Care Coordination in
the Patient-Centered
Medical Home
New York Academy of Medicine
May 24, 2011
Starting Point
Care Coordination -- one of the core
functions of primary care and the PatientCentered Medical Home
 Goal – to provide patients with care that is:

 Accessible
 Comprehensive
 Continuous
(relationship-based)
 Coordinated
Definition of Care Coordination in
the PCMH
Care coordination is the deliberate
organization of patient care activities
between two or more participants (including
the patient) involved in a patient’s care to
facilitate the appropriate delivery of health
care services
Myers D, et al. The Roles of the PCMH and ACOs in Coordinating Patient Care.
AHRQ Publication No 11-M005-EF, Dec 2010
The Patient Centered Medical
Home


Medical home is a model for the organization of primary care
that delivers the core functions of primary health care.
The medical home encompasses five functions and
attributes:
 Patient-Centered
 Comprehensive & Coordinated care
 Superb access
 System based approach to quality & safety
http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/what_is_pcmh_
Medical Home: What it Looks Like

A health care setting that provides patients with:








well-organized & on-time visits
enhanced access with their own provider & care team for
continuity (same day appointment availability, 24/7 telephone
access, alternatives to the 1:1 visit)
proactive care management (evidence base clinical care, panel
management, reminder systems, registries)
care coordination across settings (assistance with referrals,
tracking for tests & referrals; care during transitions)
patient activation, engagement & participation in decisions on
care (patient centered  customer driven)
connections to community resources to extend resources for care
focus on health outcomes & goals for improvement
use of Health IT as tool to support the achievement of advanced
primary care practice
Health System:
Community
Resources
Informed,
Activated
Patient
Health Care Organization
SelfDecision Delivery Clinical
Management Support System Information
Support
Design
Systems
Productive
Interactions
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
Medical Home: Aligned with (Chronic) Care Model
Relationships Are Key

“Coordination may be facilitated by certain
design elements but it is more
fundamentally a process of interaction
among participants... specifically,
coordination is carried out through
relationships of shared goals, shared
knowledge, and mutual respect.”
(Gittell 2002, www.pcpcc.net)
What’s Required to Make it Work






Well-trained workforce organized as multidisciplinary care teams
Mutual accountability among the team and
between team and patients
System designed to support care management
& coordination through enhanced access,
continuity and information availability
Cross boundary cooperation & partnership
among all provider types
Technology infrastructure for information
management & exchange
Payment reform to support the work
What Works

Well-organized primary care itself
 better
patient/staff experience, quality, reduced
ED and hospital utilization
Well-designed, targeted interventions to
right patients (high risk/high need patients;
transitions)
 Face-to-face interaction between patients
and care coordinators to establish &
maintain personal relationships

Myers, D, AHRQ, Dec 2010
What Has Not Worked
Disease management services delivered
primarily by telephone (for Medicare
beneficiaries)
 Targeted care coordination to low-risk
Medicare patients

Myers, D. AHRQ, Dec 2010
The Care Team
Typically: primary care provider, nurse,
medical assistant(s), front desk (greeter,
registration)
 Associated/shared among care teams:
referral specialist, nutritionist, social
worker, pharmacist, behavioralist, financial
specialist, educators
 Patient

Challenge: Bridge the Gaps in
the Core Care Team
Front
Desk
Clerk
Unlicensed
medical
assistants
Licensed
Nursing
staff
Primary
Care
Provider
New Model: Continuous
Capability in Team & Aligned
Resources
Front
Trained MA Health
Desk
Medical Coaches
Specialist Assistant
Licensed Primary
Nursing
Care
Staff
Provider
Referral Specialist, Pharmacist,
Social Worker, Nutritionist,
Behaviorist, Financial Specialist,
Educator
Referral & Test Tracking, Registry
& Panel Management, Self
Management Support
Self Management Support,
Medication Reconciliation,
Clinical Issues
Medical Assistants  Health Coaches  CDEs, Licensed Nurses
Increasing Complexity of Patients Care Needs
Unite Here Health Center, NYC
Serves 10,000 patients -- who are members
of several unions – and their families
 55,000 visits annually
 Patients are low-wage, largely immigrant
workers
 Center’s staff reflects its community
 Pharmacy, radiology, PT on site
 Capitated payments

Principles




Efforts to improve care need to focus on the sickest
patients
Doctors cannot successfully manage patients’ diseases
alone
Self-management is crucial for treating chronic conditions
Using highly trained medical assistants for selfmanagement frees up clinicians (MD, DO, NP) to manage
complex medical decisions
Nelson, K. et al. Transforming the Role of Medical Assistants in Chronic Disease
Management, Health Affairs, May 2010
What’s Possible





Medical Assistants: well-trained by UHC to provide
assistance to their medical provider
All M.As trained to review charts to prepare for each day’s
team huddle and for preventive care needs against
protocols; to provide basic patient education
Nine month intensive training available for M.A.s to move
to being health coaches who provide clinical and selfmanagement support, e.g., monitor home BP & glucose;
lead groups.
Gives patients significant access to the care team
EMR was key for registries to identify patients needing
care management & coordination
Results
 Data
on outcomes show statistically
significant improvements (p<0.05)
%
pts with HbA1c < 7%
BP below 130/80
LDL < 100 mg/dL
All A, B, C markers controlled increased
from 13% to 36%
Results
Broader skill set for M.A.s creates new
career pathways
 Allowed UHC to hire from its communities
for cultural concordance
 Institutionalize strong relationships and
shared backgrounds between patients and
caregivers that are important to success of
the model

The Medical Home in the
Neighborhood
Community Health Workers
 Promotoras
 Extend the medical home to the
neighborhood
 Cultural concordance
 Incorporate/address social factors of
health in our medical homes

Team Building



Central to the PCMH model of care
Team has shared responsibility for the health of the patient
panel
Building high-performance teams:
 Clinical & administrative systems to support team-based
care and functions
 Clear roles among team members
 Permanent training environment
 High levels of communication within the team
 Team members with professional training actively
mentor and train non professional/unlicensed team
members
Bodenheimer, Transforming Primary care: From Past Practice to Practice of the Future,
Health Affairs, May 2010
Challenges
Need medical training to adopt interprofessional learning opportunities as part of
core curriculum
 Current scope of work regulations may
require reform for some of these changes to
take hold more widely and securely
 Team-building will require moving more
responsibilities to non-physician team
members; change management support
needed (also see bullet above)

Thank You