How to Apply Patient Centered Medical Home Concepts August 2, 2012

1. How to Apply Patient Centered Medical Home ConceptsAugust 2, 2012 Nina Brown - Public Health Analyst, HRSA/BPHC/OQD CandiChitty - Consultant, MSCG

2. 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 visits.

3. Primary Health Care Mission Improve the health of the Nation’s underserved communities and vulnerable populations by assuring access to comprehensive, culturally competent, quality primary health care services

4. BPHC Quality Strategy Better Care Healthy People & Communities Affordable Care INTEGRATED HEALTH SYSTEM Priorities & Goals • Implementation of QA/QI Systems • All Health Centers fully implement their QA/QI plans • Adoption and Meaningful Use of EHRs • All Health Centers implement EHRs across all sites & providers • Patient Centered Medical Home Recognition • All Health Centers receive PCMH recognition • Improving Clinical Outcomes • All Health Centers meet/exceed HP2020 goals on at least one UDS clinical measure • Workforce/Team-Based Care • All Health Centers are employers/providers of • choice and support team-based care INTEGRATED SERVICES COMPREHENSIVE SERVICES ACCESS

5. PCMH Change ConceptsSafety-Net Medical Home Initiative An approach to providing comprehensive, patient centered, and coordinated primary care for health center patients - System wide transformation. • Empanelment • Continuous and Team-based Healing Relationships • Patient-Centered Interactions • Engaged Leadership Source: Safety-Net Medical Home Initiative • Quality Improvement (QI) strategy • Enhanced Access • Care Coordination • Organized, Evidence-Based Care

6. Why PCMH? • Demonstrates the quality of care provided in health centers and provides opportunity for continuous quality improvement. • 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.

7. The Patient Centered Medical Home • BPHC Quality Strategy Priority Goal 3: Patient Centered Medical Home Recognition • 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

8. Many Paths to PCMH • Many entities across the country are embracing the PCMH model: • 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 recognition. • The Accreditation Initiative: The Accreditation Association for Ambulatory Health Care & The Joint Commission • The Patient Centered Medical Health Home Initiative: National Committee for Quality Assurance

9. Paths Available Through HRSA

10. Summary 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 EHR. • Tracking and Coordinating Care • Using Data to Manage Populations & Performance Improvement • 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

11. 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 FY2013 Goal: 25% Health Centers Recognized as PCMH CY2012 Goal: 13% Health Centers Recognized as PCMH

12. PCMH OverviewAssessing Patient-Centeredness within the context of Performance Improvement OpportunitiesMaking the Most of Technical Assistance to Advance Patient-Centered Medical Home Transformation

13. 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 • NCQA • AAAHC • TJC • Transformed • Medical Home Safety Net

14. 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.

15. 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 Staffing Hospital Admitting Privileges and Continuum of Care Collaborative Relationships • System Accountability Need Key Management Staff Board Authority

16. How can Patient-Centered Medical Home Support Program Requirement Areas • Peer Review and Teamwork for High-Value Care Staffing Quality Improvement and Assurance • Continuous Innovation Staffing 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

17. Need 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 prioritized? 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?

18. 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 reporting)? • 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?

19. Staffing High Performing Attribute: Care Coordination and Transitions and Continuous Innovation PCMHApproach • Care is based on continuous healing relationships • Care is customized according to patient needs, values • Patient is source of control • Knowledge is shared and flows freely • Transparency is necessary • Needs are anticipated TraditionalApproach • 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

20. Staffing 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?

21. Staffing 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.)

22. 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.?

23. 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, etc?) • 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?

24. 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?

25. Quality Improvement/Assurance High Performing Attribute: Information Continuity, Peer Review and Teamwork for High Value, and Continuous Innovation Improving patient-centeredness: • Is the quality improvement program systematic? Does it include cross-cutting 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 points) • 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?

26. 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)?

27. Key Management Staff High Performing Attribute: System Accountability Improving patient-centeredness: • Do all key management staff support and promote PCMH transformation? • 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 goals? • 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?

28. 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?

29. 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)

30. Health Information Technology Connection

31. Board Authority High Performing Attribute: Information Continuity and System Accountability Improving Patient-Centeredness: • Does the BOD demonstrate knowledge and support of Patient-Centered Medical Home transformation? • Does the BOD have commonly shared PCMH goals with key management staff?

32. Quality Improvement Resources • National Quality Recognition • Accreditation: http://bphc.hrsa.gov/policiesregulations/accreditation.html • AAAHC, TJC • NCQA recognition: http://bphc.hrsa.gov/policiesregulations/policies/pal201101.html • Comparison chart: http://bphc.hrsa.gov/policiesregulations/policies/qualrecogn.pdf • ECRI Institute Resources • Available to all Health Centers and FQHC LALs https://www.ecri.org/clinical_rm_program/Pages/default.aspx

33. Quality Improvement Resources • HRSA • FTCA Resources http://bphc.hrsa.gov/ftca/index.html • BPHC QI Plan Learning Series and Modules http://bphc.hrsa.gov/policiesregulations/quality/index.html • BPHC Training and Technical Assistance http://bphc.hrsa.gov/technicalassistance/tatopics/qualitymanagementimprovement/index.html • HRSA Office of HIT and Quality http://www.hrsa.gov/quality/toolsresources.html • HIV/AIDS Bureau Quality Resources http://nationalqualitycenter.org/ • Safety Net Medical Home Initiative http://www.qhmedicalhome.org/safety-net/qistrategy.cfm

34. HIT Resources • HRSA’s HIT Web Page (http://www.hrsa.gov/healthit/) • HIT Health IT Adoption Tool Boxes: http://www.hrsa.gov/healthit/toolbox/ • HIT Health IT and Quality Webinars: http://www.hrsa.gov/healthit/toolbox/webinars/index.html • HRSA Network Guide, currently including information on 46 networks: http://www.hrsa.gov/healthit/networkguide/index.html • The Office of the National Coordinator for Health Information Technology: http://healthit.hhs.gov • HIT Regional Extension Center program: http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__rec_program/1495 • 2010 report on HIT in Underserved Communities:http://www.healthit.gov/sites/default/files/pdf/hit-underserved-communities-health-disparities.pdf • The AHRQ National Resource Center for HIT: http://healthit.ahrq.gov

35. Data Resources HRSA Data Warehouse:http://datawarehouse.hrsa.gov/ Public site for UDS Data: http://bphc.hrsa.gov/healthcenterdatastatistics/index.html UDS Performance Reports: Health Center Trend Report (National/State/Grantee) Health Center Summary Report (National/State/Grantee) Performance Profile (National/State) – Performance on Key Indicators UDS Mapper: http://www.udsmapper.org/

36. PCMH Resources • PCMH Readiness Assessment Tools • Primary Care Development Corporation (PCDC): http://www.pcdc.org/resources/patient-centered-medical-home/pcdc-pcmh/ncqa-2011-medical-home.html • PCMH Assessment (PCMH-A) from the Safety Net Medical Home Initiative: http://www.safetynetmedicalhome.org/practice-transformation/assessment • Medical Home Implementation Quotient Assessment (MHIQ) from TransforMED: http://www.transformed.com/userLogin.cfm • PCMH Change Concepts: http://www.safetynetmedicalhome.org/change-concepts • Patient-Centered Primary Care Collaborative (PCPCC): http://www.pcpcc.net/content/pcmh-outcome-evidence-quality

37. PCMH Resources • Agency for Healthcare Research and Quality (AHRQ) PCMH Resource Center: http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483 • Clinical Practice Guidelines: http://www.ahrq.gov/clinic/cpgsix.htm • US Preventive Services Task Force: http://www.uspreventiveservicestaskforce.org/tools.htm • Consumer Assessment of Healthcare Providers and Systems (CAHPS patient experience survey): https://www.cahps.ahrq.gov/default.asp • Innovations Exchange: http://www.innovations.ahrq.gov/ • Patient Health Literacy Toolkit: http://www.ahrq.gov/qual/literacy/

38. Behavioral Health Resources • HRSA BH website: www.hrsa.gov/publichealth/clinical/BehavioralHealth/index.html • 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 http://www.thenationalcouncil.org/cs/center_for_integrated_health_solutions • SAMHSA SBIRT page http://www.samhsa.gov/prevention/SBIRT/index.aspx