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The Interprofessional Approach to “Medical Home” In Rural Health Care

Panel Presenters Louise Anderson, MSN, RN, AHEC, ISU Peter Duong, PhD, IU Medical School Susan Eley, PhD, RN, FNP-BC, ISU Roseanne Fairchild, PhD, RN, CNE, ISU Shaun Grammer, MS, PA-C, ISU. The Interprofessional Approach to “Medical Home” In Rural Health Care.

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The Interprofessional Approach to “Medical Home” In Rural Health Care

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  1. Panel Presenters Louise Anderson, MSN, RN, AHEC, ISU Peter Duong, PhD, IU Medical School Susan Eley, PhD, RN, FNP-BC, ISU Roseanne Fairchild, PhD, RN, CNE, ISU Shaun Grammer, MS, PA-C, ISU The Interprofessional Approach to “Medical Home” In Rural Health Care What Does It Mean? How Do We Get There as Providers and Educators?

  2. Rural Health Care • Uniqueness of Care Delivery in Rural Settings • Barriers to health care: • Remote geographic location • Healthcare workforce shortages • Limited financial resources of rural critical access hospitals and clinics serving the rural U.S.1,2 • Barriers promote health disparities due to potential for delays in appropriate treatment as people try to access health care services they need.3

  3. Rural Health Care • Compared with their urban counterparts, residents of rural areas report greater incidence of: 1) Fair or poor health; 2) Chronic conditions such as diabetes; 3) Death from heart disease.4,5 4) Rural residents are reported to have fewer visits to health care providers, less likely to receive recommended preventive services.6 5) Rural minorities appear to be particularly disadvantaged, and differences are observed in cancer screening and in the management of cardiovascular disease and diabetes.7

  4. Rural Health Care • To successfully address barriers unique to rural settings, specific interprofessional strategies need to be developed, tested and implemented in both healthcare provider education and patient education to decrease health disparities and improve patient health outcomes.1,2 • How might the Medical Home Model help decrease health disparities in rural settings? 8

  5. Medical Home Definitions Agency for Health Research Quality (AHRQ) 9 Centers for Medicare and Medicaid (CMS) 10 • Patient-centered Care Model for Primary Practice • Relationship-based, holistic orientation • Care providers partner with patients and their families • Respect patient’s unique needs, culture, values, preferences • Support patients in learning to manage their own care • Recognize patients/families are core members of care team • Ensure patients are fully informed partners in care plans • The Advanced Primary Care model (APC), aka patient-centered medical home • Model for efficient management and delivery of healthcare • Team approach with patient at the center of care • Emphasizes prevention, health information technology, care coordination, shared decision-making among patients and providers • Current demonstration in 8 States: ME, VT, NY, RI, PA, NC, MI, MN

  6. Evaluation of Medical Home Outcomes Evaluation Tools 11 (Standards of Care 2008-2011) Common Survey Criteria • National Council on Quality Assurance (2) • Accreditation Association for Ambulatory Health Care (AAAHC) • Joint Commission’sPrimary Care Home • Utilization Review Accreditation Committee (URAC)’s Patient Centered Health Care Home (PCHCH) Program Toolkit • TransforMED (subsidiary of American Academy of Family Physicians)’s Medical Home Implementation Quotient (IQ) (2006 – first NDP in 2006) • Center for Medical Home Improvement’s Medical Home Index • AHRQ PCMH 18-item sub-scale (2011) • Survey Item Domains: • Access to care • Patient satisfaction with care • Coordination of care • Chronic disease management (if applicable) • Resource availability and management • Perceptions of interprofessional care team communication *Burton, Devers & Berenson (2011). Patient-Centered Medical Home Recognition Tools: A Comparison of Ten Surveys’ Content and Operational Details. Washington, DC: Urban Institute.

  7. Medical Home Evaluation Domains 11Burton, Devers & Berenson (2011). Patient-Centered Medical Home Recognition Tools: A Comparison of Ten Surveys’ Content and Operational Details. Washington, DC: Urban Institute.

  8. Medical Home: Purpose • Different Definitions – Similar Purpose • Continuity and Care Coordination Across Providers! • Improve safety, effectiveness, timeliness, efficiency • Increase ability of patients and families to participate in decisions concerning their care • Reduce unjustified variation in utilization and health care expenditures • Increase availability/delivery of care that is consistent with evidence-based guidelines in historically underserved areas • Applicable to CAHs, LTCs, Primary Practices, Clinics

  9. Medical Homes in Indiana • Indiana’s Data-driven initiatives • Pediatrics • Origination (American Academy of Pediatrics,1967) • Indiana State Department of Health, Children’s Special Health Care Services – “Sunny Start” • Integrated Community Systems for Children and Youth with Special Health Care Needs (CYSHCN) • Adults • Veterans’ Administration (VA) Clinics

  10. Medical Home Domains • Five domains typically measured: • Access to Care • Care Management • Population-based Issues • Quality • Clinical Information Management

  11. Medical Home – VA Demo Project Outcomes *Healthcare Effectiveness Data and Information Set (HEDIS) is used by 90% of US health plans and contains 75 measures across eight domains of care: Effectiveness of care, access of care, patient satisfaction, use of services, cost of care, health plan descriptive information, health plan stability, informed health care choices.

  12. Medical Home = Interprofessional Collaboration and Education • IP educational models need to support excellence in: • Accessibility • Family-centered care • Comprehensive • Coordinated • Self-Management of care (adults) • Culturally effective • IP clinical teams need to learn how to tailor “medical home” approach to rural settings utilizing the model’s hallmark • Patient-centered approach to care.

  13. Interprofessional Education and Patient-Centered Care • Current IPE Activities • Interprofessional Education Days – ISU/IUSM • Annual Event Across HC Professions • Sports Medicine elective • Indiana State University • PA/Athletic Training • APN interprofessional service learning projects • Health Information Technology • Community Health Planning • Doctoral-level Scholarly Projects • Health Fairs • RHIC • Online pilot – Virtual COPD Case study • Lugar Center for Rural Health • Medical, APN or PA, X-Ray Tech, Pharmacy • Rural Research teams – Grant-writing

  14. Interprofessional Education and Patient-Centered Medical Home • Future IPE Plans • Building sense of IPE community • Grow current programs across hc professions • Patient-Centered Social Networking Website (NING) • Wellness promotion/chronic disease management • New IPE curriculum development • Faculty/Preceptor development • Time/Accreditation/Geographic location/Resource Needs • IPE/Medical Home Grant-writing

  15. Group Discussion Scenarios – IPE and Medical Home • You have been named the Director of a Patient-Centered Medical Home in a rural county. • After one year, you need to give a report to your Advisory Board describing your major achievements. • Work in your group to prepare your report addressing your delegated area/domain: • Access to Care • Care Management • Population-based Issues • Quality • Clinical Information Management

  16. Wrap-up -- Thank You! Contact info if you are interested in participating in an IPE project or study: Roseanne.fairchild@indstate.edu Susan.eley@indstate.edu Louise.anderson@indstate.edu Taihung.duong@iupui.edu Shaun.grammer@indstate.edu

  17. References • 1. Institute of Medicine Committee on Quality of Health Care in America. Crossing Quality Chasm: a new health system for 21st century. Washington, DC: National Academy Press; 2001. • 2. Institute of Medicine Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academy Press; 2004. • 3. Magee, M. (2005). Health Politics: Power, populism, and health. New York: Spencer. • 4.Muskie School of Public Service and Kaiser Commission on Medicaid and the Uninsured. Health insurance coverage in rural America. Washington, DC: Kaiser Family Foundation; 2003. • 5. Schull MJ, Vermeulen MJ, Stukel TA. The risk of missed diagnosis of acute myocardial infarction associated with emergency department volume. AnnEmergMed2006; 48(6):1163-70. • 6. Larson SL, Fleishman JA. Rural-urban differences in usual source of care and ambulatory service use: analyses of national data using Urban Influence Codes. Med Care. 2003 Jul;41(7 Suppl):III65-III74. • 7. Slifkin RT, Goldsmith LJ, Ricketts TC. Race and place: urban-rural differences in health for racial and ethnic minorities. Chapel Hill, NC: University of North Carolina at Chapel Hill; 2000. • 8. Helseth, C. Medical homes offer comprehensive care approach. The Rural Monitor: Rural Assistance Center; 2009. Available from: http://www.raconline.org/newsletter/web/spring09.php#cover • 9. Agency for Healthcare Research and Quality (AHRQ). Patient-Centered Medical Home Resource Center: What is the PCMH? 2011. Available from: http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/what_is_pcmh_ • 10. Centers for Medicare and Medicaid (CMS). Multi-Payer Advanced Primary Care Practice Demonstration (2011). Available from: https://www.cms.gov/DemoProjectsEvalRpts/downloads/mapcpdemo_QA.pdf • 11. Burton, Devers & Berenson (2011). Patient-Centered Medical Home Recognition Tools: A Comparison of Ten Surveys’ Content and Operational Details. Washington, DC: Urban Institute. • 12. Marshall et.al. (2011). Patient-centered medical home: An Emerging primary care model and the military health system. MILITARY MEDICINE, 176, 11:1253-1259.

  18. Back-Up Slides

  19. VA Medical Home Initiative • Center for Comprehensive Access & Delivery Research and Evaluation (CADRE)* • Goals: • Improve access to high quality care • Reduce costs • Grassroots-driven development and implementation • VA Clinics and Home Health • Overall Focus: • Rural health research to identify gaps/improve care for rural veterans • Telehealth and e-health strategies to extend specialty care to remote sites and expand delivery of care to veterans’ homes (home health) • Patient-centered behavioral and self-management interventions tailored to the unique traits and capabilities of individual patients • Nursing health services research to improve coordination of care and promote evidence-based infection prevention *Retrieved from: http://www.cadre.research.va.gov/

  20. Medical Home “Lessons Learned” • Transforming into a PCMH requires: • 1. Continuous changes in clinical procedures • 2. Technology that is integrated into routine practices • 3. Personal transformation for physicians and all care providers • 4. Successful management of change fatigue even with motivated practices -- PCMH is a developmental process • 5. A local process -- providers need to draw on community resources • 6. Is dependent upon the local/regional health care environment in which the practice is located • 7. Potential for change in billing systems • Current system of billing and the use of work-related value units as basis for compensation is reported to be an impediment to PCMH

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