EXPLORING CONNECTIONSPCMH & CCHH

Lori Hinga

Melody Robinson

• Why is it important to view PCMH and CCHH as different, yet connected ?

PCMH• Patient Centered Medical Home--The patient-centered

medical home is a way of organizing primary care that emphasizes care coordination and communication to transform primary care into "what patients want it to be." Medical homes can lead to higher quality and lower costs, and can improve patients’ and providers’ experience of care.

• Patient focused Prescriptive in benchmarks and government directed

• Traditional partners tend to be health focused

• Improvements to clinical services delivery

CCHH

• Community Centered Health Home--Effectively integrating community prevention into health services delivery

• Community focused

• Directed by the community

• Broad range of partners

• Improvements in broad policy and system changes

CONNECTIONS

• Comprehensive

• Patient Center/Community

• Coordinated

• Accessible

• Quality and Safety

• Date Driven

BEFORE IMPLEMENTING CCHH…

• Current ‘Operational Health’ of the Organization• Engaged Leadership• Efficient Workflow/Process

• Standardized• Sustainable

• Reliable Data Management• Effective Data Entry • Efficient / Scheduled Data Extraction• Evidence Based Benchmarks • Trending and Reporting (Dashboards)• Performance/Quality Improvement (Based on Benchmarks / Trends)

• Electronic Health Registry• Efficient (Interfaced)• Population Health Management

• Care Team Implemented• Roles Identified• Trained• Engaged

TRANSITIONING TO CCHH REQUIRES…

• Change Management

• Non-Traditional Thinking

• Standardized / Sustainable processes

• Accurate / Reliable data

• Developing / Maintaining a reporting schedule

• Developing / Maintaining a quality dashboard displaying evidence based benchmarks and ‘real-time’ trends

• Deliberately analyzing and translating information to actively encourage meaningful change in the community

• Identifying established community coalitions, neighborhood associations etc.

• Relationship building with community partners, associations and coalitions

PCMH TO CCHH

PCMHInternal Data Collection and Evaluation Prioritizes Chronic/Acute Conditions Identifies Risk(s) Associated with Conditions

CCHHExternal Data Sharing with Community Partners Discusses Environmental Risk(s) Discusses Opportunities for Community

Change/Improvement Prioritizes and Plans

PCMH TO CCHHTHE CONNECTION…

• CCHH - Assessment • Standard set of questions related to community, social and

economic conditions

• PCMH Systematic/Elements 2014 (NCQA)• Assessment

• 3.B.4.5.6.8 - Height, Weight, BMI, Tobacco Use• 2.C.1 - Assessing population diversity• 2.C.2 - Assessing language needs• 3.C.2 - Family / Social / Cultural Characteristics• 3.C.6 - Behaviors affecting health• 3.C.7 - Mental health /substance use history• 3.C.9 - Depression Screening using standardized tool

• 4.A.1-5 BH Condition / High Cost / High Utilization / Poorly Controlled or Complex Conditions / Social Determinants of Health / Referrals by Outside Organizations

• 4.B.3 - Assesses and addresses potential barriers to meeting self-care goals

• 4.E.7 - Assesses usefulness of identified community resources

PCMH TO CCHHTHE CONNECTION…

• CCHH – Analysis

• PCMH – Standards/Elements 2014 (NCQA)• Analysis

• 1.A.5 Monitoring no-show rates• 1.A.6 Acting on identified opportunities to improve access• 3.D.1-4 Identifies populations of patients and reminds them of needed care• 4.A.6 Monitors the percentage of total patient populations identified through

its process and criteria• 6.A.1-4 Measures or receives data on two immunization measures / two other

preventive care measures / three chronic or acute care clinical measures / data stratified for vulnerable populations

• 6.B.1 Measures or receives quantitative data on at least two care coordination measures

• 6.B.2 Measures or receives quantitative data on at least two utilization measures affecting health care costs

• 6.C.1 Conducts a survey to evaluate patient/family experience on at least three of the following categories: Access, Communication, Coordination, Whole person care/self-care management support

FROM PCMH TO CCHH

• Poorly controlled or complex conditions• Diabetic Registry (PCMH)

Diabetic patients greater than 19 years old with an A1C > 8 living within zip code XXXXX

What are the risks associated with this condition (CCHH )?• Poor dietary intake?• Lack of exercise?• Medication compliance?• Minimal understanding of condition?

CCHH – THE COMMUNITY PARTNERSHIP

Poor dietary intake…• Access to healthy food?

(Nutrition and Physical Activity / Exposures and Behaviors)• Grocery store locations• Transportation to and from• Limited financial resources

Community Prioritization and Planning Share the data with community partners Identify possible contributors (Environment) Discuss collaborative improvement strategies/solutions Make it happen Continue to collect and analyze data (PCMH) Maintain/monitor data for improvement Share data with community partners

PCMH TO CCHHTHE CONNECTION…

• CCHH – Community and Advocate Mobilization• PCMH – Standards / Elements 2014 (NCQA)

• Community and Advocate Mobilizationo 2.B.4 The care team provides access to evidence-based care, patient/family education and self-

management supporto 2.B.7 The practice provides uninsured patients information about obtaining coverageo 2.D.6 Training and assigning members of the care team to support patients/families/caregivers in self-

management, self-efficacy and behavior changeo 3.E.4 The practice implements clinical decision support following Evidence Based Guidelines (EBG) for a

condition related to unhealthy behaviorso 3.E.5 The practice implements clinical decision support following EBG for well child or adult careo 3.E.6 The practice implements clinical decision support following EBG for overuse/appropriateness

issueso 4.A.1-5 The practice establishes a systematic process and criteria for identifying patients who may

benefit from care management. The process includes consideration of Behavioral Health Conditions / High Cost & Utilization / Poorly Controlled or Complex Conditions / Social Determinants of Health / Referrals by Outside Organizations

o 4.B.1-5 The care team and patient/family/caregiver collaborate to develop and update an individual care plan that includes the following features for at least 75%of the patients identified in Element A – Patient Preference and Functional/Lifestyle Goals / Identifies Treatment Goals / Assesses and Addresses Potential Barriers to Meeting Goals / Includes a Self-management Plan / Is Provided in Writing to the Patient/Family/Caregiver

o 4.C.3 Provides information about new prescriptions to more than 80% of patients/families/caregiverso 4.C.6 Assesses response to medications and barriers to adherence for more than 50% of

patients/families/caregiverso 4.E.1 Uses and EHR to identify patient-specific education resources and provides them to more than

10% of patientso 4.E.2 Provided educational materials and resources to patientso 4.E.3 Provides self-management tools to record self-care resultso 4.E.5 Offers or refers patients to structured health education programs such as group classes and peer

supporto 4.E.6 Maintains a current resource list on five topics or key community service areas of importance to

the patient population including services offered outside the practice and its affiliates

FROM PCMH TO CCHH

4.B.1-5 The care team and patient/family/caregiver collaborate to develop and update an individual care plan that includes the following features for at least 75%of the patients identified in Element A – Patient Preference and Functional/Lifestyle Goals / Identifies Treatment Goals / Assesses and Addresses Potential Barriers to Meeting Goals / Includes a Self-management Plan / Is Provided in Writing to the Patient/Family/Caregiver

• Identify Potential Barriers to Meeting Goals (PCMH)

• Extractable data from templates and/or registry

• Identify common barriers (PCMH)

• What are the risks associated with these barriers (CCHH)?

FROM PCMH TO CCHH

• Common barriers to meeting the individual care plan (Risk)

• Personal Safety (Parks / Recreation)• Transportation (Public / Personal)

• Cost• Effective Education • Health and Social Services• Community Engagement• Gathering Places

CCHH – THE COMMUNITY PARTNERSHIP

Cost of public transportation (Barrier)…

Community Prioritization and Planning (CCHH) Share the data (barriers / risk) with community partners Identify possible contributors (Environment) Discuss collaborative improvement strategies/solutions Plan the change (project) Make it happen Continue to collect and analyze data (PCMH) Maintain/monitor data for improvement Share data with community partners on a continuous basis

Possible Community Strategies• Low/No cost public transportation to specific venues• Bicycle friendly cities (New Orleans)• Bicycle share program (Marquette, MI)• Social agency to assist with alternate financial resources• Community Programs (Budgeting)• Providing healthcare within priority areas (highest identified barrier

communities)

PCMH TO CCHHTHE CONNECTION…

• CCHH – Model Organizational Practices• PCMH – Standards / Elements 2014 (NCQA)

• Model Organizational Practices• 1.A.1 Providing same-day appointments for routine and urgent care

(Critical)• 1.A.2 Providing routine and urgent care appointments outside regular

business hours• 1.A.3 Providing alternative types of encounters• 1.A.4 Availability of appointments• 2.D.1 Defining roles for clinical and non-clinical care team members• 2.D.2 Identifying the team structure and the staff who lead and sustain

team-based care• 2.D.3 Holding scheduled patient care team meetings or a structured

communication process focused on individual patient care (Critical)• 2.D.5 Training and assigning members of the care team to coordinate care

for individual patients• 2.D.6 Training and assigning members of the care team to support

patients/families/caregivers in self-management, self efficacy and behavior change

• 2.D.7 Training and assigning members of the care team to manage the patient populations

• 2.D.8 Holding scheduled team meetings to address practice functioning• 2.D.9 Involving care team staff in the practice’s performance evaluation

and performance / quality improvement activities• 2.D.10 Involving patients/families/caregivers in performance / quality

improvement activities or the practice’s advisory council

FROM PCMH TO CCHH

• Model Organizational Practices• Develop and maintain an operational infrastructure to

support the performance of community centered health functions…

• Patient-Centered Access• The Practice Team

• Defined Roles• Team Structure• Communication Process (must be internal and external)• Training and Support (Self-Management / Self Efficacy / Behavior

Change)• Care Team Involvement in Performance Evaluation and

Improvement Activities• Patients/Families/Caregivers Involvement in Performance

Evaluation and Improvement Activities or The Advisory Council

PCMH TO CCHHTHE CONNECTION…

• Maintain Patient Access (PCMH)• Keep collaborative/partners informed / up to date

• Develop Internal Care Team (PCMH)• Train• Support• Inform – Schedule and/or participate in scheduled care team

meetings• Community Updates

• Partners• Projects• Risks• Environment

• Involve care team (CCHH)• Patients/Families/Caregivers Involvement in Performance

Evaluation and Improvement Activities or The Advisory Council

• Care Team Involvement in Performance Evaluation and Improvement Activities

THE CONNECTION…

• PCMH•Evaluate the status

of the Organization as it relates to CCHH

Engaged Leadership

Workflow Analysis Data Management

Analyze Data Identify Trends Identify Risks

Efficient / Effective / Trained Care Team

• CCHH• Identify Community Partners /

Coalitions• Develop Relationships • Share Data• Share Identified

Improvement Areas•Share with Community Partners•Share Identified Risks•Discuss Environmental

Influences•Discuss Community Strategies

to Improve•Develop a Project Plan

(Campaign)•Maintain Relationships and

Monitor Progress Toward the Project Goal

•Continue to Share Data

QUESTIONS?

THANK YOULori Hinga

Melody Robinson