[PDF] - Patient Centered Medical Home primary care that facilitates PDF Document

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Patient Centered Medical Home

Jeremy Thomas, PharmD, CDE UAMS Department of Pharmacy Practice

What is a Patient Centered Medical Home (PCMH)?

"an approach to providing comprehensive primary care that facilitates partnerships between individual patients, and their personal providers, and when appropriate, the patient’s family"

Joint Principles of the PCMH

Ongoing relationship with personal physician
Physician directed medical practice
Whole person orientation
Coordinated care across the health system
Quality and safety
Enhanced access to care
Payment recognizes the value added

agreed upon by American Academy of Family Physicians, American College of Physicians, American Academy of Pediatrics, American Osteopathic Association

History of PCMH concept

1967 1967

American Academy of Pediatrics’ call for a model to organize the care of

children with complex health care needs. 2001 2001

Institute of Medicine. Committee on Quality of Health Care in America.

Crossing the Quality Chasm: A New Health System for the 21st Century. 2002 2002

Creation of Future of Family Medicine Project to "transform and renew the

specialty of family medicine”. 2003 2003

Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic

Disparities in Healthcare. 2004 2004

Institute of Medicine. Insuring America’s Health: Principles and

Recommendations. 2005 2005

American Academy of Family Physicians creates TransforMED.

History of PCMH concept

2006 2006

American College of Physicians Policy Monograph. The advanced medical home: a

patient‐centered, physician‐guided model of health care. 2006 2006

Creation of the Patient Centered Primary Care Collaborative.

2007 2007

Joint Principles of the Patient Centered Medical Home.

2008 2008

National Committee for Quality Assurance released Physician Practice Connections–

Patient‐Centered Medical Home (PPC‐PCMH) Recognition program. 2009 2009

Accreditation Association for Ambulatory Health Care (AAAHC) began accrediting

medical homes. 2011 2011 • UAMS Internal Medicine Clinic initiates development of PCMH.

6

Clinic operations center on meeting the doctor’s needs

Optimal Function:

An interdisciplinary team works at the top of

ur licenses to serve patients

Patients are responsible for coordinating their

wn care

Team: Coordinated, Integrated

Patient trusts providers deliver quality care

Quality and Safety Measures

Care varies by scheduled time and memory or skill of the doctor

Evidence‐based Point‐of‐Service Care

Care is determined by today’s problem and time available today

Proactive Plans

It’s up to the patient to tell us what happened to them

Tracking: Test and Referrals Registries

Patients are those who continue to make appointments at the practice

What does a PCMH look like?

Tomorrow’s Home Today’s House

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Great Outcomes

Practice Organization Quality Measures

Patient Centeredness

Patient Experience Heath Information Technology

Building Blocks of a PCMH

Health Information Technology

Patient Centeredness Business & Clinical Process Automation Connectivity & Communication Evidence‐Based Medicine Support Clinical Data Analysis & Representation

Intra‐office team

coordination

Results, referrals and

procedures tracking

Schedule and resource

management

All patient, all condition

registry

Quality measurement

collection and analysis

Reporting to third

parties

E‐prescribing
Clinical messaging

with patients

Health information

exchange

Evidence‐based

template for documentation

Access to online

medical information

Clinical decision

support

Lab testing
Prescriptions
Registries

Practice Organization

Personnel Management Clinical Systems

Every team member

understands the important role they play in delivering efficient care and is empowered to make suggestions for improvement

Lab testing
Prescriptions
Patient Registries

Financial Management

All staff are aware of the

most effective ways to deliver care

National policies support the

investment of resources into primary care practices that are effective and efficient Patient Experience

Patient Centeredness

Health Information Technology Quality Measures

Patient Centeredness Performance Measurement Culture of Improvement Reliable Systems

Quality measures should

be based in clinical evidence

Patient satisfaction

surveys

Staff education
Team meetings
Ensure quality

improvement initiatives are not punitive

Develop reliable systems

to collect information

Check list and reminders
Evidence‐based decision

support tool

Practice Organization Health Information Technology Patient Experience Quality Measures

Patient Centeredness Personalized Care Convenient Access Care Coordination

Same‐day appointments
After‐hours access

coverage

Online patient services
Reminders
Non‐physician care

management

Shared decision‐making
Self‐management support
Referral management
Patent engagement and

education

Prevention screening and

services

Practice Organization Health Information Technology Family Medicine Foundation

Great Outcomes

Good for patients

– Patients enjoy better health. – Patients share in health care decisions.

Good for physicians

– Physicians focus on delivering excellent medical care.

Good for practices

– Team works effectively together. – Resources support the delivery of excellent patient care.

Good for payors and employers

– Ensures quality and efficiency. – Avoids unnecessary costs.

Patient Experience Health Information Technology

Great Outcomes

Practice Organization Quality Measures

Patient Centeredness

Patient Experience Heath Information Technology

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Outcomes of PCMH Interventions

29% reduction in ER visits and 11% reduction in

ambulatory sensitive care admission Group Health Cooperative of Puget Sound Community Care of North Carolina

93% of asthmatics received appropriate maintenance

medications

40% decrease in hospitalizations for asthma and 16% lower ER

visit rate

Health Partners Medical Group MN

350% reduction in appointment waiting time

The Outcomes of Implementing Patient‐Centered Medical Home Interventions: A Review of the Evidence on Quality, Access and Costs from Recent Prospective Evaluation Studies, August 2009. www.pcpcc.net

Outcomes of PCMH Interventions

Geisinger Health System

Statistically significant improvements in quality of

preventive (74.0% improvement), coronary artery disease (22.0%) and diabetes care (34.5%) for PCMH pilot practice sites Genesee Health Plan

72% of the uninsured adults in Genesee County

now identify a primary care practice as their medical home

The Outcomes of Implementing Patient‐Centered Medical Home Interventions: A Review of the Evidence on Quality, Access and Costs from Recent Prospective Evaluation Studies, August 2009. www.pcpcc.net

Outcomes of PCMH Interventions

39% Decrease in emergency room admissions
24% Decrease in hospital admissions
Net reduction cost of $640 per patient and $1,650 among

high risk patients

Intermountain Healthcare Medical Group Management Plus Blue Cross Blue Shield of NC‐ Palmetto Primary Care Physicians

12.4% decrease in ER visits
10% decrease in hospital admissions
Total medical and pharmacy costs were 6.5% lower

The Outcomes of Implementing Patient‐Centered Medical Home Interventions: A Review of the Evidence on Quality, Access and Costs from Recent Prospective Evaluation Studies, August 2009. www.pcpcc.net

PHARMACIST INVOLVEMENT

The Patient Centered Medical Home

NCQA PCMH 2011 Standards

Enhance Access and Continuity
Identify and Manage Patient Populations
Plan and Manage Care
Provide Self‐Care Support and Community

Resources

Track and Coordinate Care
Measure and Improve Performance

Identify and Manage Patient Populations Standard 2, Element B

Practice uses a searchable electronic system to record the following data:

Allergies, including medication allergies and

adverse reactions, for more than 80% of patients

List of prescription medications with the date
f updates for more than 80% of patients

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Practices uses patient data and evidence‐based guidelines to generate lists and remind patients about needed services:

At least three different preventive care

services

At least three different chronic care services
Patients not recently seen by the practice
Specific medications

Identify and Manage Patient Populations Standard 2, Element D Medication Management Standard 3, Element D

The practice manages medications in the following ways

Reviews and reconciles medications with patients for

more than 50% of care transitions

Provides information about new prescriptions to more

than 80 % of patients

Assesses patient understanding of medications for more

than 50% of patients with date of assessment

Assesses patient response to medications and barriers

to adherence for more than 50% of patients with date

f assessment
Documents over‐the‐counter medications, herbal

therapies and supplements for more than 50% of patients, with the date of updates

Electronic Prescribing Standard 3, Element E

Practice uses e‐prescribing system with the following capabilities:

Generates and transmits at least 40% of

prescriptions to pharmacies

Generates at least 75% of eligible prescriptions
Integrates with patient medical records
Performs patient‐specific checks for drug‐drug and

drug‐ allergy interactions

Alerts prescribers to generic alternatives
Alerts prescribers to formulary status

Self‐Management Support Standard 4, Element A

The practice conducts activities to support patients/families in self‐ management:

Provides educational resources or refers at least 50% of patients

to educational resources to assist in self‐management

Uses an EHR to identify patient‐specific education resources and

provide them to more than 10 percent of patients, if appropriate

Develops and documents self‐management plans and goals in

collaboration with at least 50% of patients

Documents self‐management abilities for at least 50% of patients
Provides self‐management tools to record self‐care results for at

least 50%of patients

Counsels at least 50% of patients to adopt healthy behaviors

Why involve pharmacist is PMCH?

3.5 billion prescriptions written annually in US
4 of 5 patients leave MD office with Rx
Rx’s are involved in 80% of all treatments
Most commonly identified drug problems

– patient requires additional therapy – dosages need to be titrated to achieve benefit

WHO estimates adherence rate of 50% for

chronic medications

Academy of Managed Care Pharmacy American Association of Colleges of Pharmacy American College of Clinical Pharmacy American Pharmacists Association American Society of Consultant Pharmacists American Society of Health-System Pharmacists College of Psychiatric and Neurologic Pharmacists National Association of Chain Drug Stores National Community Pharmacists Association

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PRINCIPLES FOR INCLUSION OF PHARMACISTS’ CLINICAL SERVICES IN THE PATIENT‐CENTERED PRIMARY CARE MEDICAL HOME

Available at http://www.accp.com/docs/positions/misc/IntegrationPharmacistClinical ServicesPCMHModel3‐09.pdf

Principles for Pharmacist Incorporation into PCMH Framework

Access to pharmacists’ clinical services
Patient‐focused collaborative care
Flexibility in medical home design
Development of outcome measures
Access to relevant patient information
Effective health information technology
Aligned payment policies

PATIENT‐CENTERED PRIMARY CARE COLLABORATIVE (PCPCC)

Integrating Comprehensive Medication Management to Optimize Patient Outcomes

PCPCC Comprehensive Medication Management

medication management service needs to be

delivered directly to a specific patient

assessment of the specific patient’s medication‐

related needs

care plan is developed to resolve the problems
service is expected to add unique value to the

care of the patient

work of pharmacists and medication therapy

practitioners needs to be coordinated with

ther team members in the PCMH

COMPREHENSIVE MEDICATION MANAGEMENT SERVICES

Patient‐Centered Primary Care Collaborative (PCPCC)

Assessment of the Patient’s Medication‐ Related Needs

all current Rx, OTC, Supplements, vitamins,

meds from friends and family, etc.

– current systems don’t capture everything

uncovering patient’s medication experience
complete medication history
medications are linked to indicated condition
goal is to determine if outcomes are achieved

through medication use

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Identification of the Patient’s Medication‐related Problems

Each Medication is assessed for

– Appropriateness – Effectiveness – Safety – Adherence

Development of a Care Plan

Intervene to solve medication‐related problems
Establish individualized therapy goals
Design personalized education and interventions
Establish measureable outcome parameters
Determine appropriate follow‐up time frames

PCPCC Comprehensive Medication Management: Patient Identification

Not meeting the intended therapy goal
Experiencing adverse effects
Difficulty understanding/following regimen
In need of preventive therapy
Frequently readmitted to the hospital

PCPCC Comprehensive Medication Management: Payment and Coverage

monthly care coordination payment
visit‐based fee‐for‐service component
performance‐based component

COMPREHENSIVE PRIMARY CARE INITIATIVE

Opportunities in Arkansas

Comprehensive Primary Care Initiative

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CPC Opportunities

selected primary care practices who are

committed to improving the patient experience through

– increased access and continuity – planned care for chronic conditions and preventative care – patient and caregiver engagement – coordination of care across the medical neighborhood – risk‐stratified care management

receive enhanced payments based on a per

member per month formula.

CPC Sites in Arkansas CPC vs PCMH

CPC initiative aligns with the PCMH model:

– include a personal physician – physician directed medical practice – whole‐person orientation – coordinated care – access – continuity of care – population and disease management through electronic health records and patient registries – quality – safety

Summary

The PCMH has the potential to improve the

care of patients

Appropriate medication management is vital

component of providing comprehensive care

Pharmacist have the capacity and ability to

provide medication therapy management

References and Resources

PCMH and Pharmacists

– http://iforumrx.org/node/126 – http://www.pcpcc.org/resources

Comprehensive Primary Care Initiative

– http://innovation.cms.gov/initiatives/Comprehens ive‐Primary‐Care‐Initiative/index.html – http://www.aafp.org/practice‐ management/pcmh/initiatives/cpci.html