“Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years ?”

1. “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC

2. Learning Objectives • Understand the value of the PCMH initiative to “We the Patients” • Review the goals of PCMH and the need for comprehensive medical care • Define the components of the PCMH model • Establish realistic expectations and time lines for implementation • Articulate what studies indicate the impact PCMH will have on our system

3. US Health Care Problems • Fragmented • Inaccessible • Costly • Culturally ineffective • “I got there and you know that doctor didn’t have any of my information.” • “You know that clinic is never open when I need them.” • “But I was just here last week.” • “What is a Shaman anyway?”

4. Problems Continued • Burden is on patient and family • Mediocre quality • Excessive use of high cost services with marginal benefits. • “We drove to three different pharmacies and none of them had the medication.” • “I waited 45 minutes and she only spent five minutes with me.” • “I’ve had laser treatment twice for my nail fungus and it came back.”

5. National Health Expenditures 2010 • Hospital and physician/clinical services account for 51% of the $2.3 Trillion. • Technology and prescription drug use. • Rise in chronic diseases (75%). Sources:1Martin A.B. et al., “Growth In US Health Spending Remained Slow in 2010; Health Share of Gross Domestic Product Was Unchanged from 2009,” Health Affairs, 2012 2Centers for Disease Control and Prevention.  Rising Health Care Costs Are Unsustainable. April 2011.

6. “What do they think we have been doing…..?” • Medical home. • Term originated in 1967. • Care coordination dates back 1859.

7. Current PCMH Status • State Participation • National Participation

8. PCMH Core Primary Care Goals • Access • Patient Centered • Comprehensiveness • Coordination • Systems based approach to quality and safety

9. Team Approach to Care • Team members • Virtual team members

10. Becoming a PCMH • Human Capital • Dollars and sense’ • Process

11. Human Capital/PCMH Implementation • Cultural Changes • Organized around the patient not the practice • Team based versus classic hierarchy approach • Change in patient habits • Work flow and system changes • Staff function at highest level • Removal of volume driven practice ideology • Significant human capital expense

12. Dollars and Sense’ • Incremental cost estimates for the patient centered medical home • Statistically significant increase in cost for information technology (IT) expenses2 • Average practice spent $8,000 in IT per FTE physician/provider • There was not a statistically significant increase in any other cost component 4S. Zuckerman, K. Merrell, R. Berenson et al., Incremental Cost Estimates for the Patient-Centered Medical Home, The Commonwealth Fund, October 2009.

13. Process • Appoint PCMH Director and send to training • After training director should: • Order the PCMH standards and guidelines (free) • Complete self-assessment • Meet with management and strategically select team • Determine potential fee sponsors • Order online application and ISS survey tool* • Launch Online Application and Self Assess • Respond to Elements & attach documentation

14. Time Frame to PCMH • Short process, challenging endeavor • Change management • Two to three year process* • Some will never transform their practice to PCMH level 3 • Some will reach PCMH level 3 but will never transform their practice

15. Team Member Roles • Director-coordinate and direct all PCMH activities • Primary Care Physician • Team Leader • Removed from volume driven practice • NPs/PAs • Team leaders, health coaches, expanded practice roles • Administrators • Facilitators for acquiring recognition and increased payment

16. Proposed Payment Model • The American College of Physicians is advocating for a three part payment model. • A care coordination payment • Fee-for-service payment • Performance based component3 5 American College of Physicians. A System in Need of Change: Restructuring Payment Policies to Support Patient-Centered Care. Philadelphia: American College of Physicians; 2006: Position Paper. (Available from American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.)

17. Evidence-Based Movement • Evidence on PCMH Effectiveness • Quality of Care • Cost of Care • Experience of Care

18. Improving the Quality of Care • Processes of Care • Lack of rigorous Studies • Three evaluations with rigorous methodology • Only one with favorable effects • Health Outcomes • Only three evaluations with rigorous evidence • Two of those three found favor • Mortality • Inconclusive but optimistic

19. Costs of Care • Costs (Including the Intervention) • Four Rigorous Evaluations • Limited to high-risk subgroups • Mixed reviews • Hospital Use • Five Rigorous Evaluations • One out of five indicated 18% reduction across risk groups • Emergency Department Use • Three Rigorous Evaluations • One of three finding favorable effects

20. The Experience of Care • Patient and Caregiver Experience • Only three rigorous studies • Two with mostly favorable outcomes • Healthcare Professional Experience • One lone evaluation with adequate rigor • Results were inconclusive

21. Summative Review • A guide to the medical home as a practice-level intervention6 6Friedberg MW, Lai DJ, Hussey PS, Schneider EC. A guide to the medical home as a practice level intervention, Am J Manag Care. 2009; 15(10)(supl):S291-299.

22. To PCMH or Not To PCMH • Evidence with scientific rigor is scant. • Current evidence in favor of the medical home is lacking. • More work to be completed, well implemented and well conducted studies are needed. • The cutting edge…..

23. Closing Remarks Patient-centered medical home characteristics and staff morale in safety net clinics 6 6Lewis, SE, Nocon, RS, Tang, H, Park, SY, Vable, AM, MV, Casalino, LP, Huang, ES, Quinn, MT, Burnet, DL, Summerfelt, WT, Birnberg, JM, Chin, MH. Patient-Centered Medical Home Characteristics and Staff Morale in Safety Net Clinics. Archives of Internal Medicine. 2012; 172(1)p23-31.