Improving Effectiveness in the PCMH. Shawn Stinson, MD FACP

Transcription

1 Improving Effectiveness in the PCMH Shawn Stinson, MD FACP 1

2 Overview Introduction to BCBSSC PCMH program Must haves for successful outcomes in a primary care practice Agreement on evidence based practices Agreement on important outcomes Data Support Barriers to achieve successful outcomes Training Patient involvement Data incorporation into workflows Lack of care coordination support Payment for support Next steps/summary 2

3 A move from reactive care to proactive care The Patient-Centered Medical Home (PCMH) is a model of care designed to strengthen the physician-patient relationship by moving from episodic (reactive) care to coordinated (proactive) care. 3

4 Patient-Centered Medical Home Member Care Team Personal Physician Physician Directed Team Whole Person Orientation Coordinated, Integrated Care Emphasis on Quality and Safety Enhanced Access Appropriate Payment Structure Source: Joint Principles of a Patient-Centered Medical Home, Adopted March 2007 by: American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association 4

5 PCMH: Changing the Way We Care Today s Care PCMH Care Episodic (reactive) care Treat patient symptoms Appointments unavailable Care varies by scheduled time and memory or skill of the doctor Patients are responsible for coordinating care among their providers Uncoordinated referrals that lead to less-than-optimal treatment and gaps in care Limited follow-up care Coordinated (proactive) care Care for patient overall health Same-day appointments Care delivered by physician-led team with right skills at right time PCMH coordinates all patient s care Coordinated referrals within the PCMH Ongoing follow-up care to avoid disease and improve health 5

6 BCBS of South Carolina s PCMH Program

7 BCBSSC PCMH Practice Transformation Achieve PCMH recognition National Committee for Quality Assurance (NCQA) or other accrediting body. BCBSSC Innovation Specialists transformation roadmaps Based on practice goals, needs, and resources Help achieve NCQA PCMH Recognition Standards requirements Must Pass Elements of NCQA PCMH Recognition: Patient Centered Access; Team Based Care; Population Health Management; Care Management and Support; Care Coordination and Care Transition; Performance Measurement and Quality Improvement 7

8 PCMH Growth Rapid expansion in the past three years. 800 PCMH Physicians Chronic Members Total Members 70, , ,000 50, , /1/12 12/1/13 12/1/14 8/1/15 EOY ,000 30,000 20,000 10, /1/12 12/1/13 12/31/14 8/1/15 EOY , ,000 50, /1/12 12/1/13 12/31/14 8/1/15 EOY 2015 PCMH /1/15 EOY 2015 Practices Physicians Chronic Members 20,788 28,755 50,828 50,116 59,400 Total Membership 58,541 97, , , ,

9 9 BCBSSC PCMH Innovations

10 10 Must haves

11 Agreement on evidence based processes and important outcomes Percentage of eligible population who have had: BP exam in the past 12 months BP exam in the past 12 months with the most recent being < 140/90 Adult Hypertension (HTN) BMI documentation in the past 12 months BMI < 30 Creatinine measurement in the past 12 months Prescribing a generic medication for medication related to hypertension control Tobacco usage assessed 11

12 HTN 80.0% 73.5% 70.0% 66.7% 60.0% 50.0% 47.1% 40.0% 30.0% 40.7% % 10.0% 0.0% Serum Creatinine Smoking Status 12

13 HTN 100.0% 90.0% 86.5% 87.7% 80.0% 70.0% 60.0% 50.0% 60.7% 59.0% 2013 BP Reading Present 2014 BP Reading Present 2013 BP<140/ % 2014 BP<140/ % 20.0% 10.0% 0.0% BCBS PCMH 13

14 HTN BMI Measures 100.0% 90.0% 86.1% 87.7% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 36.8% 35.7% 2013 BMI Present 2014 BMI Present 2013 BMI< BMI< % 10.0% 0.0% BCBS PCMH 14

15 15 What about the data?

16 Why collect and report performance data? National Business Coalition on Health, Physician Performance Measurement & Reporting Introduction,

17 Imagining Elisabeth Kübler Ross on Healthcare Data Denial You re wrong. There is no way that data is from my practice. Anger Who do you think you are? What do you know about practicing medicine anyway? Bargaining I think my patients are sicker than the comparison group. Is there some way to adjust for this? Depression I give up. You know, I m thinking of retiring anyway. This is not what I signed up for when I went into medicine. Acceptance Got it; this is important work and times have changed. 17

18 Access to data: Population Health Management and Reporting Tool BlueCross provides the tool that a PCMH needs to effectively manage patient populations and optimize performance. Up-to-date patient registries Identification of gaps in care Near/real-time data sharing Automated performance tracking and reporting Compare performance between clinicians and practice sites 18

19 Robust Data Collection: Structured and Unstructured Practice EMR Pharmacy Practice Scheduling System Claims Practice Management System Population Health and Reporting Platform Member Eligibility Progress Notes Direct Data Entry Transcription (Word, etc.) 19

20 Barriers to success Data silos Unwillingness to share Inadequate system communication Unavailability of real world solutions to support population health 20

21 21 It s more than just having the data

22 Support Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care. Care Coordination Measures Atlas AHRQ June

23 23 NCQA expectations: Care Management and Support

24 Barriers to success: available support in the PCMH setting Limited clinical support Limited non-clinical support Inadequate relationship with partners outside of the PCMH Approach to care coordination hindered by silo mentality Unavailable or inadequate resources to address social determinants of health 24

25 What to do with the data? 25

26 Barriers to achieve successful outcomes - Training Until very recently most of us had little exposure to team based care formally - we don t know how to successfully lead multidisciplinary teams Our focus has been on the individual patient and not on the population of those we serve Evidence based guideline adherence Understanding population based data Formal quality improvement/performance improvement training has been lacking 26

27 Barriers to success Payment support Still paid to do things and not achieve outcomes FFS Systems designed to run on FFS/claims Compensation for care coordination insufficient to promote change 27

28 Barriers to success Patient involvement Paternalistic view of patients non-compliance Time Addressing social determinants Relying on partners often non-traditional 28

29 Summary The PCMH is a promising model Mutual agreement on aims and essential support is a must have Overcoming barriers needs to be a joint exercise providers, patients, payers, partners 29

30 Trim tab Something hit me very hard once, thinking about what one little man could do. Think of the Queen Mary the whole ship goes by and then comes the rudder. And there's a tiny thing at the edge of the rudder called a trim tab. It's a miniature rudder. Just moving the little trim tab builds a low pressure that pulls the rudder around. Takes almost no effort at all. So I said that the little individual can be a trim tab. Society thinks it's going right by you, that it's left you altogether. But if you're doing dynamic things mentally, the fact is that you can just put your foot out like that and the whole big ship of state is going to go. So I said, call me Trim Tab. Buckminster Fuller The original uploader was Shriramk at English Wikipedia - Transferred from en.wikipedia to Commons. 30

31 Summary The PCMH is a promising model Mutual agreement on aims and essential support is a must have Overcoming barriers needs to be a joint exercise providers, patients, payers, partners The PCMH a trim tab? 31