1. April 2014 * PCMH and Health Coaching

2. * Purpose * Provide an overview of Patient Centered Medical Home, Population Health Management and the role of the Health Coach in PCMH, Population Health initiatives and working with individual clients.

3. * Objectives * Identify two components of a Patient Centered Medical Home * Describe two ways a Health Coaching interaction differs from a typical patient/staff interaction * Identify one action you can take to help improve the health of your patients that contributes to Population Health Management

4. * Poll Question * Show of hands * Who works in a clinic that has attained Patient Centered Medical Home designation? * What factors drove this change?

5. * Triple Aim * Enhanced patient experience of care * Improved quality * Improved efficiency

6. * Why become a PCMH? * Demonstrates that you and your colleagues put the patient at the center of care * Continuity of care * Quality * Patient Safety * Enhanced reimbursement for clinic * Relationship building with patient and team * Improved quality of work life

8. * NCQA 2011 Standards for PCMH Recognition * Enhanced Access and Continuity * Identify and Manage Patient Populations * Plan and Manage Care * Provide Self-Care and Community Support * Track and Coordinate Care * Measure and Improve Performance

9. * NCQA 2014 Standards for PCMH Recognition * Patient-Centered Access * Team-Based Care * Population Health Management * Care Management and Support * Care Coordination and Care Transitions * Performance Measurement and Quality Improvement

10. * Our path to PCMH * Focus on Population Health in Diabetes * Wagner’s Chronic Care Model * Data driven * Implementation of Registries and EHR * NCQA Diabetes Recognition for providers * Health Coaching

11. * Wagner’s Chronic Care Model

12. * Population Health Management Slide provided by the Clinical Health Coach Training Program 3% of population 39% of cost 40% of population 41% of cost 50% of population 7% of cost

13. * Cost of Chronic Disease * Social * Emotional * Economic * Physical

14. * The coordination of care delivery across a population to improve clinical and financial outcomes, through disease management, case management and demand management. * Population Health Management

15. * MMS path to Population Management in Diabetes * In 2000 MMS implemented the Improving Diabetes Outcomes project in 13 clinics * Wagner’s Chronic Care Model

16. * MMS path to Population Management in Diabetes * ADA Standards of Care for Diabetes * A1c in past 12 months and value * LDL in past 12 months and value * Microalbumin in past 12 months * BP < 130/80 * Dilated Retinal Exam in past 12 months * Monofilament foot exam in past 12 months

17. * MMS path to Population Management in Diabetes * The Dual Challenge of Diabetes and Hypertension project * Diabetes Recognition Program * Wellmark Collaboration on Quality * Health Coaching * PCMH * IME Health Home

18. * MMS path to Population Management in Diabetes * Data * Excel spreadsheet initially * CDEMS Registry (free download) * Wellcentive Registry * Implementation of Electronic Health Record * Currently building reports that will allow us to query EHR

20. * Population Management

21. * Best Practice Guidelines * National Quality Forum http://www.qualityforum.org * US Preventive Services Task Force http://www.uspreventiveservicestaskforc e.org/recommendations.htm

22. * Best Practice Guidelines *NCQA http://www.ncqa.org * Diabetes Recognition Program * Heart/Stroke Recognition Program * PCMH Recognition

23. * Driving Forces: Past * In 2000 it was the right thing to do * No monetary incentive * Possible negative financial impact in FFS environment * Pay for Performance programs * Insurance companies – quality and cost containment

24. * Driving Forces: Present & Future * Patient Centered Medical Home Recognition * Financial benefit to clinics * Affordable Care Act * CMS’ move to Value Based instead of Fee for Service Payment * No payment for readmission in 30 days * ACO

25. * Ruby Slipper Moment * The moment the patient recognizes that the power to make the changes lies within.

26. * Video Examples * The Ineffective Physician: Non-Motivational Approach - YouTube The Ineffective Physician: Non-Motivational Approach - YouTube www.youtube.com/watch?v=80XyNE89eCs * The Effective Physician https://www.youtube.com/watch?v=URiKA7CK tfc

27. * Motivational Interviewing - OARS+E * Structuring the interaction using OARS+E * Open ended questions * Affirmation * Reflection * Summarizing * Eliciting Change Talk

28. * Health Coaching - WAIT * Why * Am * I * Talking

29. * Health Coaching - Righting Reflex * We automatically want to fix things * Advice giving * Directing the patient * You should …. conversations * Not recognizing the person’s power to make change from within

31. * “ I knew I needed to fulfill a previously set goal of walking 30 minutes a day but I easily made excuses and put off walking…….Carol and I talked about it. She didn’t tell me that I had to walk for exercise. She said just enough to make me want to do it. That motivated me to become more disciplined…Now that I have established the habit with Carol’s coaching, walking has become a pleasure that I look forward to.” * A1c improved from 7.4 to 7.1 in 6 months with the walking program * Patient Quote

32. * A NCQA PCMH Experience * Credible data is imperative to success * Front end functions must be done well to submit a successful application * Eg. 50% of all patients who request an electronic copy of their health information must be provided it within 3 business days * Electronic system with functionality a must have

33. * A NCQA PCMH Experience * Coordinating care across the continuum * Must support patients and demonstrate this is done * Provide input to key brochures * Patient access key * Application requires extreme attention to detail * Do not hesitate to contact reviewer with questions

34. * You matter in the PCMH * Your work benefits your patients, coworkers and the clinic’s bottom line * Be prepared for change *Be willing to stretch *New processes and workflows * Work to the top of your licensure *Leverage technology

35. * PCMH TEAM * Care delivery in a PCMH is a TEAM EFFORT * Huddle Video link

36. * How do I contribute to PCMH? * Enhance Access and Continuity * Chart Scrub * Pre-visit Planning * Run daily huddle * Identify and Manage Patient Populations * CMA roles vary - some are in data analysis roles in a clinic

37. * How do I contribute to PCMH? * Plan and Manage Care: * Pre-visit Chart review : * Identifying gaps in care * Addressing those gaps contributes to improving the health of individual patients and the entire patient population

38. * How do I contribute to PCMH? * Provide Self-Care and Community Support * Look for the patient’s strengths and capitalize on those strengths * Utilize patient education materials * Link patient to community resources

39. * How do I contribute to PCMH? * Track and Coordinate Care * Referral Tracking System * Measure and Improve Performance * Utilize Clinical Guidelines in your daily work * Utilize data to improve care

40. * Thank You Contact Information: Carol Brinkert RN, BAN, CHC brinkerc@mercyhealth.com Danielle Pingel, MHA danielle.lentsch@mercyhealth.com