New Models of Health Care: The Patient Centered Medical Home Mark Gwynne, DO UNC- Chapel Hill Department of Family Medicine August 17, 2013
Objectives of this session: What s the burning platform for change? What are key components of new models of care? What are the core concepts of the PCMH? Does the PCMH work? How is it paid for? What does it mean to be Patient Centered and what does a PCMH look like? 2
Institute of Medicine
IOM: Crossing The Quality Chasm About 50% of the time, interventions that we all agree should happen don t, no matter what the problem or setting and it is much worse for patients who are poor or of color Quality of Chronic Illness Care» 15-24% adequate control of HTN» 42% of DM have appropriate lipid control» 38% A-fib on appropriate anticoagulation» 25% of Depression adequately treated» 40% CHF readmitted within 120 days 30-40% of US health care spending is waste (IOM 2005, CBO 2008) 4
IOM: Crossing The Quality Chasm Improvement in 6 domains 1) Safety 2) Effectiveness 3) Patient Centeredness 4) Timeliness 5) Efficiency 6) Equity Outline change at 4 levels: 1) Patient experience 2) Function of Microsystems 3) Function of organizations that have microsystems 4) Policy and Payment environment to support change 5
Future of Family Medicine 6
Traditional Model» Physician centered» Unnecessary barriers to access for patients» Reactive, fragmented care» Individual physician-patient visits» Experienced based» Haphazard chronic disease management New Model Patient centered Advanced access for patients Responsive, proactive and integrated Planned visits Evidence based Purposeful, organized chronic disease management
www.improvingchroniccare.org
9 Joint Principles of the Patient Centered Medical Home Principles Personal Physician Physician directed medical practice Whole Person Orientation Care Coordination/ Integrated Care Quality and Safety Enhanced Access Payment
Joint Principles of the Patient Centered Medical Home Joint Principles of PCMH Personal Physician Physician directed medical practice Whole Person Orientation Care Coordination/ Integrated Care Quality and Safety Enhanced Access Payment Pillars of Primary Care First-contact care Continuity of care over time Comprehensiveness, or concern for the entire patient rather than one organ system Coordination with other parts of the health system. * Physicians can t do this alone: The PCMH brings together several systems interventions 10
Outcomes of PCMH Trials Site ED Visits Quality Hospitalizations Cost Group Health -29% +36% sta)n -16% all cause $17 PMPM use CCNC -16% + asthma assessment + influenza vaccine -40% (asthma) - 20% reduction readmissions at 1 year -$380M in 2010 Geisenger (PA) +74 % preventa)ve care -18% all cause -50% readmission -7% total PMPM Genesis (MI) -50% -15% 26.6% fewer days Intermountain - 10% reduction $640/pt/year Hopkins Guided Care NCBCBS - 32.2% reduction in visits -15% 24% 37% Nursing Home Days Savings $1364/Pt $75K/RN $9-$13 PM/PM HealthPartners (MN) -39% +129% optimal DM score -24% hospitalization -40% readmissions - 8% 11
NCQA PCMH 2.0 2011 Standards 2011 Standard Changes from 2008 Standard 1 Access redefined After hours Same day access/advanced Access Continuity Electronic access 2 Population Management Move from tools (point of care) to managing populations 3 Expanded Care Management Behavioral Health - 3 rd Important Condition as unhealthy behavior, mental health, substance abuse Identification of High Risk Patients 4 Expanded self-management support and community resources 5 Expanded Care Coordination Transitions, referral tracking, specialist agreements 6 Expanded Quality Improvement continuous quality improvement Disparities/vulnerable populations Patient experience Patient Advisory Council 12
UNC Family Medicine Center 17,200 empaneled patients with visits in the past 18 months 64 PCP s 56,000 visits 2012-13 PCMH level 3 (2011 standards)
Access is critical Access redefined: not just extended hours and overbooking.» Advanced access scheduling 60.0 UNC Family Medicine Center - Historical Appointment Access Data Days 50.0 40.0 30.0 20.0 10.0-10.8 (Jun'13) Faculty Resident Overall Linear (Overall) 100.0 95.0 PATIENT SATISFACTION - Overall Satisfaction (3-month running average) by Month Introduction of new Press Ganey sampling method 90.0 85.0 80.0 75.0 70.0 14
Access is critical Access redefined: not just extended hours and overbooking» Asynchronous communication Message response time: email 10 hours less than phone calls Remote INR monitoring» After hours access: Good phone triage Management of symptoms new medications, new diagnoses» Access to the Team» MA, Pharmacist, RN, Care manager Minutes 50 40 30 20 32 24 29 21 30 19 Total Pa8ent Wait Time: FMC Faculty YTD 2012-2013 36 30 31 28 28 30 27 26 23 23 22 14 15 22 22 29 28 25 21 18 38 30 32 23 23 16 30 23 25 46 25 18 30 10 0 15
Care Management A collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual s and family s comprehensive health needs through communication and available resources to promote quality costeffective outcomes. Case Management Society of America, 2012 140 Trends: ED Visits and Inpatient Admissions MSW Model High risk panel 120 100 80 60 40 20 Inpatient Admission s trend_inp atient 8 ED visits/month 7.5 admissions per month 0 Year/Month (YYYYMM) 8/17/13 16
Team Based Care: Transitions Inpatient Service ACTion appointment (< 7 days post-discharge) Pharmacist PCP Care Manager (LCSW) % Discharges seen by ACTion team 25% No show rate 22.2% Overrall re-admission rate 25.0% Readmission rate of patients who attended ACTion appointment 16.7% Routine Care Co-management with Pharmacy Re-admission rate of no-show 27.3% Care Manager/PCP high risk panel
Continuous Quality Improvement: Engagement at All Levels Resident QIP project Screening rate = 58% 80% when visit was for DM, CHF, or CAD 18% when presented for different chief complaint Total patients 2578 Total screened 969 Positive PHQ-2 Positive PHQ-9 New Diagnosis 175 85 30 0 1000 2000 3000 18
Continuous Quality Improvement: The Practice 60% 50% 40% 30% 20% 10% 0% % of Patients with Diabetes & BP > 140/90 Not an error 37% 31% 33% 36% 39% 33% 30% 30% 30% 28% 30% 31% 31% 33% 36% 35% 26% 27% 28% 27% 26% 29% 22% Overall Team 1 Team 2 Team 3 Team 4 Goal 5% 7% 7% 30.0% 20.0% Disparities in Care: % of Patients with Diabetes & A1C > 9 10.0% 0.0% Overall African American Caucasian Hispanic GOAL 201102 201103 201104 201105 201106 201107 19
Continuous Quality Improvement: The Practice 100 Mammography Rate - Weekly Data Mammography Rate by Provider: 90 Mammo Rate 80 70 74% (National Average) 63.18 62.09 62.56 64.21 60 50 5/19/2013 5/26/2013 Date 6/2/2013 6/9/2012 Project: Family Medicine Mammo Data.MPJ; Worksheet: Mammo Weekly - 6 wks; 6/11/2013; Lindsay Stortz, LStortz@unch.unc.edu Goal: 74% (National Average) Mean: 62% (FMC Average) High Performer: Margaret Helton (82%) 20
Continuous Quality Improvement: The Staff Before After 21
UNC DFM Patient Advisory Council Council Work Committee Work Strategic goals: Patient satisfaction Operational groups: QI, Supervisors, Communications, Renovation, Epic Individual/Small Group Work Research, curriculum design, community outreach PAC Successes: Family Medicine Center Renovation and Re-design Help redesign pediatric triage process. Patient input on faculty research/grant proposals. Review and analyze patient satisfaction data direct interventions Review and provide feedback on patient surveys Help prepare monthly patient e-newsletter Provide on-call service for FMC patients in need of addiction counseling. Review current internal and external departmental signage. Make recommendations for change 22
In a patient-centered medical home, it is hoped that the wheel would recognize the importance of treating each patient (the hub) as an individual in providing the best healthcare and clinic operations possible. This simply means a respect for the individual patient's health issues, socioeconomics, education and most important, an interactive treatment. In other words, the patient's welfare is a consideration from the check-in (or before) to the check-out. - HD, 2013 23
Shared savings pilots: Paying for the PCMH» NY, MN, CO, MD, NC (CCNC)» PMPM (risk stratified), pay-for-performance, one-time payments BCBS: NC, CareFirst WellPoint: Indiana United Healthcare» Reimbursement tied to quality and cost-effectiveness, contracts linked to quality measurements will increase to $50 billion by 2017 CMS 2013 fee schedule» Transitional care Proposed CMS 2014 fee schedule» complex chronic care (CCC) conditions PQRS value based reimbursement Meaningful Use 24
Key Components of Practice Transformation to a PCMH Leadership and Change Management (culture change) Big Bang implementation Access Redefined A core interdisciplinary team celebrate success Care Management at the center of practice Risk Stratification resources where they are most impactful Team based care delivery large and small See our practice through our patients lens 25
ACOFP.org» Medical Home Quality Markers» Links to resources AAFP.org» PCMH checklist» Many links to resources Resources IHI.org (Institute for healthcare Improvement) PCPCC.com (patient Centered Primary Care Collaborative) In North Carolina AHEC NC AHEC: 9 regional centers across the state, each center has a team of professionals to help primary care practices in the following areas: Achieving MU Improving clinical outcomes of patients Transforming into a patient centered medical home (many of the consulting staff are newly certified content experts by NCQA) If interested, contact your local AHEC or visit www.ahecqualitysource.com 26
UNC Family Medicine Top 12 Hurdles for Level 3 PCMH, 2011 Standards 1) Documenting Self-Management - provide self-care tools, self-mgmt. resources, set goals with date, etc. 2) Medication review document OTCs & herbals, assess understanding of meds and barriers to adherence, etc 3) Clinical summaries provide clinical summary at each relevant visit (med list, problem list, allergies, etc.) 4) Care transitions info transfer between PCP/hospital following discharge; not issue for FM due to integrated UNC EMR (WebCIS) 5) Defining an unhealthy behaviors/mental health condition as 1 of the 3 important conditions FM used tobacco use 6) Define high-risk population in a reasonable/low-impact way FM used those with diabetes +smoking (comorbidity) 7) Patient Experience - Are you going to use CAHPS to track patient experience? Can you get it up and running in time? FM did not. 8) Choose your preventive screening outreach wisely. FM: false positives on pneumovax and retinal photo outreach. 9) For re-application, look early at what elements require documentation; this saves a lot of work. 10) Patient experience feedback and patient advisory council 11) Documenting team based approach to care for element 1G need team-based care in job descriptions, training materials, etc. 12) Record review (shorter time period) vs Registry report (1 year) for data collection: Decide early 27