Integrating Population Health Management into Patient-Centered Medical Home Meeting NCQA MHP Recognition Requirements

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Integrating Population Health Management into
Patient-Centered Medical HomeMeeting NCQA MHP
Recognition Requirements

• CDR Patricia Taylor, NC, USN
• Deputy Director Medical Services
• Naval Hospital Bremerton, WA

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Defining the Medical Home
Grundy (2012)
Source Health2 Resources 9.30.08
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Investing in Primary Care Patient Centered
Medical Home

• Group Health Cooperative of Puget Sound (Seattle,
  Washington)
• Cost
• 10 PMPM reduction in total costs
• 16 reduction in hospital admissions
• 29 reduction in ER visits
• Return on investment 1.5 1
• Quality
• 4 more patients achieving target levels on HEDIS
  quality measures
• 10 of pilot clinic staff reporting high
  emotional exhaustion at 12
• months compared to 30 percent of staff in control
  clinics
• Improvement in recruitment and retention
• Geisinger Health System (Pennsylvania)
• Cost
• 18 reduction in hospital admissions
• 7 reduction in total PMPM costs
• Return on investment 21
• Quality

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Population HealthTranslating Strategy into Action

• Focus on Better Health
• Partnership between primary care and population
  health
• Prevention and Chronic Care Management
• IT tools allowing for actionable, near time data
• Embedded training and population health support

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Correlation to 2011 NCQA MHP Standards

• Identify and management patient populations (PCMH
  2 Elements C D)
• Plan and manage care (PCMH 3 Elements A-C)
• Providing self-care support and community
  resources (PCMH 4 Element A)

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Integrating Planned Care into Primary Care

• Planned care for chronic conditions and
  preventive care
• Patient and caregiver engagement

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Planned Care for Chronic Conditions Preventive
Care

• Primary care practices will proactively assess
  patients to determine need
• Provide appropriate and timely preventive care
• Use disease registries to track and appropriately
  treat chronically ill patients

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Patient Caregiver Engagement

• Primary care practices will engage patients and
  families in active participation in goal setting
  and decision making
• Patients will be full partners in truly
  patient-centered care

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Integrating Planned Care into the Primary Care
Setting

• Key components
• Leadership support and buy-in at all levels
• Roles/Responsibilities defined for entire team
• Ongoing training for targeted preventive care and
  chronic conditions
• Information tools for point of care and outreach
  efforts
• Delivery system process redesign
• Embedded population health/health educator

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Planned Care Management ProcessPoint of Care

• Preventive Health Assessment
• Proactive Office Encounter Preparation Process

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Preventive Health Review

• Part I Patient Appointment Information
• Part II Preventive Health Screenings
• Part III Disease and Condition Management

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Preventive Health Review
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Part I Patient Appointment InformationPart II
Preventive Health Screenings
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Part III Disease and Condition Management
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Proactive Office Encounter Preparation

• Staff Roles/Responsibilities
• Review PHR during huddle/team meeting
• If screenings are flagged red or due take
  appropriate action (colorectal CA, breast CA, or
  Cervical CA screenings)
• If patient has specific chronic conditions review
  take appropriate action (Asthma, diabetes,
  dyslipidemia)
• Gather appropriate educational resources

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Office Encounter Process

• Staff Roles/Responsibilities
• Support Staff
• Review PHR with patient
• If screenings are flagged red or due take
  appropriate action (colorectal CA, breast CA, or
  Cervical CA screenings)
• If patient has specific chronic conditions review
  take appropriate action (Asthma, diabetes,
  dyslipidemia)
• Provider
• Review/reinforce tests/screenings needed
• Patient
• Takes home PHR
• Leaves clinic with appropriate orders, consults,
  f/u appts
• Has appropriate educational resources
• Acts on orders and consults
• Achieves self-management goals

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Planned Care Management Process Outreach Efforts
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Planned Care Management Staff Training Components

• CarePoint
• Familiarization with various features
• Patient Population Management (PPM)
• Preventive Care
• Chronic Care
• CarePoint Skills competencies/PPM knowledge exam
• Patient Communication Scripts
• Documentation/Exclusions

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Planned Care Management ProcessOutreach Efforts
Support Staff use CarePoint to identify patients
who are overdue or due for tests/screening
Contacts via phone
Unable to contact

1. Address all patient needs in one phone call
2. Place appropriate orders/consults /schedule
   appointments
3. Document in CarePoint (Notes, exclusions, ordered
   tests/screenings

1. Documents in CarePoint. Enters AHTLA t-con with
   reason for notification
2. Patient returns call, Communication Room staff
   can address issue with patient
3. Three attempts Letter sent

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Embedded Population Health/Health Educator

• Population Health responsibilities
• Streamline CarePoint account application process
• Established and conducts CarePoint and Population
  Management staff training
• Clean up data outside reports, coding
  corrections, amending records
• Provide team updates on HEDIS Captains Cup
  Challenge
• Strengthen partnership between Medical Home team
  and Population Health department

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HEDIS Captains Cup Challenge
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Embedded Population Health/Health Educator

• Health Educator responsibilities
• Provides individualized patient education in
  support of PCMH team
• Created standard objective-based education
  curriculums for use by MH team support staff.
  (Pathways for brief point of care education)
• Provides clinical support staff training for
  specific health conditions and risk factors
  (PCMH/HEDIS)
• Documents self-management plans and goals

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Impact of Integrating Planned Care into Primary
Care

• Enhanced Team-based approach
• Maximized Provider/patient time
• Enhanced patient/caregiver engagement
• Improvements in HEDIS measures

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NH Bremerton Points of Contact

• CDR Patricia Taylor patricia.taylor2_at_med.navy.mil
• Dr. Dan Frederick daniel.frederick_at_med.navy.mil
• Aimee Aldendorf aimee.aldendorf.ctr_at_med.navy.mil