Perso-Cetered Care Coordiatio December 8, 2016
Preseters Departmet of Social Services (DSS) Perso-Cetered Medical Home (PCMH) Program Lead Erica Garcia-Youg, MPH Commuity Health Network of Coecticut, Ic. (CHNCT) Commuity Practice Trasformatio Specialist (CPTS) Kathy Roy, MBA, NCQA PCMH CCE 1
Learig Objectives Uderstad the DSS PCMH & the Natioal Committee for Quality Assurace (NCQA) Patiet-Cetered Medical Home Describe perso-cetered care Defie ad provide a uderstadig of care coordiatio Recogize the eed for a effective care coordiatio workflow Discover how to improve cliical quality outcomes Idetify importat CHNCT resources 2
PCMH Program Structure DSS Departmet of Social Services Free Program Support Ehaced Fee for Service Paymet NCQA Natioal Committee for Quality Assurace CHNCT Commuity Health Network of CT, Ic. Admiistrative Services Orgaizatio (ASO) for DSS Glide Path Program ad Commuity Practice Trasformatio Specialist (CPTS) NCQA Patiet- Cetered Medical Home Level 2 or 3 Recogitio DSS Perso-Cetered Medical Home Recogitio Ehaced Fee For Service Paymet 3
Patiet-Cetered Medical Home A PCMH has the patiet at the ceter of the healthcare system The healthcare system provides primary care that is: Accessible Cotiuous Comprehesive Family-cetered Coordiated Compassioate Culturally effective 4
A Perso-Cetered Medical Home Is available 24/7 Kows the patiet ad their health history I a medical home the care team: Esures the patiet uderstads their coditio(s) Helps coordiate the patiet s health care 5
Perso-Ceteredess Needs Hopes Wats PERSON Iterest s Desires Barriers 6
What is Care Coordiatio? The deliberate orgaizatio of patiet care activities betwee two or more participats (icludig the patiet) ivolved i a patiet s care to facilitate the appropriate delivery of health care services. Care Coordiatio. May 2015. Agecy for Healthcare Research ad Quality, Rockville, MD. http://www.ahrq.gov/professioals/prevetio-chroic-care/improve/coordiatio/idex.html 7
Primary Care Physicia (PCP) Coordiates Care Lab Tests Imagig Tests Specialist Visits Hospital/Emergecy Departmet Visits Behavioral Health Services Detal Services Dietitia Visits Physical/Occupatioal Therapist Visits Facilities Trasitios Medicatio Recociliatio Patiet Self-care Results Self-referrals Prior Authorizatios for Isurace 8
PCMH Model - Triple Aim Improve patiet health outcomes through cliical quality Ehace patiet experiece Reduce healthcare costs 9
Cotiuous Quality Improvemet Desig Elemets of Care Coordiatio Accoutability Patiet Support Relatioships ad Agreemets Coectivity Safety Net Medical Home Iitiative. Horer K, Schaefer J, Wager E. Care Coordiatio: Reducig Care Fragmetatio i Primary Care. I: Phillips KE, Weir V, eds. Safety Net Medical Home Iitiative Implemetatio Guide Series. 2d ed. Seattle, WA: Qualis Health ad The MacColl Ceter for Health Care Iovatio at the Group Health Research Istitute; 2013. Accessed from: http://www.safetyetmedicalhome.org/sites/default/files/implemetatio-guide-care-coordiatio.pdf 10
Pediatric Case Study Cliical Summary: 12 year-old boy Attetio-deficit/hyperactivity disorder ad seizure disorder Hospitalized for ucotrolled seizures Seamless trasitio of care from hospital to home Scheduled post-hospitalizatio visit with pediatric practice withi 7 days after discharge Module 2: Leveragig the Power of Care Coordiatio. Copyright 2015 by the America Academy of Pediatrics https://www.aap.org/e-us/documets/cliicalsupport_module_2_medical_home_modules_pediatric_residecy_educatio.pdf 11
Pediatric Case Study (cot d) PCMH Care Coordiatio Itervetios: Nurse proactively reached out to hospital for records Morig of visit Medical team huddled to discuss patiet ad check all ecessary iformatio At visit Pediatricia reviewed medicatios, coducted lab tests, ad coordiated followup visit with specialist Cliical Care Maager Provided access to patiet portal Updated care pla Set care pla to school urse Outcome: Care coordiatio efforts resulted i effective commuicatio with the patiet ad specialists, collaboratio with educatioal system, ad access to commuity resources. Module 2: Leveragig the Power of Care Coordiatio. Copyright 2015 by the America Academy of Pediatrics https://www.aap.org/e-us/documets/cliicalsupport_module_2_medical_home_modules_pediatric_residecy_educatio.pdf 12
Care Team Resposibility Support patiets i carig for themselves Commuicate with patiets Teach patiets about their medical home 13
Care Coordiatio Challeges Time & Capacity Maual ad iefficiet processes overburde the cliical staff Data Maagemet Isufficiet system capabilities Resources Navigatig a complex healthcare system 14
Electroic Health Record Techology Pre-visit Prep Gap-i-care alerts Remider services Lab ad test results Poit of Care Medicatio adherece Gap-i-care itervetio Doctor/patiet discussios Support erollmet Post-visit Follow-up Specialist referrals Educatio ad commuity resources 15
Care Coordiatio Workflow Coduct pre-visit preparatio Recalls for prevetive care Use poit of care remiders Follow-up o missed appoitmets Stregthe the foudatio Track test ad lab results Iformatio exchage ad follow-up for care trasitios Provide educatio ad commuity resources Address gaps i care 16
Workflow Process Improve performace ad icrease efficiecy Use techology pre visit, at poit of care ad post visit Idetify ad address challeges faced by staff ad patiets Decide what is ad what is NOT realistic Aalyze data to measure patiet outcomes ad effectiveess 17
Care Coordiatio & Cotiuity Staff Resposibilities Effective commuicatio Teamwork Patiet/Family Ivolvemet Access to Iformatio Persoalizatio of care 18
Care Coordiatio Success Teamwork Care Maagemet Medicatio Maagemet Reduced Cost of Care Ehaced Patiet ad Family Egagemet Improved Commuicatio Across Multiple Settigs 19
Compoets of Perso-Ceteredess Commuity Resources Primary Care Specialty Care Medica7o & Pharmacy Pa7et / Family Perspec7ve Ipa7et Care Educa7o & Support Pa7et Prefereces ad Needs Behavioral Health Services Iformal Caregivers System Perspec7ve Health Care Professioal Perspec7ve Log-term Care Home Care Test Results Medical History Chapter 2. What is Care Coordiatio? Jue 2014. Agecy for Healthcare Research ad Quality, Rockville, MD. http://www.ahrq.gov/professioals/prevetio-chroic-care/improve/coordiatio/atlas2014/chapter2.html 20
CHNCT Resources HUSKY Health website: www.ct.gov/husky Secure Provider Portal: http://www.huskyhealthct.org/providers/providers_logi.html CareAalyzer : https://careaalyzer.dsthealthsolutios.com/careaalyzer/logi.aspx HUSKY Health PCMH Microsite: http://www.huskyhealthct.org/providers/pcmh.html Itesive Care Maagemet & Commuity Health Worker Provider Lie: 800.440.5071, ext. 2024 CPTS Team By email: pathwaytopcmh@chct.org By phoe: 203.949.4194 All PCMH webiars are located o the HUSKY Health website page: Pathway to PCMH Webiar Recordigs ad Presetatio Materials 21
Questios/Commets 22