An Overview of Patient-Centered

Health Care Home

Napualani Spock, MA, MBAPacific Islands PCA

Goals for today’s session Provide overview and historical

context for the Patient Centered Medical Home (PCMH) movement

Review and discuss PCMH change concepts

Group discussion on PCMH in the Pacific context

Determine next steps for PIPCA CHCs

The U.S. Healthcare System is broken

2001 Institute of Medicine Report—health system error is leading cause of death in the U.S.

Fragmented care—poor communication between doctors, hospitals, pharmacies

Bureaucratic—emphasis on needs of the providers, not the patient: i.e. scheduling, processes

Patients are labeled “non-compliant” when they don’t conform (‘obey’)

Patients need to manage their own appointments, follow-up, etc.

Physicians work alone to provide all aspects of healthcare; in short visits

Institute of Medicine’s “Crossing the Quality Chasm”

New Vision for Health Care Patient Safety is a priority Evidence-based decision making Cooperation among providers Customize to patient needs and values Shared knowledge (patients/providers) allows

patients to make informed decisions about their own health care

Care based on continuous healing relationships Anticipation of needs/not reacting Goal is to eliminate waste (time and resources)

Fixing the Broken U.S. Healthcare System

Video: http://www.youtube.com/watch?v=DE9rG3ACJ9Q&feature=player_detailpage

(12min)

History of Patient Centered Medical Homes

1967: “Medical Home” developed as an approach to provide comprehensive services to special needs children

1978-79: Dr. Calvin Sia (pediatrician) and others campaigned to adopt the medical home concept into Hawaii’s State Child Health Plan

2001: Institute of Medicine Report—new vision—mentions patient-centeredness

2002: ACP and AAFP expand Medical Home concept to include adults

2007: Joint Principles of the PCMH developed by American College of Physicians, American Academy of Family Physicians, American Osteopathic Association, American Academy of Pediatrics

2007

PCMH is very similar to the National Health Disparities Collaborative—

Chronic Care Model

PCMH--CHCs

PCMH is also based on many of the same principles as community health centers: Promote access to underserved All care in one place Treat the whole person Provide enabling services to

address socio-economic needs

Video: PCMH in Clinical Settings

American Academy of Family Physiciansadopting PCMH across the U.S. http://

www.youtube.com/watch?v=2j5ImY8yvtA&list=PLC00ECBFBB45D4A72&feature=player_detailpage (9min)

Recent PCMH MilestonesHealth Care Reform –

Affordable Care Act (ACA) of 2010 Patient Protection and Affordable

Care Act and Health Care and Education Reconciliation Act

Supports Advanced Primary Care and Innovation across the U.S., across providers

Provides new payment opportunities (through Medicaid matching and Insurance regulations)

HRSA Promotes PCMH in CHCs

HRSA/NCQA partnership (Program Assistance Letter 2011-01)

• Encourages and supports health centers to gain NCQA recognition as medical homes• Provides structure and resources for

centers’ expansion and quality improvement efforts• Alignment with pilot/demonstration

projects with CMS, State Medicaid Agency, Health Plans

HRSA’s Safety Net Medical Home Initiative

PCA/CHC Milestones by 2014 (coordinated by NACHC)• PCMH Certification•HIT Infrastructure• Integrated Health Delivery Model• Payment Reform•Engaged Patients•Aligned Measurement and Reporting Systems

Change Concepts for PCMH (2)

Handout: http://www.safetynetmedicalhome.org/sites/default/files/Change-Concepts-for-Practice-Transformation.pdf

EmpanelmentContinuous / Team-Based Healing RelationshipsPatient-Centered Interactions

Engaged LeadershipQI StrategyEnhanced AccessCare CoordinationOrganized, Evidence-Based Care

PCMH concepts

Ed Wagner presenting Change Concepts:http://www.safetynetmedicalhome.org/sites/default/files/Change-Concepts-7-25-09.wmv

PCMH I. Engaged Leadership

Provide visible and sustained leadership to lead overall cultural change as well as specific strategies to improve quality and spread and sustain change.

Ensure that the PCMH transformation effort has the time and resources needed to be successful.

Ensure that providers and other care team members have protected time to conduct activities beyond direct patient care that are consistent with the medical home model.

Build the practice’s values on creating a medical home for patients into staff hiring and training processes.

II. Quality Improvement Strategy Choose and use a formal model for quality

improvement.

Establish and monitor metrics to evaluate routinely improvement efforts and outcomes;

Ensure all staff members understand the metrics for success.

Ensure that patients, families, providers, and care team members are involved in quality improvement activities.

Optimize use of health information technology to meet Meaningful Use criteria.

III. Empanelment Assign all patients to a provider panel and

confirm assignments with providers and patients; review and update panel assignments on a regular basis.

Assess practice supply and demand, and balance patient load accordingly.

Use panel data and registries to proactively contact and track patients by disease status, risk status, self-management status, community and family need.

IV. Continuous and Team-Based Healing Relationships

Establish and provide organizational support for care delivery teams that are accountable for the patient population/panel.

Link patients to a provider and care team so both patients and provider/care teams recognize each other as partners in care.

Assure that patients are able to see their provider or care team whenever possible.

Define roles and distribute tasks among care team members to reflect the skills, abilities, and credentials of team members.

V. Patient-Centered Interactions

Respect patient and family values and expressed needs.

Encourage patients to expand their role in decision-making, health-related behaviors, and self-management.

Communicate with patients in a culturally appropriate manner, in a language and at a level that the patient understands.

Provide self-management support at every visit through goal setting and action planning.

Obtain feedback from patients/families about their healthcare experience and use this information for quality improvement.

VI. Organized, Evidence-Based Care

Use planned care according to patient need. Identify high risk patients and ensure they

are receiving appropriate care and case management services.

Use point-of-care reminders based on clinical guidelines.

Enable planned interactions with patients by making up-to-date information available to providers and the care team prior to the visit.

Example: TEAM HUDDLE AT UC Davis (9 min) http://www.youtube.com/watch?v=VxdG2_nZ2fc

&feature=player_detailpage

VII. Enhanced Access

Promote and expand access by ensuring that established patients have 24/7 continuous access to their care teams via phone, e-mail, or in-person visits.

Provide scheduling options that are patient and family-centered and accessible to all patients.

Help patients attain and understand health insurance coverage.

VIII. Care Coordination Link patients with community resources to

facilitate referrals and respond to social service needs.

Integrate behavioral health and specialty care into care delivery through co-location or referral agreements.

Track and support patients when they obtain services outside the practice.

Follow up with patients within a few days of an emergency room visit or hospital discharge.

Communicate test results and care plans to patients.

Patient Experience of PCMH

Video, from a Patient’s Perspective:http://www.youtube.com/watch?v=LIPk9o0NUaY&feature=player_detailpage

PCMH Certification

Multiple PCMH Accrediting Entities in the U.S.

National Committees for Quality Assurance (NCQA)

The Joint Commission (JACHO) Accreditation Association for Ambulatory

Health Care (AAAHC) URAC

NCQA RecognitionNCQA is part of the HRSA Safety Net Demonstration Project 9 Elements examined 3 levels of recognition with different

levels of compensation for each level Video on NCQA process (22min)http://www.youtube.com/watch?feature=player_detailpage&v=ZC4YCLG4h5k

NCQA Recognition Process

OVERVIEW OF STEPS:1. Take self-assessment2. Submit data to NCQA3. NCQA evaluates and scores4. 5%+ of sites are audited onsite5. NCQA provides final evaluation to site6. If site passes, recognition is reported on

website and to users, including health plans

How does your CHC fare?

Assessment: “PCMH-A” Created by the Safety Net Medical Home

Initiative (SNMHI) Organized in order of NCQA PCMH Certification

Standards • PCMH Crosswalk• PCMH-A Document

12 point rating scale Helps you to determine your organization’s

readiness; and to identify areas of need for training and technical support

How do we adapt PCMH to

fit diverse community

health centers?

How did Hawai’i CHCs approach it?

PCHCH Pilot 2008-2012 Project participants:

AlohaCare Hawaii Primary Care Association

Kalihi-Palama Health Center

Waianae Coast Comprehensive Health Center

Waimanalo Health Center

West Hawaii Community Health

Center

Core Values of Hawai’i CHCs Pilot Project

“Patient Centered Healthcare Home” Patient-Driven and Family Centered

Care Barrier Free Access Team-Based Care Delivery Integrated and Holistic Care

Hawai’iPCHCH Pilot

Hawai’i Activities Monthly Steering Committee Meetings ICSI PCMH Consultants April 2011: Go Live

All processes/ workflows in place Care coordination tools and care plans

implemented Baseline data collected

3 min. video on PCMH coordination at W. Hawai’i CHC http://www.youtube.com/watch?v=tnrFcDSy-N8&feature=player_detailpage#t=73s

Other CHCs across America

Oregon “Storyboard” PCMH Handouts\sample of 'storyboard' from Oregon CHC.pdfCHC In Connecticut (4 min video) http://www.youtube.com/watch?v=DroZOEt5q0s&feature=player_detailpage

Where do we go from here?

Next Steps?

Some Ideas: NACHC Model

Learning Communities•Email group (listserve)• Face-to-face training

Online webinars Site visits; coaching

Pacific Islands PCMH Plan

Discussion: Next steps for PIPCA CHCs

What do You think?

Mahalo.