11/7/2016. Objectives. Patient-Centered Medical Home

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1 Team-Based Care November 10, 2016 Objectives Overview of Patient-Centered Medical Home (PCMH) Recognition Overview of PCMH Team-Based Care Discuss examples of practice teams in Montana health centers Source: Patient-Centered Medical Home A model of care that emphasizes care coordination and communication to transform primary care into what patients want it to be. Source: 1

2 Patient-Centered Medical Home Recognition The most widely adopted model for transforming primary care practices into medical homes. 3 different levels, Level 3 is the highest level of recognition 6 Standards, 179 measures Points-based system Defining the Medical Home The medical home is an approach to primary care that is: Person-Centered Supports patients and families in managing decisions and care plans Comprehensive Whole-person care provided by a team Coordinated Care is organized across the medical neighborhood Committed to Quality and Safety Maximizes use of health IT, decision support and other tools Accessible Care is delivered with short waiting times, 24/7 access and extended in-person hours Source: Changing to a new Paradigm Today Treating Sickness / Episodic Fragmented Care Specialty Driven Isolated Patient Files Utilization Management Fee for Service Payment for Volume Adversarial Payer-Provider Relations Everyone For Themselves Future Managing Populations Collaborative Care Primary Care Driven Integrated Electronic Records Evidence-Based Medicine Shared Risk/Reward Payment for Value Cooperative Payer-Provider Relations Joint Contracting 2

3 Patient-centered care associated with better processes of care and better health outcomes Patients with positive patient experience are: More likely to follow physicians advice and medication regimens More likely to stay with their primary care provider (improved loyalty and retention) Less likely to file malpractice complaints More likely to report better outcomes post hospital discharge, if their ambulatory care experience was positive Often more likely to receive better process of care (e.g., preventive care screening, chronic disease management) Sources: I. Wilson et al. (2005) Cost-Related Skipping of Medications and Other Treatments Among Medicare Beneficiaries Between 1998 and Journal of General Internal Medicine; A. M. Fremont et al., (2001) Patient-centered Processes of Care and Long-term Outcomes of Acute Myocardial Infarction. Journal of General Internal Medicine. 14:800 8; K. Browne et al. (2010). Primary Care Analysis & Commentary Measuring Patient Experience As A Strategy For Improving Primary Care. Health Affairs. 29(5). PCMH Standards Standard 1: Patient-Centered Access (3 Elements,10 points) Standard 2: Team-Based Care (4 Elements,12 points) Standard 3: Population Health Management (5 Elements,20 points) Standard 4: Care Management and Support (5 Elements,20 points) Standard 5: Care Coordination and Care Transitions (3 Elements,18 points) Standard 6: Performance Measurement and Quality Improvement (7 Elements,20 points) Source: UCSF Center for Excellence in Primary Care. 3

4 PCMH uses diverse empowered care teams Care coordinators Patient navigators Health coaches Peer support Care managers Behavioral health/mental health Community supports and social workers Pharmacists Patients, families & Caregivers Hold care team meetings or a structured communication process to focus on individual patient care (CF) Informal daily meetings Review daily schedules with follow-up tasks Structured communication process including the clinician or team leader Use standing orders E.g., testing protocols, defined triggers for Rx orders, vaccinations Emphasis is on on-going interactions of the team to: Understand each member s role Define each team member s responsibilities Provide efficient and sufficient communication Provide effective patient-hand off Ultimately, working together to enhance the care provided to patients 4

5 Training and assigning care team members to: Coordinate care for individual patients Support patients in selfmanagement, selfefficacy and behavior change Manage the patient population Examples Team meetings or structured process Huddles Structured chart review process by team on scheduled pts using protocols or checklists for chart information to review Standing Orders - Many standing orders can enhance team function, and removing load from clinician for routine items Examples Different members can have differing functions, Examples- MA assist with population management and outreach RNs do high risk care management by collaborating with providers and using protocols for chronic illnesses Pharmacists help with high risk patient transfers, med reviews; patients with chronic disease not reaching goals (Hypertension, high A1cs, complex behavioral health issues) Scheduled meetings- team practice Monthly or quarterly meetings to review processes of team practice- what is working,what is not, mapping out situation, analyzing, reworking if needed, continual work to maintain high functioning team Practice team always evolving 5

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