NJAFP Medical Home Project and Health Information Technology in Medical Home Practices Cari Miller Director, Advocacy and Program Operations May 26, 2010 © NJAFP

Today’s Presentation New Jersey Academy of Family Physicians (NJAFP) Patient-Centered Medical Home (PCMH) Patient-Centered Medical Home Pilot Project Health Information Technology Tie-in

New Jersey Academy of Family Physicians (NJAFP) Non-profit medical association for Family Medicine (Family Physicians) –Approximately 1800 New Jersey members –Largest primary care association in New Jersey Full time staff Office in Trenton Web site:

NJAFP Mission Promote excellence in the standards and practice of family medicine to benefit the citizens of the state of New Jersey

Advancing the Mission Endorse and promote the importance of the physician/patient relationship* Procure, provide and support continuing medical education Promote/support family medicine legislatively Assist medical students interested in family medicine *Focus area for today’s presentation

Patient-Centered Medical Home (PCMH) The Patient-Centered Medical Home is not a place. It is a model of care that provides continuous, comprehensive, coordinated, compassionate, culturally sensitive care, and fosters a partnership between patients and their physician and personal healthcare team, in an environment of trust and mutual responsibility.

PCMH (cont) Model and principles developed and endorsed by: –American Academy of Family Physicians (AAFP) –American Academy of Pediatrics (AAP) –American College of Physicians (ACP) –American Osteopathic Association (AOA)

PCMH Fundamental Characteristics Personal physician –Physician drives and coordinates care Physician directed –Oversee and coordinate multidisciplinary office team responsible for care and coordination of services including access and communications Patient-centered care –Provide and coordinate care across specialties, throughout life stages, in a culturally and linguistically appropriate manner

PCMH Fundamental Characteristics (cont.) Coordination of care –Integration of care across specialties and settings, supported by health information technology including registries, electronic health records, personal health records and health information exchange Quality and safety –Implement/use evidence-based medicine, clinical-decision support tools, coordinated care planning and patient self- management for continuous quality improvement, physician reporting and feedback Payment –Recognize value of PCMH through higher payment rates and incentive payments

PCMH Recognition National recognition can be obtained –National Committee on Quality Assurance (NCQA) Builds consensus around important healthcare quality issues by working with large employers, doctors, patients, policymakers, and insurers to decide what’s important, how to measure it, and how to promote improvement; develops quality standards and performance measures for health care entities –Others

NCQA PCMH Recognition Assesses if practices are operating utilizing components of medical home concepts –Practices complete online data collection tool Provide documentation to validate responses –Nine standards/more than 30 elements Includes 10 must pass elements –Three levels of recognition

Plan of Action for Primary Care NJAFP/Horizon Blue Cross Blue Shield of New Jersey (Horizon) Pilot Project

Project Overview Mission –Accelerate assimilation of New Jersey primary care practices receiving patient-centered medical home (PCMH) designation to help ensure highest quality of care is provided Goal –Implement a comprehensive project resulting in primary care practices putting processes and systems in place to receive designation and begin operating as PCMH

NJAFP Roles Design, implement and oversee all activities –Recruitment –Monitoring “active” practice participation –Created and deployed curriculum for practices to achieve NCQA recognition and attain quality metric goals Dedicated resource for practices –Trainings and communications –Liaison with NCQA –Tools, resources, materials –Quality improvement –Health information technology

Horizon Roles Provided funding for project –NJAFP infrastructure –Care coordination fee/defined payment to practices receiving NCQA PCMH recognition –Share cost savings with practices Patient attribution list development and dissemination Collaboratively identify quality measures and metrics

Pilot Project Project components –NCQA PCMH Recognition Care coordination fee/per member per month fee –Quality metrics/cost savings Sharing in costs savings for those practices achieving quality metric goals Focus on adult patients with diabetes Additional measures include prevention services and screenings

Project Components and Time Frames NJAFP/Horizon project agreement began (Feb. 2009) Recognition project implementation (March 2009 – Oct. 2009) Quality metrics/cost savings component implementation (Oct – Sept. 2010) Evaluation/lessons learned/successes (Nov – Winter 2011)

Participating Practice Demographics Practices located in 15 (out of 21) counties Solo, medium and large family practice, internal medicine sites, hospital owned sites, residency programs –Single location practices: 25 –Multi-location practices: 9 Two to nine sites

The Numbers More than 60 practice locations More than 165 primary care physicians Number of patients –Largest practice Number of Horizon patients with diabetes: 619 –Smallest practice Number of Horizon patients with diabetes: 23 –Average size practice Number of Horizon patients with diabetes: 194

Recognition Component Practice kick off meeting to launch project NJAFP developed and implemented 16 week educational curriculum for practices –Collaborative and consultative model NJAFP team provided guidance, assistance, resources and tools –Policy and process development and review –Documentation review and assessment –More

NCQA PCMH Recognition NCQA PCMH –Nine standards and 30 elements/items To achieve recognition –Practices must score points and pass must pass elements Three levels of recognition and 100 points –Level 1 ( points/5 must pass elements) –Level 2: ( points/10 must pass elements) –Level 3 (75+ points/10 must pass elements)

NCQA PCMH Recognition Standards 1.Access & Communication 2.Patient Tracking & Registry Functions 3.Care Management 4.Patient Self- Management Support 5.Electronic Prescribing 6.Test Tracking 7.Referral Tracking 8.Performance Reporting & Improvement 9.Advanced Electronic Communication

Amazing Accomplishment in ONLY Four Months (or Less) ! 34 practices submit for recognition 8/7/09-9/21/09 –First practices received recognition 9/10/09; project required NCQA recognition by 10/30/09 –Currently 32 practices received recognition Level 1: 21 practices Level 2: 4 practice Level 3: 7 practices –Several were paper-based practices –Average number of points achieved: 69.59

Pilot Project Care Coordination Fees Practices receiving quarterly care coordination fees –Per member/per month fee First quarterly payment October 2009 through December 2009 –Practices received in December 2009 –Average practice will receive additional $35,000/yr

Continuing the Journey: Transitioning to a Patient- Centered Medical Home

Practices are Changing Due to NCQA PCHM survey submission, practices have made changes Survey conducted in early September –Results of 22 practices that responded –All practices responding made changes

Changes Made “ Did you make changes… due to submission for PCMH, if so which standards/elements? ” Most frequently practices made changes regarding Standards/Elements 1A and 1B –Next frequent changes made to Standards/Elements 7A (referral tracking) and 6A (test tracking/follow up) –Fewest changes made to 5B and 5C (e-prescribing) 9A and 9C (advanced electronic communications)

Changes Made (cont.) “List one change made in the practice that you deem has important impact as practice transforms to PCMH?” Top changes (in order) –Test tracking –Improved inter-office/team communications –Patient satisfaction surveys –Flow sheet implementation

Changes Made (cont.) “List one change made in the practice that you deem has important impact as practice transforms to PCMH?” Additional changes –Pre-visit planning –Implementing guidelines –Standardize and formalize office procedures and policies –Select physician leader –Patient portal –Audit processes

Current Activities Practices working on meeting/exceeding quality measure goals Communicating PCMH status with specialists, hospitals, service venues and others –NJAFP provided template letters Very successful Care coordination activities Horizon Physician Network Executive interactions Sharing of best practices among practices and with recognized leaders Other

Successes 32 practices PCMH recognized and transforming practice in ONLY four months! Practice satisfaction with project extremely positive Recognition for Horizon and NJAFP Waiting list of practices interested in future participation

Practice Feedback “Better follow up for patients and awareness of our deficits, realizing that we need to implement an electronic record to maintain control and provide better follow up to all our patients, it is difficult to keep control in a paper based system and always there is gaps in the care. The project made us aware of many aspects that need improvement in the education and training of our staff to better serve our patients.” “We consistently implemented guidelines for important conditions. Best practices for both clinical and administrative were put into an organized system. Communication between administration and physicians as well as physician to patient are more cohesive in nature and outcomes are tracked and easily accessible.”

Physician and Practice Engagement and Transformation Our practice is committed to the PCMH concept. We are working with our entire staff from the front desk to the physicians on diabetes management we've made a number of other related efforts that we hope will work synergistically to improve outcomes and cost. We have redesigned our web site and added an interactive patient portal to improve communications. I have personally been working with the CEO and senior information management staff at our primary hospital to develop same day communications about our patients utilizing the hospital and ER. We have identified a significant number of homebound patients who have poor regular follow-up and primarily surface during acute situations, and we have already interviewed and will be hiring a fellowship trained geriatrician to manage these patients at home, or in other outpatient residential settings. For the patients identified as high risk, we have put an electronic note on the front of those specific electronic records and have educated our staff about the fact that these patients are high risk and that they need to be particularly attentive and thoughtful about medication refills and getting these patients seen as quickly as possible when they call to schedule a problem visit.

Implications for HIT Greater focus on technology in PCMH model –Care facilitated by registries, information technology, health information exchange and other means to assure patients get appropriate care when and where needed, in culturally and linguistically appropriate manner

Implications for HIT (cont.) To enhance the PCMH community full access to necessary clinical and other information obtained at various sites is needed (physicians' offices, laboratories, hospitals, nursing homes and more) –Current model encourages practices to use electronic health records, but does not focus on integration with others’ systems Consider incentives for primary care physicians, other physicians, hospitals and others to exchange information, improve coordination, and support shared decision making

HIT Professionals Should Ponder… Important practice components for recognition –Practices have clinical data system with clinical data in searchable data fields –Practices can generates lists of patients and reminds patients and clinicians of services needed (population management) –Coordinates care/follow-up for patients who receive care in other settings

HIT Professionals Should Ponder… Important practice components for recognition –Uses electronic system to write prescriptions which can also conduct safety and cost checks –Uses electronic systems to order and retrieve tests and flag duplicate tests –Transmits reports with standardized measures electronically to external entities –Uses advanced electronic patient communications including interactive website

“It is not necessary to change. Survival is not mandatory.” – William Edwards Deming

Questions Cari Miller Director, Advocacy and Program Operations New Jersey Academy of Family Physicians 224 West State Street Trenton, NJ