OUR ROAD TO
PCMH RECOGNITION
Baldwin Family Health Care
Russ Kolski RN
• Strategic Projects Director
• Background in
• Quality Management
• Safety and Compliance
• Accreditation (Joint Commission / AAAHC)
• Given Medical Home Responsibility in July 2011
• PCMH Accreditation
• Meaningful Use
• Pay for Performance
(Not my only role)
Baldwin Family Health Care
• Health Center since 1967
• Rural Area
• Serve West Central Michigan
• 5 Medical Locations
• 3 Locations with Retail Pharmacies
• 3 School Based Health Centers
• 25,000 Annual Medical Visits
• PCMH Status as of 2011
• AAAHC Recognized for PCMH
• BCBS Recognized for PCMH at 2 of 5 locations
Baldwin Family Health Care
Referral
Pre-Visit
Dedicated
Annual
PCMH
Staff
First
HRSA
Last
Implemented
NCQA
Participation
MiPCT
HRSA
Hired
Transition
Implemented
LEAN
Submitted
Education
Trial
Road
PCMH
Site
Training
Training
Quality
Added
Weekly
Tracking
Staff
PCMH
Event
/Planning
Case
CMS
to
Live
Lead
to
Report
Development
Registry
Enhancement
Moved
i2i
Huddles/Pre-plan
Steering
Submission
(Familiarization)
Submission
Staff
Managers
Demonstration
PCMH
NextGen
Open
for
Quality
NCQA
Quality
Tracks
MU
Workgroup
MU
Selected
Funding
in
All
Work
to
Stage
Year
ACO
Access
Module
Patients
PCMH
Registry
Dept.
Comm.
Registry
Staff
EHR
Hired
Flow
Pt.
1Pt.1
2 2
Oct.
2012
Feb.
2013
September
December
November
February
October
January
Started
January
August
June
April
March
July
May –2012
2012
2011
2013
2012
2011
2012
2011
2013
2012
2011
2012
2013
2011
2012
“If we keep doing what we are doing,
we will keep getting what we got.”
Yogi Berra
Personal PCMH Learning
• Limited Understanding at Start
• Attended PCMH Seminars
• Local PHO
• Michigan State Medical Society
• Obtained Chronic Care Professional Certification
• Reading
•
•
•
•
LEAN – Toyota Production System
TransforMed
IHI
PATH
Internal Planning
• EHR Transition (1st site live 12/2011 – last 6/2012)
• Provider Coordinating Committee
• Transition Committee
• Established PCMH Steering Committee
• Education at all levels
• Visit Workflow Re-design
• Transition from Acute Care to Preventative / Wellness Based Care
• Match pre-EHR Provider Productivity
• Integrate PCMH Elements into Standard Work
Steering Committee Membership
• CEO (Ex-Officio)
• PCMH Lead
• Quality Manager
• Chief Medical Officer
• Physician Lead for EHR
• Mid-level Provider
• COO / Privacy Officer
• Site Facility Manager
• Finance Representative
• Dental Representative*
• Behavioral Health*
“Every system is perfectly designed
to get the results it gets.”
Paul B. Batalden MD
Co-founder Institute for Healthcare Improvement
Founding Director Center for Healthcare Improvement
and Leadership – The Dartmouth Institute
New Structure
• Eliminate Medical Support Specialist Role at 5 sites
• Former Diabetes Registry Coordination (Old PECS System)
• Centralize Registry Function within Quality Department
• Added Quality Department Staff
• PCMH Registry Specialist – May 2012
• PCMH Report Generator – May 2012
• Care Managers for 2 locations (MiPCT) – January 2012
• CMS Muliti-payer Demonstration Project
• Create PCMH Lead at each site – May 2012
• Additional responsibility for selected staff member
Planning Tools
• Annual Performance Improvement Plan
• Schedule of Activities
• Comparison of Clinical Quality Measures
for UDS/MU/PCMH/Pay for Performance Measures
• Crosswalk between NCQA and BCBS PCMH Standards
• Working examples will be shown at end of presentation
Annual PI Plan Activity
Activity Schedule
Clinical Quality Indicator Reporting
January
UDS
ED Visits
Open Access
February
March
April
May
June
July
Record Audit
MU
UDS
Record Audit
MU
UDS
7 Day post Hospitalization
Generic Rx Rate
ED Visits
7 Day post Hospitalization
Generic Rx Rate
ED Visits
Visits with PCP
Patient Self Mgt.
Open Access
Visits with PCP
Patient Self Mgt.
Open Access
Framework for Clinical Portion of Annual PI Plan
August
Record Audit
7 Day post Hospitalization
Visits with PCP
September
October
November
December
UDS/MU
PH Medications
UDS
MU
Generic Rx Rate
ED Visits
7 Day post Hospitalization
Generic Rx Rate
Patient Self Mgt.
Open Access
Visits with PCP
Patient Self Mgt.
Monthly Patient Contact Schedule
January
February
March
April
May
June
July
August
September
October
November
December
Item 1
Diabetes
HTN
Asthma
Diabetes
HTN
Asthma
Diabetes
HTN
Asthma
Diabetes
HTN
Asthma
Item 2
Well Child Well Child Well Child Well Child Well Child Well Child Well Child Well Child Well Child Well Child Well Child Well Child -
7-21
Years
3 to 6
7-21
Years
3 to 6
7-21
Years
3 to 6
7-21
Years
3 to 6
/ Lead
/ Lead
/ Lead
/ Lead
Item 3
Immunizations
Immunizations
Immunizations
Immunizations
Immunizations
Immunizations
Immunizations
Immunizations
Immunizations
Immunizations
Immunizations
Immunizations
7-12
- 15 Mo
3-6
7-12
- 15 Mo
3-6
7-12
- 15 Mo
3-6
7-12
- 15 Mo
3-6
Item 4
Chlamydia
Pap/Mam
Colonoscopy
Chlamydia
Pap/Mam
Colonoscopy
Chlamydia
Pap/Mam
Colonoscopy
Chlamydia
Pap/Mam
Colonoscopy
Item 5
Cardiovascular
Osteoporosis / RA
COPD
Cardiovascular
Osteoporosis / RA
COPD
Cardiovascular
Osteoporosis / RA
COPD
Cardiovascular
Osteoporosis / RA
COPD
Item 6
Smoking Cessation
BMI
Chronic Kidney
Smoking Cessation
BMI
Chronic Kidney
Smoking Cessation
BMI
Chronic Kidney
Smoking Cessation
BMI
Chronic Kidney
Periodic Assessment - BCBS
What Needs Measured?
Goal Comparisons
Periodic Assessment - NCQA
NCQA Report Priorities
Data Location and Reporting
NCQA Reporting
Evidenced Based Care - MQIC
Protocol Creation / Modification
Staff / Patient Tools
• PCMH Brochure
• Care Management / Self Management Documentation
• Standardized Work Documentation
• Staff Education Tools
PCMH Brochure
Care Planning
Create Staff Documentation
Success’
• NextGen EHR Implementation
• i2i Tracks Registry Implementation
• Centralized PCMH Functions
• Mailings for all sites using fold and seal mailers
• Report processing and distribution
• One Time download of all immunization in State
Immunization Registry (MCIR) to our EHR
• PCMH Module in Annual Competency Training
• Planning
• Worked Smarter, not Harder
• Made sure Measures met multiple goals
Weak Areas (Failures)
• Open Access Scheduling
• Competing Priorities
• Internal CAHPS Surveying
• Costly
• Time Consuming
• Interfaces
• MCIR Upload
• Identification of Managed Care Population
• 4 different attempts
• Too Large – Wrong Measures – Too Small – Just Right
• Provider Engagement
• Competing Priorities (Productivity / EHR / PCMH)
Pearls
• Education
• Leadership (Administration and Board)
• Provider
• Staff (Clinical and Support)
• Change is Difficult
• Changing to the Chronic Care Model is More Difficult than meeting
the NCQA PCMH Standards
• Staff and Providers do not want to give up the old way
• Competing Priorities
• Care Management Population Selection
• What is your time frame to meet goal? – Work Backwards
• What percent of your proposed patients are seen during that time?
• Who will do Care Magement?
Pearls
• Registry
•
•
•
•
Data Validation
How will you measure various aspects of care?
Will your registry report on those items?
Success is tied to staff proficiency with EHR.
• Standardize
• What will be documented where?
• Who will perform specific ongoing reporting tasks?
• Adopt the “Everyone works to their highest level of
licensure or training” philosophy.
• Live the “Triple Aim” and immerse yourself in PCMH
Pearls
• Communication
• Newsletters
• Reference Materials for Staff
• Investment
• Financial (Registry / Licenses / Education / Staffing)
• Staff Time (Education / New Tasks / Learning Curve)
• Flexibility
• Modify timeline as needed
• Ask for help
Success?
• NCQA PCMH Designation at all 5 sites
• Meaningful Use Payments for Stage 2 (2014)
• Reporting
• Valid Results
• Available for all known measures
• Trending data available
• Improved Quality Scores
• UDS
• Pay for Performance Indicators – All Payers
• Gain Sharing with our new ACO Initiative