AltaMed - The Patient Centered Medical Home, PCMH
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AltaMed - The Patient Centered Medical Home, PCMH
- 1. The Patient Centered Medical Home at AltaMed Health Services Esiquio Casillas, MD, MPH Michael Hochman, MD, MPH October 13, 2015
- 2. AGENDA • Background about AltaMed • The PCMH Model • AltaMed PCMH Model • Senior Buena Care (Program for All Inclusive Care for the Elderly) PCMH
- 3. Founded as the East Los Angeles Barrio Free Clinic in 1969, a volunteer-staffed storefront operation Now the largest independent FQHC in U.S., serving over 170,000 patients annually Serve safety net population 28 sites in LA and Orange Counties (including Primary Care Clinics, HIV, PACE and Mobile Service Sites) Programs & services include: general medicine, dental services, senior services, women’s health, pediatrics, youth services, HIV services, health education, obesity prevention About AltaMed
- 4. AltaMed- Patient Demographic Patients by Hispanic or Latino Ethnicity Hispanic/Latino Non Hispanic/ Latino Unreported/ Refused to Report Total 139,381 (81%) 30,323 (18%) 1,428 (1%) 171,132 Insurance: None/uninsured: 31,993 (19%) Medicaid: 109,247 (64%) Medicare: 6,685 (4%) Other public insurance, non-CHIP: 1,267 (1%) Private insurance: 21,940 (13%)
- 5. BIRTH OF THE PCMH MOVEMENT • Concerns about sustainability of primary care in the U.S. • Desire to increase primary care revenue PCMH
- 6. THE PCMH MOVEMENT • Primary care organizations lay out principles of primary care (2007): “The Patient- Centered Medical Home (PCMH)” PCMH
- 7. PCMH PRINCIPLES • Personal primary care provider • Whole person orientation • Coordinated care • Enhanced access to care • Emphasis on quality and safety • Team-based care • New payment models PCMH
- 8. TEAM BASED CARE • It’s not all about super-human primary care doctors! PCMH
- 9. What Does the Evidence Show?
- 10. Group Health: 2002 • Online patient interaction with clinic: - emails with PCP - med refills • Advanced access scheduling • Direct access to specialists • Incentives for PMC productivity and patient satisfaction (40% of salary)
- 11. Results • Impact on patient satisfaction: Positive • Impact on staff satisfaction: Negative: - bigger panel sizes, emails, productivity pressures
- 12. Results • Impact on ER/hospital visits and specialty visits: increased
- 13. Group Health: Take 2 (2006) • Decreased PCP panel sizes from 2300 to 1800 • Visit time increased from 20 to 30 minutes • Daily ‘desktop time’ for care coordination • Team-based care!!! (RNs, MAs, PAs, NPs, and pharmacists)
- 14. Group Health: Take 2 • Daily team huddles • ED/hospital follow-up outreach • Continued emphasis on email and phone communication with patients • Eliminated productivity incentives • $16 per-patient per-year investment
- 15. Results • Impact on patient satisfaction: positive • Impact on staff satisfaction: positive • Impact on quality of care: positive
- 16. Results • Impact on ER/hospital visits: Positive: - 29% fewer ED visits - 6% fewer hospitalizations
- 17. Results • Impact on cost: Positive: - $16 per-patient per-year up-font investment - $10.30 SAVINGS per member per month (P=0.08)
- 18. Lessons • PCMH-guided reform has the potential to improve primary care • Requires investment • Team approach very important • New payment models will be critical to enable sustainability
- 19. ALTAMED PCMH MODEL PCMH Physician and Medical Assistants Nurse Practitioner and Medical Assistants Physician Assistant and Medical Assistants Physician and Medical Assistants Care Coordination Team Care Coordination Team Care Coordination Team Care Coordination Team
- 20. CARE COORDINATION TEAM • Clinical Care Coordinator = RN Case Manager • Health Promoter (Health Coach) • Behavioral health (LCSW/psychologist) • Clinical Pharmacist • Mid-level chronic disease manager PCMH
- 21. RN CASE MANAGER • Target the most complex patients (‘hotspotters’) • Caseloads of 200-33 patients • Also sporadic assistance PCMH
- 22. HEALTH PROMOTERS/HEALTH COACHES • Target patients with stable chronic illnesses • Lifestyle teaching, education, action plans • Goal: 5 visits per day PCMH
- 23. CHRONIC DISEASE MANAGEMENT • Pharmacists as population health managers • Mid-level chronic disease managers PCMH
- 24. BEHAVIORAL HEALTH • 7 LCSWs/clinical psychologists • Depression/anxiety counseling PCMH
- 25. TEAM-BASED CARE • Daily huddles • IDT/ICT Case Management
- 26. COMMUNITY APPROACH: OBESITY • CDC REACH Grant • County Health Department, YMCA, local grocery stores, restaurants • Parks and Rec • Food trucks Innovation
- 27. CHALLENGES • Team based care • Fee for service • Standardization throughout the system • Partnerships with hospitals • Patient engagement PCMH
- 28. 28 AltaMed Health Services (PACE) Program of All-Inclusive Care for the Elderly An integrated Health Plan/Medical Group designed to provide complete access to Medical, Social, Psychological, Transportation, Homecare, Nutritional, Rehabilitative services, End of life through one comprehensive program.
- 29. VERTICAL INTEGRATION AT PROVIDER LEVEL PACE Basics
- 30. PACE REGULATORY FRAMEWORK PACE Basics County/State Regulation ADHC Transportation CDHCS Regulation for Licensure or Waiver Dietary Health Dept Regulation Clinic CDHCS Regulation PACE CMS PACE Regulation Medi-Cal Regulation CDHCS Contract
- 31. • 108 PACE programs nationally-32 states • 30,000 enrollees nationally • PACE programs in California • On Lok in SF and Fremont • CEI in East Bay • AltaMed Senior BuenaCare • Sutter Senior Care in Sacramento • St. Paul’s in San Diego • Fresno-PACE • Jewish Home of Aging • Cal-Optima-Orange County • InnovAge-Riverside/SB County • Redwood Coast/Eureka PACE PROGRAMS PACE Basics
- 34. HEALTH AND WELL BEING • Health care accounts for 10% of contributing factors in life expectancy • Social determinants of health account for 60% of risk of premature death Adapted from McGinnis, Russo and Knickman. “The case for more active policy attention to health promotion.”Health Affairs, 2002.
- 35. SOCIAL DETERMINANTS OF HEALTH 85% of physicians believe unmet social needs are directly leading to worse health 80% of physicians state they are not confident in their capacity to address their patients’ social needs Health care’s Blind side: the overlooked connection between patients social needs and good health, RWJF, 2011.
- 36. SOCIAL DETERMINANTS OF HEALTH Physicians wish they could write prescriptions to help patients with social needs 1 out of 7 prescriptions physicians write would be to address patients’ social needs • Fitness program 75% • Nutritional food 64% • Transportation assistance 47%
- 37. SOCIAL DETERMINANTS OF HEALTH
- 38. PACE Basics IDT- COMPREHENSIVE APPROACH Nursing Specialists Primary Care PT/OT Adult Day Health Care/Activities Social Work Pharmacy Home Care Coordinator Transportation Personal Care Dietary/RD
- 44. PACE Basic PACE OUTCOMES Improved health status Higher patient satisfaction Improved physical functioning Increased days living independently in community Improved quality of life Lower mortality Lower hospitalization rates Higher utilization of primary care services
- 47. ALTAMED-PACE PROGRAM AltaMed • ~1900 patients • 25 Providers (110 Patients/Provider panel) • 8 Sites • Patients at PACE Center ~9 days/month • ~80% patients receive maintenance PT-OT • 14 Transportation round trips/month/pt • ~20 Meals/month/pt • ~70 Caregiver support service hrs/month/pt • Required Biannual IDT Assessments • Minimum Q-6 week clinic visits
- 49. UTILIZATION 0 200 400 600 800 1000 1200 Admits/1000 Admits/1000 AltaMed Milliman ACN Report, AltaMed UM 2012 ytd,C-SNP-XL Health
- 51. SNF Beddays/1000 Duals-Custodial 29,634 Duals-Community 2,506 C-SNP 1,887 AltaMed PACE 1,460 UTILIZATION-SNF BED-DAYS AltaMed
- 52. AltaMed ALTAMED PACE FALL RATE PER 100 MM/QUARTER 52
- 53. PACE-HIGH RISK MEDICATION % AltaMed 0 5 10 15 20 25 2010 2012 2013 2014
- 54. QUALITY MEASURES • Pneumococcal vaccine rate = 95% • Nephropathy screening in Diabetes = 96% • Hospital Discharge f/u visit within 72hrs ~ 90% • Readmit rate ~ 14% • Patient Satisfaction-Would refer friend/family = 96% AltaMed
- 55. AltaMed PACE LOCATION OF DEATH
- 58. PERMANENT NURSING HOME PLACEMENT AltaMed
- 59. COMPLEX HEALTH CARE PACE Basics
Editor's Notes
- PACE is a managed-care program that uses an interdisciplinary team approach to provide patients with medical, social, nutritional and rehabilitative services. The PACE program makes it possible for those who are frail and meet nursing home eligibility criteria to live with dignity and pride in their own homes while receiving all the care they need. PACE is a managed care-like plan that requires disenrollment from other managed care plans to be accepted. Placing most frail and time consuming patients in the most appropriate environment.
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