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A short presentation on Patient Centered Medical Home for Truman Medical Center - Lakewood

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  • No matter what measure US is an outlier
  • Not getting value for money spent
  • All of these programs have common elementsWHP – Wellness and Health Plan PromotionACO – Accountable Care OrganizationPCMH – Patient Centered Medical HomePPC – Physician Practice ConnectionsSPM – Society for Participatory Medicine
  • But applies to networksConclusionGroup Health’s experience in a prototype clinic suggests that primary care enhancements, in the form of the medical home, hold promise for controlling costs, improving quality, and better meeting the needs of patients and care teams. We offer an operational blueprint, but success in other settings will depend on leadership, resourcing, electronic health records, change management, and aligned incentives. Primary care transformation represents a complex system redesign that requires a policy environment that aligns payment and training to support this work. It also requires organizations in which leaders, managers, and care providers are highly engaged in achieving this change. ▪
  • Bilal JavedData Analyst, Physician Recognition ProgramsNational Committee for Quality Assurance (NCQA)1100 13th Street N.W. Suite 1000Washington, DC 20005Ph: (202) 955-3503Fax: (202) 955-3599Email: javed@ncqa.org
  • http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/2012-03-27_series_pcmh-mu.pdf
  • "Association between patient-centered medical home rating and operating cost at Federally-funded health centers," by Robert S. Nocon, M.H.S., Ravi Sharma, Ph.D., Jonathan M. Birnberg, M.D., M.S., and others in the July 4, 2012, Journal of the American Medical Association 308(1), pp. 60-66http://www.uchospitals.edu/news/2012/20120624-pcmh.html
  • We have already learned enough from the NDP to identify some potentially dangerous red flags fluttering over the demonstrations just getting underway. Our early analysis raises concerns that current demonstration designs seriously underestimate the magnitude and time frame for the required changes, overestimate the readiness and expectations of information technology, and are seriously undercapitalized. We fear that with current assumptions, many demonstrations place participating practices at substantial risk and may jeopardize the evolution of the PCMH as unrealistic expectations set up demonstrations and evaluations for failure. The lessons described below arise from both the real-time or “live” qualitative analysis conducted during the NDP and the in-depth and comprehensive analysis currently underway. The live analysis included realtime reading of all data and multidisciplinary analysis team discussion in biweekly conference calls, quarterly reports to the NDP board,18 site visits by a member of the evaluation team, 3 analytic retreats, and member checking with NDP facilitators and practice participants to both expand understanding and seek disconfirming data. This special report, based on our ongoing analysis, raises timely concerns and opportunities. The pressure toward widespread adoption of this is model is gaining momentum so rapidly that we feel compelled to share our observations and summarize the early process-evaluation lessons. We describe 6 critical lessons, suggest 4 recommendations for health policy and 4 for practices, and raise hopeful warnings at this critical juncture for primary care reform.
  • Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical HomePaul A. Nutting, MD, MSPH, William L. Miller, MD, MA, [...], and Kurt C. Stange, MD, PhD Ann Fam Med. 2010 May; 8(Suppl 1): S57–S67.
  • Steven A. Schroeder, MD and William Frist, MD for the National Commission on Physician Payment Reform, “Phasing Out Fee-for-Service Payment.” New England Journal of Medicine 368;21:2029-2032http://physicianpaymentcommission.org/wp-content/uploads/2013/03/physician_payment_report.pdf
  • Pcmh?

    1. 1. PATIENT CENTEREDMEDICAL HOME?REALLY?DAVID VORAN, MDA look into the future of Primary Care5/31/2013
    2. 2. Agenda Reality check: US healthcare Why Patient Centered Medical Homes? What we are now Implications for you
    3. 3. How does our current system stack up?Reality Check
    4. 4. Middle to Bottom of the PackOf 13 countries in recent study…13th for low-birth weight %13th for neonatal & infant mortality11th for postnatal mortality13th for years of potential life lost11th for life expectancy @ 1 yrs (females), 12th(males)10th for life expectancy @ 15 yrs (females ),12th(males)10th for life expectancy @ 40 yrs (females), 9th(males)7th for life expectancy @ 65 yrs (females), 7th(males)3rd for life expectancy @ 80 yrs (females), 3rd(males)10th for age adjusted mortalityBarbara Starflield, MD, MPH. JAMA July 26, 200
    5. 5. An Outlier by Any Measure
    6. 6. Mediocre overall performance
    7. 7. We can’t afford to continue with our currentparadigmsWhy PCMH?
    8. 8. Many Programs :: Similar Goals
    9. 9. In Support of Medical Homes Policies Community Practice EncounterAlignment of Incentives International findings
    10. 10. Fundamental Concept: Teams Physicians ANPs and Nurses PA’s Pharmacists Nutritionists Social Workers Educators Care CoordinatorsComprehensive RequiresTeamsTeam MembersVirtual Teams
    11. 11. What is the PCMH? Clinic that puts patient’s at the center of thehealth care system Provides primary care Accessible Continuous Comprehensive Family Centered Coordinated Compassionate Culturally effectiveAmerican Academy of Pediatrics
    12. 12. Physician PracticesConnections© Formally recognize practices that use systemicprocesses and information technology to enhancethe quality of patient care Know and use patient histories Follow up with patients and other providers Manage patient populations and use evidence basedcare Employ electronic tools to prevent medical errors 9 PPC© standards and 3 levels of recognition
    13. 13. Joint Principles Provide a personal physician for each patient Physician directed medical practice Oriented around the whole person Coordinated and integrated Care Adhere to quality and safety hallmarks Provide enhanced access Dedicated to payment reformAAFP, ACP, AAP, AOA
    14. 14. NCQA and PCMH Defined standards with 3-tiered recognitionPhysician Practice Connections – PCMHprogram PPC – PCMH recognition Application completion Submit documentation proving processes andpolicies are in place Levels Basic – Level 1 Intermediate – Level 2 Advanced – Level 3
    15. 15. 9 PPC-PCMH Standards (7 mustpass)Standards Must Pass Elements1) Access and Communication Written patient access and communicationstandardsUse data showing standards are met2) Patient tracking and Registry Clinical information organized in paper orelectronic toolsData used to identify diagnoses and conditions3) Care management Adopt and implement evidence based guidelinesin 3 conditions4) Patient self-management support Support patient self-management5) Electronic prescribing6) Test tracking Track tests & identify abnormals systematically7) Referral tracking Paper or electronic referral tracking system8) Performance reporting &improvementMeasure clinical and/or service performance byphysicianReport performance across practice by physician9) Advanced electroniccommunications
    16. 16. PPC – PCMH Content andScoring
    17. 17. PPC – PCMH Content andScoring
    18. 18. Coordinated Care Pays
    19. 19. Most PCMH sites are level 3Sites Recognized as of 4-30-20135,660 PCMH sites (27, 328physicians)Most in NY, NC, PA*Over 230,000 physician practices in US830 5494,281-1,0002,0003,0004,0005,000Level 1 Level 2 Level 3Courtesy of Bilaf Javed, Data Analyst, Physicain Recognition Programs, N020040060080010001200MilAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPAPRRISCSDTNTXUTVAVTWAWIWVWY
    20. 20. PCMH and MU Alignment
    21. 21. Story Gets ComplicatedPhysician FTE/yr PPMPatient Tracking $27,300 $1.06Quality Improvement $32,731 $1.86Access/Communication ($39,809)JAMA 308(1), pp 60-66
    22. 22. Evidence of Success?
    23. 23. Recognition not alwaysmeaningful Assure adequate financial resources Tailor approach to each practice Assist physicians with personal transformation NCQA needs to modify its PCMH-RecognitionProcess
    24. 24. Middle of the road to recognitionWhere we are now
    25. 25. Where we are now
    26. 26. Where we are now
    27. 27. Where we are now
    28. 28. Where we are now
    29. 29. Where we are now
    30. 30. Where we are now
    31. 31. Change is hard work … you’ll probably bedoing something different than for whichyou’re now being trainedImplications For You
    32. 32. Doing it right requires changes Requires transformation Means personal transformation of physicians Developmental Local Required technology is not Plug and Play Change Fatigue is a big problemAnnals of Family Medicin
    33. 33. At the heart of all programs Inexorable shift from individual to populationcare Reduction of the cost burden of health care Transparent and open access to information
    34. 34. Payers should largely eliminate stand-alone fee-for-servicepaymentsTransition to a quality and value based system and adoptedwith broad adoption by the end of the decadeContinue recalibrating fee-for-service payments toencourage…cost effectiveness and penalize behavior thatmisuses or overuses careAnnual updates should be increased for E&M and freezeprocedural diagnosis codes for a period of three yearsEliminate higher payment for facility-based services that can beperformed in a lower-cost settingFee-for-service contracts should always incorporate qualitymetricsFee-for-service reimbursement should encourage smallpractices (< 5 providers) to form virtual relationshipsFixed payments should initially focus on areas where significantpotential exists for cost savings and higher qualityMeasures to safeguard access to care, adequacy of risk-adjustment indicators, and promote strong physiciancommitment to patients should be put into place for fixedpayment modelsEliminate the Sustainable Growth RatePay for SGR repeal from Medicare cost savingsRelative Value Scale Update Committee (RUC) should makedecision-making more transparent and diversify its membership.
    35. 35. What You Might Experience Patients come to you Serial work flow Treat individual Work relatedreimbursement Patient a passiverecipient of care 9-5 M-F You bring patients in Parallel work flow Treat a population Quality basedreimbursement Patient an activeparticipant 24x7x365Current Future
    36. 36. Real Patient Centered Care“Gimme mydamn data”“My Mom ismy MedicalHome” About me, after all I’m the patient Let me “in” and be a user of thesystem Where I go for medical care Need to take me 24x7x365 Easy access to all of my medicalinformation Care for most problems withoutreferrals Person answering phone, e-mails,etc. Treating me at home wheneverpossible