Patient-Centered Medical Home (PCMH) Transformation and Recognition/Certification Programs

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1 Patient-Centered Medical Home (PCMH) Transformation and Recognition/Certification Programs Ruth S. Gubernick, PhDc, MPH, PCMH CCE For the NJAAP s Systems Integration Medical Home Project October 27, 2016

2 Learning Objectives At the end of this presentation, participants will be able to: Discuss the positive impact of medical homes on pediatric populations and their families Describe a framework to guide Patient-Centered Medical Home (PCMH) transformation Discuss medical home assessment Define Patient-Centered Medical Home (PCMH) recognition and accreditation programs Define steps toward achieving recognition

3 Adapted from ECHO and Family Center Early Childhood Council. (2016). A Family s Guide to Medical Home. Retrieved from

4 What are the components of a Patient- Centered Medical Home (PCMH)? Source: Xavier Sevilla, MD. Used with permission.

5 For the pediatric population, with and without special health care needs, evidence shows an association between access and utilization of a medical home to the following: Decreased hospitalizations, including days spent at the hospital Decreased visits to the emergency department Less out-of-pocket spending from families, particularly those with public insurance Lower Per Member Per Month (PMPM) costs Source: National Center for Medical Home Implementation. Why is Medical Home Important? Impact on Health Care Costs. (accessed 2/10/16).

6 For Children and Youth with Special Health Care Needs, a medical home can provide additional benefits Care coordination Shared care planning Self-care management and support Collaboration and integration with community-based resources Population management cwise@umich.edu

7 Research shows that access to and utilization of a pediatric medical home is associated with the following: Increased provision of preventive services for children, such as: Increased likelihood of having anticipatory guidance provided Increased likelihood of being seen by a primary care clinician within the last year Increased rates of childhood immunizations Increased rates of well-child visits Increased likelihood to have had height, weight, and blood pressure checked Decreased amount of outpatient sick visits Decreased rate of inappropriate use of antibiotics Improved health outcomes and health status Source: National Center for Medical Home Implementation. Why is Medical Home Important? Impact on Quality of Care, Health Outcomes and Medical Needs. (accessed 2/10/16).

8 Research findings include the following: Increased family satisfaction and positive parental experiences Increased ability for families' to meet day-to-day demands of parenthood Decreased missed workdays for families Decreased parental worry, increased family feedback Source: National Center for Medical Home Implementation. Why is Medical Home Important? Impact on Family Satisfaction. (accessed 2/10/16).

9 PCMH transformation is a journey

10 A Framework to Guide PCMH Transformation: Change Concepts Source: Safety Net Medical Home Initiative. Sugarman JR, Wagner E. Introduction to the Safety Net Medical Home Initiative Implementation Guide Series. In: Phillips KE, Weir V, eds. Safety Net Medical Home Initiative Implementation Guide Series. 2nd ed. Seattle, WA: Qualis Health and The MacColl Center for Health Care Innovation at the Group Health Research Institute; Used with permission.

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12 Engaged Leadership PCMH leaders: Provide visible and sustained leadership in overall culture change as well as specific strategies to improve quality and spread and sustain change Establish a QI team that meets regularly and guides the effort Ensure that team members have protected time to conduct activities beyond direct patient care that are consistent with the medical home model Incorporate the practice s values on creating a medical home for patients into staff hiring and training processes Source: Safety Net Medical Home Initiative. Altman Dautoff D, Philips KE, Manning C. Engaged Leadership: Strategies for Guiding PCMH Transformation. In: Phillips KE, Weir V, eds. Safety Net Medical Home Initiative Implementation Guide Series. 2nd ed. Seattle, WA: Qualis Health and The MacColl Center for Health Care Innovation at the Group Health Research Institute; 2013.

13 Quality Improvement (QI) Strategy PCMH practices: Choose and use formal models for quality improvement Establish and monitor metrics to evaluate improvement efforts and outcome and provide feedback Obtain feedback from patients/families about their healthcare experience and use information for quality improvement Ensure that patients/families, providers and care team members are involved in QI activities Optimize use of information technology Source: Safety Net Medical Home Initiative. Altman Dautoff D, Van Borkulo N, Daniel D. Quality Improvement Strategy: Tools to Make and Measure Improvement and Hummel, J. Optimizing Health Information Technology for Patient-Centered Medical Homes.. In: Phillips KE, Weir V, eds. Safety Net Medical Home Initiative Implementation Guide Series. 2nd ed. Seattle, WA: Qualis Health and The MacColl Center for Health Care Innovation at the Group Health Research Institute; 2013

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15 Empanelment PCMH practices: Determine and understand which patients should be empanelled in the medical home Use panel data and registries to proactively contact, educate and track patients by disease/condition status, risk status, etc. Understand practice supply and demand and balance patient load accordingly Source: Safety Net Medical Home Initiative. Brownlee B, Van Borkulo N. Empanelment: Establishing Patient-Provider Relationships. In: Phillips KE, Weir V, eds. Safety Net Medical Home Initiative Implementation Guide Series. 2nd ed. Seattle, WA: Qualis Health and The MacColl Center for Health Care Innovation at the Group Health Research Institute; 2013.:

16 Continuous and Team-based Healing Relationships PCMH practices: Clearly link patients to a provider and care team so both patients and provider/care team recognize each other as partners in care Assure the patients are able to see their provider or care team whenever possible Define roles and distribute tasks among care team members to reflect the skills, abilities and credentials of team members Cross-train care team members to maximize flexibility and ensure that patients needs are met Source: Safety Net Medical Home Initiative. Coleman K, Reid R. Continuous and Team-Based Healing Relationships: Improving Patient Care Through Teams. In: Phillips KE, Weir V, eds. Safety Net Medical Home Initiative Implementation Guide Series. 2nd ed. Seattle, WA: Qualis Health and The MacColl Center for Health Care Innovation at the Group Health Research Institute; 2013.

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18 Organized, Evidence-Based Care PCMH practices: Use planned interactions according to patient need Enable planned interactions with patients/families by having available, up-to-date information and standing orders for the care team before any interaction Use point-of-care reminders and other decision support based on clinical guidelines Assure access to care management resources to provide more intensive support to high risk patients Source: Safety Net Medical Home Initiative. Austin B, Wagner E. Organized, Evidence-Based Care: Planning Care for Individual Patients and Whole Populations. In: Phillips KE, Weir V, eds. Safety Net Medical Home Initiative Implementation Guide Series. 2nd ed. Seattle, WA: Qualis Health and The MacColl Center for Health Care Innovation at the Group Health Research Institute; 2013.

19 Patient- (and Family-) Centered Interactions PCMH practices: Assess and respect patient/family values and expressed needs Encourage patients/families to expand their role in decision-making, health-related behavior change and self-management Communicate with their patients/families in a culturally appropriate manner, in a language and at a level that the patient understands Provide self-management support at every visit through goal setting and action planning Source; Safety Net Medical Home Initiative. Schaefer J, Van Borkulo N, Morales L, Coleman K, Brownlee B. Patient-Centered Interactions: Engaging Patients in Health and Healthcare. In: Phillips KE, Weir V, eds. Safety Net Medical Home Initiative Implementation Guide Series. 2nd ed. Seattle, WA: Qualis Health and The MacColl Center for Health Care Innovation at the Group Health Research Institute; 2013.

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21 Enhanced Access PCMH practices: Promote and expand access; ensure that established patients have 24/7 access to their care teams via phone, or in-person visits Scheduling options are patient- and familycentered and accessible to all patients Help patients attain and understand health insurance coverage Source: Safety Net Medical Home Initiative. Neal R, Moore LG, Powell J. Enhanced Access: Providing the Care Patients Need, When They Need It. In: Phillips KE, Weir V, eds. Safety Net Medical Home Initiative Implementation Guide Series. 2nd ed. Seattle, WA: Qualis Health and The MacColl Center for Health Care Innovation at the Group Health Research Institute; 2013.

22 Care Coordination PCMH practices: Link patients/families with community resources to facilitate referrals and respond to social service needs Provide care management services for high risk patients Proactively track and support patients as they go to and from specialty care, the hospital and the ED Follow-up with patients within a few days of an emergency room visit or hospital discharge Test results and care plans are communicated to patients/families Source: Safety Net Medical Home Initiative. Horner K, Schaefer J, Wagner E. Care Coordination: Reducing Care Fragmentation in Primary Care. In: Phillips KE, Weir V, eds. Safety Net Medical Home Initiative Implementation Guide Series. 2nd ed. Seattle, WA: Qualis Health and The MacColl Center for Health Care Innovation at the Group Health Research Institute; 2013.

23 Coordinated Care Partnerships and Collaboration Medical Neighborhood Specialists Emergency Departments Inpatient service Schools Community organizations Public Health Department Community Health Workers Schools Faith-based organizations The Medical Neighborhood Community Partners Patient-Centered Medical Home EMR/Health IT Specialists It takes a Village.. Mental + Behavioral Health Inpatient Care Pharmacy Emergency Department Adapted from Source: Holder-Niles, F. Medical Home Neighborhood: A Primer for Primary Care and Subspecialty Pediatrics. Presented at the American Academy of Pediatrics Medical Home Chapter Champions Program on Asthma, Allergy and Anaphylaxis Learning Session, January 29, 2016

24 Medical Neighborhood: Community Partnerships Food Insecurity WIC, Farmers market, food banks Housing Inspectional services Pest management Utility assistance programs Local utility companies, heating and fuel assistance Parent partners Community Health Workers Source: Holder-Niles, F. Medical Home Neighborhood: A Primer for Primary Care and Subspecialty Pediatrics., Part 2. Presented at the American Academy of Pediatrics Medical Home Chapter Champions Program on Asthma, Allergy and Anaphylaxis Learning Session, January 30, 2016

25 Medical Home Assessment Why assess? Determine current level of Medical Home Identify gaps for improvement Help develop plan to achieve recognition Monitor gains/slippage in Medical Home-ness More easily communicate status and progress to staff and patients Source: Jennifer Edwards, J. and Melissa Corrado,, HMA. Patient-Centered Medical Home Recognition Programs. Presented at the FL CHIPRA Medical Home Demonstration Project Learning Session 2, April 25, 2014.

26 Medical Home Assessment Tools Medical Home Index (MHI) Developed by the Center for Medical Home Improvement (CMHI) PCMH-A Qualis/Commonwealth Fund/ MacColl Center for the Safety Net Medical Home Initiative MHIQ Developed by TransforMED National Center for Medical Home Implementation: overview of tools and links.

27 Assessment Recommendations Pick one tool to use Define assessment schedule short and long term Complete before you start making improvements Complete as a group or part of a team Use and share the information you find to: Guide future improvement efforts, priorities, strategic planning Communicate progress to staff and patients Source: Jennifer Edwards, J. and Melissa Corrado,, HMA. Patient-Centered Medical Home Recognition Programs. Presented at the FL CHIPRA Medical Home Demonstration Project Learning Session 2, April 25, 2014.

28 PCMH Recognition or Accreditation Programs (All use own assessment tools) National Committee for Quality Assurance (NCQA) Accreditation Association for Ambulatory Health Care (AAAHC) The Joint Commission (TJC) URAC State-developed programs Minnesota s Health Care Homes program BCBS of Michigan s PCMH Oklahoma SoonerCare PCMH

29 National PCMH Recognition/Accreditation Programs NCQA mepcmh.aspx AAAHC TJC URAC

30 NCQA s PCMH Recognition Program (2014) Content and Scoring (6 standards/27 elements) 1: Enhance Access and Continuity A. *Patient-Centered Appointment Access B. 24/7 Access to Clinical Advice C. Electronic Access 2: Team-Based Care A. Continuity B. Medical Home Responsibilities C. Culturally and Linguistically Appropriate Services (CLAS) D. *The Practice Team 3: Population Health Management A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. *Use Data for Population Management E. Implement Evidence-Based Decision- Support Pts Pts Pts : Plan and Manage Care A. Identify Patients for Care Management B. *Care Planning and Self-Care Support C. Medication Management D. Use Electronic Prescribing E. Support Self-Care and Shared Decision- Making 5: Track and Coordinate Care A. Test Tracking and Follow-Up B. *Referral Tracking and Follow-Up C. Coordinate Care Transitions 6: Measure and Improve Performance A. Measure Clinical Quality Performance B. Measure Resource Use and Care Coordination C. Measure Patient/Family Experience D. *Implement Continuous Quality Improvement E. Demonstrate Continuous Quality Improvement F. Report Performance G. Use Certified EHR Technology Scoring Levels Level 1: points. Level 2: points. Level 3: points. Pts Pts Pts *Must Pass Elements NCQA, used with permission

31 Why would a Practice Become a Recognized/Certified PCMH? Financial reward payments Per member per month and/or lump sum payments for care coordination, over and above standard payments for medical services Enhancing rates for certain services (e.g., well child visits) to encourage outreach to patients Leveraging the managed care procurement process to favor medical homes by modifying selection criteria or contractual requirements Shared savings Pay-for-performance, based on achieving set benchmarks on measures of quality

32 Why would a Practice Become a Recognized/Certified PCMH? Non-monetary incentives Continuing education credits Linkages to care coordination networks Learning collaboratives/information sharing/assistance incorporating best practices Onsite practice coaches Demonstrate commitment to patient- and familycentered care Source: Jennifer Edwards, J. and Melissa Corrado,, HMA. Patient-Centered Medical Home Recognition Programs. Presented at the FL CHIPRA Medical Home Demonstration Project Learning Session 2, April 25, 2014.

33 Barriers to Pursuing Recognition/Accreditation Programs No financial incentives Costs of transformation can be daunting Work required to document PCMH features can be daunting Competes with the time required to adopt an electronic health record Source: Jennifer Edwards, J. and Melissa Corrado,, HMA. Patient-Centered Medical Home Recognition Programs. Presented at the FL CHIPRA Medical Home Demonstration Project Learning Session 2, April 25, 2014.

34 Steps towards achieving PCMH Recognition/Accreditation Make an informed decision to apply Buy-in from leadership and engagement of physicians and staff Use a team approach Establish a reasonable time frame Set goals Assign tasks Use your assessment tool to track progress Celebrate milestones along the way and remember

35 PCMH transformation is a journey Not a destination

36 Resources for more information Agency for Healthcare Research& Quality (AHRQ) The Commonwealth Fund 012/Apr/Becoming-a-Medical-Home-Implementation-Guides.aspx National Center for Medical Home Implementation

37 Contact Information Ruth Gubernick Stephanie Kneeshaw-Price, PhD, NJ DOH Stephanie.Kneeshaw-Price.doh.nj.gov Harriet Lazarus, MBA, NJAAP

38 THANK YOU!