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THE PCMH Lyndee Knox, PhD LA Net A Project of Community Partners.

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1 THE PCMH Lyndee Knox, PhD LA Net A Project of Community Partners

2 Change is Hard...

3 Objectives Create a common departure point for discussion to follow A 101 overview, not a deep dive into PCMH Introduce PCMH efforts underway in L.A.

4 Presentation Outline Defining the patient-centered medical home model PCMH recognition program Specialty Care Connections Growing support for the PCMH model Efforts to test the PCMH model PCMH Evaluations & Results Resources for practices LA Area

5 What is a Patient Centered Medical Home (PCMH) The patient-centered medical home is "a model for care provided by physician practices aimed at strengthening the physician-patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship." (NCAQ) A recent Journal of General Internal Medicine provides a core definition of the PCMH as a team of people committed to improving the health and healing of individuals in a community.

6 According to the ACP, it is: …a vision of health care as it should be …a framework for organizing systems of care at both the micro (practice) and macro (society) level …a model to test, improve, and validate…part of the health care reform agenda

7 Other descriptions The PCMH is a political construct that includes new ways of organizing and financing care, while attempting to remain true to the proven value of primary care (Stange et al, 2010) PCMH requires a compact between payers and primary care practices. Simultaneously, – Practices improve their care – Payers pay the practices more to help them improve their care – Neither practices or payers can do it themselves. Both are needed (T. Bodenheimer)

8 Based on the Joint Principles Personal physician in physician-directed practice teams Whole person orientation responsible for care or arranging care for all health care needs Coordinated care, integrated across health care settings and community facilitated by registries, IT, HIE etc Quality and safety emphasis with EBM, point of care support, performance reporting, patient input Enhanced patient access to care through open scheduling, expanded hours, new option for communication Supported by payment structure that recognizes services and value Team-based care: NP/PA RN/LPN Medical Assistant Office Staff Care Coordinator Nutritionist/Educator Pharmacist Behavioral Health Case Manager Social Worker Community resources DM companies Others…

9 Principles were created by the ACP, AAFP, AAP, and AOA—representing 330,000 physicians—and IBM and other major businesses in March 2007 To provide a standard definition of the delivery model and describe the environment necessary to support it (2007)

10 Referred to as the Patient Centered Primary Care Collaborative (PCPCC) Organizations representing over 350,000 physicians— including ACP and other primary care societies, American College of Cardiology, American Academy of Neurology Organizations representing over 50 million employees, including large employer umbrella groups, and individual companies such as IBM, General Motors All major health plans CVS Caremark, including MinuteClinic Consumer organizations including AARP Bridges to Excellence National Association of Community Health Centers The Patient Centered Primary Care Collaborative (PCPCC), which formed in 2007, has over 700 member organizations PCPCC organizations attest to their support of the PCMH Joint Principles, including the belief that the PCMH will “improve health of patients and the viability of the health delivery system,” and support a better payment model to facilitate implementation PCPCC on the web: http://www.pcpcc.net

11 Critique of the PCMH: Some feel it doesn’t go far enough The rushed 15 minute visit and lone doctor model are central to the problem Driven by payment models and tradition Team based care is essential to practice of the future PCMH may not go far enough in addressing these issues T. Bodenheimer

12 Presentation Outline Overview of the patient-centered medical home model PCMH recognition program Specialty Care Connections Growing support for the PCMH model Efforts to test the PCMH model PCMH Evaluations & Results Resources for practices LA Area

13 How do you Know a PCMH When you See One? Process needed to recognize practices that have and use the capability to provide patient-centered care Practice recognition ostensibly provides purchasers (employers, government) and patients with prospective assurance that the practice has capabilities National Committee on Quality Assurance (NCQA) announced a voluntary recognition process based on its Physicians’ Practice Connection (PPC) module, the PPC-PCMH in January 2008 ACP, AAFP, AOA, and AAP helped NCQA develop the module Undergoing revisions now, with new version to be released in January 2011 Other entities are developing PCMH recognition/accreditation processes - Joint Commission, URAC, CARF, AAAHC. MacColl Institute just published a new measure as a teaching/learning tool, and based on the 8 joint principles.

14 Recognition Programs for PCMH Developed or Under Development 14 Quality Organizations PCMH Standards Activity 2010

15 NCQA PPC-PCMH Recognition Module; Major Domains/Standards 1.Access & Communication 2.Patient Tracking & Registry Functions 3.Care Management 4.Patient Self-Management Support 5.Electronic Prescribing 6.Test Tracking 7.Referral Tracking 8.Performance Reporting & Improvement 9.Advanced Electronic Communication Each standard contains sub- elements – 10 of which are considered “must pass” For more information: Each standard contains sub-elements 10 of which are considered “must pass” Standards are currently under revision and will be available Jan 2011 – Integrate IT w/in core domains

16 Key Points for Level 1 PCMH Does not require electronic health recordDoes require registry & tracking functions Access to care Organization of office structure & processes Enhancing patient self-management; addressing health literacy issues Introduction of evidence-based guidelines, measurement & quality improvement Emphasis is on providing better care through:

17 Level 2 → Level 3 Advanced access options for patientsElectronic health recordMore, and more complex care coordination and patient supportRobust population managementAdvanced reporting and quality improvement initiativesAdditional technology solutions

18 More Features of a PCMH Practice Uses each team member to his/her highest capabilitySupports cultural competency training for clinical teamUnderstands health literacyEstablishes connections to the community and available resourcesProvides extensive self-management supportEngages a Patient/Family Advisory Group

19 NCQA Recognition Activity >1500 practices have received recognition 33% Level 1 5% Level 2 62% Level 3 58 % of practices have < 5 physicians at the site47% of practices are part of multi-sitesConcentration in the Northeast and Mid-South Practices more likely to seek recognition when/where tied to reward About 66% are adult primary care practices; 15% are pediatric practices31 (17%) are community health centers SOURCE: NCQA, July 2010

20 SOURCE: NCQA, December 2009

21 Critique of NCQA Beal et al created a patient centered definition of a medical home w/ 4 questions: – Do you have a regular doctor or place of care? – Can you easily contact your provider by phone? – Can you easily get care or medical advice on weekends or evenings? – Are your physician visits well organized and running on time? Practices doing well on these could flunk NCQA Many standards require that a practice have a “plan” to improve, but do not require demonstration of improvement and no clear benchmarks in many cases T. Bodenheimer

22 Presentation Outline Overview of the patient-centered medical home model PCMH recognition program Specialty Care Connections Efforts to test the PCMH model PCMH Evaluations & Results Resources LA area

23 Complex Delivery Health care delivery is complex – e.g., the typical primary care physician coordinates care with 229 other physicians working in 117 practices H H Pham, et al Ann Intern Med. 2009;150:236-242

24 Specialty Care Connections PCMH is NOT a gatekeeper system Emphasis on transitions in care & continuity (e.g., referral agreements, care transitions programs) ACP Council of Specialty Societies PCMH workgroup: * FAQs available at: running_practice/pcmh/understanding/specialty_physicians.htm

25 Patient Centered Medical Home Neighbor (PCMH-N) Draft Definition A specialty practice recognized as a Patient Centered Medical Home Neighbor (PCMH-N) engages in processes that: These processes would take the form of service agreements (compacts) between/among the participating practices.

26 Presentation Outline Overview of the patient-centered medical home model PCMH recognition program Specialty Care Connections Growing support for the PCMH model Efforts to test the PCMH model PCMH Evaluations & Results ResourcesLA Area

27 Combined Commercial and Medicaid/CHIP PCMH Activity = Identified to have at least one private payer medical home pilot under development or underway = Identified to have a Medicaid and/or CHIP medical home initiative = Identified to have both a private payer and a Medicaid and/or CHIP medical home initiative * As tracked by the American College of Physicians (updated March 2010)

28 Federal PCMH Efforts Medicare Medical Home Demonstration Project Authorized under Section 204 of the Tax Relief and Health Care Act of 2006 October 26, 2009: Project put on hold by CMS pending legislation that would repeal it and replace it with a similar pilot Medicare “Advanced Primary Care” Demonstration Project New 3-year project announced by HHS Secretary Kathleen Sebelius on September 16, 2009 Will allow the participation of Medicare beneficiaries in state-initiated medical home projects that also include Medicaid and private payers Currently seeking applicants – due by August 3, 2010 CMS/Health Services and Resources Administration (HRSA) Announced by President Obama on December 9, 2009 Will evaluate the impact of the advanced primary care practice model on the accessibility, quality, and cost of care provided to Medicare beneficiaries served by Federally Qualified Health Centers (FQHCs). For more information on CMS/Medicare PCMH Efforts: ml ml

29 Federal PCMH Efforts (cont.) Veterans Administration 820 primary care sites 4.5 million primary care patients Using the ACP Medical Home Builder Department of Defense National Naval Medical Center PCMH Pilot Air Force Family Health Initiative Tri-Service Medical Home Summit 2009; Second Summit being planned for 2010 “The PCMH model of care will be implemented across the Services” – MHS Policy Statement on September 18, 2009 PCMH Activities also occurring in: AHRQ, SAMHSA, CDC

30 Safety-Net Medical Home Initiative Source: net/index.cfm Launched by The Commonwealth Fund, Qualis Health and the MacColl Institute for Healthcare Innovation Project duration: April 2009 – April 2013 Project goal – to develop a replicable and sustainable implementation model for medical home transformation Five Regional Coordinating Centers (RCCs) have been selected: Colorado Community Health Network Executive Office of Health and Human Services & Massachusetts League of Community Health Centers Idaho Primary Care Association Oregon Primary Care Association & CareOregon Pittsburgh Regional Health Initiative

31 Common Practice Support Approaches in PCMH Demos Payment – e.g., PMPM, performance bonus, shared savings Learning Collaboratives – face-to-face and and/or virtual Practice facilitation– on-site and/or virtual ACP Medical Home Builder Provision of and support for information technology – e.g., registries, EHRs Data services – e.g., aggregation for patient population management and performance reporting Engagement of patients as advisors

32 Presentation Outline Overview of the patient-centered medical home model PCMH recognition program Specialty Care Connections Growing support for the PCMH model Efforts to test the PCMH model Evaluations & Results on he PCMH ResourcesLA Area

33 Evaluation Collaborative sponsored by Commonwealth Approximately 14 independent evaluations represented in the PCMH Evaluators’ Collaborative. The evaluations are examining a breadth of demonstrations: From one payer to multi-payer pilots Involve anywhere from 5-70 primary care practices with 28-250 clinicians Include 27,000 -- 1,000,000 beneficiaries Many include safety net centers, pediatric sites and Medicaid as a payer Variety of payment models (hybrid, PMPM, annual comprehensive PC fee) All of these independent evaluations have comparison groups

34 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 Improvements in diabetes and heart disease care 9 % reduction in costs ROI greater than 2 to 1 Source: PCPCC Pilot Guide, 2009

35 Community Implications – Published Results of PCMH Projects (cont.) Colorado Medicaid & SCHIP Median annual costs $785 vs $1000 Reduction in ER visits & hospitalizations More well-child visits (72% vs 27%) Lower median costs for children with chronic conditions ($2,275 versus $3,404) HealthPartners Medical Group (MN) 39% decrease in ER visits 24% decrease in hospital admissions Better diabetes and cardiac care Reduced costs Source: PCPCC Pilot Guide, 2009

36 Community Implications Metcare of Florida/Humana PCMH Program Started in November 2008 & Concluded in October 2009 Studied the impact of the PCMH model in a Medicare Advantage (MA) capitated group Hospital days per 1000 customers dropped by 4.6 percent compared to an increase of 36 percent in the control group Hospital admissions per 1000 customers dropped by three percent, with readmissions running six percent below Medicare benchmarks Emergency room expense rose by only 4.5% for the Metcare group compared to an increase of 17.4% for the control group Recent study – National Demonstration Project Source: Metcare Press Release, February 23, 2010 Practices made changes, process measures improved, docs happier, but patients were dissatisfied and felt disconnected from physician

37 Community Implications Not yet published: WellMed Advanced PCMH All cause mortality down 34% in last 8 years. CVD patients BP under control last visit > 90%, LDL under control >90% Diabetes - similar numbers Actual improvement in care are possible and realizable but it will take huge payment reform on top of the PCMH model. Source: Metcare Press Release, February 23, 2010

38 Estimates on Co$t? Transition costs of $23,000 - $90,000 per physician $15 PMPM for patients with chronic conditions Future of Family Medicine Initial investment of $100,000/FTE Ongoing expenses would increase $150,000 per year/FTE Deloitte Analysis Future of Family Medicine Report ( ), 2004 Deloitte: The Medical Home, Disruptive Innovation for a New Primary Care Model (, 2008

39 What Does it Co$t? Average of $40–50 PMPM for patients with qualifying conditions AMA Relative Value Update Committee (RUC) Using cost data from Medical Group Management Association and ACP Checkup Tool for 2006, from 35 practices, found less than a $1-per-month difference in patient costs between highest PPC-PCMH scores and those in the middle and lower thirds. (Zukerman et al 2009) Commonwealth report AMA ( practice/coding-billing-insurance/medicare/ruc-medicare-medical-home-demonstration-project.shtml), 2008 practice/coding-billing-insurance/medicare/ruc-medicare-medical-home-demonstration-project.shtml Urban Institute Report - Co-Funded by The Commonwealth Fund and ACP – Available at: Reports/2009/Oct/Incremental-Cost-Estimates-For-The-Patient-Centered-Medical-Home.aspx, 2009 Reports/2009/Oct/Incremental-Cost-Estimates-For-The-Patient-Centered-Medical-Home.aspx

40 Presentation Outline Overview of the patient-centered medical home model PCMH recognition program Specialty Care Connections Efforts to test the PCMH model PCMH Evaluations & Results Resources to support PCMH Advancement LA area

41 Some resources for Practices PCPP --- – Tools for practices, patients – Meaningful Connections: IT and the PCMH National Academy for State Health Policy AAP Toolkit ACP Medical Home builder TransforMed resources NCQA webex training on accreditation MacColl Institute’s Tool PCMH-A‐net/change‐concepts.cfm Planned: AHRQ National Learning Collaborative for Facilitating PCMH advancement Recent Journal supplements on the PCMH AFM Supplement Health Affairs, 29, no. 5 (2010) supplement on the PCMH Annals of Internal Medicine Links are available to much of this material on LA Net’s website:

42 Presentation Outline Overview of the patient-centered medical home model PCMH recognition program Specialty Care Connections Efforts to test the PCMH model PCMH Evaluations & Results Resources to support PCMH Advancement Projects in LA

43 Local Activities to Support PCMH L.A. Care PCMH Initiative LA Net CCM and PCMH funded by AHRQ L.A. County initiative

44 LA Net Is a Practice-Based Research and Resource Network (PBRN) for the region Focused on improving quality and reducing disparities and through: – provider-led research on issues that matter – supporting local learning and innovation – implementing best practices

45 Network for generating & disseminating good ideas

46 LA Net (cont) Consists of 16 FQHC/CHC “partners” representing 116 practice sites Governed by a board of 80% clinicians, 20% researchers, others. – John Kotick – Current Chair – Felix Nunez – Past Chair

47 LA NET Part of a national network of more than 100 PBRNs in the U.S.

48 Some recent projects Management of Obstructive Sleep Apnea in Primary Care (AHRQ/CMS) National Children’s Study pilot (NICHD) Study of AHRQ’s web-based medication errors and adverse drug event reporting system for primary care (MEADERS)

49 Examples of projects Replication of a diabetes self-management program in 23 PC practices in Texas (AAFP, Lilly, WHO) Development of low-cost “talking” survey software to use with low-literacy patients available in 7+ languages

50 AHRQ funded CCM and PCMH project Evaluating use of practice facilitation to support 20 FQHC/CHCs in CCM and PCMH changes Based on input from steering cmt: Tom Bodenheimer, Jim Mold, Grace Floutsis, Rich Seidman And experts from US and Canada during Consensus Panel hosted by LA Net in January 2010 Blueprint Vermont, CareOregon, Oklahoma, IPIP, Impact BC, Quality Counts, QIIP, and others Continuation of project by MacColl, RAND, Safety Net Institute

51 Demonstration of Primary Care Extension Program Created by recent reform legislation –modeled after agricultural extension program Jim Mold was author - working with us to design demonstration PCMH projects and REC in LA might provide foundation Long-term goal: Provide sustained workforce to practices

52 Acknowledgements Shari M. Erickson, MPH Senior Associate, Center for Practice Improvement & Innovation Tom Bodenheimer, MD UCSF Katie Coleman, MPH MacColl Institute Jim Mold, MD U of Oklahoma

53 References American College of Physicians. 2006. The Advanced Medical Home: A Patient-Centered Physician Guided Model of Healthcare. df df American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA). 2007. Joint Principles of the Patient- Centered Medical Home. March 2007. rinc_05_17.pdf rinc_05_17.pdf American Academy of Family Physicians (AAFP). 2004. The Future of Family Medicine: A Collaborative Project of the Family Medicine Community. Annals of Family Medicine 2 (1): S3-S32. American Academy of Pediatrics, Council on Pediatric Practice. Pediatric Records and a "medical home." In: Standards of Child Care. Evanston, IL: American Academy of Pediatrics; 1967: 77–79

54 Thank you

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