Your SlideShare is downloading. ×
Patient Centered Medical Home; The Army Medical Department Experience
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Patient Centered Medical Home; The Army Medical Department Experience

8,736
views

Published on


0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
8,736
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
202
Comments
0
Likes
2
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • AUSA Family Forum Brief
  • Transcript

    • 1. Patient Centered Medical Home
      The Army Medical Department Experience
      29 April 2011
      Gary A. Wheeler, MD, COL
      Western Regional Medical Command CMIO
    • 2. “The views expressed are those of the author and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.”
      Slide 2 of
    • 3. Board Certified, Internist
      Fellow, American College of Physicians
      Education: BS, UC Berkeley; MD, USUHS
      Residency: Walter Reed Army Medical Center
      Member, Army Medical Department PCMH WG
      Internal Medicine Consultant, OTSG
      Past jobs:
      Department Chief, Madigan Army Medical Center
      Deputy Commander for Clinical Services (CMO), Weed ACH
      Chief, Clinical Informatics, MAMC
      Chief, Internal Medicine Service, MAMC
      Staff Internist, Walter Reed; Moncrief ACH, Ft Jackson, SC
      Who Am I?
    • 4. Terminal Learning Objectives
      Define Patient Centered Medical Home
      Understand PCMH History
      Identify principles of patient centered care
      Review the current evidence for patient-centered care
      Review the 2008 and 2011 NCQA standards
      Review PCMH implementation in the Army Medical Department
      Introduce the Comprehensive Care Plan
      PATIENT CENTERED MEDICAL HOME
    • 5. PATIENT CENTERED MEDICAL HOME
      Definition
      • Medical home, also known as Patient-Centered Medical Home (PCMH), is defined as "an approach to providing comprehensive care that facilitates partnerships between individual patients and their personal providers and when appropriate, the patient’s family”
    • PATIENT CENTERED MEDICAL HOME
      History
      • American Academy of Pediatrics introduced the term in 1967
      • 6. Model in caring for children with special needs
      • 7. Single source of patients’ medical information (medical record)
      • 8. Grew to include a partnership approach with families to provide primary health care
      • 9. Accessible
      • 10. Family-centered
      • 11. Coordinated
      • 12. Comprehensive
      • 13. Continuous
      • 14. Compassionate
      • 15. Culturally effective
      • 16. Within a decade it was AAP policy
    • PATIENT CENTERED MEDICAL HOME
      History
      • Joint Statement of PCMH Principles – March 2007
      • 17. Four groups
      • 18. American Academy of Family Physicians (AAFP)
      • 19. American Academy of Pediatrics (AAP)
      • 20. American College of Physicians (ACP)
      • 21. American Osteopathic Association (AOA)
      • 22. Represent 333,000 physicians
      • 23. Provide the vast majority of primary care services to children, adolescents, and adult patients in the United States.
    • PATIENT CENTERED MEDICAL HOME
      History - 2007 Joint Statement Principles
      • Personal physician
      • 24. Physician directed medical practice
      • 25. Whole person orientation
      • 26. Care is coordinated and/or integrated across all elements of the complex health care system
      • 27. Quality and Safety
      • 28. Enhanced Access to Care
      • 29. Payment appropriately recognizes the added value
    • PATIENT CENTERED MEDICAL HOME
      Personal Physician
      • Primary care physician
      • 30. Could be a specialist or subspecialist for patients requiring ongoing care for certain conditions
      • 31. Severe asthma
      • 32. Complex diabetes
      • 33. Complicated cardiovascular disease
      • 34. Rheumatologic disorders
      • 35. Malignancies
      • 36. HIV
      • 37. Primary care physicians are defined as physicians who are trained to provide first-contact, continuous, and comprehensive care
    • PATIENT CENTERED MEDICAL HOME
      Primary Care Manager Directed Medical Practice
      • PCM is team leader
      • 38. The personal physician
      • 39. Leads a team of individuals at the practice level
      • 40. Team collectively take responsibility for the ongoing care of patients
    • PATIENT CENTERED MEDICAL HOME
      Whole Person Orientation
      • Respectful, patient centered
      • 41. Not disease centered
      • 42. Not provider centered
      • 43. Family and cultural sensitive
    • PATIENT CENTERED MEDICAL HOME
      Whole Person Orientation
      • Personal physician
      • 44. Provides for all the patient’s health care needs
      or
      • Takes responsibility for appropriately arranging care with other qualified professionals
      Includes care for all stages of life
    • PATIENT CENTERED MEDICAL HOME
      Care is Coordinated and/or Integrated across all levels of care
      • Subspecialty care
      • 48. Hospitals
      • 49. Home health agencies
      • 50. Nursing homes
      • 51. Patient’s community
    • PATIENT CENTERED MEDICAL HOME
      Care is Coordinated and/or Integrated across all levels of care
      • Care is facilitated by
      • 52. registries
      • 53. information technology
      • 54. health information exchange
      • 55. 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.
    • 56. PATIENT CENTERED MEDICAL HOME
      Care is Coordinated and Integrated across all levels of care
    • 57. PATIENT CENTERED MEDICAL HOME
      Quality and Safety
      • Evidenced-based, safe medical care
      • 58. Outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family
      • 59. Evidence-based medicine and clinical decision-support tools guide decision making
      • 60. Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement
    • PATIENT CENTERED MEDICAL HOME
      Quality and Safety
      • Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met
      • 61. Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication
      • 62. Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.
      • 63. Patients and families participate in quality improvement activities at the practice level.
    • PATIENT CENTERED MEDICAL HOME
      Enhanced Access
      • Meet access standards from the patient perspective
      • 64. Enhanced Access to care is available through systems such as open scheduling, expanded hours and new options for communication
    • Comparison of PPC-PCMH and PCMH 2011
      PPC-PCMH (9 standards/30 elements)
      Access and Communication
      Processes
      Results
      Patient Tracking and Registry Function
      Care Management
      Continuity Between Settings
      Self-Management Support
      Electronic Prescribing
      Test Tracking
      Referral Tracking
      Performance Reporting and Improvement
      Measures of Performance
      Patient Experience
      Advance Electronic Communication
      PCMH 2011 (6 standards/25 elements)
      Access and Continuity
      Access - Practice Organization
      Continuity - Electronic Access
      Medical Home Responsibilities
      Identify/Manage Patient Populations
      Plan / Manage Care
      Care Management
      Medication Management
      Self-Management Support
      Track and Coordinate Care
      Test/Referral Tracking
      Facilities
      Community Resources / Referrals
      Performance Measurement and Quality Improvement
      Measures of Performance
      Patient Experience
      Quality Improvement
    • 65. NCQA 2011 standards
      Slide 20
      NCQA has refreshed their recognition standards effective February 1, 2011
      6 Standards
      • Enhance Access and Continuity
      • 66. Identify and Manage Patient Populations
      • 67. Plan and Manage Care
      • 68. Provide Self-Care Support and Community Resources
      • 69. Track and Coordinate Care
      • 70. Measure and Improve Performance
      Achieving NCQA standards will require the AMEDD to optimize all existing IT technologies by aligning them with defined PCMH care delivery processes.
    • 71. PCMH 2011 Alignment with Measures of Meaningful Use
      E-prescribing – medication list, allergies
      Patient tracking/registry – demographics, diagnoses, vital signs, smoking, population management, insurance
      Care management – reminders for follow-up care, decision support, RX reconciliation
      Electronic capability – e-health info. to patient, visit summary, e-access to health information, provider information exchange
      Performance reporting/improvement
    • 72. PATIENT CENTERED MEDICAL HOME
      Outcomes
      Geisinger Health System
      • Implemented a Patient Centered Medical Home redesign in 11 of its primary care practices beginning in 2007.
      • 73. Focus on Medicare beneficiaries, primary care-based care coordination with team models featuring nurse care coordinators, EHR decision-support, and performance incentives.
      • 74. Two year follow-up results:
      • 75. Better quality: Statistically significant improvements in quality of preventive (74.0% improvement), coronary artery disease (22.0%) and diabetes care (34.5%) for PCMH pilot practice sites.
      • 76. Reduction in costs: 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.
      • 77. $3.7 million net savings from the implementation of its PCMH model, for a return on investment of greater than 2 to 1
    • PATIENT CENTERED MEDICAL HOME
      R. A. Paulus, K. Davis, and G. D. Steele, Continuous Innovation in Health Care: Implications of the Geisinger Experience, Health Affairs, Sept./Oct. 2008 27(5):1235?45
    • 78. PATIENT CENTERED MEDICAL HOME
      Outcomes
      Group Health
      • Quality
      • 79. Pilot clinic had an absolute increase of 4% more of its patients achieving target levels on HEDIS quality measures
      • 80. Patients also reported significantly greater improvement on measures of patient experiences, such as care coordination and patient activation.
      • 81. Better work environment
      • 82. Less staff burnout, with only 10% of pilot clinic staff reporting high emotional exhaustion at 12 months compared to 30% of staff at control clinics, despite being similar at baseline;
      • 83. Major improvement in recruitment and retention of primary care physicians.
      • 84. 29% reduction in ER visits 11% reduction in admissions.
      • 85. Investment in primary care of $16 per patient per year was associated with a savings of $17 per patient per year
    • The Quadruple Aim
      Enabling a medically ready force, a ready medical force, and resiliency of all MHS personnel.
      Experience of Care
      Population Health
      Patient and family centered care that is seamless and integrated. Providing patients the care they need , exactly when and where they need it.
      Readiness
      Improving quality and health outcomes for a defined population. Advocating and incentivizing healthy behaviors.
      Per Capita Cost
      Managing the cost of providing care for the population. Eliminate waste and reduce unwarranted variation; reward outcomes, not outputs.
      25
    • 86. Creating Alignment: Military Health System Quadruple Aim
      Readiness
      Pre-, During, and Post-deployment
      Family Health
      Behavioral Health
      Professional Competency/Currency
      Population Health
      Healthy service members, families, and retirees
      Quality health care outcomes
      A Positive Patient Experience
      Patient and Family centered Care, Access, Satisfaction
      Cost
      Responsibly Managed
      Focused on value
      Quadruple Aim as an Enduring Construct for Care
      26
    • 87. Army Medical Home:Experience to Date
    • 88. 35 Hospitals (Parent Sites)
      114 Child Sites
      PCMH early adopters
      11 MTFs with 66 PCMH Teams
      No NCQA recognized sites yet
      PCMH in Army Inventory
      10 of 11
    • 89. OPORD 11-20 published Feb 2011
      9 of 11
    • 90. Army PCMH Model
      PCMH ratios.
      2 exam rooms per PCM
      3.1 support staff
      direct staff who work for a single PCM
      shared staff who work among several PCMs in the PCMH Team
      < two exam rooms per PCM, the enrollment cap will be reduced accordingly
    • 91.
    • 92. Army Medical Home Initiative
      • OPORD 11-20 published Feb 2011
      • 93. NCQA 2008 Self Assessments Feb-Mar 2011
    • Army Medical Home Implementation Timeline
      STAFFING ADJUSTMENTS
      Caveat: Implementation progress depends on Payment Reform, Workforce Transformation, Performance Measure Alignment, Facility Optimization, and Marketing/STRATCOM Effectiveness
    • 94. Phase 1:
      Build the Team and Patient Centered Experience of Care
      Duration: 6-12 Months
      Phase 3:
      Implement Advanced Medical Home Practices
      Duration: 6-12 Months
      Phase 2:
      Manage Demand
      Duration: 6-12 Months
      Team STEPPS
      Staff Roles and Responsibilities
      Building the Patient Partnership
      Service and Communication Standards
      Patient Centered Workflow
      The Huddle
      Empanelment
      Access Management
      E-visits
      Care Coordination
      Population Health
      Comprehensive Care Plan
      Advanced Access
      Team Care
    • 95. Army Medical Home Transformation Plan
      Three phases:
      1. MEDCOM trains Regional transformation teams in San Antonio (Apr 26-28 2011)
      2. Regional teams assess MTF readiness and develop MTF-specific transformation plans. (May-Jun 2011)
      3. Regions oversee and support MTF transformation plans. (Begin NLT Sep 11)
    • 96. Phase 1 Concept of Operation
      1. Command guidance
      Training topics: TSG on PCMH and standardization, Critical Performance Measures, PBAM, Funding, Work Force Transformation
      2. Franchise Model of Operations (based on CBMH model)
      Integrates Team STEPPS and Customer Service training already slated for Army-wide roll-out.
      3. Transformation support
      Informatics, Logistics, Facilities, Marketing and Strategic Communications
      4. Expanding the Team and Scope of Practice
      Integrated Behavioral Health, Post-deployment Health, Pharmacy, Health Promotion and Wellness, Subspecialty Care, Pain Management
    • 97. Key Points
      Community-based and MTF-based PCMH are integrated
      Key leaders for vision, strategy, and implementation plan support both versions of Army Medical Home
      CBMH initiative is “clean slate, start from scratch” version
      MTF MH initiative is “transformative” version
      EHR Workflow reengineering is critical piece for both initiatives
      Secure Messaging will begin deployment this year
      CBMH’s are first priority
      Team-based workflow and processes must be in place first
      Ongoing Tri-Service integration efforts – will be essential component of our success
      Common experience of care
      Resourcing
      Metrics
      Payment reform
    • 98. Community based medical homes
    • 99. 17 Clinics in 11 Markets -- Beginning in Fall of 2010
      Army Community Based Medical Homes
      The Army is Investing inHealthcare Capacity
      • Improve the readiness of our Army & our Army Family
      • 100. Improve access to and continuity of care
      • 101. Facilitate Patient-Centered Medical Home
      • 102. Reduce emergency room episodes
      • 103. Improve patient and provider satisfaction
      • 104. Implement Best Practices & standardize services
      • 105. Increase space available in MTFs for expanded active
      duty and specialty services
      • Improve physical and psychological health promotion
      and prevention
      FT Bragg, NC – 3 clinics
      FT Campbell, KY – 2 clinics
      FT Hood, TX – 3 clinics
      FT Jackson, SC – 1 clinic
      FT L. Wood, MO – 1 clinic
      FT Lewis, WA – 2 clinics
      FT Sam Houston, TX – 1 clinic
      FT Shafter, HI – 1 clinic
      FT Sill, OK – 1 clinic
      FT Stewart, GA – 1 clinic
      Ft Benning – 1 clinic
      8 of 11
    • 106. The Screaming Eagle Medical Home Experience
      29 Nov- Staff assembled for training, TSG ribbon cutting
      29 Dec- Open for patient care
      12,585 Square feet of leased space on Clarksville Gateway Hospital campus
      Pharmacy, Moderate Complexity Lab, Tx Room, Vax onsite
      Radiology from Blanchfield or Gateway
      5/6 PCMs,1 float and Psych NP on-hand
    • 107. Typical Appointment
      Greeted by Patient Care Coordinator
      LPN takes to room, presents orientation packet, acquires vital signs, med reconciliation, allergies, PMH, SHx, acquires HPI, conducts ROS, identifies age appropriate preventive medical and wellness requirements, and documents all.
      Conveys pertinent data to Provider
      Provider engages patient, expounds on history, conducts PE while nurse documents findings
      Assessment and Plan formulated, orders input. Care plan completed
      Physician exits; nurse educates patient as needed
      Warm handoff to lab, pharmacy, Care Coordinator as needed
    • 108. Military treatment facility army medical homes
    • 109. FY 2010 ATC Metrics: Dunham Clinic
      DUNHAM CLINIC %
      MEDCOM %
      TARGET %
      PRIMARY CARE MANAGER (PCM) CONTINUITY
      PRIMARY CARE MANAGER TEAM CONTINUITY
      60%
      85%
      HEDIS
      ARMY PROVIDER LEVEL SATISFACTION SURVEY (APLSS) 52 WEEK AVG.
      90%
      85.5%
      Q9 – OVERALL PHONE SERVICE
      Q13 – STAFF COURTESY / HELPFULLNESS
      Q10 – CONSIDERATE SCHEDULE
      Q14 – COORDINATION OF VISIT
      Q11 – TIME BETWEEN SCHEDULE & VISIT
      Q21 – OVERALL VISIT SATISFACTION
      Q12 – WAIT TIME
      Q11 – TIME BETWEEN SCHEDULE & VISIT
      Q12 – WAIT TIME
    • 110. Internal Medicine ClinicMadigan Healthcare System
      • Approximately 15,000 patients
      • 111. 22 internists / nurse practitioners
      • 112. IM residency continuity clinic
      • 113. Annual well-come visits Nov 2009
      • 114. Pre-visit HEDIS review, lab / rad
      • 115. 30 minute LPN screen pre-visit
      • 116. De novo or copy forward PMHx, PSHx, SocHx, FamHx, Allergies, Med Rec
    • 117. Source: APLSS
    • 118. Sources: a) RVU’s per FTE per Day – Decision Support Center
      b) MEDCOM Target 16.04 RVU’s/FTE/Day – Decision Support Center
    • 119. Sources: a) RVU’s per encounter – Decision Support Center
      b) Workload RVU’s per E/M Code – Decision Support Center
      c) National Average – ACP Practice Management Center
    • 120. Source: June 2010 PIFA Report
    • 121. Source: June 2010 PIFA Report
    • 122. Source: June 2010 PIFA Report
    • 123. Source: June 2010 PIFA Report
    • 124. Source: June 2010 PIFA Report
    • 125. Source: June 2010 PIFA Report
    • 126. Source: June 2010 PIFA Report
    • 127. Army Medical Home:Comprehensive Care Plan
    • 128. Patient Care Landscape - Current
      CPGs
      RGs
      Consults
      Registries
      Discharge
      Summaries
      Essentris ED note
    • 129. PATIENT CENTERED MEDICAL HOME
      History - 2007 Joint Statement Principles
      • Personal physician
      • 130. Physician directed medical practice
      • 131. Whole person orientation
      Care is coordinated and/or integrated across all elements of the complex health care system
      Quality and Safety
      • Enhanced Access to Care
      • 132. Payment appropriately recognizes the added value
    • PATIENT CENTERED MEDICAL HOME
      Communication of care
      One of the best benefits of implementation of the Patient Centered Medical Home is the establishment of standard work. Everyone has an expected role and a way to document. Before the PCMH, reviewing the medical record was like dumpster diving for data
      • Group Health Provider
    • How Do We Integrate Care?
      60
    • 133. Integrating Care Delivery Pathways:The Comprehensive Care Plan Concept
      Slide 61
    • 134. Primary Caregiver Serves as a Portal Between Specialist and the CCP
      The Patient Centered Medical Home (PCMH) Primary Care Team manages the CCP lifecycle with co-management roles defined for the Accountable Care Organization (ACO) and the patient.
      Value Added CCP Lifecycle Activities
      Outcomes (Quadruple Aim)
      Specialist
      Specialist
      Specialist
      PCMH
      CCP
      ACO
      Patient
      All CCP activities are recognized allowing better attribution of value to MHS strategic outcome measures.
      Slide 62
    • 138. Patient Today
      Patient Ideal
      Unhealthy behaviors/High disease burden
      High utilization of resources
      Lower PCMH empanelment capability
      Healthy behaviors/Lower disease burden
      Less utilization of resources
      Higher PCMH empanelment capability
      Comprehensive Care Plan (CCP) Overview
      The Comprehensive Care Plan will be based on a database of organized and searchable
      information and will serve as the primary portal for each patient touch point.
      Patient
      Comprehensive, CoordinatedCare Delivery
      Electronic Representation
      • Individualized: Contains only the information relevant to that patient
      • 139. Automated: Makes proactive requests for care activities
      • 140. Integrated: Organizes information logically from all data sources
      Comprehensive Care Plan (CCP)
      7 of 11
    • 141. Documentation Allows Provider Recognition
      One of the key value propositions from the implementation of PCMH is increased patient-provider interaction and review. Increased documentation allows provider recognition.
      MultipleInteractions
      Documentation Result
      PCM Team
      Face to Face Visit
      Group Visits
      RN Visit
      Case Management
      Telephone
      Email
      Web Visit
      VTC
      Result Review
      Specialty Input
      Specialist
      Specialist
      CCP Documentation
      • Increased awareness of providers implementing the principles of PCMH within their respective teams.
      • 142. Recognition in correlation with the value proposition of a PCMH
    • Transforming into a PCMH:Capabilities Provided by the CCP
      Slide 65
    • 143.
    • 144. All CCP Elements copy forward from AIM to AIM within
      the Triservice Workflow AIM Group
    • 145. Standard CCP
      7 Condition Blocks (each ties to a CPG)
      Metabolic Syndrome (DM, HTN, HLD, Obesity)
      Asthma/COPD
      Low Back Pain
      CV Disease
      Depression/PTSD/SPMI
      Pain Management
      Substance Abuse
      68
    • 146. CCP – 7 Core Items
      Diagnosis
      Goal of Therapy: (Generally pre-populated – example “A1C <7, BP <130/80, LDL<100, BMI <25)
      Actionable data: (Generally pre-populated with name of data – example A1C: 8.2 on 12/16/10)
      Co-managing Team/Consultants: (“Which cooks are in the kitchen?” - nurse/tech will ask pt the 1st time this is documented, any additions can be added by ordering provider)
      Barriers to achieving goal: Provider-driven entry (requires judgment)
      Timeframe for f/u: Provider-driven entry
      Patient’s goal for next appt: Provider-driven entry, negotiated between provider and pt at today’s visit (example: cut smoking rate in ½, exercise additional 1 hr/week, lose 2 lbs, take meds as prescribed)
      Ideally, provider only has to enter these 3 fields. Additional data can be added at provider discretion and copied forward. The above 7 items are the minimum standard for CCP.
      69
    • 147. New Patient To Your Clinic
      36 year Old female
      How do you learn of this patient?
      How should you learn of this patient?
      In a PCMH Clinic what should you do when you learn of your new patient?
      70
    • 148. Initial Intake
      Pro-active data gathering
      71
    • 149. Chart ReviewConducted Prior to Visit By Nurse
      Records review
      Seasonal allergies
      Hyperlipidemia
      BMI 30
      Generalized anxiety
      Family Planning OCP’s
      Smoker
      72
    • 150. Now What?
      Provider Concerns
      Smoking / OCP use
      Quit smoking
      Lipid management
      Weight loss to BMI 25
      73
    • 151. Intake Nurse Visit
      Patient Concerns
      Husband deployed
      Two children under age 8 (one with ADD)
      Full-time job
      Worries all the time
      74
    • 152. Put It All Together(shared decision making)
      Individualized Comprehensive Care Plan (CCP)
      Pt satisfied with SAR tx if she can stop sneezing and itchy eye and not feel tired from any medication (has a job and kids)
      Pt has been thinking about quitting smoking but too much stress right now (contemplative stage with barriers)
      Willing to stop her OCP to reduce stroke risk since husband is deployed anyway
      Willing to see someone about her anxiety but doesn’t want to start any medication that will “knock her out or get her addicted”
      Wants help with her “hyper child” causing her a lot of stress and she gets very frustrated with him.
      She has tried to lose weight many times and will be stressful right now to lose all the weight needed to get to BMI of 25 but willing to work with team to achieve 10% weight loss to reduce risk of medical complications
      75
    • 153. QUESTIONS ?
      gary.a.wheeler@us.army.mil
      76

    ×