Attaining the True Patient-Center in the PCMH Through Health Coaching and Office-Based Care Coordination Heartland Rural Physician Alliance Annual Conference IV May 8, 2015 William Appelgate, PhD, CPC Kathy Kunath, RN Iowa Chronic Care Consortium
How would you describe the nature of your organization in managing individuals with chronic disease? 1. We treat those with chronic conditions when they present themselves to us with symptoms. 2. We identify and manage those with chronic conditions fairly well. 3. We identify, engage and manage those with chronic conditions in a proactive partnership.
Healthcare s New Version 3.0 Version 1.0 Version 2.0 Version 3.0 Healthcare professionals are accountable for treating the ill, the sick, and the broken who present themselves. Historical. Healthcare professionals accept accountability for prevention, education and care management to guide all patients to better health outcomes. Present Trending. Healthcare professionals inspire accountability at the level of the patient by partnering with them to create a care management plan that prompts improved health behaviors and builds self-care skills. Future.
What s responsible for the gap between where we are and where we need to be? 1. A system oriented to acute disease that isn t working for individuals (patients) or professionals when chronic conditions are often the most costly, and can be managed. 2. The misappropriation of education as an end game when patients benefit most from activation to self-care. 3. Lack of patient skill or accountability in self-management of chronic conditions which often lead to exacerbations and high cost. 4. A predominately volume based reimbursement system that is migrating toward value.
Strategies for Shift to Healthcare 3.0 Create real patient centered medical homes. Build a true population health capacity. Develop robust, differentiated healthcare teams. Activate patients toward self-care, inspire their accountability. Utilize trained, performance oriented health coaches.
Clinical Health Coach Trainings A very particular set of skills enabling health care professionals to partner with patients to build self-care skills, prompt better health behaviors and inspire accountability as a path to achieve the triple aim. Population health patient care strategies to align evidence based care with the patient centered resources of an effective healthcare team.
Concept of the Clinical Health Coach Team member working closely with physician lead in PCMH or clinical healthcare setting. Engages and partners with patients to improve health behaviors, build self-care skills, inspire personal accountability. Part behavior change specialist; part care management facilitator.
Why Clinical Health Coaching Skills? 1. Value salutogenesis, the origin and maintenance of health. 2. Recognize that most healthcare takes place outside the provider s office. 3. Know that patients can be inspired to better health behaviors, improved self-care skills and greater personal accountability for their health. 4. Verify that the Triple Aim can be achieved in entire populations. 5. Define health coaching in the clinical as a blend of behavior change skills and care management facilitation. 6. Believe that patients are the greatest underutilized resource in healthcare.
#1. Transforming the Conversation Employ performance oriented health coaching. Rely upon the science of behavior change. Evoke patient motivations to guide goal setting. Partner with patients for self-management support. Exhibit empathy, self-efficacy & empowerment. Develop whole person strategies, inspire accountability, follow-up, affirm, count upon success.
#2. Transforming the Care Processes Employ population health management practices. Align best practice care with patient centered resources. Identify and reduce care gaps. Increase planned prevention visits. Communicate to improve health literacy. Connect patients with best community resources.
Journey Population health capacity building organization -- to reduce the burden of chronic conditions. Success prompted inquiries about secret sauce. Part of the secret was a personalized coaching approach. Large clinic system invited us to create and build formal training. Developed based on competencies required in an active PCMH.
Principles #1 Transform healthcare professionals from do, teach, tell to ask, listen, inspire. Leverage patient self-management behaviors for better individual and population outcomes. Prepare for move to value based from volume based funding of healthcare. Recognize patient as the greatest underutilized resource in healthcare.
Behavioral Informatics We are in an era looking at all of the underutilized resources in healthcare. And, the greatest underutilized resource is the patient and their family. Farsad Mostashari
Principles #2 Build a very particular set of skills to engage, partner with and activate each patient not necessarily a position description. Develop workforce team member to support the all-too-busy physician. Equip team members to complete essential behind the scenes work to increase clinic throughput in population health strategy enterprise. Create an architect for reducing risk and lifting health status to achieve Triple Aim with patients.
Essential Knowledge, Skills, Competencies 1. Population health strategies knowing principles and processes. 2. Coaching sciences and skills knowing and performance competence. 3. Next level communication skills knowing and performance skills. 4. Implementing coaching in clinical settings knowing and leading. 5. Best practice development (stratifying populations, care management, team based care, health literacy, behavioral health, utilizing neighborhood resources, evaluation, registries and medication management) knowing and skills for implementing. 6. Health behavior change knowing and performance competence.
They Acknowledge Healthcare s Challenges Pathogenic healthcare ecosystem. Chronic conditions running wild. Costs that are unsustainable. Over-worked physicians. Technology burdens which sometimes distract.
Title Slide
No Software Update for People While technology has developed and evolved dramatically, individuals still have worries, fears, hopes, desires and ambitions. They want to be moved, validated, cared for, respected and seen as capable. It doesn t matter the technology, platform or medium through which you reach them people are still people. Humans haven t had a software update in 200,000 years. Peter Diamandis
Challenges to Effective Health Coaching Coaching in a clinical setting marries the care management process with health behavior change if it doesn t, it isn t coaching. Since health coaching is hot, patient education often portrayed as coaching it may be valuable; it is not coaching. Coaching takes time coaches must have time and a place in the care management process to actually coach and follow-up. Choose the right personality type for coaching not everyone can coach effectively. Extreme practice variation exists in the implementation of coaching. Effective health coaching integrated inside the PCMH requires knowledgeable leadership, training and practice.
True Architects for Health 98% of patient healthcare takes place outside the provider office reach them Most care is self-care build them Patient is greatest underutilized resource in healthcare tap them 69% of healthcare costs are influenced by health behaviors inspire them
So.. Just what does a Clinical Health Coach Do? It depends!
Health Coaching in the Medical Home: Lessons from Early Adopters Report by Roberts Health Solutions Sponsored by Opus Science and Iowa Chronic Care Consortium www.clinicalhealthcoach.com/medicalhome
National Survey: Rating Health Coaching s Impact
Survey: What Makes Coaching Work? Right people in the role Specific staff trained in a full-time role Outcomes documented with data Movement from a volume to value-based model Recognition of the value of team-based care Sufficient time with patients to help them reach their potential Supportive physicians Unwavering leadership commitment
Opportunity Spaces - Individual Practices/Systems A Team Sport: Getting the entire team to value patients as a capable resource Reducing intra-system variation: Deploying a consistent coaching model across practices to achieve practice goals Metrics: Linking clinical outcomes to financial outcomes Mobile technology: Leveraging this as yet untapped asset within health coaching
NCQA 2011 PCMH Standards 1. Enhance Access and Continuity 2. Identify and Manage Patient Populations 3. Plan and Manage Care 4. Provide Self-Care Support and Community Resources 5. Track and Coordinate Care 6. Measure and Improve Performance
New NCQA 2014 Standards Additional emphasis on team-based care Care management focus on high-need populations Improved care transitions Alignment of quality improvement activities with the Triple Aim Further integration of behavioral health Sustained transformation
Three Pillars of Care Transform the Care 1. Care Management (Internal) 2. Care Coordination (External) Transform the Conversation 3. Patient Self-Care/Management (Patient/Family)
Effective Care Management More intense care for high-risk patients through establishing and monitoring care plans. More frequent follow-up visits. Regular outreach between office visits (telephonic). Extensive support for disease management and self-care. Tracking and coordination of specialty care and referrals. Linkage to community resources. www.ajmc.com: Dec. 2013
Effective Care Coordination (External) Partnerships - integrated care delivery - medical neighborhoods Connect the health care dots and communication Team based care Decrease fragmentation
Clinical Health Coach Training Options 1. Clinical Health Coach Training Onsite 2. Clinical Health Coach Training Online 3. Clinical Health Coach Training Online plus Two-Day Live Intensive (Fusion)
Certificate of Competency in Clinical Health Coaching Earned through: Passing all written exams with a minimum score of at least 70% Passing the Performance-Based Competency Evaluation (a telephonic coaching session with a standardized patient)
Workflow and Throughput Preschedule and plan proactive visits Schedule physicals and clinical guideline indicated tests for all patients Actively manage patients with chronic conditions toward better health and lower cost
Paying for Health Coaching in Future Current evidence affirms value of coaching; in a future of value based payment the benefits will be compelling. As payment in PCMH, ACO, shared savings models shift to value, health coaching holds promise to be a standard practice. Care coordination payments by several health plans, Medicare and Medicaid currently exist and will expand. The Affordable Care Act allows health plans to include spending for quality improvements (coaching is an example) as an allowable cost of care expense.
Shift Happens Payment Models Uncertain, Yet Inevitable
Paying for Health Coaching Now Many health plans and Medicaid programs are providing care coordination payments for PCMH, including the CMS Care Management Fee. Incentive payments for enhanced outcomes for patients with chronic conditions are often available. Accelerating proactive visits for all patients for physicals, labs and preventative screens adds revenue in excess of expense. Assessing gaps in care for patients with chronic conditions prompts additional lower cost office visits.
Paying Now Example #1 A Clinical Health Coach trained care coordinator found that their physician's practice had more than 714 Medicare patients, only 17 of whom had had a Welcome to Medicare or annual physical. Practice began scheduling 10-15 Medicare patients per week for Welcome and annual physicals. The added revenue from the physicals, labs, related tests, and services averaged $272 per patient. Revenue generated was in excess of $160,000 in first year. A new staff member was hired; the health coach was supported. Previously unknown chronic conditions were diagnosed and followed. Better health, better health care and lower cost was achieved.
Paying Now Example #2 Large primary care clinic system began using health coaches on a regular basis with emphasis upon managing their patients with diabetes. Clinic was paid P4P incentive by leading health plan and CMS paid PQRI bonus; in first year there was a 51% increase in visits for diabetes, a 178% increase in micro albumin tests, and a 46% increase in HGA1c testing. Selected physician and nurse work was shifted to coaches which billed for level I visits. Companion increase in physician level 4 visits. Related coach benefits included: hypertension reviews, referrals for physicals, immunizations, mammograms, blood testing, etc. Non-quantified benefits included: improved patient outcomes; higher patient experience; increase office visits and referrals to other patients. Incremental revenues exceeded cost of health coaches, labs, etc. and yielded a 2 to 1 return on health coaches before P4P income. Mercy Clinics: The Medical Home, Group Practice Journal (2008)
Questions william.appelgate@iowaccc.com kathy.kunath@iowaccc.com 515-971-3234 www.clinicalhealthcoach.com