1. Patient Centered Medical Home What it means for Duffy Health Center Board Presentation September 10th 2012

2. Patient Centered Medical Home • The aim is increased access to quality patient care • It involves a team based approach to care

3. DEFINITION OF PCMH LEVEL 1 • 6 MUST-PASS ELEMENTS • 1A • Providing Same Day Appointments • Providing timely clinical advice by telephone • Documenting clinical advice in the medical record

4. PCMH 2D Use Data for Population Management • Practice uses patient information, clinical data and evidence based guidelines to generate lists and proactively remind patients and clinicians about • At least 3 different preventive care services • At least 3 different chronic care services • Patients not recently seen by practice • Specific medications.

5. PCMH 3C – Care Management - Patient collaboration with individual care plan including treatment goals • Written plan of care/Clinical summary • Assess and Address barriers when treatment goals not met • Identify patients/families who might benefit from additional care management • Follow up if missed appointments

6. PCMH 4A – Support Self Care Process - Provides educational resources to at least 50% patients in the identified group to assist in self management - Develops and documents self management plans - Provides self management tools - Documents self management abilities - Counsels on adopting healthy behaviors

7. PCMH 5B – Referral Tracking and Follow up - Tracking referral status including timing - Following up to obtain specialist’s report - Providing electronic summary of care record for >50% referrals - Asking patients about self-referrals and requesting reports -Demonstrate capability of electronic exchange of key clinical information

8. PCMH 6C- Implement Continuous Quality Improvement - Set goals and act to improve performance on 3 clinical quality and resource measures - Set goals and act to improve performance on at least 1 patient experience measure -Set goals to address 1 identified disparity in care or service for vulnerable populations

9. OTHER IDEAS BEHIND PCMH • QUALITY IMPROVEMENT • TEAM CREATION • HUDDLE • CARE MANAGEMENT – RN BILLING • PREPARATION FOR NCQA LEVEL 2 AND 3 WHICH INVOLVES MORE CRITERIA

10. New Tasks that will be added as part of PCMH • Disease registry data entry, maintenance, monitoring • Increased patient outreach, phone contact • Increased results reporting • Time intensive patient education • Group visits • Motivational interviewing

11. New Tasks cont’d • Self management follow up • Expanded hours • Open access • Increased patient phone, email access • More thorough documentation • Increased patient follow up • Increased communication with other providers/specialists

12. New Tasks mean cross training staff and elevating to top of license care • Examples • Providers – develop medical care plan which lower level staff can carry out and monitor • RN uses care plan to assess and treat complex patients, also educate and coach chronic patients e.g. strep throat protocol, STD training protocol • MA – maintain disease registry, basic admin tasks • Front desk – keep data for open access scheduling, follow up patients who don’t keep specialists appointments

13. Suggestions for achieving New Tasks • INFRASTRUCTURE • TIME • STAFF – RN CARE MANAGER

14. PROPOSED TIMELINE • September 13th – Follow up start of open access – Medical/BH • September 27th – BH open access, follow up data from Medical, decide clinical reminders • October 11th – Team formation, challenges with BH, decide with PIC input on which groups high risk

15. PROPOSED TIMELINE CONT’D • November 5th – Patient experience is one of the measures, review current survey and/or use developed survey • December – data review, places where we need improvement