This continuing education activity is managed and accredited by Professional Education Service...
-
Upload
brandon-henry -
Category
Documents
-
view
216 -
download
2
Transcript of This continuing education activity is managed and accredited by Professional Education Service...
HIV Patient Centered Medical Homes Construction:
A Multi-Site Experience
Erin Gael Friedman Sonali Kulkarni, MD, MPH
Amy Sitapati, MDWayne Steward, PhD, MPH
DisclosuresThis continuing education activity is managed and accredited by
Professional Education Service Group. The information presented in this activity represents the opinion of the author(s) or faculty. Neither PESG, nor any accrediting organization endorses any commercial product displayed or mentioned in conjunction with this activity.
Commercial Support was not received for this activity.
2
DisclosuresErin Gael Friedman
Has no financial interest or relationships to disclose
Sonali Kulkarni, MD, MPHHas no financial interest or relationships to disclose
Amy Sitapati, MDHas no financial interest or relationships to disclose
Wayne Steward, PhD, MPHHas no financial interest or relationships to disclose
3
Learning ObjectivesAt the conclusion of this activity, the participant will be able to:1. Identify the major elements of a patient-centered medical
home (PCMH).2. Characterize how implementation of a PCMH in HIV primary
care settings is similar to or different from implementation in other care environments.
3. Develop a set of questions to help determine if a PCMH model would work well in his or her own clinic.
4
Overview1. Introduction to the Patient-Centered Medical Homes
Demonstration Project Research Initiative2. Introduction to the PCMH Model3. Implementing the PCMH in HIV Care Settings
HIV ACCESS, Alameda County, CADepartment of Public Health, Los Angeles County, CAANCHOR, Owen Clinic, UC San Diego Health System
4. Summary5. Questions & Answers
5
Introduction to the Patient-Centered Medical Homes
Demonstration Project Research Initiative
6
• Supported by the California HIV/AIDS Research Program (CHRP)
• CHRP funds research projects that inform HIV prevention and treatment efforts in the state
• National Advisory Board for the PCMH Initiative includes HRSA/HAB representation
• Funded demonstration sites are all Ryan White Program grantees
Patient-Centered Medical Homes (PCMH) Demonstration Project Research Initiative
• Conduct research that demonstrates the effectiveness of
Patient-Centered Medical Homes (PCMH) for persons with HIV /AIDS in California.
Purpose of the Initiative
• Up to $400,000 per year for three years in direct costs
• Single Institution or Consortium• Research populations represent those most
highly impacted by HIV, particularly those with a history of health disparities and/or over the age of 50.
• Required representative set of critical services provided directly and through referral.
• Electronic health record system.
CHRP RFA: Funding & Eligibility
CHRP RFA: Use of Funds
PCMH Model DevelopmentElectronic Health Record Systems
• Improve electronic exchange of information with other providers
• Improve/expand electronic health record systemDissemination Direct Patient Care and/or Prevention Services
Not Eligible for Funding
GranteesFive PCMH Demonstration Projects
San Francisco Department of Public HealthLA County Division of HIV and STD ProgramsTri-City Health Center (Alameda County in San
Francisco Bay Area)St. Mary Medical Center, Long BeachUC San Diego Health System, Owen Clinic
Cross-Site Evaluation CenterUCSF Center for AIDS Prevention Studies
Introduction to the PCMH ModelWayne T. Steward, PhD, MPH
Principal InvestigatorCross-Site Evaluation Center
Center for AIDS Prevention StudiesUniversity of California, San Francisco
12
National Committee for Quality Assurance (NCQA)
“The PCMH 2011 program’s six standards align with the core components of primary care.”
Access and ContinuityIdentify and Manage Patient PopulationsPlan and Manage CareProvide Self-Care Support and Community
ResourcesTrack and Coordinate CareMeasure and Improve Performance
13
Future of Family Medicine
PCMH has the following characteristics:Personal medical homePatient-centeredTeam approachElimination of barriers to accessAdvanced information systemsRedesigned offices
14
Future of Family Medicine
PCMH has the following characteristics (continued):Whole-person orientationCare provided within a community contextEmphasis on quality and safetyEnhance practice financeCommitment to provide family medicine’s basket of services
15
Synthesis
Key elements of a PCMH:Structure of Provider TeamsStructure and Practices of CareStructure and Design of Information SystemsEngagement of PatientsPerformance Monitoring and Improvement
16
Structure of Provider Teams
Clinical care is designed so that:Patients have a primary care providerProvider is a part of a team that is collectively responsible for
the person’s careCare is coordinated across the health care system and
patient’s communityProviders have a patient-centered focus
17
Structure and Practice of Care
Overall care environment facilitates access. This can be accomplished by:
Co-location of servicesAssistance with health system navigationCoordination and tracking of referralsOpen-scheduling and expanded hoursEnhanced patient-provider communication (e.g., secure
emails)
18
Structure and Design of Information Systems
Providers exchange patient health information via electronic health records to:
Augment quality of care through referral trackingMake use of databases containing evidence-based guidelinesBetter track needed tests or carePromote better patient-provider dialog by facilitating
electronic communications
19
Engagement of Patients
Goal is promote more active patient engagement (more active role) in care. Facilitated through:
Patient portals allowing access to electronic health recordsEducational tools and programsPatient-provider collaboration in development of treatment
plansEncouraging use of available community resources
20
Performance Monitoring and Improvement
Strive for higher quality servicesConsistent review of services provided, both at provider and clinic
levelConducting patient surveys to understand satisfaction or
concerns with services deliveredDistributing performance findings within and outside of the
PCMH
21
22
PCMH Causal PathwayChanges in PCMH elements
(care practices, information systems, and performance monitoring tools
and practices)
Patient engagement
in care
Patient and Provider
Satisfaction
HIV-related health
outcomes
Changes in care (improved coordination
and quality of care)
Implementing the PCMH in HIV Care Settings
23
HIV ACCESS PCMH Demonstration Project
Alameda CountyErin Gael Friedman
Project Director
24
Panel Management DefinitionsPopulation-based, data-driven approach to care
improvement, esp. chronic diseaseTeam-basedRequires registry functionRequires protected timeAllows for shared responsibility, improved
coordination of care and “task shifting”
25
Project Work Plan
26
27
Patient Centered Medical HomeImplementation Continuum
Pre-contemplation (Inconvenient hours, no outreach to missing patients, difficult to reach clinic on phone)
Visualized as PCMH (Philosophic commitment to PCMH and talk about concepts, no action yet)
Organized as PCMH(Patient navigators, panel management, staff huddles, using registry)
Standardized as PCMH (Staff training and job descriptions include new duties, reimbursement is tied to pt satisfaction)
Recognized as PCMH (By NCQA, etc.)
Realized as PCMH (Org culture and operations have fully integrated PCMH)
Doctor and Staff Centered model
PCMH Fully Integrated
Project GoalsImprove health outcomes
Improve continuity of care
Reduce transmission of HIV
28
What We DidLeveraged Countywide alignment of
incentives
Capacity building
Recruited executive leaders as project champions
Used Steering Committee members as on-site educators and movement builders 29
Pilot Snapshot
30
Panel management pilot in early stages at Alameda County Medical Center
Preliminary Clinical Outcomes
6 months post-implementation
31
Denta
l Ref
erra
l
Viral S
uppr
ession
Qua
ntife
ron
or P
PD Pap
0%
40%
80%
120%
Pre-PilotPost-Pilot
Tools We Used: Telling a Story
Innovative use of video
32
Tools We Used: Movement BuildingSteering Committee
33
Tools We Used: Clinic SupportCoaching
Webinars
Home Improvement Bulletin
Workflow analysis & clinic observation
34
What We Learned: Challenges
FQHCs can be a chaotic environment in which to conduct research
Organizational changes at all levelsStaff turnover made it difficult to build
momentumRepetition of message and project objectives
was key
No way to reimburse for panel management activities
35
What We Learned: SolutionsIncentives and priorities must be aligned
Create opportunities for synergistic resource sharing
Leaders must be engaged
System changes take timeMethodical documentation of change is keyJob descriptions must reflect enhanced job
dutiesKeep the focus on the patients
Patients appreciated extra attention during pilot panel management clinics
36
On the Horizon…Embedding PCMH transformation processes
into clinic workflowsMaking PCMH part of “Organizational DNA”
Orientation for staff at participating clinicsPanel Management 101PCMH Concepts
Further engagement of leadersCreating systems of accountability
37
Los Angeles County Patient-Centered HIV Medical Home
Sonali Kulkarni, MD, MPHHIV Medical Director/Principal
InvestigatorDivision of HIV and STD Programs
Los Angeles County Department of Public Health
38
Rationale for PCMH in LACFragmented HIV service delivery
Large service area – over 4,000 square milesMedical and support service providers at different locations and/or agencies
with limited coordination of care across sitesDuplication of services with medical and non-medical case managementPatient information not being shared or used to create care plan that
address both medical and psychosocial problems
Suboptimal health outcomes for HIV patientsRetention in care and viral suppression
39
Ryan White “in Care” Treatment Cascade, 2009
RW System of Care
RW Medical Care
On ART
Retained in HIV Care
Undetectable VL
- 5,000 10,000 15,000 20,000
18,345
12,752
90%
74%
65%
Number of Individuals
40Ryan White Casewatch Data, January – December 2009 (CY2009)
Among RW clients in medical care and on ART, 72% have an undetectable VL.
LAC-PCMH Model
A Medical Care Coordination (MCC) service model to improve health outcomes and care-seeking behaviors for people living with HIV/AIDS
A population health management system (i2i Tracks) that interfaces with the electronic health record (EHR) to enhance HIV panel management and care delivery
41
PCMH Components
Provider Teams
Practice of Care
Engagement of Patients
Information Systems
Performance Monitoring and Improvement
LAC-PCMH: Provider Teams
MCC team consists of an RN, a Master-level Social Worker, and paraprofessional Case WorkerCo-located at HIV clinicWork with all clinic providers to identify and address issues that may be impeding patients’ health
Attend patient appointments as needed Follow-up visits or calls between appointmentsMultidisciplinary case conferencing on regular basis
Physicians, nurses, psychiatrists, MCC team, navigators
Brief interventions and referrals
42
LAC-PCMH: Structure and Practice of care
MCC team works with patients and their providers to:Identify and address medical and psychosocial factors that may affect
patient’s health through assessment and development of individualized care plans
Address preventive health needs (TB screening) or management of comorbidities (out of control diabetes)
Referrals to needed psychosocial services
Deliver evidence based interventions ART adherence intervention Risk reduction intervention (DEBI)
43
LAC-PCMH: Engagement of Patients
The services delivered by the MCC team are intended to increase patient self-care capacities through:
Tracking and monitoring patient acuity levels through formal assessment
Motivational Interviewing and Strengths Based approach to develop individualized patient-centered care plans
Brief, structured interventions to support behavior change around health and well-being
44
LAC-PCMH: Information Systemsi2i Tracks is a population health management software program that
integrates EMR, laboratory, pharmacy, and other patient data systems
Allows providers to track patient outcomes for their panel
Creates reminders for overdue procedures or referrals to improve quality of care
Facilitates care coordination and group based panel management
Created HIV-specific tracking modulePatients with no visit in >6 monthsPatients whose last viral load was >200
45
LAC-PCMH: Monitor and Improve Performance
Health registry to readily generate standard or tailored performance reports for providers
Programmed 20 HIV performance measures
Providers can assess their performance in comparison to other providers in their practiceEasy identification of areas for improvement and patients to follow up with
46
Measure Number Percentage
Syphillis – Completed in past 12 months
150 75.0%
Syphilis – Not Completed in past 12 months
50 25.0%
LAC-PCMH: Lessons Learned
SuccessesCoordination with RW Planning Body critical
MCC teams allocated to all 30 RW funded HIV clinics
CHRP grant has allowed investment of time to develop thorough MCC assessment tools, acuity trees, protocols, and training materials
ChallengesTime line for making dramatic changes to the LAC RW
landscape of services prolongedHiring staff, IT infrastructure to implement disease registry system
47
A Novel Centered Home Optimizing Retention Amy Sitapati, MD Anchor PI & Owen Clinic Director
48
UCSD Owen ClinicANCHOR
Funded by California HIV/AIDS Research Program (CHRP) to serve as a pilot center for application of Patient Centered Medical Home in HIV
Site based focus to improve Retention
The OWEN CLINICUniversity of California, San Diego20 years of experience 3,000 HIV/AIDS patientsHigh proportion of Medi-Cal/ Medicare/ RW funding
Who are we?
CaliforniaHIV/AIDS:112,602
ALAMEDA
ALPINEAMADOR
BUTTE
CALAVERAS
COLUSA
CONTRACOSTA
DEL NORTE
EL DORADO
FRESNO
GLENN
HUMBOLDT
IMPERIAL
INYO
KERN
KINGS
LAKE
LASSEN
LOS ANGELES
MADERA
MARIN
MARIPOSA
MENDOCINO
MERCED
MODOC
MONO
MONTEREY
NAPA
NEVADA
ORANGE
PLACER
PLUMAS
RIVERSIDE
SACRAMENTO
SANBENITO
SAN BERNARDINO
SAN DIEGO
SANJOAQUIN
SAN LUIS OBISPO
SANMATEO
SANTA BARBARA
SANTA CLARA
SANTACRUZ
SHASTA
SIERRA
SISKIYOU
SOLANOSONOMA
STANISLAUS
SUTTER
TEHAMA
TRINITY
TULARE
TUOLUMNE
VENTURA
YOLO
YUBA
San DiegoHIV/AIDScases:11,275HIV/AIDSDischarges:1,211
UC San DiegoHealth System
Owen clinic3,073 (27.2%)
InpatientHIV discharges1,211 (39.6%)
CY 2011 OSHPD Patient Discharge Data
Where are we?
Definition of terms
Epic Ambulatory Care UCSD is running version 2010 of Epic EMR
MyChart Patient Portal Secure website for UCSD patients to view EMR
Population Management Clinical workflow to manage groups of patients that
need similar health screenings
Group Visit (Shared Medical Appointment) A 90 minute office visit with one doctor and 10 patients who are treated sequentially with group observation and discussion
51
Snapshot
Website for HIV literacy and resourcesComputer Training Lab for PatientsSpanish Web Portal for Electronic Medical RecordEHR enhancements
RegistriesPopulation managementProvider Report CardsProvider Efficiency Metrics
Shared Medical Visits
52
Source: National Committee for Quality Assurance http://www.ncqa.org
Spanish MyChart Web Site/Computer Lab
EMR Registry Build
EMR Health Maintenance
Provider Report CardsEMR Performance
Metrics
Shared Medical Visits
PCMH elements addressed
Snapshot
Website for HIV literacy and resources Computer Training Lab for PatientsSpanish Web Portal for Electronic Medical RecordEHR enhancements
RegistriesPopulation managementProvider Report CardsProvider Efficiency Metrics
Shared medical visits
54
Patient Centered Web site
55
Snapshot
Website for HIV literacy and resourcesComputer Training Lab for PatientsSpanish Web Portal for Electronic Medical RecordEHR enhancements
RegistriesPopulation managementProvider Report CardsProvider Efficiency Metrics
Shared medical visits
56
MyUCSDChart in Spanish
Human Translation of Clinical MessagesCompliance and Risk Considerations
Current Laws and Regulations (Important consideration)
Federal HIPAA – Business Associate Agreement (BAA)
State California SB 853: HC providers must provide language services
Proposed Legislation SAFE-ID Act (Safeguarding Americans from Exporting
Identification Data Act): proposed act prohibiting exportation of PI off-shore
Institution Polices and ProceduresInsurance requirements for third party
providers of medical translation servicesOffshoring of medical translation services
Snapshot
Website for HIV literacy and resourcesComputer Training Lab for PatientsSpanish Web Portal for Electronic Medical RecordEHR enhancements
RegistriesPopulation managementProvider Report CardsProvider Efficiency Metrics
Shared medical visits
59
Clinical Performance• Patient satisfaction• Compliance/Billing• Meaningful Use
Provider Performance• EMR use• Provider Report Card
(Standards of Care)
Patient • Demographics• Acuity
Epic System Performance• Response time• Decision
Support• Click counts• Cognitive load
Clinical Metric Model
Individual Provider Quality Indicator Report Cards16 HIVQUAL IndicatorsEach indicator chart contains
Provider score Clinic score HIVQUAL CY 2009 mean
scoreThe indicator sidebar
contains Indicator definitions Provider’s total patient count Provider’s compliant patient
count
64
Provider report cards based on HIVQual measures … circulated by email
Snapshot
Website for HIV literacy and resourcesComputer Training Lab for PatientsSpanish Web Portal for Electronic Medical RecordEHR enhancements
RegistriesPopulation managementProvider Report CardsProvider Efficiency Metrics
Shared medical visits
63
64
Key lessons learnedCore challenges to PCMH uptake
65
On-site: Dissemination of knowledge across diverse silosLimited resourcesComplexity of PCMH construct
Local/Regional:Limited time contactLimited baseline knowledgeState:Relevancy across different sitesDiverse PCMH portfolio and active workNational:
Interest in standardizationSheer number of different care provider
settings,Resources, electronic health platform, isolated HIV Populations within larger health
communities
Summary
66
Comprehensive Model
The PCMH represents a holistic change to clinic organization and approach to care
The model has underlying common objectives, but is ultimately tailored to each clinical environment
67
Diverse Stakeholders
WITHIN a site (e.g., patients, providers, IT department, larger institutions)
ACROSS sites (e.g., providers, IT departments, legal affairs offices, planning groups)
68
Multiple Steps to Implementation
1. Create necessary infrastructure (e.g., IT systems, protocols)
2. Begin using new systems and new protocols
3. Monitor performance
All three steps are necessary to achieve true PCMH status 69
Why the PCMH Model is Appropriate for HIV Care
HIV disease is complex. Treatment may involve expertise from multiple healthcare fields.
Vulnerable populations affected by HIV benefit from complementary support services.
As people with HIV age, often experience co-morbid conditions. Treatments must be coordinated.
70
How the PCMH Model is Unique When Applied to HIV Care
HIV disease has its own routine/preventive care standards.HIV care, particularly in Ryan White funded settings, has a strong
emphasis on support services.Linkages between primary care and support services may
have different complications than linkages between medical specialties.
HIV notable for its impact on diverse populations that have varying levels of health literacy.
Not all patients can engage (participate actively) in the same way.
71
Questions & Answers
72
Contact Information
Erin Friedman: [email protected]
Sonali Kulkarni: [email protected]
Amy Sitapati: [email protected]
Wayne Steward: [email protected]
Obtaining CME/CE Credit
If you would like to receive continuing education credit for this activity, please visit:
http://www.pesgce.com/RyanWhite2012
73