The Patient-Centered
       Medical Home:
 Overview, Outlook & Trends

              FEBRUARY 20, 2009
              Eliza...
What a Medical Home is NOT
            Meet Rebecca…
                      Working
            Mother.
            Today s...
What a Medical Home is NOT
Difficulty in          No alternative
scheduling appt        way to seek
for that day.         ...
What a Medical Home is NOT
Waited for             Physician was
almost an hour;        rushed; Rebecca
staff still had    ...
Slide courtesy of
www.pcpcc.net
Primary Care Crisis
  Good evidence that primary care that countries
  with strong primary care infrastructures have
  low...
Enter: The Medical Home
        • In 1967, The American
        Academy of Pediatrics
        introduced the term to descr...
Medical Home Core Features

• In 2007, four major medical organizations
  (AAFP, AAP, ACP, AOA) reached
  agreement on “Jo...
Medical Home 7 Core Features
1. Person Physician
Each patient has an
ongoing relationship
with a personal
physician traine...
Medical Home Core Features
          2. Physician directed
          medical practice – the
          personal physician l...
Medical Home Core Features
3. Whole person orientation
The personal physician is
responsible for providing for
all the pat...
Medical Home Core Features
         4. Care is coordinated and/or
            integrated across all
            elements o...
Medical Home Core Features
5. Quality & Safety are Hallmarks:
•   Decisions are made by EBM and appropriate
    decision s...
Medical Home Core Features
6. Enhanced access to
  care is available
  through systems such
  as open scheduling,
  expand...
Medical Home Core Features
  7. Payment appropriately recognizes the
  added value provided to patients who have
  a patie...
Testing the Feasibility
            of the Medical Home
The Future of Family Medicine:
“Ultimately, system wide changes
wi...
www.transformed.com
Access to Care & Information                                                                                           Pra...
Medical Home: Is it possible?
         Early data point to a cautiously
         optimistic “YES” but…
         - Two year...
Will it save money & improve
                outcomes?
• Getting the attention of payers & politicians
• > 25 multi-stakeh...
Community Care of North Carolina
•Since 1999, the state has invested in many MH
components through disease management
paym...
MH Outlook: Pilots & Payers



• PCPCC is a coalition of >300 organizations:
employers, consumer groups, patient advocates...
MH Outlook: Accreditation



• National Committee for Quality Assurance
offers 3 tiers of “medical home recognition”
• Pra...
PCMH Outlook: CMS Demonstration


 CMS preparing to launch 2-year Medicare
 Medical Home Demonstration (MMHD).
 Looking at...
PCMH Outlook: CMS Demonstration
•Practices must meet criteria of NCQA to qualify
          (Tier 2 and Tier 3 only)
•Quali...
PCMH Outlook:
       Gaining Political Traction
 New economic stimulus
bill earmarks ≈ $19 billion
 to implement electroni...
PCMH Outlook: Gaining Political Traction
Senator Baucus (D-Montana) white
paper on health care reform
endorsed medical hom...
PCMH Outlook: Gaining Public Traction
Medical Home: Challenges
• Transformative change doesn’t happen
  overnight… pilots under pressure for quick
  results may...
Medical Home: Physician Outlook

• Excited
• Cautiously optimistic

• Skeptical/cynical
• Too exhausted &
  stressed to ca...
Medical Home: Physician Outlook
• Financially-strapped FM physicians are fearful
  of the high cost of MH changes (time,
 ...
“…some health care policy experts
"worry that the push for medical homes
could be yet another example of the
latest health...
Medical Home: Outlook
“I no longer practice medicine
encounter to encounter, taking
care of the problem the patient
presen...
Medical Home: Outlook
“I do take care of my patients how
and when they want to be seen as
much as I can, whether it is in ...
Medical Home: Outlook
• We know that a strong primary care
  system reduces health care costs and
  improves quality outco...
Medical Home: Outlook
• We know that the majority of primary care
  physicians would like to embrace the medical
  home co...
Medical Home: Trends

       From the ground level:
       What seems to be
       working for physicians,
       practice...
PCMH
  Trends:
  Same Day
 Scheduling:
  Patients can
schedule an appt
for the same day
 OR in advance
PCMH Trends: Same Day Scheduling
• Huge leap of faith for many physicians
  fearful of an open schedule.

• Once in place,...
Trends: Same Day Scheduling
• Requires constant education of patients
  using multiple channels.

• Some patients prefer t...
PCMH Trends:
     e-Visits:
 Physicians offer
structured, secure
   “office visits”
       online
PCMH Trends: e-visits
• Only lukewarm response from patients; takes
concerted & consistent promotion by practice

• Many e...
PCMH Trends: e-visits
• Currently, patients seem to prefer non-secure, non-
reimbursable email communication with physicia...
PCMH Trends: Group Visits
• Typically centered around a
chronic disease; goal is for
physician to facilitate peer-to-
peer...
PCMH Trends: Group Visits
• Require paradigm shift from physicians: solo
encounter to group facilitation process.
• Requir...
Population Management


Chronic Disease         PCMH Trends:
Management                 Disease
                          ...
PCMH Trends: Disease Registries
          • Practice runs report on all
          diabetics overdue for a follow-up
      ...
PCMH Trends: Disease Registries
• Many EMRs do not yet offer disease registry
capabilities OR process is difficult to esta...
PCMH Trends: Care Teams
                     MA/RN does vital signs,
 Care teams           medications, history,
usually c...
PCMH Trends: Care Teams
     Care teams       MA/RN does follow-up
require increased      education wit pt & follow-
 staf...
PCMH Trends: Care Teams
• Evidence of increase in
   - Pt volume & revenue
   - Quality of care
   - Doctor/staff satisfac...
PCMH Trends: Patient Portals
• Interactive patient portals
  interfaced with practice EMR

• Pts can schedule appts, refil...
PCMH Trends: Patient Portals
• Allows patient greater
  participation in their care

• Physicians note that having
  chart...
PCMH Trends: Patient Portals
CHALLENGES:
• Portals cost money to implement & maintain but
  most pts are not willing to pa...
Greatest PCMH Promises:
 Quality of care
 Overall costs
 Satisfaction
 * patients   * families
 * physicians * staff
Greatest PCMH Challenges:
• Transformation of a practice takes
  incredible time, energy & resources.
• Currently, majorit...
What a Medical Home IS
          Meet Rebecca…
                    Working
          Mother.
          Today she woke up w...
What a Medical Home IS
         She was able to make her appt that day
         before 8am by using online scheduling.
   ...
Thank you.

 Elizabeth E. Stewart, PhD
estewart@transformed.com
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  1. 1. The Patient-Centered Medical Home: Overview, Outlook & Trends FEBRUARY 20, 2009 Elizabeth E. Stewart, PhD Center for Research in Primary Care & Family Medicine TransforMED
  2. 2. What a Medical Home is NOT Meet Rebecca… Working Mother. Today she woke up with a fever and UTI symptoms. She needs to juggle work coverage, child care and household responsibilities along with her immediate healthcare problem.
  3. 3. What a Medical Home is NOT Difficulty in No alternative scheduling appt way to seek for that day. treatment from practice. Staff sounded Hours at practice harried; had were limited so trouble locating Rebecca had to her records arrange to leave work.
  4. 4. What a Medical Home is NOT Waited for Physician was almost an hour; rushed; Rebecca staff still had was too timid to not found her ask about strange records. pain in her breast. Did not see her When Rebecca tried to own physician make a follow-up and repeated the appointment for full same information physical, the wait time to multiple people. would be 4 months.
  5. 5. Slide courtesy of www.pcpcc.net
  6. 6. Primary Care Crisis Good evidence that primary care that countries with strong primary care infrastructures have lower costs and better outcomes.1 In the US, fewer and fewer graduates are choosing primary care: * Shrinking reimbursements * Increasing demands * Overall lack of respect. A recent study revealed 49% of PCP’s said they plan to cut back or retire in 3 years.2
  7. 7. Enter: The Medical Home • In 1967, The American Academy of Pediatrics introduced the term to describe a single source of medical information and coordination for sick children.3 • Over the next 40 years, many other organizations endorsed the concept and the term.4
  8. 8. Medical Home Core Features • In 2007, four major medical organizations (AAFP, AAP, ACP, AOA) reached agreement on “Joint Features of the Patient-Centered Medical Home.” 5 • In 2008, the AMA gave their endorsement.6
  9. 9. Medical Home 7 Core Features 1. Person Physician Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous, and comprehensive care.
  10. 10. Medical Home Core Features 2. 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
  11. 11. Medical Home Core Features 3. 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.
  12. 12. Medical Home Core Features 4. Care is coordinated and/or integrated across all elements of the complex health care system, making sure patients get the indicated care when and where they need and want it.
  13. 13. Medical Home Core Features 5. Quality & Safety are Hallmarks: • Decisions are made by EBM and appropriate decision support tools • Information Technology is used appopriately • Patients participate in decision making • Patient feedback is actively sought to ensure expectations are met.
  14. 14. Medical Home Core Features 6. Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication.
  15. 15. Medical Home Core Features 7. Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. • Reflect the value of physician and non-physician staff patient-centered care management • Should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.
  16. 16. Testing the Feasibility of the Medical Home The Future of Family Medicine: “Ultimately, system wide changes will be needed to ensure high- quality health care for all Americans. Such changes include taking steps to ensure that every American has a personal medical home…” 7 2006
  17. 17. www.transformed.com
  18. 18. Access to Care & Information Practice Management • Health care for all • Disciplined financial management • Same-day appointments • Cost-Benefit decision-making • After-hours access coverage • Revenue enhancement • Lab results highly accessible • Optimized coding & billing • Personnel/HR management • Online patient services • Facilities management • e-Visits • Optimized office design/redesign • Group visits • Change management Practice Services Health Information Technology • Comprehensive care • Electronic medical record for both acute and chronic conditions • Electronic orders and reporting • Prevention screening and services • Electronic prescribing • Surgical procedures • Evidence-based decision support • Ancillary therapeutic & support services • Population management registry • Practice Web site • Ancillary diagnostic services • Patient portal Care Management Quality and Safety • Population management • Evidence-based best practices • Wellness promotion • Medication management • Disease prevention • Patient satisfaction feedback • Chronic disease management • Clinical outcomes analysis • Care coordination • Quality improvement • Patient engagement and education • Risk management • Leverages automated technologies • Regulatory compliance Continuity of Care Services Practice-Based Care Team • Community-based services • Provider leadership • Collaborative relationships • Shared mission and vision Hospital care • Effective communication Behavioral health care • Task designation by skill set Maternity care • Nurse Practitioner / Physician Assistant Specialist care Pharmacy • Patient participation Physical Therapy • Family involvement options Case Management
  19. 19. Medical Home: Is it possible? Early data point to a cautiously optimistic “YES” but… - Two years is not enough. - Transformation process is far greater challenge than previously anticipated. - Many lessons to be learned from real life application.8
  20. 20. Will it save money & improve outcomes? • Getting the attention of payers & politicians • > 25 multi-stakeholder projects are underway in 22 states, most with formal evaluations. • Growing interest in the formation of state MH demonstration projects; use of term in crafting legislation.9
  21. 21. Community Care of North Carolina •Since 1999, the state has invested in many MH components through disease management payments to practices with Medicaid pts. • Emphasis on physician led team approach, disease tracking & care managers within practices. •Significant improvements in cost, utilization, and quality measures. Two major evaluations estimate it CNCC saved the state between $230 and $260 million in 2004.12
  22. 22. MH Outlook: Pilots & Payers • PCPCC is a coalition of >300 organizations: employers, consumer groups, patient advocates, etc • Collaboration of like-minded stakeholders actively working toward medical home vision. • Comprehensive list of pilot projects: www.pcpcc.net
  23. 23. MH Outlook: Accreditation • National Committee for Quality Assurance offers 3 tiers of “medical home recognition” • Practices are hopeful that such recognition will lead to higher reimbursement by public and private payers… such recognition is a required part of many ongoing and future pilots.
  24. 24. PCMH Outlook: CMS Demonstration CMS preparing to launch 2-year Medicare Medical Home Demonstration (MMHD). Looking at impact of medical home on: - Medicare cost - Utilization - Health outcomes - Patients - Physicians & Practices
  25. 25. PCMH Outlook: CMS Demonstration •Practices must meet criteria of NCQA to qualify (Tier 2 and Tier 3 only) •Qualified practices receive additional care management fees based on RUC work RVUs, practice expenses, and insurance. • MMHD link on CMS website: http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp
  26. 26. PCMH Outlook: Gaining Political Traction New economic stimulus bill earmarks ≈ $19 billion to implement electronic medical records and other health information technology.13
  27. 27. PCMH Outlook: Gaining Political Traction Senator Baucus (D-Montana) white paper on health care reform endorsed medical home concept, even suggesting that specialists may see a small cut in reimbursements in order to pay primary care physicians for currently non-reimbursable coordination services.14
  28. 28. PCMH Outlook: Gaining Public Traction
  29. 29. Medical Home: Challenges • Transformative change doesn’t happen overnight… pilots under pressure for quick results may do more harm than good. • Simply inserting HIT is not the solution. • Primary care physicians have mixed responses to the concept.
  30. 30. Medical Home: Physician Outlook • Excited • Cautiously optimistic • Skeptical/cynical • Too exhausted & stressed to care
  31. 31. Medical Home: Physician Outlook • Financially-strapped FM physicians are fearful of the high cost of MH changes (time, resources, equipment) without a guarantee of increased reimbursement. • Like many researchers/policy makers, they are concerned about short time frame of current pilot projects given enormity of necessary changes.
  32. 32. “…some health care policy experts "worry that the push for medical homes could be yet another example of the latest health care fad -- quickly embraced by employers desperate to slow their soaring health costs, and just as quickly forgotten when they do not provide immediate results.” 15
  33. 33. Medical Home: Outlook “I no longer practice medicine encounter to encounter, taking care of the problem the patient presents with. I take care of them in between visits online, plus I use each visit as an opportunity to improve their overall health, addressing any overdue health Dr. Susan Andrews Nat’l Demonstration Project maintenance or disease mgt with Family Practice Partners the help of my nurses…” Murfreesboro, TN
  34. 34. Medical Home: Outlook “I do take care of my patients how and when they want to be seen as much as I can, whether it is in the office, online, or by phone and letter… I love my job. I look forward to working with my staff each day. It is a real pleasure seeing a nurse or MA, a receptionist, or an office manager stretch herself and grow. I Dr. Susan Andrews Family Practice Partners treasure my interactions with each Murfreesboro, TN and every patient.” 16
  35. 35. Medical Home: Outlook • We know that a strong primary care system reduces health care costs and improves quality outcomes. 17 • We know that primary care doctors feel underpaid and demoralized and their labor forces is shrinking. 18
  36. 36. Medical Home: Outlook • We know that the majority of primary care physicians would like to embrace the medical home concept… and those that have, cite greater satisfaction with their jobs.19 • Finally, we know that the evidence for a medical home is being created right now... but true change takes time, and so do results.
  37. 37. Medical Home: Trends From the ground level: What seems to be working for physicians, practices and patients?
  38. 38. PCMH Trends: Same Day Scheduling: Patients can schedule an appt for the same day OR in advance
  39. 39. PCMH Trends: Same Day Scheduling • Huge leap of faith for many physicians fearful of an open schedule. • Once in place, overwhelmingly positive response from physicians and patients. • Requires an understanding of the supply/demand cycle by day, week, season.20
  40. 40. Trends: Same Day Scheduling • Requires constant education of patients using multiple channels. • Some patients prefer the option to schedule ahead. • $$ saved – drops in no-show rates, less staff time on reminder calls.21
  41. 41. PCMH Trends: e-Visits: Physicians offer structured, secure “office visits” online
  42. 42. PCMH Trends: e-visits • Only lukewarm response from patients; takes concerted & consistent promotion by practice • Many e-visit modules do not interface with EMRS requiring extra work for documentation • Currently, limited reimbursement by payers23
  43. 43. PCMH Trends: e-visits • Currently, patients seem to prefer non-secure, non- reimbursable email communication with physicians in lieu of phone calls. • Physicians acknowledge time saving by email vs. multiple phone calls. • Potential to be popular with certain pt populations.24
  44. 44. PCMH Trends: Group Visits • Typically centered around a chronic disease; goal is for physician to facilitate peer-to- peer learning. • Evidence that group visits can result in improved health outcomes & increased pt compliance. 25
  45. 45. PCMH Trends: Group Visits • Require paradigm shift from physicians: solo encounter to group facilitation process. • Require tremendous planning and preparation work up-front; difficult without extra staff. • Concerns about reimbursement & coding. • Patients often reluctant to attend; then report increased satisfaction after visit.26
  46. 46. Population Management Chronic Disease PCMH Trends: Management Disease Registries Disease Prevention
  47. 47. PCMH Trends: Disease Registries • Practice runs report on all diabetics overdue for a follow-up visit or out of compliance. •Pts are called or emailed to set up an appt and get lab work. • During appt, EBM point-of-care reminders guide staff to arrange additional care (e.g., flu shot, mammogram).
  48. 48. PCMH Trends: Disease Registries • Many EMRs do not yet offer disease registry capabilities OR process is difficult to establish. • Many stand-alone disease registries do not interface with EMRs, requiring double data entry. • Requires paradigm shift: from acute, one-on-one episodic care to proactive management of a population of patients. 27
  49. 49. PCMH Trends: Care Teams MA/RN does vital signs, Care teams medications, history, usually consist of standing orders, etc a physician and 1 or 2 support staff who take on increased Doctor completes exam & responsibility of talks with pt; MA in room patient care. might document on EMR during exam
  50. 50. PCMH Trends: Care Teams Care teams MA/RN does follow-up require increased education wit pt & follow- staff training and up coordination of care allocation of (scheduling labs, etc) resources up front; willingness of physician to delegate.28 Doctor goes to next pt with no downtime
  51. 51. PCMH Trends: Care Teams • Evidence of increase in - Pt volume & revenue - Quality of care - Doctor/staff satisfaction29 • Challenges: - Upfront allocation of resources w/out immediate pay-off - Qualified staff cost more
  52. 52. PCMH Trends: Patient Portals • Interactive patient portals interfaced with practice EMR • Pts can schedule appts, refill medication, send in BP or blood sugar results, etc • Pts can view all or parts of their chart, lab work, test results, etc
  53. 53. PCMH Trends: Patient Portals • Allows patient greater participation in their care • Physicians note that having charts online can be “humbling” but helpful to increasing pt engagement • Online services can save practice staff time & calls
  54. 54. PCMH Trends: Patient Portals CHALLENGES: • Portals cost money to implement & maintain but most pts are not willing to pay extra for services • Some pts are not web-enabled • Takes additional Dr/staff time upfront to train pts to use portal and redesign workflow processes (e.g. how to return lab results). 30
  55. 55. Greatest PCMH Promises:  Quality of care  Overall costs  Satisfaction * patients * families * physicians * staff
  56. 56. Greatest PCMH Challenges: • Transformation of a practice takes incredible time, energy & resources. • Currently, majority of implementation & refinement of PCMH is non-reimbursable. • Engagement and education of patients – their role in the PCMH is also different.31
  57. 57. What a Medical Home IS Meet Rebecca… Working Mother. Today she woke up with a fever and UTI symptoms. She needs to juggle work coverage, child care and household responsibilities along with her immediate healthcare problem.
  58. 58. What a Medical Home IS She was able to make her appt that day before 8am by using online scheduling. She was in & out of the office in <45 min. The disease registry reminded the MA of overdue health maintenance services. Rebecca could later check her lab results online without playing phone tag. Rebecca felt warm & welcomed at her PCMH.
  59. 59. Thank you. Elizabeth E. Stewart, PhD estewart@transformed.com

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