Fletcher Allen Primary Care
Medical Home Model of Care
Jeffords Institute for Quality
Randall Messier MT, MSA
Presentation Agenda
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Outline of program
How we started
Medical Home/Panel Management
Community Care Team
Behavioral Health
NCQA
Financing
Patient stories
Medical Home Definition
 The Patient Centered Medical Home is a
health care setting that facilitates
partnerships between individual patients,
and their personal physicians, and when
appropriate, the patient’s family. Care is
facilitated by registries, information
technology, health information exchange
and other means to assure that patients
get the indicated care when and where
they need and want it in a culturally and
linguistically appropriate manner.
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Chronic Conditions Lead to
Illness, Disability, Death
 51% of all Vermont adults have one or
more lifelong health conditions that likely
require ongoing medical care.
 88% of Vermonters >65 report one or
more chronic conditions.
 Ca. 25% of people with chronic conditions
have limitations which restrict normal
activities.
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Global Aim Statement
 We aim to improve care to our patients by
implementing a patient centered medical home.
The process begins with identifying and
evaluating our patients and their current health
status. The process ends with improved
outcomes for our patients within our medical
home. By working on this process we expect to
improve quality, engage and empower patients,
educate, and foster a team approach to care
management while improving efficiency within
the practice. It is important to do this now
because the 1:1 visit alone leaves Primary Care
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unsustainable.
Medical Home & CCT Team
Members
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Jennifer Gilwee, MD, Aesculapius
Eugene Moore, MD, Private
Practice
Pam Farnham, RN, CCT Nurse
Clinical Lead
Jen Daley, MSW, Social Worker
Erica Hoyt, Educator
Mary Ann Ludlow, Dietician
Sue Johansen, Dietician
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Kevin Hatin, YMCA
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Jean Mahoney, Dept Assistant
Audra Jenkins, CCT Coordinator
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Patty Ross,
Medical Assistant
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Dawn Weening, Coordinator, CHI
Nickie Pouteaux, Medical
Assistant
Chris Pellegrino, Quality
Consultant
Nina Buss, Public Health
specialist
Jessica Young, LCSW
Beth Hallock, RN Blueprint
coordinator
Robyn Skiff, Practice Supervisor
Randall Messier, MT, MSA Project
Mgr.
Penrose Jackson, Project Mgr.
Emeritus
Medical Home Model
Community
Specialty Referral
it y
un
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Co
Clinic
•RN
•MA
•PSS
•HIM
Psychiatric Referral
CCT
•Nutrition/CDE
•MSW
•RN
•Exercise/Fitness
•Admin
•VDH
•Health Educator
am
Te
The
Patient
re
Ca
Pa
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lM
an
ag
em
en
t
PCP
Chronic Care Support
Behavioral Health
Acute Care Support
Preventive Care Support
Panel MA
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Prism/Docsite
CCT
What’s in it for
Providers?
PROVIDERS:
 work more extensively with patients with or at risk for
chronic disease.
 use Docsite, a web based program, to track patients
and help manage patient population.
 Panel manager Medical Assistant (MA) helps provider
with care management.
 can refer patients to the Community Care Team to help
facilitate behavior change.
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Community Care Team (CCT)
Providers involved in pilot can refer their patients to the
CCT. Team members provide regular ongoing support as
needed via phone or in person. The team helps patients
set realistic goals and timelines for improving health.
Services include:
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Nutrition help
Exercise advice
Diabetes Education
Medication Management
Behavioral/Mental Health
Connection to community
and financial resources
How Did We Start?
•Evaluated our current system using Clinical
Microsystems process. (Necessary first step)
•Used Clinical Microsystem processes to trial
test of change and implemented several
improvements to test tracking, message
handling, prescription refill etc.
•Cleaned up our registries/started new ones.
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Medical Home
Panel Mgmt./CCT
 Trialed process with one MD.
 Moved to second MD that was supported
by the same clinical team.
 Added one MD at a time to new processes
 All MD’s/staff were involved in design and
review prior to being added to the pilot.
 Roll out lasted 5 months.
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Panel Management
 MD’s determine criteria for screening
patient panel. i.e. A1C value, A1C on time,
Colonoscopy etc.
 Panel MA runs report, and based on
predetermined algorithm designed by the
providers, takes action on report.
 All patients who fall outside of algorithm
are reviewed directly with provider.
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Panel Management
 Searchable database is imperative to
success.
 Predetermined algorithm and query design
standardizes the process for everyone.
 This standard approach systematizes the
preventive care component of panel
management. Freeing up MD’s to be
MD’s.
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CCT
 Started by taking referrals from one MD.
 Roll out mimicked Medical Home roll out.
 Needed to test system, needs, scale
before expanding.
 MD’s involved in determining the CCT
services to be offered.
 Fax referral form instituted.
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CCT Patient Flow
 Visit planner printed for patient visit.
 Patient arrives and roomed as usual
 Staff/MD utilize planner to ensure required
preventive measures are performed,
scheduled or discussed with patient.
 MD determines that patient is a candidate
for CCT.
 MD discusses the program with patient.
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CCT Patient Flow Cont.
 Fax form sent to CCT indicating needs.
 CCT contacts patient with in 24-48 hours
to set up appointment at Aesc, home or at
the CCT location.
 Patient meets with the appropriate CCT
staff.
 1 to 6 visits.
 Note placed in patients chart regarding
visit. Provider contacted if needed.
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CCT Patient Flow Cont.
 CCT team meets weekly to discuss active
cases with entire team
 CCT staff member meets with MD monthly
to discuss active cases.
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CCT Activity
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706 Referrals
1462 visits
46 graduates
295 active patients
143 inactive patients
447 patients seen YTD.
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Integrated Behavioral Health
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Added an on-site LCSW at Aesc.
Provides immediate consultation.
Is a full member of the clinical team.
Works with CCT on follow up and referral.
Patients “DO” come back for visits.
Short term intervention and support.
Complicated long term referred out.
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Medical Home Designation
and Financing
 Agreement with payors was to become
NCQA certified as a patient medical home.
 Payment directly linked to score achieved
on NCQA review.
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NCQA Medical Home Criteria
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Access & Communication
Patient Tracking & Registry Functions
Care Management
Patient Self-Management Support
Electronic Prescribing
Test Tracking
Referral Tracking
Performance Reporting & Improvement
Advanced Electronic Communication
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Proposed PMPM with Insurers
Provider Payment Table
($PPPM for each provider)
Requires 5 of 10 must pass elements
Requires 10 of 10 must pass elements
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NCQA PCMH
Points
Average
PPPM
Payment
0
0.00
5
0.00
10
0.00
15
0.00
20
0.00
25
1.20
30
1.28
35
1.36
40
1.44
45
1.52
50
1.60
55
1.68
60
1.76
65
1.84
70
1.92
75
2.00
80
2.07
85
2.15
90
2.23
95
2.31
100
2.39
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NCQA Scoring & Provider Payment
$3.00
$ PPPM per provider
$2.50
PPPM Payment
$2.00
$1.50
$1.00
$0.50
5 of 10 MP
$0.00
0
10
20
30
40
10 of 10 MP
50
60
70
NCQA PCMH Score
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80
90
100
What We’ve Learned So Far
 Patients love it!! They love the extra time
they have with the team.
 Challenged to have quick outcomes.
 Behavioral Health integration is essential.
 It’s a lot of work to get started!
 Not all Providers embrace systems
change.
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Patient Stories
 70 year old female
 Type II diabetes, Controlled by diet and exercise.
 Patient referred to CCT for help with HbA1C and
weight loss.
 Two appointments with CCT.
 Education on carbohydrates. Plan for diet control
and exercise. Agreed to walk 30 minutes per
day.
 Since December she has lost 20 pounds, is
exercising daily and her blood sugars have been
100-120. She says she hasn’t felt this good in
29
years!
Patient Story
 67 year old man.
 Type II diabetes
 Referred to CCT for nutrition, diabetes education
and exercise advice.
 Met with CCT Nurse. Educated on carbohydrate
counting, healthy diet.
 Referred him for a fitness assessment and
personal training sessions with a trainer at the
YMCA.
 4 months later patient has lost 15 pounds and is
at his goal weight, HBA1C went from 10.2 to 6.2,
and he feels great!
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Medical Home Model
Community
Specialty Referral
it y
un
mm
Co
Clinic
•RN
•MA
•PSS
•HIM
Psychiatric Referral
CCT
•Nutrition/CDE
•MSW
•RN
•Exercise/Fitness
•Admin
•VDH
•Health Educator
am
Te
The
Patient
re
Ca
Pa
ne
lM
an
ag
em
en
t
PCP
Chronic Care Support
Behavioral Health
Acute Care Support
Preventive Care Support
Panel MA
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Prism/Docsite
CCT