PCMHPutting the Patient First:

Using Quality to Transform Primary CareJulia Barton, RN, MSN

Purdue Healthcare Advisors

Purdue Research Foundation 2012

Why PCMH?

Institute of Medicine: Crossing the Quality Chasm (2001)10 Simple Rules

1. Care based on continuous healing relationships2. Care based on patient needs and values3. Patient as the source of control4. Patient access to medical information and

clinical knowledge5. Evidence-based decision making6. Patient safety7. Transparency of information8. Anticipation of needs9. Continuous decrease in waste10. Cooperation among clinicians

Crossing the Quality Chasm: 6 Aims

2001 IOM Report: Crossing the Quality Chasm: A New Health System for the 21st Century• Health care should be:

Safe Effective Patient-Centered Timely Efficient Equitable

The Joint Principles of the PCMH (2007)

Endorsed by the ACP, AAFP, AAP, AOA

Key Characteristics of the Medical Home:• Personal physician• Physician directed medical practice• Whole person orientation• Care is coordinated and/or integrated

across all elements of the complex health care system and the patient’s community

The Joint Principles of the PCMH

Also included that:• Quality and safety are hallmarks of the

medical home Care planning, evidence-based medicine,

clinical decision support, continuous quality improvement, patient participation and feedback, and appropriate Health Information Technology

• Enhanced Access• Payment Based on Value not Volume

The Triple Aim (2008)

• A framework developed by the Institute for Healthcare Improvement (IHI) that describes an approach to health system performance

• The three dimensions are:1. Improving the patient experience of care

(including quality and satisfaction)2. Improving the health of populations3. Reducing the per capita cost of health care( Donald Berwick-The Institute for Healthcare Improvement—2008)

The National Committee for Quality Assurance (NCQA)

• Founded in 1990• Private, independent non-profit healthcare

quality oversight organization• >32 States have Public and Private PCMH

initiatives that use NCQA recognition• >5,000 NCQA-Recognized medical homes

nationwide• PCMH Standards are aligned with Meaningful

Use objectives• 3 Levels of recognition

Patient Centered Medical Home: A Strategy for Quality Improvement

1. Long-term partnerships, not hurried visits2. Care that is coordinated among providers3. Better access through expanded hours

and on-line tools4. Shared decisions so patients make

informed choices5. Lower costs from reduced ER/hospital

use6. More satisfied patients and providers

6 PCMH Standards

PCMH 1: Enhance Access and ContinuityPCMH 2: Identify and Manage Patient PopulationsPCMH 3: Plan and Manage CarePCMH 4: Provide Self-Care Support and Community ResourcesPCMH 5: Track and Coordinate CarePCMH 6: Measure and Improve Performance

6 Must Pass Elements (27 total)

PCMH 1, Element A: Access During Office HoursPCMH 2, Element D: Use Data for Population ManagementPCMH 3, Element C: Care ManagementPCMH 4, Element A: Support Self-Care ProcessPCMH 5, Element B: Referral Tracking and Follow-UpPCMH 6, Element C: Implement Continuous Quality Improvement

Factors

• 149 Total Factors A scored item in an element. For example,

an element may require the practice to demonstrate how the practice team provides a range of patient care services. Each type of item, in this case, is a factor

• 8 Critical Factors A factor that is required for practices to

receive more than minimal points, or in some cases any point for the element

The Factor PathTM

STANDARD 1: Enhance Access and Continuity

The practice provides access to culturally and linguistically appropriate routine care and urgent team-based care that meets the needs of

patients/families

Element D: Continuity

Factors:1. Selecting a personal

clinician2. Documenting patient

choice3. Monitoring team visit

percentage

Key Points: Notify patients about the

process for choosing a personal clinician

Patient’s choice of personal clinician and care team documented in patient’s chart

Monitor the percentage of patient visits that occur with the selected personal clinician and care team

STANDARD 1: Enhance Access and Continuity

The practice provides access to culturally and linguistically appropriate routine care and urgent team-based care that meets the needs of

patients/families

Element G: The Practice Team

Factors:1. Defined Team Roles2. Team meetings and

communication4. Care teams trained to

coordinate care for individual patients

5. Care teams trained to support self-management, self-efficacy and behavior change

6. Care teams trained to manage patient populations

Key Points: Team meetings may include

daily huddles or review of daily schedules, with follow-up tasks

Care team members are trained in evidence-based approaches to self-management support, such as patient coaching and motivational interviewing

STANDARD 3: Plan and Manage CareThe practice systematically identifies individual patients and plans,

manages and coordinates their care, based on their condition and needs and on evidence-based guidelines

Element A: Implement Evidence-Based Guidelines

Factors:1. The first important

condition2. The second important

condition3. The third condition,

related to unhealthy behaviors or mental health or substance abuse

Key Points: Analyze the entire practice

population to determine the important conditions

Conditions can include chronic or recurring conditions such as COPD, hypertension, HIV/AIDS, and asthma

Factor 3 is a critical factor

STANDARD 3: Plan and Manage CareThe practice systematically identifies individual patients and plans,

manages and coordinates their care, based on their condition and needs and on evidence-based guidelines

Element B: Identify High-Risk Patients

Factors:1. Identify high-risk or

complex patients2. Determines the

percentage in its population

Key Points: The practice establishes

criteria and a systematic process for identifying complex or high risk may include

The criteria may include: • Frequent visits for

urgent or emergent care • Frequent

hospitalizations • Noncompliance with

prescribed treatment/medication

• Terminal illness• Multiple risk factors

STANDARD 3: Plan and Manage CareThe practice systematically identifies individual patients and plans,

manages and coordinates their care, based on their condition and needs and on evidence-based guidelines

Element D: Medication Management

Factors:1. Medication reconciliation

for >50% of care transitions

3. New prescription information to >80% of patients/families

4. Assesses medication understanding for >50% of patients

5. Assesses medication response/barriers to adherence for >50% of patients

6. Documents OTC, herbals, & supplements for >50% of patients/families

Key Points: Information given on new

prescriptions includes side effects, drug interactions, medication instructions and the consequences of not taking it

Factor 6 - at least annually, the practice reviews and documents in the medical record

STANDARD 5: Track and Coordinate Care

The practice systematically tracks tests and coordinates care across specialty care, facility-based care and community organization

Element A: Test Tracking and Follow-Up

Factors:1. Tracks lab tests until available,

following up on overdue results

2. Tracks imaging tests until available, following up on overdue results

3. Flags abnormal lab results to the attention of the clinician

4. Flags abnormal imaging results to the attention of the clinician

5. Notifies patients/families of normal and abnormal lab and imaging test results

9. Electronically incorporates >40% of all clinical lab test results into medical record

Key Points: Factor 1 & 2 are critical

factors Flagging draws attention to

results as an icon that automatically appears in the EHR or a manual tracking system with a timely surveillance process

Factor 5 - filing normal and abnormal results in the patient’s medical record for patient’s next office visit does not meet the intent of the factor

STANDARD 6: Measure and Improve Performance

The practice uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient

experience

Element B: Measure Patient/Family Experience

Factors:1. Conduct a survey to

evaluate patient/family experiences

Key Points: The practice conducts a

survey to evaluate patient/family experiences on at least 3 of the following categories: • Access• Communication• Coordination of Care• Whole-person care/self-

management support

Applying Lean to Quality Improvement Efforts

• Lean is a methodology based on providing better quality, identifying value and eliminating waste.

• Lean methodology employs a bottom up approach where improvement ideas and changes come from patients and staff.

• This requires commitment to quality and improvement throughout the organization.

Lean Key Points

• Identify, name and reduce waste• Engage everyone involved to help fix a

broken process• Use visual displays to engage and inform

staff of progress• Agree on standard work and build in training• Managers and senior leaders set priorities

and keep the organization focused

Quality Improvement Strategy

• QI strategy is the driver of PCMH transformation

• Case study: Group Health Cooperative in Seattle, WA used Lean to Implement and Spread the Patient-Centered Medical Home Model of Care– Before: 7% of patients got their questions

answered via phone on their first attempt– After: 65% of patients got their questions

answered on their first attempt

Additional Services Available from PHA• Meaningful Use for Stage 1 & Stage 2• Security Risk Assessment• Consulting• Patient Centered Medical Home Transformation• Lean Six Sigma Healthcare

Allison Bryan, MS, CHESField Operations Manager(765) 496-9791

abryan@purdue.edu

www.pha.purdue.edu

Purdue Research Foundation 2012