Medical Home: How does it intersect with genetics?

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1 Medical Home: How does it intersect with genetics? Ingrid Larson BA, MSN, MBA, RN, CPNP Learning Session 2 November 8-9,

2 Disclosure I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/ investigative use of a commercial product/device in my presentation. NOTE: Some of the slides were adapted with permission from a slide deck provided by Michelle Haley, MD at Children s Mercy Hospital 2 2

3 Objectives Review the patient centered medical home (PCMH) model and define the need for the CYSHCN population Review the basic components of the medical home model, including NCQA PCMH recognition Discuss how the GPCI QuIIN project fits with this model 3 3

4 PCMH History 1967: Concept first introduced by the AAP 2001: The IOM s Crossing the Quality Chasm: A New Health System for the 21 st Century patient centered 2002: AAP policy statement with components defined 2007: Joint Principles of the Patient-Centered Medical Home is put forth by the AAP, AAFP, ACP, and AOA 4 4

5 PCMH Building Blocks Personal provider Provider directed practice Whole person orientation Coordinated care Quality and safety Enhance access Payment reform 5 5

6 PCMH Components AAP Accessible Family-centered Continuous Comprehensive Coordinated Compassionate Culturally effective NCQA Primary care providers Practice team Defined roles Regular team meetings Standing orders Training for Coordination of care Self-management Communication skills 6 6

7 PCMH Participants Primary care provider Family Child / youth Nurses and allied health care professionals Family s community Pediatric office staff If necessary, pediatric sub-specialists 7 7

8 PCMH Process Care Teams (providers, nurses, care assistants, scheudlers, RT, social work Empanelment Changed schedules / increased access Pre-visit planning / standing orders Data monitoring Clinically important conditions (preventive, acute, cost) Follow-up phone calls ER / UCC and inpatient 8 8

9 What does PCMH do? Research shows: Fewer ER visits Fewer hospital readmissions Fewer inpatient admissions Lower per capita cost Estimated cost savings Improvement in medication management Care coordinator positions hired 9 9

10 IHI Triple Aim Improving the patient experience of care (including quality and satisfaction); Improving the health of populations Reducing the per capita cost of health care

11 PCMH Transformation Current Care Model Reactive Physician Centered Fragmented Address reason for visit only My patients are those that have an appointment today Patients are responsible to coordinate their own care PCMH Model Proactive Patient Centered Coordinated Care determined by proactive plan Our patients are those that are registered in our medical home A prepared team coordinates all patient s care 11 11

12 Who can PCMH serve? Everyone But especially Children and Youth with Special Health Care Needs (CYSHCN) 12 12

13 CYSHCN definition The share of children under age 18 who are at increased risk of a chronic physical, developmental, behavioral, or emotional condition, and who also require health and related services of a type or amount beyond that required by children generally. More than 12 million U.S. children meet the definition of CYSHCN Source: Maternal and Child Health Bureau 13 13

14 CYSHCN Need Approximately 40,000 CYSHCN in the United States, or 13% of children, have a special health care need. Approximately 1 out of 5 homes in the United States has a child or youth with special health care needs 14 14

15 CYSHCN across the U.S

16 CYSHCN Financial Reality CYSHCN alone account for 80% of pediatric health care expenditures Annual cost of providing medical care to CYSHCN Hospitalization: 61% Specialists: 14% Durable medical equipment: 5% Primary care: 5% Other: 15% 16 16

17 CYSHCN Reality for families 39.5% indicate their child s or youth s condition impacts family s financial situation 13.5% say they spend 11+ hours/wk coordinating care for their child or youth 24.9% indicate families cut back on work due to child s or youth s condition 28.5% indicate families stop working due to child s or youth s condition 17 17

18 CYSHCN Reality for practices Time Clinical evaluation Record reviews Patient/Family counseling and education Coordination of services Clinic Environment / Resources Physical clinic space / accessibility Staffing / personnel comfort and training Electronic resources and documentation Unfamiliarity with the patient / family Reimbursement 18 18

19 Changing health care climate In response to health care reform, the medical home model has been presented as the answer to the delivery of primary care Image from Oakland Physician Network Services 19 19

20 PCMH NCHA Recognition 20 20

21 Who s already a NCQA PCMH 4,937 sites & 23,396 clinicians as of 10/31/2012 WA OR NV CA AK ID AZ UT MT WY CO NM ND SD NE KS OK TX MN WI IA IL MO AR MS LA MI OH IN KY TN ME VT NH NY MA CT RI PA NJ DE WV VA MD NC SC 0 sites AL GA 1 20 sites sites FL sites HI 201+ sites Source: Analysis by the National Committee for Quality Assurance, Oct

22 NCQA PCMH Standards 2011 Core Components Enhance Access and Continuity Identify and Manage Patient Populations Plan and Manage Care Provide Self-Care and Community Support Track and Coordinate Care Measure and Improve Performance Must Pass Components Access during office hours Use data for population management Care management Support self-care process Track referrals and followup Implement continuous quality improvement 22 22

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