PCMH

1. PCMH Putting the Patient First: Using Quality to Transform Primary Care Julia Barton, RN, MSN Purdue Healthcare Advisors Purdue Research Foundation 2012

2. Why PCMH?

3. Institute of Medicine: Crossing the Quality Chasm (2001)10 Simple Rules Care based on continuous healing relationships Care based on patient needs and values Patient as the source of control Patient access to medical information and clinical knowledge Evidence-based decision making Patient safety Transparency of information Anticipation of needs Continuous decrease in waste Cooperation among clinicians

4. Crossing the Quality Chasm:6 Aims 2001 IOM Report: Crossing the Quality Chasm: A New Health System for the 21st Century • Health care should be: • Safe • Effective • Patient-Centered • Timely • Efficient • Equitable

5. The Joint Principles of the PCMH (2007)Endorsed by the ACP, AAFP, AAP, AOA Key Characteristics of the Medical Home: Personal physician Physician directed medical practice Whole person orientation Care is coordinated and/or integrated across all elements of the complex health care system and the patient’s community

6. The Joint Principles of the PCMH Also included that: • Quality and safety are hallmarks of the medical home • Care planning, evidence-based medicine, clinical decision support, continuous quality improvement, patient participation and feedback, and appropriate Health Information Technology • Enhanced Access • Payment Based on Value not Volume

7. The Triple Aim (2008) • A framework developed by the Institute for Healthcare Improvement (IHI) that describes an approach to health system performance • The three dimensions are: • Improving the patient experience of care (including quality and satisfaction) • Improving the health of populations • Reducing the per capita cost of health care ( Donald Berwick-The Institute for Healthcare Improvement—2008)

8. The National Committee for Quality Assurance (NCQA) Founded in 1990 Private, independent non-profit healthcare quality oversight organization >32 States have Public and Private PCMH initiatives that use NCQA recognition >5,000 NCQA-Recognized medical homes nationwide PCMH Standards are aligned with Meaningful Use objectives 3 Levels of recognition

9. Patient Centered Medical Home: A Strategy for Quality Improvement Long-term partnerships, not hurried visits Care that is coordinated among providers Better access through expanded hours and on-line tools Shared decisions so patients make informed choices Lower costs from reduced ER/hospital use More satisfied patients and providers

10. 6 PCMH Standards PCMH 1: Enhance Access and Continuity PCMH 2: Identify and Manage Patient Populations PCMH 3: Plan and Manage Care PCMH 4: Provide Self-Care Support and Community Resources PCMH 5: Track and Coordinate Care PCMH 6: Measure and Improve Performance

11. 6 Must Pass Elements (27 total) PCMH 1, Element A: Access During Office Hours PCMH 2, Element D: Use Data for Population Management PCMH 3,Element C: Care Management PCMH 4, Element A: Support Self-Care Process PCMH 5, Element B: Referral Tracking and Follow-Up PCMH 6, Element C: Implement Continuous Quality Improvement

12. Factors • 149 Total Factors • A scored item in an element. For example, an element may require the practice to demonstrate how the practice team provides a range of patient care services. Each type of item, in this case, is a factor • 8 Critical Factors • A factor that is required for practices to receive more than minimal points, or in some cases any point for the element

13. The Factor PathTM

14. STANDARD 1: Enhance Access and Continuity • The practice provides access to culturally and linguistically appropriate routine care and urgent team-based care that meets the needs of patients/families • Element D: Continuity • Factors: • Selecting a personal clinician • Documenting patient choice • Monitoring team visit percentage • Key Points: • Notify patients about the process for choosing a personal clinician • Patient’s choice of personal clinician and care team documented in patient’s chart • Monitor the percentage of patient visits that occur with the selected personal clinician and care team

15. STANDARD 1: Enhance Access and Continuity • The practice provides access to culturally and linguistically appropriate routine care and urgent team-based care that meets the needs of patients/families • Element G: The Practice Team • Factors: • Defined Team Roles • Team meetings and communication • Care teams trained to coordinate care for individual patients • Care teams trained to support self-management, self-efficacy and behavior change • Care teams trained to manage patient populations • Key Points: • Team meetings may include daily huddles or review of daily schedules, with follow-up tasks • Care team members are trained in evidence-based approaches to self-management support, such as patient coaching and motivational interviewing

16. STANDARD 3: Plan and Manage Care • The practice systematically identifies individual patients and plans, manages and coordinates their care, based on their condition and needs and on evidence-based guidelines • Element A: Implement Evidence-Based Guidelines • Factors: • The first important condition • The second important condition • The third condition, related to unhealthy behaviors or mental health or substance abuse • Key Points: • Analyze the entire practice population to determine the important conditions • Conditions can include chronic or recurring conditions such as COPD, hypertension, HIV/AIDS, and asthma • Factor 3 is a critical factor

17. STANDARD 3: Plan and Manage Care • The practice systematically identifies individual patients and plans, manages and coordinates their care, based on their condition and needs and on evidence-based guidelines • Element B: Identify High-Risk Patients • Factors: • Identify high-risk or complex patients • Determines the percentage in its population • Key Points: • The practice establishes criteria and a systematic process for identifying complex or high risk may include • The criteria may include: • Frequent visits for urgent or emergent care • Frequent hospitalizations • Noncompliance with prescribed treatment/medication • Terminal illness • Multiple risk factors

18. STANDARD 3: Plan and Manage Care • The practice systematically identifies individual patients and plans, manages and coordinates their care, based on their condition and needs and on evidence-based guidelines • Element D: Medication Management • Factors: • Medication reconciliation for >50% of care transitions • New prescription information to >80% of patients/families • Assesses medication understanding for >50% of patients • Assesses medication response/barriers to adherence for >50% of patients • Documents OTC, herbals, & supplements for >50% of patients/families • Key Points: • Information given on new prescriptions includes side effects, drug interactions, medication instructions and the consequences of not taking it • Factor 6 - at least annually, the practice reviews and documents in the medical record

19. STANDARD 5: Track and Coordinate Care • The practice systematically tracks tests and coordinates care across specialty care, facility-based care and community organization • Element A: Test Tracking and Follow-Up • Factors: • Tracks lab tests until available, following up on overdue results • Tracks imaging tests until available, following up on overdue results • Flags abnormal lab results to the attention of the clinician • Flags abnormal imaging results to the attention of the clinician • Notifies patients/families of normal and abnormal lab and imaging test results • Electronically incorporates >40% of all clinical lab test results into medical record • Key Points: • Factor 1 & 2 are critical factors • Flagging draws attention to results as an icon that automatically appears in the EHR or a manual tracking system with a timely surveillance process • Factor 5 - filing normal and abnormal results in the patient’s medical record for patient’s next office visit does not meet the intent of the factor

20. STANDARD 6: Measure and Improve Performance • The practice uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience • Element B: Measure Patient/Family Experience • Factors: • Conduct a survey to evaluate patient/family experiences • Key Points: • The practice conducts a survey to evaluate patient/family experiences on at least 3 of the following categories: • Access • Communication • Coordination of Care • Whole-person care/self-management support

21. Applying Lean to Quality Improvement Efforts Lean is a methodology based on providing better quality, identifying value and eliminating waste. Lean methodology employs a bottom up approach where improvement ideas and changes come from patients and staff. This requires commitment to quality and improvement throughout the organization.

22. Lean Key Points Identify, name and reduce waste Engage everyone involved to help fix a broken process Use visual displays to engage and inform staff of progress Agree on standard work and build in training Managers and senior leaders set priorities and keep the organization focused

23. Quality Improvement Strategy • QI strategy is the driver of PCMH transformation • Case study: Group Health Cooperative in Seattle, WA used Lean to Implement and Spread the Patient-Centered Medical Home Model of Care • Before: 7% of patients got their questions answered via phone on their first attempt • After: 65% of patients got their questions answered on their first attempt

24. Additional Services Available from PHA Meaningful Use for Stage 1 & Stage 2 Security Risk Assessment Consulting Patient Centered Medical Home Transformation Lean Six Sigma Healthcare Allison Bryan, MS, CHES Field Operations Manager (765) 496-9791 abryan@purdue.edu www.pha.purdue.edu Purdue Research Foundation 2012