1. EXPLORING CONNECTIONS PCMH & CCHH
Lori Hinga
Melody Robinson

2. Why is it important to view PCMH and CCHH as different, yet connected ?

3. PCMH
Patient Centered Medical Home--The patient-centered medical home is a way of organizing primary care that emphasizes care coordination and communication to transform primary care into "what patients want it to be." Medical homes can lead to higher quality and lower costs, and can improve patients’ and providers’ experience of care.
Patient focused Prescriptive in benchmarks and government directed
Traditional partners tend to be health focused
Improvements to clinical services delivery

4. CChh
Community Centered Health Home--Effectively integrating community prevention into health services delivery
Community focused
Directed by the community
Broad range of partners
Improvements in broad policy and system changes

5. connections Comprehensive Patient Center/Community Coordinated
Accessible
Quality and Safety
Date Driven

6. Before Implementing CCHH…
Current ‘Operational Health’ of the Organization
Engaged Leadership
Efficient Workflow/Process
Standardized
Sustainable
Reliable Data Management
Effective Data Entry
Efficient / Scheduled Data Extraction
Evidence Based Benchmarks
Trending and Reporting (Dashboards)
Performance/Quality Improvement
(Based on Benchmarks / Trends)
Electronic Health Registry
Efficient (Interfaced)
Population Health Management
Care Team Implemented
Roles Identified
Trained
Engaged
Value-based care requires a complete transformation of many business and financial processes
For a large practice, leadership must be aligned with this vision and…have the ability to implement change management strategies throughout all levels of the practice -
Efficient Workflow/Process
Care Management / Care Coordination / Referral & Diagnostic Test done electronically and monitored for completion
Everyone is performing the same tasks the same way EVERY TIME
Sustainable – workflow performance is manageable for all disciplines
Data is entered into the same reportable field by all staff EVERY TIME
Reportable data is extracted easily and routinely
“Real” data is benchmarked against national standards (HEDIS, AMA ETC)
Data is trended for increase/decrease/unchanged prior to reporting
Pay close attention to negative trends – trends identified must be rolled into a performance improvement plan
Registry – Set up to meet the individual organizational requirements
Must be validated and used to manage certain populations –
The Care Team MUST be have a complete understanding of their individual roles
Training MUST be prioritized – from new employee orientation and beyond
Employee engagement requires satisfied and knowledgeable employees
Care Management / Care Coordination / Referral & Diagnostic Test done electronically and monitored for completion.

7. Transitioning to CCHH Requires…
Change Management
Non-Traditional Thinking
Standardized / Sustainable processes
Accurate / Reliable data
Developing / Maintaining a reporting schedule
Developing / Maintaining a quality dashboard displaying evidence based benchmarks and ‘real-time’ trends
Deliberately analyzing and translating information to actively encourage meaningful change in the community
Identifying established community coalitions, neighborhood associations etc.
Relationship building with community partners, associations and coalitions
Change management - Prior to implementation, practices need to plan for the changes in work flow required to operate in a value-based care environment. Planning ahead can help minimize inefficiency and staffing pressures
Many initiatives and even more requirements…manage organizational change or it will manage you
Must begin training/teaching/encouraging ‘outside of the box’ thinking throughout the organization – top – down and bottom – up
Data that is not reliable is an example of ‘WASTE’ - Spend time developing templates/workflows (front end) to ensure accuracy on the back end
Analyze ALL data – share with the community – this will encourage meaningful change
CONNECT AND BUILD trusting relationships with established community partners

8. PCMH to CCHH PCMH CCHH Internal Data Collection and Evaluation
Prioritizes Chronic/Acute Conditions
Identifies Risk(s) Associated with Conditions
CCHH
External Data Sharing with Community Partners
Discusses Environmental Risk(s)
Discusses Opportunities for Community Change/Improvement
Prioritizes and Plans
PCMH - VALID DATA IS KING – Review data routinely and systematically – identify trends – look for common risks
CCHH- Bring your data to the table – share identified risks – be open to discussion and community input
Discover opportunities for meaningful change – identify strategies for improvement
Prioritize and Plan – With your community

9. PCMH to CCHH The Connection…
CCHH - Assessment
Standard set of questions related to community, social and economic conditions
PCMH Systematic/Elements 2014 (NCQA)
Assessment
3.B Height, Weight, BMI, Tobacco Use
2.C.1 - Assessing population diversity
2.C.2 - Assessing language needs
3.C.2 - Family / Social / Cultural Characteristics
3.C.6 - Behaviors affecting health
3.C.7 - Mental health /substance use history
3.C.9 - Depression Screening using standardized tool
4.A BH Condition / High Cost / High Utilization / Poorly Controlled or Complex Conditions / Social Determinants of Health / Referrals by Outside Organizations
4.B.3 - Assesses and addresses potential barriers to meeting self-care goals
4.E.7 - Assesses usefulness of identified community resources
You are collecting this data which is needed to establish a strong CCHH
Examples of community, social and/or economic conditions?

10. PCMH to CCHH The Connection…
CCHH – Analysis
PCMH – Standards/Elements 2014 (NCQA)
Analysis
1.A.5 Monitoring no-show rates
1.A.6 Acting on identified opportunities to improve access
3.D.1-4 Identifies populations of patients and reminds them of needed care
4.A.6 Monitors the percentage of total patient populations identified through its process and criteria
6.A.1-4 Measures or receives data on two immunization measures / two other preventive care measures / three chronic or acute care clinical measures / data stratified for vulnerable populations
6.B.1 Measures or receives quantitative data on at least two care coordination measures
6.B.2 Measures or receives quantitative data on at least two utilization measures affecting health care costs
6.C.1 Conducts a survey to evaluate patient/family experience on at least three of the following categories: Access, Communication, Coordination, Whole person care/self-care management support
These required elements of PCMH provide the foundation for Analysis
What might be risks associated with no-show rates?
6.B.1 Examples of two care coordination measures
6B.2 Examples of two utilization measures affecting health care costs
Patient Experience Survey- What does it tell you? Are you conducting a Patient Satisfaction Survey because HRSA mandates it or are you using this tool to improve the organization/community?

11. From PCMH to CCHH Poorly controlled or complex conditions
Diabetic Registry (PCMH)
Diabetic patients greater than 19 years old with an A1C > 8 living within zip code XXXXX
What are the risks associated with this condition (CCHH )?
Poor dietary intake?
Lack of exercise?
Medication compliance?
Minimal understanding of condition?
3.C.6 – Behaviors affecting health
6.A.3 Measures or receives data on three chronic or acute care clinical measures
Your data indicates the percentage of diabetic who are poorly controlled is greater than the national average (Registry/Dashboard)
A1C >8 within zip code XXXXX

12. CCHH – The Community Partnership
Poor dietary intake…
Access to healthy food?
(Nutrition and Physical Activity / Exposures and Behaviors)
Grocery store locations
Transportation to and from
Limited financial resources
Community Prioritization and Planning
Share the data with community partners
Identify possible contributors (Environment)
Discuss collaborative improvement strategies/solutions
Make it happen
Continue to collect and analyze data (PCMH)
Maintain/monitor data for improvement
Share data with community partners
Theoretically – Poor dietary intake – what might influence this?
Access to health food? Why?

13. PCMH to CCHH The Connection…
CCHH – Community and Advocate Mobilization
PCMH – Standards / Elements 2014 (NCQA)
Community and Advocate Mobilization
2.B.4 The care team provides access to evidence-based care, patient/family education and self- management support
2.B.7 The practice provides uninsured patients information about obtaining coverage
2.D.6 Training and assigning members of the care team to support patients/families/caregivers in self- management, self-efficacy and behavior change
3.E.4 The practice implements clinical decision support following Evidence Based Guidelines (EBG) for a condition related to unhealthy behaviors
3.E.5 The practice implements clinical decision support following EBG for well child or adult care
3.E.6 The practice implements clinical decision support following EBG for overuse/appropriateness issues
4.A.1-5 The practice establishes a systematic process and criteria for identifying patients who may benefit from care management. The process includes consideration of Behavioral Health Conditions / High Cost & Utilization / Poorly Controlled or Complex Conditions / Social Determinants of Health / Referrals by Outside Organizations
4.B.1-5 The care team and patient/family/caregiver collaborate to develop and update an individual care plan that includes the following features for at least 75%of the patients identified in Element A – Patient Preference and Functional/Lifestyle Goals / Identifies Treatment Goals / Assesses and Addresses Potential Barriers to Meeting Goals / Includes a Self-management Plan / Is Provided in Writing to the Patient/Family/Caregiver
4.C.3 Provides information about new prescriptions to more than 80% of patients/families/caregivers
4.C.6 Assesses response to medications and barriers to adherence for more than 50% of patients/families/caregivers
4.E.1 Uses and EHR to identify patient-specific education resources and provides them to more than 10% of patients
4.E.2 Provided educational materials and resources to patients
4.E.3 Provides self-management tools to record self-care results
4.E.5 Offers or refers patients to structured health education programs such as group classes and peer support
4.E.6 Maintains a current resource list on five topics or key community service areas of importance to the patient population including services offered outside the practice and its affiliates
4.B.1-5 – What type of data extracted from ‘lifestyle goals’ or ‘treatment goals’ may be useful/helpful when building a CCHH?

14. From PCMH to CCHH Identify Potential Barriers to Meeting Goals (PCMH)
4.B.1-5 The care team and patient/family/caregiver collaborate to develop and update an individual care plan that includes the following features for at least 75%of the patients identified in Element A –
Patient Preference and Functional/Lifestyle Goals / Identifies Treatment Goals / Assesses and Addresses Potential Barriers to Meeting Goals / Includes a Self-management Plan / Is Provided in Writing to the Patient/Family/Caregiver
Identify Potential Barriers to Meeting Goals (PCMH)
Extractable data from templates and/or registry
Identify common barriers (PCMH)
What are the risks associated with these barriers (CCHH)?
What might be common barriers be to meeting lifestyle/treatment goals (care plan)?

15. From PCMH to CCHH
Common barriers to meeting the individual care plan (Risk)
Personal Safety (Parks / Recreation)
Transportation (Public / Personal)
Cost
Effective Education
Health and Social Services
Community Engagement
Gathering Places
We’ve chosen ‘Cost’ as the possible barrier…what are other possible barriers to transportation?

16. CCHH – The Community Partnership
Cost of public transportation (Barrier)…
Community Prioritization and Planning (CCHH)
Share the data (barriers / risk) with community partners
Identify possible contributors (Environment)
Discuss collaborative improvement strategies/solutions
Plan the change (project)
Make it happen
Continue to collect and analyze data (PCMH)
Maintain/monitor data for improvement
Share data with community partners on a continuous basis
Possible Community Strategies
Low/No cost public transportation to specific venues
Bicycle friendly cities (New Orleans)
Bicycle share program (Marquette, MI)
Social agency to assist with alternate financial resources
Community Programs (Budgeting)
Providing healthcare within priority areas (highest identified barrier communities)

17. PCMH to CCHH The Connection…
CCHH – Model Organizational Practices
PCMH – Standards / Elements 2014 (NCQA)
Model Organizational Practices
1.A.1 Providing same-day appointments for routine and urgent care (Critical)
1.A.2 Providing routine and urgent care appointments outside regular business hours
1.A.3 Providing alternative types of encounters
1.A.4 Availability of appointments
2.D.1 Defining roles for clinical and non-clinical care team members
2.D.2 Identifying the team structure and the staff who lead and sustain team-based care
2.D.3 Holding scheduled patient care team meetings or a structured communication process focused on individual patient care (Critical)
2.D.5 Training and assigning members of the care team to coordinate care for individual patients
2.D.6 Training and assigning members of the care team to support patients/families/caregivers in self-management, self efficacy and behavior change
2.D.7 Training and assigning members of the care team to manage the patient populations
2.D.8 Holding scheduled team meetings to address practice functioning
2.D.9 Involving care team staff in the practice’s performance evaluation and performance / quality improvement activities
2.D.10 Involving patients/families/caregivers in performance / quality improvement activities or the practice’s advisory council

18. From PCMH to CCHH Model Organizational Practices
Develop and maintain an operational infrastructure to support the performance of community centered health functions…
Patient-Centered Access
The Practice Team
Defined Roles
Team Structure
Communication Process (must be internal and external)
Training and Support (Self-Management / Self Efficacy / Behavior Change)
Care Team Involvement in Performance Evaluation and Improvement Activities
Patients/Families/Caregivers Involvement in Performance Evaluation and Improvement Activities or The Advisory Council
Team Structure – who is part of your care team? Is the patient included? Is this an opportunity for ‘thinking outside of the box”?
Investing resources into the care team will support/sustain the operational infrastructure…
What is meant by resources?

19. PCMH to CCHH The Connection…
Maintain Patient Access (PCMH)
Keep collaborative/partners informed / up to date
Develop Internal Care Team (PCMH)
Train
Support
Inform – Schedule and/or participate in scheduled care team meetings
Community Updates
Partners
Projects
Risks
Environment
Involve care team (CCHH)
Patients/Families/Caregivers Involvement in Performance Evaluation and Improvement Activities or The Advisory Council
Care Team Involvement in Performance Evaluation and Improvement Activities
The community connection is a fabulous opportunity to share organizational updates
Care Team meetings is a great opportunity to share community updates/resources/risks
Involve the care team…remember-patients are part of the team!

20. THE CONNECTION… PCMH CCHH
Evaluate the status of the Organization as it relates to CCHH
Engaged Leadership
Workflow Analysis
Data Management
Analyze Data
Identify Trends
Identify Risks
Efficient / Effective / Trained Care Team
CCHH
Identify Community Partners / Coalitions
Develop Relationships
Share Data
Share Identified Improvement Areas
Share with Community Partners
Share Identified Risks
Discuss Environmental Influences
Discuss Community Strategies to Improve
Develop a Project Plan (Campaign)
Maintain Relationships and Monitor Progress Toward the Project Goal
Continue to Share Data
The FINAL Connection…
A HIGH FUNCTIONING PATIENT CENTERED MEDICAL HOME is the connection to CCHH
Identify any PCMH weak areas – Embrace performance improvement – For a smooth transition into CCHH
THANK-YOU!

21. Questions?

22. Lori Hinga Melody Robinson
Thank You
Lori Hinga
Melody Robinson