The Patient-centered Medical Home Webinar #4 Topic 4A: Foundational Changes Reducing Barriers to Care Webinar Ed Wagner, MD, MPH, MACP MacColl Center for Health Care Innovation Group Health Research Institute Krista Collins, BS Central City Concern, Old Town Clinic Linda Thomas-Hemak, MD The Wright Center for Primary Care January 2013
Welcome Introductions and Housekeeping - lori.hooks@tmf.org FQHC_MH_DEMO@cms.hhs.gov - PCMH-GRIP@ncqa.org www.ncqa.org/gri Please visit the AIR FQHC Learning Portal for more information on upcoming events at http://fqhcportal.airprojects.org Speaker introductions
Don t try to change everything at once Group and sequence the changes: 1. Lay the foundation Engaged leadership Quality Improvement (QI) strategy 2. Build relationships 3. Change care delivery 4. Reduce barriers to care Empanelment Continuous, team-based relationships Patient-centered interactions Organized, evidence-based care Enhanced access Care coordination 3
Enhanced access The goal is to ensure that established patients have 24/7 continuous access to their care teams by phone, email, or inperson visits and to avoid unnecessary emergency department (ED) visits. What is access? It s patients sense/belief that they can get the care they need when they need it. Where to begin? Help patients understand their care system and how to use it. 4
The cost of poor access Patients who face waits and delays will sometimes skip needed care. More access to primary care results in improved outcomes and reduced Medicare spending per beneficiary. Lacy N, et al. Ann Fam Med. 2004;2:541-545. Fisher ES, et al. Ann Intern Med. 2003;138:273 287. 5
Enhanced access Promote and expand access; ensure that established patients have 24/7 continuous access to their care teams by phone, email, or in-person visits. Provide scheduling options that are patient- and familycentered and accessible to all patients. Help patients attain and understand health insurance coverage. 6
The PCMH access standard Promote and expand access; ensure that established patients have 24/7 continuous access to their care teams by phone, email, or in-person visits. Can this be realistically accomplished? Even in a smaller health center? 7
NCQA QI must-pass element 1A: Same-day access The practice reserves time for same-day appointments for routine and urgent care Clinicians return calls or respond to secure electronic messages in a timely manner Clinical advice must be documented in the patient record. Use the PCMH-A to help pass the must-pass items. To pass these items your PCMH-A scores should be: at least at level B on items 20-23. 8
Steps toward same-day access Measure demand Use log sheets to record requests for appointments, refills, or other provider services. Understand supply & demand Look at the relationship between demand (requests for appointments) and supply (available appointments by provider. Work down the backlog Same-day appointments are difficult if patients are having to wait longer than they want for an appointment. Adjust appointments Simplify appointment types & leave open slots each day. Add options: email, group, phone/video, home visits. 9
Approaches to providing access after hours Even a few hours of after-hours appointments reduces ED visits. Cross-coverage arrangements, if well organized, can satisfy patients. Email patient portals with assurances of reasonable response time are changing practice. Many physicians tell us they give their patients their cell phone numbers & survive. Also: nurse consultation lines. 10
Clinic Example: Advanced Access Central City Concern, Old Town Clinic Portland, OR 12 physicians More than 3,000 patients and 20,000 visits annually FQHC and safety net clinic serving patients primarily impacted by homelessness, poverty, and addiction Presented by Krista Collins, BS, Lead Quality Improvement Specialist 11
Advanced Access initial launch - 2007 Advanced Access during initial launch did not stick rapid regression to the mean, then abandonment altogether. Why: Problems we encountered in 2007: Lack of technical expertise (internal and external) Collected lots of data and didn t know what to do with/lacked will to do something with it Launch and preparation itself was anemic No internal QA/QI once system was launched No feedback from staff and patients 12
Advanced Access 2.0-2012 Went live with Advanced Access 2.0 in early 2012: Incorporated same-day/next-day appointment slots into provider schedules Reduced the number of appointment types Standardized the length of general medical appointments (20 minutes) Standardized how far out an appointment could be scheduled in advance (2 weeks) 13
Advanced Access 2.0 - Results Same-day/next-day access increased from 21% to 40%(average) Third Next Available decreased from 6-12 to 2-4 days Maintained team continuity (>80%) Positive patient and provider feedback Third Next Available Same-Day/Next-Day 14
Factors for success 15
Lessons learned & future improvements Same-day/Next-day appointment slots Most slots used for next-day appointments (additional team capacity absorbed after new providers established panels) Now testing classic AA model by adding sameday appointment slots for one care team Governance: review current AA model & suggest improvements Standardization of appointment timeframe Tension between 2- week appointment window and 28-day refills RENEW, our clinic s chronic pain and wellness program, helps to ensure that these patients have the opportunity to see a provider before their refills are needed Access Went live with phone tree in July of 2012; scheduling option of our phone tree among highest abandonment rate for the clinic Standardized provider schedules, but still need to work toward matching supply with demand based on day of the week 16
Care coordination The goal is to track and support patients when they obtain services outside the practice, and to ensure safe and timely referrals or transitions. 17
Care coordination Link Integrate Track & support Follow up Communicate patients with community resources to facilitate referrals and respond to social service needs. behavioral health and specialty care into care delivery through co-location or referral arrangements. patients when they obtain services outside the practice. with patients within a few days of an emergency room visit or hospital discharge. test results and care plans to patients & families. Provide care management services for high-risk patients. 18
Care fragmentation Provider referral networks have become larger and depersonalized. Obtaining specialty support is still a major problem for safety net providers. The gulf between inpatient and outpatient care has widened. Valuable social/support services are often underutilized. Studies demonstrate that critical patient information for referrals and transitions are often missing, which distresses patients and is unhelpful (or worse) for providers. 19
Effects of care fragmentation Primary care providers (PCPs) reporting that they always get information back after a referral: PCPs routinely notified about discharges: PCP involved in discussion before discharge: Discharge summaries received by PCP within 2 weeks: Discharge summaries without info on pending tests: Discharge summaries without discharge medications: Discharge summaries without follow-up plans: 37% 17-20% 3-23% 20-40% 65% 21% 14% Kripilani, et al. JAMA 2007. Bell, et al. JGIM 2008. 20
Care coordination Care coordination is the deliberate integration of patient care activities between two or more participants involved in a patient s care to facilitate the appropriate delivery of health care services. It refers to activities and interventions that attempt to reduce fragmentation and improve the quality of referrals and transitions. McDonald, et al. Closing the Quality Gap, Vol. 7. AHRQ, 2007. 21
NCQA must-pass element (PCMH 5B): Referral tracking and follow up The practice coordinates referrals by: Providing reason for referral and relevant clinical information. Tracking referral status. Following up to obtain specialist s report. Documenting agreements with specialists for co-management. Providing electronic exchange of patient information. Use the PCMH-A to help pass the must-pass items. To pass these items your PCMH-A scores should be: at least level B on items 24-26. 22
Care Coordination Model 23
How to improve care coordination 1. Assume accountability 2. Provide patient support 3. Build relationships & agreements 4. Develop connectivity 24
Clinic example: Referral Tracking The Wright Center for Primary Care Mid-Valley Practice Archibald, PA Academic, Level 3 NCQA, Safety Net Medical Home 5 physicians (4 FTE) 1 NP, 3 PAs 1 RN Care Manager, 1 Social Worker 3 LPNs and 8 MAs 3 Receptionists, 1 Referral/Scheduler 1 EHR Application Specialist Presented by Dr. Linda Thomas-Hemak, MD 25
What we changed and why Care coordination: Closing the loop through referral tracking is one of the greatest benefits we provide as patient advocates. Uncoordinated, reactive care Causes patient and provider frustration & anxiety Diminishes health outcomes Redundant & reactive work vs. Strategic referral tracking Care utilization & compliance are enhanced Barriers to care are identified & mitigated Patients appreciate the organized effort! 26
How we implemented changes Leadership: Physician and management consensus Intentional Meaningful Use of EHR software functionality Building an accountable and leaner Medical Home and Medical Village 27
Intentional MU of EHR software functionality One process and language for REAL Meaningful Use Noting preferred provider, indication, and risk stratified, color coded time expectations Engaging data management: Close only with attached outcomes For example: a colonoscopy order remains open until procedural notes/biopsies are done Specialty specific referral attachments Collectively working the open referrals exception report 28
Building a leaner Medical Home & Village Collective Office Accountability Assigning an accountable Referral Queen Open referrals run chart Emphasizing shared accountability for clean up Building our office capacity with work redistribution Specialty-specific and destination-driven referral attachments Redistributing scheduling work to specialty offices Hunting for missing outcomes and high-volume offenders Preferentially promoting our Good Neighbors Identifying and Mitigating Barriers to Care Enhancing utilization to avoid acute problems Reducing duplicative work 29
Results & lessons learned Expert-centric, meaningless EHR use is a real nightmare that agitates everybody! Referral tracking is daunting and endless, but the power is undeniable for leaner workflow and better care Care utilization and compliance are enhanced as barriers to care utilization are identified and addressed Patients appreciate the organized advocacy effort It s just the beginning: orders, x-rays & labs need the same strategy 30
Steps for improving care coordination 1. Assume accountability Initiate conversations with key consultants, EDs, hospitals, and community service agencies. Set up an infrastructure to track and support patients going outside the PCMH for care referral coordinator and tracking system. 31
Steps for improving care coordination (cont.) 2. Provide patient support Help patients identify sources of service especially community resources. Help patients make appointments. Track referrals & help resolve problems. Ensure transfer of information. Monitor hospital and ED utilization reports. Manage e-referral system. 32
Steps for improving care coordination (cont.) 3. Build relationships & agreements Primary care leaders initiate conversations with key specialists, hospitals, and community services around mutual expectations. Specialists have legitimate concerns about inappropriate or unclear reasons for referral, inadequate prior testing, etc. Agreements are sometimes put in writing or incorporated into e-referral systems. 33
Steps for improving care coordination (cont.) 4. Develop connectivity Most of the complaints from both PCPs and specialists focus on communication problems: too little or no information, etc. Evidence indicates that standardized formats increase provider satisfaction. Consider three options for more effective flow of standardized information: shared EHR, e-referral, & structured referral forms. 34
Why make care coordination a priority? Happier patients Patients and families hate it that we can t make this work. Fewer problems Poor hand-offs lead to delays, lapses in care, adverse drug effects, and other problems that may be dangerous to health. Less waste Happier physicians & staff Enormous waste is associated with duplicate testing, unnecessary referrals, unwanted specialist-to-specialist referrals, and failed transitions from hospitals, EDs, & nursing homes. Clinical practice will be more rewarding. 35
Safety Net Medical Home Initiative Resources To help practices understand and implement the Patient-centered Medical Home (PCMH), we have created a library of resources and tools, all of which are publicly available on the web site. http://www.safetynetmedicalhome.org/ A good way to find resources is to look at the Change Concepts tab (e.g., care coordination) on the web site. 36
Safety Net Medical Home Initiative This presentation is based on content produced for the Safety Net Medical Home Initiative, which is supported by The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice policy. The views presented here are those of the author and not necessarily those of The Commonwealth Fund, its directors, officers, or staff. The Initiative also receives support from the Colorado Health Foundation, Jewish Healthcare Foundation, Northwest Health Foundation, The Boston Foundation, Blue Cross Blue Shield of Massachusetts Foundation, Partners Community Benefit Fund, Blue Cross of Idaho, and the Beth Israel Deaconess Medical Center. For more information about The Commonwealth Fund, refer to www.cmwf.org. The objective of the Safety Net Medical Home Initiative is to develop and demonstrate a replicable and sustainable implementation model to transform primary care safety net practices into patient-centered medical homes with benchmark performance in quality, efficiency, and patient experience. The Initiative is administered by Qualis Health and conducted in partnership with the MacColl Center for Health Care Innovation at the Group Health Research Institute. Five regions were selected for participation (Colorado, Idaho, Massachusetts, Oregon and Pittsburgh), representing 65 safety net practices across the U.S. For more information about the Safety Net Medical Home Initiative, refer to www.safetynetmedicalhome.org. 37
Acknowledgement This presentation was produced by the MacColl Center for Health Care Innovation under a contract with the American Institutes for Research (AIR), with funding from the Center for Medicare & Medicaid Innovation, as part of the Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration (contract no. GS-10F-0112J, order no. HHSM-500-2011- 00147G). AIR would like to thank its partners the National Association of Community Health Centers, Inc.; Qualis Health; and the MacColl Center for Health Care Innovation at Group Health Research Institute for assisting with this endeavor. 38
Electronic referrals: PCMH & MU standards PCMH 5B -2: Tracking Status including timing for receiving report PCMH 5B-3: Follow up to obtain specialists reports PCMH 5B -1: Referral reason PCMH 5B-6: Capability to exchange key clinical information between clinicians PCMH 5B-7: Provide electronic summary of care to another provider MU Core Measure 15: Summary care record for each transition of care or referral
Risk-stratified open referrals report URGENT NOTES PRIORITY PCMH 5B -2: Tracking Status including timing for receiving report NORMAL NOTES
Advanced Access 2.0 Messaging Strong messaging campaign to both staff and patients about Advanced Access, including flyers and brochures for patients 41
Advanced Access 2.0 Education Created Advanced Access toolkit to explain what staff should do in different scenarios (e.g., urgent request, no appointments available, etc.) Staff educated about scheduling guidelines prior to launch Compliance was closely monitored after launch 42