Patient Centered Care

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1 Patient Centered Care and dthe Future of Healthcare e Delivery e PCH Group Patient Centered Health Group A Division of R.S. Williamsand and Associates, Inc.

2 Introduction PCMH Background and the Medical Neighborhood PCMH PCH Group Services PCH Group and MDR Q and A 2

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4 R. Steven Williams, MPH, CEO and Senior Consultant Sheila A. Lawson, BS, NCQA, PCMH Content Certification Expert (CCE), Vice President of Development 4

5 Team of professionals with extensive experience in healthcare consulting and management services Provide services to clients that allows them to maintain long-term success, maximize their strengths and avoid unforeseen pitfalls With help from PCH Group, clinicians can stay focused on their services as we assist them with the ever-changing healthcare environment 5

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7 A Model of Primary Health Care Delivery that is patient-centered, comprehensive, team-based, coordinated, accessible and focused on quality and safety An Established Model of Care Coordination The Patient-Centered Medical Home is a model of 21 st century primary care that combines access, teamwork, and technology to deliver quality care and improve health. Margaret E. O Kane, President, NCQA 7

8 Ten Rules that were foundational to development of a better healthcare system: Care based on continuous health relationships Care based on patient needs and values Patient as the source of control Patient access to medical information and clinical knowledge Evidence-based decision making Patient safety Transparency of information Anticipation of needs Continuous decrease in waste Cooperation among clinicians 8

9 Key Characteristics: Personal physician Physician directed medical practice Whole person orientation Care is coordinated and/or integrated across all health care system and patient s community Quality/safety are hallmarks of medical home Care planning Evidence-based medicine Clinical decision support Continuous quality improvement Patient participation and feedback Appropriate HIT Enhanced access Payment reform 9

10 Since the Joint Principles were developed 18 additional physician membership organizations have endorsed Joint Principles Multiple other health professionals have embraced the PCMH with emphasis on team-based care, including: Nurse Practitioners Physician Assistants Psychologists Social Workers Nutritionists Pharmacists Physical, Occupational, and Speech Therapists Palliative Care Providers 10

11 A framework developed by the Institute for Healthcare Improvement (IHI) that describes an approach to health system performance The three dimensions are: Improving the patient experience of care (including quality and satisfaction) Improving the health of populations Reducing the per capita cost of health care Better Health Better Care Lower Cost 11

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13 ACO is an extension of the medical home concept Some commentators say that ACO s are the expansion of the patient-centered medical home concept to the Neighborhood level of the overall healthcare delivery system The Medical Neighborhood foundation is the PCMH with Coordinated Care across multiple care settings 13

14 We conceptualize the medical neighborhood as a PCMH and the constellation of other clinicians providing health care services to patients within it, along with community and social service organizations and State and local public health agencies. Defined in this way, the PCMH and the surrounding medical neighborhood can focus on meeting the needs of the individual patient but also incorporate aspects of population health and overall community health needs in its objectives. While the patient is the primary stakeholder in the medical neighborhood, we place the PCMH at its center, given its role as the central point of contact for the patient and primary coordinator of the patient s care across various neighbors. Within the PCMH, the primary clinician caring for the patient may be a physician, nurse practitioner, or physician assistant. Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms WHITE PAPER Prepared for: U.S. Department of Health and Human Services Agency for Healthcare Research and Quality AHRQ June

15 Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms WHITE PAPER Prepared for: U.S. Department of Health and Human Services Agency for Healthcare Research and Quality AHRQ June

16 NCQA published Standards for ACO Accreditation in 2011 Released HEDIS Measures for ACOs in 2012 Concepts and standards from PCMH 2011 are integrated into ACO criteria for Accreditation The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Altogether, HEDIS consists of 75 measures across 8 domains of care. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an "apples-to-apples" basis. 16

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18 Each patient has a Personal Clinician providing first contact and continuous and comprehensive care; clinician leads a care team that is collectively responsible for patients care; long-term healing relationship with clinician and patient Practice takes on a whole person orientation for all its patients providing for all the patient s health care needs or appropriately arranging care with other qualified professionals; including all stages of life Patient care is coordinated assuring patients receive care when and where they need it in a culturally and linguistically appropriate manner, providing excellent communication among patients, clinicians, and staff; facilitated by information technology to prescribe, communicate, track test results, obtain clinical support information and monitor performance 18

19 Improved patient experience Reduced clinician burnout Reduced hospitalization rates Reduce ED visits Increased savings per patient Higher quality of care Reduced cost of care 19

20 in higher performing demonstrations: Dedicated care managers Expanded access Data-driven analytic tools Learning collaborative Shared best practices Use of incentives 20

21 Primary Care is the foundation to effective health care system change Efforts to transform primary care at the practice level (PCMH) have gained tremendous momentum and broad support Major insurers are driving primary care transformation through payments for patient-centered services nationwide Momentum for transforming the U.S. health system is reaching the tipping point, and the PCMH and primary care are central to better health outcomes, better care, and lower costs Source: Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012 Patient-Centered Primary Care Collaborative 21

22 Major health plans and industry partners are embracing the PCMH model with enthusiasm by creating insurance plans and developing tools and resources contributing to the implementation of medical homes. Source: Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012 Patient-Centered Primary Care Collaborative 22

23 Source: Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012 Patient-Centered Primary Care Collaborative HealthPlan Americans (millions) Providers What Wellpoint ,000 Jan invest in PCMH across network Aetna 18 55,000 primary care Humana 11.8 medical; 2.2 Medicare PCMH rollout 2012 PCMHservices in 10 states; 70,000 Medicare Advantage; 35,000 Commercial United Health 34 February 2012, implement value-based payment model; impact 50-70% of customers VariousBC/BS >4 39states participating in PCMH initiative Kaiser Permanente and other integrated plans >8.8 Embraced PCMH model of care delivery 23

24 Recognition Programs provide plans with many ways to improve care. Add Recognition seals to provider directories and identify top quality physicians. Aetna Blue Cross Blue Shield Association BlueCross BlueShield of Western New York BlueShield of Northeastern New York CIGNA CDPHP Highmark Blue Cross Blue Shield Humana United 24

25 Pay rewards for achieving Recognition or supplement application fees for Recognized providers AL BCBS AL AZ CIGNA AZ United Health Care CA Kaiser -Southern California Permanente Medical Group CO Kaiser - Kaiser Permanente Colorado DC Kaiser Mid-Atlantic FL BCBS FL FL Sunshine State Health Plan GA Kaiser GA Wellstar Health System/Humana ID BCBS Idaho LA BCBS Louisiana MA UMASS/ Bailit Heath MD CareFirst BlueCross BlueShield MD Kaiser Mid-Atlantic MI MedAdvantage MI Priority Health MN BCBS of Minnesota ICSI MO BCBS of Kansas City NC BCBS North Carolina NH CIGNA/ Dartmouth Hitchcock NJ Horizon NM United Health Group NY Emblem Health NY Excellus NY Independent Health PA Highmark BCBS PA Independence Blue Cross RI BCBS of Rhode Island SC BCBS of South Carolina TN BCBS of TN TX BCBS TX UT BCBS UT VA VA Carillion VA Kaiser Mid-Atlantic WI Aurora Health System 25

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27 2003: Physician Practice Connections (Wagner Chronic Care Model) 2006: PPC Standards updated and Recognition program launched 2008: PPC PCMH Recognition program launched (Joint Principles) 2011: PCMH 2011 released 27

28 Raised the bar for what a medical home is by: Emphasizing patient access to care, health IT, and clinician-patient collaboration New standards defined excellence Even more patient-centered than 2008 Lower Barriers: Explored ways to forge partnerships with IT Vendors (Prevalidation) -use of vendor s products allows practices to meet some PCMH 2011 factors automatically 28

29 Increase patient-centeredness Align requirements with processes that improve quality and eliminate waste Increase emphasis on patient experience Enhance use of clinical performance measure results Integrate: unhealthy behaviors, mental health and substance abuse Enhance coordination of care Enhance applicability to pediatric practices 29

30 NCQA s goal is for the PCMH standards to move transformation of primary care practices forward but to ensure that the standards are reasonably within reach of a range: practice sizes configurations (solo, multi-site, community health center, FQHC, RHC) electronic capabilities populations served and locations (urban, rural) 30

31 NCQA Recognizes outpatient primary care practices that meet the scoring criteria for Level 1, 2, or 3 as assessed against the Patient-Centered Medical Home requirements NCQA defines a practiceas a clinician or clinicians practicing together at a single geographic location, includes nurse-led practices in states where state licensing designates NPs as independent practitioners PCMH Recognition identifies primary care clinicians (MDs and DOs) practicing at the site, including nurse practitioners and physicians assistants, that can be designated as a patient s personal clinician Recognition is at the practice-site level 31

32 Emphasis on patient-centeredness and patient experience of care Reinforces incentives for meaningful use (HIT) Focuses attention on aspects of primary care that improve quality and reduce cost Based on advances in evidence and changes in practice capability 32

33 Congress enacted the American Recovery & Reinvestment Act (ARRA) with subsection on Health Information Technology for Economic and Clinical Health Act (HITECH) effective February 18, 2009 Centers for Medicare and Medicaid Services provides incentives for using health information technology to improve quality with a certified EHR Stage 1 Meaningful Use (MU) embedded in PCMH 2011 evaluation standards Synergy: PCMH 2011 medical practices will be well prepared to qualify for meaningful use, and vice versa 33

34 Medicare EHR Incentive Payment Schedule for Eligible Professionals Payment Amounts If a Medicare Eligible Professional Qualifies to Receive First Payment in 2011 If a Medicare Eligible Professional Qualifies to Receive First Payment in 2012 If a Medicare Eligible Professional Qualifies to Receive First Payment in 2013 If a Medicare Eligible Professional Qualifies to Receive First Payment in 2014 If a Medicare Eligible Professional Qualifies to Receive First Payment in 2015 Payment $18,000 Amount for 2011 Will Be Payment Amount for 2012 Will Be Payment Amount for 2013 Will Be Payment Amount for 2014 Will Be Payment Amount for 2015 Will Be Payment Amount for 2016 Will Be Total Payment Amount Will Be $12,000 $18,000 $8,000 $12,000 $15,000 $4,000 $8,000 $12,000 $12,000 $2,000 $4,000 $8,000 $8,000 $2,000 $4,000 $4,000 $44,000 $44,000 $39,000 $24,000

35 Medicare eligible professionals who predominantly furnish services in an area designated as a Health Professional Shortage Area (HPSA) will receive a 10% increase in their annual EHR incentive payments. The additional 10% HPSA incentive is not available for eligible professionals who participate in the Medicaid EHR Incentive Program. CAHs (Critical Access Hospitals) are eligible for both Medicare and Medicaid MU incentives.

36 Medicaid EP Qualifies to Receive First Payment in 2011 Medicaid EP Qualifies to Receive First Payment in 2012 Medicaid EP Qualifies to Receive First Payment in 2013 Medicaid EP Qualifies to Receive First Payment in 2014 Medicaid EP Qualifies to Receive First Payment in 2015 Medicaid EP Qualifies to Receive First Payment in 2016 Payment Amount in 2011 $21, $0.00 $0.00 $0.00 $0.00 $0.00 Payment Amount in 2012 $8, $21, $0.00 $0.00 $0.00 $0.00 Payment Amount in 2013 Payment Amount in 2014 Payment Amount in 2015 Payment Amount in 2016 Payment Amount in 2017 Payment Amount in 2018 Payment Amount in 2019 Payment Amount in 2020 Payment Amount in 2021 TOTAL Incentive Payments $8, $8, $21, $0.00 $0.00 $0.00 $8, $8, $8, $21, $0.00 $0.00 $8, $8, $8, $8, $21, $0.00 $8, $8, $8, $8, $8, $21, $0.00 $8, $8, $8, $8, $8, $0.00 $0.00 $8, $8, $8, $8, $0.00 $0.00 $0.00 $8, $8, $8, $0.00 $0.00 $0.00 $0.00 $8, $8, $0.00 $0.00 $0.00 $0.00 $0.00 $8, $63, $63, $63, $63, $63, $63,750.00

37 Medicaid Eligible Professionals The Medicaid EHR Incentive Program will continue to pay incentives through Eligible professionals can participate for 6 years, and participation years do not have to be consecutive. The last year that an eligible professional can begin participation in the Medicaid EHR Incentive Program is 2016.

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39 PCMH 2011 aligns with MU Stage 1 CMS MU Stage 2 release in 2014 PCMH 2014 (updated program) will align with MU Stage 2 39

40 The Accreditation Association for Ambulatory Health Care: 2011 Medical Home Standards The Joint Commission: Primary Care Medical Home 2011 Standards and Elements of Performance (Available July 2011) The National Committee for Quality Assurance: Patient-Centered Medical Home 2011 Standards URAC: Patient Centered Health Care Home (PCHCH) Practice Achievement Version 1.0 (Available June 2011) 40

41 MGMA in February 2012 surveyed: member and nonmembers 1,257 responses received various healthcare organization every state represented 29,302 physicians (primary and specialty) 26,769 non-physician providers Source: Medical Group Management Association (MGMA): MGMA Patient-Centered Care: 2012 Status and Prospects Report 41

42 PCMH1: Enhance Access and Continuity A. Access During Office Hours** B. After-Hours Access C. Electronic Access D. Continuity E. Medical Home Responsibilities F. Culturally and Linguistically Appropriate Services G. Practice Team PCMH2: Identify and Manage Patient Populations A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. Use Data for Population Management** PCMH3: Plan and Manage Care A. Implement Evidence-Based Guidelines B. Identify High-Risk Patients C. Care Management** D. Manage Medications E. Use Electronic Prescribing Pts Pts Pts PCMH4: Provide Self-Care Support and Community Resources A. Support Self-Care Process** B. Provide Referrals to Community Resources PCMH5: Track and Coordinate Care A. Test Tracking and Follow-Up B. Referral Tracking and Follow-Up** C. Coordinate with Facilities/Care Transitions PCMH6: Measure and Improve Performance A. Measure Performance B. Measure Patient/Family Experience C. Implement Continuously Quality Improvement** D. Demonstrate Continuous Quality Improvement E. Report Performance F. Report Data Externally **Must Pass Elements Pts Pts Pts

43 Level of Qualifying 6 standards = 100 points 6 Must Pass elements Must Pass elements requirea 50% performance level to pass Points Must Pass Elements at 50% Performance Level Level of 6 Level of 6 Level of 6 Not Recognized 0-34 < 6 Practices with a numeric score of 0 to 34 points and/or achieve less than 6 Must Pass Elements are not Recognized. 43

44 1. Enhance Access and Continuity: Accommodate patient s needs with access and advice during and after hours, give patients and their families information about their medical home and provide patients with team-based care 2. Identify and Manage Patient Populations: Collect and use data for population management 44

45 3. Plan and Manage Care: Use evidence-based guidelines for preventive, acute and chronic care management, including medication management 4. Provide Self-Care Support and Community Resources: Assist patients and their families in self-care management with information, tools and resources 45

46 5. Track and Coordinate Care: Track and coordinate tests, referrals and transitions of care 6. Measure and Improve Performance: Use performance and patient experience data for continuous quality improvement 46

47 Rationale for Must Pass Elements Identifies critical concepts of PCMH Helps focus Level 1 practices on most important aspects of PCMH Guides practices in PCMH evolution and continuous quality improvement Standardizes Recognition Must Pass Elements 1A: Access During Office Hours 2D: Use Data for Population Management 3C: Manage Care 4A: Self-Care Process 5B: Referral Tracking and Follow-Up 6C: Implement Continuous Quality Improvement Possible Must Pass Points = 14.5 points (50% of score) to 29 points (100 %) 47

48 Factors A scored item in an element. For example, an element may require the practice to demonstrate how the practice team provides a range of patient care services. Each type of item, in this case a service, is a factor. Critical Factors-A factor that is required for practices to receive more than minimal points, or in some cases any points for the element. Critical factors are identified in the scoring section of the element. Explanation-Specific requirements that a practice must meet and guidance for demonstrating performance against the factor. Examples/Documentation-Descriptions of the evidence practices need to submit to demonstrate performance for specific factors. Each factor must be documented. 48

49 Practice has written process/standards and demonstrates that it monitors performance against the standards to: 1. Provide same-day appointments CRITICAL FACTOR 2. Provide timely advice by telephone 3. Provide timely advice by electronic message 4. Document clinical advice 49

50 Six Standards 27 scored Elements Six MUST PASS Elements 152 Factors (Nine Critical Factors) Recognition is based on 100 point scoring system Level I points Level points Level points All six Must Pass Elements must be passed at 50% Performance Level Recognition is for three years 50

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52 Whole person, patient-centered care requires practice to: 1. Embrace principles of PCMH 2. Maximize team-based care 3. Enable patient access to care 4. Implement systematic approach to care, e.g. track/coordinate care 5. Coordinate with specialists, facilities 6. Include patients in planning/managing their evidence-based care 7. Educate patients about PCMH 8. Establish performance measurement and quality improvement 9. Evaluate patient experience 10. Manage populations of patients 11. Understand/meet cultural and linguistic need of patients 52

53 1. Initial Practice Assessment and Assignment of Project Manager. 2. PCMH Mock Survey 3. Policies and Procedures Review 4. Electronic Health Record (EHR) System Review 5. Provider Care Team Training 6. Practice Implementation Training 7. PCMH Documentation Review 8. PCMH ISS Tool Review and Submission 9. On-Site Consultation One (1) Day Per Month 10. Social Media Assistance 53

54 1. Initial PCMH Practice Assessment: Assessment of provider(s) and Practice for eligibility and readiness for conversion to NCQA PCMH Recognition; and, assignment of Project Manager. 2. PCMH Mock Survey: TheProject Manager will meet with appropriate practice staff to review each Standard, Element, and Factor of NCQA s PCMH Survey Tool to determine current performance, readiness and work required to pursue PCMH Recognition. This process will include numerically scoring the practice. 3. Policies and Procedures Review: Consultants will review policies and procedures documents currently utilized by the practice for alignment with PCMH and make recommendations as appropriate. 54

55 4. Electronic Health Record System Review: Assessment of EHR hardware system(s), software, internal and external support, overall EHR utilization, and Meaningful Use. 5. Provider Care Team Training: The PCMH model of care delivery is built upon patient s choice of a personal provider and a care team that takes responsibility for consistent, whole person, comprehensive, coordinated care. This training includes details regarding the care team and their responsibilities. 6. Practice Implementation Training: Training for the Practice that includes detailed information regarding PCMH and what implementation will mean for the practice. 55

56 7. PCMH Documentation Review: Review and discuss prepared documentation required for submission for PCHM Recognition assuring the documentation will meet PCMH standards. Much of this review will be accomplished through the use of drop-box technology. 8. PCMH ISS Tool Review and Submission: Consultants will review and assist with the submission of documents through the ISS (Interactive Survey System) Tool in order to gain PCMH Recognition. 9. On-Site Consultation One (1) Day Per Month: The Project Manager will work one day each month on-site at the practice. The Project Manager will work primarily with the practice s PCMH Champion. This is an individual that acts as a contact for the Project Manager and Coordinator and Coach for the practice throughout the process. They truly Champion the cause. 10. Social Media Assistance: Consultants will assist with development and implementation of a Social Media Plan to include patient portal and secured electronic messaging. 56

57 PCMH Maintenance Services Bacterial and Biological Safety Assessment and Plan Quality Improvement Plan Development and Assistance PCSP Recognition Consulting Services ACO Development Consulting Services 57

58 PCMH Recognition should be celebrated PCMH Recognitions is verification that the practice is capable and will deliver highquality care Must not stop at recognition it s not the end of a Journey but a beginning 58

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