Transcript ABC`s of PCMH - Introduction

ABCs of a Thriving PCMH
from a
Provider’s Perspective
The Gulf Region Health Outreach Program
4th Annual Regional Care Collaborative
Sustaining Patient-Centered Medical Home, Improving Population Health
Christopher H. Tashjian MD, FAAFP
HIT fellow using the EHR and practice innovations to increase participation
in the Million Hearts Initiative and improve performance on the Million
Hearts goal
Medical Advisor, Lake Superior QIO
February 24th, 2016
◦ A’s Application
◦ B’s Background
◦ C’s Concept
ABC’s of PCMH
Learning Objectives:
PCMH definition
 History & background of PCMH
 Benefits & Adoption of PCMH
 Clinical Example from the field
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ABC’s of PCMH
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What is this PCMH?
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Patient Centered Medical Home
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1967
ABC’s of PCMH
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1967
ABC’s of PCMH
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The concept of the "medical home" has evolved
since introduction of the terminology by the
American Academy of Pediatrics in 1967, which
was envisioned at the time as a central source
for all the medical information about a child,
especially those with special needs.
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Efforts by Dr. Calvin C.J. Sia, a Honolulu-based
pediatrician, to pursue new approaches to
improve early childhood development in Hawaii
in the 1980s
ABC’s of PCMH
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the American Academy of Family Physicians, American
Academy of Pediatrics, American College of Physicians, and
American Osteopathic Association — the largest primary care
physician organizations in the United States — released the
Joint Principles of the Patient-Centered Medical Home in
2007.
Personal physician
Physician-directed medical practice
Whole person orientation
Care is coordinated and/or integrated
Population health management
Focus on integrating behavioral health into clinic
Quality and safety
Enhanced access
Payment Reform
ABC’s of PCMH
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NCQA: National Committee for Quality
Assurance
2008: PPC-PCMH Recognition program
launched
 2011: PCMH 2011 released
 2014: PCMH 2014 released
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ABC’s of PCMH
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What is Patient Centered Medical Home?
a model(concept) of care that is
patient-centered, comprehensive,
team-based, coordinated, accessible,
and focused on quality and safety.
ABC’s of PCMH
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Studies have shown the benefits
Geisenger Health System ProvenHealth Navigator
PCMH Model
 The system serves more than 2.6 million residents
throughout 44 counties in central and northeastern
Pennsylvania
 Statistically significant 14% reduction in total hospital
admissions relative to controls, and a trend towards a
9% reduction in total medical costs at 24 months.
 Estimated $3.7 million net savings, for a return on
investment of greater than 2 to 1.
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ABC’s of PCMH
ABC’s of PCMH
North Carolina:
Patient Centered Medical Home
implementation saves the state of
North Carolina more than
$200 Million
each year in health care costs.
ABC’s of PCMH
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NCQA developed a set of standards and a 3-tiered
recognition process (Patient-Centered Medical Home
(PCMH) program) to assess the extent to which health care
organizations are functioning as medical home
Obtaining recognition via the PCMH programs requires
completing an application and providing adequate
documentation to show evidence that specific processes
and policies are in place
6 Standards, 28 Elements, 152 Factors
Recognition is offered at three levels:
Level 1 – basic
Level 2 – intermediate
Level 3 – advanced
ABC’s of PCMH
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2014 PCMH Standards
More integration of behavioral healthcare.
Additional emphasis on team-based care.
Focus care management for high-need
populations.
Encourage involvement of patients and
families in QI activities
Alignment of QI activities with the Triple
Aim: improved quality, cost and experience
of care.
Alignment with health information
technology Meaningful Use Stage 2.
ABC’s of PCMH
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Attested could be 38 points
ABC’s of PCMH
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Access During Office Hours
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Must pass is Access During Office
Hours and outside of regular business
hours
ABC’s of PCMH
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Identify and Manage Patient Populations
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Must Pass is Use Data for Population
Management
ABC’s of PCMH
Care Management and Support
 Must Pass is Care Planning and SelfCare Support
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Pre-Visit Planning
 Care Plan
 Evidence Based Guidelines
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ABC’s of PCMH
Care Coordination and Care Transitions
 Must Pass is Referral Tracking & Follow
Up
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ABC’s of PCMH
Referrals
ABC’s of PCMH
ABC’s of PCMH
ABC’s of PCMH
Performance Measurement and Quality
Improvement
 Must Pass is Implement Continuously
Quality Improvement
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PCMH Hypertension Control
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How we have used PCMH at the
Ellsworth Medical Clinic to achieve 90%
BP control for our patients.
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This is practice not theory
Hypertension Goal
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To assure elevated blood pressures
>139/89 for any adult patient are
rechecked and appropriate follow up is
given for HCP follow up. To assure that
abnormal BP information is sent to Care
Coordination following any visit within
the clinic including specialty and
Procedure visits.
A Different Mindset
• We changed our overall thinking
from:
• It’s a physician problem
To
• It’s a team challenge
What does this mean?
• Physicians had to give up TOTAL
ownership
• Staff had to be trained to
understand the problem
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Medical Assistants and Nurses
Lab
Care Coordinators
Front Office
Schedulers
What this really means!
• My patients are my partner’s
patients
• My partner’s patients are my
patients
• Every visit is a hypertension visit!
Starts with Pre-Visit Planning
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Our Medical Assistants (CSS) will
◦ Review the chart and last blood pressures
◦ Review lab work that has been done and
look for what’s overdue
◦ Review co-morbidities
◦ Review Care Management notes and care
plan
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Report to the provider
◦ Usually on half sheet of paper
In the Exam Room
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CSS checks patient BP as the last thing
when rooming patient.
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If BP is not in range based on the BP
range recommended in the chronic
disease guidelines, the CSS will retake
BP using manual cuff if automatic BP
machine used (if time allows).
In the Exam Room
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If still elevated,
CSS will put a
“Blood Pressure
Recheck” magnet
from the inside
door frame and
place on the
outside door
frame for HCP
awareness.
New Idea
In the Exam Room
HCP completes patient exam, reviews
chart and determines if recheck BP is
necessary.
 HCP either checks and documents BP at
end of visit and moves the “Recheck BP”
sign to inside door frame or leaves the
“Recheck BP” sign in place for CSS to
recheck and document BP.
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In the Exam Room
Provider determines best course and
has the patient follow up after change
in plan of care.
 Initiate BP medication titration protocol
 Recommendations are entered into the
EMR.
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Titration Protocols
Titration Protocols
Titration Protocols
Titration Protocols
Titration Protocols
Titration Protocols
Blood Pressure Protocol
Evidence
The JAMA Recs really did focus on evidence-based criteria for blood pressure
treatment guidelines. The JAMA article in late 2013 or early 2014 did lay out a
very good, succinct argument for BP recommendations based both on age
and by disease specific criteria.
There is no RCT that supports a BP target any <140/90 criteria in the general
population. Most RCTs in disease specific populations (CAD and CKD) show
limited difference in outcomes for SBP <150 as compared to <140.
Hence the reason why <150/90 is now an acceptable target goal in ages >60
without DM, CAD, or CKD. Prior versions of JNC really were more centered
around committee/expert opinion. The JAMA committee intentionally tried to
tailor all recommendations based on level of evidence available.
Between Provider Visits
If recheck BP is abnormal, CSS gives
patient a BP card and asks the patient
to return for a BP recheck with the
support staff in one week for additional
BP reading.
 If abnormal, recheck again after 15
minutes rest. CSS documents any
educational materials given
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Between Provider Visits
If BP remains elevated, CSS reviews
HCP progress note for instructions,
documents follow up recommendation
in progress note in EMR and sends a
message to the HCP/Care Coordinator
as needed.
 If BP is normal, patient is instructed to
follow up with HCP at next regular
chronic disease visit.
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Care Coordinators
Review Clinical Course
Use protocols to adjust measurement
Have direct access to mid-level providers
(and physicians when available)
 Recommend medication change per BP
protocol
 Are in contact with patients multiple
times between visits
 Medicare now pays for Chronic Care
Management
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Chronic
Care
Management
Video
Life Style Changes
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Care Coordinators:
Health coaching
Patient goal setting
Trained in motivational interviewing
Discuss life style changes over the phone and when they meet
with patients for blood pressure checks at office visits.
Review tools such as 2gm sodium guidelines provided by the
American Dietetic Association
Review diet information provided by our diabetic
educator/dietician.
 Sample menus
Personalized HTN education uploaded in our EMR
 How to measure your blood pressure?
 What are your BP goals?
Monitoring Protocol Use
• Care Coordinators review HTN patient panels on a monthly
basis:
Identify patients who have elevated blood pressures, review
record and discuss possible changes with the patient’s HCP and
with the patient.
Follow-up with patients who have had a medication changed or
added.
Discuss medication compliance, tolerance, current BP readings,
ensure labs completed if needed. If BP remains elevated-will
communicate to HCP on additional titration needs based off of
protocol
Educate the Clinical Staff on areas of improvement such as the
need to recheck a patient’s BP at every opportunity.
Graph, distribute and display data quarterly
Review data at Quality Leadership Meetings
Graph data over time twice per year to identify trends
Uncontrolled Patient Management
• Care Coordinators:
Meet monthly with each HCP to review BP’s that remain out
of control.
Develop follow up plan including medication titration, follow
up, dietician visit, increased contact with the patient between
HCP visits, frequent BP checks and ongoing education.
Continue to work with patients via the phone, meet with the
patient when here for HCP visits, identify patients not
presenting for visits and making contact, assuring patients
are in our reminder system, assure the entire patient care
team is aware of the patients care plan
Adjusting Work Flow Over Time
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Identify areas of improvement using data over time
Develop a team care approach including “Depart Process” to
assure the patients questions are answered before they leave,
medications are reviewed and understood, education has been
provided
Provide the Clinical Staff with revisions to practice in regards to
BP rechecks: Implement one change at a time
Review compliance/understanding before moving on to the next
change/update
Reinforce the role of the Clinical Staff at patient visits, when
patient is here for BP recheck and with the protocol
Be persistent and willing to try new things (BP recheck slips, BP
recheck contest)
Implementation Strategies
 Strong Quality Leadership group to assist in development
and implementation strategies
 Appoint a “provider champion” to lead implementation
process
 Flow Chart or Process Map current practice then do it again
with the new protocol. Create a visual map.
 Assure Providers and Clinical Staff have a clear
understanding of the protocol and agreement to follow
 Staff education:
• Review the protocol at staff meetings every month during implementation
• Collect, publish, distribute and display data transparently
• Skills Fair for staff
Does it Work?
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In just four years, Ellsworth Medical Clinic
reported the following improvements in
blood pressure control:
◦ Among patients with diabetes, hypertension
control increased from 73% to 97% (2007–2011)
◦ Among patients with cardiovascular disease,
BP control increased from 68% to 97% (2007–
2011)
◦ Currently as of December 2015
ALL patients with hypertension controlled at 85%
Does it work?
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Results for Chris Tashjian,MD/and MA
◦ For December 2015
IVD
BP
52/62
84%
Statin
59/62
95%
Aspirin
62/62
100%
Smoking
52/62
84%
Total (All 4)
43/62
69%
http://millionhearts.hhs.gov
Take the Pledge!
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