1. Patient Centered Medical Home
Delaware Health Care Commission
Janice E. Nevin, MD, MPH
Chief Medical Officer
Christiana Care Health System

2. What is a Patient Centered Medical Home?

3. Defining the Medical Home
Superb Access to Care
Patients can easily make appointments and select the day and time.
Waiting times are short.
and telephone consultations are offered.
Off-hour service is available.
Patient Engagement
in Care
Patients have the option of being informed and engaged partners in their care.
Practices provide information on treatment plans, preventative and follow-up care reminders, access to medical records, assistance with self-care, and counseling.
Clinical Information Systems
These systems support high-quality care, practice-based learning, and quality improvement.
Practices maintain patient registries; monitor adherence to treatment; have easy access to lab and test results; and receive reminders, decision support, and information on recommended treatments.
Care Coordination
Specialist care is coordinated, and systems are in place to prevent errors that occur when multiple physicians are involved.
Follow-up and support is provided.
Team Care
Integrated and coordinated team care depends on a free flow of communication among physicians, nurses, case managers and other health professionals (including BH specialists).
Duplication of tests and procedures is avoided.
Patient Feedback
Patients routinely provide feedback to doctors; practices take advantage of low-cost, internet-based patient surveys to learn from patients and inform treatment plans.
Publicly available information
Source: Health2 Resources 8

4. PCMH - History 1967 – American Academy of Pediatrics: “Medical Home”
1996 – Institute of Medicine, Committee on the Future of Primary Care: integrated… accountable…sustained partnership with patient
2001 – IOM, Crossing the Quality Chasm – 6 aims: safe, effective, Pt-centered, timely, efficient, equitable
2007 – Joint Principles of PCMH

5. PCMH – Joint Principles
Feb, 2007 – Joint Principles by ACP, AAFP, AAP, AOA
Personal physician – pt has 1 doc, 1st contact, continuous, and comprehensive care
Physician directed care – provider leads medical team
Whole person orientation – acute, chronic, preventative, home care & specialty services
Coordinated care – subspecialty, hospital, NH, uses registry, IT exchange, culturally sensitive
Quality & Safety – evidenced-based, CQI
Enhanced access – expanded hrs, e-visit, patient portal & group visits
Payment – should reflect added value to patients

8. TODAY’S CARE MEDICAL HOME CARE
My patients are those who make appointments to see me
Our patients are those who are registered in our medical home
Care is determined by today’s problem and time available today
Care is determined by a proactive plan to meet patient needs with or without visits
Care varies by scheduled time and memory or skill of the doctor
Care is standardized according to evidence-based guidelines
I know I deliver high quality care because I’m well trained
We measure our quality and make rapid changes to improve it
Patients are responsible for coordinating their own care
A prepared team of professionals coordinates all patients’ care
It’s up to the patient to tell us what happened to them
We track tests & consultations, and follow-up after ED & hospital
Clinic operations center on meeting the doctor’s needs
A multidisciplinary team works at the top of our licenses to serve patients 8
Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma

9. Recognition Programs for PCMH Developed or Under Development
Quality Organizations
PCMH Standards Activity
2010
National Quality Forum – draft of Care Coordination measures – 25 “Preferred Practices”
Joint Commission – Primary Care Home Initiative – release mid 2011 ,
Originally, URAC was incorporated under the name "Utilization Review Accreditation Commission." However, that name was shortened to just the acronym "URAC“
National Committee for Quality Assurance

10. Comparison of PCMH 2008 and PCMH 2011
PCMH 2008 (9 standards/30 elements)
Access and Communication
Processes
Results
Patient Tracking and Registry Function
Care Management
Continuity Between Settings
Self-Management Support
Electronic Prescribing
Test Tracking
Referral Tracking
Performance Reporting and Improvement
Measures of Performance
Patient Experience
Advance Electronic Communication
PCMH 2011 (6 standards/24 elements)
Access and Continuity
Access
Electronic Access
Continuity
Patient/Family Partnership
Practice Organization
Identify/Manage Patient Populations
Plan/Manage Care
Care Management
Medication Management
Self-Management Support
Track and Coordinate Care
Test/Referral Tracking
Facilities
Community
Performance Measurement and Quality Improvement
Measures of Performance
Patient Experience
Quality Improvement 10

11. AAFP – National Demonstration Project (NDP)
36 FP practices from across the country
June 2006 – June 2008
Randomized to facilitated learning vs. self-directed
“The PCMH represents the essentials for better primary care, improved delivery of chronic care, and active partnership with an informed patient synergized by appropriate use of information and communications’ technology.”
Nutting PA, Miller WL, et. Al. Initial lessons from the first National Demonstration Project on Pt Transformation and PCMH. Ann Fam Med 2009;7:

12. National Demo Project conclusions
1. Practice transformation is more than a series of changes and requires shifts in roles and mental models
2. The larger system can help or hinder
3. Practice adaptive reserve is critical to managing
change
4. Motivation of key practice members is critical
5. Developmental pathways to success vary considerably by practice
6. Practice change is enabled by the multiple roles that facilitators play
Ann Fam Med 2010;8(suppl 1):s45-s56.

13. Evidence of Cost Reduction
Recent studies estimate that if every American had access to a Medical Home, national health care expenditures would drop by 5.6% – translating into a national savings of at least $67 billion per year.1
States which relied more on Primary Care have:
Lower Resource Inputs (hospital beds, ICU beds, total physician labor, primary care labor, and medical specialist labor);
Lower Utilization Rates (physician visits, days in ICUs, days in the hospital, and fewer patients seeing 10 or more physicians);
Lower Medicare Spending (inpatient reimbursements and Part B payments).2
1. Dartmouth Atlas of Health Care, Variation among States in the Management of Severe Chronic Illness, 2006
Commonwealth Fund, Chartbook on Medicare, 2006;
2. Spann SJ, for the members of Task Force 6 and The Executive Editorial T: Report on Financing the New Model of Family Medicine. Ann Fam Med 2004; 2(suppl_3):S1-21 PMID

14. Community Implications - Published Results of PCMH Projects to Date
Group Health Cooperative of Puget Sound
29% reduction in ER visits; 11% reduction in ambulatory care sensitive admissions
Improvements in diabetes and heart disease care
Cost neutral after 1 year
Geisinger Health System
14% decrease in hospital admissions
9 % reduction in costs
ROI greater than 2 to 1
Source: PCPCC Pilot Guide, 2009

15. Community Implications – Published Results of PCMH Projects (cont.)
Intermountain Healthcare Medical Group Care Management Plus
39% Decrease in emergency room admissions
24% Decrease in hospital admissions
Net reduction cost of 640$ per patient and 1,650$ among high risk patients
BlueCross BlueShield of NC-Palmetto Primary Care Physician
12.4% decrease in ER visits
10% decrease in hospital admissions
Total medical and pharmacy costs were 6.5% lower
Source: PCPCC Pilot Guide, 2010 15 15

16. Care Team Transformation16

17. Health Coach Functions17

18. Questions?