The PCMH St Joseph s Experience Priya Radhakrishnan, MD Roshni Kundranda, MD, MSPH Binh Doung, DO Jenni Schroeder, RN, BSN ACP Regional Meeting Tucson, 2013
Disclosure No financial conflicts of interest 2
My dogs Have a pet portal Online method of contacting for refills Gets a call one day and one week after illness
What is a Medical Home? The Patient-Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for children, youth and adults. The PCMH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient s family - Joint Principles of the Patient Centered Medical Home, Feb 2007 4
Joint Principles Personal Physician- ongoing relationship with a physician to provide continuous and comprehensive care Physician directed medical practice- team of individuals take responsibility for ongoing care of patients Whole person orientation -responsible for care or for arranging for care for all healthcare needs Care is coordinated and integrated- across health care systems e.g. hospitals, nursing homes, and community based services by registries, IT etc, Quality and safety- with EBM, shared decision making, point of care support, voluntary reporting Enhanced access through open scheduling, expanded hours, other options for communication Team Based Care -NP/PA - RN/LPN -MA -Front office -Back office -Care coordinator -Social worker -Nutritionist/Educator -Pharmacist -Behavioral health -Others Payment- supported by structures that recognizes services and value 5
Update on Medical Homes As of June 2013, more than 5,700 practices and 26,000 physicians have been designated by NCQA as medical homes Nationwide, >90 commercial health plans, 42 state Medicaid programs, federal agencies and the military have adopted the PCMH on varying scales. PCMH is projected to save $189 billion nationally over the next 10 years 6
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Background St. Joseph s Hospital and Medical Center is a 667 bed quaternary hospital in downtown Phoenix The internal medicine clinic is a combined resident and faculty run practice (9 faculty physicians and NP; 35 residents and students) 80 % of patients served have one or more chronic disease Non-emergent ER visits comprise about 20-30 % of all ER visits By payer, AHCCCS accounts for 51.6 % of all ER visits The clinic averages about 100 patients a day, with 40 % of patients having 3 or more chronic conditions 8
Before Medical Home Paper charts Lack of access to patient information 90% post hospitalized patients- no information Lack of data re: health care costs Lack of data re: use of preventive services Access- next available appt follow up- 2 weeks- 2 months Physicians did it all Reactive- patient presents 9
Transformation 10
Transformation 2010-3 Physicians, RN, Practice Manager Rapid cycle PDSA Increased daily open access, evening hours, Saturday hours EMR implementation Process and Policy Updates in line with NCQA standards Ambulatory information registry Partnership with Mercy Care Plan, 2011 Evaluation of Practice Metrics Patient Advisory Council Care Coordinator- NCQA training Weekly meetings with Core Team NCQA certification December 2012 11
Partnership with Mercy Care Plan Care coordinator Monthly meetings Information on members- ED visits/ inpatient admissions, disease based metrics, SMI, controlled substance prescribing Preferential assignment of patients to the medical home Higher payment per member for care coordination and bonuses based on quality metrics achieved 12
Transformation Weekly Meetings With Core Team / Evaluation of Practice Metrics PCMH Core Team: 1. Practice Manager 2. 3 Faculty Providers 3. PCMH Care Coordinator Weekly Meetings: 1. Initial evaluation of practice compared to PCMH 2011 Standards - What was currently being done was not always what the team thought was being done 2. Discussed/revised policies & procedures - Small workgroups including members of the practice were formed 3. Worked with Allscripts (EMR) and Ambulatory Information Management (AIM) to determine tracking and documentation capabilities 4. Developed quality improvement projects 13
Transformation Process and Policy Updates in Line With NCQA Standards Written policies and procedures are required for many elements within the PCMH 2011 standards Developed, or re-wrote, 23 policies to comply with the PCMH standards Written by PCMH Care Coordinator Approved by core PCMH team Signed by medical director Educated staff/providers/residents of policies and procedures Staff meetings Emails Huddles 14
Transformation Rapid Cycle PDSA: Plan-Do-Study-Act Four-stage problem-solving model used for improving a process or carrying out change: * Stage 1: Plan Identify an opportunity, and plan for improvement Stage 2: Do Start carrying out your plan Stage 3: Study Examine your results Stage 4: Act Continue to examine and re-examine your process using the PDSA cycle, by standardizing the improvement or developing a new theory, and establishing future plans * http://www.health.state.mn.us/divs/opi/qi/toolbox/pdsa.html 15
Transformation Rapid Cycle PDSA: Plan-Do-Study-Act Access to Care: Can we improve patient satisfaction by offering same-day (urgent) appointments? 2 month project: 11.49% Tdap Immunizations in Diabetic Patients: Can we increase the number of diabetics that receive the Tdap immunizations? 1 month project: 11.7% Pneumonia Vaccine in Older Adults: Can we increase the number of older adults that receive the pneumonia vaccine? 1month project: 13.46% ED Visits: Can we increase the number of patients that are seen in the clinic following a visit to the emergency department? First month: 69% (Did not meet goal of 75%) Second month: 78% (Goal met!) 16
Transformation Increased Daily Open Access Two time slots per provider, per session, are maintained for same day appointments for urgent and non-urgent medical issues. The chart below demonstrates to NCQA how our practice was able to provide same-day appointments, which provides patients with access to routine/urgent care appointments. 17
Transformation Saturday Hours Extended hours appointments are available on Saturday from 8 AM to 12 noon Patients were notified of the available extended hours through the hospital internet system and flyers and brochures that are posted in the lobby of the Internal Medicine Health Center 18
Transformation Evening Hours Extended hour appointments have been available since August 6, 2012 Currently offered Monday through Wednesday from 5 PM to 7 PM. Patients were notified of the available extended hours through the hospital internet system and flyers and brochures that are posted in the lobby of the Internal Medicine Health Center 19
Transformation Ambulatory Information Management (AIM) Available through Allscripts (EMR) Registries: COPD, Diabetes, Asthma, Congestive Heart Failure (CHF), Coronary Artery Disease Preventive Screenings: Mammograms, Colonoscopies, Flu Vaccine Patient Information: DOB, Ethnicity, Email Addresses Clinical Data: Problem List, Allergies, Height/Weight, Smoking Status 20
Transformation Ambulatory Information Management Use Data for Population Management: - Preventive care services: Mammograms, Pneumovax >65 years and diabetics - Chronic care services (diabetic patients): HgbA1c, Lipids, Eye Exam, Pneumonia Vaccine, Foot Exam, Urine Microalbumin - Patients not seen in >1 year - Patients on specific medications: Coumadin 21
Transformation Patient Advisory Council SJHMC Internal Medicine Patient Advisory Council is a group of committed patients, caregivers, healthcare providers and staff who work together as active partners to improve the healthcare experience Mission Statement: Working to create patient-centered care through the voice of our patients Vision Statement: An innovative healthcare community that will respectfully and compassionately listen, learn and communicate with patients and their families to create safe, high-quality care What have they done? Produced an educational/informative DVD for the waiting room Developed a pre-appointment questionnaire Write articles for quarterly newsletter Update bulletin boards in the clinic Review patient satisfaction survey 22
Outcomes PCMH 1: Enhanced access and continuity Enhanced open access Every patient has an assigned PCP preferably at the first appointment Team based approach to maintain continuity of care (max 3 different providers) 30 minute time frame to return calls after hours and improved documentation of advice given in the EMR Reduction in ED visits and inpatient admissions 23
% of Calls that Meet Policy Documentation of After Hour Calls in the EMR 100% Provider Performance for After Hour Calls 90% 80% 70% 60% 50% 40% YES NO 30% 20% 10% 0% 7 8 9 10 11 12 1 2 3 4 2012 2013 24
ED Visits/k 01/01/2012-12/31/2012 Perfomance for ED visits per 1000 1,800 1,600 1,645 1,400 1,257 1,200 1,101 1,155 1,117 1,000 949 800 600 400 200 - Baseline Q1 Jan-Mar Q2 Apr-Jun Q3 Jul-Sep Q4 Oct-Dec Annual Performance Period 25
ED Visits/k 01/01/2012-12/31/2012 Perfomance for IP Visits per 1000 500 450 459 400 350 357 355 312 327 300 285 250 200 150 100 50 - Baseline Q1 Jan-Mar Q2 Apr-Jun Q3 Jul-Sep Q4 Oct-Dec Annual Performance Period 26
Outcomes ED visits Inpatient admissions 32 % 29 % 27
Outcomes PCMH 2: Identify and manage patient populations >90% of patients provided clinical summary of visit Currently managing Diabetes, Coumadin, preventive screenings Identifying patient s who have not been seen in the practice for > 1 year and calling them for appointments 28
Outcomes PCMH 3:Plan/Manage Care Development of templates/care guides in EMR which are evidence based. Registry data collection is based on evidence based guidelines Now able to identify patients who are high risk- based on chronic conditions, polypharmacy, age, insurance, controlled substance use, SMI, ED visits (from registry + MCP data) 40% of our practice is high risk 14-25% of patients from MCP are high risk Individualized plan for high risk, high utilizers- intensive care co-ordination Medication reconciliation January 1, 2013 June 30, 2013 41.4% July 1, 2013 September 23, 2013 74.4% 29
Outcomes PCMH 4: Provide Self Care Support/ Community Resources Increased ability to connect patient s with community based services Diabetes group visits, on site monthly CDE classes Increase in counseling documentation 30
Outcomes PCMH 5: Track and coordinate care Daily reports on ED visits from St. Joseph s Hospital and Banner First contact within 48 hours after ED visit or inpatient admission, and appointment within 7-14 days Transitional care visits Actively track referrals and obtain consultation reports 31
Outcomes PCMH 6: Measure/Improve Performance Comment cards in the rooms Patient survey Individual provider quality metrics 32
Implications Medical home yields results with significant investment Physician and practice adoption is a major challenge Care coordination is key Health information technology is essential Ability to populate and manage registries One size does not fit all Long term sustainability and maintenance of certification 33
Collateral Projects Population based curriculum QI projects for residents Active management of registries Patient portal E-visits Partnership with more health care plans Coordinating PCMH efforts across St. Joseph s primary care sites to ensure long term sustainability of all practices 34
Resources for Practices 1. http://www.health.state.mn.us/divs/opi/qi/toolbox/docs/pdsa_flowchart.pdf 2. http://www.integration.samhsa.gov/pbhci-learning-community/pdsa_worksheet.pdf 3. https://www.communitycarenc.org/emerging-initiatives/pcmh-central1/2011-pcmh-resources/ 4. http://www.ncqa.org/ 5. Benefits or Implementing the Primary care Patient- Centered Medical Home: A review of cost and quality results, 2012: Nielsen, M, Langner, B, Zema, C, Hacker, C,Grundy P 35
IMPACT 36
What do we need to change? Think Systems not individual Build resilience Teams HIT champions Systems change champions 37
If my dog can have coordinated care I deserve it too
Acknowledgements Brett Mcclain, CEO SJMG William Ellert, MD, CMO SJMG Mercy Care Plan Jo Barone, RN Veena Dhillon, Manager IMHC Cynthia ( Kim) Phan Rachita Gupta 39
Thank you