Welcome to today's Healthcare Web Summit Event. Patient-Centered Medical Home: Transforming Care into Outcomes

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1 Welcome to today's Healthcare Web Summit Event Patient-Centered Medical Home: Transforming Care into Outcomes Faculty: Paige Cooke, Manager of External Relations, Clinician Recognition Programs, NCQA, Shawn Tester, COO/CIO, Ammonoosuc Community Health Services and Sue Feury, Product Marketing Manager, GE Healthcare To listen to the audio portion of this live presentation, please reference your dial-in instructions. Should you experience any technical difficulties with the web portion of this presentation, a pdf version of the slides may be accessed at: For any other assistance during the live event, contact us at or clairet@mcol.com.

2 Patient-Centered Medical Home: Transforming Care into Outcomes Healthcare Websummit Webinar September 18, PM ET Sponsored by: GE Healthcare

3 General Electric reserves the right to make changes in specifications and features, or discontinue the product or service described at any time, without notice or obligation. This does not constitute a representation or warranty or documentation regarding the product or service featured. Illustrations are provided for informational purposes, and your configuration may differ. This information does not constitute legal, financial, coding, or regulatory advice in connection with your use of the product or service. Please consult your professional advisors for any such advice. Operation of GE Healthcare products should neither circumvent nor take precedence over required patient care, including human intervention of healthcare providers. GE Healthcare products and services do not code medical procedures. Accurate coding is the responsibility of the provider or billing professional. GE, the GE Monogram, Centricity and Imagination at Work are trademarks of General Electric Company General Electric Company All rights reserved.

4 Portions of this presentation and the content herein are the opinions and experiences, and represent the views, of the specific authors and presenters and are not statements of advice, opinion or information of GE Healthcare. These portions of the presentation have not been prepared, screened, approved, reviewed or endorsed by GE Healthcare.

5 Pat ient -Centered Medical Home: Transforming Care into Outcomes 1. NCQA s perspective on PCMH What it is, why it is successful, and how to become one. 2. Ammonoosuc Community Health Services A study in data-driven care at a Level 3 PCMH. 3. Centricity Practice Solution Tools to help you transform into a PCMH. 4. Q&A

6 Today s speakers: Paige Cooke Manager of External Relations, Clinician Recognition Programs and ACO Accreditation Program NCQA Shawn Tester COO / CIO Ammonoosuc Community Health Services Sue Feury Product Marketing Manager GE Healthcare

7 The Patient Centered Medical Home Movement: An NCQA Perspective September 18, 2013

8 NCQA Mission Improve the quality of health care through: Measurement Transparency Accountability 8

9 NCQA RECOGNITION PROGRAMS >44322 Clinician Recognitions nationally across all Recognition programs Clinical Programs Diabetes Recognition Program (DRP) Heart/Stroke Recognition Program (HSRP) Back Pain Recognition Program (BPRP) - Retiring * As of 8/31/13 Standards-Based Programs Physician Practice Connections - Retiring Physician Practice Connections-Patient-Centered Medical Home (PPC-PCMH) 2008 Patient-Centered Medical Home (PCMH) 2011 Patient centered Specialty Practice (PCSP) clinicians* 3993 clinicians* 64 clinicians* 409 clinicians* 32 practices* 90 practices* clinicians* 6037 practices* PCSP *New* 73 Early Adopters NCQA s Patient-Centered Medical Home (PCMH)

10 What is the Patient-Centered Medical Home & Current Landscape?

11 Opportunities Targeted by Medical Home Standards Source: Nace, D. iht2 Conference Proceedings. May 12, 2010 NCQA s Patient-Centered Medical Home (PCMH)

12 PCMH Development History PCMH incorporates Joint Principles Whole-person care that is coordinated, integrated and comprehensive providing a patient-selected clinician that offers team-based care support. Validate measures by relating them to clinical performance and patient experience reporting NCQA s Patient-Centered Medical Home (PCMH)

13 PCMH Model Framework Encourage behaviors that improve outcomes and reduce cost Access & Continuity of Care Expanded hours and/or care delivery pathways Deliver team-based care Population Management Identify chronic and high-risk populations Deliver evidence-based care Remind patients of preventive and chronic services Care Management Deliver team-based care Pre-visit planning, care planning during visit, medication management Includes mental health/substance abuse/behaviors affecting health Care-Coordination Information to/from specialists/facilities/patient, update care plan Self-Care & Community Resources Ensure patients understand their role and responsibilities as a member of the medical home and ensure resources to maintain good health are provided Quality Improvement Measure performance and patient experience 13

14 PCMH Early Findings Medical homes have yielded promising results ED visits Hospitalizations Cost of care Source: Nace, D. iht2 Conference Proceedings. May 12, Reimbursement Practice efficiency Provider satisfaction Patient satisfaction NCQA s Patient-Centered Medical Home (PCMH)

15 Summary of PCMH Research Today Predominantly industry reports vs. peer-reviewed articles Two Primary Narratives: PCMHs lead to improvements in quality, cost and or patient satisfaction (seeing more) Devries et. al, Impact of Medical Homes on Quality, Healthcare Utilization, and Costs, American Journal Managed Care, 2012;18(9): Raskas et al, Early Results Show WellPoint s Patient-Centered Medical Home Pilots Have Met Some Goals For Costs, Utilization, And Quality, Health Affairs, September 2012 We don t know enough about the model, or results are inconclusive (seeing less) Peikes et al, Early Evidence on the PCMH, Prepared for AHRQ, February 2012 NCQA s Patient-Centered Medical Home (PCMH)

16 Keys to a Successful PCMH Leadership Motivation to Change Commitment to Quality Improvement Practice Culture team and patient-centered mentality Change process capability Resistance (barrier) Health Information Technology Functional and integrated EHR/registry Inter-operability with local hospitals and other providers NCQA s Patient-Centered Medical Home (PCMH)

17 Keys to a Successful PCMH Formal Approach to Quality Improvement Quality of care indicators, patient experience PDSA and other methods to make change Feedback to providers Team-based Care Training Delegation (e.g. standing orders) Utilizing staff to the maximum potential of license Resources Financial Technical assistance for application Learning Collaborative/On-Site Coaching (PCMH-CCE) NCQA s Patient-Centered Medical Home (PCMH)

18 NUMBER OF PPC-PCMH & PCMH CLINICIAN RECOGNITIONS BY STATE WA OR NV CA ID AZ UT MT WY CO NM ND SD NE KS OK MN IA MO AR WI IL *As of 8/31/13 MI NY PA OH IN WV VA KY NC TN SC VT NH ME MA RI CT NJ DE MD TX LA MS AL GA 0 Recognitions 1-20 Recognitions AK FL Recognitions HI PPC-PCMH CLINICIAN RECOGNITIONS Recognitions 201+ Recognitions NCQA s Patient-Centered Medical Home (PCMH)

19 Support Behind NCQA s PCMH Recognition Program Contributes to Success

20 Why Does the NCQA s Medical Home Program Succeed? 1. It s practical. 2. It s evidence based. 3. It s collaborative. 4. It s flexible. 5. It addresses/solves a problem. NCQA s Patient-Centered Medical Home (PCMH)

21 If the PCMH Model Is So Successful, Why Aren t All Practices Seeking Recognition? Financial Limitations EMR reporting capabilities/inclusion of Population Health Management Tools Limited staff support for case management Practice Transformation Challenges Staff Re-training Maintaining same level of care while undergoing transformation efforts Cooperation of transfer of communication on patient care outside of the Medical Home Changing the status quo NCQA s Patient-Centered Medical Home (PCMH)

22 Organizations Supporting PCMH EMR Vendors EMR vendors are getting certified to meet Meaningful Use requirements and aligning system capabilities to meet the requirements of the PCMH State-Based Initiatives Organizations like health plans and medical societies in over 35 states support medical home transformation (and NCQA Recognition) through incentive payments, learning collaborative and other activities Medical Societies A number of state medical societies are working as medical home consultants and funding learning collaborative trainings for their members Health Plans Health Plans are providing P4P rewards, technical assistance, preferred provider sites and care mgmt support for practices transforming into medical homes NCQA s Patient-Centered Medical Home (PCMH)

23 Sampling of Health Plans Offering Financial & Other Incentives Associated w/ NCQA PCMH Recognition (Not All Inclusive) Aetna Cigna Anthem/WellPoint Kaiser UHC BCBS of NC BCBS of SC BCBS of AL BCBS of LA BCBS of FL BCBS of TN BCBS of GA BCBS of DE BCBS of RI BCBS of ID Horizon (NJ) Empire (NY) Emblem Health (NY) Medical Advantage Group (MI) Priority Health (MI) L.A. Health Care Plan (CA) Wellstar Health System (GA) Excellus BCBS (NY) Independence BCBS (PA) Highmark (PA) CareFirst (MD, DE, DC) Rocky Mountain Health Plan (CO) Summacare (OH) Amerigroup Corporation NCQA s Patient-Centered Medical Home (PCMH)

24 Sampling of Initiatives in States Using NCQA PCMH California - Coalition of Orange County Community Health Centers Colorado HealthTeamWorks Multi-payer Pilot (CPCi); Multi-payer Advanced PCP Demo Connecticut - Connecticut Primary Care Glide Path Program Delaware Medical Society of Delaware PCMH Initiative (Highmark) Florida Medicaid Medical Home Task Force (endorsing NCQA still pending w/ current support: BCBSFL, MDVIP) Georgia Georgia AFP and Pediatric Health Improvement Coalition (PHIC) Idaho Idaho Medical Home Collaborative Kansas Kansas AFP PCMH Initiative (Kansas Health Foundation, Pfizer, Sunflower, BCBS of KS) Kentucky Greater Louisville Medical Society Louisiana DHH -Louisiana Health Care Quality Forum, LPCA Maine Patient Centered Medical Home Pilot Maryland Maryland Health Care Collaborative (MHCC) +1 Model Massachusetts State Medicaid PCMH Initiative/MassGen: Partners Healthcare Missouri Missouri Medical Home Collaborative (Wellpoint & UHC) Montana - PCMH Montana Project New Hampshire Citizens Health Initiative New Jersey NJ Medicaid Medical Home Pilot (NJAFP) New York State Medicaid, PCIP; NYS Health Foundation; NYS Hospital Medical Home Demo North Carolina Community Care of North Carolina (N3CN)/BCBS of NC Ohio PCMH Education Pilot Project Oregon Patient Centered Primary Care Home (PCPCH) +1 Model Pennsylvania Chronic Care Initiative, Phase II includes Medicare Rhode Island Chronic Care Sustainability Initiative (CSI- RI) South Carolina South Carolina Department of HHS (BCBS of SC) Washington - State Medicaid Medical Home Initiatives Reviewing NCQA PCMH Recognition Programs Vermont - Blueprint for Health Wyoming Wyoming Health Care Innovation Award (DOH, CMS, Transformed) NCQA s Patient-Centered Medical Home (PCMH)

25 How to Begin the Journey Towards Becoming a Recognized NCQA PCMH

26 NCQA Roadmap for Success Start to Finish NCQA s Patient-Centered Medical Home (PCMH)

27 NCQA Recognition Practice submits documentation and reporting exhibiting its ability to meet NCQA Standards & Guidelines NCQA issues decision on recognition status and level Level 3 Level 2 Level 1 Level depends on demonstrated performance and current practice capabilities: 6 Standards 28 Elements (6 must-pass) 152 Factors NCQA s Patient-Centered Medical Home (PCMH)

28 PCMH Scoring 6 standards = 100 points 6 Must Pass elements Level of Qualifying Points Must Pass Elements Level of 6 Level of 6 Level of 6 Not Recognized 0-34 < 6 Practices with a numeric score of 0 to 34 points and/or achieve less than 6 Must Pass Elements are not Recognized. NCQA s Patient-Centered Medical Home (PCMH)

29 2011 PCMH Content and Scoring Standard 1: Enhance Access and Continuity A. Access During Office Hours** B. After-Hours Access C. Electronic Access D. Continuity E. Medical Home Responsibilities F. Culturally and Linguistically Appropriate Services G. Practice Team Standard 2: Identify and Manage Patient Populations A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. Use Data for Population Management** Standard 3: Plan and Manage Care A. Implement Evidence-Based Guidelines B. Identify High-Risk Patients C. Care Management** D. Medication Management E. Use Electronic Prescribing Pts Pts Pts Standard 4: Provide Self-Care Support and Community Resources A. Support Self-Care Process** B. Provide Referrals to Community Resources Standard 5: Track and Coordinate Care A. Test Tracking and Follow-Up B. Referral Tracking and Follow-Up** C. Coordinate with Facilities/Care Transitions Standard 6: Measure and Improve Performance A. Measure Performance B. Measure Patient/Family Experience C. Implement Continuously Quality Improvement** D. Demonstrate Continuous Quality Improvement E. Report Performance F. Report Data Externally G. Use of Certified EHR Technology Pts Pts Pts **Must Pass Elements 30

30 2011 PCMH Content and Scoring: Areas Where an EMR Can Help Standard 1: Enhance Access and Continuity A. Access During Office Hours** B. After-Hours Access C. Electronic Access D. Continuity E. Medical Home Responsibilities F. Culturally and Linguistically Appropriate Services G. Practice Team Standard 2: Identify and Manage Patient Populations A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. Use Data for Population Management** Standard 3: Plan and Manage Care A. Implement Evidence-Based Guidelines B. Identify High-Risk Patients C. Care Management** D. Medication Management E. Use Electronic Prescribing Red indicates where EMR can help Pts Pts Pts Standard 4: Provide Self-Care Support and Community Resources A. Support Self-Care Process** B. Provide Referrals to Community Resources Standard 5: Track and Coordinate Care A. Test Tracking and Follow-Up B. Referral Tracking and Follow-Up** C. Coordinate with Facilities/Care Transitions Standard 6: Measure and Improve Performance A. Measure Performance B. Measure Patient/Family Experience C. Implement Continuously Quality Improvement** D. Demonstrate Continuous Quality Improvement E. Report Performance F. Report Data Externally G. Use of Certified EHR Technology Features of EMR that help: Portal & secure messaging Reporting on Structured data Clinical decisionsupport Pts Pts Pts E-prescribing/ Drug-drug interactions Collaboration tools Referral tracking Workflow Assessment/ Gap Analysis 31

31 What is Automatic Credit? For meeting requirements that are previously met in another NCQA program, and may be met by another entity NCQA PCMH Prevalidation provides automatic credit that can be conveyed to practices for scored factors where the technology solution completely meets a factor s requirements NCQA ACO Accreditation provides automatic credit for the Primary Care Elements (PC1 and PC2) if a minimum number of ACO members are cared for in NCQA PCMH Recognized primary care practices by their clinicians NCQA s Patient-Centered Medical Home (PCMH)

32 PCMH Prevalidation Program NCQA s Patient-Centered Medical Home (PCMH)

33 NCQA Resources Help You Get Started NCQA s Website Participate in Free Monthly Trainings! (calendar found on website) Getting On Board PCMH Start to Finish Standards Review (2 Part Program) Using the ISS Tool (Uses for Self-Assessment) How to Complete the Online Application and Submit as a Multi-Site View Recorded Record Review Workbook Tutorial View Frequently Asked Questions and Materials Contact Us at PCMH@Ncqa.org Ask about interpretation of standards or elements Request technical assistance with the application process Ask about Prevalidation for Autocredit Review List of PCMH Certified Content Experts: NCQA s Patient-Centered Medical Home (PCMH)

34 Ammonoosuc Community Health Services (ACHS): A study in data-drive care 1. ACHS s journey 2. The importance of collaborative care 3. Population management and continuous improvement 4. Benefits of the PCMH model

35 Ammonoosuc Community Health Services Ranked among top 26 FQHCs nationwide for patient outcomes in 2009 Recognized as Level 3 PCMH in 2009 Re-certified as Level 3 PCMH in 2012 Why PCMH? It just makes sense. Because we already provide care that way! EMR facilitates tracking, reporting, and improvement. Integrated care already in place. Patient-centered model provides the tools for healthy living. Community Health Center in Rural NH 1975 Founded in Littleton, NH FQHC Adopt EMR 2009 PCMH Level 3 Today 17 providers 5 locations 10,000 patients 30,000+ encounters/yr

36 New Hampshire Citizens Health Initiative Multi-stakeholder Medical Home Pilot 9 sites in NH Launched in 2008 as 2-3 year study Key non-clinical stakeholders include: NH Medicaid, MVP health, Anthem Blue Cross/Blue Shield, Harvard Pilgrim Health, Cigna.

37 The Importance of Collaborative Care

38 Traditional Care Model. See Patient Order Tests Provider Wait for results Prescribe meds

39 vs. Team-Based Care Director of Patient Services Information Systems Patient accounts Administration Support staff Care delivery team The Patient Care Model Team Doctor Clinical Support Front desk Behavioral Health Patient Navigators Doctors Behavioral Health Support staff

40 Empowering Care teams Reconfigure staff into care-delivery teams. Patients assigned to provider panels. Incentivize team-based care. Facilitate team engagement. Regular meetings & morning huddles Optimize space to improve workflow Seating arrangements that enable teamwork Support structure

41 Key elements of Collaborative Care Patient navigators Integrated Health Services Care model team

42 Patient Navigators Supports patient with nonclinical assistance & Social issues Coordinate human services programs. Access affordable medications. Break down barriers to quality healthcare.

43 Success story: Integrated Behavioral Health Primary Care and Behavioral Health collaborate to enhance outcomes: PCP leverages the PHQ-9 template to assess depression, integrated in the EMR. Communicate via flags and notes Track progress in same chart Share Patient Navigator EMR is helpful: One chart Collaboration tools Results in improved care, better outcomes.

44 The Care Model Team A Cross section of Healthcare professionals Focused on patient population health Monthly meetings to discuss best practices & develop patient engagement protocols. Tightly coordinated with EMR administrator.

45 Population Management and Continuous Improvement

46 What is Data-driven care? Continuous Improvement Identify population Analyze Data Brainstorm improvements Adopt new best practices Measure results EMR is helpful: Report on structured data Adjust workflow

47 Success Story: Patient Safety Pharmacy Collaborative 2010 Pilot program intended to reduce Pharmaceutical Misadventures Identified patient population: Analyzed data: Queried database to identify 62 polypharm diabetics on 12+ meds Partnered with local pharmacist to identify: Potential adverse drug interactions Duplicative, expired, or unnecessary Rxs Tools to help educate the patient. Brainstormed improvements: 1. Write CLEAR instructions for the patient without abbreviations. 2. Link a diagnosis to each Rx 3. Print a Medication List for patient at EACH visit

48 Success Story: Patient Safety Pharmacy Collaborative Adopted new best practice: Adjusted encounter form to facilitate implementation

49 Success Story: Patient Safety Pharmacy Collaborative Measured results: 32% decrease in avoidable Emergency Department use 22% decrease in avoidable Hospitalizations. EMR is helpful: Report on structured data Adjust workflow A collaborative approach to medicine works!

50 Benefits of the PCMH Model

51 Key Benefits of the PCMH Pilot for ACHS Expand on CHC approach: Integrated care, single PCP, Patient Navigators, Integrated Behavioral Health services. Increase the ACHS revenue stream: Insurer pays $3-$6 extra per insured per month Total additional PCMH revenue: $100,507 (2010), $72,658 (2011) Revenue model now transitioning to ACO pilot, 2012 Revenue: $75,000 Same expected for 2013 Guide direction of NH PCMH implementation: You re either at the table or on the menu

52 Factors to consider A robust EMR is necessary The culture of your organization must embrace continuous improvement May strain financial situation of local hospitals as their revenues decline

53 Final thoughts Pilot demonstrates that PCMH model improves care quality. Collaboration enhances patient care. Population management and continuous improvement elevate the standard of care. More revenue AND better care? Imagine that!

54 Centricity* Practice Solution The right complement of tools to help you become a Patient-Centered Medical Home

55 Clinical and Administrative Electronic Medical Records Centricity Practice Solution is an integrated EMR and PM solution that helps provide enhanced quality care, streamlined day-to-day operations, and reduced operating costs Monitor quality with an integrated quality dashboard Identify financial inefficiencies and opportunities to help reduce costs Integrated EDI for clearer, faster results from insurance companies Designed with physicians for optimal efficiency

56 PCMH Prevalidated. Reduced administrative burden. Centricity Practice Solution Version 11 is PCMH prevalidated by NCQA to receive autocredit toward NCQA s PCMH 2011 scoring. Transferrable to practices utilizing version 11 functionality Eliminating the provision of documentation for the associated factors within your PCMH 2011 Survey

57 Increase patient/family access and engagement Patient Portal: 24-hr secure online access Patients can retrieve test results, schedule appointments, and retrieve continuity of care documents. Secure clinician-patient messaging Facilitates remote or after-hours access to care and documentation of clinical advice. Visit summaries and patient reminders Easily-generated tools to help improve patient compliance with care plans.

58 Deliver proactive, team-based care Collaboration tools Alerts, flags, and secure clinician-clinician messaging enable providers to exchange clinical information and coordinate care in real time. Evidence-based care Using guidelines to generate lists and remind patients about needed services (preventive, chronic, check-up, medications) enhances the quality of care. Tracking referrals Enables thorough follow-up and more-informed care.

59 Measure quality and continuously improve Powerful reporting on structured data Help your practice quickly and easily identify patient populations and brainstorm ways to deliver better care to them. Adapt workflows and add point-of-care reminders Help providers implement care model improvements more quickly and easily into day-to-day practice. Monitor quality metrics Quality dashboards are directly integrated into Centricity Practice Solution. Drill down to the patient level to identify opportunities for care enhancement.

60 Thank you for joining us. Learn more: Follow Questions?

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