The Healthcare Team as the Healthcare Provider: A Different View of the Patient Centered Medical Home.
Upcoming SlideShare
Loading in...5
×
 

The Healthcare Team as the Healthcare Provider: A Different View of the Patient Centered Medical Home.

on

  • 3,848 views

Presentation to the Ohio State Society of Medical Assistant's annual convention about the Patient Centered Medical Home and the role of the medical assistant

Presentation to the Ohio State Society of Medical Assistant's annual convention about the Patient Centered Medical Home and the role of the medical assistant

Statistics

Views

Total Views
3,848
Views on SlideShare
3,835
Embed Views
13

Actions

Likes
2
Downloads
133
Comments
0

2 Embeds 13

http://www.slideshare.net 12
http://translate.googleusercontent.com 1

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • #1 http://www.graham-center.org/PreBuilt/PCMH.pdf #2 http://www.priorityhealth.com/provider/manual/performance/medical-home/definition-of-pcmh
  • http://www.centerforhit.org/online/etc/medialib/chit/documents/cme-learn/pcmh.Par.0001.File.tmp/IT_and_the_Medical_Home.pdf
  • http:// www.pcpcc.net /content/evidence-quality

The Healthcare Team as the Healthcare Provider: A Different View of the Patient Centered Medical Home. The Healthcare Team as the Healthcare Provider: A Different View of the Patient Centered Medical Home. Presentation Transcript

  • The Healthcare Team as the Health Care Provider A Different Perspective on the Patient Centered Medical Home James Dom Dera, MD, FAAFP 23 April 2010
  • Objectives
      • Describe the current structure of the healthcare team
      • List to problems inherent to the current model
      • Define the concept of the healthcare team
      • Define and describe the PCMH
  • Conflicts of Interest
    • None
  • Preventive Medicine Behavioral Health Medical Assistants Medication Refills Acute Care Nursing Case Manager Test Results Chronic Disease Monitoring Physician
  • The Current Approach
    • Hierarchal
      • Physician on top
      • Support Staff
    • Reactive
      • To problems
      • Treat symptoms
      • Acutes are ideal
    • Problem Oriented
    • NOT disease oriented
    MD MA, Mid level Providers, Nursing Staff Ancillary: therapist, dieticians, pharmacist, etc.
  • Diabetes as an example
    • Problem Oriented:
    • Hyperglycemia
    • Hypoglycemia
    • Peripheral Neuropathy
    • Vision changes
    • Example: Sliding Scale Insulin
    • Disease Oriented:
    • Lifestyle Modification
    • Disease markers: LDL, A1C, BP, Retinal Exam
    • Prevention of secondary complications: CAD, CKD, PAD, etc.
  •  
  • IOM’s “Crossing the Quality Chasm”
    • 10 Rules
    • Care based on continuous relationships
    • Customized based on the patient’s needs
    • Patient is in control
    • Shared knowledge
    • Evidence Based
    • Safe
    • Transparent
    • Anticipates patients needs
    • Decrease in waste
    • Cooperation amongst clinicians
    • 6 Aims
    • Safe
    • Effective
    • Patient-Centered
    • Timely
    • Efficient
    • Equitable
  • Example
    • Mr. Jones is 78 year old male with multiple medical problems, including BPH with recurrent UTI's, mild cognitive impairment, and a poor support system. He calls the office to complain of dysuria. He is offered an appointment three days later with another physician in the practice.
    • After a review of his medical record, the MD gathers a history and physical, performs a urinalysis, diagnoses a UTI, and prescribes a course of Cipro.
    • Three days later the patient is in the hospital's intensive care unit for a coagulopathy secondary to an interaction between Cipro and warfarin (which the prescribing MD was unaware he was on).
    What Went Wrong?!!
  • What went wrong .... plenty!
      • Patient Safety
        • Debate exits about the numbers of errors per year that occur in the health care system. Some put it as high as 20% to 50% of encounters.
        • In this instance: ciprofloxacin and warfarin strongly interact
      • Communication between physicians
        • This patient had a history of being unable to manage his own medications, and FP warned cardio
        • The cardiologist re-started warfarin despite the patient's primary care MD's previous warning. 
  • … continued
      •  
      • Anticipation of need
        • Is this patient safe for warfarin?
        • This patient has frequent UTI's – other therapies more appropriate?
        • Support system?
      • Patient control
        • Should this patient have to wait three days?
        • Should this patient have to see another MD?
  • Preventing examples like this requires a fundamental change in how healthcare is delivered.
  • Patient Centered Medical Home (PCMH)
    • Definition #1: a single source of medical information about a patient [including] a partnership approach with families to provide primary health care that is accessible, family-centered, coordinated, comprehensive, continuous, compassionate, and culturally effective
    • Definition #2: a model for care provided by physician practices aimed at strengthening the physician-patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship
  • PCMH definition (continued)
    •  
    • Another Definition: A patient-centered medical home integrates patients as active participants in their own health and well-being. Patients are cared for by a personal physician who leads the medical team that coordinates all aspects of preventive, acute and chronic needs of patients using the best available evidence and appropriate technology. These relationships offer patients comfort, convenience and optimal health throughout their lifetimes
  • Huh???
  • IOM’s “Crossing the Quality Chasm”
    • 10 Rules
    • Care based on continuous relationships
    • Customized based on the patient’s needs
    • Patient is in control
    • Shared knowledge
    • Evidence Based
    • Safe
    • Transparent
    • Anticipates patients needs
    • Decrease in waste
    • Cooperation amongst clinicians
    • 6 Aims
    • Safe
    • Effective
    • Patient-Centered
    • Timely
    • Efficient
    • Equitable
  • Core Features of the PCMH
    • Personal Physician
    • Physician Directed Medical Practice
    • Whole Person Orientation
    • Care is Coordinated and/or Integrated
    • Quality and Safety
    • Enhanced Access
    • Health Information Technology (HIT)
    • Payment Reform
  • Personal Physician
    • Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care
  • Physician Directed Medical Practice
    • The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients
    • From FPM in 2009 “Ten Steps to a Patient-Centered Medical Home”:
    • HIRE MORE MEDICAL ASSISTANTS!!
  • Whole Person Orientation
    • The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals.
    • This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care
  • Coordinated & Integrated Care
    • Across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes)
    • The community (e.g., family, public and private community-based services).
  • Quality and Safety
    • Evidence-based medicine and clinical decision-support tools guide decision making
    • Physicians accept accountability for quality improvement through voluntary performance measurement and improvement
    • Patients participate in decision-making and feedback is sought to ensure patients’ expectations are being met
    • IT is utilized to support optimal patient care, performance measurement, patient education, and enhanced communication
    • Patients and families participate in quality improvement activities at the practice level
  • Enhanced Access
    • Through systems such as open scheduling and expanded hours
    • New options for communication between patients, their personal physician, and practice staff
      • Internet Visits
      • E-mail
      • Group Visits
  • Health Information Technology (HIT)
    • CPOE
    • CDSS
    • EBM guideline integration
    • Health Exchanges
    • Electronic Prescribing
    • Practice based research, registries, quality improvement
  •  
  • Wellness Illness Health Risk Disease Impairment Treatment and Rehabilitation (Tertiary Prevention) Early Detection & Case Finding (Secondary Prevention) Health Promotion & Protection (Primary Prevention)
  • Health Care Costs Concentrated in Sick Few 1% 5% 10% 55% 69% 27% Source: A.C. Monheit, “Persistence in Health Expenditures in the Short Run: Prevalence and Consequences,” Medical Care 41, supplement 7 (2003): III53–III64. Distribution of Health Expenditures for the U.S. Population, By Magnitude of Expenditure, 1997 50% 97% $27,914 $7,995 $4,115 $351 Expenditure Threshold (1997 Dollars)
  • Payment Reform
    • NOW: Volume Based Payment (a.k.a. fee for service)
    • FUTURE: Value Based Payment; mix of:
      • Payment for case management
      • Fee-for-service
      • Payments for achieving measurable and continuous quality improvements
  • CMA Where does the CMA fit into this? Coordination of Care Enhanced Access Physician Directed Healthcare TEAM Whole Person Orientation Quality/Safety
  • Origins of the PCMH
    • AAP – 1967 introduced the concept of the medical home by posing the following "Wherever the child is cared for, the question should be asked, ‘Where is the child’s medical home?’ and any pertinent information should be transmitted to that place"
    • WHO – 1978 established some principles of the medical home and the need for primary care
    • IOM – 2001 the “Chasm Report”
    • FFM – 2002 to 2004, highlighted the importance of family medicine to this concept
  • Evidence for the PCMH
    • An increase in one primary care physician per 10,000 persons results in 1.44 fewer deaths
    • Adults with a primary care physician rather than a specialist had 33 percent lower costs of care and were 19 percent less likely to die (after adjusting for demographic and health characteristics)
    • RAND / UC Berkeley looked at care according to PCMH principles. For almost 4,000 patients they found that:
      • Patients with diabetes had significant reductions in cardiovascular risk
      • CHF patients had 35% fewer hospital days;
      • Asthmatics and diabetics were more likely to receive appropriate therapy
  • PCMH – Bottom Line
    • The PCMH would be responsible for all of the patients’ health care needs – acute care, chronic care, preventive services, and end of life care working with teams of health care professionals. The PCMH would coordinate the care of its patients with specialists, lab/x-ray facilities, hospitals, home care agencies, and all other health care professionals on the patient care team.
    • The PCMH would adopt the principles of patient-centeredness: allowing patients free choice of physician, providing prompt appointments, reducing waiting times, delivering care based on the best evidence on clinical effectiveness, empowering patients to partner with their personal physicians on decision-making, and providing care in a culturally and linguistically appropriate manner.
    • The PCMH would use health information systems to provide data and reminder prompts such that all patients receive needed services.
  • PCMH – Bottom Line
    • Care delivered by primary care physicians in a Patient-Centered Medical Home is consistently associated with better outcomes, reduced mortality, fewer preventable hospital admissions for patients with chronic diseases, lower utilization, improved patient compliance with recommended care, and lower Medicare spending.
  • Preventive Medicine Point of Care Testing Chronic Disease Monitoring Medication Refills Test Results Acute Care Behavioral Health Mid-Level Provider Acute Mental Health Complaint Chronic Disease Compliance Barriers Provider Physician Medical Assistant Preventive Medicine Behavioral Health Medical Assistants Medication Refills Acute Care Nursing Case Manager Test Results Chronic Disease Monitoring Physician
  • Preventive Medicine Point of Care Testing Chronic Disease Monitoring Medication Refills Test Results Acute Care Behavioral Health Mid-Level Provider Acute Mental Health Complaint Chronic Disease Compliance Barriers Provider Physician Medical Assistant
  • Other Examples
    • ACO
      • integrated health care delivery system that relies on a network of primary care physicians, one or more hospitals, and subspecialists to provide care to a defined patient population
    • Hospice IDG
    • Plan of Care (POC) Meetings
  • Thank-You!