The Medical Home & The Eight Change Concepts for Primary Care Transformation

1. The Medical Home &The Eight Change Concepts for Primary Care Transformation WYPCA PCMH Summit II January 25, 2019 Trudy Bearden, PA-C, MPAS

2. Change Concepts for Practice Transformation Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient-Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:241-259.

3. 10 Building Blocks Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 Building Blocks of High-Performing Primary Care. Ann Fam Med 2014; 12;166-171..

4. Why This Work Matters The Quadruple Aim Outcomes Patient Experience Staff Experience Cost Value-based reimbursement is now a potent driver of the work. Ann Fam Med 2014;12:573-576.

5. What gets in the way? • Urgent vs. important • Change fatigue  change tolerance • Skills • Priority, focus and shiny objects • Personalities • Unaware. Anxious to learn. “We’re good, thanks.” • Leadership and leadership • Data collection • Sustainability – 30% rule • We can’t do that because…  if…

6. PCMH Practice Coaching

7. Engaged Leadership • Provide visible and sustained leadership to lead overall cultural change as well as specific strategies to improve quality and spread and sustain change. • Ensure that the PCMH transformation effort has the time and resources needed to be successful. • Ensure that providers and other care team members have protected time to conduct activities beyond direct patient care that are consistent with the medical home model. • Build the practice’s values on creating a medical home for patients into staff hiring and training processes.

8. Change Leaders • “One key role of practice leadership is to help members at all levels of an organization understand the importance of making purposeful and systematic changes to the care processes”1. Leadership is super number one! Asaf Bitton, MD Ann Fam Med. 2013 May; 11(Suppl 1): S27–S33

9. Leadership The only thing of real importance that leaders do is to create and manage culture. - Edgar Schein A leader is best when people barely know he exists, when his work is done, his aim fulfilled, they will say: we did it ourselves. - Lao Tzu

10. What do They Say? • "My job was to keep the eye on the prize. The prize for us was doing the right thing for the patient." (The best!) • "It's important to be visibly demonstrating the support." • "They see you walking the walk." • "The nature of what we do is goofy sometimes.“ • "Make sure they know you're paying attention." • "We wanted it bad enough to do it." • "Include it [PCMH] in your vision and strategic plan." • "...make the complex simple."  

11. Engaged Leadership

12. Quality Improvement Strategy • Choose and use a formal model for quality improvement. • Establish and monitor metrics to evaluate routinely improvement efforts and outcomes; ensure all staff members understand the metrics for success. • Ensure that patients, families, providers, and care team members are involved in quality improvement activities. • Optimize use of health information technology

13. Model for Improvement What are we trying to Aims accomplish? How will we know that a change is an improvement? Measures Change Ideas What change can we make that will result in improvement? Act Plan Study Do The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost.

14. QI Readiness – Critical Elements?Reflections from the Field

15. Empanelment Assign all patients to a clinician panel and confirm assignments with providers and patients; review and update panel assignments on a regular basis. Assess practice supply and demand, and balance patient load accordingly. Use panel data and registries to proactively contact and track patients by disease status, risk status, self-management status, community and family need.

17. Continuous and Team-Based Healing Relationships • Establish and provide organizational support for care delivery teams that are accountable for the patient population/panel. • Link patients to a provider and care team so both patients and provider/care teams recognize each other as partners in care. • Assure that patients are able to see their provider or care team whenever possible. • Define roles and distribute tasks among care team members to reflect the skills, abilities, and credentials of team members.

18. Sustainability Worksheet

19. Organized, Evidence-Based Care • Use planned care according to patient need. • Identify high risk patients and ensure they are receiving appropriate care and case management services. • Use point-of-care reminders based on clinical guidelines. • Enable planned interactions with patients by making up-to-date information available to providers and the care team prior to the visit.

20. Patient-Centered Interactions • Respect patient and family values and expressed needs. • Encourage patients to expand their role in decision-making, health-related behaviors, and self-management. • Communicate with patients in a culturally appropriate manner, in a language and at a level that the patient understands. • Provide self-management support at every visit through goal setting and action planning. • Obtain feedback from patients/families about their healthcare experience and use this information for quality improvement.

21. Enhanced Access • Promote and expand access by ensuring that established patients have 24/7 continuous access to their care teams via phone, e-mail, or in-person visits. • Provide scheduling options that are patient and family-centered and accessible to all patients. • Help patients attain and understand health insurance coverage.

22. Enhanced Access To… • Right care at the right time at the right place • The care team, including the clinician • After-hours advice • Health information & personal health info • Healthcare cost information • Community (and other) resources for the other 365 days 23 hours and 45 minutes

23. Care Coordination • Link patients with community resources to facilitate referrals and respond to social service needs. • Integrate behavioral health and specialty care into care delivery through co-location or referral agreements. • Track and support patients when they obtain services outside the practice. • Follow up with patients within a few days of an emergency room visit or hospital discharge. • Communicate test results and care plans to patients.

24. The Sheer Magnitude • In just one year the typical primary care physician must coordinate with 229 physicians working at over 100 different practices. Ann Intern Med. 2009;150:236-242

25. Trudy Bearden, PA-C, MPAS NCQA PCMH CCE Project Lead, WY PCMH TA Project trudyb@qualishealth.org 208.478.1434

26. The Primary Care Imperative:Care Coordination WYPCA PCMH Summit II January 25, 2019 Trudy Bearden, PA-C, MPAS

27. Objectives • Identify and describe the key elements of a comprehensive care coordination system • Detail the operational considerations and best practices of coordinating care • Anchor the work to measurement to ensure effectiveness and sustainability At least three action items to improve care coordination

28. Change Concepts for Practice Transformation Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient-Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:241-259.

29. Key Changes for Care Coordination • Proactively track and support patients when they obtain services outside the practice. • Have referral protocols and agreements in place with an array of specialists to meet patients’ needs • Close the loop by sharing test results and care plans with patients in a timely manner. • Follow-up with patients after an emergency department (ED) visit or hospital discharge. • Link patients with community resources to facilitate referrals and respond to social service needs. • Coordinate care management services for high risk patients.

30. “Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care.” Coordination of Care Agency for Health Care Research and Quality – Care Coordination Measures Atlas https://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html

31. Cost Value-based reimbursement Accountable Care Organizations Outcomes Risk management & harm Patient & Staff Experience Person-centered medical home MU clinical quality measures Uniform Data System - UDS Reimbursement CMS & pilot programs And more…

32. The Sheer Magnitude In just one year the typical primary care physician must coordinate with 229 physicians working at over 100 different practices. Ann Intern Med. 2009;150:236-242

33. The Sheer Magnitude

34. What gets in the way? • Lack of referral notes/discharge summary sent to PCP • Not enough time to build therapeutic relationships with PCP/care team • Incomplete medical information (both from patient and from others involved in care of the patient) • Poor transitions – inpatient, ED, leaving clinicians/residents, nursing home, etc. • Language barriers • Cultural beliefs/barriers • Homelessness or food/shelter insecurity • Drug/alcohol addiction • Racial/ethnic/gender disparities • Health beliefs (clinician or patient) • Lack of adherence to treatment plan and/or medication regimen • Management multiple chronic illnesses (clinician and/or patient) • Poor education/low literacy • Competing priorities/life • FEAR • Financial concerns • Lack of insurance • Lack of transportation • Lack of consistent, evidence-based care • Inability to take time off from work • Mental illness and/or cognitive impairment • Physical disability • Confusion about how the “system” works • Lack of child (or other family member) care • Long wait to get in to see a clinician/specialist (health professional shortages) • Long wait to see clinician at office (clinicians run behind) • Poor or no communication with care team • Poor communication of lab and test results to patients • Lack of social support • Use of ED for primary care • Poor referral tracking/lack of system • Referral partners become gatekeepers

35. Care Coordination System Design Every system is perfectly designed to achieve exactly the results it gets. Adapted from Arthur Jones Like Magic? (“Every system is perfectly designed…”) http://tinyurl.com/hoqyerx

36. System = interconnected, interdependent parts processes, workflows, care teams, communication, information flow Outcome measures for system are essential Results reflect design – to improve, look at design first, not people Systems Thinking

37. Model for Improvement What are we trying to Aims accomplish? An improvement framework is a critical part of the system! How will we know that a change is an improvement? Measures Change Ideas What change can we make that will result in improvement? Act Plan Study Do The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost.

38. What would our patients say about their experience with care coordination?

39. Care Coordinator vs. Care Manager R Adapted from the Safety Net Medical Home Initiative Implementation Guide: “Care Coordination – Reducing Care Fragmentation in Primary Care” http://www.safetynetmedicalhome.org/sites/default/files/Implementation-Guide-Care-Coordination.pdf

40. The Role of the Care Coordinator • Track referrals and tests, including calling patients and notifying of results • Follow-up after ED and inpatient discharge • Connect patients with resources • Make appointments – lots of appointments! • Outreach for care due • Pre-visit planning/chart scrubs • And so much more! R Job Description Responsibilities with Operational Considerations

41. Care Coordination Metrics - Examples

42. Operational Aspects of an Effective Care Coordination System • Referral and Test Result Management • Post-Discharge Follow-Up • Community Resources • Pre-Visit Planning

43. Referral and Test Result ManagementHighly Reliable, Closed-Loop Systems

44. 2 Optional Curbside Consult Life Cycle Tracking 1 Referral ordered 11 3 Pt told of report & tx options Apptscheduled c. 4 10 ID missed appt Consult note& MD ackn. entered in MR • Discrete data elements • Messaging b. 5 9 Req MD reviews missed appt Consult notereviewed by req MD 6 8 Apptrescheduled Consult notesent to req MD a. 7 Documentmissed/cancel appt a. % referral appointments completed b. % consult notes acknowledged by PCP c. % consult notes communicated to patient CRICO Guideline for Referral Management - Slide used with permission from Steve Gray, Program Manager, CRICO

45. Referrals and Test ManagementBest Practices • Map the process • Define all referral and test order dispositions in the EHR (e.g., open, pending, scheduled, closed, and cancelled) • Stratify referrals (e.g., urgent vs. routine) • Standardize how referral and test orders are entered • Outline roles and responsibilities • Centralize referral coordination or dedicate referral coordinators WRITTEN POLICIES & PROCEDURES

46. Referrals and Test ManagementBest Practices - More • Identify measures to ensure loops are closed • Decide if all referrals and tests will be tracked • Build in notification when patients no-show • Have standard documentation for when patients decline (Risks, benefits, alternatives, failure to intervene/go to specialist) • Ensure continuous and relentless management of the referral and test order queue • Build open orders into pre-visit chart scrubs WRITTEN POLICIES & PROCEDURES R Addressing when Patients Decline CRC Screening

47. Closed-Loop Options • Results in chart and entered as structured data • PCP acknowledges results • Patient notified of specialist findings & recommendations • Patient follows up with recommendations • Patient no shows and unable to contact/reschedule • Patient declines R P&P Straw Man Declines Best Practices

49. CLINIC A CLINIC B

50. Referrals Tracking