1. L. Gregory Pawlson MD, MPH, FACP
Patient Centered Medical Home
Knowing when we see one
L. Gregory Pawlson MD, MPH, FACP

2. Patient-Centered Medical Home: The Concept

3. The Patient-Centered Medical Home Defined ACP, AAFP, AAP, AOA joint statement – April 2007
Personal physician – each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.
Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

4. Brief History of the evolution of the Medical Home
1980-present
The American Academy of Pediatrics defined the medical home concepts related to caring for children with special needs
2000-present
AAFP and ACP developed and extended the concept to include care for all patients with chronic illness (ACP-Advanced Medical Home; AAFP-Personal Medical Home) and patient centeredness
AAFP, AAP, ACP and AOA (with input from NCQA) develop common definition of “patient-centered medical home” (PCMH) and link PCMH to reform of payment for physicians.

5. PCMH-a sharp end (practice) translation
Closely linked to conceptual frameworks for transforming health care from acute and physician-centered to prevention and chronic care and patient-centered
Chronic care model
IOM Crossing the Chasm report (systemness)
Emergence of disease and care management, health promotion-disease prevention to address defects in care

6. Wagner Model for Effective Prevention and Chronic Illness Care

7. Linkage to all levels of health care Old: Acute Model
Linkage to all levels of health care Old: Acute Model New: Prevention-Chronic
Patient: passive
Clinician: delivers visits and procedures
Microenvironment: supports for visits and procedures
Organization (group): billing and scheduling
Environment: medical necessity benefits and pay for procedures
Patient: engaged in own care
Clinician: provides ongoing planned care
Microenvironment: systems for care management over time
Organization: systems support and feedback
Environment: value-based benefits and payment
I am still not sure everyone on the board understands how the PCMH builds on- and extends, much of what we have been going- especially our physician hospital quality in accred 08- but also our work in DM and even in member connections.

8. Medical home as practice connection for other areas
Patient
Empowerment
Disease-Care
Care Management
PATIENT-CENTERED
MEDICAL HOME
Value-based
Reimbursement and Benefit
Design
Evidence-Based
Primary Care as Brake on
Overuse-Misuse
Would need to emphasize that PCMH ALONE cannot accomplish much- it will have to be linked to and feed on and feed into other efforts to change the way we deliver health care.

9. Linkage of PCMH to Reimbursement: One Model
Pay for Performance
Quality, Resource Use and Patient Experience
Fee Schedule for Visits/Procedures
Payment per Patient for Qualified Medical Homes
(services not normally reimbursed)

10. A lot of potential-some key concerns
Considerations
Demonstrations are needed to show impact
PCMH qualification provides a road map for practices for what leads to quality care; small practices may or may not be able to adapt
Focus is on coordination and information exchange; not gate keeping; sub-specialists who take care of patients over time can serve as PCMH’s
A major role for NCQA is to focus PCMH on being patient-centered
Issue
It won’t solve cost or quality issues
It is just a way to try to preserve small practices
It will create a barrier between specialty care and patients
It is more doctor-centered than patient-centered

11. Sounds good-but how do we know one when we see it??

12. Two roads converged Result: Convergence of PPC Recognition tool
Over the past seven years, NCQA developed, tested and implemented a web based tool to measure how well practices implemented chronic care model
Physician Practice Connection or PPC used in a NCQA recognition program also called the PPC
Over past three years, NCQA has been working on defining and measuring “Patient Centeredness”
ACP, AAFP, AAP and AOA noted convergence of concepts between chronic care model and medical home and need for stronger tie to patient centeredness
Result: Convergence of PPC Recognition tool
and program and PCMH “Qualification”

13. A bit about the PPC tool and Recognition Program

14. Need for tool to measure systems-CCM
Response to IOM reports
To Err is Human and Crossing the Quality Chasm both provide evidence on critical importance of systems
Change from “blaming” individual clinicians for mistakes and shortfalls to improving systems so clinicians can succeed
Raise awareness of physicians of importance of systems in enhancing quality
Research Translation: Link health services research on systems to clinical practice

15. Steps in Development of PPC
Document evidence base linking specific system to clinical performance
Convene expert panel to review evidence and suggest standards/measures
Conduct analysis of practice defects using six sigma process (with GE in Bridges to Excellence project)
Create standards (aka structural measures)
Test tool for reliability and for validity by showing linkage to clinical process and outcome measures and to patient experience of care
Implement tool in NCQA recognition program-linked to payment for “systemness”

16. Conclusions from Initial testing of PPC tool
Assessment of systems-CCM is feasible though challenging
Finding from testing PPC strong indicate that review of documentation or on-site audit needed to verify some systems
Overall score on PPC correlates with better quality on clinical measures (diabetes etc) but NOT on patient experience of care
Educating physicians and practice staff about systems is high priority
More research on relationship of systems to quality and patient experiences is needed

17. Overall NCQA PPC Recognition Program
Recognition is based on:
Responses in Web-based Survey Tool
Supporting documentation attached to Survey Tool
Each element specifies type of documentation
Reports
Reports from EHR, registry, practice management & billing systems
Documented processes
Policies and procedures, protocols
Records or files
Medical record review – documented in NCQA’s workbook

18. PPC Recognition (current-Sept 2007)
Recognized practice sites – 273
Physicians practicing at recognized sites – 2,137
Characteristics of recognized practices
Practice Size
Median number of physicians – 6
Number of solo practitioner sites - 27
Practice Specialties
57% - Primary Care
19% - Pediatrics
9% - Cardiology
2% - OB-GYN
13% - Multi-specialty

19. Current PPC Initiatives
BCBS NC
CareFirst (BCBS plan-DC metropolitan area)
BTE pilot markets – OH-KY, NY, New England
Silicon Valley – Health Information Technology
MVP Health Plan (New York)
CHPHP (Health Plan, New York)
Most successful projects linked to pay for performance

20. BTE Use of Recognition Programs
National Measure set
Physician Activation
Consumer Activation
Physician Office Link (POL)
Physician Practice Connections (PPC)
Up to $50 pmpy
Physician-level report card, and patient experience of care survey
Diabetes Care Link (DCL)
Diabetes Provider Recognition Program (DPRP)
Up to $100 pdppy
Diabetes care management tool, and rewards for care compliance
Cardiac Care Link (CCL)
Heart Stroke Recognition Program (HSRP)
Up to $160 pcppy
Cardiac care management tool, and rewards for care compliance

21. Linking the PPC to the PCMH

22. Content of PPC-PCMH-Wagner CCM Patient Centered Medical Home
Delivery System Design
Patient Centered Medical Home
Clinical Information Systems P C
Decision Support
Self- Management Support
This shows the multiple instruments that are being built from the PSAS- (RWJ systems project)- the PSAS is a paper survey research tool, the Physician Office Link is a web based version that has been developed specifically for the GE Bridges to Excellence Project (pay for performance) and the Practice Systems is a web based version that in in development for use in a NCQA recognition program and LEAP IV is the proposed fourth leap for the Leapfrog Purchaser group.
Community Support
Wagner CCM
What’s Included? (Infrastructure)
How Much Used? (Extent)
What Functions? (Implementation)
Evidence and Scoring (Verification)

23. Work on tool to identify PCMH’s
AAFP, AAP, ACP AOA reviewed, refined and then endorsed modification of PPC (PCC-PCMH) as desirable tool for “qualifying” medical homes
CMS medical home demonstration project included in TRSCA legislation
NCQA with Mathmatica and Center for Health Systems Strategies awarded contract for assisting in design of MH demo

24. PPC-PCMH Content and Scoring
Standard 1: Access and Communication
Has written standards for patient access and patient communication**
Uses data to show it meets its standards for patient access and communication**
Pts 4 5 9
Standard 2: Patient Tracking and Registry Functions
Uses data system for basic patient information (mostly non-clinical data)
Has clinical data system with clinical data in searchable data fields
Uses the clinical data system
Uses paper or electronic-based charting tools to organize clinical information**
Uses data to identify important diagnoses and conditions in practice**
Generates lists of patients and reminds patients and clinicians of services needed (population management) 2 3 6 21
Standard 3: Care Management
Adopts and implements evidence-based guidelines for three conditions **
Generates reminders about preventive services for clinicians
Uses non-physician staff to manage patient care
Conducts care management, including care plans, assessing progress, addressing barriers
Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities 20
Standard 4: Patient Self-Management Support
Assesses language preference and other communication barriers
Actively supports patient self-management**
Standard 5: Electronic Prescribing
Uses electronic system to write prescriptions
Has electronic prescription writer with safety checks
Has electronic prescription writer with cost checks
Pts 3 2 8
Standard 6: Test Tracking
Tracks tests and identifies abnormal results systematically**
Uses electronic systems to order and retrieve tests and flag duplicate tests 7 6 13
Standard 7: Referral Tracking
Tracks referrals using paper-based or electronic system** PT 4
Standard 8: Performance Reporting and Improvement
Measures clinical and/or service performance by physician or across the practice**
Survey of patients’ care experience
Reports performance across the practice or by physician **
Sets goals and takes action to improve performance
Produces reports using standardized measures
Transmits reports with standardized measures electronically to external entities 1 15
Standard 9: Advanced Electronic Communications
Availability of Interactive Website
Electronic Patient Identification
Electronic Care Management Support
**Must Pass Elements

25. Implementing and Evaluating PCMH-Proposed Model
Office Systems
Decision Support
Information Technology
Delivery System Design
Patient Support
Individual
Clinician-Staff
Attitudes, behaviors
and proficiencies
Educational
Support
Inputs
Output
Patient Centered
Coordinated Care
NCQA
Qualification
as PCMH
(PPC-PCMH)
Boards
Evaluation
Programs
Tools
Patient
Experience
of Care
Measures
(CG-CAHPS)
Clinical Process &
Outcome Measures
(underuse,
misuse, resource use)
(NQF endorsed)

26. Recent Developments Major concern: Proliferation of Approaches
12/06–CMS medical home demonstration project included in TRSCA legislation
NCQA, in collaboration with Mathematica Policy Research and Center for Health System Change, have received a contract from CMS for assisting CMS in planning PCMH demo
2007–Increasing interest from health plans, employers and consumers
Creation of Patient-Centered Primary Care Collaborative by ERISA Employers to advocate for PCMH projects
Interest from private payers
PCP shortage
Controlling costs
More than 50 active “leads”- with several close to implementation
Major concern: Proliferation of Approaches
Confusion of Practices-Blurring of Meaning

27. Moving Forward
Critical need to do meaningful demonstration projects USING COMMON METRICS to evaluate whether:
PCMH can be successfully implemented on large scale
Linking PCMH to revised reimbursement accelerates adoption and use of systems in clinical practice
Implementation of PCMH leads to
higher quality of clinical care
enhanced patient experiences of care
Lower (or at least more rational) resource use/cost
In addition, ACP, AAFP, AAP and AOA want to show that PCMH leads to renewed interested in primary care

28. Questions? Contact: Pawlson@ncqa.org

29. Appendix Slides: Development and content of PPC-PCMH

30. Goals of PPC Measure Development
Develop measures for evaluating systems use and effectiveness in prevention, chronic illness and if possible patient safety
Create measures that are “actionable” at level of physician office practice
Validate measures by relating them to existing disease-specific performance measures and patient perceptions of care

31. Study of Validity: Accuracy of Self-Report
Test accuracy of self-reports of practice systems using on site audit as “gold” standard
Varies by domain, by staff position, and by medical group
The predictive value of a positive report of a practice system is generally high.
Overall agreement with the on-site audit ranges from high (clinical information systems, quality improvement) to low (care management, population management).
Several factors may explain lack of agreement
Variable implementation of systems across sites and conditions
Variations in staff members’ exposure to systems
Lack of familiarity with systems
Conclusion: Need Audit or Documentation

32. Studies of Correlation of PPC with Clinical Performance and Patient Experience
Preliminary results from Minnesota (California and Massachusetts in prep)
Overall PPC score, and sub-scores have positive correlation with higher clinical performance on most measures (diabetes, CV, asthma)
Overall PPC score does NOT appear to correlate with patient experiences of care
Presence or absence of EMR per se, correlates ONLY WEAKLY with clinical measures
However, practices with fully functional EMR’s achieve highest scores on PPC

33. Using the PPC in Practice

34. Use of PPC, DPRP and HRSP in BTE
Employers want to improve the quality of care their employees receive, and they want to increase the value of their health care spend:
BTE Programs have actuarially validated savings and BTE recognized physicians deliver higher quality care
Employers want operational simplicity:
BTE is now administered by licensed or certified administrators, mainly health plans
Physicians want to be measured by reliable and valid measures and independent third party organizations:
BTE’s Provider Performance Assessment Organizations and measurement systems are accepted by the physicians
Physicians need to know up front what performance is expected of them and what they will get for achieving it:
BTE’s Operations give physicians a market-wide view

35. Three levels of recognition, based on total points achieved
PPC Scoring
9 standards = 100 points
Three levels of recognition, based on total points achieved
Recognized—Level 1
25 – 49 points
Recognized—Level 2
50 – 74 points
Recognized—Level 3
75 – 100 points
Not Recognized (or reported)
0 – 24 points