Objectives for presentation

Objectives for presentation At the end of the session, learners will be able to: 1. Define the Patient-Centered Medical Home model 2. Review chronic Disease Management in the Patient-Centered Medical Home model 3. Explore the role of the Case Manager in the Patient-Centered Medical Home model

WHY?

THE ANSWER (?)

THE RIVER A group of people are standing at a river bank fishing. Suddenly a person comes down river struggling for life. One person immediately dives in to rescue the person. But as this is going on, yet another person comes floating down the river, and then another!

UPSTREAM People continue to jump in to save the people and then see that one person has started to walk away from the group still on shore. Accusingly they shout, Where are you going?" The response: "I'm going upstream to find out why so many people are falling in the river.

PCMH- Moving upstream Don t you see if we find out how they re getting in the river, we can stop the problem and no one will drown? By going upstream we can eliminate the cause of the problem!

History of PCMH 1967: Concept first introduced by the American Academy of Pediatrics (AAP) 2001: The IOM s Crossing the Quality Chasm: A New Health System for the 21 st Century states that the system of care should revolve around the patient 2007: Joint Principles of the Patient-Centered Medical Home is put forth by the AAP, AAFP, ACP, and AOA

Improve the Health of Populations Improve the Patient Experience of Care Reduce the per capita Costs of Care of Healthcare Institute for Healthcare Improvement

HEALTHCARE REFORM

Healthcare reform- what if?

The ANSWER

Evidence Horizon Blue Cross Blue Shield of New Jersey 25% fewer hospital readmissions 21% fewer inpatient admissions 10% overall lower cost Upfront funding of care coordinators

Evidence Maryland CareFirst Blue Cross Blue Shield More than 8.5 million in grants to Safety Nets for PCMH 4.2% reduction in patients' overall health care costs Estimated cost savings of $40 million (2011)

Evidence Vermont Medicaid 31% fewer ER visits 21% reduction in inpatient services 22% lower per member per month costs (2008-10

Evidence Geisinger Health System, Danville, PA 25% fewer hospital admissions 50% fewer hospital readmissions 7% lower cumulative total spending

Group Health of Washington, Seattle, WA 15% fewer inpatient stays 15% fewer hospital readmissions Estimated costs savings of $15 million 18-65% improvements in medication management

WHY create a Medical Home? Value Improve clinical outcomes= QUALITY Decrease ER visits Decrease hospital admissions Increase preventative screenings, quality measures Improve reimbursement and reduce COSTS Higher satisfaction for patient, providers and staff

What is a House? Structure Place to keep stuff Requires Technical knowledge Materials Money

What is a HOME? Home is the place where, when you have to go there, They have to take you in. Robert Frost Requires People Culture Money

What is a Medical Home?

Building a HOUSE

Building a HOME

New HOMES

WHAT are the Building Blocks of PCMH? Personal Physician Physician directed practice Whole person orientation Coordinated care Quality and Safety Enhance access Payment Reform Joint Principles of the Patient-Centered Medical Home - AAP, AAFP, ACP, and AOA 26

WHAT are the Building Blocks of PCMH? Personal Physician Physician directed practice Whole person orientation each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care Coordinated care Quality and Safety Enhance access Payment Reform 27

WHAT are the Building Blocks of PCMH? Personal Physician Physician directed practice Whole person orientation Coordinated care Quality and Safety the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. Enhance access Payment Reform 28

WHAT are the Building Blocks of PCMH? Personal Physician Physician directed practice Whole person orientation Coordinated care Quality and Safety Enhance access Payment Reform personal physician is responsible for providing for all the patient s health care needs This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care. 29

Whole person Orientation

WHAT are the Building Blocks of PCMH? Personal Physician Physician directed practice Whole person orientation Coordinated care Enhance access Integrated across all elements of the complex health care system and the patient s community Facilitated by registries, information technology, health information exchangequality and Safety Payment Reform 31

WHAT are the Building Blocks of PCMH? Personal Physician Physician directed practice Whole person orientation Coordinated care Quality and Safety Enhance access Evidence based medicine Physician accountability for CQI Patient participation in decision making and feedback Use of IT Volunteer recognition by non governmental entity Patients participate in QI at the practice level Payment Reform In quality and safety all of the pieces come together in the right way, at the right time and in the right place. 32

WHAT are the Building Blocks of PCMH? Personal Physician Physician directed practice Whole person orientation Coordinated care Quality and Safety Enhance access Care is available through systems such as: open scheduling, expanded hours new options for communication between patients, their personal physician, and practice staff. Payment Reform 33

WHAT are the Building Blocks of PCMH? Personal Physician Physician directed practice Whole person orientation Coordinated care Quality and Safety Enhance access Payment Reform recognizes the added value provided to patients who have a patient-centered medical home 34

Patient Centered Medical Home

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 elements Access during office hours Use data for population management Care management Support self-care process Track referrals and follow-up Implement continuous quality improvement

NCQA PCMH Scoring

NCQA-Recognized Practices Across the United States 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 21 60 sites FL 61 200 sites HI 201+ sites Source: Analysis by the National Committee for Quality Assurance, Oct. 2012.

Current status of PCMH

Paradigm Shift- Upstream 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 Medical Home 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

Medical Home Concepts Enhanced Access Empanelment/ Population Management Team-based Healing Relationships QI Patient- Centered Interactions Care Coordination Organized, Evidence Based Care

What is Empanelment/ Population Management? An approach to care that uses information on a group ("population") of patients within a primary care practice or group of practices to improve the care and clinical outcomes of patients within that practice --AHRQ

What is Patient-Centered Care? Patient-centered orientation- considering unique needs, cultures, values and preferences Self Management Support (SMS) -Developing plans of care with the patient, not for the patient All staff working at their capacity to engage with patient effectively

What is Care Coordination? Care that is coordinated across the health care system and the patient s community Promotes: Peer to peer communication Referral tracking -closed loop Tools and information that promote best practices and guidelines Opportunities to connect with specialists and services- Transitions of care I just want my doctors to talk to each other 45

What is Organized, Evidence-based Care? Clinical Practice Guidelines (CPG s) for clinically important conditions Asthma Diabetes Immunization schedules Educating providers-everyone on the same page Consistent message for patients Standardized workflow can create more satisfaction for staff Performance monitoring Improved outcomes

What are Team-based Healing Relationships? Care determined by proactive plan Meet patients needs Address chronic disease at every visit Staff work flow- Pre-visit Planning/Huddles Working at the top of license

Moving from Traditional Disease Management to Medical Home Chronic disease self management- empower patients to take an active role Regardless of chronic condition, people have similar challenges with self management Partnership with primary care and population health Prevention and Chronic Care management IT tools Training and population health support 48

Traditional Disease Management to Medical Home Disease Management Population focused Disease managers Remote patient activation Change patients & physicians PCMH Office practice focused Multidisciplinary teams Local patient activation Change physicians & patients SHS

Challenges of Disease Management in PCMH Need to move from helping patients become engaged to: helping the struggling clinics become expert training office staff in registry and care coordination functions, providing patient self management support, helping leverage community services. http://diseasemanagementcareblog.blogspot.com/2008/09/disease-management-patient-centered.html

Case Management in a Medical Home Setting

What is the role of a Case Coordination of Care Across Continuum Manager? Utilize Case Management to identify barriers Transition patients with complex medical needs Helps access resources Proactively manage Discharge planning

Coordination of Care Across Continuum Utilize Case Management to identify barriers Transition patients with complex medical needs Helps access resources Proactively manage Discharge planning

Role of Embedded Nurse Care Manager in PCMH Pre-visit planning for patients with chronic disease, update medication list, manage refills, recommend and order evidence-based guidelines care per protocol, and identify any care provided between visits to the primary care physician. Manage phone message requests for clinical information as appropriate between visits. ER/hospital visit follow-up via phone call for ambulatory sensitive chronic disease visits or others as necessary. Ensures care plan is updated and available for all team members. Patient goals are addressed during visit; provides or affirms education. Coordinates with discharge planner, case management or other team members

Scope of Medical Home Case Management Dyad Model- experienced RN and Social worker Motivational interviewing- holistic, comprehensive patient assessment Open access when the patient needs us at their convenience Telephonic monitoring Risk assessment- drives interventions and level of monitoring Patient Centric, Medical Home philosophy Incorporates wellness, prevention and self management of disease

Role of Nurse Case Manager -external Develop and update monthly care plan. Perform readiness-to-change and needs assessment. Distribute educational materials and resources for patient and family (these should be made available to all team members for content review). Communicate all of the above to the primary care practice via an established method of communication (e.g., email, fax, telephone). Address and document any evidence-based guidelines gaps in care.

Role of Discharge Planner-external Ensure medication reconciliation at admission and discharge. Use teach-back techniques to ensure patient understanding of discharge instructions. Perform needs assessment of financial, social, transportation needs prior to discharge. Provide discharge notification and care plan to primary care practice the same day of discharge.

TEAM CHALLENGES TRANSITIONS ROLES

CAUTION- The River A huge controversy erupted in the village. One group argued that every possible hand was needed to save everyone since they were barely keeping up with the current flow. The other group argued that if they found out how those people were getting into the water further upstream, they could repair the situation up there that would save all the people and eliminate the need for those costly rescue operations downstream.

CAUTION- The River But it s too risky, said the village elders. It might fail. It s not for us to change the system. And besides, how would we occupy ourselves if we no longer had this to do?

CAUTION PCMH is a marathon not a sprint PCMH is Transformation not only Application PCMH is Massive System and Culture Change

Inconvenient Truths

Common Barriers Resistance to change Limited training of physicians in communication skills Non-productive team processes Staffing Cost/time

Coming together is the beginning. Keeping together is progress. Working together is success. -Henry Ford

1. Call a PCP to solicit input into the Plan of Care/Discharge Plan 2. Introduce the Role of a Case Manager to practices 3.???

Future of PCMH

Questions and Comments Candace Ramos, MHA, RRT 816-559-9340 cramos@cmpcn.org Michelle Haley, MD 816-559-9382 mhaley@cmpcn.org