1. Achieving PCMH Status Using CHWs
Harold Brown, MBA – Chief Executive Officer
Tammy Smith – Care Coordinator & CHW

2. Today’s Agenda Who are WE and who are YOU?
What is a Patient-Centered Medical Home (PCMH)?
CHW Role in Achieving PCMH Status?
Now What? – Preparing for PCMH Application 2

4. Sterling Health Solutions, Inc
Sterling Health Solutions, Inc., is a Federally Qualified Health Center, located in beautiful Mount Sterling, Kentucky, the heart of East Central Kentucky’s Gateway Area. Mount Sterling is rich in history and culture, with many arts and family-oriented community events scheduled throughout the year. Mount Sterling is situated thirty minutes east of the larger city of Lexington, Kentucky, which is the regional seat of equine, college sports and popular entertainment. Also, Mount Sterling is within driving distances of Louisville, Kentucky, which is the home of the internationally acclaimed Kentucky Derby.
For further information on Mount Sterling and surrounding area, please click on the following links:
Mount Sterling, Kentucky

5. OUR MISSION
To improve the lives for all people in the communities we serve through improved health regardless of the ability to pay for the services.
OUR FOCUSES
Improve the health of the patients in our service area
Increase access to quality healthcare services
Reduce healthcare costs

6. 3 Primary Care Clinic Sites BATH FAMILY HEALTH SERVICES
STERLING HEALTH CARE
Primary Care, Pediatrics, and Behavioral Health Services
209 North Maysville Street, Suite 200
Mount Sterling, KY
STERLING WOMEN’S CARE
Obstetrics and Gynecology
15 Sterling Avenue
Mount Sterling, KY
BATH FAMILY HEALTH SERVICES
Primary Care and Substance Abuse/Behavioral Health Services
44 Water Street
Owingsville, KY

7. 6 School Based Clinic Sites
Mapleton Elementary
809 Indian Mound Drive
Mount Sterling, KY 40353
Montgomery High School
724 Woodford Drive
Mount Sterling, KY 40353
J.B. McNabb Middle School
3570 Indian Mound Drive
Mount Sterling, KY 40353
Camargo Elementary
4307 Camargo Road
Mount Sterling, KY 40353
Mt. Sterling Elementary
6601 Indian Mound Drive
Mount Sterling, KY 40353
Montgomery County Intermediate School
1040 Maysville Road
Mount Sterling, KY 40353

8. What is a Patient-Centered Medical Home (PCMH)?

9. Patient-Centered Medical Home
The medical home, also known as the patient- centered medical home (PCMH), is a team-based health care delivery model led by a health care provider that is intended to provide comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes.
a model of care that emphasizes care coordination and communication
The model is intended to improve the quality and efficiency of care delivery.
A concept centered on managing the health of populations, 1 patient at a time. 9

10. Benefits of the PCMH Model
Quality – Patient Outcomes
Fewer ER visits
Fewer hospital admissions
Lower mortality rates
Better preventive service delivery
Better chronic disease care
Higher patient satisfaction
Groups that have undertaken this redesign process have demonstrated:
ER visits:
Group Health Cooperative – 29% reduction in 2 years
Health Partners – 39% reduction in 5 years
Genesee – 50% reduction in 4 years
Johns Hopkins – 15% reduction in 8 months
SC BCBS – 32.2% reduction
Hospitalization rates:
Group Health – 6% reduction in admissions in 2 years
Health Partners – 24% in admissions in 5 years
Geisinger – 14% reduction in admissions in 2 years
Genesee – 15% reduction in admissions in 4 years
Intermountain – 10% reduction in admissions in 2 years
Johns Hopkins – 24% reduction in inpatient days in 8 months
SC BCBS – 10.7% reduction in admissions, 36.3% reduction in inpatient days
Mortality rates:
Intermountain – 3.5% reduction in 2-year mortality
Preventive Service Delivery:
Geisinger – 74% increase in preventive care in 2 years
Genesee – 137% increase in mammography in 4 years
Colorado Medicaid/SCHIP – 267% increase in well-child visits
Chronic Disease Care:
Health Partners – 129% increase in optimal diabetes care, 48% increase in optimal heart disease care in 5 years
Geisinger – 22% increase in CAD care, 34.5% improvement in diabetes care 10

11. Benefits of the PCMH Model
Efficiency – Cost
Lower total costs of care
Shorter patient wait times
Less staff burnout/turnover
Higher staff satisfaction/productivity
These same groups have demonstrated reductions in total costs of care, patient wait times, and staff burnout.
Total Costs of Care:
Group Health – savings of $10.30 PMPM at month 21
Health Partners – 8% reduction in total costs at 5 years
Geisinger – 9% reduction in total costs at 2 years
Intermountain – savings of $53.33 PMPM at 2 years
Colorado Medicaid/SCHIP – 21.5% reduction in total costs
SC BCBS – 6.5% lower total medical/pharmacy costs 11

12. PCMH Accrediting Organizations
JACHO
Joint Commission on the Accreditation of Healthcare Organizations
AAAHC
The Accreditation Association for Ambulatory Health Care
NCQA
National Committee on Quality Assurance

13. NCQA (PCMH Program)
501(c)(3) dedicated to improving health care quality
NCQA offers “recognition” programs for various aspects of clinical care: diabetes, cardiovascular disease, back pain
One of the recognition programs is for PCMH
3 levels of accreditation: Level 1 (lowest), Level 2, and Level 3 (highest)

14. Scoring a Standard
Each Element in a Standard is worth a certain number of points. To achieve the points, you must complete some (or all) of the factors in that element.
Note: The actual details of scoring each element depends on that specific element and is NOT the same across the board.

15. Point Requirements Level of Recognition Points Required (2011) Level I
35-59 (6/6 must pass)
Level 2
60-84 (6/6 must pass)
Level 3
(6/6 must pass)

16. “Must Pass” Elements Some elements are “Must Pass”
**To “Pass” one of these elements, you must receive a 50% score or higher**
You must pass all 6/6 of the “Must Pass” elements to achieve any level of recognition.

17. NCQA Lingo each “standard” is composed of several “elements”
each “element” is composed of several “factors”

18. PCMH (2011) Overview Enhance Access and Continuity
Access During Office Hours
Access After Hours
Electronic Access
Continuity (with provider)
Medical Home Responsibilities
Culturally/Linguistically Appropriate Services
Practice Organization
Identify/Manage Patient Populations
Patient Information
Clinical Data
Comprehensive Health Assessment
Use Data for Population Management
Plan/Manage Care
Implement Evidence-Based Guidelines
Identify High-Risk Patients
Manage Care
Plan/Manage Care (continued)
Manage Medications
Electronic Prescribing
Provide Self-Care and Community Resources
A. Self-Care Process
B. Referrals to Community Resources
Track/Coordinate Care
Test Tracking and Follow-Up
Referral Tracking and Follow-Up
Coordinate with Facilities/Care Transitions
Measure & Improve Performance
Measures of Performance
Patient/Family Feedback
Implements Continuous Quality Improvement
Demonstrates Continuous Quality Improvement
Report Performance
Report Data Externally

19. CHW Role in Achieving PCMH

20. CHW Definition
“ a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served”
American Public Health Association 2009

21. CHW’s role in the care setting
Community health workers provide seamless, continuous, coordinated, and patient-centered care in the community and clinical sector.

22. Other services provided by CHW
Provide support to both patients and staff
Filter incoming calls for providers, assess the patient’s need or concerns, staffing with the provider and returning a call with the resolution
Connecting patients to resources in the community
Coordinates care between our facility and other facilities
Increases patient access to insurance coverage by helping patient’s sign up on the federal exchange
Ultimately a CHW’s role in this setting is to close the care gaps for the patient’s they serve.

23. PCMH Planning / Steering Committee
Team Includes:
“PCMH Champion” who will help guide the practice through the quality transformation process
“Communicator-In-Chief” who will serve as a point person for interactions with Community Care and other support staff
“Lead Administrator” who will track progress, organize materials, complete the PMCH application (should have computer skills) 23

24. PCMH Planning Team / Steering Committee
Lead Administrator & Chief Communicator - CEO
PCMH Champion - CMO
Clinical Support Staff Rep – DON
Non-Clinical Support Staff Rep – CHW
Expert Support - Consultant

25. PCMH (2011) Overview Enhance Access and Continuity
Access During Office Hours
Access After Hours
Electronic Access
Continuity (with provider)
Medical Home Responsibilities
Culturally/Linguistically Appropriate Services
Practice Organization
Identify/Manage Patient Populations
Patient Information
Clinical Data
Comprehensive Health Assessment
Use Data for Population Management
Plan/Manage Care
Implement Evidence-Based Guidelines
Identify High-Risk Patients
Manage Care
Plan/Manage Care (continued)
Manage Medications
Electronic Prescribing
Provide Self-Care and Community Resources
A. Self-Care Process
B. Referrals to Community Resources
Track/Coordinate Care
Test Tracking and Follow-Up
Referral Tracking and Follow-Up
Coordinate with Facilities/Care Transitions
Measure & Improve Performance
Measures of Performance
Patient/Family Feedback
Implements Continuous Quality Improvement
Demonstrates Continuous Quality Improvement
Report Performance
Report Data Externally

26. Standard 1, Element B Factor 2 Providing timely clinical advice
Filters incoming calls for BH providers. Staffs the issue with the correct provider and places a return call with a resolution.
Factor 4
Documenting clinical advice in the patient chart
Records the interaction in the patient’s chart in the log notes.

27. Standard 2, Element B Factor 1
Coordinating patient care across multiple settings
Gets information about services the provider is referring the patient to and aids in arranging the service.
Factor 7
Gives uninsured patients information about obtaining coverage.
Helps the patient’s sign up for coverage through the federal exchange or refers the patient to the appropriate agency.

28. Standard 2, Element C Factor 3
Provides interpretation or bilingual services to meet the language needs of its population
We have a CHW staff that is bilingual and provides interpretation services for our Hispanic patients.

29. Standard 2, Element D Factor 6
Assisting patient’s/families/caregivers in self-management
Helping the patient/families/caregivers overcome whatever barriers they may be facing in achieving self-management of their mental or health conditions.

30. Standard 3, Element D Factors 1-5
Run reports and send notifications to patients that have care gaps such as chronic health conditions, immunizations or not been seen for an extended period of time.
It is important to help our patients maintain and improve their health. By running reports that are targeted need specific we can send reminder letters to our patients about needed appointments, missing immunizations, preventative screenings and more. This goes a long way in helping close care gaps that can often prevent the patient from reaching or maintaining their goals.

31. Standard 4, Element E Factor 2
Provides educational material and resources to patients.
Helping patients gain access to educational material and resources on a local, state and national level.
Factor 6
Maintains a current resource list on five topics or key community services.
Continually updating resource lists for such things as housing, clothing, food, treatment centers and group meetings.

32. Now What? – Preparing for PCMH Application

33. Next Steps: Applying for PCMH Recognition
Application (free)
Demographic information
Interactive Survey Tool ($Charge – 80 for 2014 Recognition)
Self-directed practice assessment
When ready, submit Interactive Survey Tool, Application, and final application fee

34. Next Steps Build Your PCMH Team:
Identify a “PCMH Champion” who will help guide the practice through the quality transformation process
Identify a “Communicator-In-Chief” who will serve as a point person for interactions with Community Care and other support staff
Identify a “Lead Administrator” who will track progress, organize materials, complete the PMCH application (should have computer skills) 34

35. Next Steps
Begin team discussions about where the manpower will come from. Practice transformation is valuable for your patients and your practice, but it takes time.
Will you:
Be able to reduce your patient load?
Have to extend your hours?
Need to work on the weekends?
Need to shift duties/responsibilities?

36. Next Steps
Peruse the NCQA “Standards and Guidelines” document or other Accrediting Body
This is a long, but important document that is the backbone of the recognition process and familiarity with it is CRUCIAL to your success.

37. Sterling Health Solutions, Inc. 209 North Maysville Street, Suite 200
Mt. Sterling, Kentucky
Phone:
Fax: