Patient-Centered Medical Home 101: General Overview

Transcription

1 Patient-Centered Medical Home 101: General Overview Publicly Available Slide Deck Last Updated: January 2015 Suggested Citation: PCPCC Map Tools. (2015). Patient-Centered Medical Home 101: General Overview. Patient-Centered Primary Care Collaborative. Accessed at

2 Purpose of Slide Deck We invite users to adapt these slides for your own presentations. Please see the notes sections for more detailed information. This slide deck PCMH is focused on explaining what is the patient-centered medical home (PCMH) along with how and why it s effective. For slides on the outcomes of PCMH, please access the second slide deck PCMH 201: A Snapshot of the Evidence. For the most current publicly reported outcomes data, please go to PCPCC s Outcomes View of the Primary Care Innovations and PCMH Map: 2

3 Outline Introduction & General Overview to the Patient- Centered Medical Home (PCMH) What it is Why it works How it works 3

4 Defining the Medical Home The medical home is an approach to primary care that is: Person-Centered Supports patients and families in managing decisions and care plans Comprehensive Whole-person care provided by a team Coordinated Care is organized across the medical neighborhood Committed to Quality and Safety Maximizes use of health IT, decision support and other tools Accessible Care is delivered with short waiting times, 24/7 access and extended in-person hours 4 Source:

5 Why the Medical Home Works: A Framework Feature Definition Sample Strategies Potential Impacts Patient- Centered Supports patients and families to manage & organize their care and participate as fully informed partners in health system transformation at the practice, community, & policy levels Dedicated staff help patients navigate system and create care plans Focus on strong, trusting relationships with physicians & care team, open communication about decisions and health status, compassionate/culturally sensitive care Patients are more likely to seek the right care, in the right place, and at the right time Comprehensive A team of care providers is wholly accountable for patient s physical and mental health care needs includes prevention and wellness, acute care, chronic care Care team focuses on whole person and population health Primary care could co-locate with behavioral, oral, vision, OB/GYN, pharmacy, etc. Special attention paid to chronic disease and complex patients Patients are less likely to seek care from the emergency room or hospital, and delay or leave conditions untreated Coordinated Accessible Committed to quality and safety Ensures care is organized across all elements of broader health care system, including specialty care, hospitals, home health care, community services & supports, & public health Delivers consumer-friendly services with shorter wait-times, extended hours, 24/7 electronic or telephone access, and strong communication through health IT innovations Demonstrates commitment to quality improvement through use of health IT and other tools to ensure patients and families make informed decisions Care is documented and communicated effectively across providers and institutions, including patients, primary care, specialists, hospitals, home health, etc. Communication and connectedness is enhanced by health information technology Implement efficient appointment systems to offer same-day or 24/7 access to care team Use of e-communications and telemedicine to provide alternatives for face-to-face visits and allow for after hours care EHRs, clinical decision support, medication management to improve treatment & diagnosis. Establish quality improvement goals; use data to monitor & report about patient populations and outcomes Providers are less likely to order duplicate tests, labs, or procedures Better management of chronic diseases and other illness improves health outcomes Focus on wellness and prevention reduces incidence / severity of chronic disease and illness Lower use of ER & avoidable hospital, tests procedures & appropriate use PCPCC of medicine All rights = $ savings reserved.

6 Changing to a new Paradigm Today Treating Sickness / Episodic Fragmented Care Specialty Driven Isolated Patient Files Utilization Management Fee for Service Payment for Volume Adversarial Payer-Provider Relations Everyone For Themselves 6 Future Managing Populations Collaborative Care Primary Care Driven Integrated Electronic Records Evidence-Based Medicine Shared Risk/Reward Payment for Value Cooperative Payer-Provider Relations Joint Contracting

7 Health System transformation requires Delivery Reform Public Engagement Payment Reform Benefit Redesign 7

8 Solutions point to strengthened Primary Care Significant problems Rising healthcare costs $2.4 trillion (17% of GDP) Gaps/variations in quality and safety Poor access to primary care providers Below-average population health Aging population & chronic disease 8 Experiments underway PCMHs ACOs EHR/HIE investment Disease-management pilots Alternative care settings Patient engagement Care coordination pilots Health insurance exchanges Top-of-license practice Primary carecentric projects have proven results Across 300+ studies, better primary care has proven to increase quality and curtail growth of health care costs

9 Source: UCSF Center for Excellence in Primary Care.

10 PCMH at of Medical Neighborhood Community Centers Health IT $ Home Health Hospital Public Health Employers Schools Faith-Based Organizations Community Organizations 10 Patient-Centered Medical Home Health IT $ Skilled Nursing Facility Pharmacy Specialty & Subspecialty Diagnostics Mental Health Health Care Delivery Organizations

11 PCMH as hub for medical neighborhood and broader community PCMHs serves as central hub for all health and social support services to achieve care coordination Clinical partners Specialists Hospitals Home health Long term care Clinical providers Non-clinical partners Community centers Faith-based organizations Schools Employers Public health agencies YMCAS Meals on Wheels 11

12 Public Engagement: Patients, Families & Caregivers, and Consumers must drive demand for the model Public Engagement

13 PCMH can enhance community partnerships Benefits for Practices: Improved access to community networks Increased market share Better care transitions Reduced disparities Increased patient satisfaction Access to community health data Increased use of preventive services Increased use of community services in prevention of rehospitalization Source: 13 Benefits for Patients: Increased access to supportive services Better experience of care Support addressing healthy behaviors Hospitalization and ED visits Better health outcomes Benefits for the Community: Lower prevalence of disease and disability Decreased health costs Decreased lost productivity Better coordination between clinical and public health efforts Improved outcomes for diverse populations

14 Patient-centered care associated with better processes of care and better health outcomes Patients with positive patient experience are: More likely to follow physicians advice and medication regimens More likely to stay with their primary care provider (improved loyalty and retention) Less likely to file malpractice complaints More likely to report better outcomes post hospital discharge, if their ambulatory care experience was positive Often more likely to receive better process of care (e.g., preventive care screening, chronic disease management) Sources: I. Wilson et al. (2005) Cost-Related Skipping of Medications and Other Treatments Among Medicare Beneficiaries Between 1998 and Journal of General Internal Medicine; A. M. Fremont et al., (2001) Patient-centered Processes of Care and Long-term Outcomes of Acute Myocardial Infarction. Journal of General Internal Medicine. 14:800 8; K. Browne et al. (2010). Primary Care Analysis & Commentary Measuring Patient Experience As A Strategy For Improving Primary Care. Health Affairs. 29(5). 14

15 Delivery reform: Growing evidence to support that the model works Delivery Reform

16 PCMH enhances ability to identify and manage high-risk, high-need populations Risk stratification and diligent monitoring for all patients Track care plans and medication adherence Proactive outreach from care team with collaboration among specialists and primary care Patient engagement and activation 16

17 PCMH uses diverse empowered care teams Care coordinators Patient navigators Health coaches Peer support Care managers Behavioral health/mental health Community supports and social workers Pharmacists Patients, families & Caregivers 17

18 PCMH facilitates care that is documented and shared electronically Shared with patients through electronic records, portals, mobile apps, Includes patient-generated data Shared across providers and institutions through health information exchanges Shared across public and private payers 18

19 PCMH supports improved access to care and better patient experience 24/7 access to care team (phone or e-consults with nurses, etc.) Alternatives to traditional faceto-face visits, including telemedicine, group visits, e- consults, peer support Access to electronic health records and patient portals 19

20 PCMH includes patients, families & caregivers as part of care team Consider experience of care from the patient s perspective and includes families & caregivers Patients with multiple chronic conditions (and/or their caregivers) often in best position to advise care team on challenges/opportunities to improve care Through their stories, patients can energize and encourage team to promote compassionate care 20

21 PCMH includes patients, families & caregivers in practice transformation Invite patients/caregivers into quality improvement efforts from the very beginning Invite patients/caregivers that represent the larger patient population (i.e. ethnicity, culture) Invite patients/caregivers with experience managing their own condition Provide compensation for patients/caregiver advisors Invite more than one patient, family, caregiver 21

22 Need to Integrate Behavioral Health into Consultative Model Primary Care Psychiatrist/psychologist/social worker (behavioral /mental health expert) sees patients in consultation in behavioral health setting Co-located Model Behavioral/mental health expert sees patients in primary care setting Collaborative (or Embedded) Model Behavioral/mental health expert provides caseload consultation about primary care patients; works closely with primary care team 22 Source:

23 Payment Reforms: Necessary to sustain the model (and the progress made) Payment Reform

24 Primary Care Remains Undervalued U.S. per-capita health spending, 2012 (under 65 with employer-sponsored health insurance) Primary Care 4% Drugs 17% Hospital inpatient 21% Professional procedures (non-hospital) 30% Hospital outpatient visits/other 28% 2012 Health Care Cost and Utilization Report. Health Care Cost Institute, Inc. (2013): Table A1 [Internet] Washington, DC: HCCI; 2013 Sept

25 Emerging Payment Reform Trends Fee-For- Service Global budget contracts Bundled payments ACOs Volume-based reimbursement Value-based reimbursement

26 Trajectory to Value-Based Purchasing It is a journey, not a fixed model of care Primary Care Capacity: Patient Centered Medical Home HIT Infrastructure: EHRs and Connectivity Operational Care Coordination: Embedded RN Coordinator and Health Plan Care Coordination $ Value/ Outcome Measurement: Reporting of Quality, Utilization and Patient Satisfaction Measures Source: THINC - Taconic Health Information Network and Community 26 Value-Based Purchasing: Reimbursement Tied to Performance on Value Supportive Base for ACOs, PCMH Networks, Bundled Payments, Global Capitation

27 The payment reform imperative Increasing % spend on primary care and payment reform is integral to the success of the model In fee-for-service (FFS), many PCMH strategies and care processes are rarely/poorly reimbursed (i.e. team based care, care coordination, phone/e-visits) Many PCMH practices are paid through FFS component coupled with care management payment (per member per month PMPM) Growing number including: shared savings, bundled payments, partial/full capitation 27

28 Multi-payer payment reforms key to health system transformation Many states are convening private and public payers and using uniform set of payment & quality metrics to provide needed alignment: State/local government used as convening entity (to mitigate antitrust concerns and provide participation of numerous stakeholders) Recognizes differences in various markets and encourages local collaboration Data from early evaluations trending positive Funding from Comprehensive Primary Care (CPC) Initiative & Multi-payer Advanced Primary Care Practice (MAPCP) 28 Source: Dulsky Watkins (2014) Milbank Memorial Fund

29 CMS Innovations Portfolio: Testing New Models to Improve Quality Accountable Care Organizations (ACOs) Capacity to Spread Innovation Medicare Shared Savings Program (Center for Medicare) Partnership for Patients Community-Based Care Transitions Pioneer ACO Model Advance Payment ACO Model Million Hearts Comprehensive ERSD Care Initiative Health Care Innovation Awards Primary Care Transformation Comprehensive Primary Care Initiative (CPC) Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration State Innovation Models Initiative Initiatives Focused on the Medicaid Population Strong Start Initiative Independence at Home Demonstration Graduate Nurse Education Demonstration Medicare-Medicaid Enrollees Bundled Payment for Care Improvement Model 1: Retrospective Acute Care Model 2: Retrospective Acute Care Episode & Post Acute Model 3: Retrospective Post Acute Care Model 4: Prospective Acute Care Medicaid Emergency Psychiatric Demonstration Medicaid Incentives for Prevention of Chronic Diseases Financial Alignment Initiative Initiative to Reduce Avoidable Hospitalizations of Nursing Facility Residents 19

30 Need to change Supply and Demand Supply side reforms Reimbursement changes that impact health care delivery: Increased payment for providers who adopt PCMH model Increased use of shared savings, bundled payments, capitated payments Alignment across all payers through multi-payer or all-payer initiatives Demand side reforms Reimbursement changes that impact consumers and employers: Consumers pay less in premiums/copays to use higher-value, PCMH services Limit co-pays for wellness visits/primary care Use of tiered pharmacy benefits that encourage the use of cost effective prescriptions (including generics) Improve consumer understanding of the PCMH model and primary care to better manage health 30

31 Download Slide Deck 2 - PCMH 201: A Snapshot of the Evidence For real-time program and outcome updates, visit PCPCC s Primary Care Innovations and PCMH Map: 31

32 Resources Agency for Healthcare Research and Quality: Advancing Integrated Mental Health Solutions Center: Centers for Medicare and Medicaid Services Innovation: Health Care Cost Institute: Milbank Memorial Fund: Patient-Centered Primary Care Collaborative: Robert Wood Johnson Foundation: Aligning Forces for Quality Taconic Health Information Network and Community: UCSF Center for Excellence in Primary Care: