patient-centered medical home 101: general overview · 2017-09-05 · 2 . pcpcc 2015. all rights...

PCPCC 2015. All rights reserved.

Patient-Centered Medical Home 101: General Overview

Publicly Available Slide Deck Last Updated: January 2015

Suggested Citation: PCPCC Map Tools. (2015). Patient-Centered Medical Home 101: General Overview. Patient-Centered Primary Care Collaborative. Accessed at https://www.pcpcc.org/resource/map-tools-pcmh-slide-presentations.


Purpose of Slide Deck

• We invite users to adapt these slides for your own

presentations. Please see the notes sections for more

detailed information.

• This slide deck – PCMH 101 - is focused on explaining what is

the patient-centered medical home (PCMH) along with how

and why it’s effective. For slides on the outcomes of PCMH,

please access the second slide deck – PCMH 201: A Snapshot

of the Evidence.

• For the most current publicly reported outcomes data, please

go to PCPCC’s “Outcomes View” of the Primary Care

Innovations and PCMH Map:

http://www.pcpcc.org/initiatives/evidence

2


Outline

Introduction & General Overview to the Patient-Centered Medical Home (PCMH)

– What it is

– Why it works

– How it works

3

PCPCC 2015. All rights reserved. Source: www.ahrq.gov

Defining the Medical Home The medical home is an approach to primary care that is:

Committed to

Quality and Safety

Maximizes use of health IT,

decision support and other tools

Accessible

Care is delivered with short

waiting times, 24/7 access and

extended in-person hours

Coordinated

Care is organized across

the ‘medical

neighborhood’

Comprehensive

Whole-person care

provided by a team

Person-Centered

Supports patients and

families in managing

decisions and care plans

4


Patient-Centered

Comprehensive

Coordinated

Accessible

Committed to quality and

safety

A team of care providers is wholly accountable for patient’s physical and mental health care needs – includes prevention and wellness, acute care, chronic care

Ensures care is organized across all elements of broader health care system, including specialty care, hospitals, home health care, community services & supports, & public health

Delivers consumer-friendly services with shorter wait-times, extended hours, 24/7 electronic or telephone access, and strong communication through health IT innovations

Demonstrates commitment to quality improvement through use of health IT and other tools to ensure patients and families make informed decisions

• Dedicated staff help patients navigate system and create care plans

• Focus on strong, trusting relationships with physicians & care team, open communication about decisions and health status,

compassionate/culturally sensitive care

• Care team focuses on ‘whole person’ and population health

• Primary care could co-locate with behavioral, oral, vision, OB/GYN, pharmacy, etc.

• Special attention paid to chronic disease and complex patients

• Care is documented and communicated effectively across providers and institutions, including patients, primary care, specialists, hospitals, home health, etc.

• Communication and connectedness is enhanced by health information technology

• Implement efficient appointment systems to offer same-day or 24/7 access to care team

• Use of e-communications and telemedicine to provide alternatives for face-to-face visits and allow for after hours care

• EHRs, clinical decision support, medication management to improve treatment & diagnosis.

• Establish quality improvement goals; use data to monitor & report about patient populations and outcomes

Feature Definition Sample Strategies Potential Impacts

Patients are more likely to seek the right care, in the right place, and at the right time

Patients are less likely to seek care from the emergency room or hospital, and delay or leave conditions untreated

Providers are less likely to order duplicate tests, labs, or procedures

Better management of chronic diseases and other illness improves health outcomes

Focus on wellness and prevention reduces incidence / severity of chronic disease and illness

Lower use of ER & avoidable hospital, tests procedures & appropriate use of medicine = $ savings

Why the Medical Home Works: A Framework

Supports patients and families to manage & organize their care and participate as fully informed partners in health system transformation at the practice, community, & policy levels


Changing to a new Paradigm

Today Future

Treating Sickness / Episodic Managing Populations

Fragmented Care Collaborative Care

Specialty Driven Primary Care Driven

Isolated Patient Files Integrated Electronic Records

Utilization Management Evidence-Based Medicine

Fee for Service Shared Risk/Reward

Payment for Volume Payment for Value

Adversarial Payer-Provider Relations

Cooperative Payer-Provider Relations

“Everyone For Themselves” Joint Contracting

6


Delivery Reform

Payment Reform

Public Engagement

Benefit Redesign

Health System transformation requires…

7


Solutions point to strengthened Primary Care

Significant problems

Rising healthcare costs $2.4 trillion (17% of GDP)

Gaps/variations in quality and safety

Poor access to primary care providers

Below-average population health

• PCMHs

• ACOs

• EHR/HIE investment

• Disease-management

pilots

• Alternative care

settings

• Patient engagement

• Care coordination

pilots

• Health insurance

exchanges

• Top-of-license practice

… “Experiments” underway

Across 300+ studies, better primary care

has proven to increase quality and curtail

growth of health care costs

… Primary care-centric projects

have proven results

↑ Aging population & chronic disease

8

PCPCC 2015. All rights reserved. Source: UCSF Center for Excellence in Primary Care.

http://cepc.ucsf.edu/



Public Health

Employers

Schools

Faith-Based Organizations

Community Centers

Home Health

Hospital

Pharmacy

Diagnostics

Specialty & Subspecialty

Skilled Nursing Facility

Mental Health

Patient-Centered Medical Home

Community Organizations

Health IT

Health IT

$

$

PCMH at of “Medical Neighborhood”

Health Care Delivery Organizations

10


PCMH as hub for “medical neighborhood” and broader community

PCMHs serves as central “hub” for all health and social support services to achieve care coordination

Clinical partners • Specialists • Hospitals • Home health • Long term care • Clinical providers

Non-clinical partners • Community centers • Faith-based organizations • Schools • Employers • Public health agencies • YMCAS • Meals on Wheels

11


Public Engagement: Patients, Families & Caregivers, and Consumers must drive demand for the model

Public Engagement


PCMH can enhance community partnerships

Benefits for Practices: • Improved access to community

networks

• Increased market share

• Better care transitions

• Reduced disparities

• Increased patient satisfaction

• Access to community health data

• Increased use of preventive services

• Increased use of community services in prevention of rehospitalization

Benefits for Patients: • Increased access to supportive

services

• Better experience of care

• Support addressing healthy behaviors

• Hospitalization and ED visits

• Better health outcomes

Benefits for the Community: • Lower prevalence of disease and

disability • Decreased health costs • Decreased lost productivity • Better coordination between clinical

and public health efforts • Improved outcomes for diverse

populations Source: http://forces4quality.org/provider_community_partnerships

13

http://forces4quality.org/provider_community_partnerships




Patient-centered care associated with better processes of care and better health outcomes

Patients with positive patient experience are:

• More likely to follow physicians’ advice and medication regimens

• More likely to stay with their primary care provider (improved loyalty and retention)

• Less likely to file malpractice complaints

• More likely to report better outcomes post hospital discharge, if their ambulatory care experience was positive

• Often more likely to receive better process of care (e.g., preventive care screening, chronic disease management)

Sources: I. Wilson et al. (2005) Cost-Related Skipping of Medications and Other Treatments Among Medicare Beneficiaries Between 1998 and 2000. Journal of General Internal Medicine; A. M. Fremont et al., (2001) Patient-centered Processes of Care and Long-term Outcomes of Acute Myocardial Infarction. Journal of General Internal Medicine. 14:800–8; K. Browne et al. (2010). Primary Care Analysis & Commentary Measuring Patient Experience As A Strategy For Improving Primary Care. Health Affairs. 29(5).

14


Delivery reform: Growing evidence to support that the model works

Delivery Reform


PCMH enhances ability to identify and manage high-risk, high-need populations

• Risk stratification and diligent monitoring for all patients

• Track care plans and medication adherence

• Proactive outreach from care team with collaboration among specialists and primary care

• Patient engagement and activation

16


• Care coordinators

• Patient navigators

• Health coaches

• Peer support

• Care managers

• Behavioral health/mental health

• Community supports and social workers

• Pharmacists

• Patients, families & Caregivers

PCMH uses diverse empowered care teams

17


PCMH facilitates care that is documented and shared electronically

• Shared with patients through electronic records, portals, mobile apps, email – Includes patient-generated data

• Shared across providers and institutions through health information exchanges

• Shared across public and private payers

18


PCMH supports improved access to care and better patient experience

• 24/7 access to care team (phone or e-consults with nurses, etc.)

• Alternatives to traditional face-to-face visits, including telemedicine, group visits, e-consults, peer support

• Access to electronic health records and patient portals

19


• Consider experience of care from the patient’s

perspective – and includes families & caregivers • Patients with multiple chronic conditions (and/or

their caregivers) often in best position to advise care team on challenges/opportunities to improve care

• Through their stories, patients can energize and encourage team to promote compassionate care

PCMH includes patients, families & caregivers as part of care team

20


• Invite patients/caregivers into quality improvement efforts from the very beginning

• Invite patients/caregivers that represent the larger patient population (i.e. ethnicity, culture)

• Invite patients/caregivers with experience managing their own condition

• Provide compensation for patients/caregiver advisors

• Invite more than one patient, family, caregiver

PCMH includes patients, families & caregivers in practice transformation

21


Need to Integrate Behavioral Health into Primary Care

22 Source: http://uwaims.org

Consultative Model

• Psychiatrist/psychologist/social worker (behavioral /mental health expert) sees patients in consultation in behavioral health setting

Co-located Model

• Behavioral/mental health expert sees patients in primary care setting

Collaborative (or Embedded) Model • Behavioral/mental health expert provides

caseload consultation about primary care patients; works closely with primary care team


Payment Reforms: Necessary to sustain the model (and the progress made)

Payment Reform


Primary Care Remains Undervalued U.S. per-capita health spending, 2012

(under 65 with employer-sponsored health insurance)

Hospital inpatient

21%

Hospital outpatient visits/other

28%

Professional procedures

(non-hospital) 30%

Drugs 17%

Primary Care 4%

2012 Health Care Cost and Utilization Report. “ Health Care Cost Institute, Inc. (2013): Table A1 [Internet] Washington, DC: HCCI; 2013 Sept http://www.healthcostinstitute.org/


Emerging Payment Reform Trends

Volume-based reimbursement

Value-based reimbursement

Bundled payments

ACOs Global budget

contracts

Fee-For-Service


HIT Infrastructure: EHRs and Connectivity

Primary Care Capacity: Patient Centered Medical Home

Operational Care Coordination: Embedded RN Coordinator and Health Plan Care Coordination $

Value/ Outcome Measurement: Reporting of Quality, Utilization and Patient Satisfaction Measures

Value-Based Purchasing: Reimbursement Tied to Performance on Value

Supportive Base for ACOs, PCMH Networks, Bundled Payments, Global Capitation

Trajectory to Value-Based Purchasing It is a journey, not a fixed model of care

26

Source: THINC - Taconic Health Information Network and Community


The payment reform imperative

• Increasing % spend on primary care and payment reform is integral to the success of the model

• In fee-for-service (FFS), many PCMH strategies and care processes are rarely/poorly reimbursed (i.e. team based care, care coordination, phone/e-visits)

• Many PCMH practices are paid through FFS component coupled with care management payment (per member per month – PMPM)

• Growing number including: shared savings, bundled payments, partial/full capitation

27


Multi-payer payment reforms key to health system transformation

Many states are convening private and public payers and using uniform set of payment & quality metrics to provide needed alignment: • State/local government used as convening entity

(to mitigate antitrust concerns and provide participation of numerous stakeholders)

• Recognizes differences in various markets and encourages local collaboration

• Data from early evaluations trending positive • Funding from Comprehensive Primary Care (CPC)

Initiative & Multi-payer Advanced Primary Care Practice (MAPCP)

28 Source: Dulsky Watkins (2014) Milbank Memorial Fund


CMS Innovations Portfolio: Testing New Models to Improve Quality

Accountable Care Organizations (ACOs) Capacity to Spread Innovation

• Medicare Shared Savings Program (Center for Medicare)

Pioneer ACO Model

Advance Payment ACO Model

Comprehensive ERSD Care Initiative

•

•

•

Partnership for Patients

Community-Based Care Transitions

Million Hearts •

•

• Health Care Innovation Awards

State Innovation Models Initiative Primary Care Transformation

•

•

Comprehensive Primary Care Initiative (CPC)

Multi-Payer Advanced Primary Care Practice

(MAPCP) Demonstration

Federally Qualified Health Center (FQHC) Advanced

Primary Care Practice Demonstration

Independence at Home Demonstration

Graduate Nurse Education Demonstration

Initiatives Focused on the Medicaid Population

•

•

Medicaid Emergency Psychiatric Demonstration

Medicaid Incentives for Prevention of Chronic

Diseases

Strong Start Initiative

•

• •

• Medicare-Medicaid Enrollees

•

•

Financial Alignment Initiative

Initiative to Reduce Avoidable Hospitalizations of

Nursing Facility Residents

Bundled Payment for Care Improvement

•

•

Model 1: Retrospective Acute Care

Model 2: Retrospective Acute Care Episode &

Post Acute

Model 3: Retrospective Post Acute Care

Model 4: Prospective Acute Care

•

•

19


Need to change “Supply” and “Demand” “Supply side” reforms Reimbursement changes that impact health care delivery: • Increased payment for providers who adopt PCMH model

• Increased use of shared savings , bundled payments, capitated payments

• Alignment across all payers through multi-payer or all-payer initiatives

“Demand side” reforms Reimbursement changes that impact consumers and employers: • Consumers pay less in premiums/copays to use higher-value, PCMH

services

• Limit co-pays for wellness visits/primary care

• Use of tiered pharmacy benefits that encourage the use of cost effective prescriptions (including generics)

• Improve consumer understanding of the PCMH model and primary care to better manage health

30


Download Slide Deck 2 - PCMH 201: A Snapshot of the Evidence https://www.pcpcc.org/resource/map-tools-pcmh-slide-presentations

For real-time program and outcome updates, visit PCPCC’s Primary Care Innovations and PCMH Map: http://www.pcpcc.org/initiatives.

31

https://www.pcpcc.org/resource/map-tools-pcmh-slide-presentations











http://www.pcpcc.org/initiatives


Resources • Agency for Healthcare Research and Quality: www.ahrq.gov • Advancing Integrated Mental Health Solutions Center:

http://aims.uw.edu/ • Centers for Medicare and Medicaid Services Innovation: http://innovation.cms.gov/ • Health Care Cost Institute: http://www.healthcostinstitute.org/ • Milbank Memorial Fund: http://www.milbank.org • Patient-Centered Primary Care Collaborative: http://www.pcpcc.org • Robert Wood Johnson Foundation: Aligning Forces for Quality http://forces4quality.org/provider_community_partnerships • Taconic Health Information Network and Community:

http://www.thincrhio.org/ • UCSF Center for Excellence in Primary Care: http://cepc.ucsf.edu/

http://www.ahrq.gov/

http://aims.uw.edu/

http://aims.uw.edu/

http://aims.uw.edu/

http://www.healthcostinstitute.org/

http://www.milbank.org/

http://www.milbank.org/

http://www.pcpcc.org/

http://www.thincrhio.org/

http://www.thincrhio.org/



patient-centered medical home 101: general overview · 2017-09-05 · 2 . pcpcc 2015. all rights...

Documents