1. Integrating Population Health Management into Patient-Centered Medical Home Meeting NCQA MHP Recognition Requirements
CDR Patricia Taylor, NC, USN
Deputy Director Medical Services
Naval Hospital Bremerton, WA

2. Defining the Medical Home
Care Coordination
Specialist care is coordinated, and systems are in place to prevent errors that occur when multiple physicians are involved.
Follow-up and support is provided.
Team Care
Integrated and coordinated team care depends on a free flow of communication among physicians, nurses, case managers and other health professionals (including BH specialists).
Duplication of tests and procedures is avoided.
Patient Feedback
Patients routinely provide feedback to doctors; practices take advantage of low-cost, internet-based patient surveys to learn from patients and inform treatment plans.
Superb Access to Care
Patients can easily make appointments and select the day and time.
Waiting times are short.
and telephone consultations are offered.
Off-hour service is available.
Patient Engagement
in Care
Patients have the option of being informed and engaged partners in their care.
Practices provide information on treatment plans, preventative and follow-up care reminders, access to medical records, assistance with self-care, and counseling.
Clinical Information Systems
These systems support high-quality care, practice-based learning, and quality improvement.
Practices maintain patient registries; monitor adherence to treatment; have easy access to lab and test results; and receive reminders, decision support, and information on recommended treatments.
To understand the health risks and information needs of patients/families, requires a comprehensive health assessment. Uses this patient information to proactively remind patient and clinicians of preventive and follow-up care needed.
-Implementing evidence-based guidelines through point of care reminders for patients. Care team performs pre-visit preparations, assess & addresses barriers when patient has not met treatment goals, follows up with patients/families not keeping important appts.
Activities to support patients in self-management
Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs.
Publically available information
Grundy (2012)
Source: Health2 Resources 8

3. Investing in Primary Care Patient Centered Medical Home
Group Health Cooperative of Puget Sound (Seattle, Washington)
• Cost:
$10 PMPM reduction in total costs
16% reduction in hospital admissions
29% reduction in ER visits
Return on investment 1.5: 1
• Quality:
4% more patients achieving target levels on HEDIS quality measures
10% of pilot clinic staff reporting high emotional exhaustion at 12
months compared to 30 percent of staff in control clinics
Improvement in recruitment and retention
Geisinger Health System (Pennsylvania)
18% reduction in hospital admissions
7 % reduction in total PMPM costs
Return on investment 2:1
74% improvement in preventive care
22% improvement in coronary artery disease care
34.5% improvement in diabetes care
Resource: Grumback & Grundy. (2010)
BUMED Team visited Group Health Cooperative (BUMED Comptroller, MHP PMO, etc)

4. Population Health
- Do this right & it will have a positive affect on readiness, patient experience & per capita cost

5. Population Health Translating Strategy into Action
Focus on Better Health
Partnership between primary care and population health
Prevention and Chronic Care Management
IT tools allowing for actionable, near time data
Embedded training and population health support
-Culture of Change for patients & medical staff: Focusing on health while treating illness. Shifting the control and power out of the hands of those who give care and into the hands of those who receive it.
Population health someone else’s job?
Think prevention & chronic disease management
IT tools that actually give the needed information
Embedded training and population health support

6. Correlation to 2011 NCQA MHP Standards
Identify and management patient populations (PCMH 2: Elements C & D)
Plan and manage care (PCMH 3: Elements A-C)
Providing self-care support and community resources (PCMH 4: Element A)
Standard Two:
Electronic systems used to identify patients who need service
Standard Three: (3C-Must Pass)
Care team performs care management through pre-visit planning, developing plan, and treatment goals
Standard Four: (4A-Must Pass)
Assess self-management abilities
Document self-care plan; provide tools and resources
Counsel on health behaviors
Provide community resources

7. Integrating Planned Care into Primary Care
Planned care for chronic conditions and preventive care
Patient and caregiver engagement
This is all about integrating planned care into the primary care setting. Planned care for chronic conditions & planned care for preventive health needs
Requires patient and caregiver involvement in the healthcare delivery processes

8. Planned Care for Chronic Conditions & Preventive Care
Primary care practices will proactively assess patients to determine need
Provide appropriate and timely preventive care
Use disease registries to track and appropriately treat chronically ill patients
What are your patient’s needs? The population and the individual patient. Can’t provide planned care until you know what your patient population looks like
Focus on preventive care
Identifying and aggressively managing your chronically ill patients with a focus on maintaining health

9. Patient & Caregiver Engagement
Primary care practices will engage patients and families in active participation in goal setting and decision making
Patients will be full partners in truly patient-centered care
No matter what we do, we’ve got to engage our patients & their families in the healthcare. Sometimes that means actually having a conversation about what they are willing to do & developing a plan that assists them in the behavior changes that will make a positive impact.
Making patients full partners in their care requires understanding what patients want to know & how to help them know it. Patients and families can bring useful knowledge to care if they are invited to do so.

10. Integrating Planned Care into the Primary Care Setting
Key components
Leadership support and buy-in at all levels
Roles/Responsibilities defined for entire team
Ongoing training for targeted preventive care and chronic conditions
Information tools for point of care and outreach efforts
Delivery system process redesign
Embedded population health/health educator
-Leadership support at all levels
-Define roles and responsibilities for every member of the team (clerks, medical assistants, corpsmen, nurses, providers, case managers, etc)
Staff training – what, when, & why do they need to focus on specific preventive care & chronic conditions
Tools that will assist staff in maximizing point of care & outreach efforts
Delivery system redesign: not just “vital signs” techs, but integral members of the healthcare team
Embedded specialists should include population health/health educator in a clearly defined supportive role to staff & patients

11. Planned Care Management Process Point of Care
Preventive Health Assessment
Proactive Office Encounter Preparation Process
Planned Care Management at Point of Care – patient appt
Using the Preventive Health Assessment, a tool to assist in preparing for the patient’s office visit

12. Preventive Health Review
Part I: Patient Appointment Information
Part II: Preventive Health Screenings
Part III: Disease and Condition Management

13. Preventive Health Review
Patient action lists are downloaded from CarePoint into our SQL server. This is done manually every Monday AM.
Every morning the appointments for today & tomorrow are automatically downloaded from a CHCS adhoc report into SQL.
SQL then automatically batch generates & automatically s to each Medical Home Team each AM
Thus most appointments are covered by one of these batches:
If appt made greater than 24 hours before
If appt made within the last 24 hours

14. Part I: Patient Appointment Information Part II: Preventive Health Screenings
Part 1: Patient Appointment Information
-Patient Name & identifiers, Clinic being seen in, Provider seeing patient, Appt Date & time
Part 2: Preventive Health Screenings
-Cancer Screening Recommendations (color coded indicates whether action is required. Meaning an order, consult, or appts is made (cervical cancer screenings can be done the day of the appt if patient agreeable)
- Key indicates the specifics about the screening, i.e. CRC screening begins at age screening options (FOBT, Flex sig, colonoscopy)

15. Part III: Disease and Condition Management
Part 3: Disease and Condition Management:
Asthma – Read items in column

16. Proactive Office Encounter Preparation
Staff Roles/Responsibilities
Review PHR during huddle/team meeting
If screenings are flagged “red or due” take appropriate action (colorectal CA, breast CA, or Cervical CA screenings)
If patient has specific chronic conditions review & take appropriate action (Asthma, diabetes, dyslipidemia)
Gather appropriate educational resources

17. Office Encounter Process
Staff Roles/Responsibilities
Support Staff
Review PHR with patient
If screenings are flagged “red or due” take appropriate action (colorectal CA, breast CA, or Cervical CA screenings)
If patient has specific chronic conditions review & take appropriate action (Asthma, diabetes, dyslipidemia)
Provider
Review/reinforce tests/screenings needed
Patient
Takes home PHR
Leaves clinic with appropriate orders, consults, f/u appts
Has appropriate educational resources
Acts on orders and consults
Achieves self-management goals

18. Planned Care Management Process Outreach Efforts
Use CarePoint for Outreach efforts

19. Point out various elements

20. Point out various elements in view

21. Planned Care Management Staff Training Components
CarePoint
Familiarization with various features
Patient Population Management (PPM)
Preventive Care
Chronic Care
CarePoint Skills competencies/PPM knowledge exam
Patient Communication Scripts
Documentation/Exclusions
Staff Trained to use CarePoint effectively

22. Planned Care Management Process Outreach Efforts
Support Staff use CarePoint to identify patients who are overdue or due for tests/screening
Contacts via phone
Unable to contact
Address all patient needs in one phone call
Place appropriate orders/consults /schedule appointments
Document in CarePoint (Notes, exclusions, ordered tests/screenings
Documents in CarePoint. Enters AHTLA t-con with reason for notification
Patient returns call, Communication Room staff can address issue with patient
Three attempts – Letter sent
Review diagram ( may also use secure messaging system)

23. Embedded Population Health/Health Educator
Population Health responsibilities
Streamline CarePoint account application process
Established and conducts CarePoint and Population Management staff training
Clean up data: outside reports, coding corrections, amending records
Provide team updates on HEDIS Captain’s Cup Challenge
Strengthen partnership between Medical Home team and Population Health department
Embedded Population Health/Health Educator extremely valuable to MHP team & patient care processes. Population Health responsibilities include:

24. HEDIS Captain’s Cup Challenge

25. Embedded Population Health/Health Educator
Health Educator responsibilities
Provides individualized patient education in support of PCMH team
Created standard objective-based education curriculums for use by MH team support staff. (Pathways for brief point of care education)
Provides clinical support staff training for specific health conditions and risk factors (PCMH/HEDIS)
Documents self-management plans and goals
This individual also serves as a Health educator. Extremely valuable to the team

26. Impact of Integrating Planned Care into Primary Care
Enhanced Team-based approach
Maximized Provider/patient time
Enhanced patient/caregiver engagement
Improvements in HEDIS measures

28. NH Bremerton Points of Contact
CDR Patricia Taylor
Dr. Dan Frederick
Aimee Aldendorf