Patient Centered Medical Home The Army Medical Department Experience 29 April 2011 Gary A. Wheeler, MD, COL Western Regional Medical Command CMIO
“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
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?
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
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
Model in caring for children with special needs
Single source of patients’ medical information (medical record)
Grew to include a partnership approach with families to provide primary health care
to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
PATIENT CENTERED MEDICAL HOME Care is Coordinated and Integrated across all levels of care
PATIENT CENTERED MEDICAL HOME Quality and Safety
Evidenced-based, safe medical care
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
PATIENT CENTERED MEDICAL HOME Quality and Safety
Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met
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 non-governmental 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.
PATIENT CENTERED MEDICAL HOME Enhanced Access
Meet access standards from the patient perspective
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
NCQA 2011 standards Slide 20 NCQA has refreshed their recognition standards effective February 1, 2011 6 Standards
Achieving NCQA standards will require the AMEDD to optimize all existing IT technologies by aligning them with defined PCMH care delivery processes.
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
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.
Focus on Medicare beneficiaries, primary care-based care coordination with team models featuring nurse care coordinators, EHR decision-support, and performance incentives.
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;
Major improvement in recruitment and retention of primary care physicians.
29% reduction in ER visits 11% reduction in admissions.
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
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
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
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
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
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)
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
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
Implement Best Practices & standardize services
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
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
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
Military treatment facility army medical homes
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
Internal Medicine ClinicMadigan Healthcare System
Care is coordinated and/or integrated across all elements of the complex health care system Quality and Safety
Enhanced Access to Care
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
Integrating Care Delivery Pathways:The Comprehensive Care Plan Concept Slide 61
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
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
Automated: Makes proactive requests for care activities
Integrated: Organizes information logically from all data sources
Comprehensive Care Plan (CCP) 7 of 11
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.
Recognition in correlation with the value proposition of a PCMH
Transforming into a PCMH:Capabilities Provided by the CCP Slide 65
All CCP Elements copy forward from AIM to AIM within the Triservice Workflow AIM Group
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
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
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
Chart ReviewConducted Prior to Visit By Nurse Records review Seasonal allergies Hyperlipidemia BMI 30 Generalized anxiety Family Planning OCP’s Smoker 72
Now What? Provider Concerns Smoking / OCP use Quit smoking Lipid management Weight loss to BMI 25 73
Intake Nurse Visit Patient Concerns Husband deployed Two children under age 8 (one with ADD) Full-time job Worries all the time 74
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