How to Apply Patient Centered Medical Home Concepts

August 2, 2012

Nina Brown - Public Health Analyst, HRSA/BPHC/OQDCandi Chitty - Consultant, MSCG

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Learning Objectives

By the end of this session participants will be able to:• Assess a grantee’s readiness for PCMH transformation;• Identify gaps that need to be addressed, in the context of

the core program requirements;• Explain and encourage PCMH transformation during site

visits.

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Primary Health Care Mission

Improve the health of the Nation’s underserved communities and vulnerable populations by assuring access to comprehensive, culturally competent, quality primary health care services

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BPHC Quality Strategy

1. Implementation of QA/QI SystemsAll Health Centers fully implement their QA/QI plans

2. Adoption and Meaningful Use of EHRsAll Health Centers implement EHRs across all sites & providers

3. Patient Centered Medical Home RecognitionAll Health Centers receive PCMH recognition

4. Improving Clinical OutcomesAll Health Centers meet/exceed HP2020 goals on at least one UDS clinical measure

5. Workforce/Team-Based Care All Health Centers are employers/providers of choice and support team-based care

Priorities & Goals

ACCESS

COMPREHENSIVE SERVICES

INTEGRATED SERVICES

INTEGRATED HEALTH SYSTEM

Better Care Healthy People & Communities Affordable Care

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1. Empanelment2. Continuous and Team-based

Healing Relationships3. Patient-Centered

Interactions4. Engaged Leadership

Source: Safety-Net Medical Home Initiative

5. Quality Improvement (QI) strategy

6. Enhanced Access7. Care Coordination8. Organized, Evidence-Based

Care

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PCMH Change ConceptsSafety-Net Medical Home Initiative

An approach to providing comprehensive, patient centered, and coordinated primary care for health center patients - System wide transformation.

• Demonstrates the quality of care provided in health centers and provides opportunity for continuous quality improvement.

• Positions health centers at an advantage for the changing health care landscape.

• Investment in the health center workforce through reduced staff turnover and improved recruitment.

• Transforms patient care to help health centers achieve the three part aim of: better care, better health and communities, and affordable care.

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Why PCMH?

• BPHC Quality Strategy Priority Goal 3: Patient Centered Medical Home Recognition– All Health Centers receive PCMH recognition

• HHS Priority Recognition Goal– Goal: 25% of grantees recognized by 9/30/2013– Goal: 13% of grantees recognized by 12/31/2012

• HRSA investments in the patient centered medical home– Patient-Centered Medical Health Home Initiative– Accreditation Initiative– PCMH Supplemental funds– Partnership with the CMS Primary Care Demonstration

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The Patient Centered Medical Home

• Many entities across the country are embracing the PCMH model:– Private Payers: Blue Cross Blue Shield, United Health

Care, etc.– States: Oregon & Minnesota

• HRSA supports 2 initiatives to assist grantees with the survey costs and assistance in achieving PCMH recognition.– The Accreditation Initiative: The Accreditation

Association for Ambulatory Health Care & The Joint Commission

– The Patient Centered Medical Health Home Initiative: National Committee for Quality Assurance

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Many Paths to PCMH

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Paths Available Through HRSA

AAAHC The Joint Commission NCQA

• Patient and provider relationship

• Patient-Centeredness • Plan and Manage Care

• Accessibility • Superb Access to Care • Enhance Access and Continuity

• Comprehensiveness of care

• Continuity of care

• Comprehensive Care

• Coordinated Care

• Track and Coordinate Care

• Identify and Manage Patient Populations

• Provide Self-Care Support and Community Resources

• Quality • System-Based Approach to Quality and Safety

• Measure and Improve Performance

Summary

PCMH is a health care delivery model that:• Aligns with the health center program requirements.

– Enhanced Access & Comprehensive Services• Supports the implementation and meaningful use alignment of

EHR.– Tracking and Coordinating Care– Using Data to Manage Populations & Performance

Improvement • Requires a functioning QA/QI system for continuous QI

– Made easier with a functional EHR• Results in system & Infrastructure changes that demonstrate full

transformation to a PCMH• 100% PCMH recognition in health centers ultimately leading to

cost savings10

SWD NCD CSD NED National0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

5.8%

13.8%8.1%

14.7%10.7%

21.4%

25.1%

28.0%

31.6%

26.5%

Total % PCMH Recognized % PCMHHI Participants

Data Includes PCMH Recognition from: NCQA, AAAHC, The Joint Commission, Independently Recognized Health Centers with NCQA Recognition, and Oregon State PCMH Recognition

PCMH Recognition as of 7/1/2012

CY2012 Goal: 13%

Health Centers

Recognized

as PCMH

FY2013 Goal: 25%

Health Centers

Recognized

as PCMH

PCMH OverviewAssessing Patient-Centeredness within the context

of Performance Improvement Opportunities

Making the Most of Technical Assistance to Advance Patient-Centered Medical Home Transformation

Patient-Centered Medical Home What do they all strive to accomplish?

• Joint Principles• HHS National Quality Strategy - Better Care, Healthy

People & Communities, and Affordable Care • NCQA• AAAHC• TJC• Transformed• Medical Home Safety Net

Patient-Centered Medical Home Transformation is linked to a high

performing health care delivery system.

The six attributes of a high performing health care delivery system

Information ContinuityCare Coordination and TransitionsSystem AccountabilityPeer Review and Teamwork for High-Value CareContinuous InnovationEasy Access to Appropriate CareSource: The Path to a High Performance US Health System: A 2020 Vision and Policies to Pave The

Way.. (New York: Commonwealth Fund Commission on a High Performance Health System, February 2009.

How can Patient-Centered Medical Home Support Program Requirement Areas

Information ContinuityQuality Improvement/AssuranceData Reporting SystemsBoard Authority

Care Coordination and TransitionsRequired and Additional ServicesStaffingHospital Admitting Privileges and Continuum of CareCollaborative Relationships

System AccountabilityNeedKey Management StaffBoard Authority

How can Patient-Centered Medical Home Support Program Requirement Areas

Peer Review and Teamwork for High-Value CareStaffingQuality Improvement and Assurance

Continuous InnovationStaffingQuality Improvement and Assurance

Easy Access to Appropriate CareRequired and Additional Services Accessible Hours/LocationsAfter hoursHospital Admitting Privilege and Continuum of CareSliding Fee Discounts

Need

Related High Performance Attribute: System Accountability

Improving Patient-Centeredness:Does the needs assessment provide an analysis of key important conditions and risky behaviors for the population? Are these prioritized?Does the needs assessment include a language and cultural analysis?Does the needs assessment fully analyze health disparities and gaps across the service area?Is the QI program, strategic plan , outreach plan, and program services consistent and relevant to the identified needs? How well does the BOD and key leadership utilize the needs assessment and other key documents such as UDS and QI program performance when evaluating the effectiveness of program services?

Required and Additional Services

Related High Performance Attribute: Care Coordination and Transitions and Easy Access to CareImproving Patient-Centeredness:• Do referral agreements and arrangements include provision for coordination and

continuity of care (roles and responsibilities, how patients access services, communication and coordination expectations/deliverables, monitoring and reporting)?

• How well does the grantee manage internal referrals?• Is the grantee able to track and monitor all referred services (internal and external)

from initiation of the referral to referral completion?• Does the grantee provide patient materials that define patient roles and

responsibilities in coordination of care processes?• What does the grantee provide to patients and the community informing them of

services provided (website, brochures, newsletters, etc.)?• What documentation protocols are in place to ensure all referrals are entered into the

patients medical record?• Does the grantee provide appropriate translation services for the size/needs of its

population? Does the grantee assess and document language preference?

Staffing

High Performing Attribute: Care Coordination and Transitions and Continuous Innovation

Traditional Approach•Care is based on visits•Professional autonomy drives clinical variability•Professionals control care•Information is a record•Secrecy is necessary•The system reacts to needs

PCMH Approach•Care is based on continuous healing relationships•Care is customized according to patient needs, values•Patient is source of control•Knowledge is shared and flows freely•Transparency is necessary•Needs are anticipated

StaffingImproving Patient-Centeredness:• What type of staffing model is implemented at the health center? Do

the staff function in care teams?• Does the primary care clinician have the educational background

and broad-based knowledge and experience needed to handle most medical needs of the patient?

• Who are the members of the care team? Do job descriptions match care team responsibilities?

• Are staff being optimized to the highest level of their job descriptions? Does the grantee utilize standing orders for clinical support staff?

• How proactive and flexible can the staffing model adjust to changing patient need and preferences?

• Does the grantee have policies and procedures describing care team interaction?

Staffing

Improving Patient Centeredness (continued):• Does the grantee identify and manage populations? If so, can the grantee

demonstrate how populations are identified based on need? • Is there documented evidence of coordination of care (referral management,

chronic condition management, etc.)?• How does the grantee demonstrate involvement of the patient in his/her

treatment plan?• Does the grantee provide patient-centered education activities for staff

(motivational interviewing, readiness to change, social assessments)?• Does the grantee have patient self-care management processes in place?

Are self-management goals and the patient’s progress included in the patients clinical record?

• Does the grantee identify needs/risks based on an assessment process? (social, health risks, clinical, environment, readiness, confidence, etc.)

Hours of Operation/Locations & After Hours Coverage

High Performing Attribute: Easy Access to Care

Improving patient-centerednessDoes the grantee:• Provide extended hours?• Can patients select a personal primary care clinician?• Allow patients to speak to a health care professional after office hours?• Allow patients to interact with health center staff via web?• Make available to patients materials explaining accessibility and availability and

in languages that meet the language preferences of the population?• Is the appointment system flexible?• Does the grantee have triage protocols?• Have policies and procedures for same-day access, triage protocols, after hours

coverage, hours of operation?• Do policies and procedures make provisions for patient contact via their

preference (web, secure email, text, phone, etc.?

Hospital Admitting Privileges & Continuum of Care

High Performing Attribute: Care Coordination and Transitions and Easy Access to Care

Improving patient-centeredness• Does the grantee make provisions for ER visits and

hospitalizations that include effective transitions of care upon discharge (back to health center, home health, rehabilitation, etc?)

• Do these provisions include proactive patient communication and health center notification?

• What are the processes/protocols for care transitioning? Does it include a closed-loop process?

• Can the grantee demonstrate (reports, logs, etc) implementation of care transitioning?

Sliding Fee

High Performing Attribute: Easy Access to Care

Improving patient-centeredness:• Is the sliding fee discount program designed to promote access or

does it inadvertently create a barrier?• Does the grantee evaluate patient’s perception of the sliding fee

program to identify actual or potential barriers?

Quality Improvement/Assurance

High Performing Attribute: Information Continuity, Peer Review and Teamwork for High Value, and Continuous InnovationImproving patient-centeredness:• Is the quality improvement program systematic? Does it include cross-cutting

performance metrics (satisfaction, clinical care, utilization of services, patient safety, etc.)

• Are evidence-based standards of care shared across all providers?• What types of performance metrics are reported across the practice and at the

provider level? Are they reported as a comparison analysis using percentage calculations (trending reports or single measurement points)

• Is the QI Committee structure effective demonstrating multidisciplinary involvement, analysis of performance and active participation in identifying opportunities for improvement, establishing action plans and monitoring the effectiveness of actions taken.

• How efficient is quality improvement information distributed across the organization and the BOD?

Quality Improvement/Assurance

High Performing Attribute: Information Continuity, Peer Review and Teamwork for High Value, and Continuous InnovationImproving patient-centeredness:• Are peer review activities based on the organizations important conditions

and/or risky behaviors?• Can peer review results be quantitatively measured to assess performance

against performance thresholds?• How well to providers work as teams to improve the quality of care and

services across the organization vs. silo approach?• Do QI Committees and/or other committees involve patients/families in quality

improvement discussion?• How does the grantee share QI information with patients and other entities?• What types of innovative ideas are promoted as a result of QI Improvement

activities (social media, RN Chronic condition manager, telehealth, home visits, web-based communication, use of social media)?

Key Management Staff

High Performing Attribute: System AccountabilityImproving patient-centeredness:• Do all key management staff support and promote PCMH transformation?• How informed are key management staff in the PCMH transformation

process and transfer the knowledge across the organization?• Are key management staff aware and taking advantage of appropriate

PCMH initiatives (e.g., state, payors)?• Are collaborative efforts, supported by effective leadership and shared

goals? • Is there a plan developed for allocating appropriate resources to the

transformation process?• Who has overall accountability for the effectiveness of the PCMH?• What is the frequency of progress reporting to the BOD?

Collaborative Relationships

High Performing Attribute: Care Coordination and TransitionsImproving patient-centeredness:• Do collaborative relationships enhance coordination of care and

services within the community?• Does the grantee engage collaborative partners in problem solving

activities when gaps in care/services are identified among the population or the community as a whole?

• What type(s) and frequency of interaction occur between the grantee and its collaborative partners?

Program Data Reporting Systems

High Performing Attribute: Information Continuity

Improving Patient-Centeredness:Does the grantee’s data management system(s) : Support the people in the task of care coordination? Keep track of large amounts of data? Keep track of data over long periods of time? Provide data that is easily accessible and meaningful? Integrate information into carefully designed workflows to achieve care

coordination goals? Organize data so that patterns are apparent? Remember complex rules and protocols? Enhance communication across a provider network? Maintain check-lists for completeness? Prompt humans with decision support? Integrate between internal and/or external systems (interoperability)? Function with constant reliable performance? Provide key alerts (allergy, medication interactions, etc)

Health Information Technology Connection

Board Authority

High Performing Attribute: Information Continuity and System Accountability

Improving Patient-Centeredness:• Does the BOD demonstrate knowledge and support of Patient-

Centered Medical Home transformation?• Does the BOD have commonly shared PCMH goals with key

management staff?

Quality Improvement Resources

• National Quality Recognition– Accreditation: http://bphc.hrsa.gov/policiesregulations/accreditation.html

o AAAHC, TJC– NCQA recognition: http://bphc.hrsa.gov/policiesregulations/policies/pal201101.html

– Comparison chart: http://bphc.hrsa.gov/policiesregulations/policies/qualrecogn.pdf

• ECRI Institute Resources– Available to all Health Centers and FQHC LALs https

://www.ecri.org/clinical_rm_program/Pages/default.aspx

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Quality Improvement Resources

• HRSA– FTCA Resources http://bphc.hrsa.gov/ftca/index.html

– BPHC QI Plan Learning Series and Modules http://bphc.hrsa.gov/policiesregulations/quality/index.html

– BPHC Training and Technical Assistance http://bphc.hrsa.gov/technicalassistance/tatopics/qualitymanagementimprovement/index.html

– HRSA Office of HIT and Quality http://www.hrsa.gov/quality/toolsresources.html

– HIV/AIDS Bureau Quality Resources http://nationalqualitycenter.org/

• Safety Net Medical Home Initiative http://www.qhmedicalhome.org/safety-net/qistrategy.cfm

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HIT Resources

• HRSA’s HIT Web Page (http://www.hrsa.gov/healthit/)

– HIT Health IT Adoption Tool Boxes: http://www.hrsa.gov/healthit/toolbox/

– HIT Health IT and Quality Webinars: http://www.hrsa.gov/healthit/toolbox/webinars/index.html

– HRSA Network Guide, currently including information on 46 networks: http://www.hrsa.gov/healthit/networkguide/index.html

• The Office of the National Coordinator for Health Information Technology: http://healthit.hhs.gov

– HIT Regional Extension Center program: http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__rec_program/1495

– 2010 report on HIT in Underserved Communities: http://www.healthit.gov/sites/default/files/pdf/hit-underserved-communities-health-disparities.pdf

• The AHRQ National Resource Center for HIT: http://healthit.ahrq.gov

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Data Resources

• HRSA Data Warehouse: http://datawarehouse.hrsa.gov/

• Public site for UDS Data: http://bphc.hrsa.gov/healthcenterdatastatistics/index.html

• UDS Performance Reports:⁻ Health Center Trend Report (National/State/Grantee)⁻ Health Center Summary Report

(National/State/Grantee) ⁻ Performance Profile (National/State) – Performance

on Key Indicators

• UDS Mapper: http://www.udsmapper.org/ 35

PCMH Resources

• PCMH Readiness Assessment Tools– Primary Care Development Corporation (PCDC):

http://www.pcdc.org/resources/patient-centered-medical-home/pcdc-pcmh/ncqa-2011-medical-home.html

– PCMH Assessment (PCMH-A) from the Safety Net Medical Home Initiative: http://www.safetynetmedicalhome.org/practice-transformation/assessment

– Medical Home Implementation Quotient Assessment (MHIQ) from TransforMED: http://www.transformed.com/userLogin.cfm

• PCMH Change Concepts: http://www.safetynetmedicalhome.org/change-concepts

• Patient-Centered Primary Care Collaborative (PCPCC): http://www.pcpcc.net/content/pcmh-outcome-evidence-quality

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PCMH Resources

• Agency for Healthcare Research and Quality (AHRQ) PCMH Resource Center: http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483

⁻ Clinical Practice Guidelines: http://www.ahrq.gov/clinic/cpgsix.htm

⁻ US Preventive Services Task Force: http://www.uspreventiveservicestaskforce.org/tools.htm

⁻ Consumer Assessment of Healthcare Providers and Systems (CAHPS patient experience survey): https://www.cahps.ahrq.gov/default.asp

⁻ Innovations Exchange: http://www.innovations.ahrq.gov/

⁻ Patient Health Literacy Toolkit: http://www.ahrq.gov/qual/literacy/

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Behavioral Health Resources

• HRSA BH website: www.hrsa.gov/publichealth/clinical/BehavioralHealth/index.html

• Center for Integrated Health Solutions:– Motivational Interviewing for Better Outcomes– Peer Support Wellness Respite Centers – Screening, Brief Intervention, and Referral to

Treatment (SBIRT) in Clinical Settings – Person-Centered Health Homes– Introduction to Effective Behavioral Health in

Primary Care http://www.thenationalcouncil.org/cs/center_for_integrated_health_solutions

• SAMHSA SBIRT page http://www.samhsa.gov/prevention/SBIRT/index.aspx

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