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Built to Last: The Successful Patient Centered Medical-Home (PCMH) Team PCPCC Stakeholders’ Working Meeting April 28, 2009. Guy Mansueto, VP, Phytel Moderator. Our Panelists. Richard C. Antonelli, M.D., M.S., FAAP Medical Director, Integrated Care Organization, - PowerPoint PPT Presentation
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Built to Last: The Successful Patient Centered Medical-Home (PCMH) TeamPCPCC Stakeholders’ Working Meeting
April 28, 2009
Guy Mansueto, VP, PhytelModerator
Our Panelists
Richard C. Antonelli, M.D., M.S., FAAPMedical Director, Integrated Care Organization, Children's Hospital Boston/ Harvard Medical School
Suzanne Mitchell, M.D. M.Sc.Faculty, Boston University School of Medicine
Christine Sinsky, M.D.Medical Associates Clinic, Dubuque, Iowa
Linda Strand, Pharm.D., Ph.D., D.Sc.(Hon)Distinguished Professor, College of Pharmacy, University of Minnesota
2
Successful PCMH Team: What Constitutes Care Coordination in a Pediatric Medical Home?
Richard C. Antonelli, M.D., M.S., FAAPMedical Director, Integrated Care Organization, Children's Hospital Boston/ Harvard Medical School
Challenges to Implementing Family-Centered Medical Home
• TIME, TIME, TIME • Lack of organized systems of care with defined
roles• Inadequately developed family/patient -
professional partnerships• Knowledge
– Care pathways – how to change
• Lack of Care Coordination function• Lack of awareness of community resources and
programs• “Reimbursement”
4
Defining Care Coordination
Pediatric care coordination is a patient- and family-centered, assessment-driven, team-based activity designed to meet the needs of children and youth while enhancing the care giving capabilities of families. Care coordination addresses interrelated medical, social, developmental, behavioral, educational, and financial needs in order to achieve optimal health and wellness outcomes.
5
Source:MAKING CARE COORDINATION A CRITICAL COMPONENT OF THE PEDIATRIC HEALTH SYSTEM: A MULTIDISCIPLINARY FRAMEWORKRichard C. Antonelli, Jeanne W. McAllister, and Jill PoppThe Commonwealth Fund, April 2009
Family-centered and Community-based
Proactive, Providing Planned, Comprehensive Care
Promotes the Development of Self Management Skills (Care Partnership Support) with Children, Youth and Families
Facilitates cross-organizational linkages and relationships
Components of Care Coordination
Source:MAKING CARE COORDINATION A CRITICAL COMPONENT OF THE PEDIATRIC HEALTH SYSTEM: A MULTIDISCIPLINARY FRAMEWORKRichard C. Antonelli, Jeanne W. McAllister, and Jill PoppThe Commonwealth Fund, April 2009
• Provides separate visits and care coordination interactions • Manages continuous communications • Completes/analyzes assessments• Develops care plans with families• Manages/tracks tests, referrals, and outcomes• Coaches patients/families • Integrates critical care information • Supports/facilitates care transitions• Facilitates team meetings• Uses health information technology
Care Coordination Functions
Focus of Encounter
Primary Focus % Encounters
Clinical / Medical Management 67%
Referral Management 13%
Social Services (ie. Housing, food, clothing…) 7%
Educational / School 4%
Developmental / Behavioral 3%
Mental Health 3%
Growth / Nutrition 2%
Legal / Judicial 1%
8
Source:National Study of Care Coordination Measurement in Medical HomesAntonelli, Stille, and Antonelli, 2008
Prevented Outcome
The CCMT allows only one outcome prevented per encounter. 32% of total 3855 CC encounters prevented something. Of the 1232 CC Encounters where prevention was noted as an outcome: Outcome Prevented # CC Encounters Percentage
Visit to Pediatric Office / Clinic 714 58%
Emergency Department Visit 323 26%
Subspecialist Visit 124 10%
Hospitalization 47 4%
Lab / X-Ray 16 1%
Specialized Therapies 8 1%
62% of RN CC Encounters prevented something.33% of MD CC Encounters prevented something.
RNs are responsible for coding 81% of the Emergency Department preventions and 63% of the sick office visit preventions.
9
Implications for Policy and Practice
• Re-examine the traditional, office-based interaction• Service unit for primary care in PCMH must include CC• Service unit must value non-face-to-face care provided
by non-MD staff supporting care coordination • Use Care Plans to drive (and to monitor) care provision• All PCMH team members function at “the top of their
license”• Multiplicity of demands for CC demands participation by
integrated team: MD, NP/PA, RN, LPN, MA, pharmacy, community partners (eg, dental,mental;education)
• All aspects of system performance transparent to families and payers/ purchasers
10
Successful PCMH Team: The Patient / Family as Team Members
Suzanne Mitchell, M.D. M.Sc.Faculty, Boston University School of Medicine
A Structured Approach to Relationship-Centered Care
• Build Relationships / Serve
• Collaborate• Educate• Negotiate
12
Rapport-building Skills
1. Mindfulness
2. Reflection
3. Transparency
4. Goal alignment
5. Express Empathy
Negotiate Plan
Collaborative AgendaSetting
Tools•LEARN/MI
•Patient Activation•Self-Management
Ed
Provider Inquiry:Interview,Physical exam, Tests,DiagnosisTreatment Plan
Adapted from:Mauksch LB et al, Relationship, Communication and Efficiency in the Medical Encounter, Arch Intern Med, 168(13): July 14, 2008
Tools and Techniques
14
• Collaborative Agenda Setting
• LEARN Interview Model– Active Listening Skills– Eliciting the Explanatory Models– Motivational Interviewing
• Self-Management Ed.
What do you think caused
this problem?
What do you think caused
this problem?
Listen(Reflection)
Elicit/Explain
What do you think will make you better?
What do you think will make you better?
AcknowledgeAnd Ask
Recommend Negotiate
I would like to
show you this chart
of your HbA1c. Is that OK?
I would like to
show you this chart
of your HbA1c. Is that OK? We seem to
see things differently in this situation. What would you do if you were in my
shoes?
We seem to see things
differently in this situation. What would you do if you were in my
shoes?
What would
you like to
work on to
lower your
blood sugar?
How could you
imagine doing
that?
What would
you like to
work on to
lower your
blood sugar?
How could you
imagine doing
that?
Let’s do a reality Check.
How important is this to you?
How confident are you?
Tools and Techniques:
The L-E-A-R-N Model
Tools and Techniques:
Self-Management Education
• Patients identify their problems
• Problem-solving skills
• Decision-Making Techniques
• Builds and Relies on Self-Efficacy
• Addresses:– Communication Skills, – LifeStyle Changes, – Medication Adherence, – Mood Challenges, – Assessing New Treatments
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Source:Bodenheimer et al JAMA November 20, 2002—Vol 288, No. 19
Tools and Techniques:
Action Plans Fuel Motivation
• Action plans are developed by patients - not providers.
• The action plans build confidence that fuels internal motivation.
17
Relationship-Centered Care
18
• Reduces Patient Anxiety
• Promotes Patient-centered Treatment Goals
• Enhances Self-Efficacy
• Optimizes Use of Resources
• Improves Quality of Care
• Restores Provider Commitment and Prevents Burn-out
Successful PCMH Team: Nurse-PhysicianPartnerships
Christine A. Sinsky, MDMedical Associates Clinic and Health Plans
Patient Centered Patient Centered Medical HomeMedical Home
Integrated, Continuous Care
Office VisitOffice Visit
Between Between Visit CareVisit Care
Efficiencies and care coordination
Nurse-MD Team
Build-inrather than Carve-out
1.5 nurses: MD
Between Visit
•Extension of me when dealing with patients; patients recognize this.
•Coordinates transitions (hospital, NH, Hospice)
•Manages & returns most phone calls
•Does prescriptions
•Updates EHR
•Completes all paperwork
Visit
•Med. Reconciliation
•Initial review of lab
•Patient education
•Immunizations
•Colonoscopy
•Sx driven tests (PFT, EKG)
•Diabetic foot exam/eye exam
•Present patient(↓ info drop-off)
THE BOSS: Nexus of organization of our practice
Core Team: Mini-huddle
• 47 yo “Rapid Access” new patientCC: dysphagia
• Nurse Mini-huddle– “She seems
depressed”– “Is anyone hurting
you?”
• Physician better prepared
Nurse-MD Team
HTN HTN CholChol GlucoseGlucoseOsteoporosisOsteoporosisDepressionDepression
LL
AA
BB
OORRDDEERRSS
Planned CarePlanned Care
Same Day Same Day Surgery ApptSurgery Appt
Integrated, Continuous Care
LDL 75, LDL 75, A1c 6.2A1c 6.2
LabLabMammoMammo
SeptSept
PreventionPrevention
HTN HTN CholChol GlucoseGlucoseOsteoporosisOsteoporosisDepressionDepressionLipids,FBSLipids,FBSCr, K, MamCr, K, Mam
LL
AA
BB
OORRDDEERRSS
ComprehensiveComprehensive
MarMar
Efficiencies and care coordination
MammoMammo
SSCCRRIIPPTTSS
Nurse-MD Team
LL
AA
BB
OORRDDEERRSS
JunJun
HTN HTN DM 2 DM 2 DepressionDepression
LL
AA
BB
OORRDDEERRSS
Planned CarePlanned Care
FBS, A1cFBS, A1c
LipidsLipids
Integrated, Continuous care
HTN HTN DM 2 DM 2 DepressionDepression
Planned CarePlanned Care
MarMar
Rapid Rapid AccessAccess
LBPLBP
AprApr
Rapid Rapid Access Access
Pneumonia Pneumonia
AugAug
A1c 6.8A1c 6.8LDL 145LDL 145
Efficiencies and care coordination
HTN HTN DM 2 DM 2 DepressionDepression
Planned CarePlanned Care
SeptSept
FBS, A1cFBS, A1c
LL
AA
BB
OORRDDEERRSSCXRCXR
CHF CHF Education/Education/
Clinic Clinic
Diabetic Diabetic Education Education
Home Care Home Care
Family Family
INRINR
INRINR
INRINR
INRINR INRINR
INRINR
INRINR
INRINR
INRINR
INRINR
INRINR
INRINR
Hospital Hospital CHF CHF
NovNov
PreventionPrevention
HTN HTN DM 2 DM 2 DepressionDepression
LL
AA
BB
OORRDDEERRSS
ComprehensiveComprehensive
FBS, A1c, FBS, A1c, lipids, alb,lipids, alb,mammomammo
DecDecSSCCRRIIPPTTSS
Architecture Architecture Of Of
Care Care
At the center of the PCMH are face-to-face healing relationships.
26
Patient: NursePatient: Nurse Nurse: PhysicianNurse: Physician
Nurse: NurseNurse: Nurse Patient: PhysicianPatient: Physician
Successful PCMH Team: Medication Management in Medical Home
Linda M. Strand, Pharm.D., Ph.D., D.Sc.(Hon)Distinguished Professor, College of Pharmacy University of MinnesotaAnd Consultant, Medication Management Systems, Inc. Discloser: Founding Member of the Board of Directors Medication Management Systems, Inc
Dispensing
Clinical pharmacist
Medication therapy management
Roles of the Pharmacist
1. APhA Consensus Statement
2. American Medical Association
3. Minnesota Legislation for Minnesota Medicaid
Definitions of Medication Therapy Management
1. Patient specific
2. Involves an assessment of drug-related needs, care plan to resolve drug therapy problems and follow-up to determine actual impact
3. Comprehensive
4. Coordinated with other team members
5. Adds unique value to care
Medication Management in Medical Home
Clinic Practices
Telephonic services
Retail Settings
Practice Settings for Medication Management
Reveal the patient’s medication experience
Identify drug therapy problems of appropriateness, effectiveness, safety, and compliance with medications
Establish personalized goals of therapy
Resolve drug therapy problems
Personalize Interventions
Evaluate Effectiveness and Safety
Determine Actual Patient Outcomes
ASSESSMENT CARE PLAN
FOLLOW-UP
MedicationTherapy
Management
The Pharmacist in Medical Home
Panelist Q&A
Richard C. Antonelli, M.D., M.S., FAAPMedical Director, Integrated Care Organization, Children's Hospital Boston/ Harvard Medical School
Suzanne Mitchell, M.D. M.Sc.Faculty, Boston University School of Medicine
Christine Sinsky, M.D.Medical Associates Clinic, Dubuque, Iowa
Linda Strand, Pharm.D., Ph.D., D.Sc.(Hon)Distinguished Professor, College of Pharmacy, University of Minnesota
33
Thank You!
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References: Care Coordination
• McPherson, M., Arango, P., Fox, H., et al. (1998). A new definition of children with special health care needs. Pediatrics, 102,137–140
• Porter, M. and Teisberg, E., Redefining Health Care: Creating Value-Based Competition on Results. Harvard Business School Press, 2006.
• Antonelli, R, McAllister, J, and Popp, J. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework, April, 2009, The Commonwealth Fund.
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References: Care Coordination (cont.)
• Antonelli, R. and Antonelli, D., Providing a Medical Home:The Cost of Care Coordination Services in a Community-Based, General Pediatric Practice, Pediatrics, Supplement, May, 2004.
• Antonelli, R., Stille, C. and Freeman, L., Enhancing Collaboration Between Primary and Subspecialty Care Providers for CYSHCN, Georgetown Univ. Center for Child and Human Development, 2005
• Antonelli, RC, Stille, C, and Antonelli, DM, Care coordination for children and youth with special health care needs: A descriptive, multisite study of activities, personnel costs, and outcomes. Pediatrics. 2008 Jul;122(1):e209-16.
• Turchi, R, Gatto, M, and Antonelli, R, Children and Youth with Special Health Care Needs: There is No Place Like (a Medical) Home, Curr Opin Pediatr 2007, 19: 503.
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Links to Resources: Relationship-Centered Care
• Stanford Self-Management Education Program http://patienteducation.stanford.edu/programs/cdsmp.html
• http://motivationalinterview.org • Kleinman A, Eisenberg L, Good B. Culture,
illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88(2):251-258
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1.Kuo GM et.al. Collaborative drug therapy management services and reimbursement in a family medicine clinic. Am J Health-Syst Pharm. 2004;61:343-54.2.Nkansah NT et.al. Clinical outcomes of patients with diabetes mellitus receiving medication management by pharmacists in an urban private physician practice. Am J Health-Syst Pharm. 2008;65:145-9. 3.Isetts, et.al. Clinical and economic outcomes of medication therapy management services: The Minnesota Experience. J Am Pharm Assoc 2008;48:203-211.4.Isetts, et.al. Quality assessment of a collaborative approach. Arch Int Med 2003;163:1813-20.
Links to Resources: Medication Management in Medical Home
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