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Patient Centered Medical Home; The Army Medical Department Experience
 

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Patient Centered Medical Home; The Army Medical Department Experience Patient Centered Medical Home; The Army Medical Department Experience Presentation Transcript

  • 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
  • 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
    • 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
    • Accessible
    • Family-centered
    • Coordinated
    • Comprehensive
    • Continuous
    • Compassionate
    • Culturally effective
    • Within a decade it was AAP policy
  • PATIENT CENTERED MEDICAL HOME
    History
    • Joint Statement of PCMH Principles – March 2007
    • Four groups
    • American Academy of Family Physicians (AAFP)
    • American Academy of Pediatrics (AAP)
    • American College of Physicians (ACP)
    • American Osteopathic Association (AOA)
    • Represent 333,000 physicians
    • 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
    • Physician directed medical practice
    • 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
    • Payment appropriately recognizes the added value
  • PATIENT CENTERED MEDICAL HOME
    Personal Physician
    • Primary care physician
    • Could be a specialist or subspecialist for patients requiring ongoing care for certain conditions
    • Severe asthma
    • Complex diabetes
    • Complicated cardiovascular disease
    • Rheumatologic disorders
    • Malignancies
    • HIV
    • 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
    • The personal physician
    • Leads a team of individuals at the practice level
    • Team collectively take responsibility for the ongoing care of patients
  • PATIENT CENTERED MEDICAL HOME
    Whole Person Orientation
    • Respectful, patient centered
    • Not disease centered
    • Not provider centered
    • Family and cultural sensitive
  • PATIENT CENTERED MEDICAL HOME
    Whole Person Orientation
    • Personal physician
    • 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
    • acute care
    • chronic care
    • preventive services
    • end of life care
  • PATIENT CENTERED MEDICAL HOME
    Care is Coordinated and/or Integrated across all levels of care
    • Subspecialty care
    • Hospitals
    • Home health agencies
    • Nursing homes
    • Patient’s community
  • PATIENT CENTERED MEDICAL HOME
    Care is Coordinated and/or Integrated across all levels of care
    • Care is facilitated by
    • registries
    • information technology
    • health information exchange
    • 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.
  • 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
    • Enhance Access and Continuity
    • Identify and Manage Patient Populations
    • Plan and Manage Care
    • Provide Self-Care Support and Community Resources
    • Track and Coordinate Care
    • 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.
  • 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.
    • Two year follow-up results:
    • 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.
    • 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.
    • $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
  • PATIENT CENTERED MEDICAL HOME
    Outcomes
    Group Health
    • Quality
    • Pilot clinic had an absolute increase of 4% more of its patients achieving target levels on HEDIS quality measures
    • Patients also reported significantly greater improvement on measures of patient experiences, such as care coordination and patient activation.
    • Better work environment
    • 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 Medical Home:Experience to Date
  • 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
  • OPORD 11-20 published Feb 2011
    9 of 11
  • 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 Initiative
    • OPORD 11-20 published Feb 2011
    • 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
  • 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
  • Community based medical homes
  • 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
    • Improve access to and continuity of care
    • Facilitate Patient-Centered Medical Home
    • Reduce emergency room episodes
    • Improve patient and provider satisfaction
    • 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
    • Approximately 15,000 patients
    • 22 internists / nurse practitioners
    • IM residency continuity clinic
    • Annual well-come visits Nov 2009
    • Pre-visit HEDIS review, lab / rad
    • 30 minute LPN screen pre-visit
    • De novo or copy forward PMHx, PSHx, SocHx, FamHx, Allergies, Med Rec
  • Source: APLSS
  • Sources: a) RVU’s per FTE per Day – Decision Support Center
    b) MEDCOM Target 16.04 RVU’s/FTE/Day – Decision Support Center
  • 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
  • Source: June 2010 PIFA Report
  • Source: June 2010 PIFA Report
  • Source: June 2010 PIFA Report
  • Source: June 2010 PIFA Report
  • Source: June 2010 PIFA Report
  • Source: June 2010 PIFA Report
  • Source: June 2010 PIFA Report
  • Army Medical Home:Comprehensive Care Plan
  • Patient Care Landscape - Current
    CPGs
    RGs
    Consults
    Registries
    Discharge
    Summaries
    Essentris ED note
  • PATIENT CENTERED MEDICAL HOME
    History - 2007 Joint Statement Principles
    • Personal physician
    • Physician directed medical practice
    • 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
    • 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)
    • Experience of Care
    • Population Health
    • Readiness
    • Per Capita Cost
    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
  • Initial Intake
    Pro-active data gathering
    71
  • 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
  • QUESTIONS ?
    gary.a.wheeler@us.army.mil
    76