An Overview of Patient-Centered Health Care Home Napualani Spock, MA, MBA Pacific Islands PCA

1. An Overview of Patient-Centered Health Care Home Napualani Spock,MA, MBAPacific Islands PCA

2. Goals for today’s session • Provide overview and historical context for the Patient Centered Medical Home (PCMH) movement • Review and discuss PCMH change concepts • Group discussion on PCMH in the Pacific context • Determine next steps for PIPCA CHCs

3. The U.S. Healthcare System is broken • 2001 Institute of Medicine Report—health system error is leading cause of death in the U.S. • Fragmented care—poor communication between doctors, hospitals, pharmacies • Bureaucratic—emphasis on needs of the providers, not the patient: i.e. scheduling, processes • Patients are labeled “non-compliant” when they don’t conform (‘obey’) • Patients need to manage their own appointments, follow-up, etc. • Physicians work alone to provide all aspects of healthcare; in short visits

4. Institute of Medicine’s “Crossing the Quality Chasm” New Vision for Health Care • Patient Safety is a priority • Evidence-based decision making • Cooperation among providers • Customize to patient needs and values • Shared knowledge (patients/providers) allows patients to make informed decisions about their own health care • Care based on continuous healing relationships • Anticipation of needs/not reacting • Goal is to eliminate waste (time and resources)

5. Fixing the Broken U.S. Healthcare System • Video: http://www.youtube.com/watch?v=DE9rG3ACJ9Q&feature=player_detailpage (12min)

6. History of Patient Centered Medical Homes • 1967: “Medical Home” developed as an approach to provide comprehensive services to special needs children • 1978-79: Dr. Calvin Sia (pediatrician) and others campaigned to adopt the medical home concept into Hawaii’s State Child Health Plan • 2001: Institute of Medicine Report—new vision—mentions patient-centeredness • 2002: ACP and AAFP expand Medical Home concept to include adults • 2007: Joint Principles of the PCMH developed byAmerican College of Physicians, American Academy of Family Physicians, American Osteopathic Association, American Academy of Pediatrics

7. 2007

8. PCMH is very similar to the National Health Disparities Collaborative—Chronic Care Model

9. PCMH--CHCs PCMH is also based on many of the same principles as community health centers: • Promote access to underserved • All care in one place • Treat the whole person • Provide enabling services to address socio-economic needs

10. Video: PCMH in Clinical Settings American Academy of Family Physicians adopting PCMH across the U.S. • http://www.youtube.com/watch?v=2j5ImY8yvtA&list=PLC00ECBFBB45D4A72&feature=player_detailpage (9min)

11. Recent PCMH Milestones Health Care Reform – Affordable Care Act (ACA) of 2010 • Patient Protection and Affordable Care Act and Health Care and Education Reconciliation Act • Supports Advanced Primary Care and Innovation across the U.S., across providers • Provides new payment opportunities (through Medicaid matching and Insurance regulations)

12. HRSA Promotes PCMH in CHCs • HRSA/NCQA partnership (Program Assistance Letter 2011-01) • Encourages and supports health centers to gain NCQA recognition as medical homes • Provides structure and resources for centers’ expansion and quality improvement efforts • Alignment with pilot/demonstration projects with CMS, State Medicaid Agency, Health Plans

13. HRSA’s Safety Net Medical Home Initiative • PCA/CHC Milestones by 2014 (coordinated by NACHC) • PCMH Certification • HIT Infrastructure • Integrated Health Delivery Model • Payment Reform • Engaged Patients • Aligned Measurement and Reporting Systems

14. Change Concepts for PCMH (2) Handout: http://www.safetynetmedicalhome.org/sites/default/files/Change-Concepts-for-Practice-Transformation.pdf

15. PCMH concepts Ed Wagner presenting Change Concepts: http://www.safetynetmedicalhome.org/sites/default/files/Change-Concepts-7-25-09.wmv

16. PCMH I. Engaged Leadership • Provide visible and sustained leadership to lead overall cultural change as well as specific strategies to improve quality and spread and sustain change. • Ensure that the PCMH transformation effort has the time and resources needed to be successful. • Ensure that providers and other care team members have protected time to conduct activities beyond direct patient care that are consistent with the medical home model. • Build the practice’s values on creating a medical home for patients into staff hiring and training processes.

17. II. Quality Improvement Strategy • Choose and use a formal model for quality improvement. • Establish and monitor metrics to evaluate routinely improvement efforts and outcomes; • Ensure all staff members understand the metrics for success. • Ensure that patients, families, providers, and care team members are involved in quality improvement activities. • Optimize use of health information technology to meet Meaningful Use criteria.

18. III. Empanelment • Assign all patients to a provider panel and confirm assignments with providers and patients; review and update panel assignments on a regular basis. • Assess practice supply and demand, and balance patient load accordingly. • Use panel data and registries to proactively contact and track patients by disease status, risk status, self-management status, community and family need.

19. IV. Continuous and Team-Based Healing Relationships • Establish and provide organizational support for care delivery teams that are accountable for the patient population/panel. • Link patients to a provider and care team so both patients and provider/care teams recognize each other as partners in care. • Assure that patients are able to see their provider or care team whenever possible. • Define roles and distribute tasks among care team members to reflect the skills, abilities, and credentials of team members.

20. V. Patient-Centered Interactions • Respect patient and family values and expressed needs. • Encourage patients to expand their role in decision-making, health-related behaviors, and self-management. • Communicate with patients in a culturally appropriate manner, in a language and at a level that the patient understands. • Provide self-management support at every visit through goal setting and action planning. • Obtain feedback from patients/families about their healthcare experience and use this information for quality improvement.

21. VI. Organized, Evidence-Based Care • Use planned care according to patient need. • Identify high risk patients and ensure they are receiving appropriate care and case management services. • Use point-of-care reminders based on clinical guidelines. • Enable planned interactions with patients by making up-to-date information available to providers and the care team prior to the visit. • Example: TEAM HUDDLE AT UC Davis (9 min) • http://www.youtube.com/watch?v=VxdG2_nZ2fc&feature=player_detailpage

22. VII. Enhanced Access • Promote and expand access by ensuring that established patients have 24/7 continuous access to their care teams via phone, e-mail, or in-person visits. • Provide scheduling options that are patient and family-centered and accessible to all patients. • Help patients attain and understand health insurance coverage.

23. VIII. Care Coordination • Link patients with community resources to facilitate referrals and respond to social service needs. • Integrate behavioral health and specialty care into care delivery through co-location or referral agreements. • Track and support patients when they obtain services outside the practice. • Follow up with patients within a few days of an emergency room visit or hospital discharge. • Communicate test results and care plans to patients.

24. Patient Experience of PCMH Video, from a Patient’s Perspective: http://www.youtube.com/watch?v=LIPk9o0NUaY&feature=player_detailpage

25. PCMH Certification Multiple PCMH Accrediting Entities in the U.S. • National Committees for Quality Assurance (NCQA) • The Joint Commission (JACHO) • Accreditation Association for Ambulatory Health Care (AAAHC) • URAC

26. NCQA Recognition NCQA is part of the HRSA Safety Net Demonstration Project • 9 Elementsexamined • 3 levels of recognition with different levels of compensation for each level • Video on NCQA process (22min) http://www.youtube.com/watch?feature=player_detailpage&v=ZC4YCLG4h5k

27. NCQA Recognition Process OVERVIEW OF STEPS: • Take self-assessment • Submit data to NCQA • NCQA evaluates and scores • 5%+ of sites are audited onsite • NCQA provides final evaluation to site • If site passes, recognition is reported on website and to users, including health plans

28. How does your CHC fare? • Assessment: “PCMH-A” • Created by the Safety Net Medical Home Initiative (SNMHI) • Organized in order of NCQA PCMH Certification Standards • PCMH Crosswalk • PCMH-A Document • 12 point rating scale • Helps you to determine your organization’s readiness; and to identify areas of need for training and technical support

29. How do we adapt PCMH to fit diverse community health centers?

30. How did Hawai’i CHCs approach it?PCHCH Pilot 2008-2012 • Project participants:

31. Hawai’iPCHCH Pilot Core Values of Hawai’i CHCs Pilot Project “Patient Centered Healthcare Home” • Patient-Driven and Family Centered Care • Barrier Free Access • Team-Based Care Delivery • Integrated and Holistic Care

32. Hawai’i Activities • Monthly Steering Committee Meetings • ICSI PCMH Consultants • April 2011: Go Live • All processes/ workflows in place • Care coordination tools and care plans implemented • Baseline data collected • 3 min. video on PCMH coordination at W. Hawai’i CHChttp://www.youtube.com/watch?v=tnrFcDSy-N8&feature=player_detailpage#t=73s

33. Other CHCs across America Oregon “Storyboard” PCMH Handouts\sample of 'storyboard' from Oregon CHC.pdf CHC In Connecticut (4 min video) http://www.youtube.com/watch?v=DroZOEt5q0s&feature=player_detailpage

34. Where do we go from here?

35. Next Steps? Some Ideas: NACHC Model • Learning Communities • Email group (listserve) • Face-to-face training • Online webinars • Site visits; coaching

36. Pacific Islands PCMH Plan Discussion: Next steps for PIPCA CHCs What do You think?

37. Mahalo.