The Medical Home: A Continuing Renovation Job
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1 Summit 2011 LEARN SHARE TRANSFORM The Medical Home: A Continuing Renovation Job Paul Kaye, MD Hudson River HealthCare Session 2C March 7, 3:45PM-5:00PM
2 2
3 HRHCare Sites New Paltz Walden Monticello Goshen SULLIVAN Pine Plains Amenia Poughkeepsie (2) Dover Plains Beacon Health Center Migrant Health Migrant Voucher program Public Housing Haverstraw Yonkers(2) Peekskill (2) Greenport 3
4 Hudson River HealthCare s Quality Journey Childhood Immunization-HRSA 1998 Improving Efficiency and Access-IHI Diabetes-HRSA 2000 Cliniflow-1 st EHR 2002 HIV Prevention Pilot 2005 Patient Visit Redesign 2005 Planned Care Innovation Community 2006 Harvesting Meeting 2008 eclinicalworks- 2 nd EHR 2009 Patient Centered Medical Home 4
5 Common Themes Integrated Teams Everyone does the highest level of work possible Consistent support staff with defined roles Work centered around the patient Planning of visits Daily huddles Standing orders All tools readily available in every patient room 5
6 Ideal Team Composition 2 Providers 1-2 Nurses 2 Medical Assistants 1 Patient Care Partner 0.5 FTE Social Worker 2 Patient Representatives (front desk) 1 Health Information Worker 0.5 FTE Care Solutions/Financial Access Specialist 6
7 Key Changes-Ranked Chart preparation/visit planning Team Huddles Cross Training Don t Move the Patient Implement EMR Standing Orders Prescription Refill Line 7
8 Quality Lessons Learned System change should precede technology introduction Relentless Board and Senior Leadership essential Quality management IS management-not a separate function National expertise in change (IHI,HRSA) adds value 8
9 The PPC-PCMH Survey What We Learned About Ourselves When We Looked in the Mirror 9
10 The Good, the Bad, and the Ugly The Good Access to Appointments (PPC 1)* Telephone Response Time (PPC 1) Performance Improvement (PPC 8) Population Management (PPC 2) Language support (PPC 1) The Not So Good Off Hours response time-could be better (PPC 1) Self management-inconsistent documentation (PPC 4B) E prescribing (PPC 5) around 40% e-transmitted The Ugly Referral tracking (PPC 7) We satisfied the points but were unhappy with the backlog Lab and X ray tracking (PPC 6) 11 systems at 11 sites *STAY TUNED!! 10
11 Open Access 10 year project started with IHI Do today s work today Adjust supply to meet demand when possible Schedule with PCP/PCG-also promotes Medical Home Monitor backlog of appointments and time to 3 rd open slot Culture change-admit you have no control! 11
12 Process Changes Always offer appointment with PCP first Empower multiple staff to add on or double book Limited triage Regular monitoring of practice data Control of vacation time (partial success!) 12
13 Agency - Timeliness: Access to Appointments (Time to 3rd Appt. - Goal=1 day) 16.0 Days to third appointment Nov-05 Nov-06 Nov-07 Nov-08 Nov-09 13
14 6.0 Time to 3rd Appointment Days /27/ /11/ /25/ /8/ /22/ /7/ /30/2010 1/4/2011 1/18/
15 I got an appointment when I wanted it Very satisfied Satisfied Total Alamo Amenia Beacon Dover Plains Greenport Haverstraw Monticello Partnership Peekskill Pine Plains Pou Atrium Walden
16 NCQA Standards: Self Management Support 4A Assess language and other barriers Assessment of language and learning needs 4B Support patient self management Chart audit of Self management tools 16
17 Patient Education Assessment Developed by primarily by nursing staff Administered by intake nurse or MA Visible on EHR note Placed in Social History section of Progress Note Structured Data-reportable 17
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20 It s Only a Medical Home If the Patient Says So 220
21 CAHPS Clinician & Group Survey Developed by AHRQ Multiple versions Adopted by AQA and submitted for endorsement by NQF Core composites: Access: Getting appointments and care when needed Doctor communication Office staff courtesy and helpfulness NCQA and AHRQ developing MH CAHPS 21
22 CAHPS Domains Getting Appointments and Health Care When Needed How Well Doctors Communicate Courteous and Helpful Office Staff Doctor's Attention to Your Child's Growth and Development Doctor's Advice on Keeping Your Child Safe and Healthy Overall Rating 22
23 HRHC August 2010 CAHPS CAHPS - Composite Measures Never Sometimes Usually Always 90.0% 80.0% 81.0% 70.0% 65.5% 60.0% 50.0% 47.7% 40.0% 30.0% 27.2% 23.7% 20.0% 10.0% 0.0% 9.3% 15.9% Access 13.5% 1.9% 3.6% 1.3% How Well Doctors Communicate 9.5% Courteous and Helpful Office Staff 23
24 7.0 Time to 3rd Appointment Days 3.0 Yonkers- Valentine Lane
25 25
26 Lessons Learned Patient experience data yielded much more than traditional patient satisfaction scores Patient experience data revealed flaws in our QI data Despite CHC Board-majority governance, accurate picture of patient experience requires systematic approach 26
27 Next Steps Improve consistency-share data and practices across sites Refine CAHPS usage Improve e-prescribing rates Standardize tracking workflow using teams Continued training on ECW documentation Develop stronger teamwork with more sharing of tasks 27
28 28
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