PCMH Model and the Foundational Building Blocks Steve Bromer, MD - PDF document

6/27/2014 PCMH Model and the Foundational Building Blocks Steve Bromer, MD Department of Family and Community Medicine UCSF Joint Principles of the Patient Centered Medical Home February 2007 American Academy of Family Physicians American Academy of Pediatrics American College of Physicians American Osteopathic Association Transforming the Delivery of Primary Care: The Patient Centered Medical Home  Ongoing Relationship with provider for first-contact, continuous, and comprehensive care;  Health Care Team that collectively cares for the patient;  Whole-person Orientation, including acute, chronic, preventive, and end-of-life care;  Coordinated Care across all elements of the health care system and the patient’s community; 1

6/27/2014 Transforming the Delivery of Primary Care: The Patient Centered Medical Home  Quality and Safety through evidence-based medicine and clinical decision-support tools, information technology, registries, and continuous quality improvement;  Enhanced Access , achieved through such systems as open scheduling, expanded hours, and new options for communication between patients, their physician, and practice staff; and  Payment Reform to reflect the added value that a PCMH provides to patients. Patient Centered Medical Home C ontinuous First C ontact C omprehensive C oordinated HIV Medical Homes Resource Center Evidence on Value of New Primary Care Models: Case Study of Group Health Cooperative of Puget Sound  Patient Centered Medical Home model piloted at one site in 2007  Avg PCP panel size reduced from 2327 to 1800  Longer face-to-face visits and scheduled time for phone and email encounters  Increased team staffing and teamwork  HIT  Panel management 2

6/27/2014 Group Health PCMH Pilot: Controlled Evaluation 12 Month Outcomes  Improved continuity of care  Better patient experiences (6 of 7 measures)  Better composite quality of care score  Reductions in ED visits and Ambulatory Care Sensitive Hospitalizations  No difference in total costs at year 1 (lower total costs by year 2) Source: R Reid et al. Am J Managed Care 2009;15:e71 Group Health PCMH Pilot: Effect on Clinic Staff 40% 34.5% 33.3% 35% p=.02 Percent with High 30.0% 30% Level Emotional Exhaustion 25% Baseline 20% 12 Months 15% 9.7% 10% 5% 0% Control Sites PCMH Site 3

6/27/2014 Change Concepts for the PCMH  Engaged Leadership  Quality Improvement Strategy  Empanelment  Continuous and Team-based Healing Relationship  Organized, Evidence-Based Care  Patient-Centered Interactions  Enhanced Access  Care Coordination Wagner, EH et al, Guiding Transformation: How Medical Practices Can Become Patient-Centered Medical Homes; February, 2012 The Building Blocks of High-Performing Primary Care: lessons from the field  23 high-performing practices  Intensive visits to 7 West Coast practices  Discussions with and observations of clinicians, RNs, MAs, front desk, leaders  High-performing practices look about the same, with variation in the details  10 building blocks -- the foundation of these practices Willard R, Bodenheimer T: CHCF April 2012 Building Blocks of High-Performing Primary Care: Share-the-Care TM Model 4

6/27/2014 Change Concepts Building Blocks NCQA Recognition Engaged Leadership Data for Improvement Enhance Access/Continuity Quality Improvement Empanelment, Panel size Identify/Manage Patient Strategy management Populations Empanelment Team-based Care Plan/Manage Care Continuous and Team-based Population Management Provide Self-Care Healing Relationships Support/Community Resources Organized Evidence-based Continuity of Care Track/Coordinate Care Care Patient-Centered Interaction Prompt Access to Care Measure/Improve Performance Enhanced Access Expanded Access Template Care Coordination Mission with objectives and goals Care coordination with Medical Neighborhood Trained Leaders DATA/Quality Improvement Strategy Are we Data Driven organizations? Do we use real-time Formal QI process Defined metrics data on important Optimized HIT clinical/operational data to guide day-to- day actions? Grant requirement to Robust data collection have CQI, robust Reporting systems to metrics, early adopter share data of registry, variable Strategic decisions HIT capacity about metrics HIV Medical Homes Resource Center Empanelment Is empanelment a deliberate process Assign all patients to where we can use provider panel provider panels for Balance supply and quality data , proactive demand care and to actively Use panel data to manage supply and manage population demand? Prioritizes patients Empanelment not seeing own PCP specific grant requirement, often Clear denominator at happens because of structure of practice panel level HIV Medical Homes Resource Center 5

6/27/2014 Team-Based Care Are our teams organized around getting the work Patients are connected done with an explicit to a Care Team vision and clear Roles/tasks defined principles? With defined workflows, skills training and groun d rules? Culture shift to Multi-disciplinary Teams ar e central to share-the-care. Flexible, functional RWCA teams, with clearly defined rol es HIV Medical Homes Resource Center Team-based Care 4. Team-based Care Why does team- based care matter?  Align roles to meet population needs  Non-clinician team- members contribute to continuous healing relationship  Build capacity to make timely access possible  Foundation for the Template of the future 6

6/27/2014 Traditional Methods of Managing Work Flow Preventive Chronic Med Disease Medication New Acute Intervention Monitoring Refill Complaint Test Results Provider Referral to Healthcare Specialist Certified Case Support Mental Health after Medical Manager Team Provider Assessment Assistant 7

6/27/2014 Team-based care • Culture shift: share the care  Stable teamlets • Co-location  Staffing ratios  Standing orders/protocols • Defined workflows and roles – workflow mapping • Training, skills checks, and cross training • Ground rules • Communication – healthy huddles, terrific team meetings and constant conversation Team-based care: stable teamlets Patient Patient Patient panel panel panel Clinician/MA MA Clinician/MA MA Clinician/MA MA teamlet teamlet teamlet Health coach, behavioral health professional, social worker, RN, pharmacist, panel manager, complex care manager 1 team, 3 teamlets Prompt Access to Care 24/7 access to care Do we have a patient- team, patient-centered centered approach to scheduling options, access? address barriers to access After hours coverage, Balance supply and +/- use of advanced demand, open access, access tools multiple channels of access HIV Medical Homes Resource Center 8

6/27/2014 http://www.careinnovations.org/knowledge-center/knowledge-centerwest-county-health- center-video/ Population Management/Panel Management Are we able to focus at the population level and Plan care according to proactively assign need, manage high-risk resources where patients, point-of-care needed? Is data used in reminders day-to-day care? Robust population Case Management key management, Self- feature of RWCA, client management, level data, self- Complex Case management support management, planned visits HIV Medical Homes Resource Center Care Coordination How good are we at Link patient with managing the care that community resources, happens outside of our referral tracking, four walls? coordination of specialty care Management of care Comprehensive transitions, behavioral model of care, often health services, under one-roof, communication of expectation that results transitions are tracked HIV Medical Homes Resource Center 9

6/27/2014 Conscious Trained Leadership/Values and Mission Statement HIV Medical Homes Resource Center 100 P 90 80 P C 70 P 60 C P 50 C 40 C Series 3 30 Series 2 20 10 Series 1 0 Engagement in HIV Care Vital Signs: HIV Prevention Through Care and Treatment -- United States. MMWR December 2, 2011/60(47);1618-1623 =Access =Care Co-ordination =Population Management Summary  Both Primary Care and the RWCA are at a crossroad  PCMH is one model of transformation  RWCA clinics have many components of PCMH  There is much to learn from PCMH model and high performing primary care  Our health care system will have to change to meet our goal of an AIDS Free Generation HIV Medical Homes Resource Center 10

6/27/2014 Roadmap for Medical Home Resource Center PCMH concepts in Change Management of RWCA Clinics – Action Improvement PCMH Certification Planning Opportunities Strategic Planning Workshops TA and Virtual Learning Community for practice change TA to support certification Year 1 Year 2 Year 3 11