All About the Patient-Centered Medical Home

1

All About thePatient-Centered

Medical Home

Brett Lawton, MPAChief Operations Officer

Jericho Road Family [email protected]

Kyle Vath, BSN, RNClinical Coordinator

Crossroad Health [email protected]

Saturday, May 11, 2013

• Objectives:– Share about the process of obtaining recognition

as a Patient-Centered Medical Home (PCMH)– Discuss the options for PCMH certification.– Discuss the benefits of the process for community

health delivery organizations, and faith-based clinics.

All About the Patient-Centered Medical Home

2 All About the Patient-Centered Medical Home

• Outline:– A little about us…– The Patient-Centered Medical Home Model– The Path to Recognition– Examples of the PCMH in Practice– The Unique Opportunities for Christian Health

Ministries and PCMH



• A Little About Us:– Brett Lawton, COO, Jericho Road Family Practice,

Buffalo, NY– Kyle Vath, Clinical Coordinator, Crossroad Health

Center, Cincinnati, Ohio



• The PCMH Model:– Core Features:• Personal Provider• Provider Directed Medical Practice • Whole Person Orientation• Care is Coordinated and/or Integrated• Quality and Safety• Enhanced Access• Payment Reform



The Patient Centered Medical Home: History, Seven Core Features, Evidence and Transformational Change. http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/pcmh.Par.0001.File.dat/PCMH.pdf

http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/pcmh.Par.0001.File.dat/PCMH.pdf

• The PCMH Model:– The Origins of the PCMH Model:• 1967 - Pediatric Health Homes (AAP)• 1978 - Tenets of MHs (WHO)• 1990 - MH in Literature (IOM)• 2002 - 37 Criteria of MHs (AAP)• 2004 - Chronic Care Model (E. Wagner)• 2010 - PPACA Signed into Law• 2012 - ACA Funding for PCMH/FQHCs



Origins of PCMH. http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/pcmh.Par.0001.File.dat/PCMH.pdf



• The PCMH Model:– PCMH and the ACA:

• Title II Subtitle I– Sec. 2303 – Payment. See Amendment by Reconciliation Act below– Sec. 2703. State option to provide health homes for enrollees with chronic

conditions.– Sec. 2706. Pediatric Accountable Care Organization demonstration project.

• Title III– Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation within

CMS.• Title V

– Sec. 5301. Training in family medicine, general internal medicine, general pediatrics, and physician assistantship.

– Sec. 5501. Expanding access to primary care services and general surgery services.• Health Care and Education Reconciliation Act

– Sec. 1202. Payments to primary care physicians.



ACA and PCMH. http://www.pcpcc.net/content/health-care-reform-and-patient-centered-medical-home

http://www.pcpcc.net/content/health-care-reform-and-patient-centered-medical-home



http://www.kff.org/insurance/upload/7692_02.pdf

• The PCMH Model:– Traditional Model:

• Provider-centered• Provider-based treatment plans• Focus on individual treatment• Physician does it all• Reactive - patient presents• Answer patient questions• Patient as passive recipient of care• Scheduled out for weeks• Decisions based on comfort and

tradition• Random communication within practice



The Patient Centered Medical Home: History, Seven Core Features, Evidence and Transformational Change. http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/pcmh.Par.0001.File.dat/PCMH.pdf

– PCMH Model:• Patient-centered• Evidence-based treatment plans• Population/condition management• Care team• Care plans and outreach• Patient education and resources• Patient engaged in self-mgmt goals• Same-day access available• Decisions based on data and trends• Purposeful communication


• The Path to PCMH Recognition:– Accreditation Programs:• National Committee for Quality Assurance (NCQA)*• Utilization Review Accreditation Commission (URAC)• The Joint Commission• Accreditation Association for Ambulatory Health Care

(AAAHC)



Medical Home Accreditation Programs. http://www.medicalhomeinfo.org/national/recognition_programs.aspx

http://www.medicalhomeinfo.org/national/recognition_programs.aspx

• The Path to PCMH Recognition:– NCQA’s Six Standard Categories

(27 elements, 149 factors):• Enhance Access and Continuity• Identify and Manage Patient Populations• Plan and Manage Care• Provide Self-Care Support and Community Resources• Track and Coordinate Care• Measure and Improve Performance



NCQA's 6 Core Standards. http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH_2011_Scoring_Summary.pdf

http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH_2011_Scoring_Summary.pdf

• The Path to PCMH Recognition:– Standard 1: Enhance Access and Continuity• Accommodate patients’ needs with access and advice

during and after hours; give patients and their families information about their medical home and provide patients with team-based care.• Empanelment studies• Expanding hours• Transportation barriers• 30% no-show



• The Path to PCMH Recognition:– Standard 2: Identify and Manage Patient Populations

• Collect and use data for population management.• 60% smokers• Focus on diabetics• 1/3 Complex• 50-60% have some type of significant mental illness• 40% have a HgbA1C >9%• In 6 month period, over half have gone to the ED - avg 4

visits/yr



• The Path to PCMH Recognition:– Standard 3: Plan and Manage Care• Use evidence-based guidelines for preventative, acute,

and chronic care management, including medication management.



• The Path to PCMH Recognition:– Standard 4: Provide Self-Care Support and

Community Resources• Assist patients and their families in self-care

management with information, tools, and resources.



• The Path to PCMH Recognition:– Standard 5: Track and Coordinate Care• Track and coordinate tests, referrals, and transitions of

care.



• The Path to PCMH Recognition:– Standard 6: Measure and Improve Performance• Use performance and patient experience data for

continuous quality improvement.



• The Path to PCMH Recognition:– Benefits of the PCMH Model

• Decreased ED utilization• Improved health outcomes• Health system economic savings• Fewer hospitalizations• Shortened hospital LOS• Improved chronic illness management• Improved patient satisfaction• Higher reimbursement rates (PMPM)



• The Path to PCMH Recognition:– Challenges in Implementing PCMH• Payment structures not yet fully supportive• Increased overhead for primary care centers• Cumbersome EHR systems• Turf wars• Competing special interests• Changes in how we use volunteers



• Examples of the PCMH in Practice:– What’s Going On Here?



• Examples of the PCMH in Practice:– What’s Going On Here?• Access problem?• Continuity problem?• Hospital problem?• Population problem?• Language problem?• Transportation problem?



• Examples of the PCMH in Practice:– Chronic Care Management Template– Non-Emergency Transportation Program

(SafetyN.E.T. Program)– COA/Crossroad Collaboration– ED utilization



All About The Patient-Centered Medical Home

• Examples of the PCMH in Practice – Jericho Road– Population management - now we know!

• We have 706 patients with Diabetes– 38% have HbA1c above 9%– 59 haven’t had an A1c check in the past year

• We have 237 patients with COPD– 198 need a new spirometry reading

• We have 138 patients with Hepatitis B– 49 need a liver function test

– Helps us carry out our mission to serve “the least of these” who might otherwise be missed



• Examples of the PCMH in Practice – Jericho Road– Making our EMR work for us!Multilingual Patient Education Material



• Examples of the PCMH in Practice – Jericho Road– Recognized in 2009• Extra revenue• Qualified for Meaningful Use Attestation (Year 1)• Qualified for Meaningful Use Data (Year 2)• Test results received electronically, excellent connection

with RHIO



PCMH consultants• HealthTeamWorkswww.healthteamworks.org/medical-home• Primary Care Development Corporation (PCDC)

www.pcdc.org/resources/patient-centered-medical-home/• Qualis Healthwww.qhmedicalhome.org/• Quality First Healthcare Consulting, Inc. (QFHC)www.qfhc.com• Research & Marketing Strategies, Inc. http://www.rmsresults.com/index.php• TransforMED - Center for Medical Home Improvement (CMHI)

www.medicalhomeimprovement.org/medical-home/developments.html• Health Partners Consulting (Crossroad used)

[email protected]


http://www.healthteamworks.org/medical-home

http://www.pcdc.org/resources/patient-centered-medical-home/

http://www.qhmedicalhome.org/

http://www.qfhc.com/

http://www.rmsresults.com/index.php

http://www.rmsresults.com/index.php

http://www.medicalhomeimprovement.org/medical-home/developments.html

mailto:[email protected]


Resources for Population Health Maintenance data management• i2iSystemswww.i2isys.com/patient-centered-medical-home.htm

• Phytelwww3.phytel.com/

• CareSentry (Crossroad Uses)http://www.simbiote.com/home.html


http://www.i2isys.com/patient-centered-medical-home.htm

http://www3.phytel.com/

http://www.simbiote.com/home.html

http://www.simbiote.com/home.html


NCQA PPC-PCMH Recognition Standards Meaningful Use Health Outcome Policy Priority

Access and CommunicationWritten standards for patient access and patient communication

Engage Patients and families in their health careProvide patients with an electronic copy of health infoProvide patients with timely electronic access to health infoProvide Clinical Summaries for each visit

Patient Tracking and Registry FunctionsBasic non-clinical dataSearchable Clinical DataUses paper or electronic based charting tools for clinical infoUses data to identify important diagnosesGenerates lists of patients and reminds patients and clinicians of needs services.

Improving quality, safety, efficiency, and reducing healthdisparitiesMaintain an up-to-date problem list of diagnosesRecord demographicsRecord changes in vital signsGenerates lists of patients by specific conditionsImplement 5 clinical decision support rules

Care ManagementAdopts evidence-based guidelines for 3 conditionsConducts care-managementCoordinates Care

Improve Care CoordinationCapability to exchange key clinical information among providers of careProvide summary care record for each transition of care

Patient Self-Management SupportActively supports patient self-management

Engage patients and families in their health careSend reminders to patientsProvide patients with an electronic copy of their health informationProvide patients with timely electronic access to their health information

Electronic PrescribingUses electronic system to write prescriptionsHas electronic prescription writer with safety and cost checks

Improving quality, safety, efficiency, and reducing health disparitiesGenerate and transmit permissible prescriptions electronicallyMaintain active medication listMaintain active medication allergy list

Test TrackingTracks Tests and identifies Abnormal resultsUses electronic systems to order and retrieve tests

Improving quality, safety, efficiency, and reducing healthdisparitiesUse CPOEIncorporate clinical lab-test results into EHR as structured data

Referral TrackingTracks referrals using paper-based or electronic system

Improve Care CoordinationCapability to exchange key clinical information among providers of careProvide summary care record for each transition of care and referral

Performance ReportingMeasures Clinical PerformanceReports PerformanceTransmits Reports with standardized measures electronically to external entities

Improving quality, safety, efficiency, and reducing health disparitiesReport ambulatory quality measures to CMS or the States

Advanced Electronic Communications Ensure adequate privacy and security protections forpersonal health information

http://www.csms-ipa.com/Portals/0/Docs/NCQA%20Recognition.pdf

http://www.csms-ipa.com/Portals/0/Docs/NCQA%20Recognition.pdf

• Unique Opportunities for Christian Health Ministries:– Christ was extremely relational.– Christ cared for “the least of these”.– Christ cared about social justice.– Christ cared for the whole person.– Christians are strongest when they collaborate.



Questions?



All About the Patient-Centered Medical Home

Health & Medicine

Transcript of All About the Patient-Centered Medical Home