Angela Herman, MPA Missouri Primary Care Association

Angela Herman, MPA Missouri Primary Care Association

Center for Primary Care Quality and Excellence Staff Providing Assistance on PCHH Angela Herman, Clinical Programs Manager and Center Deputy Director Janice Pirner, Member Services Manager Kathy Davenport, Quality Improvement and Risk Management Manager Noelle Parker, MO Quality Improvement Network Team Manager Joyce Hill, Clinical Programs Coordinator Lane Jacobs, Outreach Manager Karen Dent, Director Oral Health Network Susan Wilson, COO and Center Director Michael Felix, Consultant

What is a Patient-Centered Health Home (PCHH)? Patient-centered health homes provide comprehensive care in the context of individual, cultural, and community needs; they emphasize education, activation, and empowerment through system-level protocols and interpersonal interactions. At the center of the patient-centered health home are the patient and their relationship with their primary care team.

PCMH/PCHH National Recognition National Committee for Quality Assurance (NCQA) The Joint Commission (Standard Release January 2011 with Implementation July 2011) Accreditation Association for Ambulatory Care, Inc (Adjunct Standard Release Fall 2010)

National Committee for Quality Assurance (NCQA) and the PCMH NCQA developed a set of standards and a 3- tiered recognition process program) to assess the extent to which health care organizations are functioning as medical home Recognition requires completing an application and providing adequate documentation to show evidence that specific processes and policies are in place Recognition is offered at three levels: Level 1 basic Level 2 intermediate Level 3 advanced

NCQA Patient Centered Medical Home Standards Access and Communication Patient Tracking and Registry Functions Care Management Patient Self Management Support Electronic Prescribing Test Tracking Referral Tracking Performance Reporting and Improvement Advanced Electronic Communications

NCQA Scoring Methodology Level Points Must-Pass Elements Level 1 25-49 Level 2 50-74 Level 3 75-100 5 of 10, with a performance level of at least 50% 10 of 10, with a performance level of at least 50% 10 of 10, with a performance level of at least 50%

Key Components of Patient-Centered Health Homes Engaged Leadership Quality Improvement (QI) Strategy Patient-Centered Interactions Organized, Evidence-Based Care Continuous and Team-Based Healing Relationships Enhanced Access Empanelment Care Coordination The Commonwealth Fund

Key Components and Standards of Patient- Centered Health Homes are Interrelated NCQA Standards provide an opportunity for National Recognition and address the policy and procedures of care coordination and HIT Commonwealth Fund Key Components address the organizational/systems changes of care coordination and HIT

Benefits of PCHH Process Provides an excellent review of the organization s : Quality Improvement Programs Care Coordination- Both internal and external Community Linkages and access to specialty care Policies and procedures Corporate compliance Data extraction/reporting Meaningful Use of EMR

PCHH Consultation Services Offered by Center for Quality Conduct informational/buy-in meetings with Board of Directors and senior staff Conduct a site status assessment regarding PCHH based on Commonwealth Fund Key Components Create training and technical assistance plan based on site status assessment Provide consultation, training, and technical assistance to the organization s PCHH coordinator and team

Sample Site Implementation Team Members Clinical Director/Nursing Director Chronic Care Coordinator Front Office Supervisor IT Manager Medical Records Supervisor Staff Member Taking Lead on Template Development/Work Flow Analysis for EMR Referral Coordinator/Patient Assistance Coordinator Other Staff Members organization feels would provide input into the PCHH efforts Lead Contact Person will need to be identified for the team

Common Challenges Staff Shortage and Turnover Buy-In of all staff regarding importance of quality improvement Balance productivity demands with efficient and effective Patient-Centered Care Managing Change Maintaining High Functioning Teams Current Economic Climate Coordinating patient care with other providers in the community

Measures of Success Improved and/or enhanced: Patient-Centered Care Care Coordination- Both Internal and External Patient and Staff Satisfaction Clinical Outcomes Quality improvement Patient Safety Efficient and effective care Community Partnerships and Linkages Access to Specialty Care Revenue

Lessons Learned from the Field

Southeast Missouri Health Network SEMO Health Network(SEMOHN) is a Community Health Center that consists of five medical and three dental clinics located throughout the Bootheel of Missouri. SEMOHN is committed to provide affordable, quality healthcare to the communities of Southeast Missouri and finding more ways to serve our patients and communities and supply them with outstanding healthcare. Some of the services provided are Primary Health Care, Pediatrics, Women's Health, Men's Health, Family Medicine, Immunizations, Physicals, Accident/Work- Related Injuries, Dental, Digital X-rays, Outreach Lab and Medication Assistance.

Funding Mississippi Delta Consortium funding allows for the three CHC s involved to provide Mental Health Services, Diagnostic testing and Higher Levels of care to qualifying chronic care patients. Grant utilizes Healthy People 2020 Goals and Objectives for CVD, DM and Depression Partners: Cross Trails Medical Center and Great Mines Health Care Partnership with CMHC s, Private Physicians and Hospitals for specialized care, testing, mental health and an occasional surgery.

Organization Goal Regarding PCHH Recognition Achieve NCQA Level Three Recognition by August 31, 2010 Organization was notified August 12, 2010 that they received Level 3 Recognition for three of their sites First Missouri CHC to apply and receive Recognition Third Missouri primary care practice to receive Level 3 Recognition

PCHH Team Core Team Members Christa Tucker, MCS-P, Accounting Manager and Corporate Compliance and Ann Lawrence, LPN, Special Programs Director Other Team members Terunda Farr, Billing Supervisor Cindy Miller, Personnel Manager Mark Menley, RTR, Radiology Manager

Buy-in from Board PCHH Process Focus on Must Pass Initially Tips for pulling together supporting documentation Use policy and procedure manual Practice Management and EMR reports Work flow documents.

How has the PCHH Process Changed the Organization? Formalized policies and procedures Training for staff on EMR documentation Enhanced corporate compliance Revamping of Quality Improvement Program/Plan of the CHC Assisting in the enhancement of partnerships with hospitals and community mental health centers to improve access to care coordination and specialty care.

Dedicated coordinator Team effort Keys to Success Assistance from PCA to provide an objective review of the information Cooperation of staff Team members must have first hand knowledge of daily clinic operations

Funding Potential Funding Sources Hospital Community Betterment Grants Foundations Missouri HealthNet exploring 90-10 Program that is outlined in the Accountable Care Act Office of Rural Health s Delta States Rural Development Network Grant Program

Contact Information Angela Herman, MPA Clinical Programs Manager, MO-PCA Deputy Director of the Center for Quality aherman@mo-pca.org Ann Lawrence, LPN Special Programs Director Southeast Missouri Health Network ann.lawrence@semohealthnetwork.org Christa Tucker, MCS-P Accounting Manager and Corporate Compliance Southeast Missouri Health Network christa.tucker@semohealthnetwork.org