WHAT IT FEELS LIKE

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1 PCMH and PCSP

2 WHAT IT FEELS LIKE

3 Presentation Outline Goals of the Patient Centered Medical Home and the Patient Centered Specialty Practice Identifying the Joint Principles Recognition Programs Standards Examples

4

5 Goals PCMH A model for care provided by physician practices aimed at strengthening the physician-patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship PCSP A program designed to improve quality and reduce waste and poor patient experiences that result from poorly coordinated care. The program focuses on coordinating and sharing information among primary care clinicians and specialists. It requires clinicians to organize care around patients and to include patients and their families or other caregivers in planning care and as partners

6 How Many Standards????

7 Facilitate communication, coordination and integration Facilitate appropriate and timely consultations and referrals Facilitate the efficient, appropriate and affective flow of necessary patient and care info Effectively address issues of responsibility in co-management situations Support patient centered care, enhanced care access and high levels of care quality and safety Recognize the PCP as the provider of whole person care to the patient and as having overall responsibility for ensuring the coordination and integration of care Patient Centered Comprehensive Coordinated Accessible Committed to Quality and Safety

8 What s Pushing the PCMH/PCSP Model

9 Impact on Cost and Quality Data from the Patient-Centered Medical Home s Impact on Cost & Quality: An Annual Update of the Evidence January 2014 Peer Review 61% Cost Reduction 61% Fewer ED Visits 31% Fewer Inpatient Admissions 13% Fewer Readmissions 31% Improvement in Population Health 31% Improved Access 31% Increase in Preventive Services 23% Improvement in Satisfaction Industry Reports 57% Cost Reduction 57% Fewer ED Visits 57% Fewer Inpatient Admissions 29% Fewer Readmissions 29% Improvement in Population Health 14% Improved Access 29% Increase in Preventive Services 14% Improvement in Satisfaction

10 THE PROMISE OF PCMH

11 Joint Principles Personal physician Whole person orientation Coordinated care Determine Recognition Program Step 1 Evaluate Requirements Quality and safety emphasis Enhanced patient access to care Develop Leadership Team Step 2 Supported by payment structure that recognizes the added value to patients Step 3 Assess Current Procedures and Policies Implement New Systems and Record Data Submit for Accreditation

12 Accreditation and Recognition Programs PCMH National Committee for Quality Assurance NCQA Utilization Review Accreditation Commission URAC Joint Commission Accreditation Association for Ambulatory Health Care - AAAHC Agency for Healthcare Research and Quality - AHRQ TransforMED Many State Programs Some Payer Specific Programs PCSP National Committee for Quality Assurance Agency for Healthcare Research and Quality - AHRQ Some Payer Specific Programs * Most programs offer different levels for accreditation depending on number of items met. Each specify MUST MEET criteria

13 PCMH Transformation Set a Timeline Phase 1

14 PCMH Transformation Set a Timeline Phase 2

15 PCMH Enhance access and continuity PCSP Track and coordinate referrals Identify and manage patient populations Provide access and communication Plan and manage care Identify and coordinate patient populations Provide self-care support and community resources Plan and manage care Track and coordinate care Track and coordinate care Measure and improve performance Measure and improve performance

16 The Trends are Moving Toward PCMH s and ACO s GE Cincinnati Michigan Kroger Johnson & Johnson Department of Health and Human Services NCQA The Office of the National Coordinator for Health Information Technology Florida Health Care Coalition Healthy Orange Collaborative

17 Why Should I Do More? And More? And More? Enhanced Reimbursement Increased Patient Volume Improved Outcomes Recognition and Marketing But it is going to be more work. Most practices already have informal workflows that meet the guidelines, why not formalize it Many of the guidelines cross over between Meaningful Use and PQRI Recognition helps maintain MOC Credit for enhanced reimbursements

18 Why Participate?

19 Practice provides access to culturally and linguistically appropriate routine care and urgent team based care that meets the needs of patients and families Appointment Accessibility and timely clinical advice during and after office hours Practice provides continuity of care for patients and families in regards to clinician of choice Practice provides education on the medical home or medical neighbor model identifying the role of the PCP vs specialist Practice aims to meet cultural and linguistic needs of patients by providing interpretation or bilingual services and educational materials in the languages of their patients Practice utilizes the team approach to patient care Practice has procedures to ensure proper documentation and access to the medical record after hours PCMH Standard 1 PCSP Standard 2 Enhance Access and Continuity

20 Enhanced Communication

21 Practice has formal and informal agreements with PCP s identifying specified methods of communication, co-management or transition strategies, confirmation of receipt and acceptance, information regarding patient demographics and timing of the referral Referral must contain clinical question, the type of referral, urgency of referral, patient demographics, clinical information, primary practice care plan, treatment, test results and procedures Practice must respond to the PCP as to their plan of care, care management, patient education, follow up, and secondary referrals In MU stage 2 the practice must provide an electronic summary of care for more than 50% of referrals PCSP Standard 1 Track and Coordinate Referrals

22 How do you identify who is on your team: -Every player is wearing a different colored jersey and playing with out a clear cut position -You can t win the NBA title with 5 Forwards -Must identify the players and their role Patient PCP Specialist Hospital Insurance Government

23 PCMH Standard 2 and PCSP Standard 3 Population Health Management The practice systematically records patient information and uses it for population management to support patient care Structured demographics Up to date problem and medication list Complete past medical history to include: allergies, advance care planning, mental health/substance abuse, etc. Vital signs recorded, including BMI and BP Immunizations Practice must use patient information, clinical data and evidence based guidelines to generate lists of patients and proactively remind them of services

24 High blood pressure has increased dramatically over the past 10 years That proves global warning causes high blood pressure

25 PCMH Standard 3 and PCSP Standard 4 Plan and Manage Care Practice must be able to identify individual patients, manage and coordinate their care based on conditions and evidence based guidelines Practice must have evidence based point of care reminders for patients first and second important condition as well as unhealthy behaviors or mental health/substance abuse Must be able to identify high-risk or complex patients Utilize a care team for pre-visit preparation, collaboration regarding individual care plan, assess and address barriers, identify patients that can benefit from additional care and follow up with patients not keeping appointments Practice must actively manage the medications by reviewing and reconciling medications for care transitions, provide education about new prescriptions, assess understanding of the medication and treatment goal and identify any barriers to adherence Practice must transmit electronic prescriptions, perform drug-drug and drug-allergy interactions, alert provider to generic alternatives and formulary status

26 Disease Management

27 Practice improves patients ability to manage their health by providing a self-care plan, tools, educational resources and ongoing support Provide educational resources Document and develop self management ability and plans Counsel patients regarding healthy lifestyle choices Maintain current resource list Track referrals Arrange or provide treatment for mental health and substance abuse Standard 4 Self Care Support and Community Resources Offer opportunities for health education programs

28 Community Resources

29 DRP/HSRP Crosswalk to PCMH Standard 3 & 6 PCMH 3 PCMH 6 Element A, factors 1 and/or 2: Implement evidence-based guidelines. The practice implements evidence-based guidelines through point-of-care reminders for patients with first and second important conditions (factors 1, 2) and a third unhealthy behavior/ mental health/substance abuse. Automatic credit may be awarded for factors 1 and 2 for DRP and HSRP* recognition (or for one factor for DRP or HSRP recognition). Element C: Care Management. The care team performs the following for at least 75% of the patients identified in Elements A and B. If the practice has DRP (or HSRP) as an important condition, automatic credit is given for factors 1 7 in the Record Review Workbook, where each patient in the chart review matches the DRP or HSRP condition. Element A, factor 2: Measure performance.** The practice measures or receives data on at least three chronic or acute care clinical measures (factor 2). Automatic credit is awarded for this factor if the practice has DRP and/or HSRP recognition*. Element C, factors 1 and/or 2: Implement continuous quality improvement. The practice uses an ongoing quality improvement process to set goals and to act to improve on at least three measures from Element A (factor 1) and to set goals and act to improve quality on at least one measure from Element B (factor 2). Recognition* may be used as a baseline for goals for factor 1; however, additional documentation is required to demonstrate the practice s actions to improve performance. Element D, factor 1: Demonstrate continuous quality improvement. The practice demonstrates ongoing monitoring of the effectiveness of its improvement process by tracking results over time. Practices may use the process and data to establish comparative data from recognition* programs; but data must show comparison of at least two sets of DRP or HSRP data from practices with DRP or HSRP recognition to demonstrate improvement.* Element E, factors 1 and 3: Report performance. The practice shares performance data from Elements A and B within the practice, results by individual clinician (factor 1) and outside the practice to patients or publicly, results across the practice or by clinician (factor 3). Automatic credit is awarded to practices with current HSRP or DRP recognition that report performance data for Element A portions. Element F, factor 2: Report data externally. The practice electronically reports ambulatory clinical quality measures to external entities. Automatic credit is awarded for this factor for practices with DRP recognition* (HSRP also may apply).

30 Systematically track tests and coordinate care across specialty care, facility based care and community organizations Track lab and imaging tests until available, flag and follow up on overdue items All abnormal lab and imaging must be brought to the attention of the provider and the patient/family must be notified Electronically communicate with labs and facilities for results and incorporate these into the HER Coordinate and track referrals by documenting clinical reason and clinical information as well as required timing Establish agreements when co-management is needed Demonstrate and provide electronic exchange of clinical information to other providers and provide the summary of care to patient Develop process for identifying patients with hospital/er visit as well as ability to share clinical information. Obtain discharge summaries from hospital and other facilities Provide an electronic summary of care record to outside facilities PCMH and PCSP Standard 5 Track and Coordinate Care

31 PCMH and PCSP Standard 6 Measure and Improve Performance Use performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience Identify three preventive, acute and chronic measures as well as two utilization measures affecting health care costs Identify vulnerable populations to assess for disparities in care Obtain feedback from patients/families on their experiences with the practice and their care via survey tools Use ongoing quality improvement processes to set goals Identify at least three measures from element A, one from element B and one identified disparity in care Involve the patient/families in quality improvement teams Demonstrate ongoing monitoring of the effectiveness by tracking results over time, assessing the effect, achieving improved performance on two measures Share performance data within the practice as well as to patients and the community Electronically report clinical quality measures, data to immunization registries or syndromic surveillance to public health agencies

32 Improved Patient Satisfaction You can still have a cocktail with dinner, have you ever tried the fish oil martini?

33 Meaningful Use and Security Risk Analysis Currently not used in the PCMH/PCSP Final Score but is required for Meaningful Use certification

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