The Role of the PCMH in Healthcare Reform -- Corporate and Global Considerations

1. The Role of the PCMH in Healthcare Reform -- Corporate and Global Considerations SC Business Coalition on Health 7th Annual Meeting E. G. “Nick” Ulmer, Jr., MD CPC Vice President, Clinical Services SRPG Medical Director, Case Management SRHS

2. Objectives • Discuss reasons behind Healthcare Reform • Show how the Patient Centered Medical Home meets some of the needs addressed by the Reform Act • Explain the real-life application of the PCMH model

3. The 2013 American Healthcare Results • The US spends more on healthcare than any other country in the world ($2.6 Trillion) • In America, the rate of obesity doubles that of other peer countries • The US has the highest prevalence of diabetes from age 20-79 • Similar poor performance with COPD, Asthma, obesity, diabetes

4. Why so poorly performed? • Health Systems have large under- and un-insured populations, limited access to primary care, and the care is unaffordable. • Americans spend more $$ on healthcare and live shorter, unhealthier lives. • IOM report and National Research Council

5. Why the disjoined approach to healthcare? • Institute of Medicine • …patients are not engaged with the healthcare team. Those without a medical home will wander into any POS for any reason

6. The problem hits corporate America as well • Ever increasing healthcare costs • Presenteeism or absenteeism • Small businesses are at a disadvantage in the current market • Small businesses pay up to 18% more per worker at times due to broker fees, fixed costs, and adverse selection • 20-50% of work force does NOT have a PCP • Younger the population, the higher

7. The Need • Innovations that drive better value and give: • Better health • Better care • Better costs

8. The Reality • Research comparing the US to the world • Health systems built on strong primary care deliver care that is • More effective • More efficient • More equitable • Only 5% of the total US medical spend is devoted to primary care • What seems to work: • Ease of access to coordinated, team-based care • Connected care: real time access to medical record • Long-term, continual relationship with provider and patient in supportive self-management • Compensation model that encourages these ideals

9. The Healthcare Fix • The Healthcare Reform • The Reconciliation Act of 2010 • The Affordable Care Act • Those two together = “ObamaCare”

10. The Health Reform Law • Focus on primary care and try to beef up providers on front line • Better fee for service for payments • More expanded insurance access • More preventive care covered • Pilots and demonstration projects

11. Patient Centered Focus Patient centeredness refers to health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they require to make decisions and participate in their own care. Institute of Medicine Envisioning a National Healthcare Quality Report

12. Patient Centered Medical Home (PCMH) • Term coined by American Academy of Pediatrics 1967 • Primary health care that is • accessible, • family-centered, • coordinated, • comprehensive, • continuous, • compassionate, and • culturally effective

13. Patient Centered Medical Home (PCMH) • 2002 American Academy of Family Physicians • 2004 modified to add chronic disease management models • 2012 COSEHC (Wake Forest) • One of very few integrated clinical pathways of care models (AT GOAL) • Diabetes, Hypertension, Heart Disease, High Cholesterol (“Cardiometabolic Disease”)

14. PCMH Results, global • Lower medical costs • 2 year engagement: 36% less cost • FINANCIAL • Less use of ED, less hospital days, deceases in costs of imaging services, prescriptions and procedures • CLINICAL (HEDIS) • 85% had improvement in BP, A1c (diabetes) control rate, and Cholesterol

15. What did Spartanburg Regional Do? • Partnership with Regional HealthPlus (RHP) • Physician-Hospital Organization • History of clinical quality emphasis • Both independent and employed practices • RHP to help develop the PCMH network

16. What is a PCMH? • Accredited by the NCQA • National Centers for Quality Assuredness is oldest • Joint Commission, others • NCQA assigns four levels • Failed and Level I-III (III is highest) • 3 year accreditation • Process to attempt to achieve PCMH takes up to 2 years (never) • RHP process was much shorter • Higher level with more measures met

17. PCMH Certification Criteria 1. Access & Communication • Access & Communication processes • Access & Communication results • System for patient data mgmt a. Electronic system for clinical data b. Use of electronic data c. Organizing clinical data d. Identify important clinical conditions e. Use system for population mgmt • Care Management • Implement evidence-based guidelines • Identify high risk patients • Provide Self-care Support and Community Resources • Support the self-care process • Provide referrals to community resources • Track and coordinate care a. Test tracking and follow-up process b. Referral tracking and follow-up c. Coordinate with facilities and offer care transitions • Measure and improve performance • Measure performance • Measure patient/family experience • Implement continuous quality improvement • Demonstrate CQI • Report performance • Report data externally • Use a certified EHR Technology

18. PCMH Certification Criteria (must pass) 1. Access & Communication • Access & Communication processes • Access & Communication results • System for patient data mgmt a. Electronic system for clinical data b. Use of electronic data c. Organizing clinical data d. Identify important clinical conditions e. Use system for population mgmt • Care Management • Implement evidence-based guidelines • Identify high risk patients • Care Management • Medication Management • Use electronic eRx • Provide Self-care Support and Community Resources • Support the self-care process • Provide referrals to community resources • Track and coordinate care a. Test tracking and follow-up process b. Referral tracking and follow-up c. Coordinate with facilities and offer care transitions • Measure and improve performance • Measure performance • Measure patient/family experience • Implement continuous quality improvement • Demonstrate CQI • Report performance • Report data externally • Use a certified EHR Technology

19. What does a “must pass” application look like? • Access and communication • Walk-in ability at some sites, same day appointments at most • 24/7 RN on call to answer phones • Use system for population management • Immunization needs for school aged children • Care Management • Most difficult to meet

20. CarePlusTeam Approach to Healthcare Primary Care Physician • Make complex medical decisions • Chronic disease manager • Develop treatment plans • Use extenders

21. CarePlusTeam Approach to Healthcare Centralized Care Coordination Team Medical Director RN Case Manager Wellness Coach Care Navigator • Improve care coordination • Improve quality and outcomes • Improve patient satisfaction • Improve cost of healthcare

22. What does a “must pass” application look like? 4. Support the self-help process • Wellness coach supportive

23. Regional HealthPlusPatient Centered Medical Home Centralized Care Coordination Team & Decision Support Primary Care Physician Practice

24. CarePlusCare Coordination Model

25. CarePlusCare Coordination for Patients PCP Practice PCP Practice PCP Practice Patient Centered Medical Home

26. CarePlusCare Coordination for Patients PCP Practice PCP Practice PCP Practice Patient Centered Medical Home Behavioral Health Regional Call Center Home Health Carolina’s Center for Diabetes Weight Loss Center PharmD Parrish Nurses Transport Heart Failure Clinic

27. Regional HealthPlus’ Goal:A system of PCMH PCPs PCP Practice PCP Practice PCP Practice PCP Practice PCP Practice PCP Practice PCP Practice PCP Practice PCP Practice PCP Practice PCP Practice PCP Practice PCP Practice Centralized Care Coordination Team & Decision Support

28. CarePlusTeam Approach to Healthcare Centralized Decision Support Clinical Reporting Financial Reporting Performance Reporting • Data warehouse • Provide data to providers • Provide data to Care Coordination Team • Provide data to employer

29. What does a “must pass” application look like? 4. Support the self-help process • Wellness coach supportive 5. Referral tracking 6. Continuous Quality Improvement

30. Spartanburg Regional • Same standards for the PCMH practices are employed at the on-site clinics we have with corporate partners

31. Quality Patient CarePerformance Measurement Population Health Management Chronic Disease Management Post Acute Transition Management Inpatient Management • Evidence based medicine • Compliance • Control (Outcomes) • Clinical dashboards

32. Data Mining Hypertension Diabetes Hyperlipidemia (Cholesterol) Others: smoking status, BMI (obesity)

33. Questions? • Thank you! • Nick Ulmer, MD CPC • EUlmerMD@srhs.com • 864-684-4248