Patient-Centered Medical Home: The Process and Initiative


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Learn more about the process and initiative of the Patient-Centered Medical Home model. This slideshow highlights the legislation, programs involved, and how to receive the PCMH certification and incentive funds.

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Patient-Centered Medical Home: The Process and Initiative

  1. 1. Patient-Centered Medical Home: The Process & Initiative Adele Allison National Director of Government Affairs, SuccessEHS
  2. 2. Notable Acronyms
  3. 3. <ul><li>PCMH </li></ul><ul><ul><li>Patient Centered Medical Home </li></ul></ul><ul><li>PPACA </li></ul><ul><ul><li>Patient Protection and Affordable Care Act </li></ul></ul>
  4. 4. <ul><li>NCQA </li></ul><ul><ul><li>National Committee for Quality Assurance </li></ul></ul><ul><li>HRSA </li></ul><ul><ul><li>Health Resources and Services Administration </li></ul></ul>
  5. 5. <ul><li>AHRQ </li></ul><ul><ul><li>Agency for Healthcare Research and Quality </li></ul></ul><ul><li>ACO </li></ul><ul><ul><li>Accountable Care Organization </li></ul></ul>
  6. 6. PCMH Initiatives
  7. 7. <ul><li>27 multi-stakeholder projects in 20 states </li></ul><ul><li>21 states with single, commercial payer project </li></ul><ul><li>38 states with Medicaid/CHIP projects </li></ul><ul><li>Only 5 states do not have PCMH </li></ul>
  8. 8. AHRQ * * Agency for Healthcare Research and Quality
  9. 9. <ul><li>Primary Care with orientation toward whole person and relationship-based collaboration </li></ul><ul><li>Caregiver (“Home”) is accountable for majority of physical and mental health through a team </li></ul>
  10. 10. <ul><li>Home coordinates care needs across the health continuum </li></ul><ul><li>Patient accessibility is increased </li></ul><ul><li>Systems-based approach to Quality and Safety (CDS) </li></ul>
  11. 11. Health Plans & NCQA Add Recognition Seals to Provider Directories Aetna Blue Cross Blue Shield Association Blue Cross Blue Shield of Western New York Blue Shield of Northeastern New York CIGNA CDPHP GeoAccess Highmark Blue Cross Blue Shield Humana Medical Mutual of Ohio MVP Health Plan, Inc. United Assistance with Recognition by Supporting Data Collection Blue Care Network of Michigan Highmark Blue Cross Blue Shield MVP Health Plan of New York Oxford of New York United (4 areas) Pay Rewards for Achieving Recognition or Supplement Fees for Recognized Providers Anthem (Virginia) Bridges to Excellence Blue Cross Blue Shield of South Carolina/Companion CareFirst (DC-Maryland and Georgia) CDPHP ConnectiCare HealthAmerica (Pennsylvania) Health First (Florida) Highmark Blue Cross Blue Shield Independence Blue Cross MVP Health Plan of New York Oxford of New York Priority Health Silicon Valley HIT Use Recognition as a Requirement for Entry into High-Performance Networks Aetna CIGNA United
  12. 12. PPACA – Accountable Care Organizations
  13. 13. <ul><li>ACOs contract to provide services for a defined population of Medicare patients </li></ul><ul><li>ACOs share savings if quality objectives are achieved and performance measures met </li></ul><ul><li>Model is effective January 1, 2012 </li></ul>
  14. 14. <ul><li>ACO models include: </li></ul><ul><ul><li>Integrated Delivery Systems (e.g. Kaiser, Group Health Coop.) </li></ul></ul><ul><ul><li>Multi-specialty Group Practices (e.g. Mayo Clinic) </li></ul></ul><ul><ul><li>Physician-Hospital Organizations (PHOs) </li></ul></ul><ul><ul><li>Independent Physician Associations (IPAs) </li></ul></ul><ul><ul><li>Virtual Physician Organizations </li></ul></ul><ul><li>Must be Physician-led with PCMH at the hub </li></ul>
  15. 15. PCMH Movement & The Hill
  16. 16. <ul><li>HHS - Workforce Development and Training - $250M </li></ul><ul><ul><li>↑ PCP Residency Slots </li></ul></ul><ul><ul><li>Support PA training in Primary Care </li></ul></ul><ul><ul><li>Support full-time nursing careers </li></ul></ul><ul><ul><li>Establish new NP-led Clinics </li></ul></ul><ul><ul><li>Encourage state planning for health care professional workforce needs </li></ul></ul>
  17. 17. <ul><li>Medicaid / Medicare Pilots </li></ul><ul><ul><li>PPACA§ 2703 – New Medicaid state plan option to cover PCMH for certain chronic condition enrollees – 90% federally funded care for first 8 Quarters </li></ul></ul><ul><ul><li>CMMI – Research, develop, test and expand innovative payment / delivery models </li></ul></ul>
  18. 18. Legislation & Policy PPACA or Reconciliation Act Section Opportunity Description Effective Date PPACA § 5501 Increased Reimbursement PCPs receive 10% increase in reimbursement for Medicaid and Medicare primary care services. FY 2011-2016 Reconciliation § 1202 Increased Reimbursement Medicaid payment rates to PCPs for primary care services shall be no less than 100% of the Medicare payment rates. 2013 and 2014 Reconciliation § 1202 Increased Reimbursement 100% of federal funding for incremental state costs to meet the above-noted Medicaid requirement. 2013 and 2014 PPACA § 4104-6 Prevention Support Improved access for preventive services, including Medicaid and Medicare clinical preventive services recommended with a grade A / B by the USPSTF and adult immunizations recommended by ACIP. CY 2011 PPACA § 4108 Prevention Support Incentives for prevention of chronic disease for Medicaid patients As early as CY2011 PPACA § 2001 Coverage / Service Expansion $11B in new funding over 5 years for health center program expansion ($9.5B for operational capacity and $1.5B for facility improvement, expansion, and construction). FY 2011 PPACA § 5207 Workforce Development <ul><li>Expands education/training under Titles VII and VIII of the Public Health Service Act with: </li></ul><ul><li>$1.5B in new funding for the National Health Service Corps for 15,000 PCPs in HPSAs. </li></ul><ul><li>National Health Service Corps members may count up to 50% of their time spent teaching towards service obligation. </li></ul>FY 2010 - 2016
  19. 19. Legislation & Policy PPACA or Reconciliation Act Section Opportunity Description Effective Date PPACA § 5508 Workforce Development Authorizes health centers to develop residency programs and pays for CHCs operating teaching programs. FY 2010 - 2012 PPACA § 2706 Payment Delivery PPACA establishes Accountable Care Organization (ACO) contracting with CMS effective January 1, 2012. Included is a 5-year Medicaid pediatric demonstration with shared savings incentives. CY 2012 PPACA § 3022 Payment Delivery Establishment of ACOs for Medicare shared savings incentives with CMS. CY 2012 PPACA § 2703 Health Home Medicaid State Plan Option with enhanced FMAP for enrollees with 2 chronic conditions (or 1 condition with a risk for a second) can designate qualified provider as their health home for care management, coordination, health promotion, transitional care, and community / social support services. Beginning CY 2011 PPACA § 3502 Health Home Grants to create community health teams to support PCMH development for patients with chronic conditions. CY 2013 PPACA § 3503 Care Delivery Grants available to pharmacists for medication therapy management (MTM) May 1, 2010
  20. 20. Legislation & Policy PPACA or Reconciliation Act Section Opportunity Description Effective Date PPACA § 10333 Care Delivery <ul><li>Grants available for creation of Community Based Collaborative Care Networks (hospital + FQHC) for comprehensive care coordination for low-income populations. Grants may be used for: </li></ul><ul><li>Enrollment assistance and provider assignment </li></ul><ul><li>Case management and care management </li></ul><ul><li>Health outreach through neighborhood health workers </li></ul><ul><li>Transportation </li></ul><ul><li>Expansion for tele-health, after hours services or urgent care </li></ul><ul><li>Direct patient care services </li></ul>FY 2011 - 2015 PPACA § 1139B Reporting Adult quality health measures for Medicaid-eligible adults through a Medicaid Quality Measurement Program. CY 2013 PPACA § 3015, 10305 Reporting Grants for data collection and other public reporting requirements FY 2010 - 2014
  21. 21. NCQA – Role & Process
  22. 22. <ul><li>Program contains 6 standards consisting of 27 elements and 149 factors. </li></ul><ul><li>Standards contain “Must Pass” and non-must pass elements </li></ul><ul><li>Elements are associated with points, resulting recognition Level </li></ul><ul><li>3 Levels – Level 1 (lowest) to Level 3 (highest) </li></ul>
  23. 23. NCQA-PPC-PCMH 2011 Level 3 85-100 points + all 6 must pass elements Level 2 50-84 points + all 6 must pass elements Level 1 35-59 points + all 6 must pass elements No Recognition 34 points or less and/or less than 6 must pass elements
  24. 24. NCQA PCMH 2011 Scoring Points NCQA PCMH 2011 Standard and Element Number of Factors Must Pass? 20 PCMH Standard 1: Enhance Access and Continuity 34 4 Element A: Access during office hours 4 Yes 4 Element B: Access after hours 5 No 2 Element C: Electronic Access 6 No 2 Element D: Continuity 3 No 2 Element E: Medical Home Responsibilities 4 No 2 Element F: Culturally & Linguistically Appropriate Services (CLAS) 4 No 4 Element G: Practice Organization 8 No 17 PCMH Standard 2: Identify and Manage Patient Populations 35 3 Element A: Patient Information 12 No 4 Element B: Clinical Data 9 No 4 Element C: Comprehensive Health Assessment 10 No 5 Element D: Using Data for Population Management 4 Yes 17 PCMH Standard 3: Plan and Manage Care 23 4 Element A: Implement evidence-based guidelines 3 No 3 Element B: Identify High-Risk Patients 2 No 4 Element C: Manage Care 7 Yes 3 Element D: Management Medications 5 No 3 Element E: Electronic Prescribing 6 No 9 PCMH Standard 4: Provide Self-Care and Community Support 10 6 Element A: Self-Care Process 6 Yes 3 Element B: Referrals to Community Resources 4 No 18 PCMH Standard 5: Track and Coordinate Care 25 6 Element A: Test Tracking and Follow-up 10 No 6 Element B: Referral Tracking and Follow-up 7 Yes 6 Element C: Coordinate with Facilities / Care Transitions 8 No 20 PCMH Standard 6: Measure and Improve Performance 22 4 Element A: Measures of performance 4 No 4 Element B: Patient / Family feedback 4 No 4 Element C: Implements Continuous Quality Improvement 4 Yes 3 Element D: Demonstrates Continuous Quality Improvement 4 No 3 Element E: Performance Reporting 3 No 2 Element F: Report Data Externally 3 No 100 149 6
  25. 25. 10 Commandments of PCMH Health IT Support
  26. 26. <ul><li>Collect standardized, accurate, essential data -> Knowledge Base, eRx, Interfaces </li></ul><ul><li>Incorporate data from outside systems -> Interfaces / HIE </li></ul><ul><li>Support care coordination -> Referral Tracking / HIE </li></ul><ul><li>Facilitate medication reconciliation -> eRx, Rx History </li></ul>
  27. 27. <ul><li>Capture/Respond to population health needs -> Clinical Event Mgmt. Tools </li></ul><ul><li>Link to community resources -> Evidence-based CDS </li></ul><ul><li>Collect, store, measure and report on individual and population process, outcomes and quality -> Registry, Ad Hoc Reporting, Pop. Mgmt., Dashboards </li></ul>
  28. 28. <ul><li>Engage care team in decision support at the point of care -> CDS, Pop. Mgmt. </li></ul><ul><li>Facilitate provider engagement to reduce risk stratification -> Referral Management, HIE, CPOE with audit trails and alerts </li></ul>
  29. 29. <ul><li>Support patient self-management and enhance patient access/communication -> Patient Portal, Surveys, Summaries, Education </li></ul>
  30. 30. HRSA & PCMH
  31. 31. <ul><li>HRSA Patient-Centered Medical Health Home Initiative (PCMHH Initiative) </li></ul><ul><li>Provides cost coverage for recognition process fees ( $580-$4,080+ depending on number of clinicians) </li></ul>
  32. 32. <ul><li>Coordinating strategy with primary care associations, national cooperative agreements and Health Center Controlled Networks (HCCNs) </li></ul><ul><li>Eligibility based upon Section 330 funding </li></ul><ul><li>HRSA provides 3 types of: </li></ul><ul><ul><li>Technical assistance </li></ul></ul><ul><ul><li>Training </li></ul></ul><ul><ul><li>Mock Surveys </li></ul></ul><ul><ul><li>Consultant advice </li></ul></ul>
  33. 33. <ul><li>Health Centers must complete a Notice of Intent to receive HRSA support </li></ul><ul><li>NOI available at </li></ul><ul><li>Completed NOI should be emailed to [email_address] </li></ul><ul><li>Once approved, NCAQ will provide PCMH standards and guidelines, instructions and details regarding application </li></ul>
  34. 34. <ul><li>Additional Links: </li></ul><ul><ul><li>Helpline: 877.974.2742 or [email_address] </li></ul></ul><ul><ul><li>NCQA Project Liaison: 888.375.7585 or [email_address] </li></ul></ul><ul><li>Does your Vendor offer PCMH Specialized Project Management? </li></ul><ul><ul><li>Gap Analysis </li></ul></ul><ul><ul><li>Workflow redesign </li></ul></ul><ul><ul><li>Coordination with development of Policies & Procedures </li></ul></ul><ul><ul><li>Reporting Assistance </li></ul></ul>
  35. 35. Call to Action: Why do PCMH?
  36. 36. <ul><li>National Recognition </li></ul><ul><li>Increased Market Competitiveness </li></ul><ul><li>Potential Increased Reimbursement </li></ul><ul><li>Aligns with PPACA Legislation </li></ul><ul><li>Added Structure for CHC Expansion </li></ul><ul><li>Parallels and Compliments Meaningful Use </li></ul><ul><li>Aligns with new and existing pilots / demonstration projects </li></ul><ul><li>Positions for ACOs under PPACA </li></ul>
  37. 37. For more information about PCMH, visit our site for white papers, articles, blog posts and more! Click here