G UIDANCE ON INTERVENING WITH PANEL MANAGEMENT : HIV CLINICS AT THE FOREFRONT OF PCMH MODELS Itta Aswad, MPH November 28 th , 2012- Ryan White All Grantees Meeting

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ISCLOSURES This continuing education activity is managed and accredited by Professional Education Service Group. The information presented in this activity represents the opinion of the author(s) or faculty. Neither PESG, nor any accrediting organization endorses any commercial products displayed or mentioned in conjunction with this activity.

Commercial Support was not received for this activity.

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ISCLOSURES  Itta Aswad, MPH Has no financial interest or relationships to disclose  Kathleen Clanon, MD Has no financial interest or relationships to disclose

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EARNING OBJECTIVES At the conclusion of this activity, the participant will be able to: 1. Define Panel Management and describe a typical PM program.

2. Describe the association between the Patient Centered Medical Home Model and Panel Management.

3. Identify barriers and facilitators to implementing this design in their agencies

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BTAINING

CME/CE C

REDIT If you would like to receive continuing education credit for this activity, please visit: http://www.pesgce.com/RyanWhite2012

W HO ARE WE HIV ACCESS is a consortium of Primary Care clinics working to provide comprehensive quality care to PLWHA

The Family

Care Network is a consortium of agencies that works to provide comprehensive, services across disciplines for children, youth, women and families living with HIV

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GENDA  Overview of PCMH    What is Panel Management?

How PM works How PM can be implemented in your clinic

T HE REALITY OF THE 15 MINUTE VISIT IN PRIMARY CARE  Only 37% of patients in one study were adequately informed about medications they were taking  50% of patients leave office visit not understanding what the doctor said  Study of 1000 physician visits, the patient did not participate in decisions 91% of the time.

Roter and Hall. Ann Rev Public Health 1989;10:163. Braddock et al. JAMA 1999;282;2313.

R ACIAL D ISPARITIES IN S URVIVAL   Late initiation or early HAART discontinuation results in life expectancy loss Data indicate minorities present later and have higher rates of premature discontinuation White 7.0

6.0

5.0

4.0

3.0

2.0

1.0

0.0

Women Losina E et al. 14th CROI; 2007; Los Angeles, CA. Abstract 142.

Black Men Slide courtesy of Dr. William King Hispanic Overall

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HAT IS A

PCMH?

A primary care practice that has gone through an independent evaluation process, such as through the NCQA, to validate that it is able to:     Deliver comprehensive, patient centered care Of the whole person, Supported by health information systems And with accountability for results.

Slide courtesy of Dr. Kathleen Clanon

K EY FEATURES OF A PCMH INCLUDE :

      Enhanced Access and Open Scheduling Adopting and Implementing Evidence Based Guidelines Systematic, HIT based tracking of tests, results, screens, preventative therapy Referral tracking, and follow-up Alternate forms of patient-physician interaction (email, phone) PCMHs are accountable for reporting on evidence-based measures of quality and patient satisfaction.

Slide courtesy of Dr. Kathleen Clanon

Patient Centered Medical Home Implementation Continuum

Doctor and Staff Centered model Pre contemplation

(Inconvenient hours, no outreach to missing patients, difficult to reach clinic on phone)

Visualized

as PCMH (Philosophic commitment to PCMH and talk about concepts, no action yet)

PCMH Fully Integrated Organized

as PCMH (Patient navigators, panel management, staff huddles, using registry)

Standardized

as PCMH (Staff training and job descriptions include new duties, reimbursement is tied to pt satisfaction)

Recognized

as PCMH (By NCQA, etc.)

Realized

as PCMH (Org culture and operations have fully integrated PCMH) Slide courtesy of Dr. Kathleen Clanon 12

W HY DO WE NEED THIS CHANGE ?

 PLWH/A are living longer  List of beneficial preventative disease activities is growing  Resources are becoming more limited  Payer models are changing (pay for performance)  Utilizing meaningful use incentives

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HAT IS

P

ANEL

M

ANAGEMENT     Use a registry to track who needs what Have written selection criteria to decide which patients to focus on for what Link criteria to standing orders for labs, immunizations, counseling referrals, etc Empower MA/peer teams to take over managing routine care outside of the MD/NP visit Slide courtesy of: Barbara Ramsey, MD

W HAT CAN P ANEL M ANAGEMENT DO FOR US ?

 Uncouple the Dr. visit from some of the  - Adherence counseling cessation - Smoking   - Prevention counseling - Vaccinations - Mental Health and Substance Abuse treatment  Produce actionable interventions - phone messaging - med reconciliation

P

ILOT PROJECT

- A

LAMEDA

M

EDICAL

C

ENTER

, O C

AKLAND OUNTY

CA

   Goal: Increase retention in care Increase vL suppression Increase health maintenance activities     Team Approach: 1 Clinician 1 Medical Assistant 1 Registered Nurse ~125 clients

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ASK

S

HIFTING

Pre Panel Management

 MA- Vitals and referrals

as ordered Post Panel Management

 MA- Vitals, promotes for HM tasks, referrals, in reach to the out of care

without order

 RN- Case Management and discharge orders  RN- Case Management and discharge orders  MD- focus on HIV care and Primary care needs

as remembered

 MD- Focus on HIV and Primary care needs

using support tools

W HAT DOES SOUND LIKE ?

P ANEL M ANAGEMENT “ Hi Andre, I’m calling from Dr. J’s office. I see you are overdue for your labs. I have a lab slip for you, can you come in a see me tomorrow? Great, and we can get your flu shot done then too, and we’ll set you up to see Dr. J.” “Hello Ms. R, this is Itta calling from Dr. C’s office. How are you today? We were looking over your chart and noticed that you are coming up due for your pap smear and also your ADAP needs renewal. Is it ok if I make appts for you next week to get those done?”

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NTERVENTIONS AND TOOLS  Health messages     In-reach Registry reports Huddles Decision Support sheets

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DVANTAGES  Proper provider assignments     Focused HIV and Primary Care tasks Increase quality numbers Organized care coordination Movement toward NCQA qualification

A LAMEDA P ANEL C OUNTY M EDICAL M ANAGEMENT A C ENTER T WORK :

U SE OF A R EGISTRY R EPORT  - How many clients in your panel?

    - What information is available on each patient?

- Which patients are overdue for CD4, Viral Load, TB, Paps?

- Which patients are at goal? Which are not?

- Which patients could be prioritized for self management support groups?

E XERCISE : U SING THE R EGISTRY Exercise: 15 minutes. In groups of 3-4, degsinate each person a role (MA, RN, Panel Manager, Clinician).

Which clients should the Panel Manager work with first?

    How did you prioritize the clients? Why?

What interventions would you recommend for follow-up?

What is the role of other team members?

PM

AT WORK

…

THE RESULTS TELL ALL 100% 50% 0%

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HALLENGES AND

S

OLUTIONS

Challenges

 Time   Prioritizing needs Shifting medical practices

Solutions

   Scheduling protected time Use Registry report and Decision Support tools Communication

D O YOU HAVE THE RESOURCES TO PULL THIS OFF ?

1.

2.

3.

4.

4 Central PM concepts Use a registry A team of providers willing to align resources Prioritizing criteria Take care out of the PCP visit when possible

DISCUSSION

N EXT S TEPS …..

     Identify staff Determine PM activities Carve out protected time with PCP Celebrate successes Learning opportunities

R ESOURCES     Itta Aswad, MPH [email protected]

Kathleen Clanon, MD [email protected]

William King, MD, JD Barbara Ramsey, MD [email protected]

[email protected]