The Patient-Centered Medical Home: Overview, Outlook

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The Patient-Centered Medical Home Overview,
Outlook Trends

• FEBRUARY 20, 2009
• Elizabeth E. Stewart, PhD
• Center for Research in Primary Care Family
  Medicine
• TransforMED

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What a Medical Home is NOT
Meet Rebecca Working Mother. Today she
woke up with a fever and UTI symptoms. She needs
to juggle work coverage, child care and household
responsibilities along with her immediate
healthcare problem.
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What a Medical Home is NOT
Difficulty in scheduling appt for that day.
No alternative way to seek treatment from
practice.
Hours at practice were limited so Rebecca had to
arrange to leave work.
Staff sounded harried had trouble locating her
records
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What a Medical Home is NOT
Waited for almost an hour staff still had not
found her records.
Physician was rushed Rebecca was too timid to
ask about strange pain in her breast.
Did not see her own physician and repeated the
same information to multiple people.
When Rebecca tried to make a follow-up
appointment for full physical, the wait time
would be 4 months.
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Slide courtesy of www.pcpcc.net
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Primary Care Crisis
Good evidence that primary care that countries
with strong primary care infrastructures have
lower costs and better outcomes.1 In the US,
fewer and fewer graduates are choosing primary
care Shrinking reimbursements Increasing
demands Overall lack of respect. A recent
study revealed 49 of PCPs said they plan to cut
back or retire in 3 years.2
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Enter The Medical Home

• In 1967, The American Academy of Pediatrics
  introduced the term to describe a single source
  of medical information and coordination for sick
  children.3
• Over the next 40 years, many other organizations
  endorsed the concept and the term.4

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Medical Home Core Features

• In 2007, four major medical organizations (AAFP,
  AAP, ACP, AOA) reached agreement on Joint
  Features of the Patient-Centered Medical Home. 5
• In 2008, the AMA gave their endorsement.6

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Medical Home 7 Core Features

• 1. Person Physician
• Each patient has an ongoing relationship with a
  personal physician trained to provide first
  contact, continuous, and comprehensive care.

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Medical Home Core Features

• 2. Physician directed medical practice the
  personal physician leads a team of individuals at
  the practice level who collectively take
  responsibility for the ongoing care of patients

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Medical Home Core Features

• 3. Whole person orientation The personal
  physician is responsible for providing for all
  the patients health care needs or taking
  responsibility for appropriately arranging care
  with other qualified professionals.

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Medical Home Core Features

• 4. Care is coordinated and/or integrated across
  all elements of the complex health care system,
  making sure patients get the indicated care when
  and where they need and want it.

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Medical Home Core Features

• 5. Quality Safety are Hallmarks
• Decisions are made by EBM and appropriate
  decision support tools
• Information Technology is used appopriately
• Patients participate in decision making
• Patient feedback is actively sought to ensure
  expectations are met.

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Medical Home Core Features

• 6. Enhanced access to care is available through
  systems such as open scheduling, expanded hours
  and new options for communication.

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Medical Home Core Features

• 7. Payment appropriately recognizes the added
  value provided to patients who have a
  patient-centered medical home.
• Reflect the value of physician and non-physician
  staff patient-centered care management
• Should pay for services associated with
  coordination of care both within a given practice
  and between consultants, ancillary providers, and
  community resources.

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Testing the Feasibility of the Medical Home
The Future of Family Medicine Ultimately,
system wide changes will be needed to ensure
high-quality health care for all Americans. Such
changes include taking steps to ensure that every
American has a personal medical home 7
2006
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www.transformed.com
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Medical Home Is it possible?

• Early data point to a cautiously optimistic YES
  but
• Two years is not enough.
• Transformation process is far greater challenge
  than previously anticipated.
• Many lessons to be learned from real life
  application.8

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Will it save money improve outcomes?

• Getting the attention of payers politicians
• gt 25 multi-stakeholder projects are underway in
  22 states, most with formal evaluations.
• Growing interest in the formation of state MH
  demonstration projects use of term in crafting
  legislation.9

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Community Care of North Carolina

• Since 1999, the state has invested in many MH
  components through disease management payments to
  practices with Medicaid pts.
• Emphasis on physician led team approach, disease
  tracking care managers within practices.
• Significant improvements in cost, utilization,
  and quality measures. Two major evaluations
  estimate it CNCC saved the state between 230 and
  260 million in 2004.12

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MH Outlook Pilots Payers

• PCPCC is a coalition of gt300 organizations
  employers, consumer groups, patient advocates,
  etc
• Collaboration of like-minded stakeholders
  actively working toward medical home vision.
• Comprehensive list of pilot projects
  www.pcpcc.net

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MH Outlook Accreditation

• National Committee for Quality Assurance offers
  3 tiers of medical home recognition
• Practices are hopeful that such recognition will
  lead to higher reimbursement by public and
  private payers such recognition is a required
  part of many ongoing and future pilots.

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PCMH Outlook CMS Demonstration
CMS preparing to launch 2-year Medicare Medical
Home Demonstration (MMHD). Looking at impact of
medical home on - Medicare cost - Utilization
- Health outcomes - Patients - Physicians
Practices
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PCMH Outlook CMS Demonstration

• Practices must meet criteria of NCQA to qualify
• (Tier 2 and Tier 3 only)
• Qualified practices receive additional care
  management fees based on RUC work RVUs, practice
  expenses, and insurance.
• MMHD link on CMS website
• http//www.cms.hhs.gov/DemoProjectsEvalRpts/MD/li
  st.asp

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PCMH Outlook Gaining Political Traction
New economic stimulus bill earmarks 19 billion
to implement electronic medical records and other
health information technology.13
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PCMH Outlook Gaining Political Traction
Senator Baucus (D-Montana) white paper on health
care reform endorsed medical home concept, even
suggesting that specialists may see a small cut
in reimbursements in order to pay primary care
physicians for currently non-reimbursable
coordination services.14
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PCMH Outlook Gaining Public Traction
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Medical Home Challenges

• Transformative change doesnt happen overnight
  pilots under pressure for quick results may do
  more harm than good.
• Simply inserting HIT is not the solution.
• Primary care physicians have mixed responses to
  the concept.

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Medical Home Physician Outlook

• Excited
• Cautiously optimistic
• Skeptical/cynical
• Too exhausted stressed to care

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Medical Home Physician Outlook

• Financially-strapped FM physicians are fearful of
  the high cost of MH changes (time, resources,
  equipment) without a guarantee of increased
  reimbursement.
• Like many researchers/policy makers, they are
  concerned about short time frame of current pilot
  projects given enormity of necessary changes.

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• some health care policy experts "worry that
  the push for medical homes could be yet another
  example of the latest health care fad -- quickly
  embraced by employers desperate to slow their
  soaring health costs, and just as quickly
  forgotten when they do not provide immediate
  results. 15

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Medical Home Outlook

• I no longer practice medicine encounter to
  encounter, taking care of the problem the patient
  presents with. I take care of them in between
  visits online, plus I use each visit as an
  opportunity to improve their overall health,
  addressing any overdue health maintenance or
  disease mgt with the help of my nurses

Dr. Susan Andrews Natl Demonstration
Project Family Practice Partners Murfreesboro, TN
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Medical Home Outlook

• I do take care of my patients how and when they
  want to be seen as much as I can, whether it is
  in the office, online, or by phone and letter I
  love my job. I look forward to working with my
  staff each day. It is a real pleasure seeing a
  nurse or MA, a receptionist, or an office manager
  stretch herself and grow. I treasure my
  interactions with each and every patient. 16

Dr. Susan Andrews Family Practice
Partners Murfreesboro, TN
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Medical Home Outlook

• We know that a strong primary care system reduces
  health care costs and improves quality outcomes.
  17
• We know that primary care doctors feel underpaid
  and demoralized and their labor forces is
  shrinking. 18

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Medical Home Outlook

• We know that the majority of primary care
  physicians would like to embrace the medical home
  concept and those that have, cite greater
  satisfaction with their jobs.19
• Finally, we know that the evidence for a medical
  home is being created right now... but true
  change takes time, and so do results.

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Medical Home Trends

From the ground level What seems to be working
for physicians, practices and patients?
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PCMH Trends Same Day Scheduling Patients can
schedule an appt for the same day OR in advance
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PCMH Trends Same Day Scheduling

• Huge leap of faith for many physicians fearful of
  an open schedule.
• Once in place, overwhelmingly positive response
  from physicians and patients.
• Requires an understanding of the supply/demand
  cycle by day, week, season.20

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Trends Same Day Scheduling

• Requires constant education of patients using
  multiple channels.
• Some patients prefer the option to schedule
  ahead.
• saved drops in no-show rates, less staff
  time on reminder calls.21

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PCMH Trendse-Visits Physicians offer
structured, secure office visits online
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PCMH Trends e-visits

• Only lukewarm response from patients takes
  concerted consistent promotion by practice
• Many e-visit modules do not interface with EMRS
  requiring extra work for documentation
• Currently, limited reimbursement by payers23

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PCMH Trends e-visits

• Currently, patients seem to prefer non-secure,
  non-reimbursable email communication with
  physicians in lieu of phone calls.
• Physicians acknowledge time saving by email vs.
  multiple phone calls.
• Potential to be popular with certain pt
  populations.24

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PCMH Trends Group Visits

• Typically centered around a chronic disease
  goal is for physician to facilitate peer-to-peer
  learning.
• Evidence that group visits can result in
  improved health outcomes increased pt
  compliance. 25

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PCMH Trends Group Visits

• Require paradigm shift from physicians solo
  encounter to group facilitation process.
• Require tremendous planning and preparation work
  up-front difficult without extra staff.
• Concerns about reimbursement coding.
• Patients often reluctant to attend then report
  increased satisfaction after visit.26

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• Population Management

Chronic Disease Management
PCMH Trends Disease Registries
Disease Prevention
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PCMH Trends Disease Registries

• Practice runs report on all diabetics overdue
  for a follow-up visit or out of compliance.
• Pts are called or emailed to set up an appt and
  get lab work.
• During appt, EBM point-of-care reminders guide
  staff to arrange additional care (e.g., flu shot,
  mammogram).

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PCMH Trends Disease Registries

• Many EMRs do not yet offer disease registry
  capabilities OR process is difficult to
  establish.
• Many stand-alone disease registries do not
  interface with EMRs, requiring double data entry.
  
• Requires paradigm shift from acute, one-on-one
  episodic care to proactive management of a
  population of patients. 27

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PCMH Trends Care Teams

• MA/RN does vital signs, medications, history,
  standing orders, etc

Care teams usually consist of a physician and 1
or 2 support staff who take on increased
responsibility of patient care.
Doctor completes exam talks with pt MA in room
might document on EMR during exam
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PCMH Trends Care Teams
Care teams require increased staff training and
allocation of resources up front willingness of
physician to delegate.28
MA/RN does follow-up education wit pt
follow-up coordination of care (scheduling labs,
etc)
Doctor goes to next pt with no downtime
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PCMH Trends Care Teams

• Evidence of increase in
• Pt volume revenue
• Quality of care
• Doctor/staff satisfaction29
• Challenges
• - Upfront allocation of resources w/out
  immediate
• pay-off
• - Qualified staff cost more

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PCMH Trends Patient Portals

• Interactive patient portals interfaced with
  practice EMR
• Pts can schedule appts, refill medication, send
  in BP or blood sugar results, etc
• Pts can view all or parts of their chart, lab
  work, test results, etc

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PCMH Trends Patient Portals

• Allows patient greater participation in their
  care
• Physicians note that having charts online can be
  humbling but helpful to increasing pt
  engagement
• Online services can save practice staff time
  calls

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PCMH Trends Patient Portals

• CHALLENGES
• Portals cost money to implement maintain but
  most pts are not willing to pay extra for
  services
• Some pts are not web-enabled
• Takes additional Dr/staff time upfront to train
  pts to use portal and redesign workflow processes
  (e.g. how to return lab results). 30

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Greatest PCMH Promises

• ? Quality of care
• ? Overall costs
• ? Satisfaction
• patients families
• physicians staff

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Greatest PCMH Challenges

• Transformation of a practice takes incredible
  time, energy resources.
• Currently, majority of implementation
  refinement of PCMH is non-reimbursable.
• Engagement and education of patients their role
  in the PCMH is also different.31

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What a Medical Home IS
Meet Rebecca Working Mother. Today she
woke up with a fever and UTI symptoms. She needs
to juggle work coverage, child care and household
responsibilities along with her immediate
healthcare problem.
61
What a Medical Home IS
She was able to make her appt that day before 8am
by using online scheduling. She was in out of
the office in lt45 min. The disease registry
reminded the MA of overdue health maintenance
services. Rebecca could later check her lab
results online without playing phone tag.
Rebecca felt warm welcomed at her PCMH.
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• Thank you.
• Elizabeth E. Stewart, PhD
• estewart_at_transformed.com