The Medical Home Model: Case Management - cmsa
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Transcript The Medical Home Model: Case Management - cmsa
The Medical Home Model: Case
Management Perspectives
James W. Mold, MD, MPH
Department of Family and Preventive Medicine
University of Oklahoma HSC-OKC
Disclosures
To my knowledge I have no conflicts of interest.
I won’t mention any specific companies or products in
my presentation.
I am a family physician with additional training in
geriatrics and I bring those biases with me.
Learning Objectives
By the time I have finished, you should be able to:
Define the Patient-Centered Medical Home (PCMH)
Explain the relationship between the PCMH and the
Chronic Care Model
Summarize the conditions under which case
management has been found to be effective in primary
care settings
Explain differences between a disease-oriented approach
and a patient-oriented approach to care
Outline
Definitions and conceptual models
Primary care
Chronic Care Model (CCM)
Patient-Centered Medical Home (PCMH)
Case management in primary care
Evidence review
Implications
Patient-centeredness and its implications
Goal-orientation vs. disease orientation
Case management in rural America
County health improvement organizations
Primary Care
The Institute of Medicine, in 1996, defined primary care as
“the provision of integrated, accessible, health-care services
by clinicians that are accountable for addressing a large
majority of personal health-care needs, developing a
sustained partnership with patients, and practicing within the
context of family and community.”
Attributes
Accessible
Comprehensive
Coordinated
Longitudinal
Person-centered
Family-centered
Community-centered
Relationship-Based
Integrated
Primary Care
Organizational Attributes
Accessible
Comprehensive
Coordinated
Longitudinal
Clinical Attributes
Person-centered
Family-centered
Community-centered
Relationship-Based
Integrated
Integrated
Impact of the CCM on Primary Care
Information systems
Electronic health records (EHRs)
Health information exchange (HIE)
Registries for population management
Decision support
Guidelines
Prompt/reminder systems, dashboards, protocols, checklists
Delivery system design
Teamwork
Standardized consultations
(Concierge practices)
Patient self-management support
Patient Self-Management Support
Patient education
One-on-one
DVDs
Bibliotherapy
Training for monitoring health parameters
Action plans (what to do, who and when to call)
Monthly phone contacts
Connections
Community resources
Support groups
Reminders and incentives to make positive behavior changes
Examples
Diabetes
Diabetes education
Q3month visits
ADA Guideline-based protocols, flow sheet
Single eye consultant
Registry
Prenatal care
Prenatal classes
Scheduled visits
ACOG Guidelines, flow sheet
High-risk OB clinic
Due date registry
Impact on Primary Care
Applicable to prevention as well as chronic illness care
CCM now often referred to as the Care Model
Enhancement of comprehensiveness, coordination and
longitudinality
Emphasis on diseases and guidelines could threaten personcenteredness, relationship-based care
Industrial quality model (every widget the same)
Would require an additional 3.5 to 10.6 hours per day for 10
most common chronic diseases.
Ostbye T et al. Ann Fam Med 2005; 3(3): 209-214.
Impact on Primary Care
Creates need/increased opportunities for:
Health educators
Case managers
Panel managers, registry managers
Social workers
Patient coaches
Patient navigators
Community health workers
Practice – Community Connectors
Patient-Centered Medical Home (PCMH)
“A patient-centered medical home integrates patients as active
participants in their own health and well-being. Patients are
cared for by a physician who leads the medical team that
coordinates all aspects of preventive, acute and chronic needs
of patients using the best available evidence and appropriate
technology. These relationships offer patients comfort,
convenience, and optimal health throughout their lifetimes.”
American Academy of Family Physicians, the American
Academy of Pediatrics, and the American College of
Physicians Spring, 2008.
The Patient-Centered Medical Home
PCMH as Advanced Primary Care
Primary care that incorporates the CCM while preserving
(enhancing) person-centeredness and adding HIT and QI
Increased emphasis on access and convenience
Open access scheduling
Extended hours
Incorporation of new technologies
Electronic health records, health information exchnage
Personal health records
Patient portals and E-visits
Quality Monitoring
Disease-oriented or standardized preventive services
Patient satisfaction
PCHMH Standards
NCQA criteria look like CCM plus e-prescribing, test
tracking, referral tracking, and continuous quality
improvement
“Care management” is one of nine sections
AAFP/TransforMed criteria look like primary care plus
continuous quality improvement
Case management not specifically listed
OK SoonerCare criteria emphasize care management; 3 tiers
Other criteria: AAAMC, The Joint Commission, the Center
for Medical Home Improvement, BCBS of Michigan,
Minnesota’s Health Care Home Certification Program
PCMH Standards
Care
Coordination
Population
Management
Care Plan
Health IT
EvidenceBased
Care
Team-Based
Care
Etc.
Burton RA, et al. Report to CMS by the Urban Institute, May, 2011
Case Management
Case Management is a collaborative process that
promotes quality care, and cost effective outcomes
which enhance the physical, psychosocial and
vocational health of individuals.
It includes assessing, planning, implementing,
coordinating, and evaluating health related service
options.
Case Management in Primary Care
What we now know:
Case managers must interact with patients in person; not just
by phone
Ayanian JZ. JAMA 2009; 301(6): 668-670
Case management must be integrated into primary care
Seow H, et al. JAGS 2006; 54:535-540
Wolff JL, et al. Ann Intern Med 2005; 143(6): 439-445
A disease-oriented, guideline-driven approach is probably
less effective than a patient-centered, goal-directed approach
Congressional Budget Office Analysis, 2004
Bosmans J, et al. J Gen Intern Med 2006; 21: 1020-1026
Patient selection is important, but the best approach isn’t
clear yet
Primary Care
Organizational Attributes
Accessible
Comprehensive
Coordinated
Longitudinal
Clinical Attributes
Person-centered
Family-centered
Community-centered
Relationship-Based
Integrated
Integrated
Case Management in the PCMH
Organizational Integration
Access process
Same office
Same record
Unified assessment
Effective and efficient communication channels
Clinical Integration
Person-centered
Goal-directed
Relationship-based
Context-sensitive
Case Management in the PCMH
Access options
Disease-based (CHF, DM, asthma, etc.)
Risk projections (computer formulas)
Internal referrals (from primary care clinicians)
Patient self-referrals (e.g. availability advertised)
CM self-referrals (e.g. all patient’s screened)
Combinations of above options
Transitions between care settings also very important
Hospital to home
Home to AL, NH
Home to ED to home
Case Management in the PCMH
Same Office
“I’m calling from Dr Smith’s office. He wanted me to visit with
you about…”
Same record
CM notes in same section as physician notes
Unified assessment
CM begins with information already in record.
Additional information is added to appropriate sections of the
record.
Communication channels
EHR messaging, daily event reports
Hallway huddles
Weekly team meetings?
Care plan visits (clinician, patient, family, CM)?
Case Management in the PCMH
Person-centered
Primary focus is on the needs of the person, not on
management of their diseases (though that too)
Goal-directed
A goal is a desired outcome for which it makes little sense to
say, “…so that?”
I’d like to live long enough to see my grandchild get married.
I’d like to get be able to use my sewing machine again.
Not, “I’d like to get my A1c to <8%.”
Relationship-based
Human interpersonal interactions my be the most powerful
therapeutic agents in our armamentarium.
Practical Considerations
Who can/should do it?
Children mostly need a social worker
Old people mostly need a skilled nurse
Some combination of these might be ideal
How many case managers are needed?
Assistive care management to address adherence problems, complex
medication regimens, and co-morbidities for the 20 percent to 30
percent of patients whose diseases are not under control.
Intensive case management and specialty care for the 1 percent to 5
percent of patients with advanced disease and complex co-morbidities
or frailty.
How should it be organized and financed?
Reimbursement to practices (fee-for-service)
Capitation payment to practice
Support for a set of shared resources
Bodenheimer T, et al. JAMA 2002; 288(14): 1775-1779 and 288(15): 1909-1914.
NC Community Care
14 non-profit networks covering the entire state
NC Medicaid puts $3 PMPM into the networks and gives
primary care clinicians $2 PMPM to join a network
Networks use the money to hire or contract for case
managers and others needed to improve care and reduce cost
QI projects initially directed by the state (CHF, DM, asthma)
Networks now encouraged to initiate QI projects
Successful projects spread to other networks
Extremely successful in terms of cost savings, improved
quality measures, and better relations (PCC and Medicaid)
OK Health Access Networks
3 non-profit HANs (Canadian County, OU-Tulsa, OSU
COM)
Medicaid puts $5 PMPM into the networks
Networks hire or contract for case managers
Required to help practices reach level 3 PCMH
Some empahsis on HIT and HIE
Too early to tell if effective
Effective Implementation of Innovations in Primary Care
Literature and Exemplar
Methods
Performance
Feedback
Facilitation
IT Support
Local Learning Collaboratives
Academic
Detailing
Practice Enhancement
Assistant
Primary
Care
Mental
Health
Regional
AHEC
Public
Health
Practice
Practice
OHIET
Practice
County Health
Improvement Office
QI Facilitators
Case Managers
IT Support
Practice
Academic
Medical
Centers
Practice
Practice
Hospital
Funders
Turning
Point
OHIET
NW
AHEC
SW
AHEC
NE
AHEC
SE AHEC
P
P
CHIO
P
P
CHIO
CHIO
CHIO
CHIO
CHIO
CHIO
P
P
CHIO
P
CHIO
P
P
P
OUHSC
OKC
P
CHIO
P
OSUCOM
P
P
CHIO
OUCCM
Tulsa
P
CHIO
P
P
P
P
P
P
P
Annual Funding
Public and
Private Insurers
Project Specific
Funding
CDC, HRSA,
etc.
County Extension
Program
Oklahoma Health
Information Exchange
Trust
Project Specific
Funding
AHRQ, NIH,
etc.
Regional AHECs
County Extension
Program
County Extension
Program
State, Local, Private Funding??
County Extension
Program
Learning Objectives
By the time I have finished, you should be able to:
Define the Patient-Centered Medical Home (PCMH)
Explain the relationship between the PCMH and the
Chronic Care Model
Summarize the conditions under which case
management has been found to be effective in primary
care settings
Explain differences between a disease-oriented approach
and a patient-oriented approach
Questions and Comments?