using patient registries and automated patient outreach to qualify for ncqa level 3 medical home
TRANSCRIPT
The Patient Centered Medical Home:
Using Patient Registries and Automated Patient Outreach to Qualify for NCQA Level 3
Medical Home
Joseph Mambu MD CMD CHENovember 2009
The Joint Principles of the Patient Centered Medical Home (PC-MH)
AAFP, AAP, ACP, AOA: March, 2007
Personal physician Physician directed medical practice Whole person orientation Enhanced access to care Care is coordinated and/or integrated Quality of care / culture of patient safety Payment reform
Core Care Components &
Infrastructure Components
Patient Centeredness… Delivers effective treatment by a trustworthy physician &
medical staff. Offers access to timely reliable healthcare information and
advice. Considers patients’ cultural traditions, their personal
preferences, values and their family situations. Involves the patient in all decision making and respects the
patients’ preferences and right to decline treatment. Makes the patient & loved ones an integral part of the
healthcare team collaborating with the team in making clinical decisions.
Puts responsibility for important aspects of self-care and monitoring in patients’ hands — along with the necessary tools and support .
Ensures that transitions between providers, departments and health care settings are respectful, coordinated, and efficient.
When care is patient centered, then unneeded and unwanted services can be reduced.
The Current Model of Care:Connection by Billing
Insurer
The Future Model of Care: Patient Centered Integrated Delivery System
Sub-specialty “Medical Home Neighbors” Referrals and Procedures
Insurer
Patient Centered Hospital
Patient Centered Medical Home
Data Center
PCPCC–THE BUYERS OF HEALTHCARE
Linkage of PCMH to Reimbursement:One Model
Monthly Management Fee per patientBased upon NCQA level of recognition
Enhanced Fee Schedule for Visits/ProceduresE&M Coding
Quality, and Patient ExperienceBased upon performance reporting and patient satisfaction reporting
Profit-sharing
Which Payment System Is Best?
Depends on the Disease/Condition
OveruseUnderuse
Underpayment
Inefficiency
CostPer
Episode
Episode Payment
Comprehensive Care Pmt.(or Year-Long Episodes)
Fee for Service
Comprehensive Care Pmt.+
Episode Payment
Examples:COPD,
Congestive Heart Failure
Examples:Heart Disease,
Back Pain
Examples:Immunizations,Simple Injuries
Examples:Hip Fractures,
Labor & Delivery
Frequency of Episodes
•Since 1999, the state has invested in many MH components through disease management payments to practices with Medicaid pts.
• Emphasis on physician led team approach, disease tracking & care managers within practices.
•Significant improvements in cost, utilization, and quality measures. Two major evaluations estimate it CNCC saved the state between $230 and $260 million in 2004.
Community Care of North Carolina
300
325
350
375
400
425
450
CY 2006 CY 2007
Medical Home Non-Medical Home
Geisinger Medical Home Sites and Hospital Admissions
Source: Geisinger Health System, 2008.
Hospital admissions per 1,000 Medicare patients
Geisinger Medical Home Pilot Sites Reduce Medical Cost
Source: G. Steele, “Geisinger Quality—Striving for Perfection,” Presentation to The Commonwealth Fund Bipartisan Congressional Health Policy Conference, Jan. 10, 2009.
550
560
570
580
590
600
610
620
630
CY 2006 CY 2007
Non-medical home
Medical home
Allowed per member per month
Cost Savings of DM Management
National Committee for Quality Assurance (NCQA) Currently, the most used
“stamp” of approval Practices can apply for
and achieve “recognition” (not certification . . )
Three levels possible Long application Fees involved Can re-apply/get level
changed
PPC-PCMH: What it is
Provides valid, reliable and “auditable” means for incentivizing investment in quality infrastructure and processes
Encourages practices to adopt proven systems for improving care
Complements evaluation of clinical effectiveness, patient experiences, and efficiency
PPC-PCMH: What it’s NOT
The definition of a PCMH The joint principles (and others as well) “define”
the PCMH A tool to “certify” practices as medical homes
It, along with attestation only qualifies a practice as having met the basic standards that COULD be a PCMH
Permanent in content and scoring Was designed to evolve over time
Physician Practice Connections/PCMH
January, 2008
PPC-PCMH Content and ScoringStandard 1: Access and CommunicationA. Has written standards for patient access and patient
communication**B. Uses data to show it meets its standards for patient
access and communication**
Pts
45
9
Standard 2: Patient Tracking and Registry Functions A. Uses data system for basic patient information (mostly
non-clinical data) B. Has clinical data system with clinical data in searchable
data fields C. Uses the clinical data system D. Uses paper or electronic-based charting tools to
organize clinical information**E. Uses data to identify important diagnoses and
conditions in practice**F. Generates lists of patients and reminds patients and
clinicians of services needed (population management)
Pts
2
33
64
3
21
Standard 3: Care ManagementA. Adopts and implements evidence-based guidelines
for three conditions **B. Generates reminders about preventive services for
clinicians C. Uses non-physician staff to manage patient care D. Conducts care management, including care plans,
assessing progress, addressing barriers E. Coordinates care//follow-up for patients who receive care
in inpatient and outpatient facilities
Pts
3
4
35
5
20
Standard 4: Patient Self-Management Support A. Assesses language preference and other communication
barriersB. Actively supports patient self-management**
Pts
24
6
Standard 5: Electronic Prescribing A. Uses electronic system to write prescriptions B. Has electronic prescription writer with safety checksC. Has electronic prescription writer with cost checks
Pts33
2
8
Standard 6: Test Tracking A. Tracks tests and identifies abnormal results
systematically** B. Uses electronic systems to order and retrieve tests
and flag duplicate tests
Pts7
6
13
Standard 7: Referral Tracking A. Tracks referrals using paper-based or electronic
system**
PT4
4
Standard 8: Performance Reporting and Improvement A. Measures clinical and/or service performance by
physician or across the practice** B. Survey of patients’ care experience C. Reports performance across the practice or by
physician **D. Sets goals and takes action to improve performance E. Produces reports using standardized measures F. Transmits reports with standardized measures
electronically to external entities
Pts
3
33
3
21
15
Standard 9: Advanced Electronic Communications A. Availability of Interactive Website B. Electronic Patient Identification C. Electronic Care Management Support
Pts121
4**Must Pass Elements
Phytel Patient Outreach
Patient-Centered Medical Home (PPC-PCMH™) Qualification
PPC2: Patient Tracking and Registry Function Element F - Use of System for Population Management
PPC3: Care Management Element A – Guidelines for Important Conditions
PPC3: Care Management Element B - Preventive Service Clinician Reminders
"Phytel’s registry and care management activities helped our practice achieve level 3 recognition - the highest of the NCQA’s medical home qualification”
Joseph Mambu, M.D.President, Family Medicine, Geriatrics and Wellness
INITIAL LESSONS LEARNED
1. Personal Transformation of Physicians Required
2. Transformation to a PCMH is developmental requiring “Core Competencies” and “Adaptive Reserves”
3. Regarding technologies, There is no “Plug and Play”
4. “Change Fatigue” - a Serious Obstacle even within Capable and Highly Motivated Practices
PRACTICE RECOMMENDATIONS
Establish Realistic Expectations for Time and Effort a. Change in the doctor-patient relationship to a more personalized partnership b. Shift from authoritative leadership style to one that
facilitates and empowers c. Shift from physician-centered care to team-based care
Learn to be a Learning Organizationa. Systems Thinkingb. Personal Masteryc. Mental Modelsd. Shared Visione. Team Learning
Redesigned Work Flow1. Communication - enhanced electronically, daily huddles, monthly staff & weekly committee meetings2. Cross training - with licensed employees working at the tops of their licenses3. New Roles - administrator, clinical care coordinator/health coach, DM/prevention coordinator, EMR customizer, QI physician4. Pre-visit and post-visit care PRN5. Scheduled Patient visits with RN health coach6. Group visits7. Patient portal 8. Universal email access
IMPROVING THE CARE OF CHRONIC DISEASE
DISEASE MANAGEMENT
What Phytel Does Phytel Mines Data This data will help your practice begin to meet
the challenge of achieving the HEDIS, IOM, AQA, NCQA standards.
Phytel interacts with your practice management and electronic health record.
Phytel can identify patients due for recommended care based on evidenced based protocols.
Patients are contacted via automated outreach.
What Phytel Does Phytel has scripted messages to contact
patients via telephone. The system is secure and HIPPA compliant. Phytel can track patient response and monitor
compliance. Phytel will generate reports to document quality
and P4P data as well. Phytel will generate reports to document
increased bookings and financial and clinical results.
Primary Care Protocol Set*Appointment Reminders/Missed Appointment F/U
Prevention/Screening:
Annual Preventive Medicine Visits
Breast Cancer
Cervical Cancer
Immunizations:
Influenza
Pneumonia
HPV
Mammography
Osteoporosis
Prostate Cancer
Welcome to Medicare Visits
Disease Management:
Congestive Heart Failure:
F/U Visit Frequency
ACE/ARB/Beta Blocker Therapy †
Coronary Artery Disease:
F/U Visit Frequency
Anti-platelet Therapy †
________________________________________
*Provided all data-points currently coded.
† PQRI CPT II Coding Required
‡ Non-PMS data point(s) required.
Diabetes:
F/U Visit Frequency
Hemoglobin A1c Frequency †
Hemoglobin A1c Level Control ‡
Hyperlipidemia:
F/U Visit Frequency
LDL-C Frequency †
LDL-C Level Control ‡
Hypertension:
F/U Visit Frequency
Systolic/Diastolic Frequency †
Systolic/Diastolic Level Control ‡
Asthma:
F/U Visit Frequency
Appropriate Pharmacologic Therapy †
Thyroid Disease
F/U Visit Frequency
COPD
F/U Visit Frequency
Practice Development Campaigns:
Back to School Physical Examinations
Travel Examinations
Childhood Immunizations
New Providers/Services
PATIENT REGISTRIES
MEASURING PATIENT-CENTEREDNESS
SUMMARY POINTS PCMH - revolutionary redesign of primary
healthcare delivery, repositioning the doctor-patient relationship at the epicenter of that system
PCMH transformation requires superior leadership, expert change management, enough time (years) and substantial financial support in order to realize its full potential. Payment reform must “co-evolve”.
Adequately funded and fully deployed, the PCMH
can become the key component that could then catalyze regional then national networking to form the framework for a revitalized healthcare system