1. The Patient Centered Medical Home: What is it? Maeve O’Beirne

2. Introduction The PCMH is a concept that started in the US and has been modified to fit the Canadian context It was developed in order to increase the efficiency and effectiveness of primary care and in turn to decrease healthcare costs

3. The American Patient Centered Medical Home http://pcmh.ahrq.gov/page/defining-pcmh 1.Comprehensive care – Prevention and wellness, acute care, chronic care – Care provided by a team 2.Patient centered – Relationship based, whole person focus, respecting culture and values 3.Coordinated care – Care coordinated across the entire system 4.Accessible services – Enhanced in person hours, after hours phone accessibility – Alternate modes of communication (email, phone) 5.Quality and Safety – Use of EBM, decision support, shared decision making, performance measures, improvement, PREMs and PROMs

5. The Canadian Patient’s Medical Home PMH http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf A family practice defined by its patients as the place they feel most comfortable—most at home—to present and discuss their personal and family health and medical concerns. It is where patients, their families, and their personal caregivers are listened to and respected as active participants in both the decision making and the provision of their ongoing care. It is where a team or network of caregivers, including nurses, physician assistants, and other health professionals—located in the same physical site or linked virtually from different practice sites throughout the local or extended community—work together with the patient’s personal family physician to provide and coordinate a comprehensive range of medical and health care services required by each person. It is where patient–doctor, patient–nurse, and other therapeutic relationships are developed and strengthened over time, enabling the best possible health outcomes for each person, the practice population, and the community being served.

6. Goals Goal 1: A Patient’s Medical Home will be patient centred. Goal 2: A Patient’s Medical Home will ensure that every patient has a personal family physician who will be the most responsible provider (MRP) of his or her medical care.

7. Goals Goal 3: A Patient’s Medical Home will offer its patients a broad scope of services carried out by teams or networks of providers, including each patient’s personal family physician working together with peer physicians, nurses, and others. Goal 4: A Patient’s Medical Home will ensure i) timely access to appointments in the practice and ii) advocacy for and coordination of timely appointments with other health and medical services needed outside the practice.

8. Goals Goal 5: A Patient’s Medical Home will provide each of its patients with a comprehensive scope of family practice services that also meets population and public health needs. Goal 6: A Patient’s Medical Home will provide continuity of care, relationships, and information for its patients.

9. Goals Goal 7: A Patient’s Medical Home will maintain electronic medical records (EMRs) for its patients. Goal 8: Patients’ Medical Homes will serve as ideal sites for training medical students, family medicine residents, and those in other health professions, as well as for carrying out family practice and primary care research.

10. Goals Goal 9: A Patient’s Medical Home will carry out ongoing evaluation of the effectiveness of its services as part of its commitment to continuous quality improvement (CQI). Goal 10: Patients’ Medical Homes will be strongly supported i) internally, through governance and management structures defined by each practice and ii) externally by all stakeholders, including governments, the public, and other medical and health professions and their organizations across Canada

12. Required Elements Measured outcomes http://www.pcnevolution.ca/Pages/default.aspx Engaged Leadership Quality Improvement Strategy Panel Continuous Team Based Care Organised Evidence Based Care Patient Centered Interactions Enhanced Access Care Coordination Patient Involvement

13. Engaged Leadership US – Driven by Funders for some aspects – Driven by regulators (all physicians must be part of 3 QI projects/5yrs to maintain licensure Canada – Driven by governments, taken up by college of family physicians, medical associations Both need cooperation of physicians

14. Quality Improvement Strategy US example – State level committee set direction for state – Departmental cte and a QI cte in each clinic – LEAN board in clinic to outline progress of latest project – Huddles every morning to discuss QI Canadian example – Province level (government funder) sets some requirements – Network level (PCN, LHIN, CSSS) – Individual clinics may have processes

15. Panel Formal rostering of patients Panel Management: – Preventive care (screening) – Ensuring CPGs followed for each patient use EMR alerts – Calling no-shows/ not seen for a while

16. Continuous Team Based Care MD/resident, Nurse Practitioner/Physician Assistant, Some specialists Care Navigator, RNs, Psychologist, Nutrition, Dietician, Social Work, Kinesiology, Pharmacy, Clerk/reception, Referral coordinator, Panel Manager, Medical Assistants Teams meet monthly to discuss general function of clinic and specific patients, use messaging on EMR and a common chart

17. Organised, Evidence Based Care Some dictated by funders Use EMR alerts to ensure guidelines are followed Use EMR to ensure standardised care between clinics/providers Physician retreats to discuss clinic function, QI and standards of care

18. Patient Centered Interactions NP, RN or PharmD for patients that have chronic disease or are vulnerable follow via in person visits, phone calls Care Navigator follows admits/discharge from hospital for 6 weeks, follows high risk patients Use phone calls and e-mail to contact patients with results and reminders Home care physician team, palliative care physician team, adolescent clinic, Walk-in clinic to care for complex patients (depression, cardiac) The Birthday letter Patient portal Patient self management groups Patient advisory Panel to advise on programs Patient satisfaction committee Pamphlet asking what should change Computer access in waiting room to questionnaire

19. Enhanced Access Open access (no or few booked appointments) After hours walk in clinics (run by clinic so records available) On call availability (with access to patient records) Seamless electronic chart shared between community and acute care Agreements with certain specialists – Internal web page with care pathways for suspected diagnosis while waiting to be seen by specialist

20. Care Coordination Referrals done in EMR and can be tracked in EMR Team members all use same EMR record Team meetings to discuss complex or high needs patients Interdisciplinary team on site or in close proximity Some team visits with patient

21. Patient Involvement Patient advisory Panel Patient satisfaction committee Pamphlet asking what should change Computer access in waiting room to questionnaire Patient portal appointments can be viewed, cancelled or requested, refill requests submitted, bills paid, send a message (viewed by panel manager or MA), view own profile Patient self management groups

23. Major points More proactive Involves teams with allied health providers More standardised care between physicians and between clinics

24. Challenges How to ensure physician or funder agenda does not override patient agenda

26. Links American Patient Centred Medical Home http://pcmh.ahrq.gov/page/tools-resources Canadian Patient Medical Home http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/P MH_A_Vision_for_Canada.pdf Evaluation tool for Alberta http://www.pcnevolution.ca/Pages/default.aspx