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PATIENT-CENTERED MEDICAL HOME Best Practices

POPULATION HEALTH

2 | Population Health

The data and technology PCMHs need to succeed

Controlling costs, demonstrating value and capturing government grants to remain financially successful is status quo for patient-centered medical homes (PCMHs). The PCMH model, which is designed to transform how care is delivered, focuses on care coordination and patient engagement, resulting in increased quality, lower costs and improved patient experience for primary care practices.

While PCMHs stand to do a lot of good by opening up opportunities to providers and creating a unique care delivery model for patients, practices encounter many hurdles on the road to becoming a PCMH. The recognition process can take up to 18 months, and a recognized PCMH must have access to data and technology that provide a complete picture of the health of the organization’s patient population.

RecognitionTo become a PCMH, a provider organization could be recognized by the National Clinical Quality Association (NCQA), for example. The NCQA process-oriented recognition can take up to 18 months to complete and includes:

• Filing an application

• Software training

• Standards and guidelines training

• Purchasing a survey tool

• Applying those standards and guidelines to reform the practice

• Evaluation by the NCQA

Getting paidA PCMH is not compensated by The Centers for Medicare & Medicaid Services (CMS), so its distinct advantage is an open door to private payers and participation in state initiatives. The program’s overall structure allows practices to successfully participate in multiple programs — such as CMS ACOs, meaningful use (MU), the Value-based Modifier (VBM) and other overlapping programs — enabling the organization to capture significant revenue.

Each PCMH program is different across states, initiatives and payers, and payment structures vary tremendously. However, they all follow certain general recognition standards. While they generally maintain the ability to charge a fee for services, the following payment incentives have been observed in different states:

• A set care coordination fee

• Compensation for electronic visits

Takeaways

Greenway Community, our population health management tool, includes analytics, risk stratification, care management and data exchange solutions that enable providers to make more informed decisions and deliver more efficient, effective care.

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• Shared savings

• A percent increase in fees for service

• A per patient-per-month fee, ranging from $1.50 to $24

Processes and measuresBecoming a PCMH involves meeting six separate process goals:

1) The patient-centered access standard aims to provide healthcare consumers access to appointments and team-based care 24/7, whether in person, remotely, on the phone or online.

2) The team-based care standard measures approaches suited to a population culturally, linguistically and in a team-based way. This standard seeks to improve continuity of care by assigning personal clinicians to patients and families, and must also provide access to evidence-based patient education materials, equal access to care and record transfers.

3) The population health management standard provides evidence-based support to patients to manage population health. The standard requires PCMHs to collect demographic information, use EHR systems and track risk factors such as body mass index (BMI), allergies and blood pressure. To promote preventive care, comprehensive health assessments are required and practices must use data to stage proactive care interventions.

4) The care management and support standard guides practices in identifying patients who need care management, referrals, collaboration and medication management. The practice must also encourage self-care at home and work.

5) The care coordination standard focuses on the provider’s tracking and follow-up with patients. This entails tracking lab tests, flagging abnormal results and notifying patients in a timely manner. Practices must also track and follow up with referrals. Finally, the practice must coordinate care transitions by sharing information with hospitals, contacting family members and obtaining discharge summaries.

6) The performance measurement and quality improvement standard requires practices to measure quality performance, costs and resource use, then identify gaps and institute needed improvements.

All of these process improvements require documentation and detailed reporting, which is why the right technology is invaluable to a PCMH organization.

The complete pictureAn organization needs both claims and clinical data. Claims data alone cannot provide insight into the health of a population, because it is specifically designed to service payers and focuses on the patient’s treatment cost rather than clinical facts. Claims data also may not capture a patient’s surgical history or medication allergies, as that information is not assigned a billing code. It is also frequently outdated with certain procedures and diagnoses going un-coded for months at a time.

GREENWAY COMMUNITY ADVANTAGE Greenway Community pulls both claims and clinical data from a variety of resources, such as other EHRs, HIEs, hospital systems and payers, so you have a complete picture of patients’ health.

With these factors in mind, an organization must also rely on the clinical data in its EHRs to fully under-stand a patient’s health. But this data is only as good as its source. To avoid missing critical information, an organization needs a well-integrated IT system and shared information across the enterprise. Its ambu-latory practices should be able to exchange clinical care summaries to give providers the most up-to-date patient information and ensure patients are assigned appropriate clinical risk levels. Hospitals and other providers of acute care should be connected to the data, so that critical information is available on emer-gency department (ED) visits. This connectedness en-ables providers to perform medication reconciliation, help enforce post-discharge instructions and identify where high and avoidable expenditures take place.

Finally, patients themselves are important sources of clinical data. Gaps in charts should be completed at the point of care, and patient data collection should be in-tegrated into the practice’s workflow. Other sources of patient information, such as health information exchang-es and immunization registries, can also provide useful insight, such as a patient’s vaccination history.

4 | Population Health

Risk stratificationOrganizations successful in managing population health employ risk stratification — a statistical process to determine the likelihood of unwanted outcomes — to identify patients at risk of hospitalization or health complications. These organizations break patients into buckets based on their conditions and treatability, and proactively contact patients to bring them in for necessary care interventions. When transitioning to a value-based organization, one of the first things an organization will do is risk stratify its patients to gain an overall view of the population’s health.

GREENWAY COMMUNITY ADVANTAGE Greenway Community uses proprietary technology to tell you not just who is at high risk but also your ability to impact the patient, so you can maximize the use of your care management resources.

How a practice defines its buckets will depend on the types of patients it treats. A typical risk stratification breaks patients into high-, medium- (or rising-), and low-risk brackets. High-risk patients are those who consume the most healthcare services and are most likely to be hospitalized. Rising- or medium-risk patients are generally those who have chronic conditions, and low-risk patients are a practice’s healthy patients. Other models stratify risk based on more defined clinical buckets. For example, a model may place emphasis on patients with chronic conditions that have become out of control for preventable reasons; near the end of their lives; with chronic conditions that have complications; with stable chronic conditions; or healthy patients.

However you define risk, any successful organization will identify its patients with repeated hospitalizations and readmissions. These patients consume the most healthcare services in the acute environment, driving up costs. Often, these trips to the ED are visits that an urgent care or primary care physician could have addressed, or they were preventable through medication and care plan adherence.

Finally, it is important to measure risk intelligently and determine your ability to positively impact a patient’s health. For example, patients who are at the end of their life do not need help with diet and exercise; rather, they need assistance planning end-of-life instructions and with acceptance of death. The use of care management resources, typically midlevel providers, for patients in this stage would be a costly misallocation of resources. However, a patient who is at high risk because of uncontrolled diabetes is a prime target for intervention by a care manager and a potential source of cost savings.

Care coordination and patient engagementAfter identifying patients you can help through data and analytics, the question becomes what to do with those patients. Care managers,

Takeaways

Greenway Community can improve your data analyst’s efficiency by 5 percent.

Greenway Community can improve your care management staff’s efficiency by 10 percent.

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sometimes called care coordinators, are embedded in the organization to address that issue.

GREENWAY COMMUNITY ADVANTAGE Greenway Community’s care management platform, Greenway Community Manager, allows you to manage care coordination activities not just at the frontline of care, but also at the supervisor level. This macro-level view displays managers and pa-tients across the organization, allowing supervisors to assign care managers to patients and make the best use of resources.

A care manager is a person with clinical experience, generally a nurse, who acts on the monthly and daily reports generated by your health information technology (HIT). After receiving or running reports and risk stratify-ing patients, he or she will schedule patients for appoint-ments, manage their transitions of care, and engage with them before and after an appointment. Care managers’ key responsibilities are to keep patients out of the ED, empower patients to self-manage their conditions, and facilitate transitions of care. How a care manager inter-acts with patients will generally depend on the risk level at which a patient falls, with more proactive and involved approaches for patients at a higher risk.

Care managers should actively run reports and analytics that indicate when a patient is at risk of becoming a high healthcare consumer. For example, care managers should actively monitor who in their population has an A1C level over nine, patients over 55 who have not had mammograms or colon cancer screenings, or those who have a high body mass index. The focus of these metrics is identifying the potential onset of the most com-mon chronic conditions.

After identifying these high-risk patients, the care manager’s role is to engage them depending on their

level of risk. Successful care managers employ a variety of communication tools, including:

• Phone calls

• Text messages

• Mailings

• Email

• Secure messages through a patient portal

• Passive contact — waiting for patients to show up and informing them what further care they need at the front desk

If a patient is particularly prone to onset, the care manag-er should contact him or her proactively through multiple means and with multiple attempts until contact is estab-lished. Once the patient is reached, he or she should be scheduled to come in to see the appropriate clinical staff for screenings, labs and other procedures based on his or her condition. Depending on the patient’s history, the care manager should also remind the patient of his or her appointments prior to the scheduled date and day to help decrease no-shows.

After the patient’s initial appointment, the care manager should discuss the patient’s care plan with the primary care physician. This discussion enables the care manager to identify and schedule necessary follow-up appoint-ments. Whether these appointments are with specialists or another primary care provider, it is important for the care manager to track what care the patient receives and what is outstanding.

It is also important to set and track measurable goals with each high-risk patient. For example, if a patient is diabetic, the goal could be to lose a certain number of pounds, compliance with a diet set at certain caloric and carb intakes, or a target A1C level. Following up on these goals builds an understanding of the patient from a clini-cal view and helps hold the patient accountable.

The care manager must also engage the patient’s com-munity. Caregivers and family who support the patient all need to know how they can help navigate their treatment and encourage compliance. Finally, discussed in detail below, patients and their social support network should be given relevant education materials.

With respect to low-risk patients, the care manager’s focus is on providing access and a “light touch” approach. Patients should have access to your organization through multiple points, such as patient portals, phone lines, email, your website and social media. These access points should make it easy to schedule appointments and communicate when and why healthy patients should have appointments. To help with this process, successful care managers often run annual appointment recalls, calling in all patients who have not had their annual screenings or exams in the past year.

6 | Population Health

GREENWAY COMMUNITY ADVANTAGE Using Greenway Community, you can assign patients and custom care plans in a visual way that makes it easy to track and to see where the patient is on his or her path to a healthier life.

Transitions of careManaging transitions of care from the ED is critical for improving population health, preventing future hospitalizations and reducing healthcare costs. Acute events are not only disproportionately expensive, but also traumatic, so keeping patients out of the hospital after admission is an important goal.

A care manager should identify patients with admissions and readmissions to the hospital on a daily basis. This process can be accomplished through daily reporting if the two systems are integrated, or through a managed relationship with the hospital and its staff.

If a care coordinator identifies a patient currently in the hospital, he or she should send a nurse or primary care physician to the hospital to ensure the patient’s care is transparent and the hospital has all the information it needs to best treat the patient.

Post-discharge, the care manager should take several steps to manage the transition of care and transfer to discharge. The best care managers:

• Frequently perform medication reconciliation and review discharge instructions with the patient to avoid dangerous complications that may lead to another hospitalization

• Schedule follow-up appointments with the patient’s primary care physician and other specialists he or she may need to see

• Ensure the patient had a “real” emergency and give advice if the patient could have used other healthcare resources to treat his or her problem — many conditions can be handled by an urgent care facility, helping the patient avoid costly hospital bills and keeping the healthcare organization’s costs down

• Set measurable goals with the patient and monitor his or her progress through personalized communications. Activating the patient’s support network and keeping them apprised of progress, treatment and their care plan — within the confines of HIPAA guidelines — is critical to helping high-risk patients succeed

Patient educationAn essential tenet of population health management is enabling patients to care for themselves at home by providing tools and education. In-office care is only the first step to recovery, so care managers should point patients to resources that help them understand and proactively manage their condition. Patient education should include both passive and active tools, ranging from brochures and disease guides to mobile apps that assist with carb counting or devices to monitor blood pressure.

GREENWAY COMMUNITY ADVANTAGE Greenway Community seamlessly pushes patients identified as at-risk from the analytics platform to the care management platform. It also empowers care managers at each level of the organization, not just the frontline, to coordinate care across the enterprise.

Education should also take place through online and in-person support groups that allow patients to share and learn from each other’s experiences. Care managers can refer patients to community partners, such as hospitals, or the organization can offer and promote its own group classes. For example, if the population you are treating has a high rate of diabetes, you could offer a group class on taking insulin, using an insulin pump and carb counting.

As with all care coordination outreach, a care manager should disseminate educational materials through a variety of methods, such as mailings, email, patient portals, online, social media, during office visits and by phone. By increasing the number of channels used, you also increase the chances of the right information reaching and impacting your patients.

Learn more about how Greenway Health can help you improve the lives of your patient populations and thrive in a value-based care system. Call 877-446-3859 or visit greenwayhealth.com.