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

1
The Patient-Centered Medical Home
(PCMH)Building a Better Health Care Model
2
Objectives

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

3
Patients today are savvy consumers of health care
and have higher expectations.

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

4
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

5
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 include
• 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, 1998

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Health Care Reform

• Priorities for US health care reform include
• 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 Fund

8
Health Care Reform

• Priorities for US health care reform include
• 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 barriers
• Cultural barriers
• Transportation issues
• Geography
• 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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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.

12
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 500 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
PatientExperience
Family Medicine Foundation
Patient-centered Physician-directed
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• Quality measures should be
• based in strong clinical
• evidence
• You cant improve what you
• dont measure

• Starts with a culture of
• improvement
• Ensure quality
• improvement initiatives
• are not punitive should not
• discourage physicians from
• caring for patients

• Develop reliable systems
• to collect information

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Personalized Care
Convenient Access
Care Coordination

• Patients want convenient
• access to information,
• communication, and care
• Patients want to access
• to care when they are ill

• Patients are engaged in their
• own care and want to share
• in decision-making
• Patients want increased
• ability to access information

• Patients want coordinated
• care
• Patients want new
• approaches to care group
• visits and on-line services

Patient Experience
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Personnel Management
Clinical Systems
Financial Management

• Lab testing
• Prescriptions
• Registries

• Every team member
• understands the important
• role they play in delivering
• efficient care and is
• empowered to make
• suggestions for
• improvement

• Lab testing
• Prescriptions
• Patient Registries

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

Patient Experience
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Business Clinical Process Automation
Connectivity Communication
Evidence-Based Medicine Support
Clinical Data Analysis Representation

• 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

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

• Point-of-care learning
• (e.g., Up-to-Date)
• Clinical decision support
• (e.g., Epocrates)

Health Information Technology
Patient Experience
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 Experience
Family Medicine Foundation
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The Patient Centered Medical Home
The Family Medicine Model

Heath Information Technology
Health IT
Health IT
Patient Experience
PatientExperience
Family Medicine Foundation
Patient-centered Physician-directed
20
The PCMH Model in ActionNorth Carolina
Community Care Collaborative

• Asthma and diabetes initiatives were developed
  due to high prevalence in the North Carolina
  Medicaid population.
• Care was coordinated by a primary care physician.
• Care included patient education and team
  collaboration.
• Initial goals focused on reducing unnecessary
  hospital admissions and emergency room visits.
  Additional quality, efficiency, and cost control
  elements were added later.
• The CCNC Asthma Program demonstrated
  cost-effectiveness.
• 34 lower hospital admission rate.
• 8 lower ED visit rate.
• Average ED episode cost for children was 24
  lower.
• 21 increase in asthma patients who have been
  staged.
• 112 increase in asthmatic patients receiving flu
  shots.
• 3.5 million dollar savings

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The PCMH Model in ActionNorth Carolina
Community Care Collaborative

• The CCNC diabetes initiative demonstrated
  improvement in process measures and
  implementation of evidence-based best practice
  guidelines.
• 7 increase in referrals for dilated eye exams.
• 23 increase in bi-annual foot exams.
• 2.1 million savings.
• Without any concerted efforts to control costs,
  the program overall saved 60 million in 2003,
  124 million in 2004, and 231 million in 2005
  and 2006.
• Almost 1 M in savings achieved during the first
  two quarters of 2005 just for prescription use.
• www.communitycarenc.org

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The PCMH Model in Family Medicine Residency
Training

• Preparing the Personal Physician for Practice
  (P4)
• The P4 Initiative is 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.
• Findings are being shared with all residencies to
  inspire more innovations and change.
• 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

Great Outcomes
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 coming
• 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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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.