1. The Change Concepts and NCQA PCMH Conference Call Date

2. Laying the Foundation

3. Engaged Leadership Visible and sustained leadership to encourage culture shift. Specific strategies for quality improvement (QI). Establish and support a QI team. Protected time for providers and care teams. Practice’s values centered upon the medical home model.

4. Engaged Leadership “Direct involvement of top and middle level leaders.” Leadership should: Create a quality-oriented culture. Define the practice reality, often with data. Sustain enthusiasm. (Wang et al., 2006; Reinertsen,1998; Taylor et al., 2010.)

5. Engaged Leadership Effective leaders should promote: Systems thinking Envisioning change Change management Taylor et al., 2010

6. Applicable Standards 1.Enhance Access and Continuity 2.Identify and Manage Patient Populations 3.Plan and Manage Care 4.Provide Self-Care Support and Community Resources 5.Track and Coordinate Care 6.Measure and Improve Performance

7. Quality Improvement Strategy Formal model for QI. Establish and monitor metrics. Ensure staff familiarity with metrics and outcomes Obtain and utilize patient/family feedback. Involvement of patients, families, providers, care teams in QI activities Optimal use of HIT.

8. Quality Improvement Strategy LEAN Methodology Six Sigma Timeliness Referral process time Overall clinic follow-through Health Information Technology (HIT) and the EHR Vest & Gamm, 2009; Deckard et al., 2010; Office of the National Coordinator for Health Information Technology, 2010; Reid et al., 2010

9. Applicable Standards 2D: Data for Population Management 4B: Community Resource Referrals 6A: Measure Performance 6B: Measure Patient/Family Experience 6C: Implement Continuous QI 6D: Demonstrate Continuous QI 6E: Report Performance 6F: Report Data Externally

10. Building Relationships

11. Empanelment Which patients should be empaneled in the medical home? Which patients need temporary, supplemental, or enhanced services? Use of panel data and registries. Practice’s supply and demand. Provider Panels Team- Based Care Continuity of Care Capacity Analysis Planning & Control Access to Care

12. Empanelment “A sustained partnership between the patient and physician is most important to improving health.” Institute of Medicine, 1996 Related to higher patient satisfaction Enhanced continuity of care Increase in patient trust Grumbach et al.,1999; Grumbach & Bodenheimer, 2002; Van Berckelaer et al., 2012; Donahue et al., 2005

13. Empanelment PCMH depends on the establishment of the patient-provider relationship. Visits with the same provider lead to: Quality patient-provider communication Identification of medical problems Patient satisfaction Provider satisfaction Use of preventative care Overall costs Hospital and ER admissions Cabana & Jee, 2004; Starfield et al., 1992; Fan et al., 2005; Saultz & Lochner, 2005

14. Applicable Standards 1A: Access During Office Hours 1B: After-Hours Access 2A: Patient Information 2B: Clinical Data 2C: Comprehensive Health Assessment 2D: Data for Population Management 3A: Implement Evidence-Based Guidelines

15. Changing Care Delivery

16. Patient-Centered Interactions Respect, uphold, and promote patient and family values and needs. Encourage patient activation. Cultural and linguistic awareness. Enhanced communication skills. Self-management support.

17. Patient-Centered Interactions Care must be consistent with patient needs, preferences, values, and expectations It is important to give the patient the chance to discuss treatment options, preferences, and concerns about treatment. Consider health literacy. Teach-back enhances medication adherence, self- management, and health outcomes. Paasche-Orlow et al., 2006; Marcus, 2006; Schillinger et al., 2003)

18. Patient-Centered Interactions Patient-centered interactions result in: Reduced anxiety Reduced depression Improved overall mental health Increased trust Increased self-efficacy in navigating the health care system Epstein et al., 2010; Fremont et al., 2001

19. Applicable Standards 1F: Culturally and Linguistically Appropriate services 2A: Patient Information 4A: Support Self-Care Process

20. Continuous and Team-Based Healing Relationships Care teams Linking patients to care teams Maintaining and enhancing the patient-provider relationship Defined roles and tasks Cross-train care team members

21. Continuous and Team-Based Healing Relationships Team based care is most successful when: Tasks are matched to the skills, credentials, and interests of team members Staff training Clearly defined roles Team roles are transparent to patients Team members work at the top of their licensure Cross training Bodenheimer and Laing, 2007

22. Continuous and Team-Based Healing Relationships Clinical care improves and costs decrease when the practice team members – other than the PCP – help to meet the patient’s needs. Self-management support is an on-going process best performed over the course of several interactions. Bodenheimer et al., 2002; Gibson et al., 2007; Bennett et al., 2010; Patient Centered Primary Care Collaborative, 2012

23. Continuous and Team-Based Healing Relationships Diabetes: case management – where a nurse or pharmacist – has made independent changes is associated with better glycemic control Hypertension: team member support is associated with significantly greater blood pressure reduction than contact with a physician alone. Depression: collaborative team care has a stronger effect on reducing depressive symptoms compared with physician-only care at six months. Shojania et al., 2006;. Walsh et al., 2006;. Gilbody et al., 2006

24. Applicable Standards 1A: Access During Office Hours 1B: After-Hours Access 1G: The Practice Team 2C: Comprehensive Health Assessment 2D: Data for Population Management 3A: Implement Evidence-Based Guidelines 3C: Care Management 5C: Coordinate with Facilities/Care Transitions

25. Reducing Barriers to Care

26. Organized, Evidenced-Based Care Use of planned care according to patient need. Point-of-care reminders based on clinical guidelines. Enable planned interactions.

27. Organized, Evidenced-Based Care Use proven preventive interventions, clinical assessments, and treatments Provider reminder systems in the EHR Reminder implementation results in improved: Medication orders Appropriate vaccinations Test ordering Institute of Medicine, 2001; Gilfillan et al., 2010

28. Organized, Evidenced-Based Care Care Management 1.Identify 2.Assess 3.Develop a care plan 4.Coach 5.Track 6.Revise care plan as needed

29. Applicable Standards 2C: Comprehensive Health Assessment 2D: Use of Data for Population Management 3A: Implement Evidence-Based Guidelines

30. Enhanced Access Promote and expand access. Enhanced scheduling options.

31. Enhanced Access Comprehensive Appointment System Reduced No- Shows Better Clinic Flow Reduced overall Cost

32. Applicable Standards 1A: Access During Office Hours 1B: After-Hours Access

33. Care Coordination Community resources. Care management for high risk patients. Integration of behavioral health and specialty care. Follow-up after ER or hospital discharge. Communication of tests results and care plans to patients/families.

34. Care Coordination “Communication from practice to patient is elemental to care coordination, especially communication of test results and care plans.” Cost savings. Enhanced communication. Patient experience. Opportunities for behavioral health integration. Hostetter & Klein, 2012; Porterfield et al., 2011; Coleman & Berenson, 2004; O’Malley & Cunningham, 2009; Harrison & Verhoef, 2002; Olfson et al., 1999; Department of Health and Human Services, 2007; The Commonwealth Fund, 2012

35. Applicable Standards 1G: The Practice Team 5A: Test Tracking and Follow-Up 5B: Referral Tracking and Follow-Up 5C: Coordinate with Facilities/Care Transitions

37. Office Hours Session

38. Announcements Upcoming etc.