Results from the Patient-Centered
Medical Home Collaborative
What They Mean and What’s Ahead for
Medical Homes, Health Homes & Rural Hospitals
Anne Shields, RN, MHA
Washington State Department of Health
PCMH Collaborative
• Collaboration of the Washington Academy
of Family Physicians and DOH
• 32 practice teams throughout state
• Two-year practice transformation journey
• Practice teams elect focus on selected
chronic conditions and preventive services
• Collaborative concludes September 2011
PCMH Clinical Measures
Prevention (Quarterly)
Pediatric
– Well child / two age
groupings
• Adult
– Cancer screens,
tobacco cessation
• Geriatric
– Advanced directives,
– Greater than 15 meds
Diabetes (Monthly)
• Improving
Performance In
Practice measures
– American Board of
Medical Specialties
• Clinical outcomes
– Blood sugar, BP, LDL
• Utilization measures
– Foot exams
Blood Pressure Control
• Target range: BP at 130/80 or better
• Over one third of clinics report BP under
control among half or more patients
Current Rock Star
Cheney Rockwood Medical Clinic
75% of patients in target range
Cholesterol Level
• Target range: LDL at or below 100
• One third of clinics have well over half of
patients within target range
• Half of all clinics have 47% or more at
within target range
Current Rock Star
Seattle Polyclinic
72% of patients in target range
Blood Glucose Level
• Target range: HgA1c at or below 9%
• One third of clinics have significant majority
at or below target range
• Half of all clinics have 82% or more of
patients at or below the target range
Rock Stars
Gig Harbor Medical Clinic - 92%
Medical Lake Rockwood Clinic - 95%
Measuring
“Homeness” & Experience
• Medical Home Index
– Self-assessment across six domains
– Data collection in September 2009, 2010, 2011
• Patient Experience Survey
– Based on CAHPS
– Baseline Spring 2009 and post-survey underway
• Provider Burn-out and Team Satisfaction
– Data collection in September 2009, 2010, 2011
Medical Home Index:
At Baseline and One Year
Change in Score Medical Homeness Over Time - all clinics
8.00
September 2009
7.00
6.78
September 2010
6.35
5.85
6.00
5.30
5.30
5.03
Average Score
4.99
5.00
4.19
4.00
3.00
2.00
1.00
0.00
4.44
4.13
3.94
4.01
3.54
4.69
Primary Care Providers
Maslach Burn-Out Inventory
Measured @Baseline and Year 1 ( N=44)
Change in Provider Satisfaction Over Time
6.0
5.1
5.3
Average Score
5.0
September 2009
September 2010
4.0
3.1
2.9
3.0
2.0
1.7
1.4
1.0
0.0
Personal Accomplishment
Emotional Exhaustion
Depersonalization
Provider Team Satisfaction
Item 4 - How stressful would you say it is to work
in this practice?
100
September 2009
September 2010
80
Percent
60
60
53
40
25
20
21
19
11
7
3
0
Very stressful
Somewhat stressful
A little stressful
Not stressful
PCMH Cliff Note Version
• “Rule of thirds” in learning collaboratives
– Rock stars and early adopters
– Middle of the roadsters
– Non-starters
• Degree of medical home implementation
– Improved across the board thus far
• Provider burn-out and team satisfaction
• Clinical measures @ year 1
– No significant progress in prevention measures
• Prevention data difficult to capture and report
– Diabetes measures strong but may be flattening
Rock Stars and Early Adopters
Year 1 Diabetes Measures
(In alphabetical order)
• Redmond Evergreen
Medical Group @
Redmond
• Lyndon Family
Medicine
• Olympic Clinic @
Shelton
• Pacific Medical
Center @ Seattle
• Polyclinic @ Seattle
• Port Orchard Medical
Clinic
• Rockwood Medical
Clinic @ Cheney
• Rockwood Medical
Clinic @ Medical
Lake
What’s Next?
After the conclusion of PCMH Collaborative
• Broaden practice improvement strategies under
recent DOH restructuring
– Includes Perinatal Collaborative and other efforts to
improve outcomes for moms, newborns, and infants
• Launch local TA/training to reach and engage
more providers in more care settings
– Significant role for hospitals in QI
• New partnerships in purchasing and delivery
systems to support health reform opportunities
– Quality, outcomes, and affordability aims
Financing Opportunities
for Medical Homes
• Section 2703 of the Affordable Care Act
– Health home services for Medicaid Enrollees
with chronic conditions
• 2011 Senate Bill 5394
– Promoting primary care health homes and
chronic care management
Is a health home the same thing as
a medical home?
• Health homes may or may not be within the walls of
a primary care practice
• Health homes are designed to be person-centered
systems of care that facilitate and coordinate all care
– Primary and acute physical health services, behavioral
health care, and long-term community-based services and
supports
• Both models aim to improve clinical outcomes and
patient experience while reducing per capita costs
• Medical homes can be – but don’t have to be – the
foundation for a health home
ACA Section 2703
• Allows state to incorporate health home
services for Medicaid patients
• 90% federal matching rate for first two years
• Focus on high need, high cost patients with
chronic conditions, including behavioral health
concerns
• Focus on reducing hospital readmissions,
avoiding ED visits and reducing reliance on
LTC facilities
Six “Health Home Services”
under Section 2703
• Six newly reimbursable services:
1.
2.
3.
4.
5.
Comprehensive care management
Care coordination and health promotion
Comprehensive transitional care/follow-up;
Patient and family support
Referral to community and social support
services
6. HIT to link services, if applicable
• Services may or may not be incorporated
into a primary care clinic
Who can receive
2703 health home services?
• Medicaid beneficiaries with:
– Two or more chronic conditions (mental health,
substance abuse, asthma, diabetes, heart
disease, being overweight)
– One chronic condition and at risk for a second or
– Serious and persistent mental health condition
• Cannot exclude dual eligibles
• Can target individuals within a subset of
specific chronic conditions, or target
geographically
Who can provide
2703 health home services?
• Designated provider: May be physician, clinical/group
practice, rural health clinic, community health center,
community mental health center, home health agency,
pediatrician, OB/GYN, others
• Team of health professionals that link to a designated
provider: May include primary care provider, nurse care
coordinator, nutritionist, social worker, behavioral health
professional
• Health team: A “team of health care professionals” may
include a nurse care coordinator, nutritionist, social worker,
behavioral health professional, community health worker or
other professionals deemed appropriate by the state and
approved by HHS
How will we measure success in
implementing Section 2703?
• States must track and report outcomes in
avoidable readmissions, ED, SNF admissions
and calculate cost savings
• Designated providers must report quality
measures as condition of reimbursement
• Independent evaluator will survey states on
impact of health home services on cost, clinical
and utilization measures
ESSB 5394
– Introduced by Sen. Karen Keiser to promote the
adoption of primary care health homes and
advance chronic care management strategies
– Requires HCA to include health home services
defined in Section 2703 of ACA
– Requires HCA to include health home services
incentives in its managed care contracts and selfinsured plans
– Allows HCA to prioritize health home services to
enrollees with complex, high cost, or multiple
chronic conditions
How will we measure success
for SB 5394?
• State legislation generally aligned with federal
reform
• Outcomes in avoidable hospital, readmissions, ED,
SNF admissions important
• HCA to coordinate discussion with carriers
regarding chronic care management and
principles for effective reimbursement incentives
• Role of hospitals and ED transitions is key factor
• HCA required to report progress in
implementation to Legislature by December
2012
Hospital Transitions
• 18% of Medicare discharges readmitted w/in
30 days at annual cost of $15 billion
• Result of complex interactions that may
include:
–
–
–
–
poor quality care or premature discharge
transitions between providers and care settings
lack of social support and follow-up care
Patient’s behavioral choices or lack of
understanding of discharge instructions
• Readmits more common for some conditions
Heart failure and ESRD
How are we doing on readmissions
within 30 days?
In state ranking of Medicare readmissions as %
of all admits for 31 clinical conditions:
• Washington State in the third quartile (50% to
75% of all admits )
• Neighboring states (OR, ID, AK) all in top
25%
Data from Commission on a High Performance Health System. “State Scorecard
Data Tables.” Supplement to Aiming Higher: Results from a State Scorecard on
Health System Performance. The Commonwealth Fund, June 2007.
Best Practices in Transition Home
WSHA STAAR Pilot Project
• STAAR aims to reduce
readmits by 30 percent
• Key actions include:
– Enhanced Admission
Assessment for PostHospital Needs
– Effective Teaching and
Enhanced Learning
– Real-Time Patient and
Family-Centered Hand off
Communication
– Post-Hospital Care FollowUp
Actions from IHI Guide to Creating Ideal
Transition Home (See WSHA website)
Emergency Departments
Frequently Providing the Wrong Care at the Wrong Time
• 50% of all ED visits non-emergent or
avoidable
• Number of emergency room visits
increased 20% in a decade (96 to 115
million visits)
• The cost of ED visits often 2 to 5 times
greater than cost in alternate settings
True or False?
• Lack of primary care
access is a major
contributor to avoidable
ED visits.
• Lack of or inadequate
health insurance is a
major reason for recent
increases in ED
utilization.
• Major cost savings can
result from focusing on
“frequent fliers.”
Complex Patient Incentives and
Financial Incentives for ED Use
• Recent ED visit
increases in countries
with strong primary
care access
• ED overuse across all
payers and patient
demographics
• Some hospitals make
a business case for
overuse
Effective Practices in ED Alternative Care Pilots
DSHS / WSHA / WACMHC Collaboration
•
•
•
•
•
•
•
•
•
Timely and direct communication between sites
Info sharing
Well-defined proactive referral process
Pain management program
Support from DSHS Pt Review and Coordination
Care coordination
Patient advocate
Clinic/ER liaison
Community-wide education
Final report due July 2011
Medicaid Quality Incentives
• Reducing preventable emergency
department visits is one of five incentive
measures
• Hospital reports on ED reductions due
Sept. 1, 2011
• Rate increases for qualifying hospitals in
2013
Thank you!
Questions or comments?
Anne Shields RN, MHA
Director, Practice Improvement
Office of Healthy Communities
Prevention and Community Health
Washington State Department of Health
Anne.shields@doh.wa.gov
(360) 236 - 3686