Patient Centered Medical Home

Delaware Health Care Commission

Janice E. Nevin, MD, MPH

Chief Medical Officer

Christiana Care Health System

What is a Patient Centered Medical Home?

Publicly available information

8Source: Health2 Resources 9.30.08

Defining the Medical Home

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PCMH - History

1967 – American Academy of Pediatrics: “Medical Home”1996 – Institute of Medicine, Committee on the Future of Primary Care: integrated… accountable…sustained partnership with patient2001 – IOM, Crossing the Quality Chasm – 6 aims: safe, effective, Pt-centered, timely, efficient, equitable2007 – Joint Principles of PCMH

PCMH – Joint PrinciplesFeb, 2007 – Joint Principles by ACP, AAFP, AAP, AOA• Personal physician – pt has 1 doc, 1st contact, continuous,

and comprehensive care• Physician directed care – provider leads medical team• Whole person orientation – acute, chronic, preventative,

home care & specialty services• Coordinated care – subspecialty, hospital, NH, uses

registry, IT exchange, culturally sensitive• Quality & Safety – evidenced-based, CQI• Enhanced access – expanded hrs, e-visit, patient portal &

group visits• Payment – should reflect added value to patients

TODAY’S CARE MEDICAL HOME CARE

My patients are those who make appointments to see me

Our patients are those who are registered in our medical home

Care is determined by today’s problem and time available today

Care is determined by a proactive plan to meet patient needs with or without visits

Care varies by scheduled time and memory or skill of the doctor

Care is standardized according to evidence-based guidelines

Patients are responsible for coordinating their own care

A prepared team of professionals coordinates all patients’ care

I know I deliver high quality care because I’m well trained

We measure our quality and make rapid changes to improve it

It’s up to the patient to tell us what happened to them

We track tests & consultations, and follow-up after ED & hospital

Clinic operations center on meeting the doctor’s needs

A multidisciplinary team works at the top of our licenses to serve patients

Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma 8

Recognition Programs for PCMH Developed or Under Development

Quality Organizations PCMH Standards Activity

2010

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Comparison of PCMH 2008 and PCMH 2011 PCMH 2008 (9 standards/30 elements)

1. Access and Communication• Processes

• Results

2. Patient Tracking and Registry Function

3. Care Management• Continuity Between Settings

4. Self-Management Support

5. Electronic Prescribing

6. Test Tracking

7. Referral Tracking

8. Performance Reporting and Improvement• Measures of Performance

• Patient Experience

9. Advance Electronic Communication

PCMH 2011 (6 standards/24 elements)

1. Access and Continuity • Access

• Electronic Access

• Continuity

• Patient/Family Partnership

• Practice Organization

2. Identify/Manage Patient Populations

3. Plan/Manage Care• Care Management

• Medication Management

4. Self-Management Support

5. Track and Coordinate Care• Test/Referral Tracking

• Facilities

• Community

6. Performance Measurement and Quality Improvement• Measures of Performance

• Patient Experience

• Quality Improvement

AAFP – National Demonstration Project (NDP)

36 FP practices from across the countryJune 2006 – June 2008Randomized to facilitated learning vs. self-directed

“The PCMH represents the essentials for better primary care, improved delivery of chronic care, and active partnership with an informed patient synergized by appropriate use of information and communications’ technology.”

Nutting PA, Miller WL, et. Al. Initial lessons from the first National Demonstration Project on Pt Transformation and PCMH. Ann Fam Med 2009;7:254.260

National Demo Projectconclusions

1. Practice transformation is more than a series of changes and requires shifts in roles and mental models

2. The larger system can help or hinder3. Practice adaptive reserve is critical to managing

change4. Motivation of key practice members is critical5. Developmental pathways to success vary considerably

by practice6. Practice change is enabled by the multiple roles

that facilitators play

Ann Fam Med 2010;8(suppl 1):s45-s56.

Evidence of Cost Reduction

Recent studies estimate that if every American had access to a Medical Home, national health care expenditures would drop by 5.6% – translating into a national savings of at least $67 billion per year.1

States which relied more on Primary Care have:• Lower Resource Inputs (hospital beds, ICU beds, total physician

labor, primary care labor, and medical specialist labor);

• Lower Utilization Rates (physician visits, days in ICUs, days in the hospital, and fewer patients seeing 10 or more physicians);

• Lower Medicare Spending (inpatient reimbursements and Part B payments).2

1. Dartmouth Atlas of Health Care, Variation among States in the Management of Severe Chronic Illness, 2006

Commonwealth Fund, Chartbook on Medicare, 2006;2. Spann SJ, for the members of Task Force 6 and The Executive Editorial T: Report on Financing the New Model of

Family Medicine. Ann Fam Med 2004; 2(suppl_3):S1-21 PMID 15654084

Community Implications - Published Results of PCMH Projects to Date

Source: PCPCC Pilot Guide, 200914

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

Source: PCPCC Pilot Guide, 201015

Care Team Transformation

Health Coach Functions

Questions?