update An Inside Look Into the EHR Intersections of the Updated Patient-Centered Medical Home (PCMH) Care Model May 12, 2016
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1 update An Inside Look Into the EHR Intersections of the Updated Patient-Centered Medical Home (PCMH) Care Model May 12, 2016
2 Agenda PCMH: 360 o PCMH to date o Evidence based results o Updated Standards: 2014, Projected 2017 and beyond o Montana PCMH Program Intersection of PCMH & EHR o Key functionalities needed o Care management Clinical quality platform o Multidisciplinary care teams o Integrating care across continuums Advancing your Medical Home o Metric & Transmission Consolidation Reporting Examples o Continuous Quality Improvement
3 Background: What is a PCMH? The patient-centered medical home is a model of care that emphasizes care coordination and communication to transform primary care into what patients want it to be. NCQA Patient-Centered Medical Home (PCMH) Recognition is the most widely adopted model for transforming primary care practices into medical homes. Patients in medical homes receive the right care, in the right amount, at the right time. This increasingly popular delivery system modernization leads to safer and better care, empowers patients and renews the patient-provider relationship.
4 Primary Care is not PCMH Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma
5 Another view -Group Health Innovates: Medical Home Model of Primary Care, August 2, 2012, Eric B. Larson
6 Changes over Time
7 Evidence-Based Results Source: The Patient-Centered Medical Home s Impact on Cost and Quality- Annual Review of Evidence Published February 2016 by Patient-Centered Primary Care Collaborative
8 Updated NCQA PCMH Standards
9 NCQA 2014 Standards
10 Significant growth of care model o NCQA 2017 Standards Anticipated Changes. Preparation for population health Annual check-ins Potential changes to PCMH Levels Medical homes are included in MACRA Sustained transformation In keeping with the goal of continuous improvement, practices show that they comply with NCQA standards over long periods.
11 PCMH Stakeholder Council
12 Intersection of PCMH & EHR
13 PCMH & EHR Intersection
14 Key Functionalities Access Appointment access and continuity Electronic access- patient portal Communication needs Patient Information Comprehensive assessments Clinical quality Demographic Vulnerabilities and special populations Tracking and Coordinating Care Lab, referral, test tracking- complete functionality Exporting and Reporting Data Applicable third parties MT CSI program Affiliated projects Continuous quality improvement 6 overall measures
15 Patient Self-Management Comprehensive health assessment Identify populations for care management- *TRUE POPULATION HEALTH* o Care planning- goals, barriers, treatment plans, inclusion of team members and resources o Medication management Proactive outreach to patients needing services o Builds relationship with provider and care team o Robust medical record- external results entry o Comprehensive resource- go to place for care Transitional care management o External o Internal
16 Patient Registry- Example
17 Multidisciplinary Care Teams Standardized care team & evolution of Providers, nursing, billing, coding, registration staff Enhanced care team design Diabetic health embedded in primary care setting Behavioral health is on the radar- 1 pilot site Care Manager/Specialist positions (LPN, RN) Lead role in care team care management Transitions of Care Advanced Care Planning Centralized Team Population Health/ Centralized Support Services Clinical quality driver- ERE Other underlying tasks Tele-health capacities
18 Integrating Care Across Continuums Transitions of Care & Chronic Care Coordination patients Agreements with other organizations- affiliated and external Agreements with specialty for result tracking- referral and lab/test tracking Emergency Departments Urgent Care Retail clinics Behavioral health- varying departments and providers Diabetic health- varying departments and providers
19 Advancing Your Medical Home
20 Metric & Transmission Consolidation Identify/Edit Metric List: State PCMH Program Metrics Regional & System Metrics NCQA Recognition Metrics Operationally Driven Metrics Payer Metrics NQF Metrics Develop transmission process- annual extraction, EHR sweep and send via secure portal, HIE, etc. Determine data extraction specifics How is the data derived? - structured data, free text, coding, etc. Patient level or aggregate level reporting? Provider level or per clinic? Develop clinical quality workflows to guide teams in inputting data in right area so can be pulled from back end
21 Monthly Dashboard- Example
22 Provider Reporting- Example
23 Data/Metric Transmission
24 Continuous Quality Improvement Continual component of PCMH and value based models Strict data driven force- confidence in reporting functionalities! Team developed initiatives Embedded in future payment programs o PCMH is an example of Alternative Payment Models (APMs) under new MACRA legislation Source: CMS- Quality Initiatives Patient Assessment Instruments- Value Based Programs
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