PCMH: Recognition to Impact

Transcription

1 PCMH: Recognition to Impact Prepared by: Shannon Nielson, MHA, PCMH CCE Prepared for: OACHC 2016 Annual Conference Centerprise, Inc

2 Objectives Defining a Patient Centered Medical Home Translating PCMH Concepts to a Population Health Strategy Expected Outcomes from Recognition Understanding the key changes from 2011 to 2014 NCQA Application

3 PCMH What is it? A way of organizing primary care that emphasizes care coordination and communication to transform primary care into what patients want it to be. Medical homes can lead to higher quality and lower costs, and can improve patients and providers experience of care (NCQA) Theoretical Task Based Practice Internal Practice Process CTP Definition of a PCMH: A series of processes and tasks that can result in an unspecified improvement in your patient s health

4 PCMH What it should mean to you A way of organizing primary care that practices accessibility, coordination, effective processes that transform primary care into what the population needs. Medical homes will lead to higher quality and lower costs, and will improve a population s health and provider s experience of care (as defined by Centerprise, Inc) Practical Longitudinal Efficiency Population Focused CTP: Your PCMH recognition demonstrates you have the core capability to put into effect efficient and effective processes that will result in a specified impact on the health of a population when in practice and sustainable. Transformation of Capability to Sustainable Practice

5 Process Recognition to Purpose Outcomes Roles IT Experience Cost

6 PCMH Concept: Application to Meaning 1A3. Availability of Appointments What appointment types do you have? How long does a patient have to wait for each appointment type? Are you meeting internal standards? Appropriate Availability of Appointments How do you know if you have the right appointment types for your population? Do you have the appropriate appointment types for your population? Do you have the appropriate appointment availability to meet the needs of your population?

7 PCMH Concept: Strategy 1A3: Availability of Appointments 3NA Report Schedule Template Internal protocols determined by historical data Templated same day access Appropriate Availability of Appointments Measure inappropriate utilization of appointment types Monitor appointment requests by population Understand provider specific patient population needs and demands

8 PCMH Concept: Process to Impact 1A3: Availability of Appointments 1A3: Appropriate Availability of Appointments Why is 3NA for ER/Hospital F/U > 7 days? Provider specific high utilization? Disease specific high utilization? Care Coordination activities? Appropriate vs. inappropriate utilization What is the true demand for New Patients versus availability? Why did you define at 14 days? What is the new patient demand? What is the demand from managed care enrollment lists? Does access within 7 days show better outcomes? Decrease in hospital readmission/ed Utilization? Care Coordination engagement

9 PCMH Concept: Application to Meaning 4E: Support Self Care and Shared Decision Making Do you have at least 3 educational materials in your office? Do you have at least 3 self management tools in your office? Do you have at least 3 shared decision making aids in your office? Do you refer patients to peer support or health education? 4E: Support Self Care and Shared Decision Making to engage patients resulting in improved outcomes Are the educational materials in my office relevant to the needs of my population? Are the self management tools in my office relevant to the needs of my population? Are the shared decision making aids relevant to the needs of my population? Do the tools mirror my organization s evidence based guidelines? Do I refer my patients to effective peer support or health education resources? Do I provide tools that are easy to understand? Do my patients utilize the tools that I give them?

10 PCMH Concept: Strategy 4E: Support Self Care and Shared Decision Making Tools Educational Materials Shared Decision Making Effective Community Resource referrals 4E: Support Self Care and Shared Decision Making to engage patients resulting in improved outcomes Care Team assessment of tools needed by relevant population Tracking of populations with tool implementation Re assessment of tools and population for relevance

11 PCMH Concept: Process to Impact 4E: Support Self Care and Shared Decision Making 4e: Support Self Care and Shared Decision Making to engage patients resulting to improved outcomes New BMI Plan

12 PCMH Concept: Application to Meaning 3D3: At least 3 different chronic or acute care services A list of patients in need of 3 different services An actual patient letter or script AND documentation of the call Explanation of service 3D3: At least 3 different chronic or acute care services to improve access to care for existing patients and assigned patients What services are relevant to my patient population? Are missed services leading to poor health outcomes? Do I have all the information I need to know if they have missed a service? What services are in demand for my assigned patient population?

13 PCMH Concept: Strategy 3D3:At least 3 different chronic or acute care services Evidence Based Guidelines EMR/PHM/Patient Portal Automated outreach 3D3: At least 3 different chronic or acute care services to improve access to care for existing patients and assigned patients Population stratification EMR documentation Managed Care enrollment lists Available access Opportunity for education

14 PCMH Concept: Process to Impact 3D3: At least 3 different chronic or acute care services Providing quality care through service reminders Improving access to care for patients Intermittent 3D3: At least 3 different chronic or acute care services to improve access to care for existing patients and assigned patients Continuous access to services Improved health outcomes for existing patients Improved access to primary care for assigned population Decreased cost, improved outcomes, improved patient experience and improved provider experience

15 You know you have done PCMH right when You are having to adjust schedules regularly to meet the change in demand Your patients contribute to the conversation Provider orders (labs, imaging, referrals etc ) are effective You understand and monitor the risk of your patients and can illustrate an impact Your patient knows who their Care team actually is Your data tells a story a good one

16 NCQA PCMH 2011 to 2014

17 Key Conceptual Changes 2011 Data Inform the patient Requirements Clinical Process 2014 Meaningful Data Engage the patient Practical Clinical and utilization Purpose

18 Conceptual Changes: Examples 2011 Access: Same Day; 3NA Provide educational tools and selfmanagement plan Reason for referral and clinical information in tracking log Clinical and Patient Satisfaction data NA 2014 Access: Same Day; 3NA aligned with internal standards Utilize shared decision making tools Logs OR demonstrating electronic capability and providing information to specialists Clinical, Patient Satisfaction and CC/Utilization data Data on specialists you refer to

19 Key Application Changes Alignment with Modified MU Stage 2 rule Corporate elements Care Management Audit Team Based Care Standard Population Health Management

20 Key Application Changes: Standard 1 Access Availability of all appointment types in alignment with practice standards After hours and during hours call logs combined Access data and improvement work No show data; appointment statistics Alternative types of clinical encounters

21 Key Application: Standard 2 Team Based Care Moved from 1G (2011) to Standard 2 (2014) Orient new patients Medical Home Responsibilities expanded Operations Meetings Involving patients in QI activities (Standard ) Care team structure

22 Key Application Changes: Standard 3 PHM Comprehensive Health Assessment documentation changes now part of the RRWB or Report Health literacy Outreach services includes Immunizations separate from preventive Evidence Based Decision Support Mental Health or Substance use disorder Chronic Medical Condition An Acute Condition A Condition Related to Unhealthy Behaviors Well Child or Acute Cae Overuse/Appropriateness Issues

23 Key Application Changes: Standard 4 Care Management and Support Patient populations for Care Management Registry Behavioral Health Conditions High Cost/High Utilization Poorly Controlled or Complex Conditions Social Determinants of Health Referrals by Outside Organization Lifestyle Goals Understanding of medications Care Management factors are fewer but don t forget about 3C!!! Shared Decision Making aids Usefulness of community resources

24 Key Application Changes: Standard 5 Care Coordination and Care Transitions Documentation for all tracking: Logs or OTHER capability Performance information on specialists Agreements with providers Consent for release of information

25 Key Application Changes: Standard 6 Performance Measurement and Quality Improvement Immunization measures separate from preventive measures (2) Resource use and Care Coordination measures (2 each) Improvement: 2 clinical 1 utilization/care coordination 1 pt. experience

26 How you should approach PCMH Pop Health Data Inform the patient Requirements Clinical Process Meaningful Data Engage the patient Practical Clinical and utilization Purpose Information Integrate the patient Efficient Clinical, Utilization, Cost Process, Purpose and Impact

27 Where to begin your PCMH to PHM journey: 2A2 Monitoring the percentage of patient visits with selected clinician or team NCQA PCMH 2014 Requirement %age of visits with patient s PCP Relevance to remaining application requirements and successful PHM What is your provider panel size? What is the capacity of each provider today? What are your care teams? How are you utilizing your providers to optimize access? Is over utilization leading to fewer empaneled visits? Consistent care leads to improved patient satisfaction How can we use our managed care lists?

28 Questions