PCMH Strategies Implementation and Sustainability 12/17/2013 Joseph K. Weidner, Jr. MD FAAFP Why is this needed? Defining a PCMH Improving Costs Better Provision of Care Improved Population Health PCMH functions: Care Management Care Coordination Care Transitions – tasks Different types of Care Coordinators Care Coordination Tasks At Stone Run Care Managers Consumer Reports take on PCMH How Stone Run got started Resources needed in addition to a Care Manager/Coordinator Personnel Health IT Stone Run Opportunities for Improved Patient Care: Implementation of Youscripts pharmocogenetic testing with patient reminders; Health Mirror providing targeted patient education in the exam room; Application of prompts to prescribe regular azithromycin for COPD patients in order to reduce exacerbations Trinity Clinic – details of another’s experience Income and Expenses of a PCMH Next Steps for implementation of a PCMH Addressing Social barriers helps improve medical care
Transcript
PCMH Strategies Implementation and Sustainability 12/17/2013
Joseph K. Weidner, Jr. MD FAAFP
Why is this needed?
Defining a PCMH
Improving Costs
Better Provision of Care
Improved Population Health
PCMH functions:
Care Management
Care Coordination
Care Transitions – tasks
Different types of Care Coordinators
Care Coordination Tasks
At Stone Run
Care Managers
Consumer Reports take on PCMH
How Stone Run got started
Resources needed in addition to a Care Manager/Coordinator
Personnel
Health IT
Stone Run Opportunities for Improved Patient Care: Implementation of Youscripts
pharmocogenetic testing with patient reminders; Health Mirror providing targeted patient
education in the exam room; Application of prompts to prescribe regular azithromycin for
COPD patients in order to reduce exacerbations
Trinity Clinic – details of another’s experience
Income and Expenses of a PCMH
Next Steps for implementation of a PCMH
Addressing Social barriers helps improve medical care
PCMH Strategies for Implementation
and Sustainability
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Triple Aim
• Reduce Cost
• Better Provision of Care
• Better Population Health
2
Triple Aim –
Costs Need to be reduced
USA – among 34 OECD countries
Highest (#1) in healthcare spending
16% of GDP (Average 9% of GDP) in 2005
Lowest in key health indicators
25th life expectancy
29th in infant mortality
24th in maternal mortality
3
PCMH
Patient Centered Medical Home
A way of organizing primary care that emphasizes
care coordination and communication to
transform primary care into "what patients want it
to be.“
4
PCMH
Patient Centered Medical Home
Provide higher quality
Lower costs
Improve patients’ experience of care
Providers’ experience of care.
5
PCMH: How does this save money?
Reduced utilization of high cost centers (ie,
Emergency rooms, inpatient hospital stays,
expensive testing.)
Reduce risk of “preventable” diseases
Reduce complications from chronic diseases
Have everyone work to the top of their
license
Offload from physicians work that doesn’t
require a medical degree
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Reduce Costs
• Reduce Hospital admissions
• Reduce ER Evaluations
• Reduce costly tests
• Reduce unnecessary care
7
Better Provision of Care
• Reduce Barriers to Care
• Improve Accessibility
• Improve Patient Satisfaction
• Improve Clinical Outcomes
8
Improved Population Health
• Increase rate of Preventive
Medicine testing
• Engage unengaged patients
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Better Provision of Care
Barriers to Care
Education Language
Financial Transportation
Side Effects Competing authority
Disability Cognitive deficits
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The patient is
not compliant
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THAT’S NOT
GOOD ENOUGH!
13 The patient is
not compliant
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Patient Centered Medical Home Demystified
PCMH is nothing less than an extreme make-
over for primary care practices, to make
them:
More Service Oriented for patients
More Efficient for better profit
More Effective for patient outcomes
More Fun to go to work for all
15
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Patient Centered Medical Home Demystified
Goal Driven Transition :
Improved Service Oriented for patients
More Efficient better profit, new payment
models and new expenses
More Effective for patient outcomes,
improving measurement of outcomes,
transmission of medical information
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Three Important Functions For
PCMH
Care management
Proactively managing the patient’s condition and/or preventive
services using EBM guidelines, registries and a team approach
Care coordination
Tracking and facilitating the patient’s interaction with all points of
care outside the PCMH
Care transitions
Safe and effective transfer of support and responsibility as patients
move from hospital to home or long term care (Bi-directional)
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Three Important Functions For
PCMH in SRFM
Care management
Reports on three chronic conditions;
Identify areas for improvement
Reminders to bring meds to appointments,
lab work before visit
Group diabetic classes
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Three Important Functions For
PCMH in SRFM
Care coordination
Post admission and post ER follow-up,
scheduling visits,
Calling in medicines
Assistance with scheduling appointments
Follow-up when haven’t been seen, need
med refill
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Three Important Functions For
PCMH in SRFM
Care transitions
CRISP notifications
Medication reconciliation, bring in meds for
visit,
Facilitate timely rehab and psych
evaluation
Point of Care referrals
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Care Transition Tasks
Clarify modifications in care plan
Reconcile medications with pre-hospital
orders and supplies at home
Understand level of help and support needed
from others and arrange for needed services
Solid transfer of responsibility
Re-integrate patient into community of care
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Care Transition Tasks at Stone Run
Clarify modifications in care plan– imbedded within
patient notes; localize the plan according to the EMR
capabilities
Reconcile medications with pre-hospital orders and
supplies at home. Utilizes outpatient record.
Physicians also do this – may be better at this.
Understand level of help and support needed and
available; arrange for needed services.
“Solid” transfer of responsibility
Re-integrate patient into community of care. Identify
resources. On site evaluation within 7 days.
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Transitions Of Care – by telephone
Hand-off
• Care plan
• Medication Reconciliation
• Clinical Info
• Pending issues
Connect
• Timely Access
• Coordinate Care
• Follow up on pending issues
• Utilize claims data
• Coordinate population health
• ? access to EMR
Accept
• Capable
• Team Approach
• Engages Care-givers
• Whole person orientation
Hospital Telephone
Coordinator Primary Care
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Transitions Of Care at Point of Care
Hand-off
•Care plan
•Medication Reconciliation
•Clinical Info
•Pending issues
Connect
• Timely Access
• Point of Care Coordination
• Use internal EMR
• Shortened Provider Communication Loop
• Tied to one practice location: Familiarity
Accept
•Capable
•Team Approach
•Engages Care-givers
•Whole person orientation
Hospital Point of Care
Coordinator Primary Care
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Transitions Of Care – Geographically
imbedded
Hand-off
• Care plan
• Medication Reconciliation
• Clinical Info
• Pending issues
Connect
• Coordinate Care for multiple practices
• One person for a few practices
• Not as Timely Access
Accept
• Capable
• Team Approach
• Engages Care-givers
• Whole person orientation
Hospital
Geographic
Care
Coordinator Primary Care
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Care Coordination Tasks
Share the care plan and clinical information
Arrange appointments if patient not able
Track referrals, labs and consultations
Follow up on reports and recommendations
Engage family and care givers
Set up service agreements
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Care Coordination Tasks at SRFM
Share the care plan and clinical information – develop in patient chart in reason for visit (subjective); we do not use a separate registry
Arrange appointments if patient not able – only if necessary
Track referrals, labs and consultations – based on EMR generated reports, we need better return correspondence from specialists to reconcile referrals; better systems
Follow up on reports and recommendations – insurer reports, if accurate;
Engage family and care givers – this we excel at; better
Set up service agreements – not yet, but perhaps a good idea with urgent care units,
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Care Coordination Tasks for
Northern Maryland ACO
Enrollment of Medicare patients
Promote Medicare Preventive Physicals
Health Assessment mailed to every patient
Trouble and Questions with Split authority
“Dueling” Care Coordination
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Allscripts Pro 13.0 update
Care Plans and Goals:
Build care plans,
Set goals,
Track patient progress
Identify barriers through the core EHR solution.
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How Care managers spend their
time at SRFM?
86 care plans per month or 4-5 per day
Average of 26 hours per week accounted for
Pre-visit planning
Transition Care management
Provider directed care management
Home visits, transport of patients, phlebotomy
Follow-up of chronic disease reports
Population Health Management is minimal
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Critical Elements For PCMH
True team approach to care
Quality measures and a culture of improvement
Patient and family engagement with patient self-
management support
Care management and care coordination
IT enabled for the core business, clinical and
communication functions
34
Team-based care
Focus on the top of license, training and interest
Improved communication – more of a challenge for large practices
Tracking emergency department users across unaffiliated hospitals with a health information exchange can help better identify frequent ED users, potentially allowing for interventions such as improved case management to better allocate healthcare resources, according to a study in Health Affairs.
Researchers used the New York Clinical Health Information Exchange to identify patients who had visited the emergency departments of 10 hospitals in the New York City area more than four times in one month.
Results showed the HIE data identified 20.3 percent more ED "frequent fliers" than site-specific data. Additionally, researchers discovered frequent ED users are more likely than other patients to visit multiple EDs over the 12-month study period (28.8 percent versus 3 percent), emphasizing that better care coordination across facilities and better case management has the ability to reduce ED usage and better utilize ED resources.
For patients that have two or more conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; 20 minutes or more; per 30 days.”
CMS finalized the scope of CCM services to include:
24-hour- a-day, 7-day- a-week access to address a patient’s acute chronic care needs.
Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.
Requires care management , including management or care transitions, development of a care plan, coordination of care and communication with patient.
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Primary Care conversion to PCMH -
expense
LPN average salary - $40734 annually (www.salary.com Rising Sun, MD)
IT/Reporting specialist - $30000 annually
NCQA certification - $2280 every three years
Cost $71494 per year plus benefits
Does not count employee benefits, physician work, facilities, utilities,
