An RHC Patient Centered Medical Home Experience

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1 An RHC Patient Centered Medical Home Experience NARHC October 19, 2017 Kate Hill, RN The Compliance Team

2 MACRA Recognition TCT Recognized for it s PCMH Program

3 Today s Objectives Understand the difference between a traditional primary care office and a Patient-Centered Medical Home (PCMH). Understand the benefits of becoming a PCMH with regards to patients, providers/staff, and your organization s financials. Understand the preparation to embark on a journey to become a PCMH accredited clinic and the results.

4 PCMH Definition Improving the quality, effectiveness, and efficiency of the care practices deliver while responding to each patient s unique needs and preferences.

5 The PCMH Model Comprehensive Care Patient Centered Coordinated Care Accessible Services Quality and Safety

6 What PCMH really is A patient-centered model of care that builds relationships between patients and their providers by getting to the root of a patient s challenges to achieving optimal health. The power of integration managing in-between encounters with warm handoffs to other providers. The creation of a real system of caring delivered at a community level. Follow up, follow up, and then follow up again, crafting beneficial outcomes for high-risk patients.

7 PCMH Why is it important? Consistent reductions in high-cost (and often avoidable) care: o Emergency Department utilization o Re-Admissions to Hospitals o Unnecessary secondary referrals

8 PCMH as a Value-Based Strategy Medicare has moved to change how it structures payment from a quantity to a quality approach. It will provide incentives for better processes and outcomes. Medicaid programs have made enhanced payments to providers who achieved certain distinctions or process measures.

9 PCMH Recognition Programs Can Be Rigid Burdensome Labor Intensive Expensive Overwhelming Decreases the time devoted to patient care?

10 Rethinking PCMH Anything taking you away from patient care is heading in the wrong direction! The Compliance Team s PCMH Accreditation Program focuses on getting back to patient care and looks at day to day operations. Its a Winning Approach for both Clinics and Patients.

11 Improvement not Transformation

12 Advanced access to patients Same day appointments for urgent illness Evidence of expanded weekday, evening or weekend appointments Call coverage or arrangements for after hours emergencies 24/7 A specific plan to handle all types of patient communication

13 Using Community Resources Patients are in your office only a small percentage of their lives, so providers should strive to find resources to meet the needs of patients when they leave the clinic. Community resources should be used to engage with the clinic s patient population. Discharge planners and case workers Rehabilitation centers Community outreach programs and clubs Church programs

14 Written P&P for QI using the guiding principles of PCMH Basic measures: EPSDT HEDIS BMI Measures required by Medicaid and other third party payers The freedom to collect measures that matter to your clinic

15 Preventative Health Preventative Health Measures: Mammograms Pap Smears Colonoscopy Immunizations PSA Fecal Occult Blood Tobacco Cessation

16 Team Based Approach to Patient-Centered Coordinated Care A team can be one Provider, a nurse, and an MA or many other combinations as long as it s led by a provider Patients are assigned to a primary provider Written work-flow for all team members New patients are educated on the PMCH model and what it means to them (brochures etc.)

17 Huddles Planning ahead to free up face-to-face time with the patient Highlights areas of efficiencies Missing referral notes Health maintenance items that need addressed (mammograms, colonoscopies, immunizations, etc.) Forms stronger care team bonds with the patient at the center Open communication Care team has a better understanding of the patient s needs Identify patients who may be in need of community resources

18 Team Based Approach: The Care Coordinator The Team works with the Care Coordinator to: Follow-up on labs and diagnostic testing Communicate abnormal results to patients Facilitate care between clinic providers and specialists and other healthcare providers Identify high-risk patients in need of follow-up

19 Team Based Approach: The Care Coordinator The Team works with the Care Coordinator to: Coordinate with hospital discharge planners Connect patients with needed community resources Manage medication adherence with the pharmacist Assist patients to establish health goals

20 The Care Coordinator connects patients to Resources in the Community

21 Team Based Approach: The Care Coordinator The Care Coordinator role is the hub of the Patient Centered Medical Home. Develops relationships with patients as the go to person for questions and advice Provides direct access to the care team Organizes and manages the many facets of the medical community and specialty care This position is ever evolving

22 Complete patient health records Beyond the usual elements, PCMH adds: BMI Care plans Patient health goals Behavioral Screening when symptomatic for depression (PHQ 2 or 9) Cognitive health Screening for pts over 65 BIMS (Brief interview of mental status) After-Visit summary

23 Complete patient health records Modify the patient intake form to be patient centered. Use the EMR to track preventative screening and prevention measures Care plans are essential for care coordination

24 After Visit Summary Vital signs Medications Labs Instructions Follow up

25 The organization takes steps to reduce unnecessary utilization of services The Importance of Follow-Up calls

26 The organization takes steps to reduce unnecessary utilization of services Performs after visit calls the following day to provide patient support. The Care Coordinator monitors ED visits, hospital admissions to identify high risk patients Train nurses to carefully track outside appointment for records and consult notes

27 The organization takes steps to reduce unnecessary utilization of services Utilizing generic medications Reducing avoidable patient emergency room visits Reducing patient hospital re-admissions

28 Patient Centered Care Plans Beyond the usual elements, PCMH assesses: Preferred language of the patient/caregiver Cultural beliefs that affect delivery of care

29 Patient Centered Care Plans Addresses individualized health goals Assesses the environmental factors that can affect the patient s health and compliance Family Support is documented in the care plan as a vital resource Use of neighborhood medics for assessment (especially environmental factors)

30 How the Care Plan works in an EMR

31 Patient centered care plans Address the current and future needs of the whole patient Address the communication needs of the patient Address the patient s mobility needs, abilities to perform activities of daily living, safety of the home, etc. Address healthcare requirements which cannot be met by the organization Address the patient s short and long-term health care goals

32 Patient centered care plans What matters most to the Patient Patient would like to.. But is unable to do this due to Walk a flight of stairs Play on the floor with grandchildren Drive a car

33 Patient education and self management tools to patients and family/caregivers. Written material Audio visual resources Referrals to individual counseling or groups Medication management tools Goal oriented action plans Web based interactive health programs

34 Create Self-Management Tools (based on the patient s desire to participate)

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37 A written process for follow-up: THIS IS KEY Missed patient appointments Medication refills requested by Patient New high risk medications New in home treatments Abnormal Lab or diagnostic results Referrals and consultations Preventative care or screening reminders Care coordination activities Frequent emergency department use Hospital discharges

38 The Value of follow-up Calls One clinic monitored 55 frequent ED users from Jan 1, 2017 to March 31, In all those 90 days only one patient visited the ED. An additional bonus was the increase in clinic visits from seeing those 54 patients frequently and mostly on same day appointments.

39 Studies show that PCMH: Studies show that PCMH: Make primary care more accessible, comprehensive and coordinated. Provides better support and communication Creates stronger relationships with your providers Improves patient outcomes Lowers overall healthcare costs

40 QUESTIONS AND DISCUSSION THANK YOU! Kate Hill, RN