1. Jessica Lobban, PGY-3 CCLP Family Medicine Residency Program
Can Patient Centered Medical Home effectively manage our Diabetic Patients?
Jessica Lobban, PGY-3
CCLP Family Medicine Residency Program

2. Is Patient Centered Medical Home the future of Healthcare?

3. Objectives Brief History of Patient Centered Medical Home (PCMH)
Define and explain PCMH
Identify Components of PCMH
Case discussion
Discuss how implementation of this model can effectively manage our Diabetic patients
Describe the challenges of PCMH
Conclusion

4. Medical Home History Medical home dates back to 1967
American Academy of Pediatrics envisioned ideal healthcare delivery to children as family centered, comprehensive, and coordinated
In 2002, chronic care model was born, emphasizes role of primary care to prevent and manage chronic illness
In 2006, Patient Centered Primary Care Collaborative was created to improve patient-physician relationship and healthcare delivery
In 2010 Affordable Care Act was implemented

5. Patient Centered Medical Home
PCMH is model of primary care:
Patient centered care
Comprehensive
Team Based
Accessible
Focused on quality and safety

6. Patient Centered Care
Patient Centered Care allows patients and their families to make educated decisions and participate in their own care.
goal is to maximize adherence along with self-management through proper education and consistent follow-ups

7. Comprehensive
A team of care providers is responsible for a patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.

8. Team Based Approach
Coordination of care through a diverse team of primary care physicians, specialists, nurses, social workers, physician assistants, and other nonclinical staff
Daily huddles (preview cases, go over labs, and coordinate expertise of necessary team members)

9. Accessible Open scheduling Expanded hours
Patient Portal (patients are able to their physician)

10. Quality and Safety
 Clinicians and staff enhance quality improvement through the use of health IT and other tools to ensure that patients and families make informed decisions about their health.

11. National Committee of Quality Assurance
NCQA Patient-Centered Medical Home (PCMH) Recognition is the most widely- used way to transform primary care practices into medical homes.
Access During Office Hours
Advanced electronic communication
Care Management
Support Self-Care Process
Referral Tracking and Follow-Up
Implement Continuous Quality Improvement

12. Can Patient Centered Medical Home effectively manage our Diabetic Patients?

13. Quick Facts about Diabetes
Diabetes is most common chronic disease
174 billion in medical care each year
Cost of care averaging 2.3 times higher than patients without diabetes
Only 7 % patients meet evidenced based goals of HgbA1c

14. Case
60 y/o AAF PMH Diabetes Mellitus Type 2 presents to clinic for routine office visit. She has no complaints today, states she does not take her insulin as prescribed. She often skip her 2nd dose of insulin in the evening. She states her FBS at home ranges from She denies any hypoglycemic episode. Her vital signs are stable and physical exam is unremarkable except for Obese. Upon chart review her HgbA1c is 12 and she is currently on metformin 1000mg PO BID and Insulin 70/30 20 units sub Q BID. How can we effectively manage her diabetes over the next 3-6 months?

15. How can we implement this model to effectively manage our patient?
Diabetes Educators
Education about disease and its complications
Counseling and guidance with self management and goal setting
Nutrition and Close follow up
A care coordinator/care manager can follow up between visits to address potential barriers to adherence
Encourage medication compliance

16. Diabetes and PCMH
Pennsylvania, 23,390 patients, Publication Date: July 2013
18.3 % reduction hospital admissions
2.6 % reduction in total costs
7 % increase in patients with controlled HgbA1c
23.2 % increase in eye exams
9.7% increase in LDL Screenings

17. Diabetes and PCMH Michigan (statewide 3 million patients)
10 % fewer adult ED visits
17% fewer inpatient admissions
6 % fewer hospital readmissions
The data from this study also showed that when physicians fully transform their practice to PCMH, resulted in higher quality and improved preventative care.

18. PCMH Challenges

19. PCMH Challenges Initial Capital and Restructuring Costs Staff Training
Electronic Medical Records
Scheduling (Extended/Alternative Hours of Service)

20. PCMH Challenges
Even though, there are challenges to this model PCMH has been shown to be effective by improving glycemic control in our Diabetic Patients and improve overall health outcome. Ultimately the future of PCMH is bright and it will continue to evolve and demonstrate that primary care organized around patients and their families is key to health care reform.

21. Conclusion
Medical Home Concept dates back to 1967, first envisioned by AAP
PCMH is model of primary care:
Patient centered care
Comprehensive
Team Based
Accessible
Focused on quality and safety

22. Conclusion
With the use of Diabetes Educators, Research has shown that PCMH has been effective for patients with chronic disease such as Diabetes by reducing hospital admissions and ultimately improving glycemic control. Even though this is a new change to health care, there are also some challenges PCMH such as Payment reform, EMR and scheduling

23. What are some of the changes we can make to PCMH implemented at our clinic?

24. Resources http://care.diabetesjournals.org/content/34/4/1047.extract
sp2/Diabetes-and-the-Patient-Centered-Medical-Home
diabetes
diabetes/9f84e6853a.html