PCMH Strategies Implementation and Sustainability 12/17/2013 Joseph K. Weidner, Jr. MD FAAFP

Transcription

1 PCMH Strategies Implementation and Sustainability 12/17/2013 Joseph K. Weidner, Jr. MD FAAFP Why is this needed? Defining a PCMH Improving Costs Better Provision of Care Improved Population Health PCMH functions: Care Management Care Coordination Care Transitions tasks Different types of Care Coordinators Care Coordination Tasks At Stone Run Care Managers Consumer Reports take on PCMH How Stone Run got started Resources needed in addition to a Care Manager/Coordinator Personnel Health IT Stone Run Opportunities for Improved Patient Care: Implementation of Youscripts pharmocogenetic testing with patient reminders; Health Mirror providing targeted patient education in the exam room; Application of prompts to prescribe regular azithromycin for COPD patients in order to reduce exacerbations Trinity Clinic details of another s experience Income and Expenses of a PCMH Next Steps for implementation of a PCMH Addressing Social barriers helps improve medical care

2 1 PCMH Strategies for Implementation and Sustainability

3 2 Triple Aim Reduce Cost Better Provision of Care Better Population Health

4 Triple Aim 3 Costs Need to be reduced USA among 34 OECD countries Highest (#1) in healthcare spending 16% of GDP (Average 9% of GDP) in 2005 Lowest in key health indicators 25 th life expectancy 29 th in infant mortality 24 th in maternal mortality

5 PCMH 4 Patient Centered Medical Home A way of organizing primary care that emphasizes care coordination and communication to transform primary care into "what patients want it to be.

6 PCMH 5 Patient Centered Medical Home Provide higher quality Lower costs Improve patients experience of care Providers experience of care.

7 PCMH: How does this save money? 6 Reduced utilization of high cost centers (ie, Emergency rooms, inpatient hospital stays, expensive testing.) Reduce risk of preventable diseases Reduce complications from chronic diseases Have everyone work to the top of their license Offload from physicians work that doesn t require a medical degree

8 Reduce Costs 7 Reduce Hospital admissions Reduce ER Evaluations Reduce costly tests Reduce unnecessary care

9 Better Provision of Care 8 Reduce Barriers to Care Improve Accessibility Improve Patient Satisfaction Improve Clinical Outcomes

10 9 Improved Population Health Increase rate of Preventive Medicine testing Engage unengaged patients

11 Better Provision of Care 10 Barriers to Care Education Financial Side Effects Disability Language Transportation Competing authority Cognitive deficits

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13 12 The patient is not compliant

14 The patient is not compliant 13 THAT S NOT GOOD ENOUGH!

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16 Patient Centered Medical Home Demystified 15 PCMH is nothing less than an extreme makeover for primary care practices, to make them: More Service Oriented for patients More Efficient for better profit More Effective for patient outcomes More Fun to go to work for all 15

17 Patient Centered Medical Home Demystified 16 Goal Driven Transition : Improved Service Oriented for patients More Efficient better profit, new payment models and new expenses More Effective for patient outcomes, improving measurement of outcomes, transmission of medical information 16

18 Three Important Functions For PCMH 17 Care management Proactively managing the patient s condition and/or preventive services using EBM guidelines, registries and a team approach Care coordination Tracking and facilitating the patient s interaction with all points of care outside the PCMH Care transitions Safe and effective transfer of support and responsibility as patients move from hospital to home or long term care (Bi-directional)

19 Three Important Functions For PCMH in SRFM 18 Care management Reports on three chronic conditions; Identify areas for improvement Reminders to bring meds to appointments, lab work before visit Group diabetic classes

20 Three Important Functions For PCMH in SRFM 19 Care coordination Post admission and post ER follow-up, scheduling visits, Calling in medicines Assistance with scheduling appointments Follow-up when haven t been seen, need med refill

21 Three Important Functions For PCMH in SRFM 20 Care transitions CRISP notifications Medication reconciliation, bring in meds for visit, Facilitate timely rehab and psych evaluation Point of Care referrals

22 Care Transition Tasks 21 Clarify modifications in care plan Reconcile medications with pre-hospital orders and supplies at home Understand level of help and support needed from others and arrange for needed services Solid transfer of responsibility Re-integrate patient into community of care

23 Care Transition Tasks at Stone Run 22 Clarify modifications in care plan imbedded within patient notes; localize the plan according to the EMR capabilities Reconcile medications with pre-hospital orders and supplies at home. Utilizes outpatient record. Physicians also do this may be better at this. Understand level of help and support needed and available; arrange for needed services. Solid transfer of responsibility Re-integrate patient into community of care. Identify resources. On site evaluation within 7 days.

24 Transitions Of Care by telephone 23 Hospital Telephone Coordinator Primary Care Hand-off Care plan Medication Reconciliation Clinical Info Pending issues Connect Timely Access Coordinate Care Follow up on pending issues Utilize claims data Coordinate population health? access to EMR Accept Capable Team Approach Engages Caregivers Whole person orientation

25 Transitions Of Care at Point of Care 24 Hospital Point of Care Coordinator Primary Care Hand-off Care plan Medication Reconciliation Clinical Info Pending issues Connect Timely Access Point of Care Coordination Use internal EMR Shortened Provider Communication Loop Tied to one practice location: Familiarity Accept Capable Team Approach Engages Caregivers Whole person orientation

26 Transitions Of Care Geographically 25 imbedded Hospital Geographic Care Coordinator Primary Care Hand-off Care plan Medication Reconciliation Clinical Info Pending issues Connect Coordinate Care for multiple practices One person for a few practices Not as Timely Access Accept Capable Team Approach Engages Caregivers Whole person orientation

27 Care Coordination Tasks 26 Share the care plan and clinical information Arrange appointments if patient not able Track referrals, labs and consultations Follow up on reports and recommendations Engage family and care givers Set up service agreements

28 Care Coordination Tasks at SRFM 27 Share the care plan and clinical information develop in patient chart in reason for visit (subjective); we do not use a separate registry Arrange appointments if patient not able only if necessary Track referrals, labs and consultations based on EMR generated reports, we need better return correspondence from specialists to reconcile referrals; better systems Follow up on reports and recommendations insurer reports, if accurate; Engage family and care givers this we excel at; better Set up service agreements not yet, but perhaps a good idea with urgent care units,

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31 Care Coordination Tasks for 30 Northern Maryland ACO Enrollment of Medicare patients Promote Medicare Preventive Physicals Health Assessment mailed to every patient Trouble and Questions with Split authority Dueling Care Coordination

32 Allscripts Pro 13.0 update 31 Care Plans and Goals: Build care plans, Set goals, Track patient progress Identify barriers through the core EHR solution.

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34 How Care managers spend their 33 time at SRFM? 86 care plans per month or 4-5 per day Average of 26 hours per week accounted for Pre-visit planning Transition Care management Provider directed care management Home visits, transport of patients, phlebotomy Follow-up of chronic disease reports Population Health Management is minimal

35 Critical Elements For PCMH 34 True team approach to care Quality measures and a culture of improvement Patient and family engagement with patient selfmanagement support Care management and care coordination IT enabled for the core business, clinical and communication functions

36 Evolution of Expectations (for change) of Primary Care Practices 35 Team-based care Focus on the top of license, training and interest Improved communication more of a challenge for large practices Improved data flow and access Right patient at the right time Patient-centered aligned incentives outcomes, quality, cost Accountability outcomes, quality, cost 35

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38 PCMH Consumer Reports & SRFM 37 Medical need That was then Appointments Sick or injured at an inconvenient hour Prescription renewal Preventive care We can fit you in in three days. Go to urgent-care center or emergency room to see someone who does not know your history. Call office and wait for doctor to call you back. Remember to make appointments for checkups, screenings, and vaccines. This is now (or coming soon) Same-day attention for acute illness. Clear arrangement for after-hours care. Your medical history available electronically. Nurse handles immediately. Electronic record tracks preventive measures and reminds you and professionals. Stone Run Family Medicine 40% same day Some Urgent Care during hours. Less calls at night as urgent cares proliferate. We need to advertise our availability. EHR on providers laptops. Prescription Renewal line may not be efficient. E-refill better. Multiple models. Point of Care Reminders. Need to Develop patient contact system for Unengaged Patient

39 PCMH Consumer Reports & SRFM 38 Medical need That was then Test results Follow-up care Specialist appointments Hospital release Play phone tag with the doctor. Up to you to make timely appointments. Specialists and primary care doctors may not communicate. Doctor has no idea you re in the hospital unless you initiate contact. This is now (or coming soon) Available at online portal. Office tracks and reminds you of needed follow-up. Primary care physician coordinates with specialists. Knows when you are hospitalized and takes initiative to follow up. Stone Run Fmily Medicine Portal Use. Still Lots of Calls. Availability helps this Patient appointment reminders. I use people for this. Referral note faxed at point of care streamlined. Calls if limited patient capacity. CRISP notification. Delegation of this to Care Manager. Call while they are in hospital.

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41 Maryland MultiPayer Pilot 40 Maryland State Legislated program Promotes PCMH models in 52 practices 5 majors insurers payments per insured shared savings Coordinated by JH, U of MD, DMHMH, MHCC

42 Maryland Multi-Payer Pilot 41

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44 Other personnel 43 Social Worker Computer IT/ Reporting Support Mid Levels Dietician/ Diabetic Educator Diabetic group classes

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46 Other personnel 45 Social Worker Computer IT/ Reporting Support Mid Levels Dietician/ Diabetic Educator Diabetic group classes

47 Health IT Resources 46 EMR Patient Registries CRISP/ HIE Google Talk Cortext Web resources: Epocrates; Labcorp Hospital Information Systems

48 HIE Utilizers 47 Tracking emergency department users across unaffiliated hospitals with a health information exchange can help better identify frequent ED users, potentially allowing for interventions such as improved case management to better allocate healthcare resources, according to a study in Health Affairs. Researchers used the New York Clinical Health Information Exchange to identify patients who had visited the emergency departments of 10 hospitals in the New York City area more than four times in one month. Results showed the HIE data identified 20.3 percent more ED "frequent fliers" than site-specific data. Additionally, researchers discovered frequent ED users are more likely than other patients to visit multiple EDs over the 12-month study period (28.8 percent versus 3 percent), emphasizing that better care coordination across facilities and better case management has the ability to reduce ED usage and better utilize ED resources.

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50 YouScripts Pharmcogenetic testing 49 Data validates YouScript value in a broad population Extrapolated for to the 700,000 member plan, it was estimated retrospectively the appropriate intervention in the Warned group would have saved $25 million to $57 million Ambulatory polypharmacy treated patients followed for one year (N = 111) Drug Interaction Warned N = 77 Total Avg. per person Drug Interaction Unwarned N = 34 Total Avg. per person ER Visits Hospitalizations Days in Hospital Imaging Procedures P The pilot study encouraged the health system to dramatically expand the study and include genetic testing to show the cumulative effect and cost savings

51 Health Mirror Patient Education 50 Targeted Multimedia Patient Education 3 months Evaluation Preventive Measures Age Specific

52 Health Mirror Patient Education 51

53 Website Usage 52

54 Website Usage exit page 84% Portal % Patient Edu. 2.5% Specialists 1.6% Medications 1.3% CHADIS 1.3% Insurance 1.1% VIS 1.0% Calendar

55 Portal Usage 54 29% of patients 434 in the past 6 weeks patients visits per year This is the answer for patients who sit at a desk. (JKW s current working portal theory)

56 Azithromycin to prevent COPD 55 exacerbations 570 with COPD on 250mg Azithro. daily; 572 on placebo Comparable one year follow-up 1.48 exacerbations per patient-year in treatment group 1.83 exacerbations per patient-year in placebo (P=0.01) Mild worse hearing (25% vs. 20%) NNTT was 2.86 to prevent one excerabation

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59 Trinity Clinic, Tyler, TX 58

60 Trinity Clinic, Tyler, TX 59 NO show rate reduced from 4.5% to 2.8% 3 percent increase in total visits, as 80% of rescheduled slots filled Increased cost of $68400 employing two LVNs at $19/hour Increased revenue of $117,528 to system

61 Trinity Clinic, Tyler, TX 60

62 Trinity Clinic, Tyler, TX 61

63 Trinity Clinic, Tyler, TX 62

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65 What is the revenue? 64 Stone Run Projections to 10/ projected Fee for service collections % % MMPP PCMH payments % % % Misc % % % HPSA % % % Capitation - United % % % Aetna NCQA incentives % % % ACO % CMS MU EHR incentive % % CMS MU EHR incentive HPSA primary care bonus % % Total Income % % Non Fee for service income % % % PCMH/NCQA related income % % % Total Meaningful Use Income % %

66 What is the revenue? 65 For SRFM 10% of income comes from PCMH/NCQA related activity

67 Transitional Care Management 66 codes ($167.78) and ($236.64) Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate to high complexity during the service period Face-to-face visit within 7-14 calendar days of discharge

68 Transitional Care Management 67 codes increase revenue Everyone post discharge care manager contacts within 2 business days. See all within one week of discharge. Provider determines code based on moderate or high complexity conversion to 99495/99496 (50/50 split JKWs estimate) Assuming does 6 per week (3FTE providers), Maryland Medicare fee schedule rates ( $167.78; $236.64; $109.80) Increase in revenue by $28833 per year

69 Chronic Care Management codes 68 G code to start for Medicare in 2015 For patients that have two or more conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; 20 minutes or more; per 30 days. CMS finalized the scope of CCM services to include: 24-hour- a-day, 7-day- a-week access to address a patient s acute chronic care needs. Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments. Requires care management, including management or care transitions, development of a care plan, coordination of care and communication with patient.

70 Primary Care conversion to PCMH - 69 expense LPN average salary - $40734 annually ( Rising Sun, MD) IT/Reporting specialist - $30000 annually NCQA certification - $2280 every three years Cost $71494 per year plus benefits Does not count employee benefits, physician work, facilities, utilities, EMR, maintenance, CRISP

71 Primary Care conversion to PCMH - 70 revenue Use of Care Transition Codes $28833 ACO payments $8000 Aetna payments for NCQA recognition $7500 Increased pneumococcal vaccine. $1125 Increased influenza vaccination $4959 3% increase visit rate $36624 Income $87041 Does not include sharing savings, pilot programs, income from chronic care management codes, meaningful use/erx/pqrs incentives

72 Primary Care conversion to PCMH 71 Expense $71494 Income $87041 Does not include shared savings, pilot programs, income from chronic care management codes, meaningful use/erx/pqrs incentives, employee benefits, EMR costs, utilities, office equipment Based on SRFM experience, visits in past 12 months, 1.3M fee for service collections, 3 FTE clinicians

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74 Next steps: Take the MHIQ Medical Home Implementation Quotient Assessment 73 Free on-line practice assessment tool Great educational resource for physicians and staff around PCMH Cross-walk for NCQA recognition An easy way to identify the gaps

75 Address your Access Issues 74 Extended hours (according to provider capacity) Adequate staffing, work as a team (SRFM 3.3 FTE including billing) Develop an simple effective schedule. Move toward advanced access. Consider Patient Direct Scheduling. Do Today s Work Today

76 Next steps 75 Get an EHR if you don t already have one. Delta Exchange/ TransForMed Participate with what you see pilots; new initiatives; ACOs Assess where you can offload your work Identify staff who can take on care coordination roles Transition of Care codes Apply for PCMH recognition from Insurers. Consider dictation, a scribe, a smart high school kid

77 Engage Your Patients 76 Two way patient education front load education with Health Mirror Group education opportunities - For certain structured models, high risk patients. Patient advisory groups instead get to know your patient's enough that they will tell you when something is wrong Care plan development Patient outreach may be better for insurers Patient portals. Advocate for those if within a PATIENTS workflow. Is texting better? Will multiple workflows lead to more mistakes?

78 Triple Aim PLUS 77 Reduce Cost Better Provision of Care Better Population Health Improve physician compensation Improve work/life balance Allow physicians to do doctor things Allow all staff to work at the top of their ability

79 REDUCE COST: ADDRESS SOCIAL BARRIERS TO CARE 78 The United States has closer to average OECD total costs of combined health and social services PCMH care more appropriately shifts health care expenditures to address social ills and barriers that affect health outcomes

80 REDUCE COST: ADDRESS SOCIAL BARRIERS TO CARE 79

81 References and Resources 80 Slide 2: Amy Mullins, MD, FAAFP, Josiah Mooney, MBA, and Roger Fowler, MD, FAAFP Fam Pract Manag Nov-Dec;20(6): Patient Centered Medical Home And The Impact Of The CMS Comprehensive Primary Care Initiative, Bruce Bagley, 2/1/2012, AAFP AAFP Transitional Care Payment FAQs Feb nt/payment/tcmfaq.pdf AAFP summary of CMS final 2014 Medicare fee schedule Dec. 11, medicare/es-summarymedicarefeeschedule pdf

82 References and Resources 81 Maryland Multipater N Engl J Med 2011; 365: August 25, 2011DOI: /NEJMoa Health and social services expenditures: associations with health outcomes Elizabeth H Bradley, Benjamin R Elkins, Jeph Herrin, et al. BMJ Qual Saf2011;20:826e831. doi: /bmjqs

83 PCMH Strategies Implementation and Sustainability 12/17/2013 Joseph K. Weidner, Jr. MD FAAFP List of Abbreviations AAFP ACO American Academy of Family Physicians. Where Joe plagiarized many of his slides Accountable Care Organization. Groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their (Medicare) patients. CHADIS CMS CPCI CRISP Child Health and Developmental Interactive System Centers for Medicare and Medicaid Services Comprehensive Primary Care Initiative Chesapeake Regional Information System for our Patients. Maryland s HIE. GDP Gross Domestic Product. Market value of all gods and services in a country, typically over one year EBM HIE IHI MHIQ MMPP NCQA NNTT OECD PCMH SRFM VIS Evidence Based Medicine. Health Information Exchange Institute for Healthcare Improvement. Developed the Triple Aim Medical Home Implementation Quotient Assessment Maryland Multipayer Pilot National Committee of Quality Assurance. Their Recognition is the most widely-used way to transform primary care practices into medical homes. Number Need to Treat Organization for Economic Co-operation and Development. 34 member international body that among other tasks, develops health statistics Patient Centered Medical Home. Team based model for outpatient care Stone Run Family Medicine Vaccine Information Sheets. Education sheets require to be given to those receiving vaccinations