GUIDANCE ON INTERVENING WITH PANEL MANAGEMENT: HIV CLINICS AT THE FOREFRONT OF PCMH MODELS

Itta Aswad, MPH

November 28th, 2012- Ryan White All Grantees Meeting

DISCLOSURES

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.

DISCLOSURES Itta Aswad, MPH

Has no financial interest or relationships to disclose

Kathleen Clanon, MDHas no financial interest or relationships to disclose

LEARNING OBJECTIVESAt 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

OBTAINING CME/CE CREDITIf you would like to receive continuing

educationcredit for this activity, please visit:

http://www.pesgce.com/RyanWhite2012

WHO 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

AGENDA

Overview of PCMH What is Panel Management? How PM works How PM can be implemented in your clinic

THE 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.

RACIAL DISPARITIES IN SURVIVAL

7.06.05.04.03.02.01.00.0Lif

e Ex

pect

ancy

Los

t (y)

Women Men Overall

White Black Hispanic

Late initiation or early HAART discontinuation results in life- expectancy loss

Data indicate minorities present later and have higher rates of premature discontinuation

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

Slide courtesy of Dr. William King

WHAT 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

KEY 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

12

Patient Centered Medical HomeImplementation Continuum

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)

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)

Doctor and Staff Centered model

PCMH Fully Integrated

Slide courtesy of Dr. Kathleen Clanon

WHY 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

WHAT IS PANEL MANAGEMENT

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

WHAT CAN PANEL MANAGEMENT DO FOR US?

Uncouple the Dr. visit from some of the - Adherence counseling - Smoking

cessation- Prevention counseling - Vaccinations- Mental Health and Substance Abuse

treatment

Produce actionable interventions - phone messaging - med reconciliation

PILOT PROJECT- ALAMEDA COUNTY MEDICAL CENTER, OAKLAND CA

Team Approach: 1 Clinician 1 Medical Assistant 1 Registered Nurse ~125 clients

Goal: Increase retention in

care Increase vL

suppression Increase health

maintenance activities

TASK SHIFTING

MA- Vitals and referrals as ordered

RN- Case Management and discharge orders

MD- focus on HIV care and Primary care needs as remembered

MA- Vitals, promotes for HM tasks, referrals, in-reach to the out of care without order

RN- Case Management and discharge orders

MD- Focus on HIV and Primary care needs using support tools

Pre Panel Management Post Panel Management

WHAT DOES PANEL MANAGEMENT SOUND LIKE?“ 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?”

INTERVENTIONS AND TOOLS

Health messages In-reach Registry reports Huddles Decision Support sheets

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

ALAMEDA COUNTY MEDICAL CENTER:PANEL MANAGEMENT AT WORK

USE OF A REGISTRY REPORT

- 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?

EXERCISE: USING THE REGISTRY

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

Den-tal Ref

vL Sup

Visit PPD FIT Pap CD4

0%20%40%60%80%

100%

CHALLENGES AND SOLUTIONS

Time Prioritizing needs Shifting medical

practices

Scheduling protected time

Use Registry report and Decision Support tools

Communication

SolutionsChallenges

DO YOU HAVE THE RESOURCES TO PULL THIS OFF?

4 Central PM concepts1. Use a registry2. A team of providers willing to align

resources3. Prioritizing criteria 4. Take care out of the PCP visit when possible

DISCUSSION

NEXT STEPS…..

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

RESOURCES

Itta Aswad, MPH- iaswad@acmedctr.org Kathleen Clanon, MD- kclanon-jba@cht.org William King, MD, JD- wdking37@yahoo.com Barbara Ramsey, MD-

bramsey@chcnetwork.org