Transcript Slide 1

Patient-Centered Medical Home
M4 Seminar
Elizabeth Harlow, MD
University of Nebraska Medical Center
Division of Geriatrics
University of Nebraska Medical Center
Outline
•Patient scenario
•Care management plans
•Basic principles of Patient Centered Medical
Home(PCMH)
•Rework care management plans
•Develop ideas for possible quality improvement
projects
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Objectives
1). List the guiding principles of the PCMH model.
2). Describe how using the PCMH model could improve
patient care.
3). Understand Donabedian’s framework for assessment of
quality.
4). Design a quality improvement project with measurable
outcomes.
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Case Presentation
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Ms. J
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79 yo female
Complicated PMH including dementia, DM, a.fib
Presented to clinic with family for f/u
Family concerns for:
• AMS – increased sleepiness over a few months
• Dehydration
• Thrush
• Advancing dementia
• Recently relocated to nursing home given inability of her
prior AL facility to care for her with advancing dementia.
• Now unable to do any of own ADLs
• Prior to the last 2 months had been able to dress and
toilet self
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Ms. J’s Medications
• APAP 500mg QID
• Duonebs QID
• Chlorthalidone 25mg
qday
• Nystatin swish and spit
• Calcium citrate
• Vitamin D
• Omeprazole 40mg
qday
• Advair 250/50mcg BID
• Furosemide 40mg
qday
• Loratadine 10mg qday
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Memantine 10mgqday
MTV
Olmesartan 20mg qday
Rosuvastatin 5mg qday
Sotalol 120mg BID
Sprinolactone 25mg
qday
Metoprolol 50mg qday
Fluticasone BID
Warfarin 3mg qday
Detemir 15 units qday
Humalog SSI
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Acute Medical Issues
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ARF
AMS
Thrush
Dehydration
Weight loss/malnutrition
Hyperkalemia
A.fib with chronic anticoagulation
HTN: off of diuretics
DM: risk of hypoglycemia with decreased po intake
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Social-Economic Issues
• New NH environment – providers unfamiliar with
patient’s baseline
• Chronically missed appointments for follow up
• Multiple providers utilized by patient
• ADLs/IADLs declining
• Caregiver support
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Medical Care Systems Contributing
• No clear primary care doctor assigned
• Unclear who was responsible for lab follow up causing
delay in acting upon abnormal lab values
• No protocol for missed follow up appointments
• Sporadic visits are all for acute issues, no chronic
disease management
• Medication mismanagement
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Ideal Situation
• Team medical care
• Physician to address acute medical issues
• SW to help address social concerns (living environment
support)
• Nurse case manager to help coordinate follow up
• Pharmacy to monitor medication mismanagement
• Protocols for hospital follow up and missed appointments
• Coordination of care
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What is realistically possible?
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Time constraints of busy clinic
Patient has history of poor follow up
What gets sacrificed off of the ideal list in reality?
Is any of what is sacrificed important for good patient
care?
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The Institute of Medicine defines
primary care as “the provision of
integrated, accessible health care
services by clinicians who are
accountable for addressing a large
majority of personal health care needs,
developing a sustained partnership
with patients, and practicing in the
context of the family and community.” 1996
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Patient Centered Medical Home
• Approach to providing comprehensive care
• Facilitates partnership between patients, personal
physician, and family (when needed)
• Facilitates ideal primary care
• “Provision of comprehensive, coordinated, and
continuous services that provide a seamless
process of care.”
• Focus on this idea of being “patient centered”
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Patient Centered
Defined by Institute of Medicine as “healthcare that
establishes a partnership among practitioners,
patients, and their families (when appropriate) to
ensure that decisions respect patients’ wants, needs,
and preferences and that patients have the education
and support they need to make decisions and
participate in their own care.”
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Patient Centered
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Base care on patient/family needs and preferences
Incorporate shared decision making
Support self-management and self-care techniques
Collaboration with patients in delivery of care
Ensure cultural/linguistic competency
Collect and act upon patient satisfaction data
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Joint Principles of PCMH
• Personal physician – ongoing relationship
• Physician directed team of individuals caring for the
patient
• Whole person orientation – provision for all of the
patient’s healthcare needs
• Coordinated care across all elements of complex
healthcare system
• Quality and safety are hallmarks – evidence based
• Partnership between physician, patient, and family
• Utilization of information technology
• Enhanced access to care
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Focus on Patient Safety
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Standardized documentation of patient information
Facilitation of care transitions
Coordination of care with outside providers
Responsible for provision of evidence-based care
Ongoing efforts at quality improvement
Emphasis on continuity of care
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Accreditation as PCMH
• 2 accreditation bodies
• NCQA
• Joint Commission
• Based on the Joint Principles of PCMH
• Incorporates elements to assess a practice’s ability
to implement patient-centered care
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6 standards
1. Enhance Access and Continuity
2. Identify and Manage Patient Populations
3. Plan and Manage Care
4. Provide Self-Care and Community Support
5. Track and Coordinate Care
6. Measure and Improve Performance
*Each standard has one area considered a “must
pass” element
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Enhance Access/Continuity
PCP is the first point of contact – patient access to
care is an important issue
• Access to culturally and linguistically appropriate
routine and urgent care/advice during and after
hours
• Provision of electronic access
• Patients may select a clinician
• Focus on team-based care
• *Access during office hours
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Geriatrics as PCMH
• Walk in clinic every morning staffed by NPs
• Each patient is seen by a clinical team of MD/NP/Nurse
case manager
• SW also heavily involved in care of many patients
• Clinic briefs at the start of all clinic half days
• As part of UNMC we have access to translators
• Proactive scheduling
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Identify/Manage Patient Populations
• Collects demographic/clinical data for population
management
• Assesses/documents patient risk factors
• *Identifies patients for proactive and point-of-care
reminders
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Geriatrics as PCMH
• Developing ways to notify clinical team of flagged
prevention and chronic care conditions
• Chronic conditions: Dementia, Depression, hospital f/u
• Prevention: Immunizations, vision/hearing screens
• Follow up occurring by nurse case manager for missed
appointments
• Includes rescheduling and trouble-shooting
• Wellness visits implements to ensure preventive care
services have been completed
• Transitional care protocol in place for hospital discharges
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Plan/Manage Care
• Identifies patients with specific conditions
• Includes high risk/complex care needs, health
behaviors, mental health or substance abuse
• *Emphasizes pre-visit planning, progress toward
treatment goals, barriers to treatment goals, gives
patient/family written care-plan
• Reconciles meds at visits and post-hospitalization
• Uses e-prescribing
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Geriatrics as PCMH
• Use of AVS to reiterate treatment plan
• Medications reviewed every visit by pharmacy students
or nursing
• E-prescribing done as able
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Provide Self-Care Support
• Assesses patient/family self-management abilities
• *Works with patient/family to develop self-care plan
• Provides resources (including community)
• Counsels patients on healthy behaviors
• Assesses and provides (or arranges) for mental
health/substance abuse
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Geriatrics as PCMH
• Participation of patient/caregiver in treatment plan
decisions
• Community resources available (SW heavily involved in
this)
• Self-management course (Living Well)
• Free 6 week course on self-management for patients with
chronic diseases
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Track/Coordinate Care
• Tracks/follows-up on and coordinates:
• Tests
• *Referrals
• Care at other facilities
• Follows up on discharged patients
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Geriatrics as PCMH
• Transitions in care protocol
• Nurse case manager phone call within 48 hours
• Clinic f/u visit within 7-14 days depending on acuity
• Nurse case manager f/u on care received in other
facilities
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Measure/Improve Performance
• *Uses performance and patient experience data to
continuously improve
• Tracks utilization measures
• (ex. Hospitalization rates, ER visits)
• Identifies vulnerable populations
• Demonstrates improved performance
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Geriatrics as PCMH
• Utilization of Press-Ganey reports for continual
improvement
• M&M conferences monthly
• Development of transitions in care protocol given data
showing lack of hospital f/u appointments
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Benefits of PCMH
• Evidence to suggest that PCMH improves quality
and returns savings
• Reduced hospitalization and ER visits (Fields, et.
al, 2010)
• Improved patient and provider satisfaction (Reid,
2009)
• Proactive approach to medicine
• Management of chronic problems, not just reaction to
acute issues
• Patient accountability because care is increasingly
focused around the patient (needs, preferences, etc)
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Application for subspecialties
• Open communication with patient’s PCP provides best
clinical outcomes
• PCP as “team leader” of group of providers
• Organized co-management
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Financial Aspects
• Medicare payment systems do not recognize care
coordination services
• Payment based on face-to-face encounters (not
always the most efficient)
• No financial incentive to facilitate coordinated care
• PCMH model recognizes and financially rewards
care coordination efforts
• Due to success seen in PCMH-style patient management
• Goal = Reward healthcare teams for keeping their
patients healthy
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Affordable Care Act and PCMH
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Numerous changes to Medicare
Provisions to improve delivery of care and quality of care
Bonus payments based on quality
Improvement in coverage of preventive services
• Annual Wellness Visit
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Medicare Wellness Visit
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Height, weight, BP, and body mass index
Medical and family history
Review medications, supplements, and vitamins
Discussion of the care currently receiving from other health providers
Review of functional ability, and safety (e.g. risk of falling), cognitive
impairment, and screening for depression
• Personalized health advice taking into account risk factors, & health
conditions including weight loss, physical activity, smoking cessation,
fall prevention, and nutrition
• Discuss referrals for health education or prevention services to
minimize or treat health risks
• Plan a schedule for the Medicare screening and preventive services
over the next five to 10 years.
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Transformation to a PCMH
• Requires commitment to continuous quality
improvement
• Transition to involvement of patient in development
of plan
• Effort toward patient education for self-care
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Ms. J Revisited
• What should have been done differently?
• Would a PCMH model have helped to implement these
changes?
• How could have outcomes been different?
• Does this call for any quality improvement efforts to be
made?
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Quality Improvement and PCMH
• Central goal of a PCMH is to continuously improve
outcomes and quality of care for the patients
• QI projects regarding:
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Preventive care
Chronic care conditions
Patient/family experiences
Disparities in care for vulnerable population
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Quality Improvement Goals
Healthcare that is:
• Safe: Avoid injuries to patients from care intended to help
them.
• Effective: Match care to available evidence
• Patient-centered: Honor the patient and respect their
choices
• Timely: Reduce wait times
• Efficient: Reduce waste of resources
• Equitable: Close racial and ethnic gaps in healthcare
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Setting Goals
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State your goal clearly
Identify the population/system to be improved
Set numerical goals (measurable outcomes)
Give yourself a timeline
Avoid drifting (focus on the goal and try to not steer
away)
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Donabedian’s Framework
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Structure
Characteristics of:
• Community
• Institution
• Patient
• Provider
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Process
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Was the appropriate medical care given?
Is the testing/therapy justified?
Is the testing/therapy competently performed?
Were there unnecessary treatment delays?
Is care coordinated?
Is the care acceptable to the patient?
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Outcome
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Death
Morbidity
Quality of life
Hospital readmissions
Use of resources (length of stay, cost)
Patient’s functional abilities
Patient satisfaction with care received
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Change Concept
An approach to change useful in development of QI efforts
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Eliminate waste
Improve work flow
Manage Time
Reducing variation
Change the work environment
Error proofing (redesign the system)
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Donabedian’s Framework Revisited
• How does Ms. J’s situation fit into the concepts of
structure, process and outcome?
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Structure: Ms. J
• Misses f/u appointments
• No assigned provider team
• New living situation
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Process: Ms. J
• Unclear who will f/u on labs
• Care not coordinated
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Outcome: Ms. J
• Decline in ADLs
• Altered mental status
• Move from ALF to NH
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Quality Improvement
• What are some possible efforts toward QI that this case
brings up?
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Possible QI projects?
• Protocol for lab f/u
• Protocol for hospital f/u
• Dementia education for family
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References
ACP Americana College of Physicians®. (2007, March 5). Joint Principles of a Patient-Centered Medical Home
released by Organizations Representing more than 300,000 Physicians.
Retrieved from http://www.acponline.org/pressroom/pcmh.htm
American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP),
American College of Physicians (ACP), and American Osteopathic Association (AOA). (2011,
February). Guidelines for Patient-Centered Medical Home (PCMH) Recognition and
Accreditation Programs.
American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP),
American College of Physicians (ACP) and American Osteopathic Association (AOA). (2010, December).
Joint Principles for the Medical Education of Physicians as Preparation for Practice in the Patient-Centered
Medical Home.
Donabedian, A. (1966). Evaluating the quality of medical care.
Millbank Memorial Fund Quarterly: Health and Society. 44, 166203.
Donabedian, A. (1988). Quality assessment and assurance: Unity of purpose, diversity of means. Inquiry. 25,
173-192.
NCQA. (2011). Patient-Centered Medical Home. Retrieved from http://www.ncqa.org/tabid/631/default.aspx
TMIT Student Projects Quick Start Package™. (2013). Designing a Student-Run Quality Improvement Project Proposal.
Retrieved from
http://www.docstoc.com/docs/124115900/How-to-Guide_-Starting-a-Student-Run-Quality-Improvement-Project