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Patient Centered Medical Home Pilot Program (PCMH) Mindi S. Garner, DO, FACP Pittsburg, Kansas Veteran’s Day 11/11/11 Presentation Outline I. II. III. IV. V. My Background Define PCMH Business Model of Medical Home My PCMH Experience Unique Project With PCMH Background Background • Raised in Parsons, KS (SEK) • Undergraduate • Pittsburg State University in Pittsburg • Medical School • Oklahoma State University-COM, Tulsa • Graduated 2000 Background • Residency in Internal Medicine • University of Tennessee-Memphis • June 2000-July 2003 • Private Practice 12/1/03 • Pittsburg, Kansas • Straight out of Residency Traditional Medical Practice • Solo Independent General Internist • Both In-patient & Out-patient • Active staff privileges • Via Christi Hospital, Pittsburg, KS • Girard Medical Center, Girard, KS • 2 clinics: Pittsburg and Girard • Share call with 5 other Internists EMR Background • First Fully Functional EMR in SEK • Started from Day 1 • Fully Integrated • Website • E-scripts • Lab Result Integration • Patient Portal • Secure email messaging Control of Business • Trained in EMR and PM Software • Trained in every office activity • Do own coding • Do Own Charge Entry • Review every aspect of cash flow • Practice cost-conscious medical care Defining PCMH Concerns? • Medicare Physician Reimbursement • Commercial Insurance Trend • Recovery Audit Contractor Program • Healthcare Reform • Unsustainable Payment Structure Motivation Difficulties? • Who wouldn’t have difficulties? • Physicians are human! • Odds stacked against us? • Frightened? • I share your concerns • I am in the same situation you are • Our livelihood is in jeopardy Frustrations • Anyone understand what we are going through? • Need to be a PCP to know challenges that occur everyday • Specialists are also involved • Equal Opportunity What is the solution? • Times are changing • Reform needs Physician Leadership • Innovative Ideas • “Think outside the box” • Extreme conditions require unique approaches • Perfect Opportunity • Everyone is looking to us for solutions What is a PCMH? •PCMH is an acronym for the PatientCentered Medical Home model of care •It is not a brick and mortar building •It is a set of principles •It is a more effective model of health care delivery PCMH 16 Definition adopted in Kansas law, 2008 The definition of a medical home according to Kansas law (K.S.A. 75-7429) is: “A health care delivery model in which a patient establishes an ongoing relationship with a physician or other personal care provider in a physiciandirected team, to provide comprehensive, accessible and continuous evidence-based primary and preventive care, and to coordinate the patient’s health care needs across the health care system in order to improve quality and health outcomes in a cost effective manner.” Patient-Centered Medical Home • Background • American Academy of Pediatrics • Concept introduced 1967 • Central location of child’s medical record • Policy Statement 2002 • Expanded concept What does a PCMH do? The PMH puts patients at the center of the health care system, and provides primary care that is “accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.” Patient-Centered Medical Home • Principles • Personal physician • Physician directed medical practice • Whole person orientation • Care is coordinated and/or integrated • Long-term healing patient-physician relationship instead of episodic treatments PCMH • Focuses on expanded communication between patient and PCMH team Just Cut to the Chase! Healthcare Reform OUR Way! Physician Led-The Right Way! Reality Check: American Healthcare • Exploding costs • FFS drives volume over quality, fosters fragmentation over coordination • Lagging quality • Poor satisfaction • Misaligned incentives • Physician workforce “perfect storm” • Primary care is critical, and a fundamental answer to the health economics in US • Quality MUST increase, cost MUST stabilize Money Saving Options •There are ONLY 4 options to change the basic economics: • Serve fewer people • Provide fewer services • Rationing, quotas • Pay less per service • rationing by no willing providers • Fundamentally change how services are paid and/or system is organized • Increased prevention/primary care • PCMH, ACOs What is a Patient Centered Medical Home? •A vision of health care as it should be •A framework for organizing systems of care at both the micro (practice) and macro (society) level •A blueprint or pathway to excellent healthcare for individuals or a population PCMH Video http://www.emmisolutions.com/medicalhome/transformed/english.html Physician Leadership • Natural Leaders • This is what we do every day! • We are the authority in patient care so allow us to pave the way! • We can develop the plan to take care of our patients • This is our obligation PCMH • Hallmarks of Medical Home • Practices advocate for their patients • Evidence-based medicine • Voluntary performance measurement • Patients participate in decision-making • Informational Technology utilization • Enhanced Access to Clinic Business Model of PCMH • Three-Part Payment Model • Monthly Care Coordination Payment • Visit-Based Fee-For-Service Component • Performance-Based Component PCMH • Payment Reflects Value of Medical Home • Reflects value of work outside visit • Pay for coordination of care • Support provision of enhanced communication via email or phone • Recognize value of physician work remotely • Separate payments for face-to-face visits PCMH • Payment Reflects Value of Medical Home • Recognize case mix differences in patient population • Allow physicians to share in savings from reduced hospitalizations • Additional payments for continuous quality improvements Team Approach •Health care is delivered by a system •Implies a multidisciplinary team •Each member operates top of license •Variety of disciplines •Collaborative parallel effort is norm •Shared decision making and accountability • Paradigm and legal shift Rationale for moving toward PCMH Provides framework for sustainable process improvement Supports the Joint Commission Hospital Accreditation process Lays foundation for Accountable Care Organization (ACO) model Leverages support from Kansas PCMH Initiative (2011-2013) program Improves population health My Role in PCMH • Chosen as 1 of 8 clinics in Kansas • Huge Honor • Pilot Program • 2 years in duration • Provides resources to embrace change • “It’s what you make it” • “EMR Meaningful Use” compatible Sites Selected for the Pilot 35 • American Medical Practice of Winfield/Augusta Family Practice, PA, Winfield • Cheyenne County Clinic, Cheyenne County Hospital, St. Francis • Ellsworth County Medical Center and Rural Health Clinic, Ellsworth • Mindi S. Garner, D.O., Chartered, Pittsburg • Great Plains of Sabetha, Inc. dba Sabetha Family Practice, Sabetha • Internal Medicine Group, PA, Lawrence • KU Wichita Adult Medicine, University of Kansas School of Medicine – Wichita, Medical Practice Association, Wichita • Post Rock Family Medicine, Plainville Practice Redesign Tool • TransforMED • Non-profit subsidiary of the American Academy of Family Physicians (AAFP) • Started in 2005 • Mission • The transformation of health care delivery to achieve optimal patient care, professional satisfaction and success of primary care practices. My Motivation! PCMH • Perfect Opportunity • Needed a new focus • Embracing “Change” • No longer the “strongest survive”, it is the “most able to change” survive • Flexibility is key • Sometimes painful process PCMH • Must open practice to critiques • Prepare to change workflows • The 8 clinics help each other • Group Conference Calls Each Month • Access to online, collaborative network: Delta Exchange • Assistance to aid transformation process My Experience with PCMH How Did We Get Started? • Attended the first PCMH Pilot Program meeting • Motivational Speakers Started Process • My Self-Evaluation Started • Humbling Assessment • Control Issue was causing stagnation Self-Evaluation • I was interrupting staff workflow • Staff Survey • Job satisfaction • Anonymous feedback on frustrations • Lack of pre-visit planning • “huddles” • Brainstorming Session with follow up “Clinic Overhaul” Details • Everyone works to the top of their license • Created Lab Order Protocol • Created Phone Note Protocol Template • Same information format each and every time • • • • Regularly Scheduled Office Staff Meetings Prescription Refill Protocol New, easier to maneuver EKG machine Perform Dermatology procedures in-house “Clinic Overhaul” Details • Created additional signing privileges • Completed Policies/Procedures Manual for staff • Every employee is trained for frontdesk duties • More open-access appointment slots “Clinic Overhaul” Details • Patient Portal • Secure email • Empower patients with their own data • Increased communication • Copies of clinical summary at end of visit • Copies of med list Practice Implications • Challenges of Transformation • Initial Capital and Restructuring Costs • Ongoing support and maintenance • Reporting on quality, cost and satisfaction • Implementing HIT • Information Overload Practice Implications • Shifting “power” • Too much change to manage anyway • Job Duties completely revamped • Possible Staff Objections • Doctor has to be willing to embrace change for staff to follow Change • Change is difficult but required • Embracing change is hard but it is easier when you are in a “not so happy place” • Eliminate anger, frustration, despair Assessing Value in PCP • PCMH just gives name of what we do • Enables proper compensation • Describes the workflow of primary care • Foundation of medical care • Communicates our unique perspective • No other “branch” of medical tree similar • Without primary care, medical treatments are disorganized I already do this! But… • PCMH puts a more formalized name on “patient and family centered care.” • PCMH can generate support as the model proves it improves care and reduces cost across the health care system • PCMH gives us the opportunity to more clearly define how we can work together more effectively for our patients and their families I do this anyway! • Need to describe our work functions in order to even attempt to be compensated for “scut work” • Likely not same way each encounter • Follow systematic way to provide the same care each and every time with every patient Why Patient Centered Medical Home? • The Patient Centered Medical Home creates a framework for change • The Patient Centered Medical Home creates a common language for change • The Patient Centered Medical Home creates an opportunity for change • The framework, language and opportunity for meaningful Clinical Integration 8 Minutia? • Curbside consults • Filling Out Paperwork • Disability • Nursing Home documents and issues • Review consultations • Communicating with patients • These all add up The PCMH concept advocates enhanced access to comprehensive, coordinated, evidence-based, interdisciplinary care Today’s Care Medical Home Care My patients are those who make appointments to see me Our patients are those who are registered in our medical home Care is determined by today’s problem and time available today Care is determined by a proactive plan to meet health needs, with or without visits Care varies by scheduled time and memory or skill of the doctor Care is standardized according to evidencebased guidelines I know I deliver high quality care because I’m well trained We measure our quality and make rapid changes to improve it Patients are responsible for coordinating their own care A prepared team of professionals coordinates all patients’ care It’s up to the patient to tell us what happened to them We track tests and consultations, and follow-up after ED and hospital Clinic operations center on meeting the doctor’s needs An interdisciplinary team works at the top of our licenses to serve patients Why PCMH matters to HCPs Physicians & Staff Patients • • • • • • • • • • • • Happier staff Happier physicians Increased net revenue Team-based care Long-term returns from transformation • Increased standardization of care • Improved patient safety • Better communication reducing risk Improved satisfaction Improved preventive care Improved quality measures Reduced ED utilization Reduced readmissions Reduced hospitalizations Longer team-based appointments; enhanced communication • Reduced per capita cost for certain chronic conditions The Future of Primary Care • PCMH Concept Emphasizes Teamwork • Usual reason why doctors don’t choose PC • PCP’s usually don’t have help • Team Meetings are a Priority • The “Glue” that keeps team together • You are not alone! The Future of Primary Care • Primary Care Physicians • Career Satisfaction at all time low • Change the delivery of care • Save primary care • Desire to improve outcome for our patients • Need right balance PC + Specialists The Future of Primary Care • Doctors go to work every day wanting to serve our patients better and we feel badly about it • You can do something about it • Stronger primary care=Healthier Patients The Future of Primary Care • The influence of the PCMH • Encourage future primary care doctors • If done correctly this could re-energize primary care • Intertwines with a unique program Unique Project with PCMH Teach By Example • “Premeds with Promise, Inc.” • Introduced February 2004 • Pittsburg State University Students • Pre-Medicine Majors • Serve as Medical Assistants • Student-Employees • Pre-Med Advisors’ Help • “Win-Win” Scenario Premeds with Promise, Inc. • On the Job Training • Confirms Commitment • Opportunity to change path early • Exposed to lifestyle • On-Call • Post-Call • Benefits • Extremely Impressionable Premeds with Promise, Inc. • Experience interaction between doctors • Attend after-hours meetings • Grasp camaraderie first-hand • Assess “Rite of Passage” up close • Realize True Commitment • At my side during workday • Colleague Appreciation Premeds with Promise, Inc. • C-Corporation • Protects: • Students’ Interests • Integrity of Program • Sole Responsibility • Trust • Maintain goal of program Premeds with Promise, Inc. • Separate Payroll • HIPAA Trained • Worker’s Compensation Coverage • Open Door Policy Premeds with Promise, Inc. • Letters of Recommendation • Work Ethic Witnessed First-Hand • Detailed Letter • Compared to Shadowing • Creating competent colleagues Job Duties • Answer Phone • Complete flag requests • Check care plan after visit completed • Obtain all requested information • Complete Phone Notes • Assist in Dermatological Procedures • Document Preventive Care Measures Academic Training • Start update in EMR • Record CC, HPI, Vitals • Confirm medication changes • Prepare for SOAP Note completion • List all preventive care measures in plan at bottom of note • Just a glance at “Flowsheet View” Premeds with Promise, Inc. “Scribes” • Perform “Doctor Duties” • Up Close Interaction With Patients • Rare opportunity • Witness powerful relationship • Patient and Doctor • Experience the Doctor Role • Advantages for Doctor Premeds with Promise, Inc. • Involved in every aspect of business • Rare Opportunity • Hindsight Perspective • Premeds do payment entry • Supervision • Need Expert on Software • Avoid Outsourcing • Decrease costs Girard Satellite Clinic • Completely Premed Manpower • 3 Premeds at each clinic half-day • Drive company car from Pittsburg Premeds with Promise, Inc. • Future physicians of our community • Retiring community physicians • Alumni of local university • Good experience with physicians Premeds with Promise, Inc. • Ultimate Goal • Emphasis on Primary Care • My Clinic is Launching Pad after Residency • Rural Community Grants • Stay however long they want • 1st group is beginning 2nd year of Residency The Numbers • Current Premeds on Payroll: 14 • Past/Current Premeds: 54 • Presently in Medical School: 16 • Residency: 10 • Primary Care Residency: 7 • MD or DO + MBA: 7 Mission Statement Providing a Patient-Centered Medical Home For The Local Community While Cultivating The Resource Of Our Youth, Who Are Driven To Achieve The Professionalism And Discipline Necessary To Advance The Practice Of Medicine. PSU Homecoming Parade 2011 Highlights • Patient-Centered Medical Home • The Present and Future “Buzz Word” • Healthcare Reform • Physicians Leading the Way • Motivate by example • Re-energize Primary Care What’s Next? • Pilot Program Data Compilation • Use data as foundation for change • Every practice can begin process • Begins with self-evaluation • Where are you now and where do you want to be in your practice? • PCMH is a reality! Questions? Contact Information Mindi S. Garner, DO, FACP www.garnercares.com [email protected] www.premedswithpromise.com [email protected] 127 West 5th Street, Pittsburg, KS 66762 620-232-7900(p)------620-232-7901(f)