Michelle Brunsen & Marlene Hodges April 16, 2014

1. Michelle Brunsen & Marlene Hodges April 16, 2014 Patient-Centered Medical Home

2. Objectives • Foundation and Benefits of PCMH • Components of a PCMH • Certification/Recognition Overview • Connecting with Meaningful Use

3. Foundation & Benefits of PCMH

4. Foundation of PCMH The Patient-Centered Medical Home model is • An approach to providing comprehensive primary care for • Children, adolescents, and adults • A health care setting that facilitates partnerships • Between patients and their personal physicians, and when appropriate, the patient's family • A model or philosophy of primary care that is • Patient-centered, comprehensive, team-based, coordinated, accessible, focused on quality and safety Source: American Academy of Family Physicians

5. Foundation of PCMH Through the medical home model, practices seek • To improve the quality, effectiveness, and efficiency of the care they deliver • To ensure that the activities within the practice are focused on meeting patient needs first • To foster a relationship of trust between the care team and the patient • Actively engage patients as partners in their healthcare. Source: American Academy of Family Physicians

6. Origin of PCMH • In 2007, the Joint Principles of the Patient-Centered Medical Home were released by the four primary care physician societies • American Academy of Family Physicians (AAFP) • American Academy of Pediatrics (AAP) • American College of Physicians (ACP) • American Osteopathic Association (AOA) • In 2011 they released the “Guidelines for Patient-Centered Medical Home Recognition and Accreditation Programs.”

7. PCMH Momentum • Medical Homes achieve IHI’s Triple Aim: • Better health, better care, lower costs • Medical Home expansion at tipping point with broad private/ public sector support • 46 PCMH initiatives nationwide provided “significant evidence” of PCMH benefits • 21 states all demonstrated substantial cost savings with PCMH initiatives Benefits of Implementing the Primary Care Patient-Centered Medical Home: A review of cost and quality results;2012. Patient-Centered Primary Care Collaborative.

8. PCMH Satisfaction: A Proven Model • Research & studies have shown that the PCMH model achieves: • Improvement in quality • Higher patient satisfaction • Higher overall experience of care (patient & provider) • Cost savings • Decreased rates of provider burnout • Cost savings: reduces expensive, unnecessary hospitals and emergency department utilization

9. Components of a PCMH

10. Key Functions & Attributes of a PCMH • Patient-Centered • Comprehensive Care • Coordinated Care • Accessible Services • Quality and Safety

11. Medical Home Components • Personal physician/clinician • Team-based care • Whole person orientation • Enhanced access and continuity • Coordinated, integrated care • Quality and safety prioritized

12. 1) Personal Physician/Clinician • Building a relationship with one provider whose team guides patients’ care • Promoting continuity • Patients don’t have to explain themselves to a new doctor every visit

13. 2) Complete, Team-Based Care • Physical and mental health • Prevention, wellness, acute and chronic care • Team: MDs, PAs, RNs, pharmacists, social workers, dietitians, MAs • Coordinate medical neighborhood and transitions in care

14. 3) Patient-Centered Orientation • Relationship-based, whole person • Respect patients’ unique needs, culture, values • Actively support patients to manage, organize their own care • Patient and family core member of care team, fully informed partners

15. 4) Care is Coordinated • Across healthcare settings • Specialty care, hospitals, home health, etc. • Especially in transitions • Hospital discharge • Build clear and open communications among patient/family, MH and broader care team

16. 5) Superb Access to Care • Short wait times for urgent needs • Enhanced service hours • Around the clock telephone and electronic access to care team members • Alternate communication methods • Email, phone, EHR portal • Responsive to patient preferences regarding access

17. 6) Systems-Based Approach to Quality & Safety • Use of evidence-based medicine and clinical decision-support tools • Measure performance and improvement • Respond to patient experience of care and satisfaction • Population care management • Robust quality/safety data • QI activities are made public Source: HealthInsight

18. PCMH Considerations • PCMH involves NEW costs • EHRs, workflow analyses, staff training, time, process development • Is PCMH a good ROI? • “PCMH makes things better for all patients; but near term payback comes from one, small segment: the chronically ill” • Care Management and Patient Engagement not “traditional service” in small practices Burke G. Healthfirst 2013 Spring Symposium. Patient-Centered Medical Home: Building Healthy Communities.

19. Health IT & Meaningful Use

20. The Connected Medical Home • HIT should provide or enhance PCMH capabilities • Promotes “added value” • Focus on HIT • Connects providers, patients, other care team members • HIT supports all interrelated PCMH capabilities Source: HealthInsight

21. HIT and Patient-Centeredness • Patient-Centeredness is promoted by technology that: • Facilitates communication • Helps patients understand, organize and act upon health information

22. EHR Functions to Support PCMH EHRs should have the ability to • Collect, store, measure, report on processes and outcomes of individual and population performance and care quality • Promote communication between providers, patients and other care team members

23. EHR Functions to Support PCMH, Cont’d EHRs should have the ability to • Improve engagement of providers and their practices in decision support for evidence-based tests and treatments • Increase information sharing for patients to be informed and literate about their health and medical conditions and appropriately self-manage

24. Patients Engaged in Their Care • Patients want to electronically view their medical records • HIT engages patients in their care by giving them access to electronic tools: • Health records at PCP offices’ • Personal health records on the Web • Online Health Apps • Patient Portal • Online appointment scheduling • Provider-patient email

25. Meaningful Use Connection • MU and PCMH standards overall are in alignment • For example, NCQA standards are aligned in areas such as: • Using Patient Data (record vitals, smoking status, etc.) • Patient Education/Self Care (clinical summaries, portal access) • Care Coordination (summaries for referrals, transitions) • Rx Management (electronic prescribing and CPOE) • Disparities (record demographics as structured data) • Decision Support (use CDS to improve on high-priority conditions)

26. Healthcare Consumers & HIT • Consumers and Health Information Technology: A National Survey… “Americans pay more attention and become more engaged in their health and medical care when they have easy access to their health information online.” Consumers & Health Information Technology: A National Survey; 2010. California HealthCare Foundation.

27. Patient Centered Medical Home Family Medicine Model Health Information Technology Practice Organization Patient-Centered Care Quality Care Family Medicine Patient-centered | Physician-directed

28. PCMH Certification Overview

29. National PCMH Programs • A number of national organizations offer programs for PCMH: • Accreditation • Certification • Recognition • Achievement

30. National PCMH Programs • The Accreditation Association for Ambulatory Care (AAAHC) • The Joint Commission • The National Committee for Quality Assurance (NCQA) • Utilization Review Accreditation Commission (URAC)

31. MGMA Comparison Tool • The Medical Group Management Association (MGMA) • Developed a comparison tool to focus on how the four programs meet the guidelines • Download it here: www.mgma.com/Books/Patient-Centered-Medical-Home-Guidelines/

32. Resources & Conclusion

33. Medical Home Challenge • Medical Home transformation is not easy • Many small practices lack robust QI infrastructure found in large systems • “The transformation of a PCP into a PCMH requires significant changes in office culture”1 1. Green EP et al. Lessons learned from implementing the Patient-Centered Medical Home. International Journal of Telemedicine and Applications; 2012.

34. Resources • HealthInsight – REC, QIO, Beacon Program, Learning & Action Network, PCMH leaders serving Nevada, Utah & New Mexico www.healthinsight.org • American Academy of Family Physicians http://www.aafp.org/practice-management.html • National Committee for Quality Assurance ww.ncqa.org • Patient-Centered Primary Care Collaborative www.pcpcc.org

35. Thank you! Michelle Brunsen (515) 453-8180 mbrunsen@telligen.org Marlene Hodges (515) 457-3707 mhodges@telligen.org iowahitrec@telligen.org www.telligenhitrec.org