Applying Patient Centered Medical Home Concepts to School-Based Health Centers

1. Applying Patient Centered Medical Home Concepts to School-Based Health Centers April 13, 2010 Irene Krokos, MD Medical Director Victor Lunsford, BSN, MBA, RN Director Quality Improvement Molina Healthcare of New Mexico

2. Outline • Introduction • PCMH Designation • Molina Healthcare PCMH Program • School Based Healthcare Centers and PCMH • Questions

3. Introduction

4. Primary Care in New Mexico • In the United States the PCP to specialist ratio is about 30:70* • In other developed countries the ratio is 70:30 • In those countries health care costs are lower and outcomes often better • In New Mexico the ratio is about 20:80 • Currently about 7% of medical students enter office based primary care • *Klepper, B., Medscape Journal of Medicine. 2008; 10(12): 280 PMCID: 2644012

5. What is PCMH? Adapted from the American Academy of Family Physicians

6. Why is it important? • U.S. adults with a primary care physician rather than a specialist had 33 percent lower costs of care and were 19 percent less likely to die. • U.S. adults who reported having a PCP rather than a specialist as their regular source of care had lower 5 year mortality rates after controlling for initial differences in health status, demographics, health insurance status, health perceptions, reported diagnosis, and smoking status. • A medical home can reduce or even eliminate racial and ethnic disparities in access and quality. • Denmark has organized its entire health care system around patient-centered medical homes. It has the highest patient satisfaction ratings in the world, among the lowest per capita health expenditures and highest primary care rankings. • Investing in Primary Care Patient Centered Medical Homes results in: • Improved quality of care. • Higher patient and provider satisfaction. • Decreased cost and utilization. • Starfield B. Shi L, and Macinko J. Contributions of Primary Care to Health Systems and Health, Millbank Quarterly, Vol. 83, No. 3, 2005 (457-502), Commonwealth Fund

7. Who is NCQA and TJC? • NCQA • Independent 501(c)(3) non-profit organization in the United States designed to improve health care quality. • Established in 1990 with support from the Robert Wood Johnson Foundation . • NCQA manages voluntary accreditation programs for individual physicians, health plans, and medical groups. • TJC • Not-for-profit organization that operates accreditation programs for a fee to subscriber hospitals and other health care organizations. • A majority of state governments have come to recognize Joint Commission accreditation as a condition of licensure and the receipt of Medicaid reimbursement. • Surveys (inspections) typically follow a triennial cycle, with findings made available to the public.

8. PCMH in New Mexico • In the last year 119 providers have received NCQA PCMH Recognition • Sites • UNM - multiple • Taos Clinic for Children and Youth • Santa Fe Medical Group – Santa Fe Family Health • Santa Fe Medical Group – Corazon Family Health • Presbyterian Medical Group – Isleta Clinic • Trinity Family Medicine – Clovis, NM • Molina is working with 10 additional clinic sites and a School Based Health Center.

9. Pcmh designation

10. Patient Centered Medical Home Designation • The Joint Commission (TJC) • Primary Care Home Option • NCQA PCMH Recognition

11. TJC Primary Care Home Option • Developing standards to expand the process of accrediting ambulatory health care organizations to include Primary Care Home option • Standards released Spring 2011 • On-site surveys for Primary Care home accreditation planned to start July 2011 • “Defining and Measuring the Patient-Centered Medical Home” Journal of General Internal Medicine 2010 June; 25(6):601-610. Published online 2010 May 1

12. NCQA PCMH Recognition • Innovative program to improve primary care • Communicates an action plan for becoming a PCMH • Acknowledge as the primary standardized method for evaluating a practice’s capability of performing as a PCMH • Standards available for no cost on NCQA website • Provide educational programs across the country and free education on their web site

13. 2011 PCMH NCQA Standards Standard 1: Enhance Access and Continuity Standard 2: Identify and Manage Patient Populations Standard 3: Plan and Manage Care Standard 4: Provide Self-Care and Community Support Standard 5: Track and Coordinate Care Standard 6: Measure and Improve Performance

14. NCQA Recognition Levels • The NCQA recognition levels allow practices at different levels to become recognized • Level 1: 35 – 59 with 6 must-pass elements • Level 2: 50 – 84 with 6 must-pass elements • Level 3: 85 – 100 with 6 must-pass elements

15. Molina medical home programs

16. Molina Healthcare’s PCMH Programs • Programs are designed to advance the concept of Patient Centered Medical Home • Two programs have been developed for this purpose • PCMH NCQA Recognition Program • PCMH Module Program

17. PCMH NCQA Recognition Program • In 2009 invited select PCP groups to obtain NCQA PCMH accreditation • First come first serve basis • Subsidize application fee • Provide consultative support during process • Once accreditation achieved provide quarterly incentive payments based on assigned MHNM membership • Develop outcomes measures • Measure and report on success of program

18. Molina’s PCMH NCQA Recognition Model • Currently 13 clinics have achieved NCQA recognition and are actively participating in Molina’s incentive program • UNM Medical Group • 12 clinics currently have achieved Level 1 recognition • Taos Clinic for Children and Youth • Level 1 recognition • BCA Associates (Roswell)

19. Molina Healthcare’s PCMH Module Program • In 2010 invited select groups to participate in PCMH Module Program • Goal: assist groups towards building a foundational structure that includes successful implementation of NCQA recognition standards

20. Molina Healthcare’s PCMH Module Program • Modules: • Electronic Medical Record • Patient Tracking and Registry Functions, Test Tracking, Referral Tracking • E-Prescribing • Access and Communication • Performance Reporting and Improvement

21. Molina Healthcare’s PCMH Module Program • Progress: • Ten groups participating and SBHC • Consultant services are being utilized by some groups • Planned assessments in two phases to include April/May and August

22. Molina and school based Health

23. Molina Healthcare and SBHC • Initial meetings and interests for both parties • Helped in decision-making process for determining sites or site • Constructively worked together to determine most approachable and achievable modules for a SBHC • Developed an agreement documentation • Held collaborative meetings to provide direction and assist with understanding of module concept

24. Molina Healthcare and SBHC • The NM Alliance for School-Based Health Care selected Grant Middle School as the most capable of achieving success in the selected modules • SBHC Team selected: • Patient Tracking and Registry Functions, Test Tracking, Referral Tracking • Access and Communication • Performance Reporting and Improvement

25. Approachable PCMH Concepts for a SBHC • Access to the delivery of care • Systems management of care records • Planning, managing and coordinating student healthcare • Promotes health education and community recourses • Tracking care • Identifying data to verify practice results

26. Access to Delivery of Care • Developing policies and processes • How a SBHC provides same-day appointments • Telephone advice during office hours • Documenting clinical advice

27. Access to Delivery of Care • Provide continuity and coordination of care • Patient’s have a practitioner, document choice and percent of visits with particular practitioner/team • Coordinating care to other health settings • Instructions on after hours care • Complete medical histories • Cultural and Linguistic needs (e.g., diversity assessment, language needs and materials) • A clinical team that provides various patient care services (e.g., defines roles, team meetings, standing orders, training, involvement in practice evaluation and OFIs)

28. Systems Management of Care Records • Electronic system/registry for patient information (e.g., age, DOB, gender, phone, email) • Electronic system/registry for structured data (e.g. allergies, problem list, BMI, medication list) • Administers a health risk assessment (e.g., immunizations, med history, development screening) • Reminder lists (e.g., well-child visits, immunizations, medication follow-up)

29. Planning, Managing & Coordinating Student Healthcare • Implements evidenced-based guidelines • Creates criteria and process to identify high risk patients • Care management in the sense of the team concept (e.g., pre-visit preparations, plan, barriers, referral to care management, follow-up) • Manages medications (e.g., reconciles, education, response/adherence, documents OTC, herbal, supplements)

30. Promotes Health Education & Community Recourses • Supports self-care management (e.g., education resources, plans & goals, abilities, tools to record self-care, counsels on healthy behaviors) • Refers to community resources (keeps list, tracks referrals, arranges treatment for mental health and substance abuse, health education)

31. Tracking Care • Tracking test results and follow-up • Tracking referrals and follow-up

32. Improvement Performance • Identifying areas to measure • Identifying vulnerable populations • Assessing patient/families satisfaction (surveys, vulnerable patient groups, suggestions boxes, interviews) • Develops QI program • Tracks, assesses effectiveness of QI program • Reports on success of QI program

33. Questions & Discussion