How to Build a Medical Home

How to Build a Medical Home NOTE: Make sure your computer speakers are turned ON. Audio will be streaming through your speakers. If you do not have computer speakers, call the ACCMA at 510-654-5383 for alternatives. We will begin shortly after 12:30 pm. HOW TO BUILD A MEDICAL HOME: Principles, Policy and Payment Leah Newkirk, JD Director of Health Policy 05/30/2013 California Academy of Family Physicians 1

Goals Definition: What is a medical home? Policies that encourage medical home development. Who is paying for the medical home? Evidence from a California pilot. What is a Medical Home? 2

Medical Home Background 1967: Concept introduced by American Academy of Pediatrics (AAP) 2004: Future of Family Medicine (FFM) expanded the concept 2006: ACP introduced its version, the advanced medical home 2007: AAFP, ACP, AAP & AOA drafted joint principles on the Patient-Centered Medical Home (PCMH) Nov. 2008: AMA adopts the joint principles 7 Medical Home Principles 1. Personal physician 2. Physician-directed medical practice 3. Whole-person orientation 4. Coordinated and/or integrated care 5. Quality and safety 6. Enhanced access 7. Payment 3

Attributes Increased Access; Population Management: planned visits, patient registries; Physician-directed team approach; Quality: Continuous QI; HIT: patient registries, EHRs; and Service-oriented culture. Investment in Medical Home = Management of Chronic Illness Management of chronic illness results in: Improved quality and health and lower costs Reduced hospital inpatient days and fewer ER visits Targeting higher risk patients results in more significant cost improvements 4

Savings How are savings achieved in PCMH model? Some prominent examples: Group Health: 16% reduction in hospital admissions; 29% reduction in ER use Geisinger: 18% reduction in hospital admissions; 7% reduction in total PMPM costs HealthPartners: 39% decrease in ER visits; 24% decrease in hospital admissions Policy 5

Medical Home Aligns with Current State and National Trends Emphasis on quality and transparency: Quality Reporting and Value-Based Payment Emphasis on patient-centered care Emphasis on technology: Meaningful Use Emphasis on practice redesign/innovation Emphasis on wellness promotion/disease prevention Emphasis on integration: Accountable Care Payment 6

Payment Payment recognizes high value care. Reflects the value of primary and preventive care Encourages practice team s involvement outside the face-to-face visit Pays for care coordination Supports the adoption and use of HIT Supports provision of enhanced access and additional forms of communication Ideal Payment Model Fee-for-service PLUS to primary care teams: Fee-for-service payments for face-to-face visits PMPM for care coordination, increased access and increased HIT Bonus payments/shared savings 7

Payers In 2012, several of the largest national plans announced that they will introduce enhanced primary care payment or payment for the medical home model. Wellpoint (Anthem) Aetna Blue Shield United But this has not rolled out in CA. Payers The Office of Personnel Management Covered California Employers Medicare: Value Based Payment Modifier (2015) 8

Fresno PCMH Initiative Parameters 18 months July 1, 2012 December 31, 2013 PCMH Joint Principles ~2,751 patients; 45 provider group Three-tiered payment structure Fee-for-service (FFS) Care management fee (PMPM) Pay for Performance (P4P) 9

Highlights of Practice Change Payer Involvement HealthTeamWorks Coaching Monthly Collaborative Use of Data New Staff: Quality Improvement Practice Coach and Complex Case Manager Quality Outcomes, at 6 Months Period 1 Period 2 Metric Number Metric Numerator Denominator Benchmark Percent Numerator Denominator Benchmark Percent 1 Diabetes -- HBA1c Poor Control (>9%) 276 574 48.08% 211 573 36.82% 2 Diabetes -- BP Control (Systolic<140 and Diastolic<90) 399 574 69.51% 405 573 70.68% 3 Diabetes -- LDL Control (LDL<100) 225 574 39.20% 253 573 44.15% 4 Diabetes -- Depression Screening 1 574 0.17% 280 573 48.87% 5 IVD -- LDL Control (LDL<100) 175 397 44.08% 205 397 51.64% 6 IVD -- BP Control (Systolic<140 and Diastolic<90) 290 397 73.05% 293 397 73.80% 7 IVD -- Depression Screening 1 397 0.25% 218 397 54.91% 8 Population -- Breast Cancer Screening 345 606 56.93% 416 609 68.31% 9 Population -- BMI Documentation 1,508 2,186 68.98% 1,693 2,199 76.99% 10a Population -- BMI Counseling (18-64) 45 729 6.17% 413 627 65.87% 10b Population -- BMI Counseling (65+) 20 171 11.70% 136 174 78.16% Notes: Diabetes and IVD (cardiovascular) populations are identified via the flag supplied. With the exception of HBA1c, all metrics are presented as the percent adherent to guidelines. For all quantitative measures, missing or invalid values are considered out of control. All measures consider only the adult population. 10

Quality Outcomes, at 6 Months Measures Period 1 Period 2 Member Count 2,186 2,199 Average Age 50.9 51.3 Percent Female 64.3% 64.3% Percent with BMI Counseling 6.5% 44.2% Percent with Depression Screen 0.1% 18.7% Percent of Females with Mammogram 25.5% 30.0% Percent with Clinical Snapshot 3.2% 38.7% Percent with Activity Counseling 18.4% 52.3% Percent High Risk Contact 0.0% 14.5% A1c Count 348 421 Average A1c 6.5 6.4 Systolic BP Count 1,777 1,849 Average Systolic BP 121.4 121.2 Diastolic BP Count 1,777 1,850 Average Diastolic BP 74.5 74.4 LDL Count 553 632 Average LDL 96.8 96.4 Count of Depression Screenings 2 411 Average Depression Score 18.5 3.8 Count of BMI 1,505 1,691 Average BMI 29.9 29.7 Count of Bad BMI 900 806 Average of Bad BMI 34.1 34.1 Includes adults without respect to age groupings. Cost Outcomes, at Six Months Measure PCMH Group Full Group Compare Comment Ttl Claims -21.74-11.93-9.81 Inp Adm -16.23-3.24-12.99 Office Visits -19.67-14.66-5.01 ER Visits -9.57 3.78-13.35 High Cost Trend -44.91-17.88-27.03 Inp Cost per Day -18.34-18.81 0.47 ER Expense -26.42-10.52-15.9 In dollars $ 431,165 Inp Cost total -30.31-20.15-10.16 In dollars $ 1,821,872 Avg per Admission -9.39-11.59 2.2 Members using EAP 22.7-5.9 28.6 Avg adherence rate -4.13-5.87 1.74 Avg ER Visits w/o PCP 61.5 0.71 60.79 Variability due to denominator 12 Recent period 7 Prior period 11

CAFP More than 8,500 family physician, resident and medical student members Strategic Goal: Advance the PCMH Model Why? Improve quality of care and patient health Strengthen the primary care profession Increase professional satisfaction Rejuvenate the primary care pipeline CAFP NOW Partnering with HealthTeamWorks and California Primary Care Association to offer YOU Transformation Support. Contact lnewkirk@familydocs.org for more information. 12

Questions? Leah Newkirk, JD Director of Health Policy California Academy of Family Physicians lnewkirk@familydocs.org 415.345.8667 The Road to PCMH Recognition: My Health Medical Group Larry Shore, MD May 30, 2013 2012 Brown & Toland Physicians 13

Agenda PCMH Definition, MHMG History & Staffing The Care Model, Role & Workflow Transformation MD and NP Roles New Workflows Panel Capacity Incorporating the Triple Aim Results to Date What s Next? Confidential / For Internal Use Only / 2012 Brown & Toland Physicians 27 What is a Patient Centered Medical Home? The Patient Centered Medical Home represents a healthcare relationship between patients and their physicians. Care is facilitated by provider teams, chronic disease registries, advanced information technology and other means to insure that patients get coordinated comprehensive care when and where they need it. Confidential / For Internal Use Only / 2012 Brown & Toland Physicians 28 14

MHMG History and Formation Brown & Toland Physicians Board approved Patient Centered Medical Home initiative in 2011 45 PCP s invited to informational meetings Office Manager chosen 4 physicians selected to found the practice Site selected and developed at 1700 California Street Medical Assistants from physicians practices hired Office opened March 1, 2012 Confidential / For Internal Use Only / 2012 Brown & Toland Physicians 29 Initial Staffing 4 physicians: 2 Internal Medicine, 2 Family Practice LCSW from Brown & Toland RN Care Manager from Brown & Toland Data Analyst from Brown & Toland Office Manager Clinical Medical Assistants and Patient Service Coordinators (reception, check out, back-office ops/phones) Confidential / For Internal Use Only / 2012 Brown & Toland Physicians 30 15

My Health Medical Group Today MD/NP teams managing risk adjusted panels supported by 2 to 3 Clinical MA s functioning in expanded roles Care Manager who oversees complex Transitions of Care patients and leads Population Health Management efforts and outreach Data Analyst provides monthly and quarterly data to assist Health Management and Business Management @ 2012 Brown & Toland Physicians 31 The Care Model, Role & Workflow Transformation Confidential / For Internal Use Only / 2012 Brown & Toland Physicians 32 16

A Clinically Integrated Care Model Advanced Primary Care Patient-Centered Medical Home Prevention & Wellness Point of Care Analytics / Gaps in Care Population Management & Chronic Care Registries Generic Prescribing Team-Based Care (NPs, Care Manager, MA s) Patient & Family Cost Effective Utilization of Specialists & Ancillaries Access, Same Day Appointments, e-visits Patient Satisfaction & Loyalty Provider & Office Staff Satisfaction Source: CAPG & Sharp Medical Group The Advanced Primary Care Model Jan 2013 presentation Confidential / For Internal Use Only / 2012 Brown & Toland Physicians 33 Role Transformation Staff: Development of Clinical Medical Assistant, Back Office, & Patient Services Coordinator Teams. Everyone functions at the top of their license. Active participation in practice redesign by all employees. MD s: USPTF screening guidelines and best practices in chronic disease management drive the morning MD/CMA huddle using the Care Planner. Allscripts HMP updated by CMA following protocol. Consistent use of Action Plan and Clinical Summary. Patients: Change patient expectations and their role in care, supporting self management. @ 2012 Brown & Toland Physicians 34 17

Evolving MD and NP Roles MD focus on sick, complex, and unstable patients MD has protected time and resources to proactively manage care and coordinate with specialists NP takes on majority of stable chronic, preventive and screening health exams. Some urgent care as well. Care Manager, along with Clinical Medical Assistants and Back Ops, rounds out the team, focused on outreach and Transitions of Care @ 2012 Brown & Toland Physicians 35 New PCMH Workflows Team huddles using the Care Planner CMA starts the patient note Patients help reconcile the medications list Action Plans created during visits Clinical Summaries for virtually all visits Modified Open Access Scheduling/ Quick Sick Extended Hours BTP After Hours Clinic evenings and weekends New Patient Portal Follow My Health 12/2012 Results reported to patients within 3 days by portal or letter @ 2012 Brown & Toland Physicians 36 18

The Building Blocks of Advanced Primary Care start with Risk Adjusted Panels Without a clearly defined patient panel it is not possible to track clinical outcomes or financial performance The patient panel is also the basis for staffing the office at every level Risk adjusting allows more precise staffing and normalizes the work effort between teams How do you know who your patients are in an open (ACO/PPO) system? What is the industry standard for a full panel? @ 2012 Brown & Toland Physicians 37 MHMG Solution Based on Data Multiple sources suggest that a full panel is 1800 patients per MD, using the U18 convention (unique encounters in the last 18 months) The CMS ACO algorithm can be used for patient assignment based on who provides the majority of care over a specified time period Panel capacity is adjusted for MD FTE status and for disease burden using the Care Analyzer Relative Risk Score (RRS) number for the provider s panel FNP can expand team panel capacity, with some caveats @ 2012 Brown & Toland Physicians 38 19

Risk Adjusted Panel Capacity Team Capacity = 1800*MD FTE + 1800*NP FTE*0.8 RRS For example, an MD with an RRS of 1.5 (older/sicker), working 0.8 FTE with an NP, also working 0.8 FTE, could be expected to manage a panel of about 2100 patients A 1.0 FTE MD with an RRS of 0.8 (younger/healthier) with a 1.0 FTE NP could manage a panel of about 3700 patients @ 2012 Brown & Toland Physicians 39 MHMG Goals Incorporating the principles of the Triple Aim: Improved Patient Experience Improved Patient Outcomes Bending the Cost curve Additional MHMG goals: First NCQA level 3 PCMH in the Bay Area Performance at or above the 75 th percentile in all categories (e.g. IHA, Press Ganey) Breaking even by 18 months Bring at least one new PCP to SF Spread best practices to PCP network @ 2012 Brown & Toland Physicians 40 20

Improving the Patient Experience Confidential / For Internal Use Only / 2012 Brown & Toland Physicians 41 Patient Access Goals Target: Baseline Data: Quality Improvement Plan Reduce Third Next Available (3NA) measure for urgent appointments to less than 2 days Q3 2012: Average 13.5 days with a range of 5.2 to 31.5 days Plan/Do/Study/Act : 1. Limiting scheduling to three months in advance 2. 30-40% of each day s schedule held for same day/next day 3. 10 minute Quick Sick appointment for established patients with straightforward problems 4. Reduce unnecessary follow up appointments for stable patients @ 2012 Brown & Toland Physicians 42 21

3NA Project Results Q4 2012: Average 3NA for urgent appointments reduced from 13.5 to 4.3 days 3 NA range reduced to 1.7-9.2 days Busiest provider dropped from 10.3 to 1.7 days Happy patients! Happy schedulers! @ 2012 Brown & Toland Physicians 43 Improved Patient Experience, Current Access: Third Next Available (3NA) now averaging 2.5 days Patients able to get same day appointment 85% of the time on average After Hours clinic started 8/1/2012 at MHMG site increases access for all patients Patient Satisfaction: Press Ganey Standard Overall Assessment 91 st percentile Favorable results from BTMG marketing surveys as well @ 2012 Brown & Toland Physicians 44 22

Improving Clinical Outcomes Confidential / For Internal Use Only / 2012 Brown & Toland Physicians 45 Clinical Quality Initiatives Underway to Improve Outcomes Humedica permits clinical outcomes assessment MHMG Performance Matrix highlights opportunities for improvement, starting with Diabetes Diabetes registry created with pursuit list for missing data supervised by Care Manager Population Health Management team meetings including MD/NP/MA/Back Ops focusing on high risk/complex patients @ 2012 Brown & Toland Physicians 46 23

47 Bending the Cost Curve A work in progress Confidential / For Internal Use Only / 2012 Brown & Toland Physicians 48 24

Cost Reduction Initiatives: Generic prescribing Extended access to reduce ER use Timely follow up visits for hospitalized patients to reduce readmission Parsimonious use of labs and imaging Choosing Wisely @ 2012 Brown & Toland Physicians 49 My Health Medical Group Achieves Level 3 NCQA Recognition & Practice of the Year February 19, 2013 Level 3 NCQA PCMH recognition March 2, 2013 My Health Medical Group named 2013 Patient Centered Medical Home Practice of the Year ( California Academy of Family Physicians award) 50 25

What's Next? Confidential / For Internal Use Only / 2012 Brown & Toland Physicians 51 What s Next Round out the Healthcare Team (1 PCP, 2 NP, New LCSW) Increase Patient Portal enrollment to 70% of the practice Incorporate patient input in Quality Improvement activities Develop the Medical Neighborhood Spread the workflows of Advanced Primary Care and the PCMH to other PCP practices within BTMG Confidential / For Internal Use Only / 2012 Brown & Toland Physicians 52 26

Thank You! 2012 Brown & Toland Physicians 53 Chase Gray, RN Regional Director Reprint with permission only HealthTeamWorks 54 27

Our Mission HealthTeamWorks is a non-profit collaborative working to redesign healthcare and promote integrated communities of care, using evidence based medicine and innovative systems to optimize health. Our goals are to improve quality and safety, reduce costs and improve the care experience for patients and their healthcare teams. Reprint with permission only HealthTeamWorks 55 Coaching and Transformation Coaching provides technical assistance to practices and/or systems in the transformation process to become a Patient Centered Medical Home Our expertise is in the implementation of these elements We support practices in doing the work themselves and help them experience how to become more resilient as healthcare delivery continues to change HealthTeamWorks Reprint with Permission Only 28

Quality Improvement Coaching Colorado PCMH Multi-Payer Pilot (completed) 16 practices CMS: Comprehensive Primary Care Initiative 59 practices PCMH Foundations 101 active practices PCMH Residency Program 10 Family Residency Sites Reprint with permission only HealthTeamWorks 57 Quality Improvement Coaching Out of State Collaborative Coaching Model-Coach University California Delaware Florida Illinois Iowa Kentucky New Jersey New Mexico New York Tennessee Texas Reprint with permission only HealthTeamWorks 58 29

The Commonwealth Fund In summary, rigorously conducted research has shown that practice coaching is an efficacious intervention to improve delivery of primary care services. All stakeholders committed to improving primary care will need to devote resources to support a practice coaching infrastructure. 59 The Triple Aim By The Institute for Healthcare Improvement Population Health Experience of Care Per Capita Cost 30

Elements of PCMH Team-Based Care Patient Access Population Management Evidence based guidelines Patient Engagement Leadership And Culture Care Management Care Coordination Performance Improvement 61 Transformation Paradigm Shift From One Patient From Patient From Lone Physician From Ultimate Authority From Acute/Episodic Care From Variation in Care Panels/Population Healthcare Partner Team Based Care Shared Decision Making Planned, Proactive Whole Person Care Evidence-based Guidelines (protocols) Reprint with HealthTeamWorks Permission Only HealthTeamWorks 62 31

What is Patient Centered Medical Home? An approach to providing high-quality, safe, continuous, coordinated, comprehensive care, with a partnership between patients and their personal health care team The kind of care you d want your mom to have! Reprint with permission only HealthTeamWorks 63 Practice Transformation Cannot be achieved merely through implementation of new technology Recognition does not = transformation Transformation takes dedicated time and resources at multiple levels Practices have competing priorities Can take unexpected turns Goal is to make PCMH implementation and continuous quality improvement a cultural aspect of the practice that is sustainable in the long term HealthTeamWorks Reprint with Permission Only 32

PCMH is not a diet it is a lifestyle change 65 Measurement of Success Meeting practice milestones Keeping implementation timelines Engaging leadership in PCMH New workflows for practice effectiveness/efficiency New communication methods Protocols/standing orders Performance improvement Clinical Quality Measures Patient Satisfaction Cost measures Reprint with HealthTeamWorks permission only HealthTeamWorks 66 33

Asthma Data Documented Action Plan 100% 95% 90% 83% 80% 70% 60% 60% 72% 70% 74% 50% 40% 30% 32% 31% 46% 35% 44% 20% 10% 0% Goal Reprint with permission only HealthTeamWorks 67 PCMH Pilot Diabetes Data March 2012 68 34

PCMH Foundations Diabetes Data Feb 2013 69 Changing the Delivery of Care 70 35

Changing the Delivery of Care 71 Changing the Delivery of Care 72 36

Changing the Delivery of Care 73 37