Lyndee Knox, PhD
LA Net A Project of Community Partners
THE PCMH
Change is Hard . . .
Objectives
• Create a common departure point for
discussion to follow
• A 101 overview, not a deep dive into PCMH
• Introduce PCMH efforts underway in L.A.
Presentation Outline
Defining the
patient-centered
medical home
model
PCMH recognition
program
Specialty Care
Connections
Growing support
for the PCMH
model
Efforts to test the
PCMH model
PCMH Evaluations
& Results
Resources for
practices
LA Area
What is a Patient Centered Medical
Home (PCMH)
The patient-centered medical home is "a model for care
provided by physician practices aimed at strengthening the
physician-patient relationship by replacing episodic care
based on illnesses and patient complaints with coordinated
care and a long-term healing relationship." (NCAQ)
A recent Journal of General Internal Medicine provides a core
definition of the PCMH as a team of people committed to improving
the health and healing of individuals in a community.
According to the ACP, it is:
…a vision of health care as it should be
…a framework for organizing systems of care at both
the micro (practice) and macro (society) level
…a model to test, improve, and validate
…part of the health care reform agenda
Other descriptions
• The PCMH is a political construct that includes new
ways of organizing and financing care, while
attempting to remain true to the proven value of
primary care (Stange et al, 2010)
• PCMH requires a compact between payers and
primary care practices. Simultaneously,
– Practices improve their care
– Payers pay the practices more to help them improve their
care
– Neither practices or payers can do it themselves. Both are
needed (T. Bodenheimer)
Based on the Joint Principles
Team-based care:
Personal physician in physician-directed practice teams
Whole person orientation responsible for care or arranging
care for all health care needs
Coordinated care, integrated across health care settings and
community facilitated by registries, IT, HIE etc
Quality and safety emphasis with EBM, point of care
support, performance reporting, patient input
Enhanced patient access to care through open scheduling,
expanded hours, new option for communication
Supported by payment structure that recognizes services
and value
NP/PA
RN/LPN
Medical Assistant
Office Staff
Care Coordinator
Nutritionist/Educator
Pharmacist
Behavioral Health
Case Manager
Social Worker
Community resources
DM companies
Others…
Principles were created by the
ACP, AAFP, AAP, and AOA—representing 330,000 physicians—and IBM
and other major businesses in March 2007
To provide a standard definition of the delivery model and describe the
environment necessary to support it (2007)
Referred to as the Patient Centered
Primary Care Collaborative (PCPCC)
The Patient Centered
Primary Care
Collaborative
(PCPCC), which
formed in 2007, has
over 700 member
organizations
• Organizations representing over 350,000 physicians—
including ACP and other primary care societies, American
College of Cardiology, American Academy of Neurology
• Organizations representing over 50 million employees,
including large employer umbrella groups, and individual
companies such as IBM, General Motors
• All major health plans
• CVS Caremark, including MinuteClinic
• Consumer organizations including AARP
• Bridges to Excellence
• National Association of Community Health Centers
PCPCC organizations attest to their support of the PCMH Joint Principles, including the
belief that the PCMH will “improve health of patients and the viability of the health
delivery system,” and support a better payment model to facilitate implementation
PCPCC on the web: http://www.pcpcc.net
Critique of the PCMH: Some feel it
doesn’t go far enough
• The rushed 15 minute visit and lone doctor model are
central to the problem
• Driven by payment models and tradition
• Team based care is essential to practice of the future
• PCMH may not go far enough in addressing these
issues
T. Bodenheimer
Presentation Outline
Overview of the
patient-centered
medical home
model
PCMH recognition
program
Specialty Care
Connections
Growing support
for the PCMH
model
Efforts to test the
PCMH model
PCMH Evaluations
& Results
Resources for
practices
LA Area
How do you Know a PCMH
When you See One?
Process needed to recognize practices that have and use the capability to provide patient-centered care
Practice recognition ostensibly provides purchasers (employers, government) and patients with
prospective assurance that the practice has capabilities
National Committee on Quality Assurance (NCQA) announced a voluntary recognition process based on
its Physicians’ Practice Connection (PPC) module, the PPC-PCMH in January 2008
• ACP, AAFP, AOA, and AAP helped NCQA develop the module
• Undergoing revisions now, with new version to be released in January 2011
Other entities are developing PCMH recognition/accreditation processes - Joint Commission, URAC,
CARF, AAAHC. MacColl Institute just published a new measure as a teaching/learning tool, and based on
the 8 joint principles.
Recognition Programs for PCMH
Developed or Under Development
Quality Organizations
PCMH Standards Activity
2010
14
NCQA PPC-PCMH Recognition Module; Major
Domains/Standards
1. Access & Communication
2. Patient Tracking &
Registry Functions
3. Care Management
4. Patient Self-Management
Support
5. Electronic Prescribing
6. Test Tracking
7. Referral Tracking
8. Performance Reporting &
Improvement
9. Advanced Electronic
Communication
Each standard contains subelements – 10 of which are
considered “must pass”
Each standard contains sub-elements
10 of which are considered “must pass”
Standards are currently under revision and will be available Jan 2011 – Integrate IT
w/inmore
coreinformation:
domains
For
http://ncqa.org/tabid/631/Default.aspx
Key Points for Level 1 PCMH
Does not require electronic health record
Does require registry & tracking functions
Emphasis is on providing better care through:
• Access to care
• Organization of office structure & processes
• Enhancing patient self-management; addressing health literacy issues
• Introduction of evidence-based guidelines, measurement & quality
improvement
Level 2 → Level 3
Advanced access options for patients
Electronic health record
More, and more complex care coordination and patient support
Robust population management
Advanced reporting and quality improvement initiatives
Additional technology solutions
More Features of a PCMH Practice
Uses each team member to his/her highest capability
Supports cultural competency training for clinical team
Understands health literacy
Establishes connections to the community and available resources
Provides extensive self-management support
Engages a Patient/Family Advisory Group
NCQA Recognition Activity
>1500 practices have received recognition
• 33% Level 1
• 5% Level 2
• 62% Level 3
58 % of practices have < 5 physicians at the site
47% of practices are part of multi-sites
Concentration in the Northeast and Mid-South
• Practices more likely to seek recognition when/where tied to reward
About 66% are adult primary care practices; 15% are pediatric practices
31 (17%) are community health centers
SOURCE: NCQA, July 2010
SOURCE: NCQA, December 2009
Critique of NCQA
• Beal et al created a patient centered definition of a medical home
w/ 4 questions:
–
–
–
–
Do you have a regular doctor or place of care?
Can you easily contact your provider by phone?
Can you easily get care or medical advice on weekends or evenings?
Are your physician visits well organized and running on time?
• Practices doing well on these could flunk NCQA
• Many standards require that a practice have a “plan” to improve,
but do not require demonstration of improvement and no clear
benchmarks in many cases
T. Bodenheimer
Presentation Outline
Overview of the
patient-centered
medical home
model
PCMH recognition
program
Specialty Care
Connections
Efforts to test the
PCMH model
PCMH Evaluations
& Results
Resources
LA area
Complex Delivery
Health care delivery is complex –
e.g., the typical primary care
physician coordinates care with
229 other physicians working in
117 practices
H H Pham, et al Ann Intern Med. 2009;150:236-242
Specialty Care Connections
ACP Council of Specialty Societies PCMH workgroup:
• Developed FAQs on the relationship of the PCMH to specialty
physicians*
• Facilitating the development of the
concept
Emphasis on transitions in care & continuity (e.g.,
referral agreements, care transitions programs)
PCMH is NOT a gatekeeper system
* FAQs available at: http://www.acponline.org/
running_practice/pcmh/understanding/specialty_physicians.htm
Patient Centered Medical Home
Neighbor (PCMH-N) Draft Definition
A specialty practice recognized as a Patient Centered Medical Home
Neighbor (PCMH-N) engages in processes that:
facilitate the efficient,
appropriate and effective
effectively addresses issues
of
support
These processes would take the form of service agreements (compacts) between/among the
participating practices.
Presentation Outline
Overview of the
patient-centered
medical home
model
PCMH recognition
program
Specialty Care
Connections
Growing support
for the PCMH
model
Efforts to test the
PCMH model
PCMH Evaluations
& Results
Resources
LA Area
Combined Commercial and
Medicaid/CHIP PCMH Activity
states trying to improve
medical home availability in Medicaid/CHIP
programs
Commercial projects under way
.
= Identified to have a Medicaid and/or
CHIP medical home initiative
* As tracked by the American College of
Physicians (updated March 2010)
= Identified to have both a private payer and a
Medicaid and/or CHIP medical home initiative
= Identified to have at least one private payer
medical home pilot under development or
underway
Federal PCMH Efforts
Medicare Medical Home Demonstration Project
• Authorized under Section 204 of the Tax Relief and Health Care Act of 2006
• October 26, 2009: Project put on hold by CMS pending legislation that would repeal it and
replace it with a similar pilot
Medicare “Advanced Primary Care” Demonstration Project
• New 3-year project announced by HHS Secretary Kathleen Sebelius on September 16, 2009
• Will allow the participation of Medicare beneficiaries in state-initiated medical home
projects that also include Medicaid and private payers
• Currently seeking applicants – due by August 3, 2010
CMS/Health Services and Resources Administration (HRSA)
• Announced by President Obama on December 9, 2009
• Will evaluate the impact of the advanced primary care practice model on the accessibility,
quality, and cost of care provided to Medicare beneficiaries served by Federally Qualified
Health Centers (FQHCs).
For more information on CMS/Medicare PCMH Efforts:
http://www.acponline.org/running_practice/pcmh/demonstrations/index.ht
ml
Federal PCMH Efforts (cont.)
Veterans Administration
• 820 primary care sites
• 4.5 million primary care patients
• Using the ACP Medical Home Builder
Department of Defense
•
•
•
•
National Naval Medical Center PCMH Pilot
Air Force Family Health Initiative
Tri-Service Medical Home Summit 2009; Second Summit being planned for 2010
“The PCMH model of care will be implemented across the Services” – MHS Policy
Statement on September 18, 2009
PCMH Activities also occurring in: AHRQ, SAMHSA, CDC
Safety-Net Medical Home Initiative
Launched by The Commonwealth Fund, Qualis Health and the MacColl Institute
for Healthcare Innovation
Project duration: April 2009 – April 2013
Project goal – to develop a replicable and sustainable implementation model
for medical home transformation
Five Regional Coordinating Centers (RCCs) have been selected:
• Colorado Community Health Network
• Executive Office of Health and Human Services & Massachusetts League of Community Health
Centers
• Idaho Primary Care Association
• Oregon Primary Care Association & CareOregon
• Pittsburgh Regional Health Initiative
Source: http://www.qhmedicalhome.org/safetynet/index.cfm
Common Practice Support Approaches
in PCMH Demos
Payment – e.g., PMPM, performance bonus, shared savings
Learning Collaboratives – face-to-face and and/or virtual
Practice facilitation– on-site and/or virtual
• ACP Medical Home Builder
Provision of and support for information technology – e.g., registries, EHRs
Data services – e.g., aggregation for patient population management
and performance reporting
Engagement of patients as advisors
Presentation Outline
Overview of the
patient-centered
medical home
model
PCMH recognition
program
Specialty Care
Connections
Growing support
for the PCMH
model
Efforts to test the
PCMH model
Evaluations &
Results on he
PCMH
Resources
LA Area
Evaluation Collaborative sponsored by
Commonwealth
Approximately 14 independent evaluations represented in
the PCMH Evaluators’ Collaborative.
The evaluations are examining a breadth of demonstrations:
• From one payer to multi-payer pilots
• Involve anywhere from 5-70 primary care practices with 28-250 clinicians
• Include 27,000 -- 1,000,000 beneficiaries
• Many include safety net centers, pediatric sites and Medicaid as a payer
• Variety of payment models (hybrid, PMPM, annual comprehensive PC fee)
All of these independent evaluations have comparison groups
Community Implications - Published
Results of PCMH Projects to Date
Group Health Cooperative of Puget Sound
• 29% reduction in ER visits; 11% reduction in ambulatory care
sensitive admissions
• Improvements in diabetes and heart disease care
• Cost neutral after 1 year
Geisinger Health System
•
•
•
•
14% decrease in hospital admissions
Improvements in diabetes and heart disease care
9 % reduction in costs
ROI greater than 2 to 1
Source: PCPCC Pilot Guide, 2009
Community Implications – Published
Results of PCMH Projects (cont.)
Colorado Medicaid & SCHIP
•
•
•
•
Median annual costs $785 vs $1000
Reduction in ER visits & hospitalizations
More well-child visits (72% vs 27%)
Lower median costs for children with chronic conditions ($2,275 versus
$3,404)
HealthPartners Medical Group (MN)
•
•
•
•
39% decrease in ER visits
24% decrease in hospital admissions
Better diabetes and cardiac care
Reduced costs
Source: PCPCC Pilot Guide, 2009
Community Implications
Metcare of Florida/Humana PCMH Program
• Started in November 2008 & Concluded in October 2009
• Studied the impact of the PCMH model in a Medicare Advantage
(MA) capitated group
• Hospital days per 1000 customers dropped by 4.6 percent
compared to an increase of 36 percent in the control group
• Hospital admissions per 1000 customers dropped by three percent,
with readmissions running six percent below Medicare benchmarks
• Emergency room expense rose by only 4.5% for the Metcare group
compared to an increase of 17.4% for the control group
Recent study – National Demonstration Project
•Practices made changes, process measures improved, docs happier,
but patients were dissatisfied and felt disconnected from physician
Source: Metcare Press Release, February 23, 2010
Community Implications
Not yet published: WellMed Advanced PCMH
•
•
•
•
All cause mortality down 34% in last 8 years.
CVD patients BP under control last visit > 90%,
LDL under control >90%
Diabetes - similar numbers
Actual improvement in care are possible and realizable but it will
take huge payment reform on top of the PCMH model.
Source: Metcare Press Release, February 23, 2010
Estimates on Co$t?
Future of
Family
Medicine
Deloitte
Analysis
• Transition costs of $23,000 - $90,000 per
physician
• $15 PMPM for patients with chronic
conditions
• Initial investment of $100,000/FTE
• Ongoing expenses would increase $150,000 per
year/FTE
Future of Family Medicine Report (http://www.annfammed.org/cgi/reprint/2/suppl_3/s1 ), 2004
Deloitte: The Medical Home, Disruptive Innovation for a New Primary Care Model
(http://www.deloitte.com/dtt/cda/doc/content/us_chs_MedicalHome_w.pdf), 2008
What Does it Co$t?
AMA Relative
Value Update
Committee (RUC)
Commonwealth
report
• Average of $40–50 PMPM for
patients with qualifying
conditions
• Using cost data from Medical Group
Management Association and ACP Checkup
Tool for 2006, from 35 practices, found less
than a $1-per-month difference in patient
costs between highest PPC-PCMH scores
and those in the middle and lower thirds.
(Zukerman et al 2009)
AMA (http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-yourpractice/coding-billing-insurance/medicare/ruc-medicare-medical-home-demonstration-project.shtml),
2008
Urban Institute Report - Co-Funded by The Commonwealth Fund and ACP – Available at:
http://www.commonwealthfund.org/Content/Publications/FundReports/2009/Oct/Incremental-Cost-Estimates-For-The-Patient-Centered-Medical-Home.aspx,
Presentation Outline
Overview of the
patient-centered
medical home
model
PCMH recognition
program
Specialty Care
Connections
Efforts to test the
PCMH model
PCMH Evaluations
& Results
Resources to
support PCMH
Advancement
LA area
Some resources for Practices
•
PCPP --- http://www.pcpcc.net/
–
–
Tools for practices, patients
Meaningful Connections: IT and the PCMH
•
National Academy for State Health Policy http://www.nashp.org/node/1681
•
AAP Toolkit http://www.pediatricmedhome.org/start_building/
•
ACP Medical Home builder http://www.acponline.org/running_practice/pcmh/
•
TransforMed resources http://www.transformed.com/TransforMED_is_How.cfm
•
NCQA webex training on accreditation www.ncqa.org/rptraining.aspx
•
MacColl Institute’s Tool PCMH-A http://qhmedicalhome.org/safety‐net/change‐concepts.cfm
•
Planned: AHRQ National Learning Collaborative for Facilitating PCMH advancement
Recent Journal supplements on the PCMH
• AFM Supplement http://www.annfammed.org/content/vol8/Suppl_1/index.shtml
• Health Affairs, 29, no. 5 (2010) supplement on the PCMH
• Annals of Internal Medicine
http://www.acponline.org/running_practice/pcmh/resources_tools/abstracts.htm
Links are available to much of this material on LA Net’s website: www.lanetpbrn.net
Presentation Outline
Overview of the
patient-centered
medical home
model
PCMH recognition
program
Specialty Care
Connections
Efforts to test the
PCMH model
PCMH Evaluations
& Results
Resources to
support PCMH
Advancement
Projects in LA
Local Activities to Support PCMH
• L.A. Care PCMH Initiative
• LA Net CCM and PCMH funded by AHRQ
• L.A. County initiative
LA Net
• Is a Practice-Based Research and Resource
Network (PBRN) for the region
• Focused on improving quality and reducing
disparities and through:
– provider-led research on issues that matter
– supporting local learning and innovation
– implementing best practices
Network for generating &
disseminating good ideas
LA Net (cont)
• Consists of 16 FQHC/CHC “partners”
representing 116 practice sites
• Governed by a board of 80% clinicians, 20%
researchers, others.
– John Kotick – Current Chair
– Felix Nunez – Past Chair
LA NET
• Part of a national network of more than 100
PBRNs in the U.S.
Some recent projects
• Management of Obstructive Sleep Apnea in
Primary Care (AHRQ/CMS)
• National Children’s Study pilot (NICHD)
• Study of AHRQ’s web-based medication errors
and adverse drug event reporting system for
primary care (MEADERS)
Examples of projects
• Replication of a diabetes self-management
program in 23 PC practices in Texas (AAFP,
Lilly, WHO)
• Development of low-cost “talking” survey
software to use with low-literacy patients
available in 7+ languages
AHRQ funded CCM and PCMH project
• Evaluating use of practice facilitation to support 20
FQHC/CHCs in CCM and PCMH changes
• Based on input from steering cmt: Tom Bodenheimer,
Jim Mold, Grace Floutsis, Rich Seidman
• And experts from US and Canada during Consensus
Panel hosted by LA Net in January 2010
Blueprint Vermont, CareOregon, Oklahoma, IPIP, Impact BC, Quality
Counts, QIIP, and others
• Continuation of project by MacColl, RAND, Safety Net
Institute
Long-term goal: Provide sustained
workforce to practices
• Demonstration of Primary Care Extension Program
• Created by recent reform legislation –modeled after
agricultural extension program
• Jim Mold was author - working with us to design
demonstration
• PCMH projects and REC in LA might provide foundation
Acknowledgements
Shari M. Erickson, MPH
Senior Associate, Center for Practice
Improvement & Innovation
Tom Bodenheimer, MD
UCSF
Katie Coleman, MPH
MacColl Institute
Jim Mold, MD
U of Oklahoma
References
• American College of Physicians. 2006. The Advanced Medical Home: A
Patient-Centered Physician Guided Model of Healthcare.
http://www.acponline.org/advocacy/where_we_stand/policy/adv_med.p
df
• American Academy of Family Physicians (AAFP), American Academy of
Pediatrics (AAP), American College of Physicians (ACP), American
Osteopathic Association (AOA). 2007. Joint Principles of the PatientCentered Medical Home. March 2007.
http://www.acponline.org/running_practice/pcmh/demonstrations/jointp
rinc_05_17.pdf
• American Academy of Family Physicians (AAFP). 2004. The Future of
Family Medicine: A Collaborative Project of the Family Medicine
Community. Annals of Family Medicine 2 (1): S3-S32.
• American Academy of Pediatrics, Council on Pediatric Practice. Pediatric
Records and a "medical home." In: Standards of Child Care. Evanston, IL:
American Academy of Pediatrics; 1967: 77–79
Thank you