PatientCentered Medical Home A Multidisciplinary Perspective MARANDA HERRING

Patient-Centered Medical Home: A Multidisciplinary Perspective MARANDA HERRING, PHARMD, BCACP TARA BRUNER, MHS, PA-C 1

Conflict of Interest • Speakers have nothing to disclose 2

Objectives 1. Discuss the PCMH model and key players in the successful implementation of interdisciplinary and integrated medical care. 2. Describe the goals of PCMH and list strategies for achieving these goals. 3. Review the history and evolution of PCMH metrics and standards. 3

History of PCMH 2008 1967 NCQA developed formal recognition of PCMH 2001 “Medical Home” introduced by AAP “Crossing the Quality Chasm” was published 1978 2007 International Conference on Primary Health Care identified goals for primary care Joint Principles of the Patient. Centered Medical Home was published HTTPS: //WWW. PCPCC. ORG/CONTENT/HISTORY-0 HTTPS: //WWW. AAPA. ORG/THREECOLUMNLANDING. ASPX? ID=1702 2010 ACA offers provisions for PCMH 4

Health Care Spending as a Percentage of GDP, 1980 -2013 HTTP: //WWW. COMMONWEALTHFUND. ORG/PUBLICATIONS/ISSUE-BRIEFS/2015/OCT/US-HEALTH-CARE-FROM-A-GLOBAL-PERSPECTIVE 5

Health Care Transformation The Affordable Care Act (ACA) of 2010 was designed to: ◦ Increase the number of insured Americans ◦ Improve access to quality healthcare ◦ Decrease healthcare spending HTTP: //OBAMACAREFACTS. COM/AFFORDABLECAREACT-SUMMARY/ 6

HTTP: //WWW. AAFP. ORG/NEWS/PRACTICE-PROFESSIONAL-ISSUES/20150303 AAMCWKFORCE. HTML 7

Health Care Transformation o One provision under the ACA was the establishment of the Center for Medicare and Medicaid Innovation (Innovation Center). o The Innovation Center was tasked with designing an innovative healthcare model that would improve quality and access to care while decreasing the overall cost of care. o One method the Innovation Center implemented with the State Innovation Models (SIM) Initiative. o The SIM Initiative provides federal grants to states to design and test innovative, state-based multi-payer health care delivery and payment systems. HTTP: //OBAMACAREFACTS. COM/AFFORDABLECAREACT-SUMMARY/ HTTP: //KFF. ORG/MEDICAID/FACT-SHEET/THE-STATE-INNOVATION-MODELS-SIM-PROGRAM-AN-OVERVIEW/ 8

Health Care Transformation o In 2011, public payer—Arkansas Medicaid—and private payers —Qualchoice and Arkansas Blue Cross and Blue Shield—formed the Arkansas Payment Improvement Initiative (APII) o Together, over one year, they developed an incentivized health care payment model that would shift to a higher-quality and more cost-efficient system of care o In 2013, Arkansas was awarded $42 million in federal grants to pilot the program HTTP: //KFF. ORG/MEDICAID/FACT-SHEET/THE-STATE-INNOVATION-MODELS-SIM-PROGRAM-AN-OVERVIEW/ 9

Arkansas Payment Improvement Initiative (APII) The Arkansas Payment Improvement Initiative (APII) aims to shift the health care system from encounter-based service to care coordination by incorporating two complementary strategies statewide: 1. Episode-based payment for select disease states 2. Population-based advanced primary care through patientcentered medical homes (PCMHs) HTTP: //WWW. PAYMENTINITIATIVE. ORG/MEDICALHOMES/PAGES/DEFAULT. ASPX 10

Episodes of Care o A collection of medical conditions and procedures identified by APII as “opportunities” for population management and cost savings o ”Episodes” are characterized by a diagnosis code (ICD-10) and are time based o Providers receive a fee-for-service and either share in cost (cost sharing) or in saving (shared savings) depending upon cost and quality of care provided Medical Procedural/Surgical Behavioral Health Asthma/COPD Cholecystectomy Perinatal ADHD CHF Colonoscopy Tonsillectomy ODD URI CABG Total Joint Replacement HTTP: //WWW. PAYMENTINITIATIVE. ORG/MEDICALHOMES/PAGES/DEFAULT. ASPX 11

Episodes of Care HTTP: //WWW. NASHP. ORG/CONDUCTING-THE-ORCHESTRA-OF-MULTI-PAYER-PAYMENT-REFORM-ACHIEVING-HARMONY-IN-ARKANSAS-AND-VERMONT/ 12

PCMH “In a PCMH, clinicians work together to provide care that is comprehensive, ongoing and coordinated. The clinical team provides primary, acute and preventive medical care. The team also integrates specialty referrals and other services from the health system and community. ” https: //www. aapa. org/twocolumnmain. aspx? id=291 13

PCMH Hospita l Nurse Pharmacist M e n t a l H e a lt h Pharmacist Community Resources PCP & Patient Spec ialist Mental Health Dietition C o m m u ni ty R e s o u rc e s Dietitian PCP & Patient Specialist 14

Patient. Centered PCMH The Agency for Healthcare Research and Quality (AHRQ) has identified a PCMH as a model encompassing the following characteristics and attributes: Coordinated Safe High Quality Accessible Comprehensive HIGGINS T. C. , SCHOTTENFELD L. , & CROSSON J. (2015 PRIMARY CARE PRACTICE FACILITATION CURRICULUM (MODULE 25; AHRQ PUBLICATION NO. 15 -0060 -EF). ROCKVILLE, MD: AGENCY FOR HEALTHCARE RESEARCH AND QUALITY 15

Goals of PCMH o Achieve the “Triple Aim” HTTP: //WWW. IHI. ORG/ENGAGE/INITIATIVES/TRIPLEAIM/PAGES/DEFAULT. ASPX 16

PCMH Requirements & Incentives (State) Arkansas Payment Improvement Initiative (APII) o. Care Coordination o Per Member Per Month Payments o Implement, perform, and attest to “practice support activities” o Shared Savings o Quality metrics o Action based vs. Outcomes based =HTTP: //WWW. PAYMENTINITIATIVE. ORG/MEDICALHOMES/PAGES/DEFAULT. ASPX 17

APPI PCMH Activities and Metrics PRACTICE SUPPORT Activities ◦ Identify top 10% (most expensive) ◦ Assess practice operations ◦ Develop and implement strategies for care coordination Metrics ◦ Care plan containing: ◦ Problem list ◦ Contributions from health care team and beneficiary ◦ Instructions for follow-up ◦ Assessment of progress to date HTTP: //WWW. PAYMENTINITIATIVE. ORG/MEDICALHOMES/PAGES/DEFAULT. ASPX QUALITY METRICS o EPSDT/WCC o Diabetes Hg. A 1 c testing o Appropriate asthma medications o CHF patients on B-blocker o Women over 50 with mammograms o 30 day ADHD follow-up o TSH testing for those on thyroid medications 18

PCMH Requirements & Incentives (National) National Committee for Quality Assurance (NCQA) o Practice Recognition Program o “Gold Standard” PCMH model o Required up-front cost o. Training and assistance for practice transformation o Level of recognition increases per member per month payments o Recognition achieved by meeting predetermined standards HTTP: //WWW. NCQA. ORG/PROGRAMS/RECOGNITION/PRACTICES/PATIENT-CENTERED-MEDICAL-HOME-PCMH 19

NCQA Recognition Standards 1. Enhance Access and Continuity q Patient-centered appointment access q 24/7 access to clinical advice q Patient Portal q Meaningful Use 2. Team-Based Care q Organization assigns team roles q Scheduled team meetings 4. Plan and Manage Care q Care planning and self-care support 5. Track and Coordinate Care q Referral tracking and follow-up 6. Measure and Improve Performance q Continuous quality improvement 3. Population Health Management q Use of data for population management q Informatics HTTP: //WWW. NCQA. ORG/PROGRAMS/RECOGNITION/PRACTICES/PATIENT-CENTERED-MEDICAL-HOME-PCMH 20

Building a High-Functioning Health Care Team CHARACTERISTICS OF EFFECTIVE TEAMS CHARACTERISTICS OF EFFECTIVE TEAM MEMBERS o Shared goals and purposeful collaboration o Honesty o Diverse knowledge and experience o Discipline o Clear roles o Appropriate delegation o Creativity o Mutual trust o Humility o Effective communication and coordination o Curiosity o Measurable processes and outcomes o Cost effective o Improved health outcomes HTTPS: //WWW. NATIONALAHEC. ORG/PDFS/VSRT-TEAM-BASED-CARE-PRINCIPLES-VALUES. PDF 21

Team Members Responsibilities Physician* Physician Assistant* Nurse Practitioner* o o o o Nurse o Triage patients o Communicate results of labs, imaging, diagnostic tests, and procedure results to patient o Administer immunizations o Detailed documentation Pharmacist o o o o Patient o Attend all appointments (referrals & follow-up) o Medication and device adherence Diagnosis of disease Prescribing medications and devices Referral to specialists Ordering labs, imaging, diagnostic tests, and/or procedures Detailed documentation Disease education Develop, monitor, and modify treatment goals Medication histories and reconciliation Medication therapy assessment Assessment of medication adherence Prior authorizations and medication assistance Disease, medication, and device education Administer immunizations Detailed documentation 22

Examples in Practice: Making Pharmacists Part of the Team 23

History, Adherence, & Medication Reconciliation o Collaboration between community and clinic pharmacists o Target high priority beneficiaries o Identify and implement opportunities for improved adherence o Identify duplicate therapy and significant drug interactions o Enhanced chart documentation 24

History, Adherence, & Medication Reconciliation Service 25

Prior Authorization & Therapeutic Substitution Services o Collaboration between providers and pharmacists o Prior authorization o Ensure timely access to medication o Improves patient experience o Improve outcomes o Prospective therapeutic substitution o Avoid delay in medication therapy o Decrease cost of care 26

Diabetes Self-Management Education o Population management o High risk population o Over 29 million Americans have diabetes o Of these, nearly 28% have yet to be diagnosed o Estimated cost to healthcare system in 2012: $245 billion o Improved clinical outcomes o Opportunities for family involvement o Individual or group visits o Medicare Part B covers up to 10 hours during initial year of diagnosis and o CPT Codes: HTTPS: //WWW. PCPCC. ORG/RESOURCE/MEASURING-IMPLEMENTATION-AND-EFFECTS-COORDINATED-CARE-MODEL-FEATURING-DIABETES-SELF HTTP: //WWW. AADEMEETING. ORG/DSME-PROGRAM-STRENGTHENS-PATIENT-CENTERED-MEDICAL-HOME/ HTTP: //WWW. DIABETES. ORG/DIABETES-BASICS/STATISTICS/? REFERRER=HTTPS: //WWW. GOOGLE. COM/ 27

Smoking Cessation Counseling o Population management o. High risk population o Over 16 million Americans have a disease caused from smoking o Smoking is the leading cause of preventable death worldwide o Cigarette smoking is responsible for over 480, 000 deaths each year in the US o Numerous studies have shown that smoking cessation counseling along with pharmacotherapy improves a patient’s change of quitting and remaining smoke-free months later o Reimbursement opportunities o. Medicare Part B covers up to 8 face-to-face visits for smoking cessation counseling in 12 months o CPT Codes 99406 and 99407 HTTP: //WWW. CDC. GOV/TOBACCO/DATA_STATISTICS/FACT_SHEETS/FAST_FACTS/ HTTPS: //WWW. MEDICARE. GOV/COVERAGE/SMOKING-AND-TOBACCO-USE-CESSATION. HTML HTTPS: //WWW. CDC. GOV/MMWR/PREVIEW/MMWRHTML/MM 6044 A 2. HTM HTTP: //WWW. COCHRANE. ORG/CD 008286/TOBACCO_DOES-COMBINATION-STOP-SMOKINGHTTPS: //WWW. CMS. GOV/OUTREACH-AND-EDUCATION/MEDICARE-LEARNING-NETWORK-MLN/MLNMATTERSARTICLES/DOWNLOADS/MM 7133. PDF]MEDICATION-AND-BEHAVIOURAL-SUPPORT-HELP-SMOKERS-STOP 28

Chronic Disease-State Management Common Pharmacist-Managed Chronic Diseases Hypertension Hyperlipidemia Diabetes Osteoporosis Asthma/COPD o Population management, improved outcomes o Quality metrics o. Medicare Part B benefit o”Incident to Physician” billing o CPT Code 99211 o Only available in hospital or physician-based clinics HTTP: //WWW. AAFP. ORG/FPM/2004/0600/P 32. HTML 29

Traditional Clinical Pharmacy Services 1. Immunization Services Covered under Medicare Part B (clinic) and Medicare Part D (community) Every member of the healthcare team has a role in vaccine advocacy and patient education • • 2. Anticoagulation Services Covered under Medicare Part B Studies suggest a cost savings of over $168, 000 per 100 patients annually in pharmacist-led anticoagulation clinics Collaborative practice agreement must include written protocol Non-vitamin K antagonist oral anticoagulants now preferred over warfarin • • • INR testing and frequent follow-up not required. HTTP: //BOK. AHIMA. ORG/PDFVIEW? OID=106618 HTTP: //WWW. PHARMACYTIMES. COM/CONTRIBUTOR/BETH-LOFGREN-PHARMDBCPS/2015/01/HOW-TO-CONVERT-BETWEEN-ANTICOAGULANTS HTTP: //WWW. ACC. ORG/LATEST-IN-CARDIOLOGY/TEN-POINTS-TOREMEMBER/2016/03/02/15/45/ANTITHROMBOTIC-THERAPY-FOR-VTE-DISEASE 30

Medication Therapy Management (MTM) o Pharmacists conduct comprehensive medication reviews and identify and solve drug related problems o. MTM’s Roll in PCMH o Population management (targets patients with multiple disease states and multiple medications) o Identification and resolution of “drug-related problems” to improve health outcomes and decrease cost of care long term o Community pharmacists serve are the most accessible members of the PCMH “team” o. Opportunity o Improve patient outcomes o Currently only about 11% of patients who are eligible for MTM under Medicare Part D are receiving these services HTTP: //AVALERE. COM/EXPERTISE/MANAGED-CARE/INSIGHTS/FEW-MEDICARE-BENEFICIARIES-RECEIVE-COMPREHENSIVE-MEDICATION-MANAGEMENT-SERV 31

Device Education o. Improve patient experience and optimize outcomes o. Epi. Pens® o. Glucometers o. Insulin Pens/Syringes o. Insulin Pumps o. Inhalers and Spacers o. Peak Flow Meters o. Diastat ® HTTP: //WWW. ASHPINTERSECTIONS. ORG/2016/02/PRIMARY-CARE-CENTERS-LEVERAGE-PHARMACISTS-TO-EXPAND-PATIENT-CARE/ 32

Transitions of Care o Population management, care coordination, improving access to care, decrease cost of care (reduced readmission) o Identify patients who have been hospitalized or have visited the ER o Contact patient by phone within 2 days of discharge o Educate and answer questions o Schedule follow-up appointment with PCP within -14 days of discharge (Ins. specific) 7 o Medicare Part B benefit o CPT Codes o 99495 o 99496 HTTPS: //WWW. ACPONLINE. ORG/PRACTICE-RESOURCES/BUSINESS-RESOURCES/CODING/GENERAL-CODING-RESOURCES/WHAT-PRACTICES-NEED-TO-KNOW-ABOUTTRANSITION-CARE-MANAGEMENT-CODES 33

Utilization of Technology in PCMH o Electronic Medical Record o Standardized documentation o Template utilization o Easily collect and analyze patient data o Use in population management and quality improvement research o. Patient Portal Access to patient information anytime, anywhere o Communicate labs results o Share discharge summaries o o Improves coordination of care and health outcomes o. SHARE o Arkansas State Health Alliance for Records Exchange o Secure, state-wide health information exchange o Allows health professionals to exchange electronic information o Improves coordination of care and health outcomes HTTP: //WWW. SHAREARKANSAS. COM/ 34

High Priority Beneficiary Documentation 35

Care Plan 36

Research o Continuous quality assurance and improvement o Requirement for NCQA o. Medication Use Evaluation (MUE) o Pushing prescribing to more cost effective, evidence based drug selection 37

Requirements for Pharmacists o Scope of practice o Collaborative practice agreements o Policies, procedures, or protocols o Standardized documentation o IRB approval when applicable 38

Challenges o Logistics o Limited time and space o Workflow management o Lack of standardization in documentation/forms/requirements o Collaborative practice agreement o Scope of practice o Communication o Verbal o Written o Payment/Reimbursement o Pharmacists not recognized as provider by Medicare Part B (except when immunizing) o MTM services covered under Medicare Part D only 39

Reimbursement/Payment Opportunities: o Supported by Per Member Per Month payments o Direct billing for covered services o Immunization o Diabetes self-management education o “Incident to” billing o Use of CPT Modifier HTTP: //WWW. AAFP. ORG/FPM/2004/0600/P 32. HTML 40

Reimbursement/Payment Opportunities: “Incident-to” Billing o The delegation, by a physician, of certain medical services or tasks to be performed by a non-physician working under the supervision of the physician o Clinics may negotiate contracts with private payers to ensure pharmacist reimbursement for pharmacy services o CPT Code 99211 o Level-I established patient encounter code o “Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. ” o Use for patient education, follow-up visits, and medication reviews o Policies vary by payer o Payments vary by payer o Average unadjusted payment from Medicare for 99211 in 2004 was $21 HTTP: //WWW. AAFP. ORG/FPM/2004/0600/P 32. HTML 41

Reimbursement/Payment Opportunities: Use of CPT Modifiers o If a nurse or pharmacist sees a patient on the same day as a provider at the request of the provider, a second CPT code must be applied o To receive payment for both CPT codes, add a “modifier” o CPT Modifier 25 o Used to identify a “significant, separately identifiable E/M service by same physician on same day of procedure or other service” o Utilized for services “above and beyond” the usual E/M service o Ex. Smoking cessation counseling or immunization HTTP: //WWW. AAFP. ORG/FPM/2004/0600/P 32. HTML HTTP: //WWW. CODINGAHEAD. COM/2011/10/CPT-MODIFIER-25 -USAGE-AND-REIMBURSEMENT. HTML 42

Cost, Quality, and Access Goals Cost ◦ Reduce overall costs by reducing acute costs associated with risk and expense ◦ Increase preventive costs to reduce future risk and costs Quality ◦ Doesn’t allow for patients to slip through the cracks ◦ Makes sure the “of course we do” things are actually getting done ◦ Have to stay up on EBM in order for risk reduction Access ◦ Increase access to a “home” ◦ Increase access to round-the-clock care ◦ Increase access to preventive services 43

Clinic Team Communication: Our Experience o Progress board o ”Huddle” reports o Team incentives 44

Stumbling Blocks: Our Experience o Resources o Sizable clinic o Empowering the team o EMR support o Healthcare IT 45

Assessment: Our Experience o Opened eyes to things we thought we were doing well o Pick HPBs so that we can make the most impact o Have an IT-Medical team that communicates needs well o Build a good PCMH team o Beta test processes—ONE RIGHT WAY! o Track and audit o Don’t ease up on the non-compliant (patients and employees) o Get to autopilot 46

The Future in Arkansas Medicaid & Other Third Party Payers PCMH Medicaid PCMH Current Medicare & Other Third Party Payers Future CPC+ 47

Summary ◦ PCMH is a team-based, patient and family-centered care model—not just a location—that focuses on comprehensive, coordinated care that improves the quality of care for all patients while reducing overall healthcare spending ◦ PCMH offers opportunities for nearly all clinic staff to improve care coordination and patient care outcomes ◦ Continuous quality improvement research is important to identify stumbling blocks, improve team dynamics and processes, and increase revenue 48

Contact Information ◦Ma. Randa Herring, Pharm. D, BCACP mksherring@harding. edu ◦Tara Bruner, MHS, PA-C tbruner 1@harding. edu 49

References 50

Acknowledgements o JP Wornock, MD o Amanda Diles, MHS, PA-C o Eric Booth o Prime. Care Team o Harding University College of Pharmacy 51

Question #1 The “Triple Aim” is a strategic group of principles created by the Institute for Healthcare Improvement (IHI) to do all of the following EXCEPT: A. B. C. D. Improve the patient’s experience Improve population health Reduce the cost of healthcare Reduce medication errors 52

Question #2 The patient-centered medical home (PCMH) is a care-based delivery model where patient treatment is _______ through primary care physicians to ensure appropriate communication with downstream providers and improved patient care. A. B. C. D. Coordinated Planned Outsources Filtered 53

Questions? 54