All About the Patient-Centered Medical Home

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Using the experiences of Jericho Road Family Practice, Brett Lawton will share about the process of obtaining recognition as a Patient-Centered Medical Home (PCMH), and discuss the options for certification. He will provide resources for efforts to become recognized as a PCHM, and will discuss the benefits of the process for community health delivery organizations, and faith-based clinics.

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  • 47% of patients speak English, 12% speak Burmese, 7 % Arabic, 6% Karen, 6% Somali, etc.
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  • All About the Patient-Centered Medical Home

    1. 1. All About thePatient-Centered MedicalHomeBrett Lawton, MPAChief Operations OfficerJericho Road Family Practiceblawton@jrfp.org1Kyle Vath, BSN, RNClinical CoordinatorCrossroad Health Centerkylev@crossrd.orgSaturday, May 11, 2013
    2. 2. • Objectives:– Share about the process of obtaining recognitionas a Patient-Centered Medical Home (PCMH)– Discuss the options for PCMH certification.– Discuss the benefits of the process for communityhealth delivery organizations, and faith-basedclinics.All About thePatient-Centered Medical Home2 All About the Patient-Centered Medical Home
    3. 3. • Outline:– A little about us…– The Patient-Centered Medical Home Model– The Path to Recognition– Examples of the PCMH in Practice– The Unique Opportunities for Christian HealthMinistries and PCMHAll About thePatient-Centered Medical Home3 All About the Patient-Centered Medical Home
    4. 4. • A Little About Us:– Brett Lawton, COO, Jericho Road Family Practice,Buffalo, NY– Kyle Vath, Clinical Coordinator, Crossroad HealthCenter, Cincinnati, OhioAll About thePatient-Centered Medical Home4 All About the Patient-Centered Medical Home
    5. 5. • The PCMH Model:– Core Features:• Personal Provider• Provider Directed Medical Practice• Whole Person Orientation• Care is Coordinated and/or Integrated• Quality and Safety• Enhanced Access• Payment ReformAll About thePatient-Centered Medical Home5 All About the Patient-Centered Medical HomeThe Patient Centered Medical Home: History, Seven Core Features, Evidence and Transformational Change.http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/pcmh.Par.0001.File.dat/PCMH.pdf
    6. 6. • The PCMH Model:– The Origins of the PCMH Model:• 1967 - Pediatric Health Homes (AAP)• 1978 - Tenets of MHs (WHO)• 1990 - MH in Literature (IOM)• 2002 - 37 Criteria of MHs (AAP)• 2004 - Chronic Care Model (E. Wagner)• 2010 - PPACA Signed into Law• 2012 - ACA Funding for PCMH/FQHCsAll About thePatient-Centered Medical Home6 All About the Patient-Centered Medical HomeOrigins of PCMH. http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/pcmh.Par.0001.File.dat/PCMH.pdf
    7. 7. • The PCMH Model:– PCMH and the ACA:• Title II Subtitle I– Sec. 2303 – Payment. See Amendment by Reconciliation Act below– Sec. 2703. State option to provide health homes for enrollees with chronicconditions.– Sec. 2706. Pediatric Accountable Care Organization demonstration project.• Title III– Sec. 3021. Establishment of Center for Medicare and Medicaid Innovationwithin CMS.• Title V– Sec. 5301. Training in family medicine, general internal medicine, generalpediatrics, and physician assistantship.– Sec. 5501. Expanding access to primary care services and general surgeryservices.• Health Care and Education Reconciliation Act– Sec. 1202. Payments to primary care physicians.All About thePatient-Centered Medical Home7 All About the Patient-Centered Medical HomeACA and PCMH. http://www.pcpcc.net/content/health-care-reform-and-patient-centered-medical-home
    8. 8. All About thePatient-Centered Medical Home8 All About the Patient-Centered Medical Homehttp://www.kff.org/insurance/upload/7692_02.pdf
    9. 9. All About thePatient-Centered Medical Home9 All About the Patient-Centered Medical Home$1000 $1300$15,000/ mo$40$120
    10. 10. All About thePatient-Centered Medical Home10 All About the Patient-Centered Medical Home$1000$1300$15,000/ mo$40$120
    11. 11. All About thePatient-Centered Medical Home11 All About the Patient-Centered Medical Home
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    13. 13. • The PCMH Model:– Traditional Model:• Provider-centered• Provider-based treatment plans• Focus on individual treatment• Physician does it all• Reactive - patient presents• Answer patient questions• Patient as passive recipient of care• Scheduled out for weeks• Decisions based on comfort andtradition• Random communication withinpracticeAll About thePatient-Centered Medical Home13 All About the Patient-Centered Medical HomeThe Patient Centered Medical Home: History, Seven Core Features, Evidence and Transformational Change.http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/pcmh.Par.0001.File.dat/PCMH.pdf– PCMH Model:• Patient-centered• Evidence-based treatment plans• Population/condition management• Care team• Care plans and outreach• Patient education and resources• Patient engaged in self-mgmt goals• Same-day access available• Decisions based on data and trends• Purposeful communication
    14. 14. • The Path to PCMH Recognition:– Accreditation Programs:• National Committee for Quality Assurance (NCQA)*• Utilization Review Accreditation Commission (URAC)• The Joint Commission• Accreditation Association for Ambulatory Health Care(AAAHC)All About thePatient-Centered Medical Home14 All About the Patient-Centered Medical HomeMedical Home Accreditation Programs. http://www.medicalhomeinfo.org/national/recognition_programs.aspx
    15. 15. • The Path to PCMH Recognition:– NCQA’s Six Standard Categories(27 elements, 149 factors):• 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 PerformanceAll About thePatient-Centered Medical Home15 All About the Patient-Centered Medical HomeNCQAs 6 Core Standards. http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH_2011_Scoring_Summary.pdf
    16. 16. All About thePatient-Centered Medical Home16 All About the Patient-Centered Medical Home
    17. 17. • The Path to PCMH Recognition:– Standard 1: Enhance Access and Continuity• Accommodate patients’ needs with access and adviceduring and after hours; give patients and their familiesinformation about their medical home and providepatients with team-based care.• Empanelment studies• Expanding hours• Transportation barriers• 30% no-showAll About thePatient-Centered Medical Home17 All About the Patient-Centered Medical Home
    18. 18. • The Path to PCMH Recognition:– Standard 2: Identify and Manage Patient Populations• Collect and use data for population management.• 60% smokers• Focus on diabetics• 1/3 Complex• 50-60% have some type of significant mental illness• 40% have a HgbA1C >9%• In 6 month period, over half have gone to the ED - avg 4visits/yrAll About thePatient-Centered Medical Home18 All About the Patient-Centered Medical Home
    19. 19. • The Path to PCMH Recognition:– Standard 3: Plan and Manage Care• Use evidence-based guidelines for preventative, acute,and chronic care management, including medicationmanagement.All About thePatient-Centered Medical Home19 All About the Patient-Centered Medical Home
    20. 20. • The Path to PCMH Recognition:– Standard 4: Provide Self-Care Support andCommunity Resources• Assist patients and their families in self-caremanagement with information, tools, and resources.All About thePatient-Centered Medical Home20 All About the Patient-Centered Medical Home
    21. 21. • The Path to PCMH Recognition:– Standard 5: Track and Coordinate Care• Track and coordinate tests, referrals, and transitions ofcare.All About thePatient-Centered Medical Home21 All About the Patient-Centered Medical Home
    22. 22. • The Path to PCMH Recognition:– Standard 6: Measure and Improve Performance• Use performance and patient experience data forcontinuous quality improvement.All About thePatient-Centered Medical Home22 All About the Patient-Centered Medical Home
    23. 23. • The Path to PCMH Recognition:– Benefits of the PCMH Model• Decreased ED utilization• Improved health outcomes• Health system economic savings• Fewer hospitalizations• Shortened hospital LOS• Improved chronic illness management• Improved patient satisfaction• Higher reimbursement rates (PMPM)All About thePatient-Centered Medical Home23 All About the Patient-Centered Medical Home
    24. 24. • The Path to PCMH Recognition:– Challenges in Implementing PCMH• Payment structures not yet fully supportive• Increased overhead for primary care centers• Cumbersome EHR systems• Turf wars• Competing special interests• Changes in how we use volunteersAll About thePatient-Centered Medical Home24 All About the Patient-Centered Medical Home
    25. 25. All About thePatient-Centered Medical Home25 All About the Patient-Centered Medical Home
    26. 26. All About thePatient-Centered Medical Home26 All About the Patient-Centered Medical Home
    27. 27. All About thePatient-Centered Medical Home27 All About the Patient-Centered Medical Home
    28. 28. All About thePatient-Centered Medical Home28 All About the Patient-Centered Medical Home
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    30. 30. • Examples of the PCMH in Practice:– What’s Going On Here?All About thePatient-Centered Medical Home30 All About the Patient-Centered Medical Home
    31. 31. • Examples of the PCMH in Practice:– What’s Going On Here?• Access problem?• Continuity problem?• Hospital problem?• Population problem?• Language problem?• Transportation problem?All About thePatient-Centered Medical Home31 All About the Patient-Centered Medical Home
    32. 32. • Examples of the PCMH in Practice:– Chronic Care Management Template– Non-Emergency Transportation Program(SafetyN.E.T. Program)– COA/Crossroad Collaboration– ED utilizationAll About thePatient-Centered Medical Home32 All About the Patient-Centered Medical Home
    33. 33. All About ThePatient-Centered Medical Home• Examples of the PCMH in Practice – Jericho Road– Population management - now we know!• We have 706 patients with Diabetes– 38% have HbA1c above 9%– 59 haven’t had an A1c check in the past year• We have 237 patients with COPD– 198 need a new spirometry reading• We have 138 patients with Hepatitis B– 49 need a liver function test– Helps us carry out our mission to serve “the least ofthese” who might otherwise be missed33 All About the Patient-Centered Medical Home
    34. 34. All About ThePatient-Centered Medical Home• Examples of the PCMH in Practice – Jericho Road– Making our EMR work for us!Multilingual Patient Education Material34 All About the Patient-Centered Medical Home
    35. 35. All About ThePatient-Centered Medical Home• Examples of the PCMH in Practice – JerichoRoad– Recognized in 2009• Extra revenue• Qualified for Meaningful Use Attestation (Year 1)• Qualified for Meaningful Use Data (Year 2)• Test results received electronically, excellent connectionwith RHIO35 All About the Patient-Centered Medical Home
    36. 36. All About ThePatient-Centered Medical HomePCMH consultants• HealthTeamWorks
www.healthteamworks.org/medical-home• Primary Care Development Corporation(PCDC)
www.pcdc.org/resources/patient-centered-medical-home/• Qualis Health
www.qhmedicalhome.org/• Quality First Healthcare Consulting, Inc. (QFHC)
www.qfhc.com• Research & Marketing Strategies, Inc. http://www.rmsresults.com/index.php• TransforMED - Center for Medical Home Improvement(CMHI)
www.medicalhomeimprovement.org/medical-home/developments.html• Health Partners Consulting (Crossroad used)ronichristopher@yahoo.com36 All About the Patient-Centered Medical Home
    37. 37. All About ThePatient-Centered Medical HomeResources for Population Health Maintenancedata management• i2iSystems
www.i2isys.com/patient-centered-medical-home.htm• Phytel
www3.phytel.com/• CareSentry (Crossroad Uses)http://www.simbiote.com/home.html37 All About the Patient-Centered Medical Home
    38. 38. 38 All About the Patient-Centered Medical HomeNCQA PPC-PCMH Recognition Standards Meaningful Use Health Outcome Policy PriorityAccess and CommunicationWritten standards for patient access and patient communicationEngage Patients and families in their health careProvide patients with an electronic copy of health infoProvide patients with timely electronic access to health infoProvide Clinical Summaries for each visitPatient Tracking and Registry FunctionsBasic non-clinical dataSearchable Clinical DataUses paper or electronic based charting tools for clinical infoUses data to identify important diagnosesGenerates lists of patients and reminds patients and clinicians of needs services.Improving quality, safety, efficiency, and reducing healthdisparitiesMaintain an up-to-date problem list of diagnosesRecord demographicsRecord changes in vital signsGenerates lists of patients by specific conditionsImplement 5 clinical decision support rulesCare ManagementAdopts evidence-based guidelines for 3 conditionsConducts care-managementCoordinates CareImprove Care CoordinationCapability to exchange key clinical information among providers of careProvide summary care record for each transition of carePatient Self-Management SupportActively supports patient self-managementEngage patients and families in their health careSend reminders to patientsProvide patients with an electronic copy of their health informationProvide patients with timely electronic access to their health informationElectronic PrescribingUses electronic system to write prescriptionsHas electronic prescription writer with safety and cost checksImproving quality, safety, efficiency, and reducing health disparitiesGenerate and transmit permissible prescriptions electronicallyMaintain active medication listMaintain active medication allergy listTest TrackingTracks Tests and identifies Abnormal resultsUses electronic systems to order and retrieve testsImprovingquality, safety, efficiency, and reducing healthdisparitiesUse CPOEIncorporate clinical lab-test results into EHR as structured dataReferral TrackingTracks referrals using paper-based or electronic systemImprove Care CoordinationCapability to exchange key clinical information among providers of careProvide summary care record for each transition of care and referralPerformance ReportingMeasures Clinical PerformanceReports PerformanceTransmits Reports with standardized measures electronically to external entitiesImproving quality, safety, efficiency, and reducing health disparitiesReport ambulatory quality measures to CMS or the StatesAdvancedElectronic Communications Ensure adequate privacy and security protections forpersonal health informationhttp://www.csms-ipa.com/Portals/0/Docs/NCQA%20Recognition.pdf
    39. 39. • Unique Opportunities for Christian HealthMinistries:– Christ was extremely relational.– Christ cared for “the least of these”.– Christ cared about social justice.– Christ cared for the whole person.– Christians are strongest when they collaborate.All About thePatient-Centered Medical Home39 All About the Patient-Centered Medical Home
    40. 40. Questions?All About thePatient-Centered Medical Home40 All About the Patient-Centered Medical Home

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