Shari Erickson Senior Associate, Center for Practice Improvement & Innovation

1. Overview of The Patient Centered Medical Home (PCMH) Movement HRSA Office of Rural Health Grantee Partnership MeetingSeptember 2, 2009 Shari EricksonSenior Associate, Center for Practice Improvement & Innovation

2. Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and protection. President Harry Truman Text from a speech he delivered to a joint session of Congress in 1945

3. So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year. President Barack Obama Text from a speech he delivered to a joint session of Congress , February 24, 2009

4. The Case for Health Care Reform; Case for PCMH Poor access to care, especially for the uninsured Rising costs and gaps/variation in quality of services Increase in chronic conditions Need for better care coordination Dysfunctional payment system; rewards volume, face-to-face services Impending “collapse” of primary care Purchasers’ demand for accountability and transparency United States is lagging internationally

5. Presentation Outline • Overview of the patient-centered medical home model • Joint Principles • PCMH recognition program • Features of a PCMH practice • Growing support for the PCMH model • Efforts to test the PCMH model • Additional Activities Underway and in the Future

6. High-Level Medical Home Overview • ACP and others refer to medical home as the Patient Centered Medical Home • Strengthening the physician-patient relationship • Getting patients the care they want and need when they need it • Vision of primary care as it should be • Framework for organizing systems of care at both the micro (practice) and macro (society) level • Model to test, improve, and validate • Important component of more comprehensive reform

7. Evolution of the PCMH “Joint Principles” • ACP, American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), and American Osteopathic Association (AOA) have similar positions in promoting PCMH • ACP, AAFP, AAP, and AOA—representing 330,000 physicians—establish PCMH “joint principles” in March 2007 to provide standard definition of delivery model and describe the environment necessary to support it • These joint principles guide the collective actions of the organizations to further develop, promote, and test the PCMH

8. Joint Principles Team-based care: NP/PA RN/LPN Medical Assistant Office Staff Care Coordinator Nutritionist/Educator Pharmacist Behavioral Health Case Manager Social Worker Community resources DM companies Others… • Personal physician in physician-directed practice • Whole person orientation • Coordinated care, integrated across settings • Quality and safety emphasis • Enhanced patient access to care • Supported by payment structure that recognizes services and value

9. Joint Principles-Recommended Supporting Payment Structure Payment model is intended to facilitate and sustain improved care delivery and provide a mix of incentives to optimize patient care • Bundled, severity-adjusted care coordination fee paid on a monthly basis for the following components • The physician and non-physician clinical staff work required to manage care outside a face-to-face visit • The health information technology and system redesign incurred by the practice • Continued per-visit, fee-for-service (RBRVS) payment • Performance-based bonus payments based on evidence-based measures of care

10. How do you Know a PCMH When you See One? • Process needed to recognize practices that have and use the capability to provide patient-centered care • Practice recognition provides purchasers (employers, government) and patients with prospective assurance that the practice has capabilities • National Committee on Quality Assurance (NCQA) announced a voluntary recognition process based on its Physicians’ Practice Connection (PPC) module, the PPC-PCMH in January 2008 • ACP, AAFP, AOA, and AAP helped NCQA develop the module • Other entities can develop PCMH recognition process • Recognized PCMHs would also be accountable for quality of care by reporting on evidence-based clinical and patient experience measures—provides retrospective assurance

11. NCQA PPC-PCMH Recognition Module; Major Domains/Standards Access & Communication Patient Tracking & Registry Functions Care Management Patient Self-Management Support Electronic Prescribing Test Tracking Referral Tracking Performance Reporting & Improvement Advanced Electronic Communication Each standard contains sub-elements

12. 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

13. Key Points for Level 1 PCMH • Does not require electronic health record • Will require registry & tracking functions • Emphasis is on providing better care through: • Access to care • Organization of office structure & processes • Enhancing patient self-management; addressing health literacy issues • Introduction of evidence-based guidelines, measurement & quality improvement

14. Level 2 → Level 3 • Advanced access options for patients • Electronic health record • More, and more complex care coordination and patient support • Robust population management • Advanced reporting and quality improvement initiatives • Additional technology solutions

15. More Features of a PCMH Practice • Uses each team member to his/her highest capability • Supports cultural competency training for clinical team • Understands health literacy • Establishes connections to the community and available resources • Provides extensive self-management support • Engages a Patient/Family Advisory Group

16. More Features of a PCMH Practice • Provides individualized written care plans and monitors adherence to plan with patient/family • Assesses barriers to adherence and initiates plans to overcome them • Collaborates with other physicians & institutions to insure timely access to health information • Manages transitions of care seamlessly

17. NCQA Recognition Activity* • 149 practices have received recognition across 17 states • 46% Level 1 • 4% Level 2 • 50% Level 3 (12 of 75 in practices of 1-2 physicians) • Practices more likely to seek recognition when/where tied to reward • Smaller practices (in number of physicians) somewhat more likely to be Level 1; larger practices somewhat more likely to be Level 3 * Source: NCQA, as of June 12, 2009

18. Growing Support for the PCMH Model • Many supporting organizations have come together through the Patient Centered Primary Care Collaborative (PCPCC), which formed in 2007 and has over 560 member organizations, including: • Organizations representing over 350,000 physicians—including ACP and other primary care societies, American College of Cardiology, American Academy of Neurology • Organizations representing over 50 million employees, including large employer umbrella groups, and individual companies such as IBM, General Motors • All major health plans • CVS Caremark, including MinuteClinic • Consumer organizations including AARP • Bridges to Excellence • State governments and public health departments • PCPCC organizations attest to their support of the PCMH Joint Principles, including the belief that the PCMH will “improve health of patients and the viability of the health delivery system,” and support a better payment model to facilitate implementation PCPCC on the web: http://www.pcpcc.net

19. Overview of PCPCC Activities • Four Collaborative Centers: • Multi-Stakeholder Demonstrations; • Public Payer Implementation; • Health Benefit Redesign and Implementation; and • eHealth Information Adoption and Exchange • Events: • Two stakeholder meetings per year • One national summit • Weekly calls • Collaborative center calls • Products (all available free of charge): • Purchasers Guide to the PCMH • IT Resource Guide • Consumer Materials • PCMH Pilot Compilation

20. Overview of PCPCC Activities (cont.) • The Purchasers Guide (http://www.pcpcc.net/content/purchaser-guide): Aims to address – What is the PCMH? Why should employers/purchasers support it? What strategies and action steps should employers/purchasers consider now? • Meaningful Connections : IT Resource Guide (http://www.pcpcc.net/content/meaningful-connections-it-resource-guide): Identifies the capabilities and functionalities of eHealth applications that experts consider crucial to support PCMH. • Engaging the Consumer (http://www.pcpcc.net/content/engaging-consumer-family-patient-employee-community-etc): Multiple resources from various sources aimed at helping the consumer/patient/family better understand and become engaged in the PCMH model, including a video, brochures, checklists, guides, and white papers.* • PCMH Pilot Compilation (http://www.pcpcc.net/content/pcpcc-pilot-projects): A list of PCMH pilots underway and under development, along with their key features and contact information. * Can also link to these consumer resources via the ACP website at http://www.acponline.org/running_practice/pcmh/resources_tools/web.htm.

21. Efforts to Test PCMH • Impetus for testing is need for reform/redesign ambulatory care practice, evidence of the value of primary care, initial evidence from PCMH tests, and support for PCMH concept • Much of initial evidence pertains to large practice settings, integrated delivery groups, e.g. Geisinger (Danville, PA) experience shows 20% reduction in hospital admissions, 7% decrease in overall costs (Health Affairs, Sept/Oct 2008) • Particular need to test in small practices AND in rural areas

22. Efforts to Test PCMH (cont.) • Term “medical home” is used widely and can mean many things • Guidelines for PCMH Demonstration Projects* - developed by ACP/AAFP/AAP/AOA to provide direction to projects in the planning phase in order to facilitate consistency with the Joint Principles – they include recommendations about: • Who should collaborate on the projects; • How they should choose practices to participate; • What kind of support should be provided to participating practices; • How participating practices should be reimbursed; and • What each project should to do to analyze and distribute their results. * Detailed guidelines available at: http://www.acponline.org/running_practice/pcmh/demonstrations/guidedemo.pdf

23. Types of PCMH Test Projects • Multi-payer/multi-player commercial plans • Medicare Advantage • Medicaid transformation • Safety-Net Medical Home Iniative • Medicare FFS

24. Overview of PCMH Commercial Pilot Activity • 22 projects • 16 states • 12 are Multi-stakeholder • 10 are Insurer-based Source: PCPCC Pilot Report, as of Oct. 2008

25. Overview of PCMH Commercial Pilot Activity (cont.) Since October 2008: • New commercial PCMH projects under development in at least 4 more states: • Maryland • Indiana • Alabama • California

26. Examples of Multi-Stakeholder Efforts to Test PCMH – Pennsylvania • Pennsylvania Chronic Care Commission Rollouts • An integration of the Chronic Care Model and the Patient-Centered Medical Home concept • Six rollouts across the state – southeast, south central, southwest, northeast, northwest, north central; project underway and to run for three years • Involves multiple health plans in each area, including Medicaid and Medicare Advantage business • Includes over 100 internal medicine, family medicine, pediatric, and NP-led practices (in urban, suburban, and rural areas) • Utilizing NCQA recognition program • 3-component payment structure: (1) prospective infrastructure development payments, (2) enhanced FFS/capitation via lump sum payments associated with level of achievement on NCQA PPC-PCMH, (3) P4P using a consistent set of core measures by 2010 • Practice support provided by Improving Performance In Practice, a Robert Wood Johnson Foundation funded quality improvement program that is located in several states

27. Examples of Multi-Stakeholder Efforts to Test PCMH – Louisiana Source: Karen DeSalvo, presentation to the PCPCC on June 16, 2009 (given by Clayton Williams).

28. Initiatives to Advance Medical Homes in Medicaid/ SCHIP = Identified to have a medical home initiative Source: National Academy for State Health Policy State Scan, November 2008

29. State Medicaid/SCHIP Innovation (cont.) • Over 30 states trying to improve medical home availability in Medicaid/SCHIP programs - via legislative authority or mandates, Medicaid Transformation Grants, dedicated state resources* • Private Sector Multi-Stakeholder PCMH Pilots Involving Medicaid: • Colorado • Louisiana • Maine • New Hampshire • Rhode Island • Vermont * Source: National Academy of State Health Policy (NASHP): http://www.nashp.org/files/medicalhomesfinal.pdf discusses 10 states in depth

30. State Policy PCMH Implementation Introduced Legislation in 2009 California New Jersey Hawaii Maryland Nebraska West Virginia Texas Washington Wyoming Introduced Legislation in 2008 Iowa Kansas Massachusetts New Hampshire New York Oklahoma Minnesota Washington Maryland Maine Vermont Utah Enacted Legislation in 2007 and 2008 Colorado Louisiana Minnesota Iowa Washington Oklahoma Maine New York

31. Safety-Net Medical Home Initiative • Launched by The Commonwealth Fund, Qualis Health and the MacColl Institute for Healthcare Innovation • Project duration: April 2009 – April 2013 • Project goal – to develop a replicable and sustainable implementation model for medical home transformation • Five Regional Coordinating Centers (RCCs) have been selected: • Colorado Community Health Network • Executive Office of Health and Human Services & Massachusetts League of Community Health Centers • Idaho Primary Care Association • Oregon Primary Care Association & CareOregon • Pittsburgh Regional Health Initiative For more information: http://www.qhmedicalhome.org/safety-net/index.cfm

32. Safety-Net Medical Home Initiative (cont.) • Each RCC has partnered with 12-15 safety net clinics in their state. • These collaboratives will receive technical assistance on practice re-design topics such as enhanced access, care coordination and patient experience. • They will also receive funding to support a Medical Home Facilitator (who will lead clinic-based quality improvement projects) and other activities. For more information: http://www.qhmedicalhome.org/safety-net/index.cfm

33. Medicare Medical Home Demo • Authorized under Section 204 of the Tax Relief and Health Care Act of 2006 • 3-year demonstration • RUC made recommendations for care management fees

34. Medicare Medical Home Demo (cont.) • Physician Eligibility • Family practice, IM, geriatrics, general practice, and some specialty/subspecialty practices (CHCs are specifically included) • Patient Eligibility • Medicare Part A & B, FFS; Medicare as primary coverage • Qualifying chronic disease • Site Selection • 8 sites, 50 practices per site = 400 practices total (approx. 2000 physicians) • Geographic distribution; sufficiently large Medicare FFS population • No other CMS demonstration projects in the area • Preference given to: Medicare high cost areas and sites with private payer medical home demonstrations

35. Medicare Medical Home Demo (cont.) • Monthly Medical Home Fees • Tier 1 and Tier 2 – using revised version of NCQA PPC-PCMH • Adjusted using Hierarchal Condition Code (HCC) to reflect severity and burden • Estimate that 25% of beneficiaries with HCC <1.6 and Medicare costs at least 60% higher than average • First 2% of savings not shared • 80% of savings above 2% (minus fees) shared with practices

36. More Information on PCMH Demonstration Projects See the ACP website: http://www.acponline.org/running_practice/pcmh/demonstrations/index.html

37. Efforts Underway/the Future • Multi-payer demonstration projects 2008 – 2010 and beyond (discussed earlier) • Medicare Medical Home Demo 2010 (discussed earlier) • Role of subspecialists/specialists* • Support for practices* • Facilitating coordination with other providers and caregivers to provide optimal care * Discussed further below

38. Efforts Underway/the Future • Identifying common/recommended evaluation metrics* • Consumer organization projects aimed at communicating PCMH to patients* • Understanding/facilitating needed HIT* • Educational reform for students/residents • PCMH as part of broader health care reform * Discussed further below

39. Specialty Care Connections • PCMH is NOT a gatekeeper system • Jointly develop/identify referral guidelines • Emphasis on transitions in care & continuity (e.g., referral agreements, care transitions programs) • Some subspecialists may want to qualify as PCMH; most will likely prefer to be “neighbors” • ACP in discussions with several groups regarding the PCMH model and primary care/specialty care interface (sharing care) • ACP Council of Specialty Societies PCMH workgroup – has developed FAQs on the relationship of the PCMH to specialty physicians* * FAQs available at: http://www.acponline.org/running_practice/pcmh/understanding/specialty_physicians.htm

40. Support for Practices • ACP Medical Home BuilderSM - on-line guidance for practices involved in incremental quality improvement changes - or significant transformation of their practices. Made up of 7 modules: • Patient-Centered Care & Communication • Access & Scheduling • Organization of Practice • Care Coordination & Transitions in Care • Use of Technology • Population Management • Quality Improvement & Performance Improvement • Additional information at: http://www.acponline.org/running_practice/pcmh/help.htm

41. Support for Practices (cont.) • MedHomeInfo - A resource for physicians and practices that want to participate in the Medicare Medical Home Demonstration. • Additional information at: http://www.medhomeinfo.org/

42. PCMH Evaluations/Metrics • PCMH Evaluators Collaborative: • Sponsored by The Commonwealth Fund • For researchers actively engaged in a PCMH evaluation • Objectives: • Reach consensus about a standard set of data collection instruments • Reach consensus about a standard, core set of outcome measures • Share the Collaborative's consensus on instruments, metrics and/or methodological lessons with interested researchers around the country through public venues • Foster an ongoing and supportive exchange where evaluators share ideas that improve their evaluation designs

43. PCMH Evaluators Collaborative (cont.) • Measurement workgroups will propose standards for: • Patient experience • Physician/staff experience • Medical homeness • Clinical quality • Cost/efficiency • Process/implementation metrics • Proposed measure sets to be vetted with larger group of stakeholders • Additional information at: LINK TO BE ADDED

44. Consumer and Patient Information • Introduction to the Patient-Centered Medical Home: A multimedia program to explain the PCMH model to consumers. A collaboration between the Patient-Centered Primary Care Collaborative and Emmi Solutions®. • Merck Patient Education Brochure and Checklist: Developed for the PCPCC by Merck. in consultation with ACP and other organizations, to help health care professionals communicate with patients about the PCMH approach. • Primary Care: A Miracle of Modern Medicine: This brochure is a collaboration between Thomas Bodenheimer at the Center for Excellence in Primary Care at the Department of Family and Community Medicine at University of California, San Francisco; and the John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital. Links to these documents can be found at: http://www.acponline.org/running_practice/pcmh/resources_tools/web.htm Additional consumer materials can be found at: http://www.pcpcc.net

45. Consumer and Patient Information (cont.) • National Partnership for Women and Families Medical Home Principles: Developed by a broad coalition of more than 25 of the nation's leading consumer, labor, and health care advocacy groups to help health care providers, lawmakers, employers, and health plans consider consumer interests as they develop delivery system reforms such as the medical home. • Supporting Patient Engagement in the Patient-Centered Medical Home: White paper on patient engagement in the PCMH produced by the Center for the Advancement of Health. It includes a “Short Guide for Patients” and a sample “Patient-Clinician PACT”. • Creating a Patient Guide for a “Medical Home” Physician Practice: A resource by the Center for the Advancement of Health to assist medical home practices with creating a simple guide for their patients. Links to these documents can be found at: http://www.acponline.org/running_practice/pcmh/resources_tools/web.htm Additional consumer materials can be found at: http://www.pcpcc.net

46. Understanding/Facilitating Needed Health Information Technology • Meaningful Connections: IT Resource Guide • White paper by the PCPCC. • Identifies the capabilities and functionalities of eHealth applications that experts consider crucial to support the PCMH. • Available at: http://www.pcpcc.net/content/meaningful-connections-it-resource-guide

47. Now, there are some who question the scale of our ambitions, who suggest that our system cannot tolerate too many big plans. Their memories are short, for they have forgotten what this country has already done, what free men and women can achieve when imagination is joined to common purpose and necessity to courage. What the cynics fail to understand is that the ground has shifted beneath them, that the stale political arguments that have consumed us for so long, no longer apply. -President Barack Obama, January 20, 2009

48. Thank You! Shari M. EricksonSenior Associate, Center for Practice Improvement & InnovationDivision of Governmental Affairs & Public PolicyWashington, DCserickson@acponline.org202-261-4551