Nicole Harmon, MBA, PCMH CCE Senior Director, PCMH Advisory Services HANYS Solutions Patient-Centered Medical

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1 Nicole Harmon, MBA, PCMH CCE Senior Director, PCMH Advisory Services 2017 HANYS Solutions Patient-Centered Medical Home Advisory Services

2 Overview Current landscape Medical neighborhood Patient-Centered Specialty Practice (PCSP) Culture and change management Workflows and technology Recap

3 Time of Change (Medicine) is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line. Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try. -Atul Gawande

4 CARE WITHOUT COORDINATION MEALS/ NUTRITION SOCIAL SERVICES NURSING HOME HOUSING/ HOME SUPPORT HOME HEALTH CARE TRANSPORTATION/ MOBILITY INFORMAL CARE FINANCIAL SERVICES COMMUNITY CHURCH FRIENDS HEALTH INSURANCE HEALTH SERVICES DOCTORS HOSPITALS CLINICS Rx FAMILY CARE GRANDCHILDREN CHILDREN SPOUSE MEDICARE MEDICAID PART D LTC INSURANCE

5 Effects of Care Fragmentation

6 Overarching Goal

7 Source:

8 Medical Neighborhood Source:

9 What is Care Coordination?

10 NCBI Working Definition 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 marshaling 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. Source:

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12 Awareness Communication Follow up

13 Why Coordinated Specialty Care? 25-50% of referring physicians do not know whether their patients [saw] the specialist to which they were referred and physicians routinely misestimate the number of referrals completed PCP s report sending information 70% of the time Specialists reporting receiving the information 35% of the time PCP s report receiving a report 62% of the time Source: NCQA PCMH Congress: PCMH Medical Neighborhood_Barrett.pdf

14 Impact of Coordinated Care More efficient use of services Lab, imaging, ER, hospitalization Improved patient experience Access, coordination, clinician collaboration, involvement in care Improved outcomes CQI, evidence-based guidelines, medication management

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16 Alphabet Soup of Redesign PCMH PCSP MU TCPI PQRS

17 QPP: MIPS Track 2018 and beyond Sunsets Medicare payment adjustments for: Physician Quality Reporting System (PQRS) Value-Based Modifier (VM) Electronic Health Record (EHR) Incentive Program Source: Applies positive, negative, or neutral payment adjustment to each MIPS clinician based on a composite performance score across domains Adjusts payment beginning 2019 based on performance in 2017 Source: CMS at Initiatives-Patient-Assessment-Instruments/Value-Based- Programs/MACRA-MIPS-and-APMs/Quality-Payment- Program-MACRA-NPRM-Slides.pdf 17

18 MIPS: Sampling of Metrics Quality (using general surgery as example) Surgical site infection Unplanned readmission within 30 days Care plan Documentation of current medications in medical record Clinical Practice Improvement Activity (CPIA) Expanded access (i.e., 24/7 access for advice on urgent/emergent care) Achieving health equity (i.e., see new and follow up Medicaid patients in timely manner) Integrate behavioral and mental health (i.e., promote colocation of mental health services in primary care settings) Advancing Care Information (ACI) e-prescribing Patient electronic access Health information exchange Security risk analysis Resource Use (not used in 2017) Medicare spending per beneficiary Total spending per capita Episode measures (i.e., heart failure) CMS measure exploration tool at: 18

19 IMPROVEMENT ACTIVITIES 19

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24 Patient-Centered Specialty Practice (PCSP) Enhance coordination between primary care (PCP) and specialty care (SCP) Strengthen relationships between PCP and SCP Improve the experience of patients accessing specialty care Align requirements with processes demonstrated to improve quality and eliminate waste Encourage practices to use performance measurement and results to drive improvement Identify requirements appropriate for various specialty practices seeking recognition for excellent care integration within the medical home Source: NCQA PCSP 2016 Recognition Front Matter_FINAL pdf

25 Eligibility Non-primary care specialty MD, DO, APRN, certified nurse midwives State certified or licensed behavioral health practitioners: Doctoral or master s level psychologist Doctor or master s level clinical social worker Doctoral or master s level marriage and family counselors* *licensed by state to practice independently

26 Scoring Considerations Each standard has elements and factors Score at least 50% on must pass elements How many and how well they are performed translates into points: Level 1: points Level 2: points Level 3: points

27 Must Pass Elements 1B: Managing Initial Referrals 1D: Assessing Initial Referral Response 2E: The Practice Team 4B: Medication Management 6C: Implement and Demonstrate CQI

28 PCSP Standard 1A

29 PCSP Standard 1D

30 PCSP Standard 2E

31 PCSP Standard 5B

32 PCSP 2017 NCQA Redesign

33 Consult Orders Provide the clinical question including timing and type of referral Urgency/Timing Clinical Questions

34 Relevant Clinical Information Clinical Information Diagnoses Reason and evaluation details Clinical findings Medications Current treatment Current care plan Follow-up communication

35 Consult report lost or misfiled No consult report sent Waiting until follow up visit to review results Primary Care Physician Not enough information from PCP Specialist No appointment made Provider booked out for weeks Patient misses appointment Patient forgets referral order Authorizations

36 Co-Management Agreement between providers who regularly treat a patient Timely sharing of information Medical record documentation of plan

37 Activity

38 Lessons Learned from PCMH Culture Change management Leverage and involve HIT Celebrate small wins Train, reinforce, coach Accountability

39 Why is Culture Important? 39

40 Zappos 40

41 Practice Culture Cultural descriptors Traditional Innovative Like a family Common cultural perceptions Clinical vs. clerical Front vs. back Do what you re told 41

42 Achieving Transformation Practice Culture People, Process, and Technology Ensure awareness, desire Knowledge and ability Potential obstacles and risks

43 Change isn t Easy The transformation process can be a long and difficult journey Teamwork

44 Project vs. Change Management Project Management Task-Focused Project Plan and Milestones Transformation Process Change Management People-Focused Education and Coaching Sustainability of Change 44

45 Achieving Transformation Understand current state Develop plan Create components Implement, train, and engage Plan Do Study Act (PDSA) cycles Submission preparation 45

46 Current State vs. Standards Policies and procedures Culture and environment Team structure HIT functionality Reporting capability 46

47 Establish a Project Plan Select elements and factors to pursue Identify system-wide elements and factors Review milestones Assign project tasks, responsibilities, and due dates 47

48 Examples 48

49 CHANGE MANAGEMENT 49

50 Change Management Theory 50 Source: ADKAR A Model for Change in Business, Government and Our Community Hiatt, Jeffrey M.

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52 Change Management Theory 52 Source: John Kotter (2007) Leading Change: Why Transformation Efforts Fail, HBR

53 Preparing Yourself for Change 53

54 PREPARING OTHERS FOR CHANGE 54

55 Awareness Building Specific and clear Timing Expectations 55

56 What Could Go Wrong? 56

57 Types of Messages Healthcare environment today Vision for practice and/or system PCMH background Timeframe for transformation Basics of what is changing Status updates Success stories 57

58 Creating Awareness Readiness to recognize the need to change depends on: A person s view of the current state How a person perceives the problems Misinformation or rumors Belief in the reasons for change Credibility of the sender 58

59 Message Sender Trusted Credible Leader 59

60 Desire and Urgency How to create desire and urgency when Change is a directive, not chosen Desired state isn t fully understood by all Team is resource challenged Multiple competing priorities 60

61 Must Have Message WIIFM 61

62 What s In It for Me? 62

63 What To Do Communicate Clearly, consistently, and frequently Honest, open, transparent, and safe Ways for team to provide feedback Consider WIIFM Understand your team member s motivations Impact on daily activities of each team member Impact of the change on job security 63

64 Communication Strategy Bulletin board Staff meetings Huddles Retreat ? 64

65 Sender and Receiver 65

66 Knowledge Skills People Process Technology Expectations 66

67 Audiences Physicians, Nurse Practitioners, Physician Assistants Clinical staff Clerical staff Administration Patients 67

68 Ability Transfer knowledge to daily activities Performance in new reality Performance evaluation updates 68

69 Preparing for Resistance What type of resistance can be anticipated? Who is likely to be resistant to change? How will we approach resistance? 69

70 Overcoming Resistance Revisit steps of change Awareness WIIFM Knowledge and ability Continue to reinforce 70

71 Coaching Example Sue has been with the practice for 15 years in the front office. While she s great with patients, she is resistant to the EMR and change. During a recent staff meeting, she was heard badmouthing the changes in the practice and saying that she isn t going to do her job any differently. How will you approach Sue about this? 71

72 Take 5 Minutes Discuss your approach to Sue s resistance to change 72

73 Coaching and Feedback Seek to understand Lack of information Disagreement Personal reasons Emotional reasons 73

74 Celebrate Successes Why is this important? How will you celebrate even the smallest of successes? 74

75 Improvement Cycles

76 Health Information Technology An important part of the equation, but not the solution Redesigned workflows Understand data and reporting

77 Inclusive Workforce Engagement Communication Training Consistently monitor progress and compliance

78 Recap Time of change Payment reform Collaboration is key Medical neighborhood growth

79 Transformation Journey

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81 Questions Nicole Harmon, MBA, PCMH CCE Phone: