Practice Improvement Series Meeting #2 Lisa M. Letourneau MD, MPH May 2007

1. The Patient Centered (“Advanced”) Medical Home: A New Model for Primary Care Practice Improvement Series Meeting #2 Lisa M. Letourneau MD, MPH May 2007

2. Learning Objectives • Understand elements of Patient Centered Medical Home • Consider Medical Home as potential new model for primary care delivery & reimbursement • Help interested practices position themselves for participation in upcoming Medical Home pilot programs

3. Medical Home - Background • AAP - first introduced in 1964! • Evolving concept of AAP, AOA, ACP, AAFP – now…health plans, CMS • Attempt to reconfigure primary care to meet growing expectations • Chronic care model • Increasing focus on outcomes, P4P • Terms: Advanced Medical Home  Patient Centered Medical Home

4. Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

5. Engaged Patient Management Ideas from Business Process Redesign Health Data Exchange New Reimbursement Model Teamwork New Paradigm for Primary Care Practice Clinical Information Systems

6. Medical Home - Defined • Personal physician • Provides longitudinal, comprehensive care • Physician-directed team • Team collectively takes responsibility for care • Whole-person orientation • Cross all stages of life • Coordinated & integrated care • Across all elements of health system & community

7. Elements Of The Medical Home • Team based care • Service oriented culture • Quality physicians and staff • Clinical information systems • Community linkages • Relationships with plans and payers • Office facility and space

8. Team Based Care • All staff involved • Responsibility for patient care distributed across team • Team holds regular meetings to plan care • Clear roles and responsibilities • Common game plan • Information technology support

9. Identifying the Care Team

10. What the Care Team Looks Like • Everyone can (& does!) do many things for a patient – avoid unnecessary specialization • Work is done by the most appropriate level of staff – e.g. • Nurse reviews self-management goal with patient • MA completes paperwork (physician signature only) • Team supports the patient and the physician (provider)

11. Service Oriented Culture • Work is organized around the patient (vs. patient organized around the work) • Focus on patient needs and convenience • Friendly, personal atmosphere • Sensitive to patient culture and values • No barriers to access • Good communication at the appropriate level

12. Quality-based Care • Measurement is fundamental • Measure-improve-measure mindset • Culture of innovation • Willingness to collect, report and compare clinical data for improvement and recognition

13. Clinical Information Systems • Registries for chronic illness • Care coordination • Population management reports • Protocols, reminders and checklists • Electronic health records • Decision support • Access to internet • Email communication with patients • Personal health record (CCR)

14. Community Linkages • Service agreements with referral specialists • Participate in supporting community educational resources • Partner with plans on disease management • Help link public health and primary care

15. Relationships With Plans & Payers • Must evolve into partnership for better patient value and outcomes • Incentives aligned to promote primary care and prevention • Patients encouraged (compelled) to select a personal medical home

16. Office Facility And Space For Care • Office space clean, attractive, safe • Privacy preserved • Space designed for the function • Group visits • Team care • Patient education • Space accommodates computers, web access

17. Identifying a Medical Home How do we (or others…) know it when we see it?

18. Medical Home Assessment • Structure and process measures • NCQA Physician Practice Connection (“PPC”) • AAFP TransforMED Model • Clinical outcomes measures • AQA Starter Set measures • CMS Physician Quality Reporting Initiative (PQRI) • Patient experience of care measures • Patient satisfaction surveys • American Academy of Pediatrics • The Medical Home Index

19. Upcoming Medical Home Pilots • ACP/AAFP/ BCBS Assn/ Wellpoint • BCBS: 8 states • Wellpoint: 1 state – Maine! • CMS pilot • TBD…

20. ACP-AAFP-BCBS-Wellpoint Pilot • Announced in early 2007 • Plan to identify 2-3 pilot practices in 8-10 states • Practices self-identify, complete application for participation • NCQA Physician Practice Connection (PPC) • Plans will use alternative payment model to reimburse for Med Home svcs

21. Wellpoint-Anthem Pilot: Maine • Part of larger ACP-AAFP-AOA pilot with BCBS Assn • Maine is single Wellpoint/Anthem state • Anthem will look for interested practices to complete NCQA “PPC” application – ?Sept 07 • Applications to be reviewed by ACP • Practices chosen for participation by Anthem

22. Wellpoint-Anthem Pilot: Maine Payment system: • Will establish new prospective payment system, aligned with existing Anthem “Quality Insights” program • Ongoing FFS payments • Practices will be asked to submit “t codes” to track Medical Home services • Quality bonus for meeting quality targets

23. Making The Transition To The Medical Home A Step-Wise Approach To Move From Here To There

24. Building A Medical Home: Getting Started • Develop your team • Build systems approach to care • Registry • Prospective data collection sheet or template • Care coordination and follow-up • Adopt clinical information systems • Registry  Electronic Health Record • ePrescribing with allergy checking and medication interaction alerts • Decision support, protocols and reminders • NCQA “Physician-Practice Connection” (PPC) Application

25. Why Move to Medical Home Model? • Build a vital, sustainable staff • Professional approach to financial and personnel management • Foster a culture of innovation • Take full advantage of incentive programs and pay for performance

26. “If you ain’t the lead dog, the scenery never changes” ~ Louis Grizzard