Building a Better Home: Transformation to a Patient Centered Health Home. Anna M. Gard, FNP-BC Association of Clinicians for the Underserved

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1 Building a Better Home: Transformation to a Patient Centered Health Home Anna M. Gard, FNP-BC Association of Clinicians for the Underserved

2 A Patient Centered Health Home is not a place but an approach

3 Every Good Conversation Starts with Good Listening

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5 Building a Patient Centered Health Home ACCESS HEALTH LITERACY MEDS CARE COOR- DINATION Pt. TRACKING COMMUNI- CATION

6 Roles of Team Members Provider LPN Clinical Assistant Patient Representativ e Patient Care Partners

7 The HCH Model Outreach Community Partnerships Access Whole Person Focus Patient Engagement Internal Team

8 Why the Patient Centered Medical Home Model? Ø Improve safety, efficiency and quality Ø Move from reactive to proactive care Ø Focus on transitions of care Ø Patient engagement Ø Public and private incentive payments q Alerts, reminders, clinical decision support q Referrals, medical neighborhoods, health information exchange q Pt. summaries and lists, report on missing pts. Lost to f/u

9 High leverage activities that yield high outcome Identification and management of mental illness/addiction/cognitive dysfunction Management of transitions of care (respite) Care coordination and Team based care Complex co-morbidities Identification and management of the socially frail/ isolated individual Pharmacologic Management including optimizing medication and adherence

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11 Source: Grumbach K, Bodenheimer T & Grundy P. (2009) The Outcomes of Implementing PCMH Interventions: A Review of the Evidence on Quality, Access and Costs from Recent Prospective Evaluation Studies. Group Health Cooperative Community Care of North Carolina HealthPartners Medical Group Geisinger Health System Better Quality Better Work Environment Reduction in ER & Inpatient Hospital Costs Better Patient Satisfaction & Access X X X X X X X X X Genesee Health Plan X X X Colorado Medicaid & SCHIP Intermountain Healthcare Summary of Key Data from PCMH Interventions X X Johns Hopkins X X X X X X

12 HRSA National Quality Recognition Initiatives Resources Accredited Accreditation Association for Ambulatory Health Care (AAAHC) Designated Joint Commission Recognized NCQA 12

13 2011 NCQA PCMH Standards 1. Enhance Access and Continuity 1A. Access during office hours: same day appts., timely telephone response. Identify and Manage Patient Populations 2D. Use data for population management 3. Plan and Manage care 3C. Care Management 4. Provide Self Care Support and Community Resources 4A. Support Self Care Process 5. Track and Coordinate Care 5B. Referral tracking and follow up 6. Measure and Improve Performance 6C. Implement continuous quality improvement

14 Clinical Decision Support Ø Documentation forms or templates that provide age, disease, or co-morbidity specific tasks Ø Built in calculators to assist in categorizing conditions or recommending drug dosing (Framingham, pediatric dosing calculator) Ø Reminders or alerts (mamograms, colonoscopy) Ø Algorithms and protocols through use of clinical practice guidelines (2007 NHLBI Asthma) Ø Reference information (Epocrates) 14

15 Special Considerations for Clinicians Caring for people without homes. Some of the methods used to fulfill the PCMH requirements need to be modified. Self Management and Patient Involvement will need to be modified Working with partners will be even more critical to achieve certification for PCMH

16 Implementation guides Empanelment Team Based Healing Relationships Patient Centered Interactions Engaged Leadership QI Strategy Enhanced Access Care Coordination Organized, Evidenced Based Care 16

17 A Practical Guide to PCMH Transformation Resources Pilots and Demonstrations Consumers and Patients Employers and Health Plans Providers and Clinicians Federal and State Government 17

18 PCMH Opportuni.es through Meaningful Use of HIT Improve Quality and Safety U.lize clinical decision support within EMR to prompt clinicians U.lize quality measurement capability to track adherence, and to evaluate impact Engage Pa7ent and Families U.lize pa.ent engagement technologies to assist them in managing their health Improve popula7on and public health U.lize aggregate pa.ent level data to iden.fy popula.on level strategies

19 MU along the spectrum of PCMH Just beginning the PCMH journey, no tech in place Designated, but don t have all the tech in place or aren t fully utilizing the tech. PCMH designated MU can be used to jump- start PCMH efforts by acquiring the necessary technology * MU incentive money can help [inance PCMH efforts MU can be used to fully understand and use the technology you ve invested in * MU incentive money can help [inance PCMH efforts. MU can be used to investigate how to use technology even further to achieve ef[iciencies in your practice that automate processes critical to PCMH. * MU incentive money can help [inance PCMH efforts. 19

20 A Simple Comparison Meaningful Use Improve quality, safety, ef[iciency, & reduce health disparities Medical Home PPC1: Access and Communication PPC2: Identify/manage pt. populations Engage Patients and Families PPC3: Care Management PPC4: Self Care /Community Resouresc Improve Care Coordination Improve Population and Public Health Ensure Adequate Privacy & Security Protection for PHI PPC3: Electronic Prescribing PPC5 Test Tracking PPC5: Referral Tracking PPC6: Performance Rpt/Imprvmnt

21 What is Meaningful Use?

22 Adoption of EHRs CMS Incentives and penalties Meaningful Use of EHRs Improved individual and population health outcomes Increased transparency and ef[iciency Improved ability to study and improve care delivery Exchange of health information

23 Meaningful Use Stages

24 Stage 1 MU Requirements

25 YIKES!!! HOW DO WE LEARN HOW TO DO ALL THAT? 25

26 Office of the National Coordinator

27 Regional Extension Centers: Supporting Health IT Needs Assessment and evaluation of practice Operational work flow evaluation Vendor negotiations Implementation and project management Workforce training and development.

28 Beacon Communities 17 Beacon Communities in the United States Established by the Department of Health and Human Services Managed by the Office of the National Coordinator for Health Information Technology Goal: use Health Information Technology (HIT) and Exchange (HIE) to Improve care coordination increase quality of care slow the growth of health care spending Measures Quality Cost efficiency Population Health

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30 Health Center Controlled Networks Ø IT Project Management Strategic planning - HIPAA security management - Contract review - Turn-key IT department - Project management - Budget and staffing support Ø Training & Support Hardware and software support/help desk - Best practice implementation and support UDS training and support - Practice office management solutions - Extended hours support/help desk - 24 hour / 7 day service Ø Data Management Data security - Data storage - Data access, connectivity and portability Ø Meaningful Use Adoption Electronic health record - Electronic oral health record - Electronic behavior health record Ø Hosting Solutions Hosting - Clinical forms / provider templates - Disaster planning and recovery - System maintenance and upgrade - Business intelligence reporting - Database management 30

31 PCMH Transformation Strategies Ø Review available PCMH resources Ø Assess the current state of your practice using analytic assessment tools Ø Identify and energize key leaders to champion the PCMH transformation Ø Begin to ensure patient center focus by asking daily What would our patients think? 31

32 Barriers Fear Communication Status Quo Inadequacy Control (personal agendas) Inconsistencies Cost $$$

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35 Anna M. Gard, FNP-BC Association of Clinicians for the Underserved 35

36 PCMH Resource Catalogue PCMHResourceCatalogue.pdf 36