MAHEC Center for Quality Improvement PLEASE CREDIT MAHEC Center for Quality Improvement PLEASE CREDIT

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1 Having Technical Difficulties? An insider s introduction to PCMH for practices new to PCMH and those already engaged. Helpful background & context for providers and staff alike. Thursday June 23, :00pm-1:00pm To join webinar : Go to URL Dial in Number: (605) Conference ID#: # If you experience technical difficulties with the Webinar or with the conference call between 12 and 1pm please contact our Program Assistant, Carla Elliott Carla.Elliott@mahec.net Learning Objectives Cite at least 2 national groups (e.g. medical boards) who have endorsed the PCMH model Cite at least two sources of evidence for effectiveness of the PCMH model (e.g., clinical outcomes, cost, etc.) Describe the role of NCQA in PCMH recognition Describe the six major standards of the 2011 NCQA guidelines for PCMH recognition Demonstrate familiarity with key best practices and lessons learned, related to implementation of PCMH model and application for NCQA recognition MAHEC Center for Quality Improvement We are a team of professional consultants providing free onsite technical assistance to primary care practices in various areas including: EHR Adoption & Use Meaningful Use EHR Incentives Pay for Performance & Quality Improvement Patient Centered Medical Home (PCMH) Recognition Our Team Evan Richardson, CNM Quality Improvement Consultant Nina Vinson, MPH Department Director Terri Roberts, Masters Degree Curriculum, BA EHR Practice Support Consultant Rex McWilliams, Psy.D. EHR Technical Assistance Consultant Meeting the demands of primary care Paper Charts Learn how to: Assess the needs of your practice in an EHR system. Redesign your paper practice to ready for an EHR. Electronic Health Records Learn how to: Select a certified EHR that meets your needs Implement an EHR for optimal use in your practice Meaningful use of HIT Learn how to: Use your EHR to meet the federal requirement s for the HITECH Act Meaningful Use Incentive Payments from Medicare or Medicaid Improved Clinical Outcomes Learn how to: Produce population based reporting to test the efficacy of your care Use proven methods and techniques to improve the outcomes of your patients Patient Centered Medical Home Learn how to: Meet the requirements of the NCQA Recognition program for PCMH Approach the PCMH application process with improvement techniques 1

2 US Healthcare Compared The United States ranked 37th of 191 countries by the WHO "overall performance" in delivery of health care. National Health spending as a % of Gross Domestic Product* US In the "fairness" section of the WHO report -- that is, whether the best care was available equally in a country -- the US ranked 54 th A Commonwealth Fund study of access to medical care in 23 developed countries ranked the United States 23 rd In a joint study by Harvard Medical and Law Schools of the number of bankruptcies attributed to medical bills each year, the US total was approximately 700,000. France, Italy, Germany, Canada, and Japan had zero. * 17.2% is the current rate, totaling over $2.5 trillion Chronic Disease, Cost, Gaps in Care Almost half of patients in the United States have one or more chronic medical conditions (Anderson & Horvath, 2004) Of each dollar we spend on health care nationwide more than 75 cents -or about $1.7 trillion annually - goes toward the treatment of chronic illness. By 2023, the U.S. could save over $1 trillion in direct and indirect costs on seven of the most common chronic diseases by taking action to improve prevention and disease management. ( Forty-five percent (45%) of primary care patients did not receive evidence-based preventive & chronic illness services (McGlynn et al, 2003) Primary Care Workforce Between 1997 and 2005, the number of U.S. graduates entering family practice residencies dropped by 50% (NEJM 2006; 355: ) Many residents do not choose primary care due to perceived lack of prestige, income, encouragement from an advisor to switch, and/or the perception that family practice has an excessive breadth of content area to master. Also, lifestyle concerns (time for leisure, family and vocational pursuits, control of total weekly hours, etc.) The Medical Home: A Brief Historical Overview 1967 concept introduced by American Academy of Pediatrics 2007 American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, & American Osteopathic Association released the Joint Principles of the Patient-Centered Medical Home 2008 American Medical Association supports principles Not the same as gatekeeper model In a nutshell: current good care souped-up + more data-driven decision making Popularity & Evidence Medical homes have been tested in different incarnations for more than forty years.to date, there have been more than 100 demonstrations. (Health Affairs, 2010) Outcomes under review include clinical quality, cost, efficiency, patient experience & satisfaction, and provider experience & satisfaction Health care reform makes provision for many PCMH-esque pilots Blue Cross & Blue Shield (and many other payers) showing strong interest, many sponsored projects across the US. CMS Innovations Center Federal Agency for Healthcare Research & Quality (AHRQ) 2

3 Evidence: A Few Highlights In a recent review of over 7 major PCMH pilots, there was good evidence of reductions in hospital and ER use -as well as total cost savings (Health Affairs, 2010) The Seattle-based Group Health Cooperative saw improvements in patients experiences, quality, and clinician burnout as well as fewer hospitalizations, ER visits, and total cost savings (Health Affairs, 2010) Evidence shows that when racial and ethnic minorities receive care through the PCMH model, health disparities are reduced (Commonwealth Fund, 2007) Strong evidence that redesigning the practice of primary care to provide proactive chronic illness management may lead to improved care process and outcomes (Coleman, Mattke, Perrault, 2009) (Coleman et al, 2009) Pay for Performance $$$ A variety of pilots across the US have incentivized practices to adopt the PCMH model In NC, CMS Innovations Grant (7 rural counties, Multipayer Initiative ) requires PCMH recognition BCBS of NC - Blue Quality by invitation only, smaller independent practices up to 30% + in reimbursement for common procedures & services NCQA recognition is foundation/requisite, counts for majority of points Provider education/refreshers Web-based modules on cultural competency Chronic disease care refreshers; NC IPIP credit Accountable Care Organizations: How They Work Hosp Spec ACO PCP Coordinates care for shared patients Financial bonus from payers Improved Outcomes PCMH and MU and ACOs How can PCMH recognition make you ACO ready? How can quality improvement + data reporting tools and skills make you ACO ready? How is meaningful use (MU) a part of this? ACO Attributes Coordinates care for shared patients with the goal of meeting and improving on quality and cost benchmarks Hires an administrator and establish a formal legal structure to work with payers, monitor performance, and collect any shared savings Receives a financial bonus that is divided among its participants according to their agreement. No recognized ACOs yet. Hospitals/networks not only possible model. No duh basics such as good office operations, efficiency, revenue cycle management Providing efficient, quality care and proving it (data) Data reporting, report cards, Physician Compare Recognition Programs Is there more than one? Which should I choose? What are the differences? Is recognition really necessary? What if we are really a medical home already? Who is NCQA? National Committee for Quality Assurance Private, non-profit Most popular/known group for medical home recognition Like Joint Commission for ambulatory care Healthcare Effectiveness Data and Information Set (HEDIS) Four kinds of seals of approval: accreditation, certification, recognition, distinction The kind of seal you will receive depends on the program you participate in Accreditation programs for organizations include: health plans, disease management Provider based recognition programs include: back pain, diabetes, and heart/stroke Practice based recognition programs include: patient-centered medical home 3

4 NCQA Recognition the Basics PCMH=Patient Centered Medical Home Mid-level providers can/should be included Practice not provider based recognition Application nuts & bolts Download free copy of 2011 standards & information Buy the survey tool (~$80), like an online holding tank Upload documentation as gathered Complete application paperwork Pay fee (~$2580 for 5 providers), discounts in some cases Submit documentation for review, recognition good for 3 years Other Recognition Programs Joint Commission PCMH=Primary Care Medical Home Not as well recognized or relied upon (e.g., by payers) Who s eligible: any ambulatory care organization or practice that is seeking, or is already accredited under their ambulatory care manual. Do not have to be hospital owned/affiliated. Will launch July Other Recognition Programs Accreditation Association for Ambulatory Healthcare (AAAHC) Not as well recognized or relied upon (e.g., by payers) On-site surveyers URAC (Utilization Review Accreditation Commission) PCHCH=Patient Centered Health Care Home Not as well recognized or relied upon (e.g., by payers) What is this new model of care? What does it look like in practice? ENHANCED ACCESS PATIENT ACTIVATION SHARED DECISION MAKING COORDINATED AND INTEGRATED CARE POPULATION MANAGEMENT PRO- ACTIVE/PLANNING WHOLE PERSON ORIENTATION TEAM BASED CARE Personal care team for each patient leverages the traditional benefit of continuity of care Expanded role for clinical support and other office staff Providers direct the team with standing orders, protocols and procedures Increased training and delegation of tasks Clear role definition and job descriptions Regular team meetings and communication Everyone working at the fullest reach of their training and/or expertise POPULATION MANAGEMENT Use EHR as a data base for key patient information demographics, prevalent conditions, risk factors, clinical information, communication preferences and needs Optimize your EHR use for your population Develop templates and alerts to support patient specific care Use reports to identify care needs of your patients Develop patient education, specialty and community service referral lists, and communication resources around the needs of your patient population 4

5 QUALITY, SAFETY, IMPROVEMENT Organize care around evidence based guidelines Coordinate care Track specialty referrals and lab/test results Primary care Specialty contracts Focus on transitions of care and medication reconciliation Maintain integrity of and access to medical record Care Management for High Risk Population Electronic Rx with active alert systems Track quality outcome measures and use data to guide improvement efforts PATIENT ACTIVATION Patient self management support Patient-centered communication collaborative agenda and goal setting shared decision-making Orientation to the PCMH model and the patient s role Patient contracting Focus on cultural competency and health literacy PRO-ACTIVE Anticipate and organize care Pre-visit planning, huddles Assess demand cycles for care and be prepared to meet and restructure them, when possible Patient recall/reminder system for preventive care, chronic condition care, and high risk markers Use point of service alerts and reminders Provide patients with the right care in the right moment ENHANCED ACCESS Build and maintain capacity for same day appointments Use technology to improve communication with and access to practice Patient portal, , interactive website Provide language and communication interpreter services Offer alternative appointment formats E-visits and group medical visits After hours access to care and records NCQA 2011 Standards 1. PCMH 1: Enhance Access and Continuity 2. PCMH 2: Identify and Manage Patient Populations 3. PCMH 3: Plan and Manage Care 4. PCMH 4: Provide Self-Care Support and Community Resources 5. PCMH 5: Track and Coordinate Care 6. PCMH 6: Measure and Improve Performance LESSONS LEARNED FROM.. I3 PCMH Academic Collaborative (primary care residencies across the Southeast) Work With NC AHEC Enrolled Practices Who Have Achieved NCQA Recognition IHI, NCQA Conferences And Workshops 5

6 Take Time to Set Up the Project Identify a team Become familiar with the model and the standards Perform a self assessment Develop a time line that encompasses implementation of large and small changes strategies for documentation staff members involvement and responsibilities deadlines for submission Introduce Project to Practice Review the PCMH model for whole staff Allow them to ask questions Identify what will be expected of them Outline benefits of undergoing this change/effort Hold a Launch Event! Communicate regularly about status of project Bulletin board Staff meetings Promote staff buy in and involvement Be Realistic With Time Frame Depending on where you start in the process (based on self assessment) you should allow for a minimum of months for the NCQA application process This supports more sustainable change This will provide a solid foundation for continuing to build the infrastructure for the PCMH model Just getting recognized doesn t mean that you are functioning fully as a Patient Centered Medical Home An organization becoming a Patient Centered Medical Home is making a commitment to a system-wide transformation Celebrate and Provide Incentives Focus on successes Find opportunities to celebrate Helps keep focus around change positive and constructive Helps build team Helps motivate staff to take on extra work Supports and communicates a commitment to the model Build in incentives -- $, small gifts, recognition Bulletin board in office Celebrate and Provide Incentives Focus on successes Find opportunities to celebrate Helps keep focus around change positive and constructive Helps build team Helps motivate staff to take on extra work Supports and communicates a commitment to the model Build in incentives -- $, small gifts, recognition Bulletin board in office, recognition at staff meetings Use Application Process Wisely Other areas for improvement will be identified as you begin to assess your practice Important to focus on the key changes necessary for NCQA application first Use the parking lot concept to help you set aside the changes you want to address in the future The application process is not about being perfect, rather creating the infrastructure for handling change Keep it simple..plan to build on the changes as you mature in the PCMH model 6

7 Go For Sustainable Change Be wary of an approach that does not support real and sustainable change Partially or not effectively implemented change can put a greater stress on the system and lead to staff burn out and patient dissatisfaction Take time to support the process trying to rush through can leave you with an experience of chaos and lack of infrastructure for functioning as a PCMH Support Leaders Strong Project Management skills a key for successful application and implementation Consider ways to support leaders in having time to manage project well Administrative time for physician champion Support for PMs to have time to work on project Invest in software and technical support/training that can help with project Spreadsheet and word processing software Adobe and/or pdf conversion programs Template building and optimization of EHR NCQA Is An Important Resource NCQA provides FREE webinar and telephone conference training NCQA Free Training Programs Go here for link to pdf schedule of upcoming training programs related to PCMH Can ask questions of NCQA at pcmh@ncqa.org. May take some time to get a response. NCQA Free Training Programs Further down on page is series of links related to the different training programs. When you click on the individual items they open up with more information and in cases where the format is a telephone conference a copy of the program slides. A Few Good Tools and Websites Primary Care Development Corporation Interactive Self Assessment Tool age_id=8546&organization_id=128&&ord=595&allowo verwrite=true Medical Home Portal Project ARHQ (for PCMH specific resources) (for Clinical Practice Guidelines) 7

8 Resources from Professional Boards American Academy of Pediatrics CME available for PCMH Implementation Training American Academy of Family Physicians ives/pcmh.html American College of Physicians American College of Obstetrics and Gynecology =19&bulletin=5203 Onsite Consultation, Free! MAHEC Center for Quality Improvement FREE consultation services to primary care practices applying for PCMH recognition Team offers a range of skills related to effective implementation of the model, including EHR Implementation and Optimization Data Reporting Continuous Quality Improvement Skills/Tools Resources and practice collaboration efforts Enroll at Feedback? Questions? R. Evan Richardson, CNM Quality Improvement Consultant (cell) (office) Evan.Richardson@mahec.net Nina B. Vinson, MPH Director (office) (cell) Nina.Vinson@mahec.net Center for Quality Improvement Mountain Area Health Education Center (MAHEC) 501 Biltmore Avenue Asheville, North Carolina