CDR Patricia Taylor, NC, USN Deputy Director Medical Services Naval Hospital Bremerton, WA

1. Integrating Population Health Management into Patient-Centered Medical HomeMeeting NCQA MHP Recognition Requirements CDR Patricia Taylor, NC, USN Deputy Director Medical Services Naval Hospital Bremerton, WA

2. Defining the Medical Home • Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs. Publically available information Grundy (2012) Source: Health2 Resources 9.30.08 8

3. Investing in Primary Care Patient Centered Medical Home Group Health Cooperative of Puget Sound (Seattle, Washington) • Cost: • $10 PMPM reduction in total costs • 16% reduction in hospital admissions • 29% reduction in ER visits • Return on investment 1.5: 1 • Quality: • 4% more patients achieving target levels on HEDIS quality measures • 10% of pilot clinic staff reporting high emotional exhaustion at 12 • months compared to 30 percent of staff in control clinics • Improvement in recruitment and retention Geisinger Health System (Pennsylvania) • Cost: • 18% reduction in hospital admissions • 7 % reduction in total PMPM costs • Return on investment 2:1 • Quality: • 74% improvement in preventive care • 22% improvement in coronary artery disease care • 34.5% improvement in diabetes care Resource: Grumback & Grundy. (2010)

5. Population HealthTranslating Strategy into Action • Focus on Better Health • Partnership between primary care and population health • Prevention and Chronic Care Management • IT tools allowing for actionable, near time data • Embedded training and population health support

6. Correlation to 2011 NCQA MHP Standards • Identify and management patient populations (PCMH 2: Elements C & D) • Plan and manage care (PCMH 3: Elements A-C) • Providing self-care support and community resources (PCMH 4: Element A)

7. Integrating Planned Care into Primary Care • Planned care for chronic conditions and preventive care • Patient and caregiver engagement

8. Planned Care for Chronic Conditions & Preventive Care • Primary care practices will proactively assess patients to determine need • Provide appropriate and timely preventive care • Use disease registries to track and appropriately treat chronically ill patients

9. Patient & Caregiver Engagement • Primary care practices will engage patients and families in active participation in goal setting and decision making • Patients will be full partners in truly patient-centered care

10. Integrating Planned Care into the Primary Care Setting Key components • Leadership support and buy-in at all levels • Roles/Responsibilities defined for entire team • Ongoing training for targeted preventive care and chronic conditions • Information tools for point of care and outreach efforts • Delivery system process redesign • Embedded population health/health educator

11. Planned Care Management ProcessPoint of Care • Preventive Health Assessment • Proactive Office Encounter Preparation Process

12. Preventive Health Review • Part I: Patient Appointment Information • Part II: Preventive Health Screenings • Part III: Disease and Condition Management

13. Preventive Health Review

14. Part I: Patient Appointment InformationPart II: Preventive Health Screenings

15. Part III: Disease and Condition Management

16. Proactive Office Encounter Preparation Staff Roles/Responsibilities • Review PHR during huddle/team meeting • If screenings are flagged “red or due” take appropriate action (colorectal CA, breast CA, or Cervical CA screenings) • If patient has specific chronic conditions review & take appropriate action (Asthma, diabetes, dyslipidemia) • Gather appropriate educational resources

17. Office Encounter Process Staff Roles/Responsibilities • Support Staff • Review PHR with patient • If screenings are flagged “red or due” take appropriate action (colorectal CA, breast CA, or Cervical CA screenings) • If patient has specific chronic conditions review & take appropriate action (Asthma, diabetes, dyslipidemia) • Provider • Review/reinforce tests/screenings needed • Patient • Takes home PHR • Leaves clinic with appropriate orders, consults, f/u appts • Has appropriate educational resources • Acts on orders and consults • Achieves self-management goals

18. Planned Care Management Process Outreach Efforts

21. Planned Care Management Staff Training Components • CarePoint • Familiarization with various features • Patient Population Management (PPM) • Preventive Care • Chronic Care • CarePoint Skills competencies/PPM knowledge exam • Patient Communication Scripts • Documentation/Exclusions

22. Planned Care Management ProcessOutreach Efforts Support Staff use CarePoint to identify patients who are overdue or due for tests/screening Contacts via phone Unable to contact • Address all patient needs in one phone call • Place appropriate orders/consults /schedule appointments • Document in CarePoint (Notes, exclusions, ordered tests/screenings • Documents in CarePoint. Enters AHTLA t-con with reason for notification • Patient returns call, Communication Room staff can address issue with patient • Three attempts – Letter sent

23. Embedded Population Health/Health Educator • Population Health responsibilities • Streamline CarePoint account application process • Established and conducts CarePoint and Population Management staff training • Clean up data: outside reports, coding corrections, amending records • Provide team updates on HEDIS Captain’s Cup Challenge • Strengthen partnership between Medical Home team and Population Health department

24. HEDIS Captain’s Cup Challenge

25. Embedded Population Health/Health Educator • Health Educator responsibilities • Provides individualized patient education in support of PCMH team • Created standard objective-based education curriculums for use by MH team support staff. (Pathways for brief point of care education) • Provides clinical support staff training for specific health conditions and risk factors (PCMH/HEDIS) • Documents self-management plans and goals

26. Impact of Integrating Planned Care into Primary Care • Enhanced Team-based approach • Maximized Provider/patient time • Enhanced patient/caregiver engagement • Improvements in HEDIS measures

28. NH Bremerton Points of Contact • CDR Patricia Taylor patricia.taylor2@med.navy.mil • Dr. Dan Frederick daniel.frederick@med.navy.mil • Aimee Aldendorf aimee.aldendorf.ctr@med.navy.mil