How to Apply Patient Centered Medical Home Concepts

How to Apply Patient Centered Medical
Home Concepts
August 2, 2012
Nina Brown - Public Health Analyst, HRSA/BPHC/OQD
Candi Chitty - Consultant, MSCG
Learning Objectives
By the end of this session participants will be able to:
• Assess a grantee’s readiness for PCMH transformation;
• Identify gaps that need to be addressed, in the context of
the core program requirements;
• Explain and encourage PCMH transformation during site
Primary Health Care Mission
Improve the health of the
Nation’s underserved
communities and
vulnerable populations
by assuring access to
culturally competent,
quality primary health
care services
BPHC Quality Strategy
Better Care Healthy People & Communities Affordable Care
Priorities & Goals
1. Implementation of QA/QI Systems
All Health Centers fully implement their QA/QI
2. Adoption and Meaningful Use of EHRs
All Health Centers implement EHRs across all
sites & providers
3. Patient Centered Medical Home Recognition
All Health Centers receive PCMH recognition
4. Improving Clinical Outcomes
All Health Centers meet/exceed HP2020 goals
on at least one UDS clinical measure
5. Workforce/Team-Based Care
All Health Centers are employers/providers of
choice and support team-based care
PCMH Change Concepts
Safety-Net Medical Home Initiative
An approach to providing comprehensive, patient centered,
and coordinated primary care for health center patients System wide transformation.
1. Empanelment
2. Continuous and Teambased Healing Relationships
3. Patient-Centered
4. Engaged Leadership
Source: Safety-Net Medical Home Initiative
5. Quality Improvement (QI)
6. Enhanced Access
7. Care Coordination
8. Organized, Evidence-Based
• Demonstrates the quality of care provided in health
centers and provides opportunity for continuous quality
• Positions health centers at an advantage for the changing
health care landscape.
• Investment in the health center workforce through
reduced staff turnover and improved recruitment.
• Transforms patient care to help health centers achieve
the three part aim of: better care, better health and
communities, and affordable care.
The Patient Centered
Medical Home
• BPHC Quality Strategy Priority Goal 3: Patient Centered Medical Home
– All Health Centers receive PCMH recognition
• HHS Priority Recognition Goal
– Goal: 25% of grantees recognized by 9/30/2013
– Goal: 13% of grantees recognized by 12/31/2012
• HRSA investments in the patient centered medical home
– Patient-Centered Medical Health Home Initiative
– Accreditation Initiative
– PCMH Supplemental funds
– Partnership with the CMS Primary Care Demonstration
Many Paths to PCMH
• Many entities across the country are embracing the PCMH
– Private Payers: Blue Cross Blue Shield, United Health
Care, etc.
– States: Oregon & Minnesota
• HRSA supports 2 initiatives to assist grantees with the
survey costs and assistance in achieving PCMH
– The Accreditation Initiative: The Accreditation
Association for Ambulatory Health Care & The Joint
– The Patient Centered Medical Health Home Initiative:
National Committee for Quality Assurance
Paths Available Through HRSA
The Joint Commission
• Patient and provider
• Patient-Centeredness
• Plan and Manage Care
• Accessibility
• Superb Access to Care
• Enhance Access and
• Comprehensiveness
of care
Comprehensive Care
• Track and Coordinate Care
Coordinated Care
• Identify and Manage
Patient Populations
• Continuity of care
• Provide Self-Care Support
and Community Resources
• Quality
• System-Based Approach
to Quality and Safety
• Measure and Improve
PCMH is a health care delivery model that:
• Aligns with the health center program requirements.
– Enhanced Access & Comprehensive Services
• Supports the implementation and meaningful use alignment of
– Tracking and Coordinating Care
– Using Data to Manage Populations & Performance
• Requires a functioning QA/QI system for continuous QI
– Made easier with a functional EHR
• Results in system & Infrastructure changes that demonstrate full
transformation to a PCMH
• 100% PCMH recognition in health centers ultimately leading to
cost savings
PCMH Recognition as of 7/1/2012
Data Includes PCMH Recognition from: NCQA, AAAHC, The Joint Commission, Independently Recognized
Health Centers with NCQA Recognition, and Oregon State PCMH Recognition
Total % PCMH Recognized
% PCMHHI Participants
Goal: 25%
Goal: 13%
PCMH Overview
Assessing Patient-Centeredness within the
context of Performance Improvement
Making the Most of Technical Assistance to
Advance Patient-Centered Medical Home
Patient-Centered Medical Home
What do they all strive to accomplish?
• Joint Principles
• HHS National Quality Strategy - Better Care, Healthy
People & Communities, and Affordable Care
• Transformed
• Medical Home Safety Net
Patient-Centered Medical Home
Transformation is linked to a high
performing health care delivery system.
The six attributes of a high performing health care
delivery system
 Information Continuity
 Care Coordination and Transitions
 System Accountability
 Peer Review and Teamwork for High-Value Care
 Continuous Innovation
 Easy Access to Appropriate Care
Source: The Path to a High Performance US Health System: A 2020 Vision and Policies to Pave The Way..
(New York: Commonwealth Fund Commission on a High Performance Health System, February 2009.
How can Patient-Centered Medical Home
Support Program Requirement Areas
 Information Continuity
Quality Improvement/Assurance
Data Reporting Systems
Board Authority
 Care Coordination and Transitions
Required and Additional Services
Hospital Admitting Privileges and Continuum of Care
Collaborative Relationships
 System Accountability
Key Management Staff
Board Authority
How can Patient-Centered Medical Home
Support Program Requirement Areas
 Peer Review and Teamwork for High-Value Care
Quality Improvement and Assurance
 Continuous Innovation
Quality Improvement and Assurance
 Easy Access to Appropriate Care
Required and Additional Services
Accessible Hours/Locations
After hours
Hospital Admitting Privilege and Continuum of Care
Sliding Fee Discounts
Related High Performance Attribute: System Accountability
Improving Patient-Centeredness:
Does the needs assessment provide an analysis of key important
conditions and risky behaviors for the population? Are these
Does the needs assessment include a language and cultural analysis?
Does the needs assessment fully analyze health disparities and gaps
across the service area?
Is the QI program, strategic plan , outreach plan, and program services
consistent and relevant to the identified needs?
How well does the BOD and key leadership utilize the needs
assessment and other key documents such as UDS and QI program
performance when evaluating the effectiveness of program services?
Required and Additional Services
Related High Performance Attribute: Care Coordination and Transitions
and Easy Access to Care
Improving Patient-Centeredness:
Do referral agreements and arrangements include provision for coordination and
continuity of care (roles and responsibilities, how patients access services,
communication and coordination expectations/deliverables, monitoring and
How well does the grantee manage internal referrals?
Is the grantee able to track and monitor all referred services (internal and external)
from initiation of the referral to referral completion?
Does the grantee provide patient materials that define patient roles and
responsibilities in coordination of care processes?
What does the grantee provide to patients and the community informing them of
services provided (website, brochures, newsletters, etc.)?
What documentation protocols are in place to ensure all referrals are entered into the
patients medical record?
Does the grantee provide appropriate translation services for the size/needs of its
population? Does the grantee assess and document language preference?
High Performing Attribute: Care Coordination and
Transitions and Continuous Innovation
Traditional Approach
PCMH Approach
•Care is based on visits
•Professional autonomy
drives clinical variability
•Professionals control care
•Information is a record
•Secrecy is necessary
•The system reacts to needs
•Care is based on continuous
healing relationships
•Care is customized
according to patient needs,
•Patient is source of control
•Knowledge is shared and
flows freely
•Transparency is necessary
•Needs are anticipated
Improving Patient-Centeredness:
• What type of staffing model is implemented at the health center? Do
the staff function in care teams?
• Does the primary care clinician have the educational background
and broad-based knowledge and experience needed to handle most
medical needs of the patient?
• Who are the members of the care team? Do job descriptions match
care team responsibilities?
• Are staff being optimized to the highest level of their job
descriptions? Does the grantee utilize standing orders for clinical
support staff?
• How proactive and flexible can the staffing model adjust to changing
patient need and preferences?
• Does the grantee have policies and procedures describing care
team interaction?
Improving Patient Centeredness (continued):
Does the grantee identify and manage populations? If so, can the grantee
demonstrate how populations are identified based on need?
Is there documented evidence of coordination of care (referral
management, chronic condition management, etc.)?
How does the grantee demonstrate involvement of the patient in his/her
treatment plan?
Does the grantee provide patient-centered education activities for staff
(motivational interviewing, readiness to change, social assessments)?
Does the grantee have patient self-care management processes in place?
Are self-management goals and the patient’s progress included in the
patients clinical record?
Does the grantee identify needs/risks based on an assessment process?
(social, health risks, clinical, environment, readiness, confidence, etc.)
Hours of Operation/Locations &
After Hours Coverage
High Performing Attribute: Easy Access to Care
Improving patient-centeredness
Does the grantee:
• Provide extended hours?
• Can patients select a personal primary care clinician?
• Allow patients to speak to a health care professional after office hours?
• Allow patients to interact with health center staff via web?
• Make available to patients materials explaining accessibility and availability
and in languages that meet the language preferences of the population?
• Is the appointment system flexible?
• Does the grantee have triage protocols?
• Have policies and procedures for same-day access, triage protocols, after
hours coverage, hours of operation?
• Do policies and procedures make provisions for patient contact via their
preference (web, secure email, text, phone, etc.?
Hospital Admitting Privileges &
Continuum of Care
High Performing Attribute: Care Coordination and
Transitions and Easy Access to Care
Improving patient-centeredness
• Does the grantee make provisions for ER visits and
hospitalizations that include effective transitions of care upon
discharge (back to health center, home health, rehabilitation,
• Do these provisions include proactive patient communication
and health center notification?
• What are the processes/protocols for care transitioning? Does
it include a closed-loop process?
• Can the grantee demonstrate (reports, logs, etc)
implementation of care transitioning?
Sliding Fee
High Performing Attribute: Easy Access to Care
Improving patient-centeredness:
• Is the sliding fee discount program designed to promote access or
does it inadvertently create a barrier?
• Does the grantee evaluate patient’s perception of the sliding fee
program to identify actual or potential barriers?
Quality Improvement/Assurance
High Performing Attribute: Information Continuity, Peer
Review and Teamwork for High Value, and Continuous
Improving patient-centeredness:
Is the quality improvement program systematic? Does it include crosscutting performance metrics (satisfaction, clinical care, utilization of
services, patient safety, etc.)
Are evidence-based standards of care shared across all providers?
What types of performance metrics are reported across the practice
and at the provider level? Are they reported as a comparison analysis
using percentage calculations (trending reports or single measurement
Is the QI Committee structure effective demonstrating multidisciplinary
involvement, analysis of performance and active participation in
identifying opportunities for improvement, establishing action plans and
monitoring the effectiveness of actions taken.
How efficient is quality improvement information distributed across the
organization and the BOD?
Quality Improvement/Assurance
High Performing Attribute: Information Continuity, Peer Review
and Teamwork for High Value, and Continuous Innovation
Improving patient-centeredness:
Are peer review activities based on the organizations important conditions
and/or risky behaviors?
Can peer review results be quantitatively measured to assess performance
against performance thresholds?
How well to providers work as teams to improve the quality of care and services
across the organization vs. silo approach?
Do QI Committees and/or other committees involve patients/families in quality
improvement discussion?
How does the grantee share QI information with patients and other entities?
What types of innovative ideas are promoted as a result of QI Improvement
activities (social media, RN Chronic condition manager, telehealth, home visits,
web-based communication, use of social media)?
Key Management Staff
High Performing Attribute: System Accountability
Improving patient-centeredness:
Do all key management staff support and promote PCMH
How informed are key management staff in the PCMH transformation
process and transfer the knowledge across the organization?
Are key management staff aware and taking advantage of appropriate
PCMH initiatives (e.g., state, payors)?
Are collaborative efforts, supported by effective leadership and shared
Is there a plan developed for allocating appropriate resources to the
transformation process?
Who has overall accountability for the effectiveness of the PCMH?
What is the frequency of progress reporting to the BOD?
Collaborative Relationships
High Performing Attribute: Care Coordination and Transitions
Improving patient-centeredness:
• Do collaborative relationships enhance coordination of care and
services within the community?
• Does the grantee engage collaborative partners in problem solving
activities when gaps in care/services are identified among the
population or the community as a whole?
• What type(s) and frequency of interaction occur between the
grantee and its collaborative partners?
Program Data Reporting Systems
High Performing Attribute: Information Continuity
Improving Patient-Centeredness:
Does the grantee’s data management system(s) :
 Support the people in the task of care coordination?
 Keep track of large amounts of data?
 Keep track of data over long periods of time?
 Provide data that is easily accessible and meaningful?
 Integrate information into carefully designed workflows to achieve care
coordination goals?
 Organize data so that patterns are apparent?
 Remember complex rules and protocols?
 Enhance communication across a provider network?
 Maintain check-lists for completeness?
 Prompt humans with decision support?
 Integrate between internal and/or external systems (interoperability)?
 Function with constant reliable performance?
 Provide key alerts (allergy, medication interactions, etc)
Health Information Technology
Board Authority
High Performing Attribute: Information Continuity and
System Accountability
Improving Patient-Centeredness:
Does the BOD demonstrate knowledge and support of PatientCentered Medical Home transformation?
Does the BOD have commonly shared PCMH goals with key
management staff?
Quality Improvement Resources
• National Quality Recognition
– Accreditation:
– NCQA recognition:
– Comparison chart:
• ECRI Institute Resources
– Available to all Health Centers and FQHC LALs
Quality Improvement Resources
– FTCA Resources
– BPHC QI Plan Learning Series and Modules
– BPHC Training and Technical Assistance
– HRSA Office of HIT and Quality
– HIV/AIDS Bureau Quality Resources
• Safety Net Medical Home Initiative
HIT Resources
• HRSA’s HIT Web Page (
– HIT Health IT Adoption Tool Boxes:
– HIT Health IT and Quality Webinars:
– HRSA Network Guide, currently including information on 46
• The Office of the National Coordinator for Health
Information Technology:
– HIT Regional Extension Center program:
– 2010 report on HIT in Underserved Communities:
• The AHRQ National Resource Center for HIT:
Data Resources
• HRSA Data Warehouse:
• Public site for UDS Data:
• UDS Performance Reports:
⁻ Health Center Trend Report (National/State/Grantee)
⁻ Health Center Summary Report
⁻ Performance Profile (National/State) – Performance
on Key Indicators
• UDS Mapper:
PCMH Resources
• PCMH Readiness Assessment Tools
– Primary Care Development Corporation (PCDC):
– PCMH Assessment (PCMH-A) from the Safety Net
Medical Home Initiative:
– Medical Home Implementation Quotient Assessment
(MHIQ) from TransforMED:
• PCMH Change Concepts:
• Patient-Centered Primary Care Collaborative (PCPCC):
PCMH Resources
Agency for Healthcare Research and Quality (AHRQ)
PCMH Resource Center:
⁻ Clinical Practice Guidelines:
⁻ US Preventive Services Task Force:
⁻ Consumer Assessment of Healthcare Providers and
Systems (CAHPS patient experience survey):
⁻ Innovations Exchange:
⁻ Patient Health Literacy Toolkit:
Behavioral Health Resources
HRSA BH website:
• Center for Integrated Health Solutions:
– Motivational Interviewing for Better Outcomes
– Peer Support Wellness Respite Centers
– Screening, Brief Intervention, and Referral to
Treatment (SBIRT) in Clinical Settings
– Person-Centered Health Homes
– Introduction to Effective Behavioral Health in
Primary Care

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