Roni Christopher, M.Ed., OTR/L, PCMH-CCE

Collaborative Family Healthcare Association 15th Annual ConferenceOctober 10-12, 2013 Broomfield, Colorado U.S.A.

Session #E3a Friday, October 11, 2013

Community Partners and the PCMH

Objectives for this Session

• Define PCMH Tenets• Recognize opportunities for

PCMH/Community Partnerships• Identify how such partnerships help to

fulfill the pursuit of NCQA PCMH recognition

• Identify the key components to a successful PCMH/Community Partner PCP extension program

ACCESS

Populations

Coordination

Engagement

Referrals

Improving

Person

THE TENETS OF THE PCMH

The Opportunity and an Example

• Pursuit of the NCQA PCMH certification is intense and can be challenging

• The amount of responsibility on the PCP can feel overwhelming

• We asked the question:– Can a successful model to build a

community “extender” the PCP practice help the practice in the pursuit of PCMH?

–Would such a relationship make a difference for our patients?

Creating the “Skunk Works”

• We like skunks:

“…a group within an organization given a high degree of autonomy and unhampered by bureaucracy, tasked with working on advanced or secret projects.”

Why Crossroads Makes a Good Skunk…

• Crossroads make up– FQHC– In operation since 1992– Inner-City Cincinnati

The Council on Aging as Another Skunk

• Initial data exchanges with the COA– 6000 patient panel– 363 (6%) patients 60 years of age

and older– 32 (8.8%) shared patients (Crossroad

PCP patients receiving COA services)– Analyzed clinical outcome– Set shared goals

COA

Current Model

COA 32 shared patients

160 patients over 60yrs10,000+ patients

COA

Current Model

COA

The Cincinnati Pilot Model

Shared Goals

• Over-Arching Goals:– Formation of a relationship between COA and Crossroad,

strengthened by close physical proximity and ease of communication.

– COA to provide care coordination of Crossroad's senior patients in an effort to provide greater continuity of care.

– CR to collaborate with COA to provide access to Primary Care services and ease of scheduling to patients COA is managing.

– To develop a documentation system or process that reduces duplication of documentation for both COA and Crossroad.

– Do ALL of the work to contribute to the NCQA PCMH recognition process

Look for Shared Goals• To show clinical outcome improvement

in the following areas:– Hypertension (greater than 65% of hypertensive patients up to age 85 maintained

below 140/90mmHg)– Diabetes (greater than 75% of diabetic patients with HgbA1C maintained at or below

9% - treatment goal is for A1C to be less than 8%)– Tobacco Use (greater than 95% of patients assessed for tobacco use and greater than

50% of smokers to receive smoking cessation counseling)– Behavioral Health (greater than 40% of patients up to age 65 to receive depression

screen using the PHQ annually)– Lipid-Lowering Therapy (Greater than 86% of patients with diagnosis of CAD prescribed

lipid-lowering therapy as indicated - treatment goal is for LDL to be less than 100)– Colorectal Screening (greater than 40% of patients 50 to 75 who have had a

colonoscopy <=10y or sig<=5yrs or annual occult blood)– IVD (greater than 80% of patients with a dx of IVD on aspirin or other antithrombotic)– PAPs (greater than 75% of women 24 to 64 receiving one or more PAP tests at least

every 2yrs)– Weight (greater than 60% of patients identified with BMI less than 20 or greater than

25 who have been counseled)– Decrease ED utilization and hospital admissions

CREATE THE HAND-OFF and HAND Back

• Documentation and Collaboration Goals:– Self-management goals to be documented on all diabetic

pts, hypertensive pts, and smokers– Treatment goals to be documented on all diabetic pts,

hypertensive pts, and smokers– Assess barriers on patients and document– Follow-up on patients who have not had visits in a certain

period of time– Conduct pre-visit preparation– Provide patient with written plan of care– Refer patients for additional care management– Reconcile medications at care transitions– Educate on new prescriptions– Track referrals– Counsel patients on healthy behaviors

Ask questions and look for partners

• Model and Innovation Goals:– Identify the areas where time or resource prohibit

primary care from doing “it all”– Look for partners who could do “it” and do “it” well– Identify current pattern with those partners– Look for a “win-win” pattern with those partners– Test what will/won’t work– Put it in play

– DO NOT ASSUME THAT ANYONE BUT YOURSELF UNDERSTANDS WHAT A PCMH REALLY IS!• (maybe not even yourself?)

Why was the COA Interested?

• Taking a leading role in healthcare transitions for adults

• Wanting to understand how to maximize their products

• Had services to offer, but did not understand what was needed at the PCP level

Where They are Now…

• Initial stages– Hired RN Care Coordinator– Prepared office space –Monitoring key clinical metrics– Handing off and handing back…– Improving coordination for existing

shared patients

Where We are Now…

• Future Stages– Recruit Crossroad patients into COA

programs– Recruit COA patients without a

medical home into Crossroad–Measure outcomes for improvement

Lessons Learned

• Being a PCMH = learning how to care for the patients who aren’t in your waiting room

• Trying to do it “all” is an exercise in futility• There are community partners who truly

want to partner• Don’t assume that their desire to

partner equates to knowledge about what you need

Q&A and Contact

Roni Christopher, M.Ed, OTR/L, PCMH-CCE

• ronichristopher@yahoo.com