Medical HomeMedical Home Model of Care Model of Care

April 23, 2010April 23, 2010

Randy Messier, MT, MSA

Tupelo Group, LLC

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Presentation AgendaPresentation Agenda Quick Overview of our Story in VermontQuick Overview of our Story in Vermont Outline of Medical Home ProgramOutline of Medical Home Program Medical Home DesignMedical Home Design Community Health Team (CHT) Community Health Team (CHT) Panel ManagementPanel Management Behavioral HealthBehavioral Health NCQA Medical Home CertificationNCQA Medical Home Certification Lessons LearnedLessons Learned

Healthcare Reform In VermontHealthcare Reform In Vermont

Blueprint for Health (2006 – 2008)Blueprint for Health (2006 – 2008)– Focus: Chronic Care Model/Clinical MicrosystemsFocus: Chronic Care Model/Clinical Microsystems– 6 Pilot Communities Received Grants6 Pilot Communities Received Grants– Launched Statewide Collaboratives w/ 50+ Launched Statewide Collaboratives w/ 50+

practicespractices Blueprint for Health (2009 – 2010)Blueprint for Health (2009 – 2010)

– Focus: Integrated Medical Home ModelFocus: Integrated Medical Home Model– 3 of the 6 Pilot Communities Received Grants3 of the 6 Pilot Communities Received Grants– Launched Statewide Medical Home Readiness Launched Statewide Medical Home Readiness

Collaborative w/ 22+ practicesCollaborative w/ 22+ practices

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Medical Home DefinitionMedical Home Definition

HHealth care setting that facilitates partnerships ealth care setting that facilitates partnerships between individual patients, their personal between individual patients, their personal physicians, and their family.physicians, and their family.

Care is facilitated by:Care is facilitated by:– registries, information technology, health information registries, information technology, health information

exchangeexchange Care is delivered when and where needed.Care is delivered when and where needed. Care is delivered in a culturally and Care is delivered in a culturally and

linguistically appropriate manner.linguistically appropriate manner.

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Global Aim StatementGlobal Aim Statement We aim to improve care to our patients by We aim to improve care to our patients by

implementing a patient centered medical implementing a patient centered medical home.home.

The process begins with identifying and The process begins with identifying and evaluating our patients and their current evaluating our patients and their current health status and ends with improved health status and ends with improved outcomes. outcomes.

By working on this process we expect to:By working on this process we expect to:– Improve qualityImprove quality– Engage and empower patientsEngage and empower patients– Educate, and foster a team approach to care Educate, and foster a team approach to care

managementmanagement– Improve efficiency within the practiceImprove efficiency within the practice

It is important to do this now because the 1:1 It is important to do this now because the 1:1 visit alone leaves Primary Care unsustainable. visit alone leaves Primary Care unsustainable.

CHTHAPHLW

Diabetes EdMatter of Balance

Nutrition EdY-Exercise

Comm. Referral

ITDocSitePRISMVITL

Self-Management

HLWClinic Training

Smoking Cessation

Community AssessmentCommunity Activation

HLWMatter of Balance

Smoking Cessation

EvaluationProgram Design

Clinical OutcomesPatient Satisfaction Provide Satisfaction

Staff SatisfactionFinancial Outcomes

Quality ImprovementCoach Training

Systems ReviewSystems Design

Patient Centered Medical Home

Panel Mgmt.Care CoordinationBehavioral Health

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Community

Specialty Referral

Psychiatric Referral

The Patient

Chronic Care Support

Behavioral Health

Acute Care Support

Preventive Care Support

Pan

el M

anag

emen

tC

omm

unity Health Team

Medical Home ModelPCP

Clinic•RN•MA•PSS•HIM

CHT•Nutrition/CDE•MSW•RN•Exercise/Fitness•Admin•VDH•Health Educator

Panel MA CCTPrism/Docsite

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Community Health Team (CHT)Community Health Team (CHT)Providers involved in pilot can refer their patients to Providers involved in pilot can refer their patients to the CCT. Team members provide regular ongoing the CCT. Team members provide regular ongoing support as needed via phone or in person. The team support as needed via phone or in person. The team helps patients set realistic goals and timelines for helps patients set realistic goals and timelines for improving health.improving health.

Services include: Nutrition help Exercise advice Diabetes Education Medication Management Behavioral/Mental Health Connection to community

and financial resources

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Panel ManagementPanel Management MD’s determine criteria for screening MD’s determine criteria for screening

patient panel. i.e. HBA1C value, patient panel. i.e. HBA1C value, HBA1C on time, Colonoscopy, HBA1C on time, Colonoscopy, mammography, PHQ9 Scores etc.mammography, PHQ9 Scores etc.

Panel MA runs report, and based on Panel MA runs report, and based on predetermined algorithm designed by predetermined algorithm designed by the providers, takes action on report.the providers, takes action on report.

All patients who fall outside of All patients who fall outside of algorithm are reviewed directly with algorithm are reviewed directly with provider.provider.

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Panel ManagementPanel Management

Searchable database is imperative to Searchable database is imperative to success.success.

Predetermined algorithm and query Predetermined algorithm and query design standardizes the process for design standardizes the process for everyone.everyone.

This standard approach systematizes This standard approach systematizes the preventive care component of the preventive care component of panel management. Freeing up MD’s panel management. Freeing up MD’s to be MD’s.to be MD’s.

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Integrated Behavioral HealthIntegrated Behavioral Health

On site LICSW .On site LICSW . Provides immediate consultation.Provides immediate consultation. Is a full member of the clinical team.Is a full member of the clinical team. Works with CHT on follow up and referral Works with CHT on follow up and referral

made via EHR. made via EHR. (Makes referral and tracks)(Makes referral and tracks)

Patients “DO” come back for visitsPatients “DO” come back for visits. (No Show . (No Show rate 5.9%)rate 5.9%)

Short term intervention and support.Short term intervention and support. Screening/Brief Intervention/ReferralScreening/Brief Intervention/Referral Complicated long term referred out.Complicated long term referred out.

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Medical Home DesignationMedical Home Designationand Financingand Financing

Agreement with payors was to Agreement with payors was to become NCQA certified as a patient become NCQA certified as a patient centered medical home.centered medical home.

Payment directly linked to score Payment directly linked to score achieved on NCQA review.achieved on NCQA review.

Success requires financial reform.Success requires financial reform. NCQA Standard update comingNCQA Standard update coming

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NCQA Medical Home CriteriaNCQA Medical Home Criteria Access & CommunicationAccess & Communication Patient Tracking & Registry FunctionsPatient Tracking & Registry Functions Care ManagementCare Management Patient Self-Management SupportPatient Self-Management Support Electronic Prescribing Electronic Prescribing Test TrackingTest Tracking Referral TrackingReferral Tracking Performance Reporting & ImprovementPerformance Reporting & Improvement Advanced Electronic CommunicationAdvanced Electronic Communication

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PPC-PCMH Content and ScoringPPC-PCMH Content and ScoringStandard 1: Access and CommunicationStandard 1: Access and CommunicationA.A. Has written standards for patient access and patient Has written standards for patient access and patient

communication**communication**B.B. Uses data to show it meets its standards for patient Uses data to show it meets its standards for patient

access and communication**access and communication**

PtsPts44

55

99

Standard 2: Patient Tracking and Registry Functions Standard 2: Patient Tracking and Registry Functions A.A. Uses data system for basic patient information (mostly Uses data system for basic patient information (mostly

non-clinical data) non-clinical data) B.B. Has clinical data system with clinical data in searchable Has clinical data system with clinical data in searchable

data fields data fields C.C. Uses the clinical data system Uses the clinical data system D.D. Uses paper or electronic-based charting tools to Uses paper or electronic-based charting tools to

organize clinical information**organize clinical information**E.E. Uses data to identify important diagnoses and Uses data to identify important diagnoses and

conditions in practiceconditions in practice****F.F. Generates lists of patients and reminds patients and Generates lists of patients and reminds patients and

clinicians of services needed (population management) clinicians of services needed (population management)

PtsPts22

33

3366

44

33

2121

Standard 3: Care ManagementStandard 3: Care ManagementA.A. Adopts and implements evidence-based guidelines for Adopts and implements evidence-based guidelines for

three conditions **three conditions **B.B. Generates reminders about preventive services for Generates reminders about preventive services for

clinicians clinicians C.C. Uses non-physician staff to manage patient care Uses non-physician staff to manage patient care D.D. Conducts care management, including care plans, Conducts care management, including care plans,

assessing progress, addressing barriers assessing progress, addressing barriers E.E. Coordinates care//follow-up for patients who receive care Coordinates care//follow-up for patients who receive care

in inpatient and outpatient facilities in inpatient and outpatient facilities

PtsPts33

443355

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2020

Standard 4: Patient Self-Management Support Standard 4: Patient Self-Management Support A.A. Assesses language preference and other communication Assesses language preference and other communication

barriersbarriersB.B. Actively supports patient self-management**Actively supports patient self-management**

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Standard 5: Electronic Prescribing Standard 5: Electronic Prescribing A.A. Uses electronic system to write prescriptions Uses electronic system to write prescriptions B.B. Has electronic prescription writer with safety checksHas electronic prescription writer with safety checksC.C. Has electronic prescription writer with cost checksHas electronic prescription writer with cost checks

PtsPts333322

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Standard 6: Test Tracking Standard 6: Test Tracking A.A. Tracks tests and identifies abnormal results Tracks tests and identifies abnormal results

systematically** systematically** B.B. Uses electronic systems to order and retrieve tests Uses electronic systems to order and retrieve tests

and flag duplicate testsand flag duplicate tests

PtsPts77

66

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Standard 7: Referral Tracking Standard 7: Referral Tracking A.A. Tracks referrals using paper-based or electronic Tracks referrals using paper-based or electronic

system**system**

PTPT44

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Standard 8: Performance Reporting and Improvement Standard 8: Performance Reporting and Improvement A.A. Measures clinical and/or service performance by Measures clinical and/or service performance by

physician or across the practice**physician or across the practice** B.B. Survey of patients’ care experience Survey of patients’ care experience C.C. Reports performance across the practice or by Reports performance across the practice or by

physician **physician **D.D. Sets goals and takes action to improve performance Sets goals and takes action to improve performance E.E. Produces reports using standardized measures Produces reports using standardized measures F.F. Transmits reports with standardized measures Transmits reports with standardized measures

electronically to external entities electronically to external entities

PtsPts33

3333

332211

1515

Standard 9: Advanced Electronic Communications Standard 9: Advanced Electronic Communications A.A. Availability of Interactive Website Availability of Interactive Website B.B. Electronic Patient Identification Electronic Patient Identification C.C. Electronic Care Management Support Electronic Care Management Support

PtsPts112211

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**Must Pass Elements

PPC 7: Referral TrackingPPC 7: Referral Tracking Element AElement A: Referral tracking- Outside of paper medical : Referral tracking- Outside of paper medical

records and patient visits, the practice uses a paper records and patient visits, the practice uses a paper based or electronic system to assist tracking based or electronic system to assist tracking practitioner referrals designated as critical until the practitioner referrals designated as critical until the specialist or consultant report returns to the practice: specialist or consultant report returns to the practice: ((must passmust pass)(4 points))(4 points)

100% - Practice uses system that includes all 4 items100% - Practice uses system that includes all 4 items 75% - Practice uses system that includes 2-3 items75% - Practice uses system that includes 2-3 items 50% - Practice uses system that includes 1 item50% - Practice uses system that includes 1 item 25% - No scoring option25% - No scoring option 0% - System does not include any of the items0% - System does not include any of the items

– Must track referral origin, clinical detail, status and Must track referral origin, clinical detail, status and administrative detailadministrative detail

– Paper based logs or electronic reportsPaper based logs or electronic reports

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What We’ve Learned So FarWhat We’ve Learned So Far

Patients love it!! They love the extra Patients love it!! They love the extra time they have with the team.time they have with the team.

Challenged to have quick outcomes.Challenged to have quick outcomes. Behavioral Health integration is Behavioral Health integration is

essential.essential. It’s a lot of work to get started!It’s a lot of work to get started! Not all Providers embrace systems Not all Providers embrace systems

change at the same rate. change at the same rate.

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Significant Findings!Significant Findings!

Six month follow-up data after Six month follow-up data after “graduation”“graduation”– Diabetes patients engaged in CHTDiabetes patients engaged in CHT

59%59% of patients with a baseline HbA1c greater then 7 of patients with a baseline HbA1c greater then 7 lowered their HbA1c to below 7 at follow uplowered their HbA1c to below 7 at follow up

100%100% of patients with a baseline depression score of of patients with a baseline depression score of moderate or severe depression lowered their score to moderate or severe depression lowered their score to mild/not clinically significantmild/not clinically significant

100%100% of patients with a baseline anxiety score of of patients with a baseline anxiety score of moderate or severe anxiety lowered their score to moderate or severe anxiety lowered their score to mild anxiety at follow upmild anxiety at follow up

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Significant Findings!Significant Findings!

Six month follow-up data after Six month follow-up data after “graduation”“graduation”– Behavioral Health referralsBehavioral Health referrals

75%75% of patients with a baseline depression of patients with a baseline depression score of moderate to severe lowered their score of moderate to severe lowered their score to mild/not clinically significant at score to mild/not clinically significant at follow up.follow up.

70%70% of patients with a baseline anxiety of patients with a baseline anxiety score of moderate or severe anxiety lowered score of moderate or severe anxiety lowered their score to mild/not clinically significant at their score to mild/not clinically significant at follow up.follow up.

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QuestionsQuestions

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