New Models of Health Care: The Patient Centered Medical Home · Expanded Quality Improvement –...
Transcript of New Models of Health Care: The Patient Centered Medical Home · Expanded Quality Improvement –...
New Models of Health Care: The Patient Centered Medical Home
Mark Gwynne, DO
UNC- Chapel Hill Department of Family Medicine August 17, 2013
Objectives of this session:
• What’s the burning platform for change? • What are key components of new models of care? • What are the core concepts of the PCMH? • Does the PCMH work? How is it paid for? • What does it mean to be Patient Centered and what
does a PCMH look like?
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Institute of Medicine
IOM: Crossing The Quality Chasm
• About 50% of the time, interventions that we all agree should happen don’t, no matter what the problem or setting—and it is much worse for patients who are poor or of color
• Quality of Chronic Illness Care
» 15-24% adequate control of HTN » 42% of DM have appropriate lipid control » 38% A-fib on appropriate anticoagulation » 25% of Depression adequately treated » 40% CHF readmitted within 120 days
• 30-40% of US health care spending is “waste” (IOM 2005, CBO 2008)
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IOM: Crossing The Quality Chasm • Improvement in 6 domains
1) Safety 2) Effectiveness 3) Patient Centeredness 4) Timeliness 5) Efficiency 6) Equity
• Outline change at 4 levels: 1) Patient experience 2) Function of Microsystems 3) Function of organizations that have microsystems 4) Policy and Payment environment to support change
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Future of Family Medicine
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Traditional Model » Physician centered
» Unnecessary barriers to access for patients
» Reactive, fragmented care » Individual physician-patient
visits » Experienced based
» Haphazard chronic disease management
New Model
Patient centered
Advanced access for patients
Responsive, proactive and integrated Planned visits
Evidence based
Purposeful, organized chronic disease management
www.improvingchroniccare.org
Joint Principles of the Patient Centered Medical Home
Principles
Personal Physician
Physician directed medical
practice
Whole Person Orientation
Care Coordination/
Integrated Care
Quality and Safety
Enhanced Access
Payment
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Joint Principles of the Patient Centered Medical Home
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Joint Principles of PCMH
Personal Physician
Physician directed medical
practice
Whole Person Orientation
Care Coordination/
Integrated Care
Quality and Safety
Enhanced Access
Payment
Pillars of Primary Care • First-contact care • Continuity of care over time • Comprehensiveness, or concern for
the entire patient rather than one organ system
• Coordination with other parts of the
health system. * Physicians can’t do this alone: The PCMH brings together several systems interventions
Outcomes of PCMH Trials
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Site ED Visits Quality Hospitalizations Cost Group Health -29% +36% sta)n
use -16% all cause ↓ $17 PMPM
CCNC -16% + asthma assessment + influenza
vaccine
-40% (asthma) - 20% reduction
readmissions at 1 year
-$380M in 2010
Geisenger (PA) +74 % preventa)ve
care
-18% all cause -50% readmission
-7% total PMPM
Genesis (MI) -50% -15% 26.6% fewer days
Intermountain - 10% reduction $640/pt/year
Hopkins Guided Care
-15% ↓ 24% ↓ 37% Nursing Home
Days
Savings $1364/Pt $75K/RN
NCBCBS - 32.2% reduction in
visits
↓ $9-$13 PM/PM
HealthPartners (MN)
-39% +129% optimal DM
score
-24% hospitalization -40% readmissions
- 8%
NCQA PCMH 2.0—2011 Standards 2011 Standard Changes from 2008 Standard
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Access redefined • After hours • Same day access/Advanced Access • Continuity • Electronic access
2 Population Management • Move from tools (point of care) to managing populations
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• Expanded Care Management • Behavioral Health - 3rd Important Condition as unhealthy behavior, mental
health, substance abuse • Identification of High Risk Patients
4 Expanded self-management support and community resources
5 Expanded Care Coordination • Transitions, referral tracking, specialist agreements
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Expanded Quality Improvement – continuous quality improvement • Disparities/vulnerable populations • Patient experience – Patient Advisory Council
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• 17,200 empaneled patients with visits in the past 18 months
• 64 PCP’s • 56,000 visits 2012-13 • PCMH level 3 (2011
standards)
UNC Family Medicine Center
Access is critical • Access redefined: not just extended hours and overbooking.
» Advanced access scheduling
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10.0
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UNC Family Medicine Center - Historical Appointment Access Data
Faculty Resident Overall Linear (Overall)
10.8 (Jun'13)
70.0
75.0
80.0
85.0
90.0
95.0
100.0 PATIENT SATISFACTION - Overall Satisfaction (3-month running average) by Month
Introduction of new Press Ganey sampling method
Access is critical • Access redefined: not just extended hours and overbooking
» Asynchronous communication • Message response time: email 10 hours less than phone calls • Remote INR monitoring
» After hours access: • Good phone triage • Management of symptoms – new medications, new diagnoses
» Access to the Team » MA, Pharmacist, RN, Care manager
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Total Pa8ent Wait Time: FMC Faculty YTD 2012-‐2013
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Trends: ED Visits and Inpatient Admissions
Inpatient Admissions trend_Inpatient
Care Management
• MSW Model • High risk panel
8 ED visits/month 7.5 admissions per month
“A collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes.” Case Management Society of America, 2012
Co-management with Pharmacy
ACTion appointment (< 7 days
post-discharge) • Pharmacist • PCP • Care Manager (LCSW)
Routine Care
Care Manager/PCP high risk panel
Inpatient Service
% Discharges seen by ACTion team 25% No show rate 22.2%
Overrall re-admission rate 25.0%
Readmission rate of patients who attended ACTion appointment 16.7%
Re-admission rate of no-show 27.3%
Team Based Care: Transitions
Continuous Quality Improvement: Engagement at All Levels – Resident QIP project
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Screening rate = 58% • 80% when visit was for DM, CHF, or CAD • 18% when presented for different chief
complaint
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969
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0 1000 2000 3000
New Diagnosis
Positive PHQ-9
Positive PHQ-2
Total screened
Total patients
Continuous Quality Improvement: The Practice
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0.0%
10.0%
20.0%
30.0%
201102 201103 201104 201105 201106 201107
Disparities in Care: % of Patients with Diabetes & A1C > 9
Overall African American Caucasian Hispanic GOAL
31% 26%
30%
37%
30% 30% 28% 33%
36% 33%
30% 27%
31% 31% 33%
28% 27% 26% 29%
36% 39%
35%
22%
5% 7% 7%
0%
10%
20%
30%
40%
50%
60% % of Patients with Diabetes & BP > 140/90
Overall Team 1 Team 2 Team 3 Team 4 Goal
Not an error
Continuous Quality Improvement: The Practice
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6/9/20126/2/20135/26/20135/19/2013
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Mamm
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74% (National Average)
64.2162.5662.0963.18
Project: Family Medicine Mammo Data.MPJ; Worksheet: Mammo Weekly - 6 wks; 6/11/2013; Lindsay Stortz, [email protected]
Mammography Rate - Weekly Data
Goal: 74% (National Average) Mean: 62% (FMC Average)
High Performer: Margaret Helton (82%)
Mammography Rate by Provider:
Continuous Quality Improvement: The Staff
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Before After
UNC DFM Patient Advisory Council
Council Work
Committee Work
Individual/Small Group Work
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Strategic goals: Patient satisfaction
Operational groups: QI, Supervisors, Communications, Renovation, Epic
Research, curriculum design, community outreach
PAC Successes:
• Family Medicine Center Renovation and Re-design
• Help redesign pediatric triage process.
• Patient input on faculty research/grant proposals.
• Review and analyze patient satisfaction data – direct interventions
• Review and provide feedback on patient surveys
• Help prepare monthly patient e-newsletter
• Provide on-call service for FMC patients in need of addiction counseling.
• Review current internal and external departmental signage. Make recommendations for
change
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“In a patient-centered medical home, it is hoped that the wheel would recognize the importance of treating each patient (the hub) as an individual in providing the best healthcare and clinic operations possible. This simply means a respect for the individual patient's health issues, socio-economics, education and most important, an interactive treatment. In other words, the patient's welfare is a consideration from the check-in (or before) to the check-out.” - HD, 2013
Paying for the PCMH • Shared savings pilots:
» NY, MN, CO, MD, NC (CCNC) » PMPM (risk stratified), pay-for-performance, one-time payments
• BCBS: NC, CareFirst • WellPoint: Indiana • United Healthcare
» Reimbursement tied to quality and cost-effectiveness, contracts linked to quality measurements will increase to $50 billion by 2017
• CMS 2013 fee schedule » Transitional care
• Proposed CMS 2014 fee schedule » complex chronic care (CCC) conditions
• PQRS – value based reimbursement • Meaningful Use
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Key Components of Practice Transformation to a PCMH
• Leadership and Change Management (culture change) • Big Bang implementation • Access Redefined • A core interdisciplinary team – celebrate success • Care Management at the center of practice • Risk Stratification – resources where they are most impactful • Team based care delivery – large and small
• See our practice through our patients’ lens
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Resources • ACOFP.org
» Medical Home Quality Markers » Links to resources
• AAFP.org » PCMH checklist » Many links to resources
• IHI.org (Institute for healthcare Improvement) • PCPCC.com (patient Centered Primary Care Collaborative) • In North Carolina – AHEC
• NC AHEC: 9 regional centers across the state, each center has a team of professionals to help primary care practices in the following areas:
• Achieving MU • Improving clinical outcomes of patients • Transforming into a patient centered medical home (many of the
consulting staff are newly certified content experts by NCQA) • If interested, contact your local AHEC or visit
www.ahecqualitysource.com 26
UNC Family Medicine Top 12 Hurdles for Level 3 PCMH, 2011 Standards
1) Documenting Self-Management - provide self-care tools, self-mgmt. resources, set goals with date, etc.
2) Medication review – document OTCs & herbals, assess understanding of meds and barriers to adherence, etc
3) Clinical summaries – provide clinical summary at each relevant visit (med list, problem list, allergies, etc.)
4) Care transitions – info transfer between PCP/hospital following discharge; not issue for FM due to integrated UNC EMR (WebCIS)
5) Defining an “unhealthy behaviors/mental health” condition as 1 of the 3 important conditions – FM used tobacco use
6) Define high-risk population in a reasonable/low-impact way – FM used those with diabetes+smoking (comorbidity)
7) Patient Experience - Are you going to use CAHPS to track patient experience? Can you get it up and running in time? FM did not.
8) Choose your preventive screening outreach wisely. FM: false positives on pneumovax and retinal photo outreach.
9) For re-application, look early at what elements require documentation; this saves a lot of work. 10) Patient experience feedback and patient advisory council 11) Documenting team based approach to care for element 1G – need team-based care in job
descriptions, training materials, etc. 12) Record review (shorter time period) vs Registry report (1 year) for data collection: Decide early
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