Fletcher Allen Primary Care Medical Home Model of Care Jeffords Institute for Quality Randall Messier MT, MSA

1. Fletcher Allen Primary CareMedical Home Model of CareJeffords Institute for QualityRandall Messier MT, MSA

2. Presentation Agenda Outline of program How we started Medical Home/Panel Management Community Care Team Behavioral Health NCQA Financing Patient stories

3. Medical Home Definition The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

4. Chronic Conditions Lead to Illness, Disability, Death 51% of all Vermont adults have one or more lifelong health conditions that likely require ongoing medical care. 88% of Vermonters >65 report one or more chronic conditions. Ca. 25% of people with chronic conditions have limitations which restrict normal activities.

5. Global Aim Statement We aim to improve care to our patients by implementing a patient centered medical home. The process begins with identifying and evaluating our patients and their current health status. The process ends with improved outcomes for our patients within our medical home. By working on this process we expect to improve quality, engage and empower patients, educate, and foster a team approach to care management while improving efficiency within the practice. It is important to do this now because the 1:1 visit alone leaves Primary Care unsustainable.

6. Medical Home & CCT Team Members Jennifer Gilwee, MD, Aesculapius Eugene Moore, MD, Private Practice Pam Farnham, RN, CCT Nurse Clinical Lead Jen Daley, MSW, Social Worker Erica Hoyt, Educator Mary Ann Ludlow, Dietician Sue Johansen, Dietician Kevin Hatin, YMCA Jean Mahoney, Dept Assistant Audra Jenkins, CCT Coordinator Patty Ross, Medical Assistant Dawn Weening, Coordinator, CHI Nickie Pouteaux, Medical Assistant Chris Pellegrino, Quality Consultant Nina Buss, Public Health specialist Jessica Young, LCSW Beth Hallock, RN Blueprint coordinator Robyn Skiff, Practice Supervisor Randall Messier, MT, MSA Project Mgr. Penrose Jackson, Project Mgr. Emeritus • Jennifer Gilwee, MD, Aesculapius • Eugene Moore, MD, Private Practice • Pam Farnham, RN, CCT Nurse Clinical Lead • Jen Daley, MSW, Social Worker • Erica Hoyt, Educator • Mary Ann Ludlow, Dietician • Sue Johansen, Dietician • Kevin Hatin, YMCA • Jean Mahoney, Dept Assistant • Audra Jenkins, CCT Coordinator • Patty Ross, Medical Assistant • Dawn Weening, Coordinator, CHI • Nickie Pouteaux, Medical Assistant • Chris Pellegrino, Quality Consultant • Nina Buss, Public Health specialist • Jessica Young, LCSW • Beth Hallock, RN Blueprint coordinator • Robyn Skiff, Practice Supervisor • Randall Messier, MT, MSA Project Mgr. • Penrose Jackson, Project Mgr. Emeritus

8. What’s in it for Providers? PROVIDERS: work more extensively with patients with or at risk for chronic disease. use Docsite, a web based program, to track patients and help manage patient population. Panel manager Medical Assistant (MA) helps provider with care management. can refer patients to the Community Care Team to help facilitate behavior change.

9. Community Care Team (CCT) Services include: • Nutrition help • Exercise advice • Diabetes Education • Medication Management • Behavioral/Mental Health • Connection to community and financial resources Providers involved in pilot can refer their patients to the CCT. Team members provide regular ongoing support as needed via phone or in person. The team helps patients set realistic goals and timelines for improving health.

10. How Did We Start? • Evaluated our current system using Clinical Microsystems process. (Necessary first step) • Used Clinical Microsystem processes to trial test of change and implemented several improvements to test tracking, message handling, prescription refill etc. • Cleaned up our registries/started new ones.

11. Medical HomePanel Mgmt./CCT Trialed process with one MD. Moved to second MD that was supported by the same clinical team. Added one MD at a time to new processes All MD’s/staff were involved in design and review prior to being added to the pilot. Roll out lasted 5 months.

12. Panel Management MD’s determine criteria for screening patient panel. i.e. A1C value, A1C on time, Colonoscopy etc. Panel MA runs report, and based on predetermined algorithm designed by the providers, takes action on report. All patients who fall outside of algorithm are reviewed directly with provider.

13. Panel Management Searchable database is imperative to success. Predetermined algorithm and query design standardizes the process for everyone. This standard approach systematizes the preventive care component of panel management. Freeing up MD’s to be MD’s.

14. CCT Started by taking referrals from one MD. Roll out mimicked Medical Home roll out. Needed to test system, needs, scale before expanding. MD’s involved in determining the CCT services to be offered. Fax referral form instituted.

15. CCT Patient Flow Visit planner printed for patient visit. Patient arrives and roomed as usual Staff/MD utilize planner to ensure required preventive measures are performed, scheduled or discussed with patient. MD determines that patient is a candidate for CCT. MD discusses the program with patient.

16. CCT Patient Flow Cont. Fax form sent to CCT indicating needs. CCT contacts patient with in 24-48 hours to set up appointment at Aesc, home or at the CCT location. Patient meets with the appropriate CCT staff. 1 to 6 visits. Note placed in patients chart regarding visit. Provider contacted if needed.

18. CCT Patient Flow Cont. CCT team meets weekly to discuss active cases with entire team CCT staff member meets with MD monthly to discuss active cases.

19. CCT Activity 706 Referrals 1462 visits 46 graduates 295 active patients 143 inactive patients 447 patients seen YTD.

20. Integrated Behavioral Health Added an on-site LCSW at Aesc. Provides immediate consultation. Is a full member of the clinical team. Works with CCT on follow up and referral. Patients “DO” come back for visits. Short term intervention and support. Complicated long term referred out.

22. Medical Home Designationand Financing Agreement with payors was to become NCQA certified as a patient medical home. Payment directly linked to score achieved on NCQA review.

23. NCQA Medical Home Criteria Access & Communication Patient Tracking & Registry Functions Care Management Patient Self-Management Support Electronic Prescribing Test Tracking Referral Tracking Performance Reporting & Improvement Advanced Electronic Communication

26. Proposed PMPM with Insurers

27. NCQA Scoring & Provider Payment 5 of 10 MP 10 of 10 MP

28. What We’ve Learned So Far Patients love it!! They love the extra time they have with the team. Challenged to have quick outcomes. Behavioral Health integration is essential. It’s a lot of work to get started! Not all Providers embrace systems change.

29. Patient Stories 70 year old female Type II diabetes, Controlled by diet and exercise. Patient referred to CCT for help with HbA1C and weight loss. Two appointments with CCT. Education on carbohydrates. Plan for diet control and exercise. Agreed to walk 30 minutes per day. Since December she has lost 20 pounds, is exercising daily and her blood sugars have been 100-120. She says she hasn’t felt this good in years!

30. Patient Story 67 year old man. Type II diabetes Referred to CCT for nutrition, diabetes education and exercise advice. Met with CCT Nurse. Educated on carbohydrate counting, healthy diet. Referred him for a fitness assessment and personal training sessions with a trainer at the YMCA. 4 months later patient has lost 15 pounds and is at his goal weight, HBA1C went from 10.2 to 6.2, and he feels great!