A Step by Step Approach to Building a Patient-Centered Medical Home

What Does That Mean for One Patient? Ms. Jones, a 55 year old diabetic, is a patient of Dr. Smith’s practice In 2010, Ms. Jones: Showed poor understanding of her diabetes and link between diet and blood sugar readings Rarely checked her blood sugar at home Did not consistently take her medications for diabetes or high blood pressure Hgb A1-C  >10;  BP 170/110; Wt. 165 Went to ER 5 times with complaints of headache and blurred vision; an infected foot ulcer; pain and tingling in her feet    In 2011, Ms. Jones: Met 1:1 with the Diabetes Educator and attended group diabetes classes with her husband Learned how to check and record her blood sugar results daily The Care Manager helped her obtain low cost medications from a pharmaceutical company Hgb A1-C down to 8.3; BP 140/80; Wt. 143 Went to ER once for chest pain and shortness of breath   Case Manager coordinated her referral to cardiologist Dr. Smith’s practice in 2010 Dr. Smith’s practice in 2011 as a PCMH

Key Points from the Patient - Centered Primary Care Collaborative February 2016 Annual Update Report PCMH studies continue to demonstrate impressive improvements across a broad range of categories including: cost of medical care, utilization of services, population health, prevention, access to care, and patient satisfaction. Advanced primary care is foundational to delivery system transformation. The PCMH model continues to play an important role in strengthening the larger health care system, particularly Accountable Care Organizations and other integrated healthcare delivery systems. Payment reform is necessary to sustain delivery system changes. Multiple payment innovation models are currently being tested, such as pay-for-performance; per member per month (PMPM) payments, often adjusted for PCMH Recognition level, in addition to FFS billing; and/or shared savings arrangements.

PCMH Success: Examples of PCMH results Initiative Health Cost & Utilization Outcomes Health Outcomes Years of Data Review Patient Satisfaction PA Chronic Care Initiative All- cause hospitalization reduced 1.7% All - cause ED visits reduced 4.7% Specialty visits reduced 17.3% Higher performance 4 Diabetes measures including HbA1c testing and eye exams; and breast cancer screening 10/2007-9/2012 North Carolina: Community Care of North Carolina (Medicaid) Decreased spending almost all categories Reductions in readmissions, inpatient admissions for diabetes, ED visits for asthma Approx. 10.7% decline in prescription drug use 2003 - 2012 Colorado Multi-Payer PCMH Pilot 9.3 % fewer ED visits Reduction in ED costs of $3.50 PMPM 10.3% reduction in ACSC inpatient admissions Increased cervical cancer screening rates 2009-2012 Source: The Patient-Centered Medical Home’s Impact on Cost and Quality: Annual Review of Evidence 2014-2015; February 2016

What Is a Patient-Centered Medical Home? Defined as “a team-based model of care led by a personal physician who provides continuous, coordinated care throughout a patient’s lifetime, to maximize health outcomes.” (American College of Physicians)   The PCMH provides or arranges for all of the patient’s healthcare needs, including: Preventive care Treatment of acute and chronic illnesses Assistance with end-of-life/palliative care Key building blocks: teamwork, leadership, communication, willingness to change

Core Components of a Patient - Centered Medical Home Transformation of care delivery to become a model of primary care, delivering care that is: These core components track closely with NCQA’s PCMH Recognition Standards. Patient centered Comprehensive Coordinated Accessible Continuously focused on improvement through systems-based approach to quality and safety Source: Agency for Healthcare Research and Quality- An agency within the Department of Health & Human Services committed to improving care safety and quality

Key Attributes of a PCMH Physician Leadership/ Engagement Team-based approach to care delivery Use of Evidence-based Medicine and Clinical Decision Support Tools Identify and Measure key Quality Indicators Use of Health Information Technology

Characteristics of a PCMH Ensure continuity of care Identify and manage high risk patients Develop and document patient self-management care plans Involve patients and caregivers in shared decision making

Implementing a PCMH Model of Care: Factors to Consider Ensure that you will get a return on your investment Assess the state of your system, when applicable Assess the state of your practices Determine any gaps in care & service delivery in relation to the PCMH Standards Calculate the cost of PCMH implementation Calculate the potential benefits, including opportunity for higher reimbursement based on PCMH Recognition

Creating a Profile of Your Patients Focus Priorities Estimated percentage of Patient Panel Complex care patients Intensive, multi-disciplinary care coordination in a community-based model 5% High risk chronic care Need for aggressive, ongoing monitoring of symptoms, focus on compliance 15% Lower risk chronic care patients Longitudinal monitoring of symptoms with focus on managing risk factors 25% Healthy / chronic disease risk Longitudinal monitoring and management of risk factors 20% Healthy / primary prevention Focus on prevention 0-5 children / compromised or at risk Aggressive, early, multi-disciplinary intervention emphasizing parent engagement 0-5 healthy children / primary prevention Protocol driven primary prevention 10%

Building an Interconnected, Patient-Centric Care System The resulting COHC project design began with 1) development of an individualized plan of care 2) activation of the Health Engagement Team, 3) a patient advocate provided as needed (Community Health Worker), and 4) behavioral health care staff embedded in the primary medical homes. This multi-disciplinary team approach grounded in the individualized care plan has emphasized and supported primary medical homes and provider engagement at every step along the way, increasing collaboration in the care of each patient.

Becoming a PCMH Evaluate current work processes GAP ANALYSIS Improvement plan & implementation NCQA Accreditation Getting paid for value

Process for NCQA Recognition Purchase survey tools Submit application Obtain approval to apply for multi-site PCMH Internal review Documentation for Standards & Elements Complete online tool Upload appropriate documentation Participate in NCQA PCMH Learning Initiatives Follow required NCQA registration Self-assessment Recognition decision within 60 days of site Survey Tool submission.

NCQA Recognition Program The National Committee for Quality Assurance (NCQA)’s Patient-Centered Medical Home Recognition Program provides a roadmap to physician practices working to improve care delivery and the experience of care for both patients and clinicians. The six Standards align with the core components of primary care Three possible Recognition Levels: Level I-III Based on total points scored on the Recognition application Six PCMH Recognition Standards Patient -Centered Access Team-Based Care Population Health Management Care Management & Support Care Coordination & Care Transitions Performance Measurement & Quality Improvement

NCQA Must-Pass Elements Six Must - Pass Elements considered essential to a successful PCMH and required to achieve recognition at any level:   1A: Patient-Centered Appointment Access 2D: The Practice Team 3D: Use Data for Population Management 4B: Care Planning & Self-Care Support 5B: Referral Tracking and Follow-up 6D: Implement Continuous Quality Improvement

Enhance Access and Continuity *Must earn a score of 50% or higher to pass this element

Provide Team-Based Care Continuity

The Practice Team *Must earn a score of 50% or higher to pass this element

Plan and Manage Care

Use Data for Population Management *Must earn a score of 50% or higher to pass this element

Provide Self-Care Support and Community Resources

Provide Self-Care Support and Community Resources *Must earn a score of 50% or higher to pass this element

Track and Coordinate Care

Track and Coordinate Care *Must earn a score of 50% or higher to pass this element

Measure and Improve Performance

Measure and Improve Performance *Must earn a score of 50% or higher to pass this element

Appendix 1 – Scoring Sheet

Fundamentals Getting Started: Evaluate Current Work Processes Revenue Cycle Ability to manage documentation, billing, and collections Efficient patient flow Is it patient -centric? Information Technology Do you have a robust platform that all staff members can use effectively? Data Reporting Are you sending information to your providers on a regular basis?

Next level of requirements Evaluate Current Work Processes Next level of requirements Governance - Do you engage your physicians in decision-making? Provider compensation - Can your compensation structure accommodate quality metrics? Human Resources - Do you have the right mix of staff members and are they in the right positions? Cost of Service - How much does it cost the practice to offer a given service?

Gap analysis Evaluate Current Work Processes Revenue cycle Efficient patient flow IT platform Data reporting Governance Provider compensation Human Resources Cost of Service Evaluate current care and service delivery Pay particular attention to the NCQA Must - Pass Elements Determine priorities and identify “low-hanging fruit” to begin transforming care delivery Key questions to consider: Is the Practice organized to be “patient-centered” or “physician/provider-centered”? Example- Appointment accessibility: Is time reserved for same-day appointments? Are extended office hours offered, to include evening/weekend appointments? Are patient calls and electronic messages consistently returned in timely manner? Do providers practice independently in “silos” or are there strong, integrated care teams in place? Is patient care generally episodic in nature and focused on acute care or longitudinal and focused on the whole person, including chronic disease management?   Is HIT available and consistently utilized to support care delivery? Does the Practice utilize standardized processes, order sets, and evidence- based clinical guidelines to drive quality and consistency? Does the Practice coordinate and track all diagnostic services and referrals? Are processes in place to systematically collect data and review/evaluate outcomes of care and services?

Implementation Plan Implementing the PCMH Model of Care Develop & implement standardized treatment orders/evidenced-based clinical guidelines Utilize Disease Registries for population health management Track and coordinate care across healthcare continuum Exchange clinical information electronically with referral providers-build a strong “Medical Neighborhood” Integrate comprehensive medication management program Implementation Plan Identifying the Gaps: Evaluate current care and service delivery Pay particular attention to the NCQA Must - Pass Elements Determine priorities and identify “low-hanging fruit” to begin transforming care delivery Key questions to consider: Is the Practice organized to be “patient-centered” or “physician/provider-centered”? Example- Appointment accessibility: Is time reserved for same-day appointments? Are extended office hours offered, to include evening/weekend appointments? Are patient calls and electronic messages consistently returned in timely manner? Do providers practice independently in “silos” or are there strong, integrated care teams in place?

NCQA Patient-Centered Medical Home (PCMH 2014) Recognition Program - Standard Survey Pricing Number of Clinicians in the Practice Initial Fee for Practice to Obtain a Survey Tool License Application Fees for NCQA Review and Recognition Total License and Application Fees 1 $80 $550 $630 2 $1100 $1180 3 $1650 $1730 4 $2200 $2280 5 $2750 $2830 6 $3300 $3380 7 $3850 $3930 8 $4400 $4480 9 $4950 $5030 10 $5500 $5580 11 $6050 $6130 12 $6600 $6680 13 $6600 + $55 for each clinician $6800 + $55 for each clinician

PCMH Implementation: Potential Challenges & Obstacles Potential increased physician practice costs upfront: additional staff, expanded office hours, acquisition/implementation of Health Information Technology Limited or no reimbursement by payors for PCMH infrastructure and care management/care coordination functions Inconsistent availability/use of Health Information Technology Must have functional EHR to achieve NCQA Level 3 Recognition Lack of Electronic Health Record system interoperability between hospitals and physician practices Physician collaboration and communication Patient buy-in and participation in self-care management Engagement and collaboration with community-based organizations

Questions 34

Resources Patient Centered Primary Care Collaborative:  http://www.pcpcc.net/ National Committee for Quality Assurance : www.ncqa.org American Academy of Family Physicians: http://www.aafp.org/online/en/home/membership/initiatives/pcmh.html

Thank You Contact for more information: Louise Bryde Principal, Stroudwater Associates 404.790.8251 mobile lbryde@stroudwater.com 770.206.9160 Mike Fleischman 770.913.9094 mfleischman@stroudwater.com