Aiming for and Reaching Level 3 PCMH Recognition

UPMC Matilda Theiss
Health Center
JA N UA RY 2 0 1 2
 UPMC hospital-based clinic
 Only federally qualified health center within UPMC
 Serving a total of 1600 patients
 ~30% are uninsured
 ~60% are Medicare/Medicaid
 Offering full primary care services
 Disease state management
 Health education
 OB/GYN services
 Social, counseling, and health promotion services
 Medication dispensing through on-site dispensary
 Clinical pharmacy services
Who We Are
Our Team
Physicians, medical residents, social workers, pharmacists, nurses,
administrators and front desk staff all work together as a team to
improve our patients’ health
The Changing Landscape of Medicine
 In 2000 the WHO(World Health Organization) outlined
changes that would transition medical care systems from
pay for performance models to quality of care models
 The medical community in the United States responded
by taking measures to advance idea the healthcare
outcomes should measured in terms of quality and not
 In 2007, response to the new WHO standards of care we
began researching the new model of medicine
Becoming a Patient Centered Medical
The Medical Home Model Utilizes 8 change concepts which have been identified as
drivers of quality care. These concepts are the building blocks of the medical home
model, but they can hard to visualize and even harder to implement. To assist our
team with understanding and implementing each change concept, we enlisted the
help of the Pittsburgh Regional Health Initiative. The change concepts are as follows:
Engaged Leadership
Enhanced Access
Patient centered Interactions
Care Coordination
Organized, evidenced based care
Quality Improvement Strategy
Continuous Team Based Healing Relationships
Enhanced Access
 In 2008 we surveyed are patients prior to initiating the
Medical Home model at our Health Center
 Access to care was identified by our patients as the
number one problem with healthcare at our facility
 In January of 2009 we began a modified open access
scheduling system to meet the access need of our
~ Instead of appointments booked as far out as 90 days,
appointments are booked in within 48 hours, and follow
ups no longer than two weeks out.
 Not long after beginning Open access Scheduling, we
discovered that Empaneling all our patient to one
physician only would be key to moving forward with
medical home
 Empanelment provided us with ability to form
teams(Continuous Team Based Healing) around a
physician's panel and it is a driver of (Care Coordination).
Engaged Leadership
 Patient care teams at Matilda Theiss consist of:
 Doctor/provider
 Nurse/Medical Assistant
 Front Office clerk
 Pharmacist/pharmacist resident
 Social Worker/social work intern or fellow
Patient Centered Interaction
Evidenced Based care and Quality Improvement
Quality of care can be hard to measure, but not impossible.
Internal quality measurements were put in place to help us
collect data on how well we were doing
 We used data collection tools such as:
 ~PDSA cycles
 ~Patient satisfaction surveys
 ~Process Flow Charts
 ~Fish Bone Diagrams
 ~Toyota quality measures
NCQA Certification
 In June of 2013, after one year of planning and four years
of transforming, Matilda Theiss Health Center received
level 3 Medical Home Certification
What We’ve Accomplished
 Established leadership commitment
 Culture of quality and safety
 Partnership with the University of Pittsburgh School of Pharmacy
 Developed an integrated multi-professional care team
 Physicians, medical residents, nurses, social workers, and
 Established full time on-site clinical pharmacy services
 Provided by pharmacy residents
 Established patient-centered Medical Home
 Consistently engaging patients and families
 Consistently providing culturally appropriate care
What We’re Tracking
 Diabetes Control
# of patients whose A1c is ≤ 9%
Monthly patient reviews in EPICCare
 LDL Control
# of patients whose LDL is ≤ 100 mg/dL
Monthly patient reviews in EPICCare
 Blood Pressure Control
# of patients whose blood pressure is ≤ 130/80
Monthly patient reviews in EPICCare
 Patient Safety
# of patients receiving CPS in previous month
Clinical Pharmacist Encounters Spreadsheet
# of adverse drug events potential, actual, prevented
ADE and Clinical Pharmacy Services Tracking Form
What We’re Working On
 Integrated care delivery and patient-centered care
Received Level 3 NCQA Medical Home Accreditation in June 2013
 Patient engagement
Monthly diabetes group
Monthly calls to all PoF patients
 Diabetes, LDL, and blood pressure control
Implementing Diabetes Report Card and Goal Setting Worksheet
 Patient safety
Completion of Clinical Pharmacist Encounters Spreadsheet and ADE and
Clinical Pharmacy Services Tracking Form for each patient encounter
 Sustainability
Maintenance of current CPS and expansion of services

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