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PATIENT

CENTERRED

Emily Padula & Jayne PopeJanuary 2011

MEDICAL HOME

OVERVIEW

Patient Centered Medical Home Definitions

f d lLSCC Major Strategies for Medical Home

Future of the Patient Centered Medical Home

Future of the LSCC Patient Centered Medical Home

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JOINT PRINCIPLES OF PCMH

NCQA PPC-PCMH ELEMENTS, PART 1

P ti t T ki gAccess & Communication

Patient Tracking & Registry Functions

Care Management

Patient Self- ElectronicManagement & Support

Electronic Prescribing

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NCQA PPC-PCMH ELEMENTS, PART 2

ReferralTest Tracking Referral Tracking

Performance AdvancedPerformance Reporting & Improvement

Advanced Electronic

Communication

PPC-PCMH CONTENT AND SCORINGStandard 1: Access and CommunicationA. Has written standards for patient access and patient

communication**B. Uses data to show it meets its standards for patient

access and communication**

Pts

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Standard 2: Patient Tracking and Registry Functions A. Uses data system for basic patient information

(mostly non-clinical data)

Pts

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Standard 5: Electronic Prescribing A. Uses electronic system to write prescriptions B. Has electronic prescription writer with safety

checksC. Has electronic prescription writer with cost

checks

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Standard 6: Test Tracking A Tracks tests and identifies abnormal results

Pts7(mostly non clinical data)

B. Has clinical data system with clinical data in searchable data fields

C. Uses the clinical data system D. Uses paper or electronic-based charting tools to

organize clinical information**E. Uses data to identify important diagnoses and

conditions in practice**F. Generates lists of patients and reminds patients and

clinicians of services needed (population management)

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Standard 3: Care ManagementA. Adopts and implements evidence-based guidelines

for three conditions **B. Generates reminders about preventive services for

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A. Tracks tests and identifies abnormal results systematically**

B. Uses electronic systems to order and retrieve tests and flag duplicate tests

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Standard 7: Referral Tracking A. Tracks referrals using paper-based or electronic

system**

PT44

Standard 8: Performance Reporting and Improvement

A. Measures clinical and/or service performance by physician or across the practice**

B. Survey of patients’ care experience C. Reports performance across the practice or by

physician **

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clinicians C. Uses non-physician staff to manage patient care D. Conducts care management, including care plans,

assessing progress, addressing barriers E. Coordinates care//follow-up for patients who

receive care in inpatient and outpatient facilities

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Standard 4: Patient Self-Management Support A. Assesses language preference and other

communication barriersB. Actively supports patient self-management**

Pts246

physician **D. Sets goals and takes action to improve

performance E. Produces reports using standardized measures F. Transmits reports with standardized measures

electronically to external entities

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Standard 9: Advanced Electronic Communications A. Availability of Interactive Website B. Electronic Patient Identification C. Electronic Care Management Support

Pts121

4**Must Pass Elements

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LSCC PCMH STRATEGIES

Streamline Scheduling, Increase Continuity

Shared Leadership, Evidence Based Practice

Technology and Data

Quality Program, Joint Commission

Care Coordination by RNs

LSCC MEDICAL HOME MAJOR INITIATIVES

Quality Program

Shared

Evidence Based PracticeJoint Commission

RN Care Coordination

Streamline Scheduling & Increase Continuity

LeadershipTechnology/ Data

Medical Neighborhood

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LSCC PCMH STRATEGIES

Streamline Scheduling, Increase Continuity

Shared Leadership, Evidence Based Practice

Technology and Data

Quality Program, Joint Commission

Care Coordination by RNs

ENHANCED ACCESS & PERSONAL PHYSICIAN

Personal Physician (Continuity)( y)

Open Schedule

Open Access

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VALUE OF A PANEL/CONTINUITY PER NCQAIncreased Provider Productivity = Increased Patient Access

Lewandowski S, O'Connor PJ, Solberg LI, et al. Increasing primary care physician productivity: a case study. Am J Manag Care. 2006;12(10):573-576.

Healthier Patient Behaviors and Preventive Care ComplianceEttner SL The relationship between continuity of care and the health behaviors of patients: does having a usual physician make a difference? Med Care 1999;37:547-555Ettner SL. The relationship between continuity of care and the health behaviors of patients: does having a usual physician make a difference? Med Care. 1999;37:547-555.

Better Health Outcomes and Decreased CostDietrich AJ, Marton KI. Does continuous care from a physician make a difference? J Fam Pract. 1982;15:929-937. Saultz JW, Lochner J: Interpersonal continuity of care and care outcomes: a critical review. Ann Fam Med. 2005;3:159-166.

Decreased Emergency Department Use and HospitalizationChristakis DA, Mell L, Koepsell TD, Zimmerman FJ, Connell FA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001;107:524-529.

Indicator of High Quality Health Care Organization, Advanced Medical HomeChristakis DA, Wright JA, Zimmerman FJ, Bassett AL, Connell FA. Continuity of care is associated with well-coordinated care. Ambul Pediatr. 2003;3(2):82-86.

P id S i f i d L lProvider Satisfaction and LoyaltyLove MM, Mainous AG III, Talbert JC, Hager GL. Continuity of care and the physician-patient relationship: the importance of continuity for adult patients with asthma. J Fam Pract. 2000;49:998-1004.

Patient Satisfaction and LoyaltyBaker R, Mainous AG III, Gray DP, Love MM. Exploration of the relationship between continuity, trust in regular doctors and patient satisfaction with consultations with family doctors. Scand J Prim Health Care. 2003;21(1):27-32.

Better Depression OutcomesSolberg LI, Crain AL, Sperl-Hillen JM, et al. Improved primary care access: how does it affect depression care quality? Ann Fam Med. 2006;4:69-74.

VALUE OF A PANEL/CONTINUITY FINANCIALLY

Shorter VisitsLow Cost VisitsLow-Cost VisitsGreater Impact on Population HealthIncreased Patient Retention (Decrease Attrition)Increased Provider Retention (Decreased Replacement Cost, Retain Panel)p , )More Lucrative for Acute Care Partners (decreased ED and Inpt. Utilization by unfunded patients)

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PANELING PROCESS STEP

Determine Capacity

Determine Best Leverage Panel Size

PANELING SPREADSHEETAssumptions

FNP Capacity 5210

FP Capacity 4934

Current Providers Current Panel % of FTE J/L Return rate Ideal Panel Size Over/Under Over/Under %

Moeller Ruiz MD, Erica 743 1.00 2.9 1796 -1053 41.4%Bettes, Jeanette 501 1.00 2.9 1280 -779 39.1%Folarin, Hope 291 1.00 2.9 1508 -1217 19.3%Hauser, Cammie 1138 1.00 2.9 1796 -658 63.3%Duarte ANP, Maria C 1476 1.00 2.6 2004 -737 63.2%Gildersleeve MD, Roger 945 0.60 3.8 823 122 114.9%Duckett FNP, Kristin 827 1.00 2.9 1796 -969 46.0%Fiedler MD , Benjamin P 1615 1.00 2.9 1796 -181 89.9%Vicknair, Nicole 1411 1.00 2.9 1796 -385 78.5%M L Ch i i 341 1 00 2 9 1579 1238 21 6%McLemore, Christine 341 1.00 2.9 1579 -1238 21.6%Spaw MD, Raymond G 1548 1.00 2.7 1929 -381 80.2%Brubaker, Angela 1158 1.00 2.9 1796 -638 64.5%Victorica MD, Carlos 1427 1.00 4.0 1302 125 109.6%Hartline FNP, Meredith P 1102 1.00 3.1 1197 -95 92.0%Bribiesca MD, Gerardo 784 0.60 3.2 820 -36 95.6%Hong, Mae 239 1.00 2.9 1796 -1557 13.3%Quintana MD, Max 827 1.00 4.4 994 -167 83.2%

26011 -9847 62.1%

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OPEN ACCESS

NCQA Standard: I h lik lih d i ill bIncrease the likelihood patients will be seen

Predictive data used to ensure patients can be seen for any reason the same day that they call.

Movement toward a majority of appointments scheduled same day.

LSCC Goals:Increase Same-Day Appointments

Increase Kept Rate for Appointments

VALUE OF OPEN ACCESS PER CMS*

Access to Same Day or Preferred Day Care a significant indicator of patient satisfaction.

Lack of access to care is the most common reason for leaving a practiceLack of access to care is the most common reason for leaving a practice. Continuity and open access together lead to increased patient retention.

Patients who request a same day appointment and do not receive it are more likely than other patients to:

Go to the emergency roomNo-Show for an appointment booked into the futureNever receive primary care for the condition p y

Work-in protocols for same day patients are Staff and Patient Time-Intensive = Expensive. Same day demand averages can be predicted, and should be protected and accommodated.

*Murray M, Berwick DM. Advanced access: reducing waits and delays in primary care. JAMA. 2003;289:1035-1040.

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VALUE OF OPEN ACCESS PER CMS*

Same Day Appointments: Highest kept rate (81% better than 30 Days out at LSCC)Greatest long-term influence on patient loyalty to the clinicLower cost to the primary care system by acting on illness sooner

A financially strategic practice does today’s work today. Each no-show costs the organization an average of $10-19 in staff time, plus opportunity costSame Day Access is a Quality Indicator because Patients are y Q ymore likely to receive needed care and better outcomesThese appointments must be considered the highest priority as they are the highest leverage financially for the clinic and in health outcomes for the patient.

*Murray M, Berwick DM. Advanced access: reducing waits and delays in primary care. JAMA. 2003;289:1035-1040.

OPEN ACCESS: NO-SHOWS MATTER!

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KEPT APPOINTMENT STRATEGIES

Real-Time Scheduling

llRecalls

Established Patient Continuity visit PRIORITIZED

KEPT APPOINTMENTS

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OPEN SCHEDULE

Decrease the number f “li ” fof “lines” for an

appointment

Centralize scheduling

LSCC PCMH STRATEGIES

Streamline Scheduling, Increase Continuity

Shared Leadership, Evidence Based Practice

Technology and Data

Quality Program, Joint Commission

Care Coordination by RNs

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SHARED LEADERSHIPPractice and Education Councils

Clinician Ownership of:p

Education of Staff for

Quality of Care & Patient

Outcomes

Practice Issues: LSCC Standards

for Clinical Decision-Making

EBP

LSCC PCMH STRATEGIES

Streamline Scheduling, Increase Continuity

Shared Leadership, Evidence Based Practice

Technology and Data

Quality Program, Joint Commission

Care Coordination by RNs

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TECHNOLOGY, DATA, AND PCMH

“Meaningful Use” of the EHRCli i l D i i SClinical Decision Support

Draw Data for Registries

Use Registry Data to Contact Patients

Alerts

Lab and Referral Management Processesg

Numerous Performance Reports Submitted on Documentation of Patient Information

MEANINGFUL USE

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LSCC PCMH STRATEGIES

Streamline Scheduling, Increase Continuity

Shared Leadership, Evidence Based Practice

Technology and Data

Quality Program, Joint Commission

Care Coordination by RNs

STANDARDIZATION TO SAFE PRACTICEJoint Commission Preparation

Standard Policies and Procedures

Patient Experience

Improvement

EBP Chronic Disease

Management

National Patient Safety Goals

Quality Reporting Program

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LSCC PCMH STRATEGIES

Streamline Scheduling, Increase Continuity

Shared Leadership, Evidence Based Practice

Technology and Data

Quality Program, Joint Commission

Care Coordination by RNs

RN CARE COORDINATIONClinical Interventionists (CCRN)

Triage Calls to Prevent Unnecessary ED VisitsProactively Contact Diabetic & Asthmatic PatientsCall patients after an ED VisitPreVisit Patient Assessment

Clinic RNsContact Post-Procedure Patients for S/Sx of InfectionR fill M di i P P lRefill Medications Per ProtocolFollow up on Abnormal LabsConnect Patients with Community ResourcesProvide Education and Refer to ClassesAnswer Patient Questions

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RN CARE COORDINATION 2010

*Purple line is RN Care Coordination “encounters” per month

MEDICAL HOME TRENDS OF THE FUTURE

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PCMH FUTURE

Outcomes based vs.Outcomes based vs. Face-to-Face Encounter Based

Data Transparency

Shared Savings, Outcomes- based vs. Fee for Service

PCMHs as Members of Accountable Care Organizations

PCMH FUTURE: OUTCOMES

CostShort Term: Lowest Cost ProviderShort Term: Lowest Cost Provider

Fewer Office VisitsMore Phone, Telemedicine, and Email VisitsLower cost labs, diagnostic tests, referrals, medicationsCare Team members work at highest level of licensure

Long Term: Lifelong Cost to the Healthcare System g g yDecreased Emergency Department VisitsDecreased HospitalizationDecreased ReadmissionsShorter Length of Stay

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PCMH FUTURE: OUTCOMES

Patient ExperienceP i S i f iPatient Satisfaction

Likelihood of Referral to your Organization

Public Reporting of Data

Public Comparison of Data Changes Satisfaction Landscape

Access to Care Metrics publicly reported

Care Coordination & Case Management measures publicly reported

PCMH FUTURE: OUTCOMES

Patient Health Outcomes R i f li i h E id B dReporting of compliance with Evidence Based Practices

Reporting of Patient Health Outcomes: Do the Organization’s Services lead to patients “Getting Better”?

C h h d ( lComparison with other providers (percentile metrics rather than simple rates)

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ACCOUNTABLE CARE ORGANIZATIONS

The Patient Centered Medical Home is a key member of the Accountable Care Organization (ACO)g ( )The PCMH functions in the ACO by preventing emergency department visits and hospitalizationsThe PCMH serves as the lowest cost provider of primary care servicesFocus on Reduction of “Unnecessary Visits”N ll f h l f CMH l h ACONot all of the principles of PCMH are relevant to the ACONot all of the principles of Accountable Care are relevant to the PCMH

THE ACO & THE MEDICAL NEIGHBORHOODSPECIALIST

SERVICESACOPATIENT-

ALLCITIZENS

Referral as Medically Necessary

CareCoordination

ACUTE HOSPITALEHR

EHRCENTERED

MEDICAL HOME

Other Health care Providers

&Extension Services

EHR

SPECIALIZED

MEDICAL HOMEServices for Individuals with Complex Chronic Illnesses

or at the End of Life

Adapted from the LHCRC, October 2006; Fisher, NEJM, 2008

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FUTURE OF MEDICAL HOME FOR LSCC

Connect the Dots on Care Coordination

Technology Improvements

Plan for & Communicate the New Future

TECHNOLOGY IMPROVEMENT

Ready Access to

Data!!

Customizationfor Efficiency

Patient Portal

for Efficiency & EBP

Health Information

Exchange

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OLD MODEL FUTURE MODEL

Financial Sustainability depends on # of encounters

I i i

Financial Sustainability depends on Outcomes

I i i OIncentivize encounter numbers

Provider Face-to-Face time is highest leverage

Paid regardless of health outcome or patient experience

Incentivize Outcomes

Fewer visits and Team Based Care by non-provider staff

Paid for patient improvement and positive care experience

Internal and External data

PLAN FOR THE NEW FUTURE

Focus only on positive data Transparency