PCMH in the Direct Care System Regina Julian, MHA, MBA, FACHE Ch, Primary Care, Access, Experience and Integration Defense Health Agency Past Deputy Director of TMA Medical Management and Population Health Regina.m.julian.civ@mail.mil 12-1
Disclosures Presenter has no financial interests to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with the MedExcellence Program. PESG, and MedExcellence Staff, and accrediting organization do not support or endorse any product or service mentioned in this activity. PESG and MedExcellence Program staff has no financial interest to disclose. 12-2
Learning Objectives 1. Attendees will understand the reasons why governance selected the PCMH model of care and why those reasons still apply 2. Attendees will understand how performance has changed and the leading practices required to drive further improvement 3. Attendees will understand challenges and leadership priorities for both PCMH and the integrated delivery system. 12-3
Outline Brief History Lesson The Journey What makes a successful PCMH? How do we compare to the civilians? How Are We Doing? Service Specifics Challenges Governance Approvals Priorities and Way Ahead 12-4
Brief History Lesson Variance Fragmented care - PCM Continuity was 30% Access issues Patients got lost - literally MHS PCMH Policy signed Sep 2009 directed development of Army, Navy and Air Force PCMH operating instructions and implementation in all 440+ primary care clinics Common standards needed to drive consistency across all Uniformed Services 5 12-5
The Journey Tri-Service PCMH Advisory Board and Governance Defense Health Agency role in leading collaboration 6 12-6
The Journey Staffing models "Get Well" POM funding with ROI tied to common measures and performance goals -- Enrollment per PCM-based resourcing (away from RVUs and churn) Tri-Service Workflow forms with 18+ embedded clinical practice guidelines and prompts for preventive and other screening Selection of NCQA industry "gold standard" to drive MHS PCMH transformation and meet Seven Core Principles through recognition Access to Care Standards codified in law Embedded behavioral health specialist, clinical pharmacists and physical therapists based on our most prevalent conditions Secure messaging and a 24-hour Nurse Advice Line implementation Identification and validation of new leading practices Training curricula (Service-Specific) 7 12-7
How do we compare to the civilians? Measure PCPCC Reported Results Direct Care Results ER Utilization Recapturable to Primary Care Reduced; Multi-site/state examples range from -3.2% to -12%; Avg reduction 8.7% Reduced 11% Cost per ER Visit Recapturable ER Costs (for Primary Care reasons) Patient Satisfaction Access to Care One State Demo reported 3.5% cost reduction per ER visit One state demo reported "reduced" ER costs Multiple State Demos reported "improved" patient satisfaction One state demo reported 4% more appointments Primary Care recapturable ER cost per visit up 2.7% (visits down, cost per visit is up); cost per visit for true emergencies up 4.3% per visit Reduced total costs 2.2% from $77M in FY13 to $75M in FY15 (we had fewer visits but a higher cost per visit) All Services and TROSS have either improved and/or are over 90% 16% more primary care appointments per duty day available in Jan 16 due to Simplified Appointing and capacity accountability by Services 8 12-8
How do we compare to the civilians? Measure PCPCC Reported Results Direct Care Results Inpatient Admissions per 1,000 Reduced; Multi-site/state examples range from 1.7% to 25%; Avg reduction 11% Reduced 15% from FY12 to FY15 Bed-Days per 1,000 Reduced 8% (NY) and 11% (MD) Reduced 12% from FY12 to FY15 Inpatient (IP) Costs Anthem (Multi-state demo) reduced costs 3.5% IP Claims reduced 12% FY12 to FY15 Primary Care Utilization ER Utilization (all ER visits) Reduced; Multi-site/state examples range from 2.7% to 17% reduction. One state demo had a 11% increase in utilization State demos' results range from "some reduction" to -1.6% in Anthem multi-state demo and -22% in Oregon Medicaid demo Reduced 3.8% Total ER utilization down 7% (down 7% in direct care ER; down 5% in PSC ER) CMS Response? The most important, large-scale transformation. 9 12-9
Access to 24-Hour Appointments Mean, median and variance all improved since MHS Review Average Aug-14 Apr-16 Change since MHS Review Air Force 2.50 1.68-33% Army 2.00 1.24-38% NCR MD 2.80 1.33-53% Navy 1.20 0.85-29% Direct Care 2.00 1.32-34% August 2014 April 2016 Change Mean in days 2.00 1.32-34% Median in days 1.78 1.05-41% Variance 1.42 0.74-48% 10 12-10
ER Visits for Primary Care Reasons All ER visits for MTF enrollees decreased 11% overall since FY12 Primary Care-sensitive/capturable network ER visits down 27% since FY12 These visits account for 4% of all network ER visits and 2% of costs 11 12-11
Reducing Unnecessary Inpatient Utilization PMCHs contributed to lower inpatient dispositions and fewer bed days per MTF enrollee through comprehensive, coordinated care Since FY12, inpatient dispositions 19%; 11% for diabetesrelated admissions 12 12-12
Primary Care Market Share MTFs deliver 93% of MTF enrollee primary care workload 88% in PCMH and 4% in after-hours MTF ER/UC Fast Tracks 8% delivered in network (<.2% ER and 8% UCCs) Next step: Increase convenience for our patients and improve their MTF continuity by expanding extended hours and direct care UC Fast Tracks (integrated virtually PCMH through colleague to colleague secure messaging, etc.) 13 12-13
Leading Practices Team-based demand management to enhance access beyond face-to-face encounters with PCM Pre-visit planning/scrub templates - Focus on proactive, comprehensive care (vs. fragmented, episodic) Virtual health and Telephone Visits Nurse-run walk-in clinics for common acute conditions Proactive high utilizer outreach Fully utilize embedded specialists and MM, especially for high utilizers Simplified Appointing Guidance and First Call Resolution Two appointment types When would you like to be seen See Today s Patients Today Match supply and demand by time of day/day of week where economically feasible 14 12-14
What makes a successful PCMH? Engaged Leadership PCMH Management and Oversight Commitment to continuity Utilization of TSWF Robust use of team-based workflow and Nurse/Tech SSP (GS and other performance plans rated on use of team-based workflow) Active promotion of all team members on use of enhanced access tools (NAL, SM, internal BH) Adequate, standard training on processes, roles and responsibilities as well as periodic refresher and follow-up (accountability) Training / Roles and Responsibilities Full commitment to accept walk in during duty hours (including NAL pts) Patient education / orientation Active presence on Social Media and Patient Advocate 15 12-15
Examples Hickam- resiliency training for minor illnesses with a special card for the pharmacy Martin ACH - Direct Care Acute Care Clinic tied to the PCMHs NH Pensacola- specialty care booking in the primary care clinic at the time of the referral Colorado emsm- multidisciplinary pain team in the market showing a 60% improvement in getting patients off of narcotics, or using less narcotics 16 12-16
Seeing a Provider When Needed - Challenge Primary care annual utilization is higher than the national average in an insured population (CDC) 48% of enrollees have 5 or more visits per year - address utilization through team-based approach Develop standard processes to meet patient needs beyond a face-to-face appointment virtually via PCM phone call, T-Con, standard booking protocols for needs that do not require an appointment Leading practices demonstrated 40%+ reduction in high ER users through personalized intervention by embedded BH and Medical Management 17 12-17
Changing Landscape of Healthcare 5.00 ER Utilization and Acute Appointment Availability Trends 0.60 ED Utilization per 100 Enrolled 4.50 4.00 3.50 3.00 0.55 0.50 0.45 0.40 0.35 % Acute Appointments In Schedules 2.50 0.30 18 ED Utilization ED Use Target 3.7 % Acute Appointments 12-18
Challenges Demand and public perception of MHS/access Utilization is more than double the civilian sector Urgent Care Pilot despite recent Health Affairs study showing UCC create a new demand, and do not decrease ER demand Staff Change fatigue Hiring and other Staffing Challenges IT system limitations and MHS Genesis Resources Mobility of our staff and our patients NDAA 2016 (Patient Experience) and 2017 19 12-19
Recent Governance-Approved Activities (MDAG) PCMH is the direct care system model of primary care TSWF to be used to document screening in all primary care encounters Third Next Appointment Changes TJC to recognizes/certify PCMHs Global NAL Secure messaging to remain in place until MHS Genesis portal on-line Tri-Service standard PCMH, access and customer service training Specialty Appointing and Referral Policy Codify other leading practices into Tri-Service guidance 20 12-20
New Specialty Care Access Measures Governance recommends two specialty care access measures to evaluate the patient experience with the specialty appointing process Number of Days from Consult to CHCS Appointing; and Number of Days from CHCS Appointing to Appointment (Days to SPEC) A: Avg 12 days B: Avg 14 days A B 21 12-21
Tri-Service Priorities and Way Ahead PCMH is the foundation of what we do Integration underway to standardize patient-centered specialty care Tri-Service Priorities Optimize by implementing best practices Training from Leadership to staff Improve patient experience Increase convenience Leverage telehealth Focus on the health of our population Make the Direct Care system care location of choice 12-22
Back Up Slides Service Initiatives 23 12-23
Medical Home Port Navy Medicine (BSO-18) currently operates 188 primary care practices with 264 teams across 119 MTFs. Practice Type MEPRS Practice s Internal Medicine BAA/BAZ 5/10 Family Medicine BGZ 87 Pediatrics BDZ 16 Primary Care (AD Only and Training) BHA 40 Flight Medicine BJA 26 Undersea Medicine BKA 4 Expanded from nine Pilot locations to 19 new MHPs last year with deployment of 17 additional MCMH and two FCMH practices. 24 12-24
Navy Operational Medical Home 25 Pilot FCMH Locations 2015 Implementation Sites Location # of Teams Location # of Teams NAS Whidbey Island, WA 2 NAS Lemoore, CA 1 NAS North Island, CA 1 NS Bangor, WA 1 NS Gulfport, MS* 1 Pilot MCMH Locations Location MCB Camp Lejeune, NC (French Creek) # of Teams Location 2015 Implementation Sites 1 MCAS Beaufort, SC 2 MCAS Cherry Point, NC 2 MCB Camp Lejeune, NC (Courthouse Bay & Hadnot Point) MCB Camp Pendleton, CA (62 Area) 1 MCAS New River, NC 2 MCAS Miramar, CA 2 MCB Camp Pendleton, CA (Areas 21, 22, 33, 41, 43 & 53) MCB Okinawa, JA (Hansen & Kinser) 2 MCAS Yuma, AZ 1 *FCMH Gulfport received NCQA PCMH Level 3 recognition in 2015, and was the first to receive recognition within the MHS MCB 29 Palms, CA 2 MCB Okinawa, JA (Courtney, Foster, Futenma & Schwab) MCAS Iwakuni 1 # of Teams 2 7 4 12-25
AMH Status 136 AMHs (PCMH, CBMH and SCMH) > 44 pure SCMHs TRADOC and USASOC SCMHs in implementation phases Nurse Advice Line (NAL) Tremendous growth (i.e., FT Hood and FT Bragg) Adjunct to face-to-face encounters Access during off-duty hours/weekends/holidays Telehealth initiatives ED: FT Campbell pilot ongoing At-Home: OPORD being drafted Remote Monitoring (disease monitoring): JBLM pilot implementation Secure Messaging Huddle Tool 12-26
AF Patient Centeredness IOM 2001 Crossing the Quality Chasm Care that is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values guide all clinical decisions Trusted Care CONOPS; Patient Centeredness AFMS places the patient at the center of everything it does AFMS defines value from the patient perspective AFMS anticipates the patient s expectations and excels in every aspect of the patient experience Patients are enabled, informed, and empowered to actively engage in the delivery of their care and the systems that support it Multiple Lines of Effort/ Initiatives to launch in 2016-2017 27 12-27
Patient Activation DoD Patient Activation Reference Guide, 2013 28 Activated and Engaged Patients are Indispensable Partners on the Road to High Reliability Trusted Care with Zero Harm 12-28