The Patient Centered Medical Home:   Using Patient Registries and Automated Patient Outreach to Qualify for NCQA Level 3 M...
The Joint Principles of the Patient Centered Medical Home (PC-MH) AAFP, AAP, ACP, AOA:  March, 2007 <ul><li>Personal physi...
Core Care Components  & Infrastructure Components
Patient Centeredness … <ul><li>Delivers effective treatment by a trustworthy physician & medical staff. </li></ul><ul><li>...
 
The Current Model of Care: Connection by Billing Insurer
The Future Model of Care:  Patient Centered Integrated Delivery System Sub-specialty “Medical Home Neighbors” Referrals an...
 
 
PCPCC–THE BUYERS OF HEALTHCARE
Linkage of PCMH to Reimbursement: One Model <ul><li>Enhanced Fee Schedule for Visits/Procedures </li></ul><ul><li>E&M Codi...
Which Payment System Is Best? Depends on the Disease/Condition
<ul><li>Since 1999, the state has invested in many MH components through disease management payments to practices with Med...
Geisinger Medical Home Sites and Hospital Admissions Source: Geisinger Health System, 2008. Hospital admissions per 1,000 ...
Geisinger Medical Home Pilot Sites Reduce Medical Cost Source: G. Steele, “Geisinger Quality—Striving for Perfection,” Pre...
Cost Savings of DM Management
National Committee for Quality Assurance (NCQA) <ul><li>Currently, the most used “stamp” of approval </li></ul><ul><li>Pra...
PPC-PCMH: What it is <ul><li>Provides valid, reliable and “auditable” means for incentivizing investment in quality infras...
PPC-PCMH: What it’s NOT <ul><li>The definition of a PCMH </li></ul><ul><ul><li>The joint principles (and others as well) “...
Physician Practice Connections/PCMH January, 2008
PPC-PCMH Content and Scoring ** Must Pass Elements <ul><li>Standard 1: Access and Communication </li></ul><ul><li>Has writ...
Phytel Patient Outreach Patient-Centered Medical Home (PPC-PCMH™) Qualification <ul><li>PPC2: Patient Tracking and Registr...
 
<ul><li>INITIAL LESSONS LEARNED </li></ul><ul><li>1. Personal Transformation of Physicians Required </li></ul><ul><li>2. T...
<ul><li>PRACTICE RECOMMENDATIONS </li></ul><ul><li>Establish Realistic Expectations for Time and Effort </li></ul><ul><li>...
Redesigned Work Flow <ul><li>1.  Communication  - enhanced electronically, daily  huddles, monthly staff & weekly committe...
IMPROVING THE CARE OF CHRONIC DISEASE
DISEASE MANAGEMENT
What Phytel Does <ul><li>Phytel Mines Data </li></ul><ul><li>This data will help your practice begin to meet the challenge...
What Phytel Does <ul><li>Phytel has scripted messages to contact patients via telephone. </li></ul><ul><li>The system is s...
Primary Care Protocol Set* <ul><li>Appointment Reminders/Missed Appointment F/U </li></ul><ul><li>Prevention/Screening: </...
PATIENT REGISTRIES
 
MEASURING PATIENT-CENTEREDNESS
SUMMARY POINTS <ul><li>PCMH - revolutionary redesign of primary healthcare delivery, repositioning the doctor-patient rela...
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Using Patient Registries and Automated Patient Outreach to Qualify for NCQA Level 3 Medical Home

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  • Community Care of North Carolina Projects – relied heavily on population health management, physician-led teams for case management, and community-based networks to deliver care. Also, physicians were given a per member per month fee for Medicaid pts and also enhanced fee for service payment. Many publications cite significant improvements in cost, utilization, and quality measures.
  • Using Patient Registries and Automated Patient Outreach to Qualify for NCQA Level 3 Medical Home

    1. 1. The Patient Centered Medical Home: Using Patient Registries and Automated Patient Outreach to Qualify for NCQA Level 3 Medical Home Joseph Mambu MD CMD CHE November 2009
    2. 2. The Joint Principles of the Patient Centered Medical Home (PC-MH) AAFP, AAP, ACP, AOA: March, 2007 <ul><li>Personal physician </li></ul><ul><li>Physician directed medical practice </li></ul><ul><li>Whole person orientation </li></ul><ul><li>Enhanced access to care </li></ul><ul><li>Care is coordinated and/or integrated </li></ul><ul><li>Quality of care / culture of patient safety </li></ul><ul><li>Payment reform </li></ul>
    3. 3. Core Care Components & Infrastructure Components
    4. 4. Patient Centeredness … <ul><li>Delivers effective treatment by a trustworthy physician & medical staff. </li></ul><ul><li>Offers access to timely reliable healthcare information and advice. </li></ul><ul><li>Considers patients’ cultural traditions, their personal preferences, values and their family situations. </li></ul><ul><li>Involves the patient in all decision making and respects the patients’ preferences and right to decline treatment. </li></ul><ul><li>Makes the patient & loved ones an integral part of the healthcare team collaborating with the team in making clinical decisions. </li></ul><ul><li>Puts responsibility for important aspects of self-care and monitoring in patients’ hands — along with the necessary tools and support .  </li></ul><ul><li>Ensures that transitions between providers, departments and health care settings are respectful, coordinated, and efficient. </li></ul><ul><li>When care is patient centered, then unneeded and unwanted services can be reduced. </li></ul>
    5. 6. The Current Model of Care: Connection by Billing Insurer
    6. 7. The Future Model of Care: Patient Centered Integrated Delivery System Sub-specialty “Medical Home Neighbors” Referrals and Procedures Insurer Patient Centered Hospital Patient Centered Medical Home Data Center
    7. 10. PCPCC–THE BUYERS OF HEALTHCARE
    8. 11. Linkage of PCMH to Reimbursement: One Model <ul><li>Enhanced Fee Schedule for Visits/Procedures </li></ul><ul><li>E&M Coding </li></ul>Monthly Management Fee per patient Based upon NCQA level of recognition Quality, and Patient Experience Based upon performance reporting and patient satisfaction reporting Profit-sharing
    9. 12. Which Payment System Is Best? Depends on the Disease/Condition
    10. 13. <ul><li>Since 1999, the state has invested in many MH components through disease management payments to practices with Medicaid pts. </li></ul><ul><li>Emphasis on physician led team approach, disease tracking & care managers within practices. </li></ul><ul><li>Significant improvements in cost, utilization, and quality measures. Two major evaluations estimate it CNCC saved the state between $230 and $260 million in 2004. </li></ul>Community Care of North Carolina
    11. 14. Geisinger Medical Home Sites and Hospital Admissions Source: Geisinger Health System, 2008. Hospital admissions per 1,000 Medicare patients
    12. 15. Geisinger Medical Home Pilot Sites Reduce Medical Cost Source: G. Steele, “Geisinger Quality—Striving for Perfection,” Presentation to The Commonwealth Fund Bipartisan Congressional Health Policy Conference, Jan. 10, 2009. Allowed per member per month
    13. 16. Cost Savings of DM Management
    14. 17. National Committee for Quality Assurance (NCQA) <ul><li>Currently, the most used “stamp” of approval </li></ul><ul><li>Practices can apply for and achieve “recognition” (not certification . . ) </li></ul><ul><li>Three levels possible </li></ul><ul><li>Long application </li></ul><ul><li>Fees involved </li></ul><ul><li>Can re-apply/get level changed </li></ul>
    15. 18. PPC-PCMH: What it is <ul><li>Provides valid, reliable and “auditable” means for incentivizing investment in quality infrastructure and processes </li></ul><ul><li>Encourages practices to adopt proven systems for improving care </li></ul><ul><li>Complements evaluation of clinical effectiveness, patient experiences, and efficiency </li></ul>
    16. 19. PPC-PCMH: What it’s NOT <ul><li>The definition of a PCMH </li></ul><ul><ul><li>The joint principles (and others as well) “define” the PCMH </li></ul></ul><ul><li>A tool to “certify” practices as medical homes </li></ul><ul><ul><li>It, along with attestation only qualifies a practice as having met the basic standards that COULD be a PCMH </li></ul></ul><ul><li>Permanent in content and scoring </li></ul><ul><ul><li>Was designed to evolve over time </li></ul></ul>
    17. 20. Physician Practice Connections/PCMH January, 2008
    18. 21. PPC-PCMH Content and Scoring ** Must Pass Elements <ul><li>Standard 1: Access and Communication </li></ul><ul><li>Has written standards for patient access and patient communication** </li></ul><ul><li>Uses data to show it meets its standards for patient access and communication** </li></ul>Pts 4 5 9 <ul><li>Standard 2: Patient Tracking and Registry Functions </li></ul><ul><li>Uses data system for basic patient information (mostly non-clinical data) </li></ul><ul><li>Has clinical data system with clinical data in searchable data fields </li></ul><ul><li>Uses the clinical data system </li></ul><ul><li>Uses paper or electronic-based charting tools to organize clinical information** </li></ul><ul><li>Uses data to identify important diagnoses and conditions in practice** </li></ul><ul><li>Generates lists of patients and reminds patients and clinicians of services needed (population management) </li></ul>Pts 2 3 3 6 4 3 21 <ul><li>Standard 3: Care Management </li></ul><ul><li>Adopts and implements evidence-based guidelines for three conditions ** </li></ul><ul><li>Generates reminders about preventive services for clinicians </li></ul><ul><li>Uses non-physician staff to manage patient care </li></ul><ul><li>Conducts care management, including care plans, assessing progress, addressing barriers </li></ul><ul><li>Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities </li></ul>Pts 3 4 3 5 5 20 <ul><li>Standard 4: Patient Self-Management Support </li></ul><ul><li>Assesses language preference and other communication barriers </li></ul><ul><li>Actively supports patient self-management** </li></ul>Pts 2 4 6 <ul><li>Standard 5: Electronic Prescribing </li></ul><ul><li>Uses electronic system to write prescriptions </li></ul><ul><li>Has electronic prescription writer with safety checks </li></ul><ul><li>Has electronic prescription writer with cost checks </li></ul>Pts 3 3 2 8 <ul><li>Standard 6: Test Tracking </li></ul><ul><li>Tracks tests and identifies abnormal results systematically** </li></ul><ul><li>Uses electronic systems to order and retrieve tests and flag duplicate tests </li></ul>Pts 7 6 13 <ul><li>Standard 7: Referral Tracking </li></ul><ul><li>Tracks referrals using paper-based or electronic system** </li></ul>PT 4 4 <ul><li>Standard 8: Performance Reporting and Improvement </li></ul><ul><li>Measures clinical and/or service performance by physician or across the practice** </li></ul><ul><li>Survey of patients’ care experience </li></ul><ul><li>Reports performance across the practice or by physician ** </li></ul><ul><li>Sets goals and takes action to improve performance </li></ul><ul><li>Produces reports using standardized measures </li></ul><ul><li>Transmits reports with standardized measures electronically to external entities </li></ul>Pts 3 3 3 3 2 1 15 <ul><li>Standard 9: Advanced Electronic Communications </li></ul><ul><li>Availability of Interactive Website </li></ul><ul><li>Electronic Patient Identification </li></ul><ul><li>Electronic Care Management Support </li></ul>Pts 1 2 1 4
    19. 22. Phytel Patient Outreach Patient-Centered Medical Home (PPC-PCMH™) Qualification <ul><li>PPC2: Patient Tracking and Registry Function </li></ul><ul><ul><li>Element F - Use of System for Population Management </li></ul></ul><ul><li>PPC3: Care Management </li></ul><ul><ul><li>Element A – Guidelines for Important Conditions </li></ul></ul><ul><li>PPC3: Care Management </li></ul><ul><ul><li>Element B - Preventive Service Clinician Reminders </li></ul></ul>&quot;Phytel’s registry and care management activities helped our practice achieve level 3 recognition - the highest of the NCQA’s medical home qualification” Joseph Mambu, M.D. President, Family Medicine, Geriatrics and Wellness
    20. 24. <ul><li>INITIAL LESSONS LEARNED </li></ul><ul><li>1. Personal Transformation of Physicians Required </li></ul><ul><li>2. Transformation to a PCMH is developmental requiring “Core Competencies” and “Adaptive Reserves” </li></ul><ul><li>3. Regarding technologies, There is no “Plug and Play” </li></ul><ul><li>4. “Change Fatigue” - a Serious Obstacle even within Capable and Highly Motivated Practices </li></ul>
    21. 25. <ul><li>PRACTICE RECOMMENDATIONS </li></ul><ul><li>Establish Realistic Expectations for Time and Effort </li></ul><ul><li> a. Change in the doctor-patient relationship to a more personalized partnership </li></ul><ul><li> b. Shift from authoritative leadership style to one that facilitates and empowers </li></ul><ul><li> c. Shift from physician-centered care to team-based care </li></ul><ul><li>Learn to be a Learning Organization </li></ul><ul><ul><ul><li>a. Systems Thinking </li></ul></ul></ul><ul><ul><ul><li>b. Personal Mastery </li></ul></ul></ul><ul><ul><ul><li>c. Mental Models </li></ul></ul></ul><ul><ul><ul><li>d. Shared Vision </li></ul></ul></ul><ul><ul><ul><li>e. Team Learning </li></ul></ul></ul>
    22. 26. Redesigned Work Flow <ul><li>1. Communication - enhanced electronically, daily huddles, monthly staff & weekly committee meetings </li></ul><ul><li>2. Cross training - with licensed employees working at the tops of their licenses </li></ul><ul><li>3. New Roles - administrator, clinical care coordinator/health coach, DM/prevention coordinator, EMR customizer, QI physician </li></ul><ul><li>4. Pre-visit and p ost-visit care PRN </li></ul><ul><li>5. Scheduled Patient visits with RN health coach </li></ul><ul><li>6. Group visits </li></ul><ul><li>7. Patient portal </li></ul><ul><li>8. Universal email access </li></ul>
    23. 27. IMPROVING THE CARE OF CHRONIC DISEASE
    24. 28. DISEASE MANAGEMENT
    25. 29. What Phytel Does <ul><li>Phytel Mines Data </li></ul><ul><li>This data will help your practice begin to meet the challenge of achieving the HEDIS, IOM, AQA, NCQA standards. </li></ul><ul><li>Phytel interacts with your practice management and electronic health record. </li></ul><ul><li>Phytel can identify patients due for recommended care based on evidenced based protocols . </li></ul><ul><li>Patients are contacted via automated outreach. </li></ul>
    26. 30. What Phytel Does <ul><li>Phytel has scripted messages to contact patients via telephone. </li></ul><ul><li>The system is secure and HIPPA compliant. </li></ul><ul><li>Phytel can track patient response and monitor compliance. </li></ul><ul><li>Phytel will generate reports to document quality and P4P data as well. </li></ul><ul><li>Phytel will generate reports to document increased bookings and financial and clinical results. </li></ul>
    27. 31. Primary Care Protocol Set* <ul><li>Appointment Reminders/Missed Appointment F/U </li></ul><ul><li>Prevention/Screening: </li></ul><ul><li>Annual Preventive Medicine Visits </li></ul><ul><li>Breast Cancer </li></ul><ul><li>Cervical Cancer </li></ul><ul><li>Immunizations: </li></ul><ul><li>Influenza </li></ul><ul><li>Pneumonia </li></ul><ul><li>HPV </li></ul><ul><li>Mammography </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Prostate Cancer </li></ul><ul><li>Welcome to Medicare Visits </li></ul><ul><li>Disease Management: </li></ul><ul><li>Congestive Heart Failure: </li></ul><ul><li>F/U Visit Frequency </li></ul><ul><li>ACE/ARB/Beta Blocker Therapy † </li></ul><ul><li>Coronary Artery Disease: </li></ul><ul><li>F/U Visit Frequency </li></ul><ul><li>Anti-platelet Therapy † </li></ul><ul><li>________________________________________ </li></ul><ul><li>*Provided all data-points currently coded. </li></ul><ul><li>† PQRI CPT II Coding Required </li></ul><ul><li>‡ Non-PMS data point(s) required. </li></ul><ul><li>Diabetes: </li></ul><ul><li>F/U Visit Frequency </li></ul><ul><li>Hemoglobin A1c Frequency † </li></ul><ul><li>Hemoglobin A1c Level Control ‡ </li></ul><ul><li>Hyperlipidemia: </li></ul><ul><li>F/U Visit Frequency </li></ul><ul><li>LDL-C Frequency † </li></ul><ul><li>LDL-C Level Control ‡ </li></ul><ul><li>Hypertension: </li></ul><ul><li>F/U Visit Frequency </li></ul><ul><li>Systolic/Diastolic Frequency † </li></ul><ul><li>Systolic/Diastolic Level Control ‡ </li></ul><ul><li>Asthma: </li></ul><ul><li>F/U Visit Frequency </li></ul><ul><li> Appropriate Pharmacologic Therapy † </li></ul><ul><li>Thyroid Disease </li></ul><ul><li>F/U Visit Frequency </li></ul><ul><li>COPD </li></ul><ul><li>F/U Visit Frequency </li></ul><ul><li>Practice Development Campaigns: </li></ul><ul><li>Back to School Physical Examinations </li></ul><ul><li>Travel Examinations </li></ul><ul><li>Childhood Immunizations </li></ul><ul><li>New Providers/Services </li></ul>
    28. 32. PATIENT REGISTRIES
    29. 34. MEASURING PATIENT-CENTEREDNESS
    30. 35. SUMMARY POINTS <ul><li>PCMH - revolutionary redesign of primary healthcare delivery, repositioning the doctor-patient relationship at the epicenter of that system </li></ul><ul><li>PCMH transformation requires superior leadership, expert change management, enough time (years) and substantial financial support in order to realize its full potential. Payment reform must “co-evolve”. </li></ul><ul><li>Adequately funded and fully deployed, the PCMH can become the key component that could then catalyze regional then national networking to form the framework for a revitalized healthcare system </li></ul>

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