Value-Based Care Healthcare Delivery Lecture d - The Patient-Centered Medical Home This material (Comp 23 Unit 3) was developed by the University of Alabama at Birmingham, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0007. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org.
Patient Centered Medical HomeLearning Objectives • Describe the Patient Centered Medical Home (PCMH) • Discuss adoption and implementation decisions related to the PCMH • Discuss the effects of the patient-centered medical home
Origins of the PCMH • 1960s • Children with chronic illness • Early 2000s • Concerns about cost, quality, primary care • Seen as way to achieve “Triple Aim” • Improve individual experience of care • Improve health of population • Reduce costs Source: (Berwick, Nolan, & Whittington, 2008)
Features of the PCMH • Extension of the Wagner Chronic Care Model • Patient self-management • Team-based care • Team of complementary health care professionals Source: (Wagner et al., 2001)
Definition of the Patient-Centered Medical Home • “Comprehensive, team-based approach to providing primary care that aims to personalize, prioritize, and integrate care to improve the health of individuals, families, and populations of people” Source: (Stange et al., 2010)
PCPCC Principles • Personal physician • Physician directed medical practice • Whole person orientation • Care coordination • Quality and safety • Enhanced access • Payment
Support for PCMH Programs • Number of programs have flourished • State government: 41 state Medicaid programs • Federal government: CMS, AHRQ, VA, HRSA • Private payers and employers: Hundreds of programs • Current list of PCMH programs: www.pcpcc.org/initiatives
PCMH Accreditation • National Committee on Quality Assurance (NCQA) • The Joint Commission • Accreditation Association for Ambulatory Health Care
PCMH and MACRA • Alternative Payment Models (APMs) • Use certified electronic health records • Payment based on quality measures • Accept shared risk • CMMI authorized medical home
Types of PCMH Programs • Definitions and contents of PCMH vary as a result of growing number of PCMH programs • Most programs emphasize five capabilities • Care coordination • Health information technology • Quality measurement • Patient engagement • Presence of policies Source: (Burton, Devers, & Berenson, 2012)
Implementation of Patient-Centered Medical Homes • Levels of implementation generally low • Implementation higher among larger practices • Implementation higher for activities related to direct patient care than health information technology • Health IT challenges • EHR • Patient Portal • Health Information Exchange Sources: (Rittenhouse et al., 2011 Zickafoose et al., 2013)
Implementation Challenges • Requires whole-practice redesign • Scheduling and access processes • Coordination with other healthcare entities • Changes in visit procedures, e.g. group visits • Use of evidence at point-of-care • More quality improvement activities • More point-of-care services Source: (Nutting et al., 2009)
Implementation Challenges (2) • Other redesign challenges • Team-based care practices • Changes in practice management • More patient engagement • New uses of health information technology Source: (Nutting et al., 2009)
Implementation Challenges (3) • Lack of “plug and play” technology • Variation in functionalities • Lack of interoperability • Unexpected challenges in implementation • More difficult to implement • More time-consuming Source: (Nutting et al., 2009)
Implementation Challenges (4) • Need to follow best implementation practices • Attend to technical and “people” issues • Thorough planning • Change management • Provider training and engagement
Implementation Challenges (5) • Requires change in perspective(s) • Team approach vs independence in care management • Population health vs. individual patient • Patients expected to be more proactive • Change fatigue • Can lead to stress, burnout and turnover • Needs to be monitored and managed Source: (Nutting et al., 2009)
Recommendations for Implementation • Adopt realistic expectations • Transformation is lengthy process • Significant time, effort, funding • Need to work with external vendors • Plan for wide-scale changes • Expect short-term disruptions Source: (Nutting et al., 2009)
Recommendations for Implementation (2) • Flexible technology plan that meets provider and patient needs • Useful technologies • Clinical decision support • Registries • Personal health records/Patient portals • Telehealth • Develop plan unique to circumstances • Revisit plan regularly and modify if needed Source: (Nutting et al., 2009)
Recommendations for Implementation (3) • Monitor change fatigue • Attend to burdens on staff • Make sure staff understand goals • Develop an appreciation for adaptation and learning • Prepare to manage new problems • Apply previous solutions and experience if applicable Source: (Nutting et al., 2009)
Outcomes of PCMH • Generally positive effects • Quality • Consistent delivery of preventive care • Fewer emergency department visits Sources: (Alexander & Bae, 2012; Hoff et al., 2012; Jackson et al., 2013)
Outcomes of PCMH 2 • Mixed results • Costs • Access • Patient and staff experience Sources: (Alexander & Bae, 2012; Hoff et al., 2012; Jackson et al., 2013)
Healthcare DeliverySummary – Lecture d • Proliferation of programs with little consistency • Much promise, but many implementation challenges • Effects depend on outcome of interest
Healthcare DeliveryReferences – Lecture d References Alexander, J. A., & Bae, D. (2012). Does the patient-centred medical home work? A critical synthesis of research on patient-centred medical homes and patient-related outcomes. Health Services Management Research, 25(2), 51-59. Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: care, health, and cost. Health Affairs, 27(3), 759-769. Hoff, T., Weller, W., & DePuccio, M. (2012). The Patient-Centered Medical Home A Review of Recent Research. Medical Care Research and Review, 69(6), 619-644. Jackson, G. L., Powers, B. J., Chatterjee, R., Bettger, J. P., Kemper, A. R., Hasselblad, V., ... & Gray, R. (2013). The patient-centered medical home: a systematic review. Annals of internal medicine, 158(3), 169-178. Nutting, P. A., Crabtree, B. F., Miller, W. L., Stange, K. C., Stewart, E., & Jaén, C. (2011). Transforming Physician Practices To Patient-Centered Medical Homes: Lessons From The National Demonstration Project. Health Affairs (Project Hope), 30(3), 439–445. http://doi.org/10.1377/hlthaff.2010.0159 Office of the National Coordinator for Health Information Technology. Connecting Health and Care for the Nation. A Shared Nationwide Interoperability Roadmap. Final Version 1.0. October 2015. Available from: www.healthit.gov/ Accessed 2/10/2016.
Healthcare DeliveryReferences 2 – Lecture d References Patient-Centered Primary Care Collaborative. Joint Principles of the Patient-Centered Medical Home. February 2007. Available from www.pcpcc.net/ . Accessed 2/10/2016. Rittenhouse, D. R., Casalino, L. P., Shortell, S. M., McClellan, S. R., Gillies, R. R., Alexander, J. A., & Drum, M. L. (2011). Small and medium-size physician practices use few patient-centered medical home processes. Health Affairs, 10-1377. Stange et al. (2010). Defining and measuring the patient-centered medical home. Journal of General Internal Medicine, 25(6), 601-612. PMCID: PMC2869425 Burton, R.A., Devers, K.J., & Berenson, R.A. (2012). Patient-Centered Medical Home Recognition Tools: A Comparison of Ten Surveys' Content and Operational Details. www.urban.org/ Wagner, E. H., Austin, B. T., Davis, C., Hindmarsh, M., Schaefer, J., & Bonomi, A. (2001). Improving chronic illness care: translating evidence into action. Health Affairs, 20(6), 64-78. Zickafoose, J.S., Clark, S.J., Sakshaug, J. W., Chen, L.M., & Hollingsworth, J.M. (2013). Readiness of Primary Care Practices for Medical Home Certification. Pediatrics, 131(3), 473-482. http://doi.org/10.1542/peds.2012-2029.
Healthcare DeliveryReferences 3 – Lecture d Images Slide 6: Microsoft clip art. Used with permission.
Value-Based Care, Healthcare Delivery,Patient Centered Medical Home This material was developed by The University of Alabama at Birmingham, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0007.