Preparing for the Future Medical Home ModelA Clinical Microsystem Approach

OBJECTIVES• Define Medical Home of the future.• Describe microsystem vs.

mesosystem as pertaining to Medical Home in both Iowa and the country.• State the importance of exploring

these concepts.• Discuss current medical home model,

how applying microsystem/mesosystem can effect outlook.

Medical Home: The beginning.

• In the 1960s, the American Academy of Pediatrics (AAP) introduced a new strategy for collecting, storing, and accessing pediatric patient medical records called medical home.

Center for Medical Home Improvement (2012)

Institute of Medicine (IOM)In 2001, the IOM introduced six UNIVERSAL aims to improve healthcare, they are:

• Safe: avoiding injuries to patients from the care that is intended to help them.

• Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit (performance measures).

• Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.

• Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care.

• Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.

• Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. Institute of Medicine (2001)

IOM 10 Rules of Healthcare Redesign• Care is based on continuous healing relationships. • Care is customized according to patient needs and values. • The patient is the source of control. • Knowledge is shared and information flows freely. • Decision making is evidence-based. • Safety is a system property. • Transparency is necessary. • Needs are anticipated. • Waste is continuously decreased (performance measures).• Cooperation among clinicians is a priority.

Institute of Medicine (2001)

IOM Changing the EnvironmentFour Main Areas

• Applying evidence to health care delivery.

• Using information technology.

• Aligning payment policies with quality improvement (performance measures).

• Preparing the workforce.

Institute of Medicine (2001)

Remember the AAP• In 2002 and again in 2008, American Academy of

Pediatrics (AAP) characterized medical home as accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally sensitive care.

• This definition of medical home, now known as Patient-Centered Medical Home (PCMH), is widely adopted by other primary care physician organizations.

• Barrier – There is no agreed upon definition of medical home and it’s characteristics. Example, physician reports accessibility yet does not meet/exceed parameters of the definition.

In more detail…Definitions.• Accessibility refers to such issues as quality and

type of care being provided in the community and all forms of insurance being accepted.

• Continuity of care relates to the same physician providing care from infancy to transition and the physicians’ ability to participate in care received by other providers.

• Comprehensive care involves access to care 24 hours a day, 365 days a year

• The family-centered component addresses the family’s central role in care giving and joint decision making.Wallis, A.B., Mercer, K.L., & Askelson, N. (2005).

In more detail….Continued• Coordinating the services and care the child and

family receive and maintaining central records are part of the coordinated care component.

• Expressed concern and efforts to understand relate to compassionate care.

• Culturally effective care recognizes, values, respects and incorporates cultural background into the care and information provided to families.

Wallis, A.B., Mercer, K.L., & Askelson, N. (2005).

Today: Patient Centered Medical Home (PCMH)• A successful PCMH requires a strong primary care

sector and preventative care. A personal physician responsible for the primary and preventative care of a patient and coordinates care with other service providers reducing healthcare service usage.

• PCMH must provide performance measures, continuous quality improvement data, and ensure improved patient access to care and health information.

• Lastly, payment systems (federal and state) would reward the added value provided by PCMH. Performance measures support value added reward.

On prevention, the Secretary for Health and Human Services (HHS),“Prevention is not as exciting as life-saving surgery after a heart attack. It doesn’t create headlines like a massive food recall. Success often doesn’t show up until many years later. And even then it is hard to see. But the potential benefits are huge.”

HHS Secretary Kathleen SebeliusUS Department of Health and Human Services (2012)

The 3 Ms – Macro, Meso, and Micro

Research Mindedness (2005)

The Road to Prevention and Improved Patient

Safety

More on the 3 Ms

Macro – of great size, large scale

Meso – in the middle,

intermediate

Micro – extremely

small, basic

Some Details •Bigger systems (macrosystems) are made up of smaller systems (microsystems). •Microsystems exist at the frontline, or sharp edge, of care. •Macrosystem outcomes are only as good as the microsystems that form them. •Mesosystems provide the dialogue that keep the relationship between all 3 productive.

Microsystem • Frontline

units providing care

• Place where patients, families, care teams meet

• Building blocks that form practice

Mesosystem • Collection of

microsystems providing care to shared population of patients

• Actively guides dialogue b/t these related microsystems

• Feeds information back and forth

Macrosystem • Overarching

regulatory system

• Handles budgetary concerns

• Provides vision, goals

Macrosystem versus Mesosystem

MACROSYSTEM• From outside in.• Establishes strategic

plan, vision, and goals.• Develops budget to

support both meso and micro systems.

• Expects improvement with measured results from both meso and micro systems.

MESOSYSTEM• Creating the Conditions.• Links strategic plan,

operations, and people.• Facilitates coordination

between microsystems.• Interdisciplinary approach

to communication, performance, & improvement.

• Supports the microsystem.

Godfrey, Melin, Muething, Batalden, and Nelson (2008)

Mesosystem versus Microsystem

MESOSYSTEM• Creating the Conditions.• Links strategic plan,

operations, and people.• Facilitates coordination

between microsystems.• Interdisciplinary approach

to communication, performance, & improvement.

• Supports the microsystem.

MICROSYSTEM• From the inside out.• Evidence based practice

in action.• Understands the strategic

plan, goals, and vision of the macrosystem.

• Team and Interdisciplinary approach.

• PDSA/SDSA improvement.• Effective communication,

huddles, etc.Godfrey et al. (2008)

THE HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA)

Health Resources and Services Administration’s (HRSA) Patient-Centered Medical/Health Home (PCMHH) Initiative, which supports and encourages health centers to gain recognition under the medical home program offered in partnership with the National Committee for Quality Assurance (NCQA).

United States Department of Health and Human Services (HHS) (2012)

MACROSYSTEM

MACROSYSTEM CONTINUED• Centers for

Medicare and Medicaid Services (CMS)

• The Centers for Medicare & Medicaid Services (CMS) is a branch of the U.S. Department of Health and Human Services. CMS is the federal agency which administers Medicare, Medicaid, and the Children's Health Insurance Program. Provides information for health professionals, regional governments, and consumers.

Accreditation and Recognition Physician Practice Connections® – Patient-Centered Medical Home™ (PPC®-PCMH™).

MESO SYSTEM

NCQA’s Physician Practice Connection® Patient-Centered Medical Home™ (PPC®-PCMH™) Program, (2010)

National Committee for Quality Assurance (NCQA)

• NCQA worked with the four national organizations representing primary care physicians – the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association – and other stakeholders to develop a set of standards known as the Physician Practice Connections® – Patient-Centered Medical Home™ (PPC®-PCMH™).

• NCQA, through the PPC®-PCMH™ program, identifies and recognizes medical practices that demonstrate the standards for patient-centered medical homes (PCMH). NCQA’s Physician Practice Connection® Patient-Centered Medical

Home™ (PPC®-PCMH™) Program, (2010)

NCQA has nine standards for medical homes• 1. Access and communication• 2. Patient tracking and registry functions• 3. Care management• 4. Self-management support• 5. Electronic prescribing• 6. Test tracking• 7. Referral tracking• 8. Performance reporting and improvement

(HEDIS)• 9. Advanced electronic communications (HIMSS)NCQA’s Physician Practice Connection® Patient-Centered Medical

Home™ (PPC®-PCMH™) Program, (2010)

NCQA Healthcare Effectiveness Data and Information Set (HEDIS)• NCQA’s Healthcare Effectiveness Data and

Information Set (HEDIS®) is the most widely used performance measurement tool in health care.

• NCQA is committed to providing health care quality information through the Web, media and data licensing agreements in order to help consumers, employers and others make more informed health care choices.

• Value Added PCMH - Outpatient & Preventative performance followed by insurance companies.

NCQA’s Physician Practice Connection® Patient-Centered Medical Home™ (PPC®-PCMH™) Program, (2010)

Healthcare Information and Management Systems Society (HIMSS)

• HIMSS focuses on health information technology (health IT) that supports high-quality patient care (including electronic recordkeeping, electronic disease registries, Internet communication with patients and electronic prescribing) is crucial to a fully functioning medical home.

• Health IT can capture accurate information, while providing information to the clinician on outcome measures on a timely basis through reports. In turn, reports can be used to review trends among population groups, which may include visit frequency, medication dosage and treatment course changes, and to track patient progress and patient education. Health IT can expand performance improvement in all clinical activities by allowing practices to compare results among providers and practices.

Healthcare Information and Management Systems Society (HIMSS) (2010)

Microsystem

• Range from individual family practitioners to Federally Qualified Health Centers (FQHC).

• Participating FQHCs agree to adopt care coordination practices set by the National Committee for Quality Assurance (NCQA)

• Primary and preventative care.• Performance measures.• PDSA trials and data collection.

Centers for Medicare & Medicaid (2011)

In Summary,

• PCMH is not a new concept but the defining characteristics have evolved to include: accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally sensitive care.

• Macrosystem HHS and HRSA and CMS• Mesosystem NCQA, HEDIS, and HIMSS

(outpatient) and the Joint Commission (inpatient)• Microsystem FQHC and Individual Practices who

meet the requirements for designation.

Improving the quality of health care delivered

across America is neither a rural or urban issue

but rather a concern that touches all providers

and consumers of health care services.

URBAN• High volume• Inpatient• Technology driven• More likely to seek

accreditation• Relies less on CMS• Available resources

RURAL• Lower patient volume• Ambulatory care• Less technology• Less likely to seek

accreditation• Rely more so on CMS• Available resources

US Department of Health and Human Services (2003)

IowaCare Program Timeline • 2005: Iowa Cares authorized by Iowa

House under a Medicaid expansion program.

• 2010: Iowa Cares is modified by Iowa legislature to include an Iowa Care medical home pilot, and pilot medical homes begin rolling out.

• 2014: Federal health insurance expansion component of the Patient Protection and Affordable Care Act (PPACA) will change eligibility of Iowans for Iowa Cares to 130% of the FPL.

So what is the IowaCare Program ?• Limited benefit, public health insurance

program for adults living in Iowa. • Qualify if income is up to 200% of the

federal poverty level (FPL).• Men and women aged 19-64, pregnant

women with gross countable income < 300% FPL

• Created in part to fill gap in adult healthcare coverage when Iowa State Papers Program ended.

Details of IowaCare Coverage • Most inpatient and outpatient services. • Limited coverage for:•Preventative visits•Durable medical equipment•Dental care•Transportation•Prescriptions

Insurance Experience of IowaCare Enrollees• 1 in 6 enrollees report that prior to enrollment in Iowa Cares they had been w/o any coverage at all for at least 2 years. • 1 in 4 enrollees report that they had never had coverage in their life. • 98% of enrollees report that having health coverage is “very important.”

Enrollees & Chronic Health Conditions Most Commonly reported Chronic Health Conditions

% Enrollees Reporting Conditions in 2011

Hypertension 36%Dental problems 35%Back or neck problems 31%Arthritis, bone/joint problems 30%Allergies, sinus problems 27%Recurrent indigestion/heartburn 20%Diabetes 14%Asthma 14%Migraine 13%Bronchitis, emphysema 13%Heart problems 12%

Sounds great, right?

Maybe not….• Incredibly long wait time to access services at

UIHC or Broadlawns:• Population requiring care > Population of providers• Lack of reimbursement to UIHC and Broadlawns also led

to increased wait time, as Iowacare patients would be scheduled last

• Unmet healthcare needs due to program funding limitations:• No mental health services• Hardly any dental care services • Unreimbursed emergency care services to non IowaCare hospitals

Fragmented Healthcare • Data from 2010 report that the 4 major leading

causes of death in the United States are all chronic conditions:• Heart disease: 599,413• Cancer: 567,628• Chronic lower respiratory diseases: 137,353• Stroke (cerebrovascular diseases): 128,842

• Chronic health conditions cannot be successfully treated in the currently existing care environment: • Federal and state governments are starting to recognize

the need for prevention versus intervention. • The medical home model was adopted by Iowa healthcare

legislature as the tool to create this shift.

We Can Do Better: The Iowa Medical Home Model

The IowaCare Medical Home • IowaCare will transition to Medicaid Expansion under the

Affordable Care Act by January 1st, 2014.• Medicaid will then cover all people 133% below the FPL• Vast majority of IowaCare enrollees are actually below 100% of FPL

• Expansion of IowaCare into medical home model is actually first step in phasing IowaCare out altogether. • The ultimate goal is replication of already existing Federally Qualified Health Centers (FQHC) in the Medicaid system

Specific Goals of IowaCare Medical Home Pilot • Improve geographic access of enrollees to

quality, safe healthcare services• Improve communication among providers,

patients, families, caregivers• Improve care delivery to those with chronic

health conditions • Improve reimbursement to hospitals and

medical homes servicing enrollees

Iowa Medical Home as a Clinical Microsystem

Patient

Microsystem

Mesosystem

Macrosystem

Macrosystem: Iowa Medical Home Model • HRSA: the primary Federal agency responsible for

improving access to health care services for people who are uninsured, isolated, or medically vulnerable.• Establishes strategic plan, budget, and ways to measure

success of Iowa Medical Home model in concert with Iowa State agencies.

• NCQA: an independent 501(3) C designed to improve healthcare standards in the United States. • Identifies medical practices that demonstrate standards

for patient centered medical homes.

Mesosystem: Iowa Medical Home Model • University of Iowa Hospital and Clinics, Broadlawns• In Iowa, the two hospitals designated as organizations where surgeries, etc. will be conducted for those patients enrolled in IowaCare who need medical attention beyond what Medical Home can provide.

• These two hospitals are the actual collection of microsystems, or medical homes, that comprise the unified health system we are working to create. • Information fed back and forth between these

mesosystems and corresponding microsystems.

Microsystem: Iowa Medical Home Model

• Iowa Medical Homes: where the patient, caregiver, provider meet at the sharp edge of care. Where the primary care journey begins, services are provided. •List of the medical homes (to be inserted)

And at the Center of it all….

Is the patient….

“Improve microsystems and we improve everything. Microsystems are where we meet not just the patients we serve but each other as well. We can replace the sadness and insult that come from the current fragmented state of healthcare if we stand together at the window on our work that the microsystem view opens.”

References• Center for Medical Home Improvement. (2012). The medical home. Retrieved from

http://www.medicalhomeimprovement.org/medical-home/ • Centers for Medicare & Medicaid. (2011). Federally qualified health centers. Retrieved from

http://www.cms.gov/Outreach- and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/fqhcfactsheet.pdf

• Godfrey, M.M., Melin, C.N., Muething, S.E., Batalden, P.B., & Nelson, E.C. (2008). Clinical microsystems, part 3. Transformation of two hospitals using microsystem, mesosystem, and macrosystem strategies. The Joint

Commission Journal on Qualityand Patient Safety, 34(10), 601.• Healthcare Information and Management Systems Society (HIMSS) (2010). Leveraging health IT to achieve ambulatory

quality:The patient-centered medical home (PCMH). Retrieved from http://www.ncqa.org/Portals/0/Public%20Policy/HIMSS_NCQA_PCMH_Factsheet.pdf

• Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Retrieved from http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality- Chasm/Quality

%20Chasm%202001%20%20report%20brief.pd

References (continued)• NCQA’s Physician Practice Connection, Patient-Centered Medical Home (PPC®-PCMH) Program.

(2010). Retrieved from http://www.ncqa.org/Portals/0/Public%20Policy/NCQA%20PCMH%20Fact%20Sheet%20FINAL.pdf

• Research Mindedness. (2005). Retrieved from http://www.resmind.swap.ac.uk/content/02_what_is/what_is_09.htm

• United States Department of Health and Human Services (HHS). Health Resources and Services Administration (HRSA). (2012). HRSA Patient-Centered Medical/Health Home Initiative. Retrieved from http://bphc.hrsa.gov/policiesregulations/policies/pal201101.html

• US Department of Health and Human Services. (2003). Health care quality: The rural context. Retrieved from ftp://ftp.hrsa.gov/ruralhealth/NAC03.pdf

• Wallis, A.B., Mercer, K.L., & Askelson, N. (2005). Evaluation of the statewide implementation of the medical home concept for children with special health care needs, Phases 1 and 2. Retrieved from http://www.uiowa.edu/~nrcfcp/research/documents/2005IMHIFinalEvaluationReport.pdf