The Patient-Centered Medical Home (PCMH): Building a Better Health Care Model

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The Patient-Centered Medical Home
(PCMH)Building a Better Health Care Model
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Objectives

• Identify current priorities to enact health care
  reform.
• Describe the Patient-Centered Medical Home (PCMH)
  model of care.
• Understand how the PCMH model is an appropriate
  method to address priority health reform issues.
• Understand Family Medicines role in the
  development and adoption of the Patient-Centered
  Medical Home.

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Patients today are savvy consumers of health care
and have higher expectations.

• Communication
• Access
• Convenience
• Coordination
• Responsiveness
• Source Medfusion, an AAFP affinity partner, 2008

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Patient Expectations

• 75 want the ability to interact with their
  physician online (appointments, prescriptions,
  test results).
• 77 want to ask questions without a visit.
• 75 want email access as part of their overall
  care.
• 62 of patients say access to these services
  would influence their choice of physicians.
• Source Medfusion, an AAFP affinity partner, 2008

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Family Medicine is leading the way to make health
care more patient-centered.

• Will family medicine teachers prepare their
  students and residents to help practices
  transform and meet the infrastructure principles?
  I believe that we will, not simply because doing
  so will likely increase our financial situation
  but because building PCMHs that meet the care
  and infrastructure principles will improve the
  care we provide to meet our patients and our
  communities needs. We will build our PCMH
  practices, because it is the right thing to do
  and it reflects our core values.
• John C. Rogers, MD, MPH, MEd
• Past-President,
• Society of Teachers of Family Medicine
• Fam Med 200840(1)11-2.)

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Health Care Reform

• Priorities for US health care reform
• Quality-WHO (World Health Organization)
  identifies the US health care system as the most
  individually responsive
• WHO ranks US health care 37th overall (among 191
  countries)
• Efficiency
• People with acute and chronic medical conditions
  receive only about two-thirds of the health care
  that they need.
• Between 20 and 30 of tests and procedures
  provided to patients are neither needed nor
  beneficial.
• Leatherman and McCarthy, Quality of Health Care
  in the United States A Chartbook, 2002. The
  Commonwealth Fund
• Schuster, McGlynn, and Brook.

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Health Care Reform

• Priorities for US health care reform
• Cost
• The U.S. spends more on health care per capita
  than any other nation.
• The U.S. spends more on health care as a
  proportion of GDP (Gross Domestic Product) than
  any other nation.
• Patient-friendly
• Public confidence in hospitals and personal
  doctors remains relatively high.
• While individuals report generally positive
  experience with medical care, public confidence
  and trust in the system at large is eroding.
• Leatherman and McCarthy, Quality of Health Care
  in the United States A Chartbook, 2002. The
  Commonwealth

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Health Care Reform

• Priorities for US health care reform
• Access
• Lack of insurance is a major reason for not
  obtaining access to needed care.
• The 40 million Americans without insurance
  coverage are less likely to obtain needed medical
  care and preventive tests
• Even with insurance, barriers to care still
  exist
• Lack of an established relationship with a doctor
• Language and Cultural barriers
• Social Determinants of Health
• Transportation issues
• Geography
• High out-of-pockets costs even for those with
  insurance ie high deductibles, underinsured, etc.

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Health Care Reform

• Priorities for US health care reform
• Automation
• Infrastructure for health care delivery has not
  kept pace with the electronic innovations of
  other industries.
• Many institutions still rely on systems that are
  not automated and allow opportunities for human
  error, even though technology exists to minimize
  errors and improve efficiency.

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An effective and efficient health care system is
a primary care-based health care system

• Provides access to basic health care services
• Manages health disparities
• Coordinates care
• Controls cost
• Offers sustainability
• www.aafp.org/valueoffamilymedicine

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Brief History Of The PCMH
Future
2010s
2000s
1990s
1960s
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Innovative SolutionHistory of the PCMH Concept

• Introduced by American Academy of Pediatrics
  (AAP) in 1967
• Initially referred to a central location for
  medical records
• The medical home concept was expanded in 2002 to
  include
• Accessible
• Continuous
• Comprehensive
• Family-centered
• Coordinated
• Compassionate
• Culturally sensitive care
• In 2007, the AAP, the American Academy of Family
  Physicians (AAFP), the American Osteopathic
  Association (AOA), and the American College of
  Physicians (ACP) adopted a set of joint
  principles to describe a new level of primary
  care.

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Joint Principles of the Patient-Centered
Medical Home

• A personal physician who coordinates all care for
  patients and leads the team.
• Physician-directed medical practice a
  coordinated team of professionals who work
  together to care for patients.
• Whole person orientation this approach is key
  to providing comprehensive care.
• Coordinated care that incorporates all components
  of the complex health care system.
• Quality and safety medical practices
  voluntarily engage in quality improvement
  activities to ensure patient safety is always
  being met.
• Enhanced access to care such as through
  open-access scheduling and communication
  mechanisms.
• Payment a system of reimbursement reflective of
  the true value of coordinated care and
  innovation.

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Growing Support for the Patient- Centered Medical
Home

• Partnerships are developing as more and more
  stakeholders see value in the Joint Principles.
• The Patient Centered Primary Care Collaborative
  (PCPCC) is a coalition of major employers,
  consumer groups, patient quality organizations,
  health plans, labor unions, hospitals, physicians
  and others to develop and advance PCMH.
• The PCPCC has well over 1,000 members.
  www.pcpcc.net

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The Patient Centered Medical Home
The Family Medicine Model

Heath Information Technology
Health IT
Health IT
Patient Experience
Patient-centered Care
Family Medicine Foundation
Patient-centered Physician-directed
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• Understand ways to identify patients risk status
• Plan out care for chronic conditions and
  preventive care
• Identify high-risk patients
• Use tools to track populations by risk category

• Establish baseline performance measures
• Collect and analyze data
• Discuss best practices and improvement
• Conduct regular clinical team meetings

• Manage care transitions and build linkage to
  community resources
• Coordinate care with specialists and outside
  facilities
• Evaluate care transition process

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Shared Decision Making
Convenient Access
Patient Experience

• Same-day appointments and extended hours
• E-mail communication with patients (E-visits)
• Web portals for Rx refill and appointments
• Translation and Culturally appropriate services

• Understanding the patients social barriers,
  goals and priorities
• Create care plans in collaboration with
  patient/caregiver
• Monitor progress between visits

• Conduct patient satisfaction surveys on a regular
  basis
• Establish patient advisory panel and QI
  activities
• Conduct patient focus groups

Patient-centered Care
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Culture of Change
Practice Environment
Financial Management

• Lab testing
• Prescriptions
• Registries

• Establish a PCMH leadership team
• Engage all members of the practice in a shared
  vision
• Provide staff education and training to support
  patient-centered care

• Staffing model supports team-base care
• Define roles for team members
• Include health coach and care coordination
  functions

• All staff are aware of the most efficient ways to
  deliver care
• National policies support the investment of
  resources into primary care practices that are
  effective and efficient

Patient-centered Care
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Technology Infrastructure
Digitally Connected
Evidence-Based Medicine
EHR Reporting Tools

• Patient reminders
• Patient notification for
• new information
• Reminders for
• recommended care or
• health maintenance
• Makes patient registries
• possible

• Can quickly pull clinical
• data for quality analysis
• Can enhance business
• processes
• Population health management through patient
  registries

• Enhances care
• coordination by
• improving information
• flow with other
• physicians, practices,
• and providers
• Improves patient -
• physician communication

• Point-of-care learning , alerts and reminders
• Clinical decision support
• (e.g., Epocrates)

Health Information Technology
Patient centered Care
Family Medicine Foundation
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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.

Health Information Technology
Patient-centered Care
Family Medicine Foundation
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Does PCMH Work?

• Fully implemented the PCMH hits the triple AIM,
  better health, better care, lower costs
• Improves practice organization, work environment
  and job satisfaction
• No longer a pilotNow a program with proven
  results

www.pcpcc.net/publications
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The PCMH Model in Family Medicine Residency
Training

• Preparing the Personal Physician for Practice
  (P4)
• The P4 Initiative was designed to inspire and
  examine innovation in family medicine residency
  training.  
• Sponsors are the American Board of Family
  Medicine, the Association of Family Medicine
  Residency Directors, and TransforMED.
• Different approaches range from moving the
  continuity clinic into a new community setting,
  to expanding to a four-year program, to providing
  the opportunity for tracking and obtaining
  additional degrees while in training, and more. 
• The aim of P4 is to spur innovation in all family
  medicine residencies to best prepare family
  physicians be the excellent personal physicians
  of tomorrow.
• Initially, 84 Family Medicine residencies applied
  to participate in the P4 Initiative.
• The 14 P4 residencies were selected as
  participants for more intensive evaluation of
  outcomes to determine what works best.
• http//transformed.com/p4.cfm

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PCMH Model and Health Care Reform

• Attempts to fix part of the problem without
  addressing it comprehensively will not lead to
  viable solutions.
• Advocacy by all stakeholders is necessary.
• Community projects through local hospitals and
  resource networks
• State projects for regional payors and state
  Medicaid programs
• National support for changing how care is
  delivered and for ensuring a prepared workforce
  to deliver care

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Family Physicians and the PCMH

• PCMH is a place, not a person.
• Patient-centered, Physician-directed.
• Family physicians
• Provide comprehensive care
• Care for all patients
• Coordinate care
• Provide care that is effective
• and efficient
• Future of Family Medicine
• Starfield data

Health Information Technology
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Family PhysiciansHow we provide care

• Acute injuries and illnesses
• Health promotion and behavior change
• Hospital care
• Chronic disease management
• Maternity care
• Well-child care and child development
• Primary mental health care
• Supportive and end-of-life care

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Family PhysiciansHow we view patients

• Consider all of the influences on a persons
  health.
• Know and understand peoples limitations,
  problems, and personal beliefs when deciding on a
  treatment.
• Are appropriate and efficient in proposing
  therapies and interventions.
• Develop rewarding relationships with patients.
• Provide a continuous healing relationship over
  time.

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Family Physicians Who we care for

• Individuals and families
• Women and men regardless of age or disease
• Infants, children, and adolescents regardless of
  disease
• Communities and public health
• Global health

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Primary Care Delivers Better Health Outcomes

• ? mortality
• ? morbidity
• ? medication use
• per capita expenditures
• patient satisfaction
• greater equity in health care
• SOURCE B. Starfield, et al., The Effects of
  Specialist Supply on
• Populations Health, Health Affairs (March
  2005) W5-97

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The Patient-Centered Medical Home as a Preferred
Model of Care

• Change is here!
• Patients want more from the healthcare system and
  from their physician.
• Purchasers of insurance (individuals, employers,
  government) are looking for quality and value.
• Runaway healthcare costs must be addressed in
  ways that preserve and enhance access to
  high-quality, effective medical care.
• There are ways to do both!

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Institute for Health ImprovementTriple Aim

• The Institute for Healthcare Improvement (IHI)
  believes that focusing on three critical
  objectives simultaneously can potentially lead us
  to better models for providing healthcare.
• 1. Improve the health of the defined population
• 2. Enhance the patient care experience (including
  quality, access and reliability)
• 3. Reduce, or at least control, the per capita
  cost of care

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PCMH Recognition Programs

• National Center for Quality Assessment (NCQA)
• Accreditation Association for Ambulatory Health
  Care (AAAHC)
• Joint Commissions Primary Care Home Designation
  Standards
• Utilization Review Accreditation Committee (URAC)
• Private Payer Medical Home Recognition Programs

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Explore Family Medicine

• Learn more about PCMH. (www.aafp.org/pcmh)
• Advocate for your patients.
• Think about the future of healthcare. Are you
  learning the skills today that you will need for
  the changing healthcare system?
• Visit Virtual FMIG. (www.fmignet.aafp.org)
• Join your local FMIG.
• Join the AAFP. (www.aafp.org)
• Get involved at the state and national level.