1. New York State Department of Health Hospital-Medical Home Demonstration Reflections, Celebrations and Transformations

2. October 28, 20152 Goals of the HMH Pilot Transform healthcare and medical training in primary care residency clinics through: Better care of chronic disease Increased focus on prevention Increased access to care Improved performance on population health Involving residents in quality improvement and increasing continuity with their patients

3. October 28, 20153 Achievements Improved care for diabetes, high blood pressure, depression, and preventive health Decreased readmissions Assignment of patient panels to residents and use of population health dashboards Making significant progress toward revitalization of the spirit of primary care to again take its place as the center of a high functioning healthcare system

4. 4 PCMH Recognition 100% of HMH sites are now recognized at Level 2 or Level 3 with the 2011 standards N=15 6

5. 5 PCMH Recognition by Level N=15 6

6. 6 Growth in NYS PCMH Recognized Providers by Quarter 5,2774,813 4,684 4,6314,868 Increase of 593 new PCMH- recognized providers between January 2014 and July 2014.

7. 7 EHR achievements 97% of sites made changes to their EHR as part of HMH 82% have EHRs interoperable between their hospital and outpatient sites 96% connect to the RHIO from the outpatient site (85% regularly upload data to the RHIO) 98% connect to the RHIO from the hospital (95% regularly upload data to the RHIO) 68% have office processes that include accessing the RHIO for information 70% have processes for hospital admissions that include accessing the RHIO for information

8. 8 Clinical Performance Statistically significant changes in overall rates from Q3 2013 to final reporting were seen for the following measures (one changed in undesirable direction): Breast Cancer Screening (47% to 60%) Cervical Cancer Screening (51% to 64%) Child Immunization Status (57% to 71%) Colorectal Cancer Screening (48% to 59%) Dilated Eye Exam for Diabetics (31% to 42%) Follow Up After Hospitalization for Mental Illness within 30 days (85% to 66%) Nephropathy Testing for Diabetics (68% to 82%) Tobacco Use Assessment (70% to 86%) Weight and Physical Activity Assessment for Children/Adolescents (58% to 86%)

9. 9 Resident Continuity As of final reporting: Percentage of resident visits with patients on their panel: 55% Percentage of patient visits with assigned resident PCP: 54% High rates in these measures of continuity are: –Correlated with better performance on lipid control measures –Associated with higher rates of breast cancer screening

10. 10 Resident Continuity, continued 89% of sites report that patients are assigned to a team 91% report having assigned patient panels and/or resident/attending teams 93% report residents have been assigned a panel of patients for whom they are responsible over an extended time period 40% report having increased the number of continuity training sites or expanding the current hospital-based sites beyond the hospital environment 82% have restructured the resident training schedule to redistribute the time spent in an ambulatory setting

11. 11 Care Integration and Coordination Projects: Improved Access and Coordination Between Primary and Specialty Care (54 sites)

12. 12 Care Integration and Coordination Projects: Integration of Physical and Behavioral Health Care (34 sites)

13. 13 Care Integration and Coordination Projects: Enhanced Interpretation Services for Culturally Competent Care (28 sites)

14. 14 Care Integration and Coordination Projects: Care Transitions and Medication Reconciliation (80 sites)

15. 15 Medication Reconciliation (within Care Transitions/Medication Reconciliation Project) Patients who did not have a post-discharge medication reconciliation at the ambulatory site had 1.51 times the odds of having an all-cause 30 day readmission compared to patients who did have a medication reconciliation at the ambulatory site. There was no relationship between medication reconciliation at the ambulatory site and odds of having a potentially preventable readmission (PPR).

16. 16 Care Integration and Coordination Project Composite Scores Q3 2013 – Q4 2014

17. 17 Rates with large ranges A large range was seen in Q4 2014 reporting for the following measures: Adult BMI assessment (range: 7% to 100%) Breast cancer screening (range: 3% to 94%) Patients Enrolled in A Physical-Behavioral Health Program (range: 14% to 94%) Post visit specialty care (range: 0% to 100%) Specialty care wait times (range: 22% to 100%) Follow up visit (range: 0% to 100%) Very little variation in culturally competent care measures

18. 18 New York State Department of Health Hospital-Medical Home Demonstration Resident PCMH Survey

19. 19 ABOUT THE SURVEY Developed by Greater New York Hospital Association and administered jointly with DOH in July 2013 and January 2015 to assess knowledge of PCMH concepts Sent by e-mail to primary care Program Directors to share with residents 1000 responses per survey *Due to the data collection methodology, results should not be generalized to the entire New York State resident population. Additionally, the data should not be scientifically compared from 2013 and 2015 due to potential differences in population of the respondents.

20. 20 RESIDENT SURVEY 2013 vs. 2015 Familiarity with PCMH Respondents are more likely to say they are familiar with PCMH (89% vs. 81%). They are also more likely to say they are very familiar or familiar with the core concepts of PCMH (56% vs. 44%).

21. 21 RESIDENT SURVEY 2013 vs. 2015 PCMH Experience Respondents are more likely to strongly or somewhat agree with the following: Their residency program has involved them in activities within the clinic site associated with being a PCMH (70% vs. 60%). PCMH concepts have been incorporated into educational activities within their residency program. (71% vs. 61%).

22. 22 RESIDENT SURVEY 2013 vs. 2015 Practice Value A large majority of respondents continue to agree or strongly agree that being cared for in a PCMH is beneficial to patients (83% vs. 81%). Respondents agree or strongly agree that they are providing team- based, coordinated, patient-centered primary care at their clinic site (84% vs. 82%). Respondents agree or strongly agree that the residency program clinic schedule allows residents to develop a continuous relationship with their patients (79% vs. 81%).

23. 23 RESIDENT SURVEY 2013 vs. 2015 Practice & PCMH Decisions The same number of respondents answered affirmatively that the prevalence of the PCMH model of care will affect their decision to practice in a given state (35% vs. 35%) and the number of respondents who answered no increased slightly (18% vs. 14%). The number of respondents who reported that they would like to work in a PCMH model of care for both years remained the same (41% vs. 42%). –Approximately, half the respondents answered that they are not sure whether they would like to work in a PCMH model of care (48% vs. 53%) and those that answered ‘No’ increased (11% vs. 5%)

24. 24 Panel Discussion The Patient-Centered Medical Home Integration of Care Residency Training