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1 The Patient-Centered Medical Home (PCMH): Building a Better Health Care Model
When giving this presentation: This presentation offers a broad range of information and talking points. Draw from this resource information that best suits your objectives, the venue for the presentation, audience size and time frame. Don’t attempt to cover too much ground in one session. Keep in mind that your audience is likely to recall no more than four to six key points from your presentation. Personalize the material to reflect your style and experiences. Make changes to the slides so that the visuals complement your presentation. Feel free to change background color and add images, graphics and other elements. Encourage questions from the audience throughout your presentation. Consider using this presentation at your next Family Medicine Interest Group event, new student orientation, clerkship orientation, summer preceptor activities , medical student conference, chapter meeting and/or residency fair. Be sure you are in touch with the unique needs and specific concerns of your audience and craft your objectives accordingly. Build in time for group discussion at the end of the presentation. Keep track of the nature of the questions and schedule additional activities that allow students and family physicians to discuss topics/questions more in depth. Utilize the pre- and post-assessment tools provided to collect feedback and refine your presentation. Forward student and presenter feedback to Ashley Bieck, MPA, or Wendy Biggs, MD, in the AAFP ’s Division of Medical Education.

2 Objectives Identify current priorities to enact health care reform.
Describe the Patient-Centered Medical Home (PCMH) model of care. Understand how the PCMH model is an appropriate method to address priority health reform issues. Understand Family Medicine’s role in the development and adoption of the Patient-Centered Medical Home. Slide 2 – Objectives Before we get started I would like for you to think about what you have already seen and experienced in the field of medicine. What sorts of questions are you hearing from the many stakeholders about health care reform? Do you have perceptions or ideas about what the Affordable Care Act means meant to for primary care practice? Consider asking the audience if there are other things they would like to specifically address in this presentation.

3 Patients today are savvy consumers of health care and have higher expectations.
Communication Access Convenience Coordination Responsiveness Source: Medfusion, an AAFP affinity partner, 2008 Slides 3 &4 – Patients today are savvy consumers of health care. Patients expect to have online access to physicians and office staff, especially Access means 24/7—perhaps not to the physician or a real person but the ability to communicate via or to set appointments Convenience= same day appointments, setting up appointments online on line, early morning and/or evening and weekend appointments Coordination=obtaining lab results, films, referrals, should not rest on the patients’ shoulders Responsiveness=make sure the patient is the priority, return phone calls, s, etc.

4 Patient Expectations 75% want the ability to interact with their physician online (appointments, prescriptions, test results). 77% want to ask questions without a visit. 75% want access as part of their overall care. 62% of patients say access to these services would influence their choice of physicians. Source: Medfusion, an AAFP affinity partner, 2008

5 Family Medicine is leading the way to make health care more patient-centered.
“Will family medicine teachers prepare their students and residents to help practices transform and meet the infrastructure principles? I believe that we will, not simply because doing so will likely increase our financial situation but because building PCMH’s that meet the care and infrastructure principles will improve the care we provide to meet our patients’ and our communities’ needs. We will build our PCMH practices, because it is the right thing to do and it reflects our core values.” John C. Rogers, MD, MPH, MEd Past-President, Society of Teachers of Family Medicine Fam Med 2008;40(1):11-2.) Slide 5 – Family Medicine is leading the way to make health care more patient-centered. This is at the forefront of dialogue in the family medicine organizations. As the physicians on the front lines of care for patients and communities, family physicians believe that the patient should be the center of care, not the physician or the health care system.

6 Health Care Reform Priorities for US health care reform…
Quality-WHO (World Health Organization) identifies the US health care system as the “most individually responsive” WHO ranks US health care 37th overall (among 191 countries) Efficiency People with acute and chronic medical conditions receive only about two-thirds of the health care that they need. Between 20 and 30% of tests and procedures provided to patients are neither needed nor beneficial. *Leatherman and McCarthy, Quality of Health Care in the United States: A Chartbook, The Commonwealth Fund *Schuster, McGlynn, and Brook. Slides 6, 7,8 and 9 –Health Care Reform Patients and patient advocacy groups, employers and purchasers of insurance, federal and state government, and clinical staff ) have concerns about the current health care system. The issues at hand include improving the quality of health care, improving efficiency in health care delivery, controlling the astronomical rise of health care costs, establishing a patient-friendly system, improving access for both insured and uninsured patients, and better using technology to facilitate health care delivery. Both Barack Obama and Newt Gingrich have stated, “We do a better job tracking a FedEx package in this country than we do tracking a patient's health records.”

7 Health Care Reform Priorities for US health care reform… Cost
The U.S. spends more on health care per capita than any other nation. The U.S. spends more on health care as a proportion of GDP (Gross Domestic Product) than any other nation. Patient-friendly Public confidence in hospitals and personal doctors remains relatively high. While individuals report generally positive experience with medical care, public confidence and trust in the system at large is eroding. *Leatherman and McCarthy, Quality of Health Care in the United States: A Chartbook, The Commonwealth

8 Health Care Reform Access Priorities for US health care reform…
Lack of insurance is a major reason for not obtaining access to needed care. The 40 million Americans without insurance coverage are less likely to obtain needed medical care and preventive tests Even with insurance, barriers to care still exist: Lack of an established relationship with a doctor Language and Cultural barriers Social Determinants of Health Transportation issues Geography High out-of-pockets costs even for those with insurance ie: high deductibles, underinsured, etc.

9 Health Care Reform Priorities for US health care reform… Automation
Infrastructure for health care delivery has not kept pace with the electronic innovations of other industries. Many institutions still rely on systems that are not automated and allow opportunities for human error, even though technology exists to minimize errors and improve efficiency.

10 An effective and efficient health care system is a primary care-based health care system
Provides access to basic health care services Manages health disparities Coordinates care Controls cost Offers sustainability Slide The value of a primary care based health care system Cancer prevention, behavior modification, and control of chronic diseases are some of the ways in which primary care improves the health of individuals. When we examine medical outcomes related to primary care we find: U.S. adults and children who have a regular source of primary health care have better health outcomes than those who don’t. An increase in the proportion of physicians who practice primary care leads to earlier detection of several types of cancer including cancer of the breasts, colon, cervix and skin. Having a primary care physician reduces mortality due to cardiovascular and pulmonary diseases. States that have more primary care doctors have lower death rates. Primary care decreases hospital admission rates and decreases emergency room utilization for children and adults. Countries that emphasize primary care have better population health [as measured by longevity, infant mortality and patient satisfaction] at lower costs. Researchers who have examined the potential impact of primary care on health care spending in the United States estimate that the nation would save $67 billion dollars per year if every American used primary care physicians as their usual source of care.

11 Brief History Of The PCMH
AAP “Medical Home” Records AAP Medical Home Provider Policy AAFP Future of Family Medicine PCPCC Joint Principles of PCMH NCQA-PCMH PPACA CMMI ACOs Private Payer Initiatives Direct Primary Care CPCI Advanced Primary Care Future 2010s 2000s 1990s Slide 11 – Acronyms AAP: American Academy of Pediatrics PCPCC: Patient Centered Primary Care Collaborative NCQA: National Center for Quality Assurance PPACA: Patient Protection and Affordable Care Act CMMI: Center for Medicare and Medicaid Innovation ACO: Accountable Care Organizations CPCI: Comprehensive Primary Care Initiative 1960s

12 Innovative Solution: History of the PCMH Concept
Introduced by American Academy of Pediatrics (AAP) in 1967 Initially referred to a central location for medical records The medical home concept was expanded in 2002 to include: Accessible Continuous Comprehensive Family-centered Coordinated Compassionate Culturally sensitive care In 2007, the AAP, the American Academy of Family Physicians (AAFP), the American Osteopathic Association (AOA), and the American College of Physicians (ACP) adopted a set of joint principles to describe a new level of primary care. Slide 12 – History of the PCMH Concept This concept was introduced by the American Academy of Pediatrics and referred to a central location for medical records, particularly for children with chronic illnesses. The concept was expanded in 2002 to include many of the concepts that are congruent with the findings of the Future of Family Medicine report. ( The PCMH model seeks to integrate these concepts into a health care delivery model that is determined by what patients want and need.

13 “Joint Principles” of the Patient-Centered Medical Home
A personal physician who coordinates all care for patients and leads the team. Physician-directed medical practice – a coordinated team of professionals who work together to care for patients. Whole person orientation – this approach is key to providing comprehensive care. Coordinated care that incorporates all components of the complex health care system. Quality and safety – medical practices voluntarily engage in quality improvement activities to ensure patient safety is always being met. Enhanced access to care – such as through open-access scheduling and communication mechanisms. Payment – a system of reimbursement reflective of the true value of coordinated care and innovation. Slides 13 & 14 – Joint Principles of the PCMH and Supporting Organizations These “Joint Principles” were initially adopted by the four founding organizations mentioned in the previous slide. Many other organizations have also signed on to these principles as the core representation of what health care delivery should and must become. (

14 Growing Support for the Patient- Centered Medical Home
Partnerships are developing as more and more stakeholders see value in the Joint Principles. The Patient Centered Primary Care Collaborative (PCPCC)* is a coalition of major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, physicians and others to develop and advance PCMH. The PCPCC has well over 1,000 members. *

15 The Patient Centered Medical Home The Family Medicine Model
Practice Organization Quality Care Heath Information Technology Health IT Health IT Patient Experience Patient-centered Care Slide 15 – The Patient Centered Medical Home This graphic is a model representation of the concepts of the PCMH. We will talk about each building block to better understand how practices are changing to implement this model. Family Medicine Foundation Patient-centered | Physician-directed

16 Culture of Improvement Risk-stratified Care Management
Medical Neighborhood Establish baseline performance measures Collect and analyze data Discuss best practices and improvement Conduct regular clinical team meetings Understand ways to identify patient’s risk status Plan out care for chronic conditions and preventive care Identify “high-risk” patients Use tools to track populations by risk category Manage care transitions and build linkage to community resources Coordinate care with specialists and outside facilities Evaluate care transition process Quality Care Slide 16 – Quality Measures First, quality measures are “Built In” to the PCMH. Practices are continually taking steps to measure and improve their clinical and service quality including feedback from their patients -- they live a culture of improvement. Staff members learn from each other through a systematic and disciplined approach, such as regular team meetings. The practice installs reliable systems (e.g. to track lab results, referrals and transitions in care) and uses check- lists, reminders and evidence-based point of care decision support tools. THINK OF AN EXAMPLE WHERE YOUR PRACTICE HAS GATHERED INFORMATION TO IMPLEMENT A QUALITY IMPROVEMENT PROJECT.

17 Shared Decision Making
Convenient Access Shared Decision Making Patient Experience Same-day appointments and extended hours communication with patients (E-visits) Web portals for Rx refill and appointments Translation and Culturally appropriate services Understanding the patient’s social barriers, goals and priorities Create care plans in collaboration with patient/caregiver Monitor progress between visits Conduct patient satisfaction surveys on a regular basis Establish patient advisory panel and QI activities Conduct patient focus groups Quality Care Slide 17- Patient Experience Patients want access to comprehensive primary care when they need it, when it’s convenient for them, that’s personalized and coordinated for them. Every interaction with the patient becomes truly PATIENT CENTERED. A PCMH creates the opportunity and support for patients to engage in their own care and in shared decision-making. The practice builds in same day access and 24/7 coverage. The practice innovates with new approaches to engage patients such as group visits and on-line services. GIVE AN EXAMPLE OF A PATIENT INTERACTION THAT WAS NOT PATIENT-CENTERED (e.g.-sending a patient to the emergency department for a non-emergent issue, or when a patient couldn’t get care that they needed because of “hassle”.) IDENTIFY WAYS THAT YOUR PRACTICE IS LOOKING TO SEE THE PATIENT EXPERIENCE FROM THE PATIENT’S PERSPECTIVE. Patient-centered Care

18 Financial Management Culture of Change Practice Environment
Lab testing Prescriptions Registries All staff are aware of the most efficient ways to deliver care National policies support the investment of resources into primary care practices that are effective and efficient Establish a PCMH leadership team Engage all members of the practice in a shared vision Provide staff education and training to support patient-centered care Staffing model supports team-base care Define roles for team members Include health coach and care coordination functions Practice Organization Quality Care Slide 18 – Practice Organization Business management systems are in place to assure disciplined financial management; disciplined personnel management; and disciplined and reliable processes to manage clinical care. A PCMH, like any other business, has to be built on a strong financial base in order to be sustainable and invest in itself. Secondly, a practice-based care team with effective leadership, communication and task delegation is essential. Thirdly, a disciplined, pro-active, systematic approach to wellness promotion, disease prevention and care coordination is another essential component of the PCMH. GIVE EXAMPLES FROM YOUR CURRENT PRACTICE. WHAT ARE THE WAYS THAT TEAM MEMBERS WORK EFFECTIVELY TOGETHER TO IMPROVE QUALITY, EFFICIENCY, AND ACCESS FOR PATIENTS. Patient-centered Care

19 Family Medicine Foundation
Technology Infrastructure Digitally Connected Evidence-Based Medicine EHR Reporting Tools Patient reminders Patient notification for new information Reminders for recommended care or health maintenance Makes patient registries possible Enhances care coordination by improving information flow with other physicians, practices, and providers Improves patient - physician communication Point-of-care learning , alerts and reminders Clinical decision support (e.g., Epocrates) Can quickly pull clinical data for quality analysis Can enhance business processes Population health management through patient registries Practice Organization Health Information Technology Quality Care Slide 19 – Health Information Technology Technology is the engine that propels many functions critical to an effective medical home. Technology facilitates a variety of essential information-driven functions in a MH: business and clinical processes (e.g. intra-office electronic messaging, clinical results and test tracking); connectivity and patient communication (e.g. e-prescribing, patient portals, and clinical messaging with patients); evidence-based medicine support (e.g. point of care clinical decision support and clinical reminders); population management (e.g. patient registries).; and, In a fully implemented PCMH a fully-functioning electronic health record system serves as the practice’s central nervous system. Patient – centered Care Family Medicine Foundation

20 Great Outcomes Good for patients Good for physicians
Patients enjoy better health. Patients share in health care decisions. Good for physicians Physicians focus on delivering excellent medical care. Good for practices Team works effectively together. Resources support the delivery of excellent patient care. Good for payors and employers Ensures quality and efficiency. Avoids unnecessary costs. Great Outcomes Practice Organization Quality Care Health Information Technology Patient-centered Care Slide 20 – Great Outcomes When all of these elements come together, this is a model that is good for patients, physicians, practices, and employers/purchasers of health insurance. Family Medicine Foundation

21 Does PCMH Work?
Fully implemented the PCMH hits the triple AIM, better health, better care, lower costs Improves practice organization, work environment and job satisfaction No longer a pilot…Now a program with proven results

22 The PCMH Model in Family Medicine Residency Training
“Preparing the Personal Physician for Practice” (P4) The P4 Initiative was designed to inspire and examine innovation in family medicine residency training.   Sponsors are the American Board of Family Medicine, the Association of Family Medicine Residency Directors, and TransforMED. Different approaches range from moving the continuity clinic into a new community setting, to expanding to a four-year program, to providing the opportunity for tracking and obtaining additional degrees while in training, and more.  The aim of P4 is to spur innovation in all family medicine residencies to best prepare family physicians be the excellent personal physicians of tomorrow. Initially, 84 Family Medicine residencies applied to participate in the P4 Initiative. The 14 P4 residencies were selected as participants for more intensive evaluation of outcomes to determine what works best. Slide 22 – PCMH Model in Training It is not enough to just look at what is being done in physician practices. How are physicians in training programs learning these skills that will prepare them to practice in this new model of care? The P4 Initiative was one example of residency programs developing innovations in training and family medicine practice. There are numerous examples of residency programs developing training innovations that are in concordance with the Joint Principles of the PCMH. View the Transformed website for the full report on the P4 initiative.

23 PCMH Model and Health Care Reform
Attempts to fix part of the problem without addressing it comprehensively will not lead to viable solutions. Advocacy by all stakeholders is necessary. Community projects through local hospitals and resource networks State projects for regional payors and state Medicaid programs National support for changing how care is delivered and for ensuring a prepared workforce to deliver care Slide 23 – PCMH and Health Care Reform Many leaders in Family Medicine would emphasize that innovations in the way that primary care medicine is delivered and investments in the nation’s primary care infrastructure must include dialogue about how to effect change at the local, state, and national level. The PCMH model has implications at all levels: how do individual practices and physicians need to change, what are the regional programs that should be developed to more effectively deliver care, and what are the national policies that should be in place to invest in primary care infrastructure and in giving patients what they need?

24 Family Physicians and the PCMH
PCMH is a place, not a person. Patient-centered, Physician-directed. Family physicians Provide comprehensive care Care for all patients Coordinate care Provide care that is effective and efficient* Future of Family Medicine *Starfield data Practice Organization Health Information Technology Slide 24 – Family Physicians and the PCMH Because family physicians are trained to provide comprehensive care and care for all patients, they are uniquely prepared to be the leaders of PCMH practices, which form the foundation for health care renovation. Family physicians have been proven to enhance improve the effectiveness and efficiency of care by providing well-coordinated, comprehensive care for patients. Quality Care Patient-centered Care

25 Family Physicians How we provide care:
Acute injuries and illnesses Health promotion and behavior change Hospital care Chronic disease management Maternity care Well-child care and child development Primary mental health care Supportive and end-of-life care Slide 25 – Family Physicians, how we provide care Family physicians recognize and manage complicated acute and chronic diagnoses including diabetes, heart disease, hypertension, anxiety, depression, obesity and cancer. Helping patients and their families prevent the onset of these complex diseases is an area in which family physicians excel. Sometimes, family physicians focus on the needs of very specific kinds of patients and have the option of pursuing additional expertise and training through fellowships in areas such as geriatrics, sports medicine, palliative care, preventive medicine, and international medicine, to name a few.

26 Family Physicians How we view patients:
Consider all of the influences on a person’s health. Know and understand people’s limitations, problems, and personal beliefs when deciding on a treatment. Are appropriate and efficient in proposing therapies and interventions. Develop rewarding relationships with patients. Provide a continuous healing relationship over time. Slide 26 – Family Physicians, how we view patients Family physicians are trained to go beyond the routine family medical history and to use tools such as genograms to gain a better understanding of a patient’s situation. These tools and FPs' orientation to the whole person help a family physician know how family patterns and imbalances might affect illness management and reveal sources of support that may inhibit or contribute to well being. Family physicians integrate biomedical and psychosocial factors into every patient visit often spending time with the patient discussing issues that may not have anything to do with their current complaint. Include examples from your experience such as a time when the patient’s chief complaint was not the true reason for their visit and how you arrived at what was really on the patient’s mind, how your ability to identify the true reason for the visit affected how much the patient trusted you.

27 Family Physicians Who we care for: Individuals and families
Women and men regardless of age or disease Infants, children, and adolescents regardless of disease Communities and public health Global health Slide 27 – Family Physicians, who we care for Family physicians care for people and families of all ages. Family physicians emphasize wellness, disease prevention, and evidence-based medical interventions; they are always aware of the psychological and social dimension of their patients’ lives. Family physicians are important because they:21,22 • Care for a wide variety of medical problems, • Coordinate care with other health professionals, • Prioritize from a broad agenda to meet their patients’ needs, • Practice patient-centered medicine, • Provide care to individuals within the context of family and community, • Develop relationships over time and multiple patient visits, • Perform a significant amount of patient education, • Tailor messages about health habits to high-risk patients, • Use illness visits as opportunities for prevention, and • Use patient visits and opportunities to identify mental health problems.

28 Primary Care Delivers Better Health Outcomes
 mortality  morbidity  medication use per capita expenditures patient satisfaction greater equity in health care SOURCE: B. Starfield, et al., “The Effects of Specialist Supply on Populations’ Health,” Health Affairs (March 2005); W5-97 Slide 28 – Primary Care Delivers Better Health Outcomes When we examine medical outcomes related to primary care we find: • U.S. adults and children who have a regular source of primary health care have better health outcomes than those who don’t. An increase in the proportion of physicians who practice primary care leads to earlier detection of several types of cancer including cancer of the breasts, colon, cervix and skin. Having a primary care physician reduces mortality due to cardiovascular and pulmonary diseases. • States that have more primary care doctors have lower death rates. • Primary care decreases hospital admission rates and decreases emergency room utilization for children and adults. • Countries that emphasize primary care have better population health [as measured by longevity, infant mortality and patient satisfaction] at lower costs. • Researchers who have examined the potential impact of primary care on health care spending in the United States estimate that the nation would save $67 billion dollars per year if every American used primary care physicians as their usual source of care. To put the cost/quality value of primary care into context: • U.S. health spending per person is twice the average of that in Britain, Canada, France, Germany, and Italy -- countries that support and emphasize primary care and have better health rankings. • In 2001, as many as 2.2 million Americans and their dependents experienced medical bankruptcy; more than 75 percent of them had health insurance at the onset of the bankrupting illness. High medical bills contribute to the majority of medical bankruptcies. • In the United States, one-third of excessive costs is attributed to performance of unnecessary and non-indicated procedures.

29 The Patient-Centered Medical Home as a Preferred Model of Care
Change is here! Patients want more from the healthcare system and from their physician. Purchasers of insurance (individuals, employers, government) are looking for quality and value. Runaway healthcare costs must be addressed in ways that preserve and enhance access to high-quality, effective medical care. There are ways to do both! Slide 29 – The PCMH as a Preferred Model of Care Change to the health care system is here. Who will be the decision-makers in this reform? What are the elements that should be highly valued and preserved? What should be changed or eliminated? What model of health care is sustainable and preferred for society?

30 Institute for Health Improvement Triple Aim
“The Institute for Healthcare Improvement (IHI) believes that focusing on three critical objectives simultaneously can potentially lead us to better models for providing healthcare.” 1. Improve the health of the defined population 2. Enhance the patient care experience (including quality, access and reliability) 3. Reduce, or at least control, the per capita cost of care

31 PCMH Recognition Programs
National Center for Quality Assessment (NCQA) Accreditation Association for Ambulatory Health Care (AAAHC) Joint Commission’s Primary Care Home Designation Standards Utilization Review Accreditation Committee (URAC) Private Payer Medical Home Recognition Programs Slide 31: PCMH Recognition Programs Medical students should be aware that there are multiple national, state and insurance plan accrediting bodies for the patient –centered medical home. The qualifications for these designations are different and many practices will choose one over another due to payment or health system preference.

32 Explore Family Medicine
Learn more about PCMH. ( Advocate for your patients. Think about the future of healthcare. Are you learning the skills today that you will need for the changing healthcare system? Visit Virtual FMIG. ( Join your local FMIG. Join the AAFP. ( Get involved at the state and national level. Slide 30 – Explore Family Medicine There are many resources to assist your research about PCMH and family medicine.

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