* PCMH and Health
Coaching
April 2014
* Provide an overview of Patient Centered
Medical Home, Population Health Management
and the role of the Health Coach in PCMH,
Population Health initiatives and working with
individual clients.
* Purpose
* Identify two components of a Patient Centered
Medical Home
* Describe two ways a Health Coaching
interaction differs from a typical patient/staff
interaction
* Identify one action you can take to help
improve the health of your patients that
contributes to Population Health Management
* Objectives
*Show of hands
* Who works in a clinic that has attained Patient
Centered Medical Home designation?
* What factors drove this change?
* Poll Question
* Enhanced patient experience of care
* Improved quality
* Improved efficiency
* Triple Aim
* Demonstrates that you and your colleagues put
the patient at the center of care
* Continuity of care
* Quality
* Patient Safety
* Enhanced reimbursement for clinic
* Relationship building with patient and team
* Improved quality of work life
* Why become a PCMH?
*
*
*
*
*
*
Enhanced Access and Continuity
Identify and Manage Patient Populations
Plan and Manage Care
Provide Self-Care and Community Support
Track and Coordinate Care
Measure and Improve Performance
* NCQA 2011 Standards
for PCMH Recognition
*
*
*
*
*
*
Patient-Centered Access
Team-Based Care
Population Health Management
Care Management and Support
Care Coordination and Care Transitions
Performance Measurement and Quality
Improvement
* NCQA 2014 Standards
for PCMH Recognition
*
*
*
Focus on Population Health in Diabetes
Wagner’s Chronic Care Model
Data driven
* Implementation of Registries and EHR
*
*
NCQA Diabetes Recognition for providers
Health Coaching
* Our path to PCMH
* Wagner’s Chronic Care Model
* Population Health Management
3% of population
39% of cost
40% of population
41% of cost
50% of population
7% of cost
Slide provided by the Clinical Health Coach Training
Program
*
*
*
*
Social
Emotional
Economic
Physical
* Cost of Chronic Disease
*
The coordination of care delivery across a
population to improve clinical and financial
outcomes, through disease management,
case management and demand
management.
* Population Health Management
* In 2000 MMS implemented the Improving Diabetes
Outcomes project in 13 clinics
* Wagner’s Chronic Care Model
* MMS path to Population
Management in
Diabetes
* ADA Standards of Care for Diabetes
* A1c in past 12 months and value
* LDL in past 12 months and value
* Microalbumin in past 12 months
* BP < 130/80
* Dilated Retinal Exam in past 12 months
* Monofilament foot exam in past 12 months
* MMS path to Population
Management in
Diabetes
* MMS path to Population
Management in Diabetes
*
*
*
*
*
*
The Dual Challenge of Diabetes and Hypertension project
Diabetes Recognition Program
Wellmark Collaboration on Quality
Health Coaching
PCMH
IME Health Home
* MMS path to Population
Management in Diabetes
*
Data
*
*
*
*
Excel spreadsheet initially
CDEMS Registry (free download)
Wellcentive Registry
Implementation of Electronic Health Record
*
Currently building reports that will allow us to query EHR
* Population Management
*
National Quality Forum
http://www.qualityforum.org
*
US Preventive Services Task Force
http://www.uspreventiveservicestaskforc
e.org/recommendations.htm
* Best Practice
Guidelines
* NCQA
*
*
*
http://www.ncqa.org
Diabetes Recognition Program
Heart/Stroke Recognition Program
PCMH Recognition
* Best Practice
Guidelines
*
*
In 2000 it was the right thing to do
* No monetary incentive
* Possible negative financial impact in FFS environment
Pay for Performance programs
* Insurance companies – quality and cost containment
* Driving Forces: Past
*
*
*
*
Patient Centered Medical Home Recognition
* Financial benefit to clinics
Affordable Care Act
CMS’ move to Value Based instead of Fee for Service
Payment
* No payment for readmission in 30 days
ACO
* Driving Forces:
Present & Future
* Ruby Slipper Moment
*
The moment
the patient
recognizes that
the power to
make the
changes lies
within.
*The Ineffective Physician: Non-Motivational
Approach - YouTube
www.youtube.com/watch?v=80XyNE89eCs
*The Effective Physician
https://www.youtube.com/watch?v=URiKA7CK
tfc
*Video Examples
* Structuring the interaction using OARS+E
*
*
*
*
*
Open ended questions
Affirmation
Reflection
Summarizing
Eliciting Change Talk
* Motivational Interviewing -
OARS+E
*
*
*
*
Why
Am
I
Talking
* Health Coaching -
WAIT
*
We automatically want to fix things
* Advice giving
* Directing the patient
* You should …. conversations
* Not recognizing the person’s power to make
change from within
* Health Coaching Righting Reflex
* Patient Quote
* “I
knew I needed to fulfill a previously set goal of
walking 30 minutes a day but I easily made excuses
and put off walking…….Carol and I talked about it.
She didn’t tell me that I had to walk for exercise.
She said just enough to make me want to do it.
That
motivated
me
to
become
more
disciplined…Now that I have established the habit
with Carol’s coaching, walking has become a
pleasure that I look forward to.”
* A1c improved from 7.4 to 7.1 in 6 months with the
walking program
*
*
Credible data is imperative to success
Front end functions must be done well to
submit a successful application
*
*
Eg. 50% of all patients who request an
electronic copy of their health
information must be provided it within 3
business days
Electronic system with functionality a must
have
* A NCQA PCMH
Experience
*
Coordinating care across the continuum
*
*
Provide input to key brochures
*
*
Must support patients and demonstrate
this is done
Patient access key
Application requires extreme attention to
detail
*
Do not hesitate to contact reviewer with
questions
* A NCQA PCMH
Experience
* Your work benefits your patients, coworkers
and the clinic’s bottom line
* Be prepared for change
* Be willing to stretch
* New processes and workflows
* Work to the top of your licensure
* Leverage technology
* You matter in the
PCMH
* Care delivery in a PCMH is a TEAM EFFORT
* Huddle Video link
* PCMH TEAM
* Enhance Access and Continuity
* Chart Scrub
* Pre-visit Planning
* Run daily huddle
* Identify and Manage Patient Populations
* CMA roles vary - some are in data analysis roles
in a clinic
* How do I contribute
to PCMH?
* Plan and Manage Care:
* Pre-visit Chart review:
* Identifying gaps in care
* Addressing those gaps contributes to
improving the health of individual patients
and the entire patient population
* How do I contribute
to PCMH?
*Provide Self-Care and Community Support
* Look for the patient’s strengths and
capitalize on those strengths
* Utilize patient education materials
* Link patient to community resources
* How do I contribute
to PCMH?
* Track and Coordinate Care
* Referral Tracking System
* Measure and Improve Performance
* Utilize Clinical Guidelines in your daily work
* Utilize data to improve care
* How do I contribute
to PCMH?
Contact Information:
Carol Brinkert RN, BAN, CHC
brinkerc@mercyhealth.com
Danielle Pingel, MHA
danielle.lentsch@mercyhealth.com
* Thank You