Overview of Patient Centered Medical Home

1. Overview of Patient Centered Medical Home Susan Dezavelle, RN, Medical Informatics Presbyterian Health Plan June 2011

2. Patient Centered Medical Home Definition: An approach to providing comprehensive primary care with the goal to pro-actively manage a population of patients Guidelines: • Team approach to care • Patients actively involved in care • Coordinating care across systems • Maximize health information (EHR) • Performance measurement and quality improvement

3. Patient Centered Medical Home Methods • Alternative venues of care (e-visits, telephone, group) • Team “visits” – warm hand offs, Nurse, BH, Pharmacist • Pre-visit planning and follow up between visits • Outreach to patients with chronic conditions • Automated processes to follow up for preventive health • Effective use of EHR as registries, e-prescribing

4. Patient Centered Medical Home Methods • Consistent and timely follow up on diagnostic testing • Immediate follow up on ER and inpatient admissions • Coordination with specialists and other care systems • Systematic measurements of processes and outcomes • Evaluation of interventions and process improvements

5. PCMH Drawing National Attention Nationally recognized as a new model of care Recognition that Primary Care can impact cost and quality Programs in several states over the past 5 – 8 years Measurements starting to show impact

6. NCQA PCMH Recognition Program Application to NCQA is extensive Designate Levels 1 through 3, typically Level 3 requires EMR to meet standards (not required) Standards are self reported Focus on quality, chronic care and prevention and coordination of care Encourages measurements, primarily for quality

7. What NCQA Recognition Is Not Recognition does not ensure actual practice transformation Practice transformation can occur without NCQA program Does not specifically address utilization or cost management Does not guarantee payment for care management will be sustainable Is not an “Accreditation” program

8. State of New Mexico Mandate for PCMH State Law passed in early 2008 includes requirement for managed care Medicaid to pilot PCMH • Pay for Performance (P4P) now linked to PCMH initiatives • Included in the HSD contract language Purpose: to determine methods by which PCMH programs can be effectively implemented in New Mexico

9. State of New Mexico Mandate for PCMH Health Plans are required to: • Encourage NCQA Recognition • Provide consultative services • Provide financial assistance to develop programs • Track quality and utilization measures and expect improvement • Move towards new reimbursement models • Obtain approval from HSD for each program • Report funding to HSD

10. Presbyterian’s PCMH Vision Presbyterian Health Plan (PHP) supports the transformation of primary care delivery and reimbursement following national Patient Centered Medical Home principles to improve quality and cost management, using a team approach and comprehensive care coordination. PHP supports primary care practices promoting a population based view, globally managing healthy and chronically ill patients, leveraging systems to identify and reach out to patients, develop more efficient ways to deliver and coordinate care, while transitioning to utilizing electronic health information in their practice.

11. Presbyterian’s PCMH Programs Started in late 2009 Currently have four PCP Groups participating Each has a written agreement, specific expectations, quality and utilization measures with targets Sharing data and reports and tools to manage targeted conditions and utilization measures

12. Presbyterian’s Lessons Learned • If you’ve seen one PCMH program, you’ve seen one PCMH program – they are all unique • Consider the administrative burden for the PCP groups • Important to stay focused on outcome measures and interventions to impact • Care coordination is the key – it’s a new skill • Importance of data analysis and reporting • Patient paneling issues • How to incorporate physician involvement and engagement

13. Questions?