The Patient-Centered Medical Home The Patient-Centered Medical Home (PCMH)(PCMH)

Jane A. Weida, MD, FAAFPJane A. Weida, MD, FAAFPFaculty Associate, Reading Family Medicine ResidencyFaculty Associate, Reading Family Medicine Residency

Clinical Associate Professor, Penn State College of MedicineClinical Associate Professor, Penn State College of Medicine

November, 2009November, 2009Republic of GeorgiaRepublic of Georgia

SummarySummary

Evidence for the value of primary Evidence for the value of primary care and the PCMHcare and the PCMH

History of Patient-Centered Medical History of Patient-Centered Medical Home (PCMH)Home (PCMH)

Principles of PCMHPrinciples of PCMH Go through a sample office visitGo through a sample office visit Description of the basic structure of Description of the basic structure of

a PCMH a PCMH

Why is Primary Care so Important?Why is Primary Care so Important?

Access to primary care is associated with:Access to primary care is associated with:• 33 percent lower cost of care33 percent lower cost of care• 19 percent less likelihood of dying from their medical 19 percent less likelihood of dying from their medical

conditions than those who receive care from a specialist, conditions than those who receive care from a specialist, after adjusting for demographic and health after adjusting for demographic and health characteristicscharacteristics

• Improved health outcomes for conditions such as Improved health outcomes for conditions such as cancer, heart disease, stroke, infant mortality, low birth cancer, heart disease, stroke, infant mortality, low birth weight, and life expectancyweight, and life expectancy

Starfield, B et al: Improving chronic illness care: translating evidence into action. Starfield, B et al: Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001; 20:64-78Health Aff (Millwood). 2001; 20:64-78Starfield, B et al: Contribution of Primary Care to Health systems and health, Millbank Starfield, B et al: Contribution of Primary Care to Health systems and health, Millbank Quarterly, 2005;83:457-502Quarterly, 2005;83:457-502Starfield, presentation to The Commonwealth Fund, Primary Care Rountable: Starfield, presentation to The Commonwealth Fund, Primary Care Rountable: Strengthening Adult Primary Care Models and Policy Options, October 3, 2006Strengthening Adult Primary Care Models and Policy Options, October 3, 2006

Access to Primary Care Access to Primary Care Associated with…Associated with…

In both England and the United States, each In both England and the United States, each additional primary care physician per 10,000 additional primary care physician per 10,000 persons is associated with a decrease in mortality persons is associated with a decrease in mortality rate of 3 to 10 percent.rate of 3 to 10 percent.

In the United States, an increase of just one In the United States, an increase of just one primary care physician is associated with 1.44 primary care physician is associated with 1.44 fewer deaths per 10,000 persons.fewer deaths per 10,000 persons.

Reduced socio-demographic and socio-economic Reduced socio-demographic and socio-economic disparitiesdisparities

Primary Care Delivers Better Primary Care Delivers Better Health OutcomesHealth Outcomes

mortalitymortality

morbiditymorbidity

medication use medication use

per capita expendituresper capita expenditures

patient satisfactionpatient satisfaction

greater equity in health caregreater equity in health care

SOURCE: B. Starfield, et al., “The Effects of Specialist Supply on SOURCE: B. Starfield, et al., “The Effects of Specialist Supply on Populations’ Health,” Populations’ Health,” Health AffairsHealth Affairs (March 2005); W5-97 (March 2005); W5-97

Primary Care Delivers Better Primary Care Delivers Better Health Outcomes But…Health Outcomes But…

Patients want more from the healthcare Patients want more from the healthcare system and from their physician.system and from their physician.

Purchasers of insurance (individuals, Purchasers of insurance (individuals, employers, government) are looking for employers, government) are looking for quality and value.quality and value.

The U.S. spends 16.5% of its GDP on The U.S. spends 16.5% of its GDP on health care:health care:

Runaway healthcare costs must be addressed in Runaway healthcare costs must be addressed in ways that preserve and enhance access to high-ways that preserve and enhance access to high-quality, effective medical care that also reduces costquality, effective medical care that also reduces cost

We Can Do Better: TheWe Can Do Better: ThePatient-Centered Medical HomePatient-Centered Medical Home

Introduced by American Academy of Pediatrics (AAP) Introduced by American Academy of Pediatrics (AAP) in 1967in 1967

Initially referred to a central location for medical Initially referred to a central location for medical records records

Medical home concept was expanded in 2002 to Medical home concept was expanded in 2002 to include: include: • AccessibleAccessible• ContinuousContinuous• ComprehensiveComprehensive• Family-centeredFamily-centered• CoordinatedCoordinated• CompassionateCompassionate• Culturally-sensitive careCulturally-sensitive care

The PCMH ConceptThe PCMH Concept

In 2007, the AAP, the American Academy In 2007, the AAP, the American Academy of Family Physicians (AAFP), the American of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the College of Physicians (ACP), and the American Osteopathic Association (AOA) American Osteopathic Association (AOA) adopted a set of joint principles to adopted a set of joint principles to describe a new level of primary care – the describe a new level of primary care – the Patient-Centered Medical HomePatient-Centered Medical Home

9

Personal physician Personal physician Physician-directed medical practicePhysician-directed medical practice Whole person orientation Whole person orientation Care is coordinated and/or integratedCare is coordinated and/or integrated Quality and safetyQuality and safety Enhanced access to care Enhanced access to care Payment to support the PCMHPayment to support the PCMH

Principles of the Patient-Centered Medical Home

AAP, AAFP, ACP, AOA March 2007

The PCMH Model is The PCMH Model is Evidence-BasedEvidence-Based

Studies show the value of care coordinated by a personal Studies show the value of care coordinated by a personal physician using systems-based approaches (the PCMH model)physician using systems-based approaches (the PCMH model)• Patient-centered primary care has been implemented Patient-centered primary care has been implemented

successfully in:successfully in: ……other nations that have better overall quality scores other nations that have better overall quality scores

and lower costsand lower costs ……in the U.S in health care systems like the Veterans in the U.S in health care systems like the Veterans

Administration systemAdministration system Effective care coordination in the ambulatory setting can Effective care coordination in the ambulatory setting can

reduce hospital admissions and re-admissions for chronic reduce hospital admissions and re-admissions for chronic illnesses (such as diabetes, CHF)illnesses (such as diabetes, CHF)

Starfield, presentation to Commonwealth Fund Roundtable on Primary Care, October 2006Commonwealth Fund, Chartbook on Medicare, 2006Dartmouth Atlas, Fall, 2006

Let’s Look at a Typical Office VisitLet’s Look at a Typical Office Visit

A 50-year old female thinks she has a A 50-year old female thinks she has a urinary tract infection (UTI). She calls her urinary tract infection (UTI). She calls her doctor’s office on a Monday morning to get doctor’s office on a Monday morning to get an appointment for herself.an appointment for herself.• Gets a busy signal each time she calls; finally Gets a busy signal each time she calls; finally

gets through on the fourth trygets through on the fourth try• Frantic-sounding receptionist tells her the Frantic-sounding receptionist tells her the

office is really busy but they will “squeeze her office is really busy but they will “squeeze her in” right before lunch. Patient takes the in” right before lunch. Patient takes the appointment although it conflicts with a appointment although it conflicts with a meeting.meeting.

……continuedcontinued

Arrives at the office, finds the doctor is running Arrives at the office, finds the doctor is running one hour late. one hour late.

The doctor takes several minutes to go over The doctor takes several minutes to go over patient’s medications and allergies in paper chartpatient’s medications and allergies in paper chart

The doctor confirms presence of a UTI; she gives The doctor confirms presence of a UTI; she gives the patient a written prescription.the patient a written prescription.

Patient cannot fill the prescription until after Patient cannot fill the prescription until after work, then she discovers the medication is not work, then she discovers the medication is not covered by her health insurance. covered by her health insurance.

……continuedcontinued Patient calls the doctor’s office, which is now closed. The Patient calls the doctor’s office, which is now closed. The

doctor who is covering calls her back 2 hours later, but the doctor who is covering calls her back 2 hours later, but the pharmacy is closed.pharmacy is closed.

Patient calls the doctor’s office back the next day. They call Patient calls the doctor’s office back the next day. They call in a different antibiotic.in a different antibiotic.

Patient also asks for an appointment for her diabetes. It Patient also asks for an appointment for her diabetes. It has never been under good control. has never been under good control.

First open appointment is 6 weeks later, and patient is First open appointment is 6 weeks later, and patient is away on business. She makes an appointment for 10 away on business. She makes an appointment for 10 weeks later.weeks later.

In the meantime, she is not taking care of her diabetes…In the meantime, she is not taking care of her diabetes…

The doctor, overbooked and over-burdened by paperwork, The doctor, overbooked and over-burdened by paperwork, leaves for home at 8 PM.leaves for home at 8 PM.

This office visit does not provide care This office visit does not provide care that is:that is:

• AccessibleAccessible• ContinuousContinuous• ComprehensiveComprehensive• Family-centeredFamily-centered• CoordinatedCoordinated• CompassionateCompassionate• Culturally-sensitiveCulturally-sensitive

What Needs to Change?What Needs to Change?We Build a Patient-Centered Medical We Build a Patient-Centered Medical

HomeHome

PCMH is built on four building blocksPCMH is built on four building blocks• Quality measuresQuality measures• Patient experiencePatient experience• Health information technologyHealth information technology• Practice organizationPractice organization

Patient-centered | Physician-directed

The Patient Centered Medical HomeThe Family Medicine Model

Family Medicine Foundation

Health IT

Patient Experience

Health IT

Great Outcomes

Practice Organization

Quality Measures

Heath Information Technology

PatientExperience

PATIENT CENTERED MEDICAL HOME

Practice Organization

Health InformationTechnology

Quality Measures

PatientExperience

Quality Measures•Referral tracking•Lab result tracking•Medication interaction alerts•Allergy alerts•Performance measures•Map processes to identify efficiencies•Updated problem list•Current medication list•Analyze data for quality improvement•Discuss best practices

PATIENT CENTERED MEDICAL HOME

Practice Organization

Health InformationTechnology

Quality Measures

PatientExperience

Patient Experience•Same day appointments•E-mail•Web portal for Rx, appointments, information•Non-visit based care and support•Group visits•Motivational interviewing•Cultural sensitivity•Patient satisfaction surveys•Shared decision making with patients•Home monitoring

PATIENT CENTERED MEDICAL HOME

Practice Organization

Health InformationTechnology

Quality Measures

PatientExperience

Practice Organization•Leadership Training•Team meetings•Shared vision and responsibility for quality of care•Monitor supply and demand•Ensure adequate and fair distribution of work•Budgeting for forecasting and management•Value contributions of all individuals•Ongoing education

PATIENT CENTERED MEDICAL HOME

Practice Organization

Health InformationTechnology

Quality Measures

PatientExperience

Health Information Technology•Medication interaction checking•Allergy checking•Formulary information•Evidence based treatment recommendation templates•Home monitoring•Population health management – disease registries•Planned care visits•Internet access•Point of care answers to clinical questions

Family Medicine Foundation

Great Outcomes• Good for patients

– Patients enjoy better health.– Patients share in health care decisions.

• Good for physicians– Physicians focus on delivering excellent

medical care.

• Good for practices– Team works effectively together.– Resources support the delivery of

excellent patient care.

• Good for payors and employers– Ensures quality and efficiency.– Avoids unnecessary costs.

Great Outcomes

Practice Organization

Quality Measures

Patient Experience

Health Information Technology

The PCMH Model in Action:The PCMH Model in Action:North Carolina Community Care CollaborativeNorth Carolina Community Care Collaborative

Asthma and diabetes initiatives were developed Asthma and diabetes initiatives were developed due to high prevalence in the North Carolina due to high prevalence in the North Carolina Medicaid (government insurance for poor) Medicaid (government insurance for poor) population.population.

Care was coordinated by a primary care physician.Care was coordinated by a primary care physician. Care included patient education and team Care included patient education and team

collaboration. collaboration. Initial goals focused on reducing unnecessary Initial goals focused on reducing unnecessary

hospital admissions and emergency room visits. hospital admissions and emergency room visits. Additional quality, efficiency, and cost-control Additional quality, efficiency, and cost-control

elements were added later.elements were added later.

The PCMH Model in Action:The PCMH Model in Action:North Carolina Community Care CollaborativeNorth Carolina Community Care Collaborative

The CCNC Asthma Program The CCNC Asthma Program demonstrated cost-effectiveness. demonstrated cost-effectiveness. • 34%34% lower hospital admission rate. lower hospital admission rate.• 8%8% lower ED visit rate. lower ED visit rate.• Average ED cost for children was Average ED cost for children was 24%24% lower. lower. • 93% 93% received appropriate inhaled steroid received appropriate inhaled steroid • 21%21% increase in asthma patients who have increase in asthma patients who have

been staged (type of asthma)been staged (type of asthma)• 112%112% increase in asthmatic patients receiving increase in asthmatic patients receiving

flu shots. flu shots. • $3.5$3.5 million dollar savings million dollar savings

The PCMH Model in Action:The PCMH Model in Action:North Carolina Community Care CollaborativeNorth Carolina Community Care Collaborative

Without any concerted efforts to control Without any concerted efforts to control costs, the program overall saved costs, the program overall saved $60 $60 million million in 2003in 2003,, $124 million $124 million in 2004in 2004, and , and $231 million $231 million in 2005 and 2006in 2005 and 2006..

Almost Almost $1 M$1 M in savings achieved during in savings achieved during the first two quarters of 2005 just for the first two quarters of 2005 just for

prescription use.prescription use. www.communitycarenc.org

How does a practice transform into How does a practice transform into a PCMHa PCMH

Need extra time, extra help, extra $$Need extra time, extra help, extra $$ In Pennsylvania, the Governor created a Chronic In Pennsylvania, the Governor created a Chronic

Care Initiative to help practices become medical Care Initiative to help practices become medical homes:homes:• Provides practice coachesProvides practice coaches• Provides extra payments to the practicesProvides extra payments to the practices• Provides meetings with other practices to share “best Provides meetings with other practices to share “best

practices” (what works for them)practices” (what works for them)• Training on registries, group visits, e-visits, referral Training on registries, group visits, e-visits, referral

tracking, lab results tracking, etctracking, lab results tracking, etc• Private and government insurers working with doctors to Private and government insurers working with doctors to

transform practices.transform practices. It takes 1-2 years to transform an office to a It takes 1-2 years to transform an office to a

PCMHPCMH

How Does A Practice Transform to How Does A Practice Transform to a PCMHa PCMH

It is possible to do become a PCMH without It is possible to do become a PCMH without an electronic health record.an electronic health record.

In U.S., a practice can be certified as a In U.S., a practice can be certified as a PCMH by the NCQA (National Committee PCMH by the NCQA (National Committee for Quality Assurance) for Quality Assurance) • The NCQA has an extensive list of The NCQA has an extensive list of

qualifications (see next slide), divided into 9 qualifications (see next slide), divided into 9 sectionssections

• The items in bold are “must pass” itemsThe items in bold are “must pass” items• A practice can be certified as Level 1, 2 or 3, A practice can be certified as Level 1, 2 or 3,

depending on how many points they depending on how many points they accumulate and how many “must pass” accumulate and how many “must pass” elements they meetelements they meet

Standard 1: Access and CommunicationStandard 1: Access and CommunicationA.A. Has written standards for patient access and Has written standards for patient access and

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

patient access and communication**patient access and communication**

PtPtss

4455

99

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

(mostly non-clinical data) (mostly non-clinical data) B.B. Has clinical data system with clinical data in Has clinical data system with clinical data in

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

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

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

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

PtPtss

22

3333

6644

33

2121

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

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

for clinicians for 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 Coordinates care//follow-up for patients who

receive care in inpatient and outpatient facilities receive care in inpatient and outpatient facilities

PtPtss

33

44

3355

55

2020

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

communication barrierscommunication barriersB.B. Actively supports patient self-management**Actively supports patient self-management**

PtPtss

2244

66

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 Has electronic prescription writer with safety

checkschecksC.C. Has electronic prescription writer with cost Has electronic prescription writer with cost

checkschecks

PtsPts3333

22

88

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

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

tests and flag duplicate teststests and flag duplicate tests

PtsPts77

66

1313

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

electronic system**electronic system**

PTPT44

44

Standard 8: Performance Reporting and Standard 8: Performance Reporting and Improvement Improvement

A.A. Measures clinical and/or service Measures clinical and/or service performance by physician or across the performance by physician or across the practice**practice**

B.B. Survey of patients’ care experienceSurvey of patients’ care experience C.C. Reports performance across the practice Reports performance across the practice

or by physician **or by physician **D.D. Sets goals and takes action to improve Sets goals and takes action to improve

performance performance E.E. Produces reports using standardized Produces reports using standardized

measures measures F.F. Transmits reports with standardized measures Transmits reports with standardized measures

electronically to external entities electronically to external entities

PtsPts

33

3333

33

2211

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 SupportElectronic Care Management Support

PtsPts112211

44

NCQA PCMH Content & Scoring

How does a Practice Transform to How does a Practice Transform to a PCMHa PCMH

Level 1 can be achieved with a paper-Level 1 can be achieved with a paper-based chart; an electronic medical record based chart; an electronic medical record is not essential for this levelis not essential for this level

Some of the items you can do with a paper Some of the items you can do with a paper record include:record include:• Has written standards for patient access and Has written standards for patient access and

patient communicationspatient communications• Tracks tests and identifies abnormal results Tracks tests and identifies abnormal results

systematicallysystematically• Tracks referrals using paper-based or Tracks referrals using paper-based or

electronic system electronic system

A Patient-Centered Medical Home A Patient-Centered Medical Home ExperienceExperience

A 50-year-old female thinks she has a A 50-year-old female thinks she has a urinary tract infection (UTI). She goes urinary tract infection (UTI). She goes online to make an appointment for herself.online to make an appointment for herself.• Her doctor’s office offers “open access”, Her doctor’s office offers “open access”,

meaning many appointments are made meaning many appointments are made for the same day. for the same day.

• She books an appointment online for 4 She books an appointment online for 4 pm that day, a convenient time for her.pm that day, a convenient time for her.

……continuedcontinued She arrives at her appointment, where the She arrives at her appointment, where the

receptionist informs her that the doctor is running receptionist informs her that the doctor is running about 5 minutes behind.about 5 minutes behind.

The nurse has updated the patient’s medications The nurse has updated the patient’s medications and allergies in the electronic health record and allergies in the electronic health record before the doctor enters the room.before the doctor enters the room.

She is happy to see her doctor, who looks relaxedShe is happy to see her doctor, who looks relaxed The doctor confirms presence of a UTI and The doctor confirms presence of a UTI and

prescribes an antibiotic. The electronic medical prescribes an antibiotic. The electronic medical record checks for allergies, drug interactions, and record checks for allergies, drug interactions, and formulary coverage.formulary coverage.

The doctor faxes the prescription to the patient’s The doctor faxes the prescription to the patient’s pharmacy.pharmacy.

……continuedcontinued Meanwhile, the doctor notices a pop-up reminder Meanwhile, the doctor notices a pop-up reminder

in the patient’s record that patient is due for an e-in the patient’s record that patient is due for an e-visit for his diabetes.visit for his diabetes.

Because of the office’s diabetes registry, the Because of the office’s diabetes registry, the doctor knows that the patient needs a lipid panel doctor knows that the patient needs a lipid panel and urine for microalbumin. These are ordered and urine for microalbumin. These are ordered and sent to the lab electronically.and sent to the lab electronically.

The patient’s blood sugars have been under good The patient’s blood sugars have been under good control; she checks them regularly at home. She control; she checks them regularly at home. She will send the results electronically to the doctor will send the results electronically to the doctor before her e-visit.before her e-visit.

……continuedcontinued As she checks out after his visit, she makes an As she checks out after his visit, she makes an

appointment for her e-visit for the following week.appointment for her e-visit for the following week. She then goes to her pharmacy to pick up her She then goes to her pharmacy to pick up her

prescription, which is waiting for her.prescription, which is waiting for her. That evening she thinks of a question for her That evening she thinks of a question for her

doctor. She emails her and knows she will get a doctor. She emails her and knows she will get a reply within 24 hours…reply within 24 hours…

Having done today’s work today, the doctor Having done today’s work today, the doctor leaves for home at 5 PM.leaves for home at 5 PM.

The Patient-Centered Medical The Patient-Centered Medical HomeHome

The care we want to provideThe care we want to provide

The care we want for ourThe care we want for our familiesfamilies