PatientCentered Medical Home An Educational and Practice Challenge

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Patient-Centered Medical Home An Educational and Practice Challenge Society of Teachers of Family Medicine

Patient-Centered Medical Home An Educational and Practice Challenge Society of Teachers of Family Medicine December 6 th 2008

Overview of Presentation • Driving forces behind Patient Centered Medical Home • Origins of

Overview of Presentation • Driving forces behind Patient Centered Medical Home • Origins of Medical Home • Need for qualification and evaluation of PCMH • Development of PPC-PCMH • Beyond measurement: the challenge to Education and Practice – What is needed for the medical home to succeed? – The challenge to education Physician Practice Connections--Patient-Centered Medical Home 2

Why do we need a “new” system (some would say we don’t have one

Why do we need a “new” system (some would say we don’t have one now) • Costs have (for 50 years), and continue to, rise faster than GDP – Uninsured, underinsured and related issues – Can’t improve access without controlling costs – Major variation in costs WITHOUT relationship to quality (national/international) • Major gaps in quality – Hospital deaths and readmissions – In ambulatory care-about 50/50 chance of getting needed services Physician Practice Connections--Patient-Centered Medical Home 3

Primary Care Has Changed…. Negatively • Increasing need for PCPs – Population age 85

Primary Care Has Changed…. Negatively • Increasing need for PCPs – Population age 85 and over will increase 50% from 2000 to 2010 – Aging population means an increase in care for complex and chronic medical conditions • Decreasing number of PCPs – Projected shortage of 200, 000 PCPs by 2020 – Plunging interest in primary care • Entering internal medicine residents down to 10 % in 2008 from 54% in 1998. • Family Medicine: not filling residencies and high proportion filled by non US medical graduates – Primary care physicians are overworked and dissatisfied – Compensation is bottom of pay scale for physicians Physician Practice Connections--Patient-Centered Medical Home 4

Median Compensation for Selected Medical Specialties Data are from the Medical Group Management Association

Median Compensation for Selected Medical Specialties Data are from the Medical Group Management Association Physician Compensation and Production Survey, 1998 and 2005 Physician Practice Connections--Patient-Centered Medical Home 5

Yet Primary Care Leads to Better Quality and Lower Costs • Higher ratio of

Yet Primary Care Leads to Better Quality and Lower Costs • Higher ratio of PCPs to specialists is associated with improved health outcomes and lower costs (Starfield-both international and within US data) – Adding 1 family practitioner per 10, 000 people associated with 70 fewer deaths per 100, 000 (9% reduction in mortality) and lower costs (fewer ambulatory sensitive admissions) – Specialists practicing outside their specialty area leads to an increase in mortality and cost (Fisher) Physician Practice Connections--Patient-Centered Medical Home 6

Impact of Primary Care Decline • Patients are dissatisfied and so are doctors –

Impact of Primary Care Decline • Patients are dissatisfied and so are doctors – Patients can’t get timely access to acute care • Inability of patients to get timely appointment was 23% in 1997 and rose to 33% in 2005 – Physicians hampered in provision of comprehensive chronic care • Lack time and state-of-the-art systems and processes (the hamster on a treadmill effect) • Pay for procedures- no compensation for nearly 25% of work that occurs between visits, for quality or efficiency • Gaming rather than value (procedure hobbies that reimburse well versus counseling) Physician Practice Connections--Patient-Centered Medical Home 7

Key Steps to a true “Health Care System” • Primary Care Patient Centered Medical

Key Steps to a true “Health Care System” • Primary Care Patient Centered Medical Home as key building block • Implementation and use of health information technology and care systems at all levels of health care • Integration of care (real or virtual) • Reimbursement linked to desired process and outcomes of care (pay for what you want) • Measurement and feedback to determine if you are getting where you want to be Physician Practice Connections--Patient-Centered Medical Home 8

The Current Model of Care: Connection by Billing Physician Practice Connections--Patient-Centered Medical Home 9

The Current Model of Care: Connection by Billing Physician Practice Connections--Patient-Centered Medical Home 9

The Future Model of Care: Virtual Integration by Information Sub-specialty PCMH Sub-specialty “Medical Home

The Future Model of Care: Virtual Integration by Information Sub-specialty PCMH Sub-specialty “Medical Home Neighbor” Sub-Specialty Procedural Practice Patient-Centered Medical Home Physician Practice Connections--Patient-Centered Medical Home 10

Patient Centered Medical Home A blending of concepts and critical building block for health

Patient Centered Medical Home A blending of concepts and critical building block for health system change Physician Practice Connections--Patient-Centered Medical Home 11

The Medical Home “Defined” ACP, AAFP, AAP, AOA • Personal physician - each patient

The Medical Home “Defined” ACP, AAFP, AAP, AOA • Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. • Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. • Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care. • Care is coordinated and/or integrated across all elements of the complex health care system (e. g. , subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e. g. , family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. Physician Practice Connections--Patient-Centered Medical Home 12

Primary Care • • Multiple formulations from 1960’s on Core concepts of – –

Primary Care • • Multiple formulations from 1960’s on Core concepts of – – • First contact Coordinated Comprehensive Continuous Strong empiric base linking primary care to higher quality and lower cost (within US and international) Physician Practice Connections--Patient-Centered Medical Home 13

Patient Centeredness • Studies and formulations funded and led by Picker • Defined in

Patient Centeredness • Studies and formulations funded and led by Picker • Defined in “Crossing the Quality Chasm by IOM “the system of care should revolve around the patient, respect patient preferences and put the patient in control” • Recent work funded by Commonwealth – including work by NCQA and others in refining the definition and creating measures (ACES, CGCAHPS, supplement to CG CAHPS) Physician Practice Connections--Patient-Centered Medical Home 14

Wagner Model for Effective Prevention and Chronic Illness Care Physician Practice Connections--Patient-Centered Medical Home

Wagner Model for Effective Prevention and Chronic Illness Care Physician Practice Connections--Patient-Centered Medical Home 15

Wagner Model Chronic (Planned) Care Model • Formulated in 1980’s but with prior roots

Wagner Model Chronic (Planned) Care Model • Formulated in 1980’s but with prior roots in primary care and elsewhere • Based on varying amounts of empiric evidence (qualitative to RCT’s) • Since developed, multiple studies evaluating model and components of the model (www. improvingchronicillness. org) • Successful application to both chronic and preventive care (thus “planned care”) • Empiric basis bolstered by Shortell work on systems and quality Physician Practice Connections--Patient-Centered Medical Home 16

Content Overlap--Primary Care, CCM, PCMH Comprehensive First Contact Primary Care Self. Management Support Decision

Content Overlap--Primary Care, CCM, PCMH Comprehensive First Contact Primary Care Self. Management Support Decision Support Clinical Information Systems Patient-Centered Medical Home Community Linkages Wagner CCM What’s Included? (Infrastructure) How Much Used? (Extent) What Evidence Functions? (Implementation) Physician Practice Connections--Patient-Centered Medical Home 17

Linkage of PCMH to Reimbursement: One Model Pay for Performance Quality, Resource Use and

Linkage of PCMH to Reimbursement: One Model Pay for Performance Quality, Resource Use and Patient Experience Fee Schedule for Visits/Procedures Payment per Patient for Qualified Medical Homes (services not normally reimbursed) Physician Practice Connections--Patient-Centered Medical Home 18

Goals for PCMH Implementation • Improved quality for preventive services and care of persons

Goals for PCMH Implementation • Improved quality for preventive services and care of persons with chronic illness • Moderation-or at least, more rational use of resources (lower ambulatory sensitive hospitalization, reordered labs etc) • Improved patient centeredness as expressed in patient experience of care surveys • Enhanced reimbursement for primary care • Improved clinician and staff satisfaction with primary care practice Physician Practice Connections--Patient-Centered Medical Home 19

How would we “know” a PCMH when we see one?

How would we “know” a PCMH when we see one?

Need for a Standardized Tool for QUALIFICATION as PCMH • If payers are going

Need for a Standardized Tool for QUALIFICATION as PCMH • If payers are going to provide extra reimbursement to PCMHs, they need an valid and reliable, actionable tool • When reimbursement at stake, major problems with – Use of practice (clinician) surveys without documentation or on site verification – Use of clinical performance measures or patient experience of care (sample size, cost, risk adjustment) • Critical for practices to have standardization since practices may participate in projects for multiple payers Physician Practice Connections--Patient-Centered Medical Home 21

Theoretical Frameworks Informing Development of PPC_PCMH Planned Care Model Clinical information Systems Decision Support

Theoretical Frameworks Informing Development of PPC_PCMH Planned Care Model Clinical information Systems Decision Support Patient Self. Management Delivery System Redesign Community Linkages Health Systems Patient Centered Respect Patient Values Accessible Family-Centered Community Linkages Compassionate Culturally Appropriate Emotional Support Information and Education Physical Comfort Quality Improvement Culturally competent interactions Language services Reducing disparities Primary Care First Contact Continuous Comprehensive Coordinated Medical Home Personal physician Physician directed team Whole person orientation Enhanced access Physician Practice Connections--Patient-Centered Medical Home 22

PPC-PCMH Development • Existing PPC 2006 (based on PCM) modified with input from ACP,

PPC-PCMH Development • Existing PPC 2006 (based on PCM) modified with input from ACP, AAFP, AAP and AOA – Align standards with Joint Principles of PCMH – Incorporate critical attributes of PCMH not in CCM – Define foundational elements (“must pass” requirements)Endorsed by NQF Physician Practice Connections--Patient-Centered Medical Home 23

Research Findings: Validity of Self-Report • Practices can report on systems, however… – Overall

Research Findings: Validity of Self-Report • Practices can report on systems, however… – Overall agreement with an on-site audit ranges from high (clinical information systems, quality improvement) to low (care management, population management) • Several factors may explain lack of agreement – Variable implementation of systems across sites and conditions – Variations in staff members’ exposure to systems – Lack of familiarity with systems Conclusion: Need Audit or Documentation Physician Practice Connections--Patient-Centered Medical Home 24

Correlation of Systems, Clinical Performance • Published and in process research on PPC –

Correlation of Systems, Clinical Performance • Published and in process research on PPC – Presence or absence of EMR per se, correlates ONLY WEAKLY with clinical measures • However, practices with fully functional EMR’s achieve highest scores on PPC – Overall PPC score, and some sub-scores have positive correlation with higher clinical performance on measures tested (diabetes, CV, depression) – Overall PPC score and some sub-scores have positive coorelation with lower inpatient days for ambulatory sensitive conditions – Overall PPC score does NOT appear to correlate with overall patient experiences of care but with selected sub-components (ACES- questions with variance attributable to practice level) More research needed on all aspects –especially on relationship to cost and utilization: ER visits; tests; specialty care; drug interactions etc Physician Practice Connections--Patient-Centered Medical Home 25

PPC-PCMH Content and Scoring Standard 1: Access and Communication A. Has written standards for

PPC-PCMH Content and Scoring Standard 1: Access and Communication A. Has written standards for patient access and patient communication** B. Uses data to show it meets its standards for patient access and communication** Pts Standard 2: Patient Tracking and Registry Functions A. Uses data system for basic patient information (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) Pts Standard 3: Care Management A. Adopts and implements evidence-based guidelines for three conditions ** B. Generates reminders about preventive services for 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 Pts 3 Standard 4: Patient Self-Management Support A. Assesses language preference and other communication barriers B. Actively supports patient self-management** Pts 2 4 4 5 Standard 5: Electronic Prescribing A. Uses electronic system to write prescriptions B. Has electronic prescription writer with safety checks C. Has electronic prescription writer with cost checks 9 2 3 3 6 4 3 21 4 3 5 5 2 8 Standard 6: Test Tracking A. Tracks tests and identifies abnormal results systematically** B. Uses electronic systems to order and retrieve tests and flag duplicate tests Pts 7 Standard 7: Referral Tracking A. Tracks referrals using paper-based or electronic system** PT 4 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 ** 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 Pts 20 6 Pts 3 3 6 13 4 3 3 2 1 15 Standard 9: Advanced Electronic Communications A. Availability of Interactive Website B. Electronic Patient Identification C. Electronic Care Management Support **Must Pass Elements Physician Practice Connections--Patient-Centered Medical Home Pts 1 2 1 4 26

PCMH Must Pass Elements 1. PPC 1 A: Written standards for patient access and

PCMH Must Pass Elements 1. PPC 1 A: Written standards for patient access and patient communication 2. PPC 1 B: Use of data to show meeting standards 3. PPC 2 D: Use of paper or electronic-based charting tools to organize clinical information 4. PPC 2 E: Use of data to identify important diagnoses and conditions in practice 5. PPC 3 A: Adoption and implementation of evidence-based guidelines for three conditions 6. PPC 4 B: Active support of patient self-management 7. PPC 6 A: Tracking system to test and identify abnormal results 8. PPC 7 A: Tracking referrals with paper-based or electronic system 9. PPC 8 A: Measurement of clinical and/or service performance 10. PPC 8 C: Performance reporting by physician or across the practice Physician Practice Connections--Patient-Centered Medical Home 27

How PPC-PCMH Recognition Works Physician/practice • Self-assess, collect data using Web-based software • Submit

How PPC-PCMH Recognition Works Physician/practice • Self-assess, collect data using Web-based software • Submit documentation to NCQA when ready • May be asked to submit more data if needed NCQA • Evaluates and scores all applications • Checks licensure of physician • Audits a sample of applications • Posts Recognized physicians on web • Distributes list of Recognized physicians monthly to health plans and others • Physicians sent media kit, press releases, letter & certificate Physician Practice Connections--Patient-Centered Medical Home 28

Myths • Small practices can’t qualify (>20% of qualified practices are solo physician sites/practices)

Myths • Small practices can’t qualify (>20% of qualified practices are solo physician sites/practices) • Passing (25 points) is too hard (practices do not have to submit tool until they score above passing) • Passing (25 points) is too easy (estimate fewer than 15% of practices could pass without making changes) • You have to have an EMR to pass (can get nearly 50 points without) Physician Practice Connections--Patient-Centered Medical Home 29

Implementing and Evaluating PCMH Inputs Individual Clinician-Staff Attitudes, behaviors and proficiencies Educational Support Patient

Implementing and Evaluating PCMH Inputs Individual Clinician-Staff Attitudes, behaviors and proficiencies Educational Support Patient Centered Ongoing Care Output Evaluation Programs Tools Office Systems Decision Support Information Technology Delivery System Design Patient Support MOC (Boards) Practice Evaluation Programs NCQA Qualification Patient Clinical Process Office Experience And Systems of Care Outcome Measures Assessment Measures (Recognition programs (PPC-PCMH) Physician Practice Connections--Patient-Centered Medical Home (CG-CAHPS) & Group/plan data) 30

What Will be Needed for PCMH to Succeed? Physician Practice Connections--Patient-Centered Medical Home 31

What Will be Needed for PCMH to Succeed? Physician Practice Connections--Patient-Centered Medical Home 31

Education, Education • Education is NOT lectures or traditional CME • Education must be

Education, Education • Education is NOT lectures or traditional CME • Education must be at all levels –student, resident, and practice-and all types of practitioners and support staff Physician Practice Connections--Patient-Centered Medical Home 32

Education- Practitioners • Knowledge, Skills, Attitudes-as individuals – Collaborative “team” practice (clinical staff, support

Education- Practitioners • Knowledge, Skills, Attitudes-as individuals – Collaborative “team” practice (clinical staff, support staff and other physicians) – Population health-as a link between personal and public health – Quality measurement and improvement basics – Patient self (or better “collaborative) health and care management support Physician Practice Connections--Patient-Centered Medical Home 33

Some Promising Models (of many) • New York City – Department of Health providing

Some Promising Models (of many) • New York City – Department of Health providing EHR to 2, 000 MDs serving Medicaid population; implementation and QI support – Goal to reach PPC-PCMH Level II within 2 years • Mid-Hudson Valley – 150 practices participating in THINC consortium with common EHR, interoperability and implementation support – Goal to reach PPC-PCMH Level II within 2 years • North Carolina Medicaid – Nurse care managers shared by practices-reported >50 million in savings/year • Geisinger (reported in Health Affairs) – Introduced in Geisinger Health System – Reduced ambulatory care sensitive hospital admissions • CMS Demonstration – Large Scale (>200 practices in each of eight regions) – Practices could potentially earn nearly $100, 000/MD/year – Will use nurse case manager model similar to North Carolina Physician Practice Connections--Patient-Centered Medical Home 34

Summary: Issues to Consider • PCMH is not THE answer to our cost and

Summary: Issues to Consider • PCMH is not THE answer to our cost and quality problems, but a vital building block • Challenge to provide sufficient help to practices to become PCMH’s to enable them to achieve and demonstrate the cost savings and quality improvement we need • Challenge to build on the PCMH to create virtual accountable entities (for primary, specialty care and hospital care) Physician Practice Connections--Patient-Centered Medical Home 35