Allison Precht, MA, LPC, CADC Sneha Jacob, MD · • Inbound appointment scheduling, re-scheduling,...

2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

Making the Most of Your Patient Centered Medical Home: Guidance & Best Practices Deb McMahon, MD Allison Precht, MA, LPC, CADC Sneha Jacob, MD


Achieving and Maintaining Level 3 Medical Home Status for Ryan White Part C Clinics

Deborah McMahon, MD HIV/AIDS Program UPMC Presbyterian Shadyside Pittsburgh, PA

Presenter

Presentation Notes

Required slide. Please complete


Overview 1. Why a Medical Home? 2. What is a Medical Home? 3. Path to Medical Home Status 4. Challenges 5. Sustainability


Why a Medical Home? 1. ACA: promotes care coordination:

1. Reduce payment to hospitals with high readmission rates 2. Require health plans to report on case management and other services that improve health

outcomes 3. Supports the development of ACOs and PCMHs to emphasize need for care coordination

2. Payment models: moving towards value, assume or reward care management

3. Overarching goals: better patient experience, improved patient health, and lower healthcare costs

4. Recognition within your own institution 5. Marketing tool


What is a Medical Home? • RW Part C* Clinics are! • Primary, comprehensive

quality HIV medical care • Patient-centered care • Co-located services • Coordinated care • Multidisciplinary care • Health information

technology

*Ryan White: An Unintentional Home Builder; Saag M; AIDS Reader.2009; 19:166-168


What is a Medical Home? 1. Personal physician – long-term relationship 2. Physician-led team approach to care 3. Whole person orientation (holistic care) 4. Care is coordinated and integrated (behavioral health) 5. Quality and safety are paramount

1. Evidence-based medicine 2. Care planning 3. Continuous quality improvement 4. Patient engagement 5. Clinical decision support 6. Health Information technology

6. Enhanced access (walk-ins, urgent visits, extended hours) 7. Reimbursement (care coordination/cost savings recognized)


PCMH Content and Scoring PCMH 1: Enhance Access and Continuity A. Patient-Centered Appointment Access B. 24/7 Access to Clinical Advice C. Electronic Access PCMH 2: Team-Based Care A. Continuity B. Medical Home Responsibilities C. Culturally and Linguistically Appropriate Services D. The Practice Team (“Huddles “– critical factor)


PCMH Content and Scoring PCMH 3: Population Health Management A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. Use Data for Population Management E. Implement Evidence-Based Decision-Support PCMH 4: Care Management and Support A. Identify Patients for Care Management B. Care Planning and Self-Care Support C. Medication Management D. Use Electronic Prescribing E. Support Self-Care and Shared Decision-Making


PCMH Content and Scoring PCMH 5: Track and Coordinate Care A. Test Tracking and Follow-Up B. Referral Tracking and Follow-Up C. Coordinate Care Transitions PCMH 6: Measure and Improve Performance A. Measure Clinical Quality Performance B. Measure Resource Use and Care Coordination C. Measure Patient/Family Experience D. Implement Continuous Quality Improvement E. Demonstrate Continuous Quality Improvement F. Report Performance G. Use Certified EHR Technology


PCMH Recognition Timing 1. NCQA will base submissions through 2017 on PCMH 2014

standards 2. Redesigning application, reducing documentation 3. Streamlining standards, elements for PCMH 2017 (annual) 4. Updated PCMH application will be released in March 2017;

2014 standards will be retired at end of 2017 5. Practices that achieve recognition on 2014 standards have

choice of 3 year recognition and then moving to annual reporting process in order to sustain it or opting for an earlier transition to the new annual reporting process


Path to Medical Home Status 1. Allow enough time! Plan for it. 2. Realistically assess your readiness. 3. Determine if your health system provides direction or support. 4. Critical: foundational QI Program 5. Critical: robust electronic health record (ePrescribing, Best

Practice Alerts, data capture). 6. Critical: the right team - clinical, data, QI, logistics, consumer. 7. Identify “owners” for each Element, set timelines for reporting

on the Factors.


Path to Medical Home Status 8. Focus efforts on Critical Factors (required)

1. Same day appointments 2. Timely advice via telephone 3. Huddles 4. Tracking referrals 5. Transitions of care

9. Follow the guidelines to the “T” 10. Use the Record Review Workbook for patient reporting (trial) 11. Identify one individual to format and upload documents 12. Allow time for submission process (lots of documents) 13. Recognition fees depend on # of clinicians (program income)


Documentation • Document Processes

• Written protocols, policies, procedures, workflows

• Report • Aggregated data

• Records or files • Patient files

• Materials • Clinical guidelines,

educational tools, self-management resources


Challenges 1. Over-committed clinicians, staff 2. Finding a time to meet that does not impact clinic duties 3. Competing health system initiatives in addition to PCMH-

driven initiatives 4. Working through organizational barriers re: data access 5. Making adjustments in real-time, measuring effectiveness,

and doing it again in a timely manner


Sustainability

1. Look at the PCMH indicators on a scheduled basis 2. Re-examine new processes, evaluate effectiveness 3. Anticipate next application at least 12 months in advance 4. Assess care team capacity and breadth (reactive vs proactive) 5. Listen to your patients (Patient Satisfaction Surveys, Press-

Ganey) and adjust to improve patient care experiences


Resources 1. http://www.ncqa.org/programs/recognition/practices/patien

t-centered-medical-home-pcmh 2. http://aidsetc.org/topic/medical-homes 3. https://pcmh.ahrq.gov/page/papers-briefs-and-resources 4. https://careacttarget.org/mhrc Target Center 5. http://blog.ncqa.org/recognition-redesign-questions/

http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh

http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh

http://aidsetc.org/topic/medical-homes

https://pcmh.ahrq.gov/page/papers-briefs-and-resources

https://careacttarget.org/mhrc

http://blog.ncqa.org/recognition-redesign-questions/


E.T. Phone Home: Enhancing Access to Care via a Phone Access Line and PCMH Model Allison Precht, MA, LPC, CADC The Ruth M. Rothstein CORE Center Chicago, Il.


The Ruth M. Rothstein CORE Center Chicago, IL

• Cook County Health and Hospitals System – Public “Safety-Net” Facility

• >5,000 active patients, >25,000 primary care visits annually • 63% African American and 23% Hispanic/Latino • Male 74% Female 26% • >90% have incomes less than 200% FPL • Frequent history of drug use, incarceration • One-stop shopping model/wrap-around services

Presenter

Presentation Notes

We provide care to ~30-35% of PLWA’s known to be in care in Chicago and 205 of PLWHIV’s known to be in care in Illinois


Overview of E.T. Phone Home 1. Goals of Access Line 2. Planning & Development

A. Timeline

3. Implementation Phase 4. Challenges & Facilitators 5. Continuous Quality Improvement

Presenter

Presentation Notes

Timeline: Whether realistic or not, this was completed in 4 months time.


GOALS 1. To provide a process that enhances patient access,

thereby improving the patient experience and minimizing disruption

2. Meet capacity for main line coverage 3. Increase customer satisfaction 4. Create a more efficient clinic flow


Steering Committee Created – June, 2015

• Executive Team Members • Central Appointments • Benefits • Prevention/Education • Practice Transformative

Model • Quality

Improvement/Evaluation

Special Consultants • CCHHS

• Patient Services • Telecommunications

• Howard Brown Health Center

• Patient Services

TEAM

Presenter

Presentation Notes

Staff and consultants


ACCESS LINE AGENTS 1. All agents cross-trained representing the following

disciplines: • Central Appointments • Medical Records • Benefits • Registration


PRE-IMPLEMENTATION RESEARCH 1. Research on Best Practices*

• Light, spacious area • Physical comfort of agents • Collaborative script-writing to facilitate buy-in

2. Consultation with Howard Brown Health Center & CCHHS Patient Support

• Lessons Learned with Call Center Implementation • Field Trip to HBHC Call Center • HBHC Specialist Recommendations in Customer Service

Component 3. Outreach Area identified as best space in building 1. http://www.slideshare.net/jmckeever/leading-practice-in-medical-center-call-centers 2. www.callcentrehelper.com/images/Training%20Course%20CCH2.doc 3. Strother, J.B. (2006) Call Centers in Health Care: Effect on Patient Satisfaction. International Professional Communication

Conference.

Presenter

Presentation Notes

HBHC Lessons Learned: Use White Board Hire those with customer service background Comfortable work space with adjustable screens Resource Binders

http://www.slideshare.net/jmckeever/leading-practice-in-medical-center-call-centers

http://www.callcentrehelper.com/images/Training%20Course%20CCH2.doc


TRAINING 1. 12-hour Training Curriculum Developed

• 4 consecutive Fridays, 3 hours each session • 9 staff members trained

2. 4 Sessions • Customer Service – Part I • Pre-Registration/Registration, Scheduling • Departmental Questions • Customer Service – Part II


THE MOVE 1. Existing staff were re-located 2. 6 work stations created for Access Line

1. Equipped with new chairs, noise-cancelling headsets 2. New computers/scanners

1. Equipped with Message Manager to monitor fax/voice messages 3. 2 staff became permanently assigned 4. 4 work stations open to alternating agents.

3. Fax machine for After-Hours Answering Service Messages, PrEP Referrals, etc.

Presenter

Presentation Notes

Existing staff being relocated was not a smooth transition. They had been in a private office for 10 + years and their reaction affected the morale of the group. Something as simple as determining the functionality of the phone line/fax if it would accept faxes. Working with Telecommunications to move phone/fax lines. Process of communicating new locations of fax lines to other staff, impact on clinic operations.


THE PHONE SYSTEM 1. Comprehensive assessment of current system 2. Collaboration with CCHHS Telecommunications 3. Modifications include:

• Main phone greeting • Routing of incoming calls • Ability to Return to Main Menu in Auto Attendant

4. 6 new phones/phone extensions installed • Centralized Voice Mail

Presenter

Presentation Notes

Assessment of current phone system: Used workflow mapping to assess current system Findings: Calls ended up throughout the entire building. Not a script for incoming calls. Had to standardize the process with Steering Committee and communicate throughout organization.


THE ACCESS LINE: IN ACTION GO LIVE date: November 2, 2015 • Inbound appointment scheduling, re-scheduling, verification • Benefits Verification • Warm transfers SUCCESSES in first month of operation: • 0 Voice Mails during business hours compared to 320 Voicemails

left the month prior to implementation. • 2,948 calls received • 20-second wait time average per call.

SHORT-TERM GOALS • Outbound Pre-Registration Calls – dual function of reminder

call.

Presenter

Presentation Notes

Data: Not Interim Coordinator anymore, don’t have access to current data.


THE DATA/SUPERVISION

1. Data Monitoring • Manual live tracking log implemented, each call

documented • Intermittent data from CCHHS • Evaluation / Quality Assurance

2. Supervision by Interim Coordinator • Weekly Team Huddles • [Intermittent] Individual Supervision


CHALLENGES/FACILITATORS Challenges

1. Unions: 1 position lost 2. Group Development 3. Staffing challenges

1. Decrease of Pre-Registration

4. Data tracking

Facilitators 1. Executive Director as

champion. 2. Given resources 3. Ribbon Cutting event for

promotion. 4. Expectation from

medical leads for success.

Tuckman, B.W. (1965). Developmental sequence in small groups. Psychological Bulletin, Vol 63(6), 384-399.

Presenter

Presentation Notes

Group Development: Forming, Storming, Norming & Performing 2 staff members were removed from their office of 10+ years.


WORKFORCE CAPACITY DEVELOPMENT 1. Creation and Hiring of HIV-Access Manager 2. Further utilize cross-trained staff 3. Redeployment of personnel resources

1. Interim Coordinator


Continuous Quality Improvement 1. Identified Processes for Quality Improvement 2. Performance Metrics

1. Service Level 2. Length of Waiting time 3. Abandoned Calls 4. Benefits Verification with Pre-Registration

3. Enhance data tracking • Calls / appointments scheduled


Sample Performance Metrics Service Level &

Number of Accepted Calls by Agent

52

39 34

40 32

37

50

31 31

23

55 41

34

32 35 29 21

32

9 10

11

44 33

18 16

15

18

28

19

13

27

26

35

35

35

31

30

25

46 20

19 13

18

15

0

20

40

60

80

100

120

140

160

180

tues feb23 wed feb24 thur feb25 fri feb26 mon mar7 tues mar8 wed mar9 thur mar10 thur mar11

# ac

cept

ed c

alls

SC

CH

BL

AF

LG

LC

SERVICE


Resources 1. http://www.slideshare.net/jmckeever/leading-practice-in-

medical-center-call-centers 2. www.callcentrehelper.com/images/Training%20Course%20CC

H2.doc 3. Strother, J.B. (2006) Call Centers in Health Care: Effect on

Patient Satisfaction. International Professional Communication Conference.






Acknowledgements • Executive Director: Ms. Kathi Braswell, RN, MPA • Steering Committee Members: Jacqueline Boone,

Jennifer Catrambone, Alicia Frazier-Drake, Lucy Gonzalez, Trina Johnson-Spivey, Shanett Jones, and Freddie Shufford

• All CORE staff members who helped with the implementation of the Access Line.

• The special consultants who provided their expert guidance throughout the process.


Retention in Care: The Rock Beneath the Cascade Best Practices of an FQHC-based HIV Medical Home Sneha Jacob, M.D., M.S. Epidemiology Director of HIV Clinical Services, Rutgers-Robert Wood Johnson Medical School Eric B. Chandler Health Center


Eric B Chandler Health Center New Brunswick, NJ Federally Qualified Health Center (FQHC) Operated by Rutgers University/Robert Wood Johnson Medical School Level 3 Patient Centered Medical Home Serves 14,000 patients/year in the greater New Brunswick, NJ region Eric B. Chandler Early Intervention Services (EIS) HIV/Ryan White Program


EBCHC Ryan White Program March 2016 Data

Funded through Ryan White Part A, C grants & NJ State Navigator Grant Services for 375 people living with HIV/AIDS 66.5% Medicaid/Medicare, 28.4 % Uninsured 41.6% Black/African American, 41.3% Hispanic/Latino, 13.3% White, 2.4% Asian/Pacific Islander 60.8% Male, 38.1% Female, 1.1% Transgender Risk Factors: 56.0% Heterosexual, 26.7% MSM, 14.1% IDU, 0.8% Perinatal Transmission Serves the Local Community: Largest HIV provider in Middlesex County, Central NJ, serves patients from 7 surrounding counties


• Africa (5) • Nigeria • Ghana • Sierra Leone • Kenya • Ethiopia

• Asia (4) • India • Philippines • China • Marshall Islands

• Europe (2) • Poland • Montenegro (Balkans)

• Caribbean (5) • Puerto Rico • Dominican Republic • Jamaica • Trinidad • Guyana

• Central/South America (12) • Mexico • Cuba • Brazil • Colombia • Ecuador • Paraguay • Peru • Costa Rica • El Salvador • Guatemala • Honduras • Nicaragua

EBCHC Ryan White Program serves a Global Community (27 countries)


EBCHC Ryan White Program: Risk Factors

56.00%

14.10%

26.70%

1.30% 0.80% 1.10%

Heterosexual IDU MSM MSM and IDU Perinatal Transfusion

Risk Factor Percentage

Heterosexual 56.00%

IDU 14.10%

MSM 26.70%

MSM and IDU 1.30%

Perinatal 0.80%

Transfusion 1.10%


EBCHC Ryan White Program: Racial/Ethnic Composition

13.30%

41.60%

41.30%

2.40% 0.30% 0.30% 0.80%

White Black or African American

Hispanic or Latino(a) Asian

Native Hawaiian or Other Pacific Islander American Indian/Alaskan Native

More than one Race

Race/Ethnicity Percentage

White 13.30%

Black or African American 41.60%

Hispanic or Latino(a) 41.30%

Asian 2.40%

Native Hawaiian or Other Pacific Islander 0.30%

American Indian/Alaskan Native 0.30%

More than one Race 0.80%


EBCHC Ryan White Program: Insurance (December 2015)

4.10% 0.70%

19.40%

47.10%

0.50%

28.40%

Private - Employer Private - Individual

Medicare Medicaid, CHIP, or other public plan

Other Plan No Insurance/Uninsured

Insurance Type Percentage Private - Employer 4.10% Private - Individual 0.70% Medicare 19.40% Medicaid, CHIP, or other public plan 47.10% Other Plan 0.50% No Insurance/Uninsured 28.40%


EBCHC Ryan White Program Measure: Viral Load Suppression (2012-2016)

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

June-12 December-12 June-13 December-13 June-14 December-14 June-15 December-15 June-16

National New Jersey EBCHC


EBCHC Ryan White Program Measure: Retention in Care

0

20

40

60

80

100

120

140

160

>20 years 15-19 years 10-14 years 5-9 years <5 years

22

56 67

80

150

Current Ryan White Patients # Years at EBCHC

Number of Years Number/Percentage >20 years 22/5.9 %

15-19 years 56/14.9%

10-14 years 67/ 17.9%

5-9 years 80/ 21.3%

<5 years 150 / 40.0%

Why Focus on Retention in Care? Clinical Infectious Diseases, Jan 15, 2016

“Interventions that improve not just HIV screening but retention in care are needed to optimize the epidemiologic impact and cost-effectiveness.”


The Gardner Model/CDC Cascade


Retention in Care: The “Rock” beneath the Cascade


Building Blocks of PCMH


How does PCMH help Retention in Care?


PCMH Building Blocks that promote Retention in Care I. Team-based care (4)/Empanelment (3) → Team takes responsibility for identifying out-of-care patients and facilitating outreach II. Patient-team partnership (5) /Continuity of care (7) → Fostering long-term relationships between patient and provider/team to build a sense of connection to care III. Prompt access to care (8) → Patients can be seen by care team when they need to be IV. Care coordination (9) → Addressing patients’ other needs so they can focus on their health V. Data-driven improvement (2) Population management (6)/ → Using data to understand characteristics of out-of-care patients to identify opportunities for intervention; Utilize outreach measures

PCMH BUILDING BLOCKS I. Team-Based Care & Empanelment at the Chandler Ryan White Program

375 Active Patients

1.25 Medical Providers

2 Nurses (1 RN, 1LPN)

2 Case Managers (1 Medical,

1 Supportive)

Program Staff (Administrator,

Quality manager)

1 Patient Navigator

Additional Co-located Health Care Services:

Nutrition

Dental

Gynecology

Social Work/Mental Health Counseling

Phlebotomy


PCMH BUILDING BLOCKS II. Patient-Team Partnership/ Continuity of Care

0

20

40

60

80

100

120

140

160

>20 years 15-19 years 10-14 years 5-9 years <5 years

22 56 67 80

150

Current Ryan White Patients # Patients, # Years at EBCHC

0

5

10

15

20

25

Retired RN Medical CaseManager

ProgramAssistant

LPN HIV Provider

25 20

10 7 7

Staff # Years at EBCHC

PCMH BUILDING BLOCKS II.Patient-Team Partnership/Continuity of Care

EBCHC Ryan White Patients receive Primary care & HIV Care from One Provider & One Care Team


PCMH BUILDING BLOCKS III. Prompt Access to Care

Full-time Nurse Triage

Urgent Slots/ FQHC

Provider Support

Dedicated telephone

lines


PCMH BUILDING BLOCKS IV. Care Coordination (Case Management)

Housing

Food

Substance Abuse

Treatment Referrals

Mental Health

Counseling/Referrals

Legal Service

Referrals

Health Insurance/

Drug Coverage Assistance


PCMH BUILDING BLOCKS V. Data-Driven Improvement/Population Management

Case Management: Last Viral Load/ Last Medical Visit Data

Outreach

Monthly Team Meetings- Case

Conference of Patients

Navigator/Case Management Outreach: Appointment Reminder

Calls/Missed Visit Outreach

Navigator Outreach: Out-of-care >6 months

Monthly Team Review of Quality Data & PDSA Planning


EBCHC Ryan White Program Medical Visit Frequency

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

June-12 December-12 June-13 December-13 June-14 December-14 June-15 December-15 June-16

National New Jersey EBCHC


Conclusions • Interventions that improve retention in care have been proven

to reduce HIV incidence and HIV mortality in a manner that is cost-effective

• The Patient-Centered Medical Home Model can serve as a basis for interventions that facilitate retention in care

• PCMH Building Blocks that promote retention in care include: Team-Based care, Patient-Team Partnership, Prompt Access to Care, Care Coordination, and Data-Driven Improvement


Thank you Eric B. Chandler Ryan White Program Staff

Cindy Leon, MPH Betsy Melendez-Medina, Medical Case Manager Connie Robinson, LPN Jessica Ortiz, Supportive Case Manager Steven Levin, MD Aissa Oduro, MPH Michele Hawkins-Nunn, RN Kathy Sarnoski, RN (Retired RN), Joy Melendez, MSW (Former Program Coordinator)

Eric B Chandler Health Center Staff Rutgers University, Robert Wood Johnson Medical School HIV Medical Homes Resource Center (MHRC), HRSA Steve Bromer, MD

Eric B. Chandler Ryan White Program Patients

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