Patient Centered Medical Home Recognition Process: An Introduction and Overview

Vicki Young, PhD Janet Viars, RN, MPH

Goals - Today participants will:

Understand how PCMH is consistent with the Missions of CHCs Become familiar with the framework for PCMH Become familiar with PCMH standards and scoring Understand rationale for seeking PCMH recognition Recognize how PCMH connects to other initiatives

What is a PCMH?

A PCMH puts patients at the center of the health care system, and provides primary care that is accessible, continuous, comprehensive , family-centered, coordinated, compassionate, and culturally effective.

(American Academy of Pediatrics)

Nothing about me without me

PCMH and the Mission of Community Health Centers

We believe our community is best served by doing more than just treating illness. Our holistic approach to health care includes prevention, early screening, counseling and education as well. (Our) Community Health Center promises you affordable, convenient, individualized health care provided by a qualified and caring staff. We use our talents and resources to see you through a lifetime of health care.

PCMH and the Mission of CHCs

Our CHC is Committed To: Being the health care provider of choice for people of all ages Providing high-quality care in a patient focused manner Equipping our patients with the knowledge, ability, and motivation to make healthy choices and live healthy lives Eliminating the barriers caused by financial circumstances or social situations that may prevent people from having access to health care Continually improving the quality of care and service we provide.

PCMH and the Mission of CHCs

The mission of (Our Community Health Center)

is to provide comprehensive, high quality compassionate medical care in the spirit of the Good Samaritan. The Center is a federally qualified, community-based, comprehensive medical safety net that provides access to primary healthcare services for a traditionally underserved population.

Framework for PCMH

PCMH A Historical Perspective

American Academy of Pediatrics- late 1960s Institute of Medicine- late 1990s and early 2000 Various demonstration projects- from early 2000 to date National Committee on Quality Assurance (NCQA) Recognition - 2007 Physician Practice Connections- Patient Centered Medical Home Development of Joint Principles- AAP, AAFP, ACP, AOA- 2007

Joint Principles of the PCMH

Personal Physician Physician Directed Medical Practice Whole Person Orientation Care is Coordinated and Integrated Quality and Safety are Hallmarks Enhanced Access Payment Reform

NCQA PCMH 2011 What is New?

Robust patient centeredness Strong focus on integrating behavioral health and care management Patient survey results drive quality improvement Patients and families involved in quality improvement.

PCMH -Theoretical Frameworks

Chronic Care Model Clinical information systems; decision support; patient selfmanagement; delivery system redesign; community linkages; health systems Patient Centered Care Respect patient values; accessible; family-centered; continuous; coordinated; community linkages; compassionate; culturally appropriate; emotional support; information and education; physical comfort; quality improvement Cultural Competence Culturally competent interactions; language services; reducing disparities Medical Home Personal physician; physician directed team; whole person orientation; care is coordinated and integrated; quality and safety; enhanced access

NCQA PCMH Recognition Standards and Scoring

NCQA and the PCMH

NCQA developed a set of standards and a 3-tiered recognition process. Patient-Centered Medical Home 2011 assess the extent to which health care organizations are functioning as medical home Obtaining recognition via the PPC-PCMH programs requires completing an application and providing adequate documentation to show evidence that specific processes and policies are in place Recognition is offered at three levels: Level 1 Basic Level 2 Intermediate Level 3 Advanced

NCQA PCMH 2011:The Standards

Six standards align with core components of primary care. PCMH 1: Enhance Access and Continuity PCMH 2: Identify and Manage Patient Populations PCMH 3: Plan and Manage Care PCMH 4: Provide Self-Care and Community Support PCMH 5: Track and Coordinate Care PCMH 6: Measure and Improve Performance

NCQA PCMH Must Pass

PCMH 1, Element A: Access During Office Hours

PCMH 2, Element D: Use Data for Population Management PCMH 3, Element C: Care Management PCMH 4, Element A: Support Self-Care Process PCMH 5, Element B: Track Referrals and Follow-Up PCMH 6, Element C: Implement Continuous Quality Improvement

NCQA PCMH Scoring

Level 1: 3559 points and all 6 mustpass elements Level 2: 5084 points and all 6 mustpass elements Level 3: 85100 points and all 6 must-pass elements

Building Blocks

Level 3 Level 2

Level 1

Building Blocks of a PCMH

Personal physician
Each patient has a personal physician who provides first-contact, continuous, and comprehensive care.

Team practice
Personal physician leads a team of individuals at the practice level for ongoing care and prevention.

Building Blocks of a PCMH

Coordinated care
Care is coordinated across medical subspecialties, hospitals, home health agencies, and nursing homes Care is coordinated with the patient, the patients family, and public and private community-based services.

Building Blocks of a PCMH

Health IT
Care is facilitated by electronic health records and other information technologies. Analytical tools and patient tracking allow for clinical monitoring, specialist follow-up, population-based decision making, and predictive modeling.

Building Blocks of a PCMH

Expanded access to practitioners
Open scheduling and after-hours access to personal physicians After-hours access to personal physician and staff by telephone and through secure e-mail.

Building Blocks of a PCMH

Payment Reform
Targeted financial incentives reward physicians and providers for supporting medical home features, including additional payments for achieving cost savings and measureable and continuous quality improvement

Rationale

Rationale for Obtaining PCMH Recognition

Address the Burden of Chronic Disease
50% of Americans live with one or more chronic conditions and only 54% of chronically ill adult patients receive recommended care Over 60% of patients are non-compliant Experts estimate 20-50% of U.S. health care spending produces no benefit to patients and potential harm Health costs in the United States are growing faster than employee wages and the economy at large.

Rationale for Obtaining PCMH Recognition

Blueprint for transforming health care delivery Allows CHCs to assess strengths and achievements Allows CHCs to recognize areas for improvement

q Rationale for Obtaining PCMH Recognition Address High Health Care Costs

P4P C Meaningful Use H D S

PCMH as the Key

Access and Continuity Manage Patient Populations Plan and Manage Care Self-Care and Community Support Track and Coordinate Care Measure and Improve Performance

Becoming leaders in Health Quality M/U HITECH Incentives UDS P4P ACO

PCMH and UDS

UDS and PCMH
Identify and track patient populations Collect and report demographics Identify patients with specific conditions Identify patients for proactive reminders (preventive or follow-up care).

Recommendations of Special Commission on the Health Care Payment System

Development of Accountable Care Organizations (ACOs) composed of hospitals, CHCs, physicians and/or other providers that accept responsibility for all of most of the care that enrollees need Patient-Centered Medicaid Home (PCMH) ACOs to undergo the necessary practice redesign to become effective PCMHs Patients selection of a primary care provider will direct insurer payments to the ACO with which the patients primary care physician is affiliated

Recommendations of Special Commission on the Health Care Payment System Use of Pay-For-Performance (P4P) incentives to ensure appropriate access to care, and encourage quality improvement and care coordination among providers Global payments will be adjusted to reflect patient demographics and health conditions

Potential Reimbursement for PCMH

Private Insurance
Blue Cross/Blue Shield SC PCMH initiative

Medicare
Demonstration pilots

Medicaid
Managed care reimbursement based on performance and outcomes

PCMH: Return on Investment

Improvement in quality and equity Improved patient satisfaction/compliance Provider /staff satisfaction Helps attract new business Recognized leader among peers Eligibility for P4P

PCMH Building Blocks

Patient Experience PCMH

Quality

Practice Organization

Health Information Technology

Community Health Centers

Transformation to a Medical Home

PCMH

Quality

Patient Experience

Practice Organization Information Technology Health

Community Health Centers

Adapted from American Academy of Family Practice PCMH web page

Next Steps
Webinar Series Presentation to Board of Directors, CHC Management and Others Pre-conference for Medical Directors at June 2011 Clinical Network Retreat CHCs conduct self-assessment Identify cohort of CHCs ready to move forward Utilize a collaborative model for training Participate in the HRSA Bureau of Primary Health Care PCMH Initiative

Are you ready?

Are you able to pull together a team of 4-5 staff including management, a provider, other clinical team member, an administrative staff member and others appropriate for your CHC? Do you have electronic health records? Do you have support from the top down and the bottom up willing to work to meet the standards?