6/27/2014

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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