Patient Centered Medical Home. History of PCMH concept. What does a PCMH look like? 10/1/2013. What is a Patient Centered Medical Home (PCMH)?

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1 What is a Patient Centered Medical Home (PCMH)? Patient Centered Medical Home Jeremy Thomas, PharmD, CDE UAMS Department of Pharmacy "an approach to providing comprehensive primary care that facilitates partnerships between individual patients, and their personal providers, and when appropriate, the patient s family" Joint Principles of the PCMH Ongoing relationship with personal physician Physician directed medical practice Whole person orientation Coordinated care across the health system and safety Enhanced access to care Payment recognizes the value added agreed upon by American Academy of Family Physicians, American College of Physicians, American Academy of Pediatrics, American Osteopathic Association History of PCMH concept American Academy of Pediatrics call for a model to organize the care of children with complex health care needs. Institute of Medicine. Committee on of Care in America. Crossing the Chasm: A New System for the 21st Century. Creation of Future of Family Medicine Project to "transform and renew the specialty of family medicine. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in care. Institute of Medicine. Insuring America s : Principles and Recommendations. American Academy of Family Physicians creates TransforMED. History of PCMH concept What does a PCMH look like? American College of Physicians Policy Monograph. The advanced medical home: a patient centered, physician guided model of health care. Creation of the Patient Centered Primary Care Collaborative. Joint Principles of the Patient Centered Medical Home. National Committee for Assurance released Physician Connections Patient Centered Medical Home (PPC PCMH) Recognition program. Accreditation Association for Ambulatory Care (AAAHC) began accrediting medical homes. UAMS Internal Medicine Clinic initiates development of PCMH. Today s House Patients are those who continue to make appointments at the practice Care is determined by today s problem and time available today Care varies by scheduled time and memory or skill of the doctor Patient trusts providers deliver quality care Patients are responsible for coordinating their own care It s up to the patient to tell us what happened to them Clinic operations center on meeting the doctor s needs Tomorrow s Home Registries Proactive Plans Evidence based Point of Service Care and Safety Team: Coordinated, Integrated Tracking: Test and Referrals Optimal Function: An interdisciplinary team works at the top of our licenses to serve patients 6 1

2 Building Blocks of a PCMH Great Outcomes Business & Clinical Process Automation Intra office team coordination Results, referrals and procedures tracking Schedule and resource management Connectivity & Communication E prescribing Clinical messaging with patients information exchange Evidence Based Medicine Support Evidence based template for documentation Access to online medical information Clinical decision support Clinical Data Analysis & Representation All patient, all condition registry measurement collection and analysis Reporting to third parties Patient Heath Financial Management Personnel Management Clinical Systems Culture of Improvement Performance Measurement Reliable Systems All staff are aware of the most effective ways to deliver care National policies support the investment of resources into primary care practices that are effective and efficient Every team member understands the important role they play in delivering efficient care and is empowered to make suggestions for improvement Lab testing Prescriptions Registries Lab testing Prescriptions Patient Registries Staff education Team meetings Ensure quality improvement initiatives are not punitive measures should be based in clinical evidence Patient satisfaction surveys Develop reliable systems to collect information Check list and reminders Evidence based decision support tool Patient Convenient Access Same day appointments After hours access coverage Online patient services Patient Personalized Care Reminders Non physician care management Shared decision making Self management support Care Coordination Referral management Patent engagement and education Prevention screening and services Great Outcomes Patient Patient Heath Family Medicine Foundation Great Outcomes Good for patients Patients enjoy better health. Patients share in health care decisions. Good for physicians Physicians focus on delivering excellent medical care. Good for practices Team works effectively together. Resources support the delivery of excellent patient care. Good for payors and employers Ensures quality and efficiency. Avoids unnecessary costs. 2

3 Outcomes of PCMH Interventions Group Cooperative of Puget Sound 29% reduction in ER visits and 11% reduction in ambulatory sensitive care admission Community Care of North Carolina 93% of asthmatics received appropriate maintenance medications 40% decrease in hospitalizations for asthma and 16% lower ER visit rate Partners Medical Group MN 350% reduction in appointment waiting time The Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence on, Access and Costs from Recent Prospective Evaluation Studies, August Outcomes of PCMH Interventions Geisinger System Statistically significant improvements in quality of preventive (74.0% improvement), coronary artery disease (22.0%) and diabetes care (34.5%) for PCMH pilot practice sites Genesee Plan 72% of the uninsured adults in Genesee County now identify a primary care practice as their medical home The Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence on, Access and Costs from Recent Prospective Evaluation Studies, August Outcomes of PCMH Interventions Intermountain care Medical Group Management Plus 39% Decrease in emergency room admissions 24% Decrease in hospital admissions Net reduction cost of $640 per patient and $1,650 among high risk patients Blue Cross Blue Shield of NC Palmetto Primary Care Physicians 12.4% decrease in ER visits 10% decrease in hospital admissions Total medical and pharmacy costs were 6.5% lower The Patient Centered Medical Home PHARMACIST INVOLVEMENT The Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence on, Access and Costs from Recent Prospective Evaluation Studies, August NCQA PCMH 2011 Standards Enhance Access and Continuity Identify and Manage Patient Populations Plan and Manage Care Provide Self Care Support and Community Resources Track and Coordinate Care Measure and Improve Performance Identify and Manage Patient Populations Standard 2, Element B uses a searchable electronic system to record the following data: Allergies, including medication allergies and adverse reactions, for more than 80% of patients List of prescription medications with the date of updates for more than 80% of patients 3

4 Identify and Manage Patient Populations Standard 2, Element D s uses patient data and evidence based guidelines to generate lists and remind patients about needed services: At least three different preventive care services At least three different chronic care services Patients not recently seen by the practice Specific medications Medication Management Standard 3, Element D The practice manages medications in the following ways Reviews and reconciles medications with patients for more than 50% of care transitions Provides information about new prescriptions to more than 80 % of patients Assesses patient understanding of medications for more than 50% of patients with date of assessment Assesses patient response to medications and barriers to adherence for more than 50% of patients with date of assessment Documents over the counter medications, herbal therapies and supplements for more than 50% of patients, with the date of updates Electronic Prescribing Standard 3, Element E uses e prescribing system with the following capabilities: Generates and transmits at least 40% of prescriptions to pharmacies Generates at least 75% of eligible prescriptions Integrates with patient medical records Performs patient specific checks for drug drug and drug allergy interactions Alerts prescribers to generic alternatives Alerts prescribers to formulary status Self Management Support Standard 4, Element A The practice conducts activities to support patients/families in selfmanagement: Provides educational resources or refers at least 50% of patients to educational resources to assist in self management Uses an EHR to identify patient specific education resources and provide them to more than 10 percent of patients, if appropriate Develops and documents self management plans and goals in collaboration with at least 50% of patients Documents self management abilities for at least 50% of patients Provides self management tools to record self care results for at least 50%of patients Counsels at least 50% of patients to adopt healthy behaviors Why involve pharmacist is PMCH? 3.5 billion prescriptions written annually in US 4 of 5 patients leave MD office with Rx Rx s are involved in 80% of all treatments Most commonly identified drug problems patient requires additional therapy dosages need to be titrated to achieve benefit WHO estimates adherence rate of 50% for chronic medications Academy of Managed Care Pharmacy American Association of Colleges of Pharmacy American College of Clinical Pharmacy American Pharmacists Association American Society of Consultant Pharmacists American Society of -System Pharmacists College of Psychiatric and Neurologic Pharmacists National Association of Chain Drug Stores National Community Pharmacists Association 4

5 Principles for Pharmacist Incorporation into PCMH Framework PRINCIPLES FOR INCLUSION OF PHARMACISTS CLINICAL SERVICES IN THE PATIENT CENTERED PRIMARY CARE MEDICAL HOME Available at ServicesPCMHModel3 09.pdf Access to pharmacists clinical services Patient focused collaborative care Flexibility in medical home design Development of outcome measures Access to relevant patient information Effective health information technology Aligned payment policies Integrating Comprehensive Medication Management to Optimize Patient Outcomes PATIENT CENTERED PRIMARY CARE COLLABORATIVE (PCPCC) PCPCC Comprehensive Medication Management medication management service needs to be delivered directly to a specific patient assessment of the specific patient s medicationrelated needs care plan is developed to resolve the problems service is expected to add unique value to the care of the patient work of pharmacists and medication therapy practitioners needs to be coordinated with other team members in the PCMH Patient Centered Primary Care Collaborative (PCPCC) COMPREHENSIVE MEDICATION MANAGEMENT SERVICES Assessment of the Patient s Medication Related Needs all current Rx, OTC, Supplements, vitamins, meds from friends and family, etc. current systems don t capture everything uncovering patient s medication experience complete medication history medications are linked to indicated condition goal is to determine if outcomes are achieved through medication use 5

6 Identification of the Patient s Medication related Problems Each Medication is assessed for Appropriateness Effectiveness Safety Adherence Development of a Care Plan Intervene to solve medication related problems Establish individualized therapy goals Design personalized education and interventions Establish measureable outcome parameters Determine appropriate follow up time frames PCPCC Comprehensive Medication Management: Patient Identification Not meeting the intended therapy goal Experiencing adverse effects Difficulty understanding/following regimen In need of preventive therapy PCPCC Comprehensive Medication Management: Payment and Coverage monthly care coordination payment visit based fee for service component performance based component Frequently readmitted to the hospital Comprehensive Primary Care Initiative Opportunities in Arkansas COMPREHENSIVE PRIMARY CARE INITIATIVE 6

7 CPC Opportunities CPC Sites in Arkansas selected primary care practices who are committed to improving the patient experience through increased access and continuity planned care for chronic conditions and preventative care patient and caregiver engagement coordination of care across the medical neighborhood risk stratified care management receive enhanced payments based on a per member per month formula. CPC vs PCMH CPC initiative aligns with the PCMH model: include a personal physician physician directed medical practice whole person orientation coordinated care access continuity of care population and disease management through electronic health records and patient registries quality safety Summary The PCMH has the potential to improve the care of patients Appropriate medication management is vital component of providing comprehensive care Pharmacist have the capacity and ability to provide medication therapy management References and Resources PCMH and Pharmacists Questions: jltomas2@uams.edu Comprehensive Primary Care Initiative ive Primary Care Initiative/index.html 7