Transcript PATIENT CENTERED MEDICAL HOME Practice Organization

The Patient-Centered Medical Home
(PCMH)
Jane A. Weida, MD, FAAFP
Faculty Associate, Reading Family Medicine Residency
Clinical Associate Professor, Penn State College of Medicine
November, 2009
Republic of Georgia
Summary
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Evidence for the value of primary
care and the PCMH
History of Patient-Centered Medical
Home (PCMH)
Principles of PCMH
Go through a sample office visit
Description of the basic structure of
a PCMH
Why is Primary Care so Important?
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Access to primary care is associated with:
• 33 percent lower cost of care
• 19 percent less likelihood of dying from their medical
conditions than those who receive care from a specialist,
after adjusting for demographic and health
characteristics
• Improved health outcomes for conditions such as
cancer, heart disease, stroke, infant mortality, low birth
weight, and life expectancy
Starfield, B et al: Improving chronic illness care: translating evidence into action.
Health Aff (Millwood). 2001; 20:64-78
Starfield, B et al: Contribution of Primary Care to Health systems and health,
Millbank Quarterly, 2005;83:457-502
Starfield, presentation to The Commonwealth Fund, Primary Care Rountable:
Strengthening Adult Primary Care Models and Policy Options, October 3, 2006
Access to Primary Care
Associated with…
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In both England and the United States, each
additional primary care physician per 10,000
persons is associated with a decrease in mortality
rate of 3 to 10 percent.
In the United States, an increase of just one
primary care physician is associated with 1.44
fewer deaths per 10,000 persons.
Reduced socio-demographic and socio-economic
disparities
Primary Care Delivers Better
Health Outcomes
 mortality
 morbidity
 medication use
per capita expenditures
patient satisfaction
greater equity in health care
SOURCE: B. Starfield, et al., “The Effects of Specialist Supply on
Populations’ Health,” Health Affairs (March 2005); W5-97
Primary Care Delivers Better
Health Outcomes But…
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Patients want more from the healthcare
system and from their physician.
Purchasers of insurance (individuals,
employers, government) are looking for
quality and value.
The U.S. spends 16.5% of its GDP on
health care:
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Runaway healthcare costs must be addressed in ways
that preserve and enhance access to high-quality,
effective medical care that also reduces cost
We Can Do Better: The
Patient-Centered Medical Home
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Introduced by American Academy of Pediatrics
(AAP) in 1967
Initially referred to a central location for medical
records
Medical home concept was expanded in 2002 to
include:
• Accessible
• Continuous
• Comprehensive
• Family-centered
• Coordinated
• Compassionate
• Culturally-sensitive care
The PCMH Concept
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In 2007, the AAP, the American Academy
of Family Physicians (AAFP), the American
Academy of Pediatrics (AAP), the
American College of Physicians (ACP), and
the American Osteopathic Association
(AOA) adopted a set of joint principles to
describe a new level of primary care – the
Patient-Centered Medical Home
Principles of the PatientCentered Medical Home
AAP, AAFP, ACP, AOA
March 2007
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Personal physician
Physician-directed medical practice
Whole person orientation
Care is coordinated and/or integrated
Quality and safety
Enhanced access to care
Payment to support the PCMH
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The PCMH Model is
Evidence-Based
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Studies show the value of care coordinated by a personal
physician using systems-based approaches (the PCMH model)
• Patient-centered primary care has been implemented
successfully in:
 …other nations that have better overall quality scores
and lower costs
 …in the U.S in health care systems like the Veterans
Administration system
Effective care coordination in the ambulatory setting can
reduce hospital admissions and re-admissions for chronic
illnesses (such as diabetes, CHF)
Starfield, presentation to Commonwealth Fund Roundtable on Primary Care, October 2006
Commonwealth Fund, Chartbook on Medicare, 2006
Dartmouth Atlas, Fall, 2006
Let’s Look at a Typical Office Visit
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A 50-year old female thinks she has a
urinary tract infection (UTI). She calls her
doctor’s office on a Monday morning to
get an appointment for herself.
• Gets a busy signal each time she calls; finally
gets through on the fourth try
• Frantic-sounding receptionist tells her the
office is really busy but they will “squeeze her
in” right before lunch. Patient takes the
appointment although it conflicts with a
meeting.
…continued
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Arrives at the office, finds the doctor is running
one hour late.
The doctor takes several minutes to go over
patient’s medications and allergies in paper chart
The doctor confirms presence of a UTI; she gives
the patient a written prescription.
Patient cannot fill the prescription until after
work, then she discovers the medication is not
covered by her health insurance.
…continued
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Patient calls the doctor’s office, which is now closed. The
doctor who is covering calls her back 2 hours later, but the
pharmacy is closed.
Patient calls the doctor’s office back the next day. They call
in a different antibiotic.
Patient also asks for an appointment for her diabetes. It
has never been under good control.
First open appointment is 6 weeks later, and patient is
away on business. She makes an appointment for 10
weeks later.
In the meantime, she is not taking care of her diabetes…
The doctor, overbooked and over-burdened by paperwork,
leaves for home at 8 PM.
This office visit does not provide care
that is:
• Accessible
• Continuous
• Comprehensive
• Family-centered
• Coordinated
• Compassionate
• Culturally-sensitive
What Needs to Change?
We Build a Patient-Centered Medical
Home
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PCMH is built on four building blocks
• Quality measures
• Patient experience
• Health information technology
• Practice organization
The Patient Centered Medical Home
The Family Medicine Model
Great
Outcomes
Practice
Organization
Health IT
Heath
Health
IT
Information
Technology
Quality
Measures
Patient
Patient
Experience
Experience
Family Medicine Foundation
Patient-centered | Physician-directed
Quality Measures
•Referral tracking
Health
Practice
•Lab result tracking
Information
Organization
•Medication
interaction alerts
Technology
•Allergy alerts
•Performance measures
•Map processes to identify efficiencies
•Updated problem list
•Current
medication list
Quality
Patient
•Analyze
data for quality improvement
Measures
Experience
•Discuss best practices
PATIENT CENTERED MEDICAL HOME
Patient Experience
•Same day appointments
Health
•E-mail
Practice
Information
•Web
portal for Rx, appointments,
Organization
Technology
information
•Non-visit based care and support
•Group visits
•Motivational interviewing
•Cultural sensitivity
Quality
•Patient
satisfaction surveys Patient
Measures
Experience
•Shared
decision making with
patients
•Home monitoring
PATIENT CENTERED MEDICAL HOME
Practice Organization
•Leadership Training
Health
Practice
•Team meetings
Information
Organization
•Shared
vision and responsibility for
Technology
quality of care
•Monitor supply and demand
•Ensure adequate and fair distribution of
work
•Budgeting
for forecasting and
Quality
Patient
management
Measures
Experience
•Value contributions of all individuals
•Ongoing education
PATIENT CENTERED MEDICAL HOME
Health Information Technology
•Medication interaction checking
Health
Practice
•Allergy checking
Information
Organization
•Formulary
information
Technology
•Evidence based treatment recommendation
templates
•Home monitoring
•Population health management – disease
registries
Quality
Patient
•Planned
care visits
Measures
Experience
•Internet access
•Point of care answers to clinical questions
PATIENT CENTERED MEDICAL HOME
Great Outcomes
• Good for patients
Great
Outcomes
– Patients enjoy better health.
– Patients share in health care decisions.
• Good for physicians
Practice
Organization
Health
Information
Technology
Quality
Measures
Patient
Experience
– Physicians focus on delivering excellent
medical care.
• Good for practices
– Team works effectively together.
– Resources support the delivery of
excellent patient care.
• Good for payors and employers
Family Medicine Foundation
– Ensures quality and efficiency.
– Avoids unnecessary costs.
The PCMH Model in Action:
North Carolina Community Care Collaborative
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Asthma and diabetes initiatives were developed
due to high prevalence in the North Carolina
Medicaid (government insurance for poor)
population.
Care was coordinated by a primary care physician.
Care included patient education and team
collaboration.
Initial goals focused on reducing unnecessary
hospital admissions and emergency room visits.
Additional quality, efficiency, and cost-control
elements were added later.
The PCMH Model in Action:
North Carolina Community Care Collaborative
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The CCNC Asthma Program
demonstrated cost-effectiveness.
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34% lower hospital admission rate.
8% lower ED visit rate.
Average ED cost for children was 24% lower.
93% received appropriate inhaled steroid
21% increase in asthma patients who have
been staged (type of asthma)
• 112% increase in asthmatic patients receiving
flu shots.
• $3.5 million dollar savings
The PCMH Model in Action:
North Carolina Community Care Collaborative
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Without any concerted efforts to control
costs, the program overall saved $60
million in 2003, $124 million in 2004, and
$231 million in 2005 and 2006.
Almost $1 M in savings achieved during
the first two quarters of 2005 just for
prescription use.
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www.communitycarenc.org
How does a practice transform into
a PCMH
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Need extra time, extra help, extra $$
In Pennsylvania, the Governor created a Chronic
Care Initiative to help practices become medical
homes:
• Provides practice coaches
• Provides extra payments to the practices
• Provides meetings with other practices to share “best
practices” (what works for them)
• Training on registries, group visits, e-visits, referral
tracking, lab results tracking, etc
• Private and government insurers working with doctors to
transform practices.
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It takes 1-2 years to transform an office to a
PCMH
How Does A Practice Transform to
a PCMH
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It is possible to do become a PCMH
without an electronic health record.
In U.S., a practice can be certified as a
PCMH by the NCQA (National Committee
for Quality Assurance)
• The NCQA has an extensive list of
qualifications (see next slide), divided into 9
sections
• The items in bold are “must pass” items
• A practice can be certified as Level 1, 2 or 3,
depending on how many points they
accumulate and how many “must pass”
elements they meet
NCQA PCMH Content & Scoring
Standard 1: Access and Communication
A.
Has written standards for patient access and patient
communication**
B.
Uses data to show it meets its standards for patient
access and communication**
Pts
Standard 2: Patient Tracking and Registry Functions
A.
Uses data system for basic patient information
(mostly non-clinical data)
B.
Has clinical data system with clinical data in
searchable data fields
C.
Uses the clinical data system
D.
Uses paper or electronic-based charting tools to
organize clinical information**
E.
Uses data to identify important diagnoses and
conditions in practice**
F.
Generates lists of patients and reminds patients and
clinicians of services needed (population
management)
Pts
Standard 3: Care Management
A.
Adopts and implements evidence-based guidelines
for three conditions **
B.
Generates reminders about preventive services for
clinicians
C.
Uses non-physician staff to manage patient care
D.
Conducts care management, including care plans,
assessing progress, addressing barriers
E.
Coordinates care//follow-up for patients who
receive care in inpatient and outpatient facilities
Pts
3
Standard 4: Patient Self-Management Support
A.
Assesses language preference and other
communication barriers
B.
Actively supports patient self-management**
Pts
2
4
4
5
9
2
3
3
6
4
3
21
4
3
5
5
20
6
Standard 5: Electronic Prescribing
A.
Uses electronic system to write prescriptions
B.
Has electronic prescription writer with safety
checks
C.
Has electronic prescription writer with cost
checks
Pts
3
3
Standard 6: Test Tracking
A.
Tracks tests and identifies abnormal results
systematically**
B.
Uses electronic systems to order and retrieve
tests and flag duplicate tests
Pts
7
Standard 7: Referral Tracking
A.
Tracks referrals using paper-based or electronic
system**
PT
4
Standard 8: Performance Reporting and
Improvement
A.
Measures clinical and/or service performance
by physician or across the practice**
B.
Survey of patients’ care experience
C.
Reports performance across the practice or by
physician **
D.
Sets goals and takes action to improve
performance
E.
Produces reports using standardized measures
F.
Transmits reports with standardized measures
electronically to external entities
Pts
Standard 9: Advanced Electronic Communications
A.
Availability of Interactive Website
B.
Electronic Patient Identification
C.
Electronic Care Management Support
Pts
1
2
1
2
8
6
13
4
3
3
3
3
2
1
15
4
How does a Practice Transform to
a PCMH
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Level 1 can be achieved with a paperbased chart; an electronic medical record
is not essential for this level
Some of the items you can do with a
paper record include:
• Has written standards for patient access and
patient communications
• Tracks tests and identifies abnormal results
systematically
• Tracks referrals using paper-based or
electronic system
A Patient-Centered Medical Home
Experience
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A 50-year-old female thinks she has a
urinary tract infection (UTI). She goes
online to make an appointment for herself.
• Her doctor’s office offers “open access”,
meaning many appointments are made
for the same day.
• She books an appointment online for 4
pm that day, a convenient time for her.
…continued
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She arrives at her appointment, where the
receptionist informs her that the doctor is
running about 5 minutes behind.
The nurse has updated the patient’s medications
and allergies in the electronic health record
before the doctor enters the room.
She is happy to see her doctor, who looks
relaxed
The doctor confirms presence of a UTI and
prescribes an antibiotic. The electronic medical
record checks for allergies, drug interactions, and
formulary coverage.
The doctor faxes the prescription to the patient’s
pharmacy.
…continued
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Meanwhile, the doctor notices a pop-up reminder
in the patient’s record that patient is due for an
e-visit for his diabetes.
Because of the office’s diabetes registry, the
doctor knows that the patient needs a lipid panel
and urine for microalbumin. These are ordered
and sent to the lab electronically.
The patient’s blood sugars have been under good
control; she checks them regularly at home. She
will send the results electronically to the doctor
before her e-visit.
…continued
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As she checks out after his visit, she makes an
appointment for her e-visit for the following
week.
She then goes to her pharmacy to pick up her
prescription, which is waiting for her.
That evening she thinks of a question for her
doctor. She emails her and knows she will get a
reply within 24 hours…
Having done today’s work today, the doctor
leaves for home at 5 PM.
The Patient-Centered Medical
Home
The care we want to provide
The care we want for our
families