Carrie Finley, RN, BSN August 3, 2010

2. The Patient Centered Medical Home Model: Impact on Practices and our Advancing Outpatient Prevention Project Carrie Finley, RN, BSN August 3, 2010

3. Objectives • Identify what the Patient Centered Medical Home Model (PCMH) is, and how it benefits a practice and patients • Describe processes to developing and sustaining the Patient Centered Medical Home Model • Identify ways in which concepts from the Patient Centered Medical Home Model can positively affect our Prevention Project • Access resources about PCMH

4. Patient Centered Medical Home Model and History

5. A Brief History • 1967: The American Academy of Pediatrics (AAP) introduced the term “medical home” • 1990s: These precepts about primary care were embraced by the Institute of Medicine (IOM) which specifically mentioned “medical home” • 2002: The Future of Family Medicine: A Collaborative Project of the Family Medicine Community. • 2004: AAFP integrated Chronic Care Model

6. Patient Centeredness • Refers to health care that establishes a partnership among practitioners, patients, and their families to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they require to make decisions and participate in their own care Institute of Medicine Envisioning a National Healthcare Quality Report

7. What is a Patient Centered Medical Home? • Personal Physician • Team Based Care • Proactive Planned visits • Enhanced Access • Tracking Patients and their needed care • Support of self management of chronic conditions • Patient involvement in decision making • Coordinated care across all settings

8. Example of Traditional Office Visit

9. The Planned Care Appointment Dec Jan Comprehensive L A B HTN DM 2 Depression O R D E R S Mammogram Same Day apt Pneumonia Planned Care Visit 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 Planned Care Visit Planned Care Visit HTN DM 2 Depression HTN DM 2 Depression INR INR INR INR INR INR INR L A B O R D E R S Colonoscopy Nurse-MD Team FBS, A1c Efficiencies and care coordination INR Prevention Education Home Care Mar L A B O R D E R S Diabetic Education Family A1c 6.8 LDL 145 INR INR CXR Aug Apr FBS, A1c Lipids Jun INR

10. Many Current National Trends Align Well With the PCMH Model • Emphasis on quality and transparency • Patients, employers, CMS, payors, health systems • Emphasis on patient-centered care • Convenient, timely, patient-friendly • Emphasis on technology – not just in our practices but in individual patient’s lives • Google Health, Revolution.com, WellMark/UHC, etc. will change health care perceptions and expectations • Emphasis on practice redesign/innovation • PCPCC, TransforMed/AAFP, IHI • Emphasis on wellness promotion/disease prevention

11. Recognition Programs for PCMH Developed or Under Development Quality Organizations PCMH Standards Activity 2010

12. What is NCQA? • The National Committee for Quality Assurance is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality. Since its founding in 1990, NCQA has been a central figure in driving improvement throughout the health care system, helping to elevate the issue of health care quality to the top of the national agenda • www.ncqa.org

13. NCQA PPC-PCMH Summary • 9 standards; 100 points total • 30 elements • 10 Must Pass elements • Recognition at three different levels • Level I: 25 points and 5 Must Pass Elements • Level II: 50 points and 10 Must Pass Elements • Level III:75 points and 10 Must Pass Elements

14. Scoring: Building a Ladder to Excellence Level 3: 75+ Points; 10/10 Must Pass Level 2: 50-74 Points; 10/10 Must Pass Level 1: 25-49 Points; 5/10 Must Pass Increasing Complexity of Services

15. Source: NCQA, December 2009

16. Processes to Development and Sustainment

17. How to Start? • What’s your Medical Home IQ? • Where does your practice align with the medical home model? • What areas of the medical home model do you need to work on in your practice? • How do you take your practice from where it is today to where you want it to be?

18. QUALITY MEASURES Are you using these clinical information systems: Registries Referral tracking Lab result tracking Medication interaction alerts r Allergy alerts Your practice is a culture of improvement if you and your staff: Establish core performance measures Collect data for better clinical management Analyze the data for quality improvement Map processes to identify efficiencies Discuss best practices Does your practice use these checklists and reminders? Evidence-based reminders Preventive medicine reminders Decision support Do your care plans reflect: An updated problem list? A current medication list? Patient-oriented goals and expectations www.aafp.org/pcmh and transformed.com. PATIENT EXPERIENCE Which of the following are you using to improve your patients’ access to care? Same day appointments Email Web portal for Rx, appointments, or information Referral to online resources Non-visit based care and support Does your practice support patient self-management through: Motivational interviewing Shared goal-setting Home monitoring (when appropriate) Group visits and support groups Family and caregiver engagement Clear communication requires: Patient language preference Cultural sensitivity Active listening Plain language, no jargon Patient satisfaction surveys Do you and your patients share in the decision-making process by: Discussing treatment options in an unbiased way Considering the patient’s priorities Creating and revisiting follow-up plans Family Patient-Centered Medical Home Checklist

19. Where to Start • Get your house in order • Establish a team • Create a Work Plan • Define key areas to begin • Start with early and easy wins • Set milestones and targets for completion • Set timeframes for evaluating progress

20. Define Your Medical Home • Superb access to Care • Patient Engagement in Care • Clinical Information Systems • Care Coordination • Team Care • Patient Feedback • Publically available information

21. For Patients: Increase satisfaction Personalized care Self care management Improve patient outcomes Decrease hospitalizations Decrease ER visits Slow chronic disease progression For the Practice: Practice Improvements Workflow Teamwork Staff Satisfaction Provider Satisfaction Quality of Care Productivity Keep Your Goals in Mind…

22. Advancing Outpatient Prevention

23. How Does This Tie Into Our Outpatient Prevention Project? • Quality Improvement Models • PDSA Cycles • Action Plans • Process Mapping • Office Workflow/Redesign • Job descriptions/role identification • Standardized workflows • “Chart Prep” • Rooming process • Standing orders

24. How Does This Tie Into Our Outpatient Prevention Project? • EHR Modifications • Registries/active patient definitions • Care Management • Chronic Care model • Planned Care Appointment • Prevention screening • Mammo/Colonoscopy • Immunizations

26. Website Resources • Patient-Centered Primary Care Collaborative – www.pcpcc.net • TransforMed – www.transformed.com • AAFP – www.aafp.org • Institute for Healthcare Improvement – www.ihi.org • Wisconsin Academy of Family Physicians – www.wafp.org/pcmh/index.html

27. Contact Information: Carrie Finley, RN, BSN Quality Consultant MetaStar, Inc. 2909 Landmark Place Madison, WI 53713 (800) 362-2320 or (608) 274-1940 ext. 8246 www.metastar.com cfinley@metastar.com This material was prepared by MetaStar, the Medicare Quality Improvement Organization for Wisconsin, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.  9SOW-WI-CP-10-32.