1. Roni Christopher, M.Ed., OTR/L, PCMH-CCE
Session #E3a
Friday, October 11, 2013
Community Partners and the PCMH
Roni Christopher, M.Ed., OTR/L, PCMH-CCE
Collaborative Family Healthcare Association 15th Annual Conference
October 10-12, Broomfield, Colorado U.S.A.
Collaborative Family Healthcare Association 12th Annual Conference

2. Objectives for this Session
Define PCMH Tenets
Recognize opportunities for PCMH/Community Partnerships
Identify how such partnerships help to fulfill the pursuit of NCQA PCMH recognition
Identify the key components to a successful PCMH/Community Partner PCP extension program

3. THE TENETS OF THE PCMH ACCESS Populations Coordination Engagement
Referrals
Improving
THE TENETS OF THE PCMH
Person

4. The Opportunity and an Example
Pursuit of the NCQA PCMH certification is intense and can be challenging
The amount of responsibility on the PCP can feel overwhelming
We asked the question:
Can a successful model to build a community “extender” the PCP practice help the practice in the pursuit of PCMH?
Would such a relationship make a difference for our patients?

6. Creating the “Skunk Works”
We like skunks:
“…a group within an organization given a high degree of autonomy and unhampered by bureaucracy, tasked with working on advanced or secret projects.”

7. Why Crossroads Makes a Good Skunk…
Crossroads make up
FQHC
In operation since 1992
Inner-City Cincinnati

8. The Council on Aging as Another Skunk
Initial data exchanges with the COA
6000 patient panel
363 (6%) patients 60 years of age and older
32 (8.8%) shared patients (Crossroad PCP patients receiving COA services)
Analyzed clinical outcome
Set shared goals

9. Current Model
COA

10. 160 patients over 60yrs
10,000+ patients
32 shared patients
COA

11. Current Model
COA

12. The Cincinnati Pilot Model
COA

13. Shared Goals Over-Arching Goals:
Formation of a relationship between COA and Crossroad, strengthened by close physical proximity and ease of communication.
COA to provide care coordination of Crossroad's senior patients in an effort to provide greater continuity of care.
CR to collaborate with COA to provide access to Primary Care services and ease of scheduling to patients COA is managing.
To develop a documentation system or process that reduces duplication of documentation for both COA and Crossroad.
Do ALL of the work to contribute to the NCQA PCMH recognition process

14. Look for Shared Goals
To show clinical outcome improvement in the following areas:
Hypertension (greater than 65% of hypertensive patients up to age 85 maintained below 140/90mmHg)
Diabetes (greater than 75% of diabetic patients with HgbA1C maintained at or below 9% - treatment goal is for A1C to be less than 8%)
Tobacco Use (greater than 95% of patients assessed for tobacco use and greater than 50% of smokers to receive smoking cessation counseling)
Behavioral Health (greater than 40% of patients up to age 65 to receive depression screen using the PHQ annually)
Lipid-Lowering Therapy (Greater than 86% of patients with diagnosis of CAD prescribed lipid-lowering therapy as indicated - treatment goal is for LDL to be less than 100)
Colorectal Screening (greater than 40% of patients 50 to 75 who have had a colonoscopy <=10y or sig<=5yrs or annual occult blood)
IVD (greater than 80% of patients with a dx of IVD on aspirin or other antithrombotic)
PAPs (greater than 75% of women 24 to 64 receiving one or more PAP tests at least every 2yrs)
Weight (greater than 60% of patients identified with BMI less than 20 or greater than 25 who have been counseled)
Decrease ED utilization and hospital admissions

15. CREATE THE HAND-OFF and HAND Back
Documentation and Collaboration Goals:
Self-management goals to be documented on all diabetic pts, hypertensive pts, and smokers
Treatment goals to be documented on all diabetic pts, hypertensive pts, and smokers
Assess barriers on patients and document
Follow-up on patients who have not had visits in a certain period of time
Conduct pre-visit preparation
Provide patient with written plan of care
Refer patients for additional care management
Reconcile medications at care transitions
Educate on new prescriptions
Track referrals
Counsel patients on healthy behaviors

16. Ask questions and look for partners
Model and Innovation Goals:
Identify the areas where time or resource prohibit primary care from doing “it all”
Look for partners who could do “it” and do “it” well
Identify current pattern with those partners
Look for a “win-win” pattern with those partners
Test what will/won’t work
Put it in play
DO NOT ASSUME THAT ANYONE BUT YOURSELF UNDERSTANDS WHAT A PCMH REALLY IS!
(maybe not even yourself?)

17. Why was the COA Interested?
Taking a leading role in healthcare transitions for adults
Wanting to understand how to maximize their products
Had services to offer, but did not understand what was needed at the PCP level

18. Where They are Now… Initial stages Hired RN Care Coordinator
Prepared office space
Monitoring key clinical metrics
Handing off and handing back…
Improving coordination for existing shared patients

19. Where We are Now… Future Stages
Recruit Crossroad patients into COA programs
Recruit COA patients without a medical home into Crossroad
Measure outcomes for improvement

20. Lessons Learned
Being a PCMH = learning how to care for the patients who aren’t in your waiting room
Trying to do it “all” is an exercise in futility
There are community partners who truly want to partner
Don’t assume that their desire to
partner equates to knowledge about
what you need

22. Q&A and Contact Roni Christopher, M.Ed, OTR/L, PCMH-CCE