BUILDING THE PEDIATRIC MEDICAL HOME. Michaela Morton, MPH CIQN Practice Managers Meeting 14 June 2016

Transcription

1 BUILDING THE PEDIATRIC MEDICAL HOME Michaela Morton, MPH CIQN Practice Managers Meeting 14 June 2016

2 WHAT IS IT? What is the Patient-Centered Medical Home?

3 WHAT IS THEPCMH? The PCMH puts patients at the center of the healthcare system and provides primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective. (American Academy of Pediatrics)

4 MEDICAL HOME : ORIGIN IN PEDIATRICS AAP: Every Child Deserves a Medical Home (1978) Calvin Sia, MD (AAP) CSHCNs All children Medical Home expands to all Primary Care Endorsed by AAP-AAFP-ACP Emerging as payment model to achieve triple aim

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6 WHY? What is the benefit to our practice and our patients?

7 RATIONALE FOR PCMH RECOGNITION It s the RIGHT thing to do! For our patients and families, for modeling and training the next generation of healthcare providers Aligns our practice with emerging models for primary care redesign and reimbursement Building the primary care practice of the future as we plan, design, and move into a new ambulatory environment NQCA gives a framework for practice transformation and redesign

8 STRATEGIC ALIGNMENT PCMH Recognition is incorporated into the strategic plans for Children s National Health System and the Goldberg Center Dedicated project team Established at QI/learning collaborative model across all practices Primary care faculty and management goals QI = quality improvement; FY = fiscal year.

9 CHILDREN S NATIONAL HEALTH SYSTEM: PRIMARY CARE Children s National Health System is Washington, DC s children s hospital and regional health system for children Dedicated Center of Excellence Operates 7 primary care health centers at main campus and underserved neighborhoods across DC and mobile health program All recognized as NCQA Level 3 PCMH (2011 and 2014) Almost 40,000 attributed patients Largest primary care provider and largest primary care provider for children in DC 100,000+ annual visits

10 SNAPSHOT OF OUR PRACTICES Patient Demographics 85-90% Medicaid enrolled through Managed-Care Organizations ~10% commercial or uninsured 15% of children live with head of household without HS diploma; 50% with head of household have high school diploma 77% of fourth grade public school children do not read at level* 1550 children in the district are in foster care Staffing Model Mixed model: attending and resident 67 faculty (attending physicians) >60 resident trainees cycle through each year * DC Medicaid April 2015 Enrollment Report.

11 CHILDREN S NATIONAL: MEDICAL HOME TO DC S MOST VULNERABLE CHILDREN Medical Home is not a placebetter way of delivering care Team-based care Puts patient at the center of the health care system Provides primary care that is: - Accessible - Continuous - Comprehensive - Family-centered - Coordinated - Compassionate - Culturally effective Coordinated with community partners and resources

12 MOVING FROM THE CLINIC MODEL TO MEDICAL HOME Clinic Model Provider/Staff Centered Office hours accommodate faculty and staff Communication Telephone only Office hours only Patient Feedback When there are problems Improvement When there are problems Medical Home Patient Centered Office hours accommodate patients and families Communication Telephone/Web 24/7 Patient Feedback Routinely Improvement Continually

13 OUR MEDICAL HOME JOURNEY July 2010 Focus Areas Care management Patient management support Test tracking Transformation Areas Tracking patient satisfaction Clear and adequate EMR documentation Important conditions: asthma, obesity, and well-child care July(ish) 2012 Focus areas Care Transitions inpatient/ed/home Developing the Practice Team Maintaining previous work

14 CHILDREN S NATIONAL PCMH TIMELINE

15 HOW? How can ecw be used as a PCMH tool

16 MEANINGFUL USE OUR BLESSING IN DISGUISE Pre-built reporting available Forced us to standardize workflows and documentation at all levels Front office Providers Nursing

17 PCMH B Clinical Data 2B: Clinical Data

18 PCMH A Patient Information The practice uses an electronic system that records the following as structured data for more than 50 percent of its patients: Date of Birth Gender Race Ethnicity Preferred Language 2A: Patient Information

19 PCMH C Electronic Access Factor 1: Patients that request an electronic copy of their health information receive it within three business days Factor 3: Clinical visit summaries are provided to patients within three business days 1C: Electronic Access

20 PCMH C Electronic Access Factor 4: Patients can communicate with our practice securely via our Patient Portal 1C: Electronic Access

21 Factor 4: Two-way communication between patients/families and the practice Factor 4: Messages sent from the Patient Portal are received in the EMR as web encounters Factor 4: When staff respond to web encounters via the EMR they are sent to the patients Portal inbox 1C: Electronic Access

22 Factor 4:Request for appointments or prescription refills Factor 5: Patients can request appointments via the Patient Portal. Factor 5: Patients can request medication refills via the patient portal 1C: Electronic Access

23 POPULATION OUTREACH 2 Options for outreach in ecw 1. Registry searches for populations, eclinicalmessenger for outreach 2. Campaigns

24 PCMH D- Use Data for Population Management Factor 2: Message templates for voice and SMS messages are built into the EMR and sent directly to the patients 2D: Use Data for Population Management

25 Factor 2: The EMR is queried for patients with the following: Asthma diagnosis in their problem list No follow-up visit in the past three months Factor 2: Messenger function sends messages to eligible patients from this report Factor 2: Total patient count 2D: Use Data for Population Management

26 Factor 2: Reminder messages are sent to all patients at the same time 2D: Use Data for Population Management

27 Factor 2: Logs showing status of EMR generated messages 2D: Use Data for Population Management

28 ECW CAMPAIGNS

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31 REPORTING ASSISTANCE ebo 7 viewer includes 400+ canned reports Primarily for Practice Management Track workflows Cycle time Referral counts Lab results Locked notes

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34 FOCUS ON QUALITY PCMH 2014 stresses quality improvement several areas Access to care Patient engagement Care coordination Clinical quality

35 OPPORTUNITIES FOR QUALITY IMPROVEMENT Population outreach Analyzing populations needs Increasing volume Campaigns Alternative visit types Exploring alternate payment model Provide convenient care for families Schedule updates/standardization Scheduling more efficiently Documenting administrative process more efficiently

36 ANY MORE HELP? Tools ecw offers to help with NCQA PCMH recognition

37 ECW RESOURCES CCMR for PCMH PCMH Analytics package with 30+ reports that can be used to spur practice transformation CAHPS validated survey tool Care Planning module design care plans for specific populations Consulting services Charge by FTE Each sold separately if need be

38 FREE STUFF! PCMH Prevalidation NCQA offers a pre-validation program with EMR vendors that allows to practices to receive autocredits for certain factors if specific EMR functionality is used Up to 50 factors, 32 points

39 QUESTIONS?

40 CONTACT INFORMATION Michaela Morton, MPH Project Lead: Patient-Centered Medical Home Clinical Outcomes Analyst