Built to Last: The Successful Patient Centered Medical-Home (PCMH) Team

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

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Successful PCMH Team: What Constitutes Care Coordination in a Pediatric Medical Home?


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”

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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.

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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%

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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.

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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

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Successful PCMH Team: The Patient / Family as Team Members


A Structured Approach to Relationship-Centered Care

• Build Relationships / Serve

• Collaborate• Educate• Negotiate

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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

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• 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


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


Action Plans Fuel Motivation

• Action plans are developed by patients - not providers.

• The action plans build confidence that fuels internal motivation.

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Relationship-Centered Care

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• 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


MammoMammo

SSCCRRIIPPTTSS

Nurse-MD Team

LL

AA

BB

OORRDDEERRSS

JunJun

HTN HTN DM 2 DM 2 DepressionDepression

LL

AA

BB

OORRDDEERRSS


FBS, A1cFBS, A1c

LipidsLipids

Integrated, Continuous care



MarMar

Rapid Rapid AccessAccess

LBPLBP

AprApr

Rapid Rapid Access Access

Pneumonia Pneumonia

AugAug

A1c 6.8A1c 6.8LDL 145LDL 145




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


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.

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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



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

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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

Documents

Built to Last: The Successful Patient Centered Medical-Home (PCMH) Team