The Patient- Centered Medical Home: Why It Works and How it Works Presented by: Linda K. Shelton, MA Partner April 22, 2014 Discern Health 1120 North Charles Street Suite 200 Baltimore, MD 21201 (410) 542-4470 www.discernhealth.com
Agenda PCMH Definition and thought model What we ve learned about PCMH nationally What Discern has learned about PCMH up close and personal 2
PCMH: Definition and Thought Model 3
Principles of the PCMH from 22 Medical Associations Now The Patient-Centered Medical Home: (AAFP, AAP, ACP, AOA) Personal physician, ongoing relationship Physician-directed team all focused on patient Whole person orientation, including behavioral health Care coordinated and integrated, across the health care system, facilitated by information technology Quality and safety with and for patients through evidence-based medicine Enhanced access Payment that recognizes added value PCPCC Web site. http://www.pcpcc.net/node/14. Accessed April 11, 2012.
Patient-Centered Medical Home Think Different Population Patient Medical Home Payers, Data, Performance, Incentives A team with the patient Active, working partnerships Use of today s and tomorrow s tools Management across the practice Medical Neighborhood 5
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Moving from Passive to Active Between visits, we mobilize the help you need* Traditional: We treat those patients who come to us, when they request a visit New Think: In ongoing relationships, we reach out to patients when we know they need something *Milstein, A., Gilbertson, E. American Medical Home Runs. Health Affairs September/October 2009 vol. 28 no. 5 1317-1326.
The Patients Who Need You the Most The Most Intensive Work We try to be an ambulatory ICU for chronic care* Traditional: We respect the patient s right to not comply with our instructions New Think: Yes, but we do everything possible to engage patients in their care. The patient is our partner *Milstein, A., Gilbertson, E. American Medical Home Runs. Health Affairs September/October 2009 vol. 28 no. 5 1317-1326.
What We ve Learned About PCMH Nationally 9
The results are convincing on costs Cost-reduction outcomes, 2013 report Colorado: 18% hospitalization reduction, 15% ED visit reductions, ROI for payer ranged from 2.5:1 to 4.5:1 Maryland CareFirst: PCMH incentives associated with overall 4.7% lower costs than non-incentives Pennsylvania Highmark: 9% fewer ED visits, 13% fewer admissions, 2% decrease in overall costs Vermont: 11% hospitalization reduction, 12% ER visit reduction, $215 savings per patient All part of incentive programs 10
The results are convincing on quality Quality results, 2012 report BCBS of North Dakota MediQHome 2012- Better diabetes care- 6.7% improvement in BP control, 10.3% improvement in cholesterol control, 64.3% improvement in optimal diabetes care UPMC 2011- Improved patient outcomes for diabetes- increased eye exams from 50% to 90%, 20% long-term improvement in blood sugar control, 37% long-term improvement of cholesterol control Pennsylvania Independence Blue Cross- Better diabetes careincreased diabetes screenings from 40% to 92%, 49% improvement in HBA1C levels, 25% increase in blood pressure control, 27% increase in cholesterol control, 56% increase in patients with self-management goals 11
And How Do They Do It? 12 American Medical Home Runs (2009) Extravagant caring for patients with chronic illness Efficient service provision Careful selection of specialists Leadership with persistence, risk tolerance, and a culture of personal accountability In Search of Joy in Practice (2013) Innovations: Proactive planned care, w/ previsit planning and labs Sharing clinical care among team Collaborative documentation, nonphysician order entry and streamlined prescription management Improving communication by verbal messaging and in-box mgmt. Improving team function through co-location, team meetings, and work flow mapping
But there are outliers Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care. JAMA, 2014.... And a lot of push-back! 13
What Discern Has Learned About PCMH Up Close and Personal 14
PCMH University 2012-2013 ( Georgia Academy of Family Physicians) 10 Practices, all sizes, including one residency program 14 Month program Onsite coaching 3 Learning collaborative events Only 1 Medicaid payer offering incentives 15
PCMH Transformation: Real. Clinical. Change. (an example) Choose teamwork and communication methods Pick improvement targets Choose and implement improvements Analyze and produce DATA: starting points Survey and talk to patients ID Care Mgt patients Care-manage and population-manage March April May June July August Sept. Produce evidence Learning Collaborative 16
PCMH Transformation: Real. Clinical. Change. (an example) Choose and implement improvements Re-measure Measure access Assess and improve coordination, esp. BH Complete evidence and submit to NCQA Continue and refine all new processes, especially PI Oct. Nov. Dec. Jan. 15 Feb. 15 March 15 April 15 Produce evidence Learning Collaborative 17
Some Results Process Improvements A multi-physician practice reduced the number of patients with COPD who had not had an annual spirometry test by 31% A multi-physician practice reduced the number of female patients who had not had DEXA scans by more than 20% A small practice raised its rate of screening for depression in the elderly from 11% to 56%, having begun using the PHQ-2 at every visit A solo physician practice improved: Breast cancer screenings by 16% pneumococcal vaccinations for patients 65 and older by 11.6% A small practice achieved a 6% improvement in the rate of tobacco cessation counseling to patients who smoke. 18
More Results 14 months Outcomes A multi-physician practice achieved a 2.6% increase, to over 70%, in the percentage of hypertensive patients whose blood pressure was below 140/90 A large multi-site practice reported a 15% reduction in hospital admissions for its population in its first year of PCMH implementation, and a record high for primary care visits and revenue 19
Successes Reported By One Practice Improvement in Team-Based Care Growth of Medical Assistants New role in documentation New role in counseling Offering work email to patients to improve communication Identifying patients for group visits Growth of Front Office Staff Following up on missed appointments Retrieving records prior to visits Population Management: contacting patients on registries
More Successes Disease Management and Care Plans Daily review of who needs a Care Plan at Huddles Expectation that this is part of care Agreement that it is valuable Change in Patient Expectations Patients reporting on meeting goals Prepared with logs Increased meeting of goals Less prompting by providers Diabetes group visits Continued work on Performance Improvement
How Did They Do It? We know who you are, and we will be ready for you. www.drsinsky.com Only 70% of patients in the survey said I always asked about their mental health... So I added it to my prompts. Having huddles changed our lives. Our days go so much more smoothly now. We always have our registry handy, to call patients to fill in any empty spots in the schedule. Our diabetic patients would rather come here for their education than go to the local classes. It doesn t do much good for me to tell the patients what to do I have to find out what they are willing to try, and make recommendations that work for them 22
What Helps PCMH Transformation? Value recognition: payer incentives Strong medical neighborhoods Well -used IT and data sources Leadership 23
Thank You Linda Shelton, MA, PCMH-CCE lshelton@discernhealth.com (864)944-6855 Discern Health (410)542-4470 www.discernhealth.com 24