship with a personal
physician trained to provide first contact,
continuous and comprehensive care.
• 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.
REACH - Achieving meaningful use of your EHR
24
The Joint Principles cont.
• Whole person orientation – the personal
physician is responsible for providing for all
the patient’s health care needs or taking
responsibility for appropriately arranging care
with other qualified professionals. This
includes care for all stages of life; acute care;
chronic care; preventive services; and end of
life care.
REACH - Achieving meaningful use of your EHR
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The Joint Principles cont.
• Care is coordinated and/or integrated across all
elements of the complex health care system (e.g.,
sub-specialty 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.
REACH - Achieving meaningful use of your EHR
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The Joint Principles cont.
• Quality and safety are hallmarks of the
medical home:
– Practices advocate for their patients to support the attainment of optimal,
patient-centered outcomes that are defined by a care planning process
driven by a compassionate, robust partnership between physicians,
patients, and the patient’s family.
– Evidence-based medicine and clinical decision-support tools guide decision
making.
– Physicians in the practice accept accountability for continuous quality
improvement through voluntary engagement in performance measurement
and improvement.
– Patients actively participate in decision-making and feedback is sought to
ensure patients’ expectations are being met.
REACH - Achieving meaningful use of your EHR
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Quality and Safety cont.
– Information technology is utilized appropriately to support optimal patient
care, performance measurement, patient education, and enhanced
communication.
– Practices go through a voluntary recognition process by an appropriate nongovernmental entity to demonstrate that they have the capabilities to
provide patient centered services consistent with the medical home model.
– Patients and families participate in quality improvement activities at the
practice level.
REACH - Achieving meaningful use of your EHR
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The Joint Principles cont.
• Enhanced access to care is available
through systems such as open scheduling,
expanded hours and new options for
communication between patients, their
personal physician, and practice staff.
REACH - Achieving meaningful use of your EHR
29
The Joint Principles cont.
• Payment appropriately recognizes the added value
provided to patients who have a patient-centered
medical home. The payment structure should be
based on the following framework:
– It should reflect the value of the physician and non-physician staff
patient-centered care management work that falls outside of the
face to face visit.
– It should pay for services associated with coordination of care both
within a given practice and between consultants, ancillary providers
and community resources.
– It should support adoption and use of health information technology
for quality improvement.
– It should support provision of enhanced communication access
such as secure email and telephone consultations.
REACH - Achieving meaningful use of your EHR
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Payment structured cont.
– It should recognize the value of physician work associated with
remote monitoring of clinical data using technology.
– It should allow for separate fee-for-service payments for face-toface visits. (Payments for care management services that fall
outside of the face-to-face visit, as described above, should not
result in a reductions in the payments for face-to-face visits).
– It should recognize case mix differences in the patient population
being treated within the practice.
– It should allow physicians to share in savings from reduced
hospitalizations associated with physician-guided care
management in an office setting.
– It should allow for additional payments for achieving measurable
and continuous quality improvements.
REACH - Achieving meaningful use of your EHR
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Health IT is an “agent of change”
• Strong role for health IT to help
operationalize and implement the key
features of the PCMH, including
supporting quality improvement, patient
education, and enhanced
communication.
REACH - Achieving meaningful use of your EHR
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How does HIT support PCMH?
Ability to:
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Collect, store, manage and exchange relevant personal
health information, including patient-generated data.
Enhance or facilitate communication among providers,
patients, and the patients’ care teams for care delivery and care
management.
Collect, store, measure, and report on the processes and
outcomes of individual and population performance and quality
of care
Support Providers’ decision making on tests and
treatments.
Inform patients about their health and medical conditions
and facilitate their self management with input from Providers.
REACH - Achieving meaningful use of your EHR
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Common Features and Outcomes
of a PCMH
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Features
Outcomes
Dedicated Care Managers
Expanded Access
Data Driven analytic tools
Learning Collaborative
Shared Best Practices
Use of Incentives
• Improved patient experience
• Reduced clinical burnout
• Reduced hospitalization
rates
• Reduce ER visits
• Increase savings per patient
• Higher quality of care
• Reduced costs of care
REACH - Achieving meaningful use of your EHR
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Accreditation and Recognition
• National Committee for Quality
Assurance (NCQA)
• The Joint Commission
• Accreditation Association for
Ambulatory Health Care
• URAC – Patient Centered Health Care
Home
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PCMH activities in ND and MN
• Blue Cross Blue Shield of North Dakota
– MediQHome Program
– PCMH Pilot Program with REACH and 3 ND FQHC sites
• MN Medicaid Department
– MN Health Care Homes
• CMS Innovation Center
– FQHC Advanced Primary Care Practice (APCP) demonstration
project
• HRSA
– The Accreditation Initiative: Accreditation Association for
Ambulatory Health Care (AAAHC) and The Joint Commission
– The Patient Centered Medical Health Home Initiative: National
Committee for Quality Assurance (NCQA)
REACH - Achieving meaningful use of your EHR
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Coal Country Community Health
Center
• CMS Innovation Center
– FQHC Advanced Primary Care Practice (APCP)
demonstration project
– NCQA recognition
• Chastity Dolbec, RN and Clinical Quality Care
Director and Dr. Aaron Garman, Medical Director and
Physician Champion
REACH - Achieving meaningful use of your EHR
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References
American Academy of Family Physicians
http://www.aafp.org/online/en/home.html
American Academy of Pediatrics
http://aappolicy.aappublications.org/policy_statement/index.dtl#M
American College of Physicians
http://www.acponline.org/advocacy/?hp
American Osteopathic Association
http://www.osteopathic.org
Agency for Healthcare Research and Quality (AHRQ)
http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/PCMH_Defining%
20the%20PCMH_v2
http://www.ahrq.gov/news/newsroom/commentaries/pcmh-concept-to-reality.html
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References cont.
National Committee for Quality Assurance (NCQA)
www.ncqa.org
Health Resources and Services Administration
http://bphc.hrsa.gov/policiesregulations/policies/pcmhrecognition.pdf
CMS Innovation Center: FQHC Advanced Primary Care Practice (APCP) demonstration
project
http://innovation.cms.gov/initiatives/FQHCs/
Minnesota Department of Health
http://www.health.state.mn.us/healthreform/homes/about/index.html
Blue Cross Blue Shield of North Dakota MediQHome
https://www.bcbsnd.com/web/providers/mediqhome
REACH - Achieving meaningful use of your EHR
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Key Health Alliance—Stratis Health, Rural Health Resource Center, and
The College of St. Scholastica.
REACH is a project federally funded through the Office of the National Coordinator, Department of Health and
Human Services (grant number EP-HIT-09-003).
REACH
- Achieving
meaningful
REACH - Achieving
meaningful
use of youruse
EHRof your EHR
40
40
Presented by: Coal Country Community
Health Centers
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Have you ever tried to CUT down your
drinking?
Do you get ANNOYED when people ask you
about your drinking?
Do you ever feel GUILTY about drinking?
Do you ever need an EYE OPENER in the
morning?
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Do you feel that all the regulations are
CUTTING YOU DOWN?
Do you get ANNOYED when people ask you
about PCMH?
Do you ever feel GUILTY about missed clinical
opportunities?
Well, here is your EYE OPENER….

Continuous Quality Improvement
◦ Improved patient/family-centered care
◦ Improved patient outcomes through coordinated
comprehensive care
◦ Delivery of a new model of healthcare to align with
the changing healthcare payment systems
◦ Improved patient and staff satisfaction
www.safetynetmedicalhome.org
“Change concepts” are ideas used to promote
steps that lead to improvement.
Patient-Centered Medical Home Assessment
(PCMH-A Tool) ~ an interactive self-scoring
instrument that assists practices in understanding
their current level of “medical homeness”.
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Laying the Foundation
◦ Engaged Leadership
 Ensuring adequate time and resources for providers
and care team members
◦ Quality Improvement (QI) Strategy
 Establish and monitor patient outcomes supported by
evidence-based guidelines
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Building Relationships
◦ Empanelment
 Patients establish a PCP
◦ Continuous & Team-Based Healing Relationships
 Establish a medical home team for delivery of care
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Changing Care Delivery
◦ Organized, Evidence-Based Care
 Identify high-risk (chronic) patients
 Care coordination – case management
◦ Patient-Centered Interactions
 Establish self-management goals and support
 Patient Satisfaction
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Reducing Barriers to Care
◦ Enhanced Access
 Access to care team
◦ Care Coordination
 Integration of behavior health and specialty care
 Track referrals
 Follow-up with all ER visits and hospital discharges
Can you see the light and the need for change?
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6 Standards – 28 Elements
Six “Must-Pass” Elements
◦ Considered the basic building blocks of a PCMH
◦ All 6 must-pass elements are required
◦ Guides practices in PCMH transformation and
continuous quality improvement
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1A: Access during office hours
◦ Provide same day appointments
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2D: Use Data for Population Management
◦ Produce lists of patients needing preventative or
chronic care and use the list to manage the patients
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HTN
Diabetes
CAD
CHF
Immunizations
Mammograms
Paps
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3C: Care Management
◦ Medical home team
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MD/Mid-level
RN Chronic Care Coordinator
Staff Nurse
Shared Nursing Assistant
LRD/ RN Patient Educator
Behavioral Health Provider
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Conducts pre-visit preparations
Collaborates with patient/family to develop an
individual care plan including treatment goals
Gives patient/family a written plan of care
Assesses and addresses barriers when patient
has not met treatment goals
Give the patient/family a clinical summary at
each visit
Identifies patients/families who might benefit
from additional care management
Follows up with patients/families who have not
kept important appointments
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4A: Support Self-Care Process
◦ Provides education resources or refers at least 50% of
patients/families to educational resources to assist in
self-management
◦ Use an EHR to identify patient-specific education
resources and provides to more than 10% of patients
◦ Develops and documents self-management plans/goals
in collaboration with patient for 50%
◦ Documents self-management abilities for 50%
◦ Provides self-management tools to record self-care
results to 50%
◦ Counsels 50% of patients/families to adopt health
behaviors
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5B: Referral Tracking and Follow-Up
◦ Clinical reason for the referral and pertinent clinical
information
◦ Tracks status of referrals including the required
timing for receiving specialist report
◦ Following up to obtain the specialists report
◦ Establishing and documenting agreements with
specialists
◦ Asking patients/families about self-referrals and
requesting reports from clinicians
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6A: Measure Performance
◦ At least 3 preventative and 3 chronic
◦ At least 2 utilization measures affecting costs
◦ Performance data for vulnerable populations
6B:Measure Patient/Family Experience
6C: Implement Continuously Quality
Improvement
◦ Set goals and act to improve performance on 3 measures
from Element A
◦ Set goals and act to improve performance on one
measure from Element B
◦ Set goals and address at least one identified disparity in
care
◦ Involve patients/families in QI teams
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Establish the Foundation
◦ Engaging Leadership
◦ Transforming QA/QI Program
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Establish a New Delivery of Care Model
◦ Patient-Centered Interactions
◦ Organized and Evidence-based care
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Focus on Patient Relationships
◦ Establish Provider/Patient Panels
◦ Establish continuous team based relationship with
patient/family
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Barriers to Care
◦ Enhanced Access
◦ Care Coordination
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Administration and BOD support
Physician or provider champion
◦ Provider engagement = patient engagement
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Office champion
Time & Resources
Communication
Invest in training and educating all staff
Development of a PCMH/MU committee
No “I” in TEAM
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Patient-centered medical home concept
◦ Establish a medical home care team
◦ Quality data
◦ Population management tools
◦ Improve efficiencies
◦ Time and energy
◦ Allocated resources
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REACH
MediQhome – MDdatacor
Other healthcare organizations
◦ Identify a mentor
◦ Create partnerships
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Certification Organizations
◦ AAAHC
◦ NCQA
◦ JCAHO
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PCMH
◦ http://www.ncqa.org/Programs/Recognition/Releva
ntotoAllRecognition/RecognitionTraining.aspx#pcm
h2011
◦ SuccessEHS PCMH Toolkit
◦ SuccessEHS PCMH Self-Assessment Matrix 2012
◦ Fqhcportal.airprojects.org
◦ Safety Net Medical Home Initiative. Change
Concepts for Practice Transformation. 4th ed.
Seattle, WA. Qualis Health and the MacColl Center
for Health Care Innovation; May 2013.
Questions?
Send Questions to:
• Judy Beck
[email protected]
Phone: 701-852-4231
• Jerri Hiniker, BSN, RN, CPEHR
[email protected]
Phone: 952-853-8540
Thank You!
This material was prepared by Stratis Health, the Minnesota Medicare Quality Improvement Organization, under contract
with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human
Services. The materials do not necessarily reflect CMS policy. 10SOW-MN-C9-13-20 082013