pcmh model and the foundational building blocks · hiv medical homes resource center continuous...
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PCMH Model and the Foundational Building Blocks
Steve Bromer, MD
Department of Family and Community Medicine
UCSF
Joint Principles of the Patient Centered Medical Home February 2007
American Academy of Family Physicians
American Academy of Pediatrics American College of Physicians
American Osteopathic Association
Transforming the Delivery of Primary Care: The Patient Centered Medical Home
Ongoing Relationship with provider for first-contact, continuous, and comprehensive care;
Health Care Team that collectively cares for the patient;
Whole-person Orientation, including acute, chronic, preventive, and end-of-life care;
Coordinated Care across all elements of the health care system and the patient’s community;
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Transforming the Delivery of Primary Care: The Patient Centered Medical Home
Quality and Safety through evidence-based medicine and clinical decision-support tools, information technology, registries, and continuous quality improvement;
Enhanced Access, achieved through such systems as open scheduling, expanded hours, and new options for communication between patients, their physician, and practice staff; and
Payment Reform to reflect the added value that a PCMH provides to patients.
HIV Medical Homes Resource Center
Continuous
First Contact
Comprehensive
Coordinated
Patient Centered Medical Home
Evidence on Value of New Primary Care Models: Case Study of Group Health Cooperative of Puget Sound
Patient Centered Medical Home model piloted at one site in 2007
Avg PCP panel size reduced from 2327 to 1800
Longer face-to-face visits and scheduled time for phone and email encounters
Increased team staffing and teamwork
HIT
Panel management
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Group Health PCMH Pilot: Controlled Evaluation 12 Month Outcomes
Improved continuity of care
Better patient experiences (6 of 7 measures)
Better composite quality of care score
Reductions in ED visits and Ambulatory Care Sensitive Hospitalizations
No difference in total costs at year 1 (lower total costs by year 2) Source: R Reid et al. Am J Managed Care 2009;15:e71
Group Health PCMH Pilot:
Effect on Clinic Staff
34.5%
30.0%
33.3%
9.7%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Control Sites PCMH Site
Percent with High
Level Emotional
Exhaustion
Baseline
12 Months
p=.02
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Change Concepts for the PCMH
Engaged Leadership
Quality Improvement Strategy
Empanelment
Continuous and Team-based Healing Relationship
Organized, Evidence-Based Care
Patient-Centered Interactions
Enhanced Access
Care Coordination
Wagner, EH et al, Guiding Transformation: How Medical Practices Can Become Patient-Centered Medical Homes; February, 2012
The Building Blocks of High-Performing Primary Care: lessons from the field
23 high-performing practices
Intensive visits to 7 West Coast practices
Discussions with and observations of clinicians, RNs, MAs, front desk, leaders
High-performing practices look about the same, with variation in the details
10 building blocks -- the foundation of these practices
Willard R, Bodenheimer T: CHCF April 2012
Building Blocks of High-Performing Primary Care: Share-the-CareTM Model
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Change Concepts Building Blocks NCQA Recognition
Engaged Leadership Data for Improvement Enhance Access/Continuity
Quality Improvement Strategy
Empanelment, Panel size management
Identify/Manage Patient Populations
Empanelment Team-based Care Plan/Manage Care
Continuous and Team-based Healing Relationships
Population Management Provide Self-Care Support/Community Resources
Organized Evidence-based Care
Continuity of Care Track/Coordinate Care
Patient-Centered Interaction Prompt Access to Care Measure/Improve Performance
Enhanced Access Expanded Access Template
Care Coordination Mission with objectives and goals
Care coordination with Medical Neighborhood
Trained Leaders
DATA/Quality Improvement Strategy
HIV Medical Homes Resource Center
Formal QI process Defined metrics Optimized HIT
Robust data collection Reporting systems to share data Strategic decisions about metrics
Are we Data Driven organizations? Do we use real-time data on important clinical/operational data to guide day-to-day actions?
Grant requirement to have CQI, robust metrics, early adopter of registry, variable HIT capacity
Empanelment
HIV Medical Homes Resource Center
Prioritizes patients seeing own PCP Clear denominator at panel level
Empanelment not specific grant requirement, often happens because of structure of practice
Is empanelment a deliberate process where we can use provider panels for quality data , proactive care and to actively manage supply and demand?
Assign all patients to provider panel Balance supply and demand Use panel data to manage population
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Team-Based Care
HIV Medical Homes Resource Center
Patients are connected to a Care Team Roles/tasks defined
Culture shift to share-the-care. Flexible, functional teams, with clearly defined roles
Multi-disciplinary Teams are central to RWCA
Are our teams organized around getting the work done with an explicit vision and clear principles? With defined workflows, skills training and ground rules?
Team-based Care
Why does team-based care matter? Align roles to meet
population needs
Build capacity to make timely access possible
Non-clinician team-members contribute to continuous healing relationship
Foundation for the Template of the future
4. Team-based Care
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Traditional Methods of Managing Work Flow
Provider
Chronic
Disease
Monitoring
Preventive
Med
Intervention
Mental Health
Provider
Referral to
Specialist
after
Assessment
Medication
Refill
New Acute
Complaint
Certified
Medical
Assistant
Case
Manager
Test Results
Healthcare
Support
Team
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Team-based care
• Culture shift: share the care
Stable teamlets
• Co-location
Staffing ratios
Standing orders/protocols
• Defined workflows and roles – workflow mapping
• Training, skills checks, and cross training
• Ground rules
• Communication – healthy huddles, terrific team meetings and constant conversation
Team-based care: stable teamlets
Patient
panel
1 team, 3 teamlets
Clinician/MA
teamlet
Patient
panel
Clinician/MA
teamlet
Patient
panel
Clinician/MA
teamlet
Health coach, behavioral health professional, social worker,
RN, pharmacist, panel manager, complex care manager
Prompt Access to Care
HIV Medical Homes Resource Center
24/7 access to care team, patient-centered scheduling options, address barriers to access
Balance supply and demand, open access, multiple channels of access
Do we have a patient-centered approach to access?
After hours coverage, +/- use of advanced access tools
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http://www.careinnovations.org/knowledge-center/knowledge-centerwest-county-health-center-video/
Population Management/Panel Management
HIV Medical Homes Resource Center
Plan care according to need, manage high-risk patients, point-of-care reminders
Robust population management, Self-management, Complex Case management, planned visits
Case Management key feature of RWCA, client level data, self-management support
Are we able to focus at the population level and proactively assign resources where needed? Is data used in day-to-day care?
Care Coordination
HIV Medical Homes Resource Center
Link patient with community resources, referral tracking, coordination of specialty care
Management of care transitions, behavioral health services, communication of results
Comprehensive model of care, often under one-roof, expectation that transitions are tracked
How good are we at managing the care that happens outside of our four walls?
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Conscious Trained Leadership/Values and Mission Statement
HIV Medical Homes Resource Center
0
10
20
30
40
50
60
70
80
90
100
Series 3
Series 2
Series 1
Vital Signs: HIV Prevention Through Care and Treatment -- United States. MMWR December 2, 2011/60(47);1618-1623
Engagement in HIV Care
=Access =Care Co-ordination =Population Management
P
C
C
C C
P P
P
Summary
Both Primary Care and the RWCA are at a crossroad
PCMH is one model of transformation
RWCA clinics have many components of PCMH
There is much to learn from PCMH model and high performing primary care
Our health care system will have to change to meet our goal of an AIDS Free Generation
HIV Medical Homes Resource Center
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Roadmap for Medical Home Resource Center
PCMH concepts in RWCA Clinics– Action
Planning
Change Management of Improvement Opportunities
PCMH Certification
Strategic Planning Workshops
TA and Virtual Learning Community for practice change
TA to support certification
Year 1 Year 2 Year 3