3The Patient-Centered Medical Home Defined ACP, AAFP, AAP, AOA joint statement – April 2007 Personal physician – each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
4Brief History of the evolution of the Medical Home 1980-presentThe American Academy of Pediatrics defined the medical home concepts related to caring for children with special needs2000-presentAAFP and ACP developed and extended the concept to include care for all patients with chronic illness (ACP-Advanced Medical Home; AAFP-Personal Medical Home) and patient centerednessAAFP, AAP, ACP and AOA (with input from NCQA) develop common definition of “patient-centered medical home” (PCMH) and link PCMH to reform of payment for physicians.
5PCMH-a sharp end (practice) translation Closely linked to conceptual frameworks for transforming health care from acute and physician-centered to prevention and chronic care and patient-centeredChronic care modelIOM Crossing the Chasm report (systemness)Emergence of disease and care management, health promotion-disease prevention to address defects in care
6Wagner Model for Effective Prevention and Chronic Illness Care
7Linkage to all levels of health care Old: Acute Model Linkage to all levels of health care Old: Acute Model New: Prevention-ChronicPatient: passiveClinician: delivers visits and proceduresMicroenvironment: supports for visits and proceduresOrganization (group): billing and schedulingEnvironment: medical necessity benefits and pay for proceduresPatient: engaged in own careClinician: provides ongoing planned careMicroenvironment: systems for care management over timeOrganization: systems support and feedbackEnvironment: value-based benefits and paymentI am still not sure everyone on the board understands how the PCMH builds on- and extends, much of what we have been going- especially our physician hospital quality in accred 08- but also our work in DM and even in member connections.
8Medical home as practice connection for other areas PatientEmpowermentDisease-CareCare ManagementPATIENT-CENTEREDMEDICAL HOMEValue-basedReimbursement and BenefitDesignEvidence-BasedPrimary Care as Brake onOveruse-MisuseWould need to emphasize that PCMH ALONE cannot accomplish much- it will have to be linked to and feed on and feed into other efforts to change the way we deliver health care.
9Linkage of PCMH to Reimbursement: One Model Pay for PerformanceQuality, Resource Use and Patient ExperienceFee Schedule for Visits/ProceduresPayment per Patient for Qualified Medical Homes(services not normally reimbursed)
10A lot of potential-some key concerns ConsiderationsDemonstrations are needed to show impactPCMH qualification provides a road map for practices for what leads to quality care; small practices may or may not be able to adaptFocus is on coordination and information exchange; not gate keeping; sub-specialists who take care of patients over time can serve as PCMH’sA major role for NCQA is to focus PCMH on being patient-centeredIssueIt won’t solve cost or quality issuesIt is just a way to try to preserve small practicesIt will create a barrier between specialty care and patientsIt is more doctor-centered than patient-centered
11Sounds good-but how do we know one when we see it??
12Two roads converged Result: Convergence of PPC Recognition tool Over the past seven years, NCQA developed, tested and implemented a web based tool to measure how well practices implemented chronic care modelPhysician Practice Connection or PPC used in a NCQA recognition program also called the PPCOver past three years, NCQA has been working on defining and measuring “Patient Centeredness”ACP, AAFP, AAP and AOA noted convergence of concepts between chronic care model and medical home and need for stronger tie to patient centerednessResult: Convergence of PPC Recognition tooland program and PCMH “Qualification”
13A bit about the PPC tool and Recognition Program
14Need for tool to measure systems-CCM Response to IOM reportsTo Err is Human and Crossing the Quality Chasm both provide evidence on critical importance of systemsChange from “blaming” individual clinicians for mistakes and shortfalls to improving systems so clinicians can succeedRaise awareness of physicians of importance of systems in enhancing qualityResearch Translation: Link health services research on systems to clinical practice
15Steps in Development of PPC Document evidence base linking specific system to clinical performanceConvene expert panel to review evidence and suggest standards/measuresConduct analysis of practice defects using six sigma process (with GE in Bridges to Excellence project)Create standards (aka structural measures)Test tool for reliability and for validity by showing linkage to clinical process and outcome measures and to patient experience of careImplement tool in NCQA recognition program-linked to payment for “systemness”
16Conclusions from Initial testing of PPC tool Assessment of systems-CCM is feasible though challengingFinding from testing PPC strong indicate that review of documentation or on-site audit needed to verify some systemsOverall score on PPC correlates with better quality on clinical measures (diabetes etc) but NOT on patient experience of careEducating physicians and practice staff about systems is high priorityMore research on relationship of systems to quality and patient experiences is needed
17Overall NCQA PPC Recognition Program Recognition is based on:Responses in Web-based Survey ToolSupporting documentation attached to Survey ToolEach element specifies type of documentationReportsReports from EHR, registry, practice management & billing systemsDocumented processesPolicies and procedures, protocolsRecords or filesMedical record review – documented in NCQA’s workbook
18PPC Recognition (current-Sept 2007) Recognized practice sites – 273Physicians practicing at recognized sites – 2,137Characteristics of recognized practicesPractice SizeMedian number of physicians – 6Number of solo practitioner sites - 27Practice Specialties57% - Primary Care19% - Pediatrics9% - Cardiology2% - OB-GYN13% - Multi-specialty
19Current PPC Initiatives BCBS NCCareFirst (BCBS plan-DC metropolitan area)BTE pilot markets – OH-KY, NY, New EnglandSilicon Valley – Health Information TechnologyMVP Health Plan (New York)CHPHP (Health Plan, New York)Most successful projects linked to pay for performance
20BTE Use of Recognition Programs National Measure setPhysician ActivationConsumer ActivationPhysician Office Link (POL)Physician Practice Connections (PPC)Up to $50 pmpyPhysician-level report card, and patient experience of care surveyDiabetes Care Link (DCL)Diabetes Provider Recognition Program (DPRP)Up to $100 pdppyDiabetes care management tool, and rewards for care complianceCardiac Care Link (CCL)Heart Stroke Recognition Program (HSRP)Up to $160 pcppyCardiac care management tool, and rewards for care compliance
22Content of PPC-PCMH-Wagner CCM Patient Centered Medical Home Delivery System DesignPatient Centered Medical HomeClinical Information SystemsPCDecision SupportSelf- Management SupportThis shows the multiple instruments that are being built from the PSAS- (RWJ systems project)- the PSAS is a paper survey research tool, the Physician Office Link is a web based version that has been developed specifically for the GE Bridges to Excellence Project (pay for performance) and the Practice Systems is a web based version that in in development for use in a NCQA recognition program and LEAP IV is the proposed fourth leap for the Leapfrog Purchaser group.Community SupportWagner CCMWhat’s Included? (Infrastructure)How Much Used? (Extent)What Functions? (Implementation)Evidence and Scoring (Verification)
23Work on tool to identify PCMH’s AAFP, AAP, ACP AOA reviewed, refined and then endorsed modification of PPC (PCC-PCMH) as desirable tool for “qualifying” medical homesCMS medical home demonstration project included in TRSCA legislationNCQA with Mathmatica and Center for Health Systems Strategies awarded contract for assisting in design of MH demo
24PPC-PCMH Content and Scoring Standard 1: Access and CommunicationHas written standards for patient access and patient communication**Uses data to show it meets its standards for patient access and communication**Pts459Standard 2: Patient Tracking and Registry FunctionsUses data system for basic patient information (mostly non-clinical data)Has clinical data system with clinical data in searchable data fieldsUses the clinical data systemUses paper or electronic-based charting tools to organize clinical information**Uses data to identify important diagnoses and conditions in practice**Generates lists of patients and reminds patients and clinicians of services needed (population management)23621Standard 3: Care ManagementAdopts and implements evidence-based guidelines for three conditions **Generates reminders about preventive services for cliniciansUses non-physician staff to manage patient careConducts care management, including care plans, assessing progress, addressing barriersCoordinates care//follow-up for patients who receive care in inpatient and outpatient facilities20Standard 4: Patient Self-Management SupportAssesses language preference and other communication barriersActively supports patient self-management**Standard 5: Electronic PrescribingUses electronic system to write prescriptionsHas electronic prescription writer with safety checksHas electronic prescription writer with cost checksPts328Standard 6: Test TrackingTracks tests and identifies abnormal results systematically**Uses electronic systems to order and retrieve tests and flag duplicate tests7613Standard 7: Referral TrackingTracks referrals using paper-based or electronic system**PT4Standard 8: Performance Reporting and ImprovementMeasures clinical and/or service performance by physician or across the practice**Survey of patients’ care experienceReports performance across the practice or by physician **Sets goals and takes action to improve performanceProduces reports using standardized measuresTransmits reports with standardized measures electronically to external entities115Standard 9: Advanced Electronic CommunicationsAvailability of Interactive WebsiteElectronic Patient IdentificationElectronic Care Management Support**Must Pass Elements
25Implementing and Evaluating PCMH-Proposed Model Office SystemsDecision SupportInformation TechnologyDelivery System DesignPatient SupportIndividualClinician-StaffAttitudes, behaviorsand proficienciesEducationalSupportInputsOutputPatient CenteredCoordinated CareNCQAQualificationas PCMH(PPC-PCMH)BoardsEvaluationProgramsToolsPatientExperienceof CareMeasures(CG-CAHPS)Clinical Process &Outcome Measures(underuse,misuse, resource use)(NQF endorsed)
26Recent Developments Major concern: Proliferation of Approaches 12/06–CMS medical home demonstration project included in TRSCA legislationNCQA, in collaboration with Mathematica Policy Research and Center for Health System Change, have received a contract from CMS for assisting CMS in planning PCMH demo2007–Increasing interest from health plans, employers and consumersCreation of Patient-Centered Primary Care Collaborative by ERISA Employers to advocate for PCMH projectsInterest from private payersPCP shortageControlling costsMore than 50 active “leads”- with several close to implementationMajor concern: Proliferation of ApproachesConfusion of Practices-Blurring of Meaning
27Moving ForwardCritical need to do meaningful demonstration projects USING COMMON METRICS to evaluate whether:PCMH can be successfully implemented on large scaleLinking PCMH to revised reimbursement accelerates adoption and use of systems in clinical practiceImplementation of PCMH leads tohigher quality of clinical careenhanced patient experiences of careLower (or at least more rational) resource use/costIn addition, ACP, AAFP, AAP and AOA want to show that PCMH leads to renewed interested in primary care
29Appendix Slides: Development and content of PPC-PCMH
30Goals of PPC Measure Development Develop measures for evaluating systems use and effectiveness in prevention, chronic illness and if possible patient safetyCreate measures that are “actionable” at level of physician office practiceValidate measures by relating them to existing disease-specific performance measures and patient perceptions of care
31Study of Validity: Accuracy of Self-Report Test accuracy of self-reports of practice systems using on site audit as “gold” standardVaries by domain, by staff position, and by medical groupThe predictive value of a positive report of a practice system is generally high.Overall agreement with the on-site audit ranges from high (clinical information systems, quality improvement) to low (care management, population management).Several factors may explain lack of agreementVariable implementation of systems across sites and conditionsVariations in staff members’ exposure to systemsLack of familiarity with systemsConclusion: Need Audit or Documentation
32Studies of Correlation of PPC with Clinical Performance and Patient Experience Preliminary results from Minnesota (California and Massachusetts in prep)Overall PPC score, and sub-scores have positive correlation with higher clinical performance on most measures (diabetes, CV, asthma)Overall PPC score does NOT appear to correlate with patient experiences of carePresence or absence of EMR per se, correlates ONLY WEAKLY with clinical measuresHowever, practices with fully functional EMR’s achieve highest scores on PPC
34Use of PPC, DPRP and HRSP in BTE Employers want to improve the quality of care their employees receive, and they want to increase the value of their health care spend:BTE Programs have actuarially validated savings and BTE recognized physicians deliver higher quality careEmployers want operational simplicity:BTE is now administered by licensed or certified administrators, mainly health plansPhysicians want to be measured by reliable and valid measures and independent third party organizations:BTE’s Provider Performance Assessment Organizations and measurement systems are accepted by the physiciansPhysicians need to know up front what performance is expected of them and what they will get for achieving it:BTE’s Operations give physicians a market-wide view
35Three levels of recognition, based on total points achieved PPC Scoring9 standards = 100 pointsThree levels of recognition, based on total points achievedRecognized—Level 125 – 49 pointsRecognized—Level 250 – 74 pointsRecognized—Level 375 – 100 pointsNot Recognized (or reported)0 – 24 points