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“Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?”...

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“Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC
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Page 1: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

“Patient-Centered Medical Home (PCMH), What Do They Think We’ve

Be Doing All These Years?”Erik Southard DNP, FNP-BC

Page 2: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

Learning Objectives

• Understand the value of the PCMH initiative to “We the Patients”

• Review the goals of PCMH and the need for comprehensive medical care

• Define the components of the PCMH model• Establish realistic expectations and time lines

for implementation• Articulate what studies indicate the impact

PCMH will have on our system

Page 3: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

US Health Care Problems

• Fragmented• Inaccessible• Costly • Culturally ineffective

• “I got there and you know that doctor didn’t have any of my information.”

• “You know that clinic is never open when I need them.”

• “But I was just here last week.”

• “What is a Shaman anyway?”

Page 4: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

Problems Continued

• Burden is on patient and family

• Mediocre quality• Excessive use of high

cost services with marginal benefits.

• “We drove to three different pharmacies and none of them had the medication.”

• “I waited 45 minutes and she only spent five minutes with me.”

• “I’ve had laser treatment twice for my nail fungus and it came back.”

Page 5: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

National Health Expenditures 2010

• Hospital and physician/clinical services account for 51% of the $2.3 Trillion.

• Technology and prescription drug use.

• Rise in chronic diseases (75%).

Sources: 1Martin A.B. et al., “Growth In US Health Spending Remained Slow in 2010; Health Share of Gross Domestic Product Was Unchanged from 2009 ,”

Health Affairs, 20122Centers for Disease Control and Prevention. Rising Health Care Costs Are Unsustainable. April 2011.

Page 6: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

“What do they think we have been doing…..?”

• Medical home.• Term originated in 1967.• Care coordination dates back 1859.

Page 7: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

Current PCMH Status

• State Participation • National Participation

Page 8: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

PCMH Core Primary Care Goals

• Access• Patient Centered• Comprehensiveness• Coordination• Systems based approach to quality and safety

Page 9: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

Team Approach to Care

• Team members• Virtual team members

Page 10: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

Becoming a PCMH

• Human Capital • Dollars and sense’• Process

Page 11: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

Human Capital/PCMH Implementation

• Cultural Changes– Organized around the patient not the practice– Team based versus classic hierarchy approach– Change in patient habits– Work flow and system changes– Staff function at highest level – Removal of volume driven practice ideology– Significant human capital expense

Page 12: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

Dollars and Sense’

• Incremental cost estimates for the patient centered medical home

• Statistically significant increase in cost for information technology (IT) expenses2

• Average practice spent $8,000 in IT per FTE physician/provider

• There was not a statistically significant increase in any other cost component

4 S. Zuckerman, K. Merrell, R. Berenson et al., Incremental Cost Estimates for the Patient-Centered Medical Home, The Commonwealth Fund, October 2009.

Page 13: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

Process

• Appoint PCMH Director and send to training• After training director should:– Order the PCMH standards and guidelines (free)– Complete self-assessment – Meet with management and strategically select team

• Determine potential fee sponsors• Order online application and ISS survey tool*• Launch Online Application and Self Assess• Respond to Elements & attach documentation

Page 14: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

Time Frame to PCMH

• Short process, challenging endeavor• Change management • Two to three year process*• Some will never transform their practice to

PCMH level 3• Some will reach PCMH level 3 but will never

transform their practice

Page 15: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

Team Member Roles

• Director-coordinate and direct all PCMH activities• Primary Care Physician– Team Leader– Removed from volume driven practice

• NPs/PAs– Team leaders, health coaches, expanded practice roles

• Administrators– Facilitators for acquiring recognition and increased

payment

Page 16: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

Proposed Payment Model

• The American College of Physicians is advocating for a three part payment model.– A care coordination payment– Fee-for-service payment– Performance based component3

5 American College of Physicians. A System in Need of Change: Restructuring PaymentPolicies to Support Patient-Centered Care. Philadelphia: American College of Physicians;2006: Position Paper. (Available from American College of Physicians, 190 N. IndependenceMall West, Philadelphia, PA 19106.)

Page 17: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

Evidence-Based Movement

• Evidence on PCMH Effectiveness– Quality of Care– Cost of Care– Experience of Care

Page 18: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

Improving the Quality of Care

• Processes of Care– Lack of rigorous Studies– Three evaluations with rigorous methodology– Only one with favorable effects

• Health Outcomes– Only three evaluations with rigorous evidence– Two of those three found favor

• Mortality– Inconclusive but optimistic

Page 19: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

Costs of Care• Costs (Including the Intervention)– Four Rigorous Evaluations– Limited to high-risk subgroups– Mixed reviews

• Hospital Use– Five Rigorous Evaluations– One out of five indicated 18% reduction across risk

groups• Emergency Department Use– Three Rigorous Evaluations– One of three finding favorable effects

Page 20: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

The Experience of Care

• Patient and Caregiver Experience– Only three rigorous studies– Two with mostly favorable outcomes

• Healthcare Professional Experience– One lone evaluation with adequate rigor– Results were inconclusive

Page 21: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

Summative Review

• A guide to the medical home as a practice-level intervention6

6 Friedberg MW, Lai DJ, Hussey PS, Schneider EC. A guide to the medical home as a practice level intervention, Am J Manag Care. 2009; 15(10)(supl):S291-299.

Page 22: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

To PCMH or Not To PCMH

• Evidence with scientific rigor is scant.• Current evidence in favor of the medical home

is lacking.• More work to be completed, well

implemented and well conducted studies are needed.

• The cutting edge…..

Page 23: “Patient-Centered Medical Home (PCMH), What Do They Think We’ve Be Doing All These Years?” Erik Southard DNP, FNP-BC.

Closing RemarksPatient-centered medical home characteristics and staff morale in safety net clinics 6

6 Lewis, SE, Nocon, RS, Tang, H, Park, SY, Vable, AM, MV, Casalino, LP, Huang, ES, Quinn, MT, Burnet, DL, Summerfelt, WT, Birnberg, JM, Chin, MH. Patient-Centered Medical Home Characteristics and Staff Morale in Safety Net Clinics. Archives of Internal Medicine. 2012; 172(1)p23-31.


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