Transcript PCPCC - Built to Last PCMH

Built to Last: The Successful Patient
Centered Medical-Home (PCMH) Team
PCPCC Stakeholders’ Working Meeting
April 28, 2009
Guy Mansueto, VP, Phytel
Moderator
Our Panelists
Richard C. Antonelli, M.D., M.S., FAAP
Medical Director, Integrated Care Organization,
Children's Hospital Boston/ Harvard Medical School
Suzanne Mitchell, M.D. M.Sc.
Faculty, Boston University School of Medicine
Christine Sinsky, M.D.
Medical Associates Clinic, Dubuque, Iowa
Linda Strand, Pharm.D., Ph.D., D.Sc.(Hon)
Distinguished Professor, College of Pharmacy, University of Minnesota
2
Successful PCMH Team:
What Constitutes Care
Coordination in a
Pediatric Medical Home?
Richard C. Antonelli, M.D., M.S., FAAP
Medical Director, Integrated Care Organization,
Children's Hospital Boston/ Harvard Medical School
Challenges to Implementing Family-Centered
Medical Home
• TIME, TIME, TIME
• Lack of organized systems of care with defined roles
• Inadequately developed family/patient -professional
partnerships
• Knowledge
– Care pathways
– how to change
• Lack of Care Coordination function
• Lack of awareness of community resources and programs
• “Reimbursement”
4
Defining Care Coordination
Pediatric care coordination is a patient- and familycentered, assessment-driven, team-based activity
designed to meet the needs of children and youth while
enhancing the care giving capabilities of families. Care
coordination addresses interrelated medical, social,
developmental, behavioral, educational, and financial
needs in order to achieve optimal health and wellness
outcomes.
Source:
MAKING CARE COORDINATION A CRITICAL COMPONENT OF THE PEDIATRIC HEALTH SYSTEM:
A MULTIDISCIPLINARY FRAMEWORK
Richard C. Antonelli, Jeanne W. McAllister, and Jill Popp
The Commonwealth Fund, April 2009
5
Components of Care Coordination
Family-centered and Community-based
Proactive, Providing Planned, Comprehensive Care
Promotes the Development of Self Management Skills
(Care Partnership Support) with Children, Youth and
Families
Facilitates cross-organizational linkages and relationships
Source:
MAKING CARE COORDINATION A CRITICAL COMPONENT OF THE PEDIATRIC HEALTH SYSTEM:
A MULTIDISCIPLINARY FRAMEWORK
Richard C. Antonelli, Jeanne W. McAllister, and Jill Popp
The Commonwealth Fund, April 2009
Care Coordination Functions
•
•
•
•
•
•
•
•
•
•
Provides separate visits and care coordination interactions
Manages continuous communications
Completes/analyzes assessments
Develops care plans with families
Manages/tracks tests, referrals, and outcomes
Coaches patients/families
Integrates critical care information
Supports/facilitates care transitions
Facilitates team meetings
Uses health information technology
Focus of Encounter
Primary Focus
% Encounters
Clinical / Medical Management
67%
Referral Management
13%
Social Services (ie. Housing, food, clothing…)
7%
Educational / School
4%
Developmental / Behavioral
3%
Mental Health
3%
Growth / Nutrition
2%
Legal / Judicial
1%
Source:
National Study of Care Coordination Measurement in Medical Homes
Antonelli, Stille, and Antonelli, 2008
8
Prevented Outcome
The CCMT allows only one outcome prevented per encounter.
32% of total 3855 CC encounters prevented something.
Of the 1232 CC Encounters where prevention was noted as an outcome:
Outcome Prevented
Visit to Pediatric Office / Clinic
Emergency Department Visit
Subspecialist Visit
Hospitalization
Lab / X-Ray
Specialized Therapies
# CC Encounters
714
323
124
47
16
8
Percentage
58%
26%
10%
4%
1%
1%
62% of RN CC Encounters prevented something.
33% of MD CC Encounters prevented something.
RNs are responsible for coding 81% of the Emergency Department
preventions and 63% of the sick office visit preventions.
9
Implications for Policy and Practice
• Re-examine the traditional, office-based interaction
• Service unit for primary care in PCMH must include CC
• Service unit must value non-face-to-face care provided
by non-MD staff supporting care coordination
• Use Care Plans to drive (and to monitor) care provision
• All PCMH team members function at “the top of their
license”
• Multiplicity of demands for CC demands participation by
integrated team: MD, NP/PA, RN, LPN, MA, pharmacy,
community partners (eg, dental,mental;education)
• All aspects of system performance transparent to
families and payers/ purchasers
10
Successful PCMH Team:
The Patient / Family as
Team Members
Suzanne Mitchell, M.D. M.Sc.
Faculty, Boston University School of Medicine
A Structured Approach to Relationship-Centered
Care
•
•
•
•
Build Relationships / Serve
Collaborate
Educate
Negotiate
12
Provider Inquiry:
Interview,
Physical exam,
Tests,
Diagnosis
Treatment Plan
Collaborative Agenda
Setting
Rapport-building
Skills
1. Mindfulness
2. Reflection
3. Transparency
4. Goal alignment
Tools
•LEARN/MI
•Patient Activation
•Self-Management Ed
5. Express Empathy
Adapted from:
Mauksch LB et al, Relationship, Communication and Efficiency
in the Medical Encounter, Arch Intern Med, 168(13):
July 14, 2008
Negotiate Plan
Tools and Techniques
• Collaborative Agenda Setting
• LEARN Interview Model
– Active Listening Skills
– Eliciting the Explanatory Models
– Motivational Interviewing
• Self-Management Ed.
14
Tools and Techniques:
The L-E-A-R-N Model
Listen
(Reflection)
Elicit/Explain Acknowledge
And Ask
What do
you think
caused this
problem?
What do you
think will make
you better?
How important is this to you?
How confident are you?
I would like
to show you
this chart of
your HbA1c.
Is that OK?
Recommend
Let’s do a reality
Check.
We seem to see
things differently
in this situation.
What would you
do if you were in
my shoes?
Negotiate
Tools and Techniques:
Self-Management Education
• Patients identify their problems
• Problem-solving skills
• Decision-Making Techniques
• Builds and Relies on Self-Efficacy
• Addresses:
–
–
–
–
–
Communication Skills,
LifeStyle Changes,
Medication Adherence,
Mood Challenges,
Assessing New Treatments
Source:
Bodenheimer et al JAMA November 20, 2002—Vol 288, No. 19
16
Tools and Techniques:
Action Plans Fuel Motivation
• Action plans are developed
by patients - not
providers.
• The action plans build
confidence that fuels
internal motivation.
17
Relationship-Centered Care
• Reduces Patient Anxiety
• Promotes Patient-centered
Treatment Goals
• Enhances Self-Efficacy
• Optimizes Use of Resources
• Improves Quality of Care
• Restores Provider Commitment
and Prevents Burn-out
18
Successful PCMH Team:
Nurse-Physician
Partnerships
Christine A. Sinsky, MD
Medical Associates Clinic and Health Plans
Patient Centered
Medical Home
Integrated, Continuous Care
Build-in
rather than
Carve-out
Office Visit
Nurse-MD Team
Between
Efficiencies
and care
Visit Care
coordination
1.5 nurses: MD
THE BOSS: Nexus of organization of our practice
Between Visit
Visit
•Extension of me when
dealing with patients;
patients recognize this.
•Med. Reconciliation
•Coordinates transitions
(hospital, NH, Hospice)
•Manages & returns
most phone calls
•Does prescriptions
•Updates EHR
•Completes all
paperwork
•Initial review of lab
•Patient education
•Immunizations
•Colonoscopy
•Sx driven tests
(PFT, EKG)
•Diabetic foot exam/eye
exam
•Present patient
(↓ info drop-off)
Core Team: Mini-huddle
• 47 yo “Rapid Access”
new patient
CC: dysphagia
• Nurse Mini-huddle
– “She seems depressed”
– “Is anyone hurting
you?”
• Physician better
prepared
Integrated, Continuous Care
Lab
Mammo
Mammo
Mar
Sept
Comprehensive
Planned Care
HTN
O
L  Chol
R
 Glucose
D
A Osteoporosis E
Depression
R
B LDL 75,
S
A1c 6.2
Nurse-MD Team
HTN
O
L  Chol
R
 Glucose
D
A Osteoporosis E
Depression
B Lipids,FBS R
Cr, K, Mam S
Prevention
Efficiencies
and care
coordination
Same Day
Surgery Appt
S
C
R
I
P
T
S
Integrated, Continuous care
Dec
Nov
INR
Hospital
CHF
INR
Comprehensive
HTN
O
L DM 2
R
Depression D
A FBS, A1c, E
lipids, alb, R
B
mammo
S
INR
Architecture
Of
Care
INR
INR
Prevention
CHF
Education/
Clinic
Sept
S
C
R
I
P
T
S
Home Care
Mar
Planned Care
Planned Care
HTN
HTN
L DM 2
Depression
O
R
D
A
E
FBS, A1c
B INR CXR R
S
O
R
Depression D
A
E
A1c 6.8
R
B LDL 145
INR S
L DM 2
Diabetic
Education
Aug
INR
Nurse-MD Team
Efficiencies
and care
coordination
Rapid
Access
Pneumonia
Family
Apr
Jun
INR
Rapid
Access
LBP
Planned Care
HTN
O
R
Depression D
A
FBS, A1c E
R
B
Lipids INR S
L DM 2
INR
INR
At the center of the PCMH are face-to-face
healing relationships.
Patient: Nurse
Nurse: Nurse
Nurse: Physician
Patient: Physician
26
Successful PCMH Team:
Medication Management
in Medical Home
Linda M. Strand, Pharm.D., Ph.D., D.Sc.(Hon)
Distinguished Professor, College of Pharmacy
University of Minnesota
And Consultant, Medication Management Systems, Inc.
Discloser: Founding Member of the Board of Directors Medication Management Systems, Inc
Roles of the Pharmacist
Dispensing
Clinical pharmacist
Medication therapy management
Definitions of Medication Therapy Management
1. APhA Consensus Statement
2. American Medical Association
3. Minnesota Legislation for Minnesota Medicaid
Medication Management in Medical Home
1. Patient specific
2. Involves an assessment of drug-related needs,
care plan to resolve drug therapy problems
and follow-up to determine actual impact
3. Comprehensive
4. Coordinated with other team members
5. Adds unique value to care
Practice Settings for Medication Management
Clinic Practices
Telephonic services
Retail Settings
The Pharmacist in Medical Home
ASSESSMENT
CARE PLAN
Reveal the patient’s medication
experience
Identify drug therapy problems
Personal
Team
Relationship
Approach
of appropriateness, effectiveness,
safety, and compliance with medications
Establish personalized goals of
therapy
Resolve drug therapy problems
Personalize Interventions
Value
Medication Comprehensive
Therapy
Management
Access
Coordinated
Quality
Safety
FOLLOW-UP
Evaluate Effectiveness and Safety
Determine Actual Patient Outcomes
Panelist Q&A
Richard C. Antonelli, M.D., M.S., FAAP
Medical Director, Integrated Care Organization,
Children's Hospital Boston/ Harvard Medical School
Suzanne Mitchell, M.D. M.Sc.
Faculty, Boston University School of Medicine
Christine Sinsky, M.D.
Medical Associates Clinic, Dubuque, Iowa
Linda Strand, Pharm.D., Ph.D., D.Sc.(Hon)
Distinguished Professor, College of Pharmacy, University of Minnesota
33
Thank You!
34
References: Care Coordination
• McPherson, M., Arango, P., Fox, H., et al. (1998). A new definition
of children with special health care needs. Pediatrics, 102,137–140
• Porter, M. and Teisberg, E., Redefining Health Care: Creating
Value-Based Competition on Results. Harvard Business School Press,
2006.
• Antonelli, R, McAllister, J, and Popp, J. Making Care Coordination a
Critical Component of the Pediatric Health System: A
Multidisciplinary Framework, April, 2009, The Commonwealth Fund.
35
References: Care Coordination (cont.)
• Antonelli, R. and Antonelli, D., Providing a Medical Home:The Cost
of Care Coordination Services in a Community-Based, General
Pediatric Practice, Pediatrics, Supplement, May, 2004.
• Antonelli, R., Stille, C. and Freeman, L., Enhancing Collaboration
Between Primary and Subspecialty Care Providers for CYSHCN,
Georgetown Univ. Center for Child and Human Development, 2005
• Antonelli, RC, Stille, C, and Antonelli, DM, Care coordination for
children and youth with special health care needs: A descriptive,
multisite study of activities, personnel costs, and outcomes.
Pediatrics. 2008 Jul;122(1):e209-16.
• Turchi, R, Gatto, M, and Antonelli, R, Children and Youth with
Special Health Care Needs: There is No Place Like (a Medical)
Home, Curr Opin Pediatr 2007, 19: 503.
36
Links to Resources: Relationship-Centered Care
• Stanford Self-Management Education Program
http://patienteducation.stanford.edu/programs
/cdsmp.html
• http://motivationalinterview.org
• Kleinman A, Eisenberg L, Good B. Culture,
illness, and care: clinical lessons from
anthropologic and cross-cultural research. Ann
Intern Med. 1978;88(2):251-258
37
Links to Resources: Medication Management in
Medical Home
1.Kuo GM et.al. Collaborative drug therapy management services and
reimbursement in a family medicine clinic. Am J Health-Syst Pharm.
2004;61:343-54.
2.Nkansah NT et.al. Clinical outcomes of patients with diabetes mellitus
receiving medication management by pharmacists in an urban private physician
practice. Am J Health-Syst Pharm. 2008;65:145-9.
3.Isetts, et.al. Clinical and economic outcomes of medication therapy
management services: The Minnesota Experience. J Am Pharm Assoc
2008;48:203-211.
4.Isetts, et.al. Quality assessment of a collaborative approach. Arch Int Med
2003;163:1813-20.