Improving Western NY s Population Health Using Patient Centered Medical Home

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1 Improving Western NY s Population Health Using Patient Centered Medical Home Presented by: Dr. Riffat Sadiq Western NY Medical Center Jeanette Ball, RN BSN PCMH CCE CTG Health Solutions Session C7 IHI 2014 Summit This presenter has nothing to disclose 1 Learning Objectives Describe the drivers, formation, implementation, and realized results of Western New York Patient Centered Medical Home providing patients with improved, comprehensive, coordinated care Demonstrate the ways that PCMH principles, coupled with enhanced use of technology, were successfully applied to a community-wide effort to improve care coordination, prevention and quality outcomes Outline the specific challenges, pitfalls, and lessons learned at a multisite medical group during PCMH implementation, Identify the realized quality, efficiency and overall care management results recognized under a PCMH model including, but not limited to, improved patient satisfaction, an increased community focus on patient-centered care, improved access, and measurable results such as improved diabetic outcomes 2 1

2 What is Patient Centered Medical Home (PCMH)? A primary practice recognized by the National Committee for Quality Assurance (NCQA) for providing each patient and family with: Quality, timely, efficient care Patient-centered comprehensive care Care coordination Delivered by a compassionate team of health-care professionals. 3 National Committee for Quality Assurance (NCQA) and PCMH PCMH recognition program consists of: 3-tiered recognition process to assess the extent to which healthcare organizations are functioning as a medical home Recognition tiers ranging from Level 1 to Level 3 based on selection of improvements from: 6 standards 28 elements 152 factors Comprehensive documentation of compliance with selected standards, elements, factors Standards include MU objectives All help a practice become patient focused, quality driven organization 4 2

3 NCQA PCMH Recognition BY State 5 Health Reform Initiatives and Programs (Selected) Gov/Commercial Payer/Private Accountable Care Org (CMS/Commercial Payer) Clinical Integrated Networks Health Info Org/Exchange Commercial Payer Alliances Accountable Reimbursement: CMS & Commercial Payers Shared Savings Bundled Payments Risk adjusted capitation Risk contracts (commercial) Integrated Model for Accountable Care Structure Value-based Revenue Accountable Care Improvement Solutions Measurement Regulatory/Recognition/ Certification Programs EHR Incentive & CQM CMS ACO Commercial ACO (NCQA recognized) The Joint Commission Disease-specific recognition (NCQA/BTE) Patient-centered Primary Care (CMS/NCQA) ICD10 HIPAA 5010/21CFR11 P4P/Bonus Reporting CMS Hospital-based Purchasing CMS Meaningful Use CQM CMS Meaningful Use EHR HEDIS PQRS TJC core measures Commercial Payer Programs 6 3

4 2011 PCMH Overview A. Enhance Access and Continuity A. Access During Office Hours B. Access After Hours C. Electronic Access D. Continuity (with provider) E. Medical Home Responsibilities F. Culturally/Linguistically Appropriate Services G. Practice Organization B. Identify/Manage Patient Populations A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. Use Data for Population Management E. Plan/Manage Care A. Implement Evidence-Based Guidelines B. Identify High-Risk Patients C. Manage Care D. Manage Medications E. Electronic Prescribing 4. Provide Self-Care and Community Resources A. Self-Care Process B. Referrals to Community Resources 5. Track/Coordinate Care A. Test Tracking and Follow-Up B. Referral Tracking and Follow-Up C. Coordinate with Facilities/Care Transitions 6. Measure & Improve Performance A. Measures of Performance B. Patient/Family Feedback C. Implements Continuous Quality Improvement D. Demonstrates Continuous Quality Improvement E. Report Performance F. Report Data Externally 7 PCMH: A Community Approach Two programs combined to effect HIT and quality in WNY New York State HEAL 10 grant Goal: Expand PCMH practices Financial incentives Consulting services Local Payors EMR implementation community project Goal : Expand EMR and HIT in western New York Funding: $5K/provider after signed vendor contract Selection and implementation consulting of over 130 hours/practice All Supported by the HEALTHeLINK the WNY HIE 8 4

5 A Marriage of Two Initiatives: Clinical Transformation and Technology Clinical Improvements (PCMH) Comprehensive Care Access to Care Improved Self Management Quality Reporting Care Coordination Pre-Planning Technology Enhancements EMRS HIE Interfaces ADT information Home Care Data 9 Three Levels Of Practices A - Level Practices: PCMH Certified or Close to Submitting EMR and High use of electronic resources B - Level Practices Live on an EMR though may be new adopters Began PCMH Activity though had not achieved certification Were not connected to the HIE C - Level Practices (Offered the most services) No EMR No Organized PCMH activity No Connectivity to the HIE 10 5

6 An Introduction to the Benefits Realized for the Value of Health IT Diabetic Patient Outcomes Objective: Demonstrate chronic disease can be managed at the population level as well as patient level Population Improvement Overall improvement in HgbA1C HgbA1C of 7.0 or showed improvement LDL of 100 or showed improvement Systolic BP below 130 Diastolic BP below 80 or showed improvement 11 HEALTHeLINK Case Study Ranged from small rural practices to large FQHCs in urban setting Approach All practices selected, purchased and installed an EHR from a preapproved list of 10 different vendors 80 practices were eligible to participate in the NYS PCMH improvement initiative Diabetic population was targeted for improvement Performance data using NCQA sampling techniques and standardized tool from ACP were collected and analyzed Processes, practices and EHR templates were optimized Results: Improvements range from baseline performance 13.4 to 81.1 % 12 6

7 Population Health What factors affect the health of a community? Education Employment Income Family/social support Access to care Quality of care Physical Environment 20% Clinical Care 10% Health Behaviors 30% Social and Economic Factors 40% Tobacco use Diet/exercise Alcohol use Unsafe sex Erie County Ranks 56 th of 62 Counties in NYS for Source: Prevention Institute, July From Paper to EMR then on to PCMH Excellence CTG developed 45 project tools for distribution to each site Policy /Procedures, call logs, and other PCMH tools were created Baseline statistics collected for PCMH using a standardized tool from ACP Each practice conducted Diabetic outcome quality studies. Consistent sampling was conducted at each site using NCQA sampling selection methodology The consultants demonstrated how chronic disease can be managed at a population level, and at the exam level by including template EHR changes. This created an eye opening example for the practices to begin their journey towards quality, pay for performance, and meaningful use. Offered access to local HIE Developed worklfow with enhanced technology to drive better outcomes 14 7

8 Technology Introductions First Step is Introduction of EHR Using PCMH improve workflows Remove Paper flow Develop electronic messaging Reporting and Quality Meaurement Access to the WNY HIE: HEALTHeLINK Interface for results delivery ADT for transitions in care Workflows Home care results download Medication Reconciliation through Surescript Med History 15 Challenges EFFECTING DIABETIC HEALTH SAME PROBLEM: Rural: Amish community No Phones Cultural Barriers Cooking Restrictions City: Urban- FQHC Population High Medicaid Fast Food Diet High No show rate 16 8

9 Diabetic Patient Outcomes Objective: Demonstrate chronic disease can be managed at the population level as well as patient level Population Improvement Result Overall improvement in HgbA1C 77.4% At or below HgbA1C of 7.0 or showed improvement. 77.4% At or below LDL of 100 or showed improvement 80.3% Systolic BP was at or below % Diastolic BP was at or below 80 or showed improvement. 83.7% 17 WNY Medical PC Established in Providers 8 Locations throughout WNY 7 Primary Care and 1 Psychiatric office Serving over 60,000 Patients Multi-lingual PCMH Certified since 2011: All seven sites certified at one time Other Services Message Therapy Occupational Health Ultrasound and on site lab services 18 9

10 Why Patient Centered Medical Home Provided a proven Tool Box that supported patient centered care Resonated with WNY Medical s personal philosophy of Compassionate, Patient Centered care in a structured framework Gave the practice tools and discipline It helped us put things in a natural order Provide a calm non-chaotic manner of providing care You do not have to Reinvent the Wheel 19 What are the First Steps Developing a strong team Organizing your team and listening Use All your staff from Janitor to MD Partners- All have roles to play Nothing is Impossible when a team is centered around a common goal of patient centered care Use any community support services Fit all the pieces together like a puzzle to succeed 20 10

11 Team Reminders Team work often must be taught to physicians The whole team must be receptive to learning No Room for Arrogance Listen Carefully to what others are saying Always think the other person at the table knows more than you Keep your glass empty and ready for more knowledge 21 Largest Difference Makers of PCMH Mandatory Same Day Appointments Forced Practice to look at scheduling habits Provided practice a strategy for change Always now have 10% of appts available for same day Eases access to care Reduces ER visits Reduced Urgent Care Improves Continuity of Care 22 11

12 Referral and Test Tracking Very Difficult Processes to Launch Treatment given on time Allow Primary Care Physician to follow up on care Supports Care Management and Patient Population management Provides Piece Of Mind Just Good Care! 23 PCMH Concepts to Transform a Practice Medication Reconciliation Forces safer care Decreased Duplication Self Management Use of Patient Portals Patients Are their own doctor. Patients have to know their own bodies Care Coordination Pre-visit Planning Reducing Wait Times 24 12

13 Last Thoughts This is Not Something to Resist PCMH helps providers deliver high quality care in an organized fashion Right Care at the Right Time Decreases Duplicate Care Efficient and Cost Effective 25 Question and Answer Session Dr. Riffat Sadiq Jeanette Ball, RN BSN PCMH CCE 26 13