Patient Centered Medical Home
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1 Patient Centered Medical Home
2 Your phone has been automatically muted. Please use the Q&A panel to ask questions during the presentation!
3 Today s Presenters: Sherri Atchley Implementation Consultant with Galen Healthcare Solutions Over 8 years of EHR experience Project manager, Implementation consultant Sue D Agostino, RN Clinical Consultant with Galen Healthcare Solutions Over 7 years of EHR experience Project manager, Clinical consultant, Business/Clinical Analyst April
4 Agenda for today Review and define healthcare IT alphabet soup ( acronyms/terms) Explore and define PCMH Compare 2008 guidelines with 2011 guidelines for PCMH Review scoring for PCMH certification Review PCMH Standards and how to meet them with EEHR Technology Resources April
5 Initiatives to improve healthcare: April
6 What is Patient Centered Medical Home (PCMH) A patient-centered medical home integrates patients as active participants in their own health and well-being. Patients are cared for by a physician who leads the medical team that coordinates all aspects of preventive, acute and chronic needs of patients using the best available evidence and appropriate technology. These relationships offer patients comfort, convenience, and optimal health throughout their lifetimes April
7 Model of care April
8 Nurse Practitioner Doctor Patient Nurse Provides for patient health care needs. Physical Therapist Team approach at a single location responsible for patient care Care is more personalized, coordinated, effective and efficient. April
9 Comparison: PCC-PCMH 2008 with PCMH 2011 Enhanced Access & Continuity Identify and Manage Patient Populations Plan and Manage Care Provided Self Care Support and Community Resources Measure and Improve Performance September,
10 Comparison: PCC-PCMH 2008 with PCMH 2011 Enhanced Access & Continuity PCMH1F: Culturally and Linguistically Appropriate Services (CLAS) Assesses racial/ethnic diversity of patients Assesses language needs of patients Provides interpretation services Provides printed materials in patient language September,
11 Comparison: PCC-PCMH 2008 with PCMH 2011 Identify and Manage Patient Populations PCMH2D: Data for Population Health Practice uses electronic information to generate lists of patients and remind patients and clinicians proactively of services needed: Pre-visit planning Clinician action Specific medications Preventive care Specific tests Follow-up visits Care management April
12 Comparison: PCC-PCMH 2008 with PCMH 2011 Plan and Manage Care PCMH3A: Implement Evidence-Based Guidelines April
13 Comparison: PCC-PCMH 2008 with PCMH 2011 Plan and Manage Care PCMH3B: Identify High-Risk Patients The practice does the following to identify high-risk patients: Establishes criteria and a process to identify high-risk or complex patients Determines the percentage of high-risk patients in the population Registries, ICD-9 codes assist in identifying high risk patients Reminders are generated and guideline based alerts are utilized April
14 Comparison: PCC-PCMH 2008 with PCMH 2011 Provide Self Care Support and Community Resources PCMH4B: Provide Referrals to Community Resources & PCMH5B: Referral Tracking and Follow Up Practice supports patients who need access to community resources: Maintains current resource list covering five (5) community service areas (e.g. smoking cessation, weight loss, parenting, dental, transportation, fall prevention, meal support) Tracks referrals provided to patients Arranges for or provides treatment for mental health/substance abuse disorders Offers opportunities for health education and peer support April
15 Comparison: PCC-PCMH 2008 with PCMH 2011 Measure and Improve Performance PCMH6F: Report Data Externally Ambulatory clinical quality measures to CMS or states Core Meaningful Use Requirement Ambulatory clinical quality measures to other external entities Data to immunization registries or systems Meaningful Use Requirement Syndromic surveillance data to public health agencies Meaningful Use Requirement April
16 Comparison: PCC-PCMH 2008 with PCMH 2011 Measure and Improve Performance PCMH6G: Use Certified EHR Technology Uses an EHR that has been certified and issued a Certified HIT Products List (CHPL) Number under ONC HIT certification program Core Meaningful Use Requirement Attests to conducting a security risk analysis of its EHR and implementing security updates or resolving deficiencies* Core Meaningful Use Requirement April
17 PCMH 2011 Scoring April
18 PCMH 1: Enhance Access and Continuity Providing timely clinical advice by telephone during office hours- Using the Call Processing module and utilizing text templates consisting of protocols PCMH and EEHR Providing timely clinical advice by secure electronic messages during office hours - Patient portal, Follow my Health, Relay health, task teams to triage messages to ensure quick delivery Documenting clinical advice in the medical record.- Copying the messages to note in patient chart April
19 PCMH 1: Enhance Access and Continuity PCMH and EEHR Clinical summaries are provided to patients for more than 50 percent of office visits within three business days-using either Allscripts delivered or creating what works for your organization, utilizing the CS icon on the schedule Documenting the patient s choice of clinician- By utilizing the PCP functionality in the patient banner, users can easily identify the patient s primary care giver. April
20 PCMH 2: Identify and Manage Patient Populations Documentation of patient s preferred language- patient demographics either directly in EEHR or via PM PCMH and EEHR Allergies including medication allergies and adverse reactions are documented Tobacco use for patients 13 years and older is recorded for more than 50% of patients Use Data for Population Management April
21 PCMH 3: Plan and Manage Care The practice analyzes its entire population to determine the required important conditions, which may be chronic or recurring conditions such as COPD, hypertension, hyperlipidemia, HIV/AIDS, asthma, diabetes or congestive heart failure. PCMH and EEHR Condition specific flowsheets are created to track patient progress. April
22 PCMH 3: Plan and Manage Care Gives the patient/family a written plan of care PCMH and EEHR Gives the patient/family a clinical summary at each relevant visit April
23 PCMH 4: Provide Self-Care Support and Community Resources Offers opportunities for health education programs (such as group classes and peer support.) PCMH and EEHR 11.3 offers group session Note workflow. Arranges or provides treatment for mental health and substance abuse disorders April
24 PCMH 5: Track and Coordinate Care PCMH and EEHR Flags abnormal lab results, bringing them to the attention of the clinician Notifies patients/families of normal and abnormal lab and imaging test results April
25 PCMH 5: Track and Coordinate Care Giving the consultant or specialist the clinical reason for the referral and pertinent clinical information PCMH and EEHR April
26 PCMH 6: Measure and Improve Performance The practice uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience. PCMH and EEHR Data to immunization registries or systems April
27 PCMH 6: Measure and Improve Performance PCMH and EEHR Syndromic surveillance data to public health agencies September,
28 Resources to help in PCMH quest: National Committee for Quality Assurance Agency for Healthcare Research and Quality American Academy of Family Physicians p/initiatives/pcmh.html American Academy of Pediatrics Center for Medical Home Improvement The Commonwealth Fund April
29 Contact Information Questions? Questions: Corporate: 888-Galen-44 Information You can find all handouts as well as questions and answers from this webcast and other webcasts on our wiki at:
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