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  1. 1. Patient-Centered Medical Home Presented by: Marjorie J. Young, Administrator Inez Hawes, RN, Director of Nursing Pine Medical Group, P.C. www.pinemed.com
  2. 2. Presentation Objectives • Understand what a Patient-Centered Medical Home (PCMH) is and how it benefits your patients and primary care practice • Understand PCMH principles and origin • Know key benefits of PCMH
  3. 3. What is a Patient-Centered Medical Home (PCMH)? • A health care setting that provides care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions • A continuous relationship with a personal physician coordinating care for both wellness and illness
  4. 4. Patient-Centered Medical Home is a Primary Care Practice Model: • That provides patients with access to a single point of care that addresses a patient’s full range of health care needs (e.g., preventive care, chronic care) • Where care is guided by a personal primary care physician who works collaboratively with a multi- disciplinary team of health care professionals • Where the patient shares in the decision making • Where the practice has systems in place to support improved clinical outcomes • Where practices are accountable based on evidence- based medicine • Where care is supported by an equitable payment system relative to the documented value of primary care
  5. 5. Patient-Centered Medical Home Background • Initially introduced by American Academy of Pediatrics (AAP) (1967); focus on children • American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) expanded concept to include care of adults • Developed by AAP, ACP, AAFP and the American Osteopathic Association (AOA) in response to requests by several large national employers – To create a more effective and efficient model of health care delivery
  6. 6. Principles of the Patient-Centered Medical Home • Personal Physician • Physician-Directed Medical Practice • Whole Person Orientation • Care is Coordinated and/or Integrated • Quality and Safety • Enhanced Access • Payment
  7. 7. Personal Physician • Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care
  8. 8. 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
  9. 9. 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
  10. 10. Care is Coordinated and/or Integrated • Care is coordinated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services) • Facilitated by registries, information technology, health information exchange, etc. to assure patients get the care when and where they need and want it in a culturally appropriate manner
  11. 11. Quality and Safety • Evidence-based medicine and clinical decision- support tools guide decision making • Information technology is used to support optimal patient care, performance measurement, patient education, and enhanced communication • Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are met
  12. 12. Enhanced Access • Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician and practice staff
  13. 13. Payment • Support adoption and use of health information technology for quality improvement • Reflect the value of physician and non-physician staff patient-centered care management work that falls outside the face-to-face visit • Support provision of enhanced communication access such as secure e-mail and telephone consultation • Allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting
  14. 14. Patient-Centered Medical Home Key Benefits to Practice Unit • Redesigns primary care practices to provide improved clinical care to patients • Better preventive care • Increase of at least 10% in BCBSM reimbursement for office visits • Decreased use of emergency departments and hospitals • Fewer tests and higher patient satisfaction • And many more!
  15. 15. 2009 Basic PCMH Designation • 7 PCMH domains: – Patient/Provider Partnership Agreement – Patient Registry – Performance Reporting – Individual Care Management – Extended Access – Test Tracking and Follow-up – E-Prescribing • Each domain has 3-15 task requirements • Practice unit must comply with specific number of task requirements per domain
  16. 16. Overview: The goal of the Patient-Provider Partnership initiative is to expand physician and patient awareness of the patient-centered medical home (PCMH) model, and strengthen the bond between patients and their care-giving team. Patient-Provider Partnership
  17. 17. Please check off the criteria your office meets: __ Practice unit is prepared to implement patient- provider partnership or other documented patient communication process (REQUIRED) •Documents and patient education tools are developed that explain PCMH concepts, and outline patient and provider rights and responsibilities •Staff has been educated/trained on patient- provider partnership concepts and patient communication process •Data field has been created in patient registry to identify PCMH patients
  18. 18. (…continued) __ Practice unit is using a systematic approach to provide patient education and outreach on PCMH •Process of reaching out to patients, including patients who do not visit practice regularly, and providing information about PCMH and patient- provider partnership is underway
  19. 19. (…continued) __ Patient-provider agreement or other documented patient communication process is implemented and documented in medical record or patient registry for at least 10% of current patients (defined as patients covered by all payors seen within the past year) __ Implemented for at least 30% of patients __ Implemented for at least 50% of patients __ Implemented for at least 60% of patients __ Implemented for at least 80% of patients __ Implemented for at least 90% of patients Certification for this domain requires 4 of the 8 capabilities must be met.
  20. 20. Patient Registry Overview: The goal of the Patient Registry initiative is to establish a registry that contains comprehensive patient clinical and demographic information that can be used to efficiently and effectively manage a population of patients.
  21. 21. Please check off the criteria your office meets: __ All-payer (including Medicare) patient registry (paper or electronic; data should be entered by practice or populated with payor-provided data) containing patient demographics and key clinical parameters is in place in Practice Unit for all patients with: (REQUIRED) • Diabetes
  22. 22. (…continued) __ Registry incorporates comprehensive patient clinical information, including information from disparate electronic sources (IP, OP, lab, pharmacy, imaging) __ Registry incorporates evidence-based care guidelines __ Registry information is available at the point-of- care __ Registry incorporates information on attributed physician for each patient __ Registry can be used to generate automated community (e.g., email, fax, regular mail, text messaging) to patients regarding gaps in care
  23. 23. (…continued) __ Registry incorporates information on chronic disease gaps in care __ Registry incorporates information on physiological parameters (e.g., HbA1c > 7, LDL 100, BP >130/80 for diabetics), and flags patients not being managed to goal __ Registry is fully electronic •Data is housed electronically •Registry is linked to electronic sources of communication •Registry can be used to generate automated reports
  24. 24. (…continued) __ All-payer patient registry (paper or electronic) containing patient demographics and key clinical parameters is in place in Practice Unit for all patients with: Asthma __ All-payer patient registry (paper or electronic) containing patient demographics and key clinical parameters is in place in Practice Unit for all patients with: Coronary Artery Disease __ All-payer patient registry (paper or electronic) containing patient demographics and key clinical parameters is in place in Practice Unit for all patients with: Congestive Heart Failure
  25. 25. (…continued) __All-payer patient registry (paper or electronic) containing patient demographics and key clinical parameters is in place in Practice Unit for: All chronic condition patients __ All-payer patient registry (paper or electronic) containing patient demographics and preventive services guidelines in place in Practice Unit for: All patients Certification for this domain requires SEVEN of the FOURTEEN capabilities must be met.
  26. 26. Performance Reporting Overview: The goal of the initiative is to implement reporting technology that will allow providers to evaluate how effectively they are delivering services and treatment to their chronic care population. The measurement tools will generate data detailing patterns of care, and provide actionable data that will help providers to set goals, implement solutions, and improve performance.
  27. 27. Please check off the criteria your office meets: __ Key indicators have been established and reports are generated for: (REQUIRED) • Asthma __ Performance reports by indicator can be generated at the PO, individual provider, clinic and Practice Unit level for each condition __ Performance reports can be generated for all chronic conditions __ Data has been fully validated and reconciled to ensure accuracy __ Summary and trend performance reports (e.g., dashboard reports, score cards) are generated, enabling physicians to track patients over time, and identify need for follow-up
  28. 28. (…continued) __ Performance reports are generated on pertinent quality indicators for both adult and pediatric patients __ Performance reports are generated for all preventive services __ Interface is established enabling reports to include additional clinical information: lab values, physiological parameters from electronic records, medication lists/filled medications from E-Rx database, emergency department and urgent care records, inpatient hospitalizations __ Interface is established enabling reports to include information on services provided by specialists
  29. 29. (…continued) __ Key indicators have been established and reports are generated for: • Asthma __ Key indicators have been established and reports are generated for: • Coronary Artery Disease __ Key indicators have been established and reports are generated for: • Congestive Heart Failure Certification for this domain requires 6 of the 12 capabilities must be met.
  30. 30. Individual Care Management Overview: The goal of the initiative is to ensure that patients with chronic conditions receive organized and well- planned care that will help them to take greater responsibility for their health
  31. 31. Please check off the criteria your office meets: __ Practice Unit leaders and staff have been trained/educated and have comprehensive knowledge of the Patient-Centered Medical Home model, the Chronic Care model, and practice transformation concepts (REQUIRED)
  32. 32. (…continued) __ Practice has teams of multi-disciplinary providers and a systematic approach is in place to deliver comprehensive care that addresses patients’ full range of health care needs •Team may include physician, RN, NP, PA, nutritionist, CDE, respiratory therapist, case manager, front office staff, health educator, medical assistant, pharmacist, and information system staff •Provider Organization may elect to assemble “travel teams” to support multiple Practice Units •Practice Units hold regular team meetings
  33. 33. (…continued) __ Systematic approach is in place to ensure that established care guidelines (e.g., MQIC Guidelines) are followed by all members of the Practice Unit •Guidelines are available and used at the point-of- care by all physicians in the Practice Unit •Guidelines are used by the physician organization to evaluate performance of physicians, Practice Units, and PO
  34. 34. (…continued) __ At least one chronic condition has been identified for initial focus •Key clinical data has been assembled for all patients with that condition •Clinical outcomes measures, process measures, and patient satisfaction/office efficiency measures selected __ Action plan development and goal-setting is systematically offered to all patients with the chronic condition selected for initial focus
  35. 35. (…continued) __ A systematic approach is in place for appointment tracking, generation of reminders (based on evidence-based guidelines) for all patients with the chronic condition selected for initial focus __ A systematic approach is in place to ensure that follow-up for needed services (based on evidence- based guidelines) is provided for all patients with the chronic condition selected for initial focus __ Planned visits are offered to all patients with the chronic condition selected for initial focus
  36. 36. (…continued) __ Group visit option is available for all patients with the chronic condition selected for initial focus (as appropriate for the patient); may be done in collaboration with other practice units __ Medication review and management is provided at every visit for all patients with chronic conditions __ Action plan development and goal setting is systematically offered to all patients with chronic conditions or other complex health care needs
  37. 37. (…continued) __ A systematic approach is in place for appointment tracking and generation of reminders for all patients __ A systematic approach is in place to ensure follow- up for needed services for all patients __Planned visits are offered to all patients with chronic conditions __Group visit option is available to all patients with chronic conditions (may be done in collaboration with other Practice Units Certification for this domain requires 4 of the 15 capabilities must be met.
  38. 38. Extended Access Overview: The purpose of the initiative is to ensure that all patients have access to providers and are able to receive health care services in the least intensive, most appropriate setting based on their individual needs. Patients who have access to clinical decision makers are better equipped to make time-sensitive health care choices and ultimately choose the most appropriate level of care.
  39. 39. Please check off the criteria your office meets: __ Patients have 24 hour phone access to a clinical decision-maker who has a feedback loop (within 24 hours or next business day) to the patient (REQUIRED) •Clinical decision-maker is an MD, DO, RN, PA, or NP. If not MD or DO, clinical decision-maker must have ability to contact supervising MD or DO on an immediate basis if needed •Clinical decision-maker has the ability to direct the patient regarding self-care or to an appropriate level of care
  40. 40. (…continued) •Clinical decision-maker communicates information regarding the patient interaction to patient-centered medical home (PCMH) via phone conversation directly with PCMH physician, or via email, or fax directly to PCMH physician, within 24 hours (or next business day) of the interaction •Clinical decision-maker has a response time to patient of 15 minutes or less
  41. 41. (…continued) __ 24 hour patient access to clinical decision-maker is enhanced by enabling decision maker to access and update patient EMR or registry information •Updates to EMR system or registry occur within 24 hours of the interaction
  42. 42. (…continued) __ Patients have access to non-ED after-hours urgent care provider during at least 8 after-hours per week, and the urgent care provider has a feedback loop (within 24 hours or next business day) to the patient’s PCMH •After-hours defined as office visit availability during some weekday evening and/or early morning (e.g., 7-9) hours and some weekend hours, sufficient to reduce patients’ use of ED for non-ED care •Providers may bill after-hours codes for after- hours care
  43. 43. (…continued) •After-hours urgent care provider may be in a physically separate location from the PCMH as long as it is within 30 minutes travel time of the PCMH •Practice Units may team with other practice units/physicians to provide after-hours urgent care •PCMH provider should ensure that urgent care provider has ability to provide resuscitation, stabilization, timely triage, and appropriate transfer of all patients. Urgent care facilities with emergency medical systems response times of >10 minutes and transport times of >20 minutes to an emergency department should have adequate resuscitation drugs, equipment, and supplies
  44. 44. (…continued) __ A systematic approach is in place to ensure that all patients are fully informed about after-hours urgent care availability and location __ Patients have access to non-ED after-hours urgent care provider during at least 12 after-hours per week, and the urgent care provider has capability to access and update patient’s EMR or registry information __ Patient access to after-hours urgent care provider is enhanced by enabling after-hours urgent care provider to access and update the patient’s EMR or patient’s registry record
  45. 45. (…continued) __ Advanced access scheduling is in place reserving at least 30% of appointments for same-day appointment for routine and/or urgent care __ Advanced access scheduling is in place reserving at least 50% of appointments for same-day appointment for routine and urgent care __ Practice unit has telephonic or other access to translator(s) for all languages common to practice (established patients) Certification for this domain requires 5 of the 9 capabilities must be met.
  46. 46. Test Result Tracking and Follow-Up Overview: The goal of the initiative is to implement a standardized, reliable test tracking system to ensure that patients receive needed tests, results are communicated in a timely manner, follow-up appropriate to the patient case is conducted, and each step in the test tracking process is properly documented.
  47. 47. Please check off the criteria your office meets: __ Practice has policy in place requiring tracking and follow-up, with identified timeframes for notifying patients of results (REQUIRED) __ Systematic approach and identified timeframes are in place for tracking tests until the results have been received •Follow-up occurs with patients to ensure necessary tests are performed •Communication process in place with testing entities as necessary to ensure results are received •Results are reviewed, signed, and dated by the physician and filed in the patient’s medical record
  48. 48. (…continued) __ Process is in place for ensuring patient contact details are kept up-to-date __ Mechanism is in place for patients to obtain information about normal tests __ Systematic approach is used to inform patients about abnormal test results •Patient is contacted by phone (repeated attempts at different times of day, on different days if necessary); practice has back-up contact method to use in event phone contact is unsuccessful
  49. 49. (…continued) •Systematic approach is in place to flag as high priority results where follow-up is essential and the risk of not following up is high, i.e., tissue biopsies, diagnostic mammograms, INR tests •Systematic approach is in place to ensure communication brocess is clear and patients understand implications of test results
  50. 50. (…continued) __ Systematic approach is used to ensure that patients with abnormal results receive the recommended follow-up care within defined timeframes •Patients requiring follow-up are flagged and follow-up timeframes are specified •Cancellations and no-show appointments are tracked and assessed to determine whether any patients require follow-up •Outcomes of follow-up action are filed in patient’s medical record
  51. 51. (…continued) __ Systematic approach is used to document all test tracking steps (phone calls, letters, etc.) in the patient’s medical record __ All physicians and office staff are trained to ensure adherence to the test tracking policy; all training is documented in each staff member’s personnel file __ Practice has automated test-tracking system with Computerized Order Entry •Test-tracking system uses Computerized Order Entry system structured to log all test orders and link to automated tracking systems that support caregiver follow-up Certification for this domain requires 7 of the 9 capabilities must be met.
  52. 52. Electronic Prescribing Overview: The goal of the Electronic Prescribing Initiative is to improve the safety, quality and cost-effectiveness of the prescription process through widespread adoption and increased use of electronic prescribing and clinical decision support tools
  53. 53. Please check off the criteria your office meets: __ Practice Unit has capability to electronically print hard copy prescriptions, access at least some of patient’s eRx history, drug allergy information, and clinical decision support information (REQUIRED) __ Practice Unit has contract in place for licensed eRx program with capability to electronically transmit prescriptions point-to-point to pharmacy __ Practice Unit has full eRx functionality, with full clinical decision support information, including formularies (i.e., RxHub/BCBSM-hub certified) and staff are fully trained in use of eRx Certification for this domain requires 1 of the 3 capabilities must be met.
  54. 54. Thank you for listening

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