Patient Centered Medical Home Pilot Program (PCMH)

1. Patient Centered Medical HomePilot Program (PCMH) Mindi S. Garner, DO, FACP Pittsburg, Kansas

2. Veteran’s Day 11/11/11

3. Presentation Outline • My Background • Define PCMH • Business Model of Medical Home • My PCMH Experience • Unique Project With PCMH

4. Background

5. Background • Raised in Parsons, KS (SEK) • Undergraduate • Pittsburg State University in Pittsburg • Medical School • Oklahoma State University-COM, Tulsa • Graduated 2000

6. Background • Residency in Internal Medicine • University of Tennessee-Memphis • June 2000-July 2003 • Private Practice 12/1/03 • Pittsburg, Kansas • Straight out of Residency

7. Traditional Medical Practice • Solo Independent General Internist • Both In-patient & Out-patient • Active staff privileges • Via Christi Hospital, Pittsburg, KS • Girard Medical Center, Girard, KS • 2 clinics: Pittsburg and Girard • Share call with 5 other Internists

8. EMR Background • First Fully Functional EMR in SEK • Started from Day 1 • Fully Integrated • Website • E-scripts • Lab Result Integration • Patient Portal • Secure email messaging

9. Control of Business • Trained in EMR and PM Software • Trained in every office activity • Do own coding • Do Own Charge Entry • Review every aspect of cash flow • Practice cost-conscious medical care

10. Defining PCMH

11. Concerns? • Medicare Physician Reimbursement • Commercial Insurance Trend • Recovery Audit Contractor Program • Healthcare Reform • Unsustainable Payment Structure

12. Motivation Difficulties? • Who wouldn’t have difficulties? • Physicians are human! • Odds stacked against us? • Frightened? • I share your concerns • I am in the same situation you are • Our livelihood is in jeopardy

13. Frustrations • Anyone understand what we are going through? • Need to be a PCP to know challenges that occur everyday • Specialists are also involved • Equal Opportunity

14. What is the solution? • Times are changing • Reform needs Physician Leadership • Innovative Ideas • “Think outside the box” • Extreme conditions require unique approaches • Perfect Opportunity • Everyone is looking to us for solutions

15. What is a PCMH? PCMH is an acronym for the Patient-Centered Medical Home model of care It is not a brick and mortar building It is a set of principles It is a more effective model of health care delivery

16. PCMH 16 Definition adopted in Kansas law, 2008 The definition of a medical home according to Kansas law (K.S.A. 75-7429) is: “A health care delivery model in which a patient establishes an ongoing relationship with a physician or other personal care provider in a physician-directed team, to provide comprehensive, accessible and continuous evidence-based primary and preventive care, and to coordinate the patient’s health care needs across the health care system in order to improve quality and health outcomes in a cost effective manner.”

17. Patient-Centered Medical Home • Background • American Academy of Pediatrics • Concept introduced 1967 • Central location of child’s medical record • Policy Statement 2002 • Expanded concept

18. What does a PCMH do? The PMH puts patients at the center of the health care system, and provides primary care that is “accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.”

19. Patient-Centered Medical Home • Principles • Personal physician • Physician directed medical practice • Whole person orientation • Care is coordinated and/or integrated • Long-term healing patient-physician relationship instead of episodic treatments

20. PCMH • Focuses on expanded communication between patient and PCMH team

21. Just Cut to the Chase! Healthcare Reform OUR Way! Physician Led-The Right Way!

22. Reality Check: American Healthcare • Exploding costs • FFS drives volume over quality, fosters fragmentation over coordination • Lagging quality • Poor satisfaction • Misaligned incentives • Physician workforce “perfect storm” • Primary care is critical, and a fundamental answer to the health economics in US • Quality MUST increase, cost MUST stabilize

23. Money Saving Options • There are ONLY 4 options to change the basic economics: • Serve fewer people • Provide fewer services • Rationing, quotas • Pay less per service • rationing by no willing providers • Fundamentally change how services are paid and/or system is organized • Increased prevention/primary care • PCMH, ACOs

24. What is a Patient Centered Medical Home? A vision of health care as it should be A framework for organizing systems of care at both the micro (practice) and macro (society) level A blueprint or pathway to excellent healthcare for individuals or a population

25. PCMH Video http://www.emmisolutions.com/medicalhome/transformed/english.html

27. Physician Leadership • Natural Leaders • This is what we do every day! • We are the authority in patient care so allow us to pave the way! • We can develop the plan to take care of our patients • This is our obligation

28. PCMH • Hallmarks of Medical Home • Practices advocate for their patients • Evidence-based medicine • Voluntary performance measurement • Patients participate in decision-making • Informational Technology utilization • Enhanced Access to Clinic

29. Business Model of PCMH • Three-Part Payment Model • Monthly Care Coordination Payment • Visit-Based Fee-For-Service Component • Performance-Based Component

30. PCMH • Payment Reflects Value of Medical Home • Reflects value of work outside visit • Pay for coordination of care • Support provision of enhanced communication via email or phone • Recognize value of physician work remotely • Separate payments for face-to-face visits

31. PCMH • Payment Reflects Value of Medical Home • Recognize case mix differences in patient population • Allow physicians to share in savings from reduced hospitalizations • Additional payments for continuous quality improvements

32. Team Approach • Health care is delivered by a system • Implies a multidisciplinary team • Each member operates top of license • Variety of disciplines • Collaborative parallel effort is norm • Shared decision making and accountability • Paradigm and legal shift

33. Rationale for moving toward PCMH • Provides framework for sustainable process improvement • Supports the Joint Commission Hospital Accreditation process • Lays foundation for Accountable Care Organization (ACO) model • Leverages support from Kansas PCMH Initiative (2011-2013) program • Improves population health

34. My Role in PCMH • Chosen as 1 of 8 clinics in Kansas • Huge Honor • Pilot Program • 2 years in duration • Provides resources to embrace change • “It’s what you make it” • “EMR Meaningful Use” compatible

35. Sites Selected for the Pilot 35 American Medical Practice of Winfield/Augusta Family Practice, PA, Winfield Cheyenne County Clinic, Cheyenne County Hospital, St. Francis Ellsworth County Medical Center and Rural Health Clinic, Ellsworth Mindi S. Garner, D.O., Chartered, Pittsburg Great Plains of Sabetha, Inc. dba Sabetha Family Practice, Sabetha Internal Medicine Group, PA, Lawrence KU Wichita Adult Medicine, University of Kansas School of Medicine – Wichita, Medical Practice Association, Wichita Post Rock Family Medicine, Plainville

36. Practice Redesign Tool • TransforMED • Non-profit subsidiary of the American Academy of Family Physicians (AAFP) • Started in 2005 • Mission • The transformation of health care delivery to achieve optimal patient care, professional satisfaction and success of primary care practices.

37. My Motivation!

38. PCMH • Perfect Opportunity • Needed a new focus • Embracing “Change” • No longer the “strongest survive”, it is the “most able to change” survive • Flexibility is key • Sometimes painful process

39. PCMH • Must open practice to critiques • Prepare to change workflows • The 8 clinics help each other • Group Conference Calls Each Month • Access to online, collaborative network: Delta Exchange • Assistance to aid transformation process

40. My Experience with PCMH

41. How Did We Get Started? • Attended the first PCMH Pilot Program meeting • Motivational Speakers Started Process • My Self-Evaluation Started • Humbling Assessment • Control Issue was causing stagnation

42. Self-Evaluation • I was interrupting staff workflow • Staff Survey • Job satisfaction • Anonymous feedback on frustrations • Lack of pre-visit planning • “huddles” • Brainstorming Session with follow up

43. “Clinic Overhaul” Details • Everyone works to the top of their license • Created Lab Order Protocol • Created Phone Note Protocol Template • Same information format each and every time • Regularly Scheduled Office Staff Meetings • Prescription Refill Protocol • New, easier to maneuver EKG machine • Perform Dermatology procedures in-house

44. “Clinic Overhaul” Details • Created additional signing privileges • Completed Policies/Procedures Manual for staff • Every employee is trained for front-desk duties • More open-access appointment slots

45. “Clinic Overhaul” Details • Patient Portal • Secure email • Empower patients with their own data • Increased communication • Copies of clinical summary at end of visit • Copies of med list

46. Practice Implications • Challenges of Transformation • Initial Capital and Restructuring Costs • Ongoing support and maintenance • Reporting on quality, cost and satisfaction • Implementing HIT • Information Overload

47. Practice Implications • Shifting “power” • Too much change to manage anyway • Job Duties completely revamped • Possible Staff Objections • Doctor has to be willing to embrace change for staff to follow

48. Change • Change is difficult but required • Embracing change is hard but it is easier when you are in a “not so happy place” • Eliminate anger, frustration, despair

49. Assessing Value in PCP • PCMH just gives name of what we do • Enables proper compensation • Describes the workflow of primary care • Foundation of medical care • Communicates our unique perspective • No other “branch” of medical tree similar • Without primary care, medical treatments are disorganized

50. I already do this! But… • PCMH puts a more formalized name on “patient and family centered care.” • PCMH can generate support as the model proves it improves care and reduces cost across the health care system • PCMH gives us the opportunity to more clearly define how we can work together more effectively for our patients and their families