Implementing a Patient-Centered Primary Care Home Pilot within a Community Health Center

1. Implementing a Patient-Centered Primary Care Home Pilot within a Community Health Center Safina Koreishi MD MPH Neighborhood Health Center OCHIN learning Forum November 15 and 16, 2012

2. What will we talk about today? • What is going on in health care? • Why move towards patient-centered primary care home transformation? • NHC’s journey towards becoming a patient-centered primary care home • The role of EMR in patient-centered primary care?

3. The Platform is burning… • Costs are unsustainable • Access is increasingly difficult • Quality measures are not meeting goals…. Average spending on healthper capita ($US PPP)

4. A confusing healthcare system ?? Primary Care Community organizations Patient community Specialists Insurance Company Hospitals

5. A buffet of health care ?

6. The Platform is Burning AND… • Patient satisfaction is low • Staff satisfaction is low • High provider burnout • Access is increasingly an issue • Supply and demand issue Where is Transformational Change?

7. A Call for Change: IHI Triple Aim

8. Healthcare Transformation at all levels • National policy level: Accountable Care Act • State policy level: Coordinated Care Organizations • Local level: CCO implementation (public health, community partnerships, PCPCH) • On the ground: Primary care  Patient-centered primary care home

9. Healthcare Transformation- State Level • In 2011 the Oregon Legislature and Governor John Kitzhaber created Coordinated Care Organizations (CCOs) through House Bill 3650 • Aimed at achieving the Triple Aim: • Improving health • Increasing the availability of quality care • lowering costs by transforming the delivery of health care. • Essential elements of CCO transformation are: • Integration and coordination of benefits and services • Local accountability for health and resource allocation • Standards for safe and effective care • A global Medicaid budget tied to a sustainable rate of growth

10. Healthcare Transformation: CCO • 16 CCOs, community-based and offer primary and mental health care (sometimes dental) for Oregon Health Plan clients • CCOs focus on prevention and helping people manage chronic conditions • Helps reduce unnecessary emergency room visits • Gives people support to be healthy

11. Healthcare Transformation: CCO • CCOs have flexibility within budgets to support new models of care that are patient-centered and team-focused, and reduce health disparities • Can better coordinate services and focus on quality outcomes, prevention, chronic illness management and person-centered care • The PCPCH model is a critical component of CCOs that coordinates all the care for OHP members • Goal: Meeting the Triple Aim of better health, better care and lower costs for the population they serve

12. Oregon Patient Centered Primary Care Home Program • Developed as a charge from the Oregon Health Fund Board • Central part of health system transformation • 6 Attributes and 23 Standards developed in Oregon with communities and experts across the state • First clinics could be certified as of 10/1/2011 • 270 clinics are certified as of 9/13/2012!

13. Oregon PCPCH Program

14. Why become a primary care home? CCO ACA ACO PCPCH NCQA PCMH HRSA UDS Meaningful Use

15. Why become a primary care home? CCO PCPCH

16. What is a Primary Care Home Really? • Not just a program • Not just a stamp of recognition • It is a core component of healthcare reform • A fundamental shift in the operating principles of an organization • Core building blocks and drivers of what constitutes a primary care home

17. Patient and Population Centered Primary Care • Learned from the Primary Care Renewal Collaborative • Wanted to spread the best practices they discovered • Medical Home tools and techniques combined with process improvement skills

18. Drivers of PC3 • Setting a vision • Roles and Functions of Leadership • Planning a Kick Off • Empanelment • Setting a “True North” • Measuring the Process • Visual Systems • Tasks of medical homes • Flow mapping • Standard work of teams • Supply and Demand Management • Open Access • Telephone Processes • Risk Stratification • Standards of Care • Coaching and Follow Up

19. On the ground: primary care home transformation ALL THE WORK

20. What we did… and what we learned Our first year • Leadership • Empanelment • Data • Team-based care • Process improvement (team based and systems based)

21. Leadership • Fundamental shift in operating principles of the organization • Informs all decisions of the organization • Not just a project or program • Managing change effectively • Dealing with competing priorities • Working to change an organization while still “putting out fires” • Communicating change effectively

22. Kick-off • Presentation about primary care home concepts in 12/2011to ALL staff • Empanelment • Data • Improvement • Changing culture

23. Empanelment • First step was to “empanel” our patients • All patients are assigned a PCP • Script for schedulers • Process for continual evaluation • PCP/team “ownership” of the panel • Can then start looking at panel-level data

24. Data • Discussed data as a concept with staff • Without data, unable to measure improvement • We want the data measures to be meaningful • This is a cultural change and a shift in how we approach medical care • Rolled out dashboard to first “introduce” data without clinical indicators • Tried to get consensus on transparency

25. Dashboard

26. Data and EMR Obstacle • Data proved to be an obstacle • Report writing • Understanding data systems (business objects and solutions) • Understanding where to input information in order to ensure reports are correct • Understanding how to develop work flows to ensure data is correct • Wanted to ensure data was meaningful and could be trusted before rolling it out to staff • Unable to link data to action immediately

27. Team Based Care • Team-based care helps re-distribute work • Implemented team meetings • Team level process improvement • PDSA cycles and standard work development

28. Calling a team a “team” versus functioning as a true team • Cultivating respect and trust amongst team members • Forming, storming, norming, performing • Team norms • Team meeting guidelines • Not a griping session or a venue for blame • Changing rolls • Process improvement

29. Process Improvement • Team meetings • Standard work to improve daily work • Provider coverage process • Back office coverage process • Triage Process • MA phone call expectation • Improvement as part of job description and expectation of daily work

30. Clinic Systems Improvement • Using Lean methods of improvement to decrease waste and increase efficiency in system • Referrals • Registration • Phones • Refills

32. What we heard from staff • Confusion over what being a primary care home really means • “Waiting” for something to happen • Confusion over rolls in primary care home • Did not understand that we were already moving towards primary care home

33. A primary care home pilot: Integrating concepts in a meaningful way • One clinic, one team • Integrating concepts of primary care home • Clinical guidelines/evidence based medicine • Pre-visit planning (scrubbing) • Huddling • Proactive outreach • Team building • Using data for action • Process improvement

34. Patient-Centered Primary Care Home Pilot • Women’s Health focus • Cervical Cancer Screening • Breast Cancer Screening • Address other preventive services, but pap and mammography used as an example for pre-visit planning and outreach

35. Patient-Centered Primary Care Home Pilot • Conversation/discussion with pilot team • Shared vision • Understanding what patient centered medical home means • Understanding hopes, fears, questions, concerns • Discussing new and old tasks, and restructuring team to redistribute work • Adding new staff/roles • Team building • Involving the patient voice

36. Patient-Centered Primary Care Home Pilot: New Tasks • Panel data evaluation • Scrubbing • Huddling • Proactive outreach to close gaps in care • Systems improvement and standard work to improve clinical outcomes • “New” epic tool: health maintenance

37. EMR Integral in PCPCH Implementation • Data is not reflecting actual work • Needed to understand how data reports are being run, and from where data is being pulled • Data reports are only as accurate as the data inputted into EMR • New tasks need new work flows • New work flows must correlate with EMR • Staff need to be trained on correct work flows so that we are able to pull the correct data

38. New Work Flows: Health Maintenance • Presently not being used by NHC • Work flows in the community for scrubbing are presently not using health maintenance • Health Maintenance module in OCHIN can act as an important scrubbing tool and reminder for team what services are needed • Satisfying HM, satisfies solutions and can lead to more accurate clinical reports

39. What is Health Maintenance? • Preventive Care Tracking Tool • Alerts for Immunizations, screening, and management of chronic disease • Composed of Topic and Plans • Modifiers • OCHIN currently uses USPSTF guidelines to build topics/plans

40. A Look at Health Maintenance

41. HM Continued

42. Resulting Health Maintenance • Some Health Maintenance Plans will automatically be satisfied upon certain procedures completed others have to be manually satisfied • Paps are automatically satisfied in the system upon the order and result of a Pap lab • Mammograms must be manually satisfied (override) in HM • Procedures done externally can historically be ordered and resulted, or manually “doned” to satisfy the HM alert

43. Manual Override • The patient has reported receiving a service elsewhere • The HM topic does not include completing procedures.

44. Historical Order • Patient reported receiving lab/procedure • You have received the results • Order the lab as you would any order • The order Class must say historical lab • Access the enter/edit results activity to result the historical lab • Once resulted the HM will be satisfied (assuming it is a result procedure in the topic)

45. Solutions: Panel Data and HM • Satisfying solutions from HM requires: • Ordering and performing the service (pap smear) • Historically ordering and resulting the service (pap smear) • “doneing” pap smear/mammogram manually in HM

46. Solutions: Panel Data • Pap smears • No metrics for mammograms • Use the number “overdue” on roster as numerator • Number of women 50-74 on panel as denominator • Used as an impetus for improvement

47. Solutions Data: Rosters • Patient level information regarding who is due for a service • Allows for closing gaps of care

48. Scrubbing (pre-visit preparation) work flow Goal: identify and document any needed services that are due at the time of appointment. Ensures visit is well organized

49. Proactive outreach workflow

50. Current Restrictions with HM • Additional plans and topics to make it more comprehensive • Addition of more modifiers to include or exclude patient populations • Will be most useful if all preventive services have completing procedures (automatically satisfying HM)