Built to Last: The Successful Patient Centered Medical-Home (PCMH) Team

1. Built to Last: The Successful Patient Centered Medical-Home (PCMH) Team PCPCC Stakeholders’ Working Meeting April 28, 2009 Guy Mansueto, VP, PhytelModerator

2. Our Panelists Richard C. Antonelli, M.D., M.S., FAAP Medical Director, Integrated Care Organization, Children's Hospital Boston/ Harvard Medical School Suzanne Mitchell, M.D. M.Sc.Faculty, Boston University School of Medicine Christine Sinsky, M.D.Medical Associates Clinic, Dubuque, Iowa Linda Strand, Pharm.D., Ph.D., D.Sc.(Hon)Distinguished Professor, College of Pharmacy, University of Minnesota

3. Successful PCMH Team: What Constitutes Care Coordination in a Pediatric Medical Home? Richard C. Antonelli, M.D., M.S., FAAP Medical Director, Integrated Care Organization, Children's Hospital Boston/ Harvard Medical School

4. Challenges to Implementing Family-Centered Medical Home • TIME, TIME, TIME • Lack of organized systems of care with defined roles • Inadequately developed family/patient -professional partnerships • Knowledge • Care pathways • how to change • Lack of Care Coordination function • Lack of awareness of community resources and programs • “Reimbursement”

5. Defining Care Coordination Pediatric care coordination is a patient- and family-centered, assessment-driven, team-based activity designed to meet the needs of children and youth while enhancing the care giving capabilities of families. Care coordination addresses interrelated medical, social, developmental, behavioral, educational, and financial needs in order to achieve optimal health and wellness outcomes. Source:MAKING CARE COORDINATION A CRITICAL COMPONENT OF THE PEDIATRIC HEALTH SYSTEM: A MULTIDISCIPLINARY FRAMEWORKRichard C. Antonelli, Jeanne W. McAllister, and Jill PoppThe Commonwealth Fund, April 2009

6. Components of Care Coordination Family-centered and Community-based Proactive, Providing Planned, Comprehensive Care  Promotes the Development of Self Management Skills (Care Partnership Support) with Children, Youth and Families Facilitates cross-organizational linkages and relationships Source:MAKING CARE COORDINATION A CRITICAL COMPONENT OF THE PEDIATRIC HEALTH SYSTEM: A MULTIDISCIPLINARY FRAMEWORKRichard C. Antonelli, Jeanne W. McAllister, and Jill PoppThe Commonwealth Fund, April 2009

7. Care Coordination Functions • Provides separate visits and care coordination interactions • Manages continuous communications • Completes/analyzes assessments • Develops care plans with families • Manages/tracks tests, referrals, and outcomes • Coaches patients/families • Integrates critical care information • Supports/facilitates care transitions • Facilitates team meetings • Uses health information technology

8. Focus of Encounter Primary Focus% Encounters Clinical / Medical Management 67% Referral Management 13% Social Services (ie. Housing, food, clothing…) 7% Educational / School 4% Developmental / Behavioral 3% Mental Health 3% Growth / Nutrition 2% Legal / Judicial 1% Source:National Study of Care Coordination Measurement in Medical HomesAntonelli, Stille, and Antonelli, 2008

9. Prevented Outcome The CCMT allows only one outcome prevented per encounter. 32% of total 3855 CC encounters prevented something. Of the 1232 CC Encounters where prevention was noted as an outcome: Outcome Prevented# CC EncountersPercentage Visit to Pediatric Office / Clinic 714 58% Emergency Department Visit 323 26% Subspecialist Visit 124 10% Hospitalization 47 4% Lab / X-Ray 16 1% Specialized Therapies 8 1% 62% of RN CC Encounters prevented something. 33% of MD CC Encounters prevented something. RNs are responsible for coding 81% of the Emergency Department preventions and 63% of the sick office visit preventions.

10. Implications for Policy and Practice • Re-examine the traditional, office-based interaction • Service unit for primary care in PCMH must include CC • Service unit must value non-face-to-face care provided by non-MD staff supporting care coordination • Use Care Plans to drive (and to monitor) care provision • All PCMH team members function at “the top of their license” • Multiplicity of demands for CC demands participation by integrated team: MD, NP/PA, RN, LPN, MA, pharmacy, community partners (eg, dental,mental;education) • All aspects of system performance transparent to families and payers/ purchasers

11. Successful PCMH Team: The Patient / Family as Team Members Suzanne Mitchell, M.D. M.Sc.Faculty, Boston University School of Medicine

12. A Structured Approach to Relationship-Centered Care • Build Relationships / Serve • Collaborate • Educate • Negotiate

13. Provider Inquiry: • Interview, • Physical exam, Tests, • Diagnosis • Treatment Plan Collaborative Agenda Setting • Rapport-building Skills • Mindfulness • Reflection • Transparency • Goal alignment • Express Empathy • Tools • LEARN/MI • Patient Activation • Self-Management Ed Adapted from:Mauksch LB et al, Relationship, Communication and Efficiency in the Medical Encounter, Arch Intern Med, 168(13): July 14, 2008 Negotiate Plan

14. Tools and Techniques • Collaborative Agenda Setting • LEARN Interview Model • Active Listening Skills • Eliciting the Explanatory Models • Motivational Interviewing • Self-Management Ed.

15. Tools and Techniques:The L-E-A-R-N Model Listen(Reflection) Elicit/Explain AcknowledgeAnd Ask Recommend Negotiate What do you think caused this problem? Let’s do a reality Check. I would like to show you this chart of your HbA1c. Is that OK? What would you like to work on to lower your blood sugar? How could you imagine doing that? What do you think will make you better? We seem to see things differently in this situation. What would you do if you were in my shoes? How important is this to you? How confident are you?

16. Tools and Techniques: Self-Management Education • Patients identify their problems • Problem-solving skills • Decision-Making Techniques • Builds and Relies on Self-Efficacy • Addresses: • Communication Skills, • LifeStyle Changes, • Medication Adherence, • Mood Challenges, • Assessing New Treatments Source:Bodenheimer et al JAMA November 20, 2002—Vol 288, No. 19

17. Tools and Techniques: Action Plans Fuel Motivation • Action plans are developed by patients - not providers. • The action plans build confidence that fuels internal motivation.

18. Relationship-Centered Care • Reduces Patient Anxiety • Promotes Patient-centered Treatment Goals • Enhances Self-Efficacy • Optimizes Use of Resources • Improves Quality of Care • Restores Provider Commitment and Prevents Burn-out

19. Successful PCMH Team: Nurse-PhysicianPartnerships Christine A. Sinsky, MD Medical Associates Clinic and Health Plans

20. Patient Centered Medical Home

21. Build-in rather than Carve-out Integrated, Continuous Care Office Visit Nurse-MD Team Between Visit Care Efficiencies and care coordination 1.5 nurses: MD

22. THE BOSS: Nexus of organization of our practice • Between Visit • Extension of me when dealing with patients; patients recognize this. • Coordinates transitions (hospital, NH, Hospice) • Manages & returns most phone calls • Does prescriptions • Updates EHR • Completes all paperwork • Visit • Med. Reconciliation • Initial review of lab • Patient education • Immunizations • Colonoscopy • Sx driven tests (PFT, EKG) • Diabetic foot exam/eye exam • Present patient(↓ info drop-off)

23. Core Team: Mini-huddle • 47 yo “Rapid Access” new patient CC: dysphagia • Nurse Mini-huddle • “She seems depressed” • “Is anyone hurting you?” • Physician better prepared

24. Mar Comprehensive L A B HTN  Chol  Glucose Osteoporosis Depression Lipids,FBS Cr, K, Mam O R D E R S Nurse-MD Team Prevention Integrated, Continuous Care Mammo LabMammo Sept Planned Care S C R I P T S L A B HTN Chol  Glucose Osteoporosis Depression O R D E R S LDL 75, A1c 6.2 Efficiencies and care coordination Same Day Surgery Appt

25. Dec Aug Nov Comprehensive L A B HTN DM 2 Depression O R D E R S Rapid Access Pneumonia Hospital CHF Planned Care S C R I P T S L A B HTN DM 2 Depression O R D E R S FBS, A1c, lipids, alb,mammo Prevention Sept Mar Planned Care Planned Care Apr HTN DM 2 Depression HTN DM 2 Depression INR INR INR INR INR INR INR INR L A B O R D E R S Rapid Access LBP Nurse-MD Team FBS, A1c Efficiencies and care coordination Integrated, Continuous care Architecture Of Care INR CHF Education/ Clinic Home Care L A B O R D E R S Diabetic Education Family A1c 6.8 LDL 145 INR INR CXR Jun FBS, A1c Lipids INR

26. At the center of the PCMH are face-to-face healing relationships. Patient: Nurse Nurse: Physician Nurse: Nurse Patient: Physician

27. Successful PCMH Team: Medication Management in Medical Home Linda M. Strand, Pharm.D., Ph.D., D.Sc.(Hon) Distinguished Professor, College of Pharmacy University of Minnesota And Consultant, Medication Management Systems, Inc. Discloser: Founding Member of the Board of Directors Medication Management Systems, Inc

28. Roles of the Pharmacist Dispensing Clinical pharmacist Medication therapy management

29. Definitions of Medication Therapy Management • APhA Consensus Statement • American Medical Association • Minnesota Legislation for Minnesota Medicaid

30. Medication Management in Medical Home Patient specific Involves an assessment of drug-related needs, care plan to resolve drug therapy problems and follow-up to determine actual impact Comprehensive Coordinated with other team members Adds unique value to care

31. Practice Settings for Medication Management Clinic Practices Telephonic services Retail Settings

32. The Pharmacist in Medical Home ASSESSMENT CARE PLAN Reveal the patient’s medication experience Identify drug therapy problemsof appropriateness, effectiveness, safety, and compliance with medications Establish personalized goals of therapy Resolve drug therapy problems PersonalizeInterventions Medication Therapy Management FOLLOW-UP Evaluate Effectiveness and Safety Determine Actual Patient Outcomes

33. Panelist Q&A Richard C. Antonelli, M.D., M.S., FAAP Medical Director, Integrated Care Organization, Children's Hospital Boston/ Harvard Medical School Suzanne Mitchell, M.D. M.Sc.Faculty, Boston University School of Medicine Christine Sinsky, M.D.Medical Associates Clinic, Dubuque, Iowa Linda Strand, Pharm.D., Ph.D., D.Sc.(Hon)Distinguished Professor, College of Pharmacy, University of Minnesota

34. Thank You!

35. References: Care Coordination • McPherson, M., Arango, P., Fox, H., et al. (1998). A new definition of children with special health care needs. Pediatrics, 102,137–140 • Porter, M. and Teisberg, E., Redefining Health Care: Creating Value-Based Competition on Results. Harvard Business School Press, 2006. • Antonelli, R, McAllister, J, and Popp, J. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework, April, 2009, The Commonwealth Fund.

36. References: Care Coordination (cont.) • Antonelli, R. and Antonelli, D., Providing a Medical Home:The Cost of Care Coordination Services in a Community-Based, General Pediatric Practice, Pediatrics, Supplement, May, 2004. • Antonelli, R., Stille, C. and Freeman, L., Enhancing Collaboration Between Primary and Subspecialty Care Providers for CYSHCN, Georgetown Univ. Center for Child and Human Development, 2005 • Antonelli, RC, Stille, C, and Antonelli, DM, Care coordination for children and youth with special health care needs: A descriptive, multisite study of activities, personnel costs, and outcomes. Pediatrics. 2008 Jul;122(1):e209-16. • Turchi, R, Gatto, M, and Antonelli, R, Children and Youth with Special Health Care Needs: There is No Place Like (a Medical) Home, Curr Opin Pediatr 2007, 19: 503.

37. Links to Resources: Relationship-Centered Care • Stanford Self-Management Education Program http://patienteducation.stanford.edu/programs/cdsmp.html • http://motivationalinterview.org • Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88(2):251-258

38. Links to Resources: Medication Management in Medical Home • Kuo GM et.al. Collaborative drug therapy management services and reimbursement in a family medicine clinic. Am J Health-Syst Pharm. 2004;61:343-54. • Nkansah NT et.al. Clinical outcomes of patients with diabetes mellitus receiving medication management by pharmacists in an urban private physician practice. Am J Health-Syst Pharm. 2008;65:145-9. • Isetts, et.al. Clinical and economic outcomes of medication therapy management services: The Minnesota Experience. J Am Pharm Assoc 2008;48:203-211. • Isetts, et.al. Quality assessment of a collaborative approach. Arch Int Med 2003;163:1813-20.