Patient Centered Medical Home

Patient Centered Medical Home

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Today s Presenters: Sherri Atchley Implementation Consultant with Galen Healthcare Solutions Over 8 years of EHR experience Project manager, Implementation consultant Sue D Agostino, RN Clinical Consultant with Galen Healthcare Solutions Over 7 years of EHR experience Project manager, Clinical consultant, Business/Clinical Analyst April 2013 3

Agenda for today Review and define healthcare IT alphabet soup ( acronyms/terms) Explore and define PCMH Compare 2008 guidelines with 2011 guidelines for PCMH Review scoring for PCMH certification Review PCMH Standards and how to meet them with EEHR Technology Resources April 2013 4

Initiatives to improve healthcare: April 2013 5

What is Patient Centered Medical Home (PCMH) A patient-centered medical home integrates patients as active participants in their own health and well-being. Patients are cared for by a physician who leads the medical team that coordinates all aspects of preventive, acute and chronic needs of patients using the best available evidence and appropriate technology. These relationships offer patients comfort, convenience, and optimal health throughout their lifetimes April 2013 6

Model of care April 2013 7

Nurse Practitioner Doctor Patient Nurse Provides for patient health care needs. Physical Therapist Team approach at a single location responsible for patient care Care is more personalized, coordinated, effective and efficient. April 2013 8

Comparison: PCC-PCMH 2008 with PCMH 2011 Enhanced Access & Continuity Identify and Manage Patient Populations Plan and Manage Care Provided Self Care Support and Community Resources Measure and Improve Performance September, 2010 9

Comparison: PCC-PCMH 2008 with PCMH 2011 Enhanced Access & Continuity PCMH1F: Culturally and Linguistically Appropriate Services (CLAS) Assesses racial/ethnic diversity of patients Assesses language needs of patients Provides interpretation services Provides printed materials in patient language September, 2010 10

Comparison: PCC-PCMH 2008 with PCMH 2011 Identify and Manage Patient Populations PCMH2D: Data for Population Health Practice uses electronic information to generate lists of patients and remind patients and clinicians proactively of services needed: Pre-visit planning Clinician action Specific medications Preventive care Specific tests Follow-up visits Care management April 2013 11

Comparison: PCC-PCMH 2008 with PCMH 2011 Plan and Manage Care PCMH3A: Implement Evidence-Based Guidelines April 2013 12

Comparison: PCC-PCMH 2008 with PCMH 2011 Plan and Manage Care PCMH3B: Identify High-Risk Patients The practice does the following to identify high-risk patients: Establishes criteria and a process to identify high-risk or complex patients Determines the percentage of high-risk patients in the population Registries, ICD-9 codes assist in identifying high risk patients Reminders are generated and guideline based alerts are utilized April 2013 13

Comparison: PCC-PCMH 2008 with PCMH 2011 Provide Self Care Support and Community Resources PCMH4B: Provide Referrals to Community Resources & PCMH5B: Referral Tracking and Follow Up Practice supports patients who need access to community resources: Maintains current resource list covering five (5) community service areas (e.g. smoking cessation, weight loss, parenting, dental, transportation, fall prevention, meal support) Tracks referrals provided to patients Arranges for or provides treatment for mental health/substance abuse disorders Offers opportunities for health education and peer support April 2013 14

Comparison: PCC-PCMH 2008 with PCMH 2011 Measure and Improve Performance PCMH6F: Report Data Externally Ambulatory clinical quality measures to CMS or states Core Meaningful Use Requirement Ambulatory clinical quality measures to other external entities Data to immunization registries or systems Meaningful Use Requirement Syndromic surveillance data to public health agencies Meaningful Use Requirement April 2013 15

Comparison: PCC-PCMH 2008 with PCMH 2011 Measure and Improve Performance PCMH6G: Use Certified EHR Technology Uses an EHR that has been certified and issued a Certified HIT Products List (CHPL) Number under ONC HIT certification program Core Meaningful Use Requirement Attests to conducting a security risk analysis of its EHR and implementing security updates or resolving deficiencies* Core Meaningful Use Requirement April 2013 16

PCMH 2011 Scoring April 2013 18

PCMH 1: Enhance Access and Continuity Providing timely clinical advice by telephone during office hours- Using the Call Processing module and utilizing text templates consisting of protocols PCMH and EEHR Providing timely clinical advice by secure electronic messages during office hours - Patient portal, Follow my Health, Relay health, task teams to triage messages to ensure quick delivery Documenting clinical advice in the medical record.- Copying the messages to note in patient chart April 2013 19

PCMH 1: Enhance Access and Continuity PCMH and EEHR Clinical summaries are provided to patients for more than 50 percent of office visits within three business days-using either Allscripts delivered or creating what works for your organization, utilizing the CS icon on the schedule Documenting the patient s choice of clinician- By utilizing the PCP functionality in the patient banner, users can easily identify the patient s primary care giver. April 2013 20

PCMH 2: Identify and Manage Patient Populations Documentation of patient s preferred language- patient demographics either directly in EEHR or via PM PCMH and EEHR Allergies including medication allergies and adverse reactions are documented Tobacco use for patients 13 years and older is recorded for more than 50% of patients Use Data for Population Management April 2013 21

PCMH 3: Plan and Manage Care The practice analyzes its entire population to determine the required important conditions, which may be chronic or recurring conditions such as COPD, hypertension, hyperlipidemia, HIV/AIDS, asthma, diabetes or congestive heart failure. PCMH and EEHR Condition specific flowsheets are created to track patient progress. April 2013 22

PCMH 3: Plan and Manage Care Gives the patient/family a written plan of care PCMH and EEHR Gives the patient/family a clinical summary at each relevant visit April 2013 23

PCMH 4: Provide Self-Care Support and Community Resources Offers opportunities for health education programs (such as group classes and peer support.) PCMH and EEHR 11.3 offers group session Note workflow. Arranges or provides treatment for mental health and substance abuse disorders April 2013 24

PCMH 5: Track and Coordinate Care PCMH and EEHR Flags abnormal lab results, bringing them to the attention of the clinician Notifies patients/families of normal and abnormal lab and imaging test results April 2013 25

PCMH 5: Track and Coordinate Care Giving the consultant or specialist the clinical reason for the referral and pertinent clinical information PCMH and EEHR April 2013 26

PCMH 6: Measure and Improve Performance The practice uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience. PCMH and EEHR Data to immunization registries or systems April 2013 27

PCMH 6: Measure and Improve Performance PCMH and EEHR Syndromic surveillance data to public health agencies September, 2010 28

Resources to help in PCMH quest: National Committee for Quality Assurance www.ncqa.org/ Agency for Healthcare Research and Quality www.pcmh.ahrq.gov American Academy of Family Physicians www.aafp.org/online/en/home/membershi p/initiatives/pcmh.html American Academy of Pediatrics http://www.pediatricmedhome.org Center for Medical Home Improvement www.medicalhomeimprovement.org/ The Commonwealth Fund http://commonwealthfund.org April 2013 29

Contact Information Questions? Questions: education@galenhealthcare.com Corporate: 888-Galen-44 Information ------------------------ You can find all handouts as well as questions and answers from this webcast and other webcasts on our wiki at: http://wiki.galenhealthcare.com/webcasts.