Patient Centered Medical Home Projects and Pilots From Vision to Reality

1. Patient Centered Medical HomeProjects and Pilots From Vision to Reality Terry McGeeney MD, MBA President and CEO, TransforMED

2. Access to Care &Information • Health care for all • Same-day appointments • After-hours access coverage • Accessible patient and lab information • Online patient services • Electronic visits • Group visits • Practice Management • Disciplined financial management • Cost-Benefit decision-making • Revenue enhancement • Optimized coding & billing • Personnel/HR management • Facilities management • Optimized office design/redesign • Change management • Practice-Based Services • Comprehensive care for both acute and chronic conditions • Prevention screening and services • Surgical procedures • Ancillary therapeutic & support services • Ancillary diagnostic services • Health Information Technology • Electronic medical record • Electronic orders and reporting • Electronic prescribing • Evidence-based decision support • Population management registry • Practice Web site • Patient portal • Care Management • Population management • Wellness promotion • Disease prevention • Chronic disease management • Patient engagement and education • Leverages automated technologies • Quality and Safety • Evidence-based best practices • Medication management • Patient satisfaction feedback • Clinical outcomes analysis • Quality improvement • Risk management • Regulatory compliance • Care Coordination • Community-based services • Collaborative relationships • Emergency room • Hospital care • Behavioral health care • Maternity care • Specialist care • Pharmacy • Physical Therapy • Case Management • • Care transition • Practice-Based Care Team • Provider leadership • Shared mission and vision • Effective communication • Task designation by skill set • Nurse Practitioner / Physician Assistant • Patient participation • Family involvement options

4. Why Patient Centered Medical Home • The Patient Centered Medical Home creates a framework for change • The Patient Centered Medical Home creates a common language for change • The Patient Centered Medical Home creates an opportunity for change

5. Practice Evaluation • Virtual evaluation to include “Medical Homeness” with the MHIQ (Medical Home Implementation Quotient, Leadership assessment, Change Readiness assessment, Health Information Technology assessment • Site visit by evaluation team • Detailed report with PCMH gap analysis • Unique practice project list and timeline developed in conjunction with the practice

6. www.transformed.com/mhiq

7. In-Person Practice Facilitation • The majority of the pilots • In-person facilitation includes at least quarterly visits to practice by facilitator and appropriate experts • Facilitator is assigned for the term of a pilot/project—typically 2 years • Facilitators are all experienced with at least 10 years of experience with varied skill sets—PhD’s in change/leadership, Nurse Practitioners, MBA’s, lean six sigma’s, etc (important for credibility with the practices

8. Virtual and in-person facilitation • Virtual assessment component • Designated facilitator for the term of the pilot/project • Weekly or Bi-weekly calls or video conferencing with providers and staff on separate calls • Aggressive on-line support • Practice Management is a critical component • Delta-Exchange participation with private zones for pilots

9. Immediately connect with practices and maintain the change momentum • Access to useful PCMH resources: ”best-practices,” forms and templates, live webinars and how-to-articles • Ask questions and get useful answers from TranforMED Facilitators and Delta-Exchange Members

10. Collaborative Meetings • Shared learning is a critical success factor • Meetings are a combination of teaching, break-out sessions and shared learning • Adequate time for networking and celebration of successes • Visiting “faculty” to tell their stories • Typically from 2 to 4 per year (virtual facilitation generally involves more collaborative meetings)

11. Practice Recognition • It is important to document milestones • The role of recognition should be to document transformation, not drive transformation • Most pilots use NCQA • Practice recognition is generally driven by payment incentives

13. Thank You! Terry McGeeney MD, MBA tmcgeeney@transformed.com 913-906-6330