The Medical Home Model: Case
Management Perspectives
James W. Mold, MD, MPH
Department of Family and Preventive Medicine
University of Oklahoma HSC-OKC
Disclosures
 To my knowledge I have no conflicts of interest.
 I won’t mention any specific companies or products in
my presentation.
 I am a family physician with additional training in
geriatrics and I bring those biases with me.
Learning Objectives
By the time I have finished, you should be able to:
 Define the Patient-Centered Medical Home (PCMH)
 Explain the relationship between the PCMH and the
Chronic Care Model
 Summarize the conditions under which case
management has been found to be effective in primary
care settings
 Explain differences between a disease-oriented approach
and a patient-oriented approach to care
Outline
 Definitions and conceptual models
 Primary care
 Chronic Care Model (CCM)
 Patient-Centered Medical Home (PCMH)
 Case management in primary care
 Evidence review
 Implications
 Patient-centeredness and its implications
 Goal-orientation vs. disease orientation
 Case management in rural America
 County health improvement organizations
Primary Care
 The Institute of Medicine, in 1996, defined primary care as
“the provision of integrated, accessible, health-care services
by clinicians that are accountable for addressing a large
majority of personal health-care needs, developing a
sustained partnership with patients, and practicing within the
context of family and community.”
 Attributes
Accessible
Comprehensive
Coordinated
Longitudinal
Person-centered
Family-centered
Community-centered
Relationship-Based
Integrated
Primary Care
Organizational Attributes
 Accessible
 Comprehensive
 Coordinated
 Longitudinal
Clinical Attributes
 Person-centered
 Family-centered
 Community-centered
 Relationship-Based
Integrated
Integrated
Impact of the CCM on Primary Care
 Information systems
 Electronic health records (EHRs)
 Health information exchange (HIE)
 Registries for population management
 Decision support
 Guidelines
 Prompt/reminder systems, dashboards, protocols, checklists
 Delivery system design
 Teamwork
 Standardized consultations
 (Concierge practices)
 Patient self-management support
Patient Self-Management Support
 Patient education
 One-on-one
 DVDs
 Bibliotherapy
 Training for monitoring health parameters
 Action plans (what to do, who and when to call)
 Monthly phone contacts
 Connections
 Community resources
 Support groups
 Reminders and incentives to make positive behavior changes
Examples
 Diabetes
 Diabetes education
 Q3month visits
 ADA Guideline-based protocols, flow sheet
 Single eye consultant
 Registry
 Prenatal care
 Prenatal classes
 Scheduled visits
 ACOG Guidelines, flow sheet
 High-risk OB clinic
 Due date registry
Impact on Primary Care
 Applicable to prevention as well as chronic illness care
 CCM now often referred to as the Care Model
 Enhancement of comprehensiveness, coordination and
longitudinality
 Emphasis on diseases and guidelines could threaten personcenteredness, relationship-based care
 Industrial quality model (every widget the same)
 Would require an additional 3.5 to 10.6 hours per day for 10
most common chronic diseases.
Ostbye T et al. Ann Fam Med 2005; 3(3): 209-214.
Impact on Primary Care
Creates need/increased opportunities for:
 Health educators
 Case managers
 Panel managers, registry managers
 Social workers
 Patient coaches
 Patient navigators
 Community health workers
 Practice – Community Connectors
Patient-Centered Medical Home (PCMH)
“A patient-centered medical home integrates patients as active
participants in their own health and well-being. Patients are
cared for by a physician who leads the medical team that
coordinates all aspects of preventive, acute and chronic needs
of patients using the best available evidence and appropriate
technology. These relationships offer patients comfort,
convenience, and optimal health throughout their lifetimes.”
American Academy of Family Physicians, the American
Academy of Pediatrics, and the American College of
Physicians Spring, 2008.
The Patient-Centered Medical Home
PCMH as Advanced Primary Care
Primary care that incorporates the CCM while preserving
(enhancing) person-centeredness and adding HIT and QI
 Increased emphasis on access and convenience
 Open access scheduling
 Extended hours
 Incorporation of new technologies
 Electronic health records, health information exchnage
 Personal health records
 Patient portals and E-visits
 Quality Monitoring
 Disease-oriented or standardized preventive services
 Patient satisfaction
PCHMH Standards
 NCQA criteria look like CCM plus e-prescribing, test
tracking, referral tracking, and continuous quality
improvement
 “Care management” is one of nine sections
 AAFP/TransforMed criteria look like primary care plus
continuous quality improvement
 Case management not specifically listed
 OK SoonerCare criteria emphasize care management; 3 tiers
 Other criteria: AAAMC, The Joint Commission, the Center
for Medical Home Improvement, BCBS of Michigan,
Minnesota’s Health Care Home Certification Program
PCMH Standards
Care
Coordination
Population
Management
Care Plan
Health IT
EvidenceBased
Care
Team-Based
Care
Etc.
Burton RA, et al. Report to CMS by the Urban Institute, May, 2011
Case Management
Case Management is a collaborative process that
promotes quality care, and cost effective outcomes
which enhance the physical, psychosocial and
vocational health of individuals.
It includes assessing, planning, implementing,
coordinating, and evaluating health related service
options.
Case Management in Primary Care
What we now know:
 Case managers must interact with patients in person; not just
by phone
Ayanian JZ. JAMA 2009; 301(6): 668-670
 Case management must be integrated into primary care
Seow H, et al. JAGS 2006; 54:535-540
Wolff JL, et al. Ann Intern Med 2005; 143(6): 439-445
 A disease-oriented, guideline-driven approach is probably
less effective than a patient-centered, goal-directed approach
Congressional Budget Office Analysis, 2004
Bosmans J, et al. J Gen Intern Med 2006; 21: 1020-1026
 Patient selection is important, but the best approach isn’t
clear yet
Primary Care
Organizational Attributes
 Accessible
 Comprehensive
 Coordinated
 Longitudinal
Clinical Attributes
 Person-centered
 Family-centered
 Community-centered
 Relationship-Based
Integrated
Integrated
Case Management in the PCMH
 Organizational Integration
 Access process
 Same office
 Same record
 Unified assessment
 Effective and efficient communication channels
 Clinical Integration
 Person-centered
 Goal-directed
 Relationship-based
 Context-sensitive
Case Management in the PCMH
 Access options
 Disease-based (CHF, DM, asthma, etc.)
 Risk projections (computer formulas)
 Internal referrals (from primary care clinicians)
 Patient self-referrals (e.g. availability advertised)
 CM self-referrals (e.g. all patient’s screened)
 Combinations of above options
 Transitions between care settings also very important
 Hospital to home
 Home to AL, NH
 Home to ED to home
Case Management in the PCMH
 Same Office
 “I’m calling from Dr Smith’s office. He wanted me to visit with
you about…”
 Same record
 CM notes in same section as physician notes
 Unified assessment
 CM begins with information already in record.
 Additional information is added to appropriate sections of the
record.
 Communication channels




EHR messaging, daily event reports
Hallway huddles
Weekly team meetings?
Care plan visits (clinician, patient, family, CM)?
Case Management in the PCMH
 Person-centered
 Primary focus is on the needs of the person, not on
management of their diseases (though that too)
 Goal-directed
 A goal is a desired outcome for which it makes little sense to
say, “…so that?”
I’d like to live long enough to see my grandchild get married.
I’d like to get be able to use my sewing machine again.
Not, “I’d like to get my A1c to <8%.”
 Relationship-based
 Human interpersonal interactions my be the most powerful
therapeutic agents in our armamentarium.
Practical Considerations
 Who can/should do it?
 Children mostly need a social worker
 Old people mostly need a skilled nurse
 Some combination of these might be ideal
 How many case managers are needed?
 Assistive care management to address adherence problems, complex
medication regimens, and co-morbidities for the 20 percent to 30
percent of patients whose diseases are not under control.
 Intensive case management and specialty care for the 1 percent to 5
percent of patients with advanced disease and complex co-morbidities
or frailty.
 How should it be organized and financed?
 Reimbursement to practices (fee-for-service)
 Capitation payment to practice
 Support for a set of shared resources
Bodenheimer T, et al. JAMA 2002; 288(14): 1775-1779 and 288(15): 1909-1914.
NC Community Care
 14 non-profit networks covering the entire state
 NC Medicaid puts $3 PMPM into the networks and gives




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primary care clinicians $2 PMPM to join a network
Networks use the money to hire or contract for case
managers and others needed to improve care and reduce cost
QI projects initially directed by the state (CHF, DM, asthma)
Networks now encouraged to initiate QI projects
Successful projects spread to other networks
Extremely successful in terms of cost savings, improved
quality measures, and better relations (PCC and Medicaid)
OK Health Access Networks
 3 non-profit HANs (Canadian County, OU-Tulsa, OSU





COM)
Medicaid puts $5 PMPM into the networks
Networks hire or contract for case managers
Required to help practices reach level 3 PCMH
Some empahsis on HIT and HIE
Too early to tell if effective
Effective Implementation of Innovations in Primary Care
Literature and Exemplar
Methods
Performance
Feedback
Facilitation
IT Support
Local Learning Collaboratives
Academic
Detailing
Practice Enhancement
Assistant
Primary
Care
Mental
Health
Regional
AHEC
Public
Health
Practice
Practice
OHIET
Practice
County Health
Improvement Office
QI Facilitators
Case Managers
IT Support
Practice
Academic
Medical
Centers
Practice
Practice
Hospital
Funders
Turning
Point
OHIET
NW
AHEC
SW
AHEC
NE
AHEC
SE AHEC
P
P
CHIO
P
P
CHIO
CHIO
CHIO
CHIO
CHIO
CHIO
P
P
CHIO
P
CHIO
P
P
P
OUHSC
OKC
P
CHIO
P
OSUCOM
P
P
CHIO
OUCCM
Tulsa
P
CHIO
P
P
P
P
P
P
P
Annual Funding
Public and
Private Insurers
Project Specific
Funding
CDC, HRSA,
etc.
County Extension
Program
Oklahoma Health
Information Exchange
Trust
Project Specific
Funding
AHRQ, NIH,
etc.
Regional AHECs
County Extension
Program
County Extension
Program
State, Local, Private Funding??
County Extension
Program
Learning Objectives
By the time I have finished, you should be able to:
 Define the Patient-Centered Medical Home (PCMH)
 Explain the relationship between the PCMH and the
Chronic Care Model
 Summarize the conditions under which case
management has been found to be effective in primary
care settings
 Explain differences between a disease-oriented approach
and a patient-oriented approach
Questions and Comments?