Transcript The Patient-Centered Medical Home: Coming to a

The Patient Centered Medical Home (PCMH)
Activities, Findings, and Challenges
15th Annual NHMA Conference
March 19, 2011
Shari M. Erickson, MPH
Director, Regulatory and Insurer Affairs
Presentation Outline
Joint
Principles
Specialty
Care
Connections
Efforts to test
the PCMH
model
PCMH
Evaluations
& Results
PCMH
Recognition
programs
ACP, AAFP, AAP, and AOA Joint
Principles of the PCMH
Team-based care:
Personal physician in physician-directed
practice
Whole person orientation
Coordinated care, integrated across settings
Quality and safety emphasis
Enhanced patient access to care
Supported by payment structure that recognizes
services and value
SOURCE: http://www.acponline.org/running_practice/pcmh/
demonstrations/jointprinc_05_17.pdf (March 2007)
NP/PA
RN/LPN
Medical Assistant
Office Staff
Care Coordinator
Nutritionist/Educator
Pharmacist
Behavioral Health
Case Manager
Social Worker
Community resources
DM companies
Others…
“Neighbors” Endorsing the Joint Principles
American
Academy of
Hospice and
Palliative Medicine
American
Academy of
Neurology
American College
of Cardiology
American College
of Chest
Physicians
American College
of Osteopathic
Family Physicians
American College
of Osteopathic
Internists
American
Geriatrics Society
American Medical
Association
American Medical
Directors
Association
American Society
of Addiction
Medicine
American Society
of Clinical
Oncology
Association of
Professors of
Medicine
Association of
Program Directors
in Internal
Medicine
Clerkship
Directors in
Internal Medicine
Infectious
Diseases Society
of America
Society for
Adolescent
Medicine
Society of Critical
Care Medicine
Society of General
Internal Medicine
The Endocrine
Society
Presentation Outline
Joint
Principles
Specialty
Care
Connections
Efforts to test
the PCMH
model
PCMH
Evaluations
& Results
PCMH
Recognition
programs
Complex Delivery
Health care delivery is complex
– e.g., the typical primary care
physician coordinates care with
229 other physicians working in
117 practices
H H Pham, et al Ann Intern Med. 2009;150:236-242
Nearly Half of U.S. Adults Report Failures to Coordinate Care
Percent U.S. adults reported in past two years:
Your specialist did not receive basic
medical information from your
primary care doctor
13
Your primary care doctor did not
receive a report back from a specialist
15
Test results/medical records were not
available at the time of appointment
19
Doctors failed to provide important
medical information to other doctors
or nurses you think should have it
No one contacted you about
test results, or you had to call
repeatedly to get results
21
25
Any of the above
47
0
Source: S. K. H. How, A. Shih, J. Lau, and C. Schoen, Public Views on U.S.
Health System Organization:
A Call for New Directions (New York: The Commonwealth Fund, Aug. 2008).
20
40
60
PCMH Neighbor Model
Proposes a Framework for Interactions
between PCMH practices and Specialty
Practices:
• A scaffolding upon which Care Integration and
Information Exchange can be built
• Restore Professional Interactions for Patient Centered
Care
• Improve Care Transfers and Transitions to enhance
Safety and Stewardship/ reduce wasted resources
ACP-CSS Workgroup Policy Paper available at:
http://www.acponline.org/advocacy/where_we_stand/policy/pcmh_neighbors.pdf
PCMH Neighbor Model (cont.)
Defines concept of PCMH-N practices as
practices that:
• Communicate, coordinate and integrate bidirectionally with
PCMH
• Ensure appropriate and timely consultations and referrals
• Ensure effective flow of information;
• Address issues of responsibility in co-management situations;
• Support patient-centered care
• Support the PCMH practice as the provider of whole person
primary care to the patient
ACP-CSS Workgroup Policy Paper available at:
http://www.acponline.org/advocacy/where_we_stand/policy/pcmh_neighbors.pdf
PCMH Neighbor Model: How Does
It Work?
Via Care Coordination Agreements, which promote better
communication and care coordination by defining:
• Types of Interactions
• Pre-consultation exchange to expedite/ prioritize care
• Consultation /procedure
• Comanagement
• Shared care
• Principal care
• Responsibility for the elements of care
• Expectations for information exchange
ACP-CSS Workgroup Policy Paper available at:
http://www.acponline.org/advocacy/where_we_stand/policy/pcmh_neighbors.pdf
Additional Considerations for the
PCMH Neighbor Model:
Incentives (both nonfinancial and financial) should be
aligned with the efforts and contributions of the PCMH-N
practice to collaborate with the PCMH practice.
A PCMH-N recognition process should be explored.
ACP-CSS Workgroup Policy Paper available at:
http://www.acponline.org/advocacy/where_we_stand/policy/pcmh_neighbors.pdf
The PCMH Model and Accountable
Care Organizations (ACOs)
The PCMH, in conjunction
with the health care
“neighborhood” in which it
resides, is a critical
foundation of ACOs
Source: Premier Healthcare Alliance
Support for Primary Care Foundation for ACOs
“Some experts have advocated requiring a strong primary care foundation for Accountable Care
Organizations (ACOs). Please indicate the degree to which you support or oppose establishing
standards for primary care capacity as a condition for qualifying for ACO payment.”
Strongly
oppose
2%
Oppose
7%
Not sure
1%
Neither support
nor oppose
12%
Strongly
support
46%
Support
31%
* Percentages may not be equal to 100 percent because of rounding.
Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders
Survey, July 2010.
Presentation Outline
Joint
Principles
Specialty
Care
Connections
Efforts to test
the PCMH
model
PCMH
Evaluations
& Results
PCMH
Recognition
programs
How do you Know a PCMH
When you See One?
Process needed to recognize practices that have and use the capability to provide patientcentered care
Practice recognition provides purchasers (employers, government) and patients with prospective
assurance that the practice has capabilities
Recognized PCMHs also must be accountable for quality of care by reporting on evidencebased clinical and patient experience measures—provides retrospective assurance
National Committee on Quality Assurance (NCQA) released the PPC-PCMH in January 2008;
Revised version released in January 2011
Other entities are also developing or implementing PCMH recognition/accreditation processes
– AAAHC, The Joint Commission, URAC
Guidelines for PCMH Recognition and
Accreditation Programs
The AAFP, AAP, ACP, and AOA released these Guidelines in March
2011 to assist with the development and use of these programs.
These Guidelines state that all Patient-Centered Medical Home
Recognition or Accreditation Programs should:
• Incorporate the Joint Principles of the Patient-Centered Medical Home
• Address the Complete Scope of Primary Care Services (including comprehensive,
whole person care)
• Ensure the Incorporation of Patient and Family-Centered Care Emphasizing
Engagement of Patients, their Families, and their Caregivers
• Engage Multiple Stakeholders in the Development and Implementation of the
Program
• Align Standards, Elements, Characteristics, and/or Measures with Meaningful Use
Requirements
• Identify Essential Standards, Elements, and Characteristics
Joint Guidelines for PCMH Recognition and Accreditation Programs available at:
http://www.acponline.org/running_practice/pcmh/understanding/guidelines_pcmh.pdf
Guidelines for PCMH Recognition and
Accreditation Programs (cont.)
All Patient-Centered Medical Home Recognition or
Accreditation Programs should:
• Address the Core Concept of Continuous Improvement that is Central to the
PCMH Model
• Allow for Innovative Ideas
• Acknowledge Care Coordination within the Medical Neighborhood
• Clearly Identify PCMH Recognition or Accreditation Requirements for Training
Programs
• Ensure Transparency in Program Structure and Scoring
• Apply Reasonable Documentation/Data Collection Requirements
• Conduct Evaluations of the Program’s Effectiveness and Implement
Improvements Over Time
Joint Guidelines for PCMH Recognition and Accreditation Programs available at:
http://www.acponline.org/running_practice/pcmh/understanding/guidelines_pcmh.pdf
Presentation Outline
Joint
Principles
Specialty
Care
Connections
Efforts to test
the PCMH
model
PCMH
Evaluations
& Results
PCMH
Recognition
programs
Overview of PCMH Commercial
Pilot Activity (cont.)*
= Identified to have at least one private payer medical home pilot
under development or underway
* As tracked by the American College of Physicians and the Patient-Centered
Primary Care Collaborative (updated March 2011)
Initiatives to Advance Medical Homes
in Medicaid/ CHIP
= Identified to have a Medicaid and/or
CHIP medical home initiative underway
or under development
Source: National Academy for State Health Policy (NASHP)
State Map (http://nashp.org/med-home-map), March 2011
Medicare Multi-Payer Advanced
Primary Care Initiative States
= States participating in the Medicare
Multi-Payer Advanced Primary Care
Initiative
Source: CMS, March 2011 (http://www.cms.gov/demoprojectsevalrpts/
md/itemdetail.asp?itemid=cms1230016)
Combined Commercial, Medicaid/
CHIP, and Medicare FFS PCMH Activity
= Identified to have at least one
private payer medical home pilot
under development or underway
= Identified to have a Medicaid and/or
CHIP medical home initiative
= Identified to have both a private payer and a
Medicaid and/or CHIP medical home initiative
* As tracked by the American College of Physicians
(updated March 2011)
= Identified as a Medicare APC State, which
includes private payers, Medicaid and/or CHIP,
and Medicare FFS
More Information on PCMH
Demonstration Projects
See the ACP website:
http://www.acponline.org/running_pract
ice/pcmh/demonstrations/index.html
OR the PCPCC website:
http://pcpcc.net/
Presentation Outline
Joint
Principles
Specialty
Care
Connections
Efforts to test
the PCMH
model
PCMH
Evaluations
& Results
PCMH
Recognition
programs
PCMH Evaluations
Key Questions Under Investigation:
• What does it take to become a medical home?
• Do PCMHs improve:
• Clinical Quality?
• Patients’ Experiences?
• Physician/Staff Experience?
• Efficiency?
• Is this sustainable/ are practices financially stable?
Community Implications - Results of PCMH
Projects to Date (Integrated Systems)
Group Health Cooperative of Puget Sound
•
•
•
•
29% reduction in ER visits; 16% reduction in hospital admissions
$10 PMPM reduction in total costs
Improvements in diabetes and heart disease care
Greater staff satisfaction; less burnout; improved primary care
recruitment and retention
Geisinger Health System
•
•
•
•
18% reduction in hospital admissions
7 % reduction in total PMPM costs
Improvements in preventive, diabetes, and heart disease care
ROI greater than 2 to 1
Source: PCPCC Outcomes of Implementing PCMH Interventions (November
2010) - http://www.pcpcc.net/content/pcmh-outcome-evidence-quality
Community Implications –Results of PCMH
Projects (Private Payer Sponsored)
BCBS of South Carolina-Palmetto
• 36% fewer hospital days and 32% fewer ED visits among PCMH
patients when compared with control patients
• 6.5% reduction in total medical costs for PCMH vs. control
Metropolitan Health Networks-Humana (FL)
• Hospital days per 1000 customers dropped by 4.6 percent compared to
an increase of 36 percent in the control group
• Hospital admissions per 1000 customers dropped by three percent,
with readmissions running six percent below Medicare benchmarks
• Emergency room expense rose by only 4.5% for the PCMH group
compared to an increase of 17.4% for the control group
Source: PCPCC Outcomes of Implementing PCMH Interventions (November
2010) - http://www.pcpcc.net/content/pcmh-outcome-evidence-quality
Community Implications – Results of
PCMH Projects (Medicaid Sponsored)
Colorado Medicaid and SCHIP
•
•
•
•
Median annual costs $785 vs $1000 in controls
Reduction in ER visits & hospitalizations
More well-child visits (72% vs 27% in controls)
Lower median costs for children with chronic
conditions ($2,275 versus $3,404 in controls)
Source: PCPCC Outcomes of Implementing PCMH Interventions (November
2010) - http://www.pcpcc.net/content/pcmh-outcome-evidence-quality
More Results…
PCPCC Evidence
Summary
And on the PCPCC
website…
www.pcpcc.net
Some Challenges and Questions for PCMH
Going Forward
Is the PCMH model sustainable over the longer term?
What does it cost – to practices, payers, purchasers, and others?
Is the PCMH Neighborhood model achievable and can appropriate incentives be put into
place effectively?
What role should the PCMH and PCMH Neighborhood play in the development of ACOs?
How will other payment and delivery system reform efforts impact the development of the
PCMH model?
Will the PCMH model have a positive impact on recruitment and retention of the primary
care workforce?
How do we more fully engage employers and consumers in the model?
How do we best understand and facilitate the necessary health IT?
Can the model be effectively integrated into medical education?
Thank You!
Shari M. Erickson, MPH
Director
Regulatory and Insurer Affairs
[email protected]
202-261-4551
Questions?