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GUIDANCE ON INTERVENING WITH PANEL MANAGEMENT: HIV CLINICS AT THE FOREFRONT OF PCMH MODELS
Itta Aswad, MPH
November 28th, 2012- Ryan White All Grantees Meeting
DISCLOSURES
This continuing education activity is managed and accredited by Professional Education Service Group. The information presented in this activity represents the opinion of the author(s) or faculty. Neither PESG, nor any accrediting organization endorses any commercial products displayed or mentioned in conjunction with this activity.
Commercial Support was not received for this activity.
DISCLOSURES
Itta Aswad, MPHHas no financial interest or relationships to disclose
Kathleen Clanon, MDHas no financial interest or relationships to disclose
LEARNING OBJECTIVES
At the conclusion of this activity, the participant will be able to:
1. Define Panel Management and describe a typical PM program.
2. Describe the association between the Patient Centered Medical Home Model and Panel Management.
3. Identify barriers and facilitators to implementing this design in their agencies
OBTAINING CME/CE CREDIT
If you would like to receive continuing education
credit for this activity, please visit:http://www.pesgce.com/RyanWhite2012
WHO ARE WE
HIV ACCESS is a consortium of Primary Care clinics working to provide comprehensive quality care to PLWHA
The Family Care Network is a consortium of agencies that works to provide comprehensive, services across disciplines for children, youth, women and families living with HIV
AGENDA
Overview of PCMH What is Panel Management? How PM works How PM can be implemented in your clinic
THE REALITY OF THE 15-MINUTE VISIT IN PRIMARY CARE
Only 37% of patients in one study were adequately informed about medications they were taking
50% of patients leave office visit not understanding what the doctor said
Study of 1000 physician visits, the patient did not participate in decisions 91% of the time.
Roter and Hall. Ann Rev Public Health 1989;10:163. Braddock et al. JAMA 1999;282;2313.
RACIAL DISPARITIES IN SURVIVAL
7.0
6.0
5.04.03.0
2.0
1.00.0
Life
Expect
ancy
Lost
(y)
Women Men Overall
White Black Hispanic
Late initiation or early HAART discontinuation results in life- expectancy loss
Data indicate minorities present later and have higher rates of premature discontinuation
Losina E et al. 14th CROI; 2007; Los Angeles, CA. Abstract 142.
Slide courtesy of Dr. William King
WHAT IS A PCMH?
A primary care practice that has gone through an independent evaluation process, such as through the NCQA, to validate that it is able to:
Deliver comprehensive, patient-centered care
Of the whole person, Supported by health information
systems And with accountability for results. Slide courtesy of Dr. Kathleen Clanon
KEY FEATURES OF A PCMH INCLUDE:
Enhanced Access and Open Scheduling Adopting and Implementing Evidence
Based Guidelines Systematic, HIT based tracking of
tests, results, screens, preventative therapy
Referral tracking, and follow-up Alternate forms of patient-physician
interaction (email, phone) PCMHs are accountable for reporting
on evidence-based measures of quality and patient satisfaction.
Slide courtesy of Dr. Kathleen Clanon
12
Patient Centered Medical HomeImplementation Continuum
Pre-contemplation (Inconvenient hours, no outreach to missing patients, difficult to reach clinic on phone)
Visualized as PCMH (Philosophic commitment to PCMH and talk about concepts, no action yet)
Organized as PCMH(Patient navigators, panel management, staff huddles, using registry)
Standardized as PCMH (Staff training and job descriptions include new duties, reimbursement is tied to pt satisfaction)
Recognized as PCMH (By NCQA, etc.)
Realized as PCMH (Org culture and operations have fully integrated PCMH)
Doctor and Staff Centered model
PCMH Fully Integrated
Slide courtesy of Dr. Kathleen Clanon
WHY DO WE NEED THIS CHANGE?
PLWH/A are living longer
List of beneficial preventative disease activities is growing
Resources are becoming more limited
Payer models are changing (pay for performance)
Utilizing meaningful use incentives
WHAT IS PANEL MANAGEMENT
Use a registry to track who needs what Have written selection criteria to decide
which patients to focus on for what Link criteria to standing orders for labs,
immunizations, counseling referrals, etc Empower MA/peer teams to take over
managing routine care outside of the MD/NP visit
Slide courtesy of: Barbara Ramsey, MD
WHAT CAN PANEL MANAGEMENT DO FOR US?
Uncouple the Dr. visit from some of the - Adherence counseling - Smoking
cessation- Prevention counseling - Vaccinations- Mental Health and Substance Abuse
treatment
Produce actionable interventions - phone messaging - med reconciliation
PILOT PROJECT- ALAMEDA COUNTY MEDICAL CENTER, OAKLAND CA
Team Approach: 1 Clinician 1 Medical Assistant 1 Registered Nurse ~125 clients
Goal: Increase retention in
care Increase vL
suppression Increase health
maintenance activities
TASK SHIFTING
MA- Vitals and referrals as ordered
RN- Case Management and discharge orders
MD- focus on HIV care and Primary care needs as remembered
MA- Vitals, promotes for HM tasks, referrals, in-reach to the out of care without order
RN- Case Management and discharge orders
MD- Focus on HIV and Primary care needs using support tools
Pre Panel Management Post Panel Management
WHAT DOES PANEL MANAGEMENT SOUND LIKE?
“ Hi Andre, I’m calling from Dr. J’s office. I see you are overdue for your labs. I have a lab slip for you, can you come in a see me tomorrow? Great, and we can get your flu shot done then too, and we’ll set you up to see Dr. J.”
“Hello Ms. R, this is Itta calling from Dr. C’s office. How are you today? We were looking over your chart and noticed that you are coming up due for your pap smear and also your ADAP needs renewal. Is it ok if I make appts for you next week to get those done?”
INTERVENTIONS AND TOOLS
Health messages In-reach Registry reports Huddles Decision Support sheets
ADVANTAGES
Proper provider assignments Focused HIV and Primary Care tasks Increase quality numbers Organized care coordination Movement toward NCQA qualification
ALAMEDA COUNTY MEDICAL CENTER:PANEL MANAGEMENT AT WORK
USE OF A REGISTRY REPORT
- How many clients in your panel? - What information is available on each
patient? - Which patients are overdue for CD4, Viral
Load, TB, Paps? - Which patients are at goal? Which are not? - Which patients could be prioritized for self-
management support groups?
EXERCISE: USING THE REGISTRY
Exercise: 15 minutes. In groups of 3-4, degsinate each person a role (MA, RN, Panel Manager, Clinician).
Which clients should the Panel Manager work with first?
How did you prioritize the clients? Why? What interventions would you recommend for follow-up? What is the role of other team members?
PM AT WORK…THE RESULTS TELL ALL
Den-tal Ref
vL Sup
Visit PPD FIT Pap CD4
0%20%40%60%80%
100%
CHALLENGES AND SOLUTIONS
Time Prioritizing needs Shifting medical
practices
Scheduling protected time
Use Registry report and Decision Support tools
Communication
SolutionsChallenges
DO YOU HAVE THE RESOURCES TO PULL THIS OFF?
4 Central PM concepts1. Use a registry2. A team of providers willing to align
resources3. Prioritizing criteria 4. Take care out of the PCP visit when possible
DISCUSSION
NEXT STEPS…..
Identify staff Determine PM activities Carve out protected time with PCP Celebrate successes Learning opportunities
RESOURCES
Itta Aswad, MPH- iaswad@acmedctr.org Kathleen Clanon, MD- kclanon-jba@cht.org William King, MD, JD- wdking37@yahoo.com Barbara Ramsey, MD-
bramsey@chcnetwork.org