The Patient-Centered Medical Home

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The patient-centered medical home is "a model for care provided by physician practices aimed at strengthening the physician-patient relationship."

The patient-centered medical home is "a model for care provided by physician practices aimed at strengthening the physician-patient relationship."

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  • 1. THE PCMH
    • Lyndee Knox, PhD
    • LA Net A Project of Community Partners
  • 2. Change is Hard . . .
  • 3. Objectives
    • Create a common departure point for discussion to follow
    • A 101 overview, not a deep dive into PCMH
    • Introduce PCMH efforts underway in L.A.
  • 4. Presentation Outline
  • 5. What is a Patient Centered Medical Home (PCMH) The patient-centered medical home is "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." (NCAQ) A recent Journal of General Internal Medicine provides a core definition of the PCMH as a team of people committed to improving the health and healing of individuals in a community.
  • 6. According to the ACP, it is:
  • 7. Other descriptions
    • The PCMH is a political construct that includes new ways of organizing and financing care , while attempting to remain true to the proven value of primary care (Stange et al, 2010)
    • PCMH requires a compact between payers and primary care practices. Simultaneously,
      • Practices improve their care
      • Payers pay the practices more to help them improve their care
      • Neither practices or payers can do it themselves. Both are needed (T. Bodenheimer)
  • 8. Based on the Joint Principles Team-based care: NP/PA RN/LPN Medical Assistant Office Staff Care Coordinator Nutritionist/Educator Pharmacist Behavioral Health Case Manager Social Worker Community resources DM companies Others…
  • 9. Principles were created by the
  • 10. Referred to as the Patient Centered Primary Care Collaborative (PCPCC) PCPCC on the web: http://www.pcpcc.net
  • 11. Critique of the PCMH: Some feel it doesn’t go far enough
  • 12. Presentation Outline
  • 13. How do you Know a PCMH When you See One?
  • 14. Recognition Programs for PCMH Developed or Under Development Quality Organizations PCMH Standards Activity 2010
  • 15. NCQA PPC-PCMH Recognition Module; Major Domains/Standards
    • Access & Communication
    • Patient Tracking & Registry Functions
    • Care Management
    • Patient Self-Management Support
    • Electronic Prescribing
    • Test Tracking
    • Referral Tracking
    • Performance Reporting & Improvement
    • Advanced Electronic Communication
    • Each standard contains sub-elements – 10 of which are considered “must pass”
    For more information: http://ncqa.org/tabid/631/Default.aspx Each standard contains sub-elements 10 of which are considered “must pass” Standards are currently under revision and will be available Jan 2011 – Integrate IT w/in core domains
  • 16. Key Points for Level 1 PCMH
  • 17. Level 2 -> Level 3
  • 18. More Features of a PCMH Practice
  • 19. NCQA Recognition Activity SOURCE: NCQA, July 2010
  • 20. SOURCE: NCQA, December 2009
  • 21. Critique of NCQA
    • Beal et al created a patient centered definition of a medical home w/ 4 questions:
      • Do you have a regular doctor or place of care?
      • Can you easily contact your provider by phone?
      • Can you easily get care or medical advice on weekends or evenings?
      • Are your physician visits well organized and running on time?
    • Practices doing well on these could flunk NCQA
    • Many standards require that a practice have a “plan” to improve , but do not require demonstration of improvement and no clear benchmarks in many cases
    • T. Bodenheimer
  • 22. Presentation Outline
  • 23. Complex Delivery
    • Health care delivery is complex – e.g., the typical primary care physician coordinates care with 229 other physicians working in 117 practices
    • H H Pham, et al Ann Intern Med. 2009;150:236-242
  • 24. Specialty Care Connections * FAQs available at: http://www.acponline.org/ running_practice/pcmh/understanding/specialty_physicians.htm
  • 25. Patient Centered Medical Home Neighbor (PCMH-N) Draft Definition A specialty practice recognized as a Patient Centered Medical Home Neighbor (PCMH-N) engages in processes that: These processes would take the form of service agreements (compacts) between/among the participating practices.
  • 26. Presentation Outline
  • 27. Combined Commercial and Medicaid/CHIP PCMH Activity = Identified to have at least one private payer medical home pilot under development or underway = Identified to have a Medicaid and/or CHIP medical home initiative = Identified to have both a private payer and a Medicaid and/or CHIP medical home initiative * As tracked by the American College of Physicians (updated March 2010)
  • 28. Federal PCMH Efforts For more information on CMS/Medicare PCMH Efforts: http://www.acponline.org/running_practice/pcmh/demonstrations/index.html
  • 29. Federal PCMH Efforts (cont.)
  • 30. Safety-Net Medical Home Initiative Source: http://www.qhmedicalhome.org/safety-net/index.cfm
  • 31. Common Practice Support Approaches in PCMH Demos
  • 32. Presentation Outline
  • 33. Evaluation Collaborative sponsored by Commonwealth
  • 34. Community Implications - Published Results of PCMH Projects to Date Source: PCPCC Pilot Guide, 2009
  • 35. Community Implications – Published Results of PCMH Projects (cont.) Source: PCPCC Pilot Guide, 2009
  • 36. Community Implications Source: Metcare Press Release, February 23, 2010
    • Practices made changes, process measures improved, docs happier,
    • but patients were dissatisfied and felt disconnected from physician
  • 37. Community Implications Source: Metcare Press Release, February 23, 2010
  • 38. Estimates on Co$t? Future of Family Medicine Report ( http://www.annfammed.org/cgi/reprint/2/suppl_3/s1 ), 2004 Deloitte: The Medical Home, Disruptive Innovation for a New Primary Care Model ( http://www.deloitte.com/dtt/cda/doc/content/us_chs_MedicalHome_w.pdf ), 2008
  • 39. What Does it Co$t? AMA ( http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/ruc-medicare-medical-home-demonstration-project.shtml ), 2008 Urban Institute Report - Co-Funded by The Commonwealth Fund and ACP – Available at: http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2009/Oct/Incremental-Cost-Estimates-For-The-Patient-Centered-Medical-Home.aspx , 2009
  • 40. Presentation Outline
  • 41. Some resources for Practices
    • PCPP --- http://www.pcpcc.net/
      • Tools for practices, patients
      • Meaningful Connections: IT and the PCMH
    • National Academy for State Health Policy http://www.nashp.org/node/1681
    • AAP Toolkit http://www.pediatricmedhome.org/start_building/
    • ACP Medical Home builder http://www.acponline.org/running_practice/pcmh/
    • TransforMed resources http://www.transformed.com/TransforMED_is_How.cfm
    • NCQA webex training on accreditation www.ncqa.org/rptraining.aspx
    • MacColl Institute’s Tool PCMH-A http://qhmedicalhome.org/safety‐net/change‐concepts.cfm
    • Planned: AHRQ National Learning Collaborative for Facilitating PCMH advancement
    • Recent Journal supplements on the PCMH
    • AFM Supplement http://www.annfammed.org/content/vol8/Suppl_1/index.shtml
    • Health Affairs, 29, no. 5 (2010) supplement on the PCMH
    • Annals of Internal Medicine http://www.acponline.org/running_practice/pcmh/resources_tools/abstracts.htm
    • Links are available to much of this material on LA Net’s website: www.lanetpbrn.net
  • 42. Presentation Outline
  • 43. Local Activities to Support PCMH
    • L.A. Care PCMH Initiative
    • LA Net CCM and PCMH funded by AHRQ
    • L.A. County initiative
  • 44. LA Net
    • Is a Practice-Based Research and Resource Network (PBRN) for the region
    • Focused on improving quality and reducing disparities and through:
      • provider-led research on issues that matter
      • supporting local learning and innovation
      • implementing best practices
  • 45. Network for generating & disseminating good ideas
  • 46. LA Net (cont)
    • Consists of 16 FQHC/CHC “partners” representing 116 practice sites
    • Governed by a board of 80% clinicians, 20% researchers, others.
      • John Kotick – Current Chair
      • Felix Nunez – Past Chair
  • 47. LA NET
    • Part of a national network of more than 100 PBRNs in the U.S.
  • 48. Some recent projects
    • Management of Obstructive Sleep Apnea in Primary Care (AHRQ/CMS)
    • National Children’s Study pilot (NICHD)
    • Study of AHRQ’s web-based medication errors and adverse drug event reporting system for primary care (MEADERS)
  • 49. Examples of projects
    • Replication of a diabetes self-management program in 23 PC practices in Texas (AAFP, Lilly, WHO)
    • Development of low-cost “talking” survey software to use with low-literacy patients available in 7+ languages
  • 50. AHRQ funded CCM and PCMH project
    • Evaluating use of practice facilitation to support 20 FQHC/CHCs in CCM and PCMH changes
    • Based on input from steering cmt: Tom Bodenheimer, Jim Mold, Grace Floutsis, Rich Seidman
    • And experts from US and Canada during Consensus Panel hosted by LA Net in January 2010
        • Blueprint Vermont, CareOregon, Oklahoma, IPIP, Impact BC, Quality Counts, QIIP, and others
    • Continuation of project by MacColl, RAND, Safety Net Institute
  • 51.
    • Demonstration of Primary Care Extension Program
    • Created by recent reform legislation –modeled after agricultural extension program
    • Jim Mold was author - working with us to design demonstration
    • PCMH projects and REC in LA might provide foundation
    Long-term goal: Provide sustained workforce to practices
  • 52. Acknowledgements Shari M. Erickson, MPH Senior Associate, Center for Practice Improvement & Innovation Tom Bodenheimer, MD UCSF Katie Coleman, MPH MacColl Institute Jim Mold, MD U of Oklahoma
  • 53. References
    • American College of Physicians. 2006. The Advanced Medical Home: A Patient-Centered Physician Guided Model of Healthcare. http://www.acponline.org/advocacy/where_we_stand/policy/adv_med.pdf
    • American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA). 2007. Joint Principles of the Patient-Centered Medical Home. March 2007. http://www.acponline.org/running_practice/pcmh/demonstrations/jointprinc_05_17.pdf
    • American Academy of Family Physicians (AAFP). 2004. The Future of Family Medicine: A Collaborative Project of the Family Medicine Community. Annals of Family Medicine 2 (1): S3-S32.
    • American Academy of Pediatrics, Council on Pediatric Practice. Pediatric Records and a "medical home." In: Standards of Child Care. Evanston, IL: American Academy of Pediatrics; 1967: 77–79
  • 54. Thank you