1. Medical Home Model of Care Medical Home Model of Care April 23, 2010 Randy Messier, MT, MSA Tupelo Group, LLC

2. 2 Presentation Agenda  Quick Overview of our Story in Vermont  Outline of Medical Home Program  Medical Home Design  Community Health Team (CHT)  Panel Management  Behavioral Health  NCQA Medical Home Certification  Lessons Learned

3. Healthcare Reform In Vermont  Blueprint for Health (2006 – 2008) –Focus: Chronic Care Model/Clinical Microsystems –6 Pilot Communities Received Grants –Launched Statewide Collaboratives w/ 50+ practices  Blueprint for Health (2009 – 2010) –Focus: Integrated Medical Home Model –3 of the 6 Pilot Communities Received Grants –Launched Statewide Medical Home Readiness Collaborative w/ 22+ practices

4. 4 Medical Home Definition  H ealth care setting that facilitates partnerships between individual patients, their personal physicians, and their family.  Care is facilitated by: –registries, information technology, health information exchange  Care is delivered when and where needed.  Care is delivered in a culturally and linguistically appropriate manner.

5. 5 Global Aim Statement  We aim to improve care to our patients by implementing a patient centered medical home.  The process begins with identifying and evaluating our patients and their current health status and ends with improved outcomes.  By working on this process we expect to: –Improve quality –Engage and empower patients –Educate, and foster a team approach to care management –Improve efficiency within the practice  It is important to do this now because the 1:1 visit alone leaves Primary Care unsustainable.

6. Patient Centered Medical Home Panel Mgmt. Care Coordination Behavioral Health Quality Improvement Coach Training Systems Review Systems Design Evaluation Program Design Clinical Outcomes Patient Satisfaction Provide Satisfaction Staff Satisfaction Financial Outcomes Community Assessment Community Activation HLW Matter of Balance Smoking Cessation Self-Management HLW Clinic Training Smoking Cessation IT DocSite PRISM VITL CHT HAP HLW Diabetes Ed Matter of Balance Nutrition Ed Y-Exercise Comm. Referral FAHC Jeffords Institute for Clinical and Operational Effectiveness

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8. 8 Community Health Team (CHT) Providers involved in pilot can refer their patients to the CCT. Team members provide regular ongoing support as needed via phone or in person. The team helps patients set realistic goals and timelines for improving health. Services include:  Nutrition help  Exercise advice  Diabetes Education  Medication Management  Behavioral/Mental Health  Connection to community and financial resources FAHC Jeffords Institute for Clinical and Operational Effectiveness

9. 9 Panel Management  MD’s determine criteria for screening patient panel. i.e. HBA1C value, HBA1C on time, Colonoscopy, mammography, PHQ9 Scores etc.  Panel MA runs report, and based on predetermined algorithm designed by the providers, takes action on report.  All patients who fall outside of algorithm are reviewed directly with provider.

10. 10 Panel Management  Searchable database is imperative to success.  Predetermined algorithm and query design standardizes the process for everyone.  This standard approach systematizes the preventive care component of panel management. Freeing up MD’s to be MD’s. FAHC Jeffords Institute for Clinical and Operational Effectiveness

11. 11 Integrated Behavioral Health  On site LICSW.  Provides immediate consultation.  Is a full member of the clinical team.  Works with CHT on follow up and referral made via EHR. (Makes referral and tracks)  Patients “DO” come back for visits. (No Show rate 5.9%)  Short term intervention and support.  Screening/Brief Intervention/Referral  Complicated long term referred out. FAHC Jeffords Institute for Clinical and Operational Effectiveness

12. 12 Medical Home Designation and Financing  Agreement with payors was to become NCQA certified as a patient centered medical home.  Payment directly linked to score achieved on NCQA review.  Success requires financial reform.  NCQA Standard update coming

13. 13 NCQA Medical Home Criteria  Access & Communication  Patient Tracking & Registry Functions  Care Management  Patient Self-Management Support  Electronic Prescribing  Test Tracking  Referral Tracking  Performance Reporting & Improvement  Advanced Electronic Communication FAHC Jeffords Institute for Clinical and Operational Effectiveness

14. PPC-PCMH Content and Scoring Standard 1: Access and Communication A. Has written standards for patient access and patient communication** B. Uses data to show it meets its standards for patient access and communication** Pts45 9 Standard 2: Patient Tracking and Registry Functions A. Uses data system for basic patient information (mostly non-clinical data) B. Has clinical data system with clinical data in searchable data fields C. Uses the clinical data system D. Uses paper or electronic-based charting tools to organize clinical information** E. Uses data to identify important diagnoses and conditions in practice** F. Generates lists of patients and reminds patients and clinicians of services needed (population management) Pts233643 21 Standard 3: Care Management A. Adopts and implements evidence-based guidelines for three conditions ** B. Generates reminders about preventive services for clinicians C. Uses non-physician staff to manage patient care D. Conducts care management, including care plans, assessing progress, addressing barriers E. Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities Pts34355 20 Standard 4: Patient Self-Management Support A. Assesses language preference and other communication barriers B. Actively supports patient self-management** Pts24 6 Standard 5: Electronic Prescribing A. Uses electronic system to write prescriptions B. Has electronic prescription writer with safety checks C. Has electronic prescription writer with cost checks Pts3328 Standard 6: Test Tracking A. Tracks tests and identifies abnormal results systematically** B. Uses electronic systems to order and retrieve tests and flag duplicate tests Pts76 13 Standard 7: Referral Tracking A. Tracks referrals using paper-based or electronic system** PT4 4 Standard 8: Performance Reporting and Improvement A. Measures clinical and/or service performance by physician or across the practice** B. Survey of patients’ care experience C. Reports performance across the practice or by physician ** D. Sets goals and takes action to improve performance E. Produces reports using standardized measures F. Transmits reports with standardized measures electronically to external entities Pts333321 15 Standard 9: Advanced Electronic Communications A. Availability of Interactive Website B. Electronic Patient Identification C. Electronic Care Management Support Pts121 4 ** Must Pass Elements

15. PPC 7: Referral Tracking  Element A: Referral tracking- Outside of paper medical records and patient visits, the practice uses a paper based or electronic system to assist tracking practitioner referrals designated as critical until the specialist or consultant report returns to the practice: (must pass)(4 points)  100% - Practice uses system that includes all 4 items  75% - Practice uses system that includes 2-3 items  50% - Practice uses system that includes 1 item  25% - No scoring option  0% - System does not include any of the items –Must track referral origin, clinical detail, status and administrative detail –Paper based logs or electronic reports FAHC Jeffords Institute for Clinical and Operational Effectiveness

17. 17 What We’ve Learned So Far  Patients love it!! They love the extra time they have with the team.  Challenged to have quick outcomes.  Behavioral Health integration is essential.  It’s a lot of work to get started!  Not all Providers embrace systems change at the same rate. FAHC Jeffords Institute for Clinical and Operational Effectiveness

18. Significant Findings!  Six month follow-up data after “graduation” –Diabetes patients engaged in CHT  59% of patients with a baseline HbA1c greater then 7 lowered their HbA1c to below 7 at follow up  100% of patients with a baseline depression score of moderate or severe depression lowered their score to mild/not clinically significant  100% of patients with a baseline anxiety score of moderate or severe anxiety lowered their score to mild anxiety at follow up FAHC Jeffords Institute for Clinical and Operational Effectiveness

19. Significant Findings!  Six month follow-up data after “graduation” –Behavioral Health referrals  75% of patients with a baseline depression score of moderate to severe lowered their score to mild/not clinically significant at follow up.  70% of patients with a baseline anxiety score of moderate or severe anxiety lowered their score to mild/not clinically significant at follow up. FAHC Jeffords Institute for Clinical and Operational Effectiveness

20. 20 Questions ?