Patient Centered Medical Home Knowing when we see one

L. Gregory Pawlson MD, MPH, FACP

Patient-Centered Medical Home: The Concept

Patient-Centered Medical Home 2

• • • •

The Patient-Centered Medical Home Defined

ACP, AAFP, AAP, AOA joint statement – April 2007

Personal physician

personal physician trained to provide first contact, continuous and comprehensive care.

– each patient has an ongoing relationship with a

Physician directed medical practice

team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. – the personal physician leads a

Whole person orientation

– the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

Care is coordinated and/or integrated

across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

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• • •

Brief History of the evolution of the Medical Home

1980-present

– The American Academy of Pediatrics defined the medical home concepts related to caring for children with special needs

2000-present

– AAFP and ACP developed and extended the concept to include care for all patients with chronic illness (ACP-Advanced Medical Home; AAFP Personal Medical Home) and patient centeredness

2006-07

– AAFP, AAP, ACP and AOA (with input from NCQA) develop common definition of “patient-centered medical home” (PCMH) and link PCMH to reform of payment for physicians.

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PCMH-a sharp end (practice) translation

•

Closely linked to conceptual frameworks for transforming health care from acute and physician-centered to prevention and chronic care and patient-centered

– – – Chronic care model IOM Crossing the Chasm report (systemness) Emergence of disease and care management, health promotion-disease prevention to address defects in care

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Wagner Model for Effective Prevention and Chronic Illness Care

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Linkage to all levels of health care

Old: Acute Model New: Prevention-Chronic

• Patient: passive • Patient: engaged in own care • Clinician: delivers visits and procedures • Microenvironment: supports for visits and procedures • Clinician: provides ongoing planned care • Microenvironment: systems for care management over time • Organization (group): billing and scheduling • Environment: medical necessity benefits and pay for procedures • Organization: systems support and feedback • Environment: value-based benefits and payment

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Medical home as practice connection for other areas

Disease-Care Care Management Patient Empowerment PATIENT-CENTERED MEDICAL HOME Value-based Reimbursement and Benefit Design Evidence-Based Primary Care as Brake on Overuse-Misuse Patient-Centered Medical Home 8

Linkage of PCMH to Reimbursement: One Model

Pay for Performance Quality, Resource Use and Patient Experience

Fee Schedule for Visits/Procedures

Payment per Patient for Qualified Medical Homes (services not normally reimbursed) Patient-Centered Medical Home 9

• • •

A lot of potential-some key concerns

Issue It won’t solve cost or quality issues

•

Considerations Demonstrations are needed to show impact It is just a way to try to preserve small practices

•

PCMH qualification provides a road map for practices for what leads to quality care; small practices may or may not be able to adapt It will create a barrier between specialty care and patients

•

Focus is on coordination and information exchange; not gate keeping; sub-specialists who take care of patients over time can serve as PCMH’s

•

It is more doctor-centered than patient-centered

•

A major role for NCQA is to focus PCMH on being patient centered Patient-Centered Medical Home 10

Sounds good-but how do we know one when we see it??

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Two roads converged

• • •

Over the past seven years, NCQA developed, tested and implemented a web based tool to measure how well practices implemented chronic care model

–

Physician Practice Connection or PPC used in a NCQA recognition program also called the PPC Over past three years, NCQA has been working on defining and measuring “Patient Centeredness” ACP, AAFP, AAP and AOA noted convergence of concepts between chronic care model and medical home and need for stronger tie to patient centeredness Result: Convergence of PPC Recognition tool and program and PCMH “Qualification” Patient-Centered Medical Home 12

A bit about the PPC tool and Recognition Program

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Need for tool to measure systems-CCM

•

Response to IOM reports

– To Err is Human and Crossing the Quality Chasm both provide evidence on critical importance of systems • • •

Change from “blaming” individual clinicians for mistakes and shortfalls to improving systems so clinicians can succeed Raise awareness of physicians of importance of

systems

in enhancing quality Research Translation: Link health services research on systems to clinical practice Patient-Centered Medical Home 14

• • • • • •

Steps in Development of PPC

Document evidence base linking specific system to clinical performance Convene expert panel to review evidence and suggest standards/measures Conduct analysis of practice defects using six sigma process (with GE in Bridges to Excellence project) Create standards (aka structural measures) Test tool for reliability and for validity by showing linkage to clinical process and outcome measures and to patient experience of care Implement tool in NCQA recognition program-linked to payment for “systemness” Patient-Centered Medical Home 15

Conclusions from Initial testing of PPC tool

• • • • •

Assessment of systems-CCM is feasible though challenging Finding from testing PPC strong indicate that review of documentation or on-site audit needed to verify some systems Overall score on PPC correlates with better quality on clinical measures (diabetes etc) but NOT on patient experience of care Educating physicians and practice staff about systems is high priority More research on relationship of systems to quality and patient experiences is needed Patient-Centered Medical Home 16

Overall NCQA PPC Recognition Program

• • • • •

Recognition is based on:

– Responses in Web-based Survey Tool – Supporting documentation attached to Survey Tool

Each element specifies type of documentation Reports

– Reports from EHR, registry, practice management & billing systems

Documented processes

– Policies and procedures, protocols

Records or files

– Medical record review – documented in NCQA’s workbook

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PPC Recognition (current-Sept 2007)

• • •

Recognized practice sites – 273 Physicians practicing at recognized sites – 2,137 Characteristics of recognized practices

–

Practice Size

• Median number of physicians – 6 • Number of solo practitioner sites - 27 –

Practice Specialties

• 57% - Primary Care • 19% - Pediatrics • • • 9% - Cardiology 2% - OB-GYN 13% - Multi-specialty

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• • • • • •

Current PPC Initiatives

BCBS NC CareFirst (BCBS plan-DC metropolitan area) BTE pilot markets – OH-KY, NY, New England Silicon Valley – Health Information Technology MVP Health Plan (New York) CHPHP (Health Plan, New York)

Most successful projects linked to pay for performance

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BTE Use of Recognition Programs

National Measure set Physician Activation Consumer Activation Physician Office Link (POL) Diabetes Care Link (DCL) Cardiac Care Link (CCL) Physician Practice Connections (PPC) Up to $50 pmpy Diabetes Provider Recognition Program (DPRP) Heart Stroke Recognition Program (HSRP) Up to $100 pdppy Up to $160 pcppy Physician-level report card, and patient experience of care survey Diabetes care management tool, and rewards for care compliance Cardiac care management tool, and rewards for care compliance Patient-Centered Medical Home 20

Linking the PPC to the PCMH

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Content of PPC-PCMH-Wagner CCM

Delivery System Design Clinical Information Systems Decision Support P P C Patient Centered Medical Home Self Management Support Community Support What’s Included?

(Infrastructure) Wagner CCM How Much Used?

(Extent) What Functions?

(Implementation) Evidence and Scoring (Verification) Patient-Centered Medical Home 22

Work on tool to identify PCMH’s

•

AAFP, AAP, ACP AOA reviewed, refined and then endorsed modification of PPC (PCC-PCMH) as desirable tool for “qualifying” medical homes

•

CMS medical home demonstration project included in TRSCA legislation

– NCQA with Mathmatica and Center for Health Systems Strategies awarded contract for assisting in design of MH demo

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PPC-PCMH Content and Scoring

Pts Standard 1: Access and Communication

A.

Has written standards for patient access and patient communication** B.

Uses data to show it meets its standards for patient access and communication** 4 5

9 Standard 5: Electronic Prescribing A.

Uses electronic system to write prescriptions B.

C.

Has electronic prescription writer with safety checks Has electronic prescription writer with cost checks Standard 2: Patient Tracking and Registry Functions A.

Uses data system for basic patient information (mostly non-clinical data) B.

C.

D.

Has clinical data system with clinical data in searchable data fields Uses the clinical data system

E.

F.

Uses paper or electronic-based charting tools to organize clinical information** Uses data to identify important diagnoses and

conditions in practice** Generates lists of patients and reminds patients and clinicians of services needed (population management) Pts 2 3 3

6 4

3 21 Standard 6: Test Tracking

A.

Tracks tests and identifies abnormal results systematically**

B.

Uses electronic systems to order and retrieve tests and flag duplicate tests Standard 7: Referral Tracking

A.

Tracks referrals using paper-based or electronic system**

Standard 3: Care Management

A.

Adopts and implements evidence-based guidelines for three conditions **

B.

C.

D.

E.

Generates reminders about preventive services for clinicians Uses non-physician staff to manage patient care Conducts care management, including care plans, assessing progress, addressing barriers Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities Pts

3

4 3 5 5 20 Standard 8: Performance Reporting and Improvement

A.

B.

C.

Measures clinical and/or service performance by physician or across the practice**

Survey of patients’ care experience D.

E.

F.

Reports performance across the practice or by physician **

Sets goals and takes action to improve performance Produces reports using standardized measures Transmits reports with standardized measures electronically to external entities Standard 4: Patient Self-Management Support A.

Assesses language preference and other communication barriers

B.

Actively supports patient self-management**

Pts 2

4

6 Standard 9: Advanced Electronic Communications A.

Availability of Interactive Website B.

C.

Electronic Patient Identification Electronic Care Management Support

** Must Pass Elements Patient-Centered Medical Home

3 2 1 15 Pts 1 2 1 4 Pts 3 3 2 8 Pts

7 3

3

3

6 13 PT

4

4 Pts

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Implementing and Evaluating PCMH-Proposed Model Inputs Individual Clinician-Staff

Attitudes, behaviors and proficiencies Educational Support

Office Systems

Decision Support Information Technology Delivery System Design Patient Support

Output Patient Centered Coordinated Care Evaluation

Boards

Programs Tools

Patient Experience of Care Measures

(CG-CAHPS)

Clinical Process & Outcome Measures (underuse, misuse, resource use) NCQA Qualification as PCMH

(PPC-PCMH)

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Recent Developments

•

12/06–CMS medical home demonstration project included in TRSCA legislation

– NCQA, in collaboration with Mathematica Policy Research and Center for Health System Change, have received a contract from CMS for assisting CMS in planning PCMH demo •

2007–Increasing interest from health plans, employers and consumers

– Creation of Patient-Centered Primary Care Collaborative by ERISA Employers to advocate for PCMH projects – – Interest from private payers • PCP shortage • Controlling costs More than 50 active “leads”- with several close to implementation

Major concern: Proliferation of Approaches Confusion of Practices-Blurring of Meaning Patient-Centered Medical Home 26

Moving Forward

• •

Critical need to do meaningful demonstration projects USING COMMON METRICS to evaluate whether:

– PCMH can be successfully implemented on large scale – Linking PCMH to revised reimbursement accelerates adoption and use of systems in clinical practice – Implementation of PCMH leads to • higher quality of clinical care • enhanced patient experiences of care • Lower (or at least more rational) resource use/cost

In addition, ACP, AAFP, AAP and AOA want to show that PCMH leads to renewed interested in primary care Patient-Centered Medical Home 27

Questions? Contact: [email protected]

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Appendix Slides: Development and content of PPC-PCMH

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Goals of PPC Measure Development

• • •

Develop measures for evaluating systems use and effectiveness in prevention, chronic illness and if possible patient safety Create measures that are “actionable” at level of physician office practice Validate measures by relating them to existing disease-specific performance measures and patient perceptions of care Patient-Centered Medical Home 30

•

Study of Validity: Accuracy of Self-Report

Test accuracy of self-reports of practice systems using on site audit as “gold” standard

• – – –

Varies by domain, by staff position, and by medical group The predictive value of a positive report of a practice system is generally high. Overall agreement with the on-site audit ranges from high (clinical information systems, quality improvement) to low (care management, population management).

Several factors may explain lack of agreement

–

Variable implementation of systems across sites and conditions

–

Variations in staff members’ exposure to systems

–

Lack of familiarity with systems Conclusion: Need Audit or Documentation Patient-Centered Medical Home 31

Studies of Correlation of PPC with Clinical Performance and Patient Experience

•

Preliminary results from Minnesota (California and Massachusetts in prep)

–

Overall PPC score, and sub-scores have positive correlation with higher clinical performance on most measures (diabetes, CV, asthma)

– Overall PPC score does NOT appear to correlate with patient experiences of care – Presence or absence of EMR per se, correlates ONLY WEAKLY with clinical measures – However, practices with fully functional EMR’s achieve highest scores on PPC

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Using the PPC in Practice

Use of PPC, DPRP and HRSP in BTE

• • • •

Employers want to improve the quality of care their employees receive, and they want to increase the value of their health care spend:

– BTE Programs have actuarially validated savings and BTE recognized physicians deliver higher quality care

Employers want operational simplicity:

– BTE is now administered by licensed or certified administrators, mainly health plans

Physicians want to be measured by reliable and valid measures and independent third party organizations:

– BTE’s Provider Performance Assessment Organizations and measurement systems are accepted by the physicians

Physicians need to know up front what performance is expected of them and what they will get for achieving it:

– BTE’s Operations give physicians a market-wide view

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PPC Scoring

• •

9 standards = 100 points Three levels of recognition,

based on total points achieved

–

Recognized—Level 1

• 25 – 49 points – – –

Recognized—Level 2

• 50 – 74 points

Recognized—Level 3

• 75 – 100 points

Not Recognized (or reported)

• 0 – 24 points

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