THE PCMH

Lyndee Knox, PhDLA Net A Project of Community Partners

Change is Hard . . .

Objectives

• Create a common departure point for discussion to follow

• A 101 overview, not a deep dive into PCMH

• Introduce PCMH efforts underway in L.A.

Presentation Outline

What is a Patient Centered Medical Home (PCMH)

The patient-centered medical home is "a model for care provided by physician practices aimed at strengthening the physician-patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship." (NCAQ)

A recent Journal of General Internal Medicine provides a core definition of the PCMH as a team of people committed to improving the health and healing of individuals in a community.

According to the ACP, it is:

Other descriptions• The PCMH is a political construct that includes new

ways of organizing and financing care, while attempting to remain true to the proven value of primary care (Stange et al, 2010)

• PCMH requires a compact between payers and primary care practices. Simultaneously,– Practices improve their care– Payers pay the practices more to help them improve their

care– Neither practices or payers can do it themselves. Both are

needed (T. Bodenheimer)

Based on the Joint PrinciplesTeam-based care: NP/PARN/LPNMedical AssistantOffice StaffCare CoordinatorNutritionist/EducatorPharmacistBehavioral HealthCase ManagerSocial WorkerCommunity resourcesDM companiesOthers…

Principles were created by the

Referred to as the Patient Centered Primary Care Collaborative (PCPCC)

PCPCC on the web: http://www.pcpcc.net

Critique of the PCMH: Some feel it doesn’t go far enough

Presentation Outline

How do you Know a PCMH When you See One?

Recognition Programs for PCMH Developed or Under Development

14

Quality Organizations PCMH Standards Activity

2010

NCQA PPC-PCMH Recognition Module; Major Domains/Standards

1. Access & Communication2. Patient Tracking &

Registry Functions3. Care Management4. Patient Self-

Management Support5. Electronic Prescribing

6. Test Tracking7. Referral Tracking8. Performance Reporting &

Improvement9. Advanced Electronic

CommunicationEach standard contains sub-elements – 10 of which are considered “must pass”

For more information: http://ncqa.org/tabid/631/Default.aspx

Each standard contains sub-elements10 of which are considered “must pass”

Standards are currently under revision and will be available Jan 2011 – Integrate IT w/in core domains

Key Points for Level 1 PCMH

Level 2 → Level 3

More Features of a PCMH Practice

NCQA Recognition Activity

SOURCE: NCQA, July 2010

SOURCE: NCQA, December 2009

Critique of NCQA• Beal et al created a patient centered definition of a medical home

w/ 4 questions:– Do you have a regular doctor or place of care?– Can you easily contact your provider by phone?– Can you easily get care or medical advice on weekends or evenings?– Are your physician visits well organized and running on time?

• Practices doing well on these could flunk NCQA

• Many standards require that a practice have a “plan” to improve, but do not require demonstration of improvement and no clear benchmarks in many cases

T. Bodenheimer

Presentation Outline

Complex Delivery

Health care delivery is complex – e.g., the typical primary care physician coordinates care with 229 other physicians working in 117 practicesH H Pham, et al Ann Intern Med. 2009;150:236-242

Specialty Care Connections

* FAQs available at: http://www.acponline.org/running_practice/pcmh/understanding/specialty_physicians.htm

Patient Centered Medical Home Neighbor (PCMH-N) Draft Definition

A specialty practice recognized as a Patient Centered Medical Home Neighbor (PCMH-N) engages in processes that:

These processes would take the form of service agreements (compacts) between/among the participating practices.

Presentation Outline

Combined Commercial and Medicaid/CHIP PCMH Activity

= Identified to have at least one private payer medical home pilot under development or underway

= Identified to have a Medicaid and/or CHIP medical home initiative

= Identified to have both a private payer and a Medicaid and/or CHIP medical home initiative

* As tracked by the American College of Physicians (updated March 2010)

Federal PCMH Efforts

For more information on CMS/Medicare PCMH Efforts: http://www.acponline.org/running_practice/pcmh/demonstrations/index.html

Federal PCMH Efforts (cont.)

Safety-Net Medical Home Initiative

Source: http://www.qhmedicalhome.org/safety-net/index.cfm

Common Practice Support Approaches in PCMH Demos

Presentation Outline

Evaluation Collaborative sponsored by Commonwealth

Community Implications - Published Results of PCMH Projects to Date

Source: PCPCC Pilot Guide, 2009

Community Implications – Published Results of PCMH Projects (cont.)

Source: PCPCC Pilot Guide, 2009

Community Implications

Source: Metcare Press Release, February 23, 2010

•Practices made changes, process measures improved, docs happier, but patients were dissatisfied and felt disconnected from physician

Community Implications

Source: Metcare Press Release, February 23, 2010

Estimates on Co$t?

Future of Family Medicine Report (http://www.annfammed.org/cgi/reprint/2/suppl_3/s1 ), 2004Deloitte: The Medical Home, Disruptive Innovation for a New Primary Care Model (http://www.deloitte.com/dtt/cda/doc/content/us_chs_MedicalHome_w.pdf), 2008

What Does it Co$t?

AMA (http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/ruc-medicare-medical-home-demonstration-project.shtml), 2008

Urban Institute Report - Co-Funded by The Commonwealth Fund and ACP – Available at: http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2009/Oct/Incremental-Cost-Estimates-For-The-Patient-Centered-Medical-Home.aspx, 2009

Presentation Outline

Some resources for Practices• PCPP --- http://www.pcpcc.net/

– Tools for practices, patients– Meaningful Connections: IT and the PCMH

• National Academy for State Health Policy http://www.nashp.org/node/1681

• AAP Toolkit http://www.pediatricmedhome.org/start_building/

• ACP Medical Home builder http://www.acponline.org/running_practice/pcmh/

• TransforMed resources http://www.transformed.com/TransforMED_is_How.cfm

• NCQA webex training on accreditation www.ncqa.org/rptraining.aspx

• MacColl Institute’s Tool PCMH-A http://qhmedicalhome.org/safety net/change concepts.cfm‐ ‐

• Planned: AHRQ National Learning Collaborative for Facilitating PCMH advancement

Recent Journal supplements on the PCMH• AFM Supplement http://www.annfammed.org/content/vol8/Suppl_1/index.shtml• Health Affairs, 29, no. 5 (2010) supplement on the PCMH• Annals of Internal Medicine

http://www.acponline.org/running_practice/pcmh/resources_tools/abstracts.htm

Links are available to much of this material on LA Net’s website: www.lanetpbrn.net

Presentation Outline

Local Activities to Support PCMH

• L.A. Care PCMH Initiative

• LA Net CCM and PCMH funded by AHRQ

• L.A. County initiative

LA Net

• Is a Practice-Based Research and Resource Network (PBRN) for the region

• Focused on improving quality and reducing disparities and through:– provider-led research on issues that matter– supporting local learning and innovation– implementing best practices

Network for generating & disseminating good ideas

LA Net (cont)

• Consists of 16 FQHC/CHC “partners” representing 116 practice sites

• Governed by a board of 80% clinicians, 20% researchers, others.– John Kotick – Current Chair– Felix Nunez – Past Chair

LA NET

• Part of a national network of more than 100 PBRNs in the U.S.

Some recent projects

• Management of Obstructive Sleep Apnea in Primary Care (AHRQ/CMS)

• National Children’s Study pilot (NICHD)

• Study of AHRQ’s web-based medication errors and adverse drug event reporting system for primary care (MEADERS)

Examples of projects

• Replication of a diabetes self-management program in 23 PC practices in Texas (AAFP, Lilly, WHO)

• Development of low-cost “talking” survey software to use with low-literacy patients available in 7+ languages

AHRQ funded CCM and PCMH project

• Evaluating use of practice facilitation to support 20 FQHC/CHCs in CCM and PCMH changes

• Based on input from steering cmt: Tom Bodenheimer, Jim Mold, Grace Floutsis, Rich Seidman

• And experts from US and Canada during Consensus Panel hosted by LA Net in January 2010

Blueprint Vermont, CareOregon, Oklahoma, IPIP, Impact BC, Quality Counts, QIIP, and others

• Continuation of project by MacColl, RAND, Safety Net Institute

• Demonstration of Primary Care Extension Program

• Created by recent reform legislation –modeled after agricultural extension program

• Jim Mold was author - working with us to design demonstration

• PCMH projects and REC in LA might provide foundation

Long-term goal: Provide sustained workforce to practices

Acknowledgements

Shari M. Erickson, MPHSenior Associate, Center for Practice Improvement & Innovation

Tom Bodenheimer, MDUCSF

Katie Coleman, MPHMacColl Institute

Jim Mold, MDU of Oklahoma

References• American College of Physicians. 2006. The Advanced Medical Home: A

Patient-Centered Physician Guided Model of Healthcare. http://www.acponline.org/advocacy/where_we_stand/policy/adv_med.pdf

• American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA). 2007. Joint Principles of the Patient-Centered Medical Home. March 2007. http://www.acponline.org/running_practice/pcmh/demonstrations/jointprinc_05_17.pdf

• American Academy of Family Physicians (AAFP). 2004. The Future of Family Medicine: A Collaborative Project of the Family Medicine Community. Annals of Family Medicine 2 (1): S3-S32.

• American Academy of Pediatrics, Council on Pediatric Practice. Pediatric Records and a "medical home." In: Standards of Child Care. Evanston, IL: American Academy of Pediatrics; 1967: 77–79

Thank you